CASE 7.-Wm. Weare, æt 25, servant. Admitted April 19th, 1843, with a globular swelling about as large as a moderate sized melon, superficially subcutaneous, but stretching deep, situated on the right buttock, above and behind the trochanter major. No distinct fluctuation, but feels rather like a fatty tumour. On bending the thigh, it becomes much more tense, prominent, and defined, and the fluctuation is much more evident. Skin over it unaltered; no pain.

States that he first discovered the swelling accidentally, five months ago; it was then about the diameter of a crown-piece, and has gradually increased in size ever since. Knows of no cause.

Has been attending as out-patient for five or six weeks, when the tumour was punctured with a grooved needle, and some yellowish clear fluid escaped.

21st. Punctured with lancet. Two or three drachms only of fluid escaped, the remainder of the contents consisting of the gelatinous sort of matter which is found in bursæ and vaginiform sheaths. Masses of considerable size, and irregular form; one, opaque and somewhat broken up, was apparently in process of transformation into "melon seed" bodies. It was necessary to squeeze the cyst in order to get out the masses, some of which were left behind, and the opening was enlarged to 1 or 2 inches; a piece of wet lint was then introduced into the dependent extremity of the wound.

Catap. panis calid. H. sennæ.

22d. No symptoms of irritation. Edges already granulating. Sac nearly empty. Some yellow opaque masses were squeezed out, consisting of portions which with very little separation and attrition, would be "melon-seed bodies" or "hydatids." Vespere. Heat of skin, with foul tongue and some pain.

H. salin. efferv. 4tis horis.

25th. He has continued to have some little feverishness. There has been copious discharge generally of thin yellow matter, but now rather thicker. Pain at times. No surrounding inflammation. Tongue still rather foul.

Pil. hydrarg.

Ext. coloc. comp. āā gr. v. h. n.

Haustus sennæ cras mane.

Haustus salinus bis in die.

May 2d. Complains of severe pains across the forehead. Tongue still foul.

Infus. ros. iss.

Magnes. sulph. 3j.

Acid. sulph. dil. mx. bis in die.

Omitt. alia. Ordinary diet.

8th. Has lost the pain in the head. A little purulent discharge from the wound which is contracting. Health good.

24th. Wound now healed to a mere spot, furnishing only a little oozing. Discharged.

Spirit of the British and American Periodicals.

STRUMOUS PERITONITIS.

In the March Number of the Dublin Journal we have two Papers on this subject-one from that accomplished physician, Sir Henry Marsh-the other from Dr. Churchill.

Sir Henry Marsh's communication is chiefly occupied with cases of the disease. Dr. Churchill's contains a resumé of its history and management. To this we shall first and briefly allude.

The disease is an inflammation of the serous membrane of the abdomen, accompanied with effusion, and attacking persons of a strumous diathesis. It may occur either in an acute or chronic form, the latter being either a consequence of the former, or originating per se.

It generally occurs between childhood and puberty, or for a few years after that period-it is almost confined to children of a strumous habit and lymphatic temperament, and is often complicated with mesenteric disease.

Causes.-Bad diet, wet, cold, &c. may be enumerated. In most instances, it is hard to assign a cause. There may be extension of irritation from the intestinal mucous membrane-or it may follow febrile diseases.

Symptoms." The mode of invasion varies widely. In one class of cases the patient labours under diarrhea for a considerable time with or without pain; the appetite is pretty good, the temperature natural, and the pulse quiet; but at length -it may be weeks or months-we hear complaints of a sensation of pricking, or of paroxysms of pain, and a feeling of tightness in the abdomen, which, upon examination, is found to be more or less swollen.

"In other cases there is a certain amount of pain from the beginning, occurring in paroxysms, with perfect intervals, and though at first limited to one part of the abdomen, yet by degrees spreading over and occupying the whole." |

The early symptoms may be so slight as to escape attention, emaciation at last awakening it. There may or there may not be pain in the commencement.

Soon or later, however, this occurs most frequently in paroxysms of varying intensity and duration, with intervals of complete relief; beginning in some one part of the abdomen, and gradually spreading over the entire. There is generally tenderness on pressure, and the patient almost always complains of uneasiness on attempting to walk or stand, and in some cases finds it impossible to stand

erect.

After an uncertain interval, fulness is complained of, and the abdomen will be found more or less swollen. Percussion generally yields a dull sound, but not always, for when the bowels are much disordered, they sometimes become tympanitic.

Fluctuation is generally distinguishable, if carefully made. According to Dr. Churchill, the best mode is to lay the child on its back, and accustom it for a short time to the presence of the hand upon the abdomen; then, placing one hand, with the fingers separated, on one side, and percussing very gently with the other, the muscles will not be excited into action; and, if fluctuation be perceptible with the second or third finger, we may be certain of the presence of fluid; for the pressure of the forefinger upon the skin effectually arrests the vibration which results from its elasticity.

The enlargement of the abdomen is not always equable-as it increases, the

whole abdomen becomes tense and hard, with a hot dry skin, and large blue veins ramifying on it.

Sometimes the intestinal functions are long performed with regularity; but, in most instances, "we find the tongue white, loaded, and flabby; more or less thirst; the appetite irregular and fastidious, sometimes increased, more frequently impaired or lost altogether; the bowels relaxed or constipated, perhaps alternately; the stools fœtid, and of a whity-brown or blueish colour."

As the disease advances the pulse generally ranges from 100 to 140, with pyrexia of the hectic character.

Formations.-It is a fortunate issue when resolution occurs.

The disease may end in a circumscribed collection of the effused fluid and its final evacuation, with more or less subsidence of the original affection. Under such circumstances patients have been known to recover. Dr. Burns mentions a case of this kind; and Dr. Abercrombie states that the matter may make its way through the abdominal parietes or the inguinal ring.

But death usually occurs, sometimes with unexpected rapidity, in consequence of ulceration and perforation of the intestines.

Post-mortem appearances.- "Occasionally the vessels of the peritoneum are injected, though sparingly; there is more or less serum effused into the abdominal cavity, with shreds of lymph floating therein. The intestines are more or less agglutinated together, and often thus assume the appearance of sacs of matter. Where there has been perforation of the intestines, we find fæcal matter mixed up with the serum, and can generally detect the communication with the intestine through which it has passed. The peritoneum itself is often thickened, and coated with a layer of lymph; sometimes it is studded with miliary tubercles, or has tubercular matter deposited upon it. In some cases the mucous membrane is intact, in others, ulceration has advanced to different stages. The mesenteric glands may be free from disease, or they may be enlarged, and contain tubercular

matter."

Diagnosis." When pain and swelling of the abdomen, with fluctuation, are present, the diagnosis will be easy; but in those cases in which there is no pain, and but slight tenderness, with little disorder of the digestive organs, there may be great difficulty. Our principal guide is the enlargement of the abdomen, which ultimately always occurs, and the fluctuation, which, by a little care, may generally be perceived. When there is much dyspnoea, or when the diarrhoea is severe, we must be on our guard against supposing the disease limited to the chest or mucous membrane of the intestines. We know that both may be seriously in volved, concurrently with the peritoneal membrane. The same may be said of the mesenteric glands; they may also be diseased; but when they are affected alone, we shall find neither the abdominal swelling (at least to the same extent) nor the fluctuation."

Prognosis. It is generally unfavourable. When the mesenteric glands, or intestinal mucous membrane, or pleura are involved, the case will probably end badly.

Treatment. That usually recommended consists of leeches to the abdomen, fomentations, purgatives, of which calomel forms one of the ingredients, alteratives sometimes, tonics, chalybeates, absorbents, &c. But some cases are curable, if treated early and well. Dr. Churchill advises :-General bleeding, perhaps, never-leeches-poppy fomentations-a piece of lint wet with laudanum on the abdomen-a warm bath every, or every other night-castor oil, or Gregory's powder if necessary-astringents and anodynes for diarrhoea.

"But our principal reliance is upon mercury, given so as to affect the gums, if possible. I believe that the credit of thus administering mercury in this disease is due to Sir H. Marsh, as I have found no allusion to it in any authority. It may be exhibited internally or by inunction; in many cases the latter is preferable, as when diarrhoea occurs, the bowels are too irritable. A scruple of the strong ung. hyd. should be gently rubbed in over the abdomen, night and morning, and continued until the gums are touched, or the disease shows signs of yielding to the treatment.

"Blisters to the abdomen are very useful; they should be small, and applied successively to different parts, and dressed with the blue ointment."

On the subsidence of pyrexia, tonics and more generous diet-every precaution during convalescence.

Many cases are related by Sir Henry Marsh, and Dr. Churchill. The preceding description rather refers to the chronic form of the disease. We subjoin a sample of the acute.

Case." A girl, aged 13, one of a family, every member of which exhibited signs of struma, was attacked with gastric remitting fever, presenting the usual symptoms of that disease. On the fourteenth day of her illness, an abatement of the febrile symptoms having taken place, she was suddenly seized with abdominal pains, rendered more severe by pressure. There was a great increase of fever, the pulse became exceedingly quick, small, and tense, the skin hot and dry, with an expression of extreme distress and anxiety in the countenance. The pains were relieved by fomentations, by the application of a few leeches (for at that stage of the fever, she could ill bear the detraction of blood), and by the internal administration of calomel and opium. Still, however, the general distress continued to increase, and, after the lapse of some hours, she presented all the characters of one dying of peritoneal inflammation; the abdomen began slowly and gradually to enlarge; it became tense, but not in the slightest degree tympanitic; the pulse was now so small that it could scarcely be felt, and so rapid, that it could not be numbered; the debility was extreme, and she appeared to be sinking fast. At the expiration of about two days, during which time her death was hourly expected, the abdominal distention had considerably increased, and flucutation had become unequivocally perceptible. Mercury was rubbed in over various parts of the body, in quantities only limited by the fatigue of the patient, and was also continued internally. The bowels all the while yielded readily to injections, and the evacuations were fluid and bilious. After some time, all abdominal pain having ceased, and the abdomen having reached its highest degree of distention, the pulse became more distinct, and the debility less overwhelming; the skin began to relax, and slight mercurial ptyalism was established. The urine, which had hitherto been high-coloured and scanty, became more abundant, and deposited a copious lateritious sediment. The relaxation of the skin, the increased renal secretion, and the slight ptyalism, occurred simultaneously. Gradually the abdomen became less tense, and, as was proved by measurement, slowly diminished in size. During the progress of this slow process of absorption, the patient was nourished with farinaceous food and ass's milk. The influence of mercury on the system was still moderately maintained, and the febrile symptoms gradually receded. At the end of about twelve days the abdomen had subsided considerably. The patient daily improved in health, and ultimately no traces of the effusion remained. She is now, after the lapse of four years, restored to tolerably good health; the alvine functions are normal, but she looks pale and delicate, and requires in her general management, more than ordinary care and attention. A few months since, having been attacked with catarrhal fever, which proved tedious and obstinate, the ingress of phthisis was seriously apprehended. She is now, however, exempt from signs of pulmonary disease,

and enjoys as much health as falls to the lot of those whose constitutions are innately delicate and feeble."

We think that the profession are under obligations to Sir Henry Marsh and to Dr. Churchill, for directing their attention so decisively to this disease. And the stress laid on the use of mercury is likely to prove eminently serviceable.

ON THE USE OF NITRIC ACID IN CERTAIN FORMS OF HÆMORRHOIDAL AFFECTIONS. BY DR. HOUSTON.

After all that has been written about piles, we believe that many medical men are anything but well-informed respecting them. They look upon them as varicose veins, and as nothing else—a capital mistake. Dr. Houston's paper which we shall now notice, exposes this delusion.

1. The form in which hæmorrhoids most commonly exist, is that of a simple varicose state of the veins; and it would be well if to all such, the names "varices," or "varicose tumours of the rectum," were applied and restricted. We agree with Dr. Houston. Few persons, past middle life, are free from these. They appear and disappear on the mucous surface, or under the skin, in the neighbourhood of the anus.

On external Hæmorrhoids, of this character, we need not speak. They are sufficiently understood.

Internal Hæmorrhoids.-Dr. Houston believes that varix is not the condition which most usually produces distress in "inward piles."

"The state of the mucous membrane covering such varices would appear to influence the condition of the case, more than of the varix itself. While the mucous membrane continues smooth and pale, and free from morbid sensibility, there will be little distress; and the tumours will swell and subside, and even pour out blood occasionally, without the patient being at all aware of the extent of organic derangement which be labours under: but as soon as a relaxed state of the membrane,—a state to which it will soon be brought by the irritation and dragging to which it is subjected by the pressure of the fæces against the tumour of the varix, and the efforts of straining to overcome constipation,as soon as this state of the membrane is induced, then, the varix coming down under the sphincter, is strangled, made to bleed, and to inflame. Or when, from similar causes, ulceration of the mucous membrane over the varix is established, then, distress of another, and even a worse description, viz., tenesmus, muco-purulent discharges, strainings at stool, and hemorrhages of dangerous amount are entailed upon the sufferer. Or, still farther, when that state of the mucous membrane, to which the term vascular tumour" is applied, supervenes, as I believe it often does, upon a varix, then, a simple and otherwise innocuous affection becomes one productive of most poignant suffering."

66

Vascular Tumour.-Dr. H. is disposed to regard this as an affection of the mucous membrane and sub-mucous tissue exclusively. Though it may be independent, it usually has for its basis a knuckle or bunch of varicose veins.

"I have seen it covering the surface of one varix in a rectum, which others in the same bowel have been smooth, and free from any such growth,—the former being the source of much annoyance, the latter giving no trouble at all. I have also seen the affection, in young individuals particularly, where the veins were quite free from any varicose dilatation, but in whom, after a time, varices formed as the result of the irritation of the vascular tumour. And I have observed that, in almost all cases of inward piles of long standing, no matter whether the affec