other instances is found to moderate diarrhea; the bowels act with less violence and discomfort.

Other demulcents are used with advantage; the 1st object being as much as possible to remove exciting causes; 2nd, to check irritating secretions by correctives and astringents; 3rd, to soothe the inflamed membrane by demulcents and by opiates.

I have found the injection of borax with barley water, or of powdered charcoal with the same agent, of more service in some cases when the colon is much affected, than simple starch with opium.*

If there be severe pain the application of hot cataplasms or of mustard affords partial relief.

It is the exception to find phthisis free from abdominal complication, but the following instances present some peculiarities in reference to this affection: in Case LXXXI. the mesenteric glands were very extensively diseased, and the lacteals distended with strumous product; the diarrhoea was exceedingly obstinate, and hastened the fatal termination. In Case LXXXII. the pulmonary symptoms were entirely masked, but there is no doubt that the dysenteric inflammation was more intractable in character on account of the disorganization of the lungs. If there had been no inspection after death, the latter would probably have been considered by many practitioners, who did not take the trouble carefully to examine the chest, as simple disease of the intestine. Each case of phthisis must be considered in itself; the varying degrees of pneumonic inflammation, of the laryngeal disease, glandular or abdominal complication, &c., render the secondary symptoms exceedingly modified and varied, whilst the broad general characters bear very close similarity; much relief may be afforded by suiting the treatment to these varying sources of discomfort and danger.

Obstruction of

CASE LXXXI.-Strumous disease of Mesenteric Glands. Lacteals. Ulceration of small and large Intestine. Dysentery. Phthisis. -William S―, æt. 20, admitted into Guy's August 29th, and died November 1st, 1855. He had been a labouring man at Hoxton, and, with the exception of a slight cough, had enjoyed good health till the January previous; he then had severe cold, and his cough increased in severity; he was confined to his room for two months, and expectorated viscid mucus; he had been gradually getting more feeble and emaciated till his admission.

See Dr. Th. Thompson on Consumption.

His chest was narrow and contracted; there was dulness on percussion below the clavicles, and in the supra and infra-scapular regions, also roughness in the respiratory murmur, with bronchial respiration, more distinct on the right side than on the left, and increased resonance of voice. The pulse weak and frequent; the tongue had white fur; the bowels relaxed, and the appetite good.

Catechu, with extra. of poppies were given, and cod liver oil, and morphia at night.

The diarrhoea continued with short intermission, and his affection of the throat increased; he became extremely emaciated, and died November 1st. Inspection twenty-one hours after death. The body was extremely emaciated, and on the lower extremities presented several spots of purpura. The larynx was extensively ulcerated; the inner surface of the epiglottis was covered by follicular ulcers united together. There were no pleuritic adhesions; the lungs collapsed well; at the apices were several vomicæ, and throughout both lungs were numerous tubercular deposits and miliary tubercles. The bronchial glands were much enlarged, and infiltrated by strumous product.

Abdomen. Intestines tolerably distended; the peritoneum presented granular tubercular deposit, and considerable injection at parts of small intestine opposite to ulcerated portions of the mucous membrane; the mesenteric glands were very large and prominent, of a yellowish white colour, and infiltrated with low organized product; some of these were the size of a pigeon's egg, and occupied the whole of the mesentery; in several parts of the small intestine, lacteals were observed to extend from the enlarged glands to the walls of the intestine; they were white, irregularly distended, in some places having a moniliform appearance; they extended in several places upon the walls of the intestine, and beneath the mucous membrane, to ulcers situated there. On opening the small intestine, numerous ulcers were observed; they commenced in the upper portion of the jejunum, and extended with greater or less intervals to the cæcum; some were one and a half inch in length, their margins congested, irregular and undermined, their surface granular, as if presenting minute strumous deposits; the ulcers were scattered about six inches apart, and were larger at the jejunum than in the ileum; strumous tubercles were observed in many parts of the ileum in the substance of the mucous membrane, and there were several minute ulcers about the size of peas. The ileo-cæcal valve was much congested, swollen and oedematous. The whole of the cæcum and colon had a remarkable appearance, with the exception of a few islets of raised congested membrane; the whole surface, as far as the sigmoid flexure, was destroyed, the surface of a whitish granular appearance, presenting some congested points, or irregular pits; the section showed that there was low organized product in this superficial layer; some true tubercles, and cellular tissue dipping down into muscular coat; on the surface itself was granular and imperfect cellular deposit, like the diphtheritic membrane. The descending colon presented transverse irregular ulcers, with larger intervening spaces; the rectum was still less affected; the appendix was much distended at its superior two-thirds, and ulcerated, containing strumous tubercles. The

white substance in the lacteals consisted of particles of fat irregularly aggregated into numerous spherical masses; in the mesenteric glands was ordinary strumous imperfect cellular growth. The liver normal, not fatty; spleen, &c., healthy.

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CASE LXXXII. Ulcerated Colon. Phthisis. No Cough. Mich. M'Carty, æt. 53, admitted with violent purging, which had existed a week; much mucus was passed per rectum, but he had no cough. He sank in a very short time. The whole of the large intestine were intensely inflamed and ulcerated, and the small intestines congested; an old vomica at the apex of the lung, surrounded by iron grey pneumonia.

The pulmonary symptoms were masked; he had no cough, but the severity of the abdominal symptoms, dysentery of an acute form, rapidly led to a fatal result.

CASE LXXXIII.-Phthisis. Ulceration of Rectum and Sigmoid Flexure. Hemorrhage from the Bowels. Ulceration of the Appendix Cæci.

was admitted into Guy's under my care March 18th, 1857. He was a married man, of temperate habits, who had considered himself in health till one month before admission; his principal symptom had been discharge of blood from the rectum with diarrhoea; he had cough, had rapidly emaciated, and become completely blanched.

On examination of the chest, we found some flattening, with imperfect mobility of the left apex, soft mucous rattle, with increased resonance of the voice. The abdomen was contracted, and free from pain. There was but little doubt that he had phthisis; there was no evidence of external hæmorrhoids, and the administration of the compound logwood mixture of Guy's at once checked the diarrhoea and discharge of blood; none occurred after admission. Emaciation, however, rapidly increased, the cough became more severe, and the evidence of disorganization of the lung better marked; he died in one month; for several days he appeared in articulo mortis.

On inspection--the abdomen unusually collapsed; old pleuritic adhesions were found on both sides; at the left apex was a small vomica filled with pus, and the whole of the upper lobe presented patches of red hepatization, minute tubercles, and iron grey consolidation; at the upper part of the lower lobe there was also a vomica, and a similar condition as in the upper lobe. The right lung was less affected; the bronchi were filled with purulent mucus; the larynx presented a small ulcer on its inferior vocal cord, and the aryteno-epiglottidean fold was very oedematous; the heart was normal; there was no post-mortem solution of the stomach; the intestines, especially the small, were empty and contracted; the transverse colon presented a sigmoid twist near the spleen; in the lower part of the ileum were a few tubercles, and commencing ulceration. The ascending and transverse colon contained scybala, and presented several ulcers, oval in form, about half an inch in breadth, with injected irregular margins. In the sigmoid flexure and rectum, the whole of the mucous membrane was injected, almost covered with patches of ulceration, and in some parts were portions of adherent diphtheritic membrane. The appendix cæci was twisted in a sigmoid form;

at the right of the cæcum, near its terminal third, it became very much dilated; the mucous membrane at this part was entirely destroyed, and the muscular coat much hypertrophied. The mesenteric glands were considerably enlarged. The kidneys, liver, and spleen were healthy.

The ulceration of the rectum and sigmoid flexure had led to the hæmorrhage which blanched the patient; in this state of exhaustion the disease of the lung very rapidly advanced. It was not the part of the intestine usually affected in phthisis; and he had no pain, distension of the abdomen, or severe tenesmus; diarrhoea, with discharge of blood, were the most marked symptoms. The mesenteric glands were more than usually affected. The appendix cæci was so diseased as would probably have led to extension into the peritoneum or the cellular tissue if life had been much prolonged. The loss of blood apparently hastened the diseased action in the intestine rather than diminished it; and although the purging was checked, the patient never appeared to rally to any extent. He was unable to take cod liver oil, but appeared partially benefited by hydrochloric acid, with small doses of opium and calumba.

These instances, and many others which might have been adduced, show the general constitutional character of phthisical disease; and that although it may manifest itself with greater severity in one organ than in other, we should closely observe the state of other viscera, as having a most important influence on the curative condition of the disease; that these simultaneous developments of morbid action go on very insidiously, as in the diseased appendix in the last case; although on the verge of fatal peritoneal perforation, it would not have been known unless by post-mortem inspection; and lastly, that although the general state of strumous disorganization may be past the stage of reparative action, much may be done in partially relieving distressing urgent complication.

CHAPTER VIII.

ON DISEASES OF THE CÆCUM AND APPENDIX CÆCI.

THE diseases of the cæcum and of its appendix, are of a character so peculiar and important, as to call for special consideration.

To a certain extent, the cæcum is apart from the direct current of the contents of the alimentary canal. The valvular opening from the ileum enters two to four inches from its lowest part; and the capacity of the cæcum is several times greater than that of an equal length of the ileum. The contents of the canal move more slowly, and become less fluid in their character. The mucous membrane is destitute of villi, but is exceedingly vascular, and furnished with numerous solitary glands; and at the termination of the cæcum towards the iliac side generally, is the appendix, an elongated sac opening into the intestine, and pouring into it the secretions from its lining membrane, which is composed of gland follicles.

At this part of the intestine the longitudinal fibres assume a different arrangement; they here form three bands, which arise from the position at which the appendix is attached, and are continuous with its muscular layer.

The cæcum is situated in the right iliac fossa, and is only covered by peritoneum on its anterior and lateral surfaces; a considerable quantity of loose cellular tissue separates it from the fascia covering the psoas and iliac muscles, and the nerves and vessels in relation with them. The mobility of the cæcum is therefore considerably less than the jejunum or ileum; but in this respect there is much variation, being sometimes much more freely covered by peritoneum than at others; so far is this the case, that it is occasionally found close to the vertebral column, with a long mesentery, and the right iliac fossa is completely covered by peritoneum.