Dr. Hughes, of strumous peritonitis and perforation of the cæcum coming on in a boy aged 14, after typhoid fever. Seven months after fever, while at work, sudden and severe pain came on in the abdomen, which subsided in a few days, but again returned, continuing for several hours in each attack. When brought to Guy's the pain in the abdomen was general, with tenderness, and there was much febrile excitement. After several weeks the general distension subsided, but a hard, tolerably defined mass was felt in the region of the cæcum. This hardness

continued, and he had occasional attacks of severe pain, sometimes with diarrhoea; hectic supervened, the skin became hot, the stomach irritable, and he exceedingly restless, fretful, and distressed; the abdomen moved en masse; he sank about ten weeks after admission.

There was slight strumous deposit on the lungs, but the abdomen presented the usual appearance of strumous peritonitis; the disease, however, was most marked in the region of the cæcum, the anterior surface of which was destroyed, and a fæcal abscess had resulted; the termination of the ileum was also perforated. Other parts of the small and large intestine were ulcerated.

The ulceration consequent on the typhoid fever in this child appears to have predisposed to slow organic changes of a strumous character in the abdomen.

CASE CVII.-Cancer of the Cacum. Abscess in the Groin.-William J—, æt. 56, by trade a coach trimmer, of very temperate habits, had enjoyed excellent health till he ruptured himself in carrying a heavy weight; he afterwards had an abscess in the right groin for which he kept his bed.

In October 1855, he experienced pain and sense of heat at the lower part of the abdomen, and then found a swelling about the size of a walnut, which gave him great pain on pressure, or on walking. The swelling enlarged day by day, but became less painful, and night sweats came on.

On admission he had cachectic appearance; in the right iliac region was a hard swelling extending into the umbilical region; it descended also below Poupart's ligament on the right side; the inferior part was firmer than the upper; the pain was increased by pressure, and in defæcation. The respiration was difficult, chest normal; the urine healthy, but there was pain after passing it. The appetite tolerably good.

He was ordered castor oil, four leeches were applied to the tumour, and Dover's powder with grey powder were given night and morning.

Free action on the bowels took place, which lessened the abdominal tumour, in fact it had almost disappeared.

The tumour in the thigh remained hard and tender. It became red, more distended, and crepitant.

Severe pain in the thigh came on, and a free incision was made into the abscess; about a pint of fecal matter was discharged with gas.

This fecal discharge with pas contirned very abundantly; the edges of the wound sloughed, and a second opening formed near the crest of the Leam. The patient gradually became prostrate, and for more than a month before his death he had very troublesome diarrhoea. He died about three months after admission.

Inspection on same day.

Abdomen. The general peritoneal surface was healthy; the small intestines collapsed. There was an old inguinal sac on the right side quite free and empty. Several coils of small intestine, the lowest parts of the ileum, were firmly adherent on the inner side of the cæcum, at the brim of the pelvis, and the carum itself formed the anterior surface of a firm tumour. On carefully removing the cæcum and intestine, it was found that the posterior wall of the cæcum was destroyed by carcinomatous ulceration, and ofensive fæcal matter was poured out beneath the iliac fascia, extending downwards to the opening on the thigh. There was also an irregular nodulated growth, extending from the mucous membrane of the cæcum anteriorly, attached near the valve, and surrounding the intestine; the edges exceedingly vascular, but not flocculent. The section of the thicker portion near the Deum presented yellowish white medullary structure, and consisted of an aggregation of large nuclei, evidently medullary cancer; near the margin beautiful capillaries were observed distended with blood. At the posterior part some of the cellular tissue was infiltrated. The coil of Deum which was adherent to the cacum had an irregularly transverse opening into it, and was much injected. The remaining part of the intestinal canal was healthy, so also the mesenteric and lumbar glands.

The Ever was pale, somewhat fatty. Kidneys, bladder, &c. healthy; 80 also the thoracic viscera.

The commencement of this was different from ordinary cæcal disease. There was a small painful tumour which had more resemblance to cancerous growth, or diseased gland, than cæcal disease of a simple inflammatory character; but in other cases which I have witnessed or read of, ulceration commencing at the posterior surface of the cæcum, and leading to extravasation into the cellular tissue of the iliac fossa, the disease was evidently allied to cancer in one or other form; and I believe that nearly all such cases will be found to be of that character.

CASE CVIII-Carcinoma of Cacum, Omentum and Lumbar Glands. Færal Abscess.—James P—, æt. 21, was admitted into Guy's, under the care of one of my colleagues.

Three months before admission he discovered a small swelling in the right

iliac region; when first noticed it was only the size of a marble, but gradually increased so as to fill the whole of that region.

On admission he was pale, nervously agitated, and had a strumous aspect; there was considerable febrile excitement, and he suffered from pain in the right iliac region, where a hard tumour could be felt extending into the lumbar region. At the left axilla was a small dark coloured tumour, apparently cancerous; he had no difficulty in passing his motions, and his urine was healthy. The pain in the abdomen became more severe, and he died in a few weeks after admission.

Inspection. The lungs were emphysematous, the bronchial glands not enlarged. In the abdomen, the peritoneum was acutely inflamed; the cæcum was perforated, so also the termination of the ileum, which opened into a fæcal abscess at that part. The walls of the abscess were infiltrated with medullary cancer. The omentum was spread in front of the intestine and was adherent, it formed part of the walls of the abscess; the lumbar glands were also infiltrated. The liver and kidneys were healthy.

This was apparently an instance of carcinomatous disease, but its precise origin or point of development doubtful; whether it began in the lumbar glands or in the cæcum, probably the latter. The detection of the gland similiarly diseased in the axilla, very much assisted in forming a correct diagnosis.

CASE CIX.-Appendix in Inguinal Canal.-James C, æt. 16; the testes had not descended, and the appendix was adherent in the inguinal canal; the small intestine was fixed in the pelvis. The symptoms of hernia came on, and an explorative operation was performed. Peritonitis supervened, and after death purulent effusion was found in the abdominal cavity.

CASE CX.-Appendix Caci adherent with Omentum at the Internal Abdominal Ring. Supra-renal Capsular Disease.-Henry T. M—, æt. 38, was admitted into Guy's Hospital, March 1857. He was a man of a sallow, very anæmiated appearance, and had been losing strength for twelve months. He was exceedingly prostrate, unwilling to be disturbed or spoken to, and with the exception of occasional vomiting at the time of admission no symptoms of disease could be detected. He had no cough, the abdomen was collapsed, and he appeared to die from rapid exhaustion. On inspection miliary tubercles were found in the lungs, and some iron-grey deposit. The supra-renal capsules were twice their natural size, and infiltrated with strumous product, in a degenerating condition. The intestines were contracted and healthy throughout; one of the mesenteric glands was enlarged slightly, but there was no evident pressure on the thoracic duct. The omentum was firmly adherent in the right inguinal canal, and at the orifice the appendix was also inseparably united. It contained some semipurulent mueus, and was slightly dilated at its extremity. This condition of the appendix was not known to have produced any symptom recognisable during life.

CHAPTER IX.

ON DIARRHŒA.

DIARRHEA Consists in the abnormal frequency of the evacua tion of the bowels, as defined by Cullen, “Dejectio frequens; morbus non contagiosa; pyrexia nulla primaria:" and arises generally from an irritated condition of the large intestine.

It manifests itself in various forms, some of which have received distinctive appellations, as Diarrhea crapulosa, serosa, mucosa or catarrhalis, billosa, and dysenterica.

Diarrhiza crapuisa is that in which there is unnatural fluidity, or excess of fecal excretion, in which the evacuations are healthy in character, but in excessive frequency or fluidity; in some cases very large quantities are discharged without any discomfort, but on the contrary, with relief to the patient. This diarrhea should not be checked, it is a natural discharge; but it is more frequent as the sequence of irritating or undigested food; either that too great a quantity has been taken, and a portion of it has passed into the intestine crude and partially dissolved; or that the character of the food itself has been such that the solvent power of the gastric juice has no effect upon it, and it constitutes a mass unacted upon, and everywhere more or less irritating: it may be an excess of vegetable diet, of salads, or fruit. Again, even supposing that what has been taken is in every respect suitable, active mental or bodily exercise immediately afterwards may interfere with the proper solution of it, and lead to its too hasty passage into the duodenum.

Where the alimentary canal becomes in this way loaded with undissolved ingesta, pain, arising from irregular peristaltic action and distension, often ensues, and is of a griping and twisting character. The abdomen is full; the skin and complexion sallow ;

the tongue furred; the pulse compressible; the head frequently affected with pain; the sleep disturbed; the bowels act frequently and irregularly, and the motions present undigested substances, with fæces sometimes fluid or with firm scybala. Considerable soreness is at times experienced in the course of the large intestine, and distressing tenesmus from the irritation of the mucous membrane of the rectum.

In other cases the irritation thus manifesting itself in the intestine extends to the stomach, and vomiting is associated with diarrhoea, giving rise to English cholera when sudden and severe in its character.

In lientery the food is passed almost unacted upon, either by the gastric or intestinal secretions, and is often discharged in a very short time after having been taken; this condition arises from an irritable or inflammatory state of the whole canal, with disordered secretions; it is not unfrequent in children after protracted diarrhoea, or gastro-enteritis; and in not a few cases leads to fatal termination. It is of common occurrence among the out-patients of large hospitals.

What has been called Bilious Diarrhoea is also a form of disease produced by irritative substances being poured into the intestine; not however from without, but from the liver, and possibly other glands.

The secretion of the liver is either excessive in quantity, or irritating in quality. The contents of the canal are hurried onward, and there are frequent dejections of loose bilious evacuations. The causes are various, and sometimes the disorder of the liver is really secondary to an irritated condition of the intestine itself, caused by excess or stimulants, especially ardent spirits. Exposure to cold and wet sometimes induces disease in this manner, especially in the autumnal season of the year. The symptoms of this state are somewhat similar to those previously mentioned; but there is frequently less pain, unless the disease become aggravated and pass into dysenteric diarrhoea, when the tongue becomes furred, the complexion sallow, there is febrile excitement, pain in the abdomen, or in the hypochondriac region. This form of diarrhoea is sometimes epidemic, attacking considerable numbers exposed to similar exciting causes. Where disease of this kind is severe, with colic or spasmodic pain in the abdomen