the Pathological Tranactions of 1851 and 1852:-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 casts composed of agglutinated and interwoven masses of string and hair.

Gastric Solution of Duodenum.-The mucus of the duodenum is frequently 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 recently in a child who died under my care in Guy's.

CASE CXV.-Perforation of Duodenum after Death by Solution of Gastric Juice.-William B—, æt. 4 years, was admitted July, 1856, and died on the 23rd. He was an anæmic child, with large head; on admission he was in a semi-comatose state, and the pupils were widely dilated, and he had occasional vomiting, but no convulsions; six weeks previously he had had measles, and one week afterwards hydrocephalus gradually became developed; he was in an almost hopeless condition on admission.

Inspection was made fourteen hours after death. The arachnoid was covered with a slight layer of lymph, so as to give it a greasy appearance, 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 terminated 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.

CHAPTER VI.

MUCO-ENTERITIS AND ENTERITIS.

THERE has been considerable confusion in the application of the term enteritis; Broussais considered it to be inflammation of the colon, Abercrombie regarded it as inflammation of the peritoneal and muscular coats of the intestine; others, again, more particularly apply the term to an inflammatory disease of the small intestine, which commences in the mucous membrane, and extends in severe cases, so as to involve all the coats of the intestine, even its peritoneal investment. These latter and more severe instances correspond to the enteritis phlegmonodea of Cullen; the former, when the mucous membrane only is affected, to his enteritis erythematica.

Watson, Barlow, &c., apply the term only to the more severe cases of inflammation of all the coats, but we shall in this chapter also consider those in which little more than the mucous membrane is affected, called muco-enteritis, and closely allied to gastro-enterite and gastric remittent fever. Dr. Copland describes glandular enteritis, and ileo-colitis; the former we consider in the remarks on strumous and typhoid disease of the intestine, the latter with dysentery.

Enteritis, then, manifests itself under two forms: 1. That involving only the mucous membrane, and which has a disposition to extend in the course of the mucous membrane-mucoenteritis; and, 2. That in which the disease extends in depth, rather than on the surface, and implicates the muscular, peritoneal coats and the connecting tissues: both commence in the mucous membrane.

In hernia, whether external or internal, acute enteritis is set up; and there may be symptoms in common with enteritis, as

constipation, vomiting, &c., but their pathology and treatment are so diverse, that a separate consideration of them is required.

It would be difficult to draw a defined separation between cases of inflammatory diarrhoea, as described by Dr. West, and the simplest forms of enteritis; they pass the one into the other. Diarrhoea, however, is not an ordinary symptom of enteritis; for the bowels in the latter disease are frequently constipated.

We shall first consider enteritis in the form of muco-enteritis or enteritis erythematica. This is very frequent among children during dentition or weaning, and after the exanthemata; but in many cases of infantile diarrhoea and colic, a more transient condition is set up; the indications of which are twisting pain in the bowels, and the evacuation of watery or green motions, with general fretfulness, &c.; these symptoms pass away in a very short time, and they arise from irritation of the bowels. rather than from inflammation of the mucous membrane.

In muco-enteritis a child is found to be fretful, without its usual playfulness and mirth. The lips are dry, and the little patient has a circumscribed flush on one or other cheek; the skin is dry or roughened; the abdomen is somewhat enlarged, or considerably distended and tympanitic, and varies in degrees of tenderness; but the restlessness of the child causes it to cry when no pain is produced; it is unwilling to be disturbed; the appetite is irregular and capricious, either craving for cooling drinks, as cold water, or for unsuitable food, which is oftentimes the cause of the malady. The bowels are irregular, either constipated for several days, or attacked with diarrhoea, the motions being offensive and pale, or greenish in colour, or the evacuations consist of slimy mucus, or of food scarcely changed, and these conditions may alternate, the one with the other; the tongue has a whitish fur, and its substance or papillæ are often much injected; vomiting may easily be induced, and probably arises from the extension of the mischief to the stomach, when the disease is called gastro-enteritis. In the evening the child becomes still more restless, the skin is hot, and even pungent; the sleep is disturbed, and accompanied with grinding of the teeth or starting, and it often awakes alarmed; in the morning the

febrile disturbance is less, and the child may be cheerful and playful.

This aggregation of symptoms constitutes gastric remittent or infantile remittent fever, and many look upon it in the same light as typhoid fever, considering that the inflammatory condition of the intestine is a concomitant, not the essential part, of the disease. This is, I think, incorrect; the intestinal disturbance is the source and the cause of the continuance and extension of the disease; and not, as in typhoid fever, the manifestation of a previously existing and general condition.

When the symptoms persist severely for several weeks greater prostration ensues, the child wastes sometimes to an extreme degree, it appears haggard and aged, the lips have dry sordes upon them, the tongue is more injected, and often aphthous. There is less remission in the morning; the child will scarcely sleep at all, or, in very young children, be placed out of the arms of its nurse; the diarrhoea increases, watery evacuations or food unchanged are discharged a short time after having been taken; the pulse becomes very rapid, the eyes half closed, and the child dies from exhaustion, almost before the nurse is aware of any change; or the brain becomes oppressed, and a drowsy, torpid condition, or convulsions sometimes precede death. The convulsions and coma, to which we refer as coming on at the close of this intestinal condition, are closely allied to those produced by exhaustion, as in the hydrencephaloid disease of Dr. Marshall Hall.

Muco-enteritis is frequently followed by tympanitis, and by strumous disease of the peritoneum, or of the mesenteric glands. In such cases, although the more prominent symptoms of vomiting and purging subside, the child remains wasted, the abdomen enlarges, the appetite becomes ravenous, and exhaustion steadily progresses to a fatal termination. (See Strumous Disease.)

In young persons we sometimes find a state of muco-enteritis similar to that described, but without phthisis or strumous disease; the eyes are sunken and bright, the lips parched, the tongue exceedingly injected, and beef-like; the cheek is occasionally flushed by a circumscribed patch on one or other side;

the pulse is compressible, but frequent; the skin is at one time dry, at another perspiring; there is thirst, generally with loss of appetite, and sometimes with great irritability of the stomach; the bowels are constipated, or diarrhoea alternates with constipation. The urine is scanty and high coloured. This condition may persist for many weeks, with gradually increasing exhaustion, and in some cases it terminates fatally; in very many instances it yields to judicious treatment, but there is great danger of relapse. In young women this state is sometimes. associated with painful or deficient menstruation, or with leucorrhoea; and may be accompanied with severe neuralgic pain in the abdominal parietes, and below the mamma. This neuralgia occasionally leads to a more unfavorable prognosis than the case warrants.

CASE CXVI.-Gastro-Enteritis. Recovery.-Frederick C-, æt. 18, was admitted into Guy's Hospital under my care, October 8th, 1858; he had been employed in the Patent Office, and had resided in Chancery Lane. A month previously he felt hot and unwell, and a week before admission there was great febrile disturbance, with diarrhoea and prostration of strength; the evacuations were watery. His face was flushed on admission; the mind clear, but there was some excitement, although no delirium; the tongue was red, injected, beefy, and cracked; the bowels were still loose, and the pulse was compressible; the skin was dry, but no macula were present; no evidence of disease of the heart nor lungs existed; the abdomen was supple, but there was slight pain below the umbilicus. There was no fever in the house from which he came, nor offensive drains; and the appearance of the patient was not that of one affected with typhoid fever. Ordered milk diet and two eggs. Infusion of calumba with aromatic spirit of ammonia three times a day, and Dover's powder, gr. v., every night.

On October 13th the bowels continued loose; the motions bilious, but fluid; the abdomen was slightly tender; he was prostrate, and appeared to sink in the bed; the skin was dry, but the tongue was rather less injected; there was no delirium at night, but his countenance had a somewhat excited appearance; the cheeks were flushed, the body spare. Ordered to take compound krameria mixture 3j every six hours, and the pills to be repeated. On the 18th the bowels were quiet, the tongue less injected, and the symptoms less severe. To take quinine mixture 3j twice a day, and fish diet. 23rd. No pain. Appetite returning. Tongue less injected. Nov. 12th. He was presented convalescent.

The second form of enteritis is more severe, and all the coats of the intestine are involved. The symptoms are exceedingly acute, and too frequently advance to a fatal termination with