disease is set up, and diarrhoea, which can scarcely be checked by any means, is rapidly fatal. This inflammation, and the effusion of false membrane, may be confined to the rectum or descending colon, or be found in the cæcum and ileum. (See Strumous Discase of Intestine, Cases CXXIII, CXXIV, and CXXV.

In Case XI of perforating ulcer of the trachea and œsophagus, the rectum was acutely inflamed, but this appeared to have been produced by the direct irritation of the nutrient injections, by which life was entirely sustained for six weeks.

CASE CLXXVII.-Strumous Peritonitis. Diphtherite of Rectum. Chronic Inflammation of the Large Intestine. Tubercular Lung. Simple Ovarian Cyst. Vascular Polypus of the Urethra.-Esther W-, æt. 37, was admitted October 25th, 1854. She had menstruated regularly till eight months previously; and two months afterwards she perceived enlargement of the abdomen; this increased gradually with pain; and the swelling appeared to proceed from the right side.

November 20th. Six quarts of purulent fluid were drawn off by tapping; after a few days, sickness and diarrhoea came on, which continued more or less until death.

The body was extremely wasted; the eyes were sunken; the abdomen projected as a large round fluctuating tumour. Both lungs were closely adherent to the chest; they contained large masses of tuberculo-pneumonic deposit ; and scattered groups of tubercle were found in both lungs. In the upper lobes the tubercles were associated with indurated puckered lung and cretaceous matter. The heart was small but healthy.

Abdomen. The parietes were adherent to a cyst, which contained about a gallon of fluid. The intestines were adherent to one another, and presented here and there white tubercular masses; the greater part of the small intestine was behind the cyst, but about two feet of jejunum were closely adherent to its upper and anterior surface. Throughout the large intestine were raised rough and hardened patches of mucous membrane; and in the centre of these patches the mucous membrane was destroyed. The margins of these ulcers presented imperfect gland structure, with a considerable quantity of fibrous tissue; and in the centre also was fibrous tissue, but no gland structure. These ulcers covered a considerable portion of the large intestine; and the whole of the submucous tissue contained white fibrous tissue. In the intervening portions of membrane were several raised minute tubercles, about the size of an ordinary pin's head, and one-eighth of an inch in diameter; these were red in colour, and appeared to consist of congested fibrous tissue beneath the mucous membrane, and were not true tubercle.

The rectum was intensely congested, and covered with a whitish layer of secretion, which was firmly adherent to the mucous membrane. This diphtheritic membrane consisted of granules, of mucous cells, of columnar epithelium, some imperfect granule cells, and slightly fibrillated secretion.

Some of the mesenteric glands contained strumous matter. The liver was slightly fatty, 3lbs. in weight; there was a large calculus of cholesterine in the gall-bladder. The spleen corpuscles were large.

The ureters were much distended; the kidneys were diseased from obstruction; and their pelves distended; their cortical structure was full of white deposit, and there were some points of suppuration. The left kidney was large, and contained small abscesses. The bladder was distended; at the orifice of the urethra was a vascular growth. The ovarian cyst was simple; the fallopian tube extended upon it, and was filled with strumous deposit; the ovaries were obliterated; the ovarian cyst contained purulent serum and fibrin. The uterus and its cervix were much elongated.

The fatal termination in this severe case was much hastened by the ulcerated state of the colon; there was strumous disease of the abdomen and of the lungs; and it is probable, that the exhaustion consequent on the suppuration of the ovarian cyst led to the rapid development of strumous disease. It is important to guard against each fresh accession of diseased action, because the changes are of a rapidly degenerative character, and react upon the original disease.

Discharge of mucus from the rectum.*-The discharge of mucus in cases of catarrhal diarrhoea has already been referred to, but this flux sometimes follows as a sequence of acute dysentery; and in other instances it is set up and perpetuated by the presence of local disease of the rectum, as by hæmorrhoids, polypoid growths, &c. In irritation of the colon, such as occurs in diarrhoea, mucus is often passed with the ordinary fæcal discharges; and in dysentery, the evacuations consist occasionally of simple mucus, with blood; it is to more chronic discharges that we here refer. The discharge may be very frequent, occurring not only with defecation, but at other periods; and it is especially present when there is local disease of the rectum, but is not limited to these states. Secondly, the mucus may be in shreds; but this kind of discharge we have not found except in acute diseases; and, thirdly, it may constitute casts, more or less complete, of a portion of the intestine. These are found to be several inches or a foot in length, and consist of mucus-cells, in a tenacious albuminous basis; but it is only in those cases in which shreds of mucus are discharged

* See some interesting remarks on this subject, by Dr. A. Clark, in 'Lancet,' December, 1859.

during acute disease of the intestine that any fibrillation of the product is observed; the patient not unfrequently regards the mucus cast in chronic disease as an intestinal worm.

The patients who suffer from this chronic discharge of mucus are generally in a cachetic state, pale, and more or less emaciated; the bowels are irregular, sometimes confined, at other times affected with diarrhea; and there are occasionally intervals of several weeks or months between these mucous discharges of flakes and casts. During their passage a sense of distress and faintness, and even actual syncope may be produced, with severe colicky pain; the pulse is compressible, the tongue may be clean or furred, and the appetite uncertain; the mind is generally irritable or dejected, and sometimes almost melancholic.

In those instances which are not produced by disease of the rectum or of the sigmoid flexure, as hæmorrhoids, polypus, &c., nor are the sequence of acute dysentery, we have generally found, either that long-continued congestion of the vena portæ, or irritation of the urino-genital organs has produced or at least perpetuated the disorder. In young women, painful menstruation and ovarian disease may thus be the cause; in men, prostatic disease, calculus, &c.

The disease is a remedial one, and the prognosis may be favorable when the irritating causes can be removed, when a patient will submit to well-regulated dietetic regimen and careful habits of life, and when, for a sufficient time, he will persist in the use of proper medicinal measures.

Where disease of the rectum is present, and local and general means are unavailing, the help of the surgeon may be required to remove an irritating growth or hæmorrhoid. If the latter be present, the bowels should be regularly acted upon by the confection of senna and of black pepper; the gall ointment may be locally applied or an astringent wash used; and at the same time the diet must be carefully regulated and hepatic congestion avoided. It is, however, to the chronic form of mucous discharge that we here especially refer, and in this, careful attention to the diet and to the state of the skin is especially needed; a nourishing but unstimulating diet should be taken, and, if possible, stimulants altogether avoided. Although mercurial

medicines, in aperient or in very small doses, sometimes afford considerable temporary relief, we have often found the distress greatly increased by them; and we have seen greater benefit accrue from the use of nitro-hydrochloric acid with henbane and vegetable infusions, as of the calumba or cascarilla. If the bowels be loose, the krameria, with ipecacuanha and tincture of catechu, may be used, or the quinine with Dover's powder. When aperients are necessary, a small dose of colocynth may be given with Dover's powder, or of castor oil with tincture of rhubarb, but aloes and the more powerful purgatives are injurious. Astringent injections are sometimes of service, but are unavailing if portal congestion or pelvic irritation continue. In dysmenorrhoea and ovarian disease, absolute rest, at least for a time, is necessary, and the avoidance of tight corsets is indispensable. Dr. Clark recommends astringents, as alum, the pernitrate and the sesquichloride of iron, &c.

CHAPTER XI.

ON TYPHOID DISEASE OF THE INTESTINE.

IN typhoid fever diseased action of a special kind takes place in the glands of the intestine. This state passes through very definite conditions, and has been described by Rokitansky as the typhoid process. Dr. Jenner and others have pointed out the essential difference in the signs of typhoid and typhus fever, but it is only in the former disease that we find this abnormal condition of the intestine. The glands especially affected are those at the lower part of the ileum, namely, Peyer's or aggregate glands; the solitary also become involved, and the mesenteric are enlarged, congested, and swollen. The questions naturally arise, In what does this state consist? is it a necessary sign of fever? what are the indications of the typhoid state of the glands? and what is the course which the disease pursues?

The intestinal disease consists in the effusion of an abnormal product into the substance of the glands just mentioned, and the exudation effused from the capillary vessels is composed of a blastema, which undergoes but little development, and consists of an immense aggregation of granules, and of some large cells containing nuclei.

Soon after the commencement of the fever the glands are swollen and enlarged, and the mucous membrane becomes more vascular than usual; as the fever advances the glands are raised sometimes two or three lines above the surface of the membrane; about the fourteenth day of fever the product either becomes absorbed, or ulceration takes place, or the gland sloughs; a few days later the slough is found to have separated,