and the end of the ileum was perforated; the lower part of the ileum was ulcerated, as in typhoid fever, and one of these ulcers had given way; there was deposit in Peyer's glands, and the mesenteric glands were enlarged and softened. The liver was healthy, so also the kidneys. The spleen was large, soft, and of a dark colour. There was a cyst in the upper part of the œsophagus at its posterior part, about the size of a pigeon's egg; it consisted of a distension of the mucous membrane, and was situated beneath the muscular coat; i. e., the muscular coat did not cover it; it was filled with thick mucus.

The patient seemed to have been so far convalescent from a mild attack of fever as to consider himself well, when fatal perforation of the ileum took place. The appearance of the intestine was precisely that found in typhoid fever, nor was there any indication that the ulceration was of a strumous character.

CHAPTER XII.

ON COLIC.

By the term colic we mean a severe twisting pain in the abdomen, about the region of the umbilicus, without inflammatory action, generally with constipation, but sometimes with looseness of the bowels and vomiting. Internal strangulation of the intestine and intussusception are considered as more aggravated and severe forms of colic; but the former is often in its early stages altogether free from pain, until distension and violent peristaltic action set up inflammation, which involves all the coats of the intestines; unless, then, we consider some forms of colic to be free from pain, in some of its stages, we cannot regard fatal obstruction, arising from displacement and internal strangulation, as a form of the disease.

Dr. Copland divides colic arising from functional disorder of the bowels into four classes :—

1. Flatulent, nervous, or spasmodic colic.

2. Colic from an injurious character of the food.

3. Colic from morbid secretion, or retained excretions. 4. Colic from lead.

This division appears to be a just and useful one; for they indicate widely different conditions, which require different treatment.

In flatulent colic the intestines become distended with flatus ; severe twisting pain comes on round the region of the umbilicus; if the pain be severe, the patient becomes cold, and a clammy sweat breaks out; the pain extends to the back, and the severity of it is relieved by its changing position, but especially by eructation, or by the discharge of flatus from the rectum; during the

severity of the pain, the pulse becomes depresssed, feeble and irregular.

In nervous and spasmodic colic there is less distension of the abdomen, which may be slightly tympanitic; the pain extends to each side and to the back, and is sometimes situated across the chest. The removal of pain from one part to another, and especially the discharge of flatus, as in the flatulent colic, afford relief. The abdomen is, however, tolerant of pressure, and pain is occasionally relieved by this means. There is, also, an anxious expression of countenance, with coldness and clamminess of the surface, and with depression of the pulse, if the pain be severe. The collapse has even been mistaken for ruptured intestine, so complete may be the prostration; in colic, however, the collapse entirely disappears in a few hours; in perforation, it soon terminates in death. The tongue is not generally affected, and it may be clean or furred; the evacuations from the bowels also may be as in health, but in most cases they will be found to deviate from their normal condition. In the nervous colic of hysteria, the urine is abundant and limpid. In the spasmodic colic of gout the urine contains an excess of lithic acid, and may be turbid and scanty.

Causes.-Flatulent colic is observed in nervous and hysterical subjects, and is produced by the rapid evolution of gases from the contents of the alimentary canal, whilst in some cases it appears to arise from change in the secretions of the mucous membrane itself. In the intemperate, and in gouty patients, the chylopoietic viscera are often in a congested, and morbidly excited state; and in these cases a very trifling cause will produce intense colic.

In patients reduced by exhausting diseases, by loss of blood, by the too long continuance of farinaceous and fluid aliments, as also by over lactation, we find that colic of this kind is readily induced.

The exciting causes are alarm and affright, exposure to cold and wet, especially of the lower extremities, food not in itself indigestible, but taken when the powers of digestion are diminished, either from an enfeebled condition, or from the state of the nervous system.

Diagnosis.-There are several conditions with which this

functional colic may be mistaken, and which are important to remember.

Perforation of intestine is generally known by the intensity of the collapse; it is exceedingly unusual for collapse at all approaching in severity to that produced by ruptured intestines to arise from functional colic, but that is sometimes the case. During the passage of a calculus from the gall-bladder or from the kidney, intense pain is produced; but the position of the pain, the character of the vomiting, and in the latter, the pain and retraction of the testicle, and blood in the urine, enable us to distinguish these diseases from ordinary colic.

In disease of the spine, severe and sometimes intense pain is produced in the abdominal parietes, but this pain has less of the twisting pain of colic, and may be traced in the course of the spinal nerves.

Aneurism of the abdominal vessels and abdominal tumours are sometimes the cause of intense suffering, but the constancy of the pain, and the presence of tumour with other signs afford easy diagnostic marks of their true character.

In peritonitis there is exquisite tenderness of the abdomen, whilst in colic the pain rarely amounts to more than a diffused soreness, and pressure can often be borne.

In strumous and chronic peritonitis flatulent distension of the abdomen is associated with soreness or tenderness, less severe than in ordinary peritonitis; and these conditions may, in the early stages, be mistaken for simple colic; this is important, because by an over active plan of treatment disease may be accelerated; and afterwards, when the intestines are matted together, and attacks of peritonitis are set up, the pain and tenderness come on in severe paroxysms. It is only in the early conditions of this disease, and especially in young people of nervous and excitable temperament, that there is liability to such mistake.

The distinguishing marks between colic and hernia need not be dwelt upon; for the presence of an external tumour, with constipation and stercoraceous vomiting, can only be mistaken for simple colic by great carelessness; and in every case of colic, before severe vomiting has come on, it is well always to examine the patient for hernia. In intussusception also,

intense recurrent pain in the abdomen of a twisting character is sometimes associated with diarrhoea, and I have seen the disease mistaken for colic produced by irritating substances; this idea was strengthened by the occurrence of the attacks of pain on the days when the patient was visited by his friends. Flatulent distension of the stomach is sometimes a severe and even fatal disease, but the distension and tympanitis are great, and the pain is constant. The intense pain arising after poisons, as mineral acids, &c., is associated with violent vomiting; but the suffering is especially experienced in the mouth and gullet, and has other characteristic symptoms.

Our prognosis in colic of this kind is generally favorable, but it must be much more guarded when we have had evidence of previously existing disease, and where the collapse is great, and again in some cases of gout.

Treatment. The ordinary treatment in colic, often before the patient is seen by a practitioner, is to administer some hot brandy and water; and if the disease be of the simple kind, which we have described, the patient may be thereby relieved; but in peritonitis, in hernia, in perforated intestine, nothing can be worse, for it takes from the patient the chance of recovery. Opium, gr. i-ij, and laudanum, are the most useful remedies in severe functional colic, and may be given either alone or with ether; chloroform in doses of my-xv, with or without camphor, gr. j-v; chloric ether also, and the salts of morphia, may be advantageously administered. Warmth should be applied to the abdomen by means of hot water, hot flannels, poppy fomentation, &c., and sometimes a mustard poultice and a hot flannel sprinkled with turpentine, may be employed to relieve severe pain.

When the bowels are inactive, and when no indications of acute disease, hernia, or internal obstruction exist, a warm saline purge may be given, but some practitioners prefer gr. v-x of calomel, with gr. j or ij of opium, or colocynth with henbane, or castor oil with tincture of rhubarb and of opium. Again, enemata are sometimes of much service in emptying the colon, and thus may entirely relieve the disease; castor oil and oil of turpentine, colocynth and rue, may each be in this manner employed. If the attacks be less severe, but repeated, and if the patient