CASE CL.-Cancerous disease of Sigmoid Flexure. Perforation. Fæcal Abscess.-Elizabeth S-, æt. 55, admitted into Guy's March 29th, 1854. She was a married woman, but had had no children. She was much emaciated, and for three years had ceased to menstruate. On admission she had a hot and dry skin, the abdomen was tender, the pulse sharp and frequent. She had had pain in the hypogastric region, vomiting and purging, and the stools had contained blood. The diarrhoea became more severe, and there was increased tenderness and pain at the lower part of the abdomen, the evacuations contained inflammatory product. She died on May 16th, the purging having continued severely.

On inspection the lungs and heart were found healthy. A cancerous growth was situated above the sigmoid flexure; and there was ulceration of the new growth. The calibre of the intestine was contracted, and there was thickening of the mucous and muscular coats of the descending colon. The omentum was adherent to the large intestine at that part, where was a large fæcal abscess formed, from the giving way of the descending colon above the seat of stricture. The liver was small and fatty. The kidneys small and atrophied.

This case is one of much interest, as showing an occasional mode of fatal termination in cancerous disease of the intestine ; and that after ulceration has taken place at the seat of stricture, diarrhoea may come on. Here, however, the intestine had also given way, and had led to peritonitis, and the formation of fæcal abscess.

In the Guy's Reports, 1850, Mr. Birkett has recorded a case of insuperable constipation, arising from stricture at the upper third of the rectum, and associated with scrotal hernia. The patient was 49 years of age, and for 14 years he had had hernia. The bowels had been rather constipated. On June 13th, he could not reduce the hernia, and applied at one of the London Hospitals. On the 18th he applied at Guy's. There were slight symptoms of strangulation, but the hernia was reduced, and he felt greatly relieved. On the 21st he came to the hospital, suffering very severe pain in the abdomen, with tympanitis; the voice was weak, and the countenance expressive of great anxiety. The pulse was small and frequent, and the extremities cold. There was a swelling in the left scrotum, and although the patient did not complain of pain in it, there was much dragging, with sense of tightness across the abdomen; it was decided to make an explorative operation. No intestine was found in the sac, and the internal ring was perfectly free. He died on the 26th, nine days after any

alvine evacuation. On inspection, there was general peritonitis, and at the commencement of the rectum there was a vascular growth from the mucous membrane, with thickening of the submucous tissues, which had led to complete occlusion of the canal. The hernial sac was perfectly free.

Great obscurity existed in this case; examination per rectum could not have reached the stricture, and the whole attention of the patient was to the hernia. The symptoms, however, were more gradual in the onset, than ordinary strangulated hernia.

CASE CLI.-Cancerous Disease of Intestine.—Mary N—, æt. 40, living at Whitechapel, was admitted September, 19th, 1856. Two years previously she had been pushed by her husband from the top of the stairs, and violently struck her abdomen across the banister. She felt great pain in her loins when she recovered herself, and was unable to assume the erect posture, but felt easiest in a semi-upright position. The abdomen became swollen, and a large hard swelling was felt in the left hypochondriac and iliac regions. This tumour gave her great pain on stooping, and she was unable to bear any pressure upon it. She had vomiting and diarrhoea. The tumour continued the same for about a year; at that time it became enlarged, and there was great pain across the loins; she frequently vomited and had diarrhoea. The urine occasionally became scanty, and she had headache, vertigo and loss of appetite. She was a woman of dark complexion, was much emaciated, cachectic, and slightly jaundiced; a tumour was felt in the left iliac and hypochondriac regions, it was tender on pressure, and appeared to be felt in the lumbar region; the bowels were relaxed, the urine dark coloured, but did not contain any pus. The diarrhoea continued with occasional vomiting till death on the 18th at 8-15.

Inspection was made on the 20th.-The body slightly jaundiced. The thoracic viscera were healthy, but coloured with bile.

On opening the abdomen, the peritoneum was healthy except towards the left side, where the tumour which had been felt during life in front of the left kidney was observed. There were adhesions firmly uniting several coils of intestine together. On separating them, which could be done without tearing the intestine, a fæculent cavity was found, bounded above by the transverse colon, where it joins the descending colon, and by the greater curvature of the stomach; behind, by the pancreas; below by several coils of intestine-jejunum.

The transverse colon presented an irregular opening about three inches in circumference, the edges thickened, stained by adherent fæces, infiltrated by cancerous product, and in some parts half an inch in thickness. The pancreas at its lesser extremity was infiltrated with cancer, and some of the adjoining glands; the stomach, though adherent, was not affected. At the lower part two coils of the jejunum were firmly adherent, and perforated; one, by a transverse opening extending about half across the intestine, the edges everted and much injected; the other was a smaller opening. The

mucous membrane of the jejunum generally was injected, and covered with much mucus. The stomach and remaining parts of the intestine were healthy, so also the liver and kidneys. The uterus, ovaries, and glands were healthy.

The disease was here of a strictly local character. The examination of the growth showed that it consisted of nuclei resembling those found in cancerous disease, and the general appearance was very strikingly that of cancer; still no other part was affected. The blow which she had received at this part set up inflammatory disease, and it is probable that a cancerous action subsequently ensued.

The diagnosis was difficult; the position of the tumour was that usually found in disease of the glands about the kidney, but no abnormal condition of the urine existed. The vomiting was less persistent, and the diarrhoea more so than is usually observed in cancerous disease of the stomach.

Ovaries. Peritoneum. Acute

CASE CLII. Carcinoma of Rectum. Peritonitis. Scirrhus.-Ann S―, æt. 26, admitted March 26th, and died April 13th. She was a married woman, living at Dockhead, and had had a child two years and a half ago. For one year had had difficulty in passing her motions. She was exceedingly ill on admission, and no connected history could be obtained; the lowest part of the rectum was sacculated, about two inches upwards a stricture was found, through which a catheter could be passed; she gradually sank. She suffered considerable pain, but no vomiting.

Inspection seventeen hours after death.-The body very much emaciated. Head was not examined. At the apices of the lungs was slight pneumonic consolidation and a little chalky deposit. Heart small, without fat, tolerably firm clot on the right side, and in the right pulmonary artery.

Abdomen.-Viscera distended. The peritoneum was intensely injected, and the coils of the small intestine matted together. The mesentery shortened. The great omentum was contracted into a firm mass and nodulated; nearly the whole of the peritoneum was minutely studded with small white tubercles; they were very numerous upon the peritoneal surface of the stomach. The sigmoid flexure and the upper part of the rectum were very much distended.

On taking out the large intestine, a growth was found about three inches from the anus, having a semi-cartilaginous hardness. On its inferior surface the infiltrated mucous membrane had a double lip-like appearance, and was considerably raised. In the centre of the growth, all the coats of the intestine were destroyed, and infiltrated with heterologous deposit. The mucous membrane had a yellowish-white appearance on section; beneath it was firmer, white fibrous product mixed with iron-grey pigment;

still lower, fat with firm tissue. The whole of the external cellular membrane was semi-cartilaginous. On careful microscopical examination, the mucous membrane was found to consist of a delicate cellular tissue of nuclear fibre, interlacing and leaving spaces filled by elongated and reniform nuclei; a few cells were observed, but the cell wall was very imperfect; the submucous tissue was very beautifully composed of a series of bands of fibre tissue, with intervening columns of nuclei; at the upper part these bands of fibres formed series of arches. The muscular coat of the intestine above the stricture was much hypertrophied. In the sigmoid flexure above the stricture were one or two superficial ulcers or abrasions. The descending colon was filled with solid bilious fæces, but was otherwise healthy. The cæcum and small intestine were also healthy, as to their mucous membrane. The whole of the cellular tissue about the ovaries was thickened, white, and infiltrated; both ovaries also were infiltrated with cancer, and one mass was of a yellowish colour as if degenerating. The uterus, vagina, and bladder were healthy. Liver was fatty. Stomach and spleen healthy. No infiltration of lumbar or mesenteric glands. Kidneys and supra-renal

capsules healthy.

The disease in this case began apparently in the rectum, and extended from it, by continuity of structure. It was of a scirrhous character rather than epithelial, and although the obstruction was so great as only to allow a goosequill to pass, no vomiting was produced by the constipation; the reverse would have been the case if violent drastics had been administered. The character of the pain in this instance was more severe than we find in disease of the sigmoid flexure; there was direct pressure on nerves of sensation, and the disease extended to the adjoining structures. The growth could be felt on rectal examination, so that there was no difficulty in the diagnosis.

These instances show that with care the several forms of internal strangulation may be generally distinguished, when we have the whole of the symptoms before us;. that whilst over-active and injudicious treatment increases discomfort and hastens a fatal termination, much may be done, and in some life prolonged for many months. These are not the cases for do-nothing practice; the proper use of enemata, of such diet only as can be borne without injury, opium, rest, and other means to which we have referred, will mitigate suffering even where cure is impossible.

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CHAPTER XV.

ON INTESTINAL WORMS.

THE presence of worms in the alimentary canal ought to be considered as an indication of disordered secretion from the mucous membrane. In most cases it is only because the germs of these entozoa have found a nidus, in which their development can take place, that human beings become subject to them; this can more especially be said of those which make their habitat in the mucous membrane. As to the strongylus, the trichina spiralis, hydatids in various structures, or filiaria, their entrance into the system arises more from locality, and sometimes from causes unconnected with the condition of the patient. The germs of the tænia appear almost indestructible by ordinary means.*

Of the forms of entozoa which infest the alimentary canal, are the tænia solium and the tænia or bothricephalus lata, the tricocephalus dispar, the ascaris vermicularis and lumbricoides.

The ascaris lumbricoides somewhat resembles the earth worm in external appearance; it is found in the small intestine, and sometimes clusters of them, two or three, may exist together in different portions of the whole canal, duodenum, jejunum, ileum, stomach; I have seen them in the oesophagus, and cases have been described where they have produced fatal result by getting into the larynx; they are found also in the colou. It has been stated that they are able to destroy the coats of the intestine and thus reach the peritoneal cavity; but it is now generally believed that liberation and perforation had taken place, and the lumbricus used the opening; the irritation they produce may aggravate ulceration in a marked degree. Dr. Young, in a paper in the "Medical Gazette," records several cases where lum

* Medic. Chir. Review, Jan., 1857. On Entozoa in the Human Subject.