canal was full of blood; in the first portion of the duodenum, there was an ulcer which had formed a communication with the hepatic artery."

In a case by Dr. Hastings, the patient, a woman of 30, had vomiting which usually occurred once in twenty-four hours, and a very confined state of the bowels. She complained of severe pain in the epigastric region, in the right hypochondrium below the margin of the ribs, and in the back between the shoulders. In the two former situations there was great tenderness on pressure. She had a teasing cough, by which the pain was aggravated, but her breathing was easy. Pulse 96. She became emaciated, and her countenance was expressive of much suffering. She died in about three months. Ten or twelve days before death her skin became yellow. On inspection, the thoracic viscera, the stomach, and the liver, were found healthy. In the duodenum, beyond the opening of the biliary duct, there was an ulcer, the size of a crown-piece, of a cancerous character, with ragged and everted edges, and its surface was irregular from fungous excrescences. The coats of the intestine around the ulcer were much thickened. All the other viscera were healthy.+ This case might very readily have been mistaken for disease of the liver.

Ulceration of the duodenum may also be fatal by perforation and rapid peritonitis, in the same manner as we have seen in regard to the corresponding affection of the stomach. There is a preparation of this kind in the Museum of the Royal College of Surgeons of Edinburgh, but no account is given of the case, except that it was fatal in twenty-four hours, with symptoms of enteritis; these of

• Broussais sur la Duodenite Chronique.

+ Midland Medical and Surgical Reporter, May 1829.

course occurred after the perforation had taken place. A very interesting case has been described by M. Roberts.* A man, aged 27, had complained for some months of wandering pains in the epigastric region. For the last six weeks there had been diarrhoea, and for six days preceding the following attack, he had complained of nausea and loss of appetite. On 10th December 1827, three hours after dinner, he was suddenly seized with excruciating pain in the epigastric region, which soon spread over the abdomen, and he died in extreme agony in about twenty hours. There were the usual marks of extensive peritonitis, and the cavity of the peritoneum contained much gas, and a considerable quantity of fluid. The stomach was healthy; but, in the duodenum, near its origin, there was an oval ulcer three or four lines in diameter, with rounded edges, and so deep that it seemed to have been bounded merely by the peritoneal covering of the part; this had given way by a small opening about a line in diameter. Near this ulcer there was another about the same size, but less deep, affecting only the mucous membrane.

In a very singular case described by Dr. Streeten,† a communication took place between the duodenum and an external opening on the side of the thorax, between the seventh and eighth ribs, and articles of food or drink were frequently discharged by it. The duodenum was found greatly contracted beyond the seat of this communication, which was produced by means of a canal two inches and a half in length, passing from the opening in the duodenum through thickened cellular texture to the external aperture. The affection was complicated with extensive disease of the liver, and of the thoracic viscera. The pa

Nouvelle Bibl. Medicale, Juin 1828.

+ Midland Medical and Surgical Reporter, November 1829.

tient appears to have lived about a month after the communication took place between the duodenum and the external parts.

In concluding this imperfect outline of the pathology of the stomach, and the parts immediately connected with it, I add the following observations as possessing considerable interest in a practical point of view.

A gentleman from the country consulted Dr. Kellie and myself, in regard to a tumour in the epigastric region, of about a year's standing; and the commencement of it was dated from a violent exertion in lifting some heavy body. The tumour was large, flat, and firm, and free from pain or tenderness. On first inspection, it had the appearance of a mass of organic disease of great extent; but, when we considered that his health was good, and the functions of the stomach little impaired, we departed from this opinion, and were disposed to believe that it might be formed in the parietes. After repeated examinations, we were prepared to send him home with general instructions, when, on making a final examination, Dr. Kellie perceived in the tumour an obscure feeling of crepitus. Following this indication, persevering pressure was now employed, and the tumour gradually disappeared. It was distinctly a hernia, but what the contents of it were, we cannot decide.

A lady from the country consulted me respecting paroxysms of pain in the epigastric region, accompanied by vomiting, to which she was liable at short but uncertain intervals; and they had very much impaired her general health. After repeated examinations, I could detect no organic disease; but at last, by mere accident, discovered

a minute opening through the abdominal parietes, about half way betwixt the ensiform cartilage and the umbilicus. It felt scarcely larger than the mouth of a large pencil case, and was covered only by a thin integument. There was every ground for considering it as the aperture of a small hernia, though the patient had never observed any protrusion at the part; and, by adapting to it a light and slender truss, the paroxysms were prevented.

PATHOLOGY

OF THE

INTESTINAL CANAL.

In attempting to trace the pathology of the intestinal canal, we have to keep in mind the three distinct structures of which it is composed, namely, the peritoneal, the muscular, and the mucous coats. These structures perform separate functions, and are liable to be the distinct seats of disease. One of the most interesting points in this investigation, is to trace the different classes of symptoms which arise from or are connected with these varieties of structure. This I think we are enabled to do with some degree of accuracy, by tracing, in other parts of the body, in which the three structures are more distinct from one another, the leading phenomena connected with the diseases of each. Thus, from ample observation, we have reason to believe, that the most frequent result of inflammation in a serous membrane, is deposition of false membrane,-in a mucous membrane, ulceration,-and in a muscular part, gangrene. There are various modifications of these terminations, but those now mentioned are the most prominent, and the most peculiar to the different structures.