sed we should think it necessary." Accordingly, Mr B. once more tried the same orifice, but not altogether with the same success; it was much contracted, and the stream grew gradually smaller till it ceased, before the patient either complained of faintness, or was sensible of any relief. The quantity thus drawn might amount to 14 ounces, but, from the slow manner in which it had flowed, its quality could not be so precisely ascertained, though it had obviously the same general character as before. We then retired for a short time, to consider what ought to be done next. Neither of us felt disposed to advise the making of a fresh orifice at that moment; we determined rather to watch the symptoms very closely, and, in the first place, to try a large blister and a full dose of calomel, with some other purgative. But while Mr B. was writing the prescription, and I was conversing with the patient, he complained of such an increase of pain, as led both of us to believe that nothing but the farther abstraction of blood could arrest the progress of the mischief, and that it would be fatal loss of time to await the issue of any other expedient. We therefore proposed that a vein should be opened in the other arm, to which Mr D. objected, chiefly, if not altogether, on the ground that the operation was more difficult in the left arm, and he was afraid lest an artery should be wounded; but on being assured by Mr B. that he could bleed in the left arm as easily as in the right, he consented. When about 16 ounces of blood had thus been drawn from a large orifice, the pain ceased; and we ventured to assure the patient, that at length we had reached the cause; but, alas! we were soon to be undeceived, and to discover how far beyond all human reach the fatal cause was seated. Nothing like syncope occurred; neither did the languor appear, for the first half-hour, greater than that from which he had recovered after the bleeding in the morning, or, indeed, than that which very commonly follows such copious bleedings as are found necessary, when any important viscus is inflamed, and without which being induced, it rarely happens that extensive inward inflammation can be subdued. In fact, so little was there then to alarm either of us, that Mr B. went to visit another patient in the neighbourhood, it having been previously agreed, that I should stay till he returned, when we were to settle what was to be done farther. But during his absence I had begun to take the alarm, from observing that the pulse became less and less distinct, and the extremities less and less warm, while there was no deliquium to account for such symptoms, but, on the contrary, the patient was in full possession of his faculties; and from the sound of his voice and cough, it might have been supposed that he was in his ordinary health. Under this impression, I had begun to administer small quantities of wine whey and spt. ammoniæ aromaticus; yet still the prognostic was so far uncertain, that when Mr B. returned, after an absence of not more than half an hour, and I communicated my apprehensions to him, not only did he not immediately enter into them, but, for a moment, I was myself inclined to hope that they were groundless. It was, however, only for a moment. We soon saw too clearly, that cordials of various kinds, and of increased strength, and warmth externally applied with the utmost diligence, produced but mere transient effects on the pulse and temperature. The patient complained more and more of coldness and oppression, and about half past eleven at night he sunk without a struggle. Examination of the body, performed by Mr Bickersteth, in the presence of Drs Maccartney, Bostock, and myself, about 20 hours after death. On dividing the skin, the cellular membrane was found very much loaded with fat; near the umbilicus it was fully two inches thick. The omentum was also very fat, and extended low down. The quantity of fat surrounding the kidneys was very great; and there were besides many distinct masses of fat attached to the different viscera. The omentum was in a state of high inflammation, more particularly at its edges, and under side. The whole tract of the small intestines was inflamed, but especially the ileum. In some parts the vessels were highly injected, and in others there were marbled spots of considerable size. On tracing the ileum to its termination in the cæcum, the appendix vermiformis was found enlarged in all its dimensions to at least three times its natural size, and it was nearly black. Its coats were much thickened, but so tender that it burst at its extremity on being gently pressed, and a sanious fluid issued from it. A solid body was felt within it, near its origin, which moved freely backwards and forwards under the finger. On opening the appendix, its inner surface was gangrenous. The solid body contained in it proved to be a human tooth, the root of which had become soft, and was easily separated into strata, on being scraped with the end of the scalpel. The enamel was perfect, and, when the tooth was thrown into water, it gave the same smart sound against the basin, that a tooth recently extracted would have done. The cæcum was very much enlarged. The liver, stomach, spleen, lungs, and heart, were all natural, except that there was some slight inflammation in that part of the VOL. XII. No. 47. S liver which is contiguous to the colon, and that there was a large quantity of fat about the diaphragm, mediastinum, and heart. P. S. Since the above statement was written, my attention has been directed to a case in the London Medical and Physical Journal for this present month (February 1816), where mortification was occasioned by a chocolate-nut, lodged in the entrance of the appendix vermiformis. To this case, as resembling the one just detailed in many important particulars, I would beg leave to refer my readers. If they will be at the trouble to compare the dates, it will probably strike them as singular enough that two such cases should have occurred so nearly at the same time. In the one, no history could be traced as to the length of time that the nut had been swallowed, farther than that the patient "had experienced a similar affection of his bowels about a year before." So also in the other, after the cause had been ascertained by dissection, several of Mr D.'s friends could recollect that, at times, for a year or more, he had, when walking, been obliged to stop short by a sudden attack of pain in the right iliac region, which, however, soon went off, and no farther notice was taken of it by himself or others. None of his own family ever heard of his having swallowed a tooth. One gentleman, indeed, who had been his intimate from a very early age, thinks he recollects something of the kind having been told him by Mr D., when they were at school together, but he does not speak positively; and my friend Mr Perry, the dentist, to whom I shewed the tooth, says it must have belonged to the second set, for it is one of the upper bicuspides teeth, which do not exist in the infant set. Mr P. authorizes me to say, "that he cannot believe it to have been one of Mr D.'s own teeth, but that it must have been swallowed, as any other moderately sized substance is liable to be, in his food." And, to shew how very possible this is, he states, "that, the week immediately before Mr D.'s death, a well known individual in Liverpool happened to cut down upon a human tooth, in a hot roll which he was going to eat at breakfast." He farther says, that he had been in the habit of examining Mr D.'s teeth, and that they were more free from decay or disease of any kind, than is general perhaps; that he had lost one or two, which he thinks were molares, but that, to the best of his recollection, the bicuspides were all in their places, and sound; that the tooth in question had more the appearance of having belonged to a female; that it had a covering of what is called tartar, which occupied the natural cavity betwixt the points of the grinding surface, obliterating them as points; that ! this extended on one side about two-thirds of the length of the Liverpool, February 6, 1816. III. Fatal Case of Intestinal Disease, with the Appearance on Dissection. By GEORGE NESSE HILL, Surgeon, Chester. CON ONDESCEND once more to indulge an old correspondent, by inserting at your convenience the subsequent faithful detail of a fatal case of intestinal disease Minute histories of the rise, progress, and termination of ambiguous attacks on human health and life, where, when it has come to a close, dissection is permitted, form so many beacons of the most friendly nature to mankind, and highly serviceable to the reflecting and attentive class of medical practitioners. In the spring of 1813, I was desired to visit the unmarried daughter of a lady in this city, who had been many years suffering from an hemorrhagic affection of the bowels. She appeared about thirty-four years of age, tall, thin, fair complexioned, with a tint of sallowness in the countenance; had from childhood been prone to constipation, and what is called " delicacy of constitution;" difficult menstruation, with intense headach, and in the intervals what is fashionably termed "a bilous stomach, with much nervousness." Nearly seven years ago this great sufferer first observed occasional small discharges of blood per anum, of a dark colour, clotted, unmingled with feces or mucus, and passing off without pain or tenesmus. She had no hæmorrhoids, nor had ever been accustomed to the use of stronger purgatives than a small aloetic pill, or a little Epsom salts. The alvine hemorrhage continued much the same for a year and a half, during which period no medical assistance was sought for; because a very intimate female friend, in secret confidence, assured my patient, that such a state was very common to the sex, and not to be regarded. Soon after this advice, each sanguine evacuation was preceded by obscure pain in the left hypochondrium, gliding across the abdomen just below the umbilicus, also an occasional sense of throbbing just within the rectum; and now when blood was about to be discharged, it came off with a sudden irresistible impulse, without tenesmus, but more frequently than before the accession of pain, generally five or six times in every twenty-four hours, giving the inside of the receiving vessels a sprinkled appearance, evidently formed of arterial fluid, whilst the coagula at the bottom were darkcoloured. At the end of two years and a half, the pain had increased, extending now to the inside of the hips down the sacrum, and often very severe in the coccyx. Coughing, sneezing, bending the body forwards, stooping, or any sudden motion, always induced severe pain, however easy before; sitting up in bed had a similar effect; change of posture, especially to lying on the left side, generally, though not always, procured ease. When pain was great, with augmented hemorrhage, pyrexia, with a degree of dyspnoea, came on, and the pain was greatest after the discharge. The sufferer's appetite, spirits, and general appearance, were still good, and for short intervals the recited symptoms would entirely disappear; which vaccillation encouraged the fallacious hope, that all would ultimately be well again. At the end of three years, some medical gentlemen were consulted, to obtain relief for the bilious headach, constipation, hemorrhage, and "nervousness," with the presence of ascarides. Cathartics, particularly calomel, were given in large doses, followed by tonics, wine, and blisters; which plan, although it relieved all the other symptoms, greatly aggravated the sufferings in the rectum, especially whilst liquid feces were passing, which gave the sensation of "spirits applied to a raw place." The action of calomel never failed to induce this feeling, also great debility, mental languor, cold sweats, trembling of the knees, and the addition of great quantities of mucous stuff after each discharge of blood. Under these circumstances, a removal to Liverpool for the benefit of sea air, and the advice of some eminent medical men, was deemed prudent; residence on the beach, a liberal use of cinchona, zinci sulphas, nutritious diet, and port wine, was recommended. The bark disagreeing, the iron mixture, and after that the tinct. ferr. mur. were substituted; but, în defiance of the most rigid adherence to this plan, the hemorThage continued unabated, except for a fortnight in seven months, during which short suspension her spirits and strength were much recruited, though pain was still present. This change, |