chewed by some persons, in minute quantities, when they suffer with heartburn. When the quantity of acid is small, the solution of magnesia in carbonic acid water, by which the bicarbonate is probably formed, may be used by those who prefer it. In cases which do not require a laxative, the bicarbonate of soda is preferable to the magnesian preparations, as more acceptable to the stomach. When vomiting is connected with acidity, lime-water is often given with advantage. (See Vomiting.) If diarrhoea exist, and a laxative effect is to be avoided, prepared chalk or prepared oystershell should be preferred. In cases of great stomachic torpor or coldness, the preparations of ammonia are most appropriate. The carbonate, aqueous solution, spirit, or aromatic spirit of ammonia, may either of them be given. The last is the most elegant, though rather feeble, and may be usefully added to the other antacids, which it renders less offensive to a very weak stomach. None of these antacids should be employed unless acid is actually present, as they have no power to prevent its generation. Their beneficial operation is chiefly confined to the removal of a present evil, and, if too largely given, most of them have a tendency to debilitate the stomach. A proper regulation of the diet, and the application of all the means above detailed as remedies for dyspepsia, must be looked to for permanent relief. Recently prepared charcoal, finely powdered, is sometimes useful by absorbing the acids, and other offensive liquids and solids in the alimentary canal. It may be given in the dose of a teaspoonful or more three or four times a day; but care should be taken not to allow it to accumulate in the bowels.

When chronic gastritis has supervened upon dyspepsia, the patient must be treated for the former affection, reference being always had to the debility of stomach, and general debility which attend the latter.

SUBSECTION IV.

DISEASES OF THE BOWELS.

Article I.

INFLAMMATION OF THE BOWELS.

The intestinal tube is seldom if ever inflamed throughout its whole extent. Nor are the phenomena which different portions of it present, or the treatment they demand, in a state of inflammation, quite identical. It is, therefore, convenient to divide the intestines into distinct sections, and to consider the affection in each of these separately. It is, nevertheless, true that inflammation in any one section often spreads, to a greater or less extent, into that which adjoins it; and, in some instances, it would be impossible to decide which of the two is most prominently affected. I shall treat separately of inflammation of the upper portion or duodenum, of the middle portion, embracing chiefly the jejunum and ileum, and of the lower portion or large intestines.

1. INFLAMMATION OF THE DUODENUM, or DUODENITIS.

The duodenum is liable to the same modes of derangement as the stomach, and very frequently participates in its diseases. Thus, the various forms already described of gastric inflammation and irritation, cancer of the stomach,

and even that condition of the organ denominated dyspepsia, extend in many instances to this portion of the bowels. Indeed, the duodenum itself is very seldom independently affected. The modifications produced either in the symptoms or treatment of stomachic disease by this complication are very few; and, even where the duodenum may be supposed to be the exclusive seat of disorder, the phenomena and indications of cure are so similar to those 'presented by the analogous condition of the stomach, that it would be useless repetition to enter into minute detail, in relation to the morbid affections of the former structure. I shall, therefore, content myself with referring merely to the diagnostic symptoms, and to those points in the treatment which are in any degree peculiar.

The circumstance, in diseases of the duodenum, which most deserves notice, is their peculiar tendency to produce functional disorder of the liver. Diseases exclusively gastric have the same tendency, but in an inferior degree. Broussais appears to have been the first to call attention decidedly to this fact. Among the phenomena of hepatic or bilious disorder, accompanying affections of the duodenum, the most striking is a jaundiced state of the skin. The mode in which this is produced has been variously explained. It has been ascribed to a closure of the common duct of the liver, either by mucus, or a thickening of its coats consequent upon duodenal inflammation, and to the absorption of the bile thus impeded in its passage to the bowels. This explanation may possibly apply to some cases; but it is probably not true in general, and certainly not universally; for cases of duodenitis with jaundice occur, in which bile freely enters the bowels; and, in fatal cases, the duct has been repeatedly found upon dissection entirely unobstructed. A more probable explanation is founded upon the observation of Bichat, that, between a secreting gland and the surface upon which its excretory duct opens, there is a sympathy by which a stimulus applied to the latter causes an increased action in the former. Thus, the stimulus of food in the mouth causes an increased secretion of saliva. In like manner, the presence of the chyme in the duodenum stimulates the liver and pancreas, so that an increased supply of bile and pancreatic fluid, which are useful in the process of digestion, may be received where they are wanted. Irritation or inflammation of the duodenum should, therefore, produce irritation of the liver, which, according to its degree, may be attended either with an increase or diminution of the secretion of bile. In the former case, absorption may take place from the abundance thrown into the biliary passages and bowels; in the latter, the materials out of which the bile is formed accumulate in the blood; and, in both cases, the yellow colouring matter is eliminated upon the surface and elsewhere. Again, in the dyspeptic or depressed state of the duodenum, it is incapable of receiving the ordinary impression from the chyme, and the ordinary stimulus is consequently not supplied to the hepatic secretory function. In this way also the secretion of bile is diminished, its materials accumulate in the blood, and jaundice results. But, notwithstanding the occasional dependence of bilious affections upon disease of the duodenum, I believe that some authors have pushed this view much too far, and given to that viscus a pathological importance which it does not merit. Jaundice and other bilious symptoms may sometimes result from duodenal inflammation; but much more frequently they proceed originally from the liver, and the duodenum, if at all involved, is so either secondarily or simultaneously, from its exposure to the influence of the

same causes.

Diagnosis.-Duodenitis, when it occurs, is almost always associated with inflammation of the stomach or of the bowels. Its existence may be suspected when, in addition to the ordinary symptoms of gastritis, there is deep-seated

pain in the vicinity of the pylorus, extending below the stomach toward the left hypochondrium, or pain in the back about the first or second lumbar vertebra; when there is tenderness upon strong pressure in the space which lies immediately to the left of the right hypochondrium, without any evidence of enlarged or inflamed liver; and when the skin is more or less yellow, and the urine bilious, as in jaundice. If these symptoms should occur, without vomiting, great thirst, or pain and tenderness in the region of the stomach, indicating gastritis; without diarrhoea, pain in the lower bowels, or tympanites indicating enteritis; and without enlargement or tenderness of the liver indicating hepatitis, it may be inferred that the inflammation is confined chiefly, if not exclusively, to the duodenum. In acute duodenitis there is occasionally, along with the fever, a degree of coma dependent probably upon the hepatic derangement. In the chronic form of the complaint, a diagnostic symptom is the occurrence of pain two or three hours after a meal, arising from the passage of a portion of the contents of the stomach into the duodenum. The bowels in duodenitis are generally slow, but readily acted on by cathartics.

The appearances after death are so similar to those in gastritis as not to require particular notice, except in relation to the mucous follicles, or, as they are often called, the glands of Brunner, which are very numerous in the duodenum, especially near the pylorus, and, in inflammation of this viscus, are apt to be enlarged, exhibiting sometimes elevated, irregular, almost continuous patches, of considerable extent.

The causes of duodenitis are essentially the same as those of inflammation of the stomach. Such of them, however, as act through the liver are probably more influential in producing the former than the latter affection.

Treatment. The treatment also is that adapted to gastritis. If there is any difference, it is chiefly in the freer use of mild cathartic medicines, such as the neutral salts, bitartrate of potassa, castor oil, senna, &c., and in a more frequent employment of mercury, which in the acute form may be pushed to salivation, but in the chronic should in general be restricted to an alterative action on the functions of the liver.

2. INFLAMMATION OF THE SMALL INTESTINES,
or ENTERITIS.

Syn. Muco-enteritis.-Ileitis.-Ileo-colitis.

The name enteritis is, strictly speaking, applicable to inflammation of any portion of the bowels; yet, as this affection, in the upper and lower extremities of the intestinal tube, has received the designations of duodenitis and dysentery, and as the symptoms of these two complaints are in certain points strikingly peculiar, it becomes convenient to give a distinct name to inflammation of the intervening portion, and enteritis may perhaps, without impropriety, receive this more restricted meaning. It should be understood that inflammation of the peritoneal coat of the bowels, as a distinct affection, though hitherto frequently denominated enteritis, is not here included under that term, as it clearly belongs to peritonitis. Enteritis, then, as employed in this work, signifies inflammation of the mucous membrane of the jejunum and ileum, extending frequently to a greater or less distance into the colon, and occasionally involving the other coats as a secondary result. The force of the disease is usually spent upon the ileum; the jejunum being less liable to inflammation than any other portion of the alimentary canal. The greater liability of the ileum to be affected depends, probably, on that arrangement by which the fluids, in their passage through the bowels, are somewhat impeded at the ileo

cæcal valve, and commencement of the ascending colon, and thus have the opportunity of exercising a more protracted irritant influence on this than upon the upper portion of the tube. As the inflammation may extend indefinitely into the colon, it is obvious that the phenomena of dysentery must often be mingled with those of the complaint under consideration; and cases occur, in which it would be impossible to decide to which affection they should be referred; yet, for the most part, the symptoms are sufficiently distinctive. Attempts have been made to divide enteritis into the common diffused inflammation of the membrane, the follicular or that affecting especially the mucous follicles, and the pseudo-membranous or that attended with the formation of false membrane. But though there are cases in which each of these forms severally predominates, yet they are frequently intermingled; they offer no symptoms during life by which they can be sufficiently distinguished when occurring as original affections, and, even could they be distinguished, no great practical good would accrue. The peculiar intestinal affection of enteric fever is treated of in connexion with that disease.

Acute Enteritis.-The complaint commonly begins with uneasiness in the bowels, followed after a time by occasional slight griping pains, which gradually become more frequent and severe. In some cases, however, the symptoms are violent from the commencement, and in others, again, very little pain is felt throughout. There is generally more or less tenderness upon pressure. The seat of the pain and tenderness is usually about the umbilicus, though it varies with the part inflamed, and is not unfrequently found more especially in the right iliac region.

Diarrhoea is a very frequent symptom. Discharges from the bowels are apt to follow attacks of griping pain, which they often mitigate; and several of these discharges may occur in the course of a day. The lower in the bowels is the seat of inflammation, the more liable is it to be attended with diarrhoea, and the more frequent, as a general rule, are the evacuations. In cases where the bowels are not loose, they are for the most part readily and frequently moved by very small doses of mild cathartics. Sometimes the diarrhoea is suspended and again recurs, and this may happen several times during the course of the complaint The stools are usually liquid, consisting of the increased serous exhalation of the intestines, mixed with fecal matter, bile, mucus, and undigested food, and sometimes tinged with blood. Occasionally they are dark or green from the changed bile, or clay coloured from the absence of that fluid. There is occasionally some flatulent distension of the bowels; but this rarely amounts to tympanites, unless in children. When the inflammation depends upon obstruction in the bowels, or affects to any considerable extent the muscular and peritoneal coats, constipation instead of diarrhoea is experienced. Sometimes, indeed, the constipation, in inflammation involving the whole thickness of the bowel, is extremely obstinate, giving rise to vomiting and tympanitic distension, so as to resemble cases of obstruction, and sometimes to have been mistaken for them, with unfortunate therapeutical consequences.*

Febrile symptoms sometimes precede those of a local character, the sympa thies and sensibility of the intestinal mucous membrane being such, that its inflammation may be felt by the system at large before making itself known by pain or increased secretion. In such cases, there is general uneasiness, languor, and diminished appetite, with alternate chilliness and flushes of heat for some days before the occurrence of pain. The fever when established is

*See an interesting paper by P M. Kollock, M. D., of Savannah, Georgia, in the Am. Journ. of Med. Sci., N. S., vii. 348.

often remittent in character. The pulse is more or less excited and usually well developed, the skin dry, the urine scanty, and the tongue moist and somewhat furred. There is usually little or no headache or delirium.

The disease is often very mild, running its course in a few days, with little fever or pain, and but a slight diarrhoea. Even the severer cases, when properly treated, and not injuriously complicated, or subjected to the continued action of the cause, generally begin to decline in about a week. The result, however, is not always so favourable. The pains instead of diminishing, are aggravated; the flatulent distension increases; the discharges become very offensive; inflammation ascends to the stomach, and vomiting occurs, with burning thirst, and epigastric tenderness; the liver sometimes becomes involved, and jaundice is added to the other symptoms; delirium sets in; the tongue becomes red and dry, and the pulse frequent and feeble; great emaciation takes place; and the patient either sinks at last, or recovers after a tedious and uncertain convalescence. In other cases, the peritoneal coat becomes inflamed, in consequence either of a direct extension of the disease from the mucous coat, or of an ulcerative perforation of the intestine, and the escape of its contents into the abdominal cavity. This event is marked by the occurrence of symptoms characteristic of peritonitis, and is very generally the forerunner of a fatal issue. Acute enteritis also frequently terminates in the chronic form.

Typhlitis.-Some writers make a distinct disease of inflammation of the cæcum and its appendages, under the name of typhlitis (rvonov, cæcum), or perityphlitis, when it extends to the neighbouring cellular tissue. Pain and tenderness in the right iliac region, attended sometimes with obstinate constipation, and even the symptoms of obstruction, sometimes with a mucofeculent diarrhoea, and occasionally with an aching sensation in the lumbar region, are the characteristic phenomena. Not unfrequently a tumefaction, with more or less hardness, can be perceived upon external examination, which may be well defined when confined to the intestine alone, but is somewhat diffused when there is conjoined inflammation of the external areolar tissue. In the former case, the tumour will generally yield a dull sound on percussion, indicating that the cæcum is filled with solid matter. The cause is most frequently accumulation of feculent matter, undigested food, or insoluble bodies taken into the stomach, as the stones of fruit, &c. Like other portions of the bowels, the cæcum is liable to ulcerative perforation, which may occasion diffused or circumscribed peritonitis, or, if the perforation be in the posterior part of the bowel, where it is attached without peritoneal covering to the iliac fascia, may occasion the formation of abscesses, opening after a longer or shorter period of suffering, hectic, &c., in the lumbar region. The appendicula vermiformis is also, in some instances, the seat of inflammation which may end in ulceration, perforation, and peritonitis. This is especially apt to result from the presence of insoluble bodies, such as calculous concretions, and the stones or seeds of fruits. Sometimes the inflammation in the cellular tissue around the bowel ends in suppuration and the formation of an abscess, which opens externally, without any reason to suppose that the bowel had been perforated.

Anatomical Characters.-The same changes of colour, consistence, and thickness in the mucous membrane are found in this disease as in gastritis. (See Acute Gastritis.) The follicles, however, are more frequently seen enlarged, forming small eminences, sometimes ulcerated upon their summits, and surrounded by an areola of inflammation. Occasionally two or more of these ulcers coalesce, presenting a more extended surface, and an irregular outline. Ulceration is also observed in intervening portions of the mem