In relation to the medical treatment, the indications appear to be, to remove sources of irritation from the alimentary canal by laxatives and antacids; to promote the hepatic secretion, and thereby remove portal congestion, by calomel or some other mercurial; to divert excitement externally by diaphoretics, and by measures addressed to the surface; to relieve irritation by anodynes, and inflammation, when of a decided character, by direct depletion; to check excessive evacuations, in the advanced stages, by astringents; to modify the morbid state of the affected membrane by alteratives; and finally, to support the patient by suitable stimulants when greatly debilitated.

In the early stage, attention should be first directed to the means for allaying the excessive vomiting. For this purpose, rubefacients should be applied to the epigastrium, so as to excite a very decided irritation upon the surface. Mustard, diluted with an equal quantity of rye-meal, is perhaps the most effectual application; but bruised mint steeped in brandy, or cataplasms made of the different spices, such as powdered black pepper, ginger, cinnamon, cloves, &c., separate or mixed, may be employed. At the same time, very small and repeated draughts of fresh and cold carbonic acid water; or teaspoonful doses, repeated every quarter or half hour, of lime-water and fresh milk, mixed in equal proportions; or some one of the aromatic waters or infusions, such as mint-water, and fennelseed tea; or camphorated tincture of opium, in the dose of five or ten drops sufficiently diluted, may be given internally, one of them being preferred to another according to the particular circumstances of the case, as, for instance, the degree of vascular action, the presence or absence of acid, &c. Dr. Dewees recommends, for the same purpose, a teaspoonful of strong coffee without sugar or milk, every fifteen minutes, and an injection of a gill of warm water holding a teaspoonful of common salt in solution, which may be repeated when the vomiting is severe. The latter be considers as the most prompt and certain remedy that can be employed. (Phys, and Med. Treat. of Children, 4th ed., p. 420.) Dr. Condie speaks favourably of the oil of turpentine, and of a solution of camphor in sulphuric ether, and, when everything else has failed, generally succeeds with a solution of acetate of lead, in doses containing about one-sixth of a grain, repeated every hour or two. (Diseases of Children, p. 223.) When the vomiting is excessive, and other means fail in arresting it, an anodyne injection may be resorted to, containing from three to six drops of laudanum in a little thin starch. Indeed, opiate enemata will be found highly useful throughout the complaint, when the irritation of stomach is considerable, and no symptoms of cerebral disease exist. They may be repeated in suitable cases every day, and, if given at night, will be found very useful by enabling the child to rest. Care, however, must be taken not to employ too large a dose; a mistake often made in infantile cases.

When the stomach becomes retentive, medicines should be given to evacuate the bowels. Combinations of rhubarb and magnesia usually answer well. They may be given in powder; but the syrup of rhubarb, and the solution of carbonate of magnesia in carbonic acid water, are perhaps preferable. A teaspoonful of the syrup, with twice that quantity of the solution, may be given every two hours until they operate. The operation of the rhubarb may be known by its colour in the stools. The magnesia is peculiarly suitable, when a sour smell and green colour of the evacuations indicate acid in the bowels. Advantage will often arise from administering these medicines in some aromatic vehicle. When the discharges are small, mucous, and attended with pain, castor oil should be substituted. But probably, upon the whole, the most effective cathartic in these cases is calomel. In children two years old or upward, I have seen it act most happily in numerous cases, in doses of two grains repeated at intervals of two, four, or six hours, until evidences of

its operation were presented in the passages. Employed in this way, it often puts an almost immediate end to the disease, if given early. Another mode of exhibiting calomel, which is much employed, and is adapted to any age, is in«^ doses of from one-sixteenth to one-quarter of a grain, repeated so that from one to two grains may be given in the course of twenty-four hours. This plan is peculiarly useful when the stomach is irritable, and the secretion of bile suppressed or greatly deficient. The calomel may be administered mixed with a little powdered gum arabic, in syrup or on the surface of a teaspoonful of milk, or simply introduced into the mouth of the infant with a little sugar. A good plan is to give the mercurial one day, and the syrup of rhubarb or other laxative on the next, and thus alternate them until the stools become bilious; or the two may be alternated upon the same day, or even given conjointly, at the discretion of the practitioner. The laxative plan should be continued until the discharges assume a more natural appearance, unless there may be reason to think that it aggravates the complaint, or that no benefit accrues from it. Occasionally, from half a drop to a drop or two of laudanum may be usefully added to the laxative. It quiets pain, and relieves spasm of the bowels, without preventing the cathartic action. It may thus be combined with syrup of rhubarb or castor oil. This latter cathartic, given in the form of oleaginous mixture, made with gum arabic, loaf sugar, mint or cinnamon water, and laudanum, may be used with peculiar advantage in the advanced stage, if the intestinal irritation approach the dysenteric form.

When the complaint has the character of diarrhoea from the beginning, or assumes that character in its progress, and there is little or no irritability of stomach, but still deficiency of biliary secretion, the minute doses of calomel may be very happily associated with the powder of opium and ipecacuanha, which quiets irritation of bowels, and gives a direction to the skin. Under these circumstances, also, the cretaceous preparations should be substituted for magnesia, especially if fever is absent, and the debility considerable. They are, like it, antacid, but rather astringent than purgative; and the indication is less to promote than to check the alvine evacuations. The mercurial pill, or mercury with chalk, may be substituted for calomel. These remedies may often be advantageously given in combination, as in the formula below. If ipecacuanha should be objectionable, laudanum may be substituted for the Dover's powder in equivalent proportion. Mixtures made in the same way with carbonate of soda, or carbonate of potassa, as an antacid, are also occasionally used, but are less efficient. Cinnamon water may be substituted for that of peppermint; but, if the officinal preparation be used, it should be diluted with from two to four parts of water. This plan should be continued until the stools assume a healthy colour.

In a still more advanced stage, when the continuance of the evacuations threatens to exhaust the patient, it becomes necessary to attempt to arrest them by astringents. For this purpose, kino, catechu, or extract of krameria may be added to the cretaceous mixture above directed, from which the mercurial may be omitted, if no longer requisite. The decoction of logwood, or of cranes-bill (geranium, U. S. Ph.) may also be used; and, if a combined tonic and astringent effect is desired, that of the blackberry root or dewberry root. Some of the mineral astringents are perhaps still more efficient, especially acetate of lead, which has been highly recommended, and is certainly very useful in many cases of the diarrhoea following cholera infantum. Dr.

R. Pil. Hydrarg. gr. vj; Pulv. Ipecac, et Opii gr. ij; Cretæ, vel Testæ Ppt. zi; Acacia pulv. 3j; Sacchari 3j; Aqua Menth. P. f3ij. S. A teaspoonful every two hours, or pro re nata.

Chapman, in his lectures, spoke favourably of alum. These remedies probably operate as much by an alterative impression on the mucous membrane, as by their astringency. They may in general be usefully combined with an opiate, and sometimes with ipecacuanha. Dr. Lindsly speaks, in strong terms, of the efficacy of a combination of acetate of lead and Dover's powder. The mineral acids sometimes prove useful as alteratives and tonics. These also should be combined with an opiate. The nitromuriatic acid is perhaps to be preferred. I have employed nitric acid, in the form of Hope's mixture (see page 602), with decided benefit. Nitrate of silver was employed by Dr. Skinner, of N. Carolina, in one almost desperate case, with the happiest result. The salts of iron may be resorted to in cases of obstinate diarrhoea connected with anæmia. Other substances sometimes used as alteratives are oil of turpentine, copaiba, and creasote. In great debility it may be necessary to resort to wine whey and the ammoniacal preparations; and the vegetable tonics will often prove useful in hastening a protracted convalescence.

When, in the course of the complaint, there is much tenderness of the abdomen, and the patient is not greatly exhausted, leeches, followed by warm fomentations or emollient cataplasms, should be employed; and if these do not relieve the inflammation, they should be succeeded by a blister. In some rare cases, in which there is tension of pulse connected with gastric, intestinal, or cerebral inflammation, recourse may be had to the lancet. Should symptoms of meningeal inflammation occur early in the disease, they must be counteracted by local and general depletion, carried as far as circumstances will warrant, by cold applications to the head, and by blisters.

stances.

Throughout the complaint, remedies should be employed in reference to a direct impression upon the surface. In the early stages, the simple warmbath, and, in the more advanced, the warm salt or mustard bath, may be tried, and if found beneficial may be repeated every day. Great advantage may be expected from the salt-bath, especially when the disease has terminated in diarrhoea. Baths of oak bark may also be tried under similar circumWhen heat is deficient in the extremities, the equilibrium should be restored by frictions, and by rubefacients applied to the legs and arms. Oil of turpentine, liniment of ammonia, or warm tincture of Cayenne pepper, may be employed. Blisters to the extremities, under these circumstances, are also clearly indicated. Rubefacient applications to the abdomen should be occasionally used, and the effects of a flannel bandage in the advanced stages have been much praised.

Prophylactic measures should always be resorted to in cases in which a predisposition to this disease exists. The rules already given in relation to country air, ventilation, dentition, diet, dress, and exposure to sudden changes of temperature, are applicable here. The late Dr. Joseph Parrish used strongly to urge the propriety, when the predisposition is very strong, of for tifying the stomach and bowels by a digestible animal diet, and the use of aromatics, particularly the infusion of ginger, during the period of danger.

Article IV.

FLATULENCE.

Syn.-Eructation.-Crepitus.-Borborygmus.-Tympanites.-Meteorism.

Gases of different kinds are always found in the stomach and bowels, where their presence appears to be a provision of nature to sustain an equable dis tension of the abdominal cavity, under the constantly varying quantity of its

liquid and solid contents. It is only when they are produced so abundantly, er accumulate so much as to become a source of decided inconvenience, that they can be considered in the light of morbid phenomena. In most instances, flatulence is a mere result of other morbid affections, and is to be regarded rather as a symptom than as a disease. But it is sometimes an original affection, without any appreciable organic or functional derangement, other than that which its existence necessarily implies, and, like dropsy, deserves to rank as a distinct disorder.

Symptoms, Course, Diagnosis, &c.-The symptoms of flatulence are such as depend either upon a too copious evolution of gas in the alimentary passages, or upon its undue detention in these passages, or upon these two conditions united. A sense of distension, or of other uneasiness is experienced in the stomach or some portion of the bowels, which is soon followed by the expulsion of air either upward through the mouth, producing belching or eructation, or downward through the anus, not unfrequently with a loud report, which, however, the patient has it generally in his power to suppress. These discharges are often brought about by the voluntary contraction of the abdominal muscles and diaphragm; but sometimes they are quite involuntary, and depend solely on the contraction of the muscular coat of the alimentary canal, or the elastic force of the confined gases. They are sometimes exceedingly copious, the air rushing from the stomach or bowels, or from both together, in an almost continuous torrent, and constituting a very annoying affection, which has been called by some writers the dry cholera. Flatulence is often also attended with a disagreeable rumbling or gurgling sound in the bowels, called borborygmus, which is produced by the passage of the air from one part to another, and its intermixture with the intestinal fluids as it passes. Besides the sensation of distension or pressure, provoking and relieved by the discharges, the patient is often affected with pains, which are in some cases moderate and fugitive, in others distressing and almost constant, and in others again severe and spasmodic, amounting even to the most violent colic. Occasionally also acute pain is felt in various other parts, sympathetically connected with the stomach and bowels. Thus, it is not very uncommon for the spasmodic pain of gastric flatulence to shoot upward into the breast and throat, and even to ascend to the head.

Meteorism, or tympanites is another distressing affection connected with flatulence. This consists in a distension of the bowels so considerable as to become visible. Perhaps the term meteorism may be appropriately applied to the slighter degrees of distension, and tympanites to that condition in which the abdomen is very much swollen, so as to be quite tense and sonorous. Sometimes the swelling is local, so as even to have given rise to the suspicion of the existence of solid tumours; sometimes it is equable over the abdomen. In its higher grades it is often very injurious. The muscular coat of the bowels, when greatly distended, loses its power of contraction; and thus, not only is the collection of gas allowed to go on increasing, but the passage of the liquid and solid contents of the canal is impeded, and obstinate constipation results. Sometimes, however, diarrhoea attends tympanites. Another injurious result is the derangement of function in the neighbouring parts, pressed upon by the expanded bowels. The respiration especially suffers in this way, in consequence of the upward pressure of the diaphragm. A case is recorded by Dr. Ashmead, of Philadelphia, in which death resulted from a cessation of respiration, consequent upon an enormous tympanitic distension of the bowels. (Transact. of Col. of Phys. of Philad., Jan. 4, 1842.) Another fatal accident, sometimes proceeding from the same cause, is the rupture of the stomach or intestines by the expansive force of the confined air. In some

rare cases of tympanites, the air is accumulated in the cavity of the peritoneal sac, instead of in the alimentary canal.

it

There is nothing determinate in the course of flatulence. It may come on suddenly and as suddenly disappear, or it may continue, with various fluctuations, for a great length of time. In the form of meteorism, or tympanites, it often lasts for years with little abatement or alteration. In some cases, disappears spontaneously, in consequence apparently of the absorption of the gas; in others, it yields with greater or less facility to remedial measures; and, in others, again, it obstinately resists all the means employed, and ceases only with life.

The part of the alimentary canal in which the evolution of gas takes place, may sometimes be inferred from the point whence the ascending or descending current of flatulence seems to the patient to proceed, from the period intervening between the introduction of some flatulent substance into the sto mach and the first appearance of the symptoms, and, in the case of meteorism or tympanites, from the particular position of the tumefaction. Flatulent distensions of the abdomen may be distinguished from liquid accumulations by the absence of the feeling of fluctuation produced by the latter, when the palm of the hand is placed on one side of the abdomen, and a gentle blow given to the other; from solid tumours, by the flat sound emitted by these upon percussion, instead of the clear resonance characteristic of confined air. It is not always possible to determine, whether the gas occupies the bowels or the peritoneal cavity. The former position, however, may be inferred, when the distension was, in its forming stage, or continues to be unequal, and when a gurgling sound on auscultation indicates a mixture of liquid and air.

The air evolved or confined, in flatulence is generally a mixture of different gases, among which oxygen, nitrogen, and carbonic acid are the chief. Not unfrequently inflammable air escapes, consisting probably of hydrogen, or its gaseous compounds. Sometimes the flatulent discharges are without odour and perfectly bland, sometimes they are loaded with offensive exhalations from the alvine contents, and sometimes they are acrid and burning. Little, however, is precisely known upon this subject.

Causes.-Flatulence has its origin either in the character of the ingesta, or the condition of the alimentary canal, or in the two sources combined. Food not digested, or but imperfectly digested in the stomach, is liable to a chemical decomposition, resulting in the evolution of gaseous fluids; and the quantity thus evolved from a very small portion of solid or liquid matter is sometimes enormous. This result may take place in a perfectly healthy condition of the digestive organs, if food be employed of a nature not adapted to the modes of living, or peculiar constitution of the individual, and consequently to his strength of digestion. Certain kinds of food and drink are peculiarly apt to evolve gases in the primæ viæ, and, on this account, are called flatulent. Such are cabbage, unripe fruits, melons, tough or fibrous roots, and fermenting or fermentable liquids. These will often evolve gas copiously in a healthy stomach. But, when the powers of digestion are morbidly enfeebled, the effect takes place in a much greater degree, and substances become flatulent, which, under ordinary circumstances, are easily dissolved in the gastric liquor. Any cause, therefore, which is capable of debilitating digestion, may act as a cause of flatulence. (See Dyspepsia.) The ordinary contents of the healthy bowels, consisting of the residuary alimentary matter and various secretions, are also liable to chemical reactions, which extricate gases, especially when they are confined too long in the intestines; and constipation thus becomes a cause of the disorder. When these secretions are unhealthy, in consequence of disease of the secreting organs, they are often highly flatulent. It is, moreover, pro