bable that the chemical changes, which take place when the heterogeneous contents of the small intestines are converted into chyle, are often attended with the production of aëriform substances, even when the processes of digestion and of secretion are perfectly healthy.

There is reason to believe that a direct exhalation of gas often takes place from the mucous membrane. We know that such an exhalation occurs into the cellular tissue, constituting emphysema, and into the various closed serous cavities; and the alternation which has sometimes been observed between emphysema and flatulence of the bowels, leads to the inference, that the latter may be produced in the same manner. (Dict. de Méd., xxi. 132.) The occasional sudden substitution of tympanites for diarrhoea is another evidence of a similar character. But positive proof of the fact is not wanting. Portions of intestine entirely emptied of their contents, and inclosed between two ligatures, have been observed to become distended with gas, especially when inflamed by some stimulant application. (See Am. Journ. of Med. Sci., N. S., iv. 403.) What is the particular pathological condition of the mucous membrane which leads to this result is not known. It seems to be in some measure connected with defective or deranged innervation; for flatulent accumulations in the stomach and bowels, not attributable to any other known cause, are frequent in nervous affections, such as hysteria, hypochondriasis, and strong mental emotion. Some have supposed the globus hystericus to be a sudden distension of portions of the oesophagus by air, confined by spasmodic constrictions above and below it. Cold drinks taken too freely, during a heated state of the body, sometimes produce sudden attacks of flatulence, originating probably in exhalation or secretion. Another cause of flatulence is the habit which some acquire of swallowing air, and which may become a morbid condition, analogous to certain mental perversions ranked under hypochondriasis or monomania.

The form of flatulence denominated meteorism or tympanites, is produced by some cause preventing the discharge of the air contained in the bowels. This cause, whatever it may be, is itself sufficient to occasion the affection, without any unhealthy production or evolution of gas; for the air taken in with the food, and that which, as before stated, is always extricated to some extent in perfect health, must become morbidly accumulated, if any accidental excess of it be prevented from finding an exit. The effect, however, is much greater, when the causes of production or evolution, above enumerated, cooperate with those of detention. Among the latter are debility or atony of the muscular coat, impairing its contractile power; rigidity of the sphincter muscles of the oesophagus, pylorus, and rectum; spasmodic closures of the intestinal tube at other points; fecal accumulations; and mechanical obstructions of all kinds, as by tumours, permanent strictures, and foreign bodies. Tympanites is most commonly an attendant upon other diseases, especially enteric or typhoid fever, peritonitis, malignant dysentery, and the different forms of colic and obstruction of the bowels. In its chronic forms, it is often associated with hypochondriacal, hysterical, and uterine disorder. When dependent upon accumulation of air in the peritoneal cavity, it usually proceeds from perforation of the stomach or bowels, perforation of the diaphragm (Arch. Gén., 4e sér., i. 471), or decomposition of the peritoneal membrane. It may, however, in this, as in other serous cavities, and in the cellular tissue, be the result of a secretory or exhaling process.

Flatulence is most common in infants and young children.

Treatment. The indications are to cause the removal of the air already accumulated, and to prevent its evolution and accumulation in future. The first indication often requires prompt and energetic treatment, in consequence

of the sufferings of the patient. The object may frequently be effected by the use of stimulants calculated to act directly on the alimentary mucous membrane, and thus indirectly to excite the muscular movement. Such are the medicines denominated carminatives. To this set belong most of the aromatics. These may be variously employed, in substance, hot infusion, or tincture; or the volatile oil of the aromatic may be substituted for the medicine; and they may be given separately, or differently combined, to suit the taste of the patient, or the views of the practitioner. Among those most employed are peppermint and spearmint, fennelseed, cardamom, caraway, cinnamon, cloves, allspice, black pepper, ginger, and calamus. Twenty drops of the tincture of oil of peppermint, or oil of spearmint (essence of peppermint or spearmint), dropped on sugar, will often afford prompt relief. Compound spirit of lavender, and compound tincture of cardamom, are agreeable preparations, and may be given in the dose of a fluidrachm. Hot ginger tea will be found especially useful when there are colicky pains. Fennelseed tea, given both by the mouth and by injection, is well adapted to infants. Recourse may also be had to various stimulants, which do not belong to the aromatics. The oil of turpentine is a powerful carminative. Cayenne pepper, oil of juniper, assafetida, camphor, ammonia, and ethereal oil, may also be occasionally used with advantage. Aromatic spirit of ammonia is an excellent preparation, when there is a depressed condition of the system. Assafetida and compound spirit of sulphuric ether (Hoffmann's anodyne) are peculiarly useful when flatulence is complicated with hysteric or other nervous disorder. Prompt relief is often procured, when severe stomachic pain depends on flatulence, from a fluidrachm of camphorated tincture of opium. When the bowels are affected with flatulence, the aromatics may often be advantageously combined with mild cathartics. The free use of lime-water does good in some cases, probably, in part at least, by combining with and neutralizing carbonic acid. Friction over the abdomen, agitation of the bowels by the hand with the body in a bent position so as to relax the ab dominal muscles, jumping, jolting in a rough vehicle, or a ride on horseback, will aid much in the expulsion of the confined air. Compression by a flannel roller or otherwise, stimulating embrocations, and galvanism, have also been recommended. In meteorism or tympanites, injections of oil of turpentine or assafetida should be given, in connexion with other means; and, if the symptoms are severe, attempts should be made to draw off the air by the introduction of a long gum-elastic tube, through the rectum, far into the colon. Life has probably been saved in that way. When the danger is very imminent from the vast distension of the abdomen, and relief caunot be obtained by the ordinary measures, it may become a question, whether it would not be the duty of the practitioner to puncture the cæcum, or other part of the intestinal tube. In cases of excessive tympanites with irremovable obstruction of the bowels, the operation has been occasionally performed, with the effect of affording relief; though the cases afterwards terminated fatally, in consequence of the obstructing disease. (See Am. Journ. of Med. Sci., N. S., xxiv. 543.)

To prevent the morbid collection or evolution of air, it is necessary to remove or obviate the cause. Flatulent food and drink should be avoided, and the diet should be made to conform as nearly as possible to the digestive powers of the patient. Should, however, flatulent substances enter into the diet, their effects may be somewhat corrected by associating them with stimulating condiments, as Cayenne and black pepper and mustard. If the complaint originate in, or be associated with, debility of stomach and bowels, this should be corrected by tonic medicines, and other means indicated under

the head of dyspepsia. Constipation should be obviated by a proper regulation of the diet, and if necessary by laxatives; but, in the choice of means for this purpose, care should be taken to shun those disposed to occasion flatulence. Among the most appropriate are bran bread, as an article of diet, and rhubarb or aloes as a cathartic. Magnesia may be employed in connexion with these, when acid exists in excess in the primæ viæ. Unhealthy secretions into the bowels should be corrected, and the blue pill will often be useful to this effect, by its alterative action on the liver.

When there is reason to believe that the gas proceeds from a secretory or exhaling act of the mucous membrane, tonics and astringents are indicated. An infusion of galls with fennelseed has seemed very useful in my hands, under these circumstances; and I have repeatedly known the affection to yield to the free use of sulphate of quinia. Strychnia or nux vomica has also been recommended. Dr. Graves strongly advocates the use of acetate of lead in tympanites; and Dr. Baddeley, of Chelmsford, has employed both this salt and sulphate of zinc, in conjunction with an opiate, with success in very bad cases. (London Lancet, Jan. 8, 1848, p. 44.) As flatulence is often dependent upon other diseases, care should be taken, in all instances, to discover its source, and apply remedies to this, instead of wasting time in a direct combat with the flatulence itself. Particular attention should be paid to nervous derangements, which frequently occasion or aggravate it.

Great advantage will often be derived from combining, in the same prescription, medicines calculated to meet different indications. Thus sulphate of quinia, as a tonic, may be united in mixture with assafetida and one of the aromatic volatile oils, as carminatives; and such a mixture is often highly useful in the cases of infants subject to flatulence.* Magnesia may be associated, in mixture, with the aromatic oils, camphor water, and a little laudanum when there is pain. Rhubarb or aloes may be given in pill, with quinia or a bitter extract, and with assafetida, black pepper, or a volatile oil. Such combinations may be multiplied indefinitely, and often with great advantage, by a practitioner who possesses an adequate knowledge of medicines, and the modes of preparing them.

Article V.

PERITONEAL INFLAMMATION, or PERITONITIS.

The protection which the peritoneum gives to the alimentary canal is, perhaps, its most important function; and its diseases may, therefore, be very appropriately associated with those of the digestive organs. Inflammation of the peritoneum is susceptible of division into several varieties; but may be most conveniently considered under the two heads of the acute and the chronic.

1. ACUTE PERITONITIS.

Symptoms, Course, &c.—A chill is sometimes the first symptom of peritonitis; but perhaps more frequently the disease begins with pain; and occasionally the occurrence of the two phenomena is simultaneous. The pain is sharp and very severe, and usually commences in the lower part of the abdomen, in the hypogastric or one of the iliac regions, whence it gradually extends over the whole cavity. Sometimes it is changeable, occurring now in

* R.-Quini Sulphat. gr. ij; Assafoetida gr. iv; Acacia pulv., Sacchar., ää, 3ss; Aq. Cinnamom. f3j. Misce. S. A teaspoonful for a child one year old, four times a day.

one spot and then in another; and not unfrequently is attended with a sense of heat or burning. The abdomen is always tender to the touch. The slightest pressure by the hand occasions exquisite pain, and whatever gives rise to contraction of the abdominal muscles has the same effect. Hence, the patient suffers much from vomiting, the act of defecation, the discharge of urine, and straining of all kinds. A deep inspiration is often very painful. Movements of the body in or out of bed are also painful; and even the weight of the bedclothes is often insupportable. Hence, the patient usually lies motionless upon his back, with his knees drawn up, so as at once to relax the abdominal muscles, and take off the weight of the covering. Another object of the supine position appears to be, to obviate in some degree the pressure of the bowels upon the parietal peritoneum. But this posture is not so universal as might be inferred from the description of most medical writers. The author recollects that, in one of the worst cases of peritoneal inflammation he ever witnessed, the favourite position of the patient was upon his left side, with the knees so much drawn up as to be almost in contact with the abdomen. Most frequently the tenderness is general, but in some instances is greatest in particular spots, and in others is confined altogether to one spot; indicating, in the latter case, the local position of the inflammation. From near the commencement, there is generally a feeling of hardness, tension, and elasticity in the abdominal parietes; and very soon a tumefaction begins, which increases with the progress of the complaint, and towards the close assumes the character of tympanites. In some cases, however, there is little swelling; and in others, none at all; the abdomen being sometimes even drawn in by the constriction of the muscles. The swelling is for the most part uniform, but is sometimes irregular, giving to the hand the sensation of a tumour or tumours in the abdomen, which may be either permanent or changeable. Percussion evinces at first a resonance healthy, or greater than that of health; but, as the disease advances, the sound becomes dull, especially in the depending parts. After the complaint has lasted a short time, the abdomen frequently offers, under auscultation, a friction sound, like that observed in pleurisy, and like it arising from the rubbing together, during respiration, of the opposing surfaces of the serous membrane, roughened by the effused coagulable lymph.

Besides the above phenomena, there are many others, either sympathetic, or depending on a direct propagation of the irritation to contiguous parts. Nausea and vomiting, thirst, constipation, and scanty or suppressed urine are very frequent symptoms. The vomiting is sometimes exceedingly distressing. The constipation is obstinate, in those cases in which the muscular coat of the bowels becomes involved in the inflammation; but it is not a constant symp tom, and sometimes gives way to diarrhoea. The face is pale, contracted, and marked by an expression of deep distress and anxiety, characteristic of the disease. The respiration is short. The pulse is usually very frequent, from 110 to 130 or more in a minute, small, and tense; though, in some rare cases, it is full and but little accelerated. The tongue is usually moist, and covered with a whitish or yellowish fur; but sometimes it is red and dry, and some times nearly natural. The patient is very often wakeful. The chill with which the attack commences, or which follows the occurrence of pain, is usu ally succeeded by febrile heat of surface, which, however, soon subsides; and, during the greatest severity of the complaint, the skin is often but little warmer than in health.

The march of peritonitis is in general rapid. In fatal cases, death sometimes occurs within twenty-four hours, and generally in about a week; bat ceca sionally the disease runs on for three or even four weeks. An aggravation

of the pain, tenderness, and other symptoms marks its advance; but, when the fatal termination approaches, the pain often suddenly subsides, or ceases altogether; and this may be considered as one of the most unfavourable signs, when not attended with a marked amelioration of the disease in other respects. At this stage, the pulse is extremely frequent and feeble; the extremities are cold, and sometimes purplish or livid; the countenance is sunken and ghastly; the abdomen is either tympanitic, or soft and flaccid; a troublesome hiccough often occurs; and a green or blackish matter is thrown up from the stomach, rather by regurgitation than vomiting, and sometimes flows from the mouth of the patient without his consciousness. Occasionally the bowels give way, and a similar dark matter is discharged per anum. Coma, or convulsions, or both, sometimes precede the fatal issue.

A favourable termination is indicated by a gradual subsidence of the pain, tenderness, and tension of the abdomen, a cessation of the vomiting, a diminished frequency of pulse, and a less anxious expression of countenance. Occasionally a copious discharge from the skin, bowels, or kidneys, attends the solution of the disease. In some cases, the symptoms entirely disappear, and the recovery is perfect. In others, a greater or less degree of pain and tenderness in the abdomen and frequency of pulse continues long after the danger is over; and sometimes a hard tumour in some part of the cavity remains for a considerable time. Again, the acute may subside into the chronic form of the disease; and the result thus be long postponed, and quite uncertain. In a few cases, the pus poured out by the inflamed membrane, and confined within sacs formed by the organized coagulable lymph, makes its way by ulceration either into some one of the hollow viscera, as the stomach, intestines, or bladder, or to the surface of the body, and is discharged. In some of these cases, recovery takes place, especially when the pus has found an outlet through the skin.

Various modifications of peritonitis as above described occasionally take place, and require notice. Thus, it is sometimes entirely local, affecting some one portion of the peritoneum only; and this is apt to be the case when the disease proceeds from a local cause, such as mechanical violence, or the inflammation of an invested organ. In such cases, it frequently happens that, though the inflammation is not propagated to any great extent continuously, it affects the portion of membrane opposed to, and in contact with that inflamed. The inflammation is thus more likely to be confined to one spot, when a fixed than when a movable organ is affected. Any part of the abdomen, where there is peritoneum, may be the seat of the affection. It is scarcely necessary to say that, in these cases, all the symptoms, both local and constitutional, are less violent than in general peritonitis. The local character of the affection is marked by the limited extent of the pain and tenderness, though it must be confessed that, in some instances, it would be very difficult to establish a certain diagnosis. The symptoms are much modified by the position of the inflamed membrane, and by the organ which it may invest. Thus, when the inflammation occupies the peritoneal covering of the liver, it not unfrequently happens that the skin, eyes, and tongue, are more or less yellow, in consequence of an extension of irritation into the substance of the organ. Great epigastric pain and tenderness, with severe constitutional symptoms, mark the peritoneal inflammation of the stomach; obstinate constipation, with a lower seat of pain, that of the bowels; painful irritation with tenderness in the hypogastric region, and great pain in micturition, that of the bladder. The omentum may be separately inflamed, in which case the pain extends over the front of the abdomen, and effusion into the folds of the membrane may occasion circumscribed swellings, perceptible to the touch, and liable to be