is to be diminished by sedative remedies, and, perhaps, if the patient be plethoric, in some cases, by small abstractions of blood. It is highly important not to impoverish the blood, and anæmia, if it exist, calls for the treatment appropriate to that condition. Pain and other incidental symptoms are to be palliated by appropriate remedies.

It is well to bear in mind that the progress of the aneurism is retarded by the deposit of successive layers of fibrin within the aneurismal sac. It is in this mode that a cure is sometimes effected. It is desirable, therefore, that the blood should be rich in fibrin, and it is probable that the deposit is more likely to take place in proportion as the action of the heart is slow. Remedies which reduce somewhat the frequency of the heart's action may in this way be useful.

If spasm of the glottis be induced through the recurrent laryngeal nerve, to such an extent as to endanger life, laryngotomy is warrantable, if not advisable, with a view to palliation and the prolongation of life. operation will, of course, be of no avail if the obstruction be due to pressure of the aneurismal tumor upon the trachea.

SECTION THIRD.

DISEASES AFFECTING THE DIGESTIVE SYSTEM.

CHAPTER I.

Introductory Remarks-Sporadic Dysentery-Anatomical Characters-Clinical HistoryPathological Character-Causation-Diagnosis-Prognosis-Treatment—Epidemic Dysentery-Chronic Dysentery-Inflammation of the Cæcum-Perforation-Painful Tumor near the Cæcum.

THE important organs composing the digestive system, are, the mouth with the parotid, submaxillary, and sublingual glands, the pharynx and œsophagus, the stomach and duodenum, the small and large intestine with the mesenteric glands, and the collatitious abdominal viscera, viz., the liver, pancreas, and spleen. Affections of the two outlets of the alimentary canal, viz., the mouth, pharynx, and oesophagus, with the appended glands, and the rectum and anus, properly belong to the department of surgery, being either open to view or accessible by manual exploration, and often requiring surgical operations. These affections, for the most part, will not be considered in this work. This section will, therefore, be devoted mainly to the diseases affecting the hollow viscera and the solid organs within the abdomen. The affections of the digestive system, as of other anatomical systems, consist of, first, inflammations; second, structural lesions; and third, functional disorders. The inflammatory affections of the hollow viscera will be first considered. Inflammation affecting these viscera may be seated in the mucous membrane lining the alimentary canal, or in the investing serous membrane, the peritoneum. Inflammation seated in the mucous membrane is generally limited to a certain section of the alimentary canal, viz., the portion lining either the stomach and duodenum, the small intestine, exclusive of the duodenum, or more or less of the large intestine. This rule will also be found to apply to functional disorders, that is, the sections just named are apt to be disordered separately. Inflammation affecting these sections gives rise to separate diseases. I shall proceed to consider inflammation of the large intestine, constituting the affection commonly known as dysentery. Inflammation, in this situation, may be either acute, subacute, or chronic. Chronic dysentery will claim consideration under a distinct head. A capital distinction relates to dysentery occurring as a sporadic and as an epidemic affection. Sporadic and epidemic dysentery will claim separate consideration.

SPORADIC DYSENTERY.

The term dysentery has long been in use to designate inflammation of the large intestine, attended with mucous and bloody dejections. As a name for the disease, the term is not very distinctive, its etymology simply expressing

intestinal difficulty; but it is not easy to substitute a term conformable to the nomenclature of inflammatory affections, since there is no anatomical name for the large intestine as a whole. The term colonitis, or colitis, is sometimes used in the place of dysentery, but this implies that the inflammation is limited to the colon, whereas the rectum is generally, if not always, involved, and, in fact, in some cases of dysentery the affection may not extend above the rectum. The term dysentery has the recommendation of not expressing anything erroneous or doubtful in regard to the pathological character of the disease. Sporadic dysentery is presented in practice as an acute and a subacute affection; that is, the local and general symptoms frequently denote more or less gravity of disease, compelling the patient to keep the bed, and in some cases, it is an extremely mild and almost trivial affection. Different cases of the sporadic form present every gradation as regards severity, and there are few diseases in the nosology which offer a wider contrast than the mildest cases of sporadic, and the gravest cases of epidemic dysentery.

ANATOMICAL CHARACTERS.-In subacute or mild cases, the inflammation has but little intensity, and may be limited in extent, being confined perhaps to the rectum. As in these cases the disease involves no danger, the oppor tunity of inspecting the parts after death is not offered. The mildness of the symptoms and the short career of the disease suffice to show that ulcerations or other lesions of importance do not take place in these cases. In acute or severe cases, the inflammation is not only more intense, but more extensive, involving, not only the rectum, but the greater part or the whole of the colon. These cases are liable to end fatally, and the affected membrane is found, on examination after death, to be reddened from active congestion, swollen, softened, pulpy, presenting, in different cases, ecchymoses, excoriations from desquamation of the epithelium, abrasion, and ulcerations in greater or less number, which are sometimes small and sometimes of considerable size. The ulcers may or may not be seated in the intestinal glands and follicles. The redness and swelling are frequently not uniform over the extent of intestine affected, but are either limited to, or more marked in certain portions, more especially the projecting folds of the membrane. Small vesicles are sometimes observed. The swelling of the membrane is due, in part, to submucous infiltration, and the latter is sometimes so great, at certain points, as to give rise to protuberances resembling warty growths or fungoid excrescences. These protuberances may be more or less numerous, and sometimes coalescing, giving to the surface a lobulated aspect. Patches of exuded fibrin are frequently adherent to the inflamed membrane, presenting a greenish or brownish color. The intestine contains more or less of morbid matter corresponding to the dejections during life, consisting of mucus, pus, fibrinous flakes, desquamated epithelium, and sero-sanguinolent liquid. The intestine may present a dark and almost black appearance, from congestion, but sphacelation, beyond the circumscribed sloughing which precedes ulcerations, is rare. As a rule, the appearances denote progressively a greater amount of disease in passing from the upper part of the large intestine downward to the anus, the greatest amount being at the rectum aud sigmoid flexure. There has been much discussion whether the morbid appearances in dysentery denote ordinary inflammation varying in different cases in intensity, or whether they are due to a peculiar morbid process; also whether the intestinal glands and follicles are generally and primarily involved. It does not fall within the scope of this work to consider the morbid anatomy with reference to these points of inquiry.

The mesenteric glands are sometimes found to be considerably enlarged, and in some instances contain pus.

CLINICAL HISTORY.-The disease is generally ushered in with an ordinary diarrhoea; that is, with more or less frequent dejections of a feculent character. Of thirty-three recorded cases which I have analyzed with reference to this point, these dejections preceded the characteristic dysenteric evacuations in thirty. The latter appeared after the former had existed for a period varying from twenty-four hours to seven days.1

The characteristic evacuations consist of mucus, with which more or less blood is usually commingled. The quantity passed at each act of defecation. is generally small, but the act is frequently repeated, slight evacuations often taking place every hour or two, and sometimes after intervals of a few moments only. The quantity of mucus expelled in some cases is abundant, and forms a jelly-like mass, not unlike a collection of the rusty sputa of pneumonitis. The popular term applied to the matter of these evacuations is slime, and by those who are familiar with the preparation of intestines for sausages, they are often compared to the "scrapings of hogs' guts." Rarely in sporadic, but not infrequently in epidemic dysentery, the evacuations contain fibrinous laminæ or flakes in greater or less quantity. A serosanguinolent liquid, either small in quantity or abundant, also occurs occasionally in sporadic, but much oftener in cases of epidemic dysentery. The latter has been compared to water in which meat has been washed, and was called by the older writers lotura carnium. Most of the evacuations are exclusively dysenteric, that is, consisting of mucus, epithelium, lymph, and blood, but with some of the evacuations fecal matter is discharged. Frequently this presents a green color. Occasionally round hardened lumps of feces are expelled; these are called scybala. The amount of morbid matter evacuated, together with the absence of fecal matter, constitutes, measurably, a criterion of the extent of intestinal surface affected. In the course of the disease, the evacuations may contain more or less purulent matter, but this belongs more especially to chronic dysentery. In lieu of the fecal odor, they frequently emit a putrid fetor.

The inflammation of the rectum occasions a sensation as if this portion of the bowel were filled, and leads to the frequent desire to defecate, with as much straining as the soreness of the parts will allow. This desire to strain ineffectually is called tenesmus. Sometimes the straining efforts produce prolapsus of the intestine. The evacuations are frequently preceded by griping or colic pains which have been called tormina. The tormina and tenesmus are not proportionate to the gravity of the disease; they are sometimes wanting in fatal cases, and are prominent symptoms in some mild cases. They are, however, the chief sources of suffering. Tenderness on pressure is in some cases more or less marked over the descending colon, and sometimes over the whole tract of the large intestine. It is rarely great, and not infrequently wanting. Meteorism or tympanitic distension is rarely present; the abdomen is usually depressed. Strangury and retention of urine are occasional symptoms, and, in the female, leucorrhoea may be produced.

The pulse, in the majority of cases, is but little, and sometimes not at all, accelerated. Exceptionally, high febrile movement exists; this is in robust persons, the inflammation being more intense and diffused than usual. Great frequency of the pulse always denotes gravity and danger, but the converse does not hold good; in some fatal cases the pulse is never much accelerated. The skin is generally either cool or moderately hot, but, exceptionally, with high febrile movement, there is much heat of the surface.

* Clinical Report on Dysentery, based on an analysis of forty-nine cases, by the author. 1853.