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CHAPTER VII.

Dyspepsia From Congestion.

/the mucous membrane of the stomach is extremely vascular; . the minute blood vessels form a series of beautiful plexuses, which are arranged not only around the minute crysts from which the gastric juice is poured, but throughout the whole substance of the membrane. These vessels are received by the smaller coronary veins of the stomach, and then reach the vena porta?. The large venous sinus, the vena portae, passes to the liver, and then reaches the right side of the heart; here it meets with blood from other parts of the body, before it is propelled by the force of the right ventricle to be aerated and oxygenated in the lungs. If any obstruction take place in the heart, the lungs, or the liver, the onward course of the blood is stayed, and passive distension of the extreme veins which first receive the blood takes place. If the obstruction be in the liver, then the branches of the vena portae at once are overfilled, and passive venous engorgement is the result; but if the impediment be disease in the lungs, then the same congestion takes place by successive steps, first the lungs, then the right side of the heart, then the liver, and, lastly, the branches of the stomach and other parts. Should valvular disease on the left side of the heart be the cause, it leads to the same sequence, and congestion of a similar kind follows. In each case the veins and capillaries of the stomach become filled, and at length distended, even to the rupturing of their coats and the extravasation of blood. The minute capillaries form circular plexuses around the crysts of the mucous membrane, and are found with beautiful distinctness after continued distension. It must also be remembered, that this congestion is of a passive venous kind, and very different in its appearance and in its effects from the congestion produced by active hyperaemia of irritation or inflammation. In the former it is the veins, in the latter the arteries which are filled; in the one, the redness is of a duller colour and diffused; in the other, it is of a brighter colour and in arborescent patches.

Although it is essential for the right action ot tne gastric glands, and for the secretion from the mucous membrane, that there should be a proper supply of blood, still, whenever the blood is delayed in its course, or congestion arises from irritation, the secretions are changed; and as a necessary result of this venous congestion, the mucus is secreted in excess, and covers over the whole membrane as a tenacious layer. The mucus is sometimes found to be alkaline in its reaction, is with difficulty washed off by water, and consists of mucous corpuscles, nuclei, and epithelium. When in this state aliment is introduced, it is enveloped in mucus, and solution by the gastric juice is retarded. The mucus secreted in such excess readily undergoes chemical change, and gaseous formation arises and also flatulent distension.

The action of the glands or follicles which secrete gastric juice is lessened by the venous congestion, and that fluid is insufficient for the solution of large quantities of nitrogenous food.

Another result of the long-continued congestion is that serous transudation takes place into the substance of the membrane, and all the coats appear thickened and cedeinatous, and the surface granular; not only the mucous membrane, but the submucous and subperitoneal cellular tissue, become thus affected. This condition arises in great measure from serous transudation; but, if the capillaries give way, as is not unfrequently the case, extravasation of blood results. If the extravasation be still limited by the basement membrane, points of ecchymosis are observed; but if, on the contrary, this bounding membrane also give way, the blood is effused into the stomach, it becomes mixed with the mucus, and is passed into the intestine or rejected by vomiting. The action of the gastric juice upon this effused blood produces change in the colour, so that it would be scarcely known as blood;

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when small in quantity it assumes the appearance of coffee-grounds; if the quantity be great, it is darkened and coagulated; and if it pass downwards the colour is still more deepened, and the appearance becomes that of fluid pitch.

I The points of extravasation may be preceded or followed by superficial ulceration, and several of such minute ulcers may be found upon the surface of the stomach, as "hemorrhagic erosions." The thickened mucous membrane becomes discoloured from the deposition of pigmental granules consequent on the long continued congestion; the follicles of the stomach are Vbund very distinct, and filled with nuclei and cells; and this state has been well designated " chronic catarrh."

The symptoms produced by the state just described, and which might be designated as constituting dyspepsia from passive venous congestion, are characteristic; but they are always associated with other symptoms produced by the primary and the more important disease, whether that be of the heart, or of the lungs, or bronchi, or, lastly, chronic disease of the liver; each of these have their own symptoms, but in all, digestion is interfered with in a similar manner. The appetite is diminished, and if solid food, especially of a nitrogenous kind, be taken, pain is experienced at the scrobiculus cordis, with a sense of weight and oppression; in fact, the substance is so covered with mucus, that it is very imperfectly acted upon by the gastric juice; vomiting is occasionally produced, and if the food pass into the duodenum and intestine, colic also follows. Flatulent distension results from the imperfect 'solution of the food, and from chemical changes both in it and in the mucus; this distension increases the pain, which extends to the back, and if the affection be cardiac or pulmonary, the pressure upon the diaphragm still further distresses the patient by increasing the dyspnoea. The tongue is generally furred, and, although pain in the back is present, it is much less severe than in many other forms of gastric disorder. This kind of flatulent distension becomes exceedingly distressing, so that scarcely any food can be taken with comfort, and nearly every solid form of it is discarded; an attack of hasmatemesis, or of bleeding from haemorrhoids, &c., may remove the congestion, and afford comfort to the patient, but the symptoms are very quickly reproduced. The dyspnoea and palpitation of heart disease, the cough and gasping for breath of chronic bronchitis, engage the attention of the patient, and obscure the less urgent symptoms of disease of the alimentary canal; it is when the former have been relieved that attention is directed to the abdominal complication.

The diagnosis of this state is free from difficulty; but there are two dangers to be guarded against. 1st. That in our consideration of the primary and the more important malady, this complication be so overlooked,

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