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milder preparations of iron should be tried, the ammonio-citrate, potash-tartrate, the phosphate, or the reduced iron.

Quinine often disagrees, and if the tongue be injected, the medicine is likely to cause sickness, headache, and increased distress; the liquor cinchona is a more elegant and less bulky preparation than the decoction, and it is often borne better than quinine itself.

There is a remedy, which I have found of great service, namely, nux vomica and its alkaloid strychnia ; as a tonic, it proves beneficial, especially in promoting the contraction of involuntary muscular fibre, thus relieving flatulent distension and constipation; but it requires a careful administration, as it will sometimes produce a sense of most distressing faintness and exhaustion, even when given in small doses.

Pepsin is an artificial substitute for the normal solvent of the food; it was proposed by M. Corvisart, and introduced into English practice by Dr. Ballard. It has been employed dried, and mixed with starch constitutes the "Poudre Nutrimentive," and about gr. xv. have been given as a dose, alone, or mixed with hydrochlorate of morphia or with strychnia. The fluid pepsin is, however, more efficacious; still, as an agent in promoting digestion, it is very unsatisfactory in its action; and, it is better to remove the cause of the natural defect, than to supplement the deficiency in a very imperfect manner.

Stimulants are of great value in this form of dyspepsia, but should only be used with nourishment, or to enable the stomach to perform its normal function ; strong alcoholic liquors taken in excess during digestion, retard the solution of food; and most injurious results may follow, if the transient stimulant of wine or ardent spirits be made to supply the place of nutriment, and be habitually resorted to, as a remedy for the sensation of weakness and exhaustion.

Ipecacuanha, perhaps, increases the secretion of the gastric juice, thus it is often given with capsicum and rhubarb, as a dinner pill, and proves of great service.

The judicious use of stimulants and tonics should only be subservient to the restoration of healthy function, and in proportion as health is restored, these should be discontinued.

K

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 portæ, 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 portæ 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 su

teps, 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 hyperemia 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 of the 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 oedematous, 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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