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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.

1 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 "hæmorrhagic 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 found 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 hæmatemesis, or of bleeding from hæmorrhoids, &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,

that those means which would relieve much secondary distress are not used; or, 2ndly, the primary disease may have become so quiescent that this secondary one may be regarded as the only source of disease.

As to the prognosis, it must entirely depend upon the original malady; when that can be relieved, and the congestion diminished, the gastric symptoms are alleviated. Too often the disease is ultimately fatal; but a great deal may be done to remove the distressing symptoms, and to prolong life for many years.

In the treatment we have three means at our disposal:

1st. To attempt the relief of the congestion, 2nd. To remove the excessive mucus, and,

3rd. To regulate the diet, so that the stomach may not be unnecessarily taxed beyond its capabilities.

Some appear to consider, that because the disease cannot be cured, therefore nothing can be done; this is both untrue and unwise, as well as unjust to the suffering patient; much may be done, and great relief afforded.

To relieve the congestion the bowels should be well acted upon, and to effect this various remedies may be employed.

Purgative enema serve, not only to empty the bowels, but to relieve the portal congestion secondarily through the inferior mesenteric veins. Salt, soap, castor oil, colocynth, turpentine may thus be used; more fre

quently purgatives will be resorted to as less trying to the patient. Extract of colocynth with henbane, rhubarb pill with henbane, jalap and scammony, are useful aperients; but a free mercurial purge, whether of blue pill, calomel, black oxide, or grey powder, are more effective, and often afford great relief, not only by unloading the bowels and thus diminishing congestion, but by stimulating all the abdominal glands to greater activity. The Podophyllin resin also may be advantageously used with the extract of henbane. Saline purgatives diminish the portal congestion, and in this way the sulphate of magnesia is often of service. Croton oil and elaterium are rarely called for in these cases.

The second object of treatment is to remove the excessive mucus; and although this might be effectually done by vomiting, having previously distended the stomach by large draughts of warm water, still in cardiac disease this would not be an advisable remedy, and in severe chest complaint would greatly distress the patient. Purgatives in their action serve to clear away large quantities of mucus; but this may also be promoted by mineral acids, either the nitro-hydrochloric in combination, or alone. These acids may be combined with purgatives, as for instance, with the compound gentian mixture of the London Pharmacopeia. The saline mineral waters of Cheltenham, Leamington,

arlsbad, Vichy, &c., cautiously given, greatly mitigate

some of the symptoms to which referénce has been made; and if general anemia exist with this local congestion, the saline chalybeates may be tried, as Tunbridge Wells, some of the Harrowgate and Buxton Springs, the Brighton Spa, or Schwalbach, Franzensbad.

The third object of treatment is to regulate the diet. Solid nitrogenous food requires the complete action of the stomach; and in most of these instances, if the symptoms be severe, it cannot be borne. Soups, and the forms of nitrogenous diet most easy of digestion, may be tried; but generally bland farinaceous food best suits the patient. Milk cannot always be taken, for it often coagulates, and a caseous semi-digested mass produces pain and flatulence. Eggs are more easily digested. As to stimulants of an alcoholic kind, caution is required; malt liquors are generally injurious, they will increase the flatulence and distress; so also sweet and effervescent wines; the astringency of port wine contra-indicates its use also, and if any wine must be given, dry sherry, claret, or burgundy are the best. Brandy and other ardent spirits, although they give temporary relief by stimulating the stomach and relieving the flatulence, do not lessen the portal congestion, and are therefore only a partial benefit; still in some cases they are absolutely necessary.

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