form of diet is retained with difficulty. An affection of the mucous membrane alone is not productive of the intense suffering so frequently observed in chronic ulcer of the stomach, and in other organic diseases. It is only when the deeper tissues are involved by the extension of disease to the muscular coat, or when distension of the viscus occurs, that pain in its severity is experienced. An exceptional instance must, however, be adduced when the mucous membrane in the immediate neighbourhood of the pyloric valve is especially affected, but whether this unusual sensibility is due to spasmodic contraction of the valve is doubtful: many of these patients describe the pain as being worst at the close of the digestive process, and characterise it as the passing of food "over a raw surface" at the site of the valve. The vomiting in ulceration of the stomach is preceded by pain, the patient often stating that the pain persists till the food is either rejected or has passed onwards; not so, however, in inflammatory dyspepsia, the stomach rejects its contents almost at once, but unless the vomiting be very persistent, little complaint is made.

3. The desire for cold drinks is usually present in the dyspepsia under our consideration; and ice, or cold water, are exceedingly refreshing to the patient, and easily tolerated by the stomach.

As to other symptoms, the tongue is generally injected at its tip and edges; it is covered with an abundant yellowish-white fur, and the papillæ appear

L

as distinct red points on its surface; it does not present the large and indented appearance noticed in atonic states of the primæ viæ.

Headache, mental depression, lassitude, disturbance of vision and ringing noise in the ears, are often complained of. The countenance is expressive of anxiety, the eyes are sunken, the skin is slightly sallow, dry, and often parched, there is occasional febrile disturbance, with a burning sensation at the palms of the hands and soles of the feet. A short dry cough is a frequent symptom, the pulse is irritable and compressible, and the bowels are generally confined, although when the erythematous condition of the stomach passes downwards into the intestine, constituting gastro-enterite, diarrhoea is set up. The urine is high coloured, and urea is generally in excess; it deposits lithates freely, or with nitric acid it assumes a deep colour. It is very important to distinguish this form of dyspepsia from those previously noticed: the first atonic, from an atheromatous condition of the vessels, from an exhausted cerebro-spinal system of nerves, or from a like state of the vaso-motor; the second from passive venous congestion occurring as a sequence of disease of the liver, lungs, or heart; but this is of a more acute kind, and is generally produced by indiscretion in diet or excess, or by the immoderate use of wine or ardent spirits.

There are three forms of inflammatory dyspepsia deserving of separate description and notice; the first

is that which we find in children after sudden changes of food, or after an unsuitable diet; the symptoms are characteristic and sometimes alarming, not only in their primary, but in their secondary effects. The disturbance produced during weaning might be adduced as exemplifying this condition, and so also that set up by hard and indigestible diet or by stimulants; a state of peevish excitement is induced, especially at night, with headache, and often with more or less delirium, the child becomes fretful, its natural appetite is gone, and it craves for improper substances or for cold water; the skin is hot with remissions, so that the state has sometimes been termed gastric remittent fever, the tongue is white and injected at the tip and edges, or with distinct papillæ. The bowels are loose, and the abdomen is enlarged. In many cases the irritability of the stomach is excessive, and the blandest nourishment is rejected, and if associated with diarrhoea, rapid prostration of strength ensues, a haggard wasted appearance is presented, and the little countenance has the painful expression of old age in miniature. In some cases improper diet induces severe colic with prostration and collapse; thus the coagulation of milk in the stomach and intestines has led to exhaustion so speedily, that the effects have been attributed to poison.

Minute points of ulceration have sometimes been detected on the post-mortem examination of the stomach

of children thus affected with acute gastric symptoms; these ulcers have been called "follicular;" they vary in size from one-sixteenth to one-fourth of an inch, and sometimes stud the whole surface, being not limited to the lesser curvature alone; they do not extend beneath the mucous membrane. They are not confined to children, but have been found where no indication of disease of the stomach had existed, excepting perhaps the vomiting of coffee-ground substance. This form of ulcer is, however, distinct from the superficial or by aphthous ulceration to which reference has been made.

The second form is that in which the stomach is disordered by some accidental indiscretion in diet or by intemperance. There is headache, with vertigo and disturbed vision, sleep is broken, the appetite is taken away, the sight of food is intolerable, but cool drinks are grateful; the tongue is furred, the stomach irritable, and if the vomiting be violent, green bilious fluid is rejected; tenderness at the scrobiculus cordis is also associated with pain at the back, the bowels are irregular, and flatulence distresses the patient. It must not, however, be supposed that every attack of this kind must necessarily be referred to known indiscretion in diet, for the cause may lie in the air we have breathed or the water we have drunk; impurities in the one or the other may induce this inflammatory dyspepsia; a malarious atmosphere, or one charged with impurities from imperfect drainage, have often induced

this condition, and not less frequently, organic impurities

in water.

A third form of inflammatory dyspepsia is the result of long-continued excess in food or in stimulants. The countenance assumes a peculiar restlessness, the pupil of the eye is contracted and the conjunctiva suffused; the sleep is disturbed by dreams or entirely taken away, or it is short and broken and without refreshment; the cheeks are irregularly flushed, and their capillaries often peculiarly distinct; the tongue is furred, or unnaturally red, sometimes like raw beef, or it has red patches upon it as if deprived of epithelium, and the patient complains of offensive taste in the mouth; the appetite also is depraved or destroyed, and highly seasoned dishes are longed for; the bowels are variable, and sometimes hæmorrhoids distress the patient; the urine is scanty and high coloured, and deposits an abundance of lithates or of uric acid, and in some cases it becomes highly albuminous; there is also flatulence, spasmodic pain or "cramp" in the abdomen; to these symptoms is added a sense of weakness and exhaustion, which the patient seeks to remedy by fresh potions of stimulants, until the stomach becomes so irritable, that everything is rejected; tenderness also comes on at the scrobiculus cordis, with pain across the chest or in the back; these patients are generally hypochondriacal, and often believe themselves to be the subjects of serious disease of the liver. With other disturbances of