from the bowels. In case of dropsy, they should be replaced by diuretics.

In all cases of dyspepsia arising from congestive disease of the heart, the use of small doses of digitalis or hydrocyanic acid is advisable, in order to relieve the palpitation and lessen the action of the affected

organ.

It must be remembered that no long-continued course of purgatives or diuretics can be borne; but as soon as the congestion of the portal system is relieved, tonics should be employed, to give strength to the muscular structures both of the heart and digestive organs. If anæmia be present, the use of iron is indicated; but if this is not the case, quinine or other bitters should be employed.

When dropsy has fairly declared itself, the treatment of the dyspepsia is necessarily secondary to the more pressing necessity of relieving the general circulation.

In

In the examinations I have made of the stomachs of those who have died from affections of the aortic valves, I have detected no diseased appearances. one case the gastric cells seemed to be unusually few in number, but the tubes appeared healthy.

In the stomach of a person who had died from ancurism of the aorta I found the arteries very much enlarged and thickened, and in some places the secreting tubes were of small size, and contained chiefly granular matter; but the mucous membrane was in other respects normal. This healthy condition of the glandular structure, associated with thickening and enlargement of the smaller blood-vessels, is interesting, as a similar condition of the arteries of the

THICKENING OF THE ARTERIES OF THE STOMACH. 155

kidney has attracted the attention of pathologists, and been referred by some to the effects of obstructed circulation.

There can be no doubt that, as we have seen in the stomachs of persons affected with congestive diseases of the heart, long-continued pressure will cause thickening and dilatation of the blood-vessels. But, as in the foregoing instance, there was no obstruction to the current of blood, and as there was a diseased condition. of the coats of the main artery of the body and of the smaller arteries of the mucous membrane of the stomach, there was every reason to suppose that the affection of those different parts of the vascular system resulted from a common cause.

CHAPTER VII.

ON THE STATE OF THE STOMACH IN DISEASES OF THE

LIVER.

Ir has been affirmed by many authors that disease of the liver is often occasioned by inflammation of the stomach and duodenum, but I am not aware of any record of microscopical investigations which shows in what proportion these parts of the digestive apparatus are simultaneously affected. The results of the microscopical examination of the stomachs of seven persons who had died of hepatic disease are detailed in my notes, and in all of them the gastric mucous membrane was in an unhealthy condition. In five the gastric tubes were closely united together in the splenic and middle regions. In some parts the glandular structure was in a state of atrophy; in others, although the tubes could be distinguished, the basement membrane was thickened, and there was a great increase in the amount of connective tissue between and below them. The gastric cells were generally fatty, and in some the muscular structure was in a state of fatty degeneration. The veins in all were greatly enlarged, and all the blood-vessels occasionally exhibited the same morbid change as the

CONDITION OF THE STOMACH.

157

muscular layer. The presence of pigment from extravasated blood was also noticed in most of the cases in the mucous membrane.

In the two remaining cases the tubes were readily separable, but the veins were much enlarged. In one, the tubes were distended with fatty cells and granular matter; in the other, in the splenic and middle regions they were unusually empty of secreting cells.

From the above statements it is clear that affections of the liver tend to produce gastritis, even more generally than diseases of the heart. Doubtless this may be partly explained by the fact that the congestion is much greater when the portal circulation is obstructed by hepatic than by heart disease; but we must also remember that in the former life is maintained for a longer period than in the latter, and that most of the causes that produce disease of the liver have a tendency to excite inflammation of the stomach.

It is evident that if the stomach be so greatly affected in liver disease from the congestion of that organ, slighter derangements of the portal circulation will be also sufficient to alter the normal condition of the digestive tube. The increased flow of blood to the mucous membrane accompanying gastritis tends to congest the liver, and this re-acts upon the circulation of the stomach. On this account we rarely meet with a severe case of chronic gastritis which does not, at some period of its course, display indications of portal congestion.

When this complication occurs, the patient complains of a feeling of weight or dull pain in the right hypochondriac region. The conjunctivæ are

slightly yellow, the stools dark, the urine high coloured and loaded with lithates; the tongue is very foul, often red at the tip and edges; the appetite is variable, and flatulence is constant and troublesome. There is drowsiness, especially after food; and in many cases frequent and severe headache.

Sometimes the application of a few leeches to the epigastrium gives great relief; in others the abstraction of blood by the same means from the anus is more efficacious.

Small doses of calomel or blue pill should be given every second or third night, and in young persons, or where there is much tendency to diarrhoea, the hydrargyrum cum cretâ may be substituted. The evacuations should be regularly examined, and as soon as they have regained their natural appearance the mercury should be omitted.

Frictions of iodine ointment to the epigastrium are useful, and care should be taken to maintain the abdomen at an even temperature by means of flannel. A free action of the bowels should be kept up by the use of purgative salts, senna, or rhubarb. As the complaint subsides, alkaline remedies are of use, and may be combined with taraxicum, chirata, or calumba.

The diet should in the more severe cases consist chiefly of farinaceous food, but if the debility of the patient does not permit this, beef-tea may be given. All fat and rich articles of diet should be avoided, and alcoholic stimulants should be prohibited. Nothing is so useful in promoting the circulation of the liver as regular exercise. Riding generally answers best, but in all cases where it is