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or villosities of the mucous membrane, appear occasionally to be somewhat enlarged. In a few cases, large patches of curd-like exudation adhere to the mucous membrane;-in others, the follicles of the stomach are morbidly developed, forming a number of small, rounded granulations, of a white color, terminating in a black point; or the mucous membrane may be the seat of aphthous ulcerations, or of ulceration extending through the inner and middle coats.

When the inflammation of the stomach terminates in gangrene, which is of exceedingly rare occurrence (we have never met with a single case), sloughs of various extent, implicating the whole of the coats of the stomach, occur, which, on becoming detached, give rise to perforations; or the mucous membrane alone may be reduced to a gangrenous condition.

In cases of gelatinous softening of the stomach, the mucous membrane alone may be found reduced to a jelly-like consistence; or the softening may extend to all the tissues of the stomach, rendering them liable to be perforated by the slightest force; or a complete perforation of the coats of the stomach may have occurred. All these conditions may exist in the same stomach at different points. These softenings, or perforations, occur especially at the great curvature, seldom extending beyond the most depending parts. Some observers, however, describe the softening as involving, occasionally, the greater part of the mucous membrane. Distinct traces of inflammation are frequently observed surrounding the softened parts. The parietes of the stomach often present a serous infiltration.

Rilliet and Barthez describe the softening as being, in some cases, to such an extent that by the slightest scraping the mucous membrane is reduced to a soft amorphous mass, leaving bare the submucous tissue. This degree of softening occurs only in very severe cases, and coincides almost always with a decided uniform redness of the stomach. In the ordinary run of cases, the mucous membrane, which still preserves a certain degree of consistence, gives way upon the slightest scratching, and is thus easily removed. (Maladies des Enfans, tome 1', 444.)

Many pathologists have denied the connection, in any instance, of softening of the stomach with inflammation, and maintain that, in almost every case, it is a cadaveric phenomenon, resulting from the action of the gastric juice upon the tissues of the organ. Others, with Jaeger, Zeller, and Camerer, refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric fluid, by which the stomach is dissolved during the lifetime of the patient. A somewhat similar opinion is entertained by Laisné, Chaussier, Desbarreaux, Bernard, and others.

Dr. Messner gives a table of one hundred and seventeen cases, in which softening, either of the stomach, oesophagus or intestines, or of the lungs, or hemorrhagic erosion of the gastric mucous membrane existed. From the facts developed by these he arrives at the following conclusions: "The so called softening of the alimentary canal and lungs is a result of the fermentative action which occurs primarily in cholera, and secondarily in the other affections of chil

dren. Softening can invade the mucous membrane during life; perforation of all the coats occurs first after death. It is rarely an object of diagnosis, never one of therapeutics."

Herrich and Popp (Der Plötzlichen Tod.) give a table of one hundred and four cases, in which softening of the stomach was discovered after death, under various morbid conditions and in various ages. In no one of which cases were symptoms observed that would have enabled any one to declare during the lifetime of the patient, that softening would be found upon a post-mortem examination.

Without denying that the stomach may be dissolved after death, in consequence of the generation in its cavity of an acid, and being well aware that a softening of the tissues of the stomach, and of other parts of the alimentary canal, may be produced by causes affecting the nutrition, and impairing the cohesion of the various tissues, altogether independent of inflammation, we are still convinced, from the result of our own observations, that the gelatinous softenings frequently observed in children who have died of acute gastritis, is invariably the effect of intense inflammation of the mucous and other tissues of the stomach.

Increased redness and softening of the gastric mucous membrane, remark Rilliet and Barthez, when they occur together, are sufficient indications of inflammation, of the existence of which there can be no doubt, when to these is added a thickening of the mucous membrane. In general, the thickened parts project slightly above the healthy portions of the membrane, but without its limits being marked by a decided boundary. The thickening often occupies several very small portions of the membrane, very near to each other. It may be described as a swelling of the villi, rendering them projecting, firm, and enlarged. The surface of the mucous mem brane is, in consequence, rendered rough or granulated, like chagrin. This appearance coincides most frequently with a more general thickening of the mucous membrane, and indicates a violent inflam

mation.

The subjacent tissues of the stomach are not involved in the thickening. Under certain circumstances, however, particularly when the inflammation is of a chronic character, the submucous tissue becomes somewhat hypertrophied, fibrous, hard, and resistant, the part feels heavy, and as if its substance were increased.

The treatment of gastritis is that proper in cases of inflammation generally, modified somewhat by the seat of the disease, and by the age of the patient. Leeches should be applied to the epigastrium, in numbers proportionate to the violence of the symptoms; and if the attack be one of considerable intensity, occurring in a robust and plethoric child, and not too young to permit a vein to be opened in the arm, general bloodletting will be found of advantage. The necessity for a repetition of the leeches will depend upon the particular character of the attack, and the effects produced by the first application. Should the tenderness and heat of the epigastrium continue with little abatement, after the first application of the leeches, it will be proper to renew them. In general, however, a

less number will be required than at first. The leeches should be followed by warm fomentations, or by a soft emollient cataplasm over the epigastrium-the fomentations and cataplasm being renewed at short intervals. The occasional use of pediluvia of warm water, with the addition of a small quantity of mustard, will, in general, be productive of good effects, and should not be neglected.

The diet and drink of the child should be composed exclusively of some simple mucilage, as gum-water, or water in which the pith of sassafras or the bark of the slippery elm has been infused. These should be given cold, and in small portions at a time. The occasional administration of a spoonful of cold water, we have found to be peculiarly grateful to the patient, and often to remain upon the stomach, when everything else is instantly rejected. It is hardly necessary to say, that if the child is at the breast, it should not be allowed to suck so long as the inflammation of the stomach continues, excepting at long intervals, and for a very short period each time.

A considerable difference of opinion exists, as to the propriety of administering remedies internally, in this disease. Some proscribe them entirely, trusting the cure of the inflammation exclusively to external means; others, again, think it very necessary to administer, in the early stage of the attack, some mild purgative, especially if a costive state of the bowels exists.

We have been in the habit, immediately after the application of leeches to the epigastrium, or the employment of general bleeding, when this has been indicated and admissible, to administer to the patient calomel in small doses, repeated at short intervals-say from a sixth to one half of a grain every one or two hours. This we have known, very generally, to suspend promptly the irritability of the stomach, and to produce a favorable change in the symptoms generally. In cases attended with frequent thin, acid evacuations from the bowels, the calomel we have found to arrest the diarrhoea, and render the stools of a more consistent and natural appearance. We ordinarily combine with each dose of the calomel a grain or two of calcined magnesia, and give it mixed in a little mucilage. Where there exists a very great irritability of the stomach we direct the calomel, combined with a few grains of powdered gum acacia, to be placed dry upon the tongue, the child being shortly afterwards given. to drink a spoonful of thin mucilage.

After the inflammation of the stomach is somewhat reduced, a blister to the epigastrium will often be found of essential service; when too early applied, blisters, however, have appeared to us to do more harm than good. The blister should be kept on only sufficiently long to produce a redness of the skin, and then removed, and the epigastrium covered with a common bread-and-milk poultice. In young children great inconvenience, and often severe and protracted suffering have been the result of a blister being allowed to remain on until vesication occurs.

Inflammation of the stomach in its acute form is often attended with a condition of the pulse and surface, and a degree of extreme prostration, which have induced the inexperienced practitioner to

suppose that some remedy adapted to support the strength of the patient was demanded; in every instance, however, its use will be found to aggravate the symptoms, and hurry on a fatal result. In cases of extreme prostration, with a cool skin, and small thready pulse, we have repeatedly seen the most beneficial results, from the use of the warm bath, repeated daily-in some instances, night and morning.

The chronic form of gastritis is to be treated by a mild, unirritating diet, of some farinaceous preparation, with milk, by the warm bath and blisters to the epigastrium, frequently repeated. In this form of the disease, we have derived great advantage from small doses of calomel, combined with ipecacuanha and extract of hyoscyamus.

R.-Calomel. gr. iij.—iv.

Magnes. calc. gr. xxxvj.
Ipecacuanhæ, gr. ij.—iij.

Ext. hyoscyami, gr. iv.—vj.-M. f. chart. No. xij.
One to be given every three hours.

If a frequent and troublesome diarrhoea is present, from half a grain to a grain of acetate of lead may be added to each dose.

In the form of the disease attended with gelatinous softening of the stomach-the occurrence of which may be suspected, from the severity of the symptoms at the very commencement of the attack; from the yellowish or greenish matters ejected from the stomach and bowels, the latter particularly being often extremely acid; from the coldness of the extremities, the habitual expression of suffering which the countenance of the patient assumes, and the general state of prostration that early ensues-the most energetic treatment is demanded, from the very onset of the disease. The remedies differ in nothing from those proper in other cases of acute gastritis. The early and judicious abstraction of blood from the arm, or by leeches, to an extent commensurate with the violence of the disease, and the age of the patient, will often promptly abate the intensity of the inflammation, and prevent the occurrence of disorganization of the stomach or limit its extent.

When there is repeated vomiting, or copious diarrhoea, and a rapid depression of the powers of life-we have every reason to fear a gelatiniform softening of the stomach.-In such cases, Rilliet and Barthez recommend the administration of the gummy extract of opium either in a pill or dissolved in water, one centigramme being given every two hours, until three centigrammes (not quite half a grain) shall be taken during the day. When no accident results, and the age of the child will permit of it, they give the opium every hour in the same dose, stopping when five centigrammes (rather more than three-quarters of a grain) have been taken. When any obstacle exists to the administration of the remedy by the mouth, they recommend to sprinkle, twice a day, over a small blistered surface upon the epigastrium, half a centigramme (about one-twelfth of a grain) of the hydrochlorate of morphia.

It is hardly necessary to say, that the hydrochloride of iron, recommended by Pommer, Hergt, and others in gelatinous softening

of the stomach, is not adapted to the softening from acute gastritis. The cases in which it is reported to have been employed with ad vantage, were evidently those from defective or disturbed nutrition, unattended with inflammation.

The utmost attention should be paid to the diet and regimen of the patient, for a long period after his recovery from an attack of gastritis, as the disease is one very liable to relapse from slight causes, but particularly from errors in diet. The food should consist, if not of the breast-milk of the mother or a healthy nurse, chiefly of milk and farinaceous articles in moderate quantities. Gentle exercise, at first of a passive kind, should be taken daily, when the weather is fine, in the open air. The daily use of the warm bath should not be neglected. The surface should be preserved of a comfortable and equal temperature, by appropriate clothing, and by rooms properly warmed and ventilated in cold weather, and cooled by the admission of a current of air, and the exclusion of the sun's rays, during the heat of summer.

We have said nothing of the treatment of gastritis from the accidental ingestion of poisonous substances into the stomach, which occasionally happens during infancy and childhood. With the exception of the administration of such articles as have been found to suspend the action of, or to neutralize whatever poison has been taken, the same remedies precisely are demanded, as in the cases of ordinary gastritis.

CHAPTER V.

DISEASES OF THE INTESTINES.

1.-Enteralgia.-Colic.

INTENSE pain of the bowels is of frequent occurrence during infancy. We have already noticed its connection with indigestion, and the means best adapted for its relief, in such cases. Enteralgia, however, often occurs during infancy, under circumstances where we have no reason to suspect, as its cause, any disturbance of the digestive function from the bad quality or undue quantity of the food. We have known it to occur daily, during the first month or two of life, and nearly at the same period of the day-generally towards the latter part of the afternoon. According to Dewees, it generally occurs between four and six o'clock P. M.; others have noticed its occurrence at a regular period, in the morning or fore

noon.

In most cases, this species of colic is attended with the formation. of gas within the intestines, causing occasionally a very considerable tumid and tympanitic condition of the abdomen. In other cases, however, little or no flatulence is perceptible, the paroxysms of pain

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