versy, whether the change of structure in these cases be in the mucous membrane itself, or in the subjacent cellular texture. It is a point which it must be next to impossible to decide, and of no practical importance. 2. Diseases of the follicles, or simple glands of the membrane. This subject is involved in much obscurity, but seems to promise some interesting results. The follicles appear to be liable to a vesicular or pustular disease, which passes into small defined distinct ulcers, quite unconnected with any disease of the mucous surface. 3. Disease of a tubercular character is often met with on the mucous membranes. It is probably seated in the follicular or glandular structure, and is most commonly met with in some particular situations, as the cardia, pylorus, and the extremity of the rectum, in which situations it often assumes a scirrhous character. 4. Diseases of the parts concerned in the absorption of the alimentary matter, so that, though elaborated in the usual manner, it passes off without entering the circulation. The cause of this most familiar to us, is disease of the glands of the mesentery; but the same effect appears to result from certain conditions of the surface of the mucous membrane itself. This slight outline of the various morbid conditions, to be considered in regard to the intestinal canal, will serve to show the importance of the subject; and the extent of it will farther appear, when we recollect, that the various diseases are also greatly modified by their seat,-as being in the stomach, the small intestine, or the colon and rectum. Of a subject so extensive, it is but a very imperfect view that can be given in such an essay as the present; but I am anxious that what is given may be correct and authentic, as far as it goes, and that it may be of some use in directing the researches of those who have opportunities of prosecuting the investigation. PATHOLOGY OF THE STOMACH. THERE are few points in medical science which have undergone more discussion than affections of the stomach: and yet, it must be confessed, that when we come to investigate the subject, according to the rules of pathological induction, we find little that is satisfactory. This has in part arisen from numerous difficulties which attend the investigation. Many of the affections of the stomach, though productive of much and protracted discomfort, are not apt to be fatal; and thus few opportunities occur of investigating their pathology, except when the patient dies of another disease. The great proportion of these seem also to be entirely of a functional nature, leaving no morbid appearance that can be discovered after the death of the patient; and, in others, the appearances are of so doubtful a kind, that they do not afford sufficient ground for any precise principle in pathology. In a practical point of view, also, this is perhaps more encumbered with uncertainty than almost any other department of medical practice; for the diseases are so much under the influence of moral and other adventitious causes, that the action of remedies is aided, modified, or counteracted, in a manner which entirely eludes our observation, and is often altogether beyond our control. From these various causes, diseases of the stomach have presented a wide field for speculation, conjecture, and empiricism; a vague and indefinite phraseology has often been allowed to take the place of principles; and the whole subject is removed in some measure out of the usual limits of pathological inquiry. Amid this uncertainty we must endeavour to discover what is truth; and, should this prove to be more limited than a slight view of the subject might lead us to expect, something will at least be done by ascertaining its extent, and tracing the course by which it may be enlarged. I shall consider affections of the stomach under three classes: I. Affections of an inflammatory kind, including ulceration and its consequences. II. Affections which more properly come under the class of organic. III. Functional affections,-embracing a slight outline of the subject of dyspepsia. In an appendix, I shall briefly allude to the affections of the œsophagus and the duodenum-and to derangement of the functions of the stomach by tumours attached to it externally. SECTION I. OF THE INFLAMMATORY AFFECTIONS OF THE ACUTE gastritis is a disease described by all systematic writers, but in the records of pathology it is very difficult to find a pure example of it in an idiopathic form. I have been often very much astonished to find, in my own observation, how seldom the stomach shows marks of inflammation, even when the organs most nearly connected with it have been inflamed in the highest degree. In cases of very extensive peritonitis, the peritoneal coat of the stomach is sometimes affected; but even this is rare, and a case of pure inflammation of this membrane I have never seen, and do not find described by any writer. Dr. Armstrong, in the first fasciculus of his work on the morbid anatomy of the stomach and bowels, gives a plate representing inflammatory deposition on the peritoneal coat of the stomach; but no account is given of the case from which it was taken, so that it does not appear whether it was an example of pure idiopathic gastritis, or whether the appearance occurred in connection with more general peritonitis. The disease which we call gastritis is to be considered, therefore, as seated chiefly or entirely in the mucous membrane, and even here it is extremely rare as an acute and idiopathic disease. It is from the action of the acrid poisons that we chiefly find inflammation of the mucous coat of the stomach, but we cannot consider these cases as ne cessarily exhibiting the same symptoms which would accompany the disease in its idiopathic form. The symptoms which are usually described as those of gastritis are pain and tenderness in the region of the stomach, with urgent vomiting and fever; but, in as far as we have facts on which we can proceed with confidence, it does not appear that the symptoms are so uniform as systematic writers would lead us to believe. A man mentioned by Haller, having swallowed a large quantity of very cold water when he was much heated, was seized with acute pain in the stomach and fever, and died delirious in fifteen days,-no other symptoms being mentioned. The stomach was found to contain a fetid ichorous matter; and the fundus of it was inflamed with gangrenous spots and ulcerations. In another case, by the same writer, which was complicated with disease of the lungs, the chief symptoms were, pain and oppression of the breast, with perpetual hiccup and difficult deglutition. The stomach is said to have been everywhere inflamed, with effusion of blood into its cellular texture. In a case by Morgagni, the principal symptoms were anxiety and sense of fulness in the stomach, with frequent vomiting of a brown matter, in which were floating shreds of a membranous appearance; and these symptoms were followed by hiccup, delirium and convulsion. A young man mentioned by Storck complained chiefly of a burning uneasiness in the abdomen, with hiccup and intense thirst; and a man mentioned by Lieutaud had intense fever and violent pain in the stomach, with urgent vomiting, distention of the epigastrium and difficult breathing. In these and other cases of the same kind, however, it is merely stated in very general terms that the stomach showed marks of inflammation-except in Haller's case, in which ulceration is mentioned; and the cases described by Broussais appear to be equally unsatisfactory. |