On the other hand, we find De Haen, Stohl and Frank describing cases of what they term inflammation and gangrene of the stomach, in which none of the usual symptoms of gastritis had occurred; and other cases which had exhibited all the symptoms of gastritis, while no appearance of inflammation could be discovered on dissection. The last mentioned writer farther admits, that symptoms, closely resembling those ascribed to gastritis, frequently subside under treatment the very reverse of that which would have been applicable to inflammation. To these circumstances we have to add the important facts ascertained by Dr. Yelloly and others. In numerous cases of persons who died of other diseases, without any symptoms in the stomach, and in the bodies of criminals who had been executed, they have pointed out appearances which might have been considered as distinctly indicating inflammation of the mucous membrane of the stomach.

The older writers appear to have been very indefinite in regard to the use of the term inflammation; and it will now probably be admitted, that it ought not to be applied to any appearances consisting of mere change of colour or increased vascularity, without some decided change in the structure of the part, or some of the actual results of inflammation; and, upon the whole view of the subject, the conclusion seems to be, that we are still very much in the dark in regard to idiopathic acute gastritis. For my own part, I have never seen a case which I could consider as being of this nature; and I am disposed to regard as points not yet ascertained, what are the characters exhibited by the mucous membrane of the stomach in the earlier periods of acute gastritis, and in what they differ from appearances which may exist without any symptoms of gastric disease, or take place after death. If we might proceed in any degree upon the analogy of the corresponding affection in the

mucous membrane of the bowels, I should be inclined to suppose that the disease exists under two forms;-that in the one, it is seated chiefly in the follicles or simple glands, in the other, in the mucous membrane itself;-that, in the former case, it would consist, in its early stage, of detached and minute pustules or vesicles, and would terminate at an early period in minute and detached ulcers;-and that, in the other, it would exhibit in its first stage, the appearance of defined portions of the mucous membrane of a red or livid-brown colour, and sensibly elevated above the level of the surrounding parts-these portions afterwards terminating by softening or ulceration, or passing into a chronic state of disease with ulceration, thickening, or fungoid elevations upon the diseased parts. This is in some measure conjectural, but I think we may safely assert, that, in this investigation, nothing can be founded upon a mere general or extensive redness of the membrane, discolouration, or increased vascularity,-whether more or less extensive,-venous turgescence, extravasation of blood into the cellular texture, or upon any appearance which consists of mere change of colour, without any decided change in the structure of the part. In a case mentioned by Mr. Annesley, in his late work on the diseases of India, which was fatal in seven days, the mucous membrane of the stomach was found covered with small defined ulcers, discharging a thin sanious fluid. The symptoms were incessant vomiting and hiccup, with fever of a tertian type, without any complaint of pain. In another case, by the same writer, there was at first acute pain in the stomach, increased by pressure, with very slight fever, and no vomiting. On the fourth day vomiting began, and he died on the seventh. The coats of the stomach in this case appeared to be thickened, but its internal surface was only deeply injected.

I leave this part of the subject, merely pointing it out for farther investigation, and proceed to another of much practical importance, in regard to which we have numerous interesting facts on which we can proceed with confidence. We have every reason to believe, that the mucous membrane of the stomach is liable to inflammation in a chronic form, which often advances so slowly and insidiously, that the dangerous nature of it may be overlooked, until it has passed into ulceration, or has even assumed the characters of organic and hopeless disease. Farther, we shall find, that even ulceration may exist in the stomach without producing any symptoms of an alarming nature, until it gives rise to an attack which is very speedily fatal. In the early stages of this affection, the prominent symptoms are often such as merely indicate derangement of the functions of the stomach, and are apt to be included under the general term dyspepsia. The patient perhaps complains of extreme acidity, eructations, flatulence, and oppression of the stomach after eating. There is generally some degree of pain in the region of the stomach, but it varies very much both in its degree and its duration. In many cases, it is complained of only after eating, continues in considerable severity while the process of digestion is going on, and subsides when that process is completed. The appetite is often unimpaired, but the patient is afraid of taking food on account of the uneasiness which is produced by it, and he is entirely free from complaint when the stomach is empty. A frequent expression of such patients is, "I should be quite well, if I could do without eating." In other cases, there is more permanent uneasiness, which is aggravated by taking food; and sometimes there is pain in the back at the part corresponding to the seat of the stomach. In other cases, again, there is no actual pain, but the uneasiness is described as a feeling of

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heat, or a great degree of pyrosis. The tongue is, in some cases, little altered from the healthy appearance; but in others, it shows a peculiar rawness and tenderness, and occasionally minute ulcers may be observed on its edges. Vomiting is apt to occur, but in the early stages is only occasional, and is ascribed to some error in diet, or other accidental cause. Afterwards it becomes more frequent, but still without that regularity which would seem to indicate serious disease; by attention to diet it may be, in a great measure, prevented, and in this manner the disease may go on for months without exciting alarm. The vomiting then, perhaps, becomes more frequent, and the uneasiness in the stomach more permanent, until the patient either sinks by gradual wasting, or is suddenly cut off by one of those rapid attacks to be afterwards particularly described. In all the forms of this insidious disease there is great diversity in the symptoms. In some cases, there is little or no vomiting, the prominent symptoms being pain excited by taking food, with gradual wasting, and, as the disease advances, a feeling as if the stomach were incapable of holding any thing beyond the smallest possible quantity. In other cases, there is chiefly a constant and most painful feeling of pyrosis, with gradual emaciation; but, in many, it will be found that little or no uneasiness had ever been complained of, until the attack takes place which is fatal in a few hours. An important circumstance, therefore, in the history of this affection, is, that it may run its course almost to the last period without vomiting, and with scarcely any symptom except the uneasiness which is produced by eating, and which subsides entirely in a few hours after a meal. This most interesting modification of the disease will be strikingly illustrated by Case IV.

In some cases, again, the prominent symptom is a very

copious discharge from the stomach of a clear glairy fluid like the white of eggs. In a woman, mentioned by Andral, this discharge amounted to about four pints in twenty-four hours; and she never vomited either food or drink. Sometimes this discharge is streaked with a black matter, or is entirely of the colour of chocolate, and not unfrequently is mixed with grumous blood.

The disease which is going on during the course of symptoms now described, consists of chronic inflammation of the mucous membrane of the stomach, which in many cases appears to commence in a very small and circumscribed portion. Its progress seems to be very slow, and, it is probable that it may continue for a considerable time and then subside, and occur again after various intervals, until at last it produces more permanent and extensive disease, by thickening of the parietes of the stomach, adhesion to the neighbouring parts and ulceration. The result which we have occasion to attend to most frequently as the immediate cause of urgent symptoms, is ulceration of the inner surface of the stomach; and we shall find that it exists in various forms, the most important of which, in a practical point of view, are the following:

1. A small defined ulcer of limited extent, with evident loss of substance, and rounded and elevated edges, varying in extent from the size of a split pea to that of a shilling. We may find only one such ulcer, every other part of the stomach being in the most healthy state; or we may find that there has been a succession of them, some of them cicatrizing, and others appearing, while the health of the patient gradually sunk under the disease, which after all may be found to have been of no great extent. In the cases of this first class, there is no general disease of the