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 which Dr. A. afterwards parti cularly describes. In all the forms of this insidious disease there is great diversity in the symptoms. In many cases 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." The author gives a case in illustration of this fact. In some cases 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. This discharge is sometimes streaked with a black matter, or is entirely of the colour of chocolate, and not unfrequently is mixed with grumous blood.

The

From this chronic inflammation of the mucous membrane results very frequently ulceration, in various forms, of the inner surface of the stomach. There may be one or more small defined ulcers of limited extent, with evident loss of substance and rounded and elevated edges, every other part of the stomach being in the most healthy state. ulcer may be confined entirely to the mucous membrane, or all the membranes may be perforated. An interesting case of this latter form of disease is given in our Journal for April 1825, p. 289, by Mr. GRIFFITHS. In this instance the perforation of the stomach is described as "looking much as if it had been made with a punch" Precisely the same description is also given of similar cases related by Dr. EBERMAIER, who remarks that the real nature of the malady was in no instance suspected by the physicians. Death sometimes occurred unexpectedly, almost in the midst of apparent health. Dr. E. is of opinion that these perforations do not result from ordinary chronic inflammation. Similar ulcerations, perhaps the size of a shilling, but complicated with thickening and induration of the parietes of the stomach around the ulcer, are sometimes met

London Med. and Phys. Journal, October 1828, p. 302, and November 1828, p. 422.-An excellent article upon this subject, which still requires elucidation, is contained in the 46th volume of the Dict. des Sc. Medicales, p. 314, art. Perforation, with plates.-REV.

with. In the progress and terminations of this disease there is considerable difference.

"A singular variety in the appearances is to be referred to before leaving this part of the subject. Though a complete perforation of the stomach by ulceration may have taken place, it is frequently found that an adhesion had been formed to some of the neighbouring parts, most commonly the liver, in such a manner that a portion of the surface of the liver supplies the place of the portion of the stomach that has been destroyed, and thus no escape of the contents takes place.” (P. 21.)

This remarkable circumstance Dr. Abercrombie exemplifies by a case, which was afterwards fatal by a small perforation immediately adjoining the portion where this adhesion had been formed.

"Another important modification arises from adhesion of the stomach to the arch of the colon, and a communication being formed between them by ulceration." An instance of this kind is also given by the author, and several cases illustrative of the principal modifications of ulcerations of the stomach, and the insidious manner in which such diseases are apt to advance, with symptoms which are liable to be considered merely dyspeptic. The first case is especially interesting. The disease appeared to be seated entirely in the mucous follicles. One fact particularly worthy of notice was "the activity of the symptoms in the early stages, probably while the follicles were in a state of inflammation, and the obscurity of them when the disease was more advanced; likewise the proofs that many of the follicles had been in a state of ulceration, and had cicatrised; while, at the time of the patient's death, not above two or three were in a state of ulceration.

It must be evident, from the description which has been given of the uncertain and various symptoms which attend both the commencement and progress of the different species of the above-named affections of the stomach, that much difficulty must attend the diagnosis. Dr. A., from the facts he has stated, thinks there is every reason to conclude that the dangerous affection referred to in the preceding observations exists in two conditions:

"Namely, chronic inflammation of a defined portion of the mucous membrane of the stomach, or the mucous follicles; and the termination of this by ulceration. In both these conditions it may probably be the subject of medical treatment; for we have reason to believe that the inflammation may be arrested and prevented from passing into ulceration, and that the ulceration may heal before it has become connected with any permanent change

in the organization of the part. Hence appears the importance of minutely watching the progress of the disease in its early stages, in which only it is likely to be treated with success. The difficulty here is in the diagnosis; the disease often assuming the character of a mere dyspeptic affection through a great part of its progress, while in fact a morbid condition of a very serious nature is going on, which would require treatment in many respects very different from that adapted to dyspepsia." (P. 46.)

"Amid such a diversity of symptoms as occur in connexion with this disease, our chief reliance in the diagnosis must probably be on a careful examination of the region of the stomach itself, with the view of discovering the existence of tenderness referred to a particular part. This examination should be made with the most minute attention at various times, both when the stomach is full and when it is empty. If induration be discovered, the character of the case will be obvious; but we have seen that most extensive ulceration may exist without any induration, and likewise that extensive induration may exist without being discovered by external examination.

"Other important cautions in regard to the diagnosis will be learned from the cases which have been described. In particular, we should not be deceived either by the pain having remarkable remissions and the patient enjoying long intervals of perfect health, or by remarkable alleviation of the symptoms taking place under a careful regulation of diet; for these circumstances we have found occurring in a very striking manner, while the disease was making progress to its fatal termination." (P. 48.)

Treatment. When the disease is detected at an early period, our treatment must consist chiefly of free topical bleeding, blistering, issues, or tartar-emetic ointment. Food must be small in quantity and mild in quality, as farinaceous articles and milk. The stomach should not be distended even by the mildest articles. Bodily exertion is improper, "and hence the importance of endeavouring to distinguish the disease from mere dyspepsia, as the regimen and exercise which are proper and necessary in dyspepsia would in this case be highly dangerous." In the early periods medicine can do little more than regulate the bowels. In the more advanced stages, when ulceration may be suspected, the same remark will apply to external applications and regimen.

"Benefit may now be obtained by some internal remedies, such as the oxide of bismuth, lime-water, and nitric acid; and in some cases small quantities of mercury appear to be useful. Small opiates, combined with articles of a mucilaginous nature, appear frequently to be beneficial; likewise articles of an astringent na

ture, such as kino, alum, and the rhatany root. The arsenical solution has also been recommended, and small doses of the nitrate of silver; and, in several instances in which I suspected this disease to be going on, I have found remarkable benefit from the sulphate of iron. Whether the disease can be cured after it has advanced to ulceration, must indeed remain in some degree a matter of doubt; because, in a case which has terminated favorably, we have no means of ascertaining with certainty that ulceration had existed. In some of the cases, however, which have been described, we have seen every reason to believe that some of the ulcers had cicatrised, though the disease had afterwards gone on to a fatal termination; and, from what we observe in the intestinal canal, we can have little doubt that simple ulceration of the mucous membrane may cicatrise. I am satisfied that I have seen the cicatrices of such ulcers when the patient has died of another disease, after having been for a considerable time free from any symptom in the bowels." (P. 49.)

Under the use of strict diet, the worst cases have sometimes recovered. The following is an example:

"A female, whose age is not mentioned, had for a considerable time laboured under symptoms which were supposed to indicate scirrhus of the pylorus, and her case had been regarded as entirely hopeless. She suffered severe pain in the stomach when the smallest quantity of food was taken in, with great tenderness upon pressure and constant vomiting, which occurred regularly about the same period after eating at which it usually takes place in affections of the pylorus. A variety of treatment had been employed without benefit, when Dr. Barlow determined upon trusting entirely to regimen, by restricting her to a diet consisting wholly of fresh-made uncompressed curd, of which she was to take but a tablespoonful at a time, and to repeat it as often as she found it advisable. On this article she subsisted for several months, and recovered perfect health." (P. 51.)

Dr. A. has seen some cases of that species of aphthous affection of the mouth, fauces, and larynx, to which the French apply the name of Diphtherite. It is an epidemic chiefly affecting children, and frequently fatal. A description of the symptoms and treatment of this disease is given.

In the next section the author treats of organic diseases of the stomach. Under this head are briefly mentioned, induration and thickening of the coats of the stomach, diseases of the pylorus, and disease of the cardia.

Pathology of Dyspepsia.-All we know of the process of digestion is, that it is the result of the combined action of the gastric juice, and of a peculiar muscular motion of the stomach. In healthy digestion it appears that no gas is generated in the stomach, but that a certain quantity is

No. 365.- No. 37, New Series.

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evolved in the farther progress of the alimentary matters through the intestines, especially in the colon; and it is said to be composed of carbonic acid, hydrogen, and azote, in various proportions.

"When these actions are in any degree deranged or deficient, the alimentary matters are not converted in the regular manner into healthy chyme; but, remaining perhaps longer in the stomach than in the healthy state of the process they would do, they undergo, in a greater or less degree, those chemical changes which would happen to them in other circumstances. Hence the generation of acidity, the evolution of gases of various kinds, and the lodgment in the stomach of matters imperfectly digested, partly fermented, perhaps partly putrid: hence, also, irregular muscular contractions, arising from the morbid stimuli thus produced, giving rise to regurgitations of matter into the oesophagus, eructations, and perhaps vomiting; or, the muscular coat yielding to the distending force of the evolved gaseous fluids, there are produced painful distention, oppression, and anxiety, or, in other words, a paroxysm of dyspepsia." (P. 68.)

Dr. Abercrombie admits that the dependence of the function of digestion upon the influence of the eighth pair of nerves, is among the most beautiful discoveries of modern physiology, but he is not aware that any practical results have hitherto been deduced from it.

In the present section the attention of the reader is directed to those cases in which derangement of the stomach is of a functional nature, or not connected with any change of structure, either of the stomach itself or of any of the neighbouring parts. It is extremely difficult to ascertain the exact nature of these functional derangements, as they are merely impaired actions of living parts. The muscular action of the stomach may be deficient, so that the alimentary matters remain in it too long, are imperfectly changed, and pass into chemical decompositions.

"We know the state of the urinary bladder, in which its muscular action is lost or very much impaired, and in consequence of which it is gradually distended, so as to hold an enormous quantity of fluid; and, when emptied by the catheter, it does not contract equally, as in the healthy state, but falls flat like an empty bag. A state analogous to this we not unfrequently see in the stomach on dissection; a state in which it appears much enlarged, and collapsed by flattening, without healthy contraction." (P. 69.)

There may be a deficiency of the corresponding and harmonious intestinal action, interfering with the second stage of digestion, and giving rise to imperfect chylification and