The second form is preceded by violent pain in the epigastrium, or in some other part of the abdomen, and is immediately relieved when the fluid is rejected. In a case of this kind I examined the liquid with the microscope, and found small epithelial cells, which, from their shape, and from their being united into small casts, I believed to have come from the little pits on the surface of the stomach. In another instance the fluid was faintly acid, and contained a small amount of albumen. When mixed with baryta, it afforded a bulky precipitate soluble in acetic acid. It also gave a precipitate with nitrate of silver, the greater part of which was soluble in dilute acids. I was not able to carry out the experiments further; but, from the above reactions, I suspect that it contained a salt of phosphoric acid. From the relief afforded by the ejection of the liquid, and from its containing epithelial cells of the gastric tubes, I think it probable that, in this form of the disease, the symptoms are produced by the secretion of some irritating salt by the stomach.

The appetite in chronic gastritis is usually deficient and irregular. In many cases, one of the earliest symptoms is a dislike to digestible food, and a preference for inappropriate articles of diet.

Thirst is very generally complained of. It is usually felt after food, and is increased towards evening.

Most patients are troubled with acid eructations. But the question arises, are we to consider permanent acidity as an invariable indication of an inflammatory condition of the mucous membrane of the stomach? In order to ascertain whether this

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is the case, I produced vomiting in a number of dyspeptics, and invariably found that when acidity was constant after meals, a considerable quantity of tenacious mucus was rejected, often mixed with torulæ and particles of food; but that in cases in which this symptom was only occasionally experienced, or was felt in a slight degree, the mucus obtained from the stomach was thin and small in quantity. The vomiting was excited by tickling the fauces, shortly after a tumblerful of warm water, or of infusion of chamomile, had been taken. Vomiting was easily induced in cases of acidity, but considerable difficulty was often found in exciting it in persons in whom the symptoms were only those of feeble digestion. The experiments were always conducted in the morning before breakfast. As we know that an increased secretion of mucus is due to a congested or inflammatory state of a mucous membrane, we are justified in concluding, that when acidity is constant after meals, it is usually an indication of an inflamed or congested state of the stomach.

But in addition to this, it is probable that sometimes the gastric juice is either abnormally acid, or is secreted in increased quantity.

Thus, in some cases of gout, in which acidity is a prominent symptom before an attack, it disappears as soon as the joints become affected. In certain persons, in whom a renal calculus has acted as a cause of irritation, the acidity has been observed to disappear as soon as the stone passed from the ureter. We know that urea and other substances, when present in the blood, have been detected in

the contents of the stomach, and there is, therefore, nothing improbable in the supposition, that if the blood be charged with lactates or urates, these acids may be separated by the gastric glands.1

The patient is generally subject to flatulence, but not to the extent that we meet with in some other forms of dyspepsia. Distension is chiefly complained of when there is great venous congestion, and is, in all probability, due more to the derangement of the liver and intestines than to the state of the stomach.

The tongue furnishes us with no certain information as to the condition of the gastric mucous membrane. In the slighter cases it is generally furred, with red papillæ projecting through the fur, or its surface is of a bright red colour at the tip and edges.

The bowels are usually torpid, and there can be no doubt, that in many persons the affection of the stomach is a consequence of the imperfect action of the cæcum and colon. In another class of cases, diarrhoea is a common and troublesome symptom, and probably arises from the extension of the inflammatory action to the intestines, or from the irritation caused by acid chyme.

The urine is ordinarily scanty, and becomes turbid on standing, from being loaded with salts of lithic acid.

The skin is dry and harsh, and is not unfrequently covered with an eruption. In other cases the first symptom of improvement is a return of the perspi

1 See page 23.

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ration. Affections of the skin are most frequently met with in persons liable to gout.

The pulse in severe cases is quickened, especially towards evening, but in the milder forms of the complaint, it does not rise above the normal standard. In most persons who suffer from gastritis, there are irregularities in the circulation, such as coldness of the feet and flushings of the face or ears.

Notwithstanding the great number and variety of the symptoms of chronic gastritis, the cases of this disease may be readily divided into three classes, viz., those in which the prominent symptom is pain in the epigastrium, continuing during the whole or the greater part of digestion, and relieved only by the termination of that process, or by vomiting; those in which acid eructations after food are habitually experienced; the third class comprises all in whom there exists pain in the stomach which is relieved by the rejection of a watery or mucous fluid.

In the first class are included most of the cases in which a local thickening of all the coats is produced by chronic gastritis. Many of these terminate in ulceration, and after death a sore is discovered in the stomach, surrounded by a considerable margin of condensed tissue. In others it will be found that the patient has previously suffered from "bilious attacks," or some other variety of subacute gastritis; or that he has been subject to some less severe form of dyspepsia, which has been aggravated by irregularity in diet, or improper treatment. It will be therefore necessary, not merely to relieve the symptoms of which he is complaining, but also

afterwards to overcome the disease of which they are the result.

The occasional application of a few leeches, or of a small blister to the epigastrium, is usually the most effectual treatment. If the pain be unaccompanied by acidity, the nitrate or citrate of potash, in combination with morphia and hydrocyanic acid, will soothe the irritable mucous membrane; but if acidity be usually present, it is better to combine the sedatives with magnesia, soda, or potash.

The bowels should be carefully regulated with aloes, or rhubarb.

The diet is the most important consideration. If the patient's general health permit, he should at first be confined to farinaceous food-gruel, sago, or arrow-root. These should be given in small quantities and frequently, and if the strength be reduced, beef-tea may be also allowed. As soon

as the pain subsides, solid animal food with biscuit, or unfermented bread may be tried; but some time should elapse before a full and mixed diet is commenced.

Simultaneously with the improvement in the diet, bitter infusions in combination with alkalies may be prescribed, followed by some of the milder prepa

rations of iron.

The treatment of the second class of cases, viz., where acidity is the prominent symptom, is much more difficult; both because the inflammation is of a more chronic character, and also from the fact of the patient's sufferings being less severe, he is not so much inclined to follow the instructions of his medical adviser, with the exactness and perseverance