In

stomach is very generally met with after death. persons who have died from brain disease, post-mortem digestion is of frequent occurrence; and the cause of this seems to be explained by the experiments of Bernard, who found that any irritation of the pneumogastric nerves gave rise to an increased secretion of gastric juice.

The amount of post-mortem digestion depends also, in a great degree, on the condition of the mucous membrane itself. This is a point which has not attracted the attention it deserves. When the glandular structure is thickened by chronic inflammation, not only is the secretion of the gastric juice diminished, but the texture is also more impervious to the fluid which the stomach may contain. In order to prove this, I placed in artificial gastric juice four pieces of gastric mucous membrane. One was taken from a healthy dog; the second from a human stomach, the splenic end of which was found dissolved after death, the portion selected, however, being not softened; the third and fourth were from females who had died from cancer of the breast, both stomachs being much diseased. After the digestion had been continued for three hours at 100°, the first broke up into fragments when touched with the forceps; the second was reduced to a pulp; and the third and fourth showed only a little softening on their surface, but were in other respects unaltered.

As, therefore, the amount of the gastric juice secreted is smallest, and the state of the mucous membrane renders it least liable to be affected when it is most diseased, so we find that the cases in which there is the greatest amount of morbid change

BEST METHOD OF EXAMINING THE STOMACH. 47

are those which are least affected by post mortem digestion.

Since the mucous membrane of the stomach is

so liable to post-mortem changes, it is necessary we should be very careful in the method we employ for preparing it for microscopical examination.

The first and most important point is to harden it, either by alcohol or chromic acid. I generally prefer the former, as it does not make the preparations brittle, and causes less obscurity than the latter.

The surface of the mucous membrane sould be viewed as an opaque object, by which method the condition of the openings of the ducts, and of the ridges surrounding them, can be readily noted.

To investigate the gland structure, we may either tear it asunder with needles, or make fine sections through it. The former of these methods, although occasionally useful, is very apt to mislead, as the relative positions of the various parts are so much displaced by it. In making sections, the best plan is that recommended by Dr. Habershon, viz., to stretch the piece of stomach tightly across the thumb-nail of the left hand whilst the section is effected with a Valentin's knife held in the right. The cut should be made quite perpendicularly, as a slanting direction gives the connective tissue surrounding the tubes the appearance of being much more thickened than it really is. If the tissue is soft or fatty, we should carefully avoid any pressure upon it by the covering glass, the structure being in these conditions very readily injured.

CHAPTER II.

ACUTE GASTRITIS.

FEW diseases have given rise to more discussion than acute inflammation of the stomach. Many of the older medical writers speak of it as of not infrequent occurrence; some of the best morbid anatomists of modern times, on the contrary, have altogether doubted its existence, except as the result of irritant poisons. This difference of opinion is capable of explanation. The former class appears to have comprised under the head of acute gastritis, cases in which the appearances found after death were the effects of postmortem solution, or of simple vascular congestion; the latter has refused to consider any change in the mucous membrane as the effect of disease, unless the alterations were such as accorded with its ideas of what acute inflammation ought to produce in such a tissue.

It must be remembered, that there are reasons why acute inflammation should not leave in the gastric mucous membrane appearances as striking as those found after inflammation of other organs. The stomach, in a state of health, is liable to congestion; its vascular system is constituted so as to

WHY POST-MORTEM APPEARANCES MAY BE SLIGHT. 49

permit of the ready escape of any unusual quantity of blood that may be contained in it, and therefore a smaller amount of redness remains after death than is the case in many other structures.

Nor are we justified in accepting, as many have done, the appearances observed after irritant poisons as merely those of acute gastritis; for such morbid changes are often the results of chemical action, or of congestion resulting from the effects of the poison on the heart and lungs.

Again, it is difficult to estimate alterations in the bulk of the mucous membrane of the stomach on account of its natural tenuity, and our attention is therefore not likely to be attracted by any moderate enlargement of this structure, as is the case in acute inflammation of many other parts of the body. Softening, which is another product of inflammation, is also inadmissible as an evidence of acute gastritis, as it is a common result of post-mortem changes, and by a certain number of pathologists is always referred to this cause.

Although the appearances presented by the gastric mucous membrane, after acute inflammation has been present, are often uncertain when viewed by the naked eye, yet a careful examination with the microscope will generally enable us to discriminate the products of disease from post-mortem changes, and thus remove all doubt upon the subject.

It is a matter not only of scientific interest but of practical importance, to determine whether there is a form of disease to which we are justified in applying the term of acute gastritis. When a person suffering from some chronic malady is attacked with symptoms

indicating a severe affection of the stomach, the treatment is necessarily dependent on the views of the practitioner as to the nature of the gastric complication. If he looks upon it as arising only from irritation, his efforts will be directed to the relief of the primary disorder; but if he believes that gastritis of a dangerous character has supervened, he will spare no effort to subdue the secondary affection as quickly as possible.

The following cases are intended to serve as illustrations of a form of disease occasionally affecting the stomach, which, on account of the severity of the symptoms and the danger to life which accompany it, we are justified in considering as acute gastritis.

"CASE 1.-M. K., aged 24, admitted into King's College Hospital, August 20, under Dr. Beale, who was attending for Dr. Todd. The patient had latterly been employed in the ward in which were two cases of scarlatina. Previously to her present illness she had always enjoyed excellent health. On August 19th she felt feverish and generally ill.”

"August 20th.-This morning she complained of headache and sore throat, and vomited occasionally. The face, chest, and arms were completely covered with the rash of scarlatina. The tonsils, pharynx, and palate were of a deep red colour, and the tonsils much enlarged; skin hot and dry; appetite bad; bowels freely open. P. 108; R. 24."

"21st.-Was very much purged during the night, and vomited several times, the vomiting being immediately excited by the beef-tea. This morning