"Post-mortem Examination (twenty-four hours after death). The lungs, liver, and kidneys were much congested; the other abdominal and thoracic organs appeared healthy, with the exception of the stomach. The mucous membrane of the stomach and duodenum was much congested, but there was no extravasation of blood in any part. The muscular coat, towards the pyloric extremity, was firmly contracted, and the mucous membrane thrown into ruga; but the cardiac portion was relaxed, and the coats in this region seemed very thin: the mucous membrane was not thrown into rugæ."1

Few persons will refuse to recognise this case as one of acute gastritis. There was pain in the region of the stomach, accompanied by incessant vomiting, a portion of the epithelial coat of the mucous membrane being rejected; and after death there was evidence that the organ had been inflamed.

In the following case fibrinous casts of the stomach tubes were discovered in the matters vomited, and a microscopical examination of the mucous membrane confirmed the diagnosis made during life, that the case was one of acute gastritis.

CASE 2.-A man about fifty-five years of age had been seriously ill for two weeks before I saw him. He complained of constant pain at the epigastrium and between the shoulders, increased immediately after food. He described the character of the pain as scalding." All food was vomited a few minutes after it had been taken. The bowels were

1 Beale's Archives of Medicine, vol. i. p. 198.

obstinately confined; the urine was scanty and albuminous. Some of the fluid he had vomited was found, when examined by the microscope, to contain blood and fibrinous casts of the gastric tubes. It appeared from his account, that twentyfour years previously he had been affected with dropsy, from which he recovered and remained apparently well for twelve years. He then had another attack of the same nature, but was again relieved by medical treatment. Since that period he had never enjoyed good health. He had been subject to winter cough, expectoration, and dema of the legs, and the urine had been albuminous. The symptoms were not on this occasion relieved by treatment, and a day or two after I saw him he was attacked with convulsions, and died.

Post-mortem Examination.-There was a little fluid and some recently effused lymph in the pericardium, and a small amount of fluid in each pleura. The lungs were healthy. The liver was attached by old adhesions to the walls of the abdomen, and was also connected with the colon.

The stomach was contracted and empty, and its lining membrane was covered with a thick layer of tenacious mucus. The surface was everywhere greatly congested; on microscopical examination the gastric tubes were found to be closely adherent. The duodenum was empty, but was coated with mucus even more thickly than the stomach. The mucus in both the stomach and duodenum was very alkaline, but more so in the former than in the latter. Both kidneys were greatly congested; they were small,

and the cortical portions were much wasted.

In the next case I did not examine the mucous membrane with the microscope, but the symptoms during life, and the appearances after death, left no doubt in my mind that the patient died of acute gastritis.

CASE 3.-A lady about thirty-five years of age had for a long time been under treatment, on account of a disease of the uterus. The catamenia were excessive in amount, and returned every ten or fourteen days. There was also a systolic murmur at the apex of the heart, and she had suffered severely from rheumatic fever some years previously. She was occasionally under my care, chiefly complaining of flatulence and feeble digestion. When in her usual state of health she was suddenly attacked with severe illness. She had excessive pain in the epigastrium and between the shoulders, and refused to take any nourishment on account of the increase of suffering it produced. Her face was exceedingly anxious, and the pulse small and fluttering; she vomited all food, and also a quantity of thick mucus. She died in two or three days after the commencement of these symptoms. On post-mortem examination the stomach was found much congested, of a dark colour, and covered with a thick layer of tenacious mucus. The heart was enlarged, and the mitral valve thickened and imperfect. The uterus was large, and contained three fibrous tumours.

Many of the older writers mention inflammation of the stomach as often occurring from suppressed gout, but of late years the existence of this form

GASTRITIS ARISING FROM GOUT.

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of gastritis has been very generally denied. It has been supposed that the cases formerly described were only instances of severe indigestion. The following case, however, shows that acute inflammation of the stomach may occasionally arise from gout, and be connected with symptoms of a most alarming character.

CASE 4.-I was requested to see a gentleman about fifty years of age, who had been dangerously ill for two days. I found him lying on his back, in a state of great prostration, and suffering from violent retching. At each attempt to vomit he discharged, with urgent straining, a little glairy mucus streaked with blood. He refused any nutriment, and if persuaded to drink, the fluid was almost immediately returned. He complained of intense pain in the stomach and chest, increased by food, and he seemed unable to bear the least pressure on the epigastrium. There was frequent and distressing hiccough; the pulse was quick, very irregular, and intermittent; the face pale, and exceedingly anxious; the urine scanty, but not albuminous. The bowels had not been opened for two or three days, and a pill containing croton oil had been administered without producing any action a few hours before I was requested to see him. I learned that he had formerly suffered much from gout, but had not experienced any attack of it for the last year. For some weeks before his illness he had been subjected to great mental anxiety, and had been almost incessantly employed in writing or dictating; often sitting up half the night in order

to complete his work. His appetite had been very bad, and he consequently had recourse to stimulants more freely than had been his custom.

I recommended that his bowels should be relieved by enemata, that a mustard poultice should be applied to the abdomen, and that all nourishment should be withheld, excepting a little iced brandy and water.

The following day he became rather delirious, and the vomiting continued unabated; the pulse remaining as irregular and intermittent as before.

In a few days the vomiting became less urgent, and the pain in the epigastrium less severe; but in other respects he continued in a most precarious condition. A strong mustard poultice was then continuously applied to the foot in which he had been accustomed to suffer from gout, and in a day or two afterwards a sharp attack of that disease appeared in the toe. From this time he rapidly recovered; the vomiting ceased, the delirium disappeared, the appetite rallied, and the pulse became regular. He afterwards suffered from oedema of both legs, but he gradually regained his former health.

I subsequently learned from him that he had been twice previously affected in a similar manner. On the first occasion, when in America, he was attacked with severe vomiting and pain in the epigastrium, followed in a few days by delirium. He was ill for about two weeks, and recovered without any gout making its appearance. The physicians who attended him expressed much doubt as to what had been the exact nature of his case. On the second seizure the symptoms and the course of the disease