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were precisely similar to those of the first, except that they suddenly ceased on gout appearing in the feet. I have since attended him for a severe fit of gout, during which he had no gastric symptoms; but the pains in the joints were preceded by the passing of albuminous urine, which disappeared after the cessation of the gouty action.

The symptoms in this case were so urgent that I should have suspected poisoning, had not the patient been from the first under the observation of a very careful and intelligent practitioner. There can be no doubt that it was an instance of acute gastritis; and the rapid disappearance of the malady after the invasion of the gout points to a connection between the inflammation of the stomach and the affection of the joints. It was in reality a case of poisoning; the irritating material being lithic acid in the blood, instead of arsenic or antimony directly applied to the mucous membrane.

In all probability much of the scepticism which prevails respecting acute gastritis as a product of gout has arisen from confounding it with another affection which is not infrequent in gouty subjects. In this the disorder can be generally traced to some error in diet; and although the symptoms are often very alarming, they usually yield quickly to medical treatment. I have added the next case to illustrate this form of dyspepsia, and it is scarcely necessary to point out the differences between it and that which precedes it.

CASE 5.-An old gentleman was suddenly attacked during the night with intense pain in the left side

which obliged him to sit upright. There was no vomiting or tenderness of the epigastrium. His face was very pale and anxious, the pulse feeble, the respiration quick and constrained. He had been for many years a martyr to gout, but for some time previously had escaped its accustomed visitations. A mustard blister was applied to the epigastrium, and a dose of ether and brandy was given. A large amount of flatulence was removed with immediate relief to the oppressed heart, and a stimulating purgative next day completed the cure.

It will be observed that all the above instances of acute gastritis occurred in persons who were suffering from diseases which rendered them liable to subacute or chronic inflammation of the gastric mucous membrane; such as scarlatina, gout, affections of the heart or kidneys.

Some authors have related cases in which acute gastritis has attacked individuals in perfect health, but no such instance has fallen under my notice. The symptoms of acute gastritis are as follows :—

Severe pain at the epigastrium; in some patients, extending up the chest and between the shoulders. The pain is sometimes sharp, in others it is described as a scalding or burning sensation. The suffering is immediately increased by either food or drink. Warm liquids and stimulants generally appear to aggravate it; frequently there is a craving for cold or iced liquids.

Tenderness at the epigastrium is always present; but it is not so severe, nor is the pain produced by so slight a pressure as in peritonitis.

Vomiting is as generally complained of as pain. At the commencement of the attack this symptom is very distressing, occurring every few minutes, even when no food has been taken. The ejection of a little glairy or bloody mucus seems to give temporary relief; but the retching is renewed as soon as a fresh quantity of secretion has been formed. Both food and drink are returned directly they are swallowed; but as the disease progresses the frequency of the vomiting usually decreases.

Hiccough is in some cases a very distressing and dangerous symptom; but patients may recover even after it has been almost incessant for many days.

Thirst is present in all cases, and is often productive of much suffering. The appetite is always bad, and a loathing of food is not unfrequently manifested.

The pulse is usually quick, feeble, and sometimes intermittent; the skin is hot, the bowels are generally confined, and the urine is scanty and high coloured.

In all the cases that have come under my observation I have been particularly struck with the great prostration of the patient. The face has been pale, the countenance pinched and anxious, and the spirits exceedingly desponding. The mental faculties usually remain clear to the last.

After death from acute gastritis, the stomach is generally found contracted, and the surface of its lining membrane is more or less injected and covered with mucus. In some cases there are small ulcerations scattered over the surface; in others sloughs may be present. In two cases which were examined at St. George's Hospital "there were flakes of fibrin

and fluid, with some recent adhesions in the peritoneums of both. There were spots of effused blood and brown patches on the internal surface of the viscus; the mucous membrane was

very much thickened and pulpy; the cellular tissue too of the walls was thickened, in one being nearly one-third of an inch thick, and containing a deposit of fibrin of recent appearance in its substance." 1

When examined by the microscope the gastric tubes are obscurely seen, on account of the granular matter effused upon and between them. Their cells are either broken up, or they seem fused together into a mass with granular and fatty matters. In some cases blood is met with within and between the tubes, and is also intermixed with their cells. The subtubular spaces are loaded with granular matter and blood globules.

The diagnosis of acute gastritis is, in most cases, sufficiently easy. The severe pain at the stomach, the tenderness on pressure of the epigastrium, the urgent vomiting, and the great depression of the vascular and nervous systems will at once arrest the attention of the practitioner. It may, however, be confounded with peritonitis, with which disease it is sometimes associated.

When this complication is not present, it will be observed that the tenderness is much less marked; it is confined to the epigastrium, and is not present in other parts of the abdomen. In peritonitis, again, the vomiting is less urgent, the matters ejected are not accompanied by blood, and when examined by the microscope are found to be free from casts I Digestion and its Derangement, by Dr. Chambers, p. 347.

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of the secreting tubes of the stomach. The pulse, moreover, is less depressed in peritonitis, unless the complaint has been produced by perforation of some part of the digestive tube.

Sometimes, in persons much reduced by chronic disorders, we have symptoms indicating an affection of the stomach, which must not be confounded with acute gastritis, as it arises from a different cause and requires a very different treatment. The following case is an illustration of this form of disease.

CASE 6.—A young lady, about eighteen years of age, had been ill for nine months before I saw her, complaining of constant and severe pain on the left side of the abdomen. She was exceedingly emaciated, but had neither cough nor expectoration. Her illness had commenced with sudden pain in the abdomen; this was followed by diarrhoea and vomiting, which subsided after one month's duration.

On examination of the chest, signs of the existence of tubercular deposit were discovered in the apex of one lung. The part of the abdomen in which the pain was situated was rather duller on percussion than the adjoining regions, and was tender on pressure.

A day or two after I first saw her she was attacked by severe vomiting, followed by purging of blood, which subsided under treatment, but returned in a few days with increased severity. The vomiting became very urgent, even when no food had been taken, and the fluid rejected from the stomach was thick and ropy. Under the microscope it was proved to consist of mucus, loaded with torulæ.