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the practitioner, and lead to the detection of the real nature of the disease.

It is by no means difficult to account for the presence of torulæ in the stomach during or after a bilious attack. Dr. Beaumont, in his experiments on St. Martin, remarks that when the stomach was inflamed it secreted very little proper gastric juice, but a considerable quantity of ropy mucus, which became yellowish or muco-purulent, when the inflammation was more than usually severe. Normal gastric juice prevents fermentation; whilst the mucus, so plentifully secreted by an inflamed mucous membrane, appears to act as a ferment. We can consequently easily comprehend that if the secretion of gastric juice be suspended and its place be supplied by mucus, fermentative action will be set up, and torulæ and other vegetable forms will make their appearance.

In cases of fermentation the diet should be carefully regulated. Tea, coffee, milk, arrow-root, rice, and similar fluids, so often forced upon the patient during a "bilious attack," should be forbidden; and iced water, soda water, Seltzer water, and beef-tea should be substituted.

As regards remedies, I have generally prescribed creasote in doses of one drop, combined with magnesia; but if there be much subacute inflammation of the mucous membrane the hyposulphite of soda will be found more useful. For some time after the attack has subsided, vegetable tonics in combination with acids or alkalies are required.

In the forms of subacute gastritis described as "bilious attacks," the symptoms appear suddenly,

and disappear after a few hours' or days' duration; but in another class of cases they may continue without abatement for weeks, or even for months. The effects of this more chronic form of disease upon the general health are necessarily more severe, and the complaint is often very difficult to treat.

In addition to the morbid changes in the lining membrane of the stomach before mentioned as occuring in "bilious attacks," we often discover in the more chronic variety of the disease numerous small ulcerations scattered over the gastric mucous membrane. These are also found in the stomachs of the lower animals when gastritis has been present in them; so that there can be no doubt they are frequent results of this morbid condition.

Vomiting is generally present in this variety of gastritis, and from its being often the most prominent symptom, many writers have considered cases of this kind to depend rather upon an irritable state of the stomach than upon inflammation. The vomiting occurs shortly after taking food, and the matters rejected are sometimes very acid; at other times they seem to consist chiefly of mucus and undigested food. Occasionally the vomiting is so frequent that scarcely anything is retained, and we are surprised that the life of the patient can be preserved.

Pain is as generally present as vomiting, and is increased by all food immediately it is swallowed. The pain is usually felt in the epigastrium and between the shoulders; but in other cases it is referred to the sternum and the neighbouring parts. Sometimes it is described as "sharp," or "cutting;" in other instances as a (6 scalding" sensation. There is gene

SUBACUTE GASTRITIS FROM UTERINE DISORDERS. 79

rally some tenderness at the epigastrium upon deep pressure.

The appetite for food is almost always decreased, and is often replaced by loathing. Thirst in a greater or less degree is generally present.

The tongue affords no certain indication of the state of the stomach, but usually it is red at the tip and edges; and the lips are dry and cracked.

The pulse is feeble, and more rapid than in health, and there is ordinarily considerable loss of flesh and strength.

It must be remembered that every case does not present all these symptoms; nor are they in all equally severe.

The more acute forms are commonly met with in young women suffering from anæmia, and in these there is often considerable difficulty in the treatment.

In most of the instances of subacute gastritis occuring in the female, it will be found that the catamenia are deficient. In various affections of the uterus we meet with subacute inflammation of the stomach, but the most marked cases are seen in persons in whom narrowing of the canal of the cervix uteri prevents the free excretion of the catamenial discharge. An instance of this is shown in the following

case.

CASE 9.-A young married lady consulted me, on account of pain at the epigastrium, vomiting of all food, and other symptoms of severe subacute gastritis. She was exceedingly weak and emaciated. The symptoms were aggravated during the catamenial period, and the menstruation was very slow and painful. On

examination, the os. uteri was found to be so narrow, that a fine probe could with difficulty be passed through it. The canal of the cervix was freely incised, and with scarcely any other treatment the gastric disorder ceased, and the patient regained her health and strength.

Care must be taken that the gastritis is really dependent upon the uterine affection, for these diseases may co-exist without there being any connection between them.

We should therefore ascertain before commencing the treatment whether the gastric symptoms are greatly aggravated during the catamenial period, and whether there be really such a condition of the uterus as to require surgical interference.

Subacute gastritis is one of the most common accompaniments of ulceration of the stomach, and to it are usually due the aggravations of pain to which those affected with that complaint are liable.

In other instances it results from causes preventing the ready exit of the food from the stomach, such as thickening of the pylorus. I have seen it also connected with enlargement of the liver, and suspect that the inflammation was kept up partly by the congestion of the portal system and partly by the pressure of the diseased organ upon the stomach.

The diagnosis of subacute gastritis, though in general sufficiently easy, is sometimes attended with considerable difficulty.

In cases of phthisis, even in the earlier stages, there is often vomiting after food; and, as in subacute inflammation of the mucous membrane of the stomach,

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a troublesome cough is not unfrequently present, the one complaint may be mistaken for the other. In phthisis, however, the vomiting is usually preceded by severe coughing; the pulse is quicker, the heat of skin greater, and the emaciation more rapid than in gastritis. Any doubt as to the real nature of the disease ought to lead to a careful exploration of the chest, and the fluid rejected from the stomach should be examined with the microscope.

The incessant vomiting that accompanies certain forms of disease of the brain, may give rise to a suspicion of the existence of gastritis. Dr. Habershon mentions a case in which the vomiting was so severe that food was immediately rejected with great violence; and after death disease was discovered at the origin of the pneumo-gastric nerves. We must be chiefly guided, in forming our opinion as to the seat of the malady, by the history, and by the other symptoms manifested during the progress of the disease..

There is often difficulty in distinguishing between affections of the brain and those attacks of gastroenteritis which in children are termed "remittent fever." In brain disease, however, there is more heat of the head, the pulse is quicker, and the remissions are less distinctly marked than in the fever. The vomiting is more apt to occur when the stomach is empty, and it follows more immediately after the food is swallowed than in gastritis. Again, the bowels are generally confined in brain disease, and relaxed in remittent fever; and in the former the abdomen is generally contracted while in the latter it is distended with flatus.

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