The stomach sometimes undergoes a change of volume, which is appreciable during life. The enlargement of cavity in a hollow organ is owing to various causes. Sometimes it takes place consecutively to an obstruction at the orifice of ejection, as we see in the heart, bladder, gall-bladder, &c. in which cases the parietes of the organ may remain of their natural thickness-be attenuated-or hypertrophied. At other times we find the dilatations take place in different organs, without any obstruction of the orifices whence their contents issue. This is especially the case with the stomach, which sometimes enlarges so as to almost fill the whole cavity of the abdomen, with or without any obstruction of the pyloric orifice. The folowing cases are curious.

Case 1. A woman, aged 65 years, meagre and miserable, began, about the month of June, 1821, to experience symptoms of an organic, affection of the stomach, as difficult digestion, alternate anorexia and voracity, acid eructations, nausea, vomitings some hours after eating, pain in the epigastrium, &c. These symptoms increasing, she entered La CHARITE in March, 1822, being then reduced to a state of great emaciation. The space occupied by the stomach in the abdomen was well marked-indeed it was evident that it occupied the greater part of this division of the body. Its great curvature rested on the pubes, and the lesser curvature formed a sweep a little above the umbilicus. The patient had constant pain in what corresponded with the region of the pylorus, exasperated at intervals. She vomited a great quantity of black matters, and could not keep any food on her stomach. She died about a fortnight after entering the hospital.

Dissection. The thoracic and cranial organs sound. The abdomen being opened, the stomach was seen filling almost the whole of the cavity, descending to the left iliac fossa on one side, and stretching thence to the same situation in the other. The intestines were entirely concealed by the stomach, which contained an enormous quantity of dark-coloured fluid, resembling that which had been vomited. The mucous membrane was perfectly white, but much softened, and, for some inches round the pylorus, it was abraded, and an ulcer formed. No muscular fibres could be seen opposite the part where the mucous membrane was wanting. The orifice of the pylorus was not much narrowed-on the contrary, it was capable of admitting easily the point of the finger. There was nothing particular in the appearance of the intestines.

It is difficult to imagine the cause of this enormous distention of the stomach, without any material obstruction to the exit of its contents. Our author's explanation is far from being satisfactory, and, therefore, we shall omit it.

Case 2. A young woman, aged 23 years, had always enjoyed good health, till, having met with reverses of fortune, she repaired with her family to Paris, and there became a tutoress in a public school. Her health now soon began to suffer her appetite failed-digestion became difficult, and, in February, 1821, vomitings were added to the other symp

toms. Her food was not thrown up, however, till some hours after eating. She emaciated very fast. Leeches were repeatedly applied to the epigastrium, and various medicines were tried internally, but without avail. She entered LA CHARITÉ in February, 1822, in the last stage of marasmus. Her complexion was tinted-vomiting of food or drink took place almost immediately after swallowing them-slight pain in the epigastrium, which is soft, and presents no tumour or fulness-tongue natural constipation habitual-pulse feeble-skin dry. She died on the 14th March.

Dissection. The stomach was dilated, and covered the greater number of the abdominal viscera. Its greater arch touched the pubes. The. cavity of the organ was filled with a yellowish green liquid-the internal surface had a reddish or rosy tint, but in some places, especially near the splenic extremity, it was quite pale. There was a space, the size of a person's hand, where the mucous membrane was softened, and easily scraped off. The parietes of the stomach were, generally speaking, extenuated, and easily torn. The muscular tunic was remarkably wasted. The small intestines were much contracted, not larger than those of a dog, and their internal surface pale. There was some disease in the mucous membrane of the transverse arch of the colon. The liver was very much enlarged.

In this memoir, it will be observed that M. Andral attributes to chronic gastritis, several alterations of structure which usually have specific names, and are supposed to have specific characters as scirrhus, melanosis, &c. These changes of structure have this one character in common, namely, that they are preceded or accompanied by various degrees of vascular activity, a circumstance which may be proved, or at least inferred, first, from the anatomical characters; secondly, from the symptoms during life, 3dly, by the nature of the exciting causes, which give these diseases their development; 4thly, by the treatment found to be most advantageous, namely, the antiphlogistic. But to say that all these diseases have one common character-sanguineous congestionis only to discover a certain link by which they are connected-not the causes of their differences. How is it, it may well be asked, that, during the existence of this vascular activity, or sanguineous congestion, we see spring up such opposite kinds of changes of structure? M. Andral himself candidly acknowledges that we must take into account the predisposing causes, (or, in other words, the specific predispositions) in order to explain or reconcile such different results from the same inflammatory process-and that we must regard the sanguineous congestion as merely an occasional, or exciting cause.

66

By the antiphlogistic treatment, unfortunately, we only combat this ́ last, (the inflammatory or exciting cause) but make no impression on the specific predisposition, which, once excited into action, goes on to the formation of divers changes of structure, according to the nature of the predisposition. Hence the frequent inutility of blood-letting, which only attacks one of the elements of the disease. There are, it is true, cases where this sanguineous congestion plays a distinguished part; but there are others, where it appears quite a subordinate agent-and where,

after a trifling irritation, we see produced the most formidable degenerations of structure in the stomach. There are cases, again, where this connecting link, or common feature, (sanguineous congestion) entirely disappears, and there is no proof that it ever existed. The disease should not then be called gastritis. Such are the different neuroses of the stomach-such are also certain cases of softening and extenuation of the coats of the stomach, which may be attributable to a real diminution of the act of nutrition, such as we see in the muscles of people who die of various chronic maladies." 193.

From this extract it will be seen that M. Andral modifies greatly the doctrine of inflammation, as applied to these different organic changes in the stomach, and that he views it as no more than a connecting link (and not always even that) which binds them in one genus, without at all accounting for their formation or their variety. "Pourvu que l'on ne regarde ce mot (inflammation) que comme indiquant le lien commun qui les unit mais nullement comme rendant raison de leur formation, comme pouvant expliquer leurs innombrables varietés."

We have placed this minute description of anatomical changes in the stomach on record in our Journal, because M. Andral is universally. allowed to be one of the most accurate observers, and reporters of the present day. His opportunities for post mortem investigations in LA CHARITÉ, are very great, and he turns them to good account. The document we consider as a very valuable one, especially to the pathologists of this country, where the means of research are limited, and where we are sorry to say the zeal for pathological enquiries is far below par. We will not lay the flattering unction to the souls of our countrymen upon this nor upon any other occasion, where the interests of science are at stake.

2. FEVER.

Dr. Chambers has detailed some cases of fever occurring in St. George's Hospital, by which we are enabled to form some idea of this intelligent physician's practice, as well as doctrinal views of the disease.

Dr. C. is a warm advocate for the free use of calomel, assisted by other purgatives in the treatment of the common continued fever of this country. We cannot say, however, that our observations have led us to entertain quite such confident expectations from purgation in fever, as Dr. C. appears to have imbibed. "Those who have been in the habit of treating this disease, must have observed that, in most instances, when purgatives have been early and steadily administered, all the symptoms have, in a short time, yielded to them."

A case is first related by Dr. C. where a patient was admitted into the hospital, with the common symptoms of fever, where the tongue was of a bright red colour-the bowels irritable—the motions highly depraved,

• Dr. Chambers. St. George's Hospital. Med. and Physical Journal, October, 1826.

and the abdomen tense and painful. Leeches to the belly-five grains of calomel with antimonial powder at night-a rhubarb draught next morning-and the common saline effervescing medicine through the day. In a very few days of this treatment the patient was convalescent, and ordered to take bitters.

Dr. C. observes, however, that, notwithstanding the great advantages to be derived from this practice in general; still, some cases of fever will occur where, although the symptoms are mitigated, the patient continues to labour under the irritation of fever. "It is under these circumstances, that mercury, exhibited in small and repeated doses, appears to exert the most decided influence over the disease." What then are the circumstances or symptoms occurring in the progress of continued fever, which should induce the practitioner to change his mode of treatment, by abandoning the use of direct purgatives, and adopting the alterative practice? Dr. C. naturally conceives that, when this distinct remission or cessation of early symptoms has taken place, the primary fever is subdued-" and what remains of constitutional disturbance depends on those organic lesions which are now well ascertained to be ordinary consequences of continued fever." These lesions, in their turn, excite a new febrile action in the system, "which ought by no means to be considered as a relapse of the original disease." It is, in fact, a secondary fever, depending on irritation produced by structural injury; and is clearly distinguishable, Dr. C. thinks, from the primary disease, by its remittent or hectic character," as well as by the extraordinary irritability, joined with prostration of strength, which accompanies it after it is established. The following case is offered in illustration.

66

Case. T. Kelly, aged 45, a labourer, was admitted on the 9th of August, 1826, the fever being of nine days standing. He had headache, fullness and pain in the abdomen, especially about the epigastrium, increased on pressure-pulse 110-skin hot. He was put on fever diet, which is chiefly farinaceous decoctions-to lose 12 ounces of blood, and to take five grains of calomel at night, with senna draught in the morning. In five days of this treatment, the local pains and uneasiness were gone, the pulse reduced to eighty, and soft. He only complains of debility. The calomel and purgative medicines were left off. The next day, the skin was dry and hot, the tongue furred, &c. Three grains of calomel were ordered with three of antimonial powder, every four hours. A blister to the nucha. He continued the mercurial, the quantity being gradually reduced, for ten days, by which time he had regained his natural manner, and every function was restored to a state of integrity.

Without, for a moment, questioning the principle which Dr. Chambers has laid down, we may be permitted to doubt, whether the foregoing case affords an illustration, or at all events, a proof of it. We see that on the 14th, all local pain and uneasiness had gone, and debility alone remained. The aperients being left off, he had camphor mixture and a

few drops of spir. ammon. aromat. It is probable, though not stated, that at this period some allowance of food was made, beyond the fever diet. The very next day the skin was hot and tongue dry, &c. without any return of the local pain or uneasiness. Is it not probable that this relapse was occasioned by some little irregularity in diet, rather than by any" organic lesion" produced during the preceding attack? But Dr. Chambers shall speak for himself.

"It is not intended here to enter at length into the pathology of these changes. It will suffice to say that, when this cessation, or distinct mitigation, of the early symptoms of the disease takes place, it is probable that the primary fever has been subdued, and that what remains of constitutional disturbance depends on those organic lesions which are now well ascertained to be ordinary consequences of continued fever. These lesions, in their turn, excite a new febrile action in the system, which ought by no means to be considered as a relapse of the original disease. It is, in fact, a secondary fever, depending on the irritation produced by structural injury, and is clearly distinguishable from the primary disease by its remittent or hectic character, as well as by the extraordinary irritability, joined with prostration of strength, which accompanies it after it is established." 353.

It happens occasionally that long before the primary disease has been overcome, the secondary irritation has commenced, so that, when the former is afterwards subdued, the latter presents itself to us in an aggravated form, and is, besides, the more intractable, because the strength of the patient is proportionally diminished. A case in illus-tration is added, for which we beg to refer to the Journal itself. We think the principle which Dr. C. has laid down is correct, and the practice judicious.

3. LIGATURE OF THE SUBCLAVIan arteRY. BY BARON

DUPUYTREN..

Case. Charles Lechevalier, 37 years of age, formerly a soldier, entered the Hotel Dieu, on the 27th February, 1819, for a false or consecutive aneurism of the left axillary artery. He had been wounded in the shoulder of that side, while serving in Spain, in the year 1811. The wound was made by a pointed instrument, but healed in three weeks. Two months afterwards, however, he perceived a small tumour in his arm-pit, attended with pulsation, and in the course of two years' captivity, it had acquired the size of an egg, and the pulsations were become very strong. After a long and toilsome march of 900 miles back to France, the tumour rapidly increased, and soon reached the size of a child's head, completely preventing him from following any occupation. On this account he came to Paris, and entered the Hotel Dieu. The cicatrix of the original wound in the upper and posterior part of the shoulder was still visible. The aneurism was now the size of a

Repertoire, No. 2, (Hotel Dieu.) Reported by M. Marx.