stomach is injurious; but enemata are of themselves scarcely sufficient to meet the indication to evacuate the upper as well as the lower bowels. The gentlest laxatives should be selected and sparingly used. Magnesia is one of the best, as it answers the purpose of an antacid, which is often wanted. Rhubarb, castor oil, and the Seidlitz powder may also be employed. The same end may often be advantageously accomplished by a laxative diet of bran bread, or rye mush, or of stewed fruits when these are found not to irritate the stomach. Attention should be paid to the skin. Frictions with the flesh-brush, the warm or hot bath, according to the degree of excitement, and flannel next the skin are all useful. Opium and ipecacuanha at bed-time sometimes answer a good purpose, by producing perspiration, as well as by enabling the patient to sleep. When there is great local suffering with general restlessness, small doses of the acetate or sulphate of morphia may be given occasionally with advantage; but care is always requisite to avoid establishing an injurious habit, which the patient may have difficulty in breaking. Hydrocyanic acid has been recommended under the same circumstances. The feet should be kept warm, if necessary, by rubefacient applications. Congestion of the portal circle, visceral disease, whether functional or organic, and, in the female, disorder of the menstrual function, should be relieved by appropriate remedies; regard being always had to the probability of injuring the stomach by irritating medicines.

When the measures above detailed do not answer, especially when there is reason to suspect the existence of ulcers, recourse may be had to the alterative remedies, which prove so useful as local applications in similar affections of the mouth and fauces. Sub-nitrate of bismuth, the sulphates of iron, zine, and copper, and the nitrate and oxide of silver, have all been usefully employed. The nitrate of silver has within a few years attracted considerable attention, and has been given in larger doses than were formerly thought advisable. From one-quarter of a grain to a grain is often administered two or three times a day without disadvantage. Cures, in apparently desperate cases, are sometimes obtained by nitrate of silver thus employed. I have repeatedly seen patients rescued by this remedy, for whom all other hope had been abandoned. It has appeared to me to be peculiarly advantageous in those cases, frequently attended with vomiting, in which the tongue is smooth and glossy, as if deprived of the papillary structure. I cannot too strongly express my conviction of its great usefulness in chronic gastritis of this character. It is generally advisable to combine the metallic salts with small doses of opium, or one of the salts of morphia. Minute doses of mercurial pill, with or without ipecacuanha, according as the stomach will or will not tolerate the latter medicine, are also highly useful. A grain of the blue mass, with a sixth of a grain of ipecacuanha, may be repeated every two or three hours through the day, until the gums are very slightly touched.

Tonics in the advanced stages are sometimes useful, probably by giving to the tissue, relaxed by the previous inflammation, sufficient energy to take on a healthy action, and resume its ordinary functions. The chalybeates and simple bitters should be preferred. Oil of turpentine and copaiba have also been recommended.

In gastrorrhoea, which is often rather a condition consequent upon previous inflammation than itself inflammatory, the treatment by the mineral alteratives above mentioned, and by tonics, is peculiarly applicable. Should symptoms of inflammation exist, they should be combated in the ordinary manner. Should they be absent, the treatment may be commenced by an emetic of ipecacuanha followed by a calomel purge; and the bowels should afterwards be kept open by preparations of rhubarb or aloes, or a combina

tion of the two. The vegetable bitters, chalybeates, and mineral acids may be used; but most confidence is generally placed in the sub-nitrate of bismuth and nitrate of silver, the latter remedy being given in the dose of half a grain or a grain twice a day. Opium or some one of its preparations may be combined with the mineral salts to relieve pain and check secretion. Copaiba and the turpentines, or their volatile oil, may be given with a view to their alterative action on the mucous membrane. These also may be usefully combined with opiates. The diet should in general be nutritious and digestible, consisting chiefly of farinaceous substances and animal food.

During the course of the treatment, in every form of chronic gastritis, efforts should be constantly made to prevent the mind from reacting inju riously on the stomach, and at the same time to remove excitement from this organ by diffusing it equably over the whole system. Hence the importance of regular though not violent exercise, of relaxation from the cares and anxieties of business, and of agreeable mental occupation. A complete change of scene often proves serviceable. Excursions to different parts of the country, visits to the springs and to the sea-shore, sea voyages, and a residence or travelling abroad, often prove effectual, when much movement is not contraindicated, in bringing about a cure, or confirming convalescence.

Article II.

CANCER OF THE STOMACH.

Carcinoma attacks the stomach in all its different forms, whether of scirrhus, medullary cancer, or colloid cancer. The notion, at one time entertained by certain pathologists, that these tumours were simply the result of inflammation, has been entirely exploded. There is little doubt that mere effects of chronic inflammation, neglected or abused, have sometimes been mistaken for cancer; and there are also instances in which it would be difficult or impossible to determine, upon a mere inspection of the diseased parts, especially in scirrhous cases, to which of these complaints they should be referred. But the microscope has removed the difficulty, so far as post-mortem examination is concerned, and has satisfactorily shown, in many of the cases otherwise doubtful, that the disease is true scirrhus, by the detection of the proper cancer cells.

Symptoms and Diagnosis -The symptoms of cancer in the stomach are so nearly those of chronic inflammation, that it is often impossible to distinguish the two complaints during life. It is unnecessary, therefore, to notice any other characters of the disease than those to which some value has been attached in reference to diagnosis.

The pain, which is almost always experienced, in a greater or less degree, and is sometimes excruciating, varies very much in its character. Lancinating pains have been thought to be diagnostic of cancer in the stomach, as of the same complaint elsewhere; but the fact has been well ascertained, that such pains occur occasionally in chronic gastritis, and are by no means present in all cases of cancer.

Vomiting is a very common, and very distressing symptom; but is sometimes wanting; and, in many instances, is unfrequent at the commencement. At first, the patient discharges his food or a glairy mucus; afterwards, together with these, sour, bitter, or acrid fluids; and, in the end, not unfrequently, blood, or a black matter which has been compared to soot and water, or to coffee-grounds. This black vomit, which has been looked on as characteristic,

is, in fact, common to cancer and chronic gastritis. But, though not a certain sign, the character of the vomiting assists in forming a precise diagnosis, and sometimes points to the seat of the disease. Thus, when the food is rejected after it has been swallowed, and before it has entered the stomach, or when, after entering the stomach, it is retained, but quickly occasions excessive nausea and the discharge of a glairy mucus, there is reason to suppose that the cardiac orifice may be affected. If the stomach reject almost everything which it receives, after having retained it for some time, the probability is that the pylorus is occupied by a cancerous tumour, and resists the passage of the chyme. When, after frequent vomiting, the patient ceases to be troubled in this way, but is seized with a severe and exhausting diarrhoea, it may be inferred that the mucous membrane at the pylorus has been destroyed by ulceration, and thus opened a wider passage. Generally speaking, when the mucous coat has become disorganized, there is less vomiting, as the sensibilities through which this action is excited reside chiefly in that membrane. The bowels are usually obstinately constipated, though diarrhoea sometimes occurs towards the close.

The cachectic countenance of cancerous patients is one of the most characteristic symptoms. The complexion has a peculiar yellowish-white, waxen appearance, which is not often met with in other complaints.

But the most certain diagnostic symptom is a tumour in the epigastrium. This is discovered at various periods in the progress of the complaint, and of course is obvious in proportion to the emaciation. It is most readily perceiv able when in the pylorus, or great curvature of the stomach. Sometimes, however, the absorbent glands in the vicinity of the stomach are much swollen, and other tumours in the same neighbourhood may be mistaken for scirrhus. But, when the tumour is associated with the other symptoms above mentioned, there can be little doubt of its carcinomatous character.

The progress of cancer of the stomach, and its duration, are very variable. Sometimes the complaint runs its course in a few months, sometimes continues for many years. Occasionally it appears to be latent for a long time, and then to start at once into vigorous action; and instances are not wanting, in which the symptoms have so much remitted as to give hope of cure, but have again returned with increased severity. Death usually occurs from the exhaustion of combined irritation and deficient nutrition, and is preceded in general by great emaciation, and a long and wearisome period of diversified suffering. It is sometimes hastened by ulcerative openings into the cavity of the abdomen, producing peritoneal inflammation. The tortures of hunger are added to the other sufferings, when the disease affects the cardia.

Anatomical Characters.-The stomach is sometimes much contracted, with thickened coats, and sometimes greatly enlarged. The latter is apt to be the case when the pylorus is diseased. The interior surface is usually covered with a brown mucus. The cancerous disease may occupy the whole stomach, or any part of it; but is most frequent at the two orifices, and especially at the pyloric. It is sometimes limited by these orifices, and sometimes extends beyond them into the oesophagus or duodenum. The appearances vary with the period at which the patient dies, and with the character of the cancerous affection. In scirrhus, if ulceration has not taken place, the inner coats of the stomach are found in general more or less confounded together, into a whitish, indurated, semi-cartilaginous mass, from two or three lines to several inches in thickness. The peritoneal coat is much less liable to be affected than the others, and often remains free from disease. The muscular, mucous, and intervening cellular coats may often be recognized in a state of greater

or less alteration. Sometimes the disease is confined chiefly to the submucous cellular tissue, and sometimes to the mucous membrane itself.

Instead of this thickening of the coats, the disease occasionally consists of a roundish mass or masses, projecting from the submucous tissue, or the mucous membrane, into the stomach. Instead of being indurated and white, the tumour is sometimes of a soft or brain-like consistence, constituting medullary cancer, and sometimes red, as if injected with blood, resembling fungus hæmatodes. In another form of the disease, the parietes of the stomach are thickened, and, instead of their usual structure, present numerous cells separated by fibrous partitions, and filled with a gelatinous deposit. This is colloid cancer.

In a more advanced state of the disease, ulcers are found with hard, elevated, and reverted edges, and a surface irregular with fungoid excrescences, and often exhibiting the open orifices of blood-vessels of considerable magnitude. They are found in different stages of their progress, showing a disposition to extend both in breadth and depth, and not unfrequently perforating the coats of the stomach. In this case, the peritoneal coat has often contracted adhesions with the liver, spleen, pancreas, or other neighbouring organ, the substance of which is thus penetrated by the disease, and forms the basis of the cancerous ulcer. Sometimes the adhesion is formed with the colon or diaphragm, and the contents of the stomach thus escape into the bowels or lungs. Again, the ulcer is seen opening directly into the cavity of the abdomen, which exhibits the marks of severe peritoneal inflammation. Cases are on record in which the carcinomatous affection has extended anteriorly to the abdominal parietes, or posteriorly to the spine, before the fatal issue.

Causes. Cancer in the stomach arises probably from the same causes as those which produce cancer elsewhere. What these causes are is uncertain. We must be content with ascribing the result to a peculiar predisposition or diathesis; but of the origin of this we know nothing. It is highly probable that whatever irritates or inflames the stomach may call the predisposition into action. It is certain that the disease is at least aggravated by such influences. The abuse of alcoholic liquors, excesses in eating, and the employment of tonic and stimulant medicines, which are often administered in the early stage of cancer of the stomach, under the impression that it is dyspepsia, hasten the progress of the complaint, and perhaps call it prematurely into existence. The depressing emotions are thought to favour its production; and Napoleon, on the Island of St. Helena, may be cited as an example.

The disease is exceedingly rare before puberty, and seldom occurs until after the twenty-fifth year. It is most common in middle life; but is not unfrequent in the old. Males are said to be more subject to it than females.

Treatment. This must be entirely palliative. All that can be expected is to protract life, and alleviate suffering. For this purpose, nothing is so important as to regulate the diet properly. As a general rule, no stronger drink should be allowed than water, and spices and other condiments should be avoided. The food should be mild, easily digestible, and nutritious, so as not to stimulate the stomach either by its quality or quantity. It may consist of the farinaceous substances, milk, cream, boiled meats, broths, oysters, &c. Nothing, on the whole, is so suitable as milk. Large quantities either of food or drink should not be taken at once. The bowels should be kept open by enemata, or by the mildest laxatives. Attention should be paid to the skin as in chronic gastritis. Acidity may be corrected by the bicarbonate of soda or of potassa, or by lime-water with milk as food. A few leeches occasionally applied to the epigastrium, and revulsion towards the same place by means of rubefacients or epispastics, will sometimes prove useful by dimi

nishing inflammation. To relieve the pain or local distress, to quiet irritation, and promote sleep, it is necessary to resort to anodynes; and the preparations of opium are the most effectual. The salts of morphia, or the black drop, are probably the best of these for the purpose. The extracts of hemlock and henbane, and lactucarium may be used as adjuvants of opium, or as substitutes. Sometimes it is best to administer opium or laudanum by enema, or to sprinkle acetate of morphia, in powder, upon a raw blistered surface in the epigastrium.

Article III.

IRRITATION OF STOMACH.

By this term is meant any morbid excitement of the stomach, not amounting to inflammation. Instances of disorder of this kind are exceedingly common, although not usually associated by writers under this name, and often too much neglected in practical treatises. Though seldom in itself dangerous, irritation of stomach is in many of its forms very distressing to the patient, and, if not arrested, often terminates in gastritis, either chronic or acute. It presents itself in a variety of forms, dependent on the tissue or function affected, the nature of the cause, and the previous condition of the stomach or the system. It sometimes affects the organic functions especially, sometimes the nervous exclusively, and both at the same time. Though often merely the antecedent of inflammation of the stomach, or frequently a secondary or attendant affection of other diseases, it yet has in numerous instances an independent existence, and therefore requires an independent consideration. I shall treat of its different forms first in relation to the causes, and secondly in relation to the phenomena. This will necessarily lead to some repetition, but is necessary to a satisfactory view of the subject.

1. In Relation to its Causes.

Irritation from Congestion of the Portal Veins.-From a sluggish state of the portal capillaries of the liver, or from other causes, the blood frequently accumulates in the veins which supply the vena portarum, and consequently in the capillaries of the stomach, which is excited into morbid action by the unusual amount of stimulus. The affection is attended with a sense of fulness, weight, or uneasiness in the epigastrium, sometimes amounting to pain. The appetite is somewhat impaired, the tongue often slightly furred near the root, the stools scanty, or light coloured from deficiency of bile, the complexion sometimes sallow, and the mind irritable or depressed, and disposed to view everything in a gloomy light. The condition is one of those to which the name of bilious complaint is often vaguely applied. It is a frequent antecedent to bilious fevers, cholera morbus, jaundice, and vomiting of blood; and there is reason to believe that some of these diseases might often be prevented by its timely treatment. It occurs most commonly at the commencement, or during the prevalence of hot weather, but is found at all seasons. A full dose of the compound cathartic pill, or other active purgative combination containing calomel or the mercurial pill, with a farinaceous diet for a day or two, will frequently remove the complaint. Should the hepatic secretion not be sufficiently restored in this way, a mercurial pill, or a grain of calomel may be given at night, and followed by a mild laxative in the morning; and this plan should be continued every day, or every other day, until the passages indicate that the liver is acting freely.