materials improper for such a purpose, and of the methods of employing them, which he deems injurious, we pass over; and, in doing this, will arrive at his own method of plugging the teeth. "On looking over my cases of instruments, I find," he says, (p. 403) "that, for this operation alone, more than one hundred and seventy separate implements are ready for use; not to add, that I am always provided with some particular mechanical tools with which I can, at any time, modify certain instruments, with a view to adapt them for uncommon cases with very little delay."

Mr. K. declares that gold is the only material, the durability of which can be depended upon for properly plugging the teeth: he uses the metal in its purest state, and generally keeps about six different degrees of thickness of the gold leaves, for the purpose of being prepared to meet every diversity of circumstance. All carious teeth, in which the disease has not "completed its work of destruction," nor has advanced to such extent as to be incurable by the combined efforts of art and nature, indicate the necessity for this operation: our author's general rules relating to this question, will be perused with advantage. To render the process certain of success, it is requisite that the morbid teeth be perfectly free from all symptomatic inflammation of the lining membrane or bony structure: general fever, however slight, is a sufficient cause for delaying the operation: it should never be attempted, indeed, except when the individual enjoys good health every local exciting cause of inflammation should also be entirely removed.

Stopping a tooth is divided by Mr. K. into two parts-a curative, and a preventive treatment: the first consists in the perfect extirpation of the carious, or, as he calls it, the bony abscess; the second, in the proper stopping of the cavity, on which the permanency of the cure depends, and a relapse is prevented: by thus filling up the cavity, three great objects are attained-security against any accumulation of corrosive matter in it; protection of the lining membrane; and restoration, in a great measure, of the health and strength of its bony structure. Great care should be taken to cut away the whole unsound portion of the tooth; not merely what is brown or darker than the rest, but every particle that is not white and evidently undiseased: if one speck of caries remains, a cure cannot be accomplished. When the lining membrane is covered only with dead or putrid structure, this should be perfectly removed, and when the nerve is laid bare and bleeds, the hæmorrhagė must be allayed before the plugging can succeed. "The final consideration," says the author, (p. 416) "in the management of this part of the operation is, to take great care to give the cavity a proper form in order to retain the metal. For this purpose, it should be round or oval, entirely smooth, and free from ragged edges," (and, he' should have added, wider at the bottom than the orifice ;) "and, before the metal is placed in the tooth, the cavity should be carefully washed out with locks of cotton" (a soft feather, a hair pencil, or piece of sponge fixed to a proper handle is preferable) " dipped in warm water, and afterwards completely dried by the same means. In stopping the tooth, the metal should be firmly pressed into the cavity, and rendered as compact as if it were solid metal, so that nothing could by possibility penetrate through it. The redundant metal is then to be cut away, and the plug perfectly smoothed and polished by some burnishing instrument.”—“ When the caries is in that side which is next the adjoining tooth, a division must be made with a file between the teeth, in an oblique direction towards the neck of the tooth, so as to permit extirpation of the caries and filling of the cavity."

Continued at p. 213 et seq. of this Number.

Quarterly Periscope

OF

PRACTICAL MEDICINE;

BEING

The Spirit of the Medical Journals,

Foreign and Domestic ;

WITH COMMENTARIES.

PART I.

PERISCOPE OF HOSPITAL REPORTS.

"Neglecta reducit, sparsa colligit, utilia selegit, necessaria ostendit,-sic utile."-BAGLIVI.

1. M. ANDRAL ON CHRONIC GASTRITIS.

MEMOIRE SUR LES CARACTERES ANATOMIQUES DE LA GASTRITE CHRONIQUE. PAR M. ANDRAL, FILS.*

A MEMOIR ON THE ANATOMICAL CHARACTERS OF CHRONIC GASTRITIS. BY M. ANDRAL, JUN. [LA CHARITÉ.]

PART I.-Alterations of the Mucous Membrane.

In the great majority of cases of chronic gastritis, dissection shews the mucous membrane of the stomach altered in various degrees from its natural appearance. Sometimes, however, no appreciable lesion can be discovered after death, the surface being of its natural colour, thickness, and firmness throughout. In such cases various diseased conditions of the subjacent cellular tissue are found-especially in that condensed and whitish membrane between the villous and muscular tunics of the organ. M. Andral concludes, from analogy, that, in such cases, the inflammation has extended from the mucous membrane to the subjacent tissue, leaving its former seat in apparent integrity. He illustrates this supposition by the following analogical facts. An individual is attacked with enteritis or colitis. If he dies in the acute stage, the mucous membrane alone will be found affected, either by redness, softness, ulceration, or other alteration. If he survives for a certain period, until after the inflammation has become chronic, the intestine presents three different states: Imo. The inflammation may be confined to the mucous membrane only; 2ndo. The mucous membrane and the subjacent tissues may be affected in equal, or in very disproportionate degrees, presenting softness of Repertoire Generale, &c. No. 1 and No. 2, 1826.

VOL. VI. No. 11.

L

structure, alterations of colour, in points, stripes, or patches-or even in ulcerations, in various stages of development or cicatrization, the same as we see in the mucous membrane lining the mouth or pharynx. In some of these instances, the mucous membrane would seem to be in a mending condition, while the sanative process had not yet commenced or advanced in the subjacent tissue. 3tio. The mucous membrane returned to a perfectly sound state, while traces of disease are still cognizable in the cellular membrane underneath.

In the mucous membrane of the lungs, the same succession of phenomena may be seen: thus, in acute bronchitis, the inflammation is bounded to the mucous membrane; in chronic bronchitis, the lining membrane and the tissue underneath are both affected, in various degrees; and, finally, at a more remote period, we shall find the mucous membrane become sound in structure, at least in appearance, while diseased conditions still obtain in the neighbouring parts. If these analogies are not quite satisfactory, M. Andral resorts to a more tangible example: thus, after an inflammation, more or less intense, of the conjunctiva, and after this membrane has begun to resume its accustomed transparency, the cellular tissue connecting it with the sclerotic will sometimes continue inflamed, infiltrated with pus, thickened, or the seat of various incipient alterations of structure. The same may be observed of old gonorrhoeas, where the mucous membrane of the urethra will have regained its pristine state of integrity, the subjacent cellular tissue remaining thickened, indurated, and causing strictures of the passage. Other examples, of the same tendency, may be cited from inflammations of the serous and synovial membranes, where these last are become natural in appearance, the traces of disease still subsisting in the contiguous structures. Applying these analogies, then, to the stomach, we may conclude that the inflammation (the traces of which can only be found in parts beneath the mucous membrane) had its primary seat in this membrane itself. M. Andral avers that he has had opportunities of proving, by ocular demonstration, these transitions and changes, in cases that happened to be cut off in various stages of disease.

The next question is this:-When the mucous membrane of the stomach is returned, in appearance, to a state of integrity, the traces of disease still existing in the parts beneath, is the appearance a proof of real integrity in the membrane? It is to be observed that, notwithstanding this apparent sane state of the membrane, in the eye of the anatomist, the physician will find that the function of the part is not restored to health. The digestion will be slow and painful, and the surface of the stomach incapable of performing those changes in the food which constitute perfect chymification. This observation applies, also, to other parts, besides the stomach. Thus, in some individuals, who had presented all the symptoms of chronic bronchitis, with copious puriform expectoration, our author has found the mucous membrane of the larynx, trachea, and bronchia, in apparent integrity, and without the smallest vestige of even redness, so that its pathological condition could only be inferred from the disordered function during life.

But a sound condition of the mucous membrane of the stomach in chronic gastritis is a rare occurrence. Most frequently it presents divers alterations in consistence, thickness, and form. The alterations in colour are very often the same as in acute gastritis. These are redness, greyslate colour, (grise-ardoisée) brownness, and blackness, in various degrees of intensity. We need not enter into M. Andral's speculations on the cause of these different colours; but if any one should doubt that they are signs of previous chronic inflammation, he submits the following facts for their consideration.

Imo. If the symptoms during life have been well observed in such cases, they will always be found to have been those of chronic gastritis -at least such is the result of his observations in La Charité. But these symptoms often escape observation, if great attention be not paid, because they are not, in fact, very prominent; and because chronic gastritis is often complicated with other maladies which absorb the attention of the practitioner.

2ndo. But in the greater number of these cases of discoloration in the mucous membrane, other alterations will be observed which cannot but be considered as proofs of previous gastritis, such as thickening, induration, vegetations, &c. while the subjacent tissues present unequivocal traces of phlogosis.

3tio. In certain cases of ulceration of the stomach, and still more frequently in ulceration of the intestinal canal, we find the borders of the ulcers discoloured in the manner above-mentioned.

4to. We must not attribute the grey-slate discolorations to putrefac tion, post mortem, since, in many bodies that are highly putrid, we find marks of putrefaction, but never the grey-slate or brown color of chronic gastritis. Some have attributed this peculiar appearance to the operation of the gazeous contents of the stomach or bowels-especially to the extrication of sulphuretted hydrogen gas-but this gas has never been demonstrated in the stomach where the above appearance is most common, We shall not follow our author through all his minute descriptions of these discolorations; but it may be observed that the brown and slatecoloured appearances are very rare in acute gastritis, and the most common of all in chronic. Hence M. Andral thinks that a mére inspection of the color alone may generally determine which of these inflammations existed previously to death. But it is to be remembered that, although the grey-slate colour is rare in acute gastritis, it is by no means uncommon to find the mucous membrane of a bright red colour in chronic inflammation of the organ.

In some cases of unequivocal chronic gastritis, M. Andral has found nothing but some large stripes of thickened and condensed mucous mem brane, the colour being actually paler in those parts than in the rest of the stomach. In one case particularly, which recently occurred in La Charité, the local and general symptoms of chronic gastritis were so marked, that a cancerous affection was suspected, the patient having often vomited black matters like coffee grounds-and yet, on dissection, the internal surface of the stomach presented only one patch of a milky

white colour, with some thickening and induration of the membrane. In other instances, this milky whiteness was found to coincide with a swelling and softening of the mucous membrane, having vessels traversing it, and also some red spots scattered over its surface.

In almost every case where the stomach has been the seat of longcontinued inflammation, dissection shews some alteration in the consistence of the mucous membrane, consisting of either induration or softening. The induration is one of the best marks by which chronic may be distinguished from acute gastritis, whether as regards the membrane itself or the contiguous tissues. Softening of the membrane is a copsequence equally of chronic and acute gastritis-but induration appertains exclusively to the former. This induration may be either general or partial. It may co-exist with a natural colour of the membrane-with a white colour-or with a grey or brown colour-but never with a red or vermillion colour. Often as this induration is found in the stomach, it is less frequent than the opposite condition-softening. This last is the most frequent of all organic changes found in the stomachs of those who have sunk under chronic diseases of various kinds in the hospitals. Hence, if it can be proved (as it presently will) that this softening of the mucous membrane is the product of inflammation, it follows that gastritis, acute or chronic, is a very common disease-much more common than has hitherto been supposed, whether it exists as a primary affection, or only as a complication with, or supervention on other maladies.

This softening has been so well described by M. Louis, that our author does not deem it necessary to go into its description here :-he observes, however, that it may be divided into three principal grades, viz. in the first degree, the membrane, though much softened and easily reduced to a pulp between the fingers, yet preserves some appearance of consistence before it is scraped with the scalpel:-in the second grade, we find, in place of mucous membrane, only a pulp, of a white, grey, or reddish colour, which one would easily mistake for a layer of mucus spread over the cellular tunic. In the third degree, this semi-liquid pulp has disappeared, and the subjacent cellular tissue is left naked, in spaces of greater or lesser extent. One of the most remarkable examples of this was seen in the case of a man, aged 36 years, who died phthisical in La Charité in June, 1824. During the three months which he spent in the hospital, he had no vomiting, but complained of complete loss of appetite, an habitual sense of tightness in the epigastrium, changing into actual pain on taking food, and sometimes even on taking simple drink. Wine produced nausea, and a sensation of burning in the region of the cardiac orifice of the stomach, thence spreading up along the esophagus to the pharynx. This man died, and on dissection, there was only to be found the debris, as it were, of the mucous membrane. From the cardia to the pylorus, the sub-mucous cellular tissue was quite naked, being stripped of its mucous membrane, but still preserving its accustomed white colour, being merely a little thickened. In some spots, there were the remains of the villous coat, recognized