the stomach are scattered through the older writers. These cases have been generally passed over by modern authors; partly, perhaps, because they were cited as instances of acute gastritis, which they evidently were not, and partly, I suspect, from the idea that the descriptions of the older anatomists are not sufficiently exact for the requirements of science in our day. From this latter opinion I entirely dissent. Our forefathers examined what they saw as carefully as we do; perhaps more so, for the very reason that their opportunities were more limited.

The nature of the ulcerations just described can admit of little doubt; but this is not the case with respect to another form of more frequent occurrence. I allude to what is often termed "the perforating ulcer," as it occurs in young females.

A young woman, shortly after a meal, is attacked with vomiting, accompanied or followed by violent pain in the region of the stomach. The pain spreads rapidly over the whole abdomen, and is increased by the slightest pressure. The patient lies on the back or side with the knees raised. The countenance is pale and anxious, the nostrils dilated, the breathing quick and constrained. The pulse is small and rapid, and in a short time after the attack the abdomen becomes swollen, and its muscles tense and hard. Death generally takes place within thirty-six hours.

On post-mortem examination, the cavity of the abdomen is found to contain a turbid or bloodycoloured fluid. The intestines are red, coated with a greater or less quantity of lymph and adherent to each other. On laying open the stomach, a small round or oval ulceration is discovered, seldom exceed

APPEARANCE OF THE ULCER.

299

ing the size of a shilling, and generally situated in the lesser curvature, in or near the pyloric region. The ulcer perforates all the coats of the organ, and is conical in shape, the opening in the mucous membrane being much larger than that through the muscular structure, whilst the aperture in the peritoneum is often very minute. In other cases, it presents an appearance as if the whole of the coats had been more evenly punched out. The edges of the ulcer are thin and sharp, not raised and thickened as in the more chronic forms of the complaint. The remainder of the gastric mucous membrane is generally found to be healthy.

An important question arises as to the nature of such cases. It is possible that they may be produced partly by the action of the gastric juice, by inflammation, or by sloughing from debility.

The appearance of the ulcer is sufficient to negative the idea that the perforation is in any way the result of the secretion of the stomach. When a piece of mucous membrane is digested in gastric juice, the edges of the part dissolved become transparent and ragged; but in these sores the muscular layer is as cleanly cut through as the mucous membrane, and the peritoneum at its base has a dull sloughy aspect, instead of the gelatinous appearance of digested connective tissue. Nor can we refer them to inflammation. The edges are neither raised nor thickened, and there are no adhesions to the neighbouring parts. The remainder of the stomach is almost always healthy, neither congested nor covered with an abnormal amount of mucus. From these facts we can arrive at no other conclusion than that the ulceration

is the result of sloughing produced by deficient vitality.

This conclusion is borne out by the history of the persons in whom the disease occurs. With few exceptions, they have suffered from anæmia, and have been unfavourably situated as regards the means of maintaining health.

Dr. Crisp pointed out that most of the subjects of this form of gastric ulcer have suffered from imperfect menstruation. To this Dr. Brinton objects, "that some of them are expressly mentioned as not having arrived at puberty; others are recorded to have menstruated regularly, and even profusely; and, finally, one of the most characteritsic instances occurred in a person who, though supposed to be a female, was proved by a careful necropsy to be devoid of ovaries, and therefore, physiologically speaking, alike incapable of menstruation, or of any conceivable disorder of the function.1

Judging from my own experience, I believe Dr. Crisp to be in the main correct, and that whenever there are no signs of inflammation around the ulcer or in the other parts of the mucous membrane, the sloughing is the result of some cause that has depressed the vital powers of the system, and that, either as a cause or consequence of this state, the menstrual functions will have been imperfectly performed.

The suddenness and fatality of this disease render it a point of great importance to ascertain the nature of the symptoms that precede the perforation. In

1 Dr. Brinton On Ulcers of the Stomach, p. 32.

PRECURSORY SIGNS OF SLOUGHING ULCERS. 301

none of those that have come beneath my own observation has there been any previous sign of gastritis or other serious disorder of the digestive organs. The patient has generally stated that for two or three weeks before the fatal illness there has been a loss of appetite, a sensation of fulness or a diffused pain of the chest after food, together with constipation of the bowels. There is, in fact, a want of all those painful local sensations which we might expect in a complaint of such gravity. In one case given by Dr. Crisp, a "tall and delicate girl," fifteen years of age, and apparently in the enjoyment of good health, after giving a violent scream, became insensible. "She

was cold and pallid, the pupils were much dilated, the pulse scarcely perceptible, and there was vomiting of a glairy matter." No disease was found after death in the brain, the only morbid appearances being those of peritonitis from a perforating ulcer.

Considering the suddenness with which the symptoms of perforation occur, it is not surprising that the suspicion has arisen in many of these cases that death had been produced by poisoning. In a medico-legal point of view, the disease requires careful consideration, and the observations of Dr. Taylor appear to me of such value that I have transcribed them in this place, and would particularly direct the reader's attention to them.

"The attack commences with a sudden and most severe pain in the abdomen, generally soon after a meal. In irritant poisoning the pain usually comes on gradually and slowly increases in severity. Vomiting,

1 Lancet, 1843.

if it exist at all, is commonly slight, and is chiefly confined to what is swallowed. There is no purging; the bowels are generally constipated. In irritant poisoning the vomiting is usually severe and purging seldom absent. The person dies commonly in from eighteen to thirty-six hours; that is also the average period of death in the more common form of irritant poisoning, ie., by arsenic; but in no case yet recorded has arsenic caused perforation of the stomach within twenty-four hours; and it appears probable that a considerable time must elapse before such an effect could be produced by this or any irritant. In perforation from disease the symptoms and death are clearly referable to peritonitis."1

It is generally believed that perforation of the stomach in these cases is always fatal, but the following seems to show that recovery may sometimes take place.

CASE 26.-A woman who had for some weeks suffered from slight dyspeptic symptoms was suddenly attacked with an agonising pain in the region of the stomach. When I saw her the same evening, the pulse was small and rapid, the abdomen tense and generally tender. From the great depression, the suddenness of the attack, and the rapid production of the symptoms, I had little doubt that perforation of the stomach had taken place. After being apparently at the verge of death for some days, the peritonitis gradually subsided, and she eventually recovered.

In a case of this kind it may be said that there

1 Dr. Taylor On Medical Jurisprudence, p. 150.