HÆMORRHAGE FROM SLOUGHING ULCERS.

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had been a mistake in diagnosis; but if so, it still shows that a person may present the symptoms supposed to characterise perforation of the stomach, and yet escape death.

This form of ulcer may lay open a blood-vessel instead of producing perforation. On account of the absence or the trifling nature of the symptoms preceding the occurrence, the diagnosis is necessarily difficult.

CASE 27.-A young woman had been ill for some days before I saw her. Her exhaustion was so great that she fainted if the head was raised from the pillow, and the pulse was very rapid and feeble. There was occasional delirium, but no complaint of pain. The face and lips were blanched, and there was a systolic murmur at the third rib. The catamenia were stated to have been regular, and she had not previously suffered from anæmia. On careful inquiry, it was ascertained that for two or three weeks before her illness she had been troubled with flatulence and occasional uneasiness after food, but without any severe pain or vomiting. Whilst sitting at work she was suddenly seized with faintness and retching, but vomiting did not occur. For a few days after this attack her mother had remarked all the evacuations from the bowels to be of a dark colour, which she supposed to have been caused by bile. Considering the suddenness of the illness, the previous occurrence of slight dyspepsia, and the evidence of internal hæmorrhage, it was concluded that a blood-vessel had been laid open by ulceration. She ultimately recovered, but it was many months before she regained her former strength and colour.

Although the cases in which gastric ulcers take place are few compared with the numbers of young women who are affected with anæmia, the possibility of this accident must be borne in mind.

Iron and quinine are the best remedies for the dyspepsia accompanying anæmia, but they are frequently commenced too soon. It is generally advis able to precede their use by alkalies, gentle aperients, and vegetable tonics. It is often a good plan to alternate the use of iron with that of a vegetable bitter.

II. ULCERATIONS ACCOMPANYING CONGESTION.

In

We meet with the best instances of this form of ulceration in persons who have died from such affections of the heart and liver as tend to produce congestion of the gastric mucous membrane. such cases we often find on the surface of the stomach numerous round or oval patches of a dark colour. Many of these are covered with a small clot of blood, and when this is washed away an ulceration of greater or less depth may be observed. In some the loss of substance is but slight, in others it extends to a greater depth.

These erosions have been attributed by various authors to post-mortem solution of the blood extravasated during the last days of a lingering death. I think this explanation is incorrect, for there is not much post-mortem digestion in these cases, and the erosions occur most frequently near the pylorus where

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the gastric juice seldom affects the surface to any great degree. In addition to this, the edges of the erosion are clearly marked, and on microscopical examination there is not observed that gradual decomposition of the surrounding tubes which ought to be present if this theory were correct.

The want of correspondence between the symptoms during life and the appearances after death apparently support this explanation, as in such cases there has been seldom any severe complaint of epigastric pain. But it must be borne in mind that, under such circumstances, all the natural sensations are deadened and the patient's attention is absorbed by the urgent dyspnoea or other symptoms with which he has to contend. We cannot, then, be surprised that a passive action like a small local hæmorrhage should fail to attract his attention, or produce effects likely to demand the notice of the practitioner.

This form of ulceration requires no special treatment. As it depends upon the congested state of the mucous membrane, our only hope of relieving it is by removing the overloaded condition of the blood-vessels.

In some cases, and especially in young persons, vomiting of blood takes place; and if this occurrence seems likely to reduce the strength of the patient, it must be combated by rest and astringents. In others, an occasional oozing of blood goes on, and passes off, unobserved, by the bowels. Occasionally the hæmorrhage assists in relieving the congestion, at other times it weakens the patient and tends to hurry the case to a fatal termination.

X

III. ULCERS INDUCED BY INFLAMMATION.

This is perhaps the most common form of gastric ulceration. We meet with it not only as an idiopathic affection, but also during the course of other diseases which have a tendency to produce gastritis.

The lining membrane, in fatal cases, is red, swollen, and often considerably softened. It is covered with mucus, which may contain either shreds of blood or "coffee ground" particles. On the surface of the membrane, and chiefly towards the pyloric region, are scattered a number of small brown or sootycoloured spots, seldom larger than a shilling and often only the size of a pin's head. At other times they look like mere blood-stains, and are irregular in size and shape. With these, and evidently only later stages of the same process, are small ulcerations similar in appearance to the spots, and frequently presenting a dark colour at their edges.

In a dog, to which I had given a small dose of sulphate of zinc a few days before death, I found numerous small spots and ulcerations scattered over the mucous membrane of the stomach. Some of the spots were like those I have described as occurring in the human subject; but in others the dark parts had been thrown off, and small ulcerations had been produced. These ulcers had not elevated edges, but were bounded by a dark red line showing the remains of extravasated blood. A perpendicular section through one of them is shown in plate 10, figure 1, and it will be remarked that the tubes

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in the neighbourhood of the ulcer are not united together by inflammation. This I consider to be an important point, as in chronic ulcerations we generally find the secreting tubes at the edges of the ulcer closely matted together.

In the stomach of an Indian civet cat, lately examined by me, the whole of the splenic region was of a uniform red colour, as if overspread by an extensive blush, whilst numerous minute dark red circular spots were scattered over the surface, varying from the size of a pin's head to that of a pea. The pyloric region was less inflamed, but was covered with a thick layer of mucus. The tubes in the splenic region were distended with a confused mass of cells and granular matter, but there was no appearance of inflammatory action between or below them. In the pyloric region the greater number of the tubes were deprived of epithelium and the solitary glands were enlarged. The stomach and duodenum contained some bloody mucus, but there was no suspicion of poisoning, the animal having died of another disease.

I have met with similar appearances in others of the lower animals, associated with inflammation of the mucous membrane, and we may therefore conclude that these superficial ulcerations are a frequent consequence of subacute gastritis.

The small round superficial ulcerations have been named "follicular," from the belief that they originate in an affection of the follicles of the stomach. Dr. Fox states that, "In some cases the enlarged glands ulcerate, and it is to their undergoing this degeneration that I believe the majority of the so-called