CONDITION OF THE MUCOUS MEMBRANE.

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In nearly every case of chronic ulcer that I have examined with the microscope the blood-vessels have been diseased. Even in the mucous membrane surrounding the sore they are often, as represented in plate 5, figures 2 and 3, enlarged and thickened. These changes are still more frequent in the deeper parts. In some the arteries are most affected, their coats being thickened or fatty, or they are enlarged and tortuous. In other cases, the veins are principally diseased.

It is generally stated by authors, that except the ulceration the mucous membrane is healthy. Unless careful examination be made, this will ordinarily seem to be the case. It is not, however, unusual to find considerable thickening in some other portion of the lining membrane than that on which the sore is situated. Occasionally, small white spots showing fatty degeneration may be observed. This appearance had attracted the notice of Dr. Abercrombie, who remarks that, in a case of gastric ulcer, "higher up towards the cardia there were numerous white or ash-coloured spots of various sizes, like to marks of small-pox. They were much smoother than the surrounding membrane, and of much lighter colour, and there was every reason for considering them as the cicatrices of small ulcers." Microscopic examination often shows that the white spots similar to those just described are not cicatrices, but the result of fatty degeneration.

In the case of an ulcer of the stomach, which had proved fatal by perforation, the whole of the organ was in a state of fatty degeneration, although to the naked eye it appeared healthy. The tubes could be

readily distinguished, but they were filled with large and fatty cells, and the basement membrane was everywhere very thin, and in some places scarcely to be observed. The appearance of the mucous membrane at a little distance from the sore is shown in plate 10, figure 3.

Not unfrequently, the gastric tubes throughout the membrane are filled with cells and granular matter, and present the ordinary appearance of chronic tubular gastritis. From the quantity of tough or glairy mucus often vomited by the patients, and from the frequency with which acidity is observed, there can be little doubt that the ulceration is associated, in the greater number, either with chronic inflammation or congestion of the whole mucous membrane.

The causes of chronic ulcer of the stomach have been frequently discussed. The chief difficulty seems to be, that authors have massed together all cases in which a loss of substance in the lining membrane had been observed, without looking at the other circumstances of the disease.

There can be no question that an ulcer may originate on a mucous membrane in the same way as on the external surface of the body, viz. from sloughing produced by debility, from congestion, or from inflammation, and that it may assume a chronic form, if the powers of reparation be enfeebled.

In a large proportion of the cases it has been found that the patients were suffering from some affection of the heart, liver, or kidneys; diseases which we have already seen are generally attended with congestion or chronic inflammation of the stomach. To this group may be also referred most of the

CAUSES OF CHRONIC ULCERS.

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instances given by authors in which no symptoms of the complaint had been present; the attention of the patient having been engrossed by the sufferings produced by the original disease. Thus, Dr. Chambers gives five cases out of twenty-two in which no symptoms had been remarked, and in three of these there was disease of the heart, in one a disease of the kidneys, and in the remaining one an affection of the liver.1

Again, a similar explanation may be given of the connection between gastric ulcer and phthisis. All authors agree that this complaint is very often found in persons who have died of consumption, and it has been computed that 20 per cent. of the whole number occur in tuberculous subjects. We have seen how liable the stomach is to be inflamed in phthisis, and as the powers of life are very feeble we can easily understand that an ulcer once formed will be likely to become chronic.

But we are not, I think, justified in concluding that all chronic ulcers of the stomach originate from sloughing, congestion, or inflammation; and that the difficulty of healing them arises only from feebleness of the reparative powers of the whole system, or from some peculiarity connected with digestion.

Every surgeon knows that morbid alterations in the blood-vessels are the most frequent cause of chronic ulcers of the leg, and that the difficulty in their healing arises chiefly from this cause. As we have before seen, the vessels are constantly diseased in gastric ulcer, we can scarcely doubt that in this

London Journal of Medicine, 1852.