may CAUSES OF HÆMATEMESIS. 331 It arise from a blood-disease such as purpura or scurvy. A very fluid condition of the blood seems at times to take place without any apparent cause. These cases occur chiefly in females about the period when the catamenia usually cease. CASE 31.-A stout and healthy looking woman about fifty years of age, had for two or three years been affected with an ulcer of the leg, which resisted various methods of treatment, but ultimately healed. Shortly afterwards she was attacked with bleeding from the nose of so severe a character, as to necessitate plugging of the nostrils. When this was arrested, however, uterine flooding came on, which was again followed by severe hæmatemesis. She sank under these repeated bleedings, and on a postmortem examination, no structural change could be found in any organ of the body. The stomach was pale and healthy, and without any trace of ulceration. Vomiting of blood may be vicarious of the menstrual discharge. This has been doubted by many authors, because it is in persons suffering from irregular menstruation that we so often find gastric ulcer. The objection cannot apply however to those who experience this symptom during pregnancy. A lady about thirty-five years of age, who had no children, and had never suffered from dyspeptic symptoms, was suddenly attacked during the night with vomiting of a large quantity of dark clotted blood. She was much exhausted by the hæmorrhage, but presented no symptoms indicating disorder of the stomach. The next catamenial period passed without the usual discharge, and she was confined of a healthy child within nine months of the hæmatemesis. Another lady was under my care who had vomiting of blood during two of her pregnancies without any symptoms of gastric ulcer. Hæmatemesis may also arise from congestion of the portal system produced by diseased liver or heart, or it may be connected with a morbid condition of the spleen, or with a waxy or amyloid degeneration of the smaller vessels of the stomach and intestines.1 In these cases we have the general and physical signs of the accompanying diseases to guide us in our diagnosis of the source of the hæmorrhage. The bowels are usually much confined in cases of ulceration of the stomach, but sometimes the patient suffers from diarrhoea. The tongue is generally clean, and presents no indication of the disease in the stomach. It is evident that no one of the above symptoms by itself is sufficient to enable us to diagnose the presence of gastric ulceration; but by taking into consideration the whole history of the case we can generally arrive at a correct conclusion. In a patient who suffers from severe epigastric pain increased shortly after food and accompanied by tenderness on pressure, and in whom there has been either hæmatemesis or tar-coloured stools, without there being any other disease likely to account for the hæmorrhage, we may be tolerably certain that ulceration of the stomach is present. There are, however, exceptions to all general rules, 1 Dr. Wilson Fox, Medico-Chirurgical Review, 1865, and Dr. G. Stewart, ibid., January, 1868. PHYSICAL DIAGNOSIS OF GASTRIC ULCER. 333 and both Andral and Abercrombie have recorded cases where there had been vomiting of blood or coffee-ground materials along with symptoms indicating ulceration, but in which no such affection could be discovered after death. If there be so much uncertainty at times in ascertaining the existence of chronic ulcer of the stomach, may we not expect some assistance from the use of physical means of diagnosis? Unfortunately few attempts have been hitherto made to ascertain how far we can rely upon such methods of examination in this disease. The following remarks are brought forward as suggestions only; inasmuch as I have not had sufficient opportunity of verifying the diagnoses by post-mortem examinations. It has been already mentioned that the shape of the stomach is altered in a considerable number of cases of ulceration. If, therefore, in a person exhibiting the symptoms of ulcer, we should find the organ very small in size, or abnormal in its shape or position, we might obtain confirmatory evidence of the existence of this complaint. It must be remembered however, that the physical signs must be accompanied by the symptoms of the disease; for the stomach may present considerable alterations in shape and position, without being in a morbid condition. It has been calculated that adhesions to some of the neighbouring organs occur in 40 per cent. of the cases of ulcer, and this is in all probability below the truth as regards the chronic form of the complaint. Adhesions not only alter the shape of the organ, but they also embarrass or prevent its movements. We might consequently expect that the movements of the organ during respiration would be chiefly hindered by adhesions of its anterior surface, and that in such cases also the stomach, being prevented from collapsing, would occupy the same position both when full and empty. A middle-aged female, who presented all the symptoms of ulceration, complained of a fixed pain at the lower border of the left costal cartilages, where there was also considerable tenderness upon pressure. When examined by "auscultatory percussion," the lower edge of the stomach seemed to curve up to this point, and the organ retained its position both before and after food. The vomited matters contained large quantities of sarcinæ. As the symptoms and history of the case indicated ulceration, and the sarcina showed that the food was long retained in the stomach, I concluded from the alteration in the shape of the organ, that the disease had arisen rather from adhesions accompanying ulceration than simple dilatation. A man who had long suffered from the ordinary symptoms of gastric ulcer, complained of a fixed pain and tenderness in the umbilical region. The stomach was found to reach down to this part, and did not vary in size when examined before and after food. This case I surmised was one of gastric ulcer of the greater curvature, in which adhesions had taken place to the colon and neighbouring parts. The most frequent site for adhesions is at the posterior surface, and the attachment is usually to the pancreas. pancreas. When this is the case, the movements during respiration will be probably unaffected, but there will not be the natural difference in size between the full and empty conditions of the organ. When the attach VOMITING OF PARTICLES OF THE PANCREAS. 335 ment is to the liver the pyloric end is often tucked up beneath that organ, and we may then find a considerable difference in the size of its larger, and not of its smaller end before and after food. In many cases of this kind the rectus muscle is in a constant state of tension, so that it is impossible to relax the abdominal parietes. The pain is also referred to the part of the epigastrium where the dull sound of the liver can be discovered by percussion, and deep pressure at this spot increases the patient's suffering. The changes taking place around a chronic ulcer render it improbable that we should find in the vomited matters similar particles of the mucous membrane to those that may be met with in the more acute forms of the disease. But it has been shown that chronic tubular gastritis is generally present around the edges of the sore, and I have discovered numerous casts of the tubes in such cases. These may represent either parts or the whole length of the glands; they are opaque, and seem to be composed of cells and granular matter. Although they may occur in cases of chronic gastritis arising from any cause, I have never met with such perfect specimens as in cases of chronic ulcer. The extension of the ulceration is usually slow around its margins, but often much more rapid at its base. This is especially the case where it has involved the liver or pancreas, and in the following instance I found what appeared to be particles of pancreatic tissue in the vomited matters. CASE 32.-A man about fifty years of age had been |