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rally constipated; exhaustion gradually comes on, till at last the patient sinks from inanition. The abdominal walls are wasted and collapsed, and a tumour is often felt at the epigastric region, consisting of the thickened tissues at the pylorus. If, however, the stomach be free from adhesions, the thickened pylorus is often pushed downwards so as to be felt near the umbilicus, or even near to the pubes. Pain is not generally a marked symptom of this form of pyloric disease; but tenderness on pressure is sometimes experienced, arising probably from peritoneal adhesions.

We are not acquainted with the predisposing nor with the exciting causes of this fibroid disease; but it is probable, that long-continued irritation, as indicated by dyspepsia, generally precedes it. The intemperate do not appear to be more liable, and one sex is as prone to it as the other; although it is more common in advanced age, still it does occur in early and middle life.

The diagnosis is sometimes obscure, and the presence of other more acute disease may entirely mask the com plaint; the duration of life is greater in this fibroid degeneration of the pylorus than in the ordinary forms of cancer, especially the medullary and epithelial varieties, nor do we find in the former disease the peculiar cachexia of malignant diathesis.

As to treatment, although we cannot remove the obstruction, we can afford great relief to the symptoms and greatly prolong life. The change from solid and

irritating food to that of a fluid and bland kind is often followed by marked relief. In this way spasmodic con traction at the pylorus is lessened, and the fluid slowly : passes onwards. If, however, the stomach be very irritable, the best way of affording relief is to allow it to rest entirely, and to sustain life by nutrient enemata ! for several days. Towards the close of the disease, we are driven to this means to prolong life.

The secondary fermentation in the stomach may be greatly diminished by other remedies, by creasote, the sulphite and hyposulphite of soda, by charcoal; whilst the irritability is lessened by alkalies, by bismuth, by hydrocyanic acid, by opium, or morphia, &c.

It is remarkable that with these several forms of degenerative change we do not find the stomach subject to strumous disease of a tubercular or ulcerative kind; and although tubercles are often found upon the serous membrane, the mucous membrane is always free. The term "gastric phthisis" is, we think, very apt to be misunderstood on that account, and likely to prove very injurious in drawing attention away from the true source of disease, namely, the lungs.

CHAPTER XVII.

ULCERATION OF THE STOMACH.

DYSPEPSIA is par excellence the symptom of ulceration of the stomach, for the process of digestion is then especially difficult and painful.

The destruction of the surface of the mucous membrane and of the coats of the stomach by ulcerative process occurs in several forms and conditions; and we have already referred to some of these in describing the varieties of dyspepsia, with some of which they may be associated.

1. Ulceration may be the sequence of acute inflammation, and may be connected with abscess, or with sloughing of the surface; these are, however, instances of an unusual kind, and are caused by local mischief, or by poisons or irritating substances.

2. Although diphtheritic inflammation does occur in the stomach, it is of rare occurrence. Dr. Fenwick believes that it is frequent with scarlet fever. We have never witnessed diphtheritic ulceration.

3. Ulceration of a superficial kind, or of the character of aphthous ulceration, is not uncommon; it is the

result of sub-acute inflammatory change, and is present in inflammatory dyspepsia, and in that connected with hepatic engorgement. After the irritability of stomach present in Addison's disease of the supra-renal capsules, this form of ulceration has also been observed. It is not necessary again to describe the symptoms connected with these states, having already done so in a former chapter. In this form of ulcer the mucous membrane only is destroyed in small irregular patches, generally about the lesser curvature or towards the pyloric extremity. Other portions of the mucous membrane show arborescent injection consequent upon a hyperæmic state of the part.

4. Ulceration sometimes occurs as numerous minute points, and it has been designated follicular ulceration; the parts destroyed are very small, about one-sixteenth of an inch in diameter, and are thickly spread over the surface of the membrane. This condition has been observed in connection with the gastro-enterite of children; and after the symptoms have subsided it is probable that the surface of the stomach entirely regains its normal appearance.

5. Another ulcerative state has been designated hæmorrhagic erosion, and is especially observed in chronic catarrh of the stomach, and is caused by the long-continued congestion of obstructive disease, whether in the heart, lungs or liver. The intensely congested capillaries having given way, blood is effused in small

points or in larger patches; if the former, mere specks of ecchymosis are the result; if the latter, the surface of the membrane gives way, and a small ulcer is produced, having an irregular margin, and it is generally covered by a clot of blood almost resembling a slough.

6. Beside these conditions, which it is not necessary to describe again more fully, we have that state which is especially meant when we speak of ulcer of the stomach. It has been variously designated as simple ulcer, chronic ulcer, perforating ulcer; and in its consideration the description of the symptoms is facilitated by dividing into two classes :

1. Ulceration perforating without adhesion, and

2. Ulceration perforating when adhesions have taken place.

When the coats of the stomach are destroyed by ulceration, and no adhesion has taken place, acute peritonitis is suddenly induced from the extravasation of the gaseous or fluid contents of the stomach into the peritoneal serous membrane; intense inflammation is thus set up, and the life of the patient is at once placed in imminent jeopardy-in fact these are terrible instances of disease, and from apparently good health, without any warning, a few hours of intense suffering is followed by a fatal issue. The ulceration which leads to this untoward result may be small in size, from a quarter to half an inch in diameter, and it has on its internal aspect a peculiar appearance: peculiar appearance: the mucous

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