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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 : the mucous membrane is ulcerated to a greater extent than the muscular, and the muscular than the peritoneal, so that it has a bevelled aspect towards the mucous membrané, and the opening through the peritoneum is small and round like the hole of a punch. .

This form of disease is most frequent in young women between the ages of fifteen and thirty, and appears to be connected with an enfeebled state of general nutritive power.

The second form is that in which adhesions take place. Here the action is of a slower kind, the mucous membrane and the muscular coat are destroyed in a similar manner; but when the peritoneal surface is approached, the irritation suffices to set up change in the adjoining serous membrane ; fibrin is effused, this becomes organised, and firm adhesions surround the opening, and thereby extravasation is prevented. The edges of the ulcer are rounded and elevated ; and in consequence of long-continued irritation effusion takes place at the edges; this product becomes firm, it is fibrous in its character, and as it increases it encloses fibrillæ of the pueumogastric nerve, thereby producing severe pain. The ulceration slowly increases in size, so that the ulcer may vary from the size of a fourpennypiece to that of a crown-piece. Dr. Law mentions one six inches in length. The peritoneal surface, the lowermost in the stomach, also becomes increasingly destroyed, and the floor of the ulcer is then formed by the tissues, the adjoining viscera, to which adhesions have taken place. It may be that the floor consists of one structure, more frequently, however, of several parts, covered by a thin stratum of fibrin. If the disease be at the posterior aspect, the pancreas forms the greater portion of the base; if towards the anterior, then the abdominal parietes and the liver bound it. Sometimes it is the right, sometimes the left lobe of the liver, or the diaphragm, or several of these parts combined. With all this protective adhesion, perforation sometimes happens in a secondary manner. The adhesions are only partial, and after some unusual distension, rupture takes place into the peritoneal cavity, and inflammation which is fatal in a few hours, is the result. This opening is sometimes just on the edge of an ulcer with dense edges, or it may be in the centre of one with but feeble adhesions. It is not always that the perforation extends into the serous membrane, for it may be into the cellular tissue, and an abscess is then formed. An abscess of this kind may reach towards the spine, or extend upwards to the diaphragm; it may perforate that muscle, and communicate with the pleura, setting up intense inflammation there. We have known the earlier symptoms so insidious, that the pleurisy was almost the first indication of any abnormal change. In such instances, empyema ensues in a very short space of time. In an instance I have recorded elsewhere, a sinuous opening extended through the diaphragm

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