528 DISEASES OF THE STOMACH. 



CHAPTER VI. 



CHRONIC (BOUND, PERFORATING) ULCER OP THE STOMACH ULCUS 

 VENTRICULI CHRONICUM (ROTUNDUM, PERFORANS). 



ETIOLOGY. [This interesting disease, in spite of its frequency, 

 was first accurately described in 1831 by Cruveilhier as simple 

 chronic ulcer of the stomach, while it had previously been con- 

 founded with cancer of the stomach. Rokitansky had already dis- 

 tinguished its mode of origin from that of ordinary ulcers due to 

 disintegration of tissue, and attributed it to an original sloughing 

 of mucous membrane, which again he ascribed to hsemorrhagic ero- 

 sions. It is generally agreed that two different causes unite for the 

 formation and increase of these ulcers : 1. Feebleness of circulation 

 at a circumscribed part of the gastric mucous membrane ; 2. The 

 dissolving power of the gastric juice or of the contents of the 

 stomach undergoing acid fermentation ; the wall of the stomach is 

 destroyed because no longer protected by the alkaline blood circu- 

 lating through it. The necessity of these two factors explains why 

 this kind of ulcer is only found in the stomach and upper part of 

 the duodenum. 



Virchow showed that the flat funnel-shaped form of young 

 ulcers corresponds to the territory supplied by an arterial branch. 

 The branch being obstructed from any cause, the coats of the 

 ctomach are no longer protected by the presence of the alkaline 

 blood. This obstruction may occur in patients with heart-disease, 

 from embolism or congestion of the coats of the stomach ; in chlo- 

 rotic or consumptive patients from defective nutrition of the vessels 

 or diminution of their calibre.] 



Perforating ulcer of the stomach is probably always acute ; even 

 its extension appears to be due to an acute process of destruction at 

 its periphery and base. However, as the ulcer in question often 

 gives the patient great trouble for years, it may rightly keep its name 

 of " chronic ulcer." The sharp borders of the round ulcer, the ab- 

 sence of signs of inflammation or suppuration at its periphery, the 

 direct observation of very recent cases, as well as the striking results 

 of a series of experiments on animals, prove, beyond doubt, that the 

 destruction of the wall of the stomach is not due to a gradual 

 breaking down from suppuration, but to the formation of a slough, 

 to a partial necrosis, and that this usually, if not always, depends 

 on an obstruction of the blood-vessels running in the walls of .the 

 stomach and nourishing it. The death of a circumscribed portion 



