CHRONIC ULCER OF THE STOMACH. 531 



if the opening be not too large, may finally unite so as to form a firm, 

 hard cicatrix. 



When the ulcer first forms, and still more frequently while an ulcer 

 already formed is spreading, the vessels of the stomach, or of the 

 neighboring organ into which the ulcer has perforated, are destroyed, 

 and there is considerable haemorrhage into the stomach. Perforations 

 of the coronary, pyloric, gastro-epiploic sinistra, gastro-duodenal arte- 

 ries and their branches, of the splenic artery, but most frequently of its 

 branches going to the pancreas, and of the pancreatico-duodenalis, have 

 been observed. 



The gastric mucous membrane also exhibits the changes character- 

 istic of chronic gastric catarrh, which were described above. Sometimes 

 these are absent or very slight. 



SYMPTOMS AND COURSE. Sometimes, by perforating all the coats, 

 and thus permitting the escape of the contents of the stomach into the 

 peritonaeum, ulcer of the stomach may cause fatal peritonitis ; or, by 

 erosion of a large vessel, may cause abundant haematemesis before the 

 disease has been recognized, or before its recognition was possible. It 

 is going too far, however, to say that in such cases the signs of the 

 suddenly occurring peritonitis, or the hgematemesis, were the first symp- 

 toms of the ulcer of the stomach. On more careful inquiry, we almost 

 always find that slight disturbances of digestion, and some oppres- 

 sion in the epigastrium, increased by eating, have gone before, and that 

 the patient had been troubled by wearing any thing tight about the 

 waist. Between the first appearances of these insignificant difficulties 

 and the fatal termination, there is sometimes only an interval of a few 

 days or weeks, so there can be no doubt that, in this short time, all the 

 coats of the stomach have been perforated. (I have had a very sorrow- 

 ful opportunity of satisfying myself of the rapid course of a perforating 

 ulcer; in Magdeburg, Dr. JBrunnemann, a very distinguished and prom- 

 ising young physician, died of such an ulcer. When the perforation 

 occurred, he was not for an instant in doubt about the diagnosis, and 

 most decidedly said that he had not suffered over eight days from slight 

 trouble, which he thought proceeded from a slight gastric catarrh.) I* 

 even seems as if perforation, with escape of the contents of the stom 

 ach into the abdomen, occurred most frequently in the cases beginning 

 in this concealed manner, and running a rapid course ; that, on the 

 other hand, in the cases which begin with severe and pathognomonic 

 symptoms, and run on for months or years, the stomach has time, as it 

 were, to unite to the neighboring organs, and so prevent the escape of 

 its contents into the abdomen. I would remind my readers that the 

 cheesy infiltrations of the lungs, which run a rapid course, lead to per- 

 foration of the pleura and pneumothorax far more frequently than 



