CHRONIC ULCER OF THE STOMACH. 535 



the arteries less complete, typical cyanosis may result from the collec- 

 tion of blood in the veins, and the patient looks like one in the col- 

 lapsed stage of cholera. In these cases the perforation appears to cause 

 a paralysis in the sympathetic nervous system, analogous to what oc- 

 curs in other severe injuries. Although such cases are not rare, it is 

 more common for the patient not to die during the first day or two, 

 hut for the symptoms of a fatal peritonitis to combine with the above. 

 (b.) In rare instances death results from haemorrhage from the stomach. 

 Even when the patient appears quite bloodless and waxy-looking, 

 where every attempt to raise the head induces fainting, where oppres- 

 sion, palpitation, dizziness, tinnitus, and other symptoms of loss of 

 blood, are present, the patient often recovers, contrary to all expecta- 

 tion. Death may result very quickly, however, from erosion of large 

 arteries. I saw one case where the splenic artery was perforated, and 

 the patient suddenly fell and died before there was any vomiting of 

 blood, (c.) Death may result from gradual exhaustion, and this may 

 take place even where the ulcer has healed, but there is a stricture of 

 the stomach from cicatricial contraction. In such cases not only is 

 there the severest cardialgia, but every thing that the patient eats is 

 vomited ; he may have no passage from his bowels for weeks, the belly 

 sinks in, he wastes away to a skeleton, and dies from inanition. 



DIAGNOSIS. In the rare cases of ulcer of the stomach, where it 

 runs its course without any pathognomonic symptoms, it cannot be 

 distinguished from chronic gastric catarrh ; but in most cases the dif- 

 ferential diagnosis between the two affections presents no difficulty. 

 Great sensitiveness of the stomach at a circumscribed spot, severe 

 cardialgic attacks, but particularly vomiting of blood, exclude simple 

 catarrh with great certainty. A far less certain sign is the appearance 

 of the tongue, which is red and smooth in cases of round ulcer, and 

 almost always coated in cases of simple catarrh. It may be difficult 

 to distinguish it from stricture of the pylorus due to hypertrophy of 

 the membranes of the stomach. The slightness of the cardialgic attacks, 

 which are not in proportion to the frequency of the vomiting, the reg- 

 ular occurrence of the latter, and the presence of consecutive dilatation 

 of the stomach, aid somewhat hi the diagnosis, as they indicate stric- 

 ture rather than ulcer. 



Where, with great severity of the cardialgic attacks, there are no 

 dyspeptic symptoms, and, in spite of the long continuance of their dis- 

 ease, the patients preserve a blooming appearance, we may suspect a 

 cicatrix, which impairs the motions of the stomach. The probability 

 of this is still greater if there have formerly been for a long time sure 

 signs of an ulcer of the stomach, which, except the cardialgia, have 

 subsequently entirely disappeared. Where the symptoms of stricture 



