Gastric Ulcer 321 



vomiting brings immediate comfort ; in catarrh the trouble is more 

 constant. With ulcer there is pain in the back, over the lower dorsal 

 spines, and, generally, blood is vomited. 



Gastric ulcer is usually preceded by catarrh, the epithelial lining 

 being detached over small areas ; the ulcer is most liable to attack the 

 pyloric end of the posterior wall, near the lesser curvature. Should it 

 implicate a large branch of artery, fatal haemorrhage may result. In 

 haematemesis (e/^eo-t?, vomiting) the blood comes up in vomiting, not 

 in coughing ; it is not frothy or bright-coloured, but it is acid from 

 admixture with gastric juice ; blood from lung, pharynx, or nares may 

 find its way into the stomach and be voided by vomiting, so that blood 

 which is vomited is not necessarily the result of gastric haemorrhage. 

 If the ulcer cause perforation, the extravasated matter from the stomach 

 may come directly in contact with the solar plexus, death occurring 

 rapidly from shock or peritonitis, unless adhesions have glued the 

 margin of the ulcer to liver, pancreas, duodenum, or colon. On the 

 front of the stomach conservative adhesions are less likely to occur. 

 Sometimes, however, the ulcer opens harmlessly into the duodenum 

 or colon. If an ulceration be diagnosed upon the posterior wall, the 

 patient must be kept lying prone. 



When ' ulcer ' has been diagnosed the diet should be of the lightest 

 kind, and the patient should be kept lying down, so that if, as often 

 happens, ulceration extend to the serous coat, local plastic peri- 

 tonitis may glue the treacherous area to the liver, general peritonitis 

 being thus averted. Grave collapse is the great sign of perforation, 

 and of extravasation of food having occurred into the peritoneal cavity. 

 To ensure absolute rest, no food whatever should be given by the 

 mouth. 



Dyspepsia. In disease of the heart, as also in cirrhosis of the liver, 

 there is impeded circulation, the vena portae being overladen, and 

 gastric catarrh and dyspepsia resulting. Thus it happens that ' indiges- 

 tion ' may be the most prominent symptom of morbus cordis. The 

 nerves of the stomach grow over-sensitive, and, as soon as food comes 

 in contact with them, there is discomfort, a feeling of fulness, or actual 

 pain, which may be relieved only by vomiting. As the patient gets 

 worse the food and glairy mucus which he vomits are streaked with 

 blood which has escaped from the over-loaded capillaries, and as the 

 disease still further advances the vomit consists of acid mucus and 

 darkened blood. This is the ' black vomit ' so often seen in the 

 dying. 



Vomiting is accomplished by the abdominal muscles compressing 

 the stomach against the diaphragm and liver, the cardiac orifice being 

 relaxed. First a deep inspiration is taken, so that the diaphragm 

 may lie at its lowest level ; it is then fixed by the firm closure of the 

 glottis ; a patient with an opening in the trachea cannot vomit, as the 

 diaphragm cannot be fixed. The fuller the stomach, the easier is the 



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