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Show SECTION VI.] DISEASES OF THE ORGANS OF DIGESTION. TABLE III. FIG. I.- Hoemorrkages aml IIcemorrlmgic Infiltration into the jlfucous Jlfembraae of the Stomach, ails-oplutgus, and Duodcnum. CASE.-- A woman forty-seven years old. Illstorg and kSYII/llljlt07llS.-‘V735 treated several weeks for syphilitic ostitis and chronic amyloid degeneration of the parenchyma of the kidneys; a very rapidly extending erysipelas from very extensive bed-sores on the sacrum super- vened, with imminent collapse. In spite of all treatment, 3 were shallow and within the mucous membrane proper. The ulcers produced here by htemorrhagic infiltration were similar to those caused by corrosive poisons, for here the glands and interglandular tissue were deprived of the usual protection of the membrane, that is, the alkaline serum, against the corroding effect of the acid gastric juice, as the ext'avasates checked all circulation in the mem- b'ancous y'all. In some places the destructive process went on slower than in others, and correspondingly the color was lighter or darker. In some parts the membrane had a bluish or greenish tinge, showing a more or less advanced stage of post-mortem putrefaction. The black debility increased, and finally she was carried off by uraemia, from insufficient action of the kidneys. Post-mortem appearance: The cavities of the mouth, pharynx, and upper portion of the (esophagus were free from recent morbid changes. Cicatrices of old syphilitic sores visible on the soft palate and the root of the tongue. The effect of the benzoic acid and 'amphor in powder with which she was treated showed itself in various ways upon the mucous membrane of the stomach. In some parts spots were produced by the reducing agency of the acid in the cavity upon the haemoglobin of the exudate. In the left half of the cavity the membrane had lost its opacity, became t 'ansparent, and showed through the turgid vessels, the color of which varied according to the amount of de- there were simple hzemorrhages (especially in depressions between the folds) into the membrane. In some there were of irregular form, some being situated very deep in the erosions; their edges and fundus were infiltrated, some were blackish brown, some light-colored, some free from any infilt'atc. They were mainly of a circular or oval form, and of different dimensions (E, E, H, U). They Etiology. According to B. Zicmssen (Clinical Lecture, No. 15, Volkmann's Collection), the number of females affected with simple circular ulcer is double that of males. The statistics gathered by Brinton show that the frequency of the disease increases from the age of ten years and upward in both sexes. Chl0r0sis and amemia espe- cially predispose young persons to become thus affected, as Vir- chow and Rokitansky have both proven that the thin walls of the arteries of chlorotie young women readily undergo fatty degeneration. Such friable conditions of small arteries and capillaries will, in many instances, even under the slightest. provocation, break and produce luelnorrhages and lnemorrhagic infiltration, and coincidently lack of circulation in the mucous membrane of the stomach composition which they had already undergone. FIG. 2.-This represents a form of haemorrhagie erosion gastric \‘alls, some very superficial, thereby indicating the progress of the destructive process. (G C), great curvature; (11 U), lizemorrhagic ulce‘ations; (E E), erosions; (O E), (esophagus; (P), pylor; (D), duodenum; (H I), lurmatic injection or infiltration. cicatricial restitution. As a general thing the ci Iatriees involve a far greater portion of the gastric wall than the destroyed tissue (Section VI, Table V, Figs. 1, :2, 3). \thre ci -atrization follows very extensive ulceration (which happens very seldom), there are produced constrictions of the cavity of the stomach, which become a source of annoyance and suffering to the patient. The dangers liable to beset the ulcerative process are : first, very profuse and often fatal haunorrhages, caused by corrosion of smaller or larger blood-vessels; second, anwmia following ottel‘i-repeated profuse haemorrhages; third, perforation into the peritoneal cavity. This may happen befor} any attachment of the stomach to any neighboring tissue has been formed, or even aftery'ard, for the adhesive structure readily becomes detached, and the contents of Complication of gastric ulceration the stomach are then emptied into the peritoneal cavity, which with tuberculosis and chronic pneumonia is a very common occurrence. Inadequate nutrition of the bodily tissues is, according to always terminates in fatal peritonitis. \Vhen the ulceration is followed by hyperplastie structure, form- and subsequent ulceration. Bamberger, the probable cause of both processes. Haemophilia, produced by chronic endo 'arditis and affections of the internal membranes of the blood-vessels, also, according to Siebcrt, de ‘angements of 'ascular innervation are often the predis- posing causes of gastric ulceration. Formation of ulcers takes place in the stomach and the duodenum, and in very rare cases in the lower portions of the oesophagus. \Vhen nutrition of any portion of the mucous membrane has ceased for any length of time, there is formed, very speedily, softening of the hzcmorrhagieally infiltrated portion. A distinctly circumscribed circular portion of the membrane turns into a. sphacelous mass or a dry scab, and these become detached from the sub-mucous tissue. This eventually undergoes the same disintegration; sometimes even the muscular and serous coats become involved in this manner and are destroyed. Merkel describes a case of a nincty-four-ycar-old woman in whose stomach there was found, post mortem, a circular ulcer, in which the mucous membrane still existed, but was changed into a black mass and adherent to the fundns of the ulcer. Sometimes ing adhesion of the organ to any other, the adherent surface is always increased in thickness and density. Yet such cieatricial tissue is sometimes very friable and readily allows breaking through of the gastric walls and emptying its contents into the parenchyma of the supporting organ. Under such circumstances, formation of abscesses and pyogcnic sinuses will result. Such adhesions to and perforations into may befall almost any organ within the abdominal and thoracic ~avities. (Virc/lour's Arc/1271:, Vol. V. chlm, Ham/l). «I. Purim/0g. AQHIL, Vol. I. Lectures, No. 15. Zz'cmssm, Collcct. Clim'c. Gcr/mrrl, le‘ra. JlIal. Pros-s, 1868. Corros. Ulc., Erlaag., 1880. Binrlflcisch, Pat/lol. Anut. L. Jliullrr, Barth/arr, Dov-put. Jlfctl. Z012, 1874. Zirglcr, Pat/ml. Anat, Part II, p. 305.) Tumors (on! Other Almplusnzaz‘a of 2/10 Stomach. The most frequent, also the most important, heteroplastie forma- tions of the stomach are the many varieties of cancer. It always first takes its origin in the mucous membrane, and from there very soon passes into the sub-mucous tissue, where it often extends very rapidly, and then involves the muscular and sometimes even the membrane is perfectly obliterated and the wound is funnelshaped, the base turned outward, its apex within the deeper the serous coat of the organ. coats. The funnel shape seems due to greater and more speedy destruction of the mucous membrane by corrosive action of the gastric juice than the tissues of the deeper layers. In older wounds the sub-mucous and muscular layers become more disinte- in 'ade the 'avities of the veins and produce cancerous thrombi, grated, and the loss of substance becomes more uniform through- out. The extent of chronic ulcers is always greater than of those of recent date. RindfleiSch, in reporting a case of acute circular ulcer having the above«described form, builds his theory of the formation of such lesions upon the fact that they are always found when any luiemorrhagie infarct extends through the whole thickness of the membrane. " When such infarcts become dissolved by the gastric juice," he says, "then circular wounds are formed in the mucous membrane, and are of such regularity and have the appearance as if a portion of the membrane had been cut out by a circular punch, leaving the surrounding and underlying tissue perfectly clean. Such infarcts take place within the limit of a definite territory of circulation of an artery in the walls of the stomach, and these all have a conical shape, their base facing the epithelial surface, their apex turned inward." \Vhen the nlccrative process reaches deeper into the sub-mucous structures the same circular In the serous covering it usually assumes the nodular form, and follows the tract of the lymphatics (Section VI, Table VII, Figs. 3, 4). These nodules or nodes often appearing upon the serous surface, especially in the pyloric region, as fiat or knotty strings (Section VI, Table VIII, Figs. 4, 5). Early in the course of the disease, the lymphatic glands situated in the region of the lesser curvature become enormousl ' enlar ed and form massive cancerous knots (Section VI, Table TIII, ig. 2). 0c *asionally metastatic deposits of cancer will be produced in the liver, lungs, etc. The portal vein is usually the most frequent way of propagation of such cancerous metastases of the liver. The most frequent form of cancer of the stomach is that of raised, soft, fungoid tumors in the pyloric region (Section VI, Table VII, Fi s. 1, 4, 5), also in the lesser curvature. They are very rare in tie large cut (/1' sac, rarely also do they spread over the inner surface of the organ. )Vhen the tumor has reached a certain size its central portion soon undergoes a process of decay, changes into a cancerous ulcer, characterized by being surrounded by raised edges. The fnndus of such an ulcer is formed by the sub-mucous tissue, which is either infiltrated with -ancerous cells or becomes indurated in consequence of chronic inflammation (Section VI, Table VII, form is maintained for quite a long while. "It seems," says the same author, "as if the formative reaction at the fundus and the Fig. 2). sides is so slight, and especially as the action of the gastric. juice pyloric region is thus infiltrated enlarged, and sclerotic. .At other times the whole neoplasm on the inner surface of the stomach follows so speedily the plastic reaction, that there is but little possibility of formation of any hyperplastic infiltration in any parts adjacent to the ulcer." "The fact that ulceration may continue a great number of years in the same simple condition, and also that they are only found in the stomach and in the upper portion of the-duodenum, where the secretion is of an acid reaction, and consequently capable of dissolving liquid or liquefied albumeuates, go very far to explain the peculiar phenomena of the simple ulcer." (Rindfleisch) The smaller the ulcer, the more recent the destruction of the tissues, the oftener and sooner will there be formed Usually the muscular as well as the serous coats are exten- sively hyperplastic, enlarged, and indurated. Sometimes the Whole becomes so decayed and atrophie as to render the whole surface smooth and having the appearance of a fibroid. with no malignant indu 'ation. Even the I‘nicroscope will fail to discover any cancer cells in such a fissile, and only the metastatic deposits found in the co-ordinate digestive organs will reveal the existence of cancer. According to the histology of each, Cancer can be divided into five divisions: 1. Illa/altar" Cancer, consisting of soft, spongy tumors, pro- ducing either ridge-like, nearly parallel elevations upon the inner |