W/.
 
 
 
LECTURES
DISEASES OF  THE  STOMACH,  •
INTRODUCTION ON ITS ANATOMY AND PHYSIOLOGY,
BY
\f
WILLIAM BRINTON, M.D., F.R.S.
    PHYSICIAN TO ST. THOMAS'S HOSPITAL.
FROJfc<PHE SECOND ENGLISH ^EDITION.
      PHILADELPHIA:
LEA  AND BLANC HARD.
           1865. 
9
WIA
 BS58A
  \865
^</k> £
°i * 3 y-H^*+>  j
     PHILADELPHIA :

COLLINS, PKINTER, 105 JAYNE STREET 
PREFACE  TO  THE SECOND EDITION.
  In preparing this Edition for the press, I have taken the oppor-
tunity of revising and enlarging it.   Of the additions thus made,
many are dispersed throughout the body of  the work.  I have,
however, added two chapters; the clinical interest of which will,
I hope,  justify their admission to what still only claims to be a
brief account of the Diseases of the Stomach.
                                   WILLIAM BKINTON.

   24, Brook Street, Grosvenor Square,
          October, 1864. 
 
PREFACE.
  The following Lectures are published, in the hope that they
will be found a brief but complete account of what is at present
known concerning the Diseases of the Stomach.
  Fifteen years ago, the death  of a near relative painfully  im-
pressed me with the obscurity and uncertainty which peculiarly
attach to the maladies of the Abdominal Viscera.  From that time
I have given to these maladies whatever attention could be justi-
fiably devoted to a special group of diseases by a  student  and
practitioner of Physic in general.
  Of the materials  I have thus collected, those which form  the
basis of the following Lectures are derived from sources so various,
as to render the concord  equally important with the number of
the facts they  represent.  To the large opportunities afforded  me,
during twelve years, as a Dispensary and Hospital  Physician, I
have added whatever could be gleaned by me from  a field of ob-
servation, the  magnitude of which it is difficult to estimate.   The
Hospitals and Museums of various cities; the cases recorded by
authors of various epochs and countries; and especially, the stores
of information which are gradually accumulating in the Journals,
Reviews, and  Transactions of  the  Medical  Profession in the more
civilized parts of the world—have all been laid under contribution;
and have yielded me facts  which (considering the price of human
suffering paid for Pathological knowledge) deserve a respect  and
attention I sincerely disclaim for the manner in which I have
arranged and  used them.   To this general acknowledgment I must
add my special  thanks  to numerous professional friends, and to
hundreds of observers wbose smaller contributions  could not be
separately quoted in the following Lectures.
   Of the mode  in which  the subject is treated, it  need only be
said, that I have endeavored to  incorporate, with a clinical  and 
VI
PREFACE.
pathological inquiry into gastric disease, such physiological prin-
ciples as may afford a basis for its rational treatment.
  In making this attempt with  the brevity necessary to bring it
within the limits of a short course of Lectures, I am sensible that
retrenchment may have been misapplied, or carried too far.  But
for  the latter fault,  the  reader  will,  perhaps, find excuses more
valid  than I can offer.  It may, however, be mentioned, that  my
audience was composed chiefly of the more advanced students of
St. Thomas's Hospital; who, having attended the excellent Clinical
and Systematic Lectures on Medicine of  my colleagues (Dr. Barker
and Dr. J. R. Bennett respectively),  had already an elementary
acquaintance with my- subject.
  Perhaps, besides the defects  thus  hinted  at, I ought also to
apologize  for redundancies (as  in Lectures III. and VI.). But,
apart from the special connection of Therapeutics with gastric  dis-
ease, I have  a conviction that, in the present  era of the  Art of
Medicine, the language of those who  teach it should at least be
outspoken, if it  may not be eloquent  in the more conventional
sense of this word.
  The Lectures thus delivered have  received some additions and
corrections in passing through the press; and have been increased
in number  by one (Lecture V.) which was read  as a paper before
the  Physical  Society of St. Thomas's Hospital during the present
Session.  For the convenience  of  the reader, I have prefixed a
summary of the  Anatomy and Physiology of the Stomach.  This
chapter, derived  from my Physiological  Lectures, is illustrated by
some engravings.
                                    WILLIAM BRINTOK
Brook Street, Grosvenor Square,
     December, 1858. 
CONTENTS.
                                                        PAGE
Anatomy and Physiology.........17-48


                        LECTURE I.
Introduction............49
Symptoms of Gastric Disease Generally......50
Pai\.............50
Eructation............56
Regurgitation...........56
Vomiting............56
Hemorrhage............62
Flatulence............65


                        LECTURE II.
Circumstances connected with the Examination of the Stomach after
    Death.
Gastritis
Catarrh of the Stomach
Hemorrhagic P^rosion  .
Follicular Ulceration
71
81
92
95
98
LECTURE  III.
Ulcer of the Stomach
100
LECTURE IV.
Cancer of the Stomach  .
165 
viii                       CONTENTS.
                         LECTURE  V.
                                                            page
Cirrhotic Inflammation, or Plastic Linitis of the Stomach    .    .   221
Suppurative Linitis.......    .    •    •   234
Tumors.............236
Hypertrophy...........   239
Atrophy............240
Dilatation ; from Obstruction, Destruction, Injury, Paralysis    .   242
Secondary Inflammation.........249


                         LECTURE VI.

Dyspepsia     ............   252


                        LECTURE VII.

Gastric Phthisis...........280


                        LECTURE VIII.

" Gout in the Stomach".........291
Index.....,        ......297 
ANATOMY   AND   PHYSIOLOGY.
  The stomach, the widest and most dilatable part of the alimentary
canal, has a form which varies somewhat in different individuals.
Removed from the body, and moderately distended, it generally
takes the  shape  here represented (Fig. 1)—a shape best described
as that of a bent cone, the concave aspect of which receives a tube
at one-fourth of the distance from its base.  In it we distinguish an
anterior and a posterior surface;  a superior and an inferior border;
a right and a left  extremity; and lastly, the cardiac and pyloric
apertures, by which it communicates with the oesophagus and duode-
num respectively, and thus becomes  continuous with the remainder
of the digestive  canal.
   The description of these parts  varies with the state of the organ.
Thus, when empty and uncontracted, the stomach  is flattened ver-
tically;  its  anterior  and posterior  surfaces touching each  other,
while its upper  and lower  margins really deserve the title of
" borders."  But when the organ is distended, any  transverse verti-
cal section becomes almost a circle, its borders and surfaces merging
into each other.   Its uppermost  part, however, is  still distinguish-
able as the lesser  curvature (a, e, b, Fig.l), and its ldwer as the greater
curvature (g, d, f, c, b).   The general  concavity of the former curve
is especially marked in its first three-fifths, at the end of which part
(e) it usually becomes slightly convex.   A shallow notch (c) often
divides the greater curvature into two portions opposite this point,
and, with the latter, defines the commencement of the pyloric pouch
(c, b, b, e).  The cardiac pouch, great or splenic extremity (d) is the part
to the left of the cardia or oesophageal opening (a), beyond which
it projects for about three inches.  At this aperture the oesophagus
dilates gradually,  so as to resemble an inverted  funnel.   To the
right of  the oesophagus, the stomach expands slightly, to reach its
maximum diameter at about the  middle of the organ (/).  Beyond
this point it tapers away to the pylorus (b, b), where a sudden con-
striction marks the site of the valve.
   The dimensions of the organ are even more variable than its
form.  In the healthy middle-aged male, the moderately distended
stomach is about thirteen to fifteen inches  long; and its diameter,
       2 
18
ANATOMY AND  PHYSIOLOGY.
at the widest part five, near the pylorus two, inches.  Its total sur-
face is about one and a, quarter square feet; its capacity about 11 c
cubic inches,  or five pints;  its weight seven ounces.1

                               Fig. l.
  Stomach, as seen by inflating it, and dissectnig off its peritoneum, its longitudinal,
 •                 and j/art of its transverse, muscular coat.
  a, g, Cardia ; b, b, pylorus ; a, e, b, lesser curvature ; g, d, f, c, b, greater curvature: g, d, to near
/, cardiac sac ; c, 6, b, e, pyloric sac.  (Above a, g are seen the transverse fibres of the oesophagus:
and below these, the uppermost of the oblique fibres of the stomach, passing towards c. Covering
the pyloric sac are seen the transverse fibres. The dotted line, a, e, b, shows how extreme disten-
sion of the stomach tends to affect the lesser curvature.)

  The attachment of the stomach is effected  chiefly by the  conti-
nuity of  its extremities with the more fixed  duodenum and  oeso-
phagus.  The former tube is connected with  the posterior wall of
the belly; the latter perforates the diaphragm, so  as to enter the
abdomen about one inch in front of the left border of the aorta, by
an  aperture which  is everywhere muscular, though close to the
posterior border of the tendon. The fixation of the stomach is also
aided by certain processes of peritoneum.  To the  left of the oeso-
phagus, the short phreno-gastric omentum passes from the diaphragm
to the cardiac pouch, which  it reaches somewhat posteriorly.   Still
lower down, the stomach is united to the spleen by the gastro-splenic
omentum.  The  lower border of the organ gives  off the great omen-
 tum; this descends for some distance towards the bottom of the
belly, and is then reflected upwards to the anterior border of the
transverse colon, which it splits to inclose.   The upper  border of
the  stomach is  attached by means of the gastro-hepatic or  small
 omentum, which descends from the transverse fissure of the liver.
 All of these folds are double; though the four  layers of the reflected
 omentum majus  are often inseparably united to each other.

  1 For women and children, these estimates require a proportionate reduction.
 They are increased  by habitual distension, and by the relaxation of old age; dimi-
 nished by habitual exercise, or by the practice of taking very small  meals (as in
 dilative emphysema of the lungs). 
ANATOMY AND  PHYSIOLOGY.             19
  Situation.—The stomach is  placed  almost transversely in  the
upper  part of the abdominal cavity, in which it passes from  the
left to  the right side, as well as downwards, and slightly forwards.
This direction results from its situation relatively to the oesophagus
and duodenum ;  since it is joined by the former at its highest part,
and near its left extremity, while the latter is immediately prolonged
from its right or pyloric end.  In this course from left to right, the
stomach successively occupies the left  hypochondriac and  the epi-
gastric regions; and, just at its  termination, it reaches the right
hypochondrium.   Its anterior surface  is^ therefore, in contact with
the diaphragm, where this muscle lines the cartilages of the  left
false ribs, and with the  wall of the abdomen.  Its posterior surface
lies upon the pancreas,  the aorta, and the crura of the diaphragm,
where these parts cover the spine.  Its left extremity is in contact,
above, with the diaphragm ; below with the spleen; and, posteriorly,
it reaches the left supra-renal capsule and kidney.  Its upper border
is in apposition to the liver;  viz., to its  left lobe, to  the lobulus
Spigelii, and to part of the lobulus quadratus.  Its lower border  is
parallel, and close to, the transverse colon.  Unusual distension or
size chiefly affects the  situation of the  organ, by causing it to ex-
tend downwards, so as  to overlap or displace the transverse colon,
and thus to reach the  umbilical, the left lumbar, or even the left
iliac region.   Under similar circumstances, its left  extremity  also
passes more deeply into the corresponding hypochondrium, so  as
to be more extensively  covered by the ribs.   Its extension upwards
diminishes the size of the thorax, but is rarely sufficient to be felt
as a serious hinderance to the descent of the diaphragm in ordinary
tranquil inspiration.  Its right extremity may touch the gall-bladder.
   It may be useful to  trace the  effect  of progressive distension  of
the stomach upon its form, site, and fixation.   When void of food,
and not  distended (as  it often is) by gases, the  flattened  stomach
hangs almost vertically in the epigastrium.  In this state of the
organ, the pulpy food that enters  it from the oesophagus drops  at
once into the cardiac pouch, which forms its  most depending part.
 The reception of further quantities  effaces  its upper and lower
borders; and gradually changes them, from almost straight lines,
 into the curves above mentioned, at the same time that it separates
 the previously apposed surfaces, and converts the whole organ into
 a cone, convex below and in front.  The  latter  of  these  two  con-
 vexities is most marked  at the pyloric extremity, and is often very
 sudden.  Both result from the increased length of the organ, and
 the proximity of its comparatively fixed orifices.   But both are
 greatly assisted by the muscular coat;  since the distension  of the
 separated stomach tolerably imitates (though it scarcely equals) the
 curves taken by the organ when moderately expanded in situ.  The
 delicate and yielding omenta just enumerated allow the stomach to
 expand between their  elastic and extensive laminae, without under-
 going any disturbance of its nervous and vascular connections,  or 
20
ANATOMY AND  PHYSIOLOGY.
 any loss  of  its serous covering.   Finally, although the stomach
 itself enlarges pretty equally in all directions, still, after filling the
 left  hypochondrium, the mobility of  its bent middle directs  it
 towards that part of the inclosing cavity where it meets with the
 least resistance—namely, towards the yielding anterior wall of the
 belly.   Hence, should  the  distended  intestines not allow  it any
 great descent downwards, it comes forwards; so that what was its
 vertical surface now looks obliquely upwards, while  its inferior
 border  touches the lower part of the wall of the epigastrium, where
 its artery  has even been felt pulsating in very emaciated subjecfs.
  In the physical  examination  of the stomach during life, the accu-
 racy with which the outline of the organ can be mapped out by
 percussion is, of course, subject to great variations.  If tolerably
 distended, the mere tone afforded by the cardiac end will generally
 distinguish it from the  colon (and a fortiori from  the small  intes-
 tine), no matter how great or irregular ^he flatulent distension of
 its adjoining segments.  The gradual merging  of this deep tym-
 panitic  sound into that  of intestine, near the pylorus, is a source of
 less  ambiguity than might be expected; both from  the proximity
 of this part to the  surface, as well as from its marked contrast with
 the liver and colon above and below respectively.  Often, however,
 the latter  aid to distinction is absent, from the small or large intes-
 tine  overlying the stomach for  a longer or shorter period; a state
 which is, I think, more frequently produced by the segment thus
 concealing this stomach being pushed over by the distension of
 adjacent parts, than by its own flatulent dilatation.   Lastly,  a dis-
 tended  cardiac sac can  scarcely  be outlined with  exactness;  its
 tympanitic resonance being so  gradually obscured by the .increas-
 ingly thick  wedge of lung which  intervenes between the hypo-
 chondriac integuments  and the highest (or diaphragmatic) part of
 this  sac, that  no definite line of  demarcation is generally traceable.
  In common with all the sub-diaphragmatic segments of the
 alimentary canal, the stomach is composed of three coats or tunics
 —an external and serous, a middle and muscular, and an internal
 and  mucous  coat.  The first of these  attaches the organ to the
 cavity in which it is  inclosed; and limits, permits,  and facilitates
 those movements which it is the chief office of the second to exe-
 cute. The third is the most important, forming the secreting and
 absorbing surface on which the functions of the  organ chiefly
 depend.
  The  serous  coat of the stomach  is continuous with the double
 laminae  of peritoneum before mentioned, which  split to inclose it
 where they reach its various borders.  Here they are very loosely
connected to each other, and to the subjacent coat,  by an abund-
ance of  highly elastic areolar tissue.  But towards  the middle of
the  gastric surface, the  peritoneum, though still elastic, is closely
united  to  the subjacent  muscular tunic.   The advantage of this
mode of attachment has already been referred to. 
ANATOMY  AND PHYSIOLOGY.
21
  The structure of the serous coat is precisely that of the visceral
peritoneum elsewhere.  A single layer of flattened epithelia, of
hexagonal shape, rests upon a stratum of areolar tissue, containing
the scanty vessels by which this cell-growth is nourished.   Imme-
diately beneath the epithelial layer, the  areolar tissue is condensed
and firm;  and its aspect in contact with the cells shows the smooth
continuous outline of what  is, developmentally, a basement mem-
brane, but is  actually  inseparable  from  the fine  yellow  fibres
beneath, through which it gradually merges into loose, elastic, sub-
serous tissue.   The large meshes of the latter often inclose variable
quantity of adipose tissue.
  The muscular coat  of the  stomach consists of the unstriped or
organic  muscular fibre,  which  Koelliker has shown to  be con-
structed of fibre-cells  (Fig.  2, a, b).   The length  of  these cells
is from  ^  to   T£5  of  an inch;  their breadth  from 5oVcr to
■jJjw  at the middle,  where they are flattened, and from whence
they taper off to conical and pointed extremities.  They contain a

                             Fig. 2.
           Fibre-cells of the human stomach, magnified 450 diameters.
         a, Fibre-cell, as usually seen ; 6/fibre-cell, with wavy, irregular edge.

nucleus,  which  is from  3^0- to  tAtt °f an  m(m in  length,
about a sixth of this in breadth. Their texture is a pale substance
apparently homogeneous, but consisting, in reality, of a membrane
inclosing granulated or faintly striated contents.  In other instances
they are marked  by swellings (as in  b), which, as they are rarely
seen in the associated  fibres, are probably due to casual local con-
tractions of the sarcous substance itself.  The arrangement  of these
fibre-cells  is very simple; they  are  packed  together in  parallel
rows, their flattened surfaces adhering  strongly to each other.  They
thus form small bundles, between which are interposed the vessels
for their supply, inclosed in  a  sparing quantity of areolar tissue.
The union and interlacement of these fascicles build up the strata
of the muscular coat.  The  development of the fibre-cell  takes
place by the elongation of an oval cell, in which, at the same time,
is deposited a sarcous  content, that soon obscures the original  cell-
membrane.
   In the intestine these fibres are  arranged in two  layers—an
external, in which the bundles  take a longitudinal  course; and an
internal, in which  they are circular or transverse1 to the axis to the
tube.  But, in the stomach, the  peculiar shape of the organ is asso-
ciated  with a modification of  this arrangement.

  1 Probably in reality spiral.  For the grounds of this conclusion, see the author's
essay, "Stomach,"  Cyclopaedia of Anatomy, Suppl.,  p. 311. 
22
ANATOMY AND PHYSIOLOGY.
   The longitudinal layer of the stomach is derived from the similar
tunic of the oesophagus.  This tunic, on reaching the cardia, radi-
ates on all sides; its bundles becoming thinner as they diverge, to
be gradually lost among the various fibres with which they decus-
sate and interlace.  But, on the lesser curvature of the organ, they
continue much more distinctly; and are often  traceable, as two or
three broadish bundles, to within a short distance of the  pylorus.
The longitudinal layer which covers the pyloric extremity appears
not to have  any very direct continuity with  the  preceding.  Its
constituent fibres arise by scattered bundles at  about the middle of
the organ, and—often first uniting into two  broad bands which
occupy the middle of its anterior and posterior  surfaces—they soon
form a tubular layer, which proceeds over the  pylorus, to  join the
commencement of the duodenum.
  The transverse or circular fibres  lie immediately beneath the pre-
ceding, and form a much thicker layer.   To the left of the cardia,
its rings are very few and  indistinct; their places  being taken by
those of the third or oblique layer.   But from the right of this
orifice, it  continues towards  the pylorus (p, Fig.  3), with a con-
stantly increasing  thickness; until finally, reaching the margin of
this valve, it is inflected towards the  axis  of the  stomach by  a
rather steep  or  sudden curve,  which presents an  almost  vertical
surface towards the duodenum.    Those of its fibres  which lie

                             Fig. 3.

                                 .tr  7
    Longitudinal section of the stomach and duodenum, to show the pyloric valve.
v, Pyloric sac of the stomach ; l, its longitudinal muscular coat; tr, its transverse one, gradually
          thickening into p, the pylorus ; d, commencement of the duodenum.

nearest to the left extremity are somewhat less regularly transverse.
Hence some of them decussate slightly with  each  other;  while
others, which pass downwards from the right margin of the cardia
are directed somewhat obliquely towards the  left extremity of the
organ.
  The third or oblique layer lies more deeply than the two preced-
ing ; and is therefore best seen by everting and inflating the stomach
and carefully removing  its mucous membrane.  Where the oeso-
phagus enters the stomach, the transverse fibres of its left maroin
are so close to a flattened bundle of fibres, which occupies the notch
(g, Fig. 1) limiting the cardiac pouch, that the two are visibly con-
 
ANATOMY AND  PHYSIOLOGY.
23
tinuous.  The right or thickest part of this flattened band passes
obliquely downwards  towards the right side,  soon breaking off
from  the termination of the oesophagus; and from hence it con-
tinues across the transverse layer just described, to reach the greater
curvature, where the similar layers from both surfaces of the organ
are reflected into each other.  Its usually well-defined margin occu-
pies—and indeed  forms—the notch (c, Fig. 1).  The  posterior or
thinner part proceeds, not only from the depression (g, Fig. 1) on
the left of the cardia, but  also from the neighboring upper borders
of the great extremity;  and its more vertical fibres are also con-
tinued downwards to the lower border of the stomach, where they
meet  so as to complete the circuit of the cardiac pouch.
  Movements of the Stomach.—That there is an intimate connection
between  the oesophageal and gastric movements, is only what might
be  expected from that visible continuity of their  muscular coats
which has just been alluded to.
  At the close of each act of deglutition, the  lower fibres of the
oesophagus  contract with  such force, as not only to obliterate the
cardiac aperture, but even to cause the mucous  membrane of this
part to project into the cavity of the stomach.  This condition re-
mains during some moments.  And when the alimentary bolus has
thus been impelled into the organ, it excites muscular movements.
As regards the state of the cardia during stomach-digestion, the
force with which it is shut is effectively superior to the pressure
exerted  on  the contents of the organ  by the gastric contractions.
Still,  we are ignorant how much of this force is due to the contrac-
tion of the  lower oesophageal fibres, and  how much to the shape,
position, or  structure of the stomach itself.  But it is probable that
the decussation of the transverse and  oblique fibres of the organ
around the insertion of the oesophagus, renders their contractions a
material assistance to the obliteration of the lower part of this tube.
In any case, there can be no doubt that the cardiac orifice is chiefly
closed by an active muscular contraction of its own muscular walls
—a contraction which is  excited  by the stimulus of food in the
stomach, and is independent (so far as can be judged) of all assist-
ance from the diaphragm.
  The movements executed by the  stomach, and  impressed upon
the food during its sojourn in this cavity, vary according to the
stage of digestion,  and the nature of the aliment.
  The empty fasting stomach offers no movement whatever.  And
an unnaturally solid or massive food is not only incapable of move-
ment within the organ, but embarrasses or checks the action of the
muscular coat.  A small quantity of liquid food excites a vermicular
action, a gentle contraction or grasping motion of  the stomach, so
that the wrinkles of the  mucous membrane gently close  upon it,
and gradually diffuse it over the whole surface.1

  1 Beaumont.  "Experiments  and Observations on the Gastric Juice," Combe's
edition, lb38. 
24
ANATOMY AND PHYSIOLOGY.
  But the ordinary state of the human stomach during its digestive
act lies between these extremes; and may be defined as one  of
                     moderate distension, with food which has been
       Fig. 4.          subdivided by mastication, and diluted with
                     saliva and gastric juice, so  as to possess  a
                     pulpy or semi-fluid consistence.
                       Shortly after the ingestion of such food, the
                     stomach becomes the seat of a peristalsis  or
                     transverse constriction, which starts from the
                     cardia, and travels thence slowly towards the
                     pylorus.  Comparatively feeble until it reaches
                     the commencement (c, e, Fig. 1) of the pyloric
                     sac, it here becomes much more distinct, and
                     continues  rapidly forwards as a well-marked
                     circular depression, until it reaches the firmly
                     shut pylorus.  Its arrival here is followed by
                     a relaxation;  interrupted, after lasting about
                     a minute, by a repetition of this peristalsis—
                     which, by the  way, is accompanied  by some
                     longitudinal shortening of the stomach.
                       As  respects the movements  which  such
                     contractions impress upon the food, there  is
                     the closest correspondence between  the me-
                     chanical consequences of the process above
                     described, and the results actually observed.
                     The effect of peristalsis in a closed  and dis-
                     tended tube may be represented  by an inflexi-
                     ble hollow cylinder (Fig. 4), filled with liquid,
                     and accurately fitted with a perforated septum,
                     which is capable of free movement along its
                     interior.   Let  such a  septum be moved  in
                     either direction, and it at once exerts a  pres-
                     sure on the body of liquid contained in that
                     end towards which its motion sets. The pres-
                     sure being equal in  all directions, a portion
                     of the fluid escapes  backwards through its
                     aperture.  This  retrograde  current  will be
                     continually lengthened by the advance of the
                     septum along the remainder of the tube.  And
                     the slow successive movement of a  series of
such  septa would  thus establish two continuous  currents in the
liquid—a peripheral  of advance, and a central of return.
  The existence of two such currents is little affected by the mem-
branous nature and peculiar shape of  the human stomach (Fig. 5).
For, just as the comparative inactivity of the cardiac pouch would
not prevent their occurrence as a consequence of pyloric peristalsis,
so the very moderate contractions of  this sluggish part suffice  to
define the axis and its current, as that curved line which unites the
Diagram, to tlhtstrate the
 effect of peristalsis in a
 closed  tube containing
 liquid.

 The perforated septum is
supposed to be moving down-
wards, causing the two cur-
rents (the peripheral down-
wards, the axial upwards)
indicated  by the correspond-
ing arrows. 
                 ANATOMY AND PHYSIOLOGY.              25

cardiac and pyloric apertures.   "The bolus of food, as it enters the
cardia, turns to the left, passes the aperture, descends into the splenic

                              Fig. 5.
        Diagram to show the movement impressed on the food in the stomach.
 a, a, The peripheral or surface current effected by peristalsis, carrying the semi-fluid food towards
the closed pylorus; where it is reflected into 6, the central or axial current, occupying that real axis
of the stomach, which unites its cardiac (c) and pyloric (between b and d) apertures.

extremity, and follows the great curvature towards the pyloric end.
It  then returns  in the course of the smaller curvature, makes its
appearance again at the aperture in its descent into the great cur-
vature, to perform similar revolutions.  These revolutions are com-
pleted in from one to three  minutes."1   In other  words, there is  a
backward movement of the gastric contents, from the pylorus, along
that real  axis of the stomach which unites the two orifices of the
stomach near its lesser curvature.   Thus every part of the stomach
is  occupied by one or other of the two currents; and the mutual
interference of these at their borders, gradually causes a uniform
diffusion  of the various  alimentary matters  moving with  them.
Finally, the reflexion of one current into the other at the pylorus,
insures  an equal contact of  all  the semi-fluid food with the surface
of the mucous membrane:  since those portions of  the food which
occupy  the  axis of the stomach during one moment, are destined to
move along its periphery during the next.
  At a  later period of gastric digestion, the contractions of the car-
diac extremity appear even  less active than before; and  the longi-
tudinal shortening of the organ is also less  marked.  The chief
visible commencement of contraction is at the same place (c, e, Fig.
1), where it was formerly increased, and where it now  forms  a deep
constriction or hour-glass contraction.  After  this constriction has
continued a short time, it  sends onwards towards the pylorus  a
rapid peristalsis, which appears nearly to obliterate the tube in its
course, and  ends by engaging the muscular ring of  this valve.   A
slight relaxation closely follows this peristalsis, and is  succeeded by
1 Beaumont, op. cit., p. 101. 
26              ANATOMY AND  PHYSIOLOGY.
a complete dilatation of the pyloric sac.   Lastly,  the  hour-glass
contraction itself sometimes disappears;  and  an interval of about
two to three minutes  precedes the repetition of the whole process.
Often,  however, the constriction  remains until the peristalsis re-
commences.                                                    .
  The effect of these contractions on the contents of the  stomach is
twofold.   The obliterative peristalsis of the pyloric sac arrests all
axial current here, and extrudes a small portion of its contents into
the duodenum.  But in the intervals of these violent contractions,
the ordinary peristalsis appears to be attended  by the double cur-
rent above alluded to.
  The structure of  the pylorus already described, and  the move-
ments of the stomach just specified, demand a very different view
of its action than that selective power usually attributed to it, and
implied by its very name (nvkupos, portse custos).   Far from being a
specific and independent structure, which contracts against the food
in the earlier  stage of digestion, but subsequently relaxes to permit
the passage of the chyme, it must be regarded  as a mere terminal
thickening (Fig. 3, p) of the transverse coat;  with a strength pro-
portional  to its bulk, and an office, not only closely analogous1 to
that of the transverse fibres, but almost identical  in both stages of
gastric digestion.  Instead of relaxing only at the end  of this act,
to allow a moderate peristalsis to urge through its aperture a selected
portion of food, the pylorus is, at all periods of stomach-digestion, a
contracted inflection of the transverse coat; through whicb the more
fluid and  homogeneous parts of the gastric contents are continually
being strained, in small quantities, and at frequent intervals, by a
more or less violent muscular effort—by a process, in short, of coarse
filtration, aided by mechanical pressure.
   Mucous Membrane.—The mucous membrane,  on which the func-
tions of the various parts of the intestinal canal essentially depend,
is so modified in the stomach, as to offer a complex arrangement,
such as  remarkably contrasts it  with the simpler layer that lines
the pharynx  and oesophagus.  And it is distinguished from the
compound membrane of the intestine by the possession of a special
structure—namely, the proper gastric cell, or glandular  epithelium,
as it is sometimes called.
   The remaining histological constituents of this mucous membrane
are similar to those met with in the intestine. A delicate membrane
is involuted or moulded  upon a quantity of areolar  tissue.  The

  1 It is interesting to observe how little the action of the pylorus is connected
with any stimulus other than a gastric one.   The flow of bile into the fasting sto-
mach may perhaps be regarded as a transit, such as this janitor might will concede
to a fluid which is not only harmless, but recrementitious.  But in the obstructed
canal, feces pass through the valve from the duodenum with equal facility, al-
though the stomach soon resents their presence by vomiting—an act which seems
generally to imply a shut pylorus.  And Magendie has observed, that the gases of
this portion of the intestine can be made to pass the valve with equal facility;
while those distending the stomach excite its contraction. 
ANATOMY AND  PHYSIOLOGY.              27
latter texture thus forms  the matrix of the mucous coat;  and  as
such, contains its  vessels,  nerves, and  lymphatics, and  connects it
with the middle or muscular  coat.  While, on its opposite side, the
limitary or basement membrane sustains a number of minute cells,
which bound the cavity of the canal.
  Examined by the naked eye in situ, the mucous membrane of
the stomach is seen as a tolerably firm but soft layer, which has a
pale pink color, and everywhere  loosely  lines the interior of the
muscular coat, projecting  from  its surface in numerous wrinkled
folds.   These rugae chiefly occupy the cardiac half of the organ,
forming convolutions which, though somewhat irregular, are mainly
longitudinal.  They are effaced by distension  of the stomach.   On
putting the mucous membrane on the stretch, we may often discern
that its whole internal  surface is occupied by extremely  minute pits
or depressions; the confluent  and projecting intervals  of which
become so much longer as they  near the pylorus, that they  may be
compared to short villi.  These depressions are the openings of the
stomach-tubes or proper gastric glands.
  The stomach-tubes (a, b, c, d, Fig. 6) may be described as cylinders

                               Fig. 6.
     Vertical section of the stomach, near its middle, and parallel to its long axis.
                        Magnified 30 diameters.
 a, Openings of stomach-tubes, and their intervening ridges or projections ; b, upper parts of the
tubes, lined by columnar epithelium; e, lower parts, occupied by proper gastric cells; d, rounded
ends of the tubes ; e, dense areolar tissue, containing fibre-cells, and continuous with the intertubular
matrix • /, submucous areolar or cellular coat, of a looser texture, and containing vessels (some of
which are seen cut across); g, transverse layer of the muscular coat; h, longitudinal layer; i, peri-
toneal coat.


of basement membrane, which are packed vertically side by  side
in a sparing matrix of dense areolar tissue, and are filled by a pecu- 
28
ANATOMY AND  PHYSIOLOGY.
 liar  cell-growth.   Below, they terminate in closed and  rounded
 extremities (d).  Above, they expand slightly, before reaching the
 free  surface of the membrane (at a);  where their margins finally
 become continuous with each other, so as to form a  series of low
 ridges, the height  and width of which vary somewhat in different
 parts of the stomach.   The length of these tubes is, on an average,
 about  ^  of an inch.  Their diameter is about  3^ of an inch.
 Thus their length has to their breadth a proportion of ten or twelve
 to one.  Their form frequently so far deviates from that of a simple
 cylinder, as to present slight constrictions or  undulations.  And
 occasionally they even exhibit a kind of cascal pouch or blind offset
 of greater or less length.   These pouches usually spring from  the
 lower  extremities  of the tubes, which have generally a somewhat
 increased diameter in their  neighborhood.  But with these excep-
 tions (which  are, I believe, the result of  mechanical  violence) the
 gastric tubes form  simple, straight cylinders, and only widen where
 they open on the inner surface or cavity of the stomach.
X   The limitary or basement membrane of these tubes precisely
 resembles this delicate homogeneous layer in other mucous struc-
 tures, possessing an equal (or even greater) tenuity.   It is usually
 seen only  as a dark outline, bounding some isolated part of a tube.
 Rarely, however, it may  be identified  as a delicate, floating, and
 collapsed fold, which, on the addition of a dilute alkali, first swells
^ up, and then disappears.  On the ridges which  unite the tops of
 the tubes, it is quite  impossible to separate it from the subjacent
 structures; an intimate adhesion, in  striking contrast to the ease
 with which we can often isolate it from the matrix around the tubes
 themselves.
    As regards the contents of these tubes, the upper fourth or fifth of
 their length presents a single layer of columnar epithelium (b, Fig.
 6 ; a, a, Fig. 7).  Seen as  isolated cells, the particles of this epithe-
 lium have a cylindrical shape, and inclose a very distinct nucleus
 near their attached extremity.  But  when seen  in  their natural
 situation,  and from the free side of  the  mucous membrane, they
 appear as  hexagonal prisms, containing nuclei, which are so near
 to their lower ends as to be separated from the basement membrane
 by little more than their cell-wall at  this part.   The remainder of
 the tube is under normal' circumstances always occupied by oval
 or somewhat angular cells (at c, Fig. 6; c, c, Fig. 7) of considerable
 size.   The largest of these oval cells are about TJ 7  of an inch in
 diameter.   They have a  more or less distinct  membranous wall.
 The nucleus they contain is usually in contact with  that side of
 their parietes which is attached to the basement  membrane of the
 tube;  and it  sometimes exhibits a nucleolus.  Their contents are
 finely  granular, with  here and there refractile dots, which have a
  1 In reference to the alleged expulsion of these during gastric digestion, compa:
the remarks on the gastric juice at the end of this chapter. 
ANATOMY  AND  PHYSIOLOGY.
29
close resemblance  to  oil-globules.   And, besides the above granu-
lar material, most of these cells appear to inclose numerous (5—15)

                              Fig. 7.
 Upper part of a tube from the middle of the human stomach, shoving the arrangements
         of its columnar and oval cells.  Magnified 200 and 500 diameters.
  a, a, Columnar cells of the upper part, free and in situ ; b, b, small angular cells, also free and
in situ, into which these merge below, to form a central or axial layer within c, c, the propergastric
or glandular cells, also free and in situ.

pale, flat, and extremely delicate cytoblasts.  The centre of the layer
formed by these cells is apparently lined by a series of small angular
cells (b, b, Fig. 7), which surround and  inclose a narrow thread-like
calibre or cavity; and  above,  merge into the columnar epithelium
of the  upper part of the stomach-tube.   The interstices of the oval
cells seem to be occupied by granules and minute cytoblasts.
   Lenticular glands  are also found in the stomach.  As regards
their shape, size,  situation, and contents, they correspond with  the
follicles' or solitary glands of  the intestine.  Their number varies
extremely.  Sometimes it is impossible to find any.  In other spe-
cimens, they are scattered  more or less thickly throughout  the
whole  organ.  They are said chiefly to affect the lesser curvature;
but I have seen them sown  very plentifully over the pyloric region
only.   In children they are rarely absent.
   Matrix.—The cylindrical  tubes of the stomach are united  to each
other,  in  their  whole height, by a  sparing quantity of a  fibrous
network  or  matrix;  their  blind  ends also resting  upon a layer
(e, Fig. 6), continuous with that surrounding their sides.   Near  the
free or cavitary surface of  the stomach, this  dark firm matrix is
almost homogeneous.  But in the deeper parts of the mucous mem-
brane  it is easy to distinguish, in addition to vessels, fibres which

  1 See author's essay, "Intestine," Cyclopaedia of Anatomy, Suppl., p. 357, et seq. 
30
ANATOMY AND  PHYSIOLOGY.
 surround the tubes, and decussate with each other.  This  matrix,
 which also surrounds the intestinal tubes, and  thus extends from
 the cardia to the anus, is composed of a variable admixture  of
 areolar tissue with unstriped muscular fibres.  The latter appear
 to pass from the  oblique and  transverse layers  of the  muscular
 coat through the areolar tunic, to reach the intervals of the stomach-
 tubes, in the form of bundles, which decussate at an acute angle.
 The action of these fibres is probably connected chiefly with the
 adjustment of the mucous membrane to the effects produced by the
 contractions of the proper muscular coat.
   Areolar Tissue.—A layer of loose submucous areolar  tissue (the
 tunica nervea of authors) connects the mucous and muscular coats.
 Seen  in vertical sections (/, Fig. 6), its thickness is a little  greater
 than that of the layer of matrix beneath the ends of the tubes.   It
 is composed  of the  ordinary white and yellow fibrous elements;
 the filaments of the latter being chiefly of small size.  Externally,
 it is firmly connected with the muscular coat, from which it receives
 fibres, and to which it sends off' processes to form the septa of the
 muscular bundles.  But more internally, where it  approaches the
 fibrous matrix, its meshes are very  large and loose; so as to allow
 the mucous membrane  to be thrown into folds  by the contraction
 of the muscular tunic.   It contains the vessels, nerves, and  lym-
 phatics which supply the other coats.
   The vessels of the stomach are very large and  numerous.   The
 arteries are derived  from the abdominal aorta.   The veins empty
themselves into the vena portse, which ramifies in the liver.
   The arteries come from the cceliac axis.  This vessel, which leaves
the aorta opposite the first  lumbar vertebra, continues obliquely
forwards, as a short thick trunk, for about half an inch, when the
" axis" ceases by  giving off, at right angles to itself, three large
branches—the gastric, hepatic, and splenic.
   The arteria coronaria  ventriculi (a,  a, Fig. 8), or  proper  gastric
artery, is the smallest of these three.  It passes upwards and towards
the left side, beneath the peritoneum which forms the dorsal  and
outward  surface of the sac of the omentum; until, arriving nearly
at the upper extremity of this cavity, it turns forwards in a slight
projection or  fold of the serous membrane.  In this fold, it has a
very brief and somewhat arched course, which brings it to the left
end of the smaller curvature of the stomach.   Here it  passes be-
tween the two layers of  the gastro-hepatic omentum. From hence
it continues, in a very tortuous course, along this  curvature : lying
close to the stomach, and diminishing in size by  giving off frequent
branches; until, towards the right extremity of the organ, it becomes
continuous with  the pyloric branch (/) of the hepatic artery.
  Its larger or named branches are  the oesophageal and  the gastric.
The first  are given off from the highest point of the vessel, or where
it enters  the  gastro-splenic omentum.  They run upwards to the
oesophagus, taking a longitudinal course; so as to pass, with  this 
ANATOMY  AND  PHYSIOLOGY.
31
tube, through the opening in the diaphragm, and anastomose with
the thoracic vessels distributed to this tube from  the  aorta.  The

                              Fig. 8.
                                 7V
    Arteries of the stomach, as seen by raising this organ, to show their origin from
                            the cceliac axis.
  S, Stomach ; d, duodenum ; I, liver ; p, pancreas ; sp, spleen ; J, jejunum ; a, a, coronary artery ;
b, splenic artery; c, left gastro-epiploic artery ; e, vasa brevia ; f, superior pyloric artery ; h, hepatic
artery ; m, superior mesenteric artery ; n, aorta ; q, q, right gastro-epiploic artery.

gastric ramifications run downwards from the artery on both sur-
faces of the stomach;  inosculating, by their extremities,  with
branches from  the splenic,  gastro-epiploic, and superior pyloric
arteries.
  The arteria hepatica (h, Fig. 8), another branch of the cceliac axis,
passes outwards and slightly forwards from the trunk to reach the
commencement of the duodenum.  It now runs almost vertically
upwards, between the two layers of peritoneum that form the gastro-
hepatic omentum, in front of the foramen of Winslow, to end  by
being distributed  in  the liver.   In this  course it gives off two
branches to the stomach—the gastro-duodenal and the pyloric.
  The  gastro-duodenalis (beyond h,  Fig. 8) is the first and largest
of the two.   It leaves  the  hepatic artery behind the duodenum,
passing  vertically downwards across the  intestine  to the  lower
border of its first portion.   In this course it gives oft" a few small
branches to the neighboring parts  of the  stomach  and intestine;
some of which twigs have been distinguished as the inferior pyloric
arteries.  And  at  the inferior margin of the bowel, it  bifurcates
into two branches: a large  gastro-epiploic and a small pancreatico-
duodenal.
  The gastro-epiploica dextra (q,  q, Fig.  8), the  large vessel which
continues the gastro-duodenalis, is so named from its course between
those layers of the great omentum which descend from the stomach
to form  the "epiploon" or apron-like fold that  covers the greater 
32
ANATOMY AND  PHYSIOLOGY.
 part of the intestinal canal.  Beginning at the lower border of the
 duodenum, the artery runs from right to left, along the lower margin
 or great curvature of the stomach, and at a  little distance from  it,
 in wavy or tortuous curves.   In this course, it gives  off branches
 upwards  to both surfaces of the organ; as well as others to the
 tissues of the omentum itself.  And near the middle of the stomach,
 it ends by uniting with a corresponding branch,  of smaller size,
 from the splenic artery.
   The arteria pylorica (/, Fig. 8), which  is sometimes distinguished
 by the title of the pylorica superior from the smaller branches  of
 the gastro-duodenal above alluded to, is generally given off from
 the trunk of the hepatic  artery opposite the  upper border  of the
 duodenum.   More rarely it is derived from the commencement  of
 its gastro-duodenal branch.   In either case,  it enters  between the
 layers of the gastro-hepatic omentum, and runs in this fold, from
 right  to left, along the  upper margin or lesser curvature  of the
 stomach, to join the coronary artery.  It gives off numerous branches
 to both surfaces of the organ.
   The arteria  splenica (b, Fig. 8), the third  branch of the  cceliac
 axis, has no direct connection with the digestive canal, until near
 its division  into the terminal trunks by which it enters the spleen;
 where it gives'off the left gastro-epiploic artery, and the vasa  brevia.
   The gastro-epiploica sinistra (c, Fig. 8) leaves the trunk  of the
 splenic artery close to where this  divides at  the inner surface  of
 the spleen.   It passes downwards, forwards, and towards the right
 side; first lying for a short distance in the gastro-splenic omentum,
 and next entering between the layers of the  great omentum con-
 tinuous with this fold.   It then runs along the lower border or
 great  curvature  of the stomach, to become  continuous  with the
 corresponding vessel on the right side, supplying branches to both
 surfaces of the stomach.
   The vasa  brevia (at e, Fig. 8) are  small branches which come
 from  the  primary and  secondary divisions  of the  splenic  artery,
 and run in the gastro-splenic omentum to the cardiac pouch.  Here
 they break up and anastomose with each other, as well as with the
 coronary and left gastro-epiploic arteries.
   The veins of the stomach are the superior pyloric, and the right and
 left gastro-epiploic.
   The vena pylorica  superior receives and continues a large vein,
 which corresponds to the coronary  artery, and takes a similar (but
 reversed) course along the lesser curvature of  the stomach to the
 pylorus.   It now passes upwards for a little distance, before open-
 ing into the vena portse near its termination in the liver.  In some
 instances,  it bends down to join the splenic vein.
   The vena  gastro-epiploica dextra corresponds to the artery in the
 greater part of its distribution.  It usually ends by emptying itself
 into the superior mesenteric  vein, just before this forms  the vena
portse by joining with the splenic vein. 
ANATOMY AND PHYSIOLOGY.
33
  The vena gastro-epiploica sinistra also runs with its artery, and
joins either the splenic vein or one of its primary branches.
  All of the foregoing vessels are characterized by the great free-
dom and frequency of their inosculations, in every stage of their
course from  the aortic  to  the portal trunks.  This  condition is
especially well-marked  in the arteries, which in  number and size
far exeeed those distributed to an equal bulk of most  of  the other
structures of the body.   This fact is doubtless connected, not merely
with the large supply of blood they send to  the stomach, but also
with a smaller resistance, and greater velocity, in their channels;
and especially with that efficient and sudden control of their calibre
which the varying  exigencies of the gastric circulation would seem
to imply.
  Their tortuous course, and their loose connection with the stomach,
chiefly refer to the distension of this organ.  For as  the stomach
extends between the laminae of peritoneum, it gradually straightens
these vessels, and  alters their position with respect to itself and
each other.
  The distal branches of both  arteries and veins perforate the
muscular coat at  different intervals, by twigs which unite with
each other in the loose submucous areolar  tissue, so as to  form two
flattened networks: one, which is composed of small arteries;  and
another,  of veins.   The vessels of the latter plexus are, as usual,
both larger and more numerous than the corresponding arteries.
   Capillaries.—The arterial branches which  leave this submucous
network to enter the dense muscular layer of the  matrix of the
stomach, divide here once or twice.   And  their ultimate ramifica-
tions, which have  a diameter of about y^xj to yg1^ of  an  inch,
pass vertically upwards, along the sides of  the tubes, to their upper
apertures, where they form a superficial network of capillaries.  In
passing upwards, they also  give  off other  capillaries; which sur-
round the tubes at  all parts of their height, so as to form a second
and deeper network.  The  meshes of this latter plexus are  some-
what oblong (t, Fig. 9), but  less decidedly so  than those of the
capillary network  of striped  muscle; and are about y^ to  g£<j
of an inch  in size.  The capillaries which compose them are, on an
average,  little more than ^^^ of an inch in diameter.  The more
superficial network (b, Fig. 9) is contrasted  with  this deeper one,
not only in the fact that its capillaries are about double the above
size (or  j^g  of an inch), but also in its meshes (Fig. 10)  being
nearly twice as  close  (or  about -gjg  to  F^  of an inch).  But
the two plexuses inosculate so freely, as to be quite continuous with
each other at the upper apertures of the  tubes.  As regards the
form of  the superficial network, it corresponds exactly  with the
intervals of the tubes.   For  the ridges which occupy the surface
of the  organ are all, as  it were, moulded  upon capillaries; the
union of which forms a network that surrounds the aperture of
      3 
34
ANATOMY  AND PHYSIOLOGY.
each tube with a loop or  ring (b, Fig. 9), complicated  by the addi-
tion of  other  meshes (Fig. 10) on either  side of it, just within the
Fig. 9.
Diagram showing the vessels of the mucous membrane of the stomach, as they would be
                seen in a vertical section.  Magnified 30 diameters.
  a, Small artery of the plexus in the submucous areolar tissue; t, capillaries, forming a network
around the stomach-tubes ; 6, larger capillaries, forming a superficial network on the ridges which
separate the open mouths of these tubes; c, veins, formed by branches from the latter network, and
ending below in the submucous plexus.
orifices of the  tubes.    In shape and  size,  these meshes  closely
resemble  the  loops  beneath  the  ridges; and  are, indeed, no  way

                                  Fig. 10.
Superficial capillaries of the gastric mucous membrane, from an injected specimen.
                        Magnified 60 diameters. 
ANATOMY AND  PHYSIOLOGY.
35
distinguishablefrom them except in their  situation.  Below, their
diameter diminishes;  their loops elongate; and they finally merge
into the capillary network which surrounds the tube.
  It is from  the  large capillaries which compose the superficial
network that the radicles  of the veins (c, Fig. 9) almost exclusively
arise.  They begin as small vessels of about T^ of an  inch  in
diameter; and, by one or two successive  unions  of these and  of
their resulting larger branches, soon attain  a width of about ?^
of  an  inch.   They now  pass  vertically downwards between the
tubes to open into the venous plexus of  the submucous areolar
tissue.
  The general result of this arrangement on the circulation in the
stomach is—that the  blood which has already traversed the capil-
laries of its tubes  is further transmitted to  its surface;  and that,  in
respect to their size and  situation, the superficial capillaries of the
gastric  mucous  membrane offer some analogy to veins.  Hence it
is probable that the velocity of their contents far exceeds that of
the blood circulating  in the capillaries of many other tissues.  Such
a peculiarity would admirably adapt them to that absorptive office,
which their situation on the cavitary surface of the stomach indi-
cates to be one of  their chief functions.
  The nerves of the stomach are derived from two sources: from
the pneumogastric, and the sympathetic, nerves.
  The branches of the pneumogastric nerves leave these trunks  at
the lower end of the oesophagus; and, after a variable course in a
nearly vertical direction—those of the left anteriorly, those of the
right posteriorly, to the stomach—they perforate the muscular coat.
Diminished in size, they then ramify in  the submucous  areolar
tissue; in which they may be traced for a considerable distance,
until lost from increasing minuteness on the under surface of the
mucous membrane.   In  this course their  complexity of arrange-
ment almost baffles description.   Each, for example, forms a net-
work of its own branches near the cardia, as well as a larger plexus
below  this point.   Each  unites, not only with large and small
branches of its fellow, but with the sympathetic nerves of the
stomach, at all stages  of their distribution visible to the naked eye
—from the solar  plexus  and  semilunar ganglia, to the secondary
and tertiary offshoots  of these around the vessels, and even to their
branches in the areolar coat of  the stomach.
  The sympathetic nerves distributed to the stomach are branches
from the great prevertebral centre of this nerve in  the belly—from
the vast and complex ganglion formed in front of the aorta by the
semilunar ganglia laterally, and  the solar  plexus which  unites
these in the middle line.   The  large plexiform ganglion, thus con-
stituted, gives off a process—the cceliac plexus—which envelops
the cceliac axis with  a dense network of nerves; itself  further
breaking  up  into subordinate  plexuses   around the coronary,
hepatic, and splenic branches of this arterial trunk (a, b, h,  Fig. 8). 
36
ANATOMY AND  PHYSIOLOGY.
Closely interlaced around these  vessels, and doubtless from  time
to time distributing branches to their  coats, the plexuses corre-
sponding to the arteries just mentioned pass  along them to the
stomach; which they reach to penetrate  the muscular coat, and to
disappear in the submucous tissue, like the gastric branches of the
pneumogastric nerves.  Of the three arteries, however, the coronary
is that which appears to convey the greatest  amount  of nervous
tissue to the stomach;  and the pyloric branches of the hepatic
plexus are next in number to these.
  The further  pursuit of all these nerves under the microscope
adds little exact information to this description.  Apparently, they
interchange branches with each other at frequent intervals; though
the arrangement is hardly of sufficient regularity and frequency to
deserve the name of a plexus.  Here and there indications of gan-
glion corpuscles are sometimes discernible; as well as true bifurca-
tions of the primitive  nerve-fibres.   And it  is easy to verify  a
general diminution  in the diameter of these fibres, in their course
from the solar plexus to the under surface of the mucous membrane.
But in this tissue itself, or between the secreting tubes of the organ,
it has hitherto  been impossible to detect nerves; and we can only
conjecture their presence.
  The functions  of the nervous tissues derived from  these two
sources are also still uncertain.    Section of both pneumogastric
nerves remarkably  interferes with gastric digestion: diminishing
(if not almost suppressing) the secretion of gastric juice; provoking
vomiting; and deranging (though not destroying) the due sensations
of hunger and satiety.  But where the animal survives, these effects
seem to diminish, and even  disappear.   In like manner,  violent
irritation of the pneumogastric, or of the solar plexus, in a newly-
killed  animal, provokes movements in  the muscular coat of the
stomach.  But such facts obviously prove little as to the exact
offices of these  nerves.  And until we know far more of the real
import of the numerous communications between the pneumogastric
and sympathetic branches distributed to the  stomach,  a vague
analogy to the corresponding arrangements of  these nerves in the
heart is almost  all we can conjecture.
  The lymphatics of the stomach consist of two sets: one beneath
the peritoneum, immediately outside the muscular coat;  another (a
plexus of larger vessels, with more frequent communications) in the
submucous coat, between the mucous and  muscular tunics.  They
anastomose freely at the ends of the stomach with  the lymphatics
of the liver, spleen, and pancreas;  and are still more directly con-
tinuous with  some  glands, which are of small size in the healthy
individual, and are  placed chiefly near the lesser curvature of the
organ.  How far these vessels exercise the office of lacteals, in addi-
tion to that of  absorbents—in other words, how far  they are chy-
liferous as well as lymphatic—is a question which  can  hardly be
answered in detail.   But it is difficult to deny them some action of 
                ANATOMY AND PHYSIOLOGY.              37

this kind, even while it is certain that they rarely, if ever, convey
a visibly chylous liquid.
   Changes during Digestion.—The inner surface of the healthy fast-
ing stomach is of a pale pink  color.   The mucous membrane itself,
always exhibiting an acid reaction, is covered by a thin stratum of
alkaline fluid, derived (as its chemical and microscopical examina-
tion abundantly proves) from  the various secretions which enter the
organ by the oesophagus and duodenum.  The introduction of food
gives rise to two chief alterations in the state of the stomach.   Its
muscular coat is excited to the movements already described.  And
at the same time its  mucous membrane deepens to a bright pink
color, and begins to pour forth a liquid—the gastric juice.
   Gastric  Juice.—The discrepancies and contradictions of  the
accounts hitherto given of this secretion are in great degree due to
the difficulties which its examination involves.  The situation and
office of the organ by which  it is secreted, almost forbid  its being
obtained in a state of purity.  Occasionally admixed witb bile,
always diluted with large quantities of saliva, as well  as with  ali-
mentary  substances themselves  undergoing rapid  metamorphosis,
the gastric juice obtained from the digesting stomach is necessarily
very impure.  And in the fasting stomach, its quantity (especially
in comparison with that of the residue of food and secretions then
present) is too small for successful inquiry.  The changes produced
by disease, or consequent upon death, constitute further sources of
error.  It  must be confessed that the most careful study of these
 circumstances scarcely reduces the discrepancies and contradictions
 above hinted at to any single consistent description.  But it shows
 them to constitute conditions  which, according as they are obviated,
 noticed, or neglected, respectively render any particular observations
 or experiments  valid, comparable, or  useless.  And it  forms  the
 basis  of those opinions on  this controverted subject which  are
 summed up in the following  remarks.
   Physical Properties.—Pure gastric juice is a transparent, limpid,
 structureless liquid, of a  pale straw color.   Its taste  is  distinctly
 acid ; and its smell a peculiar faint odor, characteristic of the species
 of animal from which it is derived, and allied to that of the blood.
 Its specific gravity is  about  1003.3.  In the  healthy human adult
 the quantity secreted during  the twenty-four hours probably ranges
 from ten to twenty pints; and under favorable circumstances,1 its
 maximum in an hour may be estimated as  not  less than six or
 eight pints.
   The chemical  properties of  the gastric juice are best noticed by
 successively  considering its acid, saline, and animal constituents.
    The  Gastric  Acid.—Omitting  exceptional  instances  in  which
 acetic, butyric, and other acids,  allied to these products  of organic
 decomposition, have  been found in inefficient quantity in the  con-
 tents of the  stomach—and  further eliminating the view taken by
1 Such as long fasting followed by a large meal of meat. 
38
ANATOMY AND PHYSIOLOGY.
Blondlot, which ascribes the acidity of this secretion to the presence
of the  acid phosphate of lime—there are two views of sufficient
importance to demand notice.   One of these regards  the gastric
acid as the hydrochloric, and another as the lactic acid.   There can
be no doubt that each of these acids has been  repeatedly found in
the gastric juice as the chief or sole cause of its acidity.1  There is
just as little doubt that  they are sometimes  present together, and
that even in the same species and individual2 the hydrochloric may
be replaced by the lactic acid.   While we shall see that either of
the two would suffice  to restore  to a neutralized  gastric juice its
original digestive powers.
  But  a careful consideration of the facts hitherto known leads me
to the  opinion, that, in these latter cases, the lactic acid is always
a secondary3 and accidental product;  and that the balance of evi-
dence inclines decisively towards a single  acid of the gastric juice,
which,  as normally secreted, owes its acidity exclusively to hydro-
chloric acid.4
  Salts.—As  regards  the salts of the gastric juice, the details of an
analysis of this  secretion  may be  best comprehended  (if not  ex-
plained) by comparing them with a similar quantitative examination
of the liquor sanguinis.  The following table5 exhibits such a com-
parison, for a  thousand parts of both fluids.
                                         tiquor Sanguinis.  Gastric Juice.
        Water.......903.0       973.2
Animal matters
Mineral substances
Chlorine .
Sodium
Potassium (in dog, .2 ?)
Phosphoric acid
Phosphate of lime  .
Phosphate of magnesia
(Lime corresponding to .624 Ca. CI.)
88.5
 8.6
3.6
3.3
 .3
 .2
 .3
 .2
17.0
 9.8

 5.6
 1.2
  .6
  .6
 1.2
  .2
  .3
1000.0
1000.0
  1  Lactic acid by Chevreul, Lassaigne, Thomson, Lehmann,  Payen, Bernard,
Frerichs, and Smith; hydrochloric by Prout, Dunglison, Braconnot, Tiedemann,
Enderlin, Schroeder, Bidder, and Schmidt.
  2  In Alexis St. Martin, as it would appear from a comparison of the analyses by
Dunglison in 1833, and F.  G. Smith in 1856.
  3  [This  opinion, which is also held by Professor Dunglison, of Philadelphia, has
since been carried into conclusive details by him, as regards the earlier and later
analyses of the gastric juice of Alexis St. Martin.  In a private communication,
Professor Dunglison has specially called my attention to the great dissimilarity of
the  two modes adopted for procuring the gastric juice by himself in 1833, and by
Dr.  Smith in 1856. In the former case it was obtained pure in the fasting state,
by exciting the gastric mucous membrane with an elastic gum tube.  In the latter
it could only be obtained after food had been taken;  and hence it is not surprising'
that lactic acid was found.  The secretion occupying the fasting stomach was not
gastric juice, but a putrescent mucus.]
  4  Compare author's Essay, " Stomach," p. 330.
  5  Here the composition of the gastric juice is calculated from an analysis by
Schmidt;  and that of the  blood-liquor is quoted from  Lehmann (PhysiologLsche 
ANATOMY  AND PHYSIOLOGY.
39
  Hence, while most of the salts of the blood are present in in-
creased quantity in  the gastric juice, the chloride of sodium is so
greatly diminished  as  to lower the total saline contents of this se-
cretion below  those of the blood-liquor.   AVhile the amount of
hydrochloric acid is so great  as not only to compensate this loss,
but even to raise the total of its mineral constituents above that of
the blood-liquor.   The origin of this acid is obvious.  Its mere
quantity is sufficient to refer it to the chloride  of sodium, which is
the most plentiful chloride of the parent fluid.  And the remark-
able diminution in the sodium of the secreted fluid further confirms
this  view.   Indeed,  it is interesting to  notice  that  almost all the
differences between the salts of the two fluids may be included in
some such hypothesis  as that of—(1) a rapid  transudation  of the
blood-salts  generally, followed by their concentration  through an
absorption of  part of their water of solution; (2) a decomposition
of about half of the chlorides, probably of the chloride of sodium;1
(3) a return of the  base of this salt into the  blood.   While  it is
evidently to a derivation of acid from  some of the constituents of
the latter fluid that we must refer the important  fact established
by Dr. Bence  Jones—namely, that  during digestion,  the healthy
urine loses the acidity proper to it at other periods.
   Organic Substance, or Pepsine.—The  addition of alcohol to pure
gastric juice, or to a  watery infusion of stomach, causes a white
flocculent precipitate; which, when  dried at a low temperature,
forms a much  less voluminous mass, of  a yellowish-gray color, and
a  somewhat gummy appearance.   This substance reddens litmus,
and  is soluble  in cold water; but  may be again precipitated from
its aqueous solution by alcohol.   Its ultimate composition closely
resembles that of the various protein  compounds, from which it
differs  chiefly  in  containing more  nitrogen.   And even its other
chemical properties bear out this resemblance; its differences from
many of the albuminous compounds consisting chiefly in the fact,
that it is not precipitated from its  watery  solution by  some of the
salts which would throw down dissolved albumen.  Allowing for
variations due to impurities, the reactions due to gastric juice, and
probably of pure pepsine, are as follows.   It is not  precipitated
by heat, ferrocyanide of potassium, sulphate of copper, alum, chlo-
ride of iron, or mineral acids. It is precipitated, though not com-
pletely, by bichloride of  mercury.  Carbonates  of the  alkalies
precipitate its  lime-salts.   And the soluble salts of silver and lead

Chemie, Bd. ii. pp. 153,179).  To facilitate comparison, both analyses are reduced
to one place of decimals ; and the phosphate of lime of the former is divided into
acid and neutral phosphate.
  1 Such a decomposition would obviously present many analogies to electrolysis.
But though the acid and base are certainly unloosed and separated, the process
itself cannot be definitely referred to this cause in the existing state of our know-
ledge.  We may, however, notice that both the quantity and quality of the chloride
of  sodium would render it a more probable source of the acid by such electrolytic
action than any other of the salts present in the blood-liquor. 
40              ANATOMY AND  PHYSIOLOGY.
throw down the chlorides of these metals.  In all of these instances
a portion of the pepsine  is carried down with the precipitate.  In
the case of the salts of lead, the greater part of the pepsine is thus
deposited, but may be almost completely recovered by washing.
  Action of the Gastric  Juice.—The addition  of a few drops of
diluted muriatic acid to a solution of the above precipitate in cold
water, constitutes a liquid which possesses energetic solvent powers
over ordinary animal food.   Hence the organic substance itself has
been termed pepsine (rtl^s, concoctio), a name to which there can be
no objection, so long as its meaning is confined within proper limits,
and is not extended to  imply a single  and definite organic com-
pound, capable of  digesting all the alimentary principles.
  Temperature exercises an  important influence on the gastric
solvent.  At the ordinary temperature of the atmosphere, the action
of the  gastric juice is scarcely perceptible, even when continued
during many hours.  Lower degrees of cold suspend its action still
more completely.  Heated to the temperature of. the body, namely,
to about  100° Fahrenheit,  it  acts very energetically.  A further
accession  of temperature at first increases, but soon  injures, and
finally destroys, all  its  digestive powers.   The  precise point at
which  this  change of effect occurs is not clearly known; but it is
probably  at or near 120°.   The dried pepsine  of the  artificial
digestive fluid will, however, sustain  a temperature of 160° without
damage.   But at  a heat above this, it becomes  wholly  inactive,
and partially insoluble.  And  the pepsine of pure gastric juice is
stated by  Dunglison to be insoluble in hot water.
  Alcohols, acids,  and alkalies, when applied in excess, have also
a destructive influence on the  digestive  power of pepsine.
  In the  case of acids, this injurious effect  is much less marked.
As might have been expected from the constant reaction of the
gastric juice, an acid is essential to  its digestive  efficacy; indeed,
we might almost say, to its  very existence.   Even that incomplete
loss of acid, which is necessarily involved  in the precipitation of
its  pepsine, must be compensated by  an  artificial acidulation, before
an  aqueous solution of this substance  regains its former  powers.
Here, however, as  in  the case of heat,  it is necessary that certain
limits  should  be  observed.   About half the quantity of  hydro-
chloric acid present in  the  gastric juice forms a tolerably effective
fluid.  But the normal  proportion (about 3 parts per 1000) may
be  increased to three or four per cent., not only with impunity, but
even with advantage.
   The nature of the acid seems a matter of indifference.   Nitric,
phosphoric, sulphuric, acetic, and lactic acid, have all been success-
fully made use of.  And the range of amount already specified for
hydrochloric acid  might, a  priori, prepare us for the fact, that the
requisite quantities of these acids seem  solely related to their more
or  less dilute  state; and do  not allow us to  recognize  any trace of
an  equivalent proportion. 
ANATOMY AND  PHYSIOLOGY.             41
  Applied in still larger quantities, all of these acids first weaken,
and then destroy, the digestive power of the solution of pepsine.
The comparative amount of injury inflicted by equal quantities of
the different acids  appears  to depend (like their  solvent efficacy)
chiefly on the degree of their concentration.
  The essential aid given by the  acid is well  shown  by the  effect
of neutralizing a natural or artificial gastric juice with an alkali.
Under these circumstances, it not only loses all action upon  albu-
minous substances,  but, if mixed with them, shares their putrefac-
tion.   Left to itself, however, its powers are only suspended,  being
renewable by the  addition of an  acid.   The  addition of a larger
quantity., of  alkali permanently destroys all its solvent powers, and
is followed by its rapid putrefaction.
  But though an acid is thus one of the essential  elements of a
digestive fluid, it must not be thought  that  any such agent can
imitate the gastric secretion, even when associated with an infusion
of saliva, mucus,  intestine,  bladder,  or  other animal product  or
tissue.  The solution accomplished  by such  fluids  is excessively
slow,  superficial, and  imperfect;  and affords—not the new com-
pound produced by gastric  juice from albuminous substances, but
a weak  and turbid solution,  which  readily  yields  its dissolved
constituents to  ordinary reagents.  And  even in the  case  of  an
acidulated infusion of  intestine—where the results are necessarily
affected by  the diffusion of  gastric juice over the whole digestive
canal—the nature and amount of  the process  do not allow it to  be
any way comparable with that effected by an artificial gastric fluid.
  The effect of the neutral salts on artificial digestion has scarcely
been investigated with all the attention it merits.   But it is probable
that many of these inorganic substances assist solution, when present
in small quantities, but oppose it when added in  excess.  This is
especially the case with chloride of sodium, the ordinary condiment
of mankind and of many animals.
  The effect of  alcohol  is  also regulated by its  amount and con-
centration.  Diluted, it seems to have no chemical action whatever.
In larger quantities, as before remarked, it precipitates pepsine.  And
in still greater  excess,  it permanently  destroys  all its digestive
energy.
  In respect to the solvent  properties of the  gastric juice on the
various protein compounds,  an exact determination of the quantity
of pepsine which these substances require for their solution, would
greatly assist us in solving many problems with respect to the
chemistry of digestion.  But the estimates  derived  from actual
experiment are very conflicting—if, indeed, they can be considered
really comparable.  It may, however, be estimated, that one part
of pepsine will  dissolve about fifteen of moist  and finely divided
albumen: while the gastric  juice itself possesses the power of dis-
solving from fifteen to twenty per cent, of its weight of the same
substance. 
42
ANATOMY AND  PHYSIOLOGY.
   The gastric juice dissolves, not only the various  protein com-
pounds, but gelatin, chondrin, and gluten.   In doing so, it arrests
(and  generally removes) all decomposition  or putrefaction which
they  may  be undergoing.  The mere  physical  condition  of  the
substances to be dissolved remarkably influences the rate of the
process: density and bulk rendering it slow, while, conversely, it is
accelerated by minute division.   The quantity of solvent  required
varies with the nature and aggregation of the particular substance.
   In  any case, the  ultimate effect is that of a complete  solution,
containing a substance which (as shown by Mialhe and Lehmann),
whatever  the substance originally dissolved, possesses certain pro-
perties, entitling it to the name of peptone.
   Peptone.—The following properties are common  to all kinds of
peptone.  Beduced to the solid form by careful evaporation, it  is a
white or yellowish-white substance; almost tasteless and inodorous;
very  soluble in water; but insoluble in alcohol of eighty-three per
cent.   Its watery solution reddens litmus;  and is precipitated by
chlorine, tannic acid, and metallic salts; but is unaffected by boil-
ing, by acids, or  by alkalies.   With alkalies and  bases, it forms
very  soluble neutral compounds or salts.   An aqueous solution of
these is still less precipitable by reagents than one of peptone itself.
Thus it is only thrown down by tannic acid, bichloride of mercury,
and a mixture of the acetates  of ammonia and lead;  the acetate of
lead,  and the ferrocyanide of potassium, causing but a faint  cloudi-
ness ;  and even concentrated acids, nitrate of silver, and alum,  having
no effect.
   The ultimate chemical composition of any particular peptone so
closely resembles that of the substance from which it is formed as
scarcely to require any further notice.
   In  speaking of these chemical phenomena of stomach digestion,
there  remains but to  notice, that the addition of water, or a small
quantity of fresh acid, is capable of restoring some of its original
digestive powers to saturated gastric juice, or to a solution of pep-
tone.
   The above properties of the gastric juice  naturally suggest  the
question—What is the nature  of its action?
   In  answer to this question we may premise, that it  is obviously
no simple process of solution  by a dilute acid; no mere contactive
influence (like that of spongy  platinum in the acetification of alco-
hol);  no mere fermentation (like that excited by yeast in a solution
of sugar); no mere complex acid combining with protein compounds
as bases (as in  the  "hydrochloro-pepsic"  view propounded  by
Schmidt).
   If we must  connect the above details by some theory, we may
first remark, that the gastric  juice dissolves  protein compounds;
that it renders them highly soluble; and that it assimilates their
form and reactions to its own,  without  changing their composition.
For any parallel to such  a process, we can only look to those lower 
ANATOMY AND  PHYSIOLOGY.                43
degrees of chemical action, where solution and combination, adhe-
sion and affinity, may be supposed  to meet  and  merge  into each
other;  where proportions  are tolerably definite,  but  true equiva-
lents indistinct; and where, though form  is changed and reactions
modified, elementary composition remains little affected.   Actions
of such a kind may be found in the union of many substances with
water,  or  its elements, to  form the compounds  called  hydrates.
And the conversion of protein  into  peptone, by the gastric juice,
presents so  many analogies to  the  formation of a hydrate,1 that it

  1 The grounds of this view may be  briefly summed up as follows.  The great
change of solubility undergone by albumen in its conversion by pepsine into pep-
tone—or rather, the failure of various reagents to combine with and precipitate its
mass—point to a change, of which it may certainly be said that it is just as dis-
tinct from mere solution in water, as it is from any real alteration in the propor-
tions of the elements of the modified  albumen;  and that, unless we suppose the
combination of pepsine with albumen to constitute the process itself, we are almost
left (by exclusion) to the supposition of water being the modifying or combining
substance.  The strong attraction of pepsine for water confirms this view, as does
also the fact that both pepsine and peptone bear heat when dry, though destroyed
by it when moist; in other words, that it is  only by the changes which heat im-
presses  on their water of moisture, as distinct from any mere water of combination,
that their efficiency is affected.  It  is further to be noted, that  pepsine is, as it
were, imitated by water; in so  far as  that the addition of water to a saturated
solution of peptone gifts it with some of the energy of pepsine.  And a variety of
circumstances concur to render the analogy still more characteristic ;  and, indeed,
exhibit pepsine as an agent only differing from peptone in the sense of its sponta-
neously undergoing, with disproportionate  slowness, the same change which it
transfers to albumen with extraordinary speed and completeness ;  and of which
peptone is the final product in much the same sense  as an  artificial gastric juice
kept too long loses all its powers, though perfectly  free from the slightest taint of
decomposition, and from any discernible change  in appearance, reaction, or com-
position.  Nay more, there are strong  reasons for concluding that in  at least the
later  stages of gastric  digestion, the process of conversion is itself carried on by
the product rather than by the  original agent, by the peptone rather than by the
gastric juice.   For a digesting gastric juice seems to retain its power, and continue
its action, long after a precisely similar juice, to which no albumen has been
added, has lost all its powers.
   Pepsine, then, seems to be an organic substance  in course of hydration,  and
capable of propagating this process to albumen brought into contact with it.   The
hydration thus effected in albumen is itself capable  of at least a partial propagation
to fresh albumen.  But, unlike the  action  of some ferments, the process is in so
close a dependence on the whole organism, as to require not merely to be started,
but to be reinforced (and therefore to be quantitatively excited) by the acidulated
pepsine or gastric juice.  And while the quantity of dissolved albumen is thus in
close relation to that of the secretion of the stomach, it is highly probable that this
in  its turn  has an equally intimate dependence  on nutrition generally;  being
derived from the tissues (even if proximately formed in the blood)  in amounts
which exactly express their changes, and the consequent need of their replacement.
   In this  " hydration," however, we  seem to distinguish two stages, if not two ele-
ments, of which the  latter only represents the chemical process ordinarily known
by the term.  In the first instance, water seems to combine with albumen physi-
cally, first swelling up its mass, and then rendering it transparent, soluble, invisible,
but yet allowing it  to  be precipitated by most of its usual reagents.  To  this
rapidly succeeds a more complete metamorphosis;  in which the reactions of albu-
men are for the most part lost.  The former stage suggests something quite unlike
any ordinary process of solution ; and  it is  quite specific to the gastric juice.  The
latter suggests a new grouping of the albuminous and aqueous  elements.   Both
collectively make up a close parallel to the water of organization, which, tenaciously 
44
ANATOMY  AND PHYSIOLOGY.
would almost seem as if the chief office of this secretion were that
of enabling  water to combine with  the various members of the
albuminous  groups of alimentary  substances;   in  order to their
acquiring  that  solubility, and uniformity  of constitution, which
probably must  precede their admission into the current of  the
blood.  To this indication of a  theory, I will only add, that  the
mode  in which a definite quantity of the  organic  principle takes
part in such  a process cannot even be conjectured.  Its action cer-
tainly appears no way comparable to the  effect of diastase on starch,
or of emulsine or amygdaline.   It seems to be an assimilation, in
the  strictest  chemical  sense.  It is  not impossible that the acid
commences the process by a slight, though genuine, solution of the
more resisting substances.  And at any rate, this constituent seems
to have the power of checking putrefaction, if not of arresting all
metamorphosis, in the other  ingredients of the secretion;  like the
small  quantity of oil of vitriol which is added  by  the  chemist to
hydrocyanic  acid with the same object.
   Process of Secretion.—The process by  which the gastric juice is
secreted from the mucous membrane of the stomach can scarcely
be regarded  as known, even in its larger phenomena.   To correct
some prevalent errors, and to offer  a conjecture which future re-
searches  alone can fully substantiate,  is  all that  the author would
attempt here.
   The secretion of gastric juice is not effected by any expulsion of
the glandular contents of the stomach-tubes.  Their elaborate and
dimorphous structure might alone suffice to prove this proposition.
And the mere quantitative objections to such a  view are scarcely
less  conclusive.1   But it is better refuted  by two  facts:  (1) that
during every stage of gastric digestion, the tubes may be seen with
precisely the same form, size, arrangements, and contents,2' which
they exhibit  during the fasting state; and (2) that the pure gastric
juice is completely structureless.
   As regards the visible details of the act of secretion, Dr. Beaumont
has reported some interesting observations.  He made use of mag-
nifying glasses,  by the aid of which he could distinguish the sphe-
roidal glandular  follicles, and the papillae  situated in their  inter-
stices.  These papilla?, or villi, he found to  be scarcely visible until
food was applied to the mucous membrane, when they underwent

retained by all animal tissues, is not only the very condition of their  existence,
but is especially the agent of  that changeableuess  the results of which we sum
up by the term of  Life, and the mediator of their physical properties. In these
tissues too, as in pepsine and  peptone, we  may observe the reversal, as it were,
of the stages of albuminous digestion in the  result of heat, which first dries up,
and then destroys, the bodily substance.
   1 This expulsive view, applied to the human stomach during digestion, would
imply the entire reconstruction of its cell-growth  from 60 to 100  times in one
hour!
  * The greater softness and delicacy of these contents is no real exception to this
fact. 
ANATOMY  AND PHYSIOLOGY.              45
a kind of erection, and protruded from its surface in the shape of
small  sharp processes.  (Compare  Figs.  6, 10.)  From these,  ac-
cording to this faithful observer, the gastric juice appears to exude.
Its secretion begins by the gradual  appearance of  innumerable
lucid  specks, which are smaller than the mucous follicles.   These
specks or  points rise through the transparent mucous coat;  and
seeming to burst,  discbarge themselves upon the very  points of
these vascular papillae, as a thin, transparent, colorless, limpid, acid
fluid, which collects in small drops, trickles down their sides,  and
spreads over the whole gastric surface.1
   It is evident that the above description closely corresponds with
what would be seen on looking at the surface of the skin with a
lens during the  commencement of  a  violent  sweat.   For though,
as  a  matter of anatomy, we know  that there are no  apertures of
stomach-tubes on the ridges and processes which stud its free sur-
face, yet just as the structure of these tubes shows that it is from
them the secretion comes, so, on physical grounds, the gastric juice
would naturally tend to accumulate in drops  on the projections of
the mucous membrane, before spreading as  a layer of liquid over
the general cavitary surface of the  stomach.
   In any further surmises as to the details of the secretory process
in  the stomach, it  may be well to  note (1) the fact discovered  by
Bernard, and repeatedly verified by myself, that it is only (or at
any rate chiefly2) the surface of the mucous membrane which shows
an acid reaction, either in the digesting or fasting state; and (2) the
anatomical elements specially connected with  this secretion.
   As respects the first of these data, it points to the secretory pro-
cess being  only completed near the open ends of the tubes;  and
concurs with many other circumstances to suggest, for this process
in the stomach, a view which is almost forced upon us in the case
of  other secreting organs.  That, whatever be its exact details, the
preparation of the gastric juice, begun in the blind ends of the tubes
is only completed at or near their opposite or open extremities; that,
at any rate as regards the acid  ingredient, the process is far more
likely to be the subtraction, from a  liquid allied to blood-liquor, of
those materials which by their withdrawal would leave gastric juice,
rather than any mere construction  and effusion of this secretion;
and that, in assuming such a selective or preferential absorption, we
are only attributing to the stomach  a special form and intensity of
a process which we are forced to suppose operating in the kidney,
as well as  in the whole alimentary canal:—such are the physio-

  1  So thoroughly persuaded was Dr. Beaumont {op. cit.) that the fluid exuded
from the papillae alone, that he had not the least doubt the excretory ducts of the
follicles were inclosed in these villi, and terminated in the lucid specks just alluded
to;  although he admits that he could not see any apertures here.
  2  In verifying this observation, I have sometimes found, below the surface, a faint
acidity, such as might be derived from the mere imbibition of the acid fluid from
above. 
46
ANATOMY AND  PHYSIOLOGY.
logical opinions which a careful study of the anatomy of these tis-
sues would suggest.
  To allot the two elements of the secretion—acid and pepsine—to
two corresponding structures, is a much more doubtful and uncertain
task.   Nevertheless, the close resemblance of the axial  epithelium
of the true stomach-tube to the  epithelium of the salivary and pan-
creatic glands, suggests that the somewhat analogous ptyaline and
pepsine possess, in this minute epithelium, what is, anatomically, an
analogous source.  While the unprecedented and  mysterious pro-
cess which (as by an electrolysis) separates the chloride of sodium
into acid and base,  may be surmised to be effected by the equally
characteristic and special  structure—the  large oval gastric cell.
That the two co-extensive structures collectively achieve the secre-
tion of both pepsine and acid, is conclusively shown by the stomachs
of innumerable animals of  the vertebrate class, in whom1 I have
found  that the stomach, as ordinarily defined by the pyloric valve,
includes a large extent of mucous membrane devoid of these struc-
tures, and equally devoid (as demonstrated by careful experiments
on artificial digestion) of the proper gastric function.
  It is hardly necessary to point out the admirable manner in which
the structure and arrangements of the quasi- venous capillaries in and
beneath the gastric ridges (p. 34) would facilitate their absorptive
function.  Their position, their size, the probable swiftness of their
current, and the strong suction-force thus exercised, have an obvious
relation to that vast  and rapid withdrawal of peptone and  grape-
sugar from the gastric contents which they evidently effect.
  A controversy  of long standing as to the cause of that immunity
evidently enjoyed by the stomach from the solvent action of its own
secretion, has at length been closed by the experiments of Dr. Pavy.
He has shown that it is neither  to any abstract vitality of the living
stomach, nor even to the continual dilution (and therefore neutrali-
zation) of its interstitial liquids by the salivary or other contents
of the organ occupying its surface, that this  immunity is to  be
referred; but to a protection afforded the stomacb by the constant
irrigation of the  organ with circulating blood.  His well-selected
experiments prove  that the mass of the organ is  thus, as  it were,
perpetually neutralized by the alkaline blood-stream, and thus kept
free from the process of solution for which a free acid is a necessary
condition; and that while an arrest of the circulation permits the
stomach to  dissolve its own walls, this solvent effect is aided  by
artificial acidulation, and impeded by alkalizing, mucb in the degree
which on such a theory might be predicated.   The minor details
by prosecution into which  this theory will completely square with
all that is as yet known of stomach-digestion are not quite complete.
But they are perhaps (see p.  43) near  at  hand.   Meanwhile Dr.
Pavy's discovery can hardly be rated  too highly, as to  both the
healthy and diseased stomach (see Lecture iii.).
1 " Medico-Chirurgical Review," July, 1861. 
ANATOMY AND PHYSIOLOGY.
47
   We may  end these  remarks by a  glance at the  share of the
 stomach in digestion generally.
   The mastication and insalivation of the food is immediately fol-
 lowed by its deglutition, which propels the pulpy or semi-fluid mass
 it now forms into the stomach.
  _ On entering this organ, it is subjected  to  a special act of gastric
 digestion, the total duration of which may be estimated as averaging
 two hours.
   The energetic action of the mixed saliva is not affected by the
 gastric juice secreted by the stomach.   Much of  the starch of the
 food is probably converted into sugar during  the short sojourn  of
 the element in this cavity.   The sugar thus produced would  seem
 to be absorbed  by the vessels of the gastric mucous membrane with
 extraordinary rapidity.  The water, salts, and soluble organic com-
 pounds of the food are similarly taken up.  And the gastric juice
 attacks and dissolves the  proteinous  element of the food.  The
 perfection of this  process of solution  depends on the  mechanical
 state of the substances concerned, and on the quantity and efficiency
 of  the active liquid.  Of the resulting solution or peptone, part  is
 immediately absorbed by the gastric vessels, while part passes  on
 into the  duodenum, in company with protein which has not yielded
 to  the solvent  process, as well as  with  unsaturated gastric juice.
 Much of this protein  ultimately becomes  dissolved, and  with the
 peptone which accompanies it, is taken up by the veins of the in-
 testine.  That, of all the secretions poured into the alimentary canal,
 the gastric juice alone has the power of converting the albuminous
 compounds into peptone—is a  proposition which  has too direct a
 bearing on the function and diseases of the stomach to  be omitted
 here, though the reason which, in my opinion, demand its provisional
 reception, cannot here be fully adduced.  But while referring to
 them,1 I  may add, that it  is evident the gastric juice  retains  its

  1  It is only with  respect to the pancreatic juice that this proposition can be con-
 tested upon anything like plausible grounds.
  Allowing for dilution and impurity, the infusion of secretory tissue is found  to
 behave, in experiments on artificial digestion, like the secretion itself.  Artificial
 gastric juice converts albumen into peptone, as does the natural secretion; infusion
 of salivary gland transforms starch into sugar, as does saliva.  And hence the utter
 failure of the infusion  of intestine, whether neutral, acid, or alkaline, to dissolve
 albumen, or to transform starch, gives a decision against the possession of such
 power by the intestinal juice, which any equivocal evidence derivable from vivi-
 sections (especially when contradicted by more trustworthy lesions) quite fails to
 refute.   Indeed, the necessary admixture of many secretions and substances in the
 intestinal canal of  the living animal almost defies all satisfactory experiment.
  In the  case of the infusion  of pancreas, however, a process of solution really
 does obtain ;  and it is the kind of solution, its postponement for many hours, and
its apparently inseparable connection with utter putrefaction, which militate against
its constituting a function identical with that of the stomach in the living body.
That albumen, when digested in pancreatic infusion, crumbles down, after many
hours, into a kind  of putrescent peptone, is a  remarkable  fact.  But, limited to
these propositions, the alleged digestive power of the pancreas on albumen seems
to me reduced to little more than an elaboration of the statements long made  by
Bernard, as to the extraordinary proneness of pancreatic juice to decomposition. 
48                ANATOMY AND  PHYSIOLOGY.


digestive efficacy after passing the pylorus; and  that it is to  the
presence of this secretion  (concentrated,  perhaps, by absorption)
that the solvent powers of this kind, attributed by some physiolo-
gists to the intestinal juice, are probably due.  '

It is doubtless an  important detail of the  hitherto almost unknown chemistry of
putrefaction.  It suggests the discovery of relations between digestion and putre-
faction,  of surpassing  interest and  significance.  It permits the surmise that,
modified or held, in check by other digestive agents, the pancreatic secretion may
even in some way  supplement or conclude, in the intestine, the gastric  metamor-
phosis of albumen. But, in so far as it establishes long delay, and complete putre-
faction, to be essential conditions of this process of solution, in so far does it deny
the proposition that it is the office of the pancreas to dissolve and change albumen
in the way in which the metamorphosis thus summed up is brought about by the
stomach.  (Compare the Author's Paper  On Digestion in the Vertebrate  Series,
"Medico-Chirurgical Review," July, 1861.) 
                       LECTURE  I.

   Introduction—Symptoms of Gastric Disease generally—Pain—Eructation,
           Regurgitation, Vomiting—Hemorrhage—Flatulence.

  The lectures I now commence are so few in  number, and treat of
so large and important a subject, that I can scarcely permit myself
to occupy a minute in  introducing them  to your notice.  But I
may premise, that the  reductions lately effected in  the  number of
lectures entering into  the  medical curriculum are  nowhere more
seriously felt than in the Course  of Physiology, where they espe-
cially limit that close  and continual application of  this science to
the healing art, implied in the old name for this Course, "Institutes
of Medicine."  And it is with  the purpose of supplying this defi-
ciency, as respects the physiology  of gastric digestion, as well as of
putting before you the results  of  some special researches of  my
own, that I have obtained the sanction of  the  Hospital authorities
for delivering this brief supplementary course of lectures on the
Diseases of the Stomach.
  I need say little to enhance my subject.   The diseases of the
stomach are not only  some of the most frequent and curable which
will hereafter  claim  your skill as practitioners, but they have a
special importance from their bearing on all other  maladies.   No
matter what  the organ, or what the disease, it is by the stomach
you will have both to assault the enemy, and to victual the be-
leaguered fortress of life you come to help.  Indeed, the classical
fable of  " The Belly and the Members1'' may suffice to indicate  how
the  income and  expenditure, the  pleasures and  pains, the health
and disease,  of the stomach, are  alike vicarious and ministerial.
The stomach, in short, represents in  the constitution  a kind of
Chancellor of the Exchequer,  who (if you like to pursue the ana-
logy) has his  budget dictated  to him  by the  requirements of the
various  departments,  and is not  always  the leader, even in  the
Lower House.
   The interest thus attaching to these diseases is increased by their
obscurity.   For the physiology of the stomach is but now emerg-
ing from an uncertainty, such as has necessarily  involved many of
its  pathological  changes.  These  changes, again, are often accom-
panied  by little evidence of their occurrence in the living body.
Indeed, exact physical information concerning them is almost de-
nied us.  The aids to diagnosis afforded by auscultation in the dis-
eases of the  thoracic viscera, and by chemistry in those of the
       4 
50
SYMPTOMATOLOGY.
urinary apparatus, scarcely find any parallel in the maladies of an
organ which executes its work without perceptible sound or move-
ment, and only dismisses its products from  the  body after a com-
plex series of changes and admixtures.  And although (as already
stated) its disorders  are both  frequent  and curable, and even its
symptoms  not difficult  to  recognize, still these very facts, which
have doubtless favored the acquisition of information, seem rather
to have misled than facilitated stricter pathological inquiries; and
have thus rendered our  knowledge of the diseases of the stomach
diffuse rather than profound, and useful rather than accurate.
  To diminish this obscurity, and to add to the existing knowledge
of these diseases, is  one of the  objects of the following lectures.
And as I shall assume  that the  Physiological Course has already
acquainted you with the propositions by which these lectures will
be illustrated and sustained, so I may fairly ask  you to apply here
other branches of science you have learnt elsewhere.  It is only by
the diligent use of all our existing means of inquiry, and  not by
idly waiting for the discovery of new ones—only by putting our
shoulders to the wheel, instead of merely calling upon Jupiter—
that we can hope to advance in the study of these or any otherv
maladies.  Hence, while we shall look to physiology to explain their
symptoms, to aid their  prognosis, and to dictate their treatment—
and shall find, in the occasional successes of modern quackery, the
strongest confirmation of what physiology teaches as to the effect of
proper  food, air, and exercise on these maladies of the digestive
apparatus—we shall not neglect other means of equal value.   The
careful physical examination of the belly will afford us information
analogous to that yielded by percussion and auscultation in thoracic
disease.  The  collection and  comparison of the histories of large
numbers of cases will teach us which are the more constant and
essential of their symptoms and appearances; and the minute study
of these symptoms, in contrast with the lesions found after death,
will sometimes enable us to refine our diagnosis to a degree which
appears to border on temerity.  Lastly, with  suitable precautions
against the many sources  of error connected with the digestive
canal,  the chemical and  microscopical examination of the  sub-
stances expelled from it will sometimes afford invaluable informa-
tion respecting its state.
           SYMPTOMS OF GASTRIC DISEASE GENERALLY.

  To-day we consider the chief symptoms of gastric derangement,
in such a general way as may  prepare us hereafter to interpret
their connection with the several diseases of the stomach.

  Pain.—Amongst such abnormal phenomena, pain is naturally
the first  to  claim our notice.  You are aware that the situation 
SYMPTOMATOLOGY.                   51
and office of the stomach render quite unnecessary its endowment
with that accurate appreciation of the mechanical and thermical
properties of objects, in virtue of which the skin forms so efficient
a protection to the organs it envelops; and that, in the stomach,
all sensation of this kind is abnormal.  Hence, if we except certain
vague feelings but partially referable to this origin—the feeling of
hunger  periodically calling for food, and  of  comfort  and satiety
following its ingestion—we may safely subscribe to the popular
dictum,  that a healthy  person ought not to be conscious of having
a stomach at all.   The substances he eats  and drinks may range
from a  warmth of 120° to a cold of 32° Fahr.; and may differ
scarcely less widely in their physical properties and arrangement.
But when once they  have  traversed his oesophagus, and reached
his stomach, these peculiarities are utterly beyond his recognition.
In short, the stomach is devoid of all common sensibility.
  But we are not therefore to imagine this important organ really
insensible to stimulation; or to suppose that, because it is not every
moment arousing the brain of  its master, and demanding his fore-
thought or exertion, it remains unimpressed and inactive.   On  the
contrary, we must rather conclude that it has a special sensibility
of its own ; not one whit less marvellous (but surely more so)  for
possessing a certain  independence of  the cerebro-spinal centre.
Closely related to this  centre by the feelings of hunger and satiety
—nay more, dictating to it (so to speak) those exertions which  the
proper  alternation of  these two states imperiously demands from
the mass of mankind—it has a sphere of action altogether its own.
And the study of digestion has shown us how admirably and silently
the stomach fulfils its  various and  complex tasks;  and how, inci-
dentally to these, the unfelt particle of food no sooner touches its
mucous surface, than it excites the flow of a variety of secretions,
both far and  near, and provokes movements in the muscular sub-
stance of its walls and vessels, as well as in the analogous structures
of neighboring parts.   To these acts,  which respectively consti-
tute the sensation and motion  of the healthy stomach, its morbid
states afford an instructive parallel.  And just as the kind of sensi-
bility specific to a healthy muscle — the  feeling  of its strength,
its equilibrium, its measurable force—seems to be traceable,  by
gradual modifications,  through healthy fatigue to the feverish sore-
ness of over-exertion,  and through this to the universal  muscular
pain and prostration of various grave general ailments; so  the
indistinct sensation of  the healthy stomach affords us the best clue
to the acute sensibility of the diseased one; and allows us to trace
a scale of similar kind—from satiety to repletion;  from repletion
to distension and weight in the epigastrium;  and  from hence to
the dull, heavy aching of dyspepsia, the gnawing or burning pain
of ulcer, and the sharp agony of cancer of the stomach.
  How  nearly the sensibility proper to the  stomach approaches
(and even implies) that appreciation of  undue stimulus which con- 
52
SYMPTOMATOLOGY.
  stitutes its sensibility to pain, may be seen in the accurate observa-
  tions of Dr. Beaumont on the living  subject.   In this well-known
  case, the introduction into St. Martin's stomacb of the thermometer
  bulb, or of the  tube by which Dr. Beaumont provoked and  pro-
  cured the gastric secretion, often gave rise to considerable pain and
4k soreness;1  at other times, to  more general feelings  (vertigo, faint-
  ness, pallor, dimness of sight,  sinking, &c.), which seem to have
  been occasionally unaccompanied by any local sensation.  These
  local feelings were exactly imitated by less mechanical  causes,  such
  as casual dyspepsia or intemperance.
     The various diseases of the stomach will hereafter acquaint us
  witb the more  characteristic varieties of gastric pain: at present,
  we need only notice a  few points connected with  its nature and
  origin.                                         N
     And firstly, as regards its locality, in numerous cases pain referred
  to distant organs  really originates in the stomach.  In such cases,
  however, we must often doubt whether  that state  of the stomach
  which evidently conditionates the pain—suppose a headache  or  a
  .toothache—does so by  a direct  or indirect causation.  Thus, on
  the other hand, the gastric irritation  may act by exciting, in some
  intervening nerve and centre, a condition such as is either referred
  from this  centre to that periphery of another nerve, which is the
  seat of the pain, or really brings  about local  changes here.   On
  the other hand, the distant part,  already the seat of some change,
  may only be excited to pain by an additional irritation, which is
  either transmitted to it from the stomach, or acts by its mere de-
  pressing influence on the centre of this distant part.  In either  case,
  the  phenomenon is  so complex, and is producible by the derange-
  ments of so many other organs, that, while allowing the frequency
  and importance of its connection with the stomach, we are hardly
  entitled to discuss it as  gastric pain.
     But, in a large proportion of cases, pain originating in the sto-
  mach is referred to the region occupied by this  organ; and  with
  sufficient accuracy, to  render the precise situation of the pain  a
  matter deserving of notice.
     Great or specific exactness of such local reference of course fails
  us.   From the  physiology of pain itself, it would be easy to deduce
  why, as experience shows, a certain indistinctness generally belongs
  to this  abnormal  sensation—is, indeed, a rule, of which pains pro-
  duced by lesions involving the skin or other analogous organs are
  the  easily explained exceptions.  The accurate perception of objects

     1 These sensations do not seem to have been accompanied by anything equiva-
  lent to spasm of the pylorus, much as the energetic contraction proper to the whole
  pyloric sac probably aided to bring about the physical conditions by which the
  pain was provoked.  The notion of a cramp of the stomach analogous to a cramp
 >» of the leg (and still more of  a cramp of the pylorus produced by morsels of undi-
  gested food) is, indeed, a mere assumption; the sudden  and violent pain  which
  is all such a term really implies, being certainly producible by a variety of causes,
  and doubtfully ever due to that cause which it claims to connote. 
SYMPTOMATOLOGY.
53
demands, amongst other  things, a specific organization at the peri-
phery of the nerves by which it is mediated.  Hence the abnormal
stimulus or injury which  can bring about pain, whether it is applied
to the trunk or the branches  of a  sensitive nerve, is  only appre-
ciated with anything like local exactness when it is applied to its
terminal distribution.1  And the nervous arrangements of the sto-
mach are calculated still further to increase  this uncertainty and
indistinctness: inasmuch as they only connect the  organ with the
cerebral centre of all perception by collateral communications, and
through intervening ganglia or independent centres, such as render
the mere transmission of the stimulus far less certain, and its modi-
fication during this transit far more probable than would be the
case in  a stimulated cerebro-spinal nerve.   The pain of gastric de-
rangement does, indeed, possess all those attributes which the  ana-
tomy of the  gastric nerves in Man,  and the study of their arrange-
ment and office in various Mammalia, would lead us to expect.  It
is often absent when we might fairly expect it to be present; present
when we have no clue to any local  cause for it:  variable or inter-
mittent without any assignable reason; and lastly, even when there
is a definite and  circumscribed lesion, gives but  a wide and indis-
tinct indication of its place,  or perhaps refers  it to  a point  of the
abdominal surface much above or below, to the right or to the left
of its true situation.
   This  indistinctness  may, however, be partially ascribed to other
causes: namely, to the situation of  the stomach; to the number of
organs  with  which it  is  in contact; and to the  frequent displace-
ments which their movements and its  own permit, and even neces-
sitate.  Thus, in  pointing to the pit of the stomach as  the seat of
his pain, the patient, however  exact  in  his sensations, can  rarely
indicate one of the three directions of space—the depth to which
his sensation of pain is  to  be referred.  The various  changes  of
position associated with the movements of the  heart, the lungs, the
diaphragm, the liver,  the intestines,  and the stomach—can also
rapidly modify the exact situation of the latter organ, and  thus
increase the area of indistinctness.  Besides, in pointing to the epi-
gastrium, the patient is pointing to a kind of  focus, formed by the
convergence and attachment of a number of important organs, and
hence liable to be occupied by the pain which  the lesion of any
one of them can produce.  Pericarditis, pleurisy, gall-stones, hepatic
abscess, diaphragmatic lesions, emphysema of  the lungs,  and  a

  1 Perhaps the only glimpses of accuracy of sensation on the part of the stomach
are (as we  should expect) those in which distension distributes the morbid sti-
mulus over a large surface of the organ. The  " stoppage" of food referred to the
cardia and pylorus respectively in disease of these apertures, as well as the similar
sensation sometimes  produced by an unnatural constriction in other parts of the
stomach, well illustrate this rule.  Like the curiously exact feeling of extreme
repletion which has been noticed in general inflammatory thickening of the whole
organ, even when attended with great contraction—this sensation, however accu-
rate deviates little from the ordinary rule of gastric  sensibility above alluded to. 
54
SYMPTOMATOIOGY.
variety of intestinal causes (amongst which I have myself verified
an obstruction of the small intestine occupying the right iliac fossa)
—any one of these can produce what is, strictly speaking, pain in
the epigastrium,  and therefore so far simulative of gastric pain.
And though it is probable that the contrast of the latter with any
one of the former would  show a considerable difference—so much
so, that few persons  unfortunate enough to have  experienced  the
two would be incapable of distinguishing them—yet ordinary lan-
guage affords  little  means of expressing  the differences thus felt,
to say nothing of the rarity of such a direct comparison.
  Without anticipating what must hereafter be said respecting the
situations of pain in  different gastric ailments, I would suggest (not
without admitting their  many exceptions) the following general
rules  as to its significance.  The pain of gastric disease is grave in
proportion not only to its  severity, but also to its concentration and
fixedness.  In other words,  a  severe and continuous pain confined
to a single spot of small size, is a more serious indication than one
which, at times of equal (or nearly equal) severity, fluctuates in its
different attacks, and ranges the epigastrium, of which it habitually
occupies a wide area.  Pain is graver in or near the median line;
not only because (for  many reasons which will readily suggest
themselves) it  is, cseteris paribus, more certainly gastric here than
elsewhere, but because this  situation  (at least such is  my opinion)
indicates a more  serious derangement of the innervation of the
organ, than where the pain has a less exact correspondence with
the solar plexus.   Lastly, of all situations, a median and dorsal  one
(in anatomical language rachidian, and ranging from interscapular
to lumbar), which is  usually an addition and complication to a pre-
vious epigastric  pain, is the most serious; so much so, that it will
rarely be found associated with any but the graver gastric dyspep-
sias;  and belongs chiefly  to deep ulcers, or to cancerous lesions of
the stomach, involving all its coats.
  In  all cases it  is essential to add the information  obtainable by
pressure to the mere sensations complained of by the patient.  It
is rarely that severe  or continuous pain affects the stomach without
being associated with  some  soreness or  tenderness  to  pressure.
But  when pain   is sudden  and temporary, and is  attended  with
much flatulence, it  is often relieved  by  gentle  pressure.  Hence
the occurrence of either  modification in  any given  case is capa-
ble of  greatly influencing  our opinion  as to  the  nature of the
pain.   For, aided by a strict physical examination of the existing
state of the stomach in respect of size and situation, it  sometime?
definitely refers  to this organ a  pain which, in its  absence, could
only be conjectured as gastric.  In many cases, too, tenderness does
far more.  According as  it is moderate or excessive, superficial or
deep,  localized or diffuse—features the due  recognition  of which
often  imply great delicacy and skill—it justifies a conclusion, not
only as to the  nature of the gastric malady, but even as to its seat • 
/
                     SYMPTOMATOLOGY.                   55

distinguishes, for example, general inflammation from ulceration or
dyspepsia, or a lesion of the peritoneal from one of the mucous coat.
  As respects the immediate causes of gastric pain, it is probably
in most cases to be referred to undue distension of the vessels, irri-
tating (oiiemight almost conjecture stretching or otherwise injuring)
the nerves distributed  upon and within their coats.  The  great
changes of calibre which the arteries and veins of the  stomach so
often undergo, in the sudden transitions  of this organ from rest to
activity,  and vice  versa, are doubtless mediated by nerves, which
supply their muscular  coats, and  have so far a  motor function.
Whether these vessels also possess correlative nerves, which have
the distinct office of appreciating these and other changes, and are
therefore {pro tanto) sensitive nerves, remains at present unknown.
But on the whole, the violent gastric pains which sometimes  occur
quite independently of any perceptible lesion, and even (if we may
trust the microscope) of any interstitial exudation, are  best ex-
plained as provoked by a physical irritation or injury of nerves—
perhaps sometimes a mere excess of their  natural stimulus—imping-
ing  rather upon the nerves of submucous situation, distributed to
the small arteries and veins of the stomach, than upon any ultimate
nervous ramifications in the secretory structures themselves.  (Com-
pare pp. 35, 37.)
  Amongst less immediate causes of pain, we  may enumerate the
following as the most obvious and important.  Undue distension
of the stomach, illustrated by some forms of pyloric obstruction, as
well as (though more questionably)' by flatulence; local.injury,
eroding branches of nerves, and irritating their severed extremities,
as in gastric ulceration; and the more variable (but probably scarcely
less local) injuries producible by cancerous deposits.   Each of these
will require allusion in its respective place.

   Vomiting, the next symptom of gastric derangement,  is an act so
closely  connected  with the healthy organization  of the  stomach
(indeed so definite a constituent of the digestive process in many
Vertebrata), that our cursory view of the  physiology of the stomach
would have been incomplete without such a brief description of its
nature and mechanism as may be usefully recalled here.
  Normally, the human stomach propels its contents onwards into
the duodenum.  But, under various abnormal circumstances, this
direction is  reversed, so that  the  gastric  contents take a backward
course through the oesophagus, re-enter  the mouth, and are thence
expelled the body.  Such a reversal obtains in the acts of eructa-
tion, regurgitation, and vomiting.   And  these three acts, whatever
their difference of detail, further agree  in the conditions of their
occurrence, in so far that they all require (1), an open cardia; (2),
a closed pylorus; and (3), a compressed stomach; compressed, that
1 Compare the remarks on flatulence at the end of this lecture. 
56
SYMPTOMATOLOGY.
is, either  by its own muscular contractions, or by some extrinsic
pressure.
   In eructation or belching, part of the gaseous content of the sto-
mach is expelled from  the mouth.  How the cardia becomes patu-
lous, it is not easy to decide.  The stomach  so frequently contains
gases, and (as may be well seen in vivisections) the cardia resists
their expulsion so  efficiently, that we can  scarcely  suppose this
aperture would be opened by the mere evolution of  any quantity
of aeriform fluid in the stomach; or would allow of any consider-
able leakage, save by a definite relaxation of its walls.  The agents
of the expulsive act are also somewhat doubtful.   For though the
act appears to coincide with an expiratory effort, and  sometimes
with even a closure of  the glottis, yet the abdominal pressure thus
brought to bear on the stomach is certainly by no  means violent.
But such  mobile fluids would scarcely require any remarkable effort
for their expulsion.  Indeed, those contractions of the stomach which
are necessarily present when the act of eructation  occurs during
gastric  digestion, appear  quite sufficient to commence, if not  to
complete, the expulsion of gases from the organ.1
   In regurgitation, some of the  liquid contents of  the stomach are
returned  into the mouth.  This act seems  to be often a mere  acci-
dental complication of the preceding, a small quantity of liquid
being carried up the oesophagus  together with an eructation  of
gaseous fluid.  In other instances, however, the liquid arises alone;
and  so quietly, that it is only perceived when it reaches the fauces
and back  of the tongue, where its taste causes it  to  be recognized.
It is  probable  that  the nature of this expulsion is closely  akin  to
that of  eructation;  the abdominal pressure playing, if anything, a
still  more subordinate part.
   The act of  vomiting  differs from  the  two preceding, not only  in
the quantity and quality  of  the matters (solid as well  as liquid)
which it expels from the  stomach,  and in the far greater energy
and  completeness of the expulsive efforts, but also in  the fact that
a violent pressure, extrinsic to the organ, is the chief agent of the
process.
   As respects this abdominal pressure, it will be remembered  that,
in ordinary respiration, the viscera of the belly  sustain but a mode-
rate  compression.   For during inspiration, the  contraction  and
descent of the diaphragm exactly coincide with a relaxation of the
muscular  walls of  the abdomen;  while,  during expiration, the
compression which  these exercise is neutralized by the recession

  1 In voluntary eructation, a kind of twitch, quite unlike ordinary deglutition,
introduces air from the  pharynx into the upper end of the oesophagus, whence it
appears to be  pjopelled into the stomach.   Soon after it reaches this  organ, it
seems to be returned through the still patulous cardia by a well-marked expiratory
or abdominal pressure;  during which the glottis appears  to be  at least  partially
closed. And as the air thus artificially introduced into the stomach is often accom-
panied in its expulsion by part of the gases previously contained in the organ the
voluntary and involuntary forms of eructation almost merge into each other. ' 
SYMPTOMATOLOGY.
57
or ascent of the now relaxed diaphragm into the thorax.  Hence
the movable contents of the belly escape all violent pressure;  and
merely transfer, as it were, a  slight force from the upper to the
anterior wall of this cavity,  and conversely.  But if, while the
diaphragm remains depressed and contracted, the abdominal mus-
cles also vigorously contract, the whole force of either of these two
muscular strata may be regarded as compressing the viscera within
the abdominal cavity.  And since many of these viscera are hollow
organs, inclosing  movable contents,  and communicating with the
exterior of the body,  such a forcible  pressure must  expel  their
contents,  so soon  as  their terminal orifices are thrown open—
whether by relaxing, or by yielding to a superior force.  In  this
way the abdominal pressure plays an  important  part, not only in
vomiting, but  also  in defecation,  micturition, and  parturition;
affording a powerful, though intermittent, force in aid of those more
continuous expulsive  contractions which are effected by the mus-
cular walls of the rectum, the bladder,  and the uterus  respectively.
   There is ample evidence that the act of vomiting is effected mainly
by this abdominal pressure, which is not  only indispensable to it,
but (as proved by vivisection) suffices to effect it when reduced to
a contraction of the diaphragm, or  of the abdominal muscles, or
even to a slight muscular compression of the  hypochondria. -
   The exact aid given by the  contraction of the stomacb is less
capable of determination.   That any such assistance  not only can
be, but often is, altogether dispensed with, it is scarcely possible to
doubt.  But, on the other hand, it seems  equally certain that the
abdominal pressure, to which the act of vomiting is chiefly attribut-
able, is often  accompanied, and assisted, by a contraction of the
muscular wall of the stomach itself.   And, as might be expected,
observation on man and animals during  life shows that this con-
traction  specially engages, not  only the pyloric valve,_ but the
neighboring muscular pyloric  extremity  of  the organ; in  move-
ments which are probably rhythmic (contraction regularly alternat-
ing with  relaxation) and  peristaltic,1 and which there  is certainly
no sufficient ground for supposing to be ever anti-peristaltic.
   The phenomena of the act itself quite confirm the conclusions, as
to  its strictly co-ordinate  nature and arrangement, arrived at by
the physiological inquiry  just summed  up.  Feelings of uneasiness,
pain,  or  distension  in  the gastric  region, generally  precede an
increased flow of  saliva, and  a loathing for food,  which soon
heightens  into  downright nausea.   To  these gastric symptoms
accede others of a cerebral import; giddiness, languor; dimness of

   1 Assuming the analogy of this contraction to that verified by Dr. Beaumont in
the human subject, and by myself in the dog, during the most active stage of
eastric digestion—the rate of peristalsis, and the alternation of contraction with
relaxation would not be at all incompatible with a constriction of the whole pyloric
'sac lasting  at least  a  minute;  a duration which would more than cover the time
actually occupied by any single expulsive act during the ordinary fit of vomiting.
Compare the " Cyclopajdia of Anatomy," article Stomach (Suppl. p. 313). 
58
SYMPTOMATOLOGY.
 sight, or even  headache.  Next occur retchings, which seem to
 open the oesophagus and cardia, but not to be  attended with any
 abdominal pressure;  and which often have the effect of gradually
 distending the  stomach with air, so as to facilitate the  subsequent
 occurrence of vomiting.   Finally, an uncontrollable impulse com-
 pletely changes the action of the muscles of respiration, and brings
 into one moment two contractions,  which usually  alternate with
 each other.   An energetic closure of the glottis follows  the descent
 of the diaphragm, so that this muscular septum is fixed by the dis-
 tension of the thorax, as well as by the contraction of its own fibres.
 At the  same time, the abdominal muscles contract violently upon
 the stomach; and exercise a compression which  not only expels its
 contents, but which, aided and increased by the  contraction of
 various other muscles of the  trunk, causes  the head  to  become
 greatly congested.  Hence the features become red and swollen;
 and the large veins  of the face, temples, and neck, are visibly dis-
 tended.  The expulsion of the gastric contents is sometimes attended
 by considerable pain; which appears referable to the lower end of
 the oesophagus, and is probably due  to the spasmodic compression
 of this tube  by the diaphragm.1 , The  discharge  of the  matters
 vomited through  the pharynx and mouth appears to be aided by
 a kind.of reversal of the movements of ordinary deglutition.  But
 if the act be  violent, and the quantity of liquid  large, these move-
 ments lack their ordinary precision; so that  a part  of  the matters
s expelled generally eludes the  curtain of the soft palate, and  tra-
verses the respiratory channel of the nasal fossae, to gush out of the
 nostrils.  The subsequent phenomena vary with the origin of the
 vomiting; where, as  is often the case, it has a local cause, which is
 removed from  the stomach by the act itself, the patient speedily
 recovers his normal condition.
    As regards the causes of vomiting, it is obvious that  so complex
 and co-ordinate an act of various organs can only be accomplished
 through the intervention of that cerebro-spinal  centre from which
 the nerves of these organs radiate.  And hence we may distinguish
 these causes into two classes : one in which the irritation provoking
 the act originates at the nervous centre; and one in which, arising
 at the periphery, it is transmitted thence to the centre, to  be reflected
 into the various organs which effect the expulsive  process.  The
 first class is illustrated by the vomiting of cerebral  injury or  dis-
 ease, as well  as by the vomiting sometimes resulting from  mental
 emotion; the second, not only by that  ordinary form of vomiting
 which is excited by a direct irritation of the stomach itself, but by
 the numerous cases in which it follows an irritation  of  kindred or
 even dissimilar textures—such as irritation of the fauces, intestines,

   1 As is shown by the fact, that a similar pain sometimes may be produced, inde-
 pendently of vomiting, by a voluntary abdominal pressure  with a closed glottis. 
SYMPTOMATOLOGY.
59
or peritoneum ; disgusting sights, sounds, or smells; prolonged im-
mersion in cold water;  and even wounds of the extremities.
   But even in the second of these classes the act of vomiting can
only  be  regarded as " reflex" with  two important  qualifications.
Firstly, there are good grounds for believing that a large number
of emetic substances are not only quite as active when injected
directly into the blood as when merely introduced into the stomach,
but that,  as shown by Magendie's celebrated experiment (in which
tartar-emetic injected into the blood of a dog caused copious vomit-
ing from a  bladder which had been substituted for the stomach),
whatever their local action on the stomach in the latter of these
two cases, it is to a direct influence on the nervous centre that the
act of vomiting must chiefly be referred.  And  secondly, though,
in those numerous cases where the exciting  cause is a mechanical
irritation, the phenomena of vomiting sufficiently indicate the me-
dulla oblongata to be that segment of the cerebro-spinal centre in
which reflection  towards the periphery occurs,  still the ensuing
movement  is by no means a  simple reflex act.  On the con-
trary, it  is  effected  by the concurrent action of so many organs,
and with such characteristic and definite changes in their ordinary
times, modes, and degrees of activity—the whole process is so com-
plex, and so truly co-ordinate—that, far from limiting our atten-
tion  to the reflected course which  its exciting  cause  sometimes
takes, we ought rather to regard this as quite a subordinate feature,
and  the  act of vomiting as an involuntary or physical nervous
action of the highest order.
   Such  a view of ihe nature of vomiting receives  a remarkable
illustration from  an  experiment of  mine on the action  of tartar-
emetic,1 which conclusively shows that we  may almost  specify as
an object, a purpose, or at any rate a  function, of this complex
process.   On injecting a  solution  of tartar-emetic into the super-
ficial femoral vein of a dog, the mineral was found ten minutes
after in the fluid contents of the stomach, and in a state of  concen-
tration much exceeding that in which it must have been mingled
with the mass of the blood.  In this instance, too, the poison had
produced extreme prostration, but no  vomiting.  Taken  in con-
junction  with Magendie's  experiment already alluded to, it proves
that  the poison may first be secreted by the stomach into its cavity,
and  then removed from  this cavity, by two  processes which are
essentially independent of each other, and of any local effect of the
secreted  drug, however aided by it.   A similar process of secretion
probably obtains in the case of the salts of other metals, as well as
in that of various organic poisons:  the concurrence of such a pro-
cess with the act  of  vomiting thus rendering the latter an element
of the vis medicairix Naturae—an act by which the organism throws

  1 For the results of this  experiment, made in the year 1850, see the article
Stomach, " Cyclopaedia of Anatomy;" and the "Lancet" for 1853, vol. ii. p. 599, 
60
SYMPTOMATOLOGY.
 out a deadly poison like antimony, perhaps even a dangerous dis-
 ease like fever.1
   In some instances,  the  process of vomiting returns different
 portions of the gastric contents at different periods of time;  so
 that, for example, the  expulsion of a comparatively homogeneous
 fluid is  followed, after a considerable  interval, by that of  crude
 masses of  undigested  food.  Some of these cases perhaps depend
 on a  peculiar hour-glass shape of the  organ, or on a similar (but
 more temporary) shape produced  by the  muscular contraction of
 its middle, isolating part of the contents for a variable period. But
 most of them are probably referable to  the weight, bulk, and situa-
 tion of the substances contained  in the stomach, and to the other
t mechanical circumstances which regulate the act of vomiting itself.
 The last efforts of a prolonged vomiting often bring up bile.  But
 though there is  nothing abnormal in  the mere  presence of this
 secretion in the fasting stomach, still the above circumstances show
 that its being vomited in comparative purity is generally an indica-
 tion of the completeness or duration of the expulsive  process.  It
 is probably during the intervals of energetic vomiting, that it finds
 its way through  the pylorus into the stomach.  It may, however,
 be doubted whether the pylorus is always strictly occluded at the
 exact  moment of the  expulsive act; especially in those  cases  in
 which the intestines  are themselves distended with fluid, such as
 must necessarily be exposed  to the same  pressure as the  contents
 of the gastric cavity.
   In alluding to  vomiting as a symptom of gastric disturbance, we
 must begin by conceding, that cases sometimes occur, in which the
 vital powers are rapidly exhausted by  violent and frequent vomit-
 ing, that defies all our efforts to relieve or arrest it; and in which
 our complete uncertainty  as to the cause of this vomiting during
 the life of the patient is little affected  by a necropsy, showing  no
 apparent lesion in the stomach, or even (it is said) in any  organ of
 the body.  We cannot therefore augur  the gastric origin of vomit-
 ing from its  mere severity and frequency: nay, more, we must not
 expect that  any  single peculiarity of  this symptom—such  as  its
 excitement by food, its association with epigastric pain, or  even  its
 expelling  blood—will often suffice to  decide  its reference to the
 stomach.
   One  general rule  respecting it we  may,  however,  lay  down.
 While it is to the aggregate of symptoms that we have to  look for
 our diagnosis of  the cause of vomiting  in any given case, it may,
 I think, be propounded, that the  facility with which an irritation
 produces vomiting varies (other things being equal) with the close-
 ness of alliance between the stomach and  the irritated part.  For
 example, vomiting is  excited more frequently and readily  by  an

   1 Compare the  author's  " Essay on the Treatment of Continued Fever,"  the
 " Lancet," loc. cit. 
SYMPTOMATOLOGY.
61
irritation  of the duodenum or pharynx, than  by an irritation  of
the jejunum or mouth respectively:  and again, by irritation of the
small intestine rather than of the large; of the mucous rather than
of the peritoneal coat, throughout the whole canal;  of the brain
rather than of the integuments.  Conversely (as may be noticed  in
pleurisy, pericarditis, aneurisms, and various endocardial  lesions)
vomiting  is a grave symptom in many thoracic diseases,  because
(still  caeteris paribus only) it implies a more serious mischief than
would suffice to produce it in lesions of the abdominal cavity.
   In the  present state of our knowledge, we may usefully group
these facts by the  conjecture that, whatever the kind  of cerebral
disturbance necessary for the  production of vomiting, a certain
degree of irritation of afferent branches of the sympathetic system
will generally suffice to excite it; and with a facility which appears
to be, on the whole, tolerably proportionate to  the closeness with
which these branches are related to that great  prevertebral centre
of the abdominal sympathetic, formed by  the  semilunar  ganglia
and the solar plexus.
   Among the vomitings  produced by gastric derangements, we
may distinguish the  following varieties.  Firstly, the vomiting
brought about by  sheer destruction of tissue, involving an abnor-
mal irritation of the nerves laid bare at the seat of lesion: a variety
exemplified in simple and malignant ulceration, in wounds of the
stomach,  in  corrosive poisoning;  and characterized (as might  be
expected) by a remarkable  amenability to the physical  or chemical
properties of  substances brought into contact  with the injured
nerves  (as in  the  ingestion of food).  Secondly, the vomiting  of
obstruction, which is referable, not so  much to the mere  obstruc-
tion, as to the distension and violent  muscular movement which is
gradually brought  about behind the  occluded  part;  and which
therefore varies, not only with tbe strictness of  the occlusion, but
with its proximity to the pylorus, its superficial extent, its disposi-
tion  relatively to the muscular coat, and  other circumstances of
this kind.  This variety of vomiting is often seen in  cancer, and
(a still better example) in cicatrized ulcer of the stomach.  Thirdly,
a kind of vomiting in which the gastric distension present appears
mainly referable to a loss of contractile power by the muscular
coat  of the  stomach (the structure of  the organ remaining un-
changed); and in which we must  often doubt whether this failure
of contractility is not caused by some nervous lesion itself answer-
able for  the vomiting—whether,  in  short, the  distension of  the
stomach is simply concurrent, or really causative in the process.1
   Such allusions to the nature of vomiting may end by the general
statement that, just as it is  the kind of vomiting which dictates its
treatment—so that, for example, the cerebral vomiting  of  sea-sick-
ness is often  relieved by  food and stimulants,  the vomiting  of
1 Compare p. 69. 
62
SYMPTOMATOLOGY.
phthisis by whatever will diminish or mitigate cough—so the vomit-
ing produced by gastric derangement is most accessible  through
the function of the organ: in other words, is most amenable to a
treatment regulating the quantity and quality of the food, and the
frequency of its ingestion.  The great (though subordinate) useful-
ness of various drugs will be more  fitly discussed hereafter.

  Hemorrhage.—In  alluding  to  hemorrhage in  connection with
diseases  of the  stomach, it must be remembered that even in the
gastric maladies to which it is incident, it only gives rise to what
are, strictly speaking, symptoms, in those cases in which its  occur-
rence is betrayed of matters  expelled from the  alimentary canal
by stool or vomit.  And hence, far from regarding hsematemesis as
the exclusive (or even the chief) indication in hemorrhage in gas-
tric  disease, we must  bear in mind,  that  blood  effused  into the
stomach frequently passes  off' in  the feces without being  vomited
at all.  While,  considering that  it is rarely or never vomited so
completely and  instantaneously as  to prevent the passage of any
portion of it into the intestine, it is obvious that this exit per anum
is on the whole  much the more frequent symptom of the two.1
  The twofold  uncertainty which  attaches to most  symptoms of
disease is especially marked in the expulsion of blood as  a symp-
tom of gastric  mischief.   On the  one hand, as  above hinted, a
slight  and intermittent hemorrhage into the stomach so often de-
pends on casual circumstances for its detection, that we  can never
presume its non-occurrence because its  results  have not been ob-
served.  Nothing, indeed, but a constant and sedulous observation
of the gastric and  intestinal evacuations affords  any valid conclu-
sion of this kind.  On the other hand, it is scarcely necessary to
say, that a mere hemorrhage into the intestinal canal by no means
proves the stomach to  be the locality of the effusion, still  less a
malady of this organ to be the cause of it;  but leaves open a wide
question as to  both its source and cause—a question such as can
only be decided by that process of induction which (consciously or
otherwise) guides every scientific physician to a diagnosis.
  Merely to enumerate the causes which  may introduce  blood into
the digestive tube would be out of the limits of our subject.  But
the occasional results of epistaxis, haemoptysis, gall-stones, cysts of
the liver, and lesions of the pancreas, illustrate the obvious law:
that any lesion which brings about a  hemorrhage into the various
cavities which communicate with the digestive tube, may indirectly
give rise to the influx of blood into the  stomach and bowels, and
therefore to its expulsion thence.

  1 Hence the use of the term hcematemesis requires that of some such  cognate
(and equally uncouth) term as hozmatotcopra.sis. And the term meloena, bequeathed
us by Hippocrates—a term which now confounds vomiting and purging, and con-
notes such a color of the matters expelled as  is neither constant nor essential__
ought to be expunged from our nosology. 
SYMPTOMATOLOGY.                  63
  But the causes of even a  gastric hemorrhage are sometimes
remote from the  organ and independent of it.  For example, any
mechanical obstruction to the portal system may bring  about  so
violent a distension of  the veins which form  its commencement in
the walls of the stomach and intestine, as finally to extravasate  a
variable quantity of their contents into either of these segments of
the digestive tube.   In this way cirrhosis of the liver, or tumors,
or deposits compressing the portal  vein, may give  rise to a haema-
temesis (more frequently, however, to a hemorrhage per anum), which
is really unconnected with any disease of the stomach itself, how-
ever  it may embarrass, or even  suspend,  the functions of this
organ.
   In  noticing the causes of gastric hemorrhage, little  need be said
as to  the old doctrine of hemorrhage " by exhalation" through the
coats of the vessels, apart from any solution of their continuity.
For we now know that the walls of even the finest capillaries have
no pores of appreciable magnitude, such as would be necessary for
the transit  of  blood-corpuscles; and hence  that the extravasation
of these structures  is proof positive of some vessel having been
ruptured.   That, amongst the myriads of these minute  tubes
present, the eye often fails to detect the exact vessel or vessels in-
volved in the lesion, is of course not very surprising.
   The anatomy  of the vessels of the stomach  is intimately con-
nected with the phenomena  of these hemorrhages; especially as
explaining the great facility  and  small  risk of scanty extravasa-
tions, and the rarity  and danger of larger ones.  Thus in  the
kidney,  hemorrhage is  comparatively rare  and dangerous; and
when it once occurs, is rendered extremely liable to return, or even
to  become continuous or chronic, by those very derangements  of
the renal circulation which the effusion itself tends to bring about.
In the lungs, with perhaps a greater inherent liability to hemorrhage,
the physical and mechanical conditions of the respiratory act  add
an alarming element  of danger; so that,  for example,  we may
almost compare any casual lesion or injury of the pulmonary capil-
laries to a fissure, through which each inspiration tends to pump
out the contents  of the pulmonary artery.  In the stomach, on the
contrary, hemorrhage often occurs  under circumstances which imply
little danger to life, sometimes even little derangement of health;
may  be  frequent, and yet extremely scanty; and lastly, may be
recovered from with such completeness, as to defy the most careful
necropsy thereafter to distinguish its site, greatly as the arrange-
ment of the vessels concerned sometimes facilitates their inspection.
   The capillaries of the stomach, it will be remembered, are of two
kinds- deep, inter-tubular (t, Fig.  9, p. 34), or gastric proper, as we
may  call them ; and superficial (b, Fig. 9), or supra-tubular, which
adioin the o-eneral cavity of the organ.  In rare instances, the former
seem to constitute the chief or exclusive source  of hemorrhage, so
as to fill more or less of the blind end of a stomach-tube with blood. 
64
SYMPTOMATOLOGY.
  But hemorrhage is far more commonly confined to the latter—to
  those complex rings  of capillaries (Fig. 10, p. 34) which  surround
/■ the  open mouths of the  stomach-tubes, and directly underlie the
  ridges and papillae intervening between their orifices. These vessels,
  extremely numerous, and possessing a size and arrangement such as
  render them almost intermediate between true capillaries and veins,
  seem to be peculiarly exposed to the ordinary causes of extravasa-
  tion.  They evidently have all that liability to  congestion which
  belongs to the commencement of the venous part of the circulation
  throughout the body.  They have a situation which requires them
  to bear the  brunt of the various agents introduced into the human
  stomach in the food.  And their delicate membranous wall is only
  shielded from the physical and chemical action of these agents by
  a layer  of  columnar epithelium; the removal  of which, though
  doubtless strictly abnormal, must at any rate be a frequent accident
  in the history  of the digestive process.  Indeed,  if we think  of the
  incidents of a single meal—the fluids and  solids; the animal and
  vegetable substances; the peppers, acids, wines, liquors, spirits, the
  frozen and scalding, the hard and soft,  matters which are sometimes
  brought into rapid and successive contact with the gastric mucous
  membrane (and this,  too, at a time when the process of digestion
  itself implies a  state somewhat akin  to congestion, in so far as it
  distends and thins these delicate, vascular, and epithelial structures),
  we  can  easily understand that (as  Dr. Beaumont's observations)
  indicate) the soft columnar cells may be here and there stripped off,
  and the subjacent vessels here and there distended and ruptured
  by a casual debauch or dyspepsia, to be restored by a few days of
  abstinence or temperance to their pristine perfection.
    Little, therefore, can be concluded, from the detection of a small
  quantity of blood in the matters rejected from  the stomach of  a
  patient.   However suspicious a circumstance, it is only by careful
  collation with  other symptoms that it materially influences diag-
  nosis.  It proves a solution of continuity in  the vessels yielding it;
  but leaves us to determine whether this rupture is due to vascular
  obstruction, to congestion, to desquamation, or to ulceration.
    In  larger quantity,  gastric  hemorrhage has  not  only  more
  gravity, but a  more definite import.   Thus, sometimes it  presents
  sufficient of the characters of arterial or venous blood, to justify
  its reference to a vessel of one or other of these  two kinds.   And
  even more frequently it shows, by the clots it contains, that it must
  have been effused rapidly; either from one or two large, or  from
  numerous small vessels.   In  other cases, it presents the  peculiar
  black color  and tarry consistence which blood assumes by exposure
  to the digestive juices.  Since this change of color requires a certain
  time, as well as a certain amount of these juices, to produce, its oc-
  currence in vomited blood generally indicates that the hemorrhage

           1  Op. cit.; in which compare pp. 196, 250, 251, 255, 265. 
SYMPTOMATOLOGY.
65
has either been slowly effused, or is of but moderate amount.   In
blood  discharged  from the  stomach by the  bowels, of course no
such  rule will obtain;  indeed, such a hemorrhage will rarely fail
to exhibit somewhat of this tarry color and consistence, unless its
quantity have been excessive, or its transit through the intestinal
canal unusually rapid.  The detection of hemorrhage is sometimes
rendered difficult by the admixture of blood with  other substances
of similar appearance, especially with various articles of food, and
with more or less altered bile, occasionally even with morbid  pro-
ducts.   A careful examination1  will, however, generally  clear up
any obscurity of this kind.   Indeed, a mere dilution of the inspected
matters with water  usually suffices; or, if not, a microscopic  exa-
mination rarely fails to decide the question.

   Flatulence, as  a symptom  of gastric disease, occupies a somewhat
equivocal position, though one which is every way too  important
to be overlooked.
   I may remind  you that in speaking of the  gases found  in the
stomach and intestines, incidentally to the subject of "Digestion"
in the  Physiological Course, I laid before you reasons for coming
to the following conclusions respecting their  sources.
   1.  Air is habitually introduced into the  alimentary tube from
without the body: by some persons, voluntarily,  as an act of  deg-
lutition or eructation;  by all persons, in the ordinary act of swal-
lowing, probably in a state of mechanical adhesion to the bolus of
food, and certainly in a state of minute division in  the frothy saliva.
The air thus  introduced into the stomach undergoes a process of
diffusion  or interchange with the elastic  fluids  dissolved  in the
blood  of the  gastric capillaries: a diffusion  which converts the
ordinary gaseous  mixture  of the atmosphere into one containing
less oxygen and  more carbonic acid, and  in a degree varying ac-
cording to the duration of its sojourn in the stomach.
   2.  Gases are developed in the alimentary canal  by the decompo-
sition of the food it contains.
   There can be little doubt that the gases of the intestines are chiefly

   1 The  green liquids often vomited from  the stomach claim, by turns, at least
two rarely a third,  of the sources above  referred to.  Any transparent  liquid
possessing this color will generally be found to derive it  from bile : darker  green
hues being quite as frequently ascribable to changes undergone by this secretion
subsequently to  its reaching  the cavity of the duodenum or stomach, as  to its
original  characters while yet contained in the liver and gall-bladder,   i he dark
green flocculi of such vomited liquids are also  sometimes biliary.  But  they are
much oftener  altered blood:  a change of color which, in my opinion, generally
implies either a moderate quantity or a long delay of the hemorrhagic effusion
within the stomach, often both of these conditions simultaneously.  I may, how-
ever surmise from one or two necropsies that both the watery and the flocculent
creen vomit exceptionally derive their color from a transudation of the coloring
matter of the blood through the congested vessels, without any escape of corpuscles.
The alimentary admixtures capable of giving rise to a similar color are both too
numerous and too obvious to mention.  (Compare the remarks on this subject in
the lecture on Gastric Ulcer.)
0 
6(y
SYMPTOMATOLOGY.
due to this origin; and that even  the healthy stomach generally
contains, mixed with its gaseous contents derived  from the source
already specified, a portion of aeriform fluid referable to this origin.
The metamorphoses which constitute the digestive process are so
easily susceptible of being carried a step further, and thus of giving off
more or less gaseous fluid, that, though it is one of the offices of the
various digestive juices to repress and prevent all decomposition or
putrefaction (in the strict  sense of the words), some fraction of the
food generally escapes their influence, and distends the stomach with
a mixed gas, the  large hydrogen ingredient of which is conclusive
evidence of its having some other source than any mere deglutition
of air.  Indeed, under the influence of the heat and moisture of the
digestive  cavity, it is obvious that nothing short of the complete
adjustment—both as to quantity and quality—of the various secre-
tions to the several constituents of the food on which they operate,
could be  expected to prevent such a process.   And, practically,
the examination of the healthiest living individuals always shows
a sonorous response' of the gastric  region to percussion; such as,
taken in conjunction with the analyses of Magendie  and Chevreul,
leaves no reasonable doubt, that the term " flatulence" is  one of
degree and not of kind; and the question whether flatus is present
in abnormal amount in any given case depends (like so many other
questions involving health and disease, not to say good and  evil)
on the poco piu e poco meno, which governs so many of our decisions
in actual life.
  3. Another source of flatulence  suggests itself in  the  case  of
various constitutional diseases; namely, the evolution of gases by
the  decomposition  or putrefaction of  fluids derived  from  the
organism itself.  That gases may be thus evolved in cavities of the
body seems established by various  authentic cases of physometra;
where the elastic fluids  which distend the  uterus can only be
referred to such a source. And, from analogy,  it seems probable
that, in  numerous disorders known  to be attended with a peculiar
proneness of the fluids to  putrefaction, the spontaneous decomposi-
tion of the ingesta contained  in the  digestive tube, favored by heat
and  moisture, and unchecked  by the action of healthy digestive
juices, is accompanied and furthered  by a kindred decomposition
of the depraved and altered secretions themselves.   Such a variety
of flatulence, however, takes  but an  infrequent (as well as small
and  contingent) share in  the  production of this symptom  in the
proper gastric diseases we are now about to study.
  4. Lastly, as regards the evolution of gases in the digestive tube,
by a process of secretion from the vessels of its walls, I may remind
you that, though various  authors regard such a process as  taking
a large and important share in the production of flatulence,  a care-
ful inquiry into the subject has led  us altogether to deny it's occur-
rence.   To say nothing of the complete inapplicability of the term
"secretion" to  a  process  which,  if it occurred, would, from all 
SYMPTOMATOLOGY.
67
analogy, constitute an act of diffusion of the same kind as that which
obtains in the lungs and skin—the facts hitherto ascertained concur
to disprove even  this qualified evolution of these gases from the
blood.  The gases found in the intestines are, both in quantity and
quality, precisely those which wouIcTbe evolved by the decomposi-
tion of the various substances used  as  food;  and under circum-
stances of complete and sudden starvation, are often entirely absent
from the great part of the alimentary canal.  Some of them—such
as hydrogen, carburetted  hydrogen, and sulphuretted hydrogen—
have never been  detected in the  blood in any such appreciable
quantity as would be necessary to explain their evolution from it.
Nor can any parallel to such a gaseous excretion be found even in
the  case of those  structures which (like the lungs)  are specially
organized with reference to the  giving  out from the blood of cer-
tain of its gases, and the taking up of others from the surrounding
air.   For the gases just  alluded to, as  absent from the blood, are
equally  deficient  in  the  air of  expiration;  nay more, involve,
directly or indirectly, a deoxidation of water, such as is not  only
without parallel in the chemistry of the  organism, but is curiously
opposed by that oxidation of hydrogen  which forms about a pint
of water daily in the healthy human subject.   While the carbonic
acid and nitrogen  common to flatus and  expiratory air are scarcely
less distinguished by their quantitative relations,1, than  are these
others by their presence and absence respectively.
   One argument in favor of the secretion of gases by the digestive
tube must, however,  be  recalled;  namely, that deduced from  a
well-known experiment by  Magendie, in which the deligation of
empty intestine in a healthy dog is soon followed by its distension
with flatus. The inconclusiveness of this argument will sufficiently
appear,' when  I point out that the experiment  does not exclude
all alimentary matter; but that, on the contrary, since  one grain
of starch or sugar would yield, by decomposition, gases capable of
occupying about  eight cubic inches of  space,  no such experiment
can exclude the presence of sufficient food to account for the gases
of the resulting distension; can approach, indeed, the trustworthi-
ness of the contrary observation, as  to  the empty and  contracted
state which often results from starvation.
   Hence, in respect to flatulence, as a symptom of gastric disease,
we may start with these propositions.  That the  stoniach and in-
testines  generally contain a  certain quantity of aeriform fluids,
derived, in great part, from the decomposition  of ingesta.  That it
is only where they are excessive and troublesome that their pre-
sence is strictly abnormal.  And that, among the causes of such an
abnormal amount of these gases—in one word, of flatulence—the

  1 In round numbers we may estimate that intestinal flatus contains ten times
the quantity of carbonic acid and two hundred times the quantity of nitrogen,
exhaled from the blood in the air of expiration. 
68
SYMPTOMATOLOGY.
most immediate and obvious are (1st), a quantity of food which is
too large, either absolutely or relatively to the digestive juices of
the individual; and (2d), a quality of food which (either from  ex-
isting or nascent putrefaction, or from a  peculiar proneness  to it,
or even from a peculiar  composition') favors this change.
   The pathological import of flatulence  is, however, by no means
summed up in these general statements.  And the  diseases of the
stomach and bowels offer us  certain  phenomena, by which we  are
in some sense bound to test the conclusions we have come to against
the alleged secretion of  gases from the gastric or intestinal blood.
Not only are there various abnormal states of the digestive  canal,
in which flatulence occurs under circumstances  at first sight sug-
gestive of no very close relation to the above laws; but we  occa-
sionally meet  with cases in which this  symptom  appears and
disappears with such  startling  rapidity,  and  seems  so completely
independent of every other abnormal condition, that it is no wonder
if a superficial observer or lax  reasoner should think the secretion
of gases  an absolutely  unavoidable explanation.  A  person, for
example,2 is prevailed upon to break a fast of many hours with a
morsel of some  kind of food  which  he habitually digests with
difficulty. He is instantly seized with acute pain in the epigastrium;
but, before his alarm and  agony can obtain  any medical relief, is
restored to complete health by a copious eructation of flatus.   The
advocates of this secretory doctrine would, perhaps, think such a
case susceptible of only  one explanation; that the  empty stomach
had been the seat of a sudden  and copious evolution of  gas, pro-
ducing distension and pain, which  ended by  the expulsion of the
flatus.
   But  there  is no necessity for accepting any such  explanation.
On the  contrary, the physiology of the digestive  canal not only
justifies, but demands, a very different interpretation of the facts.
   To begin at the beginning, let me  remind  }^ou that the bulk of
an aeriform fluid is dictated by the pressure to which it is exposed;
so that, for example, to double the pressure of a cubic inch of gas
would diminish its bulk to one half; or, conversely, to halve its
pressure would convert  one cubic inch of bulk into two.
   Now within certain limits (dictated chiefly by the general pres-
sure  of the atmosphere), the intestinal  gases are exposed to the
influence of two varieties of pressure; which,  while they seem
chiefly or exclusively to  affect the bulk occupied by a given amount
of flatus, often  probably concur with  a  slower alteration in the
quantity developed in  the digestive canal.   The pressure  of the

   1 A cause which appears to have some efficacy in the well-known effects (both in
man and animals) of various articles of food (e. g., peas, beans)  rich in  protein
compounds which contain much sulphur, on the evolution of sulphuretted hy-
drogen.
   * For obvious reasons I select a striking illustration, but the above  case came
under my own observation many years ago. 
SYMPTOMATOLOGY.                   69
abdominal muscles on the intestinal canal, and that of the muscular
parietes of this tube on its contents, thus to a great extent regulate
the bulk of the aeriform fluids by which it  is so largely occupied.
It is chiefly by diminishecPpressure that the most characteristic
effects are produced.   And their pathological significance depends
mainly on the mechanism of this diminution; namely, a muscular
relaxation in answer to a stimulus.  Thus, when we irritate the
peritoneal coat of the intestine in a living animal, we excite a local
relaxation (a kind of bulla, or bulging) of the wall of  the canal;  a
swelling formed by the relaxed  coats of the bowel, and occupied
by its gaseous contents.  In the experiment of Magendie alluded
to, it is probable the distension observed was partly due to  a more
general effect of this kind, brought about by the  irritation of the
ligature.  And  it would  be easy  to adduce a variety  of morbid
conditions of the  alimentary canal to illustrate the propositions:
that relaxation of this kind is connected rather with irritation of
the peritoneal, than of the mucous  coat; of the trunks, rather than
the periphery of nerves;  and that (caeteris paribus) its degree and
extent vary with that of the irritation; so that (as exemplified by
severe peritonitis),  in its more characteristic forms, it  engages, not
only the muscular wall of the intestine, but those muscles of the
belly which we have seen1 to  be  really co-ordinate with it, and thus
produces that general gaseous distension of the flaccid  (and  so to
speak, paralyzed) abdomen, which  constitutes some forms of tym-
panites.
   It  is scarcely necessary to  insist upon the essential distinctions
between the more characteristic forms of tympanites and  flatulence;
between a merely increased bulk and a really increased  amount of
flatus; between that which is not and that which is  expelled by
the contractile  force  of the two  muscular tissues—abdominal and
intestinal—that inclose the contents of the bowel.  But there can
be little  doubt that, in many  cases regarded as mere  flatulence,  it
is impossible to exclude that reflex process of relaxation in  answer
to stimulus,  of  which the tympanites of peritoneal inflammation
affords the best illustration.  Especially is this the case  with those
temporary and local  accumulations of flatus of which we are con-
sidering an example.  Here, for instance, instead of  a  sudden se-
cretion of gas, causing pain  and distension of the stomach,  and
ending in an expulsive act, I should offer  a very different expla-
nation:  that the irritation of the morsel  of unwholesome food
caused a relaxation of the gastric coats; that the pylorus  (generally
patulous  to the non-alimentary  contents of the duodenum,2  and
specially so in virtue of this relaxation) allowed the rarefied gases
of the stomach to be increased by an  addition from the duodenum;
and  that the resulting eructation expelled  a fraction of the total

      1 " Cyclopedia of Anatomy," art. " Intestine."  Supplement, p. 370.
      2 Op. cit., pp. 315, 319. 
70
SYMPTOMATOLOGY.
gaseous mass.   That,  under these circumstances, expulsive con-
traction should follow relaxation is not surprising: indeed, you will
recollect that, in the normal rhythmic peristalsis  of the  muscular
wall of this canal, these two states have exactly the same sequence,
both in time and place.
  You will observe, however,  that such a view, which  rests not
only on its own inherent probability, but also on that disproof of
the secretion of gas by the digestive tube which we have established,
suggests considerable doubt as to how far the pain is  caused by
the flatulence.   And a careful analysis of the incidents  of such a
case will quite  confirm this doubt.   Without going  so  far as to
assert  that distension does not  often materially add to the pain of
a flatulent  attack, we are at least fully entitled  to conclude that
(far from pain being always preceded and caused by flatulence) in
this chain of abnormal phenomena, pain, relaxation, and contraction
or expulsion,  are  generally three successive  links; and that not
only may the first occur without always or necessarily calling forth
the second  and third, but that  it is essentially the exponent of an
irritation, itself the cause of all three. 
71
                       LECTURE  IT.

  Circumstances connected with the Examination of the Stomach after Death—
                            Gastritis.

   Befoee entering upon the diseases of the stomach, I purpose to
notice some  points connected with the examination of this organ
after death ; points which we must understand, if we would rightly
appreciate its morbid anatomy in the several maladies we have to
discuss.
   The history of anatomy, as  well  as  of pathology,  furnishes
numerous  examples  of the extreme  importance  of a full  and
careful study of the  processes  of death and putrefaction, such as,
in the Lectures on  Forensic Medicine, I consider it  my duty to
submit to  your notice.   The gaseous contents of the arteries after
death  led  the  ancients into an error (as to the fluids  these tubes
transmit during life), which is  still recalled  by their name.   The
solid  condition assumed by the adipose tissue of  many animals
after death, has doubtless often suggested strange  mistakes as to
the phenomena of  their muscular (and especially their  cardiac)
action.   The opaque and  solid nervous tissues of the dead body
have  probably undergone a similar (though less marked) change
of physical characters before they are seen by us.  And the serous
effusions found in certain cavities, as well as  the fibrinous clots met
with in the larger vessels, have notoriously been mistaken for  pro-
ducts of disease, instead of the mere incidents of death, which they
are now known generally to constitute.
   Of all the organs of the body, perhaps there is not one of which
the successful examination is opposed by more difficulties than the
stomach; not one in which death introduces  changes of greater ex-
tent, variety,  and rapidity, or more closely simulative of the effects
of disease.  So much is this the case, that, in our knowledge of its
healthy anatomy, the stomach has long been (perhaps still is)  con-
siderably in arrear of most  other organs.   The ordinary interval
which our reverence for human life  very properly interposes be-
tween death and dissection—between the parting of  soul and body,
and the throwing open of the untenanted mansion  to  our  gaze—
suffices, in almost all instances, seriously to alter and damage many
of the gastric  structures.  And  any circumstances which aid to
keep  the body at  a higher  temperature than it would otherwise
assume, and thus postpone  or  protract the  process of" its cooling
after death, further increase  this  impairment of the  tissues of the 
 72   EXAMINATION OF THE STOMACH AFTER  DEATH.

 stomach.   So that, for example, the examination of a corpse which
 has lain from ten to thirty hours in an atmosphere of about 60°
 Fahr., rarely affords us a stomach sufficiently perfect and entire to
 exemplify the structure of the healthy organ during life.
   It may be premised that the organ itself has some inherent diffi-
 culties, such as may be traced in a microscopic examination of the
 freshest and healthiest specimen.  Its cell-growth is so delicate as
 to  be  readily damaged and  burst  by the  endosmose of  water, or
 other fluids of low specific gravity.  The  peculiar mutual  attach-
 ments of its structures  make  it very easy to  deform and  distort
 them to an  unusual degree.   For example, the  elastic basement
 membrane of the gastric tubes is inseparably united with the  matrix
 at  their mouths,  but easily loosened  and  dislodged at their blind
 extremities.   Hence, in tearing up specimens for observation, the
 former parts of these tubes are often  destroyed altogether; and the
 latter forced into such a state—so twisted,  bulged, or even broken
 or  rolled up—as  easily to mislead the observer, when he sees them
 apparently isolated and uninjured in considerable lengths.  It would
 be invidious to specify the errors (both in  pathology and anatomy)
 to which such simple facts have given rise.
   In tracing the  dead stomach towards its decomposition, you will
 do well to bear in mind  that the clue to all the  changes detailed
 lies in a very simple proposition respecting this organ.  It  has (so
 to speak)  a general and a special set of changes: one which belongs
 to it as to a soft part, composed of much blood  and muscular sub-
 stance, and arranged so as to afford a large surface of contact with
 the aeriform fluids it incloses; and another, which is connected with
 its  function, as an organ  which secretes, by means of two peculiar
 cell-growths, a liquid which has the specific property of dissolving
 protein compounds.  The former gradually permits the  organ to
 undergo the physical and chemical changes which constitute ordi-
 nary putrefaction, the  latter adds, to  this form of dissolution, one
 effected by the powerful  gastric solvent.   The former yields as its
 products the new compounds usually disengaged by putrefaction:
 especially ammonia, carbonic acid, water,  sulphuretted and phos-
 phuretted hydrogen, &c.  The latter  forms a specific liquid singu-
 larly resistant of putrefaction—the peculiar solution of hydrated
 protein compounds called peptone.  With great differences, as we
 shall see, in the nature and rapidity of these two factors of  gastric
 dissolution after  death, they concur in a variable degree  in every
 stomach we examine by a necropsy.
  First after death comes an engorgement, which specially affects
those {quasi venous) capillaries occupying  the  free  surface of the
stomach, and  surrounding the mouths of the gastric tubes,  {b,
Fig. 9, Fig. 10, p. 34.)  In the stomach, as  in the rest of the body!
it is probable that the arteries  empty themselves into the capil-
laries by the contraction of their elastic and muscular walls at (or
immediately after) the moment of death.   The  capillaries  almost 
EXAMINATION OF  THE STOMACH  AFTER  DEATH.   73
 as quickly propel their contents  onward into the adjacent veins,
 which become correspondingly distended through a variable extent
 of  their course.  Which of the veins are thus engorged, and to
 what distance their different degrees of distension extend onwards
 toward the heart, or backwards towards the capillaries, must depend
 on a variety of circumstances, in which the mode of death, the state
 of other organs, &c, are all intimately concerned.  As regards the
 stomach it need only be said, that this engorgement specially affects
 the vessels  already mentioned, and the digesting  organ; that it
 occurs a very few minutes  after death; and that whether  from
 structural and functional peculiarities to which  I must not now
 allude, or from the mere  muscularity of this part, it specially avoids
 the pyloric region or sac.
   It is impossible to  draw an exact line of demarcation  between
 this speedy  congestion (apparently engaging the  stomach both  as
 an internal organ and  as a secreting structure) and  the true hypos-
 tasis which brings about discolorations like those seen on the exterior
 of the body ten or twelve hours after death.  For not only do they
 merge into each other  by  inconceivable gradations of time and
 amount, but it is the very  same blood  that occupies the gastric
 capillaries as an effect of this congestion, which gradually obeys
 the impulse of gravity,  and descends to a greater or less extent
 towards the lowest or inferior surface of the organ.   Such a true
 hypostasis or gravitation is, however, less complete (and  I  think
 somewhat  later) in the  stomach than in the lungs or the subcu-
 t^Tipnim 1*msu6S
    Other indications of the dominance of physical laws, heretofore
 subordinate to the living forces, may be seen in the appearances of
 infiltration  or imbibition the stomach so often exhibits.  In this
 organ, the solution and transfer of the coloring matter of the blood
 are not easy to verify (though they doubtless occur) in the presence
 of such marked changes of color as are brought  about by other
 causes.  But  the imbibition of biliary color, as well as of the various
 hues derivable from  food  or medicine—such as the red  color of
  wine or logwood,  or the black color of the  metallic sulphurets
 reduced from the solutions  of their salts—are familiar instances of
 this kind of infiltration,  greatly modifying the aspect of the organ.
    Here is perhaps the place to allude to some  other  peculiarities,
  in great  part due to the casual circumstances which precede or
- immediately follow death.  The shape and size of the stomach, and
  the thickness of its coats, as seen  in necropsies, are scarcely less
  variable than its color, its consistence, and the degree of its conges-
  tion   As regards size  and  thickness,  not  only do  they vary in
  different individuals, as  do such physical circumstances m  all other
  parts of the body, but it must be especially borne in  mind that, in
  an orcran constructed like  the stomach, the two appearances  are
  mutually  convertible into each  other.   A dilated  stomach,  for
  example, is laid  open by an incision, and speedily (with a degree 
74    EXAMINATION  OF THE  STOMACH  AFTER  DEATH.

varying according to the amount of contractility left by decompo-
sition) contracts into a state perhaps as simulative of hypertrophy
as its previous condition was of dilatation.  Hence the real degree
of either of these states must be determined as a balance of the two;
must be estimated, for  example, by  observing the hypertrophy
which co-exists with  moderate  distension,  or vice versa.  In like
manner unusual length or width of stomach are often illustrations
(occasionally permanent, more frequently temporary) of a gain in
one dimension being tolerably compensated by a loss in the other,
with little real deviation of size.  And of course it is not merely
the casual condition of the stomach at death, with the circumstances
of its rigor mortis, which regulates its size or the degree of its contrac-
tion, as seen in a necropsy ; but  also (and in an even greater degree)
the state of habitual distension  which has preceded death—a dis-
tension often essentially  independent of the stomach itself.   Thus
starvation, vomiting, heart-disease, emphysema, and  stricture of the
oesophagus during life, may all give rise to a small or contracted
state of the stomach ;  the single fact in which they sometimes con-
cur (the absence of the normal distension produced by food) giving
rise to this  state as its physical result.  In all, too,  a  slow and
careful process of artificial dilatation  will generally show the true
character of the appearance.
   What is called hour-glass contraction of the stomach is occasion-
ally a congenital peculiarity in the shape of the organ, as its situa-
tion and appearance would suggest.   Oftener, however, it also is a
mere phenomenon of the final  contraction or  rigor mortis of the
stomach.  The two are easily distinguished by inflation, no reason-
able amount of which suffices to remove the congenital constriction.
But I am  persuaded,  from careful  inspection of  specimens, and
analysis of their histories, that many cases supposed to be congenital
contractions of this kind, have been the results of a cicatrized and
contracted ulcer.
   The state called mammillation of the stomach is another effect of
the contraction of the  muscular fibres of this organ.   I am aware
that some good authorities still regard this  as a  morbid condition,
produced by an accumulation of glandular or fluid contents within
the gastric tubes.  Butt I have convinced myself that this view of
its nature is  untenable.  For it not only occurs in persons dying
suddenly during  health,  but  also in stomachs otherwise  perfectly
healthy. It  is rarely  accompanied by any  change in the bulk or
appearance of the secretory structures. It affects chiefly the more
muscular pyloric half ox two-thirds of the  organ.   Its projections
often merge, by slight gradations of size, into wrinkles closely akin
to those formed  in the  healthy and  contracted  organ.   It may
always  be  effaced by  pressure,  generally by prolonged dilatation.
And lastly, though, when of limited extent,  it is compatible with a
relaxation of some other part of the stomach, it is generally asso-
ciated with local contraction,  and is  never found both marked and 
      EXAMINATION  OF THE  STOMACH AFTER DEATH.    75

extensive, save in a contracted stomach.   As respects the mode in
which it is brought about, I believe it  to  be due, not to a mere
contraction of the longitudinal and transverse layers of the general
muscular  coat—as  is evidently the case with  the ordinary rugae
(see p. 27)—but to a much more irregular and uncertain contraction
specially shared in by the various bundles given off from this coat
to form the muscular  constituent  of the matrix (see p.  29), in
which the tubes of the mucous membrane  are packed vertically
side by side.  In short, it seems to be somewhat analogous to those
curious distortions  by  which the villi share in the rigor mortis of
the muscular coats of the intestine.  I  may add, that the perma-
nence of the phenomenon seems to be sometimes furthered by a
subsequent process  of transudation, which distends the submucous
areolar tissue of the various isolated projections or mammillae,
with a serous fluid of the  same kind as that often found occupying
a larger extent of the cellular or areolar coat.   (See p. 76.)
  Writh those  re-arrangements  of  the blood, vital and  physical,
already mentioned—with this  congestion produced by  the  phe-
nomena of death in  the three classes of vessels, and the transudation
and gravitation which  succeed  them—concur two other processes
(one of effusion, and one of solution or digestion), a brief mention
of which may end these allusions to the ordinary course of dissolu-
tion  in the stomach.  In respect to  the  date of their occurrence,
doubtless both of them commence  almost at the moment of death,
although  there is  rarely  any marked evidence of their presence
until  the  changes already described have taken place.  As to the
frequency of their  occurrence,  I believe that  neither of them is
ever completely absent, no matter what the causes or circumstances
of death.   As  to their  nature, it is doubtful whether  the effusion
occurs incidentally to the process of  transudation already mentioned
—and thus consists of a  serum which was  formerly  contained in
the vessels, and which, in permeating the gastric cell-growth, carries
away certain of its  soluble ingredients—or whether  it is a true
secretion analogous to  that poured out during life.   It is equally
doubtful how far the nature and amount of this effusion regulate
or determine the process of solution undergone  by the  gastric coats.
But the following remarks may partially describe what really takes
place.
  Nothing is more common, in  many of the healthiest animals
slaughtered as food, than  a kind of desquamation or exfoliation of
the columnar epithelium  of the gastric  ridges.   In  the pig, for
example, the whole stomach  may sometimes  be seen  to have shed
this coat as early as two or  three hours  after death;  so that what
appears to be (but is not)  the true  surface of the organ, is covered
by a  copious dense mucus, the true nature of which is at once
revealed by a microscopic inspection.
  An occurrence nearly analogous to this often occurs in the human
subject. For example, in a young adult dying of some acute disease, 
76    EXAMINATION OF THE STOMACH AFTER  DEATH.

even a speedy necropsy, in cold weather, sometimes shows a similar
superficial  mucous exuvium covering the whole organ.  And  a
careful microscopic examination  of such a stomach proves that
(together with what, for obvious reasons, is generally a far greater
amount of congestion than  in the  stomach  of the  comparatively
exsanguine slaughtered animal) there is much the same destruction
of surface, associated with equally little change of the deeper parts
of the gastric tubes, and of the pepsinous cell-growth they contain.
From this superficial change—in most, if not all cases, a combination
of desquamation, effusion, and solution—commences  the post-mortem
digestion of the stomach;  which gradually sinks throughout the
whole depth of the mucous membrane, and combines, in  innumera-
ble gradations of admixture with the vascular phenomena already
mentioned, to produce results so complex, and so variable, that we
may fairly say no stomach we see is precisely like any other.
  As a rule, however,  it may be  alleged that the younger and
healthier the subject of examination, and the more acute the disease
which has caused death, the more rapidly and effectively does this
exfoliation and dissolution take place.  It often proceeds with so
much uniformity and regularity, and  the laminae of mucous mem-
brane it strips off'  leave so level and  so  smooth a surface, that its
extent would pass quite unsuspected without a careful examination
of the organ.  In other cases it specially affects the summits of the
folds into which the mucous membrane of the stomach  is thrown
by the contraction  of its muscular coat.  Great congestion seems to
disfavor1 it;  not only by the additional materials it submits to the
solvent process,  but also (I  believe) more specifically.   It brings,
too, a set of complications all its own.  The solution of the  blood
thus attacked is preceded  by changes of  its color and consistence,
precisely analogous to those already mentioned (p. 65) in connec-
tion with hemorrhage into the stomach during life.  And hence we
not only find a  variety of shades of brown, black, or slate-color,
diffused more or  less widely and  regularly  over  the organ,  in
patches corresponding with the previous congestion ;  but  gradually,
as the superficial parts are dissolved, and the deeper attacked, the
larger vessels (and especially the large and numerous veins of the
submucous  areolar tissue)  become affected, forming a kind  of
cloudy brown network in the parts most engaged by it;  namely,
the cardiac end, and the posterior surface of the organ.
  As already stated, it is difficult to determine how far this process
is aided by the effusion into the gastric cavity of  a serous fluid,
such as we find freely poured out in many parts of  the body after
death.   Analogy, however, somewhat  discourages such a view, by
suggesting that a mucous membrane, with an elaborate and specific
office, is an unlikely seat for any large effusion of this kind.   And
1 Compare note to p. 80. 
      EXAMINATION  OF THE  STOMACH AFTER DEATH.    77

the mere structure of the mucous membrane of the stomach is such
as would probably impede and restrain a serous effusion; both  by
the close  packing of the cell-growths which cover its basement
membrane, and the remarkable density and firmness of the adherent
matrix  beneath it.   But, while we sometimes meet with cases (es-
pecially in dropsical subjects) in which the mucous membrane has
a soft and watery consistence, strongly suggestive of a serous infil-
tration,  there can be  no question that the looser sub-mucous areolar
tissue is often occupied  by a fluid of this  kind in considerable
quantity, giving it a quaggy and  humid texture, or even raising
the membrane here and  there in patches somewhat elevated above
the general surface.  And on the further decomposition of the organ,
the  areolar  tissue thus  infiltrated becomes the seat of a kind of
putrefactive emphysema, being distended with gases which crepitate
when the coats of the stomach are pressed between the fingers.
   In the subsequent changes of the stomach after death, putrefac-
tion resumes (or rather assumes) its ordinary sway : conducting the
organ to its  dissolution by processes not requiring any special dis-
tinction from those which (at a somewhat later period) complete the
destruction of the intestinal coats.  Why, after first deviating so
widely, the dissolution of the stomach reverts to an ordinary type
of decomposition, is sufficiently obvious.   In a vast majority of
cases, there  is nothing which at all suggests  any considerable pro-
cess of secretion by the stomach, either at  or  after death.  And
hence,  as soon as the pepsine already present in the stomach-sub-
stance  has dissolved so much of the blood or of the tissues as it is
capable of taking up, and the solution of peptone thus formed  has
itself been distributed by a physical process of  imbibition in  the
 neighboring parts, its solvent action comes to an end; and its anti-
septic properties are soon overbalanced by the continually increasing
decomposition of the tissues*it has penetrated.  So that, though the
solvent force of the gastric structures usually not only softens,  but
absolutely dissolves, a varying depth  of  the  stomach  from  its
 mucous surface outwards, this action often goes no further than to
 denude the submucous or muscular coats.
   Frequently, however,  the stomach exhibits proof  of a solvent
 action  far  exceeding these its customary  bounds; of a process
 which  not  only  softens, but absolutely erodes and destroys a
 variable  extent of  the entire thickness of the  stomach, and even
 attacks the neighboring viscera.
   As a matter of  mere description, little  can  be added to  the
 records left  by John Hunter, who first drew attention to this kind
 of gastric perforation.  The aperture it makes in the stomach  is
 an irregular ragged hole, with gelatinous pulpy margins of great
 tenuity, which break down under the slightest  force—a condition
 often extending over almost the  whole  of  the organ.  Of course
 there are no evidences of inflammation on the  one hand, or  of
 putrefaction, on the  other; the antiseptic action of the gastric solvent 
78    EXAMINATION  OF  THE STOMACH  AFTER  DEATH.

remarkably controlling  the latter decomposition in  most cases.
And as a rule, little congestion is present:  the  process apparently
occurring at a date prior  to the ordinary hypostasis that  follows
death, and preventing this change by a specific effect on the vessels
or their contents.  Hence the whitish or yellowish-gray appearance
of these softened and perforated stomachs is a character which aids
to distinguish them from ordinary specimens.  But, in  many cases,
even the perforation of the stomach by no means ends  this  process
of solution; which extends to other structures thus  exposed to the
action of the gastric contents, and softens and erodes the neighboring
liver, spleen, or  diaphragm, or even the lung itself,  after the  per-
foration of this septum.
   In respect to its circumstances, we may first notice, that the ordi-
nary site of this process of perforation is at the cardiac end of the
stomach;  but that it sometimes varies from this rule by affecting
the neighboring middle segment of the organ, opposite the oesopha-
gus ; either anteriorly, posteriorly, or near the small curvature, and
with a  diminishing frequency tolerably corresponding with this
order of succession.  The  pylorus is scarcely ever affected alone :
at any rate, less frequently than is the cardiac end of the oesophagus.
   Its other juvantia  and  Isedentia are equally interesting.  As
Hunter observed, it especially occurs where a sudden death has
immediately followed  a  meal: in other words,  when the stomach
contains a large quantity of newly-secreted gastric juice.  I believe,
too, that it  is greatly furthered  by a solid consistence, and  by a
starchy or floury character of the food.   It is also furthered by the
healthiness,  and  still more by the youth of  the dead subject: as is
shown by contrasting its frequency in accidental death, acute disease,
and  chronic disease;  or in  children,  adults,  and  aged  persons
respectively.  Of all maladies, phthisis is that with which it is most
frequently found associated; though in* noticing this fact, we must
remember both the frequency of the disease  itself, and the compara-
tively keen  appetite which  many of its subjects retain to the last
hour of life.   But it is occasionally met with in a variety of acute
and chronic maladies—as in the specimen before us, from a case  of
pericarditis.  And though we are obliged, on the whole, to subscribe
to the opinion of Hunter—that injuries of the head form no frequent
or special cause of this perforation—yet an interesting case brought
forward by Dr. Budd1 seems to indicate some such casual connection
between them, capable of giving rise to the process  in the fasting
stomach.  Lastly, as regards its occurrence in diff'erent species  of
animals, though  there  are few Vertebrata in whom  it may not be
often found, its variations appear to depend, less on the mere energy
and rapidity of the digestive process, than on the circumstances  of
this  act  already  hinted at.   And as respects  temperature,  this
important element in  gastric digestion has all the influence which
1 On " Diseases of the Stomach," p. 17. 
      EXAMINATION OF THE  STOMACH AFTER DEATH.    79

might be expected (compare p. 40); so much so, that; in the fish
ordinarily supplied to our London market, perforation is extremely
common in summer, but almost as rare in winter.
  If from these facts we would  deduce any explanation or theory
of this  occurrence, we  may first observe, that  while (as already
stated) we  rarely  open  a stomach  in which we cannot  trace the
specific  solvent action of this organ upon itself after death, so this
ordinary softening and  abrasion merge into complete dissolution
and perforation by such innumerable gradations, that it is impossi-
ble to draw any distinction between them, widely as their extremes
differ from each other.  That both have a similar cause is therefore
an almost  unavoidable conclusion: a conclusion  such as almost
restricts our inquiry to the various modifying circumstances, or
superadded  causes, which can increase or diminish, promote or im-
pede, the resulting solution of the gastric coats.
  But this conclusion is  better deduced more specifically.   And
when I  assert (as I do after years of research) the invariable acidity
of the columnar epithelium {a, Fig. 7) of the stomach, and the fact
that  the entire  gastric  mucous  membrane of the human subject
contains pepsine enough involved in its structures to  dissolve about
four ounces of albumen—you will see that I am stating what abun-
dantly accounts for a moderate  amount of softening and solution
in the stomach after death;  at the same time that  it suggests that
a mere  acidulation of the gastric contents, however effected, might
suffice to mediate a limited solution and perforation of the stomach,
if not also an erosion of abdominal viscera.
  In like manner I must so far anticipate some unpublished re-
searches as  to point out, that there are various causes which can
respectively oppose and further the solvent effect of the gastric
structure, by introducing modifications precisely corresponding in
their results to those which we may  observe in  experiments on
artificial digestion.  Especially would I notice, that the protection
of the tissues of the stomach against its own solvent juice seems to
be partly effected by the secretions—chiefly salivary and biliary—
it receives from the neighboring mouth, oesophagus, and duodenum;
and  that it certainly secretes no alkaline mucus (I would almost
say no  mucus whatever)  in a healthy state.  Hence among local
causes  capable  of preventing gastric solution, we may notice (1),
the presence of alkaline saliva and  bile  in any  quantity; and (2),
the presence of animal food, absorbing and engaging  (in proportion
to its minute division of surface) the powers of the  pepsinous fluids
furnished by the organ.  And conversely, among  influences capa-
ble of  increasing the  solution  produced by a given amount of
healthy gastric substance, we may mention (what has  often occurred
in the cases recorded)  a vegetable  or starchy character of  food:
(1st),  as offering little substance on which the stomach can immedi-
ately expend itself; and (2dly), as producing by its decomposition,
aided by that of the organ and its secretory contents,  an amount of 
80    EXAMINATION  OF THE  STOMACH  AFTER DEATH.

acid such as adds the very ingredient  necessary for an energetic
gastric solution, to a pepsinous fluid itself remarkably deficient
therein.
  With all this, however, it must be confessed that the more ener-
getic and complete cases of self-digestion of the stomach can scarcely
be explained, except by supposing a true secretion of gastric juice;
by a process which, so far as we know, invariably precedes death,
and which is almost always  connected  with its normal immediate
cause; namely, the  presence of food in the stomach.  WhetheT
injuries of the head, or of any parts of the nervous centres, can pro-
voke  an  increased secretion of gastric juice, or can evoke it inde-
pendently of the presence of food in the organ—or, if so,  how far
such  a result would be  comparable to Bernard's well-known ex-
periment, in which an injury of the  medulla oblongata excites an
excessive formation of grape sugar by  the liver—are questions to
which our existing information affords no answer.1
  There are many other points of  interest, connected with  the
examination of the  stomach  after  death, which time forbids our
considering here.   Amongst  these I would briefly  allude to the
pathological import of ecchymosis, and of ulceration, as found in
the gastric mucous membrane after death.  There  can  be  little
doubt, that  the first must be regarded as  generally indicating, in
the stomach, what it certainly does in the subcutaneous tissues—
an extravasation occurring during life.  In  rare instances, however
(and chiefly where death has resulted from injuries of the nervous
centre, attended with little2 hemorrhage), we see minute  spots of
extravasation under  the gastric  ridges  in  animals so perfectly
healthy,  that it is difficult  to avoid supposing  these ecchymoses
have  taken place, either as contingencies of the agony of death, or
as a result of those readjustments of the circulation which immedi-
ately  succeed it.  Hence it  is  possible that slight  and irregular
appearances of this kind in the human subject are sometimes devoid
of all pathological import;  especially when they are accompanied
by  that  general venous congestion which  we have  seen  may be
present in almost any  moderate degree, independently of gastric
disease.   And  in like manner, though a local breacji  of surface—a
loss of substance of the mucous membrane, bounded by a firm and
defined margin of this tissue in anything like its normal thickness
—can scarcely be accounted for, save as the result of an ulcerative
process during life; still, with appearances at all less definite, we must
sometimes remain in doubt.  For  example, I have seen instances
in  which  the  absence  of  all  marks  of reaction  around small
erosions  of  the mucous surface has concurred with a somewhat
thinned and softened margin of this supposed ulceration, and with

  1 The above juvantia and laedentia of this process of solution are in close accord-
ance with the results of Dr. Pavy's researches elsewhere (p. 46)  alluded to (com-
pare p. 76).
  2 As in animals killed by pithing. 
GASTRITIS.
81
irregular softening  and slight abrasion of the organ elsewhere, to
raise a strong suspicion that such  erosions are sometimes chiefly
(if not exclusively) due to the phenomena we  have traced in the
stomach after death.  Becollect then, that  in this, as in most other
departments of pathological (not to  say human) knowledge, appear-
ances are sometimes  equivocal:  that they require  careful study,
rational analysis, and, above all, a  comparison  with  the structures
of the healthy body after death, and with the symptoms of the dis-
eased subject during life; without which the dead-house will some-
times mislead  us  as  to mere morbid  anatomy, and  will never
enlighten us on that subject  to which it should always refer—the
nature and treatment of disease.
                           GASTRITIS.

  -In a systematic discussion of the  diseases of any organ, the fre-
quency and gravity of inflammation, and the rapidity of its course,
generally render it the first to claim our notice.   In the stomach,
however, this malady  has, not so much a subordinate rank, as a
diff'erent import.  Barely met with as an idiopathic disease, it has
yet so direct a bearing on the pathology of the organ, and  occurs
so frequently as  the result  of the ingestion of poisons, and as an
incident of other maladies,  that in both a practical and  scientific
point of view, gastritis  has  scarcely  less interest  than pericarditis
or pneumonia.
   For example, in conceding that acute gastritis is rarely witnessed,
save as a result of the administration of poison, we are not  in any
way excusing ourselves from the study of its symptoms.  On the
contrary, this very fact points at peculiar and heavy responsibilities
in connection with the  malady;  responsibilities which  require us
to be so thoroughly and minutely acquainted with these symptoms,
as that the mere physiognomy of an attack of gastritis may arouse
our suspicions respecting  their  cause.  And since not even the
greatest numerical  disproportion is any substitute for a diagnosis,
the rarity of the idiopathic disease by no means obviates the neces-
sity for a contrast between the two forms of gastric inflammation.
While it certainly suggests  some inquiry as to why the stomach is
so remarkably contrasted with many other organs.
   The gastritis produced by irritant poisoning is, indeed, a model
of the symptomatology of the  stomach.  Shortly after  the  poison
reaches this organ, a  gradually deepening sensation of uneasiness
or warmth ushers in a more specific  pain, soon of an acute burning
character.   Closely preceding or following this pain comes nausea,
rapidly converted into vomiting, and becoming increasingly frequent
as the pain augments in severity.  The local  appreciation of the
pain is  heightened as  the sensation itself becomes  more intense;
the epigastrium  acquiring an excessive tenderness and  soreness to
       6 
82
GASTRITIS.
pressure;  and the patient's body being bent forward, to relax the
muscular  walls  of this region.   Not unfrequently the muscles of
the belly are spasmodically contracted, as are also various  muscles
of the extremities.   During the accession of these symptoms there
is a marked excitement of the system  generally;  the  pulse and
breathing being accelerated, and the skin increased in temperature.
But this condition is soon exchanged for a state directly opposite,
which rapidly prostrates the patient.  The skin becomes  clammy
and cold;  the pulse  and breathing increasingly feeble.   The latter
acquires a catchy, intermittent, or even  slow  character;  the dia-
phragm evidently acting  more incompletely and  irregularly  as
this condition advances;  until  finally, after a variable period  of
exhaustion, frequently ushered in and accompanied by hiccough,
the sufferer dies, having often  retained the full possession of his
mental faculties up to the last moment of life.
   Of course, in the  symptoms, as well  as the lesions produced by
these agents, there is much that is too characteristic or  specific of
each poison to be included in  any  such brief outline.  The con-
centration of the particular agent,  its  solubility, its affinity for
water, its  chemical action, its solvent effect on the tissues, its con-
stitutional action after being absorbed into the blood, its attraction
or  determination to a particular  part of the  canal—can  (as you
will recall from the Lectures on Forensic Medicine) greatly modify
the symptoms just summed  up.  Hence, quite apart from the re-
sults of an analysis, they generally justify  a conjecture as to the
poison by which they have been produced.  The state of the mouth
and the oesophagus,  the date of access of the pain, its intensity, the
nature of the substances vomited, the amount and character of the
purging, may thus assist our diagnosis.   It  is equally obvious, that
even the more general or constitutional symptoms require  a careful
study;  and can only be regarded as typical under  certain limita-
tions.   Thus, the prostration which  ends  life is often  produced by
a concurrence of at least three causes: (1) the constitutional action
of the poison; (2) the depth or extent of the lesion it has produced;
and (3)  the destruction of an organ essential  to life—three causes, of
which idiopathic gastritis, even if acute, would rarely afford more
than the last and most chronic.   In  like manner, analogy  indicates
(what indeed experience confirms) that the preservation of the
mental  faculties is often  an illustration of the constituent (if we
may so speak) which time forms in  the abnormal as well as in the
normal processes of life; so that, both  in  the less acute  cases of
poisoning, and in the  somewhat correlative  examples occasionally
afforded by structural lesions, a slower death  from  exhaustion is
mostly  ushered in  by delirium  ending in coma.   A similar law
may perhaps be detected in the intense and  rapid  peritonitis of
perforation, whether from corrosive poisoning or from  ulceration
(see Lecture III.). And an analogous though different effect of ex-
haustion may be traced in the comparatively painless interval which 
GASTRITIS.                        83
often precedes death by acute poisoning, and  by idiopathic lesions
of the stomach.
   The morbid  anatomy  of poisoning, and of inflammation, can
only be contrasted with similar precautions.  The former offers us
two conditions:  a destruction of tissue, and a reaction of the neigh-
boring structures.   Of these; the latter alone is analogous to inflam-
mation ;  the former being either independent of this process, or at
any rate so greatly modified  by  the specific chemical agency of
the poison, that  it may be preferably regarded as distinct from such
a reaction.
   Among  more remote analogies to acute idiopathic gastritis, it
would be easy to  adduce the effects  produced by the introduction
of such irritants as foreign bodies  and hot liquids into the stomach.
But, among the numerous instances of this  kind recorded, I can
scarcely recall one which affords a good example of diffuse or gen-
eral inflammation  thus  produced.   In the  mechanical  irritation
produced by solid objects (such  as hair,  false teeth, pins,  nails,
knives, forks, &c.) we  trace what is occasionally a physiological
effect, rather than a physical lesion ; oftener a mere wound or other
injury  giving  rise to  local inflammation, ulceration, or abscess.
Even where the irritant is a liquid, the resulting inflammation may
be scarcely less local.   Sometimes, no doubt, the  mischief  is cir-
cumscribed by  merely casual circumstances:  such as we may trace
in its occasional limitation to the cardia and pylorus, in the case
both of  hot liquids and of corrosive poison—an effect which may
plausibly be  referred to  the  absence of diluting  mucus, and the
occurrence of coaptation and friction, at these valves.  Where molten
lead has been  swallowed, the partial and  slight character  of the
injury which sometimes  results is probably  due to the hot  metal
having vaporized part of the  fluids  of the stomach, and  thus pre-
vented or deferred its  own contact  until it  has somewhat cooled.
Finally, the  violent and diffuse  injury producible by  scalding
water is unlike  idiopathic gastritis in one important respect: namely,
that there  is good reason to  believe the resulting destruction of
tissue is chiefly due to the effect  of  the heat itself, rather than to
the inflammation it excites; a  pathological distinction, the accuracy
and importance of which is well known to surgeons in the case of
external injuries of this  kind. The remarkable variety of symp-
toms witnessed  in such cases confirms this distrust of their bearing
 on gastric inflammation.
   Hence we start with a kind of typical gastritis; a mere group of
symptoms,  obtained by subtracting,  so far  as contrast and analogy
will allow,  the  casual and the special features of gastric poisoning
from the history of this process.  If, from a narrative of this kind,
we deduct the accidents of the particular case, and the peculiarities
of the  special  poison,  the remainder is acute gastritis:1  in other

   ' Logically, the  genus of which the narrative is the species, and the peculiarities
are the differentia. 
84
GASTRITIS.
words, not only the outline of gastric  poisoning, but the type of
acute inflammation of the stomach, and the clue to the symptoms
which testify to even less intense and injurious action of this kind.
  " But is there any such substantive disease as the acute gastritis
described by nosologists, or indicated by the group of symptoms
thus dissected out of those of irritant poisoning ?"  Apparently not.
And I can only confirm the negative opinion to this effect recorded
by Abercrombie and others, by stating, that  in  all  my experience
I cannot recall a single instance of  acute general inflammation of
the gastric mucous membrane, save as a result of poison; but will
add, that the preparations and records of all the cases of this kind
I have been able to discover, indicate something quite distinct from
any such malady.   For, with the  exception  of one or two  cases
justifying a suspicion of poison, most, if not all, of them are instances
of an effusion of blood, lymph, or pus into the sub-mucous (rarely
the sub-serous) areolar tissue of the organ; its other tissues sharing
but partially or indirectly in this change.  The mucous membrane,
often no way involved, appears in other cases to be affected only in
a secondary manner; by' virtue of the dependence of its vessels on
the arteries and veins of the sub-mucous plexus entangled in the
effusion.  And  hence—without  going so far as to say that,  since
the mucous membrane is xat' ?%oXqv the stomach, whatever malady
leaves it untouched can scarcely be regarded as essentially gastric—
we may at least assert, that any such inflammation is utterly unlike
the typical gastritis  described by the earlier writers or conceived
of under the above symptoms;  which, if it  ever occurs, must be
exceedingly rare.1
  Eliminating, then, these rare inflammations of the areolar tissue2
from the subject of acute gastritis, and similarly deferring all con-
sideration  of ulcerative disease—both  from  its partial  or limited
extent in the organ, and from the doubt that often  hangs over its
inflammatory origin—we are  left without any actual disease of the
stomach corresponding with the symptoms of poisoning, and analo-
gous to the acute inflammations of other organs.
  But it is quite otherwise with the sub-acute varieties of the inflam-
matory process, which appear to affect the stomach very frequently.
And these we may distinguish into two forms.  One, in which the
malady is caused by a constitutional state, the effects of which are
shown in a variety  of other organs, as well as  in the stomach.
Another, in which it is due to causes connected  chiefly or exclu-
sively with this organ; which is submitted to an irritative process,
somewhat analogous to that  typified by the gastritis  of irritant
poisoning.
   The first is well illustrated by the  gastric inflammation which

  1 Especially if we consider the sedulous examination which its  intensity and
fatality almost imply.
  2 See Lecture V. 
GASTRITIS.
85
 attends many exanthemata, and which is especially marked in some
 cases of scarlet  fever.1   Here careful examination, after death be-
 tween the third and seventh day of the malady, will often  show
 that the  inflammation—the vivid red color, thickening, and ashy
 gray exudation—seen on  the tongue and fauces, extends through
 nearly the whole of the digestive canal; and is especially distinct
 in the stomach, where the casting off of patches or sheets of false
 membrane  is often accompanied by a scanty hemorrhage of gru-
 mous blood.  The exudation consists of cell-growth;  in which the
 healthy columnar epithelium is more or less replaced by cytoblasts
 (or cells in their earlier stages of development), and is mixed with
 variable amounts of amorphous albuminous material.
   Now though  the symptoms  present  in the acute stage of this
 malady  and  its congeners certainly  point  to the stomach,  yet  I
 should hardly feel justified in asking you to accept the few obser-
 vations on this head,  which I have  hitherto been able to make, as
 conclusive evidence that the anorexia, epigastric pain, tenderness,
 and vomiting, which form such  constant features of these maladies,
 must always be referred to a subacute gastritis, incidental to  the
 exanthemata.   But  they undoubtedly tend toward some such con-
 clusion.   And while, in the case of scarlet fever, they are in  exact
 consonance with all that is known of the pathology of this disease
 (which you will recollect rarely fails to add, to the external inflam-
 mation of the skin, and the internal  inflammation of the throat, an
 equally inflammatory process in the independent2 mucous  tract
 that lines the minute tubes of the kidney), they indicate  two points
 for our practical consideration.   One is, that  the symptoms of gas-
 tritis are perhaps more distinct than they are sometimes supposed
 to be; at  any rate  are  distinct  enough, where any large extent of
 mucous surface is involved; varying (as the difference of the tissues
 concerned would entitle us to expect) much  more with the super-
 ficies than with the depth of the lesion.3   The other is, that in this
 particular stage of  such maladies, the patient's aversion  for food is
 a wholesome  instinct; a rejection of what not only is superfluous

  1 The silence  with which this summary of the state of the stomach in scarlet
 fever has been  passed  over by some subsequent  writers on the same subject,
 obliges me to notify that it was not only contained in the above lecture delivered
 in 1857, and printed in 1858, but  had been repeatedly committed to the pub-
 licity of a large and changeable audience of students during the preceding seven
 years.  [Note to 2d Edition.]
  2 I am, however, doubtful whether much stress can be laid upon this adjective
 (" independent").   Firstly, the careful microscopic examination of the urine gene-
 rally shows that the mucous membrane of the whole urinary tract down to, and
 including, the bladder, shares in the desquamation which so gravely affects  the
kidney, and often with  a fairly proportionate severity.  And, secondly, there are
good physiological reasons for regarding this community of lesion as depending on
a natural community of function ; as well as on that continuity of structure between
the skin and the'urinary membrane which seems to be the proximate cause of
their special association in scarlet fever.
  3 Compare foot-note to p. 53. 
86
GASTRITIS.
and useless, but may be downright injurious, by embarrassing still
further the inflamed organ, and risking an increased intensity of
the local inflammation, as well as of the grave constitutional symp-
toms which it is impossible to avoid  tracing in part to this gastric
origin.  Under such circumstances opium may do good ;  but it is
difficult to conceive that  stimulants and food  (especially of such
food as specially invokes the stomach for its digestion) can do the
organ itself aught but harm.
   The other variety of subacute  inflammation of the stomach is
no doubt far  more frequent, as well as much more strictly entitled
to the term of chronic  inflammation.  Perhaps the best instances
may be seen  in delirium tremens.  As usually witnessed in  hospi-
tals, this malady may be roughly grouped under two heads, accord-
ing as it is produced by acute or chronic drunkenness: by a single
long debauch, or by a protracted  habit of tippling, ending  in the
patient's  breaking  down  under a  deficiency of proper  food, or
habitual  stimulus.   Now,  though these two  kinds  of delirium
tremens merge into each other by infinite gradations, their ordinary
distinction is very characteristic and important, both  as regards
diagnosis and treatment.  The first is generally associated with a
thickly coated tongue, and with an amount of  vomiting, pain, and
tenderness in the epigastrium, indicative of gastric inflammation;
the latter is  often quite devoid of such symptoms.   The first, in
short, is  delirium, associated with (and  doubtless aggravated by)
gastritis;  it requires counter-irritation to the epigastrium; it sug-
gests the guarding  of any opium which is administered by ipeca-
cuan or  tartar-emetic,  and  the  sedulous use of simple aperients;
while it  contraindicates (at least such  is my opinion)  the  use of
the habitual  stimulants in any but  minute and largely diluted
doses.   The  second is exactly opposite to it in all these respects.
 .. Now if, in  the  first of these two forms of delirium tremens, the
patient dies, what does the necropsy show us?   Sometimes patchy,
irregular  congestion, of varying  intensity; occasionally a  more
diffuse and less vivid color; occasionally even a scanty extravasa-
tion of blood, dotting the summits of the gastric ridges with spots
of variable  size.  And occasionally these  hemorrhages surround
points denuded of all epithelial structures, if not occupied by  down-
right ulceration; which,  indeed,  unless you  examine the  body
remarkably soon after  death, they easily simulate, owing to their
being eroded by the gastric secretion.   But none of these phenomena
are constant.   And in  some of the best marked cases of this kind
I  have  ever  examined, though the  mucous membrane has been
thicker, whiter, and more  opaque than natural, it has been singu-
larly healthy-looking in every other  respect, and has afforded me
an artificial gastric juice of remarkable potency.
   It is obviously possible that in such cases the exudation usually
evidencing the inflammatory state may have been completely got
rid of by a kind of desquamative process during life.   It is equally 
GASTRITIS.
87
possible that the vascular phenomena are materially influenced by
the agony of death, and by those readjustments of the circulating
fluid,s which immediately succeed this event.   But, on  the other
hand, mere desquamation or shedding of epithelium is so common
an occurrence (both in the stomach of the human subject, indepen-
dently of all gastric disease, and in animals killed1 while in perfect
health), and the above peculiar pale opaque condensation of the
mucous membrane is so unusual, save in this disorder, that it  may
be  conjectured to  have some specific relation to the symptoms
referable to this organ during life.  And if future researches should
corroborate  this conjecture, we may rjerhaps explain so singular a
variation from the ordinary phenomena  of inflammation as due in
great part to the effects (local, constitutional, or both) of the alcoholic
poison on the stomach itself;  giving rise to  irritation, at the same
time  that it checks and prevents those  processes of growth and
waste which, however abnormal in the  form of an  exudation,
doubtless tend  to relieve and cure the  inflammation that excites
them.
   Even  the commoner varieties of chronic inflammation maintain
somewhat of that relation to the function of the stomach which we
trace in these effects of poisoning.   Especially  does this seem to be
the case  with  those forms of gastritis which are  produced by un-
wholesome  food and  drink;  a class of cases which doubtless con-
stitute a vast majority of the less  acute inflammatory attacks to
which the stomach is liable, and which are probably a very frequent
cause of some varieties of dyspepsia.2
   It is to Dr. Beaumont3 that we owe our most specific information
as to the details of this inflammatory process.  But for the unique
opportunity he enjoyed of watching the changes that occurred from
hour to hour in the stomach of St. Martin, it would have  been  long
before the complex appearances seen in the dead stomach would
have entitled us to infer the  frequency of chronic inflammation in
this organ;  far less the nature and rapidity of that process by which
its symptoms arise, progress,  and terminate in  recovery.
   The evidence of inflammation he thus observed seems quite com-
plete and incontestable.  The pale pink color natural to the mucous
membrane of the healthy stomach was exchanged for a  somewhat
livid erythematous redness;  which was distributed throughout the
organ in irregular patches of various sizes, and in its most intense
form amounted to a kind of ecchymosis or extravasation of grumous
blood.  Secretion, too, was arrested; as was shown by the want of
all flow of gastric juice on the introduction of food, as well as by
the complete absence of mucus in  the fasting state of the  organ.
Lastly, he noticed what, in inflammations of mucous membrane, is
tantamount to  exudation; namely,  an overgrowth of epithelium,
forming patches of false membrane, which, often very well marked
' Compare p. 75.          2 See Lecture VI.         s Op. cit. 
88
GASTRITIS.
at the edges of the  erythema or  extravasation,  were elsewhere
visibly distended (or separated from their basement membrane) by
a puriform fluid,  giving them the appearance of sharp-pointed,
white pustules.  The subsequent  abrasion of these patches or pus-
tules of course set free their muco-purulent contents in the cavity
of the stomach, as well as the rolled-up shreds that had previously
inclosed them.   These local changes  in the  stomach were accom-
panied,  in their worst degrees and earlier stages, by pain  at the
epigastrium  and  sternum; nausea;  a furred  tongue; headache;
vertigo;  loss of appetite; constipation; and soreness or tenderness
at the pit of the stomach ;  the latter symptom often lasting longer
than any of the others.  But in slighter degree, they were almost
unattended by any symptoms whatever.  And even when tolerably
well marked and  persistent, they  were not incompatible with a
tolerable (or even craving) appetite.
  Such characteristic evidences of inflammation, taken in connection
with the above  symptoms—and  especially with the fact  that the
process may and does occur without symptoms at all—naturally
suggest that much of the dyspepsia met with in practice is  to be
referred  to what is thus, in every  sense, chronic  gastritis.   More
than this, however, we are scarcely entitled to assert on the slender
(though  valuable) materials now at our disposal.   That it is not
merely in alcoholic poisoning, or in the dyspepsia of drunkards,
such a process takes place, is sufficiently shown by Dr. Beaumont's
multiplied observations; where  it is recorded as having occurred
on  different occasions, with scarcely  any variations but  those of
intensity, from various causes; excess in respect of alcohol; of food;
of exercise after meals; of condimentary substances (mustard); and
lastly, of mechanical irritation, incidental to his experiments.  As
some of these are precisely the causes to which we shall hereafter
trace  ordinary dyspepsia, they strengthen our suspicions that this
malady is often due to a similar  process.  But at present we are
scarcely  entitled to  any definite  and general conclusions of this
kind; the less so, that we shall find some varieties of the malady
appear to claim a different origin.
  Indeed, we must be careful not to strain such analogies too far;
or rather, not to regard  one class of  them too  partially or exclu-
sively.  Even in this very alliance of gastritis and dyspepsia, which
is established by Dr. Beaumont's observations, and is confirmed
by experiments  on animals,1 we may trace something more than
an analogy to the effects of the less powerful irritant poisons; from
which, indeed, however we classify them, we should find it difficult
to exclude such substances as raw alcohol, or even mustard, pepper,
and other  condiments.   In short, we come  to something like a
general  conclusion with  respect  to  inflammatory affections of the
gastric mucous membrane; namely, that whatever may be  those
1 As in dogs with gastric fistula. 
GASTRITIS.
89
modifications of the process of inflammation  in  this tissue, which
our means of investigation do not allow us to appreciate, distinct
and  satisfactory evidence of its  occurrence  is almost limited to
cases in which a direct irritation of the organ has been either the
remote or exciting cause.  In other words, all the more  obvious
phenomena of gastric inflammation seem strictly incidental to the
function  of the organ—a statement for which we might  perhaps
find a parallel in true hepatitis and nephritis; and for which we
have but a doubtful contrast even in the case of such comparatively
lowly organized and inactive  structures as serous  membranes and
areolar tissue.
  Hence, then, it is only in a  very restricted sense that we can
speak of the stomach  as enjoying almost an immunity with respect
to acute  inflammation, while extremely liable to the subacute or
chronic variety of  the process.  While there may be varieties of
both acute and chronic gastritis, the rarity and obscurity of which
have allowed them hitherto to elude our research, the two forms
with which  we are acquainted appear to merge  into each other
(both in respect of  their pathology and symptoms) by infinite gra-
dations.   And although it is impossible to deny the great distinction
between  an  excessive  meal and a dose of corrosive sublimate, or
to doubt that, by defining what is relatively excessive, the state of
the constitution is really a cause of the resulting chronic inflamma-
tion;  still the circumstances of digestion—the  mechanical  and
chemical changes  the food should  undergo, and the spontaneous
decomposition which  mere deficiency of secretions can permit—go
far to explain how the constitutional  or  remote cause may bring
about a local or immediate one, in the shape of a gastric irritation.
  Any  more detailed explanation  of  the scanty  share taken by
idiopathic inflammation  in the  maladies of  the  stomach, would
perhaps be out of place here, as it certainly would  be premature in
the present state of our knowledge.  But  we  have already alluded
to the rapidity with which all evidence of the process is removed,
owing to the effusion of its products on a free mucous surface.   And
the contrast afforded by inflammations of some other organs  indi-
cates how this favorable position of the gastric membrane  not only
wards off a variety of perils, but absolutely tends  to check or pre-
vent a continuance of the inflammation.  Just as, in bronchitis, a
patient runs an imminent risk of suffocation from the mucus poured
into his respiratory organ; or, in nephritis, is in danger of uraemia
from the analogous obstruction caused  by  an inflammatory effusion
into the  minute tubes of his kidneys;  just as in  haemoptysis and
renal haematuria, the  mere effusion of  blood  sometimes provokes,
or at least augments, inflammation—so, conversely, we may conjec-
ture that, in the digestive canal, the speedy removal of all effusion
often limits the inflammatory process itself.
  Whether any part of this immunity is specifically gastric, and is
connected with the solvent action of the  stomach on  the protein 
90
GASTRITIS.
compounds, I hardly dare to inquire.   But we  may bear in mind
the density of the matrix  in which the cylindrical stomach tubes
are packed side by side;  and the repletion of these  tubes with a
twofold cell-growth,  such as allows no exudation from the sur-
rounding capillaries  to reach their minute calibre, save through a
thick mass of pepsinous cells, and a thinner but more solid layer of
smaller cells.   And  while, on such a  structure I would found  a
plausible conjecture  (remember, a conjecture only) why inflamma-
tory exudation .rarely involves  the whole mucous  membrane,  I
cannot forbear adding, that careful researches  entitle me to con-
clude that, in  all the more  subacute varieties of gastritis it is the
free mucous  surface—the  inter-tubular  ridges, the stratum of
columnar epithelium belonging to them and to the open mouths of
the tubes, and the subjacent vessels—which  the inflammatory pro-
cess chiefly, if not exclusively, affects.
   Whatever the cause of  this immunity, there can be no doubt as
to its effect; or as to the extreme  importance of an organ like the
stomach being little liable to any profound or general  disturbances,
such as an acute gastritis would involve.  Dangerous and barren
as are all  speculations on " final causes," when we find a complex
(and at least dimorphous) glandular structure  (the destruction of
which would  bring with  it the  loss of a function essential to life,
and incapable of replacement by any other organ of  the  body)
protected  against a process which in  some other organs (as, for
example, the skin) is neither rare nor dangerous, it is  surely legiti-
mate to comment upon the value of the  arrangements (whatever
they may be)  by which this immunity is secured.   The more so
that (as these imperfect  allusions have informed  you) in those
milder  and commoner varieties  of inflammation  to which  the
stomach really is amenable we trace a kind of offshoot  of its healthy
office.  That  derangement of the stomach which we  stigmatize as
chronic or subacute gastritis, and which really is a wide departure
from health, may be  viewed from another point of view as a minis-
ter of good—as a regulator of gastric digestion; an instrument which,
by diminishing or  suspending  over-taxed or  excessive function,
and removing or exhausting the results of local  injury, affords an
important protection, both to the organ  and to the organism at large.
And we have seen that its details seem to be in  exact accordance
with such a duty—that it is not  only easily provoked, but also that
it extends superficially, without increasing in depth; avoiding, as it
were, the deeper gastric structures, and thus at once  pouring out
its products into a cavity, which permits  them a speedy dismissal
from the body.
   The treatment of gastritis corresponds so specifically  to the nature
of the particular case, that a cursory  view of it may suffice.   Of
course the removal  of  the cause is its first indication: to be at-
tempted, in the acute gastritis of poisons, either  by their removal
from the organ or by their neutralization there; in chronic gastritis, 
GASTRITIS.
91
by  the  remedies and the regimen which we shall hereafter dis-
cuss more fully in speaking of dyspepsia—a disease  from which
such inflammation  is often indistinguishable.  The further object
of our efforts—namely, that of moderating and limiting the existing
mischief—is chiefly to be accomplished by attempting the removal
of the more prominent symptoms present.  Among the exceptions
to such a rule we may notice the vomiting of acute gastritis, which
often demands encouragement rather than suppression, owing to its
beneficial effect of expelling the poison contained in the stomach.
A similar exception may be found in the vomiting which sometimes
attends the slighter inflammatory phenomena of a casual surfeit or
indigestion.
  The remedies most useful in this respect are precisely the most
valuable in abdominal inflammation generally.  Depletion is only
required in cases of great severity; and even here, is best limited
to the application of leeches to the epigastrium.  Counter-irritation
is much more important, being admissible in cases where the con-
tingent general action of a poison, or the exhaustion of the patient,
would forbid the abstraction of blood.  Here turpentine stupes,
mustard poultices, or flying  blisters, may sometimes replace ordi-
nary blisters with advantage.  Akin to  the effect of these is the
extreme benefit derivable from continuous fomentations; which, to
afford  much relief, often require to be quite as  hot as the patient
can bear  them.  In the converse  application (or introduction) of
cold substances to the  inflamed stomach, we can  scarcely have a
better guide for our decision than the feelings of the sufferer as to
the relief they afford.   Iced  water, or small lumps or raspings of
ice, seem to allay thirst, and appease pain,  even in the severest
cases.
  As to sedatives, of course the gastritis of acute poisoning must
be  treated with reference to the particular agent; the depressing
or  narcotic properties of which often forbid the prescription of
remedies whose effects  might stimulate  and obscure the existing
symptoms.  In  other cases,  they are  indicated chiefly by pain;
and opium (preferably  in a watery solution of the extract) main-
tains its usual supremacy.   In slight or chronic inflammation, the
remarks hereafter made in reference to the use of sedatives in dys-
pepsia may suffice.
  The  use  of aperients in gastritis demands great  caution.  For
the constipation which obtains in acute cases is often almost a pro-
vision  of nature against a  hurtful action.  While, on  the other
hand, all experience indicates that the removal of the  secretions
and other contents accumulated in  the  bowels greatly relieves an
irritated or inflamed stomach.  I believe the best rule is one which
steers clear of either extreme, as well as of a mere routine exhibi-
tion of agents so powerful for good  or evil.  When there is reason
to believe  inflammation has extended to the peritoneal coat, the
use of  aperients is to be avoided.  In  other cases, find out (by 
92                        GASTRITIS.

verbal inquiries, and by a physical examination of the belly) what
degree of accumulation is present, and let this guide your conduct
as to removing it.  If you venture to give the aperient by  the
mouth, you will of course avoid whatever would  irritate the sto-
mach; and  are therefore, practically, almost limited  to  castor-oil.
In many cases it is preferable to give it as an enema.   And you
may secure almost any reasonable degree or  extent  of  action on
the bowels by combining, with a full dose of castor-oil, a little tur-
pentine, or even a drop of croton-oil;—a mode  of administering
the latter energetic purgative which I have long adopted to  the
exclusion of every other, because it  seems to secure all its advan-
tages, and avoid all its inconveniences and risks.
  You will observe that this meagre outline avoids alike the details
of treatment suitable for acute poisoning on the one hand, and  for
inflammatory dyspepsia on the other:  forms, in short, an unsatis-
factory diagonal between these  two converging sides of gastritis.
But this  mode of considering it (which is all that is either requisite
or possible here) is yet strictly clinical.  For we do sometimes meet
with cases in which the  diagnosis and treatment require us to be
equally acquainted with either:  and ultimately bring us to some-
thing equidistant from both.  A few months ago, I was  consulted
by a young  man  for symptoms of subacute  gastritis, which had
commenced about four days before with  catarrh and sore-throat.
The epigastrium was exceedingly tender:  and was  occupied  by
pain of such severity, that it " drew him double," and kept him in
this bent  posture,  unable either to lie or sit.  It was accompanied
by frequent vomiting,  and by obstinate  constipation.   A  careful
inquiry (especially directed  towards poison)  at  last elicited the
nature of his case.  He was the victim of domestic medicine.  A
well-meaning friend had prescribed  for his cold a teaspoonful of
" nitre," to be taken occasionally; and instead  of the Spt. ^Etheris
Nitrici, which formed the traditional prescription, he had  taken the
powdered nitrate of potash, in doses which a careful  comparison
showed to be about fifty grains.  The administration of castor oil
and opium, followed by warm fomentations, speedily got rid of all
his symptoms.

  To the foregoing remarks I append a brief notice of three other
affections of the stomach; which, in respect of their nature, symp-
toms, and  appearances after death,  must  be  regarded  rather as
varieties  of subacute  gastritis,  than as  specific or  independent
diseases.
  Thus catarrh of the stomach, often announced during life by little
more than indigestion,  and indicated after death by evidence some-
what equivocal, off'ers us, in well-marked  cases, phenomena closely
analogous to those of  chronic or subacute inflammation in  other
mucous membranes.  Among its more prominent symptoms  are
a feeling of weight  or heat in the  epigastrium, sometimes amounting 
GASTRITIS.
93
to pain, but even  then rarely associated with great tenderness to
pressure;  anorexia and nausea, the latter sometimes developed into
vomiting, but oftener stopping short of this act, as a regurgitation
of a more or less glairy alkaline fluid;  and, with these local symp-
toms, variable degrees of flatulence and constipation (rarely diar-
rhoea) ; together with the ordinary signs of constitutional reaction—
among which a furred tongue takes the precedence1 characteristic
to this symptom in gastric maladies generally.
   The moderate gastric derangement indicated  by such symptoms
is rarely  or never dangerous to  life.  And hence  it is only the
casual death of the patient, from some intercurrent malady, that
affords  us any opportunity of investigating those changes in the
gastric tissues by  which these symptoms are provoked.
   Necropsies of this kind often show the mucous  membrane of the
stomach covered, to a variable extent and depth, with glairy mucus
closely resembling that regurgitated or vomited during life.   And
beneath  this  mucus (which, by the way, varies greatly in  trans-
parency as well as viscosity) we  find a somewhat  thickened  and
spongy mucous membrane; the  increased  bulk  of which is due,
sometimes to a mere serous infiltration (as shown by its pale whitish
or grayish color), but  oftener to marked vascular congestion  (as
shown  by its deep red, slaty, or even blackish hue).   In other
respects,  however, it is quite healthy.
   But to each of these three statements  I must add  one or  two
details, from my own researches.  The glairy alkaline mucus is, in
great part, salivary.  And though it often affords, to the microscope,
a certain  quantity of cell-growth, evidently consisting of the col-
umnar epithelium of the stomach, aborted at various stages of its
development, as well as (less considerably and frequently) of an
admixture of bile; yet I  confess myself quite unable to estimate
the significance of either  of these two admixtures.  Recalling to
you what has already been said of the shedding of this epithelium
after death (p. 76), and reminding  you of  the  natural presence of
saliva and bile  in  the stomach,  I may own that the detection of
even a larger quantity of  such mucus would fail to convince me,
that  we have here a  morbid process of secretion, specific to this
disease, and comparable to bronchial or nasal catarrh.
   The color  and consistence of the subjacent  mucous membrane
itself are so various in different cases, that it is scarcely possible to
sum  them up  in one common  description.   Not only  do these
stomachs show us every  shade  of congestion, from the slightest
increase  of natural color  to  a  very decided  purple  or blackish
lividity,  but the width and depth to which this congestion extends,
as well as the abruptness of its demarcation from neighboring parts,

   ' A precedence, of course, belonging t'q it, not so much as a constitutional symp-
tom, as a condition by which the tongue sympathizes (often shares) in the derange-
ments of a  mucous membrane absolutely continuous with itself. 
94                       GASTRITIS.

are subject to infinite variety.  Sometimes it claims a large propor-
tion of the organ, sometimes  is very limited ;  sometimes it is chiefly
pyloric, sometimes affects the more suspicious (compare pp. 73, 76)
regions of the cardia and the posterior surface;  sometimes it in-
volves  all the vessels down  to the  submucous  plexus (p. 33),
oftener  (as it seems to me) is limited chiefly to the superficial capil-
laries {b, Fig. 9) and their immediate inosculations;  sometimes it "
shades off into a comparatively uncongested (if not  rather exsan-
guine) part, oftener is contrasted by a tolerably marked  outline
with  a  generally red surface.   Extravasation is rare, even in the
most  deeply colored parts: from which, in many cases, moderate
pressure partially  or completely removes  the color,  by propelling
the blood into neighboring vessels.  The moist spongy thickening
above ascribed to serous infiltration is both less marked, and less
constant, than vascular congestion; but, if present, is, on the whole,
more regularly diffused throughout the organ.
  The otherwise healthy condition of the mucous membrane is, I
am aware, a fact which stands in contradiction to the statements of
some able observers.   But with proper precautions, stomachs which
offer well-marked appearances of the kind just described, will often
show, a tubular structure perfectly normal.  And it  is my impres-
sion that the degeneration and disappearance of the gastric tubes,
and the alteration or loss of their cell-growth,  attributed to these
cases, are essentially the results of circumstances, which we have
already alluded to as liable  to occur in the  examination of the
healthy organ, and which  are necessarily  furthered  by the condi-
tions present in these cases: a statement which  may be extended, I
think, to some instances of supposed multiplication of the lenticular
glands (p. 29).
  A careful review of the details just summed up perhaps justifies
us in suspending our judgment as to the nature (or even the sub-
stantive existence) of gastric catarrh, until larger and more exact
information is before us.   At any rate, such  a study of the malady
throws doubts upon its apparent frequency, as seen in the dead body.
  Thus, the symptoms during life are common to many gastric de-
rangements, to most forms of subacute inflammation, perhaps even
to dyspepsia not essentially gastric.  And  in cases presenting these
symptoms we can very rarely confirm our diagnosis by necropsy.
  Turning to the appearances after death, we find, that in some of
the cases in which they are best marked, there have been few or no
symptoms of gastric derangements during life.  Against this, how-
ever,  we  must adduce the facts:  (1) that the  character of these
symptoms would often allow them to be completely outweighed by
those of the graver disease of which the patient  was dying;  and (2)
that Dr. Beaumont's observations conclusively show how conditions
closely  allied to this malady (and even exceeding it in  severity) may
occur with scarcely any symptoms.
  Appearances not preceded by symptoms are deservedly suspected 
GASTRITIS.                       95
by the pathologist, and certainly have no direct claim on the atten-
tion of the practical physician.  And when we find  some of these
appearances doubtfully gastric, while others are at least partially
imitated by  the processes of death and decomposition, it really
becomes our duty carefully to avoid reducing the information they
afford us, to a systematic description of a disease.  Hence,  though,
in so  far as these appearances transcend those produced by the cir-*
cumstances which attend and follow death, they must obviously be
regarded as morbid, while the mere obscurity or absence of symp-
toms  is at least partially explained as above; yet I would ask you
to pause before admitting gastric catarrh to a nosological rank like
coryza, or even leucorrhcea.  Careful histories of the symptoms of
cases, checked by a speedy  and sedulous examination after their
accidental  death—these are the facts which we want, and which
perhaps some of you may hereafter have the opportunity of sup-
plying.  Waiting the collection of such facts, the subject of catarrh
of the stomach is, I think, still sub judice.
   Hemorrhagic erosion, a more severe  and dangerous affection than
the preceding, affords, to a similar inquiry, analogous doubts.
   In  well-marked cases its symptoms are sufficiently distinct.  There
is great  pain and tenderness in the epigastrie region; often accom-
panied by pain in the back  (p. 54), and increased  by the ingestion
of  food; but  scarcely exhibiting any absolute intermission in  the
intervals of meals.   Yomiting is usually both frequent and severe;
and often occurs with an empty stomach, or on  rising from  sleep,
as well as after a meal.   At variable (in many cases frequent) inter-
vals,  this vomiting brings up blood ; usually in but moderate quan-
tity ;  and neither clotted, on the one hand, nor blackened on  the
other;  but copious streaks  and  patches of blood,  mingled with
mucus and bile.  The appetite is greatly affected; in the exacerba-
tions of the malady, almost suppressed.  Lastly, the constitutional
symptoms are in most cases proportionately severe; though  the
constipation, the furred or  occasionally aphthous tongue,  and  the
violent febrile reaction of a severe remission, sometimes merge, on
its subsidence, into degrees scarcely exceeding those seen  in ordi-
nary dyspepsia, and are accompanied  by the milder symptoms of
headache and flatulence.  The malady may last for months, or even
years:  a duration which (to judge from my own  clinical observa-
tions) may often be ascribed to the persistence of the habit to which
it appears not infrequently due, namely, dram-drinking.  It is rarely
fatal, except by either inaugurating other lesions in the stomach, or
by concurring with some more general malady.
   I shall not dwell on the details of the above symptoms, which
are subject  to many exceptions, as well as  to unnumbered grada-
tions.  Their significance will better  appear by contrasting them
with  the various corresponding symptoms  of gastric  ulcer, fully
described in my next lecture.
   The  appearances found after death  in characteristic examples 
96                        GASTRITIS.
like  those described above, quite justify the term "hemorrhagic
erosion."  On laying open a stomach thus affected, we find it occu-
pied by a variable quantity of blackened or grumous blood, mixed
with what is generally a larger quantity of  mucus, and (less fre-
quently) with a little  bile.   Removing  these fluids by  a gentle
stream of water, brings into view  a number of minute  shallow
excavations  on the surface of the mucous membrane.  These ex-
cavations (which exactly resemble ulcers in the fact that they evi-
dently correspond  to a true loss of substance of the tissue) have an
irregular, but sharply defined margin, rarely  elevated above the
neighboring healthy membrane.   Their  shape approaches a circle
or oval.   Their ordinary size varies from that of  a mustard-seed
to that of a pea.   Both their base and margin generally  have ad-
hering to them a variable  quantity of more or less  clotted and
blackened blood.   Traced out under the  microscope, they afford
indications of being, in most  cases,  the result of a process, which
begins at the inter-tubular ridges {a, Figs. 6, 7, pp. 27, 29) of the
mucous membrane, and the successive stages of which—congestion,
ecchymosis  or extravasation,  abrasion, and ulceration—may often
be seen in  different parts of the same stomach.   The occurrence
of ulceration, or what  seems to be such,  is apparently followed by
its spreading both horizontally and vertically.   But in the majority
of cases, the superficial extension so far  preponderates,  that the
breach of substance is of much  greater width than depth.  Still,
in many of  the best marked  specimens, the  gastric tubes are de-
stroyed  throughout great  part  of  their length;  and sometimes
appear here and there completely removed.   The vessels of the
margin of these excavations or erosions are almost  always gorged
with blood.   And  this apparently intense congestion,  in  concur-
rence with the mechanical results of the  lesion in its earlier stages,
seems to afford a  partial  explanation  of a peculiar appearance
(compare p. 64) which is occasionally seen in  such cases; and in
which the blind ends of the partially destroyed tubes are found to
be filled with blood, suggesting at first sight a specific hemorrhage
from the capillaries surrounding these extremities.
   Combining these appearances with the preceding symptoms, it
is impossible to doubt  that they depict a grave malady; which Is
often distinguishable in  the living  subject;  and which, in respect
to its  nature, must be regarded as an ulcerative  gastritis.   And
comparing it with gastric ulcer, its history and symptoms represent
it as a variety of ulceration more generally inflammatory, perhaps
even more strictly constitutional, than the circumscribed or aggre-
gate form of ulcerative lesion; to which  (if I may venture on such
an imperfect comparison) it  has somewhat the analogy of a severe
skin disease to a cutaneous ulcer.
   But while the very same pathological considerations which thus
define hemorrhagic erosion as an important variety of gastric dis-
ease, also explain  how, in actual practice, both its diagnosis and 
GASTRITIS.
97
treatment continually merge into those of inflammation and ulcer
respectively, they suggest some  doubts as to  the  nature of many
cases which can scarcely be distinguished from it.
   We have already noticed (p.  72, et seq.) that a considerable de-
gree of congestion is often observed in the healthy stomach after
death; and that now and then this congestion—which is often asso-
ciated  with a  shedding or abrasion of  the columnar epithelium
(p. 76) covering the vessels chiefly concerned—amounts to what is
really an extravasation (p. 90).   Dr. Beaumont's observations have
also  (p. 88) been referred to, as showing that an  amount of hemor-
rhage  and abrasion very similar to this occurs during life, as a
casualty in the history of the stomach; that it is producible by gas-
tric  irritation, is evinced by symptoms of dyspepsia, and that  (in
accordance with the rule—amotd causd, tollitur effectus) reasonable
prudence would often suffice to insure its complete and rapid dis-
appearance.  Similar (but more marked) appearances are occasion-
ally  found in the stomach after  death  from a  variety of diseases j1
the history of the last few days of life also revealing severe gastric
symptoms (including vomiting of blood), such  as conclusively show
the lesions to have preceded death.   And though, in most of these
cases,  the site  of the  hemorrhage and abrasion  affords, to the
minutest  inspection, no  trace of that loss of substance mentioned
as specific to hemorrhagic erosion;  still it must be owned that we
do sometimes  detect appearances of this kind,  and that, even  more
frequently, the most painstaking observer ftiight hesitate to pro-
nounce a decided opinion for or against the presence of ulceration.
   From such analogies, we may pass on to consider the facts on
which we have mainly to decide the nature of  a very frequent class
of appearances in the stomach.   In the necropsy of subjects dying
from a great variety of diseases, we sometimes  meet with  appear-
ances suggestive of  " hemorrhagic erosion."  A careful inspection
shows that many of these cases are disentitled to  this term: inas-
much  as the mucous membrane is not eroded, but abraded; while
both as regards its extent, and the tissues it involves, the  lesion is
quite different from that which this  term would connote.  And
even among the remaining cases, in which the  hemorrhage seems
to be accompanied by a true erosion—by a loss of substance, not
merely involving the delicate epithelium, but  excavating the base-
ment membrane and its subjacent tissues—there is a large propor-
tion in which  the evidence of disease is  but  equivocal.   For the
appearance is  suspiciously frequent;  and is  often unattended  by
any  gastric symptoms during life.   On the other hand, the presence
of a  mortal disease, in an advanced  stage, may  well mask the symp-
toms of all slighter  mischief.  And the absence of the characteris-
tic vomiting of blood is often explicable by the  considerations (p. 62)
which apply to the failure of such evidence of  hemorrhage in other

       1 Chiefly inflammatory diseases of neighboring abdominal viscera.
       7 
98
GASTRITIS.
 maladies.  But, on the whole, the circumstances of gastric decom-
 position  suggest great doubt as to  the truly ulcerative origin of
 these appearances.  How far the solvent  power of the gastric tis-
 sues  or  secretions may assist  to convert  abrasion  into erosion
 during life, is a  question which is  still quite in abeyance.  But
 that some such change  is occasionally effected after death seems
 (to say  the least) very probable; though the acceptance of this
 opinion still leaves us in doubt whether the congestion, hemorrhage,
 and abrasion, are not themselves  evidence  of a condition  in the
 living tissues, differing from true hemorrhagic erosion in  degree
 rather than in kind.
    Follicular ulceration, as another variety  of the ulcerative process,
 requires notice chiefly in a pathological point of view.   For as a
 malady of the stomach, discoverable by symptoms, and unconnected
 with other and  more constitutional diseases, it is even less frequent
 than the foregoing:  the appearances which reveal it in necropsies
 being almost confined to subjects  dead of maladies in which the
 process is certainly but a rare and an exceptional incident.  Of all
J such maladies,  phthisis is that in which it is most frequent; and
 next to this disease come the exanthemata and the acute parenchy-
 mal inflammations.
    The symptoms of its rare idiopathic cases are sufficiently alluded
 to by the statement that, comparing it with  hemorrhagic erosion,
 hemorrhage is (as we should expect) much less frequent and marked;
 and that  the other indications of gastric mischief (both local and
 constitutional) are, though irregular,  on the whole, less prominent.
 The principles  of its treatment are exactly those hereafter  laid
 down for gastric ulcer.
    On examining  a good  specimen of the  lesion, we see a number
 of minute ulcers, which are scattered over the stomach with vari-
 able degrees of  closeness; and, as a rule, are perhaps more numer-
 ous at the lesser curvature than elsewhere.  Their  width is usually
 smaller,  and their depth much greater,  than the corresponding
 dimensions of the hemorrhagic erosions.   From this circumstance,
 their edges are more sharply cut, and vertical; occasionally some-
 what  prominent;—an  appearance which, however, is  rarely or
 never due to any solid deposit.   Occasionally, their base and mar-
 gin have clinging to them some blackened  blood and mucus.   But
 generally, the quantity of such mixed liquids is so small, that these
 stomachs easily  clean into the  elegant preparations of this kind
 contained in some of our London museums of pathology: the gastric
 surface between the ulcers, and the other coats of the organ, being
 often particularly free from alteration.
   Even in respect  to these appearances, we may question whether
 the process of ulceration during life is not  in some degree aided by
 one of gastric solution after death.  But it is chiefly in regard to
 the term  " follicular"  that pathological anatomy throws  a  doubt
 on the accuracy of our existing views.   It is possible that (as the 
GASTRITIS.
99
nature of some of the associated diseases would suggest) ulceration
of this kind is at times dependent on a process akin to that which
affects the solitary and agminate follicles of the typhoid or tuber-
culous intestine: a  process  involving the lenticular glands which
are the  gastric analogues of these  follicles.   But there are  good
reasons for supposing that this is rarely the case.  Indeed, in many
instances,  the co-existence  of healthy lenticular glands, and the
shape, size, and depth of the ulcerations themselves, together afford
a conclusive negative to such a view.  And similar anatomical
grounds may be adduced for denying to the ulcerations a " folli-
cular" origin, in  the sense of their being specially concerned with
the gastric tubes.1   Observations of this kind have long led me to
the opinion, that, even in this form of ulceration, it is on the free
surface of the stomach (or the inter-tubular ridges) that the process
commences; and that, as regards  the majority of cases, we should
probably not only gain in accuracy, but avoid a downright error,
by adopting an unassuming  botanical adjective,  and naming them,
not " follicular,"  but " punctate" ulcerations.

  1 In the anatomical description of both the stomach and intestine, it would be a
great advantage if the terms " tube" and " follicle" were attached to distinct struc-
tures, the latter (as its etymology suggests) being restricted to the closed sac
formed by the lenticular or solitary gland.  (Compare Cycl. Anat., Suppl., p. 356.) 
100
VI,iss.MtMiic.il ColU'^v
                       LECTURE  III.

                       Ulcer of the Stomach.

  The disease known  under this name  may be said to  claim  pre-
cedence over all the other affections of the stomach; uniting,  as it
does, various features  of  scientific and practical interest nowhere
else found associated.   For we can say of it—what we certainly
cannot of any other gastric malady—that it occurs very frequently;
that it may generally be diagnosed in the living subject; that it
runs a protracted course, at any stage of which it may be suddenly
fatal; that it is usually eurable ; and finally, that it is the result of
a specific structural lesion such as can be at once  detected by an
examination of the dead body.   Furthermore, it will often be found
in practice that the diagnosis of cancer, dyspepsia, or chronic in-
flammation, requires a process of induction which generally amounts
to (and sometimes specifically includes) a reviewal of the phenom-
ena of ulcer of the stomach, before rejecting it as the explanation of
the symptoms present.
  AYhat I have  to say about the symptoms of gastric ulcer is de-
rived almost exclusively from  two sources:—the records1 of about
1200 cases, often  affording a mere outline of the chief  symptoms,
but always verified by careful necropsy; and the personal study of
more than 200 cases, affording minute details respecting  symptoms,
but only verified by necropsy in a small proportion of that num-
ber.  The  information derived from these two sources  has shown
me  none but negative discrepancies;  in  other words, none  but dif-
ferences  chiefly explicable by the unavoidable omissions  of  such
brief records.
  In what we may regard as typical cases, the history  of ulcer of
the stomach is made up of the following succession of symptoms.
  The malady is announced  by disturbances of gastric digestion:—
at first, mere uneasiness and  pain in the epigastrium ; then nausea
and vomiting, or  regurgitation, expelling the food previously taken,
or a tasteless or acid watery fluid.  At  this stage of the disease, it
is sometimes cut  short by the occurrence of perforation, "ending in

  1 In addition to the many hundreds of such records published as scattered cases
by scarcely less numerous observers, I have  to acknowledge larger  contributions
of materials from the various metropolitan Hospitals and Museums ;  and from
authors (Cruveilheir, Jaksch,  Dietrich, Rokitansky,  Dahlerup, Sangalli, W. T.
Gairdner, T. K. Chambers, Handfield Jones,  Habershon, and others), to whom I
have more specifically referred in the monograph (" On Ulcer of the Siomach,"
Churchill, London, 1857), from which much of this Lecture is derived. 
ULCER  OF THE  STOMACH.
101
fatal peritonitis.  Failing such an  accident, these dyspeptic symp-
toms are next complicated by hemorrhage from the stomach; some-
times a sudden  and dangerous gush, oftener a slow and intermittent
drain  of  blood.  The anasmia produced by this  hemorrhage  is
generally  associated with cachexia; which seems to be essentially
independent of it, being chiefly the result of the inanition necessarily
implied by frequent vomiting of the food, or by large_ destruction
of the gastric mucous membrane, and consequent impairment of its
function.  In young females, another symptom is often  present,  in
the form  of  more or less  complete amenorrhoea, which may be
associated with either of these two states of anaemia or cachexia;  in
other  words, may be referred to ulceration, to hemorrhage, or  to
both.
   The gradual acquisition of all these symptoms conducts the disease,
in  a  variable period of time, to  a climax, from whence we  may
next  briefly trace it  towards its termination.  Retaining the above
liabilities to death by  perforation, by hemorrhage, by vomiting,
and by exhaustion, the disease may at any time end byoneof these
modes of dying, or by two or more of them in combination.   In
other cases, a  spontaneous subsidence of the foregoing symptoms,
in  something like the inverse order of their occurrence, announces
a recovery; or a similar  amendment is only effected  by careful
medical treatment, such as quite  entitles us to dignify it by the
name of  a cure.  In less numerous instances these symptoms con-
tinue with what is (for obvious reasons) rarely more than a moderate
 intensity, during a variable period of  life;  in  the course of which
 their  uniformity is from  time to time varied by considerable fluc-
 tuations of severity.  The remissions which  form  one extreme of
 such  fluctuations sometimes merge into intermissions so complete,
 that  we  are left  in doubt whether the  process of ulceration has
 merely stood still, or has broken out  afresh after the cicatrization
 of the lesion.   In any  case,  the protraction of these symptoms
 during many  years of life gradually complicates  the  impairment
 of nutrition they produce, with  that naturally resulting from the
 approach of old age; mingled with which  they then constitute an
 indirect or conditionating cause  of death,  the influence of which
 can scarcely be estimated with any exactness.         #
    But the  symptoms alluded to  vary so remarkably  in  different
 cases that each of them demands a separate study.          <
    Pain  which is usually the first in the  order of occurrence, is also
 the most, frequent and characteristic of them all.   Indeed, we may
 doubt whether it is ever absent from the whole progress of any case
 For  though there seem to have been instances of gastric ulcer, fatal
 bv perforation, in which no pain was complained of prior to  the
 acute suffering that marked this event,  still it is obvious^ that we
 cannot assume the absence of so common a symptom as pain in  the
 redon of the stomach, merely because a  patient has failed to speak
 of it at the time, or to refer to it afterwards during a brief and ago- 
102
ULCER OF  THE STOMACH.
nizing illness.  But since I have seen one or two instances in which
the pain of a large ulcer has completely intermitted for several days
together, I think it just possible that this symptom might be absent
during the short period which sometimes includes the whole course
of the disease, in cases of rapid perforation.
   The character of the pain is peculiar.  Rarely or never does the
sufferer describe  it as1 lancinating, stabbing, or stitching.   In the
earlier stage of the disease, it is often little more than a feeling of
weight or tightness in the epigastric region, giving  the patient an
impression as though the food experienced a " stoppage" here.  From
such a dull, continuous feeling, it gradually augments into a burning
sensation,  and at  last into a gnawing pain, which produces a kind
of sickening depression, quite distinct from the  nausea often asso-
ciated with  it.
   The date of its access is  also characteristic.  In a majority of
cases it comes on from  two to ten  minutes  after  the deglutition of
food, and remains during the hour  or  two corresponding to the
period of  gastric  digestion,  at  the close of which act  it gradually
subsides  and  disappears.   And when,  as  is often  the case, it is
accompanied by vomiting, it almost  invariably  ceases as soon as
this act has emptied the stomach of its contents.   In some instances,
however, the pain immediately follows deglutition, instead of being
preceded by the usual interval of a few minutes.   Such a fact affords
a presumption that the cardiac extremity of the stomach is the site
of the lesion; a conjecture which is of course strengthened by
embarrassment in the act of swallowing, suggesting  its close prox-
imity to the oesophagus.   Sometimes the pain resembles that of an
ordinary form of dyspepsia, in coming on half an hour, an hour, or
more,  after  eating.  Lastly, in  what are  generally  either large
lesions or protracted cases—often  both—the pain loses the above
character; becoming continuous during  the intervals of the meals,
and lasting days or even  weeks without any intermission: or it even
occurs chiefly on an empty stomach, and is alleviated by the inges-
tion  of food.
   The situation of the  pain  forms another of its characteristics.
The  place of its earliest appearance and greatest intensity, and to
which it often remains strictly limited, corresponds to the centre of
the epigastrium, or to the median line of the belly  immediately
below the free  extremity of the ensiform cartilage.   The portion
of the epigastric region  to which the pain is referred, forms a circu-
lar area of rarely more than two inches diameter; sometimes, indeed,
a mere spot of less than half this size.
   But there are exceptions to the above rule.  One of these, which
is not uncommon in the female, is  apparent  rather than real, being
due  to that change in  the  situation of the cartilages of the ribs

  1 This character would often distinguish the pain  that attends scirrhus of the
stomach. 
ULCER OF  THE STOMACH.
103
which is effected by the compression of stays and which materially
deepens the epigastric region  in the vertical direction.  In other
instances, the pain is behind the ensiform cartilage instead of below
it; or occupies the boundary of the epigastric and umbilical regions,
instead of its usual  site in the middle of the former.  Finally, the
pain sometimes lies a little to the right or  left of the median line;
or extends from a  point of greatest intensity here towards either
hypochondrium, or, in still rarer instances, is referred chiefly to the
latter situation.
  In some instances, the pain in the epigastrium is associated with
the feeling of violent pulsation or throbbing ;  in others, the same
sensation is felt, independently of the paroxysm of pain, which  it
may even replace.   It appears to be analogous  to the throbbing of
an abscess, and cannot be recognized by external examination.
  The dorsal pain,  first described by Cruveilhier, constitutes almost
as important a  symptom. It  generally comes  on  a few weeks or
months later than  the epigastric pain, and from this time forth is
almost as constant and characteristic, if not as distressing.   It is a
gnawing  pain, which,  ranging in position from the spine of the
eighth or ninth dorsal, to that of the first  or second lumbar verte-
bra, is usually " interscapular" as well as " rhachidian."   Like the
epigastric pain, it  has  a fixed seat, generally remaining near the
spot of its first appearance during the whole progress of the disease ;
and like it, also shows  lateral as well as vertical deviations from
its ordinary situation.   But these deviations rarely remove it to a
greater distance from the median line than one  or two inches.  Its
worst attacks generally alternate with those of  the epigastric pain.
  How far a vertical deviation of the epigastric  or spinal pain enti-
tles us to conjecture a corresponding situation for the gastric ulcer,
it is difficult to decide.   Still some cases on record indicate such a
connection:—pain in the umbilical region being, for example, asso -
ciated with an ulcer of the greater curvature.   But with respect to
horizontal deviations of these pains, there is good reason for assert-
ing that, if well marked, they justify our inferring a similar situa-
tion for the  ulcer.  Out of about  twenty instances of this kind
which I have collected, fifteen exemplify  the concurrence of pain
in the left hypochondrium with an  ulcer of the cardiac extremity
of the stomach ; and four or five illustrate the same connection be-
tween  the right hypochondrium and  the pyloric extremity of the
organ.  My own practice has also afforded me three or four cases,
in which a similar deviation led me to predict the cardiac or pyloric
situation of the ulcer during life.  But I have found that the more
localized character of the dorsal pain  makes it  a better test than
the comparatively diffuse epigastric  pain.  While I need scarcely
add, that a coincidence of the two in respect to  this deviation is a
far  stronger testimony than either  unsupported  can afford; and
that even such an  agreement requires to be confirmed by the pre-
sumptions derivable from the  other characters of this symptom. 
104               ULCER  OF  THE  STOMACH.
  Among the latter, we may first allude to  the effect of pressure
in increasing the pain.  This is, indeed, a very important test,
being one  which  (to speak  logically) converts what may be, for
aught we know, a subjective sensitive phenomenon, into an objec-
tive one that constitutes a far more trustworthy indication  of local •
disease.  To use the expression which  generally suggests itself to
the sufferer, there is a " soreness" as well as pain: the least pressure
in the epigastrium is sometimes unbearable ; the patient, if a female,
is even content to forego the fancied advantages of her stays, rather
than endure the pain which the central piece of whalebone in these
ingenious aids to  disease often  produces.  In most  instances  the
soreness  is exactly  limited to the painful part of the epigastric
region' already specified.   As it is produced by the more or less
direct application of pressure to the diseased structures, it is not to
be excited  by pressure on the unyielding spine.  But in general, one
and the same pressure on the epigastrium will excite both epigas-
tric and spinal pain: sometimes the latter chiefly or exclusively.
   Of course it is essential to use such a degree of pressure as shall
not involve parts more distant than the  stomach: a pressure, in
short, scarcely exceeding that with which we manipulate the belly
in cases of suspected  peritonitis or  colic.  I say this, because it
would otherwise be possible to make  strange errors.  Thus I have
known cases  of mere emphysema and  bronchitis, in which deep
epigastric  pressure caused considerable distress (easily mistakable
for soreness), apparently  from embarrassing the heart, which had
gradually been forced down into the upper part of this region.  It
is not altogether superfluous to add another caution with respect to
the above test.  Not only must it be applied with great  care and
delicacy in the first examination of a supposed case of gastric ulcer,
but, as a rule, we can scarcely be too reluctant to repeat it, even to
verify a presumed amendment.  At  any rate, its effects are  some-
times so injurious, that it is necessary strictly to prohibit the patient
from all  manipulation of the epigastric region, as well as from  all
pressure producible by dress (such as stays in the female) or work
(as is the case with shoemakers).
   Whether the pain of gastric ulcer is always increased  by pres-
sure, it  seems  impossible to decide.  There is only one necropsy
on record—and this probably not of an idiopathic ulcer—in which
it is distinctly specified that pressure was altogether devoid of such
an effect.  But I have  once or twice met with cases the symptoms
of which so nearly approached  those of this lesion in all other re-
spects, that I have been obliged to suspect its presence.  The vary-
ing  degrees in which  pressure affects different patients somewhat
confirm  the suspicion, that even  this characteristic of the ulcer is
occasionally (though very rarely) absent.
   A more  frequent explanation, however, of the supposed inefficacy
of pressure in increasing the pain, may be  found in the opposite
effects producible by  pressure  applied  in different  degrees, or in 
ULCER  OF THE  STOMACH.
105
different situations.  Thus, a curious instance lately fell  under my
notice, in which pressure on the base of the ensiform cartilage re-
lieved the patient  from the sense of "stoppage," and the dull epi-
gastric pain, which came on soon after eating.  Even here, however,
there was a circular area, about  an inch below the apex of this
cartilage, in which very  moderate  pressure brought  on  severe
epigastric and spinal pain.  And after the above artificial diminu-
tion of the epigastric pain, the dorsal pain soon became much more
violent.  Another example of the same kind has since been ob-
served by me.   In this instance, the pain was  evidently relieved,
not only by that pressure  on the cartilages of the lower ribs which
the prone attitude can produce, but even by a moderate manual
pressure on the fleshy wall of the epigastrium.   Even here, how-
ever, deeper or more forcible intrusion greatly increased the pain.
In a less marked form such anomalies appear to be anything but
infrequent: and, on the whole, justify the conjectures—that (1) pres-
sure may either relieve or increase .pain, according as it supports
the periphery,  or  impinges upon the surface of an ulcer; and (2),
that,  where the  lesion is so placed  as to be exposed  to direct
mechanical interference, exceptions to the latter  rule are of extreme
rarity.  .
  The effect of posture on the pain in different cases is more vari-
able.  As a rule, a severe paroxysm is relieved by the recumbent
posture, no matter what may be  the situation of  the ulcer  in the
stomach.  But the varieties of the recumbent posture—or, to speak
technically, of  decubitus—often have  no influence whatever  in
increasing  or diminishing the pain.  But in other instances  they
afford a valuable  confirmation to our  diagnosis,  and  sometimes
even entitle us to conjecture the exact seat of the lesion.
  The facts upon which this statement  is based are the following.
Of  cases in which the symptoms have led me to diagnose an ulcer
of the stomach, about two-thirds have exhibited  a marked influence
of posture on the pain. During a paroxysm some were  obliged to
lie  prone, some supine; some on the right side, some on the left,
some were even obliged to sit up.  In the term  " obliged" to do so,
I include not only those  cases which were distinctly relieved by
the selection of a particular attitude, but those which experienced
a great increase of pain by adopting any other.   In some of them,
however, the painful posture has been borne for a minute or two,
until the increasing severity of the pain has forced its abandonment.
In  like manner,  the less  painful attitudes  have  generally been
adopted, to the complete exclusion of that habitual decubitus which
most persons naturally assume during sleep.   The remaining third
have offered no peculiarity of decubitus, though in many the pain
has been relieved by rest in the recumbent posture.
  The fewer cases in which I have  compared the effect  of posture
upon this symptom during life with the appearances  seen  after
death, have afforded me more  specific information to the same 
106
ULCER OF THE  STOMACH.
effect.1   The majority have shown a close correspondence between
the posture  adopted and the site of  the ulcer;—the prone decu-
bitus being associated with an ulcer of the posterior surface of the
stomach; the supine with one of the anterior surface; the decubitus
on the right or left side, with a lesion  of the cardiac or pyloric sac
respectively.  But,  on the other hand, in some of the cases where I
might most have expected such a connection, it has been absent;—
a large  chronic nicer,  exclusively limited to the pyloric  pouch,
having been associated with no change of an habitual decubitus on
the right side; and  an ulcer of the posterior surface, or of the small
curvature, having been relieved  by even the supine variety of the
recumbent attitude.
  Even  in  these cases, however, we may probably  distinguish,
that the decubitus fails to guide our  conjectures, rather than abso-
lutely guides them  wrong.   For the fact that  the habitual decubi-
tus remains unaltered, deprives us of all grounds for any inference.
Again, in the absence of specific cause to the contrary, we might
well expect that the efficacy of the recumbent attitude an relieving
the pain would be shared by all varieties of this posture.2
  The partially subjective character of the pain in gastric ulcer is
well illustrated by the manner  in which it  is often  affected by
sudden mental  changes.  Amongst these we  may specially allude
to the depressing passions of fear, anxiety, or anger, as capable of
provoking a paroxysm which, in severity and  duration, far exceeds
the pain excited  by distension of the stomach with food.   Here,
however, the situation and character of the pain generally remain
unchanged.
  The effect of movement upon the pain  is closely connected with
that of posture.   As a rule, all violent bodily  exertion is likely to
be followed by an attack.  While even moderate exercise, sustained
so as to  produce fatigue, generally brings about  the same effect.
And there can be little doubt that the relief generally  afforded by
the recumbent attitude is chiefly due to the perfect rest it implies.
In  some  instances which have fallen under my notice, the move-
ments of locomotion have given rise to a peculiar sensation of drag-
ging in  the right hypochondrium, such as induced me to suspect

  1 Priority in observing this interesting connection belongs to Dr. Osborne.—
Dublin Journal of Medicine, vol. xxvii. p. 361.
  2 The presence of such a correspondence in certain cases, and its absence in others,
naturally remind one of what may be called objective and subjective sensations
in the normal action of nerves, and suggest the analogous distinction of objective
and subjective pains in their abnormal states of activity.  But such a view fades
before any philosophical inquiry.  Even  in the commonest forms of irritation of
a nerve, most of the minute mechanical conditions remain unknown to us: and
yet, until we can specify and determine these, we cannot assert that a given pain
is not so far objective, as that it results from a local lesion of the nerve.   In like
manner a careful consideration would probably conduct us to the propositions:—
that all pain is subjective;  that nothing but an elaborate organization at its peri-
phery and centre enables any nerve to give an objective sensation ; and that,
even then, its objectivity is, strictly speaking, but very partial and imperfect. 
ULCER  OF  THE STOMACH.
107
 adhesion  of the ulcerous stomach to the liver.  In one  of these
 instances I have since verified this conjecture by a necropsy.
   Here I may perhaps mention another effect  of adhesion, which
 well  illustrates the accuracy of an old observation  respecting the
 symptomatology of the liver.  In two or three cases, the adhesive
 inflammation uniting the ulcerous stomach to the  surface  of the
 liver has  been accompanied by that pain in  the  right shoulder
 which has long been regarded  as characteristic of hepatic  inflam-
 mation.1
   It  has been suggested that the pain of gastric ulcer is connected
 chiefly with the extension of the disease  to the peritoneum, or with
 its location at the cardiac or pyloric orifices.  That  either of these
 peculiarities would, on the whole, tend  to increase the pain, there
 is good reason to suppose.  But that intense and continuous pain
 is quite independent  of them both, I can affirm from a large num-
 ber of necropsies.
   The pain is also  affected in a special  manner  by  food.  As
 already mentioned, its paroxysms  generally  have a close  corres-
 pondence with that period of gastric digestion during  which the
 organ is distended with food.  It is  increased by the ingestion of
 hard or indigestible substances; and it is mitigated by a  pulpy and
 bland diet.  There are also many articles of food which have spe-
 cial  irritating effects.  Among  liquids, few are more  generally
 unbearable than tea  or beer.  Finally,  hot substances are usually
 productive of great pain.
   But exceptions to all the rules are occasionally seen.  The pain
 is sometimes unconnected with the ingestion  of food;  sometimes
 relieved by it.   And I have known even brandy, or warm  water,
 taken by a patient with relief.   While careful inquiry has satisfied
 me that beer is sometimes (especially in the aged) of no injury to
 the stomach, and of advantage to the organism generally.
   Lastly, in the young female, the pain of gastric  ulcer is often
 affected by the access of menstruation.   Sometimes the pain thus
 provoked seems quite distinct from that previously present, being
 abdominal and lumbar (instead of epigastric and dorsal) in its site;
 unaffected by  pressure; unconnected by vomiting; in  short, evi-
 dently dysmenorrhceal:—a conclusion which is confirmed by the
 fact, that it recurs at the menstrual periods, long after every symp-
 tom of the gastric malady has disappeared.  But in other instances
 the access of the menstrual flux has a specific (and sometimes habit-
 ual) influence  in provoking and increasing the ordinary  pain of
 gastric ulcer, with all  its usual concomitants (tenderness to pressure,
 vomiting, peculiar decubitus, &c).  The  nature of the relation be-
 tween the pain and the menstrual epoch is shown by its mode of
 access;—commencing, as it usually does, from twenty-four to forty -

  1 This sympathetic pain belongs, I believe, chiefly to superficial inflammation
of the liver; and is mediated by the nerves of the diaphragm and wall of the belly. 
108
ULCER  OF  THE  STOMACH.
eight hours before the appearance of the flux :  when  it generally
begins to subside, to disappear about twenty-four to thirty-six hours
after the commencement of free sanguineous discharge.  It is thus
connected more intimately with the menstrual molimem—with that
disturbed state of abdominal innervation which precedes the  flux—
than with the flux itself.
  The vomiting which generally forms the next symptom  in the
history of gastric ulcer, is far from exhibiting characters equally
specific with those of the  pain.  It usually occurs when the parox-
ysm of pain has reached its greatest height; and is therefore rarely
of a violent character, the  distension of the stomach which prevails
at this  time sufficing to  render it an easy and painless kind  of
vomiting.   Once  begun, it seems rarely to end  without  emptying
the stomach of its alimentary contents:—an act of expulsion which
usually affords complete  relief to pain,  but sometimes leaves a
slight burning sensation, that only disappears after a variable inter-
val of time.
  The chief varieties of the vomiting relate to the following details.
Firstly, as regards  the date of  the malady marked by its  access,
though generally preceded by the characteristic pain during several
weeks, it occasionally comes on almost as soon as this  symptom.
As respects the substances  it expels, these vary chiefly with the
precise date of the act.   Soon after the ingestion of food they are of
course alimentary; at a later period they have an acid character,
often occasioning an intensely sour taste to the patient himself;
and still later, are  sometimes mixed with bile. Lastly, in those
rarer instances in which the act of vomiting comes on quite inde-
pendently of the ingestion  of food—for example, shortly after rising
from  a night's sleep—it expels  a glairy  alkaline fluid, consisting
chiefly of the saliva swallowed before the  attack? Here the  vomit-
ing, often  periodic, is sometimes  connected with habitual drunken-
ness ; especially with the collapse which follows a debauch.
  As regards the proportion of cases in which gastric ulcer  is
attended by this symptom, I believe that it is rarely absent from
the whole course  of the malady, except in the rapidly perforating
ulcer of the young female.   Sometimes, however, it is so easy in
character, and expels so little of the gastric contents, as to  merge
into regurgitation:—a symptom which often ushers in vomiting,
and occasionally remains as its sole representative  throughout the
whole course of the malady.   In some cases it has been represented
by mere nausea in ulcers which have remained active for years.
In others it has been limited to a single attack, or to the very close
of the disease.  Evidence to this effect may also be found in  the
result of a strict regimen  in alleviating vomiting; which in many
cases only comes on after  a full meal, and is at once suppressed by
reducing the food to a minimum  of the  blandest alimentary sub-
stances.  Among other circumstances favoring the access of vomit-
ing, there is but one which seems to have any  close and constant 
ULCER OF  THE  STOMACH.
109
relation to its frequency and intensity— namely, the size of the
gastric ulcer.  But this  character is often connected with a  long
duration of the lesion, and with its adhesion to neighboring organs:
two circumstances which may independently favor the occurrence
of vomiting.
   The danger of this symptom it is difficult to exaggerate, though
easy to explain.   By expelling the food shortly after its reception
into the stomach,' it starves the patient; with a rapidity determined
chiefly _ by the quickness of its access, and the completeness  with
which it empties the organ.  And in addition to the effects of inani-
tion, it adds the fatigue implied by violent and abnormal action  of
the nervous and muscular systems.  (Compare p. 58.)
   Hemorrhage is the next symptom of gastric ulcer.  Since the
process of ulceration itself implies a solution of continuity in the
coats of some of the vessels  of  the stomach, nothing short  of a
simultaneous obliteration of these tubes can prevent some effusion
of their contents.  And hence it  is not very surprising to  find that
the myriads of  vessels concerned  in every ulceration are rarely
occluded with that quickness, precision, and universality,  requisite
to prevent all hemorrhage from their interior.
   How far the hemorrhage which occurs in ulcer of the  stomach
may be attributed to mere congestion, it is impossible to determine.
But from analogy, we may presume that the same degree of  con-
gestion which often attends ulceration elsewhere, might constitute
an equally efficient cause of bleeding in the stomach.  Still, as the
hemorrhage  almost  invariably  occurs soon  after a meal, and  is
often distinctly traceable to the ingestion of an unusual quantity of
food, we  may suspect that the influence of such an inflammatory
congestion is far surpassed by that of the afflux of blood which
attends the act of gastric digestion; as well as by the mechanical
disturbance which distension of the stomach necessarily inflicts on
the diseased vessels of the ulcer itself.
   There are no data for determining the frequency of those scanty
hemorrhages which are poured  out, in the earliest stages of the
ulcerative process, from the minute vessels of the mucous membrane,
and  of its submucous areolar tissue.1  But it is certain that  they
occur in a large majority of cases, in many of which no symptom
reveals them.  For since a small  quantity of blood does not excite
vomiting, it depends entirely upon a casual coincidence of these two
symptoms—hemorrhage  and vomiting—whether the former  is
revealed  by the latter.    And  unless attention be particularly
directed to the stools, a moderate quantity of blood may also leave
the intestinal canal by this channel, without ever being detected.
   In cases of this kind, the blood exhibits the changes which ordi-
narily attend its exposure to the action of the fluids of the stomach

  1 Compare the remarks on the sources of such hemorrhage in a subsequent part
of this Lecture. 
110               ULCER  OF  THE  STOMACH.
and intestines; not only becoming mingled with the various ingesta
and secretions which may chance to be present, but gradually under-
going a process which has the effect of greatly modifying  its color
and consistence.   Wherever the extravasated blood  is sufficiently
exposed  to this action, it acquires a dark, grumous, or even black
color, and a  peculiar tarry or almost pultaceous consistence.  A
small quantity of blood thus altered  by digestion sometimes  even
simulates the color and appearance of inspissated bile.
  Hence the  following precautions are applicable to this symptom
of gastric ulcer.   We cannot presume it has been absent because it
has not been noticed by the patient.  Our inquiries must be directed
not only to the matters vomited, but also to the stools.   As regards
the former, we must question the patient, not only as  to  what  he
may have recognized  as blood, but as to the characters of all the
substances  he has vomited.  And the matters habitually rejected
from  the stomach  should be submitted  to  a strict  and  repeated
microscopic examination ; care being taken to select such specimens
as are free from all admixture of food—at any rate of animal food
containing  blood.   Precautions of this kind  will often show that a
comparatively clear fluid deposits a sediment containing blood cor-
puscles in considerable quantity; and perhaps ranges, in other speci-
mens from  the same patient, through  a brownish ropy mucus, to a
grumous fluid having the ordinary "coffee-grounds" appearance of
blood thus altered by digestion.  A similar examination will some-
times be useful in the case of the. blackened fecal evacuations  to
which gastric hemorrhage  gives rise.  Dilution with  water will
generally distinguish inspissated bile.  But  if not, the microscope
will at once set this question also at rest.1
  The proportionate frequency of those larger hemorrhages which
occur when the vessels external to the stomach become involved in
the ulceration, is just as uncertain.   But my own experience would
suggest  that  they occur in not  more than one-third of the gastric
ulcers which come before us in ordinary practice.
  The symptoms of such hemorrhages illustrate and confirm the
proposition implied above—namely, that the  blood poured out
from a gastric ulcer scarcely exerts any specific action as an emetic
or a purgative, but excites vomiting or diarrhoea chiefly by  its
quantity; in other words, by the mechanical stimulus which  its
distension of the stomach or bowel  supplies.  Soon  after a meal,
the patient begins to experience an unusual  fulness and weight in
the region of the stomach;  attended (sometimes  even preceded)  by
feelings of  syncope.  Nausea rapidly supervenes, and ends in the
vomiting of a large  quantity of blood; which may either be par-
tially coagulated, or, if rapidly eff'used  and  rejected, may retain a

  1 The ingestion of the salts of iron is a source of error that may of course be
easily detected ; though I have known the inky vomiting which has accidentally
followed the administration of this drag immediately after tea, excite considerable
alarm in the mind of a patient and his medical attendant. 
ULCER OF  THE STOMACH.
Ill
color and fluidity that testify to its arterial source.  In other cases
(and I am disposed to conjecture, chiefly in those rarer instances
where the hemorrhages, besides being smaller, occur independently
of a meal), the blood  is effused in considerable quantity without
exciting any vomiting whatever;  and  is  passed  at once through
the pylorus into the intestine, which it  leaves more1 or less rapidly
with the stools.   Lastly, in very exceptional  cases, the rapidity
of the hemorrhage is so great, that it distends the stomach  and
more or less of the intestine with a single gush;  and  the patient
faints and dies before any expulsive act can diminish the enormous
clot which the necropsy reveals as the cause of his sudden decease.
   The state of the bowels in this malady seems unconnected with
any special character of the lesion.  Constipation  is, however, the
rule; a fact which appears, to  have a twofold cause.   Firstly, the
ulcer itself  generally opposes  the reception, and  insures the
expulsion, of ingesta; and  thus deprives the  intestinal  canal of
those contents which require, and provoke, the act of defecation.
Secondly, there is a definite2 quiescence, or stagnation (so to speak)
of  the  intestinal walls—an  arrest  or  exhaustion of  peristalsis—
which is produced by peritonitis, by vomiting, and probably also
by intensely painful affections  of the stomach:  and which is there-
fore especially marked in many instances of gastric ulcer where all
these circumstances concur.  Diarrhoea is so much the exception,
that its frequency seems scarcely much greater than might  be ex-
pected, supposing it  quite independent of the  lesion.  But, as
already  intimated, copious  hemorrhage  generally gives  rise to
looseness of the  bowels.   A  significant  contrast to this fact  is
afforded by ulcers situated in the first portion of the duodenum (or
in the immediate neighborhood of the stomach), which give rise to
diarrhoea with  much greater frequency  than  does gastric ulcer.
There can be little doubt that this difference  is  due  to a simple
law of the peristalsis of the alimentary canal: a law in  accordance
with which the movements of the most  distant parts of the intestine
are  connected together, while they are comparatively isolated from
those of  the stomach.  Hence copious  and frequent  diarrhoea,
especially if  attended with a moderate  hemorrhage  of scarcely
blackened blood, points rather to the intestine than to the stomach :
and should direct inquiry to the precise seat of the abdominal and
dorsal pain, as well as to the symptoms of those maladies (phthisis,
typhoid fever, &c.) which are  known to  be often associated with
ulceration of the ileum and caecum.
   Amenorrhoea  is  so frequent a symptom of gastric  ulcer in  the
female, as to require a special  consideration.
   The exact frequency with which the presence of this symptom

   1 Indirectly, it may doubtless provoke diarrhoea, by undergoing decomposition
in the bowels.
  2 Compare p. 68, et seq. 
112               ULCER OF THE STOMACH.
coincides with the existence of the ulcer cannot be estimated.   But
on the whole, regular menstruation seems far more common than
is generally supposed: a fact which is quite in consonance with
what will be hereafter stated respecting the number of males, and
of females either past the menstrual epoch or not arrived at puberty,
in whom the lesion has been detected by careful necropsy.
   Further, even in the female during the menstrual epoch of life,
this  symptom appears to be associated with different groups of the
lesion, in very diff'erent degrees.
   It is  in  the chronic ulcer of middle-aged women that the cata-
menia are least affected.  Many of the cases in which the ulcer has
lasted for ten or fifteen years, are recorded  to have  menstruated
regularly;  some even profusely.  Indeed, in some the malady has
lasted  throughout the  whole  menstrual epoch  of life,  without
exercising any appreciable influence  on this function.
   The coincidence of amenorrhcea with copious  hemorrhage from
the ulcer is certainly more frequent.  But the two symptoms gene-
rally have  a very natural and obvious relation.  The amenorrhcea
follows,  the hemorrhage; and is caused by it, just as it would be
by any other hemorrhage, or  by that drain of  nutritious fluids
which pregnancy or lactation migh imply.   In other instances, the
amenorrhcea precedes the hemorrhage.  But since  hemorrhage is
not more frequent in these cases than in cases of chronic ulcer in
general, there is no ground for asserting the efficiency of suppressed
menstruation as an independent cause  of  the bleeding.  In like
manner, there is rarely any connection between the date of the
hemorrhage and the menstrual period.  And finally, whatever has
been written respecting the  liability of the  gastric ulcer to give
rise  to a periodical hemorrhage which forms  a vicarious menstrua-
tion, I  do  not know  a  single well-authenticated  instance  of this
kind on record.1
   There is, indeed, but one  group  of gastric ulcers with which
amenorrhcea seems to have any intimate relation : namely, the per-
forating ulcers of the young female.
   The majority of these cases exhibit scantiness or absence of the
menses  as one of the  most  prominent features of their history.  In
many of them the amenorrhcea is accompanied with a state of pallor
and  anaemia, resembling  chlorosis.  Some,  however  menstruate
regularly and copiously: and a few profusely.  While many are
instances of delay in the appearance  of  the menses, rather  than of
their suppression or interruption. And in consonance with this,
in may be pointed out, that though the age2 of many of these female
subjects of perforation closely approaches the epoch of puberty,
and the  year or two immediately following, yet it does not  exhibit
those fluctuations above and below the average which would assign
it exactly to the access of this state.
Compare the author, op. cit., p. 85.               * See p. 129. 
ULCER  OF  THE  STOMACH.  „
113
   Still, the coincidence between amenorrhcea and the perforating
ulcer is an unquestionable fact.   And the first question concerning
this fact suggests itself in the  form of an alternative.  Does the
amenorrhcea cause the ulcer, or the ulcer the amenorrhcea?
   The first of these two  questions I think we must answer in the
negative;—not only because  the ulcer  is present in the male sex,
and in the neuter monster,1 at the same age, as well as in the female
at all other ages;  but because, even in the female at this epoch of
life, the exceptions to the presence of the supposed cause are too
numerous to be compatible with such a causation.  Indeed, to the
various cases of regular  menstruation  thus alluded to,  we might
plausibly add a large proportion of those in which menstruation
had delayed its appearance, as well as all  those in which puberty
was absent.  For many of the former would scarcely be instances
of mere amenorrhcea, just as all the latter are certainly disqualified
for this epithet.
   In favor of an affirmative answer to the second question (or of
the view that it is the ulcer which causes the amenorrhcea), we  may
point out:—that, in most  of these cases, the dyspeptic symptoms
indicative of the establishment of the lesion have themselves  pre-
ceded the deficiency or cessation of the menses;  and that such an
explanation, just as it would receive no contradiction from the mere
age of these cases, so it would find a parallel in the case of other
grave constitutional disorders, which no pathologist would doubt
to be the cause of the amenorrhcea frequently associated with them.
A good illustration of this statement may be found in the tuber-
culous cachexia, which often selects this epoch of female life as the
period of its fatal attack, and is associated with symptoms of chlo-
rosis and amenorrhcea.
   A careful observation of the details of the so-called " chlorotic"
state which accompanies the  amenorrhcea of these gastric ulcers,
affords  some confirmation of the above view.   Not only is   the
cachexia present by no means identical  with true chlorosis, but the
differences of the two states are essential.  The cachexia which
attends the ulcer is, even when best marked, devoid of the charac-
teristic  symptoms of severe chlorosis.   The pallor, however  ex-
treme, offers no trace of that greenish hue which the very name of
chlorosis {x%apb$, green) connotes.   The dyspnoea  on  exertion,  and
the soft bellows-sound, are much less distinct.  And lastly, there
is little or no oedema of the subcutaneous areolar tissue.
  As the age of these subjects of gastric ulcer advances, it is not
uncommon for the amenorrhcea to cease, the other symptoms of the
lesion remaining unaffected.  In  rarer instances, the so-called chlo-
rosis also diminishes and  disappears.  But the  most  satisfactory
proof that  the amenorrhcea  is not in any sense the cause of the
chlorotic symptoms, is afforded by some still rarer (though authen-
8
1 Compare the author, op. cit., p. 32. 
114
, ULCER OF THE STOMACH.
tic) examples, in which  the  ulcer has been attended by a marked
degree of this cachexia, without any interruption whatever to regu-
lar and copious menstruation.
   But it is obvious that the above view does not explain the  con-
nection between amenorrhcea  and perforation ;  much less the  fact,
that the  ulcer most affects the menstrual function soon after the
age of puberty.   Nor do I think that sufficient  materials for such
explanations are at present accessible.   It would, however, be  easy
to suggest, that a periodic hemorrhage like the menstrual flux  may
well be more easily affected during the struggles of the constitu-
tion to establish and maintain it, than when  the organism  has
become accustomed to its  recurrence, or strengthened, so as to be
more indifferent to the loss of  blood it implies.
   But this epoch of female life seems to influence, not merely the
symptoms, but  also  the characters of the gastric ulcer.  That its
great liability to perforation is not due to any supposed accelera-
tion of the ulcerative process by the vigor and activity of youth, is
shown by  the fact, that the increased  tendency to perforation at
this age  is limited to the female.   (Compare p. 129.)  Indeed, all
the  peculiarities  of  the symptoms and appearances  seen  in  this
group of ulcers concur  to explain their tendency to perforation as
being due, not to any special activity or quickness of the ulcerative
process,  but rather  to the absence of that  inflammatory reaction
by which its destructive  advance is often checked, and its worst
effects warded off.
   The cachexia generally associated with the ulcer at other ages of
life appears to have  precisely the same import as the chlorotic  con-
dition which represents  it in the young female.   Like the latter, it
seems to be essentially,  not so  much a symptom, as a congeries of
symptoms: or rather a state which expresses the injury inflicted on
the organism by a variety of causes.   The wearing effect of  long
and frequent paroxysms of pain,  the fatigue and inanition implied
by constant vomiting, the drain of frequent or copious hemorrhage,
the loss of digestive power involved in the destruction of the stomach,
and finally, the mere age of the patient—are  causes  of  this kind,
each of  which  often shares  in  producing the cachexia that  is
present.
   As already intimated, it is probable that this cachexia  (which is
best marked in  ulcers of long standing, and therefore in middle-
aged or elderly people),  corresponds to the chlorotic symptoms and
the amenorrhcea above noticed as generally associated with  gastric
ulcer in  the young female.  And  my own experience entitles me
to presume that  it is rarely absent; that (contrary to what is often
stated on this point) a person suffering from gastric ulcer scarcely
ever offers an  appearance such as an observant practitioner would
mistake  for that of a person  in  health.  Nay,  more, I may  add,
this cachexia gives the disease so peculiar a physiognomy, that  I
have sometimes been forewarned  of its presence by the mere sight 
ULCER OF  THE STOMACH.
115
of the patient's features in a crowded hospital out-patient room.
With some characters  that would often leave us in complete un-
certainty as to whether the cachectic aspect was due to  ordinary
chlorosis, to tuberculosis, or (in later life) to the cancerous diathe-
sis, the  sharp lines which severe and frequent pain,  with partial
starvation, have worn on  a patient's face, sometimes afford what is
thus almost a characteristic sign of gastric ulcer.  At any rate, this
peculiar expression of countenance is, on the whole, a surer indica-
tion than mere anaemia, emaciation, or exhaustion can  afford.
   The perforation which sometimes occurs in the course of gastric
ulcer is notified by symptoms so intense and characteristic, as to
require but a very brief description.  After  more or less distinct
indications of the ulcer have existed during a variable period, the
patient  is suddenly attacked by a violent pain, which begins in the
epigastrium, and rapidly spreads over the  belly.   Its diffusion is
accompanied by the appearance  of all the ordinary symptoms of
peritonitis ; the wall of the belly becomes extremely tender to  pres-
sure; the patient assumes an attitude which relaxes the muscles of
this part;  there  is a cessation of the  usual respiratory movement
here—a stagnation soon followed by great tumefaction of the abdo-
men and tympanitic distension of the bowels.  If a strict physical
examination  of  the belly be insisted on, the peritoneal cavity will
be found to  contain fluid: usually those contents  of  the  stomach
which have streamed  through the  aperture in its coats, increased
by the  subsequent addition of an inflammatory effusion.   The con-
tinuance of these symptoms generally destroys the life of the suf-
ferer in from twenty-four to  thirty-six  hours; but death is  often
preceded by a period of comparatively painless collapse.
   Rarely does the train of symptoms that follows perforation offer
any marked deviation from the above type.
   In many  instances, however,  a remarkable paroxysm of pain
precedes the occurrence of perforation.   This intense pain—the
duration of which varies from a few minutes to several  hours—is,
I believe, generally due to a leakage of the gastric contents through
that  thin film of rotten  tissue to which, at  this period, the coats of
the stomach are reduced.   In  consonance with such an explanation,
a more chronic pain of similar character has sometimes been found
associated with a complete matting together of the  stomach and all
the neighboring viscera by a large quantity of lymph, without any
visible perforation of  the "coats of the stomach, or any escape of its
contents.
   The  symptoms of those various modifications1 of the process of
perforation which will be noticed in treating of the pathology of the
gastric  ulcer, require no special description here.   Partial perfora-
tion, allowing of a subsequent repetition  (or rather extension) of the
accident, or leading to abscess, is distinguished by symptoms which,

                         1 Compare p. 131. 
116
ULCER OF  THE STOMACH.
though  scarcely quite alike in any two instances, offer  the general
features of being  more local, more chronic, and less intense, than
those of ordinary perforation fatal by general peritonitis.
  There are other circumstances attending the accident which might
almost be enumerated among its symptoms.  Thus it almost always
occurs after a full  meal; and is often directly traceable to mechani-
cal  violence,  such  as coughing, sneezing, concussion or  constriction
of the belly.  The sensations of the patient frequently verify the
nature of the accident, by distinctly appreciating that something
has given way in the belly;  and has thus caused a gush of fluid
which has instantly provoked an agonizing pain  in the same part.
Lastly, the presence of a communication between  the cavity of the
stomach and that  of the peritoneum is  sometimes indicated by the
repeated recurrence of intense pain after the deglutition of food or
medicine.
  Dilatation or enlargement of the stomach, as a result of the con-
striction produced by the cicatrix of a gastric ulcer, constitutes a
variety of the malady which of course brings with it a special train
of symptoms.  Into these, however, I shall not now enter, but shall
content myself with pointing out that their connection with the ulcer
is both infrequent1 and indirect; while they are present  in instances
of dilatation from so many other  causes,  that nothing short of a
history revealing those general symptoms of the ulcer  already de-
scribed would entitle us to refer any particular case to this origin.
  The above varieties  in each of the  symptoms of gastric ulcer
suggest, on merely arithmetical  grounds, the infinite modifications
which necessarily result  from their  combination.  Of these it is
scarcely an exaggeration to say, that they  make each case of ulcer t
of the stomach unlike every other.  And they especially raise two
questions respecting the diagnosis of the malady.  (1) What is the
minimum of evidence which will justify us in affirming the existence
of an ulcer of the stomach during life ?   (2) What are  the diseases
with which it is most likely to be confounded ?
  A specific answer to the first of these questions it is impossible
to give.   But I am inclined to think that  nothing less than a con-
currence  of  all  the chief symptoms, as already described, entitles
us to pronounce a decided opinion.  In  other words, unless the pain
possess the characters attributed to it, and is accompanied by an
equally characteristic vomiting; and unless there be  evidence of
considerable or repeated hemorrhage in the course of the malady;
there is no sufficient  ground  for affirming  the existence of gastric
ulcer.   The drift of these symptoms may be thus summed up.   The
date, duration, and frequency of  the pain chiefly indicate some im-
portant lesion of the mucous membrane of the stomach.   The vom-

  1  Infrequent, as not occurring much oftener than once in 200 cases ; indirect, as
implying in most instances a previous cessation of the ulcerative process, or healing
of the ulcer. 
ULCER  OF THE  STOMACH.
117
iting adds, that this lesion implies great  irritation of the nervous
centres connected with  the  organ.   And it  is reserved for the
hemorrhage to show, whether the disease is one which involves an
absolute breach of continuity in the structure of the stomach.
  But an  absolute enforcement of this rule of diagnosis would lead
us to overlook'many  cases  of gastric ulcer;  and thus occasion
grievous errors in practice.   In point of fact, even when any definite
opinion is impossible, we may often suspect that the symptoms are
due to this lesion.
  Thus, as already mentioned, the pain is subject to considerable
variety in many of its features.  As might be expected, a moderate
hemorrhage  sometimes escapes the  notice of both physician and
patient.   And even where the latter habitually inspects whatever
is discharged by stool or vomit, or the physician  calls  in the aid
of the microscope to an examination of any suspicious egesta, the
irregularity of its occurrence may baffle  all attempts to verify it
for months together.  In  like manner, the vomiting seems to be
sometimes (though much less frequently) absent from the history
of the malady during  a  great part of its course;  or merges into a
trifling regurgitation after meals, such as we hardly dare consider
its representative.
   Indeed, a careful consideration of the details already adduced
affords a complete explanation of many such anomalous cases of
ulcer of the stomach.  For the slow succession of the symptoms in
a majority of cases almost  implies their absence in  a minority.
The delay of this or that particular symptom not only deprives us
of the (multiplied and not merely added)  probability it contributes
to our diagnosis,  but merges  two or more  stages of the malady into
one, or even reverses their order of sequence.  And as  the lesion
itself may be fatal at  any period of its progress, it is obvious that
the casual delay of any symptom—perhaps for a period not greatly
exceeding that of the interval which generally precedes its being
added to those previously present—is sometimes scarcely tantamount
to its absence, even though,  as a matter  of mere narrative, it has
never been noticed.
   Obscure and uncertain  cases of this kind show the importance
of a  thorough knowledge of the characters  of the disease in its
more  chronic and typical forms.  The pathology of the lesion  in
general has to supply any casual deficiencies in  the physiognomy
(so to  speak) of the particular instance.   Above all, we must re-
member  that it  is our first  duty to be useful; and that suspicions
which fall far short of a definite diagnosis, may yet be sufficiently
important to dictate the whole plan of  treatment.  Suppose, for
example,  that we  are  consulted by  a patient for protracted  or
severe dyspepsia, which has seriously affected the general health,
and is associated with pain and tenderness in the  epigastrium, and
pain  in  the interscapular region, increased or  provoked by the
ingestion of food.  If, on further inquiry, it turns out that this pain 
118
ULCER  OF  THE STOMACH.
is especially called forth by proteinous substances, or by hot liquids;
and that it is  affected as above described, by movement, rest, and
posture; there can be little objection to our keeping steadily before
us the possibility of a  gastric ulcer.   Such a suspicion, it is true,
guides us to a specific course of treatment: but that  treatment in-
volves neither pain nor danger, and a diet scarcely more stringent
than what many a dyspeptic would gladly submit to for the removal
of his distressing symptoms.  Indeed, it  is hardly too much to say
that, by treating these  cases as  ulcer of the stomach, we  may often
cure what we  cannot diagnose; and—to venture upon a paradox—
may thus witness such a triumph  of the Art  over the  Science of
Medicine, as  well illustrates the invaluable  (but yet subordinate)
relation of clinical and pathological research to the one great object
towards which all our knowledge should  tend—the successful treat-
ment of disease.
   These remarks will  especially apply to such symptoms  when
they occur, in connection with amenorrhcea, in females who have
lately arrived at puberty.   Here the  absence of hemorrhage, and
the little attention often  given  to mere dyspeptic symptoms,  some-
times obscure the diagnosis of cases, in which a careful inquiry into
the history of the malady, and a sedulous examination of the epi-
gastric region, afford only too much  reason for supposing that the
patient is in imminent danger of death by perforation of the stomach.
   The second question—" With what diseases is gastric ulcer most
likely to be confounded ?—could only be fully answered by details
of cases such as cannot here be adduced.  Dyspepsia, chronic inflam-
mation, and cancer of the stomach; disease of the duodenum; gall-
stones ; abdominal aneurisms;  enteric tuberculosis; and a variety
of diseases too numerous to mention;—all present various degrees
of similarity to  gastric ulcer.   And the variable symptoms of this
lesion often render such  similarity much more suggestive of error
than is the case in the maladies of many, other organs.
   The above  observations render it unnecessary to dilate upon the
circumstances which generally distinguish dyspepsia from gastric
ulcer.  In most instances, there is little difficulty in deciding which
of the two maladies is present.  But in  some cases the  distinction
is by no  means easy.  And of all  the Protean forms which dys-
pepsia may assume, that called  the " morbid sensibility"  of  the
stomach is the one which  is most likely to include cases of ulcer;
or, in other words, if really independent of this lesion,  is most likely
to be mistaken for it.1
   Of the other diseases just enumerated,  there is none in which the
resemblance  to ulcer is  so close, and a  definite opinion so impor-
tant,  as  in the case of  cancer of the stomach.  Hence we may
enumerate (though we cannot now discuss) the chief considerations
on which their differential diagnosis would generally depend.  The
See the remarks on this subject in Lecture VI. 
                  ULCER OF THE STOMACH.               119

cancerous disease especially  affects  the epochs  of middle  and
advancing life.  Its symptoms rarely  date from more than twelve
or eighteen months prior to the death  of the patient.   It is associa-
ted with the cancerous cachexia:  often with cancerous disease of
other organs.  In  most cases it  forms a hard  but movable tumor
in the epigastrium. Its pain generally has a lancinating character;
and a time  of appearance belonging  rather to the latter stage of
gastric digestion than to the few minutes which succeed deglutition.
Its hemorrhage is more scanty; and  is, on the whole, later in*the
history of the malady.   Its vomiting  is also generally late; rarely
of many months' continuance; and expels what the microscope will
often show to be  a cancerous cell-growth.  But unless unusually
distinct, scarcely  one  of these characters  possesses much inde-
pendent value.  For the gastric ulcer is frequent in middle  and
advancing life.  It may destroy life in a few days or weeks.   It is
often associated with cachexia; which,  again, is sometimes quite
undistinguishable  from the  cachexia  of cancer.  It is  not unfre-
quently accompanied  by pulmonary disease, such as can tolerably
simulate secondary cancer of the lungs.  The  lymph  by which an
ulcer adheres to the liver or  to other viscera may give rise  to a
tumor, which can be felt through  the wall of the belly.  Its pain
may affect a lancinating character,  and be deferred until some time
after'meals.   Its hemorrhage may  have the moderate amount, and
the " coffee-grounds" appearance, ordinarily seen in that of cancer.
And unlikely as it may seem that many of these separate and infre-
quent contingencies  should combine  to  obscure the diagnosis of
any single case, such instances really do occur.   Once or twice I
have myself met with cases of this kind, in which there was nothing
to justify any definite diagnosis  between the two diseases; and in
which the moderately large ulceration  detected  months before death
has offered no symptoms during the whole time which could war-
rant its being definitely diagnosed  as malignant or the reverse.
                          PATHOLOGY.

  It has already been stated that the preceding description of the
symptoms of gastric ulcer is derived from a large number of cases,
directly  or  indirectly authenticated  by necropsy.  The changes
which constitute the progress of the disease have also been deduced
from the examination of a series of specimens of its lesion, in suc-
cessive stages of its existence.  We have now to add some details
respecting its appearances in the  dead subject;  details which,
besides interpreting the symptoms and (as we shall hereafter find)
guiding the treatment of this malady, suggest  various deductions
of great interest in  reference to its origin and causation.
  As respects the  frequency of ulcer of the stomach, the  lesion
appears to be detected in from two to thirteen per cent.—on an ave- 
120
ULCER  OF  THE  STOMACH.
rage five per cent.—of persons dying from  all causes;  the higher
proportion probably corresponding with habits of spirit-drinking,
on the one hand, or with a high average age of the persons whose
bodies were submitted to such systematic necropsy, on the other.
  Sex.—As long believed, the ulcer is more frequent in the female
than in the male sex, the proportions being nearly as two to one
respectively.
  Age.—As respects age, it would appear from a comparison of the
number of ulcers detected  at diff'erent ages with the proportionate
numbers of persons of these ages living in this country, that the
liability of an individual to become the subject of gastric  ulcer
gradually rises, from what  is nearly a zero  at the age of ten, to a
high rate, which it maintains through  the  period of middle  life;
at the end of which period it again ascends, to reach its maximum
at the extreme age of ninety.   We may, therefore, conclude that
ulcer of the stomach is specially, though not exclusively, a disease
of middle and advancing life.
  The situation of the ulcer may be summed up by the  statement,
that the lesion occupies the various parts of the stomach in about
the following  frequency.  In forty-three cases per cent., the poste-
rior surface; in twenty-seven, the lesser curvature; in sixteen, the
pyloric extremity;  in six, both the anterior and posterior surface,
often at opposite places;  in five, the anterior surface only; in two,
its  greater curvature; in  two,  the cardiac pouch.   Thus about
eighty-six ulcers in every one hundred occupy the posterior surface,
the lesser curvature, and the pyloric sac; parts  of the stomach
which  together form a segment of less  than one-half of the total
superficies of the organ.  Hence we may estimate that any part of
this continuous (but irregular) segment of the stomach is, on a ave-
rage, about five times more  liable to the lesion than the remaining
segment  formed by the  cardiac sac, the anterior  surface,  and the
greater curvature.
  In size,  the ulcer is rarely much smaller than a fourpenny-piece,
or larger than a crown-piece.  But no precise limits can be assigned
it.   Thus, an  ulcer not  larger  than  a pea may  exhibit all the
characters of this lesion, and cause death by haematemesis, or per-
foration.    While, conversely, an ulcer may gradually extend to a
diameter of five or six  inches; in other words, to one-eighth or
one-ninth  of the total mucous surface of the  stomach.
  The shape of the ulcer is usually circular or oval.   But it  is
often oblong, with a direction either parallel or transverse to the
axis of the stomach;  and in rare instance it forms a zone around
the pyloric valve,  or the  pyloric  sac.  Some of these irregular
shapes are evidently due to the fusion of two or more  ulcers into
one, by the progressive enlargement of their adjacent margins.
  As regards the number of ulcers,  two or more are present in one
out of  every five cases, or about twenty-one per cent.   Of ninety-
seven such plural cases (corresponding to four hundred and sixty- 
ULCER  OF THE  STOMACH.
121
three instances of ulcer):  in  fifty-seven, there were two ulcers; in
sixteen, three;  and of the remaining twenty-four, in which " seve-
ral" ulcers were present, three cases offered fbur, and two cases five
ulcers each; while in four there is reason to suppose even this
number was exceeded.
   Margin.—The appearances of the tissues in and around the ulcer
are subject to just as much variety as its size and shape.  In some
instances, there is little or no evidence of inflammation in  the
neighborhood of the lesion; which consists  of a mere removal of
the mucous membrane over a  circular space, that forms a shallow
but level pit, with a sharp, smooth, vertical  edge, as though it had
been punched  out.  In  other  cases, which appear  to form  the
majority,  the  mucous  membrane that constitutes the immediate
margin of the ulcer is swollen, so as to be raised someAvhat above
the  level of the adjacent mucous surface.   And  a  microscopic
examination shows that this thickening, which is accompanied by
induration, depends upon an exudation of  lymph into the areolar
tissue beneath the mucous membrane, as well as  into the matrix of
the latter texture itself; constituting a  slight  but  appreciable
inflammatory  reaction, which, in respect of its  nature, is closely
akin to  that adhesive inflammation of the peritoneum hereafter
mentioned.
   In many instances, indeed, the swelling and induration around
the ulcer  far exceed that just  described; and convert the mucous
membrane, for  the distance of half an inch, an inch, or more, into a
thick brawny mass, which has  sometimes been mistaken for can-
cer.  Rarely, however, will  a careful examination leave us in any
doubt as to  its  nature.   Even when best marked, the total increase
of thickness in the parietes of the stomach  is but moderate.  The
exudation which causes this increase of thickness is often confined
to the mucous membrane and the areolar tissue immediately beneath
it;  and consists of fibres, in which it is usually very difficult to find
even moderate quantities of  the  cell-growth from which they are
developed.  Hence the new substance has neither the structure nor
the situation  of  the  cancerous deposit (see Lecture IV.).   The
mucous membrane, itself, however thickened, remains in  what is
essentially a healthy state.  Indeed, in  many such  instances it
seems little  more  than hypertrophied, in the strictest sense of this
term.  And, lastly, the history  of the lesion would generally afford
sufficient grounds .for a decision, even prior  to an inspection of its
appearances.
  The latter allusion suggests an explanation of the maximum,
minimum, and medium of that inflammatory action indicated  in
the above remarks.   As  might be expected, the simple, punched-
out ulcer is usually either  a small  or recent lesion, on  the one
hand, or is  associated with a weakly and cachectic (in the female,
often chlorotic) state  of constitution, on the  other.   While the
maximum of thickening is generally found in connection with the 
122               ULCER  OF THE  STOMACH.
same circumstances which favor the occurrence of adhesive inflam-
mation on the exterior of the stomach; and among these, especially
with a large size and long duration of the ulcer.  But it frequently
occurs in subjects of the age of five or twenty-five.  Still this fact
does not qualify the preceding statement as to the usual duration
and diameter of the indurated ulcer, but seems merely to express
the degree in which the process of reactive inflammation is some-
times furthered by the vigor of youth.
   Such varieties in the  size, shape, appearances, and  numbers  of
the lesion, show  in what a restricted sense we must adopt the
nomenclature by which it is generally known  in medical treatises.
It is generally called  the ulcer—often the simple,  or chronic, or per-
forating ulcer, of the stomach.  Now, as  regards the word ulcer, an
important exception may be taken to its use.   For the comparison
of any large number of specimens would  conclusively show, that
there is  no specific pathological  distinction between  " ulcer" and
" ulceration" of the stomach ; and that all the distinctive characters
which the most minute description could assign to either, merge
into  those of the other by infinite  gradations.  It  is true that
numerous  or large  ulcerations produced by a  rapid process  of
destruction, are rarely or never accompanied by those  appearances
which imply even a  moderate duration; that they are devoid of
raised edges or  a  hard margin, and  do not penetrate the larger
vessels, or even  the total parietes of the stomach.   But, practically
speaking, all this amounts only to the statement of a very obvious
fact;  namely, that such  lesions destroy  so  large a  fraction of an
organ essential  to nutrition  and life, that the  unhappy subject of
them either dies before they have time to offer appearances of re-
action, or is too prostrate to be amenable to the inflammatory pro-
cess.  While  each of the  other terms emphasized above will be
found to illustrate the rule of " lucus a non  lucendo?   Though the
lesion is called  the ulcer, it is neither  single nor  definite in its
nature and origin ;  and is  often present in  the plural number.
Though  it is called the  simple ulcer, its characters are generally
a compound of two processes of absorption and reaction, the latter
of which certain  instances show  to be  quite  independent of the
former.   Though it  is  called the chronic  ulcer, its progress is
sometimes so rapid, as to penetrate  the  stomach  and  destroy life,
in a few days.   And, finally, though it is called the perforating
ulcer, in about seven  out of every eight cases it does not perforate.
   The base of the ulcer, so long as it is formed by the tissues of the
stomach  itself, presents appearances similar to  those of its margin.
Its usually firm and  hard consistence is derived partly from the
density of the  areolar  and  muscular  tissues originally  present,
partly from an increase of their cohesion, due to that infiltration of
fluid, and exudation of lymph, which inflammation generally brings
about.  In other (and by no means unfrequent) cases,  the progress
of ulceration, apart from any such reaction, is betrayed by the soft, 
ULCER OF  THE  STOMACH.
123
flocculent, or even gelatinous consistence of the floor of the ulcer;
where we  sometimes find flakes of dead tissue, the size of which
almost entitles us to regard them as sloughs.'
   But since the ulcer, beginning in the mucous membrane, gradu-
ally extends through the coats of the stomach, so as to increase its
depth, as well  as its  surface, its base and margin are necessarily
subject to continual change.   Still the mode by which it penetrates
the various tissues of the stomach  is so characteristic, that there is
little alteration in  the  shape of the ulcer, so long as  it does not
pass beyond them.
   The whole depth of the ulcer forms a cone, of which the base is
at the free internal surface of the  stomach, while the apex points
towards the peritoneum.   The  smooth, sharp, vertical  edge which
forms the  lateral boundary of the  ulcer  as it  passes  through the
mucous  membrane, is  exchanged  for a smaller and  less regular
circle where  it  reaches  the submucous  areolar tissue.  In like
manner, the gradually narrowing aperture by which the ulcer eats
its way through the sub-adjacent muscular coat, dwindles,  as it
reaches  the peritoneum, to what is  little more than a  point, corre-
sponding to the centre of the conical ulcer.  And  it is in this point
that  the perforation which forms the last event  of simple  gastric
ulceration occurs;  generally as the  immediate result  of the pale
yellow slough into which the peritoneum has previously been con-
verted,  becoming ruptured  or detached,  and thus allowing  the
contents of the stomach to escape into the abdominal cavity.
   It is obvious that a progressive increase in the depth of an ulcer
would always  end in  the perforation of the  stomach.  But this
event is in most instances prevented or deferred by the occurrence
of adhesion, which, by uniting this organ to some neighboring sur-
face, obliterates the peritoneal cavity  at the base of the ulcer.  The
peritoneum covering the floor of the lesion undergoes inflammation:
its smooth epithelial  surface acquiring a dull, roughened aspect;
and then becoming the seat  of an exudation of coagulable lymph,
which soon fixes and unites it to the adjacent serous surface of any
viscus with which it may be in  contact.
  The frequency of intimate adhesion of course corresponds with
that of protraction of the disease; of which protraction this adhesive
inflammation may be regarded as  equally cause  and effect.  My
own observations enable me  to confirm those of Jaksch, who found
22 such  adhesions in 57 cases of ulcer;  a proportion  of about 40
per cent.   The site of these adhesions, and the viscus to which  they
attached and fixed the organ, exhibited a tolerable correspondence
with  those parts of the stomach already specified  as the most fre-
quent situations of the ulcer.  Thus of these 22 adhesions, 15 united
the pancreas to the posterior surface or lesser curvature  of the

  1 These appearances, however, often seem partially due to a post-mortem diges-
tion of the ulcerous tissues by gastric juice.  (Compare p. 141.) 
124               ULCER  OF THE  STOMACH.
organ; 5 attached the pylorus or lesser curvature to the adjacent
liver; one involved the mesentery; and one the spleen.
  But the  formation of  these adhesions  is seriously affected by
another cause—namely, by the movement of the stomach upon the
surfaces opposed  to  it.  It is only thus we can explain  the rarity
of adhesion of the anterior wall of the stomach  to the  parietes of
the belly;  coupled (as already noticed) with  a by no means infre-
quent  position of the ulcer on this wall,  and attended (as we shall
see) by an  extreme liability to perforation when so  placed.   And
it  is interesting to notice, that the situation of the ulcer seems not
only to regulate the occurrence of adhesion, but also to affect its
structure, and thus  to influence its  efficiency as a means of  pro-
tection against  perforation.  The  adhesions which occupy  the
omentum are often  little more than  a thickening of the dedicate
fibrous tissue of the peritoneum by an interstitial  deposit of inflam-
matory lymph; and  are of so little avail in warding off perforation,
as to be ruptured by very slight exertions or shocks, such as cough-
ing or sneezing with a moderately distended stomach.   The adhe-
sions of the anterior surface are often mere threads of imperfectly
organized lymph, drawn  out into this form from the pasty (compare
p. 127) exudation, by the continual  movements of the stomach, so
as to constitute a coarse network of fibres, with interstices of vari- •
ous size.   While the massy and continuous adhesions which unite
the stomach with  the liver or pancreas often  possess a densely
fibrous character, that almost  precludes all danger of perforation.
   The duration of the lesion  is very variable, and is, in most in-
stances, rather to be deduced  from the symptoms observed during
life, than from the appearances found after death.  The  latter, how-
ever, generally permit a  conjecture.   Thus, when we find a large,
shallow ulceration, of irregular shape,  unattended by any marks of
adhesion on its peritoneal aspect, or by any elevation or thickening
of its  mucous edge,  there is fair ground for presuming  it of recent
formation.   While, conversely, adhesion and-thickening around an
ulcer, or an exactly circular shape, tend to show that a certain time
has elapsed  since the first occurrence of the destructive process.
The clue sometimes afforded by the symptoms can hardly be alluded
to here, save to point out that there  is great danger of assigning
to an ulcer far too long  a duration, in consequence of the liability
of the malady to a  return.   In fact, nothing short  of  a tolerably
complete continuity of  the  symptoms during  a series of years,
entitles us  to regard an ulcer as really open  during the whole of
the  time.   In like manner,  unless  the  symptoms of  ulceration
during life were very sudden, marked, and persistent,  we should
hardly be justified  in  denying that the lesion before us might not
have existed before the feelings of illness which first called for
medical advice.
   Even with these  limitations, however,  the range  of  duration is
remarkable.  In what are certainly exceptional cases, the lesion 
ULCER OF  THE STOMACH.
125
has been  known to be fatal  in  a  few (for example, in ten) days:
generally by  perforation;  sometimes by  exhaustion, caused  or
hastened by vomiting; very  rarely by  hemorrhage.  But, in the
majority of instances, a period of several  weeks or months precedes
the fatal event.  And an extension of this period to years is by no
means uncommon.  Thus among cases of this kind—possibly fre-
quent relapses, but  probably continuous open ulcerations—I find
in my notes one of thirty-five years, two  of thirty years, three or
four of twenty, four or five of fifteen, and several of ten, seven, five,
and four years' duration.
   The healing of such ulcers by a process of cicatrization appears
to be far more frequent than  is generally supposed.   The examina-
tions of Dittrich, Jaksch, Willigk, and Dahlerup, reveal a total of
147 scars, and  156 ulcers, making the proportion ■ of the former
nearly equal to that of the latter.  Against such results, it can hardly
be alleged that  the supposed scars have really been mere local
enlargements or thickenings  of  the mucous membrane, or fibrous
deposits in its submucous areolar tissue.   While in their favor we
may point out, how easily cicatrices of small size might escape dis-
covery, in less careful scrutinies of the mucous membrane of the
stomach than those made by  these excellent observers.
   The cicatrix by which the ulcer heals is therefore, on the whole,
about as frequently met with as the ulcer itself.  In other words,
 half the instances of this disease undergo what is probably a spon-
 taneous cure.
   The precise details of the process of cicatrization differ with the
 amount of destruction that has preceded it.  Where the lesion has
 been of small size,  and the ulcerative .process has not extended
 deeper than  the mucous membrane, the scar is sometimes little
 more than a  mere  condensation and thickening of the submucous
 areolar  tissue; and in outline  (like  the  typhoid cicatrix) closely
 resembles the ulcer that  preceded it.  But in the majority of in-
 stances, it has a more characteristic shape.  The gradual  contrac-
 tion of the lymph deposited at the base of the ulcer converts it into
 a hard, thick, central mass ; which gives off cord-like processes, that
 seem to  radiate into the surrounding healthy tissues.  The latter
 are themselves thrown into folds, as the result of the tension which
 this  contraction produces.   Where the previous loss of substance
 has been considerable, this process often seriously affects the shape
 and capacity of the stomach. In  such instances, the cicatrix cor-
 responds to a constriction of the organ, which gives it more or less
 of an hour-glass  shape.   And  in extreme  cases,  the  contraction
 amounts to an absolute stricture, which impedes the transit of food,
 and thus gradually causes great hypertrophy and dilatation of the
 over-distended segments  of  the stomach  behind the obstruction.
 Such examples are, however, rare.'
   1 From the cases I have collected, I should conjecture them to form about one
 in 200 instances of ulcer; or  1 per cent,  of the cicatrices by which they are con-
 ditionated. 
126
ULCER OF  THE STOMACH.
  The cicatrices which thus modify the calibre and shape of the
stomach  are  generally those of large  ulcers, that have remained
open  for a  long  period before  undergoing the  healing process.
Hence they are often found associated with  adhesion of the stomach
to some  of the neighboring  organs: —a circumstance which itself
aggravates the perils  of the gastric constriction, by still further
embarrassing the muscular contractions of the stomach, and aiding
its changes of shape.   In most of these cases, the substance of the
adhesion is so inseparably united with that of the cicatrix  itself,
that it is impossible to distinguish one from the other.  Both are
indeed composed of the same substance:—a fibrous structure, the
elements of which gradually approach, but never attain, the develop-
ment of the ordinary white fibrous tissue.
  In some  cases, the ulcer gives rise to a  peculiar dilatation and
thickening of the pyloric end of  the stomach, so as to convert this
part into a kind of pouch, distinguishable through the anterior wall
of the belly during life.   The details of the cases are insusceptible
of a common description, far less of a single  explanation;  but it
seems probable that the accumulation of the gastric contents, which
forms the immediate cause of the dilatation and thickening of the
coats of the stomach, is chiefly due to a local failure of a muscular-
contraction, itself the result of that destruction of tissue which the
ravages of  the ulcer bring about. And although a full considera-
tion of the origin of these pouches would lead us too far from ouil,
present subject, I may point out that  the dilatations or "amplia-
tions" of the stomach caused by gastric ulcer  seem  to include
representatives of two different kinds, each of which may be traced
in other gastric maladies.  Thus the  stricture brought about by
the contraction of the  cicatrix of an ulcer  usually gives rise to an
obstruction, such as produces a state of hypertrophy and dilatation,
strictly analogous  to that variable admixture of these  conditions,
which often complicates  a scirrhus of the  pylorus.  But in rarer
instances, with no material stricture or obstruction, we meet with
a more localized dilatation and  hypertrophy; engaging, it may be,
no  part  of the stomach  save its pyloric sac;  and exactly corres-
ponding, by  its intestinal extremity, to some unusual  destruction
of the gastric parietes:—to complete division of its muscular coat;
or to a tunnelling of its submucous areolar tissue by the ulcerative
process, .which raises a bridle or bridge of mucous membrane from
off  this areolar  tissue, and  this  constructs a  new and abnormal
channel for the  food, such as  allows of the complete  disuse and
collapse of the natural outlet of the organ.   It is to these cases  (some
of which offer a curious  analogy  to the ravages of what is usually
termed a dissecting  aneurism)  that  I  should specially apply  the
above conjecture; explaining the dilatation and hypertrophy with
which they are  associated as due to an embarrassment or failure
of peristalsis, rather than to  any definite occlusion, such as  seems
to  be  definitely contradicted by the  patulous condition of  the 
ULCER OF  THE STOMACH.
127
ulcerous segment.  And by so much as any of them offer a true
destruction of muscular substance, they may be regarded as analo-
gous (at least in the locality of this destruction) to that interesting
class of dilatations of  the stomach  in which, with  little or no
hypertrophy, the tube appears  to evince an  extreme muscular
atony, itself  the cause of  the dilatation, and often  the result of
some evidently nervous disease.  In  other words,  not only are
hypertrophy and dilatation producible by destruction of the parie-
tes of the tube, as well as by obstruction of its cavity;  but the
mere paralysis  of any segment  of the alimentary canal involves
its own  dilatation, as well  as  the hypertrophy of  the  nearest
healthy part  behind it which can share in that dilatation.  In short,
as a matter of morbid anatomy, a patulous state of the canal does
not disprove the existence of a mechanical obstacle:  since such an
obstacle is at once created by a mere failure of contraction.  All
interruption  to peristalsis is pro tanto obstruction; and if not com-
pensated by hypertrophy, ends in dilatation, as  the result  of the
accumulation and distension which  the gradually increasing con-
tents of the stomach or  intestine inevitably produce above the
obstructed parts.  (Compare the  remarks  on dilatation  in Lec-
ture Y.)
   There  are other complications of  adhesion and cicatrization
which we may dismiss with a very brief notice.  In some instances
the  surface of  a broad ulcer becomes completely  skinned over,
while its firm and extensive  adhesion to the  neighboring  wall of
the  belly seems  to prevent the  complete contraction  of the cica-
trix.  Here (just  as in adherent wounds of the stomach, attended
with much destruction of its walls) the  mucous membrane around
the margin of the depression or pit formed by the cicatrix becomes
prolapsed and protruded into it, and is thus maintained in perpetual
contact with the smooth base of the ulcer.1  Where the adhesion
is smaller and less substantial, it is sometimes drawn2 out by the
constant traction  the stomach exercises, so as  to  form  a  short
and  funnel-shaped tube, which is lined by the smooth quasi-serous
surface of the cicatrix.
   Perforation.—We have  already alluded to the simplest and most
frequent variety of perforation as  being a mere  extension  of the
ulcerative process to the peritoneum, followed by the sloughing or
rupture of this delicate membrane, and  by the effusion of the con-
tents of the stomach into the  peritoneal cavity, with the result of
fatal peritonitis.   But before passing on to consider those modifica-
tions of this  process which have sufficient pathological interest to
deserve a brief notice, we  may point out a few general considera-

  1 It is not impossible that the friction of such an abnormal surface may favor
that recurrence of the ulcerative process which  appears often to obtain in such
cases.
  2 A process of elongation which is also seen in peritoneal adhesions of other
abdominal organs. 
128
ULCER OF THE  STOMACH.
tions respecting the event to which the term "perforation" is gene-
rally applied.1
  The history of a large number of such cases has been nearly as
follows.   A person, often a young  and apparently healthy female,
in other instances dyspeptic or chlorotic during a variable  time, is
suddenly attacked, soon after a meal, with excruciating pain in the
belly, followed by all the symptoms of peritonitis, speedily ending
in death.   Such  a rapid transition from apparent health to  agoniz-
ing pain and death naturally excites much attention; and sometimes
leads to the suspicion of  poison.
  But though the interest thus attracted to these cases had given rise
to much speculation respecting their nature and origin,  still it had
not led to their being collected and sifted  in such a manner  as to
admit  of  valid conclusions respecting many  of their details, until,
four years ago, I brought together from various sources  234 in-
stances of such  perforation.   The  information derived from these
cases suggested the following conclusions.
  As regards the frequency of  perforation  in the  course of gastric
ulcer, its  occurrence is so far exceptional, that not more than 1 in
every  7 or 8 cases of this lesion (1 in 7.45=13.4 per cent.) termi-
nates in this way.
  The sex of  these cases of perforation offers  nearly the same pro-
portion as that  which we have deduced for the ulcer generally.
The 234 instances collected consist of 160 females and 74 males;—
a ratio of about  2 to 1.
  In respect  of  age, however,  there is a remarkable contrast be-
tween  the perforating  ulcer and the ulcer generally.   The latter
we  have found especially to  affect the periods of middle  and ad-
vancing life, with a frequency that gradually increases  up to the
extreme age allotted to  Man.   But the perforating  ulcer not only
selects another period of life, but exhibits a marked contrast of age
in the  different sexes;  the period of life in which it  is most liable
to occur being quite a different epoch in the male  and in the female.
  Thus,  from a careful analysis2 of these cases and their ages, we
deduce the following conclusions:—■
  The total risk  of perforation during the whole of life is nearly
equal in the two sexes.
  The general or average liability to perforation, in both sexes
collectively, undergoes a constant decrease as life advances;  even
though the liability to the ulcer itself  is just as  constantly on the
increase.   The amount of these two changes of risk is such that

  1  To  avoid misunderstanding, I use the term " perforation"  in its ordinary
sense—namely, that of such a penetration of the walls of the stomach as  allows
the  effusion of its contents into the peritoneal cavity.  Of course, pathological
accuracy would require us to regard  perforation as having taken place in all cases
in which these walls had been penetrated, no matter  what viscus or exudation
might stave off the  ordinary consequences of this solution of continuity.
  1  The details of this analysis will be found in the "British and Foreign Medico-
Chirurgical Review " for January, 1856 ; and in the monograph already cited. 
ULCER  OF  THE  STOMACH.
129
we may estimate the risk  of ulcerous perforation of the stomach
as gradually sinking to one-half its former amount, as the indivi-
dual lives on from the age  of thirty to that of seventy;  while the
risk of being attacked by gastric ulcer is gradually rising to double.
  The distribution of this liability to perforation over the whole
of life varies materially in the two sexes.
  In the female about half of it (or the whole excess of cases over
those seen in the male) fall upon the years between the age of four-
teen  and thirty; and one-third upon the six years between fourteen
and twenty.  In the male it is a constant proportion up to the age
of fifty, and diminishes but little up to that of seventy.   Hence the
average  age of the subject of perforation  also differs in the two
sexes being twenty-seven in the female, forty-two in the male.
  Such a remarkable liability to perforation at this epoch of female
life,  naturally suggests the physiological events of this  period as
more or less immediately causing  the occurrence.  But not only
do the proportions of older females, and of males, who succumb to
this  accident, afford abundant evidence that  it is essentially inde-
pendent  of any such cause, but the circumstances of many of these
cases themselves inculcate  great caution in coming to  any definite
conclusion of this kind.  Some of them are expressly mentioned as
not  having  arrived at puberty;  others  are  recorded  to have
menstruated regularly, and even profusely; and, finally, one of
the most characteristic instances occurred in a person who, though
supposed to be  a  female, was proved  by a careful necropsy to be
devoid of ovaries; and  therefore, physiologically speaking, alike
incapable of menstruation, or of any  conceivable disorder of this
function.
   And whatever the relations which the various symptoms of such
cases bear to each other; or however expedient it may be to regard
these,  with their age and  sex,  and their liability to perforation, as
constituting  them  a special group; we  know nothing at present
which would justify us in regarding them as pathologically distinct
from others.  On the contrary, there is every reason to affirm, that
in a  large number of the  females who become  the  subject of the
lesion at this epoch of life, it has precisely the same origin, course,
termination, and appearances as it would have in any other person,
whether old or young, male or female.
   The maximum and minimum ages scarcely deserve notice. The
oldest case  I am acquainted with is that of a man of eighty-two;
the youngest a girl of eight, and a boy of nine years.
   As respects  the situation of  the perforating ulcer, a careful con-
trast of  large numbers  of this  and of the non-perforating lesion
indicates that this  circumstance has a remarkable influence on the
accident of perforation.  For though  the  posterior  surface of the
stomach  is the part most  frequently the seat of ulcer, it is one of
those  least liable  to  perforation;  while  conversely, the anterior
surface,  though much more rarely occupied by the  ulcer, is yet
       9 
130
ULCER OF  THE STOMACH.
one of the most frequent sites of perforation.   Indeed, if we may
rely on the cases thus analyzed, it would appear that the proportion
of perforations to ulcers is such, that of every one hundred ulcers
in each of the following situations,  the numbers which perforate
are—0n the posterior surface, about two; the pyloric sac, ten ; the
middle of the organ, thirteen; the lesser curvature, eighteen; the
anterior and posterior  surface at once, twenty-eight;  the  cardiac
extremity, forty; and the  anterior surface, eighty-five.  In other
words, in the first of these situations the probabilities are about
sixty to one against perforation; in the latter they are six to one
in its  favor; a fifty-fold increase of risk.   The relation  of these
surfaces to the occurrence of adhesion, as well as to  the nature of
the tissue which affects  it, has already been pointed out (p. 124).
   We  may perhaps notice the anomaly implied in the above state-
ment—that while the ulcer of the anterior surface perforates about
eighty-five times in  one hundred cases, the double  ulcer of the
anterior and posterior  surfaces  only does so about twenty-eight
times  in one  hundred,  or less than  one-third of that proportion.
Now we  can  scarcely  suppose  that  the  usual tendency of the
anterior ulcer to undergo perforation  is directly diminished to such
a great extent by the presence of another  ulcer on  the posterior
surface.  We are,  therefore,  left to  conjecture  some  original or
specific difference  in  the ulcerative process by which this anterior
ulcer  is  produced.   The  curiously  exact  apposition  of  the  two
ulcerated surfaces in many of these cases strengthens this suspicion;
and suggests that, in some of these instances, the anterior ulcer is
preceded and caused by the posterior one, the perpetual contact of
which  with the opposite gastric surface gives rise to  its secondary
ulceration, much -as a similar contact with the original ulcer often
leads to ulceration or suppuration of the liver, pancreas, and spleen.
That such a secondary ulceration should be less active, less intense,
and, therefore, less likely to perforate, would not be very surprising.
   The age at which  perforation occurs seems quite uninfluenced
by the site of the ulcer: the average age of 67 cases of perforating
ulcer of the anterior surface  of the stomach being exactly that of
perforating ulcer in general, in each of the two sexes (see p. 129).
   As  respects  any influence exercised by sex on the situation of
the perforating ulcer, it would seem that, on the anterior surface of
the stomach, this lesion  is twice as common, and on the cardiac end
five times as common in the  female as in the male;  in whom, con-
versely, the pyloric extremity appears to be  perforated three or
four times as often  as in the female.
   There can be no doubt that a  mechanical tension of some  kind
is generally the immediate cause of  perforation, by rupturing the
thin film of tissue to which the ulcer has already reduced the coats
of the  stomach.  Indeed, in  a great  majority of instances, the oc-
currence will  be found to have taken place  immediately after a
meal;  or in other words, with  a  distended  stomach.   And in less 
ULCER  OF  THE  STOMACH.              131
frequent cases we may find evidence of other mechanical agencies.
Thus, perforation  has been brought about  by vomiting;  by the
abdominal pressure on the stomach in the act of defecation; by the
rupture of a delicate adhesion of the omentum to the anterior wall
of the stomach, in the act of sneezing; by the sudden constriction
of the waist  by a  tight belt;  by the jolting of  a cart; and by the
displacement of a  kind of plug formed by the adherent omentum
in contact with the exterior of the ulcer.
   Complete perforation of the walls of  the  stomach is generally
accompanied by the sudden effusion of more or less of its contents
into the cavity of the belly.  But the degree  and extent of this
effusion are liable to great variety.  One or two instances are re-
corded, in which the accident has given rise to none of its ordinary
symptoms, and has been followed  by no appearances of peritonitis
in the dead body.  In some of these cases it seems very  doubtful
whether the perforation was really complete during life; or whether
the  aperture  observed may not have been caused by the solvent
action of  the gastric juice after death upon the film of peritoneum
forming the base  of the ulcer.  In others, the anomaly appears to
have been due to the state of the patient having prevented  the
access  of all symptoms; the perforation having occurred during
the  approach of death from the exhaustion produced by the ulcer,
or by  some independent disease.   In equally rare  instances  the
 stomach appears to have been retained in such close and  immova-
 ble  apposition to  the wall of the belly by the  abdominal pressure
 (see p.  57), that scarcely any of its contents have escaped, save a
 small quantity  of a clear fluid,  which has (as it were) filtered
 between the surfaces of contact, and lit up the fatal peritonitis.
   In other instances, the effusion of the  gastric contents is con-
 fined to the immediate neighborhood of the perforated spot; and
 the inflammation  which they excite, being equally limited, may be
 distinguished as  circumscribed  peritonitis.  These  cases  are of
 course less  immediately fatal than those in which a wider extent
 of the  serous surface is involved in the  inflammation.   But the
 patient often survives the first  shock of the accident, only to suc-
 cumb to  the combined effects of peritonitis and gastric  exhaustion.
 In  other instances, a different  result obtains:  the portion of the
 peritoneal cavity circumscribed by the  inflammation continues to
 suppurate, and is thus gradually  converted  into a chronic abscess,
 which  finally discharges its contents at  some point  or other of its
 exterior.  There  are about twenty cases  of this kind on record.
 Their age and sex give me precisely those averages which we have
 already deduced  for the accident of perforation  generally.  Their
 other features are almost as easily summed up.
   As implied above, the circumscribed  character of the inflamma-
 tion appears due to the limited  diffusion of the gastric contents;
 which, so far as  they reach, seem always to excite this process.
 What  restrains them in such narrow bounds it  is not always easy 
132
ULCER OF  THE STOMACH.
to specify.  Sometimes, however, it is evidently a deposit of lymph,
caused by extensive adhesive inflammation around the ulcer prior
to its perforation.   Sometimes the delicate omentum forms a septum
which bounds the lower surface of the sac.  Sometimes the trans-
verse colon lends a more or less temporary aid to the process: or
a casual coil of some other part of the  intestinal canal affords a
similar assistance.  Sometimes  the  aperture in  the peritoneum
seems too narrow to allow of more than an inconsiderable leakage,
such as spreads  very slowly on all sides of it.   In any case, the
apposition already mentioned as effected by the abdominal pressure
is soon  aided, first by the distension and immobility' which peri-
tonitis brings about, and  next by a rapid  effusion  of  lymph:—
two circumstances which combine to render such  localizations per-
manent, and  to seal up the mischief within the limits to which the
above mechanical causes tend for the time to confine it.
   The opening of a gastric ulcer into the chest is  generally accom-
plished by the mediation of such  an abscess : less frequently by a
recurrence or extension of the ulcerative process destroying an
adhesion between the stomach and the diaphragm.   The  penetra-
tion of this septum has been known to be followed by instantaneous
suffocation.  In most instances,  however, the fatal  event  is pre-
ceded by an  interval, during which gangrene of the lung or other
pulmonary lesions arise.  The  pericardium is very rarely opened.
   The communication of the ulcerous stomach with the exterior of
the belly  by a fistulous  aperture seems, in most  of  the instances2
recorded, to have been the result of a similar abscess, which  has
pointed and burst like an abscess of the liver.*  The gastric fistula,
once established, either  kills by exhaustion, or (what seems more
usual) gradually closes, just like the artificial fistula  established in
animals for the purpose of physiological experiment.   Subsequently
to its closure, the adhesion of the stomach to the anterior wall of the
belly is sometimes drawn out into a fibrous cord, which is occasion-
ally excavated by a funnel-shaped cavity, that is  itself continuous
with the inner surface of the stomach at its broad base, and is lined
by a smooth membrane of a serous aspect.
   The communication of the stomach with other parts  of the ali-
mentary canal, as the result of gastric ulcer, is generally independent
of any such abscesses.  The ulcerated part of the stomach becomes
attached by lymph to some portion of intestine in contact with it:
and a mere extension of the ulcerative process successively removes
the coats of the stomach, the lymph and  the coats of the intestine,
where these are united to each other.  As regards the situation of
such abnormal apertures, there are one or two cases recorded in
  1 Compare p. 68.
  2 About six or eight undoubted cases of this kind are all I can recollect to have
met with.
  3 In one case of this kind, fatal by hsematemesis, the abscess in front of the
stomach communicated with a suppurating cavity which occupied the areolar
tissue of the rectus abdominis muscle. 
ULCER  OF THE  STOMACH.
133
which the stomach has opened into the neighboring segment of the
duodenum;  and about ten in which a similar communication  has
been brought about between the stomach and colon.   The compa-
rative frequency with  which this segment of the canal is selected
as the  site of the communication, is  of course referable chiefly to
its situation and size.
  The  frequency with which ulceration  implicates the liver and
pancreas cannot be exactly estimated.  But  in the large propor-
tion of  ulcers (70 per cent.) occupying the posterior surface and
lesser curvature of the  organ, these viscera are often attacked.  The
cardiac  extremity of the stomach is very rarely the seat of the
ulcer;  and hence  penetration of the spleen  belongs  to the rarer
sequelae of the malady.  And as none of these viscera can be exca-
vated by the ulcer unless they have been previously attached to
the stomach by adhesive inflammation, 'the perforation which their
excavation really implies, has a much less dangerous character than
where it opens the peritoneal sac.  The chief danger, indeed, seems
to be that  of hemorrhage;  either from  the arteries which  course
along the upper border of the pancreas, or from the smaller vessels
which  ramify in the substance of the liver and  spleen for their
supply.  Gangrene of the two latter viscera is,  however, by no means
infrequent.   And  of course, the adhesions alluded to may them-
selves at any time become  the seat  of further ulceration;  which,
without causing any new perforation of  the  coats of the stomach,
may extend through the more or less organized  lymph into  the
cavity of the belly and thus cause a fatal  peritonitis.
  Hemorrhage is another incident of ulcer of the stomach which
deserves a special  mention.  We have  already  noticed that  dis-
charge of blood from the mouth or anus,  which generally follows a
considerable gastric hemorrhage, as constituting one of the most
important symptoms of this  lesion.   So  that we have now only to
describe its mode of production, and its bearing on the termination
of the malady, as a cause of death.
  In respect to the sources of such hemorrhage, we may distin-
guish four: which generally come into operation  at different dates
of the malady;  and which certainly have a very different influence
on  its course.
  In the first place, analogy and observation coincide to indicate,
that the congestion which often attends the commencement of ul-
ceration of the stomach  may give rise to a  hemorrhage from the
vessels of the mucous  membrane.  But since, without any existing
breach of surface, we  cannot define  the  case as ulcer, while, with
it, we can rarely exclude the possibility of  this lesion having been
the source of the bleeding, such a cause of  hemorrhage is rather
to be admitted as a probability, than stated as a fact.
  The progress of the  ulceration itself determines the three  follow-
ing varieties of hemorrhage.  As the breach of surface gradually
involves the vascular  mucous  membrane, it  successively erodes a 
134
ULCER OF  THE  STOMACH.
vast number of vessels:—at first mere capillaries;  then the minute
arteries and veins from which these  capillaries ramify; and lastly,
the small vessels of the arterial and venous plexuses which occupy
the submucous areolar tissue.   The  hemorrhage  permitted  by
these numerous solutions of continuity is probably often arrested
at once by a coagulation of the blood within the open extremities
of the  eroded vessels.   More  frequently, however, it gives  rise to
a slow drain of blood in very moderate quantity.   This, as it flows,
mingles with the secretions and contents of the stomach, and  gradu-
ally undergoes the  usual  changes of blood when  exposed  to  the
digestive action of  the alimentary canal: exchanging its crimson
color for one which is almost black, and exhibiting (if in sufficient
quantity for such a change to  be visible) a viscid  or tarry consist-
ence.   In  rare instances,  the quantity of blood  thus set  free is
much  more considerable, and closely imitates the  more important
hemorrhage which forms the third variety.  In such cases we may
conjecture the hemorrhage to be increased  by a sudden congestion
of the ulcerous stomach.
   The third and most  serious  class of hemorrhages is one in which
the bleeding comes from a large artery of the stomach.  Consist-
ently with such a source, it will generally be found to occur  at that
later stage of the  gastric  ulceration, when,  after  penetrating  the
mucous and the muscular coat, it reaches that interval between the
latter and the  peritoneal coat in which these vessels run;  or when,
in the  case of  an  ulcer of the posterior surface, it eats into the ad-
hesion, fixing  it to  the pancreas, so as to erode the splenic artery
which courses along the upper border of this gland.  (Compare
Fig. 8, p.  31.)
   The  blood  poured  out  by such hemorrhage often retains  the
characteristic  marks of its arterial  source after its expulsion by
vomiting.   In other instances, it assumes a dark and clotted  ap-
pearance;  in a degree  varying with its  amount, the rate of its flow,
the gastric contents with  which it  has been  mixed, and similar
circumstances. In some  cases it is rapidly effused in  such  vast
quantity that  death ensues almost instantaneously; and it  is only
at the  necropsy that its cause  is revealed, in  the shape of an enor-
mous mass of clotted blood, distending the stomach and a variable
extent of the  intestinal canal.
   Such hemorrhages  have one feature in common with perfora-
tion—namely, that  they generally occur  soon after  a full meal.
The mechanical  influence of gastric distension in disturbing the
eroded vessel  is too obvious to require  any comment.   It seems to
be assisted by that afflux of blood to the stomach which attends its
digestive  act.  This view is confirmed by several cases, in which
the hemorrhage has followed a violent mental emotion.  Doubtless,
also, the occurrence of both hemorrhage and perforation soon  after
meals  is greatly aided by the  solvent effect of the gastric juice then
poured out. 
ULCER  OF  THE  STOMACH.
135
   As  regards  the  frequency of these  larger bleedings, they  are
often absent during  the  whole progress of the ulcer.  In many
cases, again, they do  not  cause  death.  And  even when  they are
fatal, it is rarely by a single attack.
   In many instances  the  necropsy has  shown a peculiar condition
of the  vessel, such as quite explains the intermittent, though re-
peated character  of these hemorrhages.  The ulcer has cicatrized
over its whole  extent excepting that point in its centre which is
occupied by the eroded artery.   And the  calibre of this tube  has
been found filled by a clot, the casual  detachment of which from
time to time has evidently been the cause of the hemorrhage.
   The fourth kind of hemorrhage has  already been alluded to, as
forming what is strictly a sequela of perforation, and as consisting
in the erosion of vessels occupying the substance of the liver, pan-
creas,  or  spleen.   These  vessels are  generally the  small  arteries
and veins of the proper  substance or  parenchyma of the above
glands.  And  in the  moderate hemorrhage to which their breach
of continuity  usually gives rise, the blood effused undergoes a
change similar to that noticed in the second variety.
   As  regards  death  by hemorrhage in ulcer of the  stomach, its
frequency appears  to correspond  with  a proportion of 1  in 20—
30, or 3—5 per cent.  It appears to  be nearly four times as  fre-
quent in  the  male  as in  the  female.   The  average age of  the
patients is the same in both sexes:—about  forty-three years.
Unlike the perforating  ulcer, the situation of the ulcer  causing
such hemorrhage seems no way peculiar.  The protracted duration
and great depth of these lesions are their chief features; the influ-
ence of which in causing such hemorrhage is obvious enough.   The
source  of the hemorrhage is almost  invariably  one of the three
large arteries of the  stomach, or some primary branch of them.
Which of the three, is dictated chiefly by the situation of the ulcer;
the  posterior surface being the usual  seat of ulcers  eroding  the
splenic artery; while, for equally obvious reasons, it is in  or near
the smaller curvature that we generally find the source of an ero-
sion of the coronary or superior pyloric vessel.  The splenic is  the
artery which suffers  most frequently;  its  proportions (about  55
per cent.) being referable/ not merely to its larger size, but to its
closer  fixation, and to the greater frequency of  the ulcer on  the
corresponding surface of the stomach.   The rare instances of fatal
hemorrhage from the  eroded substance of the liver or spleen, show
a similar contiguity of the lesion.  (Compare pp. 31, 32, Fig. 8.)
   Concerning  exhaustion or starvation,  as one of the terminations
of gastric  ulcer, I can only tell  you that there is  no doubt,  both of
its frequent occurrence, and  of  its being often amenable to treat-
ment.   You will easily understand why I cannot offer any precise
numerical  estimate of its frequency, such  as  I  have adduced  for
the other modes of death in this malady.   Considering, for instance,
that it is often  not so  much  difficult as  impossible to analyze  this 
136
ULCER  OF  THE  STOMACH.
state in any given case—to separate the direct influence of the ulcer
on the digestive powers of the stomach from the results of the vomit-
ing it excites,  or from the debility produced by moderate hemor-
rhage—you will not wonder if I offer you conjectures rather than
large and accurate facts like those I have elsewhere set before you.
  All  the information I have been able to collect, suggests or con-
firms the following propositions.  Even in the middle-aged subjects
of this lesion, death by exhaustion claims somewhat about three,
four, or five per cent, as being  evidently the chief (if not the sole)
cause of death.  Indirectly, it  is far more frequently the cause of
this event: by rendering unusually fatal some one or other of those
illnesses which, in  the  course of years, few  persons  altogether
escape; and in which any serious impairment  of one of the most
important structures and functions of the body must suffice to turn
the wavering balance of life or  death. •
  And as regards the older subjects of gastric ulcer, I would assert
a very similar proposition.  Remember, I would  say (not as a
moralist, but as a physician), that we all  bear with  us the seeds of
a mortal disease, to which, even if we escape all other maladies, we
must inevitably succumb—old  age.  Whether for prognosis or for
treatment, the influence of age  on the course and event of disease
cannot be too sedulously borne in mind.   Certainly in this malady
it is all-important.   Despite the small absolute  number of these
lesions found at advanced ages—a fact which  doubtless  renders
their comparison with the small number of such persons living, and
the large proportion  it affords, somewhat less trustworthy—it is
impossible to doubt the substantial accuracy of the conclusion to
this effect previously deduced  (p. 120).  Both  from the foregoing
wide inquiry, and from careful clinical observations  extending over
many years, I  cannot  but conclude that mere  age, as such, has a
remarkable influence, not only in producing this disease, but also
in aggravating its effects when produced.  In about  thirty per cent.
of all cases of gastric  ulcer, it is probable that the lesion gives rise
to a process of marasmus or partial exhaustion, which anticipates,
hastens, or increases that gradual failure of  the nutritive functions
which is one of the most essential elements of death by old age.
  The relation of gastric ulcer to cancer of the  stomach  we shall
consider in treating of the latter disease.  At present it need only
be said, that though  the former is doubtless capable of provoking
a cancerous deposit,  yet  the estimate of some good observers—
that of every hundred gastric ulcers, ten exhibit concurrent cancer
of other organs—must be partly explained  by the  great difficulty
sometimes found in  distinguishing two lesions  which, whatever
their pathological  relations, can generally be  distinguished  on
anatomical grounds.
  The ordinary combinations of ulcer with  cancer  of the stomach
seem to be chiefly limited to a cancerous degeneration or  deposit
that involves the hard brawny mass which we have already  (p. 121) 
ULCER OF  THE  STOMACH.
137
noticed as generally present, in variable  quantity, in the base or
periphery of an ulcer of long standing.  In rare instances, in which
the whole of the substance around the ulcer is converted into a
cancerous excrescence, it is chiefly by the shape and other charac-
ters of the ulcerated depression that (in the absence of any history
of the case during life) we should discriminate between the can-
cerous degeneration of the  hard margin of an ulcer, and  the ulcer-
ation of a growth originally cancerous. But in  a majority of such
cases the  decision is less difficult.  Indeed, a not  infrequent form
of such a combination appears to be that  in which a fungus (gene-
rally a bleeding one) shoots up from the basis of a  gastric ulcer,
the characters of which are in all other respects those usually seen
in this lesion.
   Lastly, as regards the  complication of the  gastric ulcer with
lesions of other organs, it  appears from the statements of Jaksch,
Dittrich, and .Engel, which refer  to some hundreds of ulcers, that
pulmonary tubercle is present in about nineteen or twenty per cent.
Jaksch and Engel also concur in estimating the frequency of pneu-
monia and pleurisy at  about twenty-seven per cent.  Engel finds
ten per cent, to be preceded by syphilis.   While both from the
records I have examined, and from my own personal experience,
I deduce the general conclusion; that the lesion is associated with
a large number of diseases, in proportions much more akin to those
of their known frequency  than to any other of their circumstances.
   Such a conclusion is of course quite  compatible with  the sug-
 gestion, that the long  and exhausting malady which  gastric ulcer
 produces, and which is the  expression  of a serious lesion in so
 important an organ as the stomach, perhaps predisposes the consti-
 tution to a variety of  other diseases.   It is chiefly as regards the
 special maladies that  the contrast above hinted at becomes indis-
 pensably necessary.  For  example, the large percentage of phthisis
 renders it one of the most frequent complications of gastric ulcer,
 according to all observations hitherto on record.  But  the signifi-
 cance of such  a proportion must evidently depend, not so much on
 its absolute amount, as upon a comparison of this with the  average
 share taken by phthisis in the mortality  from all  causes.  In other
 words if the gastric ulcer really had  any direct influence as a- pre-
 disposing cause of phthisis, we should expect to find, not merely a
 lar^e absolute number of ulcerous cases dying with this  malady,
 buf such a proportion as would considerably exceed  the  average
 ratio of the deaths by phthisis to those from all causes indifferently.
 But since the deaths  by phthisis, in persons of both sexes above
 the age of twenty, amount to rather more than eighteen per cent.
 of the deaths  from all diseases, the statement that twenty per cent
 of the cases of gastric ulcer die of phthisis, is one which,  even it
 confirmed  by  a  wider series of  observations, will by no means
 justify us in assuming any such causatiom                 _
    The aetiology of the gastric ulcer has  hitherto been a subject of 
138
ULCER OF  THE STOMACH.
conjecture rather than for inductive inquiry.  And while the facts
I have adduced with such an object correct some errors and suggest
various interesting  conclusions, still they are far from affording a
complete explanation of the causes of this lesion.
  (1) There can be  no doubt as to the physiological circumstances
which predispose  to this  disease.   Old  age, privation,  fatigue,
mental  anxiety, and intemperance so frequently coincide  with it,
that we are  fully entitled to regard them as its (more or less imme-
diate) causes  in a  large  proportion  of cases.  Of  these causes,
advancing age seems to  be that which is most distinct and  indis-
putable, and which rests on the broadest numerical basis of facts.
But the careful clinical  study of the malady leaves just  as  little
doubt with  respect  to poverty and intemperance.
  (2) We have  found reason to  qualify the  ordinary notion with
respect to the influence  of the access of  female  puberty, and  its
attendant disturbances of health, in the production of the gastric
ulcer.   At least we have seen that this epoch predisposes, not so
much to the occurrence  of this lesion, as  to a peculiar character
and termination of  it; that it is a want of reaction, and a tendency
to  perforation, rather than a proneness to  ulceration, which  our
existing data would  entitle us to assert.  And  even should this
opinion be hereafter modified by a larger series of cases than those
which have led me to this conclusion, there will still  be such a
preponderance in the total formed by the  gastric ulcers of the
male, and of the middle-aged and aged female, as to exclude the
above group from  any general significance  in the aetiology of the
disease.
  (3) Respecting the influence of the puerperal  state, as well as
of  lactation, I can  only  say that, in the instances in which these
conditions have been coincident with  gastric ulcer, the connection
has seemed to  me explicable by well-known physiological laws.
In  the former state, for instance, the ulceration has appeared to be
a relapse or  recurrence  of  a similar morbid process  suspended
during pregnancy: in the  latter, to be partially referable to the
exhaustive  effect of  suckling on a feeble  constitution—perhaps
sometimes aiding an  analogous relapse.  And I know of no facts
which would justify  the  supposition of any more direct influence
being exercised by either of these conditions in the  production of
gastric ulcer.
  (4) The specific  diseases with which the gastric ulcer has been
observed to concur, seem far less influential  than the above phy-
siological conditions.  Pulmonary  tubercle,  pleurisy,  pneumonia,
syphilis, ague, and  fever, are the maladies most frequently revealed
by the necropsy and the previous history of cases of gastric ulcer.
But it has already  been  stated that the percentage of tubercle does
not seem to exceed its average in all persons indiff'erently.  And
the same statement will  probably apply to some  of the other dis-
eases above mentioned.   It would seem, too, from my own inquiries, 
ULCER OF  THE STOMACH.               139
that these  cases  of gastric ulcer do  not  exhibit that family his-
tory of phthisis  which we should expect, on the supposition of
there being any casual connection between the two diseases, and
which  we certainly find in pulmonary tubercle.
  (5) Many of the peculiarities  of the gastric ulcer appear to be
explicable  by the circumstances of stomach-digestion.  Ulceration
having once taken place, the ulcer is prevented  from healing, and
even increased, by those great and sudden  alterations in size which
the organ  undergoes at  different periods of digestion;  by the
chemical and  mechanical irritation of the food; and by the  solvent
action  of the gastric juice upon the languid tissues which form the
periphery and base of the  ulcer, or  upon the scarcely organized
lymph which has been poured out in this situation.1
  But in respect to the  aetiology of the lesion, such explanations
are useless.  For, in explaining what happens after ulceration has
once taken place, they afford no answer to the inquiry why ulcera-
tion takes  place at all; and especially why it  singles out this par-
ticular organ.
  (6) It may  be said, however, that the continuance and extension
of the gastric ulcer form  its chief characteristics:  the cicatrices
of ulcers are frequently found in the intestine; and that the pecu-
liarities of the ulcer of the stomach,  as contrasted with the  ulcer
of  any other part of the  alimentary canal, consist in its long
duration, its gradual enlargement, and its reluctance to cicatrize.
  It may seem hard to throw discredit upon an explanation pos-
sessing so  much practical usefulness as this certainly does.  But it
is the duty of clinical research to subject  to  strict scrutiny every
view not already established  on an irrefragable basis.  Now, not
only have  we no series of facts (such as the careful records of sys-
tematic necropsies would afford) sufficient  to establish the proposi-
tions these statements imply,  but all the information as yet at our
disposal inculcates the greatest caution in receiving them.  The
ulcer of the stomach appears to cicatrize, probably in many cases
without medical treatment directed to this end, in about fifty per
cent, of its total  numbers.  It does not seem to perforate  oftener
than about once in eight  cases.  No doubt, the  class of intestinal
ulcers, as  a whole, offers a large percentage of cicatrices, and a
smaller of perforations, than  the  above numbers.   But the truth
of the above propositions assumes an amount of these numerical
differences such as we have at present no right to assert.
  Further, if  we examine into  the details of those  lesions which
would be grouped under the terms " gastric" and " intestinal" ulcers,
we shall find reason to attribute still less value to the above numeri-
cal  differences.   For we have seen that the  majority of ulcers of
the stomach cannot, in the present state of our knowledge, be traced
to any specific constitutional disease.   While we know that almost

  1 Compare  Dr. Budd's " Lectures on Diseases of the  Stomach," Medical Times,
1853, vol. vi. p. 618. 
140
ULCER  OF  THE STOMACH.
all those intestinal ulcers we are now contrasting with them merely
form the local expressions of a general malady; by the nature, rate,
and duration of which they are themselves dictated and regulated.
The typhoid fever reaches its term, and the exulcerated agminate
follicles generally heal over; the attack of dysentery subsides, and
its ravages  in  the large intestine are more or less repaired; the
phthisical cachexia continues and increases, and therefore  the ul-
cers  it has  produced also persist and extend.  It is not impossi-
ble that ulcer of the stomach may be sometimes due to a chronic
vice  in the  organism which  dictates  its occurrence, duration, and
cessation, like the typhoid, dysenteric, or tubercular states of the
constitution  respectively.   But  in default of all  evidence to show
that this represents a frequent form of the lesion, there is,  at any
rate, sufficient difference between the two classes of  " gastric" and
" intestinal"  ulcer, to forbid the unqualified reception of any patho-
logical theory which regards them as alike in all save their mechani-
cal and chemical  circumstances.  Besides, it seems very easy to
overrate the influence of the- circumstances above alluded to, in
retarding the progress of cicatrization in the ulcer of the stomach.
Wounds of  this viscus  heal with  great facility, not only in the
domestic mammalia usually selected for the purposes of physiological
experiment, but in the healthy human  subject.   Indeed, in  both
man and animals, fistulas of the stomach seem to progress naturally
towards closure and cicatrization, although placed under conditions
apparently less favorable to such a result than many other fistulae.
While, as already mentioned, the ulcer itself heals with a frequency
that  can scarcely  be explained by any theory which makes the
circumstances of the digestive  process  so principal or special  a
cause of its persistence.   Lastly, every  organ  is adapted  to its
circumstances,  and is  generally organized to resist any unusual
exposure which these may imply.
  (7) The morbid appearances which  inaugurate and  attend the
ulcerative process would probably throw some light  on its  causes.
But unfortunately these still remain almost unknown to us.  Direct
observation  is  hardly  possible.   Analogy has little value.   And
the scanty  and imperfect details adducible  from  both of these
sources, are  scarcely even consistent with each  other,  much less
applicable to any single view of the aetiology of gastric ulcer.
  It may,  however, be noticed, that  necropsies  sometimes show
ulcers of the stomach associated with more or  less circumscribed
patches of  congestion, ecchymosis, or  extravasation, which are
regarded as  the beginnings of similar lesions in the neighborhood
of these ulcers.  A similar (though quite distinct) class of appear-
ances,  constituting the " hemorrhagic erosion"  of Rokitansky,  is
believed by him to represent the mode by which  the  ulcer  com-
mences.  But,  to say nothing of the  comparative  rarity of  these
appearances in conjunction with the gastric ulcer, the irregularities
which often affect the distribution of blood after death in the digest- 
ULCER  OF  THE  STOMACH.
141
ive canal (see Lecture II.) suggest  great doubt as to how far the
first class of phenomena form decisive evidence of  commencing
ulceration.  And the last is not only partially open to the same
objection, but appears to be quite  a  distinct  disease  from gastric
ulcer, capable of continuing an indefinite time without showing the
slightest disposition to merge into it, and  exhibiting a  different
train of symptoms.  (See p. 95.)
   In still more exceptional cases we  find other phenomena which
suggest similar doubts.  A distinctly oval  or circular depression
has been found in the neighborhood  of an  ulcer of the stomach;
or the mucous membrane has exhibited an appreciable softening of
the same size and shape—once or twice in conjunction with a red-
dish or darkish tinge of discoloration.   Here, again, we  have no
sufficient  proof that these depressions or  softening  would  have
become ulcers,  or even  that  they  existed during life.  Analogy,
however, affords a strong presumption that some such process  may
originate  the gastric lesion;  by sometimes exhibiting an appear-
ance of this kind in the duodenal ulceration consequent on severe
burns.
   The extremely variable  appearances which  we have found asso-
ciated with  diff'erent  examples of the lesion, confirm  (or  even
increase) the  doubts  suggested as to  its commencement  by these
remarks.   For  practical purposes,  they distribute the ulcer  into
two classes; respectively attended  by appearances  of reactive in-
flammation, and devoid of  them; but merging into each other by
infinite shades  of admixture.  And  even in  the best-marked ex-
amples of the  latter kind—in which,  as  already (pp. 121,   122)
mentioned, there seems to  be  a mere removal of  tissue—we are
unable to  describe (or even to name) the process which effects it.
We may call it "destructive  absorption;" but we cannot decide
whether, even during life the destruction of ulceration may not be
aided  by a solution effected by the  gastric juice, or  whether the
absorption by the surrounding vessels is complete enough to ex-
clude all  effusion  of the dissolved tissues  into  the gastric cavity.
While as regards the appearances seen by us after death, it is often
impossible to decide how much of the soft, flaky mass which forms
the floor and margin of such a " simple" ulcer, really occupied this
situation  before death;  and how much is  to  be attributed to the
ordinary processes of gastric decomposition.   (Compare pp. 76 and
122.)
   It would therefore seem  that our existing information  not  only
affords no single  theory of gastric ulcer, but definitely negatives
any such view. Judging by the really vast array of facts now col-
lected, not only is there  every reason to deny the existence of any
specific disease  that can lay claim to the title of " the ulcer of the
stomach,11 but the  numerous varieties in  the  form, progress, situa-
tion, number, and termination of  this lesion, seem  to find  their
parallel in the causation of the malady, both as regards the organ- 
142
ULCER OF  THE  STOMACH.
ism generally and those first departures from the normal state which
inaugurate the local mischief.  In short, we have no more right to
talk of the ulcer  of  the stomach  than of the ulcer of the leg; no
more reason to assume an invariable commencement of the gastric
ulcer by hemorrhage, or by softening, or by a submucous deposit
of lymph, than we have to restrict the beginning of  what is evi-
dently a similar process of ulceration in the limb to an ecchymosis,
a pimple, a superficial abscess, a burn, or a varicose vein.   And
just  as daily  experience assures  us  that external or  cutaneous
ulcers may begin by either of these lesions—may have, that  is,
either of them as its immediate and conditionating cause, and yet
retain a general  identity of that  ulcerative process to which  they
are chiefly due—so not only do these very facts afford us fair grounds
for supposing  a  similar diversity in cases of ulceration affecting
the stomach, but all that we  have been able to glean  respecting
such ulceration confirms this analogy.  The variety of diseases with
which it appears  to be connected, the equally numerous and diverse
physiological conditions that favor its occurrence, can only thus be
explained.  Ague, fever, the ingestion of alcoholic irritants, or the
vascular disturbances of female puberty, might perhaps be supposed
to facilitate  or  cause ecchymosis.  But the conversion of this he-
morrhage into an ulcer implies a process of destruction, which no
mere extravasation would explain; and the causes of which are hut
partially traceable in the cachexia of the aguish or feverous conva-
lescent, the toxaemia of the drunkard, or the want of due light and
air to which many of the future mothers of our nation are condemned.
While the influence  of old age, privation, or fatigue, which throws
little or  no  light on the precise  local change that ushers  in the
ulceration, exactly concurs with the efficacy of these circumstances
in the production or promotion of ulceration elsewhere.  In like
manner, to grant that the circumstances of digestion  often retard
the healing of a gastric  ulcer—and the marked effect of treatment
specially directed to  these circumstances proves no  less—is to con-
cede nothing more than what {mutatis mutandis) we may verify for
an ulcer of the leg;  in which  the same event is equally  under the
influence of such physical circumstances as exercise, posture,  pres-
sure,  and the like.  Nay, more,  the  analogy not only  applies to
these details, but  appears to illustrate some of the remarkable facts
previously elicited.  For example, we found reason  to  conclude,
that the epoch which immediately follows the access of puberty in
the female imparts to the gastric ulcer peculiar  characters, best
summed up  as a deficiency of  that  inflammatory reaction that
generally engages the base and margins of the lesion.   And a  simi-
lar character has  been observed in the ordinary cutaneous ulcer at
the same period of life; associated, too, with an analogous cachexia,
and with an equal disturbance of the menstrual flux.'  Indeed, the

  1 Critchett "On Ulcers of the Lower Extremities," p. 107, et seq.  London,
1849. 
ULCER  OF THE  STOMACH.
143
resemblance of the two lesions is completed by the facts, that in
both the ulcer precedes the amenorrhcea,  and often exhibits an
aggravation of its symptoms at the menstrual periods.
  We are left to notice certain  considerations which,  though quite
independent of any such theory of gastric  ulcer as those just de-
murred to, are nevertheless scarcely  less true, and far more useful,
than would be the  most dogmatic  view  of this morbid process.
That  ulcerations,  sufficiently large  and continuous  to merit the
title of "ulcer," are, on the whole, far more common in the stomach
and duodenum than in  any equal area  of intestinal mucous mem-
brane, is a statement which may be  as broadly expressed, as it  is
absolutely  implied in many of  the foregoing pathological data.
And  difficult (or, indeed,  impossible) as  it has hitherto been to
explain how  the  gastric juice—the only agent assignable to this
precise locality—can originate (as it  notoriously does  maintain and
enlarge) gastric ulcers, yet the exact co-extensiveness of ulceration
and gastric juice—in other words, the  coincidence in place of the
lesion and  the solvent—has of course  suggested a casual relation
between them.
   To the statement of this coincidence I may add that of another,
which repeats, in perhaps a more exact form, the same contrast of
comparative frequency.  It may  be confidently asserted that the
cancers of the stomach and duodenum (but especially the former)
ulcerate much more frequently, as  well as  much earlier, than do
those  of the  various other parts of the  alimentary canal.  This
statement  must of course be taken in such a strict pathological
sense as would allow us to find its  illustrations in outgrowths of
analogous  form,  species,  and duration, and not in cancers essen-
tially so diverse  in  many of these respects, as are ordinary cases
of  cancer of the rectum contrasted with those  of the pylorus.
   The abrupt gap thus left in the  aetiology of gastric ulceration,
by any careful and  conscientious survey of its numerous aspects,
need, I think, no longer be the  main feature in  its picture, but may
be almost regarded as filled up.  It has, perhaps, been long bridged
over  by any  who could complacently assume that  the two  well
known and striking facts  above  mentioned explained each other,
without feeling bound  to  adduce one tittle of evidence as to how
they did so.
   Hitherto no one has been able to  surmise how the gastric juice
begins any destruction or  solution of the stomach:  to assign, that
is,  any reason for  such a process of solution occurring with even
the frequency we have verified for  gastric  ulceration, and yet not
occurring  in every person, not to say every vertebrate animal, to a
decree downright incompatible with  health  aftid  life.  This has
been  the  reductio ad  absurdum  to  which  any explanation based
exclusively upon  the above coincidence would logically have led.
But Dr. Pavy's observations,1  while they remit to further, and  it
i See p. 46. 
144
ULCER OF  THE  STOMACH.
may be very different researches, the task of deciding how far an
undue acidity of gastric juice may inaugurate or enlarge an ulcer,
have the broad substantive  merit of indicating that any such ex-
treme congestion  as  can retard  and (however temporarily) arrest
the flow of blood  through a given  area of gastric  mucous mem-
brane, may thus allow this energetic secretion to cause what, with
more or less of  adjacent  reaction,  constitutes  an  "ulcer  of the
stomach."
  It is neither necessary nor desirable to carry out, in all its natural
consequences, this invaluable piece of information.  But  that it
throws  light upon many of the details of gastric ulceration col-
lected  in the preceding pages,  will  be obvious, I think, to those
who will take the trouble to glance over them with such a  clue to
their import.  Stagnation of gastric blood, whether as the physical
result of a cancerous outgrowth in the stomach,  or a venous occlu-
sion in the liver, or as the less obviously physical result of extreme
congestion inherent  to the vessels or tissues of the mucous mem-
brane, seems thus to be a main condition, a causa causativa, of
gastric ulceration; which, in so  far as it is the effect of a chemical
act of solution brought about by healthy gastric secretion, consti-
tutes a process very unlike that which we  elsewhere  connote by
this term.  The " ulcer," in short, seems to be in its outset a lesion
of  the vaso-motor system:1  an accident,  so to  speak, of extreme
gastric congestion.
                          TREATMENT.

  The means by which we endeavor to effect the cure of this dis-
ease may be all grouped together as subservient  to one or other of
the following purposes.  Of these purposes  it is not  too much to
premise that, just as they constitute the special indications of our
treatment, so the efficacy of any particular remedies we may select
will depend chiefly  on the accuracy with which the latter  fulfil
them.  To remove all local obstacles to the cicatrization of the
ulcer;  to support the  constitution  in  effecting  this process;  to
remedy the  results the  lesion may  have already brought about;
and to limit or arrest some of the more distressing and prominent
symptoms by which these  results are usually betrayed;—this  is
what we have to attempt, and can often really accomplish, towards
the cure of an ulcer of the stomach.
  In briefly glancing at these remedies,  we will accord  to medi-
cines, as  distinguished from  diet,  a rather unmerited precedence,
and consider them»first.   Such an order  is perhaps the more con-
venient, in that the  mitigation of symptoms which they can cer-

  1 Upon the class of lesions thus cursorily referred to, I may refer to Dr. Hand-
field Jones's valuable and original work just published. 
                  ULCER  OF THE  STOMACH.              145

tainly effect is generally the first step towards the slow progressive
cure of the malady.
  The question of bleeding is one which might almost be left un-
noticed, save by a simple protest against either the general or local
forms  of depletion.  A malady which not  merely originates, but
consists in,  a  process  of  destructive absorption;  which, in most
instances, implies some hemorrhage, in many, a dangerous or fatal
loss of blood ;  which is generally attended by symptoms of extenu-
ation and cachexia; and which specially affects the poor, the  intem-
perate, the ill-fed, the wretched, and the aged—is not one in which
any presumable local  benefit can counterpoise the obvious general
mischief producible by even a moderate loss of blood.  That a few
leeches to  the epigastrium will  often afford relief to the gnawing
pain which  torments the sufferer  from gastric ulcer, I see no  reason
to doubt.   That vascularity is (to speak  somewhat vaguely) so far
a condition of pain, that the re-distribution of  the blood  which
even a small general bleeding brings about may for the time  dimin-
ish suffering, seems also very probable.  But since depletion gives
but a temporary relief, while its weakening  effects on the constitu-
tion have a most mischievous local reaction, its adoption in this
malady may be compared with the  practice of the drunkard, who
stills his  stomach by a  dram, which  soon reproduces the very
craving it has for the moment appeased.
  But such a  view of  the effects  of  bleeding by no  means applies
to other forms of that revulsion which a French medical author has
characteristically termed  the " moiety of medicine."  Blisters, tur-
pentine stupes, mustard poultices, dry cupping, and hot fomenta-
tions, are exceedingly  useful adjuncts of this kind to internal reme-
dies.   The  symptom  which seems  to me  chiefly to demand the
application  of such  revulsives is pain; especially that continuous
gnawing pain which, in severe cases, sometimes occupies even the
intervals of the meals.  The epigastrium is  generally the most con-
venient site for  their  application.  But when the chief  pain is
referred to the dorsal region of the spine, they are often more effec-
tive when applied to this part.  As  regards the particular agent to
be  selected, the above enumeration  tolerably represents  the order
of  their usefulness, as  well as of  their severity.  Blisters are gene-
rally most serviceable in young and well nourished subjects, and
in comparatively recent cases, in  which they are not by any means
contra-indicated by pallor of countenance;  the less so, indeed, that
this symptom appears to be sometimes  partially due  to  gastro-
intestinal  congestion.   Tartar-emetic is rarely or never advisable :
it is too painful and troublesome, and lowers the patient  too much,
even if it does not sometimes give rise to other (and  more speci-
fically antimonial) effects on the system.   Turpentine and mustard,
which spare even that limited expenditure  of the liquor sanguinis
implied by the serous effusion of a blister, are preferable  in old
and chronic cases, in which the  strength is reduced; where they
       10 
146                ULCER  OF  THE STOMACH.

have the further advantage of being repeatable at shorter intervals
of time than the preceding counter-irritants.  Lastly, in those cases
in which  the powers of  the system are  exhausted by constant
vomiting, and (what  is rarely the case) the pain1  still forms a very
prominent  symptom, dry cupping is  the best means of mitigating
it.   Indeed, this derivative  seems to  be efficacious even in those
depressed and languid states of the circulation, in which turpentine
or mustard lose much of their effect.2
   A still more valuable remedy, of an opposite kind, may be often
found  in the local application of cold by means  of ice.   In many
cases of obstinate  vomiting or severe  pain, great relief may be
obtained by frequently swallowing small lumps or raspings of pure
ice.  And  in cases of hemorrhage its use is almost indispensable.
Here,  too,  it  is sometimes advisable to apply  it  externally,  by
means of a bladder partially filled with  powdered ice, and kept in
contact with the epigastrium for a few minutes at a time.3
   The  drugs recommended for  the  relief of  this  malady  are so
numerous  and  diverse, that it is scarcely  possible  to  avoid some
classification in discussing  them.   But  considering how moderate
is our  acquaintance with the action of many of  them on both the
healthy and diseased  organ, the only justifiable approach to a classi-
fication is  one that considers  each with relation to those special
symptoms which experience shows it can relieve.  In gastric ulcer,
as in many other  diseases, we must  both  choose and classify our
remedies on an empirical basis: and use their known physiological
and pathological effects chiefly as  means of suggesting their trial,
explaining their action, testing their efficacy for the disease in gene-
ral,  or forbidding  their application  to the particular case.   To
accord to our limited knowledge of this kind a higher function than
such a suggestive and deliberative one, would often lead us to over-
look, or even refuse, excellent remedies.  To rate it  at a lower

   1 The pain generally becomes greatly diminished on the access of exhaustion: a
fact which requires no explanation.
   1 One unpleasant consequence  of such applications I  may mention, though it
would rarely afford a definite contra-indication to their use.   In two instances that
have fallen under my notice, in which the necropsy revealed  old adhesions between
the stomach and the wall of the belly, blisters gave rise to a marked increase of
the pain.  A similar uncertainty attends the application of hot fomentations to
the epigastrium ; since in rare instances these seem to increase the pain, by raising
the temperature of the subjacent parts, including the seat of the lesion.
   3 The use of external cold being strictly empirical, both in these cases generally,
and  in  any given instance, it is hardly worth while  to inquire into any imaginary
danger of congestion of the ulcerated organ by revulsion of blood from the cooled
abdominal surface.  But how efficiently the stomach itself may be cooled by ice
applied  to the epigastrium, is illustrated by a converse  fact—namely,  that an
enema of cold water at 45° Fahr. soon lowers the temperature of the anterior wall
of the belly by three or four degrees.  (Compare E. H. Weber in Muller's " Archiv."
1849, Heft 4, p. 273 et seq.)  The effect of cold substances taken into the  organ is
well shown  by an observation of Dr. Beaumont's (op cit., p. 218), in which the
ingestion of water at 55° Fahr. lowered  the normal temperature of the stomach
during  thirty minutes. 
                  ULCER  OF  THE STOMACH.              147

value would soon lead  us  to confound recoveries and cures; and
thus to repeat the most dangerous (because the most plausible and
seductive) fallacy of homoeopathy.
  The relief of severe and  continuous pain is best effected by seda-
tives, and especially by opiates.  The form in which  these should
be administered is determined chiefly by the state of  other symp-
toms.  Where severe pain is accompanied  by very  frequent vomit-
ing, a  small pill of solid opium1 or of the watery extract of this "
drug, is often better retained than any other opiate.  Where diar-
rhoea is present, the compound kino powder is an excellent remedy;
with which we may combine what is calculated  to allay both the
flux and the pain—the trisnitrate of bismuth.
  There are probably few  drugs which have enjoyed a more dura-
ble or extensive repute  than this preparation of  bismuth in many
gastric affections attended  with much pain.  In the " morbid sensi-
bility" of the  older medical writers (a form  of  dyspepsia  which,
there  can  be no  doubt, always includes  a certain proportion of
gastric ulcers, and  which probably included a still larger number
when  this disease was comparatively unknown to  the physician),
the bismuth is  constantly praised as an efficacious sedative.   And
my own experience not  only corresponds to that of other observers,
in respect to its  usefulness  in this variety of indigestion, but would
lead me to regard it as  equally beneficial in gastric ulcer.   In
doses  of from ten to twenty grains, at intervals of six or eight
hours, either alone or in combination with five to ten grains of the
compound kino  powder, it  often has a remarkable effect in relieving
the pain and vomiting  so frequently present in this malady;  as
well as the diarrhoea sometimes combined with these symptoms.
  The mention of  this preparation of kino suggests some allusion
to other vegetable  astringents.  Diarrhoea  is so  seldom a danger-
ous complication of gastric ulcer, that they will rarely be indicated
in this way.   And their value as  tonics is greatly diminished by
their tendency to  cause constipation; as well as by the irritation
which large doses of them in the liquid form often  excite in the
ulcerated stomach.  They have, however,  been recommended  in
what is  called  "pyrosis,"  with the plausible notion  of checking
that excessive secretion from the  stomach, to which  this2 watery
regurgitation or vomiting  is often regarded as due.
  It is not easy to  give  any satisfactory explanation  of the opera-
tion of bismuth in these cases.  To say that it is a sedative, is merely
to express, by a vague generalization, its efficacy in relieving pain:
and is neither more nor less correct than it would be to call it an
astringent, because, in  other diseases,  it  often  limits  or  arrests
diarrhoea.   How  far both these effects are akin to  those of the

  1 For the other uses of opium  in this malady, see pp.  151, 154, and 166.
  2 Respecting the nature of pyrosis (which is by no means infrequent in gastric
ulcer), see Lecture VI. 
148
ULCER OF  THE STOMACH.
salts  of  lead is  difficult to determine:  though its affinity to the
latter in some other respects may partially suggest' such a com-
parison.
   Thus there can be little doubt that  it is generally decomposed
by the sulphuretted hydrogen of the  alimentary canal, and  con-
verted into a black sulphuret of the metal.1   And, in proof of this,
I may mention, that its continuous administration frequently gives
rise to the  formation of a bluish-red line along the dental edge of
the gums, analogous to (but wider and redder than) the line of sul-
phuret of  lead in the  situation which  constitutes the well-known
test of the presence of lead in the system.  Such a de-oxidation
and reduction possibly has an intimate relation  to  its  effects as
above alluded to.
  .It  is not often that  flatulence  constitutes  a very distressing or
prominent symptom of gastric ulcer.   Depending, as  it does,
almost solely (p. 65) on  a decomposition of the food introduced
into the alimentary  canal, unchecked by the  agency of the gastric
and intestinal secretions (which normally limit and restrain all
such  decomposition), its presence in gastric ulcer implies a  de-
rangement of these  secretions, which is not by any means necessa-
rily (or very often) present.   While a still more efficient reason for
its absence is found in  the fact, that any food in excess of what
the quantity  and quality of the various secretions can dissolve and
digest, is pretty sure to give rise  to an act of vomiting,  by which
it is soon expelled from the stomach.
   We do, however,  sometimes meet with cases of gastric ulcer, in
which the long interval that intervenes between the meal-time and
the paroxysm of pain, together with the extreme  distension com-
plained of  by the patient, refer the symptoms (at least in  part) to
such  a passive origin.  In these cases  the  remedies usually admi-
nistered for the common flatulent forms of dyspepsia appear to be
very  serviceable.  Amongst these we may enumerate the alkaline
carbonates (preferably  the  bicarbonate of potash), the  action of
which seems to depend in great degree on their neutralizing2 the
lactic and other acids developed by gastric decomposition;  and the
hyposulphite of soda, which appears to have a specific influence in
checking that development of confervoid growths that constitutes
(or, at any  rate, invariably accompanies) the more complete forms of
fermentation  in  the  contents  of the  stomach.  With the former I
have  found it advantageous  to combine very small  doses of the
iodide of potassium.   And of all the ordinary bitters, I have found
none  so beneficial, in flatulence attended with nausea or  vomiting,
as the infusion of calumba.

  1 A decomposition which it probably shares with the salts of lead, iron, mercury
arsenic, and many other  metals.
  2 But as these acids increase the corrosive effect of the gastric juice, the benefits
which  attend their being neutralized are at least partially referable to its reduced
solvent power. 
ULCER OF  THE  STOMACH.
149
   Vomiting, by far the most dangerous and important of all the
symptoms of the lesion, may also be regarded as that which is, on
the whole, the  least amenable to the influence of drugs.
   That variety of vomiting which accompanies the painful nausea
and flatulence just alluded to, may often be relieved by the reme-
dies mentioned, especially by a combination of the infusion of ca-
lumba with the iodide of potassium and the bicarbonate of potash.
Where it resists them, the  hydrocyanic acid,  the effervescing mix-
ture of citrate  of potash, or both these in combination, will some-
times allay it.  But I have not found much benefit from  creasote ;
and think that the salts of  ammonia (in which I include the effer-
vescing mixture of the citrate and the tartrate) generally do more
harm than good.  Indeed,  there are many cases of obstinate irrita-
bility of the stomach in which we are ultimately obliged to extend
the latter statement to all the drugs generally recommended for the
purpose of checking vomiting.  Practically, I have long  come to
the conclusion, that where one or two of the above remedies appear
to be inefficacious, it is better not to risk irritating or exhausting the
stomach by what are  really new experiments.  In these terrible
cases, in which the ulcerated organ is often so irritable that vomit-
ing is produced by the smallest quantity of the blandest food, what,
indeed, can we expect  from the contact of unnatural and  nauseous
ingesta like  many such drugs?  Of course, if experience showed
that they really did check vomiting, it would be absurd  to reject
them for want  of a full explanation of the way in which they  pro-
duced  this effect.  But as  it may be confidently asserted that they
often fail to do any good, however carefully administered, and  that
the treatment which foregoes their use is far more successful, it is
obviously important to consider how  far  that treatment is more
rational than the plan it claims to surpass.
   That variety of vomiting which occurs in gastric ulcer could be
readily shown, from  any analysis of a large number of  cases, to
possess all the ordinary relations of this  act (p. 55 et seq.) to the
system at large—to be composed, so to speak, of all the ordinary
elements of  the process; to be by turns provoked by central  and
peripheric (or cerebral and gastric)  irritation; to be favored  and
opposed by the ordinary juvantia and laedentia of activity or disten-
sion, and inactivity or emptiness, of the stomach respectively.
   Now it is according to  these  circumstances that we may best
classify the vomiting  present  in different cases  of gastric ulcer.
And the same circumstances will also to a great extent dictate the
means  of its treatment.
  For instance, the kind of vomiting most frequently seen in these
cases, and that which is usually the first to appear in the history of
the malady,  occurs as the climax of that paroxysm of pain which
begins shortly  after a meal, and is referable  in great part to the
distension of the stomach; perhaps  increased by  flatulence,  and
aided by the stimulating effect of food and  gastric juice on the raw 
150
ULCER  OF  THE  STOMACH.
surface of the ulcer.  As such, it ends so soon as the organ has
voided its contents.  And it is  best treated by limiting the amount
of ingesta, relieving flatulence,  and neutralizing undue acidity.
   In the gastric ulcer of drunkards we many often notice a morn-
ing paroxysm  of vomiting, which is sometimes  (but  not always)
accompanied by pain.   This vomiting, which occurs on an empty
stomach, seems to be chiefly cerebral: in other words, the result of
that state of general depression into which the constitution falls, as
the more immediate effect of the alcoholic  stimulus  subsides  or
wears off.   In exact consonance  with this  explanation, it is  not
unusual to find it occurring quite independently of gastric ulcer;
while it  is often habitually solaced or appeased by a dram.  And
of the drugs that one may more justifiably prescribe with the same
object, few have greater effiacy than opium, which may be preferably
given in the solid form, as a small pill of the watery extract.
   The vomiting sometimes  assumes a  greater frequency, so as to
be excited by the smallest quantity of food, or  even to be repeated
when the stomach is void of all alimentary contents.  In many of
these cases it is not easy to say whether the act is chiefly cerebral
or gastric—whether it is mainly kept up by habit,  or by the debility
of the patient acting on a nervous apparatus whose normal functions
have been shaken or reversed; or, whether it is still, in some sense,
the result of a stimulation or  irritation applied to the ulcerated
surface  itself.   In many instances, however,  the associated pain
points pretty conclusively to the latter view.  Here it is extremely
important rightly to appreciate the principles of  treatment.  And,
in accordance with the above suggestions, instead of ranging over
the drugs to which experience  or tradition attributes the power of
allaying vomiting—which we may often do with little more success
than if we were attempting to arrest sea-sickness by the same means
—it should be our object to afford the stomach  as complete and
prolonged a repose  as  the necessities of the organism will allow.
As regards drugs, the interruption to such repose, which their ad-
ministration implies, will often  do far more harm than their specific
medicinal virtues can possibly  do  good.   And  though ice and iced
water are less objectionable, yet there are some cases in which the
same rule will apply  to  these simple  and unirritating sedatives,
even in the smallest quantities.
   As respects food, our task is often much  more difficult.  There
are instances in which the patient is already so much exhausted by
the inanition  which protracted vomiting implies, that any severe
plan of diet—such as involves simple food in very small 'quantities,
or protracted abstinence—becomes quite inadmissible.   Indeed, the
patient is not  unfrequently in a state which would itself demand
the sedulous administration of food  and stimulants, if these were
not contraindicated by the state of that organ into which they must
first pass.
   Hence, in all cases in which there are any appearances of exhaus- 
ULCER OF  THE STOMACH.
151
tion, we cannot be too watchful over the effect of any system of diet
we may have thought it advisable to adopt.  It is, indeed, extremely
difficult to gauge to a nicety how small a quantity of food will pre-
vent inanition, and  at how long intervals we may  administer  it.
But it is well to bear in mind, not only that vomiting implies the
total loss to the system of the food it rejects, as well as of fluids which
are almost as valuable, but that the act itself rapidly exhausts the
various nervous and muscular tissues by which it is chiefly effected.
On this ground, the  retention of a small quantity  of food is prefe-
rable to the vomiting of a large  one, even though  the  latter act
may perhaps leave a greater surplus behind it in the stomach. And
it is often important to begin by a  decided plan of  diet, even where
the patient's weakness would necessarily forbid it being persisted
in.  For, the habit of vomiting once so far broken through, that
the  stomach can tolerate  a minute quantity of any food,  it is
frequently easy to advance to larger quantities, and better qualities
of nourishment, without provoking  any return  of the sickness.
These points will be further alluded to in connection with the sub-
ject of diet.
   The occurrence of  vomiting  with dangerous  frequency  and in-
tensity ought, however, always to  suggest the adoption of  another
form of administering both food and medicines; a form which, while
it concedes to the diseased organ the  most perfect repose,  has the
merit  of  completely obviating the  above contra-indications.  I
allude to the use of enemata; by means of which we may often  gain
a day or two of complete rest for  the stomach, and thus interrupt,
by an  equal want of absolute  tranquillity, the hitherto habitual
vomiting.  Those who have had the gloomy duty  of battling with
all the resources of their art against the starvation gradually inflicted
by obstructive cancer of the oesophagus, must have been occasion-
ally struck by  the length of time  to which life  can  sometimes  be
protracted, by a sedulous adoption of this plan of nourishing the
system.  In spite of what seems to be perfect occlusion of the oeso-
phagus, and  even in spite of that  additional extenuation which is
produced  by the cancerous cachexia, or  by secondary  cancerous
deposits in the lungs  or liver, the  patient may sometimes  be kept
alive day after  day—one might almost say week after week—by
such alimentation only.  Cases of  this kind at any rate show1 how
much enemata  may be made to compensate a  temporary disuse  of
the stomach; and  how safely, in  obstinate vomiting, we may by
their aid allow the stomach the day or two of rest, which are often

  1 It is very possible that the analogy between the obstructed oesophagus and the
ulcerous stomach is so far imperfect, as that the gastric mucous  membrane of the
former remains capable of secreting an abundance of healthy gastric juice, so long
as any food whatever enters the organ: while that of the latter  is often  robbed of
its secretory powers by the circumstances of its disease.  Indeed, the symptoms
of large gastric ulcers indicate at least a partial effect of this  kind.  But I do not
think°that this conjecture, even if proved to be correct, would modify the practical
deduction stated above. 
152
ULCER OF THE STOMACH.
all it needs.  The substances best made use of are milk, raw eggs,
cod-liver oil, strong unsalted beef-tea, wine, and in extreme cases
even diluted brandy or opium.1
  The adjustment of the size and frequency of these enemata, as
well as their choice, must be chiefly determined by the history and
the existing features of the particular case.  It should, however,
always be our object  to reduce such enemata to the1 smallest possi-
ble size.  And, as a  rule, it is rarely advisable to repeat them at
intervals of less than  three or four hours.  The ingestion of liquids
may be best accomplished by external applications;  such as wet
bandages around the arms and legs, and prolonged fomentation or
immersion of these limbs in tepid water.2  With  the aid of such
appliances, the patient may easily be  restricted for a time to the
frequent moistening  of his mouth and fauces with a few drops of
liquid.
  Hemorrhage is  another symptom which requires to be treated
with special reference to the pathology of the lesion that  produces
it.  The scanty flux  that occurs in  the  earlier stages of gastric
ulcer—often amounting to little more  than a streak or two of blood
in the vomit, or a dark coloration of the stools—scarcely demands
any special treatment, beyond that which  it is necessary to adopt
in  all cases  of gastric  ulcer.  But  where  it  occurs in a  more
advanced stage of the lesion, or amounts to a considerable quantity
of blood, we are justified in directing to it  a more special (if not
exclusive) attention.   And  as the stomach is amenable to the local
action of the astringents we introduce into it, as well as to that
general action which their absorption into the system may induce,
our means of arresting hemorrhage are (other things3 being  equal)
much more efficacious than  in the case of bleeding into the lungs.
   The course to  be generally adopted is dictated, partly by the
above conditions, partly by the  existing state of the  patient.  In
respect to the latter, I would suggest (at the risk of again  incurring
the suspicion of leaning too much towards an expectant mode of
treatment) that where there is reason  to suppose that the bleeding
comes from a large vessel, and is for  the time arrested, it is better
to  limit our treatment to  the negative plan of securing for the
stomach the most perfect rest.  A little ice from time to time, if
the patient  be very  thirsty, or  complain  of much pain; a rigid
observance of the supine posture; and the minimum of food (pre-
ferably  of boiled milk) that will support  life:—such are the

  1  Here, as  elsewhere, I  have sacrificed accuracy of arrangement to usefulness ;
and have  overstepped the not very definite  boundaries of food, stimulants, and
drugs.  In speaking of the above remedies, however, I am for the time regarding
both of them as stimulants; which, with diverse rapidity and certainty, may not
only arouse the flagging powers of the system, but may economize (and therefore
substitute) a certain amount of food.
  8 To which milk may be sometimes added with great advantage.
  3  For some of the qualifying circumstances  hinted at by this phrase, see pp. 64
and 111. 
ULCER  OF  THE  STOMACH.
153
simplest and best precautions we can take, to avoid the disturbance
of that clot which alone intervenes between the life and death of
the patient during the first few days that immediately follow a copi-
ous hemorrhage from a gastric ulcer.  A more frequent and mode-
rate oozing justifies (and  demands) a styptic treatment,'especially
where there is no great tendency to vomiting present.  Turpentine,
and the sesquichloride of  iron, which have, I believe, been recom-
mended with this view, are both open  to the  grave objection of
often exciting nausea  and vomiting, even in moderate doses  and
dilution.  The formula I  most  prefer consists of about ten grains
of gallic acid, dissolved in an ounce of distilled water by the aid
of about ten minims of the dilute sulphuric acid.   But in some
cases of this kind, in which the presence of great pain has led me
to prescribe bismuth and compound kino powder, the  bleeding
has seemed to be arrested by these astringent drugs.
  Even here, however, the internal and external application of cold
by  means of ice, and the  rigid observance of  the dietary already
referred to, forms an indispensable part of the treatment.
  The cachexia which generally accompanies the gastric ulcer,  and
the hemorrhage which, in varying amount, usually occurs in some
part of its course,  unite to constitute one of the most  important
indications of treatment.  This cachexia, which combines and ex-
presses the worst effects of all the other symptoms, and which con-
stitutes (I am convinced) one of the most frequent causes of death
in the general history of the malady, not only  modifies and limits
our application of the remedies hitherto specified, but practically
measures the general success of our treatment.
  The difficulty it sometimes opposes to that  local  treatment by
which the ulcer is  best allowed to heal, has  already been alluded
to.   The system of stimulation it sometimes dictates, we shall again
revert to in speaking of the dietetic treatment of the malady.  At
present we may chiefly view it as indicating the exhibition of tonics
in all cases in which  the state of the  ulcer does  not absolutely
forbid the introduction of these remedies into the stomach.
  Amongst the  various remedies included in this class, the prepa-
rations of iron  claim  the foremost rank.  The pathology of the
chlorotic condition  which is  simulated by the gastric ulcer of the
young female, as well  as  the results of the hemorrhage often im-
plied by the lesion, alike  point to  these preparations; which are
the best means of furthering such a growth of the red corpuscles
of the blood  as may obviate that  anaemia, or  repair this hemor-
rhage.  And experience quite confirms these  rational expectations
of the efficacy of iron.
  The chief precautions necessary to observe  in its use seem to
be the following.   Iron is contraindicated by  frequent vomiting,
and  by excessive  or  continuous   pain.  And even when these
symptoms  have partially  yielded to other remedies, it is better to
beo-in with the very mildest preparations of the metal, such as the 
154
ULCER OF  THE STOMACH.
ammonio-citrate,  or ammonio-tartrate.   They should  always be
given either  with,  or  immediately after, food;  a general rule in
using them, which  the presence  of an  open ulcer makes doubly
important.   And the various soluble salts of the  metal should be
prescribed in combinations which allow them to be introduced into
the stomach  in this dissolved  form.   In other  words,  the  use of
the insoluble oxide, either  directly or  indirectly (as in the com-
pound iron mixture a few hours after being made up), should gene-
rally be avoided.
  The bitter vegetable tonics  are, on  the whole, less  important;
though, in combination with other remedies, they are often  useful.
Thus the infusion of calumba is not contraindicated by any mode-
rate amount of vomiting; and  that of quassia may often be given
with iron.  Lastly,  of all the ordinary combinations of mineral and
vegetable tonics, none  is so  elegant and so generally useful, in the
later stages of convalescence from gastric ulcer, as a mixture of
the sulphates of quina and iron, kept  in solution by a few drops of
dilute  sulphuric  or hydrochloric  acid.   Indeed,  wherever the
stomach will bear  quina (as it certainly will in  the  majority of
cases  after suitable preparation), a course of this energetic tonic,
during at least a few weeks, is very advisable.  And in those in-
stances in which the ulcer itself seems to be a sequela of ague, such
a rule becomes, for  obvious  reasons, still more valid.
  Another combination of quinine and  iron  with opium will often
be found of great advantage for  irritable  stomachs; and may be
prescribed with the best effect in  cases where either of these drugs
in the liquid form  would give rise to much inconvenience—such
as nausea, vomiting, headache, or loss of appetite.   It consists of a
pill of about a grain of each of the above sulphates, with a small
quantity of the extract of opium, or the compound styrax or soap
pill.  The marked advantage of such a pill over the above mixture
is  probably due to its  slower  solution, and  to the comparatively
smaller gastric surface on which its direct action is exercised.
  The use of aperients in this malady requires the greatest caution;
although, in many cases, they can hardly be dispensed with.   It is
impossible  to doubt that they have sometimes been administered
in this and other gastric diseases far too indiscriminately ; and that
their abuse has occasionally led to very prejudicial results.   How
far they are really necessary  in any given case, is, however, a
question which it will  often be extremely difficult to decide.   Still
we may recollect, that where little food  is  taken into the stomach,
or much rejected from  it,  the bowels often contain so small a
quantity of excrement, that the need of defecation becomes far less
frequent and urgent—to say nothing of that abdominal stagnation
(compare p. Ill) which  the mere act of vomiting itself tends to
produce.  On the other hand, there can be no doubt that constipa-
tion may seriously increase both  the  pain  and vomiting of gastric
ulcer.  Indeed, in one or two cases, I have noticed  a definite and 
ULCER OF  THE  STOMACH.
155
repeated coincidence  between paroxysms of these symptoms, and
an accumulation of feces  in the colon.  But, not to speak of the
clue the statement of the  patient will generally afford us, a careful
examination  of the  belly will almost always  assure us  whether
the large intestine is occupied by even a moderate amount of feces.
  When an aperient is definitely indicated by appearances of this
kind, few remedies answer better that castor oil. A moderate dose
(from six drachms to one ounce) of this purgative can  often be
taken in the ordinary way, without at all increasing the pain or
vomiting.  But where the latter symptom is of frequent occurrence
it is much  better to resort to enemata, either of castor oil in emul-
sion, or of some combination of this drug, and the decoction of
aloes, with  the gruel which is  usually the vehicle of such remedies.
As a rule, large enemata are not advisable; distension of the abdo-
men being  very liable to increase the gastric pain and uneasiness.
  The milder aperients sometimes required during convalescence
may be given under limitations similar to those already mentioned
with respect to the stronger  purgatives.   When their use can be
avoided, it is better to omit  them altogether.  Indeed, on the sub-
sidence of the more serious symptoms, the state  of the bowels often
affords a fair test of the efficacy with which the tonics administered
are acting upon the system.   In any case, an  occasional dose of the
compound  rhubarb pill, mixed (if need be) with an equal quantity
of the  compound extract of colocynth, is quite sufficient;  or a
dinner  pill of one or two grains of the extract of aloes may be
given daily, with the  same object.   Of course, the slightest symp-
tom of  relapsing pain or  nausea would quite contraindicate  such
remedies.  And a proper study of the patient's diet will often
enable us altogether to dispense  with the use of aperient drugs.
  The brief allusions to aperients naturally suggest some mention
of the mercurial preparations which  so often  enter into their  com-
position.  It would be a dereliction  of duty in  me not to express
the strong opinion I entertain against the employment of mercury
in these cases, in any form, and under any pretence whatever.   I
believe that I have known one or two instances in which  the ulcer
has been definitely produced by the  administration of mercury for
other maladies;  and am  certain that I have  witnessed  relapses
which could only be attributed to a similar cause.   A single  calo-
mel  purgative  has even  appeared  to undo all that  months of
sedulous treatment had  been able to effect towards  the relief of a
gastric ulcer.
  With a  different feeling, I venture to allude to some of the
remedies, the efficacy of which has  been greatly extolled in this
malady. The preparations of silver—and especially the oxide and
the nitrate—have been alleged to possess a therapeutical effect of
the most marked  kind.   Indeed, it  is suggested by some of the
advocates of the nitrate of silver,  that it heals an ulcer of the
stomach just as it would an ulcer of  the leg;  that it stimulates the 
156
ULCER OF  THE STOMACH.
languid atonic ulcer to a new action, and soon brings about a pro-
cess of granulation.
  It would be presumptuous in me to question the excellent effects
of this caustic in the external ulcers to which surgeons often apply
it;  though I suspect  benefits are  often  attributed to the stimulus
of its application, which depend chiefly on that coagulum or crust
of organic matter which  it forms, and  by which it so admirably
shields and compresses the subjacent granulating surface.  But, in
respect to its internal administration, I have no hesitation in saying
that, as ordinarily prescribed, it is absolutely inert;  that the bene-
fits which have been observed under its use are  due either to the
diet and  adjuvant remedies also adopted, or to the  curative efforts
of Nature;  in short, that the above estimate of its value really
reflects and repeats the  fallacy—post hoc, ergo propter hoc—which
lies at the basis of  the fancied cures vaunted by homoeopathy.
  In specifying the facts on which I ground this opinion, I limit
myself to  the  doses and combinations in which  it is generally
prescribed.
  The constitutional effects produced by this or  any other salt or
silver, when absorbed into the system, I may altogether eliminate
from  the question.  Without going so far as  to deny that these
salts have any constitutional action, I may at least assert, that none
such  has ever yet been proved; that  they " may  be cautiously
exhibited for a considerable period without producing any obvious
changes  in the corporeal functions;"1 and that the only evidence
adducible to prove their influence over the constitution, consists in
the rare  amelioration of epilepsy, or the still rarer appearance of a
cutaneous  eruption, under their  use.   And, apart from this  ab-
surdly defective evidence, we may  question  whether  any such
action results from their ordinary use.  For that blue color of the
skin which testifies to their absorption  and reduction throughout
the body is so specific  an event, that, in its absence, we have  no
right to  assume  any definite series of constitutional effects what-
ever.2  While, since the most zealous  partisans of these drugs
carefully stop  short  of producing this unsightly and  permanent
change of color,  we are justified in supposing, that whatever effect
their doses have, is exclusively due to a local action of the remedy
on the mucous membrane to which it is applied.
  Now, as regards  any such local action, it is of little consequence
whether  the  usual  half-grain or grain dose of nitrate  of silver is
administered in the form of a pill or of a solution.   Far from its
giving rise to any symptoms of reaction or irritation, such as we
can see (and the patient feel) when we apply any form of this caustic
to an external or internal surface, the pain and irritation, the fever-

  1 Pereira's "Materia  Medica," vol. i. p. 692.
  2 Thus the constitutional effects of lead are rarely unaccompanied, and mostly
preceded, by its characteristic blue line around the gums. 
ULCER  OF  THE STOMACH.
157
ishness, nausea, or vomiting, which have been sometimes noticed
to result from the remedy, are expressly regarded as indicating an
over-dose.   In fact, all evidence of direct stimulation, as  a  result
of the remedy would probably be interpreted as proof that it had
been wrongly administered.
   And just as the absence of all such evidence of the stimulant
effect of the drug leaves us in very "great doubt whether its known
physiological  action is really exerted on the gastric membrane,  so
its equally well-known chemical reactions convert  this doubt into
an absolute denial.
   We will  say nothing of the chlorides of the food, the chlorides
of the gastric juice, the chlorides of the bread-crumb in which the
drug is often exhibited.  Suppose all these sources of decomposition
carefully avoided—a  supposition, however,  which is really untena-
able—the chlorides of the saliva and oesophageal mucus swallowed
with the pill, and of that mixture of these secretions with bile which
occupies the fasting  stomach, would suffice (and more than suffice)
to convert any ordinary dose of nitrate or oxide of silver into this
insoluble  compound.   And what chance a tiny pill has of seeking
and finding in the stomach a resting  place  which exactly corre-
sponds to  the ulcer;  or what chance the minute dose, diluted by an
ounce of  liquid,  has of being uniformly diffused over the gastric
surface of about  180 square inches, and yet of super-saturating the
mucus of  the same place  ; it would be  absurd seriously to inquire.
   I need  scarcely say that, in urging these1 objections  to the effi-
cacy  of  the oxide or  nitrate of silver in this malady, nothing is
further  from  my intention than  to  deny that  patients have ever
recovered  under their administration.  But, considering  that we
may  allege  the same fact of almost every  curable malady, under

  1 While referring  to Lecture'VI. for some  further incidental remarks on the
evidence which decides the therapeutical efficacy of drugs, I venture to deny that
the arguments, on  which Heller  and others come  to a conclusion apparently
resembling the above, respecting the general inertness of this salt of silver, are
applicable to the question of its efficacy in gastric diseases.  Even as respects  its
constitutional action—considering that it is an absence of proof rather than any
disproof, of absorption, which chemistry affords us—our ignorance of the minimum
of this and many other metallic salts requisite for such constitutioual action, refers
us to analogy, and to physiological and pathological considerations, for evidence
for or against its operancy. And as regards the usefulness of the nitrate of silver
in gastric maladies,  the mere discovery of chloride of silver in the feces is a piece
of evidence  both needless and inconclusive.  Needless ; for surely it needs  no
analytical chemist to tell us what happens when a soluble chloride is added to
this nitrate.  Inconclusive : because the supposed benefits of the drug are plausibly
referred to its local effect—an effect which is no more disproved by the discovery
of the insoluble chloride in the secretions of the stomach, than in those of the
vagina after its application to the mucous membrane of these two organs respect-
ively.  And since (as the latter analogy shows) the  general reaction of the local
effect of this caustic may amount to a constitutional effect of a most important
kind, it is rather a question of contact, than of absorption, with which we are here
concerned.  While it must be  remembered, that the same overstrained argument
from analysis would oblige us  to deny the unquestionable efficacy of bismuth in
many gastric and intestinal maladies. 
158
ULCER OF  THE STOMACH.
the administration of every "panacea" with which quackery has
ever afflicted mankind, few would be  inclined to lay much stress
on it.  Indeed its explanation is sufficiently obvious.  Patholgical
research conclusively shows that ulcers of the stomach often undergo
a spontaneous  cure.  The careful system of diet which is usually
adopted in conjunction with the remedy, is itself sufficient to account
for all the benefits observed.  And I am persuaded that the physi-
cian who  judges of the efficacy of his  remedies without allowing
for the natural tendency of disease to  recovery, and for the effect
of proper diet and regimen, while  he shrinks from testing their
traditional virtues by a careful scrutiny of their physiological effect
in the  healthy subject, and their therapeutic1 influence apart from
diet—that such an one, I say, has little to  prevent him from  ex-
changing  one system of credulity for another, and  enlisting under
the banner of any the most abject quackery of the day.
  Diet.—The comparative importance  of this element  of treatment
has already been alluded to.  So far as I can judge, it is impossible
to cure ulcer of the stomach by any  remedies, in  the absence of
proper  regimen.  It  is probable, that  in many of those cicatrized
ulcers which have been verified  by a  necropsy, the patients' own
feelings had guided them to such  a diet as might fairly be con-
sidered the agent of their  recovery.  It is quite certain that  many
cases have been cured by the observance of a rigid system of food,
which has been prescribed to the exclusion of all drugs.2   Hence
though the latter are (in my opinion) invaluable as aids to a strict
diet, they are powerless as substitutes for  it.  And in no disease is
it, therefore, more important for  the physician  to  protest against
that common error of the  unprofessional public, which looks upon
the deglutition of a certain quantity of  more or less nauseous  drugs
as the only means requisite for the restoration of health.
   The system  of diet which experience shows to be the best treat-
ment for  this malady is based upon certain simple and well-ascer-
tained principles in the physiology  of  digestion; such as have but
to be mentioned, to  be at once admitted as unquestionable.  The
sufferers from this disease find their symptoms greatly aggravated
by copious meals; by animal food; by  hard, tough, and indigestible
substances;  by hot  food  or drink; and, lastly, by irritant sub-
stances.   While, conversely, the use of a bland, moderately azo-
tized food, of soft, pulpy  consistence,  at  a cool temperature,  and
in small  quantities, not  only relieves  the symptoms,  but  often, if
steadily persevered  in, completely cures the malady.   And every
one of these circumstances precisely corresponds to what the  physi-
ology of digestion, and the pathology of the lesion, might,  a priori,

  1 Such a therapeutical influence—a matter of  immediate and frequent experience
—as  is illustrated, under just these circumstances, by bismuth, alkaline carbo-
nates, and many of the so-called "carminatives."
  2 The case of Beclard, the French anatomist,  seems to have been an example of
this kind.  He died at an advanced age, after a long period of perfect health ; and
the scars of two ulcers were found in his stomach. 
ULCER  OF  THE STOMACH.
159
   teach us to expect.   The organ which the ulcer occupies is  stimu-
   lated to activity  by the mere ingestion of food.   It is stretched
   and distended by a large meal.  And just as the ulcer necessarily
   shares  in  these changes, so its raw surface must be stimulated by
   the heat, and by any irritant qualities (mechanical or physiological)
   which  the food may possess.   Lastly, as it  is the express function
   of the  stomach to dissolve  the proteinous constituent of the food,
   the amount of this  constituent present in the diet adopted will not
   only to some  extent measure the degree and duration of the activity
   of the organ, but will probably also affect the ulcer more specially,
   by regulating the quantity of gastric juice secreted into that gene-
   ral cavity of the organ which the lesion occupies.
      The various requirements implied in the preceding  statements
   are best fulfilled by milk diet, given in small quantities, and  at
   frequent intervals.   This fluid, the natural food of the young ani-
   mal, and the model alimentary mixture of the scientific cook, con-
   tains all the  substances  necessary for the organism, not  only in
   suitable proportions to  each other, but in a  state which specially
   favors  their digestion, and involves no mechanical irritation of the
   stomach.   The quantity of protein, for example, is such, that there
   is little risk  (as in  the  case of some of the  simplest and blandest
   varieties of vegetable food) of our depriving the organism (perhaps
   already exhausted  by disease or  age)  of its  necessary  supply  of
   this  indispensable  constituent of food.   While,  conversely,  it
   probably  does not  much exceed  the  proportion  required  by the
   wants  of the  system.
      It is chiefly by the irritability of the stomach (as expressed by
/  the frequency and facility of the vomiting) that we must be guided
   in our  selection of  this  or that modification of milk diet.  Where
   the stomach  is excessively irritable, the  milk may be  sometimes
   better  borne  when diluted with half or one-third its bulk of lime-
   water,  or  after a  preliminary boiling.  In  rare instances,  a little
   fresh curd, mixed with  a thin pulp of arrowroot  boiled in water,
   seems  preferable even  to these.  As a  rule, however, good  new
   milk is far more easily sustained than either of these modifications;
   and the chief efforts to  adjust it to the stomach  are to be made by
   carefully  regulating its  quantity.
      Where  the more moderate irritability of the stomach allows a
   better  chance of food being retained by the organ, it is very import-
   ant to give articles of diet which possess a greater physical consistence.
   This is best  effected by mixing with milk any of the purer varie-
   ties of  starch, and boiling them together into a thin pulp, which of
   course  must only be taken when cooled.  Arrowroot is  especially
   to be recommended for this purpose.  Sago and tapioca are gene-
   rally less easily borne.  The gradations of quantity and frequency
   must also  be carefully prescribed  for the patient.   The advantage
   of taking  a single spoonful of such food for a meal  consists in the
   facts, that not only is all distension of the stomach thus avoided, 
160
ULCER  OF  THE STOMACH.
but also that the food is thus enabled to leave the stomach shortly
after entering it—becoming merely impregnated, as it were, with
gastric juice, before it passes on  into the duodenum, to receive its
complete solution there.1
  The frequency of such meals  must  of course be  regulated by
their quantity, as well  as by their effects  on the stomach.   Thus,
supposing them not to  excite vomiting, from  ten to  twenty  meals
of a single tablespoonful or dessertspoonful of the  above articles
of food will not be too many during the whole day—a number
which  would obviously demand their being repeated as frequently
as every two hours.
  As convalescence begins and  proceeds, it is important to keep
up as rapid an advance  in the scale of diet as prudence will allow.
We may at first vary the pure starch of arrowroot  by passing to
sago and  tapioca,  before venturing on  the moderately proteinous
ground rice,  to  advance  thence  to  maize, rye, or wheat  flour.
Ground rice I have generally found well borne; and both in respect
to consistence and composition,  it forms, with milk, an excellent
staple food, on which many persons can live without risk for days
or weeks together.  Wheat flour is  best given in  the  shape of
biscuit-powder, or  bread steeped in boiling  water, and  pressed
through a  muslin sieve while still hot (bread jelly), boiled with
milk.   Sugar must be  added with great caution, as it is very apt
to provoke flatulence.
  It is chiefly when, from such a diet, we desire to advance to ordi-
nary animal food, that the greatest  difficulty will  be  generally
felt:—a difficulty which a foreigner unacquainted with the waste-
ful and barbarous processes by  which the average Englishman
cooks his food could scarcely appreciate.  Strong beef-tea is rarely
well borne: and boiled or roast meat is often too sudden a change;
indeed, if badly chosen or cooked, it  may do serious mischief.  It
is my usual practice to begin with some boiled white fish (such as
sole or brill) carefully freed of all bones, and mixed with mashed
potatoes or water arrowroot in small quantity.  But a tender meat
very slowly stewed, so as to form what the French call  " bouilli,"
is almost as good;  though far less likely to be  obtained by most
patients.   Of course it would be quite possible for a patient to
subsist on  vegetable food with only the aid of milk.  But so  few
persons can be trusted  (or expected) permanently to isolate their
habits  from those  around them, that we have practically no choice
but to arrange for their return to the ordinary diet  of health.  There
are many other  articles of food (the suggestion of which belongs
rather  to cookery than to physic)  that must be taken with the same
precautions, as to quantity and consistence, which we have already
mentioned  for the  milk diet.
  The idiosyncrasy of the patient  often  obliges  us  greatly to
1 See pp. 18, 125 ; also Cycl. Anat., op. cit., pp. 315, 349, 398. 
ULCER OF  THE  STOMACH.              161
modify  any such plan  as the preceding.  Sometimes water may
be advantageously added  to  the milk; though it cannot be long
substituted for the more nutritious fluid, unless something of more
azotized composition than  arrowroot be  given with it.  Some
patients can soon take an egg beaten up with their farinaceous food ;
while in others it evidently aggravates  the  previously improved
symptoms.  Some take cold tea with advantage;  although, as a
rule, this fluid ought to be strictly prohibited.  In short, the diet—
nay more, the cookery—in each  case requires careful observation,
as well  as great prudence and tact.  Every change is to be regarded
as in  some degree an experiment, the  carefully observed results of
which can alone justify or forbid  its continuance.
   Stimulants.—The  question of employing stimulants  naturally
claims our notice in connection with diet; although we have already
briefly  alluded to them in speaking of the drugs sometimes indi-
cated by that exhaustion  or cachexia which,  in varying amount, it
is usual for gastric ulcer to produce.   As a rule, it is indispensable
to avoid all use of alcoholic  stimulants.  Even in the extreme ex-
haustion  produced  by protracted and  frequent vomiting,  it is
generally advisable so far to keep to this rule, as to administer
whatever alcohol seems necessary in shape of an enema.
   The  rare exceptions to this rule are  rather to be hinted at as
contingencies than stated as facts.   In respect to absolute experi-
ence, I have certainly known one or two glasses of sherry, and
even one or two tumblers of beer, to be taken daily without much
appearing to  impede the cure of what seemed to be an ulcer of the
stomach.   But I  do not think the comparatively slight mischief
which the disobedience of these patients produced  is at all incom-
 patible with the rule above laid down.   So many of the middle-
aged subjects of  this lesion are persons of intemperate habits, and
so much does the lesion itself increase the depression and cachexia
 which  these habits produce, that it is quite possible  the constitu-
tional advantages of a moderate amount of stimulus may sometimes
exceed (in other  words, more than neutralize) the bad  effects of
that local irritation which the raw surface of the stomach is sure to
 suffer from its application.
   Of course, if any form of alcohol were admissible, it would be a
 pure dilute fluid (such as weak cold brandy and water) in  very
 small and frequent doses.   Baw spirits, and brandied or strong
 wines  (such as  Marsala and sherry respectively) are inadmissible,
 from their  irritant  effects.  And such  compound  or  artificial
 drinks as ordinary port, beer, and champagne, are still more objec-
 tionable ;  their sugary or fermenting  constituents generally aggra-
 vating  the injurious effect of their alcohol to a remarkable extent.
 The  effect of the true or natural wines in small quantities I am
 hardly qualified to speak of; though, from one or  two instances, I
 am entitled to believe them  much less hurtful.
        11 
162
ULCER OF  THE STOMACH.
   Opium.—This antagonism between  the  local and  constitutional
effects of alcoholic drinks  in  the treatment of gastric ulcer, may
well suggest the inquiry, whether there are no stimulants which
would afford us the  advantages of alcohol without its disadvan-
tages?   The importance of this question will  excuse my pointing
out, that what I have already had occasion to say respecting the
merits of opium will, to some extent, apply to the class of sedatives
in general.  But the  peculiar  stimulant effects of  opium make it
by far the most  valuable of them all.
   Bespecting the operation of  this drug in  gastric ulcer, I might
say much that  would be both interesting and true,  but nothing
that would include those elements of accurate physiological and
chemical research on  which alone a conscientious physician ought
to base a definite theory of the action of this (or any other) medi-
cine.   As regards mere facts, I am quite certain that, though the
pain often present in  these cases is of course an additional indica-
tion for the use  of opium, yet it is by no  means the chief (far less
the only) guide to its administration.   It is not as an anodyne, not
even  as  a sedative, that opium seems to be most useful.  On the
contrary, my experience would  lead me to conclude, that it is speci-
ally in ulcers of long duration,  of large size, of obstinate character,
and in broken exhausted constitutions, that this invaluable remedy
comes more fully into play;—and that the condition these circum-
stances presuppose being present, its use is not one whit less advan-
tageous,  even though  the habitual pain is but trifling, or though
(far from having to replace the  customary alcohol of the drunkard)
it is prescribed for a  patient who  has been always of a temperate
or even abstemious habit.
   In  short, I am anxious specially to urge upon you the impor-
tance of  giving opium in this dangerous  and frequent disease, with
just the same views as those with which  I suspect it has long  been
employed in phthisis, or (a still more apt  illustration) in diabetes.
To relieve this  or that pain; to check  great  irritation, or  undue
secretion, of this or that mucous membrane, supposing such symp-
toms to  be present.   But  to support the strength, to buoy up the
nervous  system, and  to check the waste or  expenditure of the
tissues generally, whether  the  above local symptoms are present
or no.  That it  is thus opium  aids to heal a  gastric ulcer, I can
scarcely  doubt.   And that, in  this way, the same  (I would  even
say, the  only1) drug  which  considerably diminishes the saccharine
constituent of a diabetic patient's  urine, may also check that pro-
cess of destruction which a gastric ulcer expresses and  measures,
is  quite in accordance with all  that we know respecting its power
of lessening bodily waste.
   But I  am more anxious to state the fact  of its usefulness in com-
bating this lesion, than to explain  the principle upon which it does
1 See the author's monograph already cited, p. 128. 
ULCER  OF  THE  STOMACH.
163
so.  It is, therefore, with very great pleasure that I have found my
own experience of its efficacy in  ulcer of the stomach  confirmed
by the statements  of other observers with respect to its uses in
ulcer of  other  parts of the body.  You  may take the  analogy of
the two classes of ulcerative lesion at what it appears to  be worth;
and may estimate, at a  higher or lower  rate, that  remarkable
parallelism  which  the pathological details I have established re-
specting gastric ulcer exhibit with those of the ordinary ulcer of
the leg.1   But should you be disposed to think fovorably of state-
ments founded on such wide research as mine have been, you will
probably hardly fail to be struck by their perfect agreement with
the independent results of a better authority in the treatment of a
kindred  disease.   Allowing for the situation of the lesion, and for
a  variety of details which that situation chiefly dictates, there is
hardly any  difference between the opinion I have come to respect-
ing the efficacy of opium in  ulcer of the  stomach,  and that which
has  been published by  Mr. Skey,2 as  deduced by him from his
large hospital practice, with respect to its benefits in ulcers of the
limbs.
   As regards the mode of administering opium, where vomiting is
moderate, or where diarrhoea is  prominent, the compound kino
powder  is a very convenient formula.  But when vomiting is at
all excessive, or resists a combination of this powder with bismuth,
the drug is  generally better borne in the solid form; either as a
small pill of the watery  extract, or a few grains of the compound
soap or styrax pill, two or three times a day.  The effect of opium
given in  this way often seems to be quite as striking as in ordinary
ulcers of the leg.
   For the same aged and intemperate classes of patients in which
opium is so generally beneficial, other  sedatives will occasionally
afford similar (though less marked) results.   Hyoscyamus, conium,
belladonna,  and  other extracts of this kind, are thus sometimes
beneficial, though I have rarely had occasion to resort  to  them.
The extract of hemp sometimes answers  admirably; indeed, were
its effects more uniform, it might  often be  advantageously substi-
tuted for opium itself.
   In all cases, the return of the convalescent  subject  of gastric
ulcer to his  ordinary diet should by no means -end his precautions
with  respect to the disease.  Many months after  a complete re-
covery, I have repeatedly known a single excess bring back  the
whole train  of  symptoms, with all their attendant  dangers.  It is
therefore only after the  lapse of a long  period of perfect health
that we can venture  on suspending  the  system of diet now  de-
scribed.  Indeed, no lapse of time justifies a person who has once
suffered from this disease in laying aside many of the above rules.

   1  As shown by Mr.  Critchett's able treatise, already (p. 142) referred to.
   2 Report of Clinical Lecture, the " Lancet," vol. i. p. 88, 1856. 
164
ULCER  OF  THE  STOMACH.
The subject of this malady, whether convalescent  or cured, ought,
in fact, always to retain the habit  of taking  food  in small quanti-
ties; making  up, if need be, for their smallness  by a greater fre-
quency of meals.   His food ought not only to be well chosen, and
good of its kind, but well  cooked, and carefully masticated; so as
to secure  its reaching  the  stomach in  a proper  pulpy consistence.
While hot food and drink, as well as  alcoholic  excesses, ought to
be systematically avoided.
  We may end these suggestions by repeating  two  precautions
respecting the mechanical  treatment of gastric  ulcer;  precautions
which ought never to be neglected.
  Firstly, as regards its situation, it is very important to avoid all
pressure  on the epigastrium, especially where there is much ten-
derness of this region to  such interference.  The injurious effect of
tight stays, or  of any hard substance (such as the end of the last
used by shoemakers), is of course  obvious enough; though I have
reason to  believe such pressure may rupture  a stomach without its
habitual application having previously produced much pain. But
in the examination which the physician has to make (and which is
sometimes imitated afterwards by the patient), we are  ourselves
bound to  remember this  injurious effect of pressure; and to be not
only very gentle  in our manipulations, but very sparing in our
repetition of them.
  Secondly, all violent exercise must be avoided.  In cases where
life was threatened by hasmatemesis, or by constant vomiting, few
would forget to adopt this precaution.  Indeed, the feelings of most
patients would  soon enforce the recumbent attitude, even if the
medical attendant did not prescribe absolute rest in the supine
posture.   But in persons who merely regard  their complaint as an
aggravated indigestion, it becomes more necessary to state such a
rule;—a  rule,  the  infraction  of which  may be  punished  at  a
moment's  notice by the terrible  accident of perforation, and is
almost always attended with both local and  constitutional results
in the form of pain, vomiting, fatigue, or exhaustion. 
165
                      LECTURE IV.

                      Cancer of the Stomach.

  The gastric maladies we have hitherto successively studied have,
as it were, gradually risen in severity to find their climax in cancer
of the stomach;—a disease which, obscure in its symptoms, frequent
in its occurrence, fatal in its event, will, on all these grounds, well
repay that careful clinical study, of which I shall briefly describe
what seem the most important results.
  Let me premise, that I can not only offer you some new details
bearing on  the diagnosis and treatment of the disease, but  may
claim an accuracy scarcely  hitherto attainable.  Indeed, the re-
searches on  gastric ulcer epitomized  in the last Lecture themselves
suffice to demand a revision of the whole subject of gastric cancer.
For they show, not only that the frequency and importance of the
former  disease have  been underrated, but  that  its  symptoms and
appearances, though clearly distinguished twenty years ago by the
sagacity of  Cruveilhier, are yet very liable to be confounded with
those of the cancerous disease it can so closely simulate.  Now it
is evident that the study of gastric cancer in general, as well as its
differential  diagnosis  from gastric  ulcer, requires the accurate dis-
tinction of these two diseases from each other.   And nothing short
of such a  discrimination  having  been  made  would justify  my
calling  your attention to the original observations, and the large
series of necropsies,  which the following Lecture sums up and
incorporates.
  The typical course  of the malady may be sketched as follows.
  An elderly person,  perhaps  hitherto free from dyspepsia, begins
to suffer from a capricious, and soon  a diminished, appetite; which
is by and by associated with occasional nausea or even vomiting,
and with a sense of uneasiness or distension in the stomach.  His
complexion, already pale  and unwholesome, next acquires a muddy
yellowish, or faint greenish hue.  His  gastric  symptoms now in-
crease ;  often by a sudden and marked augmentation, which corre-
sponds to what is, in other cases, their first appearance.  Vomiting,
if already present, becomes more frequent or urgent; local uneasi-
ness deepens into  pain:  and both these symptoms  are excited or
increased by taking food.   At a somewhat later period, hemorrhage
generally occurs;  usually but  scanty  in  amount,  and  therefore
depending to a great extent on casual circumstances for its detec-
tion.  About this time a tumor often becomes  perceptible near the 
166
CANCER OF THE STOMACH.
middle of the epigastric region of the belly.  As the local symptoms
increase, the cachexia of the patient also augments; and is evinced,
not only by the color already mentioned, but also  by debility and
emaciation: and.  at last by  prostration,  which ends  in  anasarca,
delirium, and death.
  The disease, however, often diverges from this course: the above
symptoms  being  complicated in various  stages of their  progress
by results  more or less incidental to the locality of the  cancer-
such as ascites, jaundice,  perforation, fistula, phlebitis—or by the
addition of the various symptoms  characteristic  of consecutive
cancerous deposit in other organs, especially in the liver and lungs.
Most of these complications influence the termination of the malady,
either as intercurrent or as concurrent causes of death.  And, in
any case, the disease generally marches to  its termination  with a
continual increase of speed and severity,  rarely  receiving more
than a temporary check, and ending in death about one year  after
it first declares itself.
  In  discussing each of the chief symptoms enumerated  above,
and  in noticing some questions connected with their succession,
combination, and  duration, it will be convenient here and there to
anticipate some pathological considerations, which either explain
these symptoms, or are suggested by them.  Theory in any wider
sense it is my express object to avoid: not that I consider  it  useless
or unimportant, but rather that I doubt whether it can be  advan-
tageously entered upon in the present state of our information, and
especially in these Lectures.
  Loss of appetite seems, on the whole, the most variable and vague
among the leading symptoms of gastric cancer.  Numerically, it is
present in the great majority of cases: or, more exactly, in about
85 per cent, of their total number.
  But it is not in all these cases that the anorexia forms an early
and marked symptom of the  malady.   On the contrary, its appear-
ance is often deferred until a comparatively late period.  And its
intensity is still more frequently restricted to a degree which allows
little stress to be laid upon it, apart from the circumstances which
attend the disease.  In rare instances, too,  its variations amount
to absolute intermissions.   And in still rarer cases, the appetite is
increased, instead of diminished, by the malady.
  The value of this symptom as an element of diagnosis is there-
fore considerably less than might be supposed from its numerical
frequency.  Its presence is of little influence in this respect, unless
it  is early, as well as prominent, in the history of the case;  unless
it  precedes by some time any violent or continuous pain  or vomit-
ing ; and unless it is accompanied (rather than followed) by cachexia
and debility.   Where it exhibits these features, it combines with
the other symptoms as a valuable piece  of evidence, and is specially
useful  in assisting to distinguish between cancer and ulcer.  For
in the latter of these  two maladies, loss of appetite is so rare, that 
CANCER  OF  THE STOMACH.              167
we may almost deny its claim to be considered a symptom at all.
True, the subject of gastric ulcer often evinces a great repugnance
for food.  But a close inquiry would  show  that  this  repugnance
rarely depends on anorexia.  The patient is afraid to eat, simply
because experience has taught  him  the suffering (pain and vomit-
ing) which  this act excites.   Indeed, except  in the later stages of
the  malady, the cravings of his appetite  are (for  obvious reasons)
rather  increased  than diminished;  so that,  every now and then,
instinct prevails  over judgment, and he  eats  a hearty meal.   In
cancer, on the contrary, anorexia often seems to be a specific result
of the disease.  As such, it appears to be effected through the same
nervous1 channels which mediate the ordinary sensations of hunger
and satiety, and  to commence during a  very  early stage of  the
deposit in the coats of the stomach, prior  to  any more  local symp-
toms.   It is, on the whole, more marked in  the younger subjects
of the disease, and in  the softer varieties of cancerous deposit.
   The sex of the  patient appears to  exercise no influence what-
ever on the presence or absence of  anorexia in the history of the
case.2
   Pain, the next  symptom,  is on the whole more  frequent and
specific than anorexia.
   It appears to be present in about 92 per cent.: in round numbers,
in nearly 11  out of every 12  cases.  The sex of the patient seems
little to affect the painfulness of the malady.  And there is scarcely
more  reason to suppose that  the situation  of the lesion in  the
stomach has any  such influence.
   The region to which the pain is referred affords little deduction
as  to the exact site of the lesion, at any rate in its earlier stages.
Thus  a pyloric cancer may not only cause  pain referable to  the
right  hypochondrium,  or to  the epigastrium, but  even to  the
umbilicus, the  sternum, or  the  left hypochondrium.   In cancer of
the  cardia,  again, the pain may not  only be  local, but  may  be
referred to either hypochondrium, or  even to the right shoulder.
The cancer of the lesser curvature seems, however, to be sometimes

  1  In my experience, a sudden loss  of appetite, and  change of color, have fre-
quently preceded all other symptoms.  But the most curious form (?) of such
anorexia I ever witnessed was in the case of a German gentleman, whose ordinarily
slender appetite was little affected, but who suddenly found himself indifferent to
tobacco, which he had smoked  largely, though not to excess, throughput his life.
He was a fine, handsome man, of exceedingly long-lived ancestry.  His medical
attendant regarded his state with profound suspicion  ; but  could verify nothing
but a deterioration of color and  appearance, and  the  change above referred to.
After a careful examination, I satisfied, myself of the absence of every other sigu
or symptom of disease.  Nevertheless, as a matter of professional instinct, I could
only confirm  and  define the suspicion of my colleague, by diagnosing gastric
cancer.  In the course  of  a few weeks the case became only too distinct; and in
a few months  the patient died of an unmistakable cancerous stomach.
  2 For the details which amplify this and other statements of the same kind, as
well  as for the facts on which  they are based, the  reader is referred to an essay
"On Cancer of the Stomach," in the "British and Foreign Medico-Chirurgical
Review," 1857, p. 475 et seq. 
168
CANCER OF THE STOMACH.
connected with a peculiar reference of the pain to the inter-scapular
region, as well as with a remarkable intensity of the pain.   And
any considerable involvement of the posterior surface of the stomach
often causes a pain which ranges  from the middle of the dorsal to
the lower part of the lumbar region.
  But a careful inquiry  into the import of this symptom  soon
resolves numerical statements like the above into their more trust-
worthy (though less definite  constituents.  The pain  of gastric
cancer is evidently no single and  comparable element of its history
in all  cases—like the pain present in  most instances  of gastric
ulcer—but is rather a variable (or  even complex) symptom, pro-
ducible by several circumstances,  which impart to it a very different
relationship to the  malady, according as they are its  exclusive or
predominant causes in any given instance.
  The pain most characteristic of the malady is usually  of a lanci-
nating character.   Beginning  at a  comparatively early date, it
rapidly assumes a marked severity;  often becoming  so intense in
the course of  but a few days as to cause the patient an amount of
suffering which throws every other symptom into the  background.
Its fluctuations scarcely ever amount to more than  remissions: in
other words, it rarely intermits, or  ceases, for any length of time.
Unlike the pain of gastric ulcer,  it is either little affected by the
ingestion of food; or, if increased by eating, does not subside at the
end of the act of gastric digestion, and  after vomiting—of which
act it is often quite independent.  As time goes  on,  such  pain
sometimes becomes less urgent, subsides, or even, in rare instances,
disappears.   More frequently,  however, it changes its  character;
merging,  in  greater or less degree, into some of the  following
varieties.
   In many cases, indeed, the pain is from the first devoid of any
distinctly lancinating  character: and  is  variously described  by
different patients as dull, slow, gnawing, or burning; and as being
attended by  a sense of weight, oppression, tightness, or distension
in the epigastrium; or by soreness or tenderness to pressure in
this region.
   Many of these varieties  of pain appear due to the local circum-
stances of the cancerous lesion : and indeed, may often be traced to
specific causes, such as go  far to explain, not only their  characters,
but even the way in which they sometimes  complicate or succeed
each  other in the history of any given case.   The dull burning
variety of pain seems to belong rather to ulceration of the cancerous
stomach than to the cancerous  deposit itself;  and as such,  often
closely simulates the pain of gastric ulcer.  Thus pain of this kind
is increased by taking food, is referred (it may be) to an epigastric
and a rachidian spot, and is relieved by the expulsion of the gastric
contents.  At the same time, its  accession to the symptoms of  the
malady sometimes seems to relieve the more specifically cancerous
pain—perhaps by that mechanical relief of tension which ulceration 
CANCER OF THE STOMACH.
169
and hemorrhage (its constant companions) together imply.  Local
tenderness or soreness is also referable to ulceration ; though, where
excessive, they allow a presumption of that adhesive inflammation
so common in both cancer and  ulcer of the  stomach.  A sensation
of weight appears but rarely to correspond with a really heavy or
bulky tumor.   Tightness,  oppression,  and distension (often con-
nected with weight)  frequently belong to that constriction  of the
stomach which the cancerous deposit brings about: and when best
marked, have  repeatedly been observed  in  conjunction with  a
maximum of "stenosis;"  with  or without dilatation of the gastric
cavity behind the seat of  stricture.
   Hence the circumstances  of these varieties of pain assign them a
comparatively  subordinate  relation to the malady.  Its various
stages imply events which themselves conditionate various abnor-
mal sensations; such as we  must, for the sake of pathological accu-
racy,  eliminate  from any inquiry into the  pain produced  by the
cancerous deposit itself.  Subtracting these incidental pains, we
are left  with  a symptom which, though  greatly reduced in mere
numerical frequency, has a more characteristic aspect, and therefore
a more direct bearing on the nature and diagnosis of the disease.
   Specific pain of this  kind is probably not present in more than
one-half the total number of gastric cancers.  And it undoubtedly
varies, not only within the limits which would  ascribe it a lancina-
ting character of greater or  less intensity, but even in the fact of its
possessing this  character  at all.  It may be dull, aching, or even
burning; may remit or even intermit; may appear late, or vanish
early in the history of the case.
   Many would  probably consider that such facts went  far to show
a  subjective character  of the pain:—that they exceeded, rather
than  fell short of, the evidence upon which some good authorities
regard as subjective the pain of malignant tumors occupying parts
governed by the cerebro-spinal system of nerves.
   It  is because I believe this view to be not  only erroneous, but
likely to exercise an injurious influence on pathology, that I venture
to point out how baseless are  the  assumptions on which it rests.
Equivocal as is the language of logic when applied to the physi-
ology of innervation, still it allows us to perceive that such a view
is placed in the dilemma of being either  untrue in its facts, or, if
we correct these, still more  faulty in its deductions.
   For it is the  very essence of pain not to be objective:—in other
words, not to be precise or  accurate in the information it gives of
the properties of  any object.  Even  when  brought about  by the
application of a stimulus  to the peripheric organization of a nerve,
it gives  little or no intelligence respecting the stimulus  itself; so
that, for example, a red-hot poker, and a few drops of liquid car-
bonic acid, would  give rise  to  much  the  same kind of pain when
applied to'the palm of the hand.  And when the stimulus by which
pain  is produced impinges on  the nerve at some point between its 
170              CANCER  OF THE  STOMACH.
periphery and its centre, the pain becomes even more subjective;
gradually losing all appreciation of the locality affected; and refer-
ring (for instance) an injury of the ulnar nerve at the-elbow, to its
distribution in the fingers.
  Hence, to the statement that—" the pain of malignant tumors is
subjective," it might  fairly be answered, " True: but what pain is
not so ?  On the other hand, if by 'subjective' you mean subjective
in any other sense than the pain of a wound or a burn; or if you
regard the uncertain  and changeable relations between the malig-
nant lesion and the pain it produces,  as showing that there  cannot
possibly be the same physical  chain of causation as that which
obtains when a nerve is involved in  such injuries—then you  are
implying a statement which centuries of pathological research may
perhaps  hereafter gradually build  up, but which is  at present a
mere assertion.   Not until we  know immeasurably more of  the
structure and function of nerve, and of the exact relations of  the
cancerous deposit to the terminations  of the nerves among which it
lies, shall we be entitled to say that the adventitious mass does  not
provoke pain by a process precisely similar to that which  may be
set  up by a mechanical or chemical lesion or injury.   In the mean-
time, to remove pain into the region  of the 'subjective,' is to with-
draw it from those very researches by which  alone  its claims to
this position can never be substantiated."
  But to regard any such theory  as merely "not proven," is to
take  a far more favorable view of it than is  warranted by facts.
The nature of the above varieties of pain, and the  accuracy with
which they generally correspond to  the various conditions men-
tioned, conclusively refute it.  So also does  the  study of the pain
more specific to gastric cancer.  As in malignant tumors of other
parts, the maximum and minimum of pain  in cancer of the stomach
can generally be  traced  to  something  more  than  a  conjectural
cause.  Excruciating agony has two or three times been found to
coincide with a definite involvement of some large branches of  the
pneumogastric  nerve in the cancerous deposit.   And  conversely,
the presence of little  or no pain has far more frequently been con-
current with such a general hardening of the whole organ, as  has
converted the stomach into a rigid inflexible tube, by a scanty  but
diffuse deposit involving  scarcely any displacement of its tissues.
The somewhat greater pain of the disease in young subjects appears
to be connected with  their greater proneness to the softer and more
rapidly developed  forms of  cancer,  and  with the greater local
injury1 which these  usually imply.  Indeed, allowing for the indi-
rectness of the connection between the stomach and the cerebro-
spinal system,2 the pain produced by gastric  cancer seems to be

  1  Under opposite circumstances, even enormous fungoid  growths may be quite
painless.  Compare " British Medical Journal," 1857, p. 493.
  2  A connection, the influence of which may be roughly estimated by comparing
the pain of cancers without and within the chest. 
CANCER OF THE STOMACH.              171
rather less  irregular than  that  produced  by malignant  tumors
elsewhere.
   Vomiting seems to be  scarcely less frequent than pain in the
history of gastric cancer; being probably present in 87^ per cent.
of its cases.
   There is no sufficient ground for deducing any influence of sex
on the presence or absence of this  symptom.  Apparently it  is
rather more frequent in the gastric cancer of the female, in whom
the proportion of 87 per cent, witnessed in the male, rises to 89|.
Or, to put  the fact more strikingly, the absence of vomiting
throughout the malady is nearly one-third (1.3 to 1) more frequent
in the male.   But the numbers concerned are too  small to justify
any stress being laid on so limited a difference.  Indeed,  even  if
substantiated hereafter, it  will probably turn out to be chiefly con-
nected with  the collateral circumstances of this symptom—for
instance, with its occasional late  appearance, allowing it now and
then to be (as it were)  anticipated by  general exhaustion.
   The locality occupied by the cancer appears to  affect the occur-
rence of vomiting in a much  more marked degree; although the
number of examples I have collected only justify such a conclusion
in the case of the more frequent situations of the disease.  From
an analysis of 167 instances which specify the necessary details, it
would appear that this symptom favors cancer  of the different
parts of the stomach in the following order of increasing frequency:
the posterior wall, the whole organ, the middle, the lesser curvature,
the greater curvature, the cardia, the pylorus.
   Since the, numbers in the lesser curvature and  in the two latter
localities together make up five-sixths of the whole,1 their compa-
rison is  more trustworthy.  They especially show (what, indeed,
has long been conjectured) that cancer of the  pylorus is more fre-
quently attended with  vomiting than cancer of any other part  of
the stomach;  and suggest that this symptom is sometimes brought
about chiefly  by obstruction of the gastric cavity—that is, by such
obstruction as any deposit of cancer  around the narrow calibre  of
the pylorus would be likely to produce.
   A further study of this symptom indicates that it may be condi-
tionated  by three or four  different  causes; the precise share  of
which in the  vomiting  of any particular case it  is  sometimes im-
possible to estimate.
   Firstly, there seems to  be  a variety of vomiting (as of pain)
which is at any rate so far specific or inherent to the  malady,  as
that it is producible  by a  scanty deposit in the coats of the organ,
and is therefore observable at a very  early period in the history  of
the disease.   The frequency of this  form of  vomiting cannot be
determined.   But I should conjecture it not to occur in more than

  1 See the remarks on the  pathology of this  lesion in a subsequent part of this
Lecture. 
172
CANCER OF THE  STOMACH.
ten per cent, of the total number of cases;  and to be little (if at
all) more frequent in cancer of the stomach, than in non-malignant
deposits in or on this part  of the digestive  tube.   It seems to be
connected chiefly with a local irritation  of the  nerves distributed
to the  seat of the  disease;  and hence  to  vary chiefly with the
abruptness of outline of  the  deposit, and with the  displacement it
inflicts.
  Next  in the history of  the disease, and  of greater numerical
frequency,  comes  the vomiting produced by obstruction  or by
stenosis.  It  is affected by  locality, as above mentioned.  And in
rare instances it  is relieved or  removed by the ulceration or
sloughing  which destroys the obstructive part of  the cancerous
mass.
  A third  variety of vomiting appears to form  a still larger  frac-
tion of the above total frequency of its occurrence.  That process
of softening and ulceration which the cancerous deposit sooner or
later  undergoes, first removes the mucous membrane,  and  then
erodes  a variable extent of  the original or  adventitious tissues
beneath; thus giving rise to  an abnormal irritation which rarely
fails to cause vomiting.  In general, the symptom, once thus excited,
recurs more or less frequently throughout the further course of the
disease; a  fact sufficiently  explained  by the  continual increase of
the lesion,  and by the influence of habit on the act.   Occasionally,
however, it subsides or disappears; sometimes, it would seem, from
the low vitality or irritability of that softened or  ulcerous mass
which comes  to  form the  inner  surface of the stomach;  oftener
(for a similar reason) from the access of general prostration.
  Lastly, there is a less frequent (but more complex) class of cases,
in which this symptom is apparently due to a failure of contraction
in the muscular coat of  the stomach,  giving rise to a  virtual ob-
struction which itself provokes vomiting.  In rare instances, this
interruption to peristalsis may be due to a nervous cause, such as
would justify its  being termed  paralysis.  More frequently  it is
traceable to a direct interference with the muscular  structure; a
large extent of which is removed by ulceration, or weakened by
dilatation,  or starved (and even destroyed) by interstitial deposit.1
  Each  of the above four  varieties  exhibits peculiarities such as
often aid to distinguish it.  The first, for example, generally forms
the climax of a gradual increase of anorexia and nausea; and rarely
shows any marked relation, either to the quality of  the food, or to
the period of  digestion.   The second offers a close resemblance to
the vomiting  seen  in gastric ulcer;  and, like it, is provoked by

  1 It is true that the evidence afforded by cases of gastric cancer rarely amounts
to more than a presumption that the vomiting present is chiefly or exclusively
caused by one or other of these forms of interference with peristalsis.  But it must
be remembered that the efficiency of every one of them is proved by its constituting
the sole cause of this symptom  in some other diseases of the stomach.  (See
Lecture V.) 
CANCER OF THE STOMACH.
173
food—especially by large meals, and by hot, irritating, and protei-
nous articles of diet.1  As a rule, however, it is less constant, less
intense, and therefore less dangerous, than the vomiting of gastric
ulcer ; and is often limited to the last few weeks of the patient's life.
The third generally occurs at intervals of many hours—-indeed, is
usually a large (from two to six pints or more), dark, yeasty-looking
vomit, which is the accumulation of many meals, and contains sar-
cinse, torulee, or both: while it is of course accompanied with the
physical signs of  dilatation of the stomach.  The fourth can  only
be said to  afford  direct and independent evidence of its presence
in those rare (but  authentic) instances in which the patient has felt
that the contracted stomach could neither receive more than a small
quantity of food (all in excess of this amount being instantly vomited),
nor pass onwards  any appreciable fraction of it into the duodenum.
  Hemorrhage constitutes a less  frequent symptom  than either of
the preceding: being noticed in  about 42 per cent, of the cases on
record—a proportion which is the same in both sexes.
  In  about one-sixth of these instances, the hemorrhage was  suffi-
ciently copious to be recognized  as  tolerably pure blood.  The
remainder include a great many cases in which the blood appears
to have been more or  less mixed with gastric juice,,food, bile, or
softened cancerous substance; and to have undergone a variable
change of  color, such as would impart to it a blackish, brownish,
or " coffee-grounds" appearance.
  But the  frequency of hemorrhage is doubtless much greater than
the above statements suggest.  Indeed, the pathology of cancer in
general, together with the  history of this particular malady, will
quite entitle us to suppose that some hemorrhage rarely  fails to
occur, save in those instances in which the patient dies before the
ulceration  or softening of the deposit.  But though, in all other
cases, its occurrence seems  necessary or inevitable, its detection is
contingent; being  determined by a variety of collateral (or  even
remote) circumstances—such as the quantity of blood poured out,
the rapidity of its effusion, the casual coincidence of vomiting or
purging, or the attention  habitually bestowed  by the physician or
patient upon the  substances thus expelled.  And hence there can
be little doubt, both that a sedulous inquiry (aided if necessary by
the microscope) would reveal this symptom in  many cases in which
it must otherwise  remain unnoticed, and  that the above numerical
statement greatly  underrates its true frequency.2
  In respect to their nature and  origin, such hemorrhages may be
divided into three varieties.  First in the history of the malady
comes the  hemorrhage of  congestion; which often  occurs at an
early stage of the deposit;  and which, though usually  moderate

  1 With reference to the share probably taken by the gastric juice in producing
the ulceration which causes this vomiting, compare pp. 143-4.
  * Compare p. 109. 
174              CANCER  OF  THE STOMACH.
in amount, is in rare instances so copious as to cause death.  In
these fatal cases, the accuracy of the term congestion is rendered
probable  by the  fact, that a careful examination of the stomach,
aided by injection of its vessels, conclusively shows that the hemor-
rhage has proceeded from the minute vessels of the submucous
plexuses, or from the capillaries of the free  gastric surface, and
not from any of the trunks or larger branches of the arteries or
veins.  In other instances, the relation of the tumor to such a con-
gestion has been  still more definitely indicated by a varicose en-
largement of some of the small  veins  in its neighborhood, or a
deep  purple streaky coloration of more or less of its periphery.
Whether the passive or  obstructive congestion which such a state
suggests is more or less frequent than an active congestion or afflux
to the adventitious growth;  and whether the  latter state, in so far
as it  occurs, may not sometimes diminish, rather than aggravate,
the former;—are questions which cannot at present be answered.
Thus much we may, however, conclude respecting this variety of
hemorrhage: that while its very occurrence in gastric ulcer is in
some degree hypothetical,1 it appears to form a definite and not
infrequent form of bleeding  in gastric  cancer; and  seems to be
often produced by a passive or physical engorgement of the vessels,
itself the result of a mechanical obstruction brought about by the
deposit.2
   The second variety of hemorrhage  is the result of the  various
lesions in which the processes of ulceration and softening  involve
the vessels of the cancerous mass.  In conformity with this source,
it generally occurs at a  comparatively late  period  of the malady,
and is by far the  most  frequent cause of  the  more copious bleed-
ings witnessed in cancer of the stomach.   The degeneration and
destruction  by which it is produced  are  often  complicated by a
process of fungation or  outgrowth, which  increases the amount of
blood effused by such hemorrhage.   As a rule its amount is gene-
rally scanty—often  sufficiently so to escape  detection.   In rare
instances, however,  it  is excessive;  and  from the circumstances
that attend  it, is  always  important  (often  fatal) even when but
moderate in quantity.
   The third variety of hemorrhage is that produced by erosion of
the  larger vessels external  to the stomach.  Its production and
comparative infrequency will be again alluded to.3   Unlike the two
preceding varieties, hemorrhage of this kind is probably but seldom
overlooked.  Hence the estimate that it does not  cause death in
more than one out of 100  cases of gastric cancer, or in more than

  1 See pp. 109, 133.  The coincidence of cirrhosis of the liver with ulcer of the
stomach is suggestive, however, of such hemorrhage (p. 144).
  2 Future observations can alone show whether villous  cancer affecting the
stomach is  attended with that  peculiar disposition to hemorrhage of  this kind
which it seems to exhibit when occupying other mucous membranes.
  3 See the pathological section  of this Lecture. 
CANCER OF THE STOMACH.
175
one of the 40 of this 100 which evince such a symptom, probably
does not understate its relative frequency.   From obvious reasons,
it  generally occurs  at  a late period of the disease, as measured
both by its duration, and by the succession of it symptoms.
   The characters of the blood expelled from the stomach of course
vary with all those circumstances which affect the appearance of
this fluid in the analogous  hemorrhage that attends gastric ulcer.
According as it is poured out by an artery, or a vein; in gushes,
or by a slow oozing; in large, or small quantity;  and  is expelled
at once, or only after undergoing  more or  less  admixture and di-
gestion—the blood detected in the patient's stool or vomit may be
liquid or clotted; florid, dark, or black; pure, or so changed, and
combined with other contents of the alimentary canal, as  almost
to defy recognition.
   As regards the relative frequency of its two means of exit, hemor-
rhage seems to be detected solely in the matters vomited, about five
times as frequently  as in the stools  exclusively.  In one-fourth of
the cases, it is found in both these evacuations.  Such  proportions
correspond to five-eighths, one-eighth, and two-eighths respectively.
   It is scarcely necessary to say that the so-called "coffee-grounds"
vomiting, which was formerly supposed to be almost pathognomonic
of cancer of the stomach, has really no such diagnostic value.  It
occurs in gastric1 ulcer;  as well as  in various other lesions of the
organ  attended  with  scanty extravasation  of blood.  And  its
greater  frequency in cancer  is attributable rather  to the moderate
amount in which hemorrhage usually occurs in this disease, than
to any more specific cause.  At any rate, this circumstance, and
the comparatively greater  frequency of vomiting on an empty
stomach in cancer than in ulcer, seem quite to explain the dispro-
portion observed.
   In close connection with hemorrhage is another symptom till now
almost overlooked—namely, the detection of the characteristic
cancerous cell-growth in the substances expelled from the stomach.
   For  obvious reasons, this  sign is rarely to be  found, except at
such a date of the  malady as would generally imply the presence
of most (if not all) of the preceding symptoms.  Indeed, depending
(as it does) rather upon exfoliation  or  sloughing, than upon any
mere  slow dissolution, of the cancerous  mass,  it  is  intimately
associated with such a degeneration  or decay of its substance as  we
have already seen can rarely occur without more  or  less  hemor-
rhage.   And although  it is quite possible that sedulous research
mio-ht  detect cancerous matter in the stools of a  patient, still, in
practice, there is  scarcely any reasonable  chance  of its discovery,
save in those cases of gastric cancer in which vomiting is not only
present, but  occurs upon  an empty  stomach,  and with tolerable
frequency.

   1 Melanosis is so extremely rare as a cause of this color, that the diagnosis of
its nature is identical in the two diseases.  Compare p. 110. 
176
CANCER OF THE STOMACH.
   The ordinary difficulties  in the recognition of cancer under the
 microscope need scarcely be alluded to; although these difficulties
 are increased by the circumstances of its deposit in the stomach—
 especially by its form (almost  always medullary at its exfoliating
 surface), and by the solvent effects of the gastric juice.  For how-
 ever  the cancerous  nature of  the  substances expelled  may be
 obscured by  the equivocal size and shape of their cells, and by
 their separation and dissolution in  the stomach, its recognition is
 practically much more impeded by the large and numerous impuri-
 ties  admixed with them here.   The addition of blood, pus, bile,
 saliva, and gastric juice, together with the various and complex
 admixture of particles entering into the composition of the simplest
 foods and drinks, will often frustrate the most careful and repeated
 examination of these egesta.
-  The only practical rules I  can offer are the following:  The
 fluids selected  for  examination should  be such as are vomited
 tolerably free from any admixture of food.  If much blood or bile
 be present, they should  be  diluted carefully by the addition of a
 moderate quantity of water.   Thus  attenuated, they should be
 searched (by decanting off the clear fluid) for any flocculi or larger
 masses  they may contain.  If the examination of these be at all
 delayed, syrup will form the best means of preserving them.  To
 the practised  eye there is little danger of confounding a  mass of
 cancer, even when  already  half dissolved, with shreds  of oesopha-
 geal  or   gastric epithelium.  But  mere isolated  cells or  nuclei
 scarcely justify a decision.
   On the whole, it is evident that this symptom, rarely visible until
 little doubt is left, often defying all detection, sometimes yielding
 but equivocal evidence, can only now and then be of value. And
 its usefulness is solely positive.  In other words, its absence proves
 nothing.  In both these respects it stands in marked contrast with
 the analogous evidence afforded by the microscope in  some other
 diseases—especially  (for example)  in  suppurating  pulmonary
 tubercle;  where the distinctness of the tissue detected, and  the
 comparative constancy of its presence, render it a  ready and  un-
 mistakable piece of positive^vidence, and, with proper precautions,
 allow its absence some value as a negative.
   The detection of  a tumor constitutes a symptom which may be
 estimated as  present in  about  80 per cent, of the cases of gastric
 cancer.    The sex of the patient does not seem to influence  the fre-
 quency or distinctness of this symptom.
   The form of cancer scarcely seems to exert any more perceptible
 influence on the presence of a tumor.  From  obvious  reasons, the
 tumor produced by scirrhus generally appears at a comparatively
 late period in the history of the malady.
   The situation of the cancer in the stomach seems to exercise the
 influence we might expect on the appearance of a tumor. Whether
 we calculate this influence  directly (by comparing the  cases of its 
CANCER OF THE  STOMACH.
177
presence and absence) or indirectly (by comparing the former cases
with the general frequency of the symptom as deduced above), we
obtain results which may be briefly summed up as follows.   The
presence of a tumor is favored by the disease being situated in the
middle of the stomach, in its greater curvature, in the whole organ,
and  in the pylorus; its average frequency, as represented  by 100,
being  increased to 300, 220, 160, 120, for these  four  situations
respectively.  On the other hand, it is opposed by the cancer being
situated  at the lesser curvature, the cardiac, and the posterior sur-
face ; the same average being  respectively diminished  to 95, 44,
and  something  considerably less than 25.  These  facts are obvi-
ously  explained by the relative proximity of the corresponding
parts'  of the stomach to the yielding anterior wall of the belly, by
contact with which an ordinary cancerous tumor of the organ is
rendered easier of detection.
   The situation of the tumor in the belly varies in a degree which
is but partially explained  by its anatomical relations.  As might
be expected, it is almost limited to the epigastric, umbilical,  and
hypochondriac regions; where it forms a projection of variable size,
shape, and  smoothness, from a large,  hard, irregular,  nodulated
mass, causing a prominence which it  is impossible  to  overlook, to
a small, deep, elastic, or unresisting substance, such  as is often ex-
ceedingly difficult to recognize.  Tumors of the great  curvature
are apt to project near the umbilicus; cancer of the whole stomach
projects chiefly into the epigastrium; the upper part of which region
(from  equally obvious reasons) generally shows the swelling of a
cancer situated in the lesser curvature.   But  the variableness in
the situation of the tumor is best seen in the pyloric  cases, which
form so large  a  majority of the  whole.   In  most of  these,  the
swelling occupies the neighborhood of the  median line.  Where it
transgresses  this  rule, it  selects the right hypochondrium  more
frequently than the left—a preference which is referable, not only
to the normal situation of the pylorus, but also to the frequency of
adhesion between the diseased segment of the stomach  and the con-
tiguous liver.  The vertical level  of  these pyloric tumors appears
to be affected by the sex of the patient in a curious (though by no
means inexplicable) manner.   The  horizontal line which separates
the epigastric from the umbilical regions divides the  locality usu-
ally occupied  by such swellings into two pretty equal portions.
Of these the upper  (including  the epigastric  and  hypochondriac
regions) is, in the male, the seat of two-thirds of these  tumors;  the
lower of one-third.  The female subject of cancerous pylorus exactly

  1 We may distinguish the effect of these situations by alluding to the circum-
stances through which they oppose the appearances of a tumor, as comprising at
least three elements—(1) remoteness from the surface, as in all these sites ; (2)
influence on perforation, and incidental death, as in cancer of the posterior surface
(see pathological section) ; and (3) specific tendency to grow in another direction,
as in the cardiac cancer, which generally shoots up the oesophagus.
       12 
178
CANCER OF THE STOMACH.
reverses these proportions, two out of every three tumors occupying
the umbilical regions.   This strange contrast must be ascribed,
partly to the naturally narrower  limits of the female epigastrium,
partly (and much more) to the constriction exercised by stays ; two
circumstances which  concur  to force  the liver  and stomach,
together with any  tumors which may  be attached to  them, to a
lower level in the belly than they would  otherwise occupy.  The
same circumstances  appear to be traceable in the fact, that mobility
of the tumor is much more frequent in the female—at least, mobility
in such a degree as allows the tumor any wide deviations in the
abdominal region it occupies.
  The detection of a tumor is sometimes opposed by great  diffi-
culties.   The  resistance  offered by the  supposed mass now and
then leaves us in doubt; merging (as it does by various gradations)
into a slight fulness to palpation, or dulness to percussion.   Again,
the tumor is often in absolute contact with the liver;  and hence, if
of moderate  dimensions, may  be so  completely covered by  this
organ, as to have its physical signs fused into those of the lobe of
liver by which it is overlapped.  Nay, more, a large proportion of
these tumors  adhere to the liver: while  a still larger proportion1
are associated with  a secondary cancerous deposit in the hepatic
substance, such as often defies the greatest skill to distinguish from
the swelling produced by the gastric cancer apposed to it.   On the
other  hand,  the adhesion and  inflammation around an ordinary
gastric  ulcer may give rise  to a perceptible tumor, which  must
sometimes be suspected  as  cancerous.   Further,  the tumor pro-
duced by a gastric  cancer may be  temporarily hidden  by ascites,
as well  as by changes in the size and situation of  the neighboring
intestines.  And lastly, just as the cancerous deposit is  sometimes
too scanty, and its situation  too deep, to permit  the appearance of
this symptom at all, so I have often seen  the tumor producible by
a cancerous stomach closely  imitated by cancer of  the neighboring
mesentery or intestine.   The gastric distension  brought about by
constriction  and dilatation behind it can, however, almost always
be distinguished from a cancerous tumor.   Even when (as is not
uncommon) the two states are combined, the presence and degree
of dilatation may be decided by a physical examination ; the results
of which, again, can be  checked or verified by the characters of
the vomiting present in such cases.   (Compare Lecture V.)
  The above variations are well  illustrated by the fluctuations in
distinctness which such  tumors sometimes exhibit in  the course of
a single case.   The swelling distinguishable one day has disappeared
on the next; to reappear, it may be, a few days later.  Occasionally,
its subsidence is permanent: a fact which, if unexplained by any
of the circumstances above mentioned, points to a loss of substance
in the diseased mass, by softening, ulceration, or  sloughing.
See the pathological section of this Lecture 
CANCER OF THE STOMACH.
179
  Many of these tumors are pulsating—in other words, are so placed
as to receive and transmit the impulse of the aorta.  Of such pul-
sating tumors a disproportionate number seem to affect the pyloric
situation, and the male sex.
  Mobility of the cancerous tumor seems to be rare, in that marked
degree which permits  it to occupy different abdominal regions.
The three or four cases I have collected are all pyloric,  female, and
(at least originally) scirrhous.
  Tenderness of the tumor is generally present in some slight degree.
It is marked in about half the cases; but is rarely great, save where
the peritoneum is  either inflamed, or is  involved in the original or
secondary cancerous deposit.
  The cachectic appearance upon which so much stress is deservedly
laid in the diagnosis of gastric cancer, is scarcely a single symptom,
but rather a congeries of symptoms;  some of the slighter and less
direct of which can neither be satisfactorily grouped with it, nor
separated from it.
  In  respect to its frequency, about 3 in 4 of the cases on record
have exhibited it in a marked degree.   This proportion is exactly
alike for both sexes.  But in  a lesser extent it is probably present
in not less than 90 to 98 per cent, of cancers of the stomach.
  As elements of this cachectic  aspect, we may fairly enumerate,
not only the color of the skin of the face and body, but the loss of
cutaneous moisture and elasticity, the  diminution of the subcuta-
neous fat, the flabbiness (if I  may use such a word) of the areolar
tissue, and the softness  and smallness of the muscles.   The latter
symptoms are closely connected with emaciation and debility, and
often with kindred characters of the pulse and the  cardiac action.
  Of all these appearances, however, the altered facial  color is the
most  obvious and important, as well as the most constant.  The
more characteristic variety of this change is describable as impart-
ing to the face a kind of muddy greenish pallor, or  pale earthy hue,
such  as  can scarcely be mistaken for  any other color.   The chief
extremes (if we may so  term them) of  this symptomatic color are
jaundice on the one hand, and  an anaemic whiteness on the other.
  Jaundice appears to occur in a proportion  of about 5^ per cent.
It may be conjectured that in about one-half of the cases the jaun-
dice is due to the  hepatic disorganization produced by consecutive
cancer of the liver.
  In  the remainder the jaundice  seems quite independent of any
structural hepatic  disease.  The coloration of such jaundice appears
to merge, by numerous gradations in different cases, into the ordi-
nary hue of the cancerous cachexia.   And (if we except those rare
cases in which its symptoms, and the date of its appearance, refer
it to a cause analogous to  that of the jaundice which sometimes
comes on in the later stages of mortal cardiac disease) it is difficult
to avoid regarding it as little more than a variety  of this cachexia.
Such a  view is  especially confirmed  by one or two important 
180
CANCER  OF  THE STOMACH.
features it generally offers.   The icteroid  stain is rarely intense,
and even the  conjunctiva is often but moderately yellow.  The
stools, too, however offensive, have neither the white color, nor the
putrefying odor, characteristic of true jaundice.   And the skin and
urine are not loaded with bile in anything like usual degree.1
   Pallor of the  skin is just  as evidently a variety of the charac-
teristic color in some cases, a  complication  of it  in others.  In
other words, it often seems  traceable to  no other cause  than the
cachexia which  it accompanies; oftener,  however, is  due to some
of those incidents of the malady which, when they occur in other
diseases, bring about a similar result.  Thus hemorrhage, suppura-
tion, frequent vomiting, scanty ingestion of food, long confinement,
and a host of circumstances (among which  are recorded such rare
contingencies  as concurrent  albuminuria) may all complicate and
increase that pallor, which is an element of the peculiar facial hue
characteristic of gastric cancer.
   With allusions equally hasty and imperfect,  we must pass by
the interesting subject of inquiry which the nature of this cachexia
might afford us.  Enough to  say that of all the provisional theories
which suggest themselves, that  regarding the original  or pathog-
nomonic cachexia as the  result of a  humoral disease, which pre-
cedes and brings about the cancerous deposit, is, on the whole, the
safest, as well as the most  useful.  According to such  a vague
theory, there is  a cachexia which, in some cases, can be verified
prior to any of those local changes that afterwards rudely measure
and express it.  But besides  this specific cachexia (the nature and
date of which render it so important for pathology and diagnosis),
there are a  variety of conditions  which  closely resemble it, but
bear  to the  total malady a  relation of coincidence rather than of
identity, and of effect rather  than of cause.   Often as  these condi-
tions complicate and obscure the true cancerous cachexia, patho-
logical accuracy requires their  separation in the history of the
malady; nay,  more, so  far  as may  be practicable, in any given
instance.  Indeed, it would be difficult to find a better illustration
of  the  practical value of  such accuracy than we may see in many
cases of this malady.  Contrary to what has been  generally stated
by authors, the cachectic aspect witnessed in gastric cancer is often

  1 A full discussion of this interesting point would diverge too widely from the
present subject.  But without  wishing to deny the  analogy of this coloration to
certain forms of jaundice, I am anxious to insist on its connection with  the cancer-
ous cachexia, and its distinctness  from the commoner varieties of icterus.  And
while its presence in any particular case may help to distinguish it as cancer, its
complete absence in others scarcely counts for much less.  As regards the  urine,
indeed, I am inclined to consider that the condition imparted by the cachexia,
attending cancer of the stomach, ranges, by all possible degrees of coloration, from
a large proportion of biliverdin, through lessening qualities of this coloring matter,
to the purple urates noticed by Prout, and hence down to  a mere excess of ordi-
nary urohaematin.  Practically, in  any doubtfal case, a normal hue and amount
of urinary coloring matter is a fact of the most gratifying import. 
CANCER OF THE STOMACH.              181
imitated by mere ulcer  of the stomach—sometimes  so  closely as
really to defy distinction.  But in all these cases, the resemblance,
however close, is  easily explained.  The circumstances of both
diseases are such as to involve in a large proportion of their more
fully developed cases, a certain amount  of cachexia;—which is the
joint product of ulceration, hemorrhage, vomiting, pain, and starva-
tion.  While  in  other cases a knowledge of this fact renders the
symptom a valuable aid to diagnosis.  Wherever cachexia either
precedes these circumstances, or is present in a degree utterly dis-
proportionate  to what their aggregate  influence might lead us to
expect, there it acquires  the rank of a leading (and almost pathog-
nomonic) symptom.
   Febrile symptoms accompany gastric cancer much more frequently
than is generally supposed.  But I cannot offer you any numerical
statement respecting  the frequency of their presence.  As a rule,
these symptoms rarely amount to definite hectic, but are generally
limited to what is termed irritative or symptomatic fever.   The
tongue, often  covered with a tolerably thick  white  fur, which is
especially distinct  posteriorly, gleams  through this covering,  or
appears  at its edges of a deep-red  " raw" color.  The face  is  not
unfrequently marked by injected red patches on the centre of each
cheek, contrasting strongly with the pallid cachectic hue of  the
surrounding integuments.   The  urine  is still  more  frequently of
scanty amount, high specific gravity, and abnormal color (comp. p.
180); and is  loaded with  urea and  urates.  The various forms of
uric acid deposit  are also  anything but uncommon; indeed, it is
perhaps in this  malady that we may find the  best illustrations of
that peculiar pink variety (or  rather  complication)  of  uric acid
deposit, which has long been regarded as characteristic of consti-
tutional malignant disease.
   The import of this febrile reaction is probably very different in
different cases.  Ulceration, inflammation, and peritonitis, suggest
themselves  as its causes,  scarcely less frequently than does  the
primary malady, or even the exhaustion it directly  or  indirectly
produces.  On the whole, however, the latter state seems to me the
best clue to the nature of these  symptoms in the majority of cases
in which they are present.  Especially  is this explanation applica-
ble where none of  the above local complications appear  to be pro-
minent.  In such instances, the febrile reaction often seems strictly
analogous to that  feverish condition producible by starvation, ex-
posure,  or over-exertion, in persons otherwise healthy.  And  in
consonance with this view, I think  it will generally be found  that
its presence is a rough test of the progress of the malady—at any
rate, of its  effect  upon  the constitution;  and therefore not only
threatens the speedy prostration of the patient, but affords an indi-
cation for as much nourishment and support as  the  local circum-
stances of the malady will allow.
   The state of the bowels  in gastric cancer is another point on which 
182
CANCER OF THE STOMACH.
I have no numerical details to offer.   In most instances, however,
either constipation or diarrhoea is specified as having been present
during a considerable period of the malady.   And in  many, the
two  states  alternate with each other;  constipation in the  earlier
months of the history being  succeeded by diarrhoea  towards the
last few weeks of life.
   Constipation, the  more  frequent of the two, appears to be often
due to the  circumstances of the malady rather than to the malady
itself:  and, in this respect, is comparable with the  constipation
which  so frequently accompanies gastric  ulcer.  In  many cases,
indeed, the gastric obstruction, vomiting, and pain—which prevent
alike the distension, and the movements, of the intestinal canal—
concur to form a ready  explanation of the  frequency and intensity
of this symptom, which sometimes persists up to the  last hour of
life.
  But in other instances, constipation assumes a much closer  rela-
tion  to the diagnosis.  Wherever it is unexplained by association
with the foregoing circumstances (in other words, when it stands
almost alone with  anorexia and cachexia)  it acquires  significance.
A sudden change in the action of the bowels—which from regular
and  punctual movements every day, become, in the  course  of a
week or two, languid,  sluggish, and finally downright obstinate,
yielding to cathartics, only to relapse into constipation  as soon as
these are suspended—becomes, in such  instances, quite an element
of the diagnosis.  True, it does not of itself  point  out the affected
viscus, much less the affected segment of the digestive canal.   And
still  less does  it specify  the lesion.  But it  is nevertheless of great
practical importance: even if it be not (as it  sometimes has  been
in my own practice) recognizable  by those indefinable features
which, as is the case with other common symptoms, stamp this
variety of  constipation  with the physiognomy of gastric cancer.
   Diarrhoea seems mainly attributable to the direct irritation caused
by the cancerous, purulent, or hemorrhagic effusion which the gas-
tric lesion introduces into the intestines.   The noxious  influences
of these fluids are often aided by their  decomposition  in their pas-
sage through the  bowels.  Ulceration of  the caecum, and  of the
neighboring ileum and  colon,  is comparatively so rare, as to afford
but  a very exceptional  explanation.   The date of the occurrence
of diarrhoea is generally consonant with the above view of its pro-
duction : being  subsequent to ulceration—in other words, compa-
ratively late in the history of  the malady.   It thus  coincides with
a  period, at which the patient's strength  is generally  so far ex-
hausted,  as to be  very susceptible of  any further  depressing in-
fluence.   Hence it often indicates  imminent  danger, and is not
unfrequently the proximate cause of death.
   The symptoms  which  more specifically betray the approach of
death, offer little that is peculiar to this disease.   Anasarca  is by
no means  uncommon, and is  usually accompanied by ascites.  A 
CANCER OF THE  STOMACH.
183
disproportionate effusion into the belly points rather to some local
cause of the dropsy, such  as pressure of the cancerous tumor on
the vena portae; and is hence  less significant  for prognosis.  Jaun-
dice, as before  mentioned,  appears  to be sometimes a precursor of
death, as is also a form  of pulmonary effusion which I believe to
be  mere passive congestion.   Hiccough, again,  is usually due to
local  causes acting on  the diaphragm.   The nervous phenomena
which usher in the close of the malady are  delirium, followed by
coma.
  The duration of the aggregate malady formed by the succession
of all these symptoms, I should estimate, from 198 cases, as averag-
ing about  12 \  months.  This  average seems to differ little in the
two sexes.  Out of 142 cases, 107  male  and 35 female, the average
in the male was 12|, in the female  llf months.  This slight differ-
ence  is rendered even  less important by the smaller number of
females referred to;  especially in  conjunction with the fact, that
the deviations from  the average  are far more  striking,  and  less
trustworthy, in the case of the longer durations, than of the shorter.
Indeed, as regards the longest or most chronic instances, it is curious
to notice how few gradations exist between protraction to the close
of the second year, and the rare examples of a duration of six or
seven years.  Hence, it is probable  that many of these extremely
protracted cases are examples of  dyspepsia  ending  in cancer, an
opinion which  may also be directly deduced from their symptoms.
   Practically, then, we may deduce—that the maximum  duration
of gastric cancer  amounts to  a period of about thirty-six months
from the  first appearance of the  symptoms ;l and  that  very few
cases survive  the  twenty-fourth month.  The minimum  is  about
one month.   As  might  be  inferred from  the  historical  details
hereafter alluded to, many of the most protracted cases are shown
by necropsy to have a structure  often designated  " colloid" and
" encephaloid," though originally scirrhous.  The converse exception
is  much rarer, a large  majority of  the gastric  cancers which are
rapidly fatal really belonging to  these two  intense  forms of the
malady.
   But in  noticing these facts, we must be careful  not to overrate
their significance.  The commencement of  the symptoms  often has
little connection with the commencement of the disease.  Pathologi-
cally, it  is  of  course  not  only impossible  to fix the date of the
deposit in any given instance, but  probable that its material origin

  1  Without wishing to modify the above rules, I may notice some striking ex-
ceptions which have convinced me, after full consideration, that  the pathological
connection below hinted at does really obtain in many cancers of the stomach and
even of the pylorus.   In some, symptoms absolutely identical with those imme-
diately preceding death (pain, vomiting,  &c.) have occurred, intermittently, for
ten fifteen, seventeen, twenty years before.  In others, the first and last attack has
been of but a few weeks' duration.   In both classes, the necropsy has shown the
whole or part of the cancer  to be so shrunken, hard, or even stony, as to refer its
origin to a date at least many months prior to the last illness. 
184
CANCER OF  THE STOMACH.
may be followed by all those varieties in the  rate  of subsequent
growths which we can verify in cancers of external parts.  And
even that aggregate of symptoms which, for diagnostic purposes,
we must regard as the representative of the disease, will often give
a very  distorted view of the real duration of the case.   Slight
anorexia, cachexia, or emaciation might  often elude the notice of
the patient; or, perhaps, would'rarely cause him to seek professional
advice, such as might sometimes  detect and distinguish  the latent
causes of these early symptoms.  Hence, in most of the cases on
which the above estimate is founded,  the symptoms from which
the commencement of the malady has  been  dated are those of
active gastric disturbance, in the shape  of pain and vomiting.
  This brings us to a point on which I am anxious to be explicit,
in order not only to expose the probable bias of the above estimate,
but also to explain  the deceptive resemblance between cancer and
ulcer of the stomach;—a resemblance  which is often of vital im-
portance for the physician to unmask.   In many cases of gastric
cancer, the symptoms only date  from the commencement of ulcera-
tion in the cancerous deposit;—from a time, that is, when the incu-
rable and malignant disease acquires a  close analogy, in many of
its circumstances, to the curable ulcer;  an analogy such as neces-
sarily brings about the closest similarity in many of its local symp-
toms.  Thus, whether we explain their access as due to this cause,
or view them as independent  of it, it is certain that  the  more
marked and frequent varieties of vomiting and pain, as well as of
hemorrhage, begin at a period about midway in the history of the
best  marked cases.   Hence we  may conjecture (1st) that the can-
cerous deposit itself generally precedes the symptoms by a period
of at least some months: and  (2d) that the above estimate of the
total duration  of the symptoms  may perhaps  receive some exten-
sion  from future clinical researches.
  And now let me add a few words respecting the combined effect
of all the preceding symptoms on the diagnosis  of cancer of the
stomach.
  The numerical estimates I have offered are deduced from the
collation of  about  250  cases, verified  by necropsy.  But  in the
records  thus  used, each of these symptoms occupies one of three
categories; it  is present, or absent, or unmentioned.  Now, of the
six foregoing  estimates, all but  those relating  to  hemorrhage and
cachexia completely ignore the  latter category; and only contrast
the number of cases in which the particular symptom was present,
with those in which it is as distinctly stated to have been absent.
But  since it may be presumed that, in many such  records, it has
been unnoticed, because really absent, it may be a question whether
the corresponding estimates  ought not to be reduced; and to a
degree somewhere between the numbers we have assumed, and the
subtraction (of 38, 5, 10, and 26 per cent, respectively) required on
the supposition that the symptom unmentioned was always absent. 
CANCER OF THE STOMACH.             185
On merely numerical grounds, I should, however, prefer the larger
estimates;  not only because they are based upon a more direct and
positive comparison;  but because they seem better  to  balance the
two  kinds of  error—excess  and  deficiency—to  which all  such
calculations are liable.
   Such a  preference appears still  more imperatively called for by
the results of what are probably deeper, though narrower, inquiries
than the scattered and  independent records collected and summed
up in  the  foregoing  statements.   For the  larger estimates closely
correspond with my own observations  in about twenty-five cases;
as well as those of Lebert1 in  about thirty-five.  Indeed, if I might
argue  from so small a number,2 my experience would suggest that
some of the preceding symptoms occur with even greater frequency.
To say  nothing of hemorrhage and cachexia (the frequency  of
which would scarcely be overstated at ninety-five  per cent.), ano-
rexia,  pain, and vomiting are, I believe, all  more constant  than
these  estimates suggest.  And if  it should be objected that the
vague and indefinable nature of these symptoms perhaps throws
doubt on  this suggestion;  or that their frequencey as elements of
ordinary gastric  derangement renders it doubtful whether,  even
when  occurring in gastric cancer, they are always due to the lesion ;
it might be answered that there is still one symptom left, against
which all  such objections  are invalid; and which  yet affords the
strongest confirmation of this clinical (as opposed to a mere statis-
tical) view.  It is precisely in respect to the evidence afforded by a
tumor in  the belly, that I find the widest divergence between the
cases  I  have seen and those I have collected.  In the former, I
have rarely failed to detect a tumor long before death;  in the latter
it is only by the correction implied  above that the fifty-four per cent.
deduced from mere statistics  is raised to the  proportion of eighty
per cent.,  which  is  suggested by Lebert's inquiries.   In  short, I
believe, that even the large  estimate of this able authority under-
states, rather than overstates, the frequency  and the distinctness
with which  a  tumor can be  verified by a careful physical exami-
nation.
   Such being  the probable bias of the above estimates, it may be
interesting if we  attempt to  determine their  collective bearing on
the probabilities of a single case.   So much  has been said  about
the obscurity of gastric cancer, that I really  think it but right to
inculcate the claims of scientific medicine in respect to the diagnosis
of this malady ; claims which, if thus deducible from these records,
will3 a fortiori apply  to those strict clinical researches which I hope
many of you are preparing yourselves to carry out in after life.

   »" TraitS Pratique des Maladies Cancereuses." Paris, 1851.
   * About a hundred cases  since added  to my experience  confirm this opinion.
(Second Edition.)
   3 The more so, indeed, since the nature of some of these cases suggests that they
were recorded precisely because their symptoms were obscure and deficient. 
186
CANCER OF  THE STOMACH.
  The selected cases on record afford the following estimate:—
            Anorexia.   Pain.  Vomiting.  Hemorrhage. Tumor.    Cachexia.
   Present  .   91     189     193      81     128     3 times,
   In   .   .  115     205     221     202     159     4 cases.

Applying to these figures  the simpler laws of probabilities, brings
out the following statements :—
  The probabilities are eleven to two  against all six symptoms
being simultaneously present in any given case.  In other words,
one or other of the  six is  absent in  more than five out of six ex-
amples of the malady.
  Supposing  the  least frequent—hemorrhage—to be absent,  the
odds are still as many as  eight  to five against the concurrence of
the remaining five.
  It is  only the absence of a  second symptom—for example, ca-
chexia—which equalizes the chances, so as to render  exactly even
the probabilities for and against the concurrence of the remaining
four—pain, vomiting, anorexia, and tumor.  In other words, the
simultaneous presence of four of the above symptoms seems to be
the average  amount of evidence detected  in the recorded cases of
gastric cancer.  The numerical frequency of anorexia and cachexia
(70 and  75) is so nearly alike, that it scarcely  matters which we
include  in this four;  save that, on the whole, the  presence or ab-
sence of cachexia is  less mistakable than that of anorexia.   Hence
supposing, in  any given  instance, we find pain, vomiting, tumor,
and cachexia are all present, we may feel that the diagnosis, even
if uncertain, is as little so as, in the majority of cases, it  is likely
to be.
  The chances of  concurrence would of course  increase  as  the
number of symptoms decreased.  Thus it is 23 to 12 that pain,
vomiting, and tumor are all present; 52J to 12 that pain is associ-
ated with vomiting.
  A more practical hint is derived from an inquiry into the proba-
bilities of a concurrent failure or absence of symptoms.  Thus the
odds are  2 to 1  against the simultaneous absence of hemorrhage
and cachexia; 2 J to 1 against  the failure of hemorrhage and ano-
rexia ; 40 to 1 against the  absence of tumor and vomiting; 60 to 1
against  the absence of vomiting and pain;  65 to 1 against the
absence of tumor and  pain; 225 to 1 against the absence of the
more obvious  and important symptoms of pain, vomiting, hemor-
rhage, and tumor; and lastly, about  2560 to 1 against the absence
of all the six symptoms tabulated above.
  In alluding to such calculations,  however, we  must remember
how large a variation of probabilities could be  produced by a
slight alteration in the original estimates.  Supposing, for example,
that we  substituted  the lower of  the two  estimates mentioned for
most of  the above  symptoms,  on the assumption that  the}7 were
absent in every case in which they were not mentioned, the differ- 
CANCER OF  THE STOMACH.
187
ence would not amount to much for  each of these symptoms sepa-
rately.  But its results would of course diverge  far more widely;
so that, for example, the odds would be about 110 to 2 (instead of
11 to 2) against all six symptoms concurring in any single case.
The uncertainty which attaches to all calculations founded on limited
numbers may seem still more obvious.  But in even as few as 200
cases,  this element  of contingent error becomes comparatively
small.  Indeed, the  actual collation of these 200 cases singularly
confirms the above calculations.
  On the whole, I think we may sum up the preceding inquiry by
the statement, that the more extensively and closely we consider
the symptoms of  this malady, the more secure does its  diagnosis
become.   With reasonable care, a physician need rarely be unable
to recognize a cancer of the stomach; and will generally find, when
its presence is long doubtful, there it is in reality absent.
  But while I venture to believe that gastric cancer without symp-
toms is exceedingly rare, I must add that it is anything but infre-
quent to find this  malady simulated by other diseases.   Among
these, for obvious reasons, the  maladies of the liver, the intestines,
and the mesentery, and other neighboring parts, only yield in close-
ness of resemblance to those other gastric lesions which,  in others
of these Lectures, are expressly contrasted with cancer.
   To  this I may add, that not  only must  grounds for  a definite
opinion  be sometimes wanting throughout the whole history of a
cancer of the  stomach, but that a similar obscurity far  more fre-
quently veils  the disease in the earlier parts  of its course.  As
already pointed out, in the phenomenon of gastric cancer, time is
everything.  Hence the physician who examines a chronic case,
or (what is practically the same thing) sees the  malady only in  its
early stage, must often remain in complete uncertainty respecting
its nature, until the progress  of the disease, increasing  (in  some-
thing like a geometrical progression) the number and distinctness
of its symptoms, enables him to come to a  decision.   Indeed, it is
hardly too much to say, that this peculiar mode of accretion  of the
symptoms often forms a specific aid to our recognition of the disease.
   Time forbids me to discuss the diagnosis of the various compli-
cations of gastric cancer.   As pathological incidents or  events of
the  malady, they will be  mentioned in the next section.   Their
symptoms are, on the whole, less distinct than those of the ordinary
diseases which affect the organs they respectively occupy.  Indeed,
the late period  of the gastric  malady during which they usually
occur, brings them into a coincidence with a degree of prostration
such as  obscures these  symptoms, alike  in respect to their own
prominence, and  to their reaction on the organism generally. 
188
CANCER OF THE STOMACH.
                         PATHOLOGY.

  In discussing the pathology of cancer of the stomach, I  shall
follow as closely as possible  the  method adopted with respect to
the pathology of gastric ulcer in the preceding lecture.
  The cancerous disease being far less frequent than the ulcerative,
I have had, if possible,  greater reasons for adding, to my own per-
sonal experience,  whatever could  be contributed by researches
amongst Hospital  records, Pathological  Museums,  Beports, and
Journals, respecting it.  These inquiries seem to afford a broader
(and therefore better) basis for  deductions than  any previously
published.
  The frequency of the  malady cannot be accurately deduced from
mortuary returns; although  the statistics of Tanchou  in  Paris,
D'Espine in  Geneva, and the Begistrar-General  in this country
would afford a vast array of  figures as materials for such a deduc-
tion.  Unless founded upon necropsies, such returns are useless for
pathological inquiries like that we are now engaged in.   For though,
from the fatal character of the malady, we might with little error
regard the  number of persons whom it attacks  as exactly corre-
sponding with the  number of deaths caused by it, yet the vague-
ness and inexactitude  of the opinions which  such  returns often
include  and  sum  up, as well as the errors which are frequently
made in the  v ;ere nomenclature  of disease, invalidate  all  their
conclusions.   Indeed, to the  general uncertainty of  diagnosis, we
must add another special and obvious source of error, which would,
on the whole, greatly increase the  apparent frequency  of this par-
ticular  disease.  The frequency and fatality  of the  gastric ulcer,
coupled with the close resemblance its symptoms  often exhibit to
the cancerous disease of the stomach—a resemblance which it
sometimes baffles the most sedulous observation to unmask during
life—render it more than probable that, in returns which scarcely
attempt to distinguish the number of deaths  produced by each of
these maladies, the mortality  attributed to gastric cancer is always
far too great.   In  like manner, that interstitial inflammation of the
stomach often improperly termed " hypertrophy" (Lecture V.), may
easily be mistaken  for cancer; and, though a far  less  frequent
source of error, is  still not unworthy of notice.
  Hence it is to large numbers of necropsies, the subjects of which
have died from all causes indifferently, that we must  look for  in-
formation on this head.  From various sources—but especially from
the valuable records kindly placed at my disposal in  Guy's, St.
George's, St.  Thomas's, and St. Mary's Hospitals—I have collected
a total  of 8,468 necropsies,  which  include  81 cases of primary
cancer of the stomach; a proportion nearly equivalent to 1 per
cent., or T^  of the total mortality.
  The proportion borne  by cancer of the stomach  to  cancer of 
CANCER OF THE  STOMACH.
189
other organs is one which it belongs rather to the pathology of
cancer than of the stomach to determine.  But from researches by
Lebert,1 Willigk,2 and myself,3 it may be concluded that the "gastric
lesion forms about one-third of all primary cancers;  and equals
(if not exceeds) the number occupying the uterus and breast.
   As regards the age of its occurrence, I have collected 600 cases,
the age  of which at death averages 50 years.   The  greater part
(f ths or 435) of these 600 cases is claimed  by the epoch of life
between 40 and 70.  Arranged in decades of years, the maximum
number (f ths or 162) occurs between 50 and 60.
   Comparing such absolute numbers with the numbers of persons
living in these decades of life, we obtain an estimate of the relative
liability of the corresponding ages  to the malady.
   The maximum liability is between 60 and 70.   Up to the age
of  20, the whole risk is less  than ^th of what  it reaches between
20 and 30.   The latter liability, again, is multiplied in the follow-
ing decades of years by 3, 6, 8, and 10 respectively.   The maximum
then seems to sink to  little more than half for the two next decades,
ending at the extreme age of 100.
   It  would  thus  appear  that, before the age of 40, the liability
scarcely attains one-fifth of its total amount:  in other words, four-
fifths of this risk still remain, to be encountered in  the succeeding
years of life.  At the age of 60, nearly one-half the  risk of the
malady  has  already gone by: and at  the age of  70, two-thirds.
The small number of cases, as well  as of persons living, in the last
two decades  of life,  render  the conclusions that  refer to these
epochs somewhat less trustworthy.
   Comparing the risk of  gastric cancer with that of gastric ulcer,4
it would seem that the former is on an average barely one-fourth
of the latter, and that, though much more distinctly and exclusively
a disease of old age, its climax or maximum of  risk occurs  at least
twenty years earlier than that  of  the  gastric ulcer.   Comparing
gastric  cancer with ■apoplexy, it would  seem  that the  risk of the
latter disease, beginning  about  ten years later  than  that  of  the
former, remains, with little  deviation from the  proportion of one-
half the former, until the liability to cancer has reached its climax:
when the risk of apoplexy, rising to its own maximum in the next
ten years, reverses the above proportion; and  at length, between
the age of 80 and 90, subsides to a death-rate which  is nearly equal
for three such diverse diseases as phthisis, cancer, and apoplexy.4

  1 "Traite pratique des Maladies cancereuses," p. 97.  Paris, 1851.
  2 "Sections-Ergebnisse, Prager Vierteljahrschrift,"  x. 2.   1853.
  3 " British and Foreign Medico-Chirurgical Review," Jan. 1857.
  4 It must be recollected that the ulcerous lesion differs from the cancerous in
not being always a primary or efficient cause of death. In other words, it is often
found in the dead body without our being able to regard it as having exerted more
than a partial causative influence on the fatal event.  (See pp. 102, 136.)
  5 For details and illustrations of these statements, the reader is referred to the
author's Essay already cited.  (" British and Foreign Med.-Chir. Rev.," Jan. 1857.) 
190              CANCER  OF  THE  STOMACH.
  ■x.
  Sex.—The influence of sex is far more difficult to estimate than
that of age.   For any sufficient numerical  basis is still wanting.
Death-rates are useless, from the reasons  already mentioned.  The
personal experience  of private  practice is too  small:  and even if
many observers were to group and unite their  experience, still its
results would be too  promiscuous  and uncertain.   And in public
institutions for the cure of the sick, the numbers,  however large,
are useless for  all purposes  of comparison, unless it  be  clearly
stated what is the average proportion of male to female in the
patients among whom the cases of  gastric cancer have  occurred.
  Such considerations  well explain  the contradictory results  ar-
rived at by different  authorities; and justify our dismissing them
with a brief notice.
  Of about 250 cases treated in British hospitals,  I find that the
male are to the female  as 2 to 1.   But I believe these  institutions
admit  more  males than females (6 to 5?)   In nearly the same
number collected by Dittrich1 and Willigk,2  this excess is reversed
into a  proportion  of  3  males to 4 females.   But the  institutions
from which these cases are derived apparently admit females in
far greater numbers than males.
  Adding together all the trustworthy returns I have been able to
meet with, affords  me 784 cases; out of which 440 are male and
344  female.  Such numbers leave  little doubt  that, whatever the
exact proportions of the sexes, the male is the  more frequently
affected of the two;  a fact which it is impossible to  avoid connect-
ing with the exclusive amenability of  the female to the mammary
and  uterine localizations of cancerous disease.  The above num-
bers nearly correspond to a proportion of 4 to 3, or 56 to 43 per
cent., respectively.
  The mode  in which  age is affected by sex I deduce from 223
cases, which  I have  collected chiefly from  the London hospitals
before alluded to.   Of  these, 151  are males  and 72 females.  Dis-
tributing  them in decades  of years and  correcting their absolute
numbers by the numbers of persons living at corresponding ages,
affords us the following conclusions as to the comparative liability
of the two sexes to cancer in the stomach during the various epochs
of life.
  1. The liability of  the male up  to the age of sixty  maintains a
constant excess,  which renders it nearly double that of the  female.
  2. The specific3 influence attributed to the years which correspond
with the close of the fertile or menstrual epoch, is contradicted by the
precisely equal rise of risk which the same age brings to the male.
  3. The progression in  the  rise of the risk is the  same for  both

  1 " Prager Vierteljahrschrift," 1848, B. i. s. 1.   " Die Krebsige Entartung  des
Magens"—a brief but excellent essay.
  2 Op. cit.
  3 Specific, that is, in the sense of being supposed due to regress or involution of
the female generative system. 
CANCER OF  THE STOMACH.
191
sexes throughout the greater part of life: being treble that of the
previous decade (20 to 30) between  30 and 40, double  this latter
from 40 to 60 years of age.
  4. The period of life after the age of 60 introduces a remarkable
contrast to the above law.  The numbers  between the age of 70
and  90 are perhaps too small to justify a safe conclusion.  But it
seems  quite  certain that  the 10 years between 60 and  70  bring
about a converse alteration  of  risk in the two sexes—increasing
that of the male to double, but diminishing that of the  female to
half its former amount.  Whether this change really represents a
corresponding alteration of risk from cancer in general, or whether
it is in any degree equalized by an increased liability of the female
to the mammary and uterine localizations of the disease, must be
left to future researches to determine.
  The average age in the two  sexes is about  51 in the male, 40 £
in the female.
  As regards the exact situation of the cancerous deposit in the
stomach, out of 360 cases  collected and compared by me, the pylo-
rus was affected in 219 instances—a proportion of exactly 60 per
cent., or three-fifths of the whole.  The sex of the patient seems to
have no influence on the frequency with which  the lesion affects
this part.   Thus, in 232 British cases, concerning which I obtained
fuller details than  the others, the  sexes are  to each other nearly as
2 males to 1 female (159  to 73).   And this group of cases yields
194 which specify the exact site of the cancer;  and includes 125
lesions of the pylorus, which are divided, in nearly the same pro-
portion, into  86 males and 39 females.
  The same  group of cases also affords a  basis  for some specific
conclusions which are rendered important  by the authority of the
eminent pathologist whose opinions they somewhat modify.   Boki-
tansky' states that " the cardiac orifice of the stomach is but seldom
the seat of cancerous degeneration, and it is a circumstance worthy
of note, that  the pyloric cancer is exactly bounded by the pyloric
ring, and  never reaches beyond to the duodenum;  while that of
the cardia—even when it does not  descend from the oesophagus
above—always spreads itself over a considerable  piece of the oeso-
phagus."
  Now, firstly, it is  only  in a qualified sense that we can accept
the above word "seldom."  For  out of the 360  cases already al-
luded  to, no  less than 36 are cancers of the cardia; a  proportion
amounting to exactly 10  per cent, of  the  total numbers;"  and to
16f  per  cent., or  1  in 6, of the pyloric cancers (216).  And in
British cases which I  have collected, the proportion of cardiac
cancers is still larger: namely, 25 in 194, equal to 13 per cent, or
1 in 7 of  the whole number, and 1 in 5  of  the pyloric lesions.
From these cancers of the cardia, I have excluded all cases except

    1 " Handbuch der speciellen Pathologischen Anatomie," Bd. ii. s. 205. 
192
CANCER OF THE STOMACH.
those in which the orifice itself was either solely or chiefly affected.
And  although it is possible that some of them may have  been
originally developed around the oesophagus, and only extended to
the stomach, yet this  objection, which  applies  equally to all the
above cases, can scarcely be regarded as a frequent explanation, in
the absence of express evidence to that  effect.  We must therefore
conclude that the cardiac orifice is not  an infrequent situation of
cancer in the stomach.
  Secondly, it is curious to notice how specifically the observations
I have brought  together contradict the next proposition  of the
accurate pathologist quoted  above.  The 125 cancers of the pylorus
included no less than 10 cases in which the disease was not bounded
by the valve, but passed beyond it for a variable distance (often an
inch  or two) into the duodenum,  iebert1 gives another instance
of the same kind; making in all eleven exceptions to this (pre-
sumedly absolute and  universal) rule.
  Lastly, to the equally  absolute statement that the cardiac  cancer
always  involves  the oesophagus, I have also found two conclusive
exceptions.   Allowing for the much smaller number of these cardiac
cases, it is  not impossible  that such exceptions may be also as
numerous as the preceding.   Indeed  the proportions in the cases I
have  collected exactly  correspond to  such a  conjecture;  these
exceptions being  11  in 159 pyloric cancers, and 2 in 30 cardiac
cancers (or about 1 in  15 for each).
  Hence the rules which Bokitansky has the merit2 of having laid
down in these respects  are (like many others  in  this branch of
natural science)  of  general, though not  universal  import.   But
their  value  is not much affected  by occasional exceptions.   For
their  significance, far from depending on any mere numerical  ratio
of fifteen to one, is much more  essentially measured by the anta-
gonism of the fact in the two classes of  lesion: the limitation, and
the spread, of the cancer  beyond an analogous boundary or extre-
mity of the organ.  Hence it becomes interesting to inquire whether
any reason can be assigned  for it.
  On the whole, I think the present state of our knowledge justifies
some  conjecture of this kind.  The character of the above laws-
general, but not universal—sufficiently  hints that they depend, not
on any primary and direct  cause,  such  as would necessarily be of
universal operancy, but rather on some  secondary causation, which
indirectly brings about its result.   And the first and nearest inquiry
is one bearing on the anatomy of the stomach in relation to that of

 1  Op. cit., p. 467.
 2 I cannot think it invidious to call attention  to any inaccuracies in a work so
widely known and appreciated as the great Text-Book of  Pathological Anatomy
cited above.  Precisely because it demands and repays a thoughtful and minute
study,  and because every sentence evidently sums up a wide series of accurate
observations, we may justifiably  apply to it a criticism of unusual severity—a
criticism which, even if it weigh every word, will scarcely do more than the author's
terse and weighty propositions really deserve. 
CANCER OF THE STOMACH.
193
the cancerous deposit.   The question  naturally suggests itself—
" Is there nothing about the structure of the pyloric and cardiac
orifices which, by opposing or facilitating the continuity of the can-
cerous deposit in their tissues, may respectively limit or permit its
spread to outlying parts of the alimentary tube ?"
   The answer to this question appears  to afford exactly the kind
of explanation suggested.  The minute anatomy of gastric  cancer
conclusively shows (as we shall presently have occasion  to mention
in detail) that, in most cases, the morbid  cell-growth is at first
deposited in the submucous tissue; that it thence extends, along
those partitions of the same tissue which separate and ensheath the
bundles of the organic  muscle, into the subjacent muscular coat;
that, at a later  period, it engages the  mucous  membrane, by dis-
organizing which it soon produces symptoms of grave (if not fatal)
import;  and lastly, that the complete implication of the peritoneal
coat is a still later phenomenon, which  is therefore generally anti-
cipated by death.
   Now it is precisely in the degree and kind of continuity by which
these first and chief seats of the cancerous deposit—the submucous
and muscular tissues of the stomach—merge  into their analogues
in the adjacent segments of the digestive canal, that the cardia and
pylorus differ most remarkably from each other.  The cardia is so
organized as always to concede to whatever food may be swallowed
a transit in  the onward direction—a transit  during which its con-
traction  implies a  muscular movement that is  directly continued
(p. 24) from the oesophagus into the stomach.  In  accordance with
these requirements, there is the most perfect continuity between the
submucous  and  muscular coats of the  two  segments.   The  latter
coat, in leaving  the oesophagus, radiates its  longitudinal  layer on
all sides, and with special distinctness along the lesser  curvature;
whilst its circular or transverse layer has an almost equal continuity
with both the circular and oblique layers which together represent
it in the  stomach.
   On the other hand, the pylorus is constructed so as to resist the
onward transit of the contents of  the stomach by a powerful con-
traction during the whole period of gastric digestion; a contraction
that appears to be but overbalanced  by every wave of the powerful
peristalsis which gradually engages  the  strong muscular  layer of
the pyloric  region, so as to  strain off a little of the  more  liquid
contents  of  the  stomach during each of these undulations.   The
violent action which thus engages the pylorus from  the time the
food enters  the  stomach, requires its complete  isolation from the
adjacent duodenum.  And a careful dissection of the pylorus shows
that this isolation is attained, to a considerable degree, even for the
submucous  areolar tissue, by its small  quantity, and by  its close
and dense attachment at the  line of junction of the  two mucous
membranes.   But it is especially in the muscular structure that
       13 
194
CANCER  OF THE  STOMACH.
this isolation is most distinct.  The mode of attachment of the duo-
denum to the stomach may be best expressed by the statement that,
instead of being continuous with the pyloric extremity of this organ,
it is attached around it, at a short distance from its termination—
in short, that the commencement of the bowel receives the stomach
(p. 23), much  as the vagina receives and embraces the  neck of the
womb at some distance1  from its mouth. Hence, not only is the
continuity of the muscular walls of the two tubes reduced to a thin
linear attachment of the duodenal coat, but this delicate layer comes
off' from the stomach at such an angle, and at  so  great  a distance
from  its pyloric  extremity, as renders it far more likely that the
deposit should engage the massy pyloric  nerve beyond this attach-
ment, than that it should diverge—through what seems to be chiefly
a second or outer process of areolar tissue—towards the duodenum.
This  view is confirmed by many analogous phenomena in the dis-
tribution of cancer; by the  manner, for example, in  which sub-
peritoneal cancer almost always involves the continuous membrane
that covers two or three organs or segments of the digestive canal;
by the converse frequency with  which the disease, when  primarily
affecting a gland, leaps over (as it were) a scanty medium of areolar
tissue, to fix on  a more congenial organ  at some distance from its
original  seat;  and especially by the contrasted rapidity and fre-
quency with which the areolar tissue in front of the uterus, and the
serous membrane behind it, become involved  and perforated  by
ordinary uterine cancer.2
  It is interesting to contrast the other situations  of the above 360
cancers of the stomach, with those of as many ulcers of this organ
■—especially as some authorities seem to think that these two dis-
eases affect the pyloric and cardiac  extremities of the stomach in
nearly equal proportions.
   Such a comparison3 of the two diseases shows that the remarkable
preference of  the cancerous  lesion for the orifices of the stomach
(which together  form the  site of seventy-one per cent., or  nearly
three-fourths of  the gastric cancers),  is not at all  shared in  by the
ulcerous lesion.  In the recorded necropsies of the latter, the terms
" pylorus" and " cardial so often refer to  the mere neighborhood of
these valves, that a large deduction (probably at least one-half) must

  1 I am aware that the illustration I have selected may seem to militate against
the very conjecture for which it helps to lay the foundation : by showing an equally
discontinuous structure, where, nevertheless, cancer often spreads.  But we must
recollect that, owing to the less direct influence exercised by these sexual organs
on the life of the patient, the cancerous lesion is prolonged to a much later period ;
to one which, at any rate, might well suffice to convert the ratio of continuity of
cancerous deposit seen in the stomach (1 in 15 cases), to that which seems to pre-
vail in the uterus (1 in 3).
  2 See Dr. West, " Lectures on the Diseases  of Women," vol. i. p. 346 ;  and Dr.
A. Farre,  article " Uterus," Abnormal Anatomy, p. 700, in  the " Cyclopaedia of
Anatomy."
  3 For the sources, and the tabulated details, of this comparison, see the author's
Essay  already cited, p. 221. 
CANCER OF THE STOMACH.              195
be made from even that moderate proportion (sixteen per cent., or
less than one-sixth) which their numbers would together imply.
  The contrast  of the remaining situations does not seem to  call
for any comment.  The absence of all cases of  ulcer of the whole
stomach, or of the whole of its middle region, is explained by the
necessary intervention of death, as soon as the process of ulcerative
absorption has destroyed a large proportion of a mucous membrane
so essential to life as that of the stomach.  It may be  added, that
the cancers of the whole  stomach (thirteen  in  number) have been
carefully distinguished  from those cases of interstitial inflammation
of the gastric parietes which are sometimes mistaken for scirrhous
disease;  either  by direct evidence derived from their microscopic
and  anatomical characters, or by indirect evidence equally trust-
worthy, in the  form of the presence of secondary cancer  in  other
organs.
   The anatomy of gastric cancer is most conveniently  subdivided
according to the three chief forms of this deposit which  it affects
—the scirrhous, medullary, and colloid cancer; to which we may
add a fourth, villous cancer of the mucous membrane.
   Of these varieties of cancer, the scirrhous  is by far the most
common.   Out  of 180 cases which name the species of cancer
present,  130 (a proportion equivalent  to about  72 per cent., or
nearly three-fourths of the  whole) belong to  this variety.   The
same group affords 32 instances of medullary cancer, 17 of colloid,
3 of melanotic pigment, and 1 of villous  cancer.  These  numbers
correspond to percentages of  18  and  9J for  the medullary  and
colloid cancer respectively; or, in fractions, to rather  more than
one-sixth and one-twelfth.  The melanosis was in one case diffused
generally over the whole body, in  the form of small  tumors; in
the two others,  was such a superficial coloration  of  the gastric
mucous membrane covering the cancerous tumor, as would scarcely
merit this title, unless substantiated by careful histological exami-
nation.1
  As  my  limits oblige me to confine  myself strictly to gastric
cancer, I shall not dwell on  the histology of these three  forms of
the cancerous deposit.  The less so, indeed, that they merge into
each other by gradations  of almost infinite variety.  For  the scir-
rhous, medullary, and colloid  cancer of the stomach, must be re-
garded as not only what they are  in other parts of the body—
manifestations, in a different form, of  the  same disease; but as
constituting, with even greater frequency, mere consecutive phe-
nomena of the same local process.  For it is evident that, in many
cases, a growth originally  scirrhous undergoes an admixture of
medullary  or colloid cancer, if not an absolute metamorphosis into

  1 In order to prove that it was riot due to any of those alterations in color which
mere ecchymoses in this situation often undergo from the action of the digestive
fluids, compare pp.  64, 76. 
196
CANCER OF THE STOMACH.
it.  While collateral circumstances entitle us to conjecture that in
many more a similar complication would  occur, but for the occur-
rence of death in an earlier stage of the disease.  Whatever the
apparent temerity of such  a  view, its  truth becomes sufficiently
obvious when we consider the propositions on which it is based.
Our knowledge of the pathological anatomy of this (or any other)
disease is built up from a number of observations.   Of these ob-
servations,  many of the most valuable in respect to the origin and
succession of morbid changes  in the organ forming the seat of the
disease are only afforded us, either by casual deaths; by intercur-
rent or secondary maladies; or finally, by the disease acting on the
powers  of  life with an effect which is so  complex  and variable,
that we may fairly view it as  somewhat independent of the local
mischief.   Other observations, though  relating to appearances  by
no means frequent, must be regarded as showing the more direct
and typical effects of the disease; and  as therefore  possessing an
importance far beyond what  their numerical  rarity, and the late
period of their access,  would suggest.
  In almost all cases, the cancer begins as a deposit in the sub-
mucous areolar  tissue.  This loose, but  thick layer—which,  by
intervening between  the mucous and  muscular coats, shares in
every movement of the  two; and especially concedes and limits
that free play of the mucous membrane which permits the passive
contraction of the muscular coat to throw it into folds (p. 27) such
as are effaced by any distension  of the stomach—is composed of
its ordinary constituents of white and  yellow fibrous tissues, the
elements of the latter being  both large and numerous.  Among
these fibrous structures the first rudiments of a cancer are generally
deposited in the form of a dense knot, which has a dull white color,
and  a firm and hard  (rather than  tough) texture.   This opaque
mass incloses the above normal elements of the areolar tissue, in
such  an intimate  state of fusion, that  it  is almost impossible to
detect them in any quantity.  Indeed, their proportion is so small
that even allowing for  the mechanical difficulties that oppose their
isolation, it is difficult to avoid  the conjecture that they are com-
pressed and killed by the new growth;  in which, so to speak, they
remain dead and buried.  And it is  to the strictly retrograde
changes of this kind which these healthy orginal structures undergo,
that I am disposed to attribute the fatty molecules which are found
in even the freshest specimens of scirrhus, and in the earliest stages
of its growth.  In many cases at least,  I  believe this fatty matter
is due to a mere decay of the original tissues.  Blastema in any
quantity is rarely met with, save  in the  whitish juice which can
be obtained by compression of the scirrhous mass.  The irregularly
granular character of the layer into which these knots soon expand,
seems to be often quite unconnected with any peculiarities in  the
arrangement of the scirrhous growth with respect to those plexuses
of  vessels which  occupy  the submucous  areolar tissue  (p. 34), 
CANCER OF THE STOMACH.
197
though occasionally the  denser grains of the  mass seem to be re-
ceived  into vascular loops  or meshes of this kind.   Finally,  in
most instances, however  small or recent the  mass of scirrhus, a
large proportion  of its  substance consists either  of fibres, or  of
fusiform cells, the extremities of which  are so long as almost  to
deserve this title.   Mere nuclei are in but small proportion.
   It is often difficult to determine by  examination whether the
scirrhous deposit  has originally predominated  on the muscular or
external aspect of this  layer  of  submucous  areolar  tissue.  But
there are good grounds for supposing that this is  generally the
case.  At any rate, it is  in this direction,  and towards this constit-
uent of  the  stomach, that its progress  in  the succeeding stage
of the  disease is almost exclusively directed.  The areolar and
muscular coats become  inextricably fused into each other at their
line of contact, while as  yet the  mucous membrane itself is still
separated from the deposit by an interval of healthy areolar tissue.
The muscular coat is then transformed into scirrhus by an extension
of the same process as that by which the submucous tissue was itself
at first affected.
   The appearances of the scirrhus in this stage are too specifically
connected with the  organ it affects, to be left  unnoticed.  In rare
instances, we may  find a  dense white  semitranslucent mass,  of
tolerably uniform structure,  occupying the  whole  thickness  of
what was formerly the muscular coat, and quite undistinguishable
from the original focus of the disease in the submucous areolar
tissue.
   But in the majority of cases, the cancerous deposit is much less
homogeneous;  and exhibits characters which  may be regarded as
relics of that differentiation of tissue proper to the healthy textures
which  it has replaced.  On cutting through the  diseased mass, we
find that the deeper portion, which  corresponds  to  the  original
muscular substance, exhibits two varieties of tissue, so arranged as
to give it more or  less  of  a honeycombed appearance on section.
There  is  a -pulpy, brownish, reddish-yellow (or at  any rate some-
what darker and softer) mass, inclosed in small  polygonal  meshes
formed of whiter  and denser tissue.  Of these meshes, which are
irregular  in  shape  and  size, those  are generally strongest and
thickest which run  transversely  to the axis of the stomach from
the submucous to  the subserous areolar tissue.   They are evidently
the transformed septa of those bundles of fibre cells which form
the thick muscular coat of this part of the stomach; and they inclose
cavities which, originally occupied by these muscular bundles, now
contain, in addition to their more or less fatty and decayed relics, a
cancerous deposit, often visibly less fibrous, and richer in nuclei
and blastema than that of the septa themselves.   Their arrangement,
however, is not always  precisely  like that of the original sheaths
of the  unstriped fibres.   The thickest septa are,  as  above men-
tioned, often directed transversely to the mucous surface; and from 
198
CANCER OF THE STOMACH.
the direction of the circular fibres, are best seen by cutting length-
wise through the mass in the same plane.   But irregularities in the
deposit of the cancerous matter, as well in the septa  as in their in-
closed cavities, easily aff'ect the uniformity of this arrangement; so
as to render the meshes comparatively larger or smaller, or even
to obscure  and obliterate them altogether.  And as a tolerably
equable deposit around  the  narrow pyloric end of the  stomach is
one of the most  common arrangements of scirrhus  in this organ,
the first effect of the commencing disease often presents an obstacle
to further growth in the direction of the centre of the tube, such as
even  aids the natural tendency of the disease to  spread outwards.
Hence the septa often seem to diverge (or even radiate) in passing
from  the centre to  the periphery of  the tumor; and inclose an in-
creasing amount of their  darkish  or gelatinous-looking contents,
as they approach the tissues of the peritoneal  coat of the stomach.
   There is one circumstance which renders it important to appre-
ciate  these characteristic appearances of the gastric scirrhus in this
stage of its growth.  It is probably  not uncommon  for  the speci-
mens which present little more than the average distinctness of the
above differentiation of ordinary scirrhus, to receive the name of
" colloid" cancer.  And though it is true that in many instances of
this kind a careful histological inquiry could distinguish the tissue
as really fibrous or scirrhous cancer—a decision in which its physi-
cal as well as microscopic characters would  alike concur—still in
some cases, in which the meshes are  large and inclose much fluid
exudation, it is not easy to say to which of the two species the
cancer really belongs.  To some  examples, indeed, it  would be
difficult to deny the appellation of colloid.   And, on the whole, I
think that we may fairly assert the following propositions respecting
what is called colloid cancer  of the stomach.  (1)  That in some
cases the colloid arrangement  imitates (and indeed perpetuates) the
natural differentiation of tissue above alluded to.   (2) That in many
more the deposit is either essentially scirrhous, or is  developed out
of a cancerous deposit which was originally of this species.   Hence
(3) that the ordinary way in which this  name  is at present used,
obliges us to deduct from the recorded  cases of colloid cancer of
the stomach a very considerable proportion  as modified scirrhus.
And (4)—what is even a more practical point for the pathologist—
that such cases have little or no weight in the decision of an im-
portant question in the natural history of gastric cancer;  namely,
the average duration of the  three  forms of the malady, or the
rapidity with which they severally destroy life.
   The further progress of the disease conducts it to the mucous
and  serous  surfaces of the stomach;  still, as  it goes, fusing into
itself, and each other,  the structures previously present.
   In the serous membrane, the tenuity of its tissues, as well as its
pathological tendency to inflammation, soon  give rise to adhesion
of the cancerous segment  of stomach to some  neighboring viscus. 
CANCER OF THE STOMACH.              199
How far the cancer itself lends the aid of any specific irritation to
this process it is difficult to estimate;  although, from the analogy
afforded by gastric ulcer, one may suspect  that there is no great
need of assuming any such explanation.   Of course the particular
portion of the tumor  thus  attached, as well  as the viscus to which
it is fixed,  are subject to considerable variety.  But while (for ob-
vious  reasons) the adhesion of the ulcerous stomach  accurately
corresponds to the site of the lesion, and  to the viscus which is
normally in contact therewith, that of the cancerous organ appears
to be regulated by circumstances less obvious.  The diaphragm,
liver, pancreas, and  spleen, constitute the  most  frequent sites of
such adhesion;  and in nearly the above order of decreasing fre-
quency. In  short, it is at the upper  and posterior aspect  of the
stomach, and with a frequency which  is quite  disproportionate to
the predominance of  the cancer itself in these  situations, that this
fixation chiefly occurs.  It is probable that  this peculiarity has its
chief cause in the relative  immobility of the organs which occupy
this part of the cavity of the belly; and that it is so far analogous
(if not strictly parallel) to  the infrequency or tenuity of adhesions
between an ulcer of  the anterior  surface of the stomach and the
corresponding wall  of the belly.  Indeed  it may  fairly be  said
that the same contrast, which we  can only verify in a number of
cases of ulcer, is often illustrated  by opposite surfaces of one and
the same cancerous tumor.
   In advancing towards the mucous membrane, the cancer inaugu-
rates a series of changes which, though of secondary nature, and of
subsequent occurrence to its own  deposit, are probably more inti-
mately connected with those symptoms which generally attract the
notice, and claim the skill, of the physician, than any other of the
details which the morbid anatomist has to study.   The destruction
of the  gastric mucous membrane not only directly involves  the
partial  removal of an organ essential to life, but leads to a train of
indirect results of at least equally serious import.  The certainty
of hemorrhage and  ulceration;  the probability of a grafting of
cancerous  germs into distant organs by means of the  currents of
the lymph and the blood;  together with an  increased possibility of
obstruction, dilatation, and hypertrophy of the stomach; as  well
as of fistula opening into other parts of the canal, the chest, or the
surface of  the belly:—all these risks are  now superadded to those
of the cachexia which the cancer itself expresses, and to those of
the cachexia which it can produce.
   As the cancer approaches the immediate proximity of the mucous
membrane, its first effect often appears to be a slight (though per-
ceptible) increase in the thickness and firmness of this membrane,
such as a mere excess of its healthy nutritional fluid could probably
produce.   It resembles, in short, a stomach  taken from a younger
and  healthier person, or from a fresher corpse, than that to which 
200
CANCER OF THE  STOMACH.
it belongs.1  Then follows a fusion of the cancer with the under
surface of the mucous membrane;  giving to this latter tunic a com-
plete  immobility upon the subjacent textures;  and a dull white,
thickened  appearance.  The local anaemia which  this state seems
to imply, is probably often due to  a complete occlusion or compres-
sion of the bloodvessels  of the membrane: a state which, by  the
pressure it throws on the obstructed  current of the blood, appears
to give rise, occasionally, to a hemorrhage strictly analogous to that
which so often causes death in cirrhosis;  rarely,  to a varicose state
of the veins more immediately concerned.   And it is probable
that this interference2 with the  vessels (quite as  much as any spe-
cific tendency of the cancer itself) is answerable for the destructive
changes of the mucous membrane which next ensue.  This destruc-
tion—whether effected  by an intermediate stage of dark pulpy or
ashy gray  softening, such as gradually merges into ulceration; or
by the more  rapid  death  of the tissues, piecemeal, in a process of
sloughing  or gangrene;—in any  case, speedily leads to  the  same
result, to the production of a solution of continuity which is bounded
exclusively by the exposed or denuded cancerous growth.
  The subsequent  phenomena  still permit of  considerable variety
in different specimens.  On the whole, the most frequent change
is that in which the periphery of the cancerous mass (and especially
that part of it which  is  denuded by the removal of the mucous
membrane) becomes the seat of an infiltration  of medullary or are-
olar cancer.  This new deposit  generally protrudes into the cavity
of the stomach as a spongy mass of variable size and shape, which
constitutes what is {xat'  k^oxr-v) fungus hsematodes—a soft  pulpy
fungus, which sometimes breaks down by a process, half sloughing,
half suppuration ; but oftener associates, with a similar process, such
an amount of hemorrhage as materially to disguise and conceal it.
Hence, save to a strict  scrutiny or a careful microscopic examina-
tion, there is often no  perceptible difference  between the " coffee-
grounds" fluid which in such cases is vomited  during life, and that
which is expelled from a merely ulcerous stomach.   In like manner,
the surface and edges of the cancerous fungus itself are sometimes
occupied by  coagulated and altered blood; which, as such, bears no
testimony whatever to the character  of the lesion producing its  ex-
travasation.
  This secondary deposit of medullary cancer  seems to be precisely
analogous  to that secondary form of colloid already mentioned;
than which it is, on the whole,  much more frequent, and to which

  1 And may be compared in so far to the stomach of diabetes ; which, as I described
many years ago, from a specimen I examined for the late  Dr. Todd, is best summed
up as remarkably healthy, and unusually resistent of cadaveric changes.  Subse-
quently, I believe, Dr. Todd and myself were both misquoted as having stated
that the tubes were in a state of abnormal distension.
  2 The above paragraph is now curiously confirmed from other sources (compare
pp. 143, 173), Second Edition. 
CANCER OF THE  STOMACH.              201
it  not unfrequently serves as a basis.   Both of them suggest the
question as to how far they are real transformations of the original
scirrhus, how far they are merely admixed with it. »But the mor-
bid anatomy of a  large number of cancerous stomachs suggests a
somewhat different answer for each.  Using the term " colloid" in
its ordinary sense, we  can scarcely exclude from this category cases
in which  colloid seems to have been developed, by something very
like a genuine transformation, out of both scirrhous and medullary
cancer.  In  the former of these two species we have seen that it
occasionally (though  rarely) perpetuates a normal differentiation
of tissue; that it is the morbid analogue, so to speak, of the sheaths
and bundles of the unstriped muscle.1  In the latter it amounts to
the introduction, into a comparatively homogeneous cell-growth,
of an  exactly similar differentiation; describable in most cases as a
formation of delicate balks or partitions of fibres, which are arranged
so as  to inclose irregular  cavities containing a softer mass of cells
or rudimentary fibres.  On the whole, the ordinary situation of the
deposit, whether medullary or colloid, seems to show that it is rarely
or never produced by  any genuine transformation of the pre-existent
scirrhus;  and that, though it is not at all improbable  that a mode-
rate  interstitial  deposit  of new cancer  often  admixes a certain
quantity  of medullary or  colloid with  even the  deepest  parts of
such  a scirrhous tumor, no real conversion of the previous scirrhus
ever takes place.   At any rate, we have no evidence of such a pro-
cess :  and all the softening that occurs in the scirrhus itself seems
explained by the degeneration of those healthy tissues which this
adventitious deposit has inclosed within its mass,  and by  the true
cancerous softening to which it is liable, in common with  all other
forms of cancerous growth.
   With respect to the origin and growth of the two other  varieties
of gastric cancer, in their  uncombined form, it  need only be said
that the appearances of a large number of specimens suggest that,
as a rule, the medullary deposit begins  more immediately beneath
the mucous membrane, and the colloid beneath the serous mem-
brane, than does the  ordinary scirrhus or its combinations.  But
the exceptions to this  rule are numerous.
   The villous  cancer  of the stomach seems to commence  by a de-
posit  in the immediate neighborhood of the basement membrane;
and to be—not merely (as its form suggests) an isolated medullary

  1 It may  be objected, that definite instances of this kind are too rare to justify*
the confusion of terms that would arise from calling  them colloid.  The validity
of such an objection I quite admit.  But I think it would be impossible for any
one to  analyze and study the more modern records of this disease, without coming
to the  conclusion that (rightly  or wrongly) the name "colloid" cancer of the
stomach is often applied to a very moderate exaggeration of an appearance which
few cases of scirrhus of this organ  are altogether devoid of. Hence I offer the
above remarks chiefly as a clue to these records, and as a hint with respect to the
physiology  of cancer ; though I  should be happy if they also called attention to a
vagueness (if not inaccuracy) in the nomenclature of this disease. 
202              CANCER  OF THE  STOMACH.      ,

deposit in the submucous areolar tissue, growing by continual  ac-
cretion on its  mucous side, and thus sometimes  enlarging to a
tumor here, of which the original basis remains a  mere peduncle
or stalk—but rather a cancer of the mucous  membrane itself,  the
close proximity of  which is the chief cause of its great change of
form being associated with so little direct injury to its structure.
That, in the majority of instances, the deposit lies beneath the base-
ment membrane, the microscope leaves no reason to doubt;  a pro-
position which at once establishes an important distinction between
it and the epithelial cancer  which has been sometimes regarded as
its analogue.
  It is only by contrast with such  remarks that we can accept or
interpret the preceding statements  as to  the numerical frequency
of the three forms of cancer in the stomach.   In point of fact, these
numbers probably represent little  more  than  instances in  which
the  corresponding  variety of  cancerous deposit formed a large or
predominent portion of the whole  mass.   Of the 32 instances of
medullary cancer,  for  example, it  is probable that several were
mere  combinations or admixtures of this growth  with what was
originally and essentially a scirrhus.   And of the 17  cases of colloid,
perhaps even a larger proportion ought to be referred to a similar
category.   This conjecture is confirmed by  the observations of
Dittrich,1 who  found only 3 out of 11 cases of colloid  to be pure
and  uncombined examples of this variety of cancer; the remaining
8 being combined,  7 with scirrhus (2 of these with  medullary can-
cer also), and 1 with medullary cancer.
  The cases I  have selected afford 34  examples of colloid  in 417
of gastric  cancer.   If the proportion observed by Dittrich were
applied to  these 34, it would reduce them to 9 cases of pure alveo-
lar cancer; a change equivalent to  a reduction from 8gth to 2£th
per  cent.
  The destructive  process  which ultimately  engages the free or
internal aspect of a gastric cancer, after its mucous  membrane has
been removed by the  processes already mentioned, is  of especial
interest, from its close  connection with the  appearances by which
the cancerous and ulcerous stomach sometimes resemble each other.
  Perhaps the most frequent way in which cancer  simulates ulcer
of the stomach, is that brought  about in  the course of the process
described by Bokitansky;  in which (generally with little or no
.previous formation of medullary or areolar cancer) the  scirrhus,
denuded by ulceration or sloughing in the mucous  membrane, gra-
dually sloughs in  round circumscribed  patches, or  exfoliates in
successive  strata, so as to excavate  a tolerably smooth pit or fossa
in its mass.   Here,  however, the distinction is rarely difficult. The
bottom of the  pit  remains  more or  less  sloughy;  or even if this
characteristic appearance is disguised by a casual hemorrhage, such
1 Op. cit., p. 22. 
*      CANCER  OF THE  STOMACH.              203
as might easily complicate an  ulcer, still the quantity of the sur-
rounding mass, and especially its histological characters, as seen
under the microscope, will rarely allow of any doubt.  Besides, in
the ordinary ulcer, thickening is scarcely compatible with slough-
ing ;  and is almost  always associated with  a history which suffi-
ciently refutes the notion of malignant disease.
   But while, in the majority of cases, a careful examination scarcely
allows any hesitation as to the  ulcerous or cancerous nature of the
lesion, there are  rare instances in which even  the  most sedulous
examination of the dead  body reveals nothing to justify a decision.
Thus a smooth  and circular excavation in a scirrhus may obviously
imitate  an ulcer  surrounded  by a hard and thickened mucous
membrane.  And if the cancerous hollow be for the time denuded
of slough, or covered with blood, we lose another of the  means of
distinction which a mere inspection can afford us.  Nor  will even
the physical and microscopical characters of the hardened periphery
of the sore always decide the question.  In other words, though in
my own experience  the total  necropsy has never  yet left me in
doubt, yet the dense  cicatrix round an ulcer has sometimes yielded
portions respecting which, had I seen  them separately,  and been
obliged to decide their character solely from their microscopic  and
other appearances, I could scarcely have come to a decision.   In
respect to the microscope, indeed, the great variations in  the quan-
tity of cell-growth  contained  in a scirrhous  tumor,  and in the
developmental  stage  attained by its fibres, will sometimes render
its diagnosis from the more complete forms  of cicatrix-tissue (con-
taining a fair proportion of fibres and long fusiform cells) anything
but an easy task.
   Such equivocal cases present themselves in a still more marked
form  in some of the numerous records and specimens to which my
researches have led me.   This form, however, ought rather to be
suggested as a contingency  than announced as a fact.  On  the
whole, it seems possible that the sloughing or ulceration of a small
and circumscribed deposit  of scirrhus may not only imitate a mere
ulcer, but may produce or  become one; and that, in rare  instances,
the destructive process  may remove  the whole of the malignant
deposit present, leaving behind it what appears to be neither more
nor less than a  circular ulcer, bounded  by healthy (or at most in-
flamed) tissue.
   Such a contingency is especially suggested by one or two instances
in which a lesion offering every appearance  of a simple ulcer, with
a but slightly thickened (or even healthy) margin of mucous mem-
brane, has been  associated with  deposits in the liver and lungs,
which (if not absolutely cancerous) at  any  rate closely  simulated
secondary cancer. But having hitherto had no opportunity of a
minute  examination of these ulcers and deposits, I am obliged to
leave the question in its present form—as a mere suspicion, calling
for further inquiry. 
204              CANCER OF THE STOMACH.
  As regards mere combinations of cancer and ulcer little need be
said.  Since the gastric ulcer has no  protective influence against
cancer, we need scarcely wonder to find that its scars are  often
found in stomachs which have subsequently been  attacked by the
deadlier  malady.  The coincidence of the open ulcer with cancer
is scarcely less frequent.  But, as might be expected, in  these cases
also it is the cancer which is added to the  ulcer, and never vice versd
—the ulcer to  the cancer.  Indeed, the formation of an ulcer in a
part of the cancerous  stomach unaffected  by this growth, is, so far
as I am aware, quite unknown in the history of  gastric cancer.
Nor are there any authentic instances in my knowledge, where an
ulcerous stomach has been attacked with malignant disease, without
the ulcer  itself becoming implicated, to at least such an extent as
to have its base  or edges infiltrated with the  new  deposit.  More
frequently, indeed, it is these parts alone which become the site of
the cancerous deposit.  An ulcer, for example, which  has lasted
many years, suddenly ends in death;  the  necropsy revealing a con-
siderable cancerous infiltration in the thickened margin of the ulcer,
or in that more  chronic thickening of the walls of the stomach
which often extends some distance beyond  this  margin;  or showing
a fungous mass, of comparatively recent growth, springing up from
the centre of the excavation.   In rare instances a similar marginal
infiltration of cancer  seems to have occurred after the original  ulcer
has perforated  the stomach;  thus involving  the parietes of  that
chronic abscess  to which, under favorable circumstances, perfora-
tion (p. 159) gives rise.  And while there seems to be scarcely any
limit to  the varieties of this  kind which may occasionally occur,
still, on the whole, the relative frequency of such combinations is
quite sufficient to suggest that the presence of  an open ulcer some-
times provokes the development of the cancerous cachexia, as  well
as aids  in determining  the  deposit of cancer  in  this particular
organ.
  We shall hereafter (Lecture V.) compare with the gastric cancer
another disease which, though not known  to combine with it, often
simulates its appearances to such a degree as to be mistaken for it.
And though such an error is practically of far  less importance than
that of confounding cancer  and ulcer—because, unlike the latter of
these two diseases, the  peculiar inflammatory thickening of the
stomach to which we are now alluding seems  scarcely less fatal, or
more amenable to treatment than cancer  itself—yet the pathologi-
cal distinctness of the two lesions seems to be just as complete, and
the typical course of their symptoms just as diverse as is the case
with cancer and ulcer.
  The chief characters which distinguish this lesion from scirrhus
may be enumerated as follows.  In marked specimens,  the change
involves the whole of the stomach in a moderate thickening which,
while it allows the three coats  to be  still distinguished and sepa-
rated from  each other, increases their bulk in a tolerably equal 
CANCER OF THE STOMACH.
205
proportion.  The uniform expanse of stomach involved in the change
is yellow, tough, and elastic;  instead of having the peculiar pearly-
white appearance, and  gristly section, of cancer.  The muscular
tissue is almost always discernible;  and is generally hypertrophied
in the earlier stages of the disease.   And not only does the perfectly
homogeneous deposit offer none of those varieties which commonly
mark the later progress of a cancerous  deposit (in  the shape  of
colloid and medullary matter surrounding the original and central
scirrhus), but its microscopic examination  shows either an  absence
of the characteristic cells of cancer, or a few spindle-shaped cells
of fibrous import, scattered sparingly throughout  a  mass of lami-
nated (but scarcely otherwise organized) exudation.   The  absence
of secondary  cancer in other  organs aids the diagnosis  of this
benignant lesion.   Ulceration, too, is less  early, frequent,  and ex-
tensive, than in cancer.  Finally, the  pathological contrast of the
two diseases is  rendered complete by  cases which suggest  that the
lymph thus deposited by a kind of cirrhotic inflammation around
the gastric vessels occasionally undergoes a development into carti-
lage; rarely even into bone.
   The presence of secondary cancerous deposits in other organs is a
very frequent complication of cancer of the stomach.  Out of 437
cases 210 (equivalent to forty-eight per cent, or nearly one-half)
exhibit this complication.
   As regards the comparative liability of  the different varieties of
cancer  to be accompanied by secondary  deposits, it would seem
that the scirrhous, medullary, and colloid are associated  with se-
condary cancer, in proportions nearly  equivalent to  the respective
fractions of  three-sevenths,  four-sevenths, and  six-sevenths.  In
other words, nearly one-half the cases of gastric scirrhus are asso-
ciated with  a deposit of secondary cancer in some other organ of
the body; and this proportion, which is  increased by one-third in
the case of medullary cancer, is doubled  in that of colloid.  This
fact constitutes  at least a partial explanation of  the greater and
more rapid fatality of the two latter forms of gastric cancer.
   The cancer which forms the secondary deposit is generally of
the medullary variety.  But in the liver or peritoneum,  it some-
times  affects the  areolar  arrangement of colloid.  A  similar ar-
rangement, which is sometimes met with in the lymphatic glands
of the belly, appears due  to  a differentiation akin  to that of the
original structures.
   As regards the influence of sex on these secondary deposits,  it
would seem that they are about one and a half times more frequent
in the male than in the female subjects of gastric cancer.
   Among the organs  occupied by these secondary deposits, the
liver claims that precedence which might be expected.  Out of 431
cases, 105 (about twenty-five per cent., or one-fourth) exhibited a
cancerous deposit in the liver;  a proportion at least twice  as great
as that  of such deposit in  the lymphatic  glands  adjoining  the 
206
CANCER OF THE STOMACH.
stomach, and thrice as great as that of secondary  cancer  of the
lungs.
  In  many of these cases, the presence of cancer in the liver was
associated  with  its deposit in  other organs.   The  only exact
numbers I have been  able to obtain in respect to this further com-
plication, are derived from 47 instances of secondary hepatic cancer,
occurring in 214 cases of cancer of the stomach.   Out of these 47
instances, such a coincidence was present in 13:  nine times in the
glands or peritoneum adjacent to the stomach, twice in the kidney,
and once in each of  the following organs—the  ovary, pancreas,
intestine, spleen,  thoracic  glands, and  lung.   The close proximity
of the abdominal glands and peritoneum renders  it difficult to lay
much stress on their frequent  share in the hepatic mischief.  But
of the remaining situations of the deposit, it is interesting to notice
that the lung is affected with only one-fourth or  one-fifth of its
average frequency : while the abdominal viscera are involved about
one and a half  times  more frequently than  their  average stated
below.  In  other words, it seems as though the secondary deposit
of cancer in the liver somewhat  increased1  the  chance  of other
abdominal viscera sharing in  the deposit;  while it much more
decidedly diminished  the risk of pulmonary ingrafting of the dis-
ease.
  It is sometimes  so  difficult accurately to distinguish secondary
deposits in  the  lymphatic glands which adjoin the stomach, from
similar deposits  in and between the  layers of peritoneum which
form the gastro-hepatic and greater omenta, that it has seemed best
to group them together.  Adopting this arrangement shows these
structures to be involved in about 25J  per cent, (or rather  more
than one-fourth) of 271 cases of gastric cancer.
  The lungs seem to be affected about 1 in 12 times, or in 8jth per
cent, of the total number of cases.  This estimate is based on 35
and 431 cases respectively.
  But in adducing these numbers, it  becomes  imperative to  con-
sider some circumstances which materially detract from their value;
the more materially that, in doing  so,  they furnish no data for any
correction of the errors they indicate.
  And firstly, the cases to  which these numbers  correspond omit
all mention of a  pulmonary lesion  which, in the shape of pleurisy,
pneumonia,   or  both  these  diseases  in  combination,  occurs so
frequently in connection with cancer of the stomach, that it is im-
possible to doubt its general significance in relation to the primary
disease.  The lungs exhibit, in some  part of their mass—usually
in the lower lobes, and more frequently (I think) in the left  than

  1 Of course it is possible that, in some of  these cases, the hepatic deposit is
secondary to the visceral: being produced, for example, by the reception of cancer-
germs  into the portal system from a mesenteric deposit.  But without implying
any real causation, it seems best, for diagnostic reasons, to  give the hepatic deposit
the precedence. 
CANCER OF THE STOMACH.
207
in the right  organ—a kind of reddish-gray hepatization;  which
generally extends to the nearest pleural surface, and gives rise to
more or less adhesion here.  The adherent tissues are united  by a
small quantity of  lymph, of very  moderate tenacity, and  pasty
(rather than fibrous) consistence.  And the pleural cavity itself is
often occupied by a variable amount of serum;  much of which,
however, is doubtless in some cases effused during or after death :
of which event this pleuro-pneumonic complication seems to be no
very unusual cause.
   Another (and still more frequent) complication of gastric cancer,
relates  to the  association of what  is called "tubercle" with the
primary disease—an association of  such remarkable frequency as
to raise  suspicions akin  to those suggested by the above pleuro-
pneumonic complication.
   It is the more important to institute some inquiry into the facts
which suggest these suspicions, inasmuch as they are intimately
connected  with the general pathology of the cancerous and tuber-
cular deposits.  And even limiting this inquiry to the malady we
are now discussing, we may, I think, point out some errors in the
facts on which are built the existing doctrines relative to these two
comprehensive forms of disease.
   The incongruous ideas prevalent with respect  to these two dis-
eases are well  illustrated by the statement that, while Bokitansky
has  long regarded  them  as almost exclusive  of (or incompatible
with) each other, so large amumber of cancerous necropsies reveal
tubercles in the lungs or  other parts of the body, as almost to con-
firm, relatively  to individuals, the  propositions stated by Dr.
Christison1 relatively to  families:  namely—that "the malignant
diseases belong to the scrofulous constitution;"  and that " consump-
tion in early life, and malignant disease at a  later age, seem not
infrequent in the same family."  In short, it would seem that not
only do the two diseases  attack similar constitutions and tempera-
ments, but that  they often merge into each  other in  the  same
individual; and  that, less frequently, their respective products are
present in a quantity and  condition which conclusively indicate a
simultaneous—if not indeed a connected—activity of both maladies.
   But in respect to the mutual relation of cancer and tubercle, the
appearances  of the malady we are now discussing seem, if carefully
considered, to support Bokitansky's views.
   Firstly, as to the mere presence of the products of cancer and
tubercle in the same person.  The comparative fatality of the two
diseases, and the diff'erent epochs of life which they specially affect,
are circumstances which, apart from all  others, sufficiently explain
why cancer follows tubercle, but tubercle does not follow  cancer.
And the  frequency with which arrested  or  obsolete deposits  of

  ' " Suggestions to Medical Referees of Standard Life Assurance Company," pp.
11, 12. Edinburgh, 1852. 
208
CANCER OF THE STOMACH.
tubercle are  found scattered in sparing  quantity throughout the
lungs of persons dying of cancer, is a fact which not only fails to
establish any essential connection between them,  but is quite com-
patible with Bokitansky's views.   Whatever the estimates of differ-
ent observers as to the frequency of tubercular deposits in necrop-
sies of persons dead from all causes  indiff'erently,  there can  be  no
doubt that their average (50 per cent.) far exceeds the frequency of
similar  deposits in cancer.   Hence all that we are really entitled to
infer is, that  the deposit of tubercle in  the  earlier epochs of life
affords  no complete protection against that of cancer at a subse-
quent period : a proposition which few would question.
   Of course it might be argued that  the blood-disease, by which
the  tubercular  deposit is produced, may sometimes survive the
activity of this deposit itself: and hence that of these cases of coin-
cident deposit, some are ascribable to a concurrence of the cancerous
and tuberculous cachexias.
   It is  difficult to refute vague suggestions of this kind.  But the
histology of gastric cancer and its complications throws great doubt
on them: and certainly suggests, that a large  proportion of  what
are supposed to be tubercular deposits associated with cancer of
the stomach, are in reality cancerous deposits, having the usual
secondary relation to the gastric lesion.   Thus there are some cases
of secondary cancer of  the lungs which closely simulate ordinary
tubercle, not only in the earlier stages of its deposit, but even at the
commencement of its suppuration and softening.  A large propor-
tion of the secondary cancerous deposits which  involve the lung
possess  either  a firm  and cartilaginous texture,  akin to that of
ordinary scirrhus, or a somewhat less dense (but still tolerably firm),
white, solid appearance, such as can  scarcely be mistaken for either
miliary or crude tubercle.  But in less frequent cases, the cancerous
deposit, sometimes equally discrete and scanty, undergoes a process
of softening  and suppuration which is  hardly distinguishable, in
certain  of its small spherical granules, from the appearances of the
similar  change in tubercle.   Nor does even the microscope  always
afford a decision.  As  a rule, the medullary mass of which such
secondary cancerous deposits are composed may be easily shown
to consist almost exclusively of cytoblasts or minute cells, which
occasionally distend the pulmonary lobules so as to afford a com-
plete demonstration of their arrangement.  While in tubercle  we
find, in  addition to what are often characteristic  differences in  the
cells  themselves, such a  preponderance of the amorphous consti-
tuent, as is, on the whole, even more distinctive of the nature of the
mass.   But occasionally these grounds of distinction altogether  fail
us.  The process of  softening breaks  down the structure  of  the
cancerous deposit, to  a degree which  sometimes leaves scarcely
more of the malignant cell-growth that formerly distended the pul-
monary lobules, than might be readily mistaken for the epithelium
plentifully found in  recent  crude tubercle.  And the cancerous 
CANCER  OF THE  STOMACH.
209
deposit so closely imitates the structure of the normal  epithelium
of the pulmonary lobules, that the individual  cells, if  seen  apart
from each other, would perplex  the most experienced  histologist.
In short, there are cases in which it must be confessed that, though
the  microscope suggests a  deposit, which  at first sight closely re-
sembles tubercle, to be really cancer: still it only decides the ques-
tion with the aid  of the symptoms and history of the case, and the
appearances detected in other parts.1
   In like  manner it may be noticed,  that  Bokitansky2 specifies  a
variety of " croupy tubercle of the lung, which occurs  during the
inflammation and suppuration of cancer, as a result of the cancer-
ous degeneration of the fibrin;  and which is  distinguished  by its
whitish color, its  soft glutinous consistence, and by its breaking up
into a creamy, whitish ichor."  But while I can confirm this state-
meut, I would add, that whatever the  predominant  appearances of
this mass may sometimes be, it is not a croupy tubercle; but, on
the contrary, is neither more nor less than  a pulmonary deposit of
secondary cancer, and  as such,  consists  originally  of cell-growth.
For in favorable specimens, the various masses of this  cell-growth
may be seen offering all the degrees of such a croupy character in
the same  lung:  the smaller  nodules being white, dense, or even
semi-cartilaginous; the larger, either softened in  their centre, or
completely broken down,  and even partially emptied through  a
neighboring bronchus. And instances are not wanting which seem
to indicate that—though it is easy'to imagine that the free access of
air to such  pulmonary deposits  constitutes a  chief cause  of the
proneness to suppuration of this form of secondary cancer,  as con-
trasted with similar deposits in less exposed organs—still the more
immediate and effective impulse to the process of softening is given
by the perishing of the original lung-tissue, which  is cut off from
the sources of its nutrition by the mass  of adventitious cells that
 surrounds and incloses it.3
    Whatever of novelty or truth this view possesses, it is  not for
 me to decide.   But  I believe tnat  careful inquiry will in  great
 measure confirm it.   In any case, I think  that a thoughtful study
 of the pulmonary appearances of a series of cases of gastric  cancer
 brings us to this alternative: either  that the two diseases really
 havtTmuch of that exclusive relation to  each other which Boki-

'  '  From my own clinical  researches, I am quite entitled to affirm, that these dis-
 crete and scanty deposits of secondary cancer in the lungs sometimes  not only
 soften and suppurate, but complete their resemblance to  tubercle by being actually
 expectorated, so as to form small cavities.  And it would not be difficult to explain
 the rarity of this event, from its  requiring a concurrence of some unusual circum-
 stances, both of the primary and secondary lesion.  (Compare " Transactions of
 the Pathological Society,"  vol. vii. p. 70.)
   <  Op. cit., p. 70.
   3  In this comparison of tubercle and secondary cancer of the lung, I have pur-
 posely avoided the term "  infarction," much as  the earlier appearances  of both
 deposits suggest its use.
        14 
210
CANCER OF THE STOMACH.
tansky deduces;  or (what is at least as startling a conclusion) that
they have an  intimate  casual relation,  such as has  never been
suspected.  The frequency of their apparent coincidence demands
an explanation of one kind or the other.
  It can scarcely  be doubted that these pulmonary deposits of
secondary cancer are liable  to another  change: namely, to an
obsolescence; which  dries up their mass  of cell-growth, and  con-
ducts it,  through various grades of solidification, to what is, in rare
instances, a cretified substance closely resembling that so frequently
found as a relic of  tubercle in the  lung.   But of the frequency of
this process, as well as of the pleuro-pneumonia and softened cancer
just mentioned, I can offer no numerical  estimate.   And in dis-
missing this part of the subject, let me say, that the caution I have
suggested with respect to the  histological evidence sometimes fur-
nished by the microscope, is not in any degree intended to depreciate
the value of this indispensable means  of research;  but rather to
guard  against  the  errors  into which a  hasty and illogical use of
that evidence, or an  exclusive  attention  to it, would occasionally
lead us.   If ever the disease now regarded as a single one under
the name  of  pulmonary  tubercle, should  be distinguished  into
several different maladies—a contingency which seems by no means
improbable—it is difficult  to avoid the  suspicion  that  clinical re-
search will be at least as instrumental in this result as mere morbid
anatomy.
  The other organs  which form the seat of secondary deposit in
gastric cancer, scarcely  deserve enumeration.  The intestine was
thus affected  in  7 out of 431  cases; twice in the small intestine,
twice in  the colon, and thrice in the rectum.  The same cases  also
afford six instances of deposit in the ovary; three in  the uterus,
spleen, and pancreas; two in the kidney, the bladder, and the ribs;
and finally, one  in each  of the following  organs—the vertebras
(fourth lumbar), the sternum,  the humerus, the supra-renal capsule,
the thoracic duct,  the seminal vesicle, the diaphragm,1  and the
pericardium.   Among the rarer secondary deposits is the obstruc-
tion of the vena portse by a soft cancerous  mass.   This condition,
which was present in three or four  of a similar depost in the liver,
for obvious reasons, is accompanied by much ascites.
  The remaining pathological  phenomena of gastric cancer may
be next briefly adverted to, in the usual order of  their occurrence.
  The obstruction produced by a cancerous  thickening of the gas-
tric parietes often gives rise to a variable degree of one or more of
the following conditions:—(1), hypertrophy of the muscular coat;
(2), dilatation;  and (3), contraction of the cavity of the organ.
  The hypertrophy is a  change which  really deserves this title,
inasmuch  as it essentially consists  of an exalted nutrition, and

  1 Apart from  mere continuity of the adherent mass, which  occurs  very fre-
quently ; according to Dittrich, 22 times in 160 cases. 
CANCER OF THE STOMACH.              211
increased  growth, of the muscular  fibre-cells;  and, in favorable
specimens, is strictly limited to such a change.   The calibre of the
stomach being constricted by the tumor, an  increased  effort is re-
quired for the propulsion of its contents;  and this  addition to its
function necessitates (and indeed brings about) an unusual develop-
ment of its structure.   The thickened muscular coat retains, how-
ever, its normal texture.  Its areolar bundles certainly appear
somewhat more distinct and larger than usual; but their size  and
strength, in proportion to  the true contractile tissue,  remain  un-
changed.   The  fibres  themselves are perhaps rather  redder  and
darker  than normal;  but  even  this  alteration may be partially
referred to the enlargement which their bundles have undergone.
   The  above purer form of hypertrophy closely resembles that
which may often be seen in the muscular coat adjoining (and espe-
cially behind) the cicatrix  of an  ordinary gastric ulcer (p. 125).
Like the latter,  too, it  may  extend for a variable distance through
the organ.  It is usually limited to the neighborhood of the pyloric
region, which the cancerous deposit especially affects.
   Many of its deficiencies and complications are explained by the
circumstances under which they occur.  In the softer varieties of
cancer, and in tumors of rapid growth, such hypertrophy is gene-
rally either indistinct  or absent.  In instances where the deposit is
traceable by no very abrupt line of demarcation into the unaffected
part of the stomach, it is often less  marked; or is accompanied by
such thickening of  the areolar  dissepiments  of the  muscular
bundles, as renders it difficult for  the unassisted eye to discern
how far the  altered bulk and color of these structures is due to
mere hypertrophy, or to  their implication  in the cancerous disease.
On the whole, a marked degree of this hypertrophy is rarely found,
save in conjunction with a hard  deposit,  of slow growth, offering
a tolerably abrupt edge towards the thickened muscular coat.1
   Dilatation generally accompanies the above  hypertrophy,  and is
very rarely  found quite unmixed  with it.  Moderate degrees of
either  of these associated changes are  difficult  to verify, from
reasons mentioned elsewhere.2  But it is  probable that in a large
proportion of gastric  cancers both  these states are present.  Still
I think the proportion mentioned by Lebert (1 in 5) as evincing  a
"notable dilatation,"  must be partially referred  to the  variable
estimates of anatomists respecting the average size of the stomach.
For the cases I have collected would only furnish such an estimate
by including in it  many instances in which this organ was scarcely
larger than a full meal would render it in perfect health.  Of dila-
tation beyond this degree, the records of 214 cases afford me only
13 instances; a proportion equivalent to 6f per  cent.  In every

   1 On some of these details compare the remarks upon hypertrophy in the fol-
lowing Lecture.
   2 See remarks on this point in Lectures II. and v. 
212               CANCER OF  THE STOMACH.
one of them the pylorus was  the seat  of  the  tumor.  And  even
with respect to these extreme  instances, I think  that it is rare for
gastric cancer to bring about a degree of dilatation  equalling that
maximum of this state which is witnessed as the result of contrac-
tion in the cicatrix of a pyloric ulcer.1
   The contraction sometimes found in cancer of the stomach is sel-
dom connected  with any true  hypertrophy of the muscular  coat.
It may be regarded as of two kinds ; each depending on a different
process; and each finding its parallel in another disease of the sto-
mach.   (See Lecture Y.)  In some cases it  is the physical result
of a specific pathological phenomenon: a slow shrinking or con-
traction  of the  scirrhous mass which occupies a large portion of
the parietes of the stomach;  constricting and diminishing its cavity
in the same way as does the  contracting  tissue of that  cirrhotic
inflammation which generally attacks the organ with greater dif-
fuseness.   In other  cases, in which the tumor occupies the cardiac
orifice of the stomach, the stomach contracts (just as it sometimes
does when an  ulcer encircles the same aperture) simply because
the constant regurgitation which this occlusion produces, prevents
the cavity of the organ  from undergoing its normal distension by
receiving any quantity of contents.   Here much of the contraction
is temporary, and may be readily removed by artificial dilatation
of the stomach.  In some  instances both these varieties of con-
traction are combined.
   As regards its frequency, extreme contraction is far less common
than dilatation.   The 214 cases mentioned only include 3 instances
of contraction:  of which two seem chiefly referable to the situation
of the tumor at the cardiac aperture;  and the remaining one  to
the contraction of a scirrhous mass engaging the greater part of the
stomach.
   The ulceration, which generally engages the cancerous deposit,
has already been noticed; both as  regards the local  changes by
which it is introduced, and the variable admixture of suppuration
and sloughing  by which it  is  often  accompanied.  Its remaining
peculiarities need not detain us.  That it is rarely or  never arrested
and repaired, the  known features of cancer, in general, sufficiently
inform us.  That, as a rule, death intervenes before any large pro-
portion of the gastric mucous membrane has been devastated by its
extension, is equally explicable.
   The sequelae of this cancerous ulceration evince a marked contrast
with those seen in ulcer of the stomach.  Out of 507 cases of gastric

  1 The accuracy of this opinion seems at first sight contradicted by my subse-
quent experience, in which large dilatation  has occurred with  about equal fre-
quency in  cancer  and ulcer of the  stomach.  But the difference is probably
referable to the larger proportion of such cancers which increased practice among
the affluent (among whom gastric ulcer is certainly rarer than among hospital
patients)  has brought before me.   And the maximum of dilatation still seems
claimed by the ulcerous cases. 'Second Edition.) 
CANCER OF THE STOMACH.
213
cancer, in 21 perforation took place, with its usual result of peri-
tonitis, rapidly  ending in death.   In 4 of these  21, however, the
contents of the perforated stomach were not eff'used into the general
cavity of the belly, but into an intermediate cavity which corresponds
with  the sac of the omentum, and was bounded by the adherent
viscera that inclosed this  sac.  In 10 others, the action of perfo-
ration was shown to have been imminent by the necropsy; and had
probably so far taken place, as to have allowed that leakage of the
contents of the stomach,  to which the fatal suppurative  peritonitis
seemed due.  As regards fistulous communications, the above num-
ber includes one instance  in which an abnormal opening of this
kind  led from  the cancerous stomach to the anterior wall  of the
belly: one in which its  cavity was thus thrown  into communica-
tion with that of the jejunum; and no less than  11, in which the
transverse  colon  was the seat of a similar aperture (twice by an
intermediate cavity formed exclusively of  cancerous deposit).
  Each of these results is in striking contrast with its analogue in
ulcer of the stomach.  Thus in gastric cancer perforation seems to
be only one-half or one-third as frequent as in ulcer; its percentage
being from 4 to 6 instead of 13.  AVhile conversely, the formation
of a fistulous communication between the stomach and colon occurs
far more frequently : how much I cannot definitely estimate, though
I should assign  it a proportion from six to ten times greater than
in gastric ulcer.
   This double  contrast is in  great  part due to the peculiarities of
that destructive process which occurs in the course of gastric cancer.
Growth and decay, deposit and  ulceration, are generally going on
at one and the same time in  diff'erent parts of the diseased mass.
And  thus, even at the very time that the sloughy or ulcerous sur-
face, by which the cancerous tumor abuts on the gastric cavity, is
hourly losing a certain proportion of its bulk, the opposite or peri-
toneal aspect of  the tumor is rapidly throwing out a cell-growth
which more or less replaces these ravages.   Hence, even after long
ulceration, the  thickness of cancerous deposit between the  cavity
of the stomach and  that of the peritoneum may still  remain com-
paratively  undiminished.  No doubt this process may be regarded
as  to some extent paralleled  by the deposit of lymph at the base
and margin of a gastric ulcer; especially where (as is occasionally
the case) the symptoms  point to an uninterruptedly open state of
the ulcer during a  long period of time.   But the analogy is a
remote  one. For while it is chiefly the situation and amount of
such  lymph which determine (p. 142) the occurrence or non-occur-
rence of perforation in the gastric ulcer, and such a quantity as is
generally present in the ulcer of the posterior surface forms  (in the
majority of cases) an  efficient barrier to this  incident  during an
almost indefinite period, no amount of cancerous deposit can have
any such protective  efficacy.  The mass it interposes may indeed,
for the time, separate the gastric and abdominal cavities.  But the 
214
CANCER  OF THE  STOMACH.
protection, temporarily afforded by its quantity, is sure to be soon
abolished  by its quality.   In other words,  its  cancerous  nature
shortly brings about an extension of the same softening or ulcera-
tion as that which already occupies the neighboring  mass, and the
barrier gives way.
   These circumstances  are  well illustrated  by the  fact, that the
situation of the cancerous mass exercises no  influence on the acci-
dent of perforation at all comparable with that seen in ulcer of the
stomach.   Indeed, from the posterior and diaphragmatic aspect of
the cancerous stomach being the earliest and most frequent seat
of adhesion, it is precisely in this situation  (the  safest a  gastric
ulcer can occupy)  that  the  cancerous perforation  most frequently
takes place.
   In both cancer and ulcer of the stomach, the occurrence of per-
foration, as a pathological event, is by no means synonymous with
that characteristic and fatal group of symptoms which we generally
associate with this word.  Just as in the latter disease (p.  128) a
true perforation of the gastric coats  is often accomplished months
(or even years) before an  extension or  renewal of the ulcerative
process penetrates the new tissue which has hitherto warded off the
accident; so  in cancer of the stomach, that portion  of this organ
which corresponds to the  diseased mass  is  often destroyed long
before the destruction of the subsequent deposit  brings about a
communication between the gastric and abdominal cavities.   But
the degree in which any of  the  original structures of the part are
left, it is sometimes impossible to define.   The frequency of partial
perforation—or rather of a leakage of the gastric contents through
such a spongy mass—can  scarcely be compared with that of the
similar accident in ulcer.  But its apparently greater frequency is
readily explained by the above allusions.  Lastly,  in any  strict
comparison of the  pathology of the two diseases  with respect to
this accident, the date  and  mode  of death ought not to be  over-
looked.  It may fairly be conjectured that a  much larger propor-
tion of gastric cancer would  end in perforation, were it not that the
collateral circumstances of the disease often destroy life before the
local mischief has reached this stage of development.1
   It is not easy to offer any hypothesis for the relative frequency
of communication between  the  cancerous  stomach and the  colon.
The selection of this intestine is of course  explained  chiefly by its
situation.  But while the  above characters of the process of can-
cerous deposit no doubt constitute the main cause of this particular
variety of perforation, as well as of the accident in general, the fact

  1 For example, if we regard the establishment of an unnatural opening between
the cancerous uterus and the bladder or rectum, as analogous to perforation of the
peritoneal cavity by a cancerous stomach, it may be interesting to  notice that there
is good ground for estimating the former accident to be from two to four times
more frequent than the latter, in equal numbers  of cases of gastric and  uterine
cancer. 
CANCER OF THE STOMACH.
215
that this one variety is as frequent as all the others put together,
suggests some peculiarity, favoring either the deposit or the removal
of cancerous substance, and connected with the colon, rather than
with the various other structures which adjoin the stomach.  Fer-
haps, however, the mere thinness of the intestinal coats,  as con-
trasted with these structures, will account for its being more rapidly
and frequently penetrated when adhesion  has  once taken  place.
At any rate we can scarcely at present assume any specific liability
of the colon (in virtue of its structure or function) to an accident
of which the more immediate conditions seem so evidently local.
   The  hemorrhage which occurs in the course of gastric  cancer
affords, in some of its varieties, an equal contrast with that witnessed
in gastric ulcer..  As a rule, it only occurs after the access of ulcera-
tion ; though,  prior to this event, it  may  be produced by mere
passive or active congestion—a  form of bleeding which, from obvi-
ous reasons, seems to be much more frequent in cancer than in ulcer.
The exact frequency of moderate hemorrhage can  scarcely be esti-
mated  in either malady.  But those larger  bleedings which occur
as a result of the  lesion of a considerable artery seem to be much
rarer in cancer than in ulcer.  Out of 374 cases, only 4 exhibit such
a hemorrhage : a proportion of barely more  than 1  per cent., or one-
fifth of that estimated for gastric ulcer.  As might be expected from
the usual situation of  the cancerous deposit, all of these appear to
have been lesions of the superior pyloric artery (p. 32).
   As regards  that complete obsolescence of the cancerous deposit
which  is evinced by its conversion into cretaceous matter, the 214
cases I have  collected only afford one instance of this  kind—a
woman, aged thirty, affected with colloid cancer of the pylorus, the
liver being also occupied by medullary deposit.  A similar instance
described°by Dittrich' suggests equal doubt how far this  process
really deserves the above name.  While these  two cases suffice to
modify Bokitansky's opinion—that it is the hard and fibrous  can-
cer which is  exclusively amenable to this  process—their rarity
reduces them to a very exceptional variety of the disease.
   In respect to the healing of cancer, the dead-house scarcely modi-
fies the gloomy opinion derived from clinical experience.  In every
instance hitherto brought under my notice, I have assured  myself
that  the  gastric cicatrices  which suggested a  healed cancer were
precisely  similar to those  of ordinary  ulcers.   Of course such a
statement does not invalidate the observations of  others^ who have
found  scars cover a scanty scirrhous deposit.  But it  is possible
that some of these instances have been deposits of scirrhus in the
cicatrices  of ordinary ulcers; and that in others, the fusiform cells
and fibres of such scars have been mistaken for those of  scirrhus,
from which they are  sometimes scarcely  distinguishable by the
most sedulous examination.  It is certain that few or none of these
1 Loc. cit., p. 15. 
216
CANCER OF THE  STOMACH.
cases are authenticated (as they certainly should be to establish so
striking a fact) by a careful comparison with the symptoms of the
patient during life.   Lastly, I fear that it is more than unsafe to
accept statements which (like Lebert's) allude to these appearances
in language  so equivocal as the term " scars of cancerous ulcers"
seems to be, when brought forward by a pathologist whose clinical
research, however  assiduous, does not  enable him to depict so
common a disease as ulcer of the stomach from his own experience.1
  The aetiology of cancer  of the  stomach has so little direct con-
nection with the symptoms which attend the malady during life,
that I now only need sum up those pathological details which, from
their prominence and constancy, seem most to suggest a causative
relation.   The most  obvious (at any rate the most  convenient)
hypothesis of the disease would refer it to  a  causation, which is
probably itself the co-efficient of at least two elements: the disease
and its site; the cancer, and the stomach it invades.
  In respect to the former of these two elements of causation, there
are no facts which entitle us to suppose  that the disease (whether
humoral or not) presents any specific modifications in the stomach.
At  any rate,  the circumstances  of age,  sex, &c, already  noticed,
afford little countenance to such a supposition.
  Assuming so much of the ordinary views respecting the cancer-
ous diathesis, as to infer that its intensity is expressed and measured
by  the cancerous deposit  with tolerably equal  accuracy in all the
organs generally affected  by cancer, it is chiefly as to the selection
of the stomach by this deposit that we may examine into the facts
now brought together.
  We have successively seen that, in a  large proportion of cases,
the disease selects the stomach;  that  in this organ itself, it further
chooses out  the  cardiac  and pyloric orifices, and especially the
pyloric.  Its situation, in the earliest stages in which we detect it,
conclusively shows that it cannot be attributed to  any mechanical
or chemical effects of the  ingesta; that it is not due to  any change
in the secretory apparatus of the stomach; or even  to a lesion of
any part of the mucous membrane, or of the tissues immediately
subjacent.   In short, that, for practical purposes, the deposit must
be  regarded as seated in the loose submucous areolar tissue of the
stomach, at some little  distance from the active cell-growth of the
gastric surface; and generally, so  much nearer (or more closely
allied) to the similar  connective tissue between  the bundles of un-
striped  fibre, as to involve these long before reaching  the mucous
membrane.
  The organ thus affected is, with the exception of the rectum, the
oesophagus, and the uterus, the thickest and  strongest  mass of un-
striped  muscle  in  the  human  body.  Belatively  to its function,
indeed, it transcends  the contractile  structures of all three of these
1 Loc. cit., p. 526. 
CANCER OF THE STOMACH.
217
organs:  because that function implies constant  and  protracted
movement, instead of such an intermittent and brief contraction as
that by which all of them might readily be shown to impel  their
contents.   How violent, as well as  protracted,  that gastric move-
ment is, may be easily conceived when we recollect that, for about
six hours of the twenty-four, the stomach is  actively contracting
upon (and propelling)  its  contents; by  a movement which, during
a great part of this period, almost obliterates the cavity of the
pyloric half of the organ every two or three minutes.1  Hence, apart
from its mere bulk, we may fairly suppose that the muscular coat
possesses  an exalted nutrition, a rapidity of growth and decay,
which  proportionally exceeds that of either of the other masses of
unstriped fibre with which we have contrasted it.
   Should future researches establish, either the absolute commence-
ment of the disease in the unstriped fibre-cells themselves, or (what
seems  more probable) an exactly analogous situation of its  develop-
ment in all four of these  organs—stomach, uterus, oesophagus, and
rectum—of course the above conjecture would acquire a somewhat
firmer basis.  In any case we must recollect, that the areolar tissue
inclosing and penetrating  any muscular mass necessarily shares in
that mechanical displacement which this muscular mass  executes
(and often, from its very office, is more  suddenly and violently dis-
placed than the  contractile  fibres themselves); and  therefore, as
necessarily becomes the seat of  a nutrition, exalted beyond that of
the same tissue in less active parts.
   It is therefore to  the more  energetic movement of the pyloric
half of the stomach, and to the passive (as well as  active)  relations
of the pyloric and cardiac valves at the extremities of the organ,
that the frequent selection of these parts by the cancerous deposit
may be directly or  indirectly ascribed.   Whether  the  peculiar
structure of the organic muscle, as a comparatively permanent cell-
growth, invites the access of a  disease the morphology of which is
closely akin to its own—is a question beyond our present know-
ledge" to decide,  and little affecting those gastric peculiarities to
which  we are now limiting our attention.
   Such an hypothesis, however, as that we have advanced, ought
never  to be stated without an exposure of its chief deficiencies; a
knowledge of which restrains any conjecture to the useful office of
grouping facts, and at the same time prepares for its confirmation
or rejection.  While it is not impossible, for instance, that the con-
ditionating cause {causa causativa) of the preference of this or that
particular organ by cancerous  disease,  may be a different (or even
compound) one in each, it is difficult to fit into such an hypothesis
as the above the frequency of cancer of the uterus and mamma.  In
the former organ, we may perhaps  shadow out something compa-
tible with it in that remarkable activity of growth and decay which
1 Compare p. 25. 
218
CANCER OF THE STOMACH.
the muscular uterine wall from time to time undergoes; connected
as the disease is with a period of life, when we might readily ima-
gine an accumulation of nutritional  activity, or even a transfer of a
tendency to growth from one part of the reproductive apparatus of
the female to another.  But in the latter orgaji, this vague formula
of transferred activity is alone left us; and—if we accept the equi-
vocal influence  of  mechanical violence in producing cancerous
tumors of the external parts, and the more marked effect of cuta-
neous irritation on cancer of the  lip and scrotum—it is difficult to
trace any community of causation between the gastric  and mam-
mary lesions.  The conjecture hazarded with  respect to cancer of
the stomach therefore remains doubtful; confirmed by facts them-
selves  requiring investigation;  and opposed  (though not contra-
dicted) by some of the best evidence which can at present be adduced.
                         TREATMENT.

  The treatment of cancer  of the  stomach might  almost  be left
unnoticed.  Not merely because we  are hopeless of its effecting the
cure of the patient.   For the alleviation of sufferings which cannot
be removed, and the postponement of a death which  cannot be
escaped, are too often the only benefits  to be  expected from the
application of  the art of medicine to disease in particular,  as well
as in general.   But  rather because the conditions  through which
this terrible disease conducts the sufferer towards his death  are too
secondary and collateral to  the malady itself, to admit of such  a
common plan of treatment, as, with suitable modifications,  is  often
applicable to the numerous varieties of a given disease.
  Hence, I shall only hint at the  principles which ought to guide
our remedial attempts; and  shall refer you, for  the means of carry-
ing out those principles, to what is elsewhere (Lectures II.  III.),
said respecting the treatment of the diseases which are imitated by
the secondary results of gastric cancer.
  Looking back at my own experience, I must say that  I  have
done more good by careful feeding than by any drugs in the Phar-
macopoeia.  These cases, however, have been chiefly among hospi-
tal  patients.   In other  words, they were instances in  which the
charity of the unprofessional public made me the means  of sus-
pending that destitution and wretchedness by which cancer can be
produced, and aggravated, in the strictest pathological sense of these
words.  Pray acquit me of  exaggeration if I say that,  more than
once, as certainly as I have  seen vaccination reproduce  cow-pox, I
have witnessed misery, anxiety, and starvation,  suddenly rouse into
fatal activity a gastric cancer:  and that this cancer, having run its
course in a few weeks, the necropsy has verified anatomical details
conclusively proving that it must have been present as an unsus-
pected tumor for months, or even years, during which the  patient 
CANCER OF THE STOMACH.              219
  has literally enjoyed the most  robust health.   And even in a case
  of this kind, I have known agony and prostration  converted into
  comparative ease and cheerfulness during the  patient's last  few
  weeks of life, by the comforts of an hospital:  among which I espe-
  cially distinguish light, air, warmth, stimulants, and food of proper
  quantity and quality.
    Perhaps, in some instances,  we may suspect a  still more specific
  reason for the  remarkable  improvement evidently procured by
  careful nourishment.  As you will hear in the next Lecture, mus-
  cular hypertrophy of the stomach is one of those curative efforts by
  which nature partially and temporarily counteracts the obstruction
  producible by gastric cancer.  Now since, on the one hand, the
  nutrition of every organ  depends upon that  of the  whole body,
  while, on  the other, this  secondary obstruction sometimes dictates
  the whole  of the  gastric symptoms present, that group of symptoms
  which in every case forms (clinically speaking) the disease, may be
  relieved (and even removed) by suitable measures of this kind.
    But while a generous  diet is in most cases indicated, alike by
  the nature of the lesion, and by the age and circumstances of the
  patient, its use is generally forbidden  by the state of  the stomach.
  That complete failure of the appetite, which  often forms an early
  feature of  the malady, also opposes what is practically a great  ob-
  stacle to a diet of this kind.  While the pain, distension, and vomit-
  ing which are  present in the more advanced  stage, constitute hin-
  drances such as the physician is even less likely  to vanquish.   To
  vary the food, in what is often a fruitless search after some nou-
'  rishing articles of diet which (guided by the  patient's instinct) we
  fancy the  stomach may bear;  to give these in small and frequent
  meals; and  (especially where  the stomach will  support no other
  stimulants) to administer opium ;  such  is often all that we can ac-
  complish.   Of course, diarrhoea, constipation, and excessive pain
  suggest their appropriate remedies; which, in the two former, are
  often best  given  as enemata.
    But in all these points the  treatment of gastric cancer is often
  necessarily akin to that of gastric ulcer.  Indeed,  we have seen that
  its later stages (and sometimes even its  earlier symptoms) are asso-
  ciated with such an ulcerated state of the surface of the cancerous
  tumor, as quite  accounts  for the indications of its treatment being
  almost identical with those of gastric ulcer.  Hence, I  may refer to
  the measures recommended for the cure of the latter disease in the
  preceding  Lecture;  merely premising that, on the whole, wine and
  other  restoratives may be given, not only with fewer scruples, but
  with more advantage.
    The prognosis can  of course only vary in  respect to the date at
  which it tends to fix the fatal  termination of  the disease.  And in
  our conjectures  on  this point (which is often very important in
  practice) the treatment rendered necessary by the peculiar features
  of the case is scarcely less influential than the various  pathological 
220
CANCER OF THE STOMACH.
occurrences already dwelt upon.  Much as the fatal event may be
hastened by intense and continuous pain, by excessive vomiting
by  frequent hemorrhage, by a  rapid growth  of the tumor, by
secondary deposits  of cancer elsewhere,  and a variety  of other
circumstances of this kind;  and obviously as oedema, emaciation,
prostration, or delirium, often constitute, not so much  forebodings,
as "the  beginning of the end;"  still the inability to  take  food is
sometimes a source  of at least equally imminent danger: such as
(for example) may in a few days hurry to the grave a young and
hitherto wrell-nourished  patient, in whom the absence  of  all these
symptoms or complications in any marked degree might otherwise
lead us to expect the malady would extend to its ordinary duration
of a few months.  And as it is not always easy to say how much
food is really taken, or retained, by the patient, this rule of prog-
nosis is  practically by no means the  truism which at  first sight it
seems to be. 
221
                       LECTURE  V.

Cirrhotic Inflammation, or Plastic Linitis of the Stomach—Suppurative Linitis—
  Ttimors—Hypertrophy—Atrophy—Dilatation ;  from obstruction, destruction,
  injury, paralysis—Secondary Inflammation.

  In attempting to sum up the chief features  of several diseases
of the stomach  by the  following brief discourse, I may premise
that the maladies to which it  refers, though exceptional in one
sense, are not so in another.   For even the rarest among them are
not (at least in my judgment) the mere extremes or modifications
of a variety of diseases :  but rather constitute types and classes for
themselves.  And not only are they of great pathological interest,
but their  collected  cases  are quite numerous  enough  to afford
deductions of much practical importance in the treatment of  those
more common gastric maladies which  are allied to them.  I may
add, that my remarks are all founded on clinical and pathological
observations; and  that I hope they throw some new light upon the
maladies of  which they treat;—maladies,  some  of which are not
only obscure in their nature  (and therefore  little likely to reveal
themselves to the casual or one-sided glimpses which their  infre-
quency has caused to be bestowed  upon them), but even obscured
by  the names and descriptions they have hitherto received.
         CIRRHOTIC INFLAMMATION, OR  PLASTIC LINITIS.

  The first of these diseases is one which in its less marked forms
is not by any means unfrequent.  But  from  the obscurity of its
symptoms, and  the closeness of their resemblance  to cancer, we
may usefully reverse  the  ordinary course of description; and dis-
cuss successively its  appearances, its nature, and its  name, before
glancing at its diagnosis and its treatment.
  We shall first notice what I venture to call typical specimens of
the lesion.  In  such  cases, the necropsy of some obscure gastric
disease of long standing shows  a stomach which,  even on our
dividing the wall of  the  belly, strikes  us as remarkably altered.
Sometimes large, sometimes small, perhaps of average dimensions,
it has a peculiar  pearly whiteness and opacity; an appearance which
is partially due  to a  dulness of the peritoneal coat, in remarkable
contrast with its ordinary mirror-like brilliancy.  Bemoving the
organ  for further  examination, we find this  change  in  its  color 
222             CIRRHOSIS OF THE STOMACH.
         associated with a great increase in its weight and density; so that,
         for example, it has a hard, gristly feel;  and not only fails to col-
         lapse by its own weight, but resists  a  considerable pressure; or
         returns to its original shape on the removal of such pressure, like
         a large artery, or a  caoutchouc bottle.   An  incision through the
         coats of the organ exhibits a vast increase of its thickness; a change
         which, as it is diffused equally throughout the stomach, leaves the
         relative depth of vertical sections  at  diff'erent parts little affected;
         and is  hence summed up  by the  statement  that the thickness is
         some six or eight times greater than what is normal.   But in spite
         of this thickening (which is often attended by an increased density
         that makes the pearly-white section fairly creak while it is being
         traversed by the scalpel), the diff'erent gastric tissues remain not
         only discernible, but distinct from each other.  Often, indeed, their
         adjacent boundaries are evidently composed of a looser tissue than
         that of the mass elsewhere; while even the proportionate thickness
         of the  areolar, muscular, and serous  coats sometimes approaches
         that of the healthy tissues.  The mucous coat,  however, appears
         much less affected; its matrix being either little changed in thick-
         ness, or indistinguishably fused into the subjacent " tunica nervea,"
         and its secretory structures  remaining  substantially healthy.
         Finally, the whole organ is comparatively bloodless: a condition
         which is not only in marked contrast with its  normal state after
         death (compare  Lecture II.), but is, of course, most remarkable in
         the more vascular of its coats; to wit, the mucous membrane.
            A closer inspection  of such a specimen shows that the abnormal
         character is not limited to a mere increase in  thickness.   However
         distinct the gastric coats, they are far from  offering that contrast
         to each other which  is characteristic of their healthy structure.
         Muscle, areolar tissue, matrix, and mucous  membrane—are  all
         unnaturally alike.  All evidently owe  their increased  thickness
         to the presence of the same new substance; the uniform and inter-
         stitial deposit of which is  one of the main characteristics of this
         gastric  lesion.
      y^    The examination of this  deposit under the microscope confirms
         the impression which  it affords to the unassisted eye.  Aided by
         dissection,  the latter discovers  that the  white mass consists  of a
         tough, semi-elastic, imperfectly fibrous material, closely analogous
         to that found  in  common  fibrous  tumors, and in the indurated
         cicatrix or margin of a  common  gastric ulcer.  The microscope
         does but follow this conclusion into details, by showing  (mixed
         with the original tissues in variable quantities and conditions) a
        /mass of a  rudimentary fibrous character; composed, that  is, of a
       / substance, the wavy filamentous markings of which are less distinct
       /  than in the white fibre of ordinary areolar tissue; from which, too,
,  ■. a   |  they are further distinguished by the scarcity of vessels, the absence
       I  of yellow or elastic fibres, and the presence of scattered cytoblasts
         and nuclei.  Developmentally,  these  nuclei  seem to represent in 
CIRRHOSIS OF  THE STOMACH.             223
this new structure, the elastic fibres of the  normal tissue ;  while
functionally, they may be conjectured to afford at least a partial
compensation for the absence of vessels; the nutritive uses of which
they replace much as do the cartilage cells of those tendons which
play over  bones.  Some of these nuclei occasionally surpass the
stage of development to which the latter (their normal analogues)
are restricted; or rather, deviate from  it altogether,  so as  to be     /
traceable, not as mere  elongated nuclei, but as fusiform  cells of    /
variable (usually small) size.  The direction of these fibres  appears   /
to be  very irregular; a tangled interlacement in various senses,/
rather  than any special or systematic decussation.               '      [
   A careful comparison of  the several coats of the stomach shows  A/. v "'
that they  are engaged by  the deposit in very different amounts,  !&
and with still more different results.  As regards mere thickening,    i ,
the areolar tissue of the "tunica nervea" is much altered; its depth,  ^ v
as  seen in a vertical section, being  often increased  from  ten  to
twenty fold.  Next to this  comes the peritoneum; it (or rather its
subserous  areolar  tissue), acquiring a  thickness which,  though
rarely  exceeding a fourth  of the preceding submucous tissue, is,
proportionally to its original tenuity, sometimes almost as great an
increase; or a multiple of  seven to  ten times the  natural  bulk.
The muscular coat ranges from five to eight times its pristine thick-
ness; and  the mucous membrane (in which term the matrix ought
to  be  included) is scarcely ever more than doubled  or  trebled;
proportions which we shall see are often not exclusively due to the
new deposit.
   Barely do we find either  of these tunics merely  increased by the
new deposit, without  any degeneration  or decrease of its original
tissues.  And hence each of the above proportions must be regarded
as the  difference of two processes in addition  and subtraction, or
as the  degree in which the former outweighs the latter, rather than
as a mere increment to the corresponding normal structures.   And
while  the  degree of these  antagonist processes is liable to  great
variety, the following summary may be offered of their course in
the several tissues.
   The serous coat is almost always damaged, or rather destroyed,
over a  great extent of its  surface;  the epithelium either failing
altogether,  or being replaced by an extremely irregular and scanty
cell-growth, very unlike its beautiful tessellation  in health.   And
while its subserous tissue is  generally solidified  by  the  deposit,
which  strangles and kills its original  vessels and fibres, nothing is
commoner  than to find decisive evidence of superficial inflammation,
in the  shape  of recent pasty lymph, or older  threads and fibres,
gluing  the stomach to adjacent viscera, and having  a  structure no
way differing from that of such adhesions in  other gastric diseases.
Occasionally these  appearances of peritoneal inflammation extend
to the neighboring duodenum.
  The  mucous coat is,  in general, much  less  seriously involved. 
224             CIRRHOSIS  OF THE  STOMACH.
Often,  but for its thickened matrix, it might almost be thought
healthy.   But while its pallor of surface, and the white lines run-
ning upward between  its tubes, show how seriously its circulation
is  interfered with by the mere change of its matrix, an increased
degree of this deposition readily'inaugurates further lesions.  Thus,
here and there, the tubes become distorted from their proper direc-
tion, or even destroyed in some (usually the lower) part of their
length.  Sometimes a similar (but apparently more sudden) mechani-
cal interference with their vessels gives rise to appearances of local
extravasation or gangrene.  While the loss by ulceration of a vari-
able extent of the whole thickness of this coat is so  frequent and
dangerous a result of this kind, as really  to constitute what might
almost be called a termination or event of the malady.
   Another curious change, belonging equally to  the mucous and
submucous coats, may be  mentioned  here; namely, a kind of fold-
ing or plaiting  of a variable extent of the mucous membrane, so
as to raise it above the neighboring gastric surface.  Some of these
cases are  really  very little more than a deposit  in the submucous
tissue:  a deposit which, by obliterating and filling its meshes,
destroys their function, and thus fixes and renders quite ineffaceable
the normal rugae (p. 27) of the affected portion of mucous membrane.
In other cases, however, it is the matrix of the mucous coat which
is chiefly concerned : and in proportion as  this is the case, the raised
and wrinkled  surface becomes  a more  complex and definite ex-
crescence, in which the tubes are sure to  be  distorted and oblite-
rated to a  considerable  degree.  Even  here,  however, the low
elevations of the membrane are  seen,  in a vertical section, to possess
precisely the same structure as  the  adjacent healthier parts; and
the distinction of the  original  tissues remains  well marked.  In
short, the change looks more like (what it  doubtless is) a folding of
mucous membrane upon  and around a subjacent contraction, than
that interstitial enlargement of a true  cauliflower excrescence, which
it distantly suggests  and  resembles.
   The thickened  muscular coat  offers  changes of  even  greater
pathological interest than the foregoing.   In a vertical section, the
space belonging to this coat constitutes a  straight uniform interval
between  the parallel lines of the  dense white deposit in the sub-
mucous and subserous areolar  tissues.  If the vertical section be
parallel to the long axis of the stomach, we see a number of thick
white threads, which pass to and fro between these two surfaces of
the continuous  deposit, giving  and  receiving a branch here and
there, so as to form a kind of network, the large meshes of which
inclose a substance of  a gelatinous,  browjiish appearance.   These
dissepiments are evidently the thickened  ancl enlarged representa-
tives of those  processes, which  originally pass  between the above
strata of areolar tissue, and limit and ensheathe the bundles (p. 22)
into which the fibre-cells are aggregated  in the transverse layer of
the muscular tunic.   The microscope shows them to contain, with new 
                CIRRHOSIS OF THE STOMACH.            225

 substance, a great  deal of this original tissue.   And this view of
 their nature is confirmed by the simple expedient  of varying the
 above vertical section for one at  right angles to the axis of the
 stomach, when the muscular bundles being taken in a  direction
 parallel to their course, the marked character of the fibrous network
 by which they are isolated almost disappears.   The same expedient
 allows of an inspection, which shows that the brownish mass occu-
 pying the cells of the honeycombed longitudinal section is altogether
 made up of the proper muscular fibres.  The fibres themselves are
 sometimes distorted: occasionally shrunken and diminished in size.
 But  they  are  oftener enlarged: though not (I believe) to such a
 degree as  quite enables us to  dispense with the supposition of an
 increase in their numbers, to which the increased thickness of their
 mass is partially due.  The longitudinal layer of the original muscu-
 lar coat can rarely be traced: a disappearance which seems explica-
 ble by its original tenuity, and by its arrangement relatively to the
 subserous and transverse layers above and beneath it, without sup-
 posing it to undergo any  peculiar absorption.
   Now, just as it is impossible to question the nature of the mus-
 cular thickening above  described, so  there can scarcely be any
 doubt as to the origin of such a genuine hypertrophy of these un-
 striped fibres.- We  find a deposit which works the most serious
 (and  despite their slowness, destructive)  changes  in every other
 gastric tunic, bringing about  a positive increase and enlargement
 of the muscular  tissue;  and  that, too, in  a degree closely, if not
 exactly, proportionate to its original bulk in different parts of the
 stomach.   We shall  presently see that  it is not always  that this
 deposit is  followed by such a muscular hypertrophy.  Hence, its
 causative influence is probably indirect: and can only be found in
 that increase of the  contraction, and therefore of the nutrition, of
 the muscle, which  the obstructive effect of the deposit itself evokes.
 It is the same true hypertrophy of an overworked muscle, which
 we see in  the blacksmith's arm, in the dancer's leg, or  (a closer
 analogy) in the cardiac hypertrophy of an obstructed aorta.
    Among the variations from  the above type of this lesion, we may
v first notice the existence  of irregular lumps or patches; formed- by
 portions  of deposit,  harder and  more condensed  than  elsewhere.
 As might be expected, such aggravations of the general lesion are
 most frequent in the submucous, and next to this in the subserous
 tissue.
    Contraction and dilatation of the stomach are two other variations
 from the type we  have selected.  Of these two opposite  changes,
 contraction is not  only by far the more common, but seems to be
 contrasted with dilatation in its constituting, not merely an excep-
 tional or casual effect of the  peculiar  circumstances of any given
 case, but a law in the progress of the malady.  Some  of the ap-
 pearances already described imply at least a partial or local effect
        15 
226
CIRRHOSIS OF THE STOMACH.
of this kind.  And though we have, for  descriptive1 purposes, se-
lected a type of the lesion, such as stands midway between the above
two converse processes, yet a consideration of its characters, as just
enumerated, points definitely to a more general contraction; which
begins at an early date of the deposit, and continues steadily to increase
(if not restrained or overmatched by the causes of dilatation) through-
out a long period.  In  cases of long standing, the organ  is thus
gradually reduced in  size, and often conversely increased in the
thickness of its coats, until perhaps its cavity at last dwindles to a
capacity of five or six cubic inches, and its coats acquire an.irjcli.of
thickness.   But this effect is more frequently interrupted long
before its attaining such an extreme degree:  and the stomach ap-
pears to remain many months or years2 with little further alteration
in this  respect.   Hardness, however, seems to  increase up to the
last.
  The much rarer incident of dilatation  appears to be connected
chiefly by two circumstances: a rapid and extensive deposition of
the new substance,  and an  enfeebled  or degenerate state of the
muscular coat.   Of these two the latter may well be caused by the
former.   The  dilatation is rarely excessive; indeed, it seems to
consist  rather  in  the  thickened organ being  fixed at its largest
healthy dimensions, than in a dilatation such as is sometimes brought
about by a cicatrized ulcer.   The stomach is incontractible, rather
than really dilated.
  On the foregoing analysis of the various records and preparations
of this lesion we may found some plausible conjectures respecting
its nature,  at any rate in this  its typical form.
  As regards its  morbid  anatomy, it is evidently an  exudation,
occupying the areolar tissue of the stomach, and gradually under-
going a change, in which its  development  into  a low grade of
fibrous  tissue (like that of a fibroid tumor) is accompanied by a
constant decrease of its bulk, and increase of its density.  The con-
traction  and hardening thus brought about  not  only seriously
damage the function of an  organ to which mobility is essential, but
they obstruct its circulation and probably its innervation also, and
they inaugurate grave  lesions of its  mucous  and serous coats.
Even in the muscular tunic a similar effect sometimes obtains.  And
though, incidentally, the obstacle formed by the exudation  often
evokes, in this  powerful organ, a change  which  diminishes and
defers its disorganization, and even exalts its nutrition for the time;
still, in  the long  run, this salutary  effect generally yields to the
interference produced by the slower but surer agent—to the con-
tracting and hardening of the interstitial  deposit.  The physical

  1 Because where contraction of this kind exists, it must of course be allowed for
in estimating the increased thickness of such an organ, and especially of its mus-
cular coat (compare p. 73).   And to do this  with accuracy is difficult.
  2 To judge by the tumor perceptible in the epigastrium during these periods. 
CIRRHOSIS OF THE STOMACH.
227
effect transcends the physiological effort:  the hare is caught by the
tortoise, and then distanced in the race.
  But what is the pathology of the lesion ?   Begarding it as (what
it obviously is) both  inflanimatory and gastric, shall we therefore
name it gqstirftis; adding (it may be suggested) the term interstitial,
to distinguish it from inflammation of the mucous membrane ?  Or,'
looking to the evidently exalted nutrition and  vigor of the muscle,
and the thickening of the areolar  tissue  by a  structure somewhat
analogous to itself, shall  we therefore call it hypertrophy f  Or shall
we look to its hardness  to supply us with a name—sclerosis f   Or
find  a more characteristic title in  the  histology and arrangement
of the deposit—fibroid infiltration?
  Now, though names are even more important in pathology than
in some other sciences  (simply because  they  exercise even more
than their customary influence on ideas) it would scarcely be right"
successively to question the applicability of each of these terms to this
lesion, unless for the sake of the inquiry,  as well as of its results.   But
to call such a lesion "gastritis" is almost as objectionable as it would
be to call pleurisy pneumonitis.  For the latter termination of the
name of an organ' ought to be reserved for inflammation  more or
less specially involving its peculiar structure—that structure which
secretes gastric juice in the stomach, or which  interchanges gases
with  the  air in  the  lung.  While the involvement of the gastric
mucous membramrin this disease is inconstant, late,  and incidental.
Then, again, "hypertrophy" is clearly a misnomer, both as regards
the whole  organ, and the areolar tissue; portions of the original
mass of which may often be found  atrophied and decayed in the
new deposit that entangles and surrounds them.  While, even in
respect to the muscular  coat,  we have seen  that its genuine hyper-
trophy is not a real element of the disease, but an attempt of Nature
(so  to speak) to remedy or  palliate the effects of  the lesion; an
attempt which appears  to  be sometimes wanting,  and generally
temporary.   " Sclerosis" we need not criticize; since, apart from its
applying  chiefly to the later stages of the lesion,  its  etymology
affords no sufficient  distinction, either  from scirrhus, or from cal-
cified  deposits.   "Fibroid  infiltration" is  less objectionable than
any of the preceding.  But the adjective overstrains an analogy;
the substantive misstates a  fact.   For the histology and progress
of the deposit is very unlike fibroid.  While not only do we never
see it as an infiltration, but what we do see by no means looks like
the solidification of the liquid deposit this word ought to  connote;
inasmuch as it diff'erentiates the various tissues, instead of soaking
into  all in tolerably equal amount.1

  1 It would be easy to  show that the analogy suggested above (between this
malady and pleurisy) is rendered more exact by the close physiological relation
betwen serous"membranes and areolar tissue. (Compare "Cyclopaedia of Anatomy,"
article " Serous Membranes,"  by the author.) 
228
CIRRHOSIS  OF THE STOMACH.
   In point of fact, while this inflammatory lesion is, in many of its
 details, quite unlike any other known to our existing Pathology, it
 has two analogues  which specially deserve notice:  one as merely
 offering an interesting (though imperfect) resemblance;  the other
 apparently the result of a pathological relation  close enough to
 dictate the extension of its own name to the more obscure and in-
 frequent gastric malady.  Some of the  varieties of what is known
 under the name of phlegmasia dolens" bring about a condition which
 may be regarded {mutatis mutandis) as ultimately closely akin to
 certain stages of this disease  of the stomach.  But  though  it is
 scarcely1 impossible, it does at present seem improbable, that an
 obstructive phlebitis of this organ generally inaugurates the  lesion.
 Its other and closer analogue is found in cirrhosis of the liver.  In
 this disease we may trace  so close a resemblance to the lesion under
 discussion, and a resemblance which extends to so many circum-
 stances of the deposit—its nature, its situation, its relation  to the
 vessels,  its connection with the portal  system, its contraction, its
 effects on the adjacent original structures—that really the applica-
 tion of the term cirrhosis of the stomach seems by far the best  means
 of connecting its gastric analogue with our existing nosology.3
   But these  typical cases are so rare, that, in spite of their great
 scientific interest, I should scarcely feel justified in giving them a
 special description among the maladies of the stomach, were it not
 for their extrinsic claims to clinical importance.  It is because there
 is a class of gastric lesions, which occur with comparative frequency,
 and of which the preceding are the  best illustrations (if not repre-
 sentatives), that I have ventured to depict a lesion which you may
 perhaps never see twice in an extensive practice.
   Thus it is common enough in the pathology of the stomach, to
 find a condition which is  at least closely akin to this universal cir-
 rhosis, occupying the pyloric half or third of the organ.   All gra-
 dations, too, between this extent, and the total involvement  of the
 stomach, can be found in  the collated history of a large number of
 specimens.  And since you will recollect that even  in  this  total
 involvement, this lesion  generally  increases in thickness  up  to the
 pyloric valve, these gradations may fairly be connected with a pre-
 sumption in favor of the  identity of the two: the more so that, on
 the whole,  the lesion appears  to be increasingly frequent in pro-

   1 The actual occurrence of phlebitis in other parts of the body has been noticed
 in one or two cases.
   ' In saying this, I imply no opinion as to the  goodness of the term " cirrhosis"
 itself.  On the  contrary, like  " cyanosis" (which, to mean anything, ought to
 include such dissimilar  maladies as bronchitis, heart-disease, and Asiatic cholera),
 it connotes, not the lesion, but  one of its separable accidents.  And, although any
 new name is  likely to be merely  provisional to future pathological discoveries, I
 would suggest that the  inflammation of the filamentous network of areolar tissue
 ensheathing the vessels, which  seems the main characteristic of both lesions, might
 be well expressed by some such word as linitis (from the Homeric mvov, rete ex lino
factum). 
CIRRHOSIS OF THE STOMACH.
229
    portion to the closeness of its limitation to the pylorus.  But from
    whatever  cause, the gradations between the two, though scarcely
    deficient, do not- seem to be uniformly filled up,  being rarer than
    the universal cirrhosis itself.
      The microscopic examination of marked specimens of this kind
    confirms the above view of their  real identity with the preceding.
    The various tissues of the pyloric sac are still quite distinct from
    each other;  and the deposit still involves the same structures, in
    much the same proportions.  Histologically, too, it also is evidently
    a low fibrous tissue, devoid of the copious cell-growth rarely absent
    from  true cancerous deposits.   Its influence on the muscular coat
    equally resembles that of the general cirrhosis.  The hypertrophied
    transverse layer thickens rather more rapidly up  to the  pyloric
\f  valle: but with the slight exception thus implied, its serous and
    mucous aspects are parallel; and its network of hypertrophied dis-
    sepiments incloses a similar brownish mass  of unstriped muscular
    fibres.
      The serous and mucous membranes are not affected quite in the
    same degree as in the general lesion.  In the former tunic, inflam-
    mation is  much  less frequent, and even the dull, rough, pearly ap-
    pearance already mentioned is less constant and characteristic.  In
    the mucous membrane, again, ulcerations seem less frequent, as are
    also the irregular elevations of its surface, as well as the distortions
    of its stomach-tubes they produce.  But these diminished effects of
    the deposit on the mucous and  serous membranes appear to be ac-
    companied by a tendency to its greater (rather than less) aggrega-
    tion  in  the  submucous areolar tissue itself;  where it often has a
    vertical depth disproportionately exceeding its limited lateral extent.
    Even here, however, the looser and more distinct stratum (e,/, Fig. 6,
    p. 27), of areolar tissue which adjoins the true matrix (p. 29), some-
    times suggests the centre of this areolar layer to be the chief seat
    of the deposit.
      But as regards  the nature of these appearances,  it would be
    begging the question very reprehensibly to  omit mentioning, that
    the specimens thus classified as a more frequent (though less typical)
    variety of cirrhosis of the stomach, and described as due to a non-
    malignant fibroid  deposit in its coats, are  still regarded  by good
    authorities as cancers;—in fairness, I think we must say, as inci-
    pient cancers.   And  the  chief arguments  for and  against  this
    conclusion deserve notice; not only because  they involve one of
    the most  obscure  and important points in the  pathology of the
    stomach, but also because the facts which sustain these arguments
    incidentally elucidate the  pathological nature and relations of the
    deposit, whether cancerous or  otherwise.   They  may, I' think, be
    tolerably summed  up as follows.
      In favor of their cancerous nature are these facts.   The age of
    their subjects; which closely corresponds with that period of life 
230
CIRRHOSIS
OF  THE STOMACH.
most subject to gastric cancer.1  Their  situation in the stomach—
namely, their marked predilection for the pyloric region, which is
their chief (often  their only) seat; as well as the origin and pre-
ponderance of their deposits in the very same stratum of submucous
areolar tissue in which we have already traced the ordinary de-
velopment of true cancer.  To these  constant features of resem-
blance accede others less regular and less frequent.
  Thus in form, the two deposits often approximate to each other;
the cancerous sometimes affecting a flat or  lateral extension;  the
cirrhotic (as already noticed) a tumorous or vertical.  The manner
in which both affect the different gastric tunics, is also sometimes
very similar.  As respects the mucous membrane, the low irregular
elevations of the fibroid disease are sometimes closely imitated by
a cancerous deposit in or near the deeper surface of the matrix;
just as, conversely, an unusual prominence of these  parts of  the
mucous membrane suggests and  simulates  cancer.   The  serous
membrane is often the subject  of an analogous  (if not identical)
inflammation in both deposits.  And lastly, as regards the muscu-
lar  coat, the distinctions between cancer  and cirrhosis, often marked
enough, are so frequently obscured by similar gradations, that  the
question really becomes one of degree  rather than of kind.   As a
rule, the muscular coat of the  cancerous stomach is doubtless dis-
placed, distorted, or even destroyed, far  more frequently than that
of  the cirrhotic organ or locality.  But, on the other  hand, as
already specified (p. 211), interstitial hypertrophy of the muscular
substance is anything but uncommon; and, in exceptional cases, is
quite regular and even enough (both in its thickness, and in its
diffusion over the affected segment of stomach) to  be  scarcely dis-
tinguishable  from the hypertrophy  produced by  cirrhosis.   And
it must be remembered that in the latter lesion, not merely  the
hypertrophy, but the very structure which  forms its  seat, is often
gradually removed by the further changes of the deposit.  Lastly,
even the presence or absence of the cell-growth usually character-
istic of cancer, is not always adducible as evidence for or against
the  malignant nature of the deposit.  For, on the one hand, such
cells are  sometimes detected  in but moderate (or even scanty)
numbers in cases the true nature of which is unequivocally shown
by the presence of secondary cancerous deposits in other organs:—
so  that, for  example, the  sedulous examination of a  hardened
pylorus sometimes reveals  nothing suggestive  of cancer;  while
the  adjacent lymphatic glands, the liver, or the lungs  are occupied
by  masses of unmistakable medullary growth.  On the other hand,
the  developmental cells of the cirrhotic  fibres are sometimes to be
met with in considerable quantity, and of a form which resembles
that of the fusiform cells of a scirrhous  deposit.

  1 Here I am alluding, not to a calculated (see  p. 120) liability—for these cases
are not numerous enough to justify such an  estimate—but merely to the average
age of their subjects. 
CIRRHOSIS OF THE  STOMACH.
231
  Before stating the reasons against such an identity, I venture to
eliminate a good many facts of the above kind;  on the ground that
the distinctness  of the general  characters of two  diseases is not
much affected by the circumstance  that examples are sometimes
met with equally  referable to both.  Whether two  diseases are
distinct,  is one question;  whether we can always distinguish them,
is  another.   Nobody  doubts  the difference of the two sexes, be-
cause we sometimes meet  with an  instance in which  neither its
aspect during life, nor its  dissection after death, reveals the true
(or even preponderant) sex  of an hermaphrodite animal.   Nor need
we trouble ourselves with arguments which, if  good for anything,
would identify a fibroid with  a cancerous tumor of the breast;  and
confound gastric ulcer with the gastric cancer from which Cruveil-
hier and others distinguished and withdrew it.
   It is more  to  the purpose to point out, that some of the above
resemblances are quite insufficient  to  suggest any  real identity.
Thus, whatever the general similarity in the age chiefly affected by
the two lesions, still (like  the analogous similarity in  the case of
gastric ulcer  and cancer) it cannot  be followed into details.   For
while  we have  found the  average  age of the subjects of gastric
cancer to be about 50 (p.  189), that of  these cases of cirrhosis is
about 34. . The general selection of  the pylorus as the chief or ex-
clusive site of the deposit is almost as unlike the exact preferences
of situation shown by cancer, as are  the analogous predilections (so
to speak) of  gastric ulcer.   And in a majority of  cases,  others of
these resemblances  so far  contradict each other, that the distinct-
ness of the cirrhotic lesion  in any given instance is far less difficult
than  their mere enumeration would suggest.   In general, the de-
cision turns upon facts by  no means difficult to detect or  interpret.
When we find  a  lesion, which has been perceptibly present for
several years, and  in spite of this (compare p. 226) duration, and
of a considerable bulk, has yet failed  to fuse the coats of the stomach
together; which leaves intact the muscular (if not the mucous) tis-
sue ;  which  extends  laterally, but  not  vertically, in and between
these coats, so  as  to  thicken a large extent of stomach without
forming any tumor; which tends to condensation and contraction,
rather than to circumferential or interstitial deposit, and in contract-
ing, shrinks into a quasi-cartilaginous mass, but rarely calcifies, and
never softens; which  only  causes ulceration of the  mucous mem-
brane very late in the malady; and lastly, which contains scarcely
more cell-growth than the  cicatrix of a gastric  ulcer (p.  203), and
is not associated with the presence  of cancerous deposits in other
organs -,1 when  many (if not  all) of these characters  are simulta-

  1 A decision sometimes scarcely less difficult than that which concerns the
histology of the lesion itself; and respecting which I would suggest that, just as a
Boft or obsolescent secondary deposit of cancer has often (p. 208) been mistaken
for tubercle, so it has perhaps been too readily assumed that hard  or enlarged
lymphatic glands adjoining a lesion of this kind were cancerous. 
232            CIRRHOSIS OF THE STOMACH.
neously present, there need be little hesitation in refusing, to such a
lesion, the name of cancer.
  Of course, to deny the identity of the malady we are discussing
with true gastric cancer by no means requires us to  question all
relation between  the two.  It is scarcely possible to doubt that,
apart from one lesion sometimes imitating the other, as a result of
circumstances incidental to both, there is some close  pathological
connection between them ;  a connection similar to that which, with
equal allowances, may be traced between ulcer and cancer of the
stomach.  Whether  this cirrhotic inflammation is really the ana-
logue of what is termed "fibroid" in other parts  of the body it is
extremely difficult to conjecture.   But it is probable there is no
other gastric  parallel to  this apparently common form of new
growth in most other parts of the body.   And  it is certain that the
whole class of non-malignant tumors of the stomach (implying in
this term any new growth which is fairly protruded from the serous
or mucous coat) quite fails to supply any such deficiency.  Doubt-
less,  in these latter tumors,  as in cancer of the stomach (compare p.
193), the locality of the adventitious structure has a serious influ-
ence on the health and life of the patient;  and, through this,  on its
own size and growth; so that, for  example, there are ample reasons
why it should never approach in this organ  the bulk^or stage it
would acquire in  other {e. g., subcutaneous) tissues.  But until we
know more of the analogy  of these cirrhotic deposits to fibroid, it
is useless to  discuss that relation to cancer  which this  analogy
would imply; or to propound (what there are strong reasons for
conjecturing) the possibility of such deposits, originally non-malig-
nant, being  afterwards developed into cancer.  Nothing short of
careful histories of cases during life, and  still  more careful exam-
inations of the corresponding specimens  after death, in far larger
numbers than are at present at our disposal, can  afford materials
for any safe deductions of this kind.
  The symptoms of these cases vary even beyond the wide  limits
customary in gastric disease.  A careful analysis of those examples
hitherto recorded suggests the following statements.
  In a majority  of instances,  the lesion is  unattended  by any
symptoms whatever; and is only revealed by examination after a
death evidently due to some associated disease.  In most of these
cases, the deposit is small in amount:  regular  and even in its dis-
position relatively to the coats, and to  the surface, of the stomach;
and (in all probability) slow and gradual of access.  Barely, how-
ever, when the lesion is more extensive, it is suggested by what
we may term  circumstantial  symptoms:—for  example, an epigas-
tric tumor, formed by the hard contracted stomach, with a duration
(10 or 15 years), and at an age (20 to 30), such  as are very rare
(pp.  183, 189) in cancer of the stomach.
  A second and  more frequent  class offers what may be termed
inaugural symptoms.  These symptoms  are so precisely those of 
CIRRHOSIS OF  THE STOMACH.
233
severe gastric disturbance generally—anorexia, local pain and ten-
derness, vomiting, and  febrile  reaction—that  they need  not be
described at length: the less so, that they resemble (if not  abso-
lutely merge into) those of an  allied disease, which we shall pre-
sently  allude to  as  suppurative linitis  of the stomach.   Their
sudden  access and gradual  disappearance, followed (as  in  some
cases) by their relapse or reappearance, and by another subsidence,
confirm their import as "inaugural" symptoms; and suggest that
they are produced rather by the rapidity of the deposit, and by the
local  and constitutional reactions thus excited, than by its  mere
amount (or even extent) in the organ.  Such  a view is confirmed
by the records of some  instances of this kind, which have termi-
nated  in death a few weeks after  the  commencement of  their
symptoms;  the necropsy showing a soft albuminous exudation in
large amount.
   In the remaining (and more  frequent) class of cases, the symp-
toms, though doubtless often furthered by the immediate influences
of the deposit itself, really  seem to belong, not  so much to the
lesion,  as to  its sequelae; and  especially to those local  changes
already noticed as often resulting from its progress.  Many of  these
sequelae are  clearly traceable  to a deficiency or failure of the con-
servative process of muscular hypertrophy.  Thus, the contraction
of the deposit sometimes produces  obstruction of the organ, by
constricting the pyloric  valve;  and this  change again, sometimes
provokes dilatation of the whole  gastric  cavity.  In like manner,
whether the stomach be  contracted or dilated, the embarrassment
and degeneration of the muscular substance, and  the consequent
failure of gastric  peristalsis,  which form the frequent (if not the
final) results of the lesion, amount to obstruction (p. 127) scarcely
less serious.  Bulimia,1 and suffocative tightness in the epigastrium,
are thus often associated with the commoner symptoms of gastric
mischief; and vomiting is  distinguishable by its excessive fre-
quency, or by the  enormous quantity, and fermented or semi-putrid
quality, of the substances it expels.  Haematemesis, too, is sometimes
copious and frequent, under circumstances which (as shown by the
necropsy) refer it to a mere congestion of the  mucous membrane,
produced by the deposit itself.   Ulceration of the  mucous mem-
brane,  and  inflammation of  the peritoneal coat,  also bring  their
own train of symptoms, requiring no special mention.  And among
other prominent details,  I can only recall the comparative rarity
of ascites, and the frequency2 of general dropsy, as having much
attracted my notice.
   The diagnosis of this cirrhotic inflammation depends chiefly on

  1 Mentioned here from this apparent association, rather than from its presumably
having so physical an origin.  Many of these cases really involve starvation,  which
renders  bulimia natural enough.  (See remarks on Dilatation.)
  2 Suggesting (see note 1 to p. 228) a careful examination of the venous system
in necropsies of this kind. 
234      SUPPURATIVE  LINITIS  OF THE  STOMACH.

the characteristic features briefly summed up above.  Comparing
these, for example, with those of  cancer, it is obvious  that the
grounds for identifying during  life  the malady  we are considering,
must  be sought chiefly in its  long duration;  in  the subordinate
rank taken by vomiting and hemorrhage; in the infrequency and
lateness of ulceration;  in  the  absence of secondary cancer;  and
(last, but not  least) in the  uniform  gastric thickening (rather than
tumor) which  careful manipulation  finds  in the epigastrium.  To
the latter result of personal observation I  can only add the presence
of great anorexia and intense headache, together with an indis-
tinctness or absence  of local pain  and  tenderness,1 as  sometimes
confirming to  the conjectures thus adducible from the pathology of
the lesion to any individual case.
   The treatment—both dietetic  and  remedial—of these cases cannot
be distinguished, in principle, from that of ulcer or cancer of the
stomach; and  would differ, in practice, so greatly for each instance,
that it is useless to attempt any sketch of it here.  Many of the
subjects of this malady have been either drunkards or dram-drink-
ers :—a fact perhaps confirming that analogy to cirrhosis which we
have derived  exclusively from  the  anatomy of the disease.  How
many, it is  possible to say from  the records at our disposal.   I need
hardly recommend, in such instances, the withdrawal of the alco-
holic poison, and the substitution of tonics; aided (if necessary) by
some  unsuspected preparation  of opium, in gradually diminished
doses.  Apart from the remedies demanded  by the  circumstances
or sequelae of the deposit, perhaps the chief indication of treatment
may be stated to  be—that of  favoring (by diet, drugs, and every
other means in our power) the nutrition of the patient's organism
in general, and the hypertrophy of the muscular coat of his stomach
in particular.
 SUPPURATION OF THE AREOLAR TISSUE, OR SUPPURATIVE LINITIS.

  The disease distinguishable by the above title is more infrequent
(though less obscure) than the preceding; to which, however, some
of its cases closely approximate.  A person, usually from  twenty
to forty years of age,  and previously healthy, is attacked with  vio-
lent pain and tenderness in the region of the stomach, attended by
severe and frequent vomiting, and by high  febrile  reaction.   The
pain and vomiting increase in severity, and the tenderness becomes
so excessive as to suggest peritonitis; the more so, that it  is often
accompanied by  some tympanites—which,  however, like itself,
sometimes differs from that of general peritonitis in being limited to
the epigastrium.  By  and  by, jaundice often comes  on.   In  any

  1 Pointing to such irregular phenomena of innervation as the nature and locality
Of the deposit well explain, or even suggest. 
         SUPPURATIVE  LINITIS OF THE STOMACH.      235

case, the febrile excitement rapidly merges into prostration; which
is  associated with  delirium, and ends in death by coma, in from
forty-eight hours to a few days from the  commencement of the
attack.
  The necropsy of such cases shows that the stomach is many (often
six or seven) times its normal thickness ;  and that its rotten, spongy,
easily-torn substance is infiltered with a purulent fluid, which  is
especially accumulated in  its submucous and muscular coats. The
latter, indeed, is sometimes completely destroyed; and the former
thickened  by the effusion into a  layer many lines  in thickness.
The  peritoneal and  mucous coats  are affected in much the same
subordinate manner, and variable degree, as in the previous malady.
The  morbid condition of the former ranges, from a mere  dulness
or roughness  of ^surface, to a complete (though usually limited)
peritonitis; which  greatly increases  the thickness of the  serous
membrane; involves the stomach and adjacent viscera; and effuses
a substance varying from a solid false membrane, to a sero-purulent
fluid, by every  conceivable gradation of thickness.   That of the
latter combines, with the same purulent infiltration and rotten con-
dition  which engages  the submucous tissue, a marked change  in
the color of the  free mucous surface of the stomach.   This change
merges from mere redness, in points  or patches of variable size,  to
an intensely injected or even purplish hue, here and there suggest-
ing (if not amounting to) downright gangrene.  In cases of longer
standing, all of  these appearances are sometimes modified. The
mucous membrane either sloughs or ulcerates at varies parts of its
surface; and the  puriform  contents of the  submucous tissue are
thus set free in the interior of the  gastric cavity.   Hence, when
such a stomach is laid open, the mucous membrane is seen to be
deficient over patches of variable number and size.  These patches
often form the orifices of fistulous communications with the suppu-
rating areolar and muscular tissue; so that a  probe passed into
one of them thence enters  a kind of irregular spongy cavity, which
sometimes occupies most  of the interval between the serous and
mucous coats.   In other cases, the suppurating areolar and muscular
coats are  less  extensively affected; being occupied by a  chain  of
small  scattered  abscesses, more or  fewer  of which have burst
through correspondingly small and distant orifices in the  mucous
membrane.  In either case, the determination towards the mucous
membrane seems generally to spare the serous membrane any very
severe or extensive peritonitis.
  The modifications occasionally seen in these appearances suggest
that  this suppurative malady merges, by no very distinct  grada-
tions, into various other diseases.   That, in a circumscribed form,
it  may occasionally inaugurate an ordinary ulcer, perhaps suffi-
ciently appears from the above description.   But such  a commence-
ment of gastric ulcer is very rare; the depth to which the suppu-
ration extends being generally quite as adverse to its ending by 
236
TUMORS OF THE STOMACH.
so favorable an event, as is its lateral extension.  To peritonitis,
its relation is rarely more than that of an imitation, which careful
examination generally suffices  to  dispel.   To pyasmia, it is more
closely connected.  For though, as an element of general pyaemia,
its occurrence  is (to  say the least) extremely infrequent, yet the
nature and  situation of the lesion claim for it, in some sense, this
title.  And Dittrich1  mentions  a less copious effusion of this  kind
as being generally found (in connection with a similar infiltration
of other segments of the alimentary canal) during a fatal epidemic
of puerperal fever at Prag.  Any more specific relation to phlebitis
we cannot at present conjecture.
  But it is more interesting to point out the frequency with which
this suppurative linitis is allied  to the  preceding  plastic inflamma-
tion of the same tissues; as an  absolute mixture of the two lesions
in varying proportions.  Occasionally  structures  suspiciously like
pus-corpuscles  may be found sparingly diffused  throughout  the
dense white lymph, or tougher fibres, of the cirrhotic inflammation.
Occasionally, according to Dittrich,2 the margins of the suppurative
cavities in the  areolar tissue are surrounded  by a dense mass of
fibroid infiltration, which he regards as either of simultaneous effu-
sion, or of  reactive import.  But I should conjecture both of these
conditions to be less frequent than an admixture I have sometimes
seen, in which the  periphery of a large solid mass of  this fibroid
character was soaked  in an extensive  purulent infiltration of the
adjacent areolar tissue.   Fully conceding the equivalent character
of this admixture, I can hardly frame any other explanation of  its
occurrence  than  that suggested by  the clinical  history  of  these
cases ; namely,  a suppuration of the edges of a cirrhotic mass, itself
deposited in the organ long before.
                           TUMORS.

  In  the stomach, the word "•tumor" comprehends a group of dis-
eases  far from co-extensive with those  associated under the same
title in  the case of many other parts of the body.  For while the
stomach perhaps illustrates a general rule in the fact, that  it is its
connective or areolar tissue which is the usual seat of adventitious
deposits or  after-growths,  it is certain that in this  membranous
organ (as in the  intestine) such growths much more  frequently
affect the flattened or extended  form than, for example, do similar
formations in the subcutaneous areolar tissue.   Hence a large per-
centage of those diseases which would otherwise be treated of under
the above title, fall under that more natural and  accurate arrange-
ment  which is implied in grouping them as to their symptoms and
appearances, rather  than their mere outline or form:  the group
1 Schmidt's " Jahrbuecher," Bd. 72, s. 303.
2  Op. cit. 
TUMORS OF  THE STOMACH.             237
" tumors" being  diminished  by the subtraction of a large majority
of the cancerous, if not of the fibroid (see p. 232), after-growths.
   The very diverse cases included in  the  phrase " tumors of the
stomach" are therefore but  a minority of the deposits which pro-
duce them.  And just as we should find it difficult (if not impossi-
ble) to define the precise amount of outgrowth or  projection from
the level of the gastric coats,  which would entitle a deposit to such
a title; so, on the other hand, the histology of many a  pedunculated
gastric tumor would  refer it to ordinary  cancer of the stomach.
But, though diverse in nature and  histology, the  group of after-
growths  which claim our attention as tumors are practically asso-
ciated, not only by their outward form, but in  some degree by their
development and  history.   Any deposit which  is circumscribed
and bulky enough, and which projects from the  serous or mucous
surface of the organ, is  of course a swelling or tumor.  But the
majority of such swellings possess a distinct  peduncle.  And this
fact, which seems to express a tendency of all circumscribed gastric
deposits  to acquire this form, appears to depend  on the original
situation of these deposits;  which for  the  most  part are not only
limited in their lateral  extent, but spring from the areolar tissue of
the stomach at such a depth, as to belong  more or less exclusively
to the serous or mucous membrane.  Hence, as it increases in size,
the deposit protrudes before it that gastric lamina which can least
resist it: and thus, in  anatomical language, " acquires a covering"
from the neighboring serous or mucous membrane.  Nothing seems
more certain, than that this progress towards either surface, as well
as the tendency to pedunculation, are essentially independent of the
nature of the tumor itself.  Without at all denying that, as regards
its subsequent stages  and its event, a small villous cancer of the
gastric mucous membrane  differs from an equally polypoid fatty
tumor, just as much as  it  does in its  histology, I would suggest
that the clue to a number of the details of the two growths may be
found  in the above circumstances of the origin and progress com-
mon to both.  Indeed,  the resemblance is rendered doubly impor-
tant by the fact, that up to a  certain date they often have precisely
the same symptoms; the gravity of which, by the way, obliges us
to interpret the contrast between "malignant" and  "benignant in a
very qualified sense as applied to gastric tumor (compare p. 232).
   Comparing  the  external and internal—the peritoneal and the
mucous—tumors, it may, I think, be laid down, that the former are
not only rarer, but that they are (as a rule) smaller, less distinctly
or longly pedunculated, and  more frequently fibroid.  Sometimes,
indeed, their structure so exactly approaches that of an old inflam-
matory deposit, that it is impossible to avoid referring them to this
origin ; in spite of their considerable size, and (for example ovoid)
shape.   Indeed, referring to what has been (p. 124) specified con-
cerning the accretion or drawing out of recent peritoneal  lymph;
and connecting this with the dull appearance, and  the complete 
238
TUMORS  OF THE  STOMACH.
agglutination, which are the minimum and maximum relics of
peritonitis on this and other parts of the alimentary tube—it is im-
possible to doubt that an inflammatory exudation in the peritoneum
is subject to even more numerous contingencies than is a similar
deposit in the  pleura or pericardium.  But more  frequently, the
history of the case, and  the  histology of the specimen, concur to
trace  its origin  into the subserous  areolar tissue:  into which, for
instance, its stalk or peduncle visibly passes; often greatly distort-
ing the subjacent part of the longitudinal (and even the transverse)
muscular layer.
  The symptoms of such external tumors are extremely uncertain.
A small  tumor is often unattended by any symptoms whatever; or
is only signalized, in rare instances, by obstinate and violent vomit-
ing.   A  large  tumor, besides  the swelling which, if favorably
placed, it allows to be detected in the epigastric region, generally
gives rise to greater embarrassment of the stomach.  And of course
its nature, and  the rapidity of its growth,  often  add their  charac-
teristics ;  in the shape of pain, cachexia, adhesive peritonitis, and a
variety of other  circumstances  closely analogous to those  already
traced in describing the more diffuse cancerous and non-cancerous
deposits respectively.
  As regards the internal tumors, the fatty generally spring  from
nearly the centre of the " tunica nervea."   The cancerous (which
usually have a complexly folded or " villous" surface) are commoner
than the simple fibroid.   And all are much  more disposed to the
polypoid  form than  the preceding;  their stalks being not only
generally narrower and longer, but  appearing to be specifically so,
in proportion to the rapidity of their growth and  the softness of
their tissue, rather than to any other characters their bodies possess.
  In respect to symptoms it need only be  said—that these tumors
of the gastric cavity produce, on the  whole, much  more injurious
mechanical  effects than  those which  are placed externally: that
they disturb digestion, and provoke  vomiting, more  frequently and
seriously; besides at times giving rise to severe pain in the epigas-
trium, or even  to hemorrhage1  from  the  stomach.  Of course a
pyloric situation is, on every account, the worst they can have:
even a small tumor here being capable, not only of  bringing about
a very serious obstruction (with its sequelae of hypertrophy, dilata-
tion, vomiting,  &c.) of  the  narrow  calibre which the  stomach
possesses at this part; but, as its stalk elongates, of passing into
the first part of the duodenum, and superadding a great disturb-
ance of this segment of  the  intestine.  Still, apart  from these cir-
cumstances (which it is obvious are  scarcely more than "separable

  1 A hemorrhage which may be referred to an active (afflux) or passive (obstruc-
tive) congestion ; and to that mechanical injury to its neighborhood often brought
about by the tumor when it is forcibly acted  on by the muscular contractions of
the stomach, but of which it would be idle to attempt any stricter classification
from the cases hitherto recorded. 
             HYPERTROPHY  OF THE  STOMACH.          239

accidents" of these tumors), they may be present for a considerable
time, and may acquire a considerable  size, without giving rise to
the remotest  suspicion of their existence.
                        HYPERTROPHY.

  Hypertrophy of the stomach—a state which we  have already
described as  incident to the muscular coat  of this organ in ulcer
(p. 125),  cancer (p. 210), and cirrhotic inflammation  (p. 225);  and
a terrn which we have refused (p. 227) to  the  gastric disease to
which it  is oftenest applied—only remains to be  inquired into as
an independent or substantive malady.
  To the question—Whether that condition of over-nourishment
implied by "hypertrophy" ever constitutes such a malady?—it can
only be answered; that our existing information  affords no suffi-
cient evidence of anything which could properly be conceived of
under this title.   It is true that some stomachs (especially, I think,
those of old and gluttonous people) are much  larger or thicker
than others.  But, to say nothing of our ignorance  of the precise
original  dimensions of these stomachs, or of the exact range of
size and  thickness possessed  by this and other organs in different
individuals  (p. 18), size and  thickness are  so  seldom  increased
simultaneously, and the  gastric coats are usually so much softer
and more flabby than  those of the  healthy organ,  that it is ex-
tremely doubtful whether .the condition is one of true hypertrophy
or over-nourishment.   The organ is larger: because it is either too
violently, frequently, or continually stretched, on the  one hand; or
because it has lost the tone which should enable it to resume and
retain its proper dimensions in the  intervals of its distension with
food, on the other.  But it is no more really hypertrophied than
the enlarged  and pendulous abdomen, to the undue bulk of which
it so often contributes.
  Nor can any more limited hypertrophy of a single gastric coat
be verified by observation.  In  the  mucous membrane  there is
rarely any appearance of such a process; or, if so, the  swelling or
thickening which  suggest hypertrophy are  easily shown by the
microscope to be associated with distortion (or even destruction) of
its  tubes and their contents (p. 224) by a deposit  between (and
external  to) these structures.  In the submucous areolar tissue, any
apparent overgrowth is also shown by a careful inspection to be a
new deposit,  associated with injury to both the structure and func-
tion (p. 29) of the original tissue.  And even in the muscular coat,
that true hypertrophy which is so often present as an incident of
gastric disease, is always (so far as I am aware) a curative effort of
Nature;  itself the result of those violent and prolonged efforts by
which this coat strives to overcome an obstruction.
  The only exceptions to such a rule may perhaps  be found in a 
240
ATROPHY OF  THE STOMACH.
few cases on record; in which life has been destroyed by a violent
and continuous vomiting of several days' or weeks' duration ;  and
the necropsy  has subsequently  shown  nothing unusual  in  any
organ, save a white, hard, contracted state of the pyloric region of
the stomach:—a  condition  which,  when closely  inspected,  has
turned out to be independent of all  adventitious growth or exu-
dation.
  But while most of these cases strongly suggest a mere contraction
of the muscular tunic, without  any  superadded hypertrophy or
increase of its bulk—a passive  contraction, such as  may well have
been the result of that empty state in which the organ was con-
stantly kept during the  last few days of life—the slight  pyloric
thickening verified in  the extremely rare remainder seems to be
sufficiently explained by the physiology of  vomiting, as already
described.   That  the  muscular  apparatus concerned  in  this  act
(p. 57) should in some degree obey the ordinary law of nutrition,
and increase in proportion to its use, would  be by no means  sur-
prising ;—the less so, that the pyloric  closure generally present in
vomiting is in some sense itself an obstruction of the organ.  That
such an hypertrophy should be so moderate,  and so infrequent, as
it certainly seems to be,  is scarcely more surprising, when we  re-
flect on the  prostration  which vomiting brings  about in  all the
organs by which it is  effected;  as well as on  the  cause—a more
or less direct injury of the centre of this  co-ordinate nervous act—
to which these mysterious and  fatal vomitings must undoubtedly
be ascribed.
                           ATROPHY.

  Atrophy, the condition antagonistic to the  preceding, seems to
shrink into equally scanty dimensions when examined by the light
of experience.  Like hypertrophy, it has already  (pp. 172, 227),
been noticed as an incident in the structural maladies of the stomach;
and especially as being produced by interstitial deposits, which, by
compressing the original tissues, and thus embarrassing or destroy-
ing their vascular and nervous arrangements, cause such a degene-
ration (and even  disappearance) of these tissues, as  implies (and
indeed expresses) the completest atrophy of their substance.  And
there are indications of  another (and more independent1) kind of
atrophy which is produced in the unstriped muscular tunic of the
stomach by lesions involving  its mere  disuse.  But  while,  in this
subordinate form,  atrophy of the stomach is of grave pathological
import, as expressing, and inaugurating, changes of the most serious
kind, we can scarcely accord it the nosological rank of a substan-

  1 An independence which is of course better seen in the intestine, as the result
of a more distant lesion ; but is in exact parallelism with the atrophy of a disused
voluntary muscle. 
ATROPHY OF THE STOMACH.
241
tive or independent malady.  Indeed, I think we might go further
and say that the stomach appears to enjoy something like an im-
munity from this process; or at any rate that a marked degree of
atrophy, chiefly or exclusively involving  this organ, is one of the
very rarest lesions  met with in the human body.
  That,  in  atrophy of the  whole organism, the  stomach  should
suffer inclusively—in other words, should decrease  in  bulk and
weight  to the extent verified  by  Bidder and Schmidt1  for the
mucous membranes of the  alimentary  canal in animals starved to
death (about 31 per cent.)—is only what might be expected.  But
there are appearances of a peculiar resistance to even this inclusive
atrophy on  the part of the  stomach, as contrasted with  the intes-
tines.  At least I  am justified  in inferring as much from various
instances, both of disease2 and of chronic starvation,3 in which the
latter segments of  the digestive tube have been reduced  to  an ex-
treme tenuity,4 in the absence of any corresponding atrophy of the
stomach.
  Of the records of extreme atrophy of the stomach, almost all
exactly  correspond with what  I have myself  observed in less
marked  instances  of  the same  appearance.   A  fjew of them are
associated with minor degrees of that softening, already referred to
as being chiefly of post-mortem occurrence, and as especially marked
in childhood.  The majority have been found in cases of death by
pulmonary  consumption, or other disorders generally implying
extreme emaciation ; disorders which (you will recollect) have the
same general connection with the greater degrees of gastric solu-
tion witnessed in the dead body.
  What kind of a malady then do such considerations leave us ?
Or  what more can  we say of these cases, than that they are in great
degree explained as instances of the stomach sharing in a general
process of emaciation and  atrophy, which often  robs the whole
body of two-thirds of its weight, and  which is probably5 capable
of reducing the substance of this and other digestive mucous mem-
branes to scarcely  less than half their original bulk or quantity.
Adding to these facts the contingencies of exfoliation and solution
(p.  75) which observation shows to be sometimes  mistakable for
increased tenuity,  and to be peculiarly frequent and marked  in
the very  class of maladies  associated with such marasmus, I con-

  1 " Die Verdauungssafte und der Stoffwechsel," p. 331.
  2 Abercrombie, " Diseases of the Stomach and other Abdominal Viscera," 1830,
p. 336.
  s Donovan, "Dublin Medical Press,"  1848, p. 66 ; also my own observations in
cases of gastric ulcer.
  4 In a far less striking degree, such tenuity is illustrated by several-instances
in which I have distinctly felt the several outlines, and the consistence, of scybala
through the walls of both the colon and.the belly during life.  Most of these were
cases'of gastric ulceration, and have completely recovered.
  6 Compare Bidder and Schmidt, loc. cit.
       16 
242
DILATATION OF THE STOMACH.
fess that all the phenomena of atrophy of the stomach  at  present
known seem to me quite insufficient to establish its claims  to rank
as a substantive gastric disease.
                          DILATATION.

  It is evident that dilatation of the stomach can only be regarded
as morbid, by so much as it exceeds that degree and  duration of
distension which this organ  has necessarily to undergo from the
reception of food.  And since  large variations in  this respect are
quite compatible with health, while the size of the stomach is itself
subject to considerable difference in different individuals (p. 18), it
is obvious that we have no precise means of determining what is,
or is not, abnormal dilatation.  While we have noticed (p. 73) that
the appearance  itself, as seen  in  necropsies,  is  often  somewhat
equivocal.   Hence, for practical purposes, we are obliged to restrict
our attention to what are rather  the  best marked, than the only
instances of this condition found in the dead  body.
  Bestricted to* these  limits, dilatation of the  stomach  claims our
notice under two aspects.  On the one hand, it  is incidental to vari-
ous gastric maladies.   On the  other  hand,  it is  occasionally the
symptom (or rather expression) of a mysterious and fatal disease,
which is chiefly or exclusively concerned with  the stomach.  These
two varieties  may be  distinguished as secondary and  primary, or
casual and'idiopathic, dilatation of the stomach respectively.  But
while such terms are certainly convenient, we must recollect that
they are scarcely accurate; since, however diverse in their nature,
the conditions they represent merge into each  other by numerous
gradations of admixture.
  The diseases  to which dilatation is incident have already been
mentioned.   In ulcer (p. 126), in  cancer (p.  211), and  in cirrhotic
inflammation (p. 225), we have had occasion to notice, not only the
occurrence of dilatation, but also the circumstances by which  it is
specially furthered and restrained.  Among these we have particu-
larly noticed  the state  of muscular hypertrophy, as one which  is,
not so much the antagonist of dilatation, as its  natural prophylactic
(so to speak): an effort of nature  to stave off'  dilatation—an effort
which, if successful, prevents it altogether;  and if not, is yet capa-
ble of diminishing its worst effects, and limiting  its increase, by
being associated with it.
   Becalling these incidental dilatations so far as to enumerate the
conditions under which they occur, I would suggest the following
conclusions:—
   1.  Dilatation  of the stomach is produced by obstruction or occlu-
sion  of  its calibre.  This  proposition, which {mutatis mutandis)
holds good, as you are aware, of the whole  intestinal tube,  is well
illustrated by the frequent results of scirrhus of the pylorus, and 
DILATATION OF  THE STOMACH.
243
of contracted scars of gastric ulcers; two lesions which give rise to
what are, on the whole, the most frequent and marked of gastric
dilatations.  In minor degrees, such gastric enlargements are very
common incidents of both of these maladies.   And even the enor-
mous1  dilatations represented by  a gastric capacity of twenty or
thirty  pints are usually instances of this kind.
   2. Dilatation is brought about by the mere destruction of any
segment of the gastric muscular coat.  Thus the removal of a large
ring of this tunic, by an  ulceration affecting the circular form, is
pretty sure to give rise to a dilatation of the organ behind this loss
of continuity.  And in some cases it really seems as though a mere
embarrassment of peristalsis, by a lesion not  destroying any  con-
siderable amount of the muscular tissue, produced analogous effects
(p. 126).
   3. Closely akin to the dilatation brought about by destruction
or removal, is that produced  by injury, of  the muscular coat (and
especially by the injury of interstitial deposit), as exemplified in
many  cases of scirrhus.   Here the muscular fibres, compressed by
the hard cancerous growth which surrounds their bundles, are dis-
torted  in  their  course,  deprived  of their supply of blood,  and
embarrassed in their action, if not indeed absolutely incapacitated
for all contraction and movement.   Under such circumstances, any
co-ordinate and effective propulsion is almost as much out of their
power as if they were absolutely destroyed.  Hence the affective
part no longer forwards its contents with the necessary energy and
regularity: and  their accumulation behind the seat of this dimin-
ished or embarrassed peristalsis gives rise to dilatation, differing in
little save its degree from that which is produced  by the narrowing
or occlusion of a similar segment of the stomach.
   4. The universal  dilatation sometimes seen in cirrhotic inflam-
mation is distinguishable from  this last variety in the fact, that it
is produced  by a more general deposit in the organ;  and hence
that it engages, not only those parts  of the  stomach which lie
behind the injured muscular fibres, but also those  parts which
correspond to  these fibres  themselves.   It  is  possible that this
dilatation is sometimes (at least in part) the result of a paralysis
(p. 69) of the muscular coat, through nervous tissues which them-
selves share in the state  producing the deposit.  But  it is  more
probably connected with the situation, and the consistence, of the
inflammatory effusion.  And it is certain, both  that it is mingled
with various grades of hypertrophy, and that it rarely gives rise
to such excessive enlargement of the organ as is seen in the above
forms  of dilatation, which engage the  healthy  segments of the
stomach above (or  behind) the lesions  by which they  are condi-
tionated.

  1 Even these are probably often understated, for want of the precaution of accu-
rately filling such stomach, at the time of the necropsy, instead of merely emptying
and measuring their casual contents. 
244
DILATATION OF  THE STOMACH.
  As, in all these incidental forms of dilatation, the enlargement
is  opposed and restrained by hypertrophy, the conditions which
chiefly regulate the latter state have  an important influence Upon
the former.  And conversely, while it is of great practical import-
ance to  remember that the completeness of curative hypertrophy
varies, other things being equal, chiefly with the activity of that
nutrition (both local  and general) by means  of which  the  over-
taxed muscle has to retain its effective  force, and to  augment its
bulk and power; it must not be f6rgotton that there  are marked
indications of dilatation itself regulating hypertrophy, by a direct
and immediate influence.  And  it is chiefly by  considering the
mutual relations of these two states that we gain  the clue to their
innumerable combinations in diff'erent cases.
  A careful analysis of the dilatations incident to the three diseases
above mentioned (p. 242) tends to show that, in the production of
hypertrophy, the rate or  rapidity with which the  deposit involves
the gastric tissues is an  important element: so  that, for example,
the same obstruction which, if of sudden production, brings about
great dilatation, will, when of slower development, result in a much
smaller  degree of dilatation,  by permitting a corresponding degree
of the antagonist hypertrophy.
  It may perhaps be suggested, that this relation admits of a very
simple explanation:—that inasmuch as the process of hypertrophy
probably implies, not merely an  exalted nutrition of the original
fibres, but  also a formal development  of new  ones, it  may well
require  a certain  time  for its production in both  striped  and un-
striped  muscle.   But it  is obvious  that this is but a vague and
partial way of explaining the fact: and that, assuming its accuracy
and completeness, all cases in which  the two states concur ought
to be hypertrophied in exact proportion to their duration.  While
we have seen that, not only does  no such rule obtain, but that its
reversal  would  more  nearly correspond  with  the facts observed
(p. 225).
  A more careful consideration seems to show  that the influence
of rapidity of deposit in opposing hypertrophy is mainly due to
the suddenness and amount of the dilatation it  brings about.  In
cirrhotic inflammation it is  certainly possible  that this extreme
and rapid dilatation is  sometimes permitted by a morbid condition
of the nerves of the stomach—a condition itself capable of opposing
hypertrophy by the influence of these nerves on  the  nutrition of
the muscular coat.  But  as regards that healthier type of dilatation
which is exemplified by the obstruction of a scirrhus, or a cicatrix,
exclusively involving  the pylorus, we may find a more  probable
explanation in a law of muscular contractility.   Just as the sudden
application of a heavy weight to the end of a voluntary muscle1
not only elongates its fibres,  but  utterly  exhausts  them of all con-

   1 Valentin's "Text Book of Physiology," § 1357. Renshaw, London, 1853. 
DILATATION OF THE STOMACH.
245
 tractile power;  or just as the enormous1 distension of an occluded
 intestine soon exhausts and annihilates2 the writhing contractions
 by which its muscular coat  at first strives to propel its contents
 past the obstacle;  so  it  seems probable that a rapid  dilatation of
 the stomach may destroy the operancy of its muscular fibres—not
 only putting them "hors de combat11 by  stretching, but suspending
 those nutritive changes which are necessary to their contractility,
 and are expressed  by their  contraction.   How far each of these
 effects is " physical" or " vital" it is of little use to inquire.  For the
 antithesis is too clumsy to frame a  dilemma;  and too  inaccurate
 even to probe the  facts, which it would obviously be  unable to
 refute.
    But whatever its exact nature, it  can scarcely  be doubted that
 the muscular paralysis present in such dilatations of the stomach
 is closely related to the paralysis which  constitutes one of the chief
 elements of the next  class.: and that, in so far, it forms the  link
 between the incidental and idiopathic dilatations  of the stomach.
 And for these  latter, in  spite of their  rarity, I must particularly
 claim your attention;  not merely from  their pathological interest,
 but also from their practical bearing upon all the  derangements of
 this important organ.
    It occasionally happens, that a patient recovering  from fever is
 suddenly seized with intense pain  in the belly;  which becomes
 somewhat tympanitic, and perhaps tender to pressure, though not
 otherwise suggestive  of  peritonitis.   But  even before that brief
 lapse of time which would often  be requisite fully to develop  the
 local symptoms of the latter disease, he either dies  of extreme pros-
' tration, or, as in most  cases (in all I have seen) recovers with extra-
 ordinary rapidity.
    In alluding to the cause of such  intense symptoms,  you will
 hardly  suspect  me  of overlooking a contingency so common as
 perforation  of the' ulcerated intestine in tj'-phoid fever; or even as
 that minor degree of  this event (leakage and inflammation of the
 peritoneal base  of typhoid ulcers) which, in the exhaustion conse-
 quent on fever,  sometimes suffices to cause death, and  might elude
 a slovenly dissector.  But though I  do not ask you to accept  my
 diagnosis that in the cases I have seen,  no  perforation was present,
 or to overlook the circumstance that their successful treatment  (by
 opium,  stimulants, and local warmth) happily rendered all verifica-
 tion of  this diagnosis impossible; I can state two facts  which put
 such an explanation  out of court.   (1.) One or two of the cases
 were unmistakable examples of the typhus (or  non-ulcerous fever.
 And (2) there are authentic records of other cases, in which, after

   1  A similar paralysis  seems to occur in the rumen of cattle, as the result of a
 surfeit of rich saccharine grasses, which ferment  and distend the organ with gases
 to a degree said to be often fatal if not relieved by puncture.
   2 The author " On the Physiology of Intestinal Obstruction," Medical Gazette,
 1849. 
246
DILATATION OF  THE STOMACH.
death from this brief disease or paroxysm, a necropsy has shown
no structural lesion of any kind, to the most sedulous and skilful
examination, save perhaps  a pale  and  relaxed  condition  of a
variable length of intestine.
  In rare instances, after symptoms otherwise closely akin to these
have  ended in death, the extreme epigastric pain  and distension
which have pointed to  the  stomach as  the part chiefly affected
during life, are confirmed by  its inspection after death.  The organ
is found so enormously dilated as to occupy the greater part of the
belly, and conceal the pale and contracted intestines.   Its contents
are often verified  as formed  of matters which were taken into it
many days  before, and which  have since undergone  a  degree of
decomposition proportionate to the duration of their sojourn  in its
cavity.  The latter fact obviously proves (p. 66) a derangement, if
not a suppression, of the process of secretion proper  to the stomach.
The mucous membrane, apart from congestion of moderate degree
and doubtful  import, shows  nothing  save such  an imbibition (of
color, &c.) from  the gastric contents, as also seems  in  part (p. 73)
equivocal.   And the  muscular coat,  always of course extremely
thinned, is sometimes here and there so stretched, as  to suggest a
forcible derangement of its layers into a network of  scattered fibres
—a network which is only filled up into a continuous expanse by
the extension, over its interstices,  of the other (and especially the
areolar) tunics of the organ.
  In  these acute cases  of gastric  dilatation, the  malady is  some-
times clearly traceable to an  excess of food: in short,  to a surfeit,
such  as the voracity natural  to  persons convalescent  from fevers
and  similar disorders (a condition associated with many of  these
cases) only  too  often induces.   But  in other instances, no such
cause is  present.  And  in others, somewhat less  rapid  in  their
course, but  equally obscure in  their origin, we may trace a  kind
of intermediate gradation  as respects the important  symptom  of
vomiting;  which, usually  absent  throughout in the  above  acute
instances, and  present  (with emaciation) throughout the  many
months' duration of the  more chronic ones, ushers  in  the malady
by one or two fits, thereafter  remaining absent.
  Here then is a class of dilatations, of which these commoner and
more typical instances are marked by symptoms, such as permit
little  doubt, either of their nature  in general, or of  their  diagnosis
in particular.  Pain, though variable, is usually excessive.  Tender-
ness or soreness is scanty, or  even  absent.  Percussion and auscul-
tation map out the enormously distended stomach (p. 20), and show
that it occupies the front  of the whole  abdominal cavity.   The
walls of the belly are themselves relaxed, stagnant, and motionless;
and  (especially  in chronic instances  where emaciation assists)  so
thinned as to allow the same  statement to be made of the muscular
coat of the stomach itself.   Vomiting (as you would  expect from 
DILATATION  OF  THE STOMACH.
247
this condition of the parts by which it would have to be effected1)
is either reduced to a minimum, or is absent altogether.  Lastly,
partial or total anorexia, and  extreme prostration (as shown by the
usual constitutional symptoms of this state) complete the characters
of such  dilatation; and  thus make  up an outline, which, on con-
sideration, you will find tolerably excludes the diagnosis of every
other disease; as it certainly  does that of  the other (and more fre-
quent) class of enlargements of the stomach.
  The pathology of the  malady admits (I think) of but one expla-
nation ;  to  which, obscure and  vague as  it certainly is, all these
marked  symptoms converge (as  it were) with remarkable unanimity
and distinctness.  It is  evidently a lesion of the  nervous tissues
connected with the  stomach ;—a lesion which,  whether structural
in the sense of being recognizable by the aided or unaided eye, or
merely what our ignorance conveniently terms " functional," pros-
trates (often apparently paralyzes) the stomach in all its tissues, and
in all their  offices.  Its  mucous and muscular coats, its secretion
and motion respectively, are alike interfered with : nay, more, those
muscles of  the  locomotive system which are  linked with the con-
tractile  tissues of the stomach  in the ordinary act of vomiting are
also affected.  In short, it is not merely the  sympathetic, but the
cerebro-spinal centre, which is  injured or deranged;—a fact which
seems to concur with a violent pain and general  prostration in
pointing to the pre-vertebral  centre (or solar plexus) of the former,
or  to the pneumogastric trunks of the latter, as the parts chiefly
affected.
   The symptoms which  betray the  more  numerous class of inci-
dental dilatations differ, not  only according  to the nature of the
original malady on which they are engrafted, but according to the
amount  of the dilatation itself; and, still  more, according to the
degree of hypertrophy with which it is associated.
   But, in most instances, the symptoms developed are simple enough.
For it is chiefly in the  non-ulcerated  cancer, the cicatrized  ulcer,
and the obscure cirrhotic inflammation, that these dilatations occur:
in other words, in lesions of the stomach which are themselves for
the time comparatively quiescent and latent.2

  1 Compare p. 57 et seq.
  2 It is, therefore, not surprising  to find there exists the closest resemblance,
clinically speaking, between  these cases of hypertrophy and  dilatation of the
stomach, however produced.   The mere physiognomy of the patient is to me  so
characteristic, as to be generally recognized at a glance.  And the appearance of
the belly, even as seen prior to careful percussion and palpation, is, for the most
part, equally  characteristic.  I cannot attempt verbally to distinguish the  thin,
sharp, fleshless outlines, and  the peculiar color, which are perhaps the only defi-
nable elements of the physiognomy, from other forms of facial  emaciation.  But
I would suggest that it receives a clue (rather than a summary) in the statement
that there is a waste of muscular substance in the face disproportionate to the loss
of its fatty and subcutaneous texures. In the belly, what is recognized by the.
eye is perhaps more describable. The wall of the belly, thinned but not softened,
sits closely on the  subjacent organs; the outlines  of which are almost revealed 
248
DILATATION OF THE STOMACH.
  Enormous dilatation of the  organ, as shown by a physical ex-
amination of the belly, is of course the first and most important of
these symptoms.  With it, too, are usually associated others scarcely
less characteristic.  The vomiting present is so peculiar as almost
to be specific of the malady.  Coming on every two or three days,
and often leaving the patient free from nausea  in its intervals, it
expels from the enormous stomach, contents the quantity and quality
of which conclusively show that  they  have  been gradually accu-
mulating ever since the last attack.  The liquid (one, two,  or even
three gallons) sometimes thus discharged, is distinguished from any
ordinary vomit, not only by its quantity, but by its  horribly fetid,
putrescent odor, its black color, its  spumous yeasty look, and the
confer void growths (generally sarcinae, and  often  torulse cerevisise)
which it yields to a microscopic examination.  And in spite of this
enormous vomiting, the appetite of the patient is generally good;
often quite voracious:  a condition obviously referable to the same
cause as the debility, emaciation, or  febrile reaction frequently
present—namely, to that starvation  which is implied in the failure
of the stomach to propel  its contents into the duodenum.   Indeed,
besides this kind of  inanition, we may justifiably  presume  that
there is a certain degree of apepsia, or  failure of  the gastric func-
tions :  a failure  which, perhaps  in part inherent to the  original
malady that  provokes the dilatation, or even to  the lesion which
extreme dilatation may practically be regarded  as amounting to, is
much more attributable  to  the  decomposition  of the food itself.
Be  this as it may,  the unfortunate sufferer, after  voiding  the con-
tents of the stomach, is irresistibly impelled  to recommence filling
the organ: and  gradually adding one  meal  to another, at length
brings about a  state of repletion, and  a sense  of pain, weight, or
distension, which are the preludes to  a new attack of vomiting,
ending as before.  Of course the intervals at  which these fits recur
are materially influenced  by the degree of gastric occlusion, as well
as of hypertrophy and dilatation, present; and by the quantity (and
even quality) of the food which the patient consumes.   And promi-
nent among the  symptoms of such  a state as the  act of vomiting
certainly is, perhaps  it may still be said  to occur with  less  fre-
quency, and (as it were) with more reluctance, than might be ex-
pected from the readiness  with which this act seems to accompany
other gastric derangements.  If  this be so,  the  two  classes  into
which we  have divided gastric dilatation meet at more than one
point of contact: merging into each other,  not only by the  analogy
already (p. 244) stated; but  also by their symptoms.  For, just as
there are chronic cases in which  the gastric paralysis without oc-

through this covering.  Especially is this the case with the stomach, the curves
of which are sometimes recognizable with little or no aid from percussion or palpa-
tion ; and still oftener  define, by a slow, powerful peristalsis, the  force and situ-
ation of which no other segment of the canal can possibly imitate, the nature and
even the site of the original gastric lesion. 
SECONDARY INFLAMMATION.
249
elusion  which forms the  first class, is  associated with occasional
vomiting;  so the frequent  (but variable)  appearances of gastric
paralysis seen in the obstructive dilatation are often associated,
towards the close of the disease, with an increased rarity and diffi-
culty of vomiting;—which, indeed,  seems to  be sometimes sup-
pressed during the last few days of life.
  The preceding remarks on the nature and symptoms of gastric
dilatation are such as to  dispense with any detailed description of
its treatment. For what,  indeed, in these distressing cases, can we
hope to accomplish ?  In many instances, absolutely nothing;  in
others, temporary relief may be given to the patient by a proper
system of diet and of stimulants, in small and frequent doses, so as
specially to avoid all distension of the organ.  Systematic inunction
of the belly with olive oil, or (if the patient do not greatly object
to its smell) with, cod-liver oil, often affords relief, both by its local
effect on. the muscular wall of the belly, and doubtless by its nutri-
tive absorption.   Careful attention to the  warmth of the patient's
body is also desirable; especially' where sedatives are  being admi-
nistered.   To this it may  be added, that pain indicates opium ; that
inanition suggests nourishing enemata (seep.  151); and that the
distension produced by decomposition of the food within the stomach
is sometimes mitigated by such remedies  as the sulphite of soda.
  But on all these points I may refer to what has been already said
in speaking of those diseases by which gastric dilatation is so often
caused and accompanied.
                   SECONDARY INFLAMMATION.

   I  may end this fragmentary discourse by alluding to a curious
pathological  condition;  hitherto, I  believe, unnoticed, save as a
casual detail of the isolated records and preparations from which I
have collected so much of  my information respecting these rarer
diseases of the stomach.
   In various lesions of the stomach and intestines, death is some-
times immediately preceded (if not brought about) by a violent in-
flammation of some part of the alimentary  tract, at a distance from
the original lesion itself.' Vivid and continuous redness, often merg-
ing, from intense congestion into a downright blackness suggestive
of gangrene, sometimes quite equivalent to  the commencement of
this state; and copious exudation, covering  the whole of the affected
part with a layer of croupy-looking lymph composed of cell-growth
(compare p.  85), are the unmistakable evidence of inflammation
which may be witnessed in such cases.  The extent and distribution
of the inflammation are  subject to considerable variety.  Perhaps
the duodenum  is  its  commonest situation; but, in different cases,
it  ranges the whole of the small and large intestines.   Sometimes
it occupies but an inch or two of the bowel; or engages (it may be) 
250
SECONDARY INFLAMMATION.
but a part of its  periphery.  Usually, however, it  extends to  a
length of a foot or more, and surrounds the whole tube.  Occasion-
ally there are two, or even three, large  patches of such inflamma-
tion; separated from  each  other  by a perfectly healthy interval.
And lastly, though it seems originally and  chiefly to engage the
mucous coat, it occasionally involves the whole thickness of the
bowel: the muscular  and  areolar tunics of  which  become pulpy,
brown, and rotten, so that they give way on the slightest handling:
while the  peritoneum also  is injected, or even covered with a film
of exudation.
   The secondary relation of this inflammation to the lesions above
mentioned is sometimes clearly  established by their history; in
which, after a  long  illness referable to the primary lesion, the
patient is  attacked by all the symptoms of intense enteritis, ending
rapidly in death.   But the exact  nature of the relationship, or the
mode in which this  sequence is brought about, remains  for the
present unknown.
   The lesions themselves are such as to throw little or no lisrht on
this interesting question.   Sometimes apparently  cancerous, they
are in other cases very doubtfully so; in others, evidently cirrhotic
or suppurative inflammation of the stomach.  Generally (as in these
latter cases) the stomach is  the  seat of the  primary lesion.  In
some  cases, however,  a tumor or  stricture of the rectum or some
other segment  of  bowel forms the  original disease.  Sometimes,
again, it really seems  as if an equally discontinuous inflammation
was excited in the stomach  itself;  as  a  result  of old  ulceration
(compare  p. 140), or cirrhotic inflammation,  occupying some other
parts of its coats.
   In  other  cases,  again, it must be owmed that  the relation of
sequence  may fairly be called  in question; the appearance (and
even the history) being not incompatible with the view of a simul-
taneous involvement of two distant parts of the alimentary canal,
by one and the same disease.   Not even were such a disease what
is usually regarded as a constitutional one, this curious connection
would deserve to be recognized.   But it is certainly not to cirrhotic
inflammation,  or  to the ordinary ulcer of  the  stomach,  that the
term "constitutional" could be  applied  in any special sense;  still
less when we consider that the lesion  under  discussion (whether
secondary or no) rarely offers characters at  all approaching those
of the other one;  but is usually limited to an inflammation of the
mucous membrane, neither extending to its submucous tissue on
the one hand, nor pushed to the degree of ulceration on the other.
Again,  it  may  seem possible that, in regarding the secondary
deposit as inflammation, we perhaps overlook cancerous characters
which are obscured or hidden by the inflammatory  exudation the
adventitious growth  has provoked.  But any such  process would
obviously be very unlike that transplantation of cancer-germs which 
SECONDARY  INFLAMMATION.
251
is so frequently exemplified by the hepatic and pulmonary deposits
secondary to gastric cancer (p. 206).
  On the whole, this association of disease in different parts of the
alimentary canal not  only off'ers us a  fact worthy of notice, and
claiming  inquiry, but suggests some interesting conjectures  as  to
its nature and import.  And though among these, the relations of
cancer to the other maladies of this tube, and to inflammation in
general, as well as to cirrhotic inflammation and ulcer in particular,
seem first to  claim  our notice; yet, even allowing for the difficul-
ties connected with  such a statement, I must say that it is  not in
this  direction that the truth seems to be situated.   It is to the ner-
vous- system that this curious transfer of disease appears perfectly
ascribable.   It  is  in the  nervous centres—especially the  solar
plexus—that  I should incline to place  the seat of this apparently
reflex disease; and it  is in the peripheric branches which regulate
the distribution of blood in the gastric and mesenteric vessels that I
should look for the immediate agents or instruments of its produc-
tion.  And while it must be left  to time to confirm or refute this
theory, by bringing facts far larger and more accurate than any
now at our disposal, I would  remind you that, pathologically, it is
not unsustained by analogies in other parts of the body, or even in
this very canal;' and that, practically, it  is not unimportant,  as
showing a new and  increased risk, which the  development of any
serious structural lesion of the alimentary tube may inflict  upon
other parts of it,  hitherto healthy.

  1 Such as may perhaps  be traced  in the duodenal ulceration which has been
shown by Mr. Curling to be an occasional consequence of large burns of the tegu-
mentary surface. 
252
                      LECTURE  VI.

                           Dyspepsia.

  Though, in discussing the diseases of the stomach, it is impossible
to omit all notice of dyspepsia, yet this subject is so wide and com-
plex that  I must disclaim attempting its  full description  here.
The following Lecture will  only submit for your  consideration
some suggestions respecting  it; suggestions in which, if you can
find anything like a clue to the rational study of this malady—any-
thing which, taken in  conjunction with the other topics we have
hitherto noticed, and with the physiology of digestion, may guide
you to the principles of the pathology and treatment  of indigestion
—their purpose will be fully answered.
  Dyspepsia—equivalent to difficulty of digestion—is evidently a
wide word. One step towards  its conversion  into a definition we
may perhaps  take,  by pointing out what it evidently  implies—
namely, not only that a certain  amount of digestion is (though with
difficulty) effected, but that this difficulty is not due to any serious
structural  lesion.  To  call by  the name of " dyspepsia" such an
impairment of function as we  find  associated with cancerous or
ulcerous  destruction of the  gastric tissues, would  obviously be
almost as  absurd as to call strangulation "dyspnoea," or to speak
of a beheaded  criminal as  having been rendered " insensible."
  But even limiting the term to this conventional meaning—a difficult
character  of digestion, unexplained by structural lesion—it may
naturally be asked,  " How far is  dyspepsia  a  gastric disease ?  In
other words, considering that the function of the stomach is  but a
part (however large or essential) of the total  digestive process, how
far  are disturbances of this process in general  to be referred to the
stomach ?"
  In answer to such a question it must be conceded, that not only
is disturbance of the  gastric function no exclusive  cause of dys-
pepsia, but that it may almost be doubted whether, in the majority
of cases of this ailment, the stomach is the organ first and  most in
fault.  Certainly  if we contrast the numbers  of the affluent and
the poorer classes in this  country, and  the  corresponding propor-
tions in which the stomach often has to operate on an excess and
deficiency respectively, of the raw materials it elaborates, we may
almost infer that, in by far the greater number  of cases of dyspepsia
which come under the notice of  the  physician, this organ is per-
fectly capable  of  executing any reasonable amount of work.
  But  such a conclusion by no means disproves the close relation of 
DYSPEPSIA.                     253
dyspepsia to derangement of the stomach, or excludes it from con-
sideration among the diseases of this organ.  It may be quite true
that) in some cases, the stomach is only distressed by the excessive
amount of food introduced into it; and is only injured by being
overtasked, much as a muscle  or a tendon might be.   It may be
equally true that, in others, it is weakened  by want of exercise, or
deranged by a surplus of the materials  amenable to other parts of
the digestive process: that it languishes for want of the protein
compounds it ought to elaborate: or  is  surcharged by  starchy or
fatty matters foreign to its office—perhaps  often in excess of what
can be  assimilated  by the organs whose function  it is to do  so.
Still since, in a vast majority of cases, the  symptoms of dyspepsia
are referable mainly to  the stomach—since  the  organ is  either
primarily or secondarily deranged, and  the symptoms of  that de-
rangement are  the chief  phenomena observed by the physician
and felt  by the  patient—we may safely accept the ordinary view,
that dyspepsia  generally  represents  a  functional malady of the
stomach.  Doubtless  there are many derangements of other parts
of the alimentary canal equally entitled to the name of indigestion.
But with the exception of intestinal  dyspepsias attended  by diar-
rhoea—and often accompanied by  such a catarrhal  state of the
large intestine as amounts to  a  structural lesion—the  symptoms
strictly intestinal are  generally scanty and obscure, in comparison
with those traceable to the stomach.   And hence  these latter may
justifiably be the chief  objects  of our study.  Even  were they
mere incidents of the malady, so  long as we remembered that they
were not its essential or sole features, but only those most accessible
to our scrutiny, we should be entitled to accord them a notice pro-
portionate with their  importance.  But when we find (as we do)
that the stomach not only always shares, and sometimes almost
monopolizes, the derangements called dyspepsia; but that it is the
chief source  of their most striking  symptoms; and that it is also
more amenable to treatment than any other  part of the digestive
canal—we are justified in  describing  dyspepsia as being, for prac-
tical purposes, a gastric disease.
   Why  the symptoms of dyspepsia refer chiefly to the  stomach it
is not difficult to understand.  The physiology of Digestion affords
us plausible grounds  for presuming, that the  details which distin-
guish  this organ from the remainder  of  the  alimentary canal—
especially its shape, its size, its situation, its  office, and the pecu-
liarities  of innervation associated with  them—give it  a kind of
paramount importance; and render it, in the  main, far more sensi-
ble to various disturbing agencies, and far more disposed to betray
disturbance by  abnormal  phenomena (such  as pain, vomiting, or
flatulence) than  any other segment of the digestive tube.  So that
even  were purely intestinal dyspepsia  much  more frequent  and
important than it seems to be, the study of gastric dyspepsia would
still be the best means  of approaching its consideration.   Apart 
254                      DYSPEPSIA.
from  the frequent  secondary involvement of the stomach, in  the
intestinal variety, the symptomatology of dyspepsia of both kinds
would be best studied from  its most distinct and accessible side.
In this respect, indeed, the functional derangements of the stomach
and  intestine  do but parallel  their structural diseases: in which
we often find that  lesions, otherwise precisely  identical, are  be-
trayed by much more  distinct symptoms  when located  in  the
stomach  than in the bowels;  and that, in the latter situation, they
are sometimes mistakenly referred  to the stomach, owing to those
secondary derangements  of  this organ  which they are liable to
excite.
   Such a view of dyspepsia  suggests two considerations as to its
diagnosis.  Since it represents, not so much a single and substantive
disease, as a variety of ailments; and is characterized,  not so much
by the presence  of certain symptoms, as by  the  absence of struc-
tural  lesions;  the diagnosis of the malady in general, and of any
case of it in particular, are opposed by analogous difficulties.   As
the progress of scientific Medicine  has gradually revealed  the
morbid anatomy of the digestive canal, and thus detected structural
disease with  increasing accuracy  and frequency, the vague (but
useful) term "dyspepsia" has acquired a continually more restricted
meaning.  Nor  can we doubt  that it is destined to  still further
limitation; and that, as advancing knowledge   brings us  better
means of investigation, and so  enables us to discover and distin-
guish structural changes  of which  we now can  only  observe  the
functional results, the aggregate of maladies called dyspepsia must
undergo successive  subtractions, tending more or less completely
to its total subdivision into special maladies, and  to the removal of
this term from our nosology.   And while I hope that many of you
will hereafter  repeat (as you  advance in  the knowledge of your
Art) this increasingly restricted application of the  term  "dyspepsia,"
I venture also to predict that, even  in the investigation of a single
case, you will  often find yourselves deducing its dyspeptic nature
rather by a gradual  exclusion of what it is not, than by any such
a sudden recognition of what it is, as, in the substantive diseases
of many other organs, often anticipates the result of  a systematic
inquiry.   And (as a kind of  corollary to this) let me suggest, that
not only does  "dyspepsia"  still  probably  include  many really
structural (if not chronic or  permanent) maladies of the organs it
affects, but that so closely do  its absolute symptoms resemble those
of graver diseases,  that its importance is  enhanced by the possi-
bility of mistaking  for it such lesions as cancer or  ulcer of  the
stomach.  Sometimes, indeed, such  errors are almost unavoidable.
But, more frequently, they arise from a forgetfulness of the slight
characteristics of these structural diseases  in their earliest stages;
leading to a hasty conclusion, which a brief suspension  of judgment
would have prevented, or even reversed.   Nor is the  stomach  the
only organ whose lesions may be mistaken  or regarded  as mere 
DYSPEPSIA.
255
dyspepsia.   Just as there is none whose diseases do not react upon
the organism generally, and thus influence the nature and amount
of food the stomach  requires,  and the instinctive sensations of
hunger or anorexia associated with the fluctuations of these wants,—
so it is hardly too much to assert, that every grave constitutional
malady has its own dyspepsia; brought about by conditions strictly
analogous  to those which  produce  it as an independent ailment;
and capable (in those cases in which it is unusually early or promi-
nent) of masking any slight indications of organic mischief in the
particular organ to whose lesion it is indirectly due.  Much as the
progress of physical diagnosis has  done for modern Medicine, the
warnings of predecessors as to  the danger of mistaking phthisis
and other diseases for  the  dyspepsia secondary  to them, are even
now worthy of your recollection:—not only because .they  afford
the strongest motive for a thorough inquiry into the condition of
all suspected organs in every case  of dyspepsia; but also because
the physical signs of these diseases are, in rare  instances, so indis-
tinct, as to leave us almost exclusively to that keen scrutiny of
symptoms,  and that mental process of induction, by  which the
sagacity of the older physicians sometimes arrived  at a diagnosis
scarcely less accurate than what is  now more easily obtained from
physical investigations.
   The minor degrees of dyspepsia are so common, that few persons
in civilized life altogether  escape them.   Notoriously, most  people
have at some time or other eaten or drunk things which, in popular
phrase, "disagreed" with them.  Equally well  known  is the fact,
that the substances thus apt to  derange the digestion of one indi-
vidual  are taken with impunity by others; so that the proverb
states, " one man's meat is another  man's poison."  And, could we
suppose (not I am afraid quite an impossibility) that the substance
thus productive of  derangement  was  nevertheless so palatable
as to be  habitually made use  of by  any person; or that, in  the
mixture forming his food, the offending article escaped his detection;
there can be no doubt that the repeated or continuous symptoms
thus produced would at first resemble, and probably at last amount
to, an ordinary habitual dyspepsia.
   Symptoms of such every-day experience require little description.
As you would expect from the nature of the malady, and the func-
tional disturbance to which it  seems  limited, they usually  consist
of but moderate degrees of the various phenomena already alluded
to as generally characteristic of gastric disease (Lecture I.).   Thus
pain is often limited to weight, tightness, or dull aching: vomiting
is rarely more than casual and infrequent, or is  reduced to nausea:
flatulence is, as a rule, more severe than either:  constipation and
diarrhoea are comparatively inconstant, and of doubtful import: as
is also derangement of appetite.  Headache, on the whole, belongs
rather to  the accidental than to the habitual dyspepsias: in other
words, is not often intense as well  as continuous; but if so, often 
256
DYSPEPSIA.
masks or replaces more local symptoms.   General uneasiness, lan-
guor, exhaustion, or depression—by no  means unusual associates
of habitual dyspepsia—are attached rather to a concurrence of all
the preceding symptoms than to a remarkable prominence  of any
one or two of them; and are,  for obvious reasons, quite as often
results of the malady,  as elements or constituents of it.
  Without pausing, therefore, to trace the rise and progress of an
ordinary dyspepsia, as  it  advances from a casual or accidental indi-
gestion to an habitual and  constant malady—without attempting
the impossible task of sketching the  thousands  of forms which a
varied degree and.number of the preceding symptoms may com-
bine in  any given  instance to  produce—we will assume that the
symptoms above enumerated afford us a kind of vague outline of
the disease; and  proceed to  point out one or two of the chief va-
rieties most' frequently met with in practice.  And you must not
be surprised if our varieties, chosen as they are upon what may be
called  physiognomical grounds, mutually include and decussate
with each other; so as  to give us what, if we were attempting a
true classification, might be  logically objected to as a " cross divi-
sion" of the subject.
  First, then, the prominence of any one or two of the above symp-
toms constitutes a variety of dyspepsia too obvious to require much
notice.   For example,  severe or continuous pain  in the epigastric
region may be dignified  into "cardialgia:" "flatulent dyspepsia,"
again, is a term equally intelligible:  vomiting is  so rarely  a lead-
ing symptom, as to justify a suspicion of some graver malady than
dyspepsia, in those cases  in which it is disproportionately frequent
or severe.   Constipation, where really specific to the malady, and
not (as it often is) a mere secondary result of the habits of the pa-
tient^ belongs  rather to intestinal than  to gastric dyspepsia; a fact
in which it resembles the opposite (and less frequent)  variety
attended by diarrhoea.  Both, too, deserve notice, as varieties which
often dictate (and amply  repay) a treatment specifically directed to
these symptoms.
  Other varieties of dyspepsia  are distinguished by the relation of
the symptoms to the period of gastric digestion.  The older writers
judiciously distinguished what we may term an " ingestive dyspep-
sia "—an indigestion closely following on the reception of food into
the organ,—and gave it, under the term of "morbid sensibility" of
the stomach, a prominence to which it is strictly entitled; both as
really constituting a severe variety of the malady, and as often in-
cluding cases of commencing ulceration  of the organ.  The cases
in which dyspeptic  symptoms come on more gradually during the
activity of the stomach, to end with the propulsion of its contents
into the duodenum, are perhaps also entitled to rank  as a distinct
variety.   Those cases  in which the  access of indigestion concurs
with the close of this act are even more numerous and important.
In these, again, we may distinguish two sub-varieties: a post-diges- 
DYSPEPSIA.
257
tive, and a fasting dyspepsia; the first transient, the last enduring
until it is relieved by the ingestion of a new meal.  Both of these
are generally associated with a great disposition to flatulence.
   Another classification even more physiological may be also sug-
gested : namely, a division of dyspepsias according to that alimen-
tary constituent, the failure of which to be digested provokes their
symptoms.
   It will be  recollected that, in speaking of the composition of the
food  in the Lectures on Digestion,1  its chief ingredients were  ar-
ranged (in accordance with the classification suggested by Dr. Prout)
under the following heads.  1.  Albuminous materials or protein
compounds;  such as albumen, fibrin, casein, &o.  2. Hydro-carbons
or fats; exemplified by butter, oil, animal fats, &c.  3. Hydrates of
carbon; a group which includes the various starchy and saccharine
substances.   4.  Saline constituents which, though less exactly
known in respect to their quantity and quality, seem scarcely less
important than the preceding.  5. Water; the more or less imme-
diate solvent of some of the above constituents; and the instrument
of most of the mechanical and chemical (compare p. 43) phenomena
of life.
   Now in respect to such a classification, it must be conceded, that
in many  cases of severe and  protracted indigestion,  an undue
quantity or quality of any one of these constituents often suffices to
excite a paroxysm of the disorder.  But in others it will be found
that  only one of these  constituents is thus  resented; so  that,  for
example,  the dyspepsia of one patient is called forth by proteinous
substances ;  that of a second by saccharine or starchy matters; that
of a  third by oily or fatty  articles of food.  And  even  the saline
and the aqueous ingredients of food might perhaps be added to this
list.   At least I have  known instances in which persons appeared
to be rendered singularly dyspeptic2 by the saline contents of a hard
or calcareous drinking-water; as well  as others in which nothing
but a strict limitation in the quantity of this diluent (however pure)
habitually consumed with their food, sufficed to ward off the malady.
Of course similar effects may often be traced to  the condiments
(for example, the peppers and spices) taken with food.  But many
of these stimulant and  acrid substances really possess noxious cha-
racters.  And few of them can be fairly regarded as ranking among
the physiological constituents of food.  Besides, their ill effects are
sometimes but secondary and  collateral, being referable to the
undue quantity of food which they tempt those who use them to
consume.
   To follow  out the above allusions would open up the whole sub-
ject of diet, and so lead us far beyond the limits prescribed for the

   1 These lectures have been published as an "Introduction to Dietetics."  Long-
mans, 1861.
   An effect analogous to the marked injury which such waters often produce on
cattle.
       17 
258
DYSPEPSIA.
present course of lectures.  But while I leave it to you to take up
the suggestions they  oft'er, I would add that, in the treatment of
dyspepsia, this alimentary classification is often  of extreme practi-
cal value; pointing, as it does, to measures the  simplicity and effi-
cacy of which it is difficult  to exaggerate.  I think, too, that a
careful examination would show that each of the several dyspepsias
thus distinguished is generally (though not always) associated with
certain peculiarities of the symptoms.  In the proteinous dyspepsia,
for example, of the affluent and  sedentary, headache  is common;
pain is rarely severe;  and is often referred to the region behind
the sternum, corresponding to the cardiac aperture of the stomach.
The starchy dyspepsia1 of the poorer classes is chiefly distinguished
by the  extreme flatulence which generally accompanies it.  The
oily dyspepsia, besides much headache and pain, is usually attended
by severe and continuous nausea, or even vomiting.  In all these
varieties, that excess of the particular constituent which  provokes
the dyspepsia may of  course  be  either absolute or relative.   And
under the head of a relative excess, we must probably include, not
only a quantity disproportionate to the powers of its special diges-
tive solvent,  but also  a quantity disproportionate  to that of the
other alimentary constituents; all of which seem in their assimila-
tion, to be mutually dependent on each other.
   Another  classification, which  is  scarcely foreshadowed in the
present state of our knowledge, may yet be alluded to, as probably
destined hereafter to much  greater usefulness in discriminating the
functional derangements of the  stomach—namely the grouping of
gastric dyspepsias  according  to the chemical reactions of the fluids
expelled from this organ by regurgitation or vomiting.  The  well-
known fact that the fluids thus expelled are in different cases acid,
alkaline, and neutral,  might suggest corresponding divisions of the
malady  to which their expulsion is due.  But, just as  it is obvious
that mere acidity  or  alkalinity would be a very  insufficient  basis
of classification, and might d prion (nay more, would as a matter of
fact) group together cases in which the same reaction was due to very
diff'erent constituents; so a little reflection suggests that tjae physical
properties of such fluids (and amongst  these properties, their micro-
scopic appearances) are  indispensable  to the proper  confirmation
or checking of  their more obvious chemical characters.   Inquiries
of this kind supply some curious  details;  which, however, would
be out of place here, even if  I feel  justified in  anticipating results
that require much wider researches on my part.   Suffice it to say
that acidity which you might perhaps think generally due to an
undue secretion of acid gastric2 juice,  is more frequently  the result

   1 This form of dyspepsia may be unmistakably recognized in the sufferings so
graphically alluded to  by Dr. Livingstone (in his recently published " Travels")
as produced by an  exclusively starchy food, and cured by  meat.
  2 I have, however, reason for conjecturing that in some of these acid dyspepsias
there is a flux or excess of secretion on the part of the stomach; a secretion, not of
gastric juice, but of its  acid constituent only, or of gastric juice, minus the pepsine. 
DYSPEPSIA.                       259
of such a  lactic, acetic, or but}^ric fermentation of the food as is
quite independent of this  secretion;  that an alkaline reaction is
usually derived from  saliva,  poured forth in abnormal quantity,
and swallowed in the intervals of meals—more rarely, and scantily
from bile (p. 28); and lastly, that more neutral fluids appear to be
sometimes due simply to the effect of these two  opposite reactions
in neutralizing each  other.
   Here is, perhaps, the place to allude to that variety of dyspepsia
known under the name of pyrosis.  Certainly, if one were to adopt
the ordinary definition of this malady, I suspect that many of the
cases regarded  as pyrosis are scarcely  referable to it: and espe-
cially  that its  recorded  frequency in  gastric ulcer"  is partially
attributable to a vague and inaccurate use of this nosological term.
And  even restricting it to its true meaning—a pain and constric-
tion at the epigastrium, followed by  a simple  regurgitation of a
large  quantity of a  thin watery fluid—pyrosis must be regarded,
not only as an independent malady, but also as an occasional com-
plication of various gastric diseases, both structural and functional.
   The more obvious conditions of pyrosis, whether idiopathic or
incidental, are evidently of two kinds: the presence of a quantity
of this watery fluid  on the one hand; and an act of regurgitation
on the other.
   As  regards  the  first, a  careful  chemical  and  microscopical
examination generally shows this fluid to consist chiefly of saliva.
As such, its expulsion often implies an  excessive secretion  of  this
fluid; which  is  poured  forth in excessive quantity as the result
either of an improper character of the food,2 or  of a direct  gastric
irritation;3 and is conveyed  into  the stomach, either by  uncon-
sciously trickling down  the oesophagus, or  by being  propelled
through this tube by a process of deglutition.
   The regurgitation which expels this  fluid apparently differs in
no degree from the general act of this kind already (p. 56) described.
Like it, a  shut pylorus, an open  cardia, a contracted  pyloric  sac,
and a questionable or scanty abdominal pressure—are the circum-
stances which presumably bring about  the  expulsive act.  It is
doubtful whether the feeling of epigastric constriction which attends
this regurgitation is  referable  to the muscular action of the pyloric
end of the stomach,  to its distension, or  to irritation of the  gastric
mucous surface.  But the former is, for various reasons, the more
probable explanation.
   How far the mere accumulation of saliva  in  the stomach is an

   ' See Lecture III., p. 147.
   2 The true idiopathic pyrosis appears to be common in districts where the inha-
bitants live on too exclusively vegetable a food ; and is said to be specially caused
by the association of a sedentary calling with the consumption of large meals of
thin half cooked (and, of course, unmasticated and unsalivated) oatmeal porridge.
   3 In dogs provided with gastric fistulae, direct  irritation of the stomach readily
provokes a copious secretion of saliva. 
260
DYSPEPSIA.
 abnormal  act, it is impossible to judge in the present state of our
 knowledge.   In  other  words, whether the pylorus  usually or
 normally  contracts  against  a moderate quantity of such gastric
 contents can scarcely be decided.   But having verified the occa-
 sional presence of bile in  the fluid expelled  by true pyrosis, I
 should conjecture, that  the contraction of the pyloric valve requi-
 site for great accumulation  implies an abnormal quantity or quality
 of salivary fluid, if  not  indeed a gastric irritation itself provoking
 the flux of saliva.
   These considerations  may dispense with all but an enumeration
 of the varieties of pyrosis.  It undoubtedly occurs in gastric ulcer;
 and (though I cannot say I  have ever verified it myself) in gastric
 cancer.  In like manner, I have seen pyrosis  of quite a typical
 distinctness, in instances where there was every reason  to attribute
 it to the contraction of an  ulcerous cicatrix.   And  lastly, among
 idiopathic cases, I have known it supply an interesting commentary
 to the above statements by occurring in the course of a meal (or
 rather towards its commencement), and yet bringing up pure saliva
 (from the  pyloric sac) quite unmixed with any of the considerable
 quantity of food which must then have occupied the cardiac end of
 the organ.
   The causes of dyspepsia claim notice, not only from their relation
 to the scientific aspect of the malady, but from their extreme im-
 portance in its treatment.  For, since the disease rarely implies any
 severe  or  permanent lesion, the mere  removal of its cause would
 often suffice to effect its complete cure.  Unhappily, however,  it is
 often no single and simple cause we have to seek out and remove;
 but so complex an admixture of causes, as almost baffles  inquiry,
 or, even if it permits of successful  analysis, defies both physician
 and patient to remove it.
   In an enumeration of the causes of dyspepsia, perhaps undue
 intellectual exertion claims the first place.   The influence of such
 exertion  must not,  however, be measured by  its intensity;  but
 rather  by its rapidity, its duration, nay, even  by the faculties it
 involves.  The constructive mental efforts of genius are eminently
 wholesome; not  because (as  is sometimes  mistakenly supposed)
 they are to genius no very severe efforts, but because they demand
 a concord  of faculties, a symmetry of mind, and an  application of
 reason  and judgment—in short, a moderate and varied  exercise of
 all the mental powers.  Conversely, I think  dyspepsia  may be
 caused by a deficiency of mental exertion—a person accustomed to
• intellectual toil, being rendered amenable to this malady by the loss
 of labor which habit had made pleasant, and comparatively healthy
 to him.
   Mental  anxiety constitutes a cause of dyspepsia  which, though
 allied to the preceding,  and often concurrent with it, is a far more
 efficient agent  in producing gastric derangement; and one  which
 sometimes renders  the  physician  as powerless a ministrant  to a 
DYSPEPSIA.                     261
dyspeptic stomach, as he would be to "a mind  diseased" in the
Shakspearian  sense.  How closely all the phenomena of digestion
are connected  with the mental states is a matter of common expe-
rience—the rice which the Hindoo criminal is unable to moisten
with saliva even to avoid detection;  the destruction of appetite by
bad (or even by good) news;  nay, our very forms of speech, which,
with little exaggeration, represent a person as " sick" of any person,
or thing, or topic—all of these matters of everyday experience con-
clusively show how the chemistry of the stomach is subjected to
the least material and palpable  agents of our life, to that world of
thought and  emotion which works within every  one of us.   And
indeed there is little need for surprise at this fact.   The most zealous
morbid anatomist can scarcely  doubt that mere variations in the
mind sometimes weaken, decay, and  even  destroy life, without
bringing about specific or traceable lesions of organs.   And hence
it is not surprising that what is true of the aggregate of functions
should  be  true of any one of them, especially of one which, like
this, is  so  closely connected with the general vigor of the frame,
and with the special requirements of its every part.
   With regard to undue bodily exertion  as  a  cause of dyspepsia,
while we may trace  similar results to both  their excess and defi-
ciency,  we must reverse the rule above hinted at in respect to their
relative frequency.   Among the affluent classes, dyspepsia is much
more commonly caused by a deficiency of exercise than by its ex-
cess.  No doubt the  injurious  effects of a sedentary life are often
aggravated by the brain-work it implies, as well as by that repeated
inhalation of impure air which  all our ordinary  arrangements (as
regards house-ventilation) still more or less involve.  But its main
effect is traceable to a different source—to that diminution of bodily
waste which a want of exercise implies,  and especially to the want
of that completeness and perfectness of combustion which muscular
exertion insures to the whole  organism.  Perhaps, too, we may
conjecture another cause for a deterioration of digestion.  It seems
to me that the waste of the muscular system has a close and essen-
tial relation to the amount of the organic principle of gastric diges-
tion; so that,  other things being equal,  it  depends  in no small
degree on the  amount of muscular movement, how  much pepsine
can be secreted  from  the blood  by the proper gastric tubes.  Un-
fortunately, too, the appetite of the sedentary  individual cannot be
trusted  to  maintain that proper adjustment  of the ingesta to the
egesta which is its normal office; but often seems  rather increased
than diminished by a life of confinement—a fact which may perhaps
be  explained  by the disposition natural to  the  human mind, to
forego moderation in  its pleasures, just in  proportion as their num-
ber is restricted; and to pay all the more attention to the luxury
of the table, when circumstances render this the chief or sole enjoy-
ment at command.
  On the other hand, however, dyspepsia is also  producible by 
262
DYSPEPSIA.
undue muscular exertion.  Firstly, as a result of that feverish state
which prolonged or excessive muscular efforts bring about; a state
which (as  many an over-zealous pedestrian can  testify) destroys
alike the appetite  for food, and the  capacity  of assimilating it.
Secondly (as a modification of this law which often merges into it),
a similar gastric derangement  is producible by a much smaller
amount of exertion during the digestive act; in other words, during
the period  when the  blood which ought to be mainly sent to the
intestinal canal,  to feed those cyclical currents of secretion and ab-
sorption going on there, is derived to the muscles, the lungs, and the
skin, and thus prevented from effecting the digestive function.  From
both of these causes combined, I have repeatedly observed grave
dyspeptic maladies in persons apparently but little  exposed to a
malady presumed chiefly to  affect the affluent, the sedentary, and
the  luxurious.   I can especially recall some  severe dyspepsias of
this kind among those indefatigable galopins of the public—metro-
politan letter-carriers.
  More  effective, however, than all  other  causes of dyspepsia are
those errors of diet to which physiology and medicine have long
agreed to refer this malady.   For a few or none  of the preceding
circumstances would have much influence, if they were but met
by  suitable adjustments of the quantity and quality of food.  The
man whose intellectual  toil  spoils his digestion  (and  en revanche
is generally somewhat damaged  by the  dyspepsia  thus brought
about) would  often have little to complain of were his means less
ample; if his food  were less rich, better cooked, and better masti-
cated ; his  drinks less stimulating; and if both  were distributed
over a longer  period of  time, and less carelessly huddled into the
stomach.  The sedentary, again, might often avoid indigestion by
diminishing their food, so as to suit  the smaller waste such  a mode
of life entails upon them.  And even prolonged or excessive mus-
cular toil has its proper diet.   The hunter or pedestrian who climbs
the mountains, or the soldier who makes a forced march, in a state
of  perpetual fever  and perspiration, loathing  his  food, and  unable
to digest it, would  find {experto-^rede) that  if the meat and alcohol,
foolishly thought necessary  to  such exertions, were replaced by
bread, butter, a  little fruit, and plenty of cold water, he would feel
like a new man.   And, without pursuing  such details any further,
we may at least deduce from them, that  the diet  and regimen of
health and disease  merge into each other;  and enunciate the same
principles to which even the  cod-liver oil given in phthisis,  and the
brandy, requisite in certain cases and stages of fever, are alike re-
ferable; principles which, while they recall the old adage, "every
man at forty is either a fool or a physician," suggest that the prac-
titioner  who ignored  them would  vary the alternative (or rather
illustrate a third contingency) by supporting both these characters
simultaneously.
  But in alludiug to errors of diet, we must again guard ourselves 
DYSPEPSIA.
263
from taking too unqualified or exclusive a view.  Among the afflu-
ent classes there  can be no doubt that  excess of food  and drink,
either  absolutely or relatively to the peculiar  constitution and cir-
cumstances of the individual, is a dietetic error by far more common
than deficiency.   But among  the poor, this rule is reversed: and
insufficiency of food in general, or of certain of its constituents, is
a  fruitful source of indigestion—such as  embitters the life, and
damages the efficiency of the children of toil to a scarcely conceiv-
able degree.
   It is not always, however, that we can discriminate between ex-
cess and  deficiency.  For  example, in the dyspepsia of the poor,
we must sometimes doubt whether it is the excess of starchy pota-
toes, or the deficiency of proteinous meat, and therefore of its proper
solvent—gastric juice—which gives rise to the flatulence, and the
salivary pyrosis of the malady.   So, on the other hand, the excess
of the rich may almost amount to a deficiency: and the habitual
ingestion of large  quantities of  meat may be  attended with  as
habitual a deficiency of vegetable aliment, such as few organizations
can want with impunity,1  save under conditions of life unusually
healthy in all other respects.  Again, the food, however plentiful,
may be so ill-chosen, ill-cooked, and ill-masticated, as to defy assi-
milation;  or may be steeped in profuse  and complex alcoholic
beverages which  materially interfere  with  its solution  in the ali-
mentary canal.   Or lastly, the excess of some particular  alimentary
constituent may be only relative; the symptoms it  produces being
strictly analogous to that variety of dyspepsia which the abuse of
cod-liver oil produces:  where,  for example,  a  large  dose on an
empty stomach produces symptoms similar to those which a pat of
butter swallowed under parallel circumstances would bring about;
and where the nausea, vomiting, and heartburn thus excited are at
once got  rid of by dividing the dose, and  introducing  it into the
stomach with (or immediately after) other articles of food.
   Scarcely to be  numbered among errors of diet, and yet insepar-
ably connected with them,  is the  abuse of alcohol,  of tea, of coffee,
and of tobacco.   The effects of these substances we shall allude to
hereafter.  At present it may suffice to point out, that the influence
of all  of them in the production  of dyspepsia may be regarded as
due to two causes ;  namely, to their local, and their general action :

   1 An incident, illustrative of this  fact, was mentioned to me on good authority
some years ago.  A  lady, who  had long been under the care of  a fashionable
physician of that day for dyspepsia, was obliged by some novel symptoms to call
in a practitioner in the neighborhood of her country seat. To his plain statement,
that she was suffering from scurvy, and  required plenty of lemon-juice and vege-
tables she rejoined by quoting Dr. Blank's oracular assertion, that a particle of
fresh vegetable would kill her ; adding that, by bis advice, she had long restricted
her consumption of vegetable food to a little dry toast.  Convinced at last that the
death by scurvy was, on the whole, the  more  probable and imminent of the two,
she allowed the country practitioner to cure her, both of the  disease and of the
preposterous error of diet to which it was due. 
264                       DYSPEPSIA.
to the mode in which they  influence the. stomach and intestinal
canal by coming into direct contact  with their  mucous  surface;
and  to their influence on nutrition in general, after having been
absorbed.
   For the  sake of convenience, we will eliminate  all question as
to the deficiency  which any  excess of these substances indirectly
involves; in other  words, as to the diminished ingestion of food
which the votary of alcohol,  tea, or tobacco, often  practises.  Much
as it complicates the result, it is no  doubt greatly referable  to
the constitutional effect of these substances, and can hardly ever be
separated from it.
   Firstly, then, as regards local effects, if we except that stimulat-
ing influence on secretion which a little alcoholic fluid taken before
a meal will often excite—the results of all these  agents are more
or less injurious.  Alcohol damages gastric digestion, just in pro-
portion to the degree of  concentration in which it is added to the
gastric juice:  and where this degree is great, excites inflammatory
phenomena which additionally imply a suspension of all  true se-
cretion.   Besides, the fermenting substances often present  in alco-
holic liquids (as in beer,  sweet and effervescing wines, or liqueurs)
appear to further an analogous (and eminently dyspeptic)  fermen-
tative process  in the  ingesta  with  which they are  mixed.  The
tannin of tea and coffee probably tends also towards a repressal of
secretion.1   And as regards their other ingredients, it need only be
stated, that researches on artificial digestion, and the experience of
dyspeptic patients, concur in the  propositions: that water  is the
best diluent of the digestive  fluids; and that, while its goodness is
mainly in proportion to its purity, even it may be injurious if taken
to excess.
   Secondly, as regards the general or constitutional effects of these
substances, pray understand clearly that I neither deny nor affirm
that there are  grounds (moral, social,  or what not) for separating
and  distinguishing their action ; and that, in classing them together,
I  am doing so purely on such physiological  grounds as would
oblige me, if I were addressing a Chinese  audience, to add opium
to the list.   Tobacco  may be the exponent of all the vices; and
tea a fertilizing liquid  which, applied in  proper  quantity, encou-
rages the growth of all the virtues.  While in respect to the ethics
of alcoholic liquids, professors of Teetotal exegesis  may  explain
away those opinions as to the  lawfulness and  expediency of such
drinks which have been  handed down  to  us from the  wisest and
best of mankind—from St. Paul, and Solomon, and a greater than
Solomon—may show that the text of the Evangelist is  garbled,
and  (reversing both the miracle and its motive) turn wine into
water to  suit their narrow and gloomy views.   But we have to con-

  1 As does probably that infusion of tobacco which the  chewing of this narcotic
introduces into the stomach. 
DYSPEPSIA.
265
sider  such questions from a different aspect: and may sum up the
chief  effect of all these agents in  the theory, that, despite  great
differences of  detail, they have much in  common.   With  little
convertible material, little substance which the organism can assimi-
late, they all seem to  modify nutrition in  much  the  same  way:
stimulating the nervous energy of  this function; and  (in the case
of many  of  them) diminishing the  measurable waste of bodily
substance—especially reducing the  excretions of carbonic acid and
urea which chiefly express that waste, to  a quantity below the re-
spective amounts which would otherwise be habitually evolved.
  It must not, however, be supposed  that the effects of these dif-
ferent substances are really identical; or even that any one  of them
acts in  exactly the same manner upon a large  number of indivi-   .
duals.  Nor are we entitled to assume that their effects are really
summed up by the two kinds of influence (local and constitutional)
above ascribed to them. On the contrary, just  as  our experience
of their effects quite entitles us to believe, that each of them exerts
its own specific influences on the nervous and vascular systems;  so
we may well doubt the complete accuracy of the physico-chemical
law just laid down respecting their action.  Thus, it seems not im-
probable that the diminished evolution of carbonic acid referred to
is compensated by new varieties of metamorphosis; perhaps even
by other products of combustion which at present  elude a quanti-
tative1 (if not qualitative) recognition.   At any rate we may doubt
whether the whole of  this decrease of carbonic acid represents a
corresponding economy of waste; and still  more, whether, if so, it
measures or expresses a corresponding advantage to life and health.
   Without digressing any further toward this wide subject of the
action of alcohol and its congeners,  I may state  that experience
shows their local effect  upon the alimentary canal and upon diges-
tion to be, on the whole, unfavorable:  while their general  eff'ect of
altering (if not disturbing) the balance  of nutrition, is often scarcely
less detrimental  to this function.  That they are used by the ma-
jority of mankind, and that their moderate enjoyment is quite com-
patible  with  health, are facts which by no means  countervail this
proposition.  And that  the advantages of their general effects often
preponderate  over the  trifling disturbance they produce locally—
that, in short, they are sometimes useful remedies against the very
ailments which their abuse (or even their moderate use) can other-
wise bring about—is a statement which, while it involves no inhe-
rent improbability, rests upon  an  empirical basis such as defies
disproof.
  It may perhaps be useful to end these allusions to the symptoms
and causes of dyspepsia, by a brief summary of those conclusions

  1 Among such compensations, it may be specially conjectured that carbonic acid
is replaced by an increased oxidation of hydrogen, to form water (p. 67) ; and urea
by ammonia or its carbonate (p. 278). 
266
DYSPEPSIA.
respecting the pathology (or rather the physiology) of the malady,
to which they apparently point.
  (1.) In spite of the wonderful resistance which  the alimentary
canal exerts  against the substances to whose action it is most ex-
posed, it is so organized, that food which  is abnormal in quantity
or quality is  capable of producing derangement of its functions—
in a word, indigestion.
  (2.) But abnormal food alone is no sufficient explanation.  Apart
from those idiosyncrasies which render particular articles of diet
hurtful  (if not  poisonous) to particular individuals, we are forced
to assume that dyspepsia in most cases implies a special delicacy or
weakness  of  the organs  themselves.  For not only do  we meet
with many instances, in which  no amount of dietetic ill-usage per-
verts their functions; but we observe,  that such flaws of the diges-
tive organs can generally be so far prevented and  corrected by
favorable circumstances of the rest of the body—as that, for exam-
ple, severe or protracted dyspepsia is  rarely found associated with
an  active life of comparative exposure.   It is only thus we  can
explain the prolonged  and severe ill-treatment which these organs
often sustain, without any  apparent  derangement of  their  func-
tions; as well  as the  equally  well-known fact, that  the circum-
stances  best  calculated  to  insure  the  health of the  organism
generally—fresh air, moderate exercise, and activity of mind and
body*—are singularly efficient  as preventives of this  malady, and
as remedies against it.
   The first of these causes of dyspepsia  indicates that the liability
of the digestive organs to functional derangement is a kind of pro-
vision of Nature against graver and  more deeply seated disease:
a  provision  such as has considerable analogy to the protective
function of pain, and to  that mechanism of common sensibility of
which it forms  a part (p. 51).  The position of the alimentary canal
(and especially of the  stomach) relatively to the  food, enables its
disturbances  to forestall and prevent the mischief that might (and
in persons of powerful digestion actually does) gain access to  the
blood, and, through this  fluid, invade other organs.   Unchecked,
dyspepsia is doubtless not devoid of danger, both  by what it  thus
foreshadows,  and by what it can itself produce;  just as Physiology
must own that—in  and per se—pain is an evil.   But it stands (as it
were) midway between certain  deleterious  agents  and bad habits
on the one hand, and the penetralia of the constitution on the other;
and, if its warnings are attended to, is often the means of rescuing
its victims  from the slower and more dangerous consequences of
these errors.  It is true that no indistinct resemblance of symptoms
can entitle us  to affirm  that dyspepsia  often ends in such organic
lesions as ulcer or cancer of the stomach.  But the clinical history
of the latter maladies abundantly justifies a strong suspicion of this
kind; a suspicion which therefore suggests the cheering  corollary,
that the proper  treatment* of dyspepsia may sometimes ward off 
DYSPEPSIA.
267
the access of these terrible structural diseases.   And whatever be
the doubt inherent to this suspicion, it is impossible to question the
truth, with  respect  to  some other diseases, of  the  time-honored
dictum—that the  sufferings of indigestion  often call attention to
some of those errors of nutrition which,  if persisted in,  inflict
serious  or irreparable mischief in the form of  tubercle, rheuma-
tism, gout, or calculus: and that they thus increase  (rather than
diminish) the longevity of those  whose prudence does not allow
this epigastric monitor to warn them altogether in vain.1
                          TREATMENT.

  In treating of the means adapted to the  cure of dyspepsia, and
allotting to medicines, as  distinguished from diet and  regimen,
priority of notice, I must warn you  not  to  suppose they have any
real  precedence.   In the  vast majoritj7 of cases, drugs do not cure
dyspepsia; do not even effect so much towards a cure as they cer-
tainly do  in many other  maladies.  They mitigate its symptoms,
they diminish its effects; but they hardly touch (if we may draw
such a distinction) its nature or essence.  And their administration
is in no degree a substitute for what (always an important indica-
tion of treatment) is  in this particular malady the chief object of
the physician—the detection and removal of the causes by which it
has been  brought  about.   While since, in  a large number of in-
stances of dyspepsia, the  observance of a proper diet and regimen
would ultimately suffice alike to remove all symptoms of the exist-
ing malady, and  to prevent i^s return, it may fairly be stated that
for practical purposes, the latter class of remedial agents are by far
the more  valuable of the  two.
  If any of you  should (not unnaturally) wonder at my bringing
into  an invidious  contrast, measures  which it is the duty of the
physician to combine in the treatment of  any given case, let me
explain that I do so from a motive for which I hope your sympathy.
This particular congeries of maladies (the pathology of which we
have found is still, from various causes, less  precisely and accu-
rately established than that of most other diseases of the alimentary
canal) has for  centuries  been the subject of more quackery than
perhaps any other of the ills that flesh is heir to.  Not to dwell
upon that liability to differences of opinion which the votaries of
medicine  proverbially share with those of other arts and sciences,
and which cannot but be prominent in such a subject as the thera-
peutical action  of drugs—not to trace (what,  I think,  the  most
charitable observer of human conduct could scarcely fail to recog-
nize) the  germs of quackery in some of the specifics against indi-

  ' On this topic, as well as on the relation of dyspepsia to chronic gastritis, com-
pare the remarks in Lecture II., and the note to.p. 183. 
268
DYSPEPSIA.
gestion which have emanated from the ranks of our own profession,
I will  only remind you of the systematic impostures  which live,
and thrive, in  great part on  the treatment  of dyspepsia.  As a
malady which is often  slight, almost always easily curable;  which
peculiarly affects the affluent and luxurious; and is itself sometimes
the result of  a  form of sensuality which perhaps implies, and cer-
tainly produces, a somewhat enfeebled state of the mind—dyspepsia
is from all these reasons the vantage ground of that numerous, but
illegitimate, offspring  of  Esculapius which  is sustained by the
trumpet instead of the  caduceus.  Dyspepsia is, indeed, the malady
above  all others, in which a variety of quackeries work their pre-
tended cures.   It is the efficacy of diet and regimen that  explains
the small nucleus of facts around which  they cluster their menda-
cious statements.  And the very same  considerations which thus
expose systematic imposture,  are those which we must recognize,
if we would  avoid  casual error; if we would know what can be
effected by drugs in the treatment of dyspepsia, and which drugs
we ought to select.   With some doubt as to whether those I recom-
mend  to your  notice will be  found  by  others to possess all the
merits which experience  leads me  to assign them, and with a full
certainty that we have much  to  learn respecting them, I may at
least point out with what cautions they are to be appraised.
— A person suffering from dyspepsia takes a certain remedy.  He
recovers.   Therefore he is cured  by it.   So runs the popular con-
clusion.  But the conscientious physician can accept no  such flatter-
ing  or delusive estimate of his remedy.  And  if the power of the
latter be specifically the subject of inquiry, he asks himself, " Was
the recovery  due to that spontaneous amendment which sometimes
occurs in this disease, as in most other  diseases; or was it due to
the diet and regimen adopted simultaneously with the drug ?  Are
its traditional virtues, again, in any degree confirmed by its physio-
logical effects on the healthy subject? And, as regards its thera-
peutical influence, can it  be  traced apart from diet?   Can it  be
verified as a  matter of frequent experience, and (in the case of the
stomach) as an immediate result of its ingestion ?  Lastly, can it be
confirmed by the results of interrupting, omitting, and repeating its
administration?"  Judged of thus  strictly,  our remedies would
doubtless be  fewer in number: and  discoveries of new specifics  less
frequent.   But the Art of medicine would gain by the extension of
its scientific basis.  Quackery  would lose its  chief attractions  and
excuses, by the exposure of this fundamental delusion of the public
as to the cure of disease.  The public might  become  healthier, as
well as wiser, by learning that the means of health lie rather in the
circumstances with which we constantly surround ourselves, than in
rare and exotic drugs.  And lastly, our  practice would  gain far
more than an  equivalent for  a mere number  of remedies, in  the
increased skill and efficiency which would result from concentrating 
DYSPEPSIA.
269
our study on the best way of wielding  a few of tried and unques-
tionable virtues.
  Such a scrutiny of our  Pharmacopoeia would  no way affect its
value, save to place it, if possible, on a still  more irrefragable basis.
Nor do these occasional results of the vis medicatrix Naturae (aided
perhaps by diet and regimen) which are vaunted as cures  by the
Homoeopath, or which may be deduced from the far rarer (but
more trustworthy) observations of our own profession on the natu-
ral history of Disease, by any means disprove the value of drugs
as the armament of the practical Physician.  He has not to answer
the abstract question—whether Nature and  diet can accomplish
the cure of  disease, but to  discharge the practical duty of insuring
this contingency by every  means in his power.  And, taking our
medicaments at their lowest value, there can be no doubt that their
proper use tends to bring about this desirable result more certainly
and quickly than would otherwise be the case;  sparing  suffering;
abridging convalescence; and saving the many lives which would
succumb before the arrival of less rapid and complete relief.   Even
in dyspepsia, the palliative effects of drugs are far too precious to
be  dispensed with.  WThile as  regards  their  less measurable tonic
and alterative  effects, those who have witnessed  their influence
among  the dyspeptic poor, and against all  the  terrible concomi-
tants—scanty food,  foul air, excessive toil, and  intemperance—
dyspepsia here possesses, must know that  it would be a mockery
to restrict this important class of our patients to regimen or hygiene.
To tell, an  idle and wealthy dyspeptic that  his malady might be
cured  without  drugs, would be a  hardy statement, though some-
times a true one.   But to recommend dyspeptics  in  general to
dispense with all medicines, would be not only illogical, but absurd :
indeed, considering the circumstances of most of our patients, even
in  the affluent  classes, scarcely less  foolish or cruel than to with-
hold a rope from a drowning man, and  to advise him to save him-
self by building a boat.
   Counter-irritants are chiefly useful in the severer  forms of dys-
pepsia, attended with great pain.   In speaking of their application
in  ulcer of the stomach (a malady in which they are much more
generally important) we have  already  (p.  145) alluded to details,
such as may spare  any further discussion of them  in  connection
with this malady.
   The application of heat and cold to the stomach  itself, by  the
introduction of warm liquids and ice respectively, may also be dis-
missed with slight notice.   The  former sometimes relieves pain;
but requires caution, both as  to the temperature adopted, and  the
selection of cases for its administration.   The latter is  chiefly useful
against vomiting, and (less effectively)  against pain.   Where any
definite effect of this kind is  desired, solid ice, in small lumps, or
in the semi-solid state of raspings, is preferable to iced liquids. 
270
DYSPEPSIA.
  Pepsinex has, I must confess, disappointed me in most of the cases
of dyspepsia in which I have tried  it; even after a careful  selec-
tion of those which seemed best adapted for its use.   Perhaps it is
not often, as already hinted,  that dyspepsia  is caused by a  mere
deficiency of gastric juice; and certakily  our existing means of
diagnosis do not enable us  to detect such cases with  the accuracy
that could be wished.  While in many of those  varieties of indi-
gestion in which  we are entitled to  suspect graver and  more con-
stitutional causes, it  is difficult to see how  the scanty solution of
a single alimentary constituent (generally taken up in  excess of the
systemic requirements from even a restricted food) can effect much
benefit.   Occasionally, indeed, I have found pepsine produce  con-
siderable disturbance, even in cases  where no great irritability of
stomach  appeared to be present.  I have thought some of these
disadvantages might be  obviated  by  using it  in  the shape of
peptone;2 a form in which I believe it would be of great benefit as
a highly nutritive drink or  enema in certain oesophageal and gastric
lesions (p. 151).
   The  substances termed tonics  are  often remarkably  useful:
indeed,  unless contra-indicated  by great irritability of stomach,
may be regarded as almost indispensable.   Amongst them the
various vegetable bitters claim peculiar notice";  not only because,
by the common consent of civilized mankind, they stand almost
midway between food and  medicine,  but because their effects  (both
local and general) in this malady are more uniform and beneficial
than those of most other medicines.   Some of them  (such as ca-
lumba) have a special  power over nausea and vomiting; most of
them increase the appetite; and lastly, their prolonged use produces
such invigorating effect on  the constitution, as almost suggests
some definite chemical purpose being subserved  by their addition
to the constituents of the  organism,  beyond  any  merely alterative
effect.   Among them may be included one remedy perhaps  more
frequently useful than any  other—namely, quinine; which gives us
most of the advantages of bark, where the nauseous  and bulky
powder, or  the decoction,  of this efficacious drug could  not be
borne by the irritable dyspeptic stomach.  Gentian, quassia, orange-
peel, camomile, and  a variety  of other bitters, are also at  times
useful;  chiefly, however, either as affording a selection where the
idiosyncrasies of  patients prevent the use of quinine, or as vehicles
and adjuvants for  other remedies.  As a rule  they should be ad-
ministered,  either on  an  empty stomach, or, if their appetizing
effect is desirable, shortly before a meal: but when combined with
alkalies, they may often be taken with  advantage toward the close
of the digestive act.
  The more astringent vegetable tonics are especially useful where
dyspepsia is attended with  any tendency to diarrhoea or to pyrosis.
1 See p. 39.
2 See p. 42. 
DYSPEPSIA.
271
Logwood, kino, catechu, rhatany, may thus be  administered:   in
most cases preferably as the powder or infusion, the alcohol of the
tinctures sometimes detracting from their effects.
  Various metallic substances ordinarily classed as tonics are also
extremely useful in dyspepsia.   Especially may we notice the pre-
parations  of iron: of which I would say, empirically, that it is  in
general useful, not only in proportion to the anaemia and general
derangement of nutrition present, but in proportion as the habits
and circumstances of the patient have prevented his getting that
due share of light, air, and exercise, the want of which aggravates
(if not causes) so much of the dyspepsia of civilized  life.  Hence
it is more useful in females than  in males; more in the sedentary
dyspeptic than in the florid  over-fed  subjects of indigestion whom
you will occasionally meet with in country practice.   That it has
other uses in this malady than those of a mere  aliment and  tonic
can, however, scarcely be doubted: increasing (as it appears1 to do)
both the gastric and intestinal  secretions  by a specific determina-
tion to the mucous structures which furnish them.  As regards the
cautions required for  its use, where there is great nausea and irri-
tability, it must generally be avoided.  It should always be given
immediately after a  meal:  and (as a patient  is not an ink-bottle)
never  with (or shortly  after)  tea.   Of its various preparations,
the modern citrate is  perhaps more readily borne than any, and,  in
an effervescent form,  will sometimes  agree with the most delicate
stomach.   Even of this, however (and a fortiori of the more irritant
ferruginous salts) I would caution you  against  giving too  large
doses, as they have no corresponding advantage, and  are liable  to
provoke nausea and flatulence.  The carbonate, phosphate, sulphate,
and sesquichloride, form a scale of increasingly irritative prepara-
tions:  and therefore  demand, not only a  diminished  dose, but  an
increased  dilution.  So that, for example, while we may  give ten
grains of  the citrate as a common dose, two grains of  the sulphate,
and seven or eight minims of the officinal tincture of the  sesqui-
chloride, diluted  with an ounce  of   water,  are  as much as most
dyspeptics will safely bear.  The oxide  of iron, as  well as iron
filings or  raspings, which used formerly to be given in treacle, are
now (and  I think very properly) almost obsolete.  In truth, though
these  and many other remedies have  been indispensable, and even
now would be both bearable and valuable to a large proportion  of
our patients, yet we have no right to risk the inconveniences and
accidents  which occasionally attend their use, unless some marked
superiority can be established for them.
  Zinc  in the  shape  of oxide and  sulphate is  sometimes   used:
chiefly as an adjuvant to iron, the effects of which it appears  to
resemble,  and to heighten by combination.  Bismuth, some of the
effects of  which  may perhaps  be regarded as tonic, is still  more
Compare p. 60. 
272
DYSPEPSIA.
useful as a remedy against that form of dyspepsia which constitutes
the "morbid  sensibility  of the stomach" specified by the older
writers.   Here its effects in allaying flatulence and nausea, and  in
preventing vomiting,  and (still  more) in checking the  pain pro-
duced by food, are so marked, that we may fairly accept the term
of sedative often applied  to it (p. 147).
  The alkalies and acids, as well as various salts formed by their
combination, have also been largely used  in the treatment of dys-
pepsia.
  The alkalies (with which we may conveniently mention their car-
bonates, as well as the alkaline earths) seem chiefly useful in cases
in which the close of the digestive act is attended with much flatu-
lence, regurgitation, and heartburn ; where their immediate effects
may  be attributed to a neutralization of those lactic and acetic
acids, which the decomposition of the undigested food can produce.
In other cases they appear to bring about general results at least
as  valuable  towards  the cure  of the  malady: preventing, for
example, the uric acid sediments associated with some of the more
obstinate  varieties  of the  malady;  or provoking, it may be, the
secretion of the liver, pancreas, or intestines.  Both with a view  to
these local effects,  and to avoid the neutralization  of the gastric
juice, the  administration of alkalies should be limited to the latter
part of the act of gastric digestion, and to the succeeding period  of
rest.  And in any case, unless some definite constitutional result be
sought from their use—when a smaller dose, and a larger dilution,
become advisable—these remedies should be regarded only as occa-
sional palliatives, or  as temporary measures; and should not be
pursued for a longer period than a few weeks at a time
  Acids are  regarded chiefly as tonics;  with local effects which,
whatever  their  minor differences,  probably agree  in  furthering
gastric secretion, as  well  as in  aiding the solvent powers  of the
juice  already poured out by the stomach.  The differences of their
constitutional eff'ects have yet to be established on physico-chemical
grounds:  but the astringent effects long ascribed to sulphuric acid
promise to constitute a distinction.  They are all contra-indicated
by great irritability of stomach.   It need hardly be said that such
potent remedies should only be given in a small and dilute dose
("iv—xx of  the  dilute acids, P.  L.), and  that care should be taken
to protect  the teeth  of the patient from their corrosive eff'ects.   They
should be administered during or immediately  after a meal; and,
so far as  I can judge, are more efficacious, and less likely  to dis-
agree, when mixed writh pure or distilled water  than in  any other
combination :l a  point (by  the  way) in  which  they  differ  from
alkaline carbonates, which may often be combined with bitters, not
only  with  no loss  of  effect,  but  even with an increase of power.

  1 Even quinine is scarcely an exception to this rule, when the effects of the acid
are desired. 
DYSPEPSIA.
273
Lastly, it  is said that acids  and alkalies are sometimes of great
service when given alternately: the former just before or during a
meal, and  the latter an hour or two after; a mode of administra-
tion which is certainly of use in some forms of chronic constitu-
tional and visceral disease, but which  savors of a poly-pharmacy,
such as is rarely necessary in  this malady, and should always if
possible be avoided.
   Of those various salts of the alkalies and alkaline earths which
are presumed to have effects distinct from their aperient action, we
need only select two for special mention—the iodide of potassium,
and the hyposulphite  of soda.  The latter appears to substantiate
the claims made for it by Dr. Jenner a few years ago, as a remedy
against flatulent dyspepsia: its efficacy seeming due to its power
of checking decomposition in the food, as well as to its local effects
on the stomach itself.  It  may be given in the same doses and
combinations, and with the same limitations, as the  alkaline car-
bonates, the effects of which  it somewhat resembles.   The iodide
of potassium I am in the habit of prescribing chiefly in those cases
of flatulent dyspepsia in which—whether from a too starchy diet,
deficient or hasty mastication, decayed teeth, the abuse of tobacco,
or other  causes—the salivary  secretion  seems either deficient  in
quantity, or faulty (for example, acid) in quality.   In such cases, a
very small dose' will  suffice: from  one to two grains  in combina-
tion with seven or ten of bicarbonate of potassa, sometimes effecting
a  marked  change after two or three administrations.
   Aperients constitute  a means of treatment the proper appreciation
of which is of the first importance.   When a person over-eats and
drinks himself into what used  to  be called a surfeit, but is now
more politely (but less  accurately) named an indigestion, he natu-
rally thinks of removing the  cause of the mischief, if Nature have
not already done so by a spontaneous  vomiting or diarrhoea.   The
old Baman epicures adopted the quickest and most effective means,
an emetic: which could be  speedily followed  by  another  feast.
The modern votary of good living clears off' the eff'ect of his ex-
cesses by  a purgative; a  means  of relief in which, with less  to
excite disgust, and  perhaps more to relieve the system, the same
principle may still be  traced.
   But a physician is not a censor morum: and if  I call attention  to
this  method of using  purgatives in the treatment  of dyspepsia, it
is  only with the object of pointing  out its mischievous effects in a
medical point of view.  It cannot be doubted that in these effects
of intemperance, as  well as in many casual (and even habitual)
dyspepsias which are quite independent of all such excess, many of

  1 I could bring forward several instances of the facility with which downright
iodism has resulted from small doses (e. g., three grains thrice repeated, and even
less than one grain), in young and  robust persons  of both sexes.  What graver
accidents (delirium and even mania) may follow its abuse, I only know by hearsay,
as having been observed by some  of the leading living members of the profession.
       18 
274                       DYSPEPSIA.
the most  distressing  symptoms may be suddenly and greatly re-
lieved by a smart purgative: and especially by some such purgative
as the well-known blue pill and black  draught.   But nothing can
render this immediate relief permanent save the  adoption of that
diet and regimen, and those general remedies, which form the staple
treatment of dyspepsia.  I would go further, and say that in many
instances  the immediate relief thus obtained is very evanescent:
and, without any concurrent  indiscretion, leaves  the  patient in  a
few days no better than before, as regards the local symptoms of
his malady; but considerably worse as regards that general debi-
lity and malaise which constitute its effects,  and which purgatives
(and especially mercurial  purgatives) are themselves calculated to
produce.   And of the habitual  or even repeated use of such
measures, I can only express an unqualified condemnation.
   Indeed, with respect to the use of aperients in dyspepsia gene-
rally, perhaps the following rules may be laid down.  They  are of
great service in emergencies:  of little service (almost of disservice)
as prominent features in  the course of treatment;  which  ought
almost always to aim at such a tonic effect as is incompatible with
habitual purgation.  Against  habitual constipation,  they are gene-
rally ineffective: and can in most cases  be replaced (or substituted)
by proper attention  to diet.   In administering  them, the  object
should be, to accomplish the desired effect with the  smallest possi-
ble doses.  This  indication may be greatly  aided by giving them
on an empty stomach: either before dinner, for  example, in  the
case of  a  slowly acting pill, or early in the  morning in that of  a
more rapidly acting liquid.  As a rule, the pill1 form is preferable,
especially where the aperient is often repeated; the liquid aperients
(especially  the saline) often acting injuriously  on  an  irritable
stomach.  Castor oil is, in many constitutions, an  exception to this
rule: but then, again, it is sometimes difficult to predict the exact
eff'ect of  a  given  quantity:  in other words, to hit  the  minimum
dose which  is all we  can  give without  preparing  for that  reactive
constipation generally observable after an artificial (as well as an
idiopathic) diarrhoea.
   Sedatives  are of course often indicated in a malady so painful as
dyspepsia.  And amongst them opium, in its various forms, retains
the pre-eminent value it possesses in other diseases.  As you  would
expect,  these remedies are useful chiefly as palliatives, and especi-
ally as anodynes in the more painful forms of indigestion.   In the
morbid irritability already alluded to, their use is almost indispen-
sable.  But in the purer or simpler  forms of the  malady, it  is our
object, on constitutional grounds, to administer them as rarely as
possible;  at any rate to avoid an habitual dependence on their  use,
which shares some of the  nutritional disadvantages ascribable to

  1 In many instances this rule will also be found applicable to tonics (compare
p. 154). 
DYSPEPSIA.
275
alcohol  and other stimuli.  The time, dose, and mode of adminis-
tering them are matters for decision in each case, and are regulated
chiefly  by the amount and  duration of effect desired.  Thus, to
relieve a sudden  attack, we should give the drug in solution; to
prevent or  alleviate severe  habitual pain  after  meals, and in an
irritable stomach, a pill of morphia or extract of  opium, at such a
time before the attack  as allows the effect of the drug to anticipate
the pain.  In such attacks, however, few forms of sedative are more
generally useful than the compound kino powder in combination
with bismuth (compare p. 147).
   Time fails me to sift the claims of a variety of other remedies;
mercury,  silver,  arsenic,  prussic acid,  strychnia, and some other
vegetable alkaloids.  Concerning mercury I would say that, while
it is quite possible that maladies in which dyspepsia  is prominent
may sometimes require its administration, its habitual use, even as
a purgative, seems to be not without  detriment;  and that its more
marked constitutional  effects are generally most mischievous. And
when I have told you that prussic acid will often allay vomiting,
and that  strychnia is  alleged  to be  an excellent remedy against
habitual costiveness, I have said all that is suggested to me by the
mention of these drugs.  If you  think this a meagre account of
such celebrated  remedies,  pray remember that I am speaking
mainly from experience, which is, in their case, to a great extent
negative.  After nearly twenty years of almost  uninterrupted at-
tendance on the sick, fifteen of which have  been spent in metropo-
 litan hospitals' or  dispensaries, where the  successful treatment of
dyspepsia has  been one of my most common professional duties, I
must confess that I rarely use the above energetic drugs, simply
because I rarely require them.  And withou^asking you to follow
my example, or  to overlook the strong testimony in their favor of
other observers at least as well qualified to form an opinion, I will
end by quoting to you a passage from an admirable work on this
subject by one of the first physicians in Europe,  who has lately
 died, full  of years and of honors, and leave it to you to judge
 whether these remedies may  not be really contraindicated, even
 though occasionally useful;  whether, in short, it may not be a ques-
 tion  of tact and prudence, and conscientious  care for the public,
 rather  than of abstract therapeutical operancy, which we have prac-
 tically to decide respecting them.
   " I have a great disinclination, I confess, for such remedies, which
 bring with them so great and incontestable perils,  and the  good
 effects  of which  are, in my opinion,  very uncertain.  These perils
 are capable of being prevented, it is true, if the physician is always
 attentive to everything he prescribes, if he carefully reads over his
 prescription ;  if  this is written in such a way that there can be no
 possible uncertainty as to  its  words and  figures;  if the druggist
 and his assistants are  protected from all distraction, and all error;
 if the remedy  is given to the  patient exactly at the intervals, and 
276
DYSPEPSIA.
in the doses, indicated; if (unlike what has  often happened) there
is no giving in a single day the accumulated doses of those which
have preceded it;  if,  after one parcel of strychnia  is exhausted,
that which follows is neither purer nor stronger.  But how can we
be sure that all these conditions will be observed, each and every day.
on the part of every one who has to fulfil them ?  If, in spite of these
dangers, strychnia really cured dyspepsias  against which every
other remedy had failed, I would myself resort to it.  But when  I
look back to the past,  when I see dyspepsia  almost constantly  due
to the errors of  hygiene which maintain it so long as they are  not
removed, when  it must be evident to every one that no  medica-
ment, strychnia  or anything else, can be a  substitute for the remo-
val of these causes, and when, in the  few cases where I have tried
it, I have not obtained any manifestly favorable eff'ect, I  do  not
know how I can recommend its administration.'"
   Diet we shall  not dwell upon.  For the  physiology of digestion
has already  taught you principles by which to judge of the proper
quantity, quality, and  frequency of the meals which a healthy per-
son (and d fortiori, a dyspeptic) ought to take; as well as the  im-
portance of proper cookery, and of that mastication and insalivation
which is still more indispensable as  a  preparation of the food for
the digestive  process.   To inquire in what way the practice of
your patient deviates from these physiological principles, and what
idiosyncrasies heighten or modify their application to his case, and
to prescribe  more natural and wholesome rules of alimentation, is
of course your chief duty as regards his diet.   And  there are few
rules which  could be  briefly laid down, so as to guide you in se-
lecting, from the numberless modifications  of  the diet of  health,
those which it is from  time to time  advisable to  adopt.  Hence  the
following allusions may suffice.
  In respect to quantity of food, of course we have often to  reduce
it in the first instance far below what it would be necessary or
proper to recommend for  a permanency.  In many cases of dys-
pepsia, whatever is superfluous is  hurtful; and therefore we have
first to effect  the partial restoration of the digestive process by a
diet adapted to its feeble powers, and then  gradually to revert to a
more liberal scale of food.  Where the stomach itself is chiefly or
primarily in fault, we  must just as obviously apply this principle
to those protein  compounds which it is its special office to dissolve;
reducing their quantity; securing their proper dilution and mixture
with other alimentary principles; and especially, giving them in
such small and frequent doses, or even  in  such  a bland and pulpy
consistence, as will allow them to pass  rapidly out of the organ after
being impregnated with its secretion of gastric juice, so as to receive
their solution in the intestine (pp. 159, 160).
  As to the use of alcohol in dyspepsia, while freely conceding that
1 Chomel, " Des Dyspepsies."  Paris, 1857, p. 228. 
DYSPEPSIA.
277
every case is a rule to itself, and must never be decided on general
principles, I would offer the following hints.  First of all, let me
beg of you on no account  to endanger the welfare of a reformed
drunkard who has been rescued by teetotalism from death, by pre-
•scribing -alcoholic drinks in any form whatever.   I  have known
one or  two awful relapses,  and inconceivable misery (both to  the
patient  and his family), produced by carelessness of this kind.   It
is much better that you should candidly inform such a one, that
his laudable  self-denial  requires certain precautions;  that it de-
mands parallel temperance in his eating; and that just as, morally,
it may be doubted whether he is entitled to substitute intemperance
of thought and speech for  intemperance of act, or to replace  the
privacy and penitence wrhich befit a repentant debauchee by  the
public vituperation of what  others have made a lawful and innocent
indulgence—so, medically, he must be looked upon as merely sub-
stituting one error for another, if, from drinking to excess, he takes
to eating too  large  or luxurious a food.  Indeed, supposing  the
teetotaller's avocations do not demand excessive and continuous toil,
he digests so  much more completely (at least, such is  my opinion)
what he does take, that he requires less (rather than  more) food
than  a  person in affluent circumstances who moderately indulges
in alcohol.   While  he certainly has  lost that safeguard  which
alcohol in some degree affords against the immediate results of over-
eating.
   And conversely, the uses  of alcohol—which merge, I confess, by
no very marked line into its abuses—may also be  traced in a  few
words continuing the above statements. As regards the organism
generally,  alcohol not only enables a man,  by its general eff'ects, to
sustain health on food otherwise insufficient and against toil other-
wise  injurious,  but  it also  obviates—perhaps oftener  defers and
accumulates—some of the direct consequences of gourmandise.  That
good eating requires good  drinking, has in  all ages of the world
been admitted: and to select the most invidious illustrations  of this
fact, the gigantic meals  which are sometimes ended by the slow
soaking in dilute alcohol of almost all  the food taken—so  as to
check alike digestion and decomposition, and enable  the canal to
void its contents after a very scanty absorption of their nutritious
principles into the  bloodvessels—would  scarcely  be compatible
with the health sometimes  associated with them, save by an eff'ect
of this  kind.
   The  benefits of alcohol in dyspepsia are  these:  Partly  by its
local, more perhaps by  its  general effects, it sometimes gives an
appetite to a  person otherwise  incapable  of  taking food.  Many
persons, for example, half dyspeptic, half exhausted, require some
such preparation or accompaniment for the chief meal of the day.
Similar influences are traced in the increased secretion which its
stimulating effects often seem  to bring about; an increase well
shown in the singular manner in which those  who only take these 
278
DYSPEPSIA.
fluids occasionally  find that a  small quantity of wine has  to be
substituted by a large quantity of water.  Lastly, there are cases,
and these not  infrequent, in which a suitable alcoholic fluid seems
to facilitate the whole digestive  process, and reverses what I believe
to be the rule, even for dyspeptics—namely, that  if the food be
rightly chosen and prepared, digestion is much better conducted
altogether without  alcoholic liquids.  That they render digestion
slower, and  more  precarious, and increase  the feverishness from
which dyspeptics often suffer  after meals, is undoubted.  And I
have made some observations which justify me in suspecting that,
even apart from any sensible derangement of digestion, the mode-
rate use of alcohol largely increases the ammoniacal constituent of
the feces: a  result which, if confirmed, would  indicate that  the
diminution of daily urea under its use may have some substitute
in other channels of excretion (compare p. 265).
  As to  the variety of alcoholic fluid to be used, much of course
depends on the peculiarities of the case.  But from reasons already
alluded to, the purer and  more dilute the  alcoholic mixture,  the
less danger is there of its acting injuriously on the digestive process.
Hence a small  quantity of brandy, or twice the quantity of dry
sherry, diluted with  pure cold water, is  generally preferable, both
to beer, and to the sweet and  factitious ports and sherries consumed
in this country.   Champagne and the other effervescing wines  are
mostly injurious.  The purer  and  more natural wines of French
and German growth, either diluted or undiluted, are admissible in
a vast number of cases in  which the preceding are hurtful.  And
lastly, where an alcoholic beverage is indicated by the general state
of the organism, but deranges digestion,  the expedient of its larger
dilution, or (if this  be unsuccessful) of  its  complete disseverance
from the food (or meal-time), will sometimes obviate  all such de-
rangement of this process.
  Regimen.—There  are many other measures, such as we include
under the term  "regimen," which are of extreme value in the more
protracted and  obstinate cases of this  distressing malady.  The
importance of fresh air, of exercise, of the proper regulation of  the
functions of the skin,  of the observance of a  period of rest after
meals, of the  repose of an  habitually overtaxed brain, and various
circumstances of like nature—claim attention under this head.  So,
also, much might be said of such remedies as foreign travel, mineral
waters, and the cold  water  treatment.  Mineral waters  as thera-
peutical  agents can hardly be valued too highly.  It is certain that
many of them are sustained without inconvenience, by stomachs
far too irritable to  support the artificial mixtures prepared by the
druggist in accordance with  our prescriptions; and equally certain
that they introduce into the system considerable quantities of the
very  remedies (chalybeates,  salines, and aperients) which we  are
compelled to  resort to as remedies  in many varieties of dyspepsia.
And whatever their " alterative" powers, the  circumstances which 
DYSPEPSIA.
279
attend their  administration are scarcely less beneficial;  and, espe-
cially, permit the enforcement of rules of life, which we sometimes
despair of our patients following, so long as they pursue their ordi-
nary avocations, and mix in their customary society.   The effects of
pure water (as applied externally and internally by the hydropaths)
in dyspepsia have yet to be ascertained.  Judging from the evidence
at present accessible, it is sometimes of  great benefit.  But I need
hardly say that, when it is applied by persons  who make it a system,
and regard  it as a cure for all diseases (at any rate as a substitute
for most other means of treatment), we cannot expect that selection
of suitable  cases, which can  render its results either safe to  the
patient, or conclusive to the  profession.  And from analogy1  and
experience we may safely assert, that most (if not all) of the benefits
ascribed to it are  equally explained by the fresh air, mental quiet,
early rising, simple food, and copious exercise, which the subjects
of the hydropathic course adopt, in conjunction with packings  and
douches: perhaps after having  steadily disobeyed  every such re-
commendation on the part of their more legitimate medical advisers
for months and years before.

  1 The speedy and marked benefits derivable from but a part of such a regimen
are well exemplified in what is termed the "training" of prize-fighters; and in
the pedestrian  tours, from which, annually, thousands of exhausted citizens date
a new lease of health. 
280
                      LECTURE  VII.

                         Gastric Phthisis.

  The course of pulmonary  phthisis is usually accompanied by
disturbances  of digestion which, even when they remain strictly
subordinate to the other symptoms, suffice to show that the stomach
is indirectly involved in the malady.  Evidence of such indigestion
is  seen in  the capricious defective appetite; the eructations; the
regurgitations of food or of acrid sour liquids; the vomiting; and
the various degrees and  kinds of pain after food,  from heartburn
to severe pain and soreness at the epigastrium;—symptoms which
are rarely absent, in some form or other, from the greater part of
the visible duration of the thoracic disease.
  To trace, however, this dyspepsia  to its doubtless diverse, and
often complex causes, much more to refer its several elementary
phenomena to their respective sources, is utterly impossible.  Even
to enumerate its leading varieties is  by no means easy.  In some
instances, it is fair to infer that the dyspepsia causes the phthisis;
which, in point  of time, it certainly  precedes and ushers in.  In
other cases, perhaps more  numerous, the thoracic lesion and the
gastric disturbance seem to be twin effects of a common cause—a
bad  or cachectic state of the constitution.  Far oftener, I believe,
the dyspepsia, as well as the  various appearances which we  sum
up by the word cachexia (so far as the word has any exact mean-
ing),  is itself the result of the injurious reaction of tuberculous
deposits—dying, dead, or decomposing—in the tissues of the body
or the system at large.  Such dyspepsia merges, with no very dis-
tinct line of demarcation, into the large and obvious class of indi-
gestions  in which the pulmonic lesions set up an  irritative fever,
having a dyspeptic  element evidently analogous to the digestive
disturbance attending an ordinary fracture or wound.  At a later
period of the pulmonary destruction,  there are not wanting indica-
tions that undue bodily waste, sweating, suppuration, and the toxae-
mia  which the  partial putrefaction  of various pulmonic tissues
produces in the adjacent blood, all exert an influence more or less
characteristic on nutrition,  and therefore on digestion.  And here,
again, we approach a more specifically pulmonic causation of these
dyspepsias:—(1) insufficient  aeration of blood, and the results
(many of them it  may be  suspected  less of degree  than of kind)
which imperfect oxidation of the blood brings about in the chem-
istry of the organism generally; and which we indicate (rather than 
GASTRIC PHTHISIS.
281
sum up) by such words as  incomplete combustion, defective elimi-
nation, and the like;—(2)  nervous irritation and  exhaustion, not
only such as are producible by lesions of all parts of the body,
but such  as  specially oppress a  function  which, unlike that  of
many other structures, must continue uninterruptedly in order that
life may be  carried on, and which  can only be  effected (as the
physiology of respiration shows) by an expenditure of energy con-
tinually increased1 in proportion  as  the diseased  organ, itself be-
coming  more defective, continually deteriorates in respect of even
the simplest physical conditions2 of its action.  To a similar nervous
origin we may refer the vomiting  which, in many cases of phthisis,
is scarcely to be considered in its ordinary light as a symptom  of
dyspepsia.  The gush  of emesis which  ends a fit  of cough  in ad-
vanced  consumption  seems strictly  comparable to  the vomiting
which occurs in advanced whooping-cough; and indeed, is analogous
to the retchings which, in bilious  or  intemperate persons, are pro-
voked by the gargling of  the mouth  and brushing of the  teeth
incidental to their morning ablutions.  For in all these vomitings,
an enfeebled nervous apparatus permits or conditionates a kind  of
morbid co-ordination  between  its  various parts; which lose, as  it
were, their due independence, and become  liable to be drawn into
a simultaneous  action; an extension or transference of their natural
working in some sense analogous to that abnormal protraction and
extension of muscular action which constitutes an ordinary cramp.
   With  such diversities of dyspepsia incident to various stages  of
the course of pulmonary phthisis,  it need hardly be  said that the
collective gastric disturbance of any particular case often defies an
exact pathological  analysis. But the importance of recognizing
these diverse forms or  causes of dyspepsia by no means rests on
the facility or usefulness of appraising the shares which they re-
spectively take in the casuistry of the  disease.   It is rather as a
clue to  the gastric phenomena of phthisis in general,  and as an ex-
planation of  the manifold  degrees and kinds of  indigestion met
with in this malady, that an enumeration like the above  finds its
justification.
   It has the further advantage, too, of forming, by way of exclu-
sion, a group of cases which, on clinical and practical grounds, de-
serves especial study; and which I propose  to  consider as gastric
phthisis.
   Without denying that in many cases the dyspepsias incidental  to
pulmonary consumption merge into  " gastric phthisis" by almost

  1 Of such an increased expenditure of energy, the increased frequency of breath-
ing constitutes in  the main a tolerable exponent; especially as the diminished
efficiency  of breathing, by affecting unequally various parts of the apparatus,
increases disproportionately the labor or energy claimed from the least diseased
portions.
  2 Conditions, perhaps, easiest followed out into their details under the physio-
logical grouping of the chest, the lung, and the air-tubes ; and the shares respec-
tively taken by these structures in the act of breathing. 
282
GASTRIC  PHTHISIS.
imperceptible gradations  of symptoms, I can  confidently affirrn
that in  the  study of gastric disease, increasing experience conti-
nually brings this condition before me with increasing prominence;
and that, while the latency of the thoracic mischief, and the promi-
nence of the gastric symptoms, would alone suffice to justify their
distinction;  the cases themselves, whatever may be the diversity
of their nature  as regards histological  details, possess sufficient
uniformity in the outline  of their  symptoms, and in  the  plan of
their successful treatment, to fall naturally within a common de-
scription.
  The outline of a typical case of this  kind may be drawn some-'
what as follows.  The  patient, usually under thirty-five years of
age, feels the first approach of  the malady as an " indigestion;" an
epithet which, on inquiry, resolves itself into a pain beginning be-
tween the first and second hours after food, and going off gradually.
At first such a pain often  follows but one of the daily meals;  per-
haps oftenest a full morning repast.  It  rarely brings with it any
flatulence; and is still more rarely relieved by eructation.  As the
malady advances; the pain becomes  more frequent, and follows all
the meals;  only distinguishing,  by  attacks of unusual  severity,
those in which the food is more copious in quantity, or more solid
and indigestible in quality.  By and by, the sickening depression
which has gradually been recognized as an element of the increas-
ing pain diverges into distinct nausea; and this again soon provokes
retching;  which, in its turn,  sometimes gradually deepens  into
vomiting.   Often, however, the latter symptom remains  long or
permanently absent.  If present, it is  only rarely, or after long
persistence,  that  it brings back from the stomach any of its ali-
mentary contents; and even then  scarcely ever unloads the organ,
much less relieves the  pain by which it is preceded.  By longer
continuance, the pain and retching become more severe, and more
easily provoked; and therefore continually approach the period of
taking food, so as hot only to follow it by a shorter interval, but at
length to limit the meal to  little more than painful and unavailing
attempts to take food, the  suffering which immediately follows its
deglutition  becoming almost unbearable.  This climax of gastric
disturbance thus attained  is, in rare instances, itself the chief cause
and immediate forerunner of death.   But it much more commonly
either inaugurates a rapid infiltration of the lungs with tuberculous
deposit, or is  displaced  by the thoracic symptoms  of  tubercle
already deposited; to alternate (it  may  be) with such symptoms
during the  brief remainder of life.   In  other cases, the dyspepsia
amends spontaneously, or is vanquished by appropriate treatment;
and the patient, slowly recovering  flesh and  strength, advances
towards that imperfect health which, in so many instances, is asso-
ciated with  the retardation or arrest of the progress of tuberculosis;
perhaps until the infirmities of declining years, mingled with the
insidious  symptoms of  the malady, leave us in doubt to which of 
GASTRIC PHTHISIS.
283
these two causes—natural decay or tubercular  disease—we must
chiefly refer the eventual death.
  A closer scrutiny of these cases from their clinical side—in other
words, with the very natural object of making their detection and
cure paramount to any more systematic or scientific  study—leads
us first to the  question of  their connection with other forms of
phthisis among the near relatives of the patient.
  In respect to this important point, experience seems to show that
the ordinary rule  as to the  frequency1 of such a connection holds
good: qualified, rather than really subverted, by the following ex-
ceptions.   First, the rule applies to a somewhat  smaller percentage
of these cases of gastric phthisis than of ordinary pulmonary tu-
bercle :  in other words, whatever  slender  aid to  diagnosis  the
history of phthisis in  the  family can  afford  is oftener  absent.
Secondly, there is a manifest tendency to the affection of various
members of the same family with a similar or analogous form of
phthisis:  at least in  so far as that we  may occasionally find the
gastric phthisis—itself rare—occurring in two or more such rela-
tives ; and much more frequently may observe its occurrence in
one relative, while another succumbs to the characteristic intestinal
form of tuberculosis.  Of these two qualifications, the former is the
more striking and important:  certainly, my own experience ena-
bles me to recall quite a disproportionate number of cases in which
the gastric  form  of phthisis has  attacked  persons  whose family
history was free from all suspicion of  tubercle;  and  whose active,
open-air habits were, to all appearance, very unlikely to invite it.
   The diagnostic element afforded by  an examination of the chest
in these cases is one which, practically, may be difficult to detect,
but logically, is susceptible of  an exact definition.   Paradoxical
as it may sound to  say so, it is quite  as  much by the absence of
some thoracic signs, as  by the presence of others, that the results
of  careful auscultation indicate a given case to  belong  to the cate-
gory of gastric phthisis.  Large or advanced lesions of the lungs,
just as they  are  not  likely to  be  overlooked  on  the one hand,
so, on the other,  they suggest any concurrent gastric disturbance
to  be of  that kind of which we have already enumerated several
forms; all being in great degree the frequent and necessary (though
indirect)  results  of the lesions  themselves.   But this distinction,
confessedly one of pathological grouping, curiously coincides with
a real  contrast of symptoms.  Barely or never have I met with
the typical nexus of gastric symptoms just delineated, in  concur-
rence  with  signs indicative of  the presence  of  even moderate
aggregations of tubercle in the lungs, much less of their disintegra-

  ' From careful hospital researches, I have elsewhere (on the Medical  Selection
of Lives for Assurance, 3d edition, p. 25) estimated that among phthisical patients
of the middle classes, 35 per cent, of the relatives comprised in the four nearest
degrees  of blood-relationship (parents, brothers and sisters, uncles and aunts,
and grandparents), are  recognizably phthisical. 
284
GASTRIC  PHTHISIS.
tion and removal.   Nay, more, even that  very form of pulmonary
tubercle most nearly allied to the condition of deposit which will
be pointed out as commonly associated with gastric phthisis—the
small, discrete deposits which, sown broadcast through the lungs,
often, by  their  simultaneous ripening, set  up  acute phthisis'—
appears rarely to approach in its gastric manifestations to the above
symptoms.
  The febrile reaction of these cases constitutes another diagnostic
mark, being  greatly in  excess of any such degree of this reaction
as is  ordinarily seen in  ulcer of the stomach, much more of any
merely  functional derangement or dyspepsia of this organ.  Taken
in conjunction with the  absence of  considerable thoracic lesions, it
really raises a strong presumption of the true nature of the malady.
The general  impression thus afforded may perhaps be illustrated
by  what are in some respects analogous offshoots of pulmonary
tubercle:  namely,  cases of larjmgeal phthisis.  To subtract, from
the characteristic tout ensemble of. a case of laryngeal phthisis, the
voice and  breathing (including the cough)  specific to the organ
involved, would leave, as it were, very much the condition seen in
many instances of gastric  phthisis; in which the whole condition
of the patient testifies to a deep-seated, intense, but yet latent irri-
tation, such as even the marked gastric disturbance does but par-
tially explain.
  The characters of the  pain itself are subject to even more than
the usual variations affecting this  symptom in the structural dis-
eases of the stomach. In mere intensity, it rarely or never reaches
that climax of severity which many patients term  "spasm":  but,
within  this somewhat vague  limit, ranges through innumerable
degrees, from weight and fulness to severe burning.  Its situation
shows a similar diversity;  the epigastrium (the centre of which is
its most frequent seat) by no  means limiting its extent, and often
failing to include its chief or only site.  It sometimes spreads up
behind  the sternum, sometimes diverges  towards both nipples;  is
sometimes referred to the umbilical region, sometimes exclusively
occupies the space to the left (rarely to the right) of the navel.
Tenderness almost always accompanies  its  worst forms and at-
tacks ; but is often  transient, or is even found to  be compatible
with relief from very gentle, firm, and  even  pressure over the
painful  region.
  In its relations to food,  the pain shows another distinction from
that of  the structural diseases with which, in practice, this gastric
phthisis is most likely to be confounded.   Provoked by too bulky
or too solid a meal, and  often evidently called forth by some error
of diet, it is yet much more capricious and uncertain in these re-
spects than is, for example, the pain of gastric ulceration or cancer.
Hence the instincts of the patient  may often be studied and fol-
1 Especially, as it seems to me, in the Celtic race. 
GASTRIC  PHTHISIS.
285
lowed with much greater advantage; and, in all cases, improvement
of symptoms may bring a corresponding improvement of dietary,
with far less risk, and more rapidity.  And as regards the period
of digestion which is marked  by the access of the pain, the  pre-
ceding cursory  description shows  that this also  is  not fixed or
characteristic; but is strictly one having a definite relation to the
malady, quite as much as to the digestive act.  In  the outset of
the symptoms, it is at the climax  of digestive activity,  or  rather
during its wane, when the pain is ushered in; a period which co-
incides less with any special copiousness  of secretion, than with
that powerful muscular action which wrings out the residue of the
gastric contents through the reluctant  pylorus.1  Gradually the
pain comes-on earlier; until, at last, it is the deglutition, rather
than the gastric  contact of food, which seems to provoke it; much
as the slightest noise or  sound in his neighborhood sometimes
strings up a tetanic patient into agonized  convulsion, or (to use a
more homely illustration) much as an imprudent movement of the
foot wakes up a dormant  cramp in the leg.
   The vomiting in these cases, though often quite as strictly the
climax of the attack as it is in  the similar  paroxysm which is pro-
duced by the taking of  unsuitable food into an ulcerous stomach
(p. 108), varies  widely from this  relation in many  well-marked
instances.  For in the more advanced stages of the malady, it oc-
curs with such facility, and so  rapidly after the ingestion of food,
as to anticipate (if one may so  say) all development of that parox-
ysm of pain  which  it thus displaces  and  substitutes.   In  rare
instances we thus find the malady almost reduced to a  single symp-
tom, of which the true  source of nature, evidently the chief point
for clinical study, can only be  made out with great difficulty and
caution.  For we  have  not only to guard ourselves against all the
ordinary sources of such severe vomiting, but are at times obliged
to remain in doubt whether the vomiting  in  the given case, even
though essentially due  to this  gastric phthisis, is not increased or
aggravated by some extraneous cause of this kind.  Among such
complications, hysteria, constipation, congestion of the liver, and
ulceration of the  bowels, are the most frequent and  puzzling in
actual  practice—the two latter  especially, from their frequent asso-
ciation with phthisis.
   The absence of hemorrhage  in gastric phthisis is  one of those
broad (yet safe) distinctions between it and  ulceration or cancer of
the stomach, which those who regard  the practice of physic as
based in great part on  highly educated  common-sense, are not
likely to underrate or forget.   Beyond a  streak or so of bloody
mucus, brought  up, not in the vomit, but  by the straining which
attends it, and usually with its  final efforts, I cannot recall a single
instance of the association of hasmatemesis  with a case of this kind
                             yv
                         1 Compare p. 26. 
286                   GASTRIC PHTHISIS.
—a circumstance which, if it be really the rule, certainly indicates
that  the stomach itself is rather bloodless than  congested, or even
enjoys almost an immunity from congestion during these attacks.
  Constipation is the intestinal derangement  commonly witnessed
in connection with gastric phthisis.  Often, however, the bowels
are unaff'ected.  Diarrhoea is  generally attributable to one of two
causes: to the presence of some degree of phthisical infiltration or
ulceration of the solitary and  agminate follicles, on the one hand ;
or to hepatic congestion draining off, as it were, by this channel, on
the other.
  It is with reluctance that I append to the foregoing clinical sketch,
which is  little more  than  a summary  of my notes of cases, any
speculations as to the nature of the symptoms I have ventured to
group under the heading of gastric phthisis.  But, without attempt-
ing  to define, scarcely even hoping to explain,  its exact  nature, I
venture to point out those analogies which  seem to me to indicate
the true position of the gastric malady, and especially its  relation
to ordinary tubercle of the lungs.   It is only by the study of such
analogies that this mysterious group of symptoms seems explicable:
only by the light reflected  on these darksome recesses of  the
organism, from more  exposed and  accessible structures,  that we
gain any insight into the state of  the stomach  in gastric phthisis.
Nor are attempts of this kind barren of general results.   Both the
science and  the art of Medicine justify (and indeed  demand)  all
reasonable effort to reduce every malady to its  true position  as a
mere variation from the laws of health, rather  than as a separate or
superadded entity of disease.
   If the foregoing outline of gastric phthisis be clinically accurate,
it allows us to recognize, in the symptoms thus  grouped, certain
primary or  essential  disturbances of the healthy functions of the
stomach.  Of these deviations from health, pain, the most charac-
teristic, is also  the most vague; and implies little, save irritation of
nerves.  But that  the sensibility (p.  51) proper to the organ is in-
creased to a diseased extent, is much more significant; and, taken
in connection with  the vomiting, which in its turn (p. 57) involves
a wide and  co-ordinate disturbance of the  motor  functions of the
organ, shows that the irritation may  be regarded as pervading the
whole nervous apparatus of the stomach, or at any rate, both sensi-
tive and motor nerve-elements of some part or parts of the organ.
Nay, even the very time at which the paroxysm reaches its climax,
points to the same conclusion; by showing that it is  precisely the
period of most energetic gastric digestion which is at first singled
out  for these abnormal acts  of sensation and movement of the
stomach.
   As regards  the secretion of gastric juice, there is abundant  evi-
dence that its quantity and quality are from the very first seriously
affected;  and  that, in the more advanced and intense stage of the
malady, the  secretory act is reduced almost  to a  minimum.   The 
GASTRIC  PHTHISIS.
287
clinical study of the vomiting, aided by a chemical analysis of the
substances it ejects, scarcely admits of any other conclusion.
  In the absence of any sufficient evidence of extreme congestion
—or rather in the presence of that presumption against it which
the rarity of any considerable hemorrhage in these cases substan-
tially amounts to—it is impossible to surmise whether to the irrita-
tion,  exalted  sensibility,  and  irregular  muscular  action,  thus
deduced from their symptoms, we are to add an undue vascularity
of the mucous membrane of the  stomach.  But such a  state  is
suggested by various analogies:  for example,  by the analogous
condition which Dr. Beaumont (p. 93) observed  in the acute dys-
pepsia of  intemperance, as well as  by the analogy which seems  to
me (apart from  any such suggestion) furnished  by some forms  of
neuralgia, for  the whole of that nexus of symptoms, to which the
name gastric phthisis appears fairly applicable.
   An ordinary  faceache  seems, if carefully considered, to afford
something like a clue to these cases; indeed, so much so, that  there
is a risk of  finding too many, and too close, parallels between their
circumstances, and thus of overlooking the wide diversity of nature
which separates the twro states.  For such a faceache, we may find
two chief conditions: a segment of diseased nerve in some  carious
tooth, on the one hand;  and a  disordered state of constitution,
or of digestion,  on the  other.  To open the mouth  and eliminate
the tooth, or to open the bowels and eliminate  their peccant and
superfluous contents, is what the educated common  sense of  prac-
tical medicine often regards as an alternative cure.
   But the cure of this neuralgia, save in so far as it illustrates the
connection of remote parts in the malady, is of far less importance
for our present  topic than its elementary  phenomena.    Among
these we  may enumerate (1) excessive pain, ranging over a wide
region of the adjacent tissues, but with a frequency and  severity
generally proportionate to  the nervous relations implied by their
supply from a common or congeneric division of the fifth nerve;
(2) undue sensibility, usually of still wider extent, and in the  main,
much more obviously and exclusively superficial or  cutaneous  in
its situation; (3) increased  heat,  vascularity, and interstitial fluid
—the latter often amounting to enormous swelling of the whole'bf
the cutaneous and subcutaneous tissues ; (4) muscular twitching and
spasm, which,  though  irregular in their date of occurrence, and
comparatively subordinate in their effect, are yet sufficiently recog-
nizable to be counted as tolerably constant ingredients of the  malady.
   Analogous elements to the foregoing are, I  think, traceable in
gastric phthisis.   The irritated and carious dental nerve is  repre-
sented by the irritated tissues  and nerves  of the diseased  lung;
the tuberculous deposit in which is shown by the common  incident
of haemoptysis to disorganize tissues at least as large and resistant
as nerve-tubes, long before it is  sufficiently aggregated to be dis-
cernible to physical examination in the living body.  The deranged 
288
GASTRIC  PHTHISIS.
 state of the constitution, or of the digestion, are also represented by
 corresponding conditions;  which, indeed, in respect of the function
 of digestion,  are  really often identical in the two neuralgias; in
 each of which errors of  diet,  both as to quantity and quality, or
 symptoms evidently tantamount  to  dyspepsia, precede and excite
 the larger disorder.  Increased sensibility is, mutatis mutandis, no
 less distinct in the case of the gastric mucous membrane than in
 that of the facial integuments.  Muscular spasm—which, as exem-
 plified by tetanus and cramp, is mysterious as regards its relation
 with its causes, even beyond what is usual with abnormal nervous
 phenomena—certainly seems very diverse, if we merely contrast a
 twitching facial muscle, or the agonizing cramp of a gastrocnemius,
 with the co-ordinate  act of vomiting.  Nevertheless, the maladies
 of the stomach and liver  indicate (what it  is  scarcely necessary
 seriously to prove) that there is a certain connection  between irri-
 tation of the solar  plexus of the sympathetic, and spasm of the
 unstriped muscular structures of the viscera it supplies, as well as
"with spasm of the striped voluntary  muscles of the belly,  and even
 of the limbs;  a connection such as no co-ordination having a merely
 final cause would apparently explain.
   These cases of gastric  phthisis may thus be regarded as a kind
 of neuralgia of the pneumogastric and sympathetic nerves ;* certain
 thoracic segments of these conjoined nerves forming the starting-
 point of an irritation and  morbid action, which is transferred  to
 their  abdominal  connections, and is  manifested in the visceral
 branches of the solar plexus.   It is quite possible that this latter
 irritation may substantially amount to a downright lesion  of nerve-
 structure, and, through this, may bring about a lesion of gastric or
 allied tissues.  It is  certain that, in any case, the demarcation be-
 tween functional  and structural  involvement  of both nerve and
 organ is one which cannot at present be drawn; and which perhaps
 owes its very existence to the insufficiency of our means of obser-
 vation.  But, after all, this  is no more than  may be said for  the
 most characteristic of the neuralgias; in which (as in  many forms
 of rheumatism and sciatica) we may find in different cases every
 imaginable gradation "between the  completest evidence of local
 inflammatory action in the sheaths of the affected nerves and in the
 parts they supply, and a  failure of all such  evidence of lesion  in
 connection with  the pain.  That the former neuralgias are, as a
 rule, much more continuous or  lasting, or are  remittent, perhaps
 often regularly remittent, while the latter are more transient, irre-
 gular, and intermittent, are general rules,  of clinical rather than of
 scientific import.  But the neuralgia of gastric phthisis also shows
 indications of an approach, in various cases, towards one.or other

  1 Two nerves more obviously, but not more essentially, connected in such a
 visceral neuralgia than in its facial analogue.  Even as regards anatomical admix-
 ture, the difference is more of degree than of  kind. 
GASTRIC  PHTHISIS.                 289
of these  extremes;  a fact the recollection of which may usefully
remind us that sudden and great amendments at times  occur inde-
pendently of those  dietetic  or- pharmaceutical  measures to which
the patient, or the physician, might otherwise be disposed to assign
an apparent cure.
  The treatment of these cases approaches, in  so many of its fea-
tures, that  indicated by the ulceration of the stomach which they
often closely simulate, that we may best consider it as _ contrasted
with what has already (p. 144) been said in studying this lesion.
  It may be premised that gastric phthisis is not only very amen-
able to systematic  treatment (which, it is hardly necessary to say,
must be distinguished from mere dosing with drugs), but that its
worst  symptoms often yield  with a promptness very unlike the
slower progress by which  even the most  favorable examples of
ulceration  of the stomach advance  towards their cure.   On the
other  hand,  amendment  is much more liable to  be  interrupted
without  any discernible cause; and,  where it takes place, requires
to  be  followed  up  by much more prompt and decided alterations
of  treatment, in order to prevent serious remissions  or  relapses.
These characteristic features of its treatment are, I think, to a great
extent explained by its neuralgic nature, and its relation to thoracic
disease.  But however explained, the fact is scarcely to be doubted.
I have repeatedly known the same patient who has been unable to
take a teaspoonful of milk without vomiting, and has been extenu-
ated by continuous pain, advance so rapidly toward amendment, and
be subject to such rapid enlargement of dietary during  this process,
as  to  be able in two or three weeks to consume a generous diet,
containing (in addition to all the ordinary ingredients of a day's
food and drink among the middle classes) one or two ounces of
cod-liver oil; the patient meanwhile constantly showing a propor-
tionate improvement in weight,  color, and bodily vigor.
   Empirically speaking, opium and other strong sedatives are often
but ill borne, still oftener unnecessary,  in these cases;  in which, on
the whole, carbonates of the alkalies (either free or in effervescence
 with citric  or tartaric acid) and minute doses of iodine, are gene-
rally of greatest service.  Their benefits seem to depend, partly on
their influence  on  the salivary  secretion, and on the liver ;^ partly
 on their neutralizing abnormal acidity (probably lactic acid from
 decomposition of starch and  saliva) in the stomach; partly to the
 causes which, in the absence of any perceptible influences of this
 kind  seem  to render those alkalies so serviceable in the earlier
 stages of pulmonary phthisis.  Blistering  is often of little avail;
 and when made use of, may with advantage be transferred to any
 part of the  thorax to which suspicion  is pointed by local pain, or
 by auscultatory signs.  Where there is already much fevenshness
 or heat of skin, it is better altogether dispensed with   Bismuth  is
 often  a valuable aid to the  above  drugs;  especially when there has
 been  any tendency to diarrhoea in  the patient's previous history.
        19 
290
GASTRIC PHTHISIS.
The calumba, or some other light  bitter infusion, is an  excellent
vehicle for the internal remedies ;  among which, by the way, prussic
acid, or the sulphocyanide of potassium, deserves  special mention.
Mercurials  in every form  should be carefully  shunned; even as
occasional aperients, and in spite of the immediate  relief they some-
times seem  to bring.   The  simplest forms of purgative—castor oil,
tartrate of potash with rhubarb, rhubarb pill, extract of colocynth,
guarded with henbane—are all that should be given by the mouth.
And whenever there is the slightest suspicion (p. 154) of any accu-
mulation of excrement in the cells of the colon—one might almost
say whenever there is not strong presumption against such accu-
mulation—a large  gruel  enema containing olive and castor oil, or
even  assafcetida, should be administered.  Such a procedure often
brings about extraordinary and immediate relief to the gastric pain
and vomiting which accumulation of  this kind can always greatly
aggravate,  and  of  which, in  some  cases, it even  seems  to be the
chief cause.
  The  various  preparations  of iron, though seldom well borne
without careful preliminary treatment  by some of the  above re-
medies, are of great value.   The effervescent citrate is perhaps the
form in which they are best begun.  The sulphate, as a pill, is also
very serviceable.   Both may be usefully combined with a minute
(one grain)  dose of the iodide of potassium.
  As regards diet,  the small and  frequent doses of milk, or meat-
broth, with  farinaceous food, by which the ordinarily severe vomit-
ing is best attacked, render this stage of the treatment closely akin
to that of gastric ulcer.   The absence of mastication must also be
compensated in  like  manner.1  Greater variety,  and more  rapid
enlargement of  the dietary are, however, to  be  early resorted to;
and  a moderate quantity of alcoholic stimulant (such as brandy,
largely diluted with water or soda-water), is  almost always benefi-
cial from the very first.   Bum and milk is also  of great service in
many instances.  In  others, however, it seems of absolute disser-
vice—apparently from that great proneness to hepatic congestion
which is discernible in many of the earlier stages of consumption,
and which is certainly evinced by a very large proportion of these
cases of gastric  phthisis.

  1 Insalivation, in some  form or other, is so important a part of the digestive
function, and  the deglutition of  unmasticated starchy food  so injurious  by the
acidity and flatulence it is apt to cause, that, to a patient making use of this liquid
diet, the  homely expedient of  sucking a small  pebble, or chewing a bit of soft
caoutchouc, is a remedy the suggestion of which needs no repetition to those who
have experienced the relief it often brings. 
291
                     LECTURE  VIII.

                    On "Gout in the Stomach."

  By the term  "gout in the stomach," is usually understood  an
affection having its chief, if not exclusive, seat in the tissues of this
organ; where it constitutes a manifestation of the gouty cachexia,
sometimes preventing, but far more frequently replacing (by retro-
cession  or metastasis) the ordinary paroxysm of articular gout.
Whatever may have been the  misgivings of some recent authors
as to the frequency of  this affection, or the change of its  being
now and then assumed as the  explanation of attacks more easily
and directly referable to other  causes, it is doubtful whether there
is a single  writer  on the subject who  does not  either imply the
above definition, or expressly affirm it.
  There are  many circumstances connected with  the attacks thus
named which, carefully weighed, go  far to explain how "gout in
the stomach" gradually gained  this place in  the literature of gout.
The cases themselves are sufficiently rare, obscure, and  diverse, to
throw great difficulties  in the way  of their undergoing exact or
frequent clinical comparison with each other.  Their phenomena
are essentially connected with symptoms, which are at least closely
related to the morbid acts of the stomach (Chap. II.).   They are
not only extremely dangerous to life, but are sometimes fatal with
a suddenness  itself almost explaining  the  scanty or negative ap-
pearances met with in  the  subsequent necropsies.   Lastly, their
true import is only deducible from considerations,  both clinical and
necrological, which, until lately, have been scarcely at our disposal
in respect of any of the  organs they involve, especially in respect
of the stomach.  Taking into account that  imperious necessity of
an explanation which the striking character of the so-called "gout
in the stomach" may fairly be  said to offer, it  may perhaps  be
regarded as having afforded until  lately a perfectly legitimate  and
useful hypothesis; and  it may even be questioned whether any
one has a right to disturb it without being prepared to offer some
more exact and satisfactory (if  less exhaustive) explanation.
  Conceding  so much, it will  not, I hope, be thought  irrelevant,
even in this condensed treatise on the diseases of  the stomach, if I
endeavor briefly to answer the question which years ago I used
often to ask myself, and which  since then has so often been pressed
upon me by others—" What is gout in the stomach ?"   Bightly to
answer  this question would  sum up the several answers  to  two 
292
GOUT  IN THE STOMACH.
 branches of the interrogation.  (1.) AVhat  do we see in actual
 practice suggestive  of such an  affection; and  what is the  exact
 nature of the cases thus grouped ?  And (2.) How far do these cases
 correspond with those descriptions of authors which represent what
 may be called our traditional knowledge of this affection ?  With-
 out absolutely neglecting the latter and bibliographical branch of
 the inquiry, it is to the former that I should chiefly address myself.
   1. It can hardly be doubted that any sufficiently sharp or sudden
 dyspepsia occurring in persons known or suspected to  be gouty is
 apt to be dignified by this term: a vulgar belly-ache taking rank,
 by courtesy, as gout  in the stomach.  Dr. Watson, in his admira-
 ble Lectures, has disposed of these pretentious ailments, in naming
 which, he suggests that "pork" should be sometimes  substituted
 for "gout."  That among the thousands of persons who, on any
 given  day, are doomed by fixed fate or free will to eat something
 that disagrees with them, and in whom the offending ingesta there-
 fore excite  gastric or  intestinal disturbance, some should suffer
 severely; and that, in the ages and constitutions most  exposed  to
 gout,  these  sufferings should  sometimes amount to  downright
 danger—is  not  very surprising.  For  in many such persons the
 scales  of life and death are always  so nearly poised, that a very
 slight  addition to the latter may easily determine its preponderance.
 And that irritation which provokes the salutary efforts of Nature
 to get rid of the Trichinae or  Cysticerci of underdone pork, or of the
 putridity of high game, and of stale fruit or vegetables which have
 for days been partly infecting, partly disinfecting, a townmarket, is
 such as may evidently form an efficient source of  nervous exhaus-
 tion, as well as of the pain, vomiting, and purging it more directly
 provokes.   It is hardly necessary to dwell  upon the symptoms of
 such attacks, varying, as they do, according to the degree in which
 they  have been  provoked by  undue quantity, or quality, of the
'ingesta; and according to the  proportions in which indigestion  or
 poisoning  therefore  take in  the production of  their symptoms.
 Even where most suggestive of gout in the stomach, all real claim
 to such a title is set aside by the most  cursory study.   Agonizing
 pain in the epigastrium, attended by nausea and enormous disten-
 sion with flatulence, and relieved  by eructation  or vomiting, are
 symptoms which, occurring in a person previously or thereafter
 subject to gout, have often suggested  such  an explanation.  But
 such symptoms also  not infrequently attack persons whose youth,
 health (compare pp. 68, 246), and subsequent immunity from gout,
 completely negative  any such view of  their  cause.  Furthermore,
 if examined by the light of physiology and pathology, their phe-
 nomena constitute  intrinsically evidence of nothing  more than
 gastric irritation—irritation, too, devoid of any single feature sug-
 gestive of an arthritic origin.  With no specifically gouty charac-
 ter, and no necessary (or even frequent) coincidence with the gouty 
GOUT  IN THE STOMACH.                293
habit, the most intense and mysterious cases of this kind are scarcely
entitled to any deliberate scrutiny of their claims.
  2. A less vulgar, though scarcely more valid, claimant to the title
of gout in  the stomach  is to be found in the biliary colic, which
not only  occurs with considerable frequency in the ages and con-
stitutions most amenable to gout, but is caused by hepatic condi-
tions  closely analogous  to those  producible  by gout, and—what
indeed has greatly contributed to its having been awarded this title
by  able physicians—often  so distinctly  alternates with  articular
gout,  as to suggest that  it constitutes in some sense a displacement
or metastasis of the disease from the joints to the stomach..
  In  the case of this biliary colic, the sudden invasion of the dis-
order, the violent  epigastric pain, the  vomiting, the slow, labored,
irregular or intermittent pulse (more rarely quickened and thready),
and the dyspnoea (or even asthma) which sometimes accompanies
these abdominal symptoms, together  evidently make up such  a
nexus of phenomena as closely corresponds with what is usually
regarded as the description of gout in  the stomach.  But when
these  symptoms  further occur  independently of  any distinct
approach towards jaundice, or when (as a rarer but yet  not abso-
lutely infrequent occurrence) they  replace, in an otherwise gouty
individual, the-impending or commencing fit in the joint, it is hardly
to be wondered  at that they should have received an interpretation
referring them to a malady which (like the ordinary articular gout)
is associated with a distinct structural lesion, and exhibits an intelli-
gible train  of symptoms, rather than  to  an  affection  like biliary
colic, many of the details of which we may truthfully say still lie
almost beyond the pale  of medical literature.  What  between the
frequency of  its occurrence, the  diversity of  its  symptoms, the
facility with which these are referred  to  the stomach, and the ex-
cessive  difficulty with which a  malady so vague, and  so  common,
as well  as so little dangerous to life, is traced to its proper necro-
logical  conclusions in the dead-house, there are probably few dis-
eases  which have hitherto  so completely evaded full description
and recognition as the biliary colic caused  by impaction  of thick-
ened  bile in  the 'hepatic ducts.  And while  the  above circum-
stances—and among them the defects which have till lately attached
to our  knowledge of gastric disease—are greatly  answerable for
this want, there  can be no doubt that the almost exclusive interest
which has attached  to what one may call the melodramatic aspect
of biliary colic—the paroxysm by which a gall-stone  traverses
the common duct—is also greatly chargeable with  it.  Even now,
there  are many otherwise able practitioners who scarcely recognize
any biliary  colic devoid  of jaundice; just as there are others who,
unless they  can locate the pain at or near that precise point which
they are pleased to believe represents the contact of the gall-bladder
with the wall of the belly, deduce, from  the diverse and variable
site to which the hepatic pain is often referred, a still more direct 
294                GOUT  IN THE STOMACH.

negative of its  cystic or  hepatic origin.  And whatever  be the
accuracy of such strictures, it  may be confidently asserted that
much of what is called " gout in the stomach" is really unrecognized
biliary colic.  Indeed, in some of the very cases which Scudamore
especially adduces as typical examples of such gout, the biliary
colic  may  be recognized  as complete  usque ad unguem—that is,
even  to the very finger-nails of the  patient, discolored (as they
must have  inclusively been) by the jaundice which his accurate
descriptions specify to have been present.
   3. The source of confusion constituted by the presence of renal
degeneration is  one which it would perhaps be going too far deli-
berately to  affirm as a frequent explanation of " gout in the  sto-
mach."   But that  disease of the kidneys, whether recognized or
unsuspected, does account for some cases of  this kind, it would be
affectation to doubt.1  And here, again, it must be owned that there
is much to excuse such a diagnostic error.   The gastric symptoms
producible by renal degeneration—pain, vomiting, and prostration
—are identical with those descriptive of gout in the stomach.  Their
invasion is often sudden:  in some cases as marking the  arrival of
a stage or  intensity  of the renal  malady,  capable of sufficiently
deranging  the  nervous system;  in others, as connected with what
is evidently a sudden check of renal secretion, such as is often due
to corresponding renal disease, but is occasionally to be verified in
complete independence of any structural lesion of the kidney.  Fur-
thermore, the attack is  specially incidental to the gouty malady,
and even to the gouty paroxysm, the renal degeneration being an
element of the  general disease.   Indeed, it may be fairly asserted
that some of these cases really are " gout in the stomach," a genuine
metastasis  of the disease in so far as that it is the derangement or
suppression of <the articular paroxysm which occasions (or at least
coincides with) the renal disturbance, itself provocative of the gas-
tric and intestinal symptoms. But even granting all this, the term
gout in the stomach remains quite inapplicable: alike to  the whole
symptoms; or to the gastric determination of urea, and the urasmia,
which constitute their most striking and obvious phenomena; or
to the renal disturbance which is their starting-point, and which—
doubtful, as are perhaps its own claims, in strictness, to this title—is
at any rate the only "metastatis" present.  Besides, in the symptoms
which usually accompany the ordinary paroxysms of such attacks,
there is a good  deal very diverse from  the traditional  " gout in the
stomach."   Pain, for example, is rarely intense and local; in other
words, if very severe, is  for the most  part spread over  the whole
belly, or even  diverges to the head or  limbs.   Vomiting, again, is
unduly prominent; and will be  found to have generally  been  pre-

   1 An opinion for which, some years ago, I obtained an emphatic concurrence in
conversation with the late Dr. Todd, who believed that much of the so-called gout
in the stomach was attributable to this cause. 
GOUT  IN THE STOMACH.
295
ceded by repeated  attacks of nausea and retching, if not  to have
occurred long before the onset of the paroxysm.  Purging, again,
generally accompanies it; and is also, in many cases, a mere relapse
or aggravation of a previous diarrhoea.   The prostration of the or-
ganism generally, and of the circulation in particular, is  also, for
the most part, a gradual  result of these symptoms, instead of being
synchronous with their sudden invasion.  Perhaps a similar caution
may sometimes distinguish the epigastric pain which severe and
repeated  vomiting easily  produces, from  any such  sudden and
intense suffering as is ascribed to the access of gout in the stomach.
   On the whole,  indeed, the resemblance is rarely close enough to
justify any confusion of  "gout in the stomach" with the perverted
urinary effusion of these cases of renal disease: the less so that a
careful  chemical and  microscopical examination of the urine will,
of course generally assure their exact diagnosis.
   4. Another probable claimant for some of these cases consists  in
that chain of phenomena which we occasionally see ushering in the
close of  valvular lesions of the heart, and  which seem to be far
oftener the  mode of death where  the heart is more  intrinsically
affected;  either by degeneration  of its  muscular substance, or by
disease of its  coronary vessels, or lastly by a  dilated and athero-
matous state of that tube—the aorta—which measures and  dictates
its contractile force.  As regards the mere symptoms of these cases,
which in many  respects approach the well-known  characters of
" angina pectoris," it may be noted, that it  is not so much in any
special degree or site of the pain, nor even in the degree of vomiting,
that their differentiation  from the biliary cases above mentioned is
to be sought for:  but rather in the greater prominence and severity
of dyspnoea on the one hand, and in the feeble, fluttering, thready
pulse, or threatened collapse, which testify to the more direct share
of the heart in the paroxysm, on  the other.  Nevertheless,  as dys-
pnoea and irregular pulse are common attendants upon the biliary
colic of the aged, the practical distinction between the cardiac and
hepatic varieties of the  so-called  "gout in the stomach" is some-
times by no means  easy.  The patient's face, the physician's  first
impression, are the safest grounds for a decision.  And to discrim-
inate between the labored and oppressed state of the circulation in
the one case, and  its exhausted and prostrate condition in another,
is a task which the most careful word-painting would scarcely help
in.   Doubtless, too, in  some cases a certain  degree of both  lesions
—cardiac and hepatic—is present simultaneously; just as either or
both may be complicated by their renal counterpart.
   In Dr. Gairdner's  classical  treatise1 will be found some pithy
allusions  to the  frequency and  significance of the cardiac (and
especially the  aortic) lesions  associated with inveterate gout.  My
own experience would lead me even further than he has gone;  to
1 " On Gout," Fourth Edition. 
296
GOUT IN THE STOMACH.
clinical conclusions which, as regards the frequency of such lesions,
quite correspond with  the  statistics of the dead-house; and, as
regards their significance, affirm them to be often connected with
few or slight symptoms, and to be compatible with  considerable
longevity.   These  propositions—that they  are frequent, and in
many instances of little influence on health—hold good, not only
of their  slighter and less  developed forms, but even of a large
proportion of those well-marked cases  in which they  could not
possibly be overlooked by any one accomplished in physical diag-
nosis.  So many of such cases figure in  my note-books, and have
been observed by me to enjoy tolerable health during long periods,
and even to tide over severe illnesses, with little perceptible change
of their physical signs, that I am almost afraid of underrating their
influence.   Certainly when this is only known and guarded against,
their  prognosis, however cautious, ought on every ground to be
anything but a gloomy one.
  5. Is there any " gout in the stomach" left after the subtraction
of these various affections ?  I can only say that I know of no such
case:  have never seen  one: have  never been able to get trust-
worthy evidence of one from some of the most accomplished phy-
sicians living, or from the  best  records.   Yet I would rather not
deny its existence, save in  the above qualified form. ' Just as, in
acute gout and acute rheumatism, I have  constantly found the
stomach in such a state of tympanic relaxation as  suggests great
irritation of the nerves of the organ, so I  should surmise  that it is
quite possible there may be a more intense and exceptional form of
this nervous irritation,  productive of violent pain, vomiting,  and
cardiac disturbance, perhaps  capable of giving rise to at least an
hemorrhagic  effusion from the coats of the organ.  That the dys-
pepsias of the gouty subject show a  far-off approach to phenomena
of this kind has already been stated; and, I may  add, they are in
this  respect paralleled by  the dyspepsias of convalescents from
rheumatic fever, as  well as (see p. 245) from  ordinary fever.   But
such cases, as causes of death, must  be infinitely rare.   And while
I should  demur to their being accepted  upon  any evidence at
present in the possession of scientific medicine, I should question
whether, if they occur,  they would be  rightly named  " gout;"
whether, in short,  without  having  some specially or exclusively
gouty origin, and gastric situation, they would be entitled to more
than a place in those  anomalous disorders of the  nervous system,
to which their phenomena seem so strictly to refer them. 
INDEX.
   Abdominal pressure, 55-58
   Abercrombie, 84
   Abscess, gastric, 83, 131, 132, 213, 235
   Acid, carbonic, 65, 72, 265
   Acid of gastric  juice, 37, 258
   Acids, 40, 79, 154, 258, 272, 290
v  Adhesion, of stomach, in cancer, 177,178,
           214
         in ulcer, 123-125, 127
         in linitis, 223
         from tumors, 238
   Etiology of cancer, 216-218
         dyspepsia, 260-267
         gastritis, 87-89
         gastric ulcer, 137-144
         gastric cancer, 215
         gastric cirrhosis, 234
         gastric dilatation, 243
   Age, in gastric ulcer, 120,  136-138, 142
         perforation, 128-130
         fatal hemorrhage, 135
         cancer, 189
         cirrhosis, 229, 231
   Ague, connection of, with gastric ulcer,
     138, 142
   Alcohol, 41, 87, 88, 89,142,150, 161, 162,
     164, 234, 263, 276, 290
   Alkalies, 258, 259, 272, 289
   Alkaline carbonates, 148, 272
         regurgitation, 93, 108, 258
   Amenorrhcea in gastric ulcer, 111-114
   Ammonia, 72, 265, 278
   Anaemia, 101,112, 115, 153, 179, 200, 222
   Anasarca, 166, 182, 233
   Anorexia, 95,166,167,184,186, 233, 234,
     247
   Aperients, 86, 91, 154, 155, 219, 273, 274,
     290
   Appetite, 248, 261, 270. 277
         loss of, see Anorexia
   Areolar coat of stomach, 30
         in cancer, 196, 217
         in tumors, 237, 238
         in plastic linitis, 223
         in suppurative linitis, 236
   Arteries  of stomach, 30-33
         eroded by ulcer, 134, 135
Arteries eroded by cancer, 215
Ascites, 178, 182, 210, 233
Astringents, 147, 153, 270
Atrophy of stomach, 227, 240-242
      muscular coat, 172
Attachment of stomach, 18

Beaumont, 44,52, 57, 64, 87,88,94,97,146
Beer, 107, 161
Bernard, Claude, 38, 45, 80
Bismuth, 147, 153, 158, 163, 271, 275
Bitters, 154, 270
Bleeding in gastric ulcer, 145
Brandy,152,161,278, 290
Budd, 78, 139
Bulimia, 17, 166, 233

Cachexias in gastric ulcer, 114, 119, 153,
        161
      cancer, 179. 184, 186, 199
      tumors, 238
Cancer of the stomach, 165
      typical case of, 165
      pathology of, 188
      symptoms of, 165
      treatment of, 218
      relation to tubercle of, '207
      relation to ulcer, 202-203
Cancerous egesta, 175
Capillaries, gastric, 33, 34, 35, 63, 64, 72,
  94, 133, 174
Cardia, structure of, 22
      in cancer, 191-194, 215, 217
      influencing poisoning, 83
      influencing scalding, 83
      function of, 22-25
      function  of, influencing  cancer,
        217
      in vomiting, 55
Carminatives, 158
Castor-oil, 92, 155, 274, 290
Catarrh of stomach, symptoms of, 92
      appearances, nature of, 93, 94, 95
Chambers,  T. K., 100
Changes of stomach after death,  71-81
Chevreul, 66
" Chlorosis" in gastric ulcer, 113-115 
298
INDEX.
Chomel, 276
Christison. 207
Cicatrix, 124-127,139,158, 212, 215, 231,
  243, 244
Cirrhosis of the liver, 63,199, 228
       stomach, universal, 221
       partial, 228
       histology of, 204, 205, 222, 230
       nature of, 221, 226, 231
       contrast of, with cancer, 231, 232
       relation  of, to cancer, 229-232
       symptoms of, 232
       treatment of, 234
Cod-liver oil, 151, 262, 263, 289
Coffee, 263, 264
"Coffee-grounds,"  vomiting,  110,  173,
  175, 200
Cold applications, 40, 91, 146, 152, 290
Colloid of stomach, 183, 195-202
Coma, 82, 183,  235
Combinations of cancer and ulcer, 136,
  203
Combinations  of symptoms  of  cancer,
  186,187
Confervoid growths, 148, 173, 248
Congestion, 73, 75, 76, 80, 93, 94, 96, 98,
  133, 140, 174, 215, 233,  23*, 286, 290
Constipation, 92,  95, 110, 154, 182, 256,
  274, 286
Contraction of  stomach, 74
       from cancer, 212
       from linitis, 225
       from ulcer, 125
Counter-irritants, 91, 145, 146, 269, 289
" Cramp" of stomach, 52
 Critchett, 142,  163
Croton-oil, mode of using, 92
" Croupy" cancer of lungs, 209
       lymph in secondary inflammation,
         249
 Cruveilhier, 100, 103, 165, 231
Currents of food in stomach, 24,  25
Cyanosis, 228

Dahlerup, 100,  125
Delirium, 82, 165, 183,  220, 235
       tremens, stomach in, 86
D'Espine, 188
Desquamation, gastric,  44, 64, 75, 86, 87
Diagnosis of gastric cancer, 184-187
Diarrhoea, 111, 147, 182,  253, 256,  273,
  274, 286, 289, 292, 295
Diet,  158-161, 163, 219,  234, 249,  257,
  262, 266, 276, 282, 284, 289
Dietrich, 100
Dilatation  of stomach,  242-249
       causes of, 242
       how  adjudged, 73,  74, 242
       incidental, 116,126, 127,173, 211,
         226
       idiopathic, 245
 Distension of stomach, 19, 27, 73, 74, 242
 Dittrich, 125,137,  190, 202,  210, 215, 236
Donovan, 241
Dunglison, 38, 40
Duodenum,  17,  22, 26. 31,  55, 69, 118,
  191, 192, 238,  248, 249, 251
Duration of gastric cancer, 183
       ulcer, 124
Dyspepsia, 352-379
       relation to stomach, 252
       to gastritis, 81-99
       relation to cancer, 165, 183
       gastric  catarrh,  94
       hemorrhagic erosion,  95, 97
       gastric ulcer, 117, 118
       definition of, 252
       intestinal, 253
       diagnosis of, 254
       of divers  diseases, 255
       of phthisis, 255, 280, 281
       minor degrees of, 255
       classified  by symptoms, 256
       classified  by date of digestion, 256
       classified  by food exciting it, 256
       classified  by fluids expelled, 258
       causes of, 260-267
       treatment of, 267-279

Ecchymosis, 80,  96, 140, 142
Effect  of medicines, how appraised, 146,
  157, 158
Enemata, 151,155, 219, 249, 269, 290
Engel, 137
Enteritis, 250
Erosion  of  vessels,  see  Arteries  and
  Hsemorrhagic  Erosion
       viscera, 78, 130, 132,  133, 213
Eructation, 56, 68
Exanthemata, gastritis in, 84, 97
Exhaustion, 82,  91, 135, 136, 182

Farre, A., 194
Fasting dyspepsia, 257
Fatty  tumors, 237
Febrile reaction, 92, 95,  181, 232, 234,
  262, 277, 284
Fermentation, gastric, 42, 66, 148, 172,
  233  243 264
Fever' 60, 140, 142, 245, 262,  280
Fistulse, ulcerous, 118, 132
       cancerous, 214
       gastric, 126, 140, 235
       gastro-intestinal, 132, 214
       gastro-cutaneous, 132,  216
       closure of, 132
       artificial, in dogs, 132,  259
Flatulence,  54,  55,  65-70,  93, 95, 148,
  256, 258, 282, 292, 296
Flatulent dyspepsia, 364
Follicles (lenticular glands) of stomach,
   29,98
Follicular ulceration,  98
Food (also see Diet), 61, 69, 216, 218, 248,
   257, 260-264, 276, 281, 282, 290, 292
Foreign bodies in stomach,  83 
INDEX.
299
Frequency of forms of cancer, 195
      gastric cancer, 188
      gastric ulcer, 119
Fungous growth, 137, 200, 204
Fungous nsematodes, 200

Gairdner, W., 295
Gairdner, W.  T., 100
Gall-stones, 53, 62, 118, 293
Ganglia, nervous, of stomach, 35, 54
Gangrene, 132, 133, 201, 224, 235
Gases of alimentary canal, sources of, 65-
     ..   70
      accumulation of, 69
Gastric  digestion, process of, 47
      juice, 37
      properties of,  37
      composition of, 38
      secretion of, 44
      action of, 40-42
      reactions of, 37
      phthisis, 280-291
      bowels, in, 286
      distinguished from dyspepsia, 281
      effect of food in, 282, 284
      gastric juice in, 286
      hemorrhage in, 285
      pain in, 282, 284, 287
      thorax in,  283
      treatment  of, 289
      typical case, 282
      vomiting, 282, 285
      phthisis, nature of, 287
Gastritis, acute, 82-84
      subacute,  84
      chronic, 86
      treatment of, 90
" Gout  in the stomach," 291
      biliary, 283
      cardiac, 295
      dyspeptic, 292
      meaning of term, 291
      obscurity, how explained, 291
      renal, 294
      varieties of, 292-296
Gums, blue line on, 148, 156

Habershon,  100
Hjematemesis, 62, 63, 109-111, 173, 233,
  238, 285
Hemorrhage, gastric, 62^65
      in gastric cancer, 172, 215
      in gastric ulcer, 109, 133
      in gastric tumors, 238
      in gastric cirrhosis, 233
Hemorrhagic erosion, 95-98, 183, 140
Headache, 52, 233, 255, 257
Healing of gastric cancer, 216
      of ulcer, 125-127, 139
      of gastric wounds, 13if, 140
Heller,  157
Hiccough, 82, 183
Homoeopathy, 147,156,158, 268
Hot applications, 40, 91, 145, 269
Hot substances, ingestion of, 82, 83, 107,
  158, 164
Hour-glass contraction of stomach, 25, 74,
  125
Hunger, 51, 167, 233, 248
Hunter, John, 77, 78
Hydropathy, 158, 268,  279
Hypertrophy of stomach, 239-240
      no disease, 200,  227
      how adjudged, 73
      from cancer,  210
      from linitis, 225, 227
      from ulcer, 125
Hypostasis, 73, 74,  78

Ice, 91, 146, 152, 269
Inflammation of stomach, see Gastritis
      cirrhotic, see Cirrhosis
      secondary, 249-251
Ingestive  dyspepsia, 256
Intemperance, 86, 88,  95, 145, 150, 161,
  234, 269, 276
Intestine, secondary cancer of, 205
Iodide of potassium, 148, 273, 290
Iron,  110, 148, 158,  159, 271, 290

Jaksch, 100, 123, 125, 137
Jaundice, 179, 183,  234
Jenner, 273
Jones, Bence, 39
Jones, Handfield, 100, 144

Kino, 147, 153, 271, 275

Lactation, gastric ulcer in, 138
Lead, 83, 147
Lebert, 185, 189, 192, 211, 216
Leeches, 91, 145
Lehmann, 38, 42
Liability of ages, how  measured, 120
      to gastric ulcer, 120
      to perforation, 128, 138
      to gastric cancer, 189
      comparative, to apoplexy, phthisis,
         gastric cancer, and gastric ulcer,
         189
      of sexes to gastric cancer, 190
      of sexes to gastric ulcer,  120
      of sexes to perforating ulcer, 128,
         130, 138
Linitis of stomach,  plastic, 221  *
      suppurative, 234
      derivation of, 228
Liver, secondary cancer of, 206
      erosion of, 78, 133, 135
Lungs, secondary cancer of, 205-210
      inflamed, in  cancer, 206
      " tuberculous,"  in cancer, 207
Lymphatics of stomach, 36
      in cancer, 205, 206

Magendie, 59, 67, 69 
300
INDEX.
Mammillation of the stomach, 74, 75
Matrix of stomach, 29, 72, 77, 223, 229,
  230
Medullary cancer in stomach, 195, 247
Melanosis, 175, 195
Mental anxiety, 106, 218, 260, 278
Mercury, 155, 274, 275, 289
Mialhe, 42
Microscopic  appearances  of cancer, 197,
        203, 208, 209
      ulcer, 122, 203,  215
      plastic  linitis, 205, 222, 229
Milk, 152, 153, 159, 160
Mineral waters, 278
Mobile cancerous tumors, 179
Movements  of stomach, 23-26
Mucous coat of stomach,  26
      changes during digestion, 37
      in cancer, 196, 199, 200
      in plastic linitis, 223, 224
Muscular coat of stomach, 21-23
      in cancer, 197
      in plastic linitis, 224
Muscular exertion, 106, 261, 279
Mustard poultices, 91, 145, 146

Nausea, 57,  81, 88, 93,  100, 102, 108, 149,
  165, 172,  255, 282
Nephritis, 89
Nerves of stomach, 35, 36, 52, 55, 170
      in gastric pain, 55
Neuralgia, its elements, 287
      its analogy to gastric phthisis-, 287
Nitre, 92
Nomenclature of gastric diseases, 94, 98,
  122, 198, 200, 226-228,  252

Obsolescence of gastric cancer, 215
      secondary cancer, 210
Obstruction of  stomach,  125,  210, 233,
         238,  242
      of portal veins, 183, 210
      of intestine, 244
(Edema, 113, 220 (also see Anasarca)
ffisophagus, 18, 22, 23, 51, 55, 58, 102,
  151, 191,  192,193
Opium, 86, 91, 92,147, 150, 152, 154, 161
  -163, 219, 234, 264,  275, 289
Osborne, 106

Pain, gastric,  50-55
      in dyspepsia, 255
      in gastric cancer, 167-170
      in gastric cirrhosis, 233
      in gastric ulcer, 101-108
      in gastritis, 81, 92
      in gastric phthisis, 282, 284
      in  "gout in stomach,"  292, 295,
         296
Paralysis of stomach, 69, 115, 172,  243,
  245, 247,  248, 249
Parts of stomach, 17
Pavy, 46, 80, 143
Pepsine, 39-42, 7% 77, 79, 90, 258, 270
Peptone, 42-44, 47, 72, 77, 270
Perforation in gastric cancer, 213
Perforation  in gastric cancer, an equi-
         vocal term, 127, 213
      in gastric ulcer, 115-116,127, 128
Pericarditis, 53
Pericardium, 132
Peristalsis of stomach, 24-26
Peritoneal lymph, accretion of, 127, 132,
         237
      elongation of, 132
Peritoneum, effect of irritation of, 69, 111
Peritonitis, 114, 128, 199, 213, 223, 234,
  237, 238, 250
Phlebitis, concurrence of, with cirrhosis,
  228, 236
Phlegmasia dolens, 228
Phthisis, 62, 78, 98, 207, 241, 255
      gastric, see Gastric phthisis
      gastric  ulcer in, 136-139  -» ' >  .
Physical examination of stomach, 20
Pills preferable to mixtures, 154
Pleurisy, 53, 137, 138, 206
Pneumogastric nerve, 35, 170, 247
Pneumonia, 137, 138, 206
Poisoning, gastritis of, 81, 88, 91
Polypoid tumors, 236-239
Portal vein, secondary cancer in,  210
Post-digestive dyspepsia, 256
Probabilities of  diagnosis, 185
Prognosis in gastric cancer, 183, 219
Proportion of gastric to other cancers,
  188
Prostration, 82, 183, 219, 235, 240, 247,
  295
Protein   compounds, 39, 41, 43,  47, 68,
  159, 160, 173, 253, 256, 258, 276
Prout, 43, 257
Puerperal fever, 236
Puerperal state, gastric ulcer in, 138
      gastric  suppuration in, 236
Pulsating cancerous tumors, 179
Pyaemia, gastric, 236
Pylorus, in vomiting, 55, 57, 60, 240
      structure of, 22
      influencing cancer, 191-194, 216-
         218
      influencing poisoning, 83
      influencing scalding, 83
      action of, 25, 26
      action of, influencing cancer, 217,
         231
      in linitis, 228, 231
      in pyrosis. 260
      in ulcer, 120, 194, 231
Pyrosis, 147, 259,  260, 270

Quinine, 154,  270

Regimen, 163, 219, 234, 278
Regurgitation, 56, 93, 100,  108, 117, 239
Retching, 58 
IND
EX.
801
Rokitansky, 100, 140, 191, 192, 202, 207,
  209, 215

Saliva, 47, 79, 93, 108, 258-260
Salts of gastric juice, 38, 39
       in dyspepsia, 273
       metallic, decomposition of, 73,148
       metallic, action of, 59
Sangalli,  100
Sarcina ventriculi, 173, 248
Satiety, 51,  167
Scalding of  stomach, 83
Scar, see Cicatrix
Scarlet fever, stomach in, 85
Schmidt, 38, 42
Scirrhus of  stomach, 195-203
Secondary cancer, 119,178, 205-210, 232,
         234
       inflammation, 249-251
Sedatives, 91, 147, 274
Sensibility of stomach, 50-52
Serous coat  (also see Peritoneum and
  Peritonitis), 20, 21
       in cancer,  198
       in plastic linitis, 223
       in tumors, 237
       in ulcer, 123
Sex in gastric cancer, 190
       ulcer, 120
Shape of stomach, 17
Silver, effects of salts of, 155-157, 275
Sites in stomach, of cancer, 191, 217
       of  ulcer, 120, 231
       of  linitis, 228
       of  secondary cancer, 205-207
       of tumors,  238
Situation of  stomach, 19
Size of stomach,  17, 239, 242
Skey, 163
Sloughing in cancer, 175, 200, 202, 212,
         213
       plastic linitis, 224
       ulcer, 123, 127
       suppurative linitis, 235
Solar plexus, 35, 54, 61, 247, 251
Solution,  post-mortem, of stomach,  72,
  81, 94, 98, 131, 141,  143
Starvation, 67, 68,109,115,151,181, 219,
  233, 241, 248
Stimulants,  86,  150, 157,  160-162, 219,
  249, 290
Strychnia, 275, 276
Subjective pain, 106, 170
Sulphite of  soda, 148, 249, 273
Sulphurets,   formation of, in digestive
  canal, 148
Suppuration in cancer, 200, 212
Suppurative linitis, 234
Sympathetic nerve, 35, 55, 58,  61, 247,
  251
Syphilis,  connection  of,  with  gastric
  ulcer, 137, 138
Tanchou, 188
Tartar-emetic, 59, 86, 145
Tea, 107, 263, 264
Teetotalism, 264, 277
Tenderness of  cancerous tumors, 179
Thickening of  stomach, 53, 73, 221
Tobacco, 263, 264
Tonics, 153, 234, 270
Toothache, 287
Torula cerevisiae, 173, 248
Tubercle, 136,  138, 206-210
Tubes of stomach, 27, 63, 94, 96, 99,  224,
  229
Tumor in gastric cancer, 176-179
Tumors of stomach, 236
      growth of, 237
      symptoms of, 238
      situation of, 238
      nature of, 238
Turpentine,  92, 145, 153
Tympanites, 69, 245

Ulcer of the stomach, 100
      aetiology of, 137
      treatment of, 144
      adhesion of, 123
      duration of, 124
      cicatrization of, 125
      symptoms of, 100
      morbid  anatomy of, 120
Ulceration, cancerous, 175,180,184,  200,
  203,  211, 215, 285
Ulceration, cirrhotic, 224
      not  distinguishable from  ulcer,
        122
      follicular, 98
      pain produced by, 55
      from  mechanical injury, 83
      in hemorrhagic erosion, 95-98
      causes of, 138-144
      commencement of, 140-144
Urea, 265, 278, 294
Uterus, cancer of, growth, 190, 193,  194,
        217
       cancer of, perforation, 214
       secondary cancer of, 210

Valentin, 244
Veins of stomach, 32
      hemorrhage from, 63, 64, 133,135,
        173, 200
Vessels of stomach (see Arteries, Veins,
        Capillaries), 30-35, 251
      engorgement of, 73, 80
Villous cancer of stomach, 201, 237, 238
Vomiting, 55-62
      mechanism of, 56-58, 240
      phenomena of, 57
      causes of, 58
      object of, 59, 60
      matters expelled by, 60
      varieties of, 61          j 
302
INDEX.
Vomiting, in gastric ulcer, 107, 108
      in gastric ulcer, treatment of, 149
        -152
      in phthisis, 281
      in gastric cancer, 170-172
      in gastric dilatation, 246-249
      in gastric phthisis, 282, 285
      in " gout in the  stomach," 292,
        294, 295, 296
Water, 38, 43,  150, 152, 257,  262, 264,
  265, 279
Weber, E. A., 146
West 194
Willlgk, 125, 189, 190
Wine, 64,161, 219, 264, 278

Yeasty vomiting, 173, 233, 248

Zinc, 271
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