Ulcer Of The Stomach.

Part 10
About two days later, during which period the offensive smell constantly persisted with undiminished strength, the patient brought up during several spasmodic coughing-spells about one pint and a half of pus, in which particles of casein and small black flakes could be clearly seen. This matter had exactly the same odor as the air expired by the patient for the last two days. Immediately after this occurrence the expired air entirely changed its character, and the atmosphere of the room was no longer unpleasant; the patient began to feel better, the temperature fell, all the symptoms of peritonitis began to disappear, and she made a slow recovery in about six weeks. In this case after the perforation of the stomach there must have formed a localized abscess, which extended through the diaphragm into the lung and emptied itself through a bronchus. By a similar process an abscess may form beneath the diaphragm, and may at times cause a condition which Leyden1 designated as "Pyopneumothorax sub-phrenicus" on account of its similarity to the real pyopneumothorax. This condition appears only when gas is contained in the abscess. Debove and Remond 2 designate it by the more correct term "gaseous subdiaphragmatic abscess," while in this country it is briefly called "subphrenic abscess." The abscess is, as a rule, situated toward the right side. Its walls are formed by the diaphragm above, by the liver and the stomach below; to the right it is surrounded by the suspensory ligaments of the liver, and to the left by the spleen. The liver is usually pushed downward and the diaphragm upward. Thick false membranes form the walls of the abscess, which contains gas and fetid liquids, the latter being composed of pus and alimentary residues. The symptoms that are caused by this condition are: the respiratory vibrations of the lower part of the thorax disappear; the liver dulness in the back and the lower part of the lung are replaced by a zone giving a tympanitic sound on percussion. On auscultation the respiratory sounds are not audible, but there are heard instead succussion sounds of a metallic pitch. The best diagnostic sign of this condition is afforded by exploratory puncture, by means of which one can

aspirate pus containing some food particles. Another diagnostic point of value has been suggested by Pfuhl,1 and consists in connecting the exploratory needle with a manometer. The pressure in this affection is greater during inspiration and less during expiration, whereas in real pyopneumothorax this condition of pressure will be found reversed. Of late this disease has been recognized during life and successfully operated upon by incision of the abscess and cleansing of the cavity. C. Beck,2 of New York, has recently reported three successfully operated cases of subphrenic abscess. 1 E. Leyden: "Ueber Pyopneumothorax subphrenicus und sub-phreniache Abscesse." Zeiteohr. f. klin. Med., 1880, p. 320. 2 Debove et Remoud: l. c., p. 272. The local abscess caused by perforation can also at times produce other complications; thus, for instance, it may perforate the abdominal wall, with establishment of a fistulous opening from the stomach to the outside. Although very rare, cases are also mentioned in which an abscess of the stomach has perforated the pericardium, and even the heart itself, causing death. As regards the frequency of perforation in the course of gastric ulcer, it occurs, according to Brinton, in not more than one out of seven or eight cases of this lesion; while sex has no influence upon the frequency of its occurrence, the age of the patient seems to play an important part in this respect. 1 Pfuhl: Berliner klin. Wochenschrift, 1877. p. 57. 2C. Beck: Medical Record, February 15th, 1896. Although gastric ulcer is met with more frequently as life advances, the occurrence of perforation, on the contrary, declines from the age of 30 to that of 70. According to Brinton, the distribution of the liability to perforation over the whole life varies materially in the two sexes. In the female about one-half of the number of cases occur between the ages of 14 and 30, one-third in the six vears between 14 and 20. In the male the distribution is constant up to the age of 50, and diminishes but little up to that of TO. The average age of those subject to perforation also differs in the two sexes,

being 27 in the female, 42 in the male. The situation of the perforating ulcer plays the chief part in the frequency of this occurrence. The anterior surface of the stomach, though much more rarely affected by ulcer, is yet one of the most frequent sites of perforation. According to Brinton, in all other situations of the ulcer, the probabilities are about 60 to 1 against perforation, while in the anterior surface of the stomach, they are 6 to 1 in its favor. The reason for this is the circumstance that the front wall of the stomach is more exposed to motion than all other parts of the stomach where ulcer is usually found. The mobility of this part prevents the formation of adhesions, which often form if the ulcer is situated elsewhere. The gastric ulcer is liable to bring in its train still other complications: thus in some instances a cancer may be developed on the base of an ulcer or on its scar. Dittrich was the first to describe this complication, and Rosenheim1 has lately published several important investigations on this subject. The same writer2 has also described another complication of chronic gastric ulcer, and that is a grave form of anaemia, which may be styled "pernicious". Pulmonary tuberculosis is a frequent occurrence in gastric ulcer? as in many other chronic diseases, and hastens the death of the patient. It does not seem, however, that there is a more intimate connection between these two affections than obtains in other diseases. As mentioned above in speaking of the pathology of the ulcer, severe complications may arise from the thickening of a cicatrix, especially if situated at the pylorus, or very near it, or again at the cardia. In the first instance, the most frequent complication is stenosis of the pylorus with dilatation of the stomach, which will be treated in a special chapter under Ischo-chymia; in the second, stricture of the cardia, causing dysphagia.