days it became more severe with some vomiting; there was no fever, and nothing could be discovered by examination. The pain was chiefly referred to a small spot in the epigastric region, rather to the left side; and no symptom occurred different from those in her former attacks, until, after eight or ten days, she was suddenly seized with copious vomiting of blood. This occurred repeatedly; and she died rather suddenly about a week from the first occurrence of it, and about three weeks from the commencement of the attack.

Inspection.-The stomach had contracted an adhesion of small extent to the left lobe of the liver, and another of greater extent, and very firm, to the pancreas. At both these places, the coats of the stomach were diseased, but in the greatest degree at the adhesion to the pancreas. Here they were much thickened and indurated, for a space about three inches long, and two inches broad; and the internal surface of this portion was entirely in a state of ulceration. There were also on this ulcerated surface several points which penetrated more deeply, and some of these contained coagulated blood, giving every reason to believe that they had been the source of the hæmorrhage. The other parts of the stomach were in a natural state, and all the other viscera were healthy.

I consider this case as one of very great interest, on account of the periodical nature of the pain, and the long intervals of perfect health. There seems every reason to believe that the paroxysms had been connected with inflammatory action, confined to a circumscribed portion of the mucous membrane of the stomach, subsiding from time to time, and leaving the part in a comparatively healthy state; but that, under these successive attacks, the parietes had become gradually thickened at the part, until the last at

tack terminated by ulceration, and this by the fatal hæmorrhage.

§ V.-SIMPLE ULCERATION OF VERY SMALL EXTENT,

SUDDENLY FATAL BY PERFORATION OF THE
STOMACH.

CASE VII-A young woman, aged 18, had been affected, for about six months, with variable appetite, and occasional pain in the stomach, which made her frequently sit with her body bent forward, and her hand pressed upon the epigastric region. Little notice was taken of the attacks, as she was going about, and otherwise in good health; and for some weeks previous to the attack now to be described, her appetite had greatly improved. On the 26th November 1824, while in a room by herself late in the evening, she was heard to scream violently; and when a person went into the room, she was found unable to express her feelings, except by violently pressing her hand against the pit of the stomach. When she was soon after seen by Mr. M'Culloch, she was moaning as if in extreme agony, but was unable to speak; the pulse was 86 and very weak; she could scarcely swallow; but soon after vomited the contents of the stomach, which seemed to be merely food which she had recently taken. Various remedies were employed without relief. She continued with every appearance of extreme suffering, and unable to speak, till seven o'clock in the morning of the 27th, when she said the pain was considerably easier, but was still very severe in the pit of the stomach, and was extending downwards over the abdomen. The abdomen was now becoming distended, and when I saw her about three o'clock in the afternoon, it was distended to the greatest degree and

very tense. The pulse was extremely feeble; she was scarcely able to speak, but her countenance was expressive of extreme suffering. Nothing afforded the smallest relief, and she died about two in the morning, 29 hours from the attack.

Inspection. The cavity of the peritoneum was distended with air, and likewise contained upwards of eight pounds of fluid of a whitish colour, and fetid smell. There was slight but extensive inflammatory deposition on the surface of the intestines, producing adhesions to each other, and to the parietes of the abdomen. In the upper part of the small curvature of the stomach near the cardia, there was a small perforation of a size which admitted the point of the little finger. Internally this opening communicated with an ulcerated space on the mucous membrane, about the size of a shilling, with slightly thickened and hardened edges, and a considerable perpendicular loss of substance. The stomach in all other respects was entirely healthy.

CASE VIII-A gentleman, aged about 60,-in the year 1825, had for a considerable time suffered from complaints in his stomach. He had occasional pain, but it was not severe; his more prominent symptoms were an intense feeling of Pyrosis, and occasional vomiting. He was often obliged to leave the table suddenly during meals from attacks of this kind, in which he chiefly brought up small quantities of an extremely acrid fluid. He became much emaciated, and had every appearance of extensive organic disease, though none could be discovered on examination. He required to be kept upon the most cautiously regulated diet; and after continuing for some months in a state from which he was not expected to recover, he gradually got into his former good health, and his stomach entirely recovered its healthy functions. He had at various times,

however, slight threatenings of his former symptoms, and required to live with great caution; but he was full in flesh, and his general health was excellent. About a fortnight before his death, he had one of those slighter attacks, which affected him chiefly with a distressing feeling of Pyrosis, impaired appetite, and occasional vomiting. On account of these symptoms he was keeping the house, though able to attend to the affairs of an extensive business, until Saturday evening, 3d February 1827, when he was suddenly seized with excruciating pain in the pit of the stomach, accompanied by some vomiting, coldness of the body, and a small frequent pulse. From the moment of this attack, nothing that was done afforded the least relief. He continued in the most violent and unceasing pain through the night and through the following day; the whole abdomen became distended and tender, with sinking of the vital powers, and he died on Sunday night, about 30 hours after the attack.

Inspection.-On the posterior surface of the stomach near the Pyloric extremity, there was a space rather larger than a shilling, where the substance of the stomach was entirely destroyed; but the margin of the opening adhered all around very closely to the surface of the liver, which thus preserved the continuity of the part. Below this portion, and very near the Pylorus, there was an ulcer on the mucous membrane, smaller than a sixpence, and through this a perforation of the coats had taken place of such an extent as would have transmitted a full-sized quill. Through this opening the contents of the stomach had escaped into the cavity of the peritoneum, where there were exhibited the usual marks of extensive but recent peritonitis. Except the two spots now referred to, the stomach was perfectly healthy.

These examples will be sufficient to illustrate this most formidable modification of the disease. Many others are on record, in some of which the previous symptoms were very slight and obscure. A young lady, aged 15, mentioned by Dr. Carmichael Smith, had for many months complained occasionally of pain in the stomach: but it was so slight, that no attention was paid to it, until one evening she was seized with violent pain and vomiting, and died in 24 hours, with symptoms of peritoneal inflammation. In the anterior part of the stomach there was a round ulcer no larger than a sixpence, with hard callous edges, and some thickening of the coats at the part on which it was situated. On farther examination it was found that the ulcer had entirely penetrated the coats of the stomach by an opening sufficient to transmit a quill. The other parts of the stomach were entirely healthy. M. Gerard has collected about seventeen examples of this affection, in a memoir, "Des Perforations Spontanées de l'Estomac." In some of these there had been previously chronic vomiting, and other symptoms indicating disease in the stomach; but in others the previous symptoms were slight and obscure; and some had enjoyed tolerably good health. The fatal attack and the morbid appearances corresponded with the cases now described; and death took place in periods of from 12 to 24 hours. Several cases of the same kind are described by Dr. Crampton and Mr. Travers, in the Medico-Chirurgical Transactions. In a lady mentioned in the Journ. Gen. de Medicine for August 1821, the attack commenced with severe pain in the epigastric region, extending towards the left kidney, and accompanied by cold shivering, dyspnoea, and prostration of strength. These symptoms subsided, but returned in the same manner every day, after taking food, for four days, leaving her in the intervals free from complaint. On