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Rh of the food, as well as to the irritation of the inflamed nerve filaments in the floor of the ulcer. Vomiting is a usual symptom. It occurs either soon after the food is swallowed or at a later period, and generally relieves the pain and discomfort. Vomiting of blood (haematemesis) is a frequent and important symptom. The blood may show itself in the form of a brown or coffee-like mixture, or as pure blood of dark colour and containing clots. It comes from some vessel or vessels which the ulcerative process has ruptured. Blood is also found mixed with the discharges from the bowels, rendering them dark or tarry-looking. The general condition of the patient with gastric ulcer is, as a rule, that of extreme ill-health, with pallor, emaciation and debility. The tongue is red, and there is usually constipation. In most of the cases the disease is chronic, lasting for months or years; and in those cases where the ulcers are large or multiple, incomplete healing may take place, relapses occurring from time to time. But the ulcers may give rise to no marked symptoms, and there have been instances where fatal perforation suddenly took place, and where post-mortem examination revealed the existence of long-standing ulcers which had given rise to no suggestive symptoms. While gastric ulcer is to be regarded as dangerous, its termination, in the great majority of cases, is in recovery. It frequently, however, leaves the stomach in a delicate condition, necessitating the utmost care as regards diet. Occasionally the disease proves fatal by sudden haemorrhage, but a fatal result is more frequently due to perforation and the escape of the contents of the stomach into the peritoneal cavity, in which case death usually occurs in from twelve to forty-eight hours, either from shock or from peritonitis. Should the stomach become adherent to another organ, and fatal perforation be thus prevented, chronic “indigestion” may persist, owing to interference with the natural movements of the stomach. Stricture of the pylorus and consequent dilatation of the stomach may be caused by the cicatrization of an ulcer.

The patient should at once be sent to bed and kept there, and allowed for a while nothing stronger than milk and water or milk and lime water. But if bleeding has recently taken place no food whatever should be allowed by the stomach, and the feeding should be by nutrient enemata. As the symptoms quiet down, eggs may be given beaten up with milk, and later, bread and milk and home-made broths and soups. Thus the diet advances to chicken and vegetables rubbed through a sieve, to custard pudding and bread and butter. As regards medicines, iron is the most useful, but no pills of any sort should be given. Under the influence of rest and diet most gastric ulcers get well. The presence of healthy-looking scars upon the surface of the stomach, which are constantly found in operating upon the interior of the abdomen, or as revealed in post-mortem examinations, are evidence of the truth of this statement. It is unlikely that under the treatment just described perforation of the stomach will take place, and if the surgeon is called in to assist he will probably advise that operation is inadvisable. Moreover, he knows that if he should open the abdomen to search for an ulcer of the stomach he might fail to find it; more than that, his search might also be in vain if he opened the stomach itself and examined the interior. Serious haemorrhages, however, may make it necessary that a prompt and thorough search should be made in order that the surgeon may endeavour to locate the ulcer, and, having found it, secure the damaged vessel and save the patient from death by bleeding.

Perforation of a gastric ulcer having taken place, the septic germs, which were harmless whilst in the stomach, escape with the rest of the contents of the stomach into the general peritoneal cavity. The immediate effects of this leakage are sudden and severe pain in the upper part of the abdomen and a great shock to the system (collapse). The muscles of the abdominal wall become hard and resisting, and as peritonitis appears and the intestines are distended with gas, the abdomen is distended and becomes greatly increased in size and ceases to move, the respiratory movements being short and quick. At first, most likely, the temperature drops below normal, and the pulse quickens. Later, the temperature rises. If nothing is done, death from the septic poisoning of peritonitis is almost certain.

The treatment of ruptured gastric ulcer demands immediate operation. An incision should be made in the upper part of the middle line of the abdomen, and the perforation should be looked for. There is not, as a rule, much difficulty in finding it, as there are generally deposits of lymph near the spot, and other signs of local inflammation; moreover, the contents of the stomach may be seen escaping from the opening. The ulcer is to be closed by running a “purse-string” suture in the healthy tissue around it, and the place is then buried in the stomach by picking up small folds of the stomach-wall above and below it and fixing them together by suturing. This being done, the surface of the stomach, and the neighbouring viscera which have been soiled by the leakage, are wiped clean and the abdominal wound is closed, provision being made for efficient drainage. A large proportion of cases of perforated gastric ulcer thus treated recover.

 GASTRITIS (Gr. , stomach), an inflammatory affection of the stomach, of which the condition of catarrh, or irritation of its mucous membrane, is the most frequent and most readily recognized. This may exist in an acute or a chronic form, and depends upon some condition, either local or general, which produces a congested state of the circulation in the walls of the stomach (see : Pathology).

Acute Gastritis may arise from various causes. The most intense forms of inflammation of the stomach are the toxic conditions which follow the swallowing of corrosive poisons, such as strong mineral acids of alkalis which may extensively destroy the mucous membrane. Other non-corrosive poisons cause acute degeneration of the stomach wall (see s). Acute inflammatory conditions may be secondary to zymotic diseases such as diphtheria, pyaemia, typhus fever and others. Gastritis is also caused by the ingestion of food which has begun to decompose, or may result from eating unsuitable articles which themselves remain undigested and so excite acute catarrhal conditions. These give rise to the symptoms well known as characterizing an acute “bilious attack,” consisting in loss of appetite, sickness or nausea, and headache, frontal or occipital, often accompanied with giddiness. The tongue is furred, the breath foetid, and there is pain or discomfort in the region of the stomach, with sour eructations, and frequently vomiting, first of food and then of bilious matter. An attack of this kind tends to subside in a few days, especially if the exciting cause be removed. Sometimes, however, the symptoms recur with such frequency as to lead to the more serious chronic form of the disease.

The treatment bears reference, in the first place, to any known source of irritation, which, if it exist, may be expelled by an emetic or purgative (except in cases due to poisoning). This, however, is seldom necessary, since vomiting is usually present. For the relief of sickness and pain the sucking of ice and counter-irritation over the region of the stomach are of service. Further, remedies which exercise a soothing effect upon an irritable mucous membrane, such as bismuth or weak alkaline fluids, and along with these the use of a light milk diet, are usually sufficient to remove the symptoms.

Chronic Gastric Catarrh may result from the acute or may arise independently. It is not infrequently connected with antecedent disease in other organs, such as the lungs, heart, liver or kidneys, and it is especially common in persons addicted to alcoholic excess. In this form the texture of the stomach is more altered than in the acute form, except in the toxic and febrile forms above referred to. It is permanently in a state of congestion, and its mucous membrane and muscular coat undergo thickening and other changes, which markedly affect the function of digestion. The symptoms are those of dyspepsia in an aggravated form (see ), of which discomfort and pain after food, with distension and frequently vomiting, are the chief; and the treatment must be conducted in reference to the causes giving rise to it. The careful regulation of the diet, alike as to the amount, the quality, and the intervals between meals, demands special attention. Feeding on artificially soured milk may in