As regards the second point, we have hitherto only been able to reach a certain limit in our knowledge concerning the mode of development of the ulcer. Oser' states clearly the present status of the question, viz.: Ulcer of the stomach is due to auto-digestion of the stomach at certain circum scribed spots. This anto-digestion is rendered possible by circulatory dis turbances in the gastric mucous membrane. Why this process takes place, and why the ulcer heals in some cases, and not in others, is at pres ent unknown. If we avoid entirely the present controversy over Pavy's view (that the acid gastric juice is neutralized by the alkaline blood cir culating through the tissue, etc.), it is only the factor of circulatory dis turbances, hitherto regarded as necessary, which we must keep in view. The manner in which these circulatory disturbances occur is differently explained by different writers (Virchow, Cohnheim, Klebs, Rindfleisch, Axel Key). Without doubt there are disturbances of different kinds, which may produce the effect in question. It is important, as far as we are concerned, that the supposed circulatory disturbances should, in part at least, run parallel with those which, as we know, may be produced by the climacteric. If this is the ease, then the idea that there is an increased tendency at this period to the formation of the ulcer in question is to a certain extent justified. If now Klebs finds that the probable cause of the disturbed circulation is a spastic contraction of single vessels, or Axel Key that it is due to frequent attacks of cardialgia, which, by contraction of the muscularis, cause interruption of the venous circulation, then we must allow that, considering the numerous vaso-motor disturbances as well a.s the various attacks of cramp (especially in the gastro-intestinal tract) observed during the climacteric, the connection of corresponding causes with a similar result, belongs especially to the menopause. The fact that gastric catarrh is particularly frequent at this time, lends sup port to the idea that there is an increased tendency to the formation of ulcer. According to Virchow " acute and chronic catarrhs, especially such ae are attended with violent vomiting or with severe cramp-like con tractions of the stomach, * * * even without obstruction of the vena portie or blood-stasis, e,ause byperzemia of the mucous membrane, hem orrhagic erosions and bleeding ulcers." Without pursuing this subject any farther, it seems to me to follow already from what has been said that it is certainly not opposed to the theoretical view to consider that there is a possible connection between certain gastric ulcers, and the cli macteric changes in the body. Of course we must wait for the confirma tion of this view until numerous observations have been made with regard to this point. I, for my part, on the strength of the three following ob servations, am very much inclined to regard the theory in question as a correct one.
Miss K., aged fifty-four, was always healthy. She began menstru ate at fifteen, and was regnlar until towards the end of her fortieth year. At forty-seven she began to suffer with gastric catarrh, while her men struation was still regular. At the end of her fifty-first year, she began to be irregular, and the gastric symptoms became more marked, severe pain in the epigastrium being complained of, while she vomited fresh or changed blood. She improved each time that the menstrual flow recurred until her fifty-second ye,ar, when the gastric trouble increased during a period of seven months, and was again relieved by the reappearance of the menses. The pain and vomiting then began to be so severe that it was necessary to nourish the patient by rectal enemata. After the lapse of a month she recovered, and although six months have passed since her last menstruation, she is now well in every respect. I would obiterve that this
very intelligent lady carried out the physician's directions most strictly throughout the entire period mentioned, a fact which must be kept clearly in view in deciding concerning the often brief exacerbations of the tronble. I could find no cause for the prolongation of the genital hemorrhages in this case; a most careful examination of the pelvic organs showed that they were normal. Faintly-marked climacteric phenomena increased dur ing the last two years, but showed no peculiarities.
The phenomena in the following cases were somewhat more marked, and in this instance there was a single attack and the patient had no re currence. Mrs. B., aged fifty, matured at sixteen, and ceased to men struate at forty-four without suffering any evil consequences. She had had gastric catarrh at different times, the attacks lasting three or four months. At forty-six she suddenly lost her appetite, was feverish, had pain in the stomach and back, then nausea and brematemesis, the latter continuing three or four times daily for an entire month. The inges tion of every kind of nourishment, except small quantities of milk, caused lier at once the most violent pains, so that luematemesis some times followed the swallowing of a few crumbs of bread. The en tire duration of the malady was four months; since then there has been no recurrence. I may also mention as being quite characteristic, that in this case the culmination of the peculiar nervous phenomena is just to be observed now (in her fiftieth year), although the menopause occurred at forty-four. She has lately had sleeplessness, palpitation, and nervous vomiting (caused merely by psychical disturbance), while the slightest mental excitation causes a peculiar trembling and shivering of the woman's whole body.
Finally, I shall refer briefly to the third case, Mrs. H., who was always healthy, and between the ages of forty-five and fifty was irregular in her menstruation. At fifty-one she became very ill, presenting symp toms of gastric ulcer; they continued for about six weeks, and within three months she had recovered perfectly, and has had no return. It is self-evident that no conclusions can be drawn from such a small number of cases. However, if the view is proved that there is an actual connec tion between the condition in question and climacteric changes, then it seems from the observations mentioned, as if in cases in which gastric ulcers develop after the final cessation of the menses, the inclination to recur rence is less; and that the affection is distinguished by it,s persistency and long duration, in cases in which (as in the first instance) its inception coincides with the first irregularities in menstruation. As regards the development of the condition, Cases I. and III. (not Case II., in which the patient Was a weak and previously rather an amemic woman) are valu able in connection with the generally-adopted theory of obstruction to the circulation and " fluxions at the menopause." ' In both eases there had been previously no profuse loss of blood, and in Case I., as was mentioned, there was fresh improvement with each recurring period. But it remains a striking fact at least that in Case I. the increased genital hemorrhage which subsequently occurred had no influence on the condition, and that in Case III. the symptoms began just a year after the cessation of the men strual flow. At all events, it would seem to me, adhering to our hypo thesis, that the question is worth considering, whether in these cases sim ple disturbances of innervation (analogous to most of the climacteric abnormalities) are not at the root of the phenomena, and produce secon darily those localized circulatory disturbances to which we referred above as the supposed cause of the ulcemtion in question.