- pable of being distinguished, except when it is attended with
scirrhus.
By far the most remarkable variety, however, of spontaneous perforation is that which takes place, without proper inflammatory action, from simple gelatinizing of the coats. It is very apt to be mistaken, and in a celebrated trial, which will be immediately noticed, was actually mistaken for the effect of corrosive poison.
It may be situated on any part of the stomach, but is oftenest seen on the posterior surface. It is sometimes small, more often as big as a half-crown, frequently of the size of the palm, and occasionally so great as to involve an entire half of the stomach. Sometimes there is more than one aperture. The margin is of all shapes, commonly fringed, and almost always formed of the peritoneum, the other coats being more extensively dissolved. In one instance, however, the peritonæal surface was on the contrary the most extensively destroyed;[1] and in a case which occurred in the infirmary here, and was pointed out to me by the late Dr. W. Cullen, the peritonæum alone was extensively softened, and partly dissolved, so as to lay the muscular coat bare on its outer surface. The gelatinization therefore sometimes, though very rarely, begins on the outside of the stomach. Internally the whole is surrounded by pulpiness of the mucous coat, generally white, occasionally bluish or blackish, never granulated like an ulcer, very rarely vascular; and when vascular, the blood may be squeezed out of the loaded and open vessels. The organs in contact with the hole are also frequently softened. Thus an excavation is sometimes found in the liver or spleen; or the diaphragm is pierced through and through. The margins of the latter holes are without any sign of vascular action, but are generally besmeared with a dark pulpy mass, the remains of the softened tissue. The pulp never smells of gangrene; with which, indeed, this species of softening is wholly unconnected. The edge of the hole in the stomach never adheres to the adjoining organ; yet, even when the hole is very large, the contents of the stomach have not always made their escape. Often the dissolution of the coats is incomplete. John Hunter and others, indeed, have said that a stomach is rarely seen without more or less solution of the mucous coat.[2] The best account of the appearances in this state is given by Jaeger of Stuttgardt.[3]
The circumstances under which this extraordinary appearance occurs are singularly various. Professor Chaussier and the French pathologists conceive it to be always a morbid process constituting a peculiar disease; and doubtless cases have occurred in which death appears to have arisen from the stomach being perforated during life by gelatinization.[4] But it has been found much more frequently, when death was clearly the consequence of a different disease, and when there did not exist during life a single sign of disorder in the
