py." The mucous membrane for some space around the perforation presents a dark brown or black color, of a "sooty appearance." The black matter being removed from the surface, traces of inflammation will be found, provided the individual has lived long enough for that process to have been established. Besides these, the acid passes through the perforation which it has made in the stomach, and extends its ravages to the contiguous viscera. Its presence may be detected in the fluids contained in the stomach, or the cavity of the peritoneum, or in the corroded mucous membrane. Perforation may be produced by nitric acid also; but not so many cases of it have been observed, as it is not so commonly employed as the sulphuric. In those however which have occurred, the edge of the aperture is "generally tinged of a yellow color; or if bile be present in the contents of the sto mach, then the mucous coat may have a greenish hue." Perforation has sometimes, but rarely, been produced by oxalic acid, some of the alkalies, particularly potassa, bichloride of mercury, nitrate of silver, and sulphate of copper.

In regard to perforation from ulceration and sloughing as the immediate cause, it is produced by what the author calls "the irritant poisons," which indeed is a generic division of Christison, including the corrosive poisons above spoken of. The author regards perforation from this cause as extremely rare, but that it has been produced probably two or three times by arsenic, and possibly one or two other substances. The perforation when it does occur, very much resembles that from previous disease, and requires the concurrence of a number of collateral circumstances to establish the fact, that it has been produced by poisoning.

With respect to the second class of causes of perforation, viz: "morbid causes," he says it may be a result-“1. of sim

ple ulceration, sometimes of an acute, but more frequently of a chronic character. 2. of scirrhous ulceration." The first is intended to designate an aperture in which there is an ulcer of some size, of the mucous coat, having well defined but not elevated edges-an ulceration of less dimensions of the muscular coat, and one of still less of the peritoneal coat; thus forming a funnel-shaped perforation; the apex of the funnel being at the peritoneal surface. The second is intended to designate one of the same kind, save that the border of the ulcer and coats of the stomach contiguous to it are elevated, and so hard as to seem "almost cartilaginous."

A person laboring under the first form of ulceration, will suffer from some slight dyspeptic symptoms, or some trivial derangement of the stomach which attracts but little attention, when suddenly, (most commonly after eating,) they will be attacked with vomiting and severe and even excrutiating pain in some part of the abdomen, which continues despite all the means which may be employed, and the patient succumbs in, generally, from eighteen to thirty-six hours. Vomiting though commonly an attendant, is sometimes absent; there is no diarrhoea, the bowels being in general obstinately constipated; and pain between the shoulders has been so frequently observed in these cases as, in the author's estimation, to merit attention, as being probably something more than a mere coincidence. According to the author's observation and the cases which he has introduced into his article, this disease "seems to attack frequently young females, from 18 to 23 years of age, generally unmarried," though it is by no means exclusively confined to them. The postmortem appearances present, in addition to the ulceration above described, and which is commonly from half an inch to an inch in diameter, and "almost constantly situated in or

near the lesser curvature, between the cardia and pylorus ;" "all the marks of severe peritonitis; effusion of serum with coagulable lymph; agglutination of the viscera, and extravasation of the contents of the stomach.”

The symptoms of scirrhous ulceration differ from those of the simple form, in there having been for a long time gastric symptoms, such as irritation, &c., together with constitutional disturbance. But when the perforation takes place, and the fatal attack of peritonitis comes on, the symptoms are the same as those above detailed; and the post-mortem appearances are the same, save in the character of the ulceration, which has been distinguised above. And in addition to the characteristics of the scirrhous ulcer already given, we may add that the coats of the stomach are thinned off from within outwards, the peritoneal being reduced to a sharp smooth edge, without any appearance of laceration, as if it had been effected by gradual absorption.

By "perforation by solution" is meant a large opening found in the stomach, generally at its greater extremity, and occupying a large portion of the fundus. "It is large and irregular; the edges are thin, ragged, commonly much softened for a considerable space around, and present that fringed appearance which the stomach might be conceived to acquire by the scraping of its parietes with a blunt knife. "Most commonly there is no vascularity nor trace of any other lesion of the stomach; and so also there is no trace of peritoneal inflammation, when extravasation of the contents of the stomach has taken place, which however does not always occur. 'Tis true that vascularity of the mucous membrane of the stomach may sometimes be present, but it is to be considered as incidental, and depending upon some other cause. In regard to symptoms the author says: "this singular change is either not

indicated by any symptoms during life, or they are of so slight a kind as to lead to no suspicion of the mischief which is going on." The author devotes several pages to the description of cases which he has collected-to the consideration of the cause of the perforation, whether it be the result of disease, and takes place during life, or whether the change is purely post-mortem, effected by the solvent power of the gastric secretion on dead animal matter-and "whether the gastric secretion acts on the stomach by its vital or chemical properties." But we must be content to give only the "conclusions" to which he considers himself justified in coming. They are the following:

"1. That perforations of the stomach, from solution, are very rare in the human subject.

2. That they may occur in healthy and diseased states of the body.

3. That the perforation takes place after death; and depends on the action of the gastric secretion, which, in the opinion of some, is facilitated by a diseased state of the parietes of the stomach. But that the secretion is the chief, if not the sole cause, seems probable, from the fact, that the liver, spleen and diaphragm have also been found softened, the latter even perforated where lying near the aperture in the stomach. We must then imagine, either that these accidentally contiguous parts partake of the same disease as the stomach, or that disease of that organ is not necessary for its coats to become destroyed by the secretion.

4. That the secretion cannot be the healthy gastric-juice, but some altered state of that liquid. This is rendered probable by the facts-1. If it were the ordinary secretion, perforation would be much more common in healthy persons, dying suddenly, soon after a meal. 2. It would not be met with in diseased subjects, or those laboring under disease of the stomach.'

5. That the exact nature of the liquid producing the change, and the circumstances to which it owes its solvent power, are unknown."

We come next to speak of the means of diagnosis, in all cases of perforation of the stomach, in reference to the medico-legal questions growing out of them. From what is said upon the subject we may glean the following:

1. That it is hardly possible to confound perforation from either "simple" or "scirrhous ulceration" with that produced by the corrosive poisons. For even in the absence of all general evidence in regard to some such subtance having been taken, a simple inspection of the mouth, faucus, œsophagus, the perforation itself, and perhaps the corrosion of the surrounding viscera, together with an examination of the matters vomited, "consisting of shreds of membrane and altered blood," mixed with sulphuric acid or whatever may have been taken-and the contents of the stomach and cavity of the peritoneum-will settle the question almost beyond the possibility of doubt.

2. That it is principally in distinguishing perforation by disease, from that produced by the "irritant poisons" the difficulty consists. In order to do this with any degree of certainty, it is necessary to take a good many circumstances into consideration.

1. Perforation by disease is comparatively frequent, and moreover seems most apt to attack young females, while that by arsenic, (as an example of the irritant poisons, and the one most commonly employed,) is very rare.

2. In the former, the symptoms do not generally make their appearance for several hours after eating, though occasionally in much less time; whereas those from arsenic almost uniformly come on in about half an hour after the substance containing it has been taken.

3. In cases of the former, the pain in the abdomen comes