aspect. If in the former part, it has a greater tendency to produce perforation; if in the latter, hæmorrhage. The ulcers are situated nearer to the pyloric, than to the œsophageal orifice. Dr. Brinton gives the following table, which must be regarded as relating to cases in which perforation takes place without antecedent adhesion. In every 100 such cases, the ulcer is situated

At the anterior and posterior surface at once in 28

At the cardiac extremity in

At the anterior extremity in

..

40

85

Whereas in ulcers of the stomach generally, he almost reverses the order; that in 43 per cent. the ulcer was at the posterior surface, in 27 at the lesser curvature, in 16 at the pyloric extremity, in 6 at both the anterior and posterior surfaces, often at opposite places, in 5 at the anterior surface, in 2 at the greater curvature, and in 2 at the cardiac pouch.

Ulceration of the stomach is more frequent in women, than in men. Dr. Brinton found, out of 654 cases, that 440 were female and 214 male; and that in one out of every five cases more than one ulcer was present; whilst in one out of every seven or eight cases perforation took place.

As to the age of those who are the subjects of this affection, the cases of cancer which have come under

my own immediate notice have been more advanced in life, than those who were the subjects of ulceration of the stomach. Dr. Brinton has collected statistics from a large number of cases, and he shows that the ulcer generally" affects the periods of middle and advancing life, with a frequency which gradually increases up to the extreme age allotted to man.” But the cases of ulcer in which perforation happens, "seem not only to select another period of life, but to exhibit a marked contrast of age in the different sexes, the period of life in which it is most liable to occur being quite a different epoch in the male and in the female,” in the female being between the ages of 14 and 30, in the male from 50 to 60, the diminished risk of the female at the latter periods of life rendering the total risk in the same number of cases nearly equal. Dr. Lees mentions that he has seen perforation of the stomach from ulcer "in a girl of eight, and a boy of nine years of age."

The symptoms of ulceration of the stomach may be considered first in reference to those instances in which sudden perforation takes place without any adhesion. Such cases have much general, as well as pathological interest, on account of their usually disastrous termination. They often occur in young women affected with chlorosis and amenorrhoea, or with painful menstruation. The previous gastric symptoms are very slight or altogether unnoticed, although there is generally impaired health, with leucorrhoea or chlorosis, neuralgic

pain in the side, and symptoms of hysteria. The onset of the fatal attack is unexpected, and is generally after slight muscular exertion, or after a full meal. Intense pain comes on, followed by rapid prostration and collapse. The skin becomes cold and clammy, the pulse fails, the pain in the abdomen becomes general; tympanitis follows, and occasionally vomiting supervenes. Death ensues in from five to twenty-four hours, although life is sometimes prolonged for several days, and in rare cases the patient recovers.

Various suggestions or hypotheses have been made in reference to these cases of perforation. The enfeebled nutrition, and inability of the coats of the stomach to resist the chemical action of the gastric juice, is considered by some to be the cause of this terrible result; others refer it to the state of the nervous system; and we have ample proof of the close connection of the gastric sympathetic nerve with the ovarian and uterine ganglia. The pain below the mamma in leucorrhoea arises probably from the connection of the splanchnic with the dorsal nerves.

The cause is equally obscure as to the part of the stomach usually affected with ulceration. Why the lesser curvature, either at its anterior or posterior portion, should be so generally involved, is not known. This is the part least free in its movements-in fact it is almost stationary, the stomach in its general expansion and consequent movement turning upon its lesser

curvature. This also is the region along which the branches of the pneumogastric nerve pass.

The symptoms of chronic ulceration are at first those of ordinary dyspepsia, and are often very obscure, and imperfectly marked. Thus slight uneasiness after food and constipation may be the only evidence of disease. Afterwards, the pain, with tenderness in the region of the stomach, especially at the scrobiculus cordis, attracts more attention from the patient. It is sometimes slight; at other times intense, and of a peculiar gnawing character. The pain is generally increased by food, and relieved by the rejection of it; vomiting is, therefore, generally present, and sometimes pyrosis or water brash. The other symptoms are, pain between the shoulders, more or less of abdominal uneasiness, constipation, emaciation, and a peculiar pallor and cachexia. Hæmatemesis, the rejection of food by vomiting, or melæna, the discharge of blood from the bowels as black pitchy stools, are present in most cases at one or other stage of the disease.

The pain is not always of the same character, but may be regarded as a symptom present in almost every instance. It may be almost constant, but generally undergoes degrees of exacerbation, being increased by food. The patient often states, that pain comes on as soon as the aliment reaches the stomach, and continues as long as it is retained. Sometimes it is so intense, that the patient is completely exhausted, as I have several

times found when branches of the pneumogastric nerve have been involved in the dense edges of a chronic ulcer. In a case under my care, in which other signs of ulcer were present, the patient stated that the pain was sometimes relieved by firm pressure against the back of a chair. Position has, in not a few instances, a marked effect as to the severity of the pain; and I have several times been able to confirm the statement of Dr. Osborne, that the position of the pain serves as a guide to the seat of the ulcer, according as the contents of the stomach gravitate towards or away from the injured part. Thus in an ulcer at the posterior part of the lesser curvature the patient has been most easy when leaning forwards and towards the left side. On the contrary, I have seen the pain continue, whatever position might be assumed. In young women suffering from well-marked ulceration of the stomach, with chlorosis, neuralgic pain in the side may be present at the same time that tenderness and pain are experienced at the scrobiculus cordis from ulcer; and in these patients, we find increase of pain, during or prior to the menstrual periods.

Pain in the back is rarely absent in chronic ulcer of the stomach; it is generally less severe, and comes on later, than the gastric pain, but is sometimes complained of more urgently than that at the stomach itself, the patient often stating that the pain goes through to the back. In speaking of the diagnostic value of pain,