fact there is an explanation both of their node of origin and of the intractability of many of the cases that come beneath our notice.

The ulcers of the lower extremities to which old people are subject are often preceded by thickening of the skin and sub-cutaneous tissue; and as we have proved that structural degenerations often accompany gastric ulcers, we have reason to believe that in some cases such degenerations also give rise to this disease.

It has been the custom to refer the thickening at the edges of the ulcer to inflammation. This is, no doubt, the correct view in many, but not in all cases. Instances are given by Abercrombie, Andral, and others, in which, although symptoms of gastric ulcer had been present, no sore could be discovered after death, but only a thickening of the coats of some portion of the stomach. The following case seems to show still more clearly that ulceration may be the result and not the cause of the thickening.

CASE 28.-A man about 30 years of age consulted me on account of a constant pain of the back from which he had suffered for some time. There was no deformity, but considerable pain was experienced when pressure was made upon the spine. He remained for about a year under my care, with but little variation in his symptoms, when he rather suddenly began to complain of pain in the epigastrium and occasional vomiting. He lost flesh and strength rapidly, the vomiting became very frequent, and he sank from exhaustion. On post-mortem examination the bodies of two or three of the vertebræ were

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found to be carious, and the stomach was attached to the spine at that part by a dense layer of connective tissue. Opposite to the adhesion was a large ulceration with thickened base and edges. No appearance of cancer could be detected with the microscope, either in the stomach or in the newly formed tissue in front of the spine.

From the long continuance of the spinal symptoms and the late appearance of those indicating the gastric disease, there can be little doubt that the complaint originated in the vertebræ, and that the adhesions and ulceration were the results.

It has been proved by Dr. Brinton that, the liability to ulceration of the stomach increases in proportion to the age of the patient, and the same fact is observed with regard to degenerations. But this is not the case with respect to gastritis, for it has been shown that inflammatory dyspepsia is most apt to occur in early life, and that as age incrcases feebleness of digestion and not inflammation makes its appearance. The usual site of the ulcer is also in accordance with the supposition that it often results from degeneration, for this change chiefly affects the smaller curvature and the pyloric region, the parts most frequently also attacked by chronic ulceration.

In the majority of cases peritonitis is set up as soon as the ulcer has penetrated below the mucous membrane. The surface of the peritoneum becomes opaque and thickened, lymph is effused and glues the organ to some of the neighbouring viscera. When the perforation extends through the peritoneum the base of the ulcer is thus very often found to be formed by the liver or pancreas.

The frequency with which adhesion takes place depends on a variety of circumstances. Jaksch records twenty-two cases of adhesion in fifty-seven ulcerations, or 38 per cent. Of these the pancreas was united to the stomach in fifteen, and the liver in five cases, so that when adhesion takes place it is generally to the one or other of these organs.

The primary effect of such adhesions is to save the patient from the danger of the contents of the stomach being effused into the cavity of the peritoneum. It should be also remembered that a change is often produced by them either in the shape or the position of the stomach. In some cases it is contracted to a very small size; in others, either a pouch is formed which gradually becomes dilated, or the obstruction to the egress of food produces a general enlargement, and we find on dissection, the whole organ thin and greatly increased in size.

When the ulceration is situated at the smaller curvature, this part may be drawn together, and the shape of the stomach completely altered; or, where adhesion to the liver occurs, we sometimes find the middle and pyloric regions drawn under that organ, so that only a small part is visible on laying open the abdomen.

Chronic gastric ulcers are often very rebellious to treatment; and many patients suffer from them during a long series of years. The reasons of their being often so difficult to heal are sufficiently

evident.

In the first place, the original cause of the sore usually remains in action long after the ulcer has

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been produced. If, for instance, it has been excited by congestion of the mucous membrane, arising from diseased heart or liver, or from degeneration of the coats or blood-vessels of the stomach, it is evident that the mere loss of surface does not remove these morbid conditions.

The thickened edges and base of the ulcer itself must also tend, as in the case of an old sore upon the leg, to prevent cicatrization, by diminishing the supply of blood to its surface.

In addition to these we have to contend against the motions of the organ, and the irritating secretion which is poured out whenever digestion is in progress.

Coupling the above circumstances with the advanced age and feeble health of many of those affected with this complaint, we we can easily understand how such cases often resist any remedial measures we may adopt. I have been most successful in the treatment of persons below fortyfive

years of age, who presented no indications of disease in any of the other organs of the body, and who could trace the commencement of their illness to gastritis, or chronic congestion of the mucous membrane.

In the following case, I had the opportunity of watching the patient until a cure took place, and of confirming, afterwards, the correctness of the diagnosis.

CASE 29.-A female, about 35 years of age, had suffered for many years from all the ordinary symptoms of ulcer of the stomach. The pain was

severe after food; and she was much emaciated. She was treated with morphia, bismuth, and other remedies, and, notwithstanding frequent relapses, she eventually recovered. I lost sight of her for many years until I was requested to visit her when attacked with fever. She sank under this disease, and on a post-mortem examination we found the stomach partially divided by a stellate contraction situated in the smaller cuvature. When the organ was opened, its inner surface presented a large scar from which cord-like processes radiated in every direction, puckering up the membrane and the subjacent tissues.

Ulceration of the stomach may produce death in various ways.

Considering the severity of the pain from which many patients suffer, it is surprising that so few die from exhaustion. Almost all that have come under my notice, in which a fatal termination occurred in this way, and, where I had the opportunity of postmortem examination, have presented a large extent of mucous membrane destroyed by the disease.

Even where the ulcer heals, if the complaint has been of long standing, it is I think rare to see the patient regain perfect health. He generally remains thin and imperfectly nourished; and we may often remark that such persons do not attain to old age, but are cut off by some other disease.

Hæmorrhage is a much more common cause of death than exhaustion. Dr. Brinton concluded, from his inquiries, that 5 per cent. of those affected with gastric ulcer perished from this accident. But, as in