filaments in the floor of the ulcer. Vomiting is a usual symptom. It occurs either soon after the food is swallowed or at a later period, and generally relieves the pain and discomfort. Vomiting of blood (haematemesis) is a frequent and important symptom. The blood may show itself in the form of a brown or coffee-like mixture, or as pure blood of dark colour and containing clots. It comes from some vessel or vessels which the ulcerative process has ruptured. Blood is also found mixed with the discharges from the bowels, rendering them dark or tarry-looking. The general condition of the patient with gastric ulcer is, as a rule, that of extreme ill-health, with pallor, emaciation and debility. The tongue is red, and there is usually constipation. In most of the cases the disease is chronic, lasting for months or years; and in those cases where the ulcers are large or multiple, incomplete healing may take place, relapses occurring from time to time. But the ulcers may give rise to no marked symptoms, and there have been instances where fatal perforation suddenly took place, and where post-mortem examination revealed the existence of long-standing ulcers which had given rise to no suggestive symptoms. While gastric ulcer is to be regarded as dangerous, its termination, in the great majority of cases, is in recovery. It frequently, however, leaves the stomach in a delicate condition, necessitating the utmost care as regards diet. Occasionally the disease proves fatal by sudden haemorrhage, but a fatal result is more frequently due to perforation and the escape of the contents of the stomach into the peritoneal cavity, in which case death usually occurs in from twelve to forty-eight hours, either from shock or from peritonitis. Should the stomach become adherent to another organ, and fatal perforation be thus prevented, chronic “indigestion” may persist, owing to interference with the natural movements of the stomach. Stricture of the pylorus and consequent dilatation of the stomach may be caused by the cicatrization of an ulcer.

The patient should at once be sent to bed and kept there, and allowed for a while nothing stronger than milk and water or milk and lime water. But if bleeding has recently taken place no food whatever should be allowed by the stomach, and the feeding should be by nutrient enemata. As the symptoms quiet down, eggs may be given beaten up with milk, and later, bread and milk and home-made broths and soups. Thus the diet advances to chicken and vegetables rubbed through a sieve, to custard pudding and bread and butter. As regards medicines, iron is the most useful, but no pills of any sort should be given. Under the influence of rest and diet most gastric ulcers get well. The presence of healthy-looking scars upon the surface of the stomach, which are constantly found in operating upon the interior of the abdomen, or as revealed in post-mortem examinations, are evidence of the truth of this statement. It is unlikely that under the treatment just described perforation of the stomach will take place, and if the surgeon is called in to assist he will probably advise that operation is inadvisable. Moreover, he knows that if he should open the abdomen to search for an ulcer of the stomach he might fail to find it; more than that, his search might also be in vain if he opened the stomach itself and examined the interior. Serious haemorrhages, however, may make it necessary that a prompt and thorough search should be made in order that the surgeon may endeavour to locate the ulcer, and, having found it, secure the damaged vessel and save the patient from death by bleeding.

Perforation of a gastric ulcer having taken place, the septic germs, which were harmless whilst in the stomach, escape with the rest of the contents of the stomach into the general peritoneal cavity. The immediate effects of this leakage are sudden and severe pain in the upper part of the abdomen and a great shock to the system (collapse). The muscles of the abdominal wall become hard and resisting, and as peritonitis appears and the intestines are distended with gas, the abdomen is distended and becomes greatly increased in size and ceases to move, the respiratory movements being short and quick. At first, most likely, the temperature drops below normal, and the pulse quickens. Later, the temperature rises. If nothing is done, death from the septic poisoning of peritonitis is almost certain.

The treatment of ruptured gastric ulcer demands immediate operation. An incision should be made in the upper part of the middle line of the abdomen, and the perforation should be looked for. There is not, as a rule, much difficulty in finding it, as there are generally deposits of lymph near the spot, and other signs of local inflammation; moreover, the contents of the stomach may be seen escaping from the opening. The ulcer is to be closed by running a “purse-string” suture in the healthy tissue around it, and the place is then buried in the stomach by picking up small folds of the stomach-wall above and below it and fixing them together by suturing. This being done, the surface of the stomach, and the neighbouring viscera which have been soiled by the leakage, are wiped clean and the abdominal wound is closed, provision being made for efficient drainage. A large proportion of cases of perforated gastric ulcer thus treated recover.