The frequency with which cancer of the stomach is preceded by a simple ulcer is a matter that has given rise to much discussion. According to Lebert, about 9 per cent, of all gastric carcinomata originate in the benign complaint; Sonicksen's estimate is 14 per cent., Eosenheim's 6 per cent., Plange and Berthold's 3 per cent., Steiner and Wollmann's 4 per cent., while Zenker seems to regard simple ulceration as a necessary antecedent to the malignant affection. Personally, we are inclined to agree with Haberlin that only about 3 per cent, of all cases of gastric cancer present a clinical history or post-mortem evidence of previous ulceration.

Since 1845 about thirty-two examples of the disease have been published, and although a critical examination of many of the cases tends to throw considerable doubt upon their authenticity, several facts of importance may be gleaned from them. As might have been expected from the etiology of the simple complaint, women are more often affected than men (20 : 12), and the pyloric end of the stomach is almost invariably the seat of the growth. As a general rule, the symptoms of the malignant disease are gradually engrafted upon those of the chronic ulcer, but in about one fifth of the cases an interval varying from a few months to several years existed between the apparent healing of the ulcer and the development of the neoplasm. A careful perusal of the recorded cases seems to indicate that the carcinoma ex ulcere may be divided into three classes.

In the first group the indications of malignant mischief steadily develop, and finally predominate over those of the ulcer; in the second they remain latent throughout, while the pain, vomiting, and haematemesis of the primary disease continue until the end ; while in the third all gastric symptoms remain in abeyance, and the physical signs indicate cancer of the liver, peritoneum, or pancreas.

(a) Cases in which the Symptoms of Carcinoma are engrafted upon those of Simple Ulcer constitute about 80 per cent, of the entire number. When the indications of an ulcer have persisted up to the time of its malignant invasion, they gradually become aggravated, pain and vomiting are excited by liquid as well as by solid food, and a constant sensation of nausea may be present. On the other hand, the appetite may continue good for several months, or even persist until the end. Attacks of pyrosis are apt to occur at night, loss of flesh takes place rapidly, and debility and cachexia are always prominent features of the complaint. Severe haematemesis is rare, but small quantities of altered blood are sometimes observed in the vomit or in the material extracted from the stomach by a tube. After a period varying from three to six months the appetite declines, the debility and emaciation make rapid progress, and the patient grows very depressed, and often expresses a conviction that his disease will prove fatal. The last phase is marked by complete anorexia, extreme asthenia and cachexia, and intolerance of any kind of food. The physical signs of malignant disease are very indefinite. The epigastric tenderness which had attended the simple ulcer is sometimes intensified, but in the absence of secondary growths in the omentum a tumour can rarely be detected. Owing to the fact that the neoplasm usually remains localised, the signs of pyloric stenosis are wanting, and it is rare for the liver to present palpable growths or for the glands above the left clavicle to become enlarged. The results of an exploration of the stomach are also equivocal, since the pre-existing hyper-secretion usually persists for several months after the onset of the carcinoma, and may continue until the end. As a rule, however, the secretion of the mineral acid gradually fails, and after a few months lactic acid, with or without the Oppler- Boas bacillus, may be detected in the gastric contents.

When carcinoma attacks an ulcer which has undergone cicatrisation, or which has remained latent for some time, it is much less difficult to recognise. The patient usually imagines that her old malady has recurred, and seeks medical advice on account of renewed pain or discomfort after food, and vomiting- It is observed, however, that, unlike the simple complaint, there has been a steady loss of flesh and strength from the onset of the dyspeptic symptoms; anaemia soon becomes a prominent feature, and the blood exhibits a steady diminution of red corpuscles and haemoglobin. The appetite is also affected at an early period, and complete anorexia is sometimes established after a few months. The gastric symptoms increase in severity, and if the growth involves the tissues surrounding the scar, as it usually does, the pylorus is apt to become obstructed and to give rise to periodic vomiting. This variety is more often accompanied by the presence of a tumour than the preceding, and in most instances the liver or peritoneum shows signs of invasion before death. The gastric contents vary according to the situation of the former ulcer; but unless it was located in the immediate vicinity of the pyloric orifice, hyper-secretion is usually absent, and free hydrochloric acid is replaced by lactic acid at an early period of the complaint.