It is the usual custom to describe the commencement of the complaint as insidious, and in the majority of the cases it is undoubtedly true that the local phenomena remain obscure until the morbid growth has either given rise to obstruction of an orifice or has undergone ulceration. We find, however, that in 9 per cent, of our cases the initial symptoms were stated to have appeared quite suddenly ; and since in every instance there seems to have been considerable difficulty of diagnosis, it is advisable briefly to consider this unusual mode of development.

An abrupt onset may be marked by three varieties of symptoms. As a rule the patient is attacked by acute gastritis, which, instead of subsiding under treatment, assumes a subacute or chronic character and continues throughout the whole course of the complaint. Less frequently the first indication of illness consists of severe epigastric pain, which either persists more or less constantly, or assumes a paroxysmal character and is aggravated by food. Finally, in rare instances a profuse haematemesis, like that which occurs in simple ulcer, is the first symptom to attract attention.

(a) When the symptoms of acute gastritis usher in the disease, they are generally attributed by the patient either to over-indulgence in some article of food or drink, or to the imbibition of cold water or beer. In other cases exposure to cold, an attack of influenza, over-fatigue, excitement, or mental worry is regarded as the exciting cause of the complaint. Since, however, in every instance of this kind the pylorus is found to be obstructed after death, it is probable that the inflammatory disorder was really the outcome of retention and decomposition of the food. The general features of the illness are well shown in the following case.