The question of the cancerous transformation of an ulcer of the stomach was first discussed by Cruveilhier in 1839. Rokitansky, in 1840, also recognised the difference between chronic ulcer and cancer, and said that the latter might be implanted upon the former. To Dittrich, writing in 1848, belongs the chief credit of drawing attention to the subject. He described in 160 cases of new growth six cases of cancer developing in the immediate vicinity of active or healed ulcers, two cases of the association of cancer and ulcer, and two cases in which the cancer was limited to a certain part of the margin of the ulcer, the rest remaining sound. Brinton, in 1856, recognised the possibility of the grafting* of cancer upon long-standing ulcer.

Lebert, in 1878, considered that the cancerous transformation occurred in 9 per cent, of ulcers; but Zenker, in 1882, expressed a strong* opinion that all cases of cancer of the stomach were secondary to ulceration.

He attributed the cancerous degeneration in an ulcer to glandular changes caused by inflammation and cicatrisation exciting and favouring epithelial proliferation. He called attention for the first time to the persistence of free hydrochloric acid in the stomach contents in cases of cancer grafted upon ulcer.

In 1889 Rosenheim found in forty-six cases of cancer, four in which the malignant change was secondary to ulceration. In all these, free HCl was present.

G. Fuetterer, in 1902, made an extensive research into the question of the origin of carcinoma of the stomach from chronic round ulcer. His conclusions, briefly stated, were as follows :

(1) If a carcinoma develops from a chronic ulcer of the stomach then this development occurs from those parts of the edges of the ulcer which are most exposed to mechanical irritation by the contents of the stomach.

Plate II. Cancer of anterior Avail of the stomach producing hour-glass contraction.

Man, aged sixty, with four years' history of vomiting and other signs of ulcer. This is an example of " ulcus carcinomatosum/' (No. 2 108c, Royal College of Surgeons' Museum.)

(2) In the pyloric region it is the lower pyloric margin of the ulcer which is most exposed to mechanical irritation, and from which carcinoma develops. But other parts of the edges may be the ones involved when dilatation and adhesions have changed the position of the organ.

(3) Development of carcinoma from ulcers of the stomach in the pyloric region occurs with great frequency, while such a development occurs less often in other parts of the stomach.

In 1903 Audistere recorded examples and made very careful examination of four personal cases. His conclusions are summed up in the following manner :

(1) Simple ulcer of the stomach may be the starting-point oft a cancerous growth, a condition of things which appears to be not infrequent.

(2) This malignant degeneration affects, as a rule, the chronic ulcers, especially in the pre-pyloric region. The change begins in the mucous membrane at the margin of the ulcer.

(3) The transformed ulcer presents for a long time almost the same symptoms as a simple ulcer, but the diagnosis may be made by noting the resistance to treatment, the wasting, the persistence of the symptoms, and the progressive anaemia. The pain, as a rule, is more severe than in cases of simple ulcer.

(4) In cases of cancer, apparently primary, the origin in an ulcer may be suspected if the pain is unusually severe aud paroxysmal, if hyperchlorhydria is pronounced, or if haematemesis or perforation occurs. The prognosis is decidedly more grave, for the progress of cancer grafted upon ulcer is more rapid and bleeding or perforation is liable to occur.

If these conclusions are correct, and my experience tells me they are, then it is quite clear that we must in all cases in which an ulcer of the stomach resists treatment, or its scar narrows the pylorus, recommend an early gastroenterostomy or excision of the ulcer, in order to prevent the development of carcinoma. If a gastro-enterostonry has been performed, then the mechanical irritation by food of the ulcer in the pyloric region is reduced, and the friction necessary to produce a carcinoma will probably not occur. The estimates of the frequency of this malignant implantation upon a chronic ulcer vary greatly. The number of carcinomata beginning in chronic ulcer is reckoned at 3 per cent, by Fenwick, Plange and Berthold, 4 per cent, by Wollmans, 6 per cent, by Rosenheim and Hauser, 9 per cent, by Lebert, and 14 per cent, by Sonicksen. Zenker, as already mentioned, believes that all, or almost all carcinomata are secondary to ulcer. Mayo, in 157 cases of cancer of the stomach, found a previous history of ulcer in 60 per cent. In no less than 59.3 per cent, of cases of cancer of the stomach on which I have performed gastroenterostomy for the relief of symptoms,the disease having advanced too far for gastrectomy, the long history of painful dyspepsia suggested the possibility of ulcer preceding the onset of malignant disease.

The origin of carcinoma in an ulcer of the stomach is only another instance added to many of which we have knowledge, of the effect of persisting irritation in establishing1 malignant changes. Carcinoma occurs most frequently in those areas in which the ulcers chiefly lie. Whatever the frequency of the malignant change in chronic ulcer may prove to be, the fact of its occurrence should be an additional incentive to the earlier surgical treatment of ulcers which prove rebellious.

Symptoms

Since cancer "per se" has no symptoms, it not infrequently happens that if the growth involves the body of the stomach and not the orifices, it may pursue its complete course without giving rise to any definite local symptoms, and it has happened that the cause has only been discovered at autopsy. This form of latent cancer contributes 5 per cent, of all cases according to Professor Osier, who also gives it as his opinion that 10 per cent, of all cases of cancer of the stomach run an extremely rapid course, terminating in death within three months.