The ulcerative loss of substance which results from one or the other of the processes we have hitherto considered, requires no separate examination, as it presents nothing characteristic. There are other ulcerative affections of the stomach which appear of more importance. Those connected with tubercular and cancerous affections we shall examine under the head of tubercle and carcinoma. At present we consider the following:

A. The Perforating Ulcer Of The Stomach

There is one kind of ulcer that occurs in the stomach, which, both on account of its frequency, and on account of the extreme pain it causes, as well as on account of the numerous and enigmatical symptoms that accompany it, deserves every attention, - an ulcer, termed by Cruveilhier the simple chronic ulcer of the stomach, and which we would call the perforating gastric ulcer, from its prevailing tendency to perforate the parietes of the stomach.

In a well-defined case there is, in the region of the pylorus, a circular orifice of from three to six lines in diameter, with a sharp peritoneal edge, as if a round piece of the gastric parietes had been punched out. When viewed from within, the loss of substance on the internal membranes of the stomach, and especially on the mucous layer, appears more considerable, so that the edges of the hole seem bevelled off from within outwards. There is no further morbid appearance beyond a thickening of the parietes in the immediate neighborhood of the ulcer, and a tumefaction of the gastric mucous membrane.

The pyloric half of the stomach is the seat of the ulcer; it is most frequently found in the middle zone of this portion; it is oftener seen at the posterior than at the anterior surface, almost always near to, and frequently at, the lesser curvature; and it occurs, in extremely rare cases only, at the fundus. This affection may also appear beyond the stomach in the upper transverse portion of the duodenum, but it does not occur in the remaining portion of the intestinal canal.

The size of the ulcer varies from that of a sixpence to that of half-a-crown, and even to that of a cheese-plate.

Its shape is commonly circular, but, in exceptional cases, it is from the beginning of an irregular form, though the circular form with which it commences frequently disappears subsequently. Ulcers of great extent approach the elliptical shape; but, on further extension, this too is lost, and they become irregular in consequence of the formation of sinuses varying in depth. The extension of the ulcer in the transverse diameter of the stomach, so as to form a zonular ulcer, is singular, on account of the deformity of the stomach which follows. The original form of the ulcer is also lost, when two ulcers coalesce so as to form a single one. In these cases we may for a long time be able to point out the boundaries of each, represented by a ridge of cellular tissue, but this, too, will disappear, and they then both have the same common base.

In the majority of cases there is only a single ulcer, but frequently there are two or three, occasionally four or five, and these are then commonly placed above or near to one another at the posterior surface of the stomach, or at the lesser curvature. It is very rarely the case that one occurs at the posterior, and the other at the anterior surface of the stomach, or that two ulcers are formed opposite to one another in the duodenum.

It has not been clearly ascertained in what shape the malady takes its origin, and in what manner the further development is effected. It is probable that it commences with an acute, circumscribed, red softening (hemorrhagic erosion), or with a circumscribed sloughing of the mucous membrane; it is still more probable that the ulcer increases in this manner, the tissues at the base of the ulcer sloughing and exfoliating layer by layer. We have observed this occurrence in a few solitary instances, and we would therefore view the process as offering a valuable analogy to sloughing of the lungs (gangrgena pulmonalis); on the other hand, we cannot admit that view to be well grounded, which explains the loss of substance in question solely by the absorptive process; the callosities of the surrounding tissues, and the well-marked reaction at the base, are in themselves sufficiently strong arguments against it.

The ulcer attacks the deeper-seated parts in a peculiar manner, when it presents the perfectly round form. The loss of substance is more extensive in the mucous membrane; if the muscular coat has been attacked and destroyed, we find a smaller ring with sharp edges, and the ulcer thus obtains a peculiar scarped appearance. If, finally, the peritoneum is perforated, this point will occupy the centre of the circle; the serous membrane will be converted into a yellow slough, and it will tear, or be voided.

This process may run an acute course; but it is commonly chronic; occasionally it comes to a standstill, and then again exacerbates in an acute or chronic form. A cure may result at any of the stages, as pro red by the various cicatrices frequently observed on the inner surface of the stomach. Even actual perforation of the stomach is frequently rendered innocuous by the adhesion of neighboring organs, and complete cicatrization may follow.

Loss of substance in the mucous membrane alone is repaired by a condensation of the submucous cellular tissue into a fibro-cellular tissue, which causes the edges of the mucous membrane to approach one another, and is finally blended with it and the muscular coat. A radiated, asteroid scar, varying in size, remains.

When the ulcerative process has involved the muscular coat, and has penetrated beyond it, the muscular fibres that edge the ulcer retract beyond the mucous membrane, the subserous cellular tissue and the peritoneum shrivel up, the walls of the stomach forming the bases of the ulcer, and now only consisting of these two layers, are doubled inwards, the divided portions of the mucous membrane are thus brought together, and a union is gradually effected. We then find corded cicatrices, which shorten the stomach in its transverse diameter, or form annular contractions proportionate to the extent of substance destroyed or to their position. The pylorus is particularly liable to a diminution of its calibre.