GASTRIC TJLCER. 437 



extensive contractions of the stomach at its middle part, as to 

 subject the patient to a fresh series of troubles. 



On the other hand, the gradual extension of the original 

 ulcer exposes the patient's life to three sets of risks. For 

 when the ulcer continues to increase in depth slowly but un- 

 ceasingly — 



1. It may open into a large vessel, and so cause fatal bleed- 

 ing into the stomach. Such an issue is most frequent in the 

 case of those ulcers which are situated on the posterior aspect of 

 the stomach, just over the course of the splenic artery ; some- 

 times, however, it is the trunk originallj' supplying the affected 

 area which is laid open j^er diabwsin; the haemorrhage then 

 occurring from a branch of the coronary or gastro-epiploic 

 arteries. 



2. It may open into the peritoneal cavity. This usually 

 occurs by a circular hole of fair size, which can hardly be pro- 

 duced otherwise than by necrosis of £he base of the ulcer, and 

 detachment of the necrosed part. This accident is most common 

 in the case of duodenal ulcers ; next in order of frequency come 

 ulcers on the anterior wall of the stomach, inasmuch as during 

 the various movements and changes of place which the organ 

 undergoes, its anterior surface moves up and down over a con- 

 siderable area of the opposite peritoneal surface, a circumstance 

 very unfavourable, nay, antagonistic to any prophylactic adhesion. 

 The possibility of such conservative peritonitis is clearly shown by 

 ulcers situated on the posterior wall of the stomach and in the 

 pyloric region ; these are almost invariably found to have con- 

 tracted adhesions to neighbouring viscera, such as the liver, 

 pancreas, spleen, &c., before the occurrence of perforation. 

 This wards off the risk of a rapidly fatal peritonitis ; the result 

 is one which we, as physicians, would endeavour to compass if 

 we could. We must not shut our eyes to the fact, however, that 

 this very Ijridging-over of the interval between two layers of 

 peritoneum opens a new "field for the destructive activity of the 

 ulcer, which may proceed — 



3. To burrow into a neighbouring organ and destroy it layer 

 by layer. The spleen and the left lobe of the liver are most 

 liable to be thus invaded ; and as the destructive process advances 

 with greater ease in their soft parenchyma, than in the walls of 

 the stomach and the eoimectivc tissue of the adliesion, they 



