REFERENCES. 1 4 Zeitschrift für rationelle Medicin, III, page 131. "Chirurgische Erfahrungen," Berlin, 1854. Archiv für Augenheilkunde, Band I, page 416. "Untersuchungen über die Entwickelung der Blutgefässe," Berlin, 1856. page 55. "Charité-Annalen, VII, 1856. 'Virchow's Werk-"Untersuchungen über die Entwickelung des Shädelgrundes," et cetera, Berlin, 1857, page 58. "Atlas der mikroskopischen pathologischen Histologie." Text, page 47, Tafel XXX. 10 Virchow's Archiv, Band XII, page 293. Virchow's Archiv, Band XIV, page 270. "Virchow's Archiv, Band XVII, page 367. 12 Beiträge zur pathologischen Histologie, page 209. 13 "Ueber die Entstehungsweise des Friedreich'schen Schlauchsarkoms," 1864Archiv für pathologische Anatomie und Physiologie und für klinische Medicin, Band XXXI. 14 "Ueber endotheliale Geschwüste"-Deutsche Zeitschrift für Chirurgie, Band XL. 15 "Ueber ein Endothelium mit hyalinen Kugeln (Cylindrom) des Antrum Highmori." 16"Zur Cylindromfrage"-Virchow's Archiv, Band LXIX. "Die Entwickelung der Carcinome”—Archiv für pathologische Anatomie und Physiologic, pages 133-134. 18 "Zur Cylindromfrage"-Archiv der Heilkunde, Band XII. 19 Endothelioma"-Ergebnisse der allgemeinen Pathologie und pathologischen Anatomie, 1897, II, pages 595-6-7. 20 "Hyperplasie und Geschwülste"-Ergebnisse der allgemeinen Pathologie und pathologischen Anatomie, pages 368, 369. 21 "A Case of Endothelioma of the Lachrymal Gland (Myxo-ChondroEndothelioma Cylindromatodes) with an Analysis of Previously Reported Cases of Lachrymal Gland Tumors"-Archives of Ophthalmology, Volume XXX, Number VI, 1901. 22 "Report of a Case of Metastatic Endothelioma"-American Journal of the Medical Sciences, New Series, CXXX, 643-648, 1905. 23.66 "Einteilung der Sarkome"-Beiträge zur pathologischen Anatomie und allgemeinen Pathologie, 1906, XXXIX, page 528. 24 "Text-book of Pathology," page 173. 25 "Text-book of Pathology, page 164; 168. 28 "Ueber das Zylindrom"-Deutsche medicinische Wochenschrift, 1907, XXXIII, 126. 27 Journal of Medical Research, 1904-5, Volume XIII, page 319. GASTRIC ULCER: DIAGNOSIS, DIFFERENTIAL DIAGNOSIS PORT HURON, MICHIGAN. GIVEN a patient with symptoms referred to the upper abdomen, particularly those symptoms suggestive of stomach pathology, how shall we determine the significance of each symptom and thereby estimate the pathology which must govern a rational therapy? This problem would not be so complex if all symptoms referable to the stomach could be traced to pathology in that organ, but such is not the case. The stomach, more than any other organ, manifests disturbances both adjacent to and remote from its own cavity, be they functional or organic. What, then, are the symptoms indicative of ulcer and how shall they be interpreted? The symptoms are both subjective and objective and will depend on the extent and location of pathology. The subjective symptoms as elicited by taking a careful history, are most important. The pain, vomiting, gas, sour stomach, and, in some cases, hemorrhages, about twenty-five per cent are not peculiar to gastric ulcer. It is rather the cycle of events. The periodicity of the pain, the relief which comes from food alkalies or drink, and the chronicity of the affection. The pain is frequently spoken of as a premeal pain, as food relieves it from one to five hours. The patient usually gives a history covering a long period of time, averaging twelve to thirteen years in a series of cases reported by Graham, in which they have had some periodic attacks of stomach distress, such as pain, sour stomach, water brash, vomiting, et cetera, which lasted for a week or a fortnight or more, after which their usual health was enjoyed until a recurrence of the previous cycle with a renewed attack. The subsequent attacks gradually grow more frequent and their severity increases with the progress of pathology until the patient no longer gets the intervals of complete relief. The relief which formerly came from food, vomiting and medication is more temporary and in the far advanced cases does not completely relieve. The pain area is usually limited. If the ulcer is in the pylorus or lesser curvature, the painful point is located anteriorly about the median line or slightly to the left and may extend through to the left of the spine posteriorly. When the ulcer is situated in the anterior wall the pain is not so frequently referred to the back. In some cases such a cycle of events takes places at intervals for a period of time when the ulcer apparently heals and a number of years of health is enjoyed so far as the stomach symptoms are concerned, when they recur. The old cicatrix breaks down or a new ulcer forms. The objective symptoms will assist in differential diagnosis. What diseases must be considered in making a differential diagnosis? Inasmuch as pain, vomiting, gas and sour eructations are usually present in ulcer, may not any or all of them be present in gall-stones, chronic appendicitis, or cancer. The form of appendicitis in which these symptoms are most conspicuous is chronic, recurring appendicitis in which the above symptoms have suggested ulcer in the stomach or duodenum and the pathology found in appendix, the removal of which relieved the symptoms. Again, the chronicity is not peculiar to ulcer, as gall-stones are notoriously chronic. Gas, sour eructations, chronicity and pain must, then, be considered in relation to, "First, the time of pain or other symptoms; second, the regularity of pain and other symptoms; and third, the means by which the pain or other symptoms are relieved that give the differential characteristics of gastric ulcer" (Graham). To differentiate between cancer, gall-stones, chronic appendicitis, pancreatitis, pernicious anemia, gastralgia, late syphilitic lesions and various neuroses, would seem difficult. Osler, in referring to the differential diagnosis, makes this statement: "That the Mayos should have operated to June 1, 1908, on two hundred and seventy-two cases of duodenal ulcer, nearly as many as has been reported in the whole literature, and that Moynihan should have had to June 1, 1908, one hundred and seventy-four cases, indicates that we physicians have been napping and what the modern gastroenterologist needs is a prolonged course of study at such surgical clinics." At this point, I wish to give you the history of a patient which recently came under my care from the hands of a gastroenterologist, a diagnosis not having been made, or, if made, the treatment prescribed did not give relief. Mrs. J. C., aged fifty-eight, came to me because of pain in the bowels and back, and because she is supposed to have stomach trouble. The stomach trouble dates back to when she was twenty-one years of age. The early symptoms were of water brash and vomiting, which relieved her. She had some pain in the stomach at that time. She had not had any trouble from the stomach for twenty-seven years previous to the present illness, which began twenty-six months ago. The symptoms at that time (twenty-six months ago) were persistent vomiting at intervals, which lasted for a period of six weeks, pain in the abdomen, mostly in the bowels, and through to the back in the thoracic region. Physical examination revealed a patient apparently normal for her age, with the exception that she had no uterus, it having been removed ten years previously for cancer, and the present trouble for which she seeks relief; she carried a fair amount of flesh on the body. Examination of the urine proved negative. Examination of the stomach revealed a slight ptosis, but no mass could be felt. Eighty cubic centimeters were drawn from the stomach after a test breakfast, examination of which showed a total acidity of 80; free hydrochloric acid 61; lactic acid absent; no blood. No occult blood in stool. Diagnosis-ulcer. Operation April 18 revealed a lump, walnut-size, in the first portion of the duodenum about one inch from the pylorus, to which the gall-bladder was fastened and tipped over. The gall-bladder was freed and posterior gastroenterostomy done with relief of symptoms. The limits of this paper permits of differential diagnosis in cancer, pernicious anemia, gall-stones and chronic appendicitis, but the numerous other affections, such as the nuroses, chronic gastritis, chronic pancreatitis, Bright's disease, and syphilis with its late lesions, must not be lost sight of. In cancer and gall-stones we may have any or all of the symp toms, pain, vomiting, gas, sour eructations, and chronicity, but in cancer the pain is more constant, has usually a wider radiation, and the same degree of relief is not experienced by food or medicine. Vomiting is probably not so frequent, but larger quantities with more offensive contents is the rule, with particles of food, which show that it is poorly mascerated, and contains undigested particles. Blood is more frequently present, particularly in cancer of long standing. The blood is more thoroughly mixed with the vomited contents, presenting a coffee-ground appearance. The general appearance of the facies in cancer, the pallor and drawn expression about the eyes and mouth, the hopeless expression and general loss of flesh with marked weakness and cachexia. Such a history, to which the stomach findings are added, will usually make a diagnosis reasonably positive of cancer. The stomach findings in themselves are not definite, while free hydrochloric acid was absent in eighty-four out of ninety-four in a series of cases reported by Osler. Still such a finding is only relative and must be considered with all other symptoms. A symptom of much significance is a muddy or dirty extract as a part of the stomach content (Pilcher). The Oppler-Boas bacillus, if present, is supposed to be of diagnostic value, while a palpable mass in the stomach is usually cancer. In gall-stones the pain comes on irregularly, independent of food or drink night or day, the pain radiates to the right scapula and along the right costal border, is sometimes felt over the whole abdomen, and stops suddenly as it commences at the height of an attack, with relief of all symptoms, jaundice being present in about twenty-five per cent of chronic cases. Gall-stones are not characterized by the cycle of events diagnostic of ulcer-an attack today, tomorrow, and again six months or a year hence, without the loss of flesh, which is characteristic of cancer, and to a less extent in ulcer. The stool in gall-stones shows the absence of bile when the common duct is obstructed; the regularity of the bowels is not apt to be affected in gall-stones, while constipation is the rule in ulcer and cancer. In pernicious anemia, stomach distress, gas and shortness of breath are frequent symptoms to which may be added the tinting of the skin, which is a lemon color. The fleshy and muscular systems are fairly well retained to the last. Attacks of diarrhea are frequent. Here, too, we have a disease characterized by exacerbations, but the patient does not so nearly approach the normal in the intervals as is the case in ulcer or gall-stones. The hemic murmur and loss of strength out of all proportion to wasting of flesh is quite characteristic. The blood picture will be sufficient to complete the diagnosis. The following history is pertinent: A patient suffering from stomach symptoms was referred to me for diagnosis, her condition having been diagnosed as gastric cancer by different physicians, but the possibility of pernicious anemia prevented a concurrence in diagnosis by the physician who referred her. A blood examination which showed a low hemoglobin--twenty-five per cent Tallqvist, leukocytes 10,500, red cells 1,590,000 with the stained specimen considered with the other symptoms, completed the diagnosis of pernicious anemia. Chronic recurrent appendicitis has many symptoms common to ulcer. Cases in which the usual symptoms, pain and tenderness are absent at McBurney's point, and the symptoms are referred to the epigastrium with pain, sour eructations, gas, vomiting and pyrosis, suggesting ulcer or the symptoms which are present when the stomach is crippled by adhesions or cicatrix, resulting in a degree of invalidism for the patient, will offer the greatest difficulties. As previously mentioned, the symptoms of ulcer will depend upon the location and degree of pathology. The complications, as cicatricial formation, perforation and hemorrhage, will develop symptoms in magnitude depending upon the severity of the hemorrhage, the amount of obstruction and other adhesions and location of perforation, anterior perforation being more fatal if not treated, as there is less chance for nature to protect the abdomen in this situation. Cancer development is the most serious sequela, and when we remember that upwards of sixty per cent of cancer cases give a history of precancerous condition, namely, ulcer, and that when cancer is once engrafted, the course is rapidly downward to a fatal termination, the value of an early diagnosis of ulcer becomes at once apparent. The best means of curing cancer is to cure the lesion on which it develops. As the cause of cancer has until the present eluded the efforts of the investigator, so will symptoms of pathology in the upper abdomen baffle the clinician, and in no inconsiderable number of cases will we have to open the abdomen to clear up a doubtful diagnosis. TRANSACTIONS. CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN STATED MEETING, APRIL 3, 1912. THE PRESIDENT, ALBION WALTER HEWLETT, M. D., IN THE CHAIR. REPORTED BY REUBEN PETERSON, M. D., SECRETARY. READING OF PAPERS WARTY TUMOR OF CICATRICES. DOCTOR CHARLES B. G. DE NANCREDE read a paper bearing this title. (See page 199.) DISCUSSION. DOCTOR DEAN LOREE: I would like to ask Doctor de Nancrède if many of the recurrences in carcinoma do not come in the scar? I have seen several cases of recurrent carcinoma of the breast with no enlarge |