to be fairly successful, though he had been losing in weight ever since. He was very pale with an irregular temperature of 99° to 101° and a pulse seldom below 100. His greatest tenderness and pain were in the left side of the abdomen beneath the eighth rib; but he also had pain in the left side of his neck though there was no glandular enlargement. In March, 1907, gastric analysis was done three times, the gastric secretions were below normal, but otherwise negative. No blood was found in the gastric contents. The stool was examined five times for occult blood and none found. The patient became cachectic, his blood showed hemoglobin 70%, over 5,000,000 red cells, and leukocytes 8,000 to 12,000. There was no dilatation of the stomach, but there was much tenderness over the appendix. He had a left inguinal hernia. A more perplexing case for diagnosis I have not seen in my work recently. On account of his tuberculous history and malignancies in other members of the family, his supposed malaria six years ago followed by jaundice, the diagnosis of gastric ulcer previously and the appendicitis two or three years ago, I did not care to venture a definite diagnosis one way or the other. Gall-stones were not improbable; chronic appendicitis might have explained many of his symptoms; malignancy around the seat of an old gastric ulcer was what I feared, and tuberculosis of the peritoneum was not at all improbable. Operation was advised in April, 1907, and he consulted one of the most celebrated surgeons in the land, who diagnosed gall-stones with possible malignancy. As for myself I reversed the order and felt like saying malignancy with possible gall-stones. When upon the operating table the rupture was operated upon first. Another incision in the upper part of the abdomen showed that there were no gall-stones, the appendix was normal, but there were many adhesions uniting the greater curvature of the stomach and diaphragm, especially on the left side beneath the ribs. The adhesions were dense. The surgeon diagnosed pre-existing gastric ulcer with perforation which had never leaked on account of the adhesions, he said that there was evidence of former ulceration about one-half the size of a man's hand along the greater curvature of the stomach. The stomach was held well up beneath the diaphragm by the adhesions. There was no dilatation and no stenosis of the pyloris; the adhesions were therefore only partially loosened and the organs returned to the abdomen. No other operative procedure was considered wise. The patient was put back to bed and developed a pneumonia within 10 days, which almost terminated fatally. He returned to his home at the end of four weeks weighing 109 lbs. and felt that he ought to be well on account of having undergone a surgical operation. He was advised to eat freely though carefully of a mixed diet. But in this both patient and physician were greatly disappointed. In less than 10 days he had all his former symptoms-irregular temperature from 99° to 102°, weak and rapid pulse, distress after meals, belching and bloating with nausea, sometimes vomiting, and marked constipation. Pallor was extreme and urine scant, containing albumen and casts which were not present before the operation. Orthoform to relieve his pain in the stomach was ineffectual; so were bromids. In desperation we resorted to a diet limited absolutely to milk, eggs, and purees. Flax seed poultices were applied to the abdomen for several weeks, night and day, and gave great relief. Basham's mixture was used freely. Under this regimen the patient has greatly improved. He is ready to begin his work while subsisting on a semi-solid diet. On August 30, 1907, he weighed 136 lbs. and he looked well. His temperature was 99 1/5° and pulse 100 after riding a bicycle.

Case No. 6, Miss H., age 30, was first seen in May, 1907. She had a negative family history and she herself has had good health until two years ago, since which time she has been bothered considerably with pains in the stomach increased two to three hours after eating. At that time there was pain in the epigastrium as well as posteriorly to the left of the spinal column and beneath the left shoulder blade. There was loss of weight. She vomited occasionally after taking acids. There was belching and pyrosis with much constipation. Physical examination showed con

siderable pallor with hemoglobin 75%, red cells 4,500.000 and leukocytes 4,000. Heart and lungs were negative. Liver and spleen were palpable. Both left and right kidneys were floating. The uterus was pushed to the left and there was a cyst in the right tube or ovary, not painful. Succussion splash in the stomach could be found below the umbilicus. The gastric analysis showed achylia gastrica, absence of free HCl and combined HCI with a total acidity of 10. Rennet was absent. When the stomach was expanded with air it was greatly enlarged extending three to four inches below the umbilicus. The tenderness to the right of the umbilicus lay between the gall-bladder and appendix. Examination of the stools for occult blood showed a very marked positive reaction. I had every reason to believe that in this case of splanchnoptosis there had been a former gastric ulcer but at that time an achylia gastrica, with possibly an ulcer of the duodenum. There was no blood in the gastric contents. In June the patient returned to the city for operation. At this time examinations were made as before and gave practically the same results, except that blood was found in the gastric contents and none in the stools, though several examinations were made. Gastro-enterostomy by R. E. Skeel was done with difficulty on account of the dense adhesions between the stomach and surrounding organs. There was a thick scar of ulcer near the pyloris. In cutting through the stomach bleeding ulcers were found on the mucosa. The patient made a rapid and good recovery.

These six cases show first a case of perforation which proved rapidly fatal with no pre-existing symptoms, the ulcer possibly being secondary to nephritis. Two cases of perforation with recovery for the time being without operation. Two cases of achylia gastrica with no previous symptoms of ulcer, one with formation of hour-glass stomach. One case of suspected duodenal ulcer with achylia gastrica, but operation revealed gastric ulcer. One case of extensive ulcer of the stomach, requiring exploratory incision and subsequent medical treatment. In none of the cases was there a hyperchlorhydria.

Before proceeding further in the discussion of gastric ulcer I should like to call attention to some of the cardinal features and symptoms of this condition. The distress after meals, nausea, vomiting, hematemesis, pain and tenderness, rigidity of the abdominal muscles, age and sex, together with gastric analysis, all are typical symptoms when associated, but as these symptoms often exist alone, and inasmuch as any one of them may be found in a number of other conditions also, it is always necessary to anticipate the lesions likely to be mistaken for ulcer. Gall-stones, appendicitis, chronic gastritis, cancer of the stomach, cirrhosis of the liver, diseases of the heart, kidneys and pancreas, hysteria, all are capable of causing some of the symptoms just named. would say, as has often been said before, diagnose by exclusion. Any of the diseases mentioned will produce other symptoms and physical signs in addition to any one or more of the symptoms already named. A case of severe pain in the stomach, of frequent occurrence, usually increasing after eating, especially of certain

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foods, in the absence of other symptoms has much significance referring to gastric ulcer. Vomiting of blood, or often the presence of occult blood in stomach contents and feces is an item of no mean significance whenever there are the fewest symptoms referring to gastric disturbance. But should pains come on at night and not just after meals, be very sudden and be followed a few days later by a slight icterus, one would then think of gall-stones.

Gall-stone and ulcer cause about an equal amount of tenderness and rigidity of the abdominal muscles. A case of hematemesis in a young girl, even though quite profuse, in the absence of rigidity of the abdominal muscles and tenderness in the epigastrium, is more likely to be a case of hysteria or some menstrual disorder than one of gastric ulcer. Such a case came under observation a few years ago.

A young girl with very painful menses, which alarmed her parents much more than the physician, was after all advised to submit to dilatation of the cervix. The day following the operation the patient insisted that there was complete paralysis of both legs and three weeks passed before she moved the limbs at all. After her return home from the hospital, and while she was still walking on crutches, she had one morning quite a profuse gastric hemorrhage. The family, knowing of the condition of gastric ulcer, at once became alarmed. The patient had considerable pallor but not gastric distress, no abdominal tenderness nor rigidity. The suggestion of a gastric analysis and hints as to the use of the stomach tube proved a very potent remedy in stopping further hemorrhage and the girl has been quite well ever since.

Hemorrhage associated with cirrhosis of the liver I have seen quite frequently, but I find in appendicitis a condition which is hard to differentiate from gastric ulcer in the absence of marked symptoms, especially hemorrhage. Appendicitis of itself is often hard to diagnose, and sometimes extremely hard to differentiate from chronic gastric ulcer or gall-stone. By way of illustration let me give briefly the history of another case in which this feature was marked.

Mr. T., age 37, was first seen in January, 1906. He gave a suggestive history of gall-stone, with the attacks of pain at night a few hours after dinner. Frequently there was vomiting. Gastric analysis was practically negative, but there was pain and tenderness over the pyloris. After a month's careful observation, with an uncertain diagnosis but with some improvement in his general condition, he suddenly had severe pain over the stomach and vomiting of mucus and bile. The upper portion of the abdomen was very rigid and the lower portion soft as any healthy abdomen. There was much pain over the stomach, especially about the pyloris, and none whatever over the appendix. Twelve hours later the condition was about the same. Rigidity of the abdomen in the ensiform region was so great that I feared perforation from a gastric ulcer; the lower portion of the abdomen was still as soft as dough; the temperature and pulse were rising. A few hours later he had an intense sharp pain of sudden onset in the lower portion of the abdomen just over the bladder. At once the muscles became rigid there and softer above. I was then

sure of perforation somewhere. R. E. Skeel was called in consultation. A diagnosis of perforated appendix or bowel was made and a ruptured gangrenous appendix was removed at once. The patient has been quite well ever since, having but little or no trouble with the stomach and has had no more gall-stone colic.

While willing to admit my lack of skill in diagnosis and to give credit to the modern surgeon for all kinds of skill, I at the same time feel sure that any competent surgeon would have been undecided whether to make an incision in the upper or lower portion of the abdomen had he seen this same case six hours earlier than it was seen by the consultant.

Concerning the treatment of gastric ulcer, there is still considerable difference of opinion. Fortunately the surgeon and physician are rapidly coming to a more uniform opinion as to the proper method of handling these cases. There have been some sharp criticisms in the past 10 years by both physician and surgeon concerning the manner of treatment given these cases when treated by the other fellow. Happily these criticisms are being forgotten and the profession now seems to be anxious to do the best for the patient without further vituperation of the other man's methods.

As an internist I can only endorse the sentiments of many others in the line of carrying out the strictest regimen in medical treatment whenever possible. That is, whenever necessary, and whenever the patient is willing to submit to proper treatment. The advantage derived from rest in bed in case of recent ulcer, especially if there be hemorrhage, with the total withdrawal of food by the mouth, cannot be overestimated. Rectal feeding for a week to 10 days is often necessary. Astringents, such as bismuth, silver nitrate, belladonna, adrenalin, tannic acid, as well as orthoform for the pain, are all remedies of value. Alkalis with bismuth and magnesia are extremely valuable in overcoming the acidity and constipation if they be present. One must remember, though, that these ulcers will heal of their own accord if proper rest and prolonged abstinence from food by mouth be carried out faithfully. In case of pain, and often without it, poultices to the abdomen, Leube's treatment with vaseline application, are both of value and need only to be mentioned. A more difficult subject than proper medication is proper diet and when to begin to administer it after the stomach has been deprived of food for some time. The physician's skill and tact in selecting the diet in these cases may mean his success or his failure in the handling of the case. The treatment of the complications, such as hemorrhage and perforation and frequent relapses, as well as stenosis of the pyloris, need not be discussed here, except to say that a competent surgeon, neither too conservative nor too aggressive, should be

at the elbow of the physician when such conditions arrive. The surgeons, or at least some of them, we are aware, have until very recently been claiming everything in the way of getting results by their skillful operations. But sufficient time has now passed since they have invaded this field so boldly to convince one that much of their work is not all glitter either. However, no one can have more respect than I myself for the work done by such men as the Mayos of Minnesota, Patterson and Mayo Robson of England, as well as a great many others who are doing equally efficient work in this line. I am firmly convinced that their aggressive work has been of the greatest value not only in the cures. which they have effected but in the awakening interest in the subject which they have given to the profession. That the surgeon can do much by his operations, but that he can often fail also, there is plenty of evidence. A brief report from C. A. Hamann of a fatal case of "Peptic Ulcer Following Gastrojejunostomy" in the May, 1907, number of the CLEVELAND MEDICAL JOURNAL is worthy of the consideration of both the physician and surgeon.

To me it seems that the most difficult class of cases to handle in general practice, and of these I am sure the general practitioner (not necessarily the stomach specialist) will see a great number if he only looks for them, is that class in which there is but slight ulceration, and yet the patient is not very sick and is unwilling to make any sacrifice for his cure. It is often impossible to persuade these patients that they are afflicted with anything more than a trivial disorder of the stomach. They are patients who take an ineffectual cure from a half dozen physicians, sometimes getting well in spite of treatment rather than because of it, and often after a number of good resolutions, at once broken, to carry out the physician's directions. They give up treatment as soon as they begin to improve and consequently develop a state of chronic gastric ulcer. They are ambulant cases. I have seen two instances of this kind very recently.

The first case is that of a young man of strong physique, but of reckless habits in eating and taking of stimulants, mostly beer in large quantities, he has a gastric ulcer which bleeds occasionally. He has many of the typical symptoms, though a hypo-acidity, with blood in gastric contents and stools. He was advised to take the rest cure and treatment for the ulcer, but his first prescription and first attempt at a careful diet have given him so much relief that he now is attending to a heavy business with greater vim than ever. He is quite relieved with but little sacrifice but I doubt whether he is well.

The other case is that of a nurse girl. I am convinced that she has been suffering with ulcer for five or six months though she has been