Ulcer of the stomach demands attention, first, because of the distress and pain which makes life miserable and unprofitable; secondly, because through lack of proper nourishment the general resistance is so reduced that destructive diseases find ready lodgment; thirdly, because of frequent pyloric obstruction and its associated evils; fourthly, perforation and hemorrhage threaten life; and, fifthly, malignant degeneration often develops in the ulcer area.

With each case presenting these factors to the clinician, with the multitude of sufferers who daily seek relief, it should be an earnest duty to put forth every effort to an exact diagnosis, a matter often easy, and again well nigh impossible.

In the cases that have come to our clinics, the symptoms complained of have been various, but when one holds in mind this common pathological condition the symptoms present rarely fail to give a definite pointing,-gas, belching or bloating, usually both, burning, distress, pain, eructations, "heartburn," sour stomach, vomiting, weakness and hemorrhage. Some or all of these are complained of soon after food is taken or during the digestive act. Headache, constipation, pallor, cachexia, general weakness, mental weakness, melancholia, and anxious, worn expression, may appear at any stage, but are oftener seen in the chronic type.

A careful history is of the utmost importance in reaching a correct diagnosis. First, determine the length of time the symptoms have run, how

*Read before the Minnesota Valley Medical Society, December 2, 1902.

NO. 1

constant they are, and when they appear; secondly, get the full history of the relapses, for so prone is ulcer to long spells of relief with sudden relapses that one can scarcely help thinking of and diagnosticating ulcer with such history before him; thirdly, learn the number of symptoms present, their severity, and when at their height; fourthly, get the location of the pain or complaint; fifthly, determine carefully the reason, if wasting is present. The last-named is very important, for one cannot argue from the state of nutrition as to the condition of the appetite. Is he able to eat, is he eager for food, is he without desire for food, or has he a disgust for it? As a rule, the patient with ulcer has a desire for food, even craves it. This is natural, as the digestive juices are abundant, even in excess; but through fear of gas, distress, and pain, he abstains, and hence the emaciation.

This history, together with inspection, percussion, and palpation, with chemical reaction after a test-meal, with inflation of the stomach, and blood examination, will enable one to arrive at a diagnosis.

Hydrochloric acid is usually present and often increased in quantity,-a condition favoring ulceration of the stomach. Anemia is, as a rule, present. In the acute form it is often pronounced, with little if any emaciation. Perhaps anemia is at times secondary, but I am sure it is oftener primary, and is thus an inviting cause. It precedes the onset of symptoms, and is certainly worthy of careful attention when considering gastric ulcer. Another symptom or condition worthy of special attention is dilatation. This is

present in a greater number of sufferers, and is rarely absent in any case where the type is chronic.

Some of the more characteristic and constant symptoms demand special attention.

PAIN. The pain våries from mere distress to intense suffering, and is described as burning, gnawing, boring, and is, when properly interpreted, the most important and characteristic symptom. Not the kind of pain, however, for the kind rarely helps. Cramp-like pains in the stomach and hemorrhage fixes a diagnosis for ulcer, while the same described pain, with jaundice, enlarged liver, and gall-bladder, or with passage of stones in the stools, points just as clearly to gall-stones. The time and location of the pain are the factors. The pain depends upon the meal (quantity and quality of food), appears oftenest at or soon after eating, is relieved by vomiting, and is rarely present when the stomach is empty. As the case becomes more chronic, the interval between the taking of food and the appearance of pain is lengthened and may be present only daily; or even longer periods of ease may be experienced. The location of the pain is valuable. The pain in ulcer is oftenest located in the epigastric region, just below the xiphoid cartilage or to the left of the median line, and very rarely to the right. Often a diffuse pain is complained of, with radiation to the back, but this is rarely to the right of the median line. If found to the right the location is low, and we usually find prolapse or dilatation, or both, and the case is more or less chronic. We frequently find general epigastric tenderness to pressure but painful circumscribed areas are much less common, while dorsal points of tenderness scarcely enter into reckoning.

VOMITING.-Like pain, vomiting is not misleading if the interpretation is made. A few cases do not vomit, but of these the greatest number have nausea. However, by far the greater majority at some stage of the attack, do vomit. Like pain in the acute stage, vomiting usually comes on as soon as the food enters the stomach or soon thereafter, usually not much. beyond the hour mark. As the case becomes more chronic the interval between food-taking and vomiting may increase, until, as is seen in the most chronic type with pyloric obstruction and great dilatation, the vomiting interval is of

daily or weekly occurrence, and the vomitus large in quantity, acid, and containing considerable fluid with food debris. Relief is afforded for a time, the symptoms gradually returning as the stomach re-accumulates ingesta and its secretions.

The kind of vomitus is diagnostic. In the acute ulcer the food is returned as taken. In more delayed vomiting there is more or less of the digestive juices mixed with the food, while in the chronic cases the vomitus is usually quite fluid, the food well broken up, and the whole mass so acid and corroding that the teeth are often eaten to the gums by contact with the material so vomited. Some patients raise this without effort, or complain that it runs from the mouth on lying down. Vomiting of blood, when other causes, such as kidney and heart trouble, tuberculosis, and cirrhosis of the liver, can be excluded, is satisfactory evidence of ulcer; but in our experience it is among the rarer symptoms, and a diagnosis can scarcely wait for such evidence. Careful examination of the stomachwashings will frequently reveal blood-cells, and this method of information should be followed for this clinching evidence. Lest the digestive juices destroy the cells, the microscopic examination should be made immediately after the washings are taken. The chemical test for blood may succeed when the microscope fails. In our cases hyperacidity has been quite a constant factor, unless the case was thoroughly chronic, and it would appear, as Riegel has pointed out, that hyperacidity is primary and ulcer secondary. Constipation, regardless of age or sex, is so constant a factor that it has a place in diagnosis. In differential diagnosis the chief diseases are cancer, gall-stones, nervous gastrosuccorrhea, and gastralgia.

CANCER. In cancer the pain is more constant and diffuse, and not relieved by vomiting; blood is less in amount, more frequently found, and is of a dark "coffee-ground" appearance. The appetite is usually poor, and there is often no taste for food, or utter disgust appears. Emaciation and cachexia develop rapidly. Tumor and glandular enlargements are more often found. There is lessened hydrochloric acid, or absence; presence of lactic acid, yeast fungi and Oppler-Boas bacilli and cancer fragments (Hemmeter). (Hemmeter). Age, and a steady downward

course of short duration is the rule. Finally an exploratory incision is demanded, because it is the only positive means of diagnosis.

GALL-STONES. The pain in case of gallstones is oftener described as terrible, and is more often diffused over a larger area at the onset, or has points of intensity farther removed from the pathological seat of the trouble, that is, the pain may be high in the chest, far to the left, or low in the abdomen; but the time of occurrence, suddenness of the onset, and independence of food (normal hydrochloric), with the history of the attack and tender spot under the right costal arch, will lead to the correct location of the trouble. In the great majority of cases the pain is to the right of the median line, shooting through to the right shoulder, and has irregular intervals of appearance, long duration, sudden recovery, especially in the earlier attacks, and is not eased by abstinence from food or by vomiting. The pain often comes at night when the digestive function is at rest. The characteristic symptom is the point of tenderness to pressure under the right costal arch. This, with the enlarged liver, distended gall-bladder, jaundice or passage of stones, simplifies the diagnosis.

NERVOUS GASTROSUCCORRHEA.-This disease, often called nervous dyspepsia, may be mistaken for ulcer, because it is often a precursor of such a condition. These patients have pain when the stomach is empty, and they digest food readily, perhaps rapidly early in the trouble, and are at perfect ease during the digestive act; but when the food has left the stomach, the over-abundant and continual gastric secretion irritates the mucous membrane, and extreme pain may result. Usually the severest pain is before dinner and supper, yet many are awakened during the latter part of the night, and get rest only through food and drink. Early in these cases there is good motive power, no pyloric trouble, and rarely dilatation; but later all seem to suffer, save perhaps the pylorus. Many of these cases do develop ulcer. The symptoms gradually change, there is a lessening of the premeal pain, shorter after relief, with pain again developing shortly after the meal or before the stomach is emptied, finally passing to typical ulcer symptoms, with ulcer, dilatation, loss of motive power, and perhaps pyloric obstruction. These cases have been common in our clinic. We have developed it in

many histories, and followed it in several cases. These are the ulcer cases that are rarely free from pain. GASTRALGIA. Gastralgia appears often in the distinctly neurotic. The pain is sudden, irregular, independent of food, save that food may diminish the pain, not relieved by vomiting, pressure oftener gives relief, and rest and diet have little influence. The nutrition is not often impaired, there is no hemorrhage, no tumor, no dilatation, no gastric distress. Between attacks there is no tender spot.

Finally, in making a diagnosis of ulcer of the stomach, like most other diseases, we cannot rely on purely pathognomonic symptoms; but it is only by weighing and considering all, the history, symptoms and combination of symptoms,— that we may hope to reach positive conclusions.

AN EPIDEMIC

The Copenhagen papers publish this piquant little story:

A prominent business man appeared at the office of his family physician, and communicated to him with great concern, that his son, the joy and hope of the family, to all appearances was suffering from diphtheria.

The doctor shrugged his shoulders in a sympathic way: "Very sorry to hear it. No mother's soul is safe when that sneaking disease comes around."

"But," continued the man, "the dear young lad has confessed that he caught the disease from the house-maid, whom he had kissed."

"Well, what in the world shall one say to that? Young people are very thoughtless, remarked the doctor discreetly."

"But, don't you see, doctor-how-to be plain-between you and me-I have also kissed the girl (the horrid thing); perhaps I too will be down with the disease."

"Yes, by thunder, that is the next thing to expect

"And I kiss my dear wife every morning and evening, so we risk having her—”

"My God and Creator, exclaimed the doctor, bringing his fist down with emphasis, then I too will have it.

Tableau.