takes place, or impairment of the motor activity of the stomach becomes decided, dilatation of the viscus (gastrectasia) may result. A succession of meals may be taken before vomiting occurs; when it does, astounding quantities of liquid, containing the macerated and fermenting remains of food, and various fungi (especially the yeast-fungi and sarcina), are ejected. The quantity of hydrochloric acid in the gastric juice may or may not be changed. Organic acids of fermentation are usually present. What are the physical signs of dilatation of the stomach? Dilatation of the stomach gives rise to abnormal prominence of the upper portion of the abdomen, with extension of the area of gastric percussion-tympany when the organ is empty, and of percussion-dulness when it is filled. When partially filled (the ordinary condition), succussion-splashing is easily elicited, the stethoscope being placed over the pyloric region while sudden motion is imparted to the left hypochondrium and lumbar region. If so late as thirty-six hours after the administration of salol, salicylic acid can still be detected in the urine by a purplish or purplish-brown precipitate on the addition of tincture of ferric chloride, the delay in the propulsion of the stomach-contents into the duodenum is considered sufficient to warrant the diagnosis of gastrectasia. Gastric Ulcer. What are the symptoms of gastric ulcer? Destruction of the mucous coat of the stomach may be a result of acute gastritis. More commonly, however, gastric ulceration develops in the course of chronic gastric catarrh, especially in anemic women with impaired nutrition. In some cases, ulcers of the stomach result from occlusion or obstruction of gastric vessels. Gastric ulcer is not infrequent in cases of cirrhosis of the liver. The symptoms are sometimes obscure, and the disease may go unrecognized until suddenly perforation and death result. Symptoms of gastric catarrh are usually present, with vomiting, impaired appetite, discomfort after meals, flatulence, acidity, coated tongue. There are acute pain and marked tenderness in the epigastrium or hypochondrium, also sometimes in the lower dorsal or upper lumbar region. Pain and tenderness over or near the spinal column opposite the site of epigastric pain is quite characteristic of gastric ulcer. The pain and accompanying tenderness, anteriorly as well as posteriorly, are most frequently distinctly circumscribed. Pain is aggravated by the ingestion of food, especially solid food, and relieved by vomiting, which usually occurs soon after food is taken. The vomited matters are often blood-streaked; or a considerable quantity of blood, bright-red in hue, or discolored by the gastric juice, is vomited. Following hematemesis the stools contain more or less black, tarry matter. Anemia is a common attendant upon gastric ulcer. Dyspnea and palpitation are its concomitants. There are often great emaciation and profound prostration. Occasionally perforation of the walls of the stomach results; if adhesive inflammation have occurred, adjacent structures, as liver or pancreas, may constitute the floor of the ulcer; otherwise fatal peritonitis ensues. How is chronic gastritis to be distinguished from gastric ulcer? The difference is one of degree. With ulceration of the stomach are associated the symptoms of chronic gastritis, but in addition there are the exquisite localized epigastric pain and tenderness, which differ from the diffuse soreness of simple gastritis. Hematemesis is usual in ulcer of the stomach and less usual in chronic gastritis of other than alcoholic origin; and the blood in the latter case is not likely to be bright in color or of frequent appearance in the vomit. In gastritis vomiting occurs not only after taking food, but not uncommonly on an empty stomach as well. The vomiting of ulceration is usually brought on by eating. Chronic gastritis responds more readily than gastric ulcer to judicious treatment. The age and sex of the patient sometimes help the diagnosis, as ulcer is most frequent in young persons and especially in anemic girls. Carcinoma of the Stomach. What are the symptoms of carcinoma of the stomach? Carcinoma of the stomach appears principally in two forms. In the one the cellular element predominates; in the other the fibrous. The former involves the coats of the body of the stomach; the latter almost exclusively the pylorus. The symp toms occasioned differ in each case. When the body of the stomach is involved the symptoms are those of an aggravated chronic gastritis: impaired appetite, pain after meals, sometimes vomiting, with slow emaciation. As time goes on, ulceration takes place in the neoplasm, with the addition of the symptoms of this condition: severe, deep-seated pain in the region of the epigastrium, aggravated by the ingestion of food, vomiting of blood-streaked matters and of discolored blood presenting an appearance of coffee-grounds. The stools contain tarry matters, from disorganized blood. With the infiltration of the walls of the stomach, adhesions are formed with adjacent organs, which may be progressively invaded. When the new-growth involves the pylorus, a characteristic feature is dilatation of the stomach. The organ may be considerably displaced by the weight of the tumor. Emaciation ensues; while the development of the carcinomatous cachexia is of diagnostic significance. The feature without the establishment of which the diagnosis of carcinoma of the stomach is doubtful is the presence of a tumor in the epigastrium. In scirrhus of the pylorus death results from exhaustion, as a result of inanition; in cellular carcinoma metastasis plays a prominent part in determining a fatal issue. How are carcinoma and ulceration of the stomach to be differentiated? The similitude between the symptoms of ulcer of the stomach and those of carcinoma of the stomach is sometimes so great that the diagnosis is extremely difficult. The detection of a tumor in the area occupied by the stomach is convincing. In its absence, a cachexia or the detection of enlarged glands or new-growths at other parts of the body may afford corroborative evidence. While the symptoms of ulceration may set in acutely, and rapidly assume a grave aspect, they may on the other hand be comparatively mild; recovery is the rule. The symptoms of carcinoma are more slowly developed, more persistent and more profound than those of ulcer, and the pro gress of the case reveals its malignancy. If the pylorus is involved, vomiting does not take place for some time after food has been taken, while both in ulceration and in cellular carcinoma of the body of the stomach vomiting, when it occurs, takes place early. Obstruction of the pylorus by carcinoma occasions dilatation of the stomach. Before the fortieth year of life ulceration is the more common; after forty, carcinoma. In ulcer, the gastric hydrochloric acid is said to be excessive; in carcinoma, to be wanting. In simple ulcer, sudden, more or less profuse hemorrhages occur; hence the blood is often bright, and when discolored it is a viscid fluid or coagulated in coherent clots. In carcinomatous ulcer there is a slight but more or less continuous oozing; hence vomiting of blood rarely occurs apart from the admixture with food of the disorganized “coffee-grounds” sediment. How is carcinoma or sarcoma of the omentum to be distinguished from carcinoma of the stomach? The detection of a tumor in the region of the epigastrium is not exclusively indicative of carcinoma of the stomach. The omentum may be the seat of carcinoma or sarcoma. In such a case the symptoms of gastritis are not necessarily present; in particular the vomiting of matter resembling coffee-grounds is wanting. How is carcinoma of the stomach to be distinguished from carcinoma of the pancreas? It may be impossible to decide from anatomic considerations, especially in view of the displacement that often occurs, whether a tumor in the epigastrium is gastric or pancreatic. If the former, definite symptoms of gastric derangement are present; the visceral symptoms of the latter are ill-defined. The existence of diabetes and the imperfect digestion of fats would point to involvement of the pancreas. Jaundice sometimes accompanies carcinoma of the pancreas from pressure upon the bileducts. In gastric carcinoma without hepatic complication this does not occur. How is chronic gastritis to be distinguished from carcinoma of the stomach? It is not sufficient to make a diagnosis of chronic gastritis. The existence of carcinoma should, if possible, always be excluded. If, in addition to the symptoms of gastritis, there is severe and persistent pain in the epigastrium, or pain increased or developed after eating, with vomiting shortly after meals or after a variable interval, the ejected matters resembling coffeegrounds; if there exist cachexia, new-growths in various parts of the body, and a tumor can be detected in the region of the epigastrium, the gastritis is but a concomitant of the malignant disease, which, in the course of a year or eighteen months, is almost necessarily fatal. Carcinoma is uncommon before forty; gastritis may occur at any time of life. The gastric juice is said to contain free hydrochloric acid in nearly all cases of chronic gastritis, but to contain none in cases of gastric carcinoma. While the persistent absence of free hydrochloric acid should excite suspicion of the existence of malignant disease, it is not conclusive evidence. THE INTESTINES. Acute Enteritis. What are the symptoms of acute enteritis? Acute inflammation of the small intestine may vary greatly in severity, from a simple catarrh of the mucous lining to an intense inflammation involving the submucous and muscular tunics and even the peritoneal investment. Acute intestinal catarrh or mucous enteritis is, in most cases, dependent upon the presence of irritating matters in the bowel. As a result, there occur diarrhea, with colicky pains, and often considerable tenderness in the abdomen, and febrile and other constitutional manifestations of varying intensity. The stools may number from three to six or more in twenty-four hours; they are thin and liquid, containing undigested food and considerable mucus, and may be streaked with blood. The stomach is |