cirrhosis, chronic appendicitis, and cholecystitis with bacillary invasion of the lymphoid follicles of the gastric mucosa, must be considered. Ewald in "Lectures on Digestion" says: "Whenever living blood circulates in the mucous membrane under normal pressure, the gastric juice has no point of attack. But when the normal blood nutrition ceases, either in consequence of emboli (Virchow), or of ligature of vessels. (Pavy), and necrosis of tissue occurs, then, as elsewhere, the gastric juice digests the dead tissue."

It would appear in the light of later surgical experience that our text-books, particularly those on Practice, are in need of revision, and our.basis of diagnosis changed in relation to gastric ulcer. The usual conception of this condition has been limited to three classical symptoms-pain, vomiting and hæmatemesis. As a matter of fact it is astonishing how few physicians think of gastric ulcer until a copious hæmorrhage supervenes. The concensus of opinion among our most experienced surgeons indicates that in probably sixty per cent. of cases of gastric ulcer this symptom is absent, consequently if we were to rely on this classical symptom it is obvious that more than half the cases would not be recognized. Patients as a rule do not present themselves to the physician in the earlier stages of the disease. Their symptoms are usually those of grumbling discomfort in the stomach, and they become addicted to the use of various patent nostrums. With the progression of the symptoms, however, the physician is consulted and under the widely comprehensive terms of "gastric catarrh," "indigestion," "dyspepsia," "biliousness," etc., a diagnosis is made. This diagnosis has usually no conception of any distinct pathological entity, but simply denotes a group of symptoms. Medical treatment as a result is usually unsatisfactory. After having suffered greatly from many physicians, the patient is often induced to consult some eminent medical gastro-enterologist who may render a more æsthetic diagnosis of, say, a motor or sensory neurosis. Only as a last resort do patients consult the sur

geon, and it is astonishing that the mortality of stomach operations should be so low in view of this fact.

Pain following from a few minutes to several hours after eating is a very constant symptom of gastric ulcer. It is variously described as gnawing, boring, or stinging and corresponds to a point of tenderness about two inches below and a little to the left of the ensiform appendix. This is the so-called Brinton's point. If the ulcer is in the posterior wall of the stomach a similar point of tenderness is found a little to the left of the last two dorsal vertebræ, and this is known as Cruvielhier's point. Now these would be pathognomonic were they found only in gastric ulcer, but may be mistaken for cholecystitis. However, nearly always in the latter condition we find the pain radiating on a level with the tenth rib to a point at the angle of the right scapula. The pain of gastric ulcer has a further significance in that it marks a relatively advanced progress of the disease. Contrary to the general impression, the greater part of the stomach wall is relatively devoid of sensibility. It is only the parietal peritoneum that has sensory nerves, and ulcerations of the gastric mucosa does not cause pain until the irritation incident to it affects the parietal peritoneum or that which lines the under surface of the diaphragm. Pain pressure is not so much pathognomonic of ulcer as that the ulceration is extending and liable to end in perforation.

Vomiting and nausea are frequently associated with ulcer, but as these conditions are common to functional gastric affections they are in no sense pathognomonic, but of considerable corroboratory value. The same may be said of hyperacidity, which condition is, however, said to occur in ninety per cent. of gastric ulcers.

Periodic attacks of headache is a symptom often complained of and frequently indeed patients seek aid for the relief of this, when upon close inquiry we find it coincident with the gastric trouble.

There is one other symptom which has been specially

emphasized by Futterer, of Chicago, which I think marks a most important advance in the diagnosis of gastric ulcer. This is a persistent hæmoglobinæmia, and upon it largely, I am convinced, depends the ultimate prognosis of ulcer either from a medical or surgical standpoint. Moreover, the failure to recognize this condition is largely responsible for the subsequent non-healing of gastric ulcer treated by the various methods of rest cure and rectal feeding. These patients constantly show a hæmoglobin percentage of from sixty-five to twenty-five per cent., and the ultimate prognosis is obvious unless we appreciate the necessity of overcoming this deficiency.

At the present I wish to outline Futterer's mode of treatment, the success or failure of which determines the necessity of surgical intervention.

(1) If we diagnose an ulcer of the stomach, or if in the absence of convincing symptoms which are so often lacking, we have cause to suspect an ulcer, we must at once ascertain the percentage of hæmoglobin.

(2) We advise the patient to go to bed, either in a hospital or at home, employing the services of a trained nurse.

(3) We give the juice of five pounds of fresh beef daily as the case may require to bring the percentage of hæmoglobin up to normal as soon as possible (prepared beef extract does not give the desired result).

Directions for preparing the beef juice:

(a) Order five pounds of finely chopped round steak to be brought in at eight o'clock every morning. The fat should be removed before the beef is chopped.

(b) Mix with the meat a teaspoonful of salt and put it in the upper part of a double boiler; cover without adding water. (c) Fill the lower part of the boiler with warm (not hot)

water.

(d) Keep the boiler on the kitchen stove for four hours, keeping water in the lower part just warm.

(e) Turn the beef every hour.

(f) After four hours press the juice out with a potato masher-season-and let the patient drink in two portions, one-half at dinner and the other half at supper time.

Five pounds of beef will yield about a pint of juice." This treatment may be supplemented by rectal feeding. In every case of gastric ulcer there are two prognoses to be given (1) that which relates to the immediate repair of the ulcer and disappearance of symptoms; (2) the ultimate prognosis which relates to the amount of pyloric stenosis and consequent dilatation, and more emphatically to the probability of remote carcinoma. Competent observers claim that ninety per cent. of gastric carcinomata develop from pre-existing ulcers. Futterer, in a recent autopsy, found an ulcer in the lower pyloric region, the lower border of which had undergone distinct malignant degeneration, while the upper border was still benign, indicating the mechanical effect of food irritation, a heretofore unsuspected factor, the significance of which cannot be over-estimated.

ent.

When we consider some of the complications of gastric ulcer the indications for surgical intervention become apparAmong these are (1) perigastritis with adhesions; (2) local peritonitis ending with localized abscess; (3) subphrenic abscess; (4) abscess in neighboring viscera, as the liver, pancreas and spleen; (5) acute perforations of the stomach wall; (6) hæmatemesis and melena; (7) tumor of the pylorus; (8) cicatricial stenosis of the pylorus, with spasm; (9) atonic motor deficiency; (10) tetany; (11) adhesions around the bile-ducts producing cholecystitis, pancreatitis, with attacks simulating gall-stone colic; (12) carcinoma.

Pyloric stenosis with resulting dilatation probably furnishes the most common cause for operations. It becomes then simply a question of drainage and the marvelous improvement following gastro-enterostomy for the relief of this condition amply justifies the procedure. Pyloric spasm with severe pain continuing, is in itself a relative indication, and the complications already referred to are for the most part

positive indications for surgical intervention. Moreover, the steadily decreasing mortality attending gastro-enterostomy, pylorectomy, with partial resection of the stomach, offers most encouraging results for these patients.

In conclusion, I think the following deductions are tenable:

(1) Gastric ulcer is an affection more prevalent than has generally been supposed.

(2) If we rely on the so-called classical symptoms, we will fail to render an early diagnosis in about sixty per cent. of the cases.

(3) It may reasonably be asserted that a patient suffering from trouble in the right upper quadrant of the abdomen, unrelieved by medical treatment or suitable diet, probably has a gastric ulcer or cholecystitis, or both.

(4) Any medical treatment under which the hæmoglobin percentage fails to approximate the normal will fail, and surgical intervention is contra-indicated with a low hæmoglobin percentage accompanied by a high leucocytosis.

(5) The mechanical irritation of food in ulcer is a strong factor in the subsequent development of carcinoma; hence drainage by means of gastro-enterostomy should be instituted early to secure the physiologic rest necessary to the repair of the ulcer.