The principal forms of chronic ulcer, according to Fenwick, are the following:

1. The gastralgic form, characterized by attacks of severe pain, resembling biliary colic.

2. The catarrhal or vomiting form, which may be confounded with acute gastric catarrh, hysteria, or uncontrollable vomiting of pregnancy.

3. The dyspeptic form, which must be distinguished from chronic gastritis and nervous dyspepsia.

4. The hemorrhagic form, which may be confounded with cirrhosis of the liver and thoracic aneurysm, in both of which diseases hæmatemesis may occur.

5. The cachectic form, characterized by emaciation, debility, and cachexia; so that it may be difficult to distinguish it from cancer or pernicious

anæmia.

Leaving out of the question the sequelae of chronic gastric ulcer, such as benign stenosis of the pylorus, hour-glass contraction of the stomach, perigastric abscess, etc., the indications for surigcal intervention and perforation and hemorrhage. Hemorrhage

in acute ulcer is a common occurrence; but it seldom recurs because the edges of the sore are soft and yielding, the wounded vessel readily contracts, the bleeding ceases spontaneously and in a few weeks the ulcer heals.

Hemorrhage in chronic ulcer occurs in only about 18 per cent. of all cases; but when it does occur it is a much more serious matter than in the acute form of the disease, for the reason that the edges of the sore are fibrous and unyielding; the wounded vessel lies like a rigid pipe in the wall of the ulcer, and not being able to contract, the bleeding can only be stopped by a process of clotting. Here hemorrhage is very apt to recur either from insufficient clotting in the first place or from displacement of the thrombus (Fenwick). Therefore when hemorrhage occurs in chronic ulcer operation should not be too long delayed, as the bleeding is likely to recur again and again, at shorter or longer intervals, and will, without surgical interference, often result in the death of the patient. When perforation occurs an operation should be performed as soon as possible. Recently well-known English and American surgeons have advocated operation for the cure of the ulcer itself. Many heard the statement made by an eminent American surgeon in a very able paper read before this Academy in January, 1904, that Leube and Cramer in the treatment of chronic ulcer of the stomach advise washing the stomach out every day for four weeks, meantime feeding the patient by the bowel; and if at the end of that time there is no improvement they propose gastroenterostomy. Cramer1 advocates this treatment in benign stenosis of the pylorus but not in ulcer. "In such cases"-that is, in dilatation of the stomach from benign stenosis of the pylorus-he says, "operation should be early advised, especially in the high degrees of stenosis, so that they do not lose too much time by internal treatment. If after four weeks of rational diet and gastric lavage no improvement is manifest, then do I in every case propose operation." Then he goes on to say that one has peculiar experiences. "I had," he says, "a man under treatment who had a stenosis of the pylorus from ulcer, and also a large secondary dilatation of the stomach. A rest cure of three weeks' duration brought about such a degree of improvement that we decided to at least defer the operation."

Schleip was the first to recommend washing out the stomach as a therapeutic measure in gastric ulcer. Leube, however, objected to this method on the ground that the sound might easily come in

direct contact with the ulcerated portion of the stomach wall, and in this way lead to perforation cr hemorrhage. Reigel' writes as follows: "I do t think that ulcer per se calls for treatment by the sound, as long as complications or sequelæ are a sent. I consider this method of treatment algether useless, and believe, moreover, that it may be dangerous under certain circumstances. In uncomplicated ulcer digestion proceeds in an altogether normal manner, as a matter of fact more rapidly than normal, chiefly owing to the condition of i perchlorhydria that usually exists. Stagnation food remnants therefore does not occur. Those r think it is necessary therefore to remove all att from the stomach are wrong; all that is needed is reduce the excess of acid. I do not see what lavage of the stomach would accomplish under trea conditions, for we usually remove the stomach c tents either because there is decomposition or longed stagnation. In simple ulcer neither of the states exist."

Being unable to find in any publication Leube recommends operation in all cases of ga ulcer, if lavage and rectal feeding do not cure patient in four weeks, I wrote to him in regard the matter and he did me the great kindness: reply as follows: "The surgeon referred to ably meant that I consider an operation advisa if the ulcer is bleeding, and if this condition let on for weeks. If the patient has a bleeding I feed him by the bowel while the ulcer is be if the ulcer is not bleeding, usually not, er in case only during the first three days of treatme On the other hand I do not use the tube, or a

only in such cases in which there is heavy v and when I am fearing for the patient more: the vomiting than from using the stomach The latter case, however, is very rare." Inn to operation for the cure of chronic gastric Mansell Moullin' says, "I maintain that chronic ulcer of the stomach that persists causes serious pain and vomiting in spite i thorough trial of the ordinary method of ment should be exposed, examined, and surgically." Now what constitutes one the trial of the ordinary method of treatmenti usually means the Leube-Ziemssen rest cure extends over a period of from four to six ** and, while well adapted to the treatment t gastric ulcer, is not adequate for the cure chronic form of the disease, for the reason does not extend over a sufficiently long time. Fenwick says all clinical experienc to show that even under the most favorable stances the disease requires many months cure, and that the mere subsidence of p vomiting is no proof that cicatrization has place. He divides the period of treatment stages: The first period lasts for two or three during which the patient remains in bed of course only liquid food. The second lasts from the end of the second or third the end of the second month; during he advises rest if possible, the liquid food continued, with the addition to the milk a rice, flour, powdered biscuit or tapioca, ceri and expressed beef juice. The third pen tends from the beginning of the third of the sixth month. Although milk t constitute the staple diet, the patient permitted to have bread and milk, bread an poached eggs, scraped and pounded ra chicken cream, and broiled white fish passed through a sieve. The fourth period should extend from the sixth to the

or eighteenth month, according to the severity of the case. During this time the diet is gradually increased until at its termination there are only a few articles which have to be prohibited. Milk then, according to this author, should constitute the chief articles of food for the first six months in the treatment of chronic gastric ulcer; and the diet should be carefully regulated for twelve months longer, making the total period a year and a half, during which the patient is restricted to those articles of food which are not difficult of digestion.

My own habit has been not to confine all patients to a liquid diet for a given length of time; but to be guided by the symptoms in each individual case. Some patients may be allowed solid food in two or three months, others not for five or six months, and two of my patients were obliged to live on liquid food for nine months. There is no danger, however, in continuing liquid food too long, the danger is in beginning solid food too soon. In regard to permanency or cure in chronic gastric ulcer under medical treatment, so far as I have been able to learn, in only two out of thirty-two cases which I have reported have the patients suffered from a recurrence of the ulcer. One of these was a man of intemperate habits; and the other was a domestic who would not follow instructions in regard to diet. Within two months past I have seen three of the patients who were treated in 1888-9, and have heard directly from two others; these are all enjoying excellent health, and do not suffer from any form of stomach trouble whatever.

In regard to the prognosis in chronic gastric ulcer under medical treatment, Lebert places the mortality at 8 per cent., Rosenheim at 20 per cent., but Leube found the mortality in 556 cases to be only 2.4 per cent. Fenwick observes that when the disease is aken in hand at an early stage and properly treated, he mortality does not exceed 4 per cent. On the >ther hand Haberkant found the mortality in gastronterostomy for ulcer to be 25.5 per cent. Keorte, eported by Cramer, had seven deaths in twentyight operations, a mortality of 25 per cent. Rogers ays the mortality from gastroenterostomy now tands between 15 and 30 per cent., as given in he majority of statistics. Einhorn states that mong his own patients the death rate (from astroenterostomy) has been nearly or quite 25 er cent., and Mitchell" reports six gastroenteros>mies for benign stenosis of the pylorus with iree deaths, a mortality of 50 per cent. Three of y own patients, and three others seen in consultion, have been operated upon in Mercy Hostal with one death, a mortality of 16.2 per cent. is a well-established fact, therefore, that the ortality from gastroenterostomy is higher than the ortality from chronic gastric ulcer, when the tients have the benefit of proper medical treatent. As to the frequency with which stenosis the pylorus follows chronic ulcer, Brinton comted that severe stenosis occurs in one out of 200 ses; and Fenwick believes the pylorus becomes rtially obstructed in 16 to 20 per cent., when è ulcer is situated in its vicinity, but that in only out 2 per cent. of these is the stenosis extreme. view, therefore, of the comparative infrequency hemorrhage and perforation, which are the most nmon complications of chronic gastric ulcer, 1 of stenosis of the pylorus, which is its most nmon sequela requiring operation; and taking > consideration the high percentage of deaths m gastroenterostomy, and the low rate of morty attending chronic ulcer of the stomach, it ild certainly seem to be the part of wisdom to -id surgical procedures as long as possible; and

to resort to operation only when the indications for doing so are perfectly clear. What these indications are, has been pointed out by Deaver' in an article published in February, 1904, and so may be regarded as the latest authoritative statement on the subject. He does not advocate gastroenterostomy for the cure of the ulcer, but only for its complications or sequelæ. He says: "The one great indication for gastroenterostomy is found in all lesions of the stomach when the contents of the latter are not evacuated; whether this is due to a malignant or benign obstruction, an inflamed or ulcerated pylorus, or atony of the gastric muscle; the retained stomach contents must be provided for by an anastomotic opening."

In cases of stenosis of the pylorus when the stomach cannot empty itself of solid food, liquid diet should be tried. If this readily passes through the pyloric opening, and the patient can with comfort take sufficient nourishment to maintain him in a condition of health; and if he is willing to live on liquid food for an indefinite period, surgical intervention is not indicated, for should the stenosis ever reach such a high degree as to prevent the passage even of liquids, an operation can be done at any time; and it should then be done at once, as the only means of saving the life of the patient. REFERENCES.

1. Cramer: "Vorlesungen über Magen- und Darmkrankheiten.' I Heft, p. 128.

2. Reigel: "Diseases of the Stomach," American Translation, p. 641.

3. Mansell Moullin: British Medical Journal, October

THE patient, an unmarried woman, aged twenty-two years, of large frame, rather fleshy, weight 180 lbs., a liberal eater; often constipated. Father was an invalid for several years, perhaps had tuberculosis, finally suffering an aberration of mind, wandering into a forest and dying alone. A paternal aunt had an attack of incipient insanity but recovered and is now quite well. Patient has a brother and two sisters who are in good health, except one sister who suffers considerably at her monthly periods. Up to the age of twenty years the patient enjoyed good health, but at this time the monthly flow became excessive, growing worse month by month until it became almost continuous. I saw her in October, 1903, when she had been in her room several weeks. Every time she took exercise hemorrhage followed. On examination the uterus was found slightly enlarged and immovable, the depth being three inches. A slight enlargement of the right ovary and tube could be detected, and marked tenderness but no enlargement of the left ovary. Curettage was done, but the amount of diseased endometrium was quite insignificant. Pure creoline was applied to the endometrium, and in a few days all discharge ceased. For two months there was no recurrence, and when the discharge did return it was a normal menstruation lasting about six days. In February, 1904, she had a hemorrhage which was continuous up to March 14, 1904, at which time she returned for further treatment. On examination the ovaries and tubes were found in the same condition as at the

*Read before the McLennan County (Texas) Medical Association.

continued down to the time of her visit. The losses of blood were very considerable. Two weeks previously she had had an attack of violent abdominal pain for which a physician was called. During the attack she felt weak, but did not faint. When the doctor arrived she felt better. No hypodermic medication was necessary, and the doctor simply prescribed some pills without venturing an opinion as to the nature of the ailment. The pains at this time were general, but kept on in a mild degree, and were located mostly on the left side. A week previously a small bit of tissue was expelled from the vagina which did not seem to resemble the usual blood-clots.

The pelvic examination of this woman revealed a small anteflexed uterus deflected to the right and connected along its left border with a soft, moderately sensitive tumor, the size of a hen's egg.

The diagnosis of unruptured ectopic gestation with a tendency to tubal abortion was made and the patient frankly told that a curettage would not be done. She consented to submit the entire operative progam to my wishes.

On March 18, 1904, under anæsthesia, the uterine interior was explored with a sound and curette and found to be about normal in size and entirely empty. An abdominal incision was then made along the outer border of the left rectus muscle, and (after drawing the muscle inward toward the median line a distance of a half inch or so) the peritoneal cavity was opened. The unruptured tubal sac, with its corresponding ovary, was removed-the few adhesions due to a recent peritonitis being readily separated. There were not more than a half dozen small black clots and no free blood in the peritoneal cavity. The right adnexa were not enlarged but were so firmly bound down by old adhesions that it was thought best to leave them undisturbed. The patient reacted beautifully after the operation. Examination of the tumor showed the fimbriated end to have been completely obliterated. The specimen shows an unruptured tube with its contents intact.

In reviewing this case we note the following similarities to the usually accepted symptoms and history of ectopic gestation.

1. The six years of sterility succeeding the birth of her first child.

2. The preexisting pelvic disease which required a curettage five years previously.

3. The suspension of menstruation for a period of seven weeks.

4. The succeeding uterine bleedings during an entire month.

5. The attack of general abdominal cramps suggesting a beginning tubal abortion and accounting for the black clots found in the peritoneal cavity at the time of operation.

6. The tendency to syncope during this attack. 7. The localization of the pain for the most part in the left pelvis.

8. The discharge of probably decidual tissue a week previous to operation.

With these symptoms and facts tabulated there could be little fear, in connection with a soft unilateral pelvic tumor, of risking the diagnosis of ectopic gestation. And still one of the best general practitioners in this city overlooked the condition, and for three reasons: (1) because it did not occur to him to think of ectopic gestation in this individual case; (2) because, for certain unknown reasons, he was unable at the time to map out the pelvic tumor; (3) because of the fact that, with the exception of one or two days, this patient was not confined to bed and suffered so little that she came to the doc

tor's office for treatment as an ambulant patient. In other words, the case was so mild and the patient presented so few symptoms that so serious a condition as ectopic gestation was not even suspected.

CASE II. On March 18,1900, I was requested by a colleague to examine Mrs. H. S., thirty-nine years old. She gave a history of having been married twicethree years to her second husband-but of never having conceived. During eleven years she had been a widow.

At thirteen she began to menstruate. For a year previously she had been somewhat irregular, so that it was not unusual for the period to be delayed a few days or weeks. Her last menstruation was one week overdue, but this attracted no especial attention. Two weeks previously she was taket with abdominal cramps and bleeding from the vagina, which lasted thirteen days. She had to fainting spells. The bleeding had ceased nine days previous to her operation.

When I saw her in consultation at her home ste had been confined to bed for several days and had had a temperature of 101.5° F. (rectal) with a puls of 88. There was no suggestion of acute anam about her skin or mucous membranes. The face was drawn and anxious. She complained of intense general abdominal pains. The abdomen presented the characteristic appearances of ace general peritonitis. Tympanites was excessive and the entire abdominal surface up to the costal anti was exquisitely tender. A local vaginal examine tion revealed a doughy mass behind the uterus.

The differentiation between a general peritoni dependent on an old pus-tube suddenly rupture and one dependent on an ectopic gestation coll not be made without the aid of an aspirating neede introduced into the retrouterine mass. The doct declined to resort to this procedure and preferred: turn the woman over to my care at the hospital.

Fortunately, perhaps, for the patient there was i delay of two days in getting her admitted to the overcrowded hospital, and when she got there I fout that there was a marked subsidence of the tymp

ites and tenderness over the abdomen although th mass in Douglas's cul-de-sac was still quite clea present. Her temperature was normal and she we fairly comfortable. Under the circumstances I cided to wait and get away a little further from the general peritonitic manifestations. After thret four days I decided to operate.

Under anæsthesia I passed an aspirating into the now clearly fluctuating mass behind uterus and drew off dark liquid blood. Her poste was now changed to that of Trendelenburg and laparotomy was done. The intestine was very inflated and there were numerous adhesions betwe the omentum and the pelvic structures. There 7-S no free blood in the peritoneal cavity. After s and tedious work it was possible to get the tines and omentum sufficiently out of the way inspect and palpate the pelvic organs. The was small. The right adnexa were not exis and were buried in old adhesions which cou readily be separated. On the left side a t apparently the size of a baseball, was felt down to the depths of the cul-de-sac of De By the sense of touch the mass was gently sep from its surroundings and found to be the dise left tube arching behind the uterus. At its border was an hæmatocele which was ruptur removing the tube, its contents (a certain am black blood and clots) escaping. The tun clamped off at its uterine and pelvic attach and removed. The specimen consisted of the filled with blood, and showed a raw area