flation, two occurring in old people with carcinoma, and one in ulcer of the stomach with perforation, so that moderate inflation should be produced first, and gradually and cautiously increased. If the quantities of bicarbonate and acid previously recommended are used, however, usually no untoward results need be feared.

Phillippow has recently called attention to dilatation of the stomach occurring in young children, especially in milk-fed infants of the better social class. Local symptoms referable to the stomach occur, and general malnutrition and weakness exist as a result of the toxemia.

Under the term "Spastic Stenosis of the Pylorus and Intermittent Dilatation," Korn describes a condition which appears suddenly, with practically no premonitory gastric symptoms, and manifests typical signs of motor insufficiency, pyloric obstruction, dilatation, and vomiting of large amounts of decomposing, fermenting foods, rich in bacterial flora.

The attack may pass off rapidly, or may gradually improve. The condition is probably caused by erosion or ulceration of the mucosa of the pylorus, causing reflex contraction of the muscular coat. The diagnosis must be made by exclusion, and it must also be borne in mind that repeated attacks will result in a chronic dilatation. Again, it must be borne in mind that a structural pyloric stenosis may have periods of cessation of all symptoms, so that the diagnosis should be guarded, especially if a clear previous history is unobtainable.

Of the inflammatory conditions of the stomach acute catarrhal gastritis is by far the most frequent, and may present any degree of severity, with concomitant, local, and constitutional disturbance. Some pyrexia is nearly always present, and may even reach 104. This condition should really include all cases of toxic gastritis, as the pathology of all cases seems to be produced by fermentation products, or ptomaines of some type. In case of poisoning by violent corrosives, as phosphorus, antimony, arsenic, or mercuric chloride, the symptoms come on rapidly, and the pain, vomiting, and prostration may be alarming. Blood may appear in the vomitus and urine, and a history of having swallowed the poison can usually be obtained. In the non

corrosive cases the attack usually comes on a short while after eating, with a sense of fulness, thirst, oppression, dull pain, headache, eructations, nausea, and vomiting, which in the milder cases brings relief. In those cases of somewhat greater severity the symptoms are accentuated, prostration occurs, herpes appear, the breath becomes offensive, and the temperature may ascend several degrees, sometimes preceded by a chill. An erythematous rash may make its appearance, especially in children, and in some cases some jaundice is noted. The attack, however, subsides in from a few hours to four or five days.

The chief danger of confusion lies in the similarity of this symptom complex with the onset of some of the acute infectious diseases, especially scarlet fever, tubercular meningitis in children, and typhoid in adults. In scarlet fever the absence of angina and the "strawberry tongue" are significant. are significant. In the other conditions, especially where the cerebral symptoms are marked in one case or the intestinal involvement is accentuated in the other, it may be necessary to wait for a day or two before making a positive statement, and treat the case symptomatically. In case a corrosive gastritis is suspected, the vomited material should be received in a clean vessel, and saved in case subsequent analysis may be desirable.

Acute suppurative gastritis or phlegmonous gastritis may resemble the foregoing in the beginning, but the pain and constitutional disturbances usually differ somewhat. The pain is frequently sharp and localized, and the temperature may be irregular and frequently interpersed with chills. The physical signs are not distinctive, but any pressure usually intensifies the pain. Prostration soon passes into a typhoid state, and that frequently into coma. The vomitus should be examined microscopically for pus cells and blood, and if the disease has progressed for several days, a leucocytosis will usually be observed.

In chronic catarrhal gastritis the walls of the stomach may either be thinner or thicker than normal, depending upon whether or not an inflammatory deposit of new fibrous tissue has occurred. In any event, however, the glands of the mucosa will be found to be atrophied, and the distinction between acid and parietal cells nearly if not completely lost. The pyloric end

of the stomach usually suffers most, and may even be found to contain eroded areas closely bordering upon ulceration. The stomach is usually coated heavily with viscid, tenacious mucus, which microscopically usually is found to contain desquamated epithelium.

The amount of hydrochloric acid is diminished, so that fermentative changes more easily occur. The motor function is also decreased to a considerable extent.

Among the important subjective symptoms anorexia, feeling of distress after eating, heartburn, and belching of gases soon after eating, with epigastric pain, and frequently palpitation of the heart, a bitter taste in the mouth, which is persistent, excessive thirst, and nausea, are also frequently complained of. The reflex nervous symptoms are most varied, and may be exceedingly troublesome. Among those most often encountered are headache, which may be either frontal or occipital, tending to occur before meals, and which may be associated with some nausea, as in "sick headache;" vertigo, depression of spirits, which may be extreme, amounting to hypochondriasis or melancholia, or an inability for concentrated attention, or disinclination to any activity. Insomnia may occur, or drowsiness during the day, especially after meals, be complained of. During sleep, bad dreams may cause the sufferer to dread to go to bed. The urine is abundant, pale, of low specific gravity, and tends to deposit large amounts of urates and phosphates.

This condition may resemble or be associated with the more immediately dangerous gastric lesions, but the diagnosis must. be principally based upon the absence of the characteristic physical signs of the lesions, and upon the large amount of alkaline mucus, motor deficiency, and small percentage of HCl.

In this connection I might mention a new physical sign which was first called to my attention by Dr. W. A. Bryan, and which I have constantly verified and rely upon almost entirely for distinguishing the boundary between the greater curvature and the colon. If we percuss from above downward, when the line between the two structures is reached there will be a line of about a finger's breadth where neither the colon nor the stomach touches the abdominal parietes firmly. When this space is firmly per

cussed, a peculiar and characteristic "back slap " is experienced by the pleximeter finger, and the tone is a complex one instead of the more nearly pure vibration of the stomach or colon tympany.

Gastric ulcer, which is the term now usually restricted to mean the round or simple' ulcer of the stomach, when typical, is extremely easy of diagnosis, but as it is usually associated with catarrhal gastritis and other conditions, it is frequently a task which taxes to the extreme the diagnostic acumen of the physician. The three cardinal symptoms are pain, vomiting, and hematemesis. The pain is rather constant, and may be dull, but is more usually severe, and described as gnawing or boring, and almost always circumscribed and constant in position. Besides this, more or less periodic attacks of gastralgia may be complained of; any food usually intensifies the pain, and emesis tends to bring relief. The posture which gives the greatest pain or most relief may be of some value in locating the ulcer. Vomiting occurs two hours after meals, and is frequent, and the vomitus will be found to contain an excessive amount of HCl. When blood is present it is of significance, but this sign is frequently absent. When it is present in small amounts the cellular character of the corpuscles may be destroyed by digestion, in which case it is necessary to recognize it by laboratory tests. Of course, when a large vessel is eroded, there is no trouble to recognize it at once, as the hemorrhage may be so severe as to cause collapse and death in a short time.

Anders gives gastralgia, chronic gastritis, passage of gallstones, cirrhosis of the liver, and gastric carcinoma as the conditions most likely to be confused with gastric ulcer.

In gastralgia the pain is frequent when the stomach is empty, and may be relieved by eating. Tenderness upon deep pressure is usually absent, in fact, steady pressure may give relief, whereas hyperæsthesia of the skin may be present. Between attacks there may be no disturbance. Hematemesis is absent, although this may also be absent for a time in ulcer also. The diet has little or no effect, and the general health may be good. Signs of tumor or dilatation are absent, and neurasthenia and hysterical tendencies are usually manifest. In females the period of life. near or during the menopause is frequently a predisposing cause.

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While hematemesis may be chronic gastritis, as a rule it is absent. The large alkaline mucus is not found associated with ulcer. chronic gastritis the amount of HCl is diminished, whereas in ulcer it is increased.

In cirrhosis there may be hematemesis, but none of the other gastric symptoms, and the history and clinical signs referable to the liver will be elicited. In gall-stones the acuteness of the onset and sudden cessation of pain are diagnostic.

The diagnosis of gastric carcinoma, especially when it occurs upon an old ulcer and develops insidiously, may be impossible for a time, but nevertheless it should be our constant endeavor to recognize it as soon as possible, as a large percentage will be found amenable to surgical interference if recognized and brought to operation in time. The onset, however, may be abrupt. Anorexia, with but little pain, is the rule in the early stages. When much pain is complained of, it is of a lancinating or cutting character, and not of the burning or boring nature usually described in ulcer. The pain is not localized as strictly, as a rule, and may be referred to the back, arms, or shoulders, or other parts of the abdomen, sometimes suggesting appendicitis. Vomiting is less frequent than in ulcer or dilatation, and the vomited material is not usually characteristic. It may contain some blood if erosion has occurred, but is more frequently free from it. I agree with Anders that a chemical examination of the stomach contents for HC1 is of great diagnostic value, although, as many writers have shown, not of absolute certainty. In not one of 154 consecutive tests of the albumin digesting power made by Reigel in carcinoma, was the power to digest this substance present. When HC1 is present in carcinoma the former may be said with confidence to be secondary to an ulcer. Lactic acid is usually present if HC1 is absent, and is due to fermentation, which the HCl normally restricts. In addition the microscope may reveal epithelial cells from the growth, red b. c., and certain characteristic bacteria which were first described by Boas and Uppler.

While no one of these points, taken singly, may safely be used as a basis for a diagnosis, still all of them together form a symp