2. Gastric dilatation and enteroptosis.

3.-Pyloric strictures.

4.-Gall-bladder lesions.

5.-Movable or floating kidney.

6. Chronic appendicitis.

7.- Intestinal strictures and adhesions.

8.-Diseases of the uterus and its adnexa.

Time absolutely forbids a study in detail of these several lesions as symptom-producing factors. It is likewise impossible for me to introduce more than a few of the many strikingly illustrative cases which have passed under my observation and which have been relieved by surgical or mechanical measures. The object of this paper will have been attained if I succeed, by grouping the causes which frequently do excite the distrubances suggested by its title, in such form that the practician will be placed on his guard in dealing with them.

Gastric Ulcers.-Gastric ulcer gives rise to pain, to indigestion, to nausea, to vomiting, and to hemorrhage. As to its frequency there is a wide difference of opinion. Indeed the whole question of gastric ulcer is as yet in dispute. Stark found it in 13 per cent. of autopsy cases; Geiff in 8.03 per cent.; Brinton in 5 per cent., and Berthold at the Berlin Charite in 2.7 per cent. In 2,200 autopsies Fiedler found evidence of recent or old ulcers in 20 per cent. of female bodies; whereas, in the male bodies, such evidence was found in only 1.5 per cent. Welsch, on the other hand, in 793 ulcers, found 60 per cent. in women and 40 per cent. in men. The statistics of other observers show a disparity in the sexes much in harmony with those furnished by Welsch. The number of ulcers varies from 1 to 35. In by far the larger per cent. they are located in the pyloric portion of the stomach. In 793 cases Welsch found 335 in the posterior wall, 288 in the lesser curvature, 96 in the anterior wall, 95 in the pyloric ring, 29 in the fundus and 27 along the greater curvature.

The diagnostic symptoms are:

1. Indigestion.-This may be slight or of a most aggravated character. There is much nausea and, frequently, vomiting. The vomited matter contains a large per cent. of hydrochloric acid.

2. Hemorrhage.-Present in 50 per cent. of all cases. The blood may be clear or coffee-ground masses; it may be small in quantity or very profuse. Blood sometimes makes its appearance in the stools.

3. Pain. This also varies greatly in character and in intensity. It is chiefly felt after eating but is sometimes relieved, contrary to teaching, by taking food. It may be only a gnawing or burning sensation or it may be an intense boring pain, occurring in paroxysms of

the most severe gastralgia radiating from the epigastrium to the back and to the sides.

The foregoing are the classic symptoms of gastric ulcers. While it cannot be said that they are pathognomonic, they should, when present, demand of the practician most thoughtful attention and care. If now there be found on physical examination, tenderness on pressure; or if, with the symptoms described as precedent factors, there be found an indurated mass in the region of the pylorus, one can be reasonably sure that he has to do with gastric ulcer. Differentiating tables distinguishing gastric ulcers from gastric cancers and gastralgia, without organic lesion, are to be found in nearly all text-books and I will presume upon neither your patience nor your intelligence by introducing them. Sufficient for present purposes is the fact that a certain per cent. of gastric ulcers are curable only by surgical measures. Except in those cases where life is immediately endangered by hemorrhage or by perforation, an effort should of course be made to heal the ulcer by absolute rest in bed, by a carefully and systematically regulated diet, by nutrient enemata and by internal medication. Indeed, a very large proportion of gastric ulcers will heal spontaneously, but, as remarked by Osler, the process is slow and tedious and often requires months or years. The rate of mortality as given by Ewald, from perforation and hemorrhage, is 6.5 per cent. and 4 per cent. respectively. Brinton estimates that only about 50 per cent. are cured by medical means. Tricomi, Remond and Luebe think the mortality about 25 per cent. Graham in 125 cases of gastric cancer found a precedent ulcer history in 60 per cent.

Osler gives as indications for surgical interference: (a) When perforation has taken place; (b) in very intractable cases which have resisted all treatment and which are accompanied by attacks of very severe pain and recurring hemorrhage; and (c) alarming hæmatemesis. Osler emphasizes the fact that very severe and profuse hemorrhage does not always come from large round ulcers, but may proceed from quite small erosions.

In 13 operations for hemorrhage recorded by Bryant, 9 deaths ensued, so that the mortality is very high. The mortality is also necessarily high when perforation takes place. In non-perforating ulcers, on the other hand, an entirely different prognosis confronts us in properly selected cases. Henri Hartman (Med. News, March 14, 1903) presents two series of cases, placing in the first series those referred by physicians well informed on diseases of the stomach, and in the second series those sent by other physicians late in the disease. Of the former series of 36 cases but one ended fatally; in the second series

of 26 cases 9 were fatal. Hartman's statistics speak volumes and cannot well be ignored. "Were it not," he says, "that operation has so frequently to be performed upon patients weakened by too long waiting, the operative mortality would be reduced to nearly nothing.

In by far the larger number of cases gastro-enterostomy is the operation of choice, the question being largely one of drainage in order to secure rest for the disease. The ulcers may be excised, but the procedure is open to the strong objection of prolonging the operation without accomplishing much more than can be accomplished by drainage. In those instances where there is a narrow stricture of the pylorus, pyloroplasty has a limited field of usefulness. As observed by Mayo the objections to it are that there is great liability to fixation of the pylorus after operation with great tendency to recontraction. All things considered I believe gastro-jejunostomy to be the operation of choice.

Pyloric Stenosis with Gastric Dilatation.-In the larger number of dilated stomachs there is present pyloric stenosis to a greater or less degree. These cases are pre-eminently surgical in character. There is a form of dilatation which is atonic in character and which is not so readily overcome by surgical measures. Even in these cases a gastro-enterostomy sometimes becomes necessary in order to afford anything like permanent relief. I am inclined to believe, however, that there has been too much surgical work done in the purely atonic cases. At any rate, the more conservative operators do not speak very encouragingly of the results obtained by operative procedures in these cases. Gastroplication, as practiced by Bircher and others, has not yet become an established surgical procedure. I myself rather doubt its utility and have never given it a trial.

The diagnosis of gastric dilatation is not difficult. Dyspepsia is usually present, with a feeling of uneasiness and distress in the region of the stomach. Frequently there is inordinate hunger and thirstthe patient eating and drinking large quantities; then there will come, at intervals varying from one to four days, vomiting of enormous quantities of liquid and food. Inspection, palpation, percussion, auscultation, distension and mensuration will all have to be utilized in making a physical diagnosis.

One of the worst cases of dilatation that has passed under my observation occurred in a young girl of 20, who swallowed a corrosive poison with suicidal intent. There was absolute closure of the pylorus for two weeks. The stomach was then washed twice a day and, within a week after this treatment was inaugurated, food began to pass into the intestine. She ultimately recovered without further treatment.

I cite this case to show that in stenosis due to chemic irriation there may be a temporary obstruction which can be overcome without surgical interference.

Gastropexy, or the fixation of a distended and prolapsed stomach by opening the abdomen and holding it in proper position by stitching the duodenum and the lesser curvature of the stomach to the abdominal wall, like gastroplication, is not yet an established operation. The first operation was done by Dura in 1896. Five cases have thus far been reported and all have recovered. The more radical operations of gastrectomy (which term implies the removal of the stomach wholly or in part for malignant disease) is rapidly gaining in popularity. The Mayo's have operated upon 135 cancers of the stomach, of which 34 were radical extirpations; 5 of these cases died within a month, and one later from another cause; of the 28 that recovered 1 lived three years and seven months, and several are alive now after more than two years. I quote these statistics to show that it is not absolutely necessary to say to the victim of cancer of the stomach that his case is hopeless.

Gall-Bladder Lesions.-I desire to call attention to a condition of the common and cystic ducts which may give rise to the most intense suffering in the region of the stomach, and be mistaken for stomach lesions. I have met with two cases which had for years been treated for gastralgia with presumable ulceration. In both there were attacks of pain radiating from the gall-bladder to the stomach, of the most intense character, and with obstinate vomiting. In neither was there jaundice or white stools. In both it was possible immediately preceding the attacks of pain to outline the gall-bladder by palpation and percussion. In the first case I explored the gall-bladder, found it empty as far as stones were concerned, but there was an evident stricture of the cystic duct. This I carefully dilated, and drained the gall-bladder through the abdominal wound. The patient was entirely relieved so long as drainage was maintained, but as soon as the external wound closed the old symptoms returned. I then did a cysto-enterostomy, and the patient has for two years remained perfectly well, having since given birth to a child. This patient was exceedingly neurotic and I imagine that it required but a slight degree of cystic distension to profoundly impress the terminal nerves. The second case was much like the first, except that I did not drain the gall-bladder through the abdomen, but at once made a cysto-enterostomy. The results have been equally good and all symptoms of gastralgia and dyspepsia have disappeared. In a third case I removed the entire gall-bladder with equally good results.

Movable or Floating Kidney.-I am not one of those who thinks: that every case of movable kidney requires surgical operation. A large per cent. of loose kidneys occur in women. Of the 667 cases collected in the literature by Kuttner, 584 were in women and only 83 in men. If the patient suffers no inconvenience from the condition, and it is discovered accidentally, it is unwise to inform him of its presence. When a movable kidney does give rise to distress, there will be found nervous manifestations with dyspepsia. Usually there is a sense of dragging and discomfort, with pain in the lumbar region. Theremay be intercostal neuralgia. Hypochondriasis in men and hysteria. in women not infrequently occur. Pressure upon the duodenum may cause dilatation of the stomach, or, as suggested by Lyton, dilatation of the stomach may cause a movable kidney. The dyspepsia is of the nervous type and not infrequently the condition is associated with a catarrhal appendicitis. There may be attacks of severe abdominal pain characterized by nausea, vomiting, chills, fever, and collapsethe so-called crisis of Dietl. These attacks are probably due to dilatation of the kidney pelvis, or to kinks in the renal vessels. I have met with two instances of it in intermittent hydronephrosis, attended with the symptoms described, in which the kidney became as large as: an adult head. In both I found it necessary to remove the kidney after first trying fixation. Ordinarily fixation is all that is necessary, stripping the capsule if there is any evidence of Bright's, and fixing it in the usual way. I have not been very successful in holding a loose kidney in place by the ordinary non-surgical mechanical contrivances.. More relief has been afforded by a long well-fitted corset aplied whilethe patient is on her back, from below upward, than by any other method.

Chronic Appendicitis.-I have but little to add to what has already been said regarding chronic appendicitis as a factor in the production of gastro-intestinal disturbance. I believe that if the physician will note the symptoms which I have enumerated as being almost pathognomonic of chronic appendicitis (indigestion with gaseous distension, coated tongue, foul breath, bad taste in the mouth, constipation or diarrhea with mucous stools), and will carefully palpate the appendix if such symptoms are present, he will find under reasonably favorable conditions a hard, cord-like mass in the region of the appen-dix which is tender, and which frequently will involve the stomach in a reflex way. I have met with so many cases of this kind in which absolute and permanent relief has been afforded by removing the offending organ, that I have become almost an enthusiast on the subject. One is surprised to see how slight a disease of the appendix will