diet. With early operation properly and carefully performed from 80 to 90 per cent. of these cases can be cured.

DR. EDWARD W. SMITH (Meriden): The very valuable paper of Dr. McKnight and the full discussion of Dr. Oliver C. Smith leave very little for me to say from the literary standpoint, but it is very unusual to find present in one patient the demonstration of a healed ulcer and also the production of symptoms of pyloric stenosis due to conditions lower down in the intestines. By courtesy of Dr. Oliver C. Smith I will report a case that showed these points. The patient was a grinder, twenty-six years of age, who consulted me on October 20, complaining of stomach trouble. He gave a history of having had symptoms for a year and a half. He had left work on the 12th of October. These were the bedside notes that I took at that time, and the history was something as follows: From breakfast until nine o'clock in the morning he felt very sick. From that time on he felt well until after dinner. At about two o'clock he would have sharp radiating pains in the stomach. These continued until about four o'clock, and then he would feel sick and nauseated until bedtime, and have belching of gas and other symptoms. From these symptoms and the excessive sensitiveness in the region of the stomach, at the left of the median line, I made a diagnosis of ulcer of the stomach. He consulted his old physician, Dr. Kellogg, and remained under his care from October 5 to November 10, when he was taken with fainting spells. I was called to see him that evening, and he showed symptoms of hemorrhage. The sensitiveness over the stomach was still excessive, and the next day the evidence of hemorrhage was found in the dark, tarry stools. I put him to bed under medical treatment, a rigid diet, and rest for four weeks. In a week's time he improved. His appetite came back, and at the end of six weeks he was getting a pretty good diet. He went back to work and remained well for a month. Then he complained of a return of his stomach symptoms. I examined him and found no tenderness over the stomach, and I was hesitating as to the diagnosis and waiting to see what would develop. Then he drifted to the Hartford Hospital and came under the care of Dr. Oliver C. Smith and the staff doctors. A week later I was invited up to Hartford to see a gastroenterostomy done. The symptoms were those of obstruction. Previously there had been no obstructive symptoms-no vomiting. I saw the operation performed. Dr. Smith opened the abdomen and found the stomach in good shape; but there was a place where an ulcer had apparently been healed, leaving the pylorus open. Dr. O. C. Smith went on down to the appendix and found a kinked-up very long appendix. This was removed and the man made a good recovery. I saw him a few days ago and he was feeling fine. He

had had a peptic ulcer healed by medical treatment. He then had pylorospasm caused by an irritated appendix. When you have a gastric ulcer, the appendix had better be looked out for also.

DR. WILLIAM H. CARMALT (New Haven): There is a point I should like to speak of which Dr. McKnight has not made so much of as might be, i.e., the symptomatology of supposedly cured cases. Dr. William J. Mayo has repeatedly said that the cases of gastric and duodenal ulcer operated on by himself and his brother have been cured, on the average, six times. This is up to the medical men to think about-that the condition of relief which the patients obtain from a course of medical treatment is not a cure, but simply a temporary improvement. When a patient has had several such experiences it is time for his medical advisor to “sit up and think” and allow himself to be guided by the judgment of men looking for end results, not being satisfied with simply temporary relief.

DR. WILLIAM F. VERDI (New Haven): I should like to call attention to the fact that there is a difference between a chronic ulcer and a perforated ulcer. The symptoms are different. In the first place, perforating ulcers come on, as a rule, in young persons, between twentyeight and thirty. The symptoms are usually not severe. The patients complain of a little sour stomach, and have to cut out one or two articles of diet; but they are able to continue with their work. They are usually seized with perforation while at work, and are brought into the hospital with intense pain, requiring immediate relief. There were two such cases brought into the New Haven Hospital within three or four weeks, about four weeks ago. In both cases the diagnosis of perforation was made before the operation, which in one case was performed twelve hours after the accident had taken place. The other patient had gone as long as seventeen hours after the perforation before the operation was performed. Both these patients had had no symptoms to speak of before, except a little sour stomach. No adhesion was found around the ulcer. The ulcers had very small openings, but had poured out a good deal of stomach contents. The openings were near the pylorus. Both patients recovered. The ulcers were closed, and a posterior gastroenterostomy was done in both cases.

The left half of the abdomen usually does not become involved until later. At first it is the right half only that is affected. The intestinal contents are poured out under the surface of the liver, and go toward the right iliac fossa. I put a drain over the region of the appendix and no infection followed.

The chronic ulcer is different. The patients have a long train of symptoms, going on over a number of years; and in these cases there

is not much danger of perforation, because a great many adhesions are formed around the ulcers, which protect them. Another thing is that it occurs in younger individuals.

DR. LOUIS M. GOMPERTZ (New Haven): I want to thank Dr. McKnight for his interesting paper. There are a few points that I wish to emphasize. I believe, first, that it is extremely important for the medical man to constantly bear in mind that ulcers of the stomach and duodenum are much more common than is generally supposed. In order to treat ulcer medically, the very first and most important point is to make an early diagnosis. When patients come complaining of pain on an empty stomach which is relieved by food, and then coming on again within one to four hours after eating, we should be suspicious of the presence of ulcer of the pylorus or duodenum. This is the first step in the successful treatment of ulcer. The very acute ulcers are benefited by medical treatment where an early diagnosis is made, but when a case of ulcer of the stomach continues with remissions and the patient returns complaining of the same symptoms and a marked loss of weight, it is absolute folly to continue medical treatment. You can treat patients with chronic ulcer; making no difference whether you give bismuth or silver nitrate, they still have the ulcer. If you wish them cured, send them to the surgeon for operative treatment.

DR. EVERETT JAMES MCKNIGHT (Hartford): Dr. Oliver C. Smith spoke of resection. It seems to me that we are all coming to feel that for ulcers of the stomach, resection or partial gastrectomy is the operation of choice, considering the large number of cancers that develop.

Regarding Dr. Verdi's distinction between the two classes of ulcers, I am not prepared to speak of that. I feel that when a general practitioner sees a patient with pain coming on a certain length of time after eating and having attacks lasting a few days, with intervals of feeling well, again followed by relapses, he should consider that man's life in great danger. If he is not himself prepared to make the necessary tests, he should refer the patient to someone else; and if the symptoms persist, the case should be referred to the surgeon.

The Treatment of Fractures.

GEORGE W. HAWLEY, M.D., BRIDGEPORT, CONN.

In spite of the fact that the treatment of fractures is one of the oldest branches of surgery, its development has been conspicuously slow. The power to set bones has been assumed by quacks and learned practitioners from ancient times, and, doubtless, many of the methods in use to-day would be recognized by the early masters of medical science. This is remarkable when we consider what extensive change nearly every field of surgical practice has undergone.

On first thought it appears strange that a branch which, it is said, includes one-fifth of the cases applying for surgical treatment, has progressed so slowly; but if we stop to consider for a moment, a very good reason will be found in the fact that bone is specialized connective tissue, and like all tissues of mesoblastic origin, it possesses extraordinary power of selfrepair. It is difficult to prevent bone from uniting. It will bridge over considerable area. It will heal under adverse conditions. It will even do so when the bone is continued in use and bearing weight. Fractures unite, with treatment, without treatment, and in spite of treatment. Witness the multitude of unrecognized and untreated fractures—fractures of the fibula, of the radius, of the os calcis, of the neck of the femur in adolescents, of fracture-sprains, even fractures of the tibia and shaft of the femur. Furthermore, although bone usually unites with more or less architectural deformity, it has the tendency to assume the normal functions required of it. This reparative and adaptive power of bone has been a wise provision of Nature. If bone repair was not so active or functional results on the average were not so satisfactory, the treatment of fractures would have excited far more concern than it has.

A study of the treatment of fractures as we find it to-day reveals a confusing state of affairs. Among modern methods we find many that are relics of a past age. In rare instances are fractures treated by those who have made a special study of the subject. Almost anyone is deemed competent to treat fractures and in the hospitals this work is largely turned over to the internes. As a matter of fact, little interest is taken in fractures. Surgery has been occupied with more pressing problems. There is a dislike toward assuming the responsibility of these cases and a dread of a possible damage suit. It is a commentary on medical practice that the surgeon is held more liable for disability following fracture (an accidental injury) than following injury of his own making.

We find the old traditions and ideas concerning the "setting" and "reduction" of fractures still popular. These terms imply accurate replacements, yet the X-ray, if it has done nothing else, has exposed this fallacy. Perfect apposition of fractures is rarely secured even by the most experienced surgeons. Not infrequently, radiographs are obtained which it is a temptation not to suppress or destroy. Introduced in court, some would furnish damaging evidence in support of the claim that the bones were not properly "set."

The laity labors under an erroneous and exaggerated idea of the function and limitations of surgical science in the treatment of fractures, and little has been done to dispel this illusion. The lay mind is not satisfied until the surgeon has "set" the bone, and for anything but a perfect result is he blamed. It is not uncommon to hear the accusation made by people of intelligence that bones were not properly set where a person has regained complete use of the bone, but with some slight cosmetic defect. The profession has been placed on the defensive. Such is the penalty for assuming the power to "set" bones.

We find that the treatment of fractures as commonly practiced is empirical in principle. Fractures conform to the treatment, and not the treatment to the different fractures. These principles are "reduction" and "immobilization." We will see