tis. While the rigidity of the abdominal muscles does not lessen, yet the retraction gives place to a gradual distention, and later a marked resonance. The pulse increases in frequency, the temperature rises, the distress increases, vomiting persists, delirium approaches, and a death of peritonitis closes the scene.

To one who has witnessed the moving picture of such a death the uselessness of all palliative treatment must have become so apparent as to stir him to the most active measures should he again witness the first stage of the tragedy. Men of the widest surgical and pathological experience agree that it is rare for a patient to recover after a duodenal or gastric ulcer perforation, unless surgically treated.

In many cases the perforation comes without warning or with so slight a warning that both patient and physician are totally unprepared for an occurrence fraught with so portending a fatality when the antecedent symptoms have been comparatively trivial. I well remember such a case, which I observed some twelve years ago. An apparently healthy man, of 52 years, had prided himself upon his good health and enduring strength. He occasionally complained of indigestion, but it gave such slight concern that he rarely consulted a physician. He had never vomited, had had no gastric pain. One morning soon after leaving his home, and while on his way to business, he was seized with an agonizing pain in his stomach. He became faint and held on to the fence to keep from falling. His breath came in short sobs and he groaned in agony. Friends came to his relief, a carriage was procured and he was hastened to the one hospital which the small town afforded. On arrival there he fainted and immediate death seemed imminent. His skin was cold and covered with a clammy sweat. His eyes were fixed and staring, pulse thready and rapid, respiration shallow and jerky. His own physician was as much in the dark as was the hospital staff as to the cause of his collapse. He was stimulated by rectal and hypodermic injections, artificial body heat, and hot drinks. In an hour or two he rallied, complained constantly of the agonizing pain in his stomach and was exquisitely sensitive in the upper abdomen. He was in a small town with no experienced surgeon at hand. I saw him thirty-six hours after he was stricken. He then had a well-developed general peritonitis, abdominal muscles like boards, marked distention, high temperature, and rapid, weak pulse. He was conscious and gave me a clear recital of his attack and the continued excruciating pain in the stomach a little to the right of the median line. The picture of perforation was complete in every detail. With a hope that a rapid closure of the stomach opening, the cleansing of the abdominal cavity, and the establishment of drainage might save the life which hung on so slight a thread. I operated, making the incision in the outer third of the right rectus.

Nature had rallied her forces as best she could, and I found she was attempting to stop the leak by forcing the omentum and transverse colon against the hole which was on the anterior wall of the pylorus. Unfortunately her attempts were unavailing, as the liquids given by mouth were seeping through the partially sealed opening. Flocculent pus bathed the surrounding parts and cemented loops of intestines one to another. The peritonitis was very general and extensively suppurative. The ulcer was excised. the edges closed, the abdomen cleansed, the drainage inserted, and the patient returned to his bed. The peritonitis went on unchecked, and he died two days later.

In many respects this is a typical case of perforating ulcer where surgical relief has been delayed. If a life so jeopardized can be saved at all there must be the least possible delay in securing surgical relief. If the patient survives the immediate shock, which rarely goes beyond six hours, peritonitis sets in and the hope of recovery is in inverse ratio to the elapsing minutes after the six-hour period.

Were the question when to operate as clearly answered in the non-perforating cases as in the perforating ones the problem confronting physicians and surgeons would be a simple one; but it is not, and this is the bête noir which obtrudes itself in every obstinate case of gastric distress. I am of the belief that the homeopathic physician takes a more liberal view of the possibilities of curing peptic ulcer by internal medication and diet than does his brother of the old school, and with reasonable justice, for certainly we have remedies whose similimum is matched perfectly in that disease. Moreover, we have the indisputable proof that such cures are effected. In making that statement I am well aware that men in high surgical authority claim that no remedy exists which can cure gastric ulcer and that every such case becomes a surgical subject.

Some years ago a surgeon who has perhaps operated for relief of gastric ulcer more times than any man in this country, said, "You might as well try to cure a varicose ulcer by pouring talcum powder down the patient's trouser leg as try to cure gastric ulcer by internal medicine." But were I the victim of a gastric ulcer I would try the talcum powder plus the indicated remedy and the proper diet before ornamenting the operating table.

But there is a reasonably defined border line upon which the internist and the surgeon can meet and exchange views, and it is this, persistent gastric hemorrhage. It does not follow

that vomiting blood is in itself a sign of gastric ulcer. The blood may come from any spot, beginning with the nose or teeth and extending to the stomach. Hence it is well to exclude all such possibilities before giving the verdict of ulcer.

Nor are all gastric ulcers inclined to bleed to the extent of causing hematemesis. It is estimated that about 50 per cent. of

peptic ulcers give evidence of hemorrhage. When, however, the bleeding is so persistent as to cause anaemia and failing strength and no advance has been made by careful diet and medical treatment, then the case becomes a surgical one. Again, there is the type which shows periodic attacks of bleeding, each outburst leaving the patient a little lower in the scale of resistance. Such also should be catalogued "surgical."

There is yet another class which is a source of constant anxiety to the medical attendant. This is the border-line case which, while it answers up to the requirements of gastric ulcer, does not become better or worse during a period of months or years, but keeps the patient a semi-invalid; or, again, the relapsing type which will have a long period of freedom from discomfort then a corresponding spell of distressing gastric disturbance. Were it not for the fact that cancer of the stomach follows so frequently upon the attack of gastric or pyloric ulcer, one might be content to allow this type to remain partially well rather than subject them to an operative ordeal. But with that foreboding menace even dimly in view is it not much wiser to risk the slight dangers of an operation and forestall the possibility of a cancer death?

There now remains but one class, the one of uncertain diagnosis. We have examined the stools for occult blood, we have subjected the stomach contents to a most critical analysis, we have employed the test meal, we have weighed every symptom carefully, yet we have not been able to satisfy ourselves just what ailment our patient has. These are the masked cases wherein the clinical distinction between chronic gastritis, peptic ulcer, cholecystitis, pancreatitis, and carcinoma is almost impossible to establish. It is in this type that the exploratory incision is a very present help in time of trouble. Far better is it for the welfare of the patient and the mental quietude of the physician to settle beyond doubt the exact nature of the disease and then remove it if possible rather than permit him to suffer indefinitely, floating from one medical attendant to another and in the end be told his disease is past the remedial stage.

In summarizing I should say that there is little debatable ground between the internist and the surgeon in the treatment of peptic ulcer. Both agree that many such cases get well spontaneously, many are cured by diet plus hygiene plus remedies. many that are not cured lapse into cancer. That all persistent cases of hematemesis are surgical, that obstinate, uncertain cases should be explored, and emphatically that all perforating cases should be operated at the earliest possible moment. While

the surgeon willingly gives the internist credit for his full number of cures, the latter, in turn, does not question the well-established statistical record of surgical cures which is yearly becoming more gratifying. This phase of the subject, however, will be considered by the next essayist on the end results.

THE REMOTE RESULTS IN OPERATIONS UPON THE STOMACH AND DUODENUM.*

BY CLARENCE CRANE, M.D., Boston, Mass.

We cannot well discuss the results of operations on the stomach and duodenum without considering the conditions which may call for operation. For the early diagnosis of these conditions a distinct responsibility rests upon the general practitioner. Large numbers of surgeons are now performing these operations. Their reports are providing dependable statistics as to the value of operative procedure.

Let us make a classification of four types of cases which may or may not call for operation: (1) Cases of exhaustion from starvation, the vitality being very low, and also cases of collapse due to perforation. (2) Cancer cases that are too far advanced for operation. (3) Gastric ptoses and neuroses. (4) Cases of ulcer, early cancer, obstructions and adhesions.

In the first group of cases, if the starvation is from obstruction and not from cancer, Mayo advises preliminary jejunostomy and feeds the patient through the opening, gastro-jejunostomy to be performed later when the condition of the patient will permit. In cases of collapse from perforation the only hope is in prompt surgical intervention. Here astonishing results are sometimes obtained.

The second group of cases includes patients who have, for a long time, shown gastric symptoms. As a last resort they drift into the hands of the surgeon. Exploratory incision shows extensive cancerous involvement which operation cannot benefit. Probably no one doubts the tendency of gastric ulcer to degenerate into

These inoperable cases were, in the beginning, simple ulcers and would likely have been amenable to surgical treatment. It is here that a great responsibility rests upon the physician who attempts to treat with medical and dietetic measures the case of stomach trouble which does not respond, after a reasonable length of time, to this course of treatment. However, a gastro-jejunostomy should not be performed upon every case of indigestion. The border line between medicine and surgery is to be found somewhere in the course of the case, and here is where the patient needs our most careful thought.

In the third group of cases, the ptoses and neuroses, it is the unwise application of surgical measures that has cast much discredit upon stomach and duodenal surgery. Here it is important that we keep away from operation.

It is in the fourth group of cases, the ulcers, the early cases of cancer, obstructions and adhesions that the properly applied operation affords a brilliant example of success.

A careful study of the end results in one hundred and sixty-five patients operated upon, in an English hospital, for gastric and duo

*Read before the Massachusetts Homeopathic Medical Society. Oct. 9, 1912.

denal conditions is made by Dr. Short. It was possible to obtain the subsequent history in one hundred and fourteen of these cases. This list includes simple and perforated gastric and duodenal ulcers and all other gastra-duodenal conditions calling for operation. Forty of these cases were reported as cured; twenty-six as much improved; twelve as still presenting severe symptoms; thirty-six as dying immediately or remotely following operation. Of these thirty-six deaths, perforation was present in twenty-six cases. Out of seventy-eight living patients sixty-six were either cured or much improved.

Dr. Petren reports one hundred and thirty-five cases of gastric or duodenal ulcer with operation and recovery in forty per cent., or fifty-four cases. The early operation, within twelve hours after operation, gave best results, especially when the perforation was sutured.

Dr. W. J. Mayo reports one thousand cases of ulcer of the stomach and duodenum operated upon at Saint Mary's Hospital. His conclusions are:

The treatment of all duodenal and all obstructing ulcers of the pyloric end of the stomach by gastro-jejunostomy and excision or infolding of the ulcer is satisfactory, and gives ninety-five per cent. of cures or great improvement.

2. Eighty-five per cent. of ulcers of the body of the stomach will either be cured or greatly relieved by excision or devitalizing suture compression with gastro-jejunostomy. The remaining fifteen per cent. will be more or less benefited. The mortality under present methods of operating is less than two per cent.

From some of the gastric and duodenal operations performed by the surgeons at the Massachusetts Homoeopathic Hospital the results are as follows: Four cases of cancer operated upon received great relief. One lived in comparative good health for fifteen months. Another at the present time, a year and a half after the operation, reports that he is able to eat anything and, as far as he knows, is cured. Two cases of perforating ulcer of the stomach are cured and in good health.

Case 1. Mr. D. R. Symptoms before operation, indigestion, steady, grinding pain in right hypochrondrium relieved after vomiting of frothy material. Had to give up his work. Operation, March 29, 1911. The operating table diagnosis was cancer of the duodenum. Gastro-jejunostomy was performed. Result at the present time, patient is in good health.

Case 2. Mr. A. C., age 43. For twenty years patient had stomach trouble, severe vomiting, lost 58 pounds, had to give up his work. Examination revealed indurated pyloric ulcer and pyloric obstruction. Posterior gastro-enterostomy was performed October 10, 1907. Patient has not vomited since and is cured.

Case 3. Miss M. B. R., age 57. Patient had stomach trouble twelve years, pain, soreness, constipation, dark stools, vomiting of a coffee ground material. Gastro-enterostomy was performed March