able syringe, paraffin, prepared for surgical use with a melting-point of 110°, is injected through the lower canaliculus into the sac until it is completely filled. This at once hardens, and the sac is thus easily outlined. An incision is made in the skin over the sac in its long axis, extending from onequarter of an inch below the dome way down to the lower extremity of the swelling. The sac is exposed, and can be easily seen and dissected out by means of knife, dull instruments, and scissors. It should be followed well down into the duct; if it is button-holed no damage is done, as the paraffin is hard and will not escape. Any necrosed bone found should be curetted, and drainage will take place into the nose. The skin is sutured, and the canaliculi destroyed afterwards by cauterization. By following these directions, no large vessels will be cut, and the entire incision may be made below the tendo-oculi. If the latter is cut it should be sutured. When a general anesthetic is administered the patient's head may be dropped over the end of the table. as in adenoid operations, to allow the blood to run out of the nostrils and prevent its entrance into the larynx. If cocaine is used some should be injected into the sac previous to the injection of paraffin; and before making the incision the skin is anesthetized by the infiltration method in which case adrenalin may also be used.

DUODENAL ULCER, SYMPTOMS AND DIAGNOSIS

BASED ON FORTY-SIX OPERATED CASES: 33 MALES AND 13 FE

MALES

CHRISTOPHER GRAHAM, B. S., M. D.

Rochester

The basis of diagnosis of duodenal ulcer is the carefully developed history. Physical and laboratory findings are helpful accessories. In our series, pain was perhaps the most important symptom, and had some characteristics. It may be sudden, sharp, and severe, and be manifest to the right of the median line, but rarely radiates beyond the stomach and duodenal area. As a rule, it has decided relations to meals. There is, however, a small group in which food plays an unimportant part. It includes those cases where peritonitis, due to complete or partial perforation, gives the first symptoms, where there is no motor insufficiency due to either spasm or obstruction, and where the gastric contents is not above normal in acidity. Food most often gives relief for a time, the pain appearing from three to six hours later,-in other words, when the stomach should be nearly or quite empty. Pain appears daily, or several times a day, during the period of attack. In the great majority of cases it is entirely quieted or modified by food, drink, vomiting, irrigation of the stomach, and alkalies. Pain of duodenal ulcer cannot be due to food directly; it rarely comes sooner than two hours after food enters the stomach, and much oftener four or more hours later, and the kind of food usually plays an unimportant part, if we exclude salts, sweets, and acids.

The pain is due chiefly to two factors: I. In this class of cases, it is due to peritonitis caused by a greater or less degree of perforation, and it stimulates gall-stone colic. 2.

This comprehends the greater number of cases, and the pain is due almost wholly to the irritant action of the acids on the open ulcer, with the added element of spasm. The greater the quantity of the liquid in the stomach, and the higher the degree of acidity, the more severe the pain; in other words, intensity of pain and degree of acidity run about parallel. The irritant action of the food as a cause of pain by passage over the diseased area cannot enter into the question, because anything that diverts, dilutes, neutralizes, or removes the acid liquid, lessens or entirely relieves the pain. Food and drink, by diverting and dilulting, bring relief; antacids as a rule are quieting for a time and remove nothing; vomiting or irrigation of the stomach relieves by removing the offending acid, but no rough particles of food which could irritate are found so long after a meal in either vomitus or washings, and both are as a rule abundant. Tender spots are not infrequently found and when present they are to the right of the median line in the duodenal, gall-bladder, and pyloric area. Posterior tenderness was seldom demon

strated.

Vomiting was a prominent symptom in our series, 32 giving it important mention. The chief points of vomiting are the time, the form, and the kind; that is, first, whether soon after taking food or deferred quite late, and, second, whether of small amounts and regular or only occasionally, or whether more or less irregular and quantity large, and, third, whether food is vomited as taken or only eructation of hot water, small, sour, bitter amounts, intensely acrid, and large amounts or quantities of half digested, macerated foods. In these cases vomiting was as a rule delayed, irregular and acrid, not much food contained in it except when obstruction had obtained in a decided degree. The quantity varied, it being decidedly abundant in the latter. Relief comes through vomiting, and the patient often induces vomiting to quiet distress or intense burning pain. When there was a history of hypersecretion the amount was usually large, and digestion well advanced. In other cases the amount was small if obstruction was not pronounced. The

characteristics of vomiting in these cases seem to be, coming later after food, acid liquid or liquid food well digested and more or less irregular in time, and relief following evacuation of the stomach.

Gas is also an equally important symptom here, and seems to be at its height when acidity, pain, and vomiting are ascendant; and relief by food and drink comes to gas-formation quite as frequently as it does to pain. We feel sure that gas is more prominent as a symptom in ulcer of the duodenum or pylorus than in ulcer at any other location, and certainly it should be, as gas-formation is first to herald motor insufficiency of whatever nature, and in this position slight narrowing would soon demonstrate its presence, and spasm could easiest here become effective. Acidity beyond normal is the rule, and was excessive in 13 of 24 cases, and this increased acidity is a frequent cause of gas-formation. Dilatation was much more often found than normal capacity.

A very large proportion have good appetites, nay more, most of them have keen food desire, and only pain, gas, vomiting, and acidity prevent sufficient food intake. Many are found undergoing voluntary dieting, but more often fail to secure that relief which usually comes to those whose trouble is of the stomach proper. We certainly expect the appetite to be good in cases where the digestive juices are normal or abundant, and this is the rule in duodenal ulcer. Constipation is a common symptom, and was most bitterly complained of by one-fourth of the number, four charging most of their trouble to this.

Bleeding of duodenal ulcers is common, and may be characteristic. It led to a diagnosis in one case when the passages were frequently dark and tarry or even bloody, and no pain was experienced. Twelve reported blood either by vomit, stools, or both, and in four instances it was found at test-meal, when not otherwise mentioned.

Latency of duodenal ulcer has been often demonstrated, and it is believer to be much more common than latency of gastric ulcer. It would seem that three factors influence

latency: first, if acidity is low or not above normal; second, if no motor insufficiency be present; third, if perforative peritonitis has not taken place. Under these circumstances there will be no pain, no gas, no vomit, and the pathological condition will go unrecognized by the patient, and of course by the clinician unless hemorrhage reveals the true condition. These factors have weight if the ulcer locates itself at or near the pylorus or along the lesser curvature. These latent gastric forms are prone to heal, and cancer may quite as readily follow in their wake as in that of the chronically open ulcer.

The 46 cases are placed in five groups, the division being made in the light of the operative findings.

The first group contains 4 cases, with a history of stomach or gall-bladder type, or both, for periods of from 4 to 21 years, and came to the hospital with acute perforation of chronic ulcer. Of these, one was referred to us as acute perforative appendicitis and our diagnosis was gall-stones with recent rupture of the gall-bladder; a second was sent to the hospital for ruptured gall-bladder, and a differential diagnosis was made on three points,-(a) a history of from fifteen to eighteen years of bitter trouble from gas-formation two to six hours after meals, (b) large amounts of morphine necessary to control the pain (of perforative peritonitis), (c) mass, tenderness, and rigidity well to the right. Of the other two cases, one was diagnosed gall-stones with perforation, and the other reached the distinction of being called either perforated gall-bladder or perforated duodenal ulcer.

Group two consists of one case of chronic repeated hemorrhage from the bowel over a period of three years, with repeated acute bleedings for four weeks previous to admission, and for which he was operated upon. In this case the correct diagnosis was made from the hemorrhages, for the stomach symptoms were among the mildest of the whole class.

In the third group there are 25 cases. Nine had separate ulcer in the duodenum and stomach; in 16 the ulcer was con