tinuous from the duodenum to the pylorus, rarely to the stomach. Of this number, 16 were diagnosticated ulcer of the duodenum or pyloric end of the stomach, the diagnosis in many cases favoring the duodenum as the probable seat. Pain, vomiting, gas, acidity, dilatation, constipation, and appetite characteristic of ulcer of the duodenum (or pyloric end of the stomach) predominated, the degree of the attendant motor insufficiency measuring in most instances the severity of the symptoms. In eight of the cases under group three the symptoms were such that a diagnosis of "ulcer or gall-stones" was made. Tenderness to the right, and sudden attacks of pain, more or less irregular, were experienced. Definite signs of motor insufficiency, often lasting only a short time, were clearly present. However, the whole "symptom complex" seemed not incompatible with either gall-stones or duodenal ulcer or both. Another of this group was diagnosticated gall-stones a year previous to operation, and the diagnosis was not changed when she entered the hospital, though stomach symptoms had developed the last four months.

Under group four, we find eight cases of chronic perforation. One of these had been diagnosticated gall-stones and operated upon a few months previous with negative findings; finally ulcer was decided upon and a gastroenterostomy gave relief. Two others were sent into the hospital with a diagnosis of cholelithiasis, and only ulcer found. Another in which the diagnosis of gall-stones had been made three years previously, presented symptoms of ulcer so decided that a diagnosis of probable duodenal involvement was made. Both gall-stones and ulcer were found. The remaining four cases had severe spells that in the present light would indicate perforative peritonitis. They gave decided symptoms of gastric disturbance, with temporary periods of motor insufficiency, accompanied by more or less dilatation, and were fairly diagnosticated ulcer with only a suspicion of gall-stones.

Group five includes eight cases that were purely duodenal. Most of these came with the history that in earlier

years the trouble had been diagnosticated gall-stones. In one case, a year previous to a duodeno-duodenostomy, which gave perfect relief, an operation upon the gall-bladder had been negative. Six of these cases, however, when they came to operation, had besides the gall-stone-like colics, the pain, vomiting, gas, acidity, dilatation, and constipation (with few exceptions of above symptoms) characteristic of duodenal ulcer with motor insufficiency. The insufficiency would appear to come by spells, and seemed to be due in some cases, at least, to spasm only. A history of blood was given by three. Likewise in this group, gall-stones entered largely into the diagnosis. Ulcer of the pyloric end of the stomach was not precluded in most of the cases. In one, where the complaint covered 30 years, the last three constant but not severe, where burning rather than pain came one to three hours after food; and constipation was severe, the diagnosis of ulcer was made. Gall-stone history was entirely negative. Vomiting, gas, and acidity were absent or but little emphasized. The diagnosis rested on (a) burning in the stomach, worse two hours after food; (b) marked dilatation and emaciation; (c) constipation, and perhaps foremost of all (d) length of time (30 years) the condition was complained of, and (e) its appearance in decided spells. In this group the time of the trouble ranged from 5 to 30 years.

Are there any characteristic symptoms of duodenal ulcer? If we try to differentiate between ulcer at or near the pylorus and duodenal ulcer, we meet barriers that are yet well-nigh insuperable. Often the two conditions are associated, and then the certainties of a diagnosis are quite beyond us. However, when the duodenum is involved, the pain, gas, acidity, and vomiting are, as a rule, more intense than if only pyloric ulcer (gastric side) is present, and the type of pain is more apt to approach that of gall-stones. From ulcer situated in other parts of the stomach, the differentiation usually presents fewer difficulties. In the latter condition, pain and vomiting come sooner after taking food, and the food is returned much as it is taken. Acidity is

not so great and is often not noticed; gas, if present, is rarely so annoying a symptom; and blood is perhaps oftener found in the vomit.

It will be seen that cholelithiasis was the chief error into which we fell in our diagnosis, and practically it is the only trouble worthy of consideration in making a differential

test.

Pain in cholelithiasis is oftener sudden, severe, has a wide field of radiation, comes absolutely irregularly, is independent of and is not eased by food, nor so often traced to it. No stomach history is given between the short, precise spells; spasm of the diaphragm is nearly always observed; and vomiting and gas are present only during the attack, and the relief through vomiting and gas-eructation is not as certain. The vomit is usually scanty, yellow, and bitter, and acidity is extremely rare.

In duodenal ulcer the pain comes in decided periods of attack, may be and often is sudden, has a very limited field of radiation, may be irregular as to time of separate attacks, but regular as to periods. It is quite dependent upon food, being early eased, and later pain and distress appear. The history of gas, vomiting, and acidity runs parallel to the periods of pain. No spasm of the diaphragm occurs except in some cases of perforation. The vomiting and belching are usually decided in quantity and quality and followed by relief.

Of course, stone in the common or cystic duct, or a decided infection of the gall-bladder, acute or chronic, has a definite period of attack; but jaundice, an enlarged gallbladder, chills, and fever with other symptoms, usually give little uneasiness in diagnosis. Acute infection of the gallbladder and perforation of duodenal ulcer are often so nearly identical as to pain, palpation, and location, that gall-stones is the commoner diagnosis in either case. A careful history will be the great weapon of defense-the only means of differentiation. Here let me say that the clinician who has the greatest skill in developing exact histories, and has judgment to arrange them, will be the one to make the most ac

curate diagnosis, and will usually find other methods quite unnecessary, if not wholly superfluous.

The day of duodenal pathology has scarcely advanced to dawn. The diagnosis is indeed difficult, but treatment approaches solution. Fifteen years ago the internist and surgeon alike stood helpless beside the diseased appendix; ten years later both were writing and talking intelligently, and diagnosis and operation were generally well made. To-day a large percentage of cases come to the surgeon, and the diagnosis is made, and made accurately, by the patient himself. So too, in gall-bladder surgery, during the last ten years much has been written, and numberless operations reported, so that gall-stone, per se, has been robbed of both its operative and diagnostic terrors, and the surgeon at large finds such operations to his credit. However, the surgeon who will face every gall-stone diagnosis and be master of the occasion, must be schooled in the surgery of the stomach, duodenum, and pancreas, or his record of failures will be most discouraging.

There will always remain a certain proportion of cases. that will mislead the careful physician. Those gall-stone cases where the stomach symptoms of gas, distress, sour, belching, and dilatation predominate, and pain is but little complained of, (and that only of a dull character), will usually be diagnosticated ulcer, while the duodenal case whose chief symptom is the sudden, sharp, intense pain of perforative peritonitis, and where, with no obstruction or hyperacidity, the other stomach symptoms are in abeyance, will fall to cholelithiasis. Such error in diagnosis does not militate against the clinician, as both conditions are purely surgical, and the differentiation in many cases must be made on the operating-table.

THE ETIOLOGICAL RELATIONSHIP BETWEEN CANCER AND ULCER OF THE STOMACH

GEO. DOUGLAS HEAD, M. D.

Minneapolis

That cancer of the stomach may be engrafted upon the base of an ulcer or its scar has been established by the reported cases of many observers. Hemmeter ("Diseases of the Stomach," page 570) states that Kollmann has collected 14 cases and that about 14 more have been reported in the literature. Futterer (Jour. A. M. A., March 15, 1902), who has made a most careful search of the literature, has collected 52 cases, including those reported by himself. Other cases not mentioned in Futterer's article have been reported by Billings (American Medicine, April 6, 1901), Kaufmann (Amer. Jour. Med. Sci., Vol. 127, No. 4, page 655), and Du Mesnil (Nothnagel's "Encyclopedia Diseases of the Stomach," page 570).

Granted that it is established beyond doubt that cancer may be grafted upon ulcer of the stomach, the frequency with which this combination of lesions exists is a question upon which there is much difference of opinion. On the one hand are those who take the view that cancer is only very rarely engrafted upon ulcer of the stomach.

Kollmann, in the Tübinger Clinic, states that in the last twenty years the combination of cancer superimposed on ulcer had not been seen.

Duplant of Lyons, in 1898, published a thesis in which he declared that it had never been proven that cancer of the stomach succeeded ulcer. On the other hand Zenker maintains that most cases of gastric carcinoma originate in an ulcer base.