cases gave a history of any previous stomach disturbances. Of the 150 cases 107 gave no history of stomach trouble prior to one year before coming under observation. This is 71 per cent of the total number of cases, and is a strong argument against the theory that ulcer plays an important role in the etiology of cancer of the stomach.

Any patient with cancer of the stomach who has had, up to one or two years previous to coming under observation, no gastric disturbance gives little clinical evidence of gastric cancer superimposed on ulcer. His gastric symptoms in most cases must be due to the beginning of the cancer itself.

Ulcer of the stomach in a vast majority of cases is a disease of young adult life; carcinoma of the stomach is a disease of advanced life. Where cancer is engrafted upon ulcer the vast majority of cases give a prolonged history of gastric trouble lasting over years and terminating in cancer. It may be possible in some few cases for an acute ulcer to immediately develop carcinoma within a year, but such is certainly not the rule. Graham states that in three of his cases of gastric carcinoma the history of ulcer did not cover two years.

Without more conclusive evidence than he has offered it seems more reasonable to consider these cases of short clinical history, not as instances of gastric ulcer with later developing carcinoma, but as primary gastric carcinoma from the beginning.

All writers of recent years agree that the great majority of patients with cancer of the stomach give no history of prolonged gastric disturbance. Ewald, Boas, Hemmeter, Osler and McCrae, Stockton, Riegel, and others give the same clinical picture; a sudden onset of the gastric symptoms in persons in previous good health. In only 33 of the 150 cases reported by Osler and McCrae was there a history of previous gastric trouble. In 17 of these the disturbance was confined to isolated attacks. Eleven of the cases had chronic gastric trouble

for years. In a series of 150 patients suffering from other diseases taken for comparison, 28 gave a history of old stomach trouble, only 5 less than the cancer series. There is therefore little evidence to be secured from the clinical history of cases of cancer of the stomach pointing to ulcer as a basis for the development of the disease.

All writers upon this subject agree that cases of cancer engrafted on ulcer usually show the presence of free HCl in the stomach contents after a test meal. Here we have a further standard by which to test the theory under consideration.

Riegel, speaking of cases of cancer succeeding ulcer, says such cases are characterized by normal gastric secretion, which may continue until death. They are distinguished by this symptom (presence of free HCl) from the majority of cases of ordinary carcinoma of the stomach.

Of Osler and McCrae's cases, 80 out of 87 in which gastric contents examination were made, showed a complete absence of free HCl. Granting that all the cases showing the presence of free HC1 were of ulcer basis, only 8 per cent could be counted in the category of carcinomas engrafted upon ulcer. In the light of this evidence, therefore, the idea that cancer is commonly engrafted upon ulcer fails to be established.

The total mortality for cancer of the stomach is about 1.5 per cent of all deaths. Ulcer or ulcer scars have been found in about 3.32 per cent of all persons coming to autopsy. Ulcer and cancer have been encountered at post-mortem in different parts of the same stomach entirely isolated and without any apparent relationship. each to the other. In view, therefore, of the evidence, clinical and pathological, at present at our command it does not seem reasonable for us to accept the views of those who believe that cancer of the stomach is commonly engrafted upon ulcer. The writer believes that the evidence is entirely conclusive, and that in the light

of the facts here brought forward it seems fair to conclude:

I. That cancer of the stomach is only exceptionally engrafted upon ulcer.

2. That such an event exists in not more than 6 to 8 per cent of the cases of carcinoma.

3. That ulcer of the stomach plays a very minor role as a predisposing factor in the causation of gastric can

cer

SOME IDEAS REGARDING THE NATURE OF SYPHILIS

FRANKLIN R. WRIGHT, M. D.

Minneapolis

Syphilis is an organic, infectious disease which affects the entire organism. It begins at the point of infection by lesion peculiar to itself, and passes, after a definite period of incubation, to general symptoms, that show themselves in the beginning, principally as eruptions on the skin and mucous membrane, and may continue later as morbid changes in the different organs.

The cause or virus of syphilis is still unknown. Much time and study have been given to the subject by scientific men all over the world to ascertain the true cause of this disease, but thus far their investigations have been without reliable results. Careful and laborious investigators have announced from time to time that they have discovered the real cause of syphilis only to have their work entirely disproved by other investigators in the same line of research. Other scientific men have announced the discovery of certain changes in the blood characteristic of syphilis and of diagnostic value, only to have other observers point out the error of their investigations. Research along this line may differ only by lack of culture media.

The lower animals are immune to this disease. At the present time the living human being offers the only known material on which this virus, whatever it may be, will grow.

Syphilis is transmitted either by inheritance or infection. In order that infection may take place it is necessary that fresh infectious material, that is to say, the secretion from a primary lesion, moist lesion, or blood of a syphilitic person

be brought into direct contact with a wound, or, at least, a break in the epithelium on the body of a person free from syphilis. This transmission of infectious material may be. brought directly about by a lesion on the body of a syphilitic person, or indirectly by contact with some object which has become contaminated by contact with such lesion. Though indirect transmission does occur, there can be no question but that the possibility of such infection is very small. The infectiousness of the virus of syphilis appears to be very short-lived, and very sensitive to variations of temperature; hence if indirect infection is to take place the transmission must be almost immediate; that is, before the contaminated article has time to dry or become cold. For example, it would be very dangerous for a non-syphilitic person to smoke the pipe of a syphilitic person, if the same were taken fresh from the latter's mouth; but if the pipe were to be laid aside until it had become cold before its use by the nonsyphilitic person, there would be little if any danger in his using it. Even the dead bodies of syphilitic persons lose their infectiousness when they wholly lose the body heat. I am aware that post-mortem infections have occurred, but only when the post-mortems were conducted within a few hours after death, and before the body had become entirely cold, and while it still retained some vestige of animal heat.

The first period of incubation, or the time from infection until the appearance of the initial lesion, is one of quiescence, as far as external signs are concerned. This is not true, however, of the second period of incubation. The time between the appearance of the initial lesion and the appearance of the constitutional symptoms is marked by active changes in the lymphatic system, which, occurring as they do in regular order, indicate accurately the change of the infection, and are as absolutely diagnostic as the constitutional. symptoms.

The initial lesion appears at the end of the third week. A week later, or at the end of the fourth week, the lymphatic glands in one groin begin to enlarge. This enlargement reaches its height one week later, or at the end of the fifth