came more rapid, fever developed, pneumonia supervened and the patient died on the fourth day. Just before death, I opened a large phlegmonous inflammation in behind the tonsil. The case seemed to me to be one of immediate infection of the tonsil, where the infectious material was absorbed and involved the structures below, resulting finally in pneumonia.

Dr. Conkey: I have nothing more to add, but only wish to emphasize what has already been said. I believe that a diseased tonsil that has recurrent attacks of inflammation, is a menace to the health always and should be removed, or if not removed, be destroyed in some manner. Of course, the best and most expeditious manner is to excise it, and I think that is the best way to proceed. Cases similar to those that Dr. Ground has reported can be found in every man's experience, and they are numerous all through the literature, showing that it is a dangerous organ, and has satisfactorily demonstrated that the tonsil has ceased, when it becomes hypertrophied, to have any value, and there is no reason why such an organ should be allowed to remain in the throat.

ON THE DIAGNOSIS OF GASTRIC ULCER AND

CANCER.

BY ARTHUR J. BURGESS, M. D., OF MILWAUKEE.

Welch estimates that 6 per cent. of gastric ulcers perforate; and that the average duration of ulcer is from three to five years. Of 187 cases of ulcer treated in the Massachusetts General Hospital, 17 per cent. died. Of 900 cases of gastric cancer in the Pathological Institute in Vienna, 5 per cent. were preceded by ulcer. In 2200 stomachs Fiedler found ulcers in 20 per cent. of women and in 13 per cent. of men. In certain parts of Europe the frequency of gastric ulcer is variously estimated at from 4 per cent. to 13 per cent. of the population.

The frequency of perforation, the long duration, the large mortality and the frequency of the disease, though not so frequent here as in Europe, and the preventable fatality in many cases make the diagnosis of gastric ulcer an important matter.

The more common symptoms of ulcer are pain in the stomach shortly after eating, tenderness on pressure, vomiting, hemorrhage, hyperacidity of the vomitus, anemia and emaciation.

The pain is not always distinctive. It is described variously as stabbing, burning, or as a dull heavy feeling. One of the most distinctive things about it is that it comes on soon after eating and may persist as long as there is food in the stomach; differing in this respect from the pain of duodenal ulcer, which comes on later, if at all. The pain is usually in the epigastrium or in the back, or both, but has been referred to the retrosternal region, even to the neck and arms, suggesting angina pectoris. It is sometimes referred to the left hypochondrium. I saw a patient who for eighteen months was thought by her physician to have left pleurisy. Perforation had taken place two days

before I saw her.

She died on the operating table. The stomach showed the scars of several healed ulcers. Ulceration and perigastritis at the back of the stomach may cause sacral pain like many retroperitoneal processes. These various pains may arise from adhesions about the stomach and duodenum, or from pyloric obstruction of different kinds. Neusser speaks of pain in dilated stomach relieved by lying down. The mechanism is as follows: the descending part of the duodenum, being fixed to the spine, is not very movable; when the stomach is filled, the weight of the food causes an acute bend or kink in the upper part of the duodenum, which obstructs the passage and causes pain.

The pain may be due to gastralgia, gallstones, pancreatitis or ordinary colic. The history of jaundice is an important item to set against ulcer, also pains associated with symptoms of gallduct infection, and the more violent onset and course of the usual gall-stone colic.

Perforation usually leaves no doubt as to the diagnosis. M. H. Richardson gives a clean-cut description. He says: “sudden, severe pain in the region of the stomach, accompanied with shock, tenderness, muscular rigidity of the upper abdomen, vomiting, and a history of even trivial dyspeptic symptoms, should incline one to the diagnosis of perforation rather than any other acute disease."

I saw a man who for two weeks had had what he supposed was indigestion. There was uneasiness in the epigastrium. He arose from a lounge suddenly to answer the doorbell, felt a sudden and severe pain in the right hypochondrium, became faint while talking to his visitor, had to lie down and went into collapse. Called by his physician, I saw him in twenty-four hours. His pulse was small and wiry and about 100. His temperature under 100 degrees. The abdomen was distended, its walls very rigid. The diaphragm was forced up, the liver dullness was ab

sent.

There was pain all over the abdomen.

Perforation was evident. Incision revealed perforation of the duodenum. He

died in one month of pulmonary tuberculosis. In another ulcer of the duodenum, proved by autopsy, there was never any pain, -nothing but progressive anemia.

R. II. Martin says that when there is perforation of the stomach, the legs are stretched out, whereas when it occurs in the lower abdomen the knees are more apt to be drawn up.

Sometime ago I saw a case three weeks after a perforation of a gastric ulcer. Of course there was general peritonitis, and peritonitis had been the diagnosis, though that is no diagnosis at all. The case was proved by autopsy.

Neusser relates that when he was an assistant, he was called from dinner to see a patient who had gone into collapse with severe pain in the epigastrium. On examination he felt a tumor in the stomach and diagnosed cancer. He acquainted his chief, Prof. Bamberger, with his diagnosis. Bamberger examined the patient, and on account of the smoothness and elasticity of the tumor, together with the history of ulcer, diagnosed gastric ulcer with hemorrhage in the surrounding adhesions. There was an autopsy and Bamberger was right. Of course, that was a stroke of genius, but pain is a most variable symptom and must be carefully investigated, and yet without pain and vomiting, as Osler says, the diagnosis of gastric ulcer is impossible. There are cases without either.

In attacks of pain and vomiting we must remember hysteria and look for its stigmata. Neusser used to tell his pupils to look for tape-worm in hysteria with abdominal symptoms, and sometimes demonstrated the eggs in the feces.

In pain and vomiting also, we must not forget locomotor ataxia and must look for its other symptoms.

Vomiting often takes place immediately after eating, and when associated with pain and tenderness is distinctive. Vom

iting of blood is also distinctive, though it may take place in small quantities in gastritis, in large or small quantities in cancer, or in case of rupture of esophageal veins in certain valvular incompetencies. The valvular incompetencies will be disposed of on examining the heart. I have seen two stomachs in which an ulcer had eroded a large artery with fatal hemorrhage. In such a case, and in hemorrhage from the esophagus, the blood will be bright, whereas in cancer it is the usual coffee grounds color.

Nearly all the symptoms of ulcer are characteristic of many gastric cancers except that the hyperacidity of ulcer is not often present in cancer, but on the contrary, the rule in cancer is that free hydrochloric acid is not present. Then too, in cancer, there is not only anemia, as in ulcer, but usually cachexia, gradually deepening. In the ulcerating stage of cancer foul vomitus is often expelled.

In the presence of tumor in the epigastrium, the probabilities are vastly in favor of cancer, although many chronic ulcers present large indurations and adhesions. Innocent tumor of the

stomach is however rare aside from the indurations of ulcer. If a tumor grows rapidly and is hard and nodular, cancer is almost certain.

In every suspected case, the abdomen, groins, axillae, and neck should be palpated carefully and repeatedly for enlarged glands. Two weeks may be long enough for glands to become enlarged. I had a case of supposed catarrhal jaundice with fever longer than is usual. There was no pain, no vomiting. After a time a large nodule was found above one clavicle and in two weeks many of them. Cancer was then certain. The autopsy showed the primary cancer near the pylorus, the liver was full of nodules, and there were thousands in the lungs.

It is not necessary that the glands should be very large to be distinctive. A full, rounded, shot-like, hard gland above the