no Oppler-Boas bacilli were found. By use of the suction-pump the sediment of the stomach washings was obtained and examined. Numerous cancer-cells were found.

Dr. John Deaver, in September, 1913, performed a posterior gastro-enterostomy to relieve the symptoms of retention. The patient did well, was greatly relieved, and subsequently gained 44 pounds in weight. He came to Dr. Lyon's dispensary at the Jefferson Hospital on October 8, 1914, again suffering from symptoms of retention, which were relieved by lavage. Several large fragments of the growth were vomited when the stomach-tube was passed. The patient had lost considerable weight during the past few months, but was still 16 pounds above the weight when operated upon.

Dr. McCrae referred to the three years' history of "indigestion that preceded the diagnosis of cancer, and called attention to recent views as to the number of cases of cancer of the stomach that apparently arise on the site of ulcers. He stated that there could be no doubt but that in a certain number of cases cancer of the stomach appeared on the sites of ulcers, but that he had been unable to convince himself that the majority of cancers of the stomach came from this cause. The suddenness with which gastric cancer often makes its appearance without a previous history of indigestion is against such a view of the general origin of such growths. It will be of interest to observe if cases are later reported in which malignant change has taken place in ulcers not excised at the time posterior gastroenterostomies have been performed.

Dr. McCrae strongly advised surgical measures for the relief of ulcer in those over forty years of age, and stated that such ulcers are often very chronic and show little tendency to heal. In this particular patient there had recently been a good deal of bleeding, and little could be done other than to make him as comfortable as possible. The diagnosis was an inoperable gastric carcinoma.

The next patient was a white man, a cigar maker, who came to the hospital complaining of two symptoms: First, regurgitation of his food; and, second, distress in the region of his stomach. His family history was negative, and the past medical history revealed nothing important.

In August, 1913, the patient began to be troubled by distress after eating. There was a sense of distress and oppression in the gastric

area which was not relieved until he vomited. Dr. McCrae called attention to the fact that it was not always easy to distinguish between a functional disorder and actual organic disease, but that it was advisable, in such cases, to endeavor in every way possible to decide whether there was organic disease. He mentioned that, in order to make as few mistakes as possible, one must give the patient a thorough examination to rule out reflex disturbances from gall-stones, disease of the appendix, etc. The heart must be examined for organic and functional disease, the lungs and pleuræ must be examined for tuberculous lesions which may be the cause of the gastric symptoms. The general condition of the nervous system should also be investigated, as many gastric disturbances are secondary to instability of the nervous system.

Dr. McCrae then called attention to the patient. He was well nourished, had a fair color and a clean tongue. His lungs, pleuræ, and heart proved negative on examination. A Wassermann reaction proved negative. The blood count was as follows: Hæmoglobin, 88 per cent.; erythrocytes, 4,900,000; leucocytes, 9800. His abdomen was flat; there was slight general tenderness, but no rigidity. His liver was not enlarged, nor was his spleen palpable. An examination of his stomach contents revealed no retention of food, and the acidity proved to be about normal (free hydrochloric acid, 49; total acidity, 58).

In taking one of the gastric tests (with the tube in situ) it was found that at the height of digestion there was fresh blood found in the contents which was not present during the first hour and a half after the meal was given. The presence of blood in the gastric contents, if trauma by the tube can be ruled out as in this case, would lead one to strongly suspect ulcer or neoplasm. An X-ray plate, properly illuminated, so that the class could study it, showed that the stomach was contracted into an hour-glass form. Several other plates taken at intervals during the hours of digestion revealed the same appearDr. Willis Manges, the röntgenologist, diagnosed an ulcer of the lesser curvature.

ance.

The treatment was discussed, and Dr. McCrae stated that what one must decide was whether the patient should be treated by medical measures for a time or whether he should be advised to submit to surgical measures at once. The acute ulcer was, as a rule, best treated

VOL. I. Ser. 25-8

medically for a time, while the majority of ulcers, whether acute or chronic, may be greatly improved by medical treatment, even if they are not permanently cured. The treatment consists in giving the patient a thorough rest and learning by judicious experiment what diet and in what quantities are best adapted to the particular individual. There can be no general rule of feeding applicable to all ulcer patients. When the motor power of the stomach is good a more generous diet may be administered, while if the stomach is irritable and food causes pain and distress it is well to give as little food as possible, and proceed very carefully in the transition to a more liberal diet. In certain cases there may be a real advantage in stopping all food by the mouth for several days.

Medical treatment is but a feeble aid to the more important dietary treatment. Subgallate of bismuth, calcined magnesia, and silver nitrate are drugs largely used, while opium and its derivatives are helpful aids when pain is a feature of the case. Chronic ulcers, especially in patients over forty years of age, do not heal with readiness, and after a faithful course of medical treatment has proved unsuccessful surgical measures had best be instituted. Each succeeding year's work of surgical interference in cases of ulcer shows less mortality, and at present the mortality in skilled operators is less than four per cent.

The students were advised to keep a special watch special watch upon supposed healed ulcer patients, and to ever keep in mind the possibility of beginning malignant change. In every patient with ulcer the possibility of perforation should be remembered.

THE EARLY DIAGNOSIS OF GENERAL PARESIS

BY JOHN E. LIND, M.D.

Government Hospital for the Insane, Washington, D. C.

SOCIAL IMPORTANCE

IN perhaps no other department of his humanitarian activities has the family physician a more exacting demand on his resources than in his dealings with cases of mental trouble. A large part of the difficulty attending such situations undoubtedly arises in the undeserved but indubitable obloquy apparently inseparable from affections of this sort. For years after he has had pneumonia a man is licensed to buttonhole his friends and bore them with descriptions of his symptoms; a woman may exhibit her pickled appendix to admiring visitors, and a slight affection of the heart is a conversational gold-mine, but an illness of the mind is a bête noire, a blot on the escutcheon, a skeleton in the closet.

There is danger that this almost universal attitude will bias the physician too much in the discharge of his duties to the community. He is in a peculiar sense the guardian of the public safety where it is endangered by disease, and no diplomatic scruples should shut his eyes to the onset, often insidious, of mental alienation, and make him temporize with a social foe. This danger is especially true of general paresis, owing to certain characteristics of its incipience. While there are few, if any, disease entities more clearly defined than welldeveloped paresis, there are also few diseases, mental or physical, which can create more social havoc before being recognized. This is due to several causes.

General paresis does not spring, so far as we know, from predisposed soil. The victim may have lived a happy, successful life and may just be reaching the top of the ladder, preparing to pluck the fruits of industry, when the prizes of life are ravished from his grasp. Too often he is the head of some social or business organization, the pater familias, or the small merchant. Before the disease is recog

nized, he has dissipated the family funds, played ducks and drakes with his income, and ruined his business. His dependents have him committed, only to find that they have delayed too long, and their means of sustenance have been divided between saloon-keepers, prostitutes, and swindlers.

In just such cases does the general practitioner find his field. The psychiatrist, unfortunately, does not see them until the clinical picture is so clearly defined that the veriest layman can detect the presence of mental trouble, and with the obviousness of the mental symptoms disappears, of course, most of the social danger; for it is easy enough to have committed a person who exposes his person, steals openly and recklessly, proclaims from the housetops that he is King Solomon, and writes strangers checks for a million dollars. Such a man is quickly deprived of his power to do harm by the courts. But his legal sterilization often comes too late to prevent polygamous marriages, sexual crimes, and the squandering of patrimony. The members of the family of the unfortunate paretic then inquire-and inquire with some show of right-why they were not warned in time. This is the question the family physician has to answer, and it is one whose necessity he could, as a rule, prevent by the use of a little diagnostic acumen.

THE AGE OF PARESIS

Surgeons in general and gynæcologists in particular are fond of speaking of the fifth and sixth decade of life as the "cancer age." Any tumor-like formation occurring during these years is looked upon with suspicion and must be differentially excluded from a malignant neoplasm. As the vast majority of cases of general paresis occur between the ages of thirty and fifty, why not call this period the "age of paresis"? Why not have stored away in the mental room, probably occupied by far less important details, this generality: "Any mental disorder beginning between the ages of thirty and fifty may paresis"? Of course, this is only a generality for diagnostic convenience, and as such has its limitations. Many cases of general paresis do not begin until after fifty, and some few under thirty. In dealing with cases under thirty, however, juvenile paresis should be borne in mind, of which condition we shall speak more presently.

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