tion, with the tendency to acute exacerbations, and along with this the resort by so many of the laity to the widely advertised proprietary medicines for the relief of the distress incident to the above symptom (for the term 'indigestion' as usually used really is.)

We find patients floating from one medical man to another for treatment for these conditions and during the intermissions between such consultations trying all the recommendations of friends, and the glowing reports of cures by nostrums cause these sufferers to be ever adding to the profits of the nostrum venders. Perhaps no class of remedies enjoy such sale as those prepared for the relief of "stomach, intestinal and liver disorders."

Why is this and why are we often unable to give our patients more than temporary relief and then he seeks someone else or tries some or all of the many pathies that cater to chronic cases? I venture to say that the medical profession is often at fault for this condition of affairs, not only in this class of cases, but also in other diseases ammenable to treatment and perhaps cure. I say at fault, for how many are in the habit of simply prescribing a stomach tonic, a digestive and caution as to diet-the latter too often not heededand usher the patient out without digging down to the fundamental cause of the digestive symptoms which are many times deep seated and of long standing, but may be in the incipiency or entirely reflex in the stomach from causes remote from it.

This is not said with the intention of sermonizing, but rather with the idea in view of urging the more thorough study of all chronic conditions or incipient ones before they become chronic. There is no reason why so many should be going to the larger cities to consult men following special branches if every man would endeavor to make a complete and thorough diagnosis of his cases. We all have at our disposal the modern methods of accomplishing this end and do we not often neglect to make use of them.

It is well known that there are four or five conditions which underlie these digestive derangements, namely-gastric ulcer, duodenal ulcer, chronic appendicitis, gall bladder troubles, and chronic constipation (which latter may be due to some organic disease or deflection of the intestinal tract.)

Indiscretion in eating and drinking is perhaps responsible for many of these symptoms, but it is also many times the cause of the more serious underlying disease. Then again the frequency with which malignancy is the sequlae of some of the above mentioned diseases, if not relieved, should be sufficient reason for a thorough study of all cases presenting themselves to ascertain whether we have a simple or some deep seated and perhaps serious trouble to deal with.

With this end in view I beg to bring before you a brief study

of duodenal ulcer which is perhaps of more frequent occurance than is generally believed.

Etiology: There are many cases of duodenal ulcer as well as gastric in which the cause is not determinable, but both present similar etiological factors; namely, conditions producing hyperchlohydria and the resulting erosion by the irritating gastric juice. When we remember that acid gastric contents pass into the alkaline medium in the duodenum and are there neutralized and finally made alkaline it is evident that the more acid the former the more difficult and prolonged the accomplishment of the latter with the consequent irritation. The hyperacidity is so often due to indescretions in diet and the stimulation of gastric secretions by highly seasoned foods and the injuditious use of alcoholic beverages.

Burns of the abdomen, feezing, erysipelas and septicemia are among the etilogical factors. These conditions producing a lowered vitality predispose the mucous membrane to irritation from gastric juice. Direct local infection from acute infections elsewhere in the system seems also to be a plausible argument.

Pathology: The result, regardless of the cause, however, is the same-a punched out funnel shaped ulcer, usually single, though sometimes multiple or accompanied by gastric ulcer, extending down through the submucousa and muscular layer, and still more frequently than when in the stomach perforating, with the result of producing either adhesions to adjacent viscera or general peritonitis. Duodenal ulcer when it heals is likely to produce more serious results from scar formation than when situated in any part of the stomach, other than the pylorus, because the duodenum is of so much smaller calibre that obstruction of the lumen more certainly follows cicatricial contraction. This emphasises the possible continued gastric disturbances from motor causes even if the classical course of ulcer as formerly taught did not go on to hemorrhage, perforation and resulting infection of adjacent structures. With modern means of determining its course we are led to believe that many of the ulcers heal with resulting cicatriziation and more or less obstruction to the outlet of the stomach.

This resulting obstruction would seem to suggest the reason for so many dilated stomachs that are diagnosed and reported in literature as well as the many cases of so-called fermentative dyspepsia and numerous cases in which gaseous eructation is a prominent symptom, many of these conditions existing seemingly regardless of the form of diet.

This leads to the belief that duodenal ulcer or ulcer of the very proximal end of the pylorus is of more frequent occurance than is generally supposed. The classical symptoms are not always present, the ulcer having been of a simple type and having healed leaving a

cicatricial mechanical obstruction with the above mentioned resulting pathology.

Peptic or round ulcer of the duodenum is less frequent than gastric ulcer and is still more likely than the former to run a latent course until hemorrhage or even perforation and its sequences call attention to it. The general consensus of opinion seems to be that duodenal ulcer occurs about the proportion of one to ten of gastric ulcer, but as has been suggested with more improved methods of diagnosis and a careful study of these cases, it would seem that it is more frequent than this. Mayo recently states that it occurs in the proportion of one to three or four.

It occurs more frequently in men than in women and between the ages of 20 and 60 years. It not only tends to run a more latent course than gastric ulcer, but also is more refractory to treatment and has a greater tendency to perforate, and as has been outlined above to cause obstruction, and is in consequence of these tendencies a more dangerous disease. It may occur in infancy while gastric ulcer is seldom seen before the age of ten years.

Its site is most frequent at the upper end of the duodenum between the pylorus and the common bile duct. Generally it is quite close to the pylorus, though it sometimes appears lower down, and exceptionally may be found in any part of the duodenum, or even in the upper part of the jejunum. It varies in size from that of a pea to that of a twenty-five cent piece, or even larger in exceptional cases.

Symptoms: In this connection will be considered also the pathological findings in the blood, stomach contents and stools which of course in addition to constituting the pathology of the disease are prominent symptoms in diagnosis.

Clinically there may be nothing of note until hemorrhage suddenly occurs which may be more or less severe, but by careful investigation it will very frequently be found that the patient has suffered more or less from so-called indigestion or discomfort sometime after eating which has not been of sufficient note to cause him to seek medical aid or else he has been using cathartics or digestives on his own initiative for its relief.

The symptoms may be similar to gastric ulcer, namely burning or boring pain with circumscribed tender spots.

The symptoms when present are a burning, boring pain in the epigastrium to the right of the median line about two fingers breadths below the free border of the ribs, and may radiate upward or downward and not usually through to the back. This pain and discomfort does not usually occur immediately after taking food, but rather some two to four hours afterward, and sometimes even six hours; that is, until the contents of the stomach at the termination

of peptic digestion have all passed into the doudenum. This pain is not increased by taking food or alcholic drinks as in gastric ulcer, but is more apt to be relieved by them. There is tenderness, usually on pressure almost uniformly felt to the right of the median line near the lower border of the liver or a little lower down in the right hypochondrium. However, the site of the ulcer being near the pylorus and the latter not infrequently being displaced downward the location of the tenderness may be displaced accordingly.

The above symptoms are contrasted with gastric ulcer; in the case of the latter the pain usually occurs immediately or soon after taking food and is aggravated by additional food, and the location. of the pain is usually to the left of the median line with the tenderness directly over the epigastrium and extending through to the back with tender spots over the attachment of the last two ribs.

Hemorrhage when it occurs in duodenal ulcer, if it is vomited, there is also some appears more or less simultaneously in the stool, either fresh or slightly changed or in the form of melena. In contrast to this with gastric ulcer the blood is all vomited and none appears in the stool. It may be, however, and frequently it is so, that blood appears in the stool and is never vomited. In fact blood in the stool may not appear on macroscopical examination and yet under the microscope it is found to be present. Some authors hold that blood is always present in the stool in doudenal ulcer even if it be in only minute quantities.

Another feature of the hemorrhage in these cases is that when hematemesis occurs the vomitus will, at first, consist of nothing but food remains or chyme and then later the blood will come up possibly mixed with bile; while in gastric ulcer the blood is likely to come up all at once with the food just taken. This is an important diagnostic point. The hemorrhage may be moderate and recurrent or may be sufficient to cause collapse or sudden death.

Those cases which have existed without prominent clinical symptoms are the ones most likely to experience sudden and severe hemorrhage while those that have had long continued symptoms with occasional signs of blood are less apt to have severe bleeding. Occasional tarry stools following the characteristic pain and distress is quite if not prominently suggestive of duodenal ulcer.

The examination of the test meal in duodenal ulcer is not as helpful as in gastric ulcer. In the latter hyperchlohydria is characteristic while with the former it may exist or there may be hypochlohydria. It is quite possible that when there is an excess of free hydrochloric acid in the case of duodenal ulcer there may be co-existing pyloric ulcer. Mayo points out that the laboratory findings as regards the free acid. in the stomach contents in cases of duodenal ulcer is not reliable.

The blood: This is extremely variable and it is not always evident.

what conclusions to draw from the examination. Some cases appear to have suffered no permanent change in the composition of the blood but from their anemic appearance it is probable that the total volume of the blood has been reduced without marked alteration in its quality.

The usual state of the blood, however, is one of marked secondary chlorotic anemia, with little or no leucocytosis. While the degeneration of the blood after hemorrhage is often very rapid it seldom is complete and there seems to be some influence, possibly found in the diminished digestive power in the stomach, which causes the anemia to persist.

Where severe hemorrhage has taken place the blood furnishes a marked example of post-hemorrhagic anemia. Those who survive this ordeal show as low as 1,000,000 R.B.C. with low Hb. index. Cases in which no marked hemorrhage has taken place, but the R.B.C. is down to 3,000,000 have usually suffered from slow bleeding or hemorrhages which have passed unnoticed. Grawitz reports one case with R.B.C. 400,000.

Leucocytosis of moderate grade is usually present especially if hemorrhage has taken place. In quiesent cases with rectal feeding there is usually a slight leucopenia, but the resumption of stomach feeding will usually excite a leucocytosis, Cabot reporting a case in which the first stomach meal raised the white blood count from 4,000 to 15,000.

Constipation may exist in those cases, but not sufficiently frequent to be characteristic. Jaundice is rare, but when it does occur it is very significant as to the location of the ulcer.

Boas has pointed out that it is sometimes difficult clinically to diagnose between duodenal ulcer and hyperchlohydria per se. The pain in both occuring two to four hours after a meal and he states that only by treatment with rest in bed and rectal feeding can a differentiation be made. In case the patient does not improve with the treatment and diet for hyperchlohydria he then suggests the treatment of duodenal ulcer.

Duodenal ulcer must also be differentiated from tabetic crises, gall stones, and cancer. In tabes the pain has no relation with taking of food, there is no tenderness and other characteristic symptoms are usually present. The attacks of gall stone colic and its occurance regardless of food present with the possible jaundice and other characteristics of its course should not be difficult to discern.

As has been suggested above, however, there are many times that a differentiation cannot be made clinically, but with the advent of Roentgenology and the improved recent technique in the examination of the stomach and intestines we have a method that is approaching infalibility in the examination and diagnosis of maladies of these viscera.