Shows completed operation resulting in enlargement of the pyloric orifice. chemical examination of the test meal has been proven by Mayo to be of less significance than was accorded it by for

mer authorities. The present conclusions are that high value are-that of acidity points to ulcer and low value to cancer.

The prognosis, in malignant diseases of the stomach and duodenum, is unfavorable, except in cases having the benefit of early operation. The duration of the disease depends, in some respects, upon the situation of the neoplasm, which causes more disturbances and more rapid death when occupying and occluding the cardiac or pyloric orifices. The character of the growth is a factor in prognosis; for instance, the medullary form develops very rapidly. The complications which arise, either from ulceration, hæmorrhage, or from cancerous metastasis, influence the case unfavorably.

The treatment of these diseases has, until quite recently, been confined to careful dieting and prescribing of internal medicines. These methods have signally failed to establish permanent cures. The majority of cases are chronic in character, running a protracted course, during which the patient passes through dangerous crises, wherein life may be sacrificed by the numerous, intercurrent complications which often arise. By early operative interference we can permanently relieve these patients, by removing the irritation, when the ulcers rapidly heal, and subsequent relapses will not follow. In the minority of cases the symptoms will not be sufficiently pronounced to make a positive diagnosis, as there are some cases wherein pain and tenderness over the epigastrium are the only indications, unless rigid examination of the fæces is carried out when blood may be detected. In these obscure cases the diagnosis rests between stomach or duodenal ulcer, and gallbladder or pancreatic disease. When such is the case there is only one course to pursue-namely, exploratory incision through the upper portion of the right rectus muscle, one inch to the right of the median line. This incision will bring into view the stomach, duodenum, gall-bladder, or pancreas, when proper surgical procedures can be carried out.

If the ulcers are near the pylorus, either in the stomach or duodenum, Finney's operation (Figs. 1, 2 and 3), by enlarging the pylorus, prevents further irritation of the ulcerated areas, and a permanent cure will be accomplished.

When ulceration occurs in other portions than the pyloric orifice, other measures are found necessary to remove the irri

tation of the affected areas. In many of these cases the stomach is not properly emptied; relief will not follow, unless complete drainage of the stomach contents is secured, in conjunction with the removal of the source of irritation. The most successful means of obtaining relief is by the performance of gastro-enterostomy, wherein the jejunum is attached to the lower border of the stomach.

The successful treatment of carcinoma of the stomach depends upon early diagnosis and prompt surgical interference. When malignancy is recognized in its early stages, the affected area can be satisfactorily removed, thereby securing a large percentage of cures. The operation consists of complete removal of the growth and nearby glands, subjected to possible contamination.

SURGERY OF THE GALL-BLADDER AND DUCTS.

BY J. EMMONS BRIGGS, M.D., BOSTON, MASS.

(Read before Surgical and Gynecological Society of the American Institute of Homœopathy.)

THE presence of calculi in the gall-bladder is exceedingly common in persons past middle life; is said to occur once in six persons after 60 years of age, yet is comparatively rare for them to give rise to symptoms, and may not be detected until discovered in the course of abdominal operation or at post mortem.

Biliary calculi are made up of cholesterin, bile and lime salts and bile pigments. This much has been known for years, but recent investigation has demonstrated that the true origin of the gall-stone dates from a period of microbian invasion of the gall-bladder. This involvement may have been so insignificant as to occasion few, if any, symptoms, but the presence of bacilli within the gall-bladder, and the pathological changes they produce, are nevertheless positive factors in cholelithiasis.

An evidence of the presence of bacteria in the gall-bladder during the early stages of calculus formation is the demonstration, notably, of the colon bacillus in the interior of the biliary calculus. Here is a proof of their presence while the concretion was in its infancy which is as conclusive as the fossils found in rocks are evidences of prehistoric life.

All infected elements may have disappeared from the gallbladder before the calculi caused trouble in it, or in their passage through the ducts.

The common duct opens into the duodenum, bifurcates into the cystic and hepatic ducts, at its upper end. There is practically nothing to prevent bacilli, which are inhabitants of the alimentary canal, from working their way up the ducts, except that they are opposed by a current of bile which continuously forces them backward.

Any changes or alterations in the mucous membrane of the ducts provide a favorable soil for the implantation of septic micro-organisms and facilitate extension of the septic processes.

With the gall-bladder filled with calculi, with frequent descents of one or more of these through the ducts, and the traumatism attendant thereon, with the terminus of the duct always teeming with thousands of pathogenic and pyogenic bacteria, it is easy to understand that the contents of the gall-bladder in cases of biliary lithiasis is frequently septic.

Again, it will be easy to comprehend that any condition which would hinder the flow of bile, either in the mode of life, dress or food, would tend to promote infection of the gall-bladder, which, as we have already said, will favor the formation of biliary calculi and, as we shall demonstrate later, be a causative factor in cholecystitis.

Biliary calculi, as we have previously explained, may be present in the gall-bladder and occasion no symptoms whatever, but when they become engaged in the ducts will produce symptoms known as gall-stone colic; and if they become impacted in the cystic, common or hepatic ducts occasion grave and often fatal consequences.

The time is ripe for us to consider all cases of appendicitis as surgical, i.e., they should be watched and cared for under surgical supervision; not that every case shall invariably be operated upon as soon as seen, but the patient should be observed with an eye single to the most propitious opportunity for surgical interference. Years of successful operations, with exceedingly low death-rate, and freedom from unfavorable sequelæ, have convinced surgeons, family physicians and the laity of the wisdom of surgical interference.

In cases of biliary calculus, surgeons have only recently

warmly advocated operative measures. General practitioners still incline to medical treatment, and the layman knows little of the surgery of the gall-bladder and follows the advice of the attending physician.

The profession to-day recognizes that there is a distinct field for both medicine and surgery in the treatment of gallstones. The question to-day is, what cases shall be treated medically and what demand surgical interference? In the writer's opinion, all cases of cholecystitic pain and those characterized by attacks of colic lasting a moderate length of time, unaccompanied by fever, should be treated medically.

Surgical treatment is demanded without delay in all acutely septic conditions of the gall-bladder and ducts, in septic cholecystitis, hydrops, empyema, gangrene, perforation, diffuse peritonitis, and abscess of the liver. Surgical treatment is advisable in patients suffering from oft-repeated attacks of colic, even without fever, if the attacks come so frequently that the general health is impaired or the patient's vocation interfered with; also after any attack which was attended with distention of the gallbladder and fever.

A gall-bladder which can be palpated and is sensitive will demand operation during attack if it is severe enough, or after the cessation of symptoms in order to prevent repetition.

When to Operate.-Operations upon the gall-bladder in point of urgency rarely compare with those on the appendix vermiformis. It is generally acknowledged that it is safer to perform appendectomy during an interval than in the course of an acute attack, but in appendicitis the danger in tiding the patient over is so great that a sweeping rule to operate every case as soon as diagnosis is made would lower the death-rate.

In considering the time for operating upon gall-stones the interval operation is again the safer, and we have not so serious a menace in the inflamed gall-bladder.

The walls of the gall-bladder are composed of muscular and elastic tissue, which readily distends. Its wall thickens and rarely ruptures. Distention to the capacity of a pint is frequent. Only in cases of advancing sepsis and extreme distention is there a demand for immediate operation.

It is generally safer in cholelithiasis to undertake operation during a quiescent period-where the mortality is low. An