The

bent position and a towel to his mouth, the organ is inflated with air. A stethoscope applied to the epigastrium will detect the metallic sound of the valve in the bulb, transmitted by the air, in the stomach when the bell of the stethoscope is held over the stomach, and as soon as it is moved below the stomach the sound is lost. In this way the outlines of the stomach can be accurately determined and mapped out with a wet blue pencil. air can be gently forced out when the experiment is finished. These two simple tests comprise all that is necessary, and can be employed by every practitioner without elaborate apparatus and laboratory facilities. Broadly speaking, excess of HCL is indicative of ulcer, and dilatation of the stomach considerably below the umbilicus, if the lesser curvature retains its relation to the diaphragm, most often means an obstructed pylorus, caused most frequently by the contraction of a healed ulcer, or from a constricting or stenosing cariconoma. Three-fourths of the gastric ulcers occur in the pyloric region, and it is also the most frequent site for cancer.

The history of the case is given prime consideration in the Mayo examining room. The vomiting, hematemesis and melena, with local tenderness over the ulcer, and excess of HCL, comprise the rather pathognomonic symptom-complex of acute ulcer which is so often found in chlorotic girls, and when occurring in middle age, so often terminates life by perforation and hemorrhage. Acute ulcer in all cases, and especially in chlorotic girls, is not operated except for complications, hemorrhage, and perforation. Chronic ulceration is not so clear cut and easy of diagnosis.

The most conspicuous symptom is pain after eating. It is most often referred to as a burning pain, or of a boring character. There is more or less tenderness in the epigastrium, but the pressure points of acute ulcer are not so uniformly present. The Mayos attribute much importance to the pain occurring in "spells," being off and on for days or weeks at a time, and succeeded by periods of comparative health, lasting some weeks or months. Vomiting is rare unless there is obstruction. It is not wise to throw out chronic gastric ulcer because of the absence of hemorrhage. It is not often present, and even when it is present sufficiently to cause anemia, it may not be in appreciable quantity

FIG. 4.- Showing closure of cut duodenal end by circular suture and first row of sutures being

PARTIAL GASTRECTOMY.

in vomitus or stool. Bloating is common and quite painful. Mayo believes this to be an important diagnostic sign which is rarely absent during the height of the pain. When pyloric obstruction is present, dilatation is the rule, retention and stagnation of food, late vomiting, sometimes of enormous quantities. The emaciation of this advanced form of starvation is very typi cal. The pallor of the attending anemia distinguishes it from the cachexia of cancer. The late cancer cases have the absence of HCL, and frequently a tumor. These clinicians think the early development of tumor is a fortunate circumstance for cancer victims, because it directs attention to the stomach by the obstruction and attendant symptoms which it occasions, and thus is more likely to be submitted to operation early, while there is still some hope of radical removal and permanent cure. Whereas carcinoma without tumor is not so easily and speedily diagnosed, and tends to go to its inevitable and inoperable doom.

It is strange why cancer of the stomach is still treated medically. They all die. Carcinoma in every other situation is quickly referred to the surgeon, and the permanent cure of carcinoma of the stomach in the future is regarded by Mayo to be equally as good as cancer of the breast. They have rarely had a patient who did not live longer than a year. One lived three years and seven months, and several are alive and well now after two years. Sixteen per cent. of the Mikulicz cases reached the five years period of immunity. This, too, should be possible with American operators and clinicians. Think of the possibilities it offers!

It is purely a diagnostic feat. Unfortunately many cases can not be diagnosed sufficiently early for a radical operation without exploratory incision. It therefore becomes a necessary aid to diagnosis and should be invoked by competent men often in view of the hopelessness by any other known treatment. It may seem heroic to perform an exploratory incision on merely the suspicion of cancer, and patients are supposed to object to it; but the Mayos find that when the matter is fully and frankly laid before the patient, that they rarely decline. Opposition to surgical diagnosis by exploratory incision oftenest comes from the profession, but when we reflect that we have no other positive

means of knowing, and that when all the text-books symptoms and laboratory tests are satisfied that the patient is beyond all hopes of succor, we should lend our insistence to the invocation of this the only dependable resource at our command. It is practically without mortality, and if the cancer is found inoperable from extension or fixation, the short incision can be quickly closed with buried sutures, and the patient allowed to get up and around in a few days, and leave the hospital within a week. But in reality the majority of exploratory incisions, which of course are early and suspected cases, will offer opportunity for the radical operation - pylorectomy (partial gastrectomy) which the — Mayos perform as follows:

A median incision in the epigastrium of four inches gives room for thorough inspection and subsequent manipulation. Carcinoma-site is usually at the pyloric end or along the lesser curvature. The lymph glands run along it in the lesser omentum. The greater curvature is free of glands except at the right end. A section of the cancer-bearing area and glands is comprehended by division well through healthy duodenum and diagonally from left to right, beginning at a point on the lesser curvature a little way from the esophagus. The blood supply, consisting of the four large arteries, is secured by ligatures, and the greater omentum is tied off in sections and cut, thus mobilizing the pylorus. Double clamps are placed on the upper part of the duodenum, which is cut between. A continuous chromic catgut closes the cut end of the duodenum, which is invaginated by a sero-muscular purse-string-suture of Pagenstecher linen. The gastro-hepatic omentum is then tied in sections and severed. Two long Kocher stomach clamps are placed diagonally distal to the malignant induration at the place elected, and the stomach cut across between them by a cautery knife. The two margins of the gastric wall are clamped at intervals as the section progresses on both sides, to prevent retraction, and the cut edge of the small dome-shaped cardia to be left is sewed tightly with a lock-stitch of chromic catgut that is hemostatic and water-tight. The seromuscular layer is then closed over the seam by one or two rows of a running Cushing suture of linen. A communication is then made between the smaller stomach pouch thus closed and