the crudeness and cursory way in which I have treated the subject, I will close,-adding an urgent solicitation that you will give a remedy which is as powerful as it is harmless, the confidence which it deserves. Certainly the skin, by which we are in close communication with the central nervous system, the heart, and in fact all the internal organs, should never be neglected; and half-hearted care and attention are worse than absolute neglect, because they deceive the physician himself.

ARTICLE XLIII.

OPERATIONS ON THE STOMACH, WITH REPORT OF CASES.

BY JOHN C. MUNRO, M.D.

OF BOSTON.

READ JUNE 7, 1904.

OPERATIONS ON THE STOMACH, WITH

REPORT OF CASES.

THE bulk of the work reported here has been done within the last year by Dr. Bottomley and myself at the Carney Hospital; but I have included all of my own cases of operation upon the stomach from the very first, although the earlier operations were done with much less confidence in technique and with a bad prognosis in many instances. Frequently patients were turned over to surgical care after having tried everything in the way of internal medication, with the feeling in the medical attendant, the surgeon and the patient that the knife was offered as a last resort. The earlier cases were, so to speak, filtered through medical hands. Latterly this has been done away with to a certain extent, because we are able to control our own clinic much more independently and the patients are referred to us directly for the decision whether surgery can offer relief or not. If we did not have the convincing end results of surgeons of large experience, like Mayo, Mikulicz, Robson and others, I should hesitate strongly about reporting so many recent cases. We do know, however, from the experience of these surgeons, that in cases of chronic ulcer, mechanical stasis and cancer, operation offers the best outlook at the minimum expense, and I feel confident that a good proportion of our temporary successes will abide, provided we have utilized properly the technique that has proven of benefit up to the present time. Time is necessary to establish the value of any method of treatment, and

in the earlier applications over enthusiasm and ill-trained judgment serve to weaken the virtues of any form of therapeutics. We must be willing to modify and change our surgical treatment of ulcers, dilatations and carcinomata of the stomach as the need is demonstrated. But meanwhile surgeons must continue sifting and rejecting, reporting and analyzing their failures as well as successes, just as they still do with their cases of appendicitis, gall stones, hypertrophied prostates, etc.

Last year, in a short plea made before the Medical Section of this Society, I begged that there should be a closer co-operation between the medical attendant and the surgeon, early in the progress of these cases; that for the patient's benefit, if for nothing else, he should be allowed to have an opinion from the surgical point of view. I am happy to state that I believe this plea has borne fruit in spite of the fact that our malignant cases still come too late for anything more than temporary relief.

I do not feel that surgery, or at least my surgery, has more than begun to solve the problem in the treatment of stomach diseases, and a perusal of my cases will convince you that there is much that has discouraged me throughout; but I believe a closer analysis will not place the odium for all our failures at the surgical door. In reporting the unsatisfactory results I have attempted as impartially as possible to fix the blame - if the term is not too harshwhere it belongs, whether on my own shoulders or those of the reluctant medical attendant, or on the attitude of the laity in general towards seeking surgical relief. In spite of a case now and then that does not prove as satisfactory as we should like, both Dr. Bottomley and I feel that we are steadily nearing the point where we can judge what cases are to be discouraged as useless surgical risks, and what cases can be assured of temporary or permanent relief. The risk from operation is lessening with experience and