rule, it may be stated that the nearer the pylorus and the larger the opening, the more rapidly does the stomach empty. In every case the stomach emptied itself more quickly than is the case in a normal stomach. It is for this all-important reason that the impressions gained were that a gastroenterostomy is a drainage operation. In eleven of our cases the fluoroscopic observations regarding the motility were made previous to operation, and in every instance the operation showed shorter emptying time. It has been claimed by some writers, notably Patterson, that the good effects of gastroenterostomy are due to chemical changes in the gastric secretions, that there is lessened hyperacidity, due to the presence of bile and pancreatic juices in the stomach. It is probable that both the drainage factor and the chemical changes are responsible for the cures of gastric and duodenal ulcers after gastroenterostomy. CONCLUSIONS. 1. That all patients examined in this series were uniformly well. 2. That gastroenterostomy openings properly made and placed do not obliterate. 3. That the gastroenterostomy openings functionate equally as well as in the presence of either an open or closed pylorus. 4. That it is not necessary to artificially occlude the pylorus in gastroenterostomy. 5. That the gastroenterostomy opening to secure the maximum amount of drainage must be of ample size and placed as near the pylorus as possible, preferably in the antrum pylori. Such openings must not be made on the fundus of the stomach nor on the lesser curvature. 6. That gastroenterostomy is essentially a drainage operation. 7. That serious distention in the jejunum does not occur after gastroenterostomy, the food is seen to pass rapidly through the many loops of the small intestine before it finally stops. Even in those patients who are entirely relieved of their former symptoms food can be forced backward into the stomach from the jejunum, and although this can be done easily, such regurgitations do not seem to make any difference. BIBLIOGRAPHY. 1. Cannon and Blake. Annals of Surgery, 1905, pp. 686-711. W. B. Cannon. The Mechanical Factors of Digestion, 1911, Longamen Green Co., N. Y. 2. Pers, A. Method of Action of Gastroenterostomy. Nordisches Med. Archiv (Stockholm), Dec., 1909, xlii, Part 1, Chirurgie, 1-15. 3. Ribas, T., Ribas, E. (Barcelona); The Motility of the Stomach after Gastroenterostomy. Archives of the Röntgen Ray, 1910-1911, XV, 283. 4. Schuller L. Clinical and Experimental Researches on the Functioning of the Stomach after Gastroenterostomy and Pylorectomy. Mitteil. a. d. Grenzgeb. d. Med. u. Chir., 1911, xxii, 715-770. 5. Hartel. Gastroenterostomy and Radiography. Deutsche Zeitsch. f. Chir., 1911, cix, 317, 395.. 6. Caillé, Durand and Marré. Immediate and Ultimate Results in Forty-five Cases of Gastric or Duodenal Ulcer. Arch. des mal. de l'appareil digestiv, 1912, vl, 361-402. 7. Hesse. Radiologic Study of Gastroenterostomy. Zeitsch. für Röntgenkunde, 1912, xiv, 153-178 and 195-227. 8. Zweig. The Bad Results of Gastroenterostomy for Stenosis due to Spasmodic Closure of the Gastric Opening. Archiv f. Verdauungskrankh., 1913, xix, 740. 9. Mathieu A. and Savignac, R. Study on Intestinal Disturbances Consecutive to Gastroenterostomy. Arch. d. mal. de l'appareil digestiv, 1913, vll, p. 541-581. 10. Hertz, A. F. The Cause and Treatment of Certain Unfavorable After-effects of Gastroenterostomy. Ann. of Surg., 1913, lviii, 466. 11. Mallory, W. J. Gastric Hypertony and Gastroenterostomy. Jour. Am. Med. Assn., 1914, lxii, 1883. 12. Mayo, C. H. Causes of Failure in Gastroenterostomy. Collected Reports, Mayo Clinic, vi, 1914, 97. 13. Hartman, H. On the Functioning of the Gastrointestinal Orifice in the Case of Permeable Pylorus. Bull. et mem. Soc. de Chir. de Par., 1914, xl, 798-804; also, Annals of Surgery, 1914, vol. lix, pp. 832-841. 14. Case, J. T. Röntgen Studies after Gastric and Intestinal Operations. Jour. Amer. Med. Assn., 1915, lxv, 1628. ADDITIONAL BIBLIOGRAPHY. Legueu. Bull. et mem. Soc. de Chir. Par., 1908, 156. Tuffier. Bull. et. mem. Soc. de Chir. Par., 1907, 463. Jaboulay. Lyon med., 1908, cx, 1328. Mathieu. Bull. et mem. Soc. de Chir. Par., 1910, 1028. Guibe. Jour. de Chir., 1908, i, 1. VALUE OF PAIN, JAUNDICE, AND TUMOR MASS IN ABDOMEN.* BY J. D. S. DAVIS, M. D., F. A. C. S., Birmingham, Ala. IN differentiating the various diseases of the upper right quadrant of the abdomen, pain, jaundice, and tumor mass are the most frequent and striking symptoms, each of which is of great value in the conditions in which each one occurs, if the peculiarities and characteristics common to each condition are kept in mind. A diagnosis may be based on a proper interpretation of these symptoms. Upon the correctness of the observations of the symptoms depends the accuracy of the diagnosis. If the observations are correct, the diagnosis will be correct; if the observations are wrong, the diagnosis will be wrong. It will be seen that pain, jaundice, and tumor mass-especially the first and last are the most important determining factors in a differential diagnosis of diseases of the right upper quadrant. While I do not exclude other factors in making a differential diagnosis, the characteristic pain and tumor mass are the most important factors in the differentiation, certain lesions are often so situated and so obscured that a diagnosis is difficult-often impossible. There is no field in the domain of surgery where it is more important to place a proper valuation upon the patient's history, subjective symptoms, and the laboratory findings than in diseases of the right upper quadrant. To differentiate the diseases in the right upper quadrant of the abdomen, it is necessary to differentiate the most important inflammatory and obstructive conditions producing pain, jaundice or tumor mass that affect the pyloric end of the stomach, pancreas, duodenum, liver, gall-bladder, bile ducts, kidney and appendix. The diseases affecting these organs are usually referred to individually and separately. They are not often treated as a group of organs whose diseases present a symptomatology very closely related. * Read before the Twenty-ninth Annual Meeting of the American Association of Obstetricians and Gynecologists at Indianapolis, Ind., September, 1916. These organs are at times closely situated, instead of being a good distance apart, as shown by their anatomical relation. The usual symptoms of peptic ulcer are pain, vomiting, and hemorrhage, the most important of which is pain. Pain is the earliest definite symptom which is usually aggravated by large amounts of food and often relieved by small amounts. Pain may come on during the ingestion of food, but more frequently it comes on a few hours after meals and at night. Gastric ulcers are often characterized by periods of long remission. Intermittency takes place for long periods of time, during which the patient often believes himself well; then, without apparent cause, he finds that he has a return of the old trouble. Pain is more constant than vomiting; it usually precedes vomiting and is often relieved by vomiting. Gastric analysis is important in working up these cases. If the gastric contents is more than 100 c.c., it is abnormal and indicates hypersecretion, spasm, and pyloric obstruction. The contents should be tested for continued hypersecretion and acidity. "About 70 per cent. show a hyperacidity; a few show a normal acidity; about 5 per cent. show a hypoacidity, and a few show lactic acid." Occult blood will be found in a large per cent. of ulcer and is of great value in the diagnosis. Friedenwald says that the occasional presence of occult blood in the stool is suggestive of ulcer, but its continued presence from day to day is suggestive of carcinoma. The x-ray examination will often be a helpful aid in determining the presence of peptic ulcer. Much valuable information may be secured by the röntgenologist, many of whom claim to diagnosticate 75 per cent. of ulcers. Peptic ulcer diagnosis is usually based upon the presence of localized pain, followed by vomiting, frequent presence of occult blood in gastric contents or stools, hypersecretion, increased amount of gastric contents, reliable findings with the x-ray, and often a history of an old irritated dyspepsia. Hemorrhagic pancreatitis is sudden and violent in onset. It is characterized by excruciating, deep-seated pain usually in the epigastrium or between the xiphoid and umbilicus, associated with. severe nausea and vomiting, hiccough, constipation, and albuminuria frequently results, if patient does not die in speedy collapse. Acute suppurative pancreatitis usually begins suddenly with severe epigastric pain, vomiting, hiccough, chills, an irregular pyemic temperature, and progressive tympanites. Prostration is usually great. In pancreatic calculi paroxysms of pain may be due to the impac |