could be done. Everyone knows that then there is little hope from operative intervention. There has been in the past too much of waiting and too great attention given to the apparent importance of frequent examinations into the chemistry of the stomach contents, and not enough of surgery. What is wanted is not a better surgical technic, but a knowledge of the fact that carcinoma of the stomach is primarily limited to a small area which may ordinarily be easily removed. More frequent exploratory operations are wanted for the purpose of diagnosis and less of diagnostic niceties in the way of chemical analysis, unusual symptoms and the waiting for a neoplasm. It is stated by Hemmeter that it is better to make an occasional exploratory operation and find that the patient is not suffering from carcinoma of the stomach than to allow a case to go without surgical interference and find at the autopsy that the patient had been suffering from a well-circumscribed tumor that could have been readily removed. Hemmeter advises operations under the following conditions: Ist. When dilatation is associated with cachexia. 2nd. The absence of HCL in the gastric contents. 3rd. Excessive lactic acid and 4th. The presence of Oppler-Boas bacillus. Keene adds the following: 5th. When the age of the patient is over forty years. 6th. When hæmatemesis is present and 7th. When an examination of blood shows a diminution of red blood corpuscles and hæmoglobin and when digestive leucocytosis is absent.

'Symptoms of stenosis when accompanied by these signs. are held as indicating an operation even in the absence of a palpable tumor. Hemmeter says he personally always urges operations when the first three conditions are persistently present and the case does not improve after three weeks of appropriate treatment.

I am forced to believe that should the surgeon wait in every case until the above seven indications are present not a single case of carcinoma of the stomach would be operated successfully. I have very serious objections to the first indi

cation, that is, before advising operation one should wait for dilatation of the stomach and cachexia. Dilatation of the stomach is not effected until pyloric stenosis occurs, and I have opened the abdomen in a goodly number of cases in which a tumor of the stomach as large as a cocoanut was encountered without the organ being dilated to any appreciable degree.

Lines of excision practised by different surgeons. 1. Hartmann. 2. Mikulicz. 3. Robson, Moynihan, Mayo.

But I make more serious objection to the cachexia, as firmly believe that every case of carcinoma in which there is a decided cachexia is already beyond the stage for successful operative treatment no matter where situated. A cancerous cachexia, as previously stated, is an expression of systemic poisoning and when well-marked is, in my opinion, an absolute contra-indication for operative treatment.

I would suggest the following indications for exploratory incision in cases of suspected carcinoma:

Ist. A patient usually past forty years of age.

2nd. Distress and pain in the stomach which is not relieved in three weeks by proper diet and medication. 3rd. The absence of HCL in the gastric contents and

tate very long in the absence of any one of these conditions if the others were present and the symptoms and history were indicative of carcinoma.

Cases Suitable for Resection.

Atypical Pylorectomy.This class represents those growths irrespective of size situated to the left of line 3 (Fig. 2) in which there are no distant metastases and few if any adhesions to adjacent organs.

The operative technic here is to tie off the gastro-colic and remove after ligation the gastro-hepatic omentum. That portion of the stomach is removed to the right of a perpendicular line placed at the left extremity of the lesser curvature. The stomach and duodenum are clamped at least three-quarters of an inch from the proposed line of incision, which, if possible, should not be less than one-half an inch outside of the limit of the apparent carcinomatous infiltration. The portion to be removed is then excised and the duodenum and stomach closed separately by three rows of continuous suture, the first of which rolls in the mucous membrane, the second, the muscularis, and the third approximates the surfaces of the

PERU

Fig. 4.

The Continuous Cushing Suture.

peritoneum. An anastomosis is then made between the jejunum and the anterior wall of the fundus of the stomach near its lower portion. Caremust be taken in this anastomosis that there is no undue traction upon the jejunum and that it is given a half turn to the right so that the peristaltic wave of the stomach will correspond to that of the small intestine. (Fig. 3.)

The stomach and jejunum are brought out of the wound and united as follows: They are approximated and held. ogether by two traction sutures, the peritoneal cavity, having been well protected from infection by gauze packing. An incision an inch or half long is then made through the peritoneum of the intestine directly opposite its mesenteric attachment and one of corresponding length through the peri

toneum covering the stomach near its lower border. A continuous Cushing suture including the peritoneum and getting a good hold upon the muscularis is then made to unite the surfaces below the two incisions. (Figs. 4 and 5.) The cuts are then extended directly into the lumen of the bowel and stomach and the approximating surfaces united by a continous overhand

A

C.G.W.

Fig. 5.

The First Suture in an Anastomosis.

suture which includes all of the coats. (Fig. 6.) The two widely separated sides of the opening, the lower border of the intestinal and the upper border of the opening in the stomach, are then united by a continuous suture which commences at one extremity and is made to penetrate from without inwards and then from within outwards. The anastomosis is completed by applying a Cushing suture above cor