of the pylorus which proved to be carcinoma of that portion of the stomach, involving the gall-bladder and duodenum, forming complete obstruction. Gastroenterostomy and enteroenterostomy were performed, the patient dying on the following day, probably from shock. This and the preceding case are the only ones in which deaths occurred in the entire list of gastroenterostomies.

Case XIV-John C. This patient underwent operation in December, 1902, for the relief of symptoms due to dilated stomach. His weight had fallen from one hundred twenty-five to seventy-eight pounds. A gastroenterostomy with enteroenterostomy was performed by the McGraw method. The patient recovered rapidly.

Case XV.-A male, aged forty-eight years; a salesman. He had had poor digestion and other marked symptoms of dilation of the stomach. Just above and to the left of the umbilicus was a small tumor which could be moved up and down but not from side to side. An oblique incision was made exposing the stomach, the pyloric portion of which was much thickened, and there was obstruction in that part of the organ. A growth, undoubtedly cancer, was found on the anterior portion of the stomach. A gastroenterostomy and enteroenterostomy were performed by the McGraw method. The patient nearly died because of obstruction, probably due to swelling about the suture or a kinking of the intestine. Just as I had about determined to open the abdomen a second time the condition righted itself and the patient made a good recovery.

Case XVI-A female, aged forty-three years, entered the hospital because of loss of weight and pain in the stomach. The trouble began about one year ago. The pains would be periodic, with a feeling of heaviness and distress, which was relieved by vomiting. At the time of operation she had lost ninety pounds in weight. A growth, supposed to be carcinoma, was found about two and one-half inches from the pyloric end of the stomach, which completely encircled the organ. In the lesser curvature two masses were found smaller in size but of the same character. The neighboring glands were enlarged and also those of the celiac collection. A gastroenterostomy and enteroenterostomy were made with the McGraw ligature. The patient made an uneventful recovery. Three months after leaving the hospital she wrote that she had gained twenty pounds, was feeling perfectly well and could eat anything.

Case XVII.-A woman, aged fifty-four years. Patient's discomfort began twelve years before her entrance into the hospital. Her weight was much below normal, and she had been told that she had a tumor connected with the stomach. An exploratory incision was made. The exposed stomach showed involvement of the pyloric end, including the peritoneal covering. The lymphatic nodes along both curvatures, as well as the celiac glands, were enlarged. The disease was too far advanced to attempt resection of the stomach. A gastroenterostomy and enteroenterostomy were performed with the McGraw ligature. The patient made a good recovery and when heard from some months later was doing well and able to eat all kinds of food without distress.

Case XVIII-A man, was admitted to the hospital June 22, 1903, because of distress in the stomach, which began a few months before, and was growing rapidly worse. He had lost at least fifty pounds. Little or nothing seemed to pass the pylorus and he had every evidence of rapid starvation. He was so far reduced that he seemed far from being a good subject for operation, but a few days of rectal feeding and washing of the stomach improved his condition. Exploration was advised and accepted. A mass involving the pyloric portion of the stomach and extending about four inches along the lesser curvature was found. The celiac glands were somewhat enlarged but a hope was entertained that it might be due to other causes than extension of malignant disease. The diseased portion was removed with a good margin and the divided parts united with two rows of sutures. The pathologist reported carcinoma. The patient made a good recovery except that he had a phlebitis of the left femoral vein. On December 24, 1903, the patient reported that he was in perfect health.

Case XIX.-A male, was referred from the medical clinic on July 30, 1903, because of pain in the epigastric region, difficulty in swallowing, loss of weight and eructation of gas. This had been rapidly growing worse and he was able to swallow food only at intervals. A diagnosis of carcinoma of the esophagus was made and an operation advised. August I the stomach was exposed and the lower part of the esophagus, together with a large part of the cardiac portion of the stomach, was found invested with cancerous growth. Because of the extent of the growth and the debilitated condition of the patient no attempt was made to overcome the obstruction of the esophagus. It was difficult to obtain a suitable piece of the stomach wall, free from disease, for effecting gastrostomy. This operation was performed, however, and the patient was fed by the opening every two to four hours. He recovered from the surgical procedure, but two weeks later began to show signs of mental disturbance, and at times was quite delirious. He was removed to his home, where he died some months later from extension of the disease.

Case XX.-A resident of this state, aged fifty-four years. Patient's distress began about thirty years ago, when he had a hemorrhage from the stomach. There were long periods of good health, but recently the attacks had become quite frequent. This patient gives a history of ulcers associated with dilatation of the stomach. An operation was advised and accepted. The usual incision was made and the stomach exposed. On the anterior portion of the organ, about three inches from the pylorus, a cicatrized area about one inch in diameter was found involving all of the wall. To the centre of this the omentum was attached as a heavy cord. This was separated. A single lymphatic node was found enlarged; this was removed for microscopic examination. A gastroenterostomy and enteroenterostomy were performed, the McGraw ligature being employed. The patient made a good recovery. Examination of the gland failed to reveal any signs of malignancy.

To these hospital cases I might add two others which were treated in private practice, wherein dilatation of the stomach had reached such a

serious stage that the patients had but a short time to live because of starvation and autoinfection. Gastroenterostomy and enterostomy by the McGraw method gave prompt relief from all symptoms and in both cases the patients gained rapidly in flesh.

These are not selected cases. They were all treated by general practitioners and came to the surgical clinic as a last resort. There were three cases of partial gastrectomy. One of these, who was operated upon four years ago, is alive and well. One operated upon six months ago is enjoying good health at the present time. The other lived fourteen months after operation. There were three gastrostomies, all of the patients having starved to a dangerous condition before operation. One died on the day following surgical procedure. There were five explorations where nothing further was done, all recovering from any ill effects of operation. The subjects all showed advanced carcinoma and any one of them might have been made more comfortable if an earlier diagnosis had been made. There were eleven gastroenterostomies, including two private cases, with two deaths. Seven of these were for obstruction of the pylorus from carcinomatous growth. Four were for dilated stomach. It rests with the general practitioner to advise or discourage the idea of an early exploration and possible operation in these cases. The above record should convince the most skeptical physician that surgery of the stomach is of great value in averting starvation, removing discomfort, and prolonging life, for the following reasons:

(1) The comparative safety in exploratory incisions with the possibility of doing some good.

(2) The low death rate following resection, even when a large portion of the stomach is removed, and the great comfort which follows. (3) Gastroenterostomy has become one of the safest abdominal operations in cases wherein the patient has not been too much reduced by disease and starvation, when any operation of magnitude would be considered unsafe.

The names of these operations have long been known to surgery but recent improvement in technique has given them a new and familiar meaning. Let us not believe that the best results have been obtained, but rather let us look forward to early diagnosis, with removal of malignant conditions, and a complete cure.

COMMENTS NOT FOR CONTROVERSY BUT FOR LIGHT. BY EPHRAIM CUTTER, M. D., NEW YORK.

EMPYEMA TREATMENT.

DOCTOR TRIMBLE, in American Medicine, November 7, 1903, presents an able paper on empyema treatment by rib resection, inaking clear that the drainage resulting is the main element of cure. But would not the same result be attained by a seton between, for example, the fifth and sixth ribs and the ninth and tenth, and not mar the skeleton?

In 1856, just before graduation in medicine, the writer did thoracentesis and removed one and a half gallons of clear serum from a bedrid

den case. This was followed by empyema and death. The autopsy showed the lung bound down to the spine in a bundle of massive fibers, looking like a bologna sausage. Since then he has had considerable experience in thoracentesis.

To show the fallacy of physical signs that seemed indisputable, in the case of a boy, the trocar introduced yielded no fluid. A knitting needle inserted was pushed in to strike the other side of the thorax, but no fluid. sought exit. Two other sites were explored likewise. Patient died. The autopsy showed the lung enlarged with medullary cancer and the outer third of both clavicles congenitally absent. His father's clavicles were likewise absent.

Another case wherein the physical signs were all present no fluid could be procured with the largest canulas. The writer told the assisting faculty that he would perform digital thoracentesis, that is, make an incision parallel to the ribs two inches long in the skin and force his forefinger through the intercostal space into the chest and make an opening large enough for the effusion to exit. This was done. When the finger penetrated it found the periphery of the thorax lined with a velvet carpet that felt as if one and one-fourth inches thick. Some of this removed was a golden yellow color. The pleural effusion was evacuated.

These cases are mentioned to show that the writer knows pleural effusions and to introduce the comment that in later years he has treated cases of empyema successfully simply by giving nature a means of cure, or dynamis, through the mediums of good sound, nonfattily degenerated beef and water as food, on which human life can be sustained in health indefinitely.

A case of pleuritic effusion in the lower third of the right chest existing five years, also with capillary bronchitis and uterine lesion of place, is under his care. The nascent chlorid of ammonia was used for the bronchitis, aristol vectors and replacement treatment for the uterus, and two-thirds animal food to one-third food from the vegetable kingdom-whole wheat mainly-together with a pint of hot water four times a day. The bronchitis was cured, the local lesion relieved, and the last time the patient was seen the respiratory murmur was heard nearly all ever the lower third of right chest and percussion was clear.

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AMERICAN DEMONSTRATION OF THE FORMATION OF RED BLOOD CORPUSCLES IN THE LIVING SPLEEN.

IN American Medicine, November 8, 1903, Doctor E. T. Williams has a paper on this demonstration in blood of dead spleens. It is due to cisatlantic medicine to say that a half century ago my teacher did this in the spleens, living and in situ naturali, of birds, cats, dogs, fishes, horses, opposums, oxen, pigs, raccoons, reptiles and sheep.

The writer has confirmed this formation of the red blood corpuscles in living spleens of frogs and turtles and demonstrated it to others, one of whom is Doctor G. B. Harriman, of Boston, Massachusetts. The human living spleen is yet to be examined. This the writer proposed to do with Guiteau's spleen (the murderer of President Garfield) after his convic

tion, but his proposition was refused. Hence he is in full sympathy with Doctor Williams' plea that this should be done. If all surgeons would promise, as Doctor H. O. Marcy, of Boston, has done, to examine the splenic blood in cases of laparotomy, this would soon be accomplished. The nearest the writer has come to demonstrating the formation of the red blood in man was in the discharge from a lymphatic gland abscess at the angle of the lower jaw of the right side. Quite a number of leukocytes at different times were found with red corpuscles inside.

THREE INTERESTING OPHTHALMIC CASES.

EDWARDS H. PORTER, M. D., TIFFIN, OHIO.

A WELL-PRESERVED, hard-working German, aged seventy-five years, presented himself in July, 1902, giving the following history: He had lost the left eye at the age of ten from a blow and a complete atrophy of the eyeball had been the result. Until two weeks ago the right eye had been perfect, except for the usual presbyopia. While at work in his garden hoeing potatoes, he found a great many potato bugs. One ran over a piece of board that was lying on the ground and he crushed it with his hoe. The juice from the bug flew into his face and hit him in the eye, on the nose and forehead. The bugs were not the common variety, but were the large species, megalosoma.

The accident happened two weeks before he presented himself at my office, during which time he had been under the care of his family physician. There was a very severe conjunctivitis, with corneal ulceration and a marked iridocyclitis. On the tarsal conjunctiva of the upper lid there was an ulcerated patch the size of a pencil head, and wherever the bug juice had come in contact with the skin, there was a large eschar covered by a thick yellow scab. The skin lesion did not heal for over four weeks. Appropriate treatment for the eye was vigorously begun and the symptoms gradually subsided. The eye was well in about six months. At the present writing, October, 1903, the patient has completely regained his vision, and says that he threaded a needle without glasses the other day to see what he could do. The tarsal conjunctiva is still badly scarred and has a hard cicatrix where the ulcer was, and the skin bears the marks of where the poison struck. The juice of the megalosoma is similar to cantharides, and would of course produce disastrous results wherever it touched the skin or mucous membrane.

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A WOMAN brought her little daughter, two years old, to my office, and gave the following history: Two weeks before the mother had missed the child and went to look for her, finding her before a hive of bees. As she ran to her, the bees came out of the hive and swarmed about the child's head. They were driven off and the little one carried to the house. She was stung over fifty times on the head, face, and neck. One bee had stung the child through the outer upper quadrant of the left eye. The family physician was called and treated the child, who