To illustrate, allow me to mention this case briefly, which I operated upon last December. This was a case beyond any possibility of a cure. The tumor mass was very large and noticeable on inspection. The man was close to death. The palliative operation of posterior gastro-jejunostomy was done, from which an uneventful recovery was made. The patient before operation crying for food, which could not be retained, dying as much from the lack of food as from his cancer; after operation ate anything and all he wanted, without one pain or any discomfort, and in eight weeks gained twelve pounds.

Let us for a moment look at the anatomy of the stomach as it relates to malignant disease.

In the first place it is a well established fact that the majority of carcinomata of the stomach at first grows slowly. The stomach wall seems not to be susceptible to rapid infiltration. The pyloric orifice is the seat of malignant disease in 60% of malignancy of the alimentary tract, in 80% of cancer of the stomach proper.

The lymph system is of all importance in dealing with any malignant disease. The lymphatics of the stomach, as worked out by Cuneo, shows up one or two important facts. First, the lymph channels and glands lie in the layers of the peritoneum, going to make up the gastro-colic and gastro-hepatic amenta, and are very accessible and easy of removal, and too, the glands on the lesser curvature are contained in the stomach wall and the chain is broken a little short of the junction of the œsophagus and stomach. Hence it is that if, as is the case in all favorable cases for operation, the stomach is removed through a line running from this point on the lesser curvature, down to a point beyond the glands involved at the greater curvature, the infected area is well removed, and only a portion of the stomach resected. In fact, it is stated by some that, owing to the formation of the lymphatic, along the lesser curvature, this portion of the organ should always be removed. The chain on the greater curvature ceases at about the junction of the two vessels here located.

The anatomy of the stomach thus teaches us that malignant disease can be more thoroughly removed than is the case in most other portions of the body.

It is pertinent here to ask if these unfortunate cases of carcinoma of the stomach should not be given the same consideration by the physician as is given to malignancy elsewhere? I feel that many of you would say yes," and I am sure that only a few years will roll by before this will be the established rule. Why not extend to these patients the same help as we extend to others? Carcinoma of the breast often comes to the surgeons; cancers of the cervix and uterus are frequently operated upon; malignancy everywhere is attacked radically. In no part of the body is there a better opportunity to thoroughly eradicate these growths than there is in the stomach.

On the general practitioner much depends for early diagnosis, and early operations are going to give us best results, and will surely lead on to the brightest plains of surgery.

What is the favorable case, and how determined? Briefly this: given the patient of proper age for malignant tendencies, be suspicious of the constant complaining of such symptoms as could be called the various forms of dyspepsia; determine the digestive powers of the stomach, its motor functions, and if, under proper care after the use of the clinical laboratory as an aid to your diagnosis, the patient still goes on worse or not improved, be more suspicious. Above all, if you elicit a history of a previous gastric ulcer, beware, for it is estimated that as many as 50% of the cases of gastric cancer give such history, even though the ulcer antedates some twenty or thirty years; and, at last, if still in doubt as to whether or no a malignant disease is going on, resort to exploratory operation. Do not wait until a tumor can be distinctly felt or even seen, for true it is that the more easily recognized is the tumor mass by palpation, the less favorable is the case for radical cure.

Here is a most important sphere where the clinical laboratory will aid you. Let me impress, however, that exploratory incision should be made, not to confirm but to make the diagnosis.

What of those hopeless cases, those cases where the outlook is certain death in all its horrors, where the patient dies of malignancy, of starvation and in agony? It seems to me that here is a work, too, for us, and if, with little risk to life already beyond the counting of a risk, we can relieve these sufferers, can again allow

them the pleasure of eating without pain, can cease the suffering, and give comfort, can give a little longer lease of life, truly it is our duty to do so. Such can be done by proper drainage of the stomach through the establishment of a posterior gastro-jejunostomy. Such an operation is feasible, is just.

This view is held by men who are pioneers in this work. If it has been your fortune to see, as I have, its results, then you could but be staunch in its favor. Dr. Blake, who is doing such excellent work in this line, said to me regarding this procedure, "I believe in gastro-jejunostomy as a palliative procedure in pyloric cancer, and find that it gives about four months of freedom from symptoms and then the patients die quickly of their disease."

As regards the technique of operations upon the stomach, little have I to say. First, bear in mind that the stomach allows of much severe manipulation without causing any untoward symptoms afterward. That a patient can be given little anæsthetic, for during operations the work upon the stomach causes no distress.

Regarding technique, allow me to say that I think the mechanical appliances should be abandoned and anastomoses accomplished by suture alone.

Since writing this paper I was pleased to find that Moynihan states in his last work that mechanical means should be discarded. True they have been a great step, and an aid in anastomatic operations; have made surgeons bolder and led the way back to sutures because sutures now perfected seem best.

In performing posterior gastro-jejunostomy, I have made it a point to unite the layer of the gastro-colic omentum firmly to the posterior wall of the stomach by interrupted suture, and carrying a continuous suture over the openings in the stomach and intestine, with the view of a firmer union and also preventing any spur formation. This additional suturing requires so short a time that the operation is not prolonged. The approximation of the gut to stomach, I believe, should be just far enough from the beginning of the jejunum as not to cause any stretching, but not far enough to cause a loop of jejunum to hang down loosely.

The operation of partial gastrectomy needs no comment, except to say that by the improved methods of Billroth, so finely outlined

by Mayo in Jour. Am. Med. Assoc., it can be practically bloodless.. Let us look at statistics:

80% of carcinomata of the stomach are at the pyloric region and lesser curvature.

10% in the walls.

10% at the cardia.

Thus 90% are amenable to direct attack by the surgeon.
In the remaining 10% gastrotomy can, at least, prolong
life.

Graham showed that 50% of gastric carcinomata gave a
history of gastric ulcer.

Dowd found in the United States census of 1900, 9,000 died that year of gastric cancer.

In regard to operations:

In Mayo's 100 cases, 14 died; 27.7% lived 3 years; 22% alive and well after 3 years.

Each year has decreased the death rate in all stomach surgery, till now partial gastrectomies and gastro-jejunostomies give remarkably small death rates comparatively, and the release from suffering by these measures, the prolonging of life in comfort of ⚫ these unfortunates, makes this field of surgery, to my mind, truly a triumph.

In closing, I wish to plead that early diagnosis, when this malignant disease is in its beginning, is of all importance to both the patient and the surgeon, and I want to emphasize the fact that in cases where a reasonable suspicion of cancer exists in the mind of the physician, and, after all, in the first stages of this disease a reasonable suspicion is about as close to a diagnosis as we can come, do not wait, but resort to exploratory laparotomy. Let it be that the diagnosis is made by laparotomy, not the laparotomy made to confirm diagnosis.

DISCUSSION.

Dr. William F. Verdi (New Haven): Mr. President and Gentlemen: It is a strange fact, but it is true, that it takes the internist a very long time to see the advantage which can be accomplished by surgery. We have all been through this process with appendicitis and with gall stone diseases. Of course the great drawback to the immediate resort to surgery has been, previously, the bad results which the surgeons experienced in these operations. In mostly every case of appendicitis, some ten or twelve years ago, which the surgeon was called upon to operate, the results were extremely bad. It was not the surgeon's fault at all, but it was because the patients came to him too late, general peritonitis had started up, and, of course, the mortality was very high in those cases. I don't believe now that there is an intelligent practitioner in any community who does not resort to the surgeon as soon as he has made the diagnosis of appendicitis. It is through this means that the brilliant results have been obtained in the treatment of the appendix and also in the treatment of gall stone diseases.

In the stomach the surgeon is called upon to treat three different pathological conditions; you have the carcinoma, the ulcer, and the stricture of the pylorus. I believe myself that carcinoma of the stomach, as carcinoma of the tongue and larynx, are extremely malignant, and the spread of the disease is very rapid as compared to carcinoma of the breast. Carcinomata of the stomach, I think, in order to get good results, must be attacked very early. As Dr. Lee has pointed out to you, the lymphatic supply of the stomach is now distinctly established, the glands running along the lesser curvature and toward the pyloric end of the stomach, are thoroughly established. Hartman, of Paris, a very modest and brilliant surgeon, has devised a radical operation for gastric carcinoma. He removes, in every case of carcinoma of the pylorus, the whole of the lesser curvature of the stomach. That is very important, because the glands of the lesser curvature drain the stomach so that any one of those glands that may be left behind, may contain carcinomatous cells and cause a recurrence afterwards. I believe that an operation for carcinoma of the stomach should not be made if the carcinoma has already spread out to the peritoneum and caused adhesions to the pancreas and the duodenum below, and to the gall passages. I think it is perfectly useless to perform any operation. In those cases gastro-jejunostomy is the proper procedure. It relieves a great deal of suffering and causes the patient to live a little longer, but, of course, it is not a radical procedure. In gastric ulcer, although I have not enough experience to speak with much authority, I do not believe myself that the gastric ulcer should be similarly attacked. First, the ulcer should be removed, and the rent in the stomach sutured. I do not believe that it is wise to resort to gastro-jejunostomy just because there is a gastric ulcer.