occlusion or excision of the ulcer. It is now considered that the object of the gastroenterostomy is not simply one of drainage of the stomach contents but that its chief advantage comes from the fact that thereby the hyperacidity of the stomach is permanently lowered on an average of from 20 to 30 points as has been shown and is now taught by the Mayo Clinic.

As the operation for pyloric occlusion is not permanently successful and as the pylorus will again open unless an operation of great magnitude, such as infolding the mucosa of the duodenum and the stomach or complete severance of the duodenum from the stomach, is undertaken, I have never considered it wise to add to an operative procedure which in itself gives such satisfactory results.

Of the gastric ulcers, I have excised three. One I excised without doing a gastroenterostomy and was obliged later to do a gastroenterostomy and found an ulcer of the duodenum. Whether this had been overlooked at the first operation or had formed subsequent to my first operation I do not know. At any rate the patient has been cured since the gastroenterostomy. In one case, on account of almost complete pyloric occlusion I did a Finny operation with excision of the gastric ulcer instead of a gastroenterostomy. This patient's weight had diminished from 95 to 65 lbs. and she made an uninterrupted recovery.

Immediate results are most gratifying. The patients show less shock, less abdominal distension and less elevation of pulse and temperature than after almost any abdominal operation, certainly no more if as much as following an ordinary operation for simple appendicitis.

Among this series of cases I have lost no gastroenterostomies but have had one vicious cycle in which it was necessary to do an entero-enterostomy later, which patient made a complete recovery. Another patient, with a perfectly normal temperature, vomited for two weeks and presented a condition which resembled a vicious cycle. This case, however, I lost track of as the patient left the Hartford Hospital against advice and I don't know what became of him.

In the first case I had done an iso-peristaltic instead of an

anti-peristaltic anastomosis, i. e., I had given the jejunum a turn so that the peristalsis was in the same direction as the peristalsis of the stomach, instead of against the peristalsis of the stomach as the loop seemed to fall more naturally in this direction. In the other case, if I made any error, I think it was in making the gastric opening too near the pylorus.

The result of this series of operations as to recovery is most gratifying and no more thankful patients can be found than those who have suffered for years from gastric distress, and are then relieved of their symptoms.

My only fatality was in a case where there was an enormous tumor on the lesser curvature and posterior wall of the stomach in the pars media, the size of a lemon, which was easily palpable before operation. This tumor was adherent to the pancreas, was hard and there was an enlarged mesenteric gland—in all respects resembled malignancy. The pathologist on examining the gross specimen was sure that it was malignant but microscopic examination failed to show that it was other than an extraordinarily large gastric ulcer. I did a partial gastrectomy but there was apparently some point of leakage and the patient died of peritonitis eight days after operation.

Perforated Gastric Ulcers.

I have had 6 cases, 5 duodenal and I gastric. Of these, 3 have recovered and 3 have died. I think in this type of case, more credit is due the physician who makes a correct diagnosis and rushes his patient to the hospital, than to the surgeon who simply opens the abdomen and drains, inasmuch as most of the cases operated upon inside of twelve hours recover and most of those delayed after eighteen hours die. I do not believe in doing a posterior gastroenterostomy at the time but simply infolding the perforation and draining. The ulcer is often cured by the fact that it has perforated and later infolded and why do a gastroenterostomy for something which is cured or about to be

cured?

I agree with the advice of Dr. Gibson of New York who does not think it advisable to do a gastroenterostomy at the time or

even later unless following recovery they show symptoms of continued gastric trouble. If they do, a gastroenterostomy should be performed. Of my 3 recoveries, 2 have shown no symptoms of stomach trouble, I has, and I expect to do a gastroenterostomy later upon him.

Congenital Pyloric Stenosis.

This is a most interesting condition and the results of surgical operations upon these cases spectacular. Last year when the State Medical Society met in Hartford I showed 2 of these children who had been operated upon. I regret to say that since that time I have had only one more case to add to the list making a total of 3. It is now thought, in accordance with the advice of Holt, that it is best to divide these cases into cases of congenital pyloric stenosis of a mild or severe type and to give up the classification of pylorospasm and stenosis.

After the diagnosis of congenital pyloric stenosis is made, the consideration should then be is this a case which should be treated surgically or medically? If after careful feeding and doses of paregoric to relax the pyloric muscle, the child is not improved, he should be turned over to the surgeon for operation. The operation as devised by Rammstedt is so simple, so quickly performed and these babies show so little shock, that the surgical procedure should not be looked forward to with such dread as is apt to be the case with the family and with the medical men who are unaccustomed to observe the ease with which small children go through surgical operations.

Children with this condition, as a rule, do fairly well for a while after birth-take their food properly, do not vomit and gain in weight. Any time between two weeks and eight weeks, sometimes longer, they begin to vomit after feeding, the vomitus being projectile in character. There is a progressive loss of weight and almost absolute constipation. Later on the abdomen is distended, rigid and visible peristalsis is seen and sometimes a palpable tumor appears in the region of the pylorus which can be felt at certain degrees of gastric distention. X-ray examination of these cases is very interesting and shows a

marked gastric retention at the end of three hours, in direct counterdistinction to the gastric activity of a normal baby's stomach which should empty itself of the bismuth very quickly. The additional case which I have to report is one where it

Weight chart showing rapid gain in weight after operation for Congenital Pyloric Stenosis.

was very difficult to obtain consent for operation from the parents and after I had succeeded in doing that, I operated on Sunday rather than on Monday as I was afraid that by Monday the child would be dead. The child made an uninterrupted recovery and at the end of six weeks it weighed nine pounds, had pneu