ination. It is important in functional cases to know the size, position and mobility of the stomach, with the degrees of integrity of the cardia and pylorus, and above all, and this is the gist of the entire subject of examination of stomach contents, is there stagnation? Within certain times and limits the stomach should be empty certain periods after taking food, and the discovery of food products with fermentation after such time has elapsed leads at once to the diagnosis of some obstruction at the pylorus. Now pyloric obstruction due to any cause is a condition for surgical treatment; careful regulation of the diet may put off the evil day, but the patient must sooner or later come to it. The medical attendant can easily make this diagnosis and have an operation before the patient reaches a condition of profound anaemia and exhaustion from inanition. This condition may start as a moderate degree of stenosis of the pylorus with more or less gastric dilatation. The patient will complain of nausea and vomiting with progressive emaciation. Examination will show evidences of stagnation of stomach contents; that is, their retention beyond the time when the viscus should be empty— seven hours after full meal (Boas) or one hour and a half after Ewald (test meal). The food products withdrawn will show increased lactic acid of fermentation, the presence of H2S and other fermentative bacteria and evidences of decomposition. With lavage of the stomach in a fasting condition, rectal alimentation or liquid diet and medicinal measures, such cases often improve, and the patient should be given the benefit of such treatment before considering operative measures. The importance of this condition may be understood when Einhorn states that 1.45 per cent. of all stomach cases seen by him in 1904 had ischochymia from some obstruction, benign or malignant, to the outlet of the stomach. (Here refer to case of McC., Exhibit T.) It must also be understood that ulcer of the stomach in the majority of cases is a surgical condition and demands operative treatment for its radical cure. Grave responsibility rests upon the medical attendant who defers surgical consultation in a case of gastric hemorrhage or one in which ulcer can be diagnosticated with reasonable certainty. Weir pointed out some years ago the frequency of perforating ulcer of the duodenum and aroused the profession to its recognition and treatment by surgical means. Weir contended that many lives were lost from perforation or hemorrhage from duodenal ulcer unrecognized. During the year following his article on that subject which aroused much interest in the profession, a number of successfully operated cases were reported. Gastric hemorrhage from ulcer is of great variety and manifests itself in various ways. Sometimes it is the first symptom of gastric disturbance, and in others the last of a long and tedious course of symptoms. In the first class of cases the hemorrhage antedates any other symptom, is sudden, profuse, and has a profound effect upon the patient, who shows all the classic symptoms of blood loss. There

is a marked tendency to spontaneous cessation of the bleeding; in fact, in my own experience I have not seen a fatal case from hemorrhage. In the so-called chronic cases the bleeding may be of small amounts and only discovered after a careful examination of stomach contents. It may be profuse but intermittent, occurring at intervals of two or three months. In this case the patients are anaemic and dyspeptic symptoms are marked. In another class the hemorrhage is profuse and frequently repeated, within 24 hours or less, and this condition continued at the gravest peril to the patient. The final class is that in which the patient is overwhelmed by a profuse hemorrhage, and dies as the result of the opening of a large artery. In such a case one of two procedures may be followed. The stomach may be opened and the location of the ulcer or bleeding point determined, excised or ligated, and a gastro-enterostomy performed for rest and drainage; or if the condition of the patient will not permit of such extensive work, a gastro-enterostomy may be performed, when the bleeding will usually stop. Moynihan attributes this to the fact that as in such a case operation shows the stomach widely distended, the mouths of the vessels are held widely opened, but after gastro-enterostomy the viscus collapses and the hemorrhage ceases. Such has not been the experience of the Mayos, Kocher and Peterson, all identified with gastric surgery; but Moynihan contends his experiences have been satisfactory with gastro-enterostomy as a means of combating hemorrhage. (Cite case of MW, Exhibit II.) As to perforation, I knew of a case in the practice of a surgical confere, a case patient aged 62, with perforation of the gastric wall, escape of stomach contents into the abdominal cavity, recovered by the aid of a timely operation performed a few hours after the accident. Personally my happiest results have been with posterior gastro-enterostomy, with short loop in pyloric stenosis, and posterior gastro-enterostomy and inversion or resection of the ulcerated area in ulcer. The cases of cancer during the past year have been so far advanced or possessed such complications as to render radical operation impossible or futile as to final result.

Cardio Spasm is a condition fortunately not frequently met with, but most distressing. In this condition, owing to spasmodic contraction of the cardiac orifice, there is a flask or pearshaped diverticulum extending up the oesophagus, having a cavity independent of the stomach. As this condition progresses the stomach atrophies, the diverticulum increases, the patient is reduced to a fluid diet, and finally succumbs to starvation, as in a case seen in my own practice where operation was declined. Mikulicz devised an operation which consisted in making an incision in the long axis of the stomach and introducing one, two or three fingers into the cardia, divulsing the sphincter, as is practised in dilation of the sphincter ani. Erdman reports such. a case in which he could not pass the finger through the cardia,

but used instrumental dilation until the finger would pass, then managed to get three fingers into a cavity so large that the fingers would not touch the lateral walls. Twenty months after this operation the patient had gained 35 pounds and was cured. This was the happy ending to a case of similar character to the one quoted above in my practice where the patient literally starved to death.

Congenital or acquired stenosis of the pylorus has been recognized as a condition for many years, but only recently has it received the attention it deserved. The symptoms may come on a few hours after birth or may appear within a month. Vomiting is the prominent and characteristic sign, which is of a projectile type, and becomes more and more frequent. The infant is more comfortable when the stomach is empty. There may be flatulence and constipation, sometimes diarrhoea from decomposition of food, and upon inspection of the abdomen. there is evidence of gastric dilatation and visible peristalsis may be present. In marked cases a wave of peristalsis may be seen passing from left to right, stopping momentarily and passing downward to the duodenum. The pylorus can be marked upon the body by the intersection of two lines, one drawn horizontally halfway between the top of the sternum and the pubic crest, the other drawn vertically half an inch to the right of the median line, or it may be found half an inch to the right and three-quarters of an inch above the umbilicus. It is deep set, and when palpitated feels like a filbert.

Results: Death before fourth month if not operated. With operation-Gastro-enterostomy, 42 cases, 42.56 per cent. mortality; pyloroplasty, II cases, 27.28 per cent. mortality; divulsion, 18 cases, 50 per cent. mortality; pylorectomy, I case, 100 per cent. mortality. Balance of opinion is in favor of gastro-enterostomy.

This paper is not intended as an exposition of the present status of gastric surgery, for many conditions, such as perigastric adhesions, gastroptosis, etc., which have not been referred to. should be considered from a surgical standpoint. The purpose of the writer is to impress upon the medical attendant the possibility of gastric cases assuming surgical aspects and to urge early co-operation with his surgical confere so that the patient receive aid before he is in extremis, or in the case of malignant disease the envolvement is so extensive as to preclude any very radical measure being undertaken.

The subject is one of deepest interest and should be considered carefully. Gastric surgery has to a large extent passed the stage of experiment, and in the larger hospitals where those operations are more frequent the mortality has been reduced to that of almost any laparotomy. To the credit of our profession it is gratifying to know that the development of this department of our art and science will always be associated with our own American surgeons.

EXHIBIT I.

M. Mc, age 30, born in U. S.; diagnosis, gastritis; laborer. In good health as a boy. Had diseases of childhood. Malaria and typhoid fever about eight years ago.

Present illness-Appetite poor, bowels constipated. Says "a swelling comes just below ribs and affects the heartbeats." Vomits when he takes solid food (three times in last ten hours). Trouble began five years ago while in the army, and has had four or five attacks since then, but the present attack is the worst. Began nine weeks ago and has lost 27 pounds in that time. Worked up to two weeks ago; does not sleep well; belches gas. Vomitus tastes sour, but has never vomited blood.

Physical examination-Patient is 5 feet 8 inches in height, weighs 167 pounds in good health, now weighs less than 140 pounds. Well developed, but rather thin. Skin pale, warm and moist. Tongue large, moist and coated. Thorax long and narrow; epigastric angle narrow. Heart sounds loud and distinct, no murmurs. No tenderness in abdomen, liver not enlarged, spleen not felt. Abdominal walls lax.

After continuous observation for a period of two weeks, repeated examinations of the stomach and its contents, show dilatation of the organ and retention of food products beyond the period of gastric digestion-H Cl and increased lactic acid. Diagnosis made and placed on record before operation was pyloric obstruction-cause unknown. Operation. Incision four inches long from below the ensiform appendix and the region of the pylorus palpated. Pylorus and upper portion of the duodenum bound in a large mass of adhesions. It was my intention to do Finney's operation, and in attempting to carry out the author's emphatic direction to thoroughly separate all adhesions, the duodenum on account of its brittleness was torn into and the condition of the tissues were such as to raise the question of the ultimate success of the Finney procedure. It having been demonstrated that the stoma of a gastro-enterostomy acts better if the pylorus is closed, I infolded the pyloric extremity and upper part of the duodenum in such a way as to make the stenosis absolute, then made a posterior gastroenterostomy with a short loop with clamps after the manner of Moynihan and Mayo. The patient made a good recovery, and one year after operation has gained thirty-five pounds; is in what he calls "perfect health.”

EXHIBIT II.

M. W., age 32; born in U. S. Diagnosis, gastric ulcer. Domestic.

Fairly good health as a child. Had diseases of childhood. Rheumatism as a young woman and pneumonia about a year ago on right side. One operation (double oophorectomy) seven years ago.

Present illness: Frequent vomiting of blood and passing of

blood in stool, sixteen years' duration or longer. Last few days. bleeding has been profuse, causing much weakness and headache. For eight months has had sharp pain at night over right hip and in right inguinal region. When stools are bloody has severe pain in rectum. For three weeks has had drawing pain in abdominal scar. Occasionally has sharp pain in cardiac. Appetite poor; much thirst, but vomits water as soon as taken. Bowels costive, urine very scanty, and last two days bearing down pain on urination.

Physical examination: Chest well developed, respiration regular and of good character. Heart area not enlarged, no murmurs, action regular, sounds normal, pulse regular, full and fairly good quality. Abdomen lax, not prominent, no growth detected, much tenderness over uterus and in both inguinal regions.

The patient had been in the hospital a number of times and been submitted to all kinds of treatment, medicinal and dietetic. Is thin, pale, anaemic, almost too weak to submit to an operation. Etiology-ulcer.

Gastro-enterostomy performed. Reflux of bile and alkaline intestinal juice neutralize the excessive acidity and prevents the food products from passing over the site of the ulcer.

OPPORTUNITIES FOR POST-GRADUATE MEDICAL STUDY IN VIENNA

ELIZABETH E. SHAW, M.D., BROOKLINE.

I give this short account of the medical work available in Vienna for the purpose of supplying information to any contemplating a first trip to that center of learning, the advantages of which I shall speak are given irrespectively to men and women so far as post-graduate work is concerned. I know of but one clinic from which women who have not yet taken the degree of doctor of medicine are excluded; this is the Nathnagel medical clinic, and as its exact counterpart, the Neusser clinic, welcomes women students, the above mentioned disadvantage is nominal.

For the sake of those unacquainted with European manners and customs, let me say that any letters of introduction to professors, officials or private families will be found of great value. The average European has no understanding of the American. fashion of taking a man for granted on his personal appearance, but an introduction from a third person, although very slightly known, is an assurance of a cordial reception, and from a man of note an introductory letter often brings privileges which money could not buy. Many an American physician, wishing to visit a lecture of some famous professor, enters the crowded lecture room without the formality of handing his card to the servant at the door, and never dreams that he has committed