sion of the ulcer-bearing area, that is, the muscular pyloric region, to be followed by independent gastro-jejunostomy. This would meet all of the indications and also prevent a possible malignant degeneration of the ulcer base.

Pylcroplasty has a small field of usefulness in narrow strictures of the pylorus provided the ulcer has healed. The objections to it are that there is a great liability to fixation of the pylorus after operation upon it and also considerable tendency to recontraction. It is a very safe operation; we had no deaths in 21 cases but we had to reoperate in 7.

The gastro-duodenostomy of Finney is a far better procedure. It gives a very large opening and as the enlargement is downward in the line of gravity drainage, the results are much better than in the unmodified pyloroplasty. We have made this operation 72 times with 4 deaths and our results have been most excellent.

All in all, gastro-jejunostomy is the operation of choice. It drains the stomach rapidly from its lowest point and from the cardiac sides to the left of the ulcer-bearing pyloric region. In our experience, the posterior suture method without a loop is the operation of choice, that is, an opening made within 3 irches of the origin of the jejunum.

I wish to speak briefly in regard to cancer of the stomach. Early operation is essential and diagnostic exploratory incision is necessary. We have operated 335 cancers of the stomach, of which 110 were radical extirpations, with 14 deaths. Of those who recovered the average length of life was over a year. It is surprising how few failed to live twelve months or more. One lived over 5 years and 3 are alive now more than 3 years. I am convinced that cancer of the stomach will eventually give as good ultimate results after excision as breast operations. 60 per cent. of cancers are located in the pyloric portion, that is, in the movable part of the stomach. The lymphatic arrangements are the same as the vascular and the dome of the stomach is isolated from this portion. All of the lesser curvature should be removed with the corresponding lesser omentum and all of the body and greater curvature to the right of the lymphatic glands near the middle of the greater curvature. In this way the entire diseased area is removed en masse with its tributary lymphatics.

In conclusion-the known facts warrant the following statements: First-Acute ulcers should be treated medically, sur

gery having only to do with the complications, such as perforation, hemorrhage and obstruction. Second-Chronic ulcer should be considered medically as long as the patient maintains good nutrition and is not rendered more or less unfitted for life's work by reason of pain and digestive disturbances. Third-Chronic ulcer becomes surgical when repeated medical “cures” have demonstrated the futility of further continuance of such treatment; especially if there are mechanical conditions present, such as obstruction, stagnation or retention of food, adhesions etc. Fourth-The liability of ulcer degenerating into cancer taken alone would not justify operation but must be taken into consideration in summing up the indications for interferences. Fifth-Cancer of the stomach is a purely surgical condition.

DISCUSSION.

Dr. W. D. Haggard, Nashville, Tenn.: I am very appreciative of your courtesy in asking me to open the discussion on this paper. I am sure that no words of mine can adequately express the appreciation which all of you must feel because of the pleasure and profit derived from this address. The surgery of the stomach is the most recent of the many fields taken by modern surgeons and the essayist has, perhaps, done more to perfect this great advance than any living surgeon. We should therefore feel highly honored in being permitted to listen to his remarks. I imagine that the lessons of the most value are, 1st, that a large majority of cases of chronic dyspepsia, incurable by the usual means, are due to chronic gastric ulcer that is either unhealed, or, if healed, has left a contracting scar at the pylorus which produces obstruction, dilatation, with fermentation of food, vomiting, etc. Many of these cases therefore present mechanical lesions. Again, malignant neoplasms are occurring with greater frequency, and sadly enough we most often overlook them until the disease is too far advanced for radical surgical removal. The diagnosis of these conditions rests partly upon a suspicion growing out of the frequency of the condition, partly from a careful history, and partly upon physical examination. I think the subject has been more clouded by the efforts at exhaustive laboratory diagnosis than it has been cleared. The use of the stomach tube is just as easy as any of the minor procedures which we daily employ, and it will tell us whether there is excess of free hydrochloric

acid (suggestive or ulcer) or an absence (which is suggestive of cancer)-air pumped in will disclose dilatation. The dilated stomach caused by an obstructed pylorus the result of ulcer scar is the most easily remedied of any of these conditions of the stomach. It is a typical condition which requires gastric drainage. This necessary and perfected operation has less than one per cent. mortality and is most brilliant in its prompt and permanent relief of long standing intractable dyspepsia due to pyloric obstruction. There is no other treatment for it. The short-circuiting of the food at the new opening of the stomach into the jejunum (gastro-enterostomy) and allowing the matter to go out another way than by the pylorus, is the simplest of the stomach operations. Another lesson which we should get from this paper is that we should not be too quick to operate in the presence of neurasthenia until the proper diagnosis eliminating gastric neurosis from real mechanical lesions which they may closely simulate has been made.

Lastly, that the beginnings of cancer of the stomach are so insignificant, that every persistent digestive difficulty in a person of 45 years should be looked upon with suspicion and if it cannot be shown to be benign, an exploratory operation should be done to establish the diagnosis, which cannot be done by any other method known to science.

Dr. I. L. Watkins: I do not think that I can add anything to the paper by Dr. Mayo or to the discussion by Dr. Haggard. I think the subject has been admirably presented, and the importance of it has been so emphasized that it would not be a bad plan to serve due notice on those of our patients who have stomach troubles to be on the lookout. There is no doubt that the field of stomach surgery with the large portion of our surgeons has been rather a matter of mystery. Dr. Mayo has done well to point out the danger of doing operations where no good will result; but on the contrary where harm will be done. We all have patients returning from operations who are not relieved. Therefore, we have to be careful in condemning the physician who hesitates to send these cases to the surgeon. At the same time, there is no question of the wisdom of the surgery of the stomach and that the day will soon come when these questions to which Dr. Mayo referred to as being unsettled, will be settled and when we will be exonerated and relieved of the criticism.

Dr. Porter: The time is so short that I will not speak at length. I will call your attention to the great importance of operations on ulcers, as having a tendency to produce cancer. The fact that this does occur so frequently is our chief danger in the operation.

I have seen some of these cases operated upon where appendicitis was diagnosed, and the appendix was found to be not involved or only secondarily.

My chief object in coming down here was to meet you and Dr. Mayo, and to extend to you from Boston a most hearty invitation to be with us in June at the meeting of the American Medical Association.

Dr. Mayo (closing): As the time approaches for the address of Dr. Collins, which I am very anxious to hear myself, I will forego any further discussion. In regard to the illustrations which you see, these are merely to show the amount of the stomach that can be seen and examined. These indicate that it is very simple to get at the stomach. You can get at it to operate as easily as you can a cancer of the breast.

PROPRIETARY REMEDIES.

WILLIAM WADE HARPER, M. D. SELMA.

Junior Counsellor of the Medical Association of the State of

Alabama.

Two years ago, the Medical Association of the State of Alabama passed a resolution requiring the reading of a paper on proprietary remedies from time to time at its annual meetings. Having been the accoucheur at the resolution's birth, the president, no doubt, thought that I should be accorded the honor of presenting the first baby to its awaiting father.

While I am not a nostrum infidel, I believe that the time is at hand for a serious consideration of some of the evils of this rapidly growing parasite which is more destructive to rational therapy then the Mexican boll-weevil is to the cotton

plant. Having read the hand-writing on the wall, the Proprietary Medicine Association appointed a Press Committee whose function was to contest the doctors' march from nostrum bondage to therapeutic freedom. This committee threatened to sue for libel those who dared turn the search-light of investigation upon their products; but, to the eternal credit and glory of the medical profession, there have been some like Billings who have dared "to beard the lion in his den." The conflict is on and from Maine to California there comes the call, "Arise! ye sons of Esculapius, divorce your self from the nostrum habit and woo the Pharmacopeia."

Realizing that a good name is rather to be chosen than great merit, the proprietary man seeks to inveigle the doctor with a catchy name. The affable representative assures him that "Urexine," a new and wonderful synthetical compound from the laboratory of Prof. Von Humbug, is a quick and certain cure for every case of cystitis, nephritis, and all diseases dependent upon the uric acid diathesis. Having urgent need for such a panacea, the physician immediately prescribes it, absolutely ignorant of its composition or physiological action. After using it awhile and failing to obtain the expected and promised results, the doctor looks up the pedigree of this marvelous cureall and is amazed to find that this "latest synthetical compound" is merely a mixture of some simple remedies manufactured in St. Louis and dressed in a German garb.

Some of our largest and most reliable manufacturing chemists, in addition to U. S. P. preparations, manufacture a number of proprietaries. They are careful to state on the label or on separate slips the qualitative formula. These preparations are ethical and their use perfectly legitimate, as the physician knows what he is giving and the claims of the pharmacist are within the limits of reason. Besides, he has often succeeded, after much experimenting, in rendering palatable some nauseous and bitter drug. But a large number of proprietary medicine makers prefer samples and the free use of printer's ink. The literature usually forgets to mention the formula, and,, in its haste to bespeak the many therapeutic indications overlooks entirely the physiological action. While every drug has its contraindiction, the proprietary has none. When the formula is given the drugs are printed in their botanical terms and, after a few dislocations of the jaw in his efforts to pronounce them, the doctor resignedly accepts the manufac