could survive the operation. After six days preparation with chloride of calcium and gelatine for the purpose of checking the oozing during operation, I operated. After opening the ab domen through an incision through the outer border of the rectus muscle, the gall-bladder and the cystic duct were found transformed into one hard stony mass of the size of two thumbs. After having digged out this mass, consisting, as it was shown after an incision in the gall-bladder, of numerous stones matted together (no drop of fluid was in the bladder), I made a transverse incision through the rectus to get to the common duct. I found three concretions in it movable and a hard mass absolutely immovable in the retroduodenal portion and the region of the diverticulum of Vater. Seeing the impossibility of removing this stony mass through an incision in the common duct, I opened immediately the duodenum on the anterior wall, then cut through the posterior wall of the duodenum in the region of the papilla, and removed the impacted stone of the size of a hazelnut, after which it was easy to strip the three movable stones into the duodenum also. The recovery was uninterrupted. She is perfectly well now, and gained in four months since the operation 37 pounds, as stated in her letter which I received three days ago. I intended to present her here today, but she is unable to come to town, as she has to fulfill her household duties on the farm.

Dr. Ground: Dr. Levings has evidently misunderstood one point I made. I said gallstones may remain in the gall-bladder indefinitely without producing symptoms characteristic of cholelithiasis, and that the symptoms they produced were those of irritation. There must be a pathological condition before the gallstones are formed, and their formation does not eliminate the

cause.

The symptoms are due to irritation and infection, pro

ducing chlolelithiasis and contraction of the gall-bladder on the calculi, and not the mere presence of the foreign bodies themselves.

Dr. Mackie: Although the treatment is included in the paper, I purposely refrain from reading it, because our time is limited and I believe the diagnosis is the most important point. If you will compare diseases of the gall-bladder with appendicitis, you will find that they are similar to diseases of the appendix, but while appendicitis has been worked out, that is not true of cholelithiasis.

CANCER OF THE STOMACH.

BY A. H. LEVINGS, M. D., OF MILWAUKEE.

There are many diseases both in medicine and surgery which have become as it were in times past popular, and in consequence of this popularity have received more attention from the lay press, from medical societies and journals than their importance really deserves. There is little fear, however, that the subject of carcinoma in any of its various forms and situations will ever become a matter of popular acclaim.

The time allotted to a paper by this society renders it impossible for one to enter at length into all the details of such an important subject as the one before us, consequently many of the subdivisions, although important, will be considered but briefly. It is necessary in order to gain anything like a comprehensive review of carcinoma of the stomach to take up its various subdivisions in progressive order. Not that we shall endeavor to exhaust the material or to go into detail, but only for the purpose of gaining, if possible, something like a complete review of the subject.

Etiology. Heredity. Hereditary influences here as elsewhere seemingly play some part in the production of carcinoma. In 150 cases Osler found that there were 11 in which heredity seemed to be an important factor. Welch found in 1,784 cases that 242 were the result of hereditary influences. Probably every physician in his experience has observed one or even several families in which cancer was frequent and seemingly often the result of paternal transmission.

A family was recently under the writer's observation in which the father and two sons had died of cancer of the stomach.

Whatever the influence, whether it be one actually transmitted from parent to offspring, as may occur in syphilis, or only a predisposition as occurs in scrofula, or a condition which is the result of the intimate association which occurs in families as in tuberculosis, it is difficult at the present time to state, but that there is some influence which is present and active in a family which has suffered from carcinoma there can be but little doubt.

Peptic Ulcers. There is now no question but that ulcers of the stomach have been and occasionally are the cause, direct or indirect, of carcinoma, in that the process becomes engrafted upon the ulcer, or takes origin from the cicatricial tissue formed in the healing process. In Osler's 150 cases there were four in which the carcinomatous process became engrafted upon an ulcer of the stomach. A patient suffering from carcinoma of the stomach and very recently examined by the writer, gave a history covering several months of localized pain, a sensitive area in the epigastrium, pain increased by eating, a sour stomach and then a terrific hemorrhage. Some few months following this a carcinoma developed. Traumatism is also said occasionally to act as an exciting cause. Seemingly a very frequent cause of carcinoma of the stomach is dyspeptic or catarrhal conditions produced by improper food and drinks. Here as elsewhere anything which produces and maintains an irritation, and which increases the blood-supply, is likely to lead to proliferation and may in the end be a causative condition of carcinoma. It is so common that it is almost proverbial that the regular drinker of alcoholics is predisposed to gastric carcinoma, and he whose stomach is more or less in a state of chronic irritation in consequence of the ingestion of improper food is also predisposed to carcinoma. It is claimed that in more than 70 per cent. of the cases of gastric carcinoma the patients have been previously steady drinkers of spirituous liquors, and in about 35 per cent. there has been a previous history of dyspepsia.

The Parasitic Theory. It is scarcely necessary for one to take up the time of this society with a resumé of the work done and the apparent findings along the line of the parasitic origin of carcinoma. It may be sufficient, however, to say that scientists are divided upon the subject and perhaps the majority of pathologists are opposed to the view. A great many clinicians, however, and especially surgeons, believe that the foregoing presumably etiological factors only prepare the soil and make it suitable for the growth of germs, which are the real cause of can

cer.

Frequency. Cancer is said to affect the stomach more frequently than any other organ of the body excepting the uterus. At Guy's Hospital during ten years it caused the death of sixty patients, or was responsible for 1.54 per cent. of all the deaths occurring in the institution. In 30,000 cases Welch found the stomach involved in 21.4 per cent. It affects men more fre quently than women in about the ratio of three to two, or even two to one. It is observed most frequently between the ages of fifty and sixty. Drs. Perry and Shaw found that the average age at death in their cases was 51.1 years, the youngest being thirty-two and the oldest eighty-one. Dr. Norman Moore reported a case of undoubted cancer of the stomach in a girl aged thirteen. Ordinarily one does not expect to find carcinoma of the stomach before the age of forty, but from this age on it increases rapidly in frequency up to between fifty and sixty, when it commences to become less frequent.

Situation. All statistics practically agree in placing the growth, in carcinoma of the stomach, in more than one-half of the cases at the pylorus. In 1,300 cases Welch found carcinomata at the pylorus in 791,-at the lesser curvature in 148,— in the cardia in 104, the posterior wall 68, and in 61 cases the whole or greater part of the stomach was implicated. Allbutt in 360 cases places the growth at the pylorus in 219. Habershon