primarily limited to such an area, how simple the operation necessary and how absolutely certain would be the cure.

There is another point that I desire to make: in excision of the pylorus or any part of the stomach, the use of the continuous suture is one of the greatest advances that has been made in intestinal surgery during the last century. Anyone that chooses to use the Murphy button in the anastomosis I have no quarrel with. I often use it myself-but an intestinal anastomosis by the continuous suture can be made in a few minutes by anyone that is reasonably familiar with the operation. The continuous suture can be applied more rapidly and it makes an absolutely tight scam which will not leak, whereas the old Lembert suture always left the surgeon in doubt whether leakage would occur

or not.

In conclusion, make an early diagnosis; do not wait for a tumor; subject the patient to an exploratory operation and if you practice excision, use the continuous suture or a Murphy button.

Dr. Theinhaus: It is natural that since surgery has made such advances we should advocate an early diagnosis, and the reader has pointed out quite properly and correctly that when a person, who is over forty years of age, loses rapidly in weight, and begins to complain of pain in the stomach and vomiting, in which is found by the chemical test lactic acid present and hydrochloric acid absent, that this person should be submitted immediately to an exploratory incision as soon as these symptoms do not subside after the ordinary medical treatment. We may, however, find tumor formations in the pyloric region which are not carcinomatous. I will confine my remarks strictly to tumors confined to the pylorus and not go into details of tumors originating from neighboring organs and adherent to the pylorus, thereby giving the clinical impression of malignant tumors of the pylorus as, for instance, the tumors of the gallbladder. If

a person has had a chronic ulcer in the pyloric region for some years you may find afterwards a tumor in that region. Furthermore, so-called hypertrophy of the pylorus, which may, as we know, be congenital or acquired, can give the clinical symptoms of tumors of the pylorus. Naturally the diagnosis in the early stage of carcinoma of the stomach, when no tumor is yet palpable, is very difficult. All the chemicals and microscopical findings in the vomiting, besides the cancer cells, which, however, are almost never found in the early stages, are by no means pathognomic only for carcinoma, or speak absolutely against it. At one time, for instance, one believed that the presence of sarcine in the vomiting would exclude the diagnosis of cancer, because sarcine is usually found in cases of inorganic hyperacidity, but soon it was demonstrated that there are exceptions to this rule and that sarcine may be found in cases of carcinoma. Not long ago I operated on a man who showed these symptoms of a malignant stricture of the pylorus. The operation revealed a benign stricture of the pylorus which I corrected by gastroplasty after the method of Heineke-Miculicz. He is perfectly well now. This method is only applicable for cases in which the ectasis of the stomach is not yet very large, and where the muscular wall of the organ is not relaxed too much. If the latter is the case, gastroenterostomy is the proper treatment. Dr. Levings mentioned the examination of the blood as a diagnostic means of carcinoma. I would like to say that excessive leucocytosis is oftentimes present in cases of carcinoma of the stomach. Furthermore we find sometimes in the early stages traces of blood in the vomiting as demonstrated by the Guajac test, and Boas has shown that this may be essential for carcinoma of the stomach, as it is not found in cases of neurosis with dyspepsia nervosa and gastritis.

A few remarks concerning the methods of operative treatment. In later years there has been a great difference of opin

ion whether or not gastroenterostomy or resection of the pylorus is to be preferred in suitable cases. Hartmann has shown before the International Congress in Paris that by gastroenterostomy we are only enabled to lengthen life on an average for seven months. Miculicz has operated in the last ten years on 447 cases of cancer of the stomach. By gastroenterostomy life was prolonged on an average only five and one-half months, by resec tion at least one year. Seventeen per cent. of the latter cases are radically cured, which means there are no recurrences after two years up to ten years. This shows that the pendulum of operative procedure has to swing to resection, which must be done very thoroughly, and the method which enables us to take as much away as possible from the duodenal part of the pylorus is the so-called method of Billroth No. 2.

ON THE AVOIDANCE OF SHOCK IN MAJOR AMPUTATIONS BY COCAINIZATION OF LARGE NERVETRUNKS PRELIMINARY TO THEIR DIVISION.

WITH OBSERVATIONS ON BLOOD-PRESSURE CHANGES IN SURGICAL CASES.

BY HARVEY CUSHING, M. D., OF BALTIMORE.

(1) By common usage the term "shock" has come to represent a peculiar state of depression of the normal activities of the central nervous system. Such a condition is ordinarily brought about by traumatism, of one sort or another, to peripheral afferent nerves. In order to produce shock, the impulses resulting from this traumatism must have acted reflexly upon the vasomotor mechanism in the medulla in such a way as to occasion a marked fall in blood-pressure. This diminution of arterial tension is the most characteristic symptom of shock.

(2) Under ordinary circumstances injuries of only moderate severity to peripheral nerves occasion a rise in blood-pressure. If, on the other hand, these injuries are extensive or frequently repeated, or if they are complicated by certain physical conditions, prominent among which may be mentioned primary or secondary anemias, they are commonly productive of a fall in blood-pressure, indicating a state of shock.

Shock consequently need not be occasioned even in most extensive surgical procedures on the extremities, provided due regard is given to perfect hemostasis. In operations of considerable magnitude, however, during which the division of many large nerve-trunks becomes necessary, or in operating upon such traumatic cases as have been already complicated by extensive injury to peripheral sensory nerves, so-called operative shock is rarely avoided.

When, therefore, any condition is existent which predisposes to shock, such as loss of blood, prolonged anesthesia, etc., or when a certain degree of shock is already present before operation, especial risk is attendant upon the division of important sensory nerve-trunks.

(3) Cocaine injected into a nerve-trunk effectually blocks the transmission of all centripetal or sensory impulses. Cocainiza

tion, therefore, of main trunks of nerves central to the proposed site of their division in a major amputation, prevents the conduction of those impulses resulting from the traumatic insult which otherwise, by acting reflexly through the medullary centers, might become the chief factors in the production of shock.

Three years ago, during the progress of an interscapulothoracic amputation for a metastatic sarcoma of the shoulder, and before the principles laid down in the foregoing introductory paragraphs were sufficiently appreciated, it was the writer's misfortune to have occasioned a profound and almost fatal condition of shock by the division of the brachial plexus of nerves. This case and a subsequent one of ablation of the entire upper extremity, in which precautions of anesthetization of the plexus before its division were observed, illustrate so well from the clinical side the principles which will be emphasized in this communication that they will be briefly summarized.

CASE I-(Surgical Number 9803.) Ablation of Breast, Upper Extremity and Shoulder-Girdle for Sarcoma. Profound Shock in Consequence of Operation.

Miss A., forty-one years of age, entered the hospital, December 22, 1899. A pigmented cutaneous mole had been removed from the left forearm two years before her admission. In May, 1899, following an injury to her left shoulder, a growth appeared in the axilla, which increased slowly in size up to the past few weeks. Since then it has enlarged very rapidly and a mass of glands has appeared above the clavicle. During this period of rapid growth of the axillary tumor the pain in the arm has become so severe that large doses of morphine have been necessary to control it. The patient has lost greatly in strength and weight from pain and sleeplessness. The pain evidently is occasioned by pressure on the brachial plexus, and is referred over its entire sensory distribution from shoulder to finger-tips.

Physical examination showed a large, fleshy woman, apparently suffering acutely, holding her left arm abducted forty-five