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 SURGICAL TREATMENT 
 
 GASTRIC ^niJODENAL ULCERS 
 
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THE 
 
 SURGICAL TREATMENT OF GASTRIC 
 AND DUODENAL ULCERS 
 
 BY 
 
 B. G. A. MOYNIHAN, M.S. (LOND.), F.R.C.S. Eng., 
 
 Senior Assistant Surgeon, Leeds General Infirmary ; Consulting Surgeon to the Skiptc 
 
 Hospital and to the Mirfield Memorial Hospital; Member of the Board of Examiners 
 
 in Anatomy for the Fellowship, and formerly Arris and Gale Lecturer, 
 
 Royal College of Surgeons of England 
 
 1 1 lu^trai e d 
 
 PHILADELPHIA, NEW YORK, LONDON 
 
 W. B. SAUNDERS & COMPANY 
 1903 
 
THE 
 
 SURGICAL TREATMENT 
 
 OF 
 
 GASTRIC AND DUODENAL 
 ULCERS. 
 
THE 
 
 SURGICAL TREATMENT OF GASTRIC 
 AND DUODENAL ULCERS. 
 
 In the following pages I propose to discuss my own experience 
 in the operative treatment of simple ulcer of the stomach and 
 duodenum, and to tabulate the cases upon Mdiich I have operated. 
 The subject will be dealt with under the following headings : 
 
 1. Perforation of Gastric or Duodenal Ulcers. 
 
 2. Hemorrhage. 
 
 3. Chronic Ulcer. 
 
 4. Hour-glass Stomach. 
 
 U PERFORATION OF GASTRIC OR 
 DUODENAL ULCERS. 
 
 The perforation of a gastric or duodenal ulcer is one of the 
 most serious and most overwhelming catastrophes that can befall a 
 human being. The onset of the symptoms is sudden, the course 
 rapid, and unless surgical measures are adopted early, the disease 
 hastens to a fatal ending in almost every instance. 
 
 Perforation of the stomach is usually described as being of 
 two varieties, acute and chronic ; but there is an intermediate class 
 of cases, not embraced by either of these terms, which is best de- 
 scribed as subacute. 
 
 In acute perforation the ulcer gives way suddenly and com- 
 pletely. A larger or smaller hole results, and through this the 
 stomach contents are free to escape at once into the general cavity 
 of the peritoneum. 
 
 In subacute perforation the ulcer probably gives way almost 
 as quickly as in the acute form, but, owing to the small size of the 
 
b . PERFORATION. 
 
 ulcer, or to the emptiness of the stomach, or to the instant plug- 
 ging of the opening by an omental flap or tag, or to the speedy- 
 formation of lymph, which forms, as it were, a cork or lid for the 
 ulcer, the escape of fluid from the stomach is small in quantity 
 and the damage inflicted thereby is less considerable. The symp- 
 toms at their onset may be as grave as those in acute perforation, 
 but on opening the abdomen the ulcer may be seen to be plugged, 
 and no further escape of fluid is occurring. 
 
 In the subacute form of perforation I have found that there is 
 always a complaint of greater discomfort for several days preced- 
 ing the rupture. Vague general or localized pains have been felt 
 in the abdomen, or a sharp spasm or " stitch " when the patient 
 turned quickly or attempted to laugh. One girl, a housemaid, 
 felt the pain down her left side especially when reaching up 
 to her work ; another said that it hurt her to bend, as her side felt 
 stiff. These premonitory symptoms are important, and if recog- 
 nized they should enable us to take measures to prevent the occur- 
 rence of perforation. They doubtless have their origin in a 
 localized peritonitis, and the stiffness is due to the unconscious 
 protection of an inflamed area by a muscular splint. 
 
 In chronic perforation the ulcer has slowly eaten its way 
 through the stomach coats, and a protective peritonitis has had 
 time to develop at the base. The escape of stomach contents is, 
 therefore, local merely ; barriers of lymph confine the fluid to a 
 restricted area, and a perigastric abscess may form. A chronic 
 perforation occurs more frequently on the posterior surface of the 
 stomach, and the perigastric abscess occasioned thereby is recog- 
 nized as " subphrenic." The acute and subacute forms of per- 
 forating ulcer are more common on the anterior surface. 
 
 There can be no doubt that recovery by medicinal treatment 
 alone is possible both in the acute and in the subacute forms of 
 perforation. I have had two cases under my care in which a 
 diagnosis of perforation had been made by competent medical 
 men. In both an operation was impossible, as no skilled help was 
 available until the urgency of the symptoms seemed to have 
 passed off. When I operated many months later, the evidences 
 of peritonitis completely surrounding the stomach were undenia- 
 ble. Though patients may recover, their recovery cannot be urged 
 
DIFFICULTIES OF DIAGNOSIS. 7 
 
 as a reason for the delay or withholding of surgical help in all 
 cases. For the possibility of spontaneous recovery, though not 
 denied, is yet so remote as to make it imperative to adopt 
 operative treatment at the earliest possible moment. The risk of 
 operation is definite, the hazard of delay is immeasurable. There 
 are times when the diagnosis may be difficult. If morphin has 
 been administered to still the intolerable pain, the patient's con- 
 dition becomes placid and comfortable. It may be almost impos- 
 sible then to recognize the extreme urgency of the case. In such 
 circumstances I have, however, placed great reliance upon a con- 
 tinued hardness and rigidity of the abdominal muscles. Even 
 when the patient expresses herself as free from pain, when the 
 aspect has become natural, and when the pulse has returned to 
 the normal, the abdominal rigidity remains. In the case of 
 I. S., a girl aged seventeen, upon whom I operated for a perfo- 
 rated duodenal ulcer, the medical man who sent her to the Infirmary 
 had diagnosed a perforated gastric ulcer and had told the patient 
 and her parents that immediate operation alone could save her 
 life. Having obtained consent to operation, he despatched the girl 
 to the Infirmary and gave a hypodermic injection of ^ gr. morphin 
 to lessen the distress of the journey. When I saw her, shortly after 
 her arrival, she looked in perfect health, she had no suffering, and 
 her pulse and respirations were normal. The abdomen, though 
 not distended, was absolutely rigid and immobile, and I did not 
 hesitate to operate at once. In any uncertain case I should incline 
 to operation rather than to indefinite postponement to solve the 
 diagnosis. 
 
 I have seen a difficulty in diagnosis arise, and I know of 
 three cases in which negative exploration had been performed, 
 when the patient was a woman at the commencement of a men- 
 strual period. From some unexplained and indeterminate cause a 
 sharp attack of abdominal pain, followed by vomiting, distention, 
 prostration, and collapse, had occurred in all, and had caused a 
 confusion in the diagnosis. In the case under my own observation a 
 history of previous similar, though less severe, attacks at the men- 
 strual epoch, and the absence of any marked abdominal stiffness 
 or tenderness, though the belly was obviously distended, enabled 
 me to negative the question of perforating ulcer of the stomach. 
 
8 PERFOEATION. 
 
 A difficulty may also arise in the diagnosis of a perforated 
 duodenal ulcer. In a paper published by me in the " Lancet " in 
 December, 1901, I drew attention to the fact that in 18 cases, out 
 of a total of 49 recorded, a diagnosis of appendicitis had been 
 made, and an operation had been undertaken for that condition. 
 The symptoms and signs in all these instances had been limited to 
 the right iliac region or had been more accentuated there. This 
 is due to the fact that, owing to a hillock in the transverse meso- 
 colon, under the pyloric end of the stomach, extravasated fluids 
 are directed downward and to the right into the right renal pouch, 
 and thence to the right iliac fossa. 
 
 The operation for perforated ulcer should be conducted speed- 
 
 Fig. 1.— Diagram showiug the direction of the flow of fluid ia duodenal per- 
 foration. The fluid passes to the right Icidney pouch and to the right iliac fossa, 
 and causes the symptoms to mimic those of appendicitis. 
 
 ily, and all means adopted to save the patient from shock. The 
 excision of the ulcer is not necessary. My practice is to close the 
 ulcer at once by a single catgut suture taken through from side to 
 side so as to prevent any further leakage during the application of 
 the sutures. I apply two continuous sutures of Pagenstecher 
 thread, which infold the ulcer and a portion of healthy stomach 
 around it. After the stitches are completed the cleansing of the 
 peritoneum is begun. If there is much soiling, a free flushing of 
 the cavity is necessary ; if the operation is done within ten or 
 twelve hours, a gentle wiping of the surrounding area with wet 
 swabs will suffice. Drainage, as a rule, is not necessary, except 
 in the late cases. When adopted, it should be free, a split tube 
 
MULTIPLE PERFORATIONS. 9 
 
 and a gauze wick being placed in the original incision and in a 
 second suprapubic opening. I have preferred the enlarging of the 
 original incision, and free flushing through that, to the method of 
 multiple incisions advocated by Finney. One point I think 
 requires emphasis : it is the multiplicity of perforating ulcers. 
 As soon as the ulcer first discovered is sutured, a rapid survey of 
 the whole stomach is desirable in order that any other ulcer may 
 be laid bare. An examination of a large number of recorded 
 cases has shown that double perforation occurs in no less than 20 
 per cent. In the majority the second ulcer was on the posterior 
 surface at a point exactly apposed to the first. In duodenal ulcer- 
 ation the perforation may be very large ; the ulcer seems to have 
 fallen out bodily. When the gap is stitched up, a narrowing of 
 the caliber of the duodenum results, and it may therefore be neces- 
 sary to give an alternative route from the stomach by performing 
 gastro-enterostomy. 
 
2. HEMORRHAGE. 
 
 The bleeding from gastric or duodenal ulcers is recognizable 
 either as hematemesis or as melena. In lesser degree these symp- 
 toms are seen not infrequently ; in their severer forms they are of 
 dire significance, and may be the sole cause of the patient's death. 
 It is but rarely that the surgeon is called upon for so momentous a 
 judgment as is necessary in cases of severe hematemesis or severe 
 melena. For the condition of the patient is poor — even, at times, 
 desperate. Operative intervention is therefore hazardous ; yet a 
 continued bleeding will inevitably end in death. The question as 
 to the conditions under which surgical treatment is prudent or 
 imperative is one that has interested me deeply, and as my oppor- 
 tunity for seeing extreme examples of hemorrhage and of deciding 
 upon the treatment has been large, I may briefly state my position 
 and the reasons for my action. 
 
 It is necessary at the outset to emphasize the fact — a fact fre- 
 quently ignored — that hemorrhage may manifest itself under en- 
 tirely different circumstances in different patients. In some it is 
 the earliest and for a time the only symptom of gastric disturbance ; 
 in others it is the last expression in a long and tedious course of 
 symptoms. In other words, the hemorrhage may occur from an 
 aaide or from a chronic ulcer of the stomach or duodenum. It will 
 be found when the clinical history of a series of cases is examined 
 that whereas in the latter the bleeding varies within the widest limits 
 as regards both quantity and frequency, in the former the clinical 
 history is repeated in case after case in a most remarkable manner. 
 
 Hemorrhage from an Acute Ulcer. — Under the term '^ acute 
 ulcer'' of the stomach are probably included several varieties of 
 pathologic conditions which are different iu causation, different in 
 destiny, but alike in the single fact that their clinical recognition 
 is due to the bleeding which occurs from them in abundant quan- 
 tity. There is the ordinary peptic ulcer ; there is the minute ero- 
 sion, barely recognizable even on close scrutiny, which opens up a 
 
 11 
 
12 HEMORRHAGE. 
 
 vessel ; and there are " weeping patches " and " villous areas " and 
 similar indetermiate conditions which have been recognized when 
 the stomach has been explored during life. To the clinician all 
 these conditions are betrayed by their tendency to hemorrhage. 
 
 In almost every instance the hemorrhage is the first symptom. 
 Even on close inquiry it is difficult to elicit any history of ante- 
 cedent gastric discomforts. The vomiting of blood comes unex- 
 pectedly and suddenly, a large quantity of blood is lost, and the 
 patient suffers, often in an extreme degree, from the symptoms 
 of hemorrhage. The pulse becomes feeble and fluttering, the face 
 waxen, the breathing rapid and shallow, the body-surface cold or 
 clammy. For a time the symptoms may give rise to serious alarm, 
 but a rally is seldom long delayed. The bleeding is checked spon- 
 taneously, and vomiting is rarely repeated, or, if repeated, the quan- 
 tity of blood lost is but small. 
 
 In several of my cases a sudden, apparently causeless hemor- 
 rhage has ushered in a long train of symptoms of dyspepsia. The 
 acute ulcer has been the precursor, or rather the earliest stage, of 
 a chronic ulcer. 
 
 The chai"acteristics of hemorrhage from an acute gastric ulcer 
 are, therefore : spontaneity, abruj^tness of onset, the rccpid loss of a 
 large quantity of blood, the marked tendency to spontaneous cessation, 
 the infrequency of a repetition of the hemorrhage in anything but trivial 
 quantity, and the transience of the resulting anemia. 
 
 Hemorrhage from a Chronic Ulcer. — The bleeding from a 
 chronic ulcer of the stomach or duodenum may vary within the 
 widest limits of both frequency and quantity. For convenience of 
 description I should arrange the cases in four groups. 
 
 1. In the first the hemorrhages are latent or concealed. The 
 blood lost is small in quantity, and may be recognized only after 
 minute examination of the stomach contents or of the feces. The 
 estimates given by various writers as to the occurrence of hemor- 
 rhage in ulcer vary between 20 per cent, and 80 per cent., and we 
 are entitled to assume that this wide divergence of statement is due 
 not so much to differences in the symptoms of ulcer, but rather to 
 the varying degrees of closeness with which the cases are observed, 
 and to differences in the frequency and minuteness of examination 
 of the stomach contents or the feces. It would probably not be 
 
INTEEMITTENT HEMORRHAGES. 13 
 
 rash to assume that all ulcers of the stomach or duodenum bleed 
 at some time or other ; but if the bleeding be trivial and infre- 
 quently repeated, it is never likely to obtain clinical recognition. 
 
 2. In the second group should be included those cases which 
 are characterized by intermittent hemorrhage. The bleeding is 
 copious but transient, and occurs at intervals of two, three, or 
 more months. An exemplary instance of this class is the fol- 
 lowing : 
 
 A. S., female, aged twenty-eight. In May, 1898, the patient 
 had a sudden attack of profuse bleeding from the stomach. She 
 was in bed six weeks. For eighteen months after this her health 
 was very poor ; indigestion was constant, vomiting was occasional, 
 constipation was invariable. For six months she was then in 
 fairly good health, and was able to take food much better. In 
 April, 1900, indigestion became severe, and a copious hemorrhage 
 again occurred. Treatment was continued for six months with 
 much benefit. In January, 1902, a third attack of hematemesis 
 and fainting ; after this she was kept in bed for four weeks. In 
 September, 1902, there was again hematemesis as severe as before. 
 From then to January, 1903, she was under constant treatment, 
 but improvement was very slow. Anemia has been a prominent 
 symptom since April, 1900. At the operation a large ulcer was 
 found in the stomach, and a second in the duodenum. Gastro- 
 enterostomy was performed. 
 
 In all the cases in this group indigestion is a prominent symp- 
 tom. The hemorrhage often occurs without apparent cause, but 
 at times there may have been noticed an exacerbation of gastric 
 discomfort and uneasiness for a few days. Anemia is almost 
 constant. 
 
 3. In the third group the cases are characterized by hemor- 
 rhages which are rapidly repeated and on all occasions abundant. 
 In the majority of patients the symptoms of indigestion, which 
 have been noticed for months or years before, have undergone an 
 appreciable increase in the recent days. Then, suddenly, the 
 hemorrhage occurs ; a large quantity, a pint or a pint and a half, 
 of blood is vomited. The patient may faint from loss of blood; 
 he shows, always, the general symptoms of bleeding. For twelve 
 or twenty -four hours the vomiting ceases, to reappear at the end 
 
14 HEMOREHAGE. 
 
 of this time without apparent cause and in equal or greater quan- 
 tity. A second latent period is followed by a further hemorrhage, 
 and so the patient passes into a condition of the gravest peril. 
 
 No better example of this class could be cited than the fol- 
 lowing : 
 
 N. W., female, aged twenty-four. Has suffered from symp- 
 toms of gastric ulcer, pain, vomiting, and inability to take solid 
 food for fifteen months. Eleven weeks before admission to hos- 
 pital all her symptoms became worse. Vomiting became fre- 
 quent ; pain was almost intolerable. During the five weeks before 
 admission she vomited daily, and on almost all occasions some 
 blood came. While waiting in the hospital she vomited three 
 times in five days, and on each occasion about half a pint of blood 
 came. She was seriously ill and very blanched. Pulse 112. 
 The motions were tarry on two occasions. At the operation two 
 old scars and one showing recent inflammation were seen. Gastro- 
 enterostomy led to perfect recovery. 
 
 4. The fourth group would comprise those cases in which 
 the hemorrhage occurs in enormous quantity, inundating the pa- 
 tient and leading to almost instant death. The opening of the 
 splenic artery, the aorta, the vena cava, or the pancreatico -duodenal 
 vessels allows of such a rapid escape of blood that the patient dies 
 as surely and as swiftly as if his carotid or femoral vessels were 
 divided. Such cases, fortunately, are rare. In my own experience 
 only one such example has occurred, a large oval opening being 
 found in the splenic artery. 
 
 If, then, we accept the classification of cases of hemorrhage 
 from gastric or duodenal ulcer into four groups suggested, we may 
 define their characteristics as follows : 
 
 1. The hemorrhage is latent or concealed, is always trivial, 
 and often inconspicuous. 
 
 2. The hemorrhage is intermittent, but in moderate quan- 
 tity, occurring spontaneously and with apparent caprice at infre- 
 quent intervals. The life of the patient is never in jeopardy from 
 loss of blood, though anemia is a persisting symptom. 
 
 3. The hemorrhage occurs generally, but not always, after a 
 warning exacerbation of chronic symptoms. It is rapidly re- 
 peated, is always abundant, and its persistence and excess cause 
 
TREATMENT OF HEMOERHAGE. 15 
 
 grave peril, and will, if unchecked, be the determining cause of 
 the patient's death. 
 
 4. The hemorrhage is instant, overwhelming, and lethal. 
 
 THE TREATMENT OF HEMORRHAGE. 
 
 (A) From an Acute Ulcer. — If what has been said of the 
 characteristics of hemorrhage ftpm an acute ulcer proves to be 
 true, it is clear that the aid of the surgeon will rarely need to 
 be invoked. Medicinal means alone will suffice in almost every 
 instance to insure the recovery of the patient. Though the hem- 
 orrhage is alarming from its suddenness and intensity, it may con- 
 fidently be predicted that in the majority of cases it will not recur, 
 or that if it recur, the quantity lost will certainly be small. 
 
 There are, however, a few cases in which the hemorrhage may 
 be both copious and recurring and may threaten the life of the 
 patient. Under such circumstances an operation may be re- 
 quired. An examination of the recorded cases has convinced me 
 that wherever surgical treatment is deemed advisable, gastro-enter- 
 ostomy, speedily performed, will prove the surest means of lead- 
 ing to the arrest of the bleeding. In not a few records one reads 
 that the whole surface of the mucosa seemed to be " weeping " 
 blood, that multiple points of oozing appeared scattered irregu- 
 larly over the stomach wall, or that a definite source of the blood, 
 any point from which the blood chiefly ran, could not be ascer- 
 tained. The surgeon has then fallen back upon styptics or the 
 cautery, or the ligating of a villous patch in mass. It is diffi- 
 cult to convince one's self that any of these procedures have had 
 the smallest effi^ct for good ; and in some the bleeding has re- 
 curred after the operation and has determined the fatal issue. 
 A search for a bleeding point is futile, harmful, and, in my judg- 
 ment, quite unnecessary. The performance of gastro-enterostomy 
 will prove more effective than any other procedure both in check- 
 ing the hemorrhage and in preventing its recurrence. 
 
 (B) From a Chronic Ulcer. — It is mainly in regard to the 
 cases included in Group 3 of the classification given above that the 
 question of surgical treatment will arise. If we picture to our- 
 selves the pathologic conditions present in such a case, it will be seen 
 
16 HEMOERHAGE. 
 
 that though the bleeding may be spontaneously checked for a time, it 
 will show a marked tendency to recur. The base of the ulcer is, as a 
 rule, densely hard, and the vessel traverses it like a rigid pipe. 
 The vessel is eaten into, as it were, by the ulcer, which erodes one 
 side, leaving a ragged hole. Owing to the stiffening by chronic 
 inflammatory deposit, the artery is unable to contract or retract, 
 and the bleeding can therefore be checked only by the plug- 
 ging of the opening by a thrombus. That such a plugging does 
 occur there can be no doubt, for in one case I have seen it during 
 life ; on gently detaching the cloth the bleeding began at once 
 with furious onset. The tendency, indeed, even in a chronic ulcer 
 such as I have depicted, must be to spontaneous cessation, for 
 in no other way can the stopping and recurrence of bleeding 
 constantly seen be explained. There is some condition, as yet un- 
 certain, which is responsible for the detaching of the plug. This 
 condition I venture to think is distention of the stomach, whereby 
 the base of the ulcer is stretched and the clot disturbed ; for my 
 record of cases shows indisputably that a gastro-enterostomy per- 
 formed upon a patient suffering from this form of bleeding suf- 
 fices to check the tendency to further hemorrhage and permits of 
 the speedy healing of the ulcer. In all patients so suffering a 
 prolonged search for the ulcer in the stomach is injudicious, and 
 the ulcer, when found, may, as the result of firm fusion with 
 an adjacent structure, be irremovable. In two cases I have 
 excised the ulcer; in the first the ulcer was on the posterior sur- 
 face of the stomach, and to the opening left by its removal I an- 
 astomosed a loop of the jejunum ; in the second the ulcer lay 
 on the anterior surface, near the lesser curvature, toward the 
 cardia. In this I did not perform gastro-enterostomy. In all the 
 other cases that I have operated upon I have not attempted to deal 
 directly with the ulcer, but have hastened to perform gastro-enter- 
 ostomy. Of all the patients, the one upon whom I did not per- 
 form gastro-enterostomy was the only one I lost ; the others 
 recovered speedily and without further sign of hemorrhage. 
 
 In some cases an examination of the stomach may reveal two 
 chronic ulcers, or more, from each of which the blood may be 
 coming. To deal with each would be inadvisable or impossible. 
 Cases are recorded, moreover, in which, after an ulcer had been 
 
TEEATMENT OF HEMORRHAGE. 17 
 
 excised or ligatured in mass, the bleeding had recurred and proved 
 fatal. 
 
 In all cases of hemorrhage from a chronic ulcer, therefore, an 
 operation ought to be performed at the earliest possible moment. 
 Search for, and local treatment of, the ulcer or ulcers are not 
 necessary. A gastro-enterostomy will without doubt prevent a 
 recurrence of the hemorrhage and lead to a rapid healing of the 
 ulcer from which the blood has come. 
 
3. CHRONIC ULCER. 
 
 Chronic ulcer of the stomach may present itself in great 
 diversity of form. In some the onset is brusque, a copious 
 hemorrhage from an acute ulcer being the first manifestation of 
 gastric disease ; after the lapse of a few days or weeks, howev^er, 
 gastralgia, vomiting, and other symptoms appear, and the chronic 
 ulcer is established. In others the onset is latent and the early 
 symptoms subdued. A patient may say that for several months a 
 trivial, vague uneasiness has been experienced, that would have 
 been forgotten but for the later accession of severer symptoms. 
 In still others the course of the disease may present very re- 
 markable intermissions. For several weeks the symptoms may be 
 most marked and disabling, hemorrhage may occur on one or more 
 occasions, but gradually an improvement is observed, and after a 
 time all the distress may rapidly subside, leaving the patient in good 
 health. The appetite may be restored, and the body-weight may 
 increase by a stone or even more. After a few months' inter- 
 val a recurrence of the symptoms is observed, and all the details 
 of the former illness are repeated and fresh hemorrhages may occur. 
 And so the history may be repeated. In these circumstances the 
 symptoms are due perhaps to the breaking down in the scar of 
 a solitary ulcer, or to the fresh outbreak of ulcerated patches 
 in other parts of the organ ; of the two possibilities, the former is 
 certainly the more frequent. 
 
 It is not necessary to describe several different varieties of 
 chronic ulcer, as is often done ; it is probably more correct to 
 say that chronic ulcer may present symptoms of different char- 
 acter in different individuals, or in the same individual under 
 differing conditions. Thus an ulcer which is latent in onset may 
 give rise to bematemesis and may become latent again, and so 
 the recurrence may continue for prolonged periods. If the illness 
 caused by chronic ulceration persist for several years, the patient 
 may be reduced to the very extremity of weakness. His disease 
 
 19 
 
20 CHRONIC ULCER. 
 
 may then show close resemblance to pernicious anemia or to ad- 
 vanced malignant disease of the stomach. 
 
 I have no doubt that many patients who have died from sup- 
 posed malignant disease of the stomach have suffered from noth- 
 ing but chronic ulceration. The induration which a persisting 
 ulceration may cause is remarkable both for its extent and for its 
 extraordinary mimicry of the appearances of malignant disease. 
 In some of my own cases, and especially in one case of hour-glass 
 stomach, the mass of inflammatory tissue was, with the knowledge 
 I then possessed, absolutely indistinguishable by inspection and 
 palpation from a malignant growth. Recently, however, I have 
 in doubtful cases been able, I think, to distinguish chronic inflam- 
 matory masses by their perfect smoothness of surface. A malig- 
 nant growth is almost always irregular, knotted, nodular, or 
 " gritty " on the surface ; an inflammatory mass is more smoothly 
 rounded off, and there is often a milky opacity of the peritoneum. 
 The frequency with which carcinoma will develop in chronic 
 ulcers is now generally acknowledged. Hauser estimated the 
 frequency at 6 per cent. — a proportion which seems to me to be in 
 excess of the truth. In my own experience only one case has 
 been recognized. 
 
 The pathologic conditions caused by chronic ulceration in the 
 stomach are of great variety. When marked cicatricial contrac- 
 tion occurs, the viscus is narrowed at the site of the ulcer, and an 
 hour-glass stomach, or a trifid stomach (Case 14, the only one 
 recorded of this condition), or a dilated stomach due to pyloric 
 or duodenal stenosis results. If the ulcer slowly deepen, a peri- 
 gastritis is produced, and the stomach may become ankylosed to 
 the abdominal wall, the pancreas, the liver, or any other neighbor- 
 ing structure. In all these conditions, and in others where no 
 warping of the stomach can be found, an inveterate dyspepsia is a 
 common symptom. 
 
 It has been the immemorial custom to look upon dyspepsia as 
 due chiefly, if not solely, to deficiency in the quantity or quality 
 of the gastric juice, to some lack of adequate power in the stom- 
 ach as a secreting organ. But dyspepsia of the intractable, con- 
 stantly recurring form is more often a matter of physics than of 
 chemistry. In several cases, as my records will show, I have 
 
ETIOLOGY. 21 
 
 operated for no other symptom than intolerable dyspepsia, when 
 no diagnosis of pyloric obstruction, hour-glass stomach, or other 
 mechanical deviation from the normal could be made. Yet at the 
 operation abundant proof has been obtained that there was an 
 obvious distortion or puckering or adhesion at one part or another 
 of the organ ; and that the stomach was crippled in the freedom 
 of its action by these after-effects of ulceration. One observation 
 that I have repeatedly made in operating upon cases of chronic 
 gastric and duodenal ulcers is that such ulcers are often multiple. 
 If a well-marked ulcer is found at, say, the pyloric end of the 
 stomach on the anterior surface, a second ulcer may be found per- 
 haps at an exactly apposing point on the posterior surface, perhaps 
 elsewhere in the stomach. Chronic gastric ulcers are, in my 
 experience, rarely solitary. 
 
 My own records of cases show that a duodenal ulcer very sel- 
 dom exists without unmistakable evidence of gastric ulcer. Clin- 
 ical observers have long appreciated the difficulty in the discrim- 
 ination of gastric from duodenal ulcers. The differentiation is of 
 little moment, however, for if a duodenal ulcer is present we may 
 be almost certain that a gastric ulcer will also be found. It is, 
 indeed, not unlikely that the duodenal ulcer is secondary to, and 
 directly caused by, the gastric ulcer. For there are many reasons, 
 which need not be repeated, which go to prove that duodenal ulcer 
 is due to the action of the gastric juice on the mucous membrane. 
 The ulcers are formed most frequently at the very beginning of the 
 duodenum ; and the further the distance from the pylorus, the less 
 likely is an ulcer to be present. May it not be that the digestion 
 of the duodenal mucous membrane is accomplished only, or, at the 
 least, most easily, when there is an excess of free hydrochloric 
 acid ? And this condition of hyperchlorhydria is a common, if 
 not a constant, factor at some stage in the history of a gastric 
 ulcer. The sequence of events then would be — gastric ulcer, 
 hyperchlorhydria, duodenal ulcer. The sensitiveness, as it were, 
 of the duodenal mucosa to acid contact is shown by the fact, 
 demonstrated by Pawlow, that the pylorus does not relax to allow 
 of the passage of food until the duodenal contents are alkaline in 
 reaction. Vomiting is an inconstant symptom of chronic ulcer. 
 In the typical case of dilated stomach the vomiting is copious in 
 
22 CHRONIC ULCER. 
 
 quantity, and occurs at intervals of two or three days. The stom- 
 ach fills slowly till its capacity is exhausted, and then an outburst 
 of vomiting empties away the stagnant fluids. In cases of chronic 
 ulcer without dilatation the patient may be rarely troubled with 
 vomiting. On inquiry it will be found that the abeyance of 
 this symptom is due to self-imposed restrictions in the diet. 
 Indulgence in food will often elicit the latent symptom. In one 
 of my earliest and worst cases of hour-glass stomach the patient, 
 who was in bed and under observation in the hospital for over a 
 week, never vomited, yet the constriction between the two pouches 
 would barely admit the end of a pair of pressure forceps. 
 
 The indications for operation in chronic ulcer of the stomach 
 are of widely different character. When the ulcer is near the 
 pylorus, a dilated stomach will probably be the chief clinical sign; 
 when the ulcer is in the body, an hour-glass stomach may be 
 caused ; when the ulcer is nearer the cardiac end, gastralgia and 
 dyspepsia may be the only indications. 
 
 I feel sure that, speaking, generally, the time of the onset of 
 pain after food is some guide to the position of an ulcer. The 
 nearer an ulcer lies to the pylorus, the later will be the period of 
 onset of the pain, and vice versa. Some of the seeming exceptions 
 to this rule are due to the fact, which is commonly overlooked, 
 that multiple ulcer of the stomach and duodenum is the rule. 
 For example, a patient who makes constant complaint of pain 
 within half an hour of food may be found at the operation to have 
 a stenosed pyloric antrum due to ulcer. Yet on examination a 
 second ulcer may be found within 3 or 4 inches of the cardiac 
 orifice, and may at first glance be overlooked. Of such a case I 
 have had personal experience. 
 
 The evidences of old ulceration in the stomach are at times 
 difficult to discover, A thin, fibrous adhesion, a little crumpling 
 of the surface, or a whitish blot on the serous coat may be all that 
 is left of a patch of ulceration. When the stomach is pinched up 
 between the fingers, a little local thickening may be felt, or the 
 mucous membrane may not, as it should, roll away from the mus- 
 cular coat on gentle pressure. If in performing gastro-enterostomy 
 the needle has to be passed through the stomach wall at the margin 
 of an old ulcer, the different and greatly increased resistance to 
 
OPERATIVE TREATMENT. 23 
 
 its passage is ample evidence of the change that has taken place. 
 Inveterate dyspepsia is, in itself, an ample warrant for surgical 
 treatment. Cases are within the experience of all in which pro- 
 longed medicinal treatment, most thoroughly and carefully super- 
 vised, proves ineifective, or, if temporarily beneficial, is powerless 
 to ward oiF the recurrence of dyspepsia. In such cases, be the 
 physical signs what they may, an operation is desirable, and in my 
 experience abundant justification for it will almost always be found 
 when the stomach comes to be examined. 
 
 There are few beings so abjectly miserable as those who are 
 the victims of intractable dyspepsia. The meal-time, which should 
 be a delight, is a time of despair and foreboding. The keen relish 
 of good food, which the man in physical health should appreciate, 
 is a joy unknown or long forgotten to the dyspeptic. A patient 
 who has misery written in every wrinkle of a thin haggard face, 
 who by reason of long suffering and bitter experience has felt com- 
 pelled to abandon first one dish and then another, till fluids alone can 
 be taken, and these not always with impunity ; a patient, to say 
 the truth, whose life becomes embittered by the pangs of a suffer- 
 ing which he must inflict upon himself, — this patient will find, if 
 a gastro-enterostomy be done for the chronic ulcer which is the 
 source of all his trouble, that his return to health and appetite is 
 at first almost beyond belief. 
 
 Not a few of the patients upon whom I have operated have 
 almost declined, at the first, to take solid food, vegetables, pud- 
 dings, pastry, and so forth that I have ordered them. And when 
 the meal has been taken haltingly and with grave doubt, a genuine 
 surprise is expressed that no disablement has followed. Indeed, 
 I do not know any operation in surgery which gives better results, 
 which gives more complete satisfaction both to the patient and to 
 his surgeon, than gastro-enterostomy for chronic ulcer of the 
 stomach. 
 
 OPERATIVE TREATMENT. 
 
 In operating upon chronic ulcer of the stomach I always per- 
 form gastro-enterostomy. It matters not where the ulcer is placed, 
 a gastro-enterostomy will relieve the symptoms completely and 
 permanently and will permit of the sound healing of the ulcer. 
 
24 CHEONIC ULCER. 
 
 This fact, I submit, is placed beyond dispute by the series of cases 
 I am able to record. 
 
 At first sight it might appear desirable on all occasions, or at 
 all times when possible, to excise the ulcer. Such a course is 
 entirely unnecessary ; moreover, it is futile. For I have already 
 pointed out that gastric ulcer is rarely solitary. If two ulcers are 
 found, therefore, or more than two, it is not always possible to say, 
 even by close examination, which of the two is chiefly at fault. To 
 excise all the ulcers — for I have seen a stomach so scarred that 
 the ulcers seemed universal — is quite out of the question unless a 
 partial gastrectomy is performed. But if the chief offending ulcer 
 be excised, gastro-enterostomy would still, in my judgment, be 
 necessary, for among the many cases of excision of ulcer which are 
 recorded there is not infrequent mention of little or no permanent 
 improvement. In all cases, therefore, I submit, gastro-enteros- 
 tomy, and gastro-enterostomy alone, should be performed. Excis- 
 ion is unnecessary, often impossible, always insufticient; and is, 
 therefore, not to be commended. 
 
 On three occasions I have performed pyloroplasty. The oper- 
 ation is one which, both from its ingenuity and its immediate suc- 
 cess, appeals strongly to the surgeon. It is, however, unreliable, 
 a return of the symptoms being not seldom observed. Of my 
 three patients, one remains perfectly well; the second is better, but 
 is certainly not in such good health as the average case of gastro- 
 enterostomy ; the third showed a speedy return of all the symptoms, 
 and I then performed gastro-enterostomy with a perfectly satis- 
 factory result. In this last case and in others which I have seen 
 the return of the symptoms seemed to be due in part to a narrow- 
 ing at the site of the pyloroplasty, and in part to the formation of 
 widespread and tough adhesions around the pyloric portion of the 
 stomach, — adhesions which have seriously hampered the stomach in 
 its freedom of action. Pyloroplasty is, in my judgment, an uncer- 
 tain operation, and its results cannot compare with those seen after 
 the operation of gastro-enterostomy. 
 
 In the performance of gastro-enterostomy I have made the 
 anastomosis on the anterior and on the posterior surface, and I 
 have used the Murphy button and Laplace's forceps as aids to the 
 operation. I wish to speak gratefully of the help I have received 
 
SIMPLE SUTURE IN GASTRO-ENTEROSTOMY, 25 
 
 from these instruments ; but the greatest service they have rendered 
 me is to convince me that they are entirely unnecessary. No 
 better anastomosis is possible than that made with the simple 
 suture, none is so safe, none so adaptable, and so far as speed is 
 concerned I am content to abide the decision of the timekeeper. 
 With the simple suture a gastro-enterostomy rarely takes, from 
 the beginning of the incision to the last skin suture, more than 
 thirty minutes, and I have once completed the operation in seven- 
 teen minutes. I mention these times because I think the question 
 of pace is important. Speed is essential, haste is often disastrous ; 
 the two should be distinguished. Speed should be the achieve- 
 ment, not the aim, of an operator. His work must be thoroughly 
 done ; but being so done, then the quicker it is done the better. 
 I maintain that no time is saved by any mechanical appliances, 
 and the operation is with their aid less perfect than it should be. 
 I know the view which is held as to the Murphy button in Amer- 
 ica, and I have nothing but praise for the great ingenuity dis- 
 played in its making. But not the most ardent v/ill say that the 
 Murphy button never courts disaster. I have seen two patients 
 operated upon for intestinal obstruction caused by a Murphy but- 
 ton used for gastro-enterostomy ; in one case the button had 
 remained for six years. I have myself lost one patient from per- 
 foration of a button used in the performance of ileo-sigmoidostomy, 
 three weeks after the operation. Now, by the method of suture 
 which I adopt for all forms of intestinal and gastric anastomoses, 
 there is no possibility — I speak positively — of present failure or 
 of future mechanical disaster. The suture line has not leaked in 
 one of my cases ; the anastomosis is perfection. In one case of 
 ileo-sigmoidostomy performed in acute obstruction due to cancer 
 in the splenic flexure the patient died at the end of twenty-three 
 and one-half hours. The anastomotic line was closed with the 
 most minute perfection. I claim for the method that it is simple, 
 speedy, applicable to all forms of anastomosis (and therefore time- 
 saving in each, for the operator is quicker in a method he knows 
 well), and is not open to the objection that future troubles are, at 
 the least, possible. 
 
 The following are the steps of the operation of gastro-enter- 
 ostomy : 
 
26 CHRONIC ULCER. 
 
 The abdomen is opened to the right of the middle line, and 
 the fibers of the rectus are split. On opening the peritoneum a 
 complete examination of the whole stomach and duodenum is 
 made. The importance of this cannot be over-emphasized. A con- 
 striction in the body or toward the cardiac end may be most 
 readily overlooked when, as is not uncommonly the case, a marked 
 constriction at the pylorus, seen at once, is ample to account for all 
 the symptoms. Cases of hour-glass stomach which have been 
 overlooked at the operation, and a futile anastomosis made between 
 the pyloric pouch and the jejunum, are recorded by several dis- 
 tinguished operators, and the mistake is an easy one to make unless 
 one is determined to examine the whole of the stomach in every 
 case. The importance of this examination of the whole of the 
 stomach has recently received additional emphasis from the obser- 
 vation of a case upon which I operated a few months ago. I had 
 diagnosed hour-glass stomach, and, opening the abdomen, a perfect 
 bilocular stomach at once was exposed. After demonstrating this 
 I remarked that I always liked to see quite up to the cardia before 
 beginning my operation, and, proceeding in the examination, there 
 was revealed another constriction and another loculus. There 
 were, in fact, two constrictions and three loculi in the stomach — a 
 trifid stomach. As soon as the operator is satisfied as to the con- 
 ditions which exist, the great omentum and transverse colon are 
 lifted out of the abdomen and turned upward over the epigastrium. 
 The under surface of the transverse mesocolon is exposed, and the 
 vascular arch formed mainly by the middle colic artery is seen. A 
 bloodless spot is chosen, a small incision is made in the mesocolon, 
 and the finger is passed into the lesser sac. The opening in the 
 mesocolon is then gradually enlarged by stretching and tearing 
 until all the fingers can be passed through it. It is very rarely 
 necessary to ligate any vessel. The hand of an assistant now 
 makes the posterior surface of the stomach present at this opening 
 (see Fig. 2), and the surgeon grasps the stomach and pulls it well 
 through. A fold of the stomach, about three inches in length, 
 is now seized with a Doyen's clamp. The clamp is applied in 
 such a way that the portion of the stomach embraced by it ex- 
 tends from the greater curvature obliquely upward to the lesser 
 curvature and toward the cardia (see Fig. 3). The duodeno- 
 
Fig. 2. — Showing the posterior surface of the stomach protruding through the 
 aperture made in the transverse mesocolon. 
 
 Fig. 3. — Showing the oblique application of the clamp to the stomach. 
 
 27 
 
28 
 
 CHRONIC ULCER. 
 
 jejunal angle is now sought, and readily found by sweeping 
 the finger along the under surface of the root of the transverse 
 mesocolon to the left of the spine. The jejunum is then brought 
 to the surface, and a portion of it, about nine inches from the 
 angle, is clamped in a second pair of Doyen's forceps. The 
 two clamps now lie side by side on the abdominal wall, and the 
 portions of stomach and jejunum to be anastomosed are well out- 
 side the abdomen, embraced by the clamps. The whole operation 
 area is now covered with gauze wrung out of hot sterile salt solu- 
 tion, the clamps alone remaining visible (Fig. 4). A continuous 
 
 Fig. 4. ^Showing the two damps in position, and the first suture. 
 
 suture is then introduced uniting the serous and subserous coats of 
 the stomach and jejunum. The stitch is commenced at the left 
 end of the portions of gut inclosed in the clamp, and ends at the 
 right. The length of the sutured line should be at least two inches. 
 In front of this line an incision is now made into the stomach and 
 jejunum, the serous and muscular layers of each being carefully 
 divided until the mucous membrane is reached. As the cut is made 
 the serous coat retracts and the mucous layer pouts into the incision. 
 An ellipse of the mucous membrane is now excised from both 
 
METHOD OF PLACING SIMPLE SUTURE. 
 
 29 
 
 stomach and jejunum, the portion removed being about one and 
 three-fourths inches in length and half an inch in breadth at the 
 center. The stomach mucosa shows a marked tendency to retract ; 
 it is therefore seized with a pair of miniature vulsella on each side. 
 No vessels are ligated. The inner suture is now introduced. It 
 embraces all the coats of the stomach and jejunum, and the 
 
 Fig. 5. — Showing the method of suture. 
 
 individual stitches are placed close together and drawn fairly tight 
 so as to constrict all vessels in the cut edges. The suture begins 
 at the same point as the outer one, and is continued without inter- 
 ruption all around the incision to the starting-point, where the ends 
 are tied and cut short. It will be found that there is no need to 
 
30 
 
 CHRONIC ULCER. 
 
 interrupt the stitch at any point, for there is no tendency on the 
 part of the sutured edges to pucker when the stitch is drawn tight. 
 The clamps are now removed from both the stomach and the 
 jejunum to see if any bleeding point is made manifest. Very 
 rarely — about once in ten cases — a separate stitch at a bleeding 
 
 Showing the method of suture. 
 
 point is necessary. The outer suture is now reassumed and con- 
 tinued around to its starting-point, being taken through the serous 
 coat about one-sixth of an inch in front of the inner suture. This 
 outer stitch is also continuous throughout ; when completed, the 
 ends are tied and cut short, as with the inner stitch. There are 
 
FOUR POINTS IN GASTRO-ENTEROSTOMY. SI 
 
 thus two suture lines surrounding the anastomotic opening : an 
 inner, hemostatic, which includes all the layers of the gut ; and 
 an outer, approximating, which takes up only the serous and sub- 
 serous coats. For both stitches I use thin Pagenstecher thread. 
 No sutures are passed through the mesocolon and stomach. The 
 gut is lightly wiped over with a swab wet in sterile salt solution, 
 the viscera returned within the abdomen, and the parietal wound 
 sutured layer by layer. When the patient is replaced in bed, the 
 head and shoulders are supported by three or four pillows. The 
 operation lasts, from beginning to end, about thirty to thirty-five 
 minutes, but can be shortened by five or ten minutes if the condi- 
 tion of the patient demands it. 
 
 In connection with the ojaeration of gastro-enterostomy the 
 following points are worthy of attention : 
 
 1. The sterilization of the mouth, stomach, and jejunum. 
 As soon as the patient is admitted for operation the preparation of 
 the mouth is begun ; the teeth are cleansed and brushed frequently 
 with some mild antiseptic mouth-wash ; all food given is liquid and 
 sterile. The stomach is washed out twice, once about thirty-six 
 hours before the operation, and again about six hours before, with 
 tepid boiled water. Calomel is given forty-eight hours before the 
 operation. 
 
 2. Gloves made of thin india-rubber and boiled are worn by 
 the operator, assistants, and nurses. 
 
 3. The hands are rinsed in salt solution during the operation; 
 no antiseptic is allowed to touch the peritoneum. 
 
 4. Scrupulous care is taken to avoid any possible infection 
 from the stomach or jejunal mucosa. The scissors and clips which 
 touch the mucous membrane are at once laid aside, and not used 
 during the subsequent stages of the operation. As soon as the 
 mucous membrane suture is completed the gut is lightly washed 
 with saline solution, and the hands are then thoroughly well 
 cleansed. 
 
 With regard to the after-treatment there is but little to say ; 
 nutrient enemata are given every four hours, and the bowel is 
 washed out every morning with a pint of hot water ; no fluid is 
 given by the mouth for twelve hours, or until the ether sickness 
 is over ; then water in teaspoonful doses every fifteen minutes is 
 
32 CHRONIC ULCER. 
 
 given, and the quantity increased and the intervals lessened if 
 sickness is not aroused. At the end of forty-eight hours milk and 
 a little pudding, soups, and such like are given. By the eighth 
 day fish and minced chicken are taken, and in less than a fortnight 
 solid food will be relished. The patient generally requires a 
 caution not to overeat during the first month or two, for often the 
 appetite is ravenous. 
 
4 HOUR-GLASS STOMACH. 
 
 By hour-glass stomach (bilocular stomach ; hour-glass contrac- 
 tion of the stomach) is understood that condition in which the 
 stomach is divided into two compartments by the narrowing of 
 the viscus at or near its center. The two locnli so formed may 
 
 Fig. 7. — Hour-glass stomach — found post mortem. 
 
 be almost equal in size, or one, generally the cardiac pouch, may 
 be very much larger than the other. In one instance, Case 15, I 
 have seen the stomach divided into three pouches ; and in another. 
 Case 14, a condition of hour-glass duodenum was associated with 
 hour-glass stomach, so that four pouches, two larger in the stom- 
 ach, two smaller in the duodenum, were seen. The isthmus con- 
 3 33 
 
34 
 
 HOUE-GLASS STOMACH. 
 
 necting the two parts of the stomac'h is generally found at or near 
 the middle of the viscus, but owing to stasis of food the cardiac 
 complement becomes dilated and is then much larger, thicker, and 
 more capacious than the pyloric. The pyloric pouch is, however, 
 not seldom dilated also, and in such circumstances a pyloric or 
 duodenal stenosis will also be found. 
 
 PATHOGENY. 
 
 Hour-glass stomach is usually described as being " congeni- 
 tal " and " acquired." Of these forms, the congenital is said to 
 
 3 6 
 
 Fig. 8. — Types of hour-glass stomach : 1, Obstruction near cardiac end ; 2, 
 cardiac pouch concealed by adhesions ; 3, growth in body of stomach ; 4, two 
 pouches connected by a narrow tube ; 5, cardiac pouch largely dilated ; 6, lesser 
 curvature pulled down toward the greater. 
 
 be more frequent. Thus, Fenwick in his work writes : " In about 
 45 per cent, of the cases which have been recorded neither ulcer 
 
PATHOGENY. 35 
 
 nor scar could be detected in the stomach, while in the great 
 majority of cases where an ulcer was present it was obviously of 
 more recent formation than the stricture ; " and, again, " that the 
 deformity is a rare result of ulceration is proved by the fact that 
 only one case of the kind is mentioned in the records of the Lon- 
 don Hospital for forty years, whereas several instances of the con- 
 genital form of the disease were encountered during the same 
 period of time." 
 
 Meckel considered that a congenital hour-glass stomach might 
 result from an imperfection of development, and Cruveilhier and 
 others have suggested that the sacculation is an instance of atav- 
 ism, and that there is an analogy between such a deformity and 
 the normal bifid stomach of certain rodents and the pouched 
 stomachs of ruminants. 
 
 On examination of specimens of hour-glass stomach there can 
 occasionally be seen two crossing bundles of muscular fibers on 
 each surface of the organ. These were first noticed by Mari- 
 otti, but were more fully described by Saake. The bundles are 
 generally half an inch or more in width, and cross at the point of 
 narrowing in the stomach. Traced from the upper side of the car- 
 diac complement, a bundle is seen to pass to the lower side of the 
 pyloric, and from the lower side of the cardiac complement to the 
 upper part of the pyloric, the fibers crossing like the widely 
 opened blades of a pair of scissors. It has been suggested that 
 these outstanding bands of muscle by their contraction deter- 
 mine the hour-glass form of the stomach, and their existence 
 is held to be proof of the " congenital " origin of the deformity. 
 In the only example I have seen of this muscular arrangement the 
 hour-glass stomach was clearly the result of an ulcer, whose edges 
 were immensely thickened and whose base had perforated. In this 
 case the bundles of fibers followed the lines of puckering pro- 
 duced by the contraction of the ulcer, and were therefore clearly 
 the result, and not the cause, of the deformity. 
 
 Cumston and other writers have said that in congenital hour- 
 glass stomach the two pouches are connected by a tube or cylinder 
 showing no scar of ulceration, and free externally from all adhe- 
 sions. One such case I have dealt with by operation. I slit up 
 the channel connecting the two sacs, and found a perfect example 
 
36 HOUE-GLASS STOMACH. 
 
 of "bridle" stricture, the result of healing in an ulcer which from 
 the mucous surface was easily seen and felt. 
 
 An example of congenital hour-glass stomach is said to have 
 been recorded by Sandifort ; the specimen was obtained from a 
 fetus. But the appearance of hour-glass deformity may be 
 mimicked with remarkable accuracy by a condition of dilatation 
 of the stomach and of the upper part of the duodenum, as the 
 result of a congenital narrowing of the duodenum at or near the 
 bile papilla. Such a case is recorded by Wyss. Sandifort's case 
 is certainly open to question, for the description is not convincing. 
 
 In all the recorded examples of hour-glass stomach where a full 
 examination of the viscus had been made, ulceration has been 
 found. For those who believe that the deformity is congenital the 
 theory that the ulcer is secondary is sufficient. Thus, Cumston 
 writes : " These ulcers are secondary, and are probably produced 
 by the pressure of the food passing through the strictured part of 
 the organ." 
 
 Roger Williams, in 1883, described ten examples of "congeni- 
 tal" contraction of the stomach. The account of one of the 
 cases is based on the examination of a wax model ; of another, on 
 the inspection of an " inflated dried " specimen ; and of a third, 
 on the appearance of a dried stuffed specimen. It is doubtful 
 whether one of the examples can be accepted as an hour-glass 
 stomach. In all the others pathologic conditions — ulceration, 
 puckering, thickening, or adhesions — were found. 
 
 Hochenegg, Carrington, Maier, Saake, and many other writers 
 who describe their examples as " congenital " mention thickening, 
 old ulceration, adhesion to the pancreas or to the abdominal wall, 
 localized perforation, and other conditions which are indubitably 
 the result of chronic ulcer of the stomach. Doyen, in his work 
 on the diseases of the stomach and duodenum, refers to a case in 
 which, at the isthmus of the stomach, an adhesion to the anterior 
 abdominal wall was found ; on breaking through this, a gastric 
 fistula was exposed, showing unmistakably that an ulcer had been 
 present, which had been prevented from perforating into the peri- 
 toneal cavity only by the anchoring of the organ to the anterior 
 abdominal wall. This is said to be " congenital," 
 
 Mazotti relates a case of " congenital " hour-glass stomach in 
 
ETIOLOGY. ■ 37 
 
 a woman of fifty ; he believes the deformity to l)e due to an 
 unusual development of the transverse muscular fibers in a certain 
 part of the wall of the viscus. Without entering in detail into 
 this discussion, I may say that I have very carefully considered 
 the question as to the existence of hour-glass stomach as a con- 
 genital deformity, examining all the specimens that I could find, 
 and reading carefully the records of, I believe, all the published 
 cases ; but I remain confident in my belief that tliere is no evi- 
 dence whatever which will establish the claim of those who assert 
 that the disease is often congenital in origin. Since I first threw 
 doubts upon the congenital origin of many of the cases of hour- 
 glass stomach, and showed that in almost all of the cases obvious 
 evidence of old ulceration could be found, several investigators 
 have supported my conclusion by observations made during the 
 course of operation or on post-mortem examination. There is, in- 
 deed, no inherent improbability in the existence of congenital 
 hour-glass stomach, but it lacks proof. 
 
 Acquired hour-glass stomach may be caused by : (1) Perigas- 
 tric adhesions ; (2) ulcer, with local perforation and anchoring to 
 the anterior abdominal wall ; (3) chronic ulcer, generally at or 
 near the middle of the organ ; (4) malignant disease. 
 
 1. Perigast7'ic adhesions may result from many causes — gastric 
 ulcer, old tuberculous peritonitis, inflammatory affections of the 
 gall-bladder, and so forth. In rare instances these adhesions may 
 be the sole cause of the partition of the stomach ; in many in- 
 stances they are no more than contributing causes. They were 
 well seen in a case related by Cumston. 
 
 2. Ulcer U'ith local perforation and anchoring of the stomach to 
 the anterior abdomincd wall. This was the condition I found in my 
 first case. It results from gradual deepening of a chronic ulcer. 
 As the ulcer approaches the serous coat of the stomach, a few ad- 
 hesions form, binding the viscus to the anterior abdominal wall, 
 preventing the bursting of the ulcer into the general peritoneal 
 cavity. If the ulcer be on the posterior surface, a soldering to 
 the pancreas may result, as in one case I have recently seen. 
 When the stomach is anchored in its middle, the pouches on each 
 side, but more especially on the cardiac side, show a tendency to 
 sagging, and this, with the cicatricial contraction taking place in 
 
38 
 
 HOUE-GLASS STOMACH. 
 
 the ulcer, results in hour-glass form of the stomach. In one 
 of my cases a malignant mass in the anterior wall had formed an 
 extensive adhesion to the bodj-wall. Doyen, Steffan, and Finney 
 have recorded similar examples. 
 
 In three recorded cases an ulcer at the isthmus of an hour-glass 
 stomach has perforated into the peritoneum and caused death. 
 The first case was related by Siewers, the second by my friend 
 Mr. W. H. Brown, and the third by Thomsen (Hospitals tidende 
 1901, N. 23, Kopenhagen). 
 
 3. Chronic ulcer. A chronic ulcer of the stomach is character- 
 
 Fig. 9. — Hour-glass stomach showing perforation (W. H. Brown's case). 
 
 ized by the thickening and induration at its base. In the heal- 
 ing of such an ulcer, especially if large in size or circular, a con- 
 siderable amount of contraction will necessarily take place, and a 
 high degree of narrowing of the stomach may result. There is, 
 I believe, in addition to the cicatricial contraction, another factor of 
 chief importance in determining the narrowing of the organ. I 
 refer to spasm. On several occasions during the last two years, 
 when operating for chronic ulcer, I have watched the stomach in- 
 tently for several minutes, and have seen the onset, the acme, and 
 the gradual relaxation of a spasmodic muscular contraction in its 
 
ETIOLOGY. 39 
 
 walls. Quite gradually the stomach narrows, and the wall be- 
 comes thicker and almost white in color ; when taken between the 
 fingers the contracted area feels like a solid tumor. The spasm 
 may be so marked as to prevent a finger being invaginated through 
 the segment affected. The appearance presented is very striking. 
 I have seen it in the body of the stomach and at the pylorus. As 
 slowly as it comes on, the spasm quietly relaxes, and the stomach 
 assumes its usual form. In one patient I watched four such spas- 
 modic seizures at the pylorus in a few minutes, and the tumor 
 formed by the tightly contracted muscle was so large that in a very 
 thiu subject it should have been felt on palpation of the abdomen. 
 Such constantly recurring attacks of spasm must lead to an hyper- 
 trophy of the circular muscular fibers, and this thickening, to- 
 gether with the cicatricial contraction and the induration of the 
 ulcer, will amply account for the extreme narrowing of the stomach 
 cavity, with the dense thickening of the walls met with in many 
 of the examples recorded. 
 
 The extent to which spasmodic contraction, invoked by ulcer- 
 ation, is responsible for the narrowing found in hour-glass stomach 
 (and congenital stenosis) is not capable of being measured ; but 
 my observation of the cases I have seen during the last two years 
 makes me ready to believe that it is not inconsiderable. 
 
 Klein has recorded one example of hour-glass stomach result- 
 ing from the contraction of an ulcer which had been caused by the 
 drinking of hydrochloric acid with suicidal intent. Syphilis of 
 the stomach may result in nicer or gumma and in consecutive 
 warping of the viscus. 
 
 The amount of induration found around a chronic ulcer may be 
 so considerable, and its density so marked, that a mistaken diag- 
 nosis of malignant disease of the stomach may be made. This 
 happened in Case 11 of my list. A large, densely hard, immovable 
 mass, adherent to the pancreas, was found in the stomach walls 
 between the two loculi. The appearance of malignant disease was 
 accurately simulated. I could not remove the mass, and could 
 not reach the cardiac pouch with sufficient ease to allow me to 
 perform a gastro-enterostomy, and I was therefore only able to 
 dilate the constriction between the two pouches. After consider- 
 able pressure I succeeded in invaginating my little finger through 
 
40 HOUR-GLASS STOMACH. 
 
 the isthmus, and slowly dilated it until three fingers would pass 
 through. I hoped by so doing to lessen the distress of vomiting, 
 which had been almost continuous. The patient speedily recov- 
 ered, and now, after two years, is perfectly well ; she has gained 
 2 1 stones in weight, is ruddy and healthy in appearance, and the 
 tumor, readily palpable before the operation, has entirely disap- 
 peared. 
 
 One point which is, I believe, deserving of especial emphasis 
 is the frequency with which, in cases of hour-glass stomach due to 
 chronic ulcer, a narrowing of the pylorus is also found. The con- 
 striction in the middle of the stomach hinders the passage of food 
 from {he cardiac to the pyloric pouch; the narrowing at the 
 pylorus makes difficult the emptying of the pyloric sac, which, in 
 consequence, undergoes dilatation. This double constriction is an 
 illustration of the fact I have verified in operations upon the 
 stomach — the frequency of multiple ulcers in the stomach, or in 
 the duodenum, or in both. If the cardiac loculus alone is 
 obstructed, the pylorus being free, the walls of the former are 
 much thicker than those of the latter. Lunnemann, in such a 
 case, found the circular muscular fibers 2 to 2.5 mm. thick on the 
 cardiac side, and only 1 to 1.5 mm. on the pyloric. It is possible 
 that the contraction found at the pylorus may be the result of a 
 long-continued spasm, set up by the ulcer whose healing has caused 
 the hour-glass shape of the stomach. Frequent spasm would cause 
 hypertrophy of the muscular coats, and fibrous transformation 
 would occur in the over-developed muscle. In one case under my 
 care a double constriction had been formed in the stomach and 
 three pouches had thereby resulted. This is the only recorded 
 example of trifid stomach due to ulceration. 
 
 Jf.. Cancer. Cancer as a cause of hoar-glass stomach is not 
 infrequent. Three specimens of this kind are in the Museum .of 
 the Royal College of Surgeons in London. I have operated upon 
 two cases. In the first the malignant disease, beginning rather 
 nearer the cardiac than the pyloric end of the stomach, had infil- 
 trated the greater part of the organ, and had resulted in a condition 
 of " leather bottle " stomach. In the second a large chronic ulcer, 
 with carcinoma implanted upon it — " ulcus carcinomatosum " — 
 was found. 
 
SYMPTOMS. 41 
 
 SYMPTOMS OF HOUR-GLASS STOMACH. 
 
 An hour-glass stomach can be diagnosed with certainty if 
 attention be paid to a certain comlaination of symptoms. In my 
 first six cases only one was diagnosed ;, in my last eight cases six 
 were diagnosed with certainty ; in one of these the diagnosis 
 was made by the medical attendant, Dr. M'Gregor Young, before 
 I was asked by him to see the patient. The symptoms will natu- 
 rally vary according to the position of the constriction in the 
 stomach : if this lies near the cardiac orifice, the clinical picture 
 will resemble that given by esophageal obstruction low down ; if 
 near the pyloric orifice, the symptoms are those of dilated stomach. 
 But w^herever the narrowing may be, attention to the following 
 signs will, in almost every case, enable a diagnosis to be made with 
 confidence : 
 
 1. If the stomach tube be passed, and the stomach washed out 
 with a known quantity of fluid, the loss of a certain quantity will 
 be observed when the return fluid is measured. Thus, if 30 ounces 
 be used, only 24 can be made to return, as in Dr. M'Gregor 
 Young's case already mentioned. Wolfler, who called attention 
 to this sign, said that some fluid seemed to disappear " as though 
 it had flowed through a large hole " — as indeed it has, in passing 
 from the cardiac to the pyloric pouch (Wolfler's " first sign "). 
 
 2. If the stomach be washed out until the fluid returns clear, 
 a sudden rush of foul, evil-smelling fluid may occur ; or if the 
 stomach be washed clean, the tube withdrawn and passed again, in 
 a few minutes several ounces of dirty, offensive fluid may escape. 
 The fluid has regurgitated through the connecting channel between 
 the pyloric and cardiac pouches (Wolfler's " second sign "). 
 
 3. Paradoxical dilatation. If the stomach be palpated and 
 a succussion splash obtained, the stomach-tube passed, and the 
 stomach apparently emptied, palpation will still elicit a distinct 
 splashing sound. This is due to the fact that only the cardiac 
 pouch is drained ; the contents of the pyloric remain undisturbed, 
 and cause the splashing sound on palpation. For this phenomenon 
 Jaworski has suggested the appropriate name of " paradoxical dila- 
 tation." Jaboulay has pointed out that if the cardiac loculus be 
 filled with water, a splashing sound can still be obtained by palpa- 
 
42 HOUE-GLASS STOMACH. 
 
 tion over the pyloric pouch. The sign of paradoxical dilatation is 
 best elicited after washing out the stomach in the ordinary manner. 
 When the abdomen is examined at the completion of the washing, 
 and when the stomach has been apparently drained quite dry, a 
 splashing sound is readily obtained, for some of the fluid used has 
 escaped into the pyloric pouch through the connecting channel. 
 
 4. Von Eiselsberg observed in one of his cases that on dis- 
 tending the stomach a bulging of the left side of the epigastrium 
 was produced ; after a few moments this gradually subsided, and 
 concomitantly there was a gradual filling up and bulging of the 
 right side. 
 
 5. Von Eiselsberg also called attention to the bubbling, forcing, 
 " sizzling " sound which can be heard when the stethoscope is 
 applied over the stomach, after distention with CO^. If the two 
 halves of a seidlitz powder are separately given, and the stomach 
 be normal or dilated, no loud sound is heard anywhere except at 
 the pylorus ; if a constriction is present in the stomach, a loud, 
 forcible, gushing sound can be easily distinguished, at a point 2 or 
 3 inches to the left of the middle line. 
 
 6. I first called attention, two years ago, to a sign which I 
 have since found of great service in establishing a diagnosis of 
 hour-glass stomach. The abdomen is carefully examined and the 
 stomach resonance is percussed. A seidlitz powder in two halves 
 is then administered. On percussing, after about twenty or thirty 
 seconds, an enormous increase in the resonance of the upper part 
 of the stomach can be found, while the lower part remains unaltered. 
 If the pyloric pouch can be felt, or seen to be clearly demarcated, 
 the diagnosis is inevitable, for the increase in resonance must be in 
 a distended cardiac segment. If the abdomen be watched for a 
 few minutes, the pyloric pouch may sometimes be seen gradually 
 to fill and become prominent. 
 
 7. Schmidt-Monard and Eichhorst have both seen a distinct 
 sulcus between the two pouches inflated with CO^. In Case 10 in 
 my list, the two pouches, with a hard, as I thought, malignant, 
 mass between them, could readily be seen. When both pouches 
 were distended with CO^, alternate pressure upon them showed 
 unmistakably that they communicated through a very narrow 
 orifice, for the one could be emptied slowly into the other, and the 
 
DIFFERENTIAL DIAGNOSIS. 43 
 
 fluid could be felt to ripple gently through. The diagnosis in such a 
 case is simplicity itself. In Case 8 a distinct notch was seen at 
 the lower border of the inflated stomach. 
 
 8. Ewald has called attention to two signs which he considers of 
 value in establishing a diagnosis. When the stomach is filled with 
 water and examined by gastro-diaphany, the transillumination is 
 seen only in the cardiac pouch ; the pyloric pouch remains dark. 
 
 9. The deglutable india-rubber bag of Turck and Hemmeter 
 is passed and distended. The bulging caused thereby is limited 
 to the cardiac pouch, which lies to the left of the middle line. 
 
 The two aids to diagnosis of greatest value are, it will be 
 seen, the washing out of the stomach, and its inflation with gas by 
 the administration of a seidlitz powder in two portions. The fluid 
 used for the washing must be carefully measured before use ; the 
 tube is then passed, and the stomach emptied, the contents set 
 aside in a separate dish, and the washing commenced. All the 
 fluid now returning is collected in a separate vessel and carefully 
 measured. The two signs of Ewald are of little importance ; a 
 correct diagnosis can always be made without'them. 
 
 DIFFERENTIAL DIAGNOSIS. 
 
 The two conditions for which an hour-glass stomach is liable 
 to be mistaken are obstruction in the lower part of the esoph- 
 agus and pyloric stenosis. If the constriction in the stomach is 
 within an inch or two of the cardiac orifice, the upper loculus of the 
 stomach will be very small in size, and capable, therefore, of hold- 
 ing only small quantities of food. Food, when swallowed, may 
 be regurgitated within a few minutes almost unaltered, and the 
 patient may tell the same story of difficulty in " getting the food 
 down " as is told by one whose esophagus is obstructed, A correct 
 diagnosis can be made by introducing the esophageal bougie ; if 
 the bougie passes over 16 inches from the teeth, the obstruction 
 does not lie in the stomach. 
 
 If the constriction be near the pylorus, the cardiac comple- 
 ment will be dilated, and will present the same appearance and 
 signs as a dilated stomach. Wolfler's two signs (1 and 2 in the 
 list given) will generally enable a correct diagnosis to be achieved. 
 
44 HOUR-GLASS STOMACH. 
 
 If the obstruction should lie at any point between the two 
 mentioned, there should be no difficulty in making a correct diag- 
 nosis. 
 
 TREATMENT. 
 
 The treatment of hour-glass stomach may be beset with dif- 
 ficulties. If the stricture is near the cardiac, or if the cardiac 
 complement be bound up in adhesions, there may be great me- 
 chanical hindrance to the performance of any operation. When 
 the abdomen is opened, a thorough examination of the whole 
 stomach must first be made. The dilated pyloric sac may so com- 
 pletely resemble the whole stomach as to lead to the performance 
 of a gastro-enterostomy between it and a loop of the jejunum. 
 Several cases are recorded in which this mistake has been made, 
 and it is therefore necessary to emphasize the importance of an 
 examination of the whole stomach up to the cardiac orifice in every 
 case, no matter how obvious the diagnosis of " dilated stomach " 
 may have seemed. ^ 
 
 In one case, that in which a " trifid " stomach was found, I 
 had diagnosed hour-glass stomach after eliciting several of the 
 signs mentioned. On opening the abdomen I exposed at once a 
 perfect example of bilocular stomach ; the two pouches and the 
 intervening constriction were well seen. After completing my 
 demonstration of this I remarked to my assistant that I never 
 began a stomach anastomosis until I had seen all the viscus, quite 
 up to the cardiac end. On continuing my examination in this direc- 
 tion I exposed a second constriction and a pouch. There were 
 then three pouches and two constrictions. 
 
 In many cases of hour-glass stomach no single operation will 
 suffice to relieve the symptoms. This is due to the fact, already 
 mentioned, that where a stricture is present in the body of the 
 stomach, a second stricture near the pylorus may also be found. 
 If there be any dilatation of the pyloric complement, a constriction 
 at the pylorus or in the duodenum will certainly be found. This 
 dual stenosis, which has not received adequate attention from any 
 writer, accounts for the lack of permanent improvement seen in 
 many of the recorded cases. If in such circumstances a gastro- 
 enterostomy is performed between the cardiac pouch and the 
 
OPERATIONS. 45 
 
 jejunum, the pyloric pouch becomes a reservoir incapable of effi- 
 cient emptying, wherein food lodges and becomes sour. Symptoms 
 of stasis are then observed — acid, bitter eructations, occasional 
 vomiting, a sense of heaviness and heat at the epigastrium, and 
 distaste for food — and, as in a case recorded by Terrier, a second 
 operation is necessary. If a gastroplasty is performed, the stom- 
 ach cannot empty itself because of the p}^oric stenosis, and the 
 symptoms are unrelieved. Such a condition of double stenosis 
 can therefore be adequately treated only by the performance of 
 two operations at the same time — gastroplasty and pyloroplasty ; 
 gastroplasty and gastro-enterostomy from the pyloric pouch ; gastro- 
 gastrostomy and gastro-enterostomy ; or a double gastro-enteros- 
 tomy, a loop of jejunum being opened at two points, at the upper 
 into the cardiac pouch, at the lower into the pyloric. 
 
 In operating upon hour-glass stomachs I have noticed on sev- 
 eral occasions that the pyloric pouch was partially filled with a 
 dirty-looking and slightly oifensive fluid. In washing out the 
 stomach before operation, it is obvious that when the stricture is 
 narrow the cardiac pouch only is cleansed. In the pyloric pouch 
 food remains stagnant for lengthy periods and may become foul, 
 ■putrid, evil-smelling. Before opening the pyloric sac for the 
 purposes of anastomosis, it may be necessary to empty it of its 
 contents through a needle to which is attached a long tube. Leak- 
 age from the pouch should be prevented, and any swabs used to 
 dry the surface when cut should be instantly discarded. 
 
 The following are the operations that may be practised : 
 
 1. Gastroplasty. 
 
 2. Gastro-gastrostomy or gastro-anastomosis. 
 
 3. Either of the foregoing, with gastro-enterostomy from the 
 pyloric pouch, in cases of dual stenosis. 
 
 4. Gastro-enterostomy from the cardiac pouch, when the py- 
 loric pouch is so small that it can be ignored. 
 
 5. Gastro-enterostomy from both pouches. 
 
 6. Partial gastrectomy. 
 
 The operation selected will necessarily depend upon the con- 
 dition which is found. Thus I performed : — 
 Gastroplasty alone in Cases 1, 2, 3, 5, 11. 
 Gastro-enterostomy alone in Cases 6, 7, 8, 9. 
 
46 
 
 HOUR-GLASS STOMACH. 
 
 Gastroplasty and gastro-enterostomy in Cases 12, 13. 
 Gastro-gastrostomy alone in Case 4. 
 
 Gastro-gastrostomy and gastro-enterostomy in Cases 14, 15. 
 Partial gastrectomy is the operation of choice in cases of 
 malignant stricture in the body of the stomach. 
 
 Fig. 10. — Diagrams showing the operatious for hour-glass stomach : 1, Gastro- 
 gastrostomy ; 2, 3, gastroplasty ; 4, double gastro-enterostomy ; 5, partial 
 gastrectomy ; 6, gastro-enterostomy from the cardiac pouch. 
 
 Gastroplasty was first performed by Bardeleben in 1889, later 
 by Kruckenberg, Doyen, and others. 
 
 Gastro-gastrostomy was first performed by Wolfler in 1894. 
 In 1895 Sedgwick Watson performed a gastro-anastomosis by 
 folding the pyloric pouch over the cardiac pouch, with the con- 
 striction as a hinge, and uniting the apposed surfaces. 
 

TABLES OF CASES. 
 
 Table I. 
 
 Perforating Ulcer. 
 
 12 cases. 
 
 6 recoveries, 
 
 Table II. 
 
 Gastro-enterostomy. 
 
 69 cases. 
 
 1 death. 
 
 Table III. 
 
 Pyloroplasty. 
 
 3 cases. 
 
 death. 
 
 Table IY. 
 
 Hour-glass Stomach. 
 
 15 cases. 
 
 3 deaths. 
 
 Excision of 
 
 Ulcee. 
 
 1 case. 
 
 Death. 
 
 Gasteoplication. 
 
 1 case. 
 
 Recovery. 
 
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 83 
 
SAUNDERS' BOOKS 
 
 on 
 
 SURGERY 
 
 and 
 
 ANATOMY 
 
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SAUNDERS' BOOKS ON 
 
 American 
 Text-Book of Surgery 
 
 American Text=Book of Surgery. Edited by William W. Keen, 
 M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Sur- 
 gery and of Clinical Surgery, Jefferson Medical College, Philadel- 
 phia ; and J. William White, M.D., Ph.D., John Rhea Barton 
 Professor of Surgery, University of Pennsylvania. Handsome octavo, 
 1230 pages, with 496 wood-cuts in the text and 37 colored and half- 
 tone plates. Cloth, ^7.00 net ; Sheep or Half Morocco, ^8.00 net. 
 
 THIRD EDITION, THOROVGHLY REVISED AND ENLARGED 
 
 Of the two former editions of this book there have been sold over 36,000 
 copies. This and its adoption as a text-book in eighty-five medical colleges 
 have furnished a stimulus to the authors to keep the work abreast of the times 
 by another careful revision. This has been accomplished by a vigorous scrutiny 
 of all the old matter, by the enlargement of several sections, by the addition of 
 new illustrations, and by the introduction of the many new topics that have come 
 to the front in the surgery of to-day. Among the new topics introduced are 
 a full consideration of serum-therapy ; leucocytosis ; post-operative insanity ; 
 Kronlein's method of locating the cerebral fissures ; Hoffa's and Lorenz's oper- 
 ations of congenital dislocations of the hip ; Allis' researches on dislocations of 
 the hip-joint ; lumbar puncture ; the forcible reposition of the spine in Pott's dis- 
 ease ; the use of Kelly' s rectal specula ; the use of eucain for local anesthesia ; 
 Krause's method of skin-grafting, etc. 
 
 PERSONAL AND PRESS OPINIONS 
 
 Edmond Owen, F.R.C.S.. 
 
 Member of the Board of Examiners of the Royal College of Siirgeons, England. 
 " Personally, I should not mind it being called The Text-Book (instead of A Text-Book), for I 
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 The La.i\cet, London 
 
 " If this text-book is a fair reflex of the present position of American surgery, we must admit it 
 is of a very high order of merit, and that English surgeons will have to look very carefully to their 
 laurels if they are to preserve a position in the van of surgical practice." 
 
 Boston Medica.1 3Lnd Surgical Jourival 
 
 " This book marks an epoch in American book-making. All in all, the book is distinctly the 
 most satisfactory work on modern surgery with which we are familiar. It is thorough, complete, and 
 condensed." 
 
SURGERY AND ANATOMY 
 
 Irvterrvatiorval 
 Text-Book of Surgery 
 
 SECOND EDITION, THOR.OVGHLY REVISED AND ENLARGED 
 
 The International Text=Book of Surgery. In two volumes. By 
 American and British authors. Edited by J. Collins Warren, M.D., 
 LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medical 
 School; and A. Pearce Gould, M.S., F.R.C.S., of London, England. — 
 Vol. I. General and Operative Snrgery. Royal octavo, 975 pages, 
 461 illustrations, 9 full-page colored plates. — Vol. II. Special or 
 Regional Surgery. Royal octavo, 1122 pages, 499 illustrations, and 
 8 full-page colored plates. 
 
 Per volume : Cloth, ^5.00 net; Half Morocco, $6.00 net. 
 
 ADOPTED BY THE U. S. AR_MY 
 
 In this new edition the entire book has been carefully revised, and special effort 
 has been made to bring the work down to the present day. The chapters on 
 Military and Naval Surgery have been very carefully revised and extensively 
 rewritten in the light of the knowledge gained during the recent wars. The 
 articles on the effect upon the human body of the various kinds of bullets, and 
 the results of surgery in the field are based on the latest reports of the sur- 
 geons in the field. The chapter on Diseases of the Lymphatic System has been 
 completely rewritten and brought up to date ; and of special interest is the 
 chapter on the Spleen. The already numerous and beautiful illustrations have 
 been greatly increased, constituting a valuable feature, especially so the seven- 
 teen colored lithographic plates. 
 
 OPINIONS OF THE MEDICAL PRESS 
 
 Anna.ls of Surgery 
 
 " It is the most valuable work on the subject that has appeared in some years. The clinician and 
 the pathologist have joined hands in its production, and the result must be a satisfaction to the editors 
 as it is a gratification to the conscientious reader." 
 
 Boston NedicaLl aLnd Surgica.1 JournaLl 
 
 " The articles as a rule present the essentials of the subject treated in a clear, concise manner. 
 They are sj'stematically written. The illustrations are abundant, well chosen, and enhance greatly 
 the value of the work. The book is a thoroughly modern one." 
 
 The Medica.1 Kecord, New York 
 
 "The arrangement of subjects is excellent, and their treatment by the different authors is 
 equally so. . . . The work is up to date in a very remarkable degree, many of the latest operations in 
 the different regional parts of the body being given in full details. There is not a chapter in the work 
 from which the reader may not learn something new." 
 
SAUNDERS' BOOKS ON 
 
 Senn's 
 Practical Surgery 
 
 Practical Surgery. A Work for the General Practitioner. By 
 Nicholas Senn, M.D., Ph.D., LL.D., Professor of Surgery in Rush 
 Medical College, Chicago ; Professor of Surgery in the Chicago Poly- 
 clinic ; Attending Surgeon to the Presbyterian Hospital, etc. Hand- 
 some octavo volume of 1133 pages, with 650 illustrations, many of 
 them in colors. Cloth, ^6.00 net ; Sheep or Half Morocco, ^7.00 net. 
 Sold by Subscription. 
 
 DR. SENN'S GR-EAT WORK 
 Based on His Operative Experience for 25 Years 
 
 This work represents the practical operative experience of the author for the 
 last twenty-five years. The book deals with practical subjects, and its contents 
 are devoted to those sections of surgery that are of special interest to the general 
 practitioner. Special attention is paid to emergency surgery. Shock, hemor- 
 rhage, and wound treatment are fully considered. All emergency operations 
 that come under the care of the general practitioner are described in detail and 
 fully illustrated. 
 
 The section on Military Surgery is based on the author's experience as 
 chief of the operating staff in the field during the Spanish-American War, and 
 on his observations during the Greco-Turkish War. Intestinal Surgery is given 
 a prominent place, and the consideration of this subject is the result of the 
 clinical experience of the author as surgeon and teacher of surgery for a quarter 
 of a century. The text is profusely illustrated. 
 
 OPINIONS OF THE MEDICAL PRESS 
 
 AniveLls of Surgery 
 
 " It is of value not only as presenting comprehensively the most advanced teachings of modern 
 surgery in the subjects which it takes up, but also as a record of the matured opinions and practice of 
 an accomplished and experienced surgeon." 
 
 QusLrterly Medical Journal, England 
 
 " We cannot speak too highly of this valuable contribution to the literature of practical surgery. 
 . . . The present work more than sustains the high reputation of its author." 
 
 Buffalo Medical Journal 
 
 " As an intelligent exposition of the science of surgery as practiced to-day it is deserving of 
 commendation, and it will be particularly welcomed by the general practitioner." 
 
SURCER Y AND ANA TO MY 
 
 Sc\idder's 
 Treatment of Fractures 
 
 The Treatment of Fractures. By Charles L. Scudder, M.D., 
 Assistant in Clinical and Operative Surgery, Harvard Medical School; 
 Surgeon to the Out- Patient Department of the Massachusetts General 
 Hospital, Boston. Handsome octavo volume of 485 pages, with 
 645 original illustrations. 
 
 Polished Buckram, ^4.50 net; Half Morocco, $5.50 net. 
 
 THE THIRD LARGE EDITION IN TWO YEARS 
 
 In this edition several new fractures have been described, and an excellent 
 chapter on Gunshot Fractures of the long bones has been added. The reports 
 of surgeons in the field during the recent wars have been carefully digested, and 
 the important facts regarding fractures produced by the small caliber bullet have 
 been here concisely presented. In many instances photographs have been substi- 
 tuted for drawings, and the uses of plaster-of-Paris as a splint-material have been 
 more fully illustrated . In the treatment the reader is not only told, but is shown, 
 how to apply apparatus, for as far as possible all the details are illustrated. This 
 elaborate and complete series of illustrations constitutes a feature of the book. 
 There are 645 of them, all from new and original drawings and reproduced in 
 the highest style of art. 
 
 PERSONAL AND PRESS OPINIONS 
 
 William T. Bull. M.D.. 
 
 Professor of Surgery, College of Physicians and Surgeons, New York City. 
 " The work is a good one, and I shall certainly recommend it to students." 
 
 Joseph D. BryaLnt, M.D., 
 
 Professor of the Principles aitd Practice of Stcrgery, University and Bellevue Hospital 
 Medical College, New York City. 
 " As a practical demonstration of the topic it is excellent, and as an example of bookmaking it 
 is highly commendable." 
 
 American JournsLl of the MediceLl Sciences 
 
 " The work produces a favorable impression by the general manner in which the subjsct is 
 treated. Its descriptions are concise and clear, and the treatment sound. The physical examination of 
 the injured part is well described, and . . . the method of making these examinations is illus- 
 trated by a liberal use of cuts." 
 
SAUNDERS' BOOKS ON 
 
 9 
 
 S 
 
 Moderrv S\irgery 
 
 Modern Surgery — General and Operative. By John Chalmers 
 DaCosta, M.D., Professor of the Principles of Surgery and of Clini- 
 cal Surgery in the Jefferson Medical College, Philadelphia ; Surgeon 
 to Philadelphia Hospital and to St. Joseph's Hospital, Philadelphia. 
 Handsome octavo volume of ii 17 pages, copiously illustrated. 
 
 Cloth, ^5.00 net ; Sheep or Half Morocco, ^6.00 net. 
 
 THIRD REVISED EDITION 
 
 Enlarged by over 200 Pages, with over 100 New Illustrations 
 
 The remarkable success attending DaCosta' s Manual of Surgery, and the 
 general favor with which it has been received, have led the author in this revi- 
 sion to produce a complete treatise on modern surgery along the same lines that 
 made the former editions so successful. The book has been entirely rewritten 
 and very much enlarged in this edition. It has been increased in size by new 
 matter to the extent of over 200 pages, and contains more than 100 handsome 
 neAv illustrations, making a total of 439 beautiful cuts in the text. The old 
 editions of this excellent work have long been favorites, not only with students 
 and teachers but also with practising physicians and surgeons, and it is believed 
 that the present work, presenting, as it does, the latest advances in the science 
 and art of surgery, will find an even wider field of usefulness. 
 
 OPINIONS OF THE MEDICAL PRESS 
 
 The Lancet, London 
 
 " We may congratulate Dr. DaCosta in the success of his attempt. . . . We can recommend 
 the work as a text-book well suited to students." 
 
 The Medical Record, New York 
 
 " The work throughout is notable for its conciseness. Redundance of language and padding 
 have been scrupulously avoided, while at the same time it contains a sufficient amount of information 
 to fulfil the object aimed at by its author— namely, a text-book for the use of the student and the 
 busy practitioner." 
 
 American Journal of the Medical Sciences 
 
 " The author has presented concisely and accurately the principles of modern surgery. The 
 book is a valuable one, which can be recommended to students, and is of great value to the general 
 practitioner." 
 
SURGER V ANT? ANA TO MY 
 
 McClellan's 
 Art Ana^tomy 
 
 Anatomy in its Relation to Art. An exposition of the Bones 
 and Muscles of the Human Body, with Reference to their Influence 
 upon its Actions and external Form. By George McClellan, M.D., 
 Professor of Anatomy, Pennsx'lv^ania Academy of the Fine Arts. 
 Handsome quarto volume, 9 by 11^ inches. Illustrated with 33S 
 original drawings and pliotographs, with 260 pages of text. 
 
 Dark Blue Vellum, ^10.00 net; Half Russia, $12.00 net. 
 
 Jvist Iss\ied 
 
 This is an exhaustive work on the structure of the human body as it affects 
 the external form, and although especially prepared for students and lovers of 
 art, it will prove very valuable to all interested in the subject of anatomy. It 
 will be of especial .value to the physician, because nowhere else can he find si 
 complete a consideration of surface anatomy. Those interested in athletics and 
 physical training will find reliable information in this book. 
 
 Howard Pyle, 
 
 In the Philadelphia Medical Journal. 
 " The book is one of the best and the most thorough Text-books of artistic anatomy which it has 
 been the writer's fortune to fall upon and, as a text-book, it ought to make its way into the field for 
 which it is intended." 
 
 McClellan's 
 R^egionaJ Arva».tomy 
 
 Regional Anatomy in its Relations to Medicine and Surgery. 
 
 By George McClellan, M.D., Professor of Anatomy, Pennsylvania 
 Academy of the Fine Arts. Two handsome quartos, 884 pages of text ; 
 97 full-page chromolithographic plates, reproducing the author' s orig- 
 inal dissections. Cloth, ^12.00 net; Half Russia, ^15.00 net. 
 
 Fourth R.evised Edition 
 
 This well-known work stands without a parallel in anatomic literature, and its 
 remarkably large sale attests its value to the practitioner. By a marvelous series 
 of colored lithographs the exact appearances of the dissected parts of the body 
 are reproduced, enabling the reader to examine the anatomic relations with as 
 much accuracy and satisfaction as if he had the actual subject before him. 
 
 British Medical Journal 
 
 "The illustrations are perfectly correct anatomical studies, and do not reproduce the inaccura- 
 cies which experience has taught us to look for in works of a similar kind. Some of the plates, 
 especially those of the anatomy of the chest, are of great excellence." 
 
SAUNDERS' BOOKS ON 
 
 GET A • THE NEW 
 
 THE BEST >1L n\ 6 1*1 C ©k. rV STANDARD 
 
 Illustrdcted Dictionocry 
 
 SECOND EDITION. REVISED 
 
 The American Illustrated Medical Dictionary. A New and 
 
 Complete Dictionary of the terms used in Medicine, Surgery, Den- 
 tistry, Pharmacy, Chemistry, and kindred branches ; together with new 
 and elaborate tables of Arteries, Muscles, Nerves, Veins, etc.; of 
 Bacilli, Bacteria, Micrococci, etc.; Eponymic Tables of Diseases, 
 Operations, Signs and Symptoms, Stains, Tests, Methods of Treat- 
 ment, etc. By W. A. N. Dorland, M.D. Large octavo, 770 pages. 
 Flexible leather, ^$4.50 net; with thumb index, ^5.00 net. 
 
 LARGE FIRST EDITION EXHAUSTED IN EIGHT MONTHS 
 
 In this edition the book has been subjected to a thorough revision. The 
 author has also added upward of one hundred important new terms that have 
 appeared in medical hterature during the past few months. 
 
 HowsLrd A. Kelly, M.D., 
 
 Professor of Gynecology, Johns Hopkins University, Baltbnore. 
 " Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. 
 No errors have been found in my use oi it." 
 
 Koswell Pacrk, M.D., 
 
 Professor of Principles and Practice of Surgery and of Clinical Stirgery, 
 University of Buffalo. 
 " I must acknowledge my astonishment at seeing how much he has condensed within relatively 
 small space. I find nothing to criticise, very much to commend, and was interested in finding some 
 of the new words which are not in other recent dictionaries." 
 
 American Year-Book 
 
 Saunders' American Year = Book of Medicine and Surgery. 
 
 A yearly Digest of Scientific Progress and Authoritative Opinion in all 
 branches of Medicine and Surgery, drawn from journals, monographs, 
 and text-books of the leading American and foreign authors and inves- 
 tigators. Arranged, with critical editorial comments, by eminent 
 American specialists, under the editorial charge of George M. Gould, 
 A.M., M.D. In two volumes : Vol. I — General Medicine, octavo, 715 
 pages, illustrated ; Vol. II — General Surgery, octavo, 684 pages, illus- 
 trated. Per vol.: Cloth, ;^ 3. 00 net ; Half Morocco, ^3.75 net. Sold 
 by Subscription. 
 
 In these volumes the reader obtains not only a yearly digest, but also the 
 invaluable annotations and criticisms of the editors. As usual, this issue of the 
 Year-Book is amply illustrated. 
 
 The Lancet, London 
 
 " It is much more than a mere compilation of abstracts, for, as each section is entrusted to 
 experienced and able contributors, the reader has the advantage of certain critical commentaries and 
 expositions . . . proceeding from writers fully qualified to perform these tasks." 
 
SURGER V AND ANA TOMY 
 
 Helferich aivd Bloodgood's 
 Fractures and Dislocations 
 
 Atlas and Epitome of Traumatic Fractures and Dislocations. 
 
 By Professor Dr. H. Helferich, Professor of Surgery at the Royal 
 University, Greifswald, Prussia. Edited, with additions, by Joseph C. 
 Bloodgood, M.D., Associate in Surgery, Johns Hopkins University, 
 Baltimore. From tlie Fifth Revised and Enlarged German Edition. 
 With 216 colored illustrations on 64 lithographic plates, 1 90 text- cuts, 
 and 353 pages of text. Cloth, ^3.00 net. In Saunders" Atlas Series. 
 
 A Neu^ Volume — J\ist Issued 
 
 A book accurately portraying the anatomic relations of the fractured parts, 
 together with the diagnosis and treatment of the condition, has become an abso- 
 lute necessity. This work is intended to meet all requirements. As complete a 
 view as possible of each case has been presented, thus equipping the physician 
 for the manifold appearances that he will meet with in practice. The illustra- 
 tions are unrivaled for accuracy and clearness of portrayal of the conditions 
 represented, showing the visible external deformity, the X-ray shadow, the ana- 
 tomic preparation, and the method of treatment. 
 
 Zuckerkandl aivd DaCosta's 
 Operoctive Svirgery 
 
 ADOPTED BY THE U. S. AR.MY 
 
 Atlas and Epitome of Operative Surgery. By Dr. O. Zucker- 
 kandl, of Vienna. Edited, with additions, by J. Chalmers DaCosta, 
 M.D., Professor of the Principles of Surgery and Clinical Surgery, Jef- 
 ferson Medical College, Philadelphia. 40 colored plates, 278 text-cuts,, 
 and 410 pages of text. Cloth, ;^3.50 net. In Saunders' Atlas Series. 
 
 SECOND EDITION, THOROVGHLY REVISED AND GREATLY ENLARGED 
 
 In this new edition the work has been brought precisely down to date. A 
 number of chapters have been practically rewritten, and of the newer operations, 
 all those of special value have been described. Sixteen valuable lithographic 
 plates in colors and sixty-one text figures have been added, thus greatly enhancing 
 the value of the work. 
 
 New York Medical Journal 
 
 " We know of no other work upon the subject in which the illustrations are as numerous or as- 
 generally satisfactory." 
 
lo SAUNDERS' BOOKS ON 
 
 MacdoivdLld's 
 Diatgivosis dtnd TreaLtment 
 
 A Clinical Text=Book of Surgical Diagnosis and Treatment. By 
 
 J. W. Macdonald, M.D. Edin., F.R.C.S. Edin.; Professor Emeritus 
 of the Practice of Surgery and of Clinical Surgery in Hamline Uni- 
 versity, Minneapolis, Minn. Octavo, 798 pages, handsomely illus- 
 trated. Cloth, ;^5.00 net; Sheep or Half Morocco, $6.00 net. 
 
 This work aims to furnish a guide to surgical diagnosis. It sets forth in a 
 systematic way the necessity of examinations and the proper methods of 
 making them. The various portions of the body are then taken up in order and 
 the diseases and injuries thereof succinctly considered and the treatment briefly 
 indicated. Practically all the modern and approved operations are described. 
 The work concludes with a chapter on the use of the Rontgen rays in surgery. 
 
 British Medica.1 Journa.! 
 
 " Care has been taken to lay down rules for a systematic and comprehensive examination of 
 ■each case as it presents itself, and the most advanced and approved methods of clinical investigation 
 in surgical practice are fully described." 
 
 Wa-rren's 
 PaLtKology and TKerapeutics 
 
 Surgical Pathology and Therapeutics. By John Collins War- 
 ren, M.D., LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard 
 Medical School. Octavo, 873 pages; 136 relief and lithographic 
 illustrations, 33 in colors. With an Appendix on Scientific Aids to 
 Surgical Diagnosis and a series of articles on Regional Bacteriology. 
 Cloth, ;^5.oo net; Sheep or Half Morocco, ^$6.00 net. 
 
 SECOND EDITION, WITH AN APPENDIX 
 
 The volume is for the bedside, the amphitheatre, and the ward. It deals 
 with diseases not as we see them through the microscope alone, but as the prac- 
 titioner sees their effect in his patients ; not only as they appear in and affect 
 culture-media, but also as they influence the human body ; and, following up 
 the demonstrations of the nature of diseases, the author points out their logical 
 treatment. 
 
 R.oswell PaLfk, M.D., 
 
 In the Harvard Graduate Magazine. 
 
 " I think it is the most creditable book on surgical pathology, and the most beautiful medical 
 illustration of the bookmakers' art that has ever been issued from the American press." 
 
SURGER V AND ANA TOMY 
 
 II 
 
 Golebiewski and Bailey's 
 Accidervt Disea^ses 
 
 Atlas and Epitome of Diseases Caused by Accidents. By Dr. 
 
 Ed. Golebiewski, of Berlin. Edited, with additions, by Pearce 
 Bailey, M.D., Attending Physician to the Almshouse and Incurable 
 Hospitals, New York. With 71 colored figures on 40 plates, 143 text- 
 cuts, and 549 pages of text. Cloth, $4.00 net. In Smuidcrs' Hand- 
 Atlas Series. 
 
 This work contains a full and scientific treatment of the subject of accident 
 injury ; the functional disability caused thereby ; the medicolegal questions in- 
 volved, and the amount of indemnity justified in given cases. The work is in- 
 dispensable to every physician who sees cases of injury due to accidents, to ad- 
 vanced students, to surgeons, and, on account of its illustrations and statistical 
 data, it is none the less useful to accident insurance organizations. 
 
 The Medical Record, New York 
 
 " This volume is upon an important and only recently systematized subject, which is growing in 
 extent all the time. The pictorial part Of the book is very satisfactory." 
 
 Sulte^rv ©^.n^d Coley's 
 Abdomin.^ HerrvioLS 
 
 Atlas and Epitome of Abdominal Hernias. By Privatdocent 
 Dr. Georg Sultan, of Gottingen. Edited, with additions, by Wil- 
 liam B. CoLEY, M.D., Clinical Lecturer on Surgery, Columbia Univer- 
 sity (College of Physicians and Surgeons). With 119 illustrations, 
 36 of them in colors, and 277 pages of text. Cloth, $3.00 net. 
 
 In Saunders' Hand- Atlas Series. 
 
 During the last decade the operative side of this subject has been steadily 
 growing in importance, until now it is absolutely essential to have a book treat- 
 ing of its surgical aspect. This present atlas does this to an admirable degree. 
 The illustrations are not only very numerous, but they portray most accurately 
 the conditions represented. 
 
 Robert H. M. DawbaLrn, M.D., 
 
 Professor of Surgery and of Surgical Anatomy, New York Polyclinic. 
 
 " I have spent several interesting hours over it to-day, and shall willingly recommend it to my 
 classes at the Polyclinic College and elsewhere." 
 
SAUNDERS' BOOKS ON 
 
 Grant's Surgery of 
 Face, Mouth, and Jaws 
 
 A Text=Book of the Surgical Principles and Surgical Diseases of 
 the Face, Mouth, and Jaws. For Dental Students. By H. Horace 
 Grant, A.M., M.D., Professor of Surgery and of Clinical Surgery, 
 Hospital College of Medicine ; Professor of Oral Surgery, Louisville 
 College of Dentistry, Louisville. Octavo volume of 231 pages, with 
 68 illustrations. Cloth, ;^2.5o net. 
 
 FOR- DENTAL STUDENTS 
 
 This text-book, designed for the student of dentistry, succinctly explains the 
 principles of dental surgery applicable to all operative procedures, also discussing 
 such surgical lesions as are likely to require diagnosis and perhaps treatment by 
 the dentist. Whenever necessary, for the better elucidation of the text, well- 
 selected illustrations have been employed. For the dental student the work will 
 be found an invaluable text-book, and, indeed, the medical beginner also will 
 find its perusal of more than passing benefit. 
 
 Robson dLivd MoyiviKaLiv 
 on tKe Pa^rvcrescs 
 
 Diseases of the Pancreas and Their Surgical Treatment. By 
 
 A. W. Mayo Robson, F.R.C.S., Senior Surgeon, Leeds General Infir- 
 mary ; Emeritus Professor of Surgery, Yorkshire College, Victoria Uni ■ 
 versity, England ; and B. G. A. Moynihan, M.S. (Lond.), F.R.C.S., 
 Assistant Surgeon, Leeds General Infirmary ; Consulting Surgeon to 
 the Skipton and to the Mirfield Memorial Hospitals, England. Octavo 
 of 293 pages, illustrated. Cloth, ^^3.00 net. 
 
 JUST ISSUED 
 
 This work, dealing with the surgical aspect of pancreatic disease, has been 
 written with a two-fold object : to record and to review the work done in the past, 
 and to indicate, so far as possible, the scope and trend of future research. Besides 
 containing a very commendable exposition of the various diseases and injuries of 
 the pancreas, the volume includes an accurate account of the anatomy, abnor- 
 malities, development, and structure of the gland. 
 
SURGER V AND ANA TOMY 1 3 
 
 Servrv's T\xmors 
 
 Pathology and Surgical Treatment of Tumors. By Nicholas 
 Senn, M.D., Ph.D., LL.D., Professor of Surgery, Rush Medical Col- 
 lege, Chicago. Handsome octav^o, 718 pages, with 478 engravings, 
 including 12 full-page colored plates. 
 
 Cloth, ;^5.oo net ; Sheep or Half Morocco, $6.00 net. 
 
 SECOND EDITION. REVISED 
 
 Books specially devoted to this important subject are few, and in our text- 
 books and systems of surgery this part of surgical pathology is usually condensed 
 to a degree incompatible with its scientific and clinical importance. The author 
 spent many years in collecting the material for this work, and has taken great 
 pains to present it in a manner that should prove useful as a text-book for the 
 student, a work of reference for the general practitioner, and a reliable, safe guide 
 for the surgeon. 
 
 Journa.1 of the AmericaLiv Medical AssocIa.tion 
 
 " The most exhaustive of any recent book in English on this subject. It is well illustrated, and 
 will doubtless remain as the principal monograph on the subject in our language for some years. 
 The author has given a notable and lasting contribution to surgery." 
 
 Stor\.ey*s 
 Sxirgica.! TecKivic for N\irses 
 
 Surgical Technic for Nurses. By Emily A. M. Stoney, Super- 
 intendent of the Training School for Nurses at the Carney Hospital, 
 South Boston. i2mo, 200 pages, profusely illustrated. 
 
 Cloth, $1.25 net. 
 
 The work is intended as a modern text-book on Surgical Nursing in both 
 hospital and private practice. The first part of the book is devoted to Bacteri- 
 ology and Antiseptics ; the second part to Surgical Technic, Signs of Death, and 
 Autopsies. The matter in the book is presented in a practical form, and will 
 prove of value to all nurses who are called upon to attend surgical cases. 
 
 Tra.iiYed Nurse and Hospital Review 
 
 " These subjects are treated most accurately and up to date, without the superfluous reading 
 which is so often employed. . . . Nurses will find this book of the greatest value both during 
 their hospital course and in private practice." 
 
14 SAUNDERS' BOOKS ON 
 
 He^ynes' Anactomy 
 
 A Manual of Anatomy. By Irving S. Haynes, M.D., Professor 
 of Practical Anatomy, Cornell University Medical College. Octavo, 
 680 pages, illustrated with 42 diagrams and 134 full-page half-tones 
 from photographs of the author's dissections. Cloth, ^2.50 net. 
 
 In this book the great practical importance of a thorough knowledge of the 
 viscera and of their relations to the surface of the body has been recognized by 
 according to them a prominent place in illustration and description. 
 
 The Medical Record, New York 
 
 "This book is the work of a practical instructor — one who knows by experience the require- 
 ments of the average student, and is able to meet these requirements in a very satisfactory way. The 
 book is one that can be commended." 
 
 Beck's Fractures 
 
 Fractures. By Carl Beck, M.D., Professor of Surgery, New- 
 York Post-graduate Medical School and Hospital. With an Appendix 
 on the Practical Use of the Rontgen Rays. 335 pages, 170 illus- 
 trations. Cloth, 1^3.50 net. 
 
 In this book particular attention is devoted to the Rontgen rays in diagnosis. 
 The work embodies in a systematic treatise the important essentials of this sub- 
 ject, based on the extensive experience of the author in X-ray work. 
 
 The Medical Record, New York 
 
 " The use of the rays with its technic is full}' explained, and the practical points are brought out 
 with a thoroughness that merits high praise." 
 
 AmericaLiv Pocket Dictioivary 
 
 The American Pocket Medical Dictionary. Edited by W. A. 
 Newman Borland, A.M., M.D., Assistant Obstetrician, Hospital of 
 the University of Pennsylvania, etc. 518 pages. Full leather, limp, 
 with gold edges, ^i.oo net; with patent thumb index, ^1.25 net. 
 
 THIRD EDITION, REVISED 
 
 This is an absolutely new book. It is complete, defining all the terms of 
 modern medicine, and forming an unusually full vocabulary. It makes a special 
 feature of the newer words and contains a wealth of anatomical tables. 
 
 JaLmes W. Holl&nd, M.D., 
 
 Professor of Medical Cheinistry and Toxicology, and Dean, Jefferson Medical 
 College, Philadelphia. 
 " I am struck at once with admiration at the compact size and attractive exterior. I can recom- 
 mend it to our students without reserve." 
 
SURGER Y AND ANA TOMY 
 
 15 
 
 Warwick and Tunstall's First Aid 
 
 First Aid to the Injured and Sick. By F. J. Warwick, B.A., M.B. 
 Cantab., Associate of King's College, London ; and A. C. Tunstall, M.D., 
 F.R.C.S. Edin., Surgeon-Captain Commanding the East London Volunteer 
 Brigade Bearer Company. i6mo of 232 pages and nearly 200 illustrations. 
 
 Cloth, gi.oo net. 
 
 " Contains a great deal of valuable information well and tersely expressed. It will prove 
 especially useful to the volunteer first aid and hospital corps men of the National Guard."— 
 Journal American Medical Association. 
 
 Beck's S\irgical Asepsis 
 
 A Manual of Surgical Asepsis. By Carl Beck, M.D., Professor of Sur- 
 gery, New York Post-graduate Medical School and Hospital. 306 pages ; 65 
 text-illustrations and 12 full-page plates. Cloth, $1.25 net. 
 
 " The book is well written. The data are clearly and concisely given. The facts are well 
 arranged. It is well worth reading to the student, the physician in general practice, and the 
 surgeon." — Boston Medical and Surgical Journal. 
 
 Pye's Bandaging 
 
 Elementary Bandaging and Surgical Dressing. With Directions con- 
 cerning the Immediate Treatment of Cases of Emergency. By Walter 
 Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small i2mo, 
 over 80 illustrations. Cloth, flexible covers, 75 cts. net. 
 
 " The author writes well, the diagrams are clear, and the book itself is small and portable, 
 although the paper and type are good." — British Medical Journal. 
 
 Senn's Syllabus of Surgery 
 
 A Syllabus of Lectures on the Practice of Surgery. Arranged in con- 
 formity with ' ' American Text-Book of Surgery. ' ' By Nicholas Senn, 
 M.D., Ph.D., LL.D., Professor of Surgery, Rush Medical College, Chicago. 
 
 Cloth, $1.50 net. 
 
 " The author has evidently spared no pains in making his Syllabus thoroughly comprehensive, 
 and has added new matter and alluded to the most recent authors and operations. Full refer- 
 ences are also given to all requisite details of surgical anatomy and pathology."— .g?-z?wA Medi- 
 cal Journal. 
 
 Keen's Operation Blank, Second Edition, Revised Form 
 An Operation Blank, with Lists of Instruments, etc.. Required in Various 
 Operations. Prepared by Wm. W. Keen, M.D., LL.D., F.R.C.S. (Hon.), Pro- 
 fessor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical 
 College, Philadelphia. Price per pad, blanks for fifty operations, 50 cts. net. 
 
 " Will serve a useful purpose for the surgeon in reminding him of the details of preparation for 
 the patient and the room as well as for the instruments, dressings, and antiseptics needed." 
 — New York Medical Record. 
 
 Keen on tKe Surgery of TypKoid 
 
 The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. 
 
 Keen, M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Surgery 
 and of Clinical Surgery, Jefferson Medical College, Philadelphia, etc. 
 Octavo volume of 386 pages, illustrated. Cloth, ^3.00 net. 
 
 " Every surgical incident which can occur during or after typhoid fever is amply discussed and 
 fully illustrated by cases. . . . The book will be useful both to the surgeon and physician." — 
 The Practitioner y London. 
 
l6 SURGER Y AND ANA TOMY 
 
 Moore's Orthopedic Surgery 
 
 A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor 
 
 of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 
 
 Octavo of 356 pages, handsomely illustrated. Cloth, ^2.50 net. 
 
 " The book is eminently practical. It is a safe guide in the understanding- and treatment of 
 orthopedic cases. Should be owned by every surgeon and practitioner." — Annals of Surgery. 
 
 Nancrede's Anatomy and Dissection. Editroa 
 
 Essentials of Anatomy and Manual of Practical Dissection. By 
 
 Charles B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, 
 
 University of Michigan, Ann Arbor. Post-octavo ; 500 pages, with full-page 
 
 lithographic plates in colors, and nearly 200 illustrations. 
 
 Extra Cloth (or Oilcloth for the dissecting-room), ^2.00 net. 
 
 " The plates are of more than ordinary excellence, and are of especial value to students in their 
 work in the dissecting-room."— yoM»'«a/ of the American Medical Association. 
 
 Nancrede's Principles of Surgery 
 
 Lectures on the Principles of Surgery. By Chas. B. Nancrede, M.D., 
 LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, 
 Ann Arbor. Octavo, 398 pages, illustrated. Cloth, $2.50 net. 
 
 " We can stronglj' recommend this book to all students and those who would see something 
 of the scientific foundation upon which the art of surgery is built." — Quarterly Medical Journal, 
 Sheffield, England. 
 
 Nancrede's Essentials of Anatomy. ^'^Edmon^^*^ 
 
 Essentials of Anatomy, including the Anatomy of the Viscera. By Chas. 
 
 B. Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University 
 
 of Michigan, Ann Arbor. Crown octavo, 388 pages ; 180 cuts. With an 
 
 Appendix containing over 60 illustrations of the osteology of the body. Based 
 
 Gw Gray s Anatomy . Cloth, $1.00 net. In Saunders Question Compends. 
 
 " The questions have been wisely selected, and the answers accurately and concisely given." — 
 University Medical Magazi7ie. 
 
 Martin's Essentials of Surgery. ^^"'^Revifed*'"'" 
 
 Essentials of Surgery. Containing also Venereal Diseases, Surgical Land- 
 marks, Minor and Operative Surgery, and a complete description, with illus- 
 trations, of the Handkerchief and Roller Bandages. By Edward Martin, 
 A.M., M.D., Professor of Clinical Surgery, University of Pennsylvania, etc. 
 Crown octavo, 338 pages, illustrated. With an Appendix on Antiseptic Sur- 
 gery, etc. Cloth, $1.00 net. In Sannders' Question Compends. 
 
 " Written to assist the student, it will be of undoubted value to the practitioner, containing as it 
 does the essence of surgical work." — Boston Medical and Surgical Journal. 
 
 Martin's Essentials of Minor Surgery, Band- 
 aging, and Venereal Diseases. ^^*'°gdi{k,n'''^^'^ 
 
 Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By 
 
 Edward Martin, A.M., M.D., Professor of Clinical Surgery, University of 
 
 Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. 
 
 Cloth, $1.00 net. /« Satinders' Question Compejids. 
 
 "The best condensation of the subjects of which it treats yet placed before the profession." — 
 The Medical News, Philadelphia. 
 
^^^^U^BM UNIVERSITY 
 
 Provided bylu ?^^^"te period af' '"^^^^^ed beJow o 
 ;^;=========^^ ^^^ang-ement with 
 
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COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) 
 
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 The surgical trRritmr-n' n' cactnc anrj r)u 
 
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