The late Dr. Leonard in the American Journal of Roentgenology said: "The surgeon today does not attempt an operation on the stomach until he has before him all the data which this method is capable of rendering, while the internist does not refer his patient for operation before the knowledge it affords shows that operation is necessary. In many instances the complete knowledge of the condition. of the stomach and intestine can be obtained by this method of examination as by an exploratory laparotomy, while the definite knowledge it affords localizes operative intervention and eliminates its extent and nature before it is commenced."

It has been found that ulcers of both the stomach and duodenum that have passed unnoticed and unsuspected have shown up in Roentgenological examinations with subsequent proof of their existence.

Little has been known of the normal or pathological action of the duodenum from a mechanical standpoint until its study Roentgenologically. As you well know this study is accomplished by the visualization of the digestive organs by the ingestion as well as by enema of a large quantity of Bismuth salt or some other substance of like nature, notably Barium Sulphate, the technique of which is important, but which is not necessary to detail here.

The passage of the Bismuth meal, in normal cases, through the small intestine is so rapid that the determination of its normal peristaltic action is attended with great difficulty. With the exception of a small mass in the bulbus duodeni and the collection of masses in the convuloted portions of the ileum, little is seen in normal cases. The rapid roentgenogram shows in addition small flecks of bismuth scattered throughout the duodenum, the jejunum, and upper portion of the ileum.

The first portion of the duodenum, or the bulbus duodeni, retains the Bismuth because of its different anatomical structure. Instead of the valvulae conniventies, such as are found in the other portions of the duodenum, it is perfectly smooth inside with many secretory glands distributed over its surface. It differs also in its external support being held in place by a separate fold of the gastro-hepatic ligament. The second or descending portion is bound tightly down by the parietal peritoneum and thus has no messenteric attachment. Physiologically the bulbus duodeni, which has been called the second stomach, is of great importance, as it receives the acid chyme from the stomach and neutralizes it before it passes through the rest of the intestine. It also acts as a buffer to receive the food ejected from the stomach. Because of the acid chyme it receives it is more liable to be the seat of ulceration.

The study of cases roentgenologically has shown that the doudenum in its peristalsis both mixing and progressive movements. The third or ascending limb of the duodenum passes upward and back of the stomach to form an acute angle where it unites with the

jejunum. The bismuth meal passes through, or rather each bolus of it ejected from the stomach passes through the entire duodenum in from twenty-five to sixty seconds in normal cases. A series of instantaneous radiograms taken rapidly during this period shows the entire cycle.

Many pathological conditions of the duodenum can be observed and recorded in this way, but the existence of ulcer is the one before us. In superficial ulcer of this part of the intestine the emptying time of the stomach is normal or increased, in contrast to the delayed emptying in cases of gastric ulcer, which produces a spasm of the pylorus. The stomach generally has the hypertonic form, the pylorus and greater curvature lying above the umbilicus. The stomach is not dilated at its lower pole, as in gastric or pyloric ulcer. The peristalsis of the sinus is more marked and the pylorus opens more frequently. The points of tenderness on pressure is located over the bulbus duodeni and the patient if asked to locate the pain usually places the finger over this spot.

A number of cases have been reported in which gastric and duodenal ulcers have been found to co-exist. Here a conflict in symptoms has been noted, the duodenal ulcer counteracting the spasm of the pylorus provoked by the gastric ulcer, resulting in more rapid evacuation of the stomach than normal.

Penetrating ulcer of the duodenum is less frequent and has in addition to the symptoms of superficial ulcer the characteristic diverticulum outside the normal shadow of the duodenum which persists as a small fleck of bismuth after the duodenum is empty.

A condition characteristic of ulcers of the duodenum is the retention of the opaque chyme in it for a longer period than normal as the result of a mild stenosis, possibly spasmodic, at the duodenojejunal juncture. It is probably that many of the so-called Lanes kinks situated at this juncture are in reality spasmodic stenoses due to duodenal ulcer rather than to actual kinks due to ptoses. This is more likely because of the defective mode of examining these patients which errs in making the examination in the right lateral position rather than in the upright, in which position the nature of the kink it would be most marked and more easily observed. In addition, after the administration of the opaque meal, the patient was placed upon the right side, thus causing the filling of the duodenum and aiding the retention of the bismuth in the organ.

Spasms of the duodenum due to neuroses produce transient symptoms that are characteristic of ulcer of mild stenosis but can be differentiated by their amenability to appropriate treatment.

Stenosis of the duodenum is characterized by the abnormal repletion and the presence of visible peristalsis and antiperistalsis. The dilatation of the duodenum is greater the narrower the stenosis

and the extent involved longer according to the situation of the stenosis. The peristalsis is uninterrupted so long as the opaque chyme is there retained. The character of the stenosis, whether it is spasmodic, cicatricial, due to pressure bands from without or the result of new growths, cannot always be determined by the Roentgen method.

In the diagnosis of this condition, Roentgenologically, account must be taken of the possible stage of the disease. That is whether we have an active ulcer present or whether there is partial or total healing with cicatricial contraction. For example, Barclay, X-Ray Director of the Manchester Royal Infirmary, England, in his recent work on this subject gives the following symptom complex form the Roentgenological point of view:

(1) The stomach always exhibits good tone, even if ptosis is present.

(2) The peristalsis is more active than normal, especially when the food has commenced to pass through the duodenum.

(3) The food begins to leave the stomach almost at once and as a rule continues to pass out very rapidly until the stomach is empty.

(4) The pyloric relaxation is so complete that large masses of food are seen passing through the duodenum instead of the fine. almost imperceptable stream that can only be detected with certainty by means of an instantaneous roentgenogram. In certain cases a separate bolus is seen remaining apparently in a pocket in the duodenum.

This picture is characteristic of an active disease, but with healing more or less complete with the resulting cicatricial contraction this picture changes to one of partial or complete stenosis with retention of food in the stomach and possible dilation.

The tendency toward a development of malignancy on the site of a healed duodenal ulcer does not seem to be so great as in peptic ulcer, yet such does occur.

A diagnosis having been certainly made of this condition the question immediately arises what course of treatment shall be pursued.

In simple cases undoubtedly medicinal treatment should be adopted as the first resort. Absolute rest of the diseased organs seems to be the rational procedure with rectal alimentation with. perhaps plenty of water by mouth and sufficient alkalies to neutralize the acidity of the gastric juice and thereby prevent as far as possible its irritating tendency on the lining of the duodenum. The use of bismuth in moderately large quantities may be of some benefit, but does not show in practice as marked benefit as in gastric ulcer. It is a notable fact that has been frequently observed in the

roentgenological study of the stomach and small intestine that following the ingestion of the bismuth, and continuing for sometimes several days, a relief to a more or less degree from the distressing symptoms. This relief seems to disappear in direct proportion to the rapidity with which the bismuth is carried away from the crater of the ulcer.

No doubt the diet or rather the absence of it for several hours during the series examination is also a factor in giving relief.

Rest in bed is of great importance if medicinal treatment is employed.

The use of Hydrastis (non-alcoholic) in ten to fifteen drop doses every two to three hours aids in the healing process. The following prescription meets the above suggested treatment very nicely both in this condition and also peptic ulcer cases:

Pulv. Hydrastis, 3i.; Magnesiae Calcined, 5v.; Bismuth SubNitrate, 5v. M., et. ft. Chart. No. Sig. One mixed with water every two or three hours.

If there is much. fermentation with the formation of gas, add to the above one and one-half drams of Bismuth Beta-Napthol.

When diet by the stomach is commenced give milk and cream, an ounce of each, with lime water, every hour or two, and as the symptoms improve custards, rice (well cooked), cream of wheat, raw or soft eggs, baked potato, malted milk, avoiding anything that is acid or anything containing alcohol.

If the bowels are sluggish enemas with the use of castor oil or some good preparation of the Russian Petroleum oil internally will be the least irritating and effective.

Should a symptomatic cure result from such course it should be made reasonably certain later that the healing has not resulted in sufficient cicatricial contraction as to embarrass the proper emptying of the stomach, with the secondary condition resulting that has already been outlined. This might not be apparent clinically until sometime afterward, but a careful roentgenological study of the apparently cured case would clear this matter up.

Some cases have been reported where healing with considerable cicatrix formation has taken place where the use of thiosinamin internally over a considerable period has seemed to soften the cicatrix and restore an apparently normally patulent duodenum. This, however, is doubted by some of the best authorities. Personally I have had no experience with it.

The general consensus of opinion seems to be that duodenal ulcer is per se a surgical condition and should be so dealt with. Even if healing takes place there is a great proneness to recurrence.

If a simple ulcer exists and it is of small size, so that its excision would not embarrass the lumen of the intestine, that is the

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operation of choice. If it be a perforating ulcer with perhaps adhesions to the neighboring organs more radical procedure is necessary. In cases where sudden and severe hemorrhage has occurred an emergency operation is made necessary to stop the bleeding and save the patient's life. Even with slow bleeding, with more or less rapidly developing anemia, no time should be lost in proper surgical intervention for its relief.

Where it is of such magnitude that a considerable amount of the bowel must be sacrificed with perhaps total or complete closure of the pylorus, or where this has already taken place from cicatricial contraction provision must be made for the proper emptying of the stomach by some other route. There have been many methods employed and many ways suggested with varying results. Probably the most accepted method today is the posterior gastrojujenostomy according to the Mayo method. In short, this consists of an anastamosis of a loop of the jejunum, sufficiently near the duodenum to prevent a pocket or trap formation, to the posterior wall of the stomach, low down toward the pylorus, by passing the former through a rent made in the least vascular portion of the transverse mesocolon thereby forming a new exit from the stomach. At the same time the proximal end of the duodenum and the entrance of the bile and pancreatic ducts are preserved, these fluids passing down to the new gastro-enteric union and there mixing with the chyme to perform normal intestinal digestion. In some cases all that is necessary in treating the ulcer, if the above anastamosis is done, is to Lembert it over as a reinforcement and the relief of the function of the part allows healing to take place.

The anastamosis must be near the pylorus in order that the stoma may be as efficient as possible and the accumulation of residual chyme in the pocket formed below it prevented. Then to it has been proven that a high anstamosis does not perform the function intended as the stomach peristalsis forces the chyme toward the pylorus and not through the stoma. The exit from the stomach. taking place where the pressure is the greatest.

The exact technique employed in performing this operation will not allow of elucidation here.

The mortality in this operation is less than two per cent., and with the patient not too much debilitated and in cases not too far advanced it should be almost nil.

As to the possibility of recurrence, Dr. W. J. Mayo notes that results following operation in 600 cases of gastric and duodenal ulcer, eighty-one per cent. were so relieved as to be considered cured and ten per cent. were markedly benefited: that is, that ninety-one per cent. were cured or improved and that five per cent. of the