STARCH DIGESTION IN THE STOMACH.1 (o) THE DIGESTION OF STARCH BT TAKA-DIASTA8F. IN A NEUTRAL MEDIUM AND THE RELATIVE BY A. E. AUSTIN, A.M., M.D., BOSTON. AMOUNT OF STARCH AND DIASTASE ; ALSO THE It has been usually supposed that the diastatic di- TIME REQUIRED FOR COMPLETE DIGESTION. of food in the stomach is interfered gestion starchy For this a of starch with the hydrochloric acid of gastric within purpose quantity three-per-cent. by juices or was made into 1,800 c. c. a short time after each meal. Not able to paste, clyster, by pouring being of heated distilled water 60 grammes of pure potato find auy definite statements based on actual experi- in 200 c. c. of water, with constant ments, however, I have undertaken to make a starch, suspended sys- until the mass a translucent tematic research on this func- agitation acquiretl appear- important physiological and then to 40° C. tion. ance, cooling Twelve of a of about 200 c. c. were More than two-thirds of the human food con- glasses capacity daily and marked with a file at the 100 sists of aud it will be as carefully graduated starchy food, very interesting c. c. luto each the starch was well as to learn how and where this point. glass clyster important Btarchy to the 100 c. c. 3 food is poured, up mark, representing digested. of starch in each. The were numbered, In out this human as well as grammes glasses carrying investigation, and in the order in which were numbered were stomachs were utilized to determine the actual they dogs' into a shallow pan water at 40° C. condition of digestion that is on ; and for the put large containing going Three grammes of taka-diastase was dissolved iu 100 purpose of the relative functions of starch studying " c. c. of distilled water c. c. = 0.03 and dif- aud diastase, the known as " taka-diastase (1 grammes) product ferent volumes of this solution, from 0.3 c. c. was used, for its power is varying umyolytic remarkably strong to 9 c. c, were added and stirred — as well as stable. On the other it was found up simultaneously hand, the At this it was that the diastatic of Baliva deteriorates in noting time. stage observed that power easily the of the of the starch was besides, is liable to from hour to speed liquefaction jelly keeping, and, change to the of diastase used ; that and to even in one proportionate quantity is, hour, day day, person. the more diastase the the Taka-diastase is an isolated diastatic ferment ob- present quicker liquefaction. In cases like Nos. 8 and 9 the took tained from the of A cer- 7, liquefaction growth microscopic plants. almost tain class of fungi has the property of generating place instantaneously. diastase its on the similar during growth, principle OS that diastase is formed in barley during the process of t-, « i2- or S3 germinating malting. S M all ill used for this is " Eurotum a o « is 4 S te cÜ v SI' L- x V IBS " S3 ' It oryzm," or Taka-moyashi," which is cultivated under OggS H artificial conditions with scientific precision. The pure 100 0.3 O.OOÍl 1:883 03 culture of the of this is sown on moist spore plant 100 0.4 0.012 1:250 60 sterilized wheat bran and allowed to grow at a proper temperature and humidity. The diastase thus gener- 100 0.5 0.015 1:200 40 ated on the bran is extracted with water aud precipi- 100 1 0.03 1:100 27 tated with strong alcohol. The product is a yellow- 10(1 2 0.06 2:100 25 ish-white odorless a taste. powder, possessing nutty 100 3 0.09 3:100 20 It is non-hygroscopic, yet readily soluble in water, with little or no sediment, and has a remarkably 100 4 0.12 4:100 18 strong diastatic power, converting over one hundred 100 5 0.16 5:100 15 own of times its weight starch into sugar within ten 100 G 0.18 6:100 13 minutes. too 7 0.21 7:100 10 The experiments were carried on to investigate the following points : 100 8 0.?4 8:100 7 (a) The digestion of starch by taka-diastase in a 100 0.27 9:100 5 neutral medium, the relative amount of starch aud and also the time for di- diastase, required complete At an interval of every minute or two a drop of the gestion. liquid was taken out of each glass and dropped ou a The action of free acid on the (¿) hydrochloric diges- white porcelain plate, and to each of these drops a drop tion of starch taka-diastase. by of a weak solution of iodine in potassium iodide was (c) Actiou of free orgauic acids on starch digestion added, and the color of each observed after spreading taka-diastase. by it with the finger to tho size of a silver dollar. (d) The effect of free hydrochloric acid on starch It was observed that iu the first set of tests the digestion in the presence of albuminized hydrochloric colors of the different drops varied from insoluble blue acid. to soluble blue, purple, brown, with their intermediate (e) Influence of hydrochloric acid on starch diges- colors, and eventually to colorlcssness, in showing the tion in the — presence of albuminoid foodB both animal different stages of digestion of the starch into soluble and vegetable albuminoids. starch dextrin, erythrodextriu, achrodextriu, maltose (/) The action of hydrochloric acid of dog'B gastric and dextrose. on Btarch juice digestion in a dog's stomach in the The larger the amount of diastase used the quicker normal with a dose of digestion taka-diastase. the achromatic was reached, or, in other words, Influence of point (g) hydrochloric acid of human gastric the more the For instance, in the ou starch rapid digestion. juice digestion in the human stomach both case of No. 12 an achromatic was reached in with and without taka-diastase. point three minutes, while in the case of No. 1 it took about 1From Chemical Laboratory, Tufts Medical School. an hour.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UT DALLAS on July 23, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. It waB also observed that with a given proportion of The polariscopic sugar test for Nos. 1 aud 2 both starch to diastase the transformation of starch into showed perfect digestion at the end of fifteen minutes, dextrins and sugars went on in the same order as practically 100 per cent, of sugar being formed ; while above mentioned. No. 3 contained but one-third the amount of sugar, com- Similar experiments were repeated several times pared with Nos. 1 and 2 ; and the amount of sugar in with similar results, proving conclusively that diastatic the other glasses decreased very rapidly as the acid in- digestion takes place very rapidly ; and its rapidity creased. can be regulated at will, with the quantity of diastase This experiment shows that the presence of a small used ; and also that taka-diastase digests three hundred quantity of free hydrochloric acid enhances and helps times its own weight Of starch inside of one hour in a the starch digestion ; while beyond a certain amount, neutral medium. however, tho diastatic power is weakened ; and by amountB its action is arrested at least THE FREU larger wholly (Ô) ACTION OF HYDROCHLORIC ACID ON for the time — THE DIGESTION OF STARCH BY THE DIASTASE. being. ACTION OF FREE ACIDS The following experiments were conducted: (c) ORGANIC ON STAUCH DIGESTION BY TAKA-DIASTA8E. Three-per-cent. starch jelly made in the same man- ner as described in (a) was poured into nine different As it is often possible to have some organic acids glasses, 100 c. c. in each, representing 3 grammes of present in the stomach, either from the food itself or starch in each. These glasses were placed in a pan from fermentation of the food, it was thought, interest- containing water and were kept at 40° C. Into these ing to fine! out their action on starch digestion. For glasses different quantities of free hydrochloric acid this purpose, lactic, citric and acetic acids were used. were placed, varying from 0 to 1.4 parts of the acid in The method was similar to that used in : The testing (b) 1,000. hydrochloric acid was C. P., and con- LACTIC ACID. tained 31.9 cent 11C1. After the acid was thor- per Absolute lactio acid Time of Iodine oughly mixed in the starch jelly one c. c. of 10-per- parts in 1,000. digestion. ruaotlon. UK) . 17 minutes Uolorloes cent, solution of to 0.1 " " taka-diastase, corresponding .02 . 15 " " was added to each and stirred .26 . 12 gramme, glass well " " .40 . 18 " .67 . 13 " ¿ .86 . 13 o d " " !" a . 13 sei? 2¿Sa. ¿S ,-a 1.05 t. o v " " Z . c-u n « . 1.40 13 «- » s " 8J?-?»3 isÉ iIf 1.84 . 60 Blue o «, aK E 2 o »as sa a CITRIC ACID. «s £5,2. Absolute oitrle aold Time of Iodine parts In 1,000. digestion. reaction. .00 . 15 minutes Colorless 100 " .00 .0 01 1:100 Colorless, 100 .05 . 13 .68 .8 " " " 100 .03 .1 0.1 1:100 Colorloss. 100 1.82 . 12 " " 2.43 . 16 o " 100 .06 0.1 1:100 Brown. 35 3.40 . 65 " 4.30 . 120 Bine. 100 .12 .4 o.i 1:100 Purple. COMMON VINEGAR. 100 .18 .0 o.i 1:100 Purplish bine. , Absolute acetlo aold Timo of Iodine 100 .25 .8 0.1 1:100 Solublo blue. parts in 1,000. digestion. reaction. .00 . 15 minutes Colorless " " îoo .31 1.0 0.1 1:100 Insoluble bine. .11 . 12 " " 1.23 . 5 " " 100 .37 1.2 0.1 1:100 2.35 . 7 " " 3.47 . 10 " 100 .43 1.4 0.1 1:100 4.59 . 12 " 5.71 . 12 " " 6.83 . 12 in, simultaneously noting the time. At an interval of These results demonstrate that starch is one or two minutes a of the was digestion every drop liquid not interfered with the presence of taken out of each and tested with iodine by organic acid, glass solution, particularly there seems to be no limit for as described in It was as shown in the vinegar; (a). observed, also show a table practical purposes. They that small below, that where no acid was used —as in No. of acid accelerates the starch digestion instead — quantity 1 the achromatic was reached in fourteen min- point of hindering it, as was also shown in the case of hydro- utes ; while in No. 2, where a small quantity of acid chloric acid. existed, the achromatic point was reached somewhat THE BEHAVIOR OF FREE HYDROCHLORIC ACID sooner, in ten minutes. When the (rf) namely, acidity TOWARD STARCH DIGESTION IN THE PRESENCE OF was increased a little more, as in No. 8, the drops ALBUMINIZED HYDROCHLORIC ACID. showed a purple color at the end of fifteen minutes ; in No. 4, a bluish purple ; No. 5, soluble blue ; while Taking into consideration the fact that there exists No. 6 and the remainder of the glasses all showed in- in the gastric juice of the stomach some pepsin aud soluble blue at the end of fifteen minutes — showing a combiued hydrochloric acid, besides free hydrochloric decided hindering action of free acid on diastase diges- acid, it was considered interesting to find out the be- tion in the test-glass experiments. At the end of havior of free hydrochloric acid toward starch diges- fifteen minutes the first three glasses were taken out tion iu the presence of pepsin aud albumin — com- of the warm bath and put into an ice-box to check bined hydrochloric acid. further conversion. The amount of sugar was de- For this purpose, a litre of dilute hydrochloric termined after cooling by the polariscope method, after acid, containing 2i parts of HC1 and 2 grammes pepsin removing the dextrin, if any, by precipitating it with in 1,000, was digested over night at 40° C. with some alcohol. boiled white of egg finely comminuted. The next

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UT DALLAS on July 23, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. morning tho solution was filtered and tested for the the starch digestion was wonderfully facilitated by the free acid remaining uncombined. presence of an albuminous substance. The free hydro- The liquid was titrated with deci-normal soda solu- chloric acid combines with the albumin and becomes tion, UBing a few drops of a solution of dimetbyl- non-active, or inert to starch digestion. It will bo no- amido-azo-benzine aB indicator for free acid, and it was ticed that in experiment (d) Nos. 4 and 5 wore on the found to contain two parts of free hydrochloric acid in danger line, while in this cafe even No. 6 enjoys good 1,000; while the same liquid showed 2.5 in 1,000 digestion of starch. In the case of No. 8, 100 c. c. of when rosolic acid was used as indicator — showing acid was mixed with 10 c. c. of the albumin ; at the the total amount of acid, both free aud combined. end of half an hour 1.1 part out of two, or 55 per As this acid solution necessarily takes up more cent., of free acid was found in a combined state, leav- room thati strong acid, 6-per-cent. starch paste was ing only .9 part of free acid. made and 50 c. c. of it was into each instead put glass •a of 100 c. c. of solution. Into these o—* « 3-per-cent. glasses •£ is u a « SO S So "O different amouuts of albuminized hydrochloric acid as to ü a> g — N a a, o 8- — were added B p "" P »nuit (artificial contents) a> o en & »H v a> v gastric varying « "i oj i- d c. c. 50 c. and was to 13 o os from 5 to c, each made up q> o a <» glass SÜ2.S _ a ä 100 c. c. the of water at C. 3 o S * OS g £ by addition 40° and well ° O a. S rt c ü stirred. fe ÍÍSS Into this acidified starch the same of taka- quautity 0 3 diastase was added to each and the different grammes, glass, " stages of conversion observed as before, as will be seen 5 3 in the following table. 10 .2 3 " For a aud same amount of acid given the present 20 .4 3 '• the starch in this case is better than in the digestion 30 .6 3 •' 12 case where no combined acid existed. For instance, where in experiment (¿>) in No. 3 the achromatic point 40 .8 3 " 20 was only reached at the end of fifteen minutes, in this 60 LO 3 case it was reached in and the remain- eight minutes; 100 2.0 0 ing glasses showed a similar difference in favor of the of combined acid. This Beems to indicate presence To further this c. c. that the of albumin combined with verily fact, 100 of the albu- presence hydro- minized two of free chloric acid seems to lessen the action of acid, containing parts hydro- hindering chloric acid aud one-half of combined free acid on starch part hydrochloric digestion. acid in 1,000, was digested with 50 grammes of chopped- beef meat at 40° C. for half an hour. On » o testing, it 322 H* was found that there was no free hydrochloric acid, 3-a and tho total acid showed 2.5 1,000, as jBti). as per originally 3 S existed. oS Another test was made with vegetable albumin : To = »-'S'S §s.s 100 c. c. of the same albuminized acid 25 grammes 'A of so-called canned Boston baked beans were added 1 0 .0 0.1 12 Colorless. and well stirred, and put into a water bath at 40° C. At the end of five minutes a was taken 2 5 .1 0.1 sample out, tested for free acid, and all free acid was found to be 3 10 .2 0.1 gone. While testing for total acid it was found to be 4 20 .4 0.1 Brown. 2.5 by rosolic-acid test. tests seem 5 30 0.1 Purplish blue. These to show conclusively that albu- minous which is coexistent with 6 40 0.1 Blue. food, always starchy food, takes up or combines with free hydrochloric acid 7 50 1.0 0.1 Blue. of gastric juice and gives full swing to the diastatic di- gestion of starchy food in the stomach. (e) THE INFLUENCIO OF HYDROCHLORIC ACID ON (f) THE BEHAVIOR OF HYDROCHLORIC ACID OF STARCH DIGESTION IN THE PRESENCE OF ALBU- DOG'S GASTRIC JUICE TO STARCH DIGESTION IN MINOUS FOODS—BOTH ANIMAL AND VEGETABLE A DOG'S STOMACH IN THE NORMAL DIGESTION ; ALBUMINOIDS. WITH A DOSE OF TAKA-DIASTASK. Being encouraged by the results of the foregoing Having demonstrated in test-glass experiments the tests, it was considered a natural sequence to test the fact that albuminous food combines with free hydro- starch digestion in the presence of some albuminoid. chloric acid, and the combined hydrochloric acid thus As a matter of fact, people always eat some albumi- produced does not interfere with starch digestion, it nous matter with starchy food. Generally speaking, became necessary to find out whether or not such one-third of our daily food consists of albuminous food would occur in the animal stomach. It is the usual aud two-thirds of Btarchy food. It was therefore custom to give a test breakfast consisting of toast and thought imperative to find out the relation of the tea, to find out the condition of the gastric secretion of food albuminoid to the digestion of the food. the stomach. While it may answer for some specific this starchy For purpose, a starch digestion in the presence purpose, that kind of a test meal is not a fair one to of free hydrochloric acid, identical with that of (c) was lind out the actual condition of acid in with the hydrochloric performed addition of 10 c. c. of egg albumin the stomach after a regular and ordinary meal, and to As will seen each glass. be from the following table, having iu view a desire to find out what effect albu-

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UT DALLAS on July 23, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. minons food has on the hydrochloric acid of the stom- The contents were evacuated with ease at the end of ach, the following meal was given to a dog on the first one hour and ten minutes. The contents were tested day : for starch, but no amount of starch could DOG'S 1. perceptible FOOD, No. be found except one or two bits of bread crust which raw. 200 Beef meat, grammes. and the contents showed the Starch paste, 7% strength. 200 c. c. escaped disintegration, White of egg, raw.1 egg. presence of a small quautity of free acid. White of egg, boiled.1 egg. contents Salt.i teaspoon. The were filtered aud quantitatively tested Taka-diastase.1 gramme. for free acid, total acidity, and acidity due to acid as follows : After thirty minutes the contents of the stomach were phosphate, pumped out after giving 100 c. c. of water, and the Total acidity in 1.000.1.27 Acidity duo to acid phosphate .... 0.10 contents examined. The contents were tested for Total Btarcb, but all starch waB perfectly no hydrochlorlo acid.1.17 digested, giving . Free hydrochloric acid..18 coloration with the iodine test. Combined aold.99 — hydrochloric There was no free acid present showing only a pure yellow coloration when tested with dimethyl- The second test meal was at lunch hour, and con- amido-azo-benzine. — sisted of the following : The amount of combined acid was found to be .86 One-half dozen oysters on the with crackers ; one of Manhattan shell, glass in 1,000, rosolic acid as indicator. Cocktail; consommé soup; roast beef, two ellees; using mashed potato, double portion ; .4 litre lager beer ; broad aud but- On the second the test meal was ter ; Rochefort cheese with toasted oraekors ; one gramme of taka- day following dtastase. given to the same dog : After one hour 400 c. c. of the contents were evacu- DOG'S FOOD, No. 2. ated. The starch waB found all and no free cooked digested, Chopped-beef meat, ...... 400 grammes. acid could be found. Total 20 grammes stareh cooked In. 300 o. c. acidity was as follows : Table salt. ¿teaspoon. Total Boiled white of 2 acidity.1.17 In 1,000 eggs. eggs. Acid In Taka-diastase. 1 gramme. phosphato.18 1,000 Total hydrochlorlo acid.89 in 1,000 The contents were pumped out at the end of one minutes later aud one-half hour, giving 100 c. c. of water before pumping. The Thirty (one hours after eat- another was and contents did not coûtait) any free acid, nor any starch ing) sample begged analyzed. contents at this at all. The time were found to be a good deal thinner than those of the first evacuation Having found that the stomach was comparatively and con- tained no starch — even a the toasted empty, another meal was for a forty-five-minute part of crackers given had The contents test. The same dog was fed with a similar meal, as disappeared. were filtered, aud at follows : this time free acid showed its appearance: DOG'S FOOD, No. 3. Total aoldity.1.86 Free »eld somo Chopped cooked boef. 400 grammes. (with organic aold) . . . .40 10% starch jelly. 200 c. c. Table salt.¿teaspoon. Combined add.1.46 White of eggs, raw.2 eggs. Taka-diastase.1 gramme. Qualitative test showed the presence of a small quautity of acetic and lactic acid, but no At the end of minutes the stomach's contents quantitative forty-five determination was made, for are harm- were out and examined. It contained no free they practically pumped less on starch digestion, as shown before. acid whatever, nor any trace of undigested starch. From the results of the the These confirmed the results of test- foregoiug experiments experiments following fuels seem to be well established : glass experiments (e) and (a), namely, that albuminoid Taka-dinstase starch with remarkable food neutralizes and combines with the free (1) digests hydro- in a neutral, or acid, medium and ite chloric acid of the and combined rapidity slightly ; gastric juice; hydro- rapidity is directly proportional to the quantity of taka- chloric acid does not interfere with the diastatic diastase used. Taka-diastase in the above medium is of and no free acid was found iu digestion starch, capable of digesting three hundred times its own weight the stomach contents when pumped out at intervals of starch iu one hour. of aud minutes. thirty, forty-five sixty (2) The digestion of starch by taka-diastase is ac- celerated aud THE BEHAVIOR OF HYDROCHLORIC ACID OF enhanced by the presence of a small (g) of free HUMAN GASTRIC JUICE TOWARD STARCH DIGES- quantity hydrochloric acid, while beyond a certain amount the free TION IN THE HUMAN STOMACH, BOTH WITH AND hydrochloric acid retareis and WITHOUT TAKA-DIA8TA8E. eventually arrests the diastatic digestion. The of starch taka-diastase is not In order to make the results of the (3) digestion by foregoing exper- interfered with by organic acids for all practical pur- iments conclusive the contents of a beyond dispute, poses ; on the contrary, the presence of a small human a quan- stomach (after eating square meal) were ex- tity of organic acid enhances the diastatic digestion of amined. starch. Mr. a student who has the rare Mc-, faculty of The presence of albumin combined with able to evacuate of the contents of (4) hydro- being any portion chloric acid seems to lessen the hindering action of free his stomach at his will without feeling any incon- acid on starch venience volunteered and offered his hydrochloric digestion. whatever, kindly Albuminous foods — both of auimal and services science to (5) vege- in the interest of decide this im- — table origin combine with, or neutralize, free hydro- portant question under investigation. chloric acid of gastric the acid His breakfast consisted of : juice, making perfectly inert. The combined hydrochloric acid has no hinder- One saucer of oatmeal with milk and sugar, one-quarter pound of action on diaBtatic starch. beefsteak, medium done, two slices of bread and butter, two baked ing digestion by potatoes, one cup tea, one slice of cake. (6) In dogs' stomachs, when albuminous foods are

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UT DALLAS on July 23, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. given with starchy food, no free hydrochloric acid is iuches long and throe inches wide. It was quite freely found at the end of one hour, and in the meantime movable, and could be pushed somewhat iu all direc- starchy foods are perfectly digested. tions. The tumor itself was firm and elastic, its surface (7) In the human stomach, when au ordinary regu- somewhat irregular, and in parts indistinctly nodulated. lar meal is taken, tho albuminous matter of the food There was some tenderness on deep pressure over the combines with the hydrochloric acid of the gastric tumor. juice as faBt as it is formed, at least for a period of From time to time after the woman entered the hospi- one hour, and such combined hydrochloric acid has no tal the tumor was examined, and its characteristics were hindering action on starch digestion ; and the diastatic found to be unchanged, except that occasionally it was digestion of starchy food is practically completed within apparently quite tender to the touch, and its mobility • that period. was less marked. The temperature also was up a couple of degrees or so on one or two occasions. Under ether (on October 14th), an oblique incision Clinical was made through the abdominal wall, just below and Department. parallel to the right costal border. A large mass pre- sented itself, which upon examination proved to be the A CASE OF CARCINOMA IN THE RIGHT HYPO- enlarged gall-bladder. This was opened, and found to CHONDRIAC REGION.1 contain numerous (eighty-one) very light-colored gall- stones, mixed with a considerable of soft REMOVAL OF EIGHTY-ONE GALL-STONES, AND EXCI- quautity and some After these had SION OF THE CANCER, TOGETHER WITH THE grumous material, pus. been removed and the wound washed out the wall of ENTIRE GALL-BLADDER, A SMALL PORTION OF tho was and found to be much THE LIVER AND A LARGE PART OF THE ANTERIOR gall-bladder inspected, thickened in and ne- WALL OF THE STOMACH-RECOVERY FROM THE and, spotB, softened, apparently crotic. Its was and from it OPERATION. lining shaggy, projected shreds and of reddish-white tissue. exam- BY lll-:iiltll|,'. II. HUSTON. tags Upon HONKS, M.U., ining further for stones iu or near the duct the finger Tins case seems to me to be of interest, especially came upon a firm, indurated mass, presumably cancer, for the reason that — apparently involving the apex of the gall-bladder and (1) The cancer involved several important organs. extending to the anterior free border of the right lobe (2) The case demonstrates the value of nutritive of the liver and the anterior wall of the Btomach. enemas. (The stomach would retain nothing whatever At this point it became necessary to decide whether for many days at a time, and for long periods reliance to abandon further operation, to insert drainage and was placed almost exclusively on the enemas.) apply dressings, etc., ou the ground that it would be (3) The presence of the largo number of stones in useless and too dangerous to attempt anything further, the inflamed gall-bladder suggests the possibility that or to proceed to excise the entire mass, with the idea these conditions acted as an exciting cause of the can- that the patient would stand a fair and reasonable cerous growth.8 chance of surviving the operation and the resulting History of the Case. — The patient was a woman, shock. The latter alternative was thought to be, on thirty-six years of age, and married. Her family liia- the whole, the better for the patient, and it was forth- tory revealed no case of malignant disease. She had with carried out. The cystic duct was tied off with had nine children, the youngest fifteen months ago. silk, aud a wedge-shaped piece of the liver was re- She had never had a miscarriage, and her menstrua- moved, tho edges of the liver wound being united by tion appeared to be normal in all particulars. catgut. The tumor was now free, except for that part She entered the hospital on October 7, 1898. which involved and projected into the stomach. An About five weeks before this she had discovered a incision, encircling the growth and giving it a wide lump high up in the right side of the abdomen, just margin, was now made through the anterior wall of below the costal border. There had been occasional the stomach, and the entire mass, including — be- pain in this tumor, especially when she coughed, but sides the growth itself—a large portion of the stom- it had not been noticeably tender to the touch. It ach, a part of the anterior border of the liver and the had not increased in size to any extent since she lirst entire gall-bladder, was removed. The wouud was noticed it. Tho bowels had been regular. There now thoroughly cleaned out, and the hole in the wall had been no vomiting, though occasionally after eating of the stomach (which reached to within a couple of the patient was somewhat nauseated. She had lost inches of, but did not involve, the pylorus) was stitched much flesh. with a double row of Lembert sutures, so as to bring A careful examination was made when the patient the lips of the wound teigether laterally ; that is to say, entered the hospital. She was a well-developed and the two sides were sutured together by a vertical row fairly-well nourished woman. The abdomen was soft of stitches, this method ensuring more room iu the stomach and pliable. Just to the right of, and above, the um- and less danger of stricture than would have bilicus, could be felt a tumor apparently about five been the case if the upper and lower parts of the wound had been After the entire wound i Read before tho Surgical Section of tho Suffolk District Modlcal approximated. Society, January 4, 1899. had been very and cleaned a gauze ' I believe that thoroughly irrigated ¡,,Humiliation and otlior sources of irritation exort drain was inserted anel the skin a more constant Influence In the causation of malignant disease In edges brought together than the abdomen is usually thought to bo the case. From time to by sutures, except where the gauze drain time during operations and in the examination of 1 have silkworm-gut abundant evidence spoclmens The usual was then had of this. Only a few months ago this point emerged. dressing applied. was foroibly brought to mind In a case whore I resected, for canoer, The of the showed the to tho cecum of a young man. In the middle of the growth I found, report pathologist growth in the be cancer. approximately position where the appendix should a epidermoid That portion of the of Btze and shape like tho be, long growth slough appendix. This slough suggosts, which involved the stomach seems to have of course, tho possibility of a former appendicitis as au oxoltiiifi penetrated cause. the mucous membrane of that organ " through a slit-

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