with mucus. With the increasing acidity of the stomach contents, the chances of healing of the ulcer are greatly reduced, and its extension is practically certain, hence each one of the conditions in turn becomes more and more exaggerated, and conditions go from bad to worse, unless a radical change is established whether by internal treatment, or if this prove ineffective, by surgical operation. I have had an opportunity to verify these clinical observations in a very large number of patients suffering from gastric ulcer, and they are in keeping with observations of most clinicians, who have studied such cases extensively. These facts would indicate the importance of careful treatment at the very beginning of gastric ulcer in order to secure complete healing before any of the secondary conditions have arisen, and also the necessity of eliminating all of the primary causes of the lesion in every individual case after healing has taken place, in order to prevent a possible recurrence.

This is especially important, because each successive attack is more difficult to relieve permanently. The chances for permanent relief are more and more reduced, because each time some lesion will remain, which must lessen the resistance of the tissues, or increase, at least, to a slight extent, the difficulty of emptying the stomach.

It is likely, that with proper after treatment, especially as regards diet and general hygiene, it would be possible to reduce the number of cases of recurrence to a great extent. This would reduce the number of cases, which now properly fall into the domain of the surgeon.

Fuetterer has written most effectively upon this phase of the subject, and I am confident it is worthy of our most serious attention. This is true, primarily, because it would permanently eliminate all of the many serious sequelæ, which are now so

common.

All of this would indicate that surgery of the stomach begins where internal and dietetic treatment of disease of this organ fails to give permanent relief. It also indicates that surgery, in order to be of value, must result in local rest and in the drainage of irritating contents of the stomach, in all non-malignant cases, and in the early removal of the growth in malignant cases. It seems reasonable to suppose that the most careful attention to diagnosis of non-malignant cases, and the surgical treatment of that portion of those which cannot be relieved permanently by internal treatment, must result in a vast reduction of the number of malignant cases.

At the present time some form of gastro-enterostomy seems

to have given the most satisfactory results. Robson pointed out the fact, most emphatically, that the anastomosis must be located actually, and not only theoretically, at the lowest point in the stomach, in order to be safe and effective, and leave the patient free from regurgitant vomiting "vicious circle."

Theoretically, there seems to be many arguments in favor of a posterior gastro-enterostomy, but practically the results seem equally satisfactory, provided the opening is sufficiently large, and is in fact at the lowest point of the stomcah.

A method has not yet been found, which completely satisfies all reasonable demands for performing gastro-enterostomy. I have had the time to look up only those of my cases of stomach. surgery, which I have treated in the Augustana Hospital, hence I will speak only of these in this paper. But the methods and the results have been the same in the cases I have treated in other hospitals, hence this is of no material importance. The following table will give a convenient idea of these operations:

It will be seen from this that most of the operations were performed for the purpose of securing rest for the pyloric end of the stomach, and drainage for its cavity; also that gastroenterostomy was performed oftener by means of the McGraw ligature than by any other means. This method has been more satisfactory in my hands than any other up to the present time. I still follow the original direction of the author of the method, which I published in the Journal of the American Medical Association, June 6th, 1903. It seems likely that all of the methods now in use will be displaced by some new method which will be more nearly ideal than any now in use.

So far nothing has been said concerning the treatment of any of the sequelæ, or the complications of gastric ulcer, because it is to be hoped that these will be eliminated to a great extent in the future, by the cure of the ulcer itself.

Complications.-The most common complications are perforation and hemorrhage.

Sequelae. The sequelæ are: (1) Chronic ulcer, (2) stricture of the pylorus, (3) gastric dilatation, (4) hour-glass stomach, (5) peritoneal adhesions, (6) inanition, (7) anemia, (8) neurasthenia resulting from the constant suffering, the malnutrition and the anemia, (9) carcinoma, and (10) jejunal ulcer following gastro-enterostomy.

Perforation. The diagnosis of perforation is relatively simple. There is a history corresponding to that given for gastric ulcer above. During some exertion, the patient suddenly experiences severe pain in the region of the stomach. This is frequently attributed to the eating of a large meal, and may consequently be mistaken for acute gastritis. The pain becomes diffuse very suddenly. The patient is nauseated, and sometimes vomits blood or bile. The abdominal muscles become rigid; the patient is in a severely shocked condition.

The greatest point of tenderness is in the region in which tenderness existed previously. In many cases the liver dulness is obliterated to a greater or less extent, but it is not safe to place too much weight upon this symptom, because it frequently is present only after the perforation has existed for several hours, and if operation is postponed until this diagnosis can be confirmed by this symptom, the extent of the infection is usually so great that the operation cannot save the patient.

With two exceptions, all of my cases in this class were in this hopeless condition when they were admitted. The important point in connection with these cases is an early diagnosis and an immediate operation. The latter should consist in a free abdominal incision, careful sponging out of stomach contents that have escaped into the peritoneal cavity, closure of the wound in the stomach with Lembert sutures, preferably of silk or Pagenstecher thread. Drainage should always be used.

In cases in which the diagnosis is not made for 24 hours or longer after the perforation has taken place, it is difficult to state which course is the worst to pursue. In my own experience, all of the cases which came under my care in this advanced stage, which were operated on, died within a few days, while a few which were not operated on, recovered, the opening in the stomach

being closed by a plug of omentum. In some of these cases a subphrenic abscess developed, later requiring an operation.

I am confident, however, that these cases were all somewhat less serious from the beginning than those which were operated and died; and it would consequently not be proper to attribute the recovery of the former to non-operative treatment, and the death of the latter to the operation.

It seems proper to advise an immediate operation in all cases of perforated gastric ulcer, in which an early diagnosis is made, and to use one's judgment in each individual case of perforation, in which the diagnosis is not made early.

Gastric Hemorrhage.-A few years ago there was quite a marked tendency toward the immediate operation for gastric hemorrhage. Mayo Robson's experience in this direction was so encouraging, that quite a number of surgeons favored operative treatment for this condition. It seems, however, that this is quite unnecessary, because in almost every case the hemorrhage will cease, and if the patient is carefully treated, her general condition can be greatly improved, so that the risk of the operation itself will be much less than when performed during a hemorrhage.

The treatment should consist in exclusive rectal feeding. It may be well to administer from two to four ounces of castor oil early in the treatment, and then to place nothing whatever in the stomach, until there has been no blood in the evacuations for several days. Feeding by mouth should be begun with great caution, and as soon as the patient's general condition is good, the operation should be performed.

Sequelae. In the treatment of the first three in the above list, (1) chronic ulcer, (2) stricture of pylorus, and (3) gastric dilatation, the method must be the same. It must consist of drainage of the stomach cavity by gastro-enterostomy, or in rare cases by Finney's pyloroplasty. The one point of greatest importance which must not be overlooked, is the choice of location for the opening in the stomach at its very lowest point.

Rodman's suggestion, advising the excision of the ulcerbearing area in these cases, is undoubtedly worthy of consideration. In my own experience the results have been more satisfactory in cases in which I have excised the pylorus in connection with making a gastro-enterostomy, but as this adds another element of danger to the operation, it may be well to continue our observations, before making this a routine treatment in these

cases.

In cases in which a pylorectomy is not made at the same time, the gastro-enterostomy opening is likely to become partly or

completely obstructed by contraction, and this may be followed by a recurrence of the ulcer. In cases in which a pylorectomy has been made, this has never occurred in my experience.

At the present time the choice of operation must lie between the methods introduced by McGraw, that employed by Mikulicz, Moynihan's method, or the method developed by Robson, Murphy's oblong button; or Connel's suture method can be employed in connection with the methods of Mikulicz or Robson, but it seems likely that the button will continue to lose more and more of its old advocates while it is not likely to gain many new ones. This is true, especially, because with it the size of the opening is virtually limited, and there is a distinct objection in the minds of most surgeons against a non-absorbable foreign body.

The one great point in favor of the button is its ability to punch out an opening, and to leave the union between the stomach and the intestine with the slightest possible amount of connective tissue.

In order to be of any practical value this paper must point out some of the dangers to be avoided in surgery of the stomach. Unnecessary Traumatism should be Avoided. There is great danger in unnecessary manipulation, because this increases the shock and the tendency to infection.

In all of these cases much can be done to prevent this by making an ample abdominal incision. Much time is frequently occupied in finding the jejunum, resulting in useless handling of viscera. By simply lifting out the transverse colon, and following its mesentery to a point a little to the left of the median line, one can always find the beginning of the jejunum in a few

moments.

In gastrectomy and pylorectomy it is possible to reduce the manipulations to a minimum by simply grasping the four main arteries, and also the greater and lesser omenta between these four points, and then excising the intervening portion, which has been grasped by long-jawed forceps, in order to prevent leakage.

There is danger of necrosis of the stomach, if the gastric artery is injured, and of the transverse colon, if the middle colic artery is grasped in clamping the greater omentum.

In making a posterior gastro-enterostomy, there is danger of contraction of the opening in the mesocolon, unless the edges of this are sutured to the stomach.

There is always danger of angulation of the jejunum at its point of attachment to the stomach.

In all stomach operations it is well to have the patient placed in the sitting or semi-sitting posture, within a few hours after the