Gastric ulcer may occasionally take a very obstinate course, not being amenable to medical treatment. Again, its complications, hemorrhage (which may become very abundant or frequent) and perforation, greatly endanger life; the latter, in fact, almost always terminating fatally. Barling1 says that ninety-five per cent of the patients having such perforations die, unless operated upon. For this reason Nelson C. Dobson2 in 1883 advocated operative interference for a perforating ulcer according to one of the following methods. 1. Simple abdominal section with cleansing of the peritoneum, leaving the ulcer to heal of itself under rest and rectal feeding. 2. The closure of the perforation by suture, either with or without paring its edges. 3. The suture of the stomach at the point of perforation to the abdominal wall, in order to establish a gastric fistula.

A few years later this mode of treatment was carried out by several surgeons in Europe and this country.

Robert F. Weir,3 of New York, was among the first who operated in this country. His latest report of a successful operation of this kind deserves the highest commendation. We deem it of great value to report this case in Dr. Foote's own words.

1 Barling: Birmingham Medical Review. August. 1895.

2 Dobson: Bristol Medical and Surgical Journal, 1893, p. 196.

3Robert F. Weir and E. M. Footer: "The Surgical Treatment of Round Ulcer of the Stomach and its Sequelae with an Account of a Case Successfully Treated by Laparotomy." Medical News, April 25th and May 2d, 1890.

"Mary B------consulted me in August, 1894, for an obstinate cough, with scanty expectoration and pain in the sternal and right scapular region, with dyspnoea on exertion, headache, anorexia, and constipation. She had twice spit up a small amount of blood. For four months she had had night sweats. The patient was at that time 15 years old, heavy but anaemic. Physical examination showed dulness and fine moist rales at the left apex, and right base behind, and she had an afternoon fever. Under tonic and expectorant remedies, and a month's residence in the mountains of Sullivan County, N. Y., she gained weight and the rales disappeared, except at the base of the right lung. The following winter she neglected herself, and, when I next saw her in April, 1895, her cough was worse, and she had moist rales over the greater part of both lungs, and she had lost six pounds in weight. Though living in poverty, she was able, through friends, to spend three months of the summer in the mountains, and she did not return to the city until the last of September, 1895, when she took a position as maid in an apartment, where the work was light and her food good.

Her health was excellent, the cough and rales had disappeared, and her weight, one hundred and ten and a half pounds, was greater than it had ever before been. I was never able to secure any sputum for examination, but the signs of pulmonary tuberculosis had been too well marked to be doubted.

"She had frequently been troubled with indigestion, and at various times had vomited her food, but these symptoms had not been the prominent ones. About November 20th, 1895. she began to have severe gastric pain, and her appetite failed her. She spoke to no one about it and kept on with her work, though eating almost nothing. The pain. too. was at times so severe that she was compelled to lie down. On November 27th. at 10 a.m.. she was attacked with a colicky pain in the gastric region so severe that she rolled upon the floor in agony, and vomited a small amount of coffee, which was the only nourishment she had taken that day. About noon she felt a little relief and went home by way of the elevated road. To do this, she walked about a quarter of a mile, and climbed up and down some fifty steps. Late in the afternoon she sent word to me that she had an 'attack of pain in the heart.' At 6:30 p.m. I found her lying on her back, quiet, and without much pain. Pulse. 120; temperature, l02°. The fades, though not well marked, was of a purely abdominal type. The chest revealed nothing abnormal. The abdomen was somewhat rigid, and more so on the left side than on the right. There was moderate tenderness on pressure in the epigastric and left iliac regions. There was no distention or tympanites.

Respiration was almost wholly thoracic. Palpation revealed nothing but the seat of tenderness. The pain was described as commencing to the left of the median line under the costal border, and extending thence to the left groin and into the left thigh. Appendicitis was out of the question, and the symptoms did not appear to be those of any form of intestinal obstruction. The diagnosis of perforated gastric ulcer was made, and an immediate operation advised. Dr. Weir kindly consented to admit the patient to his service at the New York Hospital, where he performed laparotomy, and sutured the stomach at 9:30 p.m., a little over eleven hours after the onser of the attack.

"Under chloroform, a median incision four and onehalf inches long was made above the umbilicus. An unusual amount of subperitoneal fat obscured the peritoneum. When its cavity was opened the stomach presented in the wound. The greater curvature appeared normal. There was no general peritonitis. The anterior surface of the stomach was adherent to the liver by recent lymph. As it was separated, a hissing sound was heard, due to the escape of gas from the stomach through the perforation.

"The opening was found without difficulty. It was minute, less than one-fourth inch in diameter, with necrotic edges, and lying in the centre of a dense ring of inflammatory and fibrinous tissue, which involved the whole thickness of the wall of the stomach. This thickened area was about two inches long and one inch wide, and was situated in the anterior wall of the stomach, about mid way between the greater and lesser curvatures, and perhaps one-third of the distance from the pyloric to the cardiac orifice.

"The operation lasted about one hour, and the patient left the table in fair condition, with a pulse of 150. For two days there was frequent and very distressing vomiting, temporarily relieved by gentle lavage with diluted Thiersch's solution. After the second day the vomiting subsided, and water was allowed by the mouth. Fluid nourishment was given on the third day, and the nutrient and stimulant ene-mata, which had been given every six hours following the operation, were stopped in four days. There were at no time any signs of general peritonitis. Recovery was otherwise uneventful".

In his exhaustive paper, Weir gives a table, containing seventy-two cases of laparotomy for acute perforation of gastric ulcer. Among the names of operators in America we notice F. Markoe, Robert F.

Weir, C. P. Parker, McCosh, Kirkpatrick, Armstrong,, and Stimson.

With regard to the results of operative treatment Weir furnishes the following table, which clearly illustrates the importance of early surgical interference:

The operations above mentioned for the treatment of a perforating gastric ulcer will also prove applicable for a perforating ulcer of the duodenum. A successful case of operation in the latter instance has recently been reported by A. Landerer and G. Glucksmann.1

Surgical procedures have also lately been advised for the treatment of very obstinate cases of gastric ulcer, consisting in excision of the latter or in the establishment of a gastroenterostomy. Severe, persistent pains due to the formation of adhesions as sequela of gastric ulcer have also been relieved surgically by separating them (Lauenstein).2

1 A. Landerer und G. Glucksmann: "Mittheilungen aus den-Grenzgebieten der Medizin und Chirurgie," Bd. i., p. 168. Jena,. 1896.

2 Lauenstein: Arch. f. klin. Chirurgie, vol. xlv.