intestine. Appendix examined and found healthy. Incision prolonged upwards; disclosed a perforation of gastric ulcer, size of a florin, situated on the anterior surface of stomach near pylorus. This was closed with Lembert's sutures, peritoneum sponged out, adbomen drained, and wound closed. Patient died next day. Bacteriological examination of peritoneal exudate showed (1) an encapsulated diplococcus, the streptococcus of Escherich--a diplococcus on solid media, chains in liquid media ; (2) a short bacillus, (3) blasto-mycetes (2 and 3 both frequent in stomach). The second case, male, aged forty-seven, had strong history of chronic alcoholism; two years' history of stomach trouble, with attacks of severe pain after food; had very violent attack of epigastric pain when on journey to surgeon, whom he saw two hours afterwards. One hour after this was operated upon, i.e., three hours after attack, and perforated gastric ulcer found and stitched. Patient recovered after a violent attack of delirium tremens. The frequency of gastric ulcer is variously estimated. Post Mortem Records Estimating Frequency of Ulcer.Gluzinski, in 11,298 autopsies, found 8.4 per thousand, equal to 0.84 per cent. Stadwell, in 7,700 cases, 1.24 per cent. F. Brunner estimates proportion of females to males as four to one. The frequency of perforation, as well as the frequency of ulcer, appears to be increasing, and is also variously estimated :-Leube, 1 per cent.; Broadbent, 6 per cent.; Greenhaugh, 3 per cent.; Brinton, 13 per cent.; Habershon, 18 per cent.; Pearce Gould, 25 per cent.; Michaux, 3 to 5 per cent. Micku History of operative interference is interesting. licz closed the first in 1880 by suture. In England, 1887, Taylor recorded first suture; and from this to 1893, Barlett, Lockwood, Barling, Haslam, Haward; but all were unsuccessful. The first success was in 1893 in England, 1892 in Germany. Kriege collected eight cases in 1892, with no success. After this, successes came thick and fast, and in 1895 Parisier collected forty-three cases, with ten cures; and in 1896, ninety-nine cases, with thirty-three cures. Bidwell, in 1900, 414 cases, with 139 cures. The site of the ulcer is shown most completely by F. Brunner, with 320 cases-278 anterior, 42 posterior. In those cases in which position of ulcer is indicated, the large majority-about eight to one-are nearer lesser curvature, but in an equal number of cases the exact position is not indicated. Cardiac portion more frequently than pyloric 5:3. The large number of anterior perforations is accounted for by several reasons :-(1) Mobility of the anterior stomach wall and its movement on anterior abdominal wall; (2) thus easily influenced by traumatism; (3) little tendency to contract adhesions on account of mobility. In the case of posterior wall, less vitality, more adhesions, and more tendency to localisation and formation of a subphrenic abscess; thus onset of case is slower, and there is less immediate danger. Characters of Perforating Ulcer.-Round or oval. Borders but rarely irregular. Borders generally indurated, and rarely wanting in this respect, the induration sometimes amounting to a tumour easily mistaken for malignant disease. The size is generally about three-eighths of an inch in diameter, sometimes reaching to three-quarters or one inch. Very occasionally the perforation is almost imperceptible, and may be even undiscoverable where it has set up fatal peritonitis. Barker mentions a case where pus was present from perforating ulcer, but perforation could not be found; and put forward the hypothesis that a small perforation had allowed the passage of the colon bacillus, which had thereupon set up formation of gas, while the hole itself rapidly cicatrised. Occasionally the hole is masked and closed in by a fibrinous exudate. Multiple perforations are rare, but there are reported cases, though multiple ulcers are not at all uncommon. Brinton collected ninety-seven cases of multiple ulcers out of 463. Of these, fifty-seven had two ulcers; sixteen had three; three had four; two had five; four had more than five ulcers. Several cases are recorded of operation upon and closure of one ulcer, and post mortem another ulcer found. In one case, second ulcer perforated three weeks later; in another case there were three perforations. Consequences of perforation depend upon the point of perforation, the state of the stomach, whether fasting or full, the state of the gastric contents, etc. Gas, as mentioned before, sometimes without being able to find perforation, may be inodorous or of a sour stomachlike odour; at other times is foetid, and smelling of bacilli coli. Gruneison, Barker, and others are of opinion that there may be gas without perforation, owing to production by gas forming bacilli coli passing through thin wall of ulcer, Umber calls it the bacillus paracoli ærogenes. During the first few hours the escaped contents of the stomach are unchanged, and may be recognised as milk, coffee, etc., but, setting up a peritonitis, this is rapidly diluted and hidden by the peritoneal exudate. During the early part of the first twenty-four hours, the signs depend upon the virulence of stomach contents and amount of gastric contents at the time of perforation. Thus, if a small perforation and contents of stomach are not great in amount, and not very virulent, the result may be the formation of a perigastric abscess, as in posterior perforations. Another point, too, is the position and occupation of the patient at the time. Thus, if standing at work, the escaped contents are spread all over the abdomen, and a general peritonitis is at once set up. But if lying in bed, there is more liability to localisation, or to the fluid finding its way to the most dependent parts, the parts, the flanks, flanks, Douglas's pouch, subdiaphragmatic spaces. This is insisted upon by Gerulanos, who describes a case of a girl of twenty-one, who perforated and had all the signs of general infection, with profound collapse, contra-indicating operation. Three weeks later he opened a lumbar abscess, and a collection in Douglas's pouch; and on the fortieth day, a subdiaphragmatic abscess, after which she recovered. Lennauder and Rauenbusch have described the function of the anatomical disposition of the abdominal viscera. In perforation of anterior wall between stomach and liver, contents are directed downwards until they meet with the transverse colon, which divides the abdominal cavity into two regions if not large in amount, the colon may serve as a barrier; then along the superior face of the colon and gastro-colic omentum, to arrive at the sides where the meso-colon ascends and descends; it is thence carried along the lumbar region in flanks to the iliac fossa, and thence to pelvis. Thus, if perforation is to cardiac extremity, the left sub-diaphragmatic space and left iliac fossa are more intensely and earlier affected. If near pylorus, along right side, to ileocecal region, it may give rise to diagnosis of appendicitis. A case is recorded by Delore of perforated ulcer, where a large left subdiaphragmatic abscess was opened, and autopsy showed a right iliac abscess and abscess in pelvis. If transverse colon is prolapsed or poorly developed, there is no barrier. Thus the authors seem to hold that, unless the escape from the stomach is large, there is always a first localisation, which is of great importance since the barriers are of such a flimsy. nature that it most easily spreads, and the belly is thus progressively invaded. Perforation of posterior wall practically always results in a localised abscess, localised to lesser sac, subhepatic, perisplenic, anterior surface of pancreas, subphrenic. Subphrenic abscess, according to Finkelstein, are in 27 per cent. of cases of stomach origin. Localisation of peritonitis in anterior perforation is also favoured by distension of colon. Thus meteorism theoretically is mechanically a good preventive of the extension of peritonitis. Old adhesions be tween stomach, liver, colon, etc., also limit effusion and direct it towards the diaphragm, as does also the suction action of the later. Gerulanos maintains that some subdiaphragmatic abscesses, as other localised intra-peritoneal abscesses, are the localised portion of a general peritonitis arrested or aborted in its development. Perforations of diaphragm are relatively rare. Jones and Horsley publish cases. Pleural complications very likely to follow are adhesive pleurisy, empyema. suppurative pericarditis. Local intra-peritoneal collections left by the arrested peritonitis due to the inundation are, according to Gerulanos, not rare. They appear after one, two, or three weeks, at a time when one does not refer them to the perforation, and appear in dependent parts. Little mention is made of them by other authors, however. Barling mentions one in great omentum. These abscesses grow and perforate neighbouring viscera, such as colon, or into general cavity-general peritonitis. Perigastritis, Adhesive and Suppurative. In certain cases, however, the escape from the stomach is small in amount and given out slowly, and under these circumstances time is allowed for protective adhesions to be thrown out limiting the gastric escape. This is more particularly the case with the indolent or callous ulcer. Doubtless this is the origin of the dense adhesions of stomach to anterior abdominal wall or to liver which are sometimes met with in a laparotomy for stomach trouble. Induration may even be recognised before operation, so that a neoplasm is suspected. Adhesive perigastritis is much more common posteriorly. Chemical and Bacteriological Examination.-The most important factor is the degree of virulence of extended fluid. Now perforation takes place at all times, either after a copious meal or even when fasting; and in the typical round ulcer the stomach contents are hyper-acid, in contrast with the malignant ulcer in which the acidity is wanting; hence the quality, as well as the quantity, of the infective agent varies. C. Brunner has well studied the effects of digestion in the stomach, with this result. At the beginning of digestion, free hydrochloric acid is wanting or small in quantity. An hour later the acidity attains its maximum. Food remains in the stomach from three to ten hours in the normal state, but in the pathological state longer. In pyloric stenosis or insufficient mobility, the stomach is never in a state of complete emptiness. According to Boas, the passage into the duodenum depends upon the degree of acidity. Many |