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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 fossæ, 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 cen 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 between 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

writers have pointed out the acid smell of the peritoneal fluid in perforation, and C. Brunner has directly determined the acidity as due to free hydrochloric acid.

Microbic elements are introduced with the food, their number varying with the state of the buccal cavity, and especially with teeth. According to Miller, they may reach the duodenum or intestines. In a recent work, Coyon has found thirty varieties of bacteria in the gastric contents. That gastric juice has a certain bactericidal power is shown · by the fact that the relative number of organisms decreases with the increase of acidity to digestion point, and also with certain albumenoid substances with which acid can enter into chemical combination. This varies also with the species of bacteria. In the pathological stomach, microbic elements are numerous, increasing if insufficient mobility favours gastric fermentation. C. Brunner's experiments on influence of degree of acidity are interesting. Stomach contents were collected after a test breakfast of Ewald, and containing free hydrochloric acid. This was injected successively, in quantities of 1 to 10, 15, and 20 c.cm., into the peritoneal cavity of rabbits. Four only succumbed to peritonitis, in two cases due to a streptococcus. The experiments were repeated with gastric fluid from a case of hysteria with neryous vomiting, from a nervous dyspeptic, from a stenosis of pylorus with gastric stasis, then from gastric ulcer with a gastro-enterostomy performed, of pyloric spasm and hyperchlorhydria with gastro-enterostomy. Forty-four rabbits were injected with from 4 to 40 c.cm. of different liquids, and eleven died. A dose of 4 or 5 c.cm. was nearly always supported, but one in sixteen died. With 10 c.cm. the number of recoveries were double the deaths, but one animal resisted a dose of 35 c.cm. When the experiment was repeated with gastric fluid deficient or wanting in acid obtained from subjects of stomach disease, non-cancerous, all died, even after injection of a small dose, 1 to 10 c.cm., the pathological agent being in most cases a streptococcus. Experiments with case of stomach cancer : a recovery after 1 c.cm., but nine deaths after 1 to 6 c.cm., still due to a streptococcus, in one case

associated with the bacilli communis. Thus Brunner contests that hypo-acidity is incontestably more virulent than normal acidity, and that the acid, while aiding digestion, diminishes the virulence of the infective microbic agents, so that it becomes possible to inject them into the peritoneal cavity of rabbits without causing fatal peritonitis. He has also shown that the effect produced depends in the same subject on the time after Ewald's test meal. Thus the contents are more pathogenic a quarter or half an hour after meal than one and a half hours. Thus, of seventeen animals, all recovered after 4 to 10 c.cm. of fluid of one hour; but six out of seven died after injection of fluid of a quarter to half an hour from the same case (a case of spasm of pylorus) ; the same result being attained with that from a healthy subject, two out of three dying where fluid was of a quarter to half an hour, but of seven injections of one and a half hours' fluid there were no deaths. Thus experimentally the conclusion is arrived at that in pathological states where the total acidity is diminished or absent, pathological organisms which enter the stomach do not lose their primary virulence; that they multiply when the contents of the stomach accumulate or are stationary; and that they become, by their number and virulence, more dangerous than when they have been exposed to the actions of acid ; and whilst in the perforation of cancer a small quantity of extrusion is very infectious to the peritoneum, in the perforation of ulcer the pathological virulence is much less, and will also vary according to the different phases of digestion. Clinical experience is entirely in accord with this. The number of cures recorded in which, in spite of general extravasation, general peritonitis does not follow, is considerable, and is explained by the fact that the gastric contents are acid in the case of ulcer, and that the peritoneum is capable of resisting even an extended contamination. . There is one point, however, which cannot be allowed for, and that is that the successful cases are invariably recorded, while the unsuccessful ones may or may not be. Still, the conclusion is correct that in perforation by gastric ulcer the infective agent, with its microbic contents, always varies both quantitatively and qualitatively.

Bacteriological researches are yet few, but they have been collected by C. Brunner, 1903. Most frequently the agent is poly-infections, and rarely a mono-infection. The chief agents are : Streptococci, pyogenes and lanceolatus, and the bacillus coli. Hydrochloric acid has no effect upon the former, which resists fluids rich in acid. Besides the streptococci, the pneumococcus, the streptococcus lanceolatus, and more particularly the streptococcus lanceolatus of Gamaleia, the micrococcus of salivary septicæmia of Miller-a microbe of the mouth-all play a certain part.

Out of 22 observations, nine times streptococcus pyogenes (twice alone and seven times with bacillus coli), staphylococcus aureus, bacillus subtilis, bacillus mesentericus, an anærobic bacillus ; the pneumococcus or streptococcus lanceolatus four times, always with the bacillus coli; bacillus coli, ten times (nine times with streptococcus pyogenes, with a staphylococcus or pneumococcus). Bacillus subtilis is frequent in the stomach, and has been found in the peritoneal exudate. In perforations, diplococci appear frequently. Anærobic bacteria do not appear to have any importance.

Finally, C. Brunner cites two observations of Warren and Allen (Boston), where the cultures made show the peritoneal fluid to be sterile. An interesting experiment of Brunner showed that rabbits successfully resisted injections of 10 с.cm. of gastric fluid collected during an operation for perforated gastric ulcer where patient died of peritonitis, and where there was a large amount of extruded fluid in belly. The exudate showed the bacillus coli and streptococcus lanceolatus. Thus, in spite of a relatively feeble virulence of the gastric fluid, since rabbits resisted 10 c.cm., the patient died, showing that it is not always the quality, but the quantity, which constitutes the danger.

(To be continued.)

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