that a hollow air-containing viscus has been torn on its extra-peritoneal surface. In other words, it is a symptom that is strongly indicative of a tear on the posterior surface of either the second or third part of the duodenum, or of the ascending or descending colon. Even had the patient's condition in this instance have been such as to allow of operation, effectual treatment of the condition would have been most difficult, owing to the position of the lesion on the extra-peritoneal surface of the gut.

PERFORATED DUODENAL ULCER.

Unlike gastric ulcer, duodenal ulcer occurs much more commonly in males than in females. According to Perry and Shaw, the lesion occurs three times as often in males as in females, while, according to Krause, out of sixty-four patients suffering from duodenal ulcer, fifty-eight were males. This remark as to relative frequency refers to the cases of so-called peptic ulcer of the duodenum, and not to the cases of ulceration of the duodenum in patients suffering from burns. The ulcer is frequently situated in the first part of the duodenum-in the proportion of eight in the first part to one in the second, and, as a matter of fact, practically all duodenal ulcers are situated above the entrance of the common bile-duct. In one of the cases recorded below, it was found post mortem that there were two ulcers present, one of which had perforated. As a rule, the ulcer is single. Out of 160 cases, records of which have been collected by Perry and Shaw, the ulcer was single in 144 instances, while in fourteen instances there were two ulcers, and in two there were more than two ulcers present.

The symptoms of ulcer of the duodenum are in a great number of cases latent, until a perforation or a severe hæmorrhage occurs. It will be seen that in one of the cases quoted below there were no symptoms at all, so far as the patient's history could be ascertained, until perforation occurred; while in the other case there were some indefinite symptoms for two months before perforation took place. Perry and Shaw collected reliable records of fifty-two cases

of perforated duodenal ulcer, and in twenty-seven of these the patient was entirely free from symptoms till perforation occurred. In both my cases there was a fatal result. This is usually the case. Perforation of a duodenal ulcer is far more fatal than that of a gastric ulcer.

Case I.-J. V., a man, aged forty-three, was admitted into the General Hospital on February 10, 1901, suffering from symptoms of acute peritonitis. The whole abdomen was distended, while the wall was rigid. The patient was vomiting, and his general condition was extremely bad. A sudden pain in the centre of the abdomen, accompanied by symptoms of collapse, had come on twenty-four hours previously. There was no previous history of abdominal trouble, and on examination there was nothing to indicate in what region of the abdomen a perforation had occurred. Looking at the case as one of suppurative peritonitis due to a perforation of intestine, it was evident that the vermiform appendix was the most probable seat of the perforation. Consequently a median incision was made below the umbilicus. A large quantity of pus escaped from the pelvis and from both flanks. There was no perforation of the appendix. The patient's condition on the table was very bad, and so the abdomen was washed out and drained, as it was evident that the man's condition was not such as to warrant prolongation of the operation. Death occurred forty-eight hours after operation. At the post mortem examination it was found that there was an ulcer, the size of a shilling, on the anterior wall of the first part of the duodenum, and that this had perforated.

66

Case II.-J. S., a man, aged twenty-five, was admitted into the General Hospital on February 27, 1904, complaining of sudden severe abdominal pain, which had come on seven hours before. When eighteen years old he had an attack of biliousness and influenza," accompanied by vomiting, but he had no pain. He was laid up for a fortnight. Since that time he has been been perfectly well until two months ago, since which time he has had on two occasions an attack of epigastric pain coming on half an hour

after food, and lasting ten minutes. He did not vomit, and the pain was not severe. On February 22 he began to suffer from attacks of pain across the upper abdomen. The pain would come on about twice a day, each attack lasting half an hour or so. Its onset had no apparent relation to the taking of food, and he did not vomit. His bowels had been open once every two days, and there was no history of melæna or hematemesis.

On February 27, at 3 p.m., while shooting with an airgun, the patient felt a sudden, severe, abdominal pain, beginning about the umbilicus. The pain then spread to the right iliac region, and then to the epigastrium. He had had a meal of bread and bacon at 11 a.m., and half a pint of beer just before the pain came on. He vomited twice two hours after the onset of the pain. I saw the patient at 10.30 p.m. on February 27, seven and a half hours after the onset of the acute symptoms. His temperature was then 99.8°, his pulse 90, and his respirations 30. The abdomen was rigid and tender all over, but was not distended. The liver dulness measured one inch in the vertical nipple line. There were no symptoms present which made it possible to definitely locate the lesion, and so, the vermiform appendix being the most probable seat of a perforation in a man of the patient's age, the abdomen was opened in the right iliac region. A little clear frothy fluid escaped, but the appendix was healthy. An incision was then made in the middle line above the umbilicus. Some clear fluid and air escaped. No perforation of the stomach was found, but in the anterior surface of the duodenum, one inch from the pylorus and rather nearer the upper than the lower border, was found a perforation a quarter of an inch in diameter. The bowel wall for half an inch round this was thickened and infiltrated. The edges of the perforation were inverted, and the opening was closed by means of Lembert's sutures. A drainage tube was passed down to the region of the ulcer, and the external wound sutured. On March 2 the patient's abdomen was flat and painless; his temperature was 98° and pulse 64, and his general condition was excellent. However, he developed a great amount of hypostatic pneumonia,

and died ten days after operation, his abdominal condition having continued to be perfectly satisfactory.

Post mortem it was found that there was hypostatic pneumonia of both lungs. There was no peritonitis present, and no leakage from the duodenal perforation. The sutures had held, and the point of perforation was also closed by adhesions to the gall-bladder. There were two ulcers in the first part of the duodenum. The one, which had perforated, was half an inch in diameter, and its centre was one inch from the pylorus. The other was the same size and about the same distance from the pylorus, but was on the posterior surface of the duodenum.

Owing to the comparative rarity of the condition, it is difficult to say what are the results of operation for perforated duodenal ulcer, but they are undoubtedly bad-much worse, as has been said, than are the results of operation for perforated gastric ulcer.

A CASE OF CHRONIC DUODENAL ULCERS, CAUSING PYLORIC STENOSIS, GASTRIC

DILATATION, TETANY, PERFORATION,

AND DEATH.

By H. WILLOUGHBY GARDNER, M.D., Physician to the Salop Infirmary.

THE patient was a woman of forty. The history was that fourteen years ago she had an attack of pain in the stomach after food, followed by hæmatemesis. Between that time and the date of her first admission into the wards of the Salop Infirmary, she had had several similar attacks of pain and hæmatemesis. She first became an in-patient at the Salop Infirmary in November, 1903. She was then suffering from an attack of pain and hæmatemesis. She remained in for a month, and went out free from pain or vomiting, and on full diet. A fortnight later the pain and vomiting after food recurred, and she continued to suffer from it more or less until on May 8, 1904, the vomiting became so much worse that it was stated that she was unable to keep down any food at all.

On May 17 she was again brought to the Salop Infirmary. She was then looking worn and thin and very ill, was suffering much pain, and had marked tenderness in the pyloric region, with an indistinct feeling of fulness there. The stomach was then found to be dilated. She improved rapidly under the ordinary treatment. On June 13 she was put on full diet, and on June 26 she went out, having then been taking full diet for nearly two weeks without its causing any pain or vomiting. The day after she went out, however, the vomiting recurred. Two weeks later, on July 9, there was severe hæmatemesis. At 11 a.m. on July 10, tetany set in, beginning with numbness and tingling of the hands and arms, and a little later of the legs and trunk; this tingling was followed by the characteristic tetany spasms, which began simultaneously in the two hands, spread up the forearms and arms, then affected the feet, spread up the abdo