IT has been amply shown that life is to be saved by I operative interference in cases of perforated gastric ulcer. I British surgeons have played a prominent part in this mportant advance in the practice of surgery. More precise knowledge is still required, however-(1) in the accurate diagnosis of the occurrence of perforation, (2) the most favourable period for surgical interference, and (3) the best method of dealing (a) with the perforation when found and (b) with the extravasation into, and

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... infection of, the peritoneum. The diagnosis that a gastric ulcer has perforated in the majority of cases is straightforward and free from doubt. There is, however, a minority in which it is not so. Firstly, there is a group in which a patient who is known to have a gastric ulcer is suddenly seized with intense pain over the stomach and symptoms of collapse ; the physical signs may corroborate the inference that the ulcer has perforated, and yet on opening the abdomen no such disaster is found to have occurred. CASE 1. Supposed perforation ('j a known gastric ulcer ; daparotomy; peritoneum fOllnd intact.-A young woman twenty-seven years of age was seen along with Dr. Francis Boyd on June 10th, 1896, at 10.30 P.M. From the age of eighteen years she had been troubled by her stomach. She suffered from pain, and vomiting occurred about half an hour after meals, the vomited matter occasionally resembling coffee-grounds. Six years ago she was under treatment in the Edinburgh Royal Infirmary for gastric ulcer. Thereafter she remained well for a period of three years ; at the .end of this time pain and vomiting after food gradually reasserted themselves, without, however, any reappearance of cofEee-ground material. About two and a half years ago she had a sudden attack of abdominal pain and collapse similar to the present, during which she was supposed to be in a dangerous condition for twenty-four hours; two or three days after the attack subsided it is stated that she passed an abundant tarry motion. For a day or two before the present attack she had been confined to bed with an aggravation of her usual gastric symptoms-namely, pain in the abdomen, inability to take food, and a feeling of sickness without actual vomiting. At 7 P.M. on the date upon which she was seen by Dr. Boyd and myself she was suddenly seized with very severe pain above the umbilicus with alarming faintness and with cramp and powerlessness in the limbs. She felt sick, but could not vomit. When we saw her at 10.30 P.M. she appeared to be in a very critical condition. She was indifferent to everything but the pain in the abdomen (a little above and to the right of the umbilicus) ; there was marked tenderness in the epigastric region ; the abdominal wall was retracted, did not move with respiration, and the muscles were hard and boardlike. The liver dulness was diminished to one inch and a half corresponding, to the fifth and sixth ribs in the right mammary line. The pulse was so rapid and weak that it was impossible to count it. Dr. Boyd and myself agreed that the most probable explanation of her condition was that the ulcer from which she was known to suffer had perforated. Exploration of the abdomen was therefore recommended. Strychnine and ether were administered hypodermically and arrangements were made for her immediate removal to the Infirmary. On admission at 1.30 A.M. on June llth the pulse was found to have much improved, while the pain and tenderness in the abdomen had subsided to a considerable extent. We agreed that this improvement might be legitimately ascribed to the reaction following the initial collapse caused by the perforation, and we were aware that a similar improvement had been observed in undoubted cases of perforation. The operation was therefore proceeded with at 2 A.M. She required an unusual amount of chloroform before the rigidity of the abdominal muscles appreciably relaxed, and the recti remained rigid until the operation was nearly completed. In the earlier stages of the anaesthesia she retched violently and vomited a quantity of pale green watery fluid. On opening the abdomen above the umbilicus the peritoneum was found normal and empty. The stomach presented at the wound. It was neither dilated nor contracted ; on its anterior wall, midway between the curvatures, there was a pale, firm, scarred area over which the serous coat was adherent but had retained its normal lustre. This area evidently corresponded to the ulcer from which she was known to suffer. A finger was pushed through the lesser omentum above the stomach and the lesser sac carefully explored with negative results. The pylorus was normal. The gall-bladder was noticed to be tensely filled with bile. The abdomen was closed and the patient put into bed. For four days she was very ill with abdominal pain and continued vomiting of green, watery fluid. The bowels were moved with enemata and sulphate of magnesia; the motions were normal in colour and never presented any traces of blood.