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Acute perforation of a duodenal ulcer is a calamity that demands prompt surgical treatment. For this reason surgeons have shown it the greatest consideration. The responsibility of the physician who first sees a patient following perforation is grave. Early diagnosis is essential to early operation\p=m-\the most important single factor in successful treatment. Frequently the responsibility of the physician does not end with the establishment of the diagnosis. Hospital interns and general practitioners, in many communities in this country, are called on to prescribe postoperative treatment for these patients\p=m-\animportant factor that has received scant consideration. Because of its emergency nature the operative treatment is frequently performed by junior surgeons, sometimes by resident hospital surgeons, and even by the occasional operator. The average mortality rate is high.An attempt has been made in this investigation to determine the causes of death from perforated duodenal ulcers in the order of their occurrence, the nature and relative frequency of fatal complications, and the impor¬ tant factors influencing these fatalities. The records of all patients who died following operation for this lesion in the wards of the Jefferson Hospital in the period from 1900 to 1929 have been scrutinized and the results tabulated. The surgical literature on this subject has been reviewed and information obtained therefrom is presented.Perforated duodenal ulcer as a cause of death was first revealed by autopsy and described by Penada in 1793. It was not, however, until 1900 that information on this lesion began to assume the form of systematized knowledge when Weir presented to the American Sur¬ gical Association a comprehensive analysis of the cases thus far reported in the literature. In 1901 Moynihan collected reports of forty-nine cases that came to oper¬ ation following perforation. The resulting mortality rate was 83.6 per cent. Mayo 2 in 1904 reported the cases of six of his own patients operated on with two deaths resulting. From this time on, the reports com¬ prise series of ever increasing numbers and the data given are constantly growing in comprehensive detail.The symptoms of acute perforation of a duodenal ulcer have been so graphically described and so ably taught that they are common knowledge of senior medi¬ cal students. Differential diagnosis is adequately treated in modern textbooks on surgery.The urgent need for early operation following perfo¬ ration has been pointed out many times by Gibbon,3 Pool,4 Moynihan,5 Deaver,ß Gibson 7 and others. The

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