In order to validate a previously derived set of risk factors, 259 consecutive patients who had simple closure or definitive operation for perforated duodenal ulcers were studied prospectively. Major medical illness, preoperative shock, and longstanding perforation (more than 24 hours) correctly predicted the outcome in 93.8% of patients. Most importantly, 16 patients (6.2%) who died after operation could be identified (no false-negative error). The mortality rate increased progressively with increasing numbers of risk factors: 0%, 10%, 45.5%, and 100% in patients with none, one, two, and all three risk factors, respectively. These findings underscore the importance of patient selection and the feasibility of a risk grading system in guiding surgical management. Definitive surgery can be done safely in good-risk patients. Simple closure is preferable in those patients with uncomplicated perforations if any risk factor is present. Truncal vagotomy and drainage may be required if there is coexisting bleeding or stenosis. Nonoperative treatment deserves re-evaluation in patients with all three risk factors because of their uniformly dismal outcome after operation.

A review of the literature on wound implantation together with a report on an unusual case of irnplantation of squamous carcinoma at the site of a gastrostomy is presented.

Sixteen cases of tuberculosis of the breast are presented. The clinical features were a firm mass or a recurring abscess of the breast, sometimes associated with discharging sinuses. Diagnosis relied on histological appearance, acid-fast bacilli being present in only 3 specimens and positive cultures obtained in 4 patients. Local excision of the mass and chemotherapy proved effective treatment.