74 Of the 25 cases of gastro-cutaneous fistula collected by Murchison, 18 were the result of disease. In 12 of these cases the probable cause was simple gastric ulcer (Med.-Chir. Trans., vol. xli. p. 11, London, 1858). Middeldorpf says that among the internal causes of the 47 cases of external gastric fistula which he tabulated, simple ulcer of the stomach played an important rôle (Wiener med. Wochenschr., 1860).
75 Of 33 cases of gastro-colic fistula collected by Murchison, 21 were from gastric cancer and 9 or 10 probably from simple ulcer. On the other hand, gastro-cutaneous fistulæ are twice as frequently the result of simple ulcer as of cancer (Edinb. Med. Journ., vol. iii. 1857).
76 Thierfelder has made the best study of the complicated relations existing in these cases (Deutsches Arch. f. klin. Med., Bd. iv. p. 33, 1868).
77 Deutsche Klinik, 1870, No. 39. Habershon also reports a case in which a subphrenic abscess communicated with the lung, the stomach, and the colon, but he believes that the ulceration was primary in the colon (Guy's Hosp. Rep., Ser. 3, vol. i. p. 109).
Four cases of perforation of gastric ulcer into the pericardium,78 with the production of pneumo-pericardium, have been reported, and two cases of perforation into the left ventricle.79 Müller found lumbricoid worms in a pleural cavity which had been perforated by gastric ulcer.80 Diaphragmatic hernia may result from perforation of the pleural cavity by gastric ulcer.81 In one instance the greater part of the small intestines passed through a hole in the transverse meso-colon which had been caused by a gastric ulcer.
78 Hallin, Schmidt's Jahrb., cxix. S. 37; Säxinger, Prager med. Wochenschr., 1865; Guttmann, Berl. klin. Wochenschr., 1880, No. 23. Murchison mentions a specimen in the museum of King's College, London, of a simple gastric ulcer opening into the pericardium (Edinb. Med. Journ., vol. iii. p. 6). In a case reported by Graves a liver abscess burst into the stomach and into the pericardium (Clin. Lect., ii. p. 237, Dublin, 1848).
79 Oser, Wiener med. Blätter, 1880, No. 52; Brenner, Wiener med. Wochenschr., 1881, No. 47.
80 Müller, Memorabilien, xvii., Oct., 1872.
81 Needon, Wiener med. Presse, 1869, No. 42. In a case of Günsburg's the hole in the diaphragm was as large as the hand, and the left pleural cavity contained the upper half of the stomach and the spleen (Arch. f. phys. Heilk., xi. 3, 1852).
The various fistulæ which have been mentioned may be either direct or through the medium of an abscess. While some of them are only pathological curiosities, others, particularly the communications of the stomach with the pleural cavity and with the lung, are sufficiently frequent to be of practical clinical interest.