PERFORATION lx GASTRIC ULCER.— Perforation may perhaps be considered the most dangerous complication of gas tric ulcer. Welch has placed the entire mortality from gastric ulcer at 15 per cent., and he states that G.G per cent. of the cases die from perforation.
The diagnosis is usually not difficult. It is based, first, upon the history of the illness in which there have almost in variably been present the symptoms of gastric ulcer or of chronic gastric ca tarrh; and, secondly, upon the severe pain which is located in the left hypo chondriurn or epigastrium, and is often accompanied by vomiting and collapse. (See STOMACH, DISEASES OF.) Perforation is met with more fre quently in the anterior wall and more commonly near the cardia than the pylorus. In some cases perforation of both walls has been found. During the first sixteen years after Mikulicz per formed the first operation 7S operations were reported, but in recent years the number of operations have rapidly in creased until, in the year following May, 189S, 57 operations were reported. This is probably due to the fact that phy sicians recognize the condition earlier and promptly call surgical aid rather than that the number of cases of perfora tions has increased. As a rule, perfora tion occurs very suddenly without any apparent exciting cause, although vio lent exertion or traumatism have some times been the immediate cause.
Gastric ulcer is one of the commonest. of diseases, it having been estimated that of the population of Europe 4 or 5 per cent. labor under it. Some have estimated as high as 13 per cent., and Fiedler, who examined post-mortem 2200 stomachs, found ulceration or its scar in 20 per cent. of the women and 1 per cent. of the men. Ewald says that ulcer forms especially in the greater curvature and in the pyloric region. The ulcer is usually single, but two or more may be present, and Orth says that in 20 per cent. of the patients with gas tric ulcer more than one ulcer is pres ent. Weir and Foote (Med. News, Apr. 25, '96).
Operative interference is called for in uncomplicated cases when medical treat ment fails and the life of the patient is endangered, but the more important place for surgery is reserved in cases of eicatricial pyloric stenosis. with or with
out dilatation, in eases where humor rhages occurring frequently put the pa tient's life in danger, in cases where the symptoms are referred to perigastric adhesions, and. last, after perforation. In the last named the operation must be undertaken within twelve hours. The dangers of operations have to be measured in each case according to cir cumstances. W. Korte (Dent. med. Wochen., Mar. 21. 1901).
Indications for surgical interference in gastric ulcer: 1. Acute htemorrhages should rarely be treated by operation. When. however, haemorrhage frequently repeats itself. even if severe in amount, it will demand operative treatment as soon as its recurrent character is plain. 2. Small, frequent htemorrhages. threat ening anaemia. clearly indicate opera tion. 3. Perforation of the stomach. either acute, with general peritonitis, or chronic, with surrounding adhesions and perigastritis, demands instant operation. 4. When an ulcer runs a chronic course with a strong tendency to recurrence. so that the patient's capacity for work and for the enjoyment of life is dimin ished, an operation is indicated. Cabot (Boston Med. and Slug. Jour., Aug. 29. 1901).
In cases of perforated gastric ulcer treated by operation the percentage of recoveries in the hands of those awls touted to operate is between forty-five and fifty. The sooner the operation is done the better will he the chances of recovery. Of Mayo Robson's 6 cases. 3 were operated upon within 24 hours and recovered: 3 after 24 hours and died.
of lister's list. S cases were operated neon within 12 hours, with 64 cent. of recoveries: 6 after 12 hours, with 3:3 per cent. of recoveries. 'Elie disease is more common in men than is gener ally supposed. The writer reports 4 cases of hi- own. 2 of which were operated upon within 13 hours and 1 recovered. The other 2 were operated upon re spectively IS and 31 hours after per foration and both died. Maunsell (Brit. :Med. Jour.. March 23. 11I01).