The rate of mortality of this proced ure has greatly improved during the past few years. The recovery-rate of all cases thus far reported is 22.72 per cent. It is more favorable under fifteen years, in the female sex, and in the fourth week of the disease. Of the series of 75 cases last reported, 54 died and 21 recovered: a recovery-rate of 28 per cent., a con siderable gain over the previous rate. If physicians were aware of the good results of operation and if they called the sur geon promptly no doubt the number of successes would be even greater.
Perforating Duodenal Ulcer. — This condition is comparatively rare. The ulcer is usually found in the first part of the duodenum, more commonly on its anterior wall, and may be associated with other disease. The symptoms are prac tically identical with those of perforat ing gastric ulcer. There is the same his tory of hmmaternesis, dyspepsia, and vomiting, followed by severe abdominal pain and collapse.
The treatment consists in suturing the ulcer and thoroughly cleansing the ab dominal cavity, as described in the treat ment of perforating gastric ulcer.
Perforating stercoral ulcer occasion ally results from a foreign body, usually with some sharp projecting part, lodging in the colon. The foreign body gives rise to inflammation and the formation of adhesions, and when perforation takes place the infection is usually localized and tends to the formation of an abscess, which should be treated by incision, cleansing, and free drainage.
Thrombosis of the Mesenteric Blood vessels.---Judging from the meagre liter ature on this subject, thrombosis of the mesenteric vessels is relatively infre quent, and no account of it is to be found in most of the standard text books. Koester has collected fifteen cases, and several have been reported since. The causes have been variously
sought in ulceration of the intestines, slowing of the portal circulation, the presence of carcinoma or cirrhosis of the liver, and sclerosis of the vessels from syphilis. The onset of the disease may be sudden, during perfect health, or it may occur during recovery from some severe illness. Invariable symptoms are intense abdominal pain, extreme tender ness, and vomiting. There is often ob struction of the bowels and collapse, and, if the patient survives the shock, abdominal distension occurs; in a lim ited number of cases bloody diarrhoea has been observed. Death usually fol lows soon, possibly within a few hours, but in a case reported it was delayed for three days. The differential diagnosis of the condition would take into con sideration perforative peritonitis, acute intestinal obstruction, and possibly ap pendicitis. An absolute diagnosis is probably possible, but the symptoms are such as to indicate immediate operation.
Recovery has followed resection of the affected portion of the intestine.
Operations for Intestinal Obstruction. —Inasmuch as practically all patients die unless they are operated upon, oper ation is indicated in every case in which there is a reasonable certainty of the diagnosis. In case of doubt one dose of purgative medicine may be administered and enemas may be freely given without harm. If there is a probability of acute intestinal obstruction, however, not more than one full dose of purgative should be administered, for such remedies may do decided harm. If the symptoms per sist and the diagnosis is still doubtful, prompt exploratory operation is indi cated. (See OnsTnuurtolc, INTESTINAL, in volume iv.)