The dilemma of the surgeon in the identification of malignant changes in a gastric ulcer is not lessened by observations of ulcer location or size. Earlier teachings favoring malignant degeneration in those ulcers over 3.5 cm in diameter, or in ulcers located on the greater curvature or in the immediate prepyloric inch, are not borne out by clinical observations in the operating room. When liver metastasis, nodular infiltration of the transverse mesocolon or peritoneal implants are present, there is little doubt as to the malignant nature of the process; the problem lies in those circumstances in which these factors are not present and the determination must be made on inspection of the ulcer alone. Preoperative study of gastric acids, cell washings, and radiographic films is often helpful, but much depends on the operative findings, when the surgeon must decide the type and extent of operation necessary.
A study of