Part 78

The Dresden statistics are in a dissertation by Stachelhausen (Würzburg, 1874), referred to by Birch-Hirschfeld, Lehrb. d. path. Anat., Bd. ii. p. 837, Leipzig, 1877.

The Erlangen statistics are reported by Ziemssen in Volkmann's Samml. klin. Vorträge, No. 15.

The Kiel report is in an inaugural dissertation by Greiss (Kiel, 1879), referred to in the Deutsche med. Wochenschr., Feb. 4, 1882, p. 79.

So far as possible, duodenal ulcers have been excluded. Only those reports have been admitted which include both open ulcers and cicatrices.]

It is important to note the relative frequency of open ulcers as compared with that of cicatrices. In 11,888 bodies examined in Prague, there were found 164, or 1.4 per cent., with open ulcers, and 373, or 3.1 per cent., with cicatrices. Here scars were found about two and one-fourth times as frequently as open ulcers. The observations of Grünfeld in Copenhagen show that when especial attention is given to searching for cicatrices in the stomach, they are found much more frequently than the figures here given would indicate. It would be a moderate estimate to place the ratio of cicatrices to open ulcers at 3 to 1.

The inexact nature of the ordinary statistics relating to cicatrices is also evident from the fact that in the four collections of cases which comprise the Prague statistics the percentage of open ulcers varies only between 0.81 and 2.44, while the percentage of cicatrices varies between 0.89 and 5.42.]

The statistics concerning the average frequency of open ulcers are much more exact and trustworthy than those relating to cicatrices. It may be considered reasonably certain that, at least in Europe, open gastric ulcers are found on the average in from 1 to 2 per cent. of persons dying from all causes.

It is manifestly impossible to form an accurate estimate of the frequency of gastric ulcer from the number of cases diagnosed as such {483} during life, because the diagnosis is in many cases uncertain. Nevertheless, estimates upon this basis have practical clinical value. In 41,688 cases constituting the clinical material of Lebert in Zurich and in Breslau between the years 1853 and 1873, the diagnosis of gastric ulcer was made in 252 cases, or about 2/3 per cent.

Of 1699 cases of gastric ulcer collected from various hospital statistics and examined post-mortem, 692, or 40 per cent., were in males, and 1007, or 60 per cent., were in females. The result of this analysis makes the ratio 2 males to 3 females.

Only series of cases from the post-examinations of a number of years have been admitted. It is an error to include isolated cases from journals, as Brinton has done, because an undue number of these are cases of perforation, which is a more common event in females than in males. Thus, of 43 cases of gastric ulcer presented to the London Pathological Society since its foundation up to 1882, 19, or 44 per cent., were cases of perforation. In my cases are included a few duodenal ulcers not easily separated from the gastric ulcers in the compilation.]

In order to determine from post-mortem records the age at which gastric ulcer most frequently occurs, all cases in which only cicatrices are found should be excluded, because a cicatrix gives no evidence as to the age at which the ulcer existed.

The following table gives the age in 607 cases of open ulcer collected from hospital statistics (post-mortem material):

Age. | No. of cases. | Totals. ----------+---------------+-------- 1-10. | 1 | 10-20. | 32 | 33 ----------+---------------+-------- 20-30. | 119 | 30-40. | 107 | 226 ----------+---------------+-------- 40-50. | 114 | 50-60. | 108 | 222 ----------+---------------+-------- 60-70. | 84 | 70-80. | 35 | 119 ----------+---------------+-------- 80-90. | 6 | 90-100. | ... | Over 100. | 1 | 7 ----------+---------------+--------

From this table it is apparent that three-fourths of the cases are found between the ages of twenty and sixty, and that the cases are distributed with tolerable uniformity between these four decades. The largest number of cases is found between twenty and thirty. The frequency of gastric ulcer after sixty years diminishes, although it remains quite considerable, especially in view of the comparatively small number of those living after that period.

The probability that many cases of ulcer included in the above table existed for several years before death makes it desirable that estimates as to the occurrence of the disease at different ages should be made also from cases carefully diagnosed during life, although the diagnosis must necessarily be less certain than that in the post-mortem records. The best {484} statistics of this character which we possess are those of Lebert, from whose work the following table has been compiled:

Age in 252 Cases of Gastric Ulcer diagnosed during Life by Lebert.

Age. | No. of cases. | Totals. | Per cent. ----------+---------------+---------+---------- 5-10. | 1 | | 11-20. | 24 | 25 | 9.92 ----------+---------------+---------+---------- 21-30. | 87 | | 31-40. | 84 | 171 | 67.85 ----------+---------------+---------+---------- 41-50. | 34 | | 51-60. | 17 | 51 | 20.24 ----------+---------------+---------+---------- 61-70. | 5 | 5 | 1.99 ----------+---------------+---------+----------

Of these cases, nearly seven-tenths were between twenty and forty years of age--a preponderance sufficiently great to be of diagnostic value.

The oldest case on record is the one mentioned by Eppinger, of an old beggar whose age is stated at one hundred and twenty years.

The occurrence of simple ulcer of the stomach under ten years of age is extremely rare. Rokitansky, with his enormous experience, said that he had never seen a case under fourteen years. There are recorded, however, a number of cases of gastric ulcer in infancy and childhood, but there is doubt as to how many of these are genuine examples of simple ulcer. Rehn in 1874 analyzed a number, although by no means all, of the reputed cases, and found only six, or at the most seven, which would stand criticism. The age in these seven cases varied between seven days and thirteen years. In one case (Donné) a cicatrix was found in the stomach of a child three years old. Since the publication of Rehn's article at least four apparently genuine cases have been reported--namely, one by Reimer in a child three and a half years old; one by Goodhart in an infant thirty hours after birth; one by Eröss in a girl twelve years old suffering from acute miliary tuberculosis, in whom the ulcer perforated into the omental sac; and one by Malinowski in a girl ten years of age.

Rehn does not mention Buzzard's case of perforating ulcer in a girl nine years old (Trans. London Path. Soc., vol. xii. p. 84, 1861). See also Chvostek's case of round ulcer in a boy (Arch. f. Kinderheilk., 1881-82) and Wertheimber's case of recovery from gastric ulcer in a girl ten years old (Jahrb. f. Kinderheilk., Bd. xix. p. 79).]

The mean age at which gastric ulcer develops is somewhat higher in {485} the male than in the female. This is apparent from the following collection of 332 cases of open ulcer in which both age and sex are given:

Age. | Males. | Females. ----------+--------+--------- 10-20. | 9 | 13 20-30. | 33 | 35 30-40. | 44 | 25 40-50. | 39 | 25 50-60. | 37 | 18 60-70. | 20 | 18 70-80. | 5 | 9 80-90. | 1 | ... 90-100. | ... | ... Over 100. | 1 | ... ----------+--------+--------- Total. | 189 | 143 ----------+--------+---------

In males the largest number of cases is found between thirty and forty years, and in females between twenty and thirty. In males 54½ per cent. of the cases occur after forty years of age, and in females 48.9 per cent.

The relation between age and perforation of gastric ulcer will be discussed in connection with this symptom.

The conclusions concerning the age of occurrence of gastric ulcer may be recapitulated as follows: Simple ulcer of the stomach most frequently develops in the female between twenty and thirty, and in the male between thirty and forty. At the post-mortem table it is found with almost equal frequency in the four decades between twenty and sixty, but clinically it appears with greatly diminished frequency after forty years of age. In infancy and early childhood simple ulcer of the stomach is a curiosity.

We have no positive information as to the influence of climate upon the production of gastric ulcer. The disease seems to be somewhat unequal in its geographical distribution, but the data bearing upon this point are altogether insufficient.

According to the returns of Dahlerup and of Grünfeld, gastric ulcer is unusually common in Copenhagen. According to Starcke's report--which, however, is not based upon a large number of cases--the percentage is also unusually high in Jena. Sperk says that gastric ulcer is very common in Eastern Siberia. Palgrave gives a high percentage of its occurrence in Arabia. The disease is less common in France than in England or in Germany, and in general appears to be more common in northern than in southern countries. The statement of DaCosta coincides with my own impression that gastric ulcer is less common in this country than in England or in Germany. I have found 6 cases of open ulcer of the stomach in about 800 autopsies made by me in New York.