Part 85

Gastric ulcers have been produced experimentally in animals in a variety of ways, but these experiments have not materially elucidated the pathenogenesis of ulcer in man. Schiff by lesions of various parts of the brain, and later Ebstein by lesions of many parts of the central and peripheral nervous system by injections of strychnine--in fact, apparently by any means which greatly increased the blood-pressure--produced in the stomachs of animals ecchymoses and ulcers. Müller by ligation of the portal vein, Pavy by ligation of arteries supplying the stomach, likewise produced hemorrhages and ulcers. The results of Pavy could not be confirmed by Roth and others. Panum, and afterward Cohnheim, produced gastric ulcers by introducing multiple emboli into the gastric arteries. Daettwyler under Quincke's direction caused, in dogs with gastric fistulæ, ulcers of the stomach by various mechanical, chemical, and thermic irritants applied to the inner surface of the stomach. Aufrecht observed hemorrhages and ulcers in the stomachs of rabbits after subcutaneous injections of cantharidin.

The most interesting of these experiments are those of Cohnheim and of Daettwyler, who demonstrated that in one essential point all of these experimental ulcers differ from simple gastric ulcer in man--namely, in the readiness with which they heal. To this ready healing the gastric juice, much as it has been accused of causing the spread of gastric ulcers in man, seems to have offered no obstacle. We know that similar losses of substance in the human stomach heal equally well. Hence it has been maintained throughout this article that it is unjustifiable to regard all of the scars found in the human stomach as the result of simple ulcer.

It appears from these experiments, as well as from observations on man, that it is more difficult to explain why ulcers in the stomach do not heal than it is to understand how they may be produced. From this point of view the observation of Daettwyler is of interest, that in dogs which had been rendered anæmic by repeated abstraction of blood not only did slighter irritants suffice to produce ulcers of the stomach, but the ulcers healed much more slowly. Practically, it is important to learn what are the obstacles to the repair of gastric ulcers, but our positive knowledge of these is slight. It is probable that such obstacles are to be found in constitutional causes, such as anæmia and chlorosis, in abnormal states of the blood-vessels around the ulcer, in catarrhal affections of the stomach, in irritating articles of food, in improper modes of living, and in increased acidity of the gastric juice.

DIAGNOSIS.--In many cases the diagnosis of gastric ulcer can be made with reasonable certainty; in other cases the diagnosis amounts only to a suspicion more or less strong, and in still other cases the diagnosis is impossible.

{515} The diagnostic symptoms are epigastric pain, vomiting, and gastric hemorrhage. The characteristics of the pain which aid in the diagnosis are its fixation in one spot in the epigastric region, its onset soon after eating, its dependence upon the quantity and the quality of the food, its relief upon the complete expulsion of the contents of the stomach, its alleviation by changes in posture, and its increase by pressure. That the pain of gastric ulcer has not always these characteristics has been mentioned under the Symptomatology. Vomiting without hæmatemesis is the least characteristic of these symptoms. It aids in the diagnosis when it occurs after eating at the acme of a gastralgic attack and is followed by the relief of pain. Hæmatemesis is the most valuable symptom in diagnosis. The more profuse the hemorrhage and the younger the individual in whom it occurs, the greater is the probability of gastric ulcer. It should not be forgotten that the blood is sometimes discharged solely by the stools.

The simultaneous occurrence of all these symptoms renders the diagnosis of gastric ulcer easy. In all cases in which gastrorrhagia is absent the diagnosis is uncertain; but gastric ulcer should be suspected whenever the ingestion of food is followed persistently by severe epigastric pain and other causes of the pain have not been positively determined. When the course of the ulcer is latent and when the symptoms are only those of dyspepsia, the diagnosis is of course impossible. In cases previously obscure a diagnosis in extremis is sometimes made possible by the occurrence of perforation of the stomach.

In making a differential diagnosis of gastric ulcer, as well as of any disease, reliance should be placed more upon the whole complexion of the case than upon any fancied pathognomonic symptoms.

The diseases which are most difficult to distinguish from gastric ulcer are nervous affections of the stomach. Like gastric ulcer, most of these are more common in women than in men, and especially in chlorotic women with disordered menstruation and with hysterical manifestations. These nervous affections are manifold and their leading characteristics are not yet well defined. The most important of these affections are nervous dyspepsia, nervous vomiting, nervous gastralgia, and gastric crises.

The leading symptoms of nervous dyspepsia, as described by Leube, are the ordinary symptoms of dyspepsia without evidence of anatomical alteration of the stomach, and with the proof by washing out the stomach that the process of digestion is not delayed. Nervous dyspepsia is often associated with other nervous affections, and is caused especially by influences which depress the nervous system. Epigastric pain, and especially tenderness on pressure over the stomach, are not common symptoms in nervous dyspepsia. Only those rare cases of gastric ulcer in which hemorrhage from the stomach is absent and epigastric pain is not prominent {516} are likely to be confounded with nervous dyspepsia. In such cases, although the diagnosis of nervous dyspepsia is by far the most probable, the patient may be confined to bed and put upon the strict regimen for gastric ulcer. If in the course of ten days or two weeks essential relief is not obtained, ulcer may be excluded, and the proper treatment for nervous dyspepsia with tonics and electricity may be adopted (Leube).

In nervous vomiting, which occurs most frequently in hysterical women, other nervous manifestations are present; there are usually less epigastric pain and tenderness than in ulcer; the nutrition is better preserved; the vomiting is less dependent upon the ingestion of food and more dependent on mental states; and there are longer intervals of relief than in ulcer. Still, it may be necessary to resort to the therapeutical diagnosis as in the preceding instance.

In this connection attention may be called to the importance of searching for reflex causes of vomiting, such as beginning phthisis, ovarian or uterine disease, cerebral disease, and pregnancy; also to certain cases of chronic Bright's disease in which gastric disturbances are the main symptoms.

Of all the nervous affections of the stomach, nervous gastralgia is the one which presents the greatest similarity to gastric ulcer. Its diagnosis from gastric ulcer is often extremely difficult, and may be impossible. The points of difference given in the following table may aid in the diagnosis:

NERVOUS GASTRALGIA. | ULCER OF THE STOMACH. | 1. Pain is often independent of | 1. Pain is mostly dependent upon the ingestion of food, and may | taking food, and its intensity even be relieved by taking food.| varies with the quality and the | quantity of the food. | 2. Pain is often relieved by | 2. Pain is increased by pressure. firm pressure. | | 3. Pain is rarely relieved by | 3. Pain after a meal is usually vomiting. | relieved by vomiting. | 4. Fixed point of tenderness and| 4. These are often present. of subjective pain not generally| present. | | 5. Relief is usually complete | 5. Some pain often continues between the paroxysms. | between the paroxysms. | 6. Nutrition frequently well | 6. Nutrition usually affected. preserved. | | 7. Usually associated with other| 7. Neuropathic states less nervous affections, such as | constantly present. hysteria, neuralgia in other | places, ovarian tenderness, etc.| | 8. Benefited less by regulation | 8. Benefited not by electricity, of diet than by electricity and | but by regulation of diet. tonic treatment. | | 9. Not followed by dilatation of| 9. Dilatation of stomach may stomach. | supervene.

According to Peter, the surface temperature of the epigastrium is elevated in gastric ulcer, but not in nervous gastralgia.

Probably not a single one of the points mentioned in the table is without exception. Nervous gastralgia may be associated with gastric ulcer, and if the ulcer is otherwise latent the diagnosis is manifestly impossible. A diagnosis of purely functional gastralgia has been repeatedly overthrown by the occurrence of profuse hæmatemesis. There is no symptom {517} upon which it is more unsatisfactory to base a diagnosis than upon pain. There is much difference among physicians as regards the frequency with which they diagnose gastric ulcer in the class of cases here described. It is probable that the error is oftenest a too frequent diagnosis of gastric ulcer than the reverse. Nevertheless, when there is doubt it is well to submit the patient for a time to the proper treatment for gastric ulcer.

In several instances gastric crises have been mistaken for gastric ulcer. These gastric or gastralgic crises, as they are called by Charcot, by whom they have been best described, are most frequently associated with locomotor ataxia, but they may occur in connection with other diseases of the spinal cord (subacute myelitis, general spinal paralysis, and disseminated sclerosis), and an analogous affection has been described by Leyden as an independent disease under the name of periodical vomiting with severe gastralgic attacks. Gastric crises have been most carefully studied as a symptom in the prodromic stage of locomotor ataxia. The distinguishing features of these crises are the sudden onset and the atrocious severity of the gastric pain; the simultaneous occurrence of almost incessant vomiting; the habitual continuance of the paroxysms, almost without remission, for two or three days; the normal performance of the gastric functions in the intervals between the paroxysms, which may be months apart; the frequent association with other prodromic symptoms of locomotor ataxia, such as ocular disorders and fulgurating pains in the extremities; and the development after a time of ataxia. Leyden has observed during the attacks retraction of the abdomen without tension of the abdominal walls, obstinate constipation, scanty, dark-colored urine, even anuria for twenty-four hours, and increased frequency of the pulse (also noted by Charcot). Vulpian mentions a case in which there was vomiting of dark-colored blood, and in which naturally the diagnosis of gastric ulcer had been made. In the autopsies of Leyden and of Charcot no lesions of the stomach have been found.

The differential diagnosis of gastric ulcer from gastric cancer will be considered in the article on GASTRIC CANCER.

It has already been said that a part of the symptoms of gastric ulcer are due to an associated chronic catarrhal gastritis. Usually other symptoms are present which render possible the diagnosis of the ulcer. There is usually some apparent external or internal cause of chronic catarrhal gastritis, whereas the etiology of ulcer is obscure; in chronic gastritis gastralgic paroxysms and the peculiar fixed epigastric pain of gastric ulcer are usually absent; in chronic gastritis profuse hæmatemesis is a rare occurrence; and in gastritis the relief obtained by rest and proper regulation of the diet, although manifest, is usually less immediate and striking than in most cases of gastric ulcer.

The passage of gall-stones is usually sufficiently distinguished from gastric ulcer by the sudden onset and the sudden termination of the pain, by the situation of the pain to the right of the median line, by the complete relief in the intervals between the attacks, by the occurrence of jaundice, by the recognition sometimes of enlargement of the liver and of the gall-bladder, and by the detection of gall-stones in the feces.

{518} There is not much danger of confounding abdominal aneurism and lead colic with gastric ulcer, and the points in their differential diagnosis are sufficiently apparent to require no description here. The diagnosis of duodenal ulcer from gastric ulcer will be discussed elsewhere. The different causes of gastric hemorrhage, a knowledge of which is essential to the diagnosis of gastric ulcer, will be considered in the article on HEMORRHAGE FROM THE STOMACH.

PROGNOSIS.--Although a decided majority of simple ulcers of the stomach cicatrize, nevertheless, in view of the frequently insidious course of the disease, the sudden perforations, the grave hemorrhages, the relapses, and the sequels of the disease, the prognosis must be pronounced serious.

The earlier the ulcer comes under treatment the better the prognosis. Old ulcers with thickened indurated margins containing altered blood-vessels naturally heal with greater difficulty than recently-formed ulcers.

Profuse hemorrhage adds to the gravity of the diagnosis. It usually indicates that the ulcer has penetrated to the serous coat of the stomach. A hemorrhage may exert a favorable influence, in so far as to convince the patient of the necessity of submitting to the repose and the strict dietetic regimen which the physician prescribes.

The severity of the pain is of little value as a prognostic sign. Vomiting and dyspepsia, if uncontrolled by regulation of the diet, lead to a cachectic state which often ends in death.

Little basis as there is to hope for recovery after perforation into the general peritoneal cavity, there nevertheless have been a very few cases in which there is reason to believe that recovery has actually taken place after this occurrence.

Other cases in which recovery followed after all of the symptoms of perforation of gastric ulcer were present, but in which no subsequent autopsy proved the correctness of the diagnosis, have been reported by Redwood (Lancet, May 7, 1870); Ross (ibid., Jan. 21, 1871); Tinley (ibid., April 15, 1871); Mancini (La Sperimentale, 1876, pp. 551, 665); and G. Johnson (Brit. Med. Journ., March 26, 1870).

Frazer's two cases, reported in the Dublin Hosp. Gaz., April 15, 1861, are not convincing. The case reported by Aufrecht (Berl. kl. Wochenschr., 1870, No. 21) and the one by Starcke (Deutsche Klinik, 1870, No. 39), which are sometimes quoted as examples of recovery, were cases of circumscribed peritonitis following perforation.

In an interesting case from Nothnägel's clinic reported by Lüderitz, the patient lived sixteen days after perforation into the peritoneal cavity, followed by all of the symptoms of diffuse perforative peritonitis. Death resulted from pneumonia secondary to the peritonitis. At the autopsy were found adhesions over the whole peritoneal surface and streaks of thickened pus between the coils of intestine. The perforation in the stomach was closed by the left lobe of the liver (Berl. kl. Wochenschr., 1879, No. 33).]