Gastric ulcer

“ The general health of the patient remains sometimes surprisingly good, even in cases of gastric ulcer with symptoms sufficiently marked to establish the diagnosis. But in most cases of chronic gastric ulcer the general nutrition sooner or later becomes impaired. This cannot well be otherwise when dyspepsia, vomiting, paroxysms of severe pain, and hemorrhage are present, separately or in combination, for any great length of time. In proportion to the severity and the continuance of these symptoms the patient becomes pale, weak, and emaciated. ”

“ 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. ”

“ Some cases of ulcer of the stomach present the queerest symptoms. For instance: they complain of pain after drinking milk, or even after taking a morphine powder, while they can eat the coarsest food without any harm. Others run along without presenting any symptoms at all, until they, as well as their physicians, are surprised by the perforation of a gastric ulcer. ”

“ The diagnosis between gastric cancer and gastric ulcer is more difficult than that between cancer and gastritis, and sometimes the diagnosis is impossible. The differential points mentioned in the table are of very unequal value. An age under thirty, profuse hemorrhage, and absence of tumor are the most important points in favor of ulcer; tumor, advanced age, and coffee-ground vomiting continued for weeks are the most important points in favor of cancer. ”

“ In 444,564 deaths in New York City from 1868 to 1882, inclusive, ulcer of the stomach was assigned as the cause of death only in 410 cases. Little value can be assigned to these statistics as regards a disease so difficult of diagnosis.
[p. 486] Gastric ulcer is more common among the poor than among the rich. Anxiety, mental depression, scanty food, damp dwellings, insufficient exercise, and exposure to extreme cold are among the depressing influences which have been assigned as predisposing causes of gastric ulcer, but without sufficient proof. ”

“ You can readily see why pain occurs more often than hemorrhage. Even a very superficial abrasion may expose nerve-endings to the irritation of the food, while it takes a deeper ulceration to lay open a larger bloodvessel. In order to make a positive diagnosis, these two symptoms should be present.
Vomiting of blood alone need not necessarily be caused by a gastric ulcer. There are a great many other conditions which may cause it. It should, however, put you on the guard, and can, in a great many cases, justify a diagnosis of probable ulcer of the stomach. ”

“ Other cases occur in which all of the just mentioned symptoms except dyspepsia are missing, the first intimation of the ulcer being hemorrhage or perforation.
The patient with gastric ulcer may recover entirely and never have a return of the trouble, but care and close attention are necessary, since the ulcers are apt to recur, at times a series of ulcers developing one after another. Death may occur from exhaustion or from perforation and peritonitis. Surgical intervention is as a rule necessary when the ulcers persist, as they generally develop at or near the pyloric opening ”

“ The large share taken by pulmonary phthisis in deaths from all causes renders this disease a frequent associate of gastric ulcer. It is probable that the lowered vitality of phthisical patients increases somewhat their liability to gastric ulcer. Moreover, it would not be strange if gastric ulcer, as well as other exhausting diseases, such as diabetes and cancer, diminished the power of resisting tuberculous infection. Genuine tuberculous ulcers occur rarely in the stomach, but they are not to be identified with simple ulcer. ”

“ After the worst has been said concerning the unfavorable issues of gastric ulcer, it yet remains true that the essential tendency of the ulcer when placed under favorable conditions is toward recovery, and that in many cases the treatment of the disease affords most excellent results, and is therefore a thankful undertaking for the physician. ”

“ It remains to be said that duodenal is much more rare than gastric ulcer, in the ratio of 1 to 30, and that, unlike gastric ulcer, it chiefly affects males. According to the statistics of Krauss, already cited, the ratio of males to females is 9 to 1, and according to Trier the ratio is 5 to 1. It occurs in greatest frequency between the ages of thirty to forty, diminishing in frequency with advancing age.
SYMPTOMATOLOGY.—Ulcer of the intestines announces itself by symptoms which are, as a rule, much more vague and indefinite than the same process in the stomach. ”

“ While gastric ulcer is to be regarded as dangerous, its termination, in the great majority of cases, is in recovery. It frequently, however, leaves the stomach in a delicate condition, necessitating the utmost care as regards diet. Occasionally the disease proves fatal by sudden haemorrhage, but a fatal result is more frequently due to perforation and the escape of the contents of the stomach into the peritoneal cavity, in which case death usually occurs in from twelve to forty-eight hours, either from shock or from peritonitis. ”

“ Simple ulcer and cancer may occur together in the same stomach, or cancer may develop in an ulcer or its cicatrix. Glässer reports a case of phlegmonous gastritis with gastric ulcer.62 Extension of inflammation to the pleura without perforation of the diaphragm sometimes occurs. Fatty degeneration of the heart may be the result of profound anæmia induced by gastric ulcer.63 Embolic pneumonia and broncho-pneumonia are occasional complications. A moderate degree of cachectic dropsy is not very infrequent in the late stages of gastric ulcer. ”

“ The perforation of a gastric ulcer may cause symptoms which rapidly place the patient in a condition in which the administration of the Sacraments is very unsatisfactory. Gastric ulcers occur especially in young women, usually in those who follow some indoor occupation. Its favourite victims are cooks, though laundresses, seamstresses, and even clerks in stores, suffer from it much more than those engaged in other occupations. It occurs by preference in anaemic or chlorotic women. Sometimes, however, as in the case of cooks, the patients may seem to be in good health. ”

“ Especial interest attaches to the relation between gastric ulcer and diseases of the heart and of the blood-vessels, because to disturbances in the circulation in the stomach the largest share in the pathenogenesis of ulcer has been assigned by Virchow. As might be expected, valvular lesions of the heart and atheroma of the arteries are not infrequently found in elderly people who are the subjects of gastric ulcer. ”

“ Loss of appetite is a much more common symptom in gastric cancer than in gastric ulcer. In cancer, as well as in ulcer, the patient sometimes refrains from food less on account of disrelish for it than on account of the distress which it causes him.
Pain is one of the most frequent symptoms of cancer of the stomach. If the pain begins early in the disease, and continues, as it often does, with increasing severity, it renders gastric cancer one of the most distressing affections. The pain is usually felt in the epigastrium, but it may be more intense in the hypochondria. ”

“ Copious hæmatemesis in cases of gastric ulcer appears usually without premonition, or it may be preceded for a day or two by increased pain. Its occurrence is somewhat more common during the digestion of food than in the intervals, but there have been cases of ulcer where the bleeding was favored by an empty stomach and was checked by the distension of the organ with food. The free use of stimulants and violent physical or mental exertion may excite hemorrhage. ”

“ Gastric ulcer may develop without an apparent cause. As a rule, however, it manifests itself in individuals between the years of fifteen and forty, particularly after prolonged digestional disturbances, especially those accompanied by a hypersecretion of acid. As the disease progresses, anemia is more or loss severe, adding difficulty to the feeding problem. Many of the symptoms are like those of chronic gastritis, such as pain. ”

“ A little cachectic dropsy may appear about the ankles. While it is true that the general nutrition is less rapidly, less continuously, and, as a rule, less deeply, impaired in gastric ulcer than in gastric cancer, nevertheless sometimes a cachexia develops in the former which is not to be distinguished from that of cancer. Litten46 relates a case of gastric ulcer which simulated for a time pernicious anæmia. In this case the profound anæmia could not be explained by vomiting, hemorrhage, or other symptoms of ulcer. ”

“ Mental emotions—particularly anxiety and anger—fatigue, even moderate exercise, exposure to cold, and the menstrual molimen may each cause exacerbations of pain in some cases of gastric ulcer.
Tenderness on pressure is a common symptom of gastric ulcer. A localized point of tenderness may be discovered even when the subjective pain is not localized. Pain sometimes follows pressure not immediately, but after a brief interval. A fixed point of tenderness can often be determined when the stomach is empty more accurately than when it is full. ”

“ In 32,052 autopsies made in Prague, Berlin, Dresden, Erlangen, and Kiel,9 there were found 1522 cases of open ulcer or of cicatrix in the stomach. If all the scars be reckoned as healed ulcers, according to these statistics gastric ulcer, either cicatrized or open, is found in about 5 per cent. of persons dying from all causes. ”

“ Gastric ulcer may give rise to no marked symptoms before profuse hemorrhage from the stomach or perforation of the stomach, resulting speedily in death, occurs. Acute ulcers in anæmic females from fifteen to thirty years of age are those most liable to perforate without previous symptoms. ”

“ Chlorosis and anæmia, especially in young women, favor the development of gastric ulcer, but that there is no necessary relation between the two is shown by the occurrence of ulcer in those previously robust. ”

“ When gastric ulcer is present, portions of the vomited matter are often dark and grumous like coffee-grounds or the settlings of beef-tea, and are found upon microscopic examination to contain blood-corpuscles. Actual hæmatemesis may also occur under these circumstances, and be repeated from time to time. The quantity of blood thrown up is frequently small; at times, however, it is excessive, and occasionally so great as to cause death. ”

“ Gastric ulcer is not a febrile disease. Temporary elevation of temperature may follow profuse gastrorrhagia and may attend various complications, of which the most important are gastritis and peritonitis. ”

“ In females the pelvic organs are often the true source of emesis. Haematemesis accompanies gastric ulcer, cancer, chronic congestion with haemorrhagic erosion, congestion of the liver, or may follow violent acts of vomiting. In cases of ulcer the blood is usually bright and in considerable amount; in cancer, darker, like coffee-grounds; and in cases of erosion, in smaller quantity and of bright colour. The reaction of the stomach contents, if the cause be doubtful, yields valuable aid towards a diagnosis. ”

“ There is evidence that about two-thirds of all the cases of cancer of the stomach originate in an old gastric ulcer, and the constant eating of hot food is perhaps enough to account for the remaining third. The delicate gastric cells, more abused than any other cells in the body, are bathed in a highly acid medium. It is no wonder that departure from their appointed path accounts for thirty per cent. ”

“ Another fact also requires taking into the most serious consideration, and this is, that it is the considered opinion of by far the large majority of experienced surgeons that exploration and some form of operation is the best treatment for every case of chronic gastric ulcer which has recurred once, or at least twice, after a thorough course of medical treatment. ”

“ GASTRITIS—THE SYMPTOMS
The symptoms are usually a dull pain in the region of the stomach and upper intestines, a swollen full feeling, now and then biting pains, followed by a dark [450] vomit, especially when the attack comes late at night.
Gastritis is often confused with gastric cancer, and in diagnosis it is difficult to speak with authority as to whether the case is ordinary gastritis, as above described, gastric ulcer, or gastric cancer. ”