Chapter XXIX: Front Matter (29)

The heart's action is often disturbed in its rhythm, and sympathetic dyspnoea leads to suspicion of disease of the lungs. And to all these {475} nervous phenomena may be added unusual languor, lassitude, irritability of temper, and a feeling of inability for either mental or physical exertion.

But in the play of morbid sympathies it must be borne in mind that the stomach may be secondarily affected. Irritations of all organs are constantly transmitted to the stomach from their very commencement. Hence the frequent loss of appetite, the thirst, the embarrassed digestion, the deranged gastric secretion, and the altered color of the tongue. This is markedly the case in all the malarious and essential forms of fever. Gastric complication in these fevers is rarely, if ever, absent, and if aggravated by the too early use of tonics and stimulants and by harsh irritating cathartics, it becomes too often a fatal complication.

Gastric symptoms are also associated with other constitutional disorders, such as phthisis, renal disease, rheumatism, gout, and almost all forms of chronic eruptive diseases.

Intestinal symptoms are rarely absent. Constipation is often obstinate, and especially is this the case if the catarrhal condition is confined to the duodenum. The lower down the inflammation the greater the probability of diarrhoea, and when present the stools are offensive and frothy; sometimes they are dry and scybalous and coated with a tough, tenacious mucus which may form casts of portions of the intestinal track. In other cases patients suffer from distressing intestinal flatulence and a sense of general discomfort. Piles is a complication frequently present without reference to complication of the liver.

The urine is more frequently disordered than in any other form of disturbance of digestion. The most common changes consist in an abundant deposit of the urates; exceptionally, however--especially in cases of long standing in which there are marked nervous symptoms associated with defective secretion of the liver and pancreas--it may be of low specific gravity and pale in color from the presence of phosphates. Slight febrile movement is not uncommon.

Finally, in all cases of chronic gastric catarrh the nutritive system becomes deeply implicated--much more so than in functional disturbances of the stomach. Emaciation is almost constantly present, the patient often showing signs of premature decay.

DIAGNOSIS.--The disease with which chronic gastritis is most liable to be confounded is atonic dyspepsia, the chief points of distinction from which have been already alluded to. In general terms it may be said that in chronic gastritis there is more epigastric tenderness, more burning sensation and feeling of heat in the stomach, more thirst, more nausea, more persistent loss of appetite, more steady and progressive loss of flesh, more acidity, more eructations of gas, more general appearance of premature decay, and greater tendency to hypochondriasis. And yet all these symptoms, in varying degrees of prominence, may be present in all forms of indigestion. To the points of distinction already mentioned, then, a few circumstances may be added which will afford considerable assistance in coming to a correct diagnosis:

1. The length of time the disease has uninterruptedly lasted. It is essentially a chronic disease.

2. The local symptoms are never entirely absent, as is not infrequently the case in functional dyspepsia.

{476} 3. The uneasy sensations, nausea, oppression, or pain, as the case may be, follow the ingestion of food. They are not so prominently present when the stomach is empty.

4. The result of treatment. In chronic gastritis it will be found that all the local symptoms are exasperated by the usual treatment of functional dyspepsia.

5. Stimulants and stimulating food are not well borne. Alcohol, especially on an empty stomach, produces gastric distress. There is also frequently slight febrile disturbance.

Chronic gastritis, with nausea, vomiting, hæmatemesis, general pallor, and loss of flesh, may be mistaken for cancer of the stomach. But in cancer vomiting is about as apt to take place when the stomach is empty as during the ingestion of food; pain is usually greater, especially when the orifices of the stomach are involved; the tenderness is more marked; the emaciation and pallor more steadily progressive; the vomiting of coffee-ground material takes place more frequently; and the disease is more rapid in its progress. The age and sex of the patient may also aid us in our diagnosis. Cancer is more frequently a disease of middle and advanced life, and localizes itself oftener in the stomach of males than females. Finally, the discovery of a tumor would remove all doubts. Hæmatemesis in chronic catarrh of the stomach is almost invariably associated with obstruction to venous circulation in the liver, heart, or lungs.

In rare cases it may be difficult to distinguish chronic gastric catarrh from ulcer of the stomach. In ulcer of the stomach pain is a more prominent and constant symptom; it is more centrally located; the vomiting after taking food is more immediate and persistent; the tongue may be clean; flatulence is not a constant symptom; the appetite is seldom much affected; the bowels are generally confined; and there is nothing characteristic about the urine.

TREATMENT.--In this, as in the more acute forms of the disease, rest of the stomach is important. From mistaken notions of disease we are prone to over-feed our patients, and thus seriously impair the digestive and assimilative processes. In chronic inflammation of the stomach a restricted diet is of prime importance. The physician should most carefully select the patient's food, and urgently insist on its exclusive use. This of itself, if faithfully persevered in, will often effect a cure.

The exclusive use of a milk diet--especially skim-milk--should be thoroughly tested. In testing it we should allow two or three weeks to elapse before any other food is taken. At the end of that time soft-boiled eggs, stale bread, and well-cooked rice may be added, with an occasional chop once a day. Some patients do not tolerate raw milk well. In such cases we should thoroughly test the peptonized or pancreatized milk or the peptonized milk-gruel, as suggested by Roberts. This artificially-digested milk agrees wonderfully well with many stomachs that cannot digest plain milk. Milk, in whatever form administered, should be given at comparatively short intervals of time, and never in quantity beyond the digestive capacity. Better err on the side of under- than over-feeding. Nothing should be left to the fancy or caprice of the patient. The food should be carefully selected by the medical adviser, and given in definite quantities at definite times. Even the moral {477} effect of such discipline is healthful for the patient. After testing milk diet for a time, we may gradually add small quantities of rare and thoroughly minced meat. Milk, eggs, and rare meat are more easily digested, as a rule, than starchy substances. Farinaceous food is apt to give rise to excessive acidity. But stale bread may be added to the milk, and, if there is tendency to acidity, better have it toasted thoroughly brown.

In addition to the dietetic treatment of the disease, diluents, timeously administered, are of essential service. As a rule, patients are too much restricted from their use, under the supposition that they dilute the gastric juice and thereby impair the digestive power. This restriction is proper at, and for some time after, the ingestion of food. But at the end of the first hour after taking food several ounces of gum-water, or some mucilaginous fluid sweetened and rendered palatable by a few drops of dilute muriatic acid, should be administered, and repeated every hour during the digestive process. Diluents, thus administered, are not only grateful in allaying the thirst of the patient, but are at the same time an essential part of the treatment. The free use of demulcents at the termination of digestion in the stomach is especially useful.

Beyond these general principles of treatment, applicable to all varieties of gastric catarrh, we must have reference to the varied etiology of the disease. This, we have seen, is most complicated. Hence the difficulty in prescribing any rules of treatment applicable to all cases. We should seek here, as in all cases, to generalize the disease and individualize our patient.

Chief among remedial agents may be mentioned the alkaline carbonates. When combined with purgative salines they are specially valuable in gastro-duodenal catarrhs associated with disease of the liver. These are a very numerous class of cases, especially in malarious regions of country, and when present in a chronic form lay the foundation of widespread disorders of nutrition. No treatment in such cases is effective until we diminish engorgements of the liver and spleen, and nothing accomplishes this so well as the use of alkaline saline laxatives. These may be assisted in their action by small doses of mercurials. It was a cardinal principle among the older practitioners, in the absence of more minute means of diagnosis, to look well to the secretions; and what was their strength is, I fear, our weakness.

Wonderful results often follow a course of the Carlsbad, Pullna, or Marienbad waters, taken on an empty stomach, fasting, in the morning. While taking the waters a rigid and restricted diet is enforced. This is an important part of the treatment. And the fact that so many varied ailments are cured by a course of these mineral waters with enforced dietetic regulations only shows the prevalence of gastro-duodenal catarrhs and their relation to a great variety of human ailments. To a certain extent the potassio-tartrate of sodium and other saline laxatives may take the place of these waters if perseveringly used and taken in the same way. In feebler subjects minute doses of strychnia or some of the simple vegetable bitters may be used in conjunction with the laxative salines.

In chronic inflammatory conditions of the gastric mucous membrane, which frequently follow acute attacks, the protracted use of hot water is often followed by excellent results. There can be no doubt of the value {478} of hot water in subacute inflammation of mucous membranes in any locality; and it is specially valuable in gastro-intestinal catarrh associated with lithæmia. Hot water, laxative salines, combined with restricted diet and healthful regimen, accomplish much in correcting morbid conditions of primary assimilation; and by accomplishing this many secondary ailments promptly disappear. A pint of water, hot as the patient can drink it, should be taken on an empty stomach on first rising in the morning, and it may be repeated again an hour before each meal and at bedtime. A few grains of the bicarbonate of sodium and a little table-salt may be added. In some cases three or four drops of tincture of nux vomica or some of the simple bitters may be taken at the same time with benefit. Alkaline bitters are natural to the upper portion of the digestive track. No food should be taken for a half hour or an hour after the hot water. This treatment, to be effective, must be persevered in for a length of time. A most rigid system of dietetics suited to individual cases should be enforced at the same time. This is an important part of the treatment.

In irritable and morbidly sensitive conditions of the mucous membrane the sedative plan of treatment is not unfrequently followed by good results; and of remedies belonging to this class bismuth is the most effective. It is specially indicated in the more irritable forms of gastric disturbance in which there is a sense of uneasiness and pain at the epigastrium after taking food. If there is much acidity present, it may be combined with magnesia or a few grains of finely-pulverized animal charcoal.

Chronic cases of long-continued inflammatory action, with intestinal complication, are often much benefited by the use of mercurials in small doses. The one-fifth of a grain of calomel, combined with bismuth or the bicarbonate of sodium, may be given for weeks without danger of salivation. Excellent results sometimes follow this treatment. In small doses calomel is undoubtedly sedative to the mucous membrane of the upper portion of the digestive track. In cases of long standing that have resisted other modes of treatment the more direct astringents have been found of great value. Of these, nitrate of silver is to be preferred, alike for its sedative, astringent, and alterative properties. It may be given in pill form in from one-quarter to one-grain doses, combined with opium, a half hour before each meal. The writer of this article can speak from much experience of the value of this drug. It proves in many cases a valuable addition to the hot-water and dietetic course already alluded to.

If large quantities of mucus are vomited from time to time, especially in the morning, we may resort with benefit to the use of other astringents, such as bismuth, oxalate of cerium, kino, and opium; and if we have reason to suspect stricture of the pylorus in connection with a catarrhal condition of the mucous membrane, the stomach-pump gives the patient great relief. It should be used about three hours after a meal, injecting tepid water, and then reversing the syringe until the water comes out perfectly clear. Niemeyer speaks highly of it in such cases. He says: "Even the first application of the pump generally gives the patients such relief that, so far from dreading a repetition of this by no means pleasant operation, they clamorously beg for it."

The gastric catarrh of phthisis is difficult to relieve. Artificial digestives may be tried, with dilute muriatic acid, as already indicated; and {479} for the relief of pain and irritation there is no remedy so efficacious as hydrocyanic acid, which may be combined with bismuth and opium in case there is diarrhoea. Hot water may be also tried, with restricted animal food.

Habitual constipation must be overcome by suitable laxatives and by enemata. Castor oil is mild and efficient in these cases, or in cases of unusual torpor of the muscular coat of the bowels small doses of aloes and strychnia may be tried. The free use of diluents toward the close of digestion favors free action of the bowels. All harsh and irritating cathartics are to be carefully avoided.

When there is much tenderness of the epigastrium, benefit may be derived from counter-irritation, and nothing is so effectual as the repeated application of small blisters.

General hygienic measures are in all cases to be insisted upon. In morbid conditions of the liver and the upper portion of the digestive track the free supply of oxygen to the lungs is a remedy of much power. Hence patients should live as much as possible in the open air. They should be warmly clad, and, if not too feeble, frequent cold baths should be resorted to.

After local irritation has been subdued by appropriate treatment, tonics may be tried to counteract the enfeebled state of the stomach. They are such as are appropriate for functional diseases of the stomach. But they should be used with caution and judgment in irritable and inflammatory forms of dyspepsia. If we attempt to force an appetite by their use, and to crowd upon the stomach more food than it has capacity to digest, we may intensify the trouble and thereby add to the patient's general debility. Food and tonics fail to impart strength because the stomach is not in a condition to digest them.

One thing should be mentioned, in conclusion, as an important item in the treatment--namely, patience. Chronic gastric catarrh, it should be remembered, is essentially a chronic disease, and time becomes an important element in its cure.

{480}

SIMPLE ULCER OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.--Simple ulcer of the stomach is usually round or oval. When of recent formation it has smooth, clean-cut, or rounded borders, without evidence of acute inflammation in its floor or in its borders. When of long duration it usually has thickened and indurated margins. The formation of the ulcer is usually attributed, in part at least, to a disturbance in nutrition and to a subsequent solution by the gastric juice of a circumscribed part of the wall of the stomach. The ulcer may be latent in its course, but it is generally characterized by one or more of the following symptoms: pain, vomiting, dyspepsia, hemorrhage from the stomach, and loss of flesh and strength. It ends frequently in recovery, but it may end in death by perforation of the stomach, by hemorrhage, or by gradual exhaustion.

SYNONYMS.--The following epithets have been employed to designate this form of ulcer: simple, chronic, round, perforating, corrosive, digestive, peptic; ulcus ventriculi simplex, s. chronicum, s. rotundum, s. perforans, s. corrosivum, s. ex digestione, s. pepticum.

HISTORY.--It is only since the description of gastric ulcer by Cruveilhier in the year 1830 that especial attention has been paid to this disease.

In the writings of the ancients only vague and doubtful references to ulcer of the stomach are found (Galen, Celsus). It is probable that cases of this disease were described under such names as passio cardiaca, gastrodynia, hæmatemesis, and melæna.

After the revival of medicine in the sixteenth century, as post-mortem examination of human bodies was made with greater frequency, the existence of ulcers and of cicatrices in the stomach could not escape attention. But only isolated and curious observations of gastric ulcer are recorded up to near the end of the eighteenth century. One of the earliest recorded unmistakable cases of perforating ulcer was observed by John Bauhin, and is described in the _Sepulchretum_ of Bonetus, published in 1679. Other cases belonging to this period were described by Donatus, Courtial, Littré, Schenck, and Margagni.[1]

[Footnote 1: References to these and to other cases may be found in Lebert's _Krankheiten des Magens_, Tübingen, 1878, p. 180 _et seq._]

To Matthew Baillie unquestionably belongs the credit of having first accurately described, in 1793, the anatomical peculiarities of simple gastric ulcer.[2] At a later date he published three good engravings of {481} this disease.[3] Baillie's concise and admirable description of the morbid anatomy of gastric ulcer was unaccompanied by clinical data, and seems to have had little or no influence in directing increased attention to this disease.

[Footnote 2: _The Morbid Anatomy of Some of the Most Important Parts of the Human Body_, London, 1793, p. 87.]

[Footnote 3: _A Series of Engravings, accompanied with Explanations, etc._, London, 1799.]

A valuable account of the symptoms of gastric ulcer was given by John Abercrombie in 1824.[4] Nearly all of the symptoms now recognized as belonging to this affection may be found in his article. He knew the latent causes of the disease, the great diversity of symptoms in different cases, and the modes of death by hemorrhage, by perforation, and by asthenia. He regarded ulcer simply as a localized chronic inflammation of the stomach, and did not distinguish carefully between simple and cancerous ulceration.

[Footnote 4: "Contributions to the Pathology of the Stomach, the Pancreas, and the Spleen," _Edinburgh Med. and Surg. Journ._, vol. xxi. p. 1, Jan. 1, 1824. See also, by the same author, _Pathological and Practical Researches on Diseases of the Stomach, etc._--an excellent work which passed through several editions.]

Cruveilhier,[5] in the first volume of his great work on _Pathological Anatomy_, published between the years 1829 and 1835, for the first time clearly distinguished ulcer of the stomach from cancer of the stomach and from ordinary gastritis. He gave an authoritative and full description of gastric ulcer from the anatomical, the clinical, and the therapeutical points of view.

[Footnote 5: J. Cruveilhier, _Anatomie pathologique du Corps humain_, tome i., Paris, 1829-35, livr. x. and livr. xx.; and tome ii., Paris, 1835-42, livr. xxx. and livr. xxxi.]

Next to Cruveilhier, Rokitansky has had the greatest influence upon the modern conception of gastric ulcer. In 1839 this pathologist gave a description of the disease based upon an analysis of 79 cases.[6] The anatomical part of his description has served as the model for all subsequent writers upon this subject.

[Footnote 6: Rokitansky, _Oesterreich. med. Jahrb._, 1839, Bd. xviii. (abstract in _Schmidt's Jahrb._, Bd. 25, p. 40).]

Since the ushering in by Cruveilhier and by Rokitansky of the modern era in the history of gastric ulcer, medical literature abounds in articles upon this disease. But it cannot be said that the importance of these works is at all commensurate with their number or that they have added very materially to the classical descriptions given by Cruveilhier and by Rokitansky. Perhaps most worthy of mention of the works of this later era are the article by Jaksch relating to symptomatology and diagnosis, that of Virchow pertaining to etiology, the statistical analyses by Brinton, and the contributions to the treatment of the disease by Ziemssen and by Leube.[7] In 1860, Ludwig Müller published an extensive monograph upon gastric ulcer.[8]

[Footnote 7: Jaksch, _Prager Vierteljahrschr._, Bd. 3, 1844; Virchow, _Arch. f. path. Anat._, Bd. v. p. 362, 1853, and A. Beer, "Aus dem path. anatom., Curse des Prof. R. Virchow in Berlin, Das einfache duodenische (corrosive) Magengeschwür," _Wiener med. Wochenschr._, Nos. 26, 27, 1857; Brinton, _On the Pathology, Symptoms, and Treatment of Ulcer of the Stomach_, London, 1857; V. Ziemssen, _Volkmann's Samml. klin. Vorträge_, No. 15, 1871; Leube, _Ziemssen's Handb. d. spec. Path. u. Therap._, Bd. vii., Leipzig, 1878.]

[Footnote 8: _Das corrosive Geschwür im Magen und Darmkanal_, Erlangen, 1860. Good descriptions of gastric ulcer are to be found in the well-known works on diseases of the stomach by the English writers, Budd, Chambers, Brinton, Habershon, Fenwick, and Wilson Fox.]

ETIOLOGY.--We have no means of determining accurately the average frequency of simple gastric ulcer. The method usually adopted is to observe the number of cases in which open ulcers and cicatrices are found {482} in the stomach in a large number of autopsies. But this method is open to two objections. The first objection is, that scars in the stomach, particularly if they are small, are liable to be overlooked or not to be noted in the record of the autopsy unless special attention is directed to their search. The second objection is, that it is not proven that all of the cicatrices found in the stomach are the scars of healed simple ulcers, and that, in fact, it is probable that many are not. In consequence of these defects (and others might be mentioned) this method is of very limited value, although it is perhaps the best which we have at our disposal.

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.

[Footnote 9: The Prague statistics embrace 11,888 autopsies, compiled from the following sources: 1, Jaksch, _Prager Vierteljahrschr._, vol. iii.; 2, Dittrich, _ibid._, vols. vii., viii., ix., x., xii., xiv.; 3, Willigk, _ibid._, vol. li.; 4, Eppinger, _ibid._, vol. cxvi.

The Berlin statistics are to be found in dissertations by Plange (abstract in _Virchow's Archiv_, vol. xviii.), by Steiner, and by Wollmann (abstracts in _Virchow und Hirsch's Jahresbericht_, 1868), and by Berthold (1883).

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.[10] It would be a moderate estimate to place the ratio of cicatrices to open ulcers at 3 to 1.

[Footnote 10: Grünfeld (abstract in _Schmidt's Jahrb._, Bd. 198, p. 141, 1883) in 1150 autopsies found 124 cicatrices in the stomach, or 11 per cent., but in only 450 of these cases was his attention especially directed to their search, and in these he found 92 cases, or 20 per cent., with scars. Grünfeld's statistics relate only to persons over fifty years of age. Gastric ulcer, moreover, is extraordinarily common in Copenhagen.

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.[11]

[Footnote 11: If in this estimate were included infants dying during the first days of life, the percentage would be much smaller.]

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[12] 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.

[Footnote 12: Lebert, _op. cit._, p. 196.]

Of 1699 cases of gastric ulcer collected from various hospital statistics[13] 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.

[Footnote 13: These statistics include the previously-cited Prague, Berlin, Dresden, and Erlangen cases so far as the sex is given, and in addition the returns of Rokitansky, _op. cit._; Starcke (Jena), _Deutsche Klinik_, 1870, Nos. 26-29; Lebert, _op. cit._; Chambers, _London Journ. of Med._, July, 1852; Habershon, _Dis. of the Abdomen_, 3d ed.; Moore, _Trans. of London Path. Soc._, 1880; and the Munich Hospital, _Annalen d. städt. Allg. Krankenh. zu München_, vols. i. and ii.

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[14] (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.

[Footnote 14: The sources of these statistics are the same as those of the statistics relating to sex in the preceding foot-note. The age in the Erlangen cases of open ulcer is given by Hauser (_Das chronische Magengeschwür_, p. 191, Leipzig, 1883). It is evident that only about two-fifths of the cases could be utilized, partly because in some the age was not stated, but mainly on account of the necessity of excluding scars--a self-evident precaution which Brinton did not take.]

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_.[15]

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.[16]

[Footnote 15: _Op. cit._, p. 199. Of these cases, 19 were fatal, and the diagnosis was confirmed after death. All of the cases were studied by Lebert in hospitals in Zurich and Breslau.]

[Footnote 16: In my opinion, clinical experience is more valuable than are post-mortem records in determining the age at which gastric ulcer most frequently develops. In support of this opinion are the following facts: In many cases no positive conclusions as to the age of the ulcer can be drawn from the post-mortem appearances, and sufficient clinical history is often wanting; a considerable proportion of the cases of gastric ulcer do not terminate fatally with the first attack, but are subject to relapses which may prove fatal in advanced life; in most general hospitals the number of patients in advanced life is relatively in excess of those in youth and middle age. By his faulty method of investigating this question, Brinton came to the erroneous conclusion that the liability to gastric ulcer is greatest in old age--a conclusion which is opposed to clinical experience.]

The oldest case on record is the one mentioned by Eppinger,[17] of an old beggar whose age is stated at one hundred and twenty years.

[Footnote 17: _Prager Vierteljahrschrift_, Bd. 116.]

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.[18] 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.[19] 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.[20]

[Footnote 18: Communication to Von Gunz in _Jahrbuch d. Kinderheilkunde_, Bd. 5, p. 161, 1862.]

[Footnote 19: _Jahrb. d. Kinderheilk._, N. F., Bd. 7, p. 19, 1874.]

[Footnote 20: Reimer, _ibid._, Bd. x. p. 289, 1876; Goodhart, _Trans. London Path. Soc._, vol. xxxii. p. 79, 1881; Eröss, _Jahrb. f. Kinderheilk._, Bd. xix. p. 331, 1883; Malinowski, _Index Medicus_, vol. v. p. 575, New York, 1883.

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:[21]

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.

[Footnote 21: These cases are obtained from the same sources as those of the first table (page 483).]

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.[22] According to Starcke's report[23]--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.[24] Palgrave gives a high percentage of its occurrence in Arabia.[25] The disease is less common in France than in England or in Germany,[26] and in general appears to be more common in northern than in southern countries. The statement of DaCosta[27] 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.

[Footnote 22: Dahlerup in Copenhagen (abstract in _Canstatt's Jahresbericht_, 1842) found 26 cases in 200 autopsies (13 per cent.) made in the course of a year and a half. Grünfeld (_loc. cit._) found 124 cicatrices in 1150 autopsies (11 per cent.).]

[Footnote 23: Starke (_loc. cit._) found 39 cases in 384 autopsies (10 per cent.); cf. also Müller, _Jenaische Zeitschr._, v. 1870.]

[Footnote 24: _Deutsche Klinik_, 1867.]

[Footnote 25: _Narrative of a Year's Journey through Central and Eastern Arabia_, London, 1865.]

[Footnote 26: Laveran and Teissier, _Nouveaux Éléments de Path. et de Clin. méd._, t. ii. p. 1060, Paris, 1879; and Godin, _Essai sur l'Ulcère de l'Estomac_, Thèse, Paris, 1877, p. 8.]

[Footnote 27: _Medical Diagnosis_, 5th ed., Philada., 1881. Keating expresses the same opinion in the _Proc. of Path. Soc. of Philadelphia_, vol. i. p. 142.

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.]

{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.

The comparative frequency of gastric ulcer among needlewomen, maidservants, and female cooks has attracted the attention of all who have had large opportunity for clinical observation.

Pressure upon the pit of the stomach, either by wearing tight belts or in the pursuit of certain occupations, such as those of shoemaking, of tailoring, and of weaving, is thought by Habershon and others to predispose to ulcer of the stomach.[28]

[Footnote 28: Bernutz found gastric ulcer in a turner in porcelain, and learned that other workmen in the same factory had vomited blood. He thinks that in this and in similar occupations heavy particles of dust collecting in the mouth and throat may be swallowed with the saliva, and by their irritation cause gastric ulcer (_Gaz. des Hôpitaux_, June 18, 1881).]

Vomiting of blood has been known in several instances to affect a number of members of the same family, but beyond this unsatisfactory evidence there is nothing to show hereditary influence in the origin of gastric ulcer.

In a few cases injury of the region of the stomach, as by a fall or a blow, has been assigned as the cause of ulcer. The efficacy of this cause has been accepted by Gerhardt,[29] Lebert, Ziemssen, and others. In many of the cases in which this cause has been assigned the symptoms of ulcer appeared so long after the injury that it is doubtful whether there was any connection between the two.

[Footnote 29: "Zur Aetiologie u. Therapie d. runden Magengeschwürz," _Wiener med. Presse_, No. 1, 1868.]

That loss of substance in the mucous membrane of the stomach may be the result of injury directly or indirectly applied to this organ cannot admit of question. But it is characteristic of these traumatic ulcers that they rapidly heal unless the injury is so severe as to prove speedily fatal. Thus, Duplay[30] relates three cases in which pain, vomiting, repeated vomiting of blood, and dyspepsia followed contusions of the region of the stomach. But these traumatic cases, which for a time gave the symptoms of gastric ulcer, recovered in from two weeks to two months, whereas the persistence of the symptoms is a characteristic of simple ulcer.[31]

[Footnote 30: "Contusions de l'Estomac," _Arch. gén. de Méd._, Sept., 1881.]

[Footnote 31: In a case reported by Potain, however, the symptoms of ulcer appeared immediately after injury to the stomach, and continued up to the time of death (_Gaz. hebdom._, Sept. 12, 1856).]

In the same way, ulcers of the stomach produced by corrosive poisons as a rule soon cicatrize, unless death follows after a short time the action of the poison. That corrosive ulcers may, however, be closely allied to simple ulcers is shown by an interesting case reported by Wilson Fox,[32] in which the immediate effects of swallowing hydrochloric acid were recovered from in about four days, but death resulted from vomiting of blood two weeks after. At the autopsy the source of the hemorrhage was found in an ulcer of the pyloric region of the stomach. An equally striking case is reported by Williams.[33] A boy who suffered severely for three or four days after drinking some strong mineral acid recovered, so that he {487} ate and drank as usual. Two months afterward he died suddenly from perforation of a gastric ulcer.

[Footnote 32: _Trans. of the Path. Soc._, vol. xix. p. 239, London, 1868.]

[Footnote 33: _The Lancet_, April 9, 1842.]

While, then, it would be a great error to identify traumatic and corrosive ulcers of the stomach with simple ulcer, it is possible that either may become chronic if associated with those conditions of the stomach or of the constitution, for the most part unknown to us, which prevent the ready healing of simple ulcer.

Gastric ulcer is often associated with other diseases, but it occurs also uncomplicated in a large number of cases. Most of the diseases with which it has been found associated are to be regarded simply as coincident or complicating affections; but as some of them have been thought to cause the ulcer, they demand consideration in this connection.

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.

There is no proof that amenorrhoea or other disorders of menstruation exert any direct influence in the production of gastric ulcer, although Crisp went so far as to designate certain cases of gastric ulcer as the menstrual ulcer.[34] Nevertheless, amenorrhoea is a very common symptom or associated condition in the gastric ulcer of females between sixteen and thirty years of age.

[Footnote 34: _The Lancet_, Aug. 5, 1843.]

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. Moreover, it is probable that in some cases in which the anæmia has been thought to precede the ulcer it has, in fact, been a result rather than a cause of the ulcer.

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. A small proportion of cases of ulcer has been associated also with other diseases in which the arteries are often abnormal, such as with chronic diffuse nephritis, syphilis, amyloid degeneration, and endarteritis obliterans. But, after making the most generous allowance for the influence of these diseases in the causation of ulcer of the stomach, there remains a large number of cases of ulcer in which no disease of the heart or of the arteries has been found.[35] Gastric ulcer develops most frequently between fifteen and forty years of age, a period when arterial diseases are not common. Changes in the {488} blood-vessels of the stomach will be described in connection with the morbid anatomy of gastric ulcer.

[Footnote 35: From Berlin are reported the largest number of cases of gastric ulcer associated with diseases of the circulatory apparatus; thus, by Berthold 170 out of 294 cases, and by Steiner 71 out of 110 cases of ulcer. Endocarditis and arterial atheroma (present in one-third of Berthold's cases of ulcer) form the largest proportion of these diseases.]

Chronic passive congestion of the stomach in cases of cirrhosis of the liver, direct injury to the mucous membrane of the stomach by parasites in trichinosis, hemorrhage into the coats of the stomach in scorbutus and in dementia paralytica, persistent vomiting in pregnancy, and anæmia induced by prolonged lactation, have each been assigned as causes in a few cases of gastric ulcer, but they are not associated with gastric ulcer in enough cases to make their causative influence at all certain.

Galliard assigns diabetes mellitus as the cause in one case of gastric ulcer.[36]

[Footnote 36: _Clin. méd. de la Pitié_, Paris, 1877, p. 77.]

Rokitansky attributed some cases of gastric ulcer to intermittent fever.

Those who believe in the inflammatory origin of ulcer of the stomach think that chronic gastritis is an important predisposing cause.

The abuse of alcohol is admitted as an indirect cause of gastric ulcer by the majority of writers.

Lastly, burns of the skin, which are an important factor in the etiology of duodenal ulcers, have been followed only in a very few instances by ulcer of the stomach.

The direct causes of ulcer of the stomach, concerning which our positive knowledge is very limited, will be considered under the pathenogenesis of the disease.

SYMPTOMATOLOGY.--The following classes of cases of gastric ulcer may be distinguished:

First: Gastric ulcer may give rise to no symptoms pointing to its existence, and be found accidentally at the autopsy when death has occurred from some other disease. This latent course is most frequent with gastric ulcers complicating chronic wasting diseases, such as tuberculosis, and with gastric ulcers in elderly people.

Second: 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.

Third: Gastric ulcer may occasion only the symptoms of chronic gastritis, or of functional dyspepsia, or of purely nervous gastralgia, so that its diagnosis is impossible. In this class of cases after a time characteristic symptoms may develop. Here, too, sudden death may occur from hemorrhage or from perforation.

Fourth: In typical cases characteristic symptoms are present, so that the diagnosis can be made more or less positively. These symptoms are pain, and hemorrhage from the stomach, associated usually with vomiting and disturbances of digestion.

The different symptoms of gastric ulcer will now be described.

Of all the symptoms, pain is the most constant and is often the first to attract attention. It is absent throughout the disease only in exceptional cases. In different cases, and often in the same case at different times, the pain varies in its quality, its intensity, its situation, its duration, and in other characteristics.

The kind of pain which is most characteristic of gastric ulcer is severe {489} paroxysmal pain strictly localized in a circumscribed spot in the epigastrium, coming on soon after eating, and disappearing as soon as the stomach is relieved of its contents.

More common, although less characteristic, than the strictly localized pain are paroxysms of severe pain, usually called cardialgic[37] or gastralgic, diffused over the epigastrium and often spreading into the surrounding regions. This is like the neuralgic pain of nervous gastralgia, which is not infrequent in chlorotic and hysterical females. The pain may be so intense as to induce syncope, or even convulsions, in very sensitive patients.

[Footnote 37: There is much confusion as to the meaning of the term cardialgia. With most English and American writers it signifies heartburn, while continental writers understand by cardialgia the severe paroxysms of epigastric pain which we more frequently call gastralgia.]

The strictly localized pain is probably caused by direct irritation confined to the nerves in the floor of the ulcer. In the diffuse gastralgic attacks the irritation radiates or is reflected to the neighboring nerves, and sometimes to those at a distance.

In most cases of gastric ulcer localized epigastric pain and diffuse gastralgic paroxysms are combined.

The painful sense of oppression and fulness in the epigastrium which is felt in many cases of gastric ulcer after eating is simply a dyspeptic symptom, and is probably referable to an associated chronic catarrhal gastritis. This dyspeptic pain is of little value in diagnosis.

Most subjects of gastric ulcer feel in the intervals between the paroxysms a more or less constant dull pain, or it may be only a sense of uneasiness, in the epigastrium. When sharp epigastric pain is felt continuously, it is usually inferred that the ulcer has extended to the peritoneum and has caused a circumscribed peritonitis, but this inference is not altogether trustworthy.

The quality of the pain caused by gastric ulcer is described variously as burning, gnawing, boring, less frequently as lancinating.

More important than the quality is the situation of the pain. The situation of the localized pain is usually at or a little below the ensiform cartilage. It may, however, be felt as low as the umbilicus or it may deviate to the hypochondria. In addition to pain in the epigastrium (point épigastrique), Cruveilhier called attention to the frequent presence of pain in the dorsal region (point rachidien). The dorsal pain, which may be more severe than the epigastric, is sometimes interscapular, and sometimes corresponds to the lowest dorsal or to the upper lumbar vertebræ. It is usually a little to the left of the spine. The pain is often described as extending from the pit of the stomach through to the back.

According to Brinton, the situation of the localized pain gives a clue to the situation of the ulcer, pain near the left border of the ensiform cartilage indicating ulcer near the cardiac orifice, pain in the median line and to the right of this indicating ulcer of the pyloric region, and pain in the left hypochondrium indicating ulcer of the fundus. It does not often happen that the pain remains so sharply localized as to make possible this diagnosis, even if the situation of the pain were a safe guide.

Of the various circumstances which influence the severity of the pain in gastric ulcer, the most important is the effect of food. Pain usually {490} comes on within a few minutes to half an hour after taking food, although it may appear immediately after ingestion or be delayed for an hour or more. The pain continues until the stomach is relieved of its contents by vomiting or by their passage into the duodenum. It is unsafe to attempt to diagnose the position of the ulcer merely from the length of time which elapses between the ingestion of food and the onset of pain. It has sometimes been noticed that as improvement progresses pain comes on later and later after eating. As might naturally be expected, coarse, indigestible, imperfectly-masticated food, sour and spirituous liquids, and hot substances are more irritating than bland articles of diet. In some exceptional cases the ingestion of even coarse food, instead of aggravating, has had no effect upon the pain, or at least for the time being has even relieved it.

External pressure usually increases the intensity of the pain of gastric ulcer; in rare instances pressure relieves the pain.

Rest and the recumbent posture as a rule alleviate the pain of ulcer of the stomach. The position of the patient may affect the severity of the pain in a more striking way. It may naturally be supposed that that posture is most agreeable which removes from the ulcer the weight of the food during digestion. Hence it was claimed by Osborne[38] that the site of the ulcer could often be inferred from the effect of posture on the pain. Thus, relief in the prone position would indicate ulcer of the posterior wall; relief in the supine position, ulcer of the anterior wall; relief on the left or on the right side, ulcer of the pyloric or of the cardiac region respectively. As ulcer of the posterior wall is the most frequent, relief should be obtained oftener by bending forward or by lying on the face than in the supine position. Experience has shown that the influence of posture on the pain is not a safe guide in diagnosing the location of the ulcer.

[Footnote 38: Jonathan Osborne, _Dublin Journal of Medical Science_, vol. xxvii. p. 357, 1845.]

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. The tender spot can sometimes be covered by the finger's end. In searching for a point of tenderness it should be remembered that many persons are very sensitive to pressure in the epigastrium, and also that pressure is not without danger to those who are the subjects of gastric ulcer. Not only may pressure induce paroxysms of pain, but it may cause even rupture of the ulcerated walls of the stomach.[39] Hence pressure should be cautiously employed and should not be often repeated.

[Footnote 39: Dalton has reported a case in which perforation of a gastric ulcer occurred while the patient was subjected in a water-cure establishment to kneading of the abdomen to relieve his flatulence (_Trans. N.Y. Path. Soc._, vol. i. p. 263.)]