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]