----------+--------+---------
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.)]
In some cases of gastric ulcer pain is felt in regions at a distance
from the stomach. The most frequent of these so-called radiation
neuralgias are--neuralgia of the lower intercostal spaces, combined
sometimes with {491} hyperæsthesia or with analgesia of the affected
region, pain in the right shoulder (perhaps due to adhesions between
the stomach and the liver or the diaphragm), pain in the left shoulder,
and pain in the loins. In a case of ulcer reported by Traube
terminating in perforation the sole complaint, besides loss of appetite
and retching, had been difficulty in breathing and oppression in the
chest. These symptoms, which may be combined with gastralgic paroxysms,
are referred by Traube to transference of the irritation from the
gastric to the pulmonary filaments of the pneumogastric nerve.[40]
[Footnote 40: _Deutsche Klinik_, 1861, No. 10. These symptoms evidently
correspond to the vagus neurosis described by Rosenbach, in which, as
the result of reflex irritation of the pneumogastric nerve in the
stomach, occur difficulty in breathing, oppression in the chest,
palpitation, arhythmical action of the heart, and epigastric pulsation
(_Deutsche med. Wochenschr._, 1879, Nos. 42, 43).]
Sometimes the pain of gastric ulcer intermits for days or even weeks.
When the intermission is of considerable duration it is probable that
cicatrization has been in progress. It should, however, be remembered
that gastralgic attacks may continue even after cicatrization of the
ulcer is completed, probably in consequence of compression of
nerve-filaments by the cicatricial tissue. Once in a while the pain
exhibits a marked periodicity in its appearance. Thus in a case of
ulcer ending fatally from hemorrhage the pain came on but once a day,
and that with considerable regularity at the same hour. In this case
the pain was relieved by taking food.[41] The pain of gastric ulcer may
be temporarily relieved by hemorrhage from the stomach, and perhaps by
division of the irritated nerve by sloughing (Habershon).
[Footnote 41: Case reported by Peacock, _Rep. of Proceedings of London
Path. Soc._, vol. i. p. 253, 1847.]
The causes of the pain of gastric ulcer are not far to seek. Foremost
is the irritation of nerve-filaments exposed by the ulcerative process.
The irritation may be by mechanical, chemical, or thermic agencies.
With our present imperfect knowledge it is profitless to discuss
whether the pneumogastric or the sympathetic nerves are the chief
carriers of the abnormal sensations.[42] In the next place, we may have
radiation of the irritation from these nerves to neighboring and even
to remote nerves. Furthermore, the extension of the inflammation to the
peritoneum and the surrounding parts, and the formation of adhesions,
are additional factors in some cases in causing pain. Finally, the
great differences in susceptibility to pain manifested by different
individuals is to be borne in mind.
[Footnote 42: Leven, without sufficient reason, distinguishes two kinds
of gastralgic attacks--the one having its point of departure in the
pneumogastric, the other in the sympathetic nerve; in the former the
pain is associated with dyspnoea and palpitation of the heart; in the
latter the pain is deeper, and is accompanied by vaso-motor (?)
troubles on one side of the body.]
Next to pain, vomiting is the most frequent symptom of gastric ulcer.
There is, however, little which is characteristic of ulcer in this
symptom, unless the vomited material contains blood. In some cases of
gastric ulcer vomiting is the most marked and most distressing symptom
of the disease. It may, however, be absent during the whole course of
gastric ulcer.