aggravated by an unregulated diet. Sometimes nearly everything which is
taken into the stomach is vomited. The vomiting of mucus or of a {492}
thin fluid unmixed with food is indicative only of chronic catarrhal
gastritis. Alimentary vomiting, which is more indicative of gastric
ulcer, usually occurs not immediately after taking food, but at the
acme of a gastralgic attack caused by the food. Soon after the stomach
is emptied by one or more acts of vomiting the pain is relieved. The
act of vomiting is usually easy, and at times is hardly more than
regurgitation of the food. Sometimes the patient experiences an
excessively sour taste from the vomit.
Vomiting exhausts the patient by withdrawing nutriment, and when
persistent may even cause death from inanition. But in some cases of
gastric ulcer, especially in women, the vomiting seems to be mainly a
nervous symptom, and even when long continued may be attended by little
or no loss of flesh. Evidently, more food is retained in these cases
than might be supposed.
There are two evident causes of vomiting in gastric ulcer--namely,
chronic catarrhal gastritis, which is a frequent complication, and
direct irritation of the nerves in the ulcer. Vomiting due to
dilatation of the stomach is oftener a sequel than an immediate symptom
of gastric ulcer.
For the diagnosis of gastric ulcer hemorrhage from the stomach is the
most important symptom.
The frequency of only the larger hemorrhages can be determined with any
degree of exactness. If the blood be effused in small quantity or
slowly, it may be discharged solely with the stools and escape
detection. Such slight hemorrhages doubtless occur in most cases of
gastric ulcer. It is probable that easily-recognized hemorrhages from
the stomach occur in about one-third of the cases of gastric ulcer.[43]
Hemorrhage is absent as a rule in the acute perforating ulcer of the
stomach.
[Footnote 43: In consequence of the uncertainty of the diagnosis in
cases of gastric ulcer which recover without hemorrhage, the estimates
of the frequency of this symptom have a very limited value, and will
vary with different observers according to their standard of diagnosis
of this disease. Lebert observed gastric hemorrhage in four-fifths of
his carefully-studied cases, and in three-fifths of his cases there was
profuse hæmatemesis. Brinton estimates that the larger hemorrhages
occur in about one-third of the cases. Müller found them in one-fourth
of the cases which he analyzed.]
In most cases hemorrhage from gastric ulcer is preceded by pain,
vomiting, and disturbances of digestion. Antecedent symptoms may,
however, be absent, or may be so obscure that no suspicion of ulcer
exists until the hemorrhage occurs.
The hemorrhage may be slight, moderate, or excessive in amount
(Cruveilhier). The larger hemorrhages are those which are most
distinctive of gastric ulcer.
The blood may be vomited, or voided with the stools, or retained in the
stomach and the intestines.
As has been remarked, when the hemorrhage is scanty all the blood may
escape by the bowel. Sometimes, although much less frequently, blood
effused in large quantity is entirely evacuated with the stools. After
hæmatemesis more or less blood is discharged by the bowel, sometimes
for several days after the vomiting of blood has ceased. Blood which
has traversed the whole length of the intestinal canal acquires a tarry
consistence and a black or brownish color in consequence of the
production of dark-brown hæmatin by the action of the digestive juices
{493} upon the hæmoglobin, and in consequence of the formation of black
sulphide of iron by the union of hydrogen sulphide in the lower part of
the intestine with the iron of the hæmatin. The passage of these black
viscid stools is called melæna. Inasmuch as we cannot presume gastric
hemorrhage to be absent simply because no blood has been vomited, it is
evidently important to examine the stools for blood when the diagnosis
of gastric ulcer is obscure, and also in cases of gastric ulcer where
there are symptoms of internal hemorrhage not accounted for by blood
vomited. It should be remembered that certain drugs, particularly iron
and bismuth, may blacken the feces.
In very exceptional cases of gastric ulcer the effusion of a large
volume of blood causes sudden death before any of the blood has been
vomited. The autopsy shows the stomach and more or less of the small
intestine distended with coagulated blood.
Hemorrhage from gastric ulcer is usually made manifest by the vomiting
of blood. The quantity of the vomited blood varies from mere traces to
several pounds. The color and the consistence of the blood depend upon
the quantity effused and the length of time that the blood has remained
in the stomach. Blood which has been acted upon by the gastric juice is
coagulated, has a grumous consistence, and acquires by the formation of
hæmatin out of hæmoglobin a dark-brown color, often compared to that of
coffee-grounds. Blood effused in small quantity is usually vomited only
with the food, and has usually the coffee-grounds appearance. The
patient's condition is not appreciably influenced by this slight loss
of blood. A little blood expelled after repeated acts of vomiting has
no diagnostic importance. Vomiting usually occurs soon after a large
gastric hemorrhage. It is the mechanical distension of the stomach
rather than any irritating quality of the blood which causes the
vomiting. Blood which is rejected immediately after a large gastric
hemorrhage is alkaline, fluid, and of an arterial (rarely of a venous)
hue. Often, however, even with large hemorrhages, the blood remains
sufficiently long in the stomach to be partly coagulated and to be
darkened in color. Ulcer more frequently than any other disease of the
stomach causes the vomiting of unaltered blood in large quantity. But
this kind of hæmatemesis is not peculiar to simple ulcer. It may occur
in other diseases, such as gastric cancer, and coffee-ground vomiting
may be associated with ulcer.
Copious hæmatemesis in cases of gastric ulcer appears usually without
premonition, or it may be preceded for a day or two by increased pain.
Its occurrence is somewhat more common during the digestion of food
than in the intervals, but there have been cases of ulcer where the
bleeding was favored by an empty stomach and was checked by the
distension of the organ with food. The free use of stimulants and
violent physical or mental exertion may excite hemorrhage. With the
onset of the hemorrhage the patient experiences a sense of warmth and
of oppression at the epigastrium, followed by faintness, nausea, and
the vomiting of a large quantity of blood. An attack of syncope often
causes, at least temporarily, cessation of the hemorrhage. But the
thrombus which closes the eroded vessel may easily be washed away, so
that the hemorrhage often recurs and continues at intervals for several
days, thereby greatly increasing the danger to the patient. Thus, the
tendency is for {494} the hemorrhage from gastric ulcer to appear in
phases or periods occupying several days.
A single hemorrhage is rarely so profuse as to cause immediate death.
More frequently the patient dies after successive hemorrhages. In the
majority of cases the hemorrhage is not immediately dangerous to life,
but is followed by symptoms of anæmia, more or less profound according
to the strength of the patient and the amount of blood lost.
Prostration and pallor follow the larger hemorrhages. Dizziness,
ringing in the ears, and dimness of vision appear when the patient
attempts to leave the recumbent posture. Thirst is often a marked
symptom. The pulse is feeble and more frequent than normal. There is
often a moderate elevation of temperature (anæmic fever) after profuse
hemorrhage. The urine is pale, abundant, and sometimes contains albumen
(Quincke). After a few days anæmic cardiac murmurs can often be heard.
Under favorable circumstances these symptoms of anæmia disappear in the
course of a few weeks.
The other symptoms of ulcer, particularly the pain, are sometimes
notably relieved, and may even disappear, after an abundant hemorrhage.
They usually, however, return sooner or later. After a variable
interval one attack of hæmatemesis is likely to be followed by others.
There is much diversity in different cases as regards the frequency of
these attacks and the character of the symptoms in the intervals. In a
few cases recovery follows a single attack of gastric hemorrhage; in
other cases the hemorrhage recurs frequently after intervals of only a
few days, weeks, or months; in still other cases hemorrhage recurs only
after long intervals, perhaps of years, although other symptoms of
ulcer continue. Sometimes the disappearance of symptoms indicates only
an apparent cure, and later the patient dies suddenly while in apparent
health by a profuse gastric hemorrhage. In the rare cases of this last
variety Cruveilhier has found sometimes that the ulcer has cicatrized
except just over the eroded blood-vessel.
The sources of the hemorrhage in gastric ulcer will be described in
connection with the morbid anatomy.
The symptoms of gastric indigestion are commonly, although not
constantly, present in gastric ulcer. They may constitute the sole
symptoms, in which case the diagnosis of the lesion is impossible. The
most important local symptoms of gastric dyspepsia are diminution, less
frequently perversion or increase, of the appetite; increased thirst;
during digestion, and sometimes independent of digestion, a feeling of
discomfort merely or of painful oppression, or even of sharp pain, in
the epigastrium; nausea; vomiting of undigested food, of mucus, and of
bile; regurgitation of thin fluids; often acid, sometimes neutral or
alkaline, flatulence, with belching of gas, and constipation. In many
cases of gastric ulcer the appetite is not disturbed, but the patient
refrains from eating on account of the pain caused by taking food.
Among the so-called sympathetic symptoms of dyspepsia are headache,
dizziness, depression of spirits, oppression in the chest, and
irregularity of the heart's action. Dyspepsia contributes its share to
the production of the anæmia and of the loss of flesh and strength
which are present in some degree in most cases of chronic gastric
ulcer.
{495} In many cases of acute perforating ulcer, as well as in some
cases of chronic ulcer, the symptoms are either absent or they are but
slightly marked. It has been demonstrated that in many cases of gastric
ulcer the resorptive power of the mucous membrane of the stomach is
unimpaired.[44]
[Footnote 44: This is shown by the experiments of Pentzoldt and Faber,
who determined the length of time which elapsed between swallowing
gelatin capsules containing iodide of potassium and the appearance of
the iodide in the saliva (_Berl. klin. Wochenschr._, No. 21, 1882).
Quetsch observed rapid absorption from the stomach in two cases of
gastric ulcer (_ibid._, 1884, No. 23). It is believed that also the
duration of the digestive process in the stomach is often within normal
limits in cases of gastric ulcer, although exact experiments upon this
point, as they require the use of the stomach-pump, have not been made
in this disease (Leube).]
The most common cause of dyspepsia in gastric ulcer is the chronic
catarrhal gastritis which usually accompanies this disease. It is
probable that the movements of the stomach may be seriously interfered
with by destruction of the muscular coat of the stomach when the ulcer
is of considerable size and is seated in the pyloric region. Adhesions
of the stomach to surrounding parts may likewise impair the normal
movements of the stomach. It is possible that ulcers, especially those
which are very painful, may cause reflex disturbance of the peristaltic
movements of the stomach and alterations in the quality or the quantity
of the gastric juice. The serious digestive disturbances which are
caused by distortions and dilatation of the stomach resulting from
cicatricial contraction of gastric ulcer are not considered in this
article.
Although Niemeyer emphasized the frequency in gastric ulcer of a
strikingly red tongue with smooth or furrowed surface, it does not
appear that any especial importance is to be attached to this or to any
other condition of the tongue as a symptom of the disease.
Increased flow of saliva is a rare symptom, which, when it occurs, is
usually associated with dyspepsia.
Constipation is the rule in gastric ulcer. The most important of the
various circumstances which combine to produce this condition is the
small amount of solid food taken and retained by the patient. The
restraint caused by gastric ulcer and gastric catarrh in the normal
movements of the stomach may diminish by reflex action the peristalsis
of the intestines (Traube and Radziejewski). The passage of large
quantities of blood along the intestinal canal is often associated with
colicky pains and diarrhoea.
Amenorrhoea is a symptom which was formerly thought to be
characteristic of gastric ulcer, although there was much discussion as
to whether it was the cause or the result of the ulcer. Amenorrhoea is
indeed common in the gastric ulcer of young women, but there is nothing
strange in this when one considers the frequency of amenorrhoea in
general, and its causation by various debilitating and depressing
influences such as are to be found in gastric ulcer. Notwithstanding a
few striking cases which have been recorded, it has not been
demonstrated that hemorrhages vicarious of menstruation take place from
gastric ulcer.
Gastric ulcer is not a febrile disease. Temporary elevation of
temperature may follow profuse gastrorrhagia and may attend various
complications, of which the most important are gastritis and
peritonitis. It has been recently claimed by Peter that the
surface-temperature of the {496} epigastrium is elevated in gastric
ulcer, but the observations upon this point are as yet too few for any
positive conclusions.[45]
[Footnote 45: According to Peter, the normal surface-temperature of the
epigastrium is from 95½° to 96° F. (35.3° to 35.5° C.), while in
gastric ulcer the temperature may equal or even exceed by one or two
degrees the axillary temperature. It is said to register the highest
during attacks of pain and of vomiting and after hemorrhages (_Gaz. des
Hôpitaux_, June 23 and 30, 1883). See also Beaurieux (_Essai sur la
Pseudo-gastralgie, etc._, Thèse, Paris, 1879).]
The general health of the patient remains sometimes surprisingly good,
even in cases of gastric ulcer with symptoms sufficiently marked to
establish the diagnosis. But in most cases of chronic gastric ulcer the
general nutrition sooner or later becomes impaired. This cannot well be
otherwise when dyspepsia, vomiting, paroxysms of severe pain, and
hemorrhage are present, separately or in combination, for any great
length of time. In proportion to the severity and the continuance of
these symptoms the patient becomes pale, weak, and emaciated. The face,
thin, anxious, of a grayish-white color, and marked with sharp lines of
suffering, presents the appearance which the older writers called
facies abdominalis, to which even so recent an author as Brinton
attaches exaggerated diagnostic importance. A little cachectic dropsy
may appear about the ankles. While it is true that the general
nutrition is less rapidly, less continuously, and, as a rule, less
deeply, impaired in gastric ulcer than in gastric cancer, nevertheless
sometimes a cachexia develops in the former which is not to be
distinguished from that of cancer. Litten[46] relates a case of gastric
ulcer which simulated for a time pernicious anæmia. In this case the
profound anæmia could not be explained by vomiting, hemorrhage, or
other symptoms of ulcer.
[Footnote 46: _Berliner klin. Wochenschrift_, Dec. 6, 1880.]
Beyond determining the existence of a fixed point of epigastric
tenderness, physical examination of the region of the stomach is
usually only of negative value in the diagnosis of gastric ulcer. In
some cases of ulcer of the stomach epigastric pulsation is very marked,
and sometimes most marked during gastralgic attacks. In these cases
there may be dilatation of the aorta from paralysis of vaso-motor
nerves analogous to the dilatation of the carotid and temporal arteries
in certain forms of migraine (Rosenbach). When the diagnosis lies
between gastric ulcer and gastric cancer, the presence of epigastric
tumor is justly considered to weigh against ulcer; but it is important
to know that tumor may be associated with ulcer. Thickening of the
tissues around old ulcers and the presence of adhesions may give rise
to a tumor. A thickened portion of omentum which had become adherent
over an old gastric ulcer produced a tumor which led to a mistake in
the diagnosis.[47] Rosenbach[48] calls attention to the occasional
production of false tumors by spasm of the muscular coat of the stomach
around a gastric ulcer. These tumors disappear spontaneously or yield
to the artificial distension of the stomach by Seidlitz powders--a
procedure which one would not venture to adopt if he suspected gastric
ulcer. Fenwick thinks that in some cases of gastric ulcer fixation of
the stomach by adhesions can be made out by physical exploration.
[Footnote 47: A. Beer, _Wiener med. Wochenschrift_, No. 26, 1857.]
[Footnote 48: _Deutsche med. Wochenschrift_, 1882, p. 22.]
The gravest symptom which can occur in gastric ulcer is the perforation
of the ulcer into the general peritoneal cavity.
{497} Only rough estimates can be made of the frequency of this
symptom. These estimates vary from 2 to 25 per cent. From the data
which I have collected I infer that perforation into the general
peritoneal cavity occurs in about 6½ per cent. of all cases of gastric
ulcer.[49]
[Footnote 49: Miquel (_Schmidt's Jahrb._, Bd. 125, p. 65, 1864) reckons
the frequency of perforation at 2 per cent. Brinton's estimate of 13½
per cent. is the one generally accepted. He found 69 cases of
perforation in 257 open ulcers collected from various sources. He
doubles the number of open ulcers, as he considers cicatrized ulcers
twice as frequent as the open. The statistics of some of the authors to
whom he refers should not be used in this computation, either because
they do not give accurately the number of cases of perforation, or
because they include under perforation all cases of ulcer which have
penetrated all of the coats of the stomach, whereas of course only
perforation into the general peritoneal cavity should be here included.
Valuable and laborious as are Brinton's researches, his statistics upon
this point, as upon many others, are inaccurate.
In 249 fatal cases of open ulcer taken from the statistics of Jaksch,
Dittrich, Willigk, Wrany (_Prager Vierteljahr._, vols. xcv. and xcix.),
Eppinger, Starcke, Chambers, Moore, and Lebert (_loc. cit._), I find 50
cases of perforation into the peritoneal cavity. This makes the
percentage of perforations 6½ if the open ulcers be multiplied by 3,
the number of cicatrized ulcers being taken as three times that of open
ulcers (p. 482). This method of computation, which is adopted by
Brinton, is defective on account of the uncertainty as to the proper
proportion between cicatrized and open ulcers.
Lebert observed 9 cases of perforation with fatal peritonitis in his
252 cases studied clinically. He places the frequency of perforation
with peritonitis at 3 to 5 per cent., which corresponds to Engel's
estimate of 5½ per cent. (_Prager Vierteljahrschrift_, 1853, ii.).]
As regards sex, perforation occurs two to three times oftener in the
female than in the male. This increased liability is referable mainly
to the preponderance of the acute perforating ulcer in young women.[50]
[Footnote 50: The liability to perforation in females seems to be not
only absolutely, but also relatively, to the number of ulcers greater
than in males, although, on the contrary, Brinton holds that the excess
of perforations in females is not greater than that of ulcers. Berthold
found perforation in 3.1 per cent. of the cases of gastric ulcer in
males, and in 9.7 per cent. of the cases in females (_op. cit._, p.
28).]
In the female the liability to perforation of gastric ulcer is greatest
between fourteen and thirty years of age. In the male there seems to be
no greater liability to perforation at one age than at another.[51]
[Footnote 51: Of 139 cases of perforated ulcer in females, Brinton
found that four-fifths occurred before the age of thirty-five. He
calculates the average age at which perforation occurs in the female as
twenty-seven, and in the male as forty-two. He thinks that the average
liability to perforation in both sexes decreases as life advances,
although he holds that the liability to ulcer itself constantly
increases with age.]
As will be explained in considering the morbid anatomy, ulcers of the
anterior wall of the stomach perforate more frequently than those in
other situations.
As regards the symptoms which may have preceded perforation three
groups of cases can be distinguished:
In the first there has been no complaint of gastric disturbance. In the
midst of apparent health perforation may occur and cause death within a
few hours. This is the ulcère foudroyante of French writers. It is met
with more commonly in chlorotic young women than in any other class.
In the second group of cases, which are more frequent, gastric symptoms
have been present for a longer or shorter time, but have been so
ambiguous that the diagnosis of gastric ulcer is not clear until
perforation occurs. Then, unfortunately, the diagnosis is of little
more than retrospective interest.
In the third group of cases perforation takes place in the course of
gastric ulcer, the existence of which has been made evident by
characteristic symptoms, such as localized pain and profuse hemorrhage.
{498} The immediate cause of perforation of gastric ulcer is often some
agency which produces mechanical tension of the stomach, such as
distension of the organ with food or with gas, vomiting, straining at
stool, coughing, sneezing, pressure on the epigastrium, violent
exertion, and jolting of the body.