the stomach into the peritoneal cavity at the moment of perforation, an
agonizing pain is felt, beginning in the epigastrium and extending
rapidly over the abdomen, which becomes very sensitive to pressure. The
pain sometimes radiates to the shoulders. Symptoms of collapse often
appear immediately or they may develop gradually. The pulse becomes
small, rapid, and feeble. The face is pale, anxious, and drawn (facies
hippocratica). The surface of the body, particularly of the
extremities, is cold and covered with clammy sweat. The internal
temperature may be subnormal, normal, or elevated; after the
development of peritonitis it is usually, but not always, elevated.
Consciousness is usually retained to the last, although the patient is
apathetic. Vomiting is sometimes absent--a circumstance which may be of
value in diagnosis, and which Traube attributes to the readiness with
which the contents of the stomach can be discharged through the
abnormal opening into the peritoneal cavity. There is usually
constipation. The respirations become more and more frequent and costal
in type. Thirst is often urgent. Suppression of urine is not an
uncommon symptom, although there may be frequent and painful attempts
at micturition. Albumen and casts may appear temporarily in the urine.
Retraction of one testicle, like that in renal colic, has been observed
(Blomfield). The patient usually lies on his back with the knees drawn
up. The abdomen is often at first hard and retracted from spasmodic
contraction of the abdominal muscles, but later it usually becomes
tympanitic, sometimes to an extreme degree. The presence of tympanitic
resonance replacing hepatic dulness in front is usually considered the
most important physical sign of gas free in the peritoneal cavity, but
this sign is equivocal. On the one hand, the presence of adhesions over
the anterior surface of the liver may prevent the gas from getting
between the liver and the diaphragm;[52] and on the other hand, in
cases of meteorism coils of intestine may make their way between the
liver and the diaphragm, or the liver may be pushed upward and
backward, so that its anterior surface becomes superior and the hepatic
dulness in front disappears. Physical examination may reveal in the
dependent parts of the peritoneal cavity an accumulation of fluid
partly escaped from the stomach and partly an inflammatory exudate.[53]
For humane reasons one should not submit the patient to the pain of
movement in order to elicit a succussion sound or to determine change
in the position of the fluid upon changing the position of the
patient.[54] There is sometimes relief from pain for some hours before
death.
[Footnote 52: Even without these adhesions liver dulness may persist
after perforation of the stomach, as in a case of Nothnägel's in which
for twenty-four hours after a large perforation from gastric ulcer the
abdomen was retracted and hepatic dulness was well marked (Garmise,
_Ulcus Ventriculi cum peritonitide perforativa_, Inaug. Diss., Jena,
1879).]
[Footnote 53: In a case of peritonitis resulting from perforation of a
latent ulcer of the duodenum, Concato found in the acid fluid withdrawn
by aspiration from the peritoneal cavity Sarcina ventriculi (_Giorn.
internaz. delle Scienze Med._, 1879, No. 9).]
[Footnote 54: Other symptoms which have been thought to be diagnostic
of pneumo-peritoneum in {499} distinction from meteorism, but the value
of which is doubtful, are these: In pneumo-peritoneum the respiratory
murmur can be heard by auscultation over the entire abdomen, while in
meteorism it does not extend beyond the region of the stomach
(Cantani); in the former amphoric sounds synchronous with respiration
can sometimes be heard over the abdomen (Larghi); borborygmi are heard,
if at all, distantly and feebly; the percussion note of gas free over
the liver is different from that of tympanitic intestine (Traube); the
percussion note is of the same character over the whole anterior wall
of the abdomen; the epigastric region is more elastic to the feel than
in tympanites; the distension of the abdomen is more uniform than in
tympanites; and coils of distended intestine, sometimes showing
peristaltic movement, cannot be seen or felt as in some cases of
meteorism (Howitz).]
There are exceptional cases of perforation in which some of the most
important of the enumerated symptoms, such as pain, tenderness of the
abdomen on pressure, tympanites, and the symptoms of collapse, are
absent.
Death sometimes occurs from shock within six or eight hours after
perforation. More frequently life is prolonged from eighteen to
thirty-six hours, it may be even for three or four days, and, very
rarely, even longer.[55] When life is prolonged more than twelve hours
an acute diffuse peritonitis is usually but not always developed.
[Footnote 55: In the _Descriptive Catalogue of the Warren Anatomical
Museum_, by Dr. J. B. S. Jackson, p. 448, Boston, 1870, is described a
case of gastric ulcer in which, so far as can be judged by the symptoms
and the post-mortem appearances, the patient lived nineteen days after
perforation.]
The contents of the stomach, instead of being diffused throughout the
peritoneal cavity, may be confined by a rapidly-developed circumscribed
peritonitis to a space near the stomach, or perforation may occur into
a space previously shut off from the general peritoneal sac by
adhesions. In this way circumscribed peritoneal abscesses form in the
neighborhood of the stomach. Diffuse peritonitis may be caused either
by an extension of the inflammation or by the rupture of these
abscesses into the general peritoneal cavity. The cases of
circumscribed peritonitis following perforation of gastric ulcer, with
escape of the contents of the stomach, although more protracted than
those in which the whole peritoneal surface is at once involved,
generally terminate fatally sooner or later. The symptoms are often
very obscure.
The most interesting of these peritoneal abscesses is the variety to
which Leyden has given the name of pyo-pneumothorax subphrenicus (false
pneumothorax of Cossy), the diagnostic features of which first were
recognized by G. W. Barlow and Wilks in 1845.[56] Here there is a
cavity, circumscribed by adhesions, just beneath the diaphragm,
containing pus and gas and communicating with either the stomach or the
intestine. By the encroachment of this cavity upon the thoracic space
the symptoms and signs of pyo-pneumothorax are simulated. Barlow and
Leyden have diagnosed during life this affection when resulting from
perforated gastric ulcer. The points in diagnosis from genuine
pyo-pneumothorax are the presence of respiratory murmur from the
clavicle to the third rib, the extension of the respiratory murmur
downward by deep inspiration, history of preceding gastric disturbance
with circumscribed peritonitis, absence of preceding pulmonary
symptoms, rapid variations in the limits of dulness with changes in the
position of the body, absence or only slight evidence of increased
intrapleural pressure (such as bulging of the {500} thorax as a whole,
and of the intercostal spaces), displacement of the heart, displacement
of the liver downward, and, if necessary, the determination by means of
a manometer that the pressure in the abscess cavity rises during
inspiration and falls during expiration, the reverse being true in
genuine pneumothorax.[57]
[Footnote 56: Barlow and Wilks, _London Med. Gazette_, May, 1845;
Leyden, _Zeitschr. f. klin. Med._, i. Heft 2; Cossy, _Arch. gén. de
Méd._, Nov., 1879; Tillmanns, _Arch. f. klin. Chirurg._, Bd. 27, p.
103, 1881.]
[Footnote 57: Schreiber has shown that this last diagnostic point,
which was given by Leyden, is not without exceptions, for the pressure
in the peritoneal cavity may sink during inspiration and rise during
expiration (as in the pleural cavity), especially when the diaphragm
takes little or no part in respiration ("Ueber Pleural- und
Peritonealdruck," _Deutsches Arch. f. klin. Med._, July 31, 1883).]
Through the medium of subphrenic abscess, or directly through adhesions
between the stomach and the diaphragm, gastric ulcer may perforate into
one of the pleural cavities (generally the left) and cause empyema or
pneumo-pyothorax. Adhesions may form between the diaphragm and the
pulmonary pleura, so that the ulcer perforates directly into the lung;
in which case pulmonary gangrene or pulmonary abscess is usually
developed. The diagnosis of the perforation into the lung has been made
by recognizing a sour odor and sour reaction of the expectoration, and
by finding in the sputum particles of food derived from the stomach.
Sudden death from suffocation has followed perforation of the stomach
into the lung.[58]
[Footnote 58: Tillmanns (_loc. cit._) has collected 12 cases of
communication between the stomach and the thoracic cavity from
perforation of gastric ulcer; all proved fatal. In Sturges's case of
recovery from pneumothorax supposed to be produced by perforation of a
gastric ulcer the diagnosis of the cause of the pneumothorax was very
doubtful (_The Lancet_, Feb. 7, 1874).]
Perforation of gastric ulcer into the transverse colon has been
followed by the vomiting of formed feces and by the passage of
undigested food by the bowel (Abercrombie). Enemata may be vomited, so
that, as suggested by Murchison, the introduction of colored enemata
may aid in the diagnosis.
Gastro-cutaneous fistulæ are among the rare results of perforation of
gastric ulcer. In these cases food, sometimes only in liquid form,
escapes through the fistula.
The opening of gastric ulcer into the pericardium is one of the rare
causes of pneumo-pericardium.
Other varieties of perforation which are of pathological rather than of
clinical interest will be mentioned under the morbid anatomy of gastric
ulcer.
COURSE.--Few diseases are more variable in their course and duration
than is simple gastric ulcer. It is customary to distinguish between
acute and chronic forms of gastric ulcer, but this is a distinction
which cannot be sharply drawn. Those cases are called acute in which,
with absence or short duration of antecedent gastric symptoms,
perforation or gastrorrhagia suddenly causes death. But in some of
these cases the thickened and indurated margins of the ulcer found at
the autopsy show that the disease has been of much longer duration than
the clinical history would indicate. Still, there is reason to believe
that within the course of a few days ulcers may form and perforate all
of the coats of the stomach.
In the great majority of cases of gastric ulcer the tendency is to
assume a chronic course, so that the often-used term chronic gastric
ulcer is generally applicable.
{501} The great diversity of the symptoms in different cases makes it
impossible to give a generally applicable description of the course of
gastric ulcer. It is, however, useful to designate the main clinical
forms of the disease. Thus we may distinguish--
1. Latent ulcers, with entire absence of symptoms, and revealed as open
ulcers or as cicatrices at the autopsy.
2. Acute perforating ulcers. With or without a period of brief gastric
disturbance perforation occurs and causes speedy death.
3. Acute hemorrhagic form of gastric ulcer. After a latent or a brief
course of the ulcer profuse gastrorrhagia occurs, which may terminate
fatally or may be followed by the symptoms of chronic ulcer.
4. Gastralgic-dyspeptic form. In this, which is the most common form of
gastric ulcer gastralgia, dyspepsia and vomiting are the symptoms.
Sometimes one of the symptoms predominates greatly over the others, so
that Lebert distinguishes separately a gastralgic, a dyspeptic, and a
vomitive variety. Gastralgia is the most frequent symptom.
5. Chronic hemorrhagic form. Gastrorrhagia is a marked symptom, and
occurs usually in combination with the symptoms just mentioned.
6. Cachectic form. This usually corresponds only to the final stage of
one of the preceding forms, but the cachexia may develop so rapidly and
become so marked that the course of the disease closely resembles that
of gastric cancer.
7. Recurrent form. In this the symptoms of gastric ulcer disappear, and
then follow intervals, often of considerable duration, in which there
is apparent cure, but the symptoms return, especially after some
indiscretion in the mode of living. This intermittent course may
continue for many years. In these cases it is probable either that
fresh ulcers form or that the cicatrix of an old ulcer becomes
ulcerated.
8. Stenotic form. By the formation of cicatricial tissue in and around
the ulcer the pyloric orifice becomes obstructed and the symptoms of
dilatation of the stomach develop.
DURATION.--The average duration of gastric ulcer may be said to be from
three to five years, but this estimate is not of great value, on
account of the absence of any regularity in the course and duration of
the disease. In cases of very protracted duration, such as forty years
in a case of Habershon's and thirty-five in one of Brinton's, it is
uncertain whether the symptoms are referable to the persistence of one
ulcer or to the formation of new ulcers, or to sequels resulting from
cicatrization.
In 110 cases (44 fatal) analyzed by Lebert[59] the course was latent
until the occurrence of perforation or of profuse hemorrhage in 15 per
cent., the duration was less than one year in 18 per cent., from one to
six years in 46½ per cent., from six to twenty years in 18 per cent.,
from twenty to thirty-five years in 2½ per cent.
[Footnote 59: _Op. cit._, p. 235.]
TERMINATIONS.--In the majority of cases gastric ulcer terminates in
recovery. The recovery is often complete. Various gastric disturbances
may, however, follow the cicatrization of gastric ulcer, especially if
the ulcer was large and of long duration. These sequential disturbances
are due to the contraction of the cicatrix, to adhesions between the
stomach and surrounding parts, to deformity of the stomach, and
especially to dilatation of the stomach by cicatricial stenosis of the
pylorus. Hence, {502} gastralgia, dyspepsia, and vomiting may continue
after the ulcer has healed, so that anatomical cure of the ulcer is not
always recovery in the clinical sense. Relapses may occur after
recovery, as those who have once had gastric ulcer are more prone to
the disease than are others. Not infrequently the patient recovers so
far as to be able to attend to the active duties of life, but to avoid
renewed attacks he is always obliged to be very careful as regards his
mode of living.
How often gastric ulcer ends in death it is impossible to say. It is
certain that Brinton under-estimates the number of recoveries when he
computes that only one-half of the ulcers cicatrize. Lebert reckons the
mortality from gastric ulcer as 10 per cent., which appears to be too
low an estimate. Perhaps 15 per cent. would be a more correct estimate
of the mortality.
The causes of death are perforation, hemorrhage, exhaustion, and
complicating diseases.
About 6½ per cent. of the cases of gastric ulcer terminate fatally by
perforation into the peritoneal cavity. Although this estimate can be
considered only approximative, there is little doubt but that the much
larger percentages given by most writers are excessive, and are
referable to the undue frequency with which cases of perforation of
gastric ulcer have been published. Such cases naturally make a strong
impression upon the observer, and are more likely to be published than
those which terminate in other ways.
Death from hemorrhage occurs probably in from 3 to 5 per cent. of the
cases of gastric ulcer.[60] In many more cases hemorrhage is an
indirect cause of death by inducing anæmia. Unlike perforation, fatal
hemorrhage from gastric ulcer is more common in males than in
females--more common after than before forty years of age. The average
age at which fatal hemorrhage occurs is given by Brinton as forty-three
and a half years both for males and females.
[Footnote 60: In 270 fatal cases of open ulcer from the statistics of
Jaksch, Dittrich, Eppinger, Starcke, Chambers, Habershon, Moore, and
Lebert, I find 27 deaths by hemorrhage. Reckoning three cicatrices to
one ulcer, this would give a percentage of 3-1/3.]
In a considerable proportion of the fatal cases exhaustion is the cause
of death. According to Lebert, death from exhaustion occurs in about 4
per cent. of the cases of gastric ulcer. The causes of exhaustion are
the pain, hemorrhage, dyspepsia, and vomiting which constitute the
leading symptoms of the disease.
Finally, death may be due to some of the complications or sequels of
gastric ulcer.
COMPLICATIONS.--Some of the complications of gastric ulcer are directly
referable to the ulcer, others are only remotely related to it, and
others are merely accidental.
Pylephlebitis is among the most important of the complications directly
referable to the ulcer. This pylephlebitis is usually of the infectious
variety, and leads to abscesses in the liver, sometimes to abscesses in
the spleen and other organs.
As has already been mentioned, chronic catarrhal gastritis stands in
close relationship to gastric ulcer. Chronic peritonitis is a rare
complication of gastric ulcer (Moore, Vierordt). Chronic interstitial
gastritis, with contraction of the stomach and thickening of its walls,
was {503} associated with ulcer in a case under my observation. In a
case of ulcer under the care of Owen Rees[61] this condition of the
stomach was associated with chronic deforming peritonitis (thickening,
induration, and contraction of the peritoneum) and ascites, so that the
symptoms during life and the gross appearances after death resembled
cancerous diseases of the peritoneum. Simple ulcer and cancer may occur
together in the same stomach, or cancer may develop in an ulcer or its
cicatrix. Glässer reports a case of phlegmonous gastritis with gastric
ulcer.[62] Extension of inflammation to the pleura without perforation
of the diaphragm sometimes occurs. Fatty degeneration of the heart may
be the result of profound anæmia induced by gastric ulcer.[63] Embolic
pneumonia and broncho-pneumonia are occasional complications. A
moderate degree of cachectic dropsy is not very infrequent in the late
stages of gastric ulcer.
[Footnote 61: _Med. Times and Gaz._, April 24, 1869.]
[Footnote 62: _Berlin. klin. Wochenschrift_, 1883, No. 51.]
[Footnote 63: Shattuck, _Boston Med. and Surg. Journ._, June, 1880,
vol. ciii.]
Other complications, such as pulmonary tuberculosis, valvular disease
of the heart, general atheroma of the arteries, cirrhosis of the liver,
syphilis, chronic Bright's disease, waxy degenerations, and malaria,
have been considered under the Etiology, and some of them will be
referred to again in connection with the Pathology, of gastric ulcer.
In most instances when ulcer is associated with these diseases the
ulcer is secondary.
SEQUELÆ.--The most important sequelæ of gastric ulcer are changes in
the form of the stomach in consequence of adhesions and in consequence
of the formation and contraction of cicatrices. These lesions are most
conveniently described under the Morbid Anatomy. The symptoms of the
most important of these sequels--namely, stenosis of the pylorus with
dilatation of the stomach--will be described in another article.
MORBID ANATOMY.--As regards number, simple ulcer of the stomach is
usually single, but occasionally two or more ulcers are present. It is
not uncommon to meet in the same stomach open ulcers and the scars of
healed ulcers. According to Brinton, multiple ulcers are found in about
one-fifth of the cases. In one case O'Rorke found six ulcers on the
anterior wall of the stomach.[64] Berthold mentions a case in which
thirty-four ulcers were found in the same stomach.[65]
[Footnote 64: _Trans. of the New York Path. Soc._, vol. i. p. 241.
Wollmann mentions the occurrence of over eight simple ulcers in the
same stomach (_Virchow und Hirsch's Jahresb._, 1868, Bd. ii. p. 126).]
[Footnote 65: _Op. cit._, p. 21. It is expressly stated that these were
not hemorrhagic erosions, but deep corrosive ulcers.]
The usual position of simple gastric ulcer is the posterior wall of the
pyloric portion of the stomach on or near the lesser curvature. Ulcers
of the anterior wall are rare, but they carry a special danger from
their liability to perforate without protective adhesions. The least
frequent seats of ulcer are the greater curvature and the fundus.
The table on page 504 gives the situation of 793 ulcers recorded in
hospital statistics:[66] {504}
Lesser curvature 288 (36.3 per cent.)
Posterior wall 235 (29.6 " )
Pylorus 95 (12 " )
Anterior wall 69 ( 8.7 " )
Cardia 50 ( 6.3 " )
Fundus 29 ( 3.7 " )
Greater curvature 27 ( 3.4 " )
From this table it is apparent that ulcers occupy the lesser curvature,
the posterior wall, and the pyloric region three and a half times more
frequently than they do the remaining larger segment of the stomach.
[Footnote 66: These statistics are collected from the previously-cited
works of Rokitansky, Jaksch, Wrany, Eppinger, Chambers, Habershon,
Steiner, Wollmann, Berthold, Starcke, Lebert, and Moore. They represent
566 cases. So far as noted, most of the ulcers on the posterior wall
were nearer to the lesser curvature than to the greater; those on the
lesser curvature extended more frequently to the posterior than to the
anterior wall. Although not apparent from the table, most of the ulcers
of the lesser curvature and of the posterior wall were in the pyloric
region. So far as possible, cicatrices were excluded. Pylorus and
cardia in the table indicate on or near those parts.]
Occasionally two ulcers are seated directly opposite to each other, the
one on the anterior, the other on the posterior, wall of the stomach.
The most plausible explanation of this is that the ulcers are caused by
a simultaneous affection of corresponding branches which are given off
symmetrically from the same arterial trunk as it runs along one of the
curvatures of the stomach (Virchow).[67]
[Footnote 67: A. Beer, "Aus dem path. Anatom. Curse et. Prof. R.
Virchow, etc.," _Wiener med. Wochenschr._, Nos. 26, 27, 1857.]
The ordinary size of the ulcer varies from a half inch to two inches in
diameter. The ulcer may be very minute, as in two cases reported by
Murchison, in each of which a pore-like hole was found leading into a
perforated artery from which fatal hemorrhage had occurred.[68] On the
other hand, the ulcer may attain an enormous size, extending sometimes
from the cardiac to the pyloric orifice and measuring five or six
inches in diameter.[69]
[Footnote 68: Murchison, _Trans. of the Path. Soc._, vol. xxi. p. 162,
London, 1870.]
[Footnote 69: In one of Cruveilhier's cases the ulcer was 6½ inches
long and 3-1/3 inches wide. Law describes an ulcer measuring 6 inches
by 3 inches (_Dublin Hosp. Gaz._, ii. p. 51).]
The ulcer is usually round or oval in shape. The outline of the ulcer
may become irregular by unequal extension in the periphery, or by the
coalescence of two or more ulcers, or by partial cicatrization. Simple
ulcers, especially when seated near the lesser curvature, have a
tendency to extend transversely to the long axis of the stomach, thus
following the course of the blood-vessels. By this mode of extension,
or more frequently by the coalescence of several ulcers, are formed
girdle ulcers, which more or less completely surround the circumference
of the stomach, oftener in the pyloric region than elsewhere.
As the ulcer extends in depth it often destroys each successive layer
of the stomach in less extent than the preceding one, so that the form
of the ulcer is conical or funnel-shaped, with a terrace-like
appearance in its sloping edges. The apex of the truncated cone, which
is directed toward the peritoneum, is often not directly opposite to
the centre of the base or superior surface which occupies the mucous
membrane, so that one side of the cone may be vertical and the other
sloping. In the half of the stomach nearer the lesser curvature the
cone slopes upward, and in the lower half of the stomach it slopes
downward. The usual explanation of its conical shape is that the ulcer
exactly corresponds to the territory supplied by an artery with its
branches. Virchow finds an explanation for the oblique direction of the
funnel in the arrangement of the arteries of the stomach. These, coming
from different sources, run along the curvatures of the stomach, and
there give off symmetrically branches which run obliquely toward the
mucous membrane, so that one of these {505} branches with its
distributive twigs (arterial tree) would supply a part shaped like an
oblique funnel. One of the chief supports of the theory which refers
the origin of simple gastric ulcer to an arrest of the circulation is
this correspondence in shape of the ulcer to the area of distribution
of the branches of the arteries supplying the stomach.
All ulcers do not present the conical form and terraced edges which
have been described. These appearances are far from constant in fresh
ulcers, and they are usually absent in those of long duration.