greater and the lesser curvature and five inches to the right of the
cardiac orifice, was a round ulcer half an inch in diameter, with
smooth, sharp edges. In the floor of the ulcer, which extended to the
muscular coat, was a small perforated aneurism of a branch of the
coronary artery. In addition there were small, granular kidneys,
hypertrophied heart without valvular lesion, and chronic interstitial
splenitis. Small and medium-sized arteries in the kidneys, spleen,
heart, lymphatic glands, and stomach were the seat of a typical
endarteritis obliterans, resulting in some instances in complete
closure of the lumen of the vessel. The patient, who was attended by
Sassdorf, was seized during the night with vomiting of blood, which
continued at intervals for twenty-four hours until his death. The
patient was a man about fifty years of age, without previous history of
gastric ulcer or of syphilis.]
In one case Powell[90] found a small aneurism of the coronary artery in
an ulcer of the lesser curvature of the stomach. Hauser[91] found an
aneurismal dilatation of an atheromatous and thrombosed arterial twig
in the floor of a recent ulcer. In my case of obliterating endarteritis
just referred to there was a small aneurism in the floor of the ulcer.
These miliary aneurisms in the floor of gastric ulcers seem to be
analogous to those in the walls of phthisical cavities. Miliary
aneurisms occur in the stomach independently of gastric ulcer, and may
give rise to fatal hæmatemesis, as in four cases reported by
Galliard.[92]
[Footnote 90: _Trans. of the Path. Soc. of London_, vol. xxix.]
[Footnote 91: _Das chronische Magengeschwür, etc._, p. 11, Leipzig,
1883.]
[Footnote 92: _L'Union méd._, Feb. 26, 1884. Curtis reported a case of
fatal hæmatemesis from an aneurism, not larger than a small pea, seated
in the cicatrix of an old ulcer (_Med. Annals of Albany_, Aug., 1880).]
Gastric ulcer is occasionally associated with waxy degeneration of the
arteries of the stomach.[93] In most of these cases there were multiple
shallow ulcers. Hæmatemesis is generally absent in gastric ulcer
resulting from waxy disease of the gastric blood-vessels. As is well
known, the amyloid material itself resists the action of the gastric
juice.
[Footnote 93: Hauser (_op. cit._) alludes to a case in which, with waxy
degeneration of the stomach, over one hundred small ulcers were found
in different stages of development, from hemorrhagic infiltrations to
complete ulcers. Cases belonging here are reported by Fehr, _Ueber die
Amyloide Degeneration_, Inaug. Diss., Bern, 1866; Merkel, _Wiener med.
Presse_, 1869; Edinger, _Deutsches Arch. f. klin. Med._, Bd. 29, p.
568; Marchiafava, _Atti del Accad. Med. di Roma_, iii. p. 114; and
Mattei, _Deutsche med. Zeitung_, July 5, 1883.]
Finally, varicosities of the veins of the stomach have been once in a
{512} while found with gastric ulcer. In a large number, probably in
the majority, of cases of gastric ulcer no changes have been found in
the blood-vessels of the stomach except such as were manifestly
secondary to the ulcer.
That gastric ulcer is frequently complicated with chronic catarrhal
gastritis has been repeatedly mentioned in the course of this article.
PATHOGENESIS.--Without doubt, the most obscure chapter in the history
of gastric ulcer is that relating to its origin and to its persistence.
Notwithstanding a vast amount of investigation and of discussion,
unanimity of opinion upon these subjects has not been reached. In view
of this uncertainty it is desirable in this article to do little more
than to summarize the leading theories as to the development of gastric
ulcer.
Most observers are agreed that the digestive action of the gastric
juice has some share in the development and the progress of the ulcer,
but as to the first cause of the ulcer there are various hypotheses.
The earliest theory refers the origin of simple ulcer of the stomach to
inflammation. Since its advocacy by Abercrombie and by Cruveilhier this
theory has always had its adherents, particularly among French writers.
It is true that in stomachs which are the seat of simple ulcer
evidences of inflammation can often be found both in the neighborhood
of the ulcer and elsewhere. In recent times the supporters of the
inflammatory origin of gastric ulcer lay especial stress upon the
presence of foci of infiltration with small round cells in the mucous
and the submucous coats.[94] But it is difficult to explain by the
inflammatory theory the usually solitary occurrence and the funnel-like
shape of gastric ulcer.
[Footnote 94: Laveran, _Arch. de Phys. norm. et path._, 1876, p. 443;
Galliard, _Essai sur la Pathogenie de l'Ulcère simple de l'Estomac_,
Thèse de Paris, 1882; Colombo, _Annali univ. di Med._, 1877.]
The theory that gastric ulcer is of neurotic origin has also been
advocated. Some refer the origin to the secretion of an excessively
acid gastric juice under abnormal nervous influence (Günsburg), others
to vaso-motor disturbances, and others to trophic disturbances. Wilks
and Moxon compare simple gastric ulcer to ulcers of the cornea
resulting from paralysis of the trigeminus. The neurotic theory of the
origin of gastric ulcer is altogether speculative and has never gained
wide acceptance.[95]
[Footnote 95: The first to attribute gastric ulcer to nervous influence
was Siebert (_Casper's Wochenschr. f. d. Heilk._, 1842, No. 29, and
_Deutsche Klinik_, 1852). Cf. also Günsburg, _Arch. f. phys. Heilk._,
xi., 1852; Wilks and Moxon, _Lect. on Path. Anat._, 2d ed., Philada.,
1875, p. 386. Osborne in 1845 attributed gastric ulcer to the secretion
of an abnormally acid juice by a circular group of the gastric glands
(_Dublin Journ. of Med. Sci._, vol. xxvii. p. 357).]
The view which has met with the greatest favor is that which attributes
the origin of gastric ulcer to impairment or arrest of the circulation
in a circumscribed part of the wall of the stomach, and to a subsequent
solution by the gastric juice of the part thus affected. Rokitansky
first suggested this view by assigning hemorrhagic necrosis of the
mucous membrane as the first step in the formation of the ulcer; but it
is Virchow who has most fully developed this view and has given it its
main support. The first cause of gastric ulcer, according to Virchow,
is a hemorrhagic infiltration of the coats of the stomach induced by
local disturbances in the circulation. The part the nutrition of which
is thus impaired or destroyed is dissolved by the gastric juice.
{513} The affections of the gastric blood-vessels to which importance
has been attached are (_a_) embolism and thrombosis; (_b_) diseases of
the coats of the vessels, as atheroma, obliterating endarteritis, fatty
degeneration, amyloid degeneration, and aneurismal and varicose
dilatations; (_c_) compression of the veins by spasm of the muscular
coats of the stomach in vomiting and in gastralgia; (_d_) passive
congestion of the stomach by obstruction in the portal circulation.
In support of this view are urged the following facts: First, it has
been proven by the experiments of Pavy that parts of the gastric wall
from which the circulation has been shut off undergo digestion; second,
hemorrhagic infarctions have been observed in the stomach, both alone
(Von Recklinghausen, Hedenius) and associated with gastric ulcer (Key,
Rindfleisch); third, the hemorrhagic infiltration in the walls of
recently-formed ulcers indicates a hemorrhagic origin; fourth, the
funnel-like shape of the ulcer resembles the funnel-shaped area of
distribution of an artery; fifth, gastric ulcers have been
experimentally produced by injecting emboli into the gastric arteries
(Panum, Cohnheim).[96]
[Footnote 96: Pavy, _Philosoph. Trans._, 1763, p. 161; V.
Recklinghausen, _Virchow's Archiv_, Bd. 30, p. 368; Axel Key, _Virchow
und Hirsch's Jahresb._, 1870, Bd. ii. p. 155; Rindfleisch, _Lehrb. d.
path. Gewebelehre_, 5te Aufl., Leipzig, 1878; Panum, _Virchow's
Archiv_, Bd. 25, p. 491; Cohnheim, _Vorles. über allgem. Path._, Bd.
ii. p. 53, Berlin, 1880.]
The main objections to this view are the infrequency with which the
assumed changes in the blood-vessels have been demonstrated, the common
occurrence of gastric ulcer at an age earlier than that at which
diseases of the blood-vessels are usually present, and the absence of
gastric ulcer in the vast majority of cases of heart disease, with
widespread embolism of different organs of the body. To meet some of
these objections, Klebs[97] presupposes in many cases a local spasmodic
contraction of the gastric arteries, causing temporary interruption of
the circulation; Rindfleisch and Axel Key, compression of the gastric
veins, with resulting hemorrhagic infiltration by spasm of the muscular
coat of the stomach in vomiting and in gastralgic attacks. But these
are pure hypotheses.
[Footnote 97: _Handb. d. path. Anat._, Bd. i. p. 185, Berlin, 1869.]
What is actually known concerning diseases of the gastric blood-vessels
in ulcer of the stomach has already been stated under the morbid
anatomy. From this it may be inferred that the origin of gastric ulcer
in diseased conditions of the blood-vessels has been established only
for a comparatively small group of cases.
Böttcher's[98] view that gastric ulcer is of mycotic origin, being
produced by micrococci, has thus far met with no confirmation.
[Footnote 98: _Dorpater med. Zeitschr._, Bd. v. p. 148, 1874.]
There are those who hold an eclectic view concerning the origin of
gastric ulcer. They believe that ulcer of the stomach may be produced
by a variety of causes, such as inflammation, circulatory disturbances,
irritating substances introduced into the stomach, traumatism, etc. The
peculiarities of the ulcer are due not to any specific cause, but to
the solvent action of the gastric juice, which keeps clean the floor
and the sides of the ulcer. These clean edges and floor, which are
incident to all ulcers of the stomach, justify no conclusion as to the
cause of the ulcer. Engel[99] over thirty years ago held that gastric
ulcer might {514} originate in various ways--that there was nothing
specific about it. Brinton was also of similar opinion.
[Footnote 99: _Prager Vierteljahrschr._, 1853, ii.]
Gastric ulcers have been produced experimentally in animals in a
variety of ways, but these experiments have not materially elucidated
the pathenogenesis of ulcer in man. Schiff by lesions of various parts
of the brain, and later Ebstein by lesions of many parts of the central
and peripheral nervous system by injections of strychnine--in fact,
apparently by any means which greatly increased the
blood-pressure--produced in the stomachs of animals ecchymoses and
ulcers. Müller by ligation of the portal vein, Pavy by ligation of
arteries supplying the stomach, likewise produced hemorrhages and
ulcers. The results of Pavy could not be confirmed by Roth and others.
Panum, and afterward Cohnheim, produced gastric ulcers by introducing
multiple emboli into the gastric arteries. Daettwyler under Quincke's
direction caused, in dogs with gastric fistulæ, ulcers of the stomach
by various mechanical, chemical, and thermic irritants applied to the
inner surface of the stomach. Aufrecht observed hemorrhages and ulcers
in the stomachs of rabbits after subcutaneous injections of
cantharidin.[100]
[Footnote 100: Schiff, _De vi motorea baseos encephali_, 1845, p. 41;
Ebstein, _Arch f. exp. Path. u. Pharm._, 1874, p. 183; Müller, _Das
corrosive Geschwür im Magen, etc._, p. 273, Erlangen, 1860; Pavy,
_Guy's Hosp. Rep._, vol. xiii., 1867; Roth, _Virchow's Archiv_, Bd. 45,
p. 300, 1869; Panum, _loc. cit._; Cohnheim, _op. cit._; Daettwyler,
Quincke, _Deutsche med. Wochenschr._, 1882, p. 79; Aufrecht,
_Centralbl. f. d. med. Wiss._, 1882, No. 31.]
The most interesting of these experiments are those of Cohnheim and of
Daettwyler, who demonstrated that in one essential point all of these
experimental ulcers differ from simple gastric ulcer in man--namely, in
the readiness with which they heal. To this ready healing the gastric
juice, much as it has been accused of causing the spread of gastric
ulcers in man, seems to have offered no obstacle. We know that similar
losses of substance in the human stomach heal equally well.[101] Hence
it has been maintained throughout this article that it is unjustifiable
to regard all of the scars found in the human stomach as the result of
simple ulcer.
[Footnote 101: Portions of the mucous membrane of the stomach,
sometimes with some of the submucous coat, have been in several
instances removed with the stomach-pump, but thus far no bad effects
have followed.]
It appears from these experiments, as well as from observations on man,
that it is more difficult to explain why ulcers in the stomach do not
heal than it is to understand how they may be produced. From this point
of view the observation of Daettwyler is of interest, that in dogs
which had been rendered anæmic by repeated abstraction of blood not
only did slighter irritants suffice to produce ulcers of the stomach,
but the ulcers healed much more slowly. Practically, it is important to
learn what are the obstacles to the repair of gastric ulcers, but our
positive knowledge of these is slight. It is probable that such
obstacles are to be found in constitutional causes, such as anæmia and
chlorosis, in abnormal states of the blood-vessels around the ulcer, in
catarrhal affections of the stomach, in irritating articles of food, in
improper modes of living, and in increased acidity of the gastric
juice.
DIAGNOSIS.--In many cases the diagnosis of gastric ulcer can be made
with reasonable certainty; in other cases the diagnosis amounts only to
a suspicion more or less strong, and in still other cases the diagnosis
is impossible.
{515} The diagnostic symptoms are epigastric pain, vomiting, and
gastric hemorrhage. The characteristics of the pain which aid in the
diagnosis are its fixation in one spot in the epigastric region, its
onset soon after eating, its dependence upon the quantity and the
quality of the food, its relief upon the complete expulsion of the
contents of the stomach, its alleviation by changes in posture, and its
increase by pressure. That the pain of gastric ulcer has not always
these characteristics has been mentioned under the Symptomatology.
Vomiting without hæmatemesis is the least characteristic of these
symptoms. It aids in the diagnosis when it occurs after eating at the
acme of a gastralgic attack and is followed by the relief of pain.
Hæmatemesis is the most valuable symptom in diagnosis. The more profuse
the hemorrhage and the younger the individual in whom it occurs, the
greater is the probability of gastric ulcer. It should not be forgotten
that the blood is sometimes discharged solely by the stools.
The simultaneous occurrence of all these symptoms renders the diagnosis
of gastric ulcer easy.[102] In all cases in which gastrorrhagia is
absent the diagnosis is uncertain; but gastric ulcer should be
suspected whenever the ingestion of food is followed persistently by
severe epigastric pain and other causes of the pain have not been
positively determined. When the course of the ulcer is latent and when
the symptoms are only those of dyspepsia, the diagnosis is of course
impossible. In cases previously obscure a diagnosis in extremis is
sometimes made possible by the occurrence of perforation of the
stomach.
[Footnote 102: That even under the most favorable circumstances
absolute certainty in the diagnosis of gastric ulcer is not reached is
illustrated by a case reported with great precision and fulness by
Banti: A female servant, twenty-one years old, had every symptom of
gastric ulcer, including repeated hæmatemesis and the characteristic
epigastric pain. She was nourished by enemata. She died from an
ulcerative proctitis four days after the last hemorrhage from the
stomach. Only a slight catarrhal inflammation of the stomach was found
at the autopsy, without trace of ulcer, cicatrix, or ecchymosis ("Di un
Caso d'Ematemesi," _La Sperimentale_, Feb., 1880, p. 168). It would
seem as if there must have been an ulcer which had healed so completely
as to leave no recognizable scar.]
In making a differential diagnosis of gastric ulcer, as well as of any
disease, reliance should be placed more upon the whole complexion of
the case than upon any fancied pathognomonic symptoms.
The diseases which are most difficult to distinguish from gastric ulcer
are nervous affections of the stomach. Like gastric ulcer, most of
these are more common in women than in men, and especially in chlorotic
women with disordered menstruation and with hysterical manifestations.
These nervous affections are manifold and their leading characteristics
are not yet well defined. The most important of these affections are
nervous dyspepsia, nervous vomiting, nervous gastralgia, and gastric
crises.
The leading symptoms of nervous dyspepsia, as described by Leube,[103]
are the ordinary symptoms of dyspepsia without evidence of anatomical
alteration of the stomach, and with the proof by washing out the
stomach that the process of digestion is not delayed. Nervous dyspepsia
is often associated with other nervous affections, and is caused
especially by influences which depress the nervous system. Epigastric
pain, and especially tenderness on pressure over the stomach, are not
common symptoms in nervous dyspepsia. Only those rare cases of gastric
ulcer in which hemorrhage from the stomach is absent and epigastric
pain is not prominent {516} are likely to be confounded with nervous
dyspepsia. In such cases, although the diagnosis of nervous dyspepsia
is by far the most probable, the patient may be confined to bed and put
upon the strict regimen for gastric ulcer. If in the course of ten days
or two weeks essential relief is not obtained, ulcer may be excluded,
and the proper treatment for nervous dyspepsia with tonics and
electricity may be adopted (Leube).
[Footnote 103: _Deutches Arch. f. klin. Med._, Dec. 18, 1878.]
In nervous vomiting, which occurs most frequently in hysterical women,
other nervous manifestations are present; there are usually less
epigastric pain and tenderness than in ulcer; the nutrition is better
preserved; the vomiting is less dependent upon the ingestion of food
and more dependent on mental states; and there are longer intervals of
relief than in ulcer. Still, it may be necessary to resort to the
therapeutical diagnosis as in the preceding instance.
In this connection attention may be called to the importance of
searching for reflex causes of vomiting, such as beginning phthisis,
ovarian or uterine disease, cerebral disease, and pregnancy; also to
certain cases of chronic Bright's disease in which gastric disturbances
are the main symptoms.
Of all the nervous affections of the stomach, nervous gastralgia is the
one which presents the greatest similarity to gastric ulcer. Its
diagnosis from gastric ulcer is often extremely difficult, and may be
impossible. The points of difference given in the following table may
aid in the diagnosis:
NERVOUS GASTRALGIA. | ULCER OF THE STOMACH.
|
1. Pain is often independent of | 1. Pain is mostly dependent upon
the ingestion of food, and may | taking food, and its intensity
even be relieved by taking food.| varies with the quality and the
| quantity of the food.
|
2. Pain is often relieved by | 2. Pain is increased by pressure.
firm pressure. |
|
3. Pain is rarely relieved by | 3. Pain after a meal is usually
vomiting. | relieved by vomiting.
|
4. Fixed point of tenderness and| 4. These are often present.
of subjective pain not generally|
present. |
|
5. Relief is usually complete | 5. Some pain often continues
between the paroxysms. | between the paroxysms.
|
6. Nutrition frequently well | 6. Nutrition usually affected.
preserved. |
|
7. Usually associated with other| 7. Neuropathic states less
nervous affections, such as | constantly present.
hysteria, neuralgia in other |
places, ovarian tenderness, etc.|
|
8. Benefited less by regulation | 8. Benefited not by electricity,
of diet than by electricity and | but by regulation of diet.
tonic treatment. |
|
9. Not followed by dilatation of| 9. Dilatation of stomach may
stomach. | supervene.
According to Peter,[104] the surface temperature of the epigastrium is
elevated in gastric ulcer, but not in nervous gastralgia.
[Footnote 104: _Gaz. des Hôp._, June, 1883.]
Probably not a single one of the points mentioned in the table is
without exception. Nervous gastralgia may be associated with gastric
ulcer, and if the ulcer is otherwise latent the diagnosis is manifestly
impossible. A diagnosis of purely functional gastralgia has been
repeatedly overthrown by the occurrence of profuse hæmatemesis. There
is no symptom {517} upon which it is more unsatisfactory to base a
diagnosis than upon pain. There is much difference among physicians as
regards the frequency with which they diagnose gastric ulcer in the
class of cases here described. It is probable that the error is
oftenest a too frequent diagnosis of gastric ulcer than the reverse.
Nevertheless, when there is doubt it is well to submit the patient for
a time to the proper treatment for gastric ulcer.
In several instances gastric crises have been mistaken for gastric
ulcer. These gastric or gastralgic crises, as they are called by
Charcot, by whom they have been best described,[105] are most
frequently associated with locomotor ataxia, but they may occur in
connection with other diseases of the spinal cord (subacute myelitis,
general spinal paralysis, and disseminated sclerosis), and an analogous
affection has been described by Leyden[106] as an independent disease
under the name of periodical vomiting with severe gastralgic attacks.
Gastric crises have been most carefully studied as a symptom in the
prodromic stage of locomotor ataxia. The distinguishing features of
these crises are the sudden onset and the atrocious severity of the
gastric pain; the simultaneous occurrence of almost incessant vomiting;
the habitual continuance of the paroxysms, almost without remission,
for two or three days; the normal performance of the gastric functions
in the intervals between the paroxysms, which may be months apart; the
frequent association with other prodromic symptoms of locomotor ataxia,
such as ocular disorders and fulgurating pains in the extremities; and
the development after a time of ataxia. Leyden has observed during the
attacks retraction of the abdomen without tension of the abdominal
walls, obstinate constipation, scanty, dark-colored urine, even anuria
for twenty-four hours, and increased frequency of the pulse (also noted
by Charcot). Vulpian[107] mentions a case in which there was vomiting
of dark-colored blood, and in which naturally the diagnosis of gastric
ulcer had been made. In the autopsies of Leyden and of Charcot no
lesions of the stomach have been found.
[Footnote 105: _Leç. sur les Maladies du Syst. nerveux_, t. ii. p. 32,
Paris, 1877.]
[Footnote 106: _Zeitschr. f. klin. Med._, iv. p. 605, 1882.]
[Footnote 107: _Maladies du Syst. nerveux_, p. 273, Paris, 1879.]
The differential diagnosis of gastric ulcer from gastric cancer will be
considered in the article on GASTRIC CANCER.
It has already been said that a part of the symptoms of gastric ulcer
are due to an associated chronic catarrhal gastritis. Usually other
symptoms are present which render possible the diagnosis of the ulcer.
There is usually some apparent external or internal cause of chronic
catarrhal gastritis, whereas the etiology of ulcer is obscure; in
chronic gastritis gastralgic paroxysms and the peculiar fixed
epigastric pain of gastric ulcer are usually absent; in chronic
gastritis profuse hæmatemesis is a rare occurrence; and in gastritis
the relief obtained by rest and proper regulation of the diet, although
manifest, is usually less immediate and striking than in most cases of
gastric ulcer.
The passage of gall-stones is usually sufficiently distinguished from
gastric ulcer by the sudden onset and the sudden termination of the
pain, by the situation of the pain to the right of the median line, by
the complete relief in the intervals between the attacks, by the
occurrence of jaundice, by the recognition sometimes of enlargement of
the liver and of the gall-bladder, and by the detection of gall-stones
in the feces.