Part 1

Transcriber Note

Text emphasis denoted as _Italics_.

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Cleveland Medical Gazette

_VOL. I._ _FEBRUARY, 1886._ _No. 4._ ----------------------------------------------------------------------

ORIGINAL LECTURES.

ULCER OF THE STOMACH.

A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA.

[Translated for the Cleveland Medical Gazette by Dr. C. Rosenwasser].

Gentlemen! The disease which we intend to study to-day is one, the traces of which are found much oftener at post-mortems than the disease itself in the clinic. A great many cases are overlooked and improperly diagnosed for reasons which I shall state hereafter.

It has been called by various names. Round ulcer, perforating ulcer, chronic ulcer, corroding ulcer and simple ulcer are only different designations for one and the same condition. I prefer to call it _peptic ulcer_, as it is always the result of self-digestion of a part of the walls of the stomach, but is not always round, nor perforating, nor chronic, nor corroded; nor is it always simple, several ulcers having occasionally been found in one and the same stomach.

Pathologists have not yet come to a positive decision on the _modus operandi_ of its origin, but several conditions are mentioned as necessary for its development.

1. The self-digestion of a part of the stomach by the gastric juice.

2. Disturbances of the circulation of the blood in the walls of the stomach.

3. The alkalinity of the blood circulating in the walls of the stomach prevents the digestion of the mucous membrane. If this action on the walls of the stomach is prevented in any way, the development of an ulcer is aided. This clause has been accepted until recently, when it has been rendered somewhat doubtful by the results of certain experiments.

The first clause is sustained by the fact that the peptic ulcer is only found in those parts which are brought into direct contact with the gastric juice. It is further proven by the softening of the stomach so frequently found at post-mortem. But as long as the circulation of the blood in the walls of the stomach is normal, ulcers do not form. The formation of an ulcer in the stomach presupposes a local disturbance of the circulation. It is usual to find thrombi and diseases of the bloodvessels in cases where ulcers of the stomach occur. For this reason the latter is more common in anaemic persons where the circulation is retarded and the bloodvessels frequently subject to fatty degeneration.

Virchow regards embolism of a small vessel as the origin of ulcer of the stomach. Cohnheim disproved this beyond doubt by showing that there is an abundant circulation in the walls of the stomach by which the parts affected are again quickly supplied with blood. Klebs takes for granted a spasmodic contraction of single bloodvessels as the cause of the retardation of the circulation, while Rindfleich attributes it to the poor anastomotic connection of the gastric veins. He calls attention to the frequent coincidence of ulcer and hemorrhagic infarct in the walls of the stomach. Cohnheim injected chromate of lead into the gastric branch of the splenic artery in animals, and when he succeeded in cutting off the arterial supply of the mucous and submucous layers _only_, he found as a result large ulcers with sharp, well-defined margins and a circular base. If the animals were examined in the second week after the experiment, they showed several small ulcers in place of the larger one. In the third week the ulcers were found to have healed. From these experiments you can see that the gastric ulcer has a natural tendency to heal when not interfered with. By experiments such as these it has been proven beyond doubt that disturbances of circulation of a small part of the stomach may lead to ulcer. But the causes of these disturbances, and the reasons why some ulcers do not heal, are still disputed questions.

Pavy claims that the alkalinity of the blood prevents the gastric juice from acting on the walls of the stomach. When he introduced acids into the stomach and allowed the circulation of the blood to continue, no ulcers resulted; if he impeded the circulation, the stomach was digested by its acid contents. Samelson instituted experiments to test the statement of Pavy. He introduced large quantities of various acids into the stomach of his animals without observing ulceration as a result; he also neutralized the blood by the injection of weakened acids into the bloodvessels, but no ulceration followed. But he did not impede the gastric circulation in his experiments, while Pavy did, hence the difference in their results. Clinical experience, however, favors Pavy's views. We can prevent the further progress of the gastric ulcer by the use of alkalies, while acids only favor its growth. These questions still need additional research before they are definitely solved.

Gastric ulcer may occur in any part of the digestive tract which is exposed to the action of the gastric juice; hence it is found in the lower part of the œsophagus, any part of the stomach and the upper part of the duodenum. It is found most frequently in the pyloric end of the stomach, because this part is most frequently subjected to mechanical irritation and to the action of the gastric juice.

The shape of the ulcer is usually conical or terraced, its diameter being largest in the mucous membrane and smallest at its base, in the deeper structures.

The gastric ulcer must be very common. In about five per cent of all cadavers we find ulcers in the stomach or else scars as traces of former ulceration. Ulcer of the stomach is frequently passed over without recognition, because most physicians do not decide upon this diagnosis, unless hæmatemesis occurs. Gastric hemorrhage, however, is not necessarily a concomitant feature of every gastric ulcer, and the hemorrhage may occur without vomiting, the blood being either digested and absorbed or passing on into the bowel and causing dark stools. Thus occasionally the only symptom of hemorrhage of the stomach is the appearance of darker stools, a symptom of doubtful value when taken alone, but of some importance when in connection with others.

A few years ago an elderly lady was admitted into the hospital on account of severe pain in the stomach and the appearance of dark stools. While in the hospital vomiting of blood set in, continuing three days, and then the patient died. At the post-mortem we found that an ulcer of the stomach had burrowed through the diaphragm and pericardium into the wall of the left ventricle, perforating finally with a small opening into the left ventricle. I can only explain the length of the time between perforation and death (three days) by assuming that part of the gastric fistula leading through the walls of the heart was firmly closed during systole, and only allowed a small quantity of blood to ooze through during each diastole.

_Symptomatology._ If you were to rely upon the occurrence of gastric hemorrhage in making your diagnosis, a great many blunders would necessarily occur, as this symptom is present in but one quarter of all the cases. I can give you an exact picture of the symptoms from experience on myself, having repeatedly been a sufferer from gastric ulcer and having studied every phase of the question carefully upon myself, frequently experimenting to get at various truths.

One of the most important and characteristic symptoms is the _localized pain or soreness_ which is felt in a small, well defined area, and either originates or is increased by chemical or mechanical irritation. This spot always was sensitive both to warm and cold food. Salty food, alcoholic or sour articles brought on pain. I could feel when the food passed the spot. It was always more sensitive about an hour or two after a meal, when the process of digestion was most active. My ulcer was on the anterior wall of the stomach, so that I could greatly ease the pain after meals by lying upon my back, while lying upon the abdomen greatly aggravated it, as the food then came in contact with the ulcer. I was a student yet when first suffering from this trouble, and was treated by one of our prominent professors for heart disease. He even gave me a certificate stating that I was suffering from beginning hypertrophy of the left ventricle. I was not improving under this treatment, and was taken one day with violent pain in the stomach, followed by vomiting of a large quantity of blood. Now the state of things was cleared up, and under the proper treatment (for ulcer of the stomach) I soon regained my health. I remained well for a long time, but in the course of the last twenty years have passed through several relapses. One of these, I distinctly remember, occurred while I was making a tour through the Alps. I had walked quite a distance that day and being very thirsty drank three glasses of water in quick succession. I immediately felt a pain in the stomach, and could distinctly feel how one of the old scars was again rent asunder.

During these repeated attacks I found that the painful sensation was really divisible into three distinct periods, that of constant increase, during which the ulcer is developing and extending, that of remaining at one height, and that of gradual decrease during the period of healing. I could distinctly tell from these various changes how my ulcer was getting along.

Two different kinds of pain are felt, the one constant and the other occasional. The _constant pain_ is usually present where the ulcer has extended deeper into the tissues or when the surrounding tissues are implicated. This pain is increased during digestion or when pressure is made on the parts from without. The _occasional pains_ are either of a dyspeptic type, caused by the catarrh which usually accompanies the ulcer, or of a cardialgic (neuralgic) type, the result of irritation of the exposed nerve-endings with the ulcer. These cardialgias are acute attacks of very severe, excruciating pain, which occur during or between the periods of digestion and are felt in the epigastrium and back mostly, but sometimes radiate over the entire abdomen, into the chest and even into the limbs. These attacks differ in no respect from those occurring in some diseases of the gall bladder, kidneys, peritoneum or uterus, and are consequently not characteristic of gastric ulcer. The dyspeptic pain partakes more of the character of feeling of fullness, a sense of oppression in the epigastrium, heartburn, etc., such sensations as occur in catarrh of the stomach and are felt during digestion.

_The characteristic pain in ulcer of the stomach is a localized feeling of soreness._ It is not always prominent. Chemical or mechanical irritation of the ulcer brings it on, or if already present, aggravates it. Especially acids, both mineral and vegetable, have this effect, while alkalies allay it. This pain only occurs during the process of digestion, when the food or gastric juice comes in contact with the ulcer, or when the stomach is distended with gas, and tension exerted on the tender spot. During the periods when the stomach is at rest it does not occur.

_Vomiting_ occurs in about three-fourths of all cases of gastric ulcer; vomiting of blood, however, only in about a quarter of all the cases. The latter occurs oftener where the ulcer is deep. In cases where the stomach is dilated, the amount vomited may be enormous, and contain food which has been retained in the dilated portion for several days.

As a result, also, of the accompanying catarrh of the stomach and the consequent diminished absorption of fluids, we find _constipation_ and _diminished secretion of urine_ in cases of ulcer of the stomach.

Perforation of the stomach is most frequently caused by gastric ulcer, and may be said to be a characteristic symptom; but it usually occurs too late to be made use of in the treatment of the ulcer. It is occasionally the first symptom which calls the patient's attention to the fact that his stomach is and has been seriously diseased. By the agglutinations of the base of the ulcer with neighboring organs, through inflammatory processes, perforation can take place into these organs. The most frequent forms of perforation under such conditions are those into the liver, spleen or pancreas, but cases have occurred where perforation into the colon or pleural cavity has taken place, or even into the pericardium, the heart or lungs. Some time ago I saw a case of gangrene of the lung, the result of the perforation of a gastric ulcer into this organ.

A few days ago I saw an interesting case, where an acute gastritis culminated in the vomiting of a large quantity of pus. The patient had been having high fever for a few days, with incessant vomiting and great tenderness in the epigastrium. Evidently an abscess had formed in the neighborhood of the stomach, and finally opened into this organ, with the given result.

_Diagnosis._ There are two classes of characteristic symptoms--those originating from the exposure of nerve-endings, and those caused by ulceration into bloodvessels. The first class includes the painful sensations, the characteristic soreness, which occurs in about four-fifths of all the cases; the second class, the hemorrhages, occurring in only one-fourth of all the cases. You can readily see why pain occurs more often than hemorrhage. Even a very superficial abrasion may expose nerve-endings to the irritation of the food, while it takes a deeper ulceration to lay open a larger bloodvessel. In order to make a positive diagnosis, these two symptoms should be present.

Vomiting of blood alone need not necessarily be caused by a gastric ulcer. There are a great many other conditions which may cause it. It should, however, put you on the guard, and can, in a great many cases, justify a diagnosis of probable ulcer of the stomach.

The localized pain occurs, according to my experience, only in cases of ulceration of the stomach; that is, in gastric or peptic ulcer and in cancer of this organ. In order to differentiate between these conditions, it becomes necessary to observe whether the patient is cachectic or emaciated or not, and whether a tumor can be felt in the region of the stomach. But even these symptoms can be deceptive, as an abnormal hardness or resistance--the result of perigastritic infiltration--may occur in cases of simple ulcer, making the diagnosis almost impossible. This is true especially in cases of ulcer of the pyloric regions, while ulcers of the anterior wall of the stomach are rarely accompanied by such infiltrations.

The pylorus is the most sensitive part of the stomach, and frequently the seat of pain, when no lesion can be detected post-mortem. The other parts of the stomach only become painful when attacked by ulcerative or other pathological processes. Another point worthy of consideration is that all forms of pain in the stomach are usually referred to the pyloric region by the patient, even if they originate in other parts.

From all this you can see that no positive diagnosis can be made where any one of these symptoms is presented unaccompanied by the others. A careful consideration of the symptoms present will frequently, however, be of aid in making a diagnosis. Intelligent patients will tell you that they have a feeling of oppression, a feeling of distress in dyspepsia, but will describe their feeling as that of distinct pain in ulcer. Pure neuralgic pain is not always localized, but radiates into distant parts, is not constant, but sets in all at once and disappears with equal celerity, sometimes intermitting for days and weeks, and then again setting in on the slightest nervous excitement. Such pain is not aggravated by local pressure, shows no relation to the digestive functions, does not depend upon the quality or quantity of food taken, and may as well occur during a fast as during a feast. Often such patients will tell you that their pain does not cease until they have taken a hearty meal.

In cases of peptic ulcer, you will find that the pain is in direct relation to the amount and quality of food taken; that the patient has little or no pain when the stomach is at rest; that coarse foods as well as acids cause or aggravate the pain, and that indifferent foods, such as milk, do not bring it about, though they may sometimes cause a sense of fullness or oppression. Some patients with ulcer will tell you that the position of their body has an influence on their pain. If they are so placed that the food, by its gravity, lies on the ulcer, the pain is brought on or increased, while if the patient under such circumstances then changes his position, he is relieved of his pain partially, or even entirely. Yes, some such patients must assume abnormal positions while their stomach is active, in order to avoid this suffering. Some patients with gastric ulcer cannot digest _any_ food without great pain, and frequently live on a very scanty diet, rather than risk taking more food and enduring these excruciating pains again.

_Anomalous Cases._ Occasionally cases will occur in which the symptoms presented do not justify the diagnosis of ulcer of the stomach, only those of dyspepsia or else of gastric catarrh being present, while we are still compelled to assume the diagnosis of ulcer from the result of the treatment. Such cases resist all kinds of treatment based upon the diagnosis of dyspepsia or catarrh, and can only be cured by a strict "ulcer cure."

Another class of cases only presents gastralgic pain without any other symptom. Such are frequently patients who have had gastric ulcer before. Others will come to you with intercostal neuralgia on the left side. They have, perhaps, tried all the usual anti-neuralgic remedies, have gone through a course of treatment by electricity, and spent a large amount of time and money, without obtaining permanent relief, until some physician puts them on a strict milk diet and cures them in this way in a short time.

Some cases of ulcer of the stomach present the queerest symptoms. For instance: they complain of pain after drinking milk, or even after taking a morphine powder, while they can eat the coarsest food without any harm. Others run along without presenting any symptoms at all, until they, as well as their physicians, are surprised by the perforation of a gastric ulcer.

All these abnormal cases, which form about one-fifth of all the cases occurring, are so indistinct that they frequently remain unrecognized throughout their entire course, and baffle the skill of the best diagnosticians.

In order to be able to make a sure diagnosis, there must be a localized pain, together with tenderness on pressure from without on the painful spot. A great many persons in good health are tender in the epigastrium, so that you have to be on your guard in this direction, too. From the occurrence of hæmatemesis in an otherwise healthy person you can, with great probability, diagnose ulcer of the stomach.

_Differential Diagnosis._ In order to differentiate _between catarrh and ulcer_, it is simply necessary to keep in mind the difference in the character of the pain, the fact that local pressure is more liable to aggravate the pain in ulcer than in catarrh, and the occurrence of hemorrhage in the former. The two conditions, however, frequently occur in the same patient.

The differentiation between _ulcer and neurosis_ has already been discussed. The direct connection of the attacks of pain with the introduction of food, and the character of the pain will soon clear up the matter. Should you still be in doubt, a course of treatment, such as an ulcer would demand, will soon clear up the matter. If the case is one of ulcer, it will have been cured or materially benefited, if it was a pure neurosis the patient will if anything feel worse than before.

By far the most difficult question to decide in making a diagnosis is whether the case is one of _ulcer or cancer_ of the stomach. Here close attention to several points will usually clear up the diagnosis. Cancer sufferers always have a sallow complexion, a worn, emaciated, cachectic appearance, no matter what or how much they eat. Ulcer patients frequently have a robust, healthy appearance, and are emaciated or run down only after repeated hemorrhages, or when other grave diseases, such as heart disease, chlorosis, tuberculosis, etc., are also present.

The _presence or absence of a tumor_ is a very important aid to the diagnosis, though as I have already stated, not always reliable. Sometimes an ulcer may be covered with granulations, and its surroundings so infiltrated and hardened, that even post-mortem the naked eye can not tell whether it is cancer or simple ulcer, and the question has to be decided by microscope. Such are likely the cases which form the bases of cancer cures which are reported from time to time to have been effected by the use of various remedies.

_Vomiting of blood_ is a symptom common to both cancer and ulcer of the stomach, but is usually more copious in the latter. If the absence of acid in the gastric juice of cancerous stomachs proves to be as reliable a symptom as has been recently asserted, this will be an important feature in the differentiation from ulcer.

You will frequently be astonished by the success of your treatment if you think of ulcer in doubtful cases of stomach trouble, such as occurs in young girls with chlorosis and institute a strict milk diet with the measures adopted for the cure of ulcer.

_Prognosis._ From what has been said you can see that in general the prognosis of ulcer of the stomach is good, that with proper avoidance of all irritation, the ulcer has a tendency to heal of itself. This tendency has been observed even in large ulcers, where death was perhaps the result of some intercurrent disease.

Ulcers of the anterior wall of the stomach are more dangerous than such as occur on the posterior wall, for the reason that in the latter case adhesion with the neighboring structures are more easily formed, and thus fatal perforation prevented. The anterior wall takes a much more active part in the peristaltic movement of the stomach, and as a result does not enter so easily into adhesion with its surroundings. Even after an ulcer has healed it always remains a weak point, and cases of rupture of the stomach in old cicatrices are described by Chiari.

_Treatment._ The pain is the most important criterion as a guide during the treatment. It is the signal by which I judge of the present condition of the ulcer. According to the variation of its character and intensity, I can judge whether the ulcer is healing, is remaining stationary, or is spreading and increasing in size or depth in spite of the treatment. If the pain has been removed permanently the ulcer has been healed. From the relation of this symptom to different kinds of food you can also judge of a progress or improvement of the ulcer.

Theoretically considered, that form of treatment would seem the best which gives the stomach absolute rest, entire abstinence from food, a fast of several weeks. But this can not be carried out in practice. The patient could be nourished per rectum, you might say, by means of nutrient enemata. In my opinion this method of nourishment does not amount to much. I believe that very little water is absorbed by the rectum, the patient would suffer from thirst and you would then be compelled to allow him to drink water at least.