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Definition,-It is a disease anatomically characterized by a circumscribed and perforated ulcer of the membranes of the stomach. It is accompanied by a painful dyspepsia, vomiting, haematemesis, and may end in perforation.
Common Form.-It is ushered in by anorexia and dyspepsia, and with the gradual increase of the dyspeptic symptoms; aversion to food increases also. Soon the process of digestion is accompanied by an acute, burning pain felt over a circumscribed area towards the xiphoid appendix. This pain is very much increased on pressure and motion, and compels the patient to lie quietly in a position that varies according to the seat of the lesion. The pain corresponds posteriorly to the first lumbar and last dorsal vertebrae. Its characteristic features are to start or increase after meals, to last during the process of gastric digestion, and to cease or decrease after vomiting or when the food has passed through the pylorus.
When the pain has acquired a certain intensity the disease is accompanied by vomiting, which is first composed of food and occurs one or two hours after meals. When the disease is further advanced vomiting becomes slimy, and occurs when the stomach is empty. In the vomited substances we often find small blackish flakes, which indicate blood exudation on the surface of the diseased stomach.
Anorexia, pains and vomiting produce a more or less rapid emaciation, but the colour of the skin remains good for a long time.
The disease, arrived at this stage, may end in cure by the cicatrization of the ulcer; then the symptoms gradually disappear in the inverse order of their appearance. But on the other hand, instead of a cure the disease may be progressively aggravated and cause death by inanition. But very frequently complications such as haemorrhage and perforation occur, which peculiarly hasten the fatal termination.
The hemorrhage, which we shall see is a common symptom of a peculiar form of simple ulcer, almost occurs as a complication in the common form; it is very profuse, sometimes fatal, and is followed by melaena. The perforation occurs in one out of eight cases. It is a more or less rapidly fatal symptom. When perforation occurs directly in the peritoneal cavity, a sudden pain, change in the features, paleness, cold announces the onset of a subacute peritonitis, ending fatally in a few hours. When the perforation is confined by adhesions, an inflammation sets in which extends to the neighbouring organs, according to the laws of pathological anatomy, and produces pleurisy and especially general peritonitis.
Haemorrhagic Form.-This from begins by hematemesis, and if vomiting of blood has been preceded by gastric disturbances, the latter often have been unnoticed, for they have nothing characteristic. Haemorrhages repeatedly occur at more or less distant intervals- every eight days or every month; at first infrequent, later they become more frequent, according to the advance of the disease. Between the intervals patients suffer in various degrees from anorexia and pain, which we have described before. Besides they exhibit all the signs of anaemia and the discolouration of the skin emphasizes still more the resemblance of this form of simple ulcer to cancer.
At its height we find black vomiting occurring frequently, and pain at the xiphoid region. The usual vomiting of food is rare in this from. We have never observed it. The disease may end in cure; then haemorrhage cease. The pain diminishes and disappears, appetite returns, and convalescence is quite rapid. But it should be remembered that after a few years there may be a relapse, with the same form. The disease most frequently terminates in death, either by exhaustion, perforation, or following a fulminant haemorrhage.
Latent Form.-There are cases where on post-mortem gastric ulcers were found, with only slight dyspeptic symptoms during life. Thus hematemesis, pain at the xiphoid region, vomiting of food may be absent during the great part of the duration of ulcer of the stomach, which is only revealed on post-mortem, when death occurs through another disease. This from may abruptly end fatally by perforation, without any warning, or may end in cure by the healing of ulcers, whose cicatrices are later found in the stomach.
Morbid Anatomy-The seat of ulcer of the stomach is most often not at the pylorus, but in the half of the stomach next to the pylorus, more on the posterior wall, and towards the lesser curvature. The ulcer is usually round, varying in diameter, often from one to three centimeters. The ulcers, whose seat is at the level of the orifices, especially at the pylorus, are annular or semi-annular in shape. The ulcer involves one or several coats and the process of loss of tissue follows such a course that the ulcer looks as if punched by an instrument, and exhibits sharp margins. The floor of the ulcer is formed either by the muscular layer or by the serous coat covered with false membranes. There blood vessels may be seen, and in cases of haemorrhage of some importance, even section of the vessels could be seen. Though frequently single, the ulcers may, however, be multiple-two, three and even more. The ulcer which sometimes occurs at the beginning of the duodenum, exhibits the same characteristics as those of the stomach.
Perforation occurs more frequently when the ulcers are situated on the anterior wall of the stomach. Of that nature will be thirteen out of one hundred cases.
Cicatrization, which is also of frequent occurrence, may assume stellate or linear forms When cicatrices occupy a larger area and are situated near the orifices, they may cause deformity of the stomach, detrimental to its functions.
In one case, microscopical examination revealed that the edges of the ulcer showed an adenomatoid infiltration and question arises whether a neoplasm of this nature could not become the starting point of simple ulcer. This is one more theory to be added to those of emboli, thrombosis, chronic gastritis and of microbes.
AETIOLOGY. Simple ulcer of the stomach is a disease of frequent occurrence. It mostly occurs in those from twenty to thirty year of age, which is not true of cancer. It is observed from the first months of life upto extreme old age, but principally from twenty to sixty years.
Females are, during puberty, more subject to it than males. Those who suffer from haemorrhoids are very liable to the disease.
The exciting causes are excess in alcoholic beverages and excess in alcoholic beverages and excess in eating. Grief, emotion, traumatism have been considered as predisposing causes. A relation between tuberculosis and simple ulcer has also been mentioned, a great number of cases ending in phthisis.
Diagnosis easy when the perforating pain, extending to the dorsal region, vomiting of bright red blood, and anaemia are combined.
It will sometimes be difficult to differentiate it from gastralgia, chronic gastritis, hyperchlorhydria and cancer.
In gastralgia the pain is irregular in its occurrence, without aggravation by food; localised tenderness, vomiting, hematemesis, and dyspeptic symptoms are absent, and the neurotic character of the patient is usually evident. hematemesis and anemia, which usually characterize cases of gastric ulcer, while the amount of hydrochloric acid in the stomach contents is decreased.
In hyperchlorhydria the pain is apt to appear two or three hours after the ingestion of food, and it is relieved by the administration of more food or of an alkali, such as sodium bicarbonate; water brash is frequently present and hematemesis does not occur.
Cancer occurs later in life; the pain is less intense but more continuous, the amount of blood vomited is comparatively small and often the vomits betrays the absence of hydrochloric and the presence of lactic acid. The appearance of cachexia and the discovery of a palpable tumour afford conclusive evidence as to the nature of the lesion.
This is generally favourable though fatal haemorrhage or perforation is possible at any time, and relapse even after apparent recovery is not unusual.