The Cleveland Medical Gazette, Vol. 1, No. 4, February 1886

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.