Symptoms.
—No matter what the cause the symptoms are essentially the same, in that they produce dilatation of the stomach and frequent vomiting. According to the cause there will also be a history of pain and hemorrhage, suggesting ulcer, or of biliary colic, denoting perigastric adhesions, or of pancreatic disease, accounting for adhesion of the duodenum and displacement of the pylorus. The discovery of tumor or the results of examination of stomach contents may also suggest or corroborate the diagnosis of cancer.
The essential feature being the failure of the gastric contents to pass onward into the bowel, and their accumulation in the stomach or rejection by vomiting, the condition will be seen to have a purely mechanical as well as a pathological aspect. The case, therefore, must be extreme in which a mechanical remedy will not afford at least temporary relief.
Surgical Treatment.
—This remedy obviously is either to overcome the stricture by dilatation, or plastic operation upon the region involved, or to form a new opening by which the stomach shall connect with the upper intestine—i. e., gastro-enterostomy. The latter has gradually supplanted the former in the choice and in the hands of most surgeons, although occasionally a case may be met which invites the performance of a pyloroplasty, by either the Heinecke-Mikulicz or the Finney operations, which will be described later. In the absence of malignant disease few serious operations give more satisfactory results than do these.
GASTRIC ULCER.
During the past few years the studies of internists, of pathologists, and of surgeons have all served to show that gastric ulcer in any form is a more common lesion than was suspected by the previous generation. At first it nearly always comes under the care of the internist, but too often, becoming chronic, it is too long continued under his care until a serious, perhaps almost fatal, hemorrhage makes operative relief more dangerous, if not impossible, or until a chronic ulcer has degenerated into a cancer, and this is permitted to go on until the patient pays with his life the penalty for such inattention.
Ulcers in the gastric mucosa vary from a simple fissure (such as may be seen in the mucosa of the lip or the anus) to extensive and deep ulcerations, which weaken the stomach structure in spite of protective infiltration and even adhesions, until a final perforation may terminate the case, either by hemorrhage or septic peritonitis. While surgical teaching has of late pointed more and more definitely to the importance of ulcers resulting from simple erosions, or apparently mere abrasions which have not been appreciated, most pathologists and surgeons fail to realize that even from so trifling a surface alarming hemorrhages may occur. Such lesions appear upon the postmortem table to be minute and unimportant, but, occurring during life, they have an importance of their own.
Gastric ulcers, then, should be referred to as erosions, as simple or complicated ulcers, and as ulcerating cancers, in addition to which there may be mentioned the rare lesions produced by tuberculosis and syphilis. These ulcers are always to be regarded seriously, because in their milder expressions they cause pain and various forms of dyspepsia and indigestion, while their more serious consequences include hemorrhage, which may be fatal, and perforation, which is essentially so unless surgical intervention be prompt and complete.