—The symptoms and discomforts which they produce include pain, which is nearly always most pronounced within a short time after the ingestion of food, and which may be accompanied by local tenderness more or less constant. As the case progresses, with the pain usually comes vomiting, by which the former is relieved, the vomitus nearly always containing excess of hydrochloric acid and sometimes fresh or old blood. The pain of gastric ulcer is usually referred to the back. The indigestion and the frequent vomiting together are sufficient to produce a well-marked anemia, which is more pronounced when much blood is lost. Blood may not be vomited but escape into the duodenum, and will then give to the stools a tarry character, which should always be looked for and identified when discovered. The greater the loss of blood in either direction the more pronounced will be the anemia. Pain, vomiting, and evidence of loss of blood constitute the most distinctive features of gastric ulcer. When these are accompanied by tenderness in the epigastrium, and by pain in the back, the diagnosis is almost complete. In the more chronic cases there may have already occurred contraction of the pylorus and consequent dilatation of the stomach. Thus symptoms of the latter may be added to those of the previous condition.[55]
[55] In doubtful cases accompanied by pain it will sometimes be of value to try the effect of orthoform in ¹⁄₂ Gm. doses, to see if it will relieve it. This remedy will not anesthetize nerve endings which are protected by skin or mucous membrane. The fact, then, that it affords relief implies an ulcerated or exposed area.
The two ever-present and alarming dangers are those of hemorrhage and perforation. Serious hemorrhage permits the escape by the mouth of large quantities of bright, fresh blood, with a corresponding degree of shock or collapse, and depression. Perforation is indicated by sudden onset of intense pain, with collapse, rapidly spreading tenderness, with abdominal rigidity and increasing distention. In other words the symptoms of perforation are those of acute local peritonitis of abrupt origin.
In either of these events the paramount indication is for prompt intervention, unless the patient is already too weak to withstand the shock of any operation. In one case this will consist of gastro-enterostomy, with or without a gastrotomy for the purpose of discovering the bleeding vessel and making local hemostasis. In the other it will consist of free incision, complete toilet of the peritoneum, with removal of all escaped material, and local attention to the site of the perforation, doing there whatever may be needed.
Treatment.
—Should the surgeon see a case of gastric hemorrhage due to ulcer after the apparent cessation of the active loss of blood he may easily decide to wait for a few days until the patient has in some degree recovered strength and atoned for such loss. On the other hand if he see the case during its active stage he need not hesitate to open the abdomen, withdraw the stomach, open it sufficiently for exploration, and then attack the source of hemorrhage, be it large or small, in such manner as he may see fit—either with the actual cautery, with a sharp spoon, with complete excision of the ulcerated area and union of its borders by suture, or by merely including a bleeding vessel in a loop of suture, addressing himself at once to the formation of an anastomosis, preferably posterior, between the stomach and the uppermost loop of the small intestine. This procedure, which is wise in all instances, would be imperative in nearly all save those perhaps where an ulcerated area could be cleanly excised and its margins neatly sutured. Should it prove that suture of the stomach wall were impracticable its edges might be fastened to those of the abdominal wound, a gastrostomy thus resulting, which could be later closed by another operation.
For perforation the surgeon might have to rely, in emergency, on a gastro-enterostomy as a relief opening, accompanied by local gauze tamponage; the point of perforation could not be made accessible for suture, but one should prefer suture for all cases that permit of it. In these cases a considerable margin should be enfolded and included within the grasp of the suture, or else the margins should be completely excised until healthy tissue is reached. In rare instances it has been feasible to fit into a perforation a drainage tube, or to pack about it a gauze strip which should conduct from the stomach cavity directly to the abdominal wound. The question of excision of the entire ulcerated area should rest entirely upon the possibility of repairing the defect by sutures, and this will depend in large degree upon the location of the ulcer and the freedom with which the stomach can be manipulated, especially with which it can be withdrawn into the wound.
Practically every case of perforation thus operated will demand posterior as well as anterior drainage. Aside from the treatment of the stomach itself the general peritoneal cavity needs the same thoroughness of cleansing and the same care in every manipulation that would be given in a case of well-marked peritonitis already established.
GASTRIC FISTULAS.
This term has reference especially to external fistulous openings, which are an exceeding rarity save as relics of injury or of operation. They have been known to occur spontaneously by perforation of an ulcerated and adherent stomach, such perforations occurring either in direct line or irregularly in the direction of least resistance. Traumatic fistulas result usually from gunshot or stab wounds, or are due to incomplete union of an opening deliberately made. In any event they permit of the escape of more or less of the stomach contents. Their tendency is usually toward spontaneous repair, but this is often so slow or so incomplete that it needs to be hastened by stimulation of the fistulous tract with silver nitrate, the actual cautery, curetting, or by a complete resection of the entire tissue involved, and a neat reunion with suture.