A system of practical medicine. By American authors. Vol. 2

by Unknown

The duodenal resembles the gastric ulcer in form as well as origin. It has the same appearance, in its recent stage at least, of having been cut out with a punch, shows no inflammation, induration, or thickening about its borders, and presents the same funnel-shape with terraced walls, its apex below eccentrically situated, as a rule corresponding to the situation of the artery. It is most frequently found in the upper horizontal portion of the duodenum, but is occasionally, though rarely, seen in the descending portion. In the further course of the duodenum the gastric juice becomes gradually neutralized, so that ulcers situated below the orifice of the gall-ducts are very great exceptions. In Krauss' collection of 47 cases but 2 were found in the lower sections of the duodenum. The intestinal like the gastric ulcer is usually found single or alone, but occasionally two, three, or even four ulcers are encountered. According to the tables of Morot, a single ulcer is found in 81.8 per cent. of cases, two in 9.2 per cent., and three and four in 4.5 per cent. each.

Duodenal like gastric ulcers are attended with the liability to hemorrhage and perforation in equal if not greater degree. There is also the same tendency to implication of contiguous structures. Stich records a case of perforation of the aorta; Eichenhorst mentions the formation of abnormal communication with the gall-bladder; and Frerichs, a thrombosis of the vena porta in consequence of duodenal ulcer. Lastly, the process of cicatrization may be followed by the same disasters as occur in pyloric ulcers in consequence of contraction and constriction. Thus, the orifices of the pancreatic or choledochus ducts may be narrowed or completely closed, or the whole lumen of the duodenum obliterated, with consecutive dilatation of the stomach and oesophagus, as in the case narrated by Biermer. A very nice question in differential diagnosis as between pyloric carcinoma and pyloric or duodenal ulcer is sometimes raised in this way. In the vast majority of cases it is safe, even in the absence of a palpable tumor and without regard to the age of the patient, to decide this question in favor of carcinoma. Cases of complete occlusion constitute the rule in carcinoma, and the very great exception in ulcer.

It remains to be said that duodenal is much more rare than gastric ulcer, in the ratio of 1 to 30, and that, unlike gastric ulcer, it chiefly affects males. According to the statistics of Krauss, already cited, the ratio of males to females is 9 to 1, and according to Trier the ratio is 5 to 1. It occurs in greatest frequency between the ages of thirty to forty, diminishing in frequency with advancing age.

SYMPTOMATOLOGY.—Ulcer of the intestines announces itself by symptoms which are, as a rule, much more vague and indefinite than the same process in the stomach. In a certain percentage of cases the symptoms may be entirely latent, and the cause of a sudden death be revealed only on the post-mortem table. In less severe cases the entire symptomatology of intestinal ulcer is grouped under the term dyspepsia, no characteristic phenomena being manifest throughout the course of the disease.

On the other hand, a very small ulcer may give rise to the most dangerous symptoms—hemorrhage and perforative peritonitis, which may be even fatal in the course of a few days or hours.

Among the symptoms that appear with prominence in the course of the disease is pain. Although cases are abundantly on record marked by the entire absence of pain, and although pain is by no means so universally present as in gastric ulcer, it occurs in the great majority of cases of ulcer of the intestine. The pain of intestinal ulcer distinguishes itself from gastric ulcer by being more independent of the character of the food or the time of taking it. For the most part, it occurs in attacks of colic, which are characterized at times by their extreme severity, long duration, and obstinacy to every means of relief. These attacks occur in paroxysms with complete or only incomplete remissions, and are ascribed, as in gastric ulcer, to the erosive action of the gastric juice upon exposed nerve-fibres, the intervals of relief corresponding to the periods of exhaustion of the nerve-centres. At the same time, in exceptional cases, a long-continued localized tenderness to pressure may indicate the seat of the disease.

Palpation may elicit, besides tenderness, points or regions of induration or intumescence. Such a condition is more especially encountered in cases of tuberculous disease, the so-called scrofula of the intestine or the tabes mesenterica of childhood. More localized enlargements are occasionally to be felt in the vicinity of the duodenal or other intestinal ulcer in consequence of circumscribed peritonitis, with its resultant agglutinations and adhesions. In this connection caution must be exercised not to confound masses of impacted feces with tumefactions. The history of constipation or the administration of a light laxative will generally suffice to remove this source of error.

Anorexia is a symptom of intestinal ulcer as a rule. The loss of appetite may amount to a complete aversion to all food or only to the more fatty articles of diet. A curious exception to this rule is not infrequently seen in the unappeasable hunger of children the victims of tuberculous ulceration. The contrast offered in the extreme emaciation of these patients has been made the subject of frequent comment.

With this loss or perversion of appetite and defective digestion of the food, the general condition soon begins to fail. Though cases are occasionally met in which a bien-être has been maintained for years, or a condition of obesity has been retained, these cases form the exception in the history of intestinal ulcer. More or less emaciation gradually develops as a rule, and a reduction of the general strength that is out of all proportion in its degree to the loss of flesh. At the same time the mental condition of the patient suffers a degradation to the level of the sufferer with chronic dyspepsia.

The disturbances of digestion which occur in intestinal ulcer present many varieties in degree and kind. Some patients show none or but few of the signs, while others run the gamut, so to speak, in the semeiology of dyspepsia. Heartburn, eructations, pyrosis, borborygmi, flatulence, gastralgias, pseudo-anginas, nausea, and vomiting, the familiar phenomena of gastric or intestinal catarrh, attend at some time or other in the course of the disease most of the cases of intestinal ulcer.