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.
As a result, also, of the accompanying catarrh of the stomach and the consequent diminished absorption of fluids, we find constipation and diminished secretion of urine in cases of ulcer of the stomach.
Perforation of the stomach is most frequently caused by gastric ulcer, and may be said to be a characteristic symptom; but it usually occurs too late to be made use of in the treatment of the ulcer. It is occasionally the first symptom which calls the patient's attention to the fact that his stomach is and has been seriously diseased. By the agglutinations of the base of the ulcer with neighboring organs, through inflammatory processes, perforation can take place into these organs. The most frequent forms of perforation under such conditions are those into the liver, spleen or pancreas, but cases have occurred where perforation into the colon or pleural cavity has taken place, or even into the pericardium, the heart or lungs. Some time ago I saw a case of gangrene of the lung, the result of the perforation of a gastric ulcer into this organ.