A few days ago I saw an interesting case, where an acute gastritis culminated in the vomiting of a large quantity of pus. The patient had been having high fever for a few days, with incessant vomiting and great tenderness in the epigastrium. Evidently an abscess had formed in the neighborhood of the stomach, and finally opened into this organ, with the given result.
Diagnosis. There are two classes of characteristic symptoms—those originating from the exposure of nerve-endings, and those caused by ulceration into bloodvessels. The first class includes the painful sensations, the characteristic soreness, which occurs in about four-fifths of all the cases; the second class, the hemorrhages, occurring in only one-fourth of all the cases. You can readily see why pain occurs more often than hemorrhage. Even a very superficial abrasion may expose nerve-endings to the irritation of the food, while it takes a deeper ulceration to lay open a larger bloodvessel. In order to make a positive diagnosis, these two symptoms should be present.
Vomiting of blood alone need not necessarily be caused by a gastric ulcer. There are a great many other conditions which may cause it. It should, however, put you on the guard, and can, in a great many cases, justify a diagnosis of probable ulcer of the stomach.
The localized pain occurs, according to my experience, only in cases of ulceration of the stomach; that is, in gastric or peptic ulcer and in cancer of this organ. In order to differentiate between these conditions, it becomes necessary to observe whether the patient is cachectic or emaciated or not, and whether a tumor can be felt in the region of the stomach. But even these symptoms can be deceptive, as an abnormal hardness or resistance—the result of perigastritic infiltration—may occur in cases of simple ulcer, making the diagnosis almost impossible. This is true especially in cases of ulcer of the pyloric regions, while ulcers of the anterior wall of the stomach are rarely accompanied by such infiltrations.
The pylorus is the most sensitive part of the stomach, and frequently the seat of pain, when no lesion can be detected post-mortem. The other parts of the stomach only become painful when attacked by ulcerative or other pathological processes. Another point worthy of consideration is that all forms of pain in the stomach are usually referred to the pyloric region by the patient, even if they originate in other parts.
From all this you can see that no positive diagnosis can be made where any one of these symptoms is presented unaccompanied by the others. A careful consideration of the symptoms present will frequently, however, be of aid in making a diagnosis. Intelligent patients will tell you that they have a feeling of oppression, a feeling of distress in dyspepsia, but will describe their feeling as that of distinct pain in ulcer. Pure neuralgic pain is not always localized, but radiates into distant parts, is not constant, but sets in all at once and disappears with equal celerity, sometimes intermitting for days and weeks, and then again setting in on the slightest nervous excitement. Such pain is not aggravated by local pressure, shows no relation to the digestive functions, does not depend upon the quality or quantity of food taken, and may as well occur during a fast as during a feast. Often such patients will tell you that their pain does not cease until they have taken a hearty meal.
In cases of peptic ulcer, you will find that the pain is in direct relation to the amount and quality of food taken; that the patient has little or no pain when the stomach is at rest; that coarse foods as well as acids cause or aggravate the pain, and that indifferent foods, such as milk, do not bring it about, though they may sometimes cause a sense of fullness or oppression. Some patients with ulcer will tell you that the position of their body has an influence on their pain. If they are so placed that the food, by its gravity, lies on the ulcer, the pain is brought on or increased, while if the patient under such circumstances then changes his position, he is relieved of his pain partially, or even entirely. Yes, some such patients must assume abnormal positions while their stomach is active, in order to avoid this suffering. Some patients with gastric ulcer cannot digest any food without great pain, and frequently live on a very scanty diet, rather than risk taking more food and enduring these excruciating pains again.
Anomalous Cases. Occasionally cases will occur in which the symptoms presented do not justify the diagnosis of ulcer of the stomach, only those of dyspepsia or else of gastric catarrh being present, while we are still compelled to assume the diagnosis of ulcer from the result of the treatment. Such cases resist all kinds of treatment based upon the diagnosis of dyspepsia or catarrh, and can only be cured by a strict "ulcer cure."
Another class of cases only presents gastralgic pain without any other symptom. Such are frequently patients who have had gastric ulcer before. Others will come to you with intercostal neuralgia on the left side. They have, perhaps, tried all the usual anti-neuralgic remedies, have gone through a course of treatment by electricity, and spent a large amount of time and money, without obtaining permanent relief, until some physician puts them on a strict milk diet and cures them in this way in a short time.
Some cases of ulcer of the stomach present the queerest symptoms. For instance: they complain of pain after drinking milk, or even after taking a morphine powder, while they can eat the coarsest food without any harm. Others run along without presenting any symptoms at all, until they, as well as their physicians, are surprised by the perforation of a gastric ulcer.