All these abnormal cases, which form about one-fifth of all the cases occurring, are so indistinct that they frequently remain unrecognized throughout their entire course, and baffle the skill of the best diagnosticians.
In order to be able to make a sure diagnosis, there must be a localized pain, together with tenderness on pressure from without on the painful spot. A great many persons in good health are tender in the epigastrium, so that you have to be on your guard in this direction, too. From the occurrence of hæmatemesis in an otherwise healthy person you can, with great probability, diagnose ulcer of the stomach.
Differential Diagnosis. In order to differentiate between catarrh and ulcer, it is simply necessary to keep in mind the difference in the character of the pain, the fact that local pressure is more liable to aggravate the pain in ulcer than in catarrh, and the occurrence of hemorrhage in the former. The two conditions, however, frequently occur in the same patient.
The differentiation between ulcer and neurosis has already been discussed. The direct connection of the attacks of pain with the introduction of food, and the character of the pain will soon clear up the matter. Should you still be in doubt, a course of treatment, such as an ulcer would demand, will soon clear up the matter. If the case is one of ulcer, it will have been cured or materially benefited, if it was a pure neurosis the patient will if anything feel worse than before.
By far the most difficult question to decide in making a diagnosis is whether the case is one of ulcer or cancer of the stomach. Here close attention to several points will usually clear up the diagnosis. Cancer sufferers always have a sallow complexion, a worn, emaciated, cachectic appearance, no matter what or how much they eat. Ulcer patients frequently have a robust, healthy appearance, and are emaciated or run down only after repeated hemorrhages, or when other grave diseases, such as heart disease, chlorosis, tuberculosis, etc., are also present.
The presence or absence of a tumor is a very important aid to the diagnosis, though as I have already stated, not always reliable. Sometimes an ulcer may be covered with granulations, and its surroundings so infiltrated and hardened, that even post-mortem the naked eye can not tell whether it is cancer or simple ulcer, and the question has to be decided by microscope. Such are likely the cases which form the bases of cancer cures which are reported from time to time to have been effected by the use of various remedies.
Vomiting of blood is a symptom common to both cancer and ulcer of the stomach, but is usually more copious in the latter. If the absence of acid in the gastric juice of cancerous stomachs proves to be as reliable a symptom as has been recently asserted, this will be an important feature in the differentiation from ulcer.
You will frequently be astonished by the success of your treatment if you think of ulcer in doubtful cases of stomach trouble, such as occurs in young girls with chlorosis and institute a strict milk diet with the measures adopted for the cure of ulcer.
Prognosis. From what has been said you can see that in general the prognosis of ulcer of the stomach is good, that with proper avoidance of all irritation, the ulcer has a tendency to heal of itself. This tendency has been observed even in large ulcers, where death was perhaps the result of some intercurrent disease.
Ulcers of the anterior wall of the stomach are more dangerous than such as occur on the posterior wall, for the reason that in the latter case adhesion with the neighboring structures are more easily formed, and thus fatal perforation prevented. The anterior wall takes a much more active part in the peristaltic movement of the stomach, and as a result does not enter so easily into adhesion with its surroundings. Even after an ulcer has healed it always remains a weak point, and cases of rupture of the stomach in old cicatrices are described by Chiari.