Synonyms.—Peptic Ulcer; Rodent Ulcer; Round Ulcer; Penetrating Ulcer, etc.
Definition.—A well-defined round or oval ulcer, due to the action of the gastric juice upon some portion of the mucous membrane, which has been weakened by some impairment of nutrition. It penetrates the mucous membrane and sometimes the entire gastric wall.
Etiology.—Dyspepsia in its various forms undoubtedly predisposes to peptic ulcer; in fact, any disease whereby the blood is impoverished favors this condition. The fact that about five per cent of all autopsies held show either ulceration or cicatrization is evidence that the disease is more frequent than is generally known.
It is more common in females than in males, possibly due to the method of dress, the stomach being pressed by corsets and tight lacing, and partly due to closer confinement. Tailors and shoemakers are prone to this condition, due, most likely, to position, causing pressure upon the stomach. It occurs most frequently in persons between the ages of twenty and forty, though it is not infrequent in children.
The exciting cause is no doubt hyperacidity of the gastric juice and the mucous membrane being digested, as it were, by its own juices. Chronic gastritis often precedes, and no doubt is often the cause of the ulceration. Some pathologists regard the disease as a neurosis. The disease is quite often secondary to anemia and chlorosis, and in women with menstrual disorders. These diseases tend to acidity of the blood, thereby favoring the digestion of the mucous surface.
Traumatism of the stomach or external injuries over the epigastrium have also been regarded as being responsible for this condition.
Pathology.—Usually there is but a single ulcer, though two or more are not uncommon, and Berthold reports a case where he found thirty-four ulcers. The usual location is near the pylorus and on the posterior wall, though they may be found in any portion. The shape is generally round or oval, with clear-cut, well-defined edges. In the more acute form it has the appearance of being made with a punch, and there is but little, if any, inflammation of the neighboring tissue, but in the more chronic variety, the edges are not so clear-cut, and infiltration gives them an indurated condition.
In size they vary from that of a dime to an inch or more in diameter, and when of undue size, the result of the coalescence of two or more, they are usually funnel-shaped, and extend to various depths, the base consisting of the submucosa, the muscular tissues, or, perforating the organ, may have for its base new tissue, the result of adhesions which nature has formed to prevent a fatal issue. Thus adhesions may form with a portion of the left lobe of the liver, with the pancreas, the spleen, the omentum, or the diaphragm.
The perforation may be into the lesser peritoneal cavity, giving rise to subphrenic pyo-pneumothorax; or it may enter the pleura, the gall-bladder, the transverse colon, and even the ventricle of the heart. Where the ulcer is located on the anterior wall and perforation occurs, it most frequently produces peritonitis, terminating in death. Again, the ulcerative process may penetrate the blood-vessels, giving rise to hematemesis, and if of the larger vessels, as the splenic artery, a fatal hemorrhage results.
In the chronic ulcer of long standing, there is more or less gastritis associated with the ulceration.
In the healing process various changes result. Where the ulcer is superficial, extending simply through the mucous membrane, cell infiltration takes place, the edges contract, and the cicatrix is smooth and sometimes invisible. Where the ulcer is located near the pylorus and extends to the muscular tissues, the contraction results in stenosis, which is followed by dilatation. Where several ulcers are found near the middle of the organ, forming a girdle, as it were, the cicatrization and contraction give rise to the hour-glass form.
In some cases there is no attempt to heal, and the ulcer presents an irregular, ragged appearance, with indurated edges. The adhesions of the stomach depend upon the location of the ulcer, and while nature has kindly prevented a fatal issue by her handy work, the contractions attending the same are sometimes followed by severe pain, which is difficult to relieve.
Symptoms.—These may be so pronounced as to render a diagnosis almost positive, or so obscure that the disease is only determined post-mortem. In the earlier stages the symptoms are those of dyspepsia or chronic gastritis; but as the disease progresses, the more positive symptoms, pain, vomiting, and hemorrhage develop, and when all are present ulceration of the stomach is assured.
The pain at first is but slight, and consists of a burning or gnawing sensation, more marked after eating. As the disease advances, the pain increases, and is present a great deal of the time, though most severe immediately after taking food, especially very hot or very cold fluids, also very acid or very highly-seasoned dishes, and where the food has been but poorly masticated. In some cases the pain is severe when the stomach is empty, the opposing surfaces producing enough irritation to cause suffering.
Pressure sometimes gives relief, and the patient may lie across a chair or at full length upon the floor. Usually, however, there is tenderness over the epigastric region, and the patient can not bear anything tight over the stomach. The pain is circumscribed, and located just below the xiphoid cartilage; from this point it may radiate to the back between the scapulae, and also to the abdomen. A corresponding painful point is over the eighth, ninth, or tenth dorsal vertebra; prolonged exertion or emotional excitement increases the pain. In advanced cases, the gnawing, boring, or burning pain, confined to a spot about the size of a silver dollar, just below the ensiform cartilage, is a characteristic symptom of much value.
Nausea is one of the early symptoms, with loss of appetite; but as the disease becomes more chronic, vomiting occurs in perhaps half the cases. This usually occurs in from one to two hours after eating. The vomited material usually contains an excess of hydrochloric acid. As a result of the inability to retain food, the patient loses flesh and strength, and presents an anemic appearance.
Hemorrhage is a symptom of great importance, and, when preceded or accompanied by the others above mentioned, is almost conclusive evidence of the disease. It varies very greatly, sometimes so slight as to pass unnoticed, the blood passing into the bowel thus escaping notice; at other times, it is so profuse as to endanger life, though this is very rare.
Where the hemorrhage is from the smaller capillaries, it is mixed with the vomitus, and appears about the color of coffee-grounds. Where the ulceration eats into an artery, the hemorrhage is more profuse, and is ejected as clear blood, or, remaining in the stomach for some time, is finally vomited in large, dark clots. When it passes into the bowel, the stools are tarry in character. Where the hemorrhages are frequent and profuse, the patient soon presents an anemic appearance. When perforation occurs in the abdominal cavity, peritonitis ensues, should the patient not succumb to collapse.
Diagnosis.—A well-marked case of ulceration, with the three characteristic symptoms—pain of a boring, gnawing, or burning character, located at or just below the xiphoid cartilage, and which point can be covered by a silver dollar; vomiting of food highly acid in character from a few minutes to two hours after eating, and hemorrhage in either large or small quantities—makes the diagnosis plain; but when hemorrhage is absent, which is the condition in fifty per cent of all cases, the diagnosis is not so clear.
Where there is severe gastralgia, and it is confined to a small surface, with a painful dorsal point, and vomiting of a highly acid character, we are justified in making our diagnosis. In gastralgia, which is most likely to be confounded with this, the pain is more diffuse and not so persistent.
Eating in most cases gives relief for some time; while in. ulceration it only aggravates. Vomiting affords relief in ulceration, while in gastritis there is but little relief, if any. In ulceration, there is not the hard, indurated tumor that is found in cancer, nor do we find the vomited material in the latter disease so acid in character. Eating produces but little additional pain in cancer, while pain is intensified by taking food in ulcer. The age of the patient is somewhat significant, as cancer usually appears only after middle life. A certain per cent of cases, however, are only recognized post-mortem.
Prognosis.—This depends upon several conditions, such as the duration, extent, and whether or not there has been hemorrhage. In recent cases the prognosis is favorable, while many of a more chronic character recover. When perforation occurs and there is much structural change, our prognosis should be guarded. Taking all cases, from sixty to eighty per cent recover.
Treatment.—In the earlier stages the treatment will be similar to that for gastritis, which it so closely resembles; but as soon as the symptoms are sufficiently pronounced to warrant a diagnosis, the patient must be put to bed and kept absolutely quiet. He must be given to understand that a cure means from four to six months in bed. Nothing will take the place of rest in the recumbent position. The diet must receive particular attention, for the most skillful line of medication will fail if we neglect this phase of the treatment. Only the blandest and most easily digested food should be allowed, peptonized foods being among the best. Where there is great irritability of the stomach and vomiting, the stomach should have absolute rest, nourishment being given by the rectum. As soon, however, as the stomach will tolerate food, I prefer giving it by mouth.
Pepsin whey is one of the blandest and most kindly received foods that can be given; mailed milk, Eskay's food, and Wells, Richardson Co.'s cereal milk are also well received. It is a good plan to change the food every two or three days, so that the patient will not tire of any one food. Where the stomach is in a rebellious mood, albumen water is generally well received. The white of one egg, stirred in a half glass of water, and taken at one time, or, in smaller quantities, one or two hours being consumed in the taking, will be found helpful. Bovinin is highly recommended, although I have used it but little, and can not speak from experience.
Some patients do well on ice-cream. After a few days or weeks the dietary may be enlarged, and may be made to include scraped beef, well-cooked rice, sweetbreads, the white meat of chicken, lamb, or clam-broths and cooked fruits, care being taken not to overfeed.
The administration of remedies will be selected for the special conditions present. To relieve the nausea and vomiting, an infusion of peach-tree bark will often give most happy results, or mint-water and bismuth subnitrate. Where the vomiting is persistent, the stomach should be washed out with a weak solution of sodium bicarbonate, though much care must be taken in using lavage, or harm, rather than good, will result.
If there be increased secretion, hamamelis, collinsonia, and liquor bismuth will be of benefit. Lloyd's colorless hydrastis is also a good agent in this condition. Where there is constipation, a glass of Hunyadi or Carlsbad water will be useful; the latter may be improvised by taking sodium sulphite five ounces, sodium bicarbonate two ounces, and sodium chloride one ounce; of this add a heaping teaspoonful to one pint of warm water, and drink freely. This is useful in overcoming the excessive acidity of the stomach.
Where there is passive hemorrhage, carbo-vegetabilis 2x, in ten-grain doses, will do nicely, but when the bleeding is active, ergot, hypodermically, will succeed better. For intense pain, morphia, hypodermically, will give relief, but should be used cautiously, that the patient do not contract the morphia habit. Where the hemorrhage is so profuse as to endanger life, intravenous injection of normal saline solution will be called for. Where perforation occurs, prompt surgical measures should be taken.
The older Eclectics secured good results from counter irritation, using the old compound tar-plaster, but patients of to-day would hardly submit to such unpleasant methods; for, to be effective, it must be carried to suppuration. A very good counter-irritant, however, used over the dorsal point, is a little chloral hydrate spread upon adhesive plaster, say about the size of a silver dollar. A vinegar-pack over the abdomen at night, to be followed by a sponge-bath cf salt water the following morning, is also good treatment.
During convalescence, great care must be exercised that the patient be not allowed to gratify his appetite.