Gastric Ulcer.
Synonyms:—Simple ulcer; round ulcer; peptic ulcer, rodent ulcer; ulcus ventriculi.
Definition:—An ulceration of the mucous memberane of the stomach, which may also penetrate the sub-mucous tissues and the muscular coats of the stomach, inducing perforation. It is local, distinctly circumscribed, and often well defined. It usually occurs as a single ulcer, but two or more may exist at the same time, scattered over a portion of the walls of the stomach, or a group of smaller ones may coalesce to form one large one.
The presence of ulcer is characterized by circumscribed tenderness on pressure, pain, vomiting and hematemesis.
Etiology:—No satisfactory explanation has as yet been given why the stomach is not digested by its own fluids. When this is understood, the reasons for the occasional occurrence of peptic ulcer will be at once explained. Local impairment of the inherent vital power of resistance, while the real cause, is not sufficiently explanatory. The ulcer is caused by the actual digestion of the tissues in a circumscribed area of the stomach wall. This is impossible if uniform vital resistance is maintained in the tissues. Impairment of this resistance is attributed, first, to alkalinity of the blood in the capillary circulation of the organ, or to greatly increased acidity or deficient alkalinity of the tissues. Gastric hyperacidity undoubtedly predisposes to it. It may be due to an embolus, by which a small branch of the gastric artery is occluded; it may be also induced by an external traumatism, by a lesion from the action of corrosives or irritants, or from the ingestion of excessively hot beverages. Conditions that result in constitutional debility, or the general impairment of the blood or tissues of the body, will lead to it.
It is more common among females than males, is present often in anemic patients and in those suffering from chlorosis or from chronic amenorrhea. Those who subject themselves to habits of dress or occupation which impede the circulation of the stomach are liable to it, as women who wear tight corsets, sewing women, and women of sendentary habits—and, among males, shoemakers and tailors.
It is most common during the active period of life, between twenty and forty-five years of age; children and those of advanced age are seldom attacked. It is more common among those who are insufficiently fed and clothed than among the wealthy. Stockton and other pathologists claim that the disease is of nervous origin, and there are cases in which there seem to be excellent grounds for this conclusion.
There is no doubt that ulcers occur in conjunction with chronic gastritis and are not diagnosed. There are cases of severe ulcer that are diagnosed and treated as cancer. The condition is probably more common than is generally supposed, as ulcers or their scars are found in nearly five per cent of all autopsies.
Symptomatology:—There are in reality three types of gastric ulcer. The first is that in which there is simple erosion of the mucous surface; the second penetrates the mucous and sub-mucous tissues; the third involves all the structures and may perforate the wall. In typical cases of this disease there are certain symptoms which are well classed as pathognomonic, or even classic. There is a characteristic distinctly localized pain, of an intense burning or gnawing character, usually just below or a little to the right of the xiphoid cartilage. Some pain may be more or less constant, and this depends upon the presence of coexisting gastritis, but the intense pain, usually paroxysmal, follows the taking of food, and disappears as the stomach becomes empty. It will disappear at once if the stomach is artificially evacuated with an alkaline solution. At other times reflex or other sympathetic nervous irritation may cause a diffused pain, which cannot be attributed to the taking of food, and is not relieved by evacuants or digestives. When perforation is imminent, the irritation to the peritoneum will induce a characteristic sharp, cutting pain, which will persist and increase with the occurrence of perforation. The actual location of the pain is of much importance in the diagnosis. In obese patients—those excessively fat—an exact location of the pain is impossible.
At first there may be considerable nausea, and later vomiting occurs quite frequently, usually after each meal. As the ulceration progresses the vomitus is excessively acid and may be streaked with blood, and finally there may be a considerable quantity of dark coagulated blood. In extreme cases, especially after violent physical exertion, the hemorrhage into the stomach may be very severe, followed by prostration, shock, cold sweats and rapid and feeble heart action.
If vomiting occurs during the hemorrhage, it may be observed that the blood is clear, light colored and free, coagulation not having taken place. This is the result of the perforation of an artery. Venous blood is usually very dark and coagulated when vomited. Blood passed from the bowels renders the fecal matter black or tarry in appearance. Coffee-ground vomiting in gastric ulcer is due to the slow oozing of the blood from the venous capillaries into the gastric juice, where the oxyhemoglobin is converted into hematin. The blood corpuscles are destroyed by the action of the juice. In very rare cases the patient will exhibit the symptoms of severe hemorrhage, with vertigo, prostration, shock, feeble pulse, and yet no vomiting of blood occur, but subsequently large quantities of coagulated blood will appear in the feces. This may be observed on several occasions, increasing in severity until death occurs. A part of the blood will have been digested and reabsorbed.
Early in the history of these cases the appetite is lost, the patient suffers from indisposition, and because of imperfect nutrition he becomes enfeebled, emaciated, and if the hemorrhage is at all persistent, very anemic.
In mild cases the temperature and pulse are not affected. As the disease progresses and hemorrhage becomes severe, the temperature may be sub-normal at the time of a hemorrhage, to increase subsequently to perhaps 100° or 101.5° F. The pulse is at first full, round and slow; when prostration or shock occurs it becomes rapid, feeble and easily compressible, sometimes irregular.
Diagnosis:—The diagnosis of this disease depends upon the typical symptoms. The intense localized pain, the exquisite soreness over a circumscribed area, with usually absence of diffused tenderness in the walls of the stomach, especially if excessive acidity be present, are presumptive evidences of the disease before hemorrhage appears. Free hemorrhage, as stated, is an absolutely pathognomonic symptom. In the absence of these symptoms, the existence of the condition is to a certain extent conjectural, and yet as the time passes—for the disease is one of long duration, exceedingly chronic in character— careful observation will exclude other conditions and tend to confirm the presence of this. The pain is more sudden and more severe than in gastritis, and is seldom if ever relieved by food, as it often is, temporarily, in that disease. As the disease progresses the general health is more impaired than in gastritis or gastralgia, and regulation of the diet gives relief, as is not true in gastralgia. A hardened mass may be found present which is only to be differentiated from cancer. This differentiation is promoted by the fact that in cancer there is an absence of hydrochloric acid, while in ulcer there is excessive hydrochloric acid.
Prognosis:—Simple recent cases, or cases of erosion, are amenable to treatment. The mortality in the chronic cases is estimated at from twelve to fifteen per cent. Complications of any character increase the danger. If recovery from ulceration occurs, cicatrization may cause chronic gastralgia, or there may be chronic spasm or permanent constriction of the pylorus from this cause with subsequent dilatation.
There is constant danger of relapse in cases of apparent cure. Those ulcers situated near the pylorus are more difficult to cure. In 125 cases of cancer of the stomach, Graham found ulcer present in 60 cases, nearly fifty per cent, furnishing proof of the oft-repeated assertion that gastric ulcer furnishes a fruitful ground for the development of cancer cells.
Treatment:—Many of the indications for the treatment of gastric ulcer closely resemble those of chronic gastritis, and should be met in much the same manner. This is especially true of all that is suggested in the rigid dieting of the patient, or in the exclusion of all food from the stomach when the extreme pain is instituted or aggravated by it. There is this important addition: if ulcer is strongly suspected before hemorrhage has appeared, the patient must at once be relieved of all anxiety, responsibility and care; must cease all work and go to bed and remain quietly and contentedly in bed until the symptoms are entirely relieved. To accomplish this may require a period of several weeks. If hemorrhage is an early symptom, thus confirming the diagnosis, this course at once enforced renders the prognosis much more favorable.
In ulcer the evidences of hyperacidity are usually plainly apparent, and these should receive the firt attention. In the early stages the carbonates or bicarbonates of sodium, calcium, or magnesium may be used, with which to neutralize the acids, but in the severe cases where perforation is at all imminent, calcined magnesia—magnesium oxid—should be selected, as there is no carbonic acid gas, which may distend the stomach and induce perforation, given off in the process of the neutralization of the acids with this agent, as is the case with carbonates.
The prompt use of an alkaline remedy during an acute attack of pain, in ulcer, will often give immediate relief. In early cases a half teaspoonful of the sodium bicarbonate in one-third of a glass of water will be very satisfactory, if the gas readily escapes from the stomach. This should be promoted by keeping the patient in a sitting posture for a short time after taking the draught.
The use of subnitrate of bismuth is attended with good results at this stage. It relieves local irritation and pain, antagonizes an excessive outpour of mucus and relieves the excessive acidity, both of the fluids and of the tissues, promoting resolution and a minimum cicatrization in the final healing of the ulcer, which is greatly to be desired. The agent should be given in large doses, preferably in warm water, when the stomach is empty, the patient lying, quietly upon the back for from half an hour to an hour after taking the remedy. From thirty to sixty grains of a pure salt may be used in this manner, once in five or six hours. Fleiner advises as high as half an ounce at a dose. Often when nausea is present, five grains of bismuth subnitrate may be given in a tablespoonful of warm water, every fifteen minutes, for three or four hours, the patient lying quietly the while and subsequently. Occasionally the sub-gallate of bismuth will be serviceable; or liquor bismuthi will be found the superior remedy. Where fermentation is pronounced from excessive acidity, sodium sulphate in fifteen grain doses will be the most available alkaline salt, or the sodium hyposulphite is of much service.
The use of alkaline laxatives is of importance. The Saratoga waters are accessible, or Carlsbad or Hunyadi, in proper doses, may be used. Or in some cases magnesium sulphate will give good results. This may be given in single full doses, or in occasional broken doses, of an effervescing preparation, drunk immediately the gas has escaped.
The bromids, with me, have seemed to exercise a soothing influence on the local condition, inhibiting the secretion of acids, or neutralizing the acidity, relieving pain, and quieting nervous irritation. The strontium bromid in from fifteen to twenty grain doses will probably be the best of this class of remedies. The potassium bromid should be avoided, as it is a local irritant. If opium or morphin are to be given, by the mouth, in any case of ulcer, they should always be given in conjunction with a bromid or with a small dose of gelsemium or hyoscyamus, if there be restlessness and nervous irritability.
Of our specifics in gastric ulcer and the conditions that lead to it, I am partial, first, to geranium maculatum. I consider this a most valuable remedy. It may be given alone in fifteen minim doses, every three hours, or in conjunction with ten minims of colorless hydrastis. I have recently had renewed confirmation of the efficacy of this course in the case of a lady music teacher, who had been in bed three months, had had repeated hemorrhages and had become extremely anemic. Geranium has a tonic influence in restoring a normal condition of the tissues, in reducing the quantity of acids secreted, in promoting the healing processes, and is of direct service if there is any hemorrhage whatever. In its every influence its action is promoted by hydrastis, best in small doses of a non-irritating preparation. Hydrastin or hydrastin hydrochlorate in small doses will greatly promote the healing of the ulcer; echinacea in small doses will exercise this influence also. Collinsonia can be given during convalescence, either alone or with reduced doses of geranium, or with small doses of hamamelis, for its influence on the capillaries of the stomach. The use of the precipitated carbonate of iron during convalescence is important. It acts directly on the walls of the stomach and upon the gastric secretions and directly overcomes the anemia.
The hemorrhage sometimes demands the entire attention. Usually geranium will be sufficient, especially where hemorrhage occurs early. The tincture of the oils of cinnamon and erigeron in fifteen minim doses will stop the flow of blood, but if repeated more than three or four times will irritate the stomach. A full dose may be given in an emergency, to be immediately followed by a hypodermic of ergot. I have used gallic acid in ten grain doses every hour with good results. Every hemostatic failed in one extreme case until I used five grains of lead acetate every hour or two for a few doses. When extreme prostration follows hemorrhage, hypodermoclysis with the normal salt solution must be resorted to. This solution may often be given per rectum, every eight, twelve or eighteen hours, or as needed, with great advantage in sustaining normal heart action and the strength of the patient, and in restoring the normal liquids to the circulation. It directly prevents the annoying thirst so common with these patients.
Dietetic Measures:—That which is altogether the most important consideration in the treatment of these cases is the food of the patient and the method of its administration. There is to be considered: (a) the effect of the food in the stomach upon the ulceration; (b) the effect of the gastric juices upon the ulceration; (c) and the imperative demand of the patient for nutrition, (a) Absolute rest of the stomach must be attained. Food of any character acts as an irritant, and pain, nausea and vomiting are increased by it, and occasionally hemorrhage is directly induced. (b) The process of ulceration depends upon the presence of the acid gastric fluids, and it is impossible for food to be taken into the stomach without inducing an outpour of these fluids, and thus directly facilitating and promoting the process of the ulceration. (c) The serious impairment of the function of the stomach results in progressive general debility and rapid emaciation, in spite of all nutriment which it is possible to supply by natural means. Unless this be overcome, all other measures are useless.
When the diagnosis is clear at the onset, or even if gastritis is known to be present and it is suspected that there is ulcer, the patient should be kept quietly in bed and no food whatever be given by the stomach for a period of several days. This is imperative if hemorrhage has confirmed the diagnosis.
In rectal feeding the intestinal canal must be kept clean and devoid of irritation. It must be thoroughly irrigated when this course is instituted, and it must be washed out before each feeding. I have used predigested milk alone, or with an egg, or half an ounce of beef juice freshly extracted and diluted, a half ounce of cream diluted, or half an ounce of bovinine, or there may be given combinations of cream, milk and eggs, or an egg may be given with the meat juice—one of these every four, five or six hours, warm.
If there is local irritation, the enema should be preceded by an ounce of warm starch water to which is added from eight to twelve drops of the tincture of opium. The opium should be omitted when possible. Occasionally this agent must be added to the food. After a few days, if the condition of the stomach is favorable, the quantity or frequency of the rectal enemas may be reduced, and small quantities of carefully prepared and measured nutrients may be given by the stomach at stated intervals; occasionally the meals given in the stomach may be alternated with the rectal feeding.
When stomach feeding alone is depended upon, I am convinced that food administered in smaller quantity every two of three hours is preferable to a full meal three times within twenty-four hours. The same article of diet may be given at every meal for two or three days, and then a complete change be made, coming back to that substance after perhaps twelve or fourteen days; but a better plan is to change each meal so that the patient will not tire of one food.
Peptonized milk is acceptable to the stomach. An egg thoroughly beaten may constitute one meal, or the white of an egg may be beaten and stirred in milk, hot or cold, or given in a small glass of water. Whey, buttermilk, kumyss, matzoon, and malted milk may be used in turn as is acceptable to the patient; some one of the proprietary milk foods of several of the well-known manufacturers can often be very acceptably adjusted to the patient.
Twenty years ago I accidentally discovered the immense advantage obtained from the careful use of pure ice-cream in this class of cases. I have continued its use with great satisfaction and success. It should be made plain, of pure constituents, with a simple flavor, and should contain but little or no sugar, if so acceptable, and must be prepared fresh on the day used; it must not be made in quantity and kept over. I have used bovinine for several years with much satisfaction. I have given it in water, in milk, and in other combinations, and have always found it acceptable. In extreme cases I have given it exclusively in half-dram doses or dram doses every hour, and to children with extreme gastric irritation and emaciation I have given ten-drop doses every fifteen to thirty minutes for considerable periods.
Gastric lavage is desirable in these cases, but in an occasional case it is attended with danger both of perforation and of increasing the irritation. The drinking of a large quantity of hot water early in the morning, or both morning and evening, will sometimes accomplish the desired results without the inconvenience and danger of the introduction of the stomach tube.
Surgical measures in the advanced stages of gastric ulcer are authorized, but have not become popular. This course is really the only available procedure when perforation has occurred, and should not be neglected, as it may save the life of the patient. More than eighty per cent of those who have been operated upon within twelve hours after perforation has occurred have been saved.
The tendency to relapse in gastric ulcer makes it obligatory upon the physician to direct the diet of the patient and to retain a strict oversight of his health for at least a year after the ulcer has apparently healed. A tendency to recurrence of the acidity and other conditions which make ulcer possible must be contended against, by proper adjustment of all habits of eating and habits of the daily life.
