Diagnosis

In cases where all the symptoms of gastric ulcer are present no difficulty will be experienced in the diagnosis. It frequently happens, however, that only one or two of the above-described symptoms exist, and it is then more difficult to make a positive diagnosis. One of the following symptoms, if present in its characteristic form, will suffice to establish a probable diagnosis of ulcer.

1. Hsematemesis

If the quantity of blood vomited be quite large, and cancer of the stomach can be excluded.

1The. Rosenheim: "Zur Kenntniss des mit Krebs coniplicirten runden Magengeschwttrs." Zeitschr. f. klin. Med., Bd. 17, p. 116 2Th. Rosenheim: Deutsche med. Wochenschr., 1890. No. 15.

2. Pains

Pains appearing shortly after meals, and lasting for a considerable time (two to three hours), being influenced by the quantity and quality of food in such a way that they are most intense after the ingestion of coarse substances in large quantities, without perfectly free intervals of several days' duration, are sufficient to warrant the suspicion of gastric ulcer. If in connection with this spontaneous pain there is a circumscribed spot in the epigastric region that is painful to pressure, or if there is a small area likewise painful to pressure to the left of the eighth or ninth dorsal vertebra, then the diagnosis of an ulcer becomes probable.

3. Vomiting

Vomiting appearing shortly after meals and preceded by a period of uneasiness in the gastric region, may also at times be suspicious of gas-trie ulcer. If this occurs in individuals who have lately grown much paler and more anaemic, the suspicion again becomes a probability. This probability is still greater if the gastric contents show a too high degree of acidity.

Differential Diagnosis

Very often cases of pure nervous gastralgia, of hyperchlorhydria, and of cancer present symptoms similar to those of gastric ulcer, and in making the diagnosis we shall have to take all these affections into consideration. Following Ewald's example, I deem it best to give all points of differential diagnosis between the above-named conditions in a table:

Gastric ulcer.

Nervous gastralgia.

Hyper-chlorhydria.

Cancer.

Age.......

Rare in youth, frequency increas-ing progressively from puberty to a very advanced age.

Most frequent between the ages of 18 to 85.

Met with in all periods of life, except in youth, when it is quite rare.

Middle age and advanced life.

Sex ........

More frequent in women (2:1).

More frequent in women.

More frequent in men.

No marked difference between the two sexes.

Epigastric pun.

Quite intense; appears shortly after meals; grows severer on pressure: disappears at the end of the digestive period; seldom perfectly free periods.

The pain appears without regularity and is not in any way dependent upon the meals; is re-1 i e v e d by pressure and shows intervals of several days* duration which are perfectly free from pain.

The pain appears about two to three hours after meals a n d disappears after partaking of some food (especially meat, milk, egg) or after the administration o f bicarbonate of soda.

The pain is less intense in char-acter but more steady: there are seldom free intermissions during which no distress is felt in the gastric region.

Appetite..

Appetite not impaired, although pa -tient as a rule eats less on account of his suffering.

Variable ............

Often increased.

Appetite, as a rule, very poor.

Tongue...

Dry and red, showing a white stripe in the middle, or smooth and moist or slightly furred.

Presents a nor-mal appearance.

Is either clean or slightly furred.

Almost always thickly coated.

Taste .................

Nothing abnormal...

do.

do.

Very often bitter or sour.

Belching..

As a rule absent; if present, without any bad odor.

do.

do.

As a rule present and very often associated with a disagreeable, even fetid odor.

Regurgitation.

At times present, frequently water brash associated with pyrosis.

Not present...

Water brash and pyrosis quite frequent.

No water brash; pyrosis quite in-teuse.

Vomiting..

Appears in some cases soon after meals.

Shows no regularity in its appearance.

No vomiting..

The vomiting, as a rule, occurs not after each meal but once or twice a day or once in two days, the quantity being often very large.

Haemate-mesis.

Vomiting of a large quantity of blood, either clear red or of coffee - ground color. Blood is also found in the stools. A repetition of the haematemesis may occur on the following day, but if once arrested it does not reappear for quite a long period.

No vomiting of blood.

Mo vomiting of blood.

Vomiting of blood occurs; the quantity is relatively small, the color ordinarily coffee brown. The blood appears in a decomposed condition, presenting f r e -quentiy a fetid odor. The vomiting often recurs with short intermissions.

Gastric ulcer.

Nervous gastralgia.

Hyper-chlorhydria.

Cancer.

Secretory function

1. Gastric juice as a rule increased.

Increased ....

As a rule, highly decreased.

2. Lactic acid absent.

As a rule, present.

Tumor....

No tumor; rarely, however, if the ulcer is near the pylorus, the latter becomes thickened and can be felt as a smooth, lengthy body.

Tumor very frequently palpable; presenting, as a rule, an uneven surface; is painful to pressure and easily movable.

Perforation.

Perforation might take place after a short period of illness.

No perforation.

No perforation.

Perforation occurs only in the last stages of the disease.

Complex-ion.

Complexion com -monly fresh, but anaemic after severe losses of blood

Complexion pale.

Complexion pale.

Complexion sallow and yellowish: skin dry; marked cachexia.