Other Theories As To The Origin Of Gastric Ulcer

As is well known, erosions of the gastric mucosa are found in chronic gastritis and in other diseases complicated with disturbances of circulation. The origin of erosions is explained by Harttung1 in the following way: The contraction of the muscularis of the stomach produces an arrest of the circulation in the rugae with intense congestion in the veins and capillaries, which in turn gives rise to hemorrhages into the mucous membrane. Hemorrhagic infiltration of the mucous membrane arises, in consequence of which the latter receives little or no fresh circulating blood, and very soon succumbs to the digestive effects of the gastric juice. In this way the decay and the destruction of the tissue and the hemorrhagic erosion are produced. These erosions are superficial defects of the gastric mucosa, extending as a rule not deeper than half its thickness. Rokitansky,1 and subsequently Rind-fleisch2 and Key,3 established the theory that the ulcer arises from the further development of an erosion (hemorrhagic erosion).

1O. Harttung: "Ueber Faltenblutungen und hamorrhagische Erosionen." Deutsche med. Wochenschr.. 1890. No. 38, p. 847.

The view, however, that there is a difference in degree hut not in type between erosion and ulcer of the stomach is not correct. Langerhans4 based his opposition to this theory on his experience gained in autopsies. 15 have shown that the diagnosis "erosions of the stomach" can be made clinically, and stated that in none of the cases observed by me an ulcer de-veloped. Virchow6 first expounded the view that the ulcerative process may result from plugging up of the nutrient artery of a certain part of the mucosa either by an embolus or by a thrombus, and that the infarct thus produced is destroyed by the gastric juice. In this way a circumscribed defect arises. Although this view has been greatly supported by Panum's* experiments, who succeeded in producing emboli in the gastric arteries and ulcers in consequence thereof, it is, however, still undecided whether this etiological factor comes into play in all cases of gastric ulcer; for very often the evidence of an embolized or thrombosed artery in the neighborhood of the ulcer is missing. Instead of the older theory that the diminished alkalinity of the blood is the cause of the ulcer (Pavy1), the newer one has been generally accepted: that the hyperacid gastric juice is the most important etiological factor in the production of ulcer.

Although this theory had already been expressed by Wilson Fox2 and others of the older writers, the credit of having placed it on a firmer basis belongs to the more recent investigators, Riegel,3 Jaworski and Korczynski,4 Ewald5 and Charles G. Stockton.5 It has been found by these authors that hyperacidity of the gastric juice is, if not of constant, at any rate of very frequeni occurrence in gastric ulcer. Furthermore, it was ascertained that those conditions in which gastric ulcer is very frequently found (as, for instance, chlorosis, anaemia, amenorrhoea) are also associated with a hyperacid gastric juice. From my own experience I would certainly say that hyperacidity is very often met with in gastric ulcer. There are, however, exceptions to this rule, and twice I had the opportunity of observing gastric ulcer in cases in which there was an entire absence of gastric juice (achylia gastrica). One of these cases did not present any symptoms indicative of an ulcer, the latter had been found accidentally in performing an exploratory laparotomy on the patient.

This case is as follows:

1 Rokitansky: "Lehrbuch der patholog. Anatomie." 2 Rindfleisch: "Lehrbuch der patholog. Anatomie." 3 Axel Key: Gurlt-Virchow's Jahresb., 1871. 4Langerbans: Virchow's Arch., Bd. 124, p. 373. 5 Max Einhorn: Medical Record, June 23d. 1894. 6R. Virchow: Virchow's Archiv, Bd. v., p. 303. 7 Panum: "Experimented Beitriige zurLehre von derEmbolie." Virchow's Archiv, Bd. 25, 1862.

1Pavy: "On Gastric Erosion." Guy's Hospital Reports, vol. xiv., 1868.

2Wilson Fox: "The Diseases of the Stomach," 1872, p. 146.

3F. Riegel: Zeitschr. f. klin. Med., Bd. xii., p. 434, and Deutsche med. Wochenschr., 1886, No. 52.

4 Jaworski und Korczynski: Deutsche med. Wochenschr., 1886, Nos. 47-49.

5 C. A. Ewald: 7. c., p. 229.

6Charles G. Stockton: "The Etiology of Gastric Ulcer." The Medical News, January 14th, 1893.

G. M------, 56 years old, has been complaining for the last three years of attacks of dizziness, extreme anorexia, and occasional vomiting. For weeks after such an attack patient could not walk well on account of a giddy feeling which he often experienced. Bowels were rather constipated. The physical examination of the patient did not reveal anything abnormal, except an anaemic state which found expression in a pale color of the mucous membrane of the lips, eyelids, and the palate. A splashing sound could be easily produced in the gastric region down to the navel. The urine did not contain sugar or albumin. The gastric contents were frequently examined in the course of a whole year with always about the same result: HC1=0, acidity between 2 and 4, no rennet, no pepsin, no biuret test. Patient improved on a richly vegetable diet and gained some pounds in weight. Suddenly, however, he was overcome with an attack of jaundice, accompanied with severe pains and fever. Since that time the pains were more constant than previously, and remained so even after the jaundice had entirely disappeared.

The patient's condition turning from bad to worse, a consultation was held With Drs. A. Rose and F. Lange, and an exploratory laparotomy was decided upon, gall-stones apparently being at the bottom of the trouble. The operation was performed by Dr. F. Lange in my presence. No gall-stones were found. The liver appeared normal. On examining the stomach, however, a small spot (the size of a twenty-five-cent piece), situated in the anterior wall about three inches distant from the lesser curvature as well as from the pylorus, was found necrotized and on the border of perforation. This piece was excised and a typical ulcer found. The stomach was sewn together. The patient got along nicely for the first week after the operation when pneumonia developed, which caused a fatal issue.

Ewald, though a fervent advocate of the last theory, presupposes a predisposition of certain persons to this affection in order to explain the many instances where the theory of hyperacidity would not apply.

The probability is that gastric ulcer is not always produced by one and the same factor, and all the above theories may apply more or less in different instances.