Number

As regards the number of ulcers, according to Brinton, 2 or more are present in 1 out of every 5 cases, or about 21 per cent. Out of 97 such plural cases (corresponding to 463 instances of ulcer), in 57 there were 2 ulcers, in 10, 3, and of the remaining 24 in which "several" ulcers were present, 3 cases offered 4 and 2 cases 5 ulcers each; while in 4 there is reason to suppose even this number was exceeded.

Further Progress Of The Ulcer

1. Cicatrization

The ulcer, as a rule, does not heal with restitution of the normal mucous membrane, but leaves behind a fibrous, centrally depressed scar, which has a tendency to contract. If such a scar be situated at the pylorus, its contraction may produce stricture of this outlet. If the ulcer had a girdle-like shape, constriction of the viscus may occur, and give it the form of an hourglass.

1 Nolte: See Ewald, l. c., 239.

2 Welch: Cited from Osier's "Practice of Medicine," p. 369.

2. Progressive Necrosis and Corrosion. If cicatrization does not occur, the necrotic process may continue for a long period and may cause the following complications:

(A) Corrosion Of Vessels

Vessels of larger or smaller calibre may become opened and give rise to hemorrhage, or if a very large vessel is affected even to fatal bleeding. Among those more frequently involved are the gastric, splenic, and pancreatic arteries.

(B) Adhesions To Neighboring Organs And Perforations

As soon as necrosis extends to the serosa, it leads either to a reactive inflammation with adhesions to surrounding organs and extension of the process to them, or where circumstances do not permit such adhesions, to a direct perforation into the abdominal cavity. After the adhesions have formed, a perforation may yet take place into a neighboring cavity. Thus perforation into the pleural or pericardial cavities occurs, or sometimes a fistula is formed between the stomach and duodenum or colon. According to the site of the ulcer, any of the neighboring organs, liver, gall bladder, pancreas, spleeu, diaphragm, heart, lungs, etc., may become subject to these adhesions. Perforations of the anterior wall of the stomach are most dangerous on account of the greater mobility of this part of the organ and the consequent lack of adhesive inflammation. These, as a rule, terminate fatally.

Symptomatology

A typical case of gastric ulcer is ushered in by disturbances of the gastric digestion. At the beginning there is merely a feeling of uneasiness and pain in the epigastric region; but these are soon followed by nausea and regurgitation or vomiting. These symptoms may undergo no change for a long period; at times, however, they become more severe in character. The pains especially take on a • more aggravated form, and many patients are afraid to eat on account of them. Very often a hemorrhage from the stomach occurs, producing an increase of the anaemia and cachexia which already exist in consequence of subnutrition. If the disease takes a progressive course, it is liable to end lethally by perforation, hemorrhage, or by inanition. In most instances, however, the course of the disease is cut short either by a spontaneous cicatrization of the ulcer, or by the same process being brought about by our rational means of treatment. The symptoms then gradually disappear, and recovery takes place. In many instances the symptoms of the disease reappear after the lapse of various periods of time (one or several years). It is then quite difficult to decide whether we have to deal in these instances with the formation of new ulcers, or a breaking down of the cicatrix of the old lesion.

As the above-mentioned symptoms of ulcer are met with likewise in many other disturbances of the stomach, and inasmuch as each of them has its specific character in the different lesions, it will be best to analyze each of the symptoms of gastric ulcer separately.