Latent Ulcer

All the above symptoms of gastric ulcer may at times be missing, and the sickness may remain concealed. It is well known that scars resulting from ulcer are found at autopsies in the stomachs of people who apparently never had any gastric trouble.

The following is a good example of an ulcer without typical subjective symptoms, showing at the same time the importance of hemorrhage as a diagnostic sign:

Mrs. H------, 44 years old, has been complaining for the last five years of frequent belching, poor appetite, and constant pains of a very slight character in the epigastric region. Patient never had any hemorrhage nor any intense pains, and her bowels were always regular. During her illness she has lost eight pounds, and looks extremely pale and anaemic. The examination of the abdomen reveals the position of the stomach between the navel and one finger's width above the pubes. There is no pain on pressure either in the epigastric or gastric region, although the epigastrium is somewhat sensitive to pressure. Right kidney movable. Ex-animation with the tube one hour after the test breakfast results in the withdrawal of coffee-colored contents mixed with fine particles of bread; the microscope shows numerous red blood corpuscles; the chemical analysis of the filtrate reveals HCl+acidity = 76. On the next day the patient's stools were black from admixture with blood.

The diagnosis of gastric ulcer was made and the patient treated accordingly. She gradually recuperated, and under a further tonic treatment entirely recovered, and has remained free from any symptoms for the last two years.

Again, such a latent ulcer may sometimes suddenly give rise to alarming symptoms, and even cause death from perforation or a profused hemorrhage.

Duration Of The Disease

The duration of gastric ulcer is sometimes extremely long. Brinton cites cases in which the sickness had lasted from thirty to thirty-five years.

Complications

Complications quite frequently appear during the protracted course of this affection. These may comprise a sudden exacerbation of one of the usual symptoms, as for instance the pain or vomiting, which may become uncontrollable, and hemorrhage, which may become fatal in a few hours or even in a few minutes. Again, they are sometimes caused by intercurrent phenomena.

Perforation

The most dangerous complication of gastric ulcer is perforation, which is due to an extension of the ulcerative process through the whole stomach wall to the peritoneum. It is followed by sloughing or rupture of these delicate membranes, and by the effusion of the contents of the stomach into the peritoneal cavity. The perforation is accompanied by very intense and characteristic symptoms. The patient is suddenly attacked by a violent pain, which begins in the epigastric region, and rapidly spreads over the abdomen. Sometimes the patients have a sensation as if something had given way in their abdominal cavity, and a gush of liquid had occurred. Symptoms of general peritonitis now quickly appear. In a short time the whole abdomen becomes greatly distended and extremely painful to the slightest touch. Entrance of gas into the abdominal cavity occurs, in consequence of which the dulness of the liver sometimes disappears; at times, again, emphysema of the skin develops. The extremities become cold, while the temperature of the body rises. The pulse becomes very small and can hardly be counted.

A cold sweat breaks out on the face, which wears an expression of extreme anxiety (facies Hippocratica); singultus is present, as a rule, while vomiting may at times be absent (in those instances where the entire contents of the stomach have escaped into the abdominal cavity). After a short period of coma the patient usually dies. Rarely does the train of symptoms following perforation offer a marked deviation from the above description. In many instances, a remarkable paroxysm of pain precedes the occurrence of perforation. This pain, the duration of which varies from a few minutes to several hours, is generally due to a leakage of the gastric contents through the thin film of rotten tissue, to which at this period the coats of the stomach are reduced. Partial perforation, allowing of a subsequent repetition of the accident, or leading to abscess, presents symptoms of a more local, more chronic, and less intense character than those of ordinary perforation. Perforation nearly always occurs after a full meal, and is often traceable to mechanical violence, such as coughing, sneezing, or constriction of the abdomen.

Sometimes, before the perforation arises, an adhesive inflammatory process takes place, in consequence of which the stomach in the affected area becomes adherent to neighboring organs, a process which may then prevent the entrance of the gastric contents into the peritoneal cavity. A local abscess is very often the result of such an occurrence. This form of abscess may open into different cavities; thus, for instance, a fistulous opening between the stomach and the colon, or the stomach and the abdomen, has frequently been found established. Again, the abscess may perforate the diaphragm and lung, and be evacuated in this way. As these instances are not so very frequent, I will here mention a case of this kind which I observed ten years ago.

A lady, about 30 years old, after a short period of slight dyspeptic symptoms, was suddenly attacked with profuse gastric hemorrhages. On the first day she vomited about one pint and a half of almost clear blood, the vomiting being accompanied by severe pains in the gastric region. She was kept in bed, an ice-bag applied to her abdomen, and large doses of opiates were administered. On the following day the hfiemateme-sis was repeated. Under the above treatment, however, the patient began slightly to improve and to take small quantities of milk. About a week after the first hemorrhage she suddenly experienced a more intense pain in her abdomen, followed by all the symptoms of severe collapse. Singultus appeared, the abdomen swelled, and became extremely painful to the touch, while the temperature rose to 104°, the pulse to 140, and the extremities grew cold. The diagnosis of perforation of the ulcer was quite clear, and the patient was believed to be dying. This critical state remained unchanged for about four or five days, when suddenly the dyspnoea, which had before existed in a slight degree, increased, while the expired air assumed a very offensive odor. This symptom increased to such a degree that it was hardly possible to sit in the same room with the patient.