Ulcer Of The Stomach.

Part 11
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: Nervous gastralgia. Most frequent between the ages of 18 to 85. Hyperchlorhydria.

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

Cancer.

Age.......

Met with in all periods of life, Middle age and except in advanced life. youth, when it is quite rare. No marked More frequent difference in men. between the two sexes.

Sex ........

More More frequent frequent in in women (2:1). women.

Epigastric pun. Quite intense; The pain The pain The pain is appears shortly appears appears about less intense in after meals; without two to three char-acter but grows severer regularity hours after more steady: on pressure: and is not in meals a n d there are disappears at any way disappears seldom free the end of the dependent after partaking intermissions digestive upon the of some food during which period; seldom meals; is re- (especially no distress is perfectly free 1 i e v e d by meat, milk, felt in the periods. pressure and egg) or after gastric region. shows the intervals of administration several o f bicarbonate days* of soda. duration which are

perfectly free from pain. Appetite not impaired, although pa Variable ....... Often -tient as a rule ..... increased. eats less on account of his suffering.

Appetite..

Appetite, as a rule, very poor.

Tongue...

Dry and red, showing a white stripe in Presents a Is either clean Almost always the middle, or nor-mal or slightly thickly coated. smooth and appearance. furred. moist or slightly furred. do. do. Very often bitter or sour. As a rule present and very often associated with a disagreeable, even fetid odor.

Taste .............. Nothing ... abnormal... As a rule absent; if present, without any bad odor.

Belching..

do.

do.

At times present, frequently Not Regurgitation. water brash present... associated with pyrosis.

Water brash No water and pyrosis brash; pyrosis quite frequent. quite in-teuse.

Vomiting..

Appears in some cases soon after meals.

The vomiting, as a rule, occurs not after Shows no each meal but regularity in once or twice a No vomiting.. its day or once in appearance. two days, the quantity being often very large. No vomiting Mo vomiting of Vomiting of of blood. blood. blood occurs;

Haematemesis.

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. Gastric ulcer. 1. Gastric juice as a rule increased. 2. Lactic acid absent. No tumor; rarely, however, if the ulcer is near the pylorus, the latter becomes thickened and can be felt as a smooth, lengthy body. Nervous gastralgia.

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. HyperCancer. chlorhydria. As a rule, Increased ... highly . decreased. As a rule, present.

Secretory function

Tumor....

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

Perforation. Perforation No No might take perforation. perforation. place after a short period

Perforation occurs only in the last stages of the

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

disease. Complexion sallow and yellowish: skin dry; marked cachexia.

Complexion.