ROYAL FREE HOSPITAL: FIVE ULCERS OF THE STOMACH: WITH HYPERTROPHY AND DILATATION FROM A CICATRIX OCCUPYING THE PYLORUS, AND HOUR-GLASS CONTRACTION FROM A CICATRIX IN THE LESSER CURVATURE.

Abstract

M. M., an unmarried female servant, aged 23, was admitted an in-patient of the Royal Free Hospital, on October 1st, 185f;, in a state of partial exhaustion. It was very difficult to extract from her any precise and satisfactory account of herself; but, as far as could be ascertained, she had been suffering for about three years from her present symptoms, with occasional remissions of their severity. She complained of pain in the chest (which, on examination, proved to be the epigastrium), somewhat alleviated by slight pressure; and obliging her, in its worst attacs, to assume a prone position. This pain was especially severe about half an hour after meals: and often ended by vomiting, which appeased it for awhile. During the whole three years, she had suffered from a deficiency of the menses, which had for many months amounted to complete amenorrhoea. Occasionally she had pain in the lumbar region; but not in the ordinary situation (in. terscapular and rachidian) of the dorsal pain generally present in gastric ulcer. Her lungs and heart, on examination, appeared healthy. Her pulse was about 85, rather feeble. Her skin was cool. Her body was flaccid and emaciatedL Her face, thin, worn, and weary-loooking, was exactly the physiognomy so often seen in protracted cases of ulcer of the stomach. Bowels constipated. A careful physical examination of the belly showed that there was a considerable enlargement of the stomach. Scarcely overlapped on the right side by the thin edge of the right lobe of the liver, the outline of the stomach could be traced, on each side, above, to the level of the fifth ribs, and below, to a line considerably lower than the umbilicus. Below this, some small intestine could just be distinguished intervening between the stomach and the pubes. On the right side, the ceecum could be traced upwards into the ascending colon, which passed for some distance alongside the distended stomach, retaining its characteristic sound with perfect distinctness until lost in the gastric sound near the anterior edge of the right hypochondrium. On inquiry, it appeared that for some time back the vomiting had become less frequent in its occurrence, while the matters rejected were of large quantity (four or five pints at a time), and of a dark greenish-brown colour. No blood had ever been known to be discharged by stool or vomit. Deep pressure in the epigastrium produced decided uneasiness; though the patient persisted in stating that she was accustomed to relieve the pain by moderate pressure (as in the prone posture) on this part of the belly. The diagnosi. of the case, as ulcer of the stomach, was thus embarrasedl by one or two circumstances, which claimed a careful consideration. With no evidence of hsemonhaga, no rachidian pain, and little tenderness of the epigastriUm, the symptoms were at any rate deficient iL that typical distinctness generally met vith in ordinary instances of gastric ulcer, especially of such long standing. But while the pain, the tenderness, and the decubigts, al pointed to a local or gastric cause of the vomiting, the characters of that vomiting conclusively added, that the stomach was obstructed somewhere in the neighbourhood of the pylorus. And this brought me, practically, almost to an alternative. Was that constriction of the pylorus which probably caused this obstruction the result of scirrhus, or of the contraction caused by the more or less partial cicatrisation of an ulcer ? Considering the youth of the patient, the long duration of her malady, the absence of any pyloric tumour, and the equal absence (so far as one could detect) of any hepatic enlargement or pulmonary deposit, I could not hesitate to prefer* the latter alternative, and to interpret the symptoms as due to an ulcer of the pylorus, giving rise to a cicatrix constricting and obstructing the stomach in this situation. In the serious state of exhaustion in which the patient was admitted, little could be hoped from treatment. She was treated chiefly by opium, with a gentle aperient dose of castor oil; and by a carefully regulated diet, consisting chiefly of milk and ground-rice, or bread, boiled together to a pulp, and allowed to cool. Under this plan, the pain was soon greatly diminished, and the vomiting reduced to