Reprinted from the 
Philadelphia Hospital Reports 
Vol. 1, 1890. 
TUBERCULOUS ULCER OF THE STOMACH. 
J. H. MDSSER, M. D. Reprinted from the 
Philadelphia Hospital Reports, 
Vol. I, 1890. 
TUBERCULOUS ULCER OF THE STOMACH 
J. H. MUSSER, M.D 
The occurrence in the writer’s experience of a case of the char- 
acter indicated in the title induced him to examine-the recorded 
knowledge of this affection. Appended to this article is found a 
bibliography which includes most of the articles that have been 
written on tubercular ulceration of the stomach. All of the 
articles referred to were carefully examined and the recorded 
cases abstracted and tabulated. After this preparation, the writer 
unfortunately lost the manuscript of the work in question from 
his carriage, save a few cases in abstract and some data; the 
bibliography alone was saved. The subsequent notes, therefore, 
are based on a recollection of the facts which the writer secured. 
They are correct in general, though lacking in precise details ; 
possibly the reader will gain by this loss, because the impres- 
ions, which include the conclusions that had been arrived at, 
will be more briefly presented than in the elaborate and, perhaps, 
labored article which the writer had in contemplation. It is 
believed all the practical portion of the subject is well illustrated 
in the paper. 
The patient in whom this rare condition existed was admitted 
to the wards of the Philadelphia Hospital in the last stages of 
pulmonary phthisis, with associate tubercular disease of the 
intestinal tract. He was a colored man, and 44 years of age; 
there was nothing peculiar about the origin and course of the 
disease. It was remarked, at the time of his illness, that lie was 
rather filthy in his personal habits, apathetic and careless about 
his appearance. He did not expectorate much, while it was 2 
TUBERCULOUS ULCER OF THE STOMACH. 
noticeable that the pulmonary discharges were swallowed. Apart 
from the pulmonary and intestinal symptoms, there was no evi- 
dence of local tuberculosis of other organs. The patient took 
food well and without discomfort. 
Abstract of Autopsy.—Mesentery toward pylorus and peritoneum about bile-ducts 
studded with tubercle. Mustard-seed tubercle of peritoneum in lesser curvature, 
extending from l£ inches from pylorus to three inches beyond. This corresponded to 
an area of thickening of the gnslric walls, which, on section, were found to be 
opposite to a transverse ulcer in the lesser curvature, 3 inches in transverse length and 
12 inches wide, door of which was cribriform. Directly in line of lesser curvature 
the submucous coal was much thickened, as well as parietal peritoneal wall, about 
g inch thick. The posterior end of ulceration extends to peritoneum. In the door 
can be seen small tubercles. At the anterior end of ulceration is a small, drm, 
yellowish tubercle, which, on section, was found to contain cheesy matter ; and, 
undoubtedly, the extensive ulceration was due to the breaking down of similar 
cheesy nodules. Adjacent to this cheesy nodule a few firm submucous mustard- 
seed tubercles are seen. The cribriform state, not unlike that seen in the bladder, 
is evidently composed of muscular structure ; mucous membrane around ulcer not 
thickened. The deep portion of this ulcer at posterior extremity, tlie size of a 
nickel, is apparently due to breaking in of a large submucous cheesy mass. 
Bronchial glands at root of lung enlarged, particularly on right side, but not 
involved as generally in the tubercular process as the solitary glands of intestine. 
Only a few anterior mediastinal glands enlarged. Mesenteric and retroperitoneal 
glands-enlarged, and some caseous. Lungs and other organs of the usual appear- 
ance in tuberculosis. The usual histological appearance of the milary tubercle 
and this cheesy mass were found on microscopical examination, and with proper 
staining the tubercle bacillus was found in its usual relations. 
Simple round ulcer of the stomach frequently occurs with 
tuberculosis. Welch remarks that, as tuberculosis claims such 
a large proportion of victims at the age when simple round ulcer 
is likely to develop, the occasional coincidence should be expected. 
Tt has been thought, however, to be a marked predisposing cause 
of tuberculosis. There is no doubt that the occurrence of this 
lesion in the stomach may cause such a degree of anaemia and such 
a debilitated state of the system as would favor infection by 
the bacillus. It has not, however, been the experience, at least 
the recorded experience, of any one to find simple ulcer of the 
stomach arise in the course of phthisis. The occurrence of gas- 
tric ulceration subsequent to tuberculosis of other organs is due 
to tubercular infection of the stomach. While, therefore, we may 
see simple round ulcer of the stomach frequently occur as 
a lesion antecedent to. tuberculosis of other organs, ulceration 
subsequent to the tubercular process is of bacillary origin. TUBERCULOUS ULCER OP THE STOMACH 
3 
As may be inferred from the above, tubercular ulcer of the 
stomach is never primary. It occurs subsequent to tubercular 
disease of other organs, and usually ensues when there is general 
infection. It is more likely to occur in the acute forms of the 
disease than in the more chronic. As it is of secondary origin, 
none of the predisposing causes of tuberculosis are operative in 
making gastric infection more probable. It is within the province 
of a discussion of this subject to inquire, why secondary infection 
of the stomach takes place, and not to discuss the cause of tuber- 
culosis. From its infrequency it is more natural, indeed, to 
inquire into the cause of its rarity than the reason for its pres- 
ence. The above assertions are anticipating some facts now to 
be stated. 
The interest attaching to tuberculous ulcer of the stomach 
arises largely from its rarity. Some forty cases only are detailed. 
Cruveilliicr, Rokitansky, Klebs and other eminent pathologists 
of large experience speak of its great rarity. Indeed, it appears 
to have been the opportunity of individual pathologists to have 
seen but one or two of these cases. Steiner and Neureuter record 
four cases in 302 autopsies on cases of tuberculosis in children ; 
Widerhofer two cases in 418 autopsies; and Rilliet and Barthez 
the unusual number of twenty-one in 141 autopsies. All authori- 
ties agree that the last mentioned authors were mistaken as to the 
nature of the ulcers. In the writer’s experience, it has occurred but 
once in a series of one hundred autopsies on cases of tuberculosis in 
adults. On the other hand, Robert thinks it is not so rare in 
children; and it is quite remarkable to note that of the recorded 
cases a very large proportion occurred in children; at least ten 
or twelve are thus recorded. Fernet says it is more frequent in 
children than in adults. Subsequent to childhood its occurence 
takes place at different ages, the oldest recorded case being in a 
person past seventy. 
The infrequency of ulceration of the stomach of tubercular 
origin has been explained in two ways. Pathologists differ 
about equally in their opinion as to the cause of the freedom of 
this organ from infection. On the one hand, it is believed that the 
secretions of the stomach are antagonistic to and virtually destroy 
the tubercle bacillus; and on the other, a largo number, on most 
excellent ground, believe that the absence of the lymphatic 
structure in the submucous coat, which forms a lodgment for the 4 
TUBERCULOUS ULCER OF THE STOMACH 
bacillus, is the cause of the absence of the disease. For the first 
theory, experiments are quoted to substantiate it. It lias been 
found over and over again that acids, and particularly the acid 
secretions of the stomach, do destroy or prevent the growth of the 
tubercle bacillus. The anatomical reason, however, has much 
to support it. It is almost impossible, therefore, to decide which 
is tho proper view. The frequent occurrence of the infection in 
children may be because of the more frequent disorder of the 
secretions in childhood, coupled with the fact that the sputum is 
almost always swallowed at this period and therefore more likely 
to infect the mucous membrane which it bathes. It is quite 
certain, too, from the case which the writer observed and from 
the memoranda of other cases, that the subjects of this disease 
had been careless and did not expectorate as they should or, as 
iu children, had not the strength or the understanding to do so. 
Morbid Anatomy.—Tuberculous ulcer in the stomach should 
not be considered such without the positive presence of the 
bacillus in the lesion, together with the histological appearances 
common to tuberculosis; indeed, it may be doubted that one 
could pronounce an ulcer tuberculous unless the bacillus were 
demonstrated. The cases which the writer has analyzed and 
which were recorded since Koch’s discovery, were examined for 
the bacillus and its presence determined. Notwithstanding this 
criterion, which has been set up by many pathologists for tuber- 
cular ulcer, the appearance and association seem to warrant one 
recognizing this form of ulcer without difficulty. The ulcer or 
ulcers, for there are more than one usually, are very large. They 
have been found most frequently in the lesser curvature, in the 
direction of which their greatest length is seen. 
Lebert, quoted by Spillman, reports a certain number of obser- 
vations in which the ulcers were at the cardia, at the pylorus and 
at the greater curvature. While the greater number are found 
in the lesser curvature, their seat is quite variable. Many, 
indeed, were seen in the anterior wall. The case reported by 
Litten was a single ulcer in this position. 
The mucous coat is entirely destroyed and the ulceration 
extends to the submucous or muscular coat; the floor of the ulcer 
is uneven, sometimes clean, sometimes bathed with cheesy and 
mucous material. Little masses of tubercle arc readily seen by 
the naked eye. Sometimes the floor appears striated or ribbed, TUBERCULOUS ULCER OF THE STOMACH. 
5 
not unlike the appearance of the bladder as seen in old people. 
The edges vary in thickness; in one portion they may be con- 
siderably indurated, in another scarcely at all. Often the edges 
are undermined and overhanging. Usually there is a great deal 
of submucous infiltration extending from one side of the ulcer 
as much as an inch or an inch and a half in distance. This on 
section is found to be caseating and indicates the direction in which 
the ulcer is extending. The submucous coat is the seat of little 
islands of infiltration scattered about the ulcer, and smaller ulcers 
frequently are seen in the vicinity. Indeed, it is usually the rule 
to find two or more ulcers rather than a single one. The vascular- 
ity of the ulcers differs; some are anasmic in appearance, others 
are situated over vessels or have penetrated the vessel. When 
death has occurred from this cause the clot and other appearances 
of the hemorrhage are seen. In one of Ilebb’s cases the thick- 
ened extremity of an artery occluded by a recent clot, projected 
about one-eighth of an inch above the level of the floor of the ulcer. 
The peritoneum over the ulcer is dull, opaque, and usually 
studded with minute tubercles. Indeed, sometimes the ulcera- 
tion seems to have extended from without inwards. Forster 
report's the case of a patient in whom a tubercle of the peritoneal 
coat of the stomach had softened and produced perforation. 
Wilson Fox reports a similar case. Boneke (in Forster) writes 
of a case of tuberculous perforating ulcer, in which the ulcera- 
tion occurred near a tuberculous lymphatic gland, with degenera- 
tion of the serosa. 
The unusual occurrence of ulcerous communication between the 
stomach and colon was observed by Oppolzer, in 1863. He believes 
it to be of tuberculous origin. Hemorrhage has been referred to. 
Peritonitis, after perforation, as in simple round ulcer, has been 
observed in one instance of tuberculous ulceration of the stom- 
ach. Paulicke found perforation with fatal peritonitis to have 
occurred in a group of tuberculous ulcers near the pylorus, one 
of which had perforated. 
The lymphatic glands in the lesser curvature of the stomach 
are enlarged and caseated. The anatomical appearances in other 
organs are those of tuberculosis. 
Symptoms.—It is quite remarkable that in the large majority 
of cases the ulceration existed without any symptoms; indeed, 
most frequently its presence was not suspected. In the cases 6 
TUBERCULOUS ULCER OF THE STOMACH. 
which manifested gastric symptoms prior to death, they occurred 
but a short time before this termination. In only one of the 
large series of cases were the symptoms sufficiently classical to 
warrant the diagnosis of ulcer of the stomach a long while before 
death. It was a case of Gerhardt’s. Pain, vomiting, and epigas- 
tric tenderness, like that of ulcer of the stomach, were present 
for many weeks. Apart from the combination of symptoms in 
this case all of the cases were without symptoms, or single gastric 
symptoms alone were complained of. Epigastric pain and ten- 
derness were noted five or six times. The occurrence of sudden 
hemorrhage was recorded a number of times, and its occurrence 
was the first indication of gastric lesion. In the larger majority 
of the cases in childhood it was the only symptom of gastric 
origin, and was followed usually in a short time by death. In 
some of the cases the vomiting that occurred could not have 
been told from the vomiting of gastritis. Perforation and peri- 
tonitis occurred in one case. From a study of the cases, there- 
fore, we are warranted in the statement that the larger portion 
of cases show no symptoms of the grave ulceration that is present. 
Hemorrhage occurred in fully one-fourth of the cases, in a suf- 
ficient amount to cause death. It is worthy of note that the 
Inematemesis is seen in children as frequently, if not more so, 
than in adults. Vomiting occurred in many cases, and was the 
only symptom of gastric disturbance, but was not significant. 
The same may be said regarding the pain. Of course the signifi- 
cance of these symptoms combined, or of one marked symptom, 
is much increased by the association with, or occurrence during 
the course of, tuberculosis. Given a case of the latter with such 
symptoms, tuberculous ulcer might well be suspected. The strik- 
ing occurrence of gastric hemorrhage in the course of tuberculosis 
without previous gastric symptoms, might be considered almost 
always to be due to ulcer. The gastric symptoms apparently did 
not influence the course of the primary disease in any way, 
unless fatal hemorrhage or perforation arose. 
JHagnosis.—Little need be said of this. As indicated above, 
when .hemorrhage occurs in the latter stages of tuberculosis, 
it is probably due to an ulcer of the stomach, and when the 
classical symptoms of ulcer of the stomach arise during the 
progress of tuberculosis, they are due, in all probability, to second- 
ary ulceration in that organ. TUBERCULOUS ULCER OF THE STOMACH. 
7 
Conclusions: 
1. Tuberculous ulceration of the stomach is rare. 
2. It occurs most frequently in children. 
3. It is never primary. 
4. Gastric infection is probably due to the voluntary or invol- 
untary swallowing of sputum. 
5. The presence of the bacillus tuberculosis is the only positive 
proof of the nature of the ulceration. 
6. The anatomical peculiarities of this form of ulceration 
include the following: 
a. The seat of the ulcer is in the lesser curvature, although it 
may be found in any position. 
b. More than one ulcer is usually seen. 
c. The ulcers are large and irregular. 
d. Miliary tubercles in the floor of the ulcer or in the sub- 
mucous coat are seen. 
e. The ulcers are near vessels and the results of vascular ulcer- 
ation arc found. 
/. Small caseating masses are seen in the ulcer or at a portion 
of the periphery. Similar collections are found in the territory 
adjacent to the ulcer, in the submucous coat. 
g. The peritoneum is studded with miliary tubercle very often. 
h. Neighboring lymphatics are involved. 
7. In the large majority of cases there were no symptoms dur- 
ing life. 
8. Sudden hemorrhage is a frequent symptom and cause of 
death ; it has been particularly noted in children. 
9. Epigastric pain and vomiting may occur. 
10. The presence of gastric symptoms of this kind, occurring 
in the course of tuberculosis, is significant of possible ulceration. 
11. In view of the fact that the swallowing of sputum is pos- 
sibly dangerous, expectoration should be insisted upon in adults 
and its method taught to children. 
BIBLIOGRAPHY. 
Widerhofer.—Article on diseases of the stomach and intestines. Gerhardt's 
Handbook, vol. iy., abth. 2. Two cases in 418 autopsies on tuberculous subjects. 
One a girl nine years old ; other a girl twelve years old. 
Steiner and Neureuter.—Prager Vierteljahresschrift, 1865, 22 Jalirg. 2. 
Bd., p. 34. 8 
TUBERCULOUS ULCER OF THE STOMACH. 
Rilliet and Barthez.—Traite Mai. des Enfants. 
Ulcus Ventriculi Tuberculosum. By D. M. Litten. Virchow’s Archiv, 1876, 
LXVII, 615. 
Kuhl (Johannes).—Tuberculose Magengeschwiire. Thesis. Kiel, 1889,16 p., 8°. 
Hebb.—Tuberc. Ulcer Stomach. Westminster Hosp. Rep., London, 1888, in, 
155-158. 
Oppolzer.—Berl. klin. Woch., 1863. 
Wilson Fox.—Reynold’s System of Medicine. 
Welch.—Pepper’s System of Medicine. Ulcer of Stomach. 
Hare.—Encyclopaedia Dis. of Children. Keating. 1890. Ulcer of Stomach. 
Bignon.—Bull, de la Soc. anat., vol. xxvm, p. 211. 
Fernet.—Soc. Mod. des Hop., Seance March 12, 1880. 
Le Uievre, Maxime, Etude sur 1’ulcere de l’estomac ehez les tuberculeux. 
These, Paris, 1882. 
Spillman.—These, Paris, p. 175, 1878. 
Bignon.—Perforations spontanees de l’Estomac, These de Paris, 1854. 
F< irste r .—Path. anat. 
Ulcers of stomach in a child the subject of general Tuberculosis. Thomas 
Barlow, Path. Soc. Loud., 1887, xxxviit. 
Cazin, II.—Des tubercules de l’estomac, specialement chez les enfants. These, 
Paris, 1881.