College of S^f)v^itiani anb burgeons! Hihravp i.[y\r\\r DISEASES OF THE STOMACH WITH SPECIAL EEFEEENCE TO TREATMENT BY CHARLES D. AARON, Sc.D., M.D. PROFESSOR OF GASTROENTEROLOGY AND ADJUNCT PROFESSOR OF DIETETICS IN THE DETROIT COLLEGE OF medicine; PROFESSOR OF DISEASES OF THE STOMACH AND INTESTINES IN THE DEXROIT POST-GRADUATE SCHOOL OF MEDICINE; CONSULTING GASTROENTEROLOGIST TO HARPER HOSPITAL WITH 42 ILLUSTRATIONS AND 21 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK Entered according to the Act of Congress, in the year 1911, by LEA & FEBIGER in the Office of the Librarian of Congress. All rights reserved. to 05 o o o DEDICATED TO PROFESSOR ADOLF SCHMIDT, M.D. DIRECTOR OF THE MEDICAL CLINIC AT THE UNIVERSITY OF HALLE IN RECOGNITION OF HIS INVALUABLE CONTRIBUTIONS TO THE SCIENCE OF GASTROENTEROLOGY ^3 Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofstomacOOaaro PREFACE In this work the author has endeavored to cover the medical aspects of gastric disorders in such a manner as to answer the actual needs of the practitioner. To keep the book within convenient limits, it has been restricted to the useful and suggestive aspects of present knowledge on the subjects discussed, the purely speculative being rigor- ously excluded. It is intentionally practical and therapeutic, hence etiology, symptomatology, pathology, and diagnosis are introduced only in so far as they are necessary to an understanding of the methods of treatment proposed. In addition to the chapter on Medication, due attention has been given to the use of Antilytic Serum and Bacterial Vaccines. Care has been exercised to reflect the latest progress in this rapidly advancing department. Because of recent discoveries in the physiology of digestion, a chapter has been added upon this subject, but from the viewpoint of the chnician rather than that of the physiologist. The chapter on Examination of the Stomach Contents includes those tests which, in the opinion of the author, will best assist the practitioner in diagnosis and treat- ment. With regard to surgical treatment, no more has been attempted than to give the indications. Although surgery is indicated in many cases of stomach disease, the utmost caution is necessary to avoid useless or injurious intervention. Inasmuch as a large number of gastric disorders may be classed as neuroses, emphasis has been placed upon this phase of the general subject. It is accordingly given priority in position, and discussed under various subdivi- sions — as neuroses resulting in sensory disturbances, those VI PREFACE responsible for motor disturbances, and those to which derangements of the secretory function may be traced. The attention of the reader is drawn to pathologic condi- tions due to ptosis of the abdominal viscera, as the author has obtained good results in the treatment of gastroptosis by employing the principle of mechanical support. Achylia Gastrica is considered under the head of Chronic Gastritis because the latter involves the diminution and eventual cessation of gastric secretion. The author wishes to make acknowledgment of his indebtedness to the many American practitioners who have contributed so greatly to the advancement of gastro- enterology, and to the foreign writers whose scientific achievements have received approval nowhere more cor- dially than in this country. C. D. A. Detroit, Michigan, 1911. CONTENTS CHAPTER I The Physiology of Digestion Salivary Digestion; Movements of the Stomach; Gastric Digestion; Intestinal Digestion 17-30 CHAPTER II Examination of the Stomach Contents Test Meals; Macroscopic Examination of Stomach Contents; Chemic Examination of Stomach Contents; Quantitative Analysis; Examination of Enzymes; Carbohydrate Diges- tion in the Stomach; Blood in Gastric Contents; Examination of Feces; Indirect Methods of Gastric Analysis; Skin Reaction in Carcinoma; Motor Function of the Stomach; Permeability of the Pylorus; Microscopic Examination of Stomach Contents; Changes in Gastric Secretion due to Pathologic Conditions . 31-76 CHAPTER III Diet in Gastric Diseases Composition of Foods; Heat Value of Foods; Dietary Regulations and Lists; Meat; Fat; Milk; Cheese; Bread; Potatoes; Rice; Green Vegetables; Liquors; Fruit; Sugar; Spices; Water; Alcohol; Tea and Coffee 77-105 CHAPTER IV Artificial Food Preparations Preparations of Animal Protein, Vegetable Protein, Milk Protein, Egg Protein; Preparations from Carbohydrates; Dextrinated Flours; Mixed Nutritive Preparations; Preparations Contain- ing Fat; Milk Preparations; Stimulating Preparations; Rela- tive Value of Meat Extracts 106-117 CHAPTER V Lavage of the Stomach Indications, Contraindications, and Technique; The Stomach Douche 118-132 viii CONTENTS CHAPTER VI Massage — Electricity Massage of the Stomach; Electric Treatment of the Stomach, Intraventricular and Extraventricular . . ... . . . 133-145 CHAPTER VII HtDROTHERAPEUTICS — ^IlXERAL WaTERS Hydriatic and Thermic Treatment of the Stomach; Half Baths, Cold and Warm Packs, Prolonged Baths, Compresses, Douches; Mineral Waters — Alkaline Chlorine, Sodium Chlo- ride, Alkaline Carbonated, Ferruginous, and Bitter; Mineral Baths, Sea Baths, and Climatic Cures; American ^Mineral Waters 146-165 CHAPTER VIII Medicatioxs Hydrochloric Acid; Pepsin; Pancreatin; Alkalies; Bismuth; Strych- nine and the Bitters; Silver Nitrate; Gastric Sedatives; Gas- tric Anodynes; Drugs Used Incidentally in Gastric Disorders; Antiseptics; Emollients 166-201 CHAPTER IX Indications for Surgical Intervention Gastroenterostomy and Gastrostomy; Gastric Ulcer; Perforation in Gastric Ulcer; Pyloric Stenosis; Acute Dilatation of the Stomach; Gastric Tetany; Perigastritis; Hourglass Contrac- tion; Carcinoma 202-219 CHAPTER X Alterations in the Position of the Stomach and Other Abdominal Organs : Gastroptosis — Enteroptosis — Nephroptosis — Hepato ptosis — Splenoptosis Pathology and Symptoms of Gastroptosis and Enteroptosis; Palpa- tion of the Ividney; Treatment; Technique of Nutrition; Exercise and Massage; Electrotherapeutics; Hydrothera- peutics; Mechanical Treatment of Enteroptosis; Medicinal Treatment; Surgical Treatment 220-258 CONTENTS IX CHAPTER XI Motor Neuroses: Hypermotility — Peristaltic Unrest — Carpio- SPASM — Pylorospasm — Eructations — Pneumatosis — Vomiting — RuxMiNATioN — Regurgitation — Pyloric Insufficiency — Singultus Gastricus Nervous Affections of the Stomach; Hypermotihty; Peristaltic Unrest of the Stomach; Cardiospasm and Pylorospasm, with Reference Especially to Treatment by Dilatation; Nervous Eructations (Aerophagy); Pneumatosis (Drum-belly); Nervous Vomiting; Rumination, Merycism; Regurgitation; Insuffi- ciency of the Pylorus; Singultus Gastricus 259-281 CHAPTER XII Sensory Neuroses : Gastralgia — Hyperesthesia — Gastralgokenosis — Nausea — Bulimia — Akoria — Anorexia — ^Eye Strain Gastralgia, Cardialgia, Gastrodynia, Neuralgia of the Stomach; Gastric Hyperesthesia; Gastralgokenosis; Nervous Nausea; Bulimia; Akoria; Nervous Anorexia; Gastric Neuroses, and Eye Strain 282-294 CHAPTER XIII Nervous Dyspepsia: Neurasthenia Gastrica Relation to Disturbances of Other Organs, Notably Appendicitis; The Rest Cure; Nutrition — Lactovegetable Diet; Physical Treatment; Mineral Waters; Sea Water Therapy; Drug Treatment; Vicarious Surgery 295-310 CHAPTER XIV Secretory Neuroses: Hyperacidity — Hyperchlorhydria — Super- acidity Hyperchlorhydria; Chronic Acid Gastritis; Treatment of Hyper- acidity, Hyperchlorhydria, and Acid Gastritis — Fats and Oils; Salt-free Diet; Silver Nitrate; Atropine; Hydrogen Peroxide; AlkaUes • 311-331 CHAPTER XV Secretory Neuroses (continued) : Hypersecretion — Gastrorrhea — Gastrosuccorrhea — Gastrochylorrhea Intermittent or Periodic Hypersecretion; Acute or Intermittent Gastrorrhea; Chronic Gastrorrhea — Reichmann's Disease; AUmentary Hypersecretion 332-345 X CONTENTS CHAPTER XVI Acute Gastritis : Simple — -Infectious — Toxic — Phlegmonous Simple Acute Gastritis; The Best Method of Cleansing the Stomach; The Use of Emetics; Gastro-enteritis as a Complication; Acute Infectious Gastritis; Toxic Gastritis; Phlegmonous Gastritis — Pathology, etc 346-361 CHAPTER XVII Chronic Gastritis: Subacid Gastritis — Anacid Gastritis — Achylia Gastrica Chronic Gastritis (Chronic Gastric Catarrh); Achylia Gastrica; Treatment of Gastritis and Achylia Gastrica 362-392 CHAPTER XVIII Motor Insufficiency: Atony (Myasthenia) — Dilatation (Ischo- chymia, Gastrectasis) — Stenosis of the Pylorus Motor Insufficiency of the First Degree; Motor Insufficiency of the Second Degree; Acute Dilatation of the Stomach .... 393-417 CHAPTER XIX Gastric Ulcer: Ulcus Ventriculi — Round Ulcer — Peptic Ulcer — Perforating Gastric Ulcer Situation; Frequency; Sex Predisposition and Age; Vomiting; Perforation; Appetite; Leube-Ziemssen Treatment; Lenhartz Treatment; Duodenal Alimentation; Medicinal Treatment; Antilytic Serum; Bacterial Vaccines; Surgery 418-459 CHAPTER XX Gastric Hemorrhage — Gastrorrhagia Differential Diagnosis; Treatment by Lavage; Diet; Ergot; Gelatin; AdrenaHn; Bismuth Salts; EscaUn; Silver Nitrate; Analgesics; Hematinics; Operative Treatment 460-476 CHAPTER XXI Erosions — Perigastritis Erosions — Predisposition; Dietetic, General and Local Treatment; Perigastritis — Development; Form; Early Diagnosis; Treat- ment 477-486 CONTENTS xi CHAPTER XXII Arteriosclerosis — Syphilis — Tuberculosis Arteriosclerosis — Manifestations and Pathology; Treatment by Means of Inorganic Blood Salts, or Serum; Syphilis — Advan- tages of Hypodermic Medication; Salvarsan; Tuberculosis — Forms and Treatment 487-502 CHAPTER XXIII Tumors of the Stomach: Carcinoma — Sarcoma — Fibroma — Fibro- MYOMA — Lipoma — Adenoma — Papilloma — Polypi — Hernia Epigastrica Carcinoma — Heredity; Situation; Forms; Comphcations; Lactic Acid as a Sign; Results of Surgical Treatment; Internal Treat- ment; Diet Lists; Lavage; Radium; Treatment of Carcinoma of the Cardia; Sarcoma — Differential Diagnosis; Treatment; Benign Tumors; Hernia Epigastrica 503-532 f\.\'\'.)\ f DISEASES OP THE STOMACH CHAPTER I THE PHYSIOLOGY OF DIGESTION The physiology of digestion appeals to the physician, the physiologist, and the chemist, from sHghtly varying viewpoints. To the physiologist and the chemist the pro- cess itself is the chief concern. The clinician must go farther: he must not only be conversant with the changes which take place under normal conditions, but he must be able to make the necessary deductions when called upon to treat abnormal digestion. While the physiologist and the chemist study the stomach or the action of the gastric secretion, the physician has to consider this organ in its relation to oral and intestinal digestion also. Digestion proper begins with the mastication and insali- vation of food. The food becomes more or less intimately incorporated with the sahva before being swallowed, and, as we shall see, the process begun in the mouth continues in the stomach. It is important that the condition of the oral and buccal cavity should be the best possible. Putre- factive processes in the mouth should receive prompt atten- tion, and the dentist should be consulted at regular intervals. By the term digestion is understood the process of rendering food material absorbable, a process which is ac- comphshed by the disintegrating and dissolving action of secretions containing enzymes, assisted to a greater or less extent by mechanical action. These ferments or enzymes are found in the saliva, gastric juice, bile, and pancreatic and intestinal juices. Certain fermentative and putrefactive agents in the intestinal canal likewise perform an important part in the process of digestion. 2 18 THE PHYSIOLOGY OF DIGESTION SALIVARY DIGESTION Action of the Saliva. — In man and in most of the higher animals the sahva has a twofold action — physical and chemical. The physical action of sahva consists in the moistening of the food so as to facilitate mastication by the teeth; moreover, by virtue of the mucin it contains, all the passages become lubricated, rendering more easy the act of deglutition and the passage of the bolus of food into the stomach. In dogs the physical action of sahva is the only one. In herbivorous and in omnivorous animals, including man, the saliva has a chemical action also, which is very important in its relation to the digestion of starch. Saliva has a specific gravity of 1.002. ' The secretion from the parotid gland contains a ferment, ptyalin, which possesses the property of converting starch into dextrin or maltose. "WTiile the action of the amylase, ptyalin, begins with the food in the mouth, the greater portion of salivary digestion is performed during the first period of digestion in the stomach; for though the partaking of food causes almost immediate secretion of hydrochloric acid by the gastric glands, some time must elapse (from twenty to forty minutes) before the acid secretion of the stomach can pene- trate the food sufficiently to inhibit salivary digestion. According to the observations of Cannon and Griitzner, the food material at the fundus portion of the stomach may remain undisturbed for a considerable time and thus escape mixture with the gastric juice. Complete mastication of food, in order that the saliva may become thoroughly incorporated with it, is imperative for complete amylolysis. Ptyalin. — Ptyalin, or the diastatic ferment of the saliva, converts starches as well as glycogen into sugar. This ferment acts in a slightly alkahne or neutral medium. Starches are first converted into maltose or isomaltose, from which dextrose appears to be a result of inversion by maltase. The change takes place to better advantage in cooked than in raw starch. The several intermediate stages SALIVARY DIGESTION 19 in the transformation of starches are as follows: The starch becomes liquefied so as to form a true solution, rather than a suspension. The product of the initial stage of salivary digestion is known as amylodextrin, ^Ji3~~turns blue when cw-jX^ treated with a dilute LugoT^solifEibn. As the process con- tinues the color produced by the Lugol solution grad- ually changes from a blue to a violet-red and finally to a mahogany brown. Starches modified to this extent are known as ej;ythrodextrin. As the process of salivary diges- tion continues still further, no color change is obtained from the addition of the Lugol solution; the term achroodextrin is used to designate the product of this stage of the diges- tive process. These changes may be summarized as follows : 1. Amylodextrin (soluble Stains blue with iodine or Lugol starches). solution. 2. Erythrodextrin. Lugol solution changes first to a violet-blue, then red-violet, and finally mahogany brown. 3. Achroodextrin. No color change produced by Lugol solution. 4. Maltose. 5. Dextrose. The rapidity of the diastatic action of the saliva upon starches is checked to a certain extent by the secretion of hydrochloric acid after the food arrives in the stomach. According to the researches of Van den Velden, Ewald, Boas, and others, the action of the ptyalin is limited by small quantities of acids, while larger quantities destroy it com- pletely. It is restricted by a hydrochloric acid secretion of 0.07 per cent., and destroyed entirely by 0.12 per cent. Lactic acid, 0.1 per cent., will restrict the action of ptyalin, and 0.15 per cent, will destroy it completely. Boas considers that when the diastatic ferment of the sahva has not been entirely destroyed by a high degree of acidity it will become again active in the stomach upon diminution of the acid secretion or alkalization of the stomach contents. He believes that ptyalin digestion is not confined to the initial twenty to forty minutes during which the food in the stomach is not fairly penetrated by the hydrochloric acid secretion. 20 THE PHYSIOLOGY OF DIGESTION MOVEMENTS OF THE STOMACH Solid food remains in the stomach for several hours, where it is subjected to the action of a special fluid, the gastric juice. During this time, b}^ muscular contractions of the walls of the stomach, the thinner portions of the chymified material are ejected into the intestine. The tonic closure of the sphincters at the cardia and pj^lorus shuts off the food from the remainder of the aUmentary canal except at such times as there is a relaxation of the pylorus to permit the entrance of chj^me into the duode- num. During the initial stages of gastric digestion the pylo- rus is closed so firmly that upon removal of the stomach none of its contents will escape. As digestion advances, however, the pjdorus offers less and less resistance, until finally it yields to permit the passage into the duodenum of digested gastric contents. Since the discovery of the .T-rays, interesting studies have been made of the movements of the stomach. Cannon, among others, has devoted much attention to the subject. By giving an animal food mixed with bismuth subnitrate, he was able to obtain skiagraphs of the stomach, the bismuth being opaque to the .r-rays. From these studies it has been confirmed that peristaltic movements take place soon after the entrance of food into the stomach. According to Walter B. Cannon,^ the stomach ''consists of two parts physiologic- ally distinct" — the cardiac portion, a food reservoir in which saUvary digestion continues, and the pyloric portion, the seat of active gastric digestion. The food passes from the former to the latter by tonic contraction of the muscles. According to Moritz, Leven, and Cannon, peristaltic mus- cular activity is confined to the pyloric portion. Tlio last writer holds that the efficiency of peristalsis in mixing the food depends upon the contraction of the pyloric sphincter, so that each peristaltic ring or contraction wave forces the • Medical News, May 20, 1905. MOVEMENTS OF THE STOMACH 21 gastric contents into a blind pouch. Unable to pass out through the pyloric exit, the food is forced back through a succeeding peristaltic ring. In this way the food is brought thoroughly under the influence of the glandular secretions of the pyloric portion of the stomach. According to Moritz, in the human stomach during digestion the peri- staltic waves occur at intervals of about twenty seconds. In periods of relaxation of the pyloric sphincter, as diges- tion progresses, these contraction waves force some of the fluid contents of the stomach into the duodenum. The hydrochloric acid secretion in the stomach apparently causes the pylorus to relax; on the other hand, the same acid secretion seems to have the opposite effect upon the pylorus after the acid chyme passes into the duodenum, namely, that of contraction. After the propulsion of a certain quantity of fluid chyme into the intestine the pylorus remains closed until the acid on the distal side of the pyloric sphincter becomes neutralized by the alkaline pancreatic secretion in the duodenum. The acid chyme provides a chemical stimulus for pancreatic secretion. By mixing bismuth subnitrate with the food and obtain- ing a skiagraph of the stomach during the process of diges- tion, it has been learned further that carbohydrate foods begin to pass out of the stomach a comparatively short time after ingestion, requiring only about one-half as much time for gastric digestion as proteins. When taken alone, fats have been found to remain for a long time in the stomach, and when taken along with other foods they delay to a marked extent the passage of the whole chymified food mass into the intestine. According to the researches of Cannon, if carbohydrates be fed before proteins in an experi- mental diet, the former, being nearest the pyloric portion of the stomach, will be almost immediately propelled into the intestinal canal, leaving the protein behind to be acted upon by the gastric juice. To reverse the order of feeding will retard the passage of carbohydrates into the duodenum. The stomach is essentially an automatic organ. Hof- meister and Schultz have shown that the excised stomach 22 THE PHYSIOLOGY OF DIGESTION when kept at the temperature of the body continues to execute regular movements. It has nerve plexuses within its walls and is also connected with the cerebrospinal and sympathetic systems. During digestion the normal peri- staltic movements of the stomach are in all probability due to a local reflex from Auerbach's plexus. Stimulation of the sympathetic fibres has an inhibitory effect upon gastric peristalsis. It has been found by experiment that, as a rule, the impulses received along the path of the vagus are motor. The automatic rhythmical contraction is inherent in the muscular coat of the stomach, however, and is merely regu- lated by impulses from the central nervous system passing down the vagi or splanchnic nerves. The pyloric sphincter as well as the remainder of the musculature of the stomach is supplied by motor fibres from the vagus nerve; the splanchnic nerves constitute the source of inhibition. Stim- ulation of the splanchnic nerves causes the contracted stomach to dilate and the pylorus to relax. GASTRIC DIGESTION We are indebted to Pawlow, the Russian investigator, for new knowledge concerning the physiology of digestion, especially that portion of the subject which is most directly concerned with gastric secretion. Pawlow's experiments enabled him to study the gastric secretion in dogs after feeding certain foods, and the effect of the so-called sham feeding upon gastric secretion. This investigator has also studied the relation between the action of gastric and that of pancreatic juice. These studies were facilitated by the establishment of a gastric fistula leading from a blind pouch or cul-de-sac. We have learned from the experiments of Pawlow that the glands of the stomach continue to secrete gastric juice until the food enters the duodenum, the quantity of secretion being in proportion to the quantity of food ingested. While the secretion of the stomach under normal conditions is always acid, the acidity increases as the gastric GASTRIC DIGESTION 23 juice is more rapidly secreted. Furthermore, the digestive power of the gastric juice is subject to variation, depending upon the kind of food ingested. Gastric juice secreted after a bread diet is said to possess the greatest digestive power, while that of least strength follows the partaking of a purely milk diet. The total acidity, on the other hand, is greatest after meat and lowest after bread diet. From the point of view of weight, meat requires the greatest and milk the smallest amount of gastric juice. In the majority of cases the so-called pyschic secretion, or that produced by the sight, taste, or odor of food, constitutes the commencement of gastric secre- tion. Such substances as meat broths and meat juices or solutions of meat extracts are excellent stimulants to gastric secretion. After gastric secretion has begun, further diges- tive power is developed by the ingestion of bread and egg foods. The amalgamation of protein and starch in bread accounts for the high digestive power that ''bread juice" is said to contain. Fats have the effect of diminishing or inhibiting secretion; they do not in any way stimulate it. Enzymes. — The study of enzymes has engrossed the atten- tion of a number of observers during recent years. The commonly accepted view of the mode of action of these ferments is that originally propounded by Osswald, namely, that they act by catalysis. The term is employed by chem- ists to designate a kind of reaction which is brought about by the mere contact or presence of certain substances known as catalyzers, which themselves appear to remain un- changed. As defined by Starling, a catalyzer is a substance which will increase the velocity of a reaction without adding in any way to the energy changes involved in the reaction or taking part in the formation of end products. The activity of enzymes appears to be specific in character; e. g., those ferments which act upon carbohydrates are not capable of producing any effect upon fats or proteins. The enzymes of the body are colloidal in structure, with an unknown composition. Most of them are soluble in water, glycerin, or physiologic salt solution. They are destroyed completely by high temperatures, 140° to 175°, 24 THE PHYSIOLOGY OF DIGESTION and their physiologic action is retarded in whole or in part by temperatures only slightly below the normal. The enzymes are capable of their greatest activity' at the temperature of the human body. They may be precipitated from solution, in part at least, by alcohol, which property is utiUzed in obtaining purified specimens. Enzymes may exist in an inactive or latent form in the cells which pro- duce them, and may be still inactive after they are secreted. The inactive or latent forms of enzymes are known as zymo- gens or proenzymes. Before the zymogen can become effectual, it requires the aid of some other agent. The inorganic substances rendering the enzymes active agents in digestion are known as activators; organic substances which produce the same result are called kinases. The fundus and the pyloric portion of the stomach are supplied with tubular glands which exhibit marked differ- ences in structure in the two parts. In man, the tubular glands of the fundus are provided with a duct lined with simple columnar epithelial cells, into which duct empty one or two secreting tubules supphed -wdth two varieties of epi- thehal cells, namely, central or peptic cells, and parietal or oxyntic cells. In the pyloric portion of the stomach there is only the one kind of cell, namely, the peptic. The pari- etal or oxyntic cells are the acid-secreting cells, while the central or peptic cells provide the pepsinogen or pepsin and rennin for gastric digestion. Pepsin. — Pepsin, or rather pepsinogen, is active only in the presence of free hydrochloric acid. Hydrochloric acid possesses the property of converting pepsinogen into pepsin more thoroughly than can be done by any other mineral acid. Pepsinogen, or pepsin in the latent state, has such a high resistant power that it is present even in markedly advanced stages of catarrhal gastritis, as well as in cancer. Peptones constitute the end result of peptic digestion. The conversion of proteins and gelatin substances into soluble peptones takes place by degrees, so gradually in fact that it is difficult to determine the intermediate products of the process. GASTRIC DIGESTION 25 Hydrochloric Acid. — Hydrochloric acid acts in various ways in performing and facilitating the normal process of diges- tion. In the first place, it is antizymotic and antiseptic, destroying pathogenic microorganisms and arresting fermen- tation; the antiseptic action of hydrochloric acid continues in the duodenum. It also acts as a means of regulating peri- stalsis. Hydrochloric acid with pepsin converts food proteins into peptones; pepsin, however, is the chief agent in this transformation process, hydrochloric acid acting as an adju- vant. By hydrochloric acid cane sugar is converted into dextrose and levulose. Normal Gastric Juice. — Normal gastric juice is a thin, colorless or nearly colorless fluid, with a strongly acid reaction and a characteristic odor; its specific gravity is about 1.002. The acidity of the gastric juice is due to the presence of free hydrochloric acid, the amount of which varies according to the duration of digestion. The acidity at the beginning of digestion is low, owing to the fact that a portion of the acid is neutrahzed by the alkalinity of the sahva incorporated with the food. While the gastric juice has a more or less constant acidity, its reaction may be diminished by alkalies in the stomach, or by combination with the protein of the food, forming acid-albumins or syntonins. The normal acidity of the gastric juice of man, estimated to be 0.2 per cent., may, according to Hornberg, reach 0.4 or 0.5 per cent, during digestion. Pawlow, in his work on the digestive glands, has demon- strated that gastric secretion is under the control of the nervous system, and that the secretory fibres are contained in the vagus. If the vagus be cut below the origin of the recurrent laryngeal, so as to avoid paralysis of the larynx, and sham feeding performed, there is no gastric secretion, proving conclusively that the vagus contains the secretory fibres. The hypothesis is confirmed by stimulation of the peripheral end of the cut nerve. Pawlow's experiment, which consists in dividing the esophagus of a dog in the neck, and connecting the esophageal mucous membrane with the skin so as to form a fistulous opening, is well 26 THE PHYSIOLOGY OF DIGESTION known. Food fed to Pawlow's dogs escaped through the fistulous opening in the esophagus without reaching the stomach. The sham meal, as the experimenter designates it, had the effect of producing a copious flow of gastric juice, so long as the vagus nerve was intact. The flow of gastric juice resulted evidently from a stimulation of the secretory fibres of the vagus nerve, by the sensations of sight, odor, taste, etc., during the masticating and swallow- ing of food. The beginning of gastric secretion, according to Pawlow, is psychic. Under normal conditions gastric juice continues to be secreted so long as food remains in the stomach. Pawlow has taught that mechanical stimulation of the gastric mu- cous membrane has no effect upon the secretion of the glands of the stomach. The sensation of eating serves to start the secretion in an ordinary meal. The afferent stimuli originate in the mouth and nostrils and, as stated, probably with the sense of sight. The efferent path is through the vagus nerve. In this way begins gastric digestion, the further action of which is conditioned by the stomach itself and its contents. Some food articles, among which are meat extracts, meat juices, and soups, and in a less degree milk and water, are said to contain substances which, when taken into the stomach, promote gastric secretion. "Secretin." — Decoctions of the mucous membrane of the pylorus injected into the blood are found to increase the secretion of gastric juice. According to Edkins, secretagogues pre-formed in the food or produced during digestion act upon the mucous membrane of the pylorus, giving rise to a "gastrin," or gastric "secretin," which, after absorption into the blood, is carried to the gastric glands and stinui- lates them to secretion. These chemical messengers deter- mining the various secretions, such as gastric, pancreatic, hepatic, and intestinal, have been designated horfnoncs (from oiiif/Ko. I arouse or excite) (Starling). Pepsin. — Pepsin is a proteolytic ferment capable of act- ing only in an acid medium, so that peptic digestion in the stomach is a result of the combined action of pepsin and GASTRIC DIGESTION 27 hydrochloric acid. Pepsin, as stated, is formed in the central or peptic cells of the gastric mucosa; it is present in the cells as a zymogen or pepsinogen, which does not becojne active pepsin until after it is secreted. Pepsinogen is quickly converted into active pepsin by the action of the hydrochloric acid of the gastric secretion. Owing to the constant presence of hydrochloric acid in normal gastric secretion, pepsin is always present in active form. The principal action of the gastric juice consists in the conversion of the proteins of the food into diffusible pep- tones. Soluble protein, after passing through several inter- mediate stages, the results of which have been isolated and named acid-albumin, parapeptone, and propeptone, be- comes peptone. The first step in the digestion of protein consists in its conversion into an acid-albumin (syntonin). Under the action of pepsin, syntonin or acid-albumin under- goes hydrolysis, producing protalbumoses. Under the con- tinued influence of pepsin these bodies undergo further hydrolysis, with the consequent formation of secondary proteoses (deutero-albumoses). The further hydrolysis of the secondary proteoses results in the production of pep- tones. Rennin. — Rennin is analogous to pepsin in that it is formed in the principal or central cells and is present in the cells as a zymogen. The conversion of prorennin into the active enzyme takes place very readily under the influ- ence of hydrochloric acid. Rennin possesses the property of curdling the casein of milk, to which its action in the stomach appears to be entirely confined. Casein, the chief protein in milk, has an important nutritive value. It is digested, like other proteins, by pepsin in the stomach and trypsin in the intestine, the end result of the process of gastric digestion being peptone. Lipase. — It has been demonstrated by Volhard that the normal gastriemucosa in man secretes a lipase, or fat-sphtting ferment, which acts readily upon the emulsified fats of milk, cream, or yolk of egg. This ferment, which is secreted by the cells of the fundus of the stomach, has been 28 THE PHYSIOLOGY OF DIGESTION extracted by means of glycerin. It is inactive in an alkaline medium. Fats in gastric digestion become liquefied by the heat of the body, and, being thus set free from their intimate admix- ture with other foodstuffs, are disseminated throughout the chyme by the movements of the stomach. In this way they are prepared for digestion by the pancreatic juice and bile in the intestine. Absorptive Power of the Stomach. — It is probable that the absorptive power of the stomach is limited to such sub- stances as salts, sugars, and dextrins that may have been formed from starch in salivary digestion. Absorption does not take place readily in the stomach; it is a distinctive feature of intestinal digestion. According to von ]\Iering, water when taken alone is practically not at all absorbed in the stomach, but as soon as introduced begins to pass into the intestine in a series of spurts, by the contraction of the walls of the stomach. Von Mering has also demon- strated that, while the stomach is capable of absorbing carbon dioxide, alcohol, sugar, dextrin, or peptones, in solution, it can absorb little or no water. On the other hand, when the foregoing substances, except water, are taken into the stomach, water is secreted b.y the gastric glands in propor- tion to the amount of the substances absorbed. INTESTINAL DIGESTION Pancreatic secretion is stimulated to its greatest activity by the presence of such acids as hydrochloric, phosphoric, citric, lactic, or acetic, which seem to be equally effective in this regard. Condiments have little or no effect upon it. It has been found impossible to stimulate pancreatic secre- tion by way of the rectum; the one efficient stimulus is contingent upon the outpouring of acid chyme into the duodenum. Pancreatic secretion is increased by tlie pres- ence of fat, which also causes an increase in the lipogenic ferment. Water is also a stimulant to pancreatic secretion. INTESTINAL DIGESTION 29 When the Hquefied food in the form of chyme passes through the pylorus it is subjected to the digestive action of the bile and the pancreatic and intestinal juices. While the greatest quantity of gastric secretion occurs the first hour after a meal, the maximum of pancreatic secretion occurs about the third hour, at a time coincident with the presence of the greatest amount of chyme in the duodenum. The cells of the intestinal mucosa produce a prosecretin, an inactive substance which is converted into secretin when the acid chyme enters the duodenum. Secretin is a hormone which acts upon the pancreas through the circulation. The secretion of pancreatic juice seems to take place automatic- ally : when the acid chyme becomes neutralized by the alka- line secretion of the pancreas, the formation of secretin is inhibited until the entrance of a further quantity of acid chyme, when secretin is again produced and taken up by the circulation, whence it again excites the flow of pan- creatic juice. The pancreatic secretion contains three ferments— namely, amylopsin, by which starch is converted into dextrin and maltose and later into glucose; lipase, a ferment which possesses the property of acting upon neutral fats, converting them into fatty acids and glycerin; and trypsinogen, a latent enzyme, which is transformed into an active enzyme by the ferment enterokinase found in the intestinal juice. The intestinal juice contains secretin, enterokinase, and a proteolytic enzyme described by Cohn- heim and named by him erepsin. Erepsin, while not capable of acting upon original protein, acts on albu- moses and peptones, which it splits into simpler molecules (amino-acids) , apparently completing the work of the pepsin and trypsin. In addition to these, the intestinal juice con- tains three enzymes which act upon carbohydrates. They are: maltase, which acts on maltose; invertin, which acts on cane sugar; and lactase, which acts on ixdlk sugar. Bile possesses weak amylolytic fermentative action. Its most important function is to assist in the digestion and absorption of fats. It is probable that in the digestion and 30 THE PHYSIOLOGY OF DIGESTION absorption of fats the action of both pancreatic juice and bile is essential. Intestinal digestion takes place in the upper portion of the small intestine. The function of the lower segments of the small intestine, as well as the colon, is absorption of fluids. The colon possesses the further function of acting as a reservoir or container for food residues. CHAPTER II EXAMINATION OF THE STOMACH CONTENTS Examination of material obtained from the fasting stomach is one of the most important diagnostic aids in ascertaining the nature and extent of pathologic conditions of the stomach. The presence of food remnants in large quantities from the last or from a preceding meal, especially if sour- smelUng, points to a disturbance of gastric motility. If the quantity of gastric juice which may be removed from the fasting stomach constantly exceeds 100 Cc, a condition known as gastrosuccorrhea (Reichmann's disease), gastrorrhea, hypersecretion, or gastrochylorrhea, is present. According to recent investigations, it is highly probable that gastrochylorrhea is a sequel to disturbance of the motor functions of the stomach. A small amount of mucus and saliva may be found in the normal fasting stomach, its viscidity being observed in pouring from one vessel to another. Numerous mucin bodies and epithelial cells are seen upon microscopic examination. The presence of mucus and saliva in the fasting stomach may be due to stomatitis, pharyngitis, ptyalism, or pathologic conditions affecting the glandular portion of the stomach. Bile may regurgitate into the stomach from the duo- denum. When it has been long in the stomach it under- goes change, its biUrubin becoming biliverdin, so that the fluid takes on a yellowish or greenish color. According to Brucke, bile does not interfere with the peptic activity of the gastric glands, except that, like every albuminoid body, it has a strong affinity for the acid of the stomach. Sometimes in the fasting stomach a mixture of bile, pan- creatic juice, and perhaps succus entericus is found. Intes- 32 EXAMINATION OF THE STOMACH CONTENTS tinal juices in small quantities have no special pathologic significance. Blood is found in the stomach under such conditions as hemorrhage from gastric ulcer, irritation of the pathologic gastric mucosa upon the passing of a stomach tube, and vigorous movements caused by expression of stomach con- tents. Hemorrhages may originate in the esophagus, pharynx, nasal cavity, or lungs. Hemoptysis and hematem- esis may exist contemporaneously; when, however, they are not found together, it is not a difficult matter to distin- guish the source in cases of either kind of hemorrhage. Slight hemorrhages, when there is an admixture of blood and mucus, are significant only when found upon repeated examinations. Pus, according to recent investigators, is frequently found in stomach contents. Boas has found it in cases of ulcerating carcinoma. It is easily recognized, even macro- scopically, in such cases, by the foul-smelling yellowish-green and occasionally blood-stained masses. TEST MEALS The normal secretion of the gastric juice has been thor- oughly studied in man by Ewald and Boas. They find that the secretion of gastric juice starts almost as soon as the food enters the stomach and continues until it enters the duodenum. The investigations of Pawlow show that the secretion of gastric juice starts even before the food reaches the stomach (psychic secretion). During the latter part of digestion in the stomach the secretion of gastric juice normally decreases, for which reason the results of analytic examination of the gastric contents are sub- ject to variation. The first hydrochloric acid secreted by the stomach unites with all the protein and salts to form combined acids. Only after all these affinities have been satisfied can we find free hydrochloric acid. If a meal consists of large quantities of protein, it is obvious that free TEST MEALS 33 hydrochloric acid will appear later than if the meal con- sisted in larger proportion of carbohydrates. A test meal should contain all the ingredients of an ordinary meal. In order to make a study of the secretory function of the stomach, it is necessary to have some one meal taken as a standard. For this reason test meals of known compo- sition are given for analytic purposes. It is customary to give test meals in the morning, w^hen the stomach is most likely to be empty; occasionally, however, the test meal is given at noon or in the evening, depending upon the pur- pose in view. Ewald-Boas Test Breakfast. — Ewald-Boas' test breakfast con- sists of a roll or two slices of white bread without butter and two small cups (300 to 400 Cc.) of water or weak tea without cream or sugar. The patient should thoroughly masticate the bread or roll. The stomach contents should be removed in one hour, since digestion is at its height at this time. This test breakfast contains protein, sugar, starches, non-nitrogenous extractives, and salts. It will thus be seen that the stomach is offered all the usual ingredients of a meal, with the advantage that the whole is liquefied in a very short time and so modified that passage of the contents through the stomach tube is not hindered, as might be the case if more solid food were taken. This test breakfast, while suitable for routine examination, has the disadvantage of introducing into the stomach a variable amount of lactic acid as well as numerous yeast cells with the bread. Boas' test breakfast consists of a tablespoonful of rolled oats in a quart of water, reduced to one pint by boiling. A pinch of salt is added to make it more palatable to the patient. This meal, inasmuch as it does not contain lactic acid, is usually given when detection of lactic acid is important, as in cases of suspected cancer. Riegel Test Dinner. — At noon the patient is given a meal consisting of beef broth, 150 to 200 grammes of beefsteak, 50 grammes potatoes as puree, and a roll of white bread. The stomach contents are removed in from three to four hours 3 34 EXAMINATION OF THE STOMACH CONTENTS and examined. The advantage of this test meal is the opportunity it affords to note the degree of digestibility of starches and proteins. Fleiner's test meal is similar. MACROSCOPIC EXAMINATION OF STOMACH CONTENTS Having withdrawn the test meal at the allotted time, the physician should carefully inspect the appearance and note the quantity and odor of the material. After the stomach tube is introduced, as stated on page 123, there are two methods of obtaining the stomach contents: (1) The ex- pression method of Ewald and Boas, and (2) aspiration by means of some suction apparatus. Methods for Obtaining Stomach Contents. — Expression Method. — The first method is the simplest and easiest at our command, and the stomach tube itself is the only instru- ment necessary. The tube being in the stomach, the patient is instructed to take a deep inspiration, to hold his breath, and bear down with his abdominal muscles, when the gas- tric contents will pour out from the end of the tube into a tumbler held for their reception. Sometimes coughing or moving the tube a little will produce a gagging sensation, and this induces the abdominal pressure that forces out the stomach contents. Should nothing come through the tube, it may be assumed that the stomach is empty. In removing the tube it is well to cover the end snugly with the finger, to prevent the escape of so much of the stomach contents as the tube contains, thereby adding so much more to the quan- tity for examination and at the same time avoiding a ''muss." Aspiration Method. — For removing gastric contents by the second method, almost any instrument that will create a vacuum may be employed. The so-called "stomach pump " has been used, but it has been found that sometimes, even in its careful use, pieces of gastric mucous membrane are detached — drawn into the eye of the tube. The aspirator bulb of Ewald seems to be now in general use. It is really a ten-ounce Politzer bag, provided at its upper MACROSCOPIC EXAMIXATIOX OF STOMACH CONTEXTS 35 end with a large-sized hard rubber tip, over which the stom- ach tube can be adjusted (Fig. 1). The air is forced out of Fig. 1 Fig. 2 Stomach tube and aspirator. Stomach bucket. 36 EXAMINATION OF THE STOMACH CONTENTS the bag, which is then attached to the stomach tube while the latter is in the stomach. By allomng the bag to expand, the stomach contents are aspirated. Aspirating bottles with stopcocks and other complicated attachments have been devised for the removing of the stomach contents, but such apparatus is really unnecessary. Einhorn^ has devised a stomach bucket to remove the stomach contents. It consists of a small capsule-shaped vessel (Fig. 2) made of silver (If cm. long, | cm. wide), open at the top and for a short distance down the side. The opening is surmounted by an arch, to which a silk thread is tied, and a knot made sixteen inches from the attachment. In order to secure a sample of the stomach contents, the bucket is first dipped in lukewarm water (filled and emptied) to facilitate filling when in the stomach; the patient is asked to open his mouth wide, and the bucket is placed on the root of the tongue (almost in the pharynx) ; the patient is then instructed to perform the act of swallowing, and within one or two minutes the bucket enters the stomach. It is left there for five minutes ,and then withdrawn. During the withdrawal of the appa- ratus, resistance is usually felt at the introitus esophagi. To overcome this difficulty the patient is again instructed to swallow, by which act the larynx is pushed forward and upward so as to free the passage, when the bucket can be easily withdrawn. If the stomach was not empty, the bucket returns with gastric contents sufficient for the making of various important tests. Inspection of Stomach Contents. — By inspection one should distinguish between absolutely undigested, partially digested, and well digested contents. It is also possible to distin- guish by inspection between carbohydrate and protein digestion. Absolutely undigested food masses are found in advanced cases of gastric catarrh, in atrophic con- ditions of the gastric mucous membrane, and likewise in achylia gastrica. The presence of undigested food points also to marked secretory disturbance. In such conditions the appearance of the test meal after removal resembles * Diseeises of the Sfomach, 1906, p. 81. MACROSCOPIC EXAMINATION OF STOMACH CONTENTS 37 that of a mixture of the bread and water before ingestion. The absence of peptic digestion is ascertained by the clear- ness of the filtrate. By inspection the presence of blood, mucus, bile, or intestinal juices, and occasionally pus, animal parasites, and fragments from the gastric mucosa, may be detected. In cases characterized by marked gastric reten- tion, the stomach contents when placed in a vessel are some- times observed to be in three separate layers. The upper consists of mucus, or undigested food particles which have undergone fermentation; the next, which is the largest, of fluid ; while that on the bottom of the vessel consists of chyme. This is the condition found in abnormal gastric fermentation and extreme gastric insufficiency. According to Boas, the filtrate of the entire contents of the normal stomach, evacuated exactly one hour after a test breakfast, measures 20 to 50 Cc. There may be much less than this, or the stomach may be entirely empty; if so, the condition is what has been designated hypermotility or hyperkinesis, found in organic and nervous gastric affec- tions, such as chronic gastritis, achyha gastrica, buhmia, and whenever there is insufficiency of the pylorus. On the other hand, if remnants of the preceding meal are con- stantly found in the stomach contents in the morning, the finding is indicative of impairment in gastric motihty, the degree of which can be ascertained only by repeated exami- nations of the stomach contents. Determination of Gastric Juice. — The method of Mathieu and Remond is commonly used to determine the total amount of gastric juice secreted. The gastric contents are removed as completely as possible at the stated interval after an Ewald test breakfast. Water, 200 cubic centi- meters, is then poured into the stomach through the stomach tube and thoroughly mixed with the gastric contents by moving the funnel up and down, as well as by pressure upon the stomach. As much as possible of this fluid is collected in a separate receptacle, and the chnician proceeds to ascer- tain the acidity of the undiluted as well as that of the diluted stomach contents. From these data, conclusions 38 EXAMIXATIOX OF THE STOMACH CONTEXTS may be drawn as to the degree of dilution and the amount of the residual gastric contents. Mathieu endeavors to ascertain the total stomach con- tents by the following formula: a = the acidity of the undiluted gastric contents. 6=the acidity of the diluted gastric contents. a;=the amount of the test meal remaining in the stomach after the first extraction. 200 C.c.=the amount of water introduced into the stomach for dilution. Then a -.b : : {x + 200) : x ax = bix + 200) 200 & ^ = — »: a — In ascertaining the acidity of the stomach contents, it is necessary to determine the total available acidity rather than the mere degree of acidity. Color. — Gastric juice is a colorless hquid, though at times it may show a mild opacity. It may vary, however, with the color of food taken. Coffee or particles of toasted bread will lend a distinctly brownish coloration, while meat will tend to discolor the juice red. A distinct red color may also be due to the presence of blood, which grows darker the longer the blood remains in the stomach. The color of gastric contents may be either yellow or green, due to the presence of bihrubin or biliverdin, bihary pigments which may be detected by the tests for bile in the urine. A brownish-black coloration and fetid odor of the stomach contents points to intestinal obstruction below the duodenum. Odor. — The odor of normal gastric juice is sHghtly sour. It is offensive when the gastric juice is mixed with materials from the intestinal canal. In the vomitus of uremia there is often a distinct odor of ammonia; an alcoholic odor is present in alcoholic intoxication. Stagnation of gastric contents gives rise to an intensely strong odor. Consistency. — Usually watery in character, the normal stomach contents vary with the character of the extraneous material composing them. In catarrhal gastritis or in cases CHEMIC EXAMINATION OF STOMACH CONTENTS 39 marked by subacidity, there may be present after a test meal so much tough, shmy mucoid material as to render filtering of the stomach contents impossible. The stomach is practically never empty, always contain- ing a certain quantity of fluid, acid in reaction, which Boas regards as normal in amounts of not less than ten or more than a hundred cubic centimeters. Riegel, on the other hand, regards any amount of material in the fasting stomach as pathologic. CHEMIC EXAMINATION OF STOMACH CONTENTS Chemic examination of gastric contents consists in the use of reagents to determine the actual state of digestion, so that by comparing it with normal physiologic digestion one may obtain information in regard to any functional dis- turbances or changes present. These examinations should Fig. 3 Necessary apparatus for making analysis of stomach contents: a, glass tumbler for holding stomach contents; 6, filter paper; c, glass funnel; d, sedimentation glass; e, gastric filtrate; /, graduated pipets, holding 5 Cc; g, porcelain spoon; h, beaker; i, alcohol lamp; j, buret for titrating with xa normal sodium hydrate solution; k, buret stand. be made as frequently as may be necessary to enable the clinician to form a correct estimate of the condition of the gastric function; it is only in rare cases that positive results can be obtained from a single examination. Apparatus. — The special apparatus required for the analytic work is very simple (Fig. 3). 40 EXAMINATION OF THE STOMACH CONTENTS In a complete chemic analysis the following tests should be made: Test. Reagents. 1. Reaction Litmus. 2. Hydrochloric acid Glinzburg. 3. Total acidity Phenolphthalein. . 4. Free hydrochloric acid .... Dimethylamidoazobenzol. 5. Combined hydrochloric acid . . . Ahzarin. 6. Lactic acid Uffelmann. 7. Pepsin Mett. 8. Rennin Calcium chloride. 9. Propeptone Copper sulphate. 10. Peptone Sodium chloride. 11. Dextrin Lugol solution. 12. Erythrodextrin Lugol solution. 13. Achroodextrin Lugol solution. 14. Maltose Fehling solution. Determination of Reaction. — After the macroscopic examina- tion of the stomach contents, a portion should be filtered and the filtrate tested by litmus paper, in order to ascertain the reaction, which may be acid, alkaline, amphoteric, or neutral. If the reaction is found to be acid, the next step is to ascertain the presence of free hydrochloric acid. This is done by means of Congo red. Congo red was intro- duced into practice and recommended in the form of Congo paper, as a reagent for free hydrochloric acid. Congo red in solution is, however, more sensitive than Congo paper. The solution is prepared by dissolving one gramme of the powdered Congo in 100 Cc. of water. By the use of the solution 0.0009 per cent, of hydrochloric acid may be detected, while the paper does not react unless 0.01 per cent, of hydrochloric acid is present. Congo red paper consists simply of filter paper saturated with an alcoholic solution of Congo red and permitted to dry. The presence of free hydrochloric acid in the gastric juice is determined by the changing of the Congo red to blue on contact with the stomach contents. The test confirms the presence of free mineral acids only. It has been found that gastric juice will sometimes react distinctly because of the presence of either free lactic or free acetic acid. The test may be used, CHEMIC EXAMINATION OF STOMACH CONTENTS 41 however, for the detection of free hydrochloric acid, since this is ordinarily the only mineral acid to be found in the stomach contents. Dimethylamidoazobenzol Test. — This test depends upon the coloration which a 0.5-per-cent. alcoholic solution of dimethylamidoazobenzol produces when treated with gastric juice containing free hydrochloric acid. To make the test, a few cubic centimeters of filtered gastric juice are placed in a porcelain spoon or dish, and one to two drops of the dimethylamidoazobenzol solution added. A carmine red color results when free hydrochloric acid is present. This reagent does not react to organic acids unless they are present in amount over 0.5 per cent. The proportion of free hydrochloric acid present may be determined by the inten- sity of coloration when the reagent is added, for so small a proportion as one part to fifty thousand, or 0.02 per thousand, gives the color reaction. From a clinical point of view it is of the utmost importance to determine the presence or absence of hydrochloric acid. After this has been deter- mined, then it must be ascertained whether the secretion is increased or decreased. When free hydrochloric acid is found to be present, it is unnecessary to test for pepsin or pepsinogen, since these ferments are always present when free hydrochloric acid can be demonstrated, \^^len, however, this acid is absent, we may still have a secretion of pepsinogen. For the detection of free hydrochloric acid the Giinzburg test is perhaps the most reliable. Giinzburg's Test. — Giinzburg's, or the phloroglucin-vanillin, reagent is prepared as follows: Gm. or Cc. I^ — Phloroglucini 2.0 3ss Vanillini 1.0 gr. xv Alcoholis absoluti 30.0 oj Misce. Three drops of filtered stomach contents are placed in a porcelain spoon or dish (Fig. 3, g); to this, 3 drops of the rea- gent are added from a small pipet, and the two solutions are thoroughly mixed. The porcelain spoon or dish is then very carefully heated over a small flame (Fig. 3, i), when if free 42 EXAMINATION OF THE STOMACH CONTENTS hydrochloric acid is present a cherry red tint is obtained around the edges of the mixture (Plate I, Figs. 3 and 4). This color is due to the deposition of very fine crystals, an effect which would occur in even aqueous solutions of 0.01 per cent. This peculiar color is not produced by any organic acid whatsoever. Instead of the phloroglucin solution, a filter paper prepared by means of it is sometimes used; when moistened with two or three drops of stomach con- tents and heated, it reveals the presence of hydrochloric acid by developing the same cherry red tint. The test with the solution is more reUable. QUANTITATIVE ANALYSIS The buret is used for all quantitative analyses. It is graduated into tenths of a cubic centimeter so as to be easily read. The buret should be fixed in a perpendicular position and firmly attached to its stand. It should be filled through a glass funnel with the solution to be used. Care must be exercised to avoid the presence of air bubbles. The buret is graduated from zero to 30 Cc. Allow enough of the solution to run out to remove the bubbles and to bring the solution down to the zero mark. In reading off the quantity of solution that has been used, great care should be taken to read at the level of the bottom of the meniscus formed by the attraction of the fluid to the cyUn- drical wall of the buret. Normal Solutions. — For the quantitative analysis of the acid in the gastric contents, normal solutions are used. A normal solution of acid or alkah is one in which each Hter represents the amount in grammes of reagent found by dividing the molecular weight of the substance by the number of replaceable hydrogen atoms or hydroxyl groups. A decinormal solution is one-tenth the strength of the normal solution. It is this latter that is used in mak- ing stomach analyses. In the various tests employed in quantitative analysis for acidity of the gastric contents, one-tenth normal sodium hydrate is used in the buret. The PLATE I FIG. 2 ^■ Pheiiolphthalein Test. Before adding 2*'- sodium hydrate solution. Phenolphthalein Test. After rendering alkaline with -If, sodium hydrate solution. 'IG. 8 Gunzburg Test (Faint Reaction). FIG. 4 Gunzburg Test (Marked Reaction). quantitative: analysis 43 amount of this alkali necessary to neutralize a given quan- tity of the acid in the gastric juice will give the degree of acidity. It has been found that the normal acidity of the stomach contents at the height of digestion (one hour after a test breakfast) will range between 40 and 60 degrees, which means the number of cubic centimeters of one-tenth normal sodium hydrate solution necessary to neutralize 100 Cc. of gastric juice. For example, if we use 2.5 Cc. of one-tenth normal sodium hydrate solution to neutralize 5 Cc. of gastric juice, the degree of acidity would be 2.5 X 20 = 50). We multiply by 20 because we always figure on the amount necessary to neutralize 100 Cc. of gastric juice, and since we have used only 5 Cc. for the test, we must multiply by 20 to bring this up to 100. One cubic centimeter of one-tenth normal sodium hydrate solution will neutrahze 0.00365 gramme of free hydrochloric acid. If now w^e multiply this factor by the number of cubic centimeters necessary to neutralize 100 Cc. of the filtered gastric juice (degree of acidity), the result will be the percentage of acid present. If the normal acidity is between 40 and 60 degrees, the percentage will be found by multiplying by 0.00365. Minimum normal acidity 40 degrees, 0.00365 X 40 = 0.146 per cent. Maximum normal acidity 60 degrees, 0.00365 X 60 = 0.219 per cent. After an Ewald-Boas test breakfast an excess of free hydrochloric acid should be present within fifty or sixty minutes, while after a Riegel test dinner it is present in from two and a half to three hours. The elements to which the acid reaction of stomach con- tents is attributable are outlined, according to Boas, in the following table: 1. Hydrochloric acid free combined (with proteins, basic substances) 2. Organic acids (lactic, butyric, acetic acids) free combined (with proteins, basic substances 3. Acid phosphates. 44 EXAMINATION OF THE STOMACH CONTENTS Since the normal acidity of the stomach contents is between 40 and 60 degrees, cHnicians have for the most part agreed that above 60 degrees shall constitute hyperchlorhydria, hyperacidity, or superacidity; below 40 degrees, hypochlor- hydria, hypoacidity, or subacidity; absence of acid, achlor- hydria, anacidity, or achylia. The total acidity is ascertained by the phenolphthalein test. Phenolphthalein Test. — The total acidity is determined with one-tenth normal sodium hydrate solution in the buret. The indicator consists of a 1-per-cent. alcoholic solution of phenolphthalein. Draw into a graduated pipet 10 Cc. of the filtered gastric juice (Fig. 3, /). Pour the contents of the pipet into a beaker (Fig. 3, h). To this, add three or four drops of the phenolphthalein solution, which will cause a grayish clouding (Plate I, Fig. 1). The one-tenth normal sodium hydrate solution is gradually added until red is discerned at the point where the solution from the buret touches the gastric juice. By agitation, the red color dis- appears. Add more of the sodium hydrate solution and again agitate the contents of the beaker. When the reddish color ceases to disappear, a sufficient quantity of the one- tenth normal sodium hydrate solution has been added to neutralize the total acidity of the stomach contents. Care must be taken not to add too much. The end of the test shows a slight red (Plate I, Fig. 2). It is now necessary to read on the buret the amount used. If we have used 4.5 Cc. we multiply by 10, because we calculate the amount neces- sary to neutrahze 100 Cc, and we find that our acidity is 45 degrees. The percentage is ascertained by multiplying the 45 by 0.00365, making 0.16425 per cent. It is very important to make a quantitative estimate of free hydrochloric acid in studying all pathologic con- ditions of the stomach. When, however, the amount of free hydrochloric acid is diminished, it is necessary to exer- cise caution in the interpretation of either qualitative or quantitative tests for free hydrochloric acid. In compara- tively rare cases all the indicators, with the exce])tion of Giinzburg's reagent, have given a positive reaction for PI ATF \] Topfer Test. Dimethylamidoazobenzol as in- dicator, before adding ^, sodium liydrate solution. Topfer Test. DimethylanTiidoazobenzor as in- dicator, after rendering alkaline with ,^ sodium hydrate .solution Topfer Test. Alizarin as indicator, before adding ^ sodium hydrate solution. Topfer Test. Alizarin as indicator, aftev rendering alkaline wi; .sodium hydrate solutic' QUANTITATIVE ANALYSIS 45 hydrochloric acid when no hydrochloric acid was actually present. Mintz's Method. — To 10 Cc. of gastric juice add 20 to 30 drops of Giinzburg's reagent as indicator. The solution is then warmed, and decinormal sodium hydrate solution added. Since the reaction takes place only when the solution is warm, the glass rod with which the solution is stirred should be warmed before using. A distinct red color will be evident along the sides of the rod as the point of neutraUzation is reached. Topfer's Method. — Topfer's method of quantitative analy- sis of gastric juice is the simplest and most delicate of tests for free hydrochloric acid. One-half per cent, dimethylamidoazobenzol alcohohc solution is used as an indicator. The titration of the filtered gastric juice is done with decinormal sodium hydrate solution. Lactic acid will not respond to the test unless it be present to the extent of 1 per cent., which is rarely the case. Acetic and butyric acids are present in fairly large amounts in fermentative processes of the stomach; when present in sufficient quanti- ties to interfere with the reaction for hydrochloric acid, their strong odor renders them easy of detection. To 10 Cc. of the filtered gastric juice, one or two drops of indicator are added; if hydrochloric acid is present, a bright red tone results (Plate II, Fig. 1), so the mere presence or absence of hydro- chloric acid is easily determined. The quantitative deter- mination is now made by adding decinormal sodium hj'drate solution; as this solution is added, the reddish tint of the mixture changes to a distinct yellow. The titration must proceed to the point at wh^ch all trace of red disappears and the color becomes clear yellow (Plate II, Fig. 2). To ascertain the amount of free hydrochloric acid present, note the number of cubic centimeters of decinormal sodium hydrate solution used from the buret. Multiply this by 10, in order to determine the amount necessary to'neutraUze 100 Cc. of gastric juice — the figures also representing the degree of free hydrochloric acid present. Multiplying this result by 0.00365 we get the percentage of hydrochloric acid. 46 EXAMINATION OF THE STOMACH CONTENTS In making these tests the physician should always work with filtered gastric contents, since otherwise, owing to the presence of food particles, an exact measurement of the quantity of gastric juice can seldom be made. Combined Hydrochloric Acid. — Since the hydrochloric acid at first secreted combines with basic substances and the protein of the ingested food, if we would know the total amount of hj^drochloric acid secreted we must ascertain just how much acid salts and acid protein has been formed in the stomach. The physiologically active hydrochloric acid consists of both free and combined acid. There may be only a small amount of free hydrochloric acid, while that combined with the pro- tein may be comparatively large. Sometimes there is no free hydrochloric acid, but a large quantity of combined acid, showing that a certain amount has been secreted by the stomach. Among the methods of determining the quantity of com- bined acid is that of Topfer. The total acidity of the gastric juice is determined by titration of 10 Cc. of filtered gastric juice with decinormal sodium hydrate solution, using phenolphthalein as an indicator, as described on page 44. This point having been determined, a second portion of 10 Cc. of gastric juice is titrated with decinormal sodium hydrate solution, using a 1-per-cent. aqueous solution of alizarin as an indicator (alizarin monosulphate of sodium). Two or three drops of this indicator are added to 10 Cc. of filtered gastric juice, when the mixture becomes distinctly yellow (Plate II, Fig. 3). The titration is carried on to the point of production of a pure violet color (Plate II, Fig. 4), which does not deepen on the further addition of an alkali. Alizarin reacts with free acid, both mineral and organic, and with free acid salts, but not with com- bined hydrochloric acid. If, therefore, we subtract the figure obtained when alizarin is used as an indicator from that obtained with phenolphthalein, the result will be combined hydrochloric acid. For example: Suppose that by the use of phenolphthalein and decinormal sodium hydrate solution all the acidities have been saturated, the color being red, PLATE in FIG. 1 V. UffeliTiaiin's Test. Fig. 1: Before adding gastric filtrate containing lactic acid. Fig. 2: After adding gastric filtrate containing lactic acid. QUANTITATIVE ANALYSIS 47 and the result is 60 degrees; then by the use of alizarin and decinormal sodium hydrate solution all the acidity excepting the combined hydrochloric acid is neutralized, the color being violet, and the result is 38 degrees. By subtracting the acidity found with alizarin (38) from the acidit}^ found with phe- nolphthalein (60) the amount of combined hydrochloric acid is determined: 60 - 38 = 22, and 22 X 0.00365 = 0.0803 per cent. If we now add this combined hydrochloric acid to the free hydrochloric acid determined by titration of the gastric juice, using dimethylamidoazobenzol as an indi- cator, we obtain the total physiologically active hydro- chloric acid. The difference between the total acidity and this factor gives us the amount of organic acid and acid salts present. Lactic Acid. — Since bread, milk, and meat contain lactic acid, any test for lactic acid can be of value only when the meal contains very little of these foods. The Boas test meal is preferable when the object is to detect the presence of lactic acid. According to Boas, under physiologic conditions no appreciable amount of lactic acid is formed during digestion. Lactic acid is apt to be found in any condition associated with stagnation of the gastric contents as a result of motor insufficiency, provided the amount of hydrochloric acid is below normal. An excess of lactic acid would suggest gastric cancer, though it should not be overlooked that an excess of lactic acid may be present in benign stenosis of the pylorus and motor insufficiency. Should the stomach be washed out the evening before the test meal, and lactic acid appear in the stomach contents after the night's fast, the pathologic condition is probably cancer. Where carcinoma has developed from the base of an old ulcer, the findings may show no lactic acid, but, on the contrary, large amounts of hydrochloric acid. Uffelmann's Test. — Uffelmann's reagent consists of 10 Cc. of a 4-per-cent. carbolic acid solution to which are added one drop of ferric chloride solution U. S. P. and sufficient water to form a transparent amethyst blue (Plate III, Fig. 1). A solution should be freshly prepared for each test. Add a 48 EXAMINATION OF THE STOMACH CONTENTS Fig. 4 ■25C.C. few drops of filtered gastric juice to 5 Cc. of this reagent in a test-tube, and in the presence of lactic acid the solution will lose its blue color and take on a beautiful canary yellow or greenish-yellow tint (Plate III, Fig. 2). Should there be considerable hydrochloric acid present in the gastric juice the result may be obscured. The stomach contents under this con- dition should be extracted with ether, which takes up the lactic acid, leaving the other substances behind. The ethereal solution is then evaporated, the residue taken up with distilled water, and the Uffelmann test applied to this solution; if lactic acid is present, the solution turns intensely green. Strauss' Test. — A clinical test that has been used with success is that recommended by Strauss. He has devised a glass funnel (Fig. 4) which makes the test quite simple. The funnel is graduated to 5 Cc. below and 25 Cc. above. It is filled to the 5-Cc. mark with filtered gastric juice, and ether is added to the 25-Cc. mark. The funnel is corked and thoroughly shaken. After standing for a short time to allow the fluids to separate, the contents are allowed to run out through the stopcock to the 5-Cc. mark. Distilled water is added up to the 25-Cc. mark, and then two drops of tincture of iron chloride. On shaking the mixture, if an appreciable quantity of lactic acid is present an intense green color results; a pale green indicates a trace of lactic acid. -5c.c. Strauss' funnel for making lactic acid test. EXAMINATION OF ENZYMES 49 EXAMINATION OF ENZYMES Pepsinogen and Pepsin. — Through the action of acids, and especially hydrochloric acid, pepsinogen is converted into active pepsin, which is able to convert proteins into a form in which they may be assimilated. If the gastric contents contain free acids and digested proteins, pepsin is present. If there are no free acids, but the digestive power be- comes apparent when the material is treated with sufficient hydrochloric acid, pepsin is demonstrated. To ascertain the presence of pepsin when free hydrochloric acid is present, 10 Cc. of gastric contents are placed in a test-tube, a little disk of coagulated egg albumin added, and the test-tube placed in an incubator, which is kept at a constant temper- ature between 98° and 100° F.; disappearance of the egg albumin after a short interval points to the presence of pepsin. When hydrochloric acid is absent, pepsinogen alone may be found in the stomach contents. This is important to the diagnostician, inasmuch as pepsinogen is rarely absent. The absence of pepsinogen means atrophy or achylia. In the absence of hydrochloric acid, pepsinogen is practically inert. Whenever pepsinogen is found, it is wise to prescribe hydro- chloric acid, thus making use of the digestive ferment natu- rally present. Hydrochloric acid transforms pepsinogen into pepsin in less than a minute. The test for pepsinogen is made by adding to 10 Cc. of filtered gastric juice one or two drops of hydrochloric acid and proceeding as with the qualitative test for pepsin. Determination of Pepsin. — Ricin Test. — Jacoby-Solrns Method. — One gramme of ricin is dissolved in 100 Cc. of a 5-per- cent, solution of sodium chloride, and the whole filtered. Two cubic centimeters of the filtrate are mixed with 0.5 Cc. of a decinormal HCl solution, 1 Cc. of diluted stom- ach contents is added, and the mixture is maintained at body temperature for three hours. Ferments clear up the ricin deposit. The quantity of pepsin is determined from the degree of dilution in which the stomach contents will 4 50 EXAMINATION OF THE STOMACH CONTENTS cause the ricin deposit to disappear. Solms considers one pepsin unit the amount of gastric juice which is sufficient to clear up 2 Cc. of a 2-per-cent. ricin solution in three hours at blood temperature. Normal stomach contents contain about 100 pepsin units to the cubic centimeter. As a means of maintaining uniform temperature, Einhorn employs an ordi- nary thermos bottle with a device to hold the tubes, which are graduated in millimeters. The thermos bottle should be partly filled with water at a temperature of 100'' F. The tubes in which the tests are being made should be tightly corked. Mett Test. — A capillary glass tube is used, into which fresh egg albumin is drawn by suction. The contents of the tube are coagulated by immersion for five minutes in boiling water. By cutting the tube into pieces 2 to 5 centimeters long the pieces can easily be placed in a beaker containing the gastric juice to be tested. They should then be kept in an incubator for ten hours at a temperature of 95° to 98° F. At the end of this time the albumin will be seen to have disappeared from the ends of each piece, while there still remains some in the central portion of each. The empty ends are measured. The square of the length of the column of albumin digested is the measure of the amount of pepsin in the gastric juice. For instance, if the empty portion of the tube be 3 millimeters in length the digestion equals 3 X 3 or 9 parts of pepsin. The peptic unit is that quantity of pepsin which will digest one millimeter of egg albumin in a Mett tube in ten hours, the tubes being im- mersed in 0.18-per-cent. free hydrochloric acid. Qualitative Test foi* Rennin. — Five to ten cubic centi- meters of filtered stomach contents are accurately neutral- ized with decinormal sodium hydrate solution. The same quantity of neutral or ainphotoric boiled milk is added and the mixture placed in an incubator. If the curdHng j)ro- cess begins within fifteen minutes and a coaguluni is formed when the mixture is further allowed to stand, the phenom- enon of coagulation is attributable to the action of rennin. Leo's test for rennin is substantially as follows: Add three EXAMINATION OF ENZYMES 51 to five drops of gastric contents to five to ten cubic centi- meters of milk, and place in an incubator; if coagulation follows in ten to fifteen minutes, lab-ferment is present. To test for rennin zymogen, add three to five drops of a 1-per-cent. calcium chloride solution to 10 Cc. of milk to which three to four drops of gastric filtrate have been added, and place in an incubator. If coagulation of casein occurs in the course of a few minutes, rennin zymogen is present. According to Boas, a pronounced diminution of the spe- cific biologic action of ferments is directly indicative of disturbance of the function of the glandular apparatus of the stomach itself. By examination of the gastric enzymes it may be determined in individual cases whether impair- ment of the glandular apparatus is transitory or permanent. Hydrochloric acid secretion is sometimes temporarily inhib- ited in anomalies of menstruation, in nervous dyspepsia, in congested conditions, and in acute and the early stages of chronic gastritis. In these conditions the presence or absence of enzymes indicates whether the physician has to deal with only a temporary suppression of the hydrochloric acid secre- tion or with an advanced or chronic gastric catarrh. Test for Propeptone. — The end products of protein diges- tion in the stomach are to be found in propeptones and peptones. The amino-acids are all formed in the intestine. To test for propeptone, mix equal parts of the filtered stom- ach contents and a saturated solution of sodium chloride. A turbid precipitation indicates the presence of propep- tones. When there is no precipitation, but the addition of two or three drops of acetic acid turns the liquid turbid, propeptone is present. When the solution is heated the tur- bidity clears up, and when it cools the turbidity returns. The more turbid the solution, other things being equal, the greater the amount of propeptone present. Test for Peptone. — After having filtered out the propeptone, 5 Cc. of the filtrate is made strongly alkaline by adding sodium hydrate solution. A few drops of a 1-per-cent. sulphate of copper solution are added. \^Tien peptone is present a purple or violet-red color (biuret reaction) appears. 52 EXAMINATION OF THE STOMACH CONTEXTS CARBOHYDRATE DIGESTION IN THE STOMACH The conversion of starches into sugar occupies three inter- mediary stages, which are determined by their behavior toward Lugol solution. The stages are amiduUn, erythro- dextrin, and achroodextrin. With Lugol solution, amiduUn gives a blue color, erythro dextrin a violet or mahogany brown, achroodextrin remains unchanged. The end prod- uct of the conversion of starch into sugar is maltose (C12H22O11 + H2O), together with small amounts of dextrose, which may be demonstrated by Fehling's or Xylander's tests. Lugol solution consists of pure iodine, 1 gramme; potassium iodide, 2 grammes; distilled water, enough to make 20 cubic centimeters. In hj-perchlorhydria the digestion of starch has been found to be considerabh^ impaii^ed; in testing the stomach contents for starch, iodine gives a pronounced blue coloring. In achlorhydria the reaction is \\'ine-yellow. The first result is more likely to be obtained when there is an impairment of the saHvary glands whereby the secretion becomes poor in ptyalin. In am^ case where hyperacidity is present sali- vary digestion stops as soon as the food enters the stomach; in subacid conditions salivary digestion may proceed indefi- nitely in the stomach, depending, of course, upon the extent of the diminution of gastric secretion. BLOOD IN GASTRIC CONTENTS The presence of blood in gastric contents must be con- sidered always pathologic; it is most frequently associated wdth erosion, gastric ulcer, and gastric carcinoma. In gastric ulcer the blood is usually bright red in appearance, unless changed by the action of the acid of the gastric juice, in which case it takes on a brownish discoloration. In hemorrhages resulting from gastric cancer the blood is more thoroughly incorporated with the stomach contents, BLOOD IN GASTRIC CONTENTS 53 giving rise to the so-called coffee-ground material, of brown- ish-black appearance. Weber's Guaiac Test. — The detection of gastric hemorrhage, especially when the bleeding is small in amount, is accom- plished by Weber's guaiac test. Technique of Examination. — A small quantity of the gas- tric filtrate is rubbed up with water; one-third its volume of glacial acetic acid is then added and the mixture shaken up with ether in a test-tube. The acetic acid changes the hemoglobin, if present, into hematin, which is in turn taken up by the ether. The clear supernatant ether is then poured off, ten drops of an alcoholic solution of resin of guaiac are mixed with it, and lastly twenty to thirty drops of turpentine or Huehnefeld's reagent are added. A blue color appearing at once points to the presence of blood in considerable quan- tity. Delayed appearance of the blue color is an indication of smaller quantities of blood. It has been known for some time that in carcinoma of the stomach there is always slight gastric hemorrhage. Chnicians have been unable to tell definitely whether the blood found in the stomach contents came from the neo- plasm or was due to irritation by the stomach tube. The slightest irritation by the stomach tube would produce a small amount of invisible blood, which would respond to the guaiac test. Boas was the first to examine the feces for invisible blood; he knew the blood corpuscles would degenerate, but the hematin crystals should be found in the feces. If these hematin crystals could be found in the feces, with other signs of either ulcer or cancer, the test would be valuable. Examination for invisible blood in the feces is of great importance, since many clinicians, among whom are Hartmann, Boas, Schloss, Schmilinsky, Einhorn, and White, report the constant presence of occult blood in cases of gastric ulcer and cancer. The term "occult blood" is applied to minute hemorrhages discharging in the gastro- intestinal canal, too small to be discerned macroscopically. By the time the blood passes through the whole intestinal . canal the corpuscles are so broken down that they cannot 54 EXAMINATION OF THE STOMACH CONTENTS be found by the microscope. The tests for occult blood are chemical. Steele and Butt,^ after examining 720 stools, con- cluded that the presence of occult blood was of decided diagnostic value only in gastric and duodenal ulcer, and cancer of the gastro-intestinal tract. In the diagnosis of carcinoma and gastric ulcer, sources of bleeding that have no significance must be excluded. Since the test is ex- tremely sensitive, very small amounts of blood can be detected. There is great Hability to error in determining the site of the hemorrhage. Besides epistaxis, hemoptysis, and hemorrhoids, any foodstuff containing hemoglobin in any amount will give the reaction. Therefore, the diet must be a blood-free one for- three days previous to the test. Weber's guaiac test can be used for feces just as it can be used for stomach contents, as stated on page 35. Bemidin Test for Occult Blood. — This test is very sensitive. It was first described by 0. and R. Adler, and has been sub- jected to slight modifications by Schlesinger and Hoist. The test is as follows : I. One gramme of benzidin is placed in a test-tube with about 2 Cc. of glacial acetic acid. This mixture should be freshly prepared. II. A small piece of feces (the size of a pea) is rubbed up with water and placed in a test-tube and boiled; boiling destroys the oxidizing ferments. III. To about 3 Cc. of peroxide of hydrogen in a test- tube, add about five drops of the above glacial acetic acid- benzidin mixture, and lastly a few drops of the boiled feces. Blood is indicated by a greenish or blue color (Plate IV). The advantage of the benzidin test over the guaiac test is emphasized by White," whose conclusions are as follows: 1. Tests for invisible hemorrhage in diseases of the diges- tive organs are very valuable and will be much used in diag- nosis and prognosis, and as a measure of the results of treatment. It is important to recognize and use the best methods. 1 American Journal of the Medical Sciences, July, 1905. ^ Boston Medical and Surgical Journal, June 10, 1909. PLATE IV FIG. 2 Benzidin Test. lion. Fig. 2: Marked reaction. BLOOD IN GASTRIC CONTENTS 55 2. A preliminary step is necessary in both guaiac and benzidin tests to exclude sources of error from food ferments. This is more important for gastric contents than for feces. Acetic-acid-ether extraction is best in the guaiac test, and boiling in the benzidin test! 3. Metallic salts, potassium iodide, and charcoal must not be given when the stomach contents are to be tested by the benzidin method. 4. Before using these tests, meat and fish and their juices must be excluded from the diet, and no hemoglobin derivatives should be administered within two days previous to the guaiac test or three or four days previous to the benzidin test. 5. Gastric contents should be examined when possible, but feces are the best material for examination, as they alone are available for the repeated examination which is usually necessary for diagnosis, and they are free from the source of error involved in the use of the stomach tube. 6. The Weber method is the best guaiac test for routine clinical work, several amounts of guaiac being used as recommended by Schroeder. 7. The original Adler benzidin test is too delicate for clinical work. This objection has been overcome in the Schlesinger and Hoist modification of the test, which is five to seven times as delicate for blood in gastric contents as the guaiac test, but only about twice as delicate for blood in the feces. 8. Schlesinger and Hoist's modification is the best ben- zidin test for clinical work. It has all the clinical value of the guaiac test, with somewhat greater delicacy, greater clearness, and much simpler technique, and acts as a con- trol on the cleanliness of the reagents and glassware. 9. Good results with the benzidin test depend on careful technique, the exclusion of oxidizing ferments in raw food, fresh material for examination, clean glassware, and the quality, strength, and proportion of the reagents used. 10. A negative benzidin test has greater value than a negative guaiac test in ruling out hemorrhage, and if both 56 EXAMINATION OF THE STOMACH CONTENTS tests are used as a control much time will be saved by using the benzidin test first, which takes only two minutes, and if negative, renders any further test for blood unnecessary. 11. It is wise to control the benzidin test with the guaiac test when positive results are found, until the technique is learned and tested individuall}^ Einhorn's Benzidin Paper. — Einhorn^has simplified the test by making a benzidin paper. The benzidin paper is pre- pared by moistening filter paper with a saturated solution of benzidin and glacial acetic acid and drying it. In prepar- ing the paper, as well as in making the test, it is important to avoid contact with the fingers, as a drop of perspiration causes a reaction similar to the blood reaction. In handhng the paper it is best to use ivory-tipped forceps or to protect the hands by means of a towel. The method of procedure is as follows: A piece of ben- zidin paper is immersed in the solution to be examined, and a few drops of hydrogen peroxide are added. The piece of paper is then removed (with forceps) and placed on white porcelain, so that the color reaction, if there is to be any, may be clearly shown. If blood is present, a green or blue color arises in a few seconds to a minute; should the color come later, the showing is, according to Einhorn, negative. Phenolphthalein Test for Occult Blood. — Boas" prefers the phenolphthalein test for occult hemorrhages of the gastro- intestinal canal. He points out that the benzidin test, which demonstrates blood in a dilution of 1 to 200,000, is altogether too delicate; it indicates the minutest quantities of alimen- tary (exogenous) blood, and the reaction may be distinctly positive after three or four days of meat-free diet. Weber's guaiac test is less susceptible, but inasmuch as the substances which disturb the test must be extracted by alcohol and ether, there are certain difhculties in the way of its practical application not present in the phenolphthalein test. The phenolphthalein test is based on the fact that phenol- phthalein, in an alkaline solution, is oxidized by blood ' Medical Record, June S, 1907. ^ Deutsche mcdizinischc Wochensclu ill, 11)11, No. J. EXAMINATION OF FECES 57 pigment so that the solution becomes pink or rose-colored. The phenolphthalein reagent is prepared as follows: 1 Gm. of phenolphthalein and 25 Gm. of potassium hydrate are dis- solved in 100 Cc. of water to which is added 10 Gm. of zinc powder. The mixture, which is at first red, is boiled over a small flame under constant stirring and shaking until complete decoloration has taken place by reduction. The hot solution is then filtered. For preservation a small excess of zinc powder may be added. The demonstration of blood is carried out as follows: Firm feces are triturated with water until they are of a fluid consistency. Acidify 5 Cc. of the fecal mixture in a test-tube with glacial acetic acid, shake, add an equal volume of ether, and carefully agitate the contents in the test-tube to extract the fecal mixture, carefully avoiding the formation of an emulsion. Decant the ethereal solution into a clean test-tube, and add to this solution 20 drops of the phenolphthalein reagent, shake slightly, and finally add 3 to 4 drops of peroxide of hydrogen. If blood pigment be present, a rose or intensely pink color will result, which will persist for some time if there is much blood. It will not, indeed, be necessary to add peroxide of hydrogen to the fecal solution if there is much blood present. The principal advantage of this test consists in the characteristic reaction, the possibility of differentiating between the presence of large and small quantities of blood, the permanency of the reagent, and simplicity of preparation. EXAMINATION OF FECES In endeavoring to test the functions of the intestine, Adolf Schmidt' devised a test diet which enabled him to get an insight into the functions of the stomach also. Schmidt's Test Diet. — Schmidt's general test diet is as follows : 1 Adolf Schmidt, Examination of the Function of the Intestine by Means of the Test Diet. Translated by Charles D. Aaron, Philadelphia, 1909, p. 11. 58 EXAMINATION OF THE STOMACH CONTENTS On arising in the morning : One-half liter of milk ; tea or cocoa (if possible with milk), together with one roll with butter and one soft-boiled egg. Breakfast: One dish of oatmeal cooked in milk and strained (salt or sugar permissible) . Gruel or porridge may, under certain conditions, also be given. At noon: One-fourth pound of finely chopped lean beef, broiled rare with butter (the interior raw) , and along with it not too small a portion of potato broth (well strained). In the afternoon: Same as in the morning, but no egg. In the evening: One-half liter of milk or one plate of soup (as in the morning), together with a buttered roll and one or two eggs soft boiled or scrambled. There are four fundamentals of the Schmidt test diet which must be strictly observed: 1. A certain moderate measure of milk (one-half to one and one-half liters), which may be boiled entirely with the foods. 2. One hundred grammes of white bread (zwieback, crackers, etc.). 3. A goodly portion (100 to 250 grammes) of potato broth. 4. One-quarter pound of chopped beef, a portion at least of which must remain raw or half-raw. The test diet is given for three days or longer, until a stool is obtained which comes with certainty from this diet. If connective-tissue residues appear in the feces, it is a sign of disturbance in stomach digestion. Of all the diges- tive secretions, as Schmidt has shown, the gastric juice alone can digest raw connective tissue. The stomach alone is at fault if connective tissue appears in the feces. In most eases it is a question of subacidity or achylia, and the dis- turbance may become so severe that the connective tissue is discharged in quantities as a fine down intermingled with the whole stool. If macroscopically discernible muscle residues appear in the feces, this is a sign of disturbance of digestion in the small intestine. The stomach takes only a small part in the solu- tion of muscle, by far the larger part falling to the intes- EXAMINATION OF FECES 59 tine. This is proved by the fact that even in cases of complete achyUa gastrica, muscle fragments never appear in the feces. If the small intestine does not perform its functions normally, muscle fragments are found in the feces. It can be stated with certainty that the difficulty is in the small intestine, inasmuch as the large intestine serves only as a reservoir without digestive action. Connective tissue and muscle together, as meat remains, indicate dis- turbances in both the stomach and the small intestine. The Bead Test. — Einhorn^ has devised a new method of testing the functions of the digestive apparatus, which is known as the Bead Test. It consists in giving the patient beads with various food substances attached, and examining the feces with the stool sieve until all the beads are recovered. The latter are then inspected with regard to the presence or absence of the attached foods; thus it is seen whether these have passed the digestive tract unaltered, or whether they have been digested. Ordinarily the following six test substances are given: (1) Catgut; (2) fishbone; (3) meat; (4) potato; (5) mutton fat; (6) thymus gland. Physiologically the first two sub- stances (catgut and fishbone) are usually digested in the stomach, and the remaining four (meat, potato, mutton fat, thymus) in the intestine. All the beads (or at least the greater part of them) usually appear in the stool under normal conditions in one or two days. The beads should be either all empty or carry but a trace of fat or thymus (possibly fishbone) . Deviations from this rule point to pathologic conditions. With regard to the functions of the digestive apparatus the following conclusions may be drawn: In case all the beads (or the greater number) appear in a much shorter time than twenty-four hours, there is accelerated motility; if they do not appear until after forty-eight hours, motility is retarded. The digestive function is good if all the beads are empty or if there are but traces of fat or thymus (also ^ Journal Araerican Medical Association, February 2, 1907. 60 EXAMINATION OF THE STOMACH CONTENTS fishbone) left. The survival of catgut or meat, potato, much fat or much thymus, always indicates a poor digestive function for the food substance in question. If all these test substances reappear in the stool, an absolutely poor digestive function exists. By stringing the different test beads and tying them together on a silk thread, they all appear in one stool and the period of examination is thus considerably abbreviated. In order to diminish the number of beads and also the length of the string, two food sub- stances may be fastened to each bead; for instance, catgut and fishbone, meat and thymus, potato and fat — only three beads. Instead of leaving the ends of the string free, they may be tied together so as to form a loop. The bead string is put into a gelatin capsule and thus administered. Preparation of Food Beads. — 1. Catgut. — Take raw catgut No. 00, draw it through the bead and tie the ends together. 2. Fishbone. — As the ordinary fishbone breaks when tied in a knot, it is best to use the long bones from a pickled herring. The bones are washed in water first, then rubbed off with a cloth. They are then kept in water in a bottle. When wanted they are taken out of the water, drawn through the bead and tied in the same manner as the catgut. 3. Meat. — The muscle fibres of raw beef are cut length- wise in the direction of the fibres and in pieces 5 to 6 Cm. long, 1 Cm. thick. These are preserved in a bottle of alcohol. Take a piece of meat from the alcohol bottle, tear off length- wise a muscle fibre 2 to 3 cm. long, 1 mm. thick, draw it through the bead and allow the ends to overlap, then tie the ends fast together over the bead with a silk thread. 4. Thymus. — Raw sweetbread from the calf is cut in cubes and preserved in alcohol. For use, lay a small piece (about 2 cm.) within a small square of gauze, fold the four ends of the gauze together and tie with thread, so that the piece of thymus Hes enclosed as in a purse; then fasten the gauze purse to a bead, passing one end of the thread through the eyelet. 5. Mutton Fat. — Beads with a largo opening (1.5 to 2 mm. in diameter) should be dropped in hot rendered mutton fat IXDIRECT METHODS OF GASTRIC ANALYSIS 61 and after a minute taken out with forceps and placed in a vessel of cold water. This congeals the fat. Then they are laid on a piece of pure filter paper and allowed to remain there until thoroughly dried. The beads thus pre- pared can be kept as long as desired and are ready when wanted. 6. Potato. — Cook a piece of unpeeled potato in boiling water for two minutes, take it out and cool it, cut off a piece (with peel) about 1 cm. long, 0.5 cm. wide, and 1.5 to 2 mm. thick, and attach it to a bead. Two or more food substances may be attached to one bead; for instance, catgut and fishbone, meat and thymus. The test beads, prepared for use, can all be kept on hand, with the exception of the potato, which must always be freshly boiled Meat and thymus beads are best kept in alcohol. Catgut, fishbone, and fat beads are simply preserved dry. The bead string is placed in a gelatin capsule and so administered — best shortly after a meal. The bead test should be used in all cases in which a thorough knowledge of the working functions of the digestive apparatus is desired. The bead test is not permissible in pronounced stenoses of the digestive tract — stricture of the esophagus, stomach, or intestine. INDIRECT METHODS OF GASTRIC ANALYSIS A number of methods are in vogue for the examination of the functioning powers of the stomach without removing the gastric contents. While such methods fail to determine the exact condition of the acidity or of the activity of fer- ments, much may be learned by means of them regarding gastric motihty as well as the digestive powers of the stomach. Giinzburg's Method of Testing the Absorptive Power of the Stomach. — Two centigrammes of potassium iodide are placed in a section of very thin though strongly vulcanized rubber tubing about three-quarters of an inch in length. The ends of the tubing are folded, and tied with threads of fibrin 62 EXAMINATION OF THE STOMACH CONTENTS hardened in alcohol. To make sure that both ends are water-tight, the tube should be placed in water and allowed to remain for several hours, the water being then tested for potassium iodide. Should none of the drug be found, the patient is directed to swallow the package three-quarters of an hour after having partaken of an Ewald test meal. Free hydrochloric acid of the stomach will dissolve the fibrin threads and liberate the potassium salt into the stomach. The saliva should be tested for potassium iodide at intervals of fifteen minutes. When the acid secretion is below normal the salivary reaction will be delayed. In cases in which the acid secretion is wholly absent the potassium salt may not appear in the saliva for at least six hours. SahJi's Desmoid Test. — By the simple means of investi- gation of the functions of the stomach described by Sahli in 1905 the physician may avoid the annoyance that certain patients experience when gastric contents are with- drawn by means of the stomach tube for analj^sis. The desmoid test is based upon the observation of Adolf Schmidt, that the digestion of raw connective tissue is confined to the stomach. Raw connective tissue passing through the stomach undigested is not affected by the pan- creatic and intestinal juices, but is ejected with the feces unchanged. The details of the test are as follows: Two small squares of rubber dam, such as dentists use, are made into bags; into one is placed one decigramme of iodoform and into the other five centigrammes of methylene blue. The bags are closed and tied tightly with No. 00 raw catgut that has been permitted to dry but has not been treated chemically. The patient is instructed to swallow the two rubber bags with their contents. Under normal conditions of gastric secretion the catgut is duly dissolved and the contents of the bags liberated into the stomach ; iodine will therefore shortly appear in the saliva and the methylene blue in the urine. Beginning three hours after the bags are swallowed, the urine and the saliva should be tested at one- hour intervals. Should the rubber bags with their contents pass through the digestive canal unchanged, gastric secretion IXDIRKCT METHODS OF GASTRIC AXALYSIS 03 is either very much retarded or entirely absent ; in such cases no change is detected in the saUva or urine. The best time for making the test is immediately after the noon meal. Under normal conditions, iodine will appear in the saliva in about two hours and methylene blue in the urine within six hours. Any deviation from this indicates hyperacidity or subacidity, depending upon the interval between the administration of the test agents and their presence in the saliva or urine. Einhorn^ declares Sahh's desmoid test to be unreliable, maintaining that catgut will dissolve in the intestine as well as in the stomach. Salomon's Test. — The principle underlying this test is the fact that carcinoma secretes albumin, which becomes mixed with the gastric contents. The diet of the patient for twenty-four hours prior to the test should be absolutely free from protein. At the beginning of this period he is given a morning meal of milk and gruel and a mid-day meal of bouillon with coffee or tea. Late in the evening the stomach should be washed out with large quantities of pure water until the return water is clear. The following morn- ing the fasting stomach is washed twice with 400 Cc. of physiologic salt solution, the same solution being used each time. This solution is then tested by the Kjeldahl method for the total amount of nitrogen, and by Esbach's method for the quantitative estimation of albumin. Salomon found in cases of gastric cancer 20 to 70 milligrammes of nitrogen and from 0.00625 to 0.05 per cent, of albumin to each 100 Cc. of the fluid that had been used in lavage. In non-malignant cases, according to this inves- tigator, no albumin could be detected, and the amount of nitrogen varied from to 16 milligrammes in each 100 Cc. Neubauer and Fischer Test for Carcinoma. — Neubauer and Fischer" have presented a method for the early diagnosis of carcinoma of the stomach. The amino-acids, products of proteolysis, are normally formed only in the intestine. These 1 Journal of the American Medical Association, May 12, 1906. ^ Deutschen Archiv ftir klinische Medizin, Band xcvii, Hefte 5 and 6. 64 EXAMINATION OF THE STOMACH CONTENTS authors have found that carcinoma of the stomach will secrete a ferment which, unhke pepsin, exerts a peptid- splitting action. The detection of this ferment in the stomach contents can be used with other cUnical data in diagnosis of carcinoma. The test is performed as follows: One-half to three-quarters of an hour after taking a test breakfast the contents of the stomach are removed and examined for blood and bile. If there is no redness, and if the tests for blood and bile are negative, the following ferment test may be made: To about 10 Cc. of the filtered contents add a small quantity of glycyltryptophan, color with a layer of toluol, and allow to stand in an incubator for twenty-four hours. Insert a pipet under the layer of toluol, take up a portion of the liquid (2 to 3 Cc), transfer this to a test-tube, and add a few drops of 3-per-cent. acetic acid. Then from a bottle containing bromine vapor carefully allow some of the vapor to fall into the test-tube, so that a slightly brown coloring is noticeable in the upper part of the tube. If, upon shaking, the solution assumes a rose shade, free trj^ptophan is present. If the rose color does not appear, the operation should be carefully repeated until excess of bromine is indicated by the liquid assuming a shghtly yellow tint, when the test may be considered negative. Great caution should be observed to avoid adding the bromine vapor too fast, as an excess will cause the pink color to appear and disappear again so quickly as to elude even the practiced eye. Instead of the bromine vapor a solution of calcium hypo- chlorite may be used. It should be about one-fifth the strength of the semi-saturated solution used in the test for indican. Owing to the instabiUty of calcium hypochlorite, the solution before being used should be tested with a solu- tion of potassium iodide (yellowish-brown color through liberation of iodine). The reagent is then added drop by drop by means of a pipet. Free tryptophan, from the decomposition or splitting up of glycyltryptophan, is indi- cated by a rose color, which disappears with excess of the reagent. In case the test is negative it may be repeated in SKIN RE ACTIOS IN CARCINOMA 65 twenty-four hours, although the decomposition of glycyl- tryptophan taking place in the first twenty-four hours after it is added to the gastric contents under investigation is the only one which has any significance. In case of doubt it is better to examine a fresh sample of gastric contents. SKIN REACTION IN CARCINOMA In the growth and breaking down of malignant tumors it has been found by clinical investigation that substances are formed and set free that act as poisons to the red blood cells. To these substances, or lysins, the anemia and cachexia of malignant disease has been ascribed. Elsberg, Neuhof, and Geist,^ reasoning on the assumption that the blood serum of patients suffering from malignant disease contains hemolysins, while that of normal individuals or those suffering from other diseases does not, maintain that in this blood phenomena there is possible a valuable agency for the diagnosis of malignant disease. They have accordingly made use of the hemolytic action of the blood serum of cancerous patients by a new method. They inject sub- cutaneously into the forearm of the suspected cancer patient five minims of a suspension of 20-per-cent. washed human blood corpuscles in salt solution. The hemolysins in the blood serum of the cancer patient attack the corpuscles so that a reaction shows in two to eight hours. The skin at the site of injection exhibits the effect in a color varying from brownish-red to bluish. The reaction was found to be positive in 89.9 per cent, of cancer cases. We have in these researches results that may lead to a method which will enable one to make an early positive diagnosis of cancer of the stomach. 1 American Journal of the Medical Sciences, February, 1910. 66 EXAMINATION OF THE STOMACH CONTENTS MOTOR FUNCTION OF THE STOMACH The motor function of the stomach may be determined by the introduction of food and subsequent examination of the stomach contents. For this purpose von Leube's test meal is employed, which consists of a plate of soup, beef steak, a roll, and a glass of water; or Riegel's, con- sisting of 400 Cc. of beef broth, 200 grammes of beefsteak, 50 grammes of bread, and 200 Cc. of water. After this meal the patient must not partake of anything during the next seven hours. At the end of the seven-hour period the stom- ach is washed out, according to von Leube, in such a manner that the funnel is twice filled with about a half-liter of water. If no food remnants appear, it may be concluded that the motor function of the stomach is normal. For practical purposes the motor function of the stomach may be deterinined by means of a test breakfast. Under normal conditions the test breakfast leaves the stomach in two hours at most; so if at the end of two hours large quanti- ties of fluid or food remnants are present, the motor function of the stomach may be regarded as impaired. According to Boas, motor insufficiency ma}^ be due either to weakness of the expelling force or to obstacles to expul- sion. The former, which includes myasthenia and paresis, may occur in the following conditions: (1) Congenital (rare) ; (2) the result of certain constitutional diseases, such as anemia, chlorosis, pulmonary tuberculosis, leukemia, dia- betes, and syphihs, or as a sequel of acute infectious dis- eases or in association with chronic catarrh; (3) myasthenia may occur independently, due to irregular modes of Uving, and is frequently combined with enteroptosis; (4) or it may result from specific diseases of the musculature of the stomach, as in flattened growth of carcinoma of the smaller curvature or the anterior wall of the stomach — in such conditions, though insufficiency cannot be ascertained by physical examination, the motor function may be so im- paired that food remnants from the evening meal are found PERMEABILITY OF THE PYLORUS 67 in the fasting stomach in the morning; (5) neurasthenia, buUmia, polyphagia, as well as local irritation of the nerve endings, occasionally lead to paralysis of the musculature of the stomach. Obstructions to the expulsion of the stomach contents may occur in the wall of the stomach itself, as in gastric ulcer or carcinoma of the pylorus; it sometimes happens that benign tumors obstruct the pyloric exit. In rare instances there is congenital stenosis of the pylorus as well as hyper- trophic thickening of the pyloric muscle fibres. PERMEABILITY OF THE PYLORUS Einhorn^ has described a new method for testing the permeability of the pylorus. The patient is instructed to swallow beads filled with methylene blue and coated with mutton tallow. Inasmuch as fat is dissolved in the duo- denum, a green or blue colored urine would indicate that the bead had passed the pylorus and that its contents had been absorbed. Under normal conditions the bead will pass into the duodenum, the tallow coating be dissolved, and the methylene blue appear in the urine in three to five hours. In order to ascertain whether the bead enters the duodenum, Einhorn makes a control test consisting of a second bead similarly prepared and anchored in the stomach at a dis- tance of fifty centimeters from the lips. The first bead is anchored at a distance of seventy-five centimeters from the lips, which is sufficient to allow it to pass through the pylorus and well into the duodenum. A similar test has been instituted by Einhorn in which he employs pieces of agar saturated with tincture of dimethylamidoazobenzol; these are placed in gauze and tied to the beads. The dimethyl-agar that is withdrawn directly from the free hydrochloric acid of the stomach will be red; that which has passed into the duodenum will, on withdrawal, exhibit no change in color. 1 New York Medical Journal, June 20, 1908. 68 EXAMINATION OF THE STOMACH CONTENTS Fig. 5 The duodenal bucket devised by Einhorn (Fig. 5) is much smaller than the stomach bucket. It is fastened to the end of a braided silk thread over seventy centimeters in length, and is administered to the patient in a gelatin capsule an hour after a small meal. The bucket should be left in the intestinal canal three hours, during which time the patient should not partake of any food. The thread at its free extremity should be tied to the ear so that it cannot go beyond the 75-centimeter mark. After the expiration of three hours the bucket is slowly withdrawn. The resistance offered at the esophageal entrance to the stomach can be overcome by the patient going through the act of swallow- ing. Einhorn advises that the patient swallow the bucket before retiring at night and that it be withdrawn in the morning while the stomach is empty. The contents of the bucket will be found to be yellowish in appearance, owing to the presence of bile in the duodenum. Einhorn assures himself of the presence of the bucket in the duo- Duodenai bucket. dcnum by means of the Roentgen rays. MICROSCOPIC EXAMINATION OF STOMACH CONTENTS Microscopic examination may be made of the gastric contents as withdrawn from the stomach by the stomach tube after the administration of a test meal, or from the vomitus. Undue importance should not be attached to the presence of meat shreds (Fig. 7, C) or starch granules, (Fig. 6, C), which are practically never absent from the gastric juice. Normal gastric juice may also contain small particles of mucus, a few bacilli, and some yeast cells. MICROSCOPIC EXAMINATION OF STOMACH CONTENTS ()9 In motor insufficiency, remains of food which has been introduced many hours previously may be found in the form of numerous fat globules or fatty acid crystals (Fig. 6, B and E), vegetable fibres and plant cells (Fig. 6, D), as well as a few red blood corpuscles which have come from abrasion of the pharynx by the stomach tube. Any red blood cells found are apt to be altered in appearance as a result of the action of the hydrochloric acid of the stomach. Fig. 6 A, epithelial cells; B, fat globules; C, starch granules; D, plant cells; E, fatty crystals; F, sarcinse. The Boas-Oppler bacillus (Fig. 7, B) is found in 75 to 85 per cent, of all cases of gastric cancer and seldom in non- malignant disease. It is found more frequently when lactic acid is present in large amounts, and may be absent in the incipient stages of carcinoma. It is three to ten microns in length and one micron broad. These bacilli are frequently found joined end to end, forming very long chains. They stain by the ordinary method as well as by Gram's method, 70 EXAMINATION OF THE STOMACH CONTENTS and take on a brown color when treated with iodine. This latter feature distinguishes them from the Leptothrix bue- calis, which stains blue with iodine. The Boas-Oppler bacillus is not infalhbly pathognomonic of carcinoma; it is present on rare occasions in the dilatation of benign stenosis of the pylorus. Fig. 7 A, pus cells; B, Boas-Oppler bacilli; C, muscle fibre. Sarcinse are occasionally found in normal gastric juice, and especially in cases of gastric dilatation when there is marked fermentation, with hydrochloric acid present; this microorganism consists of cocci arranged in squares or tetra- hedra (Fig. 6, F). It is of no pathologic significance other than being indicative of stagnation. A large number of yeast cells are found along with the sarcinse. Protozoa have been found in the gastric contents. Flagel- lates, amebae, and monads are among the more fretiuent protozoan types found. According to Simon, "From the available data there can be no question that the presence CHANGliJS IN GASTRIC SECRETION ~i of protozoa in the stomach contents is suggestive of non- obstructive carcinoma." In cases of chronic gastritis, ulcer, hyperchlorhydria, and especially cancer, small shreds of mucous membrane are sometimes found in the gastric contents withdrawn by the tube. Such tissue fragments should be carefully studied under the microscope, since it is sometimes possible to make a diagnosis of cancer thereby. Various types of crystals are occasionally noted in the gastric contents, among which may be mentioned bile acids, cholesterin, fatty acids, leucin, tyrosin, and calcium oxalate. CHANGES IN GASTRIC SECRETION DUE TO PATHOLOGIC CONDITIONS 1. Gastric Neuroses. — The gastric findings in nervous dyspepsia show the acidity to be normal or either above or below; the ferments are fairly constant. The fact that the acidity varies from day to day, being one day excessive and the next decreased, is characteristic of the disease. Hemmeter gave the name ^'heterochylia" to this condition. In chronic gastritis the acidity remains constant, while in nervous dyspepsia it is subject to variation. The ferments, which are diminished in chronic gastritis, are usually normal in nervous dyspepsia. The findings in chronic gastritis reveal much mucus, in nervous dyspepsia little or none. The former condition is associated with dietetic errors, the latter with a neurotic temperament. 2. Hyperacidity; Hyperchlorhydria. — This term is used to designate the secretion of gastric juice of excessive acidity, the amount of free hydrochloric acid varying from a small to a high degree above the normal. The normal acidity is between 40 and 60 degrees. Usually an increased total acidity is found along with the increase in free hydro- chloric acid. Hyperacidity is said to exist when there is a constant of more than 60 degrees, 0.2 per cent, of free hydro- 72 EXAMINATION OF THE STOMACH CONTENTS chloric acid. Hyperacidity or hyperchlorhydria may be due to neuroses, or to pathologic changes in the mucous membrane of the stomach itself. Often there is diminished motility due to pylorospasm, and as a result stagnation of gastric contents with fermentation. In such cases the acidity may amount to 150 degrees or over. Erythrodextrin is present in large quantities. 3. Hypersecretion; Gastrosuccorrhea ; Gastrorrhea; Gastrochy- lorrhea. — By this is understood an excessive secretion of gastric juice in the total or almost total absence of stimulus to the secretive function of the stomach. Hyper- secretion, or gastrosuccorrhea as it has been called, is always a pathologic condition. The diagnosis, as stated elsewhere, is confirmed by the finding of a pathognomonic quantity of gastric juice, containing both hydrochloric acid and pepsin, in the fasting stomach. The quantity should be, according to Strauss, at least 40 Cc. before the clinician is justified in making a diagnosis of hypersecretion. There is somewhat of an increase in the degree of acidity; erythro- dextrin and achroodextrin are absent. There must be no food remnants, sarcinse, or yeast cells. In gastric dilatation which may result from spasm of the pylorus we find fer- mentation products, yeast cells, and sarcinse. 4. Acute Gastritis. — Examination of the gastric contents in this condition reveals a diminished total acidity with little or no free hydrochloric acid. The total acidity is always below 40 degrees. Much mucus and undigested food is apt to be found. The hydrochloric acid secretion is either very much diminished or entirely absent. 5. Chronic Gastritis. — Examination of the stomach con- tents in this condition reveals nmch mucus usually mixed with the food, which shows little signs of digestion. The quantity varies from 100 to 200 Cc. Free hydrochloric acid is diminished or absent, and the gastric ferments are very much reduced. The total acidity is below 40 degrees. Pepsinogen and rennin zymogen aie always present. Erythrodextrin is found in small (juantities, and achroodextrin in abundance. The i)resence of epi- CHANGES IN GASTRIC SECRETION 73 thelial cells and leucocytes is detected by microscopic examination. The finding of large amounts of mucus in which are mingled leucocytes and epithelial cells is charac- teristic of chronic gastritis. 6. Achylia Gastrica. — For a diagnosis of this condition the Ewald-Boas test breakfast may be used with advantage. Examination of the stomach contents shows very little change in the ingested food. There is usually a small amount of fluid present. The food has a characteristic appearance, showing complete lack of digestion. There is no free hydro- chloric acid, and the total acidity is very low, 1 to 6 degrees. The gastric ferments are either very much diminished or entirely absent. There is no evidence of decomposition, no odor, and no mucus. Erythrodextrin is absent. Lactic acid is present in small quantities if at all. 7. Motor Insufficiency (Atony and Dilatation). — When motor insufficiency is suspected, a tablespoonful of currants should be given to the patient in the evening, to be followed by a test breakfast the next morning. Einhorn gives boiled rice instead of currants. If either the currants or the boiled rice, as the case may be, be found in the fasting stomach or removed with the test breakfast, a diagnosis of motor insufficiency is made. The volume of the gastric contents is generally increased, and, as a rule, more than 180 Cc. is found after the test breakfast. If after a full meal in the evening visible food remnants are found in the fasting stomach in the morning, in all proba- bility the condition is one of motor insufficiency of the second degree, inasmuch as food remnants are never found in simple atony. The quantity of residue found in the stomach is an indication of the motor power of that organ. In aggravated cases of motor insufficiency food residues are often found in the stomach seven hours after the admin- istration of a test meal, when the stomach under normal conditions would be empty. In severe cases the quantity of urine excreted during the twenty-four hours is markedly diminished, whereas in atony or motor insufficiency of the first degree it is normal. Owing to the variabihty in the 74 EXAMINATION OF THE STOMACH CONTENTS gastric secretion in motor insufficiency, chemical analysis affords but little aid to the diagnosis. In the initial stages of gastric atony the secreting glands produce an excessive amount of gastric juice, followed by a diminution due to fatigue of the glands. At first the hydrochloric acid may show a marked increase, or it may remain normal for a long time. Some cases of motor insufficiency may, upon examination of the gastric contents, show subacidity or anacidity. 8. Pyloric Stenosis. — In this condition there is always retention of food in the stomach. Should the patient par- take of mixed diet in the evening, and the gastric contents be removed the following morning, the various food resi- dues can be recognized macroscopically. Dilatation of the stomach always accompanies pyloric stenosis. When the obstruction is of benign origin, free hydrochloric acid is usually present, whereas it is usually absent in cases of malignant origin. Lactic acid, which is absent in cases of benign obstruction, is usually found in mahgnant obstruc- tion. In malignancy there is a marked decrease in total acidity of the gastric juice, while in benign obstruction the acidity may be increased several degrees. Rennin, always found in cases of benign stenosis of the pylorus, is fre- quently absent in malignant obstruction. The odor of the gastric contents is more marked and fetid in malignant than in benign stenosis. In the former condition the Boas- Oppler bacillus is found, while in benign cases it is absent. Sarcinse, which may be present in benign stenosis, are usually absent in the malignant form. In pjdoric stenosis the gastric contents, if withdrawn and allowed to stand in a glass, will separate out so as to form three layers or strata. The upper layer is frothy, due to decomposition; the middle layer is clear or slightly cloudy; the lowest layer is semisolid. 9. Pyloric Insufficiency. — The diagnosis of this condition is confirmed when the stomach is found empty after the administration of the Ewald-Boas test breakfast. The degree of pyloric insufficiency is ascertained by administering CHANGES IN GASTRIC SECRETION 75 test meals on successive days and removing the contents at stated intervals, such as three-quarters of an hour, half an hour, and fifteen minutes, after the ingestion of the test meal. Chemical analysis of the gastric secretion may reveal the presence of hydrochloric acid, pepsin, and rennin, or these may be absent. The ready passage of air from the stomach tube through the stomach into the duodenum points to insufficiency of the pylorus. 10. Gastric Ulcer. — The clinical symptoms are of greater importance than examination of gastric contents in the diagnosis of this condition. The use of the stomach tube is obviously inadvisable when ulceration is suspected. The vomitus consists of well-digested food, which may or may not be free from blood. If blood be present, it will be either of a fresh red color or dark. The total acidity, of which free hydrochloric acid constitutes the major portion, is usually increased; at times it may be three times the normal — up to 180 degrees. The test for occult blood will usually reveal it in the feces. 11. Erosions of the Stomach.- — In this condition examination of the returned water from gastric lavage reveals small fragments of mucous membrane which, under the micro- scope, show blood corpuscles and gastric glands the form of which is apt to be well preserved and distinct. These fragments of gastric mucosa are constantly found when the patient's stomach is washed out in the fasting condition (Einhorn). In perhaps the majority of cases of gastric erosion there is a decrease in the hydrochloric acid secretion. On rare occasions, on the other hand, hyperacidity may exist. Mucus is present in greater or less quantity. 12. Gastric Cancer. — In this condition the examination of gastric contents yields certain results suggestive of the disease. Among these is the absence of free hydrochloric acid. This is among the early symptoms, and is presumed to be present in about 90 per cent, of all cases. It is also found in achylia gastrica and in advanced stages of chronic gastritis. Free hydrochloric acid may, however, be present in normal or more than normal amounts when the cancer 76 EXAMINATION OF THE STOMACH CONTENTS is small and ulcerous and occupies the pyloric region. The acidity in gastric cancer is subject to marked variations from day to day. The total acidity, as well as the amount of free hydrochloric acid, is diminished. The presence of lactic acid, increased in amount, is also suggestive of cancer of the stomach; 90 per cent, of cases show lactic acid present and free hydrochloric acid absent. In testing for lactic acid the contents of the fasting stomach should be examined in the morning, after thorough gastric lavage the night before. In cancer cases this exami- nation will show very slight digestion of proteins, with fairly good digestion of carbohydrates. The finding of amino-acids in the gastric contents is important. The microscope may show fragments of the neoplasm, such as cellular masses, embedded in blood — a very definite diagnostic sign. The Boas-Oppler bacillus is said to occur in 75 to 85 per cent, of carcinomatous patients, and is rarely found in any other. The test for occult blood in the feces is usually positive. CHAPTER III DIET IN GASTRIC DISEASES For practical purposes food may be defined as any sub- stance which, when taken into the body, assists in its nutrition and maintenance, or replaces its waste and losses. Food has two main functions — namely, the provision for growth and repair of the animal body, and as a source of potential energy to be converted into heat and work. Sub- stances which may not serve either of these functions may yet fulfil a useful place in a dietary. Such articles as tea, coffee, and meat extractives, while they cannot be properly classed as foods, are important, nevertheless, in the consider- ation of dietetics. Composition of Foods. — In order to know the food value of any animal or vegetable product it is necessary to know its composition — the amount of water, salts, proteins, fats, and carbohydrates it contains. The accompanying table (p. 78), compiled by Munk,^ gives the average composition of some of the most common articles of diet. It will be seen from the table that the carbohydrate content of meats is small compared with the protein and fat; but even meats show marked variation in regard to the protein and fat. Vege- table foods, on the other hand, are rich in carbohydrates and contain comparatively small amounts of protein and fat. While carbohydrates predominate in vegetable foods, legu- ininous products show a percentage of protein which some- times exceeds that found in meat. Important as is a knowledge of the chemical composition of foods, we should not lose sight of the fact that their nutritive value is not dependent upon their chemical com- position alone, but upon their digestibihty and absorbability as well. ^ Howell's Physiology. 78 DIET IN GASTR IC DISE^ iSES Composition OF Foods Carbohydrates. In 100 parts. Water. Protein. Fat. Digestible. Cellulose. Ash. Meat .... 76.7 20.8 1 5 0.3 1.3 Eggs .... 73.7 12.6 12.1 1.1 Cheese 36-60 25-33 7-20 3-7 3-4 Cow's milk 87.7 3.4 3.2 4.8 0.7 Human milk . 89.7 2.0 3.1 5.0 0.2 Wheat flour . 13.3 10.2 0.9 74.8 0.3 0.5 Wheat bread . 35.6 7.1 0.2 55.5 0.3 1.1 Rye flour . 13.7 11.5 2.1 69.7 1.6 1.4 Rye bread 42.3 6.1 0.4 49.2 0.5 1.5 Rice .... 13.1 7.0 0.9 77.4 0.6 1.0 Corn .... 13.1 9.9 4.6 68.4 2.5 1.5 Macaroni . 10.1 9.0 0.3 79.0 0.3 0.5 Peas, beans, lentils 12-15 23-26 U-2 49-54 4-7 2-3 Potatoes . 75.5 2.0 0.2 20.6 0.7 1.0 Carrots 87.1 1.0 0.2 9.3 1.4 0.9 Cabbages . 90.0 2-3 0.5 4-6 1-2 1.3 Mushrooms . 73-91 4-8 0.5 3-12 1-5 1.2 Fruit .... 84.0 0.5 10.0 4.0 0.5 Food as it is ingested differs widely in its composition from the nutrient material ultimately required for the repair of waste and the sustenance of the body. Before it can be utilized in the animal economy it must undergo a more or less complex process, designated by the term ''digestion," which means alteration in the alimentary tract by certain unorganized ferments (enzymes). Diet plays the most important part in the treatment of diseases of the stomach. In prescribing diet for patients with gastric disease of any kind, great care should be exer- cised to avoid that which will tend to irritate the affected stomach. A properly selected diet usually fulfils a number of indications, such as diminution of, the production of mucus, or increased or decreased secretion of acid; it will obviate the danger of overburdening the muscular coats, and in this way fortify the tone of the stomach. Reduction of abnormal fermentative processes may be accomplished by a properly selected diet. The progress made in the treatment of diseases of the stomach and intestine has been due mainly to more accu- rate knowledge of the chemical composition of food and of HEAT VALUE OF FOODS 79 the changes that take place within the human organism. Simple methods of examining the stomach contents have disposed physicians to make greater use of the stomach tube to ascertain qualitative and quantitative deviations from the normal in gastric digestion. The results obtained by accurate analysis render the prescribing of proper diet a comparatively^ easy matter. We now have tables showing precisely the length of time food remains in the stomach, and also the time required for digestion. Since we are able to remove and examine the stomach contents at will, we can adapt the treatment to the disease much better than would be possible if dietetic directions had to be given with- out the laboratory aids. Heat Value of Foods. — The heat value of the various food- stuffs has been determined by experiment, and the result is expressed in calories. A calorie is the amount of heat re- quired to raise the temperature of one kilogramme of water 1° Centigrade, or approximately the amount required to raise the temperature of one pound of water 4° Fahrenheit. Ex- pressed in mechanical force, a calorie would raise a ton about 1.54 feet; in other words, it is equal to 1.54 foot-tons. According to Atwater, one gramme of protein furnishes 4 calories; one pound, 1820; one gramme of fat furnishes 9, and one pound 4004 calories; one gramme of carbohydrate furnishes 4, and one pound 1820 calories. The calorific value of foods must be borne in mind. Patients suffering from gastric disease are usually placed on a too restricted diet; the number of calorific units is too small, and as a con- sequence the patients rapidly lose flesh. It is absolutely necessary in all cases of chronic disease of the stomach to see that the patient obtains the required number of calories every twenty-four hours. Fat in the form of butter is one of the best foods for developing heat without injuring the stomach. In all chronic diseases of the stomach, fat agrees well. In many diseases of the digestive organs the most satisfactory progress has been made by adding great quantities of fat to the dietary. Investigations in metabolism have verified this. 80 DIET IN GASTRIC DISEASES Dietary Regulations and Lists. — The experience which the patient has gained in reference to his own diet should be taken into consideration when prescribing a diet for him. The postulate of Boas, ''throw away the printed dietary lists," is based upon the desire to escape from monotonous routine in the treatment of patients suffering from gastric disorders, inasmuch as it is not possible to satisfy the subjective sensations of the patients by means of fixed rules. Patients frequently maintain that they are unable to digest certain articles of food. Such assertions vary, but correspond, however, to the peculiar nature of gastric digestion, inas- much as the assimilability of certain articles of food differs markedly in different patients. The habits of the patient are likewise to be taken into consideration. The preference for or objection to certain foods, the desire for change or for certain modes of preparation, the behavior of the patient as to appetite and the sensation of hunger^ are all of great importance when considering the selection of a menu. Appetite and hunger are trustworthy guides to the healthy man for the food requirements of the body. In health, as much food as the normal appetite calls for is generally eaten; this corresponds, as a rule, to the quantity which can be assimilated and by which the body weight is kept fairly constant for a considerable space of time. In patients with disease of the stomach the appetite and the sensation of hunger are, as a rule, not a trustworthy guide for the quantity of food required; in most cases both are below normal. When this is the case the diet must be regulated in such a manner that nutrition does not suffer on account of the deficient appetite. To diet does not mean to starve. It is also of great importance to search for the causes of the anorexia. These may consist of organic disease of the stomach, or they may be of a purely nervous nature. The diminished appetite may have been induced artificially by a dietary plan which the patient himself had determined upon before seeking medical advice. The statements of patients regarding the digestibility and general effects of certain DIETARY REGULATIONS AND LISTS 81 articles of food must not be accepted unreservedly as a guide to treatment. Digestibility is a term which is frequently misunderstood and misapplied. Digestibility does not involve the question of distress, nor the question of the food containing suffi- cient calories; for not every food which is well digested is well borne, and not every food which is well borne is digested well and properly assimilated. The amount of digestive effort required varies with different articles of diet. A person whose gastro-intestinal tract is normal can digest and assimilate without discomfort any kind of reasonable food which he can eat. The term "digestible" signifies, however, something quite different in gastric disease. Riegel defines a diet as easily digestible which does not make great demand on the secre- tory and motor functions of the stomach, and which is easily absorbed without producing subjective discomforts. This definition also includes assimilabihty, or good effect after absorption. Wegele claims that a food is easily diges- tible when it fulfils the following conditions: (1) It must offer but httle resistance to the digestive juices; that is, it must be easily soluble. (2) It must not impede the peristaltic movements, nor, on the other hand, should it accelerate the movements of the stomach too much. (3) It must not seriously irritate the digestive organs chemi- cally or mechanically. (4) It must be easy of absorption, either from the stomach or from the intestine. Schmidt describes those foods as easily digestible which require the least digestive effort in the presence of gastric diseases. It has become an estabhshed practice to calculate the degree of digestibility from the length of time the foods remain in the stomach. Penzoldt has ascertained this relation in health (Table I), and with this in view has arranged four different forms of diet, proceeding from light to heavy (Table 11) ; these agree fairly well with the four forms of diet proposed by Leube, which also take into consideration the time the foods remain in the stomach. Both these dietary lists are constructed with a view to affording an 6 82 DIET IN GASTRIC DISEASES easily digestible menu for patients suffering from diseases of the stomach. Table I Leaves the stomach in : One to two hoiirs: 100 to 200 Gm. Water, pure. 200 Gm. Water containing '002. 200 Gm. Tea, pure. 200 Gm. Coffee, pure. 200 Gm. Cocoa, pure. 200 Gm. Beer. 200 Gm. Light wines. 100 to 200 Gm. Milk, boiled. 200 Gm. Bouillon, pure. 100 Gm. Eggs, soft. Two to three hours : 200 Gm. CofTee and cream. 200 Gm. Cocoa and milk. 200 Gm. Malaga. 200 Gm. Wine. 300 to 500 Gm. Water. 300 to 500 Gm. Beer. 300 to 500 Gm. Milk, boiled. 100 Gm. Eggs, raw, or scrambled, hard-boiled, or omelet. 100 Gm. Beef sausage. 250 Gm. Calf's brain, boiled. 72 Gm. Oysters, raw. 200 Gm. Carp, boiled. 200 Gm. Pike, boiled. 200 Gm. Cod, boiled. 200 Gm. Sole, boiled. 150 Gm. Cauliflower, boiled. 150 Gm. CauHflower salad. 1.50 Gm. Asparagus, boiled. 150 Gm. Potatoes, salt potatoes. 1.50 Gm. Potatoes, mashed. 150 Gm. Cherry jam. 150 Gm. Cherries, raw. 70 Gm. White bread, fresh or stale, dry or with tea. 70 Gm. Rusk, new or stale, dry or with tea. 70 Gm. Cracknel (pretzel). 50 Gm. Albert biscuits. DIETARY REGULATIONS AND LISTS 83 Table I (Continued) Leaves the stomach in : Three to four hours: 230 Gm. Chicken, young, boiled. 230 Gm. Partridge, roast. 200 to 260 Gm. Squab, boiled. 195 Gm. Squab, roast. 250 Gm. Beef, raw or boiled, lean. 250 Gm. Calf's feet, boiled. 160 Gm. Ham, raw or boiled. 100 Gm. Roast veal, warm or cold, lean. 100 Gm. Beefsteak, fried, cold or warm. 100 Gm. Beefsteak, raw, minced. 100 Gm. Sirloin steak. 200 Gm. Salmon, boiled. 72 Gm. Caviar, salted. 200 Gm. Lampreys in vinegar. 200 Gm. Smoked herring. 150 Gm. Rye bread. 150 Gm. Graham bread. 150 Gm. White bread. 100 to 150 Gm. Albert biscuits, 150 Gm. Potatoes. 150 Gm. Rice, boiled. 150 Gm. Kohlrabi, boiled. 150 Gm. Beet, boiled. 150 Gm. Spinach, boiled. 150 Gm. Cucumber salad. 150 Gm. Radishes, raw. 150 Gm. Apples. Four to five hours : 210 Gm. Squab, fried. 350 Gm. Fillet of beef. 250 Gm. Beefsteak, fried. 250 Gm. Ox tongue, smoked. 100 Gm. Smoked meat, sliced. 250 Gm. Hare, roast. 240 Gm. Partridge, fried. 250 Gm. Goose, fried. 280 Gm. Duck, fried. 200 Gm. Herring in salt. 150 Gm. Lentils, puree. 200 Gm. Peas, puree. 150 Gm. Beans, boiled. 84 DIET IN GASTRIC DISEASES Table II 1. Diet (about ten days) Foods or bev- Largest quantity Method of prepara- General character. How to be taken. erages. at one time. tion. Meat 250 Gm. From beef. Lean, unsalted or Slowly. broth. shghtly salted. Cow's milk. 250 Gm. Well boiled, or Pure milk, or ^ With tea if de- sterilized. hme water. sired. Eggs. One to two. Soft, just warm, or raw. Fresh. If raw, stir into warm (not boiling) broth. Meat sol. 30 to 40 Gm. To have merely Teaspoonful (Leube a slight odor of doses, or and Ros- bouillon. stirred in enthal) . meat broth. Biscuits Six. Without sugar. Without sugar. Hard. Masti- (Albert cate well biscuits) . and insali- vate. Water. i liter. Ordinary, or nat- ural CO2 water weak (Seltzer). Not too cold. 2. Diet (about ten days) Foods or bev- Largest quantity Method of prepara- General character. How to be taken erages. at one time. tion. Calf's 100 Gm. Boiled. Without con- Best in broth. brain. nective tissue of any kind. Calf's 100 Gm. Boiled. Without con- Best in broth. thymus nective tissue (sweet - bread). Pigeon. of any kind. One. Boiled. Young, tender, Best in broth. without ten- dons, skin, etc. Chicken. One, medium size. Boiled. Young, tender, without tcn- ilons, skin, etc. Best in l^roth. Raw beef. 100 Gm. Minced, chipped, or scraped, with little salt. Fillet. To be eaten with crackers. Beef sau- 100 Gm. No additions. Slightly smoked. To be eaten sage, raw with crackers. Tapioca. 30 Gm. With milk as pudding. DIETARY REGULATIONS AND LISTS 85 3. Diet (about eight days) 4. Diet (about eight to fourteen days) Foods or bev- erages. Largest quantity at one time. Method of prepara- tion. General character. How to be taken. Venison. 100 Gm. Roast. Back, saddle, hung, not high flavor. Partridge. One. Fried, without bacon. Young, tender. Roast beef. 100 Gm. Rare. Good breed, well Warm or cold, pounded. Fillet. 100 Gm. Rare. Good breed, well Warm or cold, pounded. Veal. 100 Gm. Roast. Saddle, leg. Warm or cold. Fish: pike, 100 Gm. Boiled in salt With bones care-: In fish sauce. sole, carp, water without fully removed. trout. addition. Caviar. 50 Gm. Raw. SUghtly salted, Russian. Rice. 50 Gm. Pudding, soft. Boiled soft. Asparagus. 50 Gm. Boiled. Soft. Butter sauce. Scrambled Two. With fresh butter, eggs. little salt. Egg, ome- Two. With 20 Gm. Well risen (Ught). To be eaten as let or sugar. prepared. custards. Fruit. 50 Gm. Fresh, boiled or Free of seeds and stewed. skin. Claret. 100 Gm. Light, pure Bor- Any good claret Slightly deaux. or red wine. warmed. 86 DIET IX GASTRIC DISEASES Table III — Dietary Lists or Leube 1. Beef tea (bouillon, meat solution), milk, soft and raw eggs, zwieback or biscuits without either sugar or fat; plain water or natural mineral waters poor in carbon dioxide. 2. Boiled calf's brain, sweetbreads, chicken, squab, glutinous soups, tapioca, milk pudding, boiled calf's feet. 3. Minced beefsteak (loin), minced raw ham, mashed potatoes, white bread (small amounts) ; small quantities of coffee or tea with milk (or trial only). 4. Roast chicken, squab, deer, partridge (hare, rather not), roast beef (rare), roast veal (leg), pike, cod (steamed), macaroni, bouillon-rice (later verj^ light pudding), wine in small portions. The following table, taken from Schmidt, shows the per- centage of nutritive material in each of the articles named that is lost in the processes of chgestion and assimilation, not being made available to the tissues: Table IV ^ , Carbo- Protein. Fat. hydrates. Meat 3 5 Fish (cod) 3 Eggs 3 5 Milk 1 to 7 3 to 5 WTiite bread (wheat) 22 ... 1 to 3 Rye bread '. . . 32 ... 11 Macaroni 17 6 1 Rice 20 7 1 Peas (puree) 17 ... 4 Potatoes (whole) 32 4 8 Potatoes (mashed) 20 ... 4 Cabbage (green) 18 6 15 Carrots (yellow) 39 6 18 Experience teaches that emaciation and loss of strength must be referred, in the majority of cases of gastric disease, to insufficient nutrition. It is, therefore, imjiortant to know the quantity of food absolutely needed by the body. In health the requirements for the average adult are 100 grammes of protein, 50 grammes of fat, and 450 grammes of carbohydrate, daily. Expressed in calories the number is 2720. Individual articles of diet may be substituted one for another in proportion to their heat values. Obviously the MEAT 87 constitution and the appetite of the patient offer certain limits which must be respected. If one or more ordinarily desirable articles of diet are not acceptable to the patient we mSLY substitute others, so long as we supply the required number of heat units. When considering this question it is important to remember that a person at rest requires fewer calories than one at work. In health the requirements per kilo body weight per day, at rest, are 30 to 35 calories; at hght labor, 35 to 40 calories; and at average labor, 40 to 45 calories. In the treatment of severe chronic gastric disease the patients should be confined to bed in order to economize the heat units contained in the comparatively small amount of food they are able to take. Meat. — Much discussion has taken place regarding the respective merits of light and dark meat. The significance of the distinction has frequently been exaggerated, but certain differences should not be disregarded. White meat (veal, fowl) possesses a shorter, softer, and more tender fibre, and differs from dark meat, such as beef and mutton, by its smaller proportion of extractives; this difference is considerable. The fat of dark meat is with difficulty dis- solved, and therefore offers resistance to the penetration of the digestive juices. Meat may be defined as the muscle of an animal together with the conjoined connective-tissue substances, such as tendons, ligaments, bones, and cartilage. The internal organs of the animal, so far as they are edible, namely, kidneys, spleen, liver, sweetbread, brain, and intes- tine, as well as sea-foods, such as fish, lobster, and clam, are also included under the term "meat." The average compo- sition of meat is: Protein, 20 to 25 per cent.; fat, gelatinous substances, glycogen, and extractives (kreatinin, xanthin). The meat of animals recently killed should be permitted to hang for some time before it is eaten. \^Tiile meat is hang- ing, lactic acid is produced which loosens the connective tissue between the muscle fibres, thereby softening it and rendering it more easily digestible. Game should hang for a time to permit of this softening process, especially for pa- tients with gastric troubles; but it should not be allowed to 88 DIET IN GASTRIC DISEASES decompose so far as to become '^gamey, " for then it is likely to arouse the aversion of the patient ; or, if eaten, to increase the digestive disturbances by introducing into the system the products of decomposition. Old animals naturally yield tougher meat than young. The preparation of meat is important. Raw meat ought to be avoided by patients with gastric disease, though it is more easily digested in health than is cooked meat. The digestion of raw meat takes place both in the stomach and in the small intestine; the coarse connective tissue is digested by the stomach, the muscle fibre by the small intestine. The stomach cannot, however, digest raw meat when the secre- tion of hydrochloric acid is defective; on the other hand, when there is too much hydrochloric acid, still more of it is produced under the stimulus of raw meat in the stomach. The dictum of Schmidt to strike out raw, rare, and smoked meat from the diet of gastric patients is, therefore, a reason- able one. Smoked and canned meats behave similarly toward hydrochloric acid. Salted or canned meats, such as ham, ox tongue, smoked or corned beef, have not the same nutri- tive value as raw meat or meat prepared in any other way; during the pickling process, extractive materials and phos- phates are lost. In partaking of uncooked meats there is always a possibility of infection by animal parasites. The custom among the German people of eating raw pork is well known. Thousands of microscopists are employed in Germany to prevent trichinosis. Stiles finds that of 274 cases of trichinosis in America 208 were Germans. The simplest and most effective method of preventing the dis- ease is ignored. The cooking of the meat is all that is necessary. The majority of people eat more meat than they require. Meat once a day is sufficient for a person not engaged in manual labor, or for one who does not take nnich vigoi-- ous outdoor exercise. Many gastric troubles owe tluMr origin to the consumption of food which causes a greater drain on the gastric juices than the system is able to stand. Of the various meats, young lean beef is, as a rule, the most MEAT 89 easily digested. The white meat of fowl enjoys a special reputation, to which most clinicians agree. Yet no chemic differences between the white meat and dark meat have yet been shown. The digestibihty of roasted, boiled, and stewed meats is in the order named. It may be increased by preliminary processes such as beating, grinding, mincing, and scraping. Meats poor in fat are generally easily digestible, owing to the ready accessibility of the gastric juice to the muscle fibres. The following varieties are permissible for gastric patients: Beef, veal, lean pork, hare, deer, fowl, squab, partridge, pheasant, and all kinds of lean fish, such as trout, pike, codfish, and shad. Because of their high per- centage of fat, goose, herring, and salmon should be avoided. Caviar, though rather salty, may be allowed, as may also oysters and lobsters. The meat of the lobster is not so tough and difficult to digest as is popularly believed. Sau- sage should be avoided because it contains about 40 per cent, of fat and a great deal of condiment. Foods containing gelatin belong to the group of meat nutrients. They are of great importance in dietetics, serv- ing as protein and fat sparers. Gelatin is almost entirely digested, leaving little or no residue. Tendons, cartilage, ligaments, connective tissue, and bones belong to this class. Gelatin is present in larger amount in the broth of veal than in beef broth. Calf's head and calf's feet are rich in gelatin. Meat jelly is a popular gelatinous food for patients with stomach disease, and may be prepared, according to Wiel, in the following manner: Four calf's feet, one kilogramme of beef, and one chicken are boiled for about five hours in five liters of water with 15 grammes of common salt. Dur- ing the last hour of boiling a small pike is added. The soup is allowed to cool over night. The layer of fat is removed the next morning, and the remaining contents of the dish are taken out and cleared. This brawn is then gradually heated, and, after it has liquefied, well beaten white of eggs together with the broken egg shells is added. The brawn is gently boiled until large pieces of protein are precipitated 90 DIET IN GASTRIC DISEASES and the edges of the brawn appear clear as wine. It is then taken from the fire and allowed to stand until com- pletely transparent. It is then filtered through a previously moistened napkin, and after a good filtrate has been ob- tained, 20 grammes of meat extract are added, and the jelly is poured into forms to be served cold. Meat broth is not considered a food, since it contains only small quantities of protein, fat, and gelatin. It is, however, rich in extractives which stimulate the secretion of hydrochloric acid. The in- dications for its use are, therefore, plain. Bouillon soups containing eggs or flour may be substituted for pure meat broths. Pure beef tea has much the same value as meat broth. It contains rather more protein and glutinous substances than broth, and has a marked effect in stimulating the appetite, favoring the secretion of gastric juice in cases of acute and chronic affections of the stomach. Beef tea is prepared by taking fresh meat free from fat and cutting it into small pieces, placing it in a bottle without water, and slowly heat- ing it on the water bath; after steaming for twenty minutes the meat juice collects as a turbid yellowish fluid. Eggs. — Eggs are to be taken, as such, only when soft boiled, the white barely coagulated. In the form of very light egg dishes, or stirred up in soups, they make a very acceptable addition to the diet. Hard-boiled or fried eggs cannot readily be reached by the gastric juice, and are apt to irritate a diseased gastric mucous membrane, unless the hard protein is first very finely triturated. Eggs are a concentrated food containing protein and fat, 12 per cent, of each. A diet consisting solely or chiefly of eggs should not be prescribed for patients with gastric trouble, since even in health it is not advisable to ingest large quantities of protein in so concentrated a form. If the functional de- rangement of the stomach is marked by subacidity the peptonizing power is of course deficient, and if by hyper- acidity the secretion of acid will he still furtluM- augmented by the ingestion of protein. MILK 91 Fat. — A diet rich in fat was at one time considered dele- terious to patients with gastric disease. At present, however, the view predominates that fat is a food which is very well adapted to this class of patients, inasmuch as it has a high calorific value in proportion to its volume. We know, moreover, that fat hinders the secretion of gastric juice, while it does not interfere with the motility of the stomach. Good results have been reported after the adminis- tration of fat in cases of disturbed motor activity of this organ. The fat best adapted to patients with gastric dis- ease, as has been said, is butter. There are but few trust- worthy substitutes for good butter. Wegele recommends '4ana, " a preparation made from milk of almonds and margarine. Vegetable (cocoanut) butter may also be con- sidered. Of other fats suitable for patients with stomach diseases, we have cream, olive oil, oil of sesame, sweet oil of almond, and cod-liver oil. Because of its disagreeable taste cod-liver oil proves repulsive to most patients; the taste may be disguised by administering the oil in capsules. Milk. — Since milk contains large proportions of protein, fat, and carbohydrate, it is an excellent article of diet. When a liquid diet alone is indicated, milk holds first place. It must, however, be borne in mind that milk alone is unable to supply the required number of calories, for three liters of milk contain only 1800 calories. Should milk prove repulsive to a patient, the taste may be disguised by com- bining it with other articles of diet. Milk ought to be given freshly boiled, as it is then more easily digested, and the germs contained in it are destroyed by the boiling process. Milk is poorly borne by many patients, and for various reasons. Sometimes the reason is purely subjective, a sort of '^ phobia" that has to be overcome by psychic influence. Then, again, with a pure milk diet a large quantity is neces- sary in order to obtain the required number of calories, and this large volume interferes with the digestion of the milk. The volume may be diminished by the use of condensed milk. The stomach contents are apt to become excessively acid when great quantities of milk are taken, the acid- 92 DIET IN GASTRIC DISEASES secreting glands being stimulated by the presence of the milk. WTien it is considered advisable to prescribe milk in large amounts, the hyperacidity may be corrected by the use of alkaline mineral waters in small amounts, beginning dur- ing the second hour of gastric digestion. The addition of lime water to milk will often aid in its digestion in cases in which the milk would not otherwise be easily borne. ]^Iilk is nearly always well borne if it does not remain too long in the stomach. The more finely the casein floccules are pre- cipitated the less discomfort is the patient likely to experi- ence from a milk diet. The drinking or sipping of milk in very small quantities will cause a fine precipitation of casein in the stomach. Part of the pronounced value of koumiss and kefir is due to the precipitation of casein in a finely subdivided condition. Pegnin (Dungern), a sterile milk- sugar rennet ferment, has a similar action in producing a finely floccular coagulation. It is found that milk causes much discomfort in cases of stenosis of the pylorus. Should milk as such not be permissible, adA^antage may be taken of one or more of the numerous milk preparations available. Buttermilk contains less fat and sugar than fresh milk, but the small percentage of lactic acid it contains gives it an agreeable and refreshing taste ; it is well borne in gastric disease and is particularly useful in febrile affec- tions of the stomach. Sour milk prepared in the following manner has a somewhat similar action: Two tablespoonfuls of sour cream are mixed with half a liter of milk which has been boiled and cooled. The mixture should be well stirred, and allowed to remain in a warm place. Two table- spoonfuls of this product are used in the preparation of sour milk by adding to half a liter of a fresh quantity of milk which has been boiled and allowed to cool. Gartner's fat-milk, obtained by the mechanical removal of part of the casein, is easil}' digested by the majority of gastric patients. Whey, the fluid remaining after the precipitation of casein, contains protein, milk sugar, poptono, and common salt; MILK 03 its nutritive value is small, and it is used to a very limited extent. Koumiss and Kefir. — Koumiss and kefir, on the other hand, are most excellent milk preparations. Koumiss is prepared from the milk of either mares or cows by lactic acid and alcoholic fermentation. It contains lactic acid, carbon dioxide, and alcohol, and has an agreeable, slightly acid taste. Kefir has been used much more extensively than koumiss. It is prepared by means of kefir tablets or pastilles, which acting upon milk produce lactic and alcoholic fermentation, the result of which is a thick, cream-like, acidulous beverage. Boiled milk, cooled, is poured over the kefir ferment and left to stand for twelve hours at ordinary room temperature. It is then stirred, filtered, and placed in bottles, which are to be thoroughly shaken three times a day and kept in a cool place. After two or three days the kefir will be ready for consumption. The advantage of kefir is that it contains small quantities of carbon dioxide together with a very small percentage (2 per cent.) of alcohol. When ingested, it hastens the secretion of hydrochloric acid and, on account of the action of the carbon dioxide, increases its power. Yoghurt Milk. — This is a Bulgarian sour milk, of recent introduction in America, but long used in the East. It has a high nutritive value, employed in the same way as kefir. The value of Yoghurt milk (pronounced yowrd) for gastric patients was first appreciated by the Bulgarian physician Grigoroff, and later by the French school. It is similar in many ways to kefir and koumiss. The acidulation is gener- ated by a ferment containing three kinds of bacteria, the most important of which is the Bacillus bulgaricus, a long bacillus which appears both singly and in chains, and which can be stained by Gram's method. This bacillus is able to induce fermentation of dextrose, sugar of milk, and sac- charose, and causes the coagulation of sterile milk within twelve hours by the formation of lactic acid. A tem- perature of 60° to 70° C. destroys the vitality of the germ in thirty minutes. The composition of Yoghurt milk and its relation to ordinary sour milk (which becomes acid 94 DIET IN GASTRIC DISEASES by mere exposure to air), to kefir, and to koumiss may be seen from the following table: Common Kefir. Koum.iss. sour milk. Yoghurt. Lactocasein 2.98 0.80^ 2.70 Lacto-albumin 0.28 0.30 I 3.55 0.98 Peptones and albumoses ... . 05 1 . 04 J 3 . 75 Fat 3.10 1.12 3.7 7.20 Milk sugar 2.78 0.39 4.5 9.40 Lactic acid 0.81 0.96 0.6 0.80 Alcohol 0.70 3.19 ... 0.20 Mineral constituents .... 0.79 0.33 0.71 1.38 The advantage of Yoghurt milk consists in the fact that its casein and albumin are rendered soluble in the shape of peptones and albumoses, and that the Hme phosphates have gone into solution up to 68 per cent. These facts serve to explain the ready digestibility of the milk. Metchnikoff ascribes a direct life-prolonging effect to Yoghurt milk, and he bases this opinion upon the fact that in Bulgaria, where Yoghurt is a regular article of diet, there are in four milUon inhabitants three thousand six hundred consumers of Yoghurt who are said to be above one hundred years of age, while in Germany, with a population of sixty-one million, there are only about seventy centenarians. Granted that the conclusions of Metchnikoff may be somewhat erroneous, it must still be admitted that the decomposition processes in the intes- tine and the whole tissue metamorphosis are favorably affected by the use of Yoghurt. Preparations analogous to Yoghurt are put out by the various pharmaceutical houses in America. Fairchild's lactic bacillary tablets are said to be prepared from the Bulgarian bacillus. Parke, Davis & Co., of Detroit, manufacture a Bacillus bulgaricus tablet (from a pure culture of Bulgarian lactic acid bacilli) which when added to sweet milk produces a beverage that is essentially the same as Yoghurt. Preparations of a similar nature and of equal merit are produced by Hynson, ^^'estcott & Co., of Baltimore, and by other pharmaceutical houses. Cheese. — Cheese is made by treating raw milk with rennet. The resulting coagulum is thoroughly beaten up, and then BREAD 95 left standing to mature. The casein is thereby spHt up into various decomposition products which give the cheese its characteristic odor and taste. Decomposed cheese, which is looked upon as a delicacy by some people, should not be prescribed for patients with gastric disease. Almost every normal stomach rebels against the Roquefort and Limburger cheeses with their characteristic odor. The semi-putrid casein cheese should never be eaten even by healthy people, not to mention those with impaired digestion. Bread. — Rye bread is prepared from rye flour by means of yeasted dough. Brown bread and ^^pumpernickle" are made from rye flour; Graham bread, from whole wheat meal. All these varieties must be excluded from the diet of gastric patients, inasmuch as they prove a source of irritation to any but a normal stomach. Yeast dough bread in the intes- tinal tract gives rise to acid fermentation, producing lactic, butyric, and acetic acids, carbon dioxide, and hydrogen. The finer baked foods, especially those made of wheat, as white bread, zwieback, and cookies or biscuits prepared by the addi- tion of butter, milk, and sugar, are especially adapted for gastric treatment. Ordinary wheat bread should be given stale, or only when roasted — as toast. Fresh and very soggy wheat bread retards penetration by the digestive fluids and is difiicult of mechanical subdivision. Wheat bread toasted, zwieback, and biscuits, like the crust of bread, contain their starch in the form of dextrin, which is easily digested. It is, however, necessary that patients with gastric disease should carefully masticate and insalivate these baked foods. There is a mistaken idea among the laity that the sick should be fed pappy liquid substances entirely different from the food taken by a person in health. If we except foods that contain a great deal of irritating waste, there is no rea- son why the diet of the sick should differ from that of the well. We must, however, eliminate fried foods and fermentable vegetables. Pure white bread is never contraindicated, and the addition of butter gives it a high calorific value. The bread should be thoroughly toasted in order to dextrinize the carbohydrates and render them easily digestible. Crackers 96 DIET IX GASTRIC DISEASES can frequently be substituted for bread. Breads made from rye, whole wheat, barley, and peas, all have their advocates. Too great efficacy should not be ascribed to anj^ one article of diet. The results of experiments made by Lauder Brunton show that the '^deal" bread has not yet been found. Brunton points out that while brown bread contains more nitrogen less nitrogen actually gets into the blood than from a similar weight of white bread. He finds that white bread is not only more digestible and less likely to cause gastritis, but more nutritious, weight for weight, than brown bread. Grain flours are used not only in the baking of bread, but in the preparation of soups. The gruel soups in the making of which the grain granules are first boiled and then pressed through a sieve are valuable in the treatment of stomach diseases. Oat and barley gruel are prepared after this manner. Their mucoid consistency is due to gluten and broken-up starch granules. Gruel soups protect the mucous membrane of the stomach from the irritating effects of other foods eaten at the same time. Noodles, macaroni, and spaghetti are useful farinaceous dishes. Potatoes. — The cheapness of and the large percentage of carbohydrates in potatoes render them a very satisfactory food for all classes of gastric patients. Potatoes must be given properly prepared — as a puree, if need be, with the addition of milk and butter. Other tuberous plants used as foods are much poorer in carbohydrates than potatoes, and should be eaten only when they can be prepared in the form of puree. Hard tubers, such as radishes, beetroots, and onions, are contraindicated in cases of impaired diges- tion. Sago and tapioca as porridge or soup are very useful foods for gastric patients. Rice. — Rice has usually been considered an inferior food owing to the excess of starch (in other words, deficiency of protein) in its composition; and this is undoubtedly true of rice as we usually get it. This alleged defect in the grain is due to the removal of a nutrient substance in making it presentable for the market by what is known as the polish- SUGAR 07 ing process. Not only the outer husk, but what is known as the "rice meal," which envelops the inner kernel, is removed, despite the fact that this is the most nutritious part of the grain. Analysis of "rice meal" made at the in- stance of Dr. George Reith, in 1900, showed it to contain 12.5 per cent, of protein and 4.5 per cent, of phosphoric acid. The Japanese, in common with other rice-eating peo- ples, polish only the grain that is intended for export; what is kept for home consumption, being unpolished, possesses a much larger proportion of nutriment and a flavor which the polished grain lacks. Rice in its natural condition is, there- fore, a very nutritious article of food; it is easily digested, and quite suitable for patients with impaired digestion. Green Vegetables. — Green vegetables and the various kinds of cabbage contain very little protein and only a small quan- tity of carbohydrates. Prepared as purees they are permis- sible, however. The small percentage of cellulose in green vegetables is no contraindication to their use. A patient with gastric disease should not, however, eat vegetables which cannot be finely divided. The tops only of asparagus are permissible. Mushrooms are contraindicated. Legumes. — Peas, beans, and lentils are all rich in protein, containing about 20 to 25 per cent., and 50 per cent, of carbohydrates. They are consequently very nutritious substances, and, when well cooked and carefully strained, suitable for gastric patients. Fruit. — Fruit contains less protein than do vegetables, but a larger quantity of carbohydrates in the shape of dextrose and levulose. The refreshing taste of fruit is due to various fruit acids, such as malic acid in apples, tartaric acid in grapes, and citric acid in lemons. Patients with gastric disease should take fruit only when it is cooked by boiling. Sugar. — Cane sugar, grape sugar, milk sugar, or fruit sugar may be eaten by patients with gastric disease, within certain limits. Solutions of sugar cause n the stomach a decreased secretion by the gastric glands. Since they inhibit the secretion of hydrochloric acid, thej^ are applicable in con- ditions of hyperacidity. Morgan carefully experimented on 7 98 DIET IN GASTRIC DISEASES several persons with cane sugar, making repeated gastric analyses ; he concluded that sugar in considerable amounts in the diet of either the healthy or the sick depresses the secretory functions of the stomach. In hyperchlorhydria a diet containing large amounts of sugar diminishes the secretion of hydrochloric acid in about the same propor- tion as it does in a healthy stomach. According to Abel/ three or four ounces of sugar can be digested by the healthy adult without difficulty. Saccharin occasionally gives rise to indigestion. Spices. — Small quantities of common salt stimulate the secretion of gastric juice; large quantities hinder digestion. The ingestion of salt in cases of gastric disease has to be regulated according to the findings on analysis of the stomach contents. In addition . to sodium chloride, the alkahne phosphates and earths are made use of in the human economy. They are, however, present in ordinary food in sufficient quantity for this purpose. Only very few spices should be allowed in the dietary of gastric patients. Vanilla and cinnamon are harmless. Practically all other spices must be eliminated, or used with care for the purpose of stimulating an insufficient secretion of gastric juice. Water. — Water stimulates secretion slightly; it remains in the stomach for a comparatively long time, and acts as a diluent. The artificial waters charged with carbon dioxide have no place in the dietary of stomach patients. The natural mineral waters, however, excite peristaltic action and have a slightly anesthetic effect upon the mucous mem- brane of the stomach. Strong natural waters, like the artificial substitutes, contain too much carbon dioxide, and consequently have a harmful effect upon t^e stomach. Not more than eight ounces of water should be taken at one time. Water is not absorbed by the stomach. The di'inking of ice water is harmful, inasmuch as it temporarily paralyzes the pyloric closure, so that the stomach contents are in dan- ger of being emptied at once into the duodenum. Accord- ' Unitt'd Stiitcs Dcparlinent of Agriculture, IJulIotiu 1)3. ALCOHOL 99 ing to Bettmann, large draughts of hot water benefit those who are well nourished and whose digestive tract is well supplied with muscular tissue. Large draughts of hot water, taken on retiring, are beneficial to corpulent people who are subject to ''bilious attacks" so called, or who are affected with gastric catarrh. An aperient pill swallowed at bedtime with a large tumblerful of hot water is usually all the medi- cine that is necessary to keep such patients comfortable. Hot water taken before meals, either with or without phos- phate or sulphate of soda, is also beneficial. It acts by dissolving and washing out of the stomach the accumulated mucus. Such treatment, however, instituted in cases of motor insufficiency, almost invariably does harm. At first the patients experience some relief, but after one or several weeks all their symptoms return in an aggravated form. This is explained by the fact that when the digestive tract is relaxed and muscularly weak the stomach is unable to propel large quantities of fluid into the intestine. In such cases it is always difficult to get sufficient water into the system. The stomach should not be overloaded with water at any one time, but water should be taken in small quanti- ties and frequently. Alcohol. — The combustion of protein and fat is diminished after small quantities of alcohol are taken. In acting as a fat-sparer, alcohol itself is consumed and yields heat and energy to the body; it is, therefore, to a certain degree a food. Alcohol is usually consumed in the shape of champagne, beer, wine, whisky, brandy, or other concen- trated spirituous liquor. The general effect of alcohol in small quantities and in not too concentrated form on gastric digestion is to stimulate secretion; but large quantities and the concentrated drinks (liquors) retard digestion. According to Chittenden, Mendel, and Jackson, ^ alcohol and alcoholic fluids have a marked effect on gastric secre- tion, increasing very greatly the flow of gastric juice and also its content of acid and total solids. Furthermore, this 1 American .Journal of Physiology 100 liJET IN GASTRIC DISEASES action is exerted not only by the alcoholic fluids in the stomach, but also reflexly through the influence of alcohol absorbed from the intestine. Ordinary ethyl alcohol intro- duced into the empty stomach of dogs, with the duodenum ligated, exhibits a markedly stimulating action upon gastric secretion as compared with the action of water under like conditions. Not only does it increase the volume of gastric juice very greatly, but it increases its acidity as well as the content of solid matter. Moreover, alcohol absorbed from the intestine, the latter being entirely shut off from the stomach, may likewise cause stimulation of the gastric glands, with a marked increase in the rate of secretion. Whisky, brandy, sherry, claret, beer, and porter all have the same effect in stimulating gastric secretion. The gastric juice under alcoholic stimulation is strongly pro- teolytic. If these results are considered in connection with our previous observations upon the influence of alcohol and alcoholic drinks upon the purely chemical processes of gastric digestion it is seen that, side by side with more or less retardation of digestive proteolysis caused by alcoholic beverages, there occurs an increased flow of gastric juice, rich in acid and of unquestionable digestive power. The two effects may thus normally counterbalance each other, though it is evident that modifying conditions may readily retard or stimulate the processes in the stomach accord- ing to circumstances. Foremost among these is the rapid disappearance of alcohol from the alimentary canal. The administration of alcohol must be guided accordingly when considering its employment in gastric disease. Boas abso- lutely forbids alcohol in cases of gastric neurasthenia. Beer should be avoided in the great majority of stomach ]ia- tients, inasmuch as it dilutes the gastric juice and induces fermentative processes, due to the yeast contained in the beverage. With respect to wine, in light cases ])ossi])ly a very mild, good quality claret, diluted if need be, should l)c considered. In acute cases champagne is a fairly practical TEA AND COFFEE 101 analeptic. Cognac and other concentrated liquors are quite inadmissible in cases of stomach disease. Tea and Coffee. — Coffee stimulates the secretion of the gas- tric glands and increases the peristaltic movements of the intestine. Tea has a constipating effect on account of the large amount of tannic acid it contains, and in animal experiments it retards the secretion of acid and delays the peptonization of protein substances. Coffee should be for- bidden in most cases of gastric disease. Very weak tea, on the contrary, may be taken with advantage, especially if used as a vehicle for milk or other nutritive materials. In health, however, there is no reason for apprehending danger to the race at large from coffee-drinking. Coffee- drinking has not affected Americans to any appreciable degree, though coffee has been the almost universal bever- age for many decades. The life insurance companies, con- stantly warring against everything that tends to shorten life, are silent in regard to coffee as a beverage. The experi- ments of Chase on three normal individuals who were not addicted to tea or coffee show that when taken wdth meals, in the amounts ordinarily used, these beverages do not retard either salivary or peptic digestion. It has been found that salivary digestion is aided slightly by tea. Both tea and coffee may act as mild stimulants to gastric secretion; the digestive power of the secretions, however, is not augmented, but, on the other hand, neither is it impaired, as in the use of whisky. Therefore, as a stimulant to gastric secretion, tea or coffee would seem preferable to whisky. In the tests wdth these beverages, strong black tea and a 10-per- cent, strength of coffee (coffee 10 Gm., water 100 Cc.) were used. Both the strengths and amounts used were sufficient to show any harmful effects which might be produced by these fluids as ordinarily taken. Admitting the generally harmful effects of large quantities of tea and coffee, there seems to be an undue prejudice against the use of these beverages, judging from laboratory experiments. A great deal has been said about the deleterious effects of tea and 102 DIET IX GASTRIC DISEASES coffee on the stomach. Apart from their stimulatmg effect on the central nervous system, if properlj^ made and not too strong, their effect on digestion is almost neutral. Cocoa. — Cocoa possesses much higher nutritive value than tea or coffee. It does not stimulate gastric diges- tion, and prepared with either water or milk it is a proper beverage for patients with stomach disease. Prepara- tions of cocoa from which the oil has been expressed, and which have not been treated with alkalies, are to be recom- mended. Chocolate prepared by admixture of sugar and spices is not so easily digested. It contains a larger pro- portion of fat and carbohydrates, and may, therefore, give rise to fermentation and the formation of acid. Tobacco. — The use of tobacco in am^ form is to be inter- dicted in all cases of stomach disease, because clinically tobacco has often proved to be the cause of chronic gastritis and its sequelsB. Nicotine may reduce the peristaltic motions of the stomach in consequence of its paralyzing effect on the vagus nerA^e. Tobacco may cause hyperacidity in the empty stomach. Smoking after meals induces sahvation, and when the saliva is swallowed the acid secretion of the stomach becomes neutralized. The patient must be definitely instructed in regard to what articles of diet are permissible and what are not. Printed schedules are frequently provided for this purpose. The permissible and the forbidden foods are all enumerated on these, and those unsuitable for the patient are crossed off. The following dietary sheet of Cramer is given as an example : GENERAL INSTRUCTIONS Preparation and Selection of Food. — Eat slowly of food wluch is not too hot; chew well. Do not drink during a meal. Keep fixed meal hours. Do not eat too late at night, i. e., no later than two hours before retiring. In the preparation of food use no lard, but butter only, anil only the quantity absolutely necessary. Avoid all sharp spices (salt must be the chief condi- ment). The meat must not be too fresh. Game must not be jiickled DIET LIST 103 Prohibited: DIET LIST Fatty and acid foods, Coarse vegetables, such Vegetable soups. fried foods, lard, ham, as cabbage, cucum- Chocolate, beer, wine, and smoked meats, bers, horseradish; sal- champagne, liquors, strongly spiced foods. ads of all kinds. Fresh Sauces (flour gravies), fruit, jam, cheese, fried potatoes, leg- black bread, sweets umes, peas, lentils, of every description, white beans, chest- nuts. II. Permissible: First breakfast: Milk; coffee, tea, or cocoa, with milk; white bread (zwie- back), butter, one soft-boiled egg, fried veal sausage, cold roast beef, buttermilk, kefir, oatmeal. Dinner: Oysters on half-shell. Soups: Gruel, rice, milk, sago, macaroni, egg, bouillon. Meat: Moderate quantities — Roast beef, veal, lamb, chicken, squab, game (except boar and wild duck); boiled beef, breast of veal, brain of veal, calf's feet, chicken, and squab. Fresh fish: Pike, white fish, trout, codfish — boiled in salt water or baked, not fried. Vegetables and side dishes: Potato puree (without onions), baked potatoes mashed, steamed rice, water noodles, macaroni spa- ghetti, spinach, green lettuce, cauliflower, green peas (puree), asparagus tips, yellow carrots (puree). Farinaceous foods: Light puddings. Supper: Cold or warm meat in moderate quantities. Side dishes same as dinner^, A cup of milk, coffee or tea with milk, and zwieback. Lists of this nature may be dispensed with, for it is pref- erable for the physician to write a hst of foods to suit the individual case. Boas advises that only the foods permis- sible be marked on the diet list. It is evident that the lines should not be drawn too exactly with respect to the per- missible foods. The prescription must be adapted to each case. The physician should aim at avoiding unnecessary mo- notony in food arrangements. If possible, food luxuries and spices should be permitted to such an extent as to- render the prescribed diet relishable. 104 DIET IX GASTRIC DISEASES It is quite proper, indeed necessary, to give exact counsel regarding the quantities of food to be taken : and the physi- cian should not confine himself to such general measure- ments as spoonfuls, cups, and glasses, the standards of which vary so widely. The quantity is more accurately specified in grammes, as: Of fruit preserves, the portion for a patient with gastric disease should not exceed 150 grammes (five ounces). Hints regarding the mode of prep- aration of food must Ukewise be carefully given: e. g., whether meat should be eaten raw boiled, or roasted: in what form and state of subdivision the various foods are to be taken (puree, mashed etc.); to what extent fats and spices may be employed in the preparation of the dishes ; and how strong tea or coffee may be made. It is quite essential, too, to impress upon the patient the number of meals to be taken, and at what hours. The rule is, light meals at frequent intervals. This holds good particularly in cases of atony, dilatation, and pyloric stenosis, because in such conditions large quantities are verj^ difficult to manage. In some cases where hypersecretion is a feat- ure, the intervals between meals should be extended in order to provide, if possible, adequate periods of rest for the irritated gastric mucous membrane. Deviations from the usual dining schedule should be as infrequent as pos- sible. Irregularity in eating is apt to prolong the stay of the food in the stomach. The patients should not retire earher than two hours after partaking of the evening meal. Mastication and oral digestion are of the utmost impor- tance. Only when these are accomplished in a correct manner is it possible for the food to reach the stomach in such a condition as to facilitate its penetration and solution by the digestive juices. Patients should eat slowly. Prolonged mastication not only thoroughly insalivates the food, but it has a favorable and stimulating effect on the secretion of the gastric juices. During the meal no strain should be put upon the mind, consecjuently reading while eating is to be forbidden. Anger, excitement, and irritating discussions must be avoided at the DIET LIST 105 table. When the patient has no appetite he is not to be coaxed or harassed into taking food. The temperature of both food and drink is of importance. The harmfuhiess of overcold or superheated beverages is well known and has already been discussed. Boas gives a list of foods and beverages, with the temperatures at which they may be consumed with most benefit: Appropriate temperature (Centigrade). Water 12° to 13° Seltzer and aerated water . . . 10° to 12° Hock or white wine 10° Claret 16° to 18° Beer 12° to 15° Coffee or tea not above 40° to 43° Beef broth (milk and flour soups) . . . not above 37° to 45° Mashed (pudding) foods 37° to 42° Milk .... not below 16° to 18° C, nor above 33° to 40° Roast meats 40° Bread not above 30° Beverages in moderate quantities are, as a rule, without evil influence in health. In gastric diseases, however, drink- ing during the meals is probably better omitted. Immediately after eating, fatiguing bodily or mental exercise should not be taken. Vigorous bodily exertions at such a time produce, even in health, sensations of dis- comfort; in disease they are positively harmful, as they are liable to diminish the secretion of hydrochloric acid in the stomach. A patient with gastric disease should lie down after eating, and on his right side, since in that position the stomach is emptied more rapidly. The clothing should not bind the stomach. It is an open question whether patients should sleep after dinner; in the majority of cases this may be left to the patient himself. The percentage of acid in the stomach, and the motility of that organ, are said to be diminished during sleep. These facts must be borne in mind when con- sidering the advisability of either forbidding or permitting the after-dinner nap. CHAPTER IV ARTIFICIAL FOOD PREPARATIONS In cases where the general nutrition is low and onlj^ small quantities of food can be ingested, it has been found neces- sary to supplement the "natural" diet by the use of specially prepared nourishing agents. We have a large number of such preparations at our disposal. To take the place of proteolysis in the stomach, which is so frequently deficient in chronic gastric diseases, a number of nutritious preparations are manufactured in which the protein is predigested into peptones and albumoses. Prep- arations of this class are not necessary when the patient is able to digest sufficient food for his requirements; but they are indicated in cases where the general nutrition is low. Many of them are, however, impracticable, owing to their disagreeable taste; and the cost of those that can be used is generally so high as to curtail their usefulness among patients in moderate circumstances. The protein preparations are made by artificial digestion of protein by means of animal and vegetable ferments with the aid of organic and inorganic acids, salts, bases, vapors, and gases, in a vacuum or under high pressure. The prin- cipal preparations of this class include the following: Preparations of Animal Protein. — Somatose is a 3'ellowish powder, nearly tasteless and odorless, and readily soluble in water. It contains over 90 per cent, of albumoses, is easily assimilated, and stimulates appetite and gastric secretion. It has been employed with benefit in chronic gastritis, in gastric crises, after surgical operations on the stomach, in the cachexia of carcinoma, in nervous dyspepsia and anorexia, and in acute gastroenteritis. Somatose is, however, not well borne in hyperacidit3^ The dose is three to four dessertspoonfuls a day. Its proper use is as an adjuvant in connection with the pre- scribed diet, to increase the nutritive value of the latter. PEPTONES 107 Somatose has the action of a tonic rather than that of a food. Liquid somatose has been furnished by pharmaceutical houses. In iron somatose the iron is organically combined; this preparation is indicated in cases of chlorosis compli- cated with gastric disturbance; the adult dose is three to four dessertspoonfuls daily. Caringen, or Sotnatine, occupies a place between somatose and meat extract as regards composition; its effect is stimu- lating. Its cost renders it impracticable as a food. Tropon is prepared from animal and vegetable protein, and is useful as a cheap meat powder. It contains 90 to 99 per cent, of protein, and is insoluble in water. It is administered in bouillon, milk, cocoa, and soup. The quantity to be given should be boiled with a small portion of the nutrient vehicle in which it is to be taken and then mixed with the entire amount. Salvatose, a French preparation, is a pure protein product. It is seldom used. Fersan contains 80 to 90 per cent, of organically com- bined soluble protein. It is fresh ox-blood mixed with twice its volume of a 1-per-cent. solution of sodium chloride and then centrifugalized, completely separating the blood corpuscles from the serum containing the metabolic products. The corpuscular mass is shaken with ether and the ethereal solution treated with concentrated hydrochloric acid under certain conditions. The acid albuminous sub- stance thus precipitated is washed with absolute alcohol, dried in vacuo, and powdered. Fersan is a dark brown, odorless powder with a slightly acid taste, soluble in water, and containing a large percentage of iron and phosphorus. The phosphorus is present in complete organic combination, and the iron almost entirely so. The preparation is an iron albuminate that calls for no digestive activity on the part of the stomach. It is not coagulated in the stomach, and is completely absorbed by the intestine. The dose is three to six teaspoonfuls a day, in milk. Peptones. — Peptone preparations are now but seldom em- ployed. Their nutritive value is due chiefly to the albumoses 108 ARTIFICIAL FOOD PREPARATIONS they contain. Laboratory experimentation and clinical ex- perience have shown that, in order to obtain sufficient nourishment from the peptone preparations, unduly large quantities must be ingested. Peptones have, as a rule, a disagreeable taste. In large doses they tend to produce diarrhea. Among the most satisfactory preparations of this class the following ma}' be briefly mentioned : Pepton-Liebig (Kemmerich) stimulates the appetite. The meat solution of Leube-Rosenthal contains 9 to 12 per cent, of soluble protein and 1.8 to 6.6 per cent, of peptone. Peptone chocolate contains only 6 per cent, more protein than the ordinary cocoa. Denayer's fluid meat peptone is merely a strong beef tea, pleasant to the taste, used principally as a stimulant, containing 1.5 per cent, peptone and 10.5 per cent, a bumoses. Koch's peptone contains 18.8 per cent, peptone, 16 per cent, propeptone, and 1.4 per cent, insolub'e protein. Cibil's peptone contains 28.1 per cent, peptone and 5.8 per cent, albumoses. Among the artificial food preparations made in the United States we have the following, with their nutritive value as determined by the Council of Pharmacy and Chemistry of the American Aledical Association: ( [Carbohy- Name of substance. Name of manufacturer. drates. Protein 1. Carpanutrine John Wyeth & Bro. 5.34 4.28 2. Carpanutrine John Wyeth & Bro. 5.78 6.24 3. Liquidpeptones Eli Lilly & Co. 6.05 4. .50 4. Liquidpeptones with Creo.sote Eli Lilly & Co. 13.47 3.84 5. Liquidpeptonoid.s Arlington Chemical Co. 10.57 4.93 6. Liquidpeptonoid.s Arlington Chemical Co. 11.53 4..53 7. Predigested Beef H. K. Mulford Co. 4.37 2.38 8. Predigested Beef H. K. Mulford Co. 4.55 2.59 9. Nutrient Wine of Beef Peptone ' Armour & Co. 15.43 0.64 10. Nutrient Wine of Beef Peptone Armour & Co. 15.57 0.43 11. Nutritive Liquid Peptone Parke, Davis & Co. 12.89 1.86 12. Nutritive Liquid Peptone Parke. Davis & Co. 13.19 1.16 13. Panopeptone Fairrhild Bros. & Foster 11.92 6.38 14. Panopeptone Fairchild Bros. & Foster 10.0.5 6 33 15. Peptonic Elixir Wm. Mcrrell Chem. Co, , 11.46 2. .54 16. Tonic Beef S. & D. Sharp & Dohme 2.36 3.40 17. Tonic Beef S. & D. Sharp & Dohme 2.22 3.28 18. 19. Liquid Peptone Cow's Milk (3w. oer cent, fat) Stevenson & Jester Co. 0.55 4.80 1.81 3.50 PEPTONES 109 There are no fatty substances in these products; their food vakie from this point of view is, therefore, a negative quantity. They all contain alcohol; the proportion ranges from 14 to 23 per cent. The printed matter distributed by some manufacturers leads the physician to believe that these preparations contain sufficient nutritive material to maintain the normal nutrition of the body. The average quantity that can be taken daily ranges from 50 to 150 Cc, the total available calories of which, based on the protein and carbohydrate bodies, varies from 9.8 to 110.5. Adding to these figures the amount of energy represented by the alcohol, in each case, the total available calories will vary from 55 to 229.5. The number of calories required per diem by a man doing very moderate work approximates 3000. In sickness the amount required is not so great, but on the average , should not fall much below 1500 calories for the twenty-four hours. This consideration alone shows the fallacy of the representation that any of the artificially prepared foods above mentioned will enable the patient to dispense with other nourishment. The report of the Council of Pharmacy and Chemistry goes on to say: ''In order to get a fair conception of the actual food value of these various preparations, it is desirable to make some comparison which can be readily comprehended by every physician. The amount of good milk necessary each twenty-four hours to sustain the vitality of a patient during a serious illness is not less than 64 ounces, or approximately 2000 Cc. The food value in calories represented by this amount of good milk may be placed at 1430. This includes not only the protein and carbohydrate matter, but the fat as well. By comparing this available potential energy with the total energy available in the predigested foods under consideration, it can be readily seen that if a physician depends on the representations made by some of the manu- facturers, and feeds his patient accordingly, he is resorting to a starvation diet. The largest number of available calories, including alcohol, present in any of the recom- no ARTIFICIAL FOOD PREPARATIONS mended daily doses is less than one-fifth of the number of calories represented by 2000 Cc. of milk; and the calories represented by the daily dose of the preparation poorest in food products is only one-twenty-fifth of the amount present in 2000 Cc. of milk. These figures tell their own story. ''Making 2000 Cc. of milk the basis of calculation, and estimating the amount of the various preparations required to yield this number of calories, it is found that the quantity to be administered daily to supply 1430 calories, including alcohol, varies from 716.2 to 1506.2 cubic centimeters (or approximately one to three pints). In many cases the amount of alcohol exhibited by these quantities would keep the patient in an alcoholic stupor continually. The cost necessary to supply this energy varies from $1.48 to $3.39. Compare these prices with the cost of two quarts of milk. Is further comment necessary? ''The average number of calories represented by 500 grammes of these products as proteins and carbohydrates is 260.6. The total average calorific value of the same amount of these foods is 802.4. "The number of calories represented by good brandies or whiskies, containing 45 per cent, of alcohol, is 1575. In other words the average calorific value of these prepa- rations is approximately one-half that contained in either good brandy or whisky. From this it must not be con- cluded, however, that equal quantities of brandy or whisky are twice as valuable as the medicinal foods, because the medicinal foods contain some material which can be utilized in building tissue, which is not the case with either whisky or brandy. "From the above it can readily be seen that not only is the patient receiving a starvation diet when the physician resorts to these preparations, but the unfortunate* sick are also compelled to pay exorbitant prices for the amount of actual nutritive matter received. "It is urged in justification of the use of j)rcpanitions of this class that they contain constituents not found in PEPTONES 111 our ordinary foods and in a more perfectly assimilable con- dition. As pointed out above, these so-called predigested foods contain no fats; the carbohydrates in them are the ordinary sugars present in our common foods, while the proteins belong to the peptone or albumose class. It is for these latter that the greatest claims are made, but even here no value can be pointed out not found in whey, pep- tonized full milk, or peptonized skimmed milk. ''There is likewise another point of considerable impor- tance to consider in this connection. The terms peptone and albumose include bodies of very uncertain composition, and their suitableness as food substances depends largely on how they are prepared. Animal experiments have shown that nitrogen equilibrium may be maintained, for a time at least, by use of enzymic hydrolytic products of the pro- teins, even where the hydrolysis has been carried far beyond the so-called peptone stage, but it appears to be Ukewise true that the mixtures secured by acid or high temperature steam hydrolysis have no such value. Some of these, indeed, may exhibit a toxic behavior. This is true in particular of some of the commercial varieties of peptone, and until more is known of the source of the bodies of protein character employed in the make-up of these 'predigested' mixtures it is unwise to assume anything concerning the food value of the nitrogen compounds found in them by analysis or even to dignify them by the name of foods." Dr. David L. Edsall,^ commenting upon this report, argues against the use of proprietary foods. The development of a moderate degree of skill and resource in the use of simple and comparatively cheap home preparations will obviate any tendency to use the proprietary article. This writer cites instances where patients virtually starved to death, through the mistaken belief of the physician that they were receiving sufficient nutrition from the much vaunted pro- prietary food. A very important disadvantage of these 1 Journal of the American Medical Association, January 15, 1910. 112 ARTIFICIAL FOOD PREPARATIONS foods is their alcohol content. This evil is dwelt upon in the Council's report. Preparations from Vegetable Protein. — Among these we have: Roborat, obtained from grain seeds, wheat, corn, and rice. It is a fine, yellow-white, odorless, tasteless powder, only slightly soluble in cold water. It contains 83 per cent, of vegetable protein. This preparation is fairly well assimi- lated. It has been found of value in the treatment of ulcus ventriculi, atony, dilatation, erosions, enteritis, and chlorosis associated with gastric disease. It may also be adminis- tered as a nutritive enema. Roborat may be given in milk or water. Aleuronat Flour is prepared from gluten. It contains 82 to 86 per cent, of vegetable protein; is almost tasteless, and is insoluble in water. Mutase is a vegetable casein prepared from leguminous seeds. It is not expensive. Food Preparations from Milk Protein. — These preparations contain the casein of milk and are for the most part useful foods. Nutrose is casein sodium, a white, odorless, tasteless powder containing 85 to 90 per cent, of protein. It is soluble in warm water. Nutrose is almost completely absorbed by the small intestine. The casein constituent does not give rise to decomposition in the- intestine. Nutrose has been employed in all kinds of gastro-intestinal diseases in which a mild food is indicated. Eucasin, casein ammonium, is an odorless, tasteless powder containing 85 to 90 per cent, of protein; it is soluble in water. Sanatogen contains 95 per cent, casein, 5 per cent, glycero- phosphate of soda; the insoluble casein has been transformed by the glycerophosphate of soda into a compound solul^le in water. Sanatogen is well borne by patients suffering from gastric ulcer, gastritis, or acute intestinal catarrh. It is particularly useful in the treatment of nervous diseases of the stomach. The dose for adults is one to three table- spoonfuls throe times a day. Like other preparations of this class, the chief l)arrier to its us(^ is its cost. NUTRITIVE SUBSTANCES FROM EGG PROTEIN 113 Plasmon consists of protein obtained by a mechanical process from skimmed milk. It is a milk-white, tasteless powder containing 74.5 per cent, of protein. Plasmon is easily soluble in hot water, and is almost completely absorbed in the intestine. Concentrated solutions curdle on cooling. Plasmon is useful in the treatment of ulcus ventricuh and intestinal catarrhs. It may be taken in connection with a variety of foods, as plasmon-chocolate, plasmon-cocoa, plasmon-beef. It is a good food, as well as the cheapest of the casein preparations. Milk Somatose is prepared from the casein of milk, and contains 5 per cent, of tannin in chemical combination. It is a yellowish-brown, odorless, almost tasteless powder, soluble in hot water. Milk-somatose is non-irritating, and may be employed with advantage in the treatment of chronic intestinal catarrh; it is likewise useful in the treat- ment of dysentery and intestinal tuberculosis. The dose is four teaspoonfuls daily. Glohon is a derivative of casein obtained by breaking up nucleoprotein by means of alkalies. Galactogen is prepared from milk; is completely soluble and easily digested. It contains 70 per cent, of protein, and is agreeable to the taste and pleasant to take in the form of galactogen-chocolate (20 to 22 per cent, soluble protein) or galactogen-cocoa (30 to 32 per cent, soluble protein) . Nutritive Substances from Egg Protein. — Nutritive-Heyden is prepared from the whites of fresh eggs, and contains 90 per cent, of protein. It is a mixture of albumoses and alkaline albuminates — a fine yellowish powder which, un- boiled, has a somewhat empyreumatic odor. It is soluble only in hot water. Heyden's Nutritive has been employed in chronic affections of the stomach, but is decidedly infe- rior in value to somatose. The dose is three to four dessert- spoonfuls, in cocoa, soup, or milk. It may be given also as an enema. Protogen is a formaldehyde protein prepared by the action of formalin on egg protein. It is not much used. 114 ARTIFICIAL FOOD PREPARATIONS Preparations from Carbohydrates. — These preparations are better adapted than protem compounds to increase the nutritive value of certain foods, especiallj^ soups, and to serve as subst'tutes for ordinar}" diet. Finely Divided Flours. — Hartenstein's legumins are fur- nished in foiu- mixtures: I 27 per cent, protein; 62 per cent, carbohydrates. II 21 " " 68 " III 18 " " 69 IV 15 " " 72 The leguminous flours of Liebig and Timpe are recom- mended. Knorr's Flours (oat, barley, rice, bean, lentil, pea) 'contain 7 to 25.0 per cent, protein, 57 to 79 per cent, carbohydrates. The meals belonging to this class are rolled oats and oat- meal, 12.67 per cent, protein, 63.8 per cent, carbohj'drates. The utihty of these preparations is great, compared with that of corresponding products in common use. Dextrinated Flour. — In these flours the carbohj^drates are dextrinated. To this group belong the extensive series of infants' flours — Carnrick's lactated, Ridge's, Wagner's, Mellin's, Nestle's, Eskay's, Allenbury's, and Imperial Granum. Owing to the fact that it contains dextrinated starch, malt extract also belongs to this group. Malt extract is a well-known product of germinating barley; it contains, condensed to a syrupy consistence, 50 to 55 per cent, of sugar, of which 10 to 15 per cent, is dextrinated soluble starch. The malt extracts of Lofflund and Trommer, maltine, and malt beers have no particular value as food agents. The "double Braunschweig Schiffsmumme, " a beverage containing more than 50 per cent, of malt extract, is of agreeable taste, and its calorific value is high. Mixed Nutritive Preparations. — The preparations above mentioned contain not only carbohj^drates, but also more or less protein. Recently mixtures of carbohydrates and proteins, the latter partially treated with ferments, have been offered. Among such preparations we have: Hjjgiama, consisting of condensed milk, specially pre- pared cereals, and fat-free cocoa. It contains 22.8 per cent. PREPARATIONS CONTAINING FAT 115 protein, 61.6 to 63.32 per cent, carbohydrates. Two dessert- spoonfuls with one-quarter liter of milk, three or four times a day, constitute the dose. Hygiama tablets have been manufactured which may be eaten without any further preparation. Odda is a mixture of yolk of egg, cocoa fat, whey, dex- trinated flour, and other carbohydrates. It contains 16.56 per cent, protein and 18.14 per cent, carbohydrates. Protem-Milksalt-Cocoa, a new compound originated by Dr. O. Simon, of Carlsbad, and manufactured by Hartwig & A'ogel, Dresden, Germany, belongs to this division. It is a cocoa containing only 15 per cent, of fat, combined with 37.23 per cent, of protein predigested with ferments, and 7.61 per cent, of nutritive milk salts. Up to 74 per cent, of the protein of this cocoa is digestible, and the cocoa itself contains more digestible protein than an equal weight of raw beef. The taste is very pleasant. This cocoa is par- ticularly useful in cases of chronic gastric disease, especially as its cost is comparatively low. Preparations Containing Fat. — RusselVs Emulsion contains beef suet, cocoanut oil, peanut oil, and cottonseed oil, to the extent of 42 per cent, of its volume. Nutrole, manufactured by Parke, Davis & Co., of Detroit, Michigan, contains 40 per cent, of mixed animal and vege- table oils, emulsified with fresh eggs. Sevetol (emulsion sevi compound, Wyeth) is a natural emulsion of mixed fats with proteins and carbohydrates. The fats are butter fat, beef fat, oHve oil, lard, and peanut oil; these make up 30 per cent, of the whole mixture. Cod-liver Oil contains a considerable proportion of fatty acids, with bihary elements. It is converted bj^ means of the bile into a very fine emulsion, and is most thoroughly absorbed. Its taste is exceedingly repugnant. Cod-liver oil in elastic gelatin capsules can sometimes be taken by those who cannot take the oil unmasked. Oil of Sesame is more agreeable to the taste than cod- liver oil, and cheaper. 116 ARTIFICIAL FOOD PREPARATIONS Lipanin is a cod-liver oil substitute, consisting of a mix- ture of 94 parts fine olive oil and 6 parts oleic acid. It has a pleasant taste and causes no subjective discomforts. Mering's "Kraft" Chocolate contains 72.44 per cent, fat to which oleic acid has been added. It is very easily diges- tible. Milk Preparations. — Lofflund's Cream Conserve contains milk sugar and maltose. Vegetable Milk is made of nuts and milk of almonds (10 per cent, protein, 25 per cent, fat, 38.5 per cent, sugar). Pfund's Cream Protein Mixture is a mixture of various kinds of proteins with milk sugar, cream, and water. Gartner's Fat Milk and VoUmer's Mother's Milk are fat milks digested with pancreatic juice; they are very similar to human milk. Kefir and Koumiss are preparations of milk which have been subjected to fermentation. Stimulating Preparations. — Liebig-Kemmerich's Meat Extract contains the extractives of meat, the meat bases xanthin and kreatinin, and inorganic salts. Toril Meat Extract, Beef Tea, and Valentine's Meat Juice are less rich than Liebig's meat extract. Brand's Essence of Beef, Wyeth's Meat Juice, Fluid Meat, and Bovril, much used in England, contain smaller quantities of extractives than Liebig's extract of meat. Karno is less nutritious than Liebig's extract of meat. Maggi's Condiment is cheap and good. Maggi's Bouillon is also to be reconmiended as a stimulating preparation. Composition and Relative Values of Meat Extracts. — The Bureau of Chemistry of the Department of Agriculture, in its Bulletin No. 114/ has given valuable data regarding the commercial meat products. The preparations taken up are divided into three general classes: 1. Solid and Fluid Meat Extracts. 2. Meat Juices. 3. Miscellaneous Preparations. > Juunuil of the Aiucricun IMcdicul Association, January 23, IIK)'.), ji. 31 1. COMPOSITION OF MEAT EXTRACTS 117 Meat extracts are not to be considered as foods, and should, therefore, not be advertised as such — a conclusion which the government officials have come to, and which they have stated as follows: ''It seems to be the consensus of opinion among scientific investigators who have studied this question that the food value of these meat extracts is rather limited, and although they are a source of energy to the body they must not be looked on as representing in any notable degree the food value of the beef or other meat from which they are derived. When prepared under the best possible conditions, a com- mercial meat extract is of necessity, in order that it may not spoil, deprived of the greater part of coagulable proteins, which constitute the chief nutritious elements of the juice." The physician should realize that in prescribing prepara- tions that have but little food value he may actually starve the patient. According to the high authority quoted, the claims of the manufacturers in regard to the food value of ''meat extracts" and "meat juices" are ridiculous. The therapeutic uses of these preparations are therefore limited. It has been claimed that such substances stimulate appetite and the nervous system. They may stimulate the appetite, but their effects upon the nervous system are open to question. When we order foods we want foods and not nerve stimulants or stomachics. CHAPTEE V LAVAGE OF THE STOMACH Lavage, or the washing out of the stomach, is not prac- ticed nearly so often as it was at one time. Our knowledge of the exact course of man}' diseases of the stomach, and of the pathologic changes accompanying them, has advanced. Lavage was formerly used in the treatment of many con- ditions in which, with our more accurate knowledge, it has been discarded. In ]\Iathieu's clinic at the Hopital Andral, Paris, gastric lavage is seldom performed; it is considered sufficient, instead, in the majority of cases, to withdraw the contents of the stomach with a stomach tube at inteiwals as indicated by the requirements of the individual case. Boas says he has occasion to wash out a stomach about tmce a 3'ear. Indications. — Lavage is always indicated in stenosis of the pylorus with dilatation — in fact, in any obstruction of the digestive tract which produces a stasis of the stomach contents with fermentation and putrefaction. Boas de- clares that he has not had good results in the treatment of simple atony by means of lavage, and advises against it on the ground that in this condition we are dealing with a retarded peristalsis and not with a direct obstacle to the passage of food into the duodenum. He feels that the washing-out process not only does not tend to remove the cause, but involves the danger of overdistention of the relaxed gastric walls, which is apt to be harmful. In certain conditions lavage is of --inestimable value; it is indicated: 1. In those cases of poisoning in which the tube can do no damage. There is always danger of perforation when the poison has been an escharotic or caustic. In morphine poisoning the tube should be used even if the drug has been INDICATIONS 1 19 taken hypodermicalh^, since much of the morphine injected hypodermically is found in the stomach within an hour after the injection. 2. In cases of uncontrollable vomiting, as in intussuscep- tion or intestinal obstruction. There have been cases reported in which lavage so relieved abdominal distention near the obstruction as to result in almost immediate recovery. Stercoraceous vomiting always demands lavage, no matter what the cause may be. 3. In cases of gastritis with the production or presence of large quantities of mucus. 4. In dilatation, with stenosis of the pylorus. Here fer- mentation and putrefaction can be inhibited by lavage. These are the cases concerning which Kussmaul originally called our attention to the value of stomach washing. 5. In acute postoperative dilatation. 6. Before any operation on the stomach or intestine is performed. 7. In vomiting following any operation on the stomach or intestine. 8. To obviate postoperative vomiting after an anesthetic. 9. In intestinal paresis following operation. 10. Lavage with ice water in hemorrhage caused by gastric ulcer (Ewald). Lavage, carefully applifed, in severe hemor- rhage from gastric ulcer, is the most expedient means of treatment (Kaufmann). 11. In meteorism of typhoid fever it is frequently of great benefit. 12. In gastric tetany. 13. In vomiting in cases of peritonitis. 14. In acute gastritis due to improper eating, and in con- vulsions following overfeeding. 15. In cicatricial closure of the pylorus, as a palliative measure until operation is performed. 16. In hematemesis following stomach operation, cau- tiously. The stomach may be distended with fluid and blood, removal of which will allow it to contract and thus stop the oozing of blood (Mayo). 120 LAVAGE OF THE STOMACH 17. In diabetes mellitus (Sawyer). 18. In selected cases of Bright's disease where urea is being eliminated through the gastric mucous membrane. 19. In eclampsia. Contraindications. — Lavage as well as the use of the tube for diagnostic purposes is contraindicated : 1. In those cases of gastric disease, for the most part of sudden onset, which have not attained any degree of chronicity and where the diagnosis is apparent from the symptoms and history of the case. 2. Where the retching and vomiting are apt to offset any good that may be derived from the use of the tube either for diagnostic purposes or for lavage. 3. In marked prostration, no matter what the cause. 4. In broken compensation in heart disease, angina pec- toris, or advanced degeneration of the heart muscle, and in cardiac neuroses, aneurism of the aorta, and marked cases of arteriosclerosis. 5. In hemorrhages of recent occurrence, as in apoplexy, pulmonary, renal, gastric, and rectal hemorrhages. 6. In pulmonary tuberculosis, emphysema, and severe bronchitis. 7. In neurasthenia, hysteria, and epilepsy. 8. In advanced cachexia. 9. In continued and remittent fever. 10. In pregnancy. 11. In gastric ulcer where hematemesis has been recent or where blood has been found in the stool; carcinoma of the pylorus accompanied by the classic symptoms of cancer; gastric or intestinal diseases accompanied by acute fever; cases in which the gastric mucous membrane is easily irritated so that bleeding results upon the passage of the stomach tube. Any rules which may be laid down in regard to the use of the stomach tube are at best but general. The good judgment of the physician must always be his guide in regard to the indications and contraindications for the use of the stomach tube, whether for i)uriioscs of diagnosis or TECHNIQUE 121 for treatment, inasmuch as there may be other conditions present which might or might not justify its use, in spite of rules for and against. Technique. — Lavage consists in the washing out of the stomach by means of a simply constructed apparatus — a stomach tube (Fig. 8, A) connected with a funnel or glass Fig. 8 Apparatus for stomach lavage: A, stomach tube; B, glass tube; C, rubber tube connection; Z), glass irrigator. irrigator {D), with a piece of glass tubing {B) between, a connecting rubber tube (C) being attached at one end to the glass and at the other to the irrigator. Jacques tubes, made of soft red rubber, are now universally employed. The stomach tube (Fig. 9) should have two lateral oval openings near the point ; and the point should be solid and closed to prevent the collection of material below the open- 122 LAVAGE OF THE STOMACH ings. The edges, of the openings should be smooth and rounded, since otherwise particles of mucous membrane may be caught and torn off. The tubes for adults should be large, averaging Nos. 32 to 34. ^ The funnel of the lavage Fig. 9 Stomach tube showing elongated lateral openings. apparatus (Fig. 10) should have a capacity of one-half to one liter. The small end of the funnel must be large enough to permit the passage of food. The rubber connecting tube must be of the same calibre as the stomach tube, and long Fig. 10 .Stoinaeli tube .showing funnel connections. enough to reach from the patient's mouth to the floor of the room. A large glass irrigator is probably better than • Some confusion has resulted from the fact tliat there are three standards of measurement, the American, English, and French. To obviate error the American Surgical Trade Association has adopted the French standard; so figures designating the sizes of tubes will be in the French or standard metric scale. TECHNIQUE 123 the glass funnel; its capacity should be at least 1500 Cc. The irrigator is provided with a handle, and has a hole near the brim by which it may be suspended on a hook. The lower or outflow opening should correspond in diameter to the calibre of the stomach tube. Lavage with this simple apparatus is accomplished as follows: The patient should be impressed by his physician with the necessity of the washing-out process. He should be seated in a comfortable position, with the body inclined slightly forward, and instructed to breathe regularly and deeply. He is taught to make energetic movements of swallowing at the command ''swallow." Artificial teeth should be removed before lavage is begun. The patient's hands may be employed in holding a pus basin or other receptacle for the purpose of cleanliness, and in this way any interference on his part may be obviated. The stomach tube should be moistened with water, not oil, and directed over the dorsum of the tongue. When the end of the tube reaches the posterior pharyngeal wall, deglutition begins. The tube slides easily over the cricoid cartilage into the first section of the esophagus. When this point is reached it is easy to pass the tube on into the stomach. (The slight irritation effected by moving the tube up and down is sufficient to cause the evacuation of large quanti- ties of stomach contents, especially if aided by pressure on the abdominal muscles on the part of the patient.) The irrigator or funnel, held low, should be filled by an assistant with 500 Cc. of lukewarm water. The tube of the irrigator is meanwhile stopped by means of the fingers or clamp at a short distance from the free end, and connection duly made with the glass joint and the stomach tube in position. The irrigator is then raised until nearly the whole quantity of water has passed into the patient's stomach. A small quantity of water should be left in the irrigator to prevent the entrance of air into the tube. The irrigator is now lowered to the floor of the room, so that the stomach contents, including the water, may be siphoned off. It should be held in such a manner that the outflowing liquid may be visible. After 124 LAVAGE OF THE STOMACH noting the difference between the outflowdng fluid and the clear water that entered the stomach, the contents of the irrigator may be emptied in a convenient receptacle. ]\Iore water is allowed to enter the stomach, and the process of lavage continues by alternately raising and lowering the irri- gator until the water comes from the stomach clear. When lavage has been completed the stomach tube should be de- tached from the irrigator and rapidly and gently withdrawn from the patient's stomach. It is important to disconnect the irrigator and tube; otherwise, -wdth the former resting on the floor, suction produced bj' the siphon effect would tend to invaginate the mucous Hning of the stomach into the lateral openings of the tube and thereby injure the stomach wall. In the absence of an assistant-, the physician should fill the irrigator with the required quantity of water before commencing the operation. In order to keep the tube of the irrigator free from air, it should be compressed by means of a large tube compressor near the glass connection after being filled with the water to this point. The introduction of the stomach tube follow^s. The patient is du-ected to keep the tube steady \\dth one hand at his mouth, while with the other he holds the basin. With the irrigator resting on the floor, the physician may connect it with the stomach tube, loosen the tube clamp or compressor, and elevate the irrigator. Patients to whom stomach lavage must be administered regularly and over a long period of time can be taught to carry out the operation without the aid of a physician. Autolavage is a form of stomach irrigation which has been called physiologic in order to distinguish it from the kind I have just described; for this the use of the stomach tube is not necessary. It is sufficient that the patient drink four to eight ounces of the irrigating fluid and then lie down on his abdomen, supported on a somewhat hard, resisting surface, across the bed or on the floor. In this position let him breathe as deeply as possible. Fifteen to twenty deep respirations are sufficient to drive the contents TECHNIQUE 125 of the stomach through the pylorus. This procedure may be repeated as often as necessary. As a rule, the patient may rest on his abdomen for five minutes, taking from time to time a number of deep respirations. It has been proved that in this way the stomach may be cleansed quite as effectively as by the introduction of the stomach tube, provided the pylorus be not occluded. This method has a considerable advantage over the other, for by it the nourishment, as prepared by the stomach, is not lost, but follows the physiologic path. Besides, the patient will submit much more readily to it than to the manipulation of the stomach tube. In order to obtain the maximum effect from this method of autolavage, we must strive by all means at our command to free the pylorus from all obstacles that interfere with its proper function. This is partially achieved by administering the fluid lukewarm. Some patients may be taught to use the stomach tube themselves with the aid of some member of the household. None but the best apparatus should be employed. After use it should be thoroughly cleansed by means of hot water. In lavage, whether the patient uses the apparatus without the aid of the physician, or whether the physician performs the operation upon a passive patient, the simple apparatus described will be found adequate for all purposes. Fig. 11 illustrates the apparatus designed by Friedlieb on the principle of suction. This instrument was designed to facilitate the removal of obstructing particles from the stomach tube by aspiration by means of a rubber bulb. The apparatus of Strauss (Fig. 12) accomplishes the same purpose by means of a double bulb. Both these instruments, in the opinion of the author, are unnecessary, inasmuch as clogging of the tube may be prevented by raising the irrigator of the apparatus described, and thus forcing the tube clear by water pressure. In cases where the stomach is greatly dilated it is fre- quently impossible to wash it out at one sitting. In such cases lavage may be better accomplished with the patient in a recumbent posture. With the patient seated, the 126 LAVAGE OF THE STOMACH thoroughness of lavage may be promoted by pressmg or kneading the hypogastric region after the water has been introduced into the stomach. In cases where, owing to irritabihty of the fauces, it seems impossible to introduce the stomach tube, the difficulty may be overcome by painting the fauces with a 5-per-cent. Fig. U Stomach tube with suction bulb. (Friedlieb.) solution of cocaine or beta-eucaine. Another effective and entirely safe method of preventing nausea from the intro- duction of the stomach tube is to freeze two or three inches of the extremity of the tube just before introducing it, the object being to secure light temporary anesthesia of the fauces and pharynx by means of the cold rubber. In tliis TECHNIQUE 127 way cold is applied exactly where anesthesia is needed, and the irritability is overcome. Thus the tube may be intro- duced for the first time with practically no gagging, strain- ing, or nausea. The extremity of the tube may be frozen by a few moments' spraying with ethyl chloride. The tube, of course, may be chilled in other ways, but the ethyl chloride is convenient and efficient. The tube has been found not to stiffen markedly under the influence of the extreme cold, so that no trauma from the frozen rubber occurs. By the time the tube reaches the cardia its low temperature is suflSciently modified to obviate danger to the gastric mucosa, even though it be allowed to remain in the stomach for some time. Fig. 12 Suction tube with double bulb. (Strauss.) The process of washing out the stomach is not attended with any danger. Temporary cessation of respiration of reflex origin occurs in many patients at the first introduction of the tube. This, however, should not occasion anxiety on the part of the physician, since it usually passes off readily. Should the patient become alarmed and attempt to pull out the tube, an emphatic request to ''breathe deeply" will overcome his fears and make possible the complete intro- 128 LAVAGE OF THE STOMACH duction of the tube. Where paroxysms of cough, severe and protracted, supervene, the operation of lavage should be interrupted before completion. Hemorrhages occasionally occur, especially in cases of carcinoma and ulcer. In the presence of such symptoms lavage would be contraindicated. Lavage is rarely employed in cases of cancer of the stomach except as a palhative measure in obstruction of the pylorus. In gastric ulcer it is apt to do a great deal of harm, and should never be em- ployed when there is any indication of gastric hemorrhage. In cases of nervous dyspepsia lavage sometimes transforms the patient into a gastric hypochondriac, a most lamentable condition. In the majority of nervous cases lavage is contraindicated. Surface hemorrhage may take place in catarrh due to gastritis; when such hemorrhages are of a pronounced character the irrigations should be discontinued. According to Musser, not over 5 per cent, of cases of gastric disease, or of patients presenting symptoms sug- gestive of gastric disease, require lavage as an element of the treatment. In the earher periods of practice, gastro- enterologists resorted to lavage much more frequently than at the present time. Gastroenterologists differ in their views regarding the time stomach irrigations should be administered. I consider it advisable in cases where there is no engorgement, for ex- ample in cases of chronic gastritis, when we wish to remove mucous secretion, to perform irrigation in the morning while the stomach is empty. In cases of stenosis of the pylorus, with stagnant masses of food in the stomach, the best time for lavage is in the evening shortly before the evening meal. The duration of the treatment must be determined in each case by the conditions present. In cases where it is impossible to determine this point, as in inoperable car- cinoma, it is advisable to have the patient wash out his own stomach. A medicated lavage may follow the cleansing lavage. The indications for the different kinds of lavage are given under the respective diseases. In lavage preliminary to surgical operation on the stomach, THE STOMACH DOUCHE 129 care should be exercised that no water remains in the viscus. In lavage kept up, as described, until the washings return clear, a further quantity of water can be dislodged by placing the patient in the Trendelenburg position ; the flow will con- tinue until the tube is withdrawn from the cardiac orifice, when the stomach will be entirely emptied. C. Neck re- ported that experiments on the cadaver showed that when the operation of lavage was performed in the ordinary way a little pool was always left behind, but on the change of position this gravitated to the cardia and could then be aspirated by slowly pulling the tube out at the mouth, the tip being kept in the fluid. THE STOMACH DOUCHE Douching of the stomach should be employed only when the viscus is empty. The sole object is to irrigate the mucous membrane, either with plain water or with medicated solu- tions. The douching may be performed by means of Rosen- heim's tube (Fig. 13). This instrument consists of a stomach Fig. 13 ^~J \^ ^^ <^ _r^ r\ r\ r^ rv Perforated tube. (Rosenheim.) tube having at its gastric extremity a number of small openings from one to two millimeters in diameter. Water is permitted to flow through the tube into the stomach so that all parts of the gastric mucosa are irrigated through the numerous small openings. The process is frequently impeded, owing to the blocking of the fenestra by mucus. The method of Richter, designed to remove mucus by means of irrigation, consists of stomach douching. The ordinary stomach tube is introduced to the extent of 40 centimeters, or to the cardia of the empty stomach. The irrigating fluid under pressure is allowed to pour into the 9 130 LAVAGE OF THE STOMACH viscus SO as to douche the collapsed walls. While a small quantity of water yet remains in the irrigator the tube is Fig. 14 Apparatus for stomach douche (Einhorn): A, stomach tube; B, hard rubber capsule; C, aluminum ball. pushed into the stomach so that the fenestras become immersed in the water there; the irrigator is then lowered THE STOMACH DOUCHE 131 to the floor and the contents are siphoned out. The tube is then withdrawn to the cardia, and the process is repeated as often as necessary to cleanse the stomach of the mucous secretion. Einhorn's apparatus (Fig. 14) consists of a tube {A) about 60 Cm. in length and 1 Cm. in diameter, having at the gastric extremity an oval piece of hard rubber shaped like a capsule {B). This capsule has numerous minute openings, and at the lower end a larger round aperture. Within the hard rubber capsule is an aluminum ball {€), which acts as a valve and closes the opening in the extremity of the capsule when the tube is introduced and the irrigation fluid forced into it. The water enters the stomach by way of the small openings. The outflow, however, forces the ball from the lower opening, and the entering liquid keeps this opening clear until the stomach is completely emptied. The defects of the Rosenheim tube are remedied in Einhorn's apparatus. Preparatory to the entrance of the irrigating fluid, Einhorn's tube should be introduced only a short distance below the cardia; but to facilitate the return flow of water and mucus, it should be pushed in 10 to 12 Cm. farther. Turck has devised a double-flow stomach douche, con- sisting of two tubes cemented together; one tube is longer than the other, which enables it to reach the fundus while the shorter tube is near the cardia. The latter has at its end a metal ball, finely perforated; the water passing through acts as a fine needle spray or douche on the mucous mem- brane of the stomach. The longer tube carries the water back, so that the stomach is not distended with too great a quantity of water at any one time. Chase has devised an improved tube (Fig. 15), by means of which (1) the gastric contents can be removed by aspira- tion; (2) the stomach washed or douched; (3) and inflation of the stomach effected without making a connection or disconnection of the apparatus and without the use of stopcock or shut-off. By substituting a ^'Rosenheim" douching tube the stomach may be douched as recom- 132 LAVAGE OF THE STOMACH mended by Rosenheim. Chase's apparatus, shown in the cut, consists of (1) an Ewald stomach tube proper, 30 inches long, marked at 22 inches from its distal end \\dth a white band; (2) an adjustable sahva shield, to prevent saliva Fig. 15 Stomach tube. (Chase.) from flowing down the tube; (3) a glass connector; and (4) a 30-inch connecting tube, to which is attached a strong valveless bulb of 3 ounces (90 Cc.) capacity. Too much should not be expected of the stomach douche. It is rarely employed as a therapeutic measure, and very often any efficacy it may possess is due to the mental impression made upon the patient. CHAPTER VI MASSAGE— ELECTRICITY MASSAGE OF THE STOMACH Massage consists of a systematic manipulation of the stomach for definite therapeutic ends. The success of the process depends upon the precise performance of certain well understood movements of the hands of the physician. The operator in applying the treatment should keep in mind the particular end to be accomplished in the individual patient. The several movements consist of various appli- cations of rubbing, kneading, stretching, and pinching of the muscles. The two hands must be directed with intelli- gence and skill. Indications. — Massage is of greatest value in diseases due to altered metabohsm, and in those in which the powers of digestion, absorption, or assiixiilation are defective. Nutri- tion may be profoundly influenced by regular and continued massage. Among the special indications for this mechanical treatment are: 1. Inert musculature, which may be strengthened by passive exercise, and connective-tissue adhesions that require to be relaxed or broken up. 2. Retention of gastric contents for an abnormally long time in the alimentary tract. This applies more particularly to the intestine than to the stomach, where under some conditions mechanical treatment may cause direct injury. 3. In certain forms of dilatation due to pyloric stenosis. Zabludowski has reported good results in such conditions. However, in the presence of marked fermentative processes massage should not be employed, owing to the possibility of propelling fermenting masses into the intestine, where the 134 MASSAGE— ELECTRICITY conditions for the gro'«i:h and multiplication of bacteria are much more favorable than in the stomach. 4. In certain sensory forms of nervous dyspepsia, where sensations of pressure or pain are present, massage may be tentatively employed. 5. The mechanical treatment has given favorable results in cases of primary intestinal atony tending to secondary disturbances of the gastric function. Contraindications. — Massage, according to Boas, is contra- indicated in all recent cases of ulcer with adhesions, in which cases even its cautious application may cause a perforation of the ulcer into a neighboring organ, \^dth the well-known disastrous effects. It should not be employed in any residual inflammatory conditions of the gastro-intestinal tract, nor in the acute inflammatory stage in which there are symp- toms of meteorism or fever. It should be avoided in the presence of abdominal pain. Patients with hyperchlorhy- dria or hypersecretion are not to be subjected to massage, owing to the danger of inducing ulcer of the stomach. Boas also considers massage to be contraindicated in atonic con- ditions of the stomach in which dilatation and organic stenosis are present. Zabludowski states that '4f the gastric muscles are spontaneously very active, if the peri- staltic movements are pronounced and frequent or some- times as if in a tetanic condition, and if the stomach felt by the hand feels somewhat as a contracted uterus after birth," the massage treatment should not be employed. Carcinomata of the stomach are always absolute contra- indications for massage, owing to the possibility of exciting to rapid growth a tumor that has hitherto been latent. Boas advises against the use of massage in the treatment of patients above forty years of age in whom the symptoms of gastric disease have appeared suddenly, unless mahg- nancy can be positively excluded. He states further that inconsiderate massage of the abdomen may stimulate a latent intestinal cancer to rapid growth and metastasis. Dormant gastric ulcers may be awakened by massage to harmful activity. Whenever the test for occult blood in MASSAGE OF THE STOMACH 135 the feces is positive, massage is contraindicated. It is im- portant to examine McBurney's point and the region of the gall-bladder before attempting massage of the abdomen. Boas notes that a history of gastralgia at any time, espe- cially before or after pregnancy, increases the probability of latent gallstone disease, contraindicating massage. There are various affections of the liver, spleen, and pancreas which contraindicate abdominal massage. In fact, pain of any kind contraindicates it. Massage may be apphed when the stomach is either full or empty. When the stomach is filled, massage is indi- cated in cases of spasm of the pylorus and in mild cases of organic stenosis, the purpose being to propel the macerated food into the intestine. It should be performed three or four hours after the chief meal. Technique. — The technique of the mechanical treatment must vary according to the object to be accomphshed. When the object is passive evacuation of the stomach contents through the pylorus, Zabludowski advises inserting the right hand deeply in the loose flesh on the left side, grasping a portion of the stomach between the thumb and the four fingers, and by a pushing motion at the fold mov- ing the gastric contents toward the pylorus. The left hand advances toward the pyloric exit, beginning near the thumb of the right hand. The patient should be lying in a slanting position, the body sloping toward the right side. These movements on the part of the physician should be repeated as often as necessary. The massage movements on the full stomach should be concluded by short tapping strokes, technically known as tapotement. Both hands of the oper- ator are placed vertically, midway between supination and pronation, over the part to be treated; they are then completely supinated and the stomach is tapped with the fingers widely separated. The movements should be executed rapidly, but too great force should be avoided. Tapotement, as it is called, has a stimulating effect upon the musculature of the stomach. Zabludowski performs petrissage in the following manner: 136 MASSAGE— ELECTRICITY The operator stands at the right side of the patient and presses with the right hand in the gastric region in the middle hne. The pressure is deep, so as to reach the spinal column, therebj^ dividing the stomach into two equal parts — one the fundus, the other the p^'lorus. The food mixture com- pressed in the pyloric half is then to be pushed toward the pylorus so that it may act somewhat like a bougie, dilating the pyloric exit. According to Gustaf Nortrom, on account of the deep situation of the stomach and the shght resistance of the deep plane on which it rests, only a hmited portion of the viscus can be reached in the dorsal decubitus. For dilated stomach the author kneads at first from left to right with patient on back, knees bent and head raised. After a few minutes he has the patient he on the right side, and petrissage is performed ^dth both hands alternately, from pylorus toward cardia. Gentleness is necessary during the seance. The operation should last about fifteen minutes for the stomach alone, and fifteen minutes more for the intes- tine if there is constipation. The treatment should be given two or three hours after a meal. The beneficial effect most frequently manifests itself first by a returning appetite, then by the disappearance of the rumblings, eructations, gastric pains, headache, vertigo, etc. At the beginning the diet must be light and limited in quantit3^ Besides dila- tation of the stomach, massage is of benefit in chronic gastritis, nervous dyspepsia, gastralgia due to nem-asthenia or anemia, and pylorospasm, but it may do harm in ulcers or tumors of the pylorus. The massage movements are not always successful in expelling the contents of the stomach into the duodenum. Hemmeter gives the following directions for improving the tone of the empty stomach: "The masseur places himself to the right of the patient, who should lie on his back with knees slightly flexed. "First movement: («) Insert the left hand, slowly and gradually, deeply under the left arch of the false ribs, under and past the edge. To increase the pressure, gently press MASSAGE OF THE STOMACH 137 the right hand firmly on the left. Second movement: (b) Now describe small circles with the hands thus arranged, proceeding slowly from the pylorus to the fundus. Third movement: (c) Perform strong vibratory movements toward the depth with the finger tips while a and b are being executed. Fourth movement: (d) Knead the stom- ach between the thumb and four fingers, and in conclusion execute stroking passes, with extended four fingers, from left to right." Crede's method may be applied. This well-known process is employed frequently in the expression of the placenta, the placenta being expelled in the same manner that a stone is removed from a cherry. The method is an attempt, by performing the expression movement transversely in the line of the transverse axis of the stomach, to propel the stomach contents into the duodenum. Massage movements may be facilitated by lubricating the epigastric region with pure olive oil or with glycerin. By the use of glycerin, oily stains on the clothing may be avoided. One-per-cent. salicylic acid added to the glycerin will prevent irritation of the skin. Wegele recommends the employment of drugs in con- junction with massage in various forms of chronic gastritis and in hyperacidity, for hyperesthesia of the mucous mem- brane, and for nervous gastralgia. The medication he em- ploys consists of physiologic salt solution; 1-per-cent. solution of ichthyol; 1.5-per-cent. Carlsbad salt solution; 5 to 6 per cent, suspension of bismuth subnitrate; 1 to 2 per cent, silver nitrate solution, followed by rinsing with normal saline solution; decoctions of bitter tonics; and disinfecting solutions. The fluids are either swallowed or introduced by means of the stomach tube. Massage of the stomach should never be delegated to a layman to perform, nor should it be undertaken by anyone who is not thoroughly conversant with the principles of the treatment. Vibratory massage is of little or no value in the treatment of diseases of the stomach. It is of value in neurasthenic 138 MASSAGE— ELECTRICITY conditions, where it should be applied to the spine. It should never be used directly on the stomach in any dis- eased condition of that viscus. Pilgrim maintains that he can relax the pylorus b}^ applying vibratory massage over the twelfth dorsal vertebra. John K. Mitchell^ maintains that in chronic constipation by careful, continued, and frequently repeated massage of the intestine the bowel may be emptied, the weakened intes- tinal muscles stimulated, and the secretions — nearly always deficient in this disease — brought back in normal quantity; and when the patients have begun to improve a careful and punctual habit of defecation may be inculcated and a per- manent cure thus result. Before attempting to use massage for chronic constipation it is necessary to empty the bowels thoroughly by high enemata, lest there be some retention of feces in the colon, which sometimes happens even when the bowels are being moved reasonably well daily by means of purgatives. Should abdominal massage be apphed while these impacted masses are in the bowel, inflammator}^ dis- turbances might result. ELECTRIC TREATMENT OF THE STOMACH The use of electricity in the treatment of stomach dis- orders has been highly recommended by various writers, but the general practitioner rarely avails himself of this important therapeutic agent. Thomas G. Ashton states that in electricity we possess an important and often efficient means of treating chronic gastritis, and that direct elec- trization of the stomach is not only an important means of combating nervous disorders of that organ, but is also of service in gastric affections having an organic basis. To Einhorn belongs the credit of bringing electrization of the stomach within the range of practical therapeutics, both by experiment and by the invention of his deglutible 1 Journal of the American Medical Association. ELECTRIC TREATMENT OF THE STOMACH 139 stomach electrode. From an extensive study of the physi- ologic effects of direct electrization of the stomach, Einhorn draws the following conclusions: 1. Direct faradization of the stomach increases gastric secretion during the application and also for a short time afterward. 2. Direct galvanization of the stomach, with negative pole within the organ, in most instances diminishes gastric secretion. 3. Direct faradization as well as galvanization of the stomach increases its absorbent faculty. His conclusions as to the therapeutic value of electricity in the treatment of gastric diseases are: 1. Du'ect gastric electrization is a potent agent in the field of chronic (non-malignant) diseases of the stomach. 2. Direct gastrofaradization proves to be useful in many ways in the majority of chronic diseases of the stomach. The favorable results appear very promptly in cases of stomach dilatation not due to pyloric obstruction. Here the benefit is apparent whether there is subacidity or hyper- acidity. Cases of relaxation of the cardia (eructation) and of relaxation of the pylorus (presence of bile in the stomach) were very favorably influenced by faradization. 3. Gastrogalvanization is almost a sovereign means for treating severe and very obstinate gastralgias, no matter whether the pain is of nervous origin or from cicatricial ulcer. 4. Gastrogalvanization exerts a favorable influence on several affections of the heart complicated with gastralgia. The good results obtained from electric treatment of the stomach would seem to indicate that the sensory and secretory nerves have been stimulated, although Freund^ made a study of the effect of electric current on gastric secretion and found that it was absolutely negative, the only result being the production of a small amount of a mucoid secretion strongly alkaline in reaction. He con- 1 Virchow's Archiv, 1905, Band clxxx, Heft 2. 140 MASSAGE— ELECTRICITY eludes that food is the only stimulus which will cause the gastric glands to react. Indications. — Electric treatment of the stomach is indi- cated in cases of atony and ptosis of the stomach and its sequelae. Favorable results may be expected in the ab- sence of organic stenosis of the pylorus. Faradization is specially recommended in cases of gastric atony. A trial of electricity is advisable as an after-treatment in cases in which organic stenoses have been removed by operation. A further indication for electric treatment is furnished by those neuroses of the stomach which, in the absence of marked objective symptoms, are to be considered as func- tional derangements. As examples we have paresthesias, gastralgias, pylorospasm, nervous vomiting, buHmia, and anorexia. In these cases the galvanic current is employed with good results, particularly in cases of gastralgia, of hysterical vomiting, and the vomiting of pregnancy. The applications are made both intraventricularly and extra- ventricularly . Good results have also been secured with intra- and extraventricular faradic treatment of such conditions. As a rule, the intraventricular application of the electric current is more successful than the extraventricular. The latter is especially adapted to those cases in which the object is to exert an influence on the abdominal muscles as well as on the stomach itself. Since the normal gastric mucous membrane is not sensitive, electric treatment of the inte- rior of the stomach is easily accomphshed. Intraventricular Electrization (Application of Electricity to the Interior of the Stomach). — Several apparatus are at our disposal for the application of electricity to the stomach. First of all there is the electric sound of Boas (Fig. 16). This is a stomach tube, with numerous small perforations at its lower extremity, containing in the interior a spiral of platinum that is held in place by a clamp at the upper opening of the tube. The closure of the oral end permits the simultaneous in-and-out flow of water. Wegele makes use of an ordinary stomach tube with a glass joint at its oral end. By means of a rubber tube a funnel ELECTRIC TREATMENT OF THE STOMACH 141 can be joined to it, if necessary, and the stomach either filled with or evacuated of water. A thin metal wire, having a button, is introduced into the stomach tube. The wire metal is made of such a length that it does not reach the stomach Fig. 1G Stomach electrode. (Boas.) Fig. 17 c s ■€) Stomach electrode. (Wegele.) end of the tube by about 1 Cm.— so that the button will not come in direct contact with the mucous membrane of the stomach. The exact length of wire to be introduced into the tube is adjusted by a set screw (Fig. 17). A third apparatus has been described by Einhorn (Fig. 18). A metal button within a perforated hard rubber capsule is joined by a fine transmission wire to an electric battery. The transmission wire is insulated by a thin rubber tubing. 142 MASS A GE—EL^CTRICI T Y In using this apparatus the patient swallows the hard rubber capsule, which it is sometimes difficult to do. Lockwoodi has modified Einhorn's gastric electrode by- making the following changes : The capsule is reduced in size to the dimensions of an ordinary five-grain gelatin capsule. To the metal button within the capsule is attached a spiral of flat steel, the flexibihty of which corresponds to that of Fig. 18 Intragastric electrode. (Einhorn.) an ordinary stomach tube. This spiral is covered by thin rubber tubing, and is tipped with a binding pin for connec- tion with the battery. Such an electrode can l)e easily introduced into the stomach without discomfort. The small size of the capsule allows of its ready passage, while the spiral attachment is sufficiently resistant to enable the operator to push the capsule along, just as a .stomach tube is introduced. ' Medical Record, March 24, 1900. ELECTRIC TREATMENT OF THE STOMACH 143 Marshall has devised an electrode for intragastric electri- zation which the writer has found very satisfactory. It consists of red rubber tubing twenty inches long, about the thickness of a No. 13 (American scale) catheter. In one end is set a round nut wound with a fine wire which runs to the other end of the rubber tube and is there fastened to a slotted post. A screw with a flattened head passes through an oval-shaped hard rubber cap, and, being fastened into the nut, holds the cap in place so that the latter protects the stomach from direct contact with the metal. When it is desired to clean the electrode, unscrew the hard rubber Fig. 19 Combined stomach tube and electrode. (Stockton.) cap by turning the screw to the left, and press out the screw, when all parts can be easily cleaned. When the screw is in place it prevents any fluid entering the tube. There is never any trouble in introducing this electrode, and the tubing, being much smaller than a stomach tube, causes very little discomfort to the patient. Stockton^ describes an instrument which is a combined stomach tube and electrode (Fig. 19). A soft rubber ordi- nary stomach tube, 28 inches long, is coupled by means of a ground steel joint to three feet of rubber tubing, termi- nating in the ordinary funnel. Through this the stomach is emptied in the usual way. Then the rubber tubing is dis- 1 New York Medical Journal, July 30, 1892. 144 MASSAGE— ELECTRICITY connected at the coupling without removing the stomach tube itself from the stomach. There is now introduced through the stomach tube, in situ, a spiral electrode, which, when in place, completely closes the proximal opening of the tube by a ground steel plug. The distal extremity of the spiral wire terminates at the upper of the two fenestrse at the lower end of the tube. This arrangement prevents the touching of the mucous membrane of the stomach by the metal point. Before the introduction of the electric sound the patient drinks a large tumblerful of lukewarm water, or the water may be introduced by means of the tube. The fluid dis- tributes the current to the gastric wall. For the purpose of faradization a large plate electrode is placed either on the epigastric region or on the back to the left of the seventh dorsal vertebra. Weak currents are employed at first, the current being gradually increased to such a force that the patient is just able to bear it. Rather forcible currents are permissible. The duration of the seance is about ten minutes. The negative electrode is applied in the stomach for the purpose of galvanization. A broad plate electrode is applied in the same manner as when faradizing, the location being altered if necessary; the current is begun slowly and carried up to the strength of 15 to 20 milliamperes, and is then slowly diminished. The duration of the treatment is from eight to ten minutes. Galvanofaradization is likewise applicable. Intraven- tricular faradization is especially recommended in atony, relaxation of the pylorus, and paresis of the cardia from disturbances in the central nerve centres or from neuras- thenia. Internal galvanization is especially worthy of appli- cation in gastralgias and chronic hypersecretion. The internal electric treatment of the stomach is, as Wegele specially remarks, the sovereign method in the treatment of nervous vomiting. Extraventricular Electrization. — Two large rectangular plate electrodes are to be employed for this purpose. One of ELECTRIC TREATMENT OF THE STOMACH 145 them, well moistened, is to be applied to the region of the stomach, the other to the back. The gastric electrode is put on firmly and pressed in deeply, making the distance between both plates as small as possible. Another arrange- ment of electrodes is as follows: Of two large plates, the larger one (300 mm. square) is applied from the front of the abdomen to the spinal column, and the other in a similar way on the opposite side. The distance between the edges of the two electrodes must be at least one or two centimeters. While faradizing, weak currents are used to begin with; these are gradually increased, and are finally made of such strength that the patient is just able to bear them. In sensitive persons the treatment may be interrupted by a short pause every half minute. An electric roller cylinder may be employed instead of the anterior electrode; this is rolled to and fro in the region of the stomach without interruption, and thus effects an even electric massage of the stomach. The electric brush may likewise be used anteriorly. While galvanizing, the current is graduaily increased to 15 or 20 milliamperes, it being a matter of indifference whether the anode is situated in front or behind. The duration of the treatment is five minutes. High frequency currents have been extensively used in England in the treatment of diseases of the digestive organs. A million volts can be made to permeate the body by a course of autocondensation. As a result, metabolism is increased and muscular contractions stimulated, while neural and glandular excitement is quieted. The effects upon the intestine seem to be more gratifying than those upon the stomach. This form of electricity is employed in gastric atony and gastralgia, but more often in intestinal neuroses, membranous colitis, and atonic and spastic con- stipation. Static electricity in the treatment of diseases of the stomach is disappointing. 10 CHAPTER VII H YDROTHERAPEUTICS— M IN ERAL WATERS HYDRIATIC AND THERMIC TREATMENT OF THE STOMACH Hydrotherapeutics constitutes an important part of the treatment of diseases of the stomach. Water is essential to the performance of all the physiologic functions. In fact, it ranks first among the therapeutic resources. It may be used internally as a drink, as a spray, in lavage, or as a douche, and externally in baths, packs, moist rub- bing, and slapping. In the use of water as a therapeutic agent the physician should have clearly in mind the results to be attained. Cold wacer applied externally should have a stimulating effect, as shown by the skin reaction. In disease conditions of the stomach the stimulus should be moderate in character. Weak stimuli tend to increase vitality, while stronger ones have an inhibitory effect. The physician should exercise great precaution in the treatment of gastric cases compli- cated with anemia, nervousness, and debility. In moist rubbing and slapping the water should be below bod}^ tem- perature, care being exercised to avoid undue shock to sensitive patients. The temperature of the water should vary from 85° to 60° F. The wet rub is best given early in the morning, inasmuch as the skin reacts best at this time, owing to the fact that it is uniformly heated on rising. The patient should stand barefooted on some non- conducting substance, such as a piece of carpet or a cork mat. A large linen sheet wrung out of water at the proper temperature is placed about him by the physician or at- tendant, who then proceeds to rub vigorously his back, arms, and legs. The patient, meanwhile, assists by rul)bing the chest and abdomen. In a few moments this should be IIYDRJATIC AND THERMIC TREATMENT 147 followed b}^ an agreeable feeling of warmth. The patient should be wiped thoroughly, and should either rest for half an hour or take a short walk before breakfast. The ''rub-off," according to Strasse, is made as follows: The patient elevates his arms, and is wrapped quickly into a moist linen sheet — one corner of which is clamped by one lowered arm while the sheet is wound around to overlap it, and is clamped under the other arm also. The towel is then wrapped around the patient's trunk so that the shoulders are covered. Energetic rubbing and beating are performed by the attendant with the palm of the hand. As soon as the patient experiences a feeling of warmth he is released from the pack and rubbed dry. In the absence of an attendant the patient may dry himself by rubbing vigorously with a rough towel. Should the skin reaction following the use of the wet pack not be well marked, before another treatment the temperature of the patient should be raised either by moder- ate exercise or by a dry rub. If, after this procedure, the cold rub fails to bring about a skin reaction, it should be omitted; better sponge the patient off with water at a tem- perature agreeable to his sensitiveness — three parts water to one of vinegar, or one part alcohol to two of water, may be used. The bath may be given by applying the mixture to the whole body before attempting to dry, or a portion of the body, an arm or a leg, may be bathed and then dried until the w^hole body has participated in the operation. Half Baths. — What are known as half baths have a favor- able and stimulating effect upon the nervous system. The patient sits in a bathtub in which the water at 90° F. reaches as high as his umbilicus. In treating more robust patients the temperature of the water may be as low as 82° or 77° F. The patient should immerse himself to the neck in the water and return to the sitting posture. The attendant, assisted by the patient, proceeds to rub the latter vigorously. The w^hole bathing process should last about three or four minutes, during which time the patient should be active. On stepping out of the tub he is covered by a dry sheet and rubbed dry while either sitting on a chair or lying in 148 HYDROTHERAPEUTICS— MINERAL WATERS bed. The bath may be followed b}' moderate exercise or by rest in the recumbent posture in bed. The patient should experience a feeling of comfort after such treatment. The half bath, so called, may be varied in several ways. The patient may sit for five to ten minutes immersed to the neck in water at a temperature of 84° to 90° F. Then the water is allowed to flow out of the tub until it is at the level of the patient's umbilicus, when the attendant begins to rub him and sprinkle him mth water. The half bath may be made even more intense and stimulating by allowing cold water to flow into the tub during the manipulations of the attendant. In all these procedures the head should not be allowed to become wet. Cold Entire Pack. — What is known as the cold entire pack produces a stimulating and refreshing effect when it is em- ployed under proper conditions. A large flannel blanket is spread upon the bed or couch, and over it a sheet which has been dipped into water of about 60° to 50° F., and which remains fairly saturated with it. After the morning evacuation of the bow^els and bladder the patient is packed into the sheet and blanket so that his shoulders and arms are included in the folds. A stimulating effect is produced by removing the pack as soon as the reaction sets in. To prolong the duration of the pack beyond this point produces a quieting effect upon the patient, so that sometimes he becomes drowsy and has a desire to sleep. Should the desired reaction not take place after the cold or wet rub, this operation may be preceded by the cold pack until the body becomes sufficiently warmed. In this mode of hydrotherapeutic treatment of patients with gastric disease we note at first a slowing of the tem- poral pulse, which soon returns to the normal rate. To avoid hyperemia in the head or in the region of the heart, cold compresses may be applied to the head, or the cooling apparatus of Leiter may be applied over the region of the heart. Warm Entire Pack. — By employing lukewarm water in our hydrotherapeutic treatment we may obtain a sedative efi"ect. HYDRIATIC AND THERMIC TREATMENT 149 The blood pressure diminishes, and with the dilatation of the bloodvessels the painful symptoms are alleviated. The patient becomes quiet, and sleep ensues. In the prolonged warm entire pack the patient is packed in cloths which have been dipped into water of from 95° to 100° F. Since the cloths cool off rapidly, this pack must be administered quickly. Prolonged Baths. — The prolonged lukewarm full bath acts as an agreeable sedative and hypnotic. The temperature of the water should be in the neighborhood of 95° F. The patient should be placed in a comfortable position, preferably recHning. The water should reach over the shoulders. The duration of the bath should be from five to twenty-five minutes. Should the bath be more pro- tracted, care must be taken that the water does not cool off too much. Any kind of exertion is to be avoided, both before and after the bath. When the end desired is the induction of sleep, the tepid bath is best employed toward evening or immediately before retiring. The prolonged baths may be medicated by the addition of various chemical agents. Sodium chloride may be used with the water so as to make a 1-per-cent. or a 2-per-cent. solution. Carbon dioxide at times exerts a beneficial in- fluence upon nervous patients. The carbon dioxide bath may be prepared in private homes by the combination of sodium bicarbonate with mineral acids or with acetic acid. Oxygen baths are beneficial in the treatment of nervous dyspepsia. Such baths are prepared by adding soda perborate and a manganese salt to the water, the soda perborate being broken up by the manganese salt in the presence of water, with the liberation of oxygen. The immersion of the body in such an effervescing solution gives a powerful impetus to the nervous system. Many patients find the addition of 250 to 500 grammes of pine-needle extract to the bath very agreeable, but the good effect is probably largely mental. Indications. — The indications for hydrotherapeutic treat- ment in gastric disease are not always clear. In a general 150 HYDROTHERAPEUTICS— MINERAL WATERS way, hot applications tend to the diminution of pain and have an antispasmodic effect; cold applications, on the other hand, stimulate. Compresses. — Hot compresses in the form of poultices are well known to the laity. To prepare a mashed-potato poultice, which is one of the best forms of cataplasm, freshly cooked potatoes are placed upon a piece of cheesecloth, a portion of which is folded in the form of a sac. This bag may be closed by means of safety pins or a few stitches. The potatoes are crushed with a wooden roller, after which the poultice is ready for use. This poultice is not only the cleanest, but retains its warmth longer than any other. Linseed poultices are made by boiling the linseed meal to a thick consistency. The mass is then placed into the cloth and used in the same manner as the potato poultice. The linseed poultice is not so satisfactory, owing to the fact that it adheres to the parts and is apt to undergo acid fermentation. It is hardly necessary to say that cataplasms should always be applied hot and of sufficient size to cover the upper portion of the abdomen. To secure the desired effect, two poultices should be prepared, so that one may be in the steam bath while the other is doing duty on the patient. To maintain the heat, double boilers are very con- venient. The cataplasm is placed in a tray with a perforated bottom held above the water level in the boiler. The water may be heated by a spirit lamp or other means, so that the poultice when not in use is subjected to the action of steam. The apparatus should be kept covered. Heat may be applied to the abdominal or gastric region by means of hot towels, or heated i)latos well wrajipcMl in cloth. The flat stomach bottle of aluminum, rubber, or zinc is of practical value. Flat rubber bottles or boxes filled with some chemical substance are obtainable, which, after being subjected to the action of boiling water for fifteen minutes will retain their heat for several hours, r^loctric warming pads and electrothermic bottles are of inoi-e i-eceni in\(>n- tion. Leiter's tubes are made of (in, nlinninuin, or hard MYDRIATIC AND THERMIC TREATMENT 151 rubber; they are placed upon the upper half of the abdomen of the patient, and hot water is allowed to run through the coil. The electrothermic bottle, electric warming pad, or Leiter's coils may be converted into moist hot compresses by encasing them in moistened folds of cloth. The temperature of the hot cataplasm must be modified according to the requirements of the patient's comfort. When hot cataplasms are used for a long period of time, for instance in gastric ulcer, the skin over the hypogastric region should be thoroughly cleansed with soap and water and weak bichloride solution, and a piece of flannel or linen laid over the parts and made secure by adhesive plaster. This forms a basis for the hot compress. In this way blisters from heat may be avoided. The Priessnitz bandage is applied moist, and either hot or cold, so that it produces a hyperemic condition of the skin. The application of this bandage is accompanied by an agreeable feeling of warmth. The effect is sedative, analgesic, and frequently hypnotic. The Priessnitz bandage consists of a towel folded several times, dipped in warm water, and wrung out. This is placed over the stomach and covered by oiled silk or gutta-percha, with a flannel binder to retain it in place. This bandage, which should be sufficiently tight not to slip down, is adjusted at night and allowed to remain on the patient until morning. Alcohol, 50 per cent., has a more stimulating effect than water. Winternitz reconunends the use of coiled tubing, such as the Leiter cooling apparatus, in which water of a tem- perature of 130° to 55° F. is allowed to circulate. The coils are interposed between the moist linen and woolen bandages (Fig. 20). Winternitz recommends this mode of treatment in nervous gastric diseases and in functional motor disturbances of the stomach. Douches. — Douches are often applied externally with good effect. We have the fan douche and the so-called Scotch or interrupted douche. A somewhat cumbersome apparatus is required for the administration of the latter. With this 152 HYDROTHERAPEUTICS— MINERAL WA TERS apparatus the temperature may be quickly alternated from 100° to 50° F. and an interrupted jet of water thrown over the region of the stomach. We obtain by the use of this Fig. 20 Coiled tubing. (Winternitz.) apparatus not only alternate contraction and dilatation of the capillaries of the skin, but reflex contractions of the abdominal muscles as well. A stimulus is likewise given to the peristaltic movements of the intestine. MINERAL WATERS 153 MINERAL WATERS An extensive therapy for diseases of the stomach and intestine is provided by the so-called mineral-water cures, bath cures, climate cures, and sea baths. Mineral waters are solutions of varying strengths of salts and gases in water. The salts present are usually very small in proportion to the amount of water. In spite of the fact that these waters are among our oldest therapeutic agents, we have much to learn in regard to their physiologic action. We have as yet no well-defined scientific basis of procedure in regard to their use. Such investigators as von Noorden, Dopper, Lareche, Jaworski, Boas, and Wolf have sought to point out the direct local and systemic effects, but their results have been contradictory. In the absence of scientific data we must continue to base our use of mineral waters on empirical knowledge, controlled only by what we know of their indi- vidual constituents. The gaseous constituents are, chiefly, carbon dioxide and sulphuretted hydrogen. The solid constituents are salts of sodium, potassium, magnesium, aluminum, calcium, iron, iodine, bromine, chlorine, and sulphur. Some of these waters have a purgative effect, some laxative, and some diuretic. Classification. — 1. Alkaline chlorine waters. 2. Sodium chloride waters. 3. Alkaline carbonated waters. 4. Ferruginous or chalybeate waters. 5. Bitter waters. Alkaline Chlorine Waters. — Waters from the alkaline chlorine springs contain principally sodium chloride, sodium sulphate, bicarbonate of soda, and carbon dioxide. In the United States we have Arondack, at Saratoga, N. Y. ; Bedford, at Bedford, Pa.; Berry Hill, Elkwood, Va.; Crab Orchard, Ken- tucky; French Lick, Indiana; Gate Springs, Tennessee; West Baden, Indiana; Hot Sulphur Springs, Colorado; Gibson's Mineral Wells, Texas; and Ferris Hot Springs, Montana. 154 HYDROTHERAPEUTICS— MINERAL WATERS To this class belong the springs of Carlsbad, Bertrich, Marienbad, Rohitsch, Tarasp, and Franzensbad, in Europe. Carlsbad and Bertrich are warm springs. Carlsbad is especially famous in regard to the treatment of diseases of the stomach. It has been found that a single dose or a few small doses of Carlsbad water or salt will excite a copious secretion of acid, but that larger doses continued for a longer period of time may greatly diminish the secretion of gastric juice. Carlsbad water dissolves mucus, increases the peristaltic action of the stomach, and, owing to its warmth, diminishes gastric sensitiveness. According to Riegel, a course of Carlsbad water is advis- able as after-treatment in cases of ulcer of the stomach without atony, especially cases in which hyperacidity is present. The treatment at Carlsbad is likewise indicated in chronic acid gastritis, especially when there is a copious secretion of mucus, and in hyperacidity not of nervous origin. Carlsbad treatment may be tentatively tried in cases of dyspepsia with hyperacidity, or in those in which the peptic powers are but slightly diminished, also in cases of mild atony accompanied by constipation. The Carlsbad cure is contraindicated in cases of cancer, marked dilatation, atony, stomach diseases with greatly decreased secretion, nervous dyspepsia, and, according to Boas, also in genuine forms of confirmed chronic gastritis with diminution or absence of hydrochloric acid. The individual Carlsbad springs vary in temperature. The springs with moderate temperatures are preferable to those with higher degrees of heat, especially for the treat- ment of ulcer of the stomach. Boas recommends and re- ports good results from the employment of small doses of the very hot springs in catarrhal affections of the small and large intestine. The good results following the use of the Carlsbad waters are partly due to the excellent diet prescribed at Carlsbad resorts. The waters of Bertrich, which are weaker than those of Carlsbad, are employed in a similar manner. The water MINERAL WATERS 155 of Marienbad, which contains twice the quantity of sodium sulphate, more sodium chloride and more free carbon dioxide than that of Carlsbad, has a stimulating effect upon motility and secretion. The other waters mentioned act in a similar manner. Many of these contain rather large quantities of free carbon dioxide, which promotes the secretion of hydro- chloric acid. It is therefore advisable to employ these waters in atony, and in subacid and anacid conditions. Boas recom- mends Elster and Marienbad in cases where Carlsbad would otherwise be indicated, but which are complicated with habitual constipation. He advises Tarasp for cases in which it is desirable to treat nervous conditions as well as the stomach. Sodium Chloride Waters. — In the United States are the Springs at Ballston, N. Y.; Hathorn, Congress, Kissingen, Selters, and Champion, at Saratoga, New York ; Colorado Springs, Colorado; Wasatko Springs, Utah; and in Canada the springs at St. Catharines, Ontario. In Europe are the springs of Kissingen, Homburg, Soden, Wiesbaden, Pyr- mont, and Mergentheim. Sodium chloride taken after a meal has the effect of inhibiting hydrochloric acid secretion and peptic digestion without interfering in any way with the motility of the stomach. Experiments with sodium chloride waters, espe- cially Kissingen and Homburg, on patients with gastric disease, have shown, on the contrary, that in cases of gas- tritis with subacidity the acid secretion was increased ; while in hyperacidity the employment of sodium chloride waters is frequently followed by a marked decrease in the hydro- chloric acid secretion. Their effects in subacid conditions seem to be fairly constant, that is, stimulating the secretion of free hydrochloric acid; but observers are at variance regarding their effects in hyperacidity. In subacidity with profuse mucous secretion the sodium chloride waters cause a marked diminution in the amount of mucus. In cases of subacid gastritis, especially in their incipiency, the secretion of hydrochloric acid may be restored to normal 156 H YDRO THERA PE UTICS—MINERA L WA TERS by a course of treatment with the sodium chloride waters. To obtain the favorable effect on the gastric secretion the waters (Saratoga, Kissingen, Wiesbaden) should be taken on an empty stomach, and the patient should refrain from partaking of food until they have passed out of the stomach. Riegel would not use sodium chloride waters in the treat- ment of hypersecretion. Boas is strongly opposed to their use in atony and dilatation; he favors a trial of them, however, in cases of ulcus ventriculi where the ulcer has become healed or cicatrized. Alkaline Carbonated Waters. — The alkaline carbonated waters contain as their chief constituents bicarbonate of soda and carbon dioxide. The principal waters of this class in the United States are Allouez, Green Bay, Wis.; Peerless, Saratoga, N. Y.; Vichy, at Saratoga; Skaggs, Hot Springs, Cal.; Canon City, Colorado. In Europe are Bihn, Fach- ingen, Neuenahr, Giesshiibel, Geilnou, Preblau, Salzbrunn, and Mchy. Owing to the fact that these waters contain sodium carbonate, they are indicated particularly in the treatment of hyperacidity, hypersecretion, and eructations. After a course of treatment with the alkaline carbonated waters, particularly Vichy, an increase in the motility of the stomach has been noted. It is important that these waters be administered warm, to lessen the sensitiveness of the stomach. The alkaline saline waters contain, in addition to carbon dioxide and bicarbonate of soda, small quantities of sodium chloride. In the United States are Deep Rock Springs, Oswego, N. Y.; Manitou, Manitou, Col.; and Sheboygan, Sheboygan, Wis. They increase the secretion of gastric juice, and are indicated in chronic gastritis, slight atony, and secondary catarrhs. Ferruginous Waters. — These waters contain bicarbonate of iron and sulphate of iron. The ferruginous springs of the United States are Mardela, Maryland; Rock Enon, \'irginia; Church Alum, Virginia; Owosso, Michigan; Sparta Mineral Wells, Wisconsin; Fruitport Wells, Michigan; Wilbot, MINERAL WATERS 157 Oregon; Mono Lake, California; Bath and Bedford Alum, Virginia. In Europe there are the acid iron springs of Elster and Franzensbad, and the waters of Reinerz, Rippoldsau, Schwalbach, and Bartfeld. These waters are useful in the treatment of chronic dyspepsia and gastric pains occurring in anemia and chlorosis. Bitter Waters. — Bitter waters are indicated in the treatment of diseases of the stomach secondary to intestinal indigestion when constipation is present. They inhibit the secretion of gastric juice. Their use is contraindicated in gastric ulcer. Among the bitter waters we have Abilena, Franz Josef, Pluto (concentrated), Veronica, Arondack, Saratoga, and West Baden Sprudel. All mineral waters should, by preference, be taken at the springs themselves; it is a matter of experience that the waters affect the patients more favorably when this is done. At these resorts the patient is free from excite- ment and business cares; his surroundings, the atmosphere, and scenery are conducive to peace of mind, and dietary regulations are more apt to be faithfully carried out. These waters, however, may be taken at home if a sojourn at the springs is impossible. Basch^ sums up the contraindications in the use of the various mineral waters: 1. Gastric motor insufficiency of any grade and from any cause whatever. It is well known that no appreciable amount of water is absorbed from the stomach, and that sahne solutions cause a transudation into the lumina of hollow viscera; hence the insufficiency can only be aggra- vated. In these conditions there is the further danger of increased distention from the large amount of free car- bonic acid gas usually present in the waters. In all non- acute conditions of this kind gastric lavage with a mineral water properly adapted to the chemistry of the stomach has been found to be very useful. 2. The existence or the probability of a malignant growth. 3. Acute hemorrhagic conditions. 1 New York Medical Journal, March 6, 1909. 158 HYDROTHERAPEUTICS— MINERAL WATERS 4. Gastro-intestinal tuberculosis. 5. Intestinal obstruction. A possible exception in this category may be found in obstructions due to impact-ed feces. 6. In acute gastritis mineral waters are apt to do more harm than good. As a fundamental principle no systematic mineral water treatment in gastro-intestinal disease should be recommended until a diagnosis, or at least careful examinations, including a thorough chemical analysis of the stomach contents, and in many cases the feces, too, shall have been made. Mineral Baths, Sea Baths, Climatic Cures. — Mineral-water treatment is sometimes combined with bath cures so called. Salt and mud baths have been found efficacious in the treatment of gastric affections. Waters containing enough sodium chloride to raise their specific gravity are designated salt. Baths in such waters are of three kinds — weak (1 to 2 per cent, salt), medium (up to 6 per cent.), and strong (above 6 per cent.). Three per cent, mineral salt solutions are employed for bathing purposes. Sea baths have a favorable effect in inflammatory and exudative processes of the stomach and intestinal tract, as well as in cases of chronic peritonitis. Alud baths are best applied at Elster, Franzensbad, or Mudlavia, Indiana ; they are very retentive of heat, conserving and prolonging the caloric effect upon the skin. Upon this fact depends their value in irritable conditions of the stomach, pylorospasm, gastric ulcer, and gastric neuroses. Sea baths are indicated for patients with dyspepsias due to neurasthenic conditions, gastric atony, or ptosis. Cold sea baths have a tonic effect, due largely to the salt they contain and to the movements of tlio waves. They stimulate gastric digestion. Well-nourished j^atients suffering from neuroses, as well as the anemic, do well at the seaside. Change of climate and residence in high altitudes are most suitable to gastric patients who are likewise suffering from mental overwork and nervousness. The institutions to be preferred are the smaller sanitaria MINERAL WATERS 159 in which diseases of the stomach and intestine are treated exclusively and along strictly scientific lines. American Mineral Waters.— Bulletin 91 of the Bureau of Chemistry, United States Department of Agriculture,' con- tains a report on American commercial mineral waters. Herewith are given the results of the Bureau's analysis of the most prominent and best-known waters: Crockett Arsenic-lithia Water, Shawsville, Virginia One U. S. gallon contains: Solids. Grains. Ammonium chloride trace Potassimn chloride 0.60 Lithium chloride trace Magnesium bicarbonate 1.74 Calcium bicarbonate 13 . 46 Sodium metaborate small amount Potassium sulphate 0.17 Sodium sulphate 3 . 09 Magnesium sulphate 4.59 Disodium arsenate 0.19 Calcium sihcate 0.52 Ferric oxide and alumina 0.06 Potassium iodide trace Sodium nitrate 0.02 Sodium nitrite heavy trace Silica ' 2.53 Total 26.97 Great Bear Water, Fulton, New York One U. S. gallon contains: Solids. Grains. Magnesium chloride 0.73 Lithium chloride trace Potassium chloride 0.18 Sodium chloride 1.01 Ammonium chloride trace Magnesium sulphate . 89 Sodium nitrate . 70 Sodium nitrite • trace Magnesium bicarbonate 1.61 Calcium bicarbonate 7.25 Ferrous bicarbonate 0.06 Silica 0.56 Total 12.99 1 Journal of the American Medical Association, ^larch 14, 1908. 160 HYDROTHERAPEUTICS— MINERAL WATERS Deep Rock Water, Os'svego, Xew York One U. S. gallon contains: Solids. Grains. Ammonium chloride 0.01 Lithium chloride trace Potassium chloride 0.40 Sodium chloride 112.98 Sodiimi sulphate 3 . 32 Calcimn phosphate trace Calcium bicarbonate 3 . 08 Magnesimn bicarbonate 1.21 Sodium bicarbonate 12 . 58 Sodium nitrate 0.70 Sodium nitrite trace Ferric oxide and alumina 0.02 Silica 0.61 Total 135.00 Tate Epsom W.a.ter, Tate Springs, Texxes.see One U. S. gallon contains: Solids. Grains. Ammonimn chloride trace Sodimn chloride 0.12 Lithium chloride 0.03 Pota.ssiimi chloride 0.91 Sodium sulphate 4.38 Magnesium .sulphate 34.71 Calciimi sulphate 76.53 Sodiima nitrate 0.02 Calcium bicarbonate 20 . 05 Calcium silicate 0.24 Ferric oxide and alumina 0.23 Silica 1.13 Total 138.35 MINERAL WATERS 161 Geneva Lithia Water, Geneva. New York One U. S. gallon contains: Solids. Grains. Ammonium chloride trace Sodium chloride 19.16 Potassium chloride 0.44 Lithium chloride 0.03 Potassium iodide trace Sodium sulphate 0.16 Magnesium sulphate 33.36 Calcium sulphate 87.01 Calcium bicarbonate 18.89 Sodium metaborate trace Sodium nitrate trace Sodium nitrite trace Ferric oxide and alumina 0.05 SiHca 0.82 Calcium phosphate trace Total 159.82 Manitou Water, Manttou, Colorado One U. S. gallon contains: Solids. Grains. Sodium chloride 17.58 Ammonium chloride trace Potassium chloride 7.89 Lithium chloride 0.08 Sodiima bicarbonate 69.20 Magnesium bicarbonate 27.65 Calcium bicarbonate 107 . 56 Ferrous bicarbonate . 33 Potassium bromide faint trace Sodium sulphate 18.80 Sodium metaborate small amoxmt Mangano-manganic oxide 0.14 Silica 2.54 Total 251.77 11 162 HYDROTHERAPEUTICS— MINERAL WATERS Allotjez Mineral Water, Green Bay, Wisconsin One U. S. gallon contains: Solids. Grains. Ammonium chloride trace Lithium chloride trace Sodium chloride 1.60 Magnesium chloride 0.99 Potassium chloride 0.17 Magnesium sulphate 4.27 Calcium phosphate trace Sodium nitrate 2.11 Magnesimn bicarbonate 8.41 Calcium bicarbonate 18.43 Ferric oxide and alumina 0.07 Calcium silicate 1.50 Silica 0.45 Total 38.00 Blue Lick Water, Blue Lick^Springs, Kentucky One U. S. gallon contains: Solids. Grains. Ammonium chloride 0.13 Potassium chloride 7.72 Magnesium chloride 40.55 Sodimn chloride 400.43 Calcium chloride 10.12 Lithium chloride 0.43 Potassium bromide 1 . 97 Potassium iodide 0.01 Calcium sulphate 27.00 Sodium metaborate small amount Calcium bicarbonate 31.61 Sodium nitrate 0.16 Sodium nitrite faint trace Calcium phosphate faint trace Mangano-manganic oxide 0.21 Ferric oxide and alumina . 08 Silica 105 Total . . . ■ 522.34 MINERAL WATERS 163 Hathohn Wate:r, Saratoga Springs, New York One U. S. gallon contains: Solids. Grains. Ammonium chloride 2.19 Lithium chloride 2.60 Potassium chloride 19.28 Sodium chloride 425.93 Potassium bromide 0.40 Potassium iodide . . 0.12 Sodium sulphate 0.24 Sodium metaborate trace Sodium nitrite trace Sodium bicarbonate 12.81 Magnesium bicarbonate 114.53 Calcium bicarbonate 179.70 Barium bicarbonate . 80 Strontium bicarbonate . 55 Strontium bicarbonate trace Ferric oxide and alumina . 55 Silica 0.95 Total 760.10 Champion Water, Saratoga Springs, New York One U. S. gallon contains: Solids. Grains. Ammonium chloride 0.54 Potassium chloride . 5.90 Sodium chloride 262.65 Lithium chloride 0.31 Sodium sulphate 1 • 71 Potassium bromide •. . . . 1.16 Potassium iodide . 01 Sodium metaborate small amount Sodium nitrate trace Sodium bicarbonate 10.31 Magnesium bicarbonate 28.32 Calcium bicarbonate 81 . 81 Barium bicarbonate 0.69 Strontium bicarbonate trace Ferric oxide and alumina 0.07 Mangano-manganic oxide trace Silica . 0.71 Total 392.84 164 HYDROTHERAPEUTICS— MINERAL WATERS Vichy Water, Saratoga Springs, New York One U. S. gallon contains: Solids. Grains. Ammonium chloride 0.05 Potassium chloride 0.43 Sodium chloride 86.94 Lithium chloride 0.03 Potassium bromide trace Potassium iodide trace Sodium sulphate 1-73 Sodium metaborate trace Sodium bicarbonate 48 . 56 Magnesium bicarbonate 3 . 52 Calcium bicarbonate 8.71 Ferric oxide and alumina 0.18 Calcium sUicate '. . . 1 . 60 Sihca 0.11 Total 151.96 MissisQuoi Springs, Sheldon, Vermont One U. S. gallon contains: Solids. Grains. Ammonium chloride trace Lithium chloride trace Potassium chloride 0.20 Sodium chloride 0.12 Sodium sulphate 1 . 43 Sodium metaborate trace Calcium phosphate trace Sodium nitrate trace Sodium bicarbonate 1-06 Magnesium bicarbonate ... 4 . 88 Calcium bicarbonate 9 . 88 F'erric oxide and alumina 0. 12 Mangano-manganic oxide 0.03 Calcium silicate 0.50 Silica 2.23 Total 20.40 MINERAL WATERS 165 Londonderry Lithia Water, Londomderry, New Hampshire One U. S. gallon contains: Solids. Grains. Sodium chloride 0.03 Lithium chloride trace Potassium chloride 0.26 Ammonium chloride trace Sodium sulphate . 65 Sodium nitrate 0-23 Sodium nitrite trace Sodium bicarbonate 0.42 iMagnesium bicarbonate 0.41 Calcium bicarbonate 2 . 14 Ferric oxide and alumina . 02 Calcium sihcate . 07 Silica 0-95 Total 5.18 Congress Water, Saratoga Springs, New York One U. S. gallon contains: Solids. Grains. Ammonium chloride 1 . 77 Potassium chloride 19.78 Sodium chloride 248.65 Lithium chloride 1 . 89 Potassium iodide . 05 Potassium bromide 2 . 32 Sodium sulphate . . . 74 Sodium bicarbonate 36.41 Magnesium bicarbonate 97.14 Calcium bicarbonate 131.03 Barium bicarbonate . 77 Strontium bicarbonate trace Sodium metaborate trace Sodium nitrite trace Ferric oxide and alumina 1-21 Silica 114 Total 542 90 CHAPTER VJII MEDICATIONS Hydrochloric Acid and Pepsin. — Hydrochloric acid has always been regarded as an available therapeutic agent in the treatment of certain forms of gastritis, especially those characterized by deficiency of acid secretion. CHnicians, however, have been at variance in regard to the quantity that should be administered. Some have doubted the advisability of giving it in certain forms of subacidity, maintaining that in subacid conditions pepsin is always present and that the therapeutic requirements of the patient can best be met by a carefully selected dietary. A small minority greatly restrict the administration of hydrochloric acid while at the same time they abandon the use of pepsin altogether. They argue that artificial aids to digestion are not necessary, and that their habitual use is to a certain extent injurious. Every organ, we are told, is strengthened by activity and weakened by lack of exercise. The researches of Leo,i based upon the experiments of Pawlow, have thrown new hght upon hydrochloric acid and pepsin as therapeutic factors in the treatment of anacid and subacid conditions. It is important, when considering the effect of hydro- chloric acid, to take into account how the ingested food becomes mixed with the acid in the stomach. The mixing varies, according to whether the hydrochloric acid has been taken medicinally or secreted by the mucous membrane of the stomach itself. In artificial acidification the degree of admixture depends also upon the interval of time between ' Die Salzsauorcthcrapic auf thcorctiHclior u. praktiscl^cr (IniiKllaKe, Berlin, 1908. HYDROCHLORIC ACID AND PEPSIN 107 the ingestion of the nutriment and the administration of the acid. Hydrochloric acid may be taken immediately after the ingestion of food, or a few minutes later (10, 15, 20); by giving small doses at frequent intervals, which is the usual practice, the normal process of secretion of hydrochloric acid is imitated. Hj'drochloric acid taken by mouth after the ingestion of food does not become thoroughly incorporated \\-ith the food; it penetrates only the upper layer of it, which later becomes the central portion. The chief bulk, and espe- cially the outer portion of the stomach contents, remains at first unaffected by the acid. That portion of the acid which does not enter into the food mixture is transported, because of its fluidity, by the shortest possible route from the cardia to the pylorus and thence into the duodenum. Hydrochloric acid may be taken during the meal. Its admixture with the food is probably accomplished best when it is so taken, as it can thus reach every particle. Hydrochloric acid may be taken in one dose, the purpose being to obtain an effect upon the food mass from the periphery, as is the case with hydrochloric acid normally secreted. It ma}^ be taken before the commencement of the meal if this is to consist of solid foods only or if it is to be a small meal, such as breakfast; or directly after the soup, should soup be the first item of the meal. The action of the natural secretion is most closely simulated when the hydro- chloric acid is administered in this manner, for the acid becomes mixed with the food mass from the periphery toward the centre; it comes in direct contact with the mucous membrane of the stomach, and is able to exert its effect to the best advantage. These methods of administering hydrochloric acid — before or during the meal, after the meal, and in single or divided doses — may be combined in various ways. Hydrochloric acid may be taken on an empty stomach, independently of the ingestion of food; but if the dose is too large or too concentrated harm may be done to the mucous membrane of both the stomach and the intestine. 168 MEDICATIONS By experiment it has been found that hydrochloric acid taken internally has the power to stimulate the secretion of the ferments of the stomach. This is brought about by the action of the acid on the pylorus producing a secretin, which in turn being absorbed stimulates the secretion of gastric juice. It has also been found that ingested hydro- chloric acid will directlj^ stimulate the secretion of hydro- chloric acid by the depraved gastric mucous membrane, and that the ingested acid makes it possible for the gastric mu- cous membrane to respond with an increased formation of acid on the introduction of food. These statements refer to the pathologically changed gastric mucous membrane only (subacidity in gastritis). The direct stimulation of acid-formation has not been proved with respect to normal mucous membrane, nor has it been observed in achj^lia gas- trica, a condition in which the gastric mucous membrane is generall}^ irreparably altered. It can be secured only when the hydrochloric acid comes in direct contact with the gastric mucous membrane. If the amount of hydrochloric acid ad- ministered be large, this effect will follow with any method of administration, even after eating. Hydrochloric acid should be given before the meal, particularly if the doses are small; this is the surest way to act on the parenchyma of the stomach. Experimental research has shown that extensive proteo- lysis cannot be obtained by the administration of hydro- chloric acid alone; pepsin must be given simultaneously. It was formerly assumed that the administration of pepsin was useless, since such a small amount of pepsin is necessary for proteolysis — for when free h^^drochloric acid was absent, some pepsin or its precursor, pepsinogen, was found in the stomach, though only in minute quantities. In order to secure activity of the pepsin, or pepsinogen, by the intro- duced hydrochloric acid, it is necessary that these two be- come mixed; this important fact has often been totally ignored. In most cases the mixing of hj^drochloric acid and pepsin does not take place, owing to the fact that only hydrochloric acid is administered, and, being given HYDROCHLORIC ACID AND PEPSIN 169 after eating, it adheres to the top of the stomach con- tents, or penetrates into its centre, and remains for the most part separated from the pepsin of the gastric mucous membrane. When during the later stages of digestion a certain mixing of the pepsin with the hydrochloric acid does take place, it is insufficient at that time, owing to the fact that the greater part of the free hydrochloric acid has formed stable combinations. Proteolysis begins immedi- ately on administering a mixture of pepsin and hydrochloric acid. Leo proved that more or less thorough proteolysis took place, even in patients with achylia, when pepsin and hydrochloric acid were administered together. It was sometimes impossible to detect macroscopically any difference between the stomach contents of such patients and of persons in good health. Microscopic examination revealed a loosening of the protein covering of the starch granules, as well as of the connective tissue surrounding the muscular fibrillse of ingested meat. The reaction of the food mass was acid. Combined hydrochloric acid could always be demonstrated, and frequently even free hydro- chloric acid. The total acidity was, as a rule, comparatively high. Albumoses, and to a less extent acid-albumin and peptones, were found in the filtrate of the stomach contents. This condition was independent of the time of administration of the hydrochloric acid, whether during or after eating. The administration of pepsin alone is of but little thera- peutic value. After reaching the stomach it comes in contact with the hydrochloric acid at a few points only — on the outer border of the stomach contents — and can therefore exert its proteolytic action nowhere else. Pepsin given alone soon passes into the intestine without having assisted materially in the digestion of the food. It is absolutely useless to prescribe pepsin alone in cases in which hydro- chloric acid is not furnished by the stomach. Hydrochloric acid assists the intestinal digestion of pro- tein to the extent that protein substances which have been treated previously with pepsin and hydrochloric acid can be digested much better with trypsin. Besides this, hydro- 170 MEDICATIONS chloric acid acts upon some precursor in the duodenum, producing an intestinal secretin or hormone, which, being absorbed, stimulates the secretion of pancreatic juice. Hj'drochloric acid, when taken internally, increases the secretion of pancreatic juice. This augmentation commences about half an hour after the introduction of the acid into the stomach, and returns to the normal after one hour. Persons with normal or hyperacid stomachs have con- siderable tolerance for large quantities of protein. It has been found that cases of achyha gastrica which suffer from the results of excessive decomposition of protein (gastro- genic diarrhea) are protected from this effect b}^ the administration of hydrochloric acid. The change of the pro-enzymes into enzymes is assisted by hydrochloric acid. This fact is of no practical importance, however, for the quantity of hj^drochloric acid secreted is sufficient in cases of subacidity for the development of the activity of the enzymes; in achyha, however, the pro- enzymes, if present at all, are present in exceedingly small amount. It has been shown that hydrochloric acid taken by the mouth, like the natural product, prolongs the stay of the food in the stomach. This is due to a periodic closure of the pylorus brought about by the action of the hj'drochloric acid on the mucous membrane of the duodenum, and takes place whether the hydrochloric acid is given during the meal or afterward. It has been noted that hydrochloric acid is able also to stimulate the secretion of bile. When large quantities of acid are given, the effect on the small intestine is the same whether the acid be administered before, during, or after meals. But when small quantities are given, it is best to give them before meals. Small quantities of acid, which per se have no direct effect whatever on the gastric digestion, may, when administered in this manner, exert an energetic influence on digestion in the small intestine. Numerous individual doses of hydrochloric acid exert a HYDROCHLORIC ACID AND PEPSIN 171 favorable influence on the general nutrition. This has been proved by a general improvement of the nutrition in cases of achyUa under hydrochloric acid treatment. It is possible also to diminish the percentage of carbon dioxide and the alkalinity of the blood by the administration of hydrochloric acid. When hydrochloric acid is being given the respiratory metabolism shows a decrease in the expendi- ture of oxygen and an increase in the exhalation of carbon dioxide. Ingested hydrochloric acid has a favorable influence on the appetite; it is, therefore, a direct stomachic. This effect is due to improvement in the general nutrition, and to stimulation of the peripheral nerve fibres which excite the sensation of hunger. The acid is also thought to stimulate the mucous membrane of the stomach, with resulting secretion of gastric juice. As will be seen from a consideration of these conclusions, hydrochloric acid is indicated as an aid to both gastric and intestinal function. It is indicated in subacidity and an- acidity to replace the deficient secretion and thus assist the proteolytic process of digestion. Taken medicinally, it exerts an influence upon the pancreatic secretion and upon the secretion of bile. The influence on biliary secretion appears to be independent of any effect on gastric digestion. Intes- tinal digestion may be greatly improved by the administra- tion of hydrochloric acid in suitable cases. Very frequently the purpose will be to exert a coordinate action on both the stomach and the intestine; one favorable result of the treatment with hydrochloric acid will always be an improve- ment in proteolytic action. According to Leo, hydrochloric acid and pepsin should be administered together. This investigator is convinced that the failures with hydrochloric acid which are so fre- quently reported are due solely to the fact of its having been administered without pepsin. A number of preparations containing hydrochloric acid are at our disposal. Two solutions of the acid are official: 172 MEDICATIONS 1. Acidum hydro chloricum — hydrochloric acid; 100 parts contain 31.9 parts hydrochloric acid and 68.1 parts water. 2. Acidum hydro chloricum dilutum — diluted hydrochloric acid; 100 parts contain 10 parts hydrochloric acid and 90 parts water. Hydrochloric acid should be taken well diluted, through a glass tube; otherwise it decalcifies the tooth substance and irritates the mucous membrane of the mouth, pharynx, and esophagus. For the protection of health}^ tissue as well as the maintenance of comfort to the patient, suitable methods of drug administration are demanded; therefore the author repeats a suggestion with regard to the administra- tion of hydrochloric acid which his personal experience has shown meets the difficulties. He has employed this method since 1899.^ In prescribing the acid it was at first suggested that it be taken in gelatin capsules (Fig. 21). It was found, however, that the acid penetrated the capsule too quickly. After repeated trials it was discovered that two capsules of differing sizes (the smaller one, containing the acid, encased in the larger one) would give sufficient thickness to obviate quick penetration — would, in fact, retain the acid for a long time (Fig. 22). This device gives the patient ample time for swallowing and reduces to a minimum whatever annoy- ance or risk is involved. The double capsule is easily con- structed. The cap of a No. "0" capsule will fit into the body of a Xo. ''00" capsule, forming with it a shell of double thickness, which, of course, offers a twofold resistance to the action of the acid (Fig. 23). The lower edge of the cap of the capsule is first moistened with the tip of the tongue, so that when it is placed over the body of the capsule it be- comes immediately sealed. The patient is instructed to use an ordinary dropper for filling the capsule just before tak- ing. Such double-bottom capsules hold 1 Cc. (15 minims) of hydrochloric acid. Additions of other medicinal agents (except pepsin) to hydrochloric acid are not usual. To correct the taste, the ' Simple Method of Administoring Hydrochloric Acid, Charles D. Aaron, Journal of the American Medical Association, June 24, 1S99. IIYDEOCIILORIC ACID AND PEPSIN 173 acid can be given to adults in tea, with or without the addition of sugar. For children syrup of orange is a good vehicle. Fig. I'l Fig. 22 Fig. 23 Single "00" gelatin capsule. Inner capsule in proper position. Double capsule closed. Acidol. — This is a betain chlorhydrate, prepared from molasses, which in watery solution splits up into non-toxic betain ftrimethylamine acetic acid) and hydrochloric acid. It is considered harmless. Acidol without pepsin is as ineffective for good as hydrochloric acid without pepsin. Combined with pepsin it has been introduced to the pro- fession as acidol-pepsin tablets. These tablets are not so efficacious as hydrochloric acid and pepsin in liquid form. Fortunately the National Formulary gives us a number of preparations containing both hydrochloric acid and pepsin. The following is especially recommended: 174 MEDICATIONS Gm. or Cc. I^ — Acidi hydrochlorici 2.5 n^xl Pepsini 21.0 3xvj Glycerini 125.0 oiv Aquse q. s. ad 250.0 oviij Misce. Sig. — A teaspoonful to a tablespoonful in a glass of water to be taken during meals. Pepsin and hydrochloric acid should not be given in an alcoholic menstruum. Fuld^ concludes that alcohol is a ferment poison. Ascher^ has found that various drugs influence pepsin digestion. Iron is particularly detrimental. While the bitters, quinine and condurango, are tonics, they should not be given with pepsin, on account of their ferment- destroying property. It is not permissible to take pepsin in hot liquids, since a higher than body temperature destroys the activity of this ferment. There are a number of other preparations intended to replace pepsin and hydrochloric acid. One of these is the so-called gasterine, or gastric juice of the dog. To obtain supplies, Pawlow makes an opening into the esophagus of the dog and another into the stomach — the former to divert the food from its natural course so that it will not reach the stomach; the latter for access to the gastric juice as it is secreted. The stomach having been emptied and thoroughly washed out, the dog is offered meat, which in the act of swallowing falls out of the upper segment of the esophagus; in the stomach, however, a copious secretion of gastric juice takes place. In this manner about 600 to 800 Cc. of gastric juice daily may be obtained from a dog weighing 17 kilos. Pawlow has recommended this canine gastric juice (gas- terine) as a medicinal agent. Gasterine, taken in daily doses of 250 to 500 Cc, has given good results in cases of sub- acidity and anacidity. The cost of the product at present is an obstacle to its general employment; besides, it is somewhat repulsive. The artificial mixture of hydrochloric acid and pepsin, fortunately, serves the same purpose. ' Salz.sauere.sekretion und Salzsaueretheraiiio, llierapcutische IVlonatshofte, Berlin, November, 190S, p. 549. 2 Archiv fiir VerdauunKs-Kr;inklu'it(Mi, I'crlin, Dccciiihcr, H)()S, p. G20. PANCREATIN 175 Another preparation intended to replace hydrochloric acid and pepsin is the so-called dyspeptine of Hepp. This is the gastric juice of pigs, obtained in a manner similar to that just described. But it has been found that dyspeptine contains no hydrochloric acid whatever, that it does not digest protein, and is, the;refore, therapeutically inactive. The quantity of hydrochloric acid to be prescribed depends upon the object to be attained. Small quantities suffice when it is intended to stimulate the gastric and intestinal mucous membrane, the stomach being empty. If, on the other hand, copious proteolysis is wanted, large quantities of hydrochloric acid are necessary. It may be stated as a general rule that, as has been shown experimentally, the ingestion of large quantities of food causes the secretion of large quantities of acid; and the physiologic proportion holds with smaller quantities. Foods with varying propor- tions of proteins require varying quantities of hydrochloric acid; for example, bread requires less hydrochloric acid and more pepsin than meat. It has been calculated that the normal stomach produces for a mixed meal about 150 Cc. (5 ounces) of the official hydrochloric acid. Of course it is rarely possible to administer such large quantities. Doses proportionally much smaller than the quantity of hj^dro- chloric acid normally secreted are given when hj^drochloric acid is prescribed medicinally. It follows from the statements made at the beginning of this chapter that the time of taking the hydrochloric acid must depend on the purpose sought. The contents of the stomach are influenced best if hydrochloric acid is taken during the meal as a beverage; taken after food, however, it also acts well in this respect. Both methods may be combined. Shortly before eating is the best time for taking the acid for its effect on the gastric mucous membrane itself. The effect on the small intestine is also best obtained by small doses before meals; if the acid be taken during the meal, larger doses are required for this purpose. Pancreatin. — The other important digestive ferment recog- nized by the U. S. P. is pancreatin. The official pancreatin 176 MEDICATIONS possesses the property of converting twenty-five times its own weight of starch into substances soluble in water. Pancreatin should contain the pancreatic ferments: Trj^psin, which digests proteins; steapsin, which emulsifies fats; amyl- opsin, which converts starch into sugar; and a milk-curdling ferment. Hare describes a method by which pancreatin may be made by the physician. The pancreas of a pig which has been killed about six hours after a full meal, when the organ is in an active state is chopped up finely and placed in four times its weight of dilute alcohol and allowed to stand twelve hours; the alcohol is then decanted or fil- tered off. The filtrate is administered in doses of 4 to 8 Cc. (1 to 2 drams). It may also be prepared as follows: Wash and chop finely the fresh pancreas, and allow the gland to soak in absolute alcohol twenty-four to forty-eight hours. The alcohol is then squeezed out and to the gland is added ten times its weight of glycerin. The mixture must stand forty-eight hours and then be filtered. The dose is 2 Cc, (30 minims). It may be given in milk. Pancreatin has marked digestive properties; in addition to its action on protein it converts all starches into sugar, emulsifies fat, and curdles milk. It is especially indicated when the stomach is deficient in secreting power. Often the gastroenterologist finds it necessary to treat the stomach as though it were a part of the duodenum. In all cases of subacidity and achylia, duodenal digestion must make up the deficiency in gastric digestion. Patients who for years have had no severe or markedly distressing gastric symp- toms may suddenly be seized with a diarrhea, due to insufficient secretion of gastric juice. When the diarrhea (gastrogenic, as it has been called) once develops, the irrita- bility of the duodenum should be reheved as much as pos- sible. The condition may be aggravated by either gas- tric hypermotihty or pyloric insufficiency. If pancreatic digestion be instituted in the stomach, the duodenum will receive the food in a more or less digested state, and in this way irritation by fermenting foods may be largely obviated. Relieved of tlic irritation, the intestine, as a PANCREATIN 177 rule, soon regains its lost tone. In cases in which hydro- chloric acid and pepsin are not indicated, but some digestant is required, pancreatin fulfils most nearly the requirements. It is especially indicated in chronic gastric catarrh associated with the secretion of much mucus. In these cases hydro- chloric acid precipitates the mucin from the mucus, and a coating is formed around the whole food mass — so digestion is interfered with instead of being promoted. Pancreatic preparations should always be given with alkalies, since the alkalies in solution in the stomach dissolve mucus. Pan- creatic preparations are particularly valuable in achylia gastrica. Brammel^ reports an instance which illustrates the im- portance of the pancreatic enzymes and their relation to normal development and growth. The patient was a youth of nineteen years whose bodily development had apparently been arrested about the age of eleven years. He was bright and intelligent, perfectly formed, and presented none of the physical alterations suggestive of sporadic cretinism. He had suffered for many years from diarrhea. The urine was free from sugar. From careful investigation it was concluded that the pancreatic secretion was defective or completely absent; and that this was the case was proved by the remarkable improvement brought about by administering a glycerin extract of pancreas. In two years he grew five inches and increased 22 pounds in weight, in spite of the fact that for eight years he was said not to have grown at all. In the same work is reported a case of a girl of eighteen years who had not grown for seven years and who had been troubled all her life with diarrhea. She also was treated with pancreatic extract, with the result that she increased nine and one-half pounds in weight and added almost two inches to her height in a little over four months. There was also a marked improvement in her general condition. Various preparations of pancreas have been placed before the profession under trade names. Pankreon is a preparation of pancreatin containing 10 per cent, of tannic acid. It is 1 The Pancreas: its Surgery and Pathology, Robson and Cammidge, p. 131. 12 178 MEDICATIONS insoluble in acid media, but is split up by alkalies; it therefore passes through the stomach unchanged, exerting its digestive power in the intestine. The best prepara- tion for us is the liquor pancreaticus of the National Formulary: P.i^XREATIC SOLrXIOX Gm. or Cc. Pancreatin (U. S. P. ) 4.38 gr. Ixvj Sodium bicarbonate 12.5 oiij Glycerin 62.5 Sij Compound spirit of cardamom (X. F.) . . . 8.7 oij Alcohol 8.7 oij Purified talc (U. S. P.) 3.7 oj Water, a sufficient quantity to make . . . 250.0 Sviij The dose should be a tablespoonful after each meal. Papayotin or papain, obtained from the juice of the Carica papaj-a tree, is a digestant that is frequentl}" used. It is said to act in both alkaUne and acid media. Pineapple juice is said to possess the power of assisting in the digestion of proteins. Boihng or heating, as in the process of canning pineapples, destroys the digestive power of the juice. Taken raw or in the natural state, this ferment is active in either acid or alkaline media but not in neutral solutions. The diastatic ferments are suggested in those cases in which there is defective secretion of these normal enzj-mes. The ptyalin of the saliva, however, is rarely absent. TSlien diastase is indicated, the best form of this ferment seems to be that present in pancreatin. Vegetable diastase, as found in extract of malt, is sometimes employed. There are also available many proprietary preparations of animal and vegetable diastases. Diastase should always be prescribed with alkalies, since the acid in the stomach destroys its action, while the alkali prolongs amylolysis. The giving of dias- tatic ferments does not remove the cause, and therefore is not resorted to as often as formerly. Alkalies. — While the administration of hydrochloric acid for therapeutic purposes dates from the discovery of the fact that the acidity of the gastric juice is due to hydro- ALKALIES 179 chloric acid (Bidder and Schmidt, 1852), the administration of alkahes has been practiced since an early period in the history of medicine. It has long been known that alkahes exert a beneficial influence over certain diseases of the stomach. The first definite work in investigating their therapeutic effect was that of Claude Bernard, who found that small doses of alkalies stimulated gastric secretion in animals, while large doses had no apparent effect but to neutralize the acidity of the gastric juice. Leube, experi- menting with dogs, announced that bicarbonate of soda as present in Carlsbad water would not only neutralize gastric hyperacidity, but would stimulate the gastric mucous mem- brane to renewed and permanent secretion of gastric juice when pathologic changes had taken place in the gastric mucosa. The medical profession is indebted to Jaworski for the first exact knowledge of the action of alkalies on the secretions of the human stomach. Jaworski taught that small doses of alkalies possess the power of neu- tralizing part of the acidity of the gastric contents, which effect is soon counteracted, however, by an in- creased secretion of hydrochloric acid. Sodium bicar- bonate and Carlsbad salts, when administered in small doses, stimulate gastric secretion, while in large doses they exercise an inhibitory effect. According to Mitchell Bruce, alkalies taken into the mouth check for the time being the secretion of saliva and impair the appetite; reaching the stomach just before meals they act as stom- achics, being natural stimulants to the gastric glands and at the same time sedative to the nerves. Sodium bicarbo- nate is preferred to the potassium salt in disturbances of the stomach when there is much pain and a tendency to nausea accompanied by a gouty or rheumatic diathesis. Its more powerful action is said to be due chiefly to the fact that it is more slowly absorbed. It is more commonly given than the other alkalies, in doses of 0.5 to 1 Gm. (7 to 15 grains) shortly before meals. A portion of the bicar- bonate becomes converted into sodium chloride, in which form it assists in the digestion of protein. Sodium bicar- 180 MEDICATIONS bonate liquefies tenacious mucus, thus enabling the gastric juice to reach the food more readily. Sodium chloride in large doses is a safe and easily available emetic. In the alimentary canal the sulphate and the phosphate of soda act as hydragogue purgatives by virtue of their immediate local action. They also act as stimulants to the intestinal glands, and are being constantly absorbed and excreted, reabsorbed and reexcreted, in their course along the bowel. Dr. Eustace Smith^ declares that disturbances are hkely to arise from the prolonged administration of the alkahes. He distinguishes between antacids and alkaline drugs: the former act as alkalies in the stomach by neutralizing acids, the latter increase the alkalinity of the blood and tend to render the urine alkaline. Among the principal antacids are calcium carbonate, lime water, magnesia, and sodium bicarbonate ; the drugs used to render urine alkaline are the alkaline potassium salts, such as the acetate, bicarbonate, and citrate. This same writer advises that the dose of an antacid, if given three times a day, should be small, and also that it be discontinued as soon as it ceases to be bene- ficial. Given in large quantities on an empty stomach, the antacids tend to increase the secretion of hydrochloric acid, and if the stomach be stimulated day after day to com- bat this unnatural alkalinity the result may be such an impairment of the power of the secreting glands as to seriously affect digestion. Furthermore, the long-continued use of most alkalies is apt to be followed by an increase in the alkalinity of the blood, modification of secretions, increased waste, and anemia. The physician should be on his guard against the unduly prolonged administration of either the potassium or the sodium salts. When hyper- acidity or hyperchlorhydria can be traced to too rapid eating, to eating excessive quantities of meat or highly seasoned foods, to the use of condiments, to nervous irrita- bility, high tension, or worry, it is better treated by elimi- nating the cause of the trouble than by prescribing a corrective of the symptoms. Temporarj'^ roliof may always 1 British Medical .Journal, .lamiary \W, 1!)()'.». ALKALIES 181 be afforded in such conditions by the administration of an antacid, as 1 Gm. (15 grains) of sodium bicarbonate. Such treatment is, however, purely symptomatic, and should be employed only while the diagnosis is being made or while the patient's habits of life are being adjusted. If sodium bicarbonate, which is undoubtedly the best of all antacids, be given three times a day, before meals, the dose should be smaller — half the quantity mentioned. If gastritis be present, bismuth subnitrate should be given along with the antacid. Among the alkalies the Carlsbad waters or those of the Congress and Hathorn Springs of Saratoga, N. Y., and the Bedford Springs in Pennsylvania come in for consideration. The chemical analysis of these waters is to be found on page 159. The artificial Carlsbad salt constitutes an effi- cient substitute for the more expensive natural salt. The composition of the artificial salt is as follows (German Pharmacopoeia) : Sodium sulphate, dry , . . 44 parts Potassium sulphate 2 parts Sodium chloride 18 parts Sodium bicarbonate 36 parts This salt may be administered in doses of one to two dessertspoonfuls in half a pint of water, in hyperchlorhydria, hypersecretion, or gastric ulcer, the purpose being to neu- tralize the excessive secretion of hydrochloric acid. It has been used with greater or less success in gastritis, though Hemmeter declares that he has not seen an instance of subacidity or achylia in which the gastric secretion ever returned after being lost, or increased when deficient. The therapeutic use of alkalies appears to be limited to stomach diseases associated with an increased secretion of hydro- chloric acid, hyperacidity from neurasthenic causes, hyper- secretion, or gastric ulcer. As a means of dissolving adherent mucus, as well as neutralizing acids, in the process of cleans- ing the stomach by lavage, the alkalies, including Carlsbad salt or waters, play a very important role. 182 MEDICATIONS The best time for the administration of alkahes in hyperacidity is from one-half to one hour after meals, at the height of digestion. The subjective symptoms of the patient, as gastralgia, eructation, pyrosis, distention, consti- tute very good guides as to the proper time for administering the alkali. Owing to the variable quantity of hydrochloric acid found in the stomach in the absence of food in cases of hypersecretion, alkalies should be administered before meals in such cases, in order to insure salivary digestion in the stomach. Amylolysis may be greatly assisted by the administration of a glass of Saratoga, Vichy, or sodium bicarbonate solution, 4 Cc. (1 drachm) to one-half pint of water, before meals. The alkalies are commonly divided into two groups — (1) alkaline earths; (2) alkaline carbonates. Of the alkaline earths, magnesium oxide or calcined magnesia is perhaps most important, as well as being the one that is generally employed when alkahes are indicated. Magnesium oxide is prepared by exposing magnesium carbonate to a dull red heat. It is a white, very light powder, sparingly soluble in water. The dose is 0.3 to 2 Gm. (5 to 30 grains), repeated if necessary. In selecting an alkali, that which liberates the least amount of carbon dioxide in the neutralization process should be chosen, inasmuch as the distention of the weak muscular walls of the stomach by gas is very annoying to the patient, not to say dangerous on account of the pressure exerted in the region of the heart. Of these alkalies, mag- nesium oxide or the light calcined magnesia occupies the first place. The chemical reaction that takes place when magnesium oxide is brought in contact with free hj'dro- chloric acid in the stomach is expressed as follows: MgO + 2HC1 = MgCl^ + H,0 Belonging to the alkaline carbonates are sodium carbonate and sodium bicarbonate. Sodium l)icarbonate combines with hydrochloric acid so as to form sodium chloride, water, and carbon dioxide. The chemical equation is as follows: NaHCOa + HCl = NaCI + H,0 + CO, BISMUTH 183 Boas calculates the dose of sodium bicarbonate necessary to counteract a hyperacidity exceeding 2'> parts in 1000 to be 8 to 10 Gm. (oij-iiss); of magnesium oxide to offset the same degree of acidity, 3 Gm. (45 grains). In treating hyperacidity or hypersecretion the magnesium salts are to be preferred to the other alkalies, especially when constipation and flatulence are pronounced. Bismuth. — The bismuth preparations are derived from the metal itself. Among the salts used most commonly in the treatment of gastric affections are (1) bismuth subnitrate, (2) bismuth salicylate, (3) the subcarbonate of bismuth, and (4) bismuth subgallate. Bismuth subnitrate is a white, odorless powder, with a high specific gravity, insoluble in water, and very faintly acid. The usual dose is 0.3 to 1.2 Gm. (5 to 20 grains). It may be employed, however, in much greater quantity for the purpose of rendering the stomach or intestinal canal opaque for Roentgenography, though the subcarbonate is better. The salicylate of bismuth is prepared by the interaction of bismuth nitrate and sodium salicylate. It is obtained as a whitish and amorphous powder insoluble in water, and is administered in doses ranging from 0.3 to 1.2 Gm. (5 to 20 grains). The subcarbonate of bismuth is the result of a chemical reaction between bismuth nitrate and ammonium carbonate. It also occurs as a heavy white powder, insoluble in water. The dose is 0.3 to 1.2 Gm. (5 to 20 grains). Bismuth subgallate is a fine, bright yellow powder, odor- less, unaffected by exposure to light. Internally it is recom- mended in gastric fermentation associated with diarrhea. The dose is 0.3 to 0.6 Gm. (5 to 10 grains). The bismuth salts are all insoluble in the stomach, where they exert a sedative and astringent action, either by their effect upon the nerve endings or the bloodvessels in the stomach walls or by coating the mucous membrane. They are used more or less extensively in the treatment of vomit- ing and pain due to gastric catarrh or to irritants such as alcohol. They constitute important therapeutic agents in 184 MEDICATIONS the treatment of gastric ulcer and gastric carcinoma. These salts often exert a favorable influence on so-called nervous or reflex vomiting in cases of pregnancy or hysteria with true gastritis. Bismuth salts were early known to be efficacious in gastric diseases. They were at one time abandoned on account of the frequency with which poisoning resulted, due to impurities, for the most part from arsenic. Since, however, by improved methods of manufacture, an abso- lutely uninjurious drug has been produced, the bismuth salts are again widely employed — for both their anodyne and their antacid effects. They ameliorate or promptly relieve pains, cramps, burnings, and sensations of weight, referable to the stomach. In certain forms of gastric neu- rosis, such, for example, as nervous dyspepsia and gastric crises of central origin, any relief obtained by the adminis- tration of bismuth is at best only temporary. The bismuth salts, especially bismuth subnitrate, are among our best agents in the treatment of gastric ulcer; owing to the soothing and astringent influence which they exert, the lesion is in many instances healed. The subnitrate of bis- muth seems to exert a very marked influence upon such reflex symptoms as retching, vomiting, and eructations. The drug has been employed with advantage in hema- temesis. According to Lyon^ there is only one contraindication to the administration of the bismuth salts, and that is stenosis of the intestinal canal, wherever situated. The tendency to constipation alleged to be caused by bismuth may bo easily overcome by olive oil enemata. In fact, the prolonged use of bismuth has been attended by looseness of the bowels — a result which may be corrected by suspending the treat- ment for a time. The salicylate of bismuth is a valuable antifermentative. It is assumed that bismuth subnitrate liberates some of its nascent nitric acid, which acts as an astringent and antiseptic on the mucous membrane of the gastro-intestinal ' Archives des maladies de I'appareil digestif, 1909. BISMUTH 185 tract. The inefficiency of bismuth subcarbonate is supposed to be due to the absence of this acid. Bismuth forms a protective layer over gastric erosions and ulcers, thus pre- venting existing lesions from coming in direct contact with the acid gastric juice. Rodari^ has made experimental and clinical investigations into the indications for the bismuth preparations in gastric affections, and gives his results as follows : 1. Bismuth subnitrate is indicated not only to furnish a mechanical protection to lesions (ulcers, erosions), but also whenever it is desired to produce inhibition of secretion, as in ulcers, erosions, primary and secondary gastritis acida, and, under certain circumstances, nervous hyperchlorhydria. The intensity of the reduction of gastric secretion is dependent upon the condition of the mucous membrane; the healthy mucosa reacts with a relatively slight inhibition. Thus it is explained that the effect is more prompt in inflamma- tory conditions than in a neurogenous increase of secretion with a normal mucosa. The astringency, upon which the secretory reduction depends, also produces a kind of simul- taneous local antiphlogistic effect. In subacid conditions, when it is desired to stimulate secretion for therapeutic purposes, bismuth subnitrate is contraindicated. 2. Bismuth bisalicylate and bismuth salicylate are appli- cable when the gastric secretion is to be stimulated — that is, in subacid conditions. The sahcylic acid that is liberated as the salicylates decompose, exerts also an antiseptic effect. Hydrochloric acid secretion is stimulated by the salicylates of bismuth; therefore, much the same as by the use of the saline mineral waters. In conditions of hyperacidity the use of these preparations is contraindicated; they might possibly be given as antiferments, on account of the sali- cyhc acid they contain, but this would lead to increased secretion of hydrochloric acid and, with it, to an undesirable vicious circle. 3. Bismuth bitannate has a twofold effect upon the gastric mucous membrane — the glands and the secretion. If the 1 Magen unci Darmkrankheiten, Zweite Auflage, p. 137. 186 MEDICATIONS mucosa is intact and uninflamed, the liberated tannin will produce increased secretion; if swollen and inflamed, there will be a tj^Dical inhibition of secretion. Thus, on the one hand, the preparation, like bismuth salicylate, appears to be indicated when it is intended to stimulate impaired secretion, as for instance in subacid conditions of a non-inflammatory nature, but then only, and not in subacid gastritis; on the other hand, its application seems indicated, hke that of bismuth subnitrate, in primary or secondary superacid gastric conditions. If the bismuth preparations are to be administered for any length of time, for the purpose of obtaining a positive therapeutic effect, their indication or contraindication can only be estabhshed by a functional examination of the stomach, which is most conveniently done by administering an Ewald test breakfast. Bismuth subcarbonate can hardly be expected to exert any other than a mechanical effect upon the injured mucosa, because under the influence of hydrochloric acid it spUts up in the stomach into bismuth oxychloride and carbon dioxide, the former an indifferent product and the latter non-astringent. Thus it seems illogical to combine this medication with an alkahne salt; in fact, it seems wrong to combine the other bismuth preparations with an alkaline salt, because the action of these bismuth preparations depends upon the effect of the hberated acid. If an alkaline salt were present, it would unite with the acid and thereby render it ineffective. On this account, Rodari says, com- binations of bismuth subnitrate with magnesium oxide and sodium bicarbonate, which are frequently used in practice, should not be given when the astringent effect of the bis- muth is desired. Strychnine and the Bitters. — Strychnine sulphate is prepared from nux vomica. It occurs in colorless, odorless, prismatic crystals, and has an intensely bitter taste. It is sparingly soluble in cold water, more soluble in boihng water. The dose is 0.001 to 0.003 Gm. U(^ to v^d grain). Strychnine and nux vomica possess the properties of stomachics. The STRYCHNINE AND THE BITTERS 187 so-called vegetable bitters or stomachics taken into the mouth stimulate the nerves of taste, producing thereby several reflex effects which are of prime importance in the promotion of digestion. The flow of saliva is increased, to the advantage of diastatic digestion, and the vessels and glands of the stomach are excited through the central nervous system. The effect on gastric secretion is said to be much more marked if the bitter be aromatic, so that it is relished by the patient. Bitters are divided into two classes — simple and complex. Simple bitters depend upon their bitterness alone for their activity. The complex bitters, which include strychnine and quinine, in addition to their local effect, act as stimulants to other portions of the gastro-intestinal membrane. Ca- lumba is an example of the first class. Probably the best type of the second class is nux vomica or its alkaloid strychnine. Strychnine is particularly useful as a means of stimulating the musculature and tone of the stomach. It increases the appetite and vital powers, as well as the senses of sight and hearing. The respiratory, cardiac, and vaso- motor centres likewise share in the stimulation. Arterial pressure is raised and the pulse rate lowered. Strychnine stimulates peristalsis to such an extent at times as to pro- duce diarrhea. The drug is slowly absorbed from the stomach, but fairly rapidly by the rectum. Owing to its slow absorption and slow elimination, the administration of strychnine should be interrupted at intervals, to avoid cumu- lative effect. Strychnine sulphate or nitrate may be used advantageously with iron and administered hypodermically, as described on page 240. Tincture of nux vomica has been found more satisfactory than strychnine in the treatment of atony of the stomach, beginning. with 0.3 Cc. (5 minims), gradually increasing the dose daily until the physiologic action of the drug becomes visible by the muscular twitch- ings. In pyloric insufficiency large doses of strychnine may be given, beginning with small doses and gradually increasing until 0.01 Gm. (i grain) can be given three times a day. 188 MEDICATIONS The alkaloid is useful in the treatment of gastralgia. in which condition 0.001 Gm. (15V grain) of the sulphate may be given hypodermically. The primary effects of nux vomica and strychnine are exerted upon the nervous system, where the drug acts as an excitant to the spinal cord in its motor tracts. The class of bitters includes also such drugs as calumba, quassia, cinchona, gentian, orange, and condurango. A dis- tinction has been drawn, as abeady stated, between simple bitters and true stomachic drugs. The former stimulate the appetite, while the latter (the complex bitters) stimulate not only the appetite, but the secretory and motor functions of the stomach as well. How the stimulating effect upon the appetite and digestive functions is brought about is not definiteh^ known. These remedies are indicated, as a rule, when the appetite is poor. Loss of appetite usually accom- panies those gastric conditions in which the secretion of gastric juice is more or less reduced. According to the experiments of Boki on dogs, quassia and calumba increase the secretion of gastric juice b^' direct effect exerted upon the excised mucous membrane of the stomach. Reichmann was among the first to investigate the action of vegetable bitters on man; he experimented "udth diseases of the gastro- intestinal tract, using two groups of bitter remedies — pure bitters and the aromatic bitters. The introduction of a bitter infusion into the empty stomach, in these experi- ments, was immediately followed hy much less stimulation to the secretory function of the stomach than was caused by the introduction of the same quantity of distilled water. As soon, however, as the bitter infusion left the stomach, there was a marked increase in gastric secretion. The administra- tion of a bitter with the food was followed by a retardation of gastric digestion. When gastric secretion is normal the value of the bitters is questionable. Alcohol is said to act as a stimulant to gastric secretion, but it has no effect whatever in the production of pepsin. When alcohol is introduced by the rectum as an ingredient of a rectal enema it has the power of stiniuhiting gastric STRYCHNINE AND THE BITTERS 1S9 secretion. The bitter tonics have been given as tinctures, and it may be that the alcohol in the tincture stimulated the secretion of gastric juice instead of the bitters themselves. According to the investigations of Pawlow, meat juices, raw meat, meat broth, meat extractives, peptones, milk, and gelatin, as well as large quantities of water, have the effect of stimulating gastric secretion. The results of several investigators show such contra- dictions that we are still in doubt as to the efficacy of the bitters. According to Pawlow, who has done much scientific work in investigating the physiologic effect of bitters, their action does not consist in a simple physiologic reflex, but rather in a certain psychic effect, which excites secondarily the secretory function. Pawlow concludes that the bitters act on the gustatory nerves of the oral cavity, calling forth a desire for food. The results of Reichmann's experiments have led him to declare that bitter remedies should be administered only in those cases in which the secretory powers of the stomach are reduced, when they should be administered about half an hour before eating. Other investigators, notably Fawitzki, agree with Reichmann in regard to both the method and the time of administering the so-called bitters and stomachics. Condurango bark was declared at one time to possess peculiar efficacy in the treatment of gastric carcinoma. Since 1874, when Friedrich first called attention to condu- rango as a therapeutic agent in cancer of the stomach, it has been widely administered, but not with the results claimed by Friedrich. While this drug has no specific action on cancer, it is of some value as a stomachic. Con- durango is best administered in the form of a decoction. I^ — Cort. condurango 15 parts Macerate for twelve hours with distilled water . . 360 parts Then evaporate down until, when strained, it equals 180 parts Sig. — A tablespoonful twice daily. Orexin (phenyldihydrochinazolin hydrochloride) was intro- duced to the profession in 1890 by Penzoldt, who claimed that it possessed the property of inducing hunger and im- 190 MEDICATIONS proving the appetite. Penzoldt's claims were studied by a number of investigators, who for the most part found orexin to be an irritant to the gastric mucous membrane. The drug, however, appears to have the effect of increasing secretion when administered in subacidity. For the original product a basic orexin was later substituted, and still later the tannate; some of the disagreeable features of the prepa- ration have been eliminated by administering it in capsules. The dose should be followed by a large draught of water. According to Penzoldt, the best results are obtained from orexin when it is administered in a dose of 0.3 Gm. (5 grains) once a day, preferably at ten o'clock in the morning, and continued for about five days. The special indications for its administration are gastric atony and acute gastritis. It is contraindicated in such conditions as gastric ulcer, hj^Der- acidity, hypersecretion, and other irritable conditions of the stomach. Silver Nitrate. — Silver nitrate is prepared by the interaction of silver and nitric acid ; it occurs as colorless tabular rhombic prisms. It is soluble in half its weight of water. Owing to the readiness with which this salt combines with chlorides, all solutions should be made with distilled water, and when they are to be preserved for any length of time they should be kept in amber-colored containers. Silver nitrate is shghtly soluble in 90-per-cent. alcohol. The incompatibles of this salt are alkahes and the carbonates, chlorides, acids (except nitric and acetic), potassium iodide, solutions of arsenic, and astringent infusions. In the stomach nitrate of silver is decomposed by hydrochloric acid and mucus, and cannot act as an irritant upon the mucous membrane unless administered in toxic doses. Baibakoff' found that silver nitrate has the property of increasing the acidity of the gastric juice, especially in cases in which there was hyperacidity before the use of the drug. According to this, silver nitrate is contraindicated in hyperacidity, hyper- secretion, and peptic ulcer. The silver salts are indicated rather in the treatment of the subacid conditions which ' Roussky \'ratch, August 20, 1905. GASTRIC SEDATIVES 191 usually accompany chronic gastric catarrh. In chronic gas- tritis the power to digest proteins is somewhat diminished, so the effect of the silver salts by way of increasing gastric secretion meets the therapeutic requirements in this class of cases. Silver nitrate has been found to have an anticatarrhal action on the gastric mucosa in gastritis. The drug exerts an antifermentative influence also, inhibiting the development of gases, belching, and eructations. Experiments have shown that silver nitrate possesses the power of increasing gastric motility. The test breakfast has been found to leave the stomach within a shorter interval when nitrate of silver has been administered than when no medication is employed. The dosage of nitrate of silver should be so regulated as to meet the requirements of the individual case or particular stage in the progress of the disease. Large doses (0.03 Gm. — 4- grain) administered three times a day increase the flow of gastric juice; usually, how^ever, this effect may be accomplished with doses as small as 0.002 Gm. (gV grain) given three times a day. The physician administering nitrate of silver should be on his guard against argjTia. Gastric Sedatives. — Among gastric sedatives are drugs which reduce the excitability of the vomiting centre. In this class are amyl nitrite, nitroglycerin, opium, chloral hydrate, the bromides, and dilute hydrocyanic acid. As sedatives to the afferent nerves of the stomach may be mentioned hot water, ice, dilute hydrochloric acid, effer- vescing carbon dioxide, bismuth, dilute alkalies, opium, ipecac, and calomel in small doses. Amyl Nitrite. — Amyl nitrite occurs in the liquid form, being chiefly an isoamyl nitrite. It is an ethereal liquid of a yellowish color, fragrant odor, and faintly acid reaction, readily soluble in 90-per-cent. alcohol, but almost insoluble in water. It is administered as a vasomotor dilator in cir- culatory disturbances, in the form of vapor (inhalation) from an amyl nitrite pearl, or thin glass shell, which is crushed by the patient in a handkerchief. The dose in- ternally as a gastric sedative is one-half to one minim in rectified spirit. 192 MEDICATIONS Nitroglycerin. — Nitroglycerin, trinitrin, or glonoin, is a colorless oily liquid with a sweetish taste, very slight Ij^ soluble in water, but freely soluble in fats, oil, alcohol, or ether. Its uses are similar to those of amyl nitrite. The dose is one-half minim to two minims. Chloral Hydrate. — Chloral hydrate is prepared from chloral by the addition of water. The drug occurs in colorless crystals, soluble in an equal quantity of distilled water, 90-per-cent. alcohol, or ether. It is likewise soluble in four parts of chloroform. The dose is 0.3 to 1.2 Gm, (5 to 20 grains) in solution. While the chief use of chloral hydrate is as a hypnotic, it has been found valuable for allaying vomiting or irritability of the stomach, owing to the sedative action exerted on the vomiting centre. Bromides. — The bromides are gastric sedatives, inasmuch as they act as depressants not only on the brain and spinal cord but on the peripheral nerves. Dilute Hydrocyanic Acid. — Dilute hydrocyanic acid is an aqueous solution, a colorless liquid, faintly acid in reaction, with a specific gravity of 0.997. It is incompatible with the salts of iron, copper, and silver. It produces a peculiar sensation in the mouth and throat when taken internally; its chief use is as a sedative to the nerves of the stomach. It is employed to relieve gastric pain and allay vomiting in ulcer, and in reflex and other nervous disorders of the stomach. In all probability the greater share of the influ- ence exerted by this drug on the conditions named is ex- erted by way of the medulla oblongata. Hydrocyanic acid is speedily disseminated throughout the tissues, selecting for its action the nerve structures. The drug also acts as a cardiac sedative, especially in heart conditions resulting from derangement of the gastric function. The dose of the dilute acid is 0.1 to 0.3 Cc. (2 to 5 minims). Cannabis Indica. — Cannabis indica (Indian hemp) is prepared from the dry tops of Cannabis sativa, grown in India. Among the preparations prescribed are the alcoholic extract, dose 0.015 to 0.06 Gm. ([ to 1 grain) in pill form, and tincture of cannabis indica, dose 0.3 to GASTRIC ANODYNES 193 1 Cc. (5 to 15 minims). The drug may be used internally as a corrective of griping purgatives such as podophyllin and colocynth. Large doses produce a peculiar species of intoxication, involving disordered consciousness of person- ality, locality, and time. The local effect upon the stomach is that of a sedative. The drug is said to provoke a ravenous appetite at times. Cocaine Hydrochloride. — Cocaine hydrochloride, the salt of cocaine most frequently employed for medicinal purposes, is obtained from the leaves of the Erythroxylon coca. The salt consists of fine crystals that are soluble in half their weight of cold water and in four parts of alcohol. With water, cocaine hydrochloride forms a colorless solution, neutral in reaction; the solution has a bitter taste, causing tingling of the tongue, soon followed by numbness. The dose is 0.01 to 0.03 Gm. (i to h grain). Cocaine hydro- chloride as a local anesthetic is well known. The effect of the drug is confined to mucous membrane and the deeper tissue; the skin is peculiarly exempt. Cocaine hydrochloride may be used as a local sedative in all irritations of the stomach. In vomiting accompanied by pain it has been found extremely valuable. Gastric Anodynes. — Chloroform. — Five to six drops of chloro- form on sugar or ice is useful in the treatment of selected cases of gastralgia. Chloroform has been found not only to afford temporary relief from pain, but to arrest the course of the general disease. Chloroform water, 1 to 150, can be administered every hour in tablespoonful doses. Its action is that of a local sedative and antiseptic. Small doses of chloroform have been found capable of arresting vomiting in gastric ulcer. Chloroform may be administered con- veniently with bismuth. Orthoform. — Orthoform is a methylaminoparaoxybenzoate. It occurs in fine, whitish, odorless, tasteless powder, sparingly soluble in water, and is credited with possessing local anes- thetic and antiseptic properties. It is said to be non-toxic. Its analgesic action is manifest only when the drug comes into direct contact with the exposed ends of nerves. Ortho- 13 194 MEDICATIONS form as a local anesthetic resembles cocaine somewhat, but differs from the latter in the fact that, owing to its insolu- bility, it does not penetrate the tissues. It has been pre- scribed extensively, to be taken by the mouth, for the relief of the pain of gastric ulcer ; and the fact that it does not get below the surface, and therefore cannot relieve any but superficial pain, makes it useful as a diagnostic agent. When relief of gastric pain follows its internal administration, this fact is considered an indication of the presence of ulcer of the stomach. The internal dose is 0.5 to 1 Gm. (7 to 15 grains) in the form of a mixture. Murdoch^ reports a number of instances where orthoform was used for the relief of pain in suspected ulcer of the stomach. In one case in particular the relief was so pro- nounced as to leave no doubt of the presence of ulcer, a condition which in spite of rest in bed and liquid food for nearly two months had showed no inclination to heal. In this case not only did the painful symptoms disappear on the administration of orthoform, but the patient made a complete recovery. The same writer mentions cases in which the diagnosis of appendicitis, biliary cohc and gas- tritis had been made, and the correct diagnosis was estab- lished only after the administration of orthoform. The diagnostic value of orthoform in gastric ulcer depends upon the fact that the drug will not anesthetize nerve endings when they are covered by skin or mucous membrane. If it relieves pain in the stomach, it can do so only by coming in contact with surface denuded of mucous membrane, as in the case of gastric ulcer. Anesthesin. — Anesthesin is ethyl paraminobenzoate, or the ethyl ester of paraminobenzoic acid. It occurs as a white, crystalhne, odorless, and tasteless powder, which produces a sensation of numbness when placed on the tongue. It is with difficulty soluble in hot water, and almost insoluble in cold. In six parts of alcohol or ether it should form a clear, colorless, neutral solution. It may be sterilized in oil solutions without undergoing decomposition. Anesthesin » Medical News, October 8, 1904. DRUGS USED INCIDENTALLY IN GASTRIC DISORDERS 195 was introduced to the profession as a local anesthetic resembling orthoform in its action. It does not penetrate mucous membranes, and, being insoluble in water, cannot be administered hypodermically. It has been prescribed for the relief of pain in gastric ulcer and gastric cancer and in various forms of gastralgia. The dose is 0.3 to 0.5 Gm. (5 to 7 grains) in capsule. The drug causes good local anesthesia without irritation when applied to raw or ulcerated surfaces. Anesthesin is practically non-toxic. Taussig reports that huge doses are necessary to produce even temporary ailments in rabbits, and no untoward effects have been observed in man. Cykloform. — Cykloform^ is a local anesthetic. It has the peculiarity that it is soluble with difficulty in water, easily soluble in alcohol and ether, but insoluble in chloroform. On account of the insolubility of cykloform in aqueous liquids, its local anesthetic effect endures longer than that of cocaine or novocaine, and its systemic effects by absorption are much less. It has been used with success in gastralgia in the dose of 0.2 to 0.5 Gm. (3 to 7 grains). In the pains of intestinal tuberculosis with diarrhea it has been found valuable, relief being afforded sometimes in fifteen minutes, often within two or three hours. In the vomiting of preg- nancy it is used in doses of 0.2 to 0.4 Gm. (3 to 6 grains). Drugs Used Incidentally in Gastric Disorders. — We have a number of drugs which are used largely for their indirect effect in the treatment of gastric conditions. Atropine, the alkaloid of belladonna leaves or root, performs an important role when there is an excess of secretion. Belladonna pro- duces a slightly anodyne effect when taken into the stomach, and has been used to relieve some forms of gas- tralgia. The hypodermic use of atropine in hyperacid con- ditions was first recommended by Riegel. Owing to the fact that in order to obtain inhibition of gastric secretion the dose of the drug must be somewhat large, there is more ' Wyss, Ueber die Wirksamkeit cles C3"kloform als Anesthetikum bei Affek- tionen des Magen-Darmtraktes, Archiv fiir Verdauungskrankheiten, October 10, 1910. 196 MEDICATIONS or less danger of poisoning from the use of it. Regarding the action of atropine, pilocarpine, and nicotine, it may be said that atropine in small doses injected directly into the blood or into the salivary gland duct prevents the action of the chorda tympani, thus producing inhibition of the sali- vary secretion; it apparently paralyzes the endings of the cerebral fibres in the glands. Pilocarpine is mentioned, owing to the fact that its effect upon the secretory mech- anism is exactly opposite to that of atropine. From the minutest doses of pilocarpine we get a continuous secretion of saliva; it is supposed that the drug stimulates the endings of the secretory fibres of the salivary glands. Pilocarpine and atropine are to a certain extent physiologic antagonists. Nicotine in its effect upon salivary secretion differs from either of the other two ; it inhibits the action of the secre- tory nerves by paralyzing the connections between the nerve fibres and the ganglion cells. Schick and Tabora^ report prompt healing in some rather obstinate cases of ulcer of the stomach when the patients were placed upon a systematic course of atropine. The drug no doubt soothed and relaxed the musculature of the pylorus, at the same time exercising an inhibitory effect upon the gastric secretion. Schick recommends that atro- pine sulphate be administered morning and evening for four to six weeks, in the dosage of 0,001 to 0.0015 Gm. (liV to 4V grain) hypodermically. According to this writer, subsidence of the subjective symptoms usually followed the administration of the drug. , Atropine has been found useful also in the treatment of spastic constipation, spas- modic asthma, pylorospasm, lead colic, and cardiospasm. Eumydrin. — Eumj^drin (atropinemethyl nitrate) is the nitrate of methylated atrojjine. It is simila]' in its action to atropine, but reputedly much less toxic, and may therefore be given in larger doses. The dose internally is 0.001 to 0.0025 Gm. {i^^ to t,V grain). According to Schoenheim, of Buda]:)est, eumydrin is fifty times less poisonous than atropine sulphate, and, owing to the introduction of the ' Wiener klinisohc Wochenschrift, Vienna, August 2r\ 1910. ANTISEPTICS 197 methyl p'oup, is entirely devoid of any action upon the central nervous system. It is therefore able to act more powerfully upon the peripheral nerve endings and secre- tory glands. The influence of eumydrin upon gastric and intestinal affections was first investigated by Haas,i who reports satisfactory results from the use of the drug in the treatment of functional secretory disturbances as well as gastric neuroses. Schoenheim and Hirchler have also noted satisfactory results in gastric ulcer as well as in nervous dyspepsia and hyperchlorhydria ; there was not only a complete subsidence of the marked gastralgia, but in the majority of cases a diminution of hydrochloric acid secretion occurred. Massini^ looks favorably upon the introduction of eumydrin as a substitute for atropine, inasmuch as the latter has produced general disturbances and intoxication. The dose of eumydrin is 0.001 to 0.003 Gm. (^V to ^V grain) . Antiseptics. — Among the drugs used as antiseptics for the stomach we have resorcinol, phenol, and the salicylates. Resorcinol. — Resorcinol is a phenol derivative which occurs in white lustrous crystals with a sweetish pungent taste. It is soluble in equal parts of water, twent}^ parts of olive oil, or half its weight of alcohol. Resorcinol is essentially an antiseptic, disinfectant, analgesic, and hemostatic, being non-irritating in solutions of 2 to 10 per cent. During the last few years it has been used in the treatment of gastric ulcer in doses of 0.12 to 0.25 Gm. (2 to 4 grains) before meals, in pill or capsule. Ewald particularly recommends it as an antiferment when the patient is troubled with gas formation in the stomach. Phenol. — Phenol, or carbolic acid, is obtained by the fractional distillation of coal tar. It occurs in colorless hygroscopic crystals, soluble in 12 parts water, freely soluble in glycerin. Phenol is an excellent antizymotic. The man- ner in which it performs the function of antizymosis is not well understood. In vomiting due to a neurosis or gastric 1 Therapie der Gegenwart, March, 1905. 2 Gazzetta degli Ospitali. 198 MEDICATIONS irritation 0.03 to 0.12 Cc. (2 to 2 minims) depresses the sensory nerves of the stomach. Phenol is valuable in cases of gastric fermentation. Salicylates. — Writing on the subject of the employment of salicylates in dyspeptic conditions, Pascault^ maintains that the salicylates are sedative in their action. Applied to a fresh wound, he says, sodium salicylate sufficiently diluted will mitigate pain, reduce congestion, and arrest hemorrhage. As antizymotics, the salicylates, particularly sodium salicylate, retard the fermentation of milk in the stomach and promote its digestion. Given to dyspeptics they destroy the fetid odor of the breath as well as of the feces. Pascault, referring to the influence of the salicylates upon hyperesthesia, favors the use of sodium salicylate. The drug should, as a rule, follow the administration of a purgative in order that the colon may be kept free, inasmuch as gastric disturbances are often caused by fecal impaction. Pascault reports that in his hands the results of the adminis- tration of the salicylates have ranged from negative, in a few nervous persons whose gastric troubles were cerebral rather than gastric, to positive and lasting in the majority of other patients. This writer advocates the use of the salicylates for controlling certain reflex symptoms of gastric origin, such as flushing of the face, congestive headache, vertigo, and insomnia of gastric origin. Iodine. — Tincture of iodine is occasionally employed in the treatment of gastric ulcer, both for its anodyne effect and as a stimulus to healing. It is likewise a valuable anti- septic. Administered in drop doses, it has proved efficacious in vomiting of pregnancy that has failed to yield to other measures. Hydrogen Peroxide. — Hydrogen peroxide is prepared by the interaction of water, barium peroxide, and a dilute mineral acid, at a temperature below 50° F. It is a colorless, odorless liquid with a slightly acrid taste. Heat decomposes it into water and oxj^gen. Aqua hydrogenii dioxidi U.S. P. should contain 3 per cent, of absolute hydro- » Bulletin G('n<'Tal tic Th<''niiK'utic|iic, July HO, I'.tOT. EMOLLIENTS 199 gen dioxide. It is a powerful oxidizing agent, possessing marked disinfectant properties. Rinsing the mouth with a 1-per-cent. solution of hydrogen peroxide has been found to cause marked increase in the secretion of saliva. Internally administered, hydrogen peroxide has been found to reduce the total acidity of the secretion, especially the proportion of free hydrochloric acid. When the purpose is to reduce the acidity within normal bounds, Petri^ advises giving the dioxide like a mineral water on the fasting stomach m the morning. It should be given in the proportion of 1 to 3 Cc. in 200 to 300 Cc. of water. In hyperacidity and acid fermentation hydrogen peroxide may be used in 0.25 to 0.5 per cent, solution for washing out the stomach. The drug is useful in the treatment of hyperacidity, hyperchlorhydria, ulcer, and spasm of the pylorus. Emollients. — Olive Oil. — Cohnheim was among the first to draw attention to the value of oil in {he treatment of gastric affections. He mentions a case of probable traumatic ulcer of the stomach so painful that the patient avoided food, in which complete relief of the distressing symptoms followed the administration of a wineglass of olive oil before meals. Amelioration of symptoms from the use of olive oil has been reported even in cancer of the stomach. Satisfactory results have likewise been reported in the treatment of pyloric stenosis. Cowie^ and Munson sum up the results of their investigation of the effects of oil upon gastric acidity and gastric motility as follows : 1. Olive oil and cottonseed oil, when given in connection with the usual test breakfast, decrease the gastric acidity at the end of the hour and retard the evacuation of the stomach. 2. The beginning of the secretion of hydrochloric acid is delayed when oil precedes the meal, unchanged when oil follows the meal. 3. The height of digestion is delayed when oil is given either before or after the meal. ^ ArcMv fiir Verdauungskrankheiten, October 15, 1908, p. 479. ■^ Archives of Internal Medicine, January, 1908. 200 MEDICATIONS 4. The height of secretion is lowered when oil precedes the meal, unchanged when oil follows the meal. 5. If the progress of digestion be watched by the removal of small samples of stomach fluid at frequent intervals, it will be observed, when oil precedes the meal bj^ one-half hour, that at the end of what is usually taken as the digestive period for a test breakfast (three-fourths to one hour) the acidity is distinctly lower, while as great a height as that attending the digestion of the control meal is frequently reached some minutes later. 6. The action of oil on the stomach functions is only a temporary one. It has no effect on subsequent meals unaccompanied by oil. 7. The therapeutic value of oil is apparent. In suitable cases it is preferable to antacids because of its calorific value. In hyperchlorhydria it should follow the meal. In stasis and in persistent slow evacuation it should be eschewed. In hypermotility it may be given before, during, or after the meal. 8. Oil lowers the gastric secretion both by reflex central inhibitory stimulation and by mechanical inhibition of food stimulation — (a) by coating the food; (b) by coating the stomach wall. Cohnheim reports satisfactory results from the use of oil in the treatment of spasm, pain, and hyperacidity, as well as for increa'sing the nutrition of the body. Permanent cures have been reported in cases of spastic stenosis, fissures and erosions of the pylorus, ulcer, and gastritis. Olive oil is laxative and nutritious. During its use patients may pass lumps of white fat composed of undigested pal- mitin. In doses of one-half to three ounces it has been known to relieve obstructive jaundice. It is a valuable remedy in hepatic colic. In gallstone disease lai-ge doses, from three to five ounces, of olive oil will frequent I3' miti- gate pain, though not, as supposed by some, bring about a disintegration of gallstones. Epinephrin. — Epincphrin is a substance obtained from the su])rarenal glands of sheep or other animals. It is EMOLLIENTS 201 an alkaloidal product, slightly alkaline in reaction. The action of epinephrin is probably a stimulation of the sympathetic nerve endings. It is a powerful styptic, exer- cising a constricting effect on the bloodvessels, with a con- sequent raising of blood pressure. The dose of a 1-to-lOOO solution is 0.3 to 2 Cc. (5 to 30 minims) every two or three hours. Hypodermically the dose is 0.06 to 1 Cc. (1 to 15 minims) of a 1-to-lOOO solution diluted with sterile water. There are analogous preparations put upon the market by various pharmaceutical houses, under such names as adren- alin, adnephrin, adrin, suprarenahn, etc. AdrenaUn has been emploj'ed to arrest gastric hemorrhage in doses of 20 to 30 drops of a 1-to-lOOO solution three to four times a day. Many investigators report no untoward sequelae even when the administration of the drug was prolonged over several weeks. CHAPTER IX INDICATIONS FOR SURGICAL INTERVENTION A NEW epoch in gastric surgery opened with Billroth's first successful resection of the stomach for cancer of the pylorus on February 28, 1881, and with the introduction of Wolfler's gastroenterostomy on September 27, 1881. Since then the results have been more favorable, owing both to the better technique and to experience derived from success and failure. Important in this regard is also the fact that, owing to the more extensive employment of the stomach tube, the diagnosis of gastric disorders has become more accurate. We should not be misled by statistics on surgery of the stomach, inasmuch as the operative results of twenty years ago cannot be compared with those of the last few years. The results of gastroenterostomy following a benign stenosis of the pylorus have been so favorable that some surgeons are led to believe that all cases of indi- gestion which have resisted medicinal treatment require an exploratory incision. They apparently overlook the fact that venous congestion of the gastric mucosa caused by a derangement of the heart, lung, liver, or kidney will produce severe digestive symptoms, and that an exploratory incision without due deliberation may do more harm than good. During the last ten years the operation of gastroenter- ostomy has come into great repute, and in some quarters the opinion seems to prevail that this radical operation is a panacea for each and every form of indigestion. That experience, however, has not warranted this extreme view is emphasized by Deaver,^ who, while insisting that gastro- enterostomy is, when indicated, one of the most valuable of surgical procedures, warns against its indiscriminate ' American .Journal of the Medical Sciences, May, lUlO. INDICATIONS FOR SURGICAL INTERVENTION 203 use, especially in the various forms of gastric neurosis. There is no class of jialients more anxious to undergo oper- ation than the neurotic, especially when neurasthenia has assumed the symptoms of indigestion and abdominal pain or discomfort. There are many sad instances of men and women who travel from one gastric surgeon to another asking that the abdomen be opened and the course of the alimentary tract so changed that their sufferings may be relieved. In such cases operation is, of course, to be con- demned, inasmuch as its results, as Deaver points out, are disastrous to the patient. Indiscriminate operation has done more harm to the advancement of gastric surgery than can be well realized. It is the internist who has to deal with the case after the surgeon has discharged the patient as cured. Some of these patients are sorry-looking indi- viduals, and yet many an internist acquiesces without a word of condemnation of this sacrifice to experimentation. How absurd to accept unchallenged the assertion that most of the stomach cases coming into the hands of the internist are cases of incipient carcinoma and should be subjected to an exploratory operation! When surgical intervention is truly indicated there is no class of cases in which success is so gratifying; but, taken as a whole, less than 2 per cent, of stomach cases require surgery. The most frequent condition demanding surgery is obstruction of the pylorus, in which condition gastric retention is extreme. In severe cases food is found in the morning in the fasting stomach, often as much as three or four quarts, some of which was* taken one or more days before. The stomach endeavors to compensate for the pyloric obstruction by increased mus- cular effort. This brings about hypertrophy of the organ, which is soon followed by dilatation. Dilatation is almost invariably present when there is stenosis of the pylorus. Before operative treatment of the stomach is advised, a number of factors should be taken into consideration, the most important of which are the general condition of the patient and the condition of the vascular system, since both indicate his power of resistance. The age of the patient is 204 INDICATIONS FOR SURGICAL INTERVENTION also important. Although young people undergo a seri- ous surgical operation with better chances of recovery than older ones, no definite lines of age can be drawn. In cases complicated with diabetes, Bright's disease, or grave cardiac affection, operation on the stomach is, as a rule, contra- indicated. Indications for Gastrostomy. — The simplest operation on the stomach is gastrostomy. It is indicated in impermeable strictures of the esophagus, for the removal of foreign bodies situated so low down in the esophagus as to make their removal from above impossible, for the removal of foreign bodies from the stomach, and for the purpose of feeding. In carcinomatous strictures of the esophagus or of the cardia, gastrostomy is of doubtful value, and should be undertaken only when the stenosed part is impervious even to fluids. In such cases the first step should be to admin- ister small doses of morphine for the relief of pain and to replace mouth feeding by rectal alimentation for several days, as it is not an uncommon occurrence under this treatment for the stenosed passage to become fairly patulous. The benefit derived from gastrostomy undertaken for the relief of carcinoma is very hmited, as it consists only in the prolongation of a wretched existence for a few weeks or months. Gastric Ulcer. — A simple uncomplicated gastric ulcer does not demand surgical intervention. Only in the event of complications, or of the ulcer defying thorough internal treatment and impairing nutrition by interference with motihty, should there be any thought of surgical intervention. In the present state of the art of diagnosis we can have only a suspicion as to the seat of the ulcer. We know that three-fifths of all gastric ulcers are situated at the lesser curvature on the posterior wall of the stomach, a surgically inaccessible place. Mayo^ reports that more than 90 per cent, of all gastric ulcers are situated along the lesser curva- ture; and that those not so situated are more frequent on ' Disorders of the Stomach and Duodenum, with Sjjecial Reference to Ulcers, Boston Medical and Surgical Journal, April 0, 1911. IN GASTRIC ULCER 205 the posterior than on the anterior wall of the stomach. Unless, therefore, there is a well-developed ulcer of the pylorus which has been diagnosticated by the fact of re- tention, it is impossible to make a safe prognosis of recovery or even of improvement through surgical intervention. In eases diagnosticated as ulcer of the stomach, either the ulcer has not been found on laparotomy, or, if found, adhesions or an unfavorable position have rendered operative measures impracticable. William J. Mayo says: ''Nearly all the failures of surgery for ulcer of the stomach are to be found in the group of so-called clinical or medical ulcers, because (a) the ulcer is not found, and many times its existence is problematic; (6) the condition is often confused with pyloric spasm, atonic dilatation, gastroptosis, gastric neuroses, or other morbid non-surgical condition; (c) simple ulcer does not give rise to that mechanical interference with the progress of food which would introduce an operative indication." Munro, in a paper read before the Congress of Physicians and Surgeons in 1907, said, referring to the unsatisfactory results from gastroenterostomy in gastric ulcer: "It is wise to close the abdomen when there is no gross ulcer, no actual pyloric obstruction, or other crippling lesion." He had learned from observation of the results of many cases that gastroenterostomy under such conditions was useless. So far as surgery is advisable, no procedure but the removal of the ulcer by excision or gastroenterostomy is to be con- sidered. Such operations do not remove the cause of the ulcer nor its tendency to new formation, nor do they improve motility or reduce hyperacidity; they do remove the dangers, however, accompanying the ulcer, such as hemorrhage, per- foration, and malignant degeneration. Gastroenterostomy and favorable drainage protect the ulcer from irritation by the hyperacid gastric contents, and some ulcers w^hich have defied every kind of therapy will sometimes heal or become latent after gastroenterostomy. This operation is frequently reported to have given successful results in ulcer of the 206 INDICATIONS FOR SURGICAL INTERVENTION stomach without obstruction. In these cases, as Murphy^ has pointed out, the operation per se may not have been the positive factor in the favorable results obtained; the operator, either intentionally or not, may have folded the ulcer on itself or ligated the vessels supplying it. The one definite indication for a gastroenterostomy in gastric ulcer is for the relief of obstruction so that the food may pass from the stomach into the intestine. Ulcer of the pylorus or duodenum can be cured by gastro- enterostomy, but this operation will not cure ulcers in other parts of the stomach. Deaver and Ashhurst^ say: ''We do not wish, however, to be understood as urging surgical intervention in every case of gastric ulcer. As has already been stated, medical treatment should always first be tried, and only when methodical and energetic medical treatment has failed to cure the patient after it has been persisted in for a reason- able time, or when several temporary cures have resulted in ultimate relapses — only then, we repeat, is surgical treatment to be considered in patients with acute, actively ulcerating lesions." It is always necessary to pay special attention to the diet after stomach operations in order to achieve the most favor- able results. It is certainly surprising to observe that a patient, compelled for years to live on milk, broth, and soups is allowed at once to partake of roast beef and potatoes. It is an overestimation of surgical effect to suppose that a stomach which has been seriously impaired for a number of years can suddenly develop normal function. It is irrational to allow such a patient to get out of bed after a couple of weeks and to discharge him as cured at the end of three weeks. After the operation a careful dietary should be maintained for weeks and even months. The surgeon should be assisted in the care of such convalescents by an internist. This course, together with the simultaneous use of alkalies, constitutes the best method of avoiding the ' Boston Medical and yurgiral Journal, November 11, 1909, p. 719. ' Surgery of the Upper Alxlonicii, 1909, p. 109. 7A^ GASTRIC ULCER 207 danger of new formation, especially of ulcer of the jejunum, in which location an ulcer is apt to come as a sequela of gastroenterostomy. One of the most frequent complications of gastric ulcer is hemorrhage. Acute hemorrhage is not a condition that lends itself to surgical treatment. Such hemorrhages can usually be stopped by internal measures, and if these should fail, operative intervention is not likely to help. Less than 5 per cent, die of these hemorrhages without operation. By subjecting patients to operation we expose them to further dangers, to which they easily succumb; without operation they have a better chance of recovery. This view is shared by a large number of experienced surgeons. As a matter of fact, few cases of gastric hemorrhage have been lost when proper therapeutic measures were instituted. Lenhartz reports 201 cases of gastric hemorrhage that were given internal treatment, with a mortality of 3 per cent.; Ewald 166 cases, with a mortality of 4.8 per cent.; and Wirsberg reports 320 cases, with a mortality of 5.9 per cent. Ligation of the arteries which supply the ulcer is not to be endorsed, since non-surgical measures have been found to be more satisfactory. Should energetic internal treatment not be successful, chronic oozing of blood from the ulcer leading to anemia of a pronounced type, and daily examination of the feces with the benzidin test showing occult blood, operative treatment should be advised. Either resection of the ulcer or, where this is impossible, gastroenterostomy should be done. The latter operation frequently stops the hemorrhage, especially if the ulcer is situated at the pylorus. In pyloric ulcer, how^- ever, it is not the hemorrhage but the stenosis which renders operation imperative. In cases which do not improve after a prolonged course of internal treatment and in which pyloric obstruction is not present, it is unwise to promise recovery by means of gastroenterostomy. Surgeons agree that good results by gastroenterostomy in ulcers of the stomach are obtained only when there is a pyloric obstruction. Gastro- enterostomy does not give drainage and physiologic rest when 208 INDICATIONS FOR SURGICAL INTERVENTION the pylorus is patulous. Cannon and Blake^ have shown that food and liquids pass through the pylorus even after gastro- enterostomy has been performed. The artificial opening does not help matters so long as the pylorus is patent. The conclusions of Cannon^ bearing on this question are important. He says: ''According to physiologic obser- vations, there is no alteration of peristalsis because of a new opening being made midway in the stomach. The notion which has been expressed by some surgeons that such an opening gives the part of the stomach beyond it rest from activity is quite erroneous. If the pjdorus is not obstructed, this continued peristalsis results in forcing food through the normal exit at the pylorus. The physi- ologist has difficulty in seeing any advantage gained by this operation under these circumstances unless the passage of bile and pancreatic juice into the stomach reduces hyper- acidity, and experienced surgeons now counsel against the operation unless pyloric obstruction is present. If obstruc- tion is present, food leaves the stomach through the artificial opening, and, though the acid chyme doubtless causes a flow of pancreatic juice and bile, it may not receive a proper admixture of these juices. As a consequence, a considerable amount of the fat and the protein of the food may pass through the alimentary canal without being absorbed." Another dangerous comphcation of gastric ulcer is perfo- ration into the abdominal cavity, followed by peritonitis or by subphrenic abscess. This comphcation requires immediate surgical intervention. Perforation in Gastric Ulcer. — Statistics show that the site of gastric ulcer is, as a rule, on the posterior wall of the stomach, yet perforations occur most frequently from ulcers on the anterior wall. They break by sloughing through the anterior wall directly into the peritoneal cavity. A sudden severe burning pain in the epigastric or umbilical region is probably the first symptom of a perforation. The pain is character- istic, inasmuch as it never shoots from one i^irt of the ' Annals of Surgery, May, 190."). 2 Boston Medical and SurKical Jouinal, Xovf-iiihcr 11, I'.XI'.t, p. 722. IN PYLORIC STENOSIS 209 abdomen to another, but remains localized. Frequently it is so severe as to compel the patient to cry out, and is often followed by collapse, sudden pallor, a quick, feeble pulse, cold clammy skin, and anxious countenance. The passage of air from within the stomach into the peritoneal cavity will immediately produce an effect on the sym- pathetic nerves, resulting in shock, when, owing to the obtunded senses, pain disappears. Acute pain, fall of tem- perature, rapid pulse, vomiting, tenderness in the epigas- trium, rigidity and shock, demand immediate surgical intervention. The operation should take place within ten hours after perforation — when the mortaUty is about 28 per cent. According to statistics, the mortality rises to 65 per cent, if the operation be delayed more than twenty-four hours, and to 87 per cent, after thirty-six hours; undertaken later, operation offers no hope. The operation may be very simple for perforation at the greater and lesser curvatures and at the anterior wall of the stomach. If the perforation has taken place at the posterior wall the operation is most difficult and usually does not do any good. The statistics in perforation show such unfavorable results from internal treatment that it seems imperative to resort at once to surgery unless there are very important consider- ations to contraindicate it. Subphrenic abscess following perforation should likewise be operated upon as soon as possible. The most frequent cause of such suppuration is gastric ulcer; it is rare to find it following any other disease. The abscess may be subhepatic or retrocolic. Pyloric Stenosis. — The surgically most important com- plication of gastric ulcer is benign pyloric stenosis with subsequent dilatation of the stomach. The diagnosis is dependent upon : 1. The history pointing to ulcer. 2. Vomiting of a large proportion of the food ingested on the previous day. 3. Decreased secretion of urine. 14 210 INDICATIONS FOR SURGICAL INTERVENTION 4. The presence of food remnants in the morning before breakfast. 5. The chemic findings : hyperacidity or hyperchlorhydria. 6. The microscopic findings: sarcinse in the gastric con- tents. Benign pyloric stenosis may be occasioned by compres- sion from tumors of the Hver, the gall-bladder, or the pan- creas, by adhesions, by true cicatricial constriction, or by spastic contraction of the pylorus. The most common cause is the contraction of a cicatrix from a previous ulcer. Unless there is a critical condition, such as exhaustion, tetany or impending tetanj, or uncontrollable vomiting, we should, after having arrived at the diagnosis of benign pyloric stenosis, attempt to relieve the engorgement by rational diet (fluid and gruels) and nourishing enemata, and also by cata- plasms, irrigations of the stomach, and oil therapy by mouth. Should this line of treatment prove successful, the daily secretion of urine increasing to normal, and the patient show- ing uninterrupted improvement from week to week, with no retention even after an increased dietary, operation is not indi- cated, because the case is one of gastric congestion caused by a spastic stenosis and not by a cicatricial condition. If all other symptoms improve but there are still food remnants early in the morning after enlarging the range of foods, the operation should not be delayed, particularly with patients who, from their position in life, are not able to continually confine their diet within the required limits. In cicatricial stenosis of the pylorus the results of gastroenterostomy are excellent. A pathologic change in the duodenum similar to that in the pylorus is apt to produce the same sjanptoms of obstruction. The conditions may be various: 1. Change in the wall of the pjdorus. 2. Change in the lumen of the pylorus. 3. Change in the route b}'^ distortion. 4. Change in the route by pressure. The condition causing a stenosis which responds well to surgery is that in which there has been an ulcer and the IN ACUTE DILATATION OF THE STOMACH 211 cicatricial and hyperplastic changes have closed the lumen. Temporary obstruction of the pylorus never produces dilatation, which condition is usually found in obstruction following ulcer or malignant tumor. The Roentgenogram has been found a valuable aid in the diagnosis of dilatation of the stomach (Plates XX and XXI). The stomach in dilatation must be differentiated from a large normal stomach (megalo- gastria), and this can easily be done by examination of the stomach contents. Gastroptosis may be mistaken for dila- tation. A displaced stomach can be located an^-i^^here, even to the symphysis pubis. If the stomach empties itself at the proper time— that is, if there is no stagnation of the gastric contents — we may exclude dilatation. The operations for the rehef of benign obstruction of the pylorus are : pyloroplasty, gastroduodenostomy, gastro- enterostomy. The method and selection of the operation will depend upon the conditions at the time of operation. In the operation of pyloroplasty, adhesions may result which will fix the pyloric exit at a high level. When the muscle fibres are weak, it may be difficult for the stomach to lift the food up through the outlet (Mayo). Acute Dilatation of the Stomach. — This condition is found as a postoperative complication, and may terminate in death within thirty-six hours. Patients complain of pain in the epigastrium. The splashing sound may be elicited over the abdomen, and the stomach may fill the whole cavity. Vomiting of large quantities of dark greenish material takes place and may continue to death or recovery. The vomitus usually consists of gastric secretion, mucus, blood, and bile, seldom of fecal material. The stomach tube relieves the patient at once of much liquid and gas and pro- duces a flattening of the protuberance of the abdomen. The stomach should be washed out with one pint of normal saline, after which the patient usually makes a complete recovery. Again, there may be cases where the stomach will refill with gastric secretion and air. If after repeated lavage the patient does not recover, he should be told to lie on his stomach and endeavor to empty it as described 212 INDICATIONS FOR SURGICAL INTERVENTION on page 124. Patients should alwaj^s lie on their right side to assist in emptying the stomach contents through the pylorus. The patient may be placed in the Trendelenburg position, a stomach tube being used for drainage. When these measures fail, gastroenterostomy is indicated. Autopsy records show that in some cases of postoperative acute dila- tation of the stomach there is a kinking of the intestine above the duodenojejunal juncture or a pyloric stenosis. Gastric Tetany. — Kussmaul was the first to draw our atten- tion to the fact that in certain cases of dilatation of the stomach tetanoid spasms occur. We now know that there are several conditions of the gastro-intestinal tract which may cause convulsive attacks. Robson and Moynihan' believe that the appropriate treatment in all cases of gastric tetany is surgical. They conclude that in almost all cases there is a grave mechanical obstacle to the onward passage of food. It is this obstacle which causes dilatation and hypertrophy of the stomach. To relieve the obstruction and to prevent stagnation of the stomach contents, surgical measures are necessary. They report several recoveries after surgical intervention. In dilatation of the stomach resulting from atrophy of the muscle fibres, when the pylorus functionates normally, operation is indicated only in exceptional cases. It should be regarded as called for only after all internal therapy, such as irrigation of the stomach, diet, tonics, massage, electricity, and hydropathic measures, have proved to be complete failures. The differential diagnosis between atony and secondary dilatation following pyloric stenosis is often a difficult matter. It depends upon the objective findings and upon a history of ulcer manifestations. Gastric rigidity and pyloric tumor point to stenosis. If, in the absence of ulcer symptoms, a rational therapy relieves the dilatation, the latter was probably atonic. Hypertrophic Stenosis of the Pylorus. — Hyi)ertro]:)hic stenosis of the pylorus has been successfully operated upon in very ' Diseases of the Stomach and Tlicir Surgical Tieal incut, I'.IOI, p. lit). IN PERIGASTRITIS 213 young children. As experience in these cases accumulates we find, however, that internal treatment is often efficient and surgical intervention usually not required. An important point to remember in this connection is that we do not know how the operative result of gastroenterostomy performed upon young children will regulate itself in advancing years. In congenital hypertrophic stenosis of the pylorus, a child at birth seems well nourished, but soon begins to vomit its food. The quantity of vomited material increases from day to day; and alteration of food, modified or peptonized milk, seems to have little or no influence on the vomiting, which continues regardless of the quantity of food taken. By the use of the stomach tube we find that if there is no vomit- ing the food taken is retained in the stomach a long time. The weight of the child, meanwhile, continues to decrease and the little patient looks old and wrinkled. Constipation is usually present. The tongue and mouth are moist and clean. Upon inspection the abdomen is found to be fiat, and a peristaltic wave can be seen to pass over the stomach. Frequently the stomach contents may be outlined through the abdominal wall and the visible waves of peristalsis easily made out. An epigastric tumor points to pyloric stenosis. Regarding congenital stenosis, Deaver and Ashhurst^ state as follows: ''It is needless to say that medicinal treatment should first be extensively tried; and it is our behef that in the immense majority of cases medical treat- ment promptly instituted and energetically applied will be successful in curing the patient." Thorough internal treat- ment, as stated in the chapter on Pyloric Stenosis, failing, surgical intervention is necessary. When inflammation of the peritoneal coat of the stomach occurs, we are apt to have adhesions. Perigastritis. — In rare cases there may be an adhesion near the pylorus, predisposing to dilatation, that leads us to believe we have a case of organic obstruction of the pylorus. Morris has called our attention to adhesions in the abdomen, which he calls "cobwebs," that may cause ^ Surgery of the Stomach and Duodenum, 1909, p. 139. 214 INDICATIONS FOR SURGICAL INTERVENTION many symptoms of indigestion. When these adhesions occur around the stomach, interfering with motihty, thej^ may produce symptoms suggesting dilatation. The methods of examination mentioned in the chapter on Motor Insuffi- ciency will help us in the diagnosis. In regard to adhesions and perigastritis we are, unfortu- nately, able to make a diagnosis in only a very small per- centage of cases. Perigastritis, unless there is a distinct disturbance of motility, is rarely a sufficient reason for surgical intervention. When firm, immovable tumors can be palpated in the epigastrium, and carcinoma can be ex- cluded, the existence of adhesions or epigastric hernia may be suspected. Adhesions may or may not interfere with the motility of the stomach. Those not interfering ma}' be wisely left undisturbed, for we all know that severed adhe- sions are likely to re-form. For adhesions that interfere with gastric motility, fibrolysin by the hypodermic method may be tried (see page 414), and should this fail, the case must be turned over to the surgeon. Hourglass Contraction. — Hourglass stomach is a condition in which the stomach is divided into two cavities. It may be either congenital or acquired. The hourglass stomach, so called, is caused by perigastric adhesions or gastric ulcer. The diagnosis depends in the main upon the use of the stomach tube, when by inspection one ma}'' be able to see that the fluid introduced into the stomach through the stomach tube produces a ballooning or prominence of one part of the stomach, and that this prominence suddenly sub- sides and after a gurgling noise another swelling shows itself in the other part of the stomach. The rr-ray and bisnuith suspension afford the best means of diagnosis. The treatment of hourglass stomach is always surgical. Gastroptosis. — In gastroptosis surgeons have attempted to estabhsh normal conditions through ventrofixation, by shortening the gastrocolic and gastroduodenal ligaments and gathering up the mesocolon. My experience has taught me to withhold my approval fi'om those procedures, since I have seen so nianv instances in whicli tliev have created IN CARCINOMA 215 new troubles without removing the old. I am still of the conviction that gastroptosis should be treated altogether by mechanical, dietetic, physical and medicinal means. (See chapter on Gastroptosis.) Deaver and Ashhurst^ say that 'SSurgical treatment is rarely called for in cases of simple gastroptosis; when suc- cessful, it is rather because the stomach was dilated, and because by operation its motility is improved, than because malposition has been corrected." They conclude as follows: "Finalty, it may be well to insist again upon the impro- priety of performing any operation in the majority of cases of gastroptosis. Much comfort, indeed an almost complete rehef from invalidism, may frequently be obtained by the use of a well-fitting abdominal binder. An ill-fitting belt is worse than useless." The most rational method of treatment in cases where the ptosis has caused a kink at the pylorus or duodenum seems to be gastroenterostomy. Gastroplication is a surgical procedure to reduce the size of the stomach by folding or gathering the gastric walls. It is seldom indicated, and the results are not good. It has been used in atony and dilatation. The causes of atony and dilatation require treatment rather than the conditions themselves. Carcinoma. — Carcinoma of the stomach, when diagnosticated early, should be operated upon at once. Even if the diag- nosis be doubtful, no harm is done, in the hands of a good operator, by exploratory incision. Indiscriminate explor- atory incision brings disrepute to surgeons and no benefit to the patient. It is sad to think that among the alarmingly large number of gastric cancer cases there are so comparatively few cures to report. The reason is that we resort to operation when it is too late. The great necessity for early diagnosis of carcinoma must be emphasized. What is an early diagnosis? It is a diagnosis of carcinoma during the stage when the growth is still circumscribed and metastasis has not taken place. At this time radical operation is possible. A diagnosis of cancer 1 Surgery of the Stomach and Duodenum, 1909, pp. 176 to 178. 216 INDICATIONS FOR SURGICAL INTERVENTION in the very early stage of its growth can rarely be made. I might cite a number of cases demonstrating that we are far from being able to make a diagnosis with certainty, even with the aid of exploratory laparotomy. It may happen, as I have seen, that operation is performed at a very early stage, at the time of the fii^st manifestations of the disease, and metastases both small and large are found but no primary tumor. I have even had exploratory incision made in cases of suspected cancer of the stomach where no lesions were found, yet carcinoma with all its manifestations con- tinued to develop and subsequently proved fatal to the patient. On the other hand, there may be an occasional case with a large and apparently inoperable tumor, and at autopsy it is discovered that there are no metastases and the tumor could have been removed without difficulty. Findings which are supposed to be a safe guide for the early recognition of carcinoma are sometimes very mislead- ing. Great importance is to be attached to the history — whether there was at any time gastric ulcer, gastritis, chole- lithiasis, or whether the affection has developed insidiously. Loss of appetite, repugnance to food, eructations, vomiting, debility, decrease in weight, are points to be considered. There should be repeated examinations of the entire body and a study of the gastric functions, including tests for the absence or deficiency of hydrochloric acid and for the pres- ence of lactic acid and blood. Microscopic examination of the stomach contents should not be omitted. Special atten- tion should be paid to disturbed motihty, to the presence of food remnants in the stomach, and to the recognition of occult blood in the feces. I consider retention the most im- portant symptom and the most important indication for immediate operation when there is the slightest suspicion of carcinoma. Examination of the contents of the stomach after a long-continued fluid diet is not sufficient. The gastric contents should be examined after the ])atient has ])ar(aken for one or two days of a diet difficult of digestion, containing such foods as apples, ])lums, currants, cherries, and sausage. If after feeding the ])atient on such food gastric retention IN CARCINOMA 217 is found on examination of the stomach contents made before breakfast, interference with motiUty is certain. The secretion of hydrochloric acid and pepsin is usually decreased as the carcinoma develops, and in an advanced stage of the disease is inhibited altogether, except in carci- noma developing from gastric ulcer, when even hyperacidity may exist. The presence or absence of hydrochloric acid is significant only in connection with all the other symptoms and findings. Lactic acid is not a specific sign of carcinoma, for not only is it frequently absent in undoubted cases, but it is sometimes present when there is no carcinoma. There is no doubt that its presence distinctly points to carcinoma, but not infalUbly so. AVhen hj^drochloric acid is present, lactic acid is invariably absent. If there is persistent vomiting, which all measures fail to relieve, exploratory operation is indicated. If hematemesis and signs of pyloric obstruction and dilatation be associated with the vomiting, the indications for prompt surgical inter- vention are very definite. Surgeons demand an exploratory laparotomy in every case in which the diagnosis is in the least doubtful and in cases which do not yield immediately to internal treat- ment. The number of cases we should have to subject to laparotomy to no purpose would be very large, were we to satisfy the demands of surgeons to perform an exploratory operation in all doubtful cases. Moreover, this is much easier said than done. Patients complain of comparatively little trouble, which msiy be occasioned by an incipient carcinoma, or equally as well by a neurosis, gastritis, erosion, ulcer, gastroptosis, cholelithiasis, or by disturbed gastric function originating in disorders of remote organs. When it is considered that two-thirds of all chi'onic diseases of the stomach belong to the type of neuroses or functional disorders, we can readily understand why the internist hesitates when the surgeon demands exploratory incision. Consideration of all the points of the examination, careful observation, and in some cases rational internal treatment, are required in order that an opinion may be formed. The 218 IXDICATIOXS FOR SURGICAL INTERVENTION procedures necessary for making a posith^e diagnosis in some cases are beset with difficulties. There are two reasons in particular for this: The stomach continues to perform its normal functions for a considerable time after the initiation of the carcinomatous process; and patients, deceived by the mildness of their sjTnptoms at the beginning of the disease, object to the frequent and detailed examinations necessarj^, and in many instances will not return and submit to them. If the ailment has a tendency to exacerbation and all attempts to stimulate the appetite fail, if vomiting proves obstinate and uncontrollable and the bodj^ weight does not show an increase, we may suspect the presence of carcinoma, and are obliged to advise an exploratory laparotomy even if no tumor be palpable. If, on the other hand, there is an increase in weight of one or two pounds every week, with improvement in appetite and the patient's appear- ance and sensation of well-being, and if the luifavorable symptoms decrease, particularly the failing secretion of hydrochloric acid, we may in most cases exclude carcinoma. With all possible precautions, however, mistaken diagnoses cannot altogether be avoided. It must be admitted further that, while exploratory laparotomy is no longer a serious operation, it is not entirely free from danger. If we advise exploratory laparotomy when the manifestations of disease are slight, the majority of patients will not submit, and if after such refusal a course of internal treatment is instituted and the patients recover we shall subject ourselves to many unjust reproaches. An important point to remember is that upon examining an opened stomach it may be very difficult for the surgeon to interpret correctly the traces of a possible old ulcer or other finding. What he may judge to be benign frequently proves to be malignant, and what seems to him malignant may be benign. Carcinoma at the fundus and body of \ho stomach generally manifests itself only at a time so late in its develop- ment that radical operation can offer little hope. Successful resection can only be hoped for in carcinoma of the pylorus IN CARCINOMA 219 and of the lesser curvature, the latter encroaching upon the pylorus at an early stage. These cases constitute about 50 per cent, of all cases of gastric cancer. When resection is possible it should always be done. The size of the tumor is no contraindication, so long as the stomach is large. An important question to consider is, whether an operation is justifiable when there are metastases though the cancer in the stomach is of such a character that it can be removed; and whether in such a case gastroenterostomy or resection should be the chosen operation. Though the results of gastroenterostomy in cases of benign pyloric stenosis are good, in cancer they are, with few exceptions, sadly deficient. The average success with a gastroenterostomy in cancer con- sists in the prolongation of life for six months. Experience shows that resection gives better results. In cases with slight metastases resection should be given the preference, if pos- sible, over gastroenterostomy. With the present improved technique it is possible to perform a complete resection in one to one and one-half hours. Gastroenterostomy is indicated only in pyloric carcinoma with retention when resection is no longer possible. If there is the slightest doubt as to the benign character of the pyloric stenosis, resection of the pylorus is indicated. The mortality in resection, according to the statistics of various prominent surgeons, is between 6 and 28 per cent., or an average of 17 per cent. The average duration of life after a resection is from sixteen to eighteen months. William J. Mayo, at the 1909 meeting of the American Gastroenterological Association, said, regarding cancer of the stomach: "1 think it was a great mistake when Koenig said that patients with cancer of the stomach who had a palpable tumor were incurable. We have one such patient who has survived a gastrectomy five years, and some others three or four years, and we do not consider a movable tumor necessarily a contraindication to operation. Obstruc- tion and a movable tumor, one or both, indicate surgical consultation." CHAPTER X ALTERATIONS IN THE POSITION OF THE STOMACH AND OTHER ABDOMINAL ORGANS: GASTROPTOSIS — ENTEROPTOSIS— NEPHROPTOSIS— HEPATOPTOSIS— SPLENOPTOSIS Gastroptosis, a term for which we are indebted to Glenard, is so frequently compUcated with displacement of the other abdominal organs that it may be considered conveniently under the heading of Enteroptosis. Separate names have been given to the downward displacement of abdominal viscera, among which we have gastroptosis, referring to downward displacement of the stomach; coloptosis, or downward displacement of the colon; hepatoptosis, spleno- ptosis, nephroptosis, enteroptosis, referring respectively to downward displacement of the liver, spleen, kidney, and intestine. The etiology and clinical manifestations of these condi- tions, as well as their treatment, are so similar that they may be considered with advantage together. Much has been written on the subject by both American and Euro- pean authors, notably Virchow, Glenard, Landau, Langer- hans, Kuttner, Ewald, Stiller, Boas, and Meinert, abroad; and Einhorn, Hemmeter, Bettmann, Lichty, Stockton, Webster, Steele, Lockwood, Roosing, Dyer, McPhedran, Kellogg, Robinson, and Spivak, in this country. Etiology. — Enteroptosis is a condition frecjuently met with in patients who consult a physician in regard to digestive disturbances. It is a disease of comparative!}' young adult life, appearing soon after puberty; it is rarely mot with in patients over fifty years of age. Females are particularly disposed to enteroptosis. Prob- ably the greater munbor of cases are lo bo found among Ihe working classes. ENTEROl'TOSIS 221 Fit:. 24 Forms. — From the viow-poiiit of etiology two different forms of enteroptosis are to be distinguished. The first is the result of causes acting mechanically, the principal etiologic factors being improper modes of dress, trau- matism, frequent childbirth, and tight lacing; all these causes are aided by poor nutrition and severe physical toil. This form of enteroptosis comprises a com- paratively small number of cases. Fre- quent pregnancies, by bringing about a condition of relaxation of the abdominal wall and of the recti muscles, producing thereby a pendulous abdomen, are re- sponsible for many of these cases of en- teroptosis. It has been shown repeatedly that tight lacing is productive of down- ward dislocation of the intestine. The removal of large abdominal tumors, and frequent paracenteses in order to free the abdomen of ascitic fluid, are also etiologic factors in enteroptosis. Organic diseases in general may like- wise lead to ptosis of the stomach. The causal relation between trauma of the abdomen and displacement of the kidney is well known. The second form of enteroptosis is due to a constitutional hereditary pre- disposition. Thanks to the researches of Stiller, more is understood of this variety of downward displacement than formerly, and his views are now almost universally accepted. According to this writer, in 90 per cent, of cases of entero- ptosis the abnormal position of the abdominal viscera is quite a distinct form of the physical conformation. Stiller speaks of universal asthenia of a congenital nature, or, as he calls it, ' ' habitus enteroptoticus " (Fig. 24) . Patients suffering from Habitus enteroptoticus (asthenia universalis). 222 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS this weakness and from the characteristic bodily form are apt to develop into neurasthenics. The condition of entero- ptosis is often complicated with gastric and intestinal atony and nervous dyspepsia. A well-marked case of habitus enteroptoticus presents a complex of symptoms, namely, those of enteroptosis, gastric atony, and nervous dyspepsia. This complex of symptoms has been designated general asthenia. These three affections are not always present, however, in the same degree of intensity. Enteroptosis gives rise, as a rule, to the most pronounced symptoms. The mechanical causes mentioned above would not, in all proba- bility, give rise to enteroptosis were the patient not pre- disposed to this condition b}^ the habitus enteroptoticus. Hence it may be concluded that enteroptosis from purely mechanical causes is a rare condition. Pathology. — Gastroptosis does not impl}^ a faUing or down- ward displacement of the entire stomach. On account of the attachment of the stomach at the cardia it is impossible for the displacement to be complete; when we speak of gastroptosis, a descension of the pylorus and that part of the stomach directly in front of the vertebral column is impUed. With the downward displacement of the pylorus there is Hkely to be a stretching of the stomach from the cardiac orifice toward the pylorus. Several abnormal con- ditions enter into the development of both gastroptosis and enteroptosis. For example, the ligaments and mesentery may become relaxed, thus permitting a displacement of the organs attached to them ; or the intra-abdominal equilibrium may be disturbed by alteration of the intra-abdominal pressure upon which it depends, and enteroptosis result. Symptoms. — Many patients with habitus enteroptoticus which has developed into pronounced enteroptosis do not experience any distressing symptoms whatever. The same may be said of those whose enteroptosis is the result of purely mechanical processes. On the other hand, many patients have been relieved of the distressing symptoms accompanying enteroptosis without correction of the ana- tomic disj)lacemcnts. It may be inferred from this that ENTEROl'TOSIS 223 entei'optosis in itself does not jiroduce any marked disturb- ance or discomfort to the patient. A long-continued me- chanical support will not permanently restore the stomach to its normal position. Steele and Francine,^ after a year's work investigating these conditions in the medical dispensary of the University of Pennsylvania, found that in all cases examined after a year of constant mechanical support the stomach (unsupported) was in exactly the same position as when first examined. According to Stiller, the constitutional neurasthenia of enteroptotics is responsible for a great many of the distressing symptoms ascribed to enteroptosis itself. The displacement merely aggravates the neurasthenic effects, or perhaps in some instances initiates them by the con- tinuous traction of the displaced viscera on the ligaments, thus placing the abdominal sympathetic nervous system in a condition of continued reflex irritation. Atony of the stomach and intestine, a frequent accompaniment of well- marked ptosis of these organs, is productive of many untoward symptoms. Patients complain of a variety of nervous manifestations, such as lassitude, dull headache, inability to work, mental depression, and general weakness. The gastric symptoms consist of pressure, fulness, nausea, and belching; occasionally pain is felt in the region of the stomach. These gastric symptoms are all due to the atonic condition of the stomach. Indications of nervous dyspepsia are also in evidence as burning sensations in the stomach, hyperacidity, and vague discomforts after eating. The ap- petite is, as a rule, poor, though on rare occasions patients have ravenous appetites. Enteroptosis is often accompanied, in women particularly, by severe backaches. Objective Symptoms. — The objective symptoms in cases of well-marked habitus enteroptoticus are very characteristic. The patients, as a rule, are tall in stature, with long arms, thin neck, narrow, elongated thorax, and long, flat abdomen. The habitus enteroptoticus impresses the observer at first as being similar to the habitus phthisicus. The bony structure is shght, the muscles are weak, and there is a marked diminution in 1 Medical Society of Pennsylvania, September 24, 1903. 224 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS the adipose tissue which gives grace to the physical appear- ance. Enteroptotic patients, as a rule, look pale and give the impression of being ill. Their spirits are usually de- pressed. Characteristic alterations of the thorax belong also to the habitus enteroptoticus : the thorax is long and narrow, and the shoulders slant downward. The epigastric angle is markedly acute. The intercostal spaces are sunken and the abdominal walls are thin and flaccid. The distance between the umbilicus and the ensiform cartilage is greater than in a normal person. The epigastric region is sunken when the patient stands erect. The abdomen, however, below the navel protrudes in consequence of the weight of the descended abdominal viscera (Fig. 24). There are frequently found broad spaces between the recti muscles. During respiration the lesser curvature of the stomach will be discerned at times and may be outlined beneath the thin abdominal wall. A special feature of the habitus entero- ptoticus, according to Stiller, is a movable tenth rib, which is shortened and freelj^ displaced in consequence of the absence of the cartilaginous attachment. This fluctu- ating rib, known as Stiller' s sign, is present in about 70 to 80 per cent, of cases of enteroptosis. Many writers, however, consider the presence or absence of this sign of doubtful diagnostic value. In female patients it is possible at times to palpate the abdominal aorta and to ascertain strong pulsation on but slight pressure. Stiller considers the ease with which the abdominal aorta ma}^ be palpated as a sign of neurasthenia; the condition, he says, is due to a dilatation or paralysis of the vessel wall brought about by reflex causes. The celiac plexus, which is located on the anterior surface of the abdominal aorta in the epigastric region, is not infrequently very sensible to pressure; this condition is also considered suggestive of neurasthenia. Diagnosis. — Gastroptosis is recognizable by means of inflation of the stomach, auscultatory percussion (Bene- dict), gastrodiaphany, and tiio .r-rays. Three degrees of gastroptosis are noted: NEPIIROPTOSTS 225 1. The greater curvature is situated wholly above the umbilicus. 2. The greater curvature is situated below the umbilicus with the lesser curvature above it. 3. The lesser curvature is situated below the level of the umbilicus. Hyperacidity is found more frequently in ptotic stomachs than is subacidity or achylia. Ptosis of the intestine may be recognized by means of auscultatory percussion, inflation through the rectum, or the x-rays. It is, as a rule, associated with chronic constipa- tion, which is due in large measure to deficiency in the tone of the abdominal muscles. Membranous enteritis is occa- sionally present. Nephroptosis. — Displacement of the kidneys is frequently found in enteroptosis — is often, indeed, a pathognomonic sign. The right kidney is usually the one affected. The terms movable kidney, dislocated kidney, wandering kid- ney, floating kidney, prolapsed kidney, and nephroptosis have been applied to a variety of renal displacements. Movable kidney is said to be five or six times more fre- quent in women than in men. Both kidneys movable is a condition observed almost exclusively in women. Inasmuch as movable kidney implies enteroptosis, it is of the utmost importance to diagnosticate the condition. The diagnosis is always made by palpation. The correctness of the result depends, of course, on the degree of technical skill applied in manipulation. Every physician can acquire the art of palpation by careful study and practice. One hand is placed on the back, over the lumbar region, and the other on the abdomen; bimanual palpation is always necessary. The cloth- ing should be removed and the palpating hands brought in direct contact with the skin. The abdomen of the patient should be relaxed as completely as possible before the exam- ination. The hands of the physician should be placed flat, one on the back and one on the abdominal wall. Severe press- ure with the fingers should be avoided. It is best to begin softly, allowing the pressure to become gradually greater. 15 226 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS The palpating hands should be warm, smce cold hands cause contraction of the abdominal muscles and prevent deep manipulation. In eases where the tension of the abdominal walls is too great, chloroform narcosis may be employed. This is, however, rarely necessary. The physician may often feel the kidney slide from under his hands; its smooth surface and distinct outline are very characteristic. In pal- pating for movable kidney the patient is placed in three different positions: 1. Standing while the manipulator sits on a chair. 2. Lying on the back while the manipulator sits on the edge of the couch. 3. Lying on either side, according to which kidney is being palpated, while the manipulator sits. First position (Fig. 25). This is the most important position for palpating a movable kidney, since it per- mits the maximum displacement, and the kidney is there- fore easily felt. Begin by superficial pressure, and later use deeper manipulation. Superficial pressure reveals the resistance in the abdomen while the abdominal muscles support the viscera, and the hands soon differentiate between the natural and the artificial support of these muscles. Deep palpation in this position is of great impor- tance, since frequently the kidney can be held in the hand. With one hand on the lumbar region the whole abdomen must be explored with the other, as a movable kidney may be displaced anywhere from its normal position, even as low as the symphysis pubis. The pecuUar shape of the kidney, its smooth characteristic feel, and the way it slips from the hand under the ribs will make it easily recognizable. When a kidney is in normal position it moves slightly during respiration. A normally located kidney cannot be palpated. When one-third of the kidney can be palpated the condition is spoken of as displacement of the first degree ; when one-half is palpable, displacement of the second degree ; when the whole kidney is palpable, displacement of the third degree. The same procedure sliould \)e followed out in palpating the kidney on either side. On account of their NEPHROPTOSIS 227 close attachment to the diaphragm, the Hver and gall- bladder move during respiration. Care should be exercised lest they be mistaken for the kidney. Fu;. 25 First position for palpating movable kidney. Second position (Fig. 26). In this position the patient lies on his back, with the shoulders raised and the legs slightly flexed. One hand of the physician is placed on the lumbar region and the other flat on the abdomen, below the costal margin along the outer border of the rectus muscle. The patient should be instructed to take a deep, slow inspiration, when the kidney, if movable, may be felt between the hands. The kidney naturally drops back to its normal position when the patient lies on his back, for which reason it is wise to resort to other positions in order to confirm the diagnosis. 228 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS Usually mobility of the third degree is best made out with the patieut in this position. Third position (Fig. 27). The patient should lie upon the side opposite to that to be explored. The shoulders should be thrown forward and the thighs shghtly flexed. Fig. 26 Second position for palpating movable kidney. Fig. 27 '''iiiii:iiiiniiiiiiiiiiiiiiiiii!iii!'-iii!iiiiiiiiiiiiiiiiiiiiiiiiiiii)iiin:iiiiii)ii))iiiiiiii)ii':" Third i)ositioii for palpating movable Uidncy. The physician should sit on the edge of the couch. One hand over the lumbar region and the other over the abdomen will bring the kidney between the two hands. To bring it lower, should it be movable, the patient is instructed to take a deep inspiration, when the diaphragm will force it downward; then during expiration it can l)e held firmly between the hands. The slightest relaxation of the hand TREATMENT OF ENTEROPTOSIS 229 will permit the kidney to slip away from between the fingers, which is characteristic of no other organ. Hepatoplosis. — Hepatoptosis, dislocation of the liver, is of frequent occurrence (Einhorni), and when overlooked may give rise to diagnostic error. Landau believes that hepatoptosis originates from the same cause as nephroptosis. Glenard found in two-thirds of his cases of hepatoptosis that nephroptosis was also present. Hepatoptosis with hepatic colic is frequently mistaken for cholelithiasis. Abnormal positions of the spleen are rarely found. Prognosis. — The prognosis for permanent replacement of the displaced organs is, as a rule, not good. A ptotic stomach remains so. The distressing symptoms accompanying the condition may, however, be entirely removed or greatly ameliorated so as to permit patients with congenital habitus enteroptoticus to pass the remainder of their lives in com- parative comfort. Prophylaxis. — -Prophylaxis, so far as the mechanical causes of enteroptosis are concerned, consists in keeping patients in bed for a longer time after childbirth, reinforcing the abdominal muscles by abdominal bandages, and strengthen- ing the muscles by massage. By these measures much of the muscular relaxation of the abdominal wall following child- birth may be avoided. Properly fitting corsets are a valuable prophylactic agency. The habitus enteroptoticus may some- times be recognized in young subjects by their peculiar physique and weak stomach. In such subjects, marked departure from the normal may be retarded by suitable preventive treatment in spite of the existing predisposition. Treatment. — The treatment of gastroptosis and enteroptosis should be directed toward improvement of the general nutrition, in order to counteract the neurasthenia and to strengthen the muscles of the abdominal walls. Diet. — Patients who are poorly nourished must be well fed. The diet should be as nutritious as possible; it should contain a large proportion of fat. Milk, cream, and butter are among the most suitable articles of food for this con- 1 Floating Liver and its Clinical Significance, Medical Record, September 16, 1899. 230 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS dition. The nutrition must be governed almost entirely by the requirements of the individual case. The motor and secretory powers of the stomach should always be con- sidered in prescribing diet. Sometimes it is necessary to resort to "forced feeding," by which we mean hypernutrition. It is well, however, before attempting systematic hypernutrition, to ascertain the actual powers of assimilation of the patient. In de- termining the status of a patient's nutrition, two factors must be borne in mind — first, the condition of the protoplasm (muscles and blood), and secondly, the amount of fat present. The protoplasm is estimated from the muscular mass. A person with weak muscles, as a rule, suffers from deficiency in nutrition. An attempt should be made to strengthen the weak muscles of these patients by hypernutrition, and thus bring about an improvement in the quality of the blood. Fat should constitute 18 to 20 per cent, of the total body weight of the adult male, and 25 to 28 per cent, of the weight of the female. It is necessary, then, for the physician to esti- mate as well as he can the quantity relation between adipose tissue and muscle. In certain diseases the presence of what might be termed an excess of fat is not an undesirable feature, while in other ailments it is desirable that the amount of fat be less than in the normal individual. In gastroptosis and neurasthenia it has been found advisable to keep the nutrition up to the highest possible point, and that patients do better when the amount of adipose tissue is above the indicated percentage for their body weight. In pursuing a course of hyperalimentation it is an advantage to know the quantity of nutriment required by each patient in order to maintain his particular body weight. The fol- lowing values have been calculated for this purpose: , Calories per kiloKniininc hotly 'J'lic patioiit requires weight for the twenty-four liours. 1. When kcpL in bed 30 to 35 2. When confined to the room 32 to 35 3. When emploj'ed ;il hght labor 35 to 40 4. When i*nii)li)yed at niediuin physical labor . 40 to 45 5. When employed at hard labor 45 to 50 TREATMENT OF ENTEROPTOSIS 231 A diet corresponding to the above table is designated a "sustaining diet." Such a regimen, it will be seen, will vary- in the same individual, depending upon the question of rest or physical activity. Before beginning the so-called hyperalimentation cure it is necessary to ascertain the sustaining diet for the patient. This may be easily accomplished by referring to the standard tables of food substances, which give the exact percentages of protein, fat, and carbohydrates in the food, with the calorific value of each. It should be remembered that one gramme of protein furnishes 4.1 calories, one gramme of carbohy- drate 4.1 calories, and one gramme of fat 9.3 calories. Atwater has given much attention and study to the heat values of various food substances. His figures are somewhat lower than those of the older investigators. According to Atwater : 1 Gm. of protein fui-nishes 4 calories. 1 Gm. of carbohydrate furnishes 4 calories. 1 Gm. of fat furnishes 9 calories. The calculation of the food value of dishes complex in composition should be entered upon with great care. An exact knowledge of the composition and food value of soups and farinaceous foods is necessary if the physician is to avoid error in dietary prescription. When it is desired to ascertain the exact condition of undernutrition of a patient, the food should be carefully weighed and estimated in calo- ries and the result compared with the sustaining diet of that particular patient. Should the amount of food ordin- arily ingested by the patient be less than the sustaining diet, the condition is one of undernutrition. It is customary to speak of slight undernutrition when the difference be- tween the sustaining diet and the actual food taken by the patient amounts to 20 per cent. ; of medium undernutrition when the difference is 20 to 40 per cent. ; of high grade under- nutrition when the difference is 40 to 50 per cent. Hyperalimentation. — Hyperalimentation consists in the inges- tion of certain quantities of nutritive material in excess of 232 ALTER ATIOXS IX POSITIOX OF ABDOMIXAL ORGAXS the amount of the sustaining diet. This added nutriment is known as the food surplus. "VMien the calorific value of the sustaining diet is thus increased to the extent of 30 to 40 per cent, the h\'peraUmentation is designated "medium." Von Xoorden has calculated the probable increase in weight during a course of hj-peralimentation as follows: Daily increase in food. Weekly increase in weight. 500 to 800 calories jield 600 to 1000 Gm. 800 to 1200 calories yield 800 to 1200 Gm. 1200 to 1800 calories jield 1200 to 2000 Gm. It has been demonstrated that the essential increa.se in weight is not obtained by hyperalimentation alone. Con- siderable quantities of nitrogen in combination are retained in the body. It is estimated that there is a retention of from 1 to 3 Gm. of nitrogen dming a medium food addition per day. According to von Xoorden the retained protein does not enter into the formation of protoplasm proper, but is deposited in the cells as the so-called reser^-ed protein. This deposited protein does not, however, possess the ^'irtue of U\dng protoplasm, and is, therefore, rapidly lost on the cessation of the food cure. The muscle tis.sue under certain favorable conditions is capable of making use of the deposited reserved protein for muscle prohferation. One of the best means for increasing the amount of muscle tissue is s\'s- tematic muscular exercise. If the patient can be persuaded to take regular muscular exercise during the food cure a marked increase in flesh will result. Of the total number of calories represented in the added food in a com-se of hj-pernutrition, 8 per cent, is used up for purposes of digestion and assimilation; about 4 per cent, is lost in the feces; and 10 per cent, is stored up as protein. The remaining 78 per cent, is assimilated as fat. It has been demonstrated that muscular activity develops the muscles. This would seem to be in opposition to the food cure as outlined b}' those who first made use of it. Weir Mitchell and Playfair insisted upon having their patients maintain the recumbent position. But one's cases TECHNIQUE OF NUTRITION 233 must be differentiated. Some are too weak for exercise, or the condition of the digestive system may require absolute quietude. It is, moreover, advisable that every patient be put to bed for the first eight days at least when undergoing the so-called food cure. This will accustom him to the regular adminis- tration of food and hkewise reduce the combustion pro- cesses to the lowest possible degree. The radiation of heat is diminished and its retention favored by complete rest. Many writers, however, prefer that patients should undergo active muscular movement as soon as there are signs of increase in weight during the first week. The slight loss of weight which may result from this muscular exercise is soon compensated by the marked increase in appetite which follows the bodily activity. In selected cases von Noorden prescribes daily gymnastics of one hour, beginning with the second week of treatment. During the third week such patients climb an inclined plane, such as a hill, to the height of 250 meters, and in certain cases the exercise prescribed consists of rowing and swimming. The muscular exercise should be so arranged as to avoid undue fatigue. The con- dition of a patient after a course of hyperalimentation com- bined with muscular exercise will be much more vigorous than if the exercise had been omitted. Technique of Nutrition. — The diet should not consist of pro- tein substances alone. Their calorific value is more than offset by the difficulty with which they are assimilated. From 12 to 15 per cent, of the energy afforded by a protein diet is lost in digestion, as compared with the 8 per cent, waste from a mixed diet. Protein increases com- bustion. In the sustaining diet the daily quantity of pro- tein is about 100 Gm.; in hyperalimentation it should be between 100 and 120 Gm. This amount of protein is found in the ordinary mixed diet. Protein may be administered in any form, such as the lean varieties of meat, fish, or fowl. Fat has the disadvantage, as compared with lean meat, of more quickly satisfying the appetite or exciting a distaste for animal food. The portion of meat should not 234 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS be SO great as to prevent the ingestion of other nutriment. Nervous patients should not receive too much meat; for this class of patients, eggs should be freely prescribed, as well as cheese and milk. The artificial protein preparations are also worthy of consideration here. Casein preparations are especially useful in cases where the amount of food the patient is able to take is small. Von Noorden prefers those preparations in which the casein is soluble, such as somatose and a preparation of easily digestible albumoses made from fish; the latter, designated '^riba, " contains 95 per cent, of protein, and 60 to 80 Gm. may be administered per day. This quantity is almost entirely absorbed. Fat, as akeady intimated, is the most valuable article of diet in the food cure, owing to its ver}^ high index of com- bustion. At least 200 Gm. per day should be tenta- tively prescribed. Patients often consume with ease as much as 250 grammes of fat during the twenty-four hours. It is well to have some standards to the quantity of fat to be consumed daily during the course of the food cure or hyperalimentation. Von Noorden suggests the following daily regimen: 200 Gm. butter = 160 Gm. fat = 1490 fat calories. 1 liter of milk = 33 Gm. fat = 307 fat calories. 300 Gm. cream = 7.5 Gm. fat = 698 fat calories. The total amount of calories yielded by the fat in this diet is 2495. Not every patient is able to partake of this quantity of fat. Cream in such large amount is apt to produce disturb- ances which destroy the appetite. It is possible, neverthe- less, in constructing a dietary with fat as a fixed basis, to attain a high calorific value. Fat should be prescribed either as liquid or in a form easily reduced to liquid, such as but- ter, milk, yolk of egg, rich cheese, and chocolate. The resourceful chef or housekeeper will find many ways in which these articles may be worked up into a variety of tasty dishes. Butter may be taken by itself or may be made an ingredient of gravies, so that as nuich as 200 grammes per day may be easily ingested. The calorific value of milk may be increased by adding cream. Coffee, tea, TECHNIQUE OF NUTRITION 235 or milk soups may be administered with milk, according to the taste. Kefir and Yoghurt milk are also useful. Milk may be concentrated by boiling. There is also to be obtained milk in powdered form which may be added to the food. Some clinicians, in cases where patients show much emaciation, restrict the amount of protein during the first few days of hyperalimentation and administer instead a milk-cream mixture in such quantities as would be equivalent to the sustaining diet. When the patient gains in strength the proper proportions of protein and carbohydrates may be added. Great precaution is necessary in the administration of the fat diet lest patients acquire a distaste for it. In order to obtain the benefits of hyperalimentation it is necessary that large quantities of fat enter into the dietary and that the patient continue thereafter to be a large consumer of fat. It is only in the presence of active infiammiation in the stomach or small intestine that fat can possibly produce any deleterious effect. The carbohydrates, owing to the fact that they permit of rich variety in food, form important elements in the food cure. They also render unnecessary the prescribing of protein. Carbohydrates in the hyperalimentation cure are capable of being absorbed to the amount of 180 grammes per day. Von Noorden increases this amount to 300 grammes and over per day. Carbohydrate foods may be used as vehicles for butter, eggs, or milk. The carbohydrate carriers usually employed are wheat bread, biscuits, zwie- back, milk soups, oatmeal, cereals, and breakfast foods. Thick soups are best taken early in the morning and during the evening meal rather than at noon, owing to their satiating qualities. Von Noorden recommends oatmeal porridge, or hominy made from corn, to be eaten with cream. Vegetables such as potatoes should be given in the form of puree with large quantities of fat. Many patients are particularly fond of chocolate, which may be taken with or without cream. Sugar and fruit juices may be prescribed. Von Noorden favors the prescribing of unfermented grape juice, which is very agreeable to the patient. The malt preparations, such 236 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS as malt extract, are acceptable to many patients; thej^ pos- sess some carbohA'drate value. Alcohol is considered by some authorities as possessing food value. It is, however, of but little importance as an element in the food cure. Undoubtedly the effect of alcohol upon the nervous system more than offsets any virtue it may possess as a food, ^lien it is deemed advisable to use alcohol, not more than fifty cubic centimeters should be given a day, and then only in the form of a light wine with a raw egg. Erb recoromends Vial's tonic wine, which contains meat extractives and bitters, in the dietarj^ treat- ment of neurasthenic patients. All dietary regulations should be made with due regard to the secretory and motor conditions of the stomach according to the directions laid down in the chapters dealing with secretory and motor derangements. Before a food cure is instituted it is necessary to know whether achylia, sub- acidity, normal acidity or hyperacidity is present, and also the condition of gastric motilitj^ Under favorable conditions the food cure maj^ be carried on at the home of the patient. Better results, however, are obtained when patients are prevailed upon to leave their home surroundings and enter a well-managed hospital or a sanitarium where special attention is given to the diet- etic treatment of disease. Those who require the food cure suffer, as a rule, from nervous exhaustion and overwork, and often from physical and mental collapse. They should be placed in a well-conducted institution, preferably in the countiy, as far removed as possible from the conditions surrounding their daily routine, and kept there for a consid- erable period. Much is achieved with this class of patients by surrounding them with salutary mental influences. The mental influence which the phj'sician may be able to exert over his patient has an important bearing upon the success of the treatment. An endeavor should be made to inspire the patient with hope, and to overcome as far as possible his prejudices. Once the patient's weight begins to increase, and hope and confidence are established, there are usually few if any TECHNIQUE OF FOOD CURE 2H7 serious difficulties to overcome. The patient should be educated to the nature of his disease; he should understand that improvement will be gradual and will depend largelj^ upon his habits of living and his mental attitude for its permanency. According to von Noorden, the patient must be educated to become a big eater of fat. Often within a few weeks after the cessation of the rest cure, patients relapse into their former condition, owing to the fact that they have neglected to continue the cure by themselves. This class of patients thrive best when in personal contact with the physician in a sanitarium, rather than at home and at the mercy of unreasonable friends and relatives. The physi- cian in the hospital or sanitarium should have the assistance of a competent chef, capable of carrying out intelligently his instructions. ^^^ ^"^^ '-'' Technique of Food Cure (Boas).— In carrying out the so-called food cure, patients should be confined to their beds for a period of at least four or five weeks, during which time a varied diet should be supplied, nourishment being given every two or three hours. Instead of the large quantities of milk that were at one time prescribed, patients will do better if given one-half to one liter of cream daily in doses of 150 to 200 Cc. The diet of the rest-cure patient should be rich in carbohydrates and fat. Constipation may often be counteracted by adding to the diet such articles as honey, marmalade, preserves, buttermilk, sour milk, or kefir. Boas does not strongly favor massage and faradization as adjuncts to the rest cure, maintaining that any effect from these agents is of necessity psychic. 7 o'clock: ^iKXfU\ , .,"- \ liter Vigor chocolate in cream. ^— \y^'^ ^ "'" 3 to 4 zwieback (2 rolls), 2e-te-30-GHi. butter. ^r\ 9.30 o'clock: Cold or warm meat, eggs, egg foods, light or white bread (perhaps Graham bread), 26 Gm. butter. "-^ \W^' 150 Gm. cream. ' Sweet preserves (stewed fruit). Farinaceous foods. 1 to 2 glasses of- eider, grape juice, or fruit wine (perhaps also some raw fruit). 238 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS 12 o'clock: Yj^^^ ^ W:;^, 150 Gm. cream. 3" I I 2 or 3 biscuits (crackers). 2 o'clock: iJiter soup. ' Vegetables and potatoes in puree form. Meat and fish. Salad. Stewed fruits (sweet). 4.30 o'clock: -"■: ^77 Coffee or tea (150 Gm.) with cream. "~ ' Zwieback, cakes, Graham bread, butter C20 Gm.) or honey. ^~ 8 o'clock: Cold or warm meat or fish. Eggs or egg foods. Light bread, Graham bread (30 Gm.), butter. Stewed fruits. kT^vA* 2 glasses of fruit wine or 1 bottle of malt beer. 9.30 o'clock: -rf l ' V ^^ 20e-€^m. cream wdth 2 or 3 crackers. Lc»-vCL VKUM] The purpose of the so-called food cure is not to render patients corpulent. The increase in weight should be made to correspond to the weight of the person in a condition of health, taking into consideration his size and hereditary constitution. Proper attention throughout the food cure should be paid to the matter of increasing muscular power. The need is apparent for systematic muscular exercise. Patients should be permitted a certain amount of mental activity, such as reading, which keeps them from dwelling upon their ailments. Hydrotherapeutic measures may be instituted and carried out in conjunction with the food cure; they should be limited, however, to methods of a stimulating and invigorating character, ^'^on Renvers recommends, in asthenic conditions of the heart muscle, systematically performed respiratory gymnastics, to be car- ried out several times a day. The muscles of the body may be stimulated by dry rubbing of the skin with rough towels. The anemic condition of the patient is often overcome during the food cure by the muscular and res]iiratory exercises. Arsenic in the form of Fowler's solution ]){)ssesses some TECHNIQUE OF FOOD CURE 239 virtue as a hematinic. Arsenic has been found to have an antihemolytic effect. Both the arsenite and the arsenate of sodium defend the red blood corpuscles from the action of certain hemolytic agents. Arsenic is indicated in anemic conditions that result from pathologic derangement of the medullary substance of the bones. In genuine chlorosis, iron should be administered hypodermically. All patients suffering from enteroptosis recjuire iron in some form. They cannot take it internally, owing to its irritating effect upon the gastric mucous membrane. This may be over- come by hypodermic medication. Of all the iron prepara- tions, ferric citrate has been found best for hj^^odermic use; as a reconstructive hematinic it is probably the best form of the metal. Iron supplies the deficiency in hemoglobin. The iron compounds are indicated in all cases of anemia. Combined with arsenic, iron acts as an alterative, and the compound may be used in all cases of cachexia and in all anemias. A pill made up of iron, arsenic, and strychnine is particularly valuable in the treatment of enteroptosis and neurasthenia. Iron, arsenic, and strychnine in the form of glycerophosphates are indicated in all dis- turbances of a nervous nature, particularly in those neuro- muscular cases where there is a marked deficiency of phos- phates. The cacodylate of iron is particularly valuable in combating the graver forms of anemia which are found sometimes associated with enteroptosis. Owing to the fact that this preparation is well borne by the kidneys, it can be prescribed in all cases of anemia and kidney involvement. Of the various forms of phosphorus, lecithin is most easily assimilated. It is useful in neurasthenia dependent upon exhaustion, as well as in other neuroses. In malnu- trition, lecithin exercises a stimulating effect upon the cell protoplasm. Of all methods of administering drugs, the hypodermic is giving the best results. Professors Carnedi and ]\Iarchetti and others among the Italians have done much to develop this mode of administering pharmacopeial preparations. These preparations are put up in the form of aseptic 240 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS solutions in hermetically sealed glass ampoules/ The stem of the ampoule in which the dose is contained is broken off, and the dose drawn up into the syringe. The injections are made deep into the gluteal region; it is necessary that the injections be intramuscular. The following combina- tions can be used: Gramme. Iron cacodylate 0.03 Iron citrate (green) 0.05 Sodium arsenate 0.001 Iron citrate (green) 0.05 Iron citrate (green) 0.05 Strychnine sulphate 0.001 Iron citrate (green) 0.05 Arsenate of soda . 001 Strychnine sulphate . 0005 Iron citrate (green) 0.05 Sodium glycerophosphate 0.05 Sodium arsenate 0.001 Iron citrate (green) . 05 Sodium glycerophosphate . 05 Strychnine sulphate 0.001 Iron citrate 0.05 Sodium glycerophosphate . 20 Bisodium met. arsenate 0.10 Strychnine sulphate 0.001 Iron citrate 0.10 Sodium glycerophosphate 0.50 Bisodium met. arsenate 0.10 Strychnine sulphate 0.001 Iron citrate . . 0.05 Sodium glycerophosphate 0.20 Bisodium met. arsenate 0.10 Sodium formate 0.15 Strychnine sulphate . 001 As the general nutrition of the patient improves, the stomach and intestine will likewise become tolerant of a greater quantity and variety of food. Patients with entero- ptosis complicated with neurasthenia should be considered cured only when they may again partake of a normal diet without any distressing after-symptoms and when the work of the intestinal tract is normally performed. To accom- plish this result is the purpose of the food cure. In the ' By Moltcni iV- Company, of Florence, Ilaly; imported hy L. .V. Seltzer, of Detroit. TECHNIQUE OF FOOD CURE 241 treatment of enteroptotic and neurasthenic patients Strauss reports favorable results from the following alimentation: Breakfast: Flour soup rich in butter; porridge, cocoa with milk-and-cream mixture, egg, and some buttered rolls. Dinner: Dishes made of flour and eggs and cream. In the afternoon : Crackers with milk-cream mixture, zwieback and butter . Supper: Should consist of the rich flour soups or dishes made from flour and eggs, with a beverage of tea and milk-cream mixture. Before going to bed the patient is permitted a glass of milk-cream mixture. In addition, side dishes of malt extract and fruit juices may be permitted. Diel (Z^aeg). Calories. 8. A.M. h Uter of milk, with tea, 50 Gm. white bread, 20 Gm. butter, 30 Gm. honey 680 10.00 A.M. \ liter kefir (one day old), 50 Gm. Graham bread, 20 Gm. butter .... . . .420 12.30 noon 150 Gm. meat or fish, 250 Gm. vegetables, 50 Gm. apple sauce, 1 omelet from two eggs, 10 Gm. butter, 10 Gm. sugar. Fruit: grapes, oranges, figs .... . . 900 4.00 P.M. 1 hter milk. 6.00 P.M. I Uter milk chocolate, 50 Gm. Graham bread, 20 Gm. butter, Tablespoonful of honey . ... 1020 8.00 P.M. 2 eggp, 100 Gm. meat, fowl, oj fish, 50 Gm. preserves, 100 Gm. vegetables, 50 Gm. Graham bread, 20 Gm. butter, 20 Gm. soft cheese .... . . 1190 \ liter milk. 9.30 P.M. \ Uter kefir. Total 4210 16 242 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS Diet Lift (Boas), 7.00 A.Ji. J liter of chocolate with cream, 3 to 4 zwieback or nisks, 20 to 30 Gm. butter. 9.30 A.M. Cold or warm meat, eggs, egg dishes, white bread, 20 Gm. butter, 1.50 Gm. cream, 1 to 2 glasse.s of apple or some other fruit wine. 12.00 M. 150 Gm. cream, 2 to 3 biscuits. 2.00 P.M. I liter soup, vegetables, mashed potatoes, meat or fish, salad, sweet preserves. 4.30 P.M. Coflfee or tea \\ith cream (1.50 Gm.), zwieback, biscuits, butter (20 Gm.), or honey. 8.00 P.M. Cold or warm meat or fish, eggs, egg dishes, white bread, 30 Gm. butter, preserves, 2 glasses of fruit vrine. 9.30 P.M. Cream with 2 to 3 biscuits. Exercise and Massage. — Phj'sical exercises perform an im- portant role in strengthening the abdominal walls while they add tone to the musculature of the gastro-intestinal tract. Massage of the stomach is indicated in those forms of gastroptosis in which there is no pyloric stenosis. It is also indicated in atony and nervous dj'spepsia. The reader is referred to the chapter on ^Massage for the technique. ^Massage of the abdomen and intestine is recommended along with gastric massage. The purpose of abdominal massage is to strengthen the relaxed abdominal walls, stimulate peristalsis, and improve the circulation in the abdominal vessels by stimulation of the sympathetic ner- vous system. The technique of abdominal massage as performed by Hoffa is as follows: The patient should be placed on a firm couch or table, with his head slightly elevated; the lower extremities are flexed at the hips and knees. The physician occupies a position to the right of the patient. Massage should be commenced very gentlj^ especially in the case of patients on whom it is being per- formed for the first time, in order to prevent rigiditj' of the PLATE V FIG. I Abdon-iinal Massage, First Movement. (Hoffa.) Abdominal Massage, Second Movenient. (Hoffa.) PLATE V Abdominal Massage, Third Movement. (Hoffa.) EXERCISE AND MASSAGE 248 abdominal walls — which renders deep massage practically impossible. Both hands should be laid upon the abdomen and slight rotating movements made (rotating effleurage). Concentric circles should be made in the direction of the hands of the clock. The movements should be begun at the symphysis, proceeding upward, and then over the entire abdomen (Plate V, Fig. 1). These movements are designed to overcome the tension of the abdominal walls; in particularly stout patients the circular movements may be followed by kneading of the abdominal walls (petris- sage). Deep kneading of the intestine should follow, the purpose being to stimulate intestinal peristalsis and thereby loosen impacted fecal matter. Both hands should grasp in the direction of the intestine through the abdominal walls; zigzag movements to and fro are to be made (Plate V, Fig. 2). Deep petrissage should involve the whole abdomen, affecting particularly the median portion of the intestinal tract, namely the ileum. The operator should next proceed toward the large intestine. The movements are made first by the right hand, which is dorsally flexed and placed in the right pubic fossa at the beginning of the ascending colon (Plate VI). Pressure is made as deeply as possible, and in order to augment it the points of the fingers of the left hand should be pressed upon those of the right. The large intestine should be constantly subjected to deep pressure; the points of the fingers are pushed at first upward, then transversely below the arch of the ribs toward the left side, and finally downward so that the stroke penetrates deeply into the left iliac fossa. The pressure then ceases and the hands glide over the blad- der back to the right iliac fossa, from which point the stroking of the large intestine should be repeated several times. A few rotating efileurage movements of a soothing nature should be performed. Then should follow kneading of the large intestine (rotating petrissage). With the left hand superimposed on the right, the fingers of both hands should push with a rotating motion into the cecal region, 244 ALTERATIOXS IN POSITION OF ABDOMINAL ORGANS with the finger ends pointing toward the chest. The initial pressure and movements should be light and rotating, to be gradually increased until the whole course of the large intestine is massaged with this rotating pressure. The muscles of the intestinal tract should then be sub- jected to shght stimulating '' tapotement." WTiile executing these latter movements the hands should be held so that the thumb is approximated to the index finger and the other fingers are slightly flexed at the metacarpophalangeal joints. With the hands in this position the abdomen should be shghtly tapped in all directions. Alore \dgorous tapote- ment may be performed with the dorsal surface of the flexed fingers, the middle finger being elevated shghtly above the others. This procedure may be advantageously followed by shaking motions with the right hand placed flat on the central part of the abdomen, the fingers of the operator being spread widely apart. The sympathetic nerve plexuses may be reached by vibra- tion. In order to get at the celiac plexus the ends of the fingers are placed lightly upon the abdomen midway between the umbilicus and the ensiform cartilage; gi'adual pressure should then be exerted, penetrating more deeply with each respiratory retraction of the diaphragm until the spinal column is reached, when motions of a vibrating or trembling nature should be executed. The splanchnic plexus is reached in the same manner, except that the straight fingers should penetrate toward the spinal column midway between the umbilicus and the symphysis. The abdominal massage ma^^ be followed with advan- tage by a general vibration of the abdomen, given gently bj- means of an electric vibratory apparatus. The stomach, bladder and rectum should be emptied before massage of the abdomen is begun. In addition to the massage the patient should perform gymnastic exercises to invigorate the abdominal wall. He may assume a squatting posture, with the knees flexed until ELECTROTHERAPEUTICS 245 the thigh rests on the calf; or he may be instructed to raise himself into the sitting posture when lying flat upon the back. Zabludowski has the patient lie at full length in order to counteract atony of the gastro-intestinal tract by a better circulation of the blood. Massage is indicated in floating kidney, the purpose being to tone up the abdominal wall. It should be practiced as already described and be followed by the left hand pressing the soft parts from behind up, the right hand in the meantime performing replacement movements upon the kidney. The massage process in gastroenteroptosis must be varied according to the anatomic relation of the parts. Gastric massage may immediately precede abdominal. "V^Hien these movements cannot be conveniently performed daily by the physician, the patients may practice on themselves by means of a cannon ball, which should not weigh more than from three to five pounds. A sphere of wood weighted with shot answers the purpose in auto-massage very nicely. Electrotherapeutics. — Gastroptosis and enteroptosis are some- times improved under a course of electrotherapeutics. In relaxation of the abdominal muscles and intestinal torpor, faradization is indicated. Two large plate electrodes four to six inches square are applied to the two sides of the ab- domen, or, if desired, over the epigastric and hypogastric regions. The faradic current should be turned on slowly and its strength increased gradually so that distinct con- traction of the abdominal muscles becomes apparent. One plate electrode may be placed over the region of the stomach and the other utilized as an electric roller to follow the course of the large intestine under deep pressure. The galvanic current is indicated in cases characterized by ab- dominal pains of neurotic origin. As much as thirty milli- amperes may be used, with one electrode over the stomach and the other over the bladder. In torpidity or sluggish- ness of the bowels, intrarectal faradization has proved to be an effective therapeutic agent. 246 ALTER ATIOXS IX POSITION OF ABDOMINAL ORGANS Hydrotherapeutics. — The hydrotherapeutic procedures suit- able to this class of cases, namely, gastroptosis or entero- ptosis complicated with neurasthenia, consist of the appli- cation of cold water, half baths, Scotch douches on the abdomen and stomach, cold friction rubbing and slapping, and cold full packs. The prolongation and intensity of these hydrotherapeutic measures must be varied to suit the requirements of the case. Nervous debility wdll at times be greatly benefited bj' sojourn in the country, at the seashore, or other climatic health resort. Mechanical Treatment of Enteroptosis. — The mechanical thera- peutics consist principally in the bandaging of the abdomen with a view to suppl^'ing support to the relaxed abdominal wall and to fixing the displaced viscera; especially is this treatment indicated in enteroptosis due to mechanical causes. In constitutional enteroptosis the mechanical treat- ment, so called, is palliative merely, but of very great value. It acts beneficially by ameliorating the symptoms which arise from tension or stretching of the abdominal organs. The mechanical support consists of abdominal bandages or abdominal corsets. Apparatus for this purpose is available in great variety, but everything has its peculiar defects, such as uncomfort- able perineal straps or badly fitting pads, which occasion patients no small degree of annoyance. It is a very difficult matter to find well-fitting "ready-made" corsets or abdomi- nal bands. Among the best known and most suitable ap- pUances for the treatment of enteroptosis and gastroptosis are the abdominal bandage of Glenard and Teufel, the girdle of Hera for pendulous abdomen, and the abdominal bandage of Burger recommended by Riegol. The last i)ossesses great adaptability; it is light in weight and leaves the hips unen- cumbered. It consists of a closely fitting body plate, and back holders made of celluloid, with removable and adjust- able eyelets. In order to ascertain whether a band is indicated in a given case, the so-called "belt sign" of (Jlenard should be PLATE VII Author's Abdominal Bandage. PLATE VIII Author's Abdominal Bandage, Showing Con- struction in Detail. MECHANICAL TREATMENT 247 employed. The physician, standing behind the patient, passes his arms on either side and places both hands on the lower abdominal wall. With the hands in this position the abdominal mass just above the pubes can be easily raised. The physician should then suddenly remove his hands, per- mitting the abdominal mass to fall; if then the patient's distressing symptoms, relieved by the temporary support, return, the indication is positive for the use of an abdominal Fig. 28 Glenard's "belt sign" (^preuve de la sangle). band or support. Glenard calls this phenomenon '^epreuve de la sangle" (Fig. 28). Should the patient experience no relief when the abdomen is lifted, and feel if anything better when it is permitted to assume its old position, the band will not give good results. The author's bandage,' as presented before the American Medical Association at Philadelphia, June, 1897, has been used by him with success in selected cases (Plate VII). It has in no way been modified from the form introduced to the profession, and has proved eminently satisfactory 1 The bandage devised by the author is manufactured by G. J. De Garmo, 108 East 23d Street, New Yorlc. 248 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS (Plate VIII). It is supplied with a truss which is fitted to the band encircling the body below the crest of the ihum and above the trochanter (Plate IX). This bandage exerts a pressure upon the hypogastrium from below up- ward, raising the intestines, which in turn act as a cushion for the stomach. In this way the tension upon the abdominal organs is reUeved (Plate X, Fig. 1). The bandage should be adjusted properly in order to prevent slipping up at the back, or no benefit will be derived from its use (Plate X, Fig. 2). \Anien the bandage is properly applied it affords abdominal support and at the same time leaves the ribs and diaphragm free from all compression and the respiratory movements free. There is no pressure over the solar plexus. The wearing of the author's abdominal bandage tends to develop in patients a deep, broad, prominent lower chest and epigastrium, which is the condition found in well- developed normal individuals. My bandage has been found valuable in the treatment of abdominal pain due to a loose sacro-iliac joint. This pain, as originally described by Goldthwait,^ is apt to be associated with more or less severe headache, generally on one side over the sacro-ihac joint. It sometimes extends through to the front of the joint, where it is most apt to be mistaken for an affection of some pelvic organ. The existence of this condition is, as a rule, indicated by the fact that the affected leg is shortened, and that pain results when the leg is rotated, forced strongly, or pulled outward. ]\Iost of these patients are relieved by the application of my bandage. Einhorn's bandage- is perforated over the iliac crests in order to prevent undue pressure on these parts. J. Madison Taylor"* describes a belt devised by Alorris Longstreth (Figs. 29 and 30), who has used it for over a quarter of a century. This belt may be used alone or attached to any well-fitting corset. Taylor's experience with this belt has been most gratifying. The belt consists of a broad band of stout ' Ro.ston Medical and Surgical Journal, 11)0"), p. .'M\. ' Remarks on Entcroptosis, Medical Record, April 13, 1901. ' New York Medical Journal, May 11, l'.)07. PLATE IX Abdoniinal Bandage in Position. PLATE X Abdominal Bandage Properly Adjusted. Abdominal Bandage Im- properly Adjusted. MECHANICAL TREATMENT 249 webbing, which may be attached to the lower edge of a corset and carefully fitted to the individual, coming well down over the external trochanters. Posteriorly it is cut vertically and the edges joined by four straps with buckles, so that the belt may be adjusted to fit the needs of the case; in front it is caught by a series of broad hooks which are joined or disengaged as the corset is put on or off. Fig. 29 Fig. 30 Longstreth's belt attached to corset- side view. Longstreth's belt attached to corset- back view. Byron Robinson advocated a rubber air-pad placed inside an elastic or non-elastic abdominal bandage. Other bandages have been devised by Boas, Ewald, Witthauer, Spivak, and Vermehren. An appliance very much in vogue is an adhesive plaster bandage by Rose/ of New York. It consists of zinc oxide moleskin adhesive plaster one yard long and eight inches Medical Fortnightly, February, 1909. 250 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS wide. From this a pattern is cut as shown in Fig. 31. The writer is in the habit of placing the patient in the Trendelen- burg position in order to apply this plaster bandage. All hairy portions of the body covered by the bandage should be shaved to facihtate removal. The plaster should not include the crest of the ilium, but should run closely along and above it. The epigastric region remains uncovered (Fig. 32). Most patients find this bandage fairly comfort- able. Unfortunately, it is impossible to keep it in place Fig. 31 Pattern for adhesive belt. (Rose.) longer than three to four weeks, owing to the fact that the plaster loses its adhesiveness. This support may be re- moved easily by applying benzin or ether. The removal of adhesive plaster from the skin of a patient is accompanied by considerable pain and discomfort. Beardsleyi found that oil of wintergrcen applied to ad- hesive plaster removed completely the adhesive elements in a very short time. It is not necessary to use more than a small amount of the oil, which is applied directly to the ' An Ea.sy and Painless Method of Removing Adhesive Plaster, Journal of the American Medical Association, January 2S, 1911, ji. 203. MECHANICAL TREATMENT Fig 32 251 Adhesive plaster bult adjusted. (Rose.) FtG. 33 FiQ 34 Adhesive plaster bandage — tront view. (Eisner.) Adiiesive plaster bandage — bacli view. (Eisner.) 252 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS plaster and easily spreads itself throughout the adhesive material. When extensive areas of plaster are to be re- FiG. 35 Adhesive bandage — front view. (Helfenberg ) Fia 30 Adhesive bandage — back view. (Helfenberg. MECHANICAL TREATMENT 253 moved the application of an ointment of adeps lana? hydrosus, with 10 per cent, of oil of wintergreen incorporated, is even more useful than the oil alone. Patients are able to bathe regularly while wearing this bandage. They often learn to apply it properly themselves. Other adhesive plaster bandages are those of Rosenwater and Eisner (Figs. 33 and 34), and the ready-made adhesive plaster bandage manufactured in Germany at the chemical works of Helfenberg, near Dresden (Figs. 35 and 36). None of these bandages is, however, as satisfying as that devised by Rose. Fig. 37 Position for adjusting corset. (Gallant.) Corsets. — The corsets most in use are Bardenheuer's, Landau's, Gallant's, and Fitz's, Bardenheuer's corsets consist of an elastic pelvic ring, from the centre of which several ribs radiate in a fan-like fashion over the abdomen. These are held in position by a strap. The Landau corset consists of an elongation of the corset proper so that the lower border reaches as far as the pubic bone. It is provided with an abdominal strap which is made to exert pressure by means of a steel spring upon a tin plate. Gallant advocates the semiopisthotonos posture (Fig. 37) 254 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS as the proper one for the patient to assume in putting on his corset.' In an address before the British Medical Association in 1888, Ray and Adami referred to the "physiological bearing of waist belts and stays." From experiments upon the human subject, as well as upon animals, these writers found that a large quantity of waste blood lay in the abdominal viscera. Gentle compression by a suitably fitting corset or bandage propels this stagnant blood into the general circulation, and thereby increases muscular and mental activity. A properly fitting corset gives support to the lower abdomen. These writers do not advocate tight lacing, but prove that the habit of wearing some form of support has a physiologic basis and is not entirely of esthetic origin. The corset I prescribe' is an ordinary long-hip, straight- front corset, and may be purchased at any up-to-date corset shop. Its main feature is the fact that it laces in front. When properly adjusted it forms a valuable thera- peutic factor in the treatment of gastroptosis. This is especially true when the abdomen is prominent, protruding anteriorly to the spines of the ilium. The corset is not so beneficial when the abdomen is flat; in such cases the author applies his abdominal bandage. These mechanical supports restore the abdominal organs as nearly as possible to their normal position and place the patient in compar- ative comfort while the hygienic, dietetic, physical, and mechanical treatment indicated for gastroptosis or entero- ptosis is being carried out. The reinforcement of the ab- dominal wall restores intra-abdominal pressure, and thus acts both directly and indirectly as a support for the abdominal viscera. Method of Adjusting Corset. — The corset should be opened the full length of the strings before hooking. After the corset is hooked in front it should be pulled down as ' The Diotctic and Hyf^iciiic Clazctte, Juiic, lilOT. 2 Demonstrated before the Twelfth Annual Meeting of the American Gastroenterological Association, Atlantic City; N. J., June 8, 1909. PLATE XI FIG. 2 Method of Adjusting Author's Corset. Corset Adjusted Ready to Lace. PLATE XI 1 Corset Laced froni Below. MECHANICAL TREATMENT 255 far as possible by grasping the lower edge with one hand, the undergarment being pulled up with the other (Plate XI, Fig. 1). The corset should be laced from below up like a shoe, thus gradually raising the displaced organs. See that the clasps reach the groin. When the lower edge of the corset is half-way over the symphysis, the garters should be fastened all around, and the buckles so adjusted as to tighten the garters (Plate XI, Fig. 2). This must be done before lacing. Beginning at the fifth eyelet from the bottom, the strings should be pulled together. Then count three from the fifth eyelet and pull the strings together. This aids in raising the abdominal organs (Plate XII). Now start at the top and lace down to the waist line, leaving the corset loose enough to relieve pressure in the epigastrium (Plate XIII). The laces should be tied at the waist line, when the corset will be found to be in proper position (Plate XIV, Fig. 1). This corset presses over the hypo- gastrium, so that when it is laced the lower abdomen has become less prominent Plate XIV, Fig. 2. Pregnancy has frequently had the effect of so raising the abdominal organs as to bring about recovery in cases of en- teroptosis. Women with ptosis who become pregnant have an increased intra-abdominal pressure, which will vary directly as the uterus increases in volume. Pregnancy produces a marked improvement in the digestive functions in these cases, and there is no reason why this improvement may not be made permanent through proper treatment. It becomes markedly apparent during the later months of pregnancy. Normal pregnancy, then, does not exert any bad influence upon gastroptosis. If after delivery the viscera are sus- tained for some time, a contraction of the abdominal walls takes place, and in due time the organs will continue in their proper position. During the period of gestation the dis- placed organs are gradually forced up into their normal position, and the mesenteries which have been placed upon the stretch have an opportunity to regain their normal tonicity. After delivery the abdominal walls should recede and hold the organs in normal position. Although preg- 256 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS nancy is admittedly a predisposing cause of enteroptosis, a few cases have come before me in which it served as a cure.^ After deUvery the patient should be confined to the bed longer than the usual time, to be certain that there will be no dragging upon the mesentery. She should have the freedom of the bed for at least three weeks and not be per- mitted to get up except for micturition and defecation. A firm band should be applied to the abdomen, tightened morning and night, so that the organs will remain in situ. At the end of three weeks the patient should be permitted to get up for an hour a day, and afterward for a longer time. From experience with many cases of this class I would conclude that: 1. Dispensing with the abdominal bandage after preg- nancy, according to the new method of obstetricians, pre- disposes to gastroptosis. 2. Pregnancy often favors the cure of gastroptosis. 3. Patients with gastroptosis need not hesitate to become exposed to pregnancy. 4. The disagreeable symptoms of gastroptosis frequently disappear during the period of gestation. 5. Keeping the patient in bed after delivery and applying an effective abdominal binder is very helpful in the cure of gastroptosis. 6. Early convalescence after delivery and insufficient support to the abdomen predispose the patient to gas- troptosis. Medicinal Treatment. — In the majority of cases of entero- ptosis the administration of drugs occupies a very minor place. Improvement in the appetite sometimes follows the administration of a stomachic. Where atony is present the medicinal agents appropriate for that condition may be given. Mineral waters, when they seem to be indicated, should be prescribed tentatively according to the principles given for the treatment of atony. In cases where there is much distress, mineral waters are contraindicated. * Aaron, Enteroptosis and Pregnancy, Medical Index- Lancet, June, 1902. PLATE XIII Corset Laced from Above. PLATE XIV FIG. I FIG. 2 Corset Adjusted Corr-ectly, Front View. Corset Adjusted Correctly, Side View. SURGICAL TREATMENT 257 Surgical Treatment. — Operative measures have been em- ployed for the reUef of severe symptoms incident to gas- troptosis and enteroptosis of marked degree. One of these is the fixation of the stomach to the parietal peritoneum by the shortening of the ligaments (gastropexy) . The operation for nephropexy has been also employed. The results of these operations have not been favorable. Opera- tive intervention seems to be indicated only when gastro- ptosis leads to secondary complications, such as stenosis of the pylorus or duodenum. Duret,^ of Lille, in 1894, raised the ptotic stomach of a woman, aged thirty years, by suturing the anterior part to the abdominal wall by a single suture. Davis- attached the lesser omentum of the stomach to the anterior abdominal wall. Roosing^ elevated the stomach by passing three rows of sutures from that organ to the parietal peritoneum. Webster, in 1891, resected and sutured the fascia of the gastric muscles. Laur^ attached the colon by suture at both the splenic and hepatic flexures to the anterior abdominal wall. R. C. Coffee'^ describes an operation whereby he sus- pended the stomach in a hammock made of the great omentum. Henry D. Beyea*^ describes an original operation for the elevation of the stomach in gastroptosis — the sur- gical plication of the gastrohepatic and gastrophrenic liga- ments with three rows of interrupted sutures. Cumston united the recti muscles with kangaroo tendon suture so as to cause overlapping, and resected the excess of the anterior aponeurosis, uniting with a second layer of kangaroo tendon. The removal of all redundant skin was effected by an elliptical incision. Ernest Laplace, of Philadelphia, devised an operation to suture the gastrocolic omentum to the anterior abdominal wall by means of continuous catgut suture. 1 Revue de Chirurgie, 1S96. 2 Western Medical Review, 1897. 3 Archiv ftir Chirurgie, 1899. * Presse Medicale Beige, 1901. ^ Philadelphia Medical Journal, October 11, 1902. " Ibid., February 7, 1903. 17 258 ALTERATIONS IN POSITION OF ABDOMINAL ORGANS The results obtained by these operations have not, how- ever, been encouraging; and since surgical intervention has proved ineffectual in the treatment of gastroptosis and enteroptosis, gastroenterologists have practically ceased to advise it. According to Fenwick/ when gastric displacement is due to organic stenosis of the pylorus or duodenum, gastro- enterostomy is usually sufficient without suturing the stomach to the liver or abdominal wall. Fixation of the right kidney has no effect whatever upon a coexisting dislocation of the stomach, and usually increases the gastric symptoms by the induction of nervous shock. ^ Dyspepsia: Its Variety and Treatment, 1910. CHAPTER XI MOTOR NEUROSES: HYPERMOTILITY— PERISTALTIC UNREST— CARDIOSPASM— PYLOROSPASM— ERUCTATIONS— PNEUMO- TOSIS — VOMITING — RUMINATION — REGURGITATION — PYLORIC INSUFFICIENCY— SINGULTUS GASTRICUS NERVOUS AFFECTIONS OF THE STOMACH It is often difficult to establish a diagnosis of a purely nervous or functional derangement of the stomach — that is, to be certain that no organic disease is present. It is also difficult to ascertain whether or not the fundamental neurasthenia lying at the bottom of every neurosis of the stomach is the primary cause. Neuroses of the stomach are differentiated from organic conditions by the one predominant symptom, referable to the motor, secretory, or sensory functions. This symptom has been termed ''nervous dyspepsia." Writers have pro- ceeded in various ways to classify the neuroses of the stomach. Some endeavor to draw distinct lines of demar- cation between motor and secretory and sensory neuroses, and speak of nervous dyspepsia as a disease in itself, in which there may be present combinations of motor, secre- tory, and sensory disturbances, giving rise to purely sub- jective symptoms. Wegele differentiates between irritative and depressive forms of these neuroses. Boas divides gastric neuroses into monosymptomatic, which include motor, sensory, and secretory, and polysymptomatic. Other authors class under the term "nervous dyspepsia" the entire range of gastric disturbances (Zweig). Gastric neuroses develop principally in individuals of a nervous temperament — that is, in neurasthenics, hypochon- driacs, and hysterical persons. Treatment must be directed to the symptoms as they present themselves. Drugs which 2(30 MOTOR NEUROSES have a specific action upon the nervous system are indicated in these conditions. Regulation of diet, hyperalimentation, education of the patient to a rational mode of life, hydro- therapeutics, gymnastics, electricity, massage, are all of value. The physician may exercise a profound influence over the patient's mental condition when he is able to do so; the progress of the case toward recovery will be much more rapid than it would otherwise be. The prognosis will depend largely upon the duration of the treatment, which, in the majority of cases, must be protracted. HYPERMOTILITY " Hypermotility" is a term which designates an abnor- mally increased movement in the evacuation of the stomach,, so that the viscus is often found empty soon after the inges- tion of food. Hypermotility may occur in cases of achylia gastrica, the closure of the pylorus being defective on account of the diminution or absence of hydrochloric acid secretion; or it may occur with any other variety of pyloric insuffi- ciency. Cases of purely neurogenous hypermotility are rare. The diagnosis is established by means of a test breakfast. Hypermotility does not often give rise to dis- tressing symptoms, and consequent!}' does not require any particular treatment. PERISTALTIC UNREST OF THE STOMACH The complex of symptoms first described by Kussmaul, and attributed })y him to peristaltic uni-est of the stomach, does not often occur as a pure neurosis. The condition con- sists in the supervention of increased peristaltic motions of the stomach. Patients experience sensations of constant "griping and moving" in the stomach and abdomen. When the abdominal walls arc tliin and the stomach more or le.ss ptotic, it is possible for tlic cxaniiiuM- lo (lis('(>rn Iho actual PERISTALTIC UNREST OF THE STOMACH 261 peristaltic movements of the stomach. These movements are invisible through the abdominal wall when the stomach is in its normal position. A more or less rapid peristalsis is occasionally accompanied by rolling sounds which can be heard at some little distance from the patient. This condi- tion is often present in stenosis of the pylorus. In making the diagnosis, mechanical obstruction about the pylorus as well as disturbances of gastric secretion must be ruled out. Treatment. — The treatment consists in combating the cause as well as the general nervous symptoms present. Excessive exertion, both mental and physical, must be care- fully avoided. Nutrition should be regulated in order to avoid the ingestion of anything that might irritate the stomach; the food should be of a bland, semiliquid nature, and too great a quantity should not be permitted at any one time, for fear of overdistending the stomach. The evening meal should be light. While the loading of the stomach with bulky foods should be avoided, it is neces- sary to prescribe the most nutritious regimen possible. The milk cure, combined with rest in bed, is worthy of trial. The direct local treatment consists of either cold or warm applications over the stomach, with lavage in the presence of dilatation and pyloric stenosis. Electric treat- ment in the form of either the galvanic or faradic current, external or intraventricular galvanization, may be employed with the cathode either upon or inside the stomach. Some- times confining the patient to bed and resorting to rectal feeding gives good results, owing to the physiologic rest thus afforded the stomach. A two weeks' course of nutritive enemata (see page 407) often results in complete recovery. The drug indications include the use of the bromides: strontium bromide, 1 Gm. (15 grains) four times a day in water, or codeine phosphate, 0.01 to 0.03 Gm. (e to 2 grain) every two to three hours, may be prescribed for the relief of pain. Extract of belladonna, 0.01 Gm. (^ grain), sometimes affords great relief. For gouty pa- tients Hemmeter recommends sodium salicylate, 1.25 Gm. (20 grains), and bismuth subnitrate, 1 Gm. (15 grains) three 262 MOTOR NEUROSES times a day. Vibratory massage over the left side of the tenth, eleventh, and twelfth dorsal vertebrae has also given relief in this condition; it should be performed daily, the treatment lasting five minutes. CARDIOSPASM Cardiospasm is a condition in which the cardiac orifice of the stomach contracts at the point of junction with the esophagus. The esophagus becomes closed up at its lower extremity at the moment of swallowing, so that it is impos- sible for either solids or liquids to enter the gastric cavity. Under normal conditions the cardia is capable of contraction and relaxation (Meltzer). The contractile force is situated in the cardia itself, while the power of relaxation is controlled from the medulla oblongata, whence the inhibitory impulses proceed to the cardia through the pneumogastric. During each act of swallowing, inhibitory impulses pass from the medulla to the cardia, causing the latter to open to receive the bolus of food. In cardiospasm this inhibitory control is apparently absent, so that the cardia remains in a state of continuous contraction. Cardiospasm is probabh' due to an affection of the pneumogastric nerve. Symptoms. — Examination of the cardia in this condition has revealed hypertrophy of the muscles and slight atrophic changes in the pneumogastric nerve. Cardiospasm, as a rule, starts suddenly during eating, and may pass off rapidly ' (acute cardiospasm); or it may persist for a long time. When the condition becomes chronic, patients while eat- ing experience a sensation of pressure in the chest, which at times assumes the character of spastic pains radiating toward the bowels. The morsel of food is felt sticking in the esophagus, only to pass, after a time, into the stomach ; or retching may cause its regurgitation into the mouth. When cardiospasm of this character continues for any con- siderable length of time, a loss in weight results, due to undernutrition. Retained food causes irritation of the CARDIOSPASM 263 esophageal mucous membrane, and the esophagus in severe cases becomes dilated above the cardia. Diagnosis. — The diagnosis of cardiospasm is made by close observation of both subjective and objective symptoms. The objective examination consists in the introduction of a soft stomach tube or esophageal bougie, which, in the pres- ence of cardiospasm, is grasped by the cardia and retained by the spastic muscular contraction. The spasm relaxes only after a period of waiting. Under any other condition, except obstruction by benign or malignant growth, the cavity of the stomach may be easily reached. This phenomenon is characteristic of cardiospasm. Dilatation of the esophagus is ascertained by the presence of undigested food remnants. Another feature of diagnostic importance is the fact that the so-called second sound of deglutition appears late or is often absent in cardiospasm. Meltzer refers to the diagnostic importance of the inability to vomit in determining spasm of the cardiac orifice. The diagnosis of this condition may be further confirmed by esophagoscopy, and the Roentgen- ray examination after the use of bismuth suspension. Prognosis. — The prognosis of cardiospasm is always uncer- tain. Acute cardiospasm occasionally disappears entirely, or reappears only at rare intervals. In chronic cardiospasm the prognosis is less favorable for complete cure, and the disease must always be regarded as serious. Treatment. — The treatment of cardiospasm consists in the treatment of the neurotic conditions underlying it. The psychic factor of treatment is important, and patients must be reassured by the physician that the dread of swal- lowing which is always present may be dispelled. The patient should be prevailed upon to perform the act of deglutition several times without any food in the mouth before each meal, after which he should attempt to eat. His attention during meals should be diverted from his condition. Change of location, change in the usual habits of life, as well as a different arrangement of the meal hours, will some- times be accompanied by favorable results. All articles of diet apt to irritate the esophagus should be avoided. 264 MOTOR NEUROSES Patients must be instructed to eat slowly and to masticate their food thoroughly. Extremes of temperature in food and beverages should be avoided. Liquids containing much carbon dioxide, as well as acid or highly seasoned foods, are not well borne by patients in this condition. It is important, likewise, that the consistency of the food should be liquid or semisolid, though sometimes patients can swallow solid food to better advantage than liquid. A highly nutritious diet with as little bulk as possible should be the rule for these patients. Sometimes nutritive enemata are indicated, and may be given for more or less prolonged periods of time, affording rest to the esophagus and cardia. Oil Cure. — The oil cure as recommended for stenosis of the cardia should be employed in the treatment of cardio- spasm, and, as in the treatment of cardiac stenosis, mayon- naise and almond milk may be given as a substitute for olive oil. Drug treatment, as a rule, has no direct effect upon the spasm. In selected cases, however, extract of belladonna has given fair results. Suppositories of atropine or eumydrin may be prescribed. Bromides in large doses are also indi- cated. In painful cases, benefit has been derived from the administration of milk of almonds with the addition of anesthesin. Mechanical Treatment. — Chronic spasm of the cardia should be treated along mechanical lines, and the cardia must be mechanically dilated b}^ means of sounds. B. W. Sippy has devised a valuable instrument for the treatment of cardiospasm as well as for the dilatation of spasmodic and other strictures of the esophagus. The in- strument is particularly useful in hypertrophic stenosis of the cardia due to cardiospasm of long duration. It must be used with great caution in organic stricture. The Sippy dilator is a rectangular rubl)er l)ag, three inches by one and one-half, at an upper corner of which is attached a piece of firm rubber tubing twenty inches in length. Parallel to the long axis of the bag is a piece of rubber tubing three inches in length and closed at one end. The uiijior end, which remains open, is fastened in the wall of the rubber bag. By CARDIOSPASM 265 introducing a whalebone bougie into this tubal compartment the bag may be guided to the location of the stricture. The danger of overdilatation is obviated by a firm linen sack which encircles the rubber bag. The lumen of the linen sack determines the degree of dilatation that may be obtained. For treating cardiospasm in adults with this dilator the width of the constricting linen band should not be greater than six or seven centimeters, and smaller sizes must be used for children or for dilating stenoses which have resulted from malignancy or cicatrization. The Sippy dilator is intro- duced after slipping a rubber condom over the dilator before inflation and tying it loosely about the tubing and bougie. The air is forced into the dilating chamber by means of a rubber bulb pump, so that great pressure may be applied to the stricture. Jesse S. Myer has devised a dilator for cardiospasm.^ The cardiac end of this instrument consists of, from within out- ward, first a rubber tube, one-fourth of an inch in diameter, closed at one end and at the other end continuous with the esophageal tube; next, extending for about six inches up this 4-inch tube, and made air-tight at each end to it, is a casing of thin rubber known as Penrose rubber tubing, which may be procured in three sizes — No. 1 and No. 2 for the large dilator and No 2 and No. 3 for the small; and encasing the Penrose rubber tubing is a bag made of ordinary w^hite silk wdth a diameter of about three centimeters (Fig. 38 j. The size to which the dilator can be distended depends upon the limitation offered by the silk bag. The outer covering of all is Penrose rubber tubing, securely fastened by means of silk at either end. A flexible mandrin consisting of a steel cable is used in introducing the dilator, and removed when the dilator is in proper position. The dilating process is per- formed by means of a large glass and metal syringe such as is used in bladder irrigation. The syringe should be of at least 150 Cc. capacity. Great pressure may be exerted, ^ Presented at the Thirteenth Annual Meeting of the American Gastro- enterological Association at St. Louis, Mo., June 6 and 7, 1910. 266 MOTOR NEUROSES overstretching of the dilator being prevented by the silk bag or collar. Large esophageal sounds or bougies should be used, and left in position in contact with the stricture. It is better to begin with sounds of medium size and to increase the size as the stricture yields to the dilating process. Special dilators have also been devised by Einhorn and Plummer, the principle of each being an India rubber bulb fixed to Fig. 38 Myer's cardia dilator: A. deflated; B, inflated; o, rubber bag; b, silk bag; c, rubber bag; d, rubber tube; e, mandrin the gastric extremity of a thin gastric sound.. When the sound has been introduced as far as the cardiac orifice, the rubber bulb is distended by means of water pressure. Simple solid sounds in many cases prove as effectual as those above mentioned. The metal spiral sound of Craw- cour, which consists of' a metal spiral tapering toward the extremity, has also been pmi)l()ycd; owing to its pliability and weight, this sound very easily passes through strictures of almost any degree. The treatment by dilatation must PYLOROSPASM 267 be continued for a long period if satisfactory results are to be obtained. Esophageal lavage should also be performed during the process of dilating the esophagus. Regin recom- mends the insufflation intb the patient's throat, immediately before meals, of a small quantity of the following powder: Gm. or Cc. I^ — Pulveris acidi borici, Sacchari lactis aa 2 . gr. xxx Orthoformi 1.0 gr. xv Pulveris talci 2.0 gr. xxx Cocainse hydrochloridi 0.05 gr. f Pulveris mentholis . 02 gr. | Misce. Electrotherapy. — Internal galvanization of the stomach has been employed in a few cases of cardiospasm, and some- times relief is only to be procured by chloroform narcosis. Surgery, too, has been employed. Cohen and Mikulicz have forcibly dilated the cardia directly from the opening made by gastrostomy. Martin^ reports a case of cardio- spasm in which palliative treatment had been carried on for some months to no effect; the patient made a good recovery after divulsion of the sphincter of the cardiac orifice. Willy Meyer^ reports a case successfully treated by thora- cotomy and esophagoplication. PYLOROSPASM Secondary pylorospasm is of comparatively frequent oc- currence. Recent studies on the subject would seem to point to the probability of spasm of the pylorus being sometimes, though rarely, of purely nervous origin. The diagnosis may be established by exclusion of the usual causes of secondary spasm of the pylorus, such as car- cinoma, gastric ulcer, and secretory disturbances. Pyloro- spasm of purely nervous origin occasions pain of greater or less severity, together with increased gastric peristalsis and sometimes vomiting. ^ JoxuTial of the American Medical Association, March 4, 1905, p. 1439. 2 Ibid., May 20, 1911, p. 14.37. 268 MOTOR NEUROSES The differentiation between benign obstruction of the pylorus and pylorospasm is frequently quite difficult. One of the best methods of determining the patency of the pylorus is the use of the Einhorn duodenal bucket (Fig. 5). This is a small gold bucket, similar in shape to the stomach bucket, attached to a silk cord. The bucket is placed in a capsule and swallowed by the patient and not withdrawn for several hours. On withdrawal, the contents of the bucket are examined for pancreatic ferments, and if these are found we are reasonably sure the bucket has been in the duodenum, thus proving that the pylorus is still patent. TMien the bucket has entered the duodenum the thread near it is golden yellow, due to the presence of bile. It is im- portant that the stain on the thread extend only a short distance (10 to 15 centimeters). If one-third or more of the thread is bile-stained, this would indicate a regurgitation of bile into the stomach, and therefore forbid any conclusion regarding the passage of the bucket through the pylorus. The bucket will never reach the duodenum when there is a genuine pyloric stenosis, while in pylorospasm it passes through. Treatment. — The treatment of this condition consists, among other things, of the application of heat, the administration of bromides and belladonna, codeine, galvanization, and mild hydrotherapeutic measures. A bland, non-irritating diet should be prescribed, such as that recommended in the treatment of gastric ulcer, and small quantities should be given during the initial stages of treatment to avoid over- distention of the stomach. Einhorn's method of dilating the pylorus by means of a thin stomach tube and a small rubber bag should be employed. The Einhorn^ pyloric dilator (Fig. 41) consists of a small metal end piece to which is attached a thin rubber tube (8 millimeters in circumference and 1 meter long), bearing markings: 1 = 40 cm.; 11 = 50 cm.; 111 = 70 cm.; and 80 cm. Right next to the metal piece and fastened to it and the 1 Max Einhorn, On Pylorospasm, Medical Reconl, .];uiu;uy 21, I'.dl, i). 97. PYLOROSPASM 2G9 tube is a tiny rubber balloon covered with silk gauze. The tube is provided with a few holes within the balloon, and is connected at its upper end with a stopcock and a gradu- ated glass syringe. The latter serves the purpose of inflating the balloon with air. Method. — The pyloric dilator is introduced in the same manner as the duodenal pump (see page 437) . After empty- ing the rubber balloon of its air contents (this is done by drawing the piston of the syringe outward), the cock is closed. The end piece of the dilator is now dipped in luke- warm water and introduced into the pharynx of the patient. The latter drinks some water and the instrument moves into the stomach. It is now left in the digestive tract for several hours; or, better, it is swallowed before the patient retires, and left undisturbed over night — for in pylorospasm it sometimes takes a long time for the apparatus to pass into the duodenum. In the morning the stretching is performed. Before doing this it is necessary to ascertain whether the dilator is in the duodenum. This is done by estimating the length of tubing within the digestive tract (it should be in as far as mark III, or 70 cm.) ; on drawing the tube slightly outward, it generally shows mark II within the mouth. The balloon is then inflated by means of the syringe. If the tube be now drawn forward there is a sensation as if the end of the instrument were held tight by something that drags along with it, not being able to escape it. It is not permissible to use much force. The balloon is then made somewhat smaller by pulling the piston of the syringe and thus deflating it slightly. This is repeatedly done until the end of the dilator by a slight pull passes through the pylorus. The syringe being graduated, one notes the number of cubic centimeters of air in the balloon during its passage through the pylorus. While the dilator is being drawn through the stomach no resistance is felt until the cardia is reached. Here the dilator should be entirely de- flated and withdrawn — which is accomphshed without trouble. ' Should, however, resistance be encountered at the introitus esophagi, the patient should swallow, and while his 270 MOTOR NEUROSES larynx moves upward the instrument is gently removed without the application of any force. The oil treatment, as outlined by Cohnheim, is valuable. The oil should be taken on the fasting stomach. Hyper- chlorhydria is frequently the cause of pylorospasm, in which case treatment of the spasm should consist of proper measures to counteract the hyperacidity. Useful drugs for this condition are to be found in atropine and eumydrin, together with the alkalies. Engel maintained that the so- called congenital stenosis of the pylorus, or the pylorospasm of infants, was caused by marked hyperacidity or hyper- secretion of gastric juice, which was in turn possibly second- ary to congenital neuroses. It was further pointed out that an early diagnosis of the condition might possibly be obtained by examination of the gastric contents of the vomiting infant for hyperacidity, and that rational thera- peutics based upon a knowledge of the hyperchlorhydria would offer hopes for better results in the treatment of this condition, which is so commonly fatal. (See Chapter XIV.) Rosenhaupt advises injection into the rectum of a con- siderable quantity of a 4-per-cent. sodium chloride solu- tion as a means of treatment of pylorospasm in infants. The suggestion is based upon an experiment on dogs, in which an injection of this kind resulted in a marked diminu- tion in the quantity of gastric juice secreted. NERVOUS ERUCTATIONS (AEROPHAGY) This condition is characterized by belching, which appears to be independent of the reception of food and to be caused by reflex nervous action; it consists in eructations of air accompanied by sounds which are audible at a considerable distance from the patient. The belching may persist for hours, and in a few cases it has been reported to have kept up for days. The condition is one which affects chiefly neurotic individuals. The air has gained entrance to the stomach by some means, though it is rare that atmospheric NERVOUS ERUCTATIONS 271 air is directly aspirated by the stomach. Such individuals are known to have a habit of eating or swallowing air (aerophagy). Neurotics suffering from indigestion some- times experience trifling discomfort in the stomach which they attribute to an accumulation of gas, and in their efforts to obtain relief they expel whatever the stomach contains, whether "gas" or atmospheric air, and in the act swallow more air. Diagnosis. — The diagnosis of this condition is not difficult when the phj^sician has an opportunity to observe the patient during a spell of eructation. The presence of food decomposition in the stomach should be ruled out by exami- nation of the gastric contents removed by the tube. Treatment. — The treatment of this condition is largely psychic, and the physician must impress upon the patient the fact that he can prevent the condition himself if he will. The nature of the affection should be carefully explained to the patient, and he should be prevailed upon to cease the eruc- tation as well as the frequent swallowing movements. The French recommend that the patient take a cork between his teeth to keep the mouth open and prevent swallowing; this should be done after meals, every day for a protracted period of time. The patient can be instructed to wear a tight collar so as to make swallowing painful and attract his attention to the act. The underlying nervous condition will in many cases yield to electricity, change of climate, or hydrotherapeutics. Hyperalimentation is known to have a salutary effect upon weakened patients. Methodic treatment by sounds introduced into the esophagus is some- times followed by beneficial results. The medicinal agents indicated in this condition consist of the bromides, bella- donna, chloroform water, and preparations of valerian. Gm. or Cc. I^ — Bismuthi salicylatis 15.0 3iv Mentholis 1.0 gr. xv Mucilaginis acacise . . . . q. s. ad 90.0 5iij Misce. Sig. — One teaspoonful every three hours for the next day or two follow- ing irrigation of the stomach with six to eight liters of water containing about 10 Cc. of chloroform water per liter. 272 MOTOR NEUROSES In cases of aerophagy accompanied by severe pain, opium or some opium preparation is indicated. Suppositories of opium and belladonna serve a good purpose. Stern advises the following combination for intestinal tympany following aerophagy : Gm. or Cc. I^ — Oleiricini 15.0 Sss Pulveris acacise 7.5 5 ij Spirit us chloroformi 10.0 oiiss Heroini 0.15 gr. iij Tincturae vanillse 2.0 Tllxxx Saccharini . 06 gr. j Aquae q. s. ad 100.0 giij Misce. Sig. — One teaspoonful every hour. PNEUMATOSIS (DRUM-BELLY) This term is used to designate a condition in which the stomach is greatly distended by air. The patient experiences symptoms which are referable to the heart, such as irregu- larity in rhythm, and dyspnea, as well as abdominal tension. Pneumatosis of a purely nervous character is due to the habit of swallowing air. Sometimes the condition is asso- ciated with spasmodic simultaneous closure of the pylorus and cardia, which renders it impossible for the air to escape. The distressing symptoms usually vanish with the expulsion of the air. Treatment. — Pneumatosis is treated as nervous eructa- tions. The treatment should be directed toward increasing the strength of the organism as a whole. The drug treatment consists of the administration of bromides, cocaine, and morphine, the latter to be given either by mouth or by hypodermic injection. Boas recommends the extract of Calabar bean and the extract of nux vomica as follows: Gm. or Co. I^ — Extract! pliyso.stigmatis 0.5 gr. viiss Extract! nucis vomicae 1.0 fir. xv Pulveris extract! glycyrrh!z:p . q. s. Misce et ft. p!l. no. 1. Sig. — One i)ill tlircc tiinc.'^ a day. NERVOUS VOMITING 273 Physostigmine is the active principle of Calabar bean. It is supposed to have a stimulating effect upon unstriped muscle fibre. If it can be used without too great discomfort to the patient, the stomach tube will give immediate relief by enabling the air to escape. Fey^ reports a case of pneumatosis in which he stretched the cardia with a Gottstein dilator after the use of bougies of progressive size. The permanent distention secured a circumference of 14.5 Cm. The patient still swallows air, but readily expels it. NERVOUS VOMITING Nervous vomiting produced by disturbances of the nerv- ous system, both central and peripheral, without external irritation or anatomic lesion, is a purely functional disorder. It occurs without any overexertion and is independent of the quantity and quality of the food ingested. It varies in relation to the different kinds of diet ; is often absent when particles difficult of digestion have been eaten, and may be present when only suitable food has been taken. Organic diseases of the central nervous system are not infrequently accompanied by vomiting of this nature. The gastric crises of tabetic patients are of peculiar interest in connection with this subject. They occur as a very early symptom of locomotor ataxia, and consist in violent attacks of vomiting, usually accompanied by intense gastric pain. The vomiting may last for days, placing the patient in a very grave condition. There are also purely motor gastric crises, which run their course without any sensa- tion of pain, vomiting being the only distressing symptom. This latter condition is not amenable to treatment, which should be directed against the cause rather than the symp- tom. The cause, in a large majority of cases, is syphilis. A few writers have described attacks of what they term idiopathic vomiting, which resemble very closely the gastric 1 Deutsche medizinische Wochenschrift, October 6, 1910. 18 274 MOTOR NEUROSES crises, and in which they were unable to detect any patho- logic condition of the spinal cord. Nervous vomiting is also frequently found in hysterical patients and in neuras- thenics; it adds sometimes to the distressing symptoms of patients suffering from enteroptosis, atony, and nervous dyspepsia. Organic conditions, however, must be excluded before a diagnosis can be established. Nervous vomiting is very characteristic. It takes place with seeming ease, without preceding nausea; it is likewise independent of the quality of the food, but largely influenced by psychic causes. The general nutrition is, as a rule, easilj^ maintained. Treatment. — The treatment of emesis of purely nervous origin is identical with that of neurasthenia, hysteria, and enteroptosis. In the presence of obstinate vomiting, recourse may be had to drug treatment, when such seda- tives as cocaine, menthol, morphine, chloral hydrate, valerian, validol, menthol-valerian, chloroform on ice, orthoform, or anesthesin may be used. Sokolsky reports a case of hyperemesis gravidarum which was completely cured by eight injections, each of 1 Cc. of a 1-per-cent. solution of cocaine, in the epigastric region. Lemoine^ claims to have found the following mixture valuable not only in the vomiting of pregnancy but also in various cases of gastritis : Gm. or Cc. I^— Mentholis 0.3 gr. v Tincturse opii, Tincturae belladonnse aa 1.0 TTlxv Tincturse hyoscyami 1.0 TTlxv Alcoholis 20.0 5v Misce. Sig. — Five drops, in a little water, every hour. Snowman^ considers bismuth one of the best drugs for the treatment of that class of vomiting which results from gastric irritation, but considers it of very little use in other forms. Cerium oxalate (U. S. P.) has probably the same action in allaying vomiting as bismuth. It has acquired a reputation in the treatment of vomiting of pregnancy which ' Nord Medical, September 15, 1904. 2 London Lancet, March 12, 1910. NERVOUS VOMITING 275 clinical experience, as a rule, fails to confirm. Creo- sote, iodine and phenol may be grouped together as a series of drugs which allay vomiting that is produced by fermentative action in the stomach. The vomiting ceases upon removal of the cause. Creosote and phenol have, however, a local anesthetic effect which may in some measure explain their anti-emetic virtue. Hydrocyanic acid is another drug with a reputation in gastric vomiting; if, however, results are not obtained immediately, it is useless to persist with it. Aconite, in rather large doses, allays vomiting by numbing the reflex centres and thereby acting as a powerful sedative to the peripheral nerves in the gastric mucous membrane. It is one of the host of drugs suggested for the vomiting of pregnancy. Chloretone in doses of 0.3 to 0.5 Gm. (5 to 8 grains) relieves pain and allays vomiting resulting from some local pathologic cause, such as cancer. When vomiting is of reflex origin it is worth while to persist with potassium bromide, which may be given per rectum if not tolerated by the stomach. Rebaudi reports a case of hyperemesis or pernicious vomiting in pregnancy which yielded to treatment with adrenalin. Ten drops of a 1-to-lOOO solution were given every morning and night, at first in an enema of 150 cubic centimeters of water, with 20 drops of tincture of opium, and after three days in ice water by mouth. The vomit- ing ceased by the second day, when the patient was able to retain a little food. The dose was reduced on the eleventh day to 10 drops a day and continued for nine days more. Opium may be administered in the form of suppositories. Morphine hypodermically administered is a most valuable remedy for vomiting that is persistent and exhausting. It acts unquestionably as a powerful sedative to the vomiting centre, and will afford relief as definitely as it does in a paroxysm of pain. Stimulants to the gastric mucous membrane, such as the following, have been found effective in allaying vomiting of purely nervous origin: 276 MOTOR NEUROSES Gm. or Cc. I^ — [Nlentholis 0.1 gr. iss Cocainse hydro cliloridi . 05 gr. j Alcoholis q. s. ad ft. sol. Aquae chloroformi 120.0 oiv SjTupi corticis aurantii 30.0 §] Misce. Sig. — One tablespoonful everj- two hours. (Wegele.) Gm. or Cc. I^ — Tinctura; iodi 0.5 gr. viiss Spiritus ^-ini galhci, SjTupi corticis aiu-antii . . . . aa 30.0 oj Misce. Sig. — One teaspoonful in half a tumbler of water three or four times a daj^ (Rodari.) Gm. or Cc. I^ — TinctuTse iodi, Chloroformi aa 5.0 5 J Misce. Sig. — Five minims to be taken on sugar after each meal. (Wegele.) Suggestive or psychic therapeutics and the use of gastric lavage, simple sounding and intraventricular galvanization have produced favorable results with hysterical patients. Apostoli, as early as 1884, recommended galvanism as especially efficacious in the control of vomiting from reflex causes, as well as the h^^sterical variety. He places the positive pole on the side of the neck and the negative over the epigastrium, on the assumption that the descending gal- vanic current passes along the pneumogastric nerve. Another method, known as Apostoli's bipolar method, con- sists in passing the current transverseh' through the neck just below the mastoid region. By experience it has been found that the passage of the current from one side of the neck to the other is more efficient than the neck-to-epigas- trium treatment. Nervous vomiting is sometimes induced reflexly by a pathologic condition of other organs. To this class belong the so-called vomiting of i)regnancy and vomiting of child- hood. RUMINATION— MERYCISM 277 RUMINATION, MERYCISM Rumination is an unhappy faculty possessed by some patients by which they can bring back at will the food from the stomach to the mouth some time after it has been swal- lowed, to be again swallowed or expectorated. It is more common in males than in females. It affects neurasthenics, hysterical and epileptic persons, and sometimes idiots. In this class of patients rumination sometimes results from fright, rapid eating, overfUhng of the stomach, traumatism, or irritation of the stomach by chemical or thermal agents. It has been observed to develop in other patients by mere imitation; children of parents who ruminate are likely to indulge in the pernicious practice. The exciting causes mentioned induce, refiexly, ante- or retro-peristaltic move- ment, which results in the opening of the cardiac orifice, permitting the food to regurgitate to the mouth. Rumination is frequently preceded by nervous dyspeptic symptoms of a mild nature, which become graduall}^ aggra- vated until the fluid contents of the stomach are regurgitated. Some persons appear to possess a peculiar power over the cardiac orifice, to open or close it at will. The regurgitation of food is not accompanied by nausea, and in many cases produces no discomfort whatever. In other cases, how^ever, the food, having remained for a considerable length of time in the stomach, has become sour and disagreeable to the taste when regurgitated; the patients, annoyed, naturally spit it out. As might be expected, the habitual expectora- tion of food masses leads to marked emaciation of the patient. In these cases the secretion of gastric juice may show great variation from the normal, or it may be perfectly normal. Treatment. — Psychotherapeutics must be resorted to as the chief factor in the treatment of these cases. The patient must be energetically persuaded to suppress the regurgita- tion of food. The nervous condition underlying the perni- cious habit requires appropriate treatment. As a prophy- 278 MOTOR NEUROSES lactic measure, patients should be instructed to eat slowly and to thoroughly masticate their food. Such patients should not be left alone, either during the meal or for some little time afterward, since the presence of company imposes a salutary restraint on the ruminating habit. When the desire to ruminate arises, expiration should be postponed for a moment or two and swallowing movements suppressed. Patients should not talk while eating. It is important that defective teeth be either repaired or extracted. Children should be kept away from ruminants in order to avoid con- tracting the habit by imitation. Good results have followed the administration of acids in achylia, and large doses of alkalies in hyperacidity. Sometimes the patient experiences pain of greater or less severity in the region of the stomach when he attempts to suppress the practice of rumination, and in such cases w^arm applications or suppositories in which narcotic drugs are incorporated assist in relieving the distress. The bromides and strychnine are also indicated. The chief requirement in the treatment of this form of gastric neurosis is to fortify the will power of the patient sufficiently to suppress the practice. Ferrannini has reported favorable results from the use of atropine in the treatment of merycism or rumination; any digestive disturbances that may be present, however, must be first corrected. The masticatory apparatus must be kept in proper condition by the dentist. Lincoln, while empha- sizing suggestion in treatment, also advises, when the regur- gitation is habitual, that the patient be forced to swallow the regurgitated food. Meals should be served in company. The administration of a bitter preparation, as quinine, with the meals is likely to do away with any desire to ruminate. REGURGITATION Regurgitation proper is a condition in which the food returns involuntarily from (ho stomach to the mouth and is expectorated. It may occur in health, but becomes A Case of Pyloric Insufficiency. The Roentgenograni was taken ininnediately after the patient was given one ounce of bismuth subearbonate in twelve ounces of koumiss. The dark area outlining the stomach shows that the organ is almost eonipletely filled, practically^ none of the test meal having passed through the pylorus. A coin covers the umbilicus. PLATE XVI A Case of Pyloric Insufficiency. The Roentgenograni -vvas taken one- half hour after patient was given one ounce of bismuth subearbonate in twelve ounces of koumiss. Com- paring this writh the preceding plate, 'we find that the dark area (outlined by the bismuth) has decreased in size so that only about one-eighth of the ingested mass reniains. A coin covers the umljilieus. PLATE XVI 1 A Case of Pyloric Insufficiency. The Roentgenogram was taken immediately after the patient was given one ounce of bismuth subearbonate in twelve ounces of koumiss. The round dark shadow is a coin fastened over the umbilicus. The dark area above shows the outline of the stomach filled with bismuth. INSUFFICIENCY OF THE PYLORUS 279 pathologic when it persists over a prolonged period and when the quantity of food brought up is large. Emacia- tion results when patients regurgitate any considerable por- tion of the food ingested. The treatment of this condition is similar to that of rumination. INSUFFICIENCY OF THE PYLORUS Pyloric insufficiency (see Plates XV, XVI, XVII, XVIII, and XIX) is a condition which has been known frequently to follow organic diseases. It has been noted after destruc- tion of the sphincter muscles of the pylorus by carcinoma ; cicatrices from gastric ulcer in the region of the pylorus; duodenal stenosis; catarrh of the stomach; and achylia. Pyloric insufficiency from purely neurotic causes is of exceed- ingly rare occurrence. Among the most important diag- nostic indications of pyloric insufficiency is the fact that air blown into the stomach escapes immediately into the gut, thus rendering artificial distention of the stomach impossible. The flow of bile and of the contents of the small intestine into the stomach is likewise suggestive of a relaxed pyloric orifice. The diagnosis is easily made by means of the x-ray. Treatment. — The treatment of pyloric insufficiency depends upon the stage of the disease. The clinician should endeavor to find out if there is any gastric secretion, and how soon after the ingestion of food the stomach becomes empty. The stomach contents should be aspirated one hour after the test meal is taken. If nothing be forthcoming, the test meal should be repeated on the following morning and the stomach tube used afc a half -hour interval after the meal. If again unsuccessful, the test should be repeated on the third day, the interval after eating being reduced to a quar- ter of an hour. By this means it is possible to ascertain the quantity of gastric contents present at any time. The drugs indicated in this disease are such as aid intestinal digestion, since derangement of intestinal digestion, accompanied by distressing symptoms, is apt to arise from the premature passage of the food into the duodenum. The combinations 280 MOTOR NEUROSES of sodium and magnesium, rhubarb, ammonium chloride, pancreatin, and bile in the form of inspissated ox-gall, are about all the drugs necessary. Quite as important as the drugs themselves is the proper time after the ingestion of food for their administration. If it be found that the stomach is emptied immediately after eating, the drugs should be prescribed to be taken immediately after eating. If, on the other hand, the examination reveals that there is still some gastric digestion and that the ingested food does not immediately leave the stomach, the interval of time be- tween food and medicine must be dete Tuined accordingly. Hydrochloric acid and pepsin should not be administered, since they are of practically^ no use at any time for helping gastric secretion in this class of cases. Hydrochloric acid can never be given in effective strength, and pepsin is very seldom absent except in achylia gastrica. In diarrhea associated with this condition, strychnine has been found to give the best results (Knapp) . This drug should be rapidly pushed to the point of tolerance. Many cases of diarrhea which have existed for years have been known to respond most satisfac- torily to the administration of strychnine sulphate. The stools at once diminish in number and gain in consistency. StrjTh- nine has been known to produce excellent results in about three and a half weeks in diarrhea resulting from insuffi- ciency of the pylorus. Coffee, tea, too rich cocoa, carbon dioxide waters, beer, wine, brandy and whisky, beans and peas (unless their cellulose envelopes are removed after soaking in water over night), cabbage, cauliflower, radishes, turnips, spices, toma- toes in every form and everything prepared with vinegar, grapes, peaches, plums, and prunes, should be denied this class of patients. The condition of the teeth should be carefully looked after and the necessary dental work done. Half a teaspoonful of sodium sulphate in a glass of hot water, taken hot about half an hour before each meal, will best cleanse the stomach of any mucus that may be present. Symptomatic treatment is not required in pyloric insufficiency of purely nervous origin. PLATE XVlll A Case of Pyloric Insufficiency. The Roentgenogram -was taken fifteen niinutes after the patient was given one ounce of bismuth subearbonate in twelve ounces of koumiss. The round dark shadow niarks the umbilicus. A large quantity of the bismuth has escaped into the small intestine. PLATE XIX A Case of Pyloric Insufficiency. The Roentgenogram was taken thirty minutes after the patient was given one ounce of bisniuth subeartaonate in twelve ounces of koumiss. The round dark shadow marks the umbilicus. Nearly all the bismuth has passed from the stomach into the small intestine and shows laelow m the irregular dark blotches. SINGULTUS GASTRICUS 281 SINGULTUS GASTRICUS Singultus, or hiccough, is a symptom manifest as a sound made by the sudden and involuntary contraction of the dia- phragm and the simultaneous contraction of the glottis which arrests the rising air in the trachea. Singultus may last for a few minutes or much longer, or it may recur for days or months. It is a symptom often found in diseases of the abdominal viscera, such as gastritis, motor insufficiency of the first and second degrees, gastric carcinoma, enteritis, intestinal obstruction, appendicitis, cholera, pancreatitis (suppurative), diseases of the liver, and peritonitis; it has also been observed in the course of such diseases of the nervous system as epilepsy, tumor of the brain, meningitis, hydrocephalus, and hysteria. In rare cases of singultus gastricus a continuous hiccough lasting for a long time, varying from weeks to months, and without any gastric return, may be present. There is usually, however, a hyperesthesia of the glandular layer of the stomach. It is found usually in well-nourished young adults and most often in female patients. Hiccough is occasionally a prominent symptom of gall-bladder disease and may be so incessant as to produce alarming exhaustion. According to Habershon, in most cases the liver is at fault, and, though the primary cause is usually an indigestible or improper diet, it is the congestion or disturbance of the liver that is the exciting cause. The treatment should be directed toward the underlying cause. CHAPTER XII SENSORY NEUROSES : GASTRALGIA — HYPERESTHESIA — G AS- TRALGOKENOSIS— NAUSEA— BULIMIA— AKORIA— ANOREXIA —EYE STRAIN GASTRALGIA, CARDIALGIA, GASTRODYNIA, NEURALGIA OF THE STOMACH Gastralgia is a condition peculiar to individuals of a nervous temperment. The diagnosis of this condition cannot be confu'med until a careful exclusion is made of organic dis- eases of the stomach and intestine and the more remote vis- cera. The pains complained of in gastralgia are due to morbid or irritating conditions of the sympathetic nervous ganglia located in front of the spinal column. The site of the pain is the epigastric portion of the lumbar sjTnpathetic. The celiac plexus, the superior mesenteric plexus and the aortic plexus may also be involved. The location of the pain is in reality exterior to the stomach. The nervous gastric pains occur periodically and spasmodically, and at times become so intense as to be unbearable. The attacks last from a few hours to several days; the pains radiate toward the back and also up into the chest. They are usually inde- pendent of the reception of food. Nervous excitement is apt to bring on the attacks, during which vomiting rarely takes place. Eructations are common. The celiac plexus is often markedly sensitive to pressure exerted in the median line of the epigastric region. The superior mesenteric plexus, as well as the aortic, occasionally becomes very sensitive, as elicited by pressure on two points situated immediately above and below the umbilicus. There is often found a hyperesthetic zone in the epigastrium. The differential diagnosis between gastralgia and ulcer of the stomach is fraught with difficult}-, and established onlj'' GASTRALGIA—CARDIALGIA—GASTRODYNIA 283 after careful consideration of the symptoms of ulcer, such as occult hemorrhage, pressure points, and relation of the pains to the reception of food. In ulcer the hyperesthetic cutaneous zone is usually smaller in area than in gastralgia. Among the recognized causes of gastralgia, Allen A. Jones says syphilis should be given a more prominent place. Treatment. — The treatment of gastralgia should be di- rected toward the generally debilitated condition of the patient, and should consist, among other things, of hydro- therap}', change of climate, and the milk cure. Very little or no restriction need be made in regard to diet, since the condition is purely extragastric. It is not necessary that patients should be kept on either fluid or light diet. The regimen may be varied and generous in quantity with- out aggravating in any way the painful symptoms. The diet, however, should be suited to the individual case. It will be necessary in many cases of this class to persuade patients to eat, and to impress upon them that there is no connection between the ingestion of food and the pains of which they complain, but that there is danger of aggravating the symptoms by abstaining from food. During the acute attack the patient should be put to bed and hot compresses or poultices should be applied to the region of the stomach. Good results are obtained by a "half bath" or a protracted hot sitz bath. When the pains are of a violent nature, resort must be had to such drugs as mor- phine or opium and belladonna in combination. Gm. or Cc. I^ — Morphinae sulphatis 0.01 gr. § Extract! belladonnse . 02 gr. | Olei theobromatis 2.0 gr. xxx Misce et ft. suppos. no. i. Sig. — As required for the relief of pain. Gm. or Cc. I^ — Extract! opii . 05 gr. | Extract! belladonnse . 02 gr. | Olei theobromatis 2.0 gr. xxx Misce et ft. suppos. no. !. Sig. — As required for the relief of pain. 284 SENSORY NEUROSES Gm. or Cc. I^ — Cocainse hydrochloridi 0.5 gr. viiss Aquae aurantii . . 30 . gr. § i Aquse chlorof ormi 75 . gr. § iiss Aquse destillatae 45.0 oiss Misce. Sig. — One to three teaspoonfuls in water at the beginning of the attack. In severe cases morphine should be given hypodermically at once. Among the medicaments which may be admin- istered per mouth are cocaine (0.05 Gm. to 150 Cc. water, in teaspoonful doses), codeine, dionin, 0.03 to 0.05 Gm. (i to 1 grain), chloral hydrate, antipyrine, 0.5 Gm. (7^ grains), phenacetine, 1.0 Gm. (15 grains), chloroform water, validol, and valerian preparations, such as the ammoniated tincture of valerian. Extract of cannabis indica has also been recommended for the pains of gastralgia. Gm. or Cc. I^ — Extracti cannabis indicse . 03 gr. ss Sacchari albi . 50 gr. viij Misce et ft. pulv. no. i. Sig. — One every four hours. Gm. or Cc. I^ — Tincturse cannabis indicae . . . . 4.0 oi Tincturse Valerianae 6.0 5 iss Misce. Sig. — Twenty drops to be taken at a dose. Hoffman's anodyne, 20 to 30 drops on a lump of sugar, is recommended by Einhorn for the treatment of this condi- tion. Hot drinks such as peppermint tea or valerian tea are productive of favorable results. If convenient, galvaniza- tion is worthy of a trial, when the anode should be placed over the epigastrium and the cathode over the spinal column for from five to ten minutes. The faradic current may also be used. In cases where pains are less violent but of prolonged duration, massage and electricity are indicated in addition to warm applications. Eisner recommends a systematic course of massage of the epigastrium in order to reduce the hypersensitive condition of the sympathetic plexus. One GASTRALGIA—CARDIALGIA—GASTRODYNIA 285 or two fingers of the right hand should be appHed over the epigastric pressure point, and by rotating movements the hand should be made to penetrate gradually toward the sympathetic plexus. In the initial stages of the massage, patients experience severe pain, which, however, eventually disappears, and rapid improvement follows. Intraventric- ular galvanization may be practiced at the same time. The physician must persist, however, in this treatment if he is to obtain permanent results. A special form of gastralgia is represented by the gas- tric crisis of locomotor ataxia, which is characterized by violent cramps in the stomach and pains in the back, followed by vomiting. Ewald maintains that idiopathic crises, so called, may be influenced therapeutically, which is hardly ever the case with true tabetic crises. As to the nature of these crises we are still in the dark, nor have we by any means been able to cut short the attacks except by the use of morphine or the injection of cocaine to anesthetize the posterior roots. The following drugs are recommended in addition to the measures already described for the acute painful seizures : Antipyrine, . 6 Gm. (10 grains), cerium oxalate, 0.3 to 0.6 Gm. (5 to 10 grains), three times a day; aspirin and the salicylates. Gm. or Cc. I^ — Sodii salicylatis 8.0 5ij Caffeinse sodiosalicylatis 2.0 gr. xxx Aquae q. s. ad 50.0 §ij Misce. Sig. — 1 to 2 Cc. of the sterilized solution to be injected daily into the median vein. (Von Mendel.) The majority of gastralgias are secondary affections, and may occur in the course of almost any infection of the stomach or other abdominal organ, in arteriosclerosis, in intoxications, anemia, and diseases of the male and female sexual organs. In gastralgia resulting from these condi- tions treatment should be directed toward the primary cause. Moszkowicz and Gozl/ of Vienna, recently reported a ' Lancet, June 11, 1910. 286 SENSORY NEUROSES case of gastric crisis in which the patient had been brought to such a degree of despair that he was prepared to undergo any form of treatment that might give promise of reUef. It was resolved to divide the posterior roots of certain spinal nerves. The seventh, eighth and ninth roots were selected and divided, so as to sever the dorsal portion which contained the sympathetic fibres leading to the stomach. Since the operation the patient is reported to have lost his former distressing symptoms of incessant pain, vomiting, and mental depression. He has gained in weight, and the only outward symptom due to the operation is an anesthetic zone around the abdomen. GASTRIC HYPERESTHESIA Gastric hyperesthesia is defined as an increased sensitive- ness of the gastric mucous membrane to chemic, mechanic, and thermal stimuli, or to any one of these. A patient with a good appetite may suffer pain when certain articles of food or drink are taken, which is not relieved until the food or drink has disappeared from the stomach. The stomach is often hypersensitive to sugar, fat, and carbo- hydrates. Of thermal stimuli the stomach is more sensitive to cold than to heat. The abnormal sensations may vary, amounting in some cases to severe pain and vomiting. Dur- ing digestion there may be sensations of fulness, pressure, tension, or burning, but these usually cease with the evacu- ation of the stomach. Gastric hyperesthesia is a condition rather frequent in neurasthenic and hysterical subjects. Patients come to associate the distressful symptoms with the ingestion of food, and as a result the quantity of food consumed becomes less and less and the patient loses flesh and strength. Treatment. — The treatment should be directed against the cause. Efforts should be made to improve the general nutrition, and, if necessary, a course of hyperalimentation should be instituted. Asthenic patients re(iuirc rest in bed, and should be kept absolutely quiet both mentally GASTRIC HYPERESTHESIA 287 and physically. The nutrition cure should be commenced with caution; it should consist at first of milk and kefir, to be gradually changed to a diet of semisolid consistency. The dietary should be such as to reaccustom the patient to ordinary food. When the distaste for food is very marked it may be necessary, at times, to resort to nutritious enemata. Nitrate of silver is particularly effective in diminishing the sensitive condition of the stomach. A tablespoonful of a solution of . 2 to . 3 Gm. (3 to 5 grains) to 100 Cc. of water is given three times a day. It is best administered as a tablespoonful of the solution to a wineglass of distilled water, before breakfast, and half an hour before dinner and supper. Lavage with silver nitrate solution (1 to 1000) also acts well. When there is much pain, belladonna, chloroform or a preparation of valerian is indicated. Anes- thesin may be given in doses of . 25 to 0.5 Gm. (4 to 7i grains), ten to fifteen minutes before meals. Pick^ recom- mends the faradic current, though he admits that this treatment is largely suggestive. Dr. Charles G. Stockton, of Buffalo, advises a bland diet, commencing with milk and eggs and going on to farinaceous foods. He also recom- mends electricity and hydrotherapy, though care should be exercised against the excessive employment of cold water. For the relief of' gastric irritation, Rochester^ advises the following combination : Gm. or Cc. I^ — Strontii bromidi 6.0 3iss Sodii bicarbonatis 40.0 5x Carbonis ligni 20.0 3v Bismuthi subcarbonatis 20.0 5v Magnesiae ISO.O 5vj Misce. Sig. — Two teaspoonfuls in water three times a day, after meals. If between meals patients are troubled with burning or pain in the stomach which may be accounted for by the presence of hyperacidity, the following will be found a satisfactory gastric sedative: ^ British Medical Jorunal. - New York State Medical Journal, April, 1908. 288 SENSORY NEUROSES Gm. or Cc. I^ — Cerii oxalatis 10.0 5ijss Bismuthi subcarbonatis 20.0 qv Magnesii oxidi 40.0 5x Misce. et. ft. pulv. no. xviii. Sig. — A powder stirred in water, and repeat in an hour if needed. GASTRALGOKENOSIS The term " gastralgokenosis" was used by Boas to desig- nate stomachache, or the sensation of painful pressure in the region of the stomach when that viscus was empty. In this condition there is hyperesthesia of the empty stomach. The pain may become very severe a few hours after eating, when the stomach is empty. Excess of hunger has never been observed to accompany this con- dition, though pain is promptly relieved by the ingestion of food. The patient should endeavor to ward off the attack bj'' never permitting the stomach to become quite empty. He should have with him always some articles of food, such as crackers or milk. Small doses of extract of opium, 0.006 to 0.008 Gm. (yV to i grain), and the bromides, are indicated for this condition. NERVOUS NAUSEA Idiopathic nausea appears most frequently in women and in consequence of a general neurotic condition, anemia and chlorosis, or disturbance of the menstrual function. Purely functional nausea may occur at intervals. Mental excite- ment acts as an exciting cause. Nervous nausea may occur in the morning while the stomach is empty after the night's fast. During these spells patients experience a pronounced aversion to food. The disease may at times assume an ob- stinate form, which Boas attributes to the variable condition of the blood supi)ly to the bruin. The gastric functions, in BULIMIA 289 the majority of cases, are normal; rarely a moderate degree of hyperacidity may be present. Treatment. — When the nausea is due to neurasthenia or anemia, these conditions should receive attention. Anemia may be improved; that is, hemoglobin can be rapidly increased by the hypodermic use of the citrate of iron, as described on page 240. Sometimes the food cure should be instituted in cases where the general nutrition is low. Patients occasionally do well when removed from their homes and customary surroundings. Particular attention should be paid to the mental state of the patient, which is often depressed. Severe cases should be treated in a properly conducted hospital or a sanitarium. Food should be served in an attractive manner, for the sake of its appe- tizing influence and the pleasure which details of this kind give the patient. Should there be nausea early in the morning, it will be well to serve breakfast in bed. Hydro- therapeutics will be found a valuable factor in the treat- ment. Zweig, as a means of cutting short the attack of nausea, recommends a bath of 64° F. or a cold douche. Both intraventricular and extra ventricular galvanization may be employed. The bromides, chloral 0.2 to 0.3 Gm. (3 to 5 grains) three or four times daily, and validol (six to eight drops every two to three hours) are indicated in the treatment of nervous nausea. BULIMIA Bulimia, cynorexia, and hyperorexia are terms used to designate a condition in which the sensation of hunger is more frequent and more intense than in the normal state. Bulimia, as it is called, may be a primary affection, or it may be associated with various other diseases, as gastric ulcer or cancer, hyperacidity, affections of the pancreas, exophthalmic goitre, hysteria, neurasthenia. There is an acute form and a chronic form of this condition; the former is more intense than the latter. ''In the midst of perfect 19 290 SENSORY NEUROSES euphoria, a feeling of intense hunger overcomes the patient, with a desire to satisfy it. This hunger sensation is associ- ated with a gnawing feeling in the stomach, and the utmost fear and anxiety, as if something alarming were going to happen. If the feeling of hunger is not satisfied very quickly, severe headache and trembling of the body, or even fainting spells, may occur." (Einhorn.) The attack of bulimia sometimes yields to the ingestion of a small amount of food, but, as a rule, large quantities have to be taken. Treatment. — The cause of this condition should be care- fully ascertained. The patient should partake of food during the attack ; to this end he should always have ready access to convenient articles of food or drink, as crackers, zwieback, chocolate, or milk. Efforts have been made to influence the irritable condi- tion of the "hunger centre" by the use of drugs. Bromides in large doses, 1 .5 to 2 Gm. (25 to 30 grains), may be given tw^o or three times daily. Boas recommends opium with belladonna, as follows: Gm. or Cc. I^ — Extract! opii, Extracti belladonnse aa 0.01 gr. f Sacchari 0.5 gr. viiss Misce et ft. chart no. i. Sig. — One powder to be taken morning and night. Arsenous acid, 0.001 Gm. (i grain), in pill form, or liquor potassi arsenitis, may be administered. Rosenthal recommends extract of opium hypodermically, or cocaine, 0.03 to O.Oo Gm. (^ to 1 grain), twice a day. Cocaine may also be prescribed in the following form : Gm. or Cc. T^ — Cocaina; hydrochloridi 0.1 gr. iss Aqua; amygdala^ aniarie 10.0 5iiss Misce. Sig. — Ten drops several times a day. Gm. or Cc. I^ — Ammonii bromidi, Sodii bromidi afi 8.0 oij Aqua) men that! piperita' 60.0 5ij Misce. Sig. — One teaspoonful twice daily. (Einhorn.) NERVOUS ANOREXIA 291 Gm. or Cc. I^ — Tincturaj opii camphoratis 90.0 3iij Tinctunc belladonnae 1.0 Tllxv Elixiris aroinatifi . ". . . q. s. ad 180.0 gvi Misce. Sig. — One-half fluidounco three times a day. (Hemmeter.) AKORIA In patients suffering from akoria the normal sensation of satiety is lacking, even after a full meal. Patients do not know when they have eaten enough. There may be no particular desire for food, however, and even well-marked anorexia may be present. Akoria is found in connection with such conditions as give rise to bulimia or polyphagia. Neurasthenics and hysterics are among its victims. The treatment should consist of change of climate, hyperalimen- tation, hydrotherapy, electricity, and psychotherapeutics. NERVOUS ANOREXIA "Nervous anorexia" is a term used to designate loss of appetite of a pronounced and chronic nature. There exists on the part of the patient a repugnance to every kind of food. In spite of this fact, the functionating powers of the stomach and intestine are, as a rule, normal. The disease is apparently characterized by anesthesia of the hunger ''nerves." Nervous anorexia is always a symptom of such general nervous conditions as neurasthenia, sexual neuras- thenia, and hysteria. It may result seriously, from lack of proper nourishment to the body. Among the exciting causes are frequently found great mental depression, worry, anxiety, and fright. Treatment. — This consists in maintaining the nutrition, if need be, by means of the so-called food or hyperahmenta- tion cures. Removal of the patient from his home surround- ings must be considered in grave cases. Sometimes it is 292 SENSORY NEUROSES necessary to resort to nutritious enemata or to gavage. In gavage, or feeding by the stomach tube, such nourishment as milk, eggs, gruel or artificial food is poured into the stomach through a funnel that fits into the external end of the tube. Care must be exercised not to cause too much distention to the stomach, unaccustomed to food in even ordinary quantities, until tolerance has been established. Stomachics, such as orexin, 0.3 Gm. (5 grains), three times a day, two hours before meals, and cinchona bark, are indicated. Gm. or Cc. I^ — Decocti cinchonse 10. Oto 180.0 5ijssto§\T Acidi sulphuric! diluti 0.3 TTl v SjTupi zingiberis . . q. s. ad 200.0 S'^'ij Misce. Sig. — One tablespoonful three times a day, half an hour before meals. Gm. or Cc. I^ — Fluidextracti cinchonse 60 . § ij Sig. — One-half teaspoonful three times a day in a wineglass of water, to be taken before meals. The stomach may also be washed out with water in which stomachics have been incorporated. Arsenic, iron, small doses of the bromides, and strychnine (0.001 to 0.002 Gm.) may be prescribed as occasion requires. Bernheim has used the following in nervous anorexia with marked success: Gm. or Cc. I^ — Acidi nitrohj'drochlorici 15.0 oSS Fluidextracti nucis vomicae 15.0 5ss Fluidextracti taraxaci, Fluidextracti gentiana; aa 30 . 5 j EUxiris glycerophosphatum compositi . . . 60 . 5 ij Misce. Sig. — One teaspoonful in one-quarter of a glass of hot water three times a day, half an hour before meals. Gm. or Cc. I^ — Tincturaj nucis vomica; 20 . 5 v Tinctura; gentiana; composita; 8.0 3ij Tinctura; rhei composita?, Aqua; laurocerasi ail 20 . o v Aqua? ment ha' piperita' . q. s. ad 00.0 oiij Misce. Sig. — One tea-spoonful in wcnk tea, before moals. GASTRIC NEUROSES AND EYE STRAIN 293 Orexin tannate is reported to have been productive of good effects in loss of appetite from purely nervous causes. The usual dose in anorexia is 0.5 Gm. (7^ grains) twice a day, though as small a dose as 0.1 to 0.2 Gm.(l| to 3 grains) three times a day is sometimes prescribed at the beginning of the treatment. GASTRIC NEUROSES AND EYE STRAIN The medical profession are indebted to Dr. George M. Gould for the persistency with which he has maintained that many of the so-called gastric neuroses are due to eye strain. Nervous dyspepsia resulting from eye strain is characterized by such symptoms as sick headache, anorexia, anemia, and many types of malnutrition, all of which may be due to astigmatism or anisometropia. The influence of the visual organs over the digestive system may be proved by the fact that a normal person wearing glasses that may be worn with comfort by another becomes nauseated, even to the point of vomiting. There is no truth in medical science more susceptible of demonstration and more per- sistently ignored in daily practice than the immediate asso- ciation of eye strain and malassimilation. Clement R. Jones^ reports four cases in which complete relief from all gastric symptoms followed the correction of refractive errors and the prescription of proper lenses. It is evident (1) that neuras- thenia gastrica, or nervous dyspepsia, is frequently due to or compHcated by eye strain; (2) that other gastric disturb- ances are sometimes aggravated by eye strain; (3) that along with other points in the examination of gastric cases, careful examination of the visual acuity should be made; (4) that when eye strain is the cause of gastric symptoms, the relief by proper refraction is prompt and satisfactory. Musser declares that ''the correction of errors of refrac- tion will many times relieve so-called 'bilious attacks,' 1 Lancet-Clinic, July 18, 1908. 294 SENSORY NEUROSES periodic vomiting, anorexia, indigestion, and other gastric symptoms." According to Stockton -.^ "Commonly, indeed almost invariably, the etiology of the trouble (functional disturb- ances of digestion) will be found in some remote and perhaps unexpected region of the organism, some leak of general energy, if the expression is permissible, some undiscovered irritation of the nervous system. Thus a retroverted uterus, proctitis, or a displaced kidney, may indirectly lead to the important disturbances in digestion, but more frequent causes of gastric asthenia are to be found in eye strain. This subject has been so widely discussed in America and from so many points of view that it is somewhat threadbare; yet its signal importance remains largely disregarded. Irregular or asymmetrical astigmatism is the visual defect most often responsible for the functional disturbance, but it is not always in astigmatism of high degree that the trouble arises. It is more commonly found in instances of moderate degree of astigmatism with axes differing in the two eyes, and especially in anisometropia. Although not limited to that period of life, the nervous disturbances following these visual defects are apt to appear after the age of maturity, and are especially active when the crystal- line lens begins, from age, to lose its pliability." Gould, after prolonged clinical experience and study of many cases of digestive disturbance, declares that relief of eye strain cures a host of the disorders of digestion. Headaches of all kinds, sick headaches, migraine, hemi- crania, "rush of blood to the head," the commonest and most health- wrecking of all diseases, are almost always due to eye strain. My personal experience confirms the belief that eye strain, as a factor in gastric disturbance, must not be overlooked, since beneficial results are obtained as soon as the errors of refraction are properly corrected. ' Osier's Modern Medicine, vol. v, p. 22. CHAPTER XIII NERVOUS DYSPEPSIA: NEURASTHENIA GASTRICA Von Leube, who first described the condition designated nervous dj'spepsia, included those subjective nervous symp- toms which were, as a rule, of marked intensity, and for which it was impossible to find cause in any of the organic or functional disturbances of the stomach. It was, however, discovered later that nervous symptoms of a like nature present themselves in disturbances of the sensory, secretory, and motor functions. In consequence of this, the term nervous dyspepsia is applied at the present time to a gastric neurosis which is entirely independent of functional dis- turbances, and is of purely nervous origin, although there may be coincident disturbances of the motor, sensory, or secretory functions. Boas says that nervous dyspepsia is not a disease, but a symptom complex, in which organic changes connected directly or indirectly with the digestive organs may be present and not detected, or may be absent. Riegel, on the other hand, believes that nervous dyspepsia is a combined neurosis in which subjective symptoms — namely, sensory disturbances of the stomach — are always present. It may appear as an independent disease and as an inde- pendent neurosis. Etiology. — The cause of nervous dyspepsia must be sought in the increased irritability of the sympathetic nerves of the stomach. This heightened irritability, however, shows itself but rarely as an independent affection. The class of persons apt to be sufferers from this condition are possessed of a more or less irritable and unstable central nervous system. They are spoken of as being of a nervous disposi- tion. In such persons mental emotions, such as fright. 296 NERVOUS DYSPEPSIA sorrow, care, and pathophobia, often act as an exciting cause of actual dyspeptic conditions. Nervous dj'spepsia may be a concomitant of diseases of other organs, particu- larly the abdominal viscera. Constipation, enteroptosis, helminthiasis, often induce nervous dyspepsia, probably by reflection of the irritation of the intestinal sympathetic nerves to the nerves of the stomach. Epigastric hernia is frequently a cause of this neurosis; as are also diseases of the female reproductive organs, such as anomalies of men- struation. During the menstrual period the gastric secretion is often hyperacid. In the male, sexual excesses are not infrequently responsible for nervous dyspepsia. Among the etiologic factors must also be mentioned diseases of such remote organs as the lungs, heart, liver, and kidneys. It has long been recognized that patients who for j^ears had been treated for nervous dyspepsia have been cured after an acute attack of appendicitis which necessitated operation. The condition of the appendix had not been considered in connection with the treatment of the nervous dyspepsia. The medical profession has been slow to appre- ciate the fact that stomach symptoms are frequently due to chronic appendicitis. Unsuspected gallstones may often produce symptoms of nervous dyspepsia. A sudden attack of gallstone colic draws our attention to the gall-bladder; and after removal of the offending gallstones the stomach symptoms entirely disappear. There is a vast amount of preventable suffering, mani- fested by general ill health, vague stomach and intestinal symptoms, progressive loss of flesh and strength, obscure nervous conditions, anemia and obstinate constipation, occasioned by chronic appendicular inflammation.^ The pathologic condition in these cases is often due to a slow proliferation of connective tissue in the walls of the appendix. There is no pus formation, and it maj^ be months or years before an acute attack clears up the diagnosis. When pain is felt in these cases, it is often not in the region of the appendix, ' Chronic Appendicular Inflammation, New York Medical Juuniai, January 13, 1906, p. 94. NERVOUS DYSPEPSIA 297 over the McBurney point; it may be more generalized about the umbiHcus or be referred to the site of the gall-bladder or be felt in the stomach. These reflex pains are not surprising when we remember the abundant connections of the rich nerve supply of the appendix, through the superior mesen- teric plexus of the sympathetic, with the pneumogastric, hepatic, and gastric plexuses. These cases are diagnosticated as nervous dyspepsia and are treated expectantly and symp- tomatically. \^^len the physician has exhausted his patience and resources he classes these patients as neurasthenics, and is likely to send them on a sea voyage, to a mineral spring, or to a sanatorium. Many such cases recover when the appendix or the gallstones are removed. Physi- cians should be on the alert for concealed appendicitis, well named by Ewald ''appendicitis larvata." Obscure as it is, the true diagnosis will often be reached only by a process of exclusion. Kohn^ says we are all too prone to call diseases we cannot understand ''nervous" diseases, for want of a better term. A more honest name for some of them would be "diseases the cause of which we do not know." Appendicitis larvata and cholelithiasis account for many so-called nervous dyspepsias. Perhaps as our knowledge broadens we may eventually be able to account for the remainder. We should endeavor to keep clearly in mind the important fact that if we are not sure the symptoms of which the patient complains are purely nervous we may always satisfy our- selves, when conditions warrant, by the relatively harmless procedure of an exploratory laparotomy. We may thereby save the patient much intense suffering without endangering his life. Symptoms. — Nervous dyspepsia gives rise to a variety of symptoms, some of which are general in character while others are referable particularly to the stomach. It is at times a difficult matter to differentiate between symptoms of purely nervous origin and those which have an organic or ^ Appendicitis Larvata, Surgery, Gynecology, and Obstetrics, October, 1906. 298 NERVOUS DYSPEPSIA functional basis. The variety and variabilit\' of the symp- toms, as well as the manner in which the patient describes them, are characteristic of the condition present. Often such patients are free from distressing symptoms for daj^s, or even weeks, when, owing to some trivial cause, most likely of a psychic nature, a recurrence of the sjmiptoms takes place. The appetite of the patient is apt to be precarious: coarse food in large quantities may perhaps be partaken of without aggravation of the symptoms, while, on the other hand, certain dietetic articles which might be taken with impunity by a person suffering from organic disease of the stomach are rejected as ''not agreeing" with the patient. The general sjmiptoms of which patients suffering from nervous dj^spepsia complain are: fulness of the head, cephalalgia, migraine, inability to work, vertigo, lassitude, insomnia, hypochondriac and melancholic illusions. Op- posed to this catalogue of subjective symptoms the objec- tive symptoms are often inconsiderable. Patients, as a rule, exhibit the well-known neurasthenic type. The condition of nutrition is usually good. When the subjective sj'mp- toms become severe, there is at times a diminution in weight, owing to the refusal of the patient to partake of adequate nourishment. A condition of genuine inanition may develop. Palpation of the stomach often elicits hypersensibility to pressure over the celiac plexus. Cutaneous hyperesthesia is sometimes found over the region of the stomach. While all this is present, the stomach may functionate in a per- fectly normal manner. In other cases, hyperacidity, sub- acidity or achylia may be present, either singly or in com- bination with atonic conditions of the stomach. It is pathog- nomonic of nervous dyspepsia that well-marked variability in the secretory functions sometimes exists, so that in the same patient achjdia, subacidity, normal acidity, and hyperacidity may be discovered at different examinations — heterochylia (Hemmeter). The physician should carefully examine the entire gastro- intestinal tract in every instance of suspected nervous dyspepsia in order to confirm or establish his diagnosis. NERVOUS DYSPEPSIA 299 Many times accurate diagnosis is only achieved after a prolonged period of observation. Prognosis. — The prognosis for a complete cure without recurrence is not favorable. It is possible, however, under proper treatment, to bring about marked improvement in the condition of the patient. Riegel never saw a case that terminated fatally, and this agrees with my experience. Prophylaxis. — As prophylaxis, the children of neurotic individuals in whom the habitus enteroptoticus is well marked should be kept well nourished and should be given gymnastic exercises. The avoidance of excessive mental exertion is an important prophylactic measure. Treatment. — The treatment of nervous dyspepsia per se should be directed toward correcting the causes, whatever they may be. If the nervous dyspepsia is secondary, the primary condition should receive appropriate treatment. The subjective symptoms of the patient yield most readily when he is removed from his customary environment and is accorded complete rest of both body and mind. Marked benefit has resulted in some cases from a "six weeks' period of absolute rest. During the rest cure, so called, the patient's mind should be occupied as little as possible. The relationship of the physician and patient in such cases is of the utmost importance. That physician will have the greatest success, other things being equal, who knows how to gain the confidence of his patient and is able to exert an influence over him. Many patients, however, owing to domestic or financial circumstances, are unable to leave their home surroundings. Such patients should be kept in the recumbent position for a few hours during the morn- ing and afternoon. The question of nutrition is of paramount importance. The diet should be adapted to the individual case, and greater latitude may be permitted in regard to varietj^ and quantity than in cases of organic gastric disease, since the dyspeptic symptoms are not intimately connected with the food in the stomach. An effort should be put forth to maintain the nutrition of the patient to the greatest possible extent. When constipation is present, coarser foods and 300 NERVOUS DYSPEPSIA foods leaving a considerable residue are indicated. Even when the general nutrition is normal the nervous symptoms sometimes disappear after a course of hyperalimentation. When, however, well-marked secretory disturbances are present, the diet should be adapted to the condition of the secretion. Atonic states of the stomach must be like- wise considered in prescribing diet. Patients whose symp- toms appear synchronously with the entrance of food into the stomach should receive a bland, non-irritating diet at the commencement of the treatment, to be gradually changed to one of a more solid consistency. \\Tien an aversion or distaste for meat exists, other protein foods must be substi- tuted. Sometimes, however, a purely vegetarian diet is fol- lowed by good results. When meat is eliminated from the diet, there is a corresponding diminution of gastric secretion. To supply the needed stimulus to secretion, meat extracts may be prescribed. The meat-free vegetarian diet, as sometimes prescribed in gastric diseases, is not identical with that of a strict vegetarian, who places great stress on the consumption of raw fruits and vegetables. A vegetarian diet proper would be too coarse, too voluminous and too poor in iron for patients with gastric disease. For the ner- vous dyspeptic the so-called lactovegetable diet is worthy of consideration; this diet includes certain animal products, such as milk, butter, and eggs. Coarse indigestible food should be avoided by patients suffering from nervous dys- pepsia, and the diet should possess as high a nutritive value as possible in proportion to the amount ingested. Such foods as radishes, celery, fresh fruit, nuts, almonds, dates, horseradish, and mushrooms should not be permitted this class of patients. These food articles are, however, suitable to dyspeptic patients suffering from constipation, provided the state of their nutrition is good and their symptoms are not associated with the ingestion of food. In prescribing a vegetarian diet the physician should take into consideration the individual requirements of the patient. While green vegetables may be used in large quantities, they should be prepared and served in a finely divided state or in the form of puree. Dry vegetables and leguminous flours NERVOUS DYSPEPSIA 301 rich in protein should be prescribed in Uberal quantities. Flour and egg dishes in the form of puddings, jam, and fruit juices are well borne by the nervous dyspeptic. The unfer- mented juice of grapes, possessing a comparatively high nu- tritive value, is a suitable beverage. Of baked foods, wheat bread, zwieback, rusks, biscuits, and brown bread may be prescribed. The protein in lactovegetable diet may be supplied in the form of eggs, milk, and cheese; the fat constituent of such diet is derived from butter, oil, milk, and cream. Milk should be fed to this class of patients in large quantities, pure, or as buttermilk, sour milk, kefir, or Yoghurt milk (see p. 93) . Yoghurt milk is said to possess the power of lessening the decomposition process in the intestinal tract. In prescribing a lactovegetable diet the condition of the gastric secretion should be closely studied. In order to assist the patient in maintaining a fair appetite, monotony in the articles of food prescribed should be avoided. Of beverages, tea is preferable to coffee. Alcoholic drinks should be avoided entirely. Lactovegetable Diet List (Wegele) Morning Forenoon Noon Afternoon Evening 250 Gm. milk cocoa 100 Gm. rolls . . . 30 Gm. butter . . 250 Gm. milk pap with white of egg 250 Gm. vegetables with rice .... 250 Gm. pudding . 150 Gm. apple sauce . 250 Gm. milk cocoa . 100 Gm. rolls . . . 30 Gm. butter . . 200 Gm. gruel with yolk of egg ... . 200 Gm. water noodles 125 Gm. plums 100 Gm. rolls . . . 30 Gm. butter . . Protein. 9.0 9.0 0.5 12.0 5.0 15.0 3.0 9.0 0.6 3.5 5.0 0.4 9.0 0.6 81.6 Fat. 10.0 1.0 24.6 8.0 18.0 25.0 10.0 1.0 24.6 7.5 1.5 1.0 24.6 1.56.8 Carbohydrate. 72.50 58.00 0.15 11.00 20.00 50.00 20.00 72.50 58.00 0.15 18.00 40.00 8.30 58.00 0.15 486 . 75 Calories 300.0 Total combustion value, 3660 calories. 1300.0 2060.00 302 NERVOUS DYSPEPSIA Physical Treatment. — Hydrotherapeutic measures are indicated for the general nervous condition which charac- terizes patients suffering from nervous dyspepsia. These measures consist of cool rubbings, half baths, cool douches, and cold baths. The Scotch douche, alternate cold and hot applications, may be used locally over the region of the stomach. Patients whose state of nutrition is good should be persuaded to persevere in gymnastic exercises; those in a run-down condition should not undertake exertion of any kind before the condition of their nutrition has improved. Massage, including vibratory treatment, may be instituted for the purpose of stimulating tissue metamorphosis; it may include the whole body or simply the stomach or abdomen. Electric treatment, galvanic or faradic, of the stomach and intestine, may be used with advantage. Rose reports excellent results from the application of his plaster belt (Fig. 32). Whenever gastroptosis or entero- ptosis is a complication in gastric neurosis, the treatment indicated for those conditions and described in detail in Chapter X should be instituted. Mineral Waters. — Mineral water cures are contraindicated in perhaps the majority of cases of gastric disease of purely nervous origin. In nervous dyspepsia resulting from chlorosis and anemia the ferruginous mineral waters may be prescribed. The ferro-arsenous waters of Levico and Roncegno are indicated in cases of anemia. Among other springs of this class may be mentioned Harbin, Hot Sulphur Springs, Crockett Arsenic Lithia Springs, and Swineford Arsenic Lithia Springs. One liter of the iron-arsenic waters contains the following quantities (grammes) of iron sulphate, arsenic acid, and arsenous salts: Iron .siilpli;ito. Arspiiic acid. ArsetKHis salts. Crockett Arsenic Lithia Springs . O.OOOG ().()()(W Gucberquellc (Srebernik) . . . 0.3700 Harbin Hot Sulphur Springs . . 0.0300 Lausigk 4.1800 Levico 2.5000 Recoaro 3.2()()0 Roncegno 3.0000 (HKil o.ooo;? 0(){)1 ().0().")0 0001 O.OOoO OOSG O.OOoO 003'.) 0.0050 1500 0.0050 NERVOUS DYSPEPSIA 303 Sea Water Therapy. — Good results have frequently been obtained from the subcutaneous injection of sea water in the treatment of cases of nervous dyspepsia of obscure origin. The results, if beneficial, are apparent soon after beginning the treatment. It has been clinically demonstrated that sea water plasma is a powerful tonic to the nervous system. It stimulates metabolism to such a degree that the appetite improves and there is an increase in the body weight. The water relieves pain, allays nervous irritability, and induces restful sleep; there is a general improvement in tone throughout the entire nervous system, and the bowels move regularly. The therapy of sea water depends upon Quinton's law of marine constancy:^ '^ Animal life, which appears as a cell in seas of well-determined saline concentration, in order to maintain its optimum cellular activity has always a tendency throughout the zoological scale to keep the cells of which each organism consists in the aquatic marine conditions of their origin." Geology and paleontology agree in admitting that animal life first appeared in the sea, and the analysis of the blood serum and ash of every animal entering into the zoological series shows that the mineral composition of the medium necessary to cellular life is the same as that of the original seas. It is from these facts that Quinton deduces his novel conception of the animal organism as an actual sea aquarium in which the cells of which it is composed continue to live under the aquatic conditions of their origin. Having shown that the primordial seas contained only 0.8 per cent, of salts, it is necessary, in order to produce a plasma of that strength, to dilute the sea water of the present day, which contains 3.3 per cent, salts. For the pur- pose of diluting, pure spring water containing a minimum of mineral and free from bacteria is used in the proportion of two parts of sea water to five of spring water. Great care must be observed in collecting the sea water in order to ' International Medical Annual, 1910, p. 98. 304 NERVOUS DYSPEPSIA Fig. 39 avoid accidental impurities. It should be obtained not less than twenty miles from any port or stream flowing from a port, and at a depth of not less than ten meters. The water must be fresh, three weeks being the limit of time which should elapse between its collection and injection. After dilution as above it should be filtered through a porcelain filter of the Pasteur type. Every precaution for the sterilization of vessels should be observed, but the water, aside from the care in handling and filtering as above, is not to be sterilized further, or it will be rendered therapeutically useless. After filtering the water it may be put in flasks or ampoules of a capacity of 30, 50, 100 Cc. or more, as the convenience of the operator may require. The injection is performed with a rubber tube 1.5 meters in length, and ending in a platinum-iridium needle 3 centimeters long; this latter should be protected by a glass tube, T (Fig. 39) . The tube and needle must be boiled before connecting with the ampoule. The connection is made as fol- lows : (1) File the lower end of the straight tube, A, of the ampoule, break its ])oint and join it to B, the free end of the rubber tube. (2) File the end of the bent tube C, break its point, and hang up the ampoule by the bend in the tube at D, about one meter above the patient. To start the flow, the bulb of a thermocautery attached to the end C is useful. It is Apparatus for the injection of sea water. NERVOUS DYSPEPSIA 305 advisable to interrupt the tube of the bulb by a glass tube packed with sterilized absorbent cotton to filter the air. (3) The ampoule being hung uj), remove the tube T and allow the fluid to run until the rubber tube is quite empty of the boiled water and the air it contains. Make sure it is salt water that is running by tasting drops on the back of the hand periodically^ Then stop the flow with the clip F. The best point for injection lies behind the great tro- chanter. After the skin has been cleansed with alcohol the needle should be driven its w^hole length at right angles to the skin surface, except in very thin persons. If this should cause pain, withdraw the needle a few millimeters. Subsequent injections should be made in the same location, to avoid a repetition of the pain which may arise twelve hours after the first injection from stretching of the tissues. After injection the needle wound should be covered for a minute or two with a pledget of cotton soaked in alcohol; it will have closed up by that time. The quantity of sea water injected is of great importance. It is advisable to start with 20 or 25 Cc. every other day. There should be no rise of temperature or other symptom of reaction. If symptoms of malaise appear, the dose must be decreased; if there is no reaction, it should be increased to 50 Cc. as soon as possible and be given every other day. The injections may be given at any time of the day. During the treatment all antiseptics by mouth should be discon- tinued. Lavage of the stomach must not be employed. The treatment need not cease on account of menstruation. When the treatment is well tolerated the dyspeptic symp- toms diminish progressively and recovery is brought about after a course of thirty or forty injections. Drug Treatment. — Drug treatment occupies an important place in the treatment of this type of dyspepsia. The tonics, stomachics, sedatives, and hypnotics are all valuable. ^Yhen nervous irritability is marked, the bromides may be pre- scribed. Chloral hydrate in small doses, 0.1 to 0.3 Gm. (li to 5 grains), may be prescribed, to be taken three or four times a day. Insomnia may be combated by veronal, 20 306 NERVOUS DYSPEPSIA trional, or chloral hydrate, the last in the dose of 2 to 3 Gm. (30 to 45 grains) per rectum in a mucilaginous vehicle. Deficient appetite calls for bitters and stomachics. Boas recommends, in cases of neurosis having an anemic basis, the following: Gm. or Cc. I^ — Ferri bromidi, Quininae hydrobromidi aa 4.00 5j Extract! rhei q.s. Misce et ft. pil. no. c. Sig. — Two pills three times a day. When constipation is a comphcation it should be treated by other means than purgatives, A diet should be pre- scribed which leaves large residues in the bowels; abdominal massage, faradization of the rectum and abdomen, and enemata in which oUve oil or cottonseed oil has been incor- porated, will usually serve to counteract the constipation. Glycerophosphates and lecithin have been used with marked success in the treatment of nervous dyspepsia. The glycerophosphates are the salts of glycerophosphoric acid. They are said to be "nerve foods" and "nerve tonics," on the theory that the phosphorus they contain approximates more nearly to lecithin than the phosphorus constituent of the hypophosphites, and is assimilated more readily. In addition to the present official elixir con- taining the glycerophosphates of sodium and calcium, a compound elixir containing the glycerophosphates of calcium, sodium, iron, manganese, quinine, and strychnine is largely used. The lecithins are preparations of both animal and vegetable origin. They are esters of fattj' acids and glycerophosphoric acid in combination with protein. Animal lecithin is found chiefly in nerve and brain tissue, for which reason it has been designated a "nerve food." It acts as a stimulant to nutrition rather than as a direct nutrient. Even in large doses these preparations are non- toxic. Many of the animal extracts put up b}^ large meat- packing houses also contain lecithin. The glycerophos- phates and lecithin in various combinations are placed before the profession in ampoule form, and may be adminis- NERVOUS DYSPEPSIA 307 tered hypodermically, together with the iron and arsenic preparations described on page 240. Cacodylate of sodium hypodermically, 0.05 Gm. (1 grain), has proved of great value in my work. I give this preparation once a day for four weeks. It is a great stimulant to metabolism, and so affects nutrition as to bring about marked improvement in general nervous conditions. Menthol has proved valuable in the treatment of nervous dyspepsia. The pain, vomiting, anorexia, or flatulence often subsides at once, and permanent relief results. It should be prescribed in the dose of . 3 Gm. (5 grains) , three times a day. It can be advantageously combined with the alkalies. The author has found the following prescriptions of value in the medicinal treatment of nervous dyspepsia: In cases of hypersecretion: Gm. or Cc. I^ — Extracti belladonnse foliorum .... 0.5 gr. viiss Magmae magnesiae . . . . q. s. ad 120.0 giv Misce. Sig. — Teaspoonful three times daily, a quarter of an hour before meals. In cases of fermentation add resorcinol : Gm. or Cc. I^ — Resorcinolis 6.0 3iss Extracti belladonnse foliorum .... 0.5 gr. viiss Magmae magnesiae . . . . q. s. ad 120.0 5iv Misce. Sig. — Teaspoonful three times a day, a quarter of an hour before meals. In cases of excessive acidity: Gm. or Cc. I^ — Sodii bicarbonatis 60.0 §ij Sig. — Teaspoonful in a half-glass of water, one hour after meals. In cases of constipation with excessive acidity: Gm or Cc. I^ — Magnesii oxidi 20.0 3v Sodii bicarbonatis 60 . 5 ij Misce. Sig. — Teaspoonful in a half-glass of water, one hour after meals. 308 NERVOUS DYSPEPSIA In cases of diarrhea with excessive acidity: I^ — Bismuthi subcarbonatis, Gm. or Cc. Cretae prajparatae, Pulveris ossis aa 30 . § j Misce. Sig. — Teaspoonful in water one hour after meals. In cases of subacidity the following bitter tonics : Gm. or Cc. I^ — Tincturae nucis vomicae 8.0 3ij Tincturae cinchonae compositae q. s. ad 90.0 Siij Misce. Sig. — Teaspoonful three times a day, before meals. Gm. or Cc. I^ — Tin cturse gentianse compositae . . . 60.0 5ij Sig. — Teaspoonful in water three times a day, before meals. In cases of deficient hydrochloric acid : Gm. or Cc. I^— Acidi hydrochlorici diluti 120.0 giv Sig. — Fill No. "00" double capsule and take four such with water, at intervals of ten minutes, after each meal. Gm. or Cc. I^— Glyceriti pepsini, N. F 240.0 oviij Sig. — Tablespoonful in water during meals. In cases of impaired motility: Gm. or Cc. I^— Strychninae sulphatis . 003 gr. ^V Ft. pil. vel tab. no. i. Sig. — One three times a day, before meals. Many cases of nervous dyspepsia may require surgical intervention, and our attention must always be given to the possible presence of gallstones or chronic appendicitis. Mayo has repeatedly called attention to the frequency with which chronic appendicitis is associated with gastric symptoms. It is now definitely established that appen- dicular disease does produce definite gastric symptoms, a condition for which Paterson' suggests the tonii "appen- dicular gastralgia." NERVOUS DYSPEPSIA 309 Clinical experience presents strong evidence that there are gastric disturbances which are relieved or even com- pletely dissipated by removal of the appendix. Examination of the appendices removed in association with gastralgia, pylorospasm, gastric and duodenal ulcers-, cholecystitis, and cholehthiasis, shows that there is a higher percentage of appendices with partially or completely obliterated lumina in all of these conditions than at general autopsy or at operations for appendicitis. MacCarty and McGrath^ found that of 365 patients in whom cholecystectomy was performed, 13 per cent, gave definite histories of pain and soreness in the region of the appendix. In 59 of these patients with cholecystitis the appendices were removed and 69 per cent, showed undoubted gross or micro- scopic evidence of inflammation, varying from a chronic catarrhal condition to complete obliteration and peri- appendicitis. Fenwick'^ states that frequently the character of the trouble in the appendix is indicated by the character of the gastric secretion, an active irritation being indicated by hypersecretion, while, on the other hand, torsion, thickening, cystic dilatation, or adhesion is followed after a time by a type of chronic gastritis characterized by flatulence, nausea, anorexia, excess of mucus, and absence of free hydrochloric acid. He says that a continuous flow of hyper- acid gastric juice, reflexly produced by disease of some other organ — the appendix, pancreas, gall-bladder, tubercu- losis or neoplasm of the cecum — always excites severe inflammation of the stomach, and is liable to be followed by ulcer of that organ or of the duodenum. It also sooner or later gives rise to spasm of the pylorus, causing pain and intermittent obstruction which may lead to a diagnosis of cancer, Frgm a careful study of 271 cases of achlorhydria gastrica hsemorrhagica, with a complex of gastric symptoms, Pilcher^ 1 Lancet, January 14, 1911, p. 97. 2 Journal of the American ^Medical Association, January 7, 1911. ■* Dyspepsia and the Prophylaxis of Cancer of the Stomach, Journal of the American Medical Association, November 26, 1910, p. 1896. 310 NERVOUS DYSPEPSIA found that in 156 cases the onset seemed to bear an immedi- ate and direct relation to various diseases. In 100 of these patients operated on, the trouble in 36 was found to be due to appendicitis, in 32 to gall-bladder trouble, in 16 to gall-bladder and pancreatic disease combined, in 12 to appendicitis and gall-bladder involvement combined, and in 16 the stomach alone was found diseased. In 24 there was pylorospasm — in 18 with appendicitis and in 6 with gall-bladder involvement. The achlorhydria is attributed to reflex inhibition of gastric secretion by disease elsewhere than in the stomach. From this it would seem that hyper- secretion and hyposecretion of hydrochloric acid may be due to the same remote causes in different patients. ' Absence of Hydrochloric Acid with Blood in the Stomach Secretion (Achlorhydria Hsemorrhagica Gastrica) as a Symptom of Chronic Gastritis, Journal of the American Medical Association, November 19, 1910, p. 1790. CHAPTER XIV SECRETORY NEUROSES: HYPERACIDITY— HYPERCHLOR- HYDRIA— SUPERACIDITY HYPERCHLORHYDRIA The term ''hyperchlorhydria" is applied to that condition of the gastric secretions in which the quantity of gastric juice is normal but the percentage of free hydrochloric acid higher than normal. The hyperacid gastric juice is secreted during digestion only, from the stimulus of food in the stomach. Many writers, especially those who follow the teachings of Pawlow, maintain that hyperacidity is not a clinical entity, but merely one aspect of hypersecretion. They claim that there is no increase in the percentage of free hydrochloric acid in the gastric juice, but only an increase in the quantity of the secretion itself, the constit- uents being normal in amount. This view is in opposition to a convincing array of clinical facts and observations; we are justified in looking upon hyperacidity as a condition entirely independent of hypersecretion. Hyperacidity is primarily a disturbance of the gastric function in which the mucous membrane of the stomach, under the stimulus of food, secretes gastric juice containing an excessive amount of free hydrochloric acid. It may be of purely nervous origin, a secretory neurosis dependent upon the abnormal stimulation or inhibition of certain nerve trunks leading to the stomach. This variety of hyper- acidity is the one most frequently observed. It is not always possible to draw a distinct line between the two varieties, neurotic and organic ; so they may be considered together. These forms of hj^jeracidity are designated genuine, in contradistinction to those which occur secondarily as 312 SECRETORY NEUROSES sequelae of other pathologic processes. Hyperacidity in gastritis chronica (gastritis acida) or ulcus ventriculi may be either secondarj^ or primary — the result or the cause. The cUnical sjonptoms characteristic of hyperacidity are sometimes misleading; the symptoms may be present when the gastric juice is of normal acidity, as shown by examina- tion after a test meal, or they may be absent when the test shows a marked hyperacidity. The presence or absence of subjective symptoms is doubtless due to a difference in the sensibihty of the gastric mucous membrane. Accord- ing to Riegel, hyperacidity has to be viewed, in the majority of cases, as a constitutional anomaly. Dalton holds that hyperacidity of the contents of the duodenum, due to the hyperacid condition of the stomach, produces derangement of physiologic metabohsm, and is the starting-point of nearly all skin diseases except the contagious exanthemata. Etiology. — Hyperchlorhydria is of very frequent occurrence. From the studies of Riegel, Reichmann, Jaworski, Glusinski, and Ewald we learn that in almost 50 per cent, of all patients suffering from digestive disorders, acidity of the gastric juice is rather increased. Einhorn states that hyperchlor- hydria is present in more than half the ''digestive" cases. It is a disease of both sexes. TMiile it is met with chiefly in adults, neither the 3'oung nor the old are exempt. Persons of a nervous temperament, those suffering from neuras- thenia, hypochondria, or melancholia are apt to be its victims. Hyperchlorhydria has followed grief, worry, and mental overwork. In the majority of cases the cause is psj'chologic. Bad habits of eating, the quick-lunch counter, insufficient mastication of food, beverages either too hot or too cold, coffee, alcohol, tobacco, the habit of taking highly spiced dishes, all predispose to hyperchlorhj'dria. It freciuently accompanies ulcus ventriculi and constipation. In chlorosis and cholehthiasis, hyperchlorhydria has been noted, but the causal connection of these diseases is by no means clear. Pathology. — No characteristic pathologic changes have been found in the few cases in which postmortem has been made. IIYPERCHLORHYDRIA 313 Symptoms. — Hyperchlorhydria develops gradually. At first the patient experiences an uneasy sensation one or two hours after dinner. Later this feeUng becomes aggravated into one of distress occurring from one to three hours after each meal. The subjective discomforts of the patient set in at the height of digestion, during which time the acid secretion, and especially hydrochloric acid, greatly exceeds the normal. The degree of discomfort at this time does not depend upon the quantity of acid so much as upon the sen- sitiveness of the gastric mucosa. Low degrees of hj^per- acidity sometimes provoke painful symptoms. The pain may last for an hour or two, or longer, and then disappear. Patients are frequently able to predict the exact time the pain or distress is likely to occur. The pains y&vj not only in duration, but in severity, from mild distress to violent cramping seizures caused by obstruction to the outflow of the acid contents, together with violent peristaltic move- ments of the stomach, iittacks of the maximum severity occur comparatively seldom. Patients are, as a rule, able to ease their pains by partaking of some article of food, such as the white of an egg, rich in albumin. Besides the gastric pain, there are very often severe headaches and vertigo. Constipation is common. The victims of hyper- chlorhydria do not usually produce the impression on the observer of being very sick. They appear to be well nour- ished, except in cases where faulty and insufficient diet has been maintained for a long time. Objective Symptoms. — During the painful attacks the region of the stomach is distended and sensitive to pressure. A splashing sound can be obtained after the ingestion of water, or after meals, but not when the stomach is empty. Diagnosis. — The diagnosis is confirmed only by examina- tion of the stomach contents. What remnants of food are found appear finely divided and well digested. The tests for free hydrochloric acid are positive. Clinicians calculate the normal total acidity after a test breakfast to be 40 to 60; in hyperacidity the total acidity is 75 to 80. A total acidity of 160 has been recorded. It is important to ascer- 314 SECRETORY NEUROSES tain the quantity of free hydrochloric acid in every case. A disk of coagulated egg albumin placed in the filtrate of the gastric contents will become digested in a short time. Gastric contents obtained three or four hours after the test meal show that meat has been entirely digested, while starches are but slightly changed. According to Einhorn, the fil- trate of gastric contents after either a test dinner or a test breakfast shows the presence of starch or large quantities of erythrodextrin. The addition of a few drops of Lugol's solution to the filtrate will produce either a blue color or an intense dark red. The presence of the unaltered or slightly altered starches is due to the fact that hydrochloric acid begins to be secreted directly after the ingestion of food, and amylolysis is thus interrupted. Prognosis. — Hyperchlorhydria or hyperacidity may yield to appropriate treatment. The prognosis is, as a rule, good, except in some very protracted and severe cases. Should there be pyloric spasm, atony and dilatation of the stomach are apt to supervene. CHRONIC ACm GASTRITIS Boas, who first described this disease, defines it as a gas- tritis with increased production of mucus and an abnormally strong secretion of hydrochloric acid. The mucus siphoned out early in the morning after the night's fast may give a positive hydrochloric acid reaction. Chronic acid gastritis approaches very closely to hyperchlorhydria so far as prac- tical therapeutics is concerned. Acid gastritis is an early form of chronic gastritis, and is found very frequently in alcohohc patients. TREATMENT OF HYPERACIDITY, HYPERCHLORHYDRIA, SUPERACmiTY, AND ACID GASTRITIS Hygienic Treatment. — In view of the fact that hyjierchlor- hydria is often brought on by grief, worry, or mental over- work, it would appear that the first thing to do is to regulate HYPERACIDITY— HYPERCIILORHYDRI A— GASTRITIS 815 the daily life and habits of the patient. Business men, lawyers, physicians, clergymen, those whose labor entails great responsibility, should be sent away from their work to an entirely different environment where they may find at least temporary relief from the strain. Women in social circles must be persuaded to lead a quieter life. Patients among the wealthy leisure class who have too much time to think over their bodily functions must be given some occu- pation which will engage the mind. Persons with a pre- disposition to hyperchlorhydria should, as a prophylactic measure, avoid errors in diet, mental overexertion, and anger. Dietetic Treatment. — The dietetic treatment is of the great- est importance in cases of uncomplicated hyperchlorhydria. In the first place, extremes of temperature should be avoided in both food and drink. Food should be eaten slowly and thoroughly masticated, not only to facilitate salivary diges- tion, but to avoid irritating the stomach mechanically. All substances that are likely to irritate the gastric mucosa must be eliminated from the dietary. All kinds of acids, including the organic, such as citric, tartaric, and acetic, must be forbidden; also spices of all kinds — pepper, mustard, horseradish, etc. Whisky and wines are in the prohibited list. The food should be rich in protein and as poor as possible in starchy substances. The total acidity of the gastric secretions is much greater with a protein than with a car- bohydrate diet, but the amount of free hydrochloric acid is much less. Owing to the large percentage of extractives in meat which excite the flow of gastric juice, it seems advisable to substitute some other form of protein, as eggs, milk, cheese, or v-egetable protein. However, when meat is prescribed, it should be well boiled to remove the extractives rather than roasted. Raw meat should be avoided, owing to its excessively stimulating effect on gastric secretion. Oatmeal, aleuronat meal, and bread and cocoa that are rich in protein are all useful food substances in the treatment of hyperchlorhydria. Carbohydrates should not be eliminated entirely from the 316 SECRETORY NEUROSES diet in hyperchlorhydria, but should be restricted. They may be taken in finely divided form; that is, vegetables such as spinach and cauliflower must be taken as puree. Salads and fresh fruits are to be avoided. When free hydro- chloric acid appears early, interrupting the digestion of carbohydrates, amylolysis may be assisted by the use of dextrinated carbohydrates (zwieback, toast). Sugar has been found valuable in the dietary of hyperacidity, inasmuch as concentrated saccharated solutions diminish not only the total acidity, but likewise the free hydrochloric acid, to a marked degree. Sugar may be given in a variety of forms, such as sweet dishes, jellies, jam and honey. Fats fulfil the same role as sugar. It has been demon- strated that fat not only hinders gastric secretion, but diminishes the quantity of free hydrochloric acid. Strauss prescribes fat after he has ascertained that it does not dis- turb the motility of the stomach or interfere with the assimi- lation of other foods. Bacon provides fat in an agreeable form. Milk, cream, and butter are indicated. Oils of various kinds have been employed with good results in the treatment of hyperchlorhydria. Cowie and Munson conclude, as the result of experimentation, that olive oil and cottonseed oil, when given in connection with the usual test breakfast, decrease the gastric acidity at the end of the hour and retard the evacuation of the stomach. The beginning of the secretion of hydrochloric acid is delayed when oil precedes the meal; it is unchanged when the oil follows the meal. The height of digestion is delayed when oil is given either before or after the meal. The height of secretion is lowered when oil precedes the meal; it is un- changed when oil follows the meal. If the progress of diges- tion be watched by the removal of small samples of stomach fluid at frequent intervals, it will be observed, when oil precedes the meal by one-half hour, that at the end of what is usually taken as the digestive period for a test breakfast (three-fourths to one hour) the acidity is distinctly lower, while as great a height as is present in the control meal is frequently reached some minutes later. The action of oil HYPERACIDITY— HYPERCIJLORII YDRI A— GASTRITIS 317 on the stomach functions is only a temporary one. It has no effect on subsequent meals unaccompanied by oil. The therapeutic value of oil is apparent. In suitable cases it is preferable to antacids because of its calorific value. In hyperchlorhydria it should precede the meal. In hypo- chlorhydria it should follow the meal. In stasis and per- sistent slow evacuation it should be eschewed. In hyper- motility it may be given before, during, or after the meal. Oil lowers the gastric secretion both by reflex central inhibi- tory stimulation and by mechanical action. Dr. H. W. Wiley says that one unit of cottonseed oil will furnish over twice as much heat and energy as the same quantity of sugar or starch. When used with salt on bread it makes a very acceptable substitute for cream and butter, and certainly is free from the diseases we contract from the animal world. Not only is cottonseed oil more easily digested than corn oil, peanut butter, or even olive oil, but it does not ferment in the stomach and bring on that long train of evils that come from the too free use of some of the articles mentioned. Beverages taken at meals are harmless, inasmuch as they dilute the gastric juice. Alkaline mineral waters, Vichy, and California seltzer waters containing no carbon dioxide, may be prescribed in large quantities. Beer and coffee should be avoided. Cocoa and weak tea well diluted with milk are permissible. Pure milk, however, is the ideal beverage in these cases. Strauss recommends the following menu as a model for a mid-day meal: A few tablespoonfuls of olive oil, if not objectionable to the patient (if olive oil cannot be borne, give a few small butter balls); cold toast well buttered; a sardine in oil, or a small amount of fresh fat cheese. Yolks of eggs may be taken before the meal. The meat course should consist of boiled meat, fowl, or fish, served with cream or butter sauces. Vegetables, in the form of puree of spinach, beans, or carrots, may be permitted. For dessert, sweet boiled fruit, sweet dishes, or pudding with fruit sauce. 318 SECRETORY NEUROSES Outline of Diet in Hyperchlorhydria (Einhorn) Calories. 7.30 a.m. Two eggs, 50 Gm 160 \Mieaten bread, 50 Gm 128 Butter, 20 Gm 163 Milk, 250 Gm 169 10.30 a.m. Matzoon or milk, 200 Gm 135 Crackers or bread, 30 Gm 77 Butter, 10 Gm 81 1.00 p.m. Broiled meat, 100 Gm. 210 jMashed potatoes, 50 Gm 63 Bread, 30 Gm 77 Butter, 10 Gm 81 Weak tea or Vichy water, 200 Gm. 3.30 p.m. Same as at 10.30 a.m 293 6.30 p.m. Soup (with barley or vermicelli), 200 Gm 100 Bread and butter (bread, 30 Gm.; butter, 10 Gm.) . 158 Meat broiled or cooked, 100 Gm 210 Potatoes, baked, 50 Gm 60 Green vegetables (spinach, green peas), 50 Gm. . . 80 Coffee (half milk), 100 Gm 34 10.00p.m. Oysters and crackers, or cold meat sandwich . . . 260 2539 Diet in Hyperchlorhydria (Habershon) 1. Avoidance of foods that stimulate secretion, i. e., all condiments, highly spiced, flavored or seasoned, cured, tinned, or salted foods, and beef foods and extracts, on account of their properties which excite secretion. 2. The free administration of alkalies or vegetables that contain alkalies, and of all oily or fatty foods. All green vegetables may be taken if they suit, such as spinach, cabbage, bunch greens, turnip-tops, broccoli, Scotch kale, and salads (such as watercress, endive, the leaf of lettuce, taraxacum), etc. Fat meat and bacon or ham, butter, cream, and milk may be taken. 3. All freshly cooked meats and fish, with eggs, and vegetable proteins, beans, peas, lentils, etc., are freely digested. Scraped meat, raw or very highly cooked, is often well digested. 4. Excess of carbohydrate food, i. e., articles of food containing starch and sugar, should be avoided. These are: starch-containing vegetables, cereals, and fruits; potatoes, and most of the roots and tubers, such as carrots, turnips, parsnips, artichokes, beetroot, radishes, etc.; white or whole-meal bread; rice, sago, and other puddings derived from cereals; sugar and syrupy fruits. 5. All acid vegetables and fruits are also to be avoided, such as rhubarb, tomatoes, cucumbers, lemons, and oranges; the spring and summer fruits — currants, raspberries, gooseberries, cranberries, mulberries, apples, pears, plums, cherries, strawberries, grapes, peaches, nectarines; likewi.se all acid drinks. HYPERACIDITY— HYPERCHLORHYDRI A— GASTRITIS 319 6. Bananas may be taken, also prunes, nuts, cheese, etc. 7. All malt liquors, and claret, sherry, hock, moselle, and sweet wines, such as liqueurs, port, and champagne, should be avoided. The only stimu- lants permissible, if these be needed, are whisky and brandy in small quantities, well diluted, and in medicinal doses; but the patient is far better without stimulants. Large quantities of fat are particularly indicated in cases of hyperacidity accompanied by constipation. On the other hand, a purely vegetarian, lactovegetable or meat-poor regimen is recommended in pronounced nervous forms of hyperacidity; the vegetables should be thoroughly cooked and finely divided. Regarding the frequency of meals, it is advisable to eat five or six times a day, three heavy and two or three light meals. Laufer attaches great importance to the salt-free diet in hyperchlorhydria patients, and Hayem maintains that an abnormally high percentage of hydrochloric acid can be reduced by an almost salt-free diet. Vincent attempts to show a more or less strict paralleHsm between the percentage of hydrochloric acid in the gastric juice and the quantity of sodium chloride ingested. He made observations on a young subject, aged twenty-two years, examining the stomach contents one hour after the ingestion of the test meal, which was always given in the morning. The first test was to find the effect of a thorough chlorination by adding 12 grammes of sodium chloride per day to an ordinary diet; the gastric juice was examined two and four days later. The second test was a complete prohibition of sodium chloride for ten days. In the first instance a violent hyper- chlorhydria developed, attended by the usual pathologic symptoms. But when the salt-free diet was established the symptoms disappeared and the subject gained six pounds in weight. Enriquez and Ambard report the results of recent research which confirm their previous assertions in regard to the beneficial effect of withdrawing salt when the secretion of gastric juice is excessive and the stomach responds with pain. In such cases a salt-free diet has a prompt and marked influ- 320 SECRETORY NEUROSES ence on the excessive secretion; the influence on the pains is not felt so soon. Once estabUshed, the effect is lasting, the pain subsiding permanently and completely in two or three weeks, or at most in five. As soon as the pain has been banished by a strictly salt-free diet, the patient is allowed to have his own salt-cellar to use as desired, the food being still prepared without salt. This gives the patient a feeling of freedom which renders the restriction less irk- some, and, as the capacity of the salt-cellar is known, the exact amount he is taking can be estimated. The salt-free diet, according to these writers, should be instituted in every case of hyperchlorhydria rebellious to other measures. M. Bonniger, Pawlow says, observed the behavior of the gastric juice secreted by a dog with a gastric fistula. The result of the administration of salt was a very marked diminution of the gastric secretion, with a corresponding diminution of the hydrochloric acid secreted. Similar results were obtained with a healthy ^man — marked subacidity without increase in the total amount of gastric juice. A priori, then, common salt would seem to be indicated in the treatment of hyperacidity. "WTiether the ill effects of large doses of salt — interference with gastric motility and with protein digestion — suffice to counterbalance its good effects in this disease, can only be settled by chnical observation. Notwithstanding the observations of Bonniger, chnical ex- perience tends to confirm the views of Laufer. Medicinal Treatment. — Astringents. — The astringents are among the most valuable drugs we have in the treatment of hyperchlorhydria. Their action is confined to the gastric mucosa. They diminish the intensity of local inflammation. Astringents are, therefore, indicated in the treatment of chronic gastritis when the inflammatory process is superfi- cial. Owing to their inhibitory eff'ect upon secretion, they are contraindicated in conditions where the acid secretion is normal, subnormal, or absent. Among the more valuable astringents are the salts of bismuth and silver. The physical effect of bismuth subni- trate is the formation of a protective layer over the gastric // YFERACIDIT Y—H YPERCIILORH YDRI A— GASTRITIS 321 mucosa, which is particularly desirable where abrasions exist. Rodari found, by animal experimentation, that bis- muth inhibits gastric secretion; the subnitrate materially diminishes the quantity of free hydrochloric acid. He found the inhibitory action of the drug to be more marked when the gastric mucosa was inflamed. The action of hydrochloric acid upon bismuth subnitrate in the stomach is represented by the following equation : NO3 Cl / / Bi + HCl = HNO3 + Bi According to Rodari, bismuth subcarbonate has no appre- ciable action upon the gastric secretion. He attributes the inhibitory effect of bismuth subnitrate to the nitric acid formed by the action of hydrochloric acid upon it. Bis- muth subnitrate is indicated in the treatment of hyper- acidity, hypersecretion, and acid gastritis. It is contra- indicated in chronic gastritis of all other forms. Rodari's animal experiments showed that the silver com- pounds (silver nitrate, protargol, albargin) diminish the quantity of gastric juice in inflammatory conditions of the gastric mucous membrane, but increase the amount of hydrochloric acid slightly. In the absence of inflammation, however, the silver salts were found to increase gastric secretion. Nitrate of silver, accordingly, would be indicated in cases of gastritis with either normal or subnormal acidity, rather than in hyperacidity, hypersecretion, or acid gastritis. I have obtained good results, however, from the use of silver nitrate in hyperacid conditions, whether accompanied by catarrh or not, and also in hypersecretion. I would not eliminate the silver salts from the therapeutic agents appli- cable to these conditions. Regarding the action of silver nitrate in mitigating the symptoms of hyperacidity, Kaufmann^ writes: ^'No treat- ment removes more quickly all the so-called hyperacidity 1 American Journal of the Medical Sciences, February, 1908. 21 322 SECRETORY NEUROSES symptoms than the appHcation, by lavage, of solutions of silver nitrate. I can state this positively on the strength of an experience gained by the treatment of hundreds of cases. When after such treatment and after the patients had been perfectly free from all subjective symptoms the stomach contents were again examined, I have often been greatly surprised to find, instead of the expected lowering of the acidity, that the high figures of hyperacidity had remained unchanged. It has already been pointed out by Baibakoff that the application of silver nitrate does not necessarily reduce the secretion of the gastric juice. Although I have observed in certain cases a decided lowering of the acidity after the treatment with silver nitrate, such lowering was not the rule. I have seen more cases in which the acidity remained high; in fact, in some I found even a higher degree of acidity after the treatment than they had before the treatment. And yet these patients had been freed of their annoying symptoms by the use of silver nitrate, and many of them had been promptly relieved from severe pains." Bismuth subnitrate is administered in powder form, 1 to 4 Gm. (15 to 60 grains) in warm water, fifteen minutes before each meal. Nitrate of silver is given in solution (1 to 750 to 1 to 1000), one tablespoonful and a half in half a glass of distilled water. Atropine. — The effect of astringents is directly upon the gastric glands. Atropine acts through the central nervous system, inhibiting gastric secretion, and diminishing the quantity of hydrochloric acid in the gastric juice without interfering with the secretion of pepsin. Atropine, further- more, acts as an antispasmodic and analgesic; it diminishes the sensibility of the sensory nerves. Atropine sulphate in doses of ^ to 1 milligramme (jhj to -/,7 grain), given in the form of tablets, is a useful agent for promptly relieving the painful attacks of pylorospasm. When atropine is to be administered over a long period of time it is best given as extract of belladonna, 0.02 to 0.03 Gm. (^ to § grain) three times a day, before meals; or it may be advantageously given with astringents and alkalies. Atropine is a poison, HYPERACIDITY— II YPERCHLORHYDRI A— GASTRITIS 323 and when it is necessary to secure its therapeutic effect for a considerable length of time some relatively harmless sub- stitute should be considered. Among the less poisonous substitutes we have eumydrin, which is supposed to be fifty times less toxic than atropine (see page 196). Guis. Massini writes concerning eumydrin as follows: "Seeing that atropine readily gives rise to general disturb- ances and intoxications, eumydrin proves itself, in many cases, an advantageous substitute. In doses of from 1 to 3 milligrammes (gV to -^V grain) it can be given for some time without producing any severe general disturbances. Most satisfactory this agent proves to be in gastric neuroses with hyperchlorhydria and increasing gastric pains." This drug has been recommended by Zweig and Wegele. The former prescribes it as follows : Gm. or Cc. I^ — Eumydrin 0.04 gr. | Sacchari 6.0 5iss Misce et ft. pulv. no. xx. Si^. — One three times a day, before meals. Other drugs that act similarly to atropine in retarding secretion are euphthalmin and scopolamine hydrobromide; the latter, prescribed in doses of 0.0003 Gm. {-j^-(j grain), has been found useful in the treatment of hypersecretion. Neither of these drugs has been used very extensively. Hydrogen Peroxide. — Petri '^ has lately shown that hydrogen peroxide, taken internally, exerts a marked influence on the hydrochloric acid output. He found by studies on himself that even a 1-per-cent. solution could be taken without any ill effects, apart from a burning taste in the mouth accom- panied by the formation of oxygen bubbles and a feeling of constriction in the esophagus. No gastric symptoms were observed. Solutions 0.25 to 0.75 per cent, in strength were easily taken, and patients to whom these were given com- plained of no unpleasant complications. Goodman, from work done in Musser's private laboratory, states that good results have been obtained with a teaspoonful of hydrogen peroxide in a glass of water after meals, but two teaspoon- 1 Archiv fiir Verdauungs Krankheiten, 1908. xiv, p. 479. 324 SECRETORY NEUROSES fuls may be taken with no unpleasant consequences. He says: ^'I regard hydrogen peroxide as an additional remedy in an already long list of measures advocated in the treat- ment of hyperchlorhydria. Its value is, however, not so great that all other means of treatment may be relegated to oblivion, but in conjunction with these it will no doubt be found of benefit." Magnesium peroxide has been introduced to the profession under the trade name of magnesium perhydrol. It is pre- pared by treating magnesium oxide with hydrogen peroxide. It is a white, tasteless, odorless powder, insoluble in water, but soluble in dilute acids. It is prepared in two strengths, containing respectively ISMgOj + 85MgO and 25Mg02 + 75MgO. When kept for a long time, it is reconverted into magnesium oxide. This preparation has been found useful in diminishing hyperacidity. The dose is 1 Gm. (15 grains) three times a day. Alkaloids. — Of the alkaloids, codeine is the only one besides atropine that does not occasion untoward after- effects. Morphine, after temporarily inhibiting secretion, is apt to cause a very copious flow of hyperacid gastric juice. Dionin and pilocarpine immediately increase the secretion. Codeine may be given in doses of 0.01 to 0.03 Gm. (l to ^ grain) with extract of belladonna or with alkalies and astringents. Analgesics. — The following analgesic agents have been found efficacious: Cannabis indica extract, 0.01 to 0.05 Gm. (^ to 1 grain) three times daily; chloral hydrate; and chloro- form water (1 to 200). According to Wegele, chloroform acts better when taken in drop doses on cracked ice. Cocaine is efficacious in painful vomiting. Menthol and validol act like cocaine. The bromides are occasionally very useful in the nervous form of hyperacidit}^ Bromide of strontium, 2 to 4 Gm. (30 to 60 grains) daily, is recommended, espe- cially by French authors. t!ni. or Cc. I^ — Extract! cannabis indicso 0.3 gr. v Extract! gentianic q. s. Misco et ft. pil. no. xx. Sig. — One three times daily. HYPERACIDITY— H YPERCHLORHYDRI A— GASTRITIS 325 Gill, or Cc. I^— Chornli hydrati 2.0 gr. xxx Aquir destillat£B 10.0 oiiss Misce. Sig. — Ten to twenty drops three times a day. Gm. or Cc, I^— Cocaina) hydrochloridi, Codeinse phosphatis ajl 0.5 gr. viiss Syrupi aurantii q. s. ad 150.0 §v Misce. Sig. — One tcaspoonful every hour until reUeved. Alkalies. — Alkalies are the remedies that are employed most frequently in the treatment of hyperchlorhydria. Experimental research concerning the effect of alkahes in the stomach has estabhshed the fact that, reaching the stomach in sufficient quantities, they are capable of neutral- izing the hydrochloric acid secreted. Consequently they should be introduced into the stomach when hydrochloric acid is secreted in excess. The following alkalies serve these purposes : Salts of Alkali7ie Earths. — The principal members of this class are magnesium oxide and ammonio-magnesium phos- phate. Magnesium oxide combines with hydrochloric acid according to the following formula : MgO + 2HC1 = MgCls + H2 O The ammonio-magnesium phosphate combines thus : Mg(NH4)P04 + 3HC1 = MgCl2 + NH4CI + H3PO4 The carbonated alkahes: Sodium bicarbonate is particu- larly useful. It combines with hydrochloric acid according to the following formula : NaHCOs + HCl = NaCl + H2O + CO2 It has been shown that bicarbonate of soda not only neutralizes the acid, but also diminishes the secretion. Carbonate of soda is used but rarely, owing to its caustic effect on the mucous membrane. Of the drugs mentioned, magnesium oxide is capable of 326 SECRETORY NEUROSES neutralizing the greatest amount of acid. The next in order is animonio-magnesium phosphate. To neutrahze equal quantities of hydrochloric acid, four times as much bicarbonate of soda as of magnesium oxide is required, and twice as much as of the ammonio-magnesium phosphate. The quantities of these drugs which it is necessary to administer vary according to the degree of hyperacidity or hypersecretion. Boas calculates, for a hyperacidity with more than 25 per cent, hydrochloric acid, 8 to 10 grammes (oij-iiss) of bicarbonate of soda, 2 to 3 grammes (30 to 45 grains) of magnesium oxide, and 4 to 6 grammes (5j- iss) of ammonio-magnesium phosphate. These quantities refer to full meals, and must be reduced- one-half for small meals. In the presence of an acidity exceeding 3 per cent, of hydrochloric acid. Boas gives the dose of bicarbonate of soda as 12 grammes; magnesium oxide, 5 grammes; ammonio-magnesium phosphate, 5 grammes. These figures are to be considered only as a general guide for the dosage required. Boas, however, maintains that they are by no means too high — rather the contrary. In some forms of disease with symptoms of hyperacidity it is advisable to avoid the carbon dioxide alkalies, on account of the gastric distention that is likely to follow from the formation of gas. An alkaline remedy frequently used in gastric disorders is Carlsbad water and its salts. The chapter on INIineral Waters discusses Carlsbad waters. The Carlsbad salts are prepared in various forms: Natural crystalline Carlsbad sprudel salt consists (after removal of the water of crystal- hzation) of sulphate of soda, 99.33; carbonate of soda, 0.45; and common salt, 0.76. Natural pulverized Carlsbad sprudel salt has the follow- ing composition: Per cent. Sulphate of soda 41.62 Sulphate of potash 3.31 Carbonate of .soda 36.11 Clilorido of aodiuiii IS. 19 Carbonate of lithium ... 0.02 Borate of sodium 0.03 Water 0.44 // YPERACIDITY—H YPERCHLORH YDRIA— GASTRITIS 327 Ai'tificial Carlsbad salt consists of: Per cent. Sulphate of soila 44 . Sulphate of potash 2.0 Chloride of soda 18.0 Bicarbonate of soda 36 . These salts are similar in their effects. The artificial salt is cheaper, but the natural salt has a more agreeable taste. The Carlsbad salts may be administered in varying doses. The smallest dose is 5 grammes, equal to one teaspoonful; the average dose, 10 grammes (2 teaspoonfuls) ; and the maxi- mum dose, 15 grammes (3 teaspoonfuls) . Doses of 5 grammes may be taken at one draught, dissolved in a quarter of a liter (one glass) of water. To avoid irritation of the stomach, not more than 15 grammes should be taken at one draught. Carlsbad salt is usually taken early in the morning, on an empty stomach, each dose being 5 grammes, and the doses being separated by a considerable interval of time. When two dessert- spoonfuls are to be taken, the interval between them should be thirty to forty-five minutes; when three dessertspoonfuls are taken, the interval between the first and second spoonful should be thirty minutes, that between the second and third spoonful forty-five minutes. One whole hour should elapse after the last dose before breakfast is taken. Carlsbad salt is taken in various vehicles, such as ordinary water, Carls- bad mineral water, or an aerated carbonated water (Vichy, Apolhnaris). The temperature of the Carlsbad salt solution should be about 30° C. A lukewarm solution has a more purgative effect than one of high temperature. The Carls- bad salt fulfils indications similar to those for the other alkalies mentioned. A salt mixture similar to the artificial Carlsbad salt is Wolff's mixture, consisting of: Grammes. Sulphate of sodium 30.0 Sulphate of potassium 5.0 Chloride of sodium 30.0 Carbonate of sodium 25.0 Bicarbonate of sodium 10.0 328 SECRETORY NEUROSES This is to be taken three times a day, early in the morning, two hours before dinner, and two hours before supper, in half-teaspoonful doses dissolved in half a tumblerful of lukewarm water. This powder is specially recommended in cases in which gastric juice is secreted in the morning before food has been ingested. In the absence of saliva, Sticker and Biernacki recommend the administration of jaborandi or pilocarpine, since these drugs are known to be sialagogues. The absence of salivary secretion retards amylolysis greatly, and proteolysis as well. In cases of such pronounced hyperacidity that salivary digestion is inhibited, Boas recommends administering ptyalin or malt diastase combined with alkalies. I think, however, that in such conditions the object could be better accomplished by more prolonged mastication and insaliva- tion of the food. In cases of hyperacidity the proper times for the adminis- tration of alkalies are: directly after eating, and at the height of digestion, when the secretion of acid is freest. Patients are frequently able to tell this particular moment with considerable exactness, as it coincides with the onset of their painful symptoms. Course of Medication. — The course of medication in hyper- chlorhydria is as follows : In hght cases the attempt is made with alkalies alone. When the cases are more obstinate and cause much discomfort, astringents may be given in addition to the alkalies. Severe cases, especially those with severe pains, a high degree of acidity, and pylorospasm, require the administration of the alkaloids, combined with alkalies and astringents. Attendant constipation has to be treated. Lavage of the Stomach. — In cases of hyperchlorhydria com- plicated with atony or disturbances in motility, lavage of the stomach is useful. Lavage may be performed late at night after an early supper, or early in the morning. It should be followed by a solution of Carlsbad salt or nitrate of silver (1 to 1000), to be washed out witli i)ui'(> water. The mineral waters have jii-ovod to be \ahial)le thera- peutic agents in the treatment of hyperchloi'hydi-ia. Cai'lsbad HYPERACIDITY— HYPERCHLORHYDRI A— GASTRITIS 329 occupies the first place. The alkahne acidulous waters are indicated in purely nervous hyperacidity. The mineral water cures are better taken at the respective resorts, but may be employed with advantage at home. Physiotherapeutic measures are indicated as palliatives in severe cases only, where something must be done at once. Hot compresses over the region of the stomach mitigate the severity of pain. The Winternitz stomach application has a quieting and antispasmodic action. The treatment of acid gastritis is the same as that of hyperacidity in respect to diet, medication, and mineral water treatment. In chlorotic patients Einhorn advises the administration of an organic iron preparation, recommending such prepara- tions as Pizzala's or Dietrich's elixir of peptonate of iron, or Boehringer's ferratin. I prefer the hypodermic administra- tion of the citrate of iron, as described on page 240. Milk of magnesia is a suspension of magnesium hydroxide in water. A dose of one-half to two tablespoonfuls will neutralize the acid in hyperacidity, and will act favorably when this condition is complicated with constipation. In the treatment of hyperacidity the alkaline powders are effective. The following formulas for combinations of alkaline substances will be found serviceable in various conditions : Gm. or Cc. I^ — Sodii bicarbonatis 4.0 3j Magnesii oxidi 4.0 3i Calcii carbonatis 6.0 3iss Misce et ft. pulv. Sig. — Take one teaspoonful immediately after each meal, with a little water. The dose may be increased or diminished as required. Gm. or Cc. 10.0 oiiss 40.0 ox I^ — Magnesii oxidi Sodii bicarbonatis Misce et ft. pulv. Sig. — One-half to one teaspoonful three times a day. one or two hours after meals, in half a glass of water. 330 SECRETORY NEUROSES Gm. or Cc. I^ — Magnesii oxidi 1.6 gr. xxv Calcii carbonatis 0.8 gr. xiiss Bismuthi subnitratis O.S gr. xiiss Sodii bicarbonatis 1.0 gr. xv Acetanilidi 0.12 gr. ij Misce et ft. pulv. Sig. — Take in a little water at the time of the attack of pain, and repeat if necessary. Gm. or Cc. I^ — Bismuthi subnitratis 20 . 5 v Magnesii oxidi 10.0 Siiss Sodii bicarbonatis 10.0 5iiss Misce et ft. chart, no. xx. Sig. — One three times daily, before meals. Gm. or Cc. I^ — Magnesii oxidi, Pulveris radicis rhei aa 20 . 5 v Sodii bicarbonatis 40 . 5 x Misce. Sig. — One-half to one teaspoonful in water one to two hours after meals. Hyperacidity with diarrhea : Gm. or Cc. I^ — CretEe prseparatce 10.0 oiiss Bismuthi subgallatis 10.0 5iiss Sodii bicarbonatis 10.0 oiiss Misce et ft. chart, no. xx. Sig. — One six times daily. Hyperacidity with pain : I^ — Codeinte phosphatis Cretae pra^parata; Bismuthi subnitratis Magnesii oxidi Sodii bicarbonatis Misce et ft. chart, no. xv. Sig. — One powder to be taken one liour after meals. Gm. or Cc. 0.25 gr. iv 4.0 oi 10.0 oiiss 4.0 5j 10.0 oiiss Gm. or Cc. 1^ — Cocaina> hydrochloridi 0.10 gr. 1S3 Heroinaj hydrochloridi 0.02 fjr. i Atropinte sulphatis 0.01 gr. i Extract! ergotaj 1.0 gr. XV Aqua) destillata' 10.0 oiiss Misce. Sig. — Five to twenty drops every hour uiiti relieved. H YPERACIDITY—H YPERCIILORH YDRIA— GASTRITIS 331 If between meals there is burning or pain in the stomach due to hyperchlorhydria, Stockton gives the following gas- tric sedative: Gm. or Cc. I^ — Ccrii oxalatis 10.0 5 iiss Bismuthi subcarbonatis 20 . 5 v IMagnesii oxidi 40 . 5 x Misce et ft. pulv. Sig. — A teaspoonful stirred in water; repeat in an hour if needed. CHAPTER Xy SECRETORY NEUROSES (Coxtixued): HYPERSECRETION— GAS- TRORRHEA— GASTROSUCCORRHEA— GASTROCHYLORRHEA The term ''gastrosuccorrhea" was introduced into medical literature as representing a clinical entity in 1882, by Reichmann. In gastrosuccorrhea, or hypersecretion, the glands of the stomach secrete gastric juice constantly; con- siderable amounts may be found in the fasting stomach, before the first meal of the day. Opinions vary as to the quantity of gastric juice that indicates hypersecretion. The percentage of hydrochloric acid may or may not be above the normal. INTERMITTENT OR PERIODIC HYPERSECRETION; ACUTE OR INTERMITTENT GASTRORRHEA Etiology. — In ascertaining the cause of hj^persecretion we must look to the nervous system. Among the etiologic factors we have neurasthenia, hysteria, anger, worry, and mental overexertion. Young adults are particularly prone to attacks. It is highly probable that chronic hyperacidity may induce acute hypersecretion, especially when the gastric mucous membrane is being irritated. A perfectly healthy mucous membrane with habitually normal secretion may, however, produce a flow of hyperacid gastric juice on the ingestion of certain articles of diet; very cold beverages may occasion hypersecretion. Acute hypersecretion occurs not infre- quently after the healing of gastric ulcer; the exciting cause is presumed to be the cicatrix of the ulcer. Symptoms. — Hypersecretion appearing at regular intervals is characterized by violent pain and copious vomiting of INTERMITTENT OR PERIODIC IIYI'ERSECRETION 333 acid materials. As a rule, the seizures are sudden and not anticipated by the patient; they occur mostly during the night or in the early morning hours. After the expulsion of food remnants, the vomited matter consists of varying quan- tities of greenish to clear watery fluid which exhibits all the characteristics of gastric juice. The chemical tests show the presence of hj'drochloric acid and pepsin. The micro- scope indicates the presence of epithelial cells and leucocytes. The violent pains, together with the retching and vomiting, reduce the patient to a condition of exhaustion. There is pronounced pallor, perspiration is free, and the pulse is feeble and rapid; appetite fails, and the bow^els are torpid; the urine is scanty and usually alkaline in reaction. The attacks may be of great severity, or they may be very shght; their duration varies from one or two hours to as many days. Convalescence is usually rapid, and the patient may feel well enough to resume his occupation the day following the attack. Not infrequently the seizures are accompanied by violent headaches. Attacks in which headache is a prominent symptom have been designated by the special term "nervous gastroxynsis " (Rossbach); they belong, however, to the class of intermittent hypersecretion. Sometimes the cephal- algia is of such a character that the local gastric disturbance is obscured. The patient may feel perfectly well during the interval between the seizures; slight gastric discomforts, such as pressure, fulness, eructations, are, however, experi- enced after eating. An examination of the stomach con- tents during the interval between attacks shows an excessive acidity, which would indicate the possibility of a coexistent chronic hj^peracidity. Diagnosis. — The diagnosis is confirmed by emesis of large quantities of liquid which responds to the tests for gastric juice. Treatment.— When the physician is called during an acute attack of hypersecretion, it is his first duty to cut short the attack, or, failing in this, to mitigate its severity. At its onset the disease may be diminished in severity, or even 334 SECRETORY NEUROSES aborted, by the administration of large doses of bicarbonate of soda or magnesium oxide. Stomach lavage is indicated either with clear water or with water containing nitrate of silver (1 to 1000). The drinking of milk has sometimes a salutary effect. Should the attack continue, atropine, 1 milligramme {-^ grain), is indicated, to be administered hypodermically. This is the most reliable medicament. Boas recommends morphine and atropine in combination, to be administered subcutaneously. Suppositories of extract of belladonna combined with morphine are useful, but do not act so promptly as atropine and morphine hypodermic- ally. The abdominal pains are to be treated with hot compresses, moist or dry. No food should be taken. Thirst should be allayed by small pieces of ice in the mouth. In the absence of distressing symptoms during the intervals between the attacks, and especially if the secretion of hydro- chloric acid be normal, a bland diet may be prescribed. Irritating food, the use of tobacco, and excessive mental effort, should all be avoided. If the patient has chronic hyperacidity an effort should be made to counteract this condition. (See chapter on Hyperacidity.) Favorable results are frequently obtained in nervous patients by sojourn in a high altitude. In some cases all therapeutic measures fail to prevent a recurrence of the attacks. CHRONIC GASTRORRHEA— REICHMANN'S DISEASE In this form of hypersecretion, first described by Reich- mann, the stomach secretes, apparently spontaneously, at any rate without the stimulating influence of food, a strong digestive juice, and that continuously. Normally only a few cubic centimeters of fluid contents are found in the fasting stomach, and pepsin and hydrochloric acid are either absent or present in minute quantities. In cases in which large (juantities of gastric juice are found regularly on removing the contents of the stomach after prolonged abstinence from food, the diagnosis of Reichmann's disease is confirmed. CHRONIC GASTRORRHEA 335 Etiology. — Chronic hypersecretion may develop from a i^re- vioiisly existing hyperacidity, which explains the frequent simultaneous occurrence of both disease processes. In such instances hypersecretion is an aggravated form of hyper- acidity, in which the secretory and sensitive condition of the mucous membrane is more pronounced than in cases of uncomplicated hyperacidity. There can be no doubt that nervous influences, too, constitute an important factor in the causation of hypersecretion. The majority of cases of chronic hypersecretion occur in youth and middle age, and in males. The secretion of gastric juice is augmented by the abuse of alcohol and tobacco. Among the causative factors are to be enumerated dietetic errors and mental perturba- tions. Gastric ulcer is also a cause of chronic hypersecretion. The frequent coincidence of chronic gastrorrhea and atony of the stomach is worthy of note. Riegel draws attention to the possibility of a relationship between hypersecretion and the traction of hernias on the linea alba, the peritoneum, and the stomach. Symptoms. — Chronic hypersecretion, or Reichmann's dis- ease, is characterized by slow onset, with mild symptoms, pressure and fulness after eating, eructations, and pyrosis. The prodromes are those of chronic gastritis. The symptoms may disappear, only to recur in aggravated form. Pain is an additional symptom; according to the statements of the patient, it does not follow the ingestion of food. Pains may, however, be induced by partaking of food, in which case they occur one to two hours after eating, or occur suddenly at irregular intervals. Thus the pain of hypersecretion differs from that of hyperacidity, which usually comes on at the height of digestion. The fact that, the stomach being empty, the ingestion of food while the pain is most severe will bring relief, is of diagnostic importance. At the height of a paroxysm, vomiting frequently occurs, and it has a marked effect in mitigating the severity of the pains. The greenish watery fluid expelled from the stomach may amount to several liters. Hematemesis is sometimes noted; when it is present, gastric ulcer or erosions of the stomach 336 SECRETORY NEUROSES should be borne in mind. The appetite is usually fair, but suffers as the pains become more persistent and severe. The quantity of food taken by the patient becomes less and less, with the result that he loses weight and flesh. In pro- nounced cases of chronic hypersecretion the patient com- plains of thirst, the bowels are constipated, and the urine is turbid from a slight degree of alkalinity. Many cases of hypersecretion are complicated with atony and motor insufficiency of the stomach. Such cases are characterized by the vomiting of large quantities of fluid. Diagnosis. — On the removal of the stomach contents in a well-marked case of hypersecretion six or seven hours after a test meal, there are found large quantities of food, with no meat remnants, but residues of starchy materials, which are precipitated to the bottom of the vessel. The total acidity of the material removed is very high, 90 to 100, and the hydrochloric acid is increased from 50 to 70. Sometimes, especially in cases of hypersecretion accompanied by dilata- tion of the stomach, the contents show copious evolution of gas in the fermentation tubes kept in the incubator. If the stomach be carefully cleansed at night and the patient per- mitted to fast, removal of the stomach contents in the morn- ing will show varying quantities of liquid secretion (up to I liter) possessing the properties of gastric juice. A positive finding of this kind serves to confirm the diagnosis of hyper- secretion. External Examination of the Stomach. — Palpation reveals an accelerated peristaltic motion. A thickened pylorus may be sometimes felt by the palpating hand, inasmuch as the pyloric exit of the stomach is often in a state .of tetanic contraction induced by the large quantity of acid present. As soon as a portion of the acid stomach contents passes through into the small intestine the pylorus closes, so that it is impossible for the stomach to properly empty itself. Each relaxation of the pylorus is followed by a spasm which blocks the exit. The muscles of the stomach, meanwhilo, attempt to force a passage by means of increased peristaltic movements. This vicious circle is the cause of the gastric CHRONIC GASTRORRHEA 337 dilatation which so frequently complicates these cases. Thickening of the pylorus may be the result of an old cicatrix from the healing of a gastric ulcer. In four cases of hypersecretion with pylorospasm, Rosen- stern applied continuous saline instillation — Murphy's proc- toclysis — to restore the needed water to the tissues. He found, to his surprise, that the treatment had a distinctly favorable influence on the spasm, promoting relaxation, as evidenced by the cessation of vomiting. He used Ringer's solution, a mixture of 7.5 parts sodium chloride, 0.42 part potassium chloride, and 0.24 part calcium chloride, with 1000 parts water. He therefore recommends systematic continuous enteroclysis as a direct means of influencing the pylorospasm, in addition to its other advantages. Prognosis. — The prognosis for complete recovery from chronic hypersecretion is not always favorable. Complete recovery may be anticipated only in that class of patients who are in a position to continue treatment for a long period of time. Patients who are unable to take the necessary care of themselves are apt to have relapses after intervals of improvement. Treatment. — The therapy of chronic hypersecretion, or Reichmann's disease, is clearly indicated on examination of the contents of the stomach, and by the subjective and objec- tive symptoms. Should there be evidence of any other pathologic condition complicating or maintaining the hyper- secretion, this must receive due consideration. If gastric ulcer is present it must be attended to ; and the neurasthenic requires special treatment. Patients suffering from hyper- acidity should be so treated as to preclude the possibihty of transforming that condition into hypersecretion. Anger, excitement, mental shock, and improper diet should be avoided as much as possible. Frequently, however, hyper- secretion would seem to be an idiopathic disease, one for which there is no assignable cause. Diet. — The chief factor in the therapeutics of hypersecre- tion is a properly selected dietary. Since the quantity of gastric juice secreted during the period of digestion is abnor- 22 33S SECRETORY NEUROSES mally large, proteolysis is likely to be satisfactory. This is attested by the fact that when the stomach contents are removed after a meal of meats and starches, scarcely any meat remnants remain; the residue is made up principally of amylaceous material. The gastric digestion of carbo- hydrates is held completely in abeyance in hypersecretion, since the ptyalin is neutralized almost as soon as the food reaches the stomach. From this it follows that the food should be mainly protein. So far as the quantity of fats in the food is concerned, the statements regarding fat in hyperacidity hold good. Fat diminishes the secretion of hydrochloric acid, and should therefore be employed exten- sively in the treatment of hypersecretion. A diet of protein and fat is indicated. The gastric mucous membrane is in a condition of chronic irritation; therefore, in prescribing diet, care must be exercised to avoid articles of food which are apt to aggravate this condition. All spices, acids, and highly seasoned foods must be eliminated from the diet. Extremes of temperature in foods and beverages should be avoided. Thorough mastication of the food is an important requirement; the food should be in a finely subdivided condition before being swallowed. The various kinds of meat may be taken by this class of patients. Meats should be well cooked, since raw meat combines readily with acids and excites the secretion of still greater quantities of gastric juice. Soft-boiled eggs, scrambled eggs, omelet, and cream cheese are indicated. Of fats, numerous articles merit consideration; for example, butter, olive oil, sesame oil, cottonseed oil, milk and cream, cocoa, and yolk of egg. Milk is an excellent liquid food ; it is non-irritant and has a neutralizing effect upon the acidity of the gastric juice. Carbohydrates, for obvious reasons, should be restricted unless they have been dextrinized; wheat bread should be eaten in the form of toast. Crackers and zwieback are suit- able articles of diet. Carbohydrates should be given in the form of leguminous flour soups, or gruels, or as sago and oatmeal. The patient ma}^ partake of a small ciuantity of mashed potatoes. All green vegetables should be prohibited. CHRONIC GASTRORRHEA 339 Sugar is allowable only in cases in which the motility of the stomach is normal, since it may give rise to excessive fer- mentation. Care should be exercised in the preparation of dishes for this class of patients, to avoid even a moderate use of condiments. Diet List for Hypersecretion (Wegele) Carbo- Protein. Fat. hydrates Morning. 100 Gm. tea with milk . 3.4 3.0 4.8 2 soft-boiled eggs . 12.0 10.0 Forenoon. 1.50 Gm. calf's-foot jelly . .35.0 17.0 1.0 Noon. 150 Gm. sweetbread in bouillon .32.0 2.50 Gm. tapioca mush 12.0 8.0 11.0 50 Gm. cream 2.0 13.5 1.7 Afternoon. 200 Gm. milk . . . 6.8 6.0 9.6 Evening. 200 Gm. ham . . . . 48.0 70.0 2 scrambled eggs . 12.0 12.0 At meal times. 100 Gm. aleuronat toast . 28.3 1.5 66.7 10 P.M. and during night. 100 Gm. milk . . . . Total . . . . 6.5 6.0 10.0 198.0 147.0 104.8 Calories 900 1360 430 Entire number of calories, 2700. Diet List for Hypersecretion (Friedenwald and Ruhrah) Calories. 8 A.Ji. 200 Gm. milk flavored with tea 135 2 soft-boiled eggs '. . 160 60 Gm. toa.st 1,54 40 Gm. butter ........... 326 10 a.m. 50 Gm. raw scraped beef 60 50 Gm. toast 130 12 M. 100 Gm. broiled steak 210 Or 100 Gm. chicken or lamb chop. 100 Gm. asparagus 18 Or 100 Gm. carrots (41) mashed and strained. Or 100 Gm. peas (318) mashed and strained. Or 100 Gm. .spinach (165). 100 Gm. stale wheat bread 258 4 P.M. 200 Gm. milk 135 1 soft-boiled egg 80 60 Gm. toast 1.54 40 Gm. butter 326 7 p.m. 100 Gm. baked trout 106 100 Gm. milk 67 2319 340 SECRETORY NEUROSES Nwiiber of Meals. — Regarding the number of meals, a good rule to follow is to partake of food at comparatively frequent intervals and in small quantities; the object is to make use of the gastric juice as fast as it is secreted. Fre- quent administration of food wdll tend to bring about an entire cessation of pain; suitable articles of food should be at hand all the time. Milk, biscuits, and hard-boiled eggs should be easily accessible to the patient on retiring at night; these taken at the beginning of a pain will often suppress it. Liquids.— lAqmd^ should be taken in moderation, since they tend to increase the quantity of fluid in the stomach. They are particularly harmful in cases of hypersecretion combined with atony or dilatation. Alcohol and coffee should be avoided. When there is great thu'st, and it is inadvisable to partake of sufficient liquid by mouth to allay the tliirst, a small enema (150 Cc.) of physiologic salt solu- tion will satisfy the craving. In severe cases of hypersecretion it is sometimes advisable to resort to rectal feeding for a period of eight or ten days. By this means irritation of the stomach by food \^'ill be obviated, and a diminished secretion of gastric juice will result. Riegel suggests an exclusive milk diet for eight or ten days; this is what is called the ''milk cure." Before prescribing a milk diet, however, he administers a milk test breakfast consisting of 400 to 500 Cc. of milk. The stomach is emptied after an interval of an hour. Absence of free hydrochloric acid, though the total acidity be high, warrants a trial of the so-called ''milk cure." The milk diet acts as a sedative to the sensory nerve endings of the gastric mucous membrane. Intercurrent diarrheas may be pre- vented by the addition of lime water to the milk in the pro- portion of 1 to 3 or 1 to 4. The feedings should consist of 350 to 400 Cc. (12 to 14 ounces) of milk every two hours, or a daily amount of 2800 Cc. (about 3 quarts) . This regimen cannot, however, be continued for more than eight days. The required number of calories may be attained by the addition of a milk-cream mixture or small (luantities of protein preparations, such as sanatogen, plasnion, roborat, or nutrose. CHRONIC GASTRORRHEA 341 Medicinal Treatment. — The alkalies are valuable therapeutic agents in the treatment of hypersecretion, as well as in hyperacidity. They niciy be prescribed to be taken before, during, or after the ingestion of food. Given during or before a meal, the alkalies are calculated to facilitate amylo- lysis, since they neutralize the free hydrochloric acid which would otherwise put a stop to the action of the ptyalin of oral digestion as soon as it reached the stomach. For the improvement of amylolysis, artificial saUvary fer- ments have been employed. One of these is the artificial ptyalin of Merck. This preparation may be given with the alkalies. Again, we have taka-diastase and malt diastase; these act in the same way as ptyalin. Taka-diastase is prepared by Parke, Davis & Co. from the aspergillus oryzse, a fungus that is employed in Japan in the manufacture of rice wine. It is a yellowish-white powder, soluble in water and somewhat more resistant to the action of acids than the other varieties of diastase. Taka-diastase may be prescribed to be taken with the food, with or without alkaUes, in cases of hyperacidity and hypersecretion. Like ptyahn, it will act as a starch digestant only in an alkaline, neutral, or slightly acid medium. Panase is a pancreatic preparation similar in its action. Alkalies are given after meals to neutralize excessive acidity that is producing painful symptoms. Large doses have the effect of iiimiediately relieving the pain. They are valuable for allaying the violent paroxysmal nocturnal pains of hypersecretion, but unfortunately the rehef is not per- manent. Magnesium oxide and bicarbonate of soda are particularly useful in these conditions. The administration of the Carlsbad salt in the morning after the night's fast is a useful procedure, since it neutralizes the gastric secretion and washes it into the duodenum. Atropine sulphate, 1 milligramme (eV grain), has been given hypodermically during violent pylorospastic attacks. Eumydrin also can be used, and is safer. Favorable results have been secured from the use of extract of belladonna in suppository form. This drug may also be given internally, either alone or in combination with the alkalies. 342 SECRETORY NEUROSES Astringent remedies are to be employed as in the treatment of hyperacidity. Preparations of bismuth or nitrate of silver may be given by mouth in combination with atropine. Jaworski recommends in the treatment of hypersecretion two alkaline waters, a stronger and a weaker. The stronger consists of 1 hter of water charged with carbon dioxide, sodium bicarbonate 8 Gm., sodium salicylate 2.5 Gm., sodium borate 2 Gm. ; the weaker water contains sodium bicarbonate 5 Gm., sodium salicylate 2 Gm., sodium borate 1 Gm. ; the dose is a half -glass to a full glass after each meal, depending upon the condition of the secretion. If constipation be present, Jaworski employs two solutions of effervescent magnesia, a milder and a stronger. The milder is as follows : . Gm. or Cc. I^ — Magnesii carbonatis 4.0 3] Magnesii salicylatis 1.0 gr. xv Aquae carbonis dioxidi . q. s. ad 1000.0 Oij Misce. Sig. — One-fourth to one-half tumblerful fifteen to thirty minutes after each meal. The stronger solution is as follows : Gm. or Cc. I^— Magnesii carbonatis 10.0 oiiss Sodii chloratis 4.0 oj Aquse carbonis dioxidi 1000.0 Oij Misce. Sig. — One to one and one-half tumblerfuls in the morning on an empty stomach, or in the evening at bedtime. Treatment by Lavage of the Stomach. — In cases of hypersecre- tion where the symptoms do not yield to dietary and drug therapeutics, the stomach should be washed out just before the evening meal. It is then in a condition to receive and to digest a small supper. The quantity of acid secreted after the supper is neuti-alizod by the food. Lavage is also indi- cated in the morning ])efore breakfast, to remove the acid secreted during the early morning liours, as well as llu> rem- nants of food that may have remained ovornight in tlie stomach. In pronounced cases of hypersecretion, lavage ALIMENTARY HYPERSECRETION 343 at these two periods is imperative; painful attacks are often cut short by a single washing. Pure water, lukewarm, is employed in the process, to be followed by lavage with a mild alkali, such as sodium bicarbonate. Lavage with 1-to-lOOO nitrate of silver or with a suspension of bismuth subnitrate has been employed with good success. Penzoldt advises the drinking of half a liter of a 1-per-cent. solution of boric acid, which is to be removed from the stomach after five minutes. Treatment with Mineral Waters. — Carlsbad water, taken in large doses and for a long period of time, has the effect of diminishing the secretion of gastric juice. It is favorable to the peristaltic movements of the stomach and tends to diminish the sensitiveness of that organ. The waters of Bertricho are similar in action to the Carlsbad waters. Instead of Carlsbad, Vichy water may be prescribed for neurotic patients. Physical Treatment. — Massage, vibration, and electric treat- ment must not be employed in hypersecretion. Hydro- therapeutic and thermic applications may, however, be made extensively and to good advantage. Hot compresses, moist or dry, applied locally, are particularly adapted to the treat- ment of painful seizures. Winternitz applied running hot water, 104° F., over cold and moist abdominal packs by means of a rubber tube (Fig. 20) . According to this authority the local heat deadens the chilly sensation of the cold wet cloth enveloping the body, as a stronger nerve stimulus deadens a less intense one. In severe cases prolonged rest in bed is essential. Surgical Treatment. — In cases of hypersecretion complicated with atony of the second degree, marked motor disturbances, and stenosis of the pylorus, gastroenterostomy may prove of permanent benefit. ALIMENTARY HYPERSECRETION Alimentary hypersecretion is a less severe variety of chronic gastrorrhea. While in Reichmann's disease the 344 SECRETORY NEUROSES gastric mucous membrane is in a state of continuous irri- tability, as a result of which the gastric secretion is con- stant and abnormal in quantity, even when the stomach is empty, in alimentary hypersecretion the symptoms, which afford the same clinical picture when thej^ appear, are only induced by stimulation of the gastric mucous mem- brane. There must be a stimulus, however sUght, before the abnormal secretion begins. Much less stimulation is required, however, than in the normal stomach; the secretion begins sooner. This variety of hypersecretion has been described by Zweig and Calvo, Strauss, Riegel, and Boas. Symptoms. — The subjective symptoms are less severe than those of chronic gastrorrhea, resembUng more closely those of hyperacidity. Gastric discomforts, consisting of pjTosis, pressure, acid eructations, and pain of greater or less severity, set in almost immediately after food is partaken. In this way is alimentary hypersecretion differentiated from hj^per- acidity, the symptoms of which do not appear until some little time after eating. In contrast with hyperacidity, the discomforts of alimentary hypersecretion are not diminished by partaking of food. The appetite is generally good, though patients often become poorly nourished because they are afraid to eat. When alimentary hypersecretion is com- plicated with motor disturbances, the distressing symptoms are in proportion to the time the food remains in the stomach. In intense attacks of pain, as in Reichmann's disease, con- stipation is a frequent concomitant symptom. Diagnosis. — Palpation of the empty stomach, as a rule, does not reveal anything of note. When the stomach is filled with food, palpation occasionally causes a sUght degree of pain. Splashing sounds can be elicited occasionally during the height of digestion, especially if atony be present. The diagnosis must be made by means of the test meal or test breakfast. The facts that the fluid portion exceeds the solid residues, and that the total quantity of fluid removed is greater than the amount introduced, are of diagnostic importance. The quantity of free hydrochloric acid will ALIMENTARY HYPERSECRETION 345 be found above normal. There are no pathologic findings which can be said to be pathognomonic of this disease. Treatment. — The dietetic treatment is the same as that prescribed for Reichmann's disease. Owing to the fact that amylolysis is deficient, the food should be chiefly of a pro- tein and fatty nature. It should be finely subdivided, pref- erably mucilaginous in consistency; and the meals should be hmited to three a day and taken at regular intervals, so as to prevent, to the greatest possible extent, irritation of the gastric mucous membrane. In these cases, too, it is sometimes expedient to place the patient on an exclusive milk diet, keeping him in bed. Milk should be given at long intervals, for the same reason that sohd food is widely spaced. Medicinal Treatment. — Alkalies are to be employed exten- sively, both before and during meals, to assist amylolysis, and also after meals and at the height of digestion. Atropine sulphate, hypodermically, by mouth, or by suppository, is of value when there is pain. Occasionally it is necessary to continue the administration of atropine over an extended period. Astringents are also indicated. Treatment by Lavage of the Stomach. — The best time for this procedure in cases of alimentary hypersecretion is late at night, after an early supper, in order to relieve the stomach of food remnants and thus prevent gastric secretion during the night. Lavage with pure water may be succeeded by lavage with alkalies or with nitrate of silver (1 to 1000). CHAPTER XVI ACUTE GASTRITIS: SIMPLE— INFECTIOUS— TOXIC— PHLEGMONOUS Acute gastritis (acute gastric catarrh) is an inflammation of the gastric mucous membrane accompanied by disturb- ances of digestion. The inflammation may be simple, infec- tious, toxic, or phlegmonous. It may be limited to the superficial layer of the gastric mucosa, or it may involve the glandular epithelium, the parenchyma, or the interstitial tissues. SIMPLE ACUTE GASTRITIS This is the form of gastritis that is most frequently met in general practice. No age or class is exempt. Etiology. — Among the etiologic factors are: errors in diet — an excessive amount of food taken at one time; mechanical, thermic, or chemic irritants ; foods highly spiced or fermented; unripe or over-ripe fruits; cold drinks, soda water, and ice cream; food in process of decomposition; the excessive use of condiments; and overindulgence in alcohol. The tendency to acute gastritis is greater in some individ- uals and families than in others. In many persons the predisposition is such that the slightest excess in diet pre- cipitates the catarrhal condition. In this class are anemic women, invalids, and elderly persons. Acute gastritis may be secondary to other affections, as the acute infectious diseases, typhoid, smallpox, pneumonia, or measles. Lebert and Oser urge the infectious nature of the disease, but no microorganisms have been found within the stomach to substantiate this claim. Toxic gastritis in its milder forms may be placed in the category of simple acute gastritis. Decom]ioRition products, SlMl'LE ACL'TE GASTRITIS 347 such as spoiled food, meat, fish, or cheese, are coiitril^utory to this form of gastric catarrh. With acute gastritis may be classed the light forms of acute infectious gastritis caused b}^ microorganisms introduced with decomposed food. It is well known that parasites, oxyuris, teniae, ascarides, and larv* of flies, taken into the stomach, may cause gastritis. Pathology. — The gastric mucosa is wholly or partially swollen and reddened, the inflamed portions covered with tenacious mucus. In occasional instances there are slight hemorrhages. The submucosa may be edematous. Micro- scopically, the surface epithelium appears altered; it is swollen, opaque, and desquamated. Similar changes are noted in the glandular epithelium. The capillaries are markedly dilated and congested. Round-celled infiltration is occasionally found in the interstitial tissue. Symptoms. — In mild forms of gastric catarrh, due to dietetic errors, the patients complain of a feeling of weight in the pit of the stomach, followed by a sensation of fulness. Belching affords relief. In some cases there is nausea, and in the more severe type of acute gastritis the onset of the disorder is characterized by gastric pains, nausea and vomiting, rise of temperature, loss of appetite, and consti- pation or diarrhea. The vomited material usually consists of bad-smelling and fermented masses, acid in reaction. The total acidity of the vomited material varies; free hydro- chloric acid is usually decreased or absent. On the other hand, in some cases there is hyperacidity and hypersecre- tion accompanied by pyrosis. A high total acidity is occa- sionally caused by the presence of the organic acids — acetic and butyric. Emesis, or retching after the stomach has been emptied, often results in the evacuation of mucobiliary masses. The tongue is coated and the breath fetid. The region over the stomach is sensitive to pressure, and the stomach shows a slight distention. Acute gastritis may be afebrile, or there may be a temperature of 102° to 104° F. Course. — The course of acute gastritis depends largely upon the intensity of the attack; its usual duration is from one to three days. An early emesis gives great relief, so 348 ACUTE GASTRITIS that the distressing symptoms often rapidly subside. Some- times, however, vomiting is followed by lassitude, weakness, and cephalalgia. Acute gastric catarrh may pass from the stomach to the intestine, involving both, so that we have a gastroenteritis. Though patients usually recover from mild attacks in two or three days, the so-called ''weak stomach " remains, and the patient has more or less prolonged periods of anorexia. Prophylaxis. — Persons subject to attacks of acute gastric catarrh should be on their guard against dietary mdiscretions. They should avoid rich foods, food that is either too cold or too hot, unripe fruits, and whatever may have been impli- cated in causing previous attacks. Were patients to avoid such articles of diet, and refrain from habits and excesses known to themselves to be causative factors in acute gastric catarrh, this disease could be prevented to a very marked degree. Treatment. — The vis medicatrix naturce is seen at its best in this affection. To get rid of the undigested material, the stomach empties itself by vomiting, or by passing the con- tents on to the small intestine, where they may set up a diarrheal discharge. When vomiting does not take place from the irritation caused by the mass of undigested food in the stomach, we should lend our assistance to bring about evacuation of the stomach contents. The first question is: Shall we give an emetic? Emetics are nowadays rarely emploj^ed, perhaps not so often as they should be. In acute gastric catarrh they should not be thought of unless there is a sense of fulness and distress in the epigastrium, with an inclination to vomit. A glass of warm water containing mustard may be given. Sometimes emesis may be induced by simply tickling the fauces. In the great majority of cases vomiting has occurred before the arrival of the physician, and the indication is to relieve excessive irritability. The best method of cleansing the stomach is by the use of the stomach tube. Since the object is not medication, but simply mechanical elimination, it is suflicient to wash SIMPLE ACUTE GASTRITIS 349 out the stomach with hikewarm water to which bicarbonate of soda, a teaspoonful to the pint, has been added. This will promote the solution of mucus. It is always wise to evacuate the stomach by means of the stomach tube when evacuation is desirable and does not occur spontaneously. Many patients are afraid of the tube, and protest at the mere mention of it; but it is the duty of the physician so to train himself in its manipulation that he can use it with the mini- mum of discomfort to the patient. I strongly commend the use of the stomach tube for promptness and thoroughness in the evacuation of stomach contents; it has the additional advantage that it does not irritate the gastric mucosa as do emetics given by mouth. In performing lavage, the patient should be instructed to occupy different positions to facilitate the thorough cleansing of the stomach. Some authors recom- mend the addition of hydrochloric acid in order to destroy ferment.ative organisms. Usually a single lavage is sufficient if it be thoroughly done. In children, lavage is the only method of cleansing the stomach that should be considered. In infants and very young children it may be accomphshed by means of a Nelaton catheter. After lavage the retching ceases and the general condition improves. It is evident that gastritis cannot be cured so long as decomposed food materials remain in the stomach. Emetics proper remain for those cases in which, for one or another reason, it is impossible or impracticable to use the stomach tube. The most useful emetic is : Gm. or Cc. I^ — ^Antimonii et potassii tartratia . 05 gr. j Pulvis radicis ipecacuanhge 1 . 00 gr. xv Misce et ft. pulv. no. v. Sig. — One powder every quarter of an hour until vomiting occurs. The following may be administered to children: Gm. or Cc. I^ — Pulvis radicis ipecacuanhaj 2.0 Sss Syrupus amygdalae 20.0 5v Misce. Sig. — One dessertspoonful every ten minutes until vomiting is induced. 350 ACUTE GASTRITIS When the administration of emetics by mouth is inad\'is- able, on account of its tendency to increase the irritable condition of the stomach, the hypodermic injection of apomorphine may be resorted to: Gm. or Cc. R — Apomorphinae hydrochloridi 0.1 gr. iss Aquae destillatae 10.0 oiiss Misce. Sig. — One-half to one syringeful hj-podermically (7 to 15 minims). Hypodermic tablets of apomorphine ready for use are to be had, and fresh supphes should be carried in the regular medicine case. The action of apomorphine is rapid and certain. After the stomach has been thoroughly emptied and cleansed, all food should be interdicted for the next twenty- foui: to forty-eight hours. This edict \\dll not be difficult to enforce, since the patients have httle or no appetite. Thirst may be allayed by means of cracked ice. Carbonated waters, iced milk, brandy and soda, and lemonade are acceptable and generally harmless. Preparations containing menthol quiet and anesthetize the hypersensitive mucosa, acting at the same time as anti- septics: Gm. or Cc. R— Mentho!i.s 1.0 gr. xv Alcoholi.s, Syrupi aa 30.0 oj Misce. Sig. — One tea.spoonful every hour. Validol is a good substitute for menthol. It is a prepa- ration of menthol and valerianic acid, containing about 30 per cent, of free menthol. It may be prescribed to be taken three times a day in doses of 0.6 to 1 Cc. (10 to 15 minims). Bicarbonate of soda, either alone or with such antizymotics as resorcinol and salicylic acid, may be given, should the contents of the stomach be markedly acid: Gm. or Cc. I^ — Rfsorfinoli.s 0.6 gr. x Sodii bicarbonalis, Bismuthi salioylatis fia 4.0 5i Misce et ft. pulv. no. x. Sig. — One powder oven,- two hours. SIMPLE ACUTE GASTRITIS 351 The coated tongue may be carefully cleansed mechanic- ally by means of a clean piece of soft linen moistened with lemon juice. A marked degree of pyrosis can be relieved by the follow- ing: Gm. or Cn. I^ — INIagnesii oxicli, Sodii bicarbonatis, Olei sacchari menthaj piperitae . . . . aa 10.0 3iiss Misce et ft. pulv. Sig. — Knife-pointful every two hours. For the rehef of pain : • Gm. or Cc. I^ — Codeinse phosphatis 0.12 gr. ij Aquae menthte piperitse 30.0 § j Misce. Sig. — One teaspoonful twice or three times a day. For acid eructations: Gm. or Cc. I^ — Resorcinolis 1.0 gr. xv Aquae destillatae, Aquae menthae piperitae aa 4.5.0 §iss Misce. Sig. — One tablespoonful every two hours. Diet. — After twenty-four to forty-eight hours' rest, liquid food (no other) should be given — soups and gruel in small but gradually increasing quantities. The yolk of an egg may be added to the soup. Later, this diet may be follow^ed by milk sipped slowly, fowl, minced ham, crackers, eggs, and filet of beef. This is usually sufficient for an ordinary case of simple acute gastritis. Should the appetite continue poor, it may be stimulated by tablespoonful doses of 1 to 1| per cent, common salt solution, by port wine, or by caviar; or hydrochloric acid dilute, 1 Gm. (15 minims), may be given before meals in lemonade or compound tincture of cinchona. Fluidextract of condurango, 1 Gm. fl5 minims) thi'ee times a day, before meals, has a good effect. Pain is sometimes complained of, though it is rareh^ of such intensity as to require treatment. Moderate pains and 352 ACUTE GASTRITIS gastric pressure are best treated by hydriatic measures. A Priessnitz bandage, renewed every two or three hours, is of good service in such cases. Should the pains be more severe, moist appUcations or hot dry compresses, hot bottles or the electric pad are indicated. These apphances may be continued for some time if necessary. The consideration of analgesic and narcotic remedies must be reserved for cases accompanied by excessive pain; these drugs must not, however, be given by mouth, but should be administered in suppository form only: Extract of opium, 0.03 to 0.05 Gm. (h to 1 grain) ; codeine phosphate, 0.03 to 0.05 Gm. (h to 1 grain) ; codeine, 0.05 Gm. (1 grain) ; extract of belladonna, 0.03 Gm. (i grain), alone or in combination, are the drugs employed. Morphine is apt to induce vomiting. The intestinal tract may be affected in acute gastric catarrh by the presence of irritating substances from the stomach, so that instead of a simple acute gastritis we have an acute gastroenteritis. When there is reason to suspect the presence of decomposed and irritating masses in the intestine, it is good treatment to induce evacuation. Calo- mel is the best remedy we have for this purpose. It is an excellent remedial agent in the treatment of gastrointestinal disorders of children. The dose for adults is 0.12 Gm. (2 grains) twice a day, or 0.01 Gm. (| grain) every hour for ten doses. Castor oil is also a useful evacuant. Patients who cannot take castor oil will readily take Carlsbad salt, 5 Gm. (3j) in a half-glass of water; it should be taken in the morning when the stomach is empty. After thorough evacuation of the bowels, three or four days may elapse before the next movement. Should constipation persist, an enema of warm water, plain or containing soap, oil, glycerin, vinegar, soda, or cottonseed oil, should be given. After cleansing the intestine, such intestinal disinfectants as resorcinol or salicylate of bismuth may be considered. ACUTE INFECTIOUS GASTRITIS 353 ACUTE INFECTIOUS GASTRITIS (INFECTIOUS CATARRH OF THE stomach) Gastric catarrh may occasionally assume what is known as a grave form. Etiology. — Usually the exciting cause of infectious gastric catarrh consists of microorganisms introduced into the stomach with articles of food, decomposed meat or fruit, or food or drink which may not appear to be tainted, such as impure milk or water from infected wells. The grave form of acute gastric catarrh may thus become epidemic. It is often a very difficult matter to determine the cause of this disease with absolute certainty. Pathology. — The pathologic changes accompanying the three forms of acute gastritis are similar to those of the mild form; the difference is one of degree only. There is marked hyperemia, tumefaction and reddening of the gastric mucosa, with marked participation of the glandular epithehum and interstitial tissue. Symptoms. — The symptoms described in the section on Acute Gastric Catarrh are present here in aggravated form, consisting of violent pains accompanied by persistent and severe vomiting and marked prostration. Fever, always absent in mild gastric catarrh, is a constant symptom of the grave variety. In fact, the febrile disturbance is a fairly reliable index of the gravity of the disease. These severer forms of acute gastritis are sometimes due to dietary indiscretions; but they are more frequently the result of infection, so that this form of the disease is designated acute infectious gastric catarrh. Every acute infectious catarrh, however, is not grave. The fever (gastric fever) is of marked intensity and of the continued or remittent type. Other symptoms are: violent throbbing headache, insomnia, thirst, rapid pulse, and occasional delirium. In the febrile cases there is a marked diminution of acid secretion; the fever itself in all probability reduces the secretion of hydrochloric acid. The 23 354 ACUTE GASTRITIS disease ordinarily runs from ten to fourteen days; in some instances the fever may persist for three weeks. In very old and very young patients this form of gastritis may assume an alarming character. The severe forms of infectious gastritis exhibit clinical symptoms similar to those that are caused by the introduction into the stomach of organic poisons, such as the metabolic products of infectious microorganisms — toxins and ptomains. The course of the disease is usually, but not always, severe. Treatment. — The treatment of these severe forms of acute gastric catarrh is based upon the same principles as that of the milder forms. The stomach must be emptied and cleansed as quickly and thoroughly as possible by means of lavage. When the disease is due to infection it is well to wash out the stomach with antiseptic solutions: for example, salicylic acid 1 to 2 parts in 1000 of w^ater, or dilute boric acid solution (3 to 1000 to 5 to 1000). Emetics should not be employed if it is possible to empty the stomach in any other way. Food should be interdicted for a number of days in the case of robust patients, to give the stomach needed rest. Thirst and persistent vomiting are to be met by small doses of cold mineral waters, carbonated waters either with or without fruit juices, cracked ice, or cold tea. The general condition of the patient, his pulse and tempera- ture, must be constantly under observation. Wine, brandy, cognac, champagne, Tokay wine and strong coffee are to be administered to the aged and weak as indicated. When a patient is in a condition to partake of food, partic- ular care should be exercised in regard to the kind and quan- tity permitted. At first onlj^ liquid foods, such as bouillon with yolk of egg, meat juices and extracts, albumin water, and leguminous soups, should be allowed. Should obstinate vomiting interfere with eating, nutritious enenuita may be given. Great caution should bo exercised when the patient is passing from liquid to solid food. The initial solids should consist of veal, sweetbread, brain, boiled fowl (chicken. S(iuab), minced raw meat, minced ham, meat jelly, flour and milk gruel, tapioca, mashed potatoes, milk, crackers, or TOXIC GASTRITIS 355 zwieback. The return to a full diet should be very gradual, not complete until ten to fourteen days after the cessation of all the symptoms. Medicinal Treatment. — The same drugs prescribed in the treatment of milder gastric catarrh are indicated in the infectious forms. Since in these severe acute cases the hydrochloric acid secretion is diminished, dilute hydro- chloric acid should be given three times a day in doses of 0.75 to 1 Gm. (10 to 15 minims), well diluted wdth water. This will serve the additional purpose of allaying the thirst. Resorcinol may be given for nausea and bad-smelUng eructations. Persistent vomiting is combated by the use of menthol, or by Potio Riveri (citric acid 2 Gm., bicarbonate of soda 3 Gm., w^ater 100 Cc), to which may be added cocaine, 0.065 Gm. (1 grain); this is given in teaspoonful doses as occasion requires. To reduce fever, 0.3 Gm. (5 grains) of quinine or phenacetine may be given; or recourse may be had to the tepid or cold bath. Calomel, 0.015 Gm. {\ grain) three times a day, will often exert a good influence on the course of the disease. When the infection has passed to the intestine, calomel should be given, to be followed if necessary by resorcinol with salicylate of bismuth; the following formula has been recommended : Gm. or Cc. I^ — Bismutbi salicylatis 3.0 gr. xlv Resorcinolis 2.0 gr. xxx Glycerini 15.0 §ss Aquae 200.0 §vij Misce. Sig. — One table.spoonful every three hours. TOXIC GASTRITIS Etiology. — Another variety of severe toxic gastritis is that caused by cheixiical poisons, such as concentrated mineral acids, caustic alkalies, ammonia, carbolic acid, oxalic acid, alcohol, phosphorus, arsenic, cyanide of potassium, chlorate of potash, corrosive sublimate, lysol, and others. 356 ACUTE GASTRITIS Pathology. — The most marked alterations of the gastric mucous membrane are produced by the corrosive poisons, acids and alkahes, oxahc acid, carbohc acid, lysol, and cor- rosive subUmate. At first the wall of the lower end of the greater curvature not far from the pyloiiis, or the posterior wall of the stomach, is attacked by these poisons, the loca- tion depending on the position of the patient (that is, whether hdng or standing) when the poisonous substance is ingested. The gastric mucosa is hyperemic and greatly swollen, subsequently becoming ulcerated; the ulcers some- times penetrate to the serous coat, or even to complete perforation. In recovery the patient may have pronounced distm'bance of the motor and chemic functions of the stomach; there is apt to be an alteration in the shape and size of the organ, due to cicatrization. Alcohol and phos- phorus do not produce such marked lesions, but cause an intense irritation and inflammation of the mucosa together with fatt}^ degeneration of the glandular epithelium. Symptoms. — The symptoms will vary according to the amount of poison taken. There is always intense burning pain in the pharynx, along the esophagus, and especially in the stomach. Vomiting soon commences, but does not bring relief to the patient. The vomited matter contains an admixture of blood. The stomach is usually distended, and the abdomen exceedingly sensitive to pressure. Thirst is always a feature. In cases of great severity the pulse is small, the lips blue, and there is perspiration, with slight coma; death may occur in collapse. Prognosis. — The prognosis in such cases depends upon the quantity of poison taken, as well as upon the condition in which the patient is found. Every case of poisoning should be considered serious, and recovery a matter of doubt. Treatment. — The prime requirement is to remove the poison from the stomach with the utmost speed, and this is best accomplished by lavage. It is sometimes dangerous to attempt to introduce the tube, owing to the possibility of perforation. Especially is this likely to happen in poisoning by acids or caustic alkalies. In all such cases the best mode PHLEGMONOUS GASTRITIS 357 of treatment is to effect a dilution of the poison, and if possible its neutralization. In the treatment of poisoning by inorganic acids, alkalies are indicated to neutralize any free acid in the pharynx, esophagus, or stomach. Large doses of magnesium oxide, 200 Gm. (o viss) in four portions of water; well diluted caustic soda in a mucilaginous vehicle; lime water, powdered chalk, large quantities of bicarbonate of soda, are suitable antidotes. Care should be exercised in the employment of chalk and bicarbonate of soda, owing to the generation of carbon dioxide on contact with the acid. In poisonmg by organic acids, saccharated lime may be given, in addition to the other substances mentioned, for the purpose of converting the acid into a nearly insoluble lime salt. Thirty grammes of oxalic acid require 50 grammes of calcium carbonate or 20 grammes of magnesia for saturation. Cracked ice should be administered, and ice packs applied over the region of the stomach. Morphine may be given for the relief of pain. In cases of poisoning by alkalies, such acids as acetic or citric are indicated to neutralize the caustic effect of the poison. Lysol and carbohc acid poisoning call for thorough lavage with large quantities of water (2 or 3 liters); large doses of sulphate of soda are useful; lime water and sac- charated lime produce the comparatively harmless phenolate of lime. It is well to note, too, that grain alcohol is the nearest approach to an ideal drug we have for neutralizing the effect of carbolic acid. In phosphorus poisoning the treatment consists in long-continued lavage and the sub- sequent administration of half a teaspoonful of turpentine every half-hour. PHLEGMONOUS GASTRITIS This is among the rarest of gastric diseases. The earliest description of the disease would seem to be in a communica- tion by Veranadeus in 1620. In the latter half of the seven- teenth century and in the beginning of the eighteenth there 358 ACUTE GASTRITIS were published observations on phlegmonous gastritis b}^ Borel (1656), Sand (1701), Vorwaltner, and Bonet. These observations describe the circumscribed form only. Andral (1839) and Cruveilhier appear to have been the first to observe the diffuse form of purulent infiltration of the gastric walls. In their case a fortunate accident led to incisions into the stomach walls, which revealed a diffuse submucous suppurative inflammation. Since 1860 papers on both the circumscribed and the diffuse forms have been published by Raynaud, Auvray, Leube, Hun, Glax, Lowenstein, Oser, Reinking, Kelynack, and, finally, a very admirable mono- graph by Leith, of Edinburgh, in 1896. Leith was able to collect only 51 positive cases of the diffuse form of phleg- monous gastritis in the entire literature of the subject, and the total number of cases of both diffuse and circum- scribed forms is given as 85. The disease is characterized by a purulent inflammation of the walls of the stomach, originating in the submucous coat and gradually extending to the other layers. A primary and a secondary or metastatic form of the disease have been distinguished. The condition has been classified also as ''diffuse phlegmonous gastritis," in which the purulent infiltration of the stomach extends over a large area, and '* circumscribed," or so-called abscess of the stomach. It usually runs an acute, though occasionally a subacute, course. Only about 90 cases have been reported, of which number the majority were males. The metastatic form of the disease usually originates in infectious diseases — puer- peral fever and pyemia. Etiology. — The cause of the primary affection is obscure. Alcoholism has been suggested. Traumatism, dietetic errors, exposure, food and drug poisoning, puerperal fever, and carcinoma, have been noted as contributory factors; they undoubtedly lessen the power of resistance so that the stomach more easily becomes a nidus for i)y()geni(' liactcria. Kinnicutt^ reports a case of phlegmonous gastritis in whicli ' I'liil;i'lcli)lii;i I\I(ilic;il .JoiiriKil, NovciiiIut 17, lUOO. PHLEGMONOUS GASTRITIS 359 bacteriologic examination revealed the universal presence of the streptococcus; it was most abundant in the connective tissue of the submucosa and the muscularis. Two cases were reported by Robertson,^ in which the direct cause was a virulent streptococcus in the gastric submucosa, entering through a defect in the mucosa or carried by the blood or Ij-mph currents. Many associated conditions act as indirect causes, and of these gastric ulcer is among the more common. If the disease be due to bacterial infection of the submucous coat through some small abrasion of the mucosa — which is the most plausible explanation — then it is strictly analogous to cellulitis of the subcutaneous tissues due to a cutaneous defect long healed before the cellulitis is observed. This hypothesis gives a clue to the surgical treatment, to be dis- cussed later. The secondary form of this disease, apparently due to metastatic infection, may originate from carcinoma or ulcer of the stomach. In one case gastritis phlegmonosa has been observed to follow an enterostomy. Pathology. — The essential lesion is a widespread inflamma- tory change in the submucous coat, which is greatly thick- ened, usually of a yellowish-white color, and so much softened that it resembles pus. Microscopically the appearance is that of fibrin with masses of leucocytes entangled in it. This change is nearly always more marked in the pyloric half of the stomach, a fact which may bear some relation to the anatomic situation of the oxyntic or acid-producing cells of the gastric mucosa. The muscular coat shows vary- ing degrees of infection and degeneration of the muscular elements. The serous coat is sometimes unaffected, but it may show leucocytic infiltration, especially in cases where a secondary purulent peritonitis is present. The mucosa is in many instances normal, but in others it is acutely inflamed — raised from its bed in ridges; in others again the deeper layers of glandular tubules are atrophied; while in a few of the recorded cases the mucous surfaces have been pitted with ' .Journal of the American Medical Association, December 28, 1907. 360 ACUTE GASTRITIS tiny apertures, giving it the appearance of a sieve, through the meshes of which pus could be squeezed from the infil- trated submucous layer. The duodenum is very rarely altered, and then only the mucosa is inflamed. Of secondary lesions, peritonitis, seropurulent or purulent, is the com- monest, and it has been found in rather more than half the cases. Pericarditis, pleurisy, and abscess of the liver have also been observed. Symptoms and Com-se. — The course of the diffuse form of this disease is atypical. We may have a severe acute gastritis, with high fever, sometimes as high as 104° F., violent pains, and uncontrollable vomiting, the abdomen greatly distended, the pulse feeble; symptoms of collapse follow, and the termination is usually fatal. The course of the circumscribed form is similar, except that . it is of longer duration, extending sometimes over several weeks. Sometimes a tumor can be felt in the region of the stomach. The prognosis in both forms of phlegmonous gastritis is very grave, practically hopeless. Up to 1896, Leith, who had pubUshed the best account of the disease, found no authentic cases of recovery; and from the records of cases since that date it appears probable that the few recoveries noted were really not cases of primary phlegmonous gas- tritis, but abscess of the stomach. Treatment. — Since the diagnosis is never positive, the treatment must be more or less symptomatic. Thei*e is no successful treatment of this disease. The stomach should be spared as much as possible. Food and drink should be administered per rectum. Ice bags, and cocaine, morphine, or codeine hypodermically, are indicated for the relief of pain. High temperatures are to be controlled by the use of antipyretic drugs. Stimulants should be administered early in the disease, as well as when symptoms of collapse appear. This disease is essentially surgical. Gastrostomy or gastroenterostomy is suggested by Robson and Moynihan as an appropriate method of dealing with the lesion surgi- PHLEGMONOUS GASTRITIS 361 cally, but it is difficult to see how a surgical operation is going to cure a cellulitis of the stomach wall. Probably incisions down to the submucous coat, with free exposure of the stomach wall and packing off of the peritoneal cavity with gauze left in position for several days, would offer the best chance of recovery. This is the treatment of cellulitis in subcutaneous lesions, and if it could be effected without infecting the general peritoneal cavity it seems reasonable to hope that satisfactory results might be obtained. If the nature of the infecting organism can be learned, the appro- priate bacterial vaccine should be administered. CHAPTER XVII CHRONIC GASTRITIS: SUBACID GASTRITIS — ANACID GASTRITIS — ACHYLIA GASTRICA CHRONIC GASTRITIS (CHRONIC GASTRIC CATARRH) Chronic catarrhal gastritis is a chronic inflammation of the gastric mucous membrane, of varying degrees of inten- sity, presenting symptoms more or less characteristic of widely different forms of gastric derangement. At one time most of the chronic dyspepsias were designated "chronic gastric catarrh;" but the epoch-making work of Leube has established a more definite classification. Chronic gastritis is a disease which requires for its positive diagnosis, and as a rule for even probable diagnosis, an examination of the gastric secretion. Etiology. — When the irritating cause of acute gastritis persists, chronic gastritis is the natural consequence; but there are generally other, often altogether different, etiologic factors. Of the cases of chronic gastritis studied b}' Wilson Fox,i pulmonary tuberculosis was responsible for 28 per cent., and the remainder were accompanied by cirrhosis of the liver, chronic lung or heart disease, chronic Bright's disease, or other chronic ailment. While acute gastric catarrh is a frequent concomitant of acute infectious disease, the chronic forms depend for the most part on chronic dis- turbance of some other organ. Habershon' classifies chronic gastric catarrh as arising (1) from repeated attacks of acute gastric catarrh due to the nature of the food or drink; (2) from congestive conditions related especially to the portal system, and a feature of cardiac, hepatic, and pulmonary diseases, the stomach sharing in the portal engorgement or in a general systemic » IlMhcnslion, Disi'UK's of tin- Sloin.icli, l'.)l(). ' Ibid. PATHOLOGY 303 congestion; (3) from chronic diseases, such as tuberculous peritonitis, where the inflammatory condition is an exten- sion from neighboring organs. Under the first subdivision must be placed alcoholic excess as the most frequent etiologic factor. Those who habitually indulge in alcoholic beverages to excess are disposed to an irregular mode of life which leads to digestive disturbances. Along with the abuse of alcohol should be placed the exces- sive use of tobacco and the prolonged use of tonics and pur- gatives. Food poisoning is another cause ; likewise errors of diet — excessive alimentation, the habit of eating at irregular intervals, the quick-lunch counter, insufficient mastication of food, and the too frequent use of ice water or of tea and coffee. ''In this country," says Einhorn, ''ice w^ater and fast eating are the two principal causes of 'American dyspepsia.'" In class 2, local mechanical influences, such as portal congestion, may result in obstruction of the outflow of venous blood from the stomach to the right heart. Thus chronic gastric catarrh occurs as a secondary process in the course of chronic affections of the liver, heart, and lungs. The explanation of the peculiar tendency of such chronic affections as gout, chronic rheumatism, tuberculosis, Bright's disease, diabetes, anemia, chlorosis, syphilis, and chronic forms of skin disease to produce chronic gastric catarrh, lies in the obstruction offered to the passage of the blood through the hepatic and cardiopulmonary circulation. Especially is this true in tuberculosis, chlorosis, and anemia. In gout, chronic Bright's disease, and syphilis, the chi^onic gastric catarrh is due more to the action of chemicovital irritants in the blood. Gastric carcinoma also has a place in the etiology of chronic gastric catarrh. Pathology. — In chronic gastritis it is not the superficial epithelium alone that is affected, but the inflammatory process extends to the glandular epithelium and to the interstitial tissue. In the initial stage of simple chronic gastritis the mucous membi^ane is pale gra}^ in color and 364 CHRONIC GASTRITIS covered with closely adherent tenacious mucus. The veins are enlarged, and patches of ecch3^mosis are sometimes seen. The glands are subject to parenchjanatous and interstitial inflammation, presenting a microscopic picture of erosion, cloudy swelhng, or atrophy, depending upon the stage of the disease. It is not possible to chfferentiate between the principal and the parietal cells, owing to the fact that the tubes have lost their regular form and instead we have, as Ewald expresses it, "atypical branching hke the fingers of a glove." There is an infiltration of round cells and proliferation of connective tissue, which exert pressure on the glands, thus inhibiting their normal function. As these pathologic changes become more marked the secretion becomes progressively less until the atrophic stage is reached, when we have an entire absence of secretion. ^Meanwhile a mucoid degeneration of the cells lining the tubules takes place and may even extend to the fundus of the glands. In the Ughter forms of chronic gastritis the submucosa and the interglandular connective tissue are infiltrated bj^ inflam- matorj^ products. When the disease has progressed to greater length and has become more severe the infiltration of the intercellular tissues is more marked. There is a prohferation of connective tissue, so that, toward the pylorus in particular, we have a rough, wrinkled, mammillated sur- face, the etat mamelonne of the French, a condition which is sometimes so prominent that it has been described as gastritis polyposa. The pathologic changes may even lead to stenosis of the pylorus. The inflammation in the more aggravated cases may pass to the muscular layers, causing partial destruction, to be replaced by connective-tissue fibres. Belonging to this form of the disease is sclerotic gastritis (cirrhosis ventriculi), in which the walls of the stomach undergo a connective- tissue metamorphosis, sometimes to such an extent that the stomach is greatly reduced in size. Fenwick, Ewald, and other writers have noted cases of extreme atrophy of the gastric mucous membrane, and the fact is now recognized that there may be such destruction of the glandular elements SYMPTOMS 365 by a progressive growth of interstitial tissue that ultimately scarcely a trace of secreting tissue remains. Osier describes a case in which the greater portion of the lining membrane of the stomach was converted into a perfectly smooth cuticular structure, showing no trace whatever of glandular elements, with enormous hypertrophy of the muscularis mucosa, and here and there formation of cysts. Symptoms. — The local symptoms have a strong resemblance to those of other forms of gastric disturbance. The disease, as a rule, develops very slowly, and, as in the case of most chronic diseases, changes from time to time. The appetite varies; sometimes it is very poor, and sometimes it is good. Patients usually complain of a disagreeable taste, which they describe as salty or pappy, or at times sour; of thirst, salivation, and eructation of gas or food remnants, which may be sour, rancid, or tasteless. The breath is often fetid. Nausea is rather common. Pressure and fulness are experi- enced after eating. Patients complain of palpitation of the heart. Belching (which is very annoying to the patient) relieves both the pressure and the consequent palpitation. Irregular stools, constipation, and diarrhea are commonly met with in chronic catarrhal gastritis. Patients suffer from headaches, vertigo, and disturbed sleep. There are vaso- motor disturbances, with sensations of coldness of the ex- tremities. Objective Symptoms. — The subjects of chronic gastric catarrh generally appear to be well nourished. Some, how- ever, are seen to have lost weight and look emaciated. The tongue is usually coated gray or yellowish-gray; still, in many cases of well-marked chronic gastritis the tongue is clean. There may be no offensive odor in the mouth, or if there is any it may be due to carious teeth or some pathologic condition of the nose or throat. The gastric region often appears bloated. Palpation reveals slight sensitiveness of the entire area over the stomach. The pylorus may be palpated when thickened by muscular hypertrophy. 366 CHRONIC GASTRITIS Diagnosis. — It is seen that there are no symptoms, either subjective or objective, which are pathognomonic of the disease. An approximate diagnosis can be estabhshed only by an examination of the secretory and motor functions of the stomach and the anamnesis. The presence of mucus in the stomach must be ascertained before we are justified in making a diagnosis of chronic gastric catarrh. From the stomach under normal conditions it is possible to obtain only a few isolated flakes of mucus, even after most thorough lavage. In chronic gastritis mucus is usually present in marked quantities, and is found mixed with food remnants. Mucus which has got into the stomach from the nose, pharynx, or trachea is found upon the surface of the liquid or food removed from the stomach with the stomach tube. The acid secretion in chronic gastric catarrh varies. In the initial stages the percentage of free hydrochloric acid is often found to be normal. Sometimes there is hyper- aciditA^, a condition which corresponds to the acid gastritis described by Boas. As the disease progresses, the secretory function becomes impaired, with a resultant decline from the normal amount of free hydrochloric acid. In the more protracted cases there is no free hydrochloric acid at all, and the other constituents of the gastric secretion are very much diminished in quantity. The diminution of free hydro- chloric acid is in direct proportion to the intensity of the disease process; when very marked, the condition is desig- nated subacid gastritis. Further progress of the disease converts the subaciditj' into anacidity, a condition in which the formation of pepsin begins to fail. This pathologic state is known as anacid gastritis. The symptoms of this form of chronic catarrhal gastritis may be ameliorated by appro- priate treatment so long as the alterations in the gastric mucosa have not become so marked as to prevent the possibility of the secretion of })oth hydrochloric acid and pepsin. The final stage of the disease is that of chronic anacid gastritis with atrophy of the secreting glands. The patho- logic changes in the gastric mucosa are so great as to ]ii-ochido DIAGNOSIS 3(37 the possibility of restitution of the secretory functions of the stomach. When this stage is reached, rennin as well as pepsin and hydrochloric acid are absent. Organic acids are, as a rule, not present in chronic gastritis, but are found only when stagnation is a complication. The production of mucus may become very large in the atrophic stage of the disease. The term ''subacidity" is applied to cases in which free hydrochloric acid is decreased and the total acidity is less than 40 degrees. The secretion of the ferments may be normal. Subacidity may be found as a secondary affection in the course of chronic diseases of the stomach, such as carcinoma and chronic gastritis. It may likewise follow anemia, phthisis, acute febrile diseases, and cardiorenal diseases. It is a question whether gastric anacidity may exist as an independent primary affection, or whether it is to be always regarded as a later stage of chronic gastritis characterized by atrophy of the gastric mucosa. The possibility of gastric anacidity as a primary affection would seem to be assured by cases of purely nervous or functional disturbance, or by cases in which there is an inherent deficiency in the secretory function of the stomach. The examination of stomach contents in such cases reveals an unaltered condi- tion of the test meal. The particles of bread are larger or smaller, depending upon the thoroughness of mastica- tion, and have the appearance of being merely moistened or softened by the water. Mucus is not present. The total acidity is extremely low — 4 to 6 degrees and frequently zero. The reaction of the stomach contents is very slightly acid, sometimes amphoteric on account of the presence of phos- phates in the food. In the majority of cases there is a slight secretion of pepsin. Very often individuals with anacidity or subacidity feel perfectly well, or at least experience no great discomfort. They appear well nourished. Cases have been observed in which gastric anacidity has persisted for periods of twelve to fifteen years. In this class of cases the power of the 368 CHRONIC GASTRITIS stomach to digest protein is entirely absent, so that the small intestine receives all the protein in an unchanged condition. The digestion of carbohydrates is impaired to a certain extent, owing to the fact that the cellulose covering of the starch granule is not dissolved. These obstacles to com- plete digestion tend, in time, to have a harmful effect upon the small intestine. The motor activity of the stomach is usually normal. Stagnation is found only in those cases in which there is hypertrophy of the muscular layers of the stomach near the pylorus. Absorption of many food substances is retarded, though Einhorn maintains that he has not been able to detect any marked departure from the normal. Prognosis. — The prognosis of chronic gastritis is favorable; the disease is amenable to treatment, so that a complete cure or material improvement may be anticipated. Relapses are, however, likely to occur. ACHYLIA GASTRICA ''Achylia gastrica" is a term introduced into medical literature by Einhorn to denote absence of gastric secretion. The stomach contents contain no free or combined hydro- chloric acid; the ferments are likewise absent or greatly reduced in amount. Achylia is a sign of disturbed function of the stomach which may accompany such diseases as cancer, severe anemia, or chronic gastric catarrh. It may also occur as a purely functional disturbance wholly apart from primary organic disease of the stomach or other organs. Etiology. — -According to White, ^ the history of achjdia is closely associated with that of atrophy of the gastric mucosa, and the discovery of a lack of gastric secretion in cancer and in gastric atrophy led to the false opinion that if no hydrochloric acid or ferments were found the diagnosis of cancer or atrophy was justified. The association of achylia with severe and fatal disease led also to the false belief that ' Boston Medical and Surgical Journal, November 8, 1906. ACHY LI A CAST RICA 369 it was necessarih^ a severe condition leading in a short time to death. We know now that an absolute and permanent lack of gastric secretion is compatible with health and well- being, and that the gastric secretion can be compensated by intestinal digestion. In short, we can make a sharp distinction clinically between (a) secondary achylia associated with cancer, severe anemia, or atrophy of the gastric mucosa, and (b) simple achylia without atrophy, which is a benign condition. The etiology of achylia gastrica is often obscure. Inherent weakness, probably hereditary, of the secretory processes, plaj^s an important part in the causation of the disease. The condition is frequently found in neurasthenia. It has been shown by animal experimentation that section of those branches of the pneumogastric nerve which supply the stomach is followed by inhibition of secretion. Inter- ference with the function of the pneumogastric nerve may account for those rare cases in which in the same person we have hyperacidity, subacidity, and achylia. Achyha gas- trica may occur at any age; the youngest patient on record was nine years old. White^ further states: ''The etiology of this simple achylia gastrica is an interesting biological problem with a practical side. A well-known and important function is absent without definite cause or apparent results. The latter may be explained by compensation. The intestinal diges- tion is so powerful that gastric digestion seems almost superfluous. It is not, however, simply an anomaly, the disappearance of a function which is unnecessary for the organism (cf. Darwin); it is a diseased condition. The individual with achylia is worse off than his mates — he is in a state of unstable equilibrium, and bowel trouble may be a real danger. The fact that achylia patients are neuras- thenic is not a sufficient reason to consider this the cause. We find neurasthenia without loss of secretion, and loss of secretion without neurasthenia. ''Alartius considers it a primary weakness of secretion 1 Loc. cit. 24 370 CHRONIC GASTRITIS which is either congenital or develops on the basis of a predisposition. The hereditary element is interesting. Cases have been reported in a mother and daughter, and in two brothers. An anatomic basis for the condition has been suggested. Hemmeter cites 10 cases of achylia (which do not include cases of cancer or chronic gastric catarrh), in 9 of which fragments of the mucosa obtained through the tube were examined. These all showed signs of granular gastritis and atrophy. Hemmeter questions whether the condition is ever a neurosis. The changes in the mucosa, however, seem far too- shght to explain the striking change in function (compare the conditions in gastric cancer, where the secondary change in the mucosa leads to achylia only when it has advanced to atrophy), and the granular gastritis may be the result, not the cause, of the achyha. It is not satisfactory to use the evidence from fragments of mucosa obtamed through the stomach tube to settle a question of secretion, which is the expression of the function of the whole stomach. In addition, we have seen one case, similar to those reported by Einhorn and others, of recovery of gastric secretion after a long period of achylia, showing that achylia may exist when the glands of the stomach have not been totally destroyed. In such cases the condition is probably due to nervous influences, with partial atrophj', but no autopsies have been reported, and the atrophy can only be conjectured, not proved. In short, cases of achylia may be divided into two groups: first, the severe and strik- ing cases, which were earliest reported, in which there is unquestioned atrophy of the mucous membrane (either idiopathic or secondary to some serious condition, such as cancer or pernicious anemia); and second, the group of cases, which are by no means rare, in which achylia occurs in neurasthenic, weak persons, those of middle life and beyond, where the condition is simply that of a weak stomach with feeble secretion." Pathology. — The mucous membrane has been for the most part normal in many cases examined, while in some cases it was found to be atrophied. TREATMENT OF GASTRITIS AND ACHY LI A GASTRIC A 371 Symptoms.— The clinical symptoms of achylia gastrica resemble those of chronic gastric catarrh; there are loss of appetite, nausea, vomiting, slight pains, and eructations. In many instances the patient feels well, and the existence of the disease is discovered by accident. Achylia gastrica may be unmarked by the presence of any distressing symptoms, or, if such symptoms are present, they may be wholly non-characteristic of the pathologic condition. The symptoms usually consist of diminished desire for food, pressure, fulness in the stomach, discomfort after eating, or eructations. There is often an acceleration of the motility of the stomach, said to be due to the absence of hydrochloric acid; hydrochloric acid, if present, would cause a periodic closure of the pylorus. The food passes with more than normal rapidity into the small intestine. Patients with achylia gastrica may maintain a fair state of health so long as the small intestine is functionally active. Should intestinal digestion, however, become impaired, the result would be a diarrhea (gastrogenic diarrhea), causing marked emaciation or even endangering life. Cases described as secondary achylia are sometimes found accompanying such diseases as diabetes, tuberculosis, cir- rhosis of the liver, cardiac disease, and arteriosclerosis of the abdominal vessels. Then there is that form of achylia which accompanies grave cases of anemia, pernicious anemia, and the anemia due to the Bothriocephalus latus. The relation between achylia and these pathologic conditions is not clear. TREATMENT OF CHRONIC GASTRITIS AND ACHYLIA GASTRICA Chronic gastritis and achylia gastrica have as a common manifestation a perversion of gastric secretion which consists for the most part of a diminution in activity of the secretory function. This common functional derangement renders it advantageous to discuss the treatment of the two condi- tions together. 372 CHRONIC GASTRITIS Since repeated attacks of simple acute gastritis may result in the development of chronic gastritis, it is important that the patient should avoid any excesses or practices which predispose to the attacks. He should masticate his food thoroughly, and should avoid overindulgence in alcohol, tobacco, extremes of temperature in food, as well as highly spiced articles of diet. The mouth and teeth should be kept in good condition. Slow eating followed by rest, exercise in the open air, sleeping with the windows open, cold salt-water sponging at night followed by a brisk rub, are excellent by way of prophylaxis. Diet. — The regulation of diet is perhaps the most impor- tant factor in the treatment of conditions marked by sub- acidity or anacidity, since a restoration of the secretory functions of the stomach to normal is sometimes impossible. The power to digest protein is either greatly impaired or altogether absent. The digestion of carbohydrates in the stomach would be satisfactory were it not for the vegetable protein enveloping the starch granule; but proteolysis must be carried on for the most part or altogether by the small intestine. The unusual demand made upon the small intestine ^\dll sooner or later result in impairment of its function. It is seen, then, that rational treatment must be directed toward protecting the stomach and small intes- tine. A diet rich in carbohydrate, with a minimum of protein, is indicated. The individual tastes of patients should not, however, be ignored. Some patients object to a monotonous diet. To avoid aversion certain con- cessions may be granted, but all food should be tender and susceptible of thorough mastication. In chronic gastritis spiced foods may be permitted, owing to their stimulating influence upon the appetite. In spite of ai)parent restric- tion, the choice of appropriate articles of diet may be suffi- ciently varied. The patient may be allowed all the tender meats, such as fowl, brain, or lean fish. Meat should be thoroughly roasted or boiled; raw, pickled, or smoked meats and salted fish should be avoided. The daily quantity of meat should not exceed 150 grammes, and in sovore cases THE AT ME XT OF GASTRITIS AND ACHY LI A GASTRIC A 373 not more than 100 grammes should be taken during the day. ]\Ieat may be replaced occasionally by eggs, soft boiled or in the form of egg soups or light omelets. Milk is, as a rule, well borne, and is strongly recommended; it may be em- ployed as a vehicle for somatose, sanatogen, or plasmon, and its digestibility may be further increased by the addition of pegnin. Fats in the form of butter and cream are per- mitted this class of patients. Vegetables may be prescribed in the form of thick strained soups (rice, tapioca, sago, peas, lentils); and mashed potatoes in moderate quantities are permissible. Biscuits, zwieback, toast, stale white bread, which can be broken up fine in the mouth or softened by being dipped into fluids, are indicated. Such condiments as salt, pepper, and mustard have a stimulating effect on the appetite, though thej^ will not bring back the gastric secre- tion. The meat extracts have a similar action. Pure water or weak lemonade is the most satisfactory beverage for allaying the thirst, and is best taken during the intervals between meals. Carbonated waters are also good. Gastric motility is usually normal in chronic gastritis. When, however, there is any disturbance in motility, it may be overcome by making the meals small and frequent, thus avoiding the overdistention of the stomach which large meals are apt to induce. The quantity of liquids should be restricted, inasmuch as they tend to produce hyperdistention. Ewald's diet for chronic gastritis is as follows: 8 A.M. 150 to 200 Gm. tea, with 75 to 100 Gm. stale white bread, toast, or zwaeback. 10 A.M. 50 Gm. white bread, 10 Gm. butter, 50 Gm. cold meat or ham, one-third hter of milk. 2 P.M. 150 to 200 Gm. water, milk, or bouillon of the white meats, 100 to 125 Gm. meat or fish, 80 to 100 Gm. vegetables, 80 Gm. compot. 4 to 5 P.M. One-fourth to one-third liter of warm milk (occasionally mixed with cocoa or coffee) . 7 to 8 P.M. 200 Gm. soup or pap, 50 Gm. white bread, 10 Gm. butter. Occasionally at 10 p.m. 50 Gm. wheaten bread (biscuits or zwieback), one cup of tea. 374 CHRONIC GASTRITIS Diet for First Week of Treatment (Einhorn) Calories. 8.00 a.m. Two eggs 160 French white bread, 60 Gm. (5'.]) 156 Butter, 15 Gm. (gss) 107 One cup of tea (100 Gm. tea, 150 Gm. milk) ... 101 Sugar, 10 Gm. (oiiss) 40 10.30 a.m. Koumiss, matzoon, or milk, 250 Gm ■ 168 Crackers, 30 Gm. (§j) 107 Butter, 20 Gm. (3 v) 163 12.30 p.m. Two ounces tenderloin steak or white meat of chicken 72 Mashed potatoes, or thick rice, 100 Gm. (giij) . . . 127 White bread, 60 Gm. (Bij) . . 153 Butter, 15 Gm. (5ss) 107 One cup of cocoa, 200 Gm. (§vij) 101 3.30 p.m. The same as at 10.30 a. m 438 6.30 p.m. Farina, hominj^, or rice boiled in milk, one plateful, 250 Gm. (Sviij) 440 Two scrambled eggs 160 Bread, 60 Gm. (§ij) 156 Butter, 15 Gm. (5ss) 107 2863 When the patient has been kept on this diet for a week or two, it should be gradually changed to one suitable for lighter forms of chronic gastritis. The distribution of meals should conform as nearly as possible to the custom of the community in which the patient lives. According to Ein- horn: "All foods derived from the vegetable kingdom should be given in large quantities, while the amount of meat should be limited. In order to permit the patient to have a greater variety of food, it is best not to point out a few articles he should eat, but to mention only those he should avoid. Forbid meat with very tough fibres, meat from too old animals, too fresh meat (right after slaughter- ing) , and meat that contains too much fat (like pork) ; forbid sausages, lobster, salmon, chicken salad, mayonnaise, cucum- bers, pickles, cabbage, strong alcoholic drinks (like liquors)." TREATMENT OF GASTRITIS AND . ACHY LI A GASTRICA 3 DiETAR-V Li.sT FOR Cases of Chronic Gastric Catarrh (Wegele) (Grave form, with destruction of the Gastric Glands Membrane) Protein. ^ in the Mucous Carbo- Fats. hydrates Morning. 150 Gm. hygiama 4.0 1.5 10.0 50 Gm. zwieback 6.5 1.5 42.0 10 Gm. butter .... 0.7 8.2 0.06 10 Gm. plasmon .... 7.4 8.1 0.2 Forenoon. 200 Gm. oatmeal .... 3.0 6.0 17.0 10 Gm. aleuronat 9.1 0.07 10.0 50 Gm. zwieback 6.5 1.5 42.0 10 Gm. butter .... 0.07 8.2 0.06 Noon. 100 Gm. beefsteak (chopped) 30.8 1.5 100 Gm. rice 2.0 7.0 8.0 100 Gm. pudding .... 9.0 16.0 13.0 100 Gm. apple sauce . 0.2 8.0 Afternoon. 150 Gm. cocoa . . . ; 4.0 1.5 10.0 50 Gm. zwieback 6.5 1.5 42.0 10 Gm. butter .... 0.07 8.2 0.06 10 Gm. somatose. 8.1 Evening. 200 Gm. pap 3.0 6.0 17.0 10 Gm. plasmon .... 2.3 1.4 3.8 100 Gm. macaroni 5.5 14.3 60.3 100 Gm. apple sauce . 10.2 8.0 118.94 92.47 291.48 Calories, about .... 440 800 1200 Total combustive value, 2440 calories. Diet Free from Meat in Chroni c Gastritis OR ACHYLIA Protein. Fats. Carbo- hydrates. Morning. 200 Gm. milk cocoa . 7.2 8.0 10.0 100 Gm. zwieback 9.0 1.0 60.0 30 Gm. butter .... 0.2 25.0 Lunch. 200 Gm. gruel .... 20 Gm. butter .... 3.0 6.0 17.0 17.0 50 Gm. zwieback 4.5 0.5 30.0 Noon. 200 Gm. rice 0.4 10.0 16.0 200 Gm. pudding .... 13.5 24.2 46.0 100 Gm. apple sauce . 0.2 8.0 Afternoon. 200 Gm. milk cocoa . 7.0 1.0 10.0 (Tea) 100 Gm. zwieback 9.0 1.0 60.0 30 Gm. butter .... 0.2 25.0 Evening. 200 Gm. oatmeal .... 3.0 6.0 17.0 (Supper) 200 Gm. water noodles 15.0 0.6 100.0 100 Gm. plum jam 0.2 10.0 50 Gm. zwieback . . . . 4.5 0.5 30.0 20 Gm. butter 76.9 17.0 142.8 414.0 Calories 300 1400 1600 375 Total combustive value, 3300^caiories. 376 CHRONIC GASTRITIS Fleiner recommends in severe cases of anacidity 300 to 800 grammes of oatmeal in the morning, after which the patient should assume the recumbent position for one hour. Two and one-half to three hours later the patient should take 300 to 500 Gm. (§x-xvj) of milk, to be followed after two hours by meat broth or gelatinous soup, with one or two yolks of egg; after three to four hours, 300 to 500 Gm. (Bx-xvij), and at night 300 to 800 Gm. (§x-xxvj) of boiled rice pudding. Diet List for Chronic Gastritis (Friedentv^ald axd Ruhrah) Calories. 8.00 a.m. 200 Gm. milk, flavored with tea 135 60 Gm. stale bread (1.54) with 40 Gm. butter (326) 480 1 soft-boiled egg 80 10.00 A.M. 100 Gm. scraped beef (119) with 60 Gm. stale bread or toast (154) 273 Or chicken sandwich (260), or 50 Gm. sherry (60) with egg (80). 11.00 a.m. Bouillon with egg 84 100 Gm. chicken 106 Or 100 Gm. lamb chops (230), or broiled steak (209). 100 Gm. spinach 166 100 Gm. mashed potatoes 127 100 Gm. stewed apples 53 60 Gm. toast 154 4.00 p.m. 120 Gm. milk, with tea 81 30 Gm. crackers 102 7.00 P.M. 60 Gm. stale bread (154) with 40 Gm. butter (326) 480 200 Gm. milk 135 2456 Diet for Chronic Gastritis (Boas) Calories. 8.00 A.M. 200 Gm. milk and flour soup (100 Gm. milk) . . 121.5 50 Gm. bread 129.4 30 Gm. butter 213.9 10.00 A.M. 2egg.s 160.0 .")OGm. white bread, 30 Gm. butter .... 343.3 Or 50 Gm. white broad, 30 Gm. Initter, GO Gm. scraped beef. 12.00 M. 200 Gm. farina milk .soup 227.2 200 Gm. milk and rice 353.4 100 Gm. prunes 44.0 TREAT MEXT OF GASTRITIS AND ACHYLIA GASTRIC A 377 Calories. 3.00 P.M. 200 Gm. milk and tea, or milk and coffee (150 Gm. milk) 101.2 50 Gm. white bread 129.4 7.00 p.m. 200 Gm. rice and milk soup 335.4 50 Gm. zwieback 178.9 2337.6 Diet for Chroxic G.astriti.s (Bo.\s) Calories 8 . 00 A.Ai. 200 Gm. milk with 40 Gm. cocoa, 30 Gm. .sugar . 462 . 50 Gm. cakes 187.0 Or 40 Gm. zwieback (178.9). 10.00 a.m. 50 Gm. bread with 30 Gm. butter 343.0 100 Gm. calf s brain 140.0 Or 100 Gm. sweetbread (90) or broiled rockfish (71.75). 12.00 m. Soup of 30 Gm. tapioca, 10 Gm butter . . . 282.0 100 Gm. noodles and 1 egg 352.6 Or 100 Gm. spinach (165 . 65), 100 Gm. puree of beans (193), 100 Gm. carrots (40), 50 Gm. mashed potatoes (63.7). 100 Gm. breast of young chicken 106.4 Or 100 Gm. veal chops or stewed veal, pigeon, venison, or fish. 100 Gm. farina, omelet or egg, pancake wdth ham 288 . 3.00 p.m. 100 Gm. milk and tea, with 28 Gm. sugar . . . 147.2 25 Gm. cakes 93.5 7.00 P.M. 50 Gm. wheat bread wath 30 Gm. butter . . . 343.0 50 Gm. scraped meat 59.5 Total 2804.2 Medicinal Treatment. — Hydrochloric Acid. — In the treatment of chronic gastritis, medicaments occupy a secondary place compared with diet and hygiene. Of the drug agents, hydrochloric acid is most important and most frequently employed, the object of its use being to supplement the deficiency of the gastric juice. (See Hydrochloric Acid and Pepsin, page 166.) Hydrochloric acid was introduced to the profession as a factor in the treatment of gastritis by Leube. Ewald states that in all cases characterized by a diminution or absence of hydrochloric acid the dilute hydrochloric acid of the Pharmacopoeia should be admin- istered in large doses, 40 to 60 drops, three times a day. 378 CHRONIC GASTRITIS The best way to give hydrochloric acid is to add from 6 to 12 drops of the dilute acid to a glassful of water, to be taken three times a day, half an hour after meals — not the whole glass at one time, but in three portions at intervals of one-quarter to one-half hour (Einhorn) . Pepsin is frequently given in combination with hydrochloric acid, 0.06 Gm. (1 grain) three times a day. Since it has been found that in the majority of cases of diminished gastric secretion there is still a sufficient quantity of pepsin secreted, many writers are opposed to the administration of medicinal pepsin. Pepsin assists in the process of proteolysis by catalysis, that is, without itself becoming used up or diminished in quantity. Perry^ says that the disrepute into which hydrochloric acid has fallen is due to its having been used in insufficient doses, and that there has been no practicable method by which larger doses could be given. The amount of hydro- chloric acid formed in the stomach daily has been calculated to be equal to 12 grammes of hydrochloric acid, c. p., or 36 grammes of strong liquid hydrochloric acid. On the basis of the amount required to combine with 225 grammes of cooked beef, the dose would be 15 Gm. (5iv) of liquid hydrochloric acid. This amount could not possibly be given in less than 50 ounces of water, an impossible quantity. When protein is digested with hydrochloric acid, an organic hydrochloric acid combination is formed, which in contact with pepsin is changed into peptone. For the digestion of 100 grammes of boiled beef 10 grammes of liquid hydro- chloric acid are required. On the addition of pepsin, the hydrochloric acid will dissolve 65 per cent, of the beef with which it is combined and an additional 40 per cent, of the beef with which it is mixed. This kind of acidity exists normally in the small intestine, and does not interfere with the action of pancreatic juice. By preparing such a protein combination from the action of hydrochloric acid on beef, we may employ doses as high as 2 grammes of strong hydrochloric acid without injury or discomfort. One heap- ing tablespoonful of such a preparation carries about ' Pacific Medical Journal, May, 1903. TREAT MEXT OF GASTRITIS AND ACIIYLIA (i AST RICA 379 1 gramme of strong hydrochloric acid in the proper condition to digest the meat with which it is combined together with 40 per cent, of additional protein. Besides what is dissolved, a part of the residue is converted into albumose, which is readily digested by the pancreatic juice. This organic combination of hydrochloric acid is made by heating to- gether, till a paste is formed, 1 part of strong hydrochloric acid, 50 parts of water, and 16 parts of boiled beef ground to a coarse consistency. Prepared in this manner the product contains about 7 per cent, of strong hydrochloric acid. In case it becomes necessary to continue the use of large doses of hydrochloric acid, it is well to give, one hour before meals, one-half as much bicarbonate of soda as the weight of strong hydrochloric acid that is to be given. "^Tienever the gastric secretion shows an absence of free hydrochloric acid, and it can be concluded that this is not due to atrophy of the mucosa, one of the most efficacious means of restoring the secretion is by lavage with a solution of hydrochloric acid, 3 or 4 parts to 1000 of warm water. As many of these cases require lavage, it is expedient to make use of this solution even if there is no stagnation; the lavage is not intended here so much for cleansing the stomach as for stimulating the mucosa. The diet may consist largely of foods requiring consider- able amounts of hydrochloric acid for digestion, as these contain 'the substances that are the most effective stimulants to the gastric secretion — finely minced or scraped beef, mutton, fish, and soft-boiled eggs. The extractive materials of beef (as in beef tea) are also stimulants. The stomachs of these patients require dietetic gymnastics (always exclud- ing dilatation, atrophy, and neoplasm), and too bland or sparing a diet wdll simply permit the secreting cells to atrophy from lack of work. In deficient gastric secretion the digestive ferments are sometimes administered. It was customary at one time to administer hydrochloric acid and pepsin in every case of gastritis. Now, after repeated experiments, we know that when free hydrochloric acid is present there is also sufficient 380 CHROXIC GASTRITIS pepsin in the stomach; even when hydrochloric acid is absent, pepsin or pepsinogen will be found to be present. Cases in which pepsinogen is absent are exceedingh- rare (Riegel). Generally speaking, then, the administration of pepsin is seldom indicated. In cases where there is a com- plete absence or great deficiency of the peptic ferment, pure pepsin in powder form ma}^ be given. AMien there is an absence of hj^drochloric acid secretion, but pepsinogen is present, only hydrochloric acid need be administered. Papain and papayotin are made from the milk juice of Carica papaya, a tropical plant. These preparations possess distinct proteolytic properties and are active in neutral, weakly acid, or even alkaline solutions. Papayotin pep- tonizes protein foods. These ferments are indicated in deficient proteolysis with absence of hydrochloric acid, in achylia gastrica, and in acute gastritis accompanied by subacidity or anacidity. Papayotin and papain are not adequate substitutes for pepsin and hydrochloric acid; they are probably non-essential as remedial agents. They are contraindicated in ulcer and in hyperacidity. The dose is 0.3 to 1 Gm. (5 to 15 grains) after meals. Pancreatin. — Boas and others have recorded favorable results from the administration of pancreatin in cases of achylia gastrica, subacid and anacid gastritis, and gastric carcinoma. Pancreatin was first prepared by Engesser, Boas recommends the administration of pancreatin in tablet form, 1 to 2 Gm. (15 to 30 grains) in combination with sodium bicarbonate, since pancreatin is active only in a neutral or weakly alkaline medium. The preparation should be administered a quarter of an hour after meals. The indi- cation for pancreatin in an anacid stomach consists in the fact that intestinal digestion is thus permitted to begin even before the ingested food passes into the intestine (see p. 175). Stomachics. — We have a number of remedies which possess the property of stimulating the appetite, and others which stimulate the secretory and motor functions of the stomach. Our knowledge of the action of this class of drugs is largely empirical. Loss of appetite is an indication for the admiu- TREAT MEST OF GASTRITIS AND ACHY LI A (J AST RICA 3S1 istration of stomachics, or bitters, as they are called. Riegel reports the results of experiments of Bokai, who found that quassia and calumba were capable of increasing the secre- tion of gastric juice by their direct effect on the mucous membrane of the stomach. According to Reichmann, who has made very careful investigations on human subjects, bitter remedies should be administered only in cases in which the secretory powers of the stomach are reduced; when prescribed, the prescrip- tion should specify half an hour before meals as the time for taking the dose. Fawitzky agrees with Reichmann in regard to vegetable bitters, both as to their advisability and as to the time of their administration; he asserts that they act beneficially on the secretion of gastric juice in cases where there is a reduced secretion of hydrochloric acid. The administration of the so-called bitter tonics, gentian, condurango, quassia, and nux vomica, has been found very helpful in chronic gastritis. The fluid extract of condurango, calumba, or quassia is to be taken in 20-drop doses three times a day. Tincture of nux vomica may be prescribed in 10-drop doses three times a day, either alone or in com- bination with the drugs mentioned. These remedies are best given a ciuarter of an hour before meals, in a little water. Their physiologic action is not well understood. Riegel beheves the favorable effect of the so-called bitter tonics or stomachics is due to their peculiar taste rather than to any direct influence on the gastric mucous membrane. He maintains that the action of the bitters begins with the sense of taste, before the medicine actually reaches the stomach. Pawlow holds similar opinions regarding the action of these drugs. The following is a useful combination of hydrochloric acid with the bitters: Gm. or Cc. I^ — Tin cturae nucis vomicae 12.0 oiij Tincturse cinchonse compositae 16.0 oSS Acidi hydrochlorici diluti 16.0 o^s Aquae destillatae q. s. ad 120.0 §iv Misce. Sig. — One to two teaspoonfuls in water one-half hour after meals, three times a day. 382 CHRONIC GASTRITIS Nausea and vomiting may be controlled by administering cerimn oxalate, 0.065 to 0.325 Gm. (1 to 5 grains), alone or in combination with bismuth subnitrate or sodium bicar- bonate, or by the methods mentioned under "Acute Gas- tritis." Fermentation may be checked by the use of antiseptic agents, to which a carminative may be added in cases of flatulence. Habershon recommends as a palliative, in con- ditions where fermentation and flatulence are present, a pill of phenol 0.06 Cc. (1 minim) with rhubarb and traga- canth powder. Hydrochloric acid alone may be sufficient; if not, some antiseptic must be employed, such as resorcinol, saccharin, salicylic acid, salicylate of bismuth, menthol, thymol, benzol. These drugs are best given before meals, either alone or in combination with other remedies. Gm. or Cc. I^ — Bismuthi salicylatis 20 . 3 v Resorcinolis 4.0 5j Sodii salicylatis, Salolis aa 2.0 oss Misce. Sig. — One-third teaspoonful three times daily. (Wegele.) Gm. or Cc. I^ — Thymohs, Resorcinolis aa . 75 gr. xij Extract! gentians' q. s. Misce et ft. pil. no. xx. Sig. — One oi- two pills before meals. (Roderi.) Gm. or Cc. H— Resor.-inolis 1 gr. ij Sacchurini 0.02 gr. ^ Misce et ft. pulv. no. i. Sig. — One powder half an hour before meals. (Eicbhorst.) Gm. or Cc. rj— Mentholis 10 V-r.w Alcoholis 20.0 ov Syrupi 30.0 oj Mi.sce. Sig. — One teasi)oonfui every liour until relieved. (Wegele.) The so-called bitters may be employed with advantage in all organic or nervous disorders of the stomach in which TREATMENT OF GASTRITIS AND ACHYLIA GASTRIC A 383 anorexia is a symptom, especially when it is accompanied by diminished gastric secretion. Penzoldt has recommended orexin (phenyldihydrochina- zolin hydrochloride) as a stomachic (see p. 189). It is said to possess the property of inducing hunger. Orexin acts as an irritant to the gastric mucosa; it would, therefore, be contraindicated in irritable conditions of the stomach. Steiner later introduced the tannate of the same base, which was claimed to be less irritating than the original product. The adult dose is 0.3 to 1 Gm. (5 to 15 grains) in capsule, with J liter of water, one to two hours before meals. Creosote has also been placed among the stomachics. It causes energetic peristalsis and slightly increases the secretion. It is especially useful in the gastritis of tuber- culosis. Klemperer recommends a mixture proposed by Bouchard-Frantzel : Gm. or Cc. I^— Creosoti 12.0 3iij Tincturae gentianse 20.0 3v Vini xerici 800 . § xxv Alcoholis 200.0 5vj Misce. Sig. — Teaspoonful before meal.=i. Resorcinol has a stimulating effect on the appetite, as has been demonstrated by clinical experience. It is best taken in solution, either pure or combined with other bitters : Gm. or Cc. I^ — Fluidextracti condurango 16.0 §s? Resorcinolis 4.0 3j Misce. Sig. — Thirty drops four times a day. Gastrosan is a preparation of salicylic acid and bismuth (bismuth bisalicylate) . It contains 40 to 50 per cent, of oxide of bismuth and 50 to 52 per cent, of salicylic acid. The saUcylic acid is liberated in the stomach under the influence of warmth and the gastric processes, and is then able to exert its antizymotic effects. The gastric secretion persists to a slight degree in chronic 384 CHRONIC GASTRITIS atrophic gastritis and in the severe forms of chronic gas- tritis where the mucous membrane has undergone structural or atrophic change, though the quantity of hydrochloric acid secreted may be very small. Patients may be allowed meat, very finely divided. An effort should be made to increase the secretory powers of the stomach by prescribing a dietary adapted to this purpose. Strauss recommends meat extractives and condiments; he advocates bouillon, which may be made more concentrated by the addition of Liebig's extract of beef, as the first course for dinner. Car- bonated waters and coffee act in a similar manner. The latter, however, should be indulged in very sparingly. The mode of preparation and of serving the food, if attrac- tive, will have a stimulating action on the gastric functions. The supply of beverages should be limited, especially during the meal, in order to avoid a further dilution of the gastric ferments which are present only in small quantities. The following dietary tables will be found useful in these conditions (Riegel) : Carbo- Protein. Fat. hydratea. Alcohol Morning. 150 Gm. cocoa 25 Gm. butter (on 8.0 6.0 7.5 toast) .... 0.18 20.8 0.15 Forenoon. 1 soft-boiled egg . 6.0 5.0 Noon. 200 Gm. oatmeal gruel .... 12.5 0.3 18.0 150 Gm. fowl 28.0 13.5 1.8 200 Gm. carrots . 2.14 0,4 16.3 Afternoon. 150 Gm. cocoa 8.0 6.0 7.5 25 Gm. butter . . O.IS 20.8 0.15 Evening. 200 Gm. barley soup 3.2 6.0 17.0 1 egg ... . 6.0 5.0 100 Gm. minced hum 25.0 8.0 100 Gm. macaroni 9.0 0.3 76.7 During Llic 200 Gm. wine 6.0 16.0 day. 75 Gm. zwieback 9.0 1.5 93.6 63.9 117.2 215.0 190.0 Galories (approximately ) 480 890 970 100 Total number of calories, 2440. TREATMENT OF GASTRITIS AND AC'HYLIA GASTRICA 385 Morning. 500 Gm. milk, 3 zwieback 10 A.M. Oatmeal gruel, with 1 yolk of egg Noon. Rice soup, with ] yolk of egg . 200 Gm. beefsteak 25 Gm. toast 100 Gm. mashed po- tatoes .... Afternoon. 250 Gm. milk cocoa, 3 zwieback with jam . . . . Supper. Rice pudding pre- pared with 500 Cc. milk and 30 Gm. sugar . . . . 25 Gm. toast Protein. 20.6 5.3 4.5 42.8 2.0 2.2 13.5 24.4 2.2 Fat. 20.2 5.2 9.2 10.4 0.2 5.1 15.8 18.8 0.2 Carbo- hydrates. 45.7 14.2 15.2 19.0 17.0 44.6 130.8 19.0 Calories. 461 129 167 272 90 125 385 812 90 Carbo- Protein. Fat. hydrates. Calories Morning. Milk cocoa (20 Gm. cocoa, 10 Gm. sugar, 250 Gm. milk) .... 10.3 18.2 25.7 321 10 A.M. 50 Gm. toast 100 Gm. breast of young chicken 4.3 0.5 39.0 160 (weighed raw) . 19.6 2.8 106 30 Gm. butter . . 23.0 214 Noon. Potato soup (100 Gm. potatoes, 50 Gm. milk, 50 Gm. flour, 5 Gm. butter) . 3.5 6.0 23.1 165 Veal hashed (200 Gm. raw) .... 42.8 10.4 272 150 Gm. macaroni (50 Gm. uncooked) 4.2 6.4 38.0 232 Evening. Soup (30 Gm. tapi- oca, 10 Gm. butter) 7.0 14.0 30.0 282 Supper. 250 Cc. milk, 2 zwie- back .... 10.9 10.5 26.3 250 Total number of calories 2002 25 386 CHRONIC GASTRITIS Diet List (Wegele) Protein. Fat. Morning. 200 Gm. cocoa 7.2 8.0 20 Gm. cream ..... 0.7 5.5 15 Gm. butter 0.1 12.5 30 Gm. toast 4.5 0.5 Forenoon. 200 Gm. oatmeal gruel . . . 3.0 6.0 15 Gm. zwieback . . . . 6.5 1.6 15 Gm. butter 0.1 12.5 Noon. 150 Gm. fowl 13.5 1.8 200 Gm. rice and vegetables . 0.4 10 . 200 Gm. pudding 13.5 24.2 50 Gm. apple sauce . . . . 0.7 .... Afternoon. 200 Gm. cocoa 7.2 8.0 20 Gm. cream 0.7 5.5 50 Gm. white bread . . . . 4.5 0.5 15 Gm. butter 0.1 12.5 Evening. 200 Gm. oatmeal gruel . . . 3.2 6.0 100 Gm. macaroni .... 9.0 0.3 100 Gm. cold roast meat . . . 24.0 36.5 90.1 151.9 Calories 403 1400 Total combustive value, 3033 calories. Carbo- hydrates. 10.0 0..7 30.0 14.0 41.0 16.3 46.0 6.5 10.0 0.7 30.0 15.0 76.7 296.9 1230 Diet List (Zweig) Calories. 370.4 Early. 200 Cc. milk soup, 50 Gm. zwieback, 10 Gm. butter Forenoon. 2 eggs or oatmeal soup (20 Gm. oatmeal and 1 egg), 50 Gm. ham (minced), 50 Gm. toast, 20 Gm. butter 420.0 Noon. 200 Gm. rice-milk soup, 150 Gm. minced meat (of chicken, squab, beefsteak, calf's brain, sweet- bread, fish), 100 Gm. vegetable pur^e (spinach, potatoes, carrots, green peas), 50 Gm. toast . . 757.8 Afternoon. Same as early 370 . 4 Evening. Milk pudding (250 Gm. milk, 20 Gm. tapioca, sago or oatmeal, 15 Gm. sugar),. 50 Gm. toast . . . 300.0 Total 2218.6 TREATMENT OF GASTRITIS AND ACHYLIA GASTRICA 387 Early. Forenoon. Noon. Afternoon. Evening. Diet as Impuovkment Proceeds (Zweig) Calories. 2.50 Gm. milk cocoa, 50 Gm. toast, 20 Gm. butter . 556.4 2 eggs or oatmeal soup (20 Gm. oatmeal and 1 egg), 50 Gm. ham (minced), 50 Gm. toast, 20 Gm. butter 420.0 200 Gm. leguminous flour souj) with 1 yolk of egg; meat and vegetable puree as above; 1 omelet souffl6 (2 eggs, 10 Gm. butter, 10 Gm. sugar) or 100 Gm. rice custard, or pancake and ham; 50 Gm. toast 912.4 Same as early 556 . 4 2 eggs soft boiled or scrambled, or 50 Gm. minced meat; leguminous meal soup with 1 yolk of egg; 50 Gm. toast 567.4 Total 3012.6 Diet of Boas Calories. 7 . 00 A.M. 200 Gm . milk with 40 Gm. cocoa and 30 Gm. sugar 462 . 50 Gm. biscuits or zwieback 187.0 10.00 a.m. 50 Gm. white bread, 30 Gm. butter .... 343.0 One egg or 50 Gm. minced ham 100.0 1.00 p.m. Soup (30 Gm. tapioca, 10 Gm. butter) .... 352.6 One egg, 100 Gm. noodles or spinach, 100 Gm. bean puree, 100 Gm. carrots, 50 Gm. mashed potatoes 282.0 100 Gm. breast of young chicken, veal cutlet, or veal (steamed), or 100 Gm. squab, game, or fish 106.4 100 Gm. rice omelet, or omelet with ham . . . 288.0 4.00 p.m. 100 Gm. milk with tea, 20 Gm. sugar .... 147.5 25 Gm. biscuits 93.5 8.00 p.m. 50 Gm. wheat bread, 30 Gm. butter .... 343.0 50 Gm. minced meat 59.5 Total 2765.4 In these conditions — namely, when the gastric secretion is present in small quantities only — hydrochloric acid and pepsin constitute the principal medicinal agents. They are employed in the same manner as in the treatment of achyUa. In chronic gastritis when the secretion is of normal or but slightly diminished acidity, as in the severer forms, diet is the paramount factor in treatment. By dietary measures alone it is frequently possible to restore the digestion to 388 CHRONIC GASTRITIS normal; the diet indicated in subacidity, and already- described, should be prescribed. It is important, especially in the initial period of treatment, that the food be finely divided and thoroughly masticated. The patient should not be restricted in the quantity and kind of food so long as the food is subjected to thorough mastication and insalivation. In fact, only such articles of diet need be interdicted as cannot be finely subdivided. Strong stimu- lants and condiments should be prohibited, inasmuch as they are not required to stimulate gastric secretion; by their use this form of chronic gastritis may be converted into an acid gastritis. Drug treatment, when considered expedient, consists of the bitters or stomachics for poor appetite, and antiseptic measures when fermentative processes are present. Astrin- gent remedies, such as nitrate of silver, are of value in cases in which there is a profuse secretion of mucus. White and Eyre^ report a case of gastritis occurring in a female, aged thirty-six years, who for over eight months had had nausea, heartburn, chilliness, slight rise in temperature, and who was severely ill when seen- — completely incapaci- tated in fact. The attacks were attended by constipation, and the patient had lost much flesh. Different physicians had diagnosticated duodenal ulcer and atonic dilatation of the stomach. Stomach washings contained many colon bacilli, from which a vaccine was prepared and administered (see p. 452). After the first injection the patient showed improvement, and after five months' treatment she had gained almost 15^ pounds in weight, her appetite was good, and she felt perfectly well. When seen seven months later she was doing well and had had no further attacks. Treatment by Gastric Lavage. — Gastric lavage is indicated in cases of chronic gastritis in which there is mucus-secre- tion, disturbance in motility, or fermentative j)rocesses. Mucus should be removed by lavage in the early morning when the stomach is empty. It is well to elevate the ' H. W. Stoner, A R<^sum6 of Vaccine 'riicniiJ.v, AiiuTicaii Jouriuil of the Medical Sciences, Februiuy 11, 1!>11. TREATMENT OF GASTRITIS AND ACIIYLIA GASTRIC A 389 irrigator and thus allow the water to enter the stomach with a certain amount of force. Not more than eight ounces of water should be used at one time. Richter's stomach douche is recommended for these cases (see p. 129). The frec^uency with which gastric lavage should be practiced must be determined by the amount of mucus in the stomach contents, the adequacy of response to diet and treatment, and the manner in which the patients bear the washing- out process. There can be no fixed rule to apply to all cases. Too frequent lavage is apt to do more harm than good. It may be w^ell to give several daily treatments and thereafter two or three a week, soon lessening the frequency. Mucus-dissolving drugs may be added to the water after all food particles have been removed. Alkalies which dis- solve mucus are: Solution of common salt (1 per cent.) ; lime water (5 teaspoonfuls to 1 liter of water) ; bicarbonate of soda (1 per cent.) ; Fleiner's compound (a mixture of sodium chloride and sodium carbonate in the proportion of 2 to 1), a heaping teaspoonful to 2 or 3 liters (quarts) of water; further, Carlsbad or Vichy salts, 2 teaspoonfuls to 1 liter (quart); or Carlsbad water, Ems water, or other mineral waters having mucus-solvent properties. Plain lukewarm water may be used uiitil the stomach is cleansed of food. At the termination of lavage distilled water should be employed to clear the stomach, and a weak solution of silver nitrate (2 to 4 grains to the ounce) introduced through the tube and allowed to flow out again. There seems no better application than silver; but hydrastis should be employed at some sittings, and resorcinol solution (5 grains to Sviij) at others. Although unpleasant in odor, there is no agent that excels ichthyol water as a lavement. With resorcinol it seems to exert a regenerating efTect upon epithelia, and is an excellent antiseptic. If fermentation be found in the stomach contents, a few grains of salicylic acid in solution may be employed as a wash, and a weak solution (2 grains to the pint) of potassium permanganate may be employed quite frequently. 390 CHRONIC GASTRITIS In cases of disturbed gastric motility lavage with luke- warni water should be performed in the evening, before the evening meal, with the patient in the recumbent position. The presence of gastric fermentation calls for antiseptic solutions: Boracic acid, 3 to 5 to 1000; salicylic acid, 1 to 3 to 1000; thymol, 1 to 1000; lysol, 1 to 1000; sahcjdate of soda, 5 to 1000; resorcinol resublimate, 1 to 100; silver nitrate, 1 to 1000; or permanganate of potash, 1 to 1000 to 1 to 5000. The most efTective drug to destroy fermentative germs is salicylic acid. In chronic gastritis with anorexia in which lavage is practiced, it is advisable to wash out the stomach with, solu- tions containing the bitters, such as quassia, 30 Gm. (§j), macerated for one night with ^ liter (1 pint) of cold water, and filtered early the morning of the lavage; hop tea (infusion of dried hops, humulus lupulus); or condurango (1 to 2 dessertspoonfuls of fluidextract condurango to ^ liter of warm water). These solutions act at the same time as stimulants to the mucous membrane and are particularly applicable in subacid and anacid cases. In cases of chronic gastritis accompanied bj^ violent vomiting, which does not yield to diet and ordinary lavage, Cramer advises novocaine after lavage. Novocaine 0.3 to 0.5 Gm. (5 to 7 grains) to ^ liter of water is introduced, and allowed to flow out after having remained two or three minutes in the stomach. Cocaine (1 to 500) may also be employed in such cases. Treatment with Mineral Waters. — Waters from the springs of Saratoga, Congress, and Kissingen are particularly useful in these gastric affections. They should be taken in small doses on an empty stomach. The artificial w^aters may be employed when it is not convenient to visit the various resorts. Good results are often obtained from the use of sodium chloride waters in subacid chronic gastritis and anacid gastritis with functionally active mucous membrane. The increase in gastric secretion is frequently so marked as to TREATMENT OF GASTRITIS AND ACHYLIA GASTRIC A 391 result in a decided improvement and amelioration of symp- toms after only a few weeks' treatment. Boas cautions against the employment of Carlsbad waters in cases of subacidity, though sodium chloride waters may be tried in the later stages. Mineral water cures are indicated only in those cases of chronic gastritis with normal acidity in which the patients complain of much discomfort, and in which large quantities of mucus are secreted. These cases are best treated by springs similar to Carlsbad. To avoid the inhibitory action of the Carlsbad waters on gastric secretion, large doses (500 to 600 Cc.) should not be prescribed for a period longer than two weeks, nor smaller doses (200 to 300 Cc.) for more than three to four weeks. Carlsbad water should be taken warm, in the morning, on the fasting stomach, slowly, and in interrupted doses. Physical Treatment. — Local applications of heat, dry and moist, are often of value in allaying pressure and pain. Compresses, thermophores, Winternitz's stomach application (the moist trunk packing), over night, are recommended. The Priessnitz poultice is also very valuable (see p. 151). The Scotch douche is indicated in the conditions described when they are complicated with atony. Massage should be adopted in cases not complicated with pyloric stenosis, stagnation, or fermentation. Simple atony is not a contraindication, but gastric pain is. As described in the chapter on Massage, this manipulation should be performed when the stomach is empty. The purpose of massage is to improve the muscle tonicity and the circulation of the blood. Massage, in connection with the use of medicinal agents, as suggested by Wegele, is useful in some conditions; the drugs used are the simple bitters, as in the lavage process. In chronic gastritis with atony, electric treatment is indicated — the extra ventricular faradic current. If there is marked gastralgia, intraventricular galvanization may be employed. When chronic gastric catarrh can be definitely traced 392 _ CHRONIC GASTRITIS to congestive conditions related to the portal system, or to diseases of the liver, heart, or lungs, in which the stomach shares in the portal engorgement, treatment of such condi- tions is especially indicated. "WTien chronic gastritis is secondary to other chronic diseases, such as tuberculous peritonitis, these must receive appropriate treatment. CHAPTER XYIII MOTOR IXSUFFICIENCY: ATONY (MYASTHENIA)— DILATATION (ISCHOCHYMIA, GASTRECTASIS)— STENOSIS OF THE PYLORUS At one time the opinion prevailed among gastroenter- ologists that abnormaUty in size or position of the stomach was largely responsible for motor disturbances. It has been found, however, that greatly dilated and ptotic stomachs do not of necessity produce any disturbance of function. Dilatation of the stomach assumes a pathologic importance only when it interferes with evacuation of the gastric con- tents into the intestine. The stomach in health should empty itself of a small meal (test breakfast) within an hour and a half, of a large meal (.test dinner) in seven hours. The emptying process is, as a rule, accomplished within these limits by either atonic or normal stomachs. In stomachs of both normal and abnormal dimensions the emptying period may be pathologically altered; usually it is extended. In comparatively rare cases there is hypermotility in the absence of hydrochloric acid secretion. Rosenbach introduced the term ''motor insufficiency" to designate motor disturbances of the stomach. This term is now in general use. MOTOR INSUFFICIENCY OF THE FIRST DEGREE Boas has classified motor disturbances as motor insuffi- ciency of the first and second degrees. In motor insufficiency of the first degree the evacuation, though complete, is retarded. Etiology. — Motor insufficiency of the first degree is con- tingent upon a primary relaxation of the muscular wall of 394 MOTOR INSUFFICIENCY the stomach (myasthenia, atony). Such muscular relaxa- tion may result from irregular modes of living — the frequent overloading of the stomach with food or distending it with fluids; the prolonged use of narcotic drugs (hypnotics); or excessive indulgence in tobacco. Idiopathic and heredi- tary myasthenias have been noted. Motor insufficiency of the first degree may result from acute or chronic diseases, grave anemias, infections, loss of blood, or childbirth; diseases of the digestive organs, as gastroptosis, chronic gastritis, nervous dyspepsia, chronic intestinal catarrh, chronic constipation, portal congestion, or cholelithiasis, may give rise to primary atony. There is a motor insufficiency which is designated second- ary; it is due to obstruction of the pyloric exit, and is hyper- tonic rather than atonic, the gastric walls being hypertro- phied from the peristaltic movements of the stomach in its persistent efforts to empty itself. (See Plate XXI.) Hyper- trophy of the pylorus may result from chronic gastritis, cicatrization of ulcers, slight torsion from gastroptosis, peri- gastric adhesions an epigastric hernias, hypersecretion with frequent pylorospasm, or repeated injuries in the region of the stomach. The hypertrophic changes in the pylorus in such cases are slowly progressive. These cases, as a rule, pass from mechanical motor insufficiency of the first degree to motor insufficiency of the second degree. Symptoms. — In primary atonic motor insufficiency^ of the first degree great discomfort may be experienced on the partaking' of food; the pressure symptoms and feeling of fulness may persist for several hours, or in severe cases as long as there is food in the stomach. Patients are apt to be annoyed by eructations, with pyrosis, when hyperacidity is present. The so-called "stomach dizziness" is sometimes experienced in gastric atony complicated with constipation. Patients may complain of many symptoms of neurasthenia, such as fulness in the head, headache, palpitation of the heart, backache, hypersensitiveness on mental or physical effort. The physician should endeavor to differentiate clearlj' MOTOR INSUFFICIENCY OF THE FIRST DEGREE 395 between primary atonic motor insufficiency of the first degree and motor insufficiency of the second degree (dila- tation) induced directly by pyloric stenosis. Diagnosis. — Gastroptosis and atony occur frequently in the same individual. Gastroptosis may sometimes be diagnosticated by inspection when the abdominal walls are thin and relaxed and the stomach is in a condition of peri- staltic movement. Permanent and absolute dilatation of the stomach does not occur in primary atony. The atonic muscles may, however, be so greatly distended by the pressure of food as to constitute a condition of transient dilatation of the stomach. Should a person with a normal musculature drink a sufficient quantity of water, the inferior border of the stomach will descend to the level of the umbilicus, as shown by the area of gastric dulness, but no low^er. The atonic stomach, on the other hand, may be so distended by fluids as to throw the lower border below the navel. Splashing sounds elicited when the stomach should be empty go to confirm a diagnosis of atony. The stomach in a condition of atony contains food remnants six to seven hours after the ingestion of a Riegel test meal. It, however, empties itself completely during the night, after a test supper. One hour and a half after a test breakfast the atonic stomach is found to contain food residues. The motility and power of evacuation of the stomach may be demonstrated by the x-rays, if a bismuth suspen- sion be first administered to render the outline opaque. (See Plates XV, XVI, XVII, XVIII, and XIX.) Examination of the stomach contents withdrawn by means of the stomach tube reveals, in atonic conditions, the presence of free hydrochloric acid in varying quantities, depending upon whether the case is one of simple non- comphcated atony or a complication of atony with gastritis or hypersecretion. Should simple atony be protracted for some length of time, the result may be diminished acid secretion. In the absence of gastritis and hypersecretion the acidity usually remains normal for a long time, and the secretion of pepsin and rennin remains normal for a much 396 MOTOR IXSUFFICIEXCY longer period. Constipation frequently accompanies atony of the stomach. Treatment. — The treatment of primary motor insufficiency of the first degree should tend to prevent overdistention of the stomach and at the same time improve the muscle tonus. Much may be accomplished by suitable diet, which should be selected so as to make the least demand upon the motor activity of the stomach. The meals should be small in quantity and comparatively frequent. In regard to the consistency of the food, Riegel maintains that the motor condition of the stomach should be the guide. In the atonic as in the normal stomach the liquid portion of the food passes into the duodenum first, then the semisolid, and lastly the soUd residues of food. Water leaves the atonic stomach with marked rapidity, so that the amount of water in the tissues of the body is fairly constant. Considering the ease with which the stomach empties itself of liquid and semiUquid foods, these should constitute a large pro- portion of the diet in atonic states. The stomach can take care of large quantities of liciuids so long as they are taken regularly and in small amounts. ]Milk holds first place in the Ust of foods for the dietetic treatment of gastric atony. In selected cases the milk cure, combined with rest in bed, may be employed for several days. By administering at intervals of two hours 250 to 300 Cc. (§viij-x) of milk, 2000 Cc. (2 quarts) may be taken during the twenty-four hours without producing over- distention of the stomach. In addition to milk, a variety of preparations with milk may be employed, as cocoa, tea, vanilla, rice, oatmeal, and cornstarch. Diarrhea, if present, may be checked by the addition of lime water to the milk. Schmidt recommends to prevent fermentation that pure salicylic acid, 0.3 Gm. (5 grains), be thoroughly mixed with a small quantity of cold milk, the mixture added to the daily quantity of milk (a liter and a half), and the whole boiled. Sour milk, kefir, and peptonized milk are useful adjuncts to the diet. MOTOR IXSIFFICIESCY OF TI/F FIRST DEGREE 397 Diet in Normal Acidity, Hyperacidity, and Hypersecretion. — In cases of gastric atony in which the acidity is normal or higher than normal, and in hypersecretion, Strauss recommends a strictly protein-fat diet, to obviate the carbohydrate fer- mentation which would otherwise result from insufficient amylolysis. Since protein is pretty thoroughly digested in such cases, it is not necessary that it be taken in liquid or semiliquid form. Should gastric ulcer or erosion be sus- pected, the nutriment must be liquid. It is necessary that the protein food be thoroughly cooked. An extensive variety of meat and fowl, and dishes prepared from them, as well as jellies, eggs, and soft cheese, may be prescribed. Fat, owing to its power of diminishing secretion, is indi- cated in hyperacid conditions. Strauss has pointed out that its use is distinctly advantageous in the treatment of atony, and that, contrary to the view once held, a fatty diet remains no longer in the stomach than food of other compo- sition. He does not class it among the so-called ''heavy" foods. ]\Iotor insufficiency with increased or normal secre- tion is benefited, and in some cases a radical cure is accom- plished, by a protein-fat diet. All kinds of fat with a low melting point and pure in quality may be employed. Butter, cream, and ohve oil are suitable forms of fat; but fat pork and the fat of roast duck or goose should be avoided. In cases of well-marked atony Strauss comcmences treat- ment with an exclusive protein-fat diet, and later adds small quantities of carbohydrates so that he has a high protein-fat and low carbohydrate combination. The carbo- hydrate constituent consists of toast, zwieback, biscuits, rice, leguminous flours prepared in the form of gruels, soups, mashed potatoes — each prepared with as large a quantity of milk and butter as can be used. Green vegetables should be avoided. Diet in Subacidity and Anacidity. — The principles underlying the dietetic treatment of chronic gastritis apply in this con- dition also. The diet should be in all cases liquid or semi- liquid. It should contain a large admixture of fat. Meats, if eaten, should be taken in a very finely subdivided condition, 398 MOTOR IXSUFFICIEXCY and eggs in the form of the light egg dishes. Carbohydrates should be taken in the form of flour soups or leguixiinous soups and vegetable purees, all of which should be prepared with as much butter and milk as possible. Alilk is the best beverage in this class of cases. Alcohol should not be given in gastric atony except in the form of small quantities of mild claret. Coffee should be interdicted, and tea given only in combination with milk. After each meal the patient should rest in the recumbent position, preferably on the right side. If thirst be a troublesome feature of the disease, it may be allayed by the daily administration of two or three enemata of physiologic salt solution of 150 to 200 Cc. (^Y-vij) each, thus avoiding distention of the stomach. Lavage of the Stomach. — Lavage of the stomach is not indi- cated in primary atony, inasmuch as the stomach evacuates itself completely though perhaps tardily. Atony complicated with hypersecretion may be benefited by an occasional lavage. The so-called gastric douche has been recommended in atony, and is said to have the effect of strengthening the muscular coats. Its value in this condition is doubtful. When the gastric douche is employed the rinsing may be performed with the aid of Rosenheim's tube, employing physiologic salt solution in subacidity and Carlsbad salt solution in hjqperacidity ; the temperature of the water may be lowered gradually to 54° F. Should the patient experience loss of appetite, the washing process may be accomplished with an infusion of hops and quassia to which has been added a little fluidextract of condurango for its stimulant effect upon the sense of hunger. Riegel proposes the following treatment, which may be termed a gymnastic exercise of the stomach: Half a liter of water is permitted to flow into the stomach through the stomach tube; the funnel or irrigator is then removed, leaving the tube in position; the patient then forces the water out through the tube by pressure on the stomach. It is claimed that the tone and motility of the stomach have been improved markedly by this method of treatment. MOTOR INSUFFICIENCY OF THE FIRST DEGREE 399 Medicinal Treatment. — The alkalies are indicated in cases of atony accompanied by hyperacidity or hypersecretion as a complication. The most suitable of these have been found to be magnesium oxide and the double phosphate of ammonia and magnesia. Bicarbonate of soda has the dis- advantage of producing, on combination with the normal acid secretion, too much carbon dioxide, which causes over- distention of the stomach. Atropine is employed for its inhibitory effect in cases of simple non-complicated hyper- acidity. Extract of belladonna is indicated for pain. Hydrochloric acid in combination with pepsin is indicated in subacidity and anacidity. In the presence of fermenta- tion such antifermentative drugs as bismuth, resorcinol, benzol, salicylic acid, and menthol are to be employed. Strychnine sulphate, 0.001 to 0.006 Gm. (^^^j to yV grain), hypodermically, or extract of nux vomica, 0.008 to 0.05 Gm. (I to 1 grain), will increase the peristaltic movements of the stomach. Boas recommends the administration of nux vomica in pill form : Gm. or Cc. I^ — Extracti nucis vomicae 0.1 gr. iss Extracti gentianse radicis, q. s. Misce et ft. pil. no. xxx. . Sig. — One or two pills three times a day, after meals. Physical Treatment. — Gastric atony of the first degree has been benefited by the employment of hydrotherapeutic measures. Muscular tonicity has been increased by means of the Scotch douche and cold compresses applied over the gastric region. Massage is indicated in all cases of primary atony uncomplicated with dilatation or organic stenosis, hyperacidity or hypersecretion; it may be employed even in ptosis of the stomach. The purpose of massage is to improve the muscular tone and aid in the expulsion of the gastric contents into the duodenum. When the purpose is to improve muscular tonicity, massage should be undertaken when the stomach is empty; to aid in emptying the stomach it is, of course, performed when that viscus is filled with food. 400 MOTOR INSUFFICIENCY Electric treatment, consisting of intra- and extra-ventricular faradization, is also emplo^^ed as a means of improving the muscular tone. Massage may be employed in conjunction with electric treatment, or electricity and general massage may be employed alternately, to be followed hy abdominal massage in cases of arrested intestinal peristalsis. Treatment with Mineral Waters. — The use of mineral waters has been found advantageous in the treatment of very mild cases of atony — being selected according to the condition of the gastric secretion; in hj^peracidity and in hypersecre- tion the Carlsbad waters and waters from alkaline-acidu- lous springs should be employed, while, on the other hand, sodium chloride waters should be used in subacidity and anacidity. The mineral water treatment should be em- ployed with great caution, and the waters prescribed in limited quantities in order to avoid overloading the stomach. Mineral waters should not be used in these cases when the patients complain of more or less severe symptoms, but the patients should be sent to the seashore for ocean baths or advised to make climatic changes. In cases of atony in which gastric ulcer, gastritis, ptosis, or neurasthenia is known to be present as a positive factor, the complicating condition should receive treatment as outlined in the respective sections of this work. MOTOR INSUFFICIENCY OF THE SECOND DEGREE Motor insufficiency of the second degree is a chronic condition in which the stomach has lost entirely the ability to expel its contents; that is, food residues remain in the stomach permanently (stagnation) ; and as a consequence of this chronic condition of gastric insufficiency we have dilatation of the stomach (ischochj^nia, gastrectasis). Etiology. — The cause of motor insufficiencj' of the second degree may be either trauma of the muscle fibres of tlie stomach or pyloric stenosis. It is possible that primary atony may in time be transformed into motor insufficiency MOTOR INSUFFICIENCY OF THE SECOND DEGREE 401 of the second degree, with stagnation of the stomach con- tents. Ciireful chnical and anatomic examinations have shown us that stenosis of the pylorus is the cause of nearly ever}' case of motor insufficiency of the second degree. The lumen of the pylorus may be narrowed from the inside or from the outside; it may be cicatrized and contracted from the healing of gastric ulcers, or there may be cicatricial tissue as a result of healed perforations from biliary calculi. Spastic stenosis of the pylorus is by no means a rare condi- tion; it is caused by the irritating effect of the ingesta upon erosion or fissure of the pylorus, or by an abnormally high degree of gastric acidity (hypersecretion). This kind of closure of the pylorus is at first periodic. When, however, the attacks become more frequent, the effect is permanent stenosis. Spastic closure of the pylorus may also result from hysterical crises. Chronic hyperplasia of the gastric mucous membrane {etat mamelonne) and hypertrophy of the muscles in the region of the pylorus in chronic gastritis and cirrhosis ventriculi also cause stenosis. Syphilis may also become an etiologic factor in chronic hypertrophy of the pylorus. Internal stenosis resulting from malignant tumors, such as carcinomata and sarcomata, is by no means rare. Polypi and myomata of the pylorus are occasionally met with. Foreign bodies may block the pyloric exit. A valuable device for ascertaining the patency of the pylorus is the Einhorn duodenal bucket (Fig. 5) ; it is very similar to the usual stomach bucket, but much smaller in size. It is made of gold and can be easily placed in a No. 00 capsule. Fastened to a silk cord 75 centimeters long, it is swallowed by the patient and allowed to remain over night. Upon its removal the contents are examined for pancreatic ferment — which, if found, assures us that the bucket has passed through the pylorus and that therefore the pylorus is patent. Einhorn has also drawn attention to an important diagnostic point in this connection : If there be an ulcer in the tract covered, the silk will be discolored by blood, and this will give us a clue to the site of the ulcer. Adhesions of the stomach to neighboring organs or to 26 402 .1/0 TOR IX S UFFICIEXC Y abdominal tumors may cause pyloric stenosis by compression or by bending the pylorus upon itself. Symptoms. — As soon as pyloric stenosis begins to interfere with the free passage of food from the stomach to the duodenum, symptoms of greater or less severity manifest themselves. They may at first be the sjmiptoms of motor insufficiency of the first degree, such as pressure and a sense of fulness after eating; and the desire for food is easily satiated. Eventually the pressure sj'mptoms become aggravated in proportion to the increasing stenosis of the pylorus, the stomach becomes distended, and pain is caused by the incessant attempt of the gastric muscles to over- come the obstruction to the pyloric exit. When the obstruc- tion becomes so pronounced as to effect a closure of the pylorus, the food remains in the stomach and stagnation results. Finally the stomach contents are expelled by vomiting. Emesis increases in frequency and becomes a troublesome sj^mptom. The appetite, fair at first, diminishes with the increasing stagnation. Patients in the meantime complain of severe thirst. The body becomes impoverished for fluid, since the stomach cannot absorb water. This condition is indicated by the remarkably small quantities of urine excreted and by hard impacted fecal matter. The pyloric stenosis is accompanied by pro- nounced emaciation. The skin is dry and clammy because of the small amount of water in the tissues. Patients, as a rule, complain of dizziness, lassitude, inability to work, and somnolence. When the decomposed stomach contents pass into the intestine, pronounced gaseous fermentation arises, producing distention of the bowels, with abdominal pains and headache. Gastrogenic diarrhea may be brought on by the fermenting gastric contents in the bowel. Diagnosis. — Dilatation of the stomach from stenosis of the pylorus may assume marked dimensions. It is a matter of diagnostic importance to ascertain the degree of dilata- tion. Apart from the anamnesis, the diagnosis is facili- tated by the presence of abnormal peristaltic movements (stiffening) of the stomach, by the signs of motor insuffi- MOTOR INSUFFICIENCY OF THE SECOND DEGREE 403 ciency of the second degree, and by examination of the stomach contents. Motor insufficiency is indicated by the nature of the food remnants in the stomach in the morning after a night's fast. Fermentation is always present, its extent depending upon the degree of stenosis of the pylorus. In benign stenosis the stomach contents are acid, owing to the presence of hydrochloric and organic acids, such as acetic and butyric, the latter resulting from fermentation; sulphuretted hydrogen gas also is present, arising from the decomposition of protein matter. In malignant stenosis (carcinoma), lactic acid predominates, but hydrochloric acid may also be present for a considerable time, especially at the beginning of the carcinomatous process. The finding of sarcinse is of diagnostic significance in benign stenosis of the pylorus; the presence of lactic acid bacilli will aid in the confirmation of malignant stenosis. When the stagnating gastric contents become strongly acid, the urine may be found to be alkaline in reaction, with a resultant lowering of the percentage of chlorides in the body. The presence of bile in the gastric contents favors a diagnosis of stenosis of the duodenum. Gastric hemorrhage may occur in either malignant or benign stenosis of the pylorus. Treatment. — The treatment of this condition is essentially dietetic. The diet should be such as to make the least possible demand upon the motor activity of the stomach. It should not be larger in amount than is absolutely essential, and should be ingested in a form most easy of expulsion from the stomach into the duodenum. The diet in this class of cases resembles that advised in atony. The condi- tion of the secretory function must be carefully estimated. Fat may be prescribed along with protein when the secretion of hydrochloric acid is either normal or above normal. Carbohydrates I prescribe in as small amounts as can be got along with, and give them in the most soluble form possible, preferably dextrinized. The artificial protein prep- arations are indicated in this condition. Green vegetables should be avoided, even in the form of purees. The food should be liquid or semisolid in consistency. 404 MOTOR INSUFFICIENCY Beverages should be restricted to the lowest practicable luiiit, and should consist of drinks with a nutritive value, such as milk or cocoa. If the patient can tolerate it, the oil cure recommended by Cohnheim may be employed with advantage. This consists in the patient drinking, or in having introduced by means of the stomach tube, three times a day, before meals, 50 to 60 Cc. (§iss-ij) of pure olive oil, at body temperature. If lavage is a part of the general treatment, 100 to 200 Cc. (giij-vj) of oil may be introduced at the conclusion of each lavage, when the stomach will be sure to be empty. The oil has an anti- spasmodic action and serves as a coating, being especially useful if fissures, erosions, or ulcers are present. Oil has the additional advantage of diminishing the secretion in cases of hypersecretion and hyperacidity. The oil treatment is recommended particularly in spastic contraction of the pylorus. When patients suffer much pain and vomit frequently, and there are manifestations of marked fermentative pro- cesses, the amount of solid and liquid food should be mate- rially reduced. In such cases not more than a liter (a quart) of fluid a day should be taken by mouth. It is sometimes necessary to resort to rectal feeding. Whatever food is given by mouth should be in a liquid or semiUquid form. Rectal Alimentation.- — The attempt should be made to allay thirst, which is often very distressing, by moistening the lips and the cavity of the mouth. The mouth should be frequently rinsed with cold aromatic waters. Small pieces of ice may be given, but the water should not be swallowed. When this method of allajdng the thirst fails, recourse must be had to rectal enemata. Water is readily absorbed by the rectum and colon, especially when the body has become much impoverished for want of fluids. Eight to ten ounces of lukewarm water should be allowed to flow into the rectum through a soft rubber tube, preferably by the droj) method, so that the patient may retain as nuich of the fluid as possi- ble until absorption takes place. Normal salt solution may be used instead of ])ure water. MOTOR INSUFFICIENCY OF THE SECOND DEGREE 405 When the quantity of urine for the twenty-four hours is less than 20 ounces, Boas recommends the daily adminis- tration of fluid enemata in such quantities as will bring the urine up to a liter (33 ounces). When the patient becomes very weak, analeptics such as sugar or whisky may be added to the enemata. The addition of alcohol to enemata is thought by some authorities to aggravate cases of hyper- secretion and hyperacidity, inasmuch as alcohol absorbed from the intestine stimulates the secretion of hydrochloric acid. When, however, the quantity is small, there is little occasion for fear that it will excite gastric secretion. In addition to the water clysmata, the bouillon-wine enema of Fleiner (two parts of bouillon to one of white wine or claret) may be given for its stimulating effect. Strauss recommends a mixture consisting of 8 ounces of water or bouillon, a small quantity of sodium chloride, half a tablespoonful of wine, and one to two tablespoonfuls of sugar. These enemata should be administered twice a day. The liquid enemata are, as a rule, well borne by the patient for a considerable length of time. When it is necessary to administer nutrient enemata, the colon should be thoroughly cleansed every day by an injec- tion consisting of a quart of water and a teaspoonful of salt, administered early in the morning. Rectal alimentation may be given an hour later. The nutrient enema is best injected by means of a fountain or Davidson syringe, or a plain hard-rubber piston syringe and a soft-rubber rectal tube which is introduced into the anus from three to five inches. The injection (5 to 10 ounces) should be given slowly and with very little or no force, in order to prevent peristalsis, which would result in emptying the lower bowel. After the tube is withdrawn from the rectum the patient should be requested to lie quietly and to endeavor to retain the enema. Three to five such enemata may be admin- istered daily. When enemata are continued over a long period of time it is advisable to wash out the rectum at least once a day with warm water, soapsuds, or boric acid solution; by this means all foreign matter is got rid of, 406 MOTOR INSUFFICIENCY feces dislodged, and mucus and any remains of former injections washed away. The large intestine is capable in a high degree of absorb- ing nutrient materials, but not all articles of nourishment are absorbed equally well. Fat cannot be handled to good advantage by the intestine; it should, therefore, be employed in as small quantities as possible as an ingredient of nutrient enemata. It has been demonstrated, however, that the large intestine can absorb fat with a low melting point, provided it is in an emulsified form. Even under these conditions not more than 10 Gm. (oiiss) should be admin- istered during the twenty-four hours. This represents a heat value of 93 calories. The addition of pancreatin to fat is said to aid its absorption somewhat. The nutritive value of milk in enemata consists chiefly in its carbohydrate content. The large intestine absorbs protein with much greater facility. It is able even to dispose of protein such as egg albumin in the natural state, especially when common salt is added to it. The administration of egg enemata over a long period of time is usually accompanied by pronounced decomposition, giving rise to gaseous fermentation. Milk protein, such as casein, is not so well absorbed as egg protein. Some experimenters have attempted to peptonize pro- teins in the large intestine by adding pancreatin to the enemata. Such preparations are, however, unsatisfactory, and it has been found more advantageous to administer the protein in the form of peptone. Albumoses are likewise absorbed by the rectum and colon. Care should be exercised not to administer enemata in too concentrated a form and thus irritate the intestine. Starch, properly prepared, is absorbed entirely, as are also dextrin and sugar. Sugar solutions in too concentrated form arc liable to cause irrita- tion of the intestine. The most suitable sugars are cane and grape; it is said that as much as 80 per cent, of the cane and grape sugar administered in ]-)ro]ior solution per rectum MOTOR INSUFFICIENCY OF THE SECOND DEGREE 407 can be appropriated by the body. Milk sugar is not so easily absorbed. Nutrient Enemata. — A large number and variety of nutri- ent enemata have been devised. Those most commonly used and shown bj'' experience to be satisfactory in the treat- ment of pyloric stenosis are: (a) The different kinds of peptones and propeptones in the market (Armour's, Carnrick's, Savory & Moore's, or Kemmericli's peptone, somatose; plasmon, sanose, nutrose), of which about two or three ounces dissolved in six to eight ounces of water are injected. The different beef juices may also be diluted with water and injected in corresponding quantities. (5) Alilk and egg enemata: Six to seven ounces of milk, one or two raw eggs well beaten up in the milk, one teaspoon- ful of powdered sugar, and one-third of a teaspoonful of common table salt. Pancreatin (one tube of Fairchild's pancreatin) may be added to such an enema in order to facilitate its assimilation (Einhorn). (c) Boas recommends 8 ounces of milk, two yolks of eggs, common salt, one tablespoonful of claret, and one teaspoon- ful of flour. Strauss modifies this enema by adding two tablespoonfuls of grape sugar. If the modified enema is badly borne, he reduces the quantity of grape sugar to one tablespoonful. In case the odor is suggestive of acid fer- mentation, he adds 0.25 Gm. (4 grains) of salicylic acid or menthol to each enema as a preservative. In cases where hyperacidity and hypersecretion are a complication, wine is omitted. {d) The nutrient enema recommended by Ewald consists of 40 Gm. (5x) of wheat flour stirred up in 150 Cc. (Bv) of tepid water or milk. To this mixture are added one to two eggs, 3 Gm. (45 grains) of sodium chloride, and 50 to 100 Cc. (5iss-iij) of a 15 to 20 per cent, solution of grape sugar; the whole is thoroughly beaten up. Claret may be added as required. (e) Riegel's enema consists of 8 ounces of milk, 2 to 3 eggs with salt, and some flour. 408 MOTOR INSUFFICIENCY (/) For hospital practice Strauss recommends, chiefly on the ground of economy: 8 ounces of bouillon, | ounce of alcohol, 1 ounce of grape sugar, 2 yolks of eggs, ^ teaspoonful of sodium chloride, 2 to 3 tablespoonfuls of gum Arabic mucilage. (g) Leube employs enemata consisting of well-chopped meat (5 ounces), fresh pancreas (2 ounces), and 1 ounce of fat (butter), all thoroughly mixed with about 6 ounces of water. (h) Kussmaul has employed the following : Two to three eggs beaten with an equal volume of water, added gradually so that a milky mass was formed. This was left standing for twelve hours in a cold place, then heated to 63° F. and administered, (i) Moritz recommends 15 Gm. (Bss) grape sugar, the same quantity of malt extract, 100 Cc. (§iij) milk, 6 Gm. (5iss) common salt, 1 wineglass of claret, and 2 to 3 eggs. (j) Leube uses as a peptone enema 60 parts of peptone to 300 of milk. (k) Brandenburg: Dried peptone, 20 parts; grape sugar, 20; sodium chloride, 1; the whole dissolved in 200 parts of water. (l) Lattier: Three teaspoonfuls of dried peptone, one yolk of egg, 125 Cc. (Siv) milk, and 5 Gm. (75 grains) pulverized starch. (m) Rosenheim: One to two teaspoonfuls of peptone, 2 of sodium chloride, 15 of grape sugar; to this add 30 Gm. (§j) of emulsion of pure cod-liver oil in a 3-per-cent. soda solution. The whole is to be increased to 250 Cc. (§viij) by the addition of tepid water. (n) Mering: 25 parts peptone and 25 parts milk sugar to 200 parts water; 25 parts of alcohol may be added if desired. Wegele recommends dextrinized food, such as Nestle's, instead of grape sugar. (o) Pancreas enemata: 150 to 200 Gm. (ov-vj) hashed beef, 60 Gm. (§ij) finely cut pancreas substance (Leube). (p) One-fourth liter (l pint) of cream, 25 Gm. (ovj) dried peptone, 5 Gm. (75 grains) pure pancreatin (Mering). MOTOR INSUFFICIENCY OF THE SECOND DEGREE 409 Klopfer's prepared nutrient enema is one of the latest preparations of this class of food substances. It is yellowish in color, consisting of small scales which have only to be stirred up with warm water to be ready for use. The formula calls for 22.5 per cent, of soluble protein, 73.46 per cent, of carbohydrates (starch, malto-dextrin) , and the salts of wheat flour. The protein of this enema is utilized only to the extent of 19 per cent., while the carbohydrates are absorbed up to 80 or 90 per cent. Klopfer's enema does not appear to possess any distinct advantages over the egg or peptone enema; only convenience of preparation seems to be in its favor. Should the patient experience difficulty in retaining an enema administered as advised above, 10 drops of simple tincture of opium may be added to each enema. The opium has a quieting effect upon the lower bowel, allaying any local irritability that may exist. The addition of opium to the enema has also been recommended for its influence upon the nerve control of thirst. Should it be found necessary to act promptly, owing to great deficiency of water in the system, Strauss advises the rectal administration, twice daily, of a fiter (quart) of water containing 50 Gm. ( § iss ) of grape sugar, the same amount of cream, a pinch of connnon salt, and 25 Gm. ('5^]) of soluble protein. The liquid should be introduced into the lower bowel by the drop method (proctoclysis). One liter of physiologic salt solution may be injected twice daily as a thirst enema. When nutrient enemata are badly borne, the intestine should be washed with a solution of sahcylic acid, 1 to 1000, or boracic acid, 1 to 100, and the nutrient enemata resumed after two days. In severe cases in which no food can be retained in the stomach, rectal alimentation may be employed with advan- tage and continued exclusively for a period of eight to four- teen days. The physiologic rest of the stomach afforded by this method of feeding is usually followed by marked improvement in the gastric symptoms; the improvement is 410 MOTOR IXSUFFICIENCY often so pronounced as to permit of a resumption of feeding by mouth. Feeding by mouth should, however, be resumed very gradually, and as the power of gastric digestion in- creases the number and quantity of rectal enemata may be as gradually decreased. Subcutaneous Nutrition. — When rectal alimentation fails, subcutaneous nutrition remains as a last resort. It has been shown that grape-sugar solutions are well borne when administered h3T)odermically; the injection is, how- ever, accompanied by much pain. About 100 Cc. (§iij) of a 10-per-cent. solution of grape sugar may be intro- duced by means of a cannula connected with a funnel. ^^arious regions of the body may be chosen for the injec- tions, as the internal and external surfaces of the thighs, the pectoral muscles, and the h5T)ogastric region. Injec- tions of oil, such as ohve oil or oil of sesame, are said to be less painful. Oil may be injected in quantities up to 100 Cc. by means of a funnel and cannula, or the syringe. The subcutaneous injection of protein is very painful and of little or no nutritive value. Whenever food is injected directly into the tissues the strictest asepsis should always be observed. Nutrition by hypodermic injection is con- sidered only as a last resort, and otherwise has very httle in its favor. Subcutaneous injection of water in cases in which the quantity of water in the tissues has become greatly reduced has been found very efficacious; the water is usually given as normal salt solution; from 1 to 1^ liters (2 to 3 pints) may be administered, and repeated. In motor insufficiency of the second degree accompanied by hyper- secretion and vomiting of acid materials the body becomes depleted of sodium chloride. In such cases Strauss notes a marked improvement as soon as the urine again shows the normal amount of sodium chloride. Treatment by Lavage. — Routine washing of the stomach is indicated in all cases of motor insufficiency in which that viscus does not completely empty itself of its contents dur- ing the night's fast. The stomach should be emptied and relieved of the retained food remnants. The most satis- MOTOR INSUFFICIENCY OF THE SECOND DEGREE 411 factory results are obtained by the use of gastric lavage in the rare forms of atonic stagnation with insufficiency, and in spastic stenosis of the pylorus. After a continued course of gastric lavage the dilated stomach has been found to approximate the normal, and the gastric muscles have shown marked improvement in tone; especially is this the case in benign stenosis of the pjdorus. We do not get this improve- ment, however, in cases of malignant stenosis. It is some- times possible, however, by means of lavage, to arrest the progress of pyloric stenosis. A proper time for the perform- ance of lavage is in the evening, before supper, so that the stomach may be relieved of undigested and decomposed food remnants before another meal is taken. The clean stomach is then in a better position to take care of a moderate sized supper, with the prospect of a minimum of gastric dis- turbance as a consequence during the night. When there is much gastric fermentation, antiseptic or antifermentative drugs may be dissolved in the water to be used for lavage purposes. Among such drugs are: Benzoate of soda, which may be used in from 1 to 3 per cent, solution: chloroform water, 1 per cent.; creolin, 10 to 15 drops to a quart of water; ichthyol, 10 to 20 drops to the quart. Gastric lavage is usually followed by a marked ameliora- tion of the subjective symptoms. The appetite increases, pain ceases, vomiting disappears, and thirst is diminished, while at the same time the urinary secretion becomes normal in amount. All this improvement should take place wdthin three or four weeks, otherwise the prognosis for improvement is not good. Instead of the gastric lavage. Boas has recommended a simple manual expression of the gastric contents morning and evening by the patient himself. Complete evacuation and cleansing of the stomach is not, however, attained by this method. When dilatation and ptosis exist, improvement sometimes follows properly fitting abdominal bandages which assure support to the stomach. The reader is referred to the chapter 412 MOTOR INSUFFICIEXCY on Gastroptosis for details in regard to this mechanical treatment. Physical Treatment. — The galvanic current is indicated in those rare forms of motor insufficiency of the second degree which are characterized by atonic insufficienc^^ In pyloric stenosis the peristaltic movements of the stomach are accelerated, thus rendering unnecessary any extraneous aid for the purpose of improving muscular tone. Massage of the stomach may be practiced in the treatment of atonic varieties of motor insufficiency of the second degree. It should not be employed when the stomach contains any quantity of food remnants, but only after lavage. ^Tiatever decomposing material there may be in the stomach should be completely removed, and not forced, as massage would be in danger of forcing it into the intestine. According to Tabora, the stomach should be slightl}^ distended with air before effleurage is performed. Treatment with Mineral Waters. — The mineral water cures, so called, are contraindicated in motor insufficiency of the second degree in the presence of stagnation, inasmuch as their employment would only serve to increase the amount of fluid in the overburdened stomach. They may, however, be tried, in selected cases, after gastric lavage. Medicinal Treatment. — The administration of drugs is prob- ably the least important factor in the treatment of motor insufficiency with, stagnation, inasmuch as the therapeutic effect of drugs in contact with decomposed food remnants in the stomach is likely to be of doubtful value. Strychnine sulphate may be administered hypodermically. As an anti- fermentative in cases of gastric distention, Boas recommends salicylate of soda, 1 to 3 Gm. (15 to 45 grains) per day, and salicylate of magnesia, 1 to 3 Gm. (15 to 45 grains) in divided doses for the twenty-four hours. One cubic centimeter (15 minims) of dilute hydrochloric acid ma}' be adminis- tered several times a day for an extended period, in order to counteract fermentation caused by the presence of lactic and butyric acids. The vegetable bitters, such as condu- rango and quassia, are sometimes useful. In spastic con- MOTOR INSUFFICIENCY OF THE SECOND DEGREE 413 traction of the pylorus brought on by hyperacidity and hypersecretion, alkalies, astringents or atropine sulphate maj^ be administered as indicated in hyperacid conditions of secretion. The latter drug should be administered imme- diately after gastric lavage, in order that it may come in contact with the empty stomach. Fig. 40 pill iiiiiniiiiiriTiiiTiiii o> »i Einhorn pyloric dilator: A, rubber bag with gauze envelope in collapsed shape; B, rubber bag with gauze envelope inflated with air; C, stopcock. Treatment of Stenosis of the Pylorus. — We should direct our treatment likewise to pyloric stenosis. Success is often at- tained by combating the causes of pylorospasm, which usually consist of hyperacidity, hypersecretion, or fissures and ulcers in the region of the pyloric exit. This treatment may be diet- etic or medicinal, or it may consist of lavage or the oil cure already described (see p. 199). Organic stenosis yields with much greater difficulty, if at all, to internal medication. Einhorn^ has constructed a special pyloric dilator (Fig. 40), which he has used in a case of congenital stenosis of the pylorus in an infant six weeks old and in spasmodic con- traction of the pylorus in adults. This mode of treatment mil probably find application in specially selected cases, principally of pylorospasm due to gastric ulcer or to remote reflexes (seep. 269). 1 Illinois Medical Journal, June, 1910. 414 MOTOR INSUFFICIENCY When pyloric stenosis can be traced to a s^'philitic cause, specific treatment will be productive of good results. In cases where the stenosis is due to gastric carcinoma little can be hoped from a course of internal medication. Some writers have reported favorable results from the administration of thiosinamine or fibrolysin. Stuart reports a case with obvious symptoms of pyloric obstruction which was greatly improved by the hypodermic administration of fibrolysin in the epigastric region in doses of 2 Cc. daily for a month, every other day for a week, and thereafter at intervals of three or four days for three weeks more. The patient became comfortable in a fortnight. Stuart states that one great factor necessary to success in the treatment of adhesions by fibrolysin is that they must be in such a location that they can be massaged and stretched; other- wise, though they may be rendered soft, they remain in the same relation to surrounding tissues as before, and no good results can be obtained. Hartz reports a case of cicatricial stenosis of the pylorus of twenty-eight years' duration, treated by thiosinamine administered hypodermically, in which a perfect cure resulted. Thiosinamine is said to possess the power of softening cicatricial tissue, irrespective of its origin, so as to impart to it some degree of elasticity. It has been apparently most successful when employed subcutaneously. The administration of the drug in this manner, however, presents difficulties, since it is necessary to inject the drug in alcoholic or ethereal solution because of its very slight solubihty in water. The injection is pain- ful. An aqueous-glycerin solution has been found to be less painful, but this combination is unstable. Thiosinamine has been superseded by the discover}^ by Mendel, in 1905, of an analogous preparation, fibrolysin (solution of thiosinamine and sodium salicylate), which is prepared by heating thiosinamine, sahcyhc acid, and con- centrated sodium hydroxide in the presence of free oxygen. The advantage of fibrolysin consists in its read}' solubilit}' in cold water, so that it may be dispensed in sterile solution, the hypodermic administration of which does not cause dis- MOTOR INSUFFICIENCY OF THE SECOND DEGREE 415 tressing symptoms. Merck supplies fibrolysin in brown glass bulbs, sterile and ready for use; each bulb or ampoule contains 2.3 Cc. of a solution of 1| parts fibrolysin to 8§ parts distilled water; 2.3 Cc. of this solution corresponds to 0.2 Gm. thiosinamine. The effect of fibrolysin is similar to that of thiosinamine, namely, the softening and rendering elastic of cicatricial tissue, thereby preventing the contrac- tion which results from cicatrix formation. This peculiar action is attributed to the lymphogenetic power of the substance. In the presence of pathologically formed con- nective tissue it is said to stimulate the formation of lymph, which in turn produces serous infiltration of the cicatrix. Disintegration of connective tissue, as well as immigration of leucocytes into the cicatricial tissue, has been observed, so that we have as a result a loose connective tissue rich in cells. In perhaps the majority of cases, however, the administra- tion of either of these drugs is not of itself sufficient to produce the effects described upon cicatricial tissue. It is necessary to employ massage, electric and hydrothera- peutic treatment as well. The peristaltic movements of the stomach assist the process in a mechanical way. As already mentioned, however, in some cases the adminis- tration of fibrolysin or thiosinamine in cicatricial stenosis of the pylorus is followed by such an amelioration of symp- toms after several weeks or months of treatment that the patients have been discharged as cured. In a few cases it has been possible to ascertain by means of palpation the diminution of the pyloric obstruction by the gradual dis- appearance of the cicatricial tumor. A number of cUni- cians have, however, been unable to report any favorable results whatsoever from this treatment. I would advise that a trial be made of these agents, especially in compara- tively vigorous patients who are able to take and retain nourishment by mouth. In severe cases, however, in which stenosis is well marked and associated with emesis and pronounced emaciation, such treatment will not be suc- cessful; to adopt it would simply be temporizing instead 416 MOTOR INSUFFICIENCY of giving the patient the benefit of early surgical inter- vention. Thiosinamine or fibrolysin should be injected in the intrascapular region; the injection should be made into the muscles; the fluid should not be allowed to lodge in the skin, owing to the tendency to produce necrosis there. Many clinicians claim that the injections should be in the vicinity of the adhesions. In pyloric stenosis, then, the abdominal muscles may be selected. The gluteal muscles are likewise adapted to intramuscular injections. Any untoward effects of thiosinamine and fibrolysin may be obviated by interrupting the treatment as soon as a peculiar odor of onions appears in the breath of the patient. This odor is due to the excretion of ethyl sulphide. Head- ache, hyperemia, vertigo, somnolence, urticaria, shght dis- turbances of sensibility such as paresthesia and anesthesia, and fever, have been noted during the administration of these drugs. Since fibrolysin is apt to produce more or less congestion, some writers consider it contraindicated in the presence of arteriosclerosis. These remedial agents should not be administered when any active inflammatory process is present. The cornea and conjunctiva are said to be particularly sensitive to the effects of the drugs. These untoward manifestations, however, are rarely observed. Should internal medication combined with the treatment outlined fail after a reasonable time, the patient should be referred to the surgeon. Gastroenterostomy^ when per- formed early is often followed b}^ favorable and permanent results. ACUTE DILATATION OF THE STOMACH This condition is noted especially after laparotomies, injuries, chloroform narcosis, torsion of the pylorus or small intestine or of the mesenter}^, dietetic errors, severe infec- tious diseases, such as pneumonia and scarlet fever, and chronic exhausting diseases. A Case of Dilatation of the Stoniacli. Roentgenogram taken immediately after laisniuth subearbonate was given and a coin placed over the umbilicus. The dark area shows the stomach below tlie umljilicus. PLATE XXI A Case of Dilatation of the Stomach. Roentgenogram was taken imnnediately after bismuth subearbonate was given and a coin placed over the XAmbilieias. The stomach had begun to contract toward the pyloric region, and for that reason presented a skiagraph which might easily be mistaken for evidence of hour-glass stomach. ACUTE DILATATION OF THE STOMACH 417 When acute dilatation of the stomach takes place in a previously healthy person the clinical symptoms are, as a rule, most pronounced. These symptoms consist of vomiting, intermittent pains, collapse, feeble pulse, accel- erated respiration, constipation. When the condition does not readily clear up it must always be regarded as very grave. Treatment. — When a diagnosis of acute dilatation has been made, the stomach should be emptied and lavage performed as frequently as indicated. No food should be given by the mouth; the nourishment should consist of nutritive enemata; otherwise treatment should be directed to the reestablishment of normal gastric peristalsis. Rectal enemata consisting of large quantities of physiologic salt solution are indicated. In selected cases strychnine sul- phate and atropine should be employed. Collapse should be treated by means of stimulants and normal salt solution. Surgical intervention remains as a last resort. In acute dilatation of the stomach following general anes- thesia, Payer^ makes a point of having the patient lie on the right side if there is any tendency to vomiting after twelve to twenty-four hours. This generally controls the dilata- tion, but if disturbances persist he gives a chamomile tea enema, with the patient still lying on the side, repeating the enema frequently at need, and giving nothing by the mouth. In very severe cases the knee-chest position was the only means of final relief; this never failed. He never had to resort to lavage of the stomach (see p. 211 j. 1 Postnarkotische Magenlahmung, Mitteilungen aus den Grenzgebieten der Med. und Chir., Januarj^ 28, 1911. 27 CHAPTER XIX GASTRIC ULCER: ULCUS VENTRICULI— ROUND ULCER- PEPTIC ULCER— PERFORATING GASTRIC ULCER Gasteic ulcer is a localized lesion of the mucous membrane of the stomach. It is characterized by a sharp, well-defined outUne, more or less deep destruction of the mucosa, and by no tendency to heal. The lesion gives rise to one or more characteristic sjnnptoms^pain, vomiting, hematemesis. Gastric ulcer was first described by Cruveilhier in 1829. Pathology. — Gastric ulcer is usually round or oval in shape. In some instances several ulcers may become confluent and thus form a larger one with an irregular border. Owing to the tendency of the ulcer, which is at first superficial, to penetrate deeply, the base is frequently the muscular or serous coat of the stomach. In "perforating ulcer" the base is one of the adjacent viscera, bound to the stomach by adhesions. The ulcer is funnel-shaped, with the base as the apex. As a rule, ulcers do not attain a size much larger than a dime, though some of the confluent variet}^ have measured ten centimeters (four inches) in their greatest diameter. An ulcer the size of a pea may exhibit all the characteristic symptoms of this pathologic condition. The typical gastric ulcer has a punched-out appearance. In microscopic section of recent ulcers the margins show the ducts of the gastric glands cut off toward the base of the ulcer. The erosive process may extend to a point where the tissues offer effective resistance to the digestive power of the gastric juice (Einhorn). In chronic ulcers, owing to a reactive inflammation at the periphery, a tumor of connective tissue is formed there, which may be palpated — especially if the ulcer is located near the pylorus. Apart from the inflammation surrounding the edges of the ulcer, the remainder of the gastric nnicosa is likely to be normal. SITUATION 419 In the acute form of the lesion the necrotic process may be so rapid that the thin serous coat is perforated, or a vessel may be eroded so as to occasion severe hemorrhage with a fatal termination. Situation. — The lesser curvature seems to be the favorite seat of ulceration. Welch collected 793 cases from hospital records which showed 288 to be on the lesser curvature, 255 on the posterior wall, 29 at the pylorus, 69 on the anterior wall, 50 at the cardia, 29 at the fundus, 27 on the greater curvature. According to Brinton's statistics, in 43 cases out of 100 the posterior wall was the location of the ulcer, in 27 cases the lesser curvature, in 16 cases the pylorus, in 6 cases both anterior and posterior surfaces, in 4 cases the anterior surface only, and in 2 cases the cardiac pouch. In about 86 per cent, of cases the ulcer is situated on the posterior surface at the lesser curvature and at the pyloric sac — parts of the stomach which together form a segment of less than half the total surface of the viscus. This portion of the stomach is subjected to the greatest irritation from the moving mass of gastric contents which a disturbed muscular mechanism ejects before it is entirely reduced to liquid form (Barker). Another explanation is that these parts of the gastric mucosa may be insufficiently nourished, in consequence of disturbances of circulation, so that they are attacked by the digestive activity of the normal gastric juice, and the so-called peptic ulcer is the result. Such disturbances in circulation may be caused by severe trauma, simple injury to the stomach, or traumatic influences extending over a prolonged period, such as pressure from corsets, the wearing of belts by workingmen, continuous work in a bent position, or the tasting of super- heated dishes by cooks. Insufficient nourishment, induced by circulatory disturbances, is also traceable to embolism or thrombosis of the small arteries supplying the lesser curvature of the stomach; specific endarteritis; venous stagnation, from chronic inflammatory processes of the 420 GASTRIC ULCER mucous membrane; and altered composition of the blood (anemia, chlorosis). Frequency. — Lebert found one case of gastric ulcer in 200 autopsies. Griinfeld places the number at 20 per cent. These are the extremes. Brinton found 5 cases in 100 autopsies; Berthold, one in every 37, or in that proportion. Sex Predisposition and Age. — Gastric and duodenal ulcers occur much more frequently in males than in females (Mayo). They have been observed at an early age, Lees having found perforation of the stomach in children aged eight and nine years. Habershon, in an analysis of 201 cases, noted the earliest age at which gastric ulcer occurred to be ten years (the patient a girl) ; several children (girls) suffered from gastric hemorrhage at fourteen, others at fifteen and sixteen; the oldest patient was a man, aged seventy-one. This writer found the disease in both sexes to be most frequent in the period between twenty and fifty years. In women the period of liability was noted to begin earlier than in men, and to reach its maximum at twenty- five to thirty. In men the earliest case occurred at the age of twenty. The healing of deep ulcers is by cicatrization. The scar is pale and star-shaped, with a puckering of the surrounding mucous membrane. Cicatrization and scarring may event- ually lead to deformity of the stomach, producing the so- called hour-glass contraction. More often, however, there is interference with gastric movement and function by adhesions to neighboring organs. Stenosis of the pylorus, with resultant obstruction and dilatation of the stomach, occurs in the healing of ulcers near the pyloric exit. The involvement of the pneumogastric nerve in the scar occa- sionally gives rise to intense suffering. As stated, per- foration of the stomach wall by a gastric ulcer gives rise to localized peritonitis, as a result of which the stomach becomes agglutinated to a neighboi-ing viscus. Sometimes the perforation extends into the adjoining organ, resulting in the formation of an abscess. Or we may have fistulous connection with the transverse colon; this is the most SYMPTOMS 421 common, though fistulsae have been recorded between the stomach and the pleura, pericardium, lungs, gall-bladder, and duodenum. When the anterior surface of the stomach, which has no anatomic relations with other viscera, becomes the seat of perforation, so that protective adhesions may not be established, a general infective peritonitis super- venes. The perforation or erosion of the larger vessels produces hemorrhage of greater or less severity, depending upon the extent of the injury. Symptoms. — The symptoms of gastric ulcer are at first ill-defined, resembling those of gastritis; there is more or less discomfort after partaking of food. This is soon followed by nausea and regurgitation or vomiting. A boring pain is characteristic of gastric and duodenal ulcer; it comes on always within an hour after eating, and is aggravated by the character of the food, especially if the latter be not well masticated. The pain usually persists as long as the food remains in the stomach. The pain in duodenal ulcer appears at any time from one to three hours after eating; it is relieved by the taking of food. Liquid food is borne much better than solid. Pain in these conditions varies in intensity from the slightest pressure discomfort to paroxysmal agony. The painful seizures are particularly frequent and severe in gastric ulcer complicated with hypersecretion or hyperacidity. The appetite is usually good, but since eating is followed by such dis- tressing symptoms, patients are inclined to eat as little as possible, and consequently become much emaciated as the condition progresses. The location q^ the pain corresponds, as a rule, to the centre of the epigastrium or to the median line of the abdo- men immediately below the ensiform appendix. The por- tion of the epigastric region to which the pain is referred forms a circular area of less than two inches in diameter (Einhorn) , Cruveilhier first described the dorsal pain, which appears a few weeks or months later than the epigastric pain. This pain, which is of a gnawing character, is to the left of the 422 GASTRIC ULCER spine and at about the eighth or ninth dorsal vertebra. It may extend occasionally to the first or second lumbar verte- bra. Boas has drawn attention to a dorsal point of pressure at the level of the tenth to the twelfth dorsal vertebra, with a lateral extension of two to three centimeters and a height of one to four centimeters. This pressure point is usually left of the median fine. The epigastric pain is increased on pressure. Regarding the inadvisability of exerting much pressure in testing the sensibility at this spot, Brinton says: ''It is not altogether superfluous to add another caution with respect to the pressure test; not only must it be applied with great care and delicacy in the first examination of a supposed case of gastric ulcer, but, as a rule, we can scarcely be too reluctant to repeat it, even to verify a presumed amendment. At any rate, its effects are sometimes so injurious that it is necessary strictly to prohibit the patient from all manipu- lations of the epigastric region, as well as from all pressure produced by dress or work, as with shoemakers." Singer^ calls particular attention to an early sign of gastric ulcer which he has found practically constant; this is a sensation of discomfort or pain radiating from the epigas- trium toward the costal arches and thence along the inter- costal nerve routes to the spine. The regularity of the appearance of this pain or sense of discomfort, especially in connection with eating, is characteristic, and almost pathognomonic of gastric ulcer, even when there is scarcely any dyspeptic disturbance. Vomiting. — Vomiting usually occurs an hour or two after meals, or when the pain is at its height;/ and the pain is, as a rule, reheved by the emesis. The vomitus consists of either gastric juice or watery fluid containing partially digested food remnants. Instead of vomiting, the patients may have attacks of nausea. Hemorrhage. — Hemorrhage, if slight, may pass unno- ticed; but if there is any considerable quantity of blood • Behandlung des runden Magengeschwiirs, Medizinische Klinik, December 18, 1910. SYMPTOMS 423 in the vomitus it will impart to the latter a red or coffee- brown appearance. When it is not possible to detect the presence of blood from the macroscopic appearance of the vomitus or dejecta, it is well, in suspicious cases, to resort to Weber's test. This test is as follows: A small portion of the suspected material is mixed with water, and this is diluted with a few cubic centimeters of glacial acetic acid and thoroughl}^ shaken with ether. The ethereal extract has a Tokay- wine color if blood is present. If the color is not distinct, add to the ethereal extract equal parts of freshly prepared tincture of gaaiacum and ozonized oil of turpentine, which mil produce a blue color in the presence of hemoglobin. Boas and Hartman advocate the examina- tion of both gastric contents and feces by means of this test to detect concealed hemorrhages. The benzidin test and, more recently, the phenolphthalein test have been devised, which give more characteristic reactions (see pages 54 to 57). When gastric hemorrhage is profuse, the patient will experience a feeling of giddiness, weakness, syncope, and extreme thirst. Among the objective symptoms is pallor, the degree of which will depend upon the amount of blood lost. If the effusion of blood in the stomach be considerable, hematemesis or melena miay occur. Hematemesis as a symptom is not necessary to the diag- nosis of gastric ulcer, though it aids in confirming the diagnosis. It occurs in about half the cases (Habershon). Perforation. — Perforation is one of the most frequent causes of death from gastric ulcer. The extravasation of gastric contents into the peritoneal cavity is attended by sudden and severe abdominal pain similar to that brought on by exertion or by some dietetic error. Syncope and collapse, weak running pulse, and peritonitis with a fatal termination, is the usual result of perforation of a full stomach. (If the stomach be empty, the symptoms of perforation are comparatively unimportant.) In the event of extravasation of gastric contents into the peritoneal cavity, life is saved only by prompt resort to operative 424 GASTRIC ULCER interference. In operations within ten hours after per- foration the mortality is 28 per cent.; if the operation be delayed for more than twenty-four hours, the mortality rises to 65 per cent.; after thirty-six hours, to 87 per cent. Later, it is practically hopeless. In perforations in which diffuse infection does not take place, owing to the fact that there was no food in the stomach, adhesions are formed with neighboring viscera. This subject is discussed under the heading Perigastritis, Chapter XXI. According to Brinton, perforation occurs in about one- eighth of all cases of gastric ulcer; in female patients, he says, about half of the cases occur between the ages of four- teen and thirty, and one-third in the six years between fourteen and twenty, while in the male the distribution is constant up to the age of fifty. The average age of those subject to perforation is, in the male forty-two, in the female twenty-seven. The anterior wall of the stomach, though rarely affected by ulcer, is one of the most frequent sites of perforation; in all sites of gastric ulcer except this the odds are about sixty to one against perforation, whereas in the anterior portion of the stomach they are six to one in its favor. This region is more exposed to external pressure and motion and less protected by adhesions than any other. Appetite. — The appetite is apparently not affected by the presence of gastric ulcer, though patients are apt to eat but sparingly through fear of the pain which the act induces. Patients complain of constant hunger, owing to this inability to satisfy the appetite. Complications and Sequelae. — Manges, from the viewpoint of origin, classifies the complications and sequelae of gastric ulcer as (1) intragastric; (2) extragastric. Among the inti-a- gastricare: (a) Hemorrhage; (6) profound anemia; (c) inter- ference with motihty of the stomach (if the lesion extends deep into the muscularis) ; (d) stenoses of the cardia, pylorus, body of the stomach (hour-glass contraction); {e) gastro- succorrhea, with its various complications, such as tetany; DIAGNOSIS 425 (/) carcinoma. The extragastric complications include (a) perforation, free and with adhesions, possibly suppuration, also subphrenic and other abscesses, fistulse of various kinds; (6) general emphysema; (c) perigastritis, with localized thickening of the serosa, adhesions to various organs, dis- placement or distortion of the stomach. These sequelae are dealt with in this and other appropriate chapters of this work. Diagnosis. — A probable diagnosis of gastric ulcer may be made from the fact of profuse hematemesis, if carcinoma of the stomach and hepatic cirrhosis can be excluded. Pain appearing shortly after eating and lasting for two or three hours is of diagnostic import, especially if there is a circum- scribed spot in the epigastric region that is painful to pres- sure, or a similar sensitive area to the left of the eighth or ninth dorsal vertebra. Vomiting occurring shortly after meals, in patients who have recently become pale and anemic, will justify a probable diagnosis of gastric ulcer. Should the vomiting culminate in hematemesis or melena, and cause a cessation of pain, the physician may reasonably conclude that the lesion is gastric ulcer. The following conditions may simulate gastric ulcer: 1. Superficial erosion of the stomach. The presence of flakes and shreds of mucous membrane in the gastric con- tents obtained by lavage will rule out the possible presence of gastric ulcer (see p. 477). 2. Acute gastritis. The patient's history will often reveal a cause for acute gastritis in the form of unsuitable or irritating food. The hydrochloric acid is either normal or decreased in this condition; in gastric ulcer the acidity is likely to be above normal. 3. Hysterical or nervous vomiting, with severe gastric symptoms. This class of cases frequently presents difficulty in the matter of diagnosis. Habershon reminds us that when a patient is desperately ill, and the vomiting is so incessant as to render the outlook most grave, the prostration is usually so great as to prevent the bestowal of much care or attention upon the personal appearance. If the patient 426 GASTRIC ULCER has prepared for the medical visit by scrupulous attention to the hair and the general toilet, some abatement must be made from the history of the violent symptoms. 4. Gastric cancer maj^ simulate ulcer. The differentia- tion may be assisted by considering the age of the patient; cancer, as a rule, is a disease of middle and later life, while ulcer usually occurs earlier. If attacks of pain and vomit- ing have recurred from time to time for several years in a patient under middle age, the diagnosis of malignancy is very improbable. The occurrence of so-called bilious attacks, always with- out hematemesis, precludes the possibility of ulcer in a complex of symptoms which might otherwise justify a diagnosis of either hepatic colic or gastric ulcer. For determining the location of gastric ulcer, the ''thread test" devised by Einhorn has been found valuable. The stomach being empty, the patient swallows, preferably at night, the Einhorn duodenal bucket (Fig. 5) attached to a braided silk thread that is knotted at a point 75 centimeters from the bucket; in swallowing, this knot does not enter the mouth, but is held back by the incisor teeth. A loop at the upper end of the thread is placed over the ear to prevent the upjDer part of the thread from passing into the stomach. The bucket is withdrawn on the following morning and the thread examined for a red or brown stain. The lower end of it is found to be yellow or greenish-yellow, and the bucket contains bile mixed with mucus, provided it has passed the pylorus — which it invariably does in from two to eight hours if there is no obstruction such as a contracted p\'lorus and no extreme gastric relaxation due to atony. Should the bucket fail to pass into the duodenum, a smaller one is used the succeeding night, and in this manner an approxi- mate idea of the calibre of the pylorus may be gained. By measuring the distance from the knot in the thread to the red or brown stain (should there be one), we are able to definitely localize the ulcer. If the stain is 39 to 42 centi- meters from the incisor teeth, the ulcer is located at the cardia; if 45 to 50 centimeters, at the lesser curvature; if PROGNOSIS 427 53 to 56 centimeters, at the pylorus; and if over 60 cen- timeters, in the duodenum. From an experience of 100 cases in which one to four tests with the duodenal bucket were made, jXIorgan^ maintains that if this test be made several times on one individual, and each time a red or brown stain is found about the same distance from the teeth, a localized lesion of the gastric mucosa exists, which is probabl}^ ulcer. Prognosis. — With a better understanding of the etiology and pathology of gastric ulcer, as well as improved methods of treatment, the prognosis for complete recovery is much more favorable than formerly. The reason there are not more successes in the treatment of this pathologic condi- tion is that patients frequently present such indefinite symptoms that the nature of the disease is obscured and improper treatment instituted. The further fact that physi- cians too often fail to insist upon the discipUne necessar}^ for the accomplishment of the best results, but content themselves with prescribing a few dietary rules and some harmless drug, has resulted in a chronicity that at times resists rational therapj^ The physician should insist very strongly on the rest cure. The older the ulcer the more unfavorable the prognosis. Peptic ulcer having its base on the serous membrane or on some organ in close proximity to the stomach will resist all medical treatment; surgery is the only recourse in such cases. The location of the ulcer is a matter of importance : in ulcers of the pylorus, owing to the fact that they tend to produce cicatricial stenoses, sometimes the only hope for recovery lies in operative treat- ment. "WTien the ulcers are deep, we are apt to have such complications as hemorrhage from perforation, adhesions to the spleen if the ulcer happens to be located in the fundus, and perigastritis. With hypersecretion as an accompani- ment the prognosis for complete recovery from gastric ulcer is less favorable than in a case of simple hyperacidity. ^ William Gerry Morgan, The Diagnosis and the Feeding in Gastric Ulcer, Medical Record, March 4, 1911, p. 381. 428 GASTRIC ULCER TREATMENT Prophylaxis. — A properly selected diet will do much to prevent the occurrence of ulcer of the stomach. An absolute milk diet should be prescribed as soon as the first symptoms of the disease become manifest. Care should be exercised to avoid extremes of temperature in food. An effort should be made to overcome the hyperchlorhydria which is an important etiologic factor in gastric ulcer. The anemia which is a frequent accompaniment of the disease should likewise be treated. Leube-Ziemssen Treatment. — A therapeutic procedure suit- able to slight or moderately severe cases of gastric ulcer uncomphcated by hemorrhage is the Leube-Ziemssen treat- ment. After the diagnosis has been confirmed, the patient is given, for the first fourteen days, complete rest in bed. Every morning, an hour before partaking of food, he is given one-quarter liter (2 pint) of Carlsbad Muhlbrunnen (at 90° F.) in which is dissolved 5 to 10 Gm. (75 to 150 grains) of natural or artificial Carlsbad salts. It is also advisable to dis- solve 10 grammes of Carlsbad salt in a quarter of a Hter of pure water at a temperature of 90°F., to be sipped at intervals. Hot fomentations should be apphed over the epigastrium during the day. For this purpose mashed potato poultices or linseed poultices are good; or a felt sponge cut to proper size and dipped in hot water, as suggested by Boas, may be employed. In using thermophores, which furnish a con- tinuous even temperature, care should be exercised to avoid pressure on the stomach. A piece of clean flannel cloth should be interposed between the skin and the poultices. During the night a moist Priessnitz bandage may be em- ployed with advantage. The diet for the first ten to fourteen days should consist chiefly of milk, neither hot nor cold. During the first two or three days of the fourteen, a quarter of a liter (2 pint) of milk should be given per day in tablespoonful doses at regular intervals. This quantity is then gradually increased LEUBE-ZIEMSSEN TREATMENT 429 to one-half liter, and at the end of the first week's treatment to one liter. The calorific value of this small quantity of milk may he enhanced by the addition of cream ; the increase in calorific value can be estimated from the following calcu- lation by Strauss: Calories. A 100 Gm. full milk 70 B 75 Gm. full milk + 25 Gm. cream 115 C 50 Gm. full milk + 50 Gm. cream 185 D 25 Gm. full milk + 75 Gm. cream 205 E 100 Gm. cream 250 Therefore there are present in one-half liter (1 pint) of each of these — milk, milk and cream, and cream — the following: Calories. A 350 B 575 C 925 D 1025 E 1250 Yolk of egg may be added to the milk. When milk is ill-borne or patients exhibit a dislike for it, it may be made more palatable b}'^ the addition of tea, cocoa, vanilla, or milk rice and milk jellies. Beaten cream or cream jellies may be given. Milk soups with rice, oatmeal, or the infant flours (half a tablespoonful of flour to half a pint of milk) will be found agreeable to most patients. Sugar may be added to suit the taste. When aversion to milk is very pronounced, Strauss does not insist on its use. In such cases the most suitable sub- stitute for the first days of treatment is yolk of egg beaten up with sugar so that the patient takes two to four eggs per day; or flour soups with the addition of butter may be employed. When the quantity of food taken is too small, on account of severe pain, it is advisable to add to the soups such concentrated foods as sanatogen, plasmon, or fluid somatose. Jellies made from chicken, meat, or raspberries may be employed with advantage. Patients who are fond of sweets 430 GASTRIC ULCER should be given syrupy fruit juices, such as are made from apples or raspberries; or malt extract may be added to the milk or cocoa. Leube recommends for the first week's treatment bouillon in the form of Leube-Rosenthal's meat solution. I do not, however, consider it ad\asable, especially in the first period of treatment, to subject the gastric mucosa to the irritation which attends the ingestion of meat extractives. ]Meat extracts, if used at all, should be prescribed for weak patients only, as analeptic agents, and should be given without condiments. This strict diet, as outhned, should be continued for at least ten days. If the pains subside rapidly the diet may be increased. WTien, however, the pain persists, it is necessary to prolong the period of physiologic rest to fourteen days. As might be expected, patients on such a regimen decrease in weight. The loss of weight, howeA'er, may be accepted calmly, since the meagre diet has contributed to the comfort of the patient and shielded the gastric mucosa from undue irritation. Near the end of the second week, if the patient's condi- tion permit, bouillon or soups enriched with yolk of egg, breast of chicken, or squab, enter into the dietary. The flour soups mentioned may be continued. WTien the pains have wholly disappeared a careful trial may be made of a few teaspoonfuls of very finely chopped breast of chicken or squab. If this be easily borne, fight egg dishes are added to the dietary. Then, tentatively, a few dessertspoonfuls of mashed potatoes, softened biscuits (crackers), or zwieback may be administered. Owing to the preponderance of Hquid nourishment, patients do not experience much thirst during the first and second periods of the treatment; thirst may be allayed bj^ small pieces of ice dissolved in the mouth. The white of an egg mixed with 200 Cc. (5vij) of water to which a teaspoonful of sugar is added is recommended as a beverage. Small quantities of carbonated waters containing a low percentage of carbon dioxide may be permitted. The diet during the second period should be maintained LEUBE-ZIEMSSEN TREATMENT 431 until the end of the third week, during which time the patient should be kept at rest in bed. Carlsbad water is continued, likewise the hot applications over the epigastrium. At the end of three weeks the patient may be placed upon a more extended diet. Strauss permits such article of foods as light cheese, boiled chicken, squab, small steak, brain and sweetbreads, minced veal cutlets, and boiled calf's-feet. Ham and uncooked meat should be avoided. At this period of the treatment, fish, such as pike or trout, well cooked and served with butter balls and butter sauce, may be intro- duced; also mashed potatoes, as well as other kinds of vege- tables in the form of purees. The quantity of biscuits and zwieback may be increased, care being exercised that such articles are completely broken up and taken in a soft, moist condition. The milk diet is meanwhile continued. This dietetic treatment is employed up to the fourth week. The hot fomentations need not be resorted to so frequently during the fourth week. During the latter part of this period the patient is allowed to get up and thfe hot applications are discontinued. The diet is arranged on an increasingly liberal basis. Such foods as biscuits, zwieback and white bread toast should be carefully masticated. The regular diet to which the patient has been accustomed should not be resumed under two months from the initial treatment. Summary of Leuhe Treatment. — There are four cardinal points to be observed: 1. Rest in bed from one to two weeks. This relieves the pain and promotes healing. After the tenth day the patients he down two hours after dinner. 2. Carlsbad water, a quarter-liter (half pint), lukewarm. 3. Application of a hot poultice or thermophore to the epigastrium. The poultice must be changed every fifteen minutes and kept very hot. Leube never uses poultices in the case of bleeding ulcers, as they are apt to cause a recur- rence of the hemorrhage. During hemorrhage ice bags are used instead. 4. Light diet of high nutritive value and ready digesti- bility. 432 GASTRIC ULCER All four of these factors must be carried out. B3' this routine Leube claims he has reduced his mortality from 13 per cent, to 2.5 per cent., and finally to barely 0.5 per cent. In severe hemorrhagic cases he puts the patients to bed, gives one dose of 30 minims of a 1-to-lOOO solution of suprarenal extract, places an ice bag on the abdomen, and quiets the stomach mth bismuth and a hypodermic injec- tion of morphine. He does not beheve in giving eggs and milk to bind the acid; he says it causes the secretion of more acid and induces peristalsis. He reports the following results: In 547 non-hemorrhagic cases, 90 per cent, cured, most of these in four to five weeks; no deaths. In hemorrhagic cases, 90 per cent, cured; 2.5 per cent, fatal. For the first few days after a hemorrhage he gives no food whatever by mouth. EiXHORx's Modification of Leube-Ziemssex Diet — ^Outlixe of Diet IX Gastric Ulcer First Three Days No. of calories. 7 A.M. Milk, 150 Cc. (5 ounces) 101 8 A.M. Milk, 150 Cc 101 9 A.M. Milk, 150 Cc 101 10 A.M. Milk with strained barley water, 1.50 Cc. ... 80 11 A.M. Milk. 1.50 Cc 101 12 M. Milk, 150 Cc 101 1 P.M. Bouillon, either alone or with the addition of one or two teaspoonfuls of a peptone preparation, 150 Cc. 30 2 P.M. Milk, 150 Cc 101 .3 P.M. Milk, 1.50 Cc 101 4 P.M. Milk, 150 Cc 101 5 P.M. Milk with strained barley or oatmeal, 150 Cc. SO 6, 7, SandOp.M Milk, 1.50 Cc 404 1402 1 A..M 9 A.M 11 A.M. 1 P.M. 3 P.M. 5 P.M. 7 P.M. 9 P.M. V A.M. 9 A.M, 11 A.M. 1 P.M. 3 P.M. 5 P.M. 7 P.M. 9 P.M. LEUBE-ZIEMSSEN TREATMENT 433 Fourth to Tenth Day No. of calories. .Milk, 300 Cc 202 Milk, 300 Cc 202 Milk with barley, rice, or oatmeal water, 300 Cc. . IGO One cup of bouillon, 200 Cc, and one egg beaten up in it 80 Milk, 300 Cc 202 Milk, 300 Cc 202 Milk with barley water, 300 Cc 160 Milk, 300 Cc 202 1410 Eleventh to Fourteenth Day No. of calories. Milk, 300 Cc 202 Milk, 300 Cc, and two softened crackers (1 ounce) 302 Milk with barley water, 300 Cc 160 One cup of bouillon, 200 Cc, one egg and two crackers 180 Milk, 300 Cc, and one egg 282 Milk, 300 Cc, and two crackers 302 Milk with barley water, 300 Cc 160 Milk, 300 Cc 202 1790 Fourteenth to Seventeenth Day No. of calories. Milk, 300 Cc 202 Milk, 300 Cc, and two crackers 302 Milk with barley, 300 Cc 342 Scraped meat, 50 Gm., two crackers, one cup of bouillon (200 Cc.) 160 Milk, 300 Cc 202 Milk, 300 Cc, one egg (soft-boiled), two crackers 382 Milk with farina, 300 Cc 342 Milk, 300 Cc 202 2134 Seventeenth to Twenty- fourth Day No. of calories. 7 A.M. Two eggs (soft-boiled); butter, 10 Gm.; toasted bread, 50 Gm.; milk, 300 Cc 573 10 A.M. Milk, 300 Cc; crackers, 50 Gm.; butter, 20 Gm. . 530 1 P.M. Lamb chops (broiled), 50 Gm.; mashed potatoes, 50 Gm.; toasted bread, 50 Gm 234 4 P.M. The same as at 10 a.m 530 6.30 p.m. Milk wdth farina, 300 Cc; crackers, 50 Gm.; butter, 20 Gm 670 9 P.M. Milk, 300 Cc; butter, 10 Gm.; one cup bouillon, 200 Cc 283 7 a.m. 9 A.M. 1 A.M. 1 P.M. 3 P.M. 5 P.M. 7 P.M. 9 P.M. 28 2820 434 GASTRIC ULCER Persons subject to ulcer should lead abstemious lives in regard to diet and beverages, and those who have been cured should not undertake heavy work or violent exercise within a year from the cessation of the sj'mptoms. Riegel advises confining the patient to bed, with rectal alimentation, for several daj's before beginning the Leube treatment . The reasonableness of this procedure is apparent, since absolute rest brings about a cessation of pain and vomiting and facilitates the healing of the ulcer. In cases in which the Leube method of treatment may be unsatisfactorv', Boas recommends for the first eight or ten daj^s an ''abstinence cure," which consists in keeping the patient in bed and feeding him by rectum three or four times a day. Small pieces of ice or small quantities of acidu- lous mineral waters are allowed to allay thirst. Suitable enemata ma}' be made of milk, five ounces, with one beaten- up egg and one teaspoonful of Fairchild's peptonizing powder. This should be alternated with six ounces of con- centrated beef tea or of meat essence. Liquor pancreaticus, N. F., may be added to the enema (see p. 178). In a large patient the size of the enema should be increased to eight ounces. AMien the patient's strength flags, two teaspoonfuls of whisky should be added to the enema ('increased if neces- sary to a tablespoonful). In every case the bowel must be washed out once daily wdth an injection of about one-half pint of warm soapy water; or an enema of four ounces of olive oil may be given if the patient is constipated. By regulating the diet it is possible to protect the ulcer from mechanical injury and to arrest further progress of the ulcerative process. Lenhaxtz Treatment. — Among the more recent methods of treatment of gastric ulcer, especially when complicated with hemorrhage, is that devised by Lenhartz. The prin- ciple underlying this treatment involves the maintenance of enforced nutrition from the beginning, that is, from the time of the hemorrhage. Lenhartz administers the minimum quantity of food with maximum calorific value. He argues that in the Leube treatment the nutrition of the patient is LEX II ART Z TREATMENT 435 SO far below his needs that the anemic condition is bound to become more pronounced and the chances for the ulcer to heal are greatly lessened, Lenhartz by his protein regimen aims to counteract the hyperacidity so frequently present in gastric ulcer. Strong emphasis is placed upon the im- portance of physical rather than physiological rest of the stomach. The Lenhartz method of treatment is as follows: Absolute rest in bed for at least four weeks. All mental excitement must be avoided. An ice bag is placed over the region of the stomach and kept there almost continually for two weeks; this prevents gaseous distention and promotes contraction of the walls; it also obviates hemorrhage, and eases the pain when pain is present. On the first day, even when •hematemesis has occurred, the patient receives between 200 and 300 Cc. (§vij-x) of iced milk, in teaspoonful doses, and from two to four beaten raw eggs — within the first twenty- four hours. At the same time bismuth subnitrate is given twice or three times a day, 2 Gm. ^30 grains) at a dose, and continued for ten days. The eggs are beaten up entire (with a little sugar), and the cup containing them is placed in a dish filled with ice, so that they remain cold. This food at once "binds" the supersecreted acid and therefore rapidly mitigates the pain; and the vomiting, which is often quite troublesome, ceases. The portion of milk is increased each day by 100 Cc. (5iij); and one additional egg is given, so that at the end of the first week the patient is receiving 800 Cc. (1^ pints) of milk and from six to eight eggs. Both these foods are continued in the same amount per diem for another week. No more than a Hter (quart) of milk a daj^ is allowed at any time. Besides milk and eggs, some raw chopped meat is given between the fourth and the eighth day, usually on the sixth — 35 Gm. (3ix) in small divided doses (stirred up with the eggs or given alone); the day after, 70 Gm. (5xviij); and later possibly more if the pre- vious portions have been well digested. The patient is now able to take some rice, well cooked, and a few zwiebacks 436 GASTRIC ULCER (softened). During the third week a mixed diet is tolerated, the meat being given well cooked or lightly broiled. Among the advantages of the Lenhartz method of treat- ing gastric ulcer are : The avoidance of an abstinence period, so distressing to many patients; the prevention of loss of weight; and the rapidity with which the hemoglobin attains the normal after hemorrhage of greater or less severity. On the eighth day after a hemorrhage Lenhartz sometimes prescribes, in addition to bismuth, Blaud's iron pills in finely powdered form. Diet in Ulcer op the Stomach (Lenhartz) Days after hemorrhage Eggs Milk (Cc.) .... Sugar to the egg (Gm.) Raw beef (Gm.) Milk rice (ground rice) (Gm.) Zw-iebaok (Gm.) Raw ham (Gm.) . Butter (Gm.) . . . Calories .... 1 2 3 4 5 6 7 8 j 9 10 11 12 13 2 3 4 5 6 7 8 8 8 8 8 8 8 200 300 400 500 600 700 800 900 1000 1000 1000 1000 1000 20 20 30 30 40 40 50 50 50 50 50 35 2x35 2x35 2x35 2x35 2x35 2x35 2x35 100 100 200 20 40 200 40 50 300 60 50 300 60 50 300 SO 50 20 j 40 40 40 280 420 637 777 955 1135 1588 1721 2138 2478 2941 2941 3007 14 1000 50 2x35 400 100 50 40 Eisner has modified the Lenhartz treatment by adminis- tering on the first day of the hemorrhage a decoction of hygiama (see p. 114) prepared with milk and a small quan- tity of sugar and kept on ice. This constitutes the diet for the first five days. Beginning with the sixth day, butter, cream, softened zwiebacks, and eggs are added. To render the acidity neutral, Eisner administers soda bicarbonate in teaspoonful doses three times a day. Duration of treatment, four to six weeks. Senator administers as nourishment gluten and gelatin to neutralize the hyperacidity and to promote hemostasis: I^ — Decoctinis gelatiiii. Oleosacchara; limoni.s . Misce. Sin. — To he waniicfl before u.se. ad Gm. or Cc 50.0 to 4o().0 5iss-xv 500.0 Oj EINHORN'S 1)1 -ODKSAL ALI MENTATIOX 437 In the presence of marked hemorrhage 5 Cc. of a 1 to 1000 adrenahn sohition may be added to this mixture. In severe cases tablespoonful doses are to be administered at quarter- to half-hour intervals; in Ughter cases, the same quantity at three-hour intervals. Liquid diet, consisting of milk, milk of almonds, cream, thin gruel soups, butter (30 Gm. in twenty-four hours), fresh eggs cooled on ice, and small lumps of ice, is administered from the commence- ment of the treatment. Cream may be supplied as whipped cream, ice cold, with or without sugar. Senator prescribes this diet, in amount 1000 calories, immediately after the hemorrhage. The number of calories may be rapidly raised by the addition of milk and eggs. Constipation is met by enemata of warm water to which soap, glycerin, olive oil, or chamomile tea may be added. Fig. 41 M 1 '''"'■"■■ ^ f u [ O" Einhorn duodenal pump: A, metal capsule, the lower half provided with numerous holes, the upper half communicating with tube B; I, II, III, marks of 40, 56, and 70 centimeters from capsule; C, rubber band with silk thread attached to end of tubing, which can be placed over the ear of the patient; F, feeding syringe; E, collapsible connecting tube; D, three-way stopcock. Einhorn's Duodenal Alimentation. — Einhorn^ has devised an instrument, his so-called duodenal pump, by which food can be introduced directly into the duodenum (Fig. 41). It consists of a small metal capsule (14 mm. long and 23 mm. in circumference), perforated, attached to but 1 Presented to the American Gastroenterological Association at its Annual Meeting held at St. Louis, Mo., June 6 and 7, 1910. 438 GASTRIC ULCER detachable from a long, thin rubber tube (8 mm. in circum- ference and 1 meter long), which is marked at 40, 56, 70, and 80 centimeters from the capsule, and at the other end of which a syringe can be attached (Fig. 41, F). Einhorn,^ describing the use of his duodenal pump, says that feeding is begun just as soon as there is no longer any doubt that the end of the tube has passed beyond the Fig. 42 Duodenal feeding. (Einhorn.) pylorus. The food should be introduced very slowly, always at body temperature, and at two-hour intervals. After each feeding, water should be forced through the tube, and afterward a little air, to expel the contents of the pump into the duodenum, after which the stopcock attachment of the tube is closed. The apparatus, which is simple in con- struction, may remain in the digestive tract for eight to twelve days without causing undue irritation or discomfort to the patient. Einhorn's diet in duodenal alimentation consists of 240 Co. 1 Medical Hcfonl, January If), 1010. EIXHORX'S DUODENAL ALIMENTATION 439 (5viij) of milk, one raw egg, and 15 Gm. (gss) of sugar of niilk, well beaten. This amount is administered at a single feeding. When it is desired to introduce a greater quantity of water into the system than that taken during the feeding ]:)rocess, a quart of physiologic salt solution may be given by proctoclj^sis. The patient may be fed while in the sitting posture, as illustrated in Fig. 42. Since the duodenal contents may be aspirated at any time, it can be easily ascertained whether or not the pump has entered the duodenum. Method of Procedure. — The capsule of the duodenal pump and the lower part of "the rubber tube are moistened with warm water and put into the pharynx of the patient. Then the patient drinks a little water, and the instrument soon passes into the stomach. To be certain that the capsule does not stick in the esophagus, it is well to have the patient shake his abdomen, when a syringeful of chyme can be aspirated if the capsule is in the stomach. Now we pass a syringeful of water and then one of air through the instru- ment. The rubber tube is then clamped off and left alone for about one hour. The patient is told not to close his mouth too tightly, so that the tube may not be retarded in its wanderings. He must also avoid intentional swal- lowing. Through the peristalsis of the stomach the capsule is pushed on farther, and usually passes through the pylorus into the duodenum and later into the upper part of the small intestine. It is advisable to have the patient read some light literature in order to divert his attention. After one hour we examine how far the capsule has progressed; if the mark III (indicating 70 centimeters from the capsule) is near the lips or inside the mouth, we try to aspirate. If the capsule is in the duodenum, we generally obtain a clear, golden yellow or watery liquid, of alkaline reaction and somewhat viscid consistency. If, however, it is in the stomach, we obtain an acid liquid resembling the one first removed. This can, of course, occur if the tube Ues coiled up in the stomach. Should the aspirated material 440 GASTRIC ULCER be acid, we must partly withdraw the tube, after putting water and air through it, up to the mark II (56 centimeters). The tube is then again clamped off, and after one-half to one hour the procedure is repeated. The capsule in nearly all cases enters the duodenum on the first trial. After having fed the patient for ten to fourteen days, the tube is clamped and slowly \\dthdrawn. TMien the esophagus is reached the patient is told to swallow, and during this act the capsule is withdrawn. Einhorn^ reports several cases which have been successfully fed by means of the duodenal pump. William Gerry Morgan" has suggested a modification of Einhorn's method of duodenal feeding by substituting the iMurphy drop method. He attaches to the upper part of the duodenal tube, by means of an additional section of rubber tubing, a porcelain-Uned irrigator of 500 Cc. capacity. The irrigator is placed at such a height that it requires about an hour for 300 Cc. of fluid to run through into the gut. He begins by gi^dng 90 Cc. of the milk, egg, and lactose solution every two hours, and gradually increases it so that by the end of the first day the patient is able to take the 300 Cc. wdth perfect comfort. His patients have experienced no inconvenience from the continuous presence of the duodenal tube in situ, and the feedings have frequently taken place while they were sleeping and entirely without their knowledge. In addition to the feeding, ?^Iorgan gives 500 Cc. of normal salt solution per rectum, by the drop method, thus adding to the bod}" fluids and keeping the feces soluble and the bowel actions regular. Medicinal Treatment. — By the administration of drugs in the treatment of gastric ulcer, an endeavor is made to stimulate cicatrization, to cover and protect the ulcer from chemical irritation, and to neutralize the gastric acidity whether due to the normal acid or to any of the abnormal acids of fermentation. Sir Lauder Brunton maintains that in a large percentage 1 Medical Record, July 10, 1910. ^ Lqc cjt^ MEDICINAL TREATMENT 441 of cases of gastric ulcer pain can be stopped by the admin- istration of sodium bicarbonate in large dosage. ' The best way of giving the medicine is to dissolve a teaspoonful in lime water, add a little spirit of peppermint, and have the patient sip the solution teaspoonful by teaspoonful until the pain has disappeared. The reason for using lime water is that the bicarbonate of soda in plain water might possibly soften the tissues too much, and thus render a patient who has suffered from gastric hemorrhage more liable to a recurrence. To lessen the constipating effect of the lime, fluid magnesia may be given along with the bicarbonate preparation. An alternative formula to the above is: Gm. or Cc. I^ — Spiritus menthae piperitae 6.0 3iss Magnesii oxidi 2.0 3ss Sodii bicarbonatis 4.0 3j Cretse prseparatse 2.0 5ss Misce. Sig. — A teaspoonful stirred in half a tumbler of water, slowly sipped, a teaspoonful at a time, until the pain is relieved. Sodium bicarbonate holds a very important place in the treatment of gastric ulcer. The quantity required to over- come the hyperacidity and diminish the pain is large, usually 10 to 15 Gm. (5iiss-iv) a day. Debove recom- mends as much as 20 to 30 Gm. (5v to §j) a day. The dosage must vary according to the patient, and must be increased until the pain ceases. Lemoine and Debove sug- gest the addition of prepared chalk to the sodium bicar- bonate — 0.5 Gm. (7| grains) chalk to 0.6 Gm. (10 grains) sodium bicarbonate every hour, to counteract the tendency to diarrhea likely to result from the administration of large quantities of sodium bicarbonate alone. Later these powders may be replaced by others composed of: Gm. or Cc. I^ — Sodii bicarbonatis 0.60 gr. x Cretse prajparatae, Magnesii oxidi aa 0.1.5 gr- ij Misce et ft. pulv. no. i. Sig. — One powder every hour until relieved. 442 GASTRIC ULCER The proportions of chalk and magnesia will vary in accordance with the tendency to diarrhea or constipation on the part of the patient. Sodium bicarbonate by itself has the objectionable feature of easilj^ forming sodium- lactate, sodium chloride, and other purgative salts. This inconvenience can be overcome with the aid of chalk or opium. The formation of sodium chloride is a grave fault, as this salt is a constant source of hydrochloric acid in the presence of gastric juice. To overcome this objection, sodium bicarbonate should always be combined with other alkahes or inert powders which may, in part at least, prevent the formation of sodium chloride. The following combi- nations are in use; each is for one powder, which may be repeated four or five times a day : Gm. or Cc. Bf, — Sodii bicarbonatis 1.0 gr. xv Calcii carbonatis 0.2 gr. iij Bismuthi subnitratis 0.3 gr. v Misce. Gm. or Cc. I^ — Sodii bicarbonatis 0.6 gr. x Calcii carbonatis . . ... 0.2 gr. iij Pulveris talci 0.3 gr. v Bismuthi salic3^1atis 0.4 gr. vj Misce. Gm. or Cc. I^ — Sodii bicarbonatis . 50 gr. viij Cretse prseparatse 0.25 gr. iv Bi.smuthi subnitratis . 25 gr. iv Pulveris opii 0.01 gr. ^'V Misce. Gm. or Cc. I^ — Sodii bicarbonatis 0.60 gr. x Magnesii oxidi 0.20 gr. iij Pulveris talci 0.20 gr. iij Pulveris belladonnte radicis ... . 02 gr. y j Misce. The last two formulae are especially intended for ulcer with hypersecretion, and for cases with pain. To favor cicatrization, Lemoine recommends: Gm. or Cc. I^ — Bismuthi subnitratis lo.O .~iv Tragacantha; 60.0 aij Misce. Sig. — To be taken in tablespoonful doses in the space of two hours. MEDICINAL TREATMENT 443 This is to be continued for two days only, when the doses of bismuth are to be reduced from 15 to 5 grannnes for the next five or six days, at the end of which time the bismuth should be stopped and the ordinary alkaline treatment followed. In order to prevent constipation while taking the bismuth, 0.25 to 4 Gm. (4 to 60 grains) of magnesia may be taken daily, at the same time that the bismuth is admin- istered.^ Einhorn, in most cases of gastric ulcer, whether compli- cated with hemorrhages or not, gives large doses of bismuth. Two grammes (30 grains) of bismuth subnitrate are given either alone or with 0.2 to 0.8 Gm. (3 to 12 grains) of mag- nesium oxide, varying the dose of the latter until one stool a day results. This powder is given three times a day, half an hour before meals, in a wineglass of water. In the treatment of gastric hemorrhage Einhorn gives adrenalin (1 to 1000) in 5- to 15-drop doses by mouth. He also administers, per rectum, calcium lactate, 1 to 2 Gm. (15 to 30 grains) twice daily in 150 Cc. (§v) of water. Small doses of codeine and atropine are administered occasionally when pains are severe. Bismuth preparations were employed over a century ago by Odier as a panacea for spasm of the stomach. The use of bismuth in the treatment of gastric ulcer was suggested about the middle of last century by Budd and Trousseau. It remained, however, for Fleiner, following the advice of Kussmaul," to bring the bismuth treatment impressively to the notice of the profession. The method which is strongly advocated by Fleiner is as follows: The fasting stomach is washed out each morning until the returning water is clear and the reaction neutral. Then a suspension of bis- muth subnitrate in water (10 to 20 Gm. in 200 Cc.) is introduced into the stomach by means of the tube. The tube is withdrawn and the patient is requested to lie in such a posture that the bismuth may lodge by gravitation over the supposed site of the ulcer. Breakfast is taken after 1 La Quinzaine therapeutique, September 25, 1907. ^ Verhandlungen des 12 Kongresses fiir innere Medicin, 1893. 444 GASTRIC ULCER half an hour's rest. The bismuth treatment should be em- ployed daily at the beginning; later, every other day or every third day. It should be continued as long as necessary. Boas prefers the subcarbonate of bismuth to the subnitrate. The favorable results of Fleiner have been corroborated by Fischer, Cramer, Saveheff, and Witthauer. Such treatment should result in a diminution of the gastric distress and a cessation of pain, nausea, and vomiting. The use of bismuth is begun at the same time as the gastric feeding at the close of the initial starvation period. Fleiner claims for the bismuth an antiseptic and astringent action, as well as a direct action to reduce the hj^Deracidity. In large doses it has a mechanical protective effect. The use of the stomach tube is not a necessity for the introduction of the bismuth into the stomach; the suspension may be swallowed. Pariser advocates the administration of 15 to 20 Gm. (oiv-v) of bismuth subnitrate in water on an empty stomach in the morning, to be followed by a httle pure water. The patient is directed to lie quietly on his back for three-ciuarters of an hour, after which he is permitted to take a cup of coffee and a roll. Pariser says he has never seen any toxic effects from such large doses of bismuth. He has, however, substituted, as a matter of economy, a mixture of 60 Gm. (§ij) each of chalk and talcum, to which is added 15 Gm. (§ss) of magnesium oxide. There is an addi- tional advantage, too, in the laxative and antacid effects of these drugs, as well as in the fact that they do not darken the stools and thus conceal slight hemorrhages which in the bismuth treatment might pass unobserved. Riegel has stated that he never limited himself to the administration of bismuth, but always insisted on rest and a careful regulation of the diet at the same time. He never ordered bismuth suspension to be introduced into the stomach by tube, but simply directed the patients to drink the suspension — as a rule, in one dose of 10 Gm. (oiiss) some time in the course of the forenoon when the stomach was empty. "I can corroborate," says Riegel, "the statement MEDICINAL TREATMENT 445 that the effect of this remedy is very favorable. I feel jus- tified, therefore, in recommending bismuth as a valuable adjunct to the dietetic rest cure. I advise its administra- tion in all cases of ulcer of the stomach." Bismuth subnitrate is a salt formed by the combination of bismuth with nitric acid. Nitric acid is caustic, anti- septic, and astringent. Bismuth subnitrate is insoluble in water, and passes quite well through the stomach into the duodenum without much change. It has been proved by the .T-rays that in the presence of ulcer some of the bismuth adheres to its raw surfaces. While adhering, the subnitrate disintegrates slightly and liberates some of its nascent nitric acid, which acts locally as a stimulant, astringent, and anti- septic. The nascent nitric acid coagulates the albuminous surface of the ulcer, which thus acts as a protective during the time of healing. If the practitioner has this object in view, he should not prescribe bismuth subnitrate with an alkali, for the alkali w^ould destroy the small quantity of nascent acid developed. It is impossible to secure as good a result in the treatment of gastric ulcer with any other salt of bismuth as with the subnitrate. The inefficiency of bismuth subcarbonate is due to the absence of nitric acid; in the decomposition of the subcarbonate, carbon dioxide is evolved. I have used large doses of subnitrate of bismuth in the treatment of gastric and duodenal ulcer for the past eighteen years, without one case showing symptoms of ill effect. I prescribe it in aqueous suspension only, to be taken before meals, three times a day. The bismuth should be continued for one to four weeks during the cure. I give it as in the following prescription: Gm. or Cc. I^ — Bismuthi subnitratis, c. p. . . . 60.0 5ij Aquae destillatse .... q. 3. ad 240.0 Sviij Misce. Sig. — Shake well. Tablespoonful three times a day, before meals, S. Fenwick and W. S. Fenwick^ always use the oxide of silver in the form of a pill in the treatment of gastric ulcer, 1 Ulcer of the Stomach and Duodenum, 1900. 446 GASTRIC ULCER commencing with half a grain and cautiously increasing to one grain, with the necessary intermissions. The silver salts are particularly valuable when hypersecretion accom- panies organic disease. As to bismuth, Fenwick prefers the subcarbonate to the subnitrate, since it has the merit of neutralizing to some extent the excessive acidity of the gastric contents. His usual custom is to prescribe 0.6 to 1 Gm. (9 to 15 grains) of the subnitrate or subcarbonate of bismuth with an equal quantity of bicarbonate of sodium and a few drops of a solution of morphine, shortly before meals, and in the majority of cases this one dose is sufficient to afford relief. Occasionally, however, a much larger amount of the bismuth is required, and Fleiner has shown that 8 to 12 Gm. (5ij-iij) may be given at a time with- out any danger of toxic symptoms. Owing to the dangers which accompany the use of the stomach tube in cases of gastric ulcer, Fenwick prefers to administer these large doses of bismuth by mouth, and suggests the following plan: About one hour before breakfast the patient assumes the posture requisite to bring the powder in contact with the ulcer, and then quickly swallows about eight ounces of warm water in which 8 to 12 Gm. (oij-iij) of subcarbo- nate of bismuth has been suspended. He remains quiet for one hour, and then partakes of breakfast. This modification of Fleiner's method has been employed frequently with marked success. For the first fortnight the dose is given each morning, during the next fortnight on alternate days, and subsequently once or twice a week. Nitrate of silver has been used for a long time in the treatment of gastric ulcer. Johnson, who was the first to recommend it, had observed that in his cases of epilepsy all the gastric symptoms disappeared after the administra- tion of nitrate of silver. Gerhardt claims to have seen many cases in which all gastric symptoms caused by ulcer cleared up after a course of nitrate of silver; he says the siher salt acts favorably in cases in which pain is ]iresent when the stomach is empty. It probably has the effect of an antacid in such cases. Cohnheim recommends nitrate of silver in MEDICINAL TREATMENT 447 cases of acute chlorotic ulcer, reserving bismuth for other forms of gastric ulcer. Boas recommends the silver nitrate treatment, particularly in mild cases of ulcer and in fol- licular ulcers. The treatment should be begun by giving, always on an empty stomach, a solution of 0.2 Gm. (3 grains) in 120 Cc. (oiv) of distilled water, in tablespoonful doses, three times a day. Boas increases the strength of the solution to 0.3 Gm. (5 grains), and later to 0.4 Gm. (7 grains), to each four ounces of water. The physician should insist upon a careful regulation of the diet. Gm. or Cc. I^ — Argenti nitratis 0.3 gr. v Aquae destillatse 180.0 5vj Misce. Sig. — A tablespoonful in a wineglass of water three times a day, half an hour before meals. Care should be exercised in the administration of silver salts, lest the condition known as argyrism result from their too long continued use. W. H. Thomson, of New York/ is strongly in favor of resorcinol as a remedy in local inflammatory conditions of the stomach and in gastric ulcer. He prescribes it very frequently in cases where there is throbbing, with rigidity and tenderness on palpation, at the epigastrium. When the signs of gastric ulcer are unmistakable, such as hematem- esis, or palpable thickening about the pylorus, resorcinol is advised as soon as the hemorrhage is checked. Thomson has also used this drug in gastric disorders sequent to gall- stone disease. Prof essor Fraser, of Edinburgh, recommends bichromate of potash for such conditions. Both these agents are powerful antacids, arresting local fermentation. Resorcinol may be administered internally as follows (Thomson) : Gm. or Cc. I^ — Resorcinolis 12.0 3iij Tincturse nucis vomica; 15.0 3iv Syrupus zingiberis 8.0 3ij Aquse menthse piperita; . . . q. s. ad 240.0 Oss Misce. Sig. — Two teaspoonfuls in water, half an hour after meals. iNew York Medical Journal, June 11, 1910. 448 GASTRIC ULCER Gm. or Cc. I^ — Potassii bichromatis .0.1 gr. iss Bismuthi subcarbonatis 6.0 5iss Extracti gentianae, q. s. ^lisce et div. in pil. no. xxx. Sig. — Take one, half an hour before meals. (Fraser.) Olive oil, owing to its high nutritive value and its abso- lutely unirritating properties, is a therapeutic agent worth a careful trial. It has a decided^ restraining action upon the hydrochloric acid secretion of the gastric juice. In recent cases several spoonfuls of the oil maj^ be administered daily, the patient rinsing the mouth with some good mouth wash each time after taking the dose. The quantity of oil is gradually increased up to 150 Cc. (ov) per day, taken in three portions. If the patient evinces a disgust for the pure oil, it may be given as an emulsion through a soft esophageal tube. All other feeding by the mouth is sus- pended so long as grave symptoms exist — that is to say, for three to six days. There is nothing to prevent giving nutritive enemata, since the oil, as a rule, does not produce diarrhea, though it usually relieves the constipation from which patients with ulcer of the stomach are apt to suffer. Generally in eight days the digestive trouble disappears, but it is wise to continue the oil, associated with an appro- priate diet, for two weeks longer. This treatment is particu- larly efficacious in chronic ulcer of the stomach, even when surgical operation proves of no avail. Bloch relates his experience with nineteen cases of gastric ulcer or pyloric stenosis in which great benefit was derived from small amounts of oil taken three times a day. It was remarkable, he states, how rapidly the pain was relieved and the debilitated patients recovered strength. This was most evident in the cases of enlargement of the stomach from spasm of the pylorus. Almost complete recovery was realized in a few cases of severe stenosis, the treatment restoring the working capacity of the patients. In private practice this writer prefers oil of sweet almonds, changing after two weeks, if the patient desires, to "almond milk," MEDICINAL TREATMENT 449 which is an emulsion of a tablespoonful of pulverized sweet almonds in a glass of hot water, to be swallowed warm, with peppermint drops afterward if desired. In winter he prefers an emulsion made according to the following formula (with or without the belladonna) : Gm. or Cc. I^ — Tinctunv bclladonnse 5.0 5j Olei amygdala^ express! 30.0 5j Vitelli ovi unum Aquae destillata? ad 200.0 5vj Misce et ft. emulsio. Sig. — A tablespoonful three times a day. The proportion of oil can be increased or reduced accord- ing to the severity of the case. In some cases Bloch gives pure olive oil or cottonseed oil. I have used tincture of iodine, a five-drop dose in a wine- glass of water to be taken three times a day on an empt}^ stomach. This treatment has allayed the pain and put the patient at ease when other therapeutic agents were inef- fectual. In the treatment of hemorrhage from the stomach (see chapter on Gastric Hemorrhage) during and following a serious crisis in the patient's illness, Pron^ advises the appli- cation of an ice bag to the pit of the stomach, supporting it on a hoop or some similar arrangement so as to prevent the weight of the bag from annoying the patient. The taking of any fluid by the mouth is to be absolutely forbidden. It is only permitted to rinse out the mouth occasionally mth either plain or aromatized water; and the patient may, if he wishes, suck small pieces of ice. To furnish the tissues Tvdth the fluid needed by them, an enema of boiled water (one pint) is given twice a day. As to diet during convalescence, iced milk should con- stitute the only food for several days, two to three ounces being given during the day. One-third of a cup of water may be allowed daih% and the quantity gradually increased to a pint. In a few days, as the patient improves, the 1 La Quinzaine therapeutique, September 10, 1909. 29 450 GASTRIC ULCER amount of water taken may be increased to two or three quarts a day. If the hemorrhage persists, the patient must be put on a more rigid diet, the quantity of milk being decreased, and nutriment administered by rectum. The following nutritive enemata are proposed: (1) Gm. or Cc. I^ — Eggs, two Milk 240.0 Bviij Tincture of opium 0.3 gtt. v Miisce. (2) Gm. or Cc. IJ — Eggs, two Milk 240.0 5viij Liquid peptone 8.0 oij Misce. (3) Robin uses the following enema : Gm. or Cc. I^ — Eggs, one to three Liquid peptone . . . . . 38 . to 48 . 5 ^'-^^i J Solution of glucose (20 per cent.) . 100.0 oiij Sea salt 1.5 gr. xxij Pepsin 0.5 gr. viiss Tincture of opium 0.2 gtt. iij Freshly prepared soup to make 240.0 o^iij Misce. At the first appearance of hemorrhage, give a hypodermic injection of ergotin, and repeat as needed two or three times during the twenty-four hours; or give the following: Gm. or Cc. I^ — Hydrastinse hydrocbloridi 0.5 gr. viiss Aquae destillata; . . . .10.0 5iiss Misce. ANTI LYTIC SERUM TREATMENT 451 Or this formula of Capitan: Gm. or Cc F^ — Extracti ergotae 5.0 gr. l.x.w Morphinae hydrochloridi 0.035 gr. }! Antipyrina! .... . . - 1.5 gr. xxij SparteiniE sulphatis 0.2 gr. iij Atropinaj sulphatis . 02 gr. -k Aquae destillatae .... q. s. ad 10. 5iiss Misce. Sig. — A Pravaz syringeful to be injected every half-hour or quarter-hour as needed, but no more than five syringefuls in all to be used. Gm. or Cc. 4.0 3j 8.0 3ij 2.0 gr. XXX 0.5 gr. vuss 0.6 TTLx 150.0 5v All other measures failing, prescribe the following mixture to be taken in tablespoonful doses every hour: I^ — Calcii chloridi Tincturse opii Extracti ergotae Acidi gallici Spiritus terebinthinse Aquae menthae piperitse . . q. s. ad Misce. Sig. — One tablespoonful every hour. Treatment by Antilytic Serum. — Antilytic serum has recently been employed with some success in the treatment of gastric ulcer. The serum of a healthy individual contains, in addi- tion to its other constituents, a substance which stimulates the repair of tissue cells and limits cell destruction by antagonizing certain enzymes of fixed and wandering cells. These bodies are of the nature of antitrypsin and are attached to the albuminous portion of the serum; they have been called antilysins.^ Antilytic serum recommended for use is the normal blood serum of the horse, fresh, atoxic, and sterile, in the natural condition or with its antilytic valency increased by the addition of globulin-free serum. The treat- ment is applicable to cases of gastric ulcer with or without hemorrhage. No other drug should be administered, except a simple purgative as required. The physician must insist upon complete rest in bed for two to three weeks. 1 Hort, British Medical Journal, August 10, 1908, p. 1081. 452 GASTRIC ULCER The antilytic serum is administered by mouth three to four times a day, immediately after meals, each dose in half an ounce of water. If pain is severe, 60 to 80 Cc. (§ij-iiss) is given in divided doses in the twenty-four hours. In all severe cases the serum treatment should be con- tinued for six weeks. Marked relief from pain has been experienced within twenty-four hours after the beginning of the treatment. Hort and others report favorable results. The diet during the antilytic serum treatment should be given in small quantities and should consist of stale bread, yolks of lightly cooked eggs, and white meat of chicken. No milk, soup, or fish should be permitted at any time. The only liquid permissible is ten ounces of water at 7 a.m., 11 A.M., and 10 P.M. If the patient shows signs of improve- ment the diet may be doubled in quantity at the end of four to five days. On the seventh day finely chopped meat hghtly cooked may be added. By the end of the second week meat in the form of beef and mutton may constitute the chief article of diet. In three weeks from the beginning of the treatment full diet may be prescribed. The patient should not partake of alcohol, soup, tea, coffee, or starch foods for at least six months. Treatment by Bacterial Vaccines. — The treatment of gastric ulcer by means of bacterial vaccines was suggested to the author by the work of Turck on the experimental produc- tion of gastric ulcer. Turck succeeded in a few instances in producing peptic ulcer in guinea-pigs by long-continued close confinement without exercise and with limited light and ventilation. These few successes suggested the possi- bihty of systemic conditions being important factors, and that alterations in the toxic state of the alimentary canal with consequent change in the blood might play some part. Experiments were begun with the Bacillus coli connnunis because that organism is found abundantly in the intestine and flourishes in catarrhal and atonic states of the stomach. Although no difference could be detected, in()ri)hologically or culturally, ))etwoon strains isolated from the stools of normal individuals and those from cases of gastric ulcer, ' BACTERIAL VACCINE TREATMENT 453 the latter were selected on account of the possibility of there being a difference in the toxicity of the two strains. The toxin of the Bacillus coli communis being intracellular suggested the use of killed as well as living cultures. In the earlier experiments the bacteria were introduced directly into the circulation, but later they were fed by mouth, thus approaching more nearly the natural conditions. Meat extractives were fed with the bacteria in some cases, as it was observed that the bacillus grew most abundantly in media containing meat extractives. Positive results were obtained in every experiment in which the cultures were fed to dogs, the number and extent of the ulcers varying from a few in the duodenum to numerous typical peptic ulcers of the stomach. In order to ascertain the percentage of gastric ulcer in dogs not experimented with, the stomachs and intestines of 189 healthy dogs killed at the dog pound and of 82 dogs dying from disease, injury, or poisoning, w^ere systematically examined. In no case was a peptic ulcer found; it appears, therefore, that the percentage of its natural occurrence must be very small. Turck thinks a dual condition is indicated in the production and persist- ence of the ulcers — a toxic condition overcoming natural resistance, and possibly some chemical substance formed within the alimentary tract which, when absorbed, may neutralize the protective bodies in the blood and tissues, resulting in autocytolysis. We have in these results, the author holds, a positive etiological factor of gastric ulcer, and have now a firm basis for the unravelling of the funda- mental or underlying etiology of peptic ulcer. This work of Turck is valuable from a therapeutic view- point when we consider the opsonic work of Sir A. E. Wright and his vaccines made of dead bacterial suspensions.^ According to the revised views which Wright now holds, and which were developed through his use of various bacterial substances in the form of vaccines, opsonin is an ingredient of the blood serum w^hich aids phagocytosis 1 Aaron, Observations of Opsonic Therapy, New York ]\Iedical Journal, December 1, 1906. 454 GASTRIC ULCER by its inhibiting action on a given microorganism. That is to say, it acts on the microbe and prepares it to be ingested by the protective body cells or phagocytes, chief among which are the polynuclear leucocytes of the circulating blood. The blood serum of man contains opsonins for various pathogenic bacteria, and in a state of health this opsonic content, or ''opsonic index," as it is called, is at a certain or normal level. By an ingenious method, devised bj" Wright and Douglas, the opsonic index for an}^ particular pathogenic microbe can be determined. This method con- sists essentialh^ in mixing with fresh human leucocytes the serum to be tested and an emulsion of the particular bac- terium under investigation. After a brief incubation this mixture is spread as in making a blood film, stained appro- priately, and then examined vAih. suitable microscopic power. The phagocytic leucocytes will now be revealed containing the bacteria in their substance; and by counting the contained bacteria in a sufficient number of leucocytes, striking an average, and comparing it with a normal serum, the opsonic index for that particular serum and that partic- ular microbe is obtained. The chief merit of Wright's work consists in his success, by the use of bacterial vaccines, in artificially stimulating the flagging opsonic power of the blood of the patient. From this it would seem rational to use the colon vaccine in the treatment of gastric ulcer. I have so used it, admin- istering a bacterial suspension of 40,000,000, hypodermically, once a week. There were apparently no untoward results, though it is rather early to accord the treatment a perma- nent place in the therapeutics of ulcer of the stomach. Surgical Intervention. — The indications for surgical interven- tion are given by Einhorn as follows: (1) In large recurrent gastric hemorrhages threatening life the ulcer should be excised in the interval, or a gastroenterostomy established to prevent renewed hemorrhage. (2) Small losses of blood that cannot be checked and that endanger life through their persistence should be dealt with surgically. (3) Per- foration of the ulcer demands always immediate operation SURGICAL INTERVENTION 455 (excision or invagination of the defect, and suture) as soon as the diagnosis has been made. (4) An ulcer situated at the pylorus and attended with peristaltic restlessness of the stomach and continuous hypersecretion indicates opera- tion. (5) Advanced cases of stenosis of the pylorus require gastroenterostomy. (6) Gastric ulcers with formation of tumor, no matter where the location may be, always demand gastroenterostomy, usually with excision of the tumor. Clairmont believes that the value of gastroenterostomy in gastric ulcer is dependent upon the situation of the ulcer; the nearer it is to the duodenum the better the prognosis. He figures that an ulcer at or near the pylorus will be favor- ably influenced by gastroenterostomy in about 62 per cent, of the cases, at a distance from the pjdorus in 47 per cent., and in the duodenum in 73 per cent. Musser is inclined to be very conservative in the matter of operative procedure for gastric ulcer. The more he sees of the results of surgery, the more he feels that we must go very slowly mth regard to advising abdominal section, particularly when we do not have the opportunity of select- ing the surgeon. Operation, which under certain circum- stances is extremely grave, should be considered carefully and in all its aspects before being decided upon. Medical measures can bring about relief and perhaps cure in a large proportion of cases, particularly acute ones. "\V. J. Mayo^ states that acute ulcers should be treated medically, surgery having only to do with the complica- tions, such as perforation, hemorrhage, and obstruction. Chronic ulcers should be considered medically so long as the patient maintains good nutrition and is not unfitted, more or less, for life's work by reason of pain and digestive dis- turbances. Chronic ulcer becomes surgical when repeated medical "cures" have demonstrated the futility of further continuance of such treatment, and especially if there are mechanical difficulties present, such as obstruction, stagna- tion or retention of food, or adhesions. The possibifity of ulcer degenerating into cancer would not of itself justify 1 Mobile Medical and Surgical Journal, June, 1906. 456 GASTRIC ULCER operation, but it must be taken into consideration in sum- ming up the indications for surgical intervention. A simple uncomplicated gastric ulcer is not, in my opinion, a case for surgical intervention. Only in the event of com- phcations, or in ulcers which defy thorough internal treat- ment, impairing nutrition by interference with motility, is there any indication for surgical treatment. The fact should always be taken into consideration that in the present state of the art of diagnosis we can have only a suspicion as to the seat of the ulcer. We know that four-fifths of all gastric ulcers are situated at the lesser curvature on the posterior wall of the stomach — a surgically inaccessible place. Unless, therefore, there is a well-developed ulcer of the pylorus, which has been diagnosticated by the signs of retention, it is impossible to make a safe prognosis of recovery or even of improvement through surgical means. In some cases, after ulcer of the stomach had been diag- nosticated and the abdominal cavity opened, either the ulcer has not been found, or, if found, adhesions or an unfavorable position of the lesion have rendered operation impracticable. So far as surgery is available, no procedure but removal of the ulcer by excision or gastroenterostomy is to be considered. However, excision of the ulcer does not remove the cause nor the tendency to re-formation; nor does it improve motility. Neither does it reduce hyperacidity; but it does remove the dangers accompanying the ulcer, such as hemorrhage, perforation, and malignant degenera- tion. Gastroenterostomy and favorable drainage protect the ulcer from irritation by the hyperacid gastric contents, and some ulcers which have defied every kind of therapy will sometimes heal or become latent after this operation. Ulcers of the pj^lorus or duodenum can be cured by gastro- enterostomy, but no others. After an exhaustive study ^ of the results of internal ' Die innere und die chirurgische Behandlung des chrouischen Magenge- sch\vurs und ihrc Erfolgo, Berlin, pp. SO, 90, 104, SURGICAL INTERVENTION 457 therapy and surgery in the treatment of chronic gastric ulcer, Bamberger arrives at the following conclusions: 1. The end results of internal treatment of chronic gastric ulcer are not satisfactory, but the same is true of all other methods of treatment. The average of good permanent results amounts to 70 per cent., the average of failures to 32 per cent., including both early and late mor- tality. Relapses have occurred in an average of 24.6 per cent, of all cases and methods of treatment. 2. The most important point in the treatment of gastric ulcer is the regulation of the diet. Lenhartz's method of administering food on the very day of hemorrhage is con- traindicated, if the stage of hemorrhage is still present. The treatment during that stage should consist in giving the stomach the greatest possible rest, which means absten- tion from all food. 3. In the further course of treatment, Lenhartz's dietary method is thoroughly justified and advisable, it being an established fact that, after cessation of bleeding, the patient will not be injured by the institution of this treatment. Although the success of both methods of treatment is approximately the same, the fact should again be empha- sized that, contrary to the opinion of other authors, Len- hartz's procedure is not better in bleeding cases (and, according to Bamberger's experience, it is even less valuable) than that of Leube. 4. On the other hand, it is the great merit of Lenhartz to have demonstrated that, without detriment to the patient, Leube's method may be so modified after cessation of the acute hemorrhage or pain period that fairly large quantities of food are administered. This is best done by additional allowance of fat in the form of butter, cream, eggs, and sugar, but in larger quantities than has so far been prac- ticed in following Leube's method. 5. The average number of failures, amounting to 32 per cent., proves that we have not yet a method of treatment at our disposal which meets all requirements. Until such 458 GASTRIC ULCER has been found, it will be absolutely necessary to bestow still greater care upon the treatment of gastric ulcer than has hitherto been done. There is no doubt that a cure can in the majority of cases be effected if the treatment is logical and persisted in for a sufficiently long time. 6. When patients who have been operated upon for ulcer are discharged, their attention should be called to the necessity of carefully following the restful diet rules, and furthermore to the fact that even slight disorders of the stomach must be heeded and properly treated lest serious consequences result. 7. While the treatment of chronic gastric ulcer belongs to the domain of internal medicine, operative intervention is necessary in all cases which defy prolonged and repeated treatment as well as suitable variations of method, espe- cially in patients whose capacity for work is heavily handi- capped by an unmitigated continuance of their painful condition. 8. Operative intervention is indicated in cases which, in spite of correct and repeated treatment, and in spite of continued complete abstention from food, cannot be cured — . cases which are associated with persistent violent symptoms, hemorrhage, vomiting, and emaciation. 9. Surgical intervention is particularly to be considered in cases of pyloric ulcer, and absolutely indicated if internal treatment has proved unsuccessful. The best method of operation is gastroenterostomy; resection should only be resorted to if carcinomatous degeneration is suspected. The lethal risk to which patients with pyloric ulcers are exposed by operation is at the most 4 per cent. 10. In non-pyloric ulcers the situation is totally different, although even in these cases surgical intervention is to be seriously taken into consideration after internal medicine has failed, even though the mortality following operation for gastric ulcer still amounts to 12.6 per cent. In regard to the choice of operation, preference should more fre- quently be given to the radical methods, provided the general condition of the patient admits. SURGICAL INTERVENTION 459 11. Adherence to a proper dietetic regimen is more important than has hitherto been assumed, even when the operation has been successful. In all cases it is advisable to institute a rigorous ulcer cure after gastroenterostomy has been done. For further information on the surgical treatment of gastric ulcer, the reader is referred to the chapter on Surgical Intervention. CHAPTER XX GASTRIC HEMORRHAGE— GASTRORRHAGIA Diagnosis. — The diagnosis of gastric hemorrhage is usually not a difficult matter. There is, as a rule, hematemesis, accompanied or followed by melena. Hemorrhages from the mouth and respiratory tract, in which the blood has been carried to the stomach by swallowing, must be excluded. Due inquiry must be made in regard to possible prior and causative injuries to the head, or coincident affections of the lungs. In gastrorrhagia there are usually some circumstances which indicate the exclusively gastric nature of the trouble ; in almost every instance there is a history of gastric dis- turbance, often of long duration, preceding the hemorrhage. Hemorrhage without any previous symptoms is rare. Furthermore, the history and clinical symptoms render the diagnosis fairly easy as to the particular disease causing the hemorrhage, whether gastric ulcer, superficial ulcera- tion, capillary bleeding, or cancer. Gastric hemorrhage has been noted by Boas in the following conditions: Venous or varicose hemorrhage in cirrhosis of the liver or obstruction to the portal circulation; parenchymatous gastric hemorrhage in diseases of the heart, liver, or blood; acute and chronic gastritis; stenosis of the pylorus; miliary aneurism; injury from foreign bodies in the stomach; caustic poisons in the stomach; jaundice (cholemic gastric hemorrhage); syphilis; arteriosclerosis; septicemia; rupture of abscesses or of an aneurism of neighboring structures into the stomach; anemia and disturbances of menstruation (vicarious gastric hemorrhage); hemorrhoids; neurogenous disturbances (hys- teria, gastric crises) ; and cholelithiasis. Gastric ulcer is the most common cause of hemorrhage from the stomach, occurring in 5 per cent, of the entire DIAGNOSIS 401 population, according to Ewald and others. Hematemesis occurs in at least 50 per cent, of all cases of gastric ulcer, and many authorities place the proportion as high as SO per cent. It is fatal in 8 per cent, of the cases in which it occurs, according to the conservative estimate of Leube, and we cannot question that it is indirectly fatal in a much greater number of cases through anemia and its remote consequences. Differential Diagnosis. — The differential diagnosis of doubtful cases, as between gastric and duodenal hemorrhage, is a matter fraught with greater difficulty. The following symptoms indicate a duodenal origin of the bleeding: (1) Pain about one to three hours after meals, which is relieved by the taking of food; (2) considerable melena, associated with hematemesis or existing alone; (3) the pain is often in the right hypochondriac region. Acute hemorrhage is not a condition that lends itself to surgical treatment. It can usually be stopped by internal treatment; and if this should fail, operative intervention is not likely to help. Less than 5 per cent, of the cases die of these hemorrhages without operation. By subjecting patients to operation we expose them to further dangers, to which they easily succumb ; while without operation they have a reasonable chance to recover. This view is shared by a large number of experienced surgeons. As a matter of fact, few cases of gastric hemorrhage have been lost when proper internal therapeutic measures were instituted. With internal treatment Lenhartz reports 201 cases of gastric hemorrhage with a mortality of 3 per cent., Ewald 166 cases with a mortality of 4.87 per cent., and Wirsberg 320 cases with a mortality of 5.9 per cent. The recognition of gastric hemorrhage arising from ulcer is usually easy, on account of the previous diagnosis of the case ; and if the patient is seen for the first time at the onset of the hemorrhage or later, the association of this with the other classical symptoms of ulcer, particularly pain and vomiting after eating, leaves little room for doubt. \Miile there may be pain, vomiting, and gastrorrhagia in carcinoma 462 GASTRIC HEMORRHAGE— GASTRORRHAGIA of the stomach, the differences that distinguish this disease from gastric ulcer are so marked that doubtful or border- line cases are rare. Prophylaxis. — Only in cases in which the diagnosis is ascer- tained with certainty, in gastric ulcer or carcinoma in which hemorrhage may be anticipated, are prophylactic measures likely to avail. In such cases occult hemorrhages frequently precede hematemesis. The stools should be examined fre- quently for occult blood. Boas believes that concealed gastric hemorrhage is of very frequent occurrence, not only in gastric ulcer, but more especially in carcinoma of the stomach, in which the patient often "bleeds to death, as it were, by drops," without the knowledge of the physician. He recommends a very careful analysis of the feces and gastric contents in all cases in which there is the least cause for suspicion; the patient, meanwhile, should be placed upon a meat-free diet. On discovery of occult blood in the stools the patient should be placed at rest in bed; the diet should be exclusively liquid, preferably milk, the quantity to be gradually increased until, at the end of eight days, three liters (quarts) a day are being consumed. It may be advisable at times to incorporate gelatin or bismuth with the milk. The patient should maintain the recumbent posture until no further signs of hemorrhage are evident from an examination of the stool. Treatment. — Visible (manifest) or macroscopic gastrorrhagia is characterized by hematemesis, tarry stools (melena), or both. In the treatment of this condition the first indication is to stop the bleeding; the second, to combat the condi- tion producing the hemorrhage. The patient must be placed at rest in bed, in the dorsal position. An ice pack suspended by a frame, to avoid pressure, is placed over the epigas- trium; this will have an analgesic effect and conduce to the comfort of the patient. When the patient is suffering much pain and is very restless and sleepless, morphine hypodermically will often bring rehef. Codeine phosphate 0.02 to O.OG Gm. (| to 1 grain) or dionin 0.02 to 0.03 Gm. (3 to I grain) may be given instead of morphine. T lib: AT ME ST BY LAVAGE 463 Suppositories of extract of belladonna, 0.0075 (ini. (| gi-ain), and extract of opium, 0.03 to O.OG Gm. (^ to 1 grain), are likewise effective. Absolute abstinence from food is neces- sary, thus keeping the stomach at rest not only physically but physiologically. Thirst is to be counteracted by small pieces of ice in the mouth and by rinsing the mouth with water. Subcutaneous injections of physiologic salt solution are an excellent means of quenching the thirst. It is rather doubtful whether nutrient enemata should be given as a prophylactic measure against inanition from continuous hemorrhage. Boas, in particular, points out that the giving of nutrient enemata always causes the patient to move about and induces lively intestinal peristaltic motions. Bodily movements should be avoided. Instead, therefore, of nutrient enemata, Boas employs proctoclysis, or pro- longed instillation of liquid by the drop method, in severe hemorrhage. When the hemorrhages are moderate in amount, nutrient enemata may be resumed earlier than in the severer cases. While the hemorrhage is in progress the ice bag should be replaced by a Priessnitz bandage. Hot compresses should not be employed after recent hem- orrhages. Should the quantity of blood lost be large, normal saline must be administered by subcutaneous or intravenous injection. Treatment by Lavage. — A number of writers, among whom is Ewald, recommend lavage of the stomach with ice water to remove clots and at the same time to act as a styptic. Gastric lavage, says Kaufmann,^ is the most expedient means in the treatment of severe hemorrhage from gastric ulcer, provided it be carefully applied. It relieves over- distention by removing the stagnating masses of accumu- lated blood, acid secretions, food remnants, and gas, which are usually present in such cases, and which not only give rise to nausea and pain, but act as a constant source of irritation to the mucous membrane, inducing 1 The Treatment of Hemorrhage from Gastric Ulcer, American Journal of the Medical Sciences, June, 1910. 464 GASTRIC HEMORRHAGE— GASTRORRHAGI A hypersecretion and thus increasing the amount of gas- tric contents. The removal of this material allows the emptied stomach to contract, and this aids in the occlu- sion of the eroded vessel. Kaufmann believes that the thrombus ordinarily formed does not usually fill the open- ing of the bloodvessel completely. Lavage removes such inefficient thrombi and gives the bleeding vessel a chance to contract and form a more efficient thrombus. With a carefully performed lavage there should be no danger of causing perforation by overdistention; the amount of water in the stomach at any one time should be comparatively small, and if perforation from the pathologic process should occur the cleansing of the stomach will prove beneficial, since it prevents the gastric contents from entering the peritoneum. It is well known that the prognosis in perfora- tion is far better when the perforation takes place at a time when the stomach is empty. The patient being in the recumbent position, the tube should be inserted far enough to secure siphonage, and about 300 Cc. (§x) of water used at a single lavage. The removal of digesting and decomposing blood from the stomach tends strongly to prevent vomiting and distress, and places the stomach at rest. After lavage, large doses of crystalline bismuth subnitrate should be administered. Bismuth in crystalline form is supposed to adhere more tenaciously to the surface of the ulcer than the ordinary amorphic form, so that the blood is agglutinated to the bismuth mass. Bismuth is not sufficiently astringent to contract the bloodvessels and thereby stop the hemorrhage; it does, however, aid in the coagulation of the blood, at the same time exercising a soothing influence upon the gastric mucous membrane. The objection to the introduction of the tube into the stomach in the presence of gastric ulcer has induced Bourget to prepare an iron-chloride gelatin, although he reports no untoward effects due to the tube. This iron gelatin compound is prepared as follows: 100 Gm. of gelatin is dissolved, with the aid of moderate heat, in 100 Gm. TREATMENT BY LAVAGE 465 water and 100 Gm. glycerin. After complete liquefac- tion, 50 Gm. of tincture chloride of iron is rapidly added to the liquid. Coagulation now takes place, with the forma- tion of a precipitate, which mixes with difficulty with the remainder of the fluid. The entire mass is gradually heated and is stirred constantly until it becomes homogeneous. It is then poured upon metal plates which are subdivided into small squares (one centimeter). The cooled mass keeps very well. Two or three tablets are administered daily, two to three hours after meals, to patients suffering from ulcer. Bourget prescribes the following diet in gastric hemor- rhage : 8 A.M. Milk and rusks. 10 A.M. Chloride-of-iron gelatin. 10.30 A.M. 100 to 1.50 Cc. alkaline water (Bourget's alkaline water contains 8 Gm. sodium bicarbonate, 4 Gm. sodium phosphate and 2 Gm. sodium sulphate in each liter). 12 M. Milk rice. 3 P.M. Chloride-of-iron gelatin. 3.30 to 4 P.M. 150 Cc. alkaline water. 6 P.M. Milk rice. 9 P.M. Chloride-of-iron gelatin. 10 P.M. 100 to 1.50 Cc. alkaline water. The results of this treatment are usually good. The pains soon cease, and cicatrization of the ulcer takes place. In cases of severe hemorrhage Bourget commences the treatment by washing the stomach with a 1-per-cent. chloride-of-iron solution, and then administers only the gelatin. In his cases this treatment resulted in an immediate and permanent cessation of the hemorrhage. Experiments made in test-tubes have shown that the chloride of iron gelatin is gradually digested, that is, becomes liquefied, under the action of pepsin and hydrochloric acid. This digestion is not immediate — a certain length of time is required to accomplish it. In the stomach the gelatin squares probably come in contact with the ulceration and there exert their cicatrizing effect. 30 466 GASTRIC HEMORRHAGE— GASTRORRHAGI A Treatment by Enemata. — Hot water enemata have been employed with favorable results. The enema consists of one-half liter (one pint) of water at 120° F.; this should be given three times a day. The object is to produce reflex anemia in the upper portions of the intestine. In several cases which had resisted all the usual medicinal and dietetic treatment, Tripier secured prompt and lasting results by hot enemata repeated twice and thrice daily. The water should be injected at a temperature of 112° to 120° F. There can be no doubt, he says, that in these cases the hemorrhage came from the stomach, duodenum, and points high up in the ahmentary tract. Hot water acts reflexly. Tripier has also found that hot enemata promptly check intestinal hemorrhage in typhoid fever, as they do bleeding from the rectum, sigmoid, and large intestine. We use hot water to check external, uterine, and other hemorrhages; and so superior is it to ice that it has almost entirely supplanted it. It certainly should be preferred in rectal and other intestinal hemorrhages where the water can come promptly in contact with the bleeding points. We also know that, with the patient in proper position, points higher up in the alimentary canal may thus be reached and the bleeding capillaries or arterioles influenced directly by the best of hemostatics — heat. There is also evidence to show that it acts reflexly, and may in this way control duodenal and even gastric hemorrhage. Plunging the hands into hot water will at times quickly arrest bleed- ing at the nose, as will also ice applied to the head. This surely must be reflex. Another and good reason for using hot water per rectum in the manner advised by Tripier is that, if nothing more be done, shock is combated in the best possible way, as it is easy to add sodium chloride to the water in proper proportion to make normal salt solution. Efforts have been made to effect a reflex contraction of the gastric arterioles by introducing ice into the rectum. Medicinal Treatment. — Hemostatics. — Ergot has a direct hemostatic action when taken internally. The following prescriptions have been found useful: MEDICINAL TREATMENT 467 Ciin. or Cc. ^ — Extract i orgota? 1.0 nr. ,\v Aqua- (lostillatiy 5.0 ITllxxv Phenolis liquefacti . 0.06 Tllj Misce. Sig. — Fifteen minims to be injected subcutunoously. (Boas.) Gm. or Cc. I^— Extracti ergotse 2.5 gr. xxxviiss Glycerini, Aqua; aa 5.0 TTllxxv Misce. Sig. — Fifteen minims several times daily, hyijodermically. (Wegele.) Hydrastine hydrochloride is less effective: Gm. or Cp. I^ — Hydrastinse hj'drochloridi 0.5 gr. Aaiss Aquae 4.0 3j Misce. Sig. — Fifteen to thirty minims hypodermically. The employment of gelatin is more promising. Sterile gelatin is furnished by Merck in strengths of 10 per cent, and 20 per cent. It is marketed in sealed glass tubes, ready for use, and is liquefied by placing the tubes in hot water. It is then taken up by means of a large syringe directly from the glass tube, and injected subcutaneously: 40 Cc, containing gelatin 10 per cent., constitutes a single dose for adults; in obstinate cases this may be repeated several times. Strict antiseptic precautions must be observed in this method of medication. When Merck's gelatin cannot be obtained, a 1 to 2 per cent, gelatin solu- tion may be prepared with physiologic salt solution. This is then sterihzed carefully, and introduced under the skin by means of a syringe. The internal administration of gelatin in the following form is recommended for the treatment of gastric and intestinal hemorrhage:^ 1 Journal de medecine de Paris, January 16, 1909. 468 GASTRIC HEMORRHAGE— GASTRORRHAGI A Gm. or Cc. I^— Gelatini 20.0 5v Acidi citrici 2.0 gr. xxx Syrupi aurantii 20.0 ov Aquse, q. s. Boil the gelatin with water for six hours until it is completely liquefied, then add sufficient water to make 200 Cc. (7 ounces). Cool, filter, and add the citric acid and syrup of orange. Sig. — One or two tablespoonfuls to be taken every two hours. The injection of home-made gelatin solutions is always fraught with danger because of the possibility of infection. Besides, the injections are painful. A 1 to 2 per cent, gelatin solution may be administered as an enema. Hot 5-per-cent. gelatin solutions have been given per rectum with advantage in doses of 250 to 1000 Cc. (^ pint to 2 pints) two to four times daily. These rectal injections have to be made in such a manner as not to interfere with, the perfect quiet of the patient. Occasionally it is well to elevate the foot of the bed. The action of gelatin is supposed to be due to its Hme salts; lime acts as a hemostatic. In severe hemorrhages chloride of lime has been emploj^ed by Boas in 5 to 10 per cent, solution in the form of small rectal enemata — 10 to 12 Cc. — every two to three hours. Wright recommends calcium lactate, to be administered by mouth, 1 to 2 Gm. (15 to 30 grains) three times a day. It may be adminis- tered hypodermically in the same doses. Another preparation of Merck's is stypticin, which is injected in 10-per-cent. watery solution, subcutaneously (15 to 30 minims three times a day). Good results have been claimed for it. According to Riegel, subcutaneous injections of atropine have produced favorable results, though the drug is not directly hemostatic; the effect is due to its inhibitory action on the secretions. The hemorrhagic blood effused into the stomach acts as a stimulus to the secretion, and thus the coagula closing up the bleeding vessels are con- stantly redissolved by the gastric juice; if atropine, by sup- pressing the secretion, prevents the thrombotic coagula MEDICINAL TREATMENT 469 from being dissolved, it may be said to act indirectly as a hemostatic agent. Clinicians of wide experience, as Boas and Riegel, reiterate their objection to the internal administration of styptics, and permit only the administration of 10-per-cent. gelatin, one tablespoonful every hour, which forms thrombi in the bleeding vessels. Adrenalin (Parke, Davis & Co.) and other preparations of the suprarenal gland are recommended, in solutions of 1 to 1000, 15 to 30 drops by mouth, two or three times, at short intervals, the day of the hemorrhage. These prepara- tions are not all of equal value; a reliable brand should be selected. Halderman^ describes the satisfactory treatment of a case of gastric hemorrhage with adrenalin. The patient was a man, aged sixty-five years, whose condition was most serious. He was in a cold, clammy perspiration, radial pulse imperceptible, and with every appearance of impending dissolution. He was given 10-drop doses of solution adren- alin chloride 1 to 1000, every thirty to sixty minutes, until he had taken one drachm of the solution. The vomiting and hemorrhage soon stopped, and for three weeks rectal alimentation was depended upon; he was given, per rectum, one pint of normal salt solution daily, with instructions to retain it if possible, which was usually done. In collapse after profuse hemorrhage, caffeine may be given : Gm. or Cc. I^ — Caffeinse sodio-salicylatis 4.0 5i Aquae ad 40.0 ox Misce. Sig. — Fifteen to thirty minims hypodermically. (Wegele.) When the hemorrhage has ceased for several days and examination of the feces show^s a complete cessation of occult bleeding, the administration of more copious nutrient enemata is indicated. Feeding by mouth may now be begun. The quantity of milk should be gradually and slowly ^ Cincinnati Lancet-Clinic. 470 GASTRIC HEMORRHAGE— GASTRORRHAGI A increased, so that about one liter (quart) will be consumed on the eighth day after the cessation of the hemorrhage. When hemorrhage is due to the presence of gastric ulcer, the ''Leube cure" or ''Lenhartz cure" may be instituted at this period. The ''Leube" and ''Lenhartz" dietetic methods of treat- ment for gastric ulcer in which hemorrhage is a complica- tion have been described (Chapter XIX). Lenhartz amis at maintaining the nutrition of the patient at the highest possible point, while at the same time he avoids overdisten- tion of the stomach by food. The protein content of his diet serves to counteract the hyperacidity when the case is one of ulcer wdth hemorrhage as a complication. Drugs, as a rule, play a subordinate part in the treatment of hemorrhage from gastric ulcer, especially when proper dietetic treatment can be instituted and carried out. When, however, patients must be treated while following their usual occupations, or when pains persist in spite of dietetic measures, medication proves especially valuable. Bismuth in the form of one of its salts is employed prob- ably more extensively than any other drug in the treatment of hemorrhage of the stomach. Its use was originally suggested by Kussmaul and Fleiner. The subnitrate of bismuth was at one time used almost exclusively; but reports of several cases where slight toxic effects were manifest led to the substitution of bismuth subcarbonate. The bismuth salts owe their efficacy to their slightly astrin- gent effect, which promotes granulation at the surface of the ulcer. Animal experimentation has shown that bis- muth stimulates the secretion of mucus, which, together with the salt itself, forms a protective film upon the denuded portions of the gastric mucous membrane. This covering is capable of protecting the ulcerated points from irritation by both food and gastric juice. The bisnuith meanwhile becomes oxidized, changing into the dioxide of bismuth. Under this bismuth coating the formation of granulation tissue can proceed without interruption, resulting in the so-called bismuth eschar. Since the bismuth preparations MEDICI.XAL TREATMENT 471 are astringent they diminish secretion, mitigate the severity of pain, and arrest hemorrhage. The bismuth salts, however, have their drawbacks as therapeutic agents in gastric hemorrhage. In addition to the toxic effects sometimes manifest, which are fortunately of rare occurrence, the salts of bismuth tend to cause con- stipation. ]Many stomachs show a marked intolerance for large doses of this drug. At times the bismuth eschar becomes so firmly attached to the surface of the ulcer as to prevent free drainage of the wound secretions. Fleiner has recommended thorough lavage of the stomach before the administration of bismuth. Bismuth sub- nitrate, 10 to 12 Gm. (oiiss-iij), in a glass vessel con- taining 200 Cc. (§vij) of lukewarm water, is permitted to enter the stomach through the stomach tube. A clamp is then applied to the upper end of the tube, and when time has been allowed for the precipitation of the heavy bismuth salt onto the walls of the stomach the water is drawn off comparatively clear. The patient assumes various postures during the precipitation of the bismuth, which favor the coating of the site of the ulcer. The bismuth suspension is used at first every day, later every second day, and finally every third day until all symptoms of irritation have ceased. In the presence of hemorrhage the tube should not be intro- duced so frequently. The patient may drink the bismuth mixture after a cleansing process, which consists of par- taking of 150 Cc. (5v) of Carlsbad water an hour before the bismuth is to be administered. Bismutose, an albuminous bismuth preparation (21 per cent, bismuth), may be em- ployed instead of the bismuth salts. Some clinicians combine Cohnheim's oil cure with the bismuth treatment, in the form of a suspension of bismuth in oil. Good results have been reported from the use of chalk and talcum, each two parts, to magnesium oxide, one part. The dose is one heaping teaspoonful, suspended in water, three times a day. One of the most recent hemostatics for the treatment of 472 GASTRIC HEMORRHAGE— GASTRORRHAGI A gastric hemorrhage is escalin, introduced by G. Klemperer. This is a paste of finely powdered aluminum in glycerin, and, according to Klemperer, it possesses the property of arresting bleeding more effectually than other means. Klemperer gives the following directions for its use: Immedi- ately after the occurrence of hemorrhage the patient takes four tablets of escalin (altogether 10 grammes of alumi- num), crushed and suspended in a glass of water. Then he abstains from food for a day, taking only small pieces of ice. Transfusion of normal salt solution is indicated in case of severe anemia from hemorrhage. The next morn- ing four tablets of escalin, suspended in 100 Cc. (Biij) of cold milk, are given during one to two hours. The same procedure is followed on the third day. On the fourth day escalin is given for the last time. The patient is now placed upon a more liberal diet, consisting of softened zwieback and yolk of egg in milk. From the fifth day mashed potatoes are added to the dietary, and a mixed diet is gradually resumed. Occasionally Klemperer permits small quantities of milk even on the first day; on the third day yolk of egg and zwieback; on the fifth day finely chopped meat. It has been found that escalin stimulates the secretion of gastric juice, and the general conclusion has been that it is not able to combat hemorrhage more quickly than either Leube's or Lenhartz's methods. It would appear, therefore, that the administration of escalin cannot be con- sidered as a valuable addition to the therapeutic measures at our disposal for arresting hemorrhages of the stomach. Silver nitrate is similar in its action to bisnuith. In the treatment of conditions associated with gastric hcmori'hage, Boas commences with a solution of 0.25 Gm. (4 grains) in 120 Cc. (4 ounces) of distilled water, one tablespoonful to be taken three times a day when the stomach is empty. The strength of the solution is gradually increased to 0.3 Gm. in 120 Cc. The stronger solution should be con- tinued for five days. Finally, a solution of 0.4 Gm. to 120 Cc. (6 grains in 4 ounces) is taken, the dose being the same as MEDICINAL TREATMENT 473 before (one tablespoonful). In the meantime the Leube method of treatment should be followed. Analgesics. — Analgesic drugs, such as morphine, dionin, codeine, extract of belladonna, may be administered with bismuth powders: Gm. or Cc. I^ — Codeinse phosphatis . 03 gr. ss Extract! belladonna' 0.02 gr. 3 Bismuthi subnitratis 0.60 gr. x Misce et ft. pulv. no. i, mitte x. Sig. — One three or four times a day. Atropine has been employed with advantage in the treat- ment of gastric hemorrhage due to slow-healing ulcers, with h}T)eracidity, hypersecretion, and motor disturbances. Tabora, who was the first to advocate the use of atropine in these conditions, begins his treatment with a period of several days' abstinence from food by mouth. Fluids only are administered, and they by rectum. After this initial period (varying in length according to the condition of the patient) has passed, the patient is given one tablespoonful of milk every hour. This quantity is increased to 50 Cc. (5xij), then to 100 Cc. (§iij), and to 200 Cc. (§vij) with one-third cream, so that by the end of two weeks the patient has attained a condition of calorific eciuilibrium. This milk- cream diet is continued for at least four weeks, when gruel or eggs should be added. At the beginning of treatment patients are given one milligramme (eV grain) of atropine sulphate hypodermically morning and night. If required, however, 3 to 4 milligrammes (217 to tV grain) may be admin- istered daily. Atropine, owing to its effect upon hyperse- cretion, has a marked influence on pain. Its administration may be continued for four to eight weeks. The chief unto- ward effects complained of by patients .are dryness of the mouth and indistinct vision resulting from the cycloplegic action of the drug. Tabora ascribes the favorable results from the use of atropine to its inhibitory action upon gastric secretion and its antispasmodic effect. Chloroform water (1 to 120), one tablespoonful every 474 GASTRIC HEMORRHAGE— GASTRORRHAGIA two hours, may be given when sHght pains are present. Chloroform may be prescribed in combination with bis- muth also: Gm. or Cc. I^ — Chlorofornii 1.0 n\xv Bismuthi subnitratis 3.0 gr. xlv Aquae q. s. ad 150.0 gv Misce. Sig. — One tablespoonful to be taken every hour. Schleich has introduced a new preparation of chloroform, which he designates desalgin. He succeeded in combining chloroform permanently up to 25 per cent, with an albumin- ous substance. From this he obtained a gray amorphous powder, which represents a colloidal chloroform in solid form, and which has proved effectual as an analgesic in all painful conditions of the abdominal organs, especially the stomach. The dose is 0.3 Gm. (5 grains) three or four times a day. Cocaine may be made use of in the presence of pain and obstinate vomiting. Orthoform and anesthesin are more recent analgesic remedies. The prompt effect of orthoform in relieving the pain of ulcer associated with hemorrhage has been noted. Orthoform acts through its paralyzing effect on the periph- eral sensory nerve-endings. It is a derivative of oxybenzoic acid. Anesthesin has the same effect as orthoform. (See p. 194.) Lenhartz recommends the following pill in the treatment of the severe anemias resulting from gastric hemorrhage: (im. or Cc. I^ — Ferri suIpliiitLs, Potassii carl)onatis aa 15.0 5ss Tragacantha', q. s. Misce et ft. pil. no. c. Sig. — Three i)ill.s three tiine.s a day. Iron in this form is sometimes badly borne, which fact has led to the inti-oduction of other iron ])reparati()ns. Rodari endorses ferratin, a preparation said to contain MEDICINAL TREATMENT 475 6 per cent, of iron combined in such a way as to render it directly absorbable. Triferrin (Knoll) is another prepara- tion of iron foi- which much has been claimed. Fersan has been described on page 107. I prefer the hypodermic administration (see p. 240). As a tonic and hematinic for the relief of the anemic and emaciated condition of the patient the following may be prescribed: Gm. or Cc. I^ — Ferri sulphatis exsiccati 0.06 gr. j Mangani dioxidi, Quinina^ bisulphatis aa 0.1 gr. iss Extracti nucis vomicte 0.01 gr- I Extract! gentiame 0.14 gr. ij Misee et ft. caps. no. i, mitte 1. Sig. — One four times daily. As a hematinic Ewald recommends a 2 to 3 per cent, solution of the sesquichloride of iron, one teaspoonful three times a day in a wineglass of egg water. The egg water, an albumin solution, is made by adding one part of egg albumin to two parts of water. Some authors recommend a combination similar to the following in cases of gastric hemorrhage: I^ — Acidi tannici Glycerini Aquse destillatse . . . . q. s. ad Misce. Sig. — To be taken at one dose. Or, I^ — Bismuthi subcarbonatis Pulveris ti'agacantha? Acidi hydrocyanic! diluti Liquoris morphinse hydrochloridi (1%) Aquae chloroformi q. s. ad Misce. Sig. — At one dose, and repeat three times a day Gm. or Cc. 2.0 gr. XXX 2.0 lllxxx 30.0 5i Gm. or Cc. 0.75 gr. xij 0.30 gr. V 0.30 TIlv 0.65 mx 15.0 5ss 476 GASTRIC HEMORRH AGE—GASTRORRH AGI A Hyperchlorhj^dria not infrequently precedes gastric hem- orrhage. To counteract this condition, bismuth subnitrate is recommended in large doses after meals, wrapped in wafers or suspended in mucilage. The following combina- tion is of value: Gm. or Cc. I^ — Sodii bicarbonatis . 50 to 1 . gr. ^aij-v x ^lagnesii oxidi 0.65 gr. x Bismuthi subnitratis .... 1 . 30 gr. xx Cretse prEeparatse . 25 gr. iv Misce et ft. chart, no. i, mitte xx. Sig. — One powder after each meal. Constipation may occur with the administration of the foregoing, and under such circumstances a saline laxative would be indicated. Operative Treatment. — If energetic internal treatment should not be successful in checking chronic oozing of blood — as can easily be observed by daily examination of the feces with the benzidin test for occult blood — operative treat- ment should be advised. Either resection of the ulcer, or, where this is impossible, gastroenterostomy, should be performed. The latter operation frequently stops the hem- orrhage, especially if the ulcer be situated at the pylorus. In pyloric ulcer, however, it is not the hemorrhage, but the stenosis, which renders operation necessary. In cases which do not improve after a prolonged course of internal treat- ment, and pyloric obstruction is not present, it is unwise to promise a recovery by means of gastroenterostomy. Surgeons agree that good results from gastroenterostomy in ulcer of the stomach are obtained only when there is a pyloric obstruction. The operation does not afford drain- age and physiologic rest when the pylorus is patulous; Cannon and others have shown that food and liquids pass through the pylorus even after gastroenterostomy has been performed. The artificial opening does not help matters so long as the pylorus is unobstructed (see p. 208). CHAPTER XXI EROSIONS— PERIGASTRITIS EROSIONS OF THE STOMACH Forms. — Acute or Hemorrhagic Erosions. — These are small abrasions of the gastric mucosa which extend partly through this layer. They are usually multiple. They occur in the newborn; in chronic diseases of the heart or arteries; accord- ing to Dieulafoy, in acute infections with the pneumococcus; and in septic infection. Hemorrhagic erosions of the gastric mucous membrane are sometimes complications of chronic gastritis in its early stages. Pain in this condition is best relieved by lavage with a 0.5-per-cent. solution of nitrate of silver, after rinsing out the fasting stomach with lukewarm water. The silver solution should be permitted to remain in the stomach for about a minute; on its removal the lavage is repeated with lukewarm normal salt solution. This treatment may be employed every other day for ten or twelve days, or until all particles of mucous membrane have disappeared from the stomach contents. Chronic Erosions of the Stomach. — Einhorn, who was the first to describe gastric erosions as a clinical entity, defines the condition as one in which the gastric mucous membrane becomes the seat of small superficial exfoliations. Gerhardt describes erosions of the stomach as follows: ''Sections made of erosions show, as a rule, that at the base of the ulcerations almost the entire lower half of the mucous membrane is still preserved. In the epithelium of these remaining glands nothing remarkable can be discovered; at the sides the glands become longer; the first ones that are intact usually curve themselves over the defect and partly 478 EROSIONS— PERIGASTRITIS cover it. Recoven^ seems to take place by the simple aftergrowth of the gland remnants." Among others who have studied the condition are Mrchow, Langerhans, Hartung, Ewald, Pariser, Quintard, and ]\Ientz. Riegel maintains that the condition is not a distinct patho- logic process; he believes the small fragments of mucous membrane washed out of the stomach are of traumatic origin, due to tearing from the lavage process. Etiology. — The exact etiology of erosions of the stomach is obscure. Einhorn reports association of the condition wdth hj'perchlorhydria. but the vast majority of cases have been ascribed to chronic gastritis. The same factors which pre- dispose to gastritis are sometimes associated with erosions of the stomach, but in most cases of gastritis there is no evidence of erosions. In many cases in which gastritis could be excluded, Turck found erosions of the mucous membrane. He claims also to have found them, in the same cases, in other locations, mouth, pharynx, colon; and many a so-called ulcer of the rectum presents more of the sjniptoms of erosion than of ulcer. In lavage of the colon, particles are found in the wash-water smiilar to the specimens of mucous membrane found in the wash-water from the stomach of the same patients. Numerous factors predispose to erosion of the stomach. Children who have been ill-fed and those who do not appro- priate the full nutrition of their food, the vascular walls losing ''tone" though the body weight may not suffer, are more or less subject to erosion of the stomach. The abuse of alcohol is also a factor. Pariser asserts that chlorosis maj' play an important part in the causation of erosions. It would appear that erosions result from obstruction of the circulation to the stomach, combined with irritation of the gastric mucosa. Symptoms. — Pain is the most pronounced symptom. This comes on after partaking of food, irrespective of the kind. The pain of erosions differs from that of gastric ulcer, inasmuch as it is not intense, never boring or cramp-Uke, though Pari.ser states that in the cases under his observation EROSIONS OF THE STOMACH 479 the pains were described as "unbearable suffering." It is probable that the annoying constancy of this symptom impresses the patient with a sense of great severity. Pain comes on immediately after eating, persists for an hour or two, then gradually subsides. In some cases it persists all the time, irrespective of the partaking of food. Lavage generally dispels the pain. Frequently patients have no appetite. In some cases vomiting is one of the distressing symptoms. Pariser advises control investigation of the fasting stomach in order to differentiate erosions from gastric ulcer or from a neurosis. Patients lose weight at the beginning of their sickness, but after that the weight is fairly constant. They present a picture of emaciation, protruding jaws, and hollow cheeks, but not the cachexia which characterizes carcinoma and the severe wasting diseases. Patients with gastric erosions complain of weakness and inability to work, a feeling most marked directly after meals. Diagnosis. — The most important diagnostic feature of gastric erosions is the presence in the water, after lavage, of small pieces of gastric mucous membrane. Einhorn describes them as 0.3 to 0.4 Cm. long, about the same width, and of a blood-red color. Under the microscope, well preserved glands and accumulations of red blood corpuscles may be seen. Blood is almost never found in the washings which contain membranous exfoliations. This is explained by the probability that the pieces of gastric mucosa peel off some little time before the performance of lavage. When the return water is tinged with blood, this is the result of coughing which violently contracts the stomach. It is difficult to ascertain whether the exfoliations are from the same spots day by day, or from different locations. Pathology. — The pathology of erosions, according to Ewald (who has studied it soon after the death of the patient), presents the following picture: "The ducts of the glands were packed full of red blood cells, having their origin from hemorrhages on the surface of the mucous membrane, which in turn could only have come from the capillary network 480 EROSIONS— PERIGASTRITIS situated close to the free surface of the mucous membrane. They develop into little hemorrhagic erosions, small streak- like or rounded losses of substance, from the size of a millet seed to that of a pea, on which at times a blackish-brown extravasation of blood is found, together with a simultaneous loosening of the mucous membrane." In the majority of cases there is a decrease in the hydrochloric acid secretion. In some there is more or less profuse secretion of mucus. Prognosis. — The course of the disease is usually prolonged, extending sometimes over several years. There are, how- ever, intervals of improvement. Treatment. — The dietetic treatment depends upon the results of analysis of the gastric contents. The condition of the secretion determines whether the case shall be treated as subacid gastritis, acid gastritis, or hyperchlorhydria. The alkalies are indicated in hyperacidity; the vegetable bitters in cases characterized by a deficiency of hydrochloric acid secretion. There is, as a rule, marked muscle weakness; consequently food is apt to remain longer in the stomach than is normal. Time must be given for one meal to pass through the pylorus into the intestine before a second meal is taken. Turck advocates two meals a day, one in the morning and one at night. There msiy be, he says, some distress in the beginning from the loss of the noonday meal, but this is purely a question of habit, and the patient soon becomes accustomed to taking two meals daily, feeling more comfortable. With great loss of motor power dietetic measures must be ob- served. Chopped meat and wheat bread are all that is desirable in the beginning. We may gradually add to this, chicken, fish (boiled or baked, not fried), sweetbread, and calf's brain. Vegetables may be added later — potatoes, squash, and mashed turnips. General Treatment. — The indication for general treat- ment is the equalization of the circulation, for which Turck advises the bath and extension movements. The patient is placed in the bath at 105° F., and the temperature is rapidly increased to 110° or 115° F. ^^'hen his skin has EROSIONS OF THE STOMACH 481 become reddened, he is taken from the bath and rubbed with ice. The ice further stimulates circulation and reduces the temperature caused by the heat of the bath. Local Treatment. — The local treatment of the stomach in gastric erosions is of great importance. 1. Nitrate of Silver. — Beneficial results have been obtained by spraying the stomach with a solution of nitrate of silver (1 or 2 parts to 1000). Einhorn administers this treatment as follows: First the stomach, in a fasting condition, is washed out with lukewarm water, and, all the water being re- moved, the tube is withdrawn. The spray apparatus is filled with 10 Cc. (oiiss) of a 0.1 to 0.2 per cent, solution of nitrate of silver, and the tube end dipped in lukewarm water and introduced into the stomach; then the whole or the greater part of the solution in the bottle is sprayed. The bottle is then opened and the spray tube removed from the stomach. Einhorn alternates the nitrate-of-silver spray treatment with intragastric galvanization. The following prescription has been found useful : Gm. or Cc. I^ — Argenti nitratis 0.25 gr. iv Aquae destillatse . . . . q. s. ad 240 . § viij Misce. Sig. — Tablespoonful three times a day, before each meal. 2. The Bismuth Treatment. — This consists of lavage every other day with an alkaline suspension of bismuth, to dis- solve mucus, and the administration of bismuth subnitrate in doses of 1 to 2 Gm. (15 to 30 grains) three times a day (before meals). Gm. or Cc. IJ — Bismuthi subnitratis 30.0 5j Aquae chloroform! . . q. s. ad 240.0 5 viij Misce. Sig. — Tablespoonful three times daily, before each meal. 3. Suprarenal Gland. — Einhorn also recommends an extract of the suprarenal gland. He administers it every other day in powder form — about 3 grains. When this is used the nitrate-of-silver spray is omitted. 31 482 EROSIONS— PERIGASTRITIS Stockton and Jones recommend attention to the general health, and advise strychnine, arsenic, malt and cod-liver oil, fresh air, sunlight, mountain climbing, and other invigorating exercise, to be used appropriately. PERIGASTRITIS According to Mikulicz, perigastritis may develop in the course of an ulcer of the stomach, in two forms, namely, as a loose adhesion between the stomach and neighboring organs, whereby the former is subjected to traction; and, secondly, as tumor-like infiltrations caused by the gradual advance of the ulcer toward the abdominal wall. The local inflammation runs a latent course, and the symptoms are obscured by the more pronounced pains of the gastric ulcer. Perigastric adhesions are caused by ulcera- tion of the stomach and duodenum, gallstones in the gall- bladder or bile ducts, traumatism, malignant disease, pan- creatic disease, umbilical hernia, and possibly tubercle and syphilis. The adhesions are usually to the pancreas, liver, or spleen. Adhesions to the anterior abdominal wall are very rare. Symptoms due to adhesions arise usually in cases where the attachment is to one of the more mobile organs, which drag on the adhesions. Liver or pancreas adhesions are usually short and broad; those to the colon or gall-bladder may be long and cord-like. The shape of the stomach may be markedly or only slightly altered. The pylorus may be narrowed, or the stomach may be nearly divided into two parts — hour-glass stomach. Other effects are: Dilatation by traction, and interference with motility and contracting power. The history of the case is usually a long one, and the symptoms finally complained of are not infrecjuently preceded by others more characteristic of gastric ulcer or gallstone colic. Pain is the most common and characteristic symptom, and a marked feature is the fact that it is frequently confined to one locality. It is usually greatly influenced by the position of the patient, PERIGASTRITIS 483 but very little by food. Violent exertion often brings on the pain; it is sometimes relieved by firm pressure or band- aging. Local tenderness is usually present. The secretion of gastric juice is normal. Forms. — ^Among the varieties of this pathologic condition are: 1. Local adhesive growths, ivhich may or may not give rise to distressing symptoms. These adhesions may cause pain of greater or less severity, especially when the adhesive bands are subjected to traction by various bodily movements (walking, gymnastics) or the distention of the stomach with food. The adhesions may result in disturbing the motility of the stomach. The diagnosis is often difficult, since little or nothing can be elicited by palpation. According to Rosen- heim, a diagnosis of perigastritis is warranted when, after the healing of a gastric ulcer, the painful symptoms persist, or when the usual treatment of the stomach for disturbances of motiUty does not lead to improvement. Boas maintains that perigastric adhesions, as such, are only exceptionally recognizable ; in most cases one can hardly arrive at a posi- tion beyond probability or supposition. The chief point lies, not in recognizing the perigastritis or the character of the tumor, but in diagnosticating the latent gastric ulcer which leads to these complications. Duplant says that symptoms of perigastritis are commonly seen in dyspeptics in whom an ulcer has been suspected for a long time. Ac- cording to this author, the only symptom of value is palpa- tion of an indurated mass corresponding to the affected part. 2. Perigastritis with the formation of tumors. When the symptoms of gastric ulcer persist for months or years, a tumor becomes apparent in the left epigastric region. The growth of the tumor is gradual, and the mass is often adherent to the anterior abdominal wall. Vomiting is frequently a symptom. It may not be possible to exclude the alternative of malignancy until after a somewhat extended period of observation. In 1895 Hofmeister reported a case of gastric ulcer adherent to the anterior abdominal parietes which, causing 484 EROSIONS— PERIGASTRITIS perigastritis and infiltration of the anterior abdominal wall, gave rise to a tumor. Hofmeister considers the following symptom-complex as typical of these cases: Some time after the beginning of long-continued indigestion of greater or less severity, a tumor, very gradually increasing in size, develops in the left epigastrium. During the later years of the malady pain becomes pronounced ; this is verj" severe, and is confined to the vicinity of the tumor; it takes the form of attacks, especially after the ingestion of food. Vomiting is sometimes observed; hematemesis occasionally. Finally the nutrition is impaired to a marked degree, and the patient may become greatly emaciated. Diagnosis. — ^^Tiite^ does not favor the exploratory lapar- otomy which Boas states is an acknowledged and necessary measure for the recognition and cure of perigastritis. He urges a more careful study of the sj^mptoms in order that a diagnosis may be made and proper treatment instituted at an early period. He believes that with some care and study the diagnosis of perigastric adhesions can be made in most instances without operation. Adhesions from gastric ulcer are by no means uncommon; in the postmortem room about 45 per cent, of the cases of gastric ulcer show more or less adhesion to neighboring organs. Fenwick's table of 123 cases shows the pancreas and liver to be the organs most frequently involved in the adhesions. Adhesion to the pancreas frequently saves the patient from the danger of perforation. White bases his remarks on a study of a series of five cases which submitted to operation. In all of these cases severe pain was the prominent symptom, two of the patients requiring large amounts of morphine. Pain is usually located at the upper part of the abdomen, and a history of its continuance for years is of the utmost diagnostic value. The pain is apt to be of a paroxj^smal character, but some j^ain is nearly always present. Carci- noma is the only other condition which is apt to produce prolonged and constant jiain wilh acute exacerbations. In cases of perigastric adhesions little or no loss of flesh ' Lf)i)(I()n Laticct. Novonihor 30, IHOl. PERIGASTRITIS 485 is observed, the eoiidition is seldom fatal, and the patients are mostly young people. In none of his cases did White find that the taking of food produced an increase of pain. The paroxysmal character of the pain is supposed to be due to peristalsis, which causes a dragging upon the adhe- sions. It is thought that many cases of "gastralgia," ''hysteria," or ''hypochondriasis," if carefully investigated, would be found to be due to intra-abdominal adhesions. Local tenderness is sometimes elicited, and more rarely still the matting together of the organs can be made out by palpation. Dilatation of the stomach is often present, but, unlike that due to ulcer, there will be no vomiting, the tongue will be clean, and there will be few symptoms of indigestion. Severe pain, in fact, is the most prominent symptom. It must be remembered, of course, that peri- gastric adhesions and an unhealed gastric ulcer may be associated. When the symptoms are due entirely to the adhesions, the pain is apt to be constant and of long dura- tion, more pronounced when the stomach is empty than when it is full ; it is not produced or increased by the taking of food. The situation of the adhesions will also influence the symptoms. For instance, if a band passes from the stomach to the colon, the contraction of either of these organs will cause severe pain; but if a large area of the stomach is fixed to the pancreas, it is not likely that the pain will be severe. The history of an old gastric ulcer is of the greatest value. Treatment. — Prophylaxis. — This consists in the early diag- nosis of gastric ulcer and its early cure, for the sooner an ulcer heals the less opportunity is there for the formation of adhesions. Of therapeutic agents, only fibrolysin and thiosinamine are worthy of consideration. These drugs may be used in the less severe forms of adhesions, cicatricial stenosis, and the so-called "hour-glass contraction." The treatment of cicatricial stenosis by fibrolysin has been described (p. 414). Tabora has recommended thiosinamine, together with massage of the distended stomach, as follows : For three months, daily, 1 Cc. (15 minims) of a 20-per-cent. 486 EROSIONS— PERIGASTRITIS thiosinamine-glycerin-water solution hypoderniically ; effleur- age at the same time over the stomach distended with air. The so-called hour-glass stomach is to be treated in other respects as motor insufficiency of the second degree. When a diagnosis of perigastritis has been made with reasonable certainty, too much time should not be spent with internal medication, inasmuch as surgical intervention is indicated. In sunple adhesions good results have been obtained bj^ simply breaking them up. TMien the condition is comphcated viith motor disturbance, a gastroenteros- tomy should be performed. The perigastric tumor must be treated surgically. The surgical treatment for cicatricial stenosis of the pylorus, and the indications therefor, have been discussed in another chapter (p. 209). It is important for the surgeon to bear in mind that there may be two ulcers and therefore two sets of adhesions in the same case. It is a mistake, in cases of gastric ulcer with sjmiptoms of adhesions, to attempt a cure by rectal feeding; the patient is sure to lose ground under such treatment. Promotion of visceral movement is the most efficient means of preventing adhesion of raw peritoneal surfaces — movement in bed, general massage, and mild laxatives. When the adhesions cannot be separated it may become necessary to perform pyloroplasty or gastrojejunostomy. CHAPTER XXII ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS ARTERIOSCLEROSIS Sclerosis of the gastric arteries may be responsible for any one of the three following pathologic manifestations: 1. Gastric Hemorrhages. — The cause of the hemorrhages is mihary aneurism of the gastric arterioles, developing on sclerotic bases. The diagnosis can be made wdth a reason- able degree of probability only in patients of advanced age who are affected with a general arteriosclerosis. The treat- ment of this form of hemorrhage is the same as that of gastrorrhagia from other causes. 2. Gastric Ulcer. — This condition is likely to supervene in vascular areas in which the blood supply has become defective in consequence of sclerotic obhteration of the arterioles. The treatment is that of the round or peptic ulcer. 3. Abdominal Angina. — Pain of a severe and paroxysmal nature sometimes follows sclerosis of the abdominal aorta and its branches. The attacks are apt to take place at night after bodily exertion or mental excitement. Arteriosclerosis consists of a thickening of the intima as a result of primary changes in the media and adventitia. The sclerotic condition may be diffuse or circumscribed; later in the progress of the disease it involves the media and adventitia. We owe our conception of arteriosclerosis as a clinical entity to the studies of Gull and Sutton. Etiology. — Among the important factors producing sclerotic changes in the arteries are: 1. Old Age. — Arteriosclerosis is preeminently a disease of the later years of life, when it occurs as an involution 488 ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS process, an expression of the natural wear and tear to which the arteries are subjected. Longevity is largely a vascular question; the relationship is well expressed in the adage, "A man is as old as his arteries." 2. Toxic Factoids. — Alcohol, lead poisoning, and gout are important factors in the causation of arteriosclerosis. 3. Syphilis. — Syphilis, inherited or accjuired, is a most important cause of sclerotic changes in the arteries of the young and the middle-aged. 4. Overeating.- — Overeating is an important etiologic factor. Osier quotes George Cheyne's thirteenth aphorism, which contains a vast amount of dietetic sense: ''Every wise man after fifty ought to begin to lessen at least the quantity of his aliment, and if he would continue free of great and dangerous distempers and preserve his senses and faculties clear to the last he ought every seven years to go on abating gradually and sensibly, and at last descend out of life as he ascended into it, even into the child's diet." 5. Overwork. — Muscular overwork or prolonged and severe exercise tends to produce hypertension by increasing the peripheral resistance. Pathology. — The changes to be described under this head- ing are of a degenerative character, and have an important bearing upon the integrity of the arterial walls as well as upon the viscera supplied by the sclerosed arteries. Owing to the proliferation of endothelium and to an increase in the connective tissue of the intermediate layer, a thickening of the intima results, which may wholly or practically occlude the lumina of small arteries. In the large arteries the new tissue may form beneath the endo- thelium diffusely or in circumscribed masses. The endo- thelium may remain intact or it may undergo various changes; it may proliferate, or it may become fatty or necrotic. The newly formed fibrous tissue of the intima is apt to undergo fatty degeneration, to become necrotic, and to disintegrate. Cavities of varying size, containing dis- integrated tissue, fat and cholesterin crystals, develop in ARTERIOSCLEROSIS 489 the newly formed tissue into what have been designated atheromatous cysts. These cysts may extend toward the lumen of the vessels, opening; into which they may give rise to emboli or form rough ulcers (often with undermined edges) upon which thrombi may form. In the newly formed tissue of the intima, as well as in the necrotic foci and in the detritus of the cysts, calcification may occur. Fatty degen- eration, atrophy, and calcification may occur in the muscu- laris and adventitia of the involved vessels. Ortner, to whom we are indebted for much light on this obscure condition, described a case of general arteriosclerosis involving the superior and inferior mesenteric arteries and through them the intestines. The s^nnptoms had to do largely with the intestines, and consisted of severe pains in the region of the navel, coming on two or three hours after eating, extreme distentions from gas, difficulty in breathing, and explosive belching. The ascending and transverse colon were distended to such an extent as to be visible through the abdominal wall. Ortner explained the condition on the basis of a pathologic examination. The aorta was thickened and calcified; there w^as a thick deposit of lime salts about the mouth of its branches, especially the mesenteric arteries, and the small branches of these were stifT, inelastic, and probably contracted. The result of this was that the intestines did not receive a sufficient quantity of blood from the aorta through the mesenteric arteries, and what did come to them was poorly distributed because of the changes in the arterioles. The intestinal w^alls were poorly nourished; the muscular coat, weak and inefficient, was unable to do its work, and when, two or three hours after eating, the intestines began to be called on to carry out their part in digestion, they could not do so — their motility was impaired, and probably also the secretory and absorptive functions. The arteries supplying the stomach are in no way exempt from arteriosclerotic degeneration. In fact, the round ulcer has been seen frequently as a result of the trophic disturbances produced by arterio- sclerosis. 490 Arteriosclerosis— s yphilis— tuberculosis The same causes to which Ortner attributes the intestinal symptoms would account for similar sjTiiptoms referable to the stomach. Symptoms. — These general arteriosclerotic changes give rise to symptoms which are attributed by the patient to the stomach and some primary disorder of digestion. The patient can never be fully con\'inced but that if his stomach were in good condition he would be well again. Among the subjective symptoms are a feeUng of fulness in the epigas- trium, pain under the ensiform cartilage running down the left arm, gaseous eructations, and extreme nervousness and anxiety. There is. as a rule, immediate relief on belching. These are the leading sj^mptoms which were complained of by a number of patients, and which subsided after appro- priate treatment directed to the vascular system. The digestive disturbances are secondary to primary changes in the arterial system. In fact, not only the stomach, but the whole intestinal tract is affected by the changes. Diagnosis. — In his diagnosis the physician should not be led astray by the complaints of his patient as to indigestion, pain in the stomach, distention, and belching, but should make a careful search for the underlying cause of the diges- tive disturbances. In patients past middle hfe who complain of pain in the stomach, distention after eating if they attempt any physi- cal exertion, and dyspnea, relieved by belching of gas — especially when nocturnal seizures, accompanied by dis- tention, heart disturbances, dyspnea, and great anxiety, are prominent symptoms — a careful examination of the vascular system will, as a rule, reveal the real cause of the condition. Such examination usually shows a heart some- what enlarged, an aortic second sound sharp and snapping, a murmur over the aortic area and rough sounds over the aorta itself, pulsation in the episternal notch, attacks of pain over the precordial region radiating to the arm, marked tenderness over the abdominal aorta down to the navel, urine perhaps increased in amount or containing allnimin in small quantit}', or both increased and albuminous. All ARTERIOSCLEROSIS 491 these point unmistakably to the circulatory system as the real cause of the trouble. Treatment. — The diet should be plain, nutritious, and easily digestible. The evening meal should be limited in size, to minhnize the formation of gas. Alcohol, tobacco, tea and coflfee should be interdicted in arteriosclerosis, or restricted to a minimum. Moderation in eating and drink- ing is essential to the arrest of the pathologic process going on in the arteries. Animal foods should be restricted, for the digestion of these foods develops substances that add to the abnormal conditions already prevailing in the body. Bathing, fresh air, moderate exercise, and attention to the bowels should enter into the hygienic treatment. In- tense excitement should be avoided. Many patients require absolute physical and mental rest, especially as they enter the stage of myocardial incapacity. By proper clothing the peripheral cumulation should be protected from sudden changes of temperature. Of medicinal agents for the treatment of arteriosclerosis producing gastric symptoms, Akin^ reconmiends diuretin, or sodiosalicjdate of thiobromine, in doses of 0.5 to 1 Gm. (8 to 15 grains) three times a day. According to this writer, so satisfactory is diuretin in bringing about an ameUoration of sjTiiptoms that it has been used as an aid to diagnosis in doubtful cases. Its effects depend on its powerful action in overcoming the vascular spasm and dilat- ing the arterioles so that they allow a greater flow of blocd to the sclerosed areas. It has been suggested by Buch that diuretin may neutralize the effect of some toxic agent which tends to irritate the vasomotor centres and cause contraction. Whatever the exact mode of action, its effects are very satisfactory, and its use may be continued for one or two weeks or even longer without harm. The effect may then be maintained b}' the use of tincture of strophanthus, 5 to 8 drops three times a day. Strophanthus has been observed to act so much like diuretin that it is used in place of the latter in some cases in which expense is a great considera- ^ Journal of the American Medical Association, June 5, 1909. 492 ARTERIOSCLEROSIS— S YPHILIS—TUBERC U LOS IS tion. Erythrol tetranitrate, introduced as a useful agent in arteriosclerosis by Turney, of Flintshire, England, lowers blood pressure and maintains its vasodilator effect for a longer period of time than other preparations of the same class. Its influence upon the bloodvessels is manifest in fifteen to twenty minutes after the dose is administered and persists for three to four hours. The dose is 0.02 to 0.06 Gm. (I to 1 grain). Variation in the amount and frequency of the dose is regulated by the demands of the case and the effect on the patient. Brown, ^ in recommending the iodides in arteriosclerosis, maintains that the continued good effects of this medication are to be obtained only by gradually increasing the dosage until the sluggish live cells are sufficiently stimulated and enough degenerated cells destroyed to insure the restitution of function in the tissues. The prolonged administration of small doses fails to accomplish permanently favorable results; but large and progressively increasing doses produce strikingly good results, in early cases particularly. He advises that in the use of potassium iodide the patient be started with a 0.6 Gm. (10 grain) dose three times daily, which should be daily increased until 4 to 4.6 Gm. (60 to 70 grains) are given each day. lodism can be prevented by the careful exclusion of acids from the diet, and by neutralization of the acid contents of the stomach by means of any agreeable alkali (as the alkaline mineral waters). With potassium iodide it is wise to combine potassium bicarbonate in the proportion of one of the former to two of the latter. The combination of sodium iodide and potassium iodide in con- nection with the use of the alkaline waters above mentioned proves more satisfactory than the separate use of either; and therefore, when the use of the iodides is to be continued for a long period of time, the combination should be pre- scribed. In this connection it should be stated that Romberg believes potassium iodide reduces the viscosity of the blood and in that way assists in the relief of blood pressure and in invigoration of the arterial tissues. ' .Journal of the Aincricim Modical Assofliafioii, January, 1910. ARTERIOSCLEROSIS 493 Thyroid extract has been administered in arteriosclerosis, with favorable results, due to its power to control high arterial pressure. Aufrecht,' in a treatise, expresses his l)elief that the ana- tomic process of arteriosclerosis has its origin in the vasa vasorum, which are overloaded with red blood corpuscles; the walls of the vessels of the connective tissue are altered, and the result is an obliteration of the vasa vasorum. The media and intima next undergo changes, arteriosclerosis being the final outcome. As to treatment, he has experi- mented with potassium iodide, which some regard as a specific, but favors iron, which he has employed for ten years. He claims to get good results from an iron pill of the following composition: Gm. or Cc. I^ — Ferri reducti .3.0 gr. xlv Sodii carbonatis exsiccati 4.0 oj Pulveris glj'cyrrhizse 2.0 5ss Extract! glycyrrhizse, q. s. Misce et ft. pil. no. Ix. Sig. — Two pills to be taken three times a day. The use of these pills is continued for two months, fol- lowed by a rest of a fortnight or a month, when the treat- ment is renewed. Some patients have been kept on the treatment for four years. In the endeavor to combat arteriosclerosis by promoting vascular metabolism, strengthening the vasomotor nerves, and reducing the tension of the vessels, Trunecek resorted to the hypodermic administration of the inorganic blood salts. His results have been confirmed by Tessier, Levj', Merklen, Zanoni, and others; the serum acts on the lime phosphate, removes dyspnea by increasing the alkalinity of the blood, has a direct effect on the heart and the vascular endothelium, and stimulates the vasomotor system. Levy has found that, given by mouth, the salts have the same effect as when administered hypodermically. Under the 1 Zur Pathologie und Therapie der Arteriosklerose. 494 ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS trade name antisclerosin, a combination consisting of these blood salts is available. Each dose (two tablets) contains: Gm. or Cc. I^ — Sodii chloridi 0.8 gr. xij Sodii sulphatis 0.08 gr-ij Mag^esii phosphatis, Sodii carbonatis exsiccati . . aa 0.03 gr. ss Sodii phosphatis, Calcii glycerophosphatis . aa 0.025 gr. f This represents at least 15 Cc. of Trunecek's serum, and equals the salt contents of about 150 Cc. of blood serum. Though certain cases are incurable, antisclerosin is said to relieve the subjective and objective symptoms even in severe cases. Its chief field of usefulness is as a prophylactic. SYPHILIS Syphilis of the stomach is a very rare affection. All the cases so far observed have occurred during the tertiary stage of the disease. Gastric syphilis appears in three forms — (1) specific ulcers of the stomach; (2) specific tumors; (3) specific stenosis of the pylorus. The syphilitic ulcer is the most frequent manifestation of syphilis affecting the stomach; it may develop as a result of disturbances in the circulation affecting circumscribed areas of the gastric mucous membrane, and having as its primary cause a spe- cific endarteritis. Ulcers may also arise from the disinte- gration of gummata in the submucous coat of the stomach. The gummatous ulcer develops in the submucosa, while that caused by specific endarteritis is essentially an ulcer of the mucosa; neither differs in any way from the ordinary round ulcer, except that the specific ulcer is much less amenable to treatment. Diagnosis. — It is a very difficult matter to make a diag- nosis of syphilitic ulcer, and the clinician nuist rel}' upon the known presence of syphilitic infection in order to be at all certain that the gastric ulcer is of luetic origin. The pres- SYPHILIS 495 ence or absence of the Treponema pallidum (Spirochaete pallida), according to both Koch and Schmorl, is not to be depended upon in determining the presence or absence of ulcer of syphilitic origin. These microorganisms are often absent in cases of undoubted syphilis; on the other hand, Koch, using the Levaditi stain, found, in cases of undoubted carcinoma of the lung, organisms of the typical appearance of the Treponema pallidum. Another important factor which plays a part in the anatomic diagnosis of syphilis of the stomach is a peculiar vascular change of high grade, resulting in partial occlusion or obliteration of vessels. Cellular accumulations are found about the vessels, which become thickened from cell increase thus beginning from without; or subendothelial change may be the prominent feature. The process tends to spare many vessels entirely, while others are thickened to the point of occlusion. Syphi- litic ulceration of the stomach should be distinguished clinically from carcinoma and the gastric crises of locomotor ataxia. The differentiation between syphilitic ulcer and other conditions producing dyspeptic symptoms may be further made by a course of antisyphilitic remedies, such as potassium iodide, which will usually ameliorate syphilitic symptoms while the same treatment would have the reverse effect upon ordinary cases of gastritis. According to Peter, a greater number of men than women are affected by syphilis of the stomach. The time between the chancre and the lesion varies from two to forty years. Allen A. Jones has called attention to syphilis as an important cause of gastralgia. He maintains that there are cases with symptoms referable to the stomach that are not caused by any apparent lesion of that organ, but are rather the result of nervous disturbance, and disappear under antisyphilitic treatment. Treatment. — The treatment of syphilis of the stomach consists in the methods and agents employed in cases of gastric ulcer and gastric hemorrhage, together with such specific remedies as mercury and the iodides, the latter being tolerated well by the luetic stomach. 496 ARTERIOSCLEROSIS— S YPHILIS—T UBERC ULOSIS Syphilitic stenosis of the pylorus is an exceedingly rare condition, which may be due to cicatrices of syphilitic ulcers or tumors and gummatous infiltration in the region of the pylorus. The treatment for this condition is the same as for motor disturbances. Williams^ classifies the hypodermic treatment of syphilis under three heads — subcutaneous, intramuscular, and intra- venous. The advantages of hypodermic medication are: accuracy and regulation of dose of the mercury adminis- tered, rapidity of action, certainty of absorption, non- impairment of the digestive functions, and mitigation of intestinal disturbances. Of the methods of hypodermic medication, the intramuscular is perhaps superior to either of the other two. The most convenient location for the administration of mercury is the gluteal region, the right and left side being used alternately. The best location for the puncture is above the level of the great trochanter, supposed to be the region of least sensation. The skin should be properly cleansed, and the needle should be thoroughly sterilized before its introduction by being held for a few seconds in the flame of a spirit lamp. After cooling, the needle may be plunged into the muscle tissues at right angles until the proper depth is reached, which will vary with the amount of subcutaneous fat, but is usually from three-quarters of an inch to one inch below the surface of the skin. After the needle is withdrawn the site of the injec- tion should be gently pressed by the finger for a few moments. The puncture wound should be sealed by means of aseptic absorbent cotton saturated in collodion. Meltzer and Auer^ have demonstrated that absorption after an intramuscular injection is far more rapid than after a subcutaneous one. The sacrospinal muscle presents a large, roundish, compact mass of muscle tissue, consisting of fine muscle bundles, densely packed, with very little connective tissue between. On the other hand, the gluteal muscles are made up of flat nuisclc layers consisting of ' London Cliniral Journal. '^Journal of Experimental Medicine, UK)"), vol. vii, p. 1. SYPHILIS 497 coarse muscle bundles separated by loose connective tissue. An injection into the sacrospinal muscle always remains intramuscular, while the medicated solutions can readily escape from the gluteal muscles into the loose connective tissue. Clinically, it has been established^ in a limited number of cases of syphilis that ''salvarsan" injected into the sacrospinal muscle exerts a fairly rapid and unmistak- ably beneficial influence upon the secondary and tertiary manifestations and upon the Wassermann reaction without causing pain or other ill effects deserving serious considera- tion. Metallic mercury is administered intramuscularly in the form of gray oil; the formula for making up this combi- nation is as follows: Gm. or Cc. I^ — Hydrargyri 2.0 3ss Unguenti hydrargyri 0.12 gr. ij Petrolati liquidi 4.0 3j Misce. Sig. — From one to two minims injected at a dose. Gm. or Cc. I^ — Hydrargyri 1.0 gr. xv Petrolati liquidi (carbolized 2 p. c.) . . 10.0 5iiss Misce. Sig. — Ten minims injected once a week. (Lambkin.) Gm. or Cc. ^ — Hydrargyri salicylatis 1.0 gr. xv Petrolati liquidi 10.0 3iiss Misce. Sig. — From 3 to 10 drops injected once a week or once every two weeks. (Gottheil.) Gm. or Cc. I^ — Hydrargyri benzoatis, Sodii chlozidi aa 0.3 gr. v Aquse destillatae 30.0 5j Dissolve with the aid of heat and then filter. Sig. — Ten minims injected once or twice a week. (Gottheil.) Gm. or Cc. I^ — Hydrargyri ehloridi mitis 0.3 gr. v Olei olivse 6.0 3is3 Misce. Sig. — Ten to fifteen minims introduced hypodermically. 1 S. J. Meltzer, On the Injection of Drugs, Especially of Salvarsan (Ehr- lich), into the Lumbar Muscles, Medical Record, March 25, 1911, p. 516. 32 498 ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS The succinimide of mercury may be given as follows: Gm. or Cc. I^ — Hydrargyri succinimidi 2.0 3ss Cocainse hj^drochloridi . 65 gr. x Aquae destillatse 45.0 giss Misce. Sig. — Fifteen drops hypodermically twice a week. Salvarsan. — A remedy for syphilis has been announced which bids fair to revolutionize the treatment of this disease. It is an arsenical compound, dioxydiamidoarsenobenzol, and is known as '' Salvarsan," the "Ehrlich-Hata prepara- tion/' and ''606." The chemical composition of the drug is C12H12O2N2AS2, and is expressed in the following graphic formula : As = As OH OH In connection with Weinberg, Ehrlich succeeded in pro- ducing a dyestuff, called trypan-red, which cured absolutely every mouse infected with the trypanosome of sleeping sickness. From this fact he inferred the possibility of pro- ducing a specific, one injection of which should destroy the parasites in the human body. Although trypan-red possesses the power of destroying all the trypanosomes in the bodj^ of an infected mouse, it has no effect on trypanosomes mixed in a test-tube with blood. It was soon discovered that certain substances which have no effect on the parasites in the test-tube are so changed inside the bodj^ that they become effective. Trypan-red either destroys all the para- sites within the body of the mouse by its specific action, or it destroys a few, and the remaining ones are destroyed by the rapidly formed antibodies. It was on lines of this experimentation that Ehrlich came upon dioxydiamido- arsenobenzol (606). He calls the drugs that destroy living parasites without injury to the organic tissue parasitropic. Those that destroy organic tissue he calls organoti-opic. SYPHILIS 499 Dioxydiamidoarsenobenzol will be classed among the para- sitropic remedies. It destroys the parasites in the body, and these dead parasites induce the formation of antibodies which assist the action of the drug. This preparation is a yellowish crystalline substance, not unlike iodoform in appearance, and must be kept in her- metically sealed ampoules, for it becomes very toxic when exposed to the air. For administration it must be handled with the greatest care, and exact details in the technique must be carried out. A safe method of administration is that of Wechselmann: The dioxydiamidoarsenobenzol is shaken out of its sealed glass ampoule and is dissolved by rubbing in a sterile agate mortar with one to two cubic centimeters of 10-per-cent. caustic soda solution. The addition of glacial acetic acid drop by drop then throws down a precipitate in the form of a fine yellow powder. This in the next place is suspended in one to two cubic centimeters of sterilized distilled water, and the fluid is neutralized by decinormal soda solution or acetic acid of 1 per cent, strength, the reaction being very carefully observed with litmus paper. The painless- ness of the injection depends upon the exactness of the neu- tralization. For this reason the suspension is centrifugalized, the fluid poured off, and the yellow sediment suspended in physiologic salt solution. This suspension is drawn up into the syringe and slowly injected subcutaneously at a point below the shoulder-blade, the place having been pre- viously made aseptic and touched with tincture of iodine. A little pain often continues for some minutes after the injection, and local lesions are not uncommon. Kromayer^ uses an emulsion of dioxydiamidoarsenobenzol in liquid petrolatum. The drug is rubbed up with the oil so that one cubic centimeter of the emulsion will contain ten centigrammes of the remedy. Kromayer says there is no pain incident to the administration of the chemical thus prepared. But while the oil preparation gives little pain at the time of the injection, a pain develops in three or four 1 Med. Klinik, 1910, No. 40. 500 ARTERIOSCLEROSIS— SYPHILIS— TUBERCULOSIS days, due to local absorption and the inflanmiatory reaction thus induced in the tissues. Ehrlich recommends intravenous injections, repeated several times and followed after some months bj^ an intra- muscular injection. The intravenous injection after the method of Schreiber is as follows: Into a graduate of 250 Cc. capacity put 10 to 20 Cc. of ster- ilized water. Add the required dose of dioxydiamidoarseno- benzol and mix thoroughl}^ until a clear solution results; add steriUzed water or normal salt solution to the 100-Cc. mark; then add for each 0.1 Gm. of dioxydiamidoarseno- benzol 0.7 Cc. of normal sodium hydrate solution and mix well until the precipitate is thoroughly redissolved. If after thorough mixture the solution is not clear, add a few drops of the sodium hydrate solution until it becomes clear, and then add sufficient normal salt solution to make 200 to 250 Cc. The fluids used must all be warm. The alkaline mixture is then ready for injection. It should be understood that all the chemicals used in the preparation of the material for injection are to be kept thoroughly sterile. The treatment consists of a single injec- tion of 0.3 to 0.9 Gm. (5 to 14 grains) of dioxydiamidoarseno- benzol in solution, given intravenously or into the gluteal or pectoral muscles. A large number of patients have been successfully treated with this preparation. It has been used in the treatment of syphilis in aU stages, from the primary chancre to the deep specific lesions of the central nervous system. It possesses apparently the peculiar property of killing and extermina- ting the Treponema pallidum fSpirochsete pallida) wherever it is to be found in the lesions. It is said to cure syphilis in all three stages. The immediate effect of this latest antisyphilitic agent is manifest in its prompt action on syphilides, mucous patches, gummata, and chancre. The drug relieves the shooting j)ain, the girdle sensation, and the tabetic crises almost immediately. But it cannot he expected to regenerate destroyed tissues. In the diagnosis of syphilis, Ehrlicli lays great stress TiBERCULOSIS 501 upon the Wasserinann reaction as a conclusive factor in determining whether or not salvarsan shall be injected. A positive reaction proves the presence of syphilis, and the injection of salvarsan is advised. Very often a positive Wassermann reaction becomes negative after one injection of salvarsan, and, on the other hand, the reaction may con- tinue positive although all symptoms indicative of the disease have subsided or disappeared. General Treatment. — Patients suffering from syphilitic diseases of the stomach should be kept at rest, preferably in bed. Their food should be of a simple, unirritating kind, its precise character depending upon the severity of the symptoms. In very severe cases it may be necessary to resort to rectal alimentation. In any case it is advisable to inaugurate the treatment by a milk diet. As the condition of the patient improves, the quantity and variety of the food may be slowly increased, and jellies flavored with lemon and sweetened, junket, eggs hghtly cooked or beaten up with milk, custards or tapioca pudding, may be permitted. This regimen may be followed later by bread and butter, fish, chicken, rabbit, or veal. No meat should be allowed for at least six months. The bowels should be carefully regulated, and for the control of constipation resort should be had to saline cathartics. TUBERCULOSIS Gastric tuberculosis is a very rare condition, and when present it is usually secondary to or associated with tuber- culosis of other organs. Forms. — Three forms of tuberculosis of the stomach have been recognized, namely: (1) Mihary tuberculosis — always secondary to general miliary tuberculosis; it cannot be diagnosticated, and is therefore not amenable to treatment. (2) Tuberculous ulcer. This occasionally produces disturb- ances similar to those produced by peptic ulcer. Hemor- rhages are not infrequent, and perforation is more likely 502 ARTERIOSCLEROSIS— S YPHILIS—T UBERC ULOSIS to occur than with peptic ulcer. Tuberculous ulcer has been attributed to the swallowing of tuberculosis sputum. It may also result from infection through the blood and lymph routes. The treatment is that of peptic ulcer. (3) Tuber- culous granulation tumors — located on the pylorus or in the region of the pylorus. The symptoms resemble those of gastric carcinoma, and the treatment is the same as for the latter. Success has followed resection in tuberculous stenosis of the pylorus. Ellis^ reports two cases of tuberculous ulcer of the stomach. One had extensive ulcerated tuberculosis of both lungs and likewise tuberculous ulcers in the ileum and colon. In the floor of most of the ulcers gray or yellow tubercles were found. The other case was a chronic adhesive tuberculous peritonitis, with multiple tuberculous fistulse in the left inguinal and trochanteric regions. On the serous surface or peritoneal coating of the stomach, scattered irregularly over the entire viscus, were numerous tubercles of varjdng size. Treatment. — The treatment of tuberculosis of the stomach is the treatment of tuberculosis localized elsewhere in the body. 1 New York Medical Journal, March 12, 1910. CHAPTER XXIII TUMORS OF THE STOMACH: CARCINOMA — SARCOMA — FIBROMA — FIBROMYOMA — LIPOMA — ADENOMA — PAPIL- LOMA — POLYPI — HERNIA EPIGASTRICA CARCINOMA. Etiology.- — Incidence. — Of all the viscera of the body, the stomach is most frequently the seat of carcinoma. Of the total number of carcinoma cases reported, from 40 to 45 per cent, are said to be cancer of the stomach. It occurs more frequently in males than in females. Many writers, among them Haeberlin, have reported carcinoma to be on the increase. Of all the cases reported during the period between 1877 and 1886, Haeberlin found 41 per cent, to be carcinoma of the stomach. According to Wyss the death rate from cancer is nearly 2 per cent, of the totalmortality; Bryant states that in New York City for the ten years immediately preceding 1896, it was 2.17 per cent, of the total mortality. The frequency of this disease varies in different countries. There are certain regions in which it seldom occurs. Griesinger states that he has never seen a case of cancer of the stomach in Egypt, while Heinemann reports that he saw only one case in Vera Cruz during a period of six years. Owing to the unreliability of registra- tion statistics it is very difficult to estimate whether cancer is increasing or not. When we consider the advances that have been made in medical science in the way of refinement of diagnosis, it is evident that carcinoma is more frequently discovered and differentiated from non-malignant growths than was formerly the case. This of itself would account, in a measure, for the apparent increase in the prevalence of the disease. 504 TUMORS OF THE STOMACH Age. — Regarding the age at which gastric carcinoma occurs most frequently, Brinton has collected some inter- esting data. In 600 cases the year of death averaged fifty — two-sevenths of these between fifty and sixty. This writer places the maximum liability between sixty and seventy. Under twenty, the whole risk is less than one-fiftieth of what it is between twenty and thirty. Lebert gives us the following figures as to the age at which cancer of the stomach occurs: Under thirty years, 1 per cent.; thirty to forty years, 17.6 per cent.; forty to sixty, 60.7 per cent.; sixty to seventy, 16.3 per cent; above seventy, 4.4 per cent. Heredity. — The influence of heredity as a predisposing cause of cancer of the stomach is still an open question. The occurrence of cancer in one or more of the offspring of carcinomatous parents has been noted, but not with marked frequency. Cancer has been known to attack persons whose health up to the time of the attack had been remarkably good. Among predisposing if not strictly etiologic factors, gastric ulcer, the cicatrix of an ulcer, achylia gastrica, and chronic gastritis may be mentioned. The mode of living is not, however, responsible for the devel- opment of cancer of the stomach, nor can traumatism be said to be specially productive of this form of malignancy. Injury, however, may stimulate into activity an incipient or dormant carcinoma. The infectious nature of cancer still remains to be proved. Brinton explains the occurrence of cancer of the cardia and pylorus as follows: The muscle fibres of these two orifices have more work to do than the rest of the stomach, since the connective tissue enclosed in them is subject to contraction and distention. This functionating process induces greater nutrition of these parts, which may give rise to a proliferation of the glandular tissues, thus foi-ming a neoplasm. Inflanmiatory conditions of the mucous lining of the stomach have been considered a contributing factor in the etiology of the disease. Pathology. — (lastric cancer consists of atyjMcal o]Mthelial proliferations having their starting point in the glandular CARCINOMA 505 cells and the epithelial lining of the excretory ducts of the glandular tissue of the gastric mucous membrane. It develops into a tumor of varying size, sometimes attaining such dimensions as to occlude the lumen of the stomach. Cancer occasionally consists of more or less flat granula- tions and excrescences. It shows a tendency toward necrotic disintegration with an ulcerated surface, productive of hemorrhage. Gastric carcinoma forms metastases in the lymphatic vessels with great rapidity. The glands in the neighborhood of the stomach likewise become rapidly involved, and there are metastases in the omentum as well as carcinomatous degeneration of the entire peritoneum. The carcinomatous masses frequently penetrate the bloodvessels, as a result of which there are metastatic cancers in the abdominal organs, particularly the liver, and not infrequently metas- tases develop in the lungs, the heart, and the rectum. Cancers differ widely in regard to rapidity of growth and degree of malignancy. Some grow with alarming rapidity, while others may remain dormant or nearly stationary for a long period of time. Gastric carcinoma has been found to be located most frequently in the pyloric portion of the stomach, and when so located occasions nearly always a stenosis of the pylorus. The location second in frequency is the lesser curvature of the stomach. Some writers have stated that cancer of the pylorus constitutes 50 per cent, of all cases of gastric cancer, while 30 to 40 per cent, have been found to occupy the lesser curvature. Next in order of frequency are cancers of the cardiac portion of the stomach; these constitute 9 per cent.; they are accompanied, as a rule, by stenosis of the cardia and of the esophageal entrance. Cancer occurs but rarely in the anterior or posterior wall of the stomach. Diffuse carcinomatous infiltration of the stomach takes place in about 6 per cent, of the total number of cases. Forms. — The forms of gastric carcinoma, in the order of their frequency, are: Medullary carcinoma, adenocarcinoma, 506 TUMORS OF THE STOMACH gelatinous carcinoma, and scirrhus (carcinoma, simple or fibrous) . Medullary Carcinoma. — Medullary carcinomata are large, flat, soft masses projecting above the gastric mucous mem- brane. These malignant growths are very rich in vessels and cells, but possess very httle connective tissue stroma. The spongy mass, on section, is seen to be whitish yellow. iNIedullary carcinoma is usually attended by frequent hemorrhages. Secondary metastases are very frequent compUcations. Adenocarcinoma. — The adenocarcinoma, or gastric epithe- lioma, consists of soft tumors with marked nodules. At first there are pseudoglandular tubuli, surrounded b}^ con- nective tissue infiltrated with white blood corpuscles; but as the neoplasm grows older the regular arrangement of the epithelium, distinguishable in the earlier stage, becomes lost, and the tubular spaces are filled with cells, the result of epithelial proliferation. Gelatinous or Colloid Carcinoma. — The gelatinous or col- loid carcinoma is the result of mucous degeneration of epithelioma and of medullary carcinoma. The growth assumes a gelatinous appearance which is very character- istic. According to Einhorn, the stroma of the tumor surrounds transparent gelatinous-looking masses which con- sist of the cancer cells in a condition of colloid degeneration. On cutting and scraping, a true cancer juice does not exude, but, instead, gelatinous fragments. Scirrhus Carcinoma. — The scirrhus carcinoma is made up of an abundance of connective tissue. The stroma, sur- rounded by dense connective-tissue fibres, contains compara- tively very few cells, so that the neoplasm has the character of a firm, compact substance. It is somewhat difficult to cut, and on section presents a cartilaginous tissue of a light color, interspersed with yellow or red spots. There is but slight tendency to formation of secondary growths from this variety of cancer. Complications. — The portion of the gastric nuicous mem- brane that is not directly involved in the carcinomatous CARCINOMA 507 process may functionate in a perfectly normal manner, especially during- the initial stage of the disease. This, however, does not continue for any great length of time, owing to the progressive atrophic changes which take place in the gastric mucous membrane. In cases of gastric car- cinoma complicated with pyloric stenosis and stagnation, a frequent feature is chronic gastritis with marked secretion of mucus. Complications of gastric carcinoma may consist of adhe- sions to or rupture into neighboring organs, such as the intestine, gall-bladder, pancreas, and liver. Perforation into the peritoneal cavity is rarely met. Other rare com- plications are rupture into the pleural cavity, subphrenic abscess, pj^opneumothorax, and free bleeding from the cancer itself Agastric hemorrhage). Symptomatology. — The earliest symptoms of carcinoma of the stomach are pressure and fulness after eating. This mild sensation is superseded sooner or later by pain of varying intensit}'; the pain may be felt in the region of the stomach, directly in front or to the right or left of the median line, or it may be felt in the dorsal region. Pain is not a constant symptom, however; it is often absent, particularly when the cancer is situated on the lesser curvature. The patient is frequently annoyed by eructations due to decomposition of the food mass within the stomach. Anorexia is among the early sj^mptoms, the patients manifesting a distaste for meat. In a few cases the normal appetite has been known to con- tinue for a long time after the appearance of the initial symptoms; and in rare cases there is a markedly increased appetite. As a rule the patients complain of weakness and are disinclined or unable to work. They lose flesh rapidly. These symptoms progress until nausea and vomit- ing become troublesome features. Vomiting depends largely upon the location of the neoplasm; cancer of the pylorus is nearly always accompanied by vomiting, owing to stenosis of the pyloric exit. In cancer of the greater or lesser curvature there may be no vomiting at any time through- out the course of the disease. When vomiting becomes 508 TUMORS OF THE STOMACH severe, great thirst is experienced, and a marked diminu- tion in the quantity of urine excreted is noted. The inabiUty to assimilate food results in rapid loss of weight. This condition becomes so marked that patients frequently die of inanition. In carcinoma of the cardia the subjective symptoms are more insidious. Difficulty in deglutition is one of the first distinct signs confirmatory of the diagnosis; it results from occlusion of the lower end of the esophagus. The patient finds that he cannot swallow solid foods with ease; he experiences a sensation of the food "sticking fast" before it enters the stomach. Pain results from the movement of the food through the stenotic cardiac orifice. As the disease progresses the patients acquire a charac- teristic cachectic appearance — loss of flesh, and sallow com- plexion. In the later stages of the disease anemia super- venes; the percentage of hemoglobin and the number of red blood cells are much below normal. The anemic con- dition may be due to hemorrhages, to insufficient nutrition, or to the effect of toxins from the carcinoma. Hemolytic substances have been discovered in the gastric contents of carcinomatous patients. Not infrequently there is edema in the region of the ankles. Diagnosis. — Examination of the stomach in a tj^pical case of gastric carcinoma reveals a tumor of varjdng location, size, and shape. Tumors of the pylorus are usually located to the right of the median line; with the stomach in the normal position it is impossible to palpate such tumors, owing to overlapping by the liver; when not concealed by the liver they may be felt below the right l^order of the ribs, protruding during deep inspiration. When the stomach has descended it may be palpated at varying distances below the ribs. Tumors of the lesser curvature may like- wise be so covered by the liver as to render palliation im- possible. The usual site of tumors of the greater curvature and of the fundus is at the level of the umbilicus or below it. These differ from neoplasms of the pylorus in the absence of symptoms of obstruction produced by pyloric stenosis. CARCINOMA 509 When the neoplasms have formed adhesions to neighboring organs of the abdominal cavity, they are found to be immovable or only slighth' movable on palpation. Motor insufficiency supervenes in cases of cancer of the pylorus, in proportion to the degree of stenosis present. An examination of the stomach contents in typical cases of gastric carcinoma reveals the presence of lactic acid and the lactic acid bacilli of Boas-Oppler (Fig. 7); such cases are marked by the absence of free hydrochloric acid. The color of the gastric contents is freciuently brown or of a coffee- ground appearance, owing to hemorrhages from the carcino- matous growth. ^Microscopicall}^, blood and pus are both seen in the gastric contents in cases of ulcerated carcinomata. Occult hemorrhages are frequently demonstrated by exami- nation of the feces. (For the peptid and the hemolytic tests see pages 63 and 65.) The most frequent seat of metastasis is the liver, which usually shows marked enlargement. When the carcinoma- tous growth has progressed for a considerable length of time the supraclavicular glands of the left side may be enlarged. Carcinomata are found, however, to vary in a marked degree from the type here presented. The latent stage of cancer is often prolonged. The tumor may not be discovered ; subacidity or achylia may be diagnosticated from an exami- nation of the gastric contents, with no further objective symptoms which would point to the presence of malignant growth. Differing from our typical case, free hydrochloric acid may be present for a long time after the initiation of the cancerous process, while the appearance of lactic acid msLY be long delayed or never present. In such cases it is extremely difficult and often impossible to make a diagnosis with certainty. Exploratory laparotomy is sometimes justi- fiable. Carcinoma of the cardia, as a rule, offers resistance more or less marked to the passage of a sound; especially is this the case when the lower portion of the esophagus is involved. 510 TUMORS OF THE STOMACH Treatment. — The treatment of carcinoma of the stomach is essentially sm'gical. The physician should, therefore, endeavor to ascertain precisely the chances offered by oper- ation in each individual case before employing internal medication, which is at best palliative and in no sense curative. As soon as the diagnosis of cancer of the stomach is confirmed, the case should be referred to the surgeon without delay. The operation for this condition consists of total or partial resection. According to some writers, it is accompanied by a mortality of about 27 per cent. Billroth, in 1878, showed the possibility of excising carcino- matous growths in the region of the pylorus. Since that time surgeons in the various countries have contributed to the development of this heroic method of treatment. By total resection of the tumor, done early enough, it is often possible to effect a radical cure. If the diagnosis of gastric cancer could be made sufficiently early, before metastases had formed or marked glandular involvement taken place, the possibility of radical cure would be very considerable. Gastric cancer, however, can rarely be diagnosticated before it has formed adhesions with other organs or before metas- tatic deposits have taken place elsewhere. The operation for partial gastrectomy and pylorectomy was performed by C. H.and W. J. Mayo,^ between April 21, 1897, and January 26, 1910, 266 times; there were 34 deaths, making a mortality percentage of 12.4. Forty-two of these operations were performed for benign tumors, or ulcers, or in cases the diagnosis of which was not microscopically estab- lished. The remaining 224 operations were for carcinoma involving the pyloric end of the stomach, the patients being classified as follows: Males 163 Females 61 Age of olrlo.st 81 Age of youngest. 30 Average age 53 ' Radical Operation for Cancer of the Pyloric End of the Stomach, Journal of the Ainorifan Modifal Assoriation, May 14, IDIO, p. 1608. CARCINOMA 511 Patients operated on over five years ago 50 Of these 50, the {)rescnt condition of 39 is known, and of these 8 are alive and well (one eight years two and one-half months; one eight years; one seven years two months; one six years; one six years eleven months; one five years three and one-half months; one five years — has since died of recurrence). Patients operated on over four years ago 85 Of these 85, the present condition of 64 is known, and of these 13 are alive and well. Patients operated on over three years ago 117 Of these 117, the present condition of S8 is known, and of these 18 are alive and well. Patients operated on less than three years ago . . . . 107 When cancerous metastases are discovered in other organs (Uver, glands) ; when adhesions have formed, which may be ascertained by finding the tumor immovable on palpation; when the tumor has attained a large size ; when high degrees of anemia or cachexia are present, or in extreme old age, radical operations for cancer are strictly contraindicated. In such conditions as these any operative interference must needs be only palliative — to permit of greater facility in the introduction of food into the digestive tract, or to diminish as much as possible the irritating effect of food upon the affected area. For this purpose either a gastros- tomy or a gastroenterostomy may be performed, the former in malignant affections of the cardiac orifice or of the esophagus, the latter in malignant affections of the pylorus or its immediate neighborhood. By gastrostomy an open- ing is established between the stomach and the abdominal wall for the direct introduction of food. Gastroenteros- tomy consists in the establishment of a new communication between the stomach and the small intestine, so that the contents of the stomach will not need to pass through the pylorus. According to Einhorn, this operation is indicated as soon as malignant trouble with ischiochymia, or stagni - tion of the gastric contents, is diagnosticated, especially if the radical operation does not appear to be feasible. Gastic - enterostomy has been the means of prolonging life aid 512 TUMORS OF THE STOMACH rendering the patient more comfortable than would have been possible by any other mode of treatment. The number of cures might be greatly increased if opera- tive treatment were instituted early, not only for estab- lished cases of cancer, but also for those diseases which have been found to predispose to cancer, such as gastric ulcer and pyloric stenosis. An exploratory operation should be undertaken in all cases in which there is the least suspicion of malignancy; this course is becoming more and more justifiable since such a high degree of skill and compara- tively low mortality have been achieved by modern surgery. Should operation be undertaken in cases of chronic ulcer and pyloric stenosis, there seems little reason to doubt that many a latent carcinoma would be exposed and a complete cure result. In determining the advisability of operation in cases of carcinoma of the stomach the physician should bear in mind the following considerations: 1. The general condition of the patient. A certain degree of vigor is necessary for recovery from operation. Cachexia is not necessarily a contraindication; but if the cachectic condition be severe, operation offers but little hope of recovery. 2. Carcinomata of the pylorus or of the lesser curvature prohferating toward the pylorus are the cases best adapted to resection. Resection is impossible in carcinoma of the cardia. During an exploratory laparotomy, should the surgeon find that a successful resection is impossible, there remains to him, as stated above, the choice of gastrostomy or gastro- enterostomy. Internal Treatment. — Internal or palliative treatment is indi- cated in those cases which, after careful study and examina- tion, are found not to be amenable to surgery. Medicinal treatment must proceed along symptomatic lines. An endeavor should be made, on the one hand, to retard or inhibit the growth of the neoplasm, while on the other the subjective symptoms of the patient should be relieved to the greatest possible extent. Complete rest, both physical and CARCINOMA 513 mental, should be procured for the patient. He should occupy the recumbent position as much as possible, and retire early at night, since physical rest conserves the heat of the body; in this way the nutrition may be much more advantageously maintained. Diet is of first importance in the internal treatment of carcinoma of the stomach. Of necessity small in quantity, it should be limited to articles of food with a high nutritious value; food containing the greatest number of calories, and which is at the same time non-irritating in its nature, should be prescribed. The regimen for a cancer patient should be of such variety as to keep the appetite stinmlated as long as possible. Anorexia is found to be the greatest impediment to the nutrition of these patients. Owing to the tendency to stag- nation of the food mass in the stomach, and consequent fermentation, the meals should be small and frequent. The character of the diet should be adapted as largely as possible to the condition of the gastric secretion — free hydrochloric acid being regarded as, to a certain extent, an indicator for the prescription of proteins. The reader is referred to the chapter on Subacidity and Anacidity for dietary measures covering those conditions of secretion. The question of motor disturbance should be kept in mind, and in the presence of marked stenosis the diet should be that laid down for the treatment of motor insufficiency of the second degree. In all cases of cancer of the stomach the diet should be of hquid or semiliquid consistency; the necessity for this is greater in the more marked stenoses of the pylorus and in cases with a tendency to hemorrhage. Of the liquid nutriments, milk occupies the first place; it may be prescribed very much according to the desires of the patient — alone or with tea, coffee, and cocoa, or legumi- nous flours. Should milk become distasteful, buttermilk, sour milk, kefir, milk of almonds, milk soups, all form agreeable substitutes. Tastily prepared soups made from leguminous flours, eggs and butter, vegetable purees, flour puddings with fruit sauces, malt extract free from fermenta- 33 514 TUMORS OF THE STOMACH tive processes, constitute valuable dietetic agents in this condition. Next to niilk, eggs are most suitable for these patients; thej" may be prescribed soft boiled, scrambled, as omelets, or raw beaten up with sugar and wine. Fat may be prescribed in large quantities so long as the fermentative process in the stomach is not too pronounced; it should be in the form of butter, oUve oil, or chocolates rich in fat. Meat should be given thoroughly boiled or roasted, and finely divided, preferably in the form of hashed meat. All meats may be permitted to these patients except those which are very rich in fat, as goose or duck. Should meat become distasteful, meat jelHes may be tried; or, if the patient's repugnance to meat in any form is marked, it would be weU to omit it altogether from the dietary for a few days. Light cheese may be prescribed. Zwieback, biscuits, and toast must be softened before being taken. All vegetables should be served in the form of puree. The consistency of the food to be administered should depend almost entirel}" upon the degree of stenosis of the pylorus; when little or no pyloric stenosis exists, the patient may be permitted to partake of some solid food. The habits of Ufe and the desires and tastes of the patient should not be disregarded entirely in prescribing diet. Various kinds of dehcacies may be incorporated in the bill of fare. The mental impression produced by the addition of a few luxuries, as well as the preparation and serving of food in an attractive manner, is bound to have a favorable effect upon the patient. Monotony in diet should be care- fully avoided, so as to keep up a fair appetite and counteract as far as possible the distaste for food which is too often a characteristic symptom of the disease. I would say, then, that a patient without marked stenosis of the pylorus may partake of a wide range of food so long as the various dietetic articles agree with him. It is often possible to keep the patient fairly well nourished for a considerable length of time. The greatest obstacle is encountered with that class of patients whose financial circumstances will not permit of such a varied diet as outlined. CARCINOMA 515 In marked stenosis of the pylorus the food should be exclusively liquid or semiliciuid. When vomiting is a troublesome feature the food should be given in small quantities. The nutritive value of liquid diet may be enhanced by the addition of such preparations as somatose, sanatogen, plasmon, or nutrose, which increase the calorific value of an otherwise simple liquid diet. Coffee or tea with the addition of milk, or mineral waters with a small percentage of carbon dioxide, may be used as beverages. In case of gastric hemorrhage resulting from cancer of the stomach, the patient should assume the recumbent position. The diet in this condition should be as prescribed in the chapter on Gastric Hemorrhage. In cases in which it is extremely difficult to maintain nutrition by oral feeding, as in severe pyloric stenosis with troublesome vomiting, nutritive enemata should be employed, but only as an adjunct to oral feeding. Exclusive rectal alimentation should not be attempted, even for a few days, since it has been found that inanition results more rapidly under this regimen than with even a minor degree of oral alimentation alone: Diet in Caecinoma of the Stomach Calories. Breakfast. § liter milk; 40 Gm. toast; 10 Gm. butter . . 504.0 Luncheon. Oatmeal soup; 15 Gm. puro 90.0 Noon Vegetable green soup, one yolk of egg; 150 Gm. (Dinner). roast beef, game, fowl or fish, finely hacked; 40 Gm. toast; 100 Gm. mashed potatoes . . 667.4 Afternoon. \ liter milk-cocoa, one yolk of egg; 30 Gm. zwie- back 400.0 Evening Flour milk gruel, viz.: 250 Gm. milk, 20 Gm. (Supper). tapioca, oatmeal or mondamin, 15 Gm. sugar; 50 Gm. toast 300.0 1961.4 (Zweig.) 516 TUMORS OF THE STOMACH Morning. Forenoon. Noon. Afternoon.' Evening. 10 P.M. With Cocoa With Kefir. 150 Gm. malt legumi- nose cocoa . 250 Gm. kefir . . . 150 Gm. mah legumi- nose soup 100 Gm. scraped beef- steak .... 250 Gm. malt legumi- nose cocoa . 100 Gm. scraped ham 150 Gm. tapioca gruel 200 Gm. kefir . . . 30 Gm. honey 20 Gm. cognac Intermediate. 50 Gm. zwdeback Carbo- r'rotein. Fat. hydrates. Alcohol. 6.0 4.0 13.5 6.0 4.5 3.8 1.0 4.0 20.0 6.0 25.0 7.0 6.0 0.4 6.6 0.15 6.0 4.0 8.0 5.0 4.5 1.0 87.0 37.15 Total combustion value, about 1250 calories. 9.3 13.5 8.0 3.8 22.0 35.0 1.0 14.0 108.9 16.0 (Wegele.) Protein. 6 A.M. 500 Gm. milk, 40 Gm. toast . 20.3 8 A.M. Oatmeal soup with 15 Gm. meal solution, or soup of \ Timpe's soup tablet . . 5.5 10 A.M. Cream mixture: 125 Gm. cream, 6 Gm. milk sugar; 40 Gm. toast 7.8 12 M. (a) soup with 1 yolk of egg . 4.0 (6) 140 Gm. roast beef, game, fowl, boiled hacked beef or fish 42,8 (c) 40 Gm. toast .... 3.3 (d) 25 Gm. cinnamon-soda cake biscuits 2.0 (e) 1 small cup black coffee 4 P.M. 250 Cc. milk-water cocoa, 3 zwieback (30 Gm.) ... 9.2 7 P.M. {a) Leguminous soup with 15 Gm. meat solution or soup of \ Timpe's soup tablet 7.6 (6) Rice-flour gruel .... 18.3 120.8 Total combustion value, about 2524 calories. Carbo- Fat. hydrates. 18.4 55.8 1.0 11.3 1.0 14.1 14.2 12.9 41.5 9.2 7.7 10.4 0.4 30.8 1.5 14.0 38.3 12.6 98.1 80.2 313.0 (Biedert.) CARCINOMA 517 Carbo- Protein. Fat. hydrates. 6 a.m. 250 Cc. milk, 30 Gm. toast . 11.0 9.3 35.6 8 a.m. 2 eggs with 20 Gm. toast . . 13.7 10.2 15.4 10 a.m. 125 Cc. cream, 20 Gm. zwieback 6.9 14.0 18.8 12 m. (a) 140 Gm. roast beef, game, or fowl, boiled choj)ped beef or fish 42. S 10.4 (6) 40 Gm. toast .... 3.3 0.4 30.8 (c) 25 Gm. soda-cinnamon bun or biscuits 2.0 l.o 14.0 4 p.m. 250 Cc. milk-cocoa, 30 Gm. zwieback with fruit jelly . 13.5 15.8 44.6 7 p..\i. Rice pudding, 20 Gm. zwieback, or 25 Gm. baked foods as above 14. S 10.8 78.7 10 p.m. 2.50 Cc. milk, 20 Gm. zwieback 10.9 10.5 26.3 118.9 82.9 264.2 Total combustion value, 2341 calories. (Biedert and Langermann.) 7 A.M. Flour soup, boiled with cream and butter. Biscuits with butter. 9.15 Tea with cream, butter roll, scraped lean ham, or one soft egg. 12 M. One plateful rice soup, spinach, carrot or bean puree, scraped chicken, boiled fish, sweet preserves. 3 P.M. Cocoa boiled with cream. Butter biscuits. 5 . 30 Flour soup or flour gruel with much butter. 7.15 Tea with cream, scraped ham, butter roll, milk ad libitum. (Cohnheim.) Treatment by Lavage. — Washing out the stomach in gastric carcinoma is an important auxihary to the dietetic treat- ment. Lavage is indicated when the motor function of the stomach is disturbed. It is especially indicated in pyloric stenosis with motor insufficiency of the second degree, as well as in motor insufficiency of the first degree. In the latter condition it is not necessary to wash the stomach every day. In motor insufficiency of the second degree, however, daily lavage should be performed, preferably at night before supper. This daily lavage has the happy effect of relieving patients of many of their distressing symptoms; vomiting ceases, the pains decrease in severity, the appetite improves, and there is a marked improvement in the nutri- tion. Patients take on new hope, which is an important 518 TUMORS OF THE STOMACH matter in the treatment of gastric cancer. Lavage, however, will not arrest the cachexia resulting from cancer; yet, in spite of the graduallj^ progressive weakness, patients remain free from many subjective symptoms which would other- wise render their existence a greater burden. Lavage should be followed up by irrigation with antifermentative solu- tions, especially when there is marked formation of gas as shown by eructations. The lavage process should not be prolonged, since it requires more or less effort on the part of the patient. Boas recommends as a substitute for lavage a partial expression of the stomach contents. This should be done in the evening and should take the place of regular lavage. Physical Treatment. — This consists of local applications in the form of moist trunk packings, or hot moist or dry stupes apphed in the gastric region to counteract the feehng of gastric pressure, pains, and nausea (see p. 150). ]\Iassage and electricity are not indicated in gastric cancer. Mineral Water Cure. — ^Mineral waters have not been found satisfactory agents in the treatment of gastric carcinoma. Sojourn at the so-called health resorts has not been attended by any marked improvement in the condition of the patient. Medicinal Treatment. — The treatment of carcinoma of the stomach hj drugs consists almost entireh' in the relief of distressing sjTnptoms. Condurango bark has been employed most frequently as a medicinal agent for the stimulation of the appetite. It was believed at one time to possess certain curative virtues in cancer. But while no drug has been found to exert any influence by way of shortening or curing the disease, condurango is still worthy of trial as a stomachic. It has an ameliorating effect upon nausea, vomiting, and pain, and on this account is to be preferred to the other bitter tonics. It is administered in the form of a decoction. Gm. or Cc. I^ — Corticis condurango 15.0 Sss Macerate for twelve hours with distilled water 360.0 5xij Sig. — Three times a day, tablespoonful before meals. CARCINOMA 519 Gm. or Cc. I^ — CorticLs c'ondurungo 15.0 5ss Macerate for twelve hours with distilled water 300.0 5x Strain and reduce to . . .■ . . . 180.0 5vj Add syrup of orange peel 15.0 5ss Sig. — One tablespoonful three times a day. (Zweig.) Condurango bark should be administered regularly over a prolonged period of time in order that the patient may secure the full benefit of it. It is apt to fail when anorexia is pronounced. In place of the decoction, the fiuidextract may be prescribed, one teaspoonful in a wineglass of water a half -hour before meals. The wine of condurango is also deserving of consideration. In addition to condurango bark, the cinchona prepara- tions, tincture of gentian, and orexin may be prescribed. In subacidity and anacidity, pepsin and hydrochloric acid may be employed for the purpose of increasing proteolysis. The hydrochloric-acid-pepsin treatment, however, occupies a much less important position in the treatment of achylia complicating carcinoma than in achylia and subacidity of benign origin. Condurango is also prescribed with hydrochloric acid, antiseptics, and tonics: Gm. or Cc. I^ — Corticis condurango 15 to 20 . Macerate for twelve hours with water Digest at mild heat and strain, obtaining Add hydrochloric acid Sig. — One tablespoonful before meals. (Riegel.) I^ — Decoctionis corticis condurango . Acidi hydrochlorici Syrupi q. s. ad Misce. Sig. — One tablespoonful three times a day. (Zweig.) 20.0 3iv-v 300.0 5x 180.0 §vj 1.5 TTlxxiv Gm. or Cc. 180.0 5vj 0.5 TTlviij 200.0 5vij 520 TUMORS OF THE STOMACH Gm. or Cc. I^ — Corticis condurango 20.0 3v Macerate for twelve hours with water . 300 .0 5 x Digest at mild heat and strain, obtaining 250 . 5 viij Add: ResorcinoHs 4.0 oj Acidi hydrochlorici dikiti 3.0 TTlxlv Syrupi zingiberis 300 .0 ox Misce. Sig. — One tablespoonful three times a day, before meals. (Kuttner.) Gm. or Cc. I^ — Resorcinolis 1.0 gr. xv Tincturse nucis vomicae 2.0 TTlxxx Vini condurango 140.0 ov Misce. Sig. — Tablespoonful three or four times daily, before meals. (Roderi.) As anodynes, tincture of valerian in drop doses, or spirits of ether, is indicated. When, however, the pains are severe, orthoform or anesthesin should be employed. Pain is occa- sionally so severe as to require the administration of some narcotic. Of narcotic drugs, codeine or extract of bella- donna may be administered in the form of rectal supposi- tories as well as by mouth. In sleeplessness resulting from pain, Wegele recommends the administration of chloral hydrate with morphine as follows: Gm. or Cc. I^— ChloraU hydrati 15.0 oSS Morphinse sulphatis 0.15 gr. ii§ Aquae destillatae 120.0 giv Syrupi aurantii 15. oss Misce. Sig. — Tablespoonful in a wineglass of water. The pain accompanying gastric carcinoma is met by the administration of opiates. Morphine should be reserved, however, until the final stages of the disease. Cocaine or 3 to 5 minims of chloroform on small pieces of ice may be given for the vomiting. Robin gives 4 or 5 drops of the following mixture before each attack: CARCINOMA 521 Gm. or Cc. ^ — Picrotoxini 0.05 gr. j Alcoholis, q. s. Morphinaj hydrochloridi O.Oo gr. j Atropinae sulphatis 0.01 gr. J Extracti crgotae 0.01 gr. ^, Aquaj destillatae 12.00 3iij Misce. Boas recommends oil of chloroform for the relief of vomiting accompanying gastric carcinoma, in the following formula: Gm. or Cc. I^ — Olei amygdalae express!, Chloroformi aa 10.0 3iiss Misce. Sig. — Ten to fifteen drops to be given as required. For distress caused by excessive gaseous fermentation, antiseptic drugs occasionally give good results: Gm. or Cc. I^ — Resorcinolis, Tincturje opii aa 2.0 3 ss Aquae 180.0 §vj Syrupi q. s. ad 200.0 ovij Misce. Sig. — One tablespoonful every two hours. When the vomiting is obstinate it will be necessary to resort to narcotics, which may be administered either hypo- dermically or by rectum. The medicinal treatment of gastric hemorrhage resulting from carcinoma is that of other kinds of hemorrhage from the stomach. To counteract diarrhea Boas recommends this prescrip- tion: Gm. or Cc. I^ — Fluidextracti condurango, Fluidextracti calumbae aa 20 . 5 v Misce. Sig. — A teaspoonful three times a day in a wineglass of water. 522 TUMORS OF THE STOMACH Since these gastrogeiiic diarrheas result from the presence of decomposed gastric contents in the intestinal tract, anti- septics such as resorcinol or bismuth salicylate are indicated. Yet the regulation of diet and the performance of gastric lavage are usually more effective than the drug treatment in counteracting this condition. When constipation is present, high rectal enemata of large quantities of water are productive of good results. OUve oil and glycerin enemata and glycerin suppositories should also be tried. Heart failure is to be met by such excitants as digitahs and caffeine. Attempts have been made to directly influence the growth of carcinoma of the stomach by means of drugs. Boas reports temporary diminution in the size of the tumors after the use of sodium iodide in daily doses of 2 to 3 Gm. (30 to 45 grains). Temporary relief has been reported from the use of arsenic in the form of Fowler's solution, adminis- tered over a long space of time in gradually increasing doses. Sodium cacodylate may be given in larger doses, 0.1 to 0.5 Gm. (1^ to 7| grains), or in sterile solution hypodermically. A few clinicians have reported a temporary diminution in the size of the tumors, as well as improvement in the general condition, from the protracted administration of methylene blue. This drug ma}^ be given in pill form, 0.06 Gm. (1 grain) three times a day, or in suppositories, 0.06 Gm. with 0.02 Gm. {\ grain) of extract of belladonna to each suppository. Of other drugs which have been used to inhibit the growth of the neoplasm, or if possible diminish its size, chlorinated soda and chelidonium might be mentioned. Although a few favorable results have been reported from the use of atoxyl in the form of a 1-per-cent. soap cream, applied endermically, the value of this treatment has not been established. The atoxyl was rubbed into the skin at first six times a day and later twice a day. The rubbing was continued until a distinct feeling of warmth was experienced by the patient. Lecithin was administered at the same time. The treatment was soon followed by CARCINOMA 52'A improvement in botli subjective and objective symptoms. The tumor began to disappear, and the patient's appetite improved. Adanikiewicz has employed a serum called cancorin, which is of doubtful value. The cancer-cure serum of Doyen is prol^ably also without much merit. Good results in the way of producing a shrinking and softening of the cancerous masses have been reported from the use of can- crodin, prepared b}^ Schmidt of Cologne. Success in the treatment of cancer has been reported from the use of the Roentgen rays; tumors of the stomach have in some instances wholly disappeared. Einhorn has used radium in the treatment of gastric cancer as well as cancer of the esophagus. The radium is deposited in radium receptacles, which consist of hard rubber capsules, the parts of which are connected by screw threads. The capsule is attached to a silk cord about 75 centimeters in length, and introduced into the stomach in the same manner as the stomach bucket. It is retained in the stomach for one hour at a time. According to Einhorn the results of the radium treatment have been satisfactory, considering that the disease has not heretofore been amenable to treatment. ' ' In the methodical application of radium we have the means to influence favorably the course and seat of the disease and to retard its progress, even if at present we cannot entirely remove it. This mode of treatment is certainly destined to play an important role in the therapeutics of cancer of the esophagus, and deserves to be tried on a large scale and in a thorough manner." (Einhorn.) Von Leyden and Bergell have ventured to treat carcinoma of the stomach along biological lines. According to the theory of these investigators, in healthy individuals certain substances are always present which act as a ferment and inhibit the growth of malignant tumors, and these sub- stances are lacking or deficient in cancer patients. Trypsin is said to develop the peculiar kind of immunity afforded by these substances. \on Leyden and Bergell have endeavored to counteract the patient's poverty in ferments by the use 524 TUMORS OF THE STOMACH of a proteolytic enzyme obtained from the fresh Uvers of ani- mals; trypsin itself has been employed. Up to the present time, however, no marked results have justified either this theory of immunity or this line of treatment. Treatment of Carcinoma of the Cardia. — The diet should be carefully regulated, to minimize the difficulties of degluti- tion which accompany stenosis of the cardia, when the seat of the carcinoma is the cardiac entrance to the stomach. It should be such as to produce as little irritation as possible at the cardiac orifice. The use of bland food, soft in con- sistency, will, to a large extent, ward off the tendency to disintegration of the tumor-like mass, and prevent hemor- rhages and rapidity of growth. Meats should be given in finely divided form, and potatoes, vegetables, and preserved fruit as puree only. Flour-and-milk soups, eggs, milk, cream, and artificially prepared foods may be prescribed so long as they can be swallowed with ease. The mainte- nance of the general nutrition will not be a difficult matter, since the articles mentioned may be taken in large quanti- ties. As the cardiac stenosis becomes more marked, the question of adequately nourishing the patient assumes a graver aspect. The diet must eventually be entirely liquid. Cohnheim proposes the following liquid regimen: 8 A.M. Tea with 125 Gm. cream. 9 A.M. Milk, 250 Gm. 11 A.M. Flour soup with 125 Gm. cream and butter. 1 P.M. Bouillon with one tablespoonful of flour, one to two yolks of egg, and butter. 4 P.M. Tea with 125 Gm. cream. 6 P.M. Flour soup or milk. 8 P..M. Bouillon with ground rice or flour and butter. Patients may partake of the following ad lihitum: Wine, beer, milk, buttermilk, kefir, fruit juices, mineral waters, vanilla ice cream, and artificial food preparations. They can be sustained for a long time with the above regimen, pro- viding the painful symptoms are not such as to prevent them from swallowing the liquid nourishment. When patients are unable to consume even a liciuid diet, owing to CARCINOMA 525 difficulties in deglutition, a good quality of olive oil should be administered in generous amount. The oil has the effect of lubricating the stenosed cardia so that food will pass into the stomach more easily. Sometimes the inability to swallow arises more from the inflamed condition of the cardia than from the degree of stenosis; the oil in such cases serves the ]:)urpose of a protective layer upon the neoplasm, rendering it less sensitive and thereby preventing spastic contraction of the cardiac orifice. Olive oil, moreover, has a high nutritive value. At least half a wineglass of the oil should be taken morning, noon, and night, half an hour before the ingestion of other food. Almond milk is the most efficient substitute for olive oil, should the latter become distasteful to the patient. When the stricture becomes so marked as to preclude the passage of even liquids, aided in their passage by the oil, then whatever is partaken of by mouth lodges in the lower portion of the esophagus, above the constriction, only to be expelled by vomiting. And the inflammatory irritation and ulceration of the diseased area will frequently cause vomiting or retching when there is no accumulation of food in the esophagus. Rosenheim recom- mends systematic lavage of the esophagus, by means of the ordinary soft stomach tube introduced as far as the stricture. When the food remnants are removed the lavage process should be continued with small quantities of warm water until all mucus, pus, and blood are washed away. The esophagus may be rinsed with mild antiseptic solu- tions. After the rinsing process, 30 to 60 Cc. (5j-ij) of olive oil should be injected into the esophagus. Esophageal lavage should be performed at first once a day, and later on every second day. Food may be taken one hour after the lavage. Patients, as a rule, are very much relieved by the systematic washing and lubrication; the irritability of the diseased area is allayed, and frequently deglutition is facilitated. By regularly sounding and dilating the cardiac stricture the progressive stenosis may be inhibited for a considerable length of time. Some clinicians, however, are opposed to 526 TUMORS OF THE STOMACH the use of the sound, fearing mechanical irritation that may stimulate the carcinoma to further growth. It is true that damage may result from the injudicious use of the sound. Mechanical dilatation of the carcinomatous stric- ture should not be considered so long as the patient is able to swallow a sufficient quantity of liquid and semisolid nourishment to maintain nutrition. When, however, this cannot be done, the physician may succeed in so far dilating the stricture as to enable the patient to swallow^ with com- parative ease. For the purpose of dilatation, elastic bougies of a diameter corresponding to the lumen of the stricture should be employed. Sounds increasing in size should be used as the stricture yields to the dilating process. The sounds need be introduced but once a day, and should be kept in position from fifteen to thirty minutes. Should symptoms of irritation arise, the dilatation must be inter- mitted for several days. The stomach tube may be utilized for the introduction of nourishment into the stomach. Any food introduced through the tube should be of a con- centrated nature, representing the highest percentage of calories per unit of volume. The food may consist of a pint of milk, with somatose or other protein preparation, two to three eggs, three ounces of sugar, malt extract or dextrinized milk, wine and salt. When the feeding by mouth (or tube) is not sufficient, rectal alimentation may be em- ployed for a few days. Analgesic and antispasmodic drugs are sometimes prescribed, to diminish the difficulties of swal- lowing. Morphine or cocaine may be swallowed as drops or tablets ; the following is very useful : Gm. or Cc. I^ — MorphinPD hj-drochloridi, Cocainae hydrochloridi aa . 0025 gr. jV Antipyrinaj 0.1 gr. iss Sacchari 0.3 gr. v Misce et ft. tab. no. i. Sig. — One tablet before partaking of food. Other useful prescriptions for internal medication in gastric cancer are: SARCOMA 527 Clni. or C'r. I^ — Tincturse bclladonnic 4 to 10.0 oj-iiss Emulsionis amygdalae . . q. s. ad 200.0 3viij Misce. Sig. — One tablespoonful to be taken before meals. (Cohnheim.) Gm. or Cc. ^ — Codeina) phosphatis . 5 to 1 . gr. viiss-xv Aqua) amygdala; amarse .... 15.0 5ss Misce. Sig. — Fifteen to twenty drops three times a day. (Cohnheim.) Solutions of 5-per-cent. cocaine or 3-per-cent. eucaine may be injected directly as far as the cardiac orifice by means of a small stomach tube or long Nelaton catheter attached to an ordinary piston syringe. SARCOMA Etiology. — While carcinoma is a comparatively frequent affection of the stomach, primary gastric sarcoma is rare. Hosch, in 13,387 autopsies, found but six primary gastric sarcomata, and Tilger in 3500 autopsies found only one. Although an admittedly rare condition, recent research has shown that many cases diagnosticated as carcinoma have upon reinvestigation proved to be of the sarcomatous type. Perry and Shaw, on examining 50 cases of so-called carci- noma ventriculi obtained from the Guy's Hospital Museum, London, discovered that four of the specimens were round- celled sarcoma. According to Fenwick, 5 to 8 per cent, of all primary neoplasms of the stomach are to be classed as sarcomata. Of the etiology of gastric sarcoma very little is known. Heredity and trauma have been considered as positive predisposing influences. Ulcer of the stomach is but rarely the starting point of sarcoma. Sex seems to have little or no influence as a determining factor. The majority of cases are noted between the ages of forty and fifty years. According to Virchow,^ sarcoma originates in the mucous 1 Geschwiilste, ii, p. 3.52. 528 TUMORS OF THE STOMACH membrane. The generally accepted view is that it originates in the submucous or mesoblastic tissue. Pathology. — Sarcoma is a neoplasm consisting of small cells of an adenoid or embryonic type, without epithelial appear- ance and in manj^ cases without stroma. We speak of round- or spindle-celled sarcoma, according to the character of the cell. Primary gastric sarcoma occurs in two forms — infiltrated and circumscribed. Round-celled sarcomata de- velop from the trabecular tissue of the gastric submucosa; lymphosarcomata from the lymphatic nodules of the sub- serous coat. The usual location or starting point of lympho- sarcomata is the pylorus; this variety of neoplasm often infiltrates the entire wall of the stomach, but, as a rule, avoids the gastric orifices. Next in frequency is the myxo- sarcoma, having its starting point in the muscular coat. Fibrosarcomata and myxosarcomata are yevy rare. INIyo- and fibrosarcomata represent the circumscribed form of sarcoma, which often acquires an enormous size, with frequent metastases; especially is this true of round-celled sarcomata and lymphosarcomata which invade the peri- toneal lymphatic glands, the pleural cavities, the kidneys, ovaries, spleen, liver, and lungs. Metastases in the skin are very rare. Many cases of gastric sarcoma cannot be distinguished clinically from gastric carcinoma; especiallj' is this true of the round-celled type, in the course of which ulceration, softening and hemorrhage, and more rarely obstruction, may occur, with occasional perforation. Sarcoma is apt to occur at a much earlier age than carcinoma. William Legg^ reports a case in a girl of seventeen; and a case of round-celled sarcoma of the stomach in a child four years of age has been reported by Thursfield. Softening, hem- orrhage and perforation occur but rarely in gastric sarcoma. Owing to the fact that sarcoma is an infiltrating growth, there is usually no contraction and no obstruction. If obstruction does occur, it is mechanical rather than due to a constriction of the growth. ' St. Bartholomew's Hospital H('i)orts, 1874, p. 234. SARCOMA 529 Alaschke^ reports two cases of primary sarcoma of the stomach. In the first case the tumor was not detected until the autopsy; it was so small that during the life of the patient it did not lead to suspicion of serious disease of the stomach; it was not of the diffuse infiltrating variety, but was sharply circumscribed. In carcinoma the tumor is never sharply circumscribed. In the second case reported by Maschke the tumor was very large and had probably developed very rapidly. Symptoms of gastric disease had made their appearance only six weeks before death; they consisted of hematemesis, bloody stools, . and some pain in the epigastrium. These symptoms and the emaciation, anemia, palpable resistance in the gastric region, and absence of free hydrochloric acid in the gastric contents, pointed to the diagnosis of carcinoma. The clinical symp- toms of sarcoma of the stomach are not essentially different from those of carcinoma, so the chnical diagnosis is very difficult and often impossible. Sarcoma in the pyloric region causes stenosis much less frequently than does carcinoma. The prognosis in gastric sarcoma is unfavor- able unless early excision is done. Symptoms. — The clinical course of gastric sarcoma is subject to great variation. In some cases symptoms have been present for years, while in others the first dyspeptic symptoms were coincident with a discovery of the tumor. In some cases where the tumor was readily palpable the subjective symptoms were very slight. Cachexia, as a rule, occurs very late in the disease. Owing to the fact that gas- tric sarcoma seldom produces stenosis, emesis is apt to be absent throughout the course of the disease. Pains in the region of the stomach appear early and may be very severe. Free hydrochloric acid is absent in the majority of cases. Lactic acid is often found when hydrochloric acid is absent. The Boas-Oppler bacilli are not constantly present in gastric sarcoma. Marked degrees of anemia develop during the progress of the disease. Hemorrhages occasionally take place, though death from hemorrhage is exceedingly rare. 1 Berliner klin. Wochenschrift, May 23, 1910. 34 530 TUMORS OF THE STOMACH The importance of an early differential diagnosis between carcinoma and sarcoma of the stomach cannot be over- estimated, since the timely surgical treatment of sarcoma is frequently followed by gratifying results. Of 26 cases of sarcoma in which resection was done, 11 were reported successful. Lymphosarcomata appear to be especially adapted for operative intervention. The results depend, of course, entirety upon the time of operation. Diagnosis. — As an aid to the differential diagnosis the reader is referred to the following: Differential Diagnosis of Gastric Carcinoma and Gastric Sarcoma Carcinoma. Sarcoma. 1. Much pain. Much pain early, which diminishes as the tumor becomes palpable. Sometines no pain at all. 2. Involvement of the orifices. Orifices either not involved or rarely involved. .3. Stenosis marked. Stenosis seldom. 4. Hemorrhage early. Hemorrhage late in the course of the disease. 5. Markedly mahgnant. Less malignant. 6. Growth rapid. Growth comparatively slow. 7. Metastases early. Metastases late. 8. Cachexia earlv. Cachexia late. Treatment. — The treatment of gastric sarcoma is essen- tially surgical. When for any reason surgical intervention would be injudicious or not likely to be followed by benefi- cial results, the palliative treatment is that already described for gastric carcinoma. W. B. Coley, of New York City, reports remarkably good results from the hypodermic injection of mixed toxins (the toxins of erj^sipelas and the Bacillus prodigiosus) in the treatment of inoperable sarcoma. BENIGN TXJMORS Benign tumors of the stomach are of exceedingly rare occurrence. They seldom give rise to any symptoms dur- ing life, though occasionally ulceration of the tumor, hemor- HERNIA EPIGASTRICA 531 rhage, or even obstruction may occur. Such growths are, as a rule, discovered at autopsy. They are simple or multiple, sessile or pedunculated. They are classified according to the tissues or gastric layers from which they are derived. Among tumors derived from the glandular structure, or gastric mucosa, are mucous polypi, mucous papilloma, and adenoma; these terms are applied to tumors of the mucosa, multiple, of small size, either sessile or pedun- culated. These tumors may present the appearance of small vegetations or mammillations ; individually they are seldom larger than a small bean. They are commonly found near the cardia, rarely in the region of the pylorus. Tumors derived from connective tissue are : (a) Lipomata, or fatty tumors arising from the submucosa in any part of the gastric walls. (6) Fibromata. Some of the older writers described these as probably slow-growing carcinomata with much fibroid stroma. To this class belong the fibrous thickenings of the pylorus due to spasm or chronic inflam- mation or resulting from an old cicatrizing ulcer. True fibromata are villous growths, usually covered with a single layer of cylindrical cells; they are often polypoid and pedunt culated. (c) Fibromyomata — benign tumors which projec- into the stomach. These consist of unstriped muscle fibres in fibrous tissue, with the mucous membrane covering intact. They develop in the muscular layer of the stomach wall, are rarely larger than a pea, and produce no symptoms. Cysts of the stomach are usually formed by the occlusion of a duct of a gastric gland; they may attain the size of a small walnut, but are usually very small and multiple, having the appearance of groups of minute vesicles. HERNIA EPIGASTRICA Hernia epigastrica consists of a rupture occurring at some part of the linea alba between the umbilicus and the ensi- form appendix. It belongs to the class of preperitoneal lipomata, is made up of omentum and fat, and varies in 532 TUMORS OF THE STOMACH size from a bean to an egg. The region must be carefully palpated in order to diagnosticate epigastric hernia; with a tumor of considerable size, there may be felt at the tips of the fingers a sensation as though small shot were hitting them when the patient coughs. Hernia epigastrica may produce symptoms simulating those of almost any gastric disease, and for that reason it is of the greatest importance that an accurate diagnosis be made. The condition has been mistaken for gastric ulcer, gastritis, gastralgia, carcinoma, enteritis, and cholelithiasis. Ehrlich^ reports success in the treatment of four cases of small epigastric and navel hernia by the use of fibrolysin. He believes these hernise cause distress by the tension of the formed adhesions. The fibrolysin softens the adhesions, and the rehef is quite prompt. Ehrlich injected the fibrolysin deep in the abdominal muscles near the hernia, and massaged the parts after each injection. The contents of one ampoule of fibrolysin, 2.3 Cc, were injected at intervals of one to three days. The pain subsided after three to five injections. He usually gave ten injections in all (see p. 414 1. One case of mine," reported in 1897, had been previously treated for over four years for a presumed chronic gastritis. There were, with intervals of freedom from symptoms, recurring attacks of nausea, vomiting, epigastric pain, and anorexia. The patient lost 28 pounds in four months on account of his persistent inability to retain food. After the removal of the tumor, which was not known to the patient as hernia, a speedy recovery took place. The patient con- tinued well, without any gastric symptoms, for eighteen years. The treatment of epigastric hernia is surgical. ' Fibrolysininjektionen zur Behandlung von Nabel und Epigastrischen Hemien, Archiv fur Verdauungskrankheiten, February, 1911, p. 43. 2 Charles D. Aaron, Stomach Disturbances Caused by Hernia of the Linea Alba in the Epigastrium, Medical Record, November 20, 1897. CO:\IPARATIVE SCALES OX TPIE METRir' AND ORDIXARY WEIGHTS AND :\IEASURES Gm. or Cc Fluid Measure, Ounces. Minims. A pot he Ounces icaries' Weight 1. Grains. 1000 = 33 + 390.6 = 32 + 72.4 500 = 16 + 435.3 = 16 + 36.2 250 = 8 + 217.7 = 8 + IS.l 100 = 3 + 1S3.1 = 3 + 103.2 50 = 1 + 331.5 = 1 + 291.6 25 = 405.77 = 385.8 10 = 162.31 = 154.3 5 = 81.2 = 77.2 1 16.23 15.4 Fluid Measure. Metric. 2 pints = 946.358 Gm. or Cc. 1 pint = 473.179 Gm. or Cc. i pint = 236.590 Gm. or Cc. 3 ounces = 88.721 Gm. or Cc. 2 ounces = 59.147 Gm. or Cc. 1 ounce = 29.573 Gm. or Cc. 60 minims = 3.697 Gm. or Cc. INDEX A Aaron's bandage for enteroptosis, 247, 248 corset for enteroptosis, 254 Abdominal region, application of heat to, 150, 151 Abscess, subphrenic, surgery of, 209 Achlorhydria gastrica hsemorrhagica, 310 iodine reaction in, 52 nervous dyspepsia and, 310 Achroodextrin in chronic gastritis, 72 conversion of starch into, 19 Achylia gastrica, 368 etiology of, 368 Ewald-Boas test breakfast, in diagnosis of, 73 gastric contents in, 73 hydrochloric acid in, 170 hypermotiUty in, 260 pathology of, 370 symptoms of, 371 treatment of, 371. See also Gastritis, chronic, treat- ment of. Acid eructations, prescription for, 351 gastritis, chronic, 314. See also Hyperchlorhydria. Acid-albumin, 27 Acidity, normal, in motor insufficiency of first degree, diet in, 397 Acidol, 173 Acidum hydrochloricum, 172 dilutum, 172 Adenocarcinoma, 506 Adhesions in carcinoma, 507 Adhesive bandage for enteroptosis, 249 Adler's original benzidin test, 55 Adrenalin for gastric hemorrhage, 469 Aerophagy, 270. See Eructations, nervous. Akoria, 291 Albumoses in peptones, 107 Alcohol, 99 in diet in enteroptosis, 236 effect of, on gastric secretion, 99, 100, 188 gastric neurasthenia and, 100 Alcohol in peptones, 109, 110 Alcoholism, gastritis and, chronic phleg- monous, 357, 363 Aleuronat flour, 112 Alimentary hypersecretion, 343 Alimentation, duodenal, Einhorn's, in gastric ulcer, 437 rectal, in motor insufficiency of second degree, 404 Alkahes, administration of, 178, 179 time for, 182 amylolysis and, 182 distinction of, from antacids, 180 effect of, on secretions, 179 groups of, 1S2 indications for, 181 in treatment of hyperchlorhydria, 325 Alkaline carbonated waters, 156 chlorine waters, 153 earths, salts of, in treatment of hyperchlorhydria, 325 saline waters, 156 Alkaloids in treatment of hyper- chlorhydria, 324 AUouez mineral water, analysis of, 162 American mineral waters, 159 Amyl nitrite, 191 Amylodextrin, conversion of starch into, 19 Amylolysis, alkalies and, 182 Amylopsin, 29 Anacid gastritis, 366 Anacidity in motor insufficiency of first degree, diet in, 397 Analgesics in gastric hemorrhage, 473 in hyperchlorhydria, 324 Anemia in carcinoma, 508 gastralgia due to, massage in, 135 motor insufficiency and, 66 in sarcoma, 529 Anesthesin, 194 Angina, abdominal, arteriosclerosis and, 487 Animal protein, preparations of, 106 Anodynes in carcinoma, 520 . gastric, 193 Anorexia in carcinoma, 507 electricity in treatment of, 140 nervous, 291 536 INDEX Anorexia, nervous, diseases associated with, 291 stomachics for, 292 treatment of, 291 Antacids, 180 distinction of, from alkalies, 180 Antilytic serum, treatment of gastric ulcer with, 451 Antiseptics, gastric, 198 Appendicitis larvata, nervous dys- pepsia and, 297 nervous dyspepsia and, 296, 309 Arsenic in carcinoma, 522 Arteriosclerosis, 487 abdominal angina and, 487 diagnosis of, 490 diet in, 491 etiology of, 487 gastric hemorrhages and, 487 ulcer and, 487 heart in, 490 old age and, 487 overeating and, 488 overwork and, 488 pathology of, 488 symptoms of, 490 syphilis and, 488 toxic factors and, 488 treatment of, 491 iodides in, 492 medicinal, 491 thyroid extract in, 493 Trunecek's serum in, 494 Artificial Carlsbad salt, 181 waters, 98 Aspiration method for obtaining stomach contents, 34 Aspirator, stomach, 35 Atony, gastric, 73, 74 electricit}^ in treatment 140 motor insufficiency of first degree and, 394 primary intestinal, massage in, 134 simple, lavage in, 118 Atoxyl in carcinoma, 522 Atropine, 195, 196 in gastric hemorrhage, 473 in hyperchlorhydria, 322 Auerbach's plexus, movements of stomach and, 22 Autolavage, 124 B Bacillus of l)();is-()|)plcr, carcinoma and, (■)!), 76, 509 bulgaiicus, 93, 94 Bacterial vaccines, treatment of gas- tric ulcer with, 452 Bandages for cnteroptosis, 247 of, Bardenheuer's corset for cnteroptosis, 253 Baths, half, 147 effect of, 147 temperature of, 147, 148 mineral, 158 oxygen, 149 in nerA'ous dyspepsia, 149 preparation of, 149 prolonged, 149 sea, 158 Bead test, Einhorn's, 59 technique of, 60 Beans, 97 Beef, essence of. Brand's, 116 tea, 116 nutritive value of, 90 "Belt sign," Glenard's, in cntero- ptosis, 246, 247 Benign tumors, 530 Benzidin paper, Einhorn's, 56 test, Adler's original, 55 for occult blood, 54, 55 Schlessinger and Hoist's modification of, 55 Bertrich waters, 154 Bile, effect of hydrochloric acid on, 170 in stomach, 31 Bilirubin, 31 Biliverdin, 31 Bismuth, 183 bisalicylate, effect of, 185 bitannate, effect of, 185 contraindications for, 184 in erosions, 481 in gastric hemorrhage, 471 ulcer, 184, 443 in hyperchlorhydria, 320, 321 indications for, 184 salicylate, effect of, 185 salts of, principal, 183 use of, in Roentgenography, 183 subcarbonate, 186 subnitrate, efl'ects of, 1S5 Bitter waters, 157 contraindications for, 157 indications for, 157 Bitters, ISO classes of, 187 Reichmann's experiments with, 189 vegetable, effect of, ISS Biuret reaction, 51 Blood in gastric contents, 32, 52 erosion and, 52 gastric carcinoma and, 52, 53 ulcer and, 52 test for, Weber's guaiac, 53 occult, 53 INDEX 537 Blood, occult, duodenal ulcer and, 54 gastric carcinoma and, 53 ulcer and, 53 tests for, 54 benzidin, 54 phenolphthalein, 56, 57 serum, hemolytic action of, diaj:;- nosis of carcinoma from, 65 Blue Lick water, analysis of, 162 Boas' diet for chronic gastritis, 376, 387 for enteroptosis, 242 electrode, 140, 141 food cure in enteroptosis, 237 nutrient enema, 407 test breakfast, 33 cancer and, 33 lactic acid and, 33 Boas-Oppler bacillus, carcinoma and, 69, 76, 509 pyloiic stenosis and, 74 sarcoma and, 529 Bouillon, Maggi's, 116 Bovril, 116 Brandenburg's nutrient enema, 408 Brand's essence of beef, 116 Bread, 95 brown, 95 graham, 95 rye, 95 value of, 95 white, 95, 96 Bright's disease, lavage in, 120 Bromides, 192 Bronchitis, contraindication for lav- age, 120 Brown bread, 95 Bucket, stomach, 35, 36 Bulgarian bacillus, 93, 94 Bulimia, 289 diseases associated with, 289 electricity in treatment of, 140 motor insufficiency and, 67 symptoms of, 290 treatment of, 290 Butter, heat value of, 79 Buttermilk, 92 Cachexia in carcinoma, 508 contraindication for lavage, 120 in sarcoma, 529 Calorie, definition of, 79 Cancer. *SVe Carcinoma. Cancorin in carcinoma, 523 Cancrodin in carcinoma, 523 Cannabis indica, 192 Canned meat, 88 Capitan's nutrient enema in gastric ulcer, 451 Carbohydrates, action of stomach on, 21 in chronic gastrorrhca, 338 in diet in enteroptosis, 235 digestion of, in stomach, 52 food preparations of, 114 in treatment of hyperchlorhydria, 315 Carbolic acid, 197 Carbonated waters, alkaline, 156 Carcinoma, 503 age and, 504 anemia in, 508 anodynes in, 520 anorexia in, 507 appetite in, 507 arsenic in, 522 atoxyl in, 522 blood in gastric contents and, 52, 53 Boas' test breakfast and, 33 Boas-Oppler bacillus and, 69, 76, 509 cachectic appearance in, 508 cancorin in, 523 cancrodin in, 523 of cardia, diet in, 524 lavage in, 525 stenosis and, 525 stricture and, 525 treatment of, 524 colloid, 506 complications of, 506 adhesions, 507 perforation, 507 rupture, 507 condurango bark in, 518, 519 contraindication for massage of stomach, 134 diagnosis of, 75, 508 early, 216 from gastric ulcer, 426 by hemolytic action of blood sei'um, 65 from motor insufficiency of second degree, 403 from perigastritis, 484 from sarcoma, 530 diet in, 512, 513, 515, 516 enemata in, nutrient, 515 etiology of, 503 fats in, 514 fibrous, 506 forms of, 505 gastrectomy in, 510 gastroenterostomy in, 219, 511 gastrogenic diarrhea in, 522 gelatinous, 506 heredity and, 504 hydrochloric acid in, 75, 217 incidence of, 503 ischiochymia and, 511 538 INDEX Carcinoma, lactic acid in, 47, 76, 217, 509 laparotomy in, explorator3', 217, 218, 509 location of, 505 h'sins in, 65 malignancy of, 505 medullar^', 506 metastases of, 505, 509, 511 narcotics in, 521 nausea in, 507 Xeubauer and Fisher's test for, 63, 64 occult blood and, 53 pain in, 507 pathology of, 504 pepsin in, 217 pepsinogen in, 24 pylorectomy in, 510 rest in, 512 Roentgen raj's in, 523 Salomon's test for, 63 scirrhous, 506 sex and, 503 simple, 506 skin reaction in, 65 stomach contents in, 509 surgery of, 215 symptoms of, 507 treatment of, 510 internal, 512 by lavage, 516 medicinal, 518 mineral water, 518 physical, 518 surgical, 510 contraindications for, 511, 512 indications for, 510, 511, 512 trypsin in, 523 vomiting in , 507 weakness in, 507 Cardia, carcinoma of, treatment of, 524 Cardialgia, 282. See also Gastralgia. Cardiospasm, 262 acute, 262 diagnosis of, 263 etiology of, 262 oil cure for, 264 prognosis of, 263 second sound of deglutition in, 263 symptoms of, 262 treatment of, 263 dilator in, Einhorn's, 266 Myor's, 265, 266 Plummer's, 206 Sippy's, 264, 265 electrotherapy in, 267 mechanical, 264 Cardiospasm, treatment of, sounds for, 266 Carigen, 107 Carlsbad salt, artificial, 181 in treatment of hvperchlor- hydria, 326, 327"^ waters, 154 contraindications for, 154 indications for, 154 ' Casein, curdling of, by rennin, 27 in milk, precipitation of, 92 Cataplasms, 150 hot, 151 Catarrh, gastric, chronic, 362. See also Gastritis, chronic, of stomach, infectious, 353. See also Gastritis, acute, infectious. Champion water, analysis of, 163 Chase's tube for stomach douche, 131, 132 Cheese, 94 Chemical examination of stomach con- tents, 39 Chloral hvdrate, 192 Chloroform, 193 for gastric hemorrhage, 473 Chlorosis, motor insufficiencv and, 66 Chocolate, 102 Mering's "Kraft," 116 CholeUthiasis, nervous dyspepsia and, 297 Cirrhosis ventricuh, 364 Climatic cures, 158 Cocaine hydrochloride, 193 Cocoa, 102 Cod-liver oil, 115 Coffee, 101 Cold pack, entire, 148 Coley's treatment for sarcoma, 530 Colloid carcinoma, 506 Colopto.sis, 220 Compresses, 150 Condiment, Maggi's, 116 Condurango bark, 189 in carcinoma, 518, 519 Congo red test for free hydrochloric acid, 40 Congress water, analj-sis of, 165 Constipation, chronic, massage of stomach in, 138 Convulsions from overfeeding, lavage in, 119 Corsets for enteroptosis, 253 Cramer's diet list, 102, 103 Cream conserve, I^offlund's, 116 Credo's method of nia.'s.saKe, 135 Crockett arsenic-lit liia water, analysis of, 159 Cykloforni, 195 Cynorexia, 289. See also Bulimia. INDEX 539 Uauk meat. S7 . Deep Rock water, analysis ot, 160 Deutero-albuinose, 027 Dextrinated flours, 114 Dextrose, test for, Fehling's, 52 Xylander's, 52 Diabetes niellitus, lavage in, 120 motor insufficiency and, 66 Diarrhea, gastrogenic, in carcinoma, 522 hydrochloric acid in, 170 pancreatin in, 176 peptones and, 108 Diastase, 178 Diastatic ferments, 178 Diet in arteriosclerosis, 491 in carcinoma, 512, 515, 516 of cardia, 524 in chronic gastritis, _372 gastrorrhea, 337 in enteroptosis, 229 in erosions, 480 in gastric disease, 77 hemorrhage, 470 heavv, 81 in motor msumciency ot tirst degree, 397 in nervous dyspepsia, 299 in operations on stomach, 206 salt-free, for hyperchlorhydria, 319 I in syphilis, 501 Dietarv' hsts, 80 regulations, 80 | Digestibihty, definition of, 81 I of meat, 89 Digestion, definition of, 17 gastric, 22 enzymes in, 23 hydrochloric acid in, 25 Pawlow's experiments on, 22, 25 pepsin in, 24 intestinal, 28 mastication and, 18 physiology of, 17 salivary, 18 inhibition of, by hydro- chloric acid, 18, 19 Dilatation, acute, of stomach, 73, 211, 416 treatment of, 211, 212, 417 due to pyloric stenosis, massage in, 133 postoperative, acute, lavage m, 119 Dilator, pyloric, Einhorn's, 413 Dimethylainidoazobenzol test for free hydrochloric acid, 41 for "reaction of stomach con- tents, 41 Dioxydiamidoarsenobenzol, 498 Douches, 151 interrupted, 151 Scotch, 151 stomach, 129 Chase's tube for, 131, 132 Einhorn's apparatus for, 130, 131 Richter's method, 129 Rosenheim's tube for, 129 Turck's tube for, 131 Drum-belly, 272. See Pneumatosis. Duodenal aUmentation, Emhorn s, in gastric ulcer, 437 Dyspepsia, atonic, hot water and, 99 nervous, 259, 295 achlorhydria and, 310 appendicitis and, 296 larvata and, 297, 309 cholelithiasis and, 297 diagnoses of, 298 diet in, 299 lactovegetable, Wegele s 301 vegetable, 300 etiology of, 295 gallstones and, 296 gastric secretion in, 71 hydrotherapeutics in, 302 inhibition of hydrochloric acid in, 51 massage in, 134, 136, 137 mineral waters in, 302 nutrition in, 299 oxygen bath in, 149 prognosis of, 299 prophylaxis of, 299 symptoms of, 297, 298 as a symptom complex, 295 treatment of, 299 _ medicinal, 305 physical, 302 sea water, 303 surgical, 308 Dyspeptine, 175 Eclampsia, lavage in, 120 Egg protein, nutritive substances from, 113 Eggs in gastric disease, 90 i EhrUch-Hata preparation, 498 1 Einhorn's apparatus for stomach douche, 130, 131 . bandage for enteroptosis, 24b I bead test, 59 540 INDEX Einhorn's benzidin test, 56 diet for chronic g;astritis, 374 for hj'perchlorhj'dria, 318 dilator in treatment of cardio- spasm, 266 duodenal alimentation in gastric ulcer, 437 bucket, 68 in diagnosis of cardio- spasm, 268 pump, 437 electrode, 142 Lockwood's modification of, 142 modification of Leube-Ziemssen treatment for gastric ulcer, 432 P3'loric dilator, 413 treatment of pyloro- spasm with, 268, 269 stomach bucket, 36 test for permeabiUty of pylorus, 67 Electric treatment in nervous vomit- ing, 276 of stomach, 138 Electricit}' in anorexia, 140 in atony of stomach, 140 in bulimia, 140 extraventricular apphcation of, 140 in gastralgia, 140 intraventricular application of, 140 in neuroses of stomach, 140 in ptosis of stomach, 140 in pylorospasm, 140 treatment by, 138 indications for, 140 in vomiting, hysterical, 140 nervous, 140 of pregnancy, 140 Electrization, extraventricular, 144, 145 intraventricular, 140 with Boas' electrode, 140 current in, 144 with Einhorn's electrode, 142 with Marshall's electrode, 143 with Stockton's electrode, 143 with Wegele's electrode, 140 Electrode, lioas', 140 Einhorn's, 142 Marshall's, 143 Stockton's, 143 Wegele's, 140 Electrotherapy in cardiospasm, 267 in cnteroptosis, 245 Eisner's adhesive bandage for cntero- ptosis, 251 Emesls. See Vomiting. EmoUients, gastric, 199 Emphvsema, contraindication for lav- age ,"" 120 Emulsion, Russell's, 115 sevi compound (Wyeth), 115 Enema, nutrient, 407 Boas', 407 Brandenburg's, 408 Capitan's, 451 in carcinoma, 515 Ewald's, 407 in gastric hemorrhage, 466 ulcer, 450 Klopfer's, 409 Kussmaul's, 408 Lattier's, 408 Leube's, 408 Mering's, 408 milk and egg, 407 Moritz's, 408 pancreas, 408 peptone and propeptone, 407 Riegel's, 407 Robin's, 450 Rosenheim's, 408 Strauss', 408 Enteroptosis, 220 bandage for, Aaron's, 247, 248 adhesive, 249 Eisner's, 251 Helfenberg's, 252 removal of, 250 Rose's, 249, 250, 251 Einhorn's, 248 Longstreth's, 248, 249 corsets for, 253 Aaron's, 254 adjustment of, 254 Bardenheuer's, 253 Landau's, 253 degrees of, 225 diagnosis of, 224 diet in, 229 alcohol in, 236 Boas', 242 carbohydrates in, 235 fats in, 233, 234 proteins in, 233 Strauss', 241 technique of, 233 Zwieg's, 241 drugs in, 238, 239, 240 clcctrotliprapoutics in, 245 etiology of, 220, 221 exercise in, 242 food cure in, Boas', 237 "forced feeding" in, 230 forms of, 221 Gl^nard's "belt sign" in, 24(5, 247 hepatoptosis in, 229 heredity in, 221 hydro! iierapeutics in, 238, 246 INDEX 541 Enteroptosis, hyperacidity' in, 225 hypcraiinieiitation in, 230, 231 massage in, 242 nephroptosis in, 22o neurasthenia and, 223 pathology of, 222 petrissage in, 243 pregnancy and, 2oo, 250 prognosis of, 229 prophylaxis of, 229 sex in, 220 Stiller's sign in, 224 symptoms of, 222 nervous, 223 objective, 223 tapotement in, 244 treatment of, 229 mechanical, 246 medicinal, 256 surgical, 257 Enzymes, action of, 23, 24 in gastric digestion, 23 in stomach contents, examination of, 49 Epilepsy, contraindication for lavage, 120 Epinephrin, 200 Erepsin , 29 \ Erosions, 477 acute , 477 I bismuth in, 4S1 blood in gastric contents and, 52 chronic, 477 diagnosis of, 75, 479 etiology of, 478 forms of, 477 gastric contents in, 75 gastritis and, 478 hemorrhagic, 477 hydrochloric acid in, 75 pain in, 479 pathology of, 478 prognosis of, 480 silver nitrate in, 481 superficial, of stomach, diagnosis of, from gastric ulcer, 425 suprarenal gland in, 481 symptoms of, 479 treatment of, 480 Eructations, acid, prescription for, 351 diagnosis of, 271 nervous, 270 s3-mptoms of, 270 treatment of, 271 Erj'throdextrin in chronic gastritis, 72 Erythrodextrose, conversion of starch into, 19 Escalin for gastric hemorrhage, 472 Etat mamelonne in chronic gastritis, 364 in motor insufficiency of second degree, 401 Eucasin, 112 Eumydrin, 196 Ewald-Boas test breakfast, 33 composition of, 33 disadvantages of, 33 Ewald's diet for chronic gastritis, 373 nutrient enema, 407 Excision in gastric ulcer, 205, 456 Exercise in enteroptosis, 242 Expression metliod for obtaining stomach contents, 34 Extracts, meat, value of, 116, 117 Extraventricular electrization, 144, 145 Eye strain, gastric neuroses and, 293 Faradization, direct, of stomach, 139 intraventricular, 144 Fat, 91 Fats in carcinoma, 514 in diet in enteroptosis, 233, 234 food preparations containing, 115 in gastric disease, 91 in hyperchlorhydria, 316 Fauces, irritability of, in lavage, 126 Feces, examination of, 57 Feeding, ''forced," in enteroptosis, 230 Fehling's test for dextrose, 52 Ferments, diastatic, 178 diminution of, in stomach, signifi- cance of, 51 Ferruginous waters, 156 indications for, 157 Fersan, 107 Fever, contraindication for massage, 134 Fibroma, 531 Fibromyoma, 531 Fibrous carcinoma, 506 Fleiner's bouillon-wine enema, 405 test meal, 34 Flour, aleuronat, 112 dextrinated, 114 finely divided, 114 Knorr's, 114 legimainous, 114 Fluid meat, 116 Food, carbohydrates in, 77 composition of, 77, 78 cure. Boas', in enteroptosis, 237 fats in, 77 heat value of, 79 nutritive value of, 86 permissible, 103 "predigested," 111 preparation of, 102 preparations, animal, 106 carbohydrate, 114 fat, 115 milk, 116 542 INDEX Food preparations, mixed, 114 stimulating, 116 prohibited, 103 proteins in, 77 quantity of, 104 requirement of, average, 86, 87 in calories, 86, 87 selection of, 102 sleep after, 105 temperature of, 105 time of, in stomach, 82, 83 •'Forced feeding" in enteroptosis, 230 Friedenwald and Ruhrah's diet for chronic gastritis, 376 gastrorrhea, 339 Friedlieb's stomach tube, 125, 126 Fruit, 97 G Galactogen, 113 Gallstones, nervous dyspepsia and, 296 Galvanization, direct, of stomach, 139 intraventricular, 144 Galvanofaradization, intraventricular, 144 "Gamey" meat, 87 Gartner's fat milk, 92, 116 Gasterine, 174 Gastralgia, 282 due to anemia, massage in, 135 to neurasthenia, massage in, 135 electricity in treatment of, 140 in locomotor ataxia, 285 symptoms of, 282 treatment of, 283 Gastralgokenosis, 288 Gastrectasis, motor insufficiency of second degree and, 400 Gastrectomy in carcinoma, 510 Gastric analvsis, indirect methods of, 61 anodynes, 193 antiseptics, 197 atony, 73, 74 carcinoma, 503 crises in locomotor ataxia, 285 digestion, 22 dilatation, 73 emollients, 199 fever, 353 hemorrhage, 460 adrenalin for, 469 analgesics in, 473 arteriosclerosis and, 487 atropine in, 473 bismuth for, 471 fhloroforiii in, 473 Gastric hemorrhage, diagnosis of, 460 differential, 461 diet for, 470 escalin for, 472 gastric ulcer and, 460, 461 gelatin for, 467 hematemesis and, 460 lavage for, 471 melena and, 460, 462 oil cure for, 471 orthoform in, 474 prescriptions for, 467 prophylaxis of, 462 silver nitrate for, 472 stypticin for, 468 treatment of, 462 bj' enemata, 466 hemostatics in, 466 by lavage, 463 medicinal, 466 operative, 476 • hyperesthesia, 286 insufficiency, lactic acid in stom- ach contents and, 47 juice, acidity of, 25 action of, 27 color of, 25, 38 consistency of, 38 determination of, 37 Alatthieu's formula for, 38 hpase in, 27 nervous control of, 25 normal, 25 odor of, 25, 38 pepsin in, 26 rennin in, 27 sarcinae in, 70 secretion of, 26 specific gravity of, 25 in stomach contents, 37 neuroses, 259 secretion, alcohol and, 188 changes in, due to patho- logic conditions, 71 sedatives, 191 tetany, 212 lavage in, 119 ulcer, 418 age and, 420 appetite in, 424 arteriosclerosis and, 487 bismuth for, 184, 443 blood in gastric contents and, 52 chronic gastrorrhea and, 335 cicatrization in, 420 complications of, 424 contraindication for mas- sago, 134 diagnosis of, 75, 425 from acute gastritis, 425 INDEX 543 Gastric ulcor, diagnosis of, froin {gas- tric faiiccr, 426 from hystorictil vomit- ing, 425 from nervous vomiting, 425 from superficial erosion of stomach, 425 diet in, 428 duodenal alimentation in, Kinhorn's, 437 procedure of, 439 excision of, 205 frequency of, 420 gastric contents in, 75 hemorrhage and, 460, 461 gastroenterostomy in, 205 heaUng of, 420 hematemesis in, 423 hemorrhage in, 207, 422 lavage in, 119 surgery of, 207 Weber's test for, 423 hydrochloric acid in, 75 nutritive enema in, 450 Capitan's, 451 Robin's, 450 occult blood and, 53 olive oil for, 448 pain in, 421 epigastric, 422 pathology of, 418 perforation in, 208, 418, 423 frequency of, 424 surgery of, 209 prognosis of, 427 prophylaxis of, 428 resorcinol for, 447 sequelae of, 424 sex and, 420 silver for, 445 situation of, 419 sodium bicarbonate in, 441 surgery of, 204, 205 symptoms of, 421 "thread test" for, Einhorn's, 426 treatment of, 428 antilytic serum in, 451 bacterial vaccines in, 452 Lenhartz, 434, 435 Leube-Ziemssen, 428 Einhorn's modifica- tion of, 432 summary of, 431 medicinal, 440 surgical, 454 excision in, 456 gastroenterostomy in, 456 indications for, 455 Gastric ulcer, vomiting in, 422 "Gastrin," 26 Gastritis, acid, chronic, 314. Sec also Hypcrchlorhydria. treatment of, 329 acute, contraindication for min- eral waters, 158 diagnosis of, from gastric ulcer, 425 gastric contents in, 72 hydrochloric acid in, 72 infectious, 353 etiology of, 353 fever in, 353 pathology of, 353 symptoms of, 353 treatment of, 354 medicinal, 355 lavage in, 119 simple, 346 course of, 347 diet in, 351 emesis in, 347 emetics for, 349 etiology of, 346 pathology of, 347 prophylaxis in, 348 symptoms of, 347 treatment of, 348 anacid, 366 catarrhal, pepsinogen in, 24 chronic, 362 achroodextrin in, 72 alcohoUsm and, 363 diagnosis of, 366 diet in, 372 Boas', 376, 387 Einhorn's, 374 Ewald's, 373 Friedenwald and Ruh- rah's, 376 meat free, 375 Riegel's, 384 Wegele's, 375, 386 Zweig's, 386, 387 erythrodextrin in, 72 etat mamelonne in, 364 etiology of, 362 gastric contents in, 72 gastrosan for, 383 hot water and, 99 hydrochloric acid in, 72, 377 inhibition of hydrochloric acid in, 51 lavage in, 388 massage in, 135 motor insufficiencj' and, 66 mucus in, 72 pancreatin for, 177, 380 papain for, 380 papayotin for, 380 pathology of, 363 544 INDEX Gastritis, chronic, pepsinogen in, 72 prognosis of, 368 rennin zymogen in, 72 resorcinol for, 383 stomacMcs for, 380 subacidity in, 367 symptoms of, 365 treatment of, 371 medicinal, 377 with mineral waters, 390 physical, 391 erosions and, 478 lavage in, 119 phlegmonous, 357 alcohohsm and, 358 course of, 360 diffuse, 358 etiology of, 358 gastroenterostomy in, 360 gastrostomy in, 360 pathology of, 359 prognosis of, 360 symptoms of, 360 treatment of, 360 polyposa, 364 sclerotic, 364 subacid, 366 toxic, 246, 355 etiology of, 355 pathology of, 356 prognosis of, 356 symptoms of, 356 treatment of, 356 Gastrochylorrhea, 31 gastric contents in, 72 Gastrodynia, 282. See also Gastral- gia. Gastroenteroptosis, massage in, 245 Gastroenterostomy in carcinoma, 219, 512 in gastric ulcer, 205, 456 in phlegmonous gastritis, 360 in ulcer of duodenum, 206 of pylorus, 206 Gastrofaradization, 139 Gastrogalvanization, 139 Gastrojejunostomy, perigastritis and, 486 Gastroplication in gastroptosis, 215 Gastroptosis, 220. See also Entero- ptosis. gastroplication in, 215 in motor insufficiency of first degree, 394 surgery of, 214 vcnirotixation in, 214 Gastrorrfiagia, 4()0. Sec also Gastric li(!morrliage. macroscopic;, 462 manifest, 402 visible, 462 Gasfrorrhca, 31 Gastrorrhea, acute, 332 chronic, 334 age and, 335 carbohydrates in, 338 diagnosis of, 336 diet in, 337 Friedenwald and Ruh- rah's, 339 Hquid in, 340 number of meals in, 340 Wegele's, 339 etiology of, 335 examination, external, of stomach in, 336 gastric ulcer and, 335 lavage in, 342 meat in, 338 "milk cm-e" in, 340 mineral waters in, 343 Murphy's proctoclysis in, 337 prognosis of, 337 symptoms of, 335 treatment of, 337 medicinal, 341 physical, 343 surgical, 343 gastric contents in, 72 intermittent, 332 Gastrosan for chronic gastritis, 383 Gastrostomy, indications for, 204 in phlegmonous gastritis, 360 Gastrosuccorrhea, 31, 332. See also Hypersecretion, gastric contents in, 72 Gastroxynsis, nervous, 333 Gelatin, 89 for gastric hemorrhage, 467 preparation of, 89 Gelatinous carcinoma, 506 Geneva lithia water, analysis of, 161 Glcnard's "belt sign" in enteroptosis, 246, 247 Globon, 113 Glycogen, conversion of, by ptyalin, 18 Graham bread, 95 Great Jiear ^^'ater, analysis of, 159 Gruel soups, 96 Guaiac test, Weber's, for blood in gastric contents, 53 Giinzburg's test for absorptive powers of stomacii, 61, 62 for free liydrochloric acid, 41 for reaction of stomach con- tents, 41 Hauersuon's diet for hyperchior- hydria, 3 IS Hal)ilns cnteropticus, 221 INDEX 545 Hathorn water, analysis of, 103 Heart in arteriosclerosis, 490 disease, contrainiiication for lav- age, 120 Heat, application of, to abdominal region, loO, 151 Helfenberg's aclhesi\e bandage for enteroptosis, 252 Heraatemesis, gastric lieinorrhage and, 460 in gastric ulcer, 423 hemoptysis and, 32 lavage in, 119 Hemmeter's directions for massage, 135 Hemoptysis, hematemesis and, 32 Hemorrhage, gastric, 460 in gastric ulcer, 207 recent, contraindication for lav- age, 120 Hemorrhagic erosions, 477 Hemostatics in treatment of gastric hemorrhage, 466 Hpi)atoptosis, 220 diagnosis of, 229 in enteroptosis, 229 Hernia epigastrica, 531 symptoms of, 532 treatment of, 532 Heterochylia, 71 Heyden's nutritive, 113 Hiccough, 281. See Singultus. "Hormones," 26 Hot cataplasms, 151 compre.s.ses, 150 Hourglass contraction, diagnosis of, 214 perigastritis and, 482 surgery of, 214 Hydriatic treatment of stomach, 146 Hydrochloric acid, 166 in achylia gastrica, 170 administration of, capsules for, 172, 173 with pepsin, 168, 171 time for, 167 in carcinoma, 217 combined, Topfer's test for, 46 conversion of sugar by, 25 dilution of, 172 dosage of, 175 effect of, on appetite, 171 on bile, 170 on pancreatic juice, 170 on proteins, 169 on secretions, 168 in erosions of stomach, 75 free, Congo red test for, 40, 41 dimethylamidoazoben- zol test for, 41 s 35 Hydrochloric acid, free, Giinzburg's test for, 41 phloroglucin-vanillin test for, 41 T()pfer's method for ana- lysis of, 45 in gastric carcinoma, 75 digestion, 25 ulcer, 75 in gastritis, acute, 72 chronic, 72, 377 in gastrogenic diarrhea, 170 in hj'persecretion, 72 indications for, 171 inhibition of, in chronic gas- tritis, 51 during menstruation, 51 in nervous dyspepsia, 51 of salivary digestion bv, 18, 19 pepsin and, 24, 26, 49 proteoly.sis and, 168, 169 in pyloric insufficiency, 75 secretin and, 168 Hydrocyanic acid, diluted, 192 Hydrogen peroxide, 198 in hyperchlorhydria, 323 Hydrotherapeutics, 146 cold entire pack, 148 in enteroptosis, 238, 246 half baths, 147 indications for, 149 prolonged baths, 149 "rub off" in, 147 skin reaction in, 147 temperature of water in, 146 warm entire pack, 148 wet rub in, 146 Hygiama, 114 Hyperacidity, 311. See also Hyper- chlorhydria. in enteroptosis, 225 gastric contents in, 71 in motor insufficiency of first degree, diet in, 397 treatment of, 329 Hyperalimentation, 230, 231 in enteroptosis, 230, 231 Hyperchlorhydria, 311 contraindication for massage, 134 diagnosis of, 313 diet in, Einhom's, 318 Habershon's, 318 salt-free, 319 Strauss', 317 digestion of starch in, 52 etiology of, 312 gastric contents in, 71 lavage in, 328 medication in, course of, 328 546 INDEX H3-perchlorhyflria, pathologj^ of, 312 physiotherapeutic measures in, 329 prognosis of, 314 sugar in, 98 symptoms of, 313 treatment of, alkahes in, 325 alkaloids in, 324 analgesics in, 324 astringents in, 320 atropine in, 322 bismuth in, 320, 321 carbohydrates in, 315 Carlsbad salt in, 326, 327 dietetic, 315 fats in, 316 hydrogen peroxide in, 323 hygienic, 314 medicinal, 320 oils in, 316 proteins in, 315 salts of aikahne earths in, 325 silver in, 320, 321 Hvperemesis gravidarum, treatment of, 274, 275 Hyperesthesia, gastric, 286 etiologj' of, 286 nitrate of silver in, 287 symptoms of, 286 treatment of, 286 Hypermotiht}-, 260 in achylia gastrica, 260 Hyperorexia, 289. See also Bulimia. Hj'persecretion, 31 alimentarj', 343 diagnosis of, 344 symptoms of, 344 treatment of, 345 lavage in, 345 medicinal, 345 chronic, 335. See also Gastror- rhea, chronic, contraindication for massage of stomach, 134 diagnosis of, 72 gastric contents in, 72 hydrochloric acid in, 72 intermittent, 332 diagnosis of, 333 etiology of, 332 headaches in, 333 nervous system and, 332 symptoms of, 332 treatment of, 333, 334 in motor insufficiency of first degree, diet in, 397 periodic, 332 Hypertrophic stenosis of pylorus, 212 Hysteria, contraindication for lavage, 120 Ice water, 98 Infectious acute gastritis, 353 catarrh of stomach, 353 Inspection of stomach contents, 36 InsuflBciencj^ motor, anemia and, 66 bulimia and, 67 chlorosis and, 66 chronic catarrh and, 66 congenital, 66 diabetes and, 66 diagnosis of, 73 of first degree, 393 acidity in, normal, diet in, 397 anaciditv in, diet in, 397 atony and, 394 diagnosis of, 395 etiologj- of, 393 gastropto.?is in, 395 hj-peracidity in, diet in, 397 hj-persecretion in, diet in, 397 lavage in, 398 myasthenia and, 394 "stomach dizzi- ness" in, 394 subacidity in, diet in, 397' sjTnptoms of, 394 treatment of, 396 medicinal, 399 milk, 396 with mineral waters, 400 physical, 399 gastric contents in, 73 leukemia and, 66 mineral waters and, 157 myasthenia and, 66 neurasthenia and, 67 paresis and, 66 polyphagia and, 67 of second degree, 400 diagnosis of, 402 dilatation and, 400 etat mameloune in, 401 etiology of, 400 gastrectasis and, 400 isrhochvmia and, 400 pyloric stenosis and, 401 rectal alimentation in, 404 INDEX 547 Insufficiency, motor, of second (lefuree, subcutaneous nutri- tion in, 410 symptoms of, 402 treatment of, 403 by lavage, 410 medicinal, 412 with mineral waters, 412 physical, 412 pyloric stenosis in, 413 syphilis and, 66 tuberculosis and, 66 urine in, 73 pyloric, 279 diagnosis of, 74 etiology of, 279 gastric contents in, 75 hj'drochloric acid in, 75 treatment of, 279 Intermittent gastrorrhea, 332 hypersecretion, 332 Interrupted douches, 151 Intestinal obstruction, contraindica- tion for mifferal waters, 158 lavage in, 118 paresis, lavage in, 119 Intestine, large, absorption of proteins by, 406 Intraventricular electrization, 140 faradization, 144 galvanization, 144 gah'anofaradization, 144 Invertin, 29 Iodides in arteriosclerosis, 492 Iodine, 198 reaction in achlorhydria, 52 Ischiochymia, carcinoma and, 511 motor insufficiency of second degree and, 400 Isomaltose, conversion of starch into, 18 Jacoby-Solms' method of determina- tion of pepsin, 49 Jacques patent tubes for lavage, 121 Jelly, meat, 89 Juices, meat, value of, 117 Karno, 116 Kefir, 92, 93, 116 composition of, 93 preparation of, 93 value of, 93 Kinases, 24 Klopfer's nutrient enema, 409 Knorr's flours, 114 Koumiss, 92, 93, 116 composition of, 93 preparation of, 93 value of, 93 Kreatinin in meat, 87 Kussmaul's nutrient enema, 408 Lactic acid bacilli, carcinoma and, 509 sarcoma and, 529 Boas' test breakfast and, 33 in carcinoma, 75, 217, 509 in meat, 87 in pyloric stenosis, 74 sarcoma and, 529 in stomach contents, 47 Lactose, 29 Lactovegetable diet in nervous dys- pepsia, 301 "Lana," 91 Landau's corset for enteroptosis, 253 Laparotomy in carcinoma, 217, 509 Lattier's nutrient enema, 408 Lavage, 118 in acute gastritis, 119 in alimentary hypersecre- tion, 345 apparatus for, 121 breathing in, 127, 128 in Bright's disease, 120 in carcinoma, 516 of cardia, 525 in chronic gastritis, 388 gastrorrhea, 342 in cicatricial closure of pylorus, 119 contraindications for, 120 bronchitis, 120 cachexia, 120 emphysema, 120 epilepsy, 120 fever, 120 gastric ulcer mth recent hematemesis, 120 heart disease, 120 hemorrhage, recent, 120 hysteria, 120 marked prostration, 120 neurasthenia, 120 pregnane}', 120 pulmonary tuberculosis, 120 in convulsions from overfeeding, 119 in diabetes meUitus, 120 in dilatation, acute postoperative, 119 duration of treatment by, 128 in eclampsia, 120 548 INDEX Lavage in gastric hemorrhage, 463, \ 471 I tetany, 119 in gastritis, 119 in hematemesis, 119 in hemorrhage from gastric ulcer, 119 in hjijerchlorhydria, 328 indications for. 118 in intestinal obstruction, 118 paresis, 119 irrigator for, 121, 123 irritabiht}' of fauces in, 126 Jacques patent tubes in, 121 in meteorism of t^'phoid fever, 119 in motor insufficiencj' of first degree, 398 of second degree, 410 | nausea in, prevention of, 126 ' in ner\-ous vomiting, 276 in poisoning, 118 in simple atony. 118 in stenosis of pvlorus, with dilata- tion. 118, 119 technique of, 121 time for, 128 tubes for, 122, 123 in vomiting from peritonitis, 119 postoperative, 119 uncontrollable, 119 Legumes, 97 Leguminous flours, 114 Leiter's coils, 151 Lenhartz treatment for gastric ulcer, 434, 435 Lentils, 97 Leo's test for rennhi, 50 Leube's diet li.sts, 86 nutrient enema, 408 test meal for determination of motor function of stomach, 66 Leube-Ziemssen treatment for gastric ulcer, 428 Leukemia, motor insuflRciencj- and, 66 Liebig-Kemmerich's meat extract, 116 Lin.seed poultice, 150 Lipanin, 116 Lipase, 29 in gastric juice, 26 Lipoma, 531 Locomotor ataxia, gastralgia in, 285 gastric crises in, 285 Lofflund's cream conserve, 116 Londonderry lithia water, analysis of, 165 Longstreth's bandage for enteroptosis, 248, 249 Lugol solution, composition of, 52 conversion of starch and, 19, 52 Lysins in carcinoma, 65 M Macroscofic gastrorrhagia, 462 Maggi's bouillon, 116 condiment, 116 Malignant growth, contraindication for mineral waters, 157 Maltase, 29 conversion of starch into, 18 Manifest gastrorrhagia, 462 Manitou water, analysis of, 161 jMarshall's electrode, 143 Mashed potato poultice, 150 Massage, 133 age and, 134 in chronic constipation, 138 gastritis, 135 contraindications for, 134 carcinoma, 134 fever, 134 gastric ulcer, 134 hyperclilorhydria, 134 hypersecretion, 134 meteorism, 134 ulcer with adhesions, 134 Crede's method of, 136 in dilatation due to pyloric stenosis, 133 in enteroptosis. 242, 245 in gastralgia, 135 Hemmeter's directions for, 135 indications for, 133 in inert musculature, 133 lubrication for, 137 medication in, 137 in nervous dyspepsia, 134, 136 petrissage in, 135 in primarj' intestinal atony, 134 in retention of gastric contents, 133 tapotement in, 135 technique of, 135 time for, 135 vibratory, 137 Mastication, digestion and, 18 slow, importance of, 104 Matthieu's formula for determination of gastric juice, 38 Meals, test, 32 Meat, 87 broth, nutritive value of, 90 canned, 88 composition of, 87 dark, 87 digestibility of, 89 extracts, composition of, 116, 117 Liebig-Kemmerich's, 116 Toril, 116 value of, relative, 116, 117 fluid, 116 free diet for chronic gastritis, 375 "gamcy," 88 INDEX 549 Meat jelly, 89 juice, Valentine's, IIG Wyeth's, 116 kreatinin in, 87 lactic acid in, 87 preparation of, 88 quantity of, required, 88 raw, 88 trichinosis and, 88 salted, 88 smoked, 88 varieties of, i)erniissible for gas- tric patients, 89 white, 87 xanthin in, 87 Medullary carcinoma, 506 Melena, gastric hemorrhage and, 460, 462 Menstruation, inhibition of hydro- chloric acid during, 51 Mering's "Kraft" chocolate, 116 nutrient enema, 408 Merycism, 277. See Rumination. Meteorism, contraindication for mas- sage, 134 of typhoid fever, lavage in, 119 Mett test for pepsin in stomach contents, 50 Miliary tuberculosis, 501 Milk, 91 cure in chronic gastrorrhea, 340 diet in carcinoma, 513 egg and, nutrient enema, 407 food preparations from, 116 ■ Gartner's fat, 116 in gastric disease, 91 "phobia" for, 91 protein, preparations of, 112 somatose, 113 treatment of motor insufficiency of first degree, 396 value of, 91 vegetable, 116 Voltmer's mother's, 116 Yoghurt, 93 Mineral baths, 158 waters, 153 alkaline carbonated, 156 chlorine, 153 American, 159 analyses of, 159 .AJlouez, 162 Blue Lick, 162 Champion, 163 Congress, 165 Crockett Arsenic-lithia, 1.59 Deep Rock, 160 Geneva lithia, 161 Great Bear, 159 Hathorn, 163 Londonderry lithia, 165 Mineral waters, aiialy.ses of, Manitou, 161 " Missisquoi, 164 Tate Epsom, 160 Vichy, 164 bitter, 157 in carcinoma, 518 in chronic gastritis, 390 gastrorrhea, 343 classification of, 1.53 constituents of, 153 contraindications for, 157 acute gastritis, 158 gastro-intestinal tuber- culosis, 158 hemorrhagic conditions, 157 intestinal obstruction, 1.58 malignant growth, 157 motor insufficienc}', 157 ferruginous, 156 in motor insufficiency of first degree, 400 of second degree, 412 sodium chloride, 155 Mintz's method of analysis of stomach contents, 45 Missisquoi water, analysis of, 164 Moritz's nutrient enema, 408 Morphine poisoning, lavage in, 118 Motor function of stomach, 66 neuroses, 259 Mucous membrane shreds in gastric contents, 71 polypi, 531 Mucus in chronic gastritis, 72 in stomach, 31 Murphy's proctoclysis in chronic gas- trorrhea, 337 Musculature, inert, massage in, 133 Mushrooms, 97 Mutase, 112 Myasthenia, motor insufficiency of first degree and, 66, 394 Myer's dilator in treatment of cardio- spasm, 265, 266 N Narcotics in carcinoma, 521 Nausea in carcinoma, 507 in lavage, prevention of, 126 nervous, 288 etiology of, 288 treatment of, 289 Nephroptosis, 220 diagnosis of, 225 by palpation, 225 positions for, 226, 227, 228 550 INDEX Nephroptosis in enteroptosis, 225 Xervous affections of stomach, 259 anorexia, 291 dyspepsia, 259, 295 eructations, 270 gastroxjTisis, 333 nausea, 288 vomiting, 273 Xeubauer and Fisher's test for gastric carcinoma, 63, 64 Neuralgia of stomach, 282. See also Gastralgia. Neurasthenia, contraindication for lavage, 120 enteroptosis and, 223 gastralgia due to, massage in, 135 gastrica, 295. See Dyspepsia, nervous. motor insufficiency and, 67 Neinroses, 71, 259 electricity in treatment of, 140 ; eye strain and, 293 I motor, 259 I secretory, 311 ' sensory, 282 Nitroglycerin, 192 Normal solutions, 42, 43 Nutrient enema, 407 Nutrition, subcutaneous, in motor insufficiency of second degree, 410 Nutritive-Heyden, 113 Nutrole, 115 Nutrose, 112 Nylander's test for dextrose, 52 Obstruction, intestinal, lavage in, 118 Occult blood, 53 Odda, 115 Oil cure for cardiospasm, 264 for gastric hemorrhage, 471 olive, 199 effects of, 199, 200 in gastric ulcer, 448 of sesame, 115 treatment of hyperchlorhydria, 316 of pylorospasm, 270 Orexin, 189 Orthoform, 193, 194 for gastric hemorrhage, 474 (Overeating, arteriosclerosis and, 488 Overwork, arteriosclerosis and, 488 Oxygen baths, 149 Pack, cold, 148 warm, 14S Pancreas nutrient enema, 408 Pancreatic secretion, 28 composition of, 29 effect of hydrochloric acid on, 170 Pancreatin, 175 administration of, 177 in chronic gastric catarrh, 177 gastritis, 380 constituents of, 176 in gastrogenic diarrhea, 176 indications for, 176, 177 preparation of, 176 properties of, 176 Pankreon, 177 Papain, 178 for chronic gastritis, 380 Papayotin, 178 for chronic gastritis, 380 Parapeptone, 27 Paresis, intestinal, lavage in, 119 motor insufficiencj^ and, 66 Parietal cells of stomach, 24 Parotid gland, secretion of, 18 Pawlow's experiments on gastric diges- tion, 22, 25 Peas, 97 Pequin, 92 Penzoldt's diet lists, 81-85 Pepsin, 24, 166. See also Hydro- chloric acid, administration of, 168 in carcinoma, 217 in gastric digestion, 24 juice, 26 hvdrochloric acid and, 24, 26, "49 in stomach contents, determina- tion of, 49 Jacoby - Solms method of, 49 Mett test for, 50 ricin test for, 49 Pepsinogen, 24 in carcinoma, 24 in catarrhal gastritis, 24 in chronic gastritis, 72 iiydrochloric acid and, 49 Peptic cells of stomach, 24 ulcer, 418. See also Gastric ulcer. Peptone.s, 24, 27, 107_ albumoses in, 107 alcohol in, 109, 110 calorics in, 109, 110 cost of, 110, HI diarrhea and, lOS food value of, 109, 1 10 nutritive value of, 107 propeptone nutrient enema, and 407 taste of, 108 lest for, 51 INDEX 551 Perforating gastric ulcer, 418. See also Gastric ulcer. Perforation in carcinoma, 507 in gastric ulcer, 208 Perigastritis, 213, 482 diagnosis of, 214, 484 from carcinoma, 484 with formation of tumors, 483 forms of, 483 gastrojejunostomy and, 486 hour-glass stomach and, 482 with local adhesive growths, 483 pain in, 484 prophylaxis of, 485 pyloroplasty and, 486 surgery of, 214 treatment of, 485 Periodic hypersecretion, 332 Peristalsis, effect of strj-chnine on, 187 of stomach, 20, 21 Peristaltic unrest, 260 symptoms of, 260, 261 treatment of, 261 Peritonitis, vomiting from, lavage in, 119 Permeability of pylorus, 67 Petrissage in enteroptosis, 135, 243 Pfund's cream protein mixture, 116 Phenol, 197 Phlegmonous gastritis, 357 Phenolphthalein test for occult blood, 56, 57 for total acidity of stomach contents, 44 Phloroglucin-vardllin test for free hydrochloric acid, 41 for reaction of stomach con- tents, 41 Pilocarpine, 196 Pineapple juice, 178 Plasmon, 113 Plummer's dilator in treatment of cardiospasm, 266 Pneumatosis, 272 treatment of, 272 Poisoning, lavage in, 118 Polyphagia, motor insufficiency of stomach and, 67 Polypi, mucous, 531 Potatoes, 96 Poultice, mashed potato, 150 Unseed, 150 " Predigested" foods. 111 Pregnancy, contraindication for lav- age, 120 enteroptosis and, 255, 256 Priessnitz bandage, 151 Proctoclysis, Murphy's, in chronic gastrorrhea, 337 Proenzymes, 24 Prolonged baths, 149 Propeptone, 27 Propeptone, test for, 51 Prostration, contraindication for lav- age, 120 Protalbumoses, 27 Proteins, absorption of, bj^ large intestine, 406 action of stomach on, 21 animal, preparations of, 106 in diet in enteropto.sis, 233 effect of hydrochloric acid on, 169 egg, nutritive substances from, 113 milk, preparations of, 112 mixture, Pfund's cream, 116 in treatment of hyperchlorhvdria, 315 vegetable, preparations of, 112 Proteolvsis, hydrochloric acid and, 168, 169 Protogen, 113 Protozoa in gastric contents, 70 Psychotherapeutics in nervous vomit- ing, 277 in rumination, 277 Ptosis of stomach, electricity in treat- ment of, 140 Ptyalin, IS Pulmonary tuberculosis, contraindi- cation for lavage, 120 Pump, stomach, 34 " Pumpernickle, " 95 Pus in stomach, 32 Pylorectomy in carcinoma, 510 Pyloric dilator, Einhorn's, 413 insufficiency, 279 strychnine in, 187 stenosis, 74, 209 Pyloroplasty, perigastritis and, 486 Pylorospasm, 267 diagnosis of, 268 Einhorn's duodenal bucket in, 268 electricity in treatment of, 140 etiology of, 267 treatment of, 268 drug, 270 wdth Einhorn's pyloric dila- tor, 268, 269 oil, 270 Pylorus, cicatricial closure of, lavage in, 119 insufficiency of, 279 permeabiUty of, 67 Einhorn's test for, 67 PjTOsis, prescription for, 351 Q Quin'ton's law, 303 ooJ INDEX B Raw meat, 88 Rectal alimentation in motor in- sufficiency of second degree, 404 Regurgitation, 278 Reichman's disease, 31, 334. See also Gastrorrhea, chronic. Rennin, action of, 27 curdling of casein by, 27 in gastric juice, 26 Leo's test for, .50 in pyloric stenosis, 74 qualitative test for, 50 zymogen, in chronic gastritis, 72 test for, 51 Resorcinol, 197 in chronic gastritis, 383 in gastric ulcer, 447 Rice, 96 meal, 97 Richter's method for stomach douche, 129 Ricin test for pepsin in stomach contents, 49 Riegel's diet for chronic gastritis, 384 nutrient enema, 407 test dinner, 33 meal ifor determination of motor function of stomach, 66 Robin's nutrient enema in gastric ulcer, 450 Roborat, 112 Roentgen raj's in carcinoma, 523 Roentgenograph}', bismuth salts in, use of, 183 Rosenheim's nutrient enema, 408 tube for stomach douche, 129 Rose's adhesive bandage for entero- ptosis, 249, 250, 251 Round ulcer, 418. See also Gastric ulcer. Rumination, 277 etiology of, 277 symptoms of, 277 treatment of, 277 drug, 278 p.sychotherapeutic, 277 Rupture in carcinoma, 507 Russell's emul.sion, 115 Rye bread, 95 S Sahli's desmoid test, 62 Salicylates, 198 .Saline waters, alkaline, 150 Saliva, action of, 18 chemical, 18 diastatic, 19 Saliva, action of, physical, 18 specific gravity of, 18 in stomach, 31 Salivarj' digestion, 18 Salomon's test for gastric carcinoma, 63 Salted meat, 88 Salt-free diet for hvperchlorhydria, 319 Salvarsan, 498 Salvatose, 107 Sanatogen, 112 Sarcin£e in gastric juice, 70 in p3'loric stenosis, 74 Sarcoma, 527 anemia in, 529 cachexia in, 529 diagnosis of, 530 from carcinoma, 530 etiology of, 527 frequency of, 527 lactic acid and, 529 bacilli and, 529 pathology of, 528 symptoms of, 529 treatment of, 530 Coley's, 530 Schlessinger and Hoist's modification of benzidin test, 55 Schmidt's table of nutritive value of foods, 86 test diet, 57 Scirrhous carcinoma, 506 Sclerotic gastritis, 364 Scotch douches, 151 Sea baths, 158 Sea water treatment of nervous dys- pepsia, 303 "Secretin," 26, 29 hydrochloric acid and, 168 Secretory neuroses, 311 Sedatives, gastric, 191 Sensor}' neuroses, 282 Serum, antilytic, treatment of gastric ulcer with, 451 Sevetol, 115 Silver in gastric ulcer, 445 nitrate, 190 action of, 190 dosage of, 191 in erosions, 481 in gastric hemorrliage, 472 indications for, 190 Simple acute gastritis, 346 Singultus, 281 gastricu.s, 281 Sippy's dilator in treatment of cardio- spasm, 264, 265 "Si.\ liuii(ircd and six," 498 Skin reaction in carcinoma, 65 Sleep after focxi, 105 Smoked meat, .S8 INDEX 553 Sodium bicarbonate, adniiniistration of, 179 in gastric ulcer, 441 chloride as an emetic, 180 waters, 155 contraindications for, 156 indications for, 155 Somatine, 107 Somatose, 106 milk, 113 Soups, gruel, 96 Sour milk, 92 Spices, 98 Splenoptosis, 220 Starch, conversion of, into achroo- dextrin, 19 into amylodoxtrin, 19 into erythrodextrose, 19 into isomaltose, 18 Lugol solution and, 19, 52 into maltose, 18 by ptj'alin, 18 stages of, 18, 19 digestion of, in hyperchlorhydria, 52 Stenosis, hypertrophic, of pylorus, 212 diagnosis of, 213 surgery of, 213 pjioric, Boas-Oppler bacillus in, 74 diagnosis of, 74, 209 with dilatation, lavage in, 118, 119 etiology of, 210 gastric contents in, 74 lactic acid in, 74 motor insufficiency of second degree and, 401 rennin in, 74 sarcinse in, 74 surgery of, 210, 211 treatment of, 413 Stiller's sign in enteroptosis, 224 Stockton's electrode and stomach tube, 143 Stomach, absorptive power of, 28 Giinzburg's test for, 61, 62 arteriosclerosis of, 487 aspirator, 35 bucket, 35, 36 carcinoma of, 503 contents, acidity of, analysis of, quantitative, 43 total, phenolphthalein test for, 44 analysis of, Mintz's method 45 quantitative, 42 Topfer's method of, 45 blood in, 52 Stomach contents, enzymes in, exami- nation for, 49 examination of, 31 chemical, 39 macroscopic, 34 microscojjic, 08 inspection of, 36 lactic acid in, 47 carcinoma and, 47 gastric insufficiency and, 47 Strauss' test for, 48 Uffelmann's test for, 47, 48 mucous membrane shreds in, 71 pepsin in, determination of, 49 Mett test for, 50 Ricin test for, 49 protozoa in, 70 reaction of, Congo red test, for, 40 determination of, 40 dimethylamidoazoben- zol test for, 41 Giinzburg's test for, 41 phi or oglucin- vanillin test for, 41 retention of, massage in, 133 dilatation of, acute, 211, 416 "dizziness" in motor insufficiency of first degree, 394 douche, 129 electrical treatment of, 138 erosions of, 477 ferments in, diminution of, signi- ficance of, 51 hemorrhage from, 460 hydriatic treatment of, 146 lavage of, 118 massage of, 133 motor function of, 66 insufficiency of, 393, 400 movements of, 23 neuroses of, 259 parietal cells of, 24 peptic cells of, 24 peristalsis of, 20, 21 pump, 34 sarcoma of, 527 thermic treatment of, 146 tube, 35 Friedlieb's, 125, 126 Strauss', 125, 127 ulcer of, 418 undigested food in, 30 Strauss' diet table for enteroptosis, 241 for hyperchlorhydria, 317 nutrient enema, 408 stomach tube, 125, 127 554 INDEX Strauss' test for lactic acid in stomach contents, 48 Stricture, carcinoma of cardia and, 525 Strychnine, 186 effect of, on peristalsis, 187 in p5'loric insufficiency, 187 Stj'pticin for gastric hemorrhage, 468 Subacid gastritis, 366 Subacidity in motor insufficiency of first degree, diet in, 397 Subphrenic abscess, surgery of, 209 Sugar, 97, 98 conversion of, by hydrochloric acid, 25 in hyperchlorhydria, 98 Suprarenal gland in erosions, 481 Syntonin, 27 Syphilis, 494 arteriosclerosis and, 488 diagnosis of, 494 diet in, 501 forms of, 494 motor insufficiency of stomach and, 66 salvarsan for, 498 treatment of, 495 general, 501 hypodermic, 496 Syphilitic ulcer, 494 Tapotement in enteroptosis, 244 in massage, 135 Tate Epsom water, analysis of, 160 Tea, 101 beef, 116 effect of, 101 Test, benzidin, Adler's original, 55 for occult blood, 54 Schlessinger and Hoist's modification of, 55 Congo red, for free hydrochloric acid, 40, 41 for reaction of stomach contents, 40 diet, Schmidt's, 57 dimethjdamidoazobenzol, for free hydrochloric acid, 41 for reaction of stomach con- tents, 41 Einhorn's bead, 59 for permeability of py- lorus, 67 Fehling's, for dextrose, 52 Gimzburg's, for absorptive powers of stomach, 61, 62 for free hydrochloric acid, 41 for reaction of stomach con- tents, 41 Leo's, for rennin, 50 Test meals, 32 Boas', 33 composition of, 31, 32 Ewald-Boas', 33 Leube's, for determination of motor function of stomach, 66 Riegel's, 33 for determination of motor function of stomach, 66 Mett's, for pepsin, 50 Mintz's, for analysis of stomach contents, 45 Neubauer and Fisher's, for gas- tric carcinoma, 63, 64 Nylander's, for dextrose, 52 phenolphthalein, for occult blood, 56, 57 for total aciditj' of stomach contents, 44 phloroglucin-vanillin, for free hy- drochloric acid, 41 for reaction of stomach con- tents, 41 ricin, for pepsin, 49 SahU's desmoid, 62 Salomon's, for gastric carcinoma, 63 Strauss', for lactic acid, 48 Topfer's, for analysis of stomach contents, 45 for combined hydrochloric acid, 46 for free hydrochloric acid, 45 Ufifelmann's, for lactic acid, 47, 48 Weber's guaiac, for blood in gastric contents, 53 Tetany, gastric, 212 diagnosis of, 212 lavage of stomach in, 119 Thermic treatment of stomach, 146 "Tliread test," Einhorn's, for gastric ulcer, 426 Thyroid extract in arteriosclerosis, 493 Tobacco, 102 Topfer's method of analysis for free hydrocliloric acid, 45 of stomach contents, 45 test for combined hydrochloric acid, 46 Toril meat extract, 116 Toxic gastritis, 346, 355 Trichinosis, raw meat and, 88 Tropon, 107 Trunecek's scrum in arteriosclerosis, 494 Trypsin in carcinoma, 523 Trypsinogen, 29 Tube, slomach, 35 Tuberculosis ,501 forms of, 501 INDEX bbb Tuberculosis, gastro-intcstinal, con- traindication for mineral waters, 158 miliary, oOl motor insufficiency of stomach and, (it) pulmonary, contraindication for lavage, 120 treatment of, 502 Tuberculous ulcer, 501 Tumors, 503 benign, 530 Tiirck's tube for stomach douche, 131 Tvphoid fever, meteorism of, lavage 'in, 119 U Uffelmaxx's test for lactic acid in stomach contents, 47, 48 Ulcer with adhesions, contraindica- tion for massage, 134 duodenal, gastro-enterostomy in, 206 occult blood and, 54 gastric, 418 peptic, 418. See also Gastric ulcer, perforating gastric, 418. See also Gastric ulcer, of pylorus, gastroenterostomy in, 206 round, 418. See also Gastric ulcer, syphilitic, 494 tuberculous, 501 Ulcus ventricuH, 418. See also Gastric ulcer. Urine in motor insufficiency, 73 Vaccines, bacterial, treatment of gastric ulcer with, 452 Valentine's meat juice, 116 Vegetable bitters, effect of, 188 diastase, 178 diet in nervous dyspepsia, 300 green, 97 milk, 116 proteins, preparations of, 112 Ventrofixation in gastroptosis, 214 Vibratory massage of stomach, 137 Vichy water, analysis of, 164 Voltmer's mother's milk, 116 Vomiting in carcinoma, 507 hysterical, diagnosis of, from gastric ulcer, 425 electricity in treatment of, 140 nervous, 273 diagnosis of, from gastric ulcer, 425 electricity in treatment of, 140 Vomiting, nervous, etiology of, 273, 274 symptoms of, 273 treatment of, 274 drug, 275 electric, 276 lavage, 276 p.sychotherapeutic, 277 from peritonitis, lavage in, 119 postoperative, lavage in, 119 of pregnancy, electricity in, 140 uncontrollable, lavage in, 119 W Warm pack, entire, 148 Water, 98 artificial, 98 ice, 98 hot, 99 atonic dyspepsia and, 99 gastric catarrh and, 99 mineral, 153 Weber's guaiac test, 53 for blood in gastric contents, 53 for hemorrhage in gas- tric ulcer, 423 Wegele's diet for chronic gastritis, 375. 386 gastrorrhea, 339 electrode, 140, 141 lactovegetable diet in nervous dyspepsia, 301 Wet rub, 146 time for, 146 Whey, 92 composition of, 92 White bread, 95, 96 meat, 87 Wines, 100 Winternitz coiled tubing, 151, 152 Wyeth's meat juice, 116 Xanthin in meat, 87 Yoghurt milk, analogous proprietary preparations, 94 compo.sition of, 94 preparation of, 93 prolongation of life by, 94 value of, 94 Zwieback, 95 Zweig's diet for chronic gastritis, 386, . 387 for enteroptosis, 241 Zymogen, 24 rennin, test for, 51 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2a(25»)«OOM RC816 Aa7 1911 Aaron Diseas QSoi' the Stnm^of,,