COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64131513 RC81 6 .Ew1 The diseases of the 1^&6)G ^\XS \ THE DISEASES OF THE STOMACH BY Dr. C. a. EWALD EXTRAORDINAET PROFESSOR OF MEDICINE AT THE UNIVERSITY OF BERLIN DIRECTOR OF THE AUGUSTA HOSPITAL, ETC. AUTHORIZED TRANSLATION FROM THE SECOND GERMAN EDITION WITH SPECIAL ADDITIONS BY THE AUTHOR By morris manges, A.M., M. D. ATTENDING PHYSICIAN TO OUTDOOR DEPARTMENT, MOUNT SINAI HOSPITAL, NEW YORK CITY, ETC. WITH THIRTY ILLUSTRATION'S NEW YORK D. APPLETON AND COMPANY 1893 Copyright, 1892, By D. APPLETON AND COMPANY. Electrotyped and Printed AT THE ApPLETON PrESS, U. S. A. AUTHOE'S PEEFACE TO THE AMEEICAN TEANSLATION. I FEEL liiglily honored that the Klinik der Yerdauungshrank- heiten should have been thought worthy of being independently rendered into English on both sides of the Atlantic ; for, in addi- tion to the present translation by Dr. Manges, another is being issued by the ISTew Sydenham Society of London. I am greatly indebted to Dr. Manges for the excellent manner in which he has performed his task. At the same time I wish to state that I have carefully read his manuscript, and have made many additions to it. In this way I believe I have included the very latest investigations on this subject. Hence the volume is not merely a rendering of the second German edition, but it practi- cally represents the third German edition, which will soon appear. I trust that the work will meet with a friendly reception among my American colleagues, and that it will lead to further investiga- tions in this interesting and difficult field. C. A. EWALD. Berlin, 3Iarch 5, 1892. (3) TEANSLATOK'S PEEFACE. The present work represents Yolume II of Professor Ewald's Klinik der Yerdauungshrankheiten, a treatise whicii has been received with so much favor abroad that two editions were called for within nine months, and translations made into the Russian, Italian, and Spanish languages. I have not included "Volume I, since it has already been rendered into English by Dr. Saundby. A second edition of this part, which treats of the physiology of digestion, has just been issued in connection with the English translation of the present volume by the New Sydenham Society of London. The two parts are entirely independent of each other. The im- portant references to it have been condensed and included in the translator's foot-notes. The numerous additions by Professor Ewald have not been spe- cially indicated, as this would have interfered with the unity of the work, and would, moreover, have caused unnecessary confusion. The new matter which I have incorporated into the text and foot-notes is inclosed in [ ]. All of the illustrations have been redrawn, while some have also been modified. Figures 2, 5, and 11 to 15 inclusive have been added by me. I am indebted to Dr. L. M. Michaelis for assistance in the preparation of a portion of the work. M. Manges. 941 Madison Avenue, New York, April 1, 1892. (4) PREFACE TO THE FIRST GERMAN EDITION. The following lectures, wliicli are intended for the use of gen- eral practitioners, are based upon the stenographic reports of my remarks at the Feriencurse fur praktische Aerzte. This volume is the second part of the Klinik der VerdauungsTcranMieiten, the first part of which discussed the physiology of digestion in its prac- tical relations. It will therefore be justifiable to simply mention ])riefly and give the final results of many subjects which have been freely discussed during the past few years ; for the general prac- titioner desires to know, not the source of discoveries, but their final, acknowledged results, which will be useful to him at the bedside. It may, perhaps, seem hazardous to publish these lectures now, at a time when this branch is being so thoroughly and enthusiasti- cally investigated with new methods, that almost every day addi- tional results are being published, which are to bring us nearer to a complete understanding of the difficult and complicated problems of the pathology of the stomach. But it is just through this active rivalry that our knowledge of the subject has been so enriched on the one hand, and on the other so cleared up, that the time seems to have come to collect these facts and to draw general conclusions from them, without having to fear lest the morrow will disprove what we have taught to-day. With this in view I have examined what has been accomplished in the past few years, and have endeavored to separate what is of permanent value from that which is merely of secondary impor- tance. Since many points are still undecided, the future alone can tell how far I may have succeeded in this effort, and also how many of the factors upon which we now depend will remain undisputed. At all events, wherever it was possible, I have endeavored to pass (5; vi DISEASES OF THE STOMACH. judgment dispassionatelj by means of the results of mj personal ex- amination, experience, and opinion. But nothing is better adapted to prevent overvaluation of our modern acquisitions than a study of the older writers, especially those of the first half of the present century, in the literature of which an abundance of splendid prac- tical observations has been stored up. I must not neglect, however, to acknowledge to what great extent we are especially indebted to Kussmaul and Leube, who so successfully inaugurated the new era in the investigations on the diseases of the stomach. In these lectures no attention has been paid to the digestive dis- orders of children, in so far as they occur independently and pecul- iarly in them ; neither has gastromalacia been considered as a sepa- rate lesion — the former, because there is no lack of splendid and complete works on the diseases of children ; the latter, because softening of the stomach is more interesting from a pathological standpoint than it is in its anatomical aspects ; while, moreover, its claims to be included among the diseases of the stomach seem more than doubtful. I am indebted to my brother. Prof. Richard Ewald, of Stras- burg, for the comprehensive review of the innervation of the stomach. The illustrations, except Vt^here otherwise stated, have been drawn by myself from original specimens. May this, the second and pathological po^^tion of the KliniJc der Verdamingskrmikheiten, enjoy the same friendly and favorable re- ception which was accorded to the first part ! This would lie an in- ducement to me to publish at an early date the third part, which shall treat of the diseases of the intestines. ^ . _^ C. A. Ewald. Berlin, WMtsuntide, 1SS8. CONTENTS LECTURE I. PAGE Methods of Exajiination. Determination of the Acidity and Acids of THE Contents op the Stomach 1 Examination of the functions of the stomach. The stomach-tube. Mode of in- troduction. — Ewald's method of exi^ression. Its advantages. Absence of danger in exploration of the stomach with the soft tube. — Test-breakfast and test-dinner. Composition of the stomach-contents during the first hour after taking the test- breakfast. — Determination of the acidity ("titration method). — Demonstration of free acid in the stomach-contents with : (1) tropteolin ; (2) Congo-red; (3) benzo- purpurin. Detection of hydrochloric acid with the aniline dyes ; Mohr's reagent ; Giinzburg's reagent (phloroglucin-vanillin) ; Boas's reagent (resorcin). — Demon- stration of lactic acid in the stomach-contents (Uffelmann). Extraction with ether. — Demonstration of the fatty acids (butyric acid). Acetic acid and alcohol in the stomach-contents. — Quantitative estimation of free and loosely combined hydrochloric acid (Mintz, SjOqvist, Ilayem, and Winter). LECTURE IL Methods of Examination {continued). Determination of the Digestion of Albumen and Starch. Absorption and Motility. The Technique of the Examination of the Stomach 41 Eelations and reactions of albumen and albuminoids. Their value in the prac- tical examination of the stomach-contents. Formation of propeptone and peptone during digestion. Digestion by pepsin and hydrochloric acid (proteolysis). Methods of testing, — Kennet (Labferment). Eennet-zymogen. — Saliva: its action on the starches. Sacchariiication. — Testing the absorptive powers of the stomach (Penzoldt, iodide of potassium). — Motor function of the stomach ; salol test (Sievers, Ewald, and Huber). Oil test (Klemperer). — Bile in the stomach-con- tents. — Physical examination of the stomach : (1) palpation ; (2) distention of the stomach and intestines with air (von Frerichs, Euneberg) ; (3) filling the stomach with water (Piorry, Penzoldt) ; (4) murmurs of deglutition ((SWi.?«c%emMsc7ie). — Gastroscope. Gastrodiaphane. — Technique of the treatment of the diseases of the stomach; washing out, electrization, massage, and hydrotherapy of the stomach. — Priority in the use of aniline dyes for detecting free acids in the stomach- contents. LECTURE IIL The Stenoses and Strictures of the Cardiac Orifice of the Stomach . 71 Stenoses due to spastic contraction or cicatricial tissue or neoplasms. General symptoms of stricture of the cardia. Consecutive dilatation of the lower segment of the cesophagus. Vomiting. Contents of the vomit. — Sounding the oesophagus. (Esophageal probang and sounds. — Stricture of the cardia due to spastic contrac- tion of the sesophagus. Symptoms.— Stricture of the cardia due to cicatrices and viii DISEASES OP THE STOMACH. PAGB neoplasms, (a) which exert pressure from without (tumors of the mediastinum and retroperitonreum and aortic aneurisms), (/3) which involve the entrance to the stomach and stenose it. — Dilatation of the oesophagus above the stenosis. Pressure and traction diverticula ; simple ectasia. Case of carcinoma of cardia which was operated, with report of autopsy.— Treatment of strictures at the cardia : passing bougies ; permanent canulse and tubes ; gastrostomy (description of operation by - Sonnenburg). Feeding of the patient; nutrient eneniata; diet after formation of a gastric fistula. LECTURE IV. The Stenoses and Strictures of the Pylorus. Megastria and Gas- TRECTASIA. DILATATION OF THE StOMACH 110 Plaster models of stomach (demonstration). Diagnosis of large and of dilated stomachs. Inspection ; percussion ; palpation (ot the tip of the sound, Leube) ; auscultation (succussion, deglutition-murmurs, Eosenbach's method) ; measuring capacity of the stomach (filling with water). — Etiology of dilatation of stomach. I. Mechanical narrowing or closure of pylorus (a) in the walls of the stomach themselves, (^) extending by continuity from without), a. Cancerous tumor ; cicatricial stenosis ; congenital narrowness of the pylorus ; bending of the duode- num toward the pylorus ; spastic contractions of the pylorus. 5, Tumors which press on or surround the pylorus growing from the pancreas, liver, omentum, or the glands. Kelations of wandering kidney to dilatation of the stomach. II. Dilatation of the stomach due to weakness of the muscles of the stomach (atonic gastrectasis). a, Enfeebled tone of the muscular fibers ; 5, weakness and paralysis of the motor nerves of the stomach ; c, exclusion of localized areas of the muscular fibers of the stomach. — Pathological anatomy of the dilated stomach. — Symptoms of gastrectasis. Insufficiency of the stomach. Micro-organisms in the stomach. Chemical relations of the gastric juice. Slowing of absorption and motion of the stomach. Peristaltic unrest of the stomach (Kussmaul). Pityriasis of the skin. Muscular spasms. Tetany. Relations of the urine. — Diagnosis of gasti*eetasis. — Course and prognosis. — Treatment. Diet. Withdrawal of fiuids. Peptone prepa- rations and peptonized milk. Nutrient enemata. Drugs. Prevention of stagna- tion of the contents of the stomach. Lavage. Massage and electricity to the stomach. Operative dilatation or excision of the stenosis. Demonstration of sev- eral patients with gastrectasis. LECTURE V. Cancer of the Stomach 1 C2 Statistics. Sex. Heredity. Causes. Traumatisms, chronic ulcer of stomach. — Pathological anatomy : scirrhus, medullary, colloid, villous, and telangiectatic varieties. Localized tumors and diffuse cancerous infiltration. — Site. — Sequel£e of cancer of the stomach: diminution in size, dilatation of, changes in site, ti'action on, bending and constriction of the stomach. — Primary and secondary gastric cancer. Propagation of cancer. Thi-ombosis. Swelling of the lymphatic glands, ulceration, perforation. — Symptoms of gastric cancer. Course and duration. Ex- ceptions to normal course. Statistics of individual symptoms. — Diagnosis : (1) Absence of free hydrochloric acid in the stomach -contents, and its presence even up to the death of the patient. Relations of pepsin and rennet. Presence of other acids in place of or along with hydrochloric acid. (2) Specific tissue-elements in the vomit or in masses evacuated through the tube. The mistaking of cancer- ous cell-nests and epithelial shreds of the mucous membrane. (3) The cancerous tumor (differential diagnosis from tumors, etc., of other organs, and fecal masses). Pain in the tumor. (4) Cancerous cachexia (hysterical cachexia). — Dittereutial diagnosis between cancer and ulcer of stomach, severe gastric catarrh, atrophy, amyloid degeneration of the mucous membrane of stomach, severe hysteria and neurasthenia. — Treatment. Condurango bark. Symptomatic treatment of pain, CONTENTS. ix vomiting and constipation. Diet. Treatment at mineral springs. — The non-can cerous tumors of the stomach. PAGE LECTURE VI. Ulcer of the Stomach. Ulcus Pepticum seu Rodens 217 Chronic round ulcer of the stomach. Origin. — Experiments on animals. Dis- proportion between the acidity of the gastric juice and the condition of the blood. Hyperacidity of the gastric juice in ulcer. Theories and views of various investi- gators. — Frequency of ulcer. Nutrition, sex, and age of patient. Situation of ulcer. Frequency of perforation. — Pathological anatomy. Htemorrhagic infarc- tion of the mucous membrane. Appearance under the microscope of sections through the edge of the ulcer. Fallacy of Witosowski's theory. Form and struct- ure of the ulcer. JResult of the ulcerative (necrotic) process in (1) cicatrization ; (2) progressive necrosis terminating in (a) corrosion of the blood-vessels, (/3) adhesions to adjacent viscera and perforation. — Tubercular and syphilitic ulcers of the stomach. — Symptoms of gastric ulcer: (1) cases with marked symptoms of irritation without further complications; (2) cases with symptoms of irritation and hasmorrhages ; (3) cases with symptoms of irritation and perforation (re- covery or death) ; (4) cases which run a latent course up to death. — Gastralgia, conditions of the bowels, state of nutrition, vomiting, heemorrhages in the stomach, perforation and extension into neighboring viscera, perforation peritonitis. Prognosis of perforation. Cicatrization. — Differential diagnosis : syphilis and ulcer, tuberculosis and ulcer. Scheme of diagnosis of nervous gastralgia, ulcer, and cancer. Use of stomach-tube in ulcer. Biliary colic and gastralgia due to ulcer of stomach. Situation of ulcer in .stomach and duodenum. — Prognosis, treatment. Kest-cure. Carlsbad water. Nutrition and diet. Iron, arsenic, bismuth, nitrate of silver, milk. Alleviation of pain, vomiting, and gastric haemorrhage. Treatment of collapse and perforation pei-itonitis. Operation (ex- cision) of the ulcer. Treatment of ulcer at the mineral springs. Appendix, page 276. — Htematemesis. Difterentiation of harnoptysis and hjema- temesis. Causes of the latter : (1) venous congestion ; (2) active hypersemia ; (3) traumatisms ; (4) changes in the walls of the vessels. LECTURE Vn. The Inflammations of the Coats of the Stomach. Gastritis Glandu- laris Acuta, Idiopathica et Sympathica. Gastritis Phlegmonosa Purulenta — Gastritis Toxica 281 Mutual relations of absorption, motion, and secretion of the stomach ; also of the affections of the stomach and those of the liver audi ntestines. — Acute gastritis. Etiology (mechanical, chemical, and thermal initants). — Pathological anatomy. The normal mucous membrane of the stomach which has been placed in alcohol immediately after death. — Symptoms : afebrile and febrile catarrh. Diagnosis. Kelations of tongue. — Difterential diagnosis (incipient typhoid fever, meningitis, peritonitis, hepatitis, biliary colic). — Treatment. — Gastritis sympathica acuta. Oc- currence in acute febrile diseases (gastritis diphtheritica). Tenninations. — Gastritis phlegmonosa purulenta. Occurrence and etiology. Idiopathic and metastatic varieties. — Pathological anatomy (abscess of stoiuach and diffuse purulent infiltra- tion). Symptoms. Diagnosis. Treatment. — Gastritis mykotica. Bacillus gastri- cus. Anthrax, maggots. — Gastritis toxica. Alcohol, phosphorus, corrosive poisons. Acute poisonings. — Treatment. Emptying of stomach with stomach-tube and washing out. Neutralization of the poison. DISEASES OF THE STOMACH. LECTURE VIII. PAGE Gastritis Glandularis Chronica. Chronic Catarrh of Stomach. Atro- phy OF the Stomach 313 General conceptions (dyspepsia, chronic inflammatory condition of the glands and the influence of the nerves on the same). — Pathological anatomy : paren- chymatous and interstitial inflammation of the mucous membrane. The mucoid degeneration of the grandular cells which may be observed even to the base of the glands in very fresh specimen. Transition of chronic gastritis into atrophy of the mucous membrane ; the parenchymatous and the interstitial forms, the former proceeding from above do vvnward, the latter from below upward (cirrhosis or sclerosis ventriculi). Phthisis ventriculi, terminating in anadenia of the stomach. Polypi of the gastric mvicosa. — Etiology of chronic gastritis. Develop- ment from the acute form : processes which produce venous congestion of the stomach ; exhausting diseases ; direct local irritants (insutficiently chewed mor- sels, improper care of mouth and teeth, abuse of alcohol and tobacco, etc.). — Symptoms. Gastritis chronica simplex and mucosa (termination in phthisis or anadenia of the stomach). Chronic dyspepsia, pyrosis, cardialgia, vomiting, gastrectasis. Bowels. General symptoms : " stomach-cough," asthma dyspepti- cum, vertigo, agoraphobia. — Atony of the stomach. — Phthisis and anadenia of the stomach. Vicarious digestion by the intestines. Eesemblance to progressive pernicious anemia. Age of the patients with gastric phthisis. — Diagnosis (simple and mucous gastritis, anadenia). — Ditlerential diagnosis between anadenia, neu- roses, and carcinoma of the stomach. — Course and pi-ognosis. — Treatment. Pep- togenous substances, hydrochloric acid and pepsin. Washing of the stomach. Bitters. Diet (care of teeth and slow eating). Food and drink allowed and to be avoided. General relations. Treatment of fermentation in stomach (lav- age, antifermentatives). Gastralgia. Purgatives. Enemata. Mineral waters. LECTURE IX. The Neuroses of the Stomach. The Physiological Relations of the Stomach 363 Functional disturbances of the stomach. Description of the innervation of the stomach (Eichard Ewald). General relations between the functions of the stomach and the nervous system. Anatomy of the vagus and sympathetic nerves and ganglion-cells. — Absorption. — Vaso-motor relations. — Movements of the stomach ; peristalsis and anti-peristalsis. Muscles of the stomach ; opening and closing of the cardiac and pyloric orifices.— Vomiting ; its origin.— Sensitiveness of the organ and its abnormal increase.— Hunger ; sensation, and its center. Locali- zation of the sensation of hunger ; its central situation. Satiation. Appetite and its relation to hunger. The taking of food. LECTURE X. The Neuroses op the Stomach {contimied) 387 Classification. Occurrence. Sex. Habit. Situation and occupation of these patients. General nervous symptoms : (1) Conditions of irritation. — Hyperesthesia of the stomach. Nausea. Differential diagnosis from the organic disorders of the stomach. Symptoms. Idiosyncrasies. Varieties of the sensation of hunger. Emptiness of the stomach. Bulimia. Perverse appetite. Anorexia. Gastralgia ; genuine gastralgia as the result of diseases of central nervous system ; of constitu- tional disorders. Neurasthenic gastralgia (irritative and depressive varieties). Painful points (Burkart). Hysterical gastralgia. Symptoms. Gastralgia in Psychoses. CONTENTS. xi LECTURE XI. PAGE The Neuroses of the Stomach {continued) , . , » . . , 414 Conditions of irritation (continued). Hyperacidity and hypersecretion of the gastric juice. Definition and difference. Periodical and continuous flow of gastric juice. Diagnosis. Gastroxynsis. Eructation. Pyrosis. Pneumatosis. Nervous vomiting. Periodical vomiting (Leyden). Cramps of stomach. Peri- staltic unrest of stomach (Kussmaul). — (2) Conditions of depression. — Ansesthesia of stomach. Polyphagia. Nervous anacidity of the gastric juice. Paresis of the cardiac orifice. Eegurgitation. Eumination ; explanatory theories. Incontinence of the pylorus. Atony of the stomach. — (3) Mixed form. Neurasthenia gastrica or vago-sympathica. Conception and nature. Views of various writers (Jurgens, Discovery of Degeneration of Meissner's and of Auer bach's Plexuses in the Intes- tines). Etiology. Special symptoms. Burkart's painful points, gastralgia, vomit- ing, stools. Differential diagnosis (Leube's test of digestion). Prognosis. Treat- ment. — (4) Eefle.xes from other organs : (a) mild disturbances of digestion ; {b) gastralgias ; (c) vomiting, in atfections of the brain and of spinal cord (gastric crises). Vomiting in abscesses and calculi in the liver and kidneys, in pregnant women, injuries to the uterus, operations on the bladder and urethra, etc. Dyspep- sia in chronic diseases of the sexual organs. Reflexes from the intestines (neo- plasms, enteroliths, parasites). — Treatment of the gastric neuroses. — Local reme- dies. Sedatives and narcotics. Chloroform-water, constant current, massage of stomach, stomach-douche, Neptune's girdle. Derivatives. — General remedies. Preparations of bromine and bromide-water, antipyrin, pilocarpine, phystostig- mine, caffeine, preparations of arsenic and iron and hydrotherapy. Weir Mitchell- Playfair rest-cure. Critique of this method. An example of it with study of the metabolism. Importance of systematic weighing. Treatment at mineral springs. LECTURE XIL The Correlation of the Diseases of the Stomach to those of other Organs. The Practical Value of the Modern Chemical Tests , 463 General considerations. — Dyspeptic disturbances and changes in digestion in tuberculosis (chemical changes in the gastric juice in tuberculosis), in valvular diseases of the heart, in diseases of the kidneys, liver, and central nervous system, diabetes, gout, and rheumatic diathesis. — Closing remarks. Value of the modern methods of examination of the stomach. Untimely occurrence of organic acids (especially lactic acid), changes in the actual digestive juice. Lessening of the production of hydrochloric acid in changes or destruction of the glandular paren- chyma of the stomach. Lessening of the production of hydrochloric acid in persons without stomach troubles. Secretion of hydrochloric acid in normal digestion. Diagnostic value of the estimation of the acidity of the gastric juice. Index 483 LIST OF ILLUSTRATIONS. PAGE 1. Lower end of Ewald's stomach-tube 7 2. Curling over of flexible tube in the stomach 11 3. Boas's bulb for suction of stomach-contents 13 4. Stand for funnel of stomach-tube 64 5. [Auto-lavage of stomach.] 65 6. Ein horn's deglutable electrode 66 7. Carcinoma surrounding cardia, side view 79' 8. Carcinoma surrounding cardia, front view 80 9. Localized carcinoma of cai'dia 87 10, Carcinoma of oesophagus just above cardia 94 11. [Cast of cylindi'iform stomach in vertical position] 110 13. [Cast of normal stomach] 110 13. [Cast of dilated stomach in vertical position] 110 14. [Cast of marked dilated stomach tending to assume vertical position]. . Ill 15. [Stomach in vertical position. In sihi] 117 16. Very vascular, polypoid tumor on posterior wall of stomach . . . 124 17. Carcinoma of pylorus with dilatation of stomach and duodenum . . 126 18. Cross-section through the mucous membrane of a dilated stomach . . 135 19. Scirrhus ventriculi totalis 172 20. Carcinoma of the cardia. Contraction of the stomach 174 21. Vomit from a case of carcinoma of the stomach . . . . . . 179 22. Colloid cancer of lesser curvature of stomach 184 23. Cancerous cell-nest raised through stomach-tube 196 24. Piece of gastric mucosa resembling cancerous cell-nest 197 25. Perforating ulcer of stomach 219 26. Piece of gastric mucosa raised after lavage of empty stomach . . .317 27. Section of mucosa from the vicinity of a resected pyloric cancer . . . 318 28. Anadenia of stomach with accompanying dilatation 319 29. Phthisis ventriculi, with cirrhotic atrophy 321 30. Total atrophic sclerosis of gastric mucosa 322 (13) DISEASES OF THE STOMACH. LECTURE I. METHODS OF EXAMINATION. DETERMINATION OF THE ACIDITY AND ACIDS OF THE CONTENTS OF THE STOMACH. Gentlemen : In undertaking to discuss tlie diseases of the digest- ive tract in the following lectures, I must, at tlie beginning, impose definite limits upon myself, and must refrain from attempting to exhaust the entire subject. If I attempted to speak of everything which lay within the extensive province of the diseases of the digest- ive tract and its adnexa, I would go far beyond the limits of these lectures, and individual facts would be slighted at the cost of the whole. The diseases of the mouth, oesoj^hagus, and of those organs which, like the spleen and liver (although closely connected with the intestinal tract through the portal vein), display no true or exclusive digestive activity, will be treated only in so far as they directly influence the functions of the stomach and intestines, and the normal or abnormal action of which is not to be distinguished therefrom. I shall, therefore, mainly confine myself to the diseases of the stomach and intestines, and shall thus follow the universal custom, Avhich, although improperly, generally includes only the affections of these two organs, under the expression, Diseases of Digestion. But you must not expect these lectures to be a systematic, con- secutive, and finished text-book. Our literature contains not a few splendid works of this character which treat this theme in an excel- lent and exhaustive way. In the following pages I wish to empha- size this difference between a text-book and a series of lectures, both in the form and in the subject-matter. The text-book must system- atize the pathological processes, must classify them nosologically. 2 DISEASES OP THE STOMACH. and from the sum of individual observations and facts must con- struct tlie so-called " tjpical case " of tlie various forms of disease. I shall take a more modest, I might almost saj a more intimate, point of view. I too shall make use of my material to delineate general pictures of disease, but as far as possible I wish to restrict myself to distinct, personally observed, and characteristic cases ; to lay stress on the special features of individual cases which impress a distinct character upon them ; to show their relation to the gener- ally acee|)ted facts ; and at the same time I desire to exjjress my personal views on the subjects at issue. I should incur the reproach of dealing in commonplaces were I to emphasize how much of this is due to the acquisitions of my own experience, including the results of both personal observation and reading and study. Accordingly, if I should fail to quote every- thing and anything that the industry of recent years has yielded, you will ascribe such omissions to my desire to avoid all superflu- ous literary ballast which is nowadays so easily paraded. That any- thing of importance has escaped my notice is hardly possible. But you, gentlemen, who, in renewing your attendance at lect- ures and hospitals, bring with you a riper experience and an acuter judgment than the students in their first " semestres," what can be more to your purpose than to obtain and make use of the personal experiences of your lecturer as much as possible, and to profit thereby in proportion as you are able to criticise them by means of the knowledge already acquired in practice ? ^^ I trust I may succeed in presenting to you in a suggestive way both what is already well known as well as what is novel. The diagnosis of the diseases of the stomach is based, as in other organs, subjectively upon the statements of the patient, and object- ively upon the results of our examination. I shall disregard the former, as this will be discussed in the description of each disease. For the latter we may utilize, first, the so-called methods of j^hysical * [This course of lectures was delivered at the Feriencurse fur practisclie Aerzte at Berlin. This is a series of post-graduate lectures given in April and September of each year by the extraordinary professors and privat-docenten of the Uni- versity of Berlin. They last one month, and precede the opening of the regular term.— Tr.] METHODS OF EXAMINATION". 3 examination — i. e., insjDection, palpation, auscultation, and mensu- ration ; secondly, ilie analysis of the chemical^ absorptive, and motor functions of the organ — in short, the investigation of the digestive activity of the stomach. The physical methods are so well known that they may be sum- marily dismissed, and we may at once pass to the consideration of the examination of the functions of the stomach. Although it is part of my task to discuss the pathology of the stomach, it is never- theless obvious that pathological deviations from the normal can only be recognized and properly treated after the normal condi- tions are thoroughly understood ; hence I must also briefly consider this topic. Formerly this was hardly possible, so long as we were restricted to the inadequate external signs and the subjective com- plaints of the patients ; but now a very important factor in the methods of examination has been supplied since we have learned to obtain the contents of the stomach at any time in an easy and rapid way, Avhich is also convenient and safe to the patient. This is accomplished by means of the hard or soft stomach- tubes, and with the general use of these instruments the new era in the pathology of the diseases of the stomach began. Before entering into the discussion of our theme, permit me to make a few brief introductory remarks. The methods which have recently enabled us to obtain a better knowledge of the chemical processes in the stomach have thrown a light upon the pathology of dyspepsia and the irregularities of gastric digestion which is analogous, comparing a small matter with a great one, to what the ophthalmoscope did in its day for the retina, and the laryngoscope for the interior of the larynx. It was inevitable that this method should soon be favorably received, and that it should have been very extensively used during the past few years in hospital and general practice. I wish, however, to warn you not to lay too much stress upon these procedures as belonging to a specialty. During the course of these lectures you will be enabled to con- vince yourselves that the technique of the methods which are in use is by no means difficult to carry out, and is within the scope of every physician who as a student has learned to titrate, to test acid and alkaline solutions, and to place a test-tube in a warm 4 DISEASES OP THE STOMACH, chamber. N^aturally, fewer persons are engaged in original inves- tigations. Hence the examinations do not require the skill char- acteristic of a S23ecialty, which can only be acquired after continu- ous occupation with that specialty. But, to obtain and analyze stomach-contents do not lie beyond the scope of the dexterity and ability which every physician ought to possess. It may happen that one is consulted especially by patients with stomach troubles because he has occupied himself chiefly with the study of these conditions, and has hence acquired the reputation of possessing a special experience. But this alone is not sufficient. Physicians and the public are here influenced not by the special but by general medical knowledge ; this is certainly not acquired if a 23hysician immediately after graduation sets himself up as a sijecialist for stomach diseases. In the course of these lectures you will see how closely the diseases of the stomach are related to those of other organs, how complicated this relation is, how often the symptoms are deceptive, how frequently in an apparent stomach disorder entirely different organs are really involved ! Hence it is ray flrm conviction that it is im]30ssible to find truly profitable and satis- factory special occupation in the treatment of the diseases of the stomach alone, because the field is too small and the technique is so easily learned and is so limited in its scope. I wished to premise these remarks because such questions are frequently put to me. It is worthy of note that the use of the stomach-tube is by no means, as is supposed, a recent acquisition.* We may disregard the crude manipulations of Fabricius ab Aquapendente and Eum- saeus (1659), who discovered a " stomach-brush " to remove the mucus from the stomach, " so that at that time there was no beer- company at which some did not apply it themselves after drinking heavily, either the same night or on the following morning after having snored out their intoxication through the open mouth, if they were distressed with the thick phlegm in the throat." f In the latter half of the previous century John Hunter' introduced cathe- * Leube. Die Magensonde. Die Greschichte ihrer Entstehung und ihrer Bedeu- tung in diagnostischer imd therapeutischer Hinsieht. Erlangen, 1879. f J. Chr. Kundman. Seltenheiten der Natur und Kunst, etc., 1737. Quoted by Leube. THE STOMACH-TUBE. 5 ters into the stomach, but only to inject irritating substances into it. The Enghsh surgeon, F. Bush, was the first to attach a pump to tlie stomach-tube to evacuate the stomach in a case of opium-poisoning ; this discovery is attributed by others to Weiss, an instrument-maker. The stomach-siphon was first proposed by Arnott* in 1829, and then by Sommerville, but passed into oblivion. Kussmaul f again directed the attention of the profession to the stomach-tube in his publications in 1867 and 1869, on the treatment of dilatation of the stomach. Meanwhile it had been occasionally recommended, as in France by Blatin, in 1832, and by Canstatt,;}: and was also used here and there. It was always a standing, though only privately uttered, claim of Prof, Frerich's clinic that the pump had regularly been used long before Kussmaul's publications. But, as is well known, in disputes as to j^i'iority in scientific matters, the time at which the subject in question is made public is decisive, and hence Kussmaul deserves the credit of having again called the attention of the whole medical profession in an im23ressive way to the use and benefits of the stomach-tube. At the N^aturforscherversammlung at Rostock, in 18Y1, Leube asserted the possibility of using it for diagnostic purposes, and, as later developments proved, opened up an excellent means of examination. Yet in his early investigations Leube as well as his predecessors exclusively used a stiff tube or a rubber tube with an elastic but more or less rigid whalebone stylet. This procedure has many inconveniences and disadvantages. Instead of this, I was the first to show that a very soft tube without any stylet, provided it had a thick wall and a sufiicient firmness, could be easily introduced into the stomach in the great majority of cases requiring examination.* As occurs so frequently, this was the re- sult of chance. In 1875 a man who had poisoned himself with prussic acid was brought to the Frerich clinic. The stomach had to * Quoted by Alderson, On the Dangers attending the Use of the Stomach-pump. Lancet, January 4, 1879. f Kussmaul, in Bericht liber die 41. Versammlung dentscher Naturforseher und Aerzte zu Franlifurt a. Main, 1867; and Ueber die Behandlung der Magenerweite- rung durch eine neue Methode mittelst der Magenpumpe. Deutsch. Archiv filr klin. Medicin, Bd. vi, S. 455. I Canstatt, in his Jahresbericht for 1841. * Ewald. A Ready Method of washing out the Stomach. Irish Gazette, August 15, 1874, and Berlin, klin. Wochenschr., 1875, No. 1. 6 DISEASES OF THE STOMACH. be washed out at once. None of tlie stiff tubes wliicli were then in use was at hand, so I cut off a piece of gas-tubing, rounded off the sharp end, cut out two eyelets, oiled the tube, and, although the man was unconscious, I easily succeeded in reaching the stomach. A similar procedure was published later by Oser.* It has been suc- cessfully tried on many patients, so that now it is quite universal only to use soft, specially prepared tubes made of smooth, vulcan- ized rubber. They have been used in France since 1880, and are known as tiibes Faucher.\ The expressions oesophageal sound, oesophageal tube, stomach- sound, siphon-sound, stomach-pump, stomach-tube, etc., are indis- criminately used by writers, and not in their true meaning. Sounds, strictly speaking, are solid instruments whose density permits the transfer of the sense of touch into deep and inaccessible places. Hollow instruments can only be indirectly used for sounding, if their walls are thick enough, as, for example, the use of a catheter for exploring the bladder. The same is true also of the so-called stiff oesophageal and stomach tubes, which may be used to explore the ossophagus and stomach if they are rigid enough and are rounded off at the end. But this use is merely secondary, as their true function is indicated by their name " tubes " — i. e., to allow the passage of fluids. It is an abuse of language to speak, as Leube does, of a siphon -sound {Hehersonde) instead of a stomach-tube or simply a stomach-siphon. In the following pages I shall speak of all solid instruments as sounds, and of the hollow tubes with more or less rigid walls as stiff oesophageal or stomach tubes {Schhmd- rohr or Magenrohr), and of the flexible tubes (made of silk or rub- ])er) simply as stomach-tubes {Magenschlauch). If the tube is introduced to obtain the contents of the stomach, it is naturally of primary importance that these can easily enter and leave the tube ; this is accomplished by having as many and as * L. Oser. Die mechanische Behandlung der Magen- und Darmkrankheiten. Wiener med. Klinik, 1875 ; and Die Magenausspiilung mittelst des elastischen Schlauches. Wiener med. Presse,sl887, No. 1. f [Faueher's tubes are about 60 inches long; the external diameter is f to f inch; the walls are of such thickness that the tube can be bent without effacing its lumen. At one extremity is a lateral eye with two orifices ; to the other extremity a funnel holding about a pint is attached. Welch, — Tr.] THE STOMACH-TUBE. large openings as possible in the lower portion. The ordinary stiff tubes and most of the soft ones in general nse till now have one or two openings, eyelets or fenestrse, as they are called, near the lower end ; this is usually a blind end formed by a closed tip made of a harder material. Unless the tube is very carefully cleansed, all kinds of organic substances may accumulate here and decompose. To avoid these objections I have the tubes made of different thick- nesses, with the lower end open, and, following Schtitz's suggestion, have one large fenestra very low down and a number of smaller openings about the size of a large pin's head (Fig. 1). In this way the contents of the stomach may easily enter the tube from all sides, and can be very readily obtained. Recently tubes made of braided silk varnished over have been introduced ; they are somewhat firmer than the soft rubber tubes, but are much less rigid than the stiff ones. At my suggestion they have been made after the same model as that above. It is self-evident that the softer the instru- ment which is introduced into the stomach and the more rounded its edges are, the less will be the danger of injuring the mucous membrane; this occurs more easily and has actually taken place with stiff instruments. Another advantage of the flexible tubes is that, in introducing them, as I shall presently show you, it is absolutely un- necessary to introduce the finger into the patient's mouth, thereby sparing him the always unpleasant gagging, and obviating the dan- ger of the physician having his finger bitten. Under certain conditions it may be impossible to pass a soft instrument through the oesophagus, even though it be free from obstruction ; then there is also the active resistance of the insane, etc. ; finally^ we may encounter mechanical obstructions, such as unusual narrowing of the entrance of the oesophagus, due to bony protuberances or to a posterior displacement of the hyoid bone or Fig. 1. 8 DISEASES OP THE STOMACH. nervous spasm of tlie oesophagus. In such cases it is necessary to use a more rigid tube, and, according to the resistance to be over- come, we may try either one of the above-described silk tubes, or a so-called red English tube made of catgut varnished over. I no longer use the black French bougies, which were formerly so popu- lar, as they wear out too easily. The majority of the above instruments are T5 ctm. [29^ inches] long, so that, having been introduced into the stomach, only a small piece is left projecting between the teeth, as we may usu- ally reckon the distance from the incisor teeth to the fundus ven- triculi as being 60 to 65 ctm. [23^ to 25|- inches]. For further manipulations, this small projecting piece may be lengthened before or after its introduction by attaching a small piece of glass tub- iug with a suitable length of rubber tube of the same size ; or, if the upper end of the stomach-tube is funnel-shaped, we may insert a hard rubber stop-cock, one side of which has a conical end with a screw thread, while the other side is a smooth tube over which soft rubber tubing may be slipped. For cases of dilatation of the stomach I have had extra long tubes made with a length of 95 ctm. [3Yi- inches].* All stifE instruments which are introduced into the oesophagus or stomach, as the sponge-probang, bougies, etc., ought to be held in the right hand like a pen ; the left index-finger is passed into the patient's mouth and depresses the tongue, the tip of the finger passing to the epiglottis if possible ; the tube is then passed rapidly along the left index-finger to the posterior pharyngeal wall, and then, and not before, by raising the right Avrist the point of the instrument is depressed into the oesophagus. The more quickly and boldly you manipulate, the more easily will the tube pass, and the less will the patient be annoyed. The danger of entering the re- spiratory passage is greatly exaggerated, and the detailed accounts given about it in most text-books are quite superfluous. Under nor- mal conditions the entrance to the larynx is at once reflexly closed by the epiglottis. But even in paralysis or anfesthesia of the larynx, and other conditions interfering with the functions of the * These tubes can be obtained at Miersch, Berlin W., Friedrichstrasse 66. THE STOMACH-TUBE. 9 epiglottis, only tlie greatest clumsiness will cause the tube to enter tlie larynx instead of tlie oesophagus. But even if it should occur — ^just as some " doctors " have extracted half of the intestines through a rupture of the uterus — the marked dyspnoea and cyanosis of the patient and the entrance and exit of air through the tube would at once show that a " mistake " had been made. At the first introduction of any oesophageal instrument patients often become markedly cyanotic, because they believe they can not breathe, and therefore hold their breath spasmodically. Such occurrences must not be confounded with the above. Holding the breath may easily be differentiated from a true dyspnoea by getting the patients to breathe rhythmically while we count for them. In introducing flexible tubes, it is su23erfluous, as Oser showed, to apply oil, vaseline, or glycerin to the outside of the instrument. It need only be dipped in warm water, as the abundant secretion of saliva by the patient will lubricate it suflSciently. Let the pa- tient open his mouth, push the tube on to the posterior wall of the pharynx (the tube is sufficiently rigid to permit this), and then ask the patient to swallow ; the tube is grasped by the muscles of deg- lutition and passes without any difficulty into the upper end of the oesojihagus, its passage through the introitus oesophagi being distinctly felt ; then, by gently pushing the tube, it speedily reaches the stomach. At times a slight resistance is felt at the cardia, frequently not. By this method we avoid the manipulations in the patient's mouth which are unpleasant both to the latter and to the physician. The procedure is much simplified and the unpleasant- ness and excitement are so much lessened that, among the many patients examined by me during the past few years, I have found very few cases in which I could not introduce the tube. A¥ith a little patience on the one hand, and determination on the other, we may succeed even in nervous and anxious subjects. The patients' conduct during this procedure has afforded me an excel- lent test of the strength of their nerves, and, as the ancients ex- pressed it, of their sanguine and lymphatic temperaments. In very sensitive persons, the local sensation may be entirely abolished by painting the posterior pharyngeal wall with a 10 to 20 23er cent cocaine solution a few minutes before introducing the tube, yet I 10 DISEASES OP THE STOMACH. have liardly ever found this necessary. But, even without its use, I may safely assert that this procedure is much less distressing to the patient than a laryngoscopic examination without cocaine, as the latter at first sets up a much greater irritation. Having introduced the tube, our next task is to obtain the con- tents of the stomach. Here, also, the past few years have witnessed a great simplification. Originally, the stomach-pump was used ; this instrument consists of a pump with two tubes — one below, the other at the side ; the fluid is drawn up through the former, and then by turning the piston, or by some similar arrangement of the valves, it is evacuated through the latter. Other even more com- plicated apparatus has been devised which, as the proverb reads, make five quarters out of a mile ! Among these may be men- tioned Jaworski's stomach-aspirator, a contrivance as incompre- hensible as it is needless, which accomplishes no more than any pump will do, and is based upon the same principle, but which requires such an array of bottles and glass tubes as from the very beginning to preclude its practical use. On the other hand, a good and simple method consists in passing the stomach-tube as usual, and then attaching a piece of rubber tubing, at whose other end a large pyriform rubber bag [like Politzer's bag] is inserted. The bag is inserted after it has been squeezed together ; in ex- panding it aspirates the stomach-contents so long as subjected to the ordinary atmospheric pressure. The bag may also be used for the reverse ; namely, by filling it with air or water, attaching it to the tube, and then by squeezing it gently we may succeed in dis- lodging any pieces of food Avhich may obstruct the lumen of the tube, as is recognized by the cessation of the resistance caused by the plug. Boas * has recently suggested the use of a rubber bulb with a short rubber tube on either side ; one of these is attached to the stomach-tube by means of a small piece of glass tubing ; on the other is a pinch-cock (Fig. 2). A vacuum is obtained by com- pressing the bulb while the cock is open ; when the latter is closed the contents of the stomach will be sucked up into the bulb. The cock is now opened while the tube on the other side of the bulb * I. Boas. Allgemeine Diagnostik und Therapie der Magenkrankheiten. Leip- zig, 1890. S. 106. THE STOMACH-TUBE. 11 is compressed ; by squeezing the bulb, whatever has been aspirated may be expelled into a vessel held under the free end of the tube with the cock. [Einhorn * has devised his stomach-hticket for obtaining small quantities of stomach-contents. This consists of a small, hollow, silver capsule, with an opening at its upper end, A long silk thread is attached to a thin bar, which is stretched across this open- ing ; the thread carries a knot at 40 ctm. (1 6 inches) to indicate when the bucket is in the stomach. The patient is directed to open his mouth widely, the bucket is placed on the root of the tongue, and with a single swallow it passes into the stomach. It is removed by traction on the thread. N^ot infrequently the oj)en- ing is plugged by mucus ; this may be prevented by placing a thin disk of gelatin over it. Sometimes only mucus is brought up ; the bucket must then be passed again. This method is not applicable where large quantities of stomach-contents are re- quired.] But usually all these manipulations are unnecessary. Some time ago Dr. Boas and myself showed that the stomach-contents could be obtained at any time by means of the abdominal pressure, since the straining of the patient suffices to drive the contents of the stomach into the tube, provided they are sufficiently fluid, so that the lumen of the tube is not occluded. f Since then the method has been tried * [Einhorn, New York Medical Record, vol. xxxviii, p. 63. Its use is condemned by Boas, loc. cit., 2d ed., p. 112. — Tr.] f Ewald und Boas. Beitrage zur Physiologic mid Pathologic der Verdauung. Virchow's Archiv, Bd. ci, S. 325-375; ib.,"Bd. civ, S. 271-305. 12 DISEASES OP THE STOMACH. by many others " witli excellent results," and has been designated the Ewald Expression Method {die Ewald''sche Expressionsmethode). It is true that some one may now and then have observed that the stomach-contents were forced from the tube during acts of coughing, etc. ; yet Boas and myself may claim the credit of having system- atized the method, and, by its means, of having greatly simplified the technique. I think that this claim is the more justifiable, since by the combination of the flexible tube and "expression" these examinations for the first time fulfilled the requirements "de- manded of every good method, namely, to operate cito, t^ito, and, as far as possible, jucunde. This is surely not unimportant, but even fundamental. This method should, however, always be avoided in cases where there is danger of rupture of an aneurism, brittle blood-vessels, etc., on account of the somewhat violent contraction of the muscles of the abdomen which it entails. But such cases, like the one which I communicated to the Berlin Medical Society (reported in the Berl. klin. Wochenschrift, July 28, 1890), are the exce^jtion, and may be avoided by the use of the proper precautions, or must be looked u23on as the unfortunate and inevitable complications which may arise in the routine application of any method in medical practice. It is a safe rule to avoid this method in any case in which force must be used for expression, and to have recourse to aspiration as soon as the outflow ceases to be smooth and easy, Eecently C. Albutt * wrote as follows concerning washing out of the stomach : " This troublesome and disgusting performance offends the more refined class of patients, and in dealing with them the physician is too soon persuaded to lay it aside, or altogether to forbear the use of the stomach-pump." If he will try the method just described, his results will be more encouraging. I could easily mention the names of very distinguished people who willingly al- lowed the introduction of the tube and the wasliing out of the stomach ; and I consider the diagnostic importance of the " expres- sion method " to be so great and the safety to be so absolute, a very * C. Albiitt. On Simple Dilatation of the Stomach, or Gastroectasis. Lancet, November 5, 1887. THE STOMACH-TUBE. 13 few eases excej^ted, that I would reproach myself had I neglected to resort to it in any doubtful case. Epstein * has even applied the treatment with the stomach-tube very successfully in very small children, even in infants ; the tube was, of course, of a corresponding size — i. e., a Nelaton catheter, ISTos. 8, 9, and 10 (French). Leo f has used this method for the sys- tematic study of the functions of the stomach in suckling infants. It soijietimes happens that, although the stomach is full, none of its contents can be obtained by any of these methods. This may be due to an occlusion of the fenestras of the tube, either by a prolapse of the mucous membrane, or they may be ]3lugged — both of these occur very rarely with my method ; or the tube may have been introduced too far and has curled around along the greater curvature, and thus the end is above the level of the contents of the stomach, as is shown in Fig. 3. This is easily remedied by withdrawing the tube a little (Fig. 3). In rare cases it may also happen that at a time after the test-breakfast when the stomach is usually full, the organ is found empty, and hence noth- ing can be expressed. In such cases the transfer of the ingesta into the intestines is unusually rapid — a condition which will be referred to in the discussion of the gastric neuroses. 1 shall now demonstrate to you on a patient how easily this Fig. 3. * Epstein. Ueber Magenausspiilung bei Sauglingen. Archiv fiir Kinderheil- kunde, 1883, Bd. iv, S. 325. f Leo. Ueber die Function des normalen iind kranken Magens, etc., im Saug- lingsalter, Berl. klin. Wochenschrift, 1888, No. 49. 14 DISEASES OF THE STOMACH. method of expression, as I have called it, is carried out. (Demon- stration.) Although very rapidly done on this patient, yet I must not neglect to tell you that in some cases it is not successful. Thus this may happen where the abdominal walls are so relaxed that tlieir jDressure can not be brought into play ; then there are also some persons who have so little control over their muscles that they can not bear down when they are told to do so. Hence this method of expression may not be successful, or at least not till after several attempts ; yet, taken all together, this occurs in scarcely five per cent of the cases. Are the passage of the tube and the washing out of the stomach, as thus described, dangerous? You know that when the stiff tubes and the pump were exclusively used, numerous cases were reported where pieces of the mucous membrane were torn off, as by Wies- ner,* von Ziemssen,f Leube, ^ Schliep, * and others ; yet they were followed by no evil consequences, at least so far as haemorrhages and the formation of gastric ulcers were concerned. This may be due to the strong contraction of the walls of the stomach, which at once closed any bleeding vessels and apjDroximated the edges of the denuded areas. The possibility of such an occurrence, and in fact of any severe lesion of the mucous membrane, is reduced to a minimum by the use of the flexible tube ; and in this way there has been removed a serious objection which prevailed up to quite recently against the internal exploration of the stomach in certain conditions, such as cancer and ulcer, where bleeding occurs easily. A very unpleasant complication is regurgitation of food alongside of the tube; this may even lead to suffocation, aspiration-pneumonia {Schkichpneu- monie), etc. || This may be guarded against by the local or internal use of cocaine in very nervous patients. The choking sensation is * Wiesner. Ueber die Behandlung der Ectasie mittelst der Magenpumpe. Ber- liner klin. Wochensehr., 1870, No. 1, S. 3. f V. Ziemssen. Zur Technik der Loealbehandlung des Magens. Deutsch. Ar- chiv flir klin. Med.. Bd. x, S. 66. X Leube. Die Magensonde. Erlangen, 1879, S. 25. * Schliep. On the Stomach-pump in the Treatment of Chronic Gastric Catarrh and Dilatation. Lancet, December 14, 1872. II Emminghaus. Einiges liber Diagnostik und Therapie mit der Schlundsonde. Deutsch. Archiv fiir klin. Med., Bd. xi, S. 304. THE STOMACH-TUBE. 15 much less marked after the test-breakfast {Prohefruhstilch — vide infrci), for its intensity is manifestly regulated by the amount of the ingesta, and the masses raised are smaller as well as less offen- sive. It ceases, as a rule, after pouring some water into the stom- ach, since the irritation of the mucous membrane by the tube is thus removed. I have never met with any serious accidents, neither large hgem- orrhages nor any other mishap ; and can agree with Leube's state- ment that, " taken all in all, the passage of the tube into the stom- ach is to be considered an operation without risk " ; * but I would modify it by substituting for " taken all in all " the expression " if the necessary care be taken." It is self-evident that in the examination of the contents of the stomach a method which is as uniform as possible should be fol- lowed. The activity of the gastric secretion depends, mutatis mutandis, upon the food eaten. The quantity is abundant if a good opportunity is offered for free secretion. An abundance of food calls forth a greater activity of the glands than a scanty diet, till the food present is saturated with the secreted juice. There- fore, different results will be obtained if the examinations are made after varying intervals and after different kinds of food. The neglect of this point was the cause of the great discrepancies be- tween the various writers up to a short time ago ; hence it is abso- lutely indispensable that the interval after the meal and the diet should always be the same, if the results are to be of any value for comparison. The question naturally arises. What is the normal course of the secretion in human beings ? A continuous series of experiments on the successive phases of digestion in animals, as well as in hu- man beings, had never been made till Dr. Boas and myself made ours on the latter some years ago. First of all we corroborated the results of Tiedeman and Gmelin (1826) and others that there is normally no gastric juice in the stomach when fasting ; that some kind of irritation of the gastric mucous membrane is necessary to produce the secretion, either by the simple introduction of a sound * Leube, loc. cit., p. 40. 16 DISEASES OP THE STOMACH. or tube, as in very nervous persons, or by giving some water, pep- per, etc. Thus, for example, Edinger * found that in 13 out of 15 cases there was no trace of hydrochloric acid, and in the other two a " by no means positive " trace of it. He used the old method of Spallanzani, in which the subjects swallowed pieces of sponge com- pressed to the size of a pill, and attached to a silk thread. Con- cerning this it must be stated that, in persons who have not eaten for an unusually long time, the introduction of the tube may not cause a secretion of gastric juice, but instead a regurgitation of bile and other contents of the duodenum. This is not a normal occur- rence, as will easily be perceived from the standards to be given later on. Schreiberf and Rosin,:}; after very thorough experiments, have recently claimed that the secretion in the stomach is continuous. At all events, it was found that in 14 out of 15 persons examined for this purpose from 2 to 50 c. c. [f 3 ss. to 3 jss.] of a fluid containing hydrochloric acid could be expressed from the stomach Avhen free from food ; the fluid was usually clear as water, with very little potash and no remnants of food ; in a few cases it was colored green or yellow. Likewise, in 10 out of 11 persons who had fasted seven hours, some of them even the greater part of the day, a fluid containing hydrochloric acid could always be obtained by expression, repeated at a few hours' interval. Schreiber thinks he can exclude the possibility of this secretion having been pro- duced at the time of the introduction of the sound or tube ; yet he does not state whether it is the product of the entire period of fasting (i. e., for instance, that secreted continuously during the whole night), nor does he make it clear when the secretion begins. Leo* and Kinnicutt j, who found hydrochloric acid, " almost with- out exception," in the stomachs of fasting suckling infants, consider * Edinger. Zur Physiologie unci Pathol ogie des Magens. Deutsch. Archiv flir klin. Med., Bd. xxix, 1881. f J. Schreiber. Die spontane Saftabscheidung des Magens ira Ntichternen imd die Saftsecretion des Magens im Fasten. Arch, fiir experim. Pathologic nnd Pharmakologie. Bd. xxiv, S. 365. X H. Rosin. Ueber das Secret des ntichternen Magens. Deutsche med. "Woch- ensehr., 1887, No. 47. * Leo, loc. cit. II Kinnicutt. Diagnosis of Diseases of the Stomach. Transactions of the Asso- ciation of American Physicians, vol. v, p. 216. THE TEST-BREAKFAST. 17 it a residue of the previous process of digestion ; while Rosen- heim * agrees perfectly with my results, and states that normally the stomach contains only traces of hydrochloric acid (never over 0-Ott per thousand f). I can not admit that Schreiber's experiments are convincing, and that the glands of the stomach, unlike all other secreting glands, are active without any specific stimulation, some- what like a steam-engine "going dead slow." I still consider that the simple act of introducing the tube in most persons who have not become accustomed to it by long practice causes a reflex fy^om the mouth downward^ and this reflex action will suffice to call forth a more or less marked secretion of gastric juice. Furthermore, this will occur more readily the longer the person has remained hungry beyond the usual time of eating, exactly as happens in the salivary glands of dogs, w^hich, when a piece of meat is held before them, secrete the more abundantly the longer they have been starved. Proof of this was afforded me in five patients who were accustomed to the passage of the instrument. I passed the tube while the patients were in bed a short time before breakfast, but I obtained only small quantities of clear mucus, at times of a yellow color. This mucus, although having a feeble acid reaction several times, never gave a reaction with the tropaeolin or the phloroglucin- vanillin tests. It may be objected that these were patients with diseased stomachs ; yet they always secreted gastric juice w^ith hy- drochloric acid after taking food. At all events, the contradictory results given by the above writers show that idiosyncrasy causes some to react more easily than others, and, as we shall see later on, this may under certain conditions even lead to a pathological in- crease of the secretion. The food should be as simple as possible ; it is well typified in the so-called test-hreakfast {ProbefriihstilcTc). On an empty stomach the patients take an ordinary dry roll and a definite quan- tity — "I litre [about f pint] — of fluid, of either simply warm water or * T. Rosenheim. Ueber die Sauren des gesunden und kranken Magens bei Einfiihrung von Kohlenhydraten. Virchow's Archv, Bd. cxi, S. 419. f [0-04 per thousand, or 0-04 pro mille, as it is usually expressed in German, equals f g^^^. This is a very convenient way of expressing these high fractions in the decimal system. They can easily be converted back into fractions by remem- bering that 1 pro mille (or O'l per cent) equals xwu- — Tr.] 18 DISEASES OP THE STOMACH. weak tea [without milk or sugar]. (Tea sometimes lias a feeble acid reaction, depending on the province from which the tea-leaves come.) According to Konig's analysis, such rolls contain Y per cent nitrogen, 0'5 per cent fat, 4 per cent sugar, and 52*5 per cent non-nitro- genous extractive substances, to which 1 per cent ash must be added. The roll is thus a mixture of the various nutritious ingre- dients, and is made up here [Berlin] of a tolerably uniform weight, about 35 grammes [540 grains]. The test-breakfast thus includes albuminoids, sugar, starches, non-nitrogenous extractives, and also salts ; the tea belongs to that group of foods which are of con- siderable importance to the gastric secretion. Klemperer recom- mends substituting -J litre [a pint] of milk instead of the tea, in order to subject the stomach to a severer test. As yet I have not been able to obtain any special advantage from this. By means of this breakfast we can offer the stomach all the ingredients which are usually taken, with the great advantage that they are liquefied in a relatively short time, or at least they are softened sufficiently to permit their passage through the tube ; while if solid food like meat is given the openings in the tube are very easily plugged. This also explains why many can not dispense with the stom- ach-pump, which naturally gives greater suction-power. My method has the additional advantage of great cleanliness. Even should the patient vomit, as occurs occasionally in a very few cases, the vomit does not consist of fatty, offensive, and viscous masses, as when a large meal is taken, but only of comparatively clean morsels of bread. These are the advantages of the method. On the other hand, it must not be forgotten that such a moderate meal makes a a very slight demand on the action of the viscus, and a stomach which may prove capable of digesting this moderate meal may not secrete enough for a more complicated diet. This objection ap- plies with even greater force to the one-sided administration of small quantities of albumen only (the whites of one or two hard- boiled eggs), as proposed by Jaworski. It is for this reason that I deny the value of such a meal to test all the digestive functions of the stomach. If we have given the trial-breakfast, and still desire to apply severer tests, nothing forbids the use of another THE TEST-DINNER. 19 kind of food to ascertain whether the latter is also properly- digested.* Larger meals, like the test-dinner {Pr6beinittaghrod\ to be taken at noon, have been employed by other observers (Leube, Riegel). The test-dinner consists of an ordinary [German] midday meal of bouillon, barley or Hour soup, a moderate piece of meat, and some bread. ISTaturally a uniform quantity should be given at these meals — about 400 grammes [about 13 il. oz.] of soup, 60 grammes [2 oz.] scraped beef, and 50 grammes [If oz.] wheat bread. This is not so easily carried out, and the same interval should also be allowed to elapse before the examination. Further- more, the large quantity of acid salts taken in the food, as shown by Einhorn,f may cause quite a serious error if the absolute quantity of HCl is unknown and the total acidity is computed as IICl. In my method digestion is at its height within one hour after eating, and all the constituents can be demonstrated ; but in the large meals either no digestion at all or very little will have taken place in that time. You must wait four to six hours, according to the state of the food, or at times upon the condition of the organ, till you can obtain all the ingredients properly digested ; and as the fluid portions of the food are absorbed much more rapidly than the solids, the contents of the stomach after a time become more and more like mush, so that it may easily hapj)en that at this time a sufficient quantity of the stotnach-contents can not be obtained. The longer period of waiting is of less importance, since, after all, we are looking for comparative results ; yet so great have been the advantages of the test-breakfast that I have not discovered any rea- son for seeking further, especially as numerous trials — even in car- cinoma of the stomach, let it be well noted — have shown that the same residts are obtained with it as with the more complicated meals. It is .especially convenient where large numbers of exam- inations must be made, and hardly anything else could be used in * [As the result of eight examinations on healthy subjects, Boas says that one hour after taking a roll and 300 c. c. [f 1 x] of water, about 40 e. c. [f 3 1^] should be obtained by expression ; the amount may vary 15 c. c. [f § ss.] either way ; otherwise the result is pathological. Boas, loc. cit., p. 115. — Tr.] f Einhorn. Probefriihstiick oder Probemittagbrod ? Berl. klin, Wochenschrift, 1888, No. 33. 3 20 DISEASES OP THE STOMACH. consultation practice, where tlie patient's general condition is deter- mined on one day and early on the following morning he may come for the examination of the stomach, and thus the inconven- iences of the procedure are reduced to a minimum. If the fluid obtained by expression after the test-breakfast is filtered, the filtrate is a clear, at times yellowish or yellowish-brown, watery fluid, like the specimen which I now show you, which was obtained by expression this morning. You know that the stomach during digestion normally has acid contents, the acidity being due to hydrochloric acid, and the inten- sity of which depends upon the functional activity of the organ and the stage of the digestive j^rocess. But the nature of the acid which imparts this acidity changes also. It is therefore necessary to determine first whether the stomach-contents are acid, then how acid they are, andfi/nally the nature of the acid which produces the acidity. During the normal digestion of the test-breakfast the fol- lowing three stages may be observed, provided the reagents to he presently described are employed. As early as ten to fifteen min- utes after eating, the stomach -contents obtained are acid ; the acid- ity depends either upon acid salts or free acid, or both. Exami- nation of the free acid with our usual reagents shows it to be lactic acid. Up to thirty to forty-five minutes the lactic acid pre- dominates, while the color-tests for hydrochloric acid are negative. Then comes a stao;e in which distinct traces of HCl can be demon- strated, coexisting with the lactic acid. Finally, the latter disappears entirely, so that normally after the first hour only HCl can be found. Of course, this must not be understood as meaning that it is then only that its secretion begins. On the contrary, it probably begins at once after the entrance of food into the stomach ; but at first it can not be demonstrated with the customary reagents, because a portion of it is in combination, and also on account of the pres- ence of acid salts which interfere with tlie delicacy of the usual reagents. The amount of free HCl rises during the course of di- gestion, and reaches its maximum, which generally seems to be higher after an abundant meal than after a light one (2 to 3'3 per thousand [^^o" '^^ wo"] against 1*5 to 2 per thousand [-g^ to -g^]). This difference in the quantity of tlie secretion bears no relation to THE THREE STAGES OP ACIDITY. 21 differences in its reaction to disturbing influences ; in other words, disturbances of digestion, as I have already said, occur in the one case as well as in the other, because they dejDend n(»t on absolute but on relative values — of course witliin certain limits, above or below which they must not go. The above results are typical, and can be demonstrated with the processes soon to be described. The clinical and practical impor- tance of these three stages of acidity lies in the fact that changes in them enable us to recognize pathological conditions. The validity of this will not be affected by the fact that Calm and von Mering,* Ritter and Hirsch,f and Rosenheim, ;}; with the aid of complicated methods of detecting traces of lactic acid, succeeded in demonstrat- ing this acid in the later stages of digestion. At all events, it is possible, as I myself have ascertained in several cases, to find small traces of lactic acid at a time — at the end of the first hour, for in- stance — when for all practical purposes the tests to be described later (page 33) no longer give a positive result. But in this lack of sensitiveness lies the value of this test. For we have no method by which an excess of lactic acid could be quickly estimated ; hence the value of a reaction which, as in the case here, only becomes evident when there is a pathological increase of lactic acid in the stage of digestion under discussion. I am therefore justified in maintaining that the value of this division of stomach digestion into three stages, as proposed by Boas and myself, is not diminished by the above- mentioned results, even should their occurrence be constant. The acid reaction of the stomach-contents may, under certain conditions, depend throughout the entire process of digestion, not upon free acids but upon the acid salts of the iugesta, especially the acid phosphates. Usually these salts play an insignificant part as compared to the free HCl, but under pathological conditions they may become important. Therefore the simple fact that the chyme reacts acid to litmus * Cahn und v. Mering. Ueber die Sauren des gesundeii und kranken Magens. Deutsch. Archiv 1 klin. Med., Bd. xxxix, Hefte 3 u. 4. f Loc. cit., p. 434. X Rosenheim. Ueber Magensaare bei Amylaceenkost. Centralblatt fiir d. medi- cin. Wissensch., 1887, No. 46 ; and Virchow's Archiv, Bd. exi, S. 414. 23 DISEASES OF THE STOMACH. does not sliow wliether the acidity is due to free HCl or acid salts. Under all conditions it is important to ascertain liow acid the stom- ach-contents are — i. e., to test the acidity with volumetric solutions and the burette (titration). Testing Total Acidity. — Titration* is most conveniently per- formed with a deci-normal solution of caustic soda, the end-reac- tion being determined with litmus-paper or phenol-phthallein. The latter is not as accurate as the so-called TujyfelnieiJiode — i. e., the alternate testing with red or blue litmus-paper — but it is much more convenient and rapid, while it is sufficiently accurate for general practice. Should the reaction of the stomach-contents be alkaline, the degree of alkalinity may be determined with a deci-normal acid solution. Phenol-phthallein is a buif-colored powder, freely soluble in alcohol, making a slightly opalescent solution, which remains colorless in acid or neutral solutions, but assumes a carmine color in alkaline solutions. The procedure is simple : a Mohr's burette is filled with the deci-normal solution of caustic soda ; 5 or 10 c. c. of the filtered stomach-contents are poured into a small glass ];>eaker, and one or two drops of the alcoholic solution of phenol- phthallein are added. The solution in the burette is very grad- ually added till the red color which appears in the contents of the beaker no longer disappears on shaking, but remains jjerma- nently. A slight turbidity or yellowish color of the stomach-con- tents does not interfere with the delicacy of the reaction ; it is also to be noted that the addition of the phenol-phthallein gives a slightly milky appearance to many stomach-contents.f In the * [The description of the technique of titration and other strictly chemical pro- cedures lies beyond the province of this work. Those who desire further informa- tion than is given in the text will find these methods fully described in the Hand- book of Volumetric Analysis, by Edward Hart ; New York, John Wiley & Sons. In all these volumetric methods the metric system is obviously alone employed. — Tr.] f Where titrations are not made daily, Kleinert's burette will be found very convenient. This burette differs from the ordinary form with glass stop-cock in liaving the latter at the upper end above the zero-mark of the scale, while the lower end is somewhat drawn out, and is ground, to permit its being closed with a glass cover. The burette is filled by dipping the lower end into the standard solu- tion to be used and sucking at the upper end while the stop-cock is open. By clos- ing the latter the atmospheric pressure will keep the column of fluid in the burette. To titrate, we simply turn the stop-coek above instead of below, as usual. After TESTING TOTAL ACIDITY. 23 specimen we are now examining 6"1 c. c. of tlie deci-normal solu- tion were added to the 10 c. c. of stomach-contents. As a rule, the acidity of the contents of the stomach obtained one hour after the test-breakfast ranges between 4 to 6 or 6*5 c. c. ; results above or below these limits are j3athological. It is a matter of convenience to express the acidity in percentage according to the amount of the deci-normal soda solution used ; thus, for example, 61 per cent acidity would mean that 100 c. c. of filtered stomach-contents were neutralized by 61 c. c. of a deci-normal soda solution. This j)re- vents any misconception that the acidity depends on free hydro- chloric acid. If we are sure that the acidity depends on the latter and not on salts or any other acids, we may express the value as HCl. One cubic centimetre deci-normal soda solution is equivalent to 0'003646 HCl. When 10 c. c. of stomach-contents are used, multiply 0'03646 by the number of cubic centimetres added from the burette till the contents of the beaker were neutralized ; this will give the percentage of HCl in the stomach-contents under ex- amination. Thus in the present specimen the actual jDercentage of HCl is 0-22 per cent ; this result is within the normal limits (0*14 to 0*24 per cent). To determine whether the acidity depends on free acids or acid salts, the aniline dyes will be found the most useful ; of these the best is TrojKeolin 00 — V orange P airier of the French. This powder, when dry, has a beautiful orange color ; in saturated watery or alcoholic solutions it is a dark yellowish-red ; in the presence of traces of free acid — even as little as about 0*25 per thousand [1 in 4,000] — it changes to dark brown, but acid salts make it straw yellow. I shall take a small quantity of the reagent and add a few drops of dilute HCl (containing about 0-05 per cent pure HCl) ; as you see, the solution at once assumes a deep, dark-brown color. If some acid sodium phosphate is added to the tropseolin solution. use, the lower extremity is closed with the well-greaserl glass coTer. In this way we avoid the annoying drying of the stop-cock and also the alteration due to ex- posure to the air which occurs in the ordinary form in the drops of fluid in the lower end, if the burette is not in continual use ; this change is due to the formation of carbonates. 24 DISEASES OF THE STOMACH. tlie color turns not brown, but a light straw yellow. Thus tropseolin enables us to determine whether free acids (hydrochloric or lactic) are present. The dye called Congo-red^ which was introduced by Hoesslin,* has a similar action ; its solutions assume a peach to a brownish-red color. The addition of a free acid changes it to a sky-blue. It is more delicate than troj)seolin, and will react to a fluid containing but 0*02 per thousand. Acid salts jDroduce no change. \_Benzopur2Juri71 was introduced by v. Jaksch ; f it is used on stri|)s of filter-paper which have been dipped into a saturated aque- ous solution of benzopurpurin 6B, and dried. Such a strip is dipped into the stomach-contents, and if the paper at once assumes a deep blackish-blue color, then there is more than 04 per cent PICl ; if the color is more of a brownish black, then it may indicate either organic acids or a mixture of these acids and HCl. To dif- ferentiate, the strip of paper is placed in a test-tube with ether : if the color remains unchanged, only HCl is present ; if it disap- pears, then only organic acids are there ; if it becomes less marked, then both kinds of acids are present.] In these tests, as well as all the other reactions to be mentioned later, there must be an excess of the fluid to be tested over the color solution ; otherwise delicate changes might escape notice. The best method is to pour 5 to 10 drops of the color solution into a small test-tube, and then add 1 to 2 c. c. [15 to 30 drops] of the filtered stomach-contents. The delicacy of all these reactions is markedly affected by the presence of salts and albuminoids, espe- cially albumose and peptone. Certain salts, as, for example, sodium chloride, enter into combinations with the dyes which are very stable, even though they are not true chemical compounds, and not even the addition of small quantities of acid suffices to break them up again ; on the other hand, albumen and its derivatives form un- stable combinations with a portion of the free acid, and thus also disturb the reaction. Yet, at all events, we can roughly estimate * Von Hoesslin. Ein neiies Reagent auf freie Sauren. Miinch. med. Wochen- schr., No. 6, 188G. f [Von Jaksch. Klinische Diagnostik innerer Krankheiten. 2. Auflage, 1889, S. 123.— Tr.] THE DETERMINATION OP HYDROCHLORIC ACID. 25 whether we are dealing with free acid or acid salts, and can obtain an approximate idea of the amount of free acid by the intensity of the reaction. Let us test whether this specimen, whose acidity is 61 per cent (= 0*2 per cent HCl), contains free acid. I shall first add some to the Congo-red solution ; it assumes a pale-blue color, but its inten- sity is much less than this control test with a 0*2 per cent hydro- chloric-acid solution. The same difference is observed in the reactions with tropseolin. Therefore, along with the free acid which is present in this specimen there are also acid salts. How can we determine the nature of the free acids ? For the Determination of Hydrochloric Acid, we must first con- sider those aniline dyes which in aqueous or alcoholic solution react with distinct changes of color to free acids in general, and to free hydrochloric acid as well. From the chemical composition of methyl-violet, Klemperer * concludes that, so far at least as this dye is concerned, loose combinations are formed which are easily split up again by every kind of organic or inorganic bases and by the albumens and their derivatives, so that the original color re- turns ; or, in other words, as I have already expressed it, these substances mentioned above have a greater affinity for hydrochloric acid than methyl-violet has. Of tropseolin and Congo-red I have already spoken. Another dye is methyl-violet^ which is used in an aqueous solution, which is diluted till it has a reddish-violet color. The addition of even 0-024 per cent of HCl to the solution changes the tint to a sky-blue, which you will observe has a differ- ent color than the original when I hold both tubes up to the light. Emerald^ smaragd, or malachite green is also employed ; its solutions are dark green, playing somewhat into a bluish-green. The addition of free HCl changes it to a beautiful moss-green. This dye is probably identical with vert hrillant, so warmly recommended by Lepine. But my experience has been that smaragd-green is not as delicate as methyl-violet or Congo-red. Even less delicate is fiicJi- sin, also called ruhin / its solutions are bright red, but turn yel- * G-. Klemperer. Zur chemischen Diagnostik der Mageiikrankheiten. Zeit- schrift f. klin. Med., Bd. xiv, S. 156, 26 DISEASES OF THE STOMACH. low on adding an acid ; bnt a relatively large amount of acid is needed to produce tliis cliange. It is only after adding a large' quantity of a solution wliicli has double the amount of acid used in the former tests that the color begins to assume a lighter shade and finally becomes yellow. The best dyes for general use are Congo-red and tropseolin, either in solution or as test-paper, like those which I now show you ; these test-paj^ers are made by dipping strips of filter - jDaper into a saturated solution of the dye and allowing them to dry. The reaction is made more distinct by carefully warming them over a flame (Boas) ; Congo-red paper in the presence of small quantities of free acid assumes a lilac color at the place heated. The same result may be obtained by pouring a few drops of the color solu- tion into a porcelain dish and distributing it into a thin layer by rotating it to and fro (Uffelmann). Then a few drojDS of the fluid to be tested are added, heat is gently applied, and a good reaction is readily obtained. Kahler * recommends sucking up some of the filtered stomach-contents into a fine glass tube, and then carefully adding [by suction] a few drops of the color solution, so that two layers are formed. The reaction is manifested by a delicate ring at the line of contact of the two fluids. It depends upon bringing together suitable quantities of the fluid and the dye in such a way that the change in color may be visible ; where the quantities are small this can naturally be done more easily in a porcelain dish than in the bottom of a test-tube. The principle is the same, however. The reaction of these aniline dyes toward hydrochloric acid is somewhat uncertain, because they are decolorized by other acids, especially the organic ; as I have already shown, their delicacy is also affected by other substances. Unfortunately, these sub- stances are the ones which we always encounter in the stomach- contents during ordinary digestion — i. e., albumen and its deriva- tives, saliva (an albuminous and saline fluid), chlorides, and phos- phates ; what I said while discussing the demonstration of free acid * Kahler. Ueber die neuen Methoden zur Untersuchung des kranken Magens. Prager raed. Wochenschr., 1887, No. 32 u. 33. THE DETERMINATION OP HYDROCHLORIC ACID. 27 is also true here. They either simulate or prevent the change of color. I shall now show you on a solution of methyl-violet that they can simulate decolorization. If to a solution of tliis dye I add some diluted white of egg you will see that the reddish-violet solution will assume a distinctly different blue color. A slight dif- ference in this color and that produced in a control test with hy- drochloric acid may be observed, yet this can only be detected when the two tubes are held alongside of each other, and when only pure hydrochloric acid is employed. I shall now pass around a third tube, in which both HCl and albumen have been added, the result being a shade between the other two. By holding the tubes up to the light, the difference and similarity can be distinctly recog- nized. The derivatives of albumen act in exactly the same way, namely, the various albumoses, syntonin, propej)tone, peptone, leucin, and, finally, certain salts, especially sodium chloride, which is so abundant the food. If to a methyl-violet solution some concentrated com- mon-salt solution (even a 5 to 10 per cent solution will suffice) is added, the reaction, when some acid stomach-contents or pure HCl is poured in, is much less distinct, or may even be absent. On the other hand, the bluish color of the methyl-violet solution after adding HCl will disappear on pouring in a definite proportionate amount of a solution of albumen, albumose, peptone, etc. ; or the color change may not occur at all if these substances have been add- ed to the HCl before using it. I say, " in proper proportion," and therel)y I also explain the entire phenomenon from whose varying distinctness with different reagents false deductions have been drawn as to their greater or less usefulness. Under the above con- ditions it was only necessary for the substances in question to com- bine with the acid to form unstable compounds with it or to absorb part of it ; hence it can no longer react as a free acid. Therefore, in making comparative tests with solutions of acids which exceed the sensitiveness of a reagent, the more delicate the reagent the greater is the amount of the above-named substances [albumen, etc.] which may be added without preventing the reaction ; the opposite result will be observed if we are working with solutions which still contain even a trace of acid to act ujDon the reagent. 28 DISEASES OP THE STOMACH. This enables us to understand the statement made, for example, by Seeman,* that a combination of equal parts of, a -J-per-cent peptone solution and a 0"2-per-cent HCl mixture will just give the methyl- violet reaction ; while Krukenberg f claims that the phloroglucin reagent (see p. 29) will do the same when one part of a 4:-per-cent peptone solution is added to two parts of the identical HCl mixt- ure. It simply means that methyl-violet is about four times less sensitive than phloroglucin-vanillin. The other dyes act just like methyl-violet ; some — e. g., tropse- olin — are more markedly affected by salts, while others, like sma- ragd-green and Congo-red, by albumens. When we are using im- pure acids, or especially stomach-contents, which always have a slight tinge of color, this behavior of the dyes may give rise to seri- ous errors, and is certainly the cause of many of the controversies which have arisen in discussing these results. As early as 1880 I called attention to this,:|: and sliowed, especially concerning the methyl-violet reaction, that " it was delayed by the presence of even small quantities of blood, and that it was markedly enfeebled or even prevented by solutions of hydrochlorate of leucin and tyrosin as well as by albumen and peptone." I shall demonstrate to you on this somewhat turbid sample of stomach-contents (obtained from a different patient) that a distinct bluish color will be given by methyl- violet, which is nevertheless not due to free acid ; for, if I test for the latter with trop8e.olin, although a darkening or, rather, a clouding of the reagent occurs, yet there is no true brown color. Free acid is therefore absent in spite of the change of color pro- duced by the methyl-violet. The organic acids which have been alluded to above as affecting the color solutions include lactic acid, acetic acid, and butyric acid ; yet, in order to simulate the changes produced by HCl, much stronger solutions are requisite than are found in the stomach-contents. Where HCl and the above organic acids occur together, the delicacy of the HCl reaction is not affected * Seeraan. Ueber das Vorhandensein freier Salzsaure im Magen. Zeitschr. fiir kliii. Med., Bd. v, 1882. f Krukenberg. Ueber die diagnostiche Bedeiitung des Salzsaurenachweises bei Magenkrebs. Inaug. Dissert. Heidelberg, 1888. X Ewald. Ueber das angebliehe Fehlen freier Salzsaure im Magensaft. Zeit- schr. fur klin. Med., Bd. i, S. 622. MOHR'S REAGENT. 29 by the latter. Concerning tliis I have constructed a table which will be found at the end of this lecture. This behavior of the aniline dyes showed the desirability of other tests in which these sources of error would not arise. The test proposed by Molir depends on the change wdiich occurs in a solution of sulphocyanide of potassium and acetate of iron on the addition of HCl ; this is due to the formation of sulphocyanide of iron, which varies in color from a peach-red to a brownish red. Two c. c. [f 3 ss.] of a 10-per-cent solution of sulphocyanide of potas- sium are added to 0'5 c. c. ['niviij] of a neutral solution of ferric acetate (the liquor ferri acetici, Pharm. Germanic, which contains between 4 and 5 per cent of iron) ; this is diluted with water to 20 c. c. [f 3 vjss.], so that the fluid assumes a light mahogany color. A little of this is poured into a test-tube and some dilute hydrochloric acid is added ; the color of the solution then changes to a dark brown-red. This method is not so distinct as when tried with a thin layer in a porcelain dish. A few drops of the reagent are placed in a small porcelain dish and spread into a thin layer by rocking the dish to and fro, and pouring off the excess. A little hydrochloric acid is allowed to trickle slowly from the edge of the dish ; at the point of contact of the two fluids a beautiful peach-red color forms at flrst, but on adding more acid it assumes a brownish tinge. This peach-red color is very characteristic and enables us to detect very small traces of hydrochloric acid, although it is not as delicate as the aniline dyes. It possesses these advantages, that it is disturbed only by larger quantities of albuminates, and not at all by salts. Instead of always preparing the solution fresh, strips of filter-paper may be dipped into it and dried, and the reaction may be obtained with them. But these papers after a time become less sensitive as a re- sult of contact with the air. I have no personal experience of the value of ultramarine and zinc sulphide proposed by Kahler,* because I considered it superfluous to search for new methods after the announcement of Giinzburff's reagent.f This test, which surpasses all of those thus far mentioned, * Kahler. Ueber die neuen Methoden zur Untersuchung des kranken Magens. Prager med. Wochenschr., 1887, No. 32 ; and Kraus, ibid., 1887, No. 53. t Gunzburg. Centralblatt fiir klinische Medicin, 1887, No. 40. 30 DISEASES OP THE STOMACH. is so sharp and at the same time so simple and positive Lhat a con- trol test with other reagents is necessary in only very few cases in- deed. According to my extensive experience thus far, using it daily and comparing it with other tests, I do not hesitate to pro- nounce Giinzburg's reagent very valuable ; my original recommen- dation of it* has in the mean time been corroborated by many other writers. The j^rinciple of the reaction is that a pine-needle which has been dipped into a solution of phloroglucin will assume a bright red color when it is brought in contact with hydrochloric acid. Max Singer has shown that this color-change is due to the presence of vanillin. The solution is made as follows : Phloroglucin 2*0 [gr. xxx] Yanillin 1-0 [gr. xv] Absolute alcohol SO'O [f 3 j] The solution is jDale yellow in color, and has a pronounced odor of vanilla or fresh pine-wood ; on exposure to light it in time assumes a dark golden-yellow color, and it must therefore be kejDt in black bottles. If a drop of the reagent is put into a small porcelain dish and some concentrated hydrochloric acid is added, a bright red color and the formation of small red crystals will be at once ob- served. If the acid is weaker, as, for example, only 0*05 per cent or less, or with stomach-contents, no change will be observed at first ; but if the dish is carefully heated over a flame, so that the fluid does not boil, but simply evaporates slowly, at the edge of the drop a bright red tinge or very delicate red stripes will be observed. These are absolute proofs of the presence of free hydrochloric acid. Blowing on the dish will cause the beautiful red stripes to appear at once. Filtration of the gastric contents is unnecessary ; one or two drops in a small dish or on a stri^) of filter-paper with an eqnal quantity of the reagent will suffice. The reaction has this great ad- vantage over all others, that it is not simulated by the albuminates which may be present ; neither is it interfered with by salts, pro- vided they are within the usual proportion ; nor is it afliected by organic acids ; but of this I shall speak again later on. Its delicacy * Ewald. Verhandlungen des Vereins f llr innere Medicin zu Berlin. Deutsch. med. Wochenschr., 1887, No, 46. GtTNZBURG'S REAGENT. 31 far surpasses every other reagent. Tropaeolin papers fail when hydrochloric acid is below 0'3 per mille [1 in 3,300] ; but I am convinced, that Giinzburg's reagent may be used when it is as low as 0-05 per mille [1 in 20,000]. The color obtained is always a bright red, but where the amounts are very small it may be a pale rose-red, yet it is never brown nor brownish yellow nor brownish red. The presence of such shades indicates overheating and the combustion of organic substances. Characteristic is the appearance of red stripes or of a uniform reddish tinge at the edge of the drop after gentle heating or slow evaporation to dryness. Strong heating and evaporation of any albuminous substance will produce a marked central red colora- tion, yet this is scarcely to be confounded with hydrochloric-acid reaction. If dilute hydrochloric acid is added to solutions of albu- men or peptone, then the above-mentioned reaction of these sub- stances will only occur after their affinity for the acid has been completely satisfied. The behavior of the reaction will afford a fairly good quantita- tive estimation of the amount of free hydrochloric acid ; an easy and reliable method for this has thus far been lacking. - By suc- cessively diluting the stomach-contents which react to Giinzburg's reagent to ^, -|-, ^, etc., till the reaction is no longer obtained, we can approximately estimate the quantity of actually free hydro- chloric acid, since we know that the limit of the reaction lies at -^^ per mille [1 : 20,000]. For example, the red color is just visible with the twentieth dilution ; then the gastric juice contains 1 per mille — i. e., O'l per cent of free hydrochloric acid. However, we can also get a rough idea of the larger or smaller amount of free acid by the more or less intense red color while making the test. Boas* discovered that resorcin was a substance with a very similar action. The reagent consists of : * Boas. Ein neues Reagens fiir den ISTachweis freier Salzsaure im Magensaft. Centralblatt filr klin. Med., 1888, No. 45. [Also, Boas. Diagnostik, etc., 2te Auflage 1891, S. 134. This test may also be applied by means of strips of filter-paper which are dipped into the stomach-contents ; add one to two drops of reagent and heat gradually. It is slower than Giinzburg's reagent, and requires greater delicacy in using it. — Tr.] 32 DISEASES OF THE STOMACH. Resorcin resublimat 5*0 [gr. Ixxv] Saccliar. alb 3'0 [gr. xlv] Spiritus dilut 100-0 [f ^ iijss.] Tliree to five drops of the reagent are poured into a porcelain dish and an equal quantity of stomach-contents is added ; it is now heated slowly, when a purple-red color appears at the edge of the drop, as in Giinzburg's test, even in the presence of only 0*05 per mille of free HCl. This reaction is also produced only by hydrochloric acid, and is never caused by organic acids. Having thus spoken of all the more important means for de- tecting free hydrochloric acid, we conclude that for simplicity and distinctness the reagents of Giinzburg and Boas and tropseolin are to be considered the best. We must next consider the other acids which are found in the stomach-contents— how they are to be de- tected, and what are their relations to and reciprocal action upon hydrochloric acid. At all events, the discussion of the color-tests for free hydrochloric acid is by far the most important, but it may be dismissed for the present, since many comparative examinations have been made by various observers — Reischauer, Kraus, Haas, Krukenberg, and others ; their conclusions as to the relative value of the difEerent tests agree fairly well. In a recent dissertation Ivuhn * arranges these substances according to their increased sensitiveness towards pure hydrochloric acid ; yet it by no means follows that the same order is true when applied to stomach-contents. He tab- ulates them thus : Ultramarine-blue, tropseolin paper, Congo paper, emerald-greeii, methyl-violet, tropseolin, phloroglucin-vanillin, Congo solution. I shall now consider the Determmation of the Organic Acids — i. e., lactic acid, acetic acid, and the true fatty acids, especially bu- tyric acid. After it had been positively settled that the true and only acid produced by the gastric glands was hydrochloric acid, the opinion for a long time prevailed that the occurrence of organic acids, especially lactic acid, was always pathological. The recent investigations of Dr. Boas and myself, which were conducted on * Kuhn. Ueber den Werth der Farbstoffreagentien, etc. Inaug. Dissert. Gies- sen, 1887. LACTIC ACID. 33 living subjects with liealtliy stomachs, definitely proved that an organic acid also exists normally in the early stages of digestion. If organic acids are found in the later stages in such quantities that they can be detected with the ordinary reagents, then they always have a pathological significance. These organic acids are the results of a normal fermentation of some of the substances acted on by the gastric juice — starch, sugar, and albuminous bodies. As far as we know at present, sarcolactic acid is to be regarded as a constant constituent of meat, from which it is dissolved. Lactic Acid. — There are two kinds of lactic acid, fermentation lactic acid and sarcolactic acid. They are distinguished not so much by diiferences in chemical character as by their source. The former is of more importance to us than the latter, yet the tests to be described presently apply to both kinds. The method used by chemists to determine the presence of lactic acid is a very elaborate one, and is too complicated for general use. A very sim- ple and rapid test for medical practice has been proposed by Uffel- mann. Diluted solutions of neutral ferric chloride turn canary-yel- low in the presence of lactic acid. If I take some ferric chloride and dilute it till it is almost colorless, and then add a trace of lactic acid, you will see this canary-yellow color at once appear. Nevertheless, the reaction is somewhat uncertain, or rather difficult of recognition, because we must merely distinguish the intensity of otherwise simi- lar shades of color. Hence the test was modified as follows : a few drops of a diluted neutral ferric chloride solution are mixed with one or two drops of pure carbolic acid, or about 10 c. c. [ 3 ijss.] of a 2 to 5 per cent solution of carbolic acid — the exact proportions are not essential — and water added till the solution assumes a beau- tiful amethyst-blue color. A few drops of even a 0'05 jDer thou- sand solution of lactic acid [1 in 20,000] will sufiice to change this blue to the characteristic yellow color. The delicacy of the reac- tion is such that 2 c. c. [ 3 ss.] of this Uffelmann's reagent will give a distinct result on adding 0"8 c. c. [12 minims] of a lactic acid solu- tion of O'Ol per cent ; with 0'6 c. c. [9 minims] of the same solution the color is pale yellow ; but no yellow color is recognizable on adding only 0*3 c. c. [4|- minims]. Unfortunately, this test is not en- tirely free from sources of error, since lactates as well as free lactic 34 DISEASES OP THE STOMACH. acid produce tlie yellow color. This, however, does not mak^ much diiference, for it is immaterial to us whether free lactic acid or lactates are present ; we simply wish to ascertain the presence of lactic acid in the stomach. But the reaction can also be caused by alcohol, sugar, and certain salts, especially phos]3hates, which are frequently found in the contents of the stomach. If I add to Uifelmann's reagent some phosphate, as for example a little phos- phate of soda in solution, you will notice a change to a canary- yellow color, which is, however, diiferent from the characteristic tinge ; but if the stomach-contents have a yellowish hue of their own, then the resemblance may be very close. Under such cir- cumstances we are compelled to resort to a modification of the method used by chemists — i. e., we must make an ethereal extract of the fluid to be examined, then evaporate it and apply the reac- tion on the residue left after evaporation. This method is very simple, as I shall now show you. I have here a gastric juice with an acid reaction, which gives a marked yellow color with UfEelmann's reagent, but which shows no reaction for free acid with tropseolin ; we must ascertain whether the yellow color is due to traces of free lactic acid or lactates or acid salts. Lactic acid may easily be extracted with ether from solutions of O'YS to 0"5 per thousand ; hence, if free lactic acid be present, the aqueous solution of the residue left after evaporating the etliereal extract ought to react acid. First, we extract with ether. We may do this by using a so-called " separatory funnel " {Scheidetrichte^'), or more simply by thoroughly shaking about 2 to 5 c. c. [3 ss. to 3 jss.] of the stomach-contents with ether ; let the ether separate, which usually occurs very rapidly, and pour it off into a small glass beaker. This is repeated with fresh portions of ether till we have used, all told, about 30 c. c. [f § j] of ether. The ether is then evap- orated without an open flame by placing the glass beaker in a vessel of hot water. Add a few drops of water to the residue, and with this try UfEelmann's reaction by carefully letting one or two drops of the reagent flow from a pipette. The reagent and the substance to be tested must always bear a definite relation to each other. If we add too much, the reaction might be concealed. Thus, this might have been the reason why Cahn, of Strassburg, FATTY ACIDS— ACETIC ACID— ALCOHOL. 35 could not at first corroborate my statements of tlie occurrence of lactic acid in the digestion of meat. The residue left in our test is acid, and gives a distinct Uffelmann reaction. The fact that there is no reaction for free acids with tropseolin shows how much more delicate Uft'elmann's test is than tropaeolin. Whereas no free acid could be detected with tropseolin because it was con- cealed by acid salts, and, even then, the quantity of free acid was very small, yet it was absolutely demonstrated with Uffelmann's reagent.* The fatty acids, and especially butyric acid, change Uffelmann's reagent to a tawny yellow color with a reddish tinge ; but this oc- curs only when they are present in over 0"5 per thousand [1 in 2,000]. Fat in the stomach-contents may be easily recognized by the small oily particles which are to be found in the aqueous solu- tion of the residue left after evaporating the ethereal extract. The butyric acid, which is present in this same aqueous solution, may be separated in the form of oily drops by adding some small pieces of calcium chloride. The best practical test for acetic acid is the nose. If present in considerable quantity, its odor is unmistakable. It may be detected by neutralizing the watery residue of the ethereal extract with car- bonate of soda and then adding neutral ferric chloride solution. A beautiful blood-red color is struck, which can only be obtained by one other substance, formic acid, but this does not occur in the con- tents of the stomach. Finally, one other substance — alcohol — is to be mentioned ; it is to be found only in the rare cases of marked yeast fermentation in the stomach. It may be detected with the so-called Lieben iodo- form reaction in the distillate of the stomach-contents : but we must * [Leo also gives a not too complicated method for testing lactic acid and lac- tates. All the volatile acids are removed by boiling the stomach-contents till litmus-paper held over the vessel is no longer reddened. Replace the water lost by evaporation. After cooling, pour an equal quantity of ether and the specimen into a test-tube, close the opening of the tube, and shake thoroughly. After letting the tube stand vertically for a few minutes till the layers have separated, suck up the ether-layer with a pipette and put it into a watch-glass. Evaporate the ether; dissolve the residue in water. If lactic acid is present, it will give acid reaction with litmus or Congo-red, or show Uffelmann's reaction. — Leo. Diagnostik der Krankheiten der Verdauungsorgane. Berlin, 1890, S. 106. — Tr.] 4 36 DISEASES OF THE STOMACH. be certain tliat the patient has not taken alcohol for some time, either in beverages or medicines (tinctures, fluid extracts, etc.). I have constructed the following table to show the delicacy of the various reagents and the mutual relations and disturbing effects on the reactions of the acids, peptone, and salts. Detailed explana- tions are unnecessary, since I have already given all the necessary data in the early part of this lecture. Methyl-violet Tropseolin Smaragd-green Congo-red* GiJnzburg's reagent.. Boas's reagent Mohr's reagent Uffelmann's reagent. Reaction Positive in the Pbesencb op Hydrochloric acid, per thousand. 0-24 0-3 0-4 0-1 0-05 0-05 1-0 Lactic acid, per thousand. 4 Over 10 10 0-2 0-1 Butyric acid, per thousand. 5 to 6 Over 10 Over 10 0-4 0-5 All the above reagents give qualitative but not quantitative results. To obtain the latter, which are not essential in daily prac- tice, we are compelled to resort to complicated processes. At the outset the questions must be answered: first, whether the amount of free hydrochloric acid is to be estimated ; secondly, whether that of the loosely comhined hydrochloric acid (see above, page 28) — i. e., that portion of HCl which, although secreted by the gastric glands, has entered into combinations with bases or or- ganic substances ; and, finally, whether the total quantity of HCl is to be ascertained. As has already been repeatedly stated, under normal conditions every time food is introduced into the stomach there is so abundant a secretion of hydrochloric acid that not alone are all of the above-mentioned affinities satisfied, but there is even an excess (the free HCl). Under pathological conditions free HCl is not infrequently absent ; it must then be determined whether any of it has been produced in the stomach at all, or whether it has only been insufficient in amount. Thus the quantity of free hydro- * HOsslin i}.oc. cit.) gives 0-02 as the lowest limit, but I agree with Boas (Deutsch. med. Wochenschr., 1887, No. 39) that a distinct blue color of the Congo paper first occurs when the proportion is as above. ESTIMATION OF HYDROCHLORIC ACID. 37 chloric acid may vary under different conditions ; lience tlie neces- sity of ascertaining its amonnt. Estimation of Free Hydrochloric Acid. — This may be done ap- proximately in the absence of other acids (especially lactic and fatty acids) by converting the acidity found by titration into that of HCl (see page 23), Mintz's method ^ is more exact ; deci-normal soda solution is added [from a burette] to 10 c. c. of the filtered stomach- contents till Giinzburg's reaction no longer occurs / here the quan- tity of alkali corres]3onds to the amount of free hydrochloric acid which is present. Mintz has estimated the limits of the Giinzburg reaction to be 0'036 per mille HCl (i. e., 1 c. c. deci-normal soda solution to 100) ; he has also demonstrated by special experiments that even in mixtures of albuminous substances and hydrochloric acid the alkali combines first with the free HCl. For example, if the Giinzburg reaction no longer occurs after adding 1*3 c. c. deci- normal soda solution to 10 c. c. stomach-contents, and is still posi- tive when only 1*2 c. c. of the soda solution have been added, then the amount of free HCl, as calculated for 100 c. c. stomach-con- tents, equals 13 c. c. deci-normal soda solution (i. e., 12 -|- 1) ; this represents 0*047 per cent HCl. f Estimation of Loosely Combined Hydrochloric Acid. — It is evident that in this way by reversing the process we can ascertain the amount of loosely combined hydrochloric acid in stomach-contents containing no free hydrochloric acid. A deci-normal hydrochloric- acid solution is added to this kind of stomach-contents till Giinz- burg's reaction is positive. ]l^ow, since the limit of this reaction is 0*036 HCl = 1 c. c. Y^o normal soda solution, then the difference between this and the amount of r^^ normal HCl solution repre- sents the quantity of combined hydrochloric acid which was present. For example, if Giinzburg's reaction was positive after adding 0*7 c. c. jig- normal HCl solution to 100 c. c. stomach-contents, then 1 — 0*7 = 0*3 c. c. is the amount of acid which was already present. * S. Mintz. Eine einfache Methode zur quantitativen Bestimmung der freien Salzsaure im Mageninhalt. Wiener klin. Wochenschrift, 1889, No. 20 ; and 1891, No. 9. t [13 X 0-003G46 (1 c. c. -^ normal soda solution = 0-003646 HCl) = 0-047398 per cent HCl.— Tr.] 38 DISEASES OP THE STOMACH. Boas * and Morner have soniewliat modified this method ; the stomach-contents are extracted with ether, and the hmits of the re- action are then determined with Congo-red, either in solution or as test-paper [10 c. c. of stomach-contents are extracted with 100 c. c. ether]. If the former is used, 5 c. c. of a watery solution are added to an equal quantity of the filtrate of the stomach-contents; the mixture is titrated with ^^ normal soda solution till the blue fluid assumes a red color. The number of cubic centimetres of the soda solution added at once indicates the quantity of free hydrochloric acid which is present. Another method is that suggested by Leo ; f this is based upon the fact that calcium carbonate is not decomposed by acid phos- phates, but with free hydrochloric acid it forms a neutral solution of calcium chloride. The Estimation of Free and Loosely Combined Hydrochloric Acid. — The best practical method is that of Sjoqvist, :{: as modified by Salkowski.* If a mixture of organic acids and free or loosely com- bined hydrochloric acid be treated with barium carbonate, evapo- rated to dryness, and then reduced to ash, all the CI combines as barium chloride, which is soluble in hot water. The organic acids are decomposed and form barimn carbonate, which is insoluble in water. From this solution, which may also contain inorganic chlo- rine compounds, the barium chloride is precipitated as barium car- * Boas, Centralblatt fur klin. Med., 1891, No. 2. [Also Boas's Diagnostik, etc, p. 134.— Tr.] ■f Leo. Eine neue Methode fiir Salzsaurebestinimung im Mageninhalt. Cen- tralblatt fiir die med. Wissenschaft., 1889, No. 26. [This method is carried out as follows : Moisten a strip of blue litmus-paper with gastric contents and keep this as a standard. A few drops of stomach-con- tents are put in a watch-glass, and a small amount of powdered, chemically pure calcium carbonate added ; stir up with a glass rod and test the reaction with blue litmus-paper. Compare this with the standard. If the, litmus-paper no longer red- dens, then the acidity was entirely due to free acid, and not to acid salts ; if it is less red, then both were present ; if there is no change, then there are only acid salts, while free acids are absent. If the stomach-contents have previously been extracted with ether to remove lactic and fatty acids, then, if free acid is found, it is hydrochloric acid, — Tk.] X Sjoqvist. Eine neue Methode freie Salzsaure im Mageninhalte quantitativ zu bestiraraen, Zeitschrift fiir physiologische Chemie, 1888, Bd. siii, S. 1. * Fawizky. Ueber den Nachweis und die quantitative Bestimmung der Salz- saure im Magensaft, Virchow's Archiv, Bd. cxxiii, S. 292. sjOqvist'S method. 39 bonate by adding soda ; it is collected on a filter and is once more converted into BaCl, by adding liydrocliloric acid. The excess of hydrochloric acid is removed by evaporation to dryness; the dry residue, which has a neutral reaction, is dissolved in water, and the BaClj is titrated with silver nitrate with the addition of potassium bichromate. One c. c. of the silver solution represents O'OOl sodium chloride, and the quantity of hydrochloric acid may be calculated according to the formula, x \ t ^ 36"5 : 58'5, in which t = number of cubic centimetres of the silver solution used. Accordingly, the examination is carried out in the following way : Ten c. c, of the filtered stomach-contents are mixed with about 0"5 gramme barium carbonate in a platinum capsule ; the fluid is then evaporated to dryness and reduced to ash. After cooling the residue is dissolved by adding 50 to YS c. c. boiling water and fil- tered. Several drops of a concentrated soda solution are added to the filtrate [until the entire BaClg is converted into BaCOg, which is thrown down as a flocculent precipitate]. Again filtration ; the precipitate on the filter is collected and washed, and then dissolved in IICl and evaporated to dryness. The residue is dissolved in water and titrated with the silver nitrate solution as stated above. The various manipulations in this test require a considerable length of time, yet the actual labor is not great ; it is not as compli- cated as the modification proposed by von Jaksch,* in which the barium chloride is converted into barium sulphate and weighed as such. Unfortunately, recent investigations by von Pfungenf and Leo :j: have shown that Sjoqvist's method is not free from sources of error, since the presence of large quantities of phosphates or sodium chloride may interfere with the accuracy of its results. However, if the quantity of these substances in the test-meal be re- stricted as far as possible, in spite of this disadvantage it is never- * Von Jakseh. Sitzungsberieht der Akademie der Wissenschaften in Wien, Bd. xcviii. [Also von Jakseh. Klinisehe Diagnostik. Translated by Cagney. p. lOl.J f Von Pfungen. Ueber den quantitativen Naehweis freier Salzsaure im Magen- safte nach der Methode von Sjoqvist. Zeitschrift fiir klin. Med., Bd. xix, Supple- mentheft, S. 224. :]: Leo. Beobaehtungen zur Saurebestimmiing im Mageninhalt. Deutsch. med. Wochenschrift, 1891, No. 41. 40 DISEASES OP THE STOMACH. theless the best and most reliable method for estimating the quan- tity of hydrochloric acid combined with organic substances and that in a free condition. A process which is even more complicated is that proposed by Hay em and Winter.* In a measured quantity of stomach-contents these investigators estimate : a. The total chlorine. h. The total chlorine minus that portion which is volatilized after prolonged heating at 100° C. c. The fixed chlorides combined with mineral bases. From these it follows that — a — h ■= free hydrochloric acid. 5 — c = hydrochloric acid combined with organic bases and ammonia. « — c = (a — 5) -j- (5 — c). Hence each trial of this method requires three determinations of the amount of chlorine ; in other words, many hours would be needed for the examination of a specimen of stomach-contents. The question arises whether the practical value of the result will repay one for the labor expended. In my opinion, this is not the case, because it is of no importance to know the quantity of chlorine combined with mineral bases, or the absolute amount of hydro- chloric acid in combination with organic bases. It will be sufii- ciently accurate to know these values as ascertained with the com- bination of the methods of Sjoqvist and Mintz or Boas. * Hayem et "Winter. Du Chimisme Stomacale. Paris, 1891, [See Amer. Jour- nal Med. Sciences, September, 1891, p. 282.— Tr.] LECTURE II. METHODS OF EXAMINATION (continued). DETERMINATION OF THE DI- GESTION OF ALBUMEN AND STAECH. ABSORPTION AND MOTILITY. THE TECHNIQUE OF THE EXAMINATION OF THE STOMACH. Gentlemen : The action of the digestive ferment pepsin on albumen is manifested by a series of characteristic derivatives — the albuminates — concerning which I shall now speak. In passing I wish to call your attention to the various well-known forms in which pepsin is artificially prepared by different manufacturers. I show you here a fine, dust-like powder, scales or lamellae, and also so- called granules. Each of these preparations bears a label indicating its digestive powers — i. e., the amount of albumen which is dis- solved by one part of pepsin. I shall, however, refrain from pass- ing judgment upon the relative value of these preparations, since it always varies according to the care in the manufacture. First one factory, then another, heads the list ; yet, taken all in all, the activ- ity of these preparations does not vary much. Some years ago I examined and compared all of the various preparations,* but I do not know whether these results are valid to-day. f The essence of the digestion of albumen consists in the well- known transformation of the various kinds of this substance, of which I shall only mention the more important varieties — Qgg-, serum-, and plant-albumen, fibrin, and casein — into a soluble and easily diffusible form, peptone. In another place :|: I have already * Ewald. Zeitschr. fur klin. Med., Bd. i, S. 236. f [Recently an excellent preparation has been put upon the market in the form of Fairchild's glycerin of pepsin ; it is essentially a glycerin extract. It may be administered with dilute hydrochloric acid, and thus constitute an artificial gastric juice. It is also free from the disagreeable odor of many of the old pepsin products, and keeps indefinitely. The dose is from 5 to 30 drops. — Translator.] X Ewald. Klinik der Verdauungskrankheiten, I. Theil, 3te Auflage, S. 92, etc. 42 DISEASES OP THE STOMACH. given an exact description of this change, and to-day I shall restrict myself to the practical deductions from the facts known to ns. You know that between albumen at the beginning and peptone at the end of the process of albuminous digestion there exist certain inter- mediate bodies which are collectively known as the albumoses. Of these we are concerned only with syntonin, the product of neutrali- zation, and propeptone or hemialbumose. Now the question arises. What significance have these bodies in the processes of digestion, and by what tests may they be recognized ? 1. Temperature. — Fluid albumen and syntonin coagulate on warming — i. e., heating to about 70° C. [158° F.]. Propeptone and peptone are not coagulated by heat. If propeptone is precipitated from its solutions in the cold and is then heated, the precipitate re- dissolves, but is again deposited on cooling. Temperature has abso- lutely no influence on peptone. 2. Biuret Reaction. — If cupric sulphate is added to propeptone and peptone in an alkaline solution in the cold, an intense purple- red color is observed, the so-called biuret reaction. If caustic pot- ash and dilute cupric sulphate are added to ordinary albumen and syntonin without warming, a more or less marked bluish-violet color is struck, which at all events may often be confounded with the biuret reaction. I have here a solution of peptone ; I add some caustic potash, and then a little dilute cupric sulphate ; you will ob- serve a deep purple-red color, which is distinctly different from this bluish-violet color obtained in a similar way with a solution of pure albumen. The same is true of propeptone, as I can show you with this solution of Kemmerisch's meat peptone. 3. Precipitation. — Albumen and syntonin are precipitated by saturated solutions of sulphate of soda or common salt in an acetic- acid solution, hot or cold. Syntonin is precipitated from acid solu- tions as soon as it is neutralized. Propeptone in neutral solution is precipitated in the cold by a saturated solution of common salt or rock salt on adding strong acetic acid ; it is soluble when heated. However, a portion remains in solution, and can only be precipi- tated by the addition of ammonium sulphate in substance or in concentrated solution. Peptones are not precipitated by the above nor by the following reagents which throw down albumen, syntonin, REACTIONS OF ALBUMEN, ETC. 43 and propeptone : cold or warm nitric acid, acetate of lead, acetic acid with ferrocyanide of potash, metaphosphoric acid, ammonium sulphate. The behavior of the above-mentioned substances may be seen at a glance in the following tables : Coagulated by heat ; ( Albumen. ) P^-ecipitated by saturated solution of sulphate ,. ^'. iQi- rof soda or common salt and acetic acid, no bmret reaction. J byntonin. l ,, V ! cold or warm. Not coagulated by r p , ^ Precipitated cold by saturated solution of heat ; biuret re- < ' I common salt and strong acetic acid. action. ' Peptone. ' Nitric acid, acetic acid. Acetic acid and ferrocyanide of potash. Acetate of lead. Metaphosphoric acid. Ammonium sulphate. Mercuric chloride. "] Phosphotungstic acid. 1 Phosphomolybdic acid. }■ Precipitate peptone. Tannin. I Mercuric iodide. J Precipitate albu- men, syntonin, < and propeptone. 'Now, what are the practical deductions from these results ? If gastric juice containing pepsin and hydrochloric acid be al- lowed to act on albumen, after a certain time the specimen ought to contain the various modifications of albumen, and, according to the nature and strength of the gastric juice, some or all of them ought to be present. The results of such an examination will give us an indication of the intensity of the digestive processes in the stomach. Accordingly, we first test whether the stomach-contents are coagu- lable by heat. If they are, albumen or syntonin, or both, may be present ; if not, we may find propeptone or peptone. If the reac- tion is acid, and coagulation occurs on heating, we must neutralize. Should a precipitate be thrown down, it is syntonin. If this is filtered out and an equal quantity of concentrated common-salt solution is added to the filtrate, and then acidulated with acetic acid, any pre- cipitate thrown down which is redissolved on heating is due to propeptone, and the biuret action must be positive. The latter pre- cipitate is also removed by filtration ; the filtrate is treated with acetic acid and ferrocyanide of potash ; if no precipitate is obtained, and if the biuret test is jDositive, and if, furthermore, precipitates 4,4: DISEASES OP THE STOMACH. are thrown down by tannin or tlie salts of tlie heavy metals, or by phosphotungstic acid, etc., then peptone is present. Such would be the method of conducting an examination. But the question naturally arises. What is the practical value of such a demonstration of the various transformation-products of the diges- tion of albumen, and what conclusions can be drawn in regard to the pathology of the cases in question ? It is a peculiar fact that as soon as the digestion of albumen has begun as the result of the action of pepsin and hydrochloric acid, the biuret reaction may be obtained in a very short time. This may be due either to pro23e]3tone or peptone. Let us, therefore, briefly consider the relations of i)roiye2)tone to digestion. Is it absorbed as such, or is it simply a necessary preliminary stage of peptone % Concerning the former we know nothing ; of the latter we can at least say that propeptone seems to be a very frequent but by no means a constant transformation-product in the digestion of albumen by pepsin and hydrochloric acid. On the other hand, by the simple action of hydrochloric acid upon albu- men at the temperature of the body, syntonin as well as propeptone may be obtained. Since propeptone will give the biuret reaction as well as peptone, the simple application of this test, as has been done heretofore, will give no positive proof of the presence of peptone. The best way is to precipitate the propeptone. As the result of investigations conducted in my laboratory, Dr. Boas * has shown that propeptone is absent in the digestion of meat, but is present in the digestion of plant albuminates and pure egg-albumen. Hence it is by no means an essential transformation- product of albumen. ISTevertheless, its demonstration is important, since it is always present in the ordinary mixed diet, and the amount of it bears some relation to the energy of digestion. But, after all, our main object is to ascertain the rapidity of the peptone forma- tion ; this could be most readily accomplished by making a quanti- tative estimation of the amount of peptone formed during diges- tion. Unfortunately, up to the present time w^e possess no simple * I. Boas. Beitrage ziir Eiweissveidauung. Zeitschr. fiir klin. Med., Bd. 13, Heft 3. RELATIONS OF PROPEPTONE. 45 and reliable metliod for tliis ; * and even if we did, it is question- able wlietlier j)athologically we would derive any benefit from it, since tlie formation of peptone rapidly reaches its maximum and then appears to be kept steadily at tliat point by special means. Yet this is by no means proved. According to our present knowledge, it is of considerable value to determine and estimate quantitatively not alone the final but also the intermedi- ate products at any given stage of the digestion of albumen. The demonstration of propeptone is valuable for this purpose. The more marked the propeptone reactions are, the less the pep- tone which has been formed and eventually removed from the stomach. ]^ow we have found that in an ordinary diet, containing an abundance of plant albuminates, and after the test-breakfast, the di- gestion of albumen has progressed so far within an hour that propep- tone is present only in traces, or usually is not to be detected at all ; whereas in abnormally slow digestion it is still abundant at that period. We may also approximately estimate the amount of peptone by the intensity of the biuret reaction, provided we always use the same quantities of stomach - contents, caustic pot- ash, and cupric sulphate, and compare it with the reaction given with a peptone solution of known strength. But it has been ob- served that the biuret reaction is equally intense where at the same time there is either no propeptone or where the amount of the lat- ter is very variable. In other words, just as Cahn f found in the digestion of meat in dogs, the formation of j)eptone remains at a cer- tain percentage, or is kept at that figure by the removal of the peptones over that amount ; in such cases the only guide to the rapidity and amount of the transformation of the albumen is the amount of propeptone formed or still remaining, l^aturally there are also cases in which the peptone formation does not reach the normal height, being thus entirely insufiicient ; for this reason it is advisable to make the test for propeptone even where the amount of peptone is apparently normal. However, according to recent * [See Boas. Diagnostik, etc. 3. Aufl., p. 24.— Te.] f A. Cahn. Die Verdauung des Fleisches im normalen Magen. Zeitschr. fiir klin. Med., Bd. 13, Hefte 1 und 2. 46 DISEASES OF THE STOMACH. investigations made by Dr. Gumlicli and myself,* the formation of true peptone in the human stomach is only slight, and for the most part the transformation of albnmen does not go beyond the albumoses. At all events, after the test-breakfast, as well as after larger meals, albumoses predominate in the stomach-contents, and these having been precipitated by ammonium sulphate, the biuret reaction is feeble and much less marked than this reaction was before the albumoses had been removed. Let me give you a practical example of the use and value of the above : I have here the filtrate of the stomaeh-coutents of a ship-chandler from H., who has been under my observation for two years. There is a very strong suspicion of cai^cinoma of the stomach, yet no tumor can be demonstrated ; and although the patient apparently digests his food well, neither has disturbance of appetite nor complains about his digestion, yet he has emaciated progressively. Repeated examinations failed to show free hydrochloric acid in the gastric contents. In this filtrate, also, there is no free hydrochloric acid, although the reaction is acid and the biuret reaction is well marked. Let us now see whether the latter is due to peptone or propeptone. I neutralize carefully, add an equal quantity of concentrated common-salt solution, and then a little pure acetic acid. There is not the slightest trace of a turbidity ; hence no propeptone can be present. On the other hand, heating causes a slight coagulation of albumen. Thus this specimen has absolutely no free hydro- chloric acid, nor have repeated examinations in the past few years at any time revealed its presence ; and yet this gastric juice can form peptone, and, as it seems, in a fair quantity. You will remember that the produc- tion of peptone may occur in the presence of other acids, especially lactic acid ; f with Uffelmann's reagent I can show you large quantities of lactic acid in this specimen. Hence this case proves that pepsin may be secreted or formed by the gastric glands independently of hydrochloric acid, as I have already shown in another patient, and as Cahn has demonstrated in dogs which have been deprived of chlorides in their food. J The most striking feature of the pepsin and hydrochloric acid digestion is the liquefaction of the solid albumen {proteolysis). The intensity of this process may be estimated approximately by noting how quickly coagulated albumen is liquefied. We may do this by adding small pieces of coagulated albumen or fibrin to the filtered * Ewald and Gumlich. Berl. klin. Wochenschr., 1890, No. 44. t Ewald. Klinik der Verdauungskrankheiten. I, Theil, 3. Auflage, S. 110. X Ewald. Ein Fall von Atrophia der Magensehleimhaut. Berliner klin. Woch- enschr, 1886, No. 32. — Cahn. Die Magenverdauung ini Chlorhnnger. Zeit- schrift flir physiolog. Chemie, 1886, Bd. x. PROTEOLYSIS. 47 contents of the stomach, and observing the rapidity of their liqne- faction at the temperature of the body. Coasulated white of egg; is cut into thin lamellae with a double section knife [Valentine's knife], and uniform disks are cut out with a cork-borer or some similar instrument with a round, hollow cutting edge. [A short piece of glass tubing will do.] By preserv- ing these disks of albumen in glycerin they are ready for use at any time. In order to determine in a given specimen of stomach- contents whether the pepsin or hydrochloric acid is present in too great or too small amount, an equal quantity of the filtered s^Deci- men is placed in four small test-tubes and one or two disks of albu- men put into each. To the first nothing else is added ; to the second, enough hydrochloric acid to make a solution of about 0"3 to 0*5 per cent ; this is accomplished by adding two drops of hydro- chloric acid (Ph. Germ.) * to 5 c. c. [f 3 ji] of stomach-contents. To the third we add a definite quantity of pepsin, about 0'2 to 0*5 gramme [gr.iij to gr. vijss.] ; to the fourth add both hydrochloric acid and pepsin. The test-tubes are placed in an incubator kept at about 100° Fahr. ; from time to time we look to see how far the liquefaction of the disks of albumen has proceeded. The rapidity of this liquefaction will at once inform us whether digestion would have occurred without having added anything, or whether acid or pepsin or both were necessary. Furthermore, it will also inform us if by adding more hydrochloric acid to the filtered gastric juice we have made the acidity too strong. In this way we can judge which factor is at fault. But we must not forget that after the amount of peptone has reached a certain percentage its further production is retarded, or even suspended, so that an apparently slow reaction may be really due to a very active gastric juice. In this, as in all laboratory experiments on digestion, we must never forget the great difference between them and the natural processes, and that in our flasks and test-tubes we can never imitate the ab- sorption on the one hand, and the removal to the intestines on the other, by which the stomach strives to maintain a fairly uniform * [Acidum hydroehloricum of the German Pharmacopoeia is somewhat feebler than that of the U. S. Pharm. ; the former has 25 per cent pure anhydrous acid, the latter 32 per cent. — Tk.] 48 DISEASES OF THE STOMACH. degree of concentration of its contents ; hence all our tests are fundamentally deviations from Nature, and are thus to a certain degree pathological. Glinzburg * and Sahli f have proposed another method to ascer- tain the rapidity and intensity of the digestion of albumen and fibrin. A small quantity of potassium iodide, 0*1 to 0*2 gramme [gr. jss. to iij], is inclosed in a gelatin capsule or gelatin - coated pill or in a thin gum packet fastened with a string of fibrin ; if the drug is introduced into the stomach in one of these ways, the iodide is liberated, and can be absorbed only after the envelope of fibrin has been digested. The length of time required for the appear- ance of the potassium iodide in the saliva or urine is said to indicate the thoroughness of gastric digestion. [See p. 52.] Unfortunately, not alone is the absorption of potassium iodide very variable, but also the rapidity of the digestion of the fibrin capsule does not bear any direct relation to the presence of free hydrochloric acid in the stomach ; for in some cases this occurs as rapidly in the absence as in the presence of this acid. Therefore, this method also is not adapted to give reliable data concerning the digestive activity of the stomach. The gastric glands secrete not alone pepsin but also rennet {Labferment), which causes the coagulation of milk. Its presence may be detected by taking a small quantity, 10 c. c. [f 3 ijss.], of boiled milk having a neutral reaction, and adding an equal amount of carefully neutralized filtered stomach- contents ; the mixture is then placed in an incubator at 100° Fahr., and, after a short time, 10 to 15 minutes on an average, the milk has coagulated and sepa- rated into a cake of casein and clear serum. [Leo X ^^ses 10 c. c. of raw milk, and only 2 to 5 drops of stomach-contents. On account of the relatively small quantity of the latter, neutralization of the mixture is unnecessary. Eaw milk is used because it coagulates * Gunzbui-g. Ein Ersatz der cliagnostischen Mageiiaushebermmg. Deutsch. med. Wochenschr., 1889, No, 41. f Sahli, Ueber eine neue Untersuchimgsmethode der Verdauungsorgane iind einige Resultate derselben. Correspondenzblatt der schweizer Aerzte, 1889, p. 402, and 1891, p. 136. X [Leo. Diagnostik, etc., 1890, p. 119. For quantitative tests for rennet, and also literature on this subject, see Boas, loc. ciL, pp. 26 and 164.— Tr.] RENNET. 49 ten times more rapidly than cooked milk. "Witli this modification it occurs from one minute to several hours after being placed in the warm chamber. The coagulation by rennet is the character- istic cake of casein floating in clear serum, and is not to be con- founded with the flaky or lumpy coagulation by acids.] The rennet ferment or enzyme {Ldbenzym) exists also in a pre- liminary stage as a pro-enzyme or rennet zymogen {Lcibzymogen) ; this itself has no action upon milk, but by adding acids, especially hydrochloric acid, and also calcium chloride while warm, it is converted into the typical ferment. This will become evident in the filtrate of a gastric juice which either has no spontaneous coag- ulating action or in which the ferment has been destroyed by add- ing an alkaline carbonate. If this filtrate be digested with dilute hydrochloric acid, or if a 5-per-cent calcium-chloride solution be added, it will curdle milk. In the stomach, while fasting, and at the beginning of digestion, the zymogen is only found, but later both it and the ferment are present. An acid reaction or the pres- ence of free acid in the original filtrate of the stomach-contents is not absolutely necessary for the curdling action of rennet, since it has been demonstrated Avhen free acid was absent, or even when the reaction was neutral. Among the various investigations on rennet in human beings I would call especial attention to the works of Eaudnitz, Boas, Johnson, Klemj)erer, and C. Rosenthal.* Digestion of Starch, and Sugar. — You will remember that in the organism starch is converted into grape sugar (dextrose) by the action of the salivary ferment, ptyalin, and that cane sugar, as shown by Leube, is changed into invert-sugar, a mixt- ure of cane and grape sugar. We know that this sugar fer- * Eaudnitz. Ueber das Vorkommen des Labferments ira Sauglingsmagen. Prager med. Wochenschr., 1887, No. 24. — Boas. Labferment und Labzymogen im gesunden und kranken Magen. Zeitsehr. fiir klin. Med., Bd. 14, S. 249. — Johnson. Studien iiber das Vorkommen des Labferments, etc. Ibid.,' S. 240. — Klemperer. Die diagnostischer Verwerthbarkeit des Labferments. Ibid., S. 280. — C. Rosenthal. Ueber das Labferment nebst Bemerkungen iiber die Production freier Salzsaure bei Phthisikern. Berl. klin. Wochenschr., 1888, No. 45. [The result of these investi- gations is that rennet, like pepsin, is a constant constituent of the gastric juice ; its absence indicates atrophy of the gastric mucosa ; otherwise it has no practical sig- nificance. Leo, Joe. cit., p. 120. — Tr.] 4 50 DISEASES OF THE STOMACH. ment exists not alone in the saliva, but also in small quantities in very many tissues, and probal)ly also in the mucus which is usually sparingly secreted in the stomach. It was formerly supposed that ptyaliu acted on the amylaceous substances only in the mouth during mastication. At all events, the transformation of starch into sugar by ptyalin occurs very rapidly indeed ; yet this would not suffice to allow the ferment to act thoroughly on the more or less compact masses swallowed. The saliva which is swal- lowed continues its action on the amylaceous substances even in the stomach, as has been shown by von den Yelden.* The only ques- tion is. How long does this process continue ? We know that pytalin acts best in neutral or feebly alkaline solutions, but is checked in acid fluids. It has been shown that the formation of sugar ceases as soon as the amount of acid (reckoned for hydro- chloric acid — a point of vital importance to us) reaches O'Ol per cent or more ; but in smaller quantities the action of the ferment is even somewhat accelerated (Chittenden), With lactic acid the acidity must be much higher, namely, 0*1 to 0*2 per cent, and with butyric acid or fatty acids may be even higher than this, up to 0"4 per cent. But, as first shown in pigs and horses by Ellenberger and ITofmeister,f and in human beings by Ewald and Boas, the simple taking of raw starch will cause the secretion of hydro, chloric acid, to which is later added the lactic acid produced by fermentation. This naturally occurs also in a mixed diet with amylaceous substances. As normally the acidity of the stomach- contents gradually becomes more marked as more hydrochloric acid is secreted, we will hence observe an initial stage in which starch is still converted into sugar ; but gradually the process becomes feebler, and finally ceases entirely. Thus the conversion of starch into sugar is not a simple uniform process, but, like the digestion of albumen, there are intermediate products, the dextrins and maltose.:}: * R. V. d. Velden. Ueber die Wirksamkeit des Mundspeichels im Magen. Deutsch. Arch, fiir klin. Med. Bd. 25, S. 105. f Ellenberger undHofmeister. Arch, fiir wissensch. und prakt. Thierheilkunde, viii, S. 395, and xii, S. 126.— Pfliiger's Archiv, Bd. 44, S, 484. X See Ewald. Klinik, etc., 1. Theil, 3 te Auflage, S. 55 et seq. Also a detailed account in Ewald : Ueber die Zuckerbildung im Magen und Dyspepsia acida. Berl. klin. Wochenschr., 188G, No. 48. DIGESTION OF STARCH AND SUGAR. 51 The two important varieties of dextrin are erythrodextrin and acliroodextrin. Maltose is to a certain extent an intermediate body between starcli and dextrin on tlie one band, and grape sugar on tbe other. Starch is recognized by the familiar deep-blue color struck with iodine or a mixture of iodine and potassium iodide — i, e., Lugol's solution : lodi O'l [gr. jss.] Potass, iodidi 0'2 [gr. iij] Aq. destillat 200-0 [f I vj 3 vj] This reaction becomes less marked in proportion to the amount of starch converted into dextrin and sugar. A solution of ery- throdextrin, as its name indicates, no longer gives a blue color, but purple ; solutions of acliroodextrin, maltose, or dextrose assume no other color than the yellow of the iodine solution. The latter substances have a closer relation to iodine than dextrin, and the latter again more than starch ; hence, in a mixture of these bodies, the first drops of iodine solution added cause either no color at all or only a transitory one, and it is only after adding more iodine that the purple of erythrodextrin or the blue tinge of starch is observed. As was shown by von Mering in laboratory experiments, and by myself on human beings, in the transformation of starch into sugar by ptyalin, the smaller portion only is converted into dex- trose, the greater into maltose. The latter passes on into the intes- tines, where it is changed into dextrose (Brown and Heron). The practical result of these conditions is the following : If the amylaceous transformation proceeds normally in the mouth and stomach, after a time, within an hour at least, so much starch has been changed into achroodextrin, maltose, or dextrose that the ad- dition of small quantities of Lugol's solution to the filtered stomach- contents no longer produces any changes of color. The occurrence of a purple (erythrodextrin) or a blue color (starch) shows that the sugar transformation has been incomplete. This may be due either to a deficiency of ptyalin or to a too rapidly increasing acidity or an original hyperacidity of the stomach. If, then, we should be unable to titrate the gastric contents — 5 52 DISEASES OF THE STOMACH. supposing, for example, that we had only a very small quantity — such a result would of itself indicate a hyperacidity of the gastric juice. But under such circumstances we might also suspect a de- ficiency of ptyalin in the saliva, and hence a normal acidity of the stomach. Yet this does not appear to be the case. For a long time I have tested the fermentative power of saliva in patients with dental caries, inflammatory lesions in the mouth, angina, diph- theria, carcinoma of the tongue, and similar conditions, but never have I found a saliva which could not convert starch into sugar ; yet I must not fail to add that no quantitative examinations were made. It appears that saliva does not lose any of its ferment, but pepsin seems now and then, although very rarely, to be absent from the gastric juice. Sugar may always be found in the stom- ach-contents after the test-breakfast, since a certain amount is con- tained in it. There are still two factors to be discussed — the dbsorptive power of the stomach and its 'motor functions — two points which have recently been underestimated because they have been overshadowed by purely chemical examinations. Absorption by the gastric mucous membrane is tested with potas- sium iodide. Penzoldt* recommends giving it in small doses of O'l gramme [gr. jss.] in capsules which have been carefully wiped oif , so that none of the drug adheres to the outside of the capsule. A capsule is taken, and the moment iodine appears in the saliva is determined by means of the well-known reaction with starch paste. Filter-paper is moistened with starch paste and dried ; after the cap- sule is taken, from time to time, say every five minutes, a little of the patient's saliva is placed upon the dried filter-paper. Then by adding some fuming nitric acid (one or two drops) the appearance of a blue color will indicate exactly when the iodine appears in the saliva. I^ormally this occurs in ten to fifteen minutes ; but in processes where absorption by the stomach is slow or fails entirely, this reaction occurs much later, being delayed a half to a whole hour or even longer. At my request. Dr. Boas investigated this * Penzoldt und Faber. Resorptionfahigkeit des menschlichen Magens. Berl. klin. Wochenschr., 1882, No. 21. MOTILITY OP STOMACH. 53 subject ; his results, as well as those of many others and myself, agree in confirming them, and I must therefore contradict the statements of J. Wolff", and regard periods of absorption of one to one and a half hours as decidedly pathological. Consequently, this procedure offers us a simple means of determining the absorptive powers of the stomach. [See also p. 48.] Another question is. How can we test the motility or motor function of the stomach? The determination of the normal peri- stalsis and proper movement of the ingesta in and expulsion out of the stomach is very important ; for a number of observations which have recently accumulated indicate more and more that a stomach whose chemical functions are more or less altered may nevertheless — I will not say completely, but almost so — fulfill its digestive duties, so that this deficiency in the chemical processes may be compensated by the motor function, and hence may effect the expulsion of the chyme from the stomach at the proper time. I have had under my observation for three years a foreign gen- tleman whose stomach - contents I have examined several times yearly, and yet have never been able to detect free hydrochloric acid and pepsin. He goes to Kissingen every summer, feels toler- ably well, eats large dinners, pursues his occupation ; and yet I must confess that without exception hydrochloric acid and pepsin -have been absent in every test made at various intervals after eating different kinds of food, both the test-breakfast as well as larger meals. Dr. L. Wolff and myself * have published analogous cases, and recently I have had a similar experience in a female patient upon whom gastrotomy was performed for carcinoma of the oesoph- agus. From this we may infer that under certain circumstances the secretory function of the stomach is not essential to maintain life providing that the lesion in the stomach does not of itself imperil life by a general intoxication, but that under these conditions the intestinal digestion seems to vicariously assume the entire burden. This is plausible, since the chemical processes of digestion are doubly provided for : two secretions digest starch — i. e., saliva and * L. Wolff undEwald. Ueber das Fehlen der freien Salzsaure ira Mageninhalt. Berl. klin. Wochenschr., 1887, No. 30; and Ewald, ibid., 1887, No. 49, Verhand- lunsren des Vereins fiir innere Mediein. 54 DISEASES OP THE STOMACH. tlie pancreatic juice ; albumen may be peptonized at two places, the stomach and intestines ; and fats may be emulsified by the pan- creatic juice and bile. The intestine is thus capable of acting vicariously for the stomach, if necessary. Similar conclusions have been reached by other writers. But Jaworski has gone to extremes in maintaining that the chemical functions of the stomach play a subordinate part, and that the stomach is nothing more than a store- room and warming-place where the food may enter and be admitted to the intestine as through a sluice. This is a wild speculation, which brings us back to the old Hippocratic doctrine of the coctio cihorum, the cooking of the food by the animal heat. Salol Test. — Up to recent times we had no suitable method for de- termining the motor function of the stomach. Leube's proposition to estimate the duration of digestion — i. e., to determine after a defi- nite average time of six to seven hours after a large meal, or two to two and a half hours after Ewald's test-breakfast, whether solid con- tents were still to be found in the stomach — is subject to too many physiological variations to permit any reliable deductions. And the great practical objection is that it requires the use of the stomach- tube. Absorption as well as motion is involved. For the separate determination of the latter I have proposed the use of salol.* Salol is a compound of phenol and salicylic acid — a phenol ether of salicylic acid which, according to Nencki, is not changed by acids but is converted by the action of the pancreas into salicylic acid and phenol. Supposing this to be true, salol would be a splendid means of determining not alone how rapidly substances pass from the stomach into the intestine, but also whether the action of the pan- creas is normal — a subject which is still enveloped in darkness. With these premises. Dr. Sievers, of Helsingfors, and myself under- took a series of observations which showed that salol is decomposed by relatively feeble alkaline fluids, but that it is not decomposed wdien introduced into the stomach or when mixed outside of this viscus with acid stomach-contents or artificial digestive mixtures with pepsin and hydrochloric acid. The splitting up of salol into * Sievers und Ewald. Zur Pathologie und Therapie der Magenectasien. The- rapeutische Monatshefte, August, 1887. SALOL TEST. 55 salicylic acid and plienol, and the appearance in the urine of sali- cyluric acid, the product of the decomposition of salicylic acid, will indicate that the salol has actually passed out of the stomach. formally, salicyluric acid will appear in the urine, 40 to 60, at most Y5 minutes after taking one gramme [gr. xv] of salol, which has been given preferably during the course of digestion. Hence delay in its appearance will indicate a retardation in the passage of food into the intestines. Salol is a white, tasteless powder which is easily administered ; it is given in capsules ; gelatin-coated pills might also be used, but these sometimes pass unchanged through the intestines, and pills may easily remain an abnormally long time, or at least for varying periods, in the folds of the gastric mucous membrane. The great advantage of salol resides in the fact that it is thoroughly mingled with the stomach-contents and certainly par- ticipates in their movements. Salicyluric acid is easily recognized in the urine by the violet color produced on the addition of neutral ferric chloride solution. To detect the earliest trace of it, acidulate the urine with hydrochloric acid and extract with ether ; the salicyluric acid combines with the ether, and may be easily de- tected in the ethereal extract. A simple method is to place a drop of urine on a piece of filter-paper, and then let a drop of a 10-per- cent ferric-chloride solution fall upon the moistened spot on the filter-paper. The edge of the drop will assume a violet color in the presence of even the smallest trace of salicyluric acid. These pa- pers may be dried and preserved, and in this way one may easily compare the reaction in the same patient at various times. Unfortunately, in this method the time of the decomposition of the salol depends on the occurrence of the neutral or alkaline reac- tion of the intestine ; even under normal conditions this may vary, since i|; depends on the changeable reaction of the chyme and the quantity of bile and pancreatic juice which reaches the intestines. We (Sievers and Ewald) thought that we could exclude this source of error by having empirically calculated the above average length of time ; and, in fact, in the great majority of our experiments this period, 60 to 75 minutes after taking the salol to the beginning of this reaction in the urine, proved to be constant. But this con- stancy has been questioned by other observers. For this reason 56 DISEASES OF THE STOMACH. Huber* has estimated the time wliich elapses from the taking of the salol to the complete disa23pearance of the reaction in the urine. In healthy persons this excretion lasts 24 hours ; in patients with enfeeblement of the motor functions of the stomach it lasted 48 hours, or even longer. Yet even here it is impossible to definitely ascertain how much of this time is due to tardy movements of the stomach, and how much to delayed intestinal absorption. How- ever, Silberstein,f unlike Pal and Decker,+ has obtained favorable results with this method ; in 26 cases of gastric dilatation and in 12 cases of atony of the muscular fibers of the stomach the excretion of salicyluric acid lasted till the second day — i. e., 30 hours or more. The condition of the bowels, diarrhoea or constij)ation, appeared to exert no influence, although a py^iori this would seem to be very improbable ; for in diarrhoea the intestinal contents are certainly evacuated more rajjidly ; hence the salol passes through the intes- tines much more rapidly than under normal conditions. To carry out Huber's test, one gramme [gr. xv] of salol is given, and the urine is examined 24 to 30 hours later. If salicyluric acid is still present at the latter period, or even later, we may with tolerable cer- tainty infer a disturbance of the muscular activity of the stomach.* An objection was raised that although the salol might not have been decomposed in the stomach, yet it could have been absorbed as such, enter the blood, and be altered there and then be excreted. This argument has been disproved by the following experiment : We took a dog, placed double ligatures about the pylorus, and then gave the animal some salol ; three hours later the dog was killed, and up to that time not a trace of salicylic or salicyluric acid could be detected in the urine. This is an absolute proof that salol is not absorbed by the stomach. * A. Huber. Zur Bestimraung der motorischen Thatigkeit des Magens. Munch, med. Wochenschr., 1887, No. 19. f Silberstein. Deutsch. med. Wochenschrift, 1891, No. 9. X Pal. Ueber die Verwerthung der Salolspaltung zu diagnostischen Zweeken. Wiener klin. Wochenschr.. 1889, No. 48. — Decker. Zur Prage des diagnostischen Werthes des Salol s bei motorischen Insufficienz des Magens. Berl. klin. Wochen- schrift, 1889, No. 45. * [Recently a death has been reported from the use of this method. See Lon- don Lancet, May 23, 1891. Such an accident must be regarded as a very rare event. — Tr.] OIL TEST.— BILE. 57 Oil Test. — Klemperer * lias proposed another method for deter- mining the motor activity of the stomach. He pours a definite quan- tity, 100 c. c. [f ^iij 3ij], of pure ohve oil into the empty stomach which has previously been washed out, if necessary ; two hours later the stomach is aspirated, and whatever oil is left is removed as thoroughly as possible, till only an insignificant trace remains. The difference between the original quantity of oil and that aspirated is used by him as an indication of the motor function of the stom- ach. However, even Klemperer himself admits that this method can' not be always used in general practice, because it is complicated and objectionable to patients. He simply proposes to use it to discover certain typical forms of motor insufficiency which are of themselves so characteristic that, having once demonstrated them by the oil method, its further use would be unnecessary. The fu- ture will show how far this object will have been accomplished ; at all events, his results thus far concerning the influence of certain drugs upon the movements of the stomach agree very well with the con- clusions arrived at with the salol method. Finally, I must state that bile may be detected in the contents of the stomach by the greenish tinge it imparts, or by Gmelin's test. It is also characteristic of biliary pigment that the bright yellow debris left upon the filter upon filtering the stomach-contents after the test-breakfast, and especially that portion at the edge of the filter, assumes a greenish tinge by oxidation after prolonged exposure to the air. This concludes the various chemical methods of examination of the diseased stomach. Their significance in the diagnosis and treat- ment of the diseases of the stomach will be distinctly stated on all occasions in the following discussions. As far as I am free from an overestimation of these methods, as you have already observed in my opening remarks, so sure, nevertheless, am I that in the future we may confidently expect many valuable additions to our stock of knowledge from the field of investigation just inaugu- rated. * Klemperer. Ueber die motorische Thatigkeit des menschlichen Magens. Deutsche med. Wochenschr., 1887, No. 47. 58 DISEASES OF THE STOMACH. The physical methods of examination, the second great group of our diagnostic aids, I can only speak of here in so far as they have a direct bearing upon the examination of the stomach, or are con- nected with it in some peculiar manner. Moreover, in the descrip- tion of the various diseases, I shall have many opportunities to speak of percussion, auscultation, inspection, etc., so that I shall now restrict myself to the following technical factors or aids. [See pages 172 et seq?^ 1. Palpation. — Of all the various means of examining the ab- dominal organs this is undoubtedly the most important. Whoever can palpate well, and has a delicate sense of touch, possesses an advantage in diagnosis which is not to be overestimated. Natu- rally there must always be a combination of the tactile impression and the mental process which will enable the observer at that par- ticular moment to draw upon the whole range of his experience and to use it upon the case in question ; or, to use a figure of speech, which will enable him to look through the abdominal walls and direct his fingers. For exam23le, the great clinician von Frerichs, who possessed a marvelous certainty and skillfulness in palpation, was certainly greatly aided by this. But a proper technique is very important here, and, as I so often see erroi'S committed and examinations rendered difficult and uncertain, I shall be pardoned if I call attention to several very well known points : Never pal- pate with the hand held perpendicularly or obliquely to the abdomi- nal wall ; gradually and carefully go deeper by small rotatory movements in a horizontal plane. Place your hands flat upon the abdomen, and only press down gradually and with very gentle pressure by bending the end phalanges. In this way we not alone prevent the contraction of the abdominal muscles whose edges have caused errors and uncertainty in even very experienced clinicians, but we also obtain a much better perception of the site, size, and form of any peculiar conditions beneath the abdominal wall ; and, finally, last but not least, we cause a minimum of discomfort and pain to the patient. Here the same considerations are true as in percussion. As is well known, differences of tone which are per- ceptible with gentle percussion are overlooked when it is forcible. It is hardly necessary to state that under certain circumstances firmer DISTENTION OF STOMACH WITH AIR. 59 pressure may be needed in jDalpation, and a stronger stroke may be required in percussion, yet such cases always have pecuHar features wliich distinguish them from the ordinary ones. Sometimes it may be of great advantage to supplement the palpation in the dorsal and lateral posture by examining the patient in the knee-elbow position. Movable tumors will then sink against the anterior ab- dominal wall, and may be recognized as such. 2. Distention of the Stomach and Intestines with Air. — The method of distending the stomach with carbonic-acid gas generated in loco was introduced by von Frerichs, and since then has been in general use. Yon Ziemssen,* following the American method, applied it also to the intestines by administering per rectum bi- carbonate of soda and some organic acid ; we may also employ carbonic - acid gas already generated outside of the body — for ex- ample, from an inverted siphon of mineral water (Schnetter).f These methods suffer from the disadvantages that we have no con- trol over the amount of gas produced after the salts have been introduced into the stomach or intestines, that disagreeable ac- companying symptoms frequently arise from the irritation of the carbonic-acid gas upon the walls of the stomach or intestines, and that, even though varying quantities of gas are needed for different persons, the degree of tension produced can not be regulated at will nor increased at a given moment. For these reasons it is better to use the method recently recommended by Runeberg,;}: which has long been used by Oser* and myself, and which con- sists in introducing a stomach or rectal tube, and then insufflating air with the double bulbs of a spray apparatus. Frequently there are also other good reasons for introducing the tube in a given case, and this does away with any objections against a special passage of the tube with its accompanying inconveniences, although the latter are really too insigniiicant to have any weight. Runeberg says cor- * V. Ziemssen. Die kiinstliche Gasaufblahung des Dickdarms zu diagnostisehen und therapeutischen Zweeken. Deutsch. Arch, fiir klin. Med., Bd. 33, S. 235. f Schnetter. Zur Behandlung der Darmverschliessungen. Deutsch. Arch, fiir klin. Med. Bd.. 34, S. 638. X "W. Runeberg. Ueber kiinstliche Aufblahung des Magens und des Dickdarms^ durch Einpumpen von Luft. Deutsch. Arch, fiir klin. Med., Bd. 34, S. 460. * Oser. Die Neurosen des Magens. Wien, 1885, S. 10. 60 DISEASES OP THE STOMACH. rectly : " In endeavoring, for example, to estimate exactly tlie size and situation of a markedly dilated stomacli it is by no means an easy task to obtain a suitable degree of distention by generating carbonic-acid gas. On the other hand, this may be very conven- iently and easily accomplished by this method of pumping in air." The same is true of the intestines, especially of the transverse colon. Any excess of air pumped in escapes alongside of the tube, or is easily expelled by a reactive contraction of the stomach as soon as the patient experiences a marked tension of that viscus. In using carbonic-acid gas the reverse usually occurs, since the irrita- tion of the gas causes a spasmodic contraction of the cardia, so that the patient must exert himself more vigorously to expel it ; fur- thermore, the pylorus may relax more readily than the cardia, and the gas may then pass on into the small intestines. I have never observed the condition described by Ebstein as insufficiency of the pylorus, in which the gas generated in the stomach passes rapidly into the duodenum ; I believe that conditions in which the pylorus is not relaxed at first, but only during the generation of the carbonic- acid gas, are due to the causes above mentioned. It is true Schiitz * has had just the reverse experience of observing the air pumped in escape rapidly into the intestine, but it seems to me that this was an exceptional case, which does not agree with the experiences of Oser f and of myself. Insufflation of the stomach and intestines may be combined. Recently Behrens :|: called attention to the value of the latter method for detecting tumors which might be present in the abdominal cavity. According to my own experience, the quantity of air to be pumped in through the rectum is very varia- ble, and the same is true of the distinctness with which the dis- tended coils of intestines may be seen. I have always been struck by the amount of air which could be pumped in through the anus without again escaping, providing, of course, that there is no marked accumulation of fseces. Where the latter exists, and in strictures * E. Schiitz. Wanderniere iind Magenerweiterung. Prag. med. Wochenschr., January 14, 1885. f Oser. Die Ursachen der Magenerweiterung. Wiener med. Klinik, 1881, S. 4. (, X 0. Behrens. Ueber den Werth der kiinstlichen Auftreibung des Dickdarms \ nit Gasen und mit Fllissigkeiten. Gottingener Inaugural Dissertation. Helm- siaJ^-it, 1886. THE DEGLUTITION-MURMURS. 61 and stenoses of the lower portion of the intestine, the air is soon expelled, together with foul-smelling gases. This feature was strik- ingly illustrated in a recent case of compression of the descending colon by a neoplasm. 3. Distention of the Stomach with Water. — A somewhat similar but less convenient idea was embodied in the j)lan proposed by Piorry, but made especially well known by Penzoldt* to deter- mine the site of the lower border of the stomach by filling that viscus with water. As water sinks to the lowest part of the stom- ach, in a sitting or standing posture, a large quantity of fluid intro- duced into the organ will indicate the course of the greater curva- ture by a curved line of dullness with the convexity downward — providing that the transverse colon contains air ; and by pouring in and siphoning out larger quantities, about one litre [quart], we will prevent mistaking it for neighboring organs, tumors, etc., having a dull percussion note. Further details concerning this method, and also a modification proposed by Dehio, will be dis- cussed while speaking of dilatation of the stomach. 4. The Deglutition - murmurs {SchluchgerdusGhe), as diagnostic aids. At another place f I have spoken of the nature and character * Penzoldt. Die Magenerweiterung. Brlangen, 1877. f Ewald. Klinik der Verdauungskrankheiten, I. Theil, 3te Auflage, S. 67 to 70. [As these murmurs are quite frequently referred to in the following pages, this brief extract of the author's views as to their nature and origin has been added. At the beginning of swallowing a murmur is propagated from the pharynx into the (Esophagus ; this sound has no significance whatsoever. The true murmurs are the Durchspritzgerdusch and the Vurchpressgerdusch. Ewald thinks it much better to call them simply the first and second murmurs respectively. The fir'st murmur (Spritzgerduseh) occurs almost immediately after the beginning of deglutition, and is a hissing sound as if the fluid were being directly squirted into the stethoscope Some time after, usually six to seven seconds, the second sound {Pressgerduscli) is heard ; this is a series of tones rapidly following one another, either gurgling, cluck- ing, sprinkling, or splashing. These murmurs are heard only near the cardia ; the best site is just below the xiphoid cartilage ; this at once distinguishes them from the sounds transmitted from the pharynx, which may be heard all along the oesophagus. The first sound is only heard rarely ; its occurrence is said to denote a relaxation of the cardia, and the direct passage of the food into the stomach ; the second is quite constant, and is absent only when the first is heard. Its nature is not so evi- dent : some (Kronecker) claim that it is due to the audible vibrations of the cardia which are caused by the passage of the food over it ; others (Zencker, Quincke, Ewald, Dirksen) assert that it is simply a result of the pressing through of the air which has been swallowed with the food. 62 DISEASES OF THE STOMACH. of tliese murmurs, and shall simply say here that they give no positive indications in the diagnosis of gastric diseases. Meltzer* claimed that the so-called Schluckgerdusch- wn.^ due to a relaxation of the cardia, and occurred as a specific symptom of old syphi- lis, phthisis accompanied by mild vomiting, neuroses of the cardia, etc. The inconstancy of the phenomenon was shown by Dirksen f and myself. I have never observed any constant and characteristic change in the intensity or quality of these murmurs, either in para- lytic spinal lesions or dilatation of the stomach, or in any other condition which at first sight might seem to include this phenome- non. On the other hand, tyjjical and of diagnostic value is the absence of the deglutition-murmurs in complete or almost complete closure of the cardia, whether the obstruction be above or below the cardia. Yet this negative proof must be determined positively by repeated examinations, since the murmur is now and then ab- sent in healthy persons. 5. Another method of examination requiring a few words is that inaugurated chiefly through the labors of Mikulicz — gastroscopy, or the direct visual examination of the mucous membrane of the stomach with a specially adapted instrument, the gastroscoj>e. Un- fortunately, the simple mention of this author's name almost ex- hausts the literature of the subject, for the instrument, as con- structed by Leiter (of Yienna), is so expensive and at the same time so difiicult to manipulate, unless both patient and physician have been well trained, that its use has been very limited. The results which Mikulicz :}; obtained in carcinoma of the pylorus are of diag- nostic interest. In the normal stomach the pylorus appears as a long slit or a triangular, oval, and often a circular opening, surrounded by a ring of bright-red folds and projections of mucous membrane, which are in active motion and show an infinite number of changes These sounds were first mentioned in 1864 by Natanson, and were carefully studied by Zencker and also by Meltzer. The literature of the subject may be found in Ewald, loc. cit., p. 92. — Tr.] * Meltzer. Schluckgerausche im Scorbiculus cordis und ihre physiologische Bedeutung. Centralbl. f. d. med. Wissenseh., 1883, No. 1. f H. Dirksen. Beitrag zur Lehre von den Schluckgerauschen. Inaug. Dissert., Berlin, 1885. X Wiener med. Wochenschrift, 33te Jahrgang, S. 748. TECHNIQUE OP LAVAGE. 63 of form. But in neoplasms at the pylorus tins region is smooth, pale, without the above-described folds and projections, and abso- lutely motionless. This would thus be a valuable aid in diagnosis, had not Pribram* reported a case of pyloric carcinoma — at all events, without gastroscopic examination, in which there were active movements of the tumor, i. e., a change in its size synchro- nous with active contractions of the whole stomach. The use of the gastrodiaphane has been suggested by Einhorn.f This instrument consists of a small electric light, which is introduced into the stomach ; the contours of this organ are outlined by the light shining through the gastric wall and the abdominal parietes. Whether this procedure will be of any practical value must be determined by experience. Similar experiments were made on animals as long ago as 1867 by Milliot. The Technique of the Treatment of Stomach Diseases. — Of the numerous methods from time to time proposed for washing otit the stomach or irrigating its mucous metnhrane, the best is the simple siphon method, concerning which we may speak as of the ex- pression method, simplex veri sigilluin. A glass funnel is attached to the free end of the stomach-tube by means of a piece of rubber tubing about one metre [one yard] \ long, and by alternately raising and lowering the funnel the stomach may be filled or emptied. The simple siphon action is all that is needed, since, with very few exceptions, we can undertake the operation at a time, or after such meals, when tliere is no danger of having the openings of the tube plugged ; and even if small pieces of meat and similar substances are aspirated into the eyelets, they can easily be dislodged by holding the funnel high up. I consider it entirely irrelevant whether we use a continuous stream with a double-current tube or * Pribram. Zur Semiotik des Pyloruscarcinoms. Prager med. Woehenschr., 1884, S. 53. f M. Einhorn. Die Gastrodiaphanie. New-Yorker med. Monatschrift, Novem- ber, 1889. [The instrument is condemned by Boas, loc. cit., S. 100. — Tr.] X [A small piece of glass tubing, the caliber of which is somewhat smaller than that of the stomach-tube, is very convenient for connecting the latter with the tubing attached to the funnel ; through it we may also see the nature of the fluid raised from the stomach, and can also readily determine when it comes up perfectly clear. — Tr.] 64: DISEASES OP THE STOMACH. whether we fill and. empty the stomach alternately ; if anything, I prefer the latter, since the rapid raising and depressing of the fun- nel agitates the fluid in the stomach more forcibly, and mucus and other solid substances caught in the folds of the mucosa may be more easily removed mechanically. I prefer to use a large glass funnel of about two litres [two quarts] capacity, with a diameter of 20 centimetres [8 inches] ; this is attached to a rubber tube of suitable length, which is joined to the upj)er end of the stomach- tube [by a small piece of glass tubing]. The funnel rests in a wood- en frame (Fig. 4) on the floor [or table], and is here filled with the requisite amount of water or other fluid used, and is then raised to a height suitable to obtain the amount of pressure desired. The water escapes from the various open- ings in the tube, as from a sprinkler, so that, by gradually withdrawing the tube a little, the various portions of the stomach may be successively irrigated. To siphon the water out of the stomach, the funnel is again placed in the wooden frame, and thus any foreign substances that may be present may rise in it, and can be obtained for exam- ination if desired. If one is alone, this technique is much more convenient than to work with a small funnel. For consultation practice out of the office, I use a small hard-rubber funnel of about 300 c. c, [f | x] capacity. Siphonage of the stomach by elevating and depressing a funnel can not be done by the patient alone. Yet, in many cases, it is essential that the patient should wash out his own stotaach ; the Fig. 4.— Stand toi holdiug funnel of stomach-tube. AUTO-LA VAGE OF STOMACH. 65 first requisite is, of course, to learn to introduce the tube himself, a manipulation which most patients acquire very readily. Here, too, the simplest method will suffice. For siphonage, the following will be found to be convenient : One extremity of the horizontal portion of a glass T-tube [c, Fig. 5] is connected with the stomach- tube [(*], the other extremity is joined to an irrigator by means of a soft-rubber tube [d], a hard-rubber stop-cock * intervening ; to the free end of the vertical portion is at- tached a rubber tube [^] about one metre [one yard] long. The patient sits near the irri- gator, which has previously been filled and placed at a suitable height ; the tube is introduced into the stomach while the stop-cock is kept closed, and the open end of the rubber tube [^] from the vertical piece of the T-tube is compressed with the fin- gers of one hand. With the other hand he then opens the stop- cock after the tube is in the stomach, and then allows a sufficient quantity of fluid to pass into the stomach. As soon as he feels the distention the stop-cock is closed, and the fingers are taken off the vertical tube ; this allows the fluid to be siphoned from the stomach. By repeating this the stomach may be filled and emptied as often as desired. Many patients become very skillful, and often do not know when to stop, so that finally they may even abuse it. Numbers of such cases can be found reported, es^^ecially in French literature. Electricity may be applied to the stomach, either by placing Fig. 5. — From Peppei-'s System of Medicine (after Leube) — Tk. * [This is not essential ; it may be replaced by a pinch-cock placed on the tub- ing (d) ; it will also be found convenient to have one upon e. — Tr.] 66 DISEASES OF THE STOMACH. botli electrodes on the anterior abdominal wall or by introducing one of them into the stomach and closing the current by means of another electrode upon the abdominal wall, the latter electrode, according to well-known physical laws,* having as large a cross- section as possible. The electrode which passes into the stomach usually consists of a copper wire whose lower end bears a leather- covered knob, while the wire itself has been passed through a stom- ach-tube. To screw on the knob, the wire must possess a certain thickness, but this renders it stiff and unpliable. This may be obvi- ated by a preliminary hammering of the wire in the fire, which ren- ders it so soft and supple that it will assume any curve desired. I usually cover it with a piece of ordinary rubber tubing of small cali- ber. The patient drinks one or two glassf uls of water before intro- ducing the electrode, or, in cases of marked dilatation, the stomach may be filled through a tube. Einhorn f has recently devised a very useful electrode. It consists of an ovoid perforated hard-rubber capsule about the size of an almond ; within is a button electrode which is connected with a very delicate wire covered with a very fine rubber tube. The accompanying drawing (Fig. 6) represents Fig. 6. — Deo-lutable stomach-electrodo. the instrument in its natural size. The method is as follows : " The patient drinks, best while fasting, one or two glasses of water ; after opening the mouth widely the capsule is placed far back on the * Vide C. Rieger. Grundriss der medicinischen Eleetricitatslehre. Jena, 1887. f Einhorn. New Method for Direct Electrization of the Stomach, New York Medical Record, May 9, 1891, p. 530. [Also Therapeutic Results of Direct Elec- trization of the Stomach. New York Medical Record, January 30 and February 6, 1892. — Stockton. A New Gastric Electrode, ibid., November 9, 1889 ; Clinical Results of Gastric Faradization, Amer. Jour. Med. Sciences, July, 1890. Both faradaic and galvanic currents may be employed ; the latter being especially indi- cated for the relief of gastralgia and nervous vomiting, the positive pole being in the stomach. — Tr.] ELECTRIZATION OF STOMACH. 07 root of tlie tongue, and the j)atient is told to swallow. He again drinks some water, and the electrode finds its way into the stomach without further assistance." The circuit is closed by means of a flat electrode placed upon the abdomen. But, since many persons can not swallow the capsule, or, if swallowed, it frequently stays in the oesophagus, I have drawn the wire through a somewhat larger rubber tube, something like a Nelaton catheter, number 13. This small instrument can be readily introduced in the same way as a stomach-tube, and yet is delicate enough to be readily tolerated for some time in the mouth or stomach. I am very well satisfied with this method of using the electrode, and have obtained very satisfac- tory results which I shall discuss later on. Yon Ziemssen* con- siders this intraventricular method of electrization inadequate be- cause the electrode always reaches only the left part of the greater curvature, since the direction of the axis of the oesophagus to the left deviates it into this direction — i. e., to the left iliac region — and hence a uniform action upon the entire organ is impossible ; and, further, even disregarding this, the procedure is very tiring and exhausting for feeble patients. But it is known that, by filling the stomach wath water, the current is distributed in all directions, and acts upon the walls of the viscus so far as they are under water ; and as to the jDOSsible feebleness of the jDatients, the method may nevertheless be used, and is used on robust persons as a rule. Yon Ziemssen's experience in this field must date from a time when the entire local treatment of the stomach had not reached its present perfection, and consequently all these procedures must have been more tedious and exhausting than they are to-day. The entire digestive tract may be electrized by having one elec- trode in the stomach and the other in the rectum, the electrode being introduced after having cleansed the intestines with an ene- ma. Schillbach f tried this method on rabbits without observing any effect, but, as it appears, neglected the preliminary cleansing of the intestines. In several cases of atony of the bowels, combined * Von Ziemssen. Ueber die physikalische Behandlung chronischer Magen- und Darmkrankheiten. Klinische Vortrage. xii. Leipzig, 1888. t E. Schillbach. Stndien liber den Einfluss der Electricitat aiif den Darm. Virchow's Archiv, Bd. 109, S. 284. 6 68 DISEASES OF THE STOMACH. ■with a moderate dilatation of the stomach, I have obtained surpris- ing results, but in others none whatsoever. A series of investigations has already been made to show the possibility of influencing the stomach with the electric current ; for example, von Ziemssen and Caragiosiadis,* Bocci,f and others. Ac- cording to these observations, the external application of the elec- trodes causes only moderate contractions, which are of very doubtful therapeutic value ; the constant current produces nothing more than a localized contraction. The induced current, especially when it is applied directly to the mucous membrane, is more powerful, and may cause the secretion of gastric juice or mucus, as Bocci has shown on a dog with a gastric fistula. Yon Ziemssen :}: says that in dogs the direct passage of a powerful current of both kinds increases the secretion of gastric juice. Regnard and Loye* observed the same thing in an executed criminal whose vagi were stimulated by an electric current forty-five minutes after his death. The experi- ments conducted by Sievers and myself || showed positively that fara- dization of the abdominal wall with a strong current and broad, flat electrodes has a decided effect on the stomach. In many persons on whom the salol test (see page 54) was tried for this j)urpose, it was found that the reaction in the urine occurred earlier than usual, and hence the salol must have been carried on into the intestines more rapidly as the result of more powerful contractions [of the stomach]. There is a good deal of clinical evidence of the beneficial effects of the constant, but more especially of the induced, current. Many reliable writers agree on this point, as Kussmaul, Leube, Fiirstner, Burkart, and others. Even Ziemssen claims good results from the percutaneous electrization of the stomach with large electrodes of about 500 to 600 square centimetres [about 80 to 100 square inches] area, and strong currents combined with a brief faradic brushing of the skin of the abdomen, chest, and back for two to three minutes. * Caragiosiadis. Die locale Behandlung der Gastro-ectasie mit dem elektrischen Strom. Inaug. Dissert.., Munich, 1878. f Bocci. Elettricita nello storaaco dell' animale e dell' uomo. Lo sperimentale, 1881, p. 561. X Von Ziemssen, loc. cit., p. 7. * Quoted by von Ziemssen, ibid., p. 7. 1 Loc. cit. ELECTRIZATION OF STOMACH. 69 As the result of tliis there is a feeling of warmth and invigoration, marked improvement of the appetite, and decidedly increased di- gestive activity. I can corroborate all this ; for example, patients with nervous anorexia frequently eat their food with relish and digest it fairly well immediately after the application of electricity. It must, unfortunately, be admitted that all such therapeutic proced- ures which may be complicated by other factors do not of them- selves prove much until we have the ocular proof of actually seeing the stomach contract under the influence of the electric current, especially as Pepper,* in a case of pyloric cancer with dilatation and visible peristalsis, could not increase the latter either with a fara- dic or a constant current, but could only cause a contraction of the abdominal muscles. Surely, by using Einhorn's stomach-electrode, or my modification of it, contractions of the muscular fibers of the stomach themselves must be obtained, and, as I have already stated, and as I shall discuss later on, excellent results have been obtained, especially in gastric dilatation. Baradui f has also obtained very satisfactory effects in stomach disorders from electrisation intra- stomacale and galvanisation d%i grand syvi^aihique an cou. At this place I might also speak of the gymnastics of the abdom- inal organs, especially of ')nassage and the hydr other apeutic proced- ures of the stomach / but, disregarding the simplest measures, like rub- bing with cold or gradually cooled water, compresses, and half baths and wet packs, with or without douches, the household remedies of hydrotherapy, as it were, the methodical treatment, especially when combined with electric baths, requires the direction of a specialist and apparatus which is only to be found and properly used in hydro- therapeutic establishments. I would also recommend the same in regard to massage, and, whenever it is possible, it ought only to be done by properly trained persons. Finally, these chapters on technique would be incomplete if I failed to state that the credit of having been the first to use the aniline colors for detecting free acids, especially hydrochloric acid, and to call attention to the clinical value of these reactions, belongs * Pepper. A Case of Scirrhus of the Pylorus, with Remarks on the Electrical Excitation of the Stomach. Philadelphia Medical Times, May, 1871. f Baradui. Journal de la Soc. scient., 1891, No. 10, p. 97. YO DISEASES OF THE STOMACH. to two Frenclimen — MM. Laborde and Dusart — who as long ago as 1874 published a paper on the Nouvelles recherches sur Vacide libre du sue gastrique. They first used aniline sulphate and lead peroxide, and later (1877) methyl-violet. This, having been ac- knowledged by von den Yelden * in 1879 and having never been contradicted, at once establishes the claims for priority recently put forth by Laborde.f * Deutsch. Arch, flir klin. Med., Bd. 23, S. 374. f Laborde. Les colorants appliques, etc. Bulletin general du Therap., 1887, 30 janv. LECTUEE III. STENOSES AND STEICTUEES OF THE CAEDIA. Gentlemen : Disregarding the obstructions situated liiglier up in the mouth, throat, and oesophagus, and the accidental swallowing of foreign bodies (bones, etc.) which become impacted at the cardia, and relegating them to the hands of the surgeon, we find that the entrance to the stomach — the mouth or cardia — may be obstructed in two ways, and the swallowed food thus more or less impeded in entering the stomach. These are (1) spastic contraction and (2) cicatricial tissue, more especially new growths at the site referred to. The latter are never exclusively limited to the ring of the cardia, but extend above into the oesophagus or below into the stomach. The symptoms to which these conditions give rise possess a great deal in common in spite of the most manifold causes which may produce them. The fundamental feature is the inability to convey the food which has been swallowed into the stomach, and from this obstruction to the introduction of food the other compli- cating phenomena are developed. In most cases the passage through the cardia is gradually oc- cluded. In the beginning there are times when absolutely no ob- struction to swallowing seems to exist ; while at others the patients distinctly feel that the food is retarded above the stomach, " that it lies like lead above the stomach," but that by repeated movements of swallowing, by waiting, and drinking, it may be forced past the narrowed spot into the viscus. At this time fluids and very soft foods do not usually cause any difficulty, but the obstruction is more marked the more consistent the food and the larger the morsels that are eaten ; for instance, if too large a piece of meat or the like be accidentally or hurriedly swallowed, it can readily cause a 72 DISEASES OF THE STOMACH. transient complete closure which will not even permit fluids to pass. Later on the intervals grow progressively shorter and finally disap- pear entirely, while the necessity of taking food in a fluid form be- comes continually greater, the choice of food continually more lim- ited. Then a new symptom appears in the form of regurgitation of the food, which is brought up unchanged except for the admixture of mucus or saliva ; for in the same degree that the obstruction at the cardia becomes greater and more marked, the masses which are swallowed must gather more and more above the opening, so that they can readily return, should the lower sections of the oesophagus be the seat of peristaltic contractions, or should they be compressed from without by coughing, etc. A further result is seen in the con- secutive dilatation of the oesophagus, which may appear the more readily since a slight congenital expansion is occasionally found in it close to the entrance into the stomach, forming what Luschka calls the " ante-stomach " ( Vormagen). Yet von Ziemssen and Zenker * rightly remark that this dilata- tion is by far not so frequently found as one would infer from the statements in the text-books. Of course, a great deal depends on what is understood by " dilatation " ; and if these authors speak of a case of ectasis of the oesophagus with a diameter of 5 centimetres [2 inches] in the widest part of the dilated portion, I can oppose thereto what I found in two out of three autopsies in cases of strict- ure of the cardia, in which the widest part of the oesophagus, situ- ated 5 centimetres [2 inches] above the cardia, measured 6*2 or pos- sibly 6 centimetres [2|- to 2f inches], while higher up the diameter was only 3 centimetres \1\ inches]. Neithsr of the cases impressed one in any way as important ectases of the oesophagus from the mere inspection of the anatomical preparations. Thus, as far as the space will permit, the ingesta collect in the oesophagus above the cardia till they irritate its walls to such an ex- tent that they are reflexly expelled by the pressure due to the strong efforts at coughing. These efforts at expulsion and vomiting, fol- lowing at first only after eating, may finally also appear between * Von Ziemssen und Zenker. Oesophaguskrankheiten, in Handbuch der Krank- heiten des chylopoetischen Apparates, i, p. 33. SYMPTOMS OP STENOSIS OF CARDIA. 73 meals without food having been taken immediately before. At first the regurgitation of food is mostly incomplete, since the oesophageal contents are forced up but a short distance and then sink down again after that jDortion which has in the mean time become fluidi- fied passes by the stricture. Later on this takes place in a more marked degree, and, as Brinton ^ says, it may be easily understood that since the oesophageal contents are compressed by the normal peristalsis which runs from above downward, a central core must escape above, just as this occurs under similar circumstances in the centrally perforated piston of a pump or syringe. The expelled masses consist of the unchanged ingesta mixed with mucus and saliva, in w^hich chemical examination completely fails to show the ]3roducts of gastric digestion. At times the spe- cific constituents of a neoplasm may be recognized under the micro- scope. Unless specially colored fluids (red wine, fruit - juices, strongly colored medicines, etc.) have been taken, the vomited mat- ter usually has a grayish-white or yellowish-gray color, without a trace of bile. I wish to call particular attention to this last point, for the absence of biliary coloring matters may be of the utmost im- portance in deciding whether we have to deal with oesophageal or gastric contents, a decision which at times may be very difficult. Exceptionally food which has been eaten at a previous meal is brought up, while none of that taken last, so far as it possesses characteristic constituents, is to be found. Since this is not a rare occurrence in diverticula of the oesophagus, and one which under the then existing circumstances can be readily explained, it might in such a case cause the diagnosis of diverticulum to be established or its presence to be suspected. In this connection 1 can refer to the autopsies made by me in two cases of stenosis of the cardia with dilatation, but without the formation of any diverticula, in which the condition described had been repeatedly observed, and conse- cjuently the question of the presence of a diverticulum was fi*equent- ly debated during life, but in which, as I have said, the oesophagus was entirely free from any such formation. Thus this condition can not be regarded as a positive diagnostic factor indicating an existing * W. Brinton. Lectures on the Diseases of the Stomach. London, 1864, p. 10. Y4 DISEASES OF THE STOMACH. diverticulum. It could only come into play in case of partial pervi- ousness of the stricture, in which certain articles of food could pass through more rapidly, while others would be detained there for a longer time. Another result of the obstruction to the passage of nourishment, and growing j_>«W 2^^^^'^'' with the increasing constriction of the cardiac orifice, is the disturbance and impairment of the nutrition of the patient, which finally leads to a marked degree of emaciation and weakness. We see groove-like hollowing of the abdomen, the epigastric and hypochondriac regions being specially retracted, and the pulsation of the aorta can be very plainly felt through the walls ; the muscles and fat w^aste away more or less ; the skin becomes pale, waxy, or, especially in the face, assumes the specific yellowish-green color of the cancerous cachexia. The eyes are sunken, the lips thin, the nose and cheek-bones become pointed and prominent. . The tongue usually has a thick white coat, and, despite careful cleansing of the mouth, a fetid odor emanates from it. The stools are small and tardy, and the faeces are hard, dry, and scybalous ; the urine is scanty, with few solid constituents — in one case I was scarcely able to find a trace of the chlorides — and toward the end of life now and then contains albumen. Pufiiness over the malleoli, and also slight oedema of the legs, usually appear toward the end of the disease. To be sure, the picture just drawn is very essentially influenced by the causative factor of the disease and by the constitution of the patient, especially in cases of spastic contraction, in which, although the resulting symptoms may be really severe and very marked, they do not as a rule lead to the most extreme consequences ; but even in organic stenosis of the cardia you will find that the patency of this orifice and the general bodily condition do not always correspond. I have repeatedly seen cases in which the stricture was very well marked, but in which the appearance and general strength were rela- tively favorable, even though the patients complained of having fallen off from their former condition. On the other hand, the can- cerous cachexia caused by carcinoma of the cardia, which is to be regarded as the result of constitutional intoxication, may reach a high degree without the presence of a correspondingly great nar- rowing of the cardia. It is a peculiarity of cancer of the cardia SYMPTOMS OF STENOSIS OF CARDIA. Y5 that the reaction upon the general system, so far as it is expressed by metastases, adenopathies, etc., is comparatively slight. Among the least frequent of the common symptoms appearing in the course of the disease are local or more diffuse pains. True cardialgia — i. e., marked cramp-like pain, with a definite localization in the epigastric region — does not occur ; and thus, too, the severe radiating pains which so often accompany carcinomatous or ulcera- tive processes of the stomach are almost always absent. Should they be present, they occasion the suspicion that the process is not limited to the cardia. Most frequently the patients complain of a slight burning or boring pain, or only of a feeling of pressure in the region of the ensiform cartilage. At times, and rather in the minor- ity of cases, this may be increased by pressure from without on the ensiform cartilage. As a rule, swallowing causes either no special increase of the pain or none at all. In one of my cases in which tlie carcinomatous neoplasm had invaded the retro-peritoneal tissues the patient complained of pain in the lumbar region. In many cases pain is entirely absent. I shall now present a case of stenosis of the cardia, and annex the discussion of diagnosis and therapy thereto : Mr. P., restaurateur, forty-eight years old, is a man of large and marked bony build. At a glance it is evident that he must lately, and in a comparatively short time, have lost considerable flesh. Not that his face has emaciated so much, but that his clothes undoubtedly were cut for a much stouter man. Indeed, he tells us that he has fallen off markedly only for the past ten weeks, because he has suffered from " stomach trouble," with constantly increasing severity. Without any warning a sensation was developed as if the food after eating were held fast in the region of the stomach " as if by a cork " ; this feeling disappeared only after he had emptied his stomach by vomiting. As I have said, in the begin- ning this took place only after a meal, but lately he has had to vomit even when he had not eaten anything. The stomach is more apt to retain fluids and very soft articles of food, but he is forced to vomit a portion even of these. The vomited masses have always been only slightly changed, and mixed with large quantities of tough mucus. No pain or belching. Appetite good. Bowels somewhat constipated, but easily regu- lated by cathartics. Lately a marked feeling of weakness has developed, and the patient spends the greater part of the day lying down. No family history of cancer. Father died of paralysis ; mother is still living. Physical examination of the gastric region in the patient is entirely negative; the abdominal walls are slightly retracted; percussion shows that neither the stomach nor the neighboring organs, liver, spleen, 76 DISEASES OP THE STOMACH. and intestines, are of abnormal size. Palpation is also negative regarding a tumor or any other abnormity in tbe abdominal cavity. The greater curvature apparently crosses the mid-line 2 centimetres [f inch] above the umbilicus. At the same time distention of the colon from the rectum, by means of the double bulb of a spray apparatus, shows that the transverse colon immediately appears as a swelling under the free border of the ribs; therefore, at any rate, no enlargement of the stomach can exist. The oesophageal sound passes with ease through the entrance of the oesopha- gus, and through its entire length; but after it is introduced 44 centi- metres [17f inches] it impinges upon a firm obstruction, just as if its point had struck against the bottom of a sack. This makes the patient force up a large quantity of a white, mucous fluid, mingled with single lumps of tough, glassy mucus. It produces no pain, occasioning rather severe choking by reflex irritation. All efforts to pass the sound further are fruitless, in spite of our using sounds of different calibers down to that of a goose-quill. No change is produced by varying the posture of the patient to the right or left side or to the knee-elbow position. While in the latter position I again palpated the abdomen, but was still unable to detect any abnormities. Examination of the fluid brought up, amounting to about 100 c. c. [f I iij], gives the following result : Eeaction with blue and red litmus- paper is neutral ; it gives a light burgundy-red color with iodine, contains sugar, and has a slight diastatic action ; salts of lactic acid present in minute quantities ; peptone and pepsin entirely absent. Even after acidu- lating the fluid, mixing it with albumen and heating, it possesses no digestive action. I here show you the test in question, in which the un- changed disk of albumen lies at the bottom of the test-tube, and with which the biuret reaction gives a negative result. Under the microscope, in addition to numerous starch graniiles which have been colored blue by the iodine, we find a few muscular fibers en- tirely intact, and numbers of fat-cells of various sizes. Eod-shaped ba- cilli are present in small numbers. On the other hand, we do not find any yeast-cells or sarcinae, or any cellular elements which might originate from a possible tumor. The patient tells us that about three hours ago he took some milk, and that some time before he had a small quantity of scraped meat. On auscultating in the infrasternal depression we can not hear any deglutition-murmurs, neither a first nor a second sound being pres- ent ; but by listening at the neck, after swallowing, we can distinctly hear the fiuid passing down without being able to appreciate the so-called " stenosis-murmur," which sounds as though the fluid were being forced through a narrow spot. Consequently there can be no doubt that we have to deal with a case of stenosis of the cardia, and a consecutive dilatation of the (Bsophagus ahove this. This is proved not only by the examination with the sound and the negative results of all exploratory proced- ures directed toward the stomach, but also by the results of the chemical examination. SOUNDING OP THE CESOPHAGUS. Y7 The distance to the cardia from the incisor teeth naturally va- ries with the height of the individual. The average figure is esti- mated to be 40 centimetres [16 inches], of which 15 centimetres [6 inches] include the distance from the incisors to the commence- ment of the oesophagus, 5 centimetres [2 inches] belong to its cervi- cal, 17 centimetres [6f inches] to its thoracic, and 3 centimetres [1^ inches] to its abdominal portion. I have repeatedly found much greater measurements, as high as -46 centimetres [18f inches] in toto. According to this, the 44 centimetres [I'Zf inches], for which dis- tance we introduced the sound from the incisors, would just repre- sent the length of the oesophagus, plus the mouth and throat, in a large man like our patient, and its point would be arrested just above the cardia. At this place I shall introduce a few practical points about the sounding of the aesophagus. For sounding the oesophagus we must use either the oesophageal sponge-probang, rigid sounds, or the tube. The first consists of a small sponge, about the size of a hazel-nut, fastened to a straight or slightly curved piece of whalebone. With this, if it be long enough — although, as a rule, the instrument-makers make them much too short — the oesophagus is swept out, as it were, the jDres- ence of any obstruction established, and possibly shreds of tissue caught in the meshes of the sponge and brought up for examina- tion. The objection to the instrument is that in patients who have a narrow entrance to the oesophagus, or in whom there is marked irritability of the constrictors, considerable force is needed both to introduce and to remove it from the oesophagus, for at times it is caught so tightly immediately at the entrance (or, in the other sense, the exit) of the oesophagus, or at a certain spot behind the larynx,* that an inexperienced person could be led thereby to assume an abnormal obstruction. It stands to reason that the sponge is not to be dry, but that it must be moistened and always thor- oughly cleansed and disinfected before it is used. I have already * Waldeyer. Beitragezur norraalen und vergleichenden Anatomie des Pharynx mit besonderer Beziehung auf den Sehlingweg. Sitzungsb. d. Akad. d. Wissensch. zu Berlin, Physik.-math. Klasse, 1886, 25 Febr. 78 DISEASES OF THE STOMACH. given you the necessary information concerning tlie technique of this manipulation on page 8 of the first lecture. The best oesophageal sounds are made of prepared catgut. They must be flexible, and are either bluntly pointed or provided with a tapering knobbed extremity. As advantageous as the latter seems to be in order to work its way through a stenosed or constricted spot, just so undesirable do these sounds prove, for the thinned por- tion above the knob is soon bent on repeated use. I never employ sounds which contain a wire or which consist only of whalebone, because they are too hard, or in the physical sense too elastic, and on account of the danger of perforation. We must have the various sizes of sounds at hand, preferably ISTos. 13 to 30 of Charriere's scale, so that if necessary we can employ progressively smaller sounds. It is to be regretted that the thinner the instrument is, the more do we lose the necessary feeling of resistance ; and when the sounds have only the diameter of a quill it is impossible to decide whether in a given case we are pushing the instrument on, or whether it has been bent or twisted like a corkscrew. For this rea- son alone the oesophageal or stomach tubes are preferable to the sounds, from which they diflier by being hollow and having an eye- let on either side of the tube above its blunt extremity. While they serve the same purpose for sounding, we can readily tell by pouring in fluid whether we have passed the constriction or are still above it, and this even with the smallest tubes. But they also possess the advantage that after we have succeeded in passing one through the oesophagus (no matter what the disease may be), w^e can immediately thereafter pour nourishing fluids into the stomach. This is an ad- vantage which is not to be underestimated, for it is often a matter of accident whether the tube glides into the stomach or not. For this reason, in sounding the oesophagus I invariably employ the so- called feeding-tube, with a funnel-shaped enlargement at the upper end, so that if necessary I can at once introduce fluid. Finally, the fenestrated tubes have another advantage in that the edges of the openings not infrequently shave off particles of tissue which would not have been caught in the sponge. As a matter of course, the soft-rubber tubes are not applicable for sounding the oesophagus or possibly for overcoming strictures, since a certain SOUNDING OP THE (ESOPHAGUS. 79 amount of rigidity is requisite for that purpose. Yet tlie soft tube, open at the lower end, has several times proved itself of advantage to me in cases of cancerous stricture, since particles of the neoplasm were forced into it by the patient's gagging or coughing when the tube was introduced as deeply as possible, and the point consequently either impinged upon the tumor or insinuated itself into the funnel- like constriction. Such particles had not become adherent at previ- ous attempts either to the sponge or to the rigid fenestrated sound. After this digression let us return to the further consideration of the results of the examination of our patient. Aside from the negative result of the physical examination, I consider the chemical examination of the masses brought up of the great- er importance because its re- sults may have enough weight to turn the scale in a doubtful case. The following case may serve as a proof of this : Mrs. S., sixty-two years old, suflPered with carcinoma of the stomach and liver. On passing the sound, she showed great simi- larity to the case we are consider- ing in regard to the resistance met by the instrument. Here, too, the sound struck an impassable bar- rier at the level of the ensiform j)rocess. Immediately above this I had the unmistakable impres- sion of having passed a constricted spot, and after this was overcome there followed the hissing sound of air escaping from the stomach. The cause of this resistance offered to the sound remained doubtful during life. The autopsy showed that a very large tumor growing up from the retroperiton£eum had encircled the cardia and had lifted the fundus of the stomach horizontally upward, so that to a certain extent two divisions of the stomach were formed, one horizontal and one vertical. The sound impinged upon the bottom of the former. In order that the condition may be more thoroughly comprehended, the accompanying illustrations (Figs. 7 and 8), made by me at the autopsy, are here inserted. Fig. 7.— Stomach of Mrs. S., died June 30, 1887. Side view, to show the- cardia and cul-de- sac surrounded bv the new growth. 80 DISEASES OF THE STOMACH. Similar conditions might also be present in our case, or, as Quincke * has shown, a kind of valve may be formed by an ulcer of the oesophagus, which would prevent the introduction of the sound. Fig. 8. — Stomach of Mrs. S. Front view, showing cancerous nodules on the anterior sur- face of the liver, the head of the pancreas, the cardia, and the retroperitoneal tissues. But while in that case the masses which came up through the tube always contained pepsin and several times also peptone, while they repeatedly showed a yellowish-green color due to admixture with bile, our case is absolutely negative in this regard. This is proof positive that they do not come from the cavity of the stomach. If according to these facts there can be no doubt about the exist- ence of stricture of the cardia, its nature and cause are not less posi- tively to be established. As I have already said at the commencement of this lecture, closure of the cardia may be caused in two ways: (1) By spastic cont/raction, and (2) hy cicatricial tissue or neojplasm situated either within or without the cardia. The former, the spastic contractions, which are always the result of a neurosis or of a reflex, consequently * Quincke. Klappenbildung an der Cardia. Deutsch. Arch, fur klin. Med., 1883, Bd. 31, S. 408. SPASMODIC STRICTURE OF CARDIA. 81 of a, purely functional nature, can in general be easily distinguished from the firm closure of the cardia by the following points : The contractions are frequently intermittent, sometimes being entirely absent, and at other times appearing only feebly — i. e., with com- plete integrity of the power of deglutition. They occur in parox- ysms due to mental disturbances, exhausting attacks,'^ neuralgias,t palpitation of the heart, etc. Direct or more remote irritating fac- tors, such as oesophagitis and gastritis, even gastric carcinoma, me- tritis, pregnancy, and irritation due to worms, can also produce spasm of the oesophagus. It occurs in neuropathic persons suffer- ing with nervousness, neurasthenia, and hysteria, and on observation they can be recognized as specially well-marked features of a general nervous disease. Furthermore, such obstructions can be overcome by a thick sound, either immediately or after it has been kept in the oesophagus for a short time. This procedure will also succeed under chloroform. Naturally, this could not be done where the stricture is organic. The larger the caliber of the sound, the more readily can spasmodic contractions be overcome. It is well known that spastic strictures may appear throughout the whole length of the oesophagus, and at times may become so marked as to sinmlate the symptoms of hydrophobia. ;{: They may exist for months and even years without specially influencing the nutrition of the patient ; thus we meet with well-fed ladies who say that they " are unable to force down a morsel." Yet such spasms may lead to the most severe disturbances of nutrition and may even result in death.* The seat of the spasm is shown by the distance to * Carron. Observation sur une suspension de la deglutition pendant plus de deux jours produit par un emetique violent chez un homme atteint d'une dyspepsie rhumatique. J. gener. de med., chirurg. et pharni. Paris, 1811, pp. 58-62. A re- markable case, entitled Spasmodic Inability of Deglutition caused by Mercurial Unction, is reported in the Med. Obs. Soc. Phys., London, 1784, which I was unable to procure. f Coin reports A Case of Spasm of the (Esophagus and Air-passages from Dorso- intercostal Neuralgia. This was mistaken for an organic stricture. Charleston Med. J. Rev., 1851, pp. 199-205. X J. Barnes. A Singular Case of Spasmodic Disease, simulating Hydrophobia. Amer. Med. Record, 1822, pp. 650-652. * H. Power. On a Case of Spasmodic Stricture of the CEsophagus terminating fatally. The Lancet, 1866, i. No. 10. The patient, refusing an operation, died of inanition. Nothing found at the autopsy. 82 DISEASES OF THE STOMACH. which the sound can be introduced until it reaches the constricted spot, unless, as I saw in one case, the sound invariably passes into the stomach with ease, and the spasm appears only on eating — i. e., swallowing solid or fluid foods, and then not at once, but only later- The patients are frequently able to overcome the spasm by various manipulations, as can be seen in the following history of such a case : * Miss M., from New York, August 15, 1885. Age thirty -three. Well nourished ; appetite good ; bowels regular. Asserts that, on swallowing, the food, both liquid and solid, lies above the stomach. She is able to take a small plate of soup and a corresponding quantity of other nourish- ment, but then she must make extra exertions to force the mass down into the stomach. Stomach in the normal position, somewhat distended. Normal on per- cussion and palpation. Patient eats two cakes and drinks a glass of water, but the murmurs of deglutition could not be heard. After repeated deep inspirations and simultaneous efforts at swallowing she forces air into the gullet, and then at the same time we can hear a very pronounced and ioud sound as if something were being squirted through (Durchspritz- gerdiisch). The stomach tube is arrested at the cardia ; the English sound enters the stomach after overcoming a certain mild resistance. In this case, consequently, in which there were no manifest hysterical or neuropathic factors to account for the spasm, it could be overcome, and the general nutrition of the patient was correspondingly but slightly influenced. Nevertheless, her con- dition was extremely painful and unpleasant, for at her meals she was forced to leave the table as soon as she had taken a couple of morsels, in order to perform her " swallowing gjannastics," and she was thus naturally debarred from all kinds of society except that of her most intimate friends. In this case there was evi- dently spasm of the cardia, due to its hypersensibility, a condition of which I shall sj)eak again under the neuroses of the stomach. Organic Strictures. — Strictures of the cardia or of the lowest por- tion of the oesophagus, due to cicatricial tissue, are the usual results of the action upon these parts of caustic or corrosive substances such as lyes and acids. Yirchow has called attention to the fact that there is here a point of predilection for the action of these sub- * This case has since been reported in detail in the Berliner klin. Wochenschr., , No. 3, by Dr. Meltzer, of New York. ORGANIC STRICTURES OF CARDIA, 83 stances, and this is easily understood, since the investigations of Kronecker and Meltzer have shown that the swallowed mass re- mains immediately above the cardia after having been hurried through the oesophagus. Rare causes of cicatricial stricture, in fact, uncommon occurrences, are syphilitic and tubercular ulcers and tdcris rotundum oesopliagi. According to Quincke,* the latter can also lead to narrowing of the gullet, and is usually situated just above the cardia. I have a drawing of such an ulcer from the portfolio of the late Prof, von Frerichs, w'hich was situated just above the cardia, and which resulted in a marked cicatricial contraction and consecutive dilatation of the oesophagus. The cicatricial tissue is firm, does not ulcerate, and has a marked contractile tendency, so that such constrictions, if left to themselves, rapidly reach a high degree, and may even lead to cord-like fibrous obliteration of the oesophagus. As a rule, it is easy to overcome the stricture with a sound of the proper size, because pockets and projections in which the point of the sound might be caught are in general not to be found in the smooth cicatricial tissue {vide the case of Quincke cited above). The history, and the negative result of the examination for cancer, are of diagnostic import. The neoplasms which lead to constriction of the cardia resolve themselves into those wdiich exert pressure from Avithout, and those which are situated in the tissues of the digestive tract, and which grow from its wall into the lumen. Among the former class we find tumors, abscesses, and firm swellings of a carcinomatous, sarcomatous, or fibrous nature, wdiich develop in the tissues of the mediastinum or retroperitouEeum ; or they may be glands which have undergone carcinomatous or scrofu- lous degeneration. There is normally a little group of glands close above the foramen oesophageum of the diaphragm. f Or they may be osseous or periosteal tumors growing from the vertebral col- umn ; or, finally, aneurisms of the large arteries. Such conditions, * H. Quincke. Ulcus oesophagi ex digestione. Deutsch. Arch, fiir klin. Med., Bd. 24, S. 72. f Vide Thaddeus. Dysphagie durch Schwellung der Bronchialdriisen. Berl. klin. Wochenschr., 1889, No. 36. 7 84 DISEASES OP THE STOMACH. as a rule, are readily recognized by a careful study of the history and all the accompanying symptoms. It would lead me too far to take up the particulars of the differential diagnosis here, but I will not omit cautioning you particularly against the use of rigid sounds or tubes in the examination of such cases. Under such circumstances, even with careful manipulation, the danger of a possible perforation is never to be entirely excluded, and is always to be avoided, especially since soft tubes will often serve our pur- pose if we wish to discover whether the passage into the stom- ach is patent, and since the obstruction caused by these processes is never, as a rule, very marked, Abercrombie reported such a per- foration. As a warning, Yon Frerichs in his lectures always cited a case in which an unrecognized aneurism of the thoracic aorta was the cause of obstruction to deglutition, A rigid sound was introduced, and the point perforated the wall of the oesophagus adjacent to the aneurism, which had been thinned by it, and also the aneurismal sac, thus producing fatal hsemorrhage. I myself saw the following case : A gentleman, forty-five years of age, had suffered for some time with la.ncinating' pains coming on in attacks and located in tlie mediastinal region back of the ensiform cartilage. At the acme of the attack the pain was so unendurable that it could only be allayed by large injections of morphine. He acquired the morphine habit and had subjected himself to treatment for this. For a time the paroxysms were less severe, but they then reappeared as intense as before. Inasmuch as there was no objective reason for these pains, the cause was suspected to be a x^sychical one, hysteria; syphilis was also thought of, although syphilitic new- growths usually cause very little or no pain, and antisyphilitic treatment was without result. Then later on there appeared difficulties connected with eating, the food seeming to remain above the stomach; his appetite, which had been capricious for a long time, now disappeared entirely, and he lost considerable strength. Fever was never present. At times he expectorated muco-pus containing no elastic fibers — this was before the era of bacilli. Sounding the cBsophagus was suggested. Percussion showed the heart dullness to be abnormally increased, extending on the right to the right margin of the sternum, above and on the left to the lower border of the third rib; no murmurs; radial pulse regulai*, equal on both sides ; the back showed no dullness or sound of any kind, except signs of a slight catarrh. In view of this, and of the attacks of pain, and the remaining general conditions, I suspected a mediastinal tumor, perhaps an aneurism, and therefore advised against the introduction of the sound. Two nights afterward the patient had a terrific hsemorrhage, consisting DANGERS OF RIGID STOMACH-TUBES. 85 of pure blood, not frothy, which " seemed as though it gushed from the mouth," and he died in a few moments. Although an autopsy was not allowed, there can be no doubt that a large blood-vessel had perforated into the oesophagus, and it is equally certain that the blame would rightly or wrongly have been ascribed to a pi'evious sounding had it been undertaken. A similar case was reported by me at the meeting of the Berlin Medi- cal Society on June 18, 1890.* A man who was suspected of having a can- cer of the stomach presented himself to have the stomach-tube introduced in oixler to obtain some of the gastric contents for examination. No tumor could be felt, yet he was emaciated and cachectic. Heart and heart-sounds normal. While the patient was introducing the tube himself, which he did without any exertion, he suddenly fell back, became pale and cya- notic, and died within a few minutes. There was no haematemesis, nor was there any blood on the tube. During the last few moments of life a rapid increase in the area of cardiac dullness and a loud friction-sound over the heart could be made out. The diagnosis made was ha^matoperi- cardium, resulting from rupture or perforation of an aneurism. The au- topsy revealed the presence of a dissecting aneurism at the beginning of the ascending aorta just above the aortic valves and still within the peri- cardium, just where the latter is reflected. At this spot the wall of the aneurism was torn, and it was here that the blood had entered the peri- cardial cavity. The stomach and oesophagus were absolutely intact and were free from any neoplasm. It must remain an open question whether this was merely a coincidence, or whether the introduction of the tube and the consequent increase in the intrathoracic pressure had caused the rupture of the aneuiism. However, the latter supposition is very im- probable, for the reason that, according to physiological laws, the blood- pressure (an increase of the pressure on the internal wall of the aneurism or aorta which alone could cause the rupture) is not increased by the introduction of the stomach-tube. Just such cases warn us to be cautions under all circumstances in making an examination with the sound, and you ought not to think that I take unnecessary trouble in a-koays assuring myself in the most careful manner of the condition of the heart and its ad- nexa before I explore the oesophagus or stomach w^th the sound. Constricting neoplasms of the cardia are always of a carci- nomatous nature, and are very rarely indeed limited exclusively to the orifice of the stomach. As a rule, they spread from above — the lower section of the oesophagus ; or from below — the cardiac portion of the stomach. Rokitanski f states that a special characteristic of cancer of the * Ewald. Ein Fall von Aneursyma dissecans. Berl. klin. Woehenschr., 1890, p. 694. f Rokitanski. Handbuch der speciellen pathologischen Anatomie. Bd. ii, S. 205. 86 DISEASES OP THE STOMACH. cardia is tliat it always lias tlie tendency to involve the oisopliagus, thus contrasting with cancer of the pylorus. As opposed to this assertion, Brinton * cites two cases of sharply locahzed cancer of the cardia, and in consideration of the rarer appearance, on the whole, of malignant growths in the region of the cardia, he believes that both cancers of the pylorus and of the cardia appear locahzed with about equal frequency— that is, one case to fifteen in which it spreads. Disregarding my own relatively small personal experi- ence, which, by the way, agrees entirely with Kokitansld's views, I can find but few recorded cases of isolated cancer of the cardia — two cases of epithelial cancer of the size of an egg, described by Hanot,t which were limited exactly to the cardia — and also through the kindness of Prof. Yirchow, I saw only one more case in the splendid collection of our [Berlin] pathological institute, of which I append a drawing made by myself (Fig. 9). Should we wish to regard the neoplasms which strictly involve only the circular muscular ring of the cardia as localized cancers, we can easily see that the tendency for them to spread has already been pro- vided for in the anatomical arrangement ; for the muscular layer, as is well known, is made up of semicircular and cross- ing fibers which spread from the cardiac to the fundal zone of the stomach. As a rule, the cause of these tumors is not to be discovered, and the hereditary factor is far oftener absent than present. I shall again treat of this subject— heredity — in the general discussion of carcinoma of the stomach. I must not forget to mention that two of my patients positively ascribed their trouble to traumatisms. One of them, a lawyer, traced it to a fall in which he hurt his chest ; and the other, a farmer, while at work in the field, suddenly experi- enced a sharp pain within his chest, and since then he claims that the disease developed. In both there was cancer of the cardia. I scarcely need say that such statements can only be accepted with the greatest caution. The well-known necessity of man, especially a sick man, of finding a cause, frequently leads him to confound the * Brinton. Lectures on the Diseases of the Stomach. Second edition, London-, 1864, p. 227. f Hanot. Arch, gener. de Med., October, 1881. CANCER OP CARDIA. 87 ^ost lioG or the simul cum with the ijropter Jioc. But since it has been proved that traumatisms may give rise to carcinomata, it ap- pears to me that this, to which as far as I know no attention has been paid, is worth mentioning. Fig. 9. — Localized cancer of cardiac orifice of stomach. (From Berlin Pathological Institute.) a, CBsophagus ; 6, localized cancer of cardia ; f, cavity of stomach. I shall consider the nature of carcinomatous tumors of the stomach and their diagnosis in a later lecture {vide Lecture Y). 88 DISEASES OP THE STOMACH. Let us now return to our case of to-day. Among the many causes which we nmst consider as producing the stenosis in our patient, one may be at once excluded, and that is cicatricial stricture of the oesophagus. He has never swallowed cor- rosive fluids ; he does not remember having taken food hot enough to cause the well-known burning sensation at any part of the digest- ive tract down to and into the stomach, although his occupation, that of a restaurateur, would offer a certain inducement therefor. He has never experienced pressure or a blow on the chest ; no sign points to disease of the organs of resjDiration or circulation or of the bones. He has had no fever. There can be no thought of a spastic contraction, judging from the history and the objective symptoms. We can exclude a diverticulum — i. e., a saccular, partial dilatation of the oesophageal wall without any narrowing — because the diver- ticula are always situated in the upper portion, chiefly the upper third, of the oesophagus, and never extend as low down as the cardia. Thus by exclusion we would arrive at the assumption of a car- cinomatous stricture of the cardia. It is true that positive evidence is entirely lacking ; yet its absence, above all the absence of en- larged glands, the deficient proof of carcinomatous tissue-elements, the freedom from all pain, and the relatively moderate loss of muscular tissue and of strength, do not oppose it. Only a short time ago I saw a case, almost the exact counterpart of the present one, differing from it only in that loss of flesh and strength had advanced much further. Here, too, there was no posi- tive evidence of cancer, either from the history or on physical ex- amination. At times the stricture would admit small sounds, but, as a rule, they could not be passed. We made an artificial gastric fistula in this patient, and at the operation we had the oj)portunity of palpating the stomach and the surrounding viscera through the abdominal wound. We could very plainly palpate a tumor in the region of the cardia beneath the diaphragm, which felt to be about as wide as a finger, somewhat fiattened, and inclosing the cardiac opening like a ring. Several weeks after the operation the patient died while absent from Berlin, and, although it is to be regretted that an autopsy was not held, yet the diagnosis of cancer in this case DILATATION OF THE CESOPHAGUS. 89 is as firmly established as tlioiigh it had been made bj ocular in- spection. Thus also in our patient, as so frequently occurs in making a diagnosis, the proper estimation of negative data is nearly as im- portant as the positive results of examination, and we are justified in making a diagnosis of carcinomatous stricture of the cardia. Whether it lies within or without the lumen is a question which we must leave unsettled. There still remains a condition to be discussed which is nearly always a result of stricture of the oesophagus or the cardia of long du- ration, and that is dilatation of tlie oesophagus above the constricted spot. But since a prolonged reaction of the narrowed jDortion upon the parts above is necessary for their formation, we can easily understand the rare occurrence of such secondary dilatations in cases of carcinomatous stricture, which, as a rule, cause death too rapidly. Saccular dilatations of the gullet have always been subdivided into the pi'essure and the traction dwerticula and simple ectasis. The first two are partial dilatations of the periphery of the oesophageal wall, which appear as blind appendices attached to the otherwise normally sized tube, and which when moderately well developed and in a filled condition may appear on the surface of the body as circumscribed projections. They have no place in the pres- ent discussion, since, as has already been mentioned, they occur in the upper two thirds of the oesophagus ; in fact, the former are situ- ated chiefly at the boundary between the throat and the oesophagus. Thus I will only consider the last form. Dilatations situated above a constricted spot, as a rule, tend to involve the whole circumference of the gullet, and, after existing for some time, to cause complete atrophy of the mucous membrane, while the muscularis is thinned and its fibers separated into wide meshes. By this I do not mean to say that the dilatation may not develop more in a certain direction and in this way gradually lead to the formation of a true pocket. For this purpose there is needed only a somewhat greater yielding of the oesophageal muscle-fibers to the pressure of masses of food. Such a case was observed by Xicoladoni '-^ in a four-year-old girl, * Nicoladoni. Wiener med. Wochenschr., 1877, Xo, 25. 90 DISEASES OF THE STOMACH. wlio liad a stricture of the oesophagus due to corrosion. The strict- ure was 8 centimetres [3-^ inches] long, and above it the oesophagus was irregularly bellied out for a distance of 2^ centimetres [1 inch], chiefly on the anterior wall and to the left, so that there existed a saccular dilatation which was sharply shut off from the stricture, and in which one could easily introduce the entire last plialanx of the forefinger. Under such conditions — that is, when the stricture is not immediately above the cardia, but is situated higher up in the gullet — partial dilatations may give the first im- petus to the formation of a diverticulum, for which there is no room immediately above the diaphragm. However, the dilata- tion existing in our case must have reached a considerable size, otherwise it would not be conceivable how it could hold 100 c. c. [f § iij 3 ij] and over. Naturally this can only take place at the expense of the neighboring viscera by compressing or displacing them. "Wheatley Hart * describes the case of a woman, fifty-eight years old, who had for twenty years suffered with dysphagia, connected with frequent vomiting, and who gradually died of marasmus. The autopsy showed the following : The stomach, the mucous membrane of which showed no abnormalities, was small and its mouth so nar- row that the little finger could only be introduced with difficulty ; but there was neither thickening nor hardening of the tissue at this place. Above this the cesophagus was enormously dilated, so that on the right side of the spine it lay in the hollow of the ribs, where it was fairly bent at a right angle and directed toward the foramen diaphragmaticum. On its removal it looked like a second stomach, and could hold Y50 grammes [ ^ xxv] of fluid. The muscularis was greatly hypertrophied. Hart believes that it was originally attached to the lungs and pericardium, but that it was afterward separated by a retracting pleuritis and mediastinitis, since both processes were found markedly developed. Spasmodic contractions of the oesophagus of long standing may also cause dilatation of the portion of the gullet lying above them. <; * Wheatley Hart. Autopsy on a Case of Prolonged Vomiting. Lancet, 1883, ii, p. 456. TREATMENT. 91 Leichtenstern * has reported a well-marked example of tliis in a patient who had suffered for seven years from obstinate hysterical vomiting. A case wdiicli I have reported elsewhere f was remarkable for the fact that the dilatation existed not above, but below the site of the carcinomatous stricture ; the latter was located at nearly the middle of the oesophagus. It was evident that this was due to a fatty degeneration and an accompanying atrophy of the muscular fibers in the lower section of the gullet ; consequently this portion of the tube lost its contractile power and became dilated by the swal- lowed masses, wdiich, as shown by the experiments of Kronecker and Meltzer, normally accumulate above the cardia and are forced through the latter by the contractions of the oesophagus. One of my patients, in whom there was a condition entirely analogous to that existing in the case under discussion, complained of severe dyspnoea as soon as he made any extra demands upon his respiratory organs, even in walking from one room to another a little faster than usual or on going up-stairs. The patient whom you see to-day was so short of breath the first time he visited me that at the first glance I took him to be suffering with pulmonary or cardiac disease. This condition may be primarily ascribed to the general weakness of the patient, but it can in part be referred to purely me- chanical causes — to compression of the lungs, and possible displace- ment of the heart. The treatment of our case is clearly indicated. Inasmuch as the stricture is entirely or practically impassable, and since internal medi- cation, even if we possessed specific remedies, would thus be of no avail, and since mechanical dilatation is impossible, there remain only rectal alimentation and the production of a gastric fistula. Al- though rectal alimentation is very valuable for a short while, it is not effective for long periods of time, and therefore if the entrance to the stomach is closed to all kinds of food or nourishing materials it is to be combined with gastrostomy. We shall perform this oper- * Leichtenstern. Enorme sackartige Erweiterung des Oesophagus ohne me- chanische Stenose desselben in einera Palle von siebenjahrigem hysterischen Er- breehen. Deutsch. med. Wochenschr., 1891, No. 4. f Ewald. Berl. klin. Wochenschr., 1889, No. 23. 92 DISEASES OF THE STOMACH. ation in our case, and, if j)ossible, we shall attempt bloodless dilata- tion of the constricted portion, working from within the stomach. The patient presented to you on the 3d of this month, on whom gastrostomy was to be performed because of our diagnosis of can- cerous stricture of the cardia, was operated on in my presence by Prof. Sonnenburg five days later. Reserving the remarks concern- ing the operation kindly placed at my disposal by Prof. Sonnenburg for the end of this lecture, I wish now to tell you that we j^alpated the stomach after the abdominal cavity was opened, but were un- able to recognize any abnormity. Two days later, when the fistula had been established, it was seen that with the exception of some mucus the stomach was empty. This mucus had a neutral reaction on strips of litmus-paper which were introduced. For the first three days after the formation of the fistula the condition of the patient was. excellent. He complained only of a feeling' of press- ure, but retained the nutrient enemata given to him and the soup poured in through the fistula. On the fourth day he began to cough a little and to bring up slightly fluid, greenish-yellow sputum, which contained small, whitish particles about the size of a grain of sand or the head of a pin. The cough increased in frequency and severity, chiefly at night, and could not be relieved by subcutaneous injections of morphine. A penetrating odor from the mouth became noticeable, and the evening temperature rose to 39'2° C [102'5° F.]. Examination of the sputum revealed numerous pus- cells, free nuclei, bacteria, and masses of cocci, but no tubercle bacilli and no elastic fibers. The minute particles mentioned above consisted of large numbers of short, rod-shaped bacilli, so that they almost represented a pure culture. An ineffectual attempt was made to check the putrid decomposi- tion by giving the patient capsules of salicylic acid to swallow and by washing out the oesophagus with a solution of the san^e drug. Dullness and bronchial breathing appeared over the lower portions of both lungs posteriorly. Elastic fibers were now found in the sputum, and a diagno- sis of double pleuro-pneumonia due to perforation or swallowing was made. The fever continued, the patient's strength rapidly failed, and he died on the eighth day after the operation in a mildly somnolent state. The autopsy which I made revealed the following : Fundus of the stomach lies in the hollow of the diaphragm. It meas- ures 12 centimetres [4| inches] in its widest portion, and 30 centimetres [12 inches] from the pylorus to tbe cardia. The organ when cut open has a transverse diameter of 19 centimetres [7| inches]. The opening of the fistula is 6 centimeti-es [2f inches] above and to the right of the ring of the • STENOSIS OP CARDIA. 93 pylorus. Its edges are puffed up, so that the mucous membrane lies quite smoothly over the muscularis toward the outer side From without the pylorus feels swollen and thickened. On cutting oi^en the viscus we see that this is caused by a trabecular thickening of the submucous connect- ive tissue, while the muscularis and serosa are not involved. Even from without we can see that the oesophagus above the cardia is converted by a dilatation measuring 6 to 7 centimetres [2| to 2^ inches] into a hard, sausage-like mass. On introducing a thin glass rod it either enters a pocket, in which it is arrested, or it passes through a narrow canal into the stomach. Water poured in from above slowly flows into the stomach after first having rapidly filled the oesophagus. The latter is widened above the tumor, so that at a distance of 5 centimetres [2 inches] from the upper margin it has a diameter of 6 centimetres [2| inches] ; then it gradually becomes narrower, and, 13 centimetres [5\ inches] higher up, is only 3 centimetres [1|- inches] wide. Opening the oesophagus, we see that the growth commences exactly at the cardia and that the incision has separated it into a larger (right) and smaller (left) ovoid portion with only a very narrow canal — admitting a thin pencil — between them, which is further marked by warty polypoid excrescences. The growth is so fri- able that the right side tears apart lengthwise, thus opening an empty cavity or cleft lined with a greenish-gray, fairly firm membrane (Fig. 10). Under the surface of the mucous membrane of the oesophagus are single small punctate nodules, appearing faintly white through the mucous membrane, the epithelium of which is desquamated in shreds as though it had been corroded. The same condition exists immediately below the tumor, where it passes on to the mucous m.embrane of the stomach. The latter membrane is smooth at the fundus and of a pretty pink color. In the remaining portions it is thrown into very many folds and is more of a slate color. No punctate haemorrhages or suggillations. The left side of the oesophagus corresponding to the expansion of the tumor is attached to the mediastinum and the pulmonic pleura by a recent adhesive inflam- mation. A lymphatic gland, situated above and to the left of the dia- phragm, is slightly tumefied, and on section shows commencing punctate suppuration. The lower lobes of both lungs are swollen, of a marked reddish-brown color, and are absolutely non aerated. The upijer lobes and the middle one of the right lung are aerated, and the pleura covering the two lower lobes shows a recent slight fibrinous deposit. "We further find sharply circumscribed round spots of a light greenish-yellow color like pus, chiefiy at the base of the right lung. They are less numerous on the posterior surface of the lower lobes of the right and left lungs. Their size varies from that of a lentil to that of a pea. On cutting into them we discover that they correspond to httle hollows with a membranous lining and filled with a smeary, greenish-yellow mass having a penetrating and most offensive odor. A bronchus or bronchiole can be traced to each hollow. The mucous membrane of the bronchi is dark bluish red in color, like satin, swollen, and filled with quantities of frothy, blood-streaked pus. All the other organs are normal. The small intestines are unusually firmly contracted, so that they are scarcely the size of a finger. DISEASES OF THE STOMACH. Fig. 10. — Carcinoma of 03Sophagus just above the cardia. Mr. P. died Aug. 3, 1887. a, oesophagus, J, cardia, c, cavity of stomach. TREATMENT OF STRICTURES OP CARDIA. 95 A fresh particle of the tumor scraped from its surface shows the most varied forms of cylindrical and pavement epithelium, round cells with large nuclei, and masses of cocci. Microscopic examination of the hard- ened tumor reveals an epithelioma extending down to the serosa, with portions of its elements undei'going degeneration. In this record of the autopsy the patency of the stricture estab- lished post mortem does not seem to correspond to the complete closure existing during life. If we consider, tliough, that the tissues, losing their turgescence, shrink after death, w^e can easily explain how during life the narrow canal was completely displaced and oc- cluded between the masses of the grow^th. At any rate, the opera- tion was not only fidly indicated, but it would have offered the best chances for the patient had not the gangi-enous aspiration pneu- monia ^ScKl'iickjpnewmonie^ intercurred. This is an accident, pre- vention of which lies beyond our power. A lady with carcinoma of the oesophagus, on whom gastrostomy was performed also by Prof. Sonnenburg, was in as good condition five months after the opera- tion as the circumstances could possibly permit, in spite of the fact that five years previously her right breast had been amputated and the right arm disarticulated subsequently on account of cancer of the breast. She died finally of a fresh metastasis which developed in the right pleura. Let us finish the history of our case w^ith a discussion of the Treatment of Strictures of the Cardia. — In all organic strictures of the oesophagus situated at the cardia we can only expect help from operative procedures. Nobody can believe that we can obtain any results with internal medication, the so-called resolvent or altera- tive drugs of a therapy which is not so very ancient, mercurials or iodine, or even with the bighly praised condurango. We can only attempt the bloodless dilatation of the stricture by means of sounds, and where this is impossible we must perform gastrostomy. Dilata- tion of the stenosis with bougies necessarily presupposes at least a partial penetration of the instrument into the constricted portion. As a rule, this will succeed at first if the stricture be a simple incom- plete one without secondary dilatation of the parts higher up. For this we should always nse the largest sounds possible — at least, we should always attempt to introduce the larger ones. The thinner 98 DISEASES OF THE STOMACH. the sound, tlie greater the danger tliat its fine point will be canglit in the inequalities of the constricted spot or in pockets due to second- ary dilatation, even when these pockets are so small that a heavier sound would glide past them. In this, as always occurs under such circumstances, accident may play an important role y at one time we may succeed in passing the sound, and at another it bends at its point. I have frequently found it to be advantageous to allow the patients to force down the sounds themselves to a certain extent by ordering them to make repeated efforts at swallowing. It may then glide into the proper path, and can be pushed on by slight pressure from above. The introduction of sounds too frequently or too rapidly re- peated is to be guarded against, I have seen a sound (ISTo. 20, Char- riere) pass through a stricture with comparative ease, but it would not do so on the fourth or fifth day, since a marked swelling or a rapid growth of the affected parts had undoubtedly been caused by the irritation of the sound. Mackenzie * has also called attention to the same fact. We allow the sound to remain in sitti for from three to five minutes, and pass from the smaller to the larger numbers. It is disagreeable to a great many patients who permit the sound to pass easily to retain it for this length of time, principally on account of the copious secretion of saliva. In such cases I usually first give a subcutaneous injection of 3 milligrammes {^-^ grain] of atropine with 5 milligrammes \j^ grain] of morphine. The salivation then ceases entirely or does not appear at all, while the morphine in- creases the tolerance of the patient. Instead of the English sounds we can use a staff of whalebone with olive-shaped ivory points, which can be unscrewed and changed to larger or smaller sizes as the occasion may demand. Thin English sounds with pyriform extremities are also made. At Frerichs' clinic we used long, smooth instruments of whalebone of various sizes. If the stricture is not too marked, we can also use a soft-rubber oesophageal tube of the proper caliber, which is intro- duced into the stomach and allowed to remain there for a while. * Morell Mackenzie. Die Krankheiten des Halses und der Nase. Uebersetzung von F. Semoii. Berlin, 1884, S. 130 u. 185. THE PERMANENT CANULA. 97 The patients tolerate this better than keeping a stiff sound in j)lace, because they can close their mouths, and they do not have the trouble- some flow of saliva ; moreover, it also seems to create less irritation at the affected spot. Finally, as early as 1843, Switzer in Copenhagen proposed the use of a permanent canula, which was used later on by Krishaber, Mackenzie, Symonds, and recently by Leyden and Renvers," in the form of a kind of catheter a deineui^e. A slightly conical tube, oval on section, made of hard rubber, or a caoutchouc catheter, to which two strong silk cords are attached, is introduced into the constricted part by means of a whalebone guide supplied with a proper obtura- tor and left there after the withdrawal of the guide. The cords hang from the mouth and are wound around the ear, or they may be carried through the nose. If the tube does not become clogged, it is allowed to remain in place as long as fourteen days. It is then re- moved and a new one substituted. This procedure naturally pre- supposes a certain size of the stricture, since canulas smaller than a large pencil can not be introduced well unless, like Mackenziejf we care to forcibly thrust the catheter through the stricture, which, granting that it be possible, is by no means advisable. Leyden and Kenvers, in two cases in which they diagnosticated oesophageal can- cer, had the good fortune to obtain excellent results by means of a permanent canula — i. e., increase in the patient's weight for a con- siderable time. In three or four cases in which the existence of car- cinoma of the oesophagus was proved by autopsy, I found that the patients could tolerate the canula only for a comparatively short time, but that I could produce a decided transient relief by it. Son- nenburg :|: properly says that but few cases are lit for this procedure, which can easily lead to rapid growth of the cancer, the occurrence of sudden haemorrhages, necrosis, perforations, etc. When the stricture is situated at the spot which interests us at present — the * E. Leyden and Renvers. Ueber die Behandlung carcinomatoser Oesophagus- strictur. Deutsch. med. Woehenschr., 1887, No. 50. [Also, Renvers. Die Be- handlung der Oesophagnsstricturen mittelst Dauerkaniilen. Zeitschrift f. klin. Med., Bd. xiii, S. 499.— Tr.] f Loc. cit. X E. Sonnenburg. Beitrage zur Gastrostomie. Berl. klin. Wochenschrift, 1888, No. 1. 98 DISEASES OP THE STOMACH. deepest portion of the oesopliagiis- — the tube must reach into the stomach. It is doubtful whether this is possible without causing persistent irritation. At any rate, it has not yet been attempted. The same may be said of Gersung's new and complicated " perma- nent sound for the oesophagus." * The difficulties of introducing the instrument grow projiortion- ately with the increase in the consecutive dilatation of the gullet or of the possible excrescences and pockets of the constricting growth. At times it would appear that in cases in which a diverticu- lum had also formed it might be possible to pass the sound beyond the pocket and into the stomach by giving it a certain direction ; thus several authors give rules for this purpose. In my opinion, if the obstruction is just above the cardia, this is entirely illusory, None of the sounds which we are able to introduce into the oesopha- gus possesses rigidity enough to enable us to give its point a definite direction after it has reached the level of the lower portion of the oesophagus. You can easily convince yourselves of this on a corpse or a suitably suspended preparation in which the stomach and oesoph- agus are preserved entire and in continuity. Keither have I been able to discover any particular advantage in a special position of the patient according to the supposed site of the dilatation. "VTe must admit that in an actual case it is a matter of luck whether the intro- duction of the sound is successful or not. However, that the post- ure of the patient may come into consideration during the passage of tlie masses swallowed is shown by the following very excellent example : On the 19th of July I was consulted by B., a farmer from Steiidal. He had been examined by several physicians because of a group of symptoms which pointed to a diverticulum of the oesophagus. By some his condi- tion was said to be a diverticulum, while others considered it a nervous spasm of the gullet. The patient's nutrition and general condition ap- peared little changed. He could attend to his business as well as ever, but he felt a slight loss of sti'ength, and as he had read about the pernicious results of oesophageal diverticula, he was in doubt whether or not to give up his property, retn-e, make all arrangements in conformity therewith, and await the threatening ^?iaZe. The difficulties in swallowing had late- ly increased very slowly ; subjectively they manifested themselves only in occasional regurgitation of the food. In reference to this the patient had * Wiener med. Wochenschr., 1887, No. 43. USE OF SOUNDS. 99 observed that at times portions of " regurgitated " food had been eaten not at the last, but at a previous meal. The sound was caught in a deeply sit- uated sac after being introduced 40 centimetres [16 inches] from the in- cisors. This made the patient cough, when he brought up unchanged coffee which he had taken three hours before.* It contained no free acid. No deglutition-murmurs could be heard with the patient in the erect post- ure. On the other hand, however, when he lay down, a second sound could be heard very distinctly twelve seconds after swallowing. This was confirmed by frequent repetition. Thus the entrance of food into the stomach was not entirely prevented, but, as the sound proved, was possible under special conditions. In spite of this, even on a second trial, I was unable to pass a sound into the stomach, whether the patient was erect or recumbent. It was plainly to be seen that in this case conditions were created by the dorsal decubitus which rendered the passage of the swal- lowed mass a possibility. We can therefore assume that the dilatation — for with this we had to deal, without any doubt — was situated anteriorly, so that when the patient lay on his back it collapsed to a certain extent, and thus did not form a '"trap." At any rate, the diverticulum was a small one, for. after the patient had been directed to drink a whole glass- ful of water, the deglutition-murmur could be heard when he was stand- ing. This proved that the sacculation was now filled, and that it neither caught any further masses which were swallowed nor prevented their en- trance into the stomach. Thus a sufficient degree of nutrition was still possible, and in this way only could I explain the relatively good condi- tion of the patient, which had manifestly been the reason why others as- sumed the presence not of stricture or of a diverticular formation, but of a spastic condition of the oesophagus, especially if, as is very possible, they could occasionally introduce a sound into the stomach without any trouble. It is to be regretted that circumstances did not permit a subse- quent examination of the patient ; nevertheless, the facts just laid before you were amply sufficient to exclude a spastic contractiu'e and to estab- lish the diagnosis of a diverticulum. As for treatment, I advised the patient to abstain from all sounding for the present, for if the sound took a false direction this might give rise to unpleasant signs of irritation, per- haps to mechanical enlargement of the diverticulum; further, only to permit it when his difficulties had become more marked, especially when the feeling of obstruction on swallowing appeared ; and, finally, to assume a recumbent position as much as possible when eating. Especially good results from the use of tlie sound are met with in cases of cicatricial strictures if the patience of both patient and physician holds out, and, in case the stricture has become more pa- tent, their use is not discontinued too soon. Even if the constriction seems to be sufficiently dilated the use of the sounds should not be * In a case of Delia Chiaje (cited by Mackenzie) cofPee was regurgitated as late as five days after it had been swallowed, without being in the least changed. 100 DISEASES OP THE STOMACH. stopped for some time, for the contractile tendency of cicatricial tis- sue is very great and constantly recurring. For a long time after the campaign of 1870 I treated a young physician who, returning to camp extremely fatigued one day, had received a burn and consecutive stricture of the oesophagus by attempting to drink from a canteen apparently filled with water. The vessel — whether purposely or not, we will leave unsettled — was filled with pure sulphuric acid! He could only spit out a portion of the first hasty swallow, and thus the poor fellow not only received a severe burn of the oesophagus, but also had to suffer from a consecutive stricture. In this patient I could follow the tendency to constantly recurring narrowing of the affected spot for years. 'Now that the true poisons are used more frequently for purposes of suicide, we do not have the opportunities which we formerly had to study these cicatricial strictures and their course when it was still the fashion for maid-servants to poison themselves with " oleum " (impure sulphuric acid) ; for, queer as it may seem, fashion has a decided influence even upon this melancholy procedure ! I regret that I do not possess any statistical records of that period, so that I can only say from my general impression, in accordance with the views of other authors, that cicatricial strictures offer a favorable prognosis unless they reach a certain degree of constriction ; but as soon as we have to deal with advanced stages, sounding leaves us in the lurch exactly as it does in cancerous constrictions. The latter especially always offer unfavorable prospects. We may indeed suc- ceed in making the canal more patent for a time, but we can not permanently contend with the progressive new growth. Again, we must not be surprised or deceive ourselves with false hopes if, espe- cially toward the end of life, the stricture suddenly seems to become more patent or to have disappeared entirely. This is a result of ulceration, and is always to be regarded as a bad omen. For most strictures nothing remains but gastrostomy (to o-rSjjia, the mouth), the establishment of a gastric fistula, first proposed by Egeberg in 183T and performed by Sedillot in 1849. The tortures which the patients suffer from their disease, the slow starvation which is their lot, are indeed so frightful that we must attempt re- lief even if we know it will only be transient. It is to be regretted that as yet the operation is performed too late in most cases. The patients are very slow to consent to a procedure about which, even GASTROSTOMY. 101 though very nnjiistlj, there still hangs a nimbus of its being a won- derful operation. They only submit from extreme necessity, and thus the best time, that of a relatively good general condition, passes by. It is true that recently there has been a decided i)rogress in this direc- tion, and consequently the results of the operation have progressive- ly become more favorable. In 1864 Mackenzie collected 67 cases of gastrostomy in carcinoma of the oesophagus, 12 of cicatricial stricture, and 2 of syphilitic stricture, and found that the longest duration of life amounted to from 5^ to Y|- months. Then in 1885 Zesas * collected 129 cases of cancer, 31 of cicatricial stricture, and 2 cases of syphilis, and estimated 16*2 per cent of cures (?) in the first, 55 per cent of cures in the cicatricial strictures, and among the deaths, IY'2 per cent who survived the operation for twelve months. If we select only those operations which have been performed since the inauguration of antisepsis (131), we get 19*5 per cent [cancer] and 68'Y per cent [cicatricial stenosis]. Gastrostomy, to-day, is in itself so free of danger that it is indi- cated in every case as soon as the diagnosis of a non-dilatable strict- ure of the cardia, with or without consecutive dilatation, is estab- lished. iN'othing else can save the patient from the starvation which threatens him. The chances for success naturally depend upon the character of the constriction, and the earlier the operation is under- taken and the less the general condition of the patient is depressed the better are the prospects. That this operation can not save life need scarcely be mentioned. At any rate, if no abnormal intercurrent at- tacks appear, life is prolonged and death in cases of carcinoma is due to the more or less rapid course of cancerous intoxication and not 'to starvation. Even the psychical influence of the operation on the patients, the advantages of which you can readily understand, is not to be underestimated, and the reproach made by a j^atient to Prof. Kocher, that "he had unnecessarily made a hole in his stomach," may well be regarded as exceptional. Among five patients to whom I proposed the operation, only one refused to undergo it, and he was a Russian general, who preferred death in St. Petersburg to an opera- tion in Berlin. * Gr. Zesas. Die Gastrostomie und ihre Resultate. Arch. 1 klinische Chirurgie, Bd. 33, S. 188. 102 DISEASES OP THE STOMACH. For tlie following statement regarding the technique of the opera- tion I am indebted to the kindness of mj colleague, Prof. Sonnen- burg, who has operated upon two of mj patients 'during the past year, and who has lately published his experiences : * "First of all, in gastrostomy for cancerous stricture it is not easy to determine the position of the stomach, %vhich is markedly shrunken on account of the insufficient supply of food. The best incision is one 5 to 6 centimetres [2 to 2-|- inches] long, beginning below the xiphoid cartilage and running parallel to and a finger's breadth away from the free border of the ribs on the left side, ex- tending with a slight concavity downward to about the ninth rib. After separation of the skin, fasciae, and muscles, and the most care- ful cliecking of hsemorrhage, the peritoneeum is opened and fixed, best by means of two looped cords. On making traction upon the loops the omentum and intestines can be seen in the depths of the wound. If we have chosen an incision nearer the mid-line, we can see the left lobe of the liver ; but this is usually only a hindrance in our attempts to find the stomach. The best way to find this viscus is by endeavoring to introduce the hand to the region of the cardia and to pull forward that portion of the intestinal tract lying there. In most cases, especially when the stomach is very much contracted, some difficulty may be experienced in distinguishing between the stomach and the transverse colon ; but we can recognize the colon by its muscular bands and the stomach by the sweep of its lower curvature and the vessels which enter there. But in a very atrophic condition, and especially if the viscus is with difficulty drawn for- ward, these otherwise readily recognizable landmarks may be very poorly marked. There have been cases in which the colon has been fixed in the wound instead of the stomach, and this in spite of great care. — Our attention now in fastening and sewing the stomach is to be directed to getting the opening in the organ as near as pos- sible to the cardia, because then only is the efficient nourishment of the patient possible later on ; for the nearer this opening lies to the pylorus the more readily will the food introduced into the stomach on being propelled forward flow out of the fistula, and thus the * Loc. cit. TECHNIQUE OP GASTROSTOMY. 103 nourishment of the patient become impossible. A small portion of tlie gastric wall, situated as high as possible, is then drawn forward in the shape of a ridge and attached all around to the parietal peri- tonseum by stitches which only include the serosa ; then the peri- tonaeum itself is stitched to the fasciae and muscles — not to the skin. If it be at all possible, the stomach is left unopened for several days, the wound being tamponed with iodoform gauze until union has taken place. After two or at most three days we may exclude the danger of the occurrence of peritonitis from the entrance of stomach- contents into the abdominal cavity. The best way to open the stom- ach itself is with a pointed thermo-cautery. The opening need only be very small at first, for it enlarges itself in a short time. The in- troduction of fluid food is best performed at first by means of a thin oesophageal tube. " In order to find the stomach more readily, the introduction of a thin sound with an easily distensible bulb attached to the lower end has been recommended. This naturally can only be thought of in case the stricture is not too marked. The introduction of a Seid- litz powder into the stomach to distend the organ by the formation of gas could hardly ever be accomplished in practice. " Many suggestions and experiments have been made as to the introduction of nourishment. We can get along, however, with very simple methods. As has already been mentioned, we may at first use a thin oesophageal tul)e for this purpose, the opening of the fistula being closed in the intervals with a rubber or wooden stop- per. Later a thin short silver canula may be permanently worn ; a rubber tube to which a short funnel is attached is then connected and the food poured in through this. Many patients chew a por- tion of their food and transfer it to a vessel which is connected with the canula by means of the rubber tube." However, it is to be regretted that the diverticulum or the dila- tation of the oesophagus is not removed by gastrostomy. The intro- duction of food into the body is naturally no longer prevented, but above the stricture there remains a breeding-place for all kinds of putrefactive germs. The patients are constantly swallowing saliva ; although after the formation of the fistula they complain very little or not at all about hunger, they are frequently troubled with severe 104 DISEASES OP THE STOMACH. thirst. We may permit tliem to swallow small pieces of ice and even to drink some wine. Later the dilated gullet becomes filled with fluid contents which at once putrefy, a strong fetid odor emanates from the mouth, and either spontaneously or through the stomach-tube the patients force up a fluid with the odor of decaying meat, which on microscopic examination proves to be almost a pure culture of putrefaction cocci. Under such circumstances we must wash out the sacculation as we do a stomach, and for this purpose we may use disinfecting fluids (salicylic acid, thymol, resorcin, borax, etc.), or we may introduce salicylic acid or boric acid in substance. I have also given strong cognac in teaspoonful doses in order to get the dis- infecting action of the alcohol. Finally, a word about feeding. At an early period the patients' own experience teaches them to take gruels and fluid nourishment instead of solid food. Since the functions of the stomach themselves have not suffered, as long as the lesion is not a cancerous growth — about which more hereafter — we must only consider the digestibility of the food in so far that we do not give indigestible articles of diet to persons who are more or less debilitated, but that we must try to give as much nourishment as possible in the most compact form. Besides pure milk, the paps and broths known in every kitchen, raw and soft-boiled eggs, thick gruels of wheat, oatmeal, and barley flour, we may also use the so- called leguminous flours* (containing varying quantities of nitro- gen) which are now sold in various forms, as well as beef peptone and peptone chocolate (see p. 348). We can also make a palatable meat broth of an almost sirupy consistency by taking raw beef which has been chopped up very fine and stirring it with an egg and adding some pepper and salt. Kefir is readily taken by some for a long time on account of its acid taste, while it soon becomes repugnant to others. Moreover, in this respect it presents no exceptions to the rest of the artificial food preparations, all of which have the same disadvantage of always sooner or later becoming unpleasant or even disgusting. ISTature does not permit herself to be mocked at ; and if, * [VideJl.Schlesinger. Aerztliches Hulfsbiichlein. Frankfurt, 1891, 2te Auflage, S. 15.— Tr.] RECTAL ALIMENTATION. 105 for instance, slie provides albuminoids, in various forms in the com- mon foods and not pure peptones, we can not substitute the latter for the former without being punished in regard to the taste and its results. However much the praises of the excellent flavor of these preparations may be sung, they all have the fault just spoken of, and a substitute for ordinary food with a good taste that is always pleas- ant and agreeable is still to be found. The amylaceous flours, such as tapioca, arrowroot, and sago, can not be recommended — first, because they are very poor in nitrogen, in fact in nourishment altogether, and secondly, because the diastatic action of the saliva is needed for their conversion ; but this reaches the stomach in a smaller amount than usual, since it is produced in a smaller quantity inasmuch as the stimulus for a more marked se- cretion of saliva, the mastication of solid food, is practically entirely abolished. Yery soon, however, there arises the necessity of supplementing the deficient nourishment by the mouth by means of the administra- tion of food ]3er rectum. Although rectal alimentation dates back to the earliest times in medicine, yet great credit is due to Kuss- maul, Leube, Rosenthal, and others for having placed it on a scien- tific basis. The necessary confidence in this method of feeding was supplied by the proof that we could maintain the nitrogen equilibrium in animals by rectal injections of peptone and pej)tone- like bodies ; but it Avas an error to suppose that we must use pep- tonized albumen for this purpose. In a special series of experi- ments * I proved that the injection of common emulsified white of Q%^ serves the same purpose, and that the mucous membrane of the lower portion of the intestine manifestly possesses the power of ab- sorbing not only peptones but unchanged white of egg as well, and to render it useful in the metabolism of the body. In estimating the values of peptones in rectal feeding, the conditions in alimenta- tion by the intestine and by the stomach have been falsely placed on the same basis, although they differ fundamentally, since in the former case the mucous membrane is healthy and in the latter it is * C. A. Ewald. Ceber die Ernahrung mit Pepton- und Eierklystieren. Zeit- sclir. f. klin. Med., Bd. xii, Heft 5 u. 6. 106 DISEASES OP THE STOMACH. diseased and its functions more or less impaired. Hence in the one case the indication is to diminish as much as possible the work of the org'an so far as it concerns the chemical changes of the food. In the other, however — i. e., in rectal alimentation — there is a healthy mucous membrane capable of performing its functions, and it is not necessary to do a portion of its work outside of the body. We will never be placed in the 230sition to employ nutrient enemata when the intestinal mucous membrane is unhealthy, because in the vast majority of such cases the stomach is capable of performing its duties. However, should both stomach and rectum be diseased in the same patient — and this is one of the greatest rarities — and should indeed the question of artificial nutrition arise, feeding by the mouth would always offer the better chances. I therefore believe that peptones may be dispensed with in nutri- tive enemata. In no case ought it be necessary to use the compli- cated procedure recommended some time ago by Leube. This con- sisted of a mixture of chopped meat, fat, and fresh pig's pancreas, which is injected into the intestine, where it is gradually peptonized. For this purpose we may now use the j^eptone preparations offered for sale, although most of them are only gelatin-peptones ; more- over, they only contain a small percentage of true peptones, being rather the earlier products in the formation of the same — i. e., syn- tonin and propeptone. E^evertheless they represent stages in the transformation of native albumen. As a matter of convenience suppositories have been made of these peptone preparations ; but, as has been said, the peptones are entirely suj^erfluous. I order the nutrient enemata to be prepared as follo\vs : A pinch of the best flour is cooked with half a cupful of a 20-per-cent solution of glucose and a wineglassful of claret added. Two or three eggs are beaten up smooth with a tablespoonful of water and slowly stirred in with this after it has cooled sufficiently to prevent the coagulation of the albumen. The entire quantity should not measure more than ^ litre [|- pint]. In hospital practice or with the poor, three to five eggs, with about 150 c. c. [f ^ v] of a 15 to 20 per cent solution of glucose, may either be injected or allowed to flow in. If necessary to make the mass thicker, we can add starch solution or mucilage ; or a few drops of tincture of opium to lessen any possible irritation. Ac- KECTAL ALIMENTATION. 107 cording to Huber,* who repeated and confirmed my experiments, the efficacy of the egg-enema may be increased by the addition of some common salt, in the proportion of about one gramme [gr. xv] to eacli egg. A cleansing enema of 250 c. c. [f § viij] of lukewarm water or of salt solution must always precede the nutrient enema, and we must wait till the passages — often frequent — are over ; other- wise it may happen that the nutrient enema will be immediately ejected. Such injections may either be given two or three times a day or the quantity divided into smaller enemata. During such a course the faeces readily assume a ribbon-like form and a light yellow color. This must be borne in mind so that no errors may arise in a given case. Such enemata may be given for a long time without the intestine reacting and causing their rapid expulsion. "We must only use the precaution of allowing the fluid to flow in very slowly through a soft tube introduced as high as possible into the bowel, the best being a large ISTelaton catheter or an oesophageal tube with an eye at the lower end and numerous lateral openings. The irrigator is held about two feet above the anal orifice of the patient or the piston of the syringe or the rubber bulb is worked gradually. For some time after, the patient remains either in the dorsal or left lateral position. In case of marked irritability of the intestines a few drops of tincture of opium may be added to the enema at first ; but this soon becomes superfluous and is rarely necessary for any length of time. I have never seen more than a transient benefit derived from the rubber tampons (similar to the colpeurynter) devised for keeping back the injected fluid. They are pushed into the bowel beyond the sphincter, and are then dilated with air or water. They can not be passed beyond the third sphincter, and after they have resisted the intestinal peristalsis several times they lose their efficacy ; also, owing to the irritation which they produce on the mucous mem- brane, they render the intestine still more sensitive and intolerant to the injections than would be the case without them. Finally, the nourishment after the production of a gastric fistula is to be considered. The kind and quantity of food which will be * A. Huber. Deutsch. Archiv fiir klin. Med., Bd. xlvii. 108 DISEASES OF THE STOMACH. l)orne under such circumstances will depend primarily upon the nature of the original disease. The celebrated Canadian, Alexis St. Martin, seems to have consumed very nourishing food without any detriment. I have myself seen the boy with the cicatricial oesopha- geal stricture who was operated on by Trendelenburg enjoy bread and butter, together with meat, potatoes, and vegetables, which he introduced into the fistula.* The patient operated on by Yerneuil also had an ample bill of fare from which to choose.f However, these are all cases of a non-cancerous nature with relatively good general condition in which, no doubt, at first a nutrient solution as unirritating and simple as possible was poured into the fistula and a mixed diet given only later on. The digestive functions of the stom- ach in such cases seem to have suffered very little, although no exact investigations have yet been made on the subject. In cases where gastrostomy is performed for carcinoma of the cardia (whether situ- ated on its oesophageal or gastric side), what are the changes in the secretion of the gastric juice and in the digestive functions of the stomach ? It is self-evident that the feeding must vary considerably according to the answer to this question ; but it is also clear that, partly at least, this will coincide with the usual changes in the di- gestive functions in gastric cancer. I shall discuss these relations in their proper connection in Lecture Y ; but I will anticipate and say that in three cases which were operated upon I have never found any secretion of hydrochloric acid or of pepsin. In two of these, who died a short time after the operation, this might be ascribed to the weakness of the patients ; but the third, the previously men- tioned case of carcinomatous stricture of the oesophagus, with numer- ous metastases, is more important. Here the chyme flowing from the fistula was repeatedly examined, the last time four months sub- sequent to the operation, after the patient had introduced gruel, or gruel with egg and zwieback, one, one and a half, and two hours pre- viously. The mass which flowed out was invariably only slightly changed, containing a little mucus, of neutral reaction, without pep- * He chewed the food, and then pressed it from his mouth into his stomach through a large rubber tube. f Cited by Ch. Richet. Du sue gastrique chez I'homme et les animaux. Paris, 1878, p. 88. FEEDING AFTER aASTROSTOMY. 109 tone, and its filtrate liad no digestive action eitliei- on tlie addition of hydrochloric acid or of pepsin. The secretion of the glands, there- fore, had ceased completely and permanently. I wish to state that in the other cases even before the operation, while it M^as still possible to introduce a sound into the stomach, I found the chyme to be like- wise free from the peptic secretion. The same result — i. e., the ab- sence of hydrochloric acid— was found by IsTeschaieff * in 105 exami- nations on four patients with carcinomatous stricture of the oesopha- gus. Riegel f found a diminished or normal secretion — therefore with- out characteristic change — in two cases, but the site of the carcinoma is not accurately given and the stricture was undoubtedly still patent. Under the circumstances wdiich I have described it is evident that we must refrain as far as possible from giving food which in any way demands more of the stomach than that which can be ab- sorbed and passed on into the intestine as quickly as possible. This, therefore, is where the various peptone preparations are indicated. They must be supplemented with carbohydrates and fats. In order to compensate for the absence of the diastatic action of the saliva we give its product, glucose, or we allow the patients to mix the food with saliva by mastication and then to transfer it by means of a tube directly from the mouth to the stomach. In such cases the nutrition depends entirely on the preservation of the absorptive and motor functions of the stomach, and therefore the " diet " of such patients could be made typically simple and restricted to simply a solution of peptone and glucose, together with some fat, were it not that we must take account of their desire to masticate and taste the food and thus satisfy the sensation of hunger as well as their ges- thetic sensations. Even our patient chewed meat and zwieback, and forced the masticated morsels into the fistula through a rubber tube in the firm belief of thus " offering something to the stom- ach." Luckily, it did not accept this, but, as it seems, promptly transferred these morsels into the intestines. * Lancet, June 4, 1887. It is not stated where the original paper is to be found, and it remains doubtful whether Neschaieff examined the contents of the oesopha- gus — or diverticulum — or of the stomach. f F. Riegel. Beitrage zur Diagnostik der Magenkrankheiten. Zeitschr. f. klin. Med., Bd. xii, S. 434. LECTUEE lY. STENOSES AND STEICTUEES OF THE PYLORUS. MEGASTEIA AND GAS- TRECTASIA, DILATATION OF THE STOMACH. Gentlemen : To-day I shall show you a series of plaster casts of stomachs which were made by filling the viscus with liquefied tal- low after it had been removed from the body and tying at both cardia and pylorus. Matrices were then taken from the casts thus formed, and the plaster models made from these. Fig. 11. Fig. 12. Fig. 13. [Fig. 11. — Cast of cylindriform stomach in vertical position. Female. Ziemssen. Fig. 12. — Cast of normal stomach. Female. Ziemssen. Fig. 1.3. — Cast of dilated stomach in vertical position. Female. Ziemssen. — Te.] At the request of Prof, von Ziemssen a Munich artist has made papier-mache models of the pathological forms only, and of these I am enal:)led to show you two specimens of enormous gastric dila- tation [.see Figs. 11, 12, 13, and 14].* You can most thoroughly * [Figs. 11, 12, 13, and 14 are from photographs of some of these plaster-of- Paris casts. They were all taken at the same distance from the camera, and were placed in the position which they occupied in the body. The differences in form, position, and size have thus been preserved. Concerning the vertical position of the stom- ach, see p. 117.-^Tr.] VARIATIONS IX SIZE OF STOMACH. m convince yourselves of the -well-known fact * of the variations in form and size of the stomach by examining these remaining eight or ten specimens, all of which were obtained from persons of about the same size, who had never dur- ing life complained of any dis- turbance of digestion. Besides the simple purse-shaped, we find stom- achs which are elongated, almost like a sausage, and others in which — be it remembered, "without the action of cicatricial contraction — a marked exaggeration of the so- '-^ _ _ [Fig. 14. — Cast of a markedly dilated stom- ealled antrum pylori (i. e., the ach tending to assume vertical position. 1 . J. 1 • • £ i. £ iX. Female. Ziemssen. — Te.1 lower quarter lying m front oi the -' pylorus) has almost caused the viscus to assume tlie shape of an hour-glass. Just as the form, so varies the capacity of the stomach, which in these preparations was always determined by filling them with water. The largest stomach held 1,680 c. c. [56 fl. oz.], the smallest only 250 c. c. [S fi. oz.] ; between these limits we find all possible variations. From this demonstration you can infer that there is no absolute standard for the size of the normal stomach, at least within the given limits, and that its capacity by no means bears a fixed relation to the size of the body. "We may find a very large stomach in a comparatively small individual, and vice versa. We can only speak of an absolute dilatation of the stomach when it exceeds the given capacity in round numbers of 1,600 to 1,700 c. c. [53 to 5Y fl. oz.]. But the stomach may be actually much smaller and yet be relatively dilated for the individual. Finally, as Kussmaul and Rosenbach+ have already shown, there exist very large stomachs which exert no disturbing influence on * For example, Von den Velden has laid great stress upon this in his paper, Ueber Vorkommen und Mangel der freien Salzsaure im Magensaft bei Gastreetasie. Deutsch. Archiv f. klin. Med.. Bd. 23, S. 369. His results are based upon the clini- cal lectures of Prof. Kussmaul. f O. Rosenbaeh. Der Mechanismus und die Diagnose der Mageninsufficienz. Volkmann's Sammlung klinisehe Vortrage, Xo. 153, p. 8. 112 DISEASES OP THE STOMACH. digestion, so that tliey are discovered accidentally wliile making some other examination. I therefore distinguish l^etween the large stomachy inegastria, and the enlargement of the stomachy gastric dilatation or gastrectasia, which in turn is to be divided into an acute or subacute and a chronic form. Megastria may lead to dila- tation, but is not a pathological occurrence. Thus it amounts to an anatomical condition, while the nature of dilatation is that of a functional disturbance, combined with a progressive anatomical process. Germain See * also distinguishes between simple dilatation, which may exist for a long time, or even permanently, without creating any disturbance and dilatation with dyspepsia — i. e., that condition which we commonly regard as gastric dilatation, by which we do not mean simply a large stomach, but that there is at the same time a morbid disturbance of its function. I understand dilatation of the stomach, or gastrectasia to be that condition of the viscus which is accompanied by the clinical symptoms of disturbed gastric function due to the enlargement of the organ, and megastria to be the ac- quired or congenital large stomach the abnormal anatomical state of which is functionally compensated. The " large stomach " may become catarrhal, and its owner dyspeptic ; but, clinically speaking, such a patient has no gastrectasia, although more disposed thereto than others. Megastria and gastrectasia have frequently been confounded with each other. An entirely different condition, if I maj^ anticipate, is gastric insitfficiency, which indeed may and fre- quently does lead to the symptoms of gastrectasia, yet does not have the anatomical basis of the dilated stomach, but is a functional disturbance occurring in the most varied conditions of size of the organ. We possess the following diagnostic aids for the recognition of the large or dilated stomach: 1. Inspection. — With relaxed and thin abdominal walls we fre- quently see the left hypochondriac region and a larger or smaller portion of the right, according to the extent to which the stomach is filled with air or ingesta, bulge out like a hemisphere or balloon, * Germain See. Du regime alimentaire. Paris, 1877, p. 280. PHYSICAL SIGNS OF GASTRECTASIS. II3 beginning just below the free margin of the ribs. The lower border of this swelling crosses the mid-line on a level with the umbilicus, or below this, between it and the symphysis. At times there is only a lower projection present, with a trough-like depression between it and the free border of the ribs, which is caused, as a rule, by the long axis of the stomach assuming a more or less vertical position ; occasionally, however, it may be produced by the region of the lesser curvature becoming collapsed, while the fundal zone is inflated or filled with ingesta. In the former case the lesser curvature runs parallel to the spinal column in the middle line, or even to the left of it, and in highly marked degrees of this condition it only passes to the right on a level with the umbilicus, so that even the pancreas may be felt between the margin of the liver and the stomach, and may be mistaken for a gastric tumor [see Fig. 15]. Peristaltic waves may travel over the stomach from left to right, either in con- stant succession or as the result of external mechanical irritation ; antiperistaltic motions may also be observed (Bamberger,* Cahn,f Glax :{:). If we inject air into the stomach, these conditions become still more marked, and the gradual appearance of the viscus as it be- comes distended produces as a rule a very characteristic picture. In advanced dilatation the body is usually, though not always, emaci- ated, the abdominal walls are relaxed and slightly sunken, and the false ribs on the left side are raised like a wing. The skin is dry, pale, and somewhat tawny. 2. Percussion. — Should any suspicion of dilatation exist, it is best before percussing to first distend the stomach with air. (Lect- ure II, page 59.) Only lately I have had occasion to experience the importance of using the double-bulb apparatus instead of setting carbonic-acid gas free in the stomach. A colleague failed to recog- nize a marked dilatation, which extended to midway between the umbilicus and the symphysis, in spite of his having given a Seidlitz powder to the patient, because the quantity of gas evolved was actu- * L. Bamberger. Krankheiten des chylopoetisehen Systems. Erlangen, 1855, S. 325. f A. Cahn. Antiperistaltische Magenbewegungen. Deutsch Archiv. f. klin. Med., Bd. 35, S. 402. X A. Glax. Ueber peristaltische und antiperistaltische Unruhe des Magens. Pester med. ehirurg. Presse, 1884. X14 DISEASES OF THE STOMACH. ally insufficient for the capacity of the stomach. The percussion note over the inflated stomach is always tympanitic and more or less high according to the contents and the tension of its walls. Should the transverse colon be markedly distended and the curvature of the stomach lie immediately next it, it may at times emit the same note, and thus render it an impossibility to define the boundary between the two organs by means of percussion. In such a case we must either fill the stomach with fiuid, and then percuss in order to con- trast its dullness with the tympanites of the colon ; or we must force more air into the latter from the rectum, thereby producing either a change in position or a higher tympanitic note. Here it is w'ell to remember that the more delicate differences in sound fre- quently become more distinct by the use of auscultatory percussion when the ordinary method of percussion with the pleximeter leaves us in the lurch, and that therefore this method can also be utilized in doubtful cases. Ferber * has called attention to the fact that the circular, tympanitic " stomach-lung region " {Magen-Ltmgenrmmi) formed by the stomach under the lower lobe of the left lung gradually disappears behind the axillary line if the organ be normal, while if it be dilated it may be traced to the vertebral column. Yet it is evident, a priori, that this must depend essentially upon the quantity of gas and ingesta in the stomach and intestines. These force the organ more or less into the hollow of the diaphragm in such a manner that the resulting tympanitic zone in favorable cases may and indeed does extend as far as the vertebral column even with a stomach of normal size. Judging by my experience thus far, the following method, recommended by Dehio f for determining the boundaries of the stomach in normal and pathological conditions appears to be far more valuable. On an empty stomach the patient drinks a litre [quart] of Avater interruptedly in four portions of i litre [ § viij] each. If, now^, after every \ litre we percuss out the resultant lower crescentic limit of dullness against the tympanitic transverse colon, we find in a healthy person, while erect, that the * Ferber. Ein Beitrag zur Magenpercussion, etc. Deutsche Zeitschr. f. prakt. Med., 1876, No. 42. f Dehio. Zur physikalischen Diagnostik der mechanisehen Insufficienz des Ma- gens. Verhandl. des vii. Congresses f. innere Medicin, 1888. PHYSICAL SIGNS OF GASTRECTASIS. 115 stomach moves downward according to the greater amount of fluid it contains, but that it never extends beyond the umbilicus as a rule, coming onlv to within a few centimetres [an inch] of the same. In the recumbent posture we get a tympanitic note due to the air swal- lowed with the water, and this prompt change of the percussion note is a strong proof that we are dealing with the stomach and not per- chance with the intestine. At the same time this procedure allows us to recognize the con- ditions, to be discussed presently, of motor insufiiciency or atony of the stomach— i. e., its temporary dilatation and its persistent ecta- sis — which so often is the immediate result of the former ; for it is evident that the more relaxed the gastric walls are, the sooner will the lower boundary of the stomach reach its most dependent posi- tion even after the introduction of small quantities of fluid, or in cases of marked dilatation it will be found in an abnormally low position at the very commencement. The conditions which must exist to enable us to use this method of exploration are, of course, that the intestines and especially the transverse colon must contain air ; that there is no abnormal configuration of the stomach ; and, finally, that the abdominal walls are not so thick as to entirely pre- vent the transmission of the more delicate differences in sound. Finally, I quote the results of Pacanowski,* which he obtained by the careful examination of 81 cases — 55 males and 26 females — in order to give you some criterion whereon to base your ideas of the normal size of the stomach, or, better, of that part which is pro- jected upon the abdominal walls when the organ is filled with air nnder medium tension. Agreeing fairly closely with earlier observ- ers ("Wagner, for instance), he found that in the left parasternal line the lowest boundary of the stomach in men lies most often 3 to 5 centimetres [1^ to 2 inches] above the umbilicus, and 4 to Y centi- metres [If to 2|- inches] above in women. The distance between the highest and lowest points of the zone of stomach tympanites was 11 to 14 centimetres [4|- to 5|- inches] in men and about 10 centimetres [1 inches] in women. The width of this zone amounted to 21 centi- * H. Pacanowski. Beitrae: zur percutorischen Bestimraung der Magengrenzen. Deutsch. Arch. f. klin. Med., Bd. xl, S. 343. 116 DISEASES OP THE STOMACH. metres [Sf inches] and 18 centimetres [Y-g- inches], respectively. Nevertheless, in accord w^ith our experience, spoken of at the com- mencement of this lecture, concerning the varying conditions of size of the normal stomach, Pacanowski found fairly marked deviations from these averages. Thus, for instance, he gives 9 centimetres [3f inches] and 20 centimetres [8 inches] for the vertical measurement, and 16 centimetres [6f inches] and 25 centimetres [10 inches] for the width, and that without being able to infer that pathological conditions existed. From this, therefore, it is also manifest that the absolute conditions of size, as far as we are able to arrive at them by the physical methods of examination, are to be regarded as of only conditional value in the diagnosis of dilatation of the stomach — i. e., only in cases of excessive ectasis — for it may easily happen that an originally small stomach may acquire a pathological dilata- tion with its resultant clinical features, and that nevertheless its ab- solute measurement may remain within those bounds which are to be regarded as normal. 3. Palpation. — I will simply mention the palpation of tumors of the pylorus in this place, reserving its explicit discussion for later. Leube has recommended "palpation of the tip of the sound" in order to recognize dilatation of the stomach. A stiff sound is intro- duced into the stomach until it meets with resistance as far as this is feasible without the employment of undue force. If, now, the point of the sound can be palpated below the level of the umbilicus, dilatation of the stomach is proved to exist. This method has been objected to on the ground that it might be dangerous, and that it is frequently impossible to palpate the tip of the sound. Leube has rejected both objections, and, as far as the former is concerned, I fully agree with him. An unusual degree of roughness would be needed to perforate the gastric wall ; but feeling the point of the sound through the abdominal walls is an entirely different matter This can very easily be done if we are dealing with an advanced case of dilatation of the stomach in which the abdominal walls are relaxed and sunken ; but in such cases we can also arrive at a diag- nosis by means of the other methods of examination. However, if the case be that of a comparatively well-nourished person, it is most frequently utterly impossible to feel the sound distinctly, even if we VERTICAL POSITION OF STOMACH. 117 go over the whole abdomen as carefully as we can, palpating one square inch after another. Further, in experimenting on the dead body it has repeatedly happened to me tliat the ti23 of the sound has failed to reach the lowest portion of the stomach. It was much more apt to be caught at some point higher up and to push this before it a little, but it nevertheless remained far above the most dependent portion. Further, we must remember that in men tlie stomach is not infrequently in a vertical position, and that this is the case much oftener in women, a fact already known to F. Meckel. This may be congenital, or it may be due to pressure, traction, etc. The lesser curvature, then, is almost perpendicular, and the pyloric portion of the fundus may extend to below the umbilicus. This malposition may not infrequently be seen in the dead body unac- companied by any abnormal increase in the capacity of the stomach [see Figs. 11, 13, 14, and 15].* Thus the stomach of the performer described by H. Yirchow in the Berlin Anthropological Society,f who was able to swallow a sword 70 centimetres [28 inches] long, may have been in a similar posi- tion. Also, by the cardia becom- ing depressed to the right with the pylorus fixed so that cardia and pylorus lie close together, we can get a marked depression of the greater curvature on account of the sharp bend in the upper border. For all these reasons, there- fore, palpation with the sound will only give us uncertain results, as Albutt :{: says, " I believe that the palpation of the tip of the [Fig. 15. — Stomach in vertical position, hi situ. I'eniale. Ziemssen. — Tr.J * [The views expressed by Lesshaft (Lancet, 1883. vol. i. p. 406) on the vertical position of the stomach have since been gradually accepted by many writers. Ziemssen considers its occurrence very frequent, especially in woraen ; in them it is usually the result of tight lacing ; the lower ribs being fixed and the epigastrium compressed, no room is left for the distended stomach except by swinging on a ver- tical axis whose fixed point is the cardia. The result is well shown in Fig. 15. — Tr.] f Meeting of July 17, 1886. % Loc. cit. llg DISEASES OF THE STOMACH. sound is unnecessary when tlie abdominal walls are thin, while in stouter persons the instrument can not be distinctly felt." 4. Auscultation. — If we place our hands flat on the region of the stomach and give the abdominal walls a series of rapid consecu- tive shocks, or if we shake the body m toto, we can hear, either at a distance or with the stethoscope, sounds of a splashing character with a faint metallic timbre, the so-called succussion or splashing sounds, the Glapotement of the French. * In themselves they have no pathognostic significance. They may arise in the transverse colon as well as in the stomach, and are frequently heard under per- fectly normal circumstances immediately after the ingestion of a large quantity of fluid, when they can readily be produced by short and energetic contractions of the abdominal muscles. They only become pathognostic (1) when they are present some time after fluid has been taken, and (2) when they are positively produced in the stomach. At times the latter can only be determined by completely emptying (siphoning out) the stomach. If, then, the succussion sounds persist, they are to be referred to the intestines. These con- ditions are frequently disregarded, and a diagnosis of dilatation of the stomach is rashly made. In this way only can we explain the fact that certain French authors (Bouchard and others) find dilata- tion of the stomach not only in every dyspeptic, but that Bouchard finds it present in about 30 per cent of all sick people. This is an exaggeration which is not shared by sober-minded observers like Germain See and Dujardin-Beaumetz. Pauli was the first after Penzoldt f to call attention to a sound in the stomach like escaping vapor, similar to that made by uncorking a bottle of Seltzer water, and in fact this can occasionally be recognized on auscultating in the region of the stomach when marked fermentative processes are present. Of a different kind are the sounds called by Kussmaul % " cooing or clapping sounds " {Gurr- oder Klatschgerdusche\ which, * Audhui. Du bruit de flot on de clapotage de I'estomac comme signe de dila- tation de I'estomac. Gaz. des hopit., 1883, No. 47. — Girandeau. De la dilatation de restomac. Arch, general, de med., 1885, p. 342. Duplay, in 1833, was the first to direct attention to this in France. f Penzoldt. Die Magenerweiterung. Erlangen, 1877. X Kussmaul, in Volkmann's Samml. klin. Vortrage, No. 181, published June 16, 1880. PHYSICAL SIGNS OF GASTRECTASIS. 119 as I have mentioned above, may be produced in many persons, both with and without dilatation of the stomach, by the active contraction of the abdominal muscles or by rapidly alternating pressure and re- laxation on the passive abdominal wall. Contrary to the succussion sounds, they are best produced in the erect posture. At times we can hear, even at a distance, the heart-sounds re- sounding with a metallic character from the stomach filled with air. Striimpell * speaks of sounds which could be heard at quite a dis- tance and which were isochronous with resj^iration in a patient with dilatation of the stomach. The note produced in Stdhchen-Plesshn- eter-Percussion f also has a metallic character, and in favorable cases can even be used to define the limits of the organ against the coils of intestine (Leichtenstern). The occurrence of the deglutition-inurinurs can not be utilized in the diagnosis of dilatation. I have never been able to observe any characteristic change in them, although I have examined every accessible case for this purpose. Kosenbach has suggested a method which is based upon auscul- tation of air blown through a tube which is introduced into the stomach. If we pour water into a healthy stomach, introduce a tube below its surface, and blow in air, we will then on auscultation hear large, moist, metallic rales, which disappear when the tube is slowly withdrawn as soon as its eye is above the level of the fiuid. Therefore the surface of the fluid is assumed to be at the spot where the rales cease to be heard. If, after having thus determined this point, we pour an additional quantity of water, say one litre [quart], into a healthy stomach, we will find that the level of the fluid has become appreciably higher, while in the case of an exist- ing dilatation very little displacement is said to occur. In practice this method is quite difiicult to carry out, and may be placed on a plane with Leube's palpation of the sound, inasmuch as it is un- necessary for the recognition of large dilatations, while in less marked conditions it fails of its purpose. * Berl. klin, Wochenschr,, 1879, No. 30. Aus den Sitzungsberichten der med. Gesellschaft zu Leipzig. f [This is a form of auscultatory percussion in which the percussion note is elicited by striking a pleximeter with some hard object, as a lead-pencil, handle of percussion-hammer, etc. — Tk.] 120 DISEASES OP THE STOMACH. 5, Mensuration of the Stomach. — The position of the greater curvature may be estimated by the distance to which a rigid sound can be introduced into the stomach till it meets with resistance. According to Penzoldt, this distance, reckoned from the incisor teeth, normally amounts to 60 centimetres [24 inches], and never equals the length of the vertebral column ; in three cases of dilata- tion of the stomach it was YO centimetres [28 inches], so that the length of both the introduced portion of the sound and of the ver- tebral column were equal. Disregarding the factors already men- tioned, namely, that we can never be certain whether the tip of the sound has really reached the lowermost point of the stomach, or whether there may not be a vertical position of the organ, it is impossible to give an absolute iigure for the distance to which the sound may be introduced normally, in view of the variable con- ditions of size, concerning which I have spoken. I shall not stop to discuss such methods as the inflation of a rubber bulb introduced into the stomach (Schreiber) or estimations by means of the manometer (Purgecz), but finally shall consider the diagnostic value of the measurement of the stomach by filling it with water. For this purpose the stomach must be filled as full as possible and then be entirely emptied ; but — when is it full ? We must either rely on the statements of the patients, who generally experience a distinct sensation when the stomach begins to be more markedly filled, or w^e must wait till they vomit the superfluous quantity of water. ISTeither sign can be absolutely depended upon, since the point in question varies with the sensi- tiveness of the patient, and the capacity of the stomach is so dif- ferent individually. Therefore we can only speak positively of an absolutely large stomach when its capacity is more than 1,500 c. c. [f § 1] of water. Etiology of Dilatation of the Stomach. — Dilatations of the stomach are produced by two etiological factors : (1) mechanical stenoses of the pylorus, (2) ahsolute or relative weakness of the expulsive forces — in other words, atonic conditions of the muscularis. It is self-evi- dent that in a normally acting stomacli the relations between con- tents, muscular action, and resistance at the pjdorus must be in the proper proportion ; therefore any change in these factors must lead ETIOLOGY OF GASTHECTASIS. 121 to a disturbance of function, wliich in most cases gives rise to dilata- tion of the organ. However, the requisite relationship may be pre- served by compensation, in spite of abnormal change of the indi- vidual factors, and only when this fails do we get functional dis- turbance, just as in cardiac disease there is no circulatory disturb- ance until the compensation of tlie valvular lesions, etc., becomes inefficient. Oser * has already made use of this explanation as the basis of his discussion of gastric dilatation, and it will also be suffi- cient for us.f For the purposes of com^jensation the organism has hypertrophy of the muscularis at its disposal ; however, it is to be remembered that only rarely does the hypertrophy of the muscular layer manifest itself in an appreciable thickening, but that as a rule it is not recognizable, since the individual fasciculi are separated and at the same time spread out by the dilatation of the organ. How- ever, if under such circumstances it were possible to conceive of the stomach being reduced to its normal size, the amount of muscular tissue remaining the same, we would find this layer quite markedly increased in thickness. In order to gain a satisfactory insight into the nature of dilata- tion of the stomach we must above all recognize the fact that we have always to deal with a consecutive process, a symptom, but not with an independent disease, and that therefore the most varied causes may be involved, as long as they call into existence the pre- liminary conditions soon to be spoken of. To be sure, the clinical picture of dilatation of the stomach, wdien it is fully developed, is very uniform, and so marked when contrasted with this diversity of the etiological factors, that as a rule it predominates and more or less relegates the original trouble to the background. Yet, for this very reason, it becomes our imperative duty to seek for the cause in every case of dilatation of the stomach, especially since by its recognition the prognosis is by no means immaterially influenced. * L. Oser. Die Ursachen der Magenerweiterung. Wiener med. Klinik, 1881, No. 1. f [Oser has graphically represented this relation in the formula C > I 4- W, in which C = contractility of the stomach, I = resistance from gastric contents, and W = resistance at pylorus. The results of disturbance of these factors in causing dilatation and the changes which are necessary to maintain the normal relations may be seen at a glance. — Tr.] 122 DISEASES OF THE STOMACH. For, according to the character of this causative factor will there be a transient or permanent condition, a reparable or an irreparable disturbance. We must therefore differentiate, as I have already mentioned at the opening of this lecture, between functional and organic dilatations ; i. e., between those forms of dilatation of the stomach which do not result in a material lesion of the motor appa- ratus together with its nerves — therefore those which can be cured — and those in which the circumstances will not permit such a result because severe degenerative processes have develoj^ed in the gas- tric wall. But at times the functional dilatations may even arise acutely ; at any rate, they are always of relatively short duration, so that they do not lead at all to the classical symptoms of dilatation of the stomach, or only do so transiently ; they run the course rather of dyspeptic conditions peculiar to the special underly- ing disease of the organ, chronic gastritis, atony, or the neuroses. Therefore I shall defer the discussion of these functional or repara- ble dilatations until I come to treat of the affections just mentioned. It is at once apparent, however, that these two groups are not independent of each other, but that the first can and does become transformed into the second when the causative conditions persist. Unfortunately, the latter is the rule, the former the exception ; for in the majority of cases we are unable to remove the primary cause of the trouble even after having discovered it, partly because, in the very nature of the matter, we can only recognize the con- dition when it has reached a relatively advanced stage, and partly because it lies beyond our power, even at the beginning, to eradicate the causative factor. However, if the latter be the case, if we suc- ceed in removing the cause, and if the dilatation has not become organic, it will then be possible to cure it. This seems to me to have been proved by a case of Klemperer,* which thus far is the only one of its kind in literature. It was as follows : Cicatricial stricture of the j^ylorus, produced by the corrosive action of hydro- chloric acid, consecutive dilatation of the stomach (capacity 2| litres [O vss.]), operation upon the stenosis, cure of the gastric dilatation, so that several months later the stomach of the patient, who died of * Klemplerer. Verein fiir iunere Medicin in Berlin. Meeting of February 4, 1889. Deutsche med. Wochenschr., No. 9, S. 170. ETIOLOGY OF GASTRECTASIS. 123 plithisis in his thirty-fifth year, although large, was found to be not truly dilated. The mechanical factors ichicli lead to the stenosis or occlusion of the pylc/rus are situated either in the wall of the stomach itself or extend to it from without. Among the most frequent causes of the former class and of prime importance are carcinoma and cica- tricial contraction, whether this be due to direct cicatrization of an ulcer, or produced by inflammatory processes following ulcer or phlegmonous gastritis. Under the former circumstances it is not necessary for the carcinomatous proliferation to surround the pylo- rus like a ring ; it may be situated above the pylorus and have warty or polypoid excrescences, which force themselves into the orifice somewhat like a cork. I observed such a condition in a case in which a very vascular polypoid tumor, larger than a walnut, was situated on the posterior wall of the stomach, its base being about 3 centimetres [1|- inches] above the pylorus, and which during life must have more or less completely occluded the passage like a ball valve according to its vascularity ; the pylorus, although somewhat narrowed, would easily admit the little finger (Fig. 16). Bernabel * reports a similar case, which is remarkable, however, by the formation of true pedunculated polypi. The largest was 6" 8 centimetres [2f inches] in length, and was situated on the anterior wall of the stomach, 5 centimetres [2 inches] above the pylorus. In Cruveilhier f may be found the drawing of a tumor, about the size of a potato, situated in the duodenum immediately below the pylo- rus, which must have had the same effect as a true pyloric stenosis. Unique among such obstructions is the case described by Pertik, j^ in which a diverticulum shaped Kke a glove-finger was situated in the duodenum at the level of Yater's papilla, which, according to the degree to which it was filled by the chyme coming from the stomach, must have prevented its passage through the duodenum. Congenital stenosis of the pylorus may also be included among * Bernabel. Contribuzione al etiologia del vomito mecanieo da polypo gastrico. Rivist. clin. di Bologna, 1882. f Cruveilhier. Anatomie pathologique du corps humain, Livr. 4, pi. 1. X 0. Pertik. Beitrag zur Aetiologie der Magenerweiterung. Yirchow's Arch. Bd. 114, S. 437. 124 DISEASES OF THE STOMACH. Fig. 16. — Very vascular, polypoid tumor, on posterior wall of stomacli, li inch above the pylorus. ETIOLOGY OP GASTRECTASIS. 125 the mechanical constrictions ; such cases have been described by Landerer* and R. Maier.f There may be either a round or a sHt-hke contraction of the ostium pylori, or the muscular portion of the pylorus may be hypertrophied, and the pyloric portion of the stomach present a spherical or conical appearance, in which latter case it projects into the duodenum like the cervix uteri into the vagina. This hypertrophy, by the way, can readily be distinguished from the form produced by chronic catarrh of the mucous mem- brane. It is very apparent that such stenoses may cause the deveh opment of a dilatation as soon as the expulsive power of the pyloric portion of the stomach becomes unable to overcome them — in other words, as soon as the antrum pylori passes from the stage of hypertrophic compensation into that of insufficiency. When this will occur depends naturally upon individual circumstances. While in these cases the obstruction to the emptying of the stomach is manifest, in other cases we find the pylorus patent after death, and yet have dilatation of the stomach, for which the factors of absolute or relative muscular insufficiency, soon to be discussed, can either not be applied, or are not sufficient to account for it. Kussmaul :{: has shown by experiments on the cadaver that with great relaxation of the abdominal walls the pylorus may assume a vertical position due to the rotation of the full stomach, and at the same time so twist and compress the horizontal portion of the duodenum at its junction with the stomach that not a drop of fluid can escape into the duodenum. As can readily be understood, the lumen of the intestine may be occluded by bending, not at the pylorus, but somewhat below it, where the horizontal curves into the descending portion ; this takes j)lace when the stomach is filled and its ligaments relaxed, so that it drags the horizontal portion of the duodenum down with it. If, in addition, there exists a con- stricting stenosis of the pylorus, then dilatations of the duodenum, in the form of ampullae, may be added to the dilatation of the stomach, as is typically depicted in the accompanying drawing, * Ueber angeborene Stenose des Pylorus. Inaug. Diss. Tubingen, 1879. f R. Maier. Beitrage zur angeborenen Pylorus-stenose. Virchow's Arch., Bd. cii, S. 413. :|: Loc, cit. 126 DISEASES OP THE STOMACH. taken from a paper bj Calm,* which at the same time gives a good idea of the position of the stomach in marked dilatation (Fig, 17). Fig. 17. — Cancer of pylorus, with dilatation of stomach and duodenum. Distance of the greater curvature from the symphysis = 4 ctm. [1§ inches]. Portion of the oesophagus in the abdominal cavity = 4 ctm. [1| inches]. Length of lesser curvature = 10 ctm. [4 in ches]. c = carcinoma. ^ = pancreas ; it has sunk behind the lesser omentum to the level of the second lumbar vertebra, d = horizontal portion of the duodenum ; its verti- cal portion descends to the pelvic brim, s — stomach. * Cahn, Ueber antipei'istaltische Magenbewegungen. Deutsch. Arch. f. klin^ Med., Bd. xxxv, S. 414. ETIOLOGY OP GASTRBCTASIS. 127 An additional factor may perhaps be found in tlie following; : While under the usual circumstances the demarkation of the pylo- rus from the duodenum consists only in a slight constriction or incline, but passes perfectly smoothly on to the stomach, we occasionally find an actual ring, so that on section of the stomach the pylorus looks as though a cord had been drawn underneath the mucous membrane. A small pouch is consequently formed on the gastric side of the orifice, which may easily become dilated from the pressure of food, and thus gradually lead to a true dilatation. Necessarily, an uncommonly firm closure of the pylorus would be requisite for this to occur — i. e., a spasmodic contraction. This brings me to the last cause which, situated within the stomach, is said to lead to gastric dilatation by closure of the pylorus — the spastic contractions of this orifice. Such a con- dition was very obvious in the case on which Sanctuary * performed an autopsy. The pylorus was quite patent, but above it lay an egg-shaped ulcer, surrounded by normal mucous membrane, 2^ inches long and 1 inch wide, the irritation of which, from the movements of the food, evidently produced a marked spastic contraction of the entire pyloric region. A pronounced dilatation of the stomach had been diagnosticated during life. However, of all the causes which have been brought forward to account for dilatation, where there is no tangible narrowing of the pylorus, spastic contraction appears to me to be the most doubtful ; for it lies in the very nature of spastic contractions that they do not per- sist continually, but relax at times — consequently, that they can not produce any lasting obstruction. According to our present ex- periences, which appear to be pretty generally recognized, spasm of the pylorus is produced by excessive acidity of the stomach- contents ; according to this, all cases of hyperacidity would finallj^ have to lead to dilatation of the stomach, which, at least as far as our present knowledge goes, is surely not the case. Yet Germain See f has lately expressed the view that a very definite * Sanctuary. Notes of Cases of Dilated Stomach, with Remarks. British Med. Journal, 1883, p. 613. f Germain See. Hyperchlorhydie et Atonie de I'Estomac. Bull, de TAcad. de med. Seance, d. 1 Mai., 1888. 128 DISEASES OF THE STOMACH. causal interdependence exists between hyperacidity — i. e., increased secretion of liydrocliloric acid — and atony of tlie stomacli, which may lead to its dilatation. Meanwhile, his cases do not present the picture of acute gastric dilatation, with its classical symptoms ; they could much more readily be included among the functional dilatations, in so far as the question of dilatation of the stomach is concerned. Yet it is possible that the condition of the pylorus, just mentioned, in such spasms, might be an important factor in the development of dilatation. But, should we ascribe persistence to such a spasmodic closure of the sphincter, then naturally it must in time lead to a form of compensatory hypertrophy of the mus- cnlar layer at the pylorus ; and to such a condition the cases of so- called idiopathic hypertrophic stenosis of the pylorus, found in literature, are probably to be referred. A well-observed case of this kind, with reference to the final result, is that reported by Nauwerk.* A woman, twenty -three years old, had sufPered for ten months with slight dyspeptic manifestations. After swallowing some cherry-pits symp- toms of closure of the pylorus suddenly ajopeared, continuous, obstinate vomiting, and absolute constipation. Death followed three months later. The muscular layer at the pylorus was found to be 7 millimetres [J inch] thick, the mucosa 4 to 5 millimetres [| inch], the serosa 2 millimetres [j-V incli], the pyloric orifice being quite patent. No neoplasm could be found either on macroscopic or microscopic examination. There were ten cherry-pits still present in the enormously dilated stoinach. According to our present ideas, we would be compelled to regard this hypertrophy as having been caused by hypersecretion of acid. The causes, situated external to the stomach, which may lead to stenosis or occlusion of the pylorus, are either tumors which exert pressure upon the pyloric orifice (or the duodenum), or which em- brace and grow around it ; such neo]3lasms arise either from the pancreas, the omentum, the retroperitoneal glands, or the liver. ]VIinkowski f reports a rare occurrence of this kind in which he observed a hard tumor which was considered a cancer of the pylo- rus during life, combined with dilatation of the stomach, but which * Nauwerk. Ein Fall hypertrophischer Pylorusstenose mit hochgradiger Ma- generweiterung. Deutsch. Arch. f. klin. Med. Bd. xxi, S. 573-580. f 0. Minkowski. Ueber die Gahrungon im Magen. Mittheilungen aus der med. Klinik zu Konigsberg in Preussen, S. 168. ETIOLOGY OF GASTRECTASIS. 129 after death was found to be the gall-bladder entirely filled by a large calculus ; this compressed the pylorus completely and led to the enormous dilatation. In this case examination for liydrochloric acid would have definitely excluded carcinoma, even though, as we shall see later, this is not positive ; at any rate, it is at times abso- lutely impossible to differentiate between tumors of the liver or gall-bladder, or biliary calculi and neoplasms of the stomach. Fur- ther, if an old peritonitis gives rise to cicatricial bands which sur- round the pylorus or force it toward the posterior abdominal walls, and make traction upon or bend the pylorus — or the horizontal portion of the duodenum — we may also get pyloric stenosis. Roki- tansky * has seen cases of gastrectasis which were caused by large scrotal hernise exerting traction upon the stomach and dislocating it (and possibly also bending the duodenum ?) Bartels was the first to call attention to the joint occurrence of wandering kidney on the right side and dilatation of the stomach, accounting for the latter by the pressure made by the kidney upon the duodenum ; this form can not become marked unless its existence dates from child- hood. Malbrancf agrees with him, and Schiitz :{: reports the case of a woman whose difiiculties rapidly disappeared on leaving off her corsets, which were supposed to have exerted pressure on the dislocated kidney. Furthermore, Litten has called special attention to the connection between diseases of the stomach and change in position of the right kidney,* and has seen displacement of the right kidney and dilatation of the. stomach occurring together in no less than 55 per cent of his cases. In common with Bartels he regards the dilatation as the primary trouble, and the wandering kidney as secondary to it ; while I agree with Oser, IS^othnagel, and Leube,! and wish to emphasize the fact that no causal relation exists in the majority of cases, but that it is a simple coincidence. Fur- thermore, in this question we must distinguish between the simple * Rokitansky. Handbuch der pathol. Anatomie, Bd. ii, S. 178. f Malbrane. Ein complicirter Fall von Magenerweiterung. Berl. klin. Woch- enschr., 1880, No. 28. I E. Schiitz. Wanderniere und Magenerweiterung. Prager medicin. Woch- enschr., 1885. January 14th. * Verhandlungen des Congresses fiir innere Medicin. Wiesbaden, 1887, S. 223. I Loo. cit., S. 225. 130 DISEASES OF THE STOMACH. palpable and tlie true wandering kidney. Among seven cases of movable and displaced riglit kidnej — i. e., true wandering kidney — whicli Brentano was able to collect in a few weeks in tlie poli- clinic of tlie Augusta Hospital, three women bad gastric dilatation ; among twelve cases of simple palpable kidney there was only one without dilatation of the stomach. I can thus confirm the fact that a movable right kidney and dilatation of the stomach frequently oc- cur, especially in women, without on that account agreeing with Bartels, who believes that on deep inspiration the kidney is forced down by the liver, when at the same time a narrowing of the lower half of the thorax also exists, and that the duodenum is compressed between the liver and the kidney. To bring this about the kidney would necessarily have to be fixed ; but its characteristic is just its mobility ; hence it slips away, and it is only necessary to have seen in an animal how energetically the intestinal contents are forced on to appreciate how easily such an obstruction could be overcome. I think Landau * is right when he says that, even for physical reasons, the kidney would be unable to exert the necessary pressure on the gut. The second great group of dilatations of tlie stomach arises from weakness of the gastric muscle, and differs from that first spoken of in that as a rule the stomach is dilated only to a slight degree, while the hypertrophy of the muscularis is absent. I shall describe these conditions as atonic gastric dilatations caused by asthenia or akinesis \_a, without KLveco, I move\ f of the stom- ach. Predisposing factors are : 1. Weakening of the muscidar tone^ due either to excessive demands (perhaps traumatisms ?) upon the muscle and its gradual relaxation, or to insufficient nourishment of the contractile elements of the gastric wall in anaemia, chlorosis, nervous affections, acute and chronic diseases of an exhausting na- ture, peritonitis, amyloid degeneration of the vessels. Thus we find * Landau. Die Wanderniere der Frauen. Berlin, 1881, S. 44. f The ancients called conditions of this kind frigiditas stomachi. Todd was probably the first to use the term atony ; Andral introduced the phrase dyspepsie par asthenie de Vestomac ; Broussais designated it dyspepsie asthenique. The most varied dyspeptic conditions were included under this term. ETIOLOGY OF GASTRECTASIS. 131 tliat clironic gastric catarrh must also be included among the etio- logical factors of dilatation of the stomach. Since the catarrhal condition causes the ingesta to remain for a longer time than normal in the stomach, it is overburdened, and a relaxation of the muscle is produced, which, as we shall see when speaking of atrophy of the stomach, finally leads to separation of the fibers of the submucosa and muscularis ; dilatation of the organ is the result, just as the bladder, when afiiected with catarrh, finally becomes the seat of paralytic dilatation. It is in this sense that we must understand Cloizier * when he includes deficient hygiene in combination with continual erect position of the body among the causes of dilatation of the stomach. The excessive tension of the walls of the stomach is not only brought about by overloading the stomach with improper quantities of solid masses, with which the muscle is unable to cope, but also by the abnormal production of gases in the stomach, together with closure of the orifices ; the latter may be of a mechanical nature from the commencement, and due to one of the aforementioned factors, or may be due to the occurrence of an abnormal fermentation of the ingesta, which only leads secondarily to muscular insufficiency. As Miller's f experiments have proved, and as daily experience con- firms, such primary fermentations will always arise whenever an improper proportion exists between the micro-organisms which are present or which are introduced into the stomach, and the amount of hydrochloric acid, Avhich normally has an antiferinentative action ; thus too many zymotic organisms may be introduced while the quantity of hydrochloric acid secreted is normal, or the latter may not be enough for their disinfection. As we know best from our observations upon the intestines, the products of fermen- tation, when absorbed, cause an irritation of the muscle, which, as long as the contractibility is intact, probably leads also to the simul- taneous closure of the sphincters, and in this way causes an abnor- * Cloizier. De la dilatation dite primitive de I'estomae. Bull, med., 1888, p. 124o. f Miller. Einis:e gasbildende Pilze des Verdauungstraetus, ihr Schicksal im Magen und ihre Reaction auf verschiedene Speisen. Deutsche med. Wochenschr., 1866, No. 8. 133 DISEASES OF THE STOMACH. mally long detention of the fermenting masses in the stomach. Later, owing partly to mechanical distention, partly to the venous stasis intimately connected thercM-ith, structural changes are pro- duced in the mucosa and muscularis ; also paresis and degeneration, and thus, finally, muscular insufficiency of the organ. Thus it is that we find dilatation of the stomach so frequently in gluttons, diabetics, insane patients with polyphagia, etc. ; it may also develop from chronic gastric catarrh, or (probably most frequently) it may arise from a combination of both causes. It is especially due to I^aunyn, * and his pupil Minkow"ski,f that these processes have been properly considered. 2. Weakness and paralysis of the motor nerve-fibers of the stomach, or diminished excitability of the nervous apparatus, pre- siding over peristalsis, may be caused by local lesions, such as destruction by ulceration of the branches of the vagus entering the stomach (Traube), or by processes of inhibition arising from other portions of the nervous system — for instance, the para- lyzing influence exerted by chronic peritoneal exudations (Bam- berger), or even by a simple catarrh of the stomach, just as paralyses of the muscles of the vocal cords are produced by lar- yngeal catarrh. Perhaps it is here that we must include those rare cases of atonic dilatation of the stomach which, quite con- trary to the ordinary course of events, develop as the result of chronic, obstinate constipation, when, as a rule, just the opposite occurs. AVe know that there is no sharp line of demarkation be- tween the peristalsis of the intestines and that of the stomach, but that, rather, the peristalsis of the upper portion of the intestines can be obliterated by the contractions of the stomach, as Braam-Houck- geest "^ has shown. Inversely, persistent sluggishness or paresis of the intestines might give rise to diminished peristalsis in the stomach. Gr. See and Mathieu * have also called attention to this * B. Naunyn. Ueber das Verhaltniss der Magengahning zur mechan. Magenin- sulflcieiiz. Deutsch. Arch. f. Idin. Med., Bd. xxxi, S. 225. f Minkowski, Joe. cit. X Ewald, Klinik etc. I. Theil., 3. Aufl., S. 192. * G. See et Mathieu. De la dilatation atoniqiie de Testomac. Rev. de med., 1884, 10 Mai, 10 Sept. ; and A. Mathieu. Les phenomenes nervo-moteurs de la dyspepsie gastrique. Gaz. d. hopit., 1888, No. 47. PATHOLOGY OF GASTRECTASIS. 133 point. I saw a very convincing example of tliis in a lady thirty years of age, who had suffered with obstinate constipation since childhood (the trouble, as is not at all infrequent, was hereditary in her family), and who, in the course of my observations, extending over a period of two years, although she had never before com- plained of stomach trouble, acquired a typical dilatation of tlie stomach, without, it is true, any marked signs of decomposition, but yet without any other referable cause. 3. Finally, the expulsive powers may be weakened by the ex- clusion of a more or less sTiwr^ly hounded portion of the muscular fibers of the stomach. Circumscribed canceroiis infiltration and ulcerations which do not stenose the stomach but destroy a portion of its muscle, result at times, if their growth be slow enough, in hypertrophic dilatation of the stomach. A similar condition is produced when broad bands of the muscular layer of the stomach are destroyed by inflammatory or ulcerative processes, and cause partial dilatation behind the site of the obstruction or complete gastrectasis. Yery instructive pictm-es of this process may be seen in Cruveilhier's celebrated atlas of pathological anatomy.* This, as far as I can see, exhausts the etiology of dilatations of the stomach. I shall now turn to the Pathology. — I have already spoken of the gross anatomical changes, the variations in the size of the dilated stomach, and the changes in the position of the neighboring organs produced there- by — the intestines being forced into the pelvis, while the liver, spleen, and diaphragm may be displaced upward — as well as the nature and shape of possible neoplasms, to which I shall again revert when discussing the symptoms of the disease. At present the changes in the individual coats of the stomach are of special importance. It has been known for a long time that the muscu- laris may be totally or partially thickened, or apparently normal or thinned ; a distinction has thus been made between hypertrophic and atrophic forms. Hypertrophy of the muscularis preponder- ates in the pyloric region, and occurs most frequently with can- cerous or cicatricial stricture of the pylorus. Whether in such cases * [Anatomie pathologique du corps humain. Paris, 1830-1843, 2 vols. — Tr.J 134 DISEASES OF THE STOMACH. there is a true liypertropliy, or only an apparent tliickening of the muscular wall of the stomach, on account of infiltration with can- cerous elements, can frequently be decided only by careful micro- scopic examination. But at times we find the muscle at the pylorus hypertrophied, without the j)resence of any manifest neoplasm or cicatrix, and Lebert* claims to have found an increase in the thickness to l-i millimetres \_-^ inch] — generally it amounts to 5 to 6 millimetres [|- inch], which is already considerable ; this he regards as the result of a chronic hypertrophic inflammation of the muscularis, j)roduced idiopathically, and not by cancerous infilti'a- tion of the muscle. There can be no doubt that the hypertrophic form may gradually pass into the atrophic. The former occurs more frequently in youthful individuals, the latter, without ex- ception, in the aged ; so that in the numerous cases of dilatation of the stomach in old people on whom I have performed autopsies I have never found hypertrophy of the muscularis, it being much oftener, in fact in the majority of cases, of normal tliickness, and far less frequently thinned. The individual muscle-fibers are nor- mal in appearance ; the nuclei stain well with picro-carmine. Since 1874: I have examined a large number of dilated stomachs micro- scopically, but I have never found hypertrophy of the individual muscle-cells, of which Lebert speaks, nor degeneration of these cells into a gelatinous mass (colloid degeneration), as described by Kuss- maul and K. Meyer, and recently also found by Calm ; while frequently there existed a more or less extensive fatty degener- ation. The interspaces between the individual muscular fasciculi appear enlarged and traversed by strands of connective tissue. Yery often an infiltration of small cells is present, proceeding from the submucosa. The latter forms a wide-meshed tissue studded with numerous round cells, and its vessels widely dilated. The mucous membrane presents the picture of chronic gastritis in its different stages. In the glandular cells of the mucosa there is no change at all in many places ; in others they are markedly cloudy and granular ; in still others they show cystic degeneration, or have entirely disappeared in a round-celled infiltration, which * Lebert, loc. cit., pp. 525 et seq. PATHOLOGY OF GASTRECTASIS. 135 also fills and foi'ces tlie meslies of tlie interstitial tissue apart. ]^o- wliere can we recognize that tliey are hypertrophied. Neither do they appear to be increased in number. The interstitial tissue is considerably thickened and studded with numerous round cells ; those ducts of the glands which are present are forced apart and separated by wide intervals, while normally they lie close together (Fig. 18), I have never found conditions which pointed to new Fig. 18. — Cross-section through the mucous membrane of a dilated stomach. The ducts of the glands are forced apart, the interstices entirely tilled by an infiltration of small cells. The glandular epithelium is unchanged in part, partly fatty, and in some places entirely gone. Single epithelial cells may be seen in the interstitial tissue. — Camera lucida. formation or increase (hyperplasia or hypertrophy) of the glandu- lar substance. In the great majority of cases the mucous mem- brane is spread smoothly over the muscularis, and is thinned rather than thickened; yet in the rare forms of hypertrophic dilatation the condition which the French call etat niaramelone is developed, owing to the unequal growth of the mucosa and the muscularis, which leads to the former being thrown up into folds. At first the dilatation of the stomach is found specially at the cul-de-sac i later on it involves the whole organ, A pathological 136 DISEASES OP THE STOMACH. curiosity are tlie rare dilatation-like diverticula wliicli are due to the persistent pressure of indigestible substances (coins, etc.), in tlie stomach. Symptoms of Gastrectasis. — As a rule, patients with dilatation of the stomach, as may be inferred from the nature of its causes, are middle-aged or advanced in years. Yet the more extensive my experience becomes the more am I astonished at the frequency with which it occurs in younger persons, and — is not recognized. Ac- cording to Pauli,* stenosis of the pylorus may be congenital and may give rise to dilatation. Andral f sjjeaks of children being born with stomachs which filled the greater portion of the abdominal cavity. Similar observations have frequently been made, and only a short time ago at the jDoliclinic I found a marked dilatation of the stomach in a girl eighteen years of age, who claimed to have heard succussion sounds (which were very evident at the examina- tion) since her earliest childhood. In the last year and a half, in my own practice, I have seen five cases of considerable and, in part, very marked gastric dilatation in young people between the ages of fifteen and twenty-one — one a farmer's lad, one a pupil at the gym- nasium, and three students. In only one had the trouble been recognized, the others having been treated for " chronic dyspepsia " or " nervous dyspepsia," and in none could a manifest cause for its origin be made out. "Wiederhofer,:|: Comby, * Malibran, |j and others have demonstrated and carefully studied dilatation of the stomach in children which they have ascribed to atonic and anaemic conditions. Before speaking of the symptomatology of dilatation, let me state that we not so very rarely see cases >\diich present the typical clinical picture of gastric dilatation as I am about to describe it to you, and yet in which there is no true dilatation of tlie stomach. * Pauli. De ventriculi dilatatione. Frankfurt a. M., 1839. \ Andral. Grundriss der pathol. Anatomie. Edited by Becker, 1830, ii, S. 91. if Wiederhofer. Gerhardt's Handb. d. Kinderkrankheiten. Bd. W, Abtheil. ii, S. 356 et seq. * Comby. De la dilatation de Testomac chez les enfants. Arch, gener. de med., Aout et Sept., 1884. I Malibran. Contribution a I'etude des ectasies gastriques. These de Paris, 1885. VOMITING IN GASTRECTASIS. 137 I shall designate such cases, as O. Eosenbach has done,* gastric insuffiyciency^ or better, irnotor insujficiency of the stomach. I sliall again refer to this in the coui'se of my remarks on the symptom- atology. The symptoms of dilatation of the stomach always develojD slowly. As a rule, dyspeptic troubles are the first to appear, and they may last for years ; indeed, they may be the only symptom of an already developed dilatation. Thus it is that the latter is dis- covered only on a very careful examination of the patient ; this occurred to me only lately in a young man whose father, a physi- cian, had given him a letter with an explicit description of the symptoms on wdiich he had based the diagnosis of nervous dyspep- sia. In addition to the dyspeptic difficulties — anorexia, pressure and fullness after eating, tension of the abdomen, bad odor from the mouth, coated tongue, epigastric tenderness, malaise, oppression and pain in the head, irregular stool, etc. — we have a characteristic symptom in vomiting. At first this occurs frequently and com- paratively soon after eating, being to a certain extent a therapeutic effort of the organism to relieve itself of the excess of the ingesta, while a portion is retained in the stomach, as urine is in a paralyzed bladder. Later the vomiting occurs less frequently in proportion to the increasing relaxation of the muscle and as the quantity of the collected masses to be evacuated becomes greater ; finally — and this is always a bad omen — it ceases entirely. Then either the obstructing neoplasm has ulcerated, thus again opening the pas- sage into the intestine, or a complete paralj^sis of the muscle has been developed. A characteristic feature of the vomit is its large quantity, which in individual cases has been quite astonishing, and is said to have been as much as 8 kilogrammes [lYf pounds] ! Por- tal says that the stomach of the Due de Chausnes, one of the great- est gourmands in Paris, could hold eight pints of fluid ; and even larger figures are given. It is well known that at times more is vomited than has been eaten, since the remnants of former meals which accumulate in the stomach for a longer time are added. If the vomit, or the masses removed from the stomach through the tube, * 0. Rosenbach. loc. cit. 138 DISEASES OP THE STOMACH. are allowed to stand in a glass cylinder, tliey soon separate into three layers, the upper one of brownish foam, a much laj-ger mid- dle layer of yellowish-brown, faintly cloudy fluid, and a lower one consisting of dark-brown, crummy, and slimy masses, chiefly remains of food. From time to time bubbles of gas rise up through the fluid, carrying particles of the deposit with them, while other frag- ments sink, since they are no longer supported by the carbonic-acid gas. Such a play of bubbles, similar to that which we see in a glass of champagne in which bread-crumbs have been placed, always indi- cates considerable yeast fermentation. Further, we find the ingre- dients of the food in the vomit in a more or less softened and digested condition ; we also find varieties of mucor, sarcinse, yeast, and numberless schizomycetes. At Kussmaul's suggestion Du Barry * examined these vegetable forms more carefully, and isolated them in pure cultures, but, it is to be regretted, without obtaining any definite pathognostic result. We are not justified, from the ob- servations made by this author, in inferring a fermentative action from the presence and growth of the fungi ; at all events, bacteria, yeast, and probably sarcinse also have a definite typical fermentative action. Sarcinae ventriculi, those peculiar colonies of cocci which occur in cubes or as tetrads, were first described by Goodsir in 1842 ; the extensive literature which has been written about them since then has been collected in detail by Falkenheim.f It is a matter of regret that the pathognostic significance of this parasite does not deserve the interest which was accorded to it by physi- cians. As early as 1849 Frerichs apologized for speaking about a subject " the literature of which is perhaps more extensive than its importance warrants " ; thus Falkenheim also was unable to add anything new as to their occun-ence or significance, while he established the important fact in the natural history of sarcinse that at times, according to external circumstances, the same cocci may form either irregular masses or typical sarcinse. Usually sarcinse are present in small numbers or are entirely absent, yet at times in conditions favorable to their growth they may appear in large * Du Barry. Beitrag zur Kenntniss der niederen Organismen im Mageninhalt. Arch. f. exp. Pathol, u. Pharmacol., Bd. xx, S. 243. f Falkenheim. Ueber Sarcine. Arch. f. exp. Pathol, u. Pharmacol., Bd. xix. FERMENTATIONS IN GASTRECTASIS. 130 masses, so that every drop of stomacli-contents is really a pure culture of them ; indeed, F. Eichter * reports a case in which the inspissated masses of sarcinse had led to complete closure of the pylorus. But if, as I have said above, Du Barry was unable, with few ex- ceptions, to refer definite processes of fermentation to individual fungi isolated from the contents of the stomach, their active par- ticipation as a whole is by no means excluded thereby, nor is it proved that their occurrence is insignificant and unimportant. I agree entirely with Minkowski f that their presence, as soon as they appear in larger numbers, invariably permits us to conclude that there exists a severe disturbance of the chemical functions, and that therefore the proof of their presence in the stomach-contents is not to be disregarded. The microscope discloses the presence, and in part also the variety, of the individual organisms ; we may examine either the masses directly vomited or the aspirated stomach- contents, or its fresh filtrate. " In those cases in which, at the height of digestion, or some time after the ingestion of food, large numbers of fungi or bacteria are found in the stomacli-contents, on microscopic examination, we may assume the existence of mor- bid gastric fermentation," says Minkowski ; but he immediately adds that the view of what is meant by " large numbers " is sub- ject to considerable uncertainty. For a few fungi can be found even in tlie contents of the healthiest stomach, where, indeed, they have no importance, since, as I have said above, their development is checked by the hydrochloric acid. This can be seen from the fact that the filtrate of normal stomach-contents may stand exposed for weeks, and even for months, without becoming cloudy or moldy, unless spores fall in from without. However, if large numbers of micro-organisms are present in the stomach-contents, in spite of the free hydrochloric acid, or if their reaction be neutral, or if the acidity be due to organic acids, there is immediately such a development of fungi in the filtrate that the variety of the pre- dominating fermentation may be recognized even by mere inspec- * Riehter, Verstopfung des Pylorus durch Sarcina ventriculi. Virehow's Arch., Bd. cvii, S. 198. f Minkowski, loc. cit. 10 J 40 DISEASES OF THE STOMACH. tion. Thus we may find mold fungi — and this even in the presence of the hydrochloric-acid reaction in the filtrate — in the form of a white or gray scum upon the surface ; or, after being cloudy at first, yeast may be deposited at the bottom of the vessel; or a more equally diffused turbidity, together with a strong sour odor, may be produced by the development of the lactic, acetic, and butyric acid fungi ; or, finally, white zooglea masses, which readily fall apart, may form upon the surface ; these finally lead to complete decompo- sition of the albumen, and to an alkaline reaction, the process being accompanied by the odor of decay. In this way we can in a given case come to a fairly rapid approximate conclusion as to the pre- dominant fermentation fungi, provided we are sure that they have not gained access thereto post festum — i. e., from the air of the room. The latter possibility can only be excluded, unless compli- cated apparatus and procedures are employed, by proving t]ie pres- ence of the fungi immediately after getting the stomach-contents — i. e., by microscopic examination. The latter is, therefore, indisjDen- sable ; and, since also, in the most favorable cases, it always takes at least twenty-four hours, and usually longer, before the filtrate " ger- minates," the diagnostic value of the conditions described above, so highly spoken of by Minkowski, becomes markedly diminished in their essential features, although they will always be of pathognostic interest. At times the vomit contains remnants of food, such as pits,^ fish-scales, etc., Avhich, as the patients can prove, had been eaten months before. Werner * found 17 plum and 920 cherry pits in a dilated stomach, which must have stayed there since the previous •cherry-season — i. e., fully three quarters of a year. But at times such things remain in stomachs which are not dilated. Thus, lately, in the stomach-contents obtained from a neurasthenic I found a .small piece of fish-skin, which, according to the positive statement of the patient, must have been in the stomach for three and a half days. The chemical relations of the gastric juice in dilatation of tlie * "Werner. Zur Casuistik des Magenkrebses, etc. Wiirteraberg. med. Corre- spondenzbl. 1869, 22-24. Could not the man have eaten cherry-pie or dried cherries in the interim ? DECOMPOSITION OF STOMACH-CONTENTS. 141 stomach, in so far as this is not dependent upon the presence of a cancer, seem to be unchanged qualitatively. Should the latter be the cause, we will find all the anomalies of secretion which will be explicitly discussed in the lecture on carcinoma of the stomach. If, on the other hand, we have to deal with cicatricial contractions of the pylorus, atonic conditions of the muscle, hypersecretion, etc., we find, almost without exception, either the usual or increased quantities of hydrocliloric acid, peptone, and propeptone, and the peptic action is satisfactory, though usually somewhat retarded. In 33 cases Riegel ^^ found 0*10 to 0'4:6 of hydrochloric acid ; in 20 cases which I titrated, the acidity due to hydrochloric acid varied between 50 and 80 = O^IT to 0-30 per cent of that acid. Tlie pres- ence of hydrochloric acid can be understood when we recollect that, as far as the microscopic picture permits us to judge, the ducts of the glands are for the most part unchanged, and that the usual se- cretion of mucus in catarrhal conditions, manifestly due to the marked acidity of the stomach-contents, is reduced to a minimum, and that a so-called mucous catarrh of the stomach does not exist. However, this picture of the normal condition of secretion is complicated by the fermentations which take place in the stomach, and which cause secondary decompositions of the stomach-contents. In another place f I have given the schema of the fermentation of carbohydrates, which, depending upon the abnormal decomposi- tion of sugar, appears at times in the form of the so-called oxidation- fermentation (Oxf/dafio?isgdkrtm(jre72), alcohol, aldehyde, and acetic acid being formed from the sugar ; or at other times lactic-acid fer- mentation sets in, in which the sugar is first decomposed into lactic acid, and later into butyric acid, carbon dioxide, and hydrogen. Both fermentative processes are due to the presence of specific organized ferments, among which we can name yeast, oidium lactis, and a number of bacteria, the recognition and isolation of which are to be especially ascribed to Iltippe. Both processes may occur to- gether, and in rare cases may be combined with the products of cellulose fermentation ; though it is questionable whether the latter, * Riegel. Beitrage zur Diagnostik und Therapie der Magenkrankheiten, Zeit- schr. f. klin. Med., Bd. xi, Heft 2 u. 8. t Ewald. Klinik etc. I. Theii, 3. Auflage, S. 125, 142 DISEASES OF THE STOMACH. namely, methane, and sometimes olefiant gas, are derived from the stomach, or whether they have not rather regurgitated from the intestines into the stomach. The best-known case of this kind is that described by Ruppstein and myself j* of a patient who, accord- ing to his own statement, " had at times a vinegar-factory and at others a gas-factory in his stomach," in whom, therefore, the fer- mentation was sometimes combined with a predominant production of acid, and at other times caused a collection of gas. When the latter condition was present, he could ignite the eructated gases through a little roll of paper or a cigar-holder, by holding a lighted match in front of it ; the result was a faintly illuminating flame. In the vomit Ruppstein demonstrated the presence of alcohol, acetic, lactic, and butyric acids, while I found the gases to be composed of carbon dioxide, hydrogen, methane, traces of olefiant gas, oxygen, nitrogen, and sulphuretted hydrogen.f However, under the usual circumstances, it will only be necessary for us to demonstrate the presence of lactic, butyric, and acetic acids, and in practice we can content ourselves with the proof of the first two. It is striking that the total acidity of the stomach-contents is not, as a rule, ex- cessively high, even in cases of very marked decomposition, in spite of the pungent odor, and in spite of the complaints of the patients concerning the acidity of the regurgitated or vomited masses ; this is evidently due to the fact that when the acids are formed they become rapidly converted into neutral or basic salts. This is also the reason why the conversion of starch into sugar is but slightly changed. Granulose is but seldom found ; we most frequently get erythrodextrin and large quantities of achroodextrin or maltose. Another form of abnormal chemical change leads to the prod- * A. Ewald. Ueber Magengahrurag und Bildung von Magengasen mit gelb brennender Flamme. Reichert's und Du Bois' Archiv, 1874, S. 217. f [The literature on this subject will be found in a paper by J. MeNaught. A Case of Dilatation of the Stomach, accompanied by the Eructation of Inflammable Gas. British Medical Journal, 1890, vol. i, p. 470. In this case the analysis of the gas was as follows : CO2 56"0 per cent. H 280 " " CH4 6-8 " " Residualair 9-2 " " 100-0 — Tr.] SYMPTOMS OF GASTRECTASIS. I43 nets of decomposition of albumen — amido-acids and ammonia — which are characterized bj their pecuHar foul odor, and under the microscope by the prevalence of cocci, vibriones, and masses of zooglea, some of which may be seen spinning about in the field in a lively manner. The reaction of the stomach-contents is, then, usually neutral ; or, if the basic products of the decomposition of albumen are in excess, it may even be faintly alkaline. At any rate, because there is either an absence of hydrochloric acid from the commence- ment, or because it is neutralized by the products of decomposition spoken of, an opportunity is given for progressive decompositions which combine with the above-mentioned processes of fermentation, and thus may produce very varied clinical pictures. As a rule in such cases we have to deal with large degenerating neoplasms. While the stagnation of the stomach-contents exerts no appre- ciable influence upon the secretion of the mucous membrane, as long as the secreting elements are intact, it disturbs absorption very seri- ously. This goes hand in hand with the paresis of the motor ele- ments. The tests with iodide of potassium and with salol show the retardation of the absorptive and motor functions. The result of the former may be obtained from half an hour to a whole hour too late, and I have seen the latter absent as long as two and three hours. Nevertheless, it is by no means asserted that, in all or in particular cases of gastric dilatation, these reactions are always typi- cally retarded. It must always be borne in mind, however, that they explain only a function, and not a group of symptoms, and that a markedly dilated stomach can very well display normal or nearly normal efficiency in this direction. But, under such circumstances, the disturbances which might otherwise develop tend, as a rule, to be comparatively slight. Thus in fourteen cases of typical dilata- tion of the stomach, in which I used the salol test, I found in five that there was no appreciable delay in the splitting up of the salol. In three of these cases, too, the subjective symptoms of dilatation of the stomach were by no means marked, proving that the ingesta were promptly passed on into the intestine, thus compensating for the dilatation. It is very apparent that these different disturbances of function react one upon the other. The development of the products of de- 144 DISEASES OF THE STOMACH. composition paralyzes the muscularis, and tliis paralysis favors the stagnation and with it the further decomposition of the ingesta. The disturbed function of absorption not only delays the removal of absorbable substances, but also interferes with their further for- mation. In view of the experiments of Schmidt-Miihlheim, Calm, and others, we must assume that the power of the gastric juice to form peptone ceases as soon as the percentage of the latter has reached a certain height, just as alcoholic fermentation is suspended as soon as a definite quantity of alcohol has been formed. IN^ow, since the peptones are neither absorbed nor transferred to the intes- tines at the proper time, it follows that the rest of the nitrogenous food is not attacked by the gastric juice ; and, hence, we find so many wholly or partly undigested masses in the stomach in spite of the excessively long time during which the ingesta remain in the organ. On the other hand, it is evident that all these conditions may be present and may manifest themselves without the existence of a really marked dilatation, but rather of motor insufiiciency, or what the ancients called atony of the stomach. They are then, it is true, less marked, yet at times they may reach a high degree of intensity, as the case spoken of above, of the patient " with the gas-fac- tory," j)roves, in whom, quite contrary to our assumption of a dila- tation of the stomach, based, it is true, upon what we would to-day consider insufiicient examination, there existed an almost concentric hypertrophy of the stomach with a stenosing carcinoma of the py- lorus.* Such cases, therefore, as I have mentioned above must be designated motor insufiiciency of the stomach ; these will be dis- cussed more carefully when speaking of the chronic inflammation of the gastric mucous membrane and of the neuroses. From these considerations we can see that very appreciable dilatations of the stomach may occur, in which the injurious effects are equalized by efficient compensation on the part of the absorptive and motor func- tions. Thus, some individuals may for years have an abnormally large stomach, which causes them little or no trouble, just as many * A similar anatomical case was described by Diemerbroeck in 1685 (and cited by Penzoldt, Die Magenerweiterungen) in order to prove that a hard drinker must not necessarily have a dilatation. SYMPTOMS OF GASTRECTASIS. I45 people live for years witli valvular lesions in ignorance of tlie exist- ence of tlieir trouble, since compensatory liypertropliy of the ven- tricle equalizes tlie defect of the valve. But some day this compen- sation fails, and then suddenly, or in a surprisingly short time, all the symptoms of dilatation appear. These are the cases in which the dilatation has apparently arisen acutely, and which are spoken of especially in English literature.* Thus, accidentally from the results of the salol test, I was able to prove the existence of marked gastric dilatation by inflating the organ in two old persons who had been in the Berliner Siechenhmts for years without having com- plained of any special stomach trouble. As the disease progresses the nutrition is affected more and more ; a highly marked marasmus appears. While vomiting occurs less frequently, the foul-smelling eructations and flatulence are in- creased. The pressure of the dilated stomach causes displacements of the neighboring organs, especially the lungs, heart, liver, and intestines, together with disturbances of their functions. Dyspnoea and palj)itation are increased according to the extent to which the diaphragm is forced upward by the stomach filled with ingesta or distended by gases. Obstructions to the portal circulation and their consequences appear. The bowels, as a rule, are sluggish, and can be moved only by enemata or strong drastics ; and the stools even then are usually not soft, but consist of hard masses mixed with water and mucus. An unusual symptom, but when present a very conspicuous one, is the peristaltic unrest of the stomach, first de- scribed by Kussmaul, to which I have already alluded above [page 113], Powerful waves are seen passing slowly over the stomach from I'ight to left, and from above downward ; they may also affect the lower sections of the intestines, and even in rare cases take an antiperistaltic course (Calm). ISTaturally, this presu]3poses a marked obstruction at the pylorus in connection with relatively intact muscle or innervation. ISTot only is absorption scanty or checked in the stomach, but it must also be markedly diminished in the intestine, which is but * For example, Hilton Fagge, On Acute Dilatation of the Stomach, Guy's Hosp. Reports, xviii, pp. 1-23 ; and Albutt, On Gastrectasis, Lancet, 1887. 146 DISEASES OF THE STOMACH. insTifficientlj provided with chyme from tlie stomach at long inter- vals. This is especially true of the absorj^tion of water, causing au abnormal dryness of the muscular and nervous tissues and of the skin ; the latter is roughened almost like in the last stages of dia- betes, and at times thickly covered with furfuraceous scales. To this dryness Kussmaul* ascribes a nervous phenomenon observed by him which manifested itself by painful spasms of the flexors of the arms, the calves, and the abdominal muscles, with which at times a kind of nystagmus, mydriasis, emprosthotonos, as well as disturb- ances of consciousness, were associated, together with a condition which closely resembled, if it really was not, the tetany which ap- pears after acute infections, rheumatism, conditions of great exhaus- tion, etc. These attacks begin with painful sensations in the stom- ach and other regions of the body, as well as with a feeling of oppression, and may at times last for many hours. Kussmaul is inclined to attribute the cause of these attacks to a sudden increase in the deficiency of water in the already parched tissues of the patient like those occurring in cholera, the sudden change being- due to vomiting or lavage. On the other hand, we find similar phenomena in other diseases ; for instance, in convalescence from typhoid, and especially in relapsing fever, in which such a factor could not come into consideration. In a case observed by Ger- hardt,f he calls attention to the fact that the convulsions began in the upper and not in the lower extremities,:]: as in cholera, and ascribes their occurrence to the absorption of the products of de- composition in the stagnant masses in the stomach. Then, however, they should not have appeared during rational treatment, which is exactly what took place in Kussmaul's cases. According to this it seems that the disturbed absorption of water and the resultant dryness of the tissues may in individual cases be * Kussmaul. Ueber die Behandlung der Magenerweiterung, etc. Deutsch. Arch, f. kl. Med., Bd. vi, S. 455. Also Laprevotte, Des accidents tetaiiiformes dans la dila- tation de I'estomac. Paris, 1884. f Gerhardt, quoted by Zabludowski. Zur Massagetherapie. Berliner klin. Wochenschr., 1887, S. 443. \ This was also observed by Dujardin-Beaumetz et Oettinger: iNote sur un cas de dilatation de I'estomac continuee de tetanic generalisee. L'Union med., 1884, Nos. 15 and 18. TETANY. 147 tlie cause of an abnormal irritability of the nervons system wliicli may become intensified sufficiently to present the picture of tetany ; in other cases, however, owing to the absorption into the blood of the products of decomposition, there may appear an auto-infection char- acterized by nervous depression, which has been aptly named " coma dyspepticumr Fr. Miiller * has reported two cases of the former kind in which, in addition to the symptoms already mentioned, there was a distinct increase in the mechanical and electrical excita- bility of nerve and muscle ; Minkowski f mentions the occurrence of deep coma in the course of a case of dilatation of the stomach, the patient dying in this state two days later ; while Litten observed similar though not such intense conditions in cases of acutely de- veloped dyspepsia, and obtained the ethyl-diacetic-acid reaction [Gerhardt's Burgundy-red reaction] in the urine. :j: This seems to point to the formation and absorption of substances wdiich are normally not present in the gastro-intestinal tract, or, at any rate, not normally absorbable ; yet from the stomach-contents of his cases of tetany Fr. Miiller failed to isolate a poisonous alkaloid or toxin, perhaps, as he himself says, because the masses examined, although they had an unpleasantly sour odor, did not have the typical odor of decay and no very marked decomposition had taken place. Finally, therefore, the possibility remains that this form of tetany represents a reflex process proceeding from the stomach, and for which many analogies, collected by Miiller, could be found, of which I will only mention the convulsions caused by worms. Tet- any is always a severe complication of gastric dilatation, for, of the eight cases collected by the author just mentioned, five w^ere fatal, a mortality of 62"5 per cent.* As long as the disease pursues its course undisturbed, the urine in dilatation of the stomach manifests no special changes. I have * Pr. Mailer. Tetanie bei Dilatatio ventriculi und Achsendrehung des Magens. Charite-Annalen, 1888, Bd. xiii, S. 273. f Minkowski, loc. cit., p. 168. X M. Litten. Eigenartiger Symptomeneomplex in Folge von Selbstinfection bei dyspeptisehen Zustanden. Zeitschr. f . klin. Med., Bd. vii. Supplementheft, S. 81 u. ff. * [See also M. Loeb. Tetany from Gastric Dilatation from Pyloric Cancer. Jour- nal of Nervous and Mental Diseases, New York, November, 1890 ; Martin, La Loire medieale, November 15, 1890. — Tr.] 148 DISEASES OP THE STOMACH. never observed the peptonuria spoken of by G. See and found by Bouchard in 7 per cent of his cases, although I have examined many patients for that purpose. At times, in the later stages of the disease, the quantity of the urine is diminished, though this is not usual. Perhaps this, like the alkalinity of the urine, which may be observed under certain circumstances,* is to be referred to the reo-ular emptying or washing of the stomach undertaken in the course of treatment. Quincke believes the cause to be the deficient absorption of the acid of the stomach by the gastric mucosa, where- by an important factor in the acidifying of the urine is removed. This is quite possible so long as the changes in the chemical func- tions connected with dilatation are not remedied. On the contrary, it seems to me that the greater the care which is taken to improve the organ by systematic lavage, the more favorable must the con- ditions of absorption become, and that therefore the urine should be acid rather than alkaline. This is also corroborated by an ob- servation of Winkhaus,t who collected the urine in separate portions at various periods dm-ing the day in a patient with a marked gas- trectasis ; the urine was alkaline as long as the fermentation in the stomach w^as not interfered with, but invariably became acid some time after the stomach was washed out. Moreover, it depends en- tirely on the actual cause of the dilatation whether any quantities of hydrochloric acid worth mentioning are secreted by the stomach. Diagnosis. — Were I to follow the usual plan and now take up the diagnosis of dilatation of the stomach, I would simply have to repeat what has already been said, for whatever has reference to the diagnosis has already been fully discussed ; it is just in dilatation of the stomach that the differential diagnos^'s is relegated more than elsewhere to the background. It is apparent that we must guard against confounding this condition with distention of the colon, ovarian cysts, sacculated ascites, hydronephrosis, and echinococcus cysts ; however, on careful examination by the methods given, these can hardly claim our earnest attention. On the whole, the tend- * Quincke. Dilatatio ventriculi mit Durchbruch in das Colon. Eigenthilm- liches Verbal ten des Urins. Correspondenzbl. fur Schweizer Aerzte. 1874. No. 1. f H. Winkhaus. Beitrag zur Lehre von der Magenerweiterung. Inaug. Diss. Marburg, 1887. COURSE AND PROGNOSIS OF GASTRECTASIS. 149 ency of physicians is to make tlie diagnosis of " dilatation of tlie stomach" ratlier too often than too seldom, except, as I have already mentioned, when it occurs in young persons. It would be of very great importance were we able to sharply distinguish be- tween insufSciency of the stomach and true gastectrasis. This is easy as long as we have to deal with the group of symptoms of a dilatation when no truly dilated stomach is present — under such circumstances it may be extremely difficult to exclude a primary catarrhal condition — yet it is impossible, and the diagnosis can only be made ex jicva/titihus when, with a relatively short duration of the disease and poorly marked symptoms, a megastria exists at the same time, and thus simulates an incipient gastrectasis. In advanced cases we can not remain in doubt, even under such circumstances. Course and Prognosis. — Both are intimately connected with the primary cause of the gastric dilatation. If it be due to a malignant tumor, the duration of life is dependent upon the course of the can- cerous disease and the prognosis is always unfavorable ; yet we must not forget that remissions may occur in the course of such processes which under the influence of rational treatment may produce a rela- tively good condition for weeks, and even for months. It is to this fact that the majority of the cases reported " cured " can probably be referred. I, at least, have never seen such a gastric dilatation cured, but I have repeatedly observed that such periods of improve- ment threw doubt upon the diagnosis till it was finally confirmed at the autopsy. When the dilatations are caused by constricting cicatrices, or by atonic conditions of the gastric muscle, they run a slower course, and the prognosis is on the whole more favorable. But here, too, alas ! we must say, " PrcBVCtlahunt fata consiliis ! " Such patients carry their dilated stomachs about with them for years, and under appropriate treatment and diet can lead an endurable life — indeed, one almost free from all difficulties ; but they never dare forget that every " step from the path" — i. e., every dietetic error — which need by no means be gross, but simply a very slight departure from the prescribed diet, entails not only a momentary feeling of sickness but usually severe disturbances, which sometimes can not be relieved at all ; for it is a peculiar characteristic of all dyspeptic conditions 150 DISEASES OP THE STOMACH. of a severe and chronic nature that thej not only may relapse easily, but that these relapses last longer and are worse than the first attack. But it must be specially emphasized that the treatment of dilatations of the stomach when they are recognized early offers us a very grateful field for treatment, unless, which is not unusually the case, they have been treated in the mean time with all manner of purposeless " stomach medicines." We can very safely promise such patients a very marked improvement in their trouble ; in fact, were we only to regard the subjective symptoms, we could promise a cure. But, if we did, such a falsehood would be punished in the future. As far as my experience goes, even these dilatations can not be cured, and the final prognosis is always unfavorable ; at least, in four cases which I have had the opportunity of watching for years — over six and as long as eight years — I have found the stomach just as large as ever when I distended it, in spite of sub- jective improvements and even apparent cure ; the result has been just the same in the many cases of dilatation of the stomach of this category which I have had the opportunity of observing for shorter periods of time. "When the stomach is once dilated Ave are unable to draw it together again like a tobacco-pouch, any more than an eccentrically hypertrophied heart (excepting the isolated cases of acute cardiac dilatation) ever returns to its normal condition. As soon as the muscular and glandular tissues have been forced apart and infiltrated by an abundant proliferation of interstitial tissue ; as soon as the muscular fibers have undergone fatty or other degen- erations ; as soon as the ducts of the glands have been destroyed or have undergone cystic degeneration — in short, as soon as atonic atrophy of the walls of the stomach has appeared, the game is lost. Gradually our therapeutic and dietetic measures lose their efficacy, and the patients die of marasmus, and with more or less marked dropsical effusions. We can only expect a decided improvement, or even a cure of the gastric dilatation, when the process is in its earliest stages and is produced by functional disturbances, atony, deficient innervation, or catarrhal conditions of the mucous membrane, or when the ob- struction to the emptying of the stomach is immediately removed by operative procedures, as in the above-mentioned case of Klem- TREATMENT OP GASTEECTASIS. 151 perer. Here the relaxed muscle may regain its tone and the mu- cous membrane its normal structure and function, the interstitial exudation may be absorbed, and the organ in toto brought back to its original size. It is very evident that all this is only possible pro- vided the anatomical changes have not exceeded a definite and very limited degree ; this is quite analogous to the conditions of other organs — the bladder, for instance. Those cases of dilatation of the stomach which arise from a chlo- rotic or anaemic condition, and which have been described as cured, can not be classed with the true dilatations, as I have defined them above, but belong to the group of gastric insufiiciency, which may at times be combined with a megastria. The treatment* of dilatation of the stomach must fulfill two indications : 1. By means of a carefully selected diet, and appro- priate medication, it must ease and assist gastric digestion as much as possible, and even supply nutriment to the organism in another way. 2. It must prevent stagnation of the stomach-contents and must expel them either upward or downward, and must also check the fermentative processes which develop in the stomach. The quantity of food in dilatation of the stomach should be as limited as possible. "We must restrict the use of fluids as far as we can ; thin soups, large quantities of alcoholic beverages, mineral or other waters, and much tea or coffee, are to be entirely avoided. I make use of milk even in only small quantities, and give it in tea- spoonful or tablespoonful doses at frequent intervals. Under such circumstances the most rational course to pursue, if possible, would be to use Schroth's dry diet {Trochenhur).\ But since the treatment must extend not over short periods of time, but over months, and even years, this is not applicable, and we must therefore satisfy ourselves with a modified dry diet. Germain See, strange to say, considers the withdrawal of fluids unnecessary, since, he thinks, * [See also yaluable paper by Oser, Wiener med. Presse, Sept. 25, 1889. — Tr.] f [This very energetic treatment, as modified by JQrgensen, consists in giving the patient as many dry rolls as he wishes^ and also a third to two thirds of a pound of lean meat and a pint of light claret wine ; no other fluids are allowed, except on every third or fourth day, when drinking is permitted. Wet packs at night. Before the cure, fluids are gradually withdrawn, and after it they are gradually increased. The treatment lasts about a month.— Schlesinger, Hulfsbiichlein, etc., S. 45. — Tr.] X52 DISEASES OF THE STOMACH. they are absorbed tlie most rapidly and easily. This is a fatal error, for there is also a delay in the absorption of fluids ; they remain in the stomach, and not only do they favor fermentation, but throngh their weight also mechanically dilate the organ. The nse of the peptone preparations is to be recommended ; for instance. Koch's or Kemmerich's meat peptones, meat peptone chocolate, Maggi's peptone pastilles, [Valentine's] meat-juice, etc., 'vrhich contain much nourishment in a small volume.* I have lately found condensed peptonized milk to be very serviceable ; it has an agreeable taste, and can be purchased in small packages as the so-called '' Miitter- railchjpatronen^'' or of a gelatinous consistency in larger boxes. The patients also like meat-powder,f which can easily be made at home from dried and pulverized meat ; it is made into a broth, with the addition of spices. It is evident that all easily fennenting food- stuffs, especially amylaceous foods and the vegetables and fi'uits which contain much sugar, are to be absolutely avoided ; and it is only as a concession to the imperative necessity for starchy foods that we permit the patients to have a smaE quantity of bread, say T5 to 100 grammes [ § ijss- to iijss.] daily — i. e., two or three rolls. The decomposition of the fats evidently takes place late and slowly, for in washing out the stojnach six to seven houi"s after a meal we find the fat floating in large and small globules on the surface of the water, and no intense odor of the fatty acids is noticeable, which is always the case unless the stomach is systematically washed out. However, since the fats seem to exert an irritant action on the mucous membrane, their use is to be restricted as much as possible. The strength of the patient may be kept up by means of small quantities of strong wine or strong, unsweetened cofiee or tea. Nu- trient enemata form an important aid in nourishment ; they may be given in the form which I have spoken of, or as suppositories of peptone, the use of which can be continued for weeks or months. By such means nourishment by the mouth may be reduced to a minimum for days — i. e., until the condition of gastric digestion has been improved as much as possil^le ; enemata also possess the ad- * [Analogous preparations are Rudiseh's sarcopeptones, Camriek's beef pepto- noids, Bush's bovinine, etc. — Tr.] "t- [Parke, Davis & Co.'s Mosquera's Beef-Meal may be used for this purpose. — Tk.] TREATMENT OF GASTRECTASIS. 153 vantage of preventing the lack of water in the tissues by means of the fluids introduced (Liehermeister). Hydrochloric acid in large doses is an excellent remedy for all .gastric dilatations which are not dependent upon pure atony of the muscle. TTe may commence with ten to fifteen drops of dilute hydrochloric acid, taken through a glass tube in a tablespoonful of water every hour. Salicylic acid pm-e, or in the form of sahcylate of bismuth, in doses of 0-3 to O'S gramme [gr. ivss. to vijss.], as well as benzin, are to be recommended. Minkowski recommends the use of carbolic acid in large doses — O'l [tU jss.] ! and over — to be taken in pills before meals. I have seen good results from the use of creasote, which was given by Mannkopff as early as 1861, in cases of gastric fermentation, in doses of 0*1 to 0-2 [^^, jss. to iij] several times daily. If carcinoma of the stomach exists, it is best to use a maceration of condurango, with the proper quantity of hydrochloric acid. In ease there is much pain in the stomach, I make use of the sedative and antiseptic action of cliloral, combined Avith cocaine, as follows : 5: Cocain. hydrochlor 0"3 [gr. jvss] Chloral hydrat 3'0 [gr. xlv] Aq. menth. pip 50-0 [f 3 jf ] Aq 100-0 [ffiiji] M. Sig. : Tablespoonful, p. r. n. Dujardin-Beaumetz speaks highly of introducing large doses of bismuth, 50 grammes, suspended in 500 c. c. of water [ § jss. bis- muth to O j water], from which the drug is said to be deposited on the gastric mucous membrane ; * injections of morphine are eventu- ally unavoidable. Atonic conditions of the muscle require the exhibi- tion of strychnine, as extract or tincture of nux vomica, wliich had been formerly recommended by Skjelderup and Duplay.f who did not draw this sharp distinction. It can be given without bad effects in large doses — O'l to 0*15 [gr. jss-iji] I of the extract pro die. Dr. AYolfE has proved at my clinic that it also increases the production of hvdrochloric acid. * Bullet, gener. de therapeutiqne, 1883, Xo. 1. f Arch, gener. de med., 1883, Xov., Dec. 154 DISEASES OF THE STOMACH. The cathartics and drastics have always played an important part in the therapy of gastric dilatation ; they are really of service, probably by syijipathetic stimulation of the gastric peristalsis, not only in evacuating the intestines but the stomach as well, as soon as they have passed the pylorus, or, indeed, have been absorbed at all, neither of which is always the case. Penzoldt was able to directly prove the beneficial effect of Carlsbad salts in lessening the quantity of the stomach-contents, for the quantity removed from the organ while the salts were used amounted to 850 c. c. [f ^ xxviij], while without them, the condition being otherwise the same, they measured 1,525 c. c. [3|- pints]. Kussmaul recommends drastic pills, composed of 1^ Extr. colocjmth. spirit. (G. P.), 0*5 [gr. vijss.] ; extr. rhei comp. (G. P.) sive extr. aloes aquos., scammonii, aa 2*0 [gr. xxx]. M. Ft. pil. no. xxx. Sig. : Before dinner. I have frequently used aloin subcutaneously with good results. To meet the second of the two indications given above, lavage, the sovereign remedy in the treatment of dilatation, is to be used. I will disregard the many appliances devised for this purpose, because, to my mind, they are like carrying coals to ]^ewcastle. The use of the stomach-tube, with a funnel attached to it, and the cleansing of the stomach by the alternate introduction and removal of large quantities of water, is the simplest and at the same time an entirely efficient method. We must not stop until the water returns clear or only very slightly turbid, but by all means entirely free from fragments of food and flakes of mucus. At times, toward the end of the operation, after the water has come back clear for some time, it suddenly becomes turbid again from the presence of large masses of stomach-contents ; this occurs especially when there are well-marked pouches in the stomach, the contents of which are only stirred up toward the last by the entrance of the water or the bearing down of the patient. We must allow all the time we can for the possible digestion of the food which may be in the stomach, and therefore we must only empty the stomach when large accumulations are present — i. e., to wash out only six or seven hours after the principal meal. Besides the actual washing out which is to prevent the mechanical overloading of the stomach, we conclude the operation with irrigation of the mucous membrane LAVAGE IN DILATATION. 155 with antiseptic or antifermentative solutions. In cases of very marked fermentation we can clean the walls of the stomach more qnicklj and thoroughly by washing out the stomach in the morn- ing before breakfast when the viscus is empty, as Naunyn and Minkowski have also advised. I have had patients in whom the morning lavage produced much better results than that done in the evening. As antiseptics we may use solutions of salicylic acid 0*3 to 0'5 per cent, or borax 2 to 4 per cent (dissolved in hot water), or sodium subsulphate 10 to 20 per cent, as well as a great number of other disinfectants, such as naphthalin, resorcin, benzoic acid, per- manganate of potash, etc. These substances, the efficacy of which is well known, should suffice. The advantages which accrue from this procedure are so appar- ent that it is really incomprehensible why this method should not have been introduced earlier into therapeutics. To avoid repetitions I shall not add anything further on the benefits of lavage of the stomach, for its manifold advantages can readily be recognized. However, of one of these I must speak, for it appears very fre- quently, if not always — namely, the effect on the stools. Many patients who have had to contend with habitual constipation throughout the whole course of their illness have had free pas- sages after the washings, especially at the commencement of the treatment. Kussmaul,* who has called attention to this effect of lavage, always considers its absence an ominous sign ; in other words, he believes that the persistence of obstinate constipation always indicates an irreparable disorganization of the stomach and an incurable stenosis of the pylorus. But this much is certain^ that in scarcely any other place in the whole range of the therai^y of diseases of the stomach can we attain such l)rilliant results as we can in the treatment of a case of protracted dilatation of the stomach. The disgusting vomiting, the feeling of fullness, the eructations, the dyspeptic difficulties, and the cerebral symptoms either cease entirely or become markedly improved. Unfortunately, in true dilatations, as I have stated above, these results are merely palliative. * Loc. cit., p. 467. 156 DISEASES OF THE STOMACH. How often sliall we wasli out the stomach ? Daily, or at longer intervals, or as often as several times a day ? I consider daily wash- ings at the time specified to be indispensable and also sufficient. But they must be conscientiously continued for a long time — the patients soon learn to do it themselves — and we must not be guided alone by the subjective sensations of the patient. Should the lat- ter's apparently good condition induce us to allow longer intervals to intervene, so-called relapses are sure to occur, since stagnation and its consequences will always return. The present technique is so simple and safe that less can be said against it than, for instance, against long-continued catheterization in hypertrophy of the pros- tate. I have as yet never seen any unpleasant accidents occurring after lavage, yet we find a case reported by Martin * in which death suddenly occurred six hours after a tube had been introduced into a dilated stomach with stricture of the pylorus. No injury of the viscus was found at the autopsy, and, since sudden collapse and death may occasionally occur in cases of cancer without any cause at all, it appears to me that this was simply a coincidence. Massage and faradization of the stomacli I consider adjuvants of lavage. The former, if intellige^ntly applied, forces the contents of the stomach into the intestines, and in this way dilates the py- lorus by means of mechanical pressure. Yet we must avoid forcing masses into the duodenum which are too acid or too acrid, which can not be sufficiently neutralized by the intestinal juices, and which produce conditions of irritation in the mucous membrane of the intestine. Zabludowski,f of Gerhardt's clinic, has published very good results from the use of massage in dilatation of the stomacli, together with an exact account of the technique employed. Up to the present time it has been difficult to say whether fara- dization of the abdominal walls had any effect upon the gastric muscle, and whether it was not rather entirely limited to the con- traction of the abdominal muscles. Pepper,:|: in a case of dilatation due to cancer of the pylorus with plainly visible peristalsis, was * Martin. Death after washing out Dilated Stomach. Lancet, 1887, No. 3. f Zabliidowski. Zur Massagetherapie. Berliner klin. Wochenschrift, 1886, S, 443. X Pepper. A Case of Scirrhus of the Pylorus, etc. Phila. Med. Times, Mav, 1871. SURGICAL PEOCEDURES. 157 unable to stimulate tlie latter by either tlie faradic or galvanic cur- rents. However, it lias been shown by the experiments made with the salol test by Dr. Sievers and myself, and also by Einhorn, that the passage of the stomach-contents into the intestine is really hast- ened by energetic external faradization in the region of the stom- ach. Brunner * obtained the same result, for he observed that the test-breakfast disappeared much more rapidly than usual from the stomach when the abdominal walls were energetically faradized, although, it is true, the salol test left him in the lurch. The effect would be more certain if we applied the electrodes locally, intro- ducing one into the stomach and placing the other upon the ab- dominal walls or in the rectum, so as to include the entire diges- tive tract in the current, and thus to obtain very powerful action. [See page 66.1 Cold douches and applications are said to have a tonic effect upon the muscle-fibers of the stomach, as well as the so-called Scotch douche, as recommended by Winternitz and Baum.f Finally, we must think of dilatation or excision of tlie stenosis. I can do no more than mention these procedures here, and therefore simply call your attention to the fact that quite a series of success- ful operations, either excision of the constricting tumor or forcible dilatation of cicatricial stenosis, has been published during the past few years. Thus, Hubert describes two cases of forcible digital dilatation of cicatricial stenosis of the pylorus which were operated upon by Prof. Loreta in Bologna, and apparently were radically cured.:}: A method which may be worthy of special consideration is that proposed by Heinecke and Mikulicz, of splitting the stricture longitudinally and then passing the sutures transversely ; a number * W. Brunner. Zur Diagnostik der motorisehen Insuffieienz des Magens. Deutsche med. Wochensehr., 1889, No. 7. f Wiener med. Presse, 1873, No. 17. ["This consists of a stream of water, the size of a finger, whic his directed against the region of the stomach. The tempera- ture of the water changes every twenty seconds between 80° and 50° Fahr. (26° and 10° C), and is continued for three minutes." Decker, Miinch. med. Wochen., May 28, 1889. Reviewed in Annual of Univers. Med. Sc, 1890, vol. i, C. p. 9.— Tr.] X Hubert. Deux cas, etc. Jour, de med. de Bruxelles, Avril, 1883, pp. 309 to 318. [Also Loreta, Lancet, April 26, 1884; Bull and Kinnicutt, "A Case of Cica- trical Stenosis of Pylorus relieved by Loreta's Operation." New York Medical Rec- ord, June 8, 1889. This paper gives results of twenty eases. — Tr.] 158 DISEASES OP THE STOMACH. of good results have lately been obtained by this method.* How- ever, I must leave this field to the surgeons, to whom the clinician can only refer suitable cases with, as exact a diagnosis and prognosis cs possible. The results of my personal observations on this subject lead me to believe that operative gastric surgery has a great future before it, and perchance the time is not far distant when we will excise a lancet or leaf shaped piece from a dilated stomach in the same way that we treat prolapse of the vaginal mucous membrane and of the uterus by wedge-shaped excision.f How our views and hopes have changed since the time when Kussmaul,:}; as recently as 1869, feared " that he would meet with quiet or outspoken scorn " by the mere mention of such possibilities ! I shall now apply the foregoing remarks to some practical ex- amples ; for this purpose I liave not selected hospital cases, with the results of autopsies, but such patients as we meet in daily practice : The first patient is a railroad secretary, fifty-two years of age, whose previous history I shall read to you in his own words : " Ten months ago, in the beginning of last year, I was taken sick with loss of appetite, constipation, slight malaise^ and also a cough, with expec- toration. On the 14th of June, a ye$,r ago, I went to Gorbersdorf, in Silesia, at the advice of my physician, and remained there under treat- ment, at the institute of Dr. Eompler, until July 10th. On July 10th I went to Carlsbad, where the diagnosis of dilatation of the stomach was made. I w^as treated there till August 14th (five weeks) ; the physician told me that I was at the proper spring. At Carlsbad I drank three half- glasses of Schlossbrunnen daily, and besides took four Sprudel and eight mud-baths (one every third day). The action of the baths was always sedative for several hours. In general the treatment at Carlsbad affected my body quite unfavorably, my strength was not con^espondingly in- creased, and a slow improvement could only be observed at intervals of * [Senn. The Surgical Treatment of Pyloric Stenosis, with a Report of Fifteen Operations for this Condition. New York Medical Record, November 7 and 14, 1891.— Tr.] f [This prophecy has practically been fulfilled in the three cases recently reported by Bircher (Correspondenzbl. fiir schweizer Aerzte, Jahr. xxi, No. 23). Bircher's method of operation consists in exposing and drawing out the stomach by an incision parallel with the free border of the left ribs ; a fold is then made in the stomach large enough to reduce it to its normal size; the greater curvature is sutured with silk nearly on a line with lesser curvature. The fold hangs within the stomach. In one of the cases there was no return of the symptoms after thirty months. See Am. Jour. Med. Sc, 1892, vol. ciii, p. 333.— Tb.] X Loc. cit., p. 485. CASES OF DILATATION OF STOMACH. 159 from four to five weeks. After the 10th of August I was under the treat- ment of another physician." When I first examined this patient, who was sent to me by his family physician on the 24th of October, although he was thin, he by no means looked sick. Lungs and heart normal ; liver not enlarged ; its lower edge can be felt distinctly a finger's breadth below the free margin of the ribs. Spleen not enlarged; the stomach, however, showed the following changes : Even on mere inspection of the abdomen, and especially on looking at it against the light, with the patient lying down, I can see a slight protuberance the size of a five-mark piece [about the same as silver dollar] in the region of the umbilicus, and extending to the right; it pro- jects so slightly above the surface of the abdomen that it is ouly recog- nizable by the relief given by its shadow. Otherwise the abdominal walls are smooth, not too relaxed, with neither trough-like depression nor ab- normal vaulted projection. Palpation reveals a tumor at the place men- tioned, about the size of an apple, hard, nodular, easily movable, which does not descend on respiration, and entirely insensitive to pressure. Ta- pottement produces loud succussion sounds. No slapping sounds (Klatsch- gerdiisch). The inguinal glands are aboLit the size of a pea, but there are no other adenopathies. The patient has taken a test-breakfast. I intro- duce the stomach-tube, and on expression obtain about 100 c. c. [ | iij^] of a thin fluid, which contains some remnants of the roll. I now inflate the stomach with the double bulb, and you can see that the tumor is displaced somewhat to the right and downward, and that the contour of the stom- ach becomes very distinct. By sight alone, but better by means of per- cussion, I can locate the greater curvature 3 centimetres [1^ inch] below the umbilicus. Examination of the stomach-contents, which have mean- while been filtered, reveals the total absence of hydrochloric acid, faint peptone reaction, large amounts of propeptone, erythrodextrin, fatty acids, but no lactic acid. I must tell you that at a former examination I ascer- tained that the filtrate of the stomach-contents did not digest albumen, and that from the examination made six hours after a dinner consisting of meat, potatoes, bread, and bouillon the same results were obtained. Neither yeast-cells, sarcinae, nor cancerous elements are present. The patient took 1 gramme [gr. xv] of salol yesterday, and has brought lis the urine voided three quarters of an houi", an hour and a quarter, and an hour and three quarters afterward. You see that in the last portion we get an in- distinct violet coloration on adding ferric chloride, but that I must first shake up the urine with ether in order to obtain a positive though only a weak reaction. In view of all this there can be no doubt that the diagnosis is cancer- ous stenosis of the pylorus, ^vith consecutive dilatation of the stomach. It is interesting that in this case the disease began so insidiously, and that it pointed so little to the stomach as its seat, that probably, in connection with a then-existing bronchial catarrh, the suspicion of phthisis could arise, which led to his being sent to Gorbersdorf. I have seen excellent results in the treatment of phthisis in Gorbersdorf, but carcinomata can not also be cured there ! The case is so far a favorable one in that, on the one hand, the bodily strength is relatively good, and, on the other, the 160 DISEASES OP THE STOMACH. tendency to decomposition of tlie stomacli-contents is comparatively slight. In the way of treatment the patient has been taking condurango, with hydrochloric acid, and for the past week his stomach has been washed out regularly every second evening, six hours after his dinner; considerable quantities of stomach -contents, brown in color, have always been brought up. I i^roposed to the patient to have the tumor excised, which, according to competent authority, can. be done in this case. However, he feels so much easier and better under the present treatment that he can not decide upon having it done, and thus, as is alas so frequent, the favorable moment for undertaking it will pass by. The second case, which I will deal with at less length, concerns this fifty-two-year-old, large, strongly built, somewhat pale woman. For about a year and a half she has suffered severely with acid eructations. To this has been added a constant loss of appetite, and partly owing to this, partly because she has kept a strict diet, her nutrition has suffered considerably. jSTo difficulties in swallowng. Vomiting has been very infrequent, lately every fortnight, and is said to have consisted of very sour, slimy masses, mixed with but slightly changed remnants of food ; blood has never been present. Stools hard and sluggish. The urine has been repeatedly exam- ined, with negative result. The patient was formerly very healthy, vigor- ous, and active about the house, and has borne nine children. Although I pass over the examination of the other organs, in which there is nothing abnormal, I wish to call your attention to the relaxed condition and mark- edly vaulted projection of the abdominal walls, on which I can at once produce loud succussion sounds. I can not palpate a tumor anywhere, yet I feel the pulsations of the aorta. The patient " expresses " a light-brown fluid — she had some meat and coffee four hours ago ; on inflation with air the entire abdominal cavity immediately becomes evenly distended, so that we can see the lower border of the stomach running just above the symphysis; the whole abdonaen appears like an evenly inflated balloon. The salol test does not show any retardation. The filtrate of the stomach- contents has an acidity of 48 per cent with a decinormal soda solution, and distinctly contains free hydi'ochloric acid, peptone, only traces of propeptone; it also digests well. Lactic acid is present in small quan- tities. The diagnosis of gastric dilatation, which can not be doubted, does not seem to have been made before. The question arises. To what can the dilatation be referred? A previous ulcer may be rejected with great probability on account of the absence of pain, and altogether on account of the previous good general condition. Thus, also, tumors of any kind whatsoever may be excluded, and, granted that further observations yield no results different from to-day's, we can only have to deal with a cica- tricial distortion or adhesion, or with a primary atony of the gastric mus- cular fibers. Even though the former could be a result of puerperal peri- tonitis which had run a latent course, yet this is only to be surmised. At any rate, the prognosis is favorable for improvement within a short time in view of the presence of free hydrochloric acid. I have persuaded the patient, who has come from a distance, to enter the sanitarium, where I shall treat her with an appropriate dry diet, systematic lavage, strych- CASES OF DILATATION OP STOMACH. 161 nine, and faradization of tlie stomach ; and at the close of this course I shall again present her to you.* The third case I present is a young student, twenty-one years of age, strong and apparently healthy. He has complained for fifteen months of distention of the abdomen, Avith jDressure and fullness there, capricious appetite, irregular bowels, and, when these symptoms are present, of poor sleep, headaches, brief attacks of dizziness, and conditions of anxiety. He therefore keeps a strict diet, refrains from all Kneipei^ei, and tends to hypochondriasis. The tongue is clean, eructation and vomiting have never been present, the stomach-contents as well as the size of the stom- ach are normal, and we would be inclined to regard this case as one of nervous dyspej)5ia, were it not that the iodide of potassium and salol tests both agree in showing retardation of absorption and motion. I there- fore do not hesitate in pronouncing this a case of gastric insufficiency, and the result of the treatment adopted seems to justify the diagnosis. For two weeks he has taken 0"03 [gr. 1] of extract of nux vomica three times daily, and has been faradized every other day. Since this time the attacks have not appeared. In these three cases I believe I have presented various types of dilatation and insufficiency of the stomach. You can see from this how the simple diagnosis of " dilatation of the stomach " does not suffice, and how much treatment and prognosis are influenced by the recognition of the underlying cause. * To prove to what errors even the most careful single examination is liable in making a diagnosis, I wish to add, while correcting the proof-sheets, that after about three weeks' observation the hydrochloric acid disapoeared permanently, and at times in certain positions of the patient, and with a definite fullness of the stom- ach, a small tumor, hardly the size of a walnut, was palpable in the pyloric region. I have purposely abstained from changing anything in ray former remarks regard- ing this case. I have heard that the patient died several months later, of '• cancer of the stomach." (Addition to the second edition. — E.) LECTUKE V. CANCEE OF THE STOMACH. Gentlemen : Altliougli it may be interesting to learn, from the various statistics which are published from time to time, that be- tween 0"5 and 2*5 per cent of the total mortality is due to cancer of the stomach, and that 35 to 45 per cent of all cases of can- cer involve the stomach, yet such facts have only a nosological interest. Of far greater importance is the question, At what age do persons most frequently succumb to gastric cancer ? The various statistics, of which Brinton's, based upon 600 cases, and Welch's, upon 2,0Y5 cases, are the most important, agree tolerably well in proving that three fourths of all cancers of the stomach occur be- tween the fortieth and the seventieth years of life. The maximum liability is between the fiftieth and the sixtieth, but, according to Lebert, it lies between the forty-first and the end of the sixtieth year. It is very rare before the thirtieth year; congenitally it almost never occurs, and the case reported by Wilkinson * must be regarded as a very great rarity. According to decades, its occur- rence is as follows : 10 to 20. 20 to 30. 30 to 40. 40 to 50. 50 to 60. 60 to 70. 70 to 80. 80 to 90. Welch Brinton . . . 2 55 11 271 31 55 499 63 96 620 88 95 428 100 61 140 52 13 60 Lebert f.. . 3 1 * Quoted by W. Hayle Walshe. The Nature and Treatment of Cancer. Lon- don, 1846, p. 146. [Other very early cases of gastric cancer may be found in Welch's article in Pepper's System of Medicine, vol. ii, p. 534, 1885. Dujardin- Beaumetz asserts that all cases of cancer of the stomach diagonsed in children have been mistakes. Bulletin gener. de therapeutique, September 15, 1890. — Tb.] f Lebert reports 162 cases. HEREDITY OF CANCER. 163 Thus tlie frequency in the four decades, between the thirty-first and the completed seventieth year is 94*6 per cent. But, as already stated, these figures are only based upon the relative morbidity of the different ages to the total morbidity from cancer. If the fre- quency of the disease Avere calculated for the total number of people living in each decade, then the ratio would increase in an ascending scale, and would not show a diminution after the sixtieth year. Modifying factors then arise (like those recently calculated by Wiirzburg for phthisis), the relative frequency of which, as esti- mated for the total number of people living at that period, steadily increases with advancing age. Sex appears to exert no influence on the frequency of gastric cancer ; at all events, Fox's tabulation of the statements of seven writers shows that, of 1,303 cases, 680 were males and 623 females; in other words, both sexes were about equally affected, if we allow for the coincidences which are unavoidable in such a small series. Ledoux-Lebard,* from a study of the mortality statistics of Vienna, announces a mortality which is about the same for both sexes (100 in 25,000 deaths in a city of a million inhabitants). Of Welch's 2,214 cases, 1,233 were men and 981 women. If the general belief is true that a gastric ulcer may be transformed into a cancer, and that ulcer of the stomach is especially frequent in women, then these statistics (in which the women are actually in the minority) prove that this change is not of frequent occurrence. It would be very important if we could come to a definite con- clusion regarding the heredity of cancer. ]^ot alone in the diag- nosis of a suspicious case, but also in the prognosis as to the prob- able duration of life of the children of cancerous parents, an important part is played by this question of the heredity of cancer, it being self-evident that cancer of the stomach is included in the general sphere of carcinomatous affections. All authors who have studied the oi^igin of carcinoma, even to the most recent date (a good resume of this discussion will be found in J. E. Alberts's book t), agree that cancer is hereditary in the sense that the predis- * Ledoux-Lebard. Arch, gener. de med., Avril, 1885. f J. E. Alberts. Das Carcinom in historischer und experimentell-patholo- gischer Beziehung. Fischer, Jena, 1887. IQ^ DISEASES OF THE STOMACH. position is transmitted from the sufferer to liis descendants, and tliis it is which may develop under certain conditions. But what are these conditions which influence the transmission and subsequent development of the disease ; how often are the subjects attacked in other words, how frequently do the children of carcinoma- tous parents acquire the disease, and what cause may be discov- ered for this ? This is really the practical side of the question ; but, strange to say, it is scarcely broached in these works, while its great importance is manifest, and confronts us daily. But here, instead of positive numerical data, we are almost exclusive- ly compelled to use more or less subjective (and hence unrelia- ble) opinions, while, the information obtained from the relatives of the deceased patients is always interpreted very differently by different physicians, yet nearly always in the view of hered- ity. The life-insurance companies, which, naturally, are vitally inter- ested in this question of the heredity of cancer, do not, as a rule, reject a candidate on account of the death of one parent from this disease ; yet it is considered to increase the risk, and a higher premi- um must be paid. This is based upon their practical experience : thus, for example, in a period of fifty years, from 1829 to 18T8, the Gotha Life Insurance Company had 334 deaths from cancer; of these, 31 — i. e., 9*3 per cent — were hereditary. Even so experienced and practical an observer as Lebert asserts that, where it is possible to watch the health of entire families during a large number of years, indubitable cases of heredity may be observed. This agrees with the experience of many old practitioners. Not alone may cancer of the stomach be directly transmitted from parents to children, but more frequently the preceding generation has had a different variety of cancer ; in mothers the uterus or mam.ma has been espe- cially frequently involved. In Lebert's cases heredity was observed in Y per cent. "Well known and frequently quoted is the case of the ISTapoleons, of whom Napoleon I, his father, and his sister Caroline died of gastric cancer, which occurred in two generations of the fam- ily. Nevertheless, in this and similar statements, no attention is paid to the fact that the disease often occurs in families in which there is no hereditary predisposition. H. Snow, physician to the London Can- ETIOLOGY OF CANCER. 165 cer Hospital, * has answered the question, to the effect tliat in 1,075 cases of carcinoma in different parts of the body, 16T — i. e., 15'7 per cent — stated that the disease had ah-eady occurred in their fami- hes, it being understood that the transmission is not always direct, but that it has affected more than one member of the family. On the other hand, among 1T5 patients who were under treatment for non-cancerous affections, 46 — i. e., 26 per cent — admitted that cancer had occurred in their families ; and in two other series, of Y8 and Y9 cases respectively, the former being healthy individuals, the latter patients with pulmonary diseases, the relative percentages were 19"2 and 11'3. It is manifest that statistics of this kind are very uncertain, since it can not be demonstrated whether the jia- tients in question have not or would not have fallen victims to the disease. At all events, the statistics show that in a malady which occurs as frequently as carcinoma, coincidence may play a great jDart in its etiology ; and it would therefore be well in an individual case not to lay too great a stress on a j)Ossible he- redity. Etiology. — In discussing this question of the hereditary trans- mission of carcinoma of the stomach, I have already encroached upon the question of the individual causes of the disease. In gen- eral, it must be admitted that we are just as ignorant of the etiology here as elsewhere. I may enumerate a list of so-called etiological factors, because in a number of cases we have observed a transient connection, and a more or less evident transition, which is called cause and effect ; yet it is not known why these causes are in some cases followed by a carcinomatous proliferation, and why in others there is no reaction whatsoever. Nevertheless, some of the factors to be mentioned presently occur so frequently that they must exert some influence on the origin of carcinomatous tumors. A discus- sion of this question is in place in a general consideration of the nature of carcinoma ; this lies within the province of general j)athol- ogy, and hence is out of place here. The assertion that Cohnheim's theory of misplaced embryonic cells does not explain the origin of cancer, but that it is due to the pernicious action of micro-organisms, * II. Snow. Is Cancer Hereditary? British Medical Journal, October 10, 1885. 166 DISEASES OP THE STOMACH. is as yet only a presumption, which Alberts, Schill, and Scheur- len * have been investigating experimentally, though without any definite results. Here I must refer you to the text-books on pathological anatomy. I must simply limit myself to a brief resume of the possible etiological factors. All of these partake more or less of the char- acter of irritants which may be due to the ingestion of acrid sub- stances, or which may result from acute or chronic inflammatory processes. Among these may be included corrosion by nitric acid and arsenic ; of the former, Andral is said to have reported an exam- ple, but the case is not re]3orted in the reference which is copied from one book to another ; the latter is regarded as a causal factor by Dittrich ; yet this is at all events doubtful, since "Walshe found a large quantity of arsenic encapsulated in the stomach of a patient without any further changes in its tissues.f Traumatisms have been repeatedly cited as causes of gastric cancer. For example, Alberts X reports the following case : A man who up to his fiftieth year had always enjoyed good health stumbled and fell against the handle of his umbrella. Three weeks later gastric symptoms appeared, and after a year the patient died of carcinoma ventriculi. A moment's consideration, however, will show that this and similar observations can not definitely settle this question, since they are not absolutely conclusive. Who can tell whether there was not already a latent cancer, and that the traumatism simply accelerated its growth ? Even in olden times inflammatory conditions of the mucous membrane of the stomach were included among the causes of gastric carcinoma. Such views may be found in the writings of Boerhaave and Yan Swieten, and in the older works they are met with more frequently in proportion as the nature of the disease is less known. But very recently Schuchardt,* in a monograph entitled Contribu- tions to the Origin of Carcinoma from Chronic Inflammatory Condi- tions of the Mucous Membranes and Skin, claims that a chronic or * Alberts, loc. cit., pp. 183 et seq — Scheiirlen. Verhandlungen des Vereins fiir innere Med. vom 28. Nov., 1887, in Deutsche med. Wochenschr., No, 48, + Walshe, loc. cit, p. 167. X Alberts, loc. cit., p. 195. * Schuchardt. Beitrage, etc. Volkmann's Sainmlung klin. Vortrage, No, 257, ETIOLOGY OF CANCER. 167 hyperplastic condition precedes the formation of the neoplasm, and that, while this condition does not necessarily cause the latter, yet it favors it to a high degree. Chronic gastric ulcers may also be classed among the predis- posing factors, Lebert has observed the direct transformation of ulcer into cancer, and Dittrich the simultaneous occurrence of both conditions. Brinton cites cases in which the lesion, macroscopically an ulcer with thickened edges, was accompanied by unquestion- able metastases in the liver and lungs; and even states that "an unhealed ulcer may at times cause the development of cancerous cachexia." * C. Meyer f describes a case of simple ulcer occurring with carcinoma of which the cell-nests, although only in the imme- diate vicinity of the ulcer, were visible as smooth nodules which had developed from the epithelium of the ducts of the glands. Heitler :|: reports three similar cases (without microscopic examina- tion), and remarks that the diagnosis carcinoima ventriculi ad hasim ulceris rotundi is not at all rare in Yienna. Hauser * has histo- logically demonstrated the transition of ulceration into carcinoma- tous proliferation, and asserts that in one of the cases examined by him he found not only the secondary development of carcinoma in a gastric ulcer of very long standing, but that " occasionally a can- cer may develop from an affection of the gastric glands, even in the sense of the theory proposed for carcinoma by Thiersch and Wal- deyer." Flatowl reports a similar case from the Pathological Institute at Munich. This case is important because the patient was only twenty-six years old, and the history of ulcer was beyond doubt. T]ie cancer was near the pylorus, and in its center was an old scar with a smooth base. As the result of his microscopical ex- amination Flatow says, " Evidently there was at first a cicatricial mass, and this facilitated an atypical proliferation of epithelium." * Brinton, loc. cit., p. 243. f C. Meyer. Ein Fall von Ulcus simplex in Verbindung mit Carcinom. Inaug. Dissertation. Berlin, 1874. X Heitler. Entwickelung von Krebs auf narbigem Grunde in Magen nnd in der Gallenblase. Wiener med. Wochensehr., 1883, No. 31. * Hauser. Das chronisehe Magengeschwiir und dessen Beziehung zur Entwick- elung des Magencarcinoms. Leipzig, 1883, S. 70 und 73. I H. Flatow. Ueber die Entwickelung des Magenkrebses aus Narben des run- dcn Magengeschwiirs. Inaug. Dissert. Miinchen, 1887. 1(58 DISEASES OF THE STOMACH. Concerning the other chronic irritants of the mucous membrane which are supposed to favor the development of cancer, the various exceptions are so evident that a discussion on the unrehability of such evidence is superfluous. In Beau's statement that gastric can- cer is often preceded by a period of " idiopathic dyspepsia," * the word often ought to be changed to seldom. For, on the contrary, it is surprising how frequently the patients assert that thej^ have always had sound stomachs, and that they have always been moder- ate in eating and drinking. While the gluttons have themselves to blame to some extent for their dilated stomachs, the unfortunate suf- ferers from gastric cancers have not even the melancholy satisfac- tion that in the days of health their stomachs at least afforded them especial joy and pleasure ! Pathological Anatomy. — I shall refrain from giving exact details of the histological features of carcinoma of the stomach, as my ex- perience on this subject has only been an ordinary one, and I can only repeat the facts which you will find more or less thoroughly described in many books. After a thorough investigation, Wal- deyer was the first to teach that the disease is developed from the glandular elements of the mucous membrane— i. e., from the peptic glands, and especially from the mucous glands of the pylorus. The process is an atypical glandular proliferation which bursts through the muscularis mucosae, and extends into the submucosa. Here cir- cumscribed cancerous nodules are formed ; these coalesce later on, and thus necessitate the subsequent flattened growth. Coincidently there is an active growth of the connective tissue which soon ex- ceeds the proliferation of the glandular elements, and thus at first produces an hypertrophy of the connective tissue, while the glandu- lar elements still remain normal. Later, it extends along the pro- liferated glandular tubules and manifests itself as a small-celled in- filtration about the cancer nodules. This growth of the connective tissue appears to exert a decided influence in determining whether the developirig cancer will be of the schirrus, encephaloid, or colloid variety. But, as I have already said, I merely wish to mention these things superficially, and shall simply recall that any of the * Beau. Gazette d. hopit., 1859, p. 390. VARIETIES OP CANCER. 169 various forms of cancer — schirrus, ence/phaloid, colloid, polypoid, and telangiectatic — may occur in the stomach. All authors state that the first is the most common : according to Brinton, it occurs in Y5 per cent of all cases, while the colloid is found only in from 2 to 8 per cent. If we agree with Waldeyer,* that the nature of the disease consists in " an atypical transformation of epithelium," then the above-mentioned individual varieties are one and the same fun- damental process, and, as actually occurs, often change into one another. Scirrhus, carcinoma simplex or Jibrosum, with its predominant development of dense connective-tissue stroma, and with relatively few cell-nests, has a firm and compact structure. It occurs some- times as large masses or tubercles, sometimes as small nodules ; at times multiple, but oftener as a diffuse infiltration. It creaks when cut, and the section presents an almost cartilaginous tissue of a white, grayish-yellow, or dull yellow color, with yellow or red spots scattered here and there ; it may, however, have a smooth and shining surface, almost like bacon. Where there is a tendency to ulceration we find a rich vascular network, and also an extensive diffuse redness ; where ulceration has already begun, an undulating fissured surface is presented by the ulcer, which is covered with ragged greenish-yellow or black detritus. Of frequent occurrence are fatty degeneration and atrophy in some parts, while in others it continues to grow. Firm pressure will cause a small amount of turbid, milky cancer juice to exude. Encephaloid cancer, carcinoma medidlare, is soft, has very little connective-tissue stroma, but is very rich in vessels and cells ; the growth is spongy, and cuts easily ; the cut section is whitish-yellow in color, and resembles brain matter both in color and consistency. It undergoes colloid degeneration more frequently than does the scirrhus. Extravasations of blood are frequent, and are marked by their characteristic discoloration. If the cells in an otherwise well-developed stroma show from * Waldeyer. Die Entwickelimg der Carcinome. Virchow's Archiv, Bd. Iv, S. 54. 170 DISEASES OP THE STOMACH. the beginning a tendency to undergo colloid degeneration, then the whole growth assumes a gelatinous appearance somewhat resem- bling glue. Thus arises the colloid carcinoma, carcinoma alveo- lare or galatinosum. On cutting and scraping, a true cancer juice does not exude, but instead gelatinous fragments. Yillous carcinoma, ZottenTirebs, carcinoma villosutn, is pro- duced by villous or papillary outgrowths in the scirrhus or medullary varieties. If the development of blood-vessels predominates, the growth is called a telangiectatic carcinoma ov fxingus Jiciematodes. Finally, if there are numerous haemorrhages into the cancerous tissues, any of the varieties of the neoplasm may assume the charac- ter of a melanotic carcinoma.^ As I have already indicated, these various forms may coexist in almost every variety. In all these types the bundles of muscular fibers are more or less infiltrated, and undergo hypertrophy ; the muscularis becomes paler, less elastic, and fragile ; at times, however, atrophy may result. Secondary inflammatory processes, with thickening and adhesions to the adjacent organs, are observed in the serosa. Having thus briefly recalled to mind the chief characteristics of the different varieties, I shall now speak more in detail of the topo- graphical features or the localization of cancer of the stomach, and of the results thereof. We must first distinguish between tumors which grow especially on the surface, and involve large areas of the mucous membrane, and those which attack only a small portion. The former are by far the less common, and are usually of the medullary or colloid variety ; they are characterized by a nodular or roughened surface like a grater ; they are flattened rather than projecting high above the surface ; other peculiarities are the frequency of assuming the villous form, the occurrence of blood extravasations and adhesions to the adjacent organs, especially to the peritonaeum and omentum. In such cases the greater portion of the stomach from the cardia to the fundus may be converted into a carcinomatous mass, yet such * [Such discolored cancers ought not to be confounded with true melanotic tu- mors. Welch could find no record of true primary melanotic cancers of the stom- ach ; all of those cases have proved to be melanotic sarcomata. Welch, loc. cit., p. 561, foot-note.— Tr.] SITUATION OF CANCER. 171 an occurrence is a great rarity. Otherwise, the greater curvature nsiiallj remains free, and the neoplasm preferably extends on the posterior wall along the lesser curvature. Generally the organ is not increased in size, but rather diminished to a iirm, sausage-like tumor. I have preserved such a medullary cancer involving the entire organ, which I obtained at an autopsy ; the capacity of the viscus was scarcely 200 c. c. [f § vjss.] of water. The scirrhus variety involves the whole organ much less frequently ; such a case is pict- ured in Fig. 19, which is taken from Carswell's Atlas. * Usually scirrhus follows the second of the above courses — i. e., it remains in a circumscribed portion of the stomach, and tends to grow in depth and height as opposed to the superficial extension of the medullary and colloid varieties. This, however, does not exclude its multiple occurrence in several parts of the mucous membrane of the organ, as, for example, at the pylorus and the lesser curvature or the cul-de-sac. Concerning the situation of the cancer, nearly all the statistics agree that in about one half of the cases the pylorus is involved : according to Brinton, 60 per cent ; Lebert, 59 '6 per cent ; Katzenel- lenbogen,f 58'3 per cent ; Luton, :{: 5Y per cent, etc. In between 10 and 11 per cent (Luton, Y"8 per cent) it is the cardia or the lesser curvature ; in the remainder the lesion is scattered over the greater and lesser curvatures. The fundus is attacked least frequently of all ; such a case with extension to the spleen was described by Tiin- gel. * Among the 1,300 cases reported by Welch, 19 were situated in the fundus. At all events, the orifices are the favorite sites — TO to 75 per cent ; thus cancer differs markedly from ulcer in this respect, as the latter involves the orifices about five times less fre- quently — i. e., 16 to 18 per cent. The situation and extent as well as the consistency of the neo- plasm influence the shape and position of the stomach in the follow- ing ways : * [Sir Robert C. Carswell. Pathological Anatomy. Illustrations on the Ele- mentary Forms of Diseases. London, 1833-'38. — Tr.] f Katzenellenbogen. Beitrage zur Statistik des Magencareinoms. Inaug. Dis- sert., Jena, 1878. X Luton. Nouv. dictionnaire de med. Paris, 1871. * Tiingel. Klinische Mittheilungen aus dem Hamburger Krankenhause, 1860, S. 108. 172 DISEASES OF THE STOMACH. Fig. 19. — Scirrlius ventriculi totalis (reduced to one fifth). CHANGES IX STOMACH. 173 1. The viscus may become smaller by a concentric contraction, as wliere a firm tumor involves the stomach in toto — i. e., infiltra- tion of the mucosa and muscularis ; or, finally, even a narrowing of the lumen by extension inward, as shown in Fig. 19. It may also re- sult from tight strictures situated at the cardia ; as a consequence of this, the absence of the normal pressure of the contents of the stomach upon its walls causes the organ to contract into the smallest possible volume, since it must yield to its elastic tissues ; its diameter may be diminished to that of the large intestine, as oc- curred in a case reported by Canstatt.* The following drawing (Fig. 20) was made by me from a case which I had under observation. While the patient was alive the pancreas and stomach could be pal- pated through the relaxed abdominal wall as a hard nodular tumor. 2. Dilatation is always the result of a tumor obstructing the pylorus. Here the stenosis may be due to all the various causes which have been fully described under dilatation of the stomach. 3. Changes in theposition of the stomach are produced by the weight of the tumor ; this may be so marked that either the fundus or the pylorus alone or both together may be dragged down deeply into the pelvis, and may contract adhesions with its organs, the ovaries, uterus, bladder, etc. 4. Distortions^ hends, and constrictions of the stomach may be developed as a consequence of the inflammatory adhesions with adjacent viscera, or of the extension of the new growth in the stomach itself. These different conditions show in what varied ways the shape and situation of the stomach may be altered. Gastric cancer occurs so overwhelmingly frequently as a pri- mary growth that a case like that reported by Cohnheim, in which the primary tumor was situated in the mamma, must always be con- sidered a very great rarity. f On the other hand, it is not exactly rare to find the disease occurring simultaneously in a remote organ '- — as, for example, cancer of the stomach may coexist with a similar * Canstatt. Klinische Rtickblicke. Erlangen, 1851, S. 178. f [Thus far thirteen cases of secondary carcinoma of the stomach have been reported. See J. S. Ely, A Study of Metastatic Carcinoma of the Stomach. Ameri- can Journal of the Medical Sciences, June, 1890, p. 584. — Tr.] 174 DISEASES OP THE STOMACH. growth in the uterus or ovaries, and no evidence can be found to indicate a metastasis from either organ. Dittrich lias never seen »s-nc. Fig. 20. — Carcinoma of the Cardia. Contraction of the Stomach. Mr. T. died April 10, 1885. «, stomach ; d duodenum ; ^, pancreas ; tc^ transverse colon ; c/c, descending colon. the simultaneous occurrence of the disease in the stomach and uterus. Recently I performed an autopsy in a case in which there was found an immense cysto-sarcoma of the uterus, and a carcinom- atous infiltration of the pylorus. Secondary cancerous metastases are, as is well known, by no means rare ; they may affect any part of the organism in about three out of four cases. The liver is CANCEROUS METASTASES. I75 involved in 25"G to 30 per cent; the peritonseiim in 13"Y to 22'Y per cent ; tlie lungs and pleurae in 0'6 to 6*2 per cent ; while in 160 cases collected by Dittrich the rectum was involved only twice and the ovaries once. However arbitrary such figures may be, according to the cases at the disposal of individual writers, the evidence as to relative frequency of these metastases, as given by Lebert, is as follows : in the liver, 40*9 per cent ; peritonaeum, 37"5 per cent ; lungs, 8-3 per cent; ovaries, 4*5 per cent. Lange's* analysis of 210 cases at the Berlin Pathological Institute gives different percent- ages: 30"9, IT'6, 0*71, and 0*14, respectively. Of greater practical interest is the simultaneous occurrence of metastases in imjjortant organs ; as, for example, in the liver and lungs, which Lange found ten times — i. e., 4*7 per cent. Although Brinton asserts that the occurrence of metastases in the liver naturallv lessens the danger of involvement of the lungs, yet it would seem more probable that, with the establishment of two cancerous depots, the chances of infection by transportation through the vascular system would be increased. I must confess, however, that my own experience cor- roborates Brinton's statement. That cancer and tuberculosis do not exclude each other, or that both may perhaps be attributed to a scrofulous diathesis, as was formerly supposed, needs no further discussion at present. Dis- regarding statistical data — as for example, Lange, who found them together in 8-1 per cent of his cases — all doubt on the subject has been removed by the direct observation of tubercle bacilli in the pulmonary deposits in lungs which are also cancerous. It nmst be confessed, however, that it is at times very difficult to decide whether small cavities are due to softening of tubercular or metas- tatic carcinomatous nodules. In many cases we can explain the path of the metastatic infec- tion by way of the blood or lymph vessels; in others we must think of direct extension in the continuity or along extra-vascular channels; as, for example, the extension of a pyloric cancer to the edge of the liver or the gall-bladder ; the involvement of the * Lange. Der Magenkrebs und seine Metastasen. Inaxig. Dissert. Berlin, 1877. 12 ^r^Q DISEASES OP THE STOMACH. colon from a tumor on the greater curvature, or of the diapliragm and lungs from one situated at the cardia (Carswell and Yirchow *). T/ie formation of thrombi in various places remote from the stomach is also to be explained by vascular transportation in so far as thej are not due to the cachexia, the altered condition of the blood, and the slowing of the circulation, just as is seen in the veins of the lower extremities. It has been repeatedly asserted that the com- position of the blood is altered, esj^ecially a lessening of the num- ber of the red blood cells, and of the solid constituents of the plasma. I shall consider this topic further when discussing the symptomatology. Andral and Gavarettf state that the percentage of iibrin is variable. There is nothing characteristic in these changes, but they are more or less peculiar to all cachectic con- ditions. Tlie swelling of the lymjyhatic glands occurs less frequently in this disease than in neoplasms elsewhere which are in close con- nection with the lymphatic system — for example, the mammary gland. Brinton has observed it in only 23"5 per cent of his cases, although "Welch gives a higher figure, 35 per cent. We must, how- ever, distinguish between a simple sw^elling and cancerous degenera- tion of the glands. The latter would be observed much more fre- quently if attention were not alone paid to the glands which are visible and palpable, but also to the entire lymphatic system. Lebert gives the high percentage of 54'5, though Katzenellenbogen places it lower, 40 per cent. The swelling- of the supraclavicular glands, W'hich was first claimed by Henoch and Yirchow, and later by many others,:}; to be a pathognomonic symptom, is, in my ex23erience, a rare and by no means constant occurrence. Ulceration occurs to a very variable extent in gastric cancer, sometimes as simple superficial erosions, sometimes as a single round or oval ulcer, not infrequently having an orifice like a crater with a thick, wall-like edge. Ulceration occurs most frequently in the medullary variety, less often in the scirrhus, and least of all in the * Virchow. Die krankhafte Geschwulste, I, S. 54. f Andral et Gavarett. Rech. sur la composit. du sang, p. 238. X Troisier. Les gangliones sus-claviculaires dans le cancer de I'estomac. Gaz. hebdom., 1886, No. 42. SYMPTOMS OF CANCER. 177 colloid. Altliougli the process usually lias a progressive tendency, yet sometimes carcinomatous ulcers may be found witli the central portion cicatrized (whence the saying that cancer is curable), but in the ede-es of which new foci continue to be formed. Erosion of the blood-vessels may lead to small or large haemorrhages with their subsequent tissue-changes. If the mucous membrane is totally de- stroyed, we then find the submucous connective tissue covered with florid, blackish fragments of the destroyed membrane, or its surface may be entirely bare, excepting here and there a few vascular loops. In a similar way arise the villous fungosities on the surface of an ulcerated carcinoma ; yet these must be carefully distinguished from the benign true polypi of the mucous membrane. Ulceration may lead to perforation^' this is comparatively infre- quent. Brinton estimates its occurrence at about 4 cent. The in- testines and peritonaeum are most frequently involved, especially the transverse colon ; these communications being sometimes of a fairly large size. If an adhesive peritonitis has preceded, the perforation may at times lead to the formation of an encapsulated sac, which in rare cases may perforate the abdominal wall in the form of an ab- scess. Altogether sixteen such cases have been reported, according to a compilation by Mislowitzer ; * to these must be added another case, which occurred in Gerhardt's clinic. Dittrich has seen a case in which the perforation was into the ileum after complete closure of the pylorus had taken place ; and thus by natural means a collateral communication between the stomach and intestines was established, such as we endeavor to obtain by operation in similar cases. General Clinical History. — Cancer of the stomach is an exceed- ingly insidious disease, and at the outset is not to be distinguished from other affections of the organ which lead to dyspejjsia. Brin- ton's epigrammatic description, " Obscure in its symptoms, frequent in its recurrence, fatal in its event," is true even to-day in spite of the great improvement in our diagnostic and therapeutic resources. Irregularity and impairment of the appetite, slowing and disturb- ance of digestion, a feeling of pressure, fullness, and tension in the * E. Mislowitzer. Ucbcr die Perforationen des Magenearcinoms naeh aussen. Berlin, 1889. 1Y8 DISEASES OP THE STOMACH. epigastrium, also regurgitation of food and a tendency to nausea, together with more or less obstinate constipation, open the scene. It is only gradually that pain in the stomach, local or diffused or cardialgic in character, is added ; then vomiting occurs, usually without any great exertion and without marked nausea. The tongue becomes thickly coated, and especially in the morning has a tena- cious w^hite fur, which is scraped ofE with difficulty and is soon re- newed. Lebert seldom found the tongue coated, and considered this cleanness of the tongue one of the most important paradoxical manifestations of the disease. My experience is, however, different ; I have, indeed, seen patients whose tongues remained relatively clean, yet such cases are exceptions. The coated condition of the tongue either in toto, or with the exception of the edges and isolated papillse which project like berries, is, quite on the contrary, to be regarded as an important point in the differential diagnosis from gastric ulcer. A striking repugnance toward meat, and other anoma- lies of taste and appetite, precede complete anorexia. (One of my patients stated that claret suddenly tasted like ink. One of Brin- ton's patients abruptly lost all desire for smoking, although strongly addicted to the habit. This, combined with a cachectic appearance, led the physician to diagnose a cancer which was subsequently dem- onstrated, although the other symptoms did not indicate it.*) The taste becomes flat and " pasty," bitter or sour, or the mouth may become foul in spite of all attempts at rinsing and cleansing. The pain becomes more intense, and at times paroxysmal, and occurs not only after the scanty meals but also between them and at night. Yomiting is more frequent ; while at first the vomit consists chiefly of mucus, remnants of food, and watery fluid mixed with bile, in time the food is vomited in a more and more undigested condition. The vomit is sometimes tasteless, sometimes sour, has a penetrating or ofi^ensive odor, and where perforation has occurred into the in- testines it may even have a fecal odor. Besides containing various kinds of epithelium and micro-organisms (Fig. 21), the vomited mat- ter may often contain blood, either in small amounts as bright-red * Loc. cit., p. 195. Although Brinton considers this diagnosis a " matter of pro- fessional instinct," yet it strikes me as having been more a " matter of hazard " ! VOMIT IN CANCER. 179 streaks in the mucus, or in large quantities as briglit-red or brown- isli-red clots or brown, cliocolate-colored to black coagula and Fig. 21. masses — the well-known coffee -ground vomit; these differences are due to the length of time the blood has remained in the stomach, and to the extent of the decomposition caused bj its contents. The vomit from which this drawing- was made consisted of a clear, red- dish fluid, with a light, flocculent deposit, in which dark-brown particles resembling snuff were suspended. The filtrate contained no free acid, but small amomits of lactic acid were present ; has no digestive action unless hydrochloric acid is added. Under the microscope may be seen the outlines of red blood-cells, granular masses stained with blood-pigment, epithelium of the oesophagus and stomach — some of which look like peptic cells, others are distinctly cylindrical. There are also yeast-cells, and also cells of another variety of fung-i (Hyphomyceten), probably an asper- gillus. A dense network of delicate and coarse fungus filaments (which is merely indicated in the figure) incloses the above-mentioned brownish detritus which is visible to the naked eye. There are also many cocci and drops of fat. The peculiar fibers to the left of the figure, resembling- elastic fibers of the lungs, are from the connective tissue of the ingested meat. I have repeatedly observed these fibers, even in the artificial digestion of meat. The patient asserted that he had taken only milk for three weeks. There is no reason to doubt the truth of this assertion ; what we find sim- ply proves how long such remnants may remain in the folds of the mucous membrane. 180 DISEASES OF THE STOMACH. The coffee-ground vomit is not, as was formerly supposed, pa- thognomonic of cancer of the stomach ; yet it must be admitted that in this disease the blood remains in the stomach for a longer period than in the other diseases of this organ which lead to hsem- orrhages and these subsequent changes. In most cases there now appears a palpable (or also visible) tumor, which is most frequently situated in the triangle formed by the free lower border of the ribs and the linea umbilicalis [a horizontal line passing through the umbilicus] ; it is somewhat higher in men than in women, in whom the lower situation is due to the downward dis- placement of the liver. Rather early, and not at all proportional to the subjective feel- ings of the patient, occur marked loss of strength and j)rogressive emaciation ; the superficial fat and the muscles rapidly waste away, till the sufferer soon drifts into a state of extreme marasmus and ex- haustion. One of my patients, with a distinct tumor but with a sur- prisingly good subjective condition, complained only at first that his limbs wei'e becoming weak in climbing stairs. Soon the charac- teristic pale-yellow color of the cancerous cachexia makes its ap- pearance. After severe haemorrhages the countenance acquires an anaemic or at times a dropsical puffiness, especially under the eye- lids. The eyes sink in, the cheeks become very prominent, the features pointed, and the patients look much older than they are. Profound depression of a melancholy nature may alternate with restlessness and excitement. The picture may be complicated by neuralgias, headaches, dizziness, and tinnitus aurium. The metas- tases in other organs, the liver, intestines lungs, etc., the insidious or the acute perforations may produce a variety of complications which in individual cases are manifested by characteristic symp- toms. Certain occurrences are especially significant of a fatal termi- nation. Among these is fever, wdiich is neither a marked nor a constant symptom, yet by no means as rare as is commonly sup- posed. Its course is irregular, ranging usually between 38° and 39° C. [100-4° and 102-2° Fahr.], rarely reaching 40° [104° Falir.], and may, as I saw in one case, assume a purely hectic character. At times absolutely or almost afebrile periods may alternate with such high febrile movements as can only arise from secondary in- FEVEEl— TERMINAL SYMPTOMS. 181 fiammations. In addition, I see that Hainpeln,* in a very interesting paper on the symptoms of obscure visceral carcinomas, lias very ac- curately described two cases of gastric cancer with an intermitting fever, which was so marked that chills followed by fever and sweat- ing were present, and the possibility of the existence of malaria had to be carefully considered. An interesting case of the latter variety recently came under my observation at the Augusta Hospital. A man forty-seven years old was admitted Decem.ber 6, 1888. Present illness began about two years ago with symptoms of dyspepsia. In Sep- tember, 1888, had haematemesis and also passed blood per anum. He was treated in the hospital dixring October for '' ulcer of the stomach," and was discharged improved. On December 3d, violent vomiting, but no haematemesis. On admission he was j)]aced on a milk diet, it being supposed that a gastric ulcer was present. An irregular fever with evening exacerbations to 39*6° C. [103 "3° Fahr.] soon manifested itself. The pains in the epigas- trium continued, and became variable in their situation, being sometimes more marked to the left, sometimes to the right. The stomach-contents contained no free hydrochloric acid. The patient became more and more emaciated, so that finally a small tumor could be palpated in the right hypochondrium near the border of the liver. Icterus was not present. A diagnosis of cancer of the stomach and liver was made. On January 5, 1889, he had a marked chill, which recurred several times ; the pains in the epigastrium increased, and from now on to the patient's death on February 20. 1889, the fever remained continuous, and a delicate fric- tion sound could be heard near the edge of the liver. A diagnosis was made of perforation of an ulcerated cancer following an adhesive in- flammation and agglutination of the adjacent tissues, and also a localized peritonitis. The autopsy revealed the presence of an ulcerated carci- noma about the size of an apple, which was situated on the lesser curva- ture, and which reached to and was adherent to the diaphragm. The surface of the liver was studded with numerous slightly elevated white nodules, all of which showed recent adhesions to the parietal peritoneum. Among the terminal symptoms belong dropsical swellings and effusions into the serous cavities ; inflammatory processes may also occur in the lungs, pleurse, and kidneys. As death approaches, de- lirium may occasionally be present ; this is to be regarded as a de- lirium due to inanition. Death is due to marasmus ; the agony is brief. Consciousness remains clear for a long time, yet disappears * P. Hampeln. Zur Symptomatologie oceulter visceraler Careinorae. Zeitschr. fill- klin. Medicin, Bd. 8, S. 233. 182 DISEASES OF THE STOMACH. as death approaclies, so that a conscious death-struggle does not occur."^ As a rule, the course of cancer is progressive, irresistible, and ad- vancing toward a fatal termination. Occasionally, longer or shorter periods may occur in Mdiich the process seems to stand still, in fact even to retrograde. Such occurrences may lead to diagnostic errors and doubts. A very striking example of this occurred to me at the beginning of my practice. The patient, a gentleman sixty-two years old, became ill very gradu- ally with symptoms which rendered a diagnosis of gastric carcinoma prob- able, but it could not be made absolutely. The patient felt worse and became weaker ; he vomited, had severe pains in the region of the stom- ach, especially on pressure ; absolute anorexia and obstinate constipation. A medical charlatan diagnosed the case as an affection of the spleen, and prescribed rhubarb wine and gruel with stewed prunes ! But — the patient improved, and, as I heard later, ate his gruel with great relish ; he even went out again, and swore by his doctor. This went on for about two months ; then the old symptoms returned, and the patient became maraslic quite rapidly and died. I saw him again a short time before his death, and could then positively demonstrate a tumor at the pylorus, which was about the size of a fist. Such periods of apparent improvement I have repeatedly ob- served. Most experienced physicians know of them ; they certainly occur much more frequently than the text-books would lead us to suppose. The duration of the disease may vary from between three to six months to two, three, or more years ; on an average it lasts be- tween six and fifteen months ; a shorter course is at all events ex- ceptional. It always terminates fatally : cases of cured cancer of the stomach have been repeatedly reported, yet they have never been positively proved. The cases reported by Dittrich, Lebert, Friedreich, and others, may have been mistaken for gastric ulcers or the superficial cicatrices which have already been described. Thus, in one of my cases of cancer of the breast, I found in the stomach a radiating cicatrix with thick, callous edges and a marked atrophy of the mucous membrane in the vicinity. It would have * [Dyspnoeic coma, as in diabetes, may also occur in the latter stages of gastric cancer. Gerhardt's reaction may or may not be present in the urine. See Welch, loG. cit., pp. 534 et seq. Tb.] OCCURRENCE OP VARIOUS SYMPTOMS. 183 been reasonable to suppose that this was a healed primary carci- noma of the stomach Avith metastases in the mammary gland. But the microscope showed just the reverse. The base of the scar was formed by firm, dense connective tissue, while in the imme- diate vicinity of the border in the submucosa scattered cell-nests were found ; these could only be regarded as the beginning of a cancerous process. The process was thus a cancer which had de- veloped in the cicatrix left after the healing of an ulcer {vide Ulcer of the Stomach). The opinion that this was a cicatrized carcinoma was also excluded, because such an abrupt transition from purely fibrous tissue to recent carcinomatous proliferation as was present in this case is never found in a cancerous cicatrix. The above clinical picture is only schematic, and in an individ- ual case numerous modifications may occur. Writers have taken great pains to determine the relative frequency of the occurrence of the various symptoms, and in the works of Brinton and Lebert you will find analyses carefully prepared from relatively large numbers of cases. In practice, i. e., in the diagnosis of a suspected case, such statistics have only a relative value, and are more interesting for the nosology of the disease. If we remember our statistics never so well, who will guarantee that a given case is the rule or an ex- ception ? To illustrate the above, I present the accompanying half-sche- matic drawing (Fig. 22) of a case in which a colloid cancer involved the lesser curvature, and, being partially covered by the left lobe of the liver, could not be palpated during life. The jjatient was a tailor, forty- eight years old, who had never complained of pain, and had never had hsematemesis. A probable diagnosis of cancer of the stomach had been made at the clinic of Prof. Frerichs, solely upon the marked anorexia and the progressive cachexia, and by the careful exclusion of other diseases. The fact that hsematemesis occurs in 42 per cent (according to Lebert, in only 12 per cent) of the cases, and that a tumor is absent in 20 per cent, would have de- cided this case neither positively nor negatively. For the sake of completeness, however, and because it may nev- ertheless be of some assistance, I shall not withhold the following ^figures. They are based upon an analysis of 250 cases reported 184 DISEASES OF THE STOMACH. Fig. 22. — Mr. E., died March 17, 1874. Colloid cancer of lesser curvature of stomach. OCCURRENCE OP VARIOUS SYMPTOMS, 185 bj Brintoii and 88 and 145 cases respectively collected by Le- bert.* Loss of appetite occurs in 45 per cent ; often is observed only toward the close of the disease ; rarely the appetite is increased Pain is present in 92 per cent (Lebert, 75 per cent). It is fre- quently absent in old people. Brinton claims that pain between the scapulae indicates a cancer on the lesser curvature. In the case which I have just cited there was no reference to such an interscap- ular pain, and my own experience leads me to consider that the sig- nificance of this symptom has been exaggerated. Vomiting occurs in 88 per cent (Lebert, 80 per cent). It is most frequent where the orifices are involved, l^evertheless, a marked stenosis of the pylorus may exist without the occurrence of vomiting. While in most cases it occurs a considerable time after the meal (one, two, or three hours), yet it may take place much sooner, and in drunkards and very debilitated persons may even be present in the morning when the stomach is empty. There is thus nothing typical in the time of its occurrence. IIcBinatemesis is noted in 42 per cent of Brinton's cases. Lebert distinguishes large haemorrhages from the stomach from true me- Isena or melanemesis [the vomiting of black altered blood] ; the fre- quency of the former he estimates at only 12 per cent. A tumor is present in 80 per cent of the cases, according to both Brinton and Lebert. It is seldom palpable before the third to the sixth month ; usually it is only distinct in the second half of the course of the disease, or during the last months of the patient's life. The howels remain regular in only 4 to 5 per cent of the cases. In the vast majority there is constipation, or constipation alternat- ing with diarrhoea ; the latter is a manifestation of a catarrhal con- dition of the intestinal mucous membrane, due to the irritation of hard fecal masses, or of products of decomposition which have not been carried off. A gastro-intestinal fistula may be formed, and faeces and gases may reach the stomach, or the stools may * A Ott (Zur Pathologie des Magenearcinoms, Inatig. Dissert., Zurich, 1867) has added 33 additional cases from Prof. Biermer's clinic, and has obtained sub- stantially the same results, 13g DISEASES OF THE STOMACH. become lienteric (i. e., tlie presence of undigested food in tlie fgeces). Yet Eampold* has observed a commnnication between the stomach and transverse colon and an adjacent loop of intestine in a patient sixty-six years of age, who gave no definite symptoms indicating a gastric lesion ; it mnst be noted, however, that the patient also suffered from dementia paralytica. Mnrchison f has called attention to the fact that stercoraceons vomiting will be absent when the contents of the stomach pass directly into the colon, since there can be no formation of faeces. Finally, we mnst mention one peculiarity wliich is observed where the orifices of the stomach are involved by the cancer — i. e., the breaking down of the new tissue may cause the symptoms due to the stenosis to dis- appear, and thus, at times, an improvement may seem to have occurred. The condition of the Mood deserves especial notice. Laache % describes a lessening of the number of the red blood-cells in this disease ; Lepine * calls attention to the temporary occurrence of numerous microcytes, whose number may be estimated at one half that of the red blood-cells. Eisenlohr || and Schneider, ^ besides the above changes, observed a relative and even an absolute in- crease in the number of white blood-cells, so that the condition of the blood may resemble that of pernicious ansemia, or even of leucocytha^mia ; Schneider also says that " these so easily recognized changes in the blood may become a not unimportant item in the differential diagnosis." Diagnosis. — Although, taking all in all, the diagnosis of the disease may be made from what has already been stated concerning the development, course, and general symptomatology, yet there still remain certain important diagnostic features, the considera- tion of which I must not omit. I shall begin with the one which * Rampold. Hufeland's Journal, 5. Stiick, 1830. f Quoted by Henoch. Klinik der Unteiieibskrankheiten. Berlin, 18G3. X S. Laache. Die Anaemie. Christiania, 1883. * Lepine et Germont. Note, etc. Gazette med. de Paris, 1877, No. 14. II Eisenlohr. Blut und Knochenmark. Deutsches Archiv fiir klin. Med., Bd. 80. S. 495. ^ G. Schneider. Ueber die morphologichen Vehaltnisse des Blutes bei Herz- krankheiten und bei Carcinoin. Inaug. Diss. Berlin, 1888. ABSENCE OP HYDROCHLORIC ACID. 187 is of most recent origin, and which has given rise to somewhat too precipitate and exaggerated hopes. I refer to — 1. The absence of free hydrocliloric acid in the stomach-con- tents. It was a great triumph of Prof. Kussmaiil's chnic to have first methodically investigated the subject. The ojjinion was origi- nally expressed by E,. von den Velden, that cancer of the pylorus, accompanied by dilatation of the stomach, leads to a suppression of the secretion of hydrochloric acid. This view was soon indis criminately applied to all varieties of cancers of the stomach. But even the combined labors of numerous investigators, and not the least, of the above-mentioned clinic, have shown that this statement can not be maintained in its entirety ; yet it has led to results of great diagnostic and therapeutic significance. But historical justice demands that we think of an investigator who, years ago, so thoroughly studied the question of the occurrence of hydrochloric acid in gastric cancer that the knowledge of his conclusions would have spared us much needless discussion. Re- markably, however, his labors, splendid for the age in which he lived, have so absolutely passed into oblivion that even his own countrymen nowhere speak of them. Golding Bird, Physician to the Islington Dispensary, and Professor of Medicine at Guy's Hos- pital in London, in 1842,* in a man forty-two years old, with pyloric cancer and dilatation (verified by autopsy), determined the relation of hydrochloric and the organic acids in a series of examinations of the vomit, the methods employed being faultless even to-day.f In about three weeks three estimations were made, the results of which led Bird to conclude that, " during the more irritative stage of the disease, free hydrochloric acid is present in the vomit in con- siderable quantities, but it gradually diminishes in proportion to the patient's loss of strength ; and that the organic acids increase pro- portionally as the free hydrochloric acid diminishes." It is worthy of note that, by a control-experiment on a healthy subject (an emetic * Golding Bird. Contributions to the Chemical Pathology of some Forms of Morbid Digestion. London Med. Oazette, 1843, vol. ii, p. 39L f Distillation of the volatile acids, incineration of the residue, boiling with dilute nitric acid, and estimating the silver salt with and without the addition of soda. 188 DISEASES OF THE STOMACH. dose of sulphate of zinc was given thirty minutes after a moderate dinner), free hydrochloric acid, but only a very small quantity of organic acids, could be demonstrated ; another experiment, on a patient with cancer of the liver and dilatation of the stomach resulting from pressure of the tumor on the pylorus showed a some- what lessened amount of free hydrochloric acid but large amounts of combined hydrochloric and organic acids. In these investigations it may be possible that a little confu- sion may exist in the relation of the free to the combined hydro- chloric acid and the organic acids, because the diet and the time of the emesis were not precisely determined ; yet Bird's deductions are not to be questioned, and are of great importance. Bird himself was conscious of this, but complains of the amount of time de- manded by these studies, and it seems he did not pursue them further. In this way they passed into obscurity, and it was only recently that this subject was again taken up, but with new meth- ods. The subject has been and is still being investigated by a daily increasing array of clinicians and physicians. To show you the ex- tent of this discussion I need merely mention in chronological order the names of von den Yelden, Ewald, Kietz, Thiersch, Eiegel, Kahn and von Mehring, Jaworski and Gluczynski, Bamberger, Kraus, Dreschfeld, Eosenbach, Krukenberg, Eosenheim, and many others. Unquestionably the largest amount of material was collected by Eiegel, who recently reported sixteen cases of cancer of the stomach, in which three hundred and six separate examinations were made.* It will be superfluous to follow the views expressed pro and con by the various writers, especially since it seems to me that a definite decision has been or soon will be reached. For the question has been much simplified since all have finally agreed as to what is to be understood by the absence of free hydrochloric acid — i. e., the results either of the color tests described in the first lecture, or of careful chemical analyses. It is apparent that the practical impor- tance of the former tests, in so far as they give a uniform result, is not diminished by theoretical considerations based upon the latter. * Loc. cit., p. 430. ABSENCE OF HYDROCHLORIC ACID. 189 It can very well be maintained, as I have always done, that carcinoma reo-arded as a histological neoplasm, in no way lessens or destroys the secretion of hydrochloric acid. This has recently received addi- tional and almost superfluous corroboration by the unearthing of Bird's researches. But, whatever view is taken, it would neverthe- less be a valuable diagnostic criterion, provided other complicating factors did not interfere with the determination of the presence of hydrochloric acid — but not of its secretion. Each is correct. "When the new growth is confined microscopically and macroscopically (which by no means always correspond) to a limited area, when the accompanying catarrh of the mucous membrane is moderate, and when there is no atrophy, then the secretion of hydrochloric acid may remain ample till it disappears with the approach of death ; or it may be much diminished, as occurs in all cachectic conditions. However, in the vast majority of cases one of the above-mentioned factors plays a prominent part, and the secretion of hydrochloric acid is either entirely annihilated or is reduced to so small a quan- tity as not to be demonstrable with the ordinary tests. This would afford us an exceedingly good diagnostic criterion but for the fact — be it said with regret — that a diminution in this secretion may occur in other pathological conditions of the gastric mucosa. These in- clude atrophy and amyloid degeneration of the membrane ; self- evidently, poisoning or corrosion, in which a large portion of the mucous lining is destroyed ; mucous catarrhs and certain neuroses depending upon or associated with a disturbance of the innervation of the gastric glands. It is manifest, as I have already stated, that acute injuries of the gastric mucosa, poisoning, and acute indigestion may cause a loss of glandular activity, just as in an acute catarrh of the kidney there is a marked diminution of its secretion, or as an injection of atropine into Wharton's duct dries up the salivary secre- tion. Likewise, in my own person I found that the stomach-con- tents were absolutely free from hydrochloric acid during a very transitory nicotine poisoning ; on another occasion, during a sea- voyage, I could obtain no reaction with Congo paper in the food which was vomited one hour after breakfast. Such conditions are only of short duration, and rapidly disappear after the removal of the irritant or under a suitable diet. The experiments of Wolf- 190 DISEASES OP THE STOMACH. ram * show that, while fever is present in all the acute infections diseases, the gastric juice contains no hydrochloric acid and exerts no digestive action either within or outside of the organism. We also know concerning certain chronic diseases — for example, Addison's disease (Kohler), pernicious ansaemia, many cases of pul- monary phthisis (C. Rosenthal) — that the secretion of hydrochloric acid is reduced to a minimum, and no free acid can any longer be detected. But even physiologically there are very marked variations in the amount of acid produced ; the free acid depends essentially upon the quantity of albumen which is converted into acid albumen or peptones, which absorb the HCl or form loose combinations with it. Thus free acid may be present or absent in the gastric juice after eating the same food, but with varying conditions of secretory activ- ity. We must, therefore, heartily agree with Eiegel when he de- mands that a positive opinion should only be expressed after exami- nations which have been conducted a long time, and with the aid of a suitable therapy. JSTormally, the production and secretion of tlie hydrochloric acid are so regulated according to the demands of the ingesta that free acid is immediately present in sufficient quantity to give a distinct reaction with the color-tests, etc. This does not occur in the vast majority of cases of cancer of the stomach. But this does not depend upon some influence of the cancer on the pro- duction of HCl, but is simply due to the accompanying catarrhal, inflammatory, or atrophic conditions of the gastric mucous mem- brane. If these are absent the acid is secreted abundantly, as in the case reported by Bird, another by Calm, and still another reported later which had been observed by von den Yelden.f But if, during our observation of such a patient, one of the above processes in- volves the gastric mucous membrane and becomes more marked, or if the organism gradually becomes weaker and weaker, and if with this the functions of the organ primarily involved naturally give way first, then the transition from the occurrence of hydrochloric acid to * Announced by Gluczynski. Ueber das Verhalten des Magensaftes in fieber- haften Krankheiten. Deutsches Arch, fiir klin. Med., Bd. 33. f Cahn. Verhandlungen des YI. Congress, fur innere Medicin, 1887, S. 362 und 373. ABSENCE OP HYDROCELORIC ACID. 191 its absence may take place in a relatively sliort space of time. In this way I explain Bird's case, and also one which came under my own observation. Mr. R., merchant, forty -two years old, was seen in consultation on January 7th. He had suffered for a long time from " chronic catarrh,'' and had complained of a severe burning sensation in the stomach for several months. He was admitted to the Augusta Hospital, and while there was treated with the stomach-tube and was very much benefited by it. He learned to wash out his stomach and did it frequently, especially as he sought in this way to remedy his frequent dietetic errors. The patient was a haggard man, with a dry skin and retracted abdo- men ; he lay in bed on account of weakness. Heart and lungs negative. There was a small movable tumor at the pylorus about the size of a wal- nut, slightly tender on pressure. No succussion sound. The stomach when distended reached to the umbilicus, causing the tumor to move downward and somewhat to the right. During the introduction of the tube by himself he vomited slimy, yellowish-green, c>ffensive masses of neutral reaction ; accordingly, no free acid was present. No glandular swellings. Urine clear and acid. Stools irregular. The stomach-contents, after taking the test-breakfast on the following morning, undoubtedly contained a considerable amount of hydrochloric acid and small quantities of lactic acid, peptone, and propeptone. The stomach-contents digest slowly. In view of the presence of hydrochloric acid, a diagnosis was made of a non - carcinomatous hypertrophy of the pylorus (cicatrization of an old ulcer ; muscular hypertrophy accompanying a chronic ca- tarrh (?) ). But on the following day the iiatient vomited bloody masses and com- plained of severe burning pain in the stomach, and an almost intolerable dryness of the mouth, pharynx, and oesophagus. Vomiting recurred very frequently during the next three weeks in spite of a rigorous diet and regular lavage of the stomach. Each time the stomach -contents were abundant, of a bloody color, or contained broken-down coagula ; frag- ments of food were also present. Hydrochloric acid was never found ; on the other hand, large quantities of yeast-cells, bacteria, and mucus could be seen. The reaction was usually neutral ; if acid, it was due to acid salts or lactic acid. On two different occasions the test-breakfast was given lege artis, and each time the absence of hydrochloric acid was noted. The tumor remained unchanged and could be felt more or less distinctly, according to the fullness of the stomach. The patient suffered intensely, lost strength rapidly, and urgently wished the removal of the tumor by operation. In view of the large quantities of " stomach-con- tents " which were siphoned through the tube from the patient's stom- ach — often amounting to four or five litres [nine to eleven pints]— dila- tation of the stomach was diagnosed, although a repetition of the disten- tion of the viscus with air again gave no positive evidence thereof. I could not quite explain this peculiar condition, but I expressed to my col- leagues the suspicion that the siphoned fluid came from the intestines 192 DISEASES OP THE STOMACH. rather than from the stomach, the fluid having regurgitated into the latter through the rigid and thus incompetent pylorus. At the patient's request, Prof. Sonnenberg resected the pylorus on Jan- uary 30th— i. e., about three weeks after the first examination. At, and sui'rounding the pylorus, was a hard tumor, the size of a walnut, which so narrowed the orifice that the tip of the little finger could be inserted only with difficulty. Several glands in the ligamentum gastro-colicum were enlarged to the size of cherries. The stomach was not dilated. After the operation everything went smoothly and for the first few days the patient's condition was excellent. On the fourth day there was a slight febrile movement, followed by marked collapse ; the patient died on the evening of the fifth day. At the autopsy I found that some of the sutures (catgut and silk) had suppurated, causing a localized purulent and adhesive peritonitis which may be regarded as the cause of death. The mucous membrane in the line of sutures was hyperaemic, hut elseivhere was entirely uninvolved. On the other hand, the muscularis as far as the fundus was infiltrated and thickened. A piece of the fresh tumor was immediately placed in absolute alcohol, which was subsequently fre- quently changed ; microscopical examination showed that it was a scir- rhus carcinoma which was almost entirely limited to the muscularis, in- filtrating it in broad bands. The greater part of the mucous membrane was entirely normal, or at most only slightly infiltrated by an interstitial proliferation of small cells from the submucosa. In places there was more atypical growth of the glandular tubules, and cysts of various sizes were found toward and in the submucosa. On comparing this section with a preparation from a catarrhal stomach no marked differences could be found. The same was true of pieces of tissue which were taken at the autopsy from the fundal and cardiac portions. In the affected area the submucosa was sharply defined from the mucosa on the one side and from the infiltrated muscularis on the other ; even with the naked eye its wide-meshed fibrous structiu'e could be I'ecognized. The great significance of tins case is manifest. It proves that with a localised cancer and an intact mucous inemhrane the secre- tion of hydrochloric acid may continue up to a short thne Ijefore death I and xinder such circumstances cortclusions based %ipon the demonstration of this acid may he erroneous. The peculiar features connected with the sipbonage of the stomach are an additional in- teresting point of this case. The distention of the stomach with gas afforded i-eliable data ; and the large quantities of fluid which were obtained without any exertion are only to be explained as above. There was thus a true and actual insufficiency of the pylorus, l^ev- ertheless, it may be said that the duodenum could not be distended. This can be readily understood if the large capacity of this part of the intestine be compared with the small amount of air which can ABSENCE OF HYDROCHLORIC ACID. I93 be pumped in. Finally, the admixture of blood in tlie stomach-con- tents, wliicli was constantly observed toward tlie close of life, re- mains entirely inexplicable ; the autopsy afforded no clew ; there- fore, as in other cases, we must assume the occurrence of gradual rhexis from the vessels. Since the observation of this case a number of careful investiga- tions have been made on the relations of hydrochloric acid to cancer of the stomach ; of these I shall only quote the following : In eight cases of this disease which were carefully studied, both auatomically and chemically, Stienon * reports that four gave no reaction to the color-tests, while the other four gave temporary, more or less posi- tive results. In fourteen examinations made on two cases with the method of Cahn and von Mering, positive reactions were obtained, the amount of hydrochloric acid varying between 0*4 and 2"3 per thousand, but the color-tests gave a negative result every time. The microscopic examination convinced him that the disease is fre- quently, if not usually, accompanied by an atrophy of the glands, and to this may be due the absence of hydrochloric acid. This may be true of many but by no means of all the cases of gastric cancer, because experience teaches us that the accompanying affection of the mucous membrane may restrict itself to a more or less extensive and intense inflammatory process (catarrh). A very comprehensive study of this subject was also made by Rosenheim f with the aid of Cahn and von Mering's method. In fourteen out of sixteen cases of gastric carcinoma he could never demonstrate y^ee hydrochloriG acid at the height of digestion ; in another it was present temporarily ; in still another it was not alone present, but there were even hyperacidity and hypersecretion. In re- gard to the latter case it must be noted that the color-tests for hydro- chloric acid were almost always negative, and that the statement of the presence of hyperacidity is based upon a method (Cahn and von Mering's) which is not free from objections. Yet this is at present * L. Stienon. Le sue gastrique et les phenoraenes chimiques de la digestion dans les maladies de restomac. Journal de Med. de Bruxelles, October 5, 1888. f Th. Rosenheim. Ueber atrophisehe Processe in der Magenschleimhaut in ihrer Beziehung zum Carcinom und als selbststandige Erkrankung. Berliner klin. Wochenschr., 1888, No. 51-53. IC 194 DISEASES OP THE STOMACH. of minor interest as compared with the unanimous result of the in- vestigations of these writers, namely, that under certain conditions free hydrochloric acid may be present in cancer of the stomach. In this disease the stomach-contents, containing no free acid, exert no digestive action, even on the addition of hydrochloric acid, or of small quantities of normal chyme. The reason for this I gave long ago in my answer to Riegel's experiment upon this point, i. e., that the HCl is seized by the excess of albumen, and hence does not come into action. Had Riegel added the acid till free HCl could be demonstrated, his trial of digestion would have been successful, since pepsin is seldom absent. For the other ingre- dients of the gastric juice, the pepsin and rennet are not lessened to the same degree as the hydrochloric acid. The products of the action of pepsin, the peptones, are found almost without exception even where neither free hydrochloric nor lactic acid is present. Hence pepsin must have been secreted, and sufficient free HCl to form peptone must have been present at some time. The majority of these filtered stomach-contents form not alone prope23tone but also true peptone, if they are acidulated to about two per thousand of free HCl. Boas {loo. cit.) claims to have found rennet even Mdiere free HCl was absent. The explanation of this apparent paradox lies in the fact that the secreted HCl combines with any free bases, weak salts and albumen and its derivatives, while the ferments remain free ; and of the latter we know that their action only begins to be lessened when the products of fermentation are present in excess. The relation of these three elements [hydrochloric acid, pepsin, and rennet], and the mode of determining them, will therefore depend very much upon the nature of the food and the energy of the secre- tion — the effects of the variety and extent of the lesion of the mu- cous membrane being self-evident. But the important fact remains that free hydrochloric acid is usually absent in carcinoma of the stomach. Unfortunately, the diagnostic value of this circumstance is decidedly affected by the occurrence of this same loss in the other conditions which I have already mentioned. JBut, granting this, the proposition, which I was the first to announce, is still true, that the demonstration of the presence of hydrochloric acid points with very great prol)a})iliiy TISSUE ELEMENTS IN VOMIT. 196 against the existence of cancer of the stomach / for the cases of this disease in whicli there is a positive reaction to the carefully applied tests are so rare that they have very little bearing on the question. Under certain conditions (stagnation of the ingesta or the intro- duction of easily fermenting food) the hydrochloric acid may be replaced, or may be accompanied by lactic acid, fatty acids and their salts, which may impart an acid reaction and penetrating odor and taste to the contents of the stomach. Of especial interest, however, is tlie fact, which has been repeatedly observed in this disease, as well as in other affections of the stomach, that, with an absolute loss of the hydrochloric-acid reaction, this deficiency in the digestive function has been replaced for a long time by the vicarious action of the intestinal digestion, or by the formation of large quantities of lactic acid (or eventually of acetic acid). 2. The presence of specific tissue elements in the voinit, or in the masses raised through the stomach-tube. I have already spoken in general of the constituents of the vomit ; here I need only reca- pitulate that in the advanced stages of this malady we may find a very great variety of fungi, yeast-cells, sarcinse, bacteria, pavement and round epithelial cells, with large nuclei, single nuclei, and nu- cleoli, and large masses of detritus colored brown to a dark green, and mixed with all kinds of remnants of food. But the present question is. Is it possible to recognize specific cancerous tissue ? This is certainly impossible with isolated epithelial cells. It must be admitted with regret that, in spite of all the time and labor whicli have been expended, no means have yet been discovered by which we can distinguish specific cancer-cells from the ordinary varieties of epithelial cells found in the stomach-contents, some of which are derived from the walls of that viscus, while others, from the mouth and oesophagus, have been swallowed. Even Brinton said : " But mere isolated cells or nuclei scarcely justify a decision." Lebert, in his Physiologic pathologique., pictures cells with six or more concentric layers, which he considers specific cancer-cells, '•''globules cancereux d paroix concentrig^ies^'' These cells are . nothing more nor less than starch granules. For my part, I only consider conclusive the concentrically stratified aggregations of 196 DISEASES OP THE STOMACH. cells, true cancer-cell nests, sucli as are shown in Fig. 23, In the case from which this specimen was obtained it was even of decisive value. Fig. 23. — Cancerous cell-nest raised through stomach-tube. (From Mr. L., December 11, 1886. Sketched with camera lucida.) Mr. L., about thirty -five years old ; no inherited diseases ; has been complaining for the last six months of anorexia, pain in the epigastrium, and frequent vomiting ; no tumor nor cancerous cachexia. By means of the stomach-tube large masses of mucus were obtained every time ; hydrochloric acid could never be demonstrated. The diagnosis lay be- tween a severe mucous catarrhal gastritis and an occult neoplasm. On renewal of the examinations faint blood-streaks were seen, and a small, firm particle was obtained ; from this the above preparation was made. By its means alone the diagnosis was established, and the death of the patient about two months later verified its correctness. But even sucli specimens as the one in question may give rise to errors. It occasionally happens that very small pieces of the gas- tric mucosa may be detached where the membrane is very vulnerable, even when a cancerous neoplasm is absent. If such a piece is placed on a slide, the pressure of the cover-glass may cause the epithelium surrounding an excretory duct to assume a concentric stratification closely resembling a cancerous cell-nest. The drawing of such a specimen is given in Fig. 23 ; it, together with a large THE CANCEROUS TUMOR. 197 shred of the epithelial lining of the stomach, was found in the wasli-water while washing the stomach of a patient twenty-eight years old, suffering from a mu- cous catarrhal gastritis, with no symptoms of cancer, and whose improvement was continuous. Later on, in the discussion of the catarrhal conditions of the stomach, I shall be able to pre- sent to you unmistakable speci- mens in totO of the detached epi- Fig. 24.— a piece of the epithelial covering , ,. j; xi, J. 1, *^f t^^s mucous membrane of the stoin- thelmm 01 the stomach. ^^j^^ resembling a cancerous cell-nest. In three cases of gastric can- (From Mr. K., March 10, 1887. Sketched . with camera lucicla.) cer Kosenbach* found pieces of the tumor in the wash-water ; he claims that even macroscopically (it is surprising that no microscopical examination was made) they may be differentiated from detached portions of the mucosa by characteristic punctate haemorrhages penetrating into the tissue, and by the old brownish-black blood. I myself have never observed such specimens, and, in spite of Eosenbach's assertions to the con- trary, I would consider them rare, and as being entirely dependent upon the nature of the neoplasm. 3. The cancerous tumor. Concerning the character of tumors in the stomach, and the peculiarities of the diagnosis of them, I shall only remark, in passing, that it is self-evident that to be pal- pable they must be situated upon the greater curvature, or at the pylorus, and that neoplasms situated upon the lesser curvature are beyond the reach of the palpating fingers, especially if the growth is along the surface and is overlapped by the liver ; such a condi- tion was present in the case from which Fig. 22 was taken ; and, finally, that tumors on the lesser curvature can only be palpated when the stomach occupies an abnormal position. It is equally obvious that the palpation of stomach tumors may be rendered impossible by the development of ascites or cancerous peritonitis. * 0. Rosenbach. Ueber die Anwesenheit von Gesehwulstpartickelschen in dem durch die Magenpumpe entleerten Mageninhalt bei Carcinoma ventriculi. Deutsclie med. Wochenschr., 1882, No. 33. 198 DISEASES OP THE STOMACH. For a long time it was considered an irrefutable axiom that move- ment of gastric tmnors with respiration became possible only after adhesions had been contracted with the liver. But even this rule is not without exceptions. At a recent meeting of the Gesellschaft der CharitS-Aerzte zu Berlin, Fr. Miiller exhibited a stomach totally involved by a carcinoma, without any adhesions to the neighboring viscera, and yet which, during life, descended with every inspi- ration, as a result of the flattening of the diaphragm. A similar movement of the tumor may be transmitted from the liver when the neoplasm lies close to the edge of the liver without the forma- tion of any adhesions. At the Policlinic I have repeatedly and care- fully examined a patient with such a tumor, the size of a fist, situated on the greater curvature near the pylorus ; it was freely movable both with the fingers and by distending the stomach with air ; the descent with every movement of inspiration was very noticeable. But such cases are always exceptional ; and, indeed, their occurrence as such merely serves to strengthen the general rule above stated. It is also important to bear in mind that most tumors feel much larger to the palpating finger than they really are, and that they may change their position according to the fullness of the stomach or intestines. In like manner a good idea of the size and situation, whether in the stomach or in one of the adjacent viscera, is not sel- dom only obtainable after the distention of the stomach or intes- tines. To distinguish a deformity on the lower border of the liver, especially in the left lobe, such as frequently result from tight lacing in women, or a true tumor of the liver, pancreas, or spleen from a new growth in the stomach, may at times be very difficult ; at other times it is even impossible. The reverse may also occur, and a car- cinoma of the stomach may be regarded as belonging to the left lobe of the liver. Thus Ott,* after giving a very careful description of such a case, says : " The complete degeneration of the entire stomach even to the region of the liver, the rigid infiltration of the greater curvature, the diminution in size and contraction of the organ which enabled one to grasp the * Ott. Zur Pathologie der Magencarcinome. Zurich, 1867, S. 60. THE CANCEROUS TUMOE. 199 greater curvature, and which caused it to feel like the edge of the liver — all of these factors led to this deception." It is equally difficult to decide wlietlier a thickening at the py- lorus is due to hypertrophy of the muscular coat, cirrhosis, foreign body encapsulated in the stomach,* cicatrized ulcer, localized peri- toneal exudate, or carcinoma. Carcinomata of the omentum or of the intestines, which may be lying alongside of the stomach, may at times be recognized by a simple distention of the gut with air. Leube very properly calls attention to the possibility of mistaking the pancreas for a growing tumor of the stomach, since the pro- gressive emaciation of the patient permits the pancreas to be more easily palpated through the relaxed abdominal wall. Frequently the question can only be decided after prolonged observation by the eventual growth of the suspected tumor, the occurrence of cancerous cachexia, the formation of metastases, and swellings of the lymph glands ; but sometimes even these signs may fail, and the autopsy alone can reveal the true condition. In all these cases the examina- tion of the stomach-contents is of great importance. If the usual amount of free hydrochloric acid is present after the test-breakfast, we may say with tolerable certainty that the stomach is not involved. That this is not always true was shown in the case described in de- tail on page 191. On the other hand, I wish to relate two cases in which this examination placed the diagnosis beyond doubt : On November 24th a colleague, Dr. X., sent to me Mrs. W., thirty- three years old, a small, emaciated woman, who had borne four children. She complained of almost continuous pain day and night in the epigas- trium. The pains were independent of eating, have lasted more than six * These foreign bodies which may simulate malignant tumors are usually spheri- cal or ovoid agglomerations of hairs which have been swallowed. But similar errors may arise from " shellac calculus " {Shellackstein), as occurred in a carpenter who mistook his varnish for liquor ; other foreign bodies of a similar nature have given rise to errors. See Pale'mon Best, Death frona Accumulation of Hair in the Stomach of a Woman, British Medical Journal, December 11, 1869, and other Eng- lish authors. The eating of hair seems to be a favorite occupation of English women ; still, unless I am mistaken, a similar case was reported by Schonborn. [Another German case may be found in 0. Bollinger. Eine seltene Haarge- schwulst im menschlichen Magen. Mlinchen. med. Wochenschr., 1891, Bd. 38, S. 383. The case of Schonborn, alluded to above, may be found in Arch, fiir klin. Chirurg., Bd. 29, S. 609 ; the bah of hair, which was mistaken for a movable kidney, was suc- cessfully removed by operation. — Tr.] 200, DISEASES OP THE STOMACH. months, and were temporarily ameliorated by the use of Carlsbad water. The patient belched frequently, but had a good appetite, and had never vomited. The tongue was not coated; the abdomen was somewhat penduloLis, and its walls relaxed. Close to and on the right of the median line was an easily movable tumor, which was painful on pressure; to the right and external to this was a second tumor, smaller, and descending with in- spiration (gall-bladder). Distention of the stomach with air revealed a dilatation and a descent of the greater curvature to midway between the symphysis and umbilicus. The stomach-contents contained an abundance of free hydrochloric acid, but no products of fermentation or decomposi- tion. Further questioning revealed that the patient had occasionally suf- fered from gastralgia. Diagnosis: Dilatation of the stomach resulting from a cicatricial stenosis of the pylorus, and hypertrophy of the inuscu- laris as a sequel of an ulcer at this point. The proof of this was the con- tinuous improvement and gain in strength after methodical lavage and suitable diet. No cancerous cachexia was present. The diagnosis of this case was possible onlj by knowing the re- sult of the examination of the stomach-contents ; and, having ascer- tained this, it was rendered sufficiently certain. It is well known that a hypertrophy of the musciilaris in the pyloric region may absolutely simulate a neoplasm ; as examples, I refer to the case re- ported by Virchow,* and to another published by myself : f The latter case was as follows: H. S., fifty-six years old, teacher from Salzwedel. The man, of a very large and powerful frame, was much ema- ciated and cachectic. The abdomen was relaxed and very flaccid, as in a multipara. In the umbilical region close to the surface could be felt a bi'oad, flat, slightly nodular tumor, which reached on the right to the axil lary line and on the left to the parasternal line. Deep inspiration gave rise to a feeling of false movement — i. e., the sliding of the abdominal wall simulated the movement of a tumor. The patient was very dyspep- tic, suffered severely from belching, and vomited occasionally. It was self-evident that there was a carcinoma of the omentum ; the only ques- tion in doubt was whether there was also a cancer of the stomach, as was indicated by the dyspeptic manifestations. The examination of the stom- ach-contents revealed an abundance of free hydrochloric acid, acidity 50 ;t the filtrate had a digestive action. An involvement of the stomach was thus excluded. The correctness of this diagnosis was verified by the autopsy. In large tumors percussion may reveal a circumscribed area of dullness, yet it is hardly necessary for me to state that the percus- * Virehow. Wiener med. Wochenschr., 1857, No. 26. t Ewald. Berl. klin. Wochenschr., 1886, No. 33. i [See p. 32.— Te.] DIAGNOSIS OF CANCER. 201 sion note will vary considerably according to the amount of air in the stomach and intestines, and according to the force used. The best results are obtained by very delicate direct percussion with the linger, or by auscultatory percussion. Small tumors may at times be inaccessible to both percussion and palpation by a twisting of the stomach on its axis, yet they may be rendered demonstrable by in- flation of the stomach or intestines. At times the tumor may pulsate distinctly when it lies upon the aorta and is lifted by it. This pulsation, which may be very marked, and owing to the retraction of the abdominal parietes may seem to be just beneath them, is distinguished from pulsation of the aorta by the fact that a tumor only expands in a vertical direction, while the aorta does so both vertically and laterally. However, this does not always suffice ; if the tumor surrounds the aorta, as occurred in Ott's case,* all the symptoms of an cortic aneurism may be j)resent : transverse and vertical pulsation, systolic bruit and distinct thrill over the tumor, smallness of the femoral arteries, even a swelling in the back may be present ; we may sometimes also observe symptoms which are exactly similar to those occurring when a calcareous an- nular infiltration has developed in the walls of the aorta and has caused a stenosis of the vessel and a dilatation above the site of the stricture. At all events, a diiferential diagnosis in such cases is out of the question. Hard fecal masses in the transverse colon or jejunum may simu- late a tumor ; hence the rule : Always previously evacuate the bow- els thoroughly in every doubtful case. This is so self-evident that I ought scarcely to mention it. Yet in practice I find that this point is very frequently disregarded, in spite of the fact that it is men- tioned in every text-book. In many cases there is continuous pain at the site of the neo- plasm ; its manifold character has already been discussed under the general symptoms. In other cases the pain varies, at times ceasing entirely or being simply manifested as a vague burning sensation or oppression in the epigastrium. The exacerbations of pain are usually due to fresh inflammatory processes or the develo|)ment of * Ott. Loc. cit, p. 73. 202 DISEASES OF THE STOMACH. new tumors, or finally to traction on the walls of the stomach, owing to the firm adhesions with the adjacent movable viscera. Propaga- tion of the pain downward into the umbilical and suprapubic re- gions renders it very probable that the neoplasm is advancing along the peritonseum ; occasionally distinct friction sounds may be heard, especially in the hepatic region ; sometimes a rubbing may also be felt. 4. The cancerous cachexia. The peculiar condition of patients with cancer, which is called the cancerous cachexia, appears almost without exception sooner or later in the course of the disease, and has afforded various authors an opportunity to write more or less poetical descriptions. Unfortunately, this condition may give rise to errors both positive and negative. The latter are due to the fact that it is usually absent at the beginning or during the first half of the disease, just at the time when it would be of the greatest serv- ice to render a diagnosis certain. I have already had an oj)por- tunity to present to you a patient who undoubtedly had been suffer- ing for months from a cancer at the pylorus, and yet his severe malady would have been suspected by no one. A few weeks ago I was called to see a patient in whom I could very easily palpate an immense nodular tumor, occupying the entire epigas- trium, and also adherent to the liver. The patient claims to have been well up to two weeks ago and to have followed his usual occupation till then; also that neither his family nor his friends noticed anything pe- culiar about him. The first symptom.s noticed were jaundice and oedema of the lower extremities, which appeared suddenly. Even when I saw him there was no trace of a true cachexia, and yet the neoplasm was evidently of long standing. On the other hand, you will not infrequently see persons with a typical cancerous cachexia, and whose history, as well as the results of the examination, point strongly toward cancer, yet after a longer or shorter course of treatment they recover entirely, and thus afford a most striking proof to the contrary. Disregarding manifest dis- eases whose nature may be discovered, it is almost superfluous to say that in this class of patients the most important place is occu- pied by hysteria in all its varieties. Every physician knows to what extent the emaciation and loss of strength of hysterical patients may sometimes reach. Even if we disregard the other characteristic DIAGNOSIS OF CANCER. 203 symptoms as a whole, it will be observed that in hysterical cachexia the turgescence of the skin is well preserved, in marked contrast with the condition of the skin in cancer ; this is a valuable diagnostic sign. The differentiation is rendered still more difiicult in the hys- teria of male subjects. Some time ago I was associated with a local colleague in the treatment of a m.an, forty years old, who had lost thirty pounds in two months ; he had quite a marked but not extreme cachexia, and a variety of symptoms, among which were complete anorexia, marked fetor of the breath, and oppression over the epigastrium ; these led to the suspicion of a rapidly growing organic lesion. In addition, the j)atient also suffered from pal- pitation of the heart and attacks of dyspnoea, apparently of a severe form ; he also had strange sensations, especially a very peculiar and annoying feeling as if his limbs were " dead and ice-cold." Other physicians had expressed an uiifavorable prognosis, and this had not failed to exert a very depressing effect on his already irritable disposition. He lay in bed for weeks and protested that he was unable to leave it. The latter symp- tom, the cardiac palpitation, the dyspnoea, the peculiar sensations for which we could find no cause either in the circulatory or respiratory sys- tem (there was a moderate dullness on the right side posteriorly, but this proved to have been due to a temporary atelectasis) — all these led us to assume the presence of hysteria complicated with a very severe gastric catarrh, possibly due indirectly to the latter. We began suitable treat- ment, and its success proved the correctness of our supj)osition ; all of the symptoms disappeared, and the patient was discharged cured, after four weeks' treatment, including washing OLit the stomach with a watery solu- tion of thymol ; the other drugs used were hydrochloric acid, bromide of potassium, and valerian. In this case the patient's age was an important factor, pointing against the presence of a neoplasm. But here also very remarkable sources of error may be encountered. On June 19, 1886, a physician consulted me about bis mother, a lady a little over fifty years old, who was so extremely emaciated and feeble, the ^skin so sallow and dry, that at first glance she looked as if she had can- cerous cachexia. She had severe stomach symptoms, especially pain after eating ; she was not relieved till she had belched repeatedly. In conse- quence of this she kept a very strict and innutritious diet, and had ema- ciated as described above. On closer observation, or rather waiting, it became evident that the whole trouble was hysteria. She suffered from such an attack of belching during the first examination ; for almost half a minute the gas was raised with a rapid succession of hiccoughs and wdth a rumbling noise almost like thunder, and yet the abdomen was not much distended. This was frequently repeated at short intervals, the whole at- tack giving one the impression of a brief cyclone. The results of the phys- ical and chemical examination of the stomach were normal, and the same was true of the stool as was ascertained later. , 204: DISEASES OF THE STOMACH. , The diagnosis of hysteria had naturally been already made by other physicians, and the entire array of nervines had been tried. I thought of a case which I had seen long ago at the clinic of Prof, von Frerichs, in which an hysterical spasm of the glottis promptly ceased whenever the electrodes were placed upon the cervical vagi and an induced current passed through them. This expedient was similarly successful in this case, as the attack ceased instantly on applying the current. But, as I wished to effect a permanent as well as a temporary cure, I concluded to wash out the patient's stomach at regular intervals, on the presumption that the mechanical irritation and the harsh treatment of the gastric mu- cous membrane would thus lessen the hyperaesthesia of the organ. I shall leave undecided whether this presumption was correct or whether the good result was due to the erratic whim of an hysterical patient, which has so frequently contributed to the success of what seemed to be the most wonderful remedies. At all events, these troublesome symptoms disap- peared after five seances, and according to a recent report have never returned. Let this suffice to emphasize once more the fact, which is already well known, that tlie cancerous cachexia regarded alone, and as the only symptom, is of doubtful trustwortliiness. Finally, I must discuss the differential diagnosis in so far as it has not already been considered. The lesions in question are especially gastric ulcer, severe catarrhal gastritis, atro|)liy and amy- loid degeneration of the mucous membrane of the stomach, and marked cases of hysteria and neurasthenia. I must premise that at times a sharp differentiation of these conditions may be impos- sible during life ; in other cases there may be phases in the course of the disease in which every factor for a positive diagnosis may be lacking. At all events, the presence or absence of free hydro- chloric acid affords a degree of certainty unattained until a few years ago. That it is not always absolute I have already endeavored to impress on you ; for it may be absent not alone in carcinoma, but it may also be permanently wanting in severe gastric catarrhs, and in atrophy of the gastric mucosa, and may also not be found for a long time in hysteria, and even in neurasthenia. Then there are also the unquestionable although rare cases of cancer without loss of hydrochloric acid. The same is true of ulcer of the stomach, where, although as a rule there is hyperacidity, yet cases occur in which the secretion of hydrochloric acid is scanty. From these statements you will once more be able to appreciate the value of the estimation of hydrochloric acid. I think that you will agree DIFFERENTIAL DIAGNOSIS OP CANCER. 205 with me that even though it is not a touchstone, as some enthusiasts would claim, yet it is a diagnostic aid of the greatest value. The demonstration of the presence of a tumor will remain as ever the most important and decisive feature. Here we must be careful not to mistake tumors situated outside of the stomach, or hypertrophic tumor-like thickening at the pylorus, gastroliths, and similar lesions already discussed on page 312 et seq. Where a tumor has not been demonstrated the diagnosis may be only rela- tively certain ; thus it is not at all positive in atrophy of the gastric mucosa, which may completely simulate a slowly and steadily grow- ing carcinoma because both hydrochloric acid and rennet are per- manently absent. The absence of the cancerous cachexia may be of importance, since it aj^pears to be less developed in atrophy. But not a few cases have been reported in which extensive carcinoma- tous processes ran their course without any special symptoms. Thus Storer* rej)orts a case in which almost the entire stomach underwent colloid degeneration without causing any marked dis- turbances of digestion and vomiting. Sieweckef has collected twelve similar cases in which the characteristic symptoms of cancer were absent throughout. I recently had an opportunity to perform an autopsy on a man, twenty-nine years old, who, up to four weeks before his death, had been able to undergo a Playfair [Weir Mitchell] treatment for a supposed neurasthenia without disturbing his digestion in any way ! Before that time an abdominal tumor could not be palpated ; later a haemorrhagic pleurisy was developed, and the patient died in coma. I found a general widely distributed " carcinomatous " condition. The stomach was imbedded in nodular masses, its walls doubled in thickness, its diameter about that of a transverse colon of medium size. The microscope showed that the mucosa was almost entirely infiltrated with a flbro-sarcomatous neoplasm ; only in small areas were the short and long glandular tubules intact, but the epithelium was very granular and cloudy, and the contours of the cells were destroyed. Stomach digestion had undoubtedly been impos- sible long before, and the food probably passed through the stomach as if it were a prolongation of the oesophagus ; the intestii>es had been able to carry on this severe labor of digestion up to a short time before death. Thus the case may be added to those already cited where the nutritive processes were kept up, although the digestive functions of the stomach * Storer. Colloid Disease of the Entire Stomach, with Tery Few Symptoms. Boston Med. and Surgical Journal, October 10, 1873. f Siewecke. Ueber Magenkrebs. Inaug. Diss. Berlin, 1868. 206 DISEASES OF THE STOMACH. had been entirely lost, and tlie whole task had been assumed by the intestines. In this category must also be placed the cases in which the disease is occult for a long time, or is only manifested by vague dyspeptic symptoms ; but subsequent to or apparently because of a marked change in the metabolism, great worry, or a very different mode of life — i. e., a " Schweninger cure," or an exhausting course of treatment at a mineral spring — suddenly the entire group of symptoms of cancer of the stomach is rapidly developed. The patients imagine that they have discovered the cause of their ailment ; while the truth is, that the change of the metabolism has simply weakened the organism's power of resistance against the neoplasm, or, in other words, has favored the growth of the carcinoma. The differential diagnosis between ulcer and cancer of the stom- ach will be discussed at length in the next lecture. Here I shall simply state that hydrochloric acid and the ferments (pejjsin and rennet) are always present in the former, but are absent in the great majority of cases, of the latter. Experience has shown that an ulcer does not protect a patient against cancer, but it seems that if the latter already exists the former is never added. The follow- ing may serve to establish the diagnosis : 1, The appetite in ca.ncer is, as a rule, more profoundly and permanently impaired. In ulcer it is lost only during the exacer- bations, but is normal in the remissions and intermissions, although the fear of causing pain makes the patients eat little or hardly at all. As already stated, the condition of the tongue is very charac- teristic : in ulcer it is usually clean, or only coated at the base ; in cancer it is furred in the great majority of cases. 2. The pain is generally more localized in ulcer, and is usually limited to the epigastric region and the left parasternal line. Corresponding to the frequency of the situation of ulcer on the posterior wall of the stomach (43 per cent), the pain very fre- quently radiates backward, the so-called lumbar pain {Kreuz- schmerz) ; the pain is usually aggravated or caused by external influ- ences — taking food, pressure from without, certain bodily move- ments and postures, and sometimes even by the simple act of DIFFERENTIAL DIAGNOSIS OF CANCER. 207 breathing. In cancer it is usually continiions, less intense, and not occurring in paroxysms. Yet the most manifold variations may occur in both. 3. In ulcer vomiting stands in an undeniable relation to the pain, and, like it, is irregular and changeable ; as a rule, it occurs ^t an early stage of the disease, while in cancer it is usually absent during the first few months, but later becomes gradually more frequent. Ott very properly says that in cancer vomiting dejDends upon the site of the tumor ; in ulcer, upon the intensity and dura- tion of the pain. The presence of characteristic kinds of tissue in the vomit, its admixture with blood, and the vomiting of pure blood, have all been discussed under the symjDtoms. I shall merely add that haemorrhage is relatively and absolutely more frecpient in ulcer ; its severity is also more marked in this lesion. On the other hand, the intervals between the haemorrhages, or a relatively brief series of them, are much longer in ulcer, Avhile in cancer, having once begun, they recur more frequently or permanently. If you are called to a patient with severe htemorrhage from the mouth and anus, which has occurred suddenly, and has been so severe that there is danger of collapse from the profound anaemia, from these points alone you may make a diagnosis of ulcer with reasonable certainty. The mistaking of the so-called essential or idiopathic angemia for carcinoma, or, on the other hand, the failure to recognize a cancer, probably occurs less frequently with us in Germany than it does elsewhere. At least, in English literature I have found the reports of quite a number of such cases in which a careful examination of the blood and of the stomach-contents ought to have prevented such errors. Finally, cancer must be distinguished from the severe forms of hysteria. At tlie first glance it would seem almost impossible to mistake these two conditions, and yet there undoubtedly occur cases in which an extemporaneous diagnosis is not to be made, and even prolonged observation may leave us in doubt. I do not like to ac- knowledge the possibility, yet it has happened more than once that hysterical women have for years swallowed portions of their hair ; these hairs form coils in the stomach, and may readily simulate a 208 DISEASES OF THE STOMACH. tumor.* But, even without these " comphcations," severe forms of liysteria may lead to such a marked disturbance of nutrition that, especially when occurring in elderly women, the suspicion of a can- cer will always arise. But, as a rule, you will discover one or an- other characteristic symptom which will enable you to make a posi- tive diagnosis. Treatment. — The old proverb that no drug is potent against can- cer is true even to-day, however dejoressing such an admission may be. From time to time a host of specifics has appeared, from cicuta and belladonna of the elder Yogel, Storck, and Hufeland, down to the condurango bark of Friedreich, of Heidelberg ; they all owe their ephemeral popularity to a conscious or unconscious decep- tion. At best, like condurango, they only relieve symptoms ; they lessen the accompanying catarrh and increase the digestive activity of the organ, but a true curative action, in the strict sense of the word, does not belong to them. The recommendation of condu- rango in 1874 by Friedreich was based upon a solitary case, and, at that, one in which no autopsy was made ! In this case it was said that after the prolonged use of the remedy a carcinoma was reduced to the size of a small tumor, and that the accompanying swelling of the lymphatic glands had disappeared. Like so many of our new remedies, it owes its reputation as a specific to the implicit faith of some half-civilized or wild Indians, and to the speculation of enter- prising exporters. At first it was received with acclamation by the medical world, which is pervaded by a surprising ndwete and an ineradicable optimism whenever new specifics for incurable diseases are introduced. It was indiscriminately tried in every variety of cancer ; the first flush of enthusiasm was soon followed by a disap- pointment which threatened to thrust the remedy back into oblivion. The one extreme is as bad as the other. For a long time it was praised and condemned without a thorough and rnethodical series of experiments having been conducted. Such an examination was first made on a few cases by Immermann ; then Riess investigated it in a large number of cases from a similar standpoint : these re- * Bussel. A Case in which the Cavity of the Stomach was occupied by an Enor- mous Mass of Human Hair. Medical Times and Grazette, June 2G, 1869. TREATMENT OF CANCER. 209 suits liave recently been published.* Immermann's cases were not all pure examples of cancer of the stomach ; upon his series he esti- mates the ratio of fatal cases treated with condurango to be 1 as against 1*3 without this remedy. Riess endeavored to limit the drug espe- cially to patients with cancer of the stomach, and, after having ob- served 80 cases with this treatment and 116 without it, he claims that condurango has a specific action. It is readily taken by patients for a long time, and it is said that under its prolonged use palpable tumors disappeared, and the general condition progressively improved botli subjectively and objectively. " In a large number of cases the impartial observer became positively impressed with the fact that life was considerably prolonged under treatment with condurango." The following table shows the result upon the mortality and the duration of the treatment : Average duration of treatment of all cases. Deaths. Average duration of treatment. Discharged. Average duration of treatment. Cases with condu- ransTO (80). 43-4 days 21-2 days 53 (= 66-3^) 107 (= 92-2^) 39-5 days 22-0 days 27 (= 33-7^) 9 (= rm 54-8 days 11*7 days Cases without condu- rango (IIG) It is to be noted that the proportion of fatal cases with and with- out this treatment is 1 : 1*4 (according to Immermann, 1 : 1'3) ; thus, the results of Kiess and Immermann are almost the same. This would have been very convincing had the diagnosis of gastric cancer been positively made in all the cases, and had the discharged patients been watched for a long period ; but this substantial basis is want- ing in these observations, and Riess himself betrays his own doubt, inasmuch as he is always very careful to speak only " of the group of symptoms of gastric cancer " {von dem Symjptomencojnplex des Magenhrebses). It is also to be regretted that this writer did not give more definite information as to the situation of the tumor, and that he did not verify his diagnoses by the aid of the newer meth- ods. He also neglects to state whether the clinical diagnosis was always verified by autopsies. This is the more to be regretted, since * L. Riess. Ueber den Werth der Condurangorinde bei dera Symptombilde des Magencarcinoms. Berl. klin. Wochenschr., 1887, No. 10. 14 210 DISEASES OF THE STOMACH. in three cases of supposed cured or improved cancer wliicli subse- quently died of other causes, and which were examined ]po8t mortem^ the diagnosis made during life was not free from doubt ; for, from the brief notes of these three autopsies given by Riess, it would seem much more probable, if not indeed actually so, that the lesion was an old cicatrized ulcer. Hence the publications thus far on the specific action of condu- rango are by no means convincing to me. You may object, and say that the involution of palpable tumors which, as Riess claims, may even be observed with a tape-measure, is a very significant occur- rence. In answer to this, I claim that the improvement of the con- comitant catarrh of the mucous membrane may lessen the hyper- gemia and the size of the tumor. It is also a well-known fact, to which I have directed attention, that abdominal tumors always seem larger than they really are when palpated through the abdominal walls, and hence increase or diminution in size will be manifested on a larger scale. How often do we believe we have palpated a pyloric tumor about, the size of a walnut or a hen's ^^^ which, on autopsy proves to have been only an insignificant muscular hyper- trophy of the cervix pylori ! * These remarks are not intended to question the beneficial infiu- ence of condurango on the general condition in gastric cancer, as I have frequently had the opportunity of convincing myself of this action. It is eminently proper that the remedy should be exten- sively used, since Riess's observations on this point are very impor- tant ; yet, in spite of Orszewsky and Erichsen,f one should not ■expect to cure cancer of the stomach wi^h it. The accompanying gastric catarrh is improved, and the same beneficial effects are •obtained in genuine catarrhal diseases of the gastric mucous mem- brane ; hence condurango may be considered an excellent stomachic * According to Retzius, I would thus designate that portion of the pyloric ring ■which in such ciises projects into the duodenum, as the cervix uteri does into the oints.* On pressing deeply down to the retroperitonseum, over the region of the superior hypogastric, aortic, and coeliac plexuses, the patient experiences exceedingly sharp and unpleasant pains, which radiate up to the epigastrium. Burkart claims to have found these points * R. Burkart. Zur Pathologic der Nearasthenia gastrica. Bonn, 1882. 408 DISEASES OP THE STOMACH. in all cases. In 1884, in the discussion on nervous dyspepsia at tlie third Congress for Internal Medicine,* I stated that in my expe- rience this was not always the case. Kichter f also asserts that, as a rule, pressure over the stomach and abdomen is not painful. Since then, this has been agreed to by others. At that time I said that the same was true of the above-mentioned painful points along the spinal column, upon which so much stress was laid by Rosenthal. They may be present (according to Rosenthal, in 75 per cent of the cases), or they may be absent ; but, even if they are present, they have no important bearing on the conception of the disease, and are by no means one of its essential features. On the contrary, I will say that my further experience has been that pain along the spinal column, both on pressure and with the faradic brush, may fre- quently be absent in undoubted cases of neurasthenia. I shall cite such a case of Rosenthal, to compare it with one of my own : A man, thirty-two years old, says that three years previously he took cold while going home one morning after a night of dissipation. Soon after he felt a steadily increasing pain in the stomach. The pain was de- scribed as glowing and boring, radiating frequently from the lower ribs to the epigastrium, and causing him to " double up " and moan loudly. The countenance was pallid and covered with clammy sweat, the hands and feet were cold, and the pulse small and tense. The attacks recurred frequently, especially in the early part of the evening, lasted for hours, and on their termination the patient fell asleep exhausted. The attacks varied in intensity, but neither the quality nor the quantity of food had any influence upon them. The condition, which was sometimes consid- ered gastric ulcer, at others biliary colic, resisted all the usual remedies ; no marked improvement followed even after daily washing out of the stomach and the methodical drinking of the water of the Milhlbrunnen at Carlsbad. A gastroscopic examination was made by Dr. Mikulicz, but no struct- ural changes could be discovered. The stomach-contents were pumped out, but were found to have normal acidity and digestive powers. Biliary colic was excluded on account of the normal size of the liver, the absolute lack of tenderness, no icteric discoloration of the skin and the urine, as well as the absence of a febrile movement during the attacks. Again, the relief afiPorded during the paroxysms by deep pressure over the stomach, the typical spontaneous origin of the pain, which was never caused by eating even very indigestible substances, as well as the non-appearance of digestive disturbances and vomiting — all these could not be reconciled with * Verhandlungen des Congresses ftir innere Medicin, 1884, S. 232. f Richter. Ueber nervosa Dyspepsie und nervosa Enteropathie. Berliner klin. Wochenschr., 1882, No. 13. NEURASTHENIC GASTRALGIA. 409 a diagnosis of gastric ulcer. For the same reasons renal colic, disorders of the pancreas and the like, which sometimes cause cardialgia, were also excluded. Ou the other hand, the constant presence of painful spots along the vertebral column, the hyperalgias which could be traced along the intercostal nerves to the epigastrium, the diffuse occurrence of mus- cular spasms in various parts of the body, the marked increase of the ten- don reflexes, the pale-yellow color of the patient, together with his un- usual psychical irritability, indicated gastric neuralgia upon a neuras- thenic hasis. The change in the diagnosis was followed by a corresponding altera- tion of the therapy. Local treatment was entirely avoided ; a nutritious diet, including even beer, was ordered; the abnormal irritability of the ceutei'S was lessened by large doses of bromide of potassium, 3 to 4 grammes [gr. xlv-lx], with one gramme [gr. xv] of bicarbonate of soda morning and evening. To combat the anaemia, ferrum pyrophosphori- cum cum natrio citrico (Ph. Austr.) was given after the midday meal (as much as would go on the point of a knife). During the two days follow- ing he felt only a touch of the pains in the stomach, after which they did not return ; the medication was kept up a fortnight longer. He was watched for six weeks more, but remained without the slightest dis- turbance. My case (the only one of this kind which has come under my observation) was as follows : In August, 1885, a merchant, forty-five years old, was brought to me by his family physician. He complained of great fatigue, especially a feeling of heaviness in his legs, disinclination for work, and dullness and confusion of the head, especially after eating. His appetite was capri- cious, and he never dared to eat the same thing many times in succession. For the past six weeks he had sufl'ered severely from painful attacks of gastralgia, which at first were far apart, but later occurred daily, and sometimes even several times a day. Although they did not occur imme- diately after eating, yet he thought that they were caused by eating, and consequently had restricted his diet ; as a result he lost over ten pounds in weight. A course of treatment for three weeks at Carlsbad had not alone not benefited him, but had even made him much worse. The bowels were constipated. The patient, a very active person, well nour- ished but pale, was the proprietor of a very large factory employing over one hundred people, a number of whom were engaged outside of Berlin ; he had to oversee many of their trips, and consequently was frequently aggravated and worried. The illness of his partner for a time threw the entire responsibility upon him. A year previously he had had a similar attack. The physical examination revealed no abnormalities ; all signs of spinal and intercostal neuralgias, as well as painful points, were absent. On the other hand, the tendon reflexes were markedly increased. The chemical processes of the stomach (after the test-breakfast) were found normal. At the flret glance it was apparent that this was a tolerably clear case 410 DISEASES OP THE STOMACH. of nervous gastralgia, in spite of tlie absence of the painful points, the symptom upon which so much stress had been laid. The treatment con- firmed the diagnosis. At first bromide of potassium was used ; later a so- journ for several weeks at one of the resorts on the Baltic Sea caused the cessation of the attacks, and the patient then gained rapidly in weight. The rest was accomplished by a proper diet and hygienic measures (daily sponging and riding). Up to the present time the attacks have not re- curred. I must not omit to mention how difficult it is in such cases, as is well shown in the case of Rosenthal, to exclude the presence of biliary colic. Even in that case this point is not definitely settled. Undoubtedly, there are cases of biliary colic without icterus, swell- ing of the gall-bladder, and febrile movement, and in whicli the diagnosis between an affection of the liver and the stomach can not be made. Among ten cases of pure gastralgia under my care no less than four are marked with an interrogation point. The follow- ing may be quoted as an example : A well-nourished woman, thirty years old, the mother of seven chil- dren, had formerly never had pain in the stomach ; five years previously, after the birth of the fifth child, had " biliary colic " ; had been to Carls- bad twice and obtained relief ; for the past year has had painful cramps in the stomach, at first infrequently, lately every fortnight. Physical ex- amination was negative. The uterus was pronounced normal by a gyn- aecologist. Never had belching or vomiting ; between the attacks the appetite was good. The bowels are constipated after the attacks, other- wise regular. Although considerable relief was afi'orded by regulating the diet, drinking the water of the Marienbader Kreuzbrunnen, and taking soda to which small doses of morphine had been added ; yet, dur- ing the two months in which the patient was under my observation, she still had occasional attacks, although less severe in character. I consid- ered the diagnosis doubtful, in spite of the fact that the patient no longer referred the pain to the right hypochondrium as formerly, but to the middle line, and even to the left of it ; the reason was, that we know that attacks of biliary colic may be followed by inflammation of the gall-blad- der, with the subsequent formation of adhesions to the adjacent viscera, the stretching of which may produce colicky pains. Hysterical Gastralgias. — It is only the peculiar nature of hys- teria which will enable us to recognize as hysterical the attacks of gastralgia which may occur during its course. In the following remarks I do not by any means propose to give a thorough description of the protean picture of hysteria ; I simply wnsh to give a few suggestions, upon the completeness of which I HYSTERICAL GASTRALGIA. 411 lay very little stress, because the characteristic features of this dis- ease are not difficult to recognize. In this affection, unlike neurasthenia, the psychical factors, per- verse thoughts and sensations, occupy a pre-eminent place. The tend- ency toward extraordinary behavior, the conscious or unconscious longing to be conspicuous by any means whatsoever, the turning away from every serious occupation, the degradation into the peculiar, fantastic existence about which the patient's entire being revolves, the capricious, willful, and impulsive actions are not those of ordi- nary life, and these are all aberrations from normal thought and sen- sation, denoting profound changes in the psychical processes. As- sociated with them are the manifold, objectively demonstrable nerv- ous disturbances, convulsions, paralyses, pupillary inequalities, liemi- ansesthesise, and changes in electrical sensibility. The manifestations of transference give additional symptoms. In the affections with gastric disturbances I have been particularly struck by the absence or lessening of the electro-cutaneous sensitiveness of the abdominal parietes ; this sign was not absent even where other hysterical symp- toms were scarcely manifested. A marked example of this is afforded in the following history which I shall relate in the exact words of the physician who sent the case to me : " The patient is a lady, fifty-two years of age, the history of whose suf- ferings is a very long one. Soon after marriage she began to be troubled with haemorrhoids; constipation was always present. For years she had suffered from chronic metritis and endometritis ; the menses were very profuse, lasted eight days, and were accompanied by many disturbances. Temporaiy relief was obtained by douches, silz-baths, local applications to the cervical canal, and evacuants. To obtain better results she was sent to Elster ; here the severe heemorrhages lessened, yet now there were very frequent disturbances of digestion combined with pains in the lumbar, inguinal, and imibilical regions. In this year she was sent to Kissingen, on account of the incessant complaints produced by variously located symptoms due to stagnation of the portal circulation. Here, for the first time, there were also pains and stitches in the breast, which usually appeared after midnight, and in fact began only at night, verj suddenly, and with great severity ; after lasting for hours they ceased, with marked eructation. Sometimes these symptoms appeared on several consecutive nights ; at other times the patient might be free for a number of nights. '' The patient appeared to be easily excitable, and, although emaciated, was very well preserved for her years ; on the back of the left hand and forearm there was an absolutely anaesthetic zone; patellar reflexes absent; the abdominal parietes were very sensitive, even to delicate i^alxjation ; on 412 DISEASES OF THE STOMACH. the other hand, faradic brushing was scarcely felt here, although it was painful on the face, arms, and legs. Undoubtedly this was a hysterical condition accompanying a reflex dyspepsia, proceeding from the uterus, the symptoms of the latter being especially prominent." The alternation with neuralgias or neuroses in other organs is characteristic of hysterical gastralgias. Oser reports a typical case of this kind in which hysterical aphonia alternated with attacks of gastralgia ; this case suggests very strongly that the nucleus of the vagus was involved. I have had under my observation at the Siechenanstalt, for almost eighteen months, a case in which, to- gether with persistent constipation — the bowels are never s23ontane- ously evacuated — peculiar sensations are experienced in the abdo- men, so that the patient thinks that a frog is in liis stomach; at other times he imagines he has swallowed a needle, or that he has a tumor ; at times he also has attacks of hysterical hoarseness and aphonia. Occasionally he also has attacks of true gastralgia. Recently I had the opportunity of seeing a case of hysterical gastralgia, which was bo characteristic that it deserves mention here, especially as the treatment renders it remarkable : On April 1, 1888, I was summoned to a distant suburb for a consulta- tion. When I arrived there the family physician was not present, because^ as I was told, he said that " nothing could b*e done for the case." I found a small, delicate woman of thirty years, very much retarded in her growth ; she was living with her mother in great poverty, and had been in bed for eight months because she claimed to be too weak to walk. What little nourishment she took was liquid ; nevertheless, she was tortured with such severe paroxysms of gastralgia that, as her mother stated, she scraped the chalk off of the walls and disturbed the house by her screaming. In her childhood she was said to have had chorea. On physical examina- tion there was pain on pressure over the ovaries and in the infrasternal depression; no anaesthetic areas, patellar reflexes present, tongue clean, no fcetor; at no times vomiting, stools very constipated, and like scybalae. The diagnosis of hystei-ia was beyond doubt. To show the patient that she could walk I took her out of the bed and, supporting her under the arms, I dragged her about the room. As I had thus convinced myself that there were no organic paralyses, I ordered her to visit me the next morning. During my office-hours I was disturbed by a loud noise; it was the patient, who had come to my house in a cab after a ride of about forty- five minutes, had been carried up-stairs by the coachman, and could go about the room when supported by two persons. I washed out the stom- ach to examine its chemical functions, to reduce the hypersensitiveness, and also to produce a moral effect ; while introducing the tube she became very cyanotic. No free hydrochloric acid was found in the wash-water. HYSTERICAL GASTRALGIA. 413 I prescribed hydrochloric acicl, tincture of belladonna, and cocaine. Six days later she came again ; but this time she was alone, had walked up the stairs very slowly and with great exertion, yet without any help; but after that she had a typical attack of hysterical barking cough. The stomach was again washed out ; no free acid, and a little peptone was found. Three days later she came up-stairs alone. The cough had disap- peared ; had occasional but only slight pains. Began to have appetite. The stomach was washed out twice more at several days' intervals. On May 31st I recorded that speech was good ; walked without aid, simply by holding her hand lightly ; complained still of nausea, pain in abdomen after eating and walking, and heaviness in the legs. The stomach was found empty two hours and a half after the test-breakfast. Arsenic and iron were ordered, and she was sent to the country. In the fall the mother reported that with the exception of trivial ailments she had kept well. I do not consider this case at all extraordinary. Similar cases occur every day, although possibly the cure is not so remarkable. There was one coincidence, however, which lent a peculiar interest to the case, that at my lecture one of the audience to whom the case was presented had formerly treated the patient for a long time with- out any success. It is superfluous to enter into further details on this subject, as such cases occur frequently in practice. The gastralgias constitute only one link in the chain of tlie manifold group of symptoms ; the only point is, not to be deceived about the true nature of the at- tacks, and to recognize the hysterical basis. This is usually easy in most cases, but it may be very difficult, especially when the hysteria is manifested by only one symptom — for example, gastralgic attacks in old women, or even in men. To exhaust all these possible forms would take me far beyond my province. Finally, gastralgias may also occur iii j^sycJioses, and, what is especially important, may be among the prodromal symptoms. For a year and a half I treated a young engineer for gastralgia associ- ated with neurasthenia. He finally became melancholic and committed suicide. Psychoses had already occurred in the family, and one brother had died in an insane asylum. LECTUEE XL THE NEUROSES OF THE STOMACH (cONTINUED), I CONSIDER hyperacidity and hypersecretion of the gastric juice to be sensory neuroses of the secretory function. Keichmann deserves the credit of having been the first to thoroughly study this subject with our modern methods ; yet it is an error to suppose that tliese conditions were unknown formerly. On the contrary, they were described almost fifty years ago by Pemberton, Copland, Todd, Budd, Trousseau, and among the Germans by Hiibner ; * but later, as these descrijjtions were based upon speculation rather than u])on direct observation, they passed into oblivion. Recently this subject has been especially investigated by the above [Reichmann], Jawor- ski, von den Yelden, Riegel, Saly, von Noorden, and Honigmann. . Hyperacidity is an increase above the normal of the amount of hydrochloric acid secreted ; it is due to the stimulation of the in- gesta, the acidity of which is heightened after being incorporated therewith. I^aturally, it is diflicult to determine where the normal acidity ceases and the abnormal hyperacidity begins, as a sharp line * As early as 1820, Pemberton (Treatise of the Various Diseases of the Abdomi- nal Viscercx) speaks of " a morbidly increased secretion from the stomach, analo- gous to a diabetic secretion of urine by the kidneys" ; also Copland : " Or in other words, that pyrosis is produced by the continuance of the secretion of the gastric juices after the food taken into the stomach has passed into the duodenum." Budd also says that pains, etc., may arise "from the presence of free acid in the empty stomach." Trousseau (Des Dyspepsies, L'Union med., 1857, p. 306) : "Le neuralgie de I'estomac augmente les secretions acides a ee point qu'elles se ferront non plus comme d'haltitude au moment de la digestion mais encore en dehors de ces moments." In Hiibner (Die gastrischen Krankheiten monographisch dargestcllt. Leipzig, 1844. S. 209) we find the following : " If the morbidly altered secretion of the gastric juice ... is the cause of the acid, then the patient suffers uninterruptedly from it ; he may eat what he will, the symptoms become more marked, and, as the cause persists, it becomes more obstinate than in the formation of acid by fermen- tation." (414) HYPERACIDITY AND nYPERSEORETIOK 41 5 like the zero-point in a tliermometer can not be drawn ; on the con- trary, there must always be an intermediate stage in which' the quantity of the secretion depends on individual circumstances ; here we remain in doubt whether this should be called hyperacidity or not. However, from the average of a very large number of examinations after the test-breakfast I consider that hyperacidity begins when the amount of acid is between 60 and YO per cent. I have already spoken of the relation of hyperacidity to gastric ulcer ; but it is beyond doubt that this condition may exist as a pri- mary neurosis independently of any organic lesions. Von Noorden has observed it in melancholia,* Jolly claims that there is an in- creased secretion of gastric juice in hysteria, and Jaworskif has frequently found it among the Jews of Galicia, who are es23ecially predisposed to nervous disturbances. It may also occur as a reflex symptom of gall-stones and renal calculi ; and also where all of these factors are absent the neurotic basis of the disorder may be recognized by the w^ant of success in treatment directed toward the cure of a supposed gastric ulcer. In the summer of 1887 I treated a girl of nineteen years for nearly three months for a supposed gastric ulcer, because she had periodical gas- tralgia, and a hyperacidity of 88 per cent. The absolute failure of the treatment, and the constant recurrence of the attacks, in spite of the im- provement in the general condition and the increase in weight, indicated a purely neurotic basis of the disorder, although other symptoms of neur- asthenia and hysteria were lacking. Hypersecretion, or better, parasecretioii (the Ifagensaftjlass of Reichmann), may occur in two forms, the periodical and the con- tinuous. The acidity is not increased, as a rule, in the former, but it is in the latter. Periodically, it usually occurs after eating, rarely while fasting, yet it does not seem to have a direct connection with the introduction of food. Wilkens;}: reports a typical case of this kind. * Sitzungsbericht tier medicin. Gesellschaft zu Giessen. Abstract in Berlin, klin. Wochensehr., 1887, No. 18. f W. Jaworski. Zusainmenhaag zwisehen subjectiven Magensymptomen und objectiven Befunden bei Magenfunetionsstorungen. "Wiener med. Wochensehr., 1886, Nos. 49-52. X S. A. Wilkens. A Case of Hypersecretion in Intermittent Attacks. Lancet, August 27, 1887. 416 DISEASES OP THE STOMACH. . A musician, thirty-six years old, who led an emotional life, for the pre- ceding three years and a half had attacks of vomiting and pain in the stomach; during the paroxysms he could neither eat nor drink, and had to go to bed. Similar attacks, which lasted twenty-seven to thirty -five hours, recurred at intervals of ten to twelve days. He lost in weight from 2 to 3i kilogrammes m to 7| pounds]. Intense hunger between the attacks. The gastric juice vomited was about two pounds and a half, and every time had 0"12 per cent HCl. Diagnosis, affection of the secretory nerves. All writers agree that tlie condition is a functional disturbance of the nerves of the stomach, which may occur alone or as part of other neuroses. In chronic hypersecretion {continuirliche Magensaft- fluss) there is a continuous secretion of gastric juice which is usu- ally hyperacid,* so that even while fasting the stomach may con- tain larger or smaller quantities, varying between 100 and 1,000 c. c. [f § iijss. to Oij], or more, of a fluid very much resembling ordinary gastric juice, but without any remnants of food, and frequently tinged grass-green or bluish-green by the admixture of bile.f The degree of acidity is bigb, but the amount of free hydrochloric acid which can affect the color reagents is very variable, as has been shown by Jaworski ; X since in cases with the same degree of acid- ity, in some there was much free acid and a feeble biuret reaction^ in others, little free acid, in spite of the absence of organic acids and a marked biuret action ; finally, in rare cases having a certain degree of acidity no reactions can be obtained, although one would expect a positive result with all the color-tests. Jaworski attributes this to the larger or smaller admixture of desquamated tissue-ele- ments of the mucous membrane or emigrated white blood-cells, or even blood-serum, which by forming peptone or acid combinations may combine with part or all of the free hydrochloric acid in the sense which I have already explained (page 27) for the albuminoids in general, and which has since been demonstrated by von Pfungen. On taking food it is found that the digestion of starches is de- layed, but is very prompt in albuminoids, so that after a meal con- * Jaworski, loc. cit.—m 121 cases of hypersecretion, hyperacidity was found at the same time in 115 of them. f Jaworski, loc. cif. — 77 times in 222 cases, t Jaworski. Ueber die Versehiedenheit in der Beschaffenheit des ntichternen Magensaftes bei Magensaftfiuss (Gastrorrhoea acida). Verhandlungen des Con- gre?ses f. innere Med. Wiesbaden, 1888, S. 280. HYPERACIDITY AND HYPERSECRETION. 41Y sisting of meat and amylaceous substances one may find abundant remnants of undigested starches, but no ,trace of meat (Riegel). While fastiiig the fluid in the stomach no longer contains the usual varieties of epithelium, but instead many nuclei with sharp con- tours, which Trinkler * (who first called attention to them in ani- mals), Jaworski, and myself consider to be remains of undigested cells. According to Jaworski, this condition of chronic hypersecre- tion must be almost the rule, since among 159 cases he found 115 with hyperacid and continuous secretion. Riegel does not go to such extremes, yet he claims that it occurs in about half of all the cases of stomach disorders. This does not agree with my experience. Strictly speaking, I am not competent to give an opinion on this question, because I have only examined while fasting those patients whose complaints — pains, heart-burn, eructation, etc., occurring during the night or in the morning before eating — afforded me an opportunity of exploring the empty stomach ; under these circumstances, I have not often found hypersecretion. Even if I follow Riegel's example, and in- clude the cases of dilatation, my experience extends only over 45 such cases among about 1,200 patients whom I have examined and kept records of during the past few years. I found, as other writers have, that men predominate — 30 men and 15 women. We must leave it a mooted question whether, as claimed by von den Yelden, hypersecretion is only a lengthened reaction toward the stimulation of the food, or whether it is continuous, as asserted by Eeichmann, Riegel, myself, and others. The irritation of the mucous membrane by the acid fluid causes hypersesthesia, the results of which are tenderness or pain in the epigastrium, acid eructation, heart-burn, vomiting of sour masses, gastralgias, and similar digestive disturbances which constitute the symptoms of a chronic inflammatory condition. Under certain con- ditions, as observed by Talma,f the stomachs of neurasthenics may react abnormally toward acids. But the tongue is usually clean, * Trinkler. Ueber den Bau der Magenschleimhaut. M. Schultze's Archiv, Bd. xxiv, S. 195. t S. Talma. Zur Behandlung von Magenkrankheiten. Zeitschrift ftir klin. Med., Bd. 8, S. 407. 418 DISEASES OF THE STOMACH. and the appetite is increased rather than diminished. Excessive thirst was common in Jaworski's cases, and (what is by no means wonderful) was said to have been relieved by drinking water and diluting the contents of the stomach. Among the results of this condition we must consider atony of the muscular coat of the stom- ach, and the gastrectasis due to it ; where the condition has lasted a long time, this is so common that twenty-nine more or less well- marked dilatations of the stomach were found in thirty cases at Prof. Riegel's clinic* But by this time the neurosis has been con- verted into an organic lesion, and such conditions must, therefore, 1)0 considered among the cases of gastrectasis, and not among the gastric neuroses. The exact diagnosis of this condition can only be made by exam- ining the stomach-contents, and so far as concerns chronic hyper- secretion this examination must be made while fasting. A clew to this state is afforded by the fact that the symptoms are temporarily ameliorated by eating proteids ; this differentiates it from the dis- turbances caused by the pyrosis and gastralgia due to acid fermenta- tion. The alkalies give temporary relief in both conditions of nerv- ous hyperacidity and acid fermentation ; yet the difference is this, that for the former we have no other direct remedy excepting this purely symptomatic one ; but fermentation may be controlled and prevented by specific measures. Among these neuroses I also classify the condition called Gas- troxynsis [Yao-TT^p, stomach, o^y?, acid] by Kossbach, which differs from migraine only in the fact that it does not occur spontaneously as frequently as the latter, but as the result of definite causes, men- tal over-exertion, or profound emotional disturbances, and that the vomited masses are very acid, containing as much as 3'4 to 4 per thousand. However, the latter is common to both the condition and typical migraine, since I have repeatedly obtained equally high results in the latter. Jiirgensen f has also observed very similar states. ITervoTis Belching, Enictatio. — It is only in hysterical persons that * Honigniann, loc. cit. f Jiirgensen. Ueber Abscheidung neuer Formen nervoser Magenkrankheiten. Deutsch. Archiv fiir klin. Med., Bd. 43, S. 9-30. NERVOUS BELCHlNa. 419 I have seen this occur alone, for in neurasthenics it is always asso- ciated with other sensations, especially oppression and tension in the epigastrium. I agree with Weissgerber,* who has published a very long paper on eructation, that in the former [hysteria] there is a heightened contractility of the stomach, together with an increased tone of the pylorus, provided the other manifestations of hysteria are also considered among the jDrocesses of irritation. Since the sphincter at the pylorus is stronger than that at the cardia, it w^ill contract more powerfully even if both are equally stimulated ; hence, when the distention of the stomach is so great that it must expel some of its gas, this can escape more readily upward than down- ward. For it can not be doubted that eructation is an active and not a passive process. It may be possible, as claimed by Stiller and Rosenthal, that a relaxation of the cardia may facilitate the exit of the gases from the stomach, and that hence, according to circum- stances, eructation may be due either to an increase or a paralysis of the muscular action of the stomach. However, in many cases, belching certainly has nothing to do with relaxation of the cardia, as is shown by the numerous patients who try in vain to empty their stomachs of the accumulated gas. There is another kind of belching which is entirely independent of the stomach, in which the gas is raised only from the cesophagus by contracting the muscles of the neck, just as Bristowe f has as- sumed in hysterical vomiting. This form escaped Weissgerber's notice entirely, I myself can belch voluntarily, and I have con- vinced myself by means of the deglutition-murmur (SGhlucJcge- rdusch) that the air which is compressed in the oesophagus does not enter the stomach unless additional true movements of deglutition are executed, We may therefore accept the fact that it is possible to belch from the oesophagus alone, and this may explain many cases of hysterical eructation in which the stomach is not distended. Belching may become a very annoying symptom, since it is never noiseless but is usually quite loud. In one attack, of an hour's dura- * Weissgerber. Ueber den Mechanismus der Ructus und Bemerkungen iiber den Lufteintritt in den Magen Neugeborener, Berl. klin. Wochenschr., 1878, No. 35. f Bristowe. Clinical Remarks on the Functional Vomiting of Hysteria, Prac- titioner, 1883, p. 161. 27 420 DISEASES OF THE STOMACH. tion, Cartellieri * was able to count it twenty-five liundred times ! The gas is always odorless and tasteless, and tlius differs in tliis re- spect from that raised in true dyspepsia, fermentative processes, etc. It therefore must consist of atmospheric air which, in the opinion of most authors, must have been swallowed, but which may also possi- bly come up from the intestines ; in many cases it is certainly raised only from the oesophagus. Cartellieri says his patient had no time to swallow air during the attack ; in such cases the question then arises. Is air really ex|)elled, or is it a manifestation in which this is simulated ? So far as I know, this subject has never been investi- gated. Pyrosis denotes the raising of sour masses from the stomach, an act which is well known under the name of heart-burn. In the nervous forms of this symptom at least, the stomach-contents are not necessarily hyperacid ; on the other hand, severe acrid and • burning sensations may be produced by the regurgitation of even normal stomach-contents or gastric juice. Here, also, one may be in doubt whether the cause resides in a heightened contraction of the muscular coat of the stomach, or in a paralysis of the cardiac sphinc- ter. I have been led to classify this phenomenon among the motor conditions of irritation, because I have in vain searched for the sign of a marked relaxation of the cardia, the occurrence of the first deg- lutition-murmur. [See foot-note, p. 61.] This brings us to the consideration of a very annoying condition called Pneumatosis, tympanites {Trommelsucht). Here the stomach is filled with sas, and mav become so distended that it causes not alone the unpleasant sensation of marked tension, but even severe nervous symptoms, by pushing the dia]3hragm upward and pressing on the heart. The patients are seized with typical attacks of asthma — the asthma dyspepticum of Henoch — in which at first there is only the annoying feeling of being compelled to take deep inspira- tions after short periods of normal breathing ; at the beginning this suffices, but later it develops into an incessant dyspnoea. ]^ow there is also palpitation of the heart, pulsation of the peripheral arteries, * P. Cartellieri. Bine seltene vorkommende Magenneurose. Wiener allgemeine med. Zeitung, 1885, S. 3. NERVOUS VOMITING. 421 fullness of the head, and even tlie feeling of impending death, or complete unconscionsness — in short, such is the condition that I have been repeatedly told by many sufferers that they were almost driven to suicide. Relief can only be afforded by bringing up some of the gas, and then the attack rapidly subsides. This condition is probably caused by the air which has been swallowed, together with a spasm of the sphincters of the stomach. The chemical processes were normal in one case which I examined, yet the same state may be produced in dyspeptics by the gas generated in fermentation. The attacks may be relieved instantly by introducing the stom- ach-tube and allowing the gas to escape. But it seems that it is very difficult to cure the disease itself where it is nervous in character. In one case of pneumatosis I had no success with — ^ Cocain. hydrochloratis 1"0 [gr. xv] Aq. amygdal. amarse lO'O [f 3 ijss.] M. Sig. : Ten drops every two hours. Large doses of bromide of potassium had also been given, but without producing any effect. In another case hypodermic injec- tions of morphine into the epigastrium gave immediate relief; a third case was cured by change of climate. The patient was a Bra- zilian, who, while at home, had suffered very severely from pneuma- tosis, but here [Germany] he was entirely free from it. Nervous Vomiting. — This includes those forms of vomiting which are caused neither by anatomical lesions of the stomach nor by quantitative or qualitative changes in the food. It is pre-eminently reflex, and may be caused either directly by the vomiting-center or indirectly from other points in the central nervous system, or from other organs. As far as we know, the causes of this condition may include palpable changes in the brain and spinal cord, kidneys, uterus, liver, and certain organs of sense. These forms of nervous vomiting may be classed among the reflex neuroses. I have had the opportunity of observing two such cases of nerv- ous vomiting in close succession ; during their course they seemed to be very much alike, yet the nature of the primaiy affection Caused them to terminate very differently. The first case was a married lady, thirty -six years old, who had been suf- fering for three weeks with uncontrollable vomiting and a continuous flow 422 DISEASES OF THE STOMACH. of saliva, together with strong foetor from the mouth. This condition had come on after an attack of catarrhal jaundice, traces of which were just recognizable in a slight discoloration of the scl erotics at the time I first saw the patient. She had emaciated very little considering that she had taken scarcely any nourishment during this period, for she vomited every- thing immediately after eating. On examination, nothing could be found anywhere, not even in the liver. The passages were loose and bright yellow. Only temporary relief was obtained by the hypodermic use of morphine with atropine, washing out the stomach with chloroform water, and chloroform internally. Finally, the attacks were controlled by with- holding all food and drink by the mouth, and using nutritive enemata for several days. But the salivation kept up some weeks longer, when it ceased entirely. The condition here was probably a reflex irritation from a gall-stone; hysteria was excluded because the patient was otherwise healthy and the mother of several grown-Tip children. I must not con- ceal the fact that for a long time the patient caused me a good deal of anxiety on account of the absence of definite points on which to base a diagnosis. The second case was a lady in the fifties, living outside of Berlin ; un- fortunately, I had the opportunity of seeing her only once. In the early part of 1888 she experienced profound emotional disturbances ; since the following summer she had suffered from mild gastric troubles which lasted, with variable intensity, till November. After that every meal was regularly followed by vomiting, which had continued with few intermis- sions till the beginning of January, when I saw the patient. The woman, who had formerly been strong, was now very much run down; she had frequent attacks iit unconsciousness, and complained of great weakness?, especially in the legs. Sleep was good. The urine had been repeatedly examined, but albumen and sugar were not found. I found a bedridden patient who was still quite well nourished in spite of the emaciation she complained of; she could move quite readily in the bed ; she spoke with deliberation ; in short, she seemed less afl'ected than was to be expected from her history. On examination I could find noth- ing but a struma, and tachycardia up to one hundred and twenty beats per minute. There was no tumor nor any tenderness in the abdomen. Pa- tellar reflexes normal ; pupils reacted well ; no limitation of the field of vision, and no complaints about sight. Sensation everywhere normal. Heart and lungs negative. In my presence the patient ate two pieces of toast and drank a glass cf water without vomiting. The tube was easily introduced and the stomach- contents expressed twenty-five minutes after. No hydrochloric acid found ; the fragments of toast were scarcely at all digested. This result left the diagnosis in doubt between a severe neurosis and an occult car- cinoma ; yet the absence of true cancerous cachexia favored the former. The rapidity of the pulse was attributed to the struma; tabes accompa- nied by gastric crises was excluded on account of the absence of its specific symptoms. The condition seemed to improve at first by using nutritive enemata and restricting feeding by the mouth as much as possible; small doses of NERVOUS VOMITING. 423 digitalis and atropine were also given. But she soon relapsed into the old condition; she gradually grew weaker, till one day she was seized with epileiJtic convulsions and died several days later. An autopsy was not allowed, yet the whole clinical picture led me to diagnosticate an affection of the medulla oblongata, probably a tumor, involving the roots of the vagus, thus causing the persistent vomiting and the rapid pulse. At all events, this presupposes such a situation of the suspected tumor that the nucleus of the fibers of the vagus distributed to the heart was paralyzed or destroyed, while those fibers going to the stomach were kept in a con- dition of chronic irritation. The soundness of this supposition remains in doubt, although it is by no means without a j)arallel (Rosenthal;. Botli of these cases are typical examples of severe vomiting caused by nervous irritation, and at the same time they show how difficult (sometimes even impossible) it is to make a diagnosis at a given time during life. For a certain group of cases we are unable to find this proof, although we may suspect the reflex origin. Pre-eminent among these stands the vomiting of neurasthenic and hysterical patients ; it is uncommon among the former, but occurs frequently in the latter. It is characteristic of this form of vomiting that it usually occurs without any true nausea, and that the retching is reduced to a minimum. Hysterical vomiting may occur after every meal ; some- times it is less frequent. Either all food may be rejected or only certain kinds or even individual dishes. I made use of this fact in making my first investigations on the course of normal digestion in human beings ; my subject was a hysterical girl who could retain all kinds of solid food, but was compelled to vomit whenever she swallowed any fluid. Another young girl, who has now been over five years at the Siechenanstalt, regularly vomits nearly all that she has eaten almost immediately after every meal. The general nutrition suffers surprisingly little from this persistent vomiting ; thus the sec- ond patient's weight has been almost the same during the j)ast four years; she has come down from 40*5 to 39'5 kilogrammes (89 to 8Y pounds). In other cases the vomiting does seem to affect the weight. Thus Tuckwell * reports that three children were very greatly emaci- ated after prolonged vomiting which lasted for months ; it was con- trolled by sitting the little patients up as soon as any tendenc}' to vomiting occurred (and also, to be sure, carefully regulating' the diet). * Tur-kwell. On Vomiting of Habit. British Med. Journal, March 22, 1873. 424: DISEASES OF THE STOMAC^H. Barras * speaks of a woman who suffered from nervous vomiting, but who ceased to vomit while she was in the bath ; she was cured after her meals were given to her in this way. This affection may pursue an acute or chronic course ; it may begin spontaneously or may follow some demonstrable cause. One young girl was attacked immediately after the death of her father ; ian other as the result of bi'eaking off an engagement of marriage. As in other neuroses, the female sex is especially liable. I must confess that my experience of the infrequent occurrence of vomiting in neurasthenics does not agree with that of Rosenthal, who claims to have seen it not infrequently in this class of patients. I shall simply content myself with giving the headings of two of his histories : Observation No. 31. — Neurasthenia, hyperaesthesia toward acids with consecutive gastric colic and vomiting. Cured by local remedies (small pieces of ice, with two to three drops of tincture of nux vomica) and gen- eral invigorating treatment. Observation No. 32. — Neurasthenia following onanism, with frequent vomiting. After the latter bad ceased it began again after each coitus, whDe a heavy meal did not cause any complaints. Neurasthenia and vomiting cured by prohibiting sexual intercourse at the beginning of the treatment, increasing doses of potassium bromide, with some pyrophosph. ferri citronatric. [Ph. Austr.], Neptune's girdle, galvanization of the sym- pathetic, and hydriatic procedures. This difference in observation might appear striking ; yet it may be readily explained by the fact that two observers in places at some distance from each other [Berlin and Yienna] deal with dif- ferent kinds of patients. Concerning the multiplicity and intensity of all neuroses it is peculiar that they most frequently attack the easily excitable Southerners, and especially the nationalities living near the military border. Hypersecretion seems also to occur more frequently there than in Germany. Finally, I must speak of a form of nervous vomiting which was described by Leyden.f It may occur as a primary neurosis, or as a secondary spinal affection, or as a reflex form. A peculiarity of this variety is the periodicity of the attacks [whence the name periodical * Barras. Traite sur les gastralgies et enteralgies. Paris, 1827. t Leyden. Ueber periodisches Erbreehen (gastrisehe Krisen) nebst Bemerkungen iiber nervose Magenaffectionen. Zeitschrift f iir klin. Medicin, 1882, Bd. iv, S. 605. PERISTALTIC UNREST OF STOMACH. 425 vomiting], wliicli may last from a few hours to a number (ten) of days. They begin with sudden nausea and coHcky contractions of the intestines, but the abdominal wall is relaxed. At first the vomit consists of food debris and slimy masses, later of bile and streaks of blood ; the attacks accompanied by migraine and tearing sensa- tions in the limbs ; they are followed by obstinate constipation, which is due to a spasm of the intestine. The trouble may last for years, but its origin can only be sought in the directions indicated above. In two of my cases the autopsies gave negative results. Stomach colics are usually included among the gastralgias. In fact, they frequently occur together, since stomach colic is accom- panied by severe pains. But, as indicated by the name, the pains are colicky, and are due to a spasmodic contraction of the viscus ; but they are not boring and shooting, as in genuine gastralgias. The causal factors are the same as those which have been described under the gastralgias. Localized spasms may occur at the cardia and pylorus. While introducing the stomach-tube we sometimes experience the sensation as if the instrument were spasmodically gripped at the cardia. It would be difficult to ascertain whether this is due to a contraction of the lower segment of the oesophagus or of the cardia. Spasm of the pylorus seems to be due, disregarding the irritation from local changes, to gastric juice which is either too acid or which has been secreted at improper times. This is the only way of explaining hyperacidity and hypersecretion, as has been sug- gested by Boas and myself. In distention of the stomach with gas, its escape upward or downward can only be prevented by an abnormally tight closure of the gastric sphincters. Peristaltic Unrest of the Stomach {PeristaltiscJie Unruhe, Tor- mina ventriculi nervosa). — This was first described by Kussmaul* as being caused by an increased peristalsis, which is so intense and so well marked that it may readily be perceived through the relaxed abdominal parietes, and which may at times be accompanied by * Kussmaul. Volkmann's Sammlung klinischeVortrage, 1880, No. 181. [Also, Boas, Deutsch. med. Wochenschr., October 17, 1889. — Tr.] 426 DISEASES OF THE STOMACH. gurgling and rumbling loud enough to be lieard at a distance. Tliis affection, bj itself, is not painful, yet it may torture the sufferer to extremes. " It is just as if the intestines were twisted around in- side m J abdomen," was told to me recently by a female patient, forty-six years of age, in whom the noises in the gut were so marked that they were audible as soon as she entered the room. They are most intense after meals, yet they do not disappear entirely between them ; and, like other neuroses, they have the characteristic pecul- iarity that they sometimes suddenly cease when the patient becomes excited — for example, during the doctor's visit — although a moment before they were present in full intensity. Knssmaurs earliest cases were persons with gastrectasis, and the majority of the cases which have since been observed have been snch patients. The reverse of this condition, antiperistaltic unrest of the stom- ach, has been observed by Glax * as a pure neurosis. His was a typical case ; the examples which had previously been published by Schiitz and Colin were not free from criticism. Glax's case was a man, thirty-two years old, who had formerly suffered from dys]3eptic disturbances and a slight dilatation of tlie stomach ; the writer de- scribes his condition as follows : " A shallow but distinct constriction could be seen passing vertically- downward over the stomach from the right sternal border. Suddenly to the left of this the fundus ventriculi ax^peared hard, and tense, and. grad- ually expanded to the size of a child's head ; this swelling slowly went down, then appeared to the right of the constriction, and then began almost immediately to the left again. Often, however, the movement distinctly passed from the right back to the left in an antiperistaltic di- rection. I then distended the stomach with carbonic-acid gas, which caused the movements to become very active." Errors may arise from the not infrequent occurrence of peri- staltic unrest of the intestines ; this may also assume an antiperistaltic form. That this may actually happen is shown by the cases of Bri- quet, Jaccoud and Fouquet, and Rosenstein, in which scjdjalse and discolored enemata were evacuated through the mouth.f In many * Glax, loc. cit, p. 190. f [A case of habitual defecation by the mouth has been recently reported by Desnos (Wiener med. Presse, 1891, No. 51, S. 1958). The case was that of a man who was found on the street in an epileptic attack ; the saliva which flowed from the mouth was apparently mixed with faecal matter. Upon inquiry, the patient POLYPHAGIA. 427 persons stroking the finger-nail rapidly and sliarj)ly across the epi- gastrium will produce distinct peristaltic movements. II. Conditions of Depression. Concerning the conditions of anaesthesia of the stomach we know very little, or rather, it would be truer to say, practically nothing. In Lecture IX attention was drawn to this point ; and, as we nor- mally have no perception of the processes going on in and about our stomachs, we can not, therefore, gain any distinct conceptions of a pathological lack of sensitiveness. Polyphagia, or acoria [a, without, Kopico, I satiate], the want of the feeling of satiation, is best regarded as a result of ansesthesia of the stomach. If in the discussion on bulimia and anorexia I have made it evi- dent that tliese conditions are due to an over-excitation of centers in the brain, then satiation must be considered an inhibition of hunger, and the absence of this sensation a negative phenomenon — i. e., either the liuno;er-center is no longer under the influence of the nervous paths passing to it, or the latter are defective. But I have already shown the vagueness and uncertainty of all such deductions, which still lack a tangible and well-established basis, and I believe this is also true of the above suggestions. Purely nervous polyphagia is a very rare occurrence ; naturally I exclude those gluttons of whom the old and new books on " gas- trosophy " are full ; but I mean those really morbid conditions which usually follow tangible lesions, and in the discussion of which these cases will be found. Nervous anacidity of the gastric juice is not as rare as it would appear after searching through the literature. I have repeatedly found it in hysterical persons (see the case of hysterical gastralgia, p. 412). I have also observed it in neurasthenics in Avhom there was no reason for suspecting an organic disease of the stomach. said that for two years he had not passed his stools per anum, but at six o'clock each evening he passed a stool by his mouth. The man was under observation only two days, but his statement was corroborated. At times the evacuation took place without any effort; at others they occurred during a nervous attack with slight convulsions and pain in the oesophagus. — Tr.] 428 DISEASES OF THE STOMACH. I shall restrict myself to the following case : Mr. P., landed proprietor in Culm, a powerful man of Herculean build, forty-three years of age, said that he had been very nervous since the death of his wife ; he imagined that he had a cancer of the stomach ; there were also abnormal sensations in the urethra and impaired sexual pow- ers. His appetite was absent ; the stools were constipated, hard, and dry. His disposition was exceedingly melancholic. On examination nothing could be found except a very marked sensi- tiveness of the spinal column on pressure against the spinous processes and with the faradic brush. The stomach and m^inary tract (catheteriza- tion) were found normal. Examination of the test-breakfast after ex- pression revealed the absence of free acid. He was admitted to the sani- tarium, where he slept with potassium bromide. Hydrochloric acid was also given, as well as lukewarm baths in the morning and warm rub- bings in the evening. He was kept under observation nearly two months, and in that time the stomach-contents, after the test-breakfast, were ex- amined five times at about weekly intervals. They were always neutral, and contained the breakfast almost without any changes, but there was no mucus. Gradually the condition improved, after all kinds of sensations in the soles of the feet, loins, larynx, and urethra had in the meanwhile ap- peared. He was advised to go to the hydriatic establishment at Elgers- burg, where he stayed several weeks. Later on I received a report from there that "Mr. P., the neurasthenic, who leaves here to-day, has been generally improved by the use of lukewarm half- and sitz-baths, elec- tricity, and massage ; yet, in spite of this, his old complaints have re- turned, etc." Eecently I heard again from this patient. Although a year and a half have elapsed, his symptoms are about the same. There are no signs of real loss of strength. We may therefore exclude organic diseases, car- cinoma, mucous catarrh, etc. It is simply a case of anacidity accompany- ing neurasthenia, of which I could cite three or four additional cases. I have already given you my opinion on the significance of the absence of free hydrochloric acidity in Lecture Y [p. 187 et seq\ Relaxation of the cardia and of the pylorus must be considered conditions which resemble paralysis. Paresis of the cardia may give rise to the annoying and trouble- some nervous eructation (see above, under Eructation, page 418). If fluids or remnants of food are raised, as well as gas, the condition is called regurgitation. In very many persons small quantities of chyme having a very sour taste are raised after eating, but they are swallowed at once ; this condition can be called neither pathological nor very annoying. But if it occurs frequently, and if larger quan- tities are regurgitated, then they are no longer swallowed again but RUMINATION. 429 are expectorated ; true rumination, sncli as occurs in animals, does not take place. This condition is very annoying and may lead to serious changes in nutrition, yet it may also exist for years "without any bad results. At times will-j)ower may succeed in repressing it ; yet I have seen a young man in whom neither will-power nor large doses of bromide of sodium had any effect. Regurgitation also occurs in diverticula of the oesophagus ; here it may be due either to the filling up of the diverticulum and its overflowing into the mouth — this occurs most frequently when there is a stricture below the site of the diverticulum — or the contents of the pouch may voluntarily be raised, or rather pressed upward, by the patient. At my lectures I have frequently presented a patient with a diverticu- lum who was able to raise its contents at will by taking a deep inspiration and bearing down. As lie restricted himself to fluids, the material which he raised contained no solid substances ; the greater part of it was mucus, and by its smell one could ascertain whether he had previously taken coffee, alcoholic drinks, etc. The reaction was alkaline or neutral. At first there was no odor, but recently the patient has observed that what he regurgitates has a slight foul smell. An entirely different thing is Rumination, Merycismus [/nrjpvKa^M, I ruminate], Wiederkduen, which has attracted the attention of lay- men and physicians ever since antiquity, and has given rise to the strangest theories. Some supposed that ruminators were necessarily descended from parents with horns ; * thus Fabricius says, " Ex quo forte datur nobis intelligi parentis semen aliquam habuisse affini- tatem cum cornigeris animalibus neque mirum fuisse genitum filium simile quid a parente contraxisse " (that is, the father is said to have had a horn on his forehead) ; others imagined that these per- sons — at least as infants — must have suckled ruminating animals ; f or even that " they had sinful intercourse with a cow." For a long time the opinion prevailed that these persons certainly had stomachs * I have taken these data from the following treatises: Bourneville and Seglas, Archiv de Neurologie, 1883, p. 86; Schmidtmann, loc. cit., p. 183; Schneider, Das Wiederkauen beim Menschen, Heidelberger med. Annalen, 1846, xii, S. 251 ; A. Johannesen, Ueber das Wiederkauen beim Menschen, Zeitsehrift fiir klin. Med., Bd. X, S. 274. f Daniel Perinetti, an eight-year-old child, was said to have been nourished by a goat for two years, and to have ruminated later on in imitation of it. 430 DISEASES OF THE STOMACH. with different compartments, like ruminants, till it was finally shown by autopsies that in the majority of cases there were no changes in the stomach or CBSophagus. As time passed by these negative results became more frequent ; but Schneider [1846] was able to report the case of a court coun- cilor from Fulda who had died at the age of seventy years, at the end of the previous century, after having ruminated all his life. In this case it was found that the cardia was wide enough to easily admit five fingers, and that the stomach was enormously dilated. Arnold (1838) observed three cases of rumination in which a sacculated dilatation of the oesophagus was found above the cardia in the an- trum cardiacum. Bourneville and Seglas * (1883) came to the con- clusion that there was no real anatomical change. In fact, the manifestations of rumination are especially liable to attract attention. ]^ot alone is it remarkable that, a shorter or longer interval after eating, the food returns to the mouth in separate mor- sels, unchanged in taste, to be chewed and swallowed a second time, yet it is still more wonderful that they should come up in a definite order, and that they should taste even better than the first time ; f or that the taste may be so unchanged that, as reported by Peter Frank, a patient could distinguish the food in the reverse order in which he had eaten it on the 23revious day. It is also stated by Darwin that any particular dish which had been eaten could be regurgitated at pleasure. This certainly seems to be almost super- human. No light is shed by the explanation of Gallois :{: that the regurgitated masses at first consist of an indistinguishable mixture of fluid and solid ingesta; but when rumination occurred during the later stages of digestion they would then contain only solids, and finally merely indigestible remnants of food, like tendons, leaves of salad, etc. A simple explanation is that during gastric digestion the fluidified ingesta are removed from the stomach ; hence, the regurgitated masses gradually contain more and more solid sub- * Archiv de Neurologie, 1883. f Anthony Kechy said, '• Indeed, it is sweeter than honey, and accompanied by a more delightful relish." t P. Gallois. Merycisme et etude physiologique de la digestion stomacale. Revue de med., 1889, No. 3. RUMINATION. 431 stances wliicli can not be attacked by the stomach, and finally con- sist of nothing but the latter. Hence, the condition of the regurgi- tated food does not depend on tlie wishes of the patient, but upon the phase of digestion in which rumination occurs. Rossier * asked one of these subjects to keep a record of the number of the regurgitated morsels. After breakfast there were six to twelve ; dinner, eleven to twenty-one ; supper, seven to sixteen. Rumination must not be confounded with the condition in which healthy persons may at will regui-gitate the contents of the stomach ; this is simply due to their ability to expel food from the stomach in the same manner as in my method of expression. It was this fact, for example, which led Montegre f to make his investigations on digestion. That rumination is due to a neurosis is beyond doubt. This is corroborated by the well-authenticated cases of heredity — e. g., Windthier's case of a Swede, forty-five years of age, who had ruminated since his thirtieth year; his son also began it in his twenty- fourth year. Kossier describes a father and son, sixty-five and twenty-four years old respectively. Another factor, imitation, may play an important part ; this is shown in the case reported by Korner,:|: where a ruminating governess gave it to her two pupils. Additional weight is lent by its relatively frequent occurrence in nervous persons suffering from neurasthenia, hysteria, epilepsy, and idiocy, and its cessation when the patients experience profound emotional disturbances — passion, anger, etc. The case of Ducasse* also confirms this ; this was a young man who had been afflicted with this disorder from his sixth to twenty-eighth year ; it was lessened on the first day after his marriage, and disappeared one week after ; in other eases the reverse has occurred ; there are still others in whom the malady is made worse by sexual excesses. The state of nutrition of the patients is very variable. The dis- * Rossier. Merycisme hereditaire dependant d'une epilepsie. Annal. de la Soe. de med. d'Anvers, avril-mai, 1867. f Montegre. Experiences sur la digestion. Paris, 1814. X 0. Korner. BeitragezurKenntnissder Rumination beimMenschen. Deutsches Archiv fiir klin. Med., Bd. 33. * Ducasse. Mem. de I'Acad. royale de Toulouse, tome iii. Quoted by Schneider, loc. cit. 432 DISEASES OF THE STOMACH. ease maj occur in all classes of society and at all ages. Haste in eating and the swallowing of large morsels seem to be of verj fre- quent occurrence in this disorder. Rumination may take place voluntarily or involuntarily, but its suppression causes pain. The most varied speculations have been indulged in as to its cause : first a central lesion was suggested ; then a peripheral one ; some thought it was due to a relaxation of the cardia; others re- ferred it to a heightened sensibility of the mucosa and stronger mus- cular contractions of the stomach, or even to some peculiar forma- tion of the latter or of the antrum cardiacum of the oesophagus. We must confess that we really know nothing of the true etiology of the affection, and it would simply be a circumlocution to follow the example of Deliio,* who designates it a " perverse and com- bined act of motion " or a reflex functional neurosis. A study of the murmurs of deglutition shows that there can be no permanent relaxation of the cardia. Deliio heard in his patient a distinct Pressgerdusch " which, according to the generally accepted view of the origin of this murmur, can not be present when the cardia is paralyzed " [see foot-note, p. 61]. Distention of the stomach with carbonic-acid gas also showed that the cardia was competent. In two cases of my own in which, at all events, rumination M-as not very marked (possibly eructation would be the proper name), re- peated examination failed to reveal the normal Pressgerdusche and the Sjyritsgerdusch. According to the prevailing views, this would also speak against a permanent relaxation of the cardia ; on the other hand, no further proof is needed to show that at the time of rumination the tone of the cardiac sphincter must be relaxed, and that there must be a paresis, or better, an unusually easy yielding of the cardia. Unfortunately, in the patient who was able to swal- low two live gold-fish, respectively 6|- and h^ centimetres [2f and '2^ inches] long, and to regurgitate them alive twenty minutes after, Alt f neglected to study the murmurs of deglutition ; yet this per- formance would seem almost impossible without a relaxation of the * K. Dehio. Ein Fall von Ruminatio humana. St. Petersburger med. Woch- enschr., 1888, No. 1— Einhorn, New York Medical Record, 1890. f K. Alt. Beitrtige zur Lehre A'on Merycismus, Berl. klin. Wochenschr., Nos. 26 and 27. RUMINATION. 433 cardia and cesopliagus, since it is scarcely possible that the delicate fish could have been squeezed through the narrow passage alive. ISTaturally this does not solve the question whether the relaxation is permanent or temporary ; yet to me it seems justifiable to classify rumination among the cases of insufiiciency of the gastric sphincters. Finally, both of my cases were neurasthenics (male) ; and in this respect they agree with the other cases which have been reported. The reports published recently in rapid succession by Alt, Boas,* Jiirgensen, f and Sievers,:}: have shed some light on the chemical processes in this condition ; they do not agree, for hyper- acidity and subacidity were each found once and anacidity twice. From this we may infer that the changes in the chemical processes of the stomach are not an essential but only an incidental feature in the symptomatology of rumination ; hence I would not be at all surprised if in one and the same patient varying degrees of acidity were found under otherwise identical conditions, since such a vari- able relation is characteristic of many of the neuroses. JN^evertheless, among the cases just referred to relief was ob- tained by the treatment which was indicated by the results of the chemical examinations ; alkalies were given in one case of Alt and three of Sievers, where there was hyperacidity, and acids in Boas's case with subacidity. These results should be appreciated still more, since every kind of treatment which had previously been tried was unsuccessful. The only exception to this was Bossier, who gave relief in one case by the internal administration of morphine in increasing doses up to 40 centigrammes [gr. vj] a day ; in another patient in whom this drug was powerless he succeeded with large doses of opium, 1"5 gramme [gr. xxijss.] ! ? In general, the best treatment seems to be that given in a case described by Ponsgen — an energetic will, and swallowing the food at once when it regurgitates, without chewing it a second time. Expectoration of the regurgi- tated food may lead to serious disturbance of nutrition, as occurred in the case reported by Sauvage, of a patient who had been afflicted for thirty years, but whose confessor had ordered him to spit out * J. Boas. Ibid., No. 31. J Sievers. Finske Lakares Allskapt, 1889. f Chr. Jiirgensen. Ibid., No. 36. 434 DISEASES OP THE STOMACH. the regurgitated masses. Two weeks later lie liacl emaciated very much, but he did not improve till, at the advice of a physician, he returned to the old habit. If the existence of 23aresis of the cardia in rumination is an as- sumption rather than a demonstrated fact, this is even more appli- cable to incontinence of the pylorus, which was considered a special nervous affection, first by L. de Sere,'^' and more recently by Eb- stein.f It is true that the latter has positively demonstrated that the pylorus may be incompetent when unyielding neoplasms involve this portion of the stomach ; this was naturally to be expected, but unfortunately we have no diagnostic criteria by which we may es- tablish the existence of this condition as dependent upon atony of the pyloric sphincter — i. e., as a pure neurosis — for an occasional incontinence of the pylorus is a normal phenomenon. An extensive experience will demonstrate to any one wdiat was first observed by Kussmaul, that, after introducing the tube into the stomach while fasting, intestinal contents or bile may be obtained ; this occurs most frequently when the patients have gone without eating for a longer period than usual. The natural inference from this is that the pylo- rus was not firmly closed ; consequently, it will be very difficult to distinguish its pathological occurrence from the physiological. Fur- thermore, Ebstein's diagnostic test, the rapid passage into the intes- tines of the carbonic-acid gas which has been artificially generated in the stomach, is unreliable, and is subject to manj errors. First, the inflation of the stomach may displace some coils of intestines up against the abdominal wall, just as if they had been distended by the passage of gas into them from the stomach ; secondly, different per- sons require very varying quantities of effervescing powder to dis- tinctly inflate their stomachs ; finally, the gastric contents may com- bine with more or less of the gas as it is generated. Hence the pylorus maj be competent, in spite of the negative result of this test. At all events, incontinence of tlie pylorus is a very rare occur- * L. de Sere. Du relachement dii pylore. Gaz. des hop., 1864, No. 62. f Ebstein. Ueber Nichtschlussfahigkeit des Pylorus (Incontinentia pylori). Volkmann's klin. Vortrage, No. 155. — Einige Bemerkungen zu der Lehre von der Nichtschlussfahigkeit des Pylorus. Deutsch. Archiv fiir klin. Med., Bd. xxxvi, S. 295. ATONY OF STOMACH. 435 rence. In the numerous cases in wliicli I have distended the stom- ach to its utmost with air, I could never distinctly demonstrate such a condition ; instead of that, the air always escaped upward with ex- plosive eructations whenever the tension became too great. ]^ever- theless, I believe that some dysj)eptic disturbances are due to pyloric incontinence ; yet many more are the result of regurgitation of the intestinal contents into the stomach rather than a too early passage of the chyme into the duodenum. On the other hand, I agree fully with Ebstein and Zeckendorf,* that the acute intestinal tympanites of hysterical persons may be largely due to the rapid passage from the stomach into the intestines of air which has been swallowed ; hence the pylorus must necessarily have been incompetent. Another fact which I have repeatedly observed may possibly be of importance in the etiology of pyloric incontinence. ]^ot infre- quently we encounter persons whose stomachs are found empty after the usual interval (an hour, or sometimes even forty-five minutes) following the test-breakfast ; yet, by pouring in water, we may easily convince ourselves that the apparatus of expression or asjjiration is intact. In these cases the chyme has passed unusually early into the duodenum ; but it is still doubtful whether this is due to a heightened peristalsis which has overcome the normal closure of the pylorus, or whether there is an incompetence of this sphincter. Atony of the stomacli is an important neurosis to which sufficient importance has not yet been attached. We have already encount- ered this condition and its results as an accompanying symptom of manifold dyspeptic disturbances ; but atonic states of the gastric musculosa may undoubtedly occur as a primary neurosis, as an inde- pendent disorder of the innervation of the nerve-centers regulating the peristalsis of the stomach ; these may occur either in loco affec- tionis or in the central nervous system, and are frequently the cause of the dyspeptic troubles resulting therefrom. It is superfluous to speak in detail about the origin of this condition as a result of in- sufficient or too tardy movement of the chyme, since we have already frequently observed this reciprocal relation of cause and effect. I * Zeckendorf. Ueber die Pathogenese der Baucbtympanie. Dissertation, Got- tingen, 1883. 28 436 DISEASES OP THE STOMACH. simply wish to distinctly state once more that I consider " atony " to include a disturbance of the gastric motor function only, not of its secretory ; in other words, it is a lack of agreement between the power of the muscular force of the stomach and the task to be ac- complished by it — i. e., it is an insufficiency of the stomach (Rosen- bach). Otherwise we may, like von Pfungen,* include three fourths of all the lesions of the stomach under this title, and yet not obtain a clear conception of its relations. Atony may be partial or complete, depending upon the involve- ment of the fundus or pylorus or the entire stomach. I consider this classification premature, for it is based upon the independence of the several portions of the stomach which has recently been re- peatedly maintained. I wdll admit the value of the experiments of Schift, von Hofmeister, and Schiitz upon the movements of the stomach,f and also the observations of von Pfungen :|: upon a patient who had undergone the operation of gastrotomy ; according to these experiments, the motor power of the body of the stomach is about one third as great as that of the antrum pylori ; while the function of the latter is especially to expel the chyme, that of the former is the trituration of the ingested food. But I maintain that we know so little about the movements of the stomach in pathological cases that we may be happy to be able even to recognize the existence of these disturbances as such. Furthermore, I can not see what is gained by such a distinction between aton}^ of the pyloric portion and of the body of the stomach ; for, so far as clinical effects are concerned, the latter will always be the more important and causal factor. Where there is no movement in the body of the stom- ach its absence can not be replaced by the peristalsis of the an- trum pylori, be the latter ever so powerful ; but if a normal or even heightened peristalsis of the fundus be associated with an atonic condition of the pyloric portion, there can be no obstruc- tion to the expulsion of the chyme ; on the other hand, this must be more easily accomplished than normally, since an atonic state * R. PreiheiT v. Pfungen. Ueber Atonie des Magens. Klinische Zeit- und Streitfragen. Vienna, 1887. t Vide Ewald. Klinik, etc., I. Theil., 3. Auflage, S. 78. X Log. cit., p. 261. GASTRIC NEURASTHENIA. 437 of this portion of tlie mnsculosa of the stomach would be incon- ceivable without a coincident diminution of the tone of the true pyloric sphincter which is so closely associated with it ; consequently, tlie nniscular power of the remainder of the stomach can easily overcome the resistance of the " dead channel " thus formed. In such cases we might possibly suppose that where this relaxation of the pyloric portion begins a closure of some kind might be effected by the contraction of the adjacent circular fibers of the stomach, and thus none of the chyme will pass on into the intestines in spite of the apparently vigorous peristalsis. This is how von Pfungen attempts to explain a case of this kind which had been reported by Kussmaul.* Such suppositions, however, lead us into the broad field of speculation, from which we must keep aloof as far as pos- sible. III. Mixed Form of Gastric JSTeuroses. Neurasthenia Gastrica (Nervous Dyspepsia). — The condition which under the name of nervous dyspepsia, has recently been the subject of so much discussion, is, in my opinion, only a complex form in which the neuroses already described in the preceding pages take a more or less prominent part, but which is at the same time charac- terized by an active participation of the entire gastro-intestinal tract. But now it is quite difficult to include these conditions within one clearly defined clinical picture. It is almost like trying to grasp a medusa which is dissipated under our grasp. For, if we adhere closely to that which is indicated by its name, we can include only actual digestive disturbances, dyspeptic conditions which lead to a distinct change in the chemical functions of the stomach. But if we follow the conception of nervous dyspejosia, which was first an- nounced by Leube in his classical work,f that it causes digestive complaints without producing digestive disturbances — i. e., without altering the chemical functions of the stomach — then, as Eossbach has very properly said, we have a condition very much like dys- pepsia, but not dyspepsia. Every one will at once feel how strained such a nomenclature is. * Kussraaul. Deutsch. Arch. f. klin. Med., Bd. vi, S. 470. t III. Congress f iir innere Mediein zu Berlin. 438 DISEASES OF THE STOMACH. According to Leube,"^ nervous dyspepsia is a group of symptoms essentially of a cerebral nature, wliicli are due to an abnormal irri- tability of the sensory nerves of the stomach toward the normal digestive processes, and which are especially manifested by the symptoms which I have already grouped together among the sen- sory phenomena caused by irritation. On the other hand, Stiller includes under this title of nervous dyspepsia all those conditions in which there is a predominance of digestive disturbances which are reflected back upon the stomach from and by means of the central nervous system and the sympa- thetic res23ectively, and which may incidentally cause definite changes in its functions. "Whereas the former writer proceeds from the center of the circle to the periphery, the latter goes in the reverse direction, from the periphery to the center. Furthermore, while the former claims that the true peptic acti\'ity of the stomach is unchanged, the latter maintains that it is altered under certain con- ditions, and, in fact, in the majority of cases. In this dilemma it would be difficult to follow the usual course and say that the truth lies midway between these two views, for in a certain sense, or rather with certain restrictions, both of them may be correct. There are some cases — i. e., the rarer cases of Leube — which correspond to the picture of nervous dyspepsia ; but I believe that this group will gradually grow smaller and smaller with the increasing delicacy of the methods of investigating the peptic pow- ers of the stomach. On further examination, Leube's criterium of normal digestion — i. e., the stomach must be empty six to seven hours after the test-meal — has proved to be insufficient. Eosenbach, Riegel, E.odzajewski,f myself, and others have emphasized the un- certainty of this test. After a careful study of the digestive pro- cesses, I have found changes in the chemical functions in quite a large number of cases in which the nervous symptoms were the prominent feature. Furthermore, we must not forget that our pres- ent methods of chemical examination are still relativelv crude, and * Leube. Ueber nervose Dyspepsie. Deutsches Archiv. fiir klin. Mediein, Bd. sxiii, 1879. f Rodzajewski. Ueber die Digestiondauer im Magen als diagnostische Methode. Petersburg, med. Wochensehr., 1885, Nos. 32, 33. GASTRIC NEURASTHENIA. 439 give us absolutely no information concerning the amount of pe^^sin secreted, and very little about the intensity of absorption and the strength of motion. Hence, we can only ascertain certain gross changes, while there is surely quite a large number of alterations which escape us because they lie beyond our present limits. The same may be true of anatomical changes, Jiirgens* has made an important contribution upon this point. In forty-one patients who, while alive, had complained of vague dyspeptic disturbances, a com- plete degeneration of Meissner's and Auerbach's plexuses was dis- covered ; in this way he gave a tangible anatomical basis to these cases of dyspepsia, many of which had been diagnosticated as " re- flex dyspepsia," Furthermore, " where the disturbance was more of a sensory character," he found " a degeneration of the muscularis mucosae of the stomach and of the intestines also, and a pronounced formation of varices in the intestinal walls, the exact examination of which revealed a degeneration not alone of the muscular fibers of the veins, but also of the sensory nerves and of the branches of Meissner's plexus in the vicinity," Unfortunately, the results of the detailed investigations have not yet been published ; but, if the}'- prove correct and are pursued further, the domain of nervous dys- pepsia will also be curtailed on this side. On the other hand, in the majority of cases we can discover no changes in the nerves outside of the stomach, of a direct or reflex nature, which may be referred to this viscus, or may give rise to immediate disturbances of the gastric digestion. In either case the clinical symptoms of this condition will always consist of the manifestations which I have already described as those of irritation or paralysis, a mosaic in which now one stone, now an- other, will be lacking ; sometimes one, sometimes another, will be especially prominent ; but they will never be firmly fixed together, and, like man himself, will always present a kaleidoscopic pict- ure. There is only one characteristic feature, that, taken all in all, the symptoms are usually mild, and severe forms of gastralgia and cramps, nervous vomiting, polyphagia and bulimia, do not occur. * Jiirgens. Verhandlungen des III. Congresses iiir innere Medicin, S. 253, 440 DISEASES OF THE STOMACH. In all these patients the symptoms of imperfect intestinal di- gestion will always be found associated with those dne to changes in the gastric functions.* In some cases the symptoms of imper- fect intestinal digestion are not well marked, and are restricted to the consequences of lessened or increased peristalsis — usually con- stipation, less frequently diarrhoea — or the stools may be normal but absorption is disturbed ; such j^atients will emaciate continuously in spite of a good apj^etite, etc. Is^ot very long ago attention was di- rected to these cases by Mobius.f In other cases the intestinal symptoms are so well marked that one might be tempted to group them into a distinct class, as was done by Cherchewsky.;}: Here, along with mild gastric disturbances, we observe anorexia, re23ugnance toward taking food, coated tongue, mild nausea — in short, symptoms which might not inaptly be desig- nated those of visceral neuralgia. The bowels are usually consti- pated, and there are severe pains in the abdomen, either spread diffusely or recognizable as separate painful spots. Rarely the ab- domen is retracted ; as a rule, it is quite distended and tympanitic, sometimes even to a marked degree, while the free escape of flatus causes great torture to the sufferer. The gas which may escape either by mouth or by rectum has caused this condition to be called flatulent dyspepsia. In addition there are also general nervous symptoms like those observed in the gastric form, except that they are usually more severe and even at times alarming. If you will recall wliat was said in the introduction to this part about the innervation of the stomach and intestines, the mutual transition of the symptoms of these viscera ought to occasion no surjDrise. The close connections of the numerous plexuses of the intestines and the fibers of the vagi, splanchnics, and the vai'ious sympathetic ganglia, necessarily cause the involvement of tlie one to * One of my patients wrote to me that " I must complain most of a feeling of oppression while walking, bitter taste in the mouth, and obstinate constipation." The bitter taste in the mouth is frequently replaced by an exceedingly annoying dryness and burning sensation. f P. Mobius. Ueber nervose Verdauungsschwache des Darms. Centralblatt fiir Nervenheilkunde von Erlenmeyer, vii. Jahrgang, 1884, No. 1. X Cherchewsky. Contribution a la pathologie des nevroses intestinales. Revue de medecine, 1884, No. 3. GASTRIC NEURASTHENIA. 441 be followed by a disturbance of the otlier, no matter whether the cause is located centrally or peripherally. Therefore, I have proposed the name neurasthenia gastrica^ or vago-symjKithlca, for this entire group of symptoms ; it may be s]ib- divided into a gastric and an intestinal form, according to the viscus which is especially iiivolved.* I consider this name is much better than the expression nervous dyspepsia, because it corresponds more closely to the nature of the affection, and my liking for the latter designation has by no means been lessened by the reasons given by Leydenf in a splendid paper on this theme. On the contrary, it seems to me better and more suitable to the nature of the lesion to leave out the " dyspepsia" altogether ; for a deficiency in the peptic powers of the stomach is either absolutely lacking or, at all events, if present plays a very subordinate part. As I have already said, gastric neurasthenia is a complex of the various nervous disturbances already described, and therefore these can give no specific and characteristic data. This is also true of R. Burkart's painful points in the abdomen, which have already been described [page 407]. There is nothing about them which is characteristic of gastric neurasthenia. They can not be mistaken for gastralgias, enteralgias, and the painful sensations in the abdominal parietes ; the latter not infrequently radiate from the infrasternal depression as lancinating pains, and might well be called epigastralgic, as proposed by Briquet. Leube has called attention in his classical work :|: to the fact that the symptoms connected with digestion are nearly always preceded by manifestations of a general nervousness or, as it is now desig- nated, neurasthenia. The writers who have since investigated the subject have laid a different stress upon this fact, according to the standpoint which they have taken. Undoubtedly there are cases in which no cause can be discovered — Fenwick* claims this for the majority of his * Ewald. Verhandlungen des III. Congresses fiir innere Mediein. f E. Leyden. Ueber nervose Dyspepsie. Berl. klin. Wochensehr., 1885, No. 30. X Leube, loc. cit. * Fenwick. On Atrophy of the Stomach and on the Nervous Affections of the Digestive Organs. London. 1880. 442 DISEASES OP THE STOMACH. observations — but surely tliere are very few patients indeed in wliom the cliaracteristics of a nervous disposition can not be discovered. Either nervous diseases are hereditary in the family, or the nervous system has been very severely taxed in some way or another — pro- found emotional excitement, business cares, severe mental exertion, sexual excesses — or the condition which we call cerebral or spinal irritation, or any other affection of the nervous system bordering upon hysteria, has preceded it. Thus, I have had under my treat- ment for a long time a young man, eighteen years old, whose father suffered from pronounced spinal irritation. Another case was an old gentleman who had all the symptoms of a well-marked neurosis of the intestinal tract, after having suffered for years from peculiar nervous symptoms, which were always associated with irregularities of intestinal digestion. There are also some cases — their number is very limited- — in which intestinal neuroses are developed without these prodromata. By watching such patients for a longer period w^e will usually be a])le to observe other neurasthenic symptoms. I Imve frequently seen a young lady in whom the condition which at first could only be called gastric neurasthenia was aggravated on account of the cessation of menstruation, and finally became hys- teria, with especial prominence of the signs of gastralgia and enter- algia. However, such an occurrence is manifestly very rare, and warrants the suspicion that it was hysteria from the beginning ; in fact, all these conditions now under discussion were formerly in- cluded under this disease, l^aturally, they have been known for a long time, but their exact description, and the chemical demonstra- tion of the integi-ity of the gastric juice, is an achievement of recent times, due especially to the labors of Leube. At this place, however, I should like to state that the same nerv- ous states which constitute the prodron.ata of the dyspeptic con- dition may also become very prominent during the course of the latter. I^ot alone are there pains in the head and back, weariness of the limbs, etc., but these patients are very gloomy and pessimis- tic, worry unnecessarily, and lose what little ambition they still pos- sess. One of my patients complained of a weak memory and in- ability to concentrate his thoughts ; another suffered very severely from vertigo during every exacerbation of his dyspepsia. At the GASTRIC NEURASTHENIA. 443 same time the pulse became small and rapid, the hands and feet were cold and livid, and treml)led, there was palpitation of the heart with oppression and dyspncjea, which became worse on getting up or walking ; these symptoms increased to a most intense fear of impending death, till suddenly relief was brought by the passage of flatus. Althougli the patient, who was a well-educated gentleman, moving in the highest circles, knew how the attack would end, he was, nevertheless, utterly unable to overcome the feeling of impend- ing death. In all these cases I wish to state emphatically that the lesions are dyspeptic conditions upon a neurotic basis, never concomitant symp- toms of really demonstrable injuries of the central nervous system — 6. g., gastric crises of tal:)es dorsalis, diffuse and localized cerebral lesions, ailments of the peripheral nerves, etc. ; or what may occur as reflex neuroses in chlorosis, menstrual disorders, uterine and ovarian diseases, and intense psychical excitement (when they are manifested as nervous diarrhoea or constipation). As opposed to tlie chronic and, if I may so express it, the milder character of gastric neuras- thenia, these conditions take the shape of acute, rapidly developed attacks, accompanied by very intense symptoms, which may either occur once or return periodically. Such attacks are described in Richter's monograph ; * Leyden f has also published a series of very well marked examples. In my opinion the only relation which they bear to neurasthenia gastrica is that they can not be grouped with those forms of psychoses or neuroses in which anatomical lesions of the central nervous system can not be dem.onstrated with the meth- ods thus far at our disposal. Although we can not positively say that real pathological ana- tomical changes are lacking, yet we can usually exclude great altera- tions in the chemical functions, even though this is not always justi- fiable. In many cases an indigestion of short or long duration, a mild catarrh, frequently recurring hyperseraia, and the like have surely been the primary cause of the manifestation of the nervous * Richter. Ueber nervose Dyspepsie und nervose Enteropathie. Berliner klin. Wochenschr., 1882, No. 13. f Leyden. Ueber periodisches Erbrechen (gastrische Crisen). Zeitschr. fiir klin. Med., Bd. iv, 1882. 444 DISEASES OP THE STOMACH, symptoms in the digestive organs. Indeed, such injurious condi- tions may recur during the course of the disease, and may produce a temporary aggravation thereof, because tliey are added to the fac- tors already existing. But if we encounter leucorrhoea or dyspeptic disturbances during chlorosis, or if we see retinal changes in Bright's disease, we will never consider these conditions as anything but symptoms of a general malady. In my opinion, there can be no doubt tliat these dyspeptic con- ditions are the manifestations of general neurasthenia. In rare cases this may be developed only in the nerves of the stomach and intestines, and apparently the lesion is in one of the peripheral nerves. In the vast majority of cases these local symptoms are com- bined with others of a nervous nature, and among which they oc- cupy a pre-eminent place. For the diagnosis of dyspeptic neurasthenia there are no single characteristic symptoms. Therefore it can not be made simply from the results of one examination, and the complaints of the patient at that time ; the more so, since not infrequently oi'ganic lesions may go hand in hand with neurasthenic conditions. A correct diagnosis is possible only after a prolonged observation of the course of the disease, discovery of the causal factors, the failure of all measures directed toward suspected organic diseases of the stomach and intes- tines, and a proper estimation of all the signs of neurasthenia which may be present. As Burkart has rightly suggested, particularly great value is to be laid upon the peculiar character of the indi- vidual symptoms, on account of their mutual relations to one an- other, and their changeable occurrence. I would also like to direct attention to the following : First, the gastralgic pains are, as a rule, diffuse, and do not have that distinct, sharply localized character observed in ulcer or cancer of the stom- ach. They are also much less dependent upon taking food, although this relation is also very variable in carcinoma. Secondly, vomiting occurs very rarely in gastric neurasthenia. When it does occur, it consists of mucus mixed with bile and rem- nants of food in various stages of digestion, but never of bloody or decomposed masses. It is distinguished from hysterical vomiting by the ease and regularity with which tlie latter usually occurs. GASTRIC NEURASTHENIA. 44.5 The taste of the vomit is not offensive but bitter ; I am inclined to ao-ree with Liebreich that the taste in these cases is due not to bile but to peptones, which are well known to have a very sharp and bit- ter taste. In belching, with the regurgitation of acrid masses, this is undoubtedly the case. Thirdly, the stools — of which I have examined a large number in the course of time — have the usual changeable character described by Lambl, and later by Nothnagel.* In no case did I find an un- usual quantity of undigested remnants of food or mucus, or even of blood. The form of the faeces is also very variable. I have ob- served nothing of a typical character, and it was only rarely that I saw the ribbon-shaped stools ujDon which Cherchewsky lays so much stress. Concerning the differential diagnosis, I shall not speak of the neoplasms, ulcers, strictures, etc., which may be recognized by pal- pation, inspection, or by very characteristic symptoms, but instead I shall invite your attention to the following points : Leube has recommended the so-called digestion-test as an aid in the differential diagnosis. According to this writer, in health and in neurasthenia gastrica the stomach should be empty seven hours after taking a simple meal, and the wash-water after lavage should contain no traces of food. I will admit that this rule is true of the majority of cases, but the exceptions to it I have already given {vide sttpra). Leube f himself speaks of two cases out of six examples of dyspeptic neurasthenia in which the stomxach-contents were undi- gested in the seventh hour after eating, and contained no acid. On the other hand, I have found the stomach empty at this time in gas- tric catarrhs, ulcers, and cancer of the stomach. Therefore, although the empty condition of the stomach after this interval is usufJly indicative of a normal condition, it by no means gives absolutely certain conclusions. The same is true of the chemical examination of the contents of the stomach which have been obtained at an earlier period. Even * Nothnagel. Beitrage zur Physiologie und Pathologie des Darmes. Berlin, 1884. f W. Leube. Beitrage zur Diagnostik der Magenkrankheiten. Deutsch. /irchiv fiir klin. Med., Bd. xxx. 446 DISEASES OP THE STOMACH. ill very well marked clironic catarrhs, where there could be no sus- picion even of a nervous origin, in ulcer, and also in carcinoma, I have found gastric juices which had the normal percentage of acid and digestive powers, as ascertained with our modern methods of examination. In fact, I am convinced that we should avoid going too far in drawing conclusions from the results of the chemical ex- amination of the gastric juice, and we should always bear in mind that a series of factors participate in the functions of the living organ which we can not reproduce in our crucibles and retorts, and can not recognize with our chemical reagents. Where the diagnosis is doubtful concerning the possibility of a gastric ulcer, there is an additional factor to which I always pay attention — i. e,, for the reasons given on page 260, I am afraid to introduce the stomach-tube, and I thus avoid the risk of causing a perforation for the sake of information which may be doubtful ; therefore, it seems much more important to me to treat the suspected ulcer with aj)proj)riate remedies, and let the diagnosis depend upon the results of such a course of treatment. Indeed, we should endeavor to realize the fact that in very many cases it is impossible to recognize a neurosis at the first glance, and that only prolonged observation, a very carefully taken history, and a consideration of the general condition will strengthen the diag- nosis and exclude ulcer, primary or secondary engorgement of the liver, and even carcinoma or chronic tubercular processes. Inter- costal neuralgia has also given rise to errors ; and although I have never met such a case, which must necessarily be rare, it should nevertheless always be borne in mind. The prognosis and treatment of neurasthenia dyspeptica may almost be inferred from the nature of the aft'ection. It would be easy to subdue the functional anomalico which might be present if they were not always reproduced by their central causes. The frog- nosis is as uncertain here as it is in all neurasthenic affections. Some cases are quite rapidly cured by suitable treatment, and may remain well permanently or temporarily ; but there are others which for years resist all the efforts of rational therapeutics. The course which an individual case will pursue can not be predicted in ad- vance. It is natural to suppose that the chances are best where the REFLEX GASTRIC NEUROSES. 447 symptoms have been mild, and vice versa / but on this very point I have repeatedly erred. Apparently very severe cases were cured in a relatively short space of time, while seemingly simple ones per- sisted for years. In general, only this much can be premised, that at best the trouble is one of long duration, lasting for months at least, and that the external appearance of the patient affords no clew to the severity of the neurasthenic symptoms. I have frequently treated young men who were the picture of health, and whose com- plaints were therefore ridiculed. There are other cases in which the patients decline very much, emaciate, and become so miserable that some English writers have even described extreme conditions of weakness, with terminal oedema, fever, and death. TV. Reflex Gastric ISTeueoses from other Organs. Under this heading I include palpable changes in organs other than the stomach, whose effects are observed in the gastric nerves ; in other words, those morbid manifestations to which, like all other reflex conditions, the axiom Ablata causa cessit effectus has a special significance. Too frequently is the cause of the cases sought, not in the real primary area, but incorrectly in the place secondarily involved ; therefore, a brief resume of the reflex symptoms known to us may serve to remind you what organs and morbid processes are to be especially considered. The reflexes manifest themselves as (1) mild disturbances of digestion ; (2) gastralgias ; (3) vomiting ; the latter occurs especially in acute affections, the former in those whose nature is more chronic. But just as these three types may very frequently be interchange- able, and even occur in combination, so may chronic processes give rise to the symptoms of an acute gastric disorder, if they exacerbate suddenly or involve specially predisposed nervous plexuses, etc., in their course. This is well shown, for example, in the crises of loco- motor ataxia. The fact has been repeatedly mentioned that the stomach is the center of a nervous plexus whose branches have very wide connec- tions, and directly or indirectly involve nearly every organ in the body ; hence, an irritation which is manifested at any point in this plexus will reach the stomach, just as in any peripheral end-appa- 448 DISEASES OF THE STOMACH. ratus. Of especial importance are the reflexes from the central nervous system, the great glandular organs in the abdomen, the in- testines, genital tract, and, finally, the heart and lungs. The cerebral disorders — meningitis, hsemorrhages, abscesses, tumors — are usually accompanied by vomiting of a transitory or more permanent character, and frequently by hypersecretion of the gastric juice, as was already known to Andral.* The presence of this abundant secretion of gastric juice during life will therefore explain the rapidity with which post-mortem softening of the stom- ach may take place in these cases. Vomiting usually occurs during the course of the disease, or it may usher it in and thus cause great misconceptions, as is well known in meningeal inflammation, espe- cially of children, and in tumors. Therefore, every case of long standing, or even unyielding vomiting, must be considered from this standpoint. The vomiting of sea-sickness, migraine, and the beginning of psychical affections, may also be included in this vari- ety of reflex vomiting. Of the latter occurrence I have two exam- ples in which, apparently from a gastric catarrh, very obstinate vomiting was developed, which, after having lasted several weeks, was followed by a psychosis. Lesions in the cervical and dorsal portions of the spinal cord cause gastralgia, sometimes with vomit- ing, as soon as the centers or nerve-roots concerned are involved. Such " gastric crises " occur not alone in the gray degeneration of the posterior columns (tabes), but also in insular lesions of dissemi- nated sclerosis. Vomiting is also of frequent occurrence in ab- scesses and calculi in the liver and kidneys, especially when they pass into the excretory ducts and thus irritate their sensory nerves. I will recall the vomiting of pregnancy not alone to indicate a very common reflex upon the stomach, but also a not infrequent source of diagnostic doubts and errors. How frequently has ap- parently serious vomiting, which simulated some grave disorder of the stomach, simply proved to be the first manifestation of a preg- nancy ! It occurs in the early part of gestation, while the uterus is still in the pelvis, since this variety of vomiting is due to the press- ure of the enlarged womb upon the sympathetic nerves. The dis- * Quoted by Budd, loc. cit. REFLEX GASTRIC NEUROSES. 449 order may reach sucli a degree that all remedies are useless, if the uterus is unusually large or is misshapen, or if its muscular fibers are inflamed, or if it is misplaced. But acute injuries or maltreat- ment of this organ may also cause vomiting — e. g., snaring a polyp at the fundus uteri preparatory to its removal. Dr. Daumann had such a case in which pain and vomiting set in every time the loop was tightened, while the latter ceased as soon as the ligature was loosened. The same thing has been observed in operations on the bladder, urethra, etc. Chronic disorders of the female as well as of the male sexual organs may be followed by chronic dyspeptic conditions. I would here remind you that the normal process of menstruation causes retardation of gastric digestion, or even complete absence of free hydrochloric acid in the stomach-contents, as was first demonstrated by Kretschy,"" and later confirmed by Fleischer, f and Boas and myself. :{: How much greater reflexes will be referred to the stom- ach and intestines by amenorrhoea and dysmenorrhoea, the climac- teric period and chronic disorders of uterus which are associated with an irritability, or even with a direct excitation of its nerves ! Hence we can understand why Ivisch* found " dyspepsia uterina" most frequently in retroflexion of the enlarged uterus, then in mal- positions in general, myomata, pelvic exudations with traction on the uterus and its adnexa, follicular or carcinomatous ulcers of the cervix, and ovai'ian tumors ; but it was absent in simple and mild endometritis, chronic catarrhs, and small perimetric and parametric exudations. Such dyspeptic conditions which may have persisted for years have been cured in a surprisingly short time by appro- priate local treatment. I have recently observed a peculiar and rare example of a reflex of this kind which first involved the salivary glands and indirectly the stomach — i. e., sialorrhoea with dyspepsia resulting" therefrom. An unmarried lady, foi^ty-one years of age, was said by her physician to have suffered for two * F. Kretsehy. Beobaehtungen iind Versuche an einer Magenfistelkraiiken. Deutsches Archiv fur klin. Med.^ Bd. 18, S. 257. f E. Fleischer. Ueber die Verdauungsvorgange im Magen unter verschiedenen Einfliissen. Berl. klin. Wochenschr., 1882, No. 7. X Ewald und Boas. Zur Physiologie und Pathologie der Verdauung. Vir- chow's Archiv, Bd. 104. * H. Kisch. Dyspepsia uterina. Berl. klin. Wochenschr., 1883, No. 18. 450 DISEASES OP THE STOMACH. and a half months from loss of appetite, bitter taste in the mouth, consti- pation, feeling of oppression over the stomach, and for several weeks very severe salivation. She was much emaciated, felt very weak, and had the greatest repugnance toward exerting herself, although she was formerly very active. She lived upon her estate, and had already taken Carlsbad water, condurango, nitrate of silver, and small doses of quinine ; cold rubbings and suitable diet had also been tried, but all without suc- cess. On the patient's admission to the sanitarium the amount of saliva secreted daily was found to be about two litres [4^ pints] ; this was exam- ined in Prof. Kossel's laboratory and found normal. No great changes discovered in the gastric chemical functions ; acidity 48. No other anom- alies found ; the mouth was free from any special disease. Every kind of poisoning by the coating of mirrors, mouth-washes, hair-dyes, and the like, was excluded. After a fortnight's trial of pills of atropine, and hy- podermic injections of morphine and atropine, with only temporary effect on the symptoms, I discovered a retroflexion of the uterus. With the introduction of a pessary the obstinate ptyalism and the dyspeptic con- dition very soon disappeared. In conclusion, I must mention the reflexes from the intestines, such as are caused bj worms, enteroliths, and neoplasms in and about the gut. The parasites, especially, play an important part here. I shall not go into details about the serious disturbances of nutrition which may be caused by the distoma and strongylus varie- ties, neither shall I speak of the disease of tunnel workmen and brick-burners.* It will suffice to mention the ordinary ascarides and taenia, and recall the fact that many a long-standing " nervous dyspepsia " has been terminated by the expulsion of a tape-worm ! Treatment of the Leukoses of the Stomach. In all the nervous diseases of the stomach the treatment will depend upon the question whether they are of an irritative or de- pressive nature. The conditions of increased irritability must be separated into those in which the hypersesthesia is local and those which are cen- tral in origin. For local hyj)er?esthesia, opium and its derivatives — morphine, codeine, and narceine — have been invaluable for ages. In general, morphine is best administered in watery solution, or in bitter-almond * [The Tunnelkranhheit or Bergkachexie is a form of anaemia caused by the anchylostomum duodenale. It has also been called Gothard-Tunnel disease. The same parasite is the cause of brick-burner's anaemia. — Tr.] TREATMENT OP THE GASTRIC NEUROSES. 45 1 water, since it is not dissolved in tlie stomach if given in substance, or has little or no action. The most rapid effects may be obtained by hypodermic injection in loco affecto / I usually follow the English custom of adding one tenth part of sulphate of atropine, partly to counteract any possible nauseating effects of the morphine, partly to obtain the relaxing effects of the atropine. This is an excellent combination, which may be very useful in patients who have inva- riably had nausea and vomiting after the simple morphine solution. For example, in bulimia, Eosenbach has recommended the hypoder- mic use of extract, opii which has been dissolved in glycerin, filtered and diluted with water ; but I have had no occasion to use it. If the general sedative effect on the entire nervous system is desired, and if there are reasons why it should not be given by the mouth, or subcutaneously, it may be administered in suppositories of 0*03 to 0*05 ! [gr. -I to f] each, or O'l to 0-15 ! [gr. j|- to iji] per day. The action of opium and morphine may be assisted by hydrocyanic acid, in small doses, in the form of aqua amygdalae amarse. Hydrochlo- rate of cocaine may be unhesitatingly given internally, in doses of 0'05 to 0"1 gramme [gr. |- to jss.] ; yet one must not forget that, in some individuals, even the first dose may be followed by unpleasant symptoms of irritation — sleeplessness, restlessness, pulsation of the arteries, and oppression and pain in the head. For prolonged use and wliere the symptoms are mild, coca wine may sometimes be valuable. As an antispasmodic we may use the preparations of belladonna, either pills of extract of belladonna or atropine, or the tincture. In hysterical hypersesthesise, gastralgias, vomiting, and even in spasmodic conditions, I have been very well satisfied with the fol- lowing combination of tlie remedies mentioned above : '^ Morphinse hydrochloratis . . 0'2 [gr. iij] CocainaB hydrochloratis . . . . 0*3-0*5 [gr. ivss.-vijss.] Tincturse belladonnge 5-0-10-0 [f3j|-ijss.] AquEe amygdalae amar^e. .. . 25*0 [-fS^ji] M. Sig. : Ten to fifteen drops every hour. However indispensable morphine may be, the fact of its subcu- taneous use being a two-edged sword in all chronic forms of disease is well known ; and it is just in neuroses now under discussion that 29 452 DISEASES OP THE STOMACH. both physician and patient should always keep before their eyes the terrible dangers of the morphine habit. This need not be feared with chloral in 3 to 5 per cent solution, sometimes in combination with cocaine, to be taken at one and one half to two hours' intervals ; it has a good sedative action. Sulphonal is an excellent hypnotic, but unfortunately it has absolutely no effect on the dyspeptic disturbances. Furthermore, it must not be for- gotten that, although it is usually well borne, yet in some persons even small doses of two to three grammes [gr. xxx-xlv] may be fol- lowed by severe toxic symptoms. The feeblest and not always re- liable analgesics are the preparations of bismuth, either alone or in combination with morphine or extract of hyoscyamus or — in mild cases, and especially in children — rhubarb. Swallowing small pieces of cracked ice with three to five drops of chloroform, may be recom- mended for rapidly allaying pain ; the same is true of chloroform- water, which may be prepared by shaking water with an excess of chloroform, decanting and diluting with half the quantity of an aromatic water ; the dose is a teaspoonful at intervals during the day. Rosenthal, Leube, Yizioli, and Rosenbach have repeatedly ob- served the lessening and even disappearance of gastralgias by the anodal action of the constant current. A sedative effect is also claimed for the continuous use of the " galvanic chain " (zinc [neg- ative] pole on the lumbar portion of the spinal column, the silver [positive] pole upon the stomach).* Surprising results may sometimes be obtained by local treatment with the internal stomach-douche, which was first recommended by Malbranc f (Prof. Kussmaul's clinic) (see p. 63). This massage of the stomach seems to exert a quieting influence on the hypersensi- tive gastric nerves, just as ordinary massage often unexpectedly re- lieves painful neuroses. Malbranc has formulated Kussmaul's ex- perience and opinion in explanation of the beneficial effects of the * [Good results have also been claimed after intraventricular galvanization, the negative pole being in the stomach and the positive over the epigastrium. — Tr.] f M. Malbranc. Ueber Behandlung von Gastralgien mit tier inneren Magen- douche nebst Bemerkungen iiber die Technik der Sondirung des Magens. Berl. klin. Wochenschr., 1876, S. 41. TREATMENT OP THE GASTRIC NEUROSES. 453 stomach-douche in the following conclusions, although in the case quoted below only the last mentioned are concerned : (1) Removal of stagnant remnants of food from the stomach ; (2) relief from acid, acrid masses (products of decomposition) and mucus ; (3) the quieting effect of the warm water bath ; (4) stimulation of the peri- stalsis by the impact of the stream of water ; (5) the mildly anaes- thetic as well as the stimulating effects on the muscular fibers of the stomach from the carbonic-acid gas ; (6) the increase in the peri- stalsis of the intestines by the last two factors. As an example of the beneficial effects of the douche I wish to describe the following case which I presented at my lecture on Oc- tober Y, 188 7 : A married woman, thirty-six years old, the mother of one child, came ten days before, complaining- of intense gastralgia, complete loss of appe- tite, and great lassitude. She was of a slight build and her appearance was bad ; her eyes especially were dull and languid, as they are after sleepless nights. Her illness began five months previously with cramps in the stomach. For the preceding eight weeks the attacks had occurred several times a day ; sometimes they were almost uninterrupted and were present at night quite independently of eating. Nothing' abnormal was found in the stomach and abdomen ; heart and lungs were normal. While fasting, about 30 c. c. [ | j] of a neutral turbid yellow liquid, which was not slimy, were exj)ressed from the stomach. This was undoubtedly regurgitated fluid from the duodenum. After the test-breakfast the acid- ity was very feeble, with only a trace of hydrochloric acid. She had a large batch of prescriptions of various narcotics and sedatives which she had taken without any benefit. The result of four douches was that only traces of the attacks occurred during the daytime ; the appetite returned, and greater quantities of food were consumed. A similar change of tone in the nervous apparatus may explain the effect of the introduction of the stomach-tube and feeding through it in severe reflex vomiting, especially in the vomiting of pregnancy ; many successful examples may be found in English literature. On the other hand, I must agree with Oser,* that wash- ing or douching the stomach has no permanent effect in hypochon- driacs. They feel well as long as the treatment is kept np, but as soon as the physician or the patient stops it, the old condition again returns. Among the remedies with a local action are also included moist * Oser. Wiener Klinik, 1875, S. 257. 454 DISEASES OP THE STOMACH. compresses upon the epigastrium, either in the form of the simple Neptune's girdle or sedative cataplasms of chamomile, valerian, etc. Mustard papers or poultices, applications of tincture of iodine, and the faradic brush may also be used as derivatives. The bromides are the most important of the agents which act centrally ; we may use either the salts of potassium, sodium, or am- monium, but the dose must be large to obtain a good effect. The limit is about two to three grammes [gr. xxx-xlv] two or three times a day ; these doses are usually well borne, although some pa- tients bear even small doses badly ; the head is confused, limbs feel heavy ; the characteristic smell may be detected iu the breath, and sometimes there is even incontinence of urine. It is therefore advis- able to begin with small doses ; and in every case where the drug has been used for long periods it is wise to make small intermis- sions in its administration for three to eight days. Erlmeyer's bro- mide water is also useful here. Antipyrin, phenacetin, salicylic acid, and salol, iu doses of 0*5 to 1*0 gramme [gr. vijss.-xv] are beneficial only for the hemicrania occurring among the other gas- tric symptoms ; but otherwise they have no direct effect on the nervous apparatus of the stomach. Rosenthal employed pilocarpine subcutaneously in the spastic forms of vomiting, inferring this use from the antispasmodic action of -this drug in obstinate singultus. From a similar theoretical standpoint we may recommend physostigma, the central paralyzing power of which is well known, and which was recently tried by Riess and G. Meyer. I have seen very favorable results from in- jections of physostigma in the spastic incoordinated gait of patients with tabes ; possibly an analogous good result may be obtained in gastric crises and nervous vomiting. I may also speak here of the valerianate and the natrio-sali- cylate of caffeine — in doses of 0"1 [gr. jss.] two to three times daily and of nitroglycerin, which Talma valued so highly. I have no personal experience with the former except in the conditions of migraine, in which it is well known that all remedies thus far rec- ommended have a prompt action at first, but are absolutely use- less sooner or later. I have used nitroglycerin only twice, and in both cases the pains in the head and the vascular excitation TREATMENT OF THE GASTRIC NEUROSES. 455 were so marked that I have been afraid to try it since. It may be used in doses of 0'5 milligramme [gr. j^^ in oil or in tablets. In nearly all of the conditions under discussion, a general toning of the constitution by improving the metabolism and the composi- tion of the blood is indicated, as well as an excitation or quieting of the nervous system. The preparations of arsenic and iron are the best for this purpose. Although I formerly used Fowler's solution (i. e., the arsenite of potassium) most frequently, yet now, in accordance with Liebreich's recommendation, I employ arsenious acid almost exclusively, either in solution : ^r Acidi arseniosi 0*02 [gr. ^] Aquae menthse piperitse 20*0 [f 3 v] M. Sig. : Ten drops t. i. d., and increase. It may also be administered in granules of one milligramme [gr. •^], or in the form of Asiatic pills : [^ Acidi arseniosi 0*75 [gr. xj] Pulveris piperis nigri 6*0 [ 3 jss.] Gummi arabici 1*5 [gr. xxiij] Pulveris radicis altheas 2'0 [gr. xxx] Aquae q. s. ut fiat pil. no. c. M. Sig. : One to three pills t. i. d.] If the precaution be taken of avoiding any irritation of arsenic upon the mucous membrane by giving it only when the stomach is full, and if the above preparations be employed, then the drug can be used for a long time and in larger doses than is usually possible — i. e., up to 10 to 15 milligrammes [gr. -i— |-] per day — without any bad ejffects. The mineral waters of Roncegno and Levico in South Tyrol ai*e excellent means of giving iron and arsenic. Even very weak and delicate persons may continue their use for a long time, provided they begin with small doses — a tablespoonful once daily, half an hour after the midday meal, and gradually increase up to two to three tablespoonfuls. Iron is also usually well borne when combined with a purgative. I frequently use Dr. Saundby's formula : , 456 DISEASES OF THE STOMACH. 5^ Ferri sulpliatis gi*- i] [0'12] Acidi sulphuric! diluti rrixv [0*'75] Magnesii sulpliatis g^'- xj [0*75] Aquse menthse piperitse § j [30'0] M. Sig. : Tal. dos. thrice daily. If we disregard the iron waters, the best way of administering this metal is in combination with albuminates, as albuminate of iron. Ferruginous preparations are as abundant as the sand on the shore, and every form has found its panegyrist ; but the preference of one above the other depends mostly upon individual experience and coincidences. I use almost exclusively the chlorine compounds of iron, to the ease of the absorption of which I have repeatedly called attention — i. e., the tincture of the chloride of iron ; the sesqui- chloride of iron in substance (combined with arsenic or quinine or chinoidin in pills) ; or liquor ferri sesquichlorati (Ph. G.) [liquor ferri chloridi, U. S. P.] mixed together in 2 to 5 per cent solution, and given in teaspoonful doses with white-of-egg water (1 part of white of egg, 5 parts water). This makes an albuminate of iron which is very well borne, almost without excejition, even by very sensitive stomachs, and may replace the expensive liq. ferri album. Drees (Ph. Germ.).* The hsematogenous remedies may be com- bined with the so-called tonics, cinchona bark, and the other bitters. The various hydriatic procedures must be considered among those methods which have a strengthening as well as a soothing influence. These include the methodical use of lukewarm half- baths, washing the whole body Math lukewarm sprinkling douches — the so-called Scotch douches f — packing with tepid water, and * [Dietterich's liquor ferri peptonati is also a useful preparation ; it may be given alone or in combination with Fowler's solution, tinet. nue. vomicse, etc. See also Goodhart, Rest and Food in the Treatment of Anaemia and Anorexia Nervosa. Amer. Jour. Med. Sciences, September, 1891, p. 238. — Tr.] f [The Scotch douche consists of a stream of water, about the size of a finger, which is directed against the epigastrium. The temperature of the water is rapidly alternated, 30° C. (86° F.) and 12° C. (54° F.), every ten to twelve seconds. It lasts two to three minutes, and may or may not be followed by a warm pack. The alter- nation of heat and cold is very stimulating to the entire neuro-museular apparatus of the digestive tract. At the same time it causes hypersemia of the abdominal parietes and viscera. Both of these actions, the stimulating and the vascular, are increased by the mechanical effects of the impact of the stream of water against TREATMENT OP THE GASTRIC NEUROSES. 457 cool sitz-batlis. I would warn against the nse of too cold water, which frequently has an exciting and irritating effect ; for this reason cold river and sea baths may sometimes be badly borne. To make an error of this kind in a feeble and anaemic person is of less importance than it would be in the by no means insignificant number of neurasthenics who apparently have, or imagine that they have, a strong constitution, and hence believe that the more the cold water causes them to shiver the greater will be its healing in- fluence. In a certain group of patients with nervous stomach-troubles, in whom persistent anorexia has led to very profound disturbances of nutrition, marked emaciation, and enfeeblement of the body, the use of the rest-cure {Mast-hur) is to be recommended. This method, as is well known, was first introduced by Weir Mitchell, and modi- fied by Playfair, of London, and Burkart, Leyden, and Binswanger, in Germany ; its object is to introduce and cause the absorption of a quantity of food which the patient under ordinary circumstances is able neither to take nor to assimilate. With this purpose, the treatment consists of two parts — a psychical and a vegetative or dietetic. The object of the former is to remove the patient from the injurious influences which his surroundings and his usual habits of daily life exert upon him, these being adapted to his complaint; therefore, he is kept isolated from these deleterious factors, so that he is completely under the control of his physician, whose orders he must obey even to the smallest, apparently trivial, details. For this, it is absolutely essential to separate the patient from his family and keep him at a sanitarium. The dietetic measures aim to overfeed him — i, e., at least during the early part of the treatment, to give more nourishment than is required to satisfy his subjective wants Rest in bed is essential to prevent, as far as possible, the conversion of the food for heat pro- duction and muscular work ; but at the same time the circulation is improved by passive muscular exercise through massage and elec- tricity. the skin. Thus, it is a powerful adjuvant to electricity and massage of the abdo- men. Ziemssen, Klinische Vortrage, No. xii, 1888. Also, see foot-note, p. 157. — Tr.] 4:68 DISEASES OF THE STOMACH. The treatment is carried out as follows : The first step is to iso- late the patient and place him in charge of a male or female nurse, whose duty it shall be to manage the feeding and the above-men- tioned mechanical procedures ; the nurse ought also to have the pleasant quality of not being personally unsym23athetic to the pa- tient. For the first few days the cure consists in giving milk in small quantities at two or three hours' intervals, so that one or two litres [quarts] are taken daily ; the milk may be raw or cooked, skimmed or fresh from the cow, warm or cold, and may have vari- ous additions according to the caprice and taste of the patient. After three or four days the food is made more substantial and is given in small amounts every two hours. This consists of milk, meat, farinaceous food, butter, and cofiee or tea ; the daily quantity should be about 2f litres [six pints] of milk, 420 grammes [ ^ xiv] of meat, about 150 grammes [ 3 v] of vegetables or stewed fruit, and the equivalent amount of wheat bread, toast, and butter. If the stomach rebels against this rigorous diet and reacts with an acute gastric catarrh — i. e., dry, coated tongue, belching, heart-burn, pains in the stomach and head — then it must be suspended for a few days. Great attention must also be paid to the regulation of the stools. In favorable cases improvement is shown as early as the second or third week. After the third or fourth week the patients may leave the bed, and may attempt to walk. Corresponding to the progressive improvement the massage and faradization are gradually lessened till they may be stopped entirely. If no improvement has been manifested by this time, it is advisable to refrain from carrying this treatment on any further. Burkart has suggested that the cure should not be tried, or, at all events, should be carried out with very great care in those patients in whom there are conditions of cerebral excitement, and especially where the disturbances of the psychical functions are very pro- nounced. The best results are obtained in severe cases of hysteria and neurasthenia, in which the activity of the digestive organs is es- pecially involved, and associated wath this a marked change in the consumption of food. It is just these extremely emaciated, feeble patients who are pining away so wretchedly, who have the very best chances from this method of treatment. TREATMENT OP THE GASTRIC NEUROSES. 459 " I never saw a more rapid restoration of the normal functions of digestion," says Burkart, " than in those digestive disturbances occasionally found in extremely emaciated hysterical subjects, and vi^hich stand in some close relation to the abnormal psychical con- dition." It makes a wonderful impression if one has the oppor- tunity of seeing such cases in which the digestive organs had pre- viously reacted very unsatisfactorily to nourishment, and apparently could only take and digest very small quantities, when, suddenly, after a few days of the Weir Mitchell regimen, immense amounts of food can be consumed without any great difficulty, and sometimes just those articles whicli have caused the most trouble can be taken without the slightest complaint. This gives a most striking demon- stration of the real nature of the functional disturbances in which, unlike organic diseases due to demonstrable pathological tissue- changes, the return to the normal functional activity may be accom- plished in a very brief time. Where patients with neurasthenia gastrica have been successfully treated with the Weir Mitchell cure, the normal conditions are restored much more slowly than in hys- terical digestive disorders. During the past few years I have had quite a large experience in this method, at least not strictly carried out as proposed by Weir Mitchell, but in a milder and somewhat modified form. The former I have used very seldom, because I have rarely found myself in such a position that I considered it absolutely necessary, on account of the great expense to the patient, and also, as stated by Burkart and Leyden, because patients are sometimes unwilling to be taken from their homes. However, in one case I not alone carried out the treat- ment to the smallest details, but also made exact investigations of the metabolism. The result was brilliant. The case was one of hysterical anorexia in a girl, sixteen years old, which had developed after an at- tack of scarlet fever eight years previously. The patient was ema- ciated to a skeleton, and suffered from headaches, tinnitus aurium, color-blindness, and photophobia, which was so intense that she had to sit in the dark, and was unable to read a line ; great lassitude and trembling after every exertion ; incontinence of feeces. At the be- ginning of the treatment she weighed 25*6 kilogrammes [56'3 pounds] ; the conversion of nitrogen as calculated for albumen was 460 DISEASES OF THE STOMACH. 37'19 grammes [5Y3'84 grains]. At first she received as food 114:'4:2 grammes [1765'50 grains] of albmnen, which was gradually in- creased in four weeks to 195*7Y grammes [3020'72 grains]. She was kept isolated from December 5th to January 26th ; on that day the conversion of albumen was 121*06 grammes [1914-24 grains] — i. e., a gain of 71'7l grammes [1106"48 grains], and her weight was 33*05 kilogrammes [72*T pounds] — i. e., an increase of Y'45 kilo- grammes [16'4 pounds]. I have had the opportunity of watching the patient three months longer ; she is with her nurse at the house of her parents, gains steadily in weight, eats well, goes out walking, and is free from her old symptoms ! This splendid result was ob- tained only because during the entire course of treatment she was free from all kinds of gastric and intestinal disturbances, except those of a very slight and transient nature. However, it seems to me as if we could derive as much benefit from a modified course of treatment in which the patient is not iso- lated, provided he has a good nurse, as we could expect from a strict observance of the Weir Mitchell cure. The important factors which have already been mentioned above, and which have also been empha- sized in the various publications of Burkart (who has undoubtedly had the largest experience in this field of any one in Germany), are the psychical efi^ect on the patient and the latter's firm determina- tion, or at least his consent, in favor of the proposed treatment. If both of these are present, we may dispense with isolation in a hos- pital, which above all has a psychical effect, provided the patient's family judiciously co-operate with the method. I have frequently and successfully carried out such cures at the patients' homes, and know that others have also done so. In connection with this therapeutic measure I wish to call atten- tion once more to the importance of systematic weighing in the nervous affections as well as in all lesions of the organs of absorp- tion. Important criteria for judging the course of a disease and the success of our treatment may be obtained by the increase or loss shown by the scales ; the latter (loss) must also frequently include a stationary condition of the weight according to the axiom, " Stand- still is retrogression." The only precaution necessary is not to be de- ceived nor influenced by small and inconstant variations in the bodily TEEATMENT OP THE GASTRIC NEUROSES. 461 weight. After systematic weighing for months of naked persons who have been kept on a uniform diet and surroundings, I am con- vinced that differences of 1 to 1^ kilogramme [2-|- to 3^ pounds], from one day to another, or in the course of a few days, may be considered normal occurrences. Even continuous considerable losses do not necessarily indicate a bad prognosis, at least as long as the cor- rect treatment has not yet been discovered. At all events, it is true that all malignant organic structural changes are also accompanied by constant loss of weight, with possibly small transient fluctuations, and accordingly always have an unfavorable significance ; but nerv- ous dyspeptics, neurasthenics, patients with hsemorrhoids, and the like, may lose 15 to 20 kilogrammes [33 to 44 pounds] within a few months. The test of a proper and successful treatment consists in the gradual increase of the bodily weight which is sometimes mani- fested within a short time after the beginning of the new regimen, but at other times may not begin till after a period of continual loss which may even last three or four weeks. Therefore, the scales play an important part in all kinds of stomach-diseases, but espe- cially in the neuroses, and ought always to be employed. Surely all should imitate the proposition made long ago by the late Be- necke, that every one should keep a regular record of his weight. Prof. Thomas tried it practically on himself, with excellent results for regulating his diet.* Finally, the treatment of the gastric neuroses should include the use of all those adjuvants which improve the general condition and the mind by the effect of a change of climate, the stimulating and quieting influence of the air of mountains and plains, so- journ at the sea-shore, the tonic springs like the alkaline waters of Franzensbad, Ems, and !Neuenaar ; even the salines, Wies- baden and Kissingen ; the mild chalybeate water of Elster, Fran- zensbad, Pyrmont, Rippoldsau, and the like ; and, last but not least, the mud-baths. Probably these are nowhere better nor more comfortably prepared than at Franzensbad, where, as even Frerichs said, in the last publication which came from his pen, there is an abundant supply of material for their preparation, * See Transactions of the Naturforscherversammlung zu Berlin, 1887. 4G2 DISEASES OF THE STOMACH. wliicli, naving been carried on for years, is attended to with the utmost care. Once more do I warn against the pernicious practice of ordering nervous patients to use the Glauber's salt waters, especially those of Carlsbad and Marienbad, because these waters are very slowly and imperfectly absorbed in these cases — " they lie heavily on the stom- ach," and exert a decidedly enfeebling effect ; the latter is due to the fact that they involve still more the already altered metabolism, that they saturate the blood with neutral salts, which are improperly excreted, and that not alone do they not improve the nutrition of the nervous system, but actually injure it. At the end of every summer I regularly see numbers of such patients who have returned from these springs with a decided deterioration of their condition. LECTUEE XIL THE COKRELATION OF THE DISEASES OF THE STOMACH TO THOSE OF OTHER ORGANS.— THE PRACTICAL VALUE OF THE MODERN CHEMI- CAL TESTS. Gentlemen : The relations wliich exist between the disturbances of digestion and other diseases, as I need scarcely mention, are of the greatest importance. There is hardly any internal disorder in which gastro-intestinal digestion may not also be affected to a greater or less degree ; or it may be associated with them by func- tional disturbances, the treatment of which is to be conducted upon the lines already laid down. However, our subject to-day is not the changes which accompany febrile and afebrile, localized and consti- tutional processes, but rather those cases of disease which depart from the ordinary course, in which the gastric symptoms are the earliest manifestations, or which, at least on superficial observation, seem to be the prominent features of pathological processes which are situated outside of the stomach. Here it is of the utmost im- portance to discover the real cause of the digestive disturbances, to distinguish the secondary features of the disease from the primary, and to recognize them as such. The effect of diseases of other organs upon the stomach and their reciprocal action as manifested in structural changes in this organ have been carefully studied by W. Fenwick.'* But as these investi- gations are concerned with the pathological-anatomical changes in the stomach rather than with the clinical features of these processes, I shall here simply state that Fenwick calls special attention to the relation between advanced atrophy of the gastric mucosa and perni- * W. Fenwick. Ueber den Zusammenhang einiger krankhafter Zustande des Magens mit anderen Organerkrankungen. Virchow's Archiv, 1889, Bd. cxviii, S. 187. (463J 46i DISEASES OP THE STOMACH. cioiis ansemia, and also of carcinomatous tumors of other organs, es- pecially the mammary gland and intestines ; as, for example, the occurrence of severe ansemia after the excision of relatively insig- nificant tumors of the breast.* However, as I have already shown in Lecture YIII [page 334], Henry and Osier f and other writers have already called attention to this fact. W. Fenwick also found more or less marked catarrh of the mucous membrane of the stomach in nearly all the diseases which were studied by him — i. e., diseases of the kidney, pulmonary phthi- sis, chronic bronchitis, emphysema, various valvular lesions of the heart ; it was least marked in acute pneumonia and typhoid fever ; and not at all in diseases of the brain (tumor, e23ilepsy, softening, apoplexy). He also states that Handheld Jones,:}: in a study of over 100 cases of " affections of the glands of the stomach," only once found disease of the brain. If, therefore, the gastric symptoms, and especially vomiting, which occur in diseases of the central nerv- ous system, are manifestly reflex nervous symptoms, then the dis- turbances of the digestive tract which occur in other disorders must undoubtedly depend upon anatomical and functional changes. The most important of the latter will now occupy our attention. The most prominent place in the consideration of this subject is occupied by tuberculosis, which indeed most frequently gives rise to errors. It is only too well known that the course of phthisis may be marked by dyspeptic symptoms which may vary from a simple loss of appetite to severe anorexia and vomiting, and may go hand in hand with the febrile movement. But, as Louis, Andral, and Bourdon pointed out long ago, there are many cases of tuberculosis in which the first symptom to attract attention is dyspepsia. Hutchinson * has analyzed a large number of cases and calcu- lated that in 33 per cent dyspeptic symptoms precede the onset of the tubercular manifestations. W. Fenwick found well-marked evi- dences of gastric catarrh in eleven out of fifteen cases of phthisis — * Samuel Fenwick. Atrophy of the Stomach. London, 1880, p. 49. f Henry and Osier. Atrophy of the Stomach with the Clinical Features of Pro- gressive Pernicious Anaemia. American Journ. of Med. Sciences, April, 1886. :j: Handfield Jones. Diseases of the Stomach. * Hutchinson. The Morbid States of the Stomach and Duodenum. London, 1878. TUBERCULOSIS. 465 i. e., T3 per cent. Marfan* considers this figure too high, and quotes the well-known and universally accepted observation of Quenu that many patients disregard the period of short, dry cough which precedes the onset of expectoration, so that the beginning of the disease mnst be placed at an earlier period than is given by them. In 61 cases he claims to have found only five in which the gastric preceded the pulmonary symptoms. Yet the point at issue is not so much these objections to the patient's previous history as the fact that persons frequently consult us complaining only about their digestion, which they consider the cause of all their troubles ; yet careful examination will either reveal the presence of a phthisi- cal process, or will cause us to entertain suspicions of such a condi- tion, the correctness of which is confirmed by the subsequent course of the malady. As a rule, these patients are delicate and anaemic ; they begin to complain of loss of appetite, oppression, and fullness after eating, and irregularity of the bowels ; they suffer from regurgitation and a foul taste in the mouth ; they feel feeble and languid. For a long time they are treated for chronic catarrhal gastritis ; but both physi- cian and patient wonder why all the apparently rational remedies are of no avail ; then a careful examination is made, and chronic pulmonary disease is either discovered or at least strongly sus- pected. A true dullness is not present, yet the apices do not ex- pand properly, or the whole of one side may expand somewhat tardily on inspiration ; the respiratory murmur has a soft, moist, interrupted character ; the movements of the entire thorax are not sufficiently deep ; the manometer shows that inspiration and expira- tion are feeble ; expiration is prolonged. Careful questioning will now reveal that the patient has " hacked " for a long time without paying any attention to it ; that he was scrofulous as a child ; that he perspired very easily, although there are no true night-sweats ; and, finally, that there is a hereditary predisposition. If we can obtain some of the sputum — which, when the expectoration is scanty, the patient frequently disregards or swallows — we may often suc- * B. Marfan. Troubles et lesions gastriques dans la phthisie poulmonaire, Paris, 1887. 466 DISEASES OF THE STOMACH. ceed in finding a few tubercle bacilli, and thus at once corroborate our diagnosis. Under these circumstances a diseased condition of the stomach is at all events present, yet it is merely the manifesta- tion of a venous hypersemia and congestion, which in its turn is due to the disturbance of the pulmonary circulation. It was, therefore, important to study the chemical processes of the stomach in pulmonary phthisis. Some incidental communica- tions were made on this subject by Edinger, and also by myself ; yet systematic examinations were first made by C. Rosenthal,* Klem- perer,f Schetty,:]: O. Brieger,* Hildebrand,|| and Immermann ; ^ their results, which agree tolerably well, are best expressed in the following propositions, formulated by Brieger : " In severe cases of phthisis a normal condition was found in only 16 per cent of the cases, in the rest more or less marked in- stifiaciency was found ; in fact, in 9"6 per cent of all the cases there was a complete absence of all the normal products of secretion. " In moderately severe cases the gastric juice was normal in only 33 per cent ; in the remainder its strength varied, the disturbance being, as a rule, well marked ; while in 6-6 per cent the normal secretory products were absolutely lacking. " In the initial stages the cases of normal and disturbed secretion were about evenly divided." Absorption and peristalsis seem to be impaired to a degree cor- responding to the disturbance of the chemical functions. It is self-evident that the above percentages give an approximate and not an absolute idea of the relative frequency of the conditions under discussion. A longer period of observation, a larger num- ber of cases, etc., may easily change them : thus, it happened that Eosenthal's observations at the Augusta Hospital (this report is * C. Rosenthal. Ueber das Labferment. Berliner klin. Wochenschr., 1888, No. 45. f Klemperer. Ueber die Dyspepsie der Phthisiker. Ibid., 1889, No. 11. 1;. Schetty, loc. cit. * 0. Brieger. Ueber die Functionen des Magens bei Phthisis pulmcnum. Deutsche med. Wochenschr., 1888, No. 14. i H. Hildebrand. Ibid., 1889, No. 15. ^ Immermann. Verhandlungen des Congresses fiir innere Mediein. Wies- baden, 1889. TUBERCULOSIS. 467 merely preliminary) included only patients without free hydrochloric acid ; Hildebrand's were those with continuous fever, which never had free hydrochloric acid ; while Klemperer and Immermann en- countered cases in which this acid was present, and in some of them it was even in excess (in the initial stages of phthisis). In testing the motor functions Immermann found no marked changes in 53 out of .5^ trials — i, e., the stomach was found empty six hours after taking Leube's test-meal ; on the other hand, Klem- perer used his oil method (page 5Y), and found a marked enfeeble- ment of the motility. Furthermore, Immermann states that lie found free hydrochloric acid in 38 out of 44 trials, even where the high fever and cachexia of the terminal stages of phthisis were pres- ent ; Brieger observed it only in 16 to 33 per cent. This discrep- ancy can be explained by the former having used Jaworski's test- breakfast (the whites of two hard-boiled eggs and 100 c. c. [f 5 iij 3 ij] of water), which is notoriously inadequate for this purpose. After careful study, with reliable methods, Grusdew * and Bern- stein f also come to the conclusion that " hydrochloric acid is either absent or reduced to very small quantities." At all events, the occurrence of gastric disturbances depends on what stage of phthisis may be present. Thus, Hutchinson states that in 9 cases dyspepsia was found after the pulmonary symptoms had begun ; in 10 it appeared at the same time, and in 33 it preceded them. Although all these investigations give us important information, yet their value would have been greatly enhanced had the observers laid more stress on the comparison between the subjective com- plaints and the results of the objective examinations. It is beyond doubt that the so-called phthisical dyspepsia is not due to a tubercu- lar affection of the gastric mucous membrane, but, as already stated, is only a complication of this disease due to disturbance of the circu- lation. But it is equally certain that a very large proportion of the successful results of the treatment in pulmonary phthisis depends on the nutrition of the patient and the possibility of maintaining it. * [Grusdew. Wratsch, 1889, Nos. 15, 16. Centralblatt fur klin. Med., 1890, S. 92.— Tr.] f Iwan Bernstein. Die Dyspepsia der Phthisiker. Inang. Dissert. Dorpat, 1889. 80 468 DISEASES OP THE STOMACH. The Frencli metliod of overfeeding {sur-alimentatioii) — the expe- riences of Dettweiler, Peiper, Kiihle, Liebermeister, Leyden, and others — are the best proofs of this. Our therapeutic efforts will have a greater effect and will be more certain if we have ascertained the functional activity of the digestive organs by means of a chemi- cal examination independently of any of the patient's subjective complaints. True, it is self-evident that the first object of treat- ment is the primary disease, with the improvement or cure of which the dyspeptic symptoms will disappear ; yet we must not lose sight of the fact that the improvement of the functions of the stomach with the resulting better state of nutrition will react favorably upon the local process in the lungs. Here it should be observed that the specific stomachics are un- successful, if not injurious, for they irritate the already congested mucous membrane, and thus increase the hypersemia. It would be much more advisable to lessen the irritating effects of thfe food, as far as possible, by ordering a simple, easily digestible diet, or by giv- ing in each individual case the drugs which may seem to be indi- cated by the results of the examination of the gastric functions, pro- vided pronounced dyspeptic disturbance should render this necessary. A general rule for these remedies can not be given, as is at once evident after a careful consideration of the changeable factors here concerned. Thus, in a large number of examinations on one patient at the Augusta Hospital, Eosenthal could never find free hydro- chloric acid during the summer, yet when he returned to the hospi- tal in the winter it was present in abundance ; Hildebrand observed the same thing during shorter periods. Only this much is certain, that the subjective complaints of the patient do not by any means always correspond to the results of the objective examination, and that therefore the former should be investigated before they are allowed to weigh against methods of treatment which (like the ali- mentation force of the French) aim to improve the general nutrition by giving larger quantities of food. Concerning the milk diet, we should remember that its power of combining with acids surely comes into play in the cases or stages of hyperacidity which have been mentioned above. But, to return to the question under discussion, these cases of ANEMIA. 4(59 pretubercular dyspepsia — if we may use tliis short but improper expression — may be readily recognized, provided sufficient care be exercised. Tlie diagnosis is not so easy if tlie dyspeptic symptoms are due to a centrally located miliary tuberculosis with slight feb- rile movement. If this is associated with a moderate enlargement of the spleen, of recent or old origin, it may readily be mistaken for typhoid fever, especially the ambulant variety. 1 recently saw an example of this in a gentleman from St. Petersburg, who thought his stomach was at fault. He presented the group of symptoms JList described : there was a moderate irregular febrile movement, with slight evening exacerbations, which was said to have existed for some time, since quinine, antipjn-ine, and hydrochloric acid had been prescribed for him. Inasmuch as he said that he had been suddenly taken ill some weeks previously after a journey in a fever district, and had nevertheless not gone to bed, but instead had attended to his business, I naturally thought of the last stage of a " walking typhoid fever " with an irregular febrile movement ; all doubt was dispelled during about the fourth week, when the symptoms of acute miliary tuberculosis became more and more prominent. He died of undoubted pulmonary tuberculosis after having been a few weeks at Gorbersdorf. The changes in the digestive tract in ansemia and chlorosis are closely allied to the above. They undoubtedly play an important part which, up to the present time, lias been very much neglected ; hence, in the treatment of ansemia, efforts should first be made to improve the condition of the digestive organs, and then the compo- sition of the blood. As has long been known, and as Hayem,* Gluczinsky,f Pick, :|: and others have shown by direct examination of the gastric juice and the functions of the stomach, a true in- sufficiency of the latter exists. But some writers, especially Hayem, go too far when they consider that the changes in the stomach and intestines are the primary cause. In my opinion, it is one-sided to * Hayem. Des alterations du ehimisme stomacal dans la chlorose. Bulletin medic, 1891, No. 87. f Buzelygan und Gluczinsky, Ueber das Verhalten des Magensaftes bei den verscbiedenen Formen der Anaemia und besonders der Chlorose. Internat. klin. Rundschau, 1891, No. 34. X Pick. Therapie der Chlorose. Wiener med. Wochensch., 1891, No. 50. 470 DISEASES OF THE STOMACH. claim that clilorosis can be cured by the relief of these disturbances ; for it is by no means certain that these changes in the digestive tract are not secondary, and can only be relieved after the compo- sition of the blood has been improved by appropriate treatment. The histories of many patients attest the truth of this. The next gi-oup of diseases includes the valvular affections of the heart. Here, also, the nature of the lesion causes a venous conges- tion and the symptoms of a chronic catarrh of the stomach. Care- ful examination is required to reveal incompetency of the valves, enlargement of the heart, latent pericarditis, pericardial adhesions, or chronic myocarditis. In such cases cures can only be effected in the early stages ; unfortunately, these therapeutic measures usually afford temporary and not permanent relief ; yet sometimes, by using digitalis and other members of this group for a short time, we may succeed in completely removing the catarrhal manifestations, and thus secure a period of relative or absolute relief. A priori, there can be scarcely any doubt, for the reasons above given, that the secretory activity of the stomach is lessened as soon as compensation is disturbed, not alone in true valvular lesions, but also in other processes which, directly or indirectly, cause func- tional disturbances of the cardiac muscle, Hlifler * thought that he had proved this, since, in ten cases of the above kinds, mostly valvu- lar lesions, total absence of hydrochloric acid and almost negative digestion of albumen were found nine times, in spite of the fact that most of tlie patients were still in the clinical stage of complete com- pensation. In the single patient (moderate mitral insufficiency) in whom hydrochloric acid was present, he is inclined to assume " hy- peracidity." But concerning this apparently exceptional case it may be stated that it is by no means certain that congestion of the gastric mucosa and its consequences always occur under these cir- cumstances, for there may also be a compensation in the stomach. Therefore, the assumption of hyperacidity seems unnecessary to me in the explanation of this exception. But it appears that insufficiency of the gastric secretion is not as * Hlifler. XJeber die Functionen des Magens bei nerzfehlern. Miinch. mcd. Wochensehr., 1889, No. 33. RENAL DISEASES. 47I constant as Hiifler supposed ; for, in twenty patients with heart dis- ease, Adler and Stern * found that free hydrochloric acid was always present in sixteen, variable in two, and always absent in two cases. Katurally these writers are inclined to believe that this discrepancy is due to the difference in the methods employed, for Hiifler gave Leube's meal in the morning — i. e., a very unfavorable time — while Adler and Stern gave the test-breakfast. However, it is also prob- able that the degree of compensation is also of importance in this question, for the clinical picture alone. does not enable us to judge it properly. The diseases of the kidney also involve the stomach if the excre- tory products of the metabolism are retained in the organism early in the course of the affection ; if excreted in the stomach and intes- tines, they will irritate these viscera. Such cases are by no means common ; the vomiting and other symptoms of disturbances of gas- tric digestion occur long before the distinct signs of dropsy or other manifestations which would lead to the correct diagnosis ; hence, these cases are thought to be independent lesions, whereas they are really only due to chronic uraemia. They may also occur without any disease of the renal parenchyma where there has been a long- standing retention of urine from obstruction of the urinary passages. Fenwick f assumes that the mucous membrane of the stomach can excrete certain poisons, including also urea ; the result of this irri- tation is an acute catarrh of the gastric glands. Degenerative pro- cesses, for example, fatty degeneration of the glandular epithelium and amyloid of the mucosa, may also occur, as well as gastritis in the true sense of this term. Biernacki :{: lays stress upon the retention of metabolic products which lessen the secretion of the gastric jnice by means of nervous influences. He has actually demonstrated this in a number of cases of nephritis which were investigated for this purpose. Therefore, he agrees with Ewald * in recommending pep- tonized milk in these cases. Renal tumors, especially carcinoma of * Adler and Stern. Ueber die Magenverdauung bei Herzfehlern. Berl. Idin. Woehenschr., 1889, No. 49. f Fenwick, loc. cit. X Biernacki. Ueber das Verhalten des Magens bei Nierenentziindung. Berl. klin. Woehenschr., 1891, Nos. 25,26. * Ewald. IX. Congress f lir innere Medicin zu Wien, 1890. 472 DISEASES OP THE STOMACH. the kidney, may for a long time cause only disturbances of diges- tion, anorexia, vomiting, and emaciation ; in fact, in a case reported by Colleville,* up to the patient's death these were the only symp- toms. Finally, without suffering any changes in the [renal] secre- tory cajjacity, the kidneys may cause disturbances and pain in the stomach on account of their unusual site or mobility ; these effects of floating kidneys, etc., have already been considered while discussing gastrectasis and gastralgia. The liver stands in such close relationship to the stomach that serious functional disturbances of the one are without exception re- flected on the other ; this close connection, and the fact that so many of the noxious substances introduced from without act on both vis- cera at once — I will only mention alcohol — render it very difficult to say which is affected first. For example, in the very great ma- jority of cases, cirrhosis of the liver is accompanied by chronic gas- tritis, yet, even if we observe that the symptoms of a doubtful he- patic cirrhosis have for a longer or shorter time preceded a chronic gastric catarrh, we are utterly unable to tell whether the two stand in a causal relation or are simply coincident. Nevertheless, we should never forget the fact that many cases of hepatic cirrhosis for a long time run their course as chronic gastritis, and that the same is true of cancer of the liver. Although I have frequently called attention to the relations of the diseases of the central nervous system with those of the stomach, yet I must not neglect to take this subject up once more at this place. On account of its great importance, I shall only specially discuss the relation of the gastric disturbances to sclerosis of the posterior columns of the spinal cord (tabes). This includes not only the classical attacks of gastralgia and gastric crises [see page 403] which occur in cases well advanced a^id recognizable, but also vaguer sensations — slight boring and radiating pains, a permanent feeling of gnawing and burning in the stomach, or even more marked perceptions which occur among the prodromata, or as the first symptoms of locomotor ataxia, but which at the time in ques- tion have not yet acquired any typical characteristics. It is self-evi- * Colleville. Progr. med., 1883, No. 20. DIABETES.— GOUT. 473 dent that it is impossible to make an exact diagnosis under such cir- cumstances, and that even if the gastralgia continue for years their true origin would not be recognized. Such a case has been de- scribed by Werner ; * an induration was found at the pylorus in a patient who had been for a long time considered hysterical ; gastro- enterostomy was performed for supposed stenosing cicatrix of an ulcer at the pylorus ; but it proved to be simply a muscular hyper- trophy. As the operation proved unsuccessful, the ovaries were subsequently removed (Hegar's method) ; nevertheless, the gastric symptoms, which were chiefly manifested as gastralgia, persisted ; and it was only five years later that distinct symptoms of tabes appeared, the existence of which was confirmed at the autopsy. Unfortunately, the early symptoms of tabes do not readily permit a positive diagnosis ; thus, for example, the absence of the patellar reflex occurs independently of this disease so frequently that the simple coincidence of this symptom and gastralgia in a suspicious case would not justify a diagnosis of locomotor ataxia. Among the constitutional diseases diabetes gives rise to errors most frequently. For years many diabetics are considered to be suffering from some stomach trouble until the urine is examined, either accidentally or on account of the development of the specific symptoms of emaciation, pruritus, polyuria, ravenous appetite, den- tal caries, ocular disturbances, [thirst,] etc. In well-developed cases of diabetes, as shown by Kosensteinf and Gans,:{: the gastric functions are very variable, and stand in no relation to the amount of sugar, acetone, and diacetic acid in the urine. Eosenstein concludes from his investigations that in some cases free hydrochloric acid may be absent ; where this is temporary, it is to be referred to a gastric neurosis ; but, when it is j)ermanent, the cause is atrophy of the mucosa in consequence of interstitial in- flammation. The relations of gout to disturbances of digestion have been * Gr. Werner. Gastrische Krisen als Initialsymptom einer Tabes dorsalis. Inaug. Dissert. Berlin, 1889. f Rosenstein. Ueber das Verhalten des Magensaftes und des Magens bei Dia- betes mellitus. Berlin, klin. Wochenschr., 1890, No. 13. X Edg. Gans. Ueber das Verhalten der Magenf unctionen beim Diabetes mellitus. IX. Congress fiir innere Medicin. Wien, 1890. 474 DISEASES OF THE STOMACH. especially discussed in English medical literature. According to some writers, there is a specific goutj disorder of the stomach re- sulting from the uric-acid diathesis, or from contamination with the products of incom23lete metabolism, or their insufficient excretion — i. e., disturbed retrograde metamorphosis. Thus, not long ago, Burnej Yeo "^ claimed that one of the prominent manifestations of this condition was dyspej)sia in all its forms. Other authors, like Brinton, Pavy, etc., do not recognize a specific gastric disorder, and may therefore be considered to take a view more closely allied to our own. The same is ti'ue of the rheumatic diathesis, which has plaj^ed quite a prominent part in French literature. Although I have not met a single case of true gout with coincident gastric dis- turbances, yet I have seen numerous such examples in chronic artic- ular rheumatism, in which they were so marked that the pains in the joints were comparatively insignificant. Whether there is any close connection between these conditions I shall refrain from saying, just as I shall do in the similar relations of affections of the skin and the stomach, to which Pidoux f has paid particular attention. Finally, I consider that there is a much better established as well as a more practical connection between the digest- ive disturbances and the various forms of malaria (i. e., the manifest and especially the latent forms of intermittent fever) and typhoid fever, particularly its ambulant variety. Malarial poisoning may be manifested as an intermittent car- dialgia (Leube j^) or in the form of the various neuroses of the stom- ach, which will be characterized by a certain regularity (Rosenthal, Glax *), and which, according to the latter observer, can be relieved only by quinine as long as the patient remains in the malarial dis- trict. Kisch II in Marienbad, and Glax in Eohitsch [an alkaline saline spring in Steiermark, Austria], both observed that it was most striking that, after the use of the waters of these places, the * Blimey Yeo. On the Treatment of the Gouty Constitution. British Med. Journal, January 7 and 14, 1888. f Pidoux. Rapport de I'herpetisme et des dyspepsies. Union med., 1886, No. 1. X Leube. Beitrage zur Diagnostik der Magenkrankheiten. Deutsch. Archiv fur klin. Med., Bd. 33. * Glax. Ueber die Xeurosen des Magens. Vienna, 1887, S. 206. 11 Loc. cit. THE PRACTICAL VALUE OP CHEMICAL TESTS. 475 neuroses first occurred in true intermitting attacks and then finally disappeared altogether. Formerly I not infrequently had the oppor- tunity of treating such cases of marked intermittent dysj^epsia. [These various manifestations are quite common in New York, and should always be borne in mind in obstinate cases. In the treat- ment, "Warburg's tincture will be found to be especially useful. — Tr.] Conclusion. — The Practical Value of the Modern Chemical Tests. — In the course of these lectures I have always brought forward the experiences which have been gained by the new methods of investi- gation, especially of the chemical functions of the diseased stomach, and I have thus been enabled to combine the old well-known noso- logical facts viath the diagnostic and therapeutic results recently gained. The task still remains to mention what place is occupied by the chemical methods of investigation in the individual affections of the stomach, and how far they warrant drawing sound conclusions upon the nature of the disease under consideration. Do the stom- ach- and the test-tubes enable us to discover specific, characteristic functional disturbances which belong invariably and exclusively to an individual case, and thus establish the diagnosis like the presence of tubercle bacilli in the sputum and hyaline casts in the urine ? Or, are they simply the signs of a more general significance which have nothing to do with a specific morbid process ? You know that some recent authors have gone so far as to classify the diseases of the stomach into those with an increase, diminution, and absence of hydrochloric acid, and possibly some of you may have regretted that I "have not followed the fashion " and arranged the subject-matter from this standpoint. I have as remote an idea of doing this as I would have of writing a text-book on special pathology in which the diseases are classified according to the presence or absence of dropsy, jaundice, albuminuria, etc. On the contrary, if we wash to adhere to facts and avoid exaggerations, our present knowledge may be summed up in the following propo- sitions : There are two great groups of results in the chemical examina- tions of the gastric juice which differ from the normal : 1. The untimely occurrence of organic acids. 2. The changes in the gas- 476 DISEASES OP THE STOMACH. trie juice itself (i. e., the secretion of hjdrocliloric acid, pepsin, and rennet), and tlie absorption and motility of the organ. 1. The occurrence of organic acids, especially lactic acid, during a stage of digestion in which they can not be demonstrated normally by the tests already known to you. This is always characteristic of definite pathological conditions, the manifestations of which are also perceived subjectively by the patient. These acids are due to ab- normal processes of decomposition or fermentation, whose causes may be manifold but which are always combined with a morbid state, provided the latter expression be made to include not only an abnormal chemical result, but also more or less well-marked disturb- ances in the afi^ected individual. This explains the significance of the demonstration of lactic and the fatty acids. The value of these tests is by no means diminished by the fact that lactic acid can be shown to persist throughout the entire course of normal digestion ; for the methods employed are complicated and not adapted for gen- eral practice. Exactly the same relation exists in diabetes, since the diagnosis of this condition by the detection of sugar in the urine is by no means affected because traces of sugar may also be found in nor- mal urine. ]^ow, since these products of fermentation are always associated with a prolonged stay of the ingesta in the stomach, and usually with an absolute or relative lessening of the secretion of hy- drochloric acid, a diagnosis may be ventured in this direction from a knowledge of these facts. 2. Much more complicated are the conditions concerning the significance of changes in the gastric juice. Since the secretion of pepsin and rennet goes hand in hand with that of hydrochloric acid — excepting trifling variations which have no practical meaning — what is said of the latter may serve as a statement for all. In my opinion, increase or diminution in the amount of the hy- drochloric-acid secretion is a sign which is related to the various types of disease only in so far that some tend to cause its increase, while others its diminution or even absence ; but this depends en- tirely upon the anatomical or functional disturbances which accom- pany these morbid types. Katurally, these cause the changes in the production of hydrochloric acid ; hence it is their extent in the course of the disease -which will determine how much the secretion THE PRACTICAL VALUE OP CHEMICAL TESTS. 477 of acid will be affected. At all events, we may say that one group will never canse an increased secretion of acid — i. e., all those forms in which an extensive organic destruction or change in the secreting parenchyma has taken place. So far as we know, there is no vica- rious increase in the activity of the remaining glandular cells. This group, therefore, includes carcinoma, chronic gastritis and its se- queliB, atrophy of the mucous membrane, mucous degeneration of the gastric glands ; possibly, also, certain chronic vascular lesions — as, e. g., amyloid degeneration of the blood-vessels [of the stomach]. It is possible, as some of ray experiences seem to indicate, that further extensive examination will reveal that profound anaemia, tuberculosis, cardiac diseases, diabetes, and similar morbid |)rocesses may cause the disappearance of free hydrochloric acid. But, if we reverse this statement, and say that certain kinds of disease cause an increased secretion, we would be going too far. An increased secretion is always functional, a sign of irritation. But, as is well known, every such overproduction may cause exactly the opposite condition ; I refer not only to the result of exhaustion following overexcitation, but also to the condition of depression from the very beginning. Thus it may hapjDcn that we sometimes encounter an absence of hypersecretion in a condition which is usually accompanied by a strong stimulation of the secreting ele- ments, as gastric ulcer. A neurosis may manifest itself at one time by an overproduction of acid during the period of digestion (hy- peracidity) ; at another time by a continuous secretion (hypersecre- tion). Other cases also exist in which there is such a diminution in the secretion of hydrochloric acid that the amount is permanently reduced to a minimum. As I know of no such case having yet been published, the details of the following example of this condi- tion may be interesting : Mr. K., an actor, twenty-eight years old; slender figure. Previous history good ; no organic diseases can be discovered. He was always in good health and lived quietly and regularly. In the winter of 1884-'85 he had to play a very exciting part several hundred times in succession at one of the local [Berlin] theatres. He felt exhausted and languid till in the following summer his condition became as follows, to use his own words : '' It seemed to me as if my entire abdomen was constricted with a coi'd, 478 DISEASES OP THE STOMACH. so that suddenly I was attacked with a feeling of anxiety ; there was also oppression which extended high up into the chest and caused a torment- ing dyspnoea. I could not take a long, deep breath, on account of the feeling of undue fullness in the abdomen. This condition persisted even when I had eaten nothing — e. g., on awakening ea,r\j in the morning. I can not complain of any real pains, yet I have never felt i*eally well ever since. The pressure in the abdomen and the oppression following it con- tinually remiiided me that my health was shattered. Although I fre- quently had a good appetite and relished food, yet not alone after eating, but even during the meal, severe disturbances set in, combined with end- less belching and eructation, and great fatigue ; in the beginning there was also vomiting, but after a few times this did not return. At times I was suddenly seized with a ravenous appetite, after the satiation of which the above attacks did not fail to appear. " The family physician's remedies wei'e all of no avail, and this condi- tion persisted till the winter of 1886. Then the discovery that I had a tape-worm gave me hope that with its removal I would be cured. But, alas! even after that, the old state persisted, and, if anything, became worse. My arduous duties in the winter of 1886-'87 did not cause the trouble to be less marked. Since then every part of my body feels very tired and languid, and in spite of careful rest and forbearance this has persisted up to the present time. The pressure from the distended abdo- men, oppression (frequently also stitches in the side), and dyspnoea still persist. In spite of this I still have an appetite, sometimes a very large one ; I usually relish food, but after meals, as a rule, though not always, the unpleasant symptoms make their appearance, and are more marked at some times than at others." I have now [1889J treated this gentleman about three months, and dur- ing this time I have tested his gastric juice for hydrochloric acid nineteen times, at the most varied intervals after the test-breakfast, and also after a moi'e abundant dinner. A small amount of free acid could be detected only three times. Propeptone was always present in relatively large quantities, but the peptone reaction was only faint, and the digestive power of the filtered gastric contents was negative, except in two tests, unless hydrochloric acid and pepsin were added. The rennet-action could be demonstrated in half of the tests, and that, too, in the absence of free hydrochloric acid, but at the same time lactic acid was present ; at other times the tests for lactic acid and peptone were positive, although free muriatic acid, pepsin, and rennet were all absent. Lai'ge quantities of mucus were never present in the wash-water except the first time, when the patient had evidently swallowed large quantities, which were due to the irritation of the tube. On the other hand, on two occasions I found small shreds which differed from those usually present in the wash-water, by sinking rapidly in the funnel. They consisted of the adherent epi- thelial cells of the gastric mucous membrane already described (see Fig. 26, p. 317). Although I consider this pathological, yet such abrasions continually occur in the mucosa of the stomach as well as in other mu- cous membranes, though they are usually not found, since the acid gas- tric juice digests them. Strychnine was fii-st given in small doses ; then THE PRACTICAL VALUE OF CHEMICAL TESTS. 479 later on his stomach was washed out and douched every second day with good results. In this case there was sui^ely no mucous catarrh ; an atro- phy of the mucosa was also absent, since this occurs only as the conse- quence ot a long'-standing catarrh, or at a much more advanced age. None of the symptoms indicate cancer ; what is, therefore, left but to assume that we are dealing with a neurosis ? Addendum. — The subsequent course of the case proved the correctness of my diagnosis. The patient went to a well-known establishment for nervous diseases, and then spent a long time in Switzerland. On his re- turn the gastric symptoms had completely disappeared, and in his own eccentric way he could not say too much in favor of his cure. But he now frequently had attacks of melancholia. The following summer he went to the country near a large lake. One evening he left the house and never returned. His body was found in the rushes at the border of the lake ; he had evidently committed suicide by drowning. The case was thus a neurosis which had at first attacked the vegeta- tive functions, and finally had involved the mind. A number of cases which were examined in 188Y by Dr. "Wolff, of Gothenburg, and myself, at the Franensieclianstalt of Berlin, to determine the condition of the gastric juice, may also be grouped in this category. To our great astonishment we found a permanent absence of free hydrochloric acid in a numljer of persons without the slightest stomach complaints. At my request, Dr. Sandberg, of Marstrand, examined these same cases again one year later, but in the majority of them he found no change ; in a few of them, how- ever, hydrochloric acid was detected. A neurosis is out of the ques- tion, since there are no indications of such a condition ; but what remarkable and latent disorders can so profoundly affect the func- tions of the stomach ? We can not assume the existence of severe degenerative processes in the mucous membrane, since free hydro- chloric acid could be occasionally detected in some of them ; fur- thermore, although I have been watching these cases for a number of years, I have seen no gastric symptoms which would necessarily be present in such a serious condition. After making similar ob- servations Dr. Grundzach * has also come to the conclusion that " the mechanism of the stomach performs its functions properly, or is very slightly disturbed, in spite of the complete cessation of this secretion." Moreover, in the course of the experiments on the * J. Grundzach. Ueber nicht carcinomatose Ftllle von ganzlich aufgehobener Absonderung der Magensaure resp. des Magensaftes. Berl. klin. Wochenschr., 1887, S. 543. 480 DISEASES OF THE STOMACH. effects of Carlsbad water mentioned on page 358, I liad the oppor- tunity of examining for two months a young, robust female nurse, twenty-eight years old, with good digestion ; I always obtained an unusually low degi-ee of acidity, so that I should surely have re- ferred to an anomaly of secretion any complaints which she might have made regarding her stomach.* Finally, one should bear in mind the great differences observed in these investigations in the daily values of the acidity of one and the same person ; these can vary as much as 27 c, c. of a deci-normal solution of caustic soda for 100 c. c. of gastric juice. This is due to the incompleteness and coarseness of our present methods, which surely give no information of a number of delicate changes in the chemistry of digestion. Undoubtedly, the normal process of digestion is accompanied by so copious a secretion of hydrochloric acid that not alone are various combinations formed with the different foods present, but there is also a certain excess of free acid which seems to be indispensable for the completion of normal gastric digestion. But we must not forget, as I showed some time ago in the digestion of albumen,f that peptonization, even though it is slight, may take place without any free acid ; that normally, as in menstruation, no free acid, or only a very small quantity, is secreted ; and that the human organ- ism manifestly possesses in no insignificant degree the capacity of compensating for an absence of hydrochloric acid, pepsin, and ren- net by driving the chyme out of the stomach much sooner, and rele- gating it for digestion to the intestine. After all this I think you will agree with me if, in general, I attribute no 230sitive diagnostic value to the simple fact that the acidity is increased or diminished or apparently normal, provided this is referred to no other acids than free hydrochloric acid ; and if I consider such results only as a supplementary, although very * [It would be well if these important facts were carefully weighed before mak- ing the diagnosis of atrophy of the stomach from the simple absence of hydro- chloric acid, pepsin, and I'ennet. That they are disregarded is shown by the sur- prising number of such cases recently reported in the various medical journals without corresponding constitutional symptoms. — Tr.] f C. A. Ewald. Ueber den " Coefficient de partage " und liber das Yorkommen von Milchsiiure und Leucin im Magen. Virchow's Archiv, Bd. 90, S. 349. THE PRACTICAL VALUE OF CHEMICAL TESTS. 481 important, feature in com^Dleting and establishing the entire clinical picture. On the other hand, I do not wish to be misunderstood, and I therefore say emphaticallv that this statement is in no way intended to detract from the value of our examinations ; on the contrary, they are indispensable to us, and in all cases where cir- cumstances will not permit them we feel in doubt and " somewhat at sea." At every step in the preceding discussions you will have observed the proof of the extent to which our knowledge has been extended and amplified by the new methods of investigation ; but, on the other hand, in view of many recent events, I believe it is my duty to warn against a one-sided overestimation of their value. Only the most careful and thorouo;h consideration and weio-hino; of all the symptoms which can be obtained yydh all the diagnostic resources will enable us to recognize the existing disease. Xot even the most careful chemical examination of the functions of the stomach will put within our grasp the divining-rod which will magically call forth the fountain of knowledge from the adamantine rocks of obscure symptoms ! Even to-day the old saying is true that — " Ubi ratio sine experimentis mendax, Ita experientia sine ratione fallax." INDEX. Abercrombie, 84, 242. Abscess of stomach, 303. Absorption in stomach, 52, 370 ; test of, 53. Acid, acetic, tests for,. 35. butyric, tests for, 35. hydrochloric. See Hydrochloric Acid. lactic, in stomach-contents, 33 ; fer- mentation-, 33 ; meat-, 33 ; tests for, 33. salicyluric, test of, in urine, 55. Acid salts, tests for, 23. Acidity of gastric juice, variations of, 480. of stomach-contents, 20 ; stages of, 20 ; testing of, 22, 37, 229. Acids, fatty, in stomach-contents, 35 ; tests for, 35. free, tests for, 23. organic, tests for, 32. See also Contents of Stomach. Acoria, 427. Adenopathies in gastric cancer, 176. Adler, 471. Agoraphobia in chronic gastritis, 331. in gastric neuroses, 389. Air, distention of stomach with, 59. Akinesis of stomach, 130. Albertoni, 216. Alberts, J. E., 163, 166. Albumen, digestion of, 41, 43. disks, 47. putrefaction of, in stomach, 141. reaction on aniline dyes, 26. reactions of, 42. Albutt, 12, 117, 145. Alcohol in contents of stomach, 35. Alderson, 5. Alimentation, rectal, 105, 268. Alt, 432, 433. 31 Anacidity of gastric juice, 187, 189, 337, 479. nervous, 427. See Hydrochloric Acid, Absence of. Anadenia of stomach, 318, 334; absence of HCl in, 337; diagnosis, 339; pathology, 318 : relation to perni- cious ana?mia, 335, 463 ; treatment, 341. Anaemia, condition of stomach in, 469. pernicious, condition of stomach in, 335, 463. Anjesthesia of skin in gastric ulcer, 245. of stomach, 427. Andral, 136, 166, 176, 253, 304, 448, 464. Aniline dyes in stomach analyses, 23. Anorexia, 397. in cancer of stomach, 185. in catarrh, 295. in dilatation, 136. in phlegmon, 305. in tumors of kidney, 472. in tuberculosis, 399, 464. in ulcer of stomach, 246. nervous, 397. Antiperistaltic unrest of stomach, 426. Appetite, 384. in gastric cancer, 206. lack of. See Anorexia. perverse, 396. ravenous, 394. Ardor ventriculi, 326. Aretaeus, 391. Arnold, 430. Arnott, 5. Asiatic pills, 455. Asp, 331. Aspirator, stomach, 12. Asthenia of stomach, 130. 484 DISEASES OF THE STOMACH, Asthma, dyspeptic, 320, 420. Atony of stomach, 144, 333, 435. in chronic gastritis, 328, 333. in dilatation, 130. Atrophy of stomach. See Anadenia. of muscularis of stomach, 139, 333. Audhui, 118. Auerbach's plexus, degeneration of, 367. Aura vertiginosa, 331. Bacillus gastricus, 307. Bacteria in acute gastritis, 288. in gastric cancer, 165. in gastric phlegmon, 304. in gastric ulcer, 233. Bamberger, 113, 133, 188. Baradui. 69. Barnes, 81. Barras, 362, 391, 424. du Barry, 138, 139. Bartels, 129, 130, 336. A'on Basch, 331. Baum, 157. Beau, 168, 363. Beaumont, 333, 387, 394, 348. Behrens, 60. Belching, nervous, 418. Belladonna in cancer of stomach, 212. Benecke, 461. Bennet, 374. Benzopurpurin, 24. Bernabel, 133. Bernstein, 331, 467. Berthold, 333. Best, 199. Biernacki, 471. Bile in stomach-contents, 57. taste of, 395. Binswanger, 457. Bircher, 158. Bird, Golding, 187, 188, 190. Bismuth, 370. Bitters, 344. Biuret reaction, 43. Blatin, 5. Blondeau, 331. Blood, condition of, in cancer of stom- ach, 186. condition of, in ulcer of stomach. 335. in stools, 346, 347, 250, 277. vomiting of. See H^matemesis. Blume, 278. Boas, 11, 12, 15, 21, 26, 31, 38, 44, 49, 50, 52, 194, 230, 335, 339, 344, 354, 358, 433, 449. Bocci, 68. Boerhave, 166. Bollinger, 199, Bouchard, 118. Bouilleaud, 253. Bourdon, 464. Bourneville, 429, 430. Braam-Houckgeest, 133. Brachet, 366. Bradypepsie, 313. Braun, 344. Brentano, 130. Bvieger, 466. Brinton, 73, 86, 162, 167, 171, 175, 177, 178, 183, 185, 194, 233, 304, 306, 316, 474, Briquet, 390, 436, 441. Bristowe, 419. Bromide-water, 463. Broussais, 313, 406. Brown, 51, 406. Brown-Sequard, 301. Briiek, 331. Brunner, 157. Brunton, Lauder, 284, 295. Brush, stomach, 4. Buch, 405. Budd, 241, 351, 865, 377, 341, 353, 362, 414, 448. Bukler, 305. Bulimia, 394; etiology, 396 ; forms, 397; occurrence, 395 ; peristalsis in, 397 ; treatment, 395, 451. Bull, E., 329. Bull, W. T., 157. Burkart, 68, 407, 445, 457, 459, 460. Bush, F., 5. Bussel, 208. Buzelygan, 469. Cachexia, in gastric cancer, 180, 203. in hysteria, 202. Cahn, 21, 34, 45, 46, 113, 136, 134, 144, 145, 188, 190, 193, 194, 229, 230, 303. Calculi, gastric, 199, 393. Callow, 307. Camerer, 231. Camus-Corrignon, 333. Canstatt, 5, 173. Cancer of stomach. See Carcinoma. Canula, permanent, of oesophagus, 97. INDEX. 485 Caragiosiadis, 08. Carbonic-acid gas, distention of stomach with, 59. Carcinoma of stomach, 163. bacteria in, 165. course, 176. diagnosis, 186; absence of hydi'ochlo- rie acid, 187 ; cachexia in, 202 ; can- cerous tumor, 197 ; from atrophy, 840 ; pieces of tissues obtained by washing out stomach, 195. differential diagnosis, 204; between gastric ulcer and cancer, 206, 255. etiology, 165. lymphadenitis, 176. occurrence, 163 ; age, 162 ; heredity, 163 ; primary or secondary, 173 ; re- lations to gasti'ic ulcer, 167 ; sex, 163. pathological anatomy,168;varieties,169. perforation, 177. prognosis, 182. propagation, 175. site, 171 ; sequelas of, 173. symptoms, 177 ; anorexia, 178 ; bow- els, 185 ; cachexia, 180, 203 ; pain, 185 ; presence of tumor, 197 ; A^omit- ing, 178, 185 ; vomiting of blood, 185. thrombosis, 176. treatment, 208 ; analgesics, 212 ; con- durango, 208 ; diet, 213 ; mineral wa- ters, 215; of constipation, 213; of ha?matemesis, 211 ; of vomiting, 311. ulceration, 176. Cardia, cancer of, 85. closure of, 375 ; in rumination, 432. contraction of, spastic, 80. function of, 375. neoplasms of, 82. paresis of, 438. relaxation of, 419, 428, 432. spasm of, 80. stenosis of, 71. stricture of, 71 ; dilatation of, 89 ; feeding in, 104 ; gastrostomy in, 100 ; organic, 82 ; pain in, 75 ; pas- sage of bougies in, 95 ; symptoms, 71 ; treatment, 95. Cardialgia, 327, 400. in gastric cancer, 178. in stricture of cardia, 75. Darlsbad water, action of, in chronic gastritis, 358 ; in gastric neuroses, 463 ; in ulcer, 267. Carron, 81. Carswell, 171, 176, 236, 277. Cartellieri, 420. Catarrh of stomach. See Gastritis Ca- TARRHALIS. Catarrh us atrophicus, 322. Celsus, 351. Chambers, 242, 363. Chantemasse, 233, Charcot, 403. Chausnes, Due de, stomach of, 137. Cherchewsky, 440, 445. Chiaje, Delli, 99. Chiari, 334, 333. Chittenden, 50, 348. Chlorosis, condition of stomach in, 469. Chomel, 313. Chovstek, 354, 306. Cirrhosis ventriculi, 316. Clapotement, 118. Cloizier, 131. Cohn, 426. Cohnheim, 165, 173, 227, 340, 281, 283. Coin, 81. Cold-water treatment, 69. CoUeville, 473. Colloid cancer of stomach, 170. Colic, biliary, 363. stomach, 435. Coma dyspepticum, 147. dyspnoeic, 183. Coinby, 136, 334. Comparetti, 363. Concretiones benzoartic^es, 393. Condurango in gastric cancer, 308. Congo-red, 34. Contents of stomach, 7, 11. acetic acid in, 35, 143. acidity of. 30, 33, 37, 339, 480, alcohol in, 35. bacteria in, 307. bile in, 57. butyric acid in, 35. fatty acids in, 33. fungi in, 307. in acute gastritis, 388. in gastric crises, 403. in gastric cancer, 187. in gastric catarrh, 338. in gastric ulcer, 258. lactic acid in, 33. larv£e in, 308. marsh-gas in, 142. 486 DISEASES OF THE STOMACH. Contents of stomach, methods of obtain- ing, 12. micro-organisms in, 307. defiant gas in, 142. organic acids in, 33, 35, 476. pepsin in, 41, 194, 342. reaction of, 20. rennet in, 49, 194. taste of, 295. Contraction of stomach, 173. Cooper, 232. Copland, 245, 313, 414. Cordes, 331, 332, 359. Cornil, 253. Cornillon, 260. Cough, stomach, 329. Cramps of stomach, 390, 425 ; in gastric dilatation, 146. Cravate de Suisse, 374. Crises, gastric, 403, 443, 472. Crisp, 227. Cruveilhier, 123, 133, 220, 239, 240, 268, 304, 323. Cullen, 326. Cure, rest, 266, 458. Schroth's dry, 151. Curling, 232. Cynorexia, 394. Da Costa, 269. Daettwyler, 222. Daguet, 260. Damaschino, 313. Danger of stomach-tube, 84, 260, 361. Darwin, 430. Daumann, 449. Debove, 277. Decker, 56, 157. Defecation by mouth, 426. Defaillance, 894. Degeneration, colloid, of stomach, 205. Degeneration of nervous plexuses of intestines, 439. Deglutition-murmurs, 61. in dilatation of stomach, 119. in rumination, 432. stricture of cardia, 82. Dehio, 61, 114, 420. Deininger, 306. Dejerine, 402. Delamare, 402. Demange, 402. Depressive neuroses of stomach, 427. Desnos, 426. Dettweiler, 468. Dextrin, 50. Diabetes, condition of stomach in, 478. Diarrhoea due to terror, 369. Diemerbock, 144. Diet in gastric cancer, 313. in gastric catarrh, 346. in gastric ulcer, 268. Dietrich, 259. Digestion of albumen, 41, 43 ; test of, 47. of starch and sugar, 49. phases of, 21. reflex disturbances of, 447. -test in gastric neuroses, 438, 445. Dilatation of oesophagus, 89. Dilatation of stomach, 110. atonic, 130. course of, 149. diagnosis of, 112, 148; auscultation, 118; inspection, 112; measuring ca- pacity of stomach in, 120 ; murmurs of deglutition in, 119 ; palpation, 116 ; percussion, 113 ; Rosenbach's method in, 119; suceussion, 118. etiology, 120 ; atony of stomach, 130 ; exclusion of limited areas of mus- cular fibers of stomach, 133 ; feeble- ness of motor nerves, 130, 132 ; polyphagia, 131 ; stenoses of pylorus, 123 ; wandering kidney, 129. occurrence, 130; with biliary calculi, 129. pathology, 133. physical signs, 112. prognosis, 149. symptoms, 136 ; chemical functions of stomach, 140 ; coma, 147 ; constipa- tion, 145 ; delayed absorption, 143 ; enlargement of stomach, 110 ; fer- mentations, 128, 131, 141 ; inflam- mable gases, 142; peristalsis, 145; sarcina3 and bacteria, 138; stagna- tion of stomach-contents, 141 ; teta- ny, 146 ; urine, state of, 147 ; vomit, 137 ; vomiting, 137. treatment, 151 ; dry diet, 151 ; resec- tion of pylorus, 157; use of cathar- tics, 154 ; faradization, 156 ; hydro- chloric acid, 153 ; massage, 156 ; strychnine, 153 ; washing out stom- ach, 154. Diphtheritic gastritis, 302. INDEX. 487 Dirksen, 61, G3. Distention of stomach, with air, 59. with carbonic-acid gas, 59. witli water, 01. Dittrich, 106, 107, 175, 177, 181, 304 Diverticula of cesophagus, 89. Douche, Scotch, 157, 456. stomach, 63, 453. Dreschfeld, 188. Drozda, 254. Dubujadoux, 316. Ducasse, 431. Dujardin Beaumetz, 118, 146, 153, 163, 341, 352. Dunglison, 245. Duodenum, ulcer of, 232, 264. Duplar, 118, 153. Dupuytren, 232. Dusart, 70. Dyspepsia, 313. asthenique, 130. atonic, 313. cardiaca, 330. flatulent, 440. in gastric cancer, 178. in gastric dilatation, 136. in stricture of eardia, 72. irritable, 313. nervous, 387, 437. reflex, 439, 449. uterina, 449. Also see Chroxic Catarrhal Gas- tritis. Dyspoenic coma in gastric cancer, 182. Dyspeptic asthma, 330. Eating, slow, 346. repugnance toward, 397. Ebstein, 60, 222, 291, 309, 323, 434, 435. Edinger, 16, 225, 393, 301, 466. Egeberg. 100. Einhorn, 19, 63, 66, 157, 336. Eisenlohr, 186. Electrization of stomach, 65, 156, 344. Electrode, stomach, 66. Elixir peptogene, 341. Ellenberger, 50. Ely, 173. Emerald green, 35. Emminghaus, 14. Emptiness of stomach, 394. Engel, 254. Enemata in chronic gastritis, 355. Enemata, nutritive, 105. Eppinger, 241, 243. Erichsen, 210, 232. Ergot, in haematemesis, 216, 279. Erlenmeyer, 454. Erosion, haemorrhagie, of stomach, 236. Eructation, foul-smelling, 142. hysterical, 419. nervous, 418. Escherich, 328. Etat mammelone, 135. Ether, extraction with, 34. Examination of stomach, 58. Ewald, C. A., 5, 13, 38, 30, 41, 46, 50, 53, 54, 61, 68, 85, 91, 105, 133, 141, 143. 157, 188, 300, 233, 326, 385, 392, 301, 311, 315, 318, 336, 341, 344, 348, 354, 364, 376, 449, 460, 466, 471, 480. Ewald, R., 363. Expression, Ewald's method of, 12. Eyeselein, 831. Faber, 52, 251, 260. Fabricius ab Aquapendente, 429. Fagge, Hilton, 145. Falkenheim, 138. Fames canina, 394. Faradization of stomach, 65, 156. Fauvel, 353. Favus of stomach, 307. Fawizky, 38. Feeding by rectum, 105. Fenwick, S., 318. 336, 362, 399, 464. Fenwick, W. S., 361, 463, 471. Ferber, 114. Fermaud, 309. Fermentation (alkaline) of albuminoids in stomach, 141, 328. in stomach, 155, 288, 351. lactic acid, 33. Finkler, 343. Finny, 248. Fistula of stomach, making of, 91, 100. Fistul;e after perforation of gastric ulcer, 252. Flatow, 167. Fleischer, 449. Flint, 335. Food, taking of, 385. refusal of, 397. Forster, 236. Forster, 266. Fothergill, 362. 488 DISEASES OP THE STOMACH. Fouquet, 426. Fox, Wilson, 163, 228, 266. Frankel, E., 308. Frerichs, von, 5, 59, 83, 84, 138, 183, 204, 254. Freund, 318. Friedreich, 181, 208. Fries, 276. Fuchsiu, 25. Full stomach, 390. Fungus hagmatodes of stomach, 170. Fiirstner, 68. Fungi in stomach-contents, 140. Gallard. 279. Galliard, 242, 254 Gallois, 480. Ganglion-cells of stomach, 367. Gans, 473. Gastralgia, 243, 327, 400. genuine, 401. hysterical, 410, diagnosis from ulcer and cancer, 254. in diseases of central nervous system, 408. in gastric cancer, 185, 206, 212. in gastric ulcer, 243, 246. in gastric neurasthenia, 406. in psychoses, 413. nervous, diagnosis of, 255. reflex, 447. treatment of, 212, 272, 451, 452. upon a constitutional basis, 405. Gastrectasis. See Dilatation of Stom- ach. Gastric crises, 403, 443, 472. Gastric fever, 296. Gastric juice. See Juice, Gastric. Gastric neurasthenia, 437. Gastritis, acute, 287 ; glandular, 287 ; idiopathic, 287 ; sympathetic, 301 ; acidity in sympathetic, 301. simple acute, 287 ; diagnosis, 296 ; eti- ology, 287; fermentation in, 290; hydrochloric acid in, 290 ; lactic acid in, 290 ; occurrence, 287 ; pathology, 291 ; stomach-contents in, 290 ; symp- toms, 294 ; treatment, 299 ; varieties, 294. chronic glandular, 313; agoraphobia in, 331 : anadenia in, see Anadenia ; antifermentatives in, 351 : anodynes in, 352; atony of stomach in, 328, 332 ; bitters in, 344; constipation in, 328 ; course, 340 ; diagnosis, 337 diet in, 346 ; dyspeptic asthma in 331 ; enemata in, 355 ; etiology, 324 hydriatic treatment of, 346 ; hydro chloric acid in, 341 ; lavage in, 343 mineral waters in, 356 ; minute anatomy of, 316 ; orexin in, 346 papoid in, 343 ; panereatin in, 343 pathology of, 315 ; pepsin in, 342 prognosis of, 340 ; purgatives in, 353 stomach-cough in, 329; symptoms, 325 ; synonyms, 313 ; treatment, 341 urine in, 329; varieties, 325, 338 vertigo in, 331 ; vomiting in, 327. diphtheritic, 289, 302. emphysematous, 308. membranous, 289. mucous, 325, 338. mycotic, 307. parasitic, 307. purulenta phlegmonosa, 303 ; diagno- sis, 306; etiology, 304; occurrence, 304 ; pathology, 304 ; symptoms, 305 ; treatment, 307. toxic, 309 ; diagnosis, 311 ; symptoms, 310; treatment, 311. Gastroadenitis, 287. Gastrodiaphane, 63. Gastrodynia, 400. Gastroenterite, 313. Gastroliths, 199, 392. Gastroscope, 62. Gastroscopy, 62. Gastrostomy, 100. feeding after, 103. technique of, 102. Gastroxynsis, 418. Gavarett, 176. Gempt, Te, 269. Gerhardt, 146, 177, 229, 233, 247, 264, 271, 309. Germont, 186. Gersung, 98. Gigglberger, 348. Gilles-Sabourin, 241. Girandeau, 118. Gliiser, 306. Glax, 113, 304, 426, 474. Gluczinsky, 188, 190, 469. Glycerin suppositories, 356. Gmelin, 15. Goldstein, 253. INDEX. 489 Goltz, 370, 376. Gorabault, 316. (loodhart, 456. Goodsir, 138. Cxout, condition of stomach in, 473. Graves, 327. Griess, 233. Griffini, 231. Griinfeldt, 234. Griitzner, 292, 344. Grundzach, 479. Grusdew, 467. Glinsburg, 231. Glinzbui-g, 29, 31, 32, 48. Guipon, 396. Gull, 402. Gumlich, 46. Gussmann, 296. Haafewinkel, 343. Haas, 32. Habershon, 239, 304. Hasmatemesis, 276. causes of, 277. diagnosis from haemoptysis, 276. in cardiac diseases, 277. in cholera, 278. in diseased gastric blood-vessels, 279. in epilepsy, 277. in fever, intermittent, 278. in fevers, exanthematous, 278. from oesopliageal varix, 277. in gastric ulcer, 245. in gastritis glandularis chronica, 278. in hysteria, 278. in liver, acute yellow atrophy of, 277. in liver, cirrhosis of, 277. in progressive anasmia, 279. in purpura hemorrhagica, 278. in scurvy, 278. treatment of, in cancer, 211: in gen- eral, 279 ; in ulcer, 273. Hgemoptysis, 276. Hafner, 278. Hair-tumors in stomach, 199, 393. Hall, 253. Haller, 379. Haller's acid elixir, 280. Hampeln, 181. Hanot, 86, 316. Hart, Wheatley, 90. Hauser, 167, 235. Hayem, 40, 469. Heart, condition of stomach in diseases of, 4G4, 470. Heart-burn, 314, 326, 420. lleberden, 341. Heidenhain, 236, 295. Heredity of cancer, 163. Ileinecke, 157. Heisshunger, 394. Heitler, 167. Henle, 236. Henoch, 176, 186, 234, 277, 297, 330, 420. Henry, 464. Heron, 51. Herpes labialis in chronic catarrhal gas- tritis, 295. Herzen, 341. Hildebrand, 309, 466, 467. Hiller, 254. Plilton, 274. Hippoci'ates, 391. Hirsch, 21, 230. Hoesslin, von, 24, 36. Hoffmann, F. A., 287, 288. Hofmeister, 50. Holmes, 232. Hoppe-Seyler, 301. Honigmann, 230, 414, 418. Hornbaum, 405. Huber, 56, 107. Hubert, 157. Hubner, 414. Hufler, 470, 471. Hiippe, 141. Hufeland, 208. Hughes, 274. Hunger, 379. causes of, 379. center of, 363, 380. feeling of, 380 ; deviations from, 394 ; inhibition of, 382; localization, 381; voracious, 394. Hunter, 4. Hutchinson, 464, 467. Hydrochloric acid, absence of, in Addi- son's disease, 190 ; in amyloid de- generation of gastric mucosa, 189 : in anadenia, 337; in gastric cancer, 187; in gastric neuroses, 189; in menstruation, 449 : in mucous ca- tarrh of stomach, 189 ; permanent, in healthy persons, 479 ; in pulmo- nary phthisis, 190, 467; in valvular diseases, 470. 490 DISEASES OP THE STOMACH. Hydrochloric acid, antiseptic action of, 287. free and combined, 36, 37, 38. permanent lessening in gastric neu- rosis, 477. tests for, 25, 37, 38. use of, 153, 341. Hydrops in gastric cancer, 181. Hydrotherapy, 66, 424, 454, 456. Hyperacidity, 414. in gastric ulcer, 229, 258. in nervous disorders, 415. test of, 22. Hypersesthesia of stomach, 890. after chloroform narcosis, 392. Hyperorexia, 394. Hypersecretion of gastric juice, 414, 415. diagnosis, 418. in cerebral disorders, 448. periodical, 415. Hypersecretio acida, 414, 415. Hypochondria. 396. Hysteria, 389, 400, 405, 410. Idiosyncrasy of stomach, 393. Immermann, 209, 466, 467. Indigestion, 303, 313. Innervation of stomach. 363. Insufficiency of stomach, 137. See Py- lorus and Cardia. Invert sugar, 49. Iodoform reaction, Lieben's, 35. Intestines, disturbed digestion of, 440. electrization of, 67. hasmorrhage in, 246, 247, 250, 277. tympanites of, 435. vicarious action of, 53, 195. 335. 480. Iron, albuminate of, 269, 456. Irritative gastric neuroses, 390. Jaksch, von, 24, 39, 233. Jaccoud, 426. Jaworski, 11, 18, 54, 188, 267, 339, 342 344, 346, 358, 414-416, 418, 467. Johannessen, 429. Johnson, 391. Jolly, 415. Jones, H.. 277, 464. Juice, gastric, acidity of, 22. changes in, significance of, 476. flow of, 414; continual, 416; in cere- bral affection, 448 ; periodical, 416. hyperacidity of, 414. Juice, gastric, hypersecretion of, 415. in gastric catarrh, 341. in gastric cancer, 187. in gastric dilatation, 140. in gastric neuroses, 446. in gastric ulcer, 229. in rumination, 433. parasecretion, 415. secretion of, 16, 315. Julien, 254. Jiirgens, 439. Jiirgensen, 418, 433. Kaczarowski, 346. Kahlden, 316. Kahler, 26, 29, 402. Kalmus, 302. Katzenellenbogen, 171, 176. Kidney, condition of stomach in dis- eases of, 464, 471. Kietz, 188. Kinnicutt, 16, 157. Kisch, 449, 474. Klebs, 253, 292, 307. Kleef, 274. Kleist, 354. Klemperer, G., 25, 49, 56, 57, 122, 301, 466, 467. Robert, 376. Koch, 222. Kocher, 101. Kohler, 190. Kollmar, 257. Konig, 18. Kooyker, 392. Korner, 431. Kossel, 450. Kraus, 32. Ki-etschy, 449. Krishaber, 97. Kronecker, 61, 91. Krukenberg, 28, 32, 188, 402. Kuhn, 32. Kundmann, 4. Kundrat, 307, 334. Kunze, 216. Kupffer, 292, 317. Kussmaul, 5, 68, 105, 111, 118, 125, 134, 145, 146, 154, 155, 158, 187, 425, 434, 437, 452. Laache, 186. Lab-enzyme, 49. INDEX. 491 Lab-ferment, 48. Lab-zymogen, 49. Labastide, 341. Laborde, 70. Laboulbene, 311. Lactic acid. See Acid, Lactic. Lambl, 445. Lanceraux, 253. Landau, 130. Landerer, 125. Landoiizi, 402. Lang, 254. Lange, 175, 239. Laprevotte, 146. Large stomach, 112. Lavage of stomach, 63, 154, 343. Lebert, 134, 162, 163, 167, 171, 175-177, 181, 183, 185, 195, 215, 233, 294, 304, 305, 314. Ledoux-Lebard, 167. Leichtenstern, 91, 119, 360. Lemaitre, 323. Leo, 16, 35, 38, 39, 48, 272, 397. Lepine, 25, 186. Lesser, 310. Lesshaft, 117. Letulle, 232, 2-79. Leube, 4, 5, 14, 19, 49, 68, 105. 116, 129, 227, 258, 266, 271, 272, 307, 362, 442, 445, 452, 474. Leucin, reaction of, 28. Leudet, 253. Lewin, W.; 306. Lewy, 318. Leyden, 97, 404, 424„ 443, 457, 468. Liebermeister, 468. Liebreicb, 271, 445. Lienteric stools, 186, 250. Litmus-paper, 22. Litten, 129, 147, 241, 336. Liver, condition of stomach in diseases of, 472. Loreta, 157. Loeb, 147. Losch, 291. Louis, 464. Low, 232. Loye, 68. Lublinski, 309. Lugol's solution, 51. Lung, hfemorrhage from, 276. Luschka, 72. Luton, 171. Mackenzie, 96, 97, 101. Macleod, 305. MacNaught, 142, 327. Magendie, 370. Maier, 125. Malachite green, 25. Malaria, condition of stomach in, 474. Malbranc, 129, 452. Malibran, 136. Maltose, 50. Malvoz, 216. Mannskopf, 153. Marcet, 224. Marcone, 344. Marfan, 254, 292, 464. Martin, 147, 156. Martin, St., 108. Massage of stomach, 69, 156, 344, 453. Mastcur. See Rest-cure. Mathieu, 132. Mayer, 331. Meat-juice, 152. Meat peptone, 152. chocolate, 152. Kemmerich's, 152. Koch's, 153. solution, Leube's, 114. Meckel, 117. Medullary carcinoma of stomach, 169. Megastria, 112. Meissner's plexus, 367, 439. Melaena, 277. Mel^enemesis, 179. Melanotic carcinoma of stomach, 69. Meltzer, 61, 82, 91. Menassein, 292, 301. Mering, von, 21, 51, 188, 193, 229, 230. Merycismus, 429. Meschede, 309. Methyl violet, 27. Meyer, C, 167. Meyer, G., 236, 320, 322, 454. Meyer, R., 134. Meyer, W., 211. Michaelis, 274. Middeldorf, 253. Mikulicz, 62. 157, 408. Milk diet, 349. peptonized, 152, 214. Miller, 131. Milliot, 67. Mineral springs, treatment at. in gastric cancer, 215. 492 DISEASES OF THE STOMACH. Mineral springs, treatment at. in gastric catarrh, 356. in gastric neuroses, 402. in gastric ulcer, 275. Mineral waters in gastric neuroses, 455. Minkowski, 128, 132, 139, 140, 147,153,155. Mintz, 37. MiqueL 227. Mislowitzer, 177. Mitan, 350. Mitchell, Weir, 457, 459, 460. Mobius, 440. Models of stomach, 110. Mohr, 22, 29. Montegre, 431. Morner, 38. Mosetig-Moorhof, 211. Motility. See Movements of Stosiach. Movements of stomach, 53, 373. in bulimia, 397. in chronic catarrhal gastritis, 332. tests of, 53. Mucous gastritis, 325, 338. Mucous glands of stomach, 294. Mucous membrane of stomach, atrophy of, 318, 334. degeneration of, granular, 319. fungi of, 307. hajmorrhage in, 230. polypi of, 323. vacuoles in cells of, 317. Miiller, Fr., 147, 198, 250. Mliller, Joh., 364. Murchison, 180, 253, 254. Ilurmur, deglutition (Schluckgerausch), 61, 119, 432. gurgling, 118. press, 61, 432. splash, 118. squirt, 61, 432. succussion, 118. Muscularisof stomach,atrophyof,134,322. feebleness of, 130. hypertrophy of, 134. paresis of, 334. Musser, 242, 254. Myalgia of abdominal muscles, 390. jSTatanson, 01. Naunyn, 132, 155. Nausea, 390. Nauwerck, 128. Nencki, 54. Neptune's girdle, 424, 456. Nerves of stomach, 360. Nervous system, condition of stomach in diseases of, 464, 472. NeschaiefE, 109. Neuralgia, visceral, 442. Neurasthenia,, 406. gastric, 437. gastro-intestinal, 441. vago-sympathetic, 441. Neuroses of stomach, 301, 387. 414. conditions of depression in, 427. conditions of irritation, 390. classification of, 387. etiology, 388, mixed form, 437. occurrence, 388. reflex, 447. relations to other neuroses, 389. treatment, 450. Nicaladoni, 89. Niemeyer, 331. Nissen, 274. Nolte, 233. Norden, Von, 230, 403, 414, 415. Normal soda solution, 22. Nothnagel, 129, 321, 336, 445. Odier, 271. Odytmann, 356. CEsophageal probang, 6. sound, 78. tube, 6. Oesophagus, dilatation of, 89. diverticula of, 89. permanent canula of, 97. sounding of, 77. strictui-e, cicatricial, 83 ; spasmodic, 80. ulcer of, corrosion, 82 ; round, 83 ; syphilitic, 83 ; tubercular, 83. Oettinger, 146. Oil-test 57. Oppenheim, 402. I'orange Poirier, 23. Orexin, 346. Organic acids. See Acids, Orszewsky, 210. Orth, 307, 308, 310. Oser, 0, 10, 59, 00, 121, 129, 151, 250, 267, 344, 302, 370, 387, 391, 404, 412, 453. Osier, 330, 404. Ott, 185, 198, 200, 206. Overloading of stomach, 291. INDEX. 493 Piicanowski, 115. Pain, epigastralgic, 441. epigastric, 390. in cancer, 185, 201, 200. in catarrh of stomach, febrile, 205 ; chronic, 328. in hyperaesthesia of stomach, 390. in hypersecretion of gastric juice, 417. in hysterical gastralgia, 410. in nervous dyspepsia, 444. in neurasthenic gasti'algia, 406. in stricture of the carclia, 75. in ulcer of stomach, 263. Pal, 56. Palpation of stomach, 58. tip of stomach-sound, 116. Pauli, 136. Pavy, 225, 227, 395, 474. Peiper, 468. Pemberton, 267, 391, 414. Peuzoldt, 52, 61, 118, 120, 144, 154, 346, 348. Pepper, 69, 156. Pepsin, artificial, 41. and hydrochloric acid, digestion by, 47. glycerin of, 41. in chronic catarrhal gastritis, 342. Pepsinogen, 339. Peptone, 42. artificial, 104. chocolate, 104. enema, 105. pastilles, Maggi's, 152. reactions of, 42. suppositories, 105. Peptonuria in gastric dilatation, 148. Perforation in gastric cancer, 178 ; in gastric ulcer. 249. Perforation-peritonitis, 274. Peristalsis of stomach, 373. Pertik, 123. Peyer, 395. Pfeiffer, 358. Pfungen, Yon. 39, 230, 272, 332, 416, 436. Phenolphthallein, 22. Phlegmon, perigasti'ic, 302. gastric. See Gastritis phlegmonosa. Phloroglucin-vanillin, 29. Phthisis ventriculi. See Anadema. Pick, 469. Pidoux, 474. Pinel, 391. Piorry, 61. Pitt, 232. Playfair, 457. Pneumatosis, 420. Points, painful, Burkart's. 407, 441. Poirier, I'orange, 23. Poensgen, 433. Poisoning, 309. ■with alcohol, .309 ; caustic alkalies, 310 ; hydrochloric acid, 310 ; nitrobenzol, 311; oxalic acid, 310; phosphorus, 310; sulphuric acid, 310. Poisson, 249. Polyphagia, 427. Polypi of stomach, 323. Portal, 137. Position, vertical, of stomach, 117. Potassium ferrocyanide in Mohr's test, 29. Potton, 395. Powell, 249. Power, 81. Pribram, 63, 331. Probefriihstiiek. See Test -breakfast. Probemahlzeit. See Test-meal. Probemittagbrod. See Test-dinner. Proenzyme, 49. Propeptone, 43. reactions of, 42. Proteolysis, 46. Ptyalin] 50. Ptyalisra, reflex, 449. Pump, stomach, 6, 12. Puncta dolorosa. See Points, Painful. Purgative, Oydtmann's, 356. Purgatives, 353. Purgecz, 120. Pylorus, cancer of. See Carcinoma of Stomach. closure of, 375. functions of, 375. hypertrophy of museularis at, 200, 205. incontinence of, 434. relaxation of, 428. spasm of, 425. spastic contraction of, 127. stenosis of, cicatricial, 122 ; congenital, 123 ; hypertrophic, 125 ; mechanical, 123. ulcer at, 229. Pyrosis, 314, 326, 420. Quenu, 465. Quincke, 61, 80, 83, 148, 222, 336. 494: DISEASES OF THE STOMACH. Rampold, 185. Raudnitz, 49. Kay, 274. Reaction, ethyldiacetic acid (in urine), 147. (For other reactions see under individual headings.) Reagent, Boas's, 81. Glinzburg's, 29. Mohr's, 29. UflEelmann's, 33. Recklinghausen, Von, 302. Reflex dyspepsia, 439, 449. Reflexes from other organs on the stom- ach, 447. Regnard, 68. Regurgitation, 428. in stricture of oesophagus and cardia, 70, 73. Reichmann, 414, 417. Reischauer, 32. Relations, mutual, of stomach, liver, and intestines, 281 ; and nervous system, 864 ; other organs, 463. Rennet. See Lab. Renvers, 97. Resorcin, 31. Rest-cure, Leube-Ziemssen, 266 ; in ul- cer, 266. Weir Mitchell, 457. Retzius, 210. Rheumatism, condition of stomach in, 474. Richet, 108, 368. Richter, 189, 408, 443. Riegel, 19, 109, 141, 188, 194, 229, 231, 258, 414, 417, 418. Rieger, 66. Riess, 209, 454. Ritter, 21, 230. Roberts, 347, 352. Rodzajewski, 488. Rompler, 158. Rokitansky, 85, 129, 223, 231, 232, 236, 238, 304. Rosenbach, 111, 119. 136, 188, 197, 330, 451, 452. Rosengart, 336. Rosenheim, 17, 21, 188, 193, 229, 259, 336. Rosenstein, 426, 473. Rosenthal, 105, 362, 397, 402, 404, 406, 408, 410, 419, 452, 454. Rosenthal, C, 49, 190, 466, 468. Rosin, 16. Ross, 313. Rossbach, 418. Rossier, 481, 433. Rowing in chronic catarrhal gastritis, 350. Rubin, 25. Ructus. See Eructation. Ruhle, 468. Rumination, 429. Rumsseus, 4. Runeberg, 59. Rupture of stomach, 310. Ruppstein, 142. Rutherford, 355. Saceharification, 49. by saliva, 50. Sachs, 292. Sahli, 48. Salkowski, 38. Salol test, 54. Saly, 414. Samuelson, 226. Sanctuary, 127. Sandberg, 358, 479. SarcinsB ventriculi, 138, 245. Sassezky, 301. Satiation, feeling of, 384. lack of, 894. Saundby, 278, 455. Sauvage, 433. Scheperlen, 336. Scherf, 253. Schetty, 301, 466. Scheuerlen, 166. Schiff, 222, 841, 366. Schill, 166. Schillbach, 67. Schliep, 14. Schlesinger, 104, 151. Schluckgeriiusch. See Murmur, Deglu- tition. Size of stomach, 115. Situation of stomach, 117. Schmidt, P., 296. Schmidt-Miihlheim, 144, 372. Schraidtmann, 891, 429. Schneider, 186, 429, 430. Schnetter, 59. Schonborn, 199. Schrader, 880. Schreiber, 16, 120. Schroth's dry diet, 151. Schuchardt, 166. INDEX. 495 Schiitz, 60, 129, 420. Soirrhus of stomach, 109. Sclerosis, hypertrophic, of gastric sub- mucosa, 317. Secretion of stomach, 3G7. Sedgwick, 234. Scdillot, 100. See, Germain, 112, 118, 127, 132, 148, 260, 314, 346, 353. Seeraann, 28. Seglas, 429, 430. Sehrwald, 226. Senator, 286, 309, 397. Senn, 158. Sensibility of the stomach, 377 ; morbid, 391. " Sere, De. 434. Shape of stomach, changes in. 111. Sialorrhoea, 449, Siebert, 353. Sievers, 54, 68, 157, 433. Siewecke, 205. Silbermann, 222. Silberstein, 56. Silver nitrate, 271. Simple gastritis, 325. Singer, 30. Siphon, stomach, 6. Siphonage in washing out stomach, 63. Sjoqvist, 38. Skin, anaesthesia of, in gastric ulcer, 245. hyperaesthesia of, in gastric ulcer, 345. condition of stomach in diseases of, 474. Skjelderup, 153. Skoda, 295. Smaragd green, 25. Smirnow, 289, 302. Snow, 164. Soda solution, normal, 22. Sodium chloride, reaction of, 26. Sohlern, Von, 233. Sommerville, 5. Sonnenberg, 92, 97, 102. Sounding of stomach, 10. Sounds, oesophageal, 78. stomach, 6. Spallanzani, 16. Springs, mineral, treatment at, in gas- trie cancer, 215 ; catarrh, 356 ; neu- roses, 455, 461 ; ulcer, 275. Stabchen plessimeter percussion, 119. Starch, digestion of, 49. Starck, 233. Status gastricus, 313. Stern, 471. Stewart, 306. Stienon, 193. Stiller, 362, 389. Stintzig, 292. Storck, 208. Stomach, anadenia of. See Axadenia. atony of. See Atoxy, atrophy of. See Atrophy. carcinoma of. See Carcixoma. catarrh of. See Gastritis catarrha- LIS. contents of. See Coxtents of Stom- ach. depressive conditions of, 427. dilatation of. See Dilatation of Stomach. ha3morrhage in See H^matemesis. inflammation of, purulent. See Gas- tritis phlegmoxosa. Inflammation of, toxic. See Gastritis, Toxic. innervation of, 363. irritative conditions of, 390. large, 113. models of, 110. motility of. Sec Movemexts of Stom- ach. mucous membrane. See Mltcous Mem- braxe. neuroses of. See Xeueoses of Stom- ach. phthisis of. See Axadexia. ulcer of. See Ulcer of Stomach. unrest of, antiperistaltic, 426 ; peri- staltic, 145, 425. vaso-motor nerves of, 371. washing of, 63, 154, 343 ; in poisoning, 311. Stools, in gastric cancer, 185 ; catarrh, 328 ; dilatation, 145 ; dyspepsia ner- vosa, 445 ; phlegmon, 305 ; ulcer, 246. in stricture of cardia, 74. lienteric, 186, 250. tarry, 247. Storer, 205. Striimpell, 119. Substances, mucinogenous, 287. pepsinogenous, 286. peptogenous, 341, zymogenous, 226. Sugar, digestion of, 49. 496 DISEASES OP THE STOMACH. Surgery of stomach, 157. Swieton, Van, 166. Switzer, 97. Symonds, 97. Sympathetic nerve, course of, 367. Syntonin, demonstration and reactions of, 42. Tabes, gastric crises in, 403, 443, 472. Talamon-Balzer, 242. Talma, 327, 417, 454. Taste in gastric cancer, 178 ; ulcer, 243 ; gastritis catarrhalis chronica, 326 ; in rumination, 430. Teeth, care of, in diseases of stomach, 346. Telangiectatic carcinoma of stomach, 170. Test-breakfast, 17. -dinner, 19. -meal, 19. Tetany after washing out stomach, 361. in gastric dilatation, 146. Thaddeus, 83. Thiersch, 167, 188. Thomas, 461. Thrombosis in gastric cancer, 176. Tiedemann, 15. Titration, method of, 22. Todd, 313, 390, 414. Tolma, 222, 225. Tongue in diseases of stomach, 297. in gastric cancer, 178; catarrh, acute, 295 ; chronic, 326 ; dilatation, 137 ; hypersecretion of gastric juice, 417 ; neurasthenia, 440 ; ulcer, 243 ; phleg- monous gastritis, 306 ; stricture of cardia, 74. Torminfe ventriculi, 425. Transformation of gastric ulcer into can- cer, 259. of starch, 41. Traube, 132, 245. Trendelenburg, 108. Trier, 265. Trinkler, 417. Troisier, 176. Tropajolin, 23. Trousseau, 331, 355, 414. TschelzofE, 344. Tube, Faucher's, 6. stomach, 4 ; dangers of, 14, 84, 260, 361 ; use of, in chronic gastritis ; neuroses, 452; ulcer, 266; tympa- nites, 421. Tuberculosis, condition of stomach in, 464. Tuckwell, 423. Tiingel, 171. TLipfelmethode, 22. Tumor in gastric cancer, 180, 185. hypertrophy of muscularis at pylorus, " 200, 205. mediastinal, 83. retroperitoneal, 83. Tumors, non-carcinomatous, of stomach, 215. Tympanites, 420. Typhoid fevei", condition of stomach in, 464. Uflelmann, 26, 33, 292. Ulcer of duodenum, 232, 264. Ulcer of stomach, follicular, 223, 402. round, 217; age in, 234: anatomical characters of, 239 ; bloody stools in, 246 ; cicatrization of, 240 ; composi- tion of blood in, 229; diagnosis of, 206, 254, 262; diet in,'268; etiology, 220; excision of, 274; fistulfe in, 252 ; hasmorrhage in, 245 ; treatment of, 273 ; hyperacidity of gastric juice in, 229 ; in cutaneous burns, 232 ; micro-organisms in, 232 ; occurrence, 233 ; operative procedures in, 274 ; pain in, 243; treatment of, 272; pathological anatomy, 235 ; perfora- tion of, 249 ; perforation-peritonitis, 251; treatment of, 274; prognosis, 265 ; relapsing, 228 ; rest-cure in, 266 ; site of, 239, 263 ; sounding of stomach in, 260 ; stools in, 243 ; symptoms of, 242 ; treatment of 266 ; at mineral springs, 275 ; use of Carlsbader water in, 267, 275 ; use of iron in, 269. syphilitic, 241, 253. tubercular, 242, 254. Ultramarine, 29. Unrest of stomach, antiperistaltic, 426. peristaltic, 145, 425. Vagus, course of, 366. Value of chemical tests, 475. Vanillin, phloroglucin, 39. Vanni, 225. INDEX. 49: Vaso-motor nerves of stomach, 371 ; re- lations of, in gastric secretion, oTl. Vassale, 221. Velden, Von den, 50, 70, 111, 187, 188, 190, 414, 417. Verneuil, 108. Vert brillant, 25. Vertigo gyrosa, 321. stomaohalis, 331. e stomacho laeso, 331. Vidal, 232. Villous carcinoma of stomach, 170. Violet, methyl, 25. Virchow, Ii.,"ll7. Virchow, R., 86, 176, 200, 237, 253, 292, 309. Visceral neuralgia, 442. Vizioli, 453. Vogel, 208. Vormagen, 72. Vomit, coffee-grounds, 179. taste of, 295, 445. Vomiting, 376. hysterical, 423. in abscess of liver, 448. in diseases" of brain, 448 ; spinal cord, 448. in gastric cancer, 211 ; catarrh, acute, 295 ; chronic, 327 ; dilatation, 137 ; iilcer, 245. in hypersesthesia of stomach, 392. in injuries to uterus, 449. in neurasthenia, 424, 444. in opei'ations on bladder, 449 ; urethra, 449. in phlegmonous gastritis, 305. in phthisis, 464. in poisoning, 310. in pregnancy, 448. in renal abscess, 448 ; colic, 448 ; dis- eases, 471. in sea-sickness, 448. in stricture of cardia, 72. nervous, 421. of blood. See HyEMATEMESIS. periodical, 424, reflex, 423. Wagner, 115. Waldeyer, 167, 169. Walshe, 162, 166, 255. Washing of stomach, 63, 154, 343. in poisoning, 311. Water, filling stomach with, 61. Watson, 278. Weighing, systematic, 460. Weiss, 5. Weissgerber, 419. Welch, 6, 162, 163, 170, 171, 216, 233, 239, 250, 253, 279, 335. Werner, 140, 473. West, 250. Westphal, 331. Westphalen, 336. Wiederhofer, 136, 334. Wiesner, 14. Wilkens, 415. Wilkinson, 162. Wilks, 232. Williams, 242. Willigk, 265. Wilson, 378. Windthier, 431. Winkhaus, 148. Winter, 40. Winternitz, 157. Wirbelweh, 405. Witosowski, 237, 238. Witte, 246. Wolff, J., 479. Wolff, L., 53, 153. Wolfram, 189. Wiirzburg, 163. Yeast-cells in stomach-contents, 308. Yellowly, 277. Yeo, Burney, 474. Zabludowski, 147, 156. Zeckendorf, 435. Zenker, 61, 63, 73. Zesas, 101. Ziegler, 304. Ziemssen, Von, 14, 59, 67, 68, 72, 110, 111, 117, 366, 457. Zinc, sulphide of, 29. THE END. December, 1892. MEDICAL AND HYGIENIC WOEKS PUBLISHED BY D. APPLETON & CO., 1, 3, & 5 Bond Street, New York. AULDE (JOHN). The Pocket Pharmacy, with Therapeutic Index. A resume of the CHnical Applications of Remedies adapted to the Pocket-case, for the Treatment of Emergencies and Acute Diseases. 12mo. Cloth, $2.00. BARKER (FORDYCE). On Sea-Sickness. A Popular Treatise for Travelers and the General Reader. Small 12mo. Cloth, 75 cents. BARKER (FORDYCE). On Puerperal Disease. 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