B£XUl li£. fsqs mtlifCttpcfilfttigork College of ^fjpsficiansi anb ^urseonsi Hitirarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/diseasesofstomacOOeinh DISEASES OF THE STOMACH A TEXT-BOOK FOR PRACTITIO:NrERS ANJ) STUDENTS. BY MAX EIXHORX, M.D. ADJUNCT PROFESSOR IN CLINICAL MEDICINE AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL ; VISITING PHYSICIAN TO THE GERMAN DISPENSARY. SeconD IReviseD JEMtion. NEW YORK WILLIAM WOOD AND COMPAITY 1898 Copyright bv WILLIAM WOOD & COMPANY 1898. TO MY FRIEND AND TEACHER, C. A. EWALD, M.D., PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF BERLIN THIS BOOK IS RKSPECTFULLY DEDICATED. PREFACE TO THE SECOND EDITION. It is about a year now since my book on " Diseases of the Stomach" was pubHshed. In this short time the first edition has been exhausted and a reprint rendered necessary. It is quite natural that in so brief a period no radical changes were called for in the text. A revision, however, was undertaken and a few alterations and slight additions were made. I trust that the second edition will be as favorably received by the medical profession as the first. Max Ekshorn. New York, October 25th, 1897. PREFACE TO THE FIRST EDITION. During the last twenty years our views in the field of diseases of the stomach have undergone great changes. W. Beaumont in this country laid the corner-stone of scientific research and experimental study on the functions of this organ in 1825. From that time on the science of gastric diseases remained in a state of quiescence until 1867, when Kussmaul methodically applied the stomach pump in the treatment of dila- tation of the stomach. The real progress, however, began a few years later, when Leube made use of the stomach pump for diagnostic purposes. Ewald, Boas, Eeichmann, Eiegel, and others then instituted exten- sive studies of the gastric functions in health and disease. This second epoch in the study of digestive diseases, which had its inception in Germany, soon made itself felt in other countries, notably France, Eussia, Austria, England, and America. In our coun- try especially it seems that a very fruitful activity is developing in this direction. Among the older writers I would mention the names of Austin Flint, Delafield, Pepper, and Osier, all of whom contributed largely to our clinical knowledge in this branch of medicine. The newer researches were taken up here and further advanced by Charles G. Stockton, Francis P. Kinni- Vlll PREFACE. cut, Allen A. Jones, D. D. Stewart, J. C. Hemmeter, and many other very active investigators. The prog- ress achieved relates to a more profound knowledge of gastric affections — by examination of the functions — and to a moro successful therapy, first by diet, secondly by the newer mechanical means of treatment (lavage, sjDray, electricity), and thirdly by surgical procedures. Our more extensive knowledge of diet and treatment is of advantage not only to the specialist, but to the general practitioner as well, and it is with the view of assisting the latter in the acquisition of all these advantages which have of late accrued that this treatise has been written. A series of articles on Diseases of the Stomach, which I contributed to the " Twentieth Century Practice of Medicine " has greatly facilitated my work. In this book the subject has been considered from a more practical standpoint, and special attention has been paid to diet and treat- ment. I trust that this work will aid in awakening a deeper interest in the study of diseases of the stomach among American physicians, and if this object be realized, I shall feel more than recompensed for the time spent in its preparation. Max Einhorn. Nfav York, June 15th, 1896. CONTENTS. CHAPTER I. Amatomy axd Physiology, PAGE Anatomy, 1 Situation, 2 Blood-vessels, 3 Relations of the Stomach to Neighboring Organs, . . 3 Structure of the Stomach, 3 Blood-vessels, Lymphatics, and Nerves of the Stomach, . 7 Physiology, 8 The Gastric Juice, 10 Gastric Digestion, 13 Intestinal Digestion 14 CHAPTER II. Methods of Examination. Interrogation of the Patient, Methods of Physical Examination, Inspection, Palpation, Percussion, Auscultatory Percussion, Sounds of the Stomach, Splashing Sound (Clapotage) Deglutition Sounds, Succussion Sounds, Gurgling Sounds, Respiratory Sounds Sizzling Sounds, Ringing Sounds, Gastroscopy, . Gastrodiaphany or Transillumination of the Stomac Roentgen Rays, 18 22 22 24 26 28 29 29 30 32 32 32 33 33 33 34 38 CONTENTS. Examination of the Functions of the Stomach, Secretory Function, .... Leube-Riegel's Test Dinner, . Test Breakfast of Ewald and Boas, Germain See's Test Meal, Kleinperer's Test Meal, . Ewald-Boas' Expression Method, Examination of the Ingesta, . Contraindications to the Use of the Stomach Tube Otlier Metliods of Testing the Gastric Secretion Exact Determination of the Quantity of Chyme w the Stomach, ...... Abnormal Constituents of tlie Gastric Contents Absorptive Function of the Stomach, . Motor Function of the Stomach, .... Mechanical Function, ...... ithi PAGE , 39 . 39 , 40 , 41 . 41 , 41 . 43 . 44 . 60 . 60 1 . 66 . 68 . 84 CHAPTER III. Diet. Animal Foods, Vegetable Foods, . Liquid Foods, Utilization of Food, Diet in Health, Diet in Diseases of the Stomach, In Acute Diseases of the Stomach, In Chronic Affections of the Stomach, 103 105 106 107 107 108 113 116 CHAPTER IV. Local Treatment of the Stomach. Lavage, The Gastric Douche, The Gastric Spray, Electricity, . 126 132 134 136 CHAPTER V. Organic Diseases with Constant Lesions. The Acute and Chronic Gastric Catarrh 151 Acute Gastritis 151 Gastritis Acuta Simplex or Acute Gastric Catarrh, . .151 Etiology, ... 151 CONTENTS. XI PAGE Gastritis Acuta Simplex or Acute Gastric Catarrh : Morbid Anatomy, . 152 Symptomatology, 153 Diagnosis, 154 Prognosis, 155 Treatment, 155 Gastritis Phlegmonosa, 158 Synonyms, . . , . . . . . . 158 Morbipetite. — Is there loss of appetite ? Does the ap- petite come when the patient begins to eat? Does the appetite disappear when tiie patient has taken a few mouthfuls of food, or is there a ijerfect aversion for food? The loss of appetite is designated by the word "anorexia." If there is a perversion of appetite — that is, appetite only for unusual substances — 'We speak of "parorexia." If the appetite is increased — that is, if the patient becomes hungry soon after a meal — we speak of "bulimia." If the patient takes large quan- tities of food, much more than normal, but at his regular meals, we speak of "polyphagia." If there is no feeling of satiety no matter how much the patient takes, then we sjDeak of "acoria." Thirst. — Inquire whether the patient becomes thirsty more frequently than usual or whether there is no desire whatever for drinks. Taste. — Inquire whether the taste in the mouth is all right or whether it is bitter, sour, or sticky, and if there is such abnormal taste, at what time it is mostly experienced. Deglutition. — Does the food pass into the stomach without difficulty or not? If not, state whether the difficulty is experienced only after ingestion of solid substances or also after fluids. Abnormal Sensations. — How do you feel after meals? Do you feel bloated? Do you experience a feeling of fulness or pressure in your gastric region? Do you feel sleepy or giddy, and if so for how long a time? Belching. — Do you belch much and if so, when? Does it occur only after a meal or also in the morning 20 DISEASES OF THE STOMACH when the stomach is emiDty? Do you belch so much that it inconveniences you in society, or that it keeps you from your business? Is the belching connected with some bad smell, or is the gas that comes up odor- less, inoffensive? Regurgitation. — Does the food come up into your mouth? If so, state whether it is sour or not, and whether this frequently occurs and how long after meals. If the food that comes up is spit out we speak of "regurgitation," but if it is chewed and swallowed we speak of "rumination," If only some sour fluid comes up, then we speak of "water brash." Pyrosis. — Do you experience a burning sensation at the j)it of your stomach, and when? Is it half an hour after a meal, or is it three hours or so afterward? How long does this sensation last? Pains. — Pains when experienced at the pit of the stomach are called cardialgia; if in the gastric region, gastralgia. Pains are the most frequent complaints met with in all kinds of digestive troubles. They may be of a severe nature so that the patient is obliged to stay in bed, or they may be of only a light character so as merely to inconvenience the sufferer. When does the pain appear? Does it come right after eating or does it occur an hour or two or three afterward? Does it exist when the stomach is empty and is it ap- peased by the ingestion of food? How long does the pain last? Does it remain all the time, or only a short while, or does it come and go independently of the food taken? If it follows the ingestion of food, is it more intense after partaking of certain coarse, in- digestible aliments? Is the pain circumscribed and THE INTERROGATION OF THE PATIENT. 21 felt ODly at one spot or does it extend all over the gas- tric region? Does it radiate to the back and shoulder blades? Does the pain come on suddenly or slowly, and does it gradually increase? Nausea. — Is the nauseous feeling present only in the morning or after each meal, or does it appear after certain foods (as meats)? Fo7?^^7mgr.— Inquire whether the patient vomits ; if so, how often this occurs, whether daily or only once in two or three weeks. Does the vomiting occur soon after a meal or at other times? Does it occur in the middle of the night? Do you vomit large quantities? If so, of what do they consist? Is it only food or is it simply an acid watery fluid? Does the vomited matter contain food from previous days? Does it con- tain much bile? Does it smell when it is vomited or has it an acid, disagreeable taste? Was there ever any blood in it? Fresh blood looks red, while digested blood that has been in the stomach a much longer time has a coffee-brown color. Is the act of vomiting connected with much exertion or does it take place easily? Do pains exist before vomiting and disajDpear after its cessation? Boiuels. — Inquire whether the bowels move every day or not. Are they constipated? Is the patient always obliged to take some aperient and what is the nature of the aperient? Is there diarrhoea? State how many movements a day and the character of the stools, whether they are very watery or whether there is some admixture of mucus or blood. Does the diar- rhoea appear after each meal? Does it alternate with periods of constipation? 22 diseases of the stomach. Methods of Physical Exai^iination. The examination of the patient should always begin with a thorough examination of his chest, for very often persons complaining of digestive troubles really suffer from diseases of other organs; while sometimes affections of the stomach exist in connection with other diseases of organic nature. After having ascer- tained the condition of the thoracic organs a special examination of the abdominal organs should then be instituted. Inspection. The general appearance of the patient very often affords us an idea of the-nature of his illness, especially with regard to its severity, whether we have to deal with some serious trouble or with an affection of only a functional character. The emaciated and sallow look of a patient suffering from cancer and the well- nourished rosy face of a patient with a neurotic dis- turbance of his digestion are striking examples of what can be made out by a mere glance. We must inspect first the oral cavity and inform ourselves about the condition of the teeth, gums, tongue, uvula, and pharynx. Defective and carious teeth sometimes give origin to gastric disorders. In olden times the tongue was regarded as a mirror of the stomach, so that every gastric affection was judged by the aj)pearance of the tongue. Although nowadays we know that there are conditions in which the stomach is diseased and still the tongue has a nor- mal appearance, and vice versa conditions where the stomach is in no way affected and still the tongue INSPECTION. 23 heavily coated, it is nevertheless true that many gas- tric affections go hand-in-hand with changes in the appearance of the tongue. The tongue may at times he thickly furred or may appear very shiny and gray ; sometimes it may show indentations around its margin, sometimes again it may look red and dry like leather. In the pharynx we sometimes discover catarrhal conditions or swollen follicles. The uvula is sometimes very much elongated and may in this way give cause to some reflex digestive troubles. The inspection of the neck will sometimes disclose a swelling to the left of the larynx, which increases after partaking of food and may he due to a diverticulum of the oesophagus. The inspection of the abdomen should never be neglected. The contours of the stomach are at times visible in patients with thin abdominal walls, and es- pecially if the stomach is either extraordinarily large or displaced downward. Osier' not long ago laid much stress upon this simple method of examination, and ascertained that in many instances we can make the diagnosis of a dilated stomach by mere inspection. I can corroborate Osier's view, as I have had occasion in several instances of making a diagnosis of ectasia ventriculi by the mere visible outlines of the stomach. Tumors may sometimes be seen and recognized as such. Their position will already give us a clew as to what organ they belong. By attentive inspection we sometimes notice peristaltic waves passing from left to ' W. Osier: "Lectures on Diagnosis of Abdominal Tumors." New York Medical Journal, 1894. 24 DISEASES OF THE STOMACH. right over a large area in the upper part of the ab- domen, which are caused by the muscular action of the stomach. If these waves are intense in character and persist for some length of time, then we have to deal with the condition called "peristaltic restlessness" of the stomach. Smaller peristaltic waves may be seen occasionally in the lower part of the abdomen and be due to a peristaltic movement of the small intestine. Palpation. Palpation is one of the best and most important methods of examination. A good clinician is as a rule an artist in palpation. The best way to prac- tise this method is as follows: The patient should assume an easy, comfortable, recumbent position; the physician stands to the right of the patient and places his right hand, which should not be cold, flat upon the abdomen. Palpation is first practised with the tips of the fingers without exerting much pressure. The en- tire abdomen may be examined in this manner by moving the hand from the left lower border of the ribs down to the left iliac region, going then to the right iliac region and then up to the margin of the ribs on the right side. If the patient contracts his abdomi- nal walls too much, it is best to divert his attention from the examination by conversing with him upon other topics. Very often then the abdominal walls will become more relaxed and palpation is rendered pos- sible. Pay attention to any resistance you encounter, also the sensitiveness or tenderness of the different re- gions. By this method of light and tender palpation PALPATION. 25 we may discover a tumor and determiDe its positioc, size, consistence, as well as its mobility. In examin- ing the lower part of the abdomen we also palpate the inguinal region and ascertain whether there are swollen glands or not. To determine the position of the abdominal organs it is always advisable to make use of both hands. The left hand should push the organ or region to be examined toward the jDalpating right hand. The colon is very often felt somewhat below the navel run- ning transversely across the abdomen as a ribbon-like body. The pulsating aorta, lying in the median line of the body somewhat above the navel, is also frequently very clearly felt. The spleen, if enlarged or displaced, can be distinctly explored especially during a deep in- spiration, the left hand of the examiner pressing the left hypochondriac region downward and the right hand palpating just below the margin of the left ribs. The kidneys are accessible to palpation if they are dis- placed downward or are movable. In examining the right kidney the left hand of the physician is placed behind the right lumbar region of the patient, pressing this part somewhat upward, while his right hand lies flat upon the right hypochondriac region, the patient being requested to take a deep breath. In examining the left kidney the position of the hand is reversed. The liver can be palpated when enlarged or when it is prolapsed. Palpation luith Exertion of Pressure. — ^This can be done with one or two fingers. The object of this method of examination is to test the degree of sensi- tiveness, tenderness, or pain fulness of different regions 26 DISEASES OF THE STOMACH. of the abdomen. In this manner the circumscribed painful area of an existing ulcer may be discovered or the diffused tenderness of the whole gastric region that is often met with in inflammatory conditions of this organ. Boas' has devised an algesimeter for the purpose of indicating at what degree of pressure pain is experienced by the patient. It is provided with a scale giving the different jDressures in weights; thus a pressure amounting to 5 or 10 kgm. in weight causes pain only in catarrhal conditions, whereas in ulcer of the stomach a weight of only half a kilo- gram produces intense pain. As a rule, I think we can dispense with this instrument. The amount of pressure exerted and felt b}^ the hand is thoroughly suflBcient to an experienced practitioner. Percussion. In percussing the stomach it is best to use finger percussion and to practise this procedure without much force. The object of this method of examination is to determine if possible the situation of the stomach. This organ, being as a rule partly filled with air, gives a tympanitic sound on percussion. It is, however, quite difficult to ascertain its exact size, as the large intestine may be filled with gas and also give the same tympanitic sound. For this reason Piorry^ suggested filling the stomach with water before resorting to per- cussion. The stomach when filled in this manner gives a dull sound, which can then be more easily differen- tiated from the tympanitic sound gf the colon. The ' J. Boas : " Diagnostik nnd Tlierapie der Magenkrankheiten, " i., p. 75, Leipzig, 1894. '^Piorry: "Die mitt§lbare Percussion," "Wiirzburg, 1828. PERCUSSION. 27 best way to examine the patient, according to Piorry, is to let him drink large quantities of water (about one litre) and to examine him when standing. The same method was frequently used afterward by Penzoldt.' Behio/ who is also a strong advocate of this method, giA^es the water, however, in fractional quantities. The patient first drinks one-fourth litre of water and is then examined ; he now takes the same amount, after which a second examination is made, and so on until the whole litre of water has been ingested. The area of dulness that is found on the abdominal wall is marked each time with a lead pencil. It is necessary to note whether the lower limit of this area has extended considerably farther down after the addition of each portion of water. In dilated stomachs the lower limit of this area will be found quite far down below the navel, whereas in normal stomachs the lower limit will usually be above it. According to Boas' the Dehio method furnishes a test of the tonicity of the gastric muscle. Boas asserts that in all cases where the lower limit of the dull area descends quickly after the further addition of the water there exists a kind of weakness or atony of the stomach. As the results obtained by the above methods of percussion are not always sufficient and clear, several other means have been introduced w^hich permit of a better recognition of the size of the stomach. The first, and so to speak clinical method, applied for this 1 Penzoldt : " Die Mageuerweiterung, " Erlangen, 1877. -Dehio- "Zur physikalipclien Diagnostik der meclianisclieu In- sufficienz des MageDs." Verhandl. des VIT. Congresses f. innere Medicin. 1888. ^ J. Boas : Loc. cit., p. 85. 28 DISEASES OF THE STOMACH. purpose is that devised by Frericbs' and consists in filling the stomach with carbonic-acid gas. It is done in the following way: The patient first takes 2 gm. of sodium bicarbonate in a half-glassful of water, then 2 gm. of tartaric acid also dissolved in the same quantity of water. The sodium bicarbonate coming in contact with the tartaric acid in the stomach gives rise to the development of carbonic-acid gas, which distends the organ. The contours of the stomach are now sometimes visible through the abdominal wall. If this is not the case percussion is now aT)plied in order to map out the tympanitic area. This method can certainly be very frequently applied and will prove useful to the practitioner. It has, however, two dis- advantages, one being that the quantity of gas is sometimes insufficient, and the other that it might be too large and give the patient a feeling of pressure in the stomach. In order to overcome these difficulties, Runeberg" first made use of a tube and a rubber bulb attachment that allowed the forcing of air into the stomach. Here the quantity of air can be easily regu- lated, the stomach examined in different states of dis- tention, and afterward the air removed through the tube. This is the method of examination most commonly applied and in dail}' use. Auscultatory Percussiofi. Auscultation by means of the stethoscope to the sounds produced by percussion has been practised by ' Frericlis : Cited from H. v. Ziemssen, "'Klin. Vortrage, " 1883, No. 12, p. 13. ''Runeberg: "Ueber kunstliche Aufblabung des Magens und des Dickdarms durch Einp-impen vonLuft." Deutsches Archiv f. klin. Medicin, vol. 34, p. 460. THE SPLASHING SOUND. 29 several observers, and recently warmly recommended by W. Pepper.' The patient holds the bulb of the stethoscope and moves it about while the physician percusses and maps out the abdominal organs. SOUXDS OF THE StOMACH. Tlie Splashing Sound {Clapotage) . Whenever the stomach is filled partly with liquid and partly with gas it is possible to produce a splasliing sound by striking the abdominal wall in the gastric region. This sound is distinctly audible at a short distance from the patient. Bouchard ^ made an extensive study of this splashing sound and considered it a sign of great diagnostic value in dilatation of the stomach. Nowadays we do not attach so much im- portance to the splashing sound j^erse. Dr. A. Eose"" and myself have recently examined a hundred cases for the existence of this symptom and found it present in many persons not troubled in any way with diges- tive disturbances. The importance of the splashing sound, in my opinion, is that wherever it is present or can be produced, it allows us to ascertain the position of the stomach. In dilated stomachs this sound can be produced over a very large area of the abdominal wall, extending sometimes far down to the pubes. Another point of importance seems to me to be the ' W. Pepper: "The Diagnosis and Treatment of Dilatation of the Stomach, " Medical Eecord, May 9th, 1896. ^ Bouchard : Gaz. hebdomadaire de Medecine et de Chirurgie, 1884. 2 A. Rose : "What is the Significance of the Splashing Sound of the Stomach?" New York Medical Journal, June loth, 1895. 30 DISEASES OF THE STOMACH. ease with which the splashing sound can be repeatedly produced. In cases of gastric dilatation and when the walls of the stomach are relaxed, even light tapping of the abdomen will always give rise to this sound. In normal conditions a splashing sound can sometimes be produced by striking the abdomen with the hand, but on repeating this procedure at once we will, as a rule, fail to produce it, as the stomach then con- tracts more or less, and it is necessary to wait quite a while until it has become relaxed before this sound can be again evoked. On examining the patient in the fasting condition the existence of the splashing sound is of value in show- ing that the stomach is not empty and hence abnormal. This, however, is not a reliable sign and I perfectly agree with Debove and Eemond ' that sometimes, although rarely, the stomach may be found empty notwithstanding a splashing sound. Moreover, the absence of this phenomenon in the fasting condition does not by any means warrant the conclusion that the organ is empty. In many instances I was able to persuade myself that the stomach contained con- siderable quantities of food notwithstanding the ab- sence of the splashing sound. 1. Deglutition Sounds. The deglutition sounds were first described by Kronecker and Meltzer.' When drinking there is at ' Debove et Remond : "Traite des maladies de I'estoraac," Paris. ''S. J. Meltzer: "Schluckgerausclie im Scrobiculus Cordis und ihre physiologische Bedeutung." Centralbl. f. die medicin. Wis- sensch., 1883, No. 1. SOUNDS OF THE STOMACH, 31 times a sound to be heard simultaneously with the act of deglutition which is termed the first deglutition sound. More frequently a second sound is noted about seven seconds after the act of deglutition. Both sounds can be heard at the ensiform process either by placing the ear at that spot or by means of a stethoscope. As a rule only the second sound is perceptible. If the first sound is present, the second sound may also appear or at times may be absent. The presence of these deglu- tition sounds permits us in some measure to judge about the permeability of the cardia, and their main diagnostic value consists in demonstrating their ab- sence, for then we are entitled to presume that the ingested liquid has not reached the stomach, but has remained in the oesophagus above the cardia. This is most often the case in strictures of the cardia, although occasionally this condition might be caused by a deficiency in the peristaltic motion of the oesophagus. 2. When the patient is drinking we can hear, by putting our ear to the abdominal wall corresponding to the gastric region, a kind of dripping sound, arising from the passing down of the fluid along the gastric wall. By mapping out exactly the spots over which the sounds can be heard while the patient is drinking we may at times be able to determine the contour and size of the stomach and form an idea whether the organ is enlarged or not. 3. O. Eosenbach' has suggested that the size of the stomach may be ascertained by giving the patient some water to drink and then blowing in some air by ' O. Rosenbach : " Der Mechanismiis und die Diagnose der Magen- insufiScienz. " Volkmann's,"SammL klin. Vortrage, " 1878, No. 153. 32 DISEASES OF THE STOMACH. means of a stomach tube. As soon as the end of the tube reaches the level of the water and ah' is blown in, a bubbling sound arises, which can be heard by placing the ear over the corresponding part of the abdominal wall, and the exact site marked out. As soon as the end of the tube is above the level of the water one can hear only the air striking the stomach wall, but unaccompanied with the bubbling sounds. By alter- nately raising and lowering the tube the height of the level of the fluid can be approximately determined. ■i. The succussion sound. This sound was first de- scribed and utilized for diagnostic purposes by Hippoc- rates. The method consists in shaking the patient and listening. If the stomach is considerably enlarged and contains liquid and gas, splashing sounds are pro- duced and can be heard at quite a distance from the patient. Such sounds also occur under other circum- stances if the patients change their position, for in- stance, when turning from one side to another in bed, and give rise to considerable annoyance. 5. Gurgling sounds may be heard when the stomach, which does not contain any liquid but some air or gas, suddenly contracts. Thus every one is acquainted by personal experience with the sound generated in the stomach when one is very hungry. As the Germans say: "The stomach growls." 6. Eespiratory sounds. Sounds arising synchro- nously with inspiration. These are heard especially in cases of gastric dilatation or of gastroptosis, or where the stomach occupies a vertical position, particularly in women who wear corsets. The sound may as- sume two characters, according to its mode of pro- GASTROSCOPY. 33 duction: One sound is produced during the act of inspiration by the gliding of the abdominal wall over the stomach when distended with gas. It is similar to the sound that is produced by the cello, and may per- haps be explained by reason of the gas being compressed and forming a resounding surface which is set into vibration by the movements of the abdominal wall. The second sound is caused by the rise and fall of liquid during the act of respiration. It has a some- what si)lashing or squirting character. These sounds are very frequently met with and especially heard in ladies' society. 7. Sizzling sounds. These can be heard only on direct auscultation, and are produced by gas forming quickly in the stomach. They are normally found after the introduction into the stomach of bicarbonate of soda and tartaric acid, carbonic-acid gas being set free and giving rise to these sounds. Pathologically they are developed spontaneously and are a positive sign of fermentation going on in the stomach and con- sequently of stagnation of food. 8. Einging sounds. These have been described by Laker' in a case of dilatation of the stomach. They are synchronous with the heart sounds and can be heard at quite a distance from the patient. Gastroscopy. The object of this method of examination is to look into the stomach and to ascertain the condition of the 'Laker: "Ueber ein rhytmisches Klangphanomen desMagens." Wiener med. Presse, 1889, Nos. 43 and 44. 3 34 DISEASES OF THE STOMACH. gastric mucosa. This method was inaugurated hy Mikulicz' in 1881. The gastroscope is similar in shape and construction to the cystoscope, but much larger iu size."" This method of examination has not, however, come into practice, and will hardly ever prove of much value; the chief reason being that a stiff metal tube has to be inserted into the stomach, which is hard to manage and causes great discomfort to the patient. As in all cases in which we have to deal with cancer or with other grave lesions of the stomach, there is always suspicion of an ulcer, this means of exami- nation would not only be inconvenient, but also dan- gerous on account of the risk of perforation. Gastrodiaphaxy, or Traxsillumixatiox of the Stomach. The method of transilluminating living tissues was first applied by Cazenave in 1S15. Milliot* in 1867 tried to transilluminate the stomach of animals, and used for that purpose a narrow glass tube in which there were two thin platinum wires connected with the electrodes of a Middeldorpf's apparatus. In 1889 I' succeeded in transilluminating the stomach of human • Mikulicz : " Ueber Gastroskopie und CEsophagoskopie. ' "Wiener med. Presse, 1881, No. 45. 2 Remark : Recently Th. Rosenheim, of Berlin, has constructed a new oesophagoscope and gastroscope. For details see "Ueber die Besichtigung der Cardia nebst Beraerkungen tiber Gastroskopie." Deutsche med. Wochenschr. , 1895. No. 45. ^Milliot: Schmidt's Jahrbucher, Bd. 136, p. 143. ••Max Einhorn : "Die Gastrodiaphanie. " New Yorker med. Monatsschrift, November, 1889. "Ou Gastrodiaphany." New York Medical Journal, December 8d, lS9'i. The Journal of the American Medical Association, 1893. G ASTRODI APH ANY . 35 beings by means of a soft-rubber tube at one end of which is fastened an Edison lamp by means of a small metal mounting. From here conducting wires run to the battery. At some distance from the rubber tube there is a current interrupter. I have called this ap- FiG. 5. — ^The Gastrodiaphane CEinhorn). paratus the gastrodiaphane and the method of trans- illuminating the stomach, gastrodiaphany. The aims of gastrodiaphany are: 1. To ascertain the exact position and the size of the stomach. 2. To recognize tumors or thickenings of the front wall of the stomach by their lack of translucency. Of late 36 DISEASES OF THE STOMACH. many investigators have busied themselves vrith this method of examination: Heryng and Eeichmann,' Renvers,* Pariser/ Stewart, Ewald, Kuttner and Jacobson.* Martins and Meltzing," Stockton, Frieden- wald,^ M. Manges,' and many others, and all have come Fig. 6.— Transilluminated Zone of a Normal Stomach (51. S.). The dotted area in the centre shows the spot which was more luminous, being nearer to the lamp. to about the same conclusion as I have. Meltzing especially has written a very extensive and elaborate ' Heryng und Reichmann : Therap. Monatshefte, 1892. ^Renvers: Ver. f. innere Medicin, April 4th, 1892. sPariser: Berl. klin. AVochenschr. , 1892, No. 32. ■•Kuttner and Jacobsohn : Berl. klin. Wochenschr., 1893, No. 39. ^Meltzing: Zeitschr. f. klin. Medicin, 1895. « J. Friedenwald : " Electric Illumination of the Stomach. " Mary- land Med. Joum., Jan. 20th, 1894. ' M. Manges : " The Value of the Modem Diagnostic Methods in Diseases of the Stomach."' Medical Record, Februarj' 2d, 1895. GASTRODI APH AN Y . 37 paper on gastrodiaphany and has tried to determine the normal position of the stomach by this means. Method of Examination. — The patient, in a fasting condition, drinks one to two glassfuls of water. The apparatus, lubricated with glycerin or simply moist- ened in water, is then inserted into the stomach and Fig. 7. — ^Transilluminated Zone of a Dilated Stomach (patient Wm. U.). connected with the battery. The examination is made in a perfectly dark room, either in the standing or re- cumbent position of the patient. The stomach trans- mits the electric light through the abdominal walls, and it thus becomes visible as a red zone at that place of the abdomen which corresponds the position of the stomach. In case the gastric front wall is occupied by a tumor, the latter will not transmit the light and 38 DISEASES OP THE STOMACH. will be recognizable as a shady spot within the red zone of the transilluminated organ. The accompanying illustrations obtained from pa- tients whose stomachs have been transilluminated by the gastrodiaphane in different conditions explain themselves. Fig. 8.— Transilluminated Zone of a Dilated Stomach (patient H. O.). The dotted area in the centr shows the spot which was more luminous, being nearer to the lamp. Roentgen Rays. Whether the Eoentgen rays will be of material aid in the examination of the stomach, is quite difficult to state at the jDresent time. As we have just seen, the gastrodiaphane enables us to recognize the shape and situation of the stomach and occasionally also tumors EXAMINATION OF THE FUNCTIONS. 39 favorably situated for this procedure. Whether the X-rays of Eoentgen will do more, further investiga- tions will have to demonstrate. Examination of the Functions of the Stomach. Secretory Function. Ewald and Boas* have studied the normal condition of gastric secretion in man. According to their ob- FiG. 9.— Transilluminated Zone of the Stomach in Gastroptosis (from Mrs. P. F.). servations, as soon as food enters the stomach, this organ begins to secrete its specific juice and continues to do so until the food has passed into the intestine. During the last period, however, the secretion is but ' Ewald and Boas : Virchow's Archiv, vol. 101, p. 325. 40 DISEASES OF THE STOMACH. very slight. That is the reason why examinations of the gastric contents reveal different results if made at various periods after partaking of food. In order to be able to judge in an exact manner whether the gas- tric secretion is normal or not, we must always make the examination under equal conditions, that is, after Fig. 10.— Result of Gastrodiaphany in a Patient with Carcinoma of Stomach. Dark area represents situation of tumor. a certain meal. Several test meals have been proposed for this purpose. 1. Leuhe-BiegeV s Test Dinner. The oldest form of test meal is the test dinner of Leube and Eiegel. This consists of a large plate of EXAMINATION OF THE FUNCTIONS. 41 soup (about 400 c.c), a large portion of meat (beef- steak or something of that kind), some potatoes, and a roll. The time for examination is about three to four hours after the partaking of this meal. 2. The Test Breakfast of Ewald and Boas. This is taken in the morning in a fasting condition and consists of one to two rolls (35-70 gm.) and one cup of tea or water (300-400 c.c). Time for examin- ation, about one hour after the meal. 3. Germain See''s Test Meal. This consists of 60-80 gm. of scraped meat and 100-150 gm. of white bread. Examination takes place two hours after the ingestion of the food. 4-. Klemperer^s Test Meal. This consists of one pint of milk and two rolls. Ex- amination takes place two hours afterward. The two test meals that are mostly in use are the Leube-Riegel's test dinner and Ewald-Boas' test breakfast. In 1888 I' made a comparative study of the results obtained three to four hours after the test dinner, and those derived in the same cases one hour after Ewald's test breakfast. In some persons I was able to find free hydrochloric acid after the test break- fast, but not after the test dinner. Besides, the degree of acidity was more constant in the same individual after the test breakfast than after the dinner. More- 'Max Einhorn : "Probemittagbrod oder Probefriihstuck." Berl. klin. Wochenschr., 1888, No. 32. 42 DISEASES OF THE STOMACH. over, we are able to recognize some remnants of food from the previous day much more easily after the test breakfast than after the test dinner. As the test breakfast consists only of water and rolls, any other particles of food found in the gastric contents, as for instance meat, asparagus, would indicate that these substances have been left there from a previous meal. The test dinner being quite a complicated meal, does not allow us to recognize this so clearly, and it is necessary to examine the patient again in a fasting condition in case there is suspicion that the motor func- tion of the stomach is impaired. These advantages have also been recognized by other authors, and now- adays almost all agree in preferring the test breakfast to the other test meals. The stomach contents may be obtained for purpose of examination by the following methods : By means of the soft-rubber tube and either as- piration or expression. In using the tube it is best to have one with several openings at the lower end and to attach a small glass tube about three to five inches in length to the upper end (see Fig. 11). The tube is first immersed in a pitcher of warm water. The pa- tient is provided with a bib or towel around his neck and sits on a chair, holding a wide-mouthed bottle in his left hand, near his chest ; the physician takes the tube from the pitcher, places the glass end piece into the bottle, tells the patient to open his mouth, and in- serts the tube, pushing it forward into the pharynx. (The physician need not insert his finger into the mouth of the patient.) The patient is now told to swallow once or twice, and the tube is rapidly pushed EXAMINATION OF THE FUNCTIONS. 43 with the right hand into the stomach (about 44-4:5 cm.). In using aspiration, one can either attach a Politzer bulb over the glass piece (Ewald) or Boas' aspirator, Fig. 11.— Ewald's Stomach Tube. which consists of a rubber bulb having two soft-rub- ber ends provided with a clamp (see Fig. 12). The bulb is first compressed and then released, and in this way aspiration is secured and the bulb fills itself with the gastric contents. Ewalcl-Boas'' expression method : The expression method consists in having the patient exert pressure upon his stomach by means of his abdominal muscles. This is best done by telling the patient first to inspire deeply and then to compress his abdominal walls in the Fig. 13. — Boas' Aspirator. same manner as during defecation. The pressure ex- erted in this way upon the gastric contents expels them through the tube into the bottle. This expres- sion method is now almost exclusively practised every- 44 DISEASES OF THE STOMACH. where. It is the easiest and best way of obtaining the gastric contents. Before removing the tube, it is necessary to occlude the glass opening with a finger of the right hand and to withdraw the instrument quickly from the stomach. (By closing the opening we avoid the return of some of the food particles contained within the tube into the oesophagus or pharynx; the tube is then emptied into the bottle containing the stomach contents.) The ingesta obtained in the above-described way one to one and a half hours after the test breakfast are then filtered, and the filtrate is subjected to the following tests: 1. Reaction. "2. Hydrochloric acid. 3. Lactic acid. 4. Acidity. 5. Propeptone. 6. Pep- tone. 7. Pepsin. S. Eennet ferment. 9. Dextrin. 10. Erythrodextrin. 11. Achroodextrin. 12. Maltose. Examination of the Ingesta. 1. The Reaction Is determined by means of litmus paper (blue and red). If the filtrate is acid it turns blue litmus paper red. 2. Hydroch loric Acid. Many coloring matters undergo some change when brought together with even weak solutions of free hydrochloric acid. Methyl violet (weak one-per-cent. solution) turns blue; fuchsin is slightly discolored; tropseolin (saturated solution) turns from yellow to dark red-brown ; benzo-purpurin turns from intense red to light red; Congo red (one-per-cent. solution) or Congo pajDcr turns from red to dark blue. Of all these EXAMINATION OF THE INGESTA. 45 colors, I think Congo red is the most reliable one. As organic acids when present in considerable quantity may also give these color changes, it is of great im- portance to have another reaction for hydrochloric acid which the organic acids do not show. Gilnzburg^s Phloroglucin- Vanillin Test. — Giinz- burg' first taught us such a test with his phloroglucin- vanillin solution. This solution contains two parts phloroglucin, one part vanillin, and thirty parts alco- hol. The test is made in the following manner: One drop of the filtrate is put on a porcelain dish. A drop of the phloroglucin-vanillin solution is added and well mixed with a glass rod. The porcelain dish is now heated over a spirit lamp and the fluid allowed to evaporate slowly. The presence of even small quan- tities of hydrochloric acid gives rise to a beautiful cherry -red color. If there be only traces of free hydro- chloric acid, the margin of the examined spot turns cherry red. Boas'' " Besorcin Sugar Test. — The solution consists of resorcin 5.0, sach. albi 3.0, alcohol ad 100. The test is made exactly in the same way as with the phloroglucin-vanillin solution. The hydrochloric acid is recognized by giving a cherry -red color with the Boas reagent. This test is also very reliable, but, as I* have shown, less sensitive than the Giinzburg re- action. ' Giinzburg : " Neue Methode zum Nachweis f reier Salzsaure im Mageninhalt." Centralblatt f . klin. Medicin, 1887, No. 40. 2 J. Boas : " Ein neues Reagens f iir den Nachweis freier Salz- saure im Mageninhalt." Centralbl. f. klin. Medicin, 1888, No. 45. ^Max Einhorn : "Die neueren Methoden der Magenunter- suchung.-' New Yorker medicinische Monatschrift, Marz, 1889. 46 DISEASES OF THE STOMACH. 3. Lactic Acid. Uffelmann^s Test. — The best test for lactic acid is made with the Uffelmann' solution, which has always to be freshly prepared before use. It consists of a two- per-cent. carbolic-acid solution in water, to which is added a drop of sesquichloride of iron. This test solu- tion has an amethyst-blue color. Place about 2 c.c. of this Uffelmann solution in a test tube, and add a few drops of the filtrate. The presence of lactic acid brings on a canary -yellow color; the presence of fatty acids produces an ashy-gray color, whereas inorganic acids decolorize the blue color of the Uffelmann solution. As some phosphates are liable to give the same re- action with the Uffelmann solution as lactic acid, and as these salts are very often present in the gastric con- tents, the surest way to discover the presence of lactic acid in the filtrate is the following: 5 or 10 c.c. of the filtrate are well shaken for quite a while in a test tube with a double quantity of ether. Then the tube is allowed to stand a few minutes until the ether has separated from the watery solution. Pour the ethereal portion into another test tube, which is placed in a glass of hot water, so as to allow its contents to evajD- orate. After evaporation has taken place, only a few drops remain in the test tube. Add 1 to 2 c.c. of dis- tilled water and test for lactic acid with the Uffelmann solution. If a canary-3''ellow color now arises, the presence of lactic acid is positively shown. Instead of evaporating the ether Fleischer' recom- ' Uffelmann : Deutsches Archiv f. klin. Med., toI. 26, p. 481. 'Fleischer: "Milchsaurenachweis ini directen Aether. " Cited from Penzoldt : Deutsch. Arch. f. klin. Medicin, Bd. li., p. 544. EXAMIXATIOX OF THE IXGESTA. 47 mends testing the poured off ethereal extract directly with the Uffelmann solution ; the presence of lactic acid gives the canary-yellow color above described. Boas^ Procediu^e for the Qualitative Determination of Lactic Acid. — The principle of this method con- sists in the fact that when solutions of lactic acid are treated and heated with oxidizable substances, a split- ting of these occurs into acetaldehyde and formic acid, according to the following formula: CH3 - CH (OH) - COOH = CH3 - CHO - CHOOH. Lactic acid Acetaldehyde Formic acid. The method of procedure is as follows: Take 10-20 c.c. of the filtrate and evaporate in a porcelain dish over the water-bath to a syrupy consistence. (If hy- drochloric acid was present, then the addition of barium carbonate during the evaporation is neces- sary.) Add a few drops of phosphoric acid, expel the carbonic acid by boiling, and after cooling, extract with small portions of ether (two or three times, 50 c.c. each). After stirring for half an hour pour off the clear layer of ether. The ether is now evaporated ; the residue, taken up witb ■±5 c.c. of water, is well shaken and filtered. To the filtrate add 5 c.c. of con- centrated sulfihuric acid (sp. gr. 1.89) and a knife- pointful of manganese. The mixture is now distilled and the vapors conducted into a cylinder which con- tains either o-lO c.c. of an alkaline solution of iodine {i.e., equal parts of decinormal iodine solution and standard potassium -hydrate solution), or the same quantity of Xessler's reagent. If lactic acid is pres- ent, the aldehyde escapes with the vapors and gives 48 DISEASES OF THE STOMACH. rise to the formation of iodoform (turbidity and iodo- form smell, Lieben's reaction), or (with Nessler's rea- gent) of the yellowish-red aldehyde of mercury as shown by the yellow color. On the same principle, Boas also devised a quantita- tive method for determining the amount of lactic acid. This new test has certainly a scientific value, but thus far it has remained without practical imjDortance. The procedure is quite complicated and hardly gives more accurate results than the usual test of Uff elmann described above. ^. Acidity. The degree of acidity is examined by adding a drop of a one-per-cent. alcoholic solution of phenol jDhthalein to 10 c.c. of the filtrate and adding again as many cubic centimetres of a one-tenth normal sodium -hydrate solution until a slightly red color arises. The amount of cubic centimetres of the one-tenth sodium -hydrate solution required for that purpose is multiplied by ten and expressed with this figure — i.e., the degree of acidity is expressed by the number of cubic centimetres of a one-tenth normal sodium-hydrate solution re- quired to saturate or make slightly alkaline 100 c.c. of the filtrate. Thus if we find that 10 c.c. of the filtrate require 6 c.c. of the one-tenth normal sodium-hydrate solution in order to bring on the red color after the addition of phenolphthalein, we say the acidity is 60. The figure of acidity multiplied by 0.00365 gives the percentage amount of hydrochloric acid. If, for in- stance, the acidity is 60, then the percentage of hydro- chloric acid will be 60X0.00365 = 0.219 per cent. EXAMINATION OP THE IXGESTA. 49 Tne different elements comprising the acidity, and their quantitative determination, we shall describe later on. 5. Propeptone. The digestive action of the stomach results in the formation of propeptones and peptones from the al- buminates. The best test for the presence of propep- tone is the addition of an equal part of a saturated solution of sodium chloride to a small quantity of the filtrate. Propeptone then, if present, is precipitated, and the solution becomes the more turbid the greater the quantity of propeptone. In case no precipitate is formed, add a drojD or two of acetic acid, then the solution will turn turbid in case propeptone is present. If heated the solution clears up again, and when allowed to cool the projDeptone precipitates anew, and the solution again turns turbid. 6. Peptone. A few cubic centimetres of the filtrate (best after having precipitated the propeptone and filtered) are made strongly alkaline by the addition of some sodium - hydrate solution and a few drops of a weak (one-per- cent) sulphate-of -copper solution added. The presence of peptone gives rise to a purplish or violet-red color (biuret reaction). 7. Pepsin. A thin disc (1 cm. in diameter and about 1 mm. thick) of the white of a hard-boiled egg is put into a test tube containing 5 c.c. of the filtrate and kept at blood temperature. If hydrochloric acid is not 50 DISEASES OF THE STOMACH. jDresent in the filtrate, it is necessary to add two drops of the dilute muriatic acid. The presence of pepsin effects a disintegration or a disappearance of the egg disc in two to six hours. S. Bennet Ferment. Take about 5 c.c. of milk in a test tube and add three to four drops of the filtrate. Mix thoroughly and keep the tube in a glass of warm water. In about ten to fifteen minutes the milk becomes curdled. In case coagulation does not occur in an hour or two, then no rennet ferment is present, although rennet zymogen may exist. To test for the latter, it is necessary to add to the same specimen of milk a few drops of a oue-per-cent chloride -of- calcium solution, and again allow it to stand a few minutes. If the milk remains uncurdled even then, there was no ren- net zymogen present, otherwise the coagulation would have taken place. 9-12. Tlw Products of Starch Digestion. The starchy derivatives resulting from the action of the ptyalin-digestion begun in the mouth and con- tinued in the stomach, consist of erythrodextrin, ach- roodextrin, and maltose. A few drops of Lugol's solution (iod. 0.1, potass, iod. 0.2, aq. dest. 200.0) are added to a small quantit}^ of the filtrate. The presence of (9) dextrin turns the fluid blue; (10) ery- throdextrin gives rise to a red color. The (11) achroo- dextrin discolors the yellowish tint of the Lugol solu- ion, while (12) maltose does not change the color of the solution. For maltose or sugar, we can besides make use of Trommer's test. EXAMINATION OF THE INGESTA. 51 In the healthy condition, the results of the analysis of the stomach contents one to one and a half hours after the test breakfast are as follows : acid reaction ; free hydrochloric acid present ; lactic acid not present ; total acidity varying from 40-60 (=0.015-0.21 per cent hydrochloric acid) ; propeptone present in small amount; peptone in larger proportions; pepsin and rennet present ; sugar present ; achroodextrin present; erythrodextrin present in small amounts or absent; dextrin absent. From these normal standards we find many deviations in the sick, and we shall have to in- vestigate later on the chemical processes in the stomach in all disturbances of this organ. Although the above tests will suffice for the great majority of cases, we find it necessary to give a few ad- ditional methods which are not complicated and which will serve to determine several factors in the gastric analysis more minutely. The acidity of the gastric contents is as a rule due to acid salts, acid compounds of albumin, and free acids (hydrochloric and lactic, and sometimes various organic acids). It is some- times of importance to ascertain the presence, respec- tively the quantity, of each of these factors sep- arately. Volatile Acids. The presence of fatty or volatile acids is recognized by boiling a few cubic centimetres of the filtrate in a test tube. A strip of wet, blue litmus paper is held over the vapors escaping at the top of the test tube. Their presence will turn blue litmus paper red. The quantity of these fatty acids can be ascertained by boiling 10 CO. of the filtrate for about half an hour, 52 DISEASES OF THE STOMACH. adding to the residue sufficient distilled water until the quantity araounts again to 10 c.c, and now de- termining the degree of acidity in this liquid by phenol- phthalein and sodium hydrate. This figure sub- tracted from the figure of the total acidity of the fil- trate will give the quantity of the fatty acids. Acetic Acid. Acetic acid if present in larger quantities can easily be detected by its characteristic smell; if present in smaller quantities it may be detected by neutralizing the watery residue of the ethereal extract with carbon- ate of soda, and then adding neutral chloride-of-iron solution, when a beautiful red color is developed. Estimation of Lactic Acid. The quantitative determination of lactic acid may be made in the following way: 10 c.c. of the filtrate are well shaken with a larger quantity of ether. The ether is then separated from the watery solution and the degree of acidity determined in this. By subtract- ing the figure thus obtained from the total acidity and multiplying by 0.09, we have the percentage of lactic acid. This method presupposes the absence of vola- tile acids: if they are present, they have to be first eliminated by boiling. The further steps in the proc- ess of determining the quantity of lactic acid will then be performed in the way described. Estimation of Free Hydrochloric Acid. This can be done by any one of the following methods: EXAMINATION OF THE INGESTA. 53 1. Mintz's' Method.— Ho 10 c.c. of the filtrate de- cinormal sodium hydrate is added in such a quantity that a drop of the mixture no longer responds to Giinz- burg's phloroglucin-vanillin test. The amount of the decinormal soda solution used multiplied by ten gives the figure of the free hydrochloric acid. The per- centage of free hydrochloric acid can be obtained from this figure in the same manner as above stated for the total acidity, by multi^Dlying it by 0.00365. 2. Method of Moerner^ and Boas.^ — The degree of acidity of free hydrochloric acid is here determined either by Congo paper or by a one-per-cent solution of Congo red as an indicator v^hich turns blue in the pres- ence of the acid. The decinormal soda solution is then added until the blue color begins to turn red. Boas takes 5 c.c. of the filtrate and 5 c.c. of the watery Congo-red solution (one per cent). I myself add only one or two drops of the same solution to the filtrate. The estimation is done in the same way as before. 3. Toejpfer^s* Method. — Toepfer makes use of dime- thylamido-azobenzol in a half-per-cent alcoholic solu- tion for the recognition and the estimation of the amount of free hydrochloric acid. Hydrochloric acid even in small quantities gives a red color with this in- dicator. The decinormal solution of sodium hydrate is added until the red color disappears; a faint yellow color arises. This method has been thoroughly ' S. Mintz : "Eine einfache Methode zur quantitativen Bestim- murig der f reien Salzsaure im Mageninhalt. " Wiener klin. Woch- enschr., 1889, No. 20. ' Moerner : Maly's Jahresbuch f. Thierchemie, vol. 19, p. 253. 3 Boas: Ceotralbl. f. klin. Medicin, 1891, No. 2. ■* G. Toepfer : Zeitschr. f. physiolog. Chemie, Bd. 19, Heft i.,. 1894. 54 DISEASES OF THE STOMACH. studied in this country by J. Friedenwald ' and highly recommended. From m}' own experience I would recommend this method for the quantitative determination of free hydrochloric acid, when the presence of the latter has been first demonstrated byGiinzburg's test; for lactic acid, if present in considerable quantity, may also give a positive reaction with Toepfer's solution. In a paper on this subject " which I published very recently it can be easily seen that lactic acid, if alone present, responds to Toepfer's test even if it exists in a percentage above 0.1, and in gastric contents if present in a percentage of 0.2, Estimation of Combined Hydrochloric Acid. The combined hydrochloric acid may be determined according to Toepfer by titrating with alizarin until the appearance of a violet color, and deducting the found acidity from the total acidity with phenol- phthalein as an indicator. Toepfer asserts that aliz- arin is sensitive for all the elements comprising the acidity except for the combined hydrochloric acid. In case free hydrochloric acid is absent, and it should be important to ascertain whether combined hydro- chloric acid is present, the following method suggested by Sjoequist ' and modified by Ewald ' may be applied: 10 c.c. of the filtrate are mixed with about one-half ' J. Friedenwald : Medical Record, April 6th, 1895. 2 Max Einhorn: "The Dimethylamido-azobenzol or Toepfer's Test for Free Hydrochloric Acid. " New York Medical Journal, May 9th, 1896. 3 Sjoequist: Zeitschr. f. physiolog. Chemie, 1887, vol. 13, Heft 1-2, p. 1. *C. A. Ewald : "Diseases of the Stomach," p. 39. EXAMINATION OF THE INGEST A. 55 gram barium carbonate in a platinum capsule. The fluid IS then evaporated to dryness and reduced to ashes. After cooling, the residue is dissolved in hot water and filtered. Several drops of a concentrated soda solution are now added to the filtrate. If the fluid remains clear, hydrochloric acid is totally absent. If a precipitate forms after the addition of the soda solution, then the amount of this precipitate will allow us to judge approximately of the quantity of com- bined hydrochloric acid. Estimation of Acid Salts. Leo'S Jlethod. — The presence as well as the quan- tity of acid salts is best determined by Leo's' method. A few drops of the filtrate are put in a watch glass and a small amount of powdered, chemically pure cal- cium carbonate is added, stirred with a glass rod, and the reaction tested with blue litmus paper. If it turns red, then acid salts are present, for the calcium carbonate combines only with the free acids but not with the acid salts. Leo's method for determining the quantity of free and combined acid is based on the principle that cal- cium carbonate neutralizes free and combined hydro- chloric acid, but not the acid salts at ordinary temper- atures. As the degree of acidity of acid phosphates is larger when calcium chloride is present, and inas- much as this salt is always developed in small quan- tities after the addition of calcium carbonate, Leo de- termines the acidity before and after the addition of the latter, having added calcium chloride to both. One proceeds as follows : 'Leo: "'Eine neue Methode zur Saurebestimmung im Magen- inlialt." Centralbl. f. die med. Wissenschaft. 1889, No. 26. 56 DISEASES OP THE STOMACH. After the separation of all organic acids from the filtrate, 10 c.c. (first portion) are taken, and 5 c.c. of a concentrated calcium -chloride solution added and the degree of acidity is determined by phenolphthalein and a decinormal sodium-hydrate solution. Fifteen cubic centimetres of the filtrate of the gastric contents (second portion) are again taken and mixed with powdered, chemically pure calcium carbonate and filtered. Of this filtrate 10 c.c. are taken and placed in a bottle provided with a rubber stopper in which are inserted two glass tubes, one short and the other reaching down nearly to the bottom of the bottle. To the upper end of this long glass tube is attached a piece of rubber tubing terminating in a bulb, by means of which air can be introduced into the bottle. After the air has been blown in for some time, in order to drive out the carbonic acid that has formed, the acid- ity of the solution is determined with phenolphthalein and decinormal sodium -hydrate solution. By sub- tracting the figure of acidity obtained from the second portion from that obtained from the first, we have the amount of acidity corresponding to the free and com- bined hydrochloric acid. If no organic acids have been present in the filtrate, the last-obtained figure, subtracted from the total acidity, will give the quantity of acid salts. Other More Complicated Methods for the Determin- ation of the Quantity of Hydrochloric Acid. Method of Hehner and Seemann.^ — 10 c.c. of the filtrate are neutralized with a decinormal standard 'Seemann: Zeitschr. f. klin. Medicin, vol. v., p. 272. EXAMINATION OF THE INGESTA. 57 solution of sodium hydrate, evaporated to dryness over the water bath, and calcined over the flame. The residue consists of neutral salts + carbonate of sodium. The latter is determined in the following manner: The residue is washed with hot water and filtered as long as the filtrate gives an alkaline reaction. This filtrate is then titrated with a decinormal standard solution of sulphuric acid, until a slightly acid reaction aT^ses. The amount of the decinormal standard sul- phuric-acid solution used corresponds to the amount of inorganic acid. The difference between this figure and the figure of the total acidity expresses the amount of free and combined hydrochloric acid. Method of Hay em and Winter.^ — The principle of this method consists in the determination, first, of the total amount of chlorides ; second, of the fixed chlorides (chloride salts); and third, of the amount of chlorides combined with acids. Proceed as follows : In each of three porcelain dishes (a, 6, c) place 5 c.c. of the filtrate. To dish a an excess of carbonate of sodium is added. All the three dishes are then evaporated to complete dryness over a water bath. A solution of carbonate of soda is now added in excess to dish h and the contents are again evaporated to dryness. All the three dishes are then calcined over a Bunsen burner, but the heat- ing should not be carried too far, and the calcination ^hould be arrested when there are no more points of ignition. To dishes a and h a slight excess of pure nitric acid is added and then some distilled water. After boiling the contents of these two dishes (a and 6), they are thrown on a filter. Dish c is treated with ■ Hayem et Winter : " Du Chimisme Stomachal, " Paris, 1891, p. 72. 68 DISEASES OP THE STOMACH. boiled water aloue and then also filtered. The amoutit of chlorides contained in the three different filtrates is then determined by a decinormal standard solution of nitrate of silver in the presence of yellow chromate of potassimn as indicator. Dish a shows the total amount of the chlorides (T = chlore total), h = com- bined + fixed chlorine, and c=F = chlore fixe; h — c corresponds to the amount of combined hydrochloric acid = C = chlore combine; a — h corresponds to the amount of free hydrochloric acid = H = free hydro- chloric acid. The total acidity is determined by titra- tion with a decinormal sodium-hydrate solution and phenolphthalein as mentioned above. Determination of the Hydrochloric Acid Deficit. Honigmann and von Noorden* advised that the amount of combined hydrochloric acid in cases in which free acid is lacking be determined by the amount of decinormal standard hydrochloric-acid solution required, in order to give a positive reaction for free hydrochloric acid, or they really determined the deficit of hydrochloric acid which exists in the filtrate, in order to combine with all the proteids. The more of the decinormal hydrochloric-acid solu- tion it is necessary to add in order to give a positive reaction for free acid, the less the amount of combined hydrochloric acid in the filtrate. I do not think that this procedure is very important, for the degree of acidity alone already gives us a sufficient clew as to 1 Honigmann und von Noordeu ; Zeitschrift f. klin. Medicin, Bd. xiii. EXAMINATION OF THE INGESTA. 59 this condition. Moreover, the amount of peptone and propeptone qualitatively found in the filtrate will also indicate the greater or smaller amount of combined hydrochloric acid. If there is no combined hydro- chloric acid whatever, then there will be no biuret reaction present. During the last six or seven years a host of methods have been described, serving the purpose of determin- ing analytically either the free and the combined hydrochloric acids or the chlorides. "We need only mention the methods of Sjoequist,* Martins and Luettke,^ and the above-described procedures of Hehner-Seemann' and Hay em-Winter.* All of these are quite complicated and far from being exact. It has been found that the gastric contents include con- siderable quantities of ammonia (NHg) in the form of ammonium chloride (NH^Cl). All the methods men- tioned are based on results obtained under the applica- tion of heat, notwithstanding the fact that the latter will lead to the evaporation of ammonia and the for- mation of free hydrochloric acid. The error which thus arises merely from this circumstance exceeds ten per cent (Rosenheim,^ H. Strauss, ° and others). But besides the errors of these analytical methods, it has been found by the most eminent authors that in refer- ence to treatment and diagnosis we do not derive from ' Sjoequist : L. c. "^ Marti us and Luettke : "Die Magensaure des Menschen," Stutt- gart, 1893. ^Seemann: Zeitschr. f. klin. Medicin, vol. 5, p. 272. ^ Hayem et "Winter : " Du Chimisme Stomachal, " Paris, 1891, p. 72. ^Th. Rosenheim: Centralbl. f. klin. Medicin, 1892, No. 39. «H. Strauss: Berl. klin. Wochenschr., 1893, No. 17. 60 DISEASES OF THE STOMACH, these tests any more data than from the simple method of titration and determination of free hydrochloric acid (Honigmann,' Von Xoorden,'H. Strauss, Eosenheim). For this reason I did not think it necessary to give a detailed account of all analytical methods. For practical purposes the determination of the total acid- ity (A = aciditas), of free hydrochloric acid (L = acidum hydrochloricum liherum), ancl the qualitative test for lactic acid as above detailed will suffice. In some in- stances Leo's method may also be applied ; in this way the quantity of combined hydrochloric acid (C=acidum hydrochloricum combinatum) and the quantity of acid salts may be ascertained. Co7itr a- Indications to the Use of the Stomach Tube. The application of the tube is not advisable in cases of recent hemorrhages, no matter whether from the stomach or from the lungs, in all cases of fresh ulcers of the stomach, aortic aneurism, and in markedly cachectic and debilitated persons. In cases in which there is a mere suspicion of an ulcer, some authors employ the soft-rubber tube, while others are opposed to its application. Other Methods of Testing the Gastric Secretion. Notwithstanding the great importance of the results derived from chemical analysis of the stomach contents obtained by means of the soft-rubber tube, this com- paratively new method has not as yet been generally 'Honigmann: Berl. klin.Wcchenschv. , 1893, Nos. 15 and 16. ^C. TonNoorden: Berl. klin. Wochenschr.. 1893, No. 18. EXAMINATION OF THE INGESTA. 61 adopted by the medical profession, for the reason that the examination by means of the tube is often unpleas- ant and repugnant to the patient. Moreover, some patients absolutely refuse to undergo this method of examination. To obviate these difSculties several other methods have been devised : 1. Giinzhurg''s^ Method. — Patient swallows 0.2 gm. potassium iodide enclosed in a small rubber bag fastened with fibrin threads. After the disintegration of the fibrin by digestion, the rubber bag opens and the po- tassium iodide is now set free and ready for absorp- tion. As soon as iodine is detected in the saliva, we are sure that the fibrin has been digested and from this Giinzburg concluded the presence of hydrochloric acid. This method, though ingenious, is not adapted for practical purposes, for while, on the one hand, it necessitates examining the saliva for quite a period of time (one to two hours), on the other hand the appear- ance of iodine in the saliva does not conclusively prove that the fibrin has been digested in the stomach. The rubber bag may have escaped into the intestines, the fibrin may have been digested there, and the potas- sium iodide absorbed. Thus we cannot reach any de- cisive conclusion as to the condition of gastric secretion by this method. The same remarks apply to Sahli's method, which corresponds in most respects to the one just described. 2. Spallanzani and Edinger^s Sponge Method. — Edinger^ fastened a small sponge to a silk thread which he caused his patient to swallow. After several 'Giinzburg: Deutsche med. Wochenschr. , 1889, No. 41. ^Edinger: "Zur Physiologie und Pathologie des Magens," Deutsch. Arch. f. klin. Medicin, toI. 28, 1881. 62 DISEASES OF THE STOMACH minutes he withdrew the sponge from the stomach, and examined the contents squeezed out for hydro- chloric acid. This method, which had heen practised before by Spallanzani, is deficient in the following par- ticulars: 1. The sponge is jDartly squeezed out during its withdrawal through the narrow passages (cardia and introitus oesophagi), and thus much of the gastric contents obtained is lost. 2. It absorbs some of the secretions of the oesoiDhagus and pharynx. Thus the few remaining drops of gastric contents in the sponge are impure (that is, mixed with other fluids) and some- times are altered in their chemical state. 3. Stomach Bucket (Einhorn^) . — The bucket consists of a small capsule-shaped vessel (If cm. long, f cm. wide) made of silver; on the top there is a large opening surmounted by an arch to which a silk thread is tied, and a knot made at a distance of sixteen inches from the attachment. Method : In order to obtain a sample of the stomach contents, proceed as follows: The bucket is dipped into lukewarm water, filled and emptied. (This serves to make the inside of the vessel moist, so that it will more easily take up the contents of the stomach.) Then the patient is asked to open his mouth widely, and the bucket is placed on the root of the tongue (almost in the pharynx) ; the patient should now swallow once or twice. The vessel after a short time (one to two minutes) enters the stomach. As soon as the knot of the thread is at the lips the bucket is in the stomach, for the dis- ' Max Einhorn : "A New Method of Obtaining Small Quantities of Gastric Contents for Diagnostic Purposes. " Medical Record, July, 1890. EXAMINATION OF THE INGESTA. 63 taDce from the teeth to the cardia is usually sixteen inches. The vessel is left there for about five min- utes and then withdrawn. During the withdrawal of the apparatus a resistance is usually felt at the introitus oesophagi. To overcome this difSculty, when the apparatus is at that narr^ow point the pa- tient should swallow. By the act of swallowing the larynx is pushed for- FiG. 13— The Stomach Bucket (Ein- horn). 1, Small size; 8, large size ; 3, top view. Fig. 14.— The Stomach Bucket Set. ward and upward, and thus the passage is free and the bucket can be withdrawn easily. If the stomach is not empty, the bucket returns filled and the amount is sufficient for making various important tests. In people suffering from an abundant secretion of the mucous membranes the bucket might become filled with mucus before entering the stomach, and then in emptying the vessel one would find clear mucus in- stead of chyme. In such cases it is necessary to make the trial again and to cover the opening with a thin gelatinous capsule, which keeps away the mucus from 64 DISEASES OF THE STOMACH, the vessel on its way to the stomach ; there the capsule is dissolved and the stomach contents can now enter the apparatus. On its return from the stomach, the bucket being filled, the mucus cannot to any extent enter it. The best time for obtaining a sample of the stomach contents is one hour after Ewald's test breakfast. This way of obtaining a small quantity of gastric contents for examination does not give any trouble, nor does it cause any exertion to the patient. Even in ulcer of the stomach there is no danger whatever from hemorrhage as a consequence of the examination. For this reason the method seems to be especially adapted to all cases where there is suspicion of an ulcer in the stomach, and where we desire to avoid the tube. It is also suitable for the general practitioner who does not intend to make an exact analysis of the gastric contents, but who desires to determine whether there exists free hydrochloric acid or not. The gastric con- tents withdrawn in the bucket are examined directly without being filtered, in the following w^ay: 1. By means of blue litmus paper it can be deter- mined whether the contents are acid ; if so, the paper turns red. 2. With Congo paper whether there are free acids or only acid salts. The presence of free acids turns Congo paper blue, otherwise the Congo color is not changed. 3. If there are free acids it is necessary to find out whether there is hydrochloric acid present or not. For this purpose take one drop of the contents and one drop of Giinzburg's solution and mix them thorough EXAMINATION OF THE INGESTA. 65 ly in a white porcelain dish. This dish is now heated over an alcohol lamp; when the fluid evaporates, a cherry-red color appears in the same spot whenever hy- drochloric acid is present even in a very small amount. 4. The amount of hydrochloric acid, or the acidity, can be approximately determined by gradually diluting one drop of the contents with water until the above- mentioned GiJnzburg's reaction for hydrochloric acid begins to disappear in the diluted fluid. Normally the stomach contents can be diluted from eight to ten times and yet will give the Giinzburg reaction. In this way^ cases in which we are able to dilute only five times, or even less, must be considered as cases of subacidity (too small amount of acidity), and cases in which we are able to dilute more than twelve times as cases of hyperacidity or superacidity (too large amount of acidity). In cases in which no acidity whatever is found, we have to deal with anacidity. 5. Pepsin and rennet, the two ferm,ents of the stomach, generally accompany each other, and we can deduce the presence of one from that of the other. We prove the presence of the ferments by making the following test for the rennet ferment : Two drops of the stomach contents are mixed with about 2 c.c. of milk and kept either in a warm place or in a glass with warm water. The presence of rennet curdles the milk in from ten to twenty minutes. Dr. Dickinson,' of Erie, Pa., has made a comparative study of the results obtained after an examination by ^ Dickinson : " A Comparative Study between the Results Ob- tained by Examination of the Stomach Contents by Means of a Stomach Tube and Einhorn's Stomach Bucket. " Medical Record, September 15th, 1894. 66 DISEASES OF THE STOMACH. means of the tube and a minute analysis of the fil- tered gastric contents, and the result gained after ex- amination with a stomach bucket and the coarse method of analysis just described. He examined thir- teen persons by means of both methods, and found that the results harmonized pretty closely. The de- gree of acidity corresiDonded quite accurately to the figure obtained by dilution. The examination with the tube is as a rule prefer- able to that with the stomach bucket, as the quantity of gastric contents obtained with the former is cer- tainly larger, and permits a more detailed examina- tion. Wherever, however, the examination with the tube is either contraindicated, or where the patients refuse its introduction, the examination with the bucket will certainly be able to replace the tube and afford us more thorough information as to the se- cretory functions of the stomach. Exact Determination of the Quantity of Chyme within the Stomach. The quantity of chyme can, as a rule, be determined by having the patient empty the contents of his stom- ach through the tube by means of the expression method. The quantity can then be directly measured, and will give the exact figure of the gastric contents, provided we are positive that the stomach is now empty. This may be determined by blowing air through the same tube into the stomach ; if no bub- bling sound is heard, but merely the sound produced by the air on striking the gastric walls, the orgaii EXAMINATION OF THE INGESTA. 67 may be regarded as empty. Occasionally, however, it is quite difficult to withdraw the eutire quantity of gastric contents (especially in cases of dilatation of the stomach with stenosis of the pylorus). In the latter instance, the quantity of the gastric contents can he ascertained by the procedure described by Mathieu and Eemond.' This is done in the following manner: Some time after a meal a small portion of the contents is obtained by the ordinary expression method. Then the tube, while still within the stomach, is attached to the funnel arrangement (ordinarily used for lavage) and a certain quantity of water (usually 200 c.c.) poured into the stomach. By moving the funnel up and down several times and by having the patient shake his abdomen thoroughly, a complete mixture of the ingested water with the contents is soon accom- plished. Another portion of the mixed gastric con- tents is now obtained. By determining the degree of acidity in the first and second portions separately, the amount of the original quantity within the stomach can be easily found, according to the following cal- culation: If b represents the undiluted portion with- drawn, a the acidity of this liquid, a the acidity of the diluted portion, q the quantity of water introduced into the stomach, — the amount of acid being the same in the diluted liquid as in the original undiluted gastric contents, — the following equation is obtained: ax = aq-|-ax which is equivalent to aq a — a ' Mathieu et Remond : Soc. de biolog., 8 Nov., 1890 68 DISEASES OF THE STOMACH. The quantity of liquid originally contained in tlie stomach is then represented by the formula : y = b + _M_ a — a or the quantity of contents originally in the stom- ach is equal to the number of cubic centimetres of water poured in within the stomach, multiplied by the degree of acidity of the second portion, divided by the figure resulting by deducting the degree of acidity of the second portion from the first, plus the portion previously withdrawn. Abnormal Constitnents of the Gastric Contents. The gastric contents are sometimes mixed with some abnormal products, which may be of importance with regard to diagnosis. They may contain mucus, bile and intestinal juice, blood, and pus. Mucus, if present in considerable quantity, is easily recognized. It usually occujDies the upper part of the fluid, presents a more watery color, and can be partly lifted from the surface by means of a glass rod on account of its adhesive quality. If it is present only in small quantities, its existence in the gastric filtrate is best revealed by adding a few drops of dilute acetic acid, which then forms a characteristic precipitate, settling on the bottom of the vessel. Bile and Intestinal Juice. — Small quantities of bile and intestinal juice in the stomach are often met with, even normally in examination of the patient in the fasting condition. The tube probably produces a slight regurgitation of the duodenal contents into the stom- ach. The frequent occurrence of considerable quanti- EXAMINATION OF THE INGESTA. 69 ties of bile aud intestinal juice within the stomach is always due to some abnormal condition, either to a relaxation of the pylorus or to a stenosis of the duo- denum, situated below the mouth of the bile duct. The presence of bile is easily noticed, either by its golden-yellow color or (if mixed with gastric juice) by its more greenish aspect. Whenever there is doubt as to the presence of bile, the usual test which serves for its detection in the urine may be applied. The presence of intestinal juice is recognized by its characteristic ferments, amylopsin, steapsin, trypsin. 1. The filtrate is mixed with one-j)er-cent solu- tion of carbonate of sodium until it has a decided- ly alkaline reaction. A flake of fibrin is then added to the filtrate, which is kept in a warm place for quite a while. The fibrin will then dissolve by the action of the trypsin. 2. Starch will be changed into maltose by the action of the amylopsin. 3. To a small portion of milk add a drop of blue lit- mus tincture and a few cubic centimetres of the neu- tralized filtrate and keep at blood temperature. The presence of steapsin very soon changes the blue color, and the milk becomes slightly reddish (caused by the decomposition of the fat into the fatty acids through the steapsin). Blood. — Blood, if present in considerable quantities in the gastric contents, is very easily recognized. Fresh blood can hardly be mistaken for anything else, if present even in small quantities. The gastric contents mixed with blood present either a reddish or (if the blood is not fresh) a slightly brov/nish or coffee-ground 70 DISEASES OP THE STOMACH, color. Occasionally, if the blood is present in large quantities, the contents may appear black. The detec- tion of blood in gastric contents which do not present the appearances just mentioned must be made in the following manner: 1. A drop of the contents may be examined under the microscope for the presence of red blood cor- puscles. 2. By the Spectroscope. If the presence of fresh blood is suspected the filtrate of the gastric contents may be directly examined with the spectroscope. Blood, if present, will show the two lines of theoxyhse- moglobin. If the blood is not fresh, or if the gastric contents include a considerable quantity of free hydro- chloric acid, then, according to Weber' and BoaSj^'the ordinary examination with the spectroscope would not show the presence of blood, as the hsematin is not soluble in the filtrate. H. Weber therefore suggested the following procedure : 3. To the gastric filtrate add a few cubic centimetres of concentrated acetic acid, and shake thoroughly with sulphuric ether. The latter presents a Tokay-wine color if hjemoglobin or hsematin is present. 4. Heller^s Blood Test. A small quantity of the gastric filtrate in a test tube is mixed with the same quantity of normal urine, and sodium-hydrate solution is added until a decided alkaline reaction is obtained. The tube is now heated over the spirit lamp until it begins to boil. The appearance of a flaky dark-red 'H. Weber: Berliner klin. Wochenschr., 1893, No. 19. ^J. Boas: "Diagnostik und Therapie der Magenkrankheiten, " Tbeil 1, 3te Auflage, p. 206. EXA-MIXATIOX OP THE IXGESTA. ^1 sediment proves blood (the reaction consists in the formation of haematin and its combination with the precipitated phosphates). 5. Sdionhein-AJmen s Blood Test. An emulsion of equal parts of freshly prepared guaiac tincture and ozonized oil of turpentine {i.e., old oil of turpentine that has been exposed to the air) is poured into a test tube over the gastric filtrate : a white ring forms at the point where both mixtures meet, which ring assumes a Prussian blue color if haemoglobin is present. Instead of ozonized oil of turpentine the following solution, which was proposed by Hiihnerfeld, may be used: IJ Acid, acetic, glacial., ... ... 2 Aq. dest., ' . . . 1 Terebinthin. et spirit, vin. rectif., . . . aa 100 6. TeichmamVs Hcemin Test. A small quantity of the gastric contents is evaporated in a porcelain dish over a spirit lamp. A small part of the residue is placed on an object-glass and mixed with a quantity of pulverized common table salt. A drop of glacial acetic acid is poured over it, covered with a cover- glass, and slightly heated over a spirit lamp until small bubbles begin to rise. Another drop of acetic acid is now again added, and the specimen examined under the microscope. The presence of haemin crys- tals (rhomboid shape and beautiful reddish color) proves blood. T. KorczynsM and Jaworski^ s ' Blood Test. A small quantity of the filtered residue is placed in a small porcelain dish, a trace of chlorate of potassium ' Korczynski und Jaworski: Deutsche rued. Wochenschr. , 1887, Nos. 47-49, p. 35. 72 DISEASES OP THE STOMACH. and a drop of concentrated muriatic acid are added, and the mixture is slowly heated over a spirit lamp. After all the chlorine gas has escaped, one to two drops of a dilute solution of potassium ferrocyanide are added; a distinctly hlue color (Berlin blue) arises if blood is present. Pus. — Pus is very seldom found in the gastric con- tents and is recognized by its characteristic appear- ance under the microscope. Fig. 15. — A Specimen of Mucus in the Gastric Juice obtained from a Patient in the Fasting Condition, showing mucous corpuscles, amorphous -material, and few epi- thelial cells. Microscopical Examination of the Gastric Contents. (a) Gastric Juice. The microscopical examination of the gastric secretion found when fasting shows nor- mally some epithelial cells, cell nuclei, mucous corpus- cles, amorphous material, and some micro-organisms (see Fig. 15). The occurrence of snail-like cells in EXAMINATION OF THE INGESTA. 73 cases of hyperchlorhydria was first described by Ja- worski/ who considered them a great rarity. Boas,* on the other hand, is of the opinion that they are of fre- quent occurrence. The latter writer considered them as substances which have developed from the mucus under the influence of the gastric juice. I concur with Boas in his statement that the snails are frequently found, and would like to add that they may also be Fig. 16.— a Specimeu of Mucus in tbe Gastric Juice obtained from a Patient in the Fasting Condition, showing single snail forms and some lying in groups ; also amor- phous material and few epithelial cells. found in patients not troubled with hyperchlorhydria. I found them once in a patient with normal secretion, and once in some fluid which had been obtained from the oesophagus of a patient troubled with cancer of the cardia. The snails may lie separately or in groups (see Fig. 16). (b) Gastric Contents. The microscopical examina- tion of the gastric contents at the height of digestion 'Jaworski: Miincliener med. Wochenschr. , 1887, No. 32. ^ J. Boas : " Diagnostik unci Therap. der Magenkrankheiten, " Theil i., 3te Auflage, p. 212. 74 DISEASES OF THE STOMACH. (either one to one and a half hours after a test break- fast or three to four hours after a test dinner) will allow us to judge to a certain extent regarding the way the act of digestion has progressed. Normally only a few starchy granules are found, most of w^hich have already lost their characteristic spiral configuration. The muscular fibres have likewise already undergone deep changes and do not show diagonal stripes. Plant Fig. 1~.— a Specimen of Gastric Conteuis in the Fasting Condition from Patient K., with Carcinoma Ventriculi. a and 6, Partly digested muscle fibres ; c, starch granules ; d, fat globules ; e, yeast cells ; /, sarcinae. cells, fat in fine globules, and different kinds of micro- organisms are found in small numbers. The pres- ence of a large amount of unchanged starchy granules is most frequently found in cases of hyperchlorhydria, while unchanged muscle fibres, showing the diagonal stripes clearly, are found in cases with a diminished gastric secretion. The different varieties of micro-or- ganisms found in the stomach have been thoroughly EXAMINATION OF THE INGESTA. 75 studied by De Bary/ Miller/ Macfadyen/ Nencki," Abelous, ' Boas, ' and others. While a few years ago it was believed that no micro-organisms can develop in the stomach containing free hydrochloric acid in its juice, of late it has been proven by several authors that micro-organisms may thrive in the stomach even if it contains too large a quantity of hydrochloric acid — or, in other words, the hydrochloric acid (of the gastric Fig. 18.— a Specimen of Gastric Contents from Patient with Ischochymia, showing sarctnse, yeast cells, fat globules, and fat crystals. juice) does not always exclude fermentative processes in the stomach. Thus Kaufmann,' of New York, has described a case in which a condition of hyper- chlorhydria existed and in which the motor function of 1 De Baiy : Arch. f. «xper. Path, und Therap., Bd. 20, p. 243. 2 Miller : " Die Mikro-organismen der Mundhohle, " Leipzig, 1892. ^Macfadyen: Journal of Anat. and Physiol. , vol. 21, 1887. ^Macfadyen, Nencki, und Sieber : Arch, f . exper. Patholog. , Bd. 28. 5 Abelous : These de Montpellier, 1888. ^ Boas : Deutsche med. Wochenschr. , 1892. ' J. Kaufmann : Berl. klin. Wochenschr. , 1895, No. 6. 76 DISEASES OF THE STOMACH. the stomach was not markedly disturbed, but which notwithstanding microscopically gave all symptoms of fermentative processes. The gastric contents al- ways contained numerous living bacteria of various types. Dr. Kaufmann succeeded in separating the eight following micro-organisms from one specimen of the gastric contents by means of culture: (1) Yellow sarcinae; (2) white yeast; (3) Micrococcus aurantiacus Fig. 19. —A Specimen of Gasti-ic Conteuts One Hour after Test Breakfast (Patient with Hyperchlorhydria), sbowing many unchanged starch granules, yeast cells, and a great number of micro-organisms. (Cohen) ; (4) Staphylococcus cereus albus (Passet) ; (5) Bacillus subtilis; (6) Bacillus ramosus; (7) a large, thick bacillus; (8) a short bacillus, resembling the Bacillus coli communis. Boas has observed several cases in which, notwith- standing the presence of hyperchlorhydria, there was a decomposition of the albuminate of the food, result- ing in the development of sulphuretted hydrogen. I have lately observed two cases of this nature myself. EXAMINATION OF THE INGESTA, T? In cases with abnormal fermentative processes within the stomach, the same kinds of micro-organisms are usually found as in the normal stomach, only in much larger number (Minkowski).' Yeast cells and sarcinse occur in large numbers in cases with a distinct motor disturbance of the stomach (especially ischochymia). The sarcinse ventriculi, which were first described by Goodsir'^ in 1842, occur in cubes or tetrahedrons (see Fig. 20. — A Specimen of Mucus from the (Esophagus (from a Patient with Carcinoma Cardies, J. C. W.), showing mucus, bacteria, fat and epithelial cells, some of the latter grouped together. Fig. lY and IS), but they have only a, pathognomonic significance if they appear in very large numbers. (c) Small pieces of gastric mucosa. In washing out the stomach (especially in the fasting condition) occa- sionally a small piece of gastric mucosa may be found in the wash-water. Such a small piece of gastric mu- cosa may also be found occasionally in the gastric con- ' Minkowski : " Mittheilungen aus der med. Klinik zu Konigs- berg, " 1888. ^ Goodsir, cited from Ewald : " Diseases of the Stomach, " New York, 1892, p. 138. 78 DISEASES OF THE STOMACH. tents when examining the patient after a test break- fast or test dinner. Boas' was the first to make use of such specimens for microscopical examination. He was of the opinion that such an examination permits one to judge of the morbid anatomical condition of the given case. A short time afterward I observed that in some cases the occurrence of small pieces of gastric mucosa in the wash-water is a constant phenomenon. $\'iW^W!i Fig. 21.— Group N (Normal). A small piece of gastric mucosa (patient Mrs. H.) presenting a cross-section of the glands in normal appearance. X 80. The number of these pieces varies from one to four (see Erosions of the Stomach). During the last five years I had the opportunity to examine a great num- ber of such small particles of gastric mucosa, a large part of which belonged to cases of erosions of the stomach, the remainder to many other affections. Such a piece of gastric mucosa looks quite red. The thickness may vary from 4^ to 1 mm., while the size may vary from that of a large pin's head to that of a small ' J. Boas : L. c. , p. 225. EXAMIXATIOX OF THE IXGESTA. 79 bean. Sometimes they are found embedded in mucus. While the presence of glands in these small pieces may be found by examining them in the fresh condition under the microscope, a thorough examination can bo made only after a sufficient preparation of these par- ticles (hardening in alcohol, embedding in celloidin and staining with eosin, hsematoxyliu, picro-carmine, methylene blue, and thionin). ^'' C5^ Fig. 22.— Group C (Connective-Tissue Formation). A piece of gastric mucosa (from patient Mrs. K. A.) showing be- ginning atrophy of glands (small pale areas within the glands) and connec- tive-tissue proliferation. X 120. Fig. 23.— Gi'oup C (Connective-Tissue Fonnatiou). Apiece of gastric mu- cosa (from H. R. D.) showing the mouths of glands; the pale spots show beginning atrophy of the glands; con- nective-tissue proliferation best shown in lower part of specimen. X 120. In examining the microscopical picture of tbe dif- ferent specimens the following groups can be easily distinguished : 1. N = Xormal: glands and interglandular tissue exist in normal proportions. 2. C= Connective tissue: while there is a normal pro- 80 DISEASES OF THE STOMACH. portion between glands and iuterglandular tissue, there is a marked proliferation of connective tissue around the glands. 3. P = Proliferation: there is a marked proliferation of glands; they are nearer each other and some- times have an elongated and curved shape. 4. B = Beginning Atrophy : the glands exist in smaller :•/'••'/ .-i^-'-ivW till V :::rii"*.' ■':)*: :'-i:M "■tj/B-^P vvi»^ '^jmi hm^i Fig. 24. —Group P (Proliferation of Glands). A piece of gastric mucosa (from patient C. C), showing proliferation of glands. X 80. numbers, and are sometimes also smaller in size; the iuterglandular spaces being quite large and filled partly with small-cell infiltration partly with connective-tissue formation. 5. A = Atrophy: comjilete atrophy ; no glands visible only indications of their previous existence ; round- cell infiltration. EXAMINATION OF THE INGESTA. 81 A^= Vacuolization : within the glands exist vacuoles of different shape, being the result of a mucoid degeneration of some glandular cells. Fi». 25 — Group B (Beginning Atrophy). A piece of gastric mucosa (from patient B. E. ■s\'ith carcinoma cardise), showing destruction of glands by connective-tissue proliferation. X 60. Sometimes one specimen shows characteristics be- longing to two of the groups mentioned. For the beautiful execution of the drawings I am ^t;l^%' .^ Fig. 36.— Group A (Atrophy). A piece of gastric mucosa (from patient R. H. D.). No glands visible, only some empty spaces where glands had previously existed X80. indebted to Dr. C. A. Elsberg, who made them from my specimens (see Figs. 21 to 27). Although I think that the microscopical examination of these DISEASES OF THE STOMACH. pieces of gastric mucosa is of great interest and may occasionally help to supplement the diagnosis, I do not believe that it permits us to judge posi- tively about the original affection of the stomach, Fig. 27.— Group V ^Vacuolization). A small piece of gastric mucosa (from patient J. with carcinoma pylori), showing mucoid degeneration of the glands with vacuo- lization; some connective-tissue proliferation. X 140. for in some cases I have noticed in the microscopical picture very few small glands, the whole field hav- ing the appearance of atrophy, and still the gastric secretion was perfectly normal. On the other hand, I ' had a patient with distinct symptoms of chronic ' For further details see Max Einhorn : " The State of the Gas- tric Mucosa in Secretory Disorders of tlie Stomach," Medical Rec- ord, June 27th, 1896. EXAMINATION OF THE IXGESTA. 83 gastric catarrh and diminished gastric secretion in which the pieces of gastric mucosa found in the wash- water presented a perfectly normal appearance (Fig. 21). (d) Particles of tumors. In the gastric contents ob- tained after test meals, in the vomited matter, in the wash-water after lavage of the stomach, or within the tube after an exploratory examination, small particles Fig. 28.— a Piece of Tumor (from B. E.) Obtained after Examination with Stomach Tube. In fresh condition i: appeared white and was thicker and firmer than pieces of gastric mucosa. Cross-section presents all appearances of alveolar carcinoma. X 140. of tissue may be found. These, if examined under the microscope, may occasionally reveal the nature of a tumor, whether cancerous or not. The examination is of importance if a characteristic picture of a malig- nant type is discovered. Most frequently such pieces may be obtained in cases of cancer of the cardia. I append a drawing obtained from a specimen of such a small piece of cancerous tissue from a patient with cancer of the cardia (Fig. 28). 84 diseases of the stomach. Other Functions of the Stomach. 1. Tlie Absorptive Function of the Stomach. The absoriDtive fniiction of the stomach is as a rule tested by Penzolclt and Faber's' method. One to two decigrams of potassium iodide are administered in a gelatin capsule and the saliva is examined every minute or two for the presence of iodine. This is done in the following manner: Strips of starch paper (filter paper saturated with a starch solution and dried) are moistened with the saliva of the patient and then a drop of fuming nitric acid is added. The presence of iodine gives to the starch paper a slightly violet or blue color. Under normal conditions, it takes as a rule eight to fifteen minutes until the appearance of this reaction in the saliva. Herschell "^ described another method of estimating the absorjitive power by means of a capsule contain- ing 3 decigm. of powdered rhubarb. If the stomach be normal, this should appear in the urine in fifteen minutes and will give a red color with liquor potassse. According to my experience, the absorptive faculty of the stomach should always be examined under simi- lar conditions, as the results will differ materially whether the test is made in the fasting condition or when the stomach is full. It seems to me that in many instances several writers have not laid much stress upon this point, and in this way have come to wrong conclusions. ' Penzoldt und Faber : "Ueber die Resorptionsfahigkeit der ilienschlichen Magenschleinhaut und ihre diagnostische Verwer- thung." Bed. klin. Wochenschr., 1882. ^Herschell; "Indigestion," London, 1895, p. 115. OTHER FUNCTIONS OF THE STOMACH. 85 2. Motor Function of the Stomach. IJDder motor function, as a rule, is understood the peristalsis of the stomach and the motion of the in- gesta caused thereby within the organ, as well as the transportation of the food from the stomach into the intestines. I prefer, however, to distinguish that func- tion which serves the purpose of expelling the gastric contents (prochoresis) ' from the merely mechanical mo- tions to which the ingesta are subjected within the organ (anakinesis).'^ This latter function we shall describe later on under the heading of mechanical function. 1. Leube's Method. The oldest method of ascer- taining the condition of the motor function of the stomach is that first devised by Leube.^ It consists in washing out the stomach six to seven hours after a large meal (dinner). Normally the stomach is found empty at that time — that is to say, all the food has al- ready left the organ. Where large quantities of food are still found, it shows that the motor function is re- tarded. Washing out the stomach two to three hours after a smaller meal, like Ewald's test breakfast, may serve the same purpose, for normally the stomach is then found empty. 2. Eivald and Sievers'' Method. Ewald and Sie- vers^ have devised another, so to speak, clinical test, for the motor faculty of the stomach. The principle of the test consists in the property of salol, which is a ' 7] Ttpoxupwig, the advancing. 2 7j avaKLvrjaLg, the shaking. ^Leube: "Krankheiten des Magens und Darins. " Ziemssen'p '*Handbuch der spec. Path, und Therap.," Bd. 17, 2te Halfte. ■* Ewald und Sievers : "Zur Pathologie und Therapie der Magen- ectasien." Therap. Monatshefte, August, 1887. 86 DISEASES OP THE STOMACH. compound of phenol and salicylic acid, of not being decomposed in acid solutions. In relatively feeble alkaline fluids salol is decomposed into salicylic acid and phenol and then absorbed. The gastric contents always being acid, the salol will not undergo any changes there. After leaving the stomach, however, and coming in contact with the intestinal juices which are alkaline, it is quickly split up into its two components. The salicylic acid is then absorbed by the blood and eliminated through the urine as salicyl- uric acid. The latter is easily recognized in the urine by the violet color produced on the addition of neutral ferric-chloride solution. The salol test is made as follows: The patient takes 1 gm. salol in two gelatinous capsules half an hour after a slight meal. Before the ingestion of the caj)- sules he empties his bladder, and then urinates every half-hour for about two hours. All the different speci- mens of urine are then examined with ferric chlor- ide solution, and it must be ascertained in which speci- men the violet color begins to appear. Normally it requires about an hour until the appearance of salicyl- uric acid in the urine ; while in case of retarded mo- tion of the stomach it takes two hours and even longer. In order to detect the earliest trace of salicyluric acid, Ewald first advised treating the urine with ether and then making the test in the ethereal residue. After- ward Ewald and I ' suggested a, simpler method which permitted us to dispense with the ether. This consists 'Ewald unci Eiuhorn : '' Verhandlung. des Veieins f. innere Medicin, " 1888, p. 58. Max Einhorn : " Die neueren Methoden der Magenuntersuchung. " New Yorker mediz. Monatschr. , Marz, 1889. OTHER FUNCTIONS OF THE STOMACH. 87 in moistsning a piece of filter paper with the urine, and then placing a drop of ferric chloride solution by means of a glass rod upon the middle of the moistened paper. The edges of the drop will assume a violet color in the presence of even the smallest trace of salicyluric acid. These papers may be dried and preserved and in this way one can easily compare the reactions of the urine in the same patient at various times. Huberts Modification. Although normally, as a rule, the salicyluric acid appears in the urine about one hour after the ingestion of the salol, there are ex- ceptions in which even in healthy people the reaction is greatly retarded. For this reason Huber * suggested to determine the length of time required for the com- plete disappearance of the reaction in the urine ; for it is readily understood that the longer the time required for the salol to be absorbed and entirely eliminated through the urine the longer it has remained within the stomach. When the urine gives no reaction what- ever, it shows that the whole amount of salol has long since left the stomach, and has been eliminated from the organism. In case of retarded motion of the stomach, parts of the salol remain and leave this organ only after a very long time. In this way the reaction of the salicyluric acid will extend over a prolonged period. Huber found that normally the excretion of the salicyluric acid after 1 gm. of salol lasted twenty- four hours ; in patients with enfeeblement of the motor function of the stomach it lasted forty-eight hours or even longer. ' Huber : " Die Metlioden zur Bestimmung cler motorischen Thatig- keit des Mageris. " Corresporiflenzbl. f. Schweiz. Aerzte, 1890. 88 DISEASES OF THE STOMACH. The salol test, as suggested by Ewald or as modified by Huber, certainly gives a clew as to the condition of the motor function of the organ and is clinically of value, although either of them is by no means ab- solutely reliable. 3. Klemperer' s Oil Test. Oil is not absorbed by the stomach wall. If, therefore, a certain quantity of oil be ingested and the stomach emptied after a certain period, it will be possible to judge from the amount of oil withdrawn the state of the motor faculty ; for the greater the quantity of oil recovered the less has left the organ. Klemperer ' proceeds as follows: After washing out the stomach, he pours about 100 c.c. of pure olive oil into the empty organ. Two hours later the stomach is aspirated and whatever oil is left re- moved as thoroughly as possible. The difference be- tween the original quantity of oil and that with- drawn indicates the state of the motor function of the stomach. According to Klemperer, normally at this time only 20 to 40 c.c. of the oil ought to be found. This method, however, is complicated- and to some ob- jectionable; and as the results obtained by it do not allow more conclusions than the method of Leube, it has not come into extensive practical use. 4-. Examination of the Stomach in the Fasting Con- dition. The best and easiest way to test the motor, function of the stomach is to examine this organ,'by means of the tube and lavage, in the morning in the fasting condition after the ingestion of a substantial supper on the night previous. Normally the stomach * Klemperer : "Ueber die niotorisclieTliatigkeit desmenschiichen Magens. " Deutsche nied. Wochenschr. , 1888, No. 47. OTHER FUNCTIONS OF THE STOMACH. 89 is empty, and therefore when the organ is found to contain a quantity of food, this is the hest sign of retarded motion. This method is practically used by most writers. Mechanical Function. Under the mechanical function of the stomach we understand those changes which arise in the physical condition of foods and are produced by motions of this organ. These motions are of two characters : (1) active (peristaltic) and (2) passive (transmitted, respi- ratory, and pulsatory). Both motions shake the con- tents of the stomach and cause all parts of the food to come into direct contact with the gastric mucosa. The Gastrograph. — Until recently there was no way of ascertaining this mechanical function of the stom- ach in the living. All the experiments made with re- gard to this subject have been performed on laparoto- mized animals. These, however, scarcel}'" permitted any conclusions as to the manner in which peristalsis of the stomach normally takes place; for animals prepared for such experiments (after being chloro- formed or etherized) are certainly not normal. As the mechanical action consists in the churning of the contents, and as by estimating the latter we may determine the first, I have constructed an apparatus which indicates every motion to which it may be sub- jected. The whole apparatus comprises: 1. The ball (being the principal part). 2. A few electric cells. 3. The ticker. The ball (Fig. 29) consists of two hollow metallic 90 DISEASES OF THE STOMACH. hemispheres (a), which are screwed together ; within it is lodged and attached to the upper hemisphere, hut perfectly insulated from the same at the attachment, another ball provided with spikes (b) radiating in all directions, but not touching the inside walls of the hemispheres ; another very small platinum ball (c) lies within the large ball and can freely move in all direc- tions, knocking at the spikes (see Fig. 30). Two in- sulated wires — one connected with the hollow ball, the other with the spiked ball — ^are encased in a very fine, HfflfflaUBrasa Fig. 29. — The Ball Apparatus of the Gastograph (Einhorn). Natural size. thin rubber tube, forming the cable, and separate at the end into two branches, which must be attached to an electric battery. As soon as the platinum ball touches one of the spikes an electric circuit is made ; when, however, the platinum ball moves a little way and ceases to touch the spike the current is broken. At each motion of the ball apparatus a rolling of the little platinum ball takes place and the electric current is either closed or broken. When the apparatus is at rest there is no change in the current. On connect- ing the "ticker" with the battery and the ball, each motion of the latter will be recorded on the OTHEK FUXCTIOXS OF THE STOMACH. 91 paper in showing the '"breaks" and "makes" of the current. If the ball is swallowed and brought into the stom- FiG. 30. — Cross Section of the Ball, showing its Interior Construction. Enlarged three and a half times, a. The two hemispheres : 6, the spiked ball ; c, theplati- Tivan. ball. ach, the motions of the former — which are caused by the active and passive motions of the stomach — can be recorded in the way described. I have called this apparatus "gastrokinesograph." or, shorter, ''gastrograph.'- ' * The gastrograpb may be obtained of Eichard Kny & Co. , 17 Park Place, Xew York. 92 DISEASES OF THE STOMACH. From numerous tests which I have made, it appears with certaiDty that the gastrograph works in the de- sired manner — i.e., it indicates the motions of the hall and can thus he utilized for the valuation of the Fig. 31.— a Patient Undergoing Examination with the Gastrograph. motions of the stomach or the mechanical action of this organ. Method. — The hall is dipped in lukewarm water, in- troduced into the pharynx of the patient, and the latter OTHER FUNCTIONS OF THE STOMACH. 93 told to swallow. The patient may driDk some water. After a short while (from a minute to a minute and a half) the ball reaches the stomach. It is advisable to let the ball slip far down into the stomach, so that the distance from the mouth to the ball (length of cable) is about 50 cm. The cable is then connected with the battery and the indicator and the latter set agoing for three minutes (Fig. 31). The patient during this pro- cedure sits quietly on a comfortable chair. At the end of three minutes the indicator is checked, the cable dis- connected from the battery, and the ball withdrawn from the stomach. When at the introitus oesophagi, it is necessary, here in the same way as when using the bucket* or the deglutable electrode, to have the patient swallow, and to utilize the moment when the larynx goes upward and forward, to withdraw the ball without using any force whatever. The strip of paper which has rolled oii from the reel is cut off and the marks are then perused. The black line shows when the current was closed, the empty places when there was no current. As an instance I give a few gastrograms (reduced ten times) (Fig. 32). It is practical to enter the marks of the strips into a copy-book. This is done in the following way : Each line is divided into three equal spaces — each space cor- responding to one minute — each space (or minute) into ten divisions, and the "breaks" and "makes" of the current marked with dots at the corresponding place. In this way the number of current changes can very easily be looked over and comparisons made. » Max Einhorn, Medical Record, July 19th, 1890. 94 DISEASES OF THE STOMACH. (a) Physiological. — I have made several tests veith the gastrograph on healthy people. The experiments show that the stomach is not so inactive mechanically as several authors believed, and that it churns the contents almost contin- ously with slight periodical interruptions. The number of motions for three min- utes averaged from four to forty-one. When fasting, the mechanical action of the stomach seems to be much less than after meals. (b) Pathological. — Most patients have been examined with the gastrograph either when fasting or from an hour to an hour and a half after the test break- fast, taking about half a glassful of water when swallowing the ball; many of the patients have been examined under both conditions on different days. Some of them have been subjected to a very great number of tests, in order to ascer- tain whether there is a certain coiDstancy in the results. The whole number of patients examined was twenty-seven, the number of tests sixt3'-four. In perusing the gastrograms obtained from my patients and comparing them with those obtained from healthy people, there are three different classes among them. One corresponds to the normal ; the second class is marked with too much mechanical action, the number of dots being greatly increased ; the third OTHER FUNCTIONS OF THE STOMACH, 95 class shows a remarkable slowness and sluggishness of the mechanical function, the number of dots being reduced to 4, 3, or 0. Hemmeter-Morntz' s Method. — As the gastrograph does not permit of a distinction between the active and passive motions of the stomach, Dr. J. C. Hemmeter,' of Baltimore, has recently devised another method for testing the gastric peristalsis. The essential part of the apparatus is a deglutible elastic stomach-shaped bag of very thin rubber and attached to an oesophageal tube. The stomach-shaped pouch has the shape of the stom- ach only when it is blown up. It does not occupy much space when it is collapsed and can be introduced without difficulty into the stomach of patients. The oesophageal tube maybe very small, not quite half the size of the ordinary tube used in lavage. When the bag has reached the stomach, which can be determined by a mark previously made on the tube, it is filled with air and connected either Vv'ith a water manometer or tambour on the Ludwig kymograph. The slightest contraction of the involuntary fibres of the gastric mus- cle layer will compress the very elastic intragastric bag and distend the tambour, to which a glass bulb ink jDen is attached, recording the gastric peristalsis as the clockwork moves the paper along. On the upper mar- gin of the kymographion paper a record pen connected with a chronometer indicates seconds on the record by small dots, so that it is possible to determine the time of occurrence and duration of the gastric peristalsis. As the stomach perceptibly moves with every inspira- tion and expiration, a pneumograph is tied around the ' J. C. Hemmetei- : New York Medical Journal, June 22d, 1895. 96 DISEASES OF THE STOMACH. patient's waist recording every respiratory movement on the kymograph. It will be seen on the tracing that many movements of the pen connected with the intra- gastric bag are passive and cansed by the act of respi- ration, but there are other very high and long excur- sions of the gastric pen which are independent of the movement of the pneumographic pen, or occur when respiration is suspended for a short while. These are the muscular contractions proper of the stomach. The same method has been independently used and described by Moritz, of Munich. In his paper Hemmeter says : "In making studies on the kymograph on the gastric motility, only such pa- tients are taken as have become accustomed to the stomach tube, as the nausea and vomiting first attend- ing the initial introduction of the tube make an exact record impossible." This sentence shows that this apparatus cannot be applied without difficulty and for this reason appears unsuitable for practical purposes. Although the gas- trograjDh does not permit a distinction between the ac- tive and passive movements, it affords, nevertheless, an accurate idea as to the mechanical action as such, for the passive movements certainly also participate in this function of the stomach and should not be ignored. In this way I think that the gastrograph method, not being so complicated and being easily performed, pre- sents many advantages over Hemmeter's apparatus. CHAPTER III. DIET. Dietetics comprise the study of nutrition in health and disease and of the substances serving for this pur- pose (the diet). All living organisms derive their nourishment from the vegetable kingdom, either di- rectly, or indirectly by living upon animals which in turn live upon a vegetable diet. Foods are substances vs^hich are required for the nutrition and maintenance of the body ; they replace its wastes and losses. In studying the normal nutrition of man we perceive quickly that there is a great variety in the food of healthy persons with regard to the quantity as well as to the different food substances. Nevertheless, they all contain the three groups of food-stuffs : Albumin, carbohydrates, and fats. Thus, for instance, vegeta- rians live and thrive principally on vegetables ; the Es- quimaux, on the other hand, almost exclusively on ani- mal diet. The golden path, however, lies intermediate, and all authors (Voit, Pettenkofer, Hoffmann, Forster, and Gruber) recommend a combination of animal and vegetable food. E. Virchow likewise is of the same opinion, and expresses himself regarding this question as follows : " Although the Kirghez and the Esquimaux show us that health and life can exist through many generations on an exclusively nitrogenous diet — other tribes (Hindoos) live principally on non-nitrogenous food — still history shows us that the highest attain- 98 DISEASES OF THE STOMACH. meiits of the human race have emanated from nations who have lived and live on mixed diet." A mixed diet, taken partly from the vegetable and partly from the animal kingdom, is the most suitable form of nour- ishment. We obtain the greatest amount of carbo- hydrates from the vegetable kingdom, while a great deal of the albumin is derived from animal food. The relation between animal and plant albumin, according to Munk and Uffelmann,' should not be less than three to seven. As regards the quantity of food, according to the same authors, an adult doing a medium amount of work requires daily 118 gm. albumin, 56 gm. fat, and 500 gm. carbohydrates. Food only in small portions serves the purpose of re- constructing tissue waste ; in its largest part, however, it is used for generating the heat requisite for the maintenance of life. For that reason it is customary to speak of the necessary amount of heat units during twenty-four hours instead of the quantity of food. By "heat unit" is meant, as is well known, that quan- tity of heat which is required to raise the temperature of 1 gm. of water 1° C. "Great heat unit" means the amount of heat required for warming 1,000 gm. of water 1° C. Each kind of food is ultimately oxidized in the body to its end products, and is in greatest part exhaled in the form of carbonic acid ; the more carbon atoms a food-stuff contains the more heat units it will generate. In speaking of the heat value of food, the great beat units are used, the term "great," however, being omitted. Thus 1 gm. of albumin generates 4.1, 'Munk und UflFolniann : "Die Ernahrung des gesunden und kranken Menschen," Wien, 1887. DIET. 99 1 gin. of fat 9.3, and 1 gm. of carbohydrate 4.1 heat units. If we know the quantity of nourishment taken, the amount of the introduced heat units is easily deter- mined by multiplying the different food -stuffs by the above-given figures. The daily amount of heat gen- erated by the body, or necessary for the maintenance of the same, has been approximately estimated at twenty-five hundred heat units.' The heat value of the food taken by an average working person amounts, according to von Noordeu," to about forty heat units when working, and when resting to about thirty-four heat units per kilogram a day. The following table of the composition of the dif- ferent foods and the amount of heat units they produce will make it easy to figure out whether a certain known quantity of taken nourishment is sufficient to maintain the body in balance or not. COMPOSITION OF THE MOST COMMON FOOD SUBSTANCES. I. Dairy Products. Albumin, per cent. Fat, per cent. Carbohydrate, per cent. Calories, per 100. Cow's milk 4.0 to 4.3 3.61 0.5 0.5 3.0 3.35 25.0 33.0 12.5 3.0 to 3. 8 26.75 90.0 0.3 1.3 r 1 2.07^ I 30.0 9.0 12.0 3.7 3.52 0.5 3.6 3.0 0.7 lactic acid 1.9 alcohol 0.8 carbonic acid 3.0 5.0 0.5 64 Cream 276.01 Butter 837 Whey Buttermilk 3.67 Kumyss (of cow's milk) Cheese (cream) Cheese 32.99 394 240 Eg-p- 165 'Koetiig: "Die menschlichen Nahrungs- und Genussmittel, Berlin, 1883, p. 53. 2 Von Noorden : Berliner Klinik, Heft 55. 100 DISEASES OF THE STOMACH. II. Meats and Game. Albumin, per cent. Beef (fat) Beef (lean) Veal (fat) Veal (lean) Mutton (very fat) Mutton (leaner) Pork (fat) Pork (lean) Ham (Westphalian) . Sweetbread Pulverized meat Poultry Spring chicken Duck (wild) Squab Game Hare Venison 17.19 20. 78 18.88 19.84 14.80 17.11 14.54 20.25 23.97 22.0 64.5 22.0 18.49 22.65 22.14 23.0 23.34 19.77 Fat, per cent. 26.38 1.50 7.41 0.82 36.39 5.77 37.34 6.81 36.48 0.4 5.24 1.0 9.34 3.11 1.00 1.0 1.13 1.92 Carbohydrate, per cent. 0.07 0.05 'iVsb 2.28 1.20 2.33 0.76 O.V9 1.42 Calories, per 100. 315.81 99.15 146.61 86.97 399.31 123.81 406.88 146.36 453.69 93.92 322.53 100 167.59 131.36 100.07 103.60 107.08 105.44 III. Fish. Albumin, per cent. Fat, per cent. Carbohydrate, per cent. Calories, per 100. Pike 18.5 20.61 17.09 15.01 22.30 4.95 19.5 28.04 0.5 1.09 9.34 6.42 2 21 o.h 17.0 16.26 0.75 2.85 0.45 o.'s 7.82 83.57 Carp 94.64 Shellfish 156.93 Salmon 132.93 Sardellen 113.83 Oysters 24 Salt herring Caviar IV. Cereals and Vegetables. Albumin, per cent. Fat, per cent. Carbohydrate, per cent. Calories, iper 100. Sago = . . . 0.5 8.5 10.0 6.0 4.5 6.82 9.5 2.0 to 5.0 traces 1.25 2.0 0.75 1.0 0.77 1.0 0.4 86.5 73.0 69.0 52.0 46.0 43.72 75.0 4.0 356.70 Wheat flour 345.78 Rve flour 342.50 Wheaten bread 245 Rve bread 216 Roll 213.87 Zwieback 356 Cauliflower 35 DIET. IV, Cereals and Vegetables. — Continued. 101 Albumin, per cent. Fat, per cent. Carbohydrate, per cent. Calories, per 100. Carrots 1.04 2.0 5.5 19.5 19.5 1.5 12.5 8.31 3.49 1.02 0.31 0.3 1.5 2.0 2.0 5.26 0.81 0.58 0.09 6.74 2.5 76.0 53.0 54.0 20.0 66.77 75.19 4.44 0.95 33 85 Asparagus 21 Rice 348.10 Beans 311 75 Peas 319.95 Potatoes 88 Oatmeal 338.80 Barley meal 323 Spinach 38 Pickles V. Soups and Beverages. AlbTimin, per cent. Fat, per cent. Carbohydrate, per cent. Calories, per 100. Milk soup with wheat flour 5.0 0.4 6.0 to 7.0 0.5 9.0 to 11.0 albumin + 1.79 to 6.5 peptone 8.0 to 10.0 1.5 8.8 3.12 12.38 0.5 0.7 3.25 0.6 0.5 0.5 i'.o* 3.0 5.18 5.35 6.0 15.0 55.0 11.0 28.6 0.3 0.3 113 Meat broth (ordinary) . . Meat juice (pressed) Beef tea r Leu he's meat solution. ^ Malt extract 358 30 Barley soup 60.96 Rice pap with milk Coffee 183.61 Tea Beer Porter 60 VI. Fruits. Free acid, per cent. Albumin, per cent. Fat, per cent. Carbohydrate, per cent. Apples 0.83 0.20 1.50 0.92 0.79 0.93 0.36 0.36 0.40 0.65 0.59 0.54 5.48 I'.SO 0.45 1.37 7 23 Pears 3 54 Plums 4 68 Peaches 7 17 Grapes Strawberries Chestnuts 1.96 1.01 38.34 Sugar cane 3.40 Honey 5.28 102 DISEASES OF THE STOMACH. AccordiDg to K. Yierordt ' an adult takes iu form of food a daily average of 120 gm. albumin, 90 gm. fat, 330 gm. carbohydrate (the relation of the nitrogenous food-stuffs to the non-nitrogenous being 1 to 4), and 2,818 gm. of water. The above-mentioned figures dif- fer from those given by F. Hirschfeld.' This author considers SO gm. of albumin as the lov^^est amount con- tained in a sufficient diet. Some experiments which IMiave made in order to determine the amount of nourishment taken by myself during the summer showed figures which resembled those of Hirschfeld. The quantity of albumin was 79.39, fat 54.3 and car- bohydrate 263.9; the total of heat-units equalled 1,912,5. The amount of heat-units per kilogramme a day was 32.2. Victuals are composed mostly of all the three food groups (albumin, carbohydrate, fat) and water, and contain in minute amounts the inorganic salts found in the body. We are accustomed to speak of easily digestible foods, and those difficult of digestion. The term of easily or less digestible cannot, however, be explained without some qualifications. Many writers judge the digestibility of foods by the length of time they re- quire for their digestion in the stomach. Penzoldt* has lately made many investigations with regard to the sojourn of food in the stomach in health. He, however, lays stress on the distinction between gastric ' K. Vierordt : " Grundriss der Pli5-siologie des Menschen, " 1887, 3 Auflage, pp. 288, 289. 2 F. Hirschfeld: Berliner klin. Wochenschr., 1893. No. 14. ' Max Einhom : " Dietetics in Diseases of the Stomach. " Medical Record, June 24th. 1893. * Penzoldt und Stinzing : "Handbuch der speciellen Therapie innerer Krankheiten," Jena, 1895. DIET. 103 and intestinal digestibility, the former being recog- nized by the length of time the food remains in the stomach, the latter being measured by its more or less complete utilization or assimilation, that is, the amount of residue excreted with the faeces. In giving a list of the digestibility of different foods I follow Penzoldt's views. A. Animal Foods. These comprise besides the flesh (muscles) of the different mammals, birds, and fishes several other por- tions of their bodies, as, for instance, various glands, brain, lung, liver, etc. Oysters and lobsters also be- long to this group. In most instances the digestibility of this group of foods corresponds to their richness in fat. The less fat they contain the more digestible they are. Thus we have the following list of animal foods classified according to their digestibility : Fat per cent. Calf's sweetbread, veal, cod-fish, pike, oysters 0.4 to 1 Beef, hare, spring chicken, pigeon, partridge, carp 1 to 1|- Mutton, pork 5 to 7 Goose, caviar, herring, salmon, eel over 8 The digestibility of food is greatly dependent on its quality and preparation. Young animals have soft and tender meat, whereas the flesh of old ones is tough. The different portions of the body vary also frequently in their digestibility. The time that has passed since the killing of the animal is also of impor- tance. Fresh meat which is yet in its rigid state is tough and therefore very indigestible. In the prepar- 104 DISEASES OP THE STOMACH. ation of the meat we must see that it is separated from all indigestible matter (fascia, tendons, cartilage). By pounding the meat the connective tissue surround- ing the muscle fibre is torn. By chojDping, scraping, or grinding the meat, its digestibility is increased. All other methods of preparing meat serve to improve its taste. For, according to Penzoldt, raw meat is more easily digested than that which has been boiled, broiled, or fried. The application of heat also di- minishes the danger of infection, as many micro- organisms are destroyed by it. Eggs are especially rich in albumin and fat. Ac- cording to Penzoldt, soft-boiled eggs (three minutes in boiling water) are easiest to digest. Then come raw eggs and scrambled eggs, while hard-boiled eggs and omelet souffle are difficult of digestion. (Soft-boiled eggs remain in the stomach one and three-quarter hours, hard-boiled, three hours). Milk is intended as the sole food of young animals and as such contains all the elements of a typical diet : (1) Albuminous substances in the form of casein and serum albumin ; (2) fats in cream ; (3) carbohydrates in the form of lactose or milk sugar ; (4) salts, chiefly calcium phosphate ; and (5) water. Milk does not stay in the stomach much longer than plain water and must therefore be considered very digestible. Several articles of food are obtained from milk : (a) Cheese, which is the casein precipitated with more or less fat, according as the cheese is made of skimmed milk (skim cheese), or fresh milk with its cream (Cheddar and Cheshire), or of fresh milk plus cream (Stilton and Double Gloucester). The precipi- DIET. 105 tated casein is allowed to ripen, by which process some of the albumin is split up with formation of fat. (6) Cream consists of the fatty globules encased in casein and which, being of lowest specific gravity, rise to the surface. (c) Butter or the fatty matter deprived of its casein envelope by the process of churning. {d) Buttermilk is the fluid obtained from cream after butter has been formed. It is therefore very rich in nitrogen. (e) Whey is the fluid which remains after the pre- cipitation of casein. It contains sugar, salt, and a small quantity of albumin. B. Vegetable Foods. All of these contain more or less carbohydrates, and the principal amount of carbohydrates of our diet is obtained from them. 1. Foods rich in proteids. Leguminous foods (peas, beans, lentils, etc.) contain a nitrogenous sub- stance called legumin, which is allied to albumin, in the proportion of twenty-five per cent. They form a chief source of the nitrogen of the food of vegetarians. 2. Foods rich in carbohydrates : (a) Cereals. Bread made from the ground grain obtained from various so-called cereals, namely, wheat, rye, maize, barley, rice, oats, etc., is the direct form in which the carbohydrate is supplied in an ordinary diet. Besides starch it contains gluten, a nitrogenous body, and a small amount of fat. White bread is easier to digest than brown bread. Various articles are made from fiour: sago, macaroni, biscuits. 106 DISEASES OF THE STOMACH. {b) Vegetables (rice, iDotatoes). They contain chiefly starch and sugar. (c) Green vegetables (cauliflower, asparagus, tur- nips, cabbage, carrots, spinach, string beansj are es- pecially rich in salts. Almost all vegetables are not eaten in their raw state, but after being cooked. The cooking produces the necessary effect of rendering them softer so that they can be more readily broken up in the mouth. It also causes the starch grains to swell up and burst and so aids the digestive fluids in penetrating into their substance. The albuminous matter is coagulated and the gummy, saccharine, and saline matters are re- moved. The conversion of flour into dough is effected by mixing it with water and adding a little salt and a certain amount of yeast. It is by the growth of the yeast which lives upon the sugar produced from the starch of the flour that a quantity of carbonic-acid gas and alcohol is formed. By means of the former the dough rises. By the action of heat during baking the dough continues to expand, and the gluten being coagulated, the bread sets as a permanently vesiculated mass. (d) Fruit (pears, apples, etc.). They all contain sugar and organic acids like tartaric, malic, citric, and others. C. Liquid Foods. Water is consumed alone or together with certain other substances added for flavoring purposes, tea, coffee, etc. Tea in moderation is a stimulant and contains an DIET. 107 aromatic oil to which it owes its peculiar aroma, an astringent of the nature of tannin, and an alkaloid, theine. The composition of coffee is very similar to that of tea. Cacao, in addition to similar substances contained in tea and coffee, contains fats, albuminous matter, and starch, and must be looked upon more as a food. Beer in various forms is an infusion of malt (barley which has been sprouted and the starch of which is converted in great part into sugar) boiled with hops and allowed to ferment. It contains from one to eight per cent of alcohol. Cider is the fermented juice of apples ; wine the fer- mented juice of grapes and contains from six or seven (Rhine wine and white and red Bordeaux) to twenty- four per cent (Ports and Sherries) of alcohol. Spirits obtained from the distillation of fermented liquors contain upward of forty to seventy per cent of ab- solute alcohol. Utilization of Food. The amount of utilization of the food by the diges- tive tract has been studied by Rubner, and according to his investigations the residues of the different food- stuffs, that is, the indigestible matter, are least under a diet of animal food and highest under one consisting of vegetables. He gave the following scale: Meat, eggs, macaroni, white bread, milk, rice, maize, carrots, cabbage, potatoes, brown bread. Diet in Health. The diet in health should not always comprise the most easily digestible substances. For by doing so we 108 DISEASES OF THE STOMACH, weaken our digestive system. Although it is not necessary always to choose the substances which are hard to digest, it is certainly not necessary to avoid them. The food should consist of mixed substances (easy and difficult to digest) and should always pre- sent a sufficient variety. As to the distribution of meals and also as to the predominance of the different food articles in diet it is impossible to give the same rule for all. Good use and custom is the best and most important guide. Dietetics in Diseases of the Stomach. Within the past five years important facts have been discovered which are of the greatest value in the treat- ment of diseases of the stomach, and the influence of which can be perceived like a red thread through the whole chapter of dietetics. It has been shown by von Noorden ' and others that emaciation in chronic dis- eases of the stomach is caused in the largest majority of cases — if not, perhaps, in all — not by specific poi- sons circulating in the organism, but by a smaller amount of food being taken. On the other hand, one might expect, judging from the universal law existing in the plant and animal kingdom of vicariousness or replacement in case of inability of the work of one organ by another similar one, that in grave disturb- ances of the digestive functions of the stomach the in- testines would do the work instead. This has been experimentally, as well as clinically, proven in the most infallible way. Several authors (Leube, Ewald, von Noorden) have observed that, in cases of atrophy of the ' Von Noorden : Berliner Klinik, Heft 55. DIET. 109 mucous membrane of the stomach in ^vhich the gas- tric secretion has entirely ceased, the patients can maintain their usual weight. In my paper on "Achylia Gastrica"' ' it is clearly shown that the pa- tients can do very well without gastric secretion ; under a proper regimen they can even gain in weight, and live long without any discomfort whatever. That means that even after the loss of the entire chemical action of the stomach, the gut is completely able to replace the function of the stomach. These two facts — (1) that the emaciation in chronic diseases of the stomach is caused by too small a quan- tity of food ; (2) that even in grave lesions of the gas- tric functions the gut appears to perform vicariously the digestive work in a complete way — are of vital im- portance for the doctrine of dietetics. For it is seen at a glance that the main object of nutrition of the sick consists in giving them sufficient quantities of food. As people with disturbances of the stomach have to replace for their existence no smaller losses than under physiological conditions, they will therefore need: 1. Just as large amounts. 2. The same kinds of food- stuffs as described for the normal state. The only difference possible will have reference to the selection of the various articles of food and to their form and special preparation. Thus the question arises. What qualities should the food of the stomach patients possess? In the treatment of a diseased organ one can often make use of two methods. One consists in sparing the diseased organ and giving it perfect rest, the other 1 Max Einhorn : Medical Record, 1893. 110 DISEASES OF THE STOMACH, consists in strengthening the same by methodical adap- tation for more work and practice. Both principles are in fact realized in the treatment of diseases of the stomach. The first method is ordinarily applied in acute diseases and but very seldom (and then only for a short time) in chronic affections of the stomach. In these latter the second princijDle, as a rule, is used. The stomach can be spared, firstly, by not introducing into it any food whatever (greatest degree of saving or rest). Secondly, by administering food substances which, during their stay in the stomach, do not impose much w^ork upon this organ, and do not greatly irritate it. Here the main object will be to give the patient easily digestible food. In turning from the saving principle to that of strengthening the organ by method- ical adaptation for w^ork, it will be quite natural to change the diet, not suddenly, but gradually, into such as requires more work on the part of the stomach for its digestion. It is therefore absolutely necessary to have an exact table of the digestibility of different foods. In prescribing or changing a diet we shall have to act according to it. Such a scale has been arranged by different authors. The main sign of di- gestibility was gauged as mentioned above by the rapidity with w^hich the various food-stuffs passed out of the stomach into the intestines. Beaumont, in many trials on his patient with the gastric fistula, deter- mined the length of time the different victuals re- mained in the stomach and constructed a scale ac- cording to the figures obtained. On the same principle, but more reliable and of greater value, is the scale constructed by Leube, ac- DIET. Ill cording to the results obtained by emptying the stom- ach of patients by means of a tube, after different kinds of food had been taken. We think it advisable and useful here to give Leube's scale: 1st Diet. — Bouillon, Leube-Rosenthal's meat solu- tion, milk, soft raw eggs, zwieback, English cakes (biscuits containing no sugar), water, natural acidu- lous waters (Apollinaris, Kronthaler, Seltzer, etc.). ^d Diet. — Boiled calf's brain, boiled calf's sweet- bread, boiled chicken (young without the skin), boiled pigeon, boiled calves' feet, tapioca pap boiled in milk, beaten white of egg. 3cl Diet. — Eaw beef (chopped very fine), raw ham (chopped very fine), beefsteak (superficially fried in freshest butter), finely scraped tenderloin of beef, mashed potatoes, white bread (stale), coffee with milk, tea with milk. ^-th Diet. — Fried chicken, fried squab, roast venison, guinea hen, roast beef (cold), roast veal (leg, saddle), boiled pike, macaroni, rice pap, finely chopped spinach, asparagus, stewed apples. This table has been verified by the above-mentioned Penzoldt's investigations. All these experiments, however, only show what food remains in the stomach the shortest time. This would perhaps give reason for inferring what food may be easily digested as far as the stomach is concerned, but not what is more easily digested as a whole, i.e., made use of for the economy of the body with the smallest amount of work. The digestibility of food substances depends firstly upon their shape and quality ; secondly, upon their per- centage of convertible material. 112 DISEASES OF THE STOMACH. "Corpora non agunt nisi fluida,*' is an old, vvell- known axiom. Following this law one could arrange the following scale of digestibility, which is con- structed according to the different physical conditions of the food : 1. Food in liquid form : (a) Liquid at ordinary temperature — milk, meat juice, beef tea, bouillon, pep- tone or sarcopeptone dissolved in water, bread water,' strained barley, oatmeal, rice "water, strained oyster soup, egg-albumin water; (b) liquid at the body tem- perature — jellies, fruit jelly, calf's-foot jelly, ice- cream, water-ice. 2. Pulpy form. The food is mechanically converted into very minute particles and well mixed in liquid — pap soups (barley, oatmeal, farina, rice, sago) ; egg in bouillon ; Leube's meat solution, pulverized meat, pul- verized crackers in milk, water, or bouillon ; butter- milk, kumyss, cream, butter. 3. Food which by slight trituration iu fluids separ- ates into minute particles : White bread in milk or water ; the tips of well-boiled asparagus; carrots, mashed potatoes, baked potatoes ; the yolk of hard- boiled eggs ; oysters (raw). 4. Solid food. White bread, rye bread ; meat, hard-boiled eggs, fish, cheese. 5. Substances not easily digested. Meat with tough fibre ; lobster ; sausages and Swiss cheese on account of their solidity ; all substances containing much cellu- lose, principally when eaten raw ; cold slaw ; all salads, ' Bread watpr. Stale bread is cut into slices and put in water at temperature of room for from two to three hours, then the water is strained. DIET. 113 cucumbers, pickles, raw fruit, apples, pears, pineap-. pie; fruit which contains much acid, therefore all un- ripe fruit, strawberries; substances containing much sulphur and forming gases in the intestines : all kinds of cabbage, principally white cabbage ; beans. This theoretically constructed scale of the digestibil- ity of food is, at the same time, in the main points, similar to the one which has long stood the test of empiricism and which I ordinarily employ in my practice. Dietetics in Acute Diseases of the Stomach. Acute Gastric Catarrh. ■ — The principle of rest here occupies the first place. In acute gastric catarrh, dur- ing the first two or three days, in which, as a rule, there is a total loss of appetite, only very little nourish- ment in liquid form should be given, containing princi- pally amjdacea, barley or oatmeal soup, bouillon, weak tea, water. As a rule, one must not force a patient to take food during the first or even during the second day of sickness. The anorexia in these conditions is a wise arrangement made by nature in order to give the stom- ach rest. If there is thirst, beverages may betaken in small quantities, and must be neither very cold nor very warm. As soon as the appetite reappears one may give some toasted bread or zwieback, milk, soft- boiled eggs or oysters, permitting after a while small quantities of bread and meat, and then passing slowly to the ordinary diet. Ulcer of the Stomach. — During the rest cure of von Ziemssen-Leube give liquid diet, consisting principally 114 DISEASES OF THE STOMACH. of milk, for two or three weeks. As is well knowu, Cruveilhier ' first recommended milk for the purpose, and even now there are some physicians who limit themselves to milk alone. As a rule, however, it is appropriate to allow, besides milk, milk in combina- tion with barley, oatmeal, or rice water. In addition to this, the different peptone preparations are here in place. I administer Rudisch's sarcopeptone, manu- factured in this country, on account of its being pala- table and highly nourishing. (The Rudisch's sarco- peptone contains forty per cent of nitrogenous sub- stances, including twenty per cent of peptones.) One may give most appropriately every three hours one to two cupfuls of milk with the addition of the above-named decoctions (four times daily) and sarco- peptone (twice daily). The patient must not drink these fluids, but eat them with a spoon. In case of hemorrhage of the stomach during the first three or four days, it is not permitted to give any food whatever by the mouth ; instead, the patient must be fed by the rectum. Ewald has proven that the large intestine has the ability of digesting and absorbing albuminates even without special previous preparation ; therefore the following may be given as a nutritive enema : 1. Three to five eggs are mixed with 150 c.c. of sugar water (30 gm. of grape sugar dissolved in 150 c.c. of water), a small quantity of common table salt is added, and the whole mixture well beaten ; one may add also a small quantity of starch solution or mucilage. 2. One-half pint of milk with two eggs and 50 gm. of grape sugar added. 1 " Anatomie Pathol. , " 1829-35. DIET. 115 3. One and a half tablespoonfuls of Rudisch's sarco- peptone dissolved in a cupful of water. The food enemata have to be given three or four times daily. It is necessary that the fluid should he at the temperature of the blood, and that it should be injected by means of a fountain syringe and a soft- rubber rectal tube. Each time before giving a nour- ishing enema a cleansing enema of 250 c.c. of luke- warm water has to be administered, in order thorough- ly to cleanse the large intestine and make it more fit for absorption. In order to facilitate the retention of the feeding enema W. Gilman Thompson ' suggests the following procedure : Upon withdrawing the tube, if there is danger that the injection will not be retained, a soft compress or folded towel should be pressed up firmly against the anus for twenty minutes or half an hour. In case of thirst the patient is allowed to take small pieces of ice into the mouth from time to time. Thirst and hunger, however, may be entirely re- lieved by nutrient enemata alone. "In an obstinate case of gastric hemorrhage in which absolutely noth- ing, not even water, was given by the mouth for more than a week," W. Gilman Thompson* says, "I questioned the patient in regard to her sensations of hunger and thirst, and she told me that they were entirely relieved after the first twenty-four hours' use of nutrient enemata. The mouth and tongue were not dry and she did not lose weight during this period." Three days after the disappearance of blood one slowly and cautiously begins the liquid diet. * W. Gilman Thompson : "Practical Dietetics, with Special Ref- erence to Diet in Disease," New York, 1895. ^ W. Gilman Thompson : I. c. 116 DISEASES OP THE STOMACH, Dietetics in Chronic Affections of the Stomach. While in acute diseases of the stomach we pay most attention to giving rest to the organ — for here even an insufficient nutrition and the loss of several pounds of bodily weight are not of much importance, as the quick- ly recuperating organism replaces the losses caused during the sickness by taking increased quantities of food — in the chronic affections it is of utmost and vital importance to see that sufficient quantities of food are taken. The greatest number of stomach patients consulting the physician, after the disease has been progressing quite a while, have lost more or less weight. The principal reason for this lies in the fact that the body has received too small a quantity of nourishment in order to replace the waste. The ordinarily insufficient appetite, the early appear- ance of a feeling of satiation, the pain often appearing after meals, and less frequently vomiting, are the principal factors of subnutrition. At this point it becomes necessary to divide the patients with stomach troubles into two large classes: 1. Into those with organic lesions of the stomach. 2. Into those with functional disturbances. The first class comprises, (a) the malignant diseases of the stomach itself or its orifices (carcinoma ventric- uli, cardise, pylori) ; (b) cicatricial strictures of the cardia or pylorus; (c) absence of secretory work of the stomach : achylia gastrica. In this whole first class, with the only exception of group c, which lies, so to speak, between the first and DIET. 117 second class, we are unable to accomplish much either by medicinal treatment or dietetics. In existing stric- tures of the cardia or pylorus it will be necessary to seek surgical aid. Even in cancer of the stomach wall the resection of the affected part is advisable when- ever the operation is possible. I cannot refrain from calling attention at this place to the splendid results of the recent stomach surgery, which of late has been frequently practised in our own country (F. Lange, N. Senn, R. Abbe, Willy Meyer, McBurney, Weir, Bull, Gerster, Roswell Park, Murphy, and others). In car- cinomatous strictures a new passage can be established, either for bringing food into the stomach, by a gastric fistula, or for allowing it to pass into the intestines, by gastro-enterostomy. In this way we succeed at least in temporarily giving these unfortunates relief and in ameliorating their nutritive condition. In the cicatri- cial strictures we are warranted in promising to the patients, nowadays, perfect recovery by undergoing operative treatment. (In strictures of the cardia a methodical dilatation with bougies may sometimes also suffice.) The pyloroplastic operation (of Heincke- Mikulicz) and the cardiotomy or cardio-fissure (Abbe) belong to the most beautiful and blissful operations which have ever been practised. After the operation the patients are enabled to eat everything, and to live without any trouble whatever, i.e., they are perfectly cured. Before the operations, or if such are unfeasible, one should administer light, very slightly irritating nour- ishment, and always endeavor to make the patient par- take of a larger quantity of food. If there is obsti- 118 DISEASES OF THE STOMACH. nate and constant vomiting, it is necessary to employ nutritive enemata. Group (c) achylia gastrica will be. advantageously discussed in regard to diet under Class 2. The second class of functional disturbances includes the largest number of all dyspeptics. Here stand uppermost chronic gastric catarrh, atony of the stom- ach, dilatation of the stomach, gastroptosis, snperacid- ity, with or without hypersecretion, nervous gastral- gia, nervous dyspepsia, and as an intermediary between the first and second class, achylia gastrica. It appears advisable to discuss first the whole class, and thereafter to give special rules for the different groups. Liquid food or partly predigested substances (as all peptone preparations) are not in place here. By making the stomach work too little, the weakened condition of this organ is retained and aggravated in time. We must always bear in mind the principle of strengthening the organ by means of appropriate work. A well-known clinician is said to express himself in his lectures in the following way regarding the dietet- ics of the dyspejDtic : When a dyspeptic patient asks you the question, "What shall I eat?" reply, "Eat what you like." If he asks, "How much shall I eat?" say to him, "Eat as much as your appetite demands." If he still asks, "When shall I eat?" answer, "Eat when you are hungry." Although I do not favor strict and severe dietetic rules, nevertheless I deem the above-mentioned re- marks as going too far. Unlike the normal healthy DIET. 119 condition, in which instinct shows us the right meas- ure to eat, neither too little nor too much, stomach patients very often have lost the feeling of self-regula- tion, and as a rule partake of too small quantities of food. (Only in a few cases of bulimia there may be an increased desire for food, and in connection with it the quantity of food taken may sometimes be too large.) It is therefore necessary to instruct the patients to eat more, or to give them exact figures of the quantity of food required. As this varies with every individual it is most practicable to let the patient weigh himself once a week and to see whether he keeps his weight. If the patient does not lose any it is the best sign that he takes sufficient nourishment. As good instances of a sufficient amount of food contained in the diet we give the following bills of fare which have been suggested by C. von Noorden : ' I. A Principally Milk Diet with Addition of Carbohydrates IN Liquid Form. Albumin, per cent. Fat, per cent. Carbo- hydrate, per cent. Calories, per 100. Milk, 1,700 cc 70.2 10 7.0 66.3 5.0 69.7 30 40 1295 Soup of tapioca flour, 30 gm. and 10 gm. alburaose.'^ 164 Soup of 40 gm. wheat flour, with some of the milk, 10 gm. sugar and one ess 244 Total 87.3 71.8 139.7 1703 » C. von Noorden : Beii. Klinik, 1838, J. 55. ^ 10 gm. albumose is contained in 90 cc. of Denayer's peptone preparation or in 22 of Kemmerich's or in 30 of Koch's. 120 DISEASES OF THE STOMACH. II. Principally Milk Diet with the Addition of Carbo- hydrates AND Fat in Pap Form and Soups. Albumin, per cent. Fat, per ceut. Carbo- hydrates, per cent. Calories, per lUO. Milk, 1,500 c.c 63 17 7 58.5 13.5 5.5 63 15 90 1056 Soup of 15 gni. sago, 10 gm. butter, one egg, 10 gm. al- bumose. Pap of 80 gm. corn flour, one egg, 10 gm. sugar (two meals) . 257 398 Total 86 77.5 168 1711 III. Milk Diet with Addition of Light Pastry and Broths. Albumin, per cent. Fat, per cent. Carbo- hydrates, per cent. Calories, per 100. Milk, 1,250 cc 51 10 5 7 49 14 12 14 52 30 50 30 878 Meat broth with one egg, 10 gm. of butter, 50 gm. of fine toasted wheat bread. Cakes 70 gm. , butter 15 gm Soup of 30 gm. tapioca flour, oue egg, 10 gm. butter. 294 337 282 Total 73 89 162 1791 IV. Milk with Tender Meat, Pastry, Butter, and Soups. Spring chicken, 100 gm Mashed potatoes, 100 gm Two eggs Toasted wheat bread, 100 gm. . . . Butter, 30 gm Trout, 100 gm Milk, 1250 cc Total Albumin, per cent. 19.6 2.0 14.1 7 19.3 51 113.0 Fat, per cent. 2.8 4.0 11.0 0.5 23.0 2.1 49 92.4 Carbo- hydrates, per cent. 20 55' 52 127 Calories, per 100. 106.4 127.4 160.1 258.8 213.9 106.4 1851 DIET. V. EiCH, NOT Ieritating Diet. 131 Tender meat, ' 250 gm. Cacao, 20 gm Three eggs 100 gm. Zwieback wheat bread. . cakes butter tapioca flour . corn flour . . . . 100 50 50 40 40 20 sugar 1250 CO. milk Total 144 Albumin, per cent. 49 4 21 8 7 4 51 Fat, per cent. 7.0 6.0 16.0 1.0 0.5 2.3 44.0 49 126.0 Carbo- hydrates, per cent. 75 55 36 '46' 40 20 52 318 Calories, per 100. 266 105 235 259 '187 407 164 164 82 878 2747 Besides the importance of a sufficient diet, we must remind patients to lead a regular life, to eat slowly (how many, especially in our country, sin against this natural law!), and to chew well and triturate the food. One must avoid either extremely cold or ex- tremely warm food. Too copious and too complicated meals must be strongly forbidden. I have made it a rule not to forbid anything, except what is, according to my conviction, obnoxious in the given case. In this way the patients have a great variety in their food and run less risk of subnutrition. Likewise we need not change the number of meals nor the hours appointed unless there should be especial indications for such a proceeding. Among the laity, as well as often among medical men, there are prejudices against certain forms of food. Thus, for instance, until recently it was cus- tomary to forbid all kinds of fat, even butter, in all ' Meat of various kinds, finely chopped, raw or fried in butter ; cold or warm, taken at two meals. 122 DISEASES OF THE STOMACH. dyspeptic conditions. Fat, however, belongs to the grouj) of food-stuffs which has the largest number of heat units, and besides, is not bulky as a nourishment (butter). Undecomposed fat passes the stomach with- out molesting the latter, and is digested in the small intestines. There is, therefore, no reason for forbid- ding butter, which should, on the contrary, be highly recommended. Fearing fermentative processes the partaking of bread and other food rich in carbohy- drates is very often greatly limited, or even totally forbidden. Although it is true that the carbohydrates easily undergo fermentative processes, those cases, however, in wiiich considerable fermentations exist in the stomach are quite rare, and as a rule are found only where there is considerable stagnation of food in the stomach. In these cases, to be certain, a diet con- sisting princij)ally of animal albumin (meat) for a short period is very useful. By means of lavage of the stomach and other appropriate treatment we soon succeed in checking the fermentative processes, and carbohydrates can then be administered. An adult, according to Koenig,' daily consumes -J- to f kgm. of bread ; fifty to sixty per cent of the total food substances, and fifty to seventy-five per cent of the carbohydrates are taken in the form of bread. This clearly shows the important part bread takes in diet. Its use is, therefore, as a rule advisable. It is ordinarily said that crust of bread, stale bread, and zwieback are easier to digest, on account of the starch contained in them being largely converted into dex- ' Koenig ; "Die meuschliclien Nahrungs- nnd Genussmittel, " Berlin, 1883, p. 430. DIET, 123 trose. Although I am of the opinion that too fresh bread must be avoided, I nevertheless rarely find much difference in the digestibility of the crust or other parts of well-baked fine white bread, judging from experience gained from my own patients. Articles of luxury (wine, beer, coffee, tea) are, as a rule, permissible. It is, however, necessary to give them in small amounts and in appropriate form. Strong liquors must be avoided, likewise all strong spices. Appetizers, as a small amount of caviare, sardellen, or anchovies, on a small slice of bread or cracker, taken one-quarter of an hour before the meal, are not only allowed but frequently directly commendable. In reference to the special rules for the different dis- eases of the second class, v/e shall have at times to re- duce the quantity of meat taken in all conditions ac- companied by a diminished secretion of hydrochloric acid (gastritis chronica glandularis, atony -j- subacid- ity) ; on the other hand, the quantity of richly carbo- hydrate vegetable food must be increased. Kumyss, matzoon, milk with cognac (7 to 10 c.c. of cognac to 200 or 250 c.c. of milk) may be taken with crackers either during or between meals. In all the conditions attended with superacidity the quantity of albuminous food should be increased ; here one may give a great deal of meat (venison included). In superacidity with hypersecretion frequent and small meals containing consistent food are most appropriate. If there is a feeling of hunger between meals, the white part of hard-boiled eggs may be taken (as is well known, albumin combines with acid and makes it, 124 DISEASES OF THE STOMACH. SO to say, inert). The quantity of beverages must be greatly limited ; most suitable in this instance are small quantities of Vichy water. In dilatation of the stomach and in gastroptosis it is also advisable to give small and frequent meals, and to restrict the quantity of liquids taken. As a rule, milk and beer do not agree well in these cases. Small quantities of wine or imported dark beer or porter may be allowed. In nervous dyspepsia and gastralgia our main object will be to systematically increase the quantity of food — here milk and its derivatives (koumyss, matzoon, bonny-clabber, buttermilk, cream) taken between meals play a great part (Weir Mitchell treatment). In achylia gastrica it is of utmost importance to give liquid or very well triturated (pulverized) food. For here the chemical action of the stomach has entire- ly ceased, and vegetable (on account of the albumin- ous membrane enclosing the starch granules) as well as animal food pass from the stomach unchanged, and not converted into small particles, into the intestines and irritate them, unless there has long been formed a sufficient adaptation for these conditions. Vege- table food, on account of its containing chiefly carbo- hydrates, will be predominant in the diet of this affec- tion. Thus achylia gastrica, in reference to diet, stands midway between the first and second classes. It approximates the first class in so far that it neces- sitates a liquid or mechanically minutely triturated or pulverized food, the second class in allowing a richly carbohydrate diet. Some readers may miss exact bills of fare for chronic affections of the stomach. They have been omitted, DIET. 125 as it is always necessary to individualize, especially in diet. We must guide ourselves more by the patients than by theoretical conclusions. Our main object must be to care for a sufficient nutrition. Only the above-given principal rules on diet must be observed, although at times even they have to be modified. In reference to this point Hippocrates* said: ''' Dandum aliquid tempori, regioni, wtati et consuetudini.^'* At present, with our more exact knowledge, we have come to appreciate this conclusion to a still greater degree. ^ Cited from Muuk and UfCelmauu, loc. cit. , p. 430. CHAPTER IV. LOCAL TREATMENT OF THE STOMACH. 1. Lavage. Gastric lavage, which is so frequently employed in the treatment of diseases of the stomach at the pres- ent day, was first introduced by Kussmaul ' in 1S67, who used for this purpose the stomach pump. Pre- vious to that time this method had been practised by Bush, Arnott, Sommerville, and Blutin/ but to Kussmaul belongs the credit of em^jloying it in a rational and scientific manner. The illustration (Fig. 33) affords an idea of the mechanism of the instru- ment employed by the latter observer which, however, is now only of historical interest, since it has been supplanted by simpler apparatuses based upon the principle of siphonage. (a) Funnel Arrangement. The one that is most commonly in use consists of a glass funnel attached to a piece of soft-rubber tubing of about one yard in length which can be slipped over the upper end (connecting glass tube) of the stomach tube. By filling the funnel with water, and alternately raising and lowering the same, the stomach may be filled or emptied. The fun- ' Kussmaul : " Ueber die Behandlung der JIagenerweiterung durch eine neue Methode raittelst der Magenpumpe. " Deutsches Archiv f. klin. Med., vol. vi., p. 4oo. 2 See Ewald : " The Diseases of the Stomach, " New York, 1892, p. 5. LOCAL TREATMENT OF THE STOMACH. 127 nel, as a rule, is not very large and has a capacity of about 300 to 500 c.c. Ewald * advises the use of a very large funnel of about two quarts capacity. This rests in a wooden frame on the floor and after being filled with the requisite amount of water 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, and the stomach is in this way irrigated. To siphon the water out of Fig. 3-3. — ^Kussmaul's Stomach Pump. the stomach, the funnel is again placed in the wooden frame, and thus the fluids of the stomach return. Here the whole quantity of the wash-water can be easily inspected. (6) Leube-JRosenthal Apparatus. The raising of the big funnel is quite troublesome, and I therefore prefer to use in my own practice the Leube-Rosenthal ap- paratus which I consider the best means of washing out the stomach (see Fig. 34). This consists of a 'C. A. Ewald, I. c. v. 64. 128 DISEASES OF THE STOMACH. large glass irrigator of about two to three quarts ca- pacit3\ Leading from the irrigator a large piece of Boft-rubber tube is connected by means of a Y-shaped Fig. 34.— Leube-Rosenthal Apparatus for Gastric Lavage. glass tube first with the stomach tube, secondly, witn another quite long piece of soft-rubber tubing. Botn arms of tubing, the one running from the irrigator the other into a waste vessel, are provided with LOCAL TREATMENT OP THE STOMACH. 129 clamps. By opening the clamp on the irrigator tub- ing, the water runs into the stomach. By closing the same and opening the tube running to the waste ves- sel, the water is withdrawn from the stomach. The amount of water which is used for each single filling of the stomach may vary from 400 c.c. to a litre. The stomach may be filled with water so long as the patient does not experience any pressure. As soon as he begins to feel some pressure, the quantity should not be increased, but at once withdrawn. This man- oeuvre can be repeated twice or three times at each sit- ting. In case large quantities of mucus are present in the wash-water, it is best to have the patient shake himself, especially his abdomen, while the water is entering the stomach. In this way it is possible to mechanically clean the organ much more thoroughl}' than would otherwise be the case. The same method of shaking has to be applied if the stomach contains some food. The advantages of this apparatus are quite mani- fold : 1. The ease with which the whole procedure can be executed. 2. The water introduced into the stomach is always clear, as the waste water passes through a separate tube ; while in the use of the funnel arrangement after the first filling the funnel and the tubing become soiled during the withdrawal of the contents, and in consequence of this, during the second filling, much of the mucus which has remained within the apparatus returns to the stomach. (c) Friedlieb's Apparatus. Another very suitable 130 DISEASES OF THE STOMACH. arrangement for washing out the stomach, especially if the patient has to perform the procedure himself, is an apparatus that has been in use in this country for many years, and is similar to the one described by Friedlieb.' It consists of a long piece of soft-rubber tubing of about two yards in length, the middle of which is expanded into a bulb. The stomach end of the tube is provided with two big openings, while the other is shaped into a funnel (see Fig. 35). In the withdrawal of the gastric contents with this a^jparatus the tube should be closed with two fingers at a point situated between the bulb and the lips of the patient. If the bulb is now compressed, and the two fin- gers applied to its distal side, then on relaxing the pres- sure on the bulb it will become filled with stomach contents. By again closing the upper end of the tube and compressing the bulb, the contents will flow out from the apparatus. In this way the con- tents of the stomach can be removed. The wash- ing of the organ is now executed in the usual way by filling the funnel end with water, raising the same and lowering again. The bulb then need not be com- pressed if the water flows out easily. If the stream of water stops flowing before the entire quantity has left the stomach, then suction by means of the bulb 'Friedlieb: Deutsche med. Woclienschrift, 1893, No. 51. Fig. 35.— Friedlieb's Apparatus for Gastric Lavage. LOCAL TREATMENT OF THE STOMACH. 131 must be performed as above described. Instead of using the fingers in order to compress the tube, two, clamps on both sides of the bulb may serve the same purpose. {d) Several writers have tried to wash out the stom- ach by means of a tube d double courant. Very re- cently J. C. Hemmeter^ in this country anew devised such an apparatus for this purpose. According to my opinion, however, all these devices are unnecessary. Lavage of the organ cannot be accomplished more thoroughly by means of these than by the three above- described simple apparatuses. A Few Rules Concerning the Application of Lavage. The introduction of the tube has to be performed as above stated, when we spoke of the introduction of the tube for the withdrawal of gastric contents for ex- amination. During the introduction of the tube, it is necessary to have the patient hold his head slightly bent forward (as a rule, patients try to throw their heads far back, which is a great obstacle to the en- trance of the tube into the oesophagus). The insertion of the tube has to be done quite rapidly. During the entire procedure it is best to have the patient breathe deeply. It is furthermore of importance to hold the tube with the hand not far from the mouth of the pa- tient in order that the apparatus may not move up and down and in this way cause irritation of the stomach and produce nausea and spells of vomiting. In case the outflow of the fluid is suddenly arrested (by food particles obstructing the opening of the tube), a ' J. C. Hemmeter : New York Medical Journal, March 30th, 1895. 132 DISEASES OF THE STOMACH. small quantity of water has to be poured in again, and the siphoning repeated. How long and how often the stomach should be washed out is difficult to define. As a rule, this procedure should be kept up until the water returns quite clear. The appearance of blood in the wash-water necessitates the withdrawal of the tubing. If, however, only a few blood stains are visi- ble in the water, they are of no import, and the lavage can be continued. Indications. Aside from diagnostic purposes lavage must be per- formed (1) when there is stagnation of food in the stomach ; (2) whenever large quantities of mucus are present in the organ. Contra-indications. These comprise all conditions in which introduction of the tube is not permissible, as for instance, hemor- rhages, ulcer of the stomach, etc. 2. The Gastric Douche {Malhranc) .* By the gastric douche is meant a sprinkling of the stomach with water under high pressure. This can be done by raising the funnel of the washing apparatus to a considerable height. Ewald's tube, which has several small openings and one large one, is most suit- able for this purpose. Eosenheim " likewise makes use of a similar tube. Boas employs a tube with many small openings of pinhead size. The latter, however, ' Malbranc : Bevl. klin. Wonhenschr. , 1878, No. 4. *Th. Rosenheim: "Ueber die Magendouche." Therapeutische Monatshefte. 1892. LOCAL TREATMENT OF THE STOMACH. 133 has the disadvantage that the water cannot return quickly. The gastric douche was applied by Malbranc and afterward by the above-named writers in order to combat severe gastralgias. According to my experience there is but little differ- ence between lavage and douching of the stomach. In fact, every form of lavage has almost the same effect as the gastric douche. Of late M. Gross/ of New York, has devised a double-current gastric douche. Both lavage and the gastric douche have been made use of for the application of medicaments directly to the mucous membrane of the stomach. Thus, for in- stance, various antiseptic solutions have been applied (boracic acid, salicylic acid, sodium salicylate, thymol, creolin, lysol, etc.). Again, chloride of sodium on the one hand, and nitrate of silver on the other (the one to increase, the other to diminish gastric section) have been used by Boas and Eosenheim,^ The solution introduced into the stomach by means of the apparatus is left there for a few minutes (two to five) and then withdrawn. This procedure has the great disadvantage that in order to apply a solution in the right concentration, covering the whole inside of the stomach, a considerable quantity of the medica- ment is absolutely necessary. The quantity of the agent has to exceed the normal dose, and reach the poisonous limit. Although by emptying we certainly remove the greatest part of the solution and in this way the danger of intoxication is greatly diminished, nevertheless a considerable quantity of the injected ' M. Gross ; Medical Record, 1895. ^ Rosenheim : L. c. 134 DISEASES OF THE STOMACH. fluid may pass through the pylorus into the intestines beyond our control and at times may do harm. That is the reason why nitrate of silver and similar poison- ous substances should not be introduced into the stomach by these means. 3. The Gastric Spray {EinJwrn). In cases in which it is necessary to apply medica- ments of a toxic or irritating character to the gastric mucosa, the risk of poisonous effect can be prevented by the use of the spray, by means of which large sur- faces can be covered with a comparatively small amount of fluid. In order to make use of the spray in diseases of the stomach, the usual spray apparatus has been modified by me in such a way that, instead of the hard -rubber branch of the apparatus, the same branch is made of soft-rubber and lengthened. In this way the gastric spray apparatus consists of the usual spray apparatus, in which there is a soft Nelaton tube, of TO cm. length, inserted between the nozzle and the hard-rub- ber branch running to the bottle; within the Xelaton tubing, another soft tube of thinner calibre connects the inner capillary tube with the nozzle (see Fig. Sfi).' As the spray is generated by the air forced by the bulb through the tube, taking up the fluid and divid- ing it into fine particles, the medicament will neces- sarily come in contact with every part touched by the air. ' Max Einhorn : "The Use of the Spray in Diseases of the Stom- ach." New York Medical Journal, September ITth, 1892. -The gastric spray apparatus is maDufactured by J. Reynders «fc Co.. 303 Fourth Avenue, New York. LOCAL TREATMENT OF THE STOMACH. 135 If the stomach is empty when spraying, the air that enters will expand the organ and transport the fluid to every part of its interior. The administration of the spray in gastrotherapeusis is a suitable form for fulfilling the following purposes: 1, To disinfect the mucous membrane of the stom- ach. 2. To exert an astringent effect. Fig. 36. — The Gastric Spray Apparatus (Einhorn). 3. To produce analgesia in gastralgia of local char- acter (from ulcer, cicatrix, or cancer). Method. — As it is possible to spray the stomach only in its empty state, it will be necessary to administer the spray either when fasting or after a previous lavage. A preceding lavage will always be indicated if we intend to disinfect or apply astringents, for in these instances it is necessary first to remove the mucus with the micro-organisms embedded therein. In order to exert an analgesic influence, the lavage may perhaps be omitted. After filling the apparatus with a sufficient amount 136 DISEASES OF THE STOMACH. of the required solution, the tube end is dipped into warm water and thereupon inserted into the stomach of the jDatient. It is best to begin with the spray as soon as the nozzle (being in the stomach) is at a dis- tance of about -±5 cm. from the Hps of the patient. Provided the nozzle is not covered by the stomach wall, there can be heard during the spraying, at times in the neighborhood of the patient — otherwise by put- ting the ear on the gastric region — the sound charac- teristic of the spray. In case the opening is covered, the spray is generally unable to pass, and it is then necessary to insert the tube a little farther. Even if the spray works well from the beginning, it will be expedient after a while to introduce the tube a little farther, in order to have the spray work from different points. The spraying of the stomach has proved very useful, according to m}^ experience, in the following conditions: (1) In erosions of the stomach; (2) in those forms of chronic gastric catarrh which are associated with an abundant amount of mucus; {^)) in cases of hypersecretion and hyperacidity. 4. Electricity. In view of the firm foothold gained by electricity in the therapeusis of gastric and intestinal disorders, it will not appear superfluous to give a brief review of the history and physiological action of this agent with reference to the digestive tract. Numerous experiments have been made in the study of the influence of electricity upon the stomach and intestines ; all of them serve to demonstrate the physi- ological effects of this agent. LOCAL TREATMENT OF THE STOMACH. 137 Ludwig and Weber,' von Ziemssen/ and Bocci' have stated that in animals the faradic, as well as the galvanic, current, applied directly to the stomach, causes contractions of this organ, and produces secre- tion of gastric juice. Schillbach," u^jon applying the galvanic current to the bowels of a rabbit, observed intense contractions at the site of the anode, followed by peristaltic move- ments. Fubini ^ lately demonstrated, after making a Vella's double intestinal fistula, that electricity quick- ens intestinal peristalsis to a high degree, viz., about five or six times. The influence of electricity upon the stomach and intestines thus being evident, many authors en- deavored to make use of this means in the thera- peutics of these organs. For many years past numerous writers have em- ployed electricity in affections of the stomach and in- testines. The method generally used for this purpose consisted in the percutaneous application of the cur- rent ; usually one electrode was held in the neighbor- hood of the vertebral column at about the sixth dorsal vertebra on the left side, the second electrode being placed at the epigastrium. A. D. Eockwell and M. Beard * were among the first • Ludwig aufl Weber: Cited from Kussmaul, Arch. f. Psych, und Nerv., 1877, Bd. viii., p. 205. ^Von Ziemssen : Klin. Vortrage, No. 13, "Die Electricitat in der Medicin." ^ Bocci : Lo Sperimentale, June, 1881. ^Schillbach: Virch. Arch., Bd. 109, p. 284. 5 Fubini: Centralbl. f. d. med. Wissensch., 1882, No. 33, p. 579. 8 A. D. Rockwell and M. Beard : Philad. Med. Surg. Eeport. , 1868, No. 20, and 1871, p. 470. 138 DISEASES OF THE STOMACH. to make use of electricity on a large scale in the treat- ment of nervous dyspepsias. To the application of electricity to the stomach they added general electri- zation, and had the most brilliant results. Xeftel ' likewise had much success from the electri- cal treatment. Fuerstuer " recommends the galvanic current for the treatment of atonic dilatations of the stomach. Oka and Harada/ Leu be, * JLicnte, ^ Semmola,' Ritcher' and Leubuscher,^ speak highly of the applica- tion of the electric current in various pathological conditions of the stomach and intestines. Besides these clinical facts, there have lately been added some more exact notes as regards the physiolog- ical effects of percutaneous electricity of the stomach in man. Ewald and myself have been able to demon- strate an acceleration of the motor faculty of the stomach under the influence of percutaneous faradiza- tion, by the appearance of the salol test in the urine about one-fourth of an hour earlier than otherwise. A. Hoffmann "showed that the galvanic current percuta- neously applied in the gastric region for twenty minutes produces an abundant secretion of gastric juice. 'Xeftel: Centralbl. f. d. rued. Wissensch., 1876, No. 21, p. 370. * Fuerstner : Berl. klin. "Wocliensch., 1876, No. 11. 'Oka and Harada : Berl. klin. Wochenscl)., 1876, No. 44. ^Leube: Deutsch. Arch. f. klin. Medicin, 1879, tome 23, p. 98. »Lente: Arcli. of Electrol. and Neurol., 1874, i., p. 193. *Semniola: "L'elettricita nel vomito. " Gaz. nied. Ital. Lorn- bard.. 1878, No. 6. 'Eichter: Berl. klin. Wochensch., 1882, Nos. 13 and 14. 8 Leubusclier : Centralbl. f. klin. Med., 1887, No. 25. ' Ewald and Einborn : Verbandhmgeu des Yereins fiir innere Medicin. 1888, p. 58. J»A. Hoffmann: Berl. klin. Wocliensch., 1889, Nos. 13 and 13. LOCAL TREATMENT OF TflE STOMACH. 139 Direct Electrization of the Stomach. Although the favorable influence of electricity, even percutaneously applied, is quite evident in numerous affections of the stomach and intestines, it, however, remains questionable whether any of the produced electricity penetrates to the stomach. The main cur- rents undoubtedly go through the skin and muscles, and if any of them reach the stomach, they must be very weak. But surely we might expect to attain better and more successful results by the application of electricity directly to the stomach. In his cele- brated book on "Electrotherapy" Erb' says: "The first maxim to observe is the treatment in loco morhi, i.e., the application of electricity to the morbid part itself. . . . There is no doubt that it is best, in the great majorit}^ of cases, to operate directly on the diseased spot." Pepper' had a patient with dilatation of the stom- ach, in whom the abdominal walls were so thin that the spontaneous peristalsis of the stomach could be perceived. On this patient he showed that electricity, percutaneously applied, never produced any peristaltic movements of the stomach. Pepper then continues as follows: "The difficulty of compelling a current, no matter what may be its strength, to penetrate through various layers of tissue of different consistence and anatomical character is well known." Speaking of the percutaneous electricity of the stomach, Kussmaul ' • Erb : " Handbuch der Electrotherapie, " p. 279. 2 Pepper : Philadelphia Medical Times, May, 1871, p. 274. ^Kussmaul; Arch. f. Psych, und Nerv., 1877, viii., p. 205. 1-iO DISEASES OF THE STOMACH. remarks : " The therapeutic results obtained by Fuerst- ner and others in cases with dilatations of the stomach do not prove that by means of the current a direct peristalsis of the stomach was induced, but could be attributed to the favorable influence of the contrac- tions of the abdominal walls." All the sentences mentioned plead for applying electricity to the stomach directly, and not percutaneously, if possible. Canstatt * first proposed to combat dilatations of the stomach by direct electrization, introducing one elec- trode into the oesophagus and putting the other in the stomach region. Duchenne" was the first who made use of this method. Kiissmaurs Method. — Very soon afterward, in 1877, Kussmaul' began to practise the direct electrization of this stomach. The electrode used for the purpose consisted of a stomach tube, through which ran a cop- per wire ending in an olive point and fastened to the cut-off end of the tube. In several patients with dila- tation of the stomach Kussmaul introduced this elec- trode into the stomach, the other (ordinary) electrode being held in the hand. In applying electricity in this way contractions of the abdominal muscles on the left side appeared, and in one patient, with thin ab- dominal walls, contractions of the stomach were visible on applying weaker electric currents. Later on Balduino Bocci,' in 1881, experimenting on animals, was persuaded " that the indirect faradization ' Canstatt : Cited from Kussmaul, I. c. ^ Duchenne : Cited from Kussmaul, I. c. ^ Kussmaul : L. c. * Bocci -. Lo Sperimentale, June, 1881. LOCAL TREATMENT OF THE STOMACH. 141 of the stomach through the abdominal walls produces in the stomach, even when applied in a very energetic way, phenomena of very little importance, and of a dubious curative effect." As the direct faradization of the stomach, on the other hand, showed all the above-mentioned physiological effects, Bocci recom- mended anew the use of the direct electrization of the stomach for therapeutic purposes. Bocci used for this end an electrode like that of Kussmaul. BardeVs MetJiod. — Great progress in the direct elec- trization of the stomach was made in 1884 by G. Bar- det.* The direct contact of the lower metal piece of the electrode with the inner wall of the stomach irri- tates only a small spot, and this very intensely, where- as the larger part of the stomach receives but very little of the electricity produced ; in consequence thereof the galvanic current could not be applied, because by the usual method it would not be possible to avoid le- sions of the mucous membrane of the stomach. In order to overcome these drawbacks Bardet constructed his stomach electrode in such a way that the metal piece running through the tube was shorter than the tube, and did not touch its windows. By filling the stomach with water the electric circuit between the stomach wall and the lower metal piece of the electrode was established. In this way the electricity was dis- tributed over the whole surface touched by the water. By means of this electrode Bardet treated three cases of dilatation of the stomach, and one case of obstinate vomiting, with the galvanic current (15 to 25 milliam- peres) and obtained splendid results. Most authors ' Bardet : Bull. Gen. de Therap. , 1884, tome 106, p. 539. 142 DISEASES OF THE STOMACH, who employed the direct electrization of the stomach have, until recently, generally used Bardet's electrode. (Charles G. Stockton's* stomach electrode does not differ very much from that of Bardet.) Although the high value of the direct electrization of the stomach is self-evident, this method did not enter much into practice, because the tube surround- ing the electrode had to be kept in the throat during the whole electric session (about ten minutes) and in- convenienced the patient to such a degree that the procedure could be carried out only in people accus- tomed to lavage of the stomach, and even by them it was disagreeably felt. That is the reason why von Ziemssen ^ rejected direct electrization of the stomach as being too straining and exhausting. Einliorn^s Method. In order to facilitate the internal or direct electriza- tion of the stomach I ^ have constructed an electrode on the same principle as the stomach bucket. This elec- trode once swallowed reaches the stomach without further artificial aid. The silk thread of the bucket is represented in the electrode by a very fine (1 mm. in diameter) rubber tube through which a very fine, soft, conducting wire runs to the battery. The end piece of the electrode consists of a hard-rubber capsule with many openings. In this capsule lies a metallic button ' Charles G. Stockton : "A New Gastric Electrode, "Medical Rec- ord, November 9th, 1889, p. 530. *Von Ziemssen: "Ueber die physikalische Behandlung chro- nischer Magen- und Darnikrankheiten, " p. 10, Leipzig, 1888. 3 Max Einhom : Medical Record, May 9th, 1891. LOCAL TREATMENT OF THE STOMACH. 143 which is connected with the wire. (Figure 37 shows the electrode in natural size.) The rubber capsule serves to avoid the direct contact of the metal with the stomach wall; the circuit is completed by the water the stomach contains. This electrode I have termed " Deglutable Stomach Electrode.'" Metliod. — ^The patient drinks, best when in a fasting condition, or one to two hours after a light breakfast, one glassful of water, tea, or coffee. The patient has now to open his mouth widely, and the electrode (the capsule piece) is placed far behind on the root of the tongue and he is ordered to swallow. He again drinks some water, and the electrode finds its way to the stomach without any further assistance. In order to recognize this point precisely, it is ad- visable to make some mark on the tubing at a distance of 40 cm. from the capsule; as soon as this mark comes to the teeth we are sure that the electrode is in the stomach and we can apply the electricity to the pa- tient. According to my belief, it is of importance to apply gastro-electrization according to a certain plan. Thus it will not appear superfluous to give a detailed ' The Deglutable Stoinach Electrode is manufacttired by John Reynders & Co. , 303 Fourth Avenue, New York. Fig. 37 -The Deglutable Stomach Electrode (Einhorn). 144 DISEASES OF THE STOMACH. description of the electric application I ' generally employ. The patient, when the deglutable electrode is within the stomach, opens his clothes, so that the abdomen is accessible. The key of the deglutable electrode is con- nected with the cord (negative pole) running to the battery. Gastrofaradization. — Sitting, ten minutes; at first large plate electrode at the gastric and epigastric re- gion for five minutes, then a small ordinary sponge electrode. The electrode is at first moved up and down from left to right in the gastric region (some- times, especially when there is constipation, the elec- trode is passed over the region of the colon — ascendens, transversum, descendens — always beginning in the right iliac region and stoj^ping at the left iliac region [duration, two minutes]); thereafter one proceeds from the gastric region from right to left to the back, and remains at the left side of the seventh dorsal vertebra for one minute. (At this place the current can be ai^plied quite strongly, and most of the patients then experience a slight sensation within the stomach; the patients find it difficult to describe this sensation ; some assert that they experience a Iragging feeling, others a feeling of weight, and others again of pinch- ing. All of them refer this feeling to the stomach and locate it opposite different heights of the abdominal wall.) We then return to the front, moving the electrode gently up and down over the gastric region 'Max Einhorn : "Therapeutic Eesults of Direct Electrization of the Stomach," Medical Record, January 30th and February 6th, 1893. — "Furtlier Experiences with Direct Electrization of the Stom- ach," New York Medical Journal. July 8th, 1893. LOCAL TREATMENT OF THE STOMACH. 145 for two minutes, gradually decreasing the current, and . thus ends the sitting. The current has to be of such a strength that it causes distinct contractions of the abdominal walls ; but it is not well to have it so strong that the patient experiences pains. Gastrogalvanization. — Negative pole within the stomach ; small sponge electrode. Duration, eight minutes. First, two minutes below the ensiform proc- ess (during the first minute the current is gradually increased to its necessary strength), then for three minutes moving the electrode up and down the gastric region. After this, we then go to the back and re- main one minute at the left side of the seventh dorsal vertebra, return to the front, move the electrode around the gastric region for one minute, and remain then quietly for one minute below the ensiform process. During this time the current is gradually weakened and the sitting is ended ; the strength of the current is ordinarily fifteen to twenty milliamperes. In withdrawing the electrode a resistance is felt at the introitus oesophagi; it is not advisable to pull the electrode with force. One has only to make the patient swallow once or twice, and to make use of the moment when the larynx, by this act, ascends and the passage becomes free, to withdraw the electrode, which is done now with perfect ease. I ordinarily apply the electrization every other day during the be- ginning of treatment; afterward — i.e., after the lapse of two to three weeks — twice weekly for about three weeks, and thereafter once a week for some time. As a rule, I begin to .decrease the frequency of the sit- tings when I notice a decided improvement in the u 146 DISEASES OF THE STOMACH. conditioD of the patient. Even after a complete dis- appearance of the symptoms it is advisable to continue the electrization (once a week) for some time. Direct electrization of the stomach by means of the degliitable electrode is very simple and handy for the patient and for the physician, and, as it seems to me. as easy to apply as percutaneous electrization. After the first application the insertion of the electrode is much easier, the patient being accustomed to the procedure. The principal advantage of the deglutable electrode consists, firstly, in that we are able to apply the method in persons not used to the stomach tube, and, secondly, in that the thin cord does not cause any un- comfortable feeling to the patient during the entire electric sitting and does not provoke salivation. Another advantage lies in the circumstance that the deglutable electrode can be swallowed even in those cases in which ulcer of the stomach is sus- pected, whereas the old stomach electrode could not be introduced in them for fear of causing perforation. By means of the deglutable electrode a regular course of electric treatment of the stomach becomes possible in many cases and is facilitated in all. I have made an extensive study of the physiological effects of direct electrization of the stomach and have published the results in several papers. From my experiments it follows conclusively : 1. Direct faradization of the stomach increases gas- tric secretion (a) during the application of electricity and also, (6) for a short period afterward. 2. Direct galvanization of the stomach with the LOCAL TREATMENl- OB THE STOMACH. 147 negative pole within the organ in most instances diminishes gastric secretion. 3. Direct faradization as well as galvanization of the stomach increases the absorbent faculty of the stomach. As regards therapeusis I came to the following conclusions : 1. Direct gastro-electrization is a potent agent in the field of chronic (non-malignant) diseases of the stomach. 2. Direct gastrofaradization proves to be useful in many ways in most chronic diseases of the stomach. The favorable results appear very clearly and pretty quickly in those cases of stomach dilatation which are not caused by any obstruction of the pylorus, but merely by the relaxation of the muscular coat of the stomach. Here the gastrofaradization is beneficial, no matter whether in these cases there is hyperacidity or subacidity of the stomach contents. Cases of relax- ation of the cardia (eructations), and also of relaxation of the pylorus (presence of bile secretion in the stom- ach), were very favorably influenced by faradization. Here the result was most markedly pronounced, inasmuch as, besides the subjective amelioration of the patient, the objective examination showed at the same time the absence of bile in the stomach con- tents. 3. Gastrogalvanization is almost a sovereign means for combating severe and most obstinate gastral- gias, no matter whether their origin is of a ner- vous nature or caused by a cicatrized ulcer of the stomach. 148 DISEASES OP THE STOMACH. 4. Gastrogalvanization exerts also a favorable in- fluence on several affections of the heart complicated with gastralgia. With regard to the effects of the current in diseases of the stomach, it is very difficult to give a full theo- retical explanation, I perfectly agree with Stockton/ who says : " Exactly what role is played by faradization I am unable to state; whether it is a gastric sedative or a gastric stimulant I do not know. My efforts were in the direction of study, and the results were so favor- able that I applied faradism to cases seemingly contra- dictory in character, and I have concluded that the great variety of gastric neuroses depend upon a com- mon cause — an imperfect innervation of the stomach ; that electricity improves this innervation, thereby re- lieving the cause and so the conditions w^hich, at first thought, are so contradictory," In therapeusis the chief factor in determining the efficacy of any means of treatment is and will be our empirical experience. For this reason I do not think it necessary to go into further details of the manner in W'hich electric currents act upon the human organ- ism. The very numerous successful results obtained by this method of treatment warrant its general use in practice. Since the publication of my papers on direct electri- zation of the stomach many authors in this country as well as in France and Germany have made use of this method of treatment and highly recommend it. Thus ' Charles G. Stockton : "Clinical Results of Gastric Faradization. " American Journal of the Medical Sciences, 1890, p. 20. LOCAL TREATMENT OF THE STOMACH. 149 Stockton, Ewaldj Eave,' A. A. Jones," D. D. Stewart,' Eosenheim,* Brock," Goldschmidt," and others have pubhshed good results obtained by intragastric electri- zation. Ewald approves of the shape and form of my electrode, but finds it difScult to introduce it into the patient's stomach. For this reason he has modified my electrode by using a thicker rubber tubing around the wire : the tubing corresponds to No. 1 3 Charriere and is about 1^ mm. thick. I have not found, how- ever, that the insertion into the stomach of the de- glutable electrode offers any difficulties. The principal point is to put the electrode far back into the pharynx and to let the patient meanwhile drink something. It is advisable to have the patient drink slowly about a glassful of water, and to have a talk with him, in order to distract his attention from the procedure. The electrode usually soon reaches the stomach, and it seldom happens that it remains lying in the fauces. If this does happen, the patient must eat a small piece of bread and drink some water; the electrode will then find its way into the stomach with the bread. If in a very rare case the deglutable electrode can- not be introduced, there is yet always time to use in- stead the electrode as modified by Ewald. 'J. Rave: "Contribution a 1' etude du traitement des dyspepsies par I'electricite, " Paris, 1893. 2 Allen A. Jones: Medical Record, June 13th, 1891. 3 D. D. Stewart : Therap. Gazette, 1893, p. 744. 4 Rosenheim: Berliner Klinik., May, 1894. 5 Brock: Therap. Mouatshefte, 1895, p. 275. ^ Goldschmidt : "Ueber den Einfluss der Elektricitat auf den gesunden und kranken menschlichen Magen." Deutsch. Arch. f. klin. Med., vol. xv., p. 295. 160 DISEASES OF THE STOMACH, Wegele ' has lately devised a new gastric electrode which he terms the sj)iral electrode. Inasmuch as this electrode has to be used through a stomach tube, it has no advantage whatever over the ordinary stom- ach electrodes formerly in use, as the principal prog- ress achieved by means of the deglutable electrode is that the stomach tube can be dispensed with in the application of electricity.'' > Wegele ; Therap. Monatshefte, 1895, p. 195. 2 Internal massage of the stomach has been recently suggested by Dr. Fen ton B. Turck, of Chicago, 111., by means of his "gyromele" or "revolving sound." This instrument consists of a flexible cable, to the end of which is attached a sponge covering a spiral spring, which can be removed from the cable at will and changed. The cable passes through a rubber tube, and this again is attached to a revolving apparatus, for the purpose of producing revolutions of the sponge. (See American Medico-Surgical Bulletin, July 1st, 1895.) CHAPTER Y. ORGANIC DISEASES WITH CONSTANT LESIONS. The Acute Ajst) Chronic Gastric Catarrh. 1. Acute Gastritis. Synonyms. — Gastritis glandularis acuta; acute gas- tric catarrh ; catarrhus ventriculi acutus. Definition. — An inflammation of the gastric mucous membrane, resulting in disturbances of digestion. Acute gastritis may be divided into the three follow- ing forms : Gastritis acuta simplex, gastritis-phlegmo- nosa, and gastritis toxica. Gastritis Acuta Simplex or Acute Gastric Catarrh. Etiology. — Acute gastric catarrh is one of the dis- eases most frequently met with in the practice of the physician, and occurs at all ages and among all classes of society. It is usually attributable to errors in diet, the chief cause being an abnormal quantity of ingesta. ; Irritation followed by inflammation of the stomach often results from the use of very hot, but especially ice-cold drinks, or from too highly spiced or fermented foods. If food be imperfectly masticated and swal- lowed in big lumps, it may mechanically disturb the stomach and lead to inflammation. The same effect 15-2 DISEASES OF THE STOMACH. is induced by maDv irritatiDg substances, as, for in- stance, alcohol, rancid butter, etc. The sensibility of the stomach is not always alike. One of the above-named causes may be productive of a catarrhal condition in one person, while in many others it remains perfectly inactive. The tendency to acute catarrh of the stomach varies very much in different individuals and families. Some people have a certain predisposition for this affection, which is designated by the expression "'delicate stomach." The latter is often found in anaemic women, in old persons, and in- valids of all kinds. The question whether the acute gastric catarrh may originate by way of infection has not as yet been settled. The epidemic appearance of this affection at a certain time speaks in favor of such an assumption, which was first propagated by Lebert * and Oser.^ Xo micro-organisms, however, have been found within the stomach wall to corroborate this theory. Besides the above-named direct causes, acute gastric catarrh is indirectly engendered by all acute infectious diseases, which it ordinarily accompanies. Morbid Anatomy. — As gastritis as such hardly ever causes death, and inasmuch as the stomach after death quickly undergoes radical changes which destroy the true picture that had before existed, the minute his- tology of the affected stomach can be studied only with the greatest difficulty. Even nowada3's we have no better description of the macroscopical aspect of the inflamed organ than that given nearly seventy years ' Lfibert : "Die Krankheiten des Magens." Tubingen, 1878, p. 29. ^Oser: -'Magenkrankheiteu." Eulenburg's " Realencjclopje- dia, " vol. xii. , p. 410. GASTEITIS ACUTA SIMPLEX. 153 ago by Beaumont ' from his observations made on the well-known Canadian St. Martin with his gastric fis- tula. The mucous membrane appears entirely or par- tially swollen and reddened and is marked here and there with small sacculations. Less gastric juice is secreted, and mucus covers the surface. The pyloric portion, as a rule, is more affected, and there exist more or less extensive extravasations of blood. The secre- tion is only weakly acid or neutral, or even alkaline. Microscopically the principal cells are found to be more granular and cloudy, partly fatty and shrunken. There is no distinction possible between the parietal and the principal cells. In the interglandular tissue numerous round cells are found. They are also met with between the epithelial cells and appear to be wandering to the surface. These round cells, accord- ing to Sachs, '' give distinct pictures of karyokinesis. Symptomatology. — 'Immediately after a manifest indiscretion of diet there is experienced, first of all, a feeling of heaviness at the pit of the stomach; later on a sensation of fulness. There is a desire to belch, and a difficulty in doing so. After belching, the pa- tient feels easier for a little v/hile, but soon the heavy sensation reappears. This condition may persist un- changed for a few days, and then gradually disappear. This is the mild form of the acute catarrh. Very often, however, w^e meet with more alarming symp- toms. At the beginning there may exist nausea, a sensation of weight, and slight pains in the gas- ' Beaumont : I. c. 2 A. Sachs : " Zur Kenntniss der Magenschleimhaut in krankhaf ten Ziistanden." Arch. f. experim. Pathologie, Bd. 23, Heft 3, and Bd. 34, Heft 1 and 3. 154 DISEASES OF THE STOMACH. trie region, severe headache, sometimes rise of tem- perature, later on vomiting, extreme anorexia, con- stipation, or diarrhoea. Soon the symptoms become less severe, and appear as described in the milder form. Objectively the gastric region appears bloated, and is sensitive to pressure. The tongue is thickly furred, and the taste pappy. If vomiting occurs, the ejected matter contains no free hydrochloric acid, is of a slightly acid or neutral or alkaline reaction, and is frequently mixed with a great deal of mucus. The duration of the affection is short, as a rule from one to three days. The more severe cases begin with a sudden rise of temperature (102° to lOi" F.), which may be accompanied with chills. In such instances the gastric symptoms may at first be less marked than the symptoms caused by the fever. After a short period, however, the gastric symptoms become more pronounced. The inflammatory process of the stomach not rarely extends into the intestines, and then causes constipa- tion or diarrhoea. The affection may also invade the gall bladder, and then gives rise to icterus. In the febrile form of gastritis herpes labialis is of frequent occurrence. Diagnosis. — It is easy to make the diagnosis in those cases which are not accompanied by fever, and where the cause of the trouble is apparent. The analysis of the gastric contents or of the vomited matter shows a marked diminution in the secretion of gastric juice. An acute gastritis accompanied by fever will at times cause some difficulty in diagnosis. As is well known, most of the infectious diseases are GASTRITIS ACUTA SIMPLEX. 155 accompanied by gastric catarrh at their commence^ ment, but they can be easily excluded by the absence of their pathognomonic symptoms. It is less easy to make a differential diagnosis between a beginning typhoid fever and acute gastric catarrh. In fact, the distinction between these two conditions is sometimes almost impossible during the first and second days of the sickness. The following may serve as differential points of diagnosis between these two conditions : In typhoid fever the temperature is characterized by its gradual rise, while in gastric catarrh the rise of temperature is quite sudden ; we may have at the very start a temperature of 103° or 104°. The remission in gastric catarrh will likewise be more pronounced. The presence of herpes labialis will speak in favor of gastric catarrh, while the appearance of Ehrlich's diazo reaction in the urine will point to typhoid fever. Biliary calculi not causing very severe pains, and not accompanied by icterus, may sometimes be mis- taken for a gastric catarrh. Such an error in diagno- sis will, however, occur but seldom ; as a rule, it is easy to differentiate between these two conditions. Prognosis. — ^The prognosis of gastric catarrh is very favorable, except in cases of very old people and in- valids, in which the process may cause serious' compli- cations. Treatment. — The vis medicatrix naturce is best seen in this affection. In order to become freed of the un- digested material, the stomach empties itself either by vomiting or transferring its contents into the small intestines, which in turn get rid of them by diarrhoeal 156 DISEASES OF THE STOMACH. passages. The anorexia prevents the patient from taking food, and in this way the stomach can enjoy perfect rest and soon recuperate. In our treatment we have to imitate or rather assist nature. If spontaneous vomiting does not take place, and a feeling of pressure and pains in the stomach are present, if percussion over the gastric region gives dul- ness, and belching of badly smelling gases occurs, then we ma}' be certain that all the symptoms men- tioned are caused by decomposed food within the organ. Here it is best to look for means which will remove this obnoxious material. Washing out of the stomach is the best way to accoixiplish this end. In- stead of lavage, however, we ma}' tell the patient to drink half a pint or even a pint of lukewarm water in which a small quantity of table salt has been dissolved, and then tickle the throat with the end of a quill or with the finger in order to produce vomiting. Cam- omile tea can also be taken in the same manner before bringing on vomiting. Emetics are rarely given nowadays. In suitable cases it is best to make use of the subcutaneous injec- tion of apomorphine (the dose being about one-half a centigram). Tartar emetic and ipecacuanha should never be employed except in children. The stomach after having been emptied should now enjoy perfect rest for some time. , Thus during the first or second day of illness it is best not to give the patient any- thing substantial to eat. Strained barley or rice water or weak tea may be taken. On the third day, as soon as the appetite reappears, the patient is per- mitted to partake of a water soup (bread and hot GA.STRIT1S ACUTA SIMPLEX. 157 water), of oatmeal or barley gruel, rice soup, and per- haps oue soft-boiled egg. Later on French bread, butter, and oysters may be added to the dietary. If the improvement is steadily progressing, we begin on the fourth day with meat once a day, and thus slowly return to the usual bill of fare. As a rule, no medi- cines whatever are needed. If obstinate constipation exists, however, and the bowels have not moved dur- ing the first two days of sickness, some aperient may be given. A large dose of calomel (ten to fifteen grains) administered once is very serviceable. This remedy should especially be employed in the febrile form of gastritis. If there is no fever, Seidlitz pow- ders or a good dose of citrate of magnesia will serve the purpose. In rare instances in which the symptoms appear in a very aggravated form they may require special at- tention. A pronounced sensation of jDressure and ful- ness in the gastric region after the ingestion of food may be relieved by small doses of dilute hydrochloric acid (ten drops in a glassful of water three times daily half an hour after meals). A high degree of pyrosis can be relieved by the following medication : I^ Calcined magnesia, Sodium bicarbonate, Peppermint sugar, aalO.O M. f . pulv. D. ad scatulam. S. A point of a knife every two hours. Severe pains may be relieved by a small dose of codeine: I^ Codein. phosph 0.1 Aq. menth. pip^ . . . . . .40.0 S. One teaspoonful twice or three times daily. 158 DISEASES OP THE STOMACH. Gastritis Phlegynonosa. Synonyms. — Gastritis phlegmonosa piiriilenta ; purulent inflammation of the stomach. This affection usually runs an acute, and very rare- ly subacute course. The inflammatory process is sit- uated in the submucous and muscular layers of the stomach, differing in this respect from acute gastritis, in which the glandular layer is affected. Phlegmon- ous gastritis is a very rare disease and occurs more frequently among men than women. Two forms of this affection are met with: the primary or idiopathic and the metastatic. Although the exact cause of primary purulent gastritis is as yet unknown, the symptoms and course of the morbid process justify the assumj)tion that it is due to some micro-organism. The metastatic form occurs in pysemic and puerperal fever or severe exanthemata. Morbid Anatomy. — There may be present either a circumscribed abscess in the gastric wall (gastritis phlegmonosa circumscripta or abscess of the stomach), or a diffuse purulent infiltration. In the latter in- stance, numerous small abscesses of pea or hazelnut size are generally found. The mucosa over these areas apjDears swollen. The abscesses lie in the sub- mucosa or muscularis and often extend to the serosa. If the purulent process progresses further, perforation may occur either into the stomach or into the abdom- inal cavity. Symptomatology . — After the existence of dyspeptic symptoms for some time, or without any previous dis- GASTRITIS TOXICA. 159 turbanceSj the patient suddenly experiences an intense pain in his gastric region. At the same time there appear a violent burning sensation within the stom- ach, extreme thirst, dry tongue, and perfect anorexia. These symptoms are accompanied by high fever (103'- 105° F.), with only very short intermissions. Some- times the onset of the disease is attended by chills. The pulse is small and irregular. In most instances there is vomiting and retching, the vomited matter consisting mainly of mucus and some bile. The gas- tric region is very painful to pressure. The bowels are either constipated, or (as is generally the case) diar- rhoeal. The disease, as a rule, ends fatally in a very short time (four to seven days). It may, however, last fourteen days. The chronic form occurs most frequently in the course of the so-called gastric ab- scess. Diagnosis. — An exact diagnosis of this affection can hardly be made during life. If, in connection with the above symptoms, there is an increased resistance in the gastric region with severe pain on pressure, we should think of purulent gastritis. Treatment. — ^The treatment should be symptomatic. Ice-cold application to the abdomen, leeches, large doses of opium, or subcutaneous injections of mor- phine, and, if there is collapse, camphor, ether, and the like will have to be administered. Gastritis Toxica. Among the poisonous substances which directly affect the gastric mucous membrane, the following de- serve special notice: Alcohol, phosphorus, arsenic, 100 DISEASES OF THE STOMACH. potassium cyanide, corrosive sublimate, nitrobenzol, potassium chlorate, concentrated mineral acids (sul- phuric acid, nitric acid), and the caustic alkalies. The first-named substances cause an intense acute gas- tritis. The raucous membrane becomes swollen and superficially necrotic, leaving behind small hemor- rhagic spots. Microscopically the glandular tubiili are found to have undergone fatty degeneration. The latter group of poisons (acids and alkalies) act quite differently. They directly destroy the parts they come in contact with and in this way the whole mucous layer may become destroyed ; sometimes, should the poison penetrate still farther, the submucosa may also be destroyed, and rupture of the stomach takes place. Symptomatology. — The symptoms will be more or less marked according to the quantity of poison taken. There is always pain in the gastric region, which is in- creased on pressure. Vomiting is of very frequent occurrence. The vomited matter may contain an ad- mixture of blood. Thirst is always present. In cases of a severe nature there is always found a small pulse, cyanosis, cold perspiration, slight coma, and death may occur in collaj)se. In other cases the course may be somewhat more protracted and either peritonitis or icterus, hsematuria caused by the poison circulating in the blood, may de- velop. In those instances in which death does not oc- cur there may arise — after the acute symptoms of poison have been subdued — a condition which is simi- lar to that of a subacute gastritis. It sometimes, though seldom, happens that the mu- GASTRITIS TOXICA. 161 cous membrane of the stomach is affected to such a high degree that it may entirely atrophy and then a condition of achyha gastrica will result. In cases of poisoning by mineral acids or caustic alkalies, it may occur that in consequence of the sloughing of an area situated either near the cardia or near the pylorus a stricture develops, thus causing serious complications. These strictures frequently develop later on, at a time w^hen the patient perhaps imagines that he is entirely rid of his trouble. The stricture of the cardia causes dysphagia, and the stricture of the pylorus ischochymia. Diagnosis. — The diagnosis is frequently made by the cross-examination of the patient, provided he is able to state w^hat kind of poison he took. The in- spection of the mouth, tongue, and pharynx may lead us to suspect poisoning by mineral acids or caustic alkalies, as both cause manifest lesions (sloughing) at these places when taken. The examination of the vomited matter will also frequently lead us to discover the nature of the poison. Prognosis. — The prognosis will greatly depend upon the quantity of poison taken, and upon the condition in which we find the patient. On the whole, every case of poisoning must be considered as quite serious, recovery being doubtful. Treatment. — In all cases of poisoning by concen- trated mineral acids and caustic alkalies, the best mode of treatment is to effect dilution of the poison, and if possible its neutralization. Thus we give cal- cined magnesia (100 gm. dissolved in a pint of milk) to the patient as a drink in case the poison con- 11 162 DISEASES OF THE STOMACH. sisted of a mineral acid; the magnesia will then neu- tralize the acid. On the other hand, we administer a drink consisting of lemonade or a weak solution of acetic acid (one to two per cent) in case the poi- sonous substance had been a caustic alkali, for the reason that the acid introduced forms a harmless com- bination with the poison. In the instances just men- tioned, lavage cannot be used for fear of a perforation of the stomach ; nor is it permitted to bring on vomit- ing, as the poisonous matters lodged within the stom- ach would cause a great deal of harm by their com- ing in contact with the oesophagus and mouth when ejected. In all other kinds of poisoning (alkaloids and metals) it is always best to use lavage as early as possible, in order to free the stomach and the organism of that portion of the poison that has not yet entered the small intestines. Although an emetic (like apomorphine) can be used for this purpose, siphonage of the stomach is, however, by all means preferable, for only the latter permits a thorough emptying and cleaning of the or- gan. It is not the place here to speak of all the anti- dotes that have to be employed in these cases. The subsequent treatment will always depend upon the symptoms in each given case. In peritonitis ice will have to be applied on the abdomen, and opiates freely given. The treatment of a resulting stricture of the cardia or of the pylorus must, in most instances, be a surgical one. In the former cases, dilating of the cardia by means of bougies will first be tried. CHRONIC GASTRIC CATARRH. 163 2. Chronic Gastric Catarrh — Gastritis Glandularis Chronica. Definition. — Chronic inflammation of the gastric mucous membrane, causing various disturbances in the act of digestion. FatJwIogical Anatomy. — The mucosa is usually covered with a thick layer of tenacious mucus pre- senting a yellowish-gray or slate-gray color, while some parts may appear intensely red. The latter con- dition is frequently found in the secondary catarrh caused by congestion. The mucosa is frequently thicker than normally, and forms pajDillar^^ projec- tions, thereby causing the so-called etat manielonne. As a rule, the pyloric portion of the stomach is chiefly involved. The inflammatory process, how- ever, may sometimes extend over the entire mucous membrane. In some instances the submucosa and muscularis may also undergo some changes, and ap- pear either in a hypertrophied state or very much atrophied. Microscopically the glands often seem en- larged, sacculated, and dilated in cyst-like forms. The tubuli have lost their normal regular arrangement and show an atypical distinct ramification. The glandular cells appear granular and in a condition of fatty de- generation, and there is no longer any difference rec- ognizable between the principal and parietal cells. An abundant small -celled infiltration is present which fills the interglandular spaces and pushes the glands apart. This small-celled infiltration is especially marked near the surface of the mucous membrane. 164 DISEASES OF THE STOMACH. The superficial layer of the epithelium of the mucosa is frequently defective. The mouths of the glands are very often filled with a pale mucous mass, which pro- jects against the lumen without any enclosing mem- brane. According to Ewald,' there is a condition of mucous catarrh in which the degeneration may be ob- served to extend down to the base of the glands, so that in place of the ordinary princijDal and parietal cells we find cells in the most varied stages of mucoid degeneration. This condition is especially found in the pyloric region. Some cells may be found which are still intact, the mucus filling only a small part of them, while the rest of the cell is occupied by granular protoplasm and a large nucleus. In others the mu- cus occupies the greater part of the cells and crowds the protoplasm and the flattened nucleus against its base; in still others the cell membrane has ruptured, and the mucus has escaped into the lumen of the duct of the gland. This mucoid degeneration Ewald found only in specimens which had been placed while still warm in alcohol. In older specimens the condition above described could not be discovered. In a patient with cancer of the pylorus, I had the opportunity to find in the wash-water a small piece of the gastric mucosa. It was placed in alcohol at once, and the microscope revealed a beautiful picture of mucoid degeneration (see Fig. 27). The inflammatory process after existing for a long period may at the end lead to a total destruction of the glandular layer of the entire organ, thereby caus- ing a condition which has been termed atrophy of the 'Ewald: I. c, p. 318. CHRONIC GASTRIC CATARRH. 165 stomach or anadenia ventriculi (Ewald). Two differ- eat processes ultimately effect this condition. The first consists in a fatty degeneration and de- struction of the gland, the process progressing from the surface of the stomach inwardly. While in the early stage no glands are found on the surface of the mucosa, there still exist glandular cysts situated near the submucosa. Later on even these glandular cysts disappear, and the whole mucosa consists almost en- tirely of round, cells. According to Ewald, this proc- ess is especially met with in those instances in which the entire organ is more or less dilated and the walls thin. The submucosa is then also partly changed, the muscular layer being much thinner. The second process takes its origin in the submu- cosa, and progresses from the deeper layers to the sur- face of the stomach. In this instance the fibrous ele- ments play the greater part. The inflammatory proc- ess causes the formation of fibrous tissue, which spreads around the glands and partly constricts them. The glands are also ultimately destroyed and their place taken up by fibrous tissue. As a rule this condi- tion is found in stomachs which are much smaller than usual, and present a thickening of their walls. The size of the organ in such instances may be reduced to that of a big pear, and the walls may attain a thick- ness of about 1 to 2 cm. Brinton * has termed this condition "cirrhosis ventriculi," while the French designate it "sclerosis ventriculi." This condition of cirrhosis ventriculi, however, may be associated with VW. Brinton : "Diseases of the Stomach." 166 DISEASES OF THE STOMACH. the first-described process, as the following drawing of a case I have observed clearly illustrates. Etiology. — Chronic gastric catarrh is more fre- quently met with among men than among women. '■Sr^i /. Fig. 38.— Cross-Section through the Stomach Wall Cof A. G., with achylia gastrica), showing relations of the layers: a, mucosa; ft, submucosa; c, d, muscularis ; e, serosa. No glands in the mucosa. X 60. It is often caused by an irrational mode of living. Fast eating, resulting in imperfect mastication of the food; overloading the stomach with too large quanti- ties of food; highly spiced dishes; ice-cold drinks — all these tend to irritate the stomach, and to cause a CHRONIC GASTRIC CATARRH. 167 catarrhal condition of the organ. In this country ice / water and fast eating are the two principal causes of j the so-called "American dyspepsia." Tea and coffee ' taken in too large quantities are also said to cause this trouble. Alcoholic drinks, especially the stronger ones, as whiskey or liquors (among them also stomach bitters), and the abuse of tobacco (smoking and chew- ing, especially the latter) also frequently give rise to this affection. But even in people leading a regular life chronic gastric catarrh may develop, either after frequently repeated attacks of the acute form or after the recovery from very severe infectious diseases. Thus typhoid fever is frequently found to be the origin of the affection. An unhealthy condition of the mouth, and more so of the teeth, is liable to pro- duce gastritis, for in these instances the food on the one hand cannot be chewed thoroughly ; on the other hand it becomes impregnated with products of decom- position originating from decayed teeth, and in this way produces an undue irritation of the gastric mu- cous membrane. Chronic gastric catarrh is moreover found as a secondary disorder in association with many other chronic diseases; thus, for instance, all kinds of pulmonary and cardiac affections, liver and kidney troubles, are frequently found to be compli- cated with chronic gastritis. Likewise some constitu- tional diseases, as for instance gout and diabetes, are frequently combined with gastritis. Symptomatology. — As a rule the disease develops very slowly. The initial symptoms are not well marked. After the condition has lasted for a longer period of time the disturbances become more pro- 168 DISEASES OF THE STOMACH. nounced, and a train of many varied symptoms is present. The patients frequently complain of an ab- normal taste in their mouths. They describe it either as salty or as pappy, in a few instances as sour. The appetite is ordinarily diminished, or, if present, the feeling of satiation appears after a few morsels of food. After meals there is a sensation of fulness in the gastric region, and the patient feels oppressed. This feeling, if j)reseut in a higher degree, sometimes gives rise to symptoms of quite an alarming nature. Thus the patients complain of palpitations of the heart and shortness of breath (asthma dyspepticum). In some instances again there appears a di zzy feeling , which is occasionally so severe that the patient cannot occupy a standing position but has to sit down or lie down. The oppression experienced is relieved by belching, but the latter may occur so frequently as to greatly annoy the patient. In fact, belc hing c onsti- tutes one of the most frequent symptoms of chronic gastric catarrh. As a rule, a quantity of odo rless gas is brought up by the act of belching, although in very rare instances it may have an unpleasant odor. Pain. — As a rule intense pains..ara-ahseni. There is a mere sensation of discomfort and sensitiveness in the gastric region, which may increase after meals, more especially after ingestion of coarse food. Pyrosis. — The patient may experience a burning sensation at the pit of the stomach. In this instance a sour liquid, alone or mixed with food, often comes up through the oesophagus into the mouth (regurgita- tion). Vomiting. — Vomiting is not of very frequent oc- CHRONIC GASTRIC CATARRH. 169 cnrrence in gastric catarrh. It is met with most fre- quently after the morning meal or in the morning on arising. In the latter instance the quantity ejected is quite small, and consists of a watery fluid containing ijrincipally mucus. A feeling of nausea is more fre- quently observed. Condition of the Bowels. — The bowels are fre- quently found abnormal : either they are very con- stipated, which is quite the rule, or there may exist diarrhoea, or again periods of diarrhoea may alternate with periods of constipation. Urine. — The urine is scanty, and frequently con- tains deposits of phosphates and urates. General Symptoms. — The patients feel languid and manifest less energy in the performance of their work. Their mental activity is frequently weakened. They often complain of headache, especially in the morning, and a heavy feeling in the limbs. A desire to yawn is often met with, and some patients assert that they cannot breathe as deeply as they desire. In some in- stances the flow of saliva is greatly increased. Some- times patients experience a constant irritating feeling in the throat, which they seek to relieve by a kind of hacking cough. Objective Signs. — The general appearance of the patient is, as a rule, quite good. He looks well nourished, and usually possesses a good panniculus adiposus. Some patients, however, show black rings around their eyes, notwithstanding their being well nourished. Under these circumstances they frequent- ly have cold hands and feet, and chill very easily. There are, however, exceptions to this rule, and pa- 170 DISEASES OF THE STOMACH. tients are sometimes observed who have lost consider- ably in weight and appear quite emaciated and thin. The tongue is, as a rule, covered with a fairly thick, grayish, and moist coating. The margins of the tongue show the indentations of the teeth. Either there is no offensive smell present in the mouth or, if it exists, it is due to some imperfection in the condition of the teeth, nose, or throat. The gastric region often appears bloated. On pal- pation it is found to be sensitive to pressure, although there is no real pain. The splashing sound can be easily produced when the stomach contains some liquid. The size of the organ is, as a rule, not increased. The gastric contents : One hour after Ew aid's test breakfast the gastric contents show a lessened de- gree of acidity, and contain either no free hydrochloric acid at all or only small quantities. The pieces of roll are not as fine as normally. Pepsin and rennet are always present; erythrodextrin is present only in small quantities, while achroodextrin and sugar are abundant. The quantity of the gastric contents ob- tained after the test breakfast is either normal or somewhat larger (120-180 c.c). Mucus may be present in great quantities in the gastric contents of some persons, while it may be absent in others. In the former case the gastritis is designated by the name of "gastritis chronica mucosa." The mucus in the gastric contents can be easily recognized by its appear- ance. A glass rod dipped into the contents and lifted in an oblique direction will cause a part of the mucus to be drawn up in the form of strings. The contents CHRONIC GASTRIC CATARRH. 171 pass very slowly through filter paper, and the addition of' acetic acid to the filtrate will produce turbidity. In the fasting condition the stomach is either found empty, or it may contain only a few cubic centimetres of a turbid liquid, consisting of mucus, and presenting either an alkaline, neutral, or acid reaction. In the latter instance free hydrochloric acid may be dis- covered in small quantities. Microscopically many round cells and some epithelial cells are found to be present. In washing out the stomach in the fasting condition, the wash-water, as a rule, contains more or less considerable quantities of mucus. Instead of ex- amining the gastric contents, the vomited matter, if such is present, can be made use of for testing the chemical qualities of the gastric juice. As a rule, the same conditions will prevail here as stated above under the examination of the gastric contents. The motor function of the stomach is either not im- paired at all, or only slightly diminished. Absorption. — Most writers assert that the absorp- tion is retarded. It seems to me, however, that this rule does not apply to all substances. On examining the absorptive power in several cases of chronic gas- tric catarrh with the potassium iodide test, I could not see any marked departure from the normal. I subjoin two cases of chronic gastric catarrh, one representing a mild and the other a more advanced form of this affection : Case I. — Mrs. L. W , about 26 years of age, suffered for about four years from frequently recur- ring digestive disturbances (poor appetite, pains in the region of the stomach and in the abdomen). She had 173 DISEASES OP THE STOMACH. been treated by several competent physicians, some- times with good results. Several months before con- sulting me the general health of the patient was impaired ; the complaints, however, had greatly in- creased during the past six weeks. She suffered from pains in the region of the stomach, and could not eat sufficiently, for soon after partaking of the food she had a sensation of being laced ; she could not sleep, and was troubled much with repeating and flatus ; during the summer she lost in weight considerably. Status 'py?■•. .--:'^:5-^s.vv'.;:.iT-:;.i^K- •■ ' .:.... vi?V^.;;:-^4?^ii»'^^ //.•'••v v;--:'v-v- •f'^-•.=^•->^■■^<;■viv:>2•v■■J^ . i- -vv. '.■-.-.•■X'i -.-Jr- •• *^'^^ ■■^■•■■'.:•?>■•^^«'•i';^-iJ•t■■.'f^• v>\>^^r--l^^^^ ,-".a'^'-" '^ ,4." V'-'-r;iiS'.--'''V-.''. v ■ •■i;-"--" ■"' Fig. 42.— The left comer of Fig. 41, as seen under the microscope with low power. Glands are visible to the left of the drawing, the rest consisting principally of a proliferation of cells and Connective-tissue formation. ually attain a diameter of five or six inches. Debove and Remond ' mention a case of gastric ulcer of the size of the palm of the hand. Situation of the Ulcer. — According to Brinton/ ' Debove etRemond : "Traice des Maladies de rEstomac, " Paris, p. 255. '^ W. Rrinton : I. c. 200 DISEASES OF THE STOMACH. gastric ulcer occupies the various parts of the stomach in the followiDg frequency: In 43 cases out of 100 the posterior surface, in 27 cases the lesser curvature, in 16 cases the pyloric extremity, in 6 cases both the Fig. 43. — Showing One Spot of a Proliferation of Cells lying in the Centre of the Specimen (Fig. 41 ) resembling very much a spindle-cell sarcoma. Highly mag- nified. anterior and posterior surfaces, often at opposite places; in 4 cases the anterior surface only, in 2 cases its greater curvature, in 2 cases the cardiac pouch. Thus about 86 ulcers in every 100 occupy the posterior ULCER OF THE STOMACH. 201 surface, the lesser curvature, the pyloric sac, parts of the stomach which together form a segment of less than half of the total superficies of the orgau. Hence we may estimate that any part of this con- tinued (but irregular) segment of the stomach is on an average about five times more liable to the lesion than the remaining segment formed by the cardiac sac, the anterior surface, and the greater curvature. Nolte's' figures do not harmonize with those just given. Xolte presents the following scale of fre- quency: At the greater curvature. 22: at the py- lorus, 13: at the anterior wall, o: at the posterior wall. 2; at the cardia, 1. Welch's statistics harmonize more with Brintou's figures. Out of 793 cases collected by this eminent American writer, 288 ulcers were situated in the lesser curvature, 235 on the posterior wall, 95 at the pylorus, 96 at the anterior wall, 50 at the cardia, 29 at the fundus, 27 on the greater curvature." Number. — As regards the number of ulcers, accord- ing to Brinton, 2 or more are present in 1 out of every 5 cases, or about 21 per cent. Out of 97 such plural cases (corresponding to 163 instances of ulcer), in 57 there were 2 ulcers, in 16. 3, and of the remaining 24 in which "■ several" ulcers were present. 3 cases offered 1 and 2 cases 5 ulcers each : while in 4 there is reason to suppose even this number was exceeded. Further Progress of the Ulcer. — 1. Cicatrization. The ulcer, as a rule, does not heal with restitution of the normal mucous membrane, but leaves behind a I Nolte : See Ewald, I. c. , 239. * Welch: Cited from Osier's "Practice of Medicine," p. 369. 202 DISEASES OF THE STOMACH. fibrous, centrally depressed scar, which has a tendeDcy to contract. If such a scar be situated at the pylorus, its contraction may produce stricture of this outlet. If the ulcer had a girdle-like shape, constriction of the viscus may occur, and give it the form of an hour- glass. 2. Progressive Necrosis and Corrosion. If cica- trization does not occur, the necrotic process may con- tinue for a long period and may cause the following complications: (a) Corrosion of vessels. Vessels of larger or smaller calibre may become opened and give rise to hemorrhage, or if a very large vessel is affected even to fatal bleeding. Among those more frequently involved are the gastric, splenic, and pancreatic arteries. (6) Adhesions to neighboring organs and perfora- tions. As soon as necrosis extends to the serosa, it leads either to a reactive inflammation with adhesions to surrounding organs and extension of the process to them, or where circumstances do not permit such ad- hesions, to a direct perforation into the abdominal cav- ity. After the adhesions have formed, a perforation may yet take place into a neighboring cavity. Thus perforation into the pleural or pericardial cavities oc- curs, or sometimes a fistula is formed between the stomach and duodenum or colon. According to the site of the ulcer, any of the neighboring organs, liver, gall bladder, pancreas, spleen, diaphragm, heart, lungs, etc., may become subject to these ad- hesions. Perforations of the anterior wall of the stomach are most dangerous on account of the greater ULCER OF THE STOMACH, 203 mobility of this part of the organ and the consequent lack of adhesive inflammation. These, as a rule, terminate fatally. Symptomatology . — ^A typical case of gastric ulcer is ushered in by disturbances of the gastric digestion. At the beginning there is merely a feeling of uneasi- ness and pain in the epigastric region ; but these are soon followed by nausea and regurgitation or vomit- ing. These symptoms may undergo no change for a long period ; at times, however, they become more severe in character. The pains especially take on a more aggravated form, and many patients are afraid to eat on account of them. Very often a hemorrhage from the stomach occurs, producing an increase of the ansemia and cachexia which already exist in conse- quence of subnutrition. If the disease takes a pro- gressive course, it is liable to end lethally by perfora- tion, hemorrhage, or by inanition. In most instances, however, the course of the disease is cut short either by a spontaneous cicatrization of the ulcer, or by the same process being brought about by our rational means of treatment. The symptoms then gradually disappear, and recovery takes place. In many in- stances the symptoms of the disease reappear after the lapse of various periods of time (one or several years). It is then quite difficult to decide whether we have to deal in these instances with the formation of new ulcers, or a breaking down of the cicatrix of the old lesion. As the above-mentioned symptoms of ulcer are met with likewise in many other disturbances of the stomach, and inasmuch as each of them has its specific character in the different lesions, it will be 204 DISEASES OF THE STOMACH. best to analyze each of the symptoms of gastric ulcer separately. 1. Pain is the most frequent and characteristic of all the symptoms. In the earlier stage 'of the disease there is a mere feeling of weight or tightness in the epigastric region. Sometimes the patient has the im- pression as though the food experienced a stoppage there. From such a dull, continuous feeling the pain gradually augments into a burning sensation and at last into a gnawing pain. In the majority of cases the pain comes on from two to ten minutes after deglutition of food and remains during the period of gastric digestion, at the close of which it gradually subsides and disappears. There are, however, exceptions to this rule, and we find cases of typical gastric ulcer where the pains appear half an hour or an hour or two and three hours after meals. Different kinds of food have a marked influ- ence upon the pain. Coarse substances and many undigestible foods increase the pain, whereas a liquid diet, especially milk, may fail to bring on the pain. The quantity of food is also of import, a large meal causing more pain than a small one. The situation of the pain corresponds, as a rule, to the centre of the epigastrium, or to the median line of the abdomen immediately below the free extremity of the ensiform process. The portion of the epigastric region to which the pain is referred forms a circular area of rarely more than two inches diameter, some- times a mere spot of less than half this size. There are, however, exceptions to this rule, and a spot of pain may be situated a little more to the right or to ULCER OF THE STOMACH. 205 the left or also farther down than the above-described spot. Occasionally the pain is associated with a feel- ing of violent pulsation or throbbing in the epigastric region. At times this sensation is felt independently of the paroxysm of pain. The dorsal pain, first described by Cruveilhier, is also an important symptom. It generally appears later (a few weeks or montbs) than the epigastric pain, and is then almost as constant and characteristic as the epigastric pain. This pain is gnawing in char- acter and situated, as a rule, to the left of the spine corresponding to the eighth or ninth dorsal vertebra, and extending occasionally to that of the first or second lumbar vertebra. Like the eiDigastric pain, it has a fixed seat, generally remaining near the spot of its first appearance during the whole progress of the disease, although it also shows lateral as well as verti- cal deviation from its ordinary situation. Its worst attacks generally alternate with those of the epigastric pain. The epigastric pain is increased on pressure. Even slight pressure with the finger upon the epigastric re- gion below the ensiform process produces intense pain. This is the most important point characteristic of gas- tric ulcer. To test the sensitiveness to jDressure by means of Boas' algesimeter. or to exert considerable pressure with the fingers, is not advisable. I perfect- ly agree with Brinton,' who says in reference to the latter point : "It is not altogether superfluous to add another caution with respect to the above test (pres- sure) : not only must it be applied w'ith great care and ' W. Brinton : I c. 206 DISEASES OF THE STOMACH. delicacy in the first examination of a supposed case of gastric nicer, but, as a rule, we can scarcely be too re- luctant to repeat it, even to verify a presumed amend- ment. At any rate, its effects are sometimes so injurious that it is necessary strictly to prohibit the patient from all manipulations of the epigastric re- gion, as well as from all pressure produced b}' dress (such as stays in the female) or work (as is the case with shoemakers)." The character of the pain, of becoming increased on pressure, is, however, not always present, and we find patients with gastric ulcer in whom the pain is rather subdued by pressure. 2. Vomiting. Vomiting in gastric ulcer occurs in nearly the same proportion of cases as pain. As a rule, it is absent during the first period of the disease, and appears somewhat later than the pain. Some- times, however, both these symptoms occur simulta- neously. The vomiting, most frequently met with in cases of ulcer, appears an hour or two after meals, at the time when the pain has reached its acme. As a rule, the vomiting relieves the pain. Sometimes the vomiting occurs less frequently, for instance once a day or still more seldom. The vomited matter ordi- narily consists of a water}' fluid mixed with particles of food. Occasionally, however, the latter are absent and the ejected matter then consists, as a rule, of clear gastric juice which, in many cases of ulcer, is secreted in too abundant a quantity. In such in- stances the vomiting may occur independently of the meals, and thus may take place either in the middle of the night or early in the morning on arising. ULCER OF THE STOMACH. 207 There are also cases in which vomiting takes place very soon after meals, or where, instead of the vomit- ing, there is regurgitation of food. The regurgitation may also occur two to three hours after a meal (the fluid brought up consisting of very acid gastric chyme or juice) and is very often accompanied hy pyrosis. Again there are cases in which instead of the vomiting we have spells of nausea. Vomiting of very large quantities of chyme, although met with in gastric ulcer, is most characteristic of cases of ulcer compli- cated with stenosis of the pylorus, and will be dis- cussed later on when dealing with that affection. 3. Hemorrhage. Hemorrhage is a symptom of the greatest importance in gastric ulcer. Since the proc- ess of ulceration implies a solution of continuity in the coats of the vessels of the stomach, there is noth- ing more natural than an effusion of blood. As a rule, however, the opening of the vessels is very soon obliterated by the formation of a coagulum. For this reason hemorrhages occurring from the very small vessels are not of much import, and pass unnoticed by the physician or the patient. It is only when a larger vessel is corroded and a considerable quantity of blood enters the stomach that grave symptoms appear. In a typical case of such a hemorrhage the patient ex- periences a sensation of fulness soon after a meal, combined with aiixiety. Some time afterward he feels nauseous, restless. Suddenly vomiting of a large quantity of blood occurs, having either a clear red, brownish, or black color, possibly mixed with food (hsematemesis). The patient, as a rule, feels faint, his face becomes pale, his extremities grow more or less 208 DISEASES OF THE STOMACH. cold, and if the hemorrhage goes on uninterruptedly, death is likely to occur in consequence of the profuse loss of blood. Under such circumstances the patient soon becomes unconscious, convulsions supervene, and life is gradually extinguished. If hemorrhage of a large vessel has taken place, it may even happen tliat the patient dies before any vomiting has occurred. In such instances the cause of death, if there have been no previous symptoms of ulcer, usually remains un- known until the autopsy, when the stomach may be found filled with liquid or coagulated blood. In most cases, however, gastric hemorrhage is not lethal. The blood, instead of being vomited, may pass into the intestines, and be evacuated with the stools, which then assume a blackish, tarry color (melsena). Very often both hsematemesis and melsena take place. Blood vomiting (hsematemesis), if present, is the most certain sign of ulcer, and its occurrence alone is sufficient to warrant a positive diagnosis of this affec- tion. In almost one-third of his cases of ulcer, Ander- son ' found this symptom present. There is no doubt that hemorrhages in gastric ulcer appear more fre- quently than we are able to recognize their existence. Very often in small hemorrhages the blood will pass through the digestive canal unnoticed, the reason being that small quantities of blood mixed with ali- mentary residues may be changed in such a way as to be unrecognizable. Even if blood be present in the stools in larger amounts, it will sometimes pass un- noticed because the patient does not pay attention to their color, especially nowadays when every one goes 'Anderson: British MedicalJonrnal, May 10th. 1890. ULCER OF THE STOMACH. 209 to the water-closet, and is not in the habit of inspect- ing his passages. Not long ago I had the opportunity twice of detecting blood in the stomach of patients who apparently never had any hemorrhages. In one of them, at the examination with the tube one hour after the test breakfast, I obtained quite a quantity of blood having a black coffee-ground color (under the microscope red blood corpuscles were present). The second patient was a lady presenting symptoms of gastric ulcer. While in the clinic, I noticed that she looked unusually pale ; she also complained of feeling somewhat faint. As she had partaken of a test break- fast, I administered the stomach bucket, which came up filled with a fluid of coffee-ground color, also con- taining red blood corpuscles. 4. Appetite. Although patients with gastric ulcer partake of very small quantities of food, the appetite per se is by no means decreased. It is merely on ac- count of the pains that the patients are afraid to eat, and avoid substantial meals. Some complain of being constantly hungry, but unable to satisfy their appe- tite, on account of the distress following the ingestion of food. This fear of taking food is sometimes exag- gerated, and the patients get into a habit of partaking of so little that the danger resulting from this source is certainly far greater than that from the original disease. 5. Constipation. As a rule, most cases of gastric ulcer are accompanied by constipation. Leube' ex- plains this fact in the following manner: He assumes that the peristalsis of the stomach is impaired in gas- 14 1 Leube : I. c. 210 DISEASES OF THE STOMACH. trie ulcer. As there is a reflex connection between the peristalsis of the stomach and that of the small intes- tines, the latter will also be retarded, and in this way the constipation would be explained. Leube's theory of the presence of retarded muscular action in gastric ulcer seems to be suj^ported by several results wdiich I have obtained with the gastrograph in a few cases of gastric ulcer, in which the motion of the stomach appeared to be materially lessened, M3" observations in this respect, however, are yet too few to fully sus- tain this theory. 6. Amenorrhoea. Amenorrhoea is quite frequently met with in women suffering from gastric ulcer. It appears, however, that this symptom is merely the consequence of the ansemic condition of these patients. Sometimes gastric hemorrhages vicariously appear instead of the monthly periods. 7. Cachexia. Although we sometimes meet with robust, healthy persons suffering from gastric ulcer, this is not the rule, and most frequently patients suffering from this trouble present an appearance which would suggest to an observant physician even at a distance the nature of the ailment. In connec- tion with the extreme cachexia, the sharp lines which severe and frequent pains, together with partial starva- tion, have graven on the patient's face afford almost a characteristic sign of gastric ulcer. The cachexia in gastric ulcer, although at first not well marked, may after a time increase to such an extent that the patient is reduced to a mere skeleton, and emaciation of this kind is very seldom met wnth in gastric cancer. Condition of the Gastric Contents. — Eiegel, and ULCER OF THE STOMACH. -211 later Jaworski and Glusinsky, first signalized the fact that hyperacidity is a coucomitant factor of gastric ulcer. Although this is uot always the case, as we have mentioned above, the fact remains true that most of the cases of gastric nicer are characterized by an hyperacid juice. The acidity may reach as high a figure as 130 or even 160 (about three or four times the acidity of normal gastric juice). This high figure, 160, I had the opportunity to observe lately in a case of gastric ulcer near the pylorus combined with ste- nosis of the latter. The patient had been operated upon, and the diagnosis verified in vivo in this man- ner. In cases in which there is vomiting the ejected matter should be examined. If vomiting is absent the gastric contents may be obtained for examination with the stomach bucket. The examination of the gastric contents by means of any instrument should be performed with the greatest caution, and only in those instances where the diagnosis of gastric ulcer is doubtful. Whenever there are sufficient symptoms to make the diagnosis pretty certain, the employment of an instrument should be omitted. Most writers are opposed to the application of the tube in gastric ulcer. Latent Ulcer. — All the above symptoms of gastric ulcer may at times be missing, and the sickness may remain concealed. It is well known that scars result- ing from ulcer are found at autopsies in the stomachs of people who apparently never had any gastric trouble. The following is a good example of an ulcer without typical subjective symptoms, showing at the same 212 DISEASES OP THE STOMACH. time the importance of hemorrhage as a diagnostic sign : Mrs. H , 44 5"ears old, has been complaining for the last five years of frequent belching, poor appetite, and constant pains of a very slight character in the epi- gastric region. Patient never had any hemorrhage nor any intense pains, and her bowels were always regu- lar. During her illness she has lost eight pounds, and looks extremely pale and ansemic. The examination of the abdomen reveals the position of the stomach be- tween the navel and one finger's width above the pubes. There is no pain on pressure either in the epigastric or gastric region, although the epigastrium is somewhat sensitive to pressure. Eight kidney movable. Ex- amination with the tube one hour after the test breakfast results in the withdrawal of coffee-colored contents mixed with fine particles of bread ; the mi- croscope shows numerous red blood corpuscles; the chemical analysis of the filtrate reveals HCl-f-acidity = 76. On the next day the patient's stools were black from admixture with blood. The diagnosis of gastric ulcer was made and the patient treated accordingly. She gradually recuper- ated, and under a further tonic treatment entirely re- covered, and has remained free from any symptoms for the last two years. Again, such a latent ulcer may sometimes suddenly give rise to alarming symptoms, and even cause death from perforation or a profused hemorrhage. Duration of the Disease. — The duration of gastric ulcer is sometimes extremely long. Brinton cites cases in which the sickness had lasted from thirty to thirty-five years. ULCER OF THE STOMACH. 213 Complications. — Complications quite frequently appear during the protracted course of this affection. These may comprise a sudden exac erba tion of one of the usual symptoms, as for instance the jDain or vomit- ing, which may become uncontrollable, and hemor- rhage, which may become fatal in a few hours or even in a few minutes. Again, they are sometimes caused by intercurrent phenomena. Perforation. — The most dangerous complication of gastric ulcer is perforation, which is due to an exten- sion of the ulcerative process through the whole stom- ach wall to the peritoneum. It is followed by slough- ing or rupture of these delicate membranes, and by the effusion of the contents of the stomach into the peritoneal cavity. The perforation is accompanied by very intense and characteristic symptoms. The pa- tient is suddenly attacked by a violent pain, which begins in the epigastric region, and rapidly spreads over the abdomen. Sometimes the patients have a sensation as if something had given way in their ab- dominal cavity, and a gush of liquid had occurred. Symptoms of general peritonitis now quickly appear. In a short time the whole abdomen becomes greatly distended and extremely painful to the slightest touch. Entrance of gas into the abdominal cavity oc- curs, in consequence of which the dulness of the liver sometimes disappears ; at times, again, emphysema of the skin develops. The extremities become cold, while the temperature of the body rises. The pulse becomes very small and can hardly be counted. A cold sweat breaks out on the face, which wears an expression of extreme anxiety (facies Hippocratica) ; singultus is 214 DISEASES OF THE STOMACH. present, as a rule, while vomiting may at times be absent (in those instances where the entire contents of the stomach have escajDed into the abdominal cavity). After a short period of coma the patient usually dies. Rarely does the train of symptoms following perfo- ration offer a marked deviation from the above descrip- tion. In many instances, a remarkable paroxysm of pain precedes the occurrence of perforation. This pain, the duration of which varies from a few minutes to several hours, is generally due to a leakage of the gastric contents through the thin film of rotten tissue, to which at this period the coats of the stomach are reduced. Partial perforation, allowing of a subsequent repetition of the accident, or leading to abscess, pre- sents symptoms of a more local, more chronic, and less intense character than those of ordinary perforation. Perforation nearly always occurs after a full meal, and is often traceable to mechanical violence, such as coughing, sneezing, or constriction of the abdomen. Sometimes, before the perforation arises, an adhesive inflammatory process takes place, in consequence of which the stomach in the affected area becomes ad- herent to neighboring organs, a process which may then prevent the entrance of the gastric contents into the peritoneal cavity. A local abscess is very often the result of such an occurrence. This form of ab- scess may open into different cavities; thus, for in- stance, a fistulous opening between the stomach and the colon, or the stomach and the abdomen, has fre- quently been found established. Again, the abscess may perforate the diaphragm and lung, and be evacu- ated in this way. As these instances are not so very ULCER OF THE STOMACH. 215 frequent, I will here mention a case of this kind which I observed ten years ago. A lady, about 30 years old, after a short period of slight dyspeptic symptoms, was suddenly attacked with profuse gastric hemorrhages. On the first day she vomited about one pint and a half of almost clear blood, the vomiting being accompanied by severe pains in the gastric region. She was kept in bed, an ice-bag applied to her abdomen, and large doses of opiates were administered. On the following day the hsemateme- sis was repeated. Under the above treatment, how- ever, the patient began slightly to improve and to take small quantities of milk. About a week after the first hemorrhage she suddenly experienced a more intense pain in her abdomen, followed by all the symptoms of severe collapse. Singultus appeared, the abdomen swelled, and became extremely painful to the touch, while the temperature rose to 104°, the pulse to 140, and the extremities grew cold. The diagnosis of per- foration of the ulcer was quite clear, and the patient was believed to be dying. This critical state re- mained unchanged for about four or five days, when suddenly the dyspnoea, which had before existed in a slight degree, increased, while the expired air assumed a very offensive odor. This symjDtom increased to such a degree that it was hardly possible to sit in the same room with the patient. About two days later, during which period the offensive smell constantly persisted with undiminished strength, the patient brought up during several spasmodic coughing-spells about one pint and a half of pus, in which particles of casein and small black flakes could be clearly seen. This matter had exactly the same odor as the air ex- pired by the patient for the last two days. Immedi- ately after this occurrence the expired air entirely 210 DISEASES OF THE STOMACH. changed its character, and the atmosphere of the room was no longer unpleasant ; the patient began to feel better, the temperature fell, all the symptoms of peri- tonitis began to disappear, and she made a slow re- covery in about six weeks. In this case after the per- foration of the stomach there must have formed a localized abscess, which extended through the dia- phragm into the lung and emptied itself through a bronchus. By a similar process an abscess may form beneath the diaphragm, and may at times cause a condition which Leyden ' designated as '" PyoiDueumothorax sub- j)hrenicus^^ on account of its similarity to the real pyo- pneumothorax. This condition appears only when gas is contained in the abscess. Debove and Eemond ' designate it by the more correct term "gaseous subdia- phragmatic abscess," while in this country it is briefly called "subphrenic abscess." The abscess is, as a rule, situated toward the right side. Its walls are formed by the diajDhragm above, by the liver and the stomach below ; to the right it is surrounded by the suspensory ligaments of the liver, and to the left by the spleen. The liver is usually pushed downward and the diaphragm upward. Thick false membranes form the walls of the abscess, which contains gas and fetid liquids, the latter being composed of pus and alimentary residues. The symptoms that are caused by this condition are: the respiratory vibrations of the lower part of the thorax disappear; the liver dulness in the back and ' E. Le.yden : "Ueber Pyopneumothorax subphrenicus iind siib- phrenische Abscesse. " Zeitschr. f. klin. Med., 1880, p. 320. '^ Debove et Remoud : I. c, p. 272. ULCER OF THE STOMACH. 217 the lower part of the luug are replaced by a zone giv- ing a tympanitic sound on percussion. On auscultation the resjDiratory sounds are not audible, but there are heard instead succussion sounds of a metallic pitch. The best diagnostic sign of this condition is afforded by exploratory puncture, by means of which one can aspirate pus containing some food particles. Another diagnostic point of value has been suggested by Pfuhl,' and consists in connecting the exploratory needle with a manometer. The pressure in this affection is greater during inspiration and less during expiration, whereas in real pyopneumothorax this condition of pressure will be found reversed. Of late this disease has been recognized during life and successfully oper- ated upon by incision of the abscess and cleansing of the cavity. C. Beck,' of Xew York, has recently re- ported three successfully operated cases of subphrenic abscess. The local abscess caused by perforation can also at times produce other complications ; thus, for instance, it may perforate the abdominal wall, with establish- ment of a fistulous opening from the stomach to the outside. Although very rare, cases are also mentioned in which an abscess of the stomach has perforated the pericardium, and even the heart itself, causing death. As regards the frequency of perforation in the course of gastric ulcer, it occurs, according to Brinton, in not more than one out of seven or eight cases of this lesion ; while sex has no influence upon the fre- iPfuhl: Berliner klin. Wochenschrift, 1877, p. 57. - C. Beck : Medical Eecord, February loth, 1896. 218 DISEASES OF THE STOMACH. quency of its occurrence, the age of the patient seems to play an important joart in tiiis respect. Although gastric ulcer is met with more frequently as life advances, the occurrence of perforation, on the contrary, declines from the age of 30 to that of TO. According to Brinton, the distribution of the liability to perforation over the whole life varies materially in the two sexes. In the female about one-half of the number of cases occur between the ages of 14 and 30, one-third in the six years between 14 and 20. In the male the distribution is constant up to the age of 50, and diminishes but little up to that of TO. The aver- age age of those subject to perforation also differs in the two sexes, being 21 in the female, 42 in the male. The situation of the perforating ulcer plays the chief part in the frequency of this occurrence. The anterior surface of the stomach, though much more rarely affected by ulcer, is yet one of the most frequent sites of perforation. According to Brinton, in all other situations of the ulcer, the probabilities are about 60 to 1 against perforation, while in the anterior surface of the stomach, they are G to 1 in its favor. The reason for this is the circumstance that the front wall of the stomach is more exposed to motion than all other parts of the stomach where ulcer is usually found. The mobility of this part prevents the forma- tion of adhesions, which often form if the ulcer is situated elsewhere. The gastric ulcer is liable to bring in its train still other complications : thus in some instances a cancer may be developed on the base of an ulcer or on its scar. Dittricli was the first to describe this compli- ULCER OF THE STOMACH. 219 catioD, and Eosenheim ' has lately published several important investigations on this subject. The same writer ^ has also described another complication of chronic gastric ulcer, and that is a grave form of ansemia, which may be styled "pernicious." Pulmonary tuberculosis is a frequent occurrence in gastric ulcer, as in many other chronic diseases, and hastens the death of the patient. It does not seem, however, that there is a more intimate connection between these tw^o affections than obtains in other diseases. As mentioned above in speaking of the pathology of the ulcer, severe complications may arise from the thickening of a cicatrix, especially if situated at the pylorus, or very near it, or again at the cardia. In the first instance, the most frequent complication is stenosis of the pylorus with dilatation of the stomach, which will be treated in a special chapter under Ischo- chymia; in the second, stricture of the cardia, caus- ing dysphagia. Diagnosis. — In cases where all the symptoms of gastric ulcer are present no difficulty will be experi- enced in the diagnosis. It frequently happens, how- ever, that only one or two of the above-described symptoms exist, and it is then more difficult to make a positive diagnosis. One of the following symptoms, if present in its characteristic form, will suffice to establish a probable diagnosis of ulcer. 1. Hgematemesis. If the quantity of blood vomited 'Th. Rosenheim: "Zur Kenntniss des mit Krebs coraplicirten runden Magengeschwiirs. " Zeitschr. f. klin. Med., Bd. 17, p. 116. - Th. Rosenheim: Deutsche med. Wochenschr. , 1890, No. 15 220 DISEASES OF THE STOMACH. be quite large, and cancer of the stomach can be excluded. 2. Pains. Pains appearing shortly after meals, and lasting for a considerable time (two to three hours), being influenced by the quantity and quality of food in such a way that the}^ are most intense after the ingestion of coarse substances in large quantities, without perfectly free intervals of several days' dura- tion, are sufficient to warrant the suspicion of gastric ulcer. If in connection with this spontaneous pain there is a circumscribed spot in the epigastric region that is painful to pressure, or if there is a small area likewise painful to pressure to the left of the eighth or ninth dorsal vertebra, then the diagnosis of an ulcer becomes probable. 3. Vomiting. Vomiting aj)pearing shortly after meals and preceded by a period of uneasiness in the gastric region, may also at times be suspicious of gas- tric ulcer. If this occurs in individuals who have lately grown much paler and more anaemic, the sus- picion again becomes a probability. This probability is still greater if the gastric contents show a too high degree of acidity. Differential Diagnosis. — Very often cases of pure nervous gastralgia, of hyperchlorhydria, and of cancer present symptoms similar to those of gastric ulcer, and in making the diagnosis we shall have to take all these affections into consideration. Following Ewald's example, I deem it best to give all points of differen- tial diagnosis between the above-named conditions in a table: ULCER OF THE STOMACH. 321 Age. Sex., Epigastric pain. Appetite . Tougue . . Taste Belching . Regurgita- tion. Vomiting. . Hsemate- mesis. Gastric ulcer. Rare in youth, frequency increas- i n g progressively from puberty to a very advanced age. More frequent in women (2 : 1). Quite intense; ap- pears shortly after meals; grovs^s s e - verer on pressure; disappears at the end of the digestive period; seldom perfectly free pe- riods. Appetite not impair- ed, although p a - tient as a rule eats less on account of his suffering. Dry and red, show- ing a white stripe in the middle, or smooth and moist or slightly furred. Nothing abnormal. . . As a rule absent; If present, without any bad odor. At times present, frequently water brash associated with pyrosis. Appears in some cases soon after meals. Vomiting of a large quantity of blood, either clear red or o f coffee - ground color. Blood is also found in the stools. A repetition of the hffimatemesis may occur on the fol- lowing day, but if once arrested it does not reappear for quite a long period. Nervous gastralgia. Most frequent between the ages of 18 to 35. More frequent in women. The pain ap- pears wi th - out regular- ity and is not in any way dep en dent upon the meals ; is re- 11 e V e d by pressure and shows inter- vals of sever- al days' dura- tion which are perfect- ly free from pain. Variable Presents a nor- mal appear- ance. do. do. Not present Shows no regu- larity in its appearance. No vomiting of blood. Hyper- chlorhydria. Met with in all periods of life, except in youth, when it is quite rare. More frequent in men. The pain a p - pears about two to three hours after meals and disa p p e a r s after partak- ing of some food (espe- cially meat, mUk, egg) or after the ad- ministration o f bicarbo- nate of soda. Often in creased. Is either clean or slightly furred. do. do. Water brash and pyrosis quite f r e - quent. No vomiting. . No vomiting of blood. Cancer. Middle age and ad- vanced life. No marked differ- ence between the two sexes. The pain is less in- tense in char- acter but more steady; there are seldom free in- termissions dur- ing which no dis- tress is felt in the gastric region. Appetite, as a rule, very poor. Almost a 1 w a y I thickly coated. Very often bitter or sour. As a rule present and very often associated with a dis agreeable, even fetid odor. No water brash; pyrosis quite in- tense. The vomiting, as a rule, occurs not after each meal but once or twice a day or once in two days, the quantity being often veiT large. Vomiting of blood occurs ; the quantity is rela- tively small, the color ordinarily coffee brown. The blood a p - pears in a decom- posed condition, presenting f r e - quently a fetid odor. The vomit- ing often recurs with short inter- missions. DISEASES OF THE STOMACH. Gastric ulcer. Xervous ^astralgia. Hyper- chlorhydria. Cancer. Secret function Tumor. . Pe r f o r a tiOD. ory J Gastric juice as a Variable., rule increased. 2. Lactic acid ab- Absent . . . ;, sent. No tumor; r are ly,iNo tumor however, if the ulcer is near the pylorus, the latter becomes thickened and can be felt as a smooth, lengthy body. Perforation m i g h t No perforation. take place after a short period of ill-: ness. ! Ci"'mpl e X - Complexion com - Complex! on ion. monly fresh, but pale, anaemic after se- vere losses of blood Increased As a rule, highly decreased. Absent As a rule, present. No tumor. No perforation. Complexion pale. Tumor very fre- quently palpable; presenting, a.s a rule, an uneven surface; is pn'm- ful to pressure and easilv mova- ble. Perforation occurs only in the last stages of the disease. Complexion sallow and yellowish; skin dry ; marked cachexia. Localization of the Ulcer. — As above mentioned in speaking of the pathology, the ulcer may be situated at different points of the stomach walls, or at the pylorus, the beginning of the duodenum, the cardia, or the lower end of the oesophagus. The exact site of the ulcer can be determined with certainty only in rare instances. Most frequently we remain in doubt with reference to this point of diagnosis. There are, however, several symptoms which can be utilized with regard to a probable diagnosis as to the situation of the ulcer. 1. Frequently patients experience relief from their pains in assuming a certain position. Thus, for instance, some feel easier in lying on the back, others less uncomfortable when they lie upon their abdomen. Again, some feel no pain in stand- ing, but the latter appears when they assume a re- cumbent position. In a few, again, this is re- versed, the pain appearing in the standing and disap- pearing in the recumbent position. As a rule, we may assume that the position in which the patient is ULCER OF THE STOMACH. 223 most comfortable is the one which permits the ulcer to remain above the gastric contents, and to come least in contact with them. Hence an ulcer situated at the lesser curvature will be diagnosed if the patient ex- periences relief in standing. Again, an ulcer of the greater curvature will be suspected if the pain is most intense on standing. The site of the ulcer will be sus- pected to be in the cardiac portion of the stomach if the patient has less pains when lying on his right side, and in the pyloric region if the pains are less severe when he occupies a left-sided position. 2. Pains ap- pearing directly after the deglutition of food, and as- sociated with vomiting immediately after meals, par- ticularly point to an ulcer in the cardiac region or in the lowest part of the oesophagus. 3. Pains appearing two or three hours after meals, referred partly to the right of the epigastric region and associated with melsena (bloody stools), point to the situation of the ulcer either at the pylorus or the beginning of the duodenum. Prognosis. — At first glance it would appear that the prognosis of gastric ulcer is quite good, especially now- adays, when the diagnosis of the affection is usually made at an early date. However, if we take into consideration the tabulated statistics given by Debove and Eemond ' in reference to the outcome of all cases of ulcer, we will become more careful in our favorable predictions. This table gives in a hundred cases of ulcer : Perfect cure, 50 Perforations and peritonitis, .... 13 Foudroyant hasmaternesis, .... 5 * Cited from Debove et Reroond : I. c, p. 376, 224 DISEASES OF THE STOMACH. Pulmonary tuberculosis, .... 20 Inanition, 5 Different complications, .... 7 Treatment of Gastric Ulcer. — Crnveilhier, to whom we are indebted for the first thorough and accurate description of gastric ulcer, recommended milk as the most suitable food in this condition, and although many decades have since passed, milk still stands first in the dietary of these patients. As rest is the foremost auxiliary in the treatment of most diseases, it appears natural to make use of this agent in ulcer. Leube and Ziemssen ' deserve credit for having laid so much stress on this point and for having devised the "rest cure-' for the treatment of ulcer. Although this mode of treatment had been practised long ago by W. Fox^ and B. Forster in Eng- land, still Leube and Ziemssen have succeeded in pop- ularizing the same, and that is the reason why it justly bears their name. The Leube-Ziemssen rest cure for the treatment of ulcer consists in the following: The patient is kept abed for two to three wrecks. He is poulticed during the day with flaxseed (warm) over the stomach and the upper part of the abdomen ; at night a priessnitz (wet linen cloth) is substituted, covering the same area. The diet consists of liquids — milk, milk with strained barley, or oatmeal, or rice water, plain water, weak tea, and peptone (one teaspoonful to a cup of water). Debove and Remond ' have suggested the addition of lactose and of meat powder to the milk, in order to make the diet richer in nourishing sub- ' Leube : I. c, p. 120. ^ Debove et Remond : I. c, p. 284. * Wilson Fox ; Z. c. ULCER OF THE STOMACH. 225 stances. As a rule, we employ the above-named additions, which fulfil the same purpose, besides vary ing the monotonous bill of fare. During the first week we give the patient half a cup (about 100-150 c.c.) of either every hour. Every- thing the patient takes must be neither cold nor very warm, and should be taken slowly (sipping or with a spoon). During the second week we order the same kind of food, with this difference, that he is nour- ished every two hours, and gets a cupful or a cupful and a half (200-300 c.c.) at a time. Occasionally we now allow the patient one raw egg beaten up in the milk, once or twice a day. In the beginning of the third week we feed the pa- tient every three hours; he is allowed barley, farina and rice (well cooked) in milk, soft-boiled eggs, crackers softened in milk, in addition to his previous food ; on the third day of the third week we begin to give the patient meat, first raw, well scraped, then broiled. Thereafter we go over to the ordinary daily diet, ex- cluding heavy salads, pastry, raw fruit, and the like. In the following table I give an outline of diet which I ordinarily prescribe in this affection ; Outline of Diet in Gastric Ulcer. FIRST THREE DAYS. Numbei of calories. 7 A.M. : milk, 150 c.c. (five ounces), , , . 101 8 ii (( a a a , , . 101 9 a il (C i( il , , . 101 10 a milk and strained barley water (each), 150 CO., .... , . 80 11 a milk, 150 c.c, . . , . 101 12 « 15 • • . 101 226 DISEASES OF THE STOMACH. Number - calorie^ 1 P.M. 2 " 3 " 4 " 5 " 6, 7, 8, bouillon either alone or with the addition of one to two teaspoonfuls of a peptone preparation, 150 c.c, . . . .30 milk, milk with strained barley or oatmeal, 9 p.m.: milk, 150 c.c, 101 101 101 80 404 1,402 7 A.M. 9 " 11 " 1 P.M. 3 " 5 " 9 " FOURTH TO THE TENTH DAY. milk, 300 c.c. (ten ounces), Number of calories. . 202 . 202 " with barley, rice, or oatmeal water, 300 c.c, 160 one cup of bouillon, 200 c beaten up in it, milk, 300 c.c, . c, and one egg with barley water, 300 c.c., 300 c.c, .... . 80 . 202 . 202 . 160 . 202 1,410 7 A.M. 9 " 11 " 1 P.M. 3 " 5 " /»< (( 9 " ELEVENTH TO THE FOURTEENTH DAY. milk, 300 C.C, . Number of calories. 202 202 and two crackers softened (one ounce), . 100 milk with barley water, 300 c.c, . . 160 one cup of bouillon, 200 c.c, one Q^^, and two crackers, . . . . . .180 milk, 300 c.c, and one egg, . . . 282 202 and two crackers, . . . . .100 milk with barlej^ water, . . . .160 milk, 300 c.c, 202 1,790 ULCER OF THE STOMACH. 227 FOURTEENTH TO THE SEVENTEENTH DAY, 7 A.M. : milk, 300 c.c, . 9 and two crackers (one ounce), 11 " milk with barley, 300 c.c, 1 P.M. : scraped meat, 50 gm., two crackers ; one cup of bouillon, 200 c.c, 100 milk, 300 c.c, . one egg (soft boiled), two crackers, milk with farina, 300 c.c, " 300 cc, . Number of calories. . 202 . 202 . 100 '. 342 . 60 . 202 . 202 . 80 . 100 . 342 . 202 2,134 SEVENTEENTH TO TWENTY-FOUETH DAY. Number of calories. 7 A.M. : two eggs (soft boiled), . . . .160 butter, 10 gm., . . . . . .81 toasted bread, 60 gm., . . . .130 milk, 300 c.c, 202 10 « " " 202 crackers, 50 gm., . . . . . 166 butter, 20 gm., 162 1 P.M. : lamb chops (broiled) 50 c.c, . . .60 mashed potatoes, 50 gm., . . .44 toasted bread, 50 gm., . . . .130 butter, 10 gm. ; one cup of bouillon, 200 c.c, 81 4 " the same as at 10 A.M., .... 530 6:30 P.M. : milk with farina, 300 cc, crackers, 50 gm., . butter, 20 gm., 9 " milk, 300 c.c, . 342 . 166 . 162 . 202 2,820 At the beginning of the third week the flaxseed poultices are discontinued and the patient is allowed to 228 DISEASES OF THE STOMACH. be up, first for a short time only (half an hour to an hour), then for several hours, and afterward for the whole day. At the beginning of the fourth week the patient may begin to walk outdoors and gradually resume his daily work. Leube and Ziemssen and most of the German writers recommend the use of either Carlsbad water (half a pint) or Carlsbad salt, 5 to 10 gm. in the same quantity of water, heated to 122° F., twice daily (the first por- tion being taken in the morning, the second at night before going to sleep). I do not believe that the Carlsbad salt is in any way essential. In most of my cases of gastric ulcer I have omitted the so-called Carlsbad drink cure, and have obtained results equally satisfactory as when the salt was employed. In cases of ulcer of the stomach presenting a more severe type — violent pains, frequent vomiting, inabil- ity to take food on account of the pains — or after haematemesis, I usually have the patient abstain from any food whatever, given by the mouth, for a period of five days. The patient is then fed by the rectum. This is done in the following way : Early each morn- ing the patient receives a large enema of about a quart of lukewarm water in which a teaspoonful of common table salt has been dissolved as a cleansing enema. About an hour after the patient has emptied the injected water the first nourishing enema is given ; this may consist either of a glassful of milk (about 200 c.c.) in which a raw egg has been well beaten and a pinch of salt added, or of a cupful of water in which a tablespoonful of a good peptone preparation has been dissolved. The temperature of either must ULCER OF THE ST03IRCH, 229 be about 100° F. Such a nourishing enema is given three or four times a day. The quantity of the feed- ing enema is 200-250 c.c, and it is slowly injected by means of a fountain syringe and a soft-rubber rectal tube. The patient may frequently wash his mouth with cold water, and is allowed from time to time to keep a small piece of chopped ice in his mouth, and to swallow the melted water. The five days being over, the mode of diet is the same as described above for the ordinary form of ulcer. Whenever the "rest cure"' is applied there is scarcely any need for constant medicinal treatment. Some- times, however, we make use of a small dose of codeine if the pains are very severe, and of Carsbald salt if there is constipation. Only in cases where the ulcer is associated with a hyperacid gastric juice may we regularly administer an alkaline salt, as for instance: :^ Magnes. ust., 5.0 ( 3 i.) Sod. carbon, exsiccat. , Sod. bicarbon., El^osaccli. menth. pip., . . . . aa 15.0 ( § ss. ) M. exactissime, f . pulv. D. ad scatulam. S. A tip of a knife every two hours. In chlorotic individuals the administration of an or- ganic iron preparation (as for instance Pizzala's or Dietrich's Elixir of peptonate of iron or Boehringer's ferratin) is often ver}' serviceable. Thus far we have spoken only of patients who can submit to the bed treatment. In patients who cannot afford to stay in bed, the following two methods, which are at jDresent in vogue, may be tried. I have practised both of them, sometimes with good results. The one is the ^'nitrate-of-silver" treatment, the 230 DISEASES OF THE STOMACH. other the "bismuth" treatment. During the use of either of these remedies the patient is allowed to at- tend to his business and partake of a light diet, in which milk plays a prominent part. I. The silver nitrate is given first : I^ Argent, nitr 0.3 (gr. v.) Aq. dest., 180.0 (svi.) D. in vitro nigro. S. A tablespoonful in a wineglassful of water three times a day, half an hour before meals. After having used up this quantity, the dose may be gradually increased, prescribing 0.4-0.6 gm. of silver nitrate to 180 of water. The silver nitrate may be used in the way mentioned for about two or three weeks, and is then discontinued. The pains usually disappear after the completion of the first week's medi- cation. II. The subnitrate of bismuth. The bismuth has been used again and again in painful affections of the stomach, the dose being from 0.2 to 1.0 gm. several times daily. The French physicians recommended the use of much larger doses, giving 5 gm. three times daily. Fleiner ' has lately laid much stress on the use of large doses of bismuth, suspended in water, in the treatment of ulcer, and Rosenheim ^ corroborated his views. I had the opportunity of applying this method quite frequently and was satisfied with the results. We may give the patient from 3 to 5 gm. of bismuth three times a day, to be taken in a wineglassful of water, well shaken, half an hour before meals. It is best to have the patient lie quietly for about half an 1 Fleiner : Verhandl. des XII. Congresses f. innere Medicin, 1893. ^Rosenheim: "Die neueren Behandlungsmethoden des Magens." Berliner Klinik, May, 1894. ULCER OF THE STOMACH. 231 hour after having partaken of the powder. The bis- muth treatment must be continued for about two or three weeks without interruption. It is remarkable that these large doses of bismuth do not, as a rule, cause constipation. In all of my cases with but few exceptions the bowels moved every day without the aid of any cathartic during the whole time of the bis- muth medication. The bismuth treatment in ulcer seems to me to deserve high recommendation. Hemorrhage. — In cases of hemorrhage from the stomach the treatment is the same as in the severe type of ulcer, with the exception that ice-cold ap- plications are made over the stomach instead of the warm poultices. Perfect rest is here absolutely neces- sary. The patient must keep very quiet and avoid any motion whatever ; even turning from one side to the other is not permissible. The patient should be prohibited all conversation except it be to indicate his wants. If the hemorrhage be profuse 'or if there are signs that the bleeding has not yet come to a standstill, hypodermic injections of ergot are advisable. One Pravaz syringe of the following should be injected two or three times a day in the gastric region : I^ Extr. secal. cornut., 2.5 (3 ss.) Aq. dest. , Glycerin., aaS.O (3i.) Chloride of iron (5-15 drops in water) and acetate of lead 0.05 gm., one powder every two hours, which in olden times were used so frequently, do not in reality have much effect. In case the hsematemesis, however, recurs frequent- 232 DISEASES OF THE STOMACH. ly, and the patient is running the risk of bleeding to death, Ewald ' recommends resort to lavage with ice- cold water. For this purpose the j^harynx must first be well cocainized, and the washing of the stomach then performed with the greatest care. Collapse. — In case the patient has sunk into a col- lapsed condition, camphor or ether should be hypo- dermically injected. An enema of warm wine or warm wine with egg should be administered, and a hot-water bag applied to the feet. In those instances where the high degree of anaemia endangers the life of the patient, transfusion of blood was formerly fre- quently resorted to. Nowadays a subcutaneous injec- tion of a physiological salt solution (4 to 6 NaCl to aq. dest. 1,000), in quantities from a pint to a litre, is used. The solution and the apparatus (fountain syringe) must be thoroughly sterilized, and one or two quite thick Pravaz needles used. The solution, warmed to blood temperature, is then injected into the subclavicular region. Perforation. — If perforation has occurred perfect rest is absolutely necessary ; nothing should be given by the mouth, ice bags should be placed over the abdo- men, and large doses of opium, preferably in the form of suppositories, should be administered. In cases in which the stomach contains large quantities of food, Ewald suggests the washing out of the stomach, per- formed after cocainization of the pharynx and with all other necessary precautions. As soon as the symptoms of collapse appear, the above-described treatment is employed. The prognosis of perforation being so very 1 C. A. Ewald : I c, p. 274. ULCER OF THE STOMACH. 233 unfavorable, notwithstandiDg all medicinal treatment, resort has been lately had to laparotomy, in order to master the situation surgically. Surgical Procedures in the Treatment of Gastric Ulcer and its Sequelce. — Gastric ulcer may occasion- ally take a very obstinate course, not being amenable to medical treatment. Again, its complications, hemorrhage (which may become very abundant or frequent) and perforation, greatly endanger life; the latter, in fact, almost always terminating fatally. Barling ' says that ninety-five per cent of the patients having such perforations die, unless operated upon. For this reason Nelson C. Dobson' in 1883 advocated operative interference for a perforating ulcer accord- ing to one of the following methods. 1. Simple ab- dominal section with cleansing of the peritoneum, leaving the ulcer to heal of itself under rest and rectal feeding. 2. The closure of the perforation bj^ suture, either with or without paring its edges. 3. The suture of the stomach at the point of perforation to the abdominal wall, in order to establish a gastric fistula. A few years later this mode of treatment was car- ried out by several surgeons in Europe and this country. Eobert F. "Weir," of New York, was among the first who operated in this country. His latest report of a ' Barling : Birmingham Medical Eeview, August, 1895. 2 Dobson : Bristol Medical and Surgical Journal, 1893, p. 196. 3 Robert F. Weir and E. M. Foote : "The Surgical Treatment of Round Ulcer of tlie Stomach and its Sequelae, with an Account of a Case Successfully Treated by Laparotomy." Medical News, April 25th and May 2d, 1896. ;>o4 DISEASES OF THE STOMACH. successful operation of this kind deserves the highest commendation. We deem it of great value to report this case in Dr. Foote's own words. "Mary B consulted me in August, 1894, for an obstinate cough, with scanty expectoration and pain in the sternal and right scapular region, with dyspnoea on exertion, headache, anorexia, and constipation. She had twice spit up a small amount of blood. For four months she had had night sweats. The patient was at that time 15 years old, heavy but ansemic. Physical examination showed dulness and fine moist rales at the left apex, and right base behind, and she had an afternoon fever. Under tonic and expectorant remedies, and a month's residence in the mountains of Sullivan County, N. Y., she gained weight and the rales disappeared, except at the base of the right lung. The following winter she neglected herself, and, when I next saw her in April, 1895, her cough was worse, and she had moist rfdes over the greater part of both lungs, and she had lost six pounds in weight. Though living in poverty, she was able, through friends, to spend three months of the summer in the mountains, and she did not return to the city until the last of September, 1895, when she took a position as maid in an apartment, where the work was light and her food good. Her health was excellent, the cough and rales had disappeared, and her weight, one hundred and ten and a half pounds, was greater than it had ever before been. I was never able to secure any sputum for examination, but the signs of pulmonary tubercu- losis had been too well marked to be doubted. '"She had frequently been troubled with indigestion, and at various times had vomited her food, but these symptoms had not been the prominent ones. About November 20th, 1895. she began to have severe gastric ULCER OF THE STOMACH. 235 pain, and her appetite failed her. She spoke to no one about it and kept on with her work, though eating almost nothing. The pain, too, was at times so severe that she was compelled to lie down. On November 27th, at 10 A.M., she was attacked with a colicky pain in the gastric region so severe that she rolled upon the door in agony, and vomited a small amount of coffee, which was the only nourishment she had taken that da3^ About noon she felt a little relief and went home by way of the elevated road. To do this, she walked about a quarter of a mile, and climbed up and down some fifty steps. Late in the afternoon she sent word to me that she had an ' attack of pain in the heart.' At 6:30 P.M. I found her lying on her back, quiet, and without much pain. Pulse, 120; temperature, 102°, The facies, though not well marked, was of a purely ab- dominal type. The chest revealed nothing abnormal. The abdomen was somewhat rigid, and more so on the left side than on the right. There was moderate ten- derness on pressure in the epigastric and left iliac regions. There was no distention or tympanites. Eespiration was almost wholly thoracic. Palpation revealed nothing but the seat of tenderness. The pain was described as commencing to the left of the median line under the costal border, and extending thence to the left groin and into the left thigh. Ap- pendicitis was out of the question, and the symptoms did not appear to be those of any form of intestinal obstruction. The diagnosis of perforated gastric ulcer was made, and an. immediate operation advised. Dr. Weir kindly consented to admit the patient to his ser- vice at the New York Hospital, where he performed laparotomy, and sutured the stomach at 9:30 p.m., a little over eleven hours after the onset of the attack. "Under chloroform, a median incision four and one- 236 DISEASES OF THE STOMACH. half inches long was made above the umbilicus. An unusual amount of subperitoneal fat obscured the peritoneum. When its cavity was opened the stom- ach presented in the wound. The greater curvature appeared normal. There was no general peritonitis. The anterior surface of the stomach was adherent to the liver by recent lymph. As it w^as separated, a hissing sound was heard, due to the escape of gas from the stomach through the perforation. "The opening was found without difficulty. It was minute, less than one-fourth inch in diameter, with necrotic edges, and lying in the centre of a dense ring of inflammatory and fibrinous tissue, which involved the whole thickness of the wall of the stomach. This thickened area was about two inches long and one inch wide, and was situated in the anterior w^all of the stomach, about midway between the greater and lesser curvatures, and perhaps one-third of the distance from the pyloric to the cardiac orifice. "The operation lasted about one hour, and the patient left the table in fair condition, with a pulse of 150. For two days there was frequent and very distressing vomiting, temporarily relieved by gentle lavage with diluted Thiersch's solution. After the second day the vomiting subsided, and water was allowed by the mouth. Fluid nourishment was given on the third day, and the nutrient and stimulant ene- mata, which had been given every six hours following the operation, were stopped in four days. There w^ere at no time any signs of general peritonitis. Eecovery was otherwise uneventful." In his exhaustive paper. Weir gives a table, con- taining seventy-two cases of laparotomy for acute perforation of gastric ulcer. Among the names of operators in America we notice F. Markoe, Robert F. ULCER OF THE STOMACH. 237 Weir, C. P. Parker, McCosh, Kirkpatrick, Armstrong, and Stimson. With regard to the results of operative treatment Weir furnishes the following table, which clearly illustrates the importance of early surgical interfer- ence: Elapsed time. Recovery. Death. Mortality per cent. Under twelve hours 14 4 4 1 9 13 28 5 39 Twelve to twenty-four hours. Over twenty-four hours Not stated 76 . 87 Total 23 55 71 The operations above mentioned for the tteatment of a perforating gastric ulcer will also prove applicable for a perforating ulcer of the duodenum. A success- ful case of operation in the latter instance has recently been reported by A. Landerer and G. Gliicksmann.' Surgical procedures have also lately been advised for the treatment of very obstinate cases of gastric ulcer, consisting in excision of the latter or in the establishment of a gastro-enterostomy. Severe, per- sistent pains due to the formation of adhesions as sequelaa of gastric ulcer have also been relieved surgi- cally by separating them (Lauenstein).^ ^ A. Landerer und G. Glticksmann : "Mittheilungen aus den Grenzgebieten der Medizin und Chirurgie, " Bd. i., p. 168. Jena, 1896. ^ Lauenstein : Arch, f . klin. Chirurgie, vol. xlv. OHAPTEE YII. ORGANIC DISEASES WITH CONSTANT IjESI01:sS. —Conti7iued. Erosions of the Stomach. Definition. — A condition in which the gastric mu- cous membrane becomes the seat of small superficial exfoliations. General Remarks. — As is well known, the term " erosion" signifies a defect of sui^erficial nature. In the stomach erosions are often found at the autopsy. Of late several valuable papers on the pathological anatomy of this subject and on the rare occurrence of erosions associated with typical ulcers of the stomach have been published. In his excellent article, " Ueber geschwiirige Pro- cesse im Magen," D. Gerhardt ' describes erosions of the stomach in the following words: "Sections made of erosions as a rule show that at the base of the ulcerations almost the entire lower half of the mucous membrane is still preserved. In the epithelium of these remaining glands nothing remarkable can be discovered ; at the sides the glands become longer ; the first ones that are intact usually curve themselves over the defect and partly cover it. The recovery seems to take place by the simple after-growth of the gland remnants." ' D. Gerhardt: Virchow's Archiv, Bd. 127, p. 85. EROSIONS OF THE STOMACH. 239 While the subject in question has been thoroughly discussed and studied in respect to the pathological anatomy by Gerhardt, Virchow/ Langerhans,' Hart- tung,' and Ewald/ very little has been done clini- cally. Although erosions of the mucous membrane of the stomach are mentioned in some text-books, there is nowhere defined how these conditions may be recognized during life. In the Medical Record of June 23d, 1894, I have published an article which embodied observations on seven patients in whom small particles of gastric mu- cous membrane were frequently found in the wash- water of the stomach. These cases resembled each other in so many respects that they appeared as if be- longing to one disease. They could best be considered as erosions of the gastric mucous membrane. The description of "erosions of the stomach" which I shall give in the following is based on the paper just mentioned. Etiology. — In the vast majority of cases chronic gastric catarrh is probably the cause of the origin of the erosions. In some instances the erosions may, however, be due to some factors yet unknown. Symptomatology. — The subjective symptoms are especially pronounced and consist of pain, emaciation, and a feeling of weakness. ThQ loains, which are not usually intense, occur im- mediately after meals, independent of the character of ' R. Virchow : Virchow's Archiv, Bd. 5, p. 363. 2 B. Langerhans : Virchow's Archiv, Bd. 124, p. 373. 2 0. Harttung: Deutsche med. Wochenschr., 1890, No. 38, p. 847. ^C. A. Ewald: "Diseases of the Stomach," p. 236, 1892. 240 DISEASES OF THE STOMACH. the food of which the patient has partaken. They persist for a variable period of time (one to two hours) and disappear gradually. We have never observed cases characterized by severe attacks of pain. Inter- vals of complete freedom from pain of variable dura- tion occur, during which the patient is perfectly well. In rare instances the pains are constant and indepen- dent of the ingestion of food. Emaciation. — Most cases lose in flesh during the first period of their sickness, but thereafter keep up their weight quite constantly. They look rather thin in the face (the jaws protrude, the cheeks are thin and somewhat hollow), but do not present that cachectic color we are accustomed to meet in carcinoma and other grave chronic troubles. Feeling of Weakness. — All patients complain of a feeling of lassitude, weakness, lack of ambition, and inability to work, and of a decrease of bodily strength. These symptoms appear most markedly right after meals, and decrease somewhat a little while afterward (one-half to one hour). In one of my patients (G. B ) there usually appeared, once in a week or in a fortnight, an exacerbation of these symptoms associated with complete anorexia, which lasted for about two days. During this period of deterioration the patient was hardly able to walk. Object i veil/ the following point is of the greatest importance: in washing the stomach, when the pa- tient is in the fasting condition, one to four small pieces of gastric mucous membrane are found. They are about 0.3 to 0.4 cm. long and nearly as wide, and present a blood-red color. Under the microscope one EROSIONS OF THE STOMACH. 241 sees well-preserved glands and accumulations of red blood corpuscles (see Fig. 39). These pieces of gas- tric mucosa are constantly found if the stomach of the patient is washed out in the fasting condition. We have not to deal here with an incidental lesion caused by the tube, for while, on the one hand, this sign is present even if the lavage is performed without any aspiration and by means of a soft tube, on the ^i ^-J:-^^^ Fig. 44.— a Piece of Gastric ^lucosa Cpatient M. G.), showing the glands mostly vertically cut, and accumulations of red blood corpuscles on the lower right-hand comer. other hand, one could not observe in a casual lesion that constancy which is found here. In most cases blood is never found in the wash- water carrying the small pieces of mucous membrane. Only rarely has the wash-water a very faint red color; this occurs especially if coughing spells frequently ap- pear during lavage. Besides containing the pieces of gastric mucosa, the water is then stained slightly red. The pieces of gastric mucosa which are found in the wash-water of these patients probably partly or 16 '242 DISEASES OF THE STOMACH. wholly peel off from the mucous membrane of the stomach some time previous to the washing. This would explain why there is iio bleeding during the lavage. The spots on which the exfoliations take place and which thus j^resent "erosions," may explain the soreness met with in these patients. One can also easily understand the appearance of blood from the sore spots caused by violent contractions of the stom- ach during a coughing spell. It is very difficult at present to decide whether the exfoliations always take jDlace at the same spots — the mucous membrane constantly becoming replaced and peeling off — or whether the whole (or a great part) of the inner surface of the stomach is affected to such an extent that small pieces of mucosa easily peel off here and there. This question can only be answered after a long study of vast clinical and pa- thologico-anatomical material. These exfoliations take place (whether always on the same or on differ- ent spots) day by day in the stomach of our patients, and effect temporary erosions. Condition of the Gastric Juice. — In most cases one encounters a decrease in the HCl secretion and in the acidity of the stomach contents. In some there is al- ways found a considerable amount of mucus. Occa- sionally, however, there is found superacidity caused by an increased HCl secretion. Course.— The course of this pathological condition is a very prolonged one. Several of the patients ap- pear to suffer from it for many years. Although there may be intervals of perfect euphoria (at the same time probably the inner layer of the stomach is EROSIOXS OF THE ST0:MACH. 243 completely intact) for a longer or shorter period of time, the old symptoms do, however, sooner or later return. One would imagine that cases of erosions of the stomach would present a very fruitful soil for the de- velopment of ulcers. This, however, does not seem to be the case, for in none of the patients was there any justifiable supposition of an existing ulcer during the long course of the sickness. As typical cases of this affection we mention the two following cases : Case I. —February 11th, 1893.— H. S , aged 35, merchant, suffers for two to three years from digestive troubles. These consist principally in the appearance of pains right after meals ; the pains are not severe; they produce, however, the effect that patient eats less. There is a feeling of fulness ; bow- els constipated. Patient always feels weak and tired. The examination reveals: chest organs intact ; the gastric region is sensitive to pressure ; there is splash- ing sound extending two fingers' width below the navel; right kidney movable. The examination of the stomach contents one hour after Ewald's test breakfast showed: HCl + ; acidity = 60. February 13th. — When fasting, stomach empty. Lavage: in the wash-water three small red pieces of mucous membrane are found. Spray with silver nitrate. February lith. — Intragastric galvanization. February 15th. — Lavage: in the wash-water three small red pieces of mucous membrane appear. A fresh microscopic specimen shows gastric glands. Spray with silver nitrate. 244: DISEASES OP THE STOMACH. February 16th. — PatieDt feels better — i.e., he is stroDger, can eat more, aDd is not troubled with pains. Direct galvanization of the stomach. February' ITth. — Lavage: no pieces of mucous membrane are found. Spray with silver nitrate. February ISth. — Intragastric galvanization. February 19th. — Lavage: no pieces of mucous membrane. Spray with silver nitrate. February 20th. — Intragastric galvanization. February 21st. — Examination of the stomach con- tents one hour after the test breakfast : HCl + ; acidity =54; no pieces of mucous membrane. February 22d. — Direct galvanization of the stom- ach. February 23d. — Lavage: no pieces of mucous mem- brane. Spray with silver nitrate. February 24th. — Intragastric galvanization. Pa- tient had to return to his native city, Chicago, on ac- count of urgent business. As I have recently heard, patient felt well all the time with but few intervals. Case IL— April 19th, 1893. —B. M. S , aged 26, merchant, complains for two and a half years of digestive troubles. At first patient had lack of appetite, pains after meals, and nausea, but no vomiting. Feeling of weariness and fatigue; consti- pation. After some continued treatment and a trip to the South the condition of the patient imjDroved for a while; soon, however, it got worse again. During the last two years patient has constantly pains right after meals, with but very few exceptions, and feels ver}^ weak. When fasting, patient as a rule feels well. Status prcesens. — Chest organs intact : the gastric region is sensitive to pressure. After drinking half a glassful of water a splashing sound can be produced. EROSIONS OF THE STOMACH. 245 extendiDg to one to two fingers' width above the navel. Liver not enlarged. Urine contains neither sugar nor albumin. April 20th. — Examination of the stomach contents one hour after Ewald's test breakfast shows: HCl + : acidity = 60 ; admixture of much mucus. Diagnosis. — Gastritis glandularis chronica mucosa. April 21st. — When fasting, stomach empty. Lav- age : in the wash- water, three red pieces of gastric mu- cous membrane. (A fresh specimen in glycerin shows gastric glands.) Spray with silver nitrate. April 23d. — Intragastric galvanization, April 25th. — ^Lavage: three red pieces of mucous membrane appear in the wash-water. Spray with silver nitrate. April 27th and 29th. — Direct galvanization of the stomach. Patient had to leave New York on account of business and returned on May lYth, May ISth. — When fasting, stomach empty. Lav- age: three red pieces of mucous membrane are found in the wash-water. Sj)ray with silver nitrate. May 20th. — Intragastric galvanization. May 22d. — Lavage: two red pieces of mucous mem- brane are found. Spray with silver nitrate. May 2ith. — Patient feels better, has a better appe- tite, and hardly any pain. Lavage: no pieces of mu- cous membrane are found. Spray with silver nitrate. May 26th. — Direct galvanization of the stomach. May 30th. — Lavage: no pieces of mucous mem- brane. Spray with silver nitrate. June 2d. — Intragastric galvanization. Patient feels well and is, therefore, for the present dismissed. Diagnosis. — The diagnosis of erosions of the stom- ach is made if the above-described subjective symp- toms exist and particles of gastric mucosa are fre- 246 DISEASES OP THE STOMACH. quently found in the wash-water when applying lavage in the fasting condition of the patient. Treatment. — The local treatment of the stomach here plays a great role. The astringent effect of ni- trate of silver solutions in similar more accessible af- fections led me to apply this substance directly to the interior of the stomach. This can best be achieved by means of the spray. It was on this occasion that I constructed the gastric spray apparatus (see Fig. 36, p. 135), and recommended its use in the field of dis- eases of the stomach.' In fact, the good result of this method of treatment can frequently be best shown in the affection in ques- tion, for after the spraying has been done several times the small pieces of gastric mucosa cease to ap- pear. Associated with the objective symptom there appears an amelioration in the subjective feeling of the patient; the pains grow considerabh' less or en- tirely disappear, and the strength increases. The treatment is given in the following way : First, the stomach in a fasting condition is washed out with lukewarm water; when all the water has been emp- tied, the tube is removed from the stomach. The spray apparatus is filled with lOc.c. of a 0.1 to 0.2 per cent solution of nitrate of silver, the tube end dipped into warm water and inserted into the stomach (length of tubing 50 cm.); thereupon the whole, or at least the greater part, of the solution in the bottle is sprayed ; the bottle is then opened and the spray tube removed from the stomach. I usually combine the nitrate-of-silver spray treat- ' M. Einhom : New York Medical Journal, September, 1893. EROSIONS OF THE STOMACH, 247 ment with intragastric galvanization, alternately ap- plying the spray or the galvanization. The reason for the use of galvanization in these cases lies in the fact that I had such effective results in two other cases of probable erosions of the stomach, complicated with heart trouble," by means of galvanization alone. The methodical application of intragastric galvanization combined with the spray seems to increase the curative effect. As to diet, there is no need for being very rigorous in these cases. Frequent meals, avoiding heavy vegetables, salads, and pastries, is all I ordinarily re- quire. Cold ablutions, light gymnastics, outdoor life are to be warmly recommended. Of medicaments condurango and nux vomica are frequently, and a good, easily assimilated iron prepara- tion is always, appropriate. Although these medicaments may be of value as adjuvants, we should rely, in my opinion, mainly upon the local treatment. 1 Max Einhorn : New York Medical Journal, July 8th, 1893. OHAPTEE VIII. OKGANIC DISEASES WITH CONSTANT LESIONS. — Continued. Cancer of the Stomach (Carcinoma Ventriculi). Definition. — Malignant epithelial growth within the stomach. Etiology. — The stomach is more frequently affected with cancer than any other organ of the body. Vir- chow's ' statistics of all the cancerous diseases which occurred in Wiirzburg between 1S52 and 1855 give for the stomach the proportion of 3i.9 per cent. Ac- cording to Lebert," Willigk,' and Brinton/ cancer of the stomach comprises about one-fourth of all cases of cancer. Haeberlin ' found the percentage of cancer of the stomach for the years from 1877 to 1886 to be ttl. According to Wyss,° the death-rate from this disease is 1.9 per cent. This figure, however, is Hable to many fluctuations. Haeberlin first pointed out the very curious and discouraging fact that the frequency of gastric cancer is steadily increasing. This writer's ' Virchow : Cited from Debove et Remond, I. c, p. 297. '^ Lebfrt : "Traite pratique des maladies cancereuses, " Paris, 1851, p. 97. ^Willigk: Prager Vierteljahresschrift, vol. x. , 3, 1853. ^W. Brlnton : British and Foreign Medico-Chiriirg. Review, January, 1857. ^Haeberlin: Deutsch. Arch. f. klin. Medicin, 1889, Heft 3 und 4, p. 461. « Wyss : Blatter f. Gesundheitspflege, Zurich, 1872-74. CANCER OF THE STOMACH. 249 statistics for Switzerland show a death-rate from cancer of the stomach for 1,000 inhabitants in the years: 1877,0.61; 1878,0.66; 1879,0.72; 1880,0.77; 1881, 0.85; 1882, 0.87; 1883, 0.85; 1884, 0.84:; 1885, 0.90; 1886, 0.99. Joseph D. Bryant,' of New York, has also lately shown that cancerous disease is constantly on the in- crease. According to this eminent writer, the average death-rate from cancer in New York City during the last ten years is 2.17 per cent of the total mortality, but that of the preceding ten years only 1.82 per cent. The following table, given by Dr. Bryant, is very in- structive as bearing on the increase of cancer in the United States: Year. Population. Total deaths. Deaths from cancer. Cancer deaths per 100,000 from all causes. Cancer deaths per 100,000 living. 1850 23,191,876 31,443,321 38,558,371 50,155,783 62, 622, 250 323,023 394,153 492, 263 756,893 875,521 2,088 3,672 6, 224 13,068 20,984 646 932 1,264 1,815 9 1860 1870 11.7 16 1880 1890 26.05 33 5 The frequency of gastric cancer appears to be dif- ferent in different countries, and it seems that there are some regions in which it very seldom occurs. Haeberlin's above-mentioned statistics for the whole of Switzerland show a death-rate from cancer of the stomach of 3 percent for the northern cantons, 1.5 per cent for the western cantons, and 1 per cent for the southern cantons. Griesinger'' states that he * Joseph D. Bryant : Tlie Wesley M. Carpenter Lecture. New York Medical Journal, May 18th, 1895. * Griesinger : Arch, f . phys. Heilkunde, 1854, p. 528. 250 DISEASES OF THE STOMACH. never observed cancer of the stomach in Egypt, and Heinemann ' reports that he saw only one case in Vera Cruz in a period of six years. j^ge,—As regards the age at which gastric cancer occurs, Brinton collected 600 cases, the ages of which at death averaged 50 years. The greater part (three- quarters, or 435) of these 000 cases fell in the epoch of life between -iO and TO. Arranged in decades of years, the maximum number (tw^o-sevenths, or 102) occurred between 50 and 00. Comparing these num- bers with the number of persons living in these decades of life, an estimate of the relative liability of the cor- responding ages to the malady is obtained. Brinton gives the maximum liability between 00 and To. Up to the age of 20, the whole risk is less than one-fiftieth of what it reaches between 20 and 30. The latter liability is multiplied in the following decades of years by 3, 0, 8, and 10 respectively. The maximum then seems to sink to little more than half for the next two decades, ending at the extreme age of 100. With ref- erence to age, Lebert gives the following figures in his statistics: Under 30 years, 1 per cent; 30 to 40 years, IT. 6 per cent; 40 to 00, 60. T per cent; 00 to TO, 10.3 per cent; above TO, 4. 4 percent. Welch's statistics of 2,0To cases of gastric cancer show the following distribution for the different ages: 10 to 20, 2; 20 to 30, 55; 30 to 40, 2T1; 40 to 50, 499; 50 to 60, 620; 60 to TO, 428; TO to 80, 140. According to all these statistics, the maximum lia- bility of gastric cancer lies between the fortieth and sixtieth year. It is very rare before the thirtieth 'Heinemann: Virch. Arch., vol. 58, p. 180. CANCER OF THE STOMACH. 251 year. Both WilkiDson and Wiederlioefer/ however, each mention a case in which the disease was con- genital. M. Mathieu "" has collected all the cases of gastric cancer below the thirtieth year mentioned in literature, and the number was 27. Debove ' recently published a case of gastric cancer in a young man of 24 years, and I observed a similar case in a man of 27 years two years ago. In this latter case the dis- ease was verified by an operation. Sex. — The influence of sex is far more difficult to estimate than that of age. Brinton mentions 784 cases, of which 440 were males and 344 females. Fox's * tabulation of the statements of seven writers shows that of 1,303 cases 680 were males and 623 fe- males. Of Welch's 2,214 cases, 1,233 were men and 981 women. These figures show a higher percentage for men than women, but this statement is not of necessity absolutely true, for the larger percentage of cancer among men may result from the larger number of male patients treated in the hospitals from which these statistics have been obtained. Heredity. — Most writers concur that in some fami- lies several members are found to be afflicted with cancer, and are inclined to attribute this fact to he- redity. Every physician has observed cases in which the father and one or two sons had been troubled with cancer. In some instances there is a history of cancer in the parents, relating perhaps to some or- ' Cited from Eichhorst : " Lehrbuch der spec. Path, und Therapie. " 2 Max Mathieu : Gaz. des Hopit. , 1884, p. 118. ^Debove: Societe med. des hopit., November, 1889. 4 Fox : "The Diseases of the Stomach," London, 1872, p. 184. 252 DISEASES OF THE STOMACH. gan other than the stomach. Cancer being such a frequent malady, however, it is quite difficult to state whether these occasionally observed facts are sufficient to prove that heredity plays an important part, or whether it is a mere coincidence. Statistical figures on this point are given by Lebert and Haeberlin. The former found an hereditary history in 7, the latter in 8 per cent. Snow found among 1,0T5 cases of cancer in different parts of the body, 176 cases, or 15.7 per cent, in which cancerous disease had existed in the family. Cause. — Many factors have been regarded as play- ing an important part in the origin of cancer. Thus a trauma in the gastric region has frequently been held responsible for a cancerous affection. There is no doubt but that cases occur in which a few weeks previous to the discovery of a tumor in the abdomen a trauma in the affected region had taken place. But it would certainly be wrong in all these cases to attribute the neoplasm to the preceding trauma; for there are certainly some cases in which the neojDlasm already existed before the trauma occurred, and in which the latter merely caused the patient to pay more attention to the injured region, and in this way led to an earlier recognition of the tumor. The fre- quent use of cider and of sour wines is said (Eichhorst and Cloquet) to favor the formation of a cancer. Mental worry and sad emotions have, probably wrongly, been regarded as playing a part in the cau- sation of this affection. Brinton suggested the following explanation for cancer of the cardia and pylorus: The muscular fibres of these two orifices are subjected to more work (con- CANCER OF THE STOMACH. 253 traction) than the rest of the stomach. The connec- tive tissue enclosed in them is subject to contraction and distention. All this causes a more vivid nutri- tion of these parts, and may give rise to proliferatiop of the glandular tissue, forming a neoplasm. Inflammatory conditions of the gastric mucous membrane have frequently been described as a predis- posing factor of the disease. Menetrier ' tried to show the connection between some forms of chronic gastri- tis (polypi) and the cancer. I must, however, agree with Ewald and Eosenheim that there is no reason to believe that a chronic gastritis favors the development of cancer, for in most instances we can state that the cancerous trouble developed more or less suddenly without any preceding history of a long-standing dys- peptic trouble. The gastritis found at the autopsy in cases of gastric cancer is rather a secondary or accom- panying condition than a primary factor in the dis- ease. Chronic gastric ulcers undoubtedly belong to the predisposing factors. Several cases have been de- scribed in which the formation of a cancer on the bor- der of a gastric ulcer or its scar could be clearly seen. Thus Hauser'^ has histologically demonstrated the transition of ulceration into carcinomatous prolifera- tion, 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 cancer may develop from an affection of the gastric glands. ^ Menetrier: Arch, de physiolog. . lofevi-., 1888. - Hauser : "Das chronische Magengeschwtir und dessen Bezie- hung zur Entwickelung des Magencarcinoms, " Leipzig. 1883. 254 DISEASES OP THE STOMACH. Parasitic Tlieory. — All the etiological factors men- tioned may perhaps give iis a better understanding of the development of the carcinoma, but do not by any means explain the ultimate cause of this malignant affection. Of late the parasitic theory of infectious diseases has furthered the belief that in cancer also we may have to deal with some micro-organism. Many recent investigators have made numerous stud- ies and experiments in order to elucidate this matter. Scheuerlen ' believed he had discovered a bacillus, to which he ascribed the origin of cancer. Later re- searches, however, have demonstrated that his asser- tions were wrong. Coley,^ of New York, and Em- merich/ of Munich, have seen good results in the treatment of sarcoma, and also carcinoma, from the use of injections of the blood serum of horses which had been treated by the erysipelas cocci. This fact speaks in favor of a parasitic origin of this malignant growth. Psorosperms have frequently been found within the cancer cells. It is, however, not as yet de- termined whether these bodies are real psorosperms, or dried-up and changed cells. Hence we must con- fess that, notwithstanding the many researches into the pathology of cancer, we are as yet totally ignorant of its origin. Morbid Au atomy. — It was first established by the researches of Waldeyer ^ that the cancerous process originates from the glandular elements of the mucous 'Scheuerlen: "VeihancU. desVer. f. innere Medicin." Deutsche med. Wochenschr., 1887, No. 48. ^ Coley : American Journal of the Medical Sciences, 1894. ^ Emmerich : Deutsche med. Wochenschrift, 1895. * Waldeyer- Virch. Arch., Bd. Iv. , p. 54. CANCER OF THE STOMACH. 255 membrane, its character being chiefly an atypical pro- liferation of the gastric follicles. Hence the origin of the neoplasm is in the mucosa, whence it penetrates the submucosa, forming here a more or less large de- posit. Frequently the larger part of the growth is situated beneath the mucosa. After a while this ma- lignant infiltration may attack the muscularis, and thereafter extend to the serosa. The spread of the infiltration, as a rule, takes place along the con- nective-tissue fibres. The neoplasm, after having reached a certain degree of development, may partly slough, thereby giving rise to irregular, ulcerated spots. This occurrence is most frequent in certain forms of cancer. Cancer of the stomach, like that of other organs, may present the following varieties: 1. Epithelioma. The adeno-carcinoma or epitheli- oma forms soft tumors, presenting quite marked nod- ules and sloughing very slowly. It consists of pseudo- glandular tubuli, surrounded by connective tissue and infiltrated with white blood corpuscles. These nodules show no regularity and have no outlets. In the early stage the cylindrical epithelium is dis- tinguishable, but as the growth gets older the regular arrangement of the epithelium is lost and the tubular spaces become filled with cells, the product of the mul- tiplication of the epithelial cells. The latter undergo various forms of degeneration, and may form small cysts containing granular material and liquid. 2. Medullary carcinoma. The medullary carcino- ma is characterized by large, flat, soft, fungating masses, projecting above the mucous membrane. The 256 DISEASES OF THE STOMACH. growth possesses very little connective-tissue stroma, but is rich in vessels and cells. It is spongy and pre- sents on section a whitish -yellow color, resembling brain matter in color and consistence. This form of growth is liable to produce frequent hemorrhages (in case the tumor looks blackish in consequence of blood pigment, it is called "melanotic"), and very often de- generates, forming ulcerous spots on the surface. Secondary metastases are very frequent complications. •'^ I , I ''i&M 'HM'^m^^^\^^&^^\'^^^^ Fig. 45.— Section of Carcinoma Ventriculi (Mrs. J.), scirrhus form, x 140. 3. Scirrhus (carcinoma simplex or fibrosum). The scirrhus is characterized by the abundance of connec- tive tissue. The stroma is encircled by dense connec- tive-tissue fibres, and contains relatively few cells. The growth has a firm and compact structure. It does not cut easily, and on section presents an almost cartilaginous tissue of a white-grayish yellow color, with yellow or red spots scattered all around. This growth shows little tendency to ulceration in its early CANCER OF THE STOMACH. 257 stages, but when older it is frequently found superfi- cially ulcerated. There is but little tendency to sec- ondar}^ metastasis. 4. Colloid carcinoma. The cells of the alveoli of the first-described two forms of cancer may undergo a colloid or mucous degeneration. The whole growth then assumes a gelatinous appearance. Thus arises Fig. 46.— Cross-Sectiou of Carcinoma Ventriculi (S.), showing cancer cells infiltrat- ing the connective tissue. Small area of inflammation in centre. X 140. the colloid carcinoma. Its appearance is very charac- teristic: the stroma of the tumor surrounds transpa- rent, gelatinous-looking masses, which consist of the cancer cells in a condition of colloid degeneration. On cutting and scrajDing, a true cancer juice does not exude, but, instead, gelatinous fragments. The above-described forms of cancer are not always typically characterized, but different forms may some- 17 258 DISEASES OF THE STOMACH. times be found in one and the same growth. At times, again, the form of the growth changes from one to the other of the just-named varieties of cancer. The scirrhus is by far the most common. Out of ISO cases of cancer Brinton found 130 belonging to this variety (73 per cent) ; 32 were medullary cancer, 14 colloid, 3 melanotic, and 1 epithelioma. Topographical Relations of Cancer of the Stom- ach. — Size.' — As regards size, two varieties of tumors may be distinguished. One is characterized by grow- ing very little above the surface and involving large areas of mucous membrane. The other extends onl}' over a small portion of the mucosa, and may develop extensively in thickness. The first form of tumors belongs to the medullary or colloid type, and is not met with very frequently. These growths present a flattened surface, covered with rough, nodular masses. Blood extravasations and adhesions to the neighboring organs are of frequent occurrence. The second form belongs to the scirrhus variety. The tumor involves a small circumscribed portion of the stomach, and tends to grow in depth and height. Localization. — The development of cancer with- in the stomach may take place at various situations, at its orifices (cardia or pylorus), or within the organ itself. The recognition of the localization of the can- cer is much more important than the distinction of the various forms, because each of the three different localizations of the cancer is accompanied by a char- acteristic train of symptoms, making its recognition possible during life, and requiring a special plan of treatment. As regards the frequency with which the CAXCEE OF THE STOMACH. 259 different regions of the stomach are affected by can- cer, Brinton found the following relation : Out of 360 cases the pyloras was affected in 219 instances, a pro- portion of exactly 60 per cent; 36 cases were cancer of the cardia, a proportion amounting to exactly 10 per cent; in the remaining 30 per cent the lesion was scattered over the greater and lesser curvatures. The fundus is attacked least frequently of all : among 1,300 cases of cancer of the stomach reported by Welch, only 19 were situated in the fundus. The figures given by Lebert,' Katzenellenbogen," and other writers, agree very closely with Brinton 's figures. It is easily seen that the localization of the cancer is very markedly different from that of ulcer, for in the lat- ter affection the orifices of the stomach are the least frequently affected. The Shape of the Stomach. — The different situations of the cancer influence the shape and the position of the stomach. The organ is found to be retracted and small in size in all cases of cancer of the oesophagus and cardia. The viscus is very much dilated in cases of cancer of the pylorus. The shape of the stomach may be distorted in case the tumor, situated near the pyloric orifice, descends by reason of its weight and drags the organ down into the pelvis. Distortions and contractions of the stomach may also be developed as a consequence of inflammatory adhesions with ad- jacent viscera. * Lebert : "Traite pratique des maladies cancereuses, " Paris, 1851, p. 97. 2 Katzenellenbogen : "Beitrage zur Statistik des Magencarci- noms. " Inaug. Diss., Jena, 1878. 260 DISEASES OP THE STOMACH. Gastric cancer is almost always primary, and sec- ondary growths of the stomach must be considered as a great rarity. Cancer of the stomach may, how- ever, coexist with a primary cancer of some other or- gan, as, for instance, the uterus and ovaries. Ewald mentions a case in which he found an immense cysto- sarcoma of the uterus and a carcinomatous infiltration of the pylorus. Secondary Changes Accompanying Cancer of the Stomach. — Aside from the cancerous lesions, the af- fected area of the stomach is usually the seat of vari- ous anatomical changes. Thus thickening of the mucosa, caused by hypertrophy of the connective tissue and muscular fibres, is frequently observed. Ewald first observed that the whole mucosa may pre- sent characteristic lesions of chronic gastritis. At some places the glands have disappeared ; at others they exhibit mucoid changes; while at still others cysts are found. Cancerous Metastases. — Secondary cancerous de- posits in other organs are of frequent occurrence in cancer of the stomach. Out of 437 cases Brinton saw this complaint in 210, or in 48 per cent. The medul- lary and colloid forms of cancer are more often asso- ciated with secondary cancer than is the scirrhous form. Among the organs in which the secondary cancer- ous deposits appear, the liver takes the first place. Brinton gives the figure of secondary deposits in the liver as 25 per cent of all cases of gastric cancer, while Lebert gives the figure of metastasis in the liver as 40.9 per cent of all the metastases. This writer gives the following figures for the metastases CANCER OF THE STOMACH. 261 in other organs: peritoneum, 37.5 per cent; lungs, 8.3 per cent; ovaries, 4.5 per cent. In some cases, however, the secondary cancer of the liver is associ- ated with deposits in the other organs; for instance, the peritoneum, pancreas, kidneys. The intestines and lungs may be affected at the same time. The metastatic infection usually takes place by way of the blood current or the lymph vessels. In some in- stances, however, a direct extension in continuity of the cancerous growth to a neighboring organ may take place. Thus the extension of a pyloric cancer to the liver or the gall bladder, or of a cancer situated at the greater curvature to the colon, or, again, of a cancer of the smaller curvature to the pylorus, is often observed. The lymphatic glands are frequently found swollen, but in cancer of the stomach this symptom does not appear as often as in neoplasm in other organs. Brin- ton has observed this symptom in 23.5 per cent of these cases. The swelling of the glands is frequently caused by cancerous deposits in them ; sometimes, however, they may be swollen simply in consequence of a condition of irritation. The cancerous deposits may appear at one spot, forming a new tumor varying in size in the respective organs; sometimes, especially if the cancerous ma- terial has been carried through the lymphatics, numerous small deposits may exist, and the whole organ may then appear as if studded with mili- ary tubercles. This condition is frequently found in the pleura. It is at first quite difficult to decide at one glance the real nature of this tubercle-like de- 202 DISEASES OF THE STOMACH. posit. The microscope will quickly solve the problem. Koch's bacillus is found in the real tubercles, while the cancerous deposits contain no bacilli and will show the characteristic structure of the neoplasm. While the cancerous deposits may at times appear in this form, simulating a tuberculous affection, the latter condition may occur independently in cases of cancer of the stomach; that is to say, both affections, viz., cancer and tuberculosis, may coexist in the same per- son. Symptomatology . — In a typical case the course of the disease is as follows: A person, usually of middle age, who has been previously in good health, experi- ences uncomfortable sensations after meals, impair- ment of appetite, more or less disturbance of sleep, and loss of strength. Although slight at first, these symptoms persist and remain obstinate to all methods of treatment. In the course of time they become more and more aggravated. Pains apjjear, which are always very annoying and sometimes show exacerbations of a very acute and intense form. While at first there is only belching and a mouthful of food is occasionally ejected, after a while vomiting appears and deprives the patient of the little nourish- ment he takes. Still later hemorrhages appear. Al- though the quantity of blood ejected is, as a rule, not large, this symptom, however, greatly debilitates the patient, as it usually occurs several times in succes- sion. About the same time that the hemorrhage be- gins to appear, a tumor becomes perceptible in the gastric region. The patient now presents a cachectic appearance and falls off daily. He becomes extremely CANCER OF THE STOMACH. 26 o weak and prostrated, and usually death from inani- tion follows. In analyzing the symptoms accompanying a neo- plasm of the stomach, it is important to divide them into: A, Those caused by the growth itself (general symptoms) ; and B, those produced by the position of the growth — (a) cardia; (6) pylorus; (c) stomach proper. A. General Symptoms. — These are partly subjective, partly objective, and may be enumerated as follows: 1. Anorexia, or loss of appetite, is a very frequent although not very characteristic symptom of gastric cancer. JSTumerically Brinton found it present in eighty-five per cent. The appearance of this symp- tom is sometimes delayed until a comparatively late period. Anorexia in this instance is not caused by any fear of pain the ingested food may invoke, but is attributable to a direct lesion of the nerve centre of hunger^ There is a real loss of apjDetite, or no desire, no inclination to take food. In some instances there exists an actual aversion for food, especially with ref- erence to all kinds of meat and food rich in albumin. Sometimes there is present in these cases a craving for highly seasoned articles, such as pickles, herring, and so on. 2. Pain. — Pain is the most constant of all symp- toms. It is present, according to Brinton, in about ninety-two per cent, and according to Katzenellen- bogen in a still larger percentage of cases. The situ- ation of the pain does not always correspond to the site of the lesion. Thus a pyloric cancer may cause pains referable not only to the right hypochondrium, 264 DISEASES OF THE STOMACH. but also to the sterDiim or the left hypochondrium. The pain most characteristic of this condition is usu- ally of a lancinating character. It begins at a com- paratively early date, and soon assumes a marked se- verity. Often it becomes so intense that all other symptoms are relegated to the background. It is characteristic of the pain of gastric cancer that it never entirely disappears. There may be remissions in the severity of the pain, but there are never really free periods. Unlike the pain of gastric ulcer, it is either little or not at all affected by the ingestion of food. Never is it relieved at the end of gastric diges- tion or after vomiting. The character of the pain is sometimes described by the patients as dull, gnawing, or burning; sometimes as being attended by a sense of weight, oppression, tightness, or distention in the epigastrium; sometimes, again, by soreness or ten- derness to pressure in this region. Exacerbations of the pains are frequently caused by ulcerative processes taking place on the surface of the cancer; some- times, again, by inflammatory adhesive processes with the neighboring organs. 3. Vomit in fj. — Youjiting is likewise one of the most frequent symptoms. Brinton found it present in eighty-seven and one-ninth per cent of his cases, and Arnold in eighty-six per cent. The frequency of this symptom is largely dependent upon the situation of the cancer, occurring much oftener in those cases in which the cancer occupies either the pylorus or the cardia. But it may exist even when the cancer has no connection whatever with the orifices of the stom- ach. The vomiting takes place either sometimes af- CANCER OF THE STOMACH. 265 ter the ingestion of food or independent of it. Thus some patients vomit in the morning when arising, and eject either a quantity of mucus or, more fre- quently, some undigested and decomposed food parti- cles. The ejected matter often has an offensive smell, and as a rule contains numerous micro-organisms, sarcinae, yeast cells, and sometimes changed blood. 4. Hemorrhage. — Vomiting of blood is observed, according to Brinton, in about forty-two per cent of the cases of gastric cancer. The blood is sometimes ejected in sufficiently large quantity to be recognized with the naked eye. More frequently, however, it is not vomited in the pure state, but mixed with gastric juice, food, mucus; sometimes the blood has under- gone many changes during its sojourn in the stomach, and then looks blackish, brownish, or jDresents a coffee- ground appearance. The quantity of blood ejected is, as a rule, smaller in gastric cancer than in ulcer ; but while in ulcer the hemorrhage if once entirely arrested very seldom recurs, it is quite different in cancer. For here small hemorrhages appear in succession for a long time, at intervals of a few days' duration. Melsena (blood in the stool) sometimes accompanies the hemorrhage. It is found, however, less fre- quently than in gastric ulcer. The hemorrhage, as a rule, takes its origin from the minute vessels of the submucous plexuses or from the capillaries of the su- perficial layer of the mucosa covering the neoplasm. It is very seldom that a larger vessel is opened, and in that case a fatal issue results. The hemorrhage is also caused by manifold processes of ulceration, in- volving the vessels of the cancerous mass. 2G6 DISEASES OF THE STOMACH. 5. Tumor. — The presence of a tumor in the gastric region is one of the most reliable and pathognomonic signs of cancer. The recognition of this will depend upon its size, and position. The larger the tumor, the more superficially it is situated, the more easily can it be detected. Inspection alone sometimes suffices to make us suspect a malignant growth: on looking at the gastric region, either in the standing or recumbent position of the patient, a protrusion is noticed, either below the ensiform process or at the margin of the ribs on the right or left side. The result of inspection must always be corroborated by the palpation method. The latter is much more reliable and by far more effec- tive. The palpating fingers encounter a resistant body of varied size and shape, often presenting the appearance of a hard, irregular, nodulated mass; sometimes, however, being smooth and small, and but slightly different from a contracted abdominal muscle. The latter cases are the most difficult to rec- ognize, and sometimes a positive diagnosis as to the presence of a tumor can hardly be made. Percussion is another means of verifying the results of palpation. The presence of a tumor in the stomach will give a dull sound on gentle percussion, and sometimes a tym- panitic note on firm percussion. Whether the existing tumor belongs to the stom- ach or not, and also what region of the organ it occupies, can be determined by the following meth- ods: A tumor of the lesser curvature moves slightly downward on deep inspiration, and becomes less dis- tinct or sometimes disappears on deep expiration. On inflating the stomach with carbonic-acid gas or with CANCER OP THE STOMACH. 267 air, the resistance will be found just above the gastric area. Tumors of the pylorus, if not adherent to the liver, will move down on inspiration, and if held in this position with the hand will not ascend during expiration; if adherent to the liver they will move up during the act of respiration. A tumor of the pylorus sometimes disappears when the stomach is full, on account of the different positions the stomach occupies in its empty and in its filled states. A tumor of the greater curvature will move up and down dur- ing inspiration and expiration, and will also descend when the stomach is inflated with air; it will then occupy the lowest border of the inflated area. According to my experience, transillumination of the stomach gives the best results with regard to the recognition of the presence of tumors and the deter- mination of their situation. The tumor, not being translucent, is visible as a dark spot within the red transilluminated zone of the abdominal wall. It ap- pears on top of this zone when the tumor occupies the lesser curvature, and at the base of the transil- luminated area when it springs from the greater cur- vature. The dark spot is at the right in tumors of the pylorus. In some instances transillumination dis- closes the presence of a tumor even when the latter is not yet accessible to palpation. 6. Fever. — The occurrence of fever in gastric can- cer does not belong to the regular symptoms. It is, however, met with oftener than is generally believed. It usually appears in the latest stages of the disease, and is always a bad omen ; for frequently the fatal issue is then impending. In rare instances the rise of 268 DISEASES OF THE STOMACH. temperature occurs at certain periods of time, and pre- sents a marked similarity to a fever of malarial origin. Hampeln ' relates a case presenting this peculiarity. In most instances the fever does not show any regu- larit}-, is, as a rule, not very high, and accompanied by frequent intermissions. The fever is probably due either to an inflammatory process w^hich occurs in the neighborhood of the neoplasm, or, more fre- quently, to the absorption of a toxic material from ulcerated areas of the tumor. The latter circum- stance is also responsible for a comatose condition which is sometimes met in these cases, especially in the last stages of the disease. 7. Constipation. — More or less obstinate constipa- tion exists in the majority of cases of gastric cancer. According to Ewald, the bowels remain regular in only four to five per cent of the cases. The constipa- tion may at times alternate with diarrhoea; the latter is the result of a catarrhal condition of the intestinal mucous membrane, due to the irritation of hard scybala or to the products of decomposition. Fre- quently diarrhoea appears whenever sloughing of the neoplasm occurs. It often indicates imminent dan- ger, and is not unfrequently the proximate cause of death. 8. Cachexia. — Cachexia is met with in almost all cases of gastric cancer after the disease has progressed long enough, and is, if present, an important symp- tom. Its absence, however, by no means militates against the existence of cancer. Brinton regarded cachexia as pathognomonic of cancer, being the re- ' P. Hampeln : Zeitschr. f. klin. Med., B<1. 8, p. 232. CANCER OF THE STOMACH, 269 suit of a humoral disease. At present, however, most writers agree that the cachexia is brought about in most instances not by specific poisons circulating in the blood, but by subnutrition. From my own ex- perience, I can state that I have frequently made the diagnosis of gastric cancer in people who pre- sented a very healthy appearance, and who had not become emaciated. The diagnosis in some of these cases was later verified either by an operation or at the autopsy. In one case of cancer of the pylorus in a man, forty -two years of age, who had slightly lost in weight but who was yet well nourished, in the first few weeks of treatment an increase in weight of eight to ten pounds was effected. The same patient was operated upon some time afterward, the pylorus being resected, but he succumbed one year later. "9. CEdema. — In the first stages of cancer malleolar oedema sometimes appears for a short time. Boas * found this symptom in twelve per cent of his cases. This oedema fugax is, however, not a pathognomonic sign, as it may occur, according to Boas, in other affections of the stomach of a non -malignant type. Ascites or anasarca, or both, frequently appear in the last stages of the disease. 10. Metastases. — As mentioned above in speaking of pathology, metastatic tumors frequently occur. Thus enlarged glands of hard consistence and nodu- lar character are suggestive of cancerous deposits. A nodular infiltration of the liver, presenting a hard and uneven surface, is very frequently met with in ' Boas : " Spec. Diagnostik und Therapie der Magenkrankheiten, " 3te Aufl. , p. 185. 270 DISEASES OF THE STOMACH. gastric cancer. A carcinomatous metastasis in the thorax is accompanied by the symptoms of pleurisy (dulness, pains, friction sound). Although these me- tastases, as a rule, appear quite late, still if present they may help to clear the diagnosis. 11. Condition of the Blood. — Laache ' first de- scribed a decrease of the number of red blood cells in this affection, while Haeberlin "" found that the haemo- globin was greatly diminished. According to this writer, the quantity of the latter is only fifty per cent of the normal. Eisenlohr ' and Schneider * found an increase of the leucocytes. While all these conditions are of some importance, as suggestive of cancer, they are b}' no means specific and are met with in other affections. Recently Schneyer ^ has stated that the usual in- crease in the number of leucocytes, which is found normally during the period of gastric digestion, is ab- sent in all cases of gastric cancer; that is, the num- ber of leucocytes in the fasting condition and at the height of gastric digestion remains the same. This symptom promises to be of great value, and it should certainl}' be further investigated. 12. Condition of the Urine. — Klemperer ^ and Miiller ^ discovered that the urine in cases of gastric cancer contains more nitrogen than the amount intro- duced with the nourishment. It has been found, ' S. Laaohe : "Die Anamie," Christiania, 1883. "^ Haeberlin : Miinchener nied. Wochenschrift, 1888, No. 22. 3 Eisenlohr: Deutsch. Arch. f. klin. Med., Bd. 30, p. 495. ^ G. Schneider : Inaugural Dissertation, Berlin, 1888. « Schneyer: Zeitschr. f. klin. Med.. 1895. «G. Klemperer: Berl. klin. Wochenschr., 1889, No. 40. 'Fr. Miiller: Zeitschr. f. klin. Med., Bd. 16, p. 498. CANCER OF THE STOMACH. 271 however, that this symptom is not constantly pres- ent. Besides, the elucidation of this fact necessitates quite complicated and laborious investigations, v^hich can be made only in clinics, but not in private prac- tice. The amount of chlorides is frequently found di- minished, v^hile the indigo-forming substances are often increased. Peptonuria is occasionally observed ; it always indicates that there is absorption from an ulcerated area (neoplasm) within the digestive tract, and is therefore of importance. B. Symptoms Produced by the Position of the Growth. — These may be divided into three groups, according to the location of the growth. {a) Cardia. Subjective Symptoms. — Dysphagia is one of the principal symptoms of cancer of the cardia. The patient first notices that he cannot eat as fast as he would like. Frequently he has to stop in the mid- dle of a meal, experiencing a sensation as if the food would not go down into the stomach. This occurs only if solid food is taken. The patient, as a rule, learns to help himself by drinking several mouthfuls of water when such an impediment occurs. Very soon these difficulties Increase in severity and in number, and the patient can hardly partake of solid substances without drinking liquids with them. Still later, the patient finds it impossible to partake of solid food, as he cannot force it down into the stomach even by means of water. Whenever he tries to do so, the food remains within the oesophagus and causes a feeling of extreme discomfort and oppression. The patient is then usually obliged to eject it after much straining and retching. Liquid food is at this time the only 272 DISEASES OP THE STOMACH. diet; on which the patient subsists. Still later, when the stenosis is of a very high degree, the patient is unable to partake even of a sufficient quantity of li- quids, as he can force through the stenosed cardia only very small amounts or none at all. Besides these difficulties in eating and drinking, the patient often complains of either pains or a burning sensation at the scrobiculus and somewhat above it. " Vomiting, " or, more correctly, ejection, of some mucus with or without food particles from the oesophagus often oc- curs, especially at night, in the recumbent position of the patient. Objective Syinptoms. — 1. Sivallowing sound. The swallowing sound, if not absent, is frequently retard- ed, and heard about twenty seconds after swallowing of water, while normally it should be heard after seven. This sign, however, is not pathognomonic; for, on the one hand, I have seen cancer of the cardia with the appearance of the swallowing sound at the normal time of seven seconds ; and, on the other hand, I have observed a case in which there was no organic trouble and still the swallowing sound was not heard for a long time. 2. Examinations with the tube. It is best to exam- ine the patient with silkworm tubes of different sizes. The examination should be directed with the following objects in view : Permeability. — It is of the utmost importance to introduce the tube through the oesophagus into the stomach, and to pay attention to the fact whether there be no resistance at any place of the passage. If a resistance is felt, mark at what distance from the CANCER OF THE STOMACH. 273 mouth it is situated, and also whether it cau be over- come without the appHcation of much force. Much force should never be exerted ; if a tube of a certain thickness has met with resistance within the oesopha- gus, then try a tube of thinner calibre. In this way the degree of stenosis can be estimated. Particles of Tumor. — When withdrawing the tube from the oesophagus, it is always necessary to close the opening with the thumb, and then empty the contents into a porcelain dish. Sometimes small particles of the neoplasm are .then found, which, when examined under the microscope, will frequently reveal the nature of the trouble, and assist us in mak- ing a positive diagnosis of cancer. Blood. — The tube sometimes contains either fresh clear blood, not smelling badly, or blackish-looking and decomposed blood mixed with mucus, with a very disagreeable, sometimes fetid odor. The latter condi- tion is very frequently found in malignant strictures of the cardia, and is sometimes pathognomonic of can- cer. Fresh, clear blood, appearing constantly at the examination of the tube, is suggestive of malignant trouble at the cardia, even when no stricture has yet been found. This symptom, however, is not a posi- tive one, as there are other conditions that may pro- duce it. The following case well illustrates the impor- tance of the detection of blood at the lower end of the oesophagus : Patient, about 45 years old, had complained of a burning sensation and pains in the epigastric region for over a year. He had no difficulty whatsoever in the partaking of food. He was not emaciated and 18 274 DISEASES OF THE STOMACH. presented a healthy, good color. On examination, the gastric region was found to he somewhat tender, but not painful to pressure. The outlines of the stomach were not enlarged. The swallowing sound was heard seven seconds after the deglutition of wa- ter. The examination with the tube one hour after test breakfast revealed no abnormal conditions what- ever. The tube passed into the stomach without the slightest resistance. The chemical analysis of the gastric contents showed the presence of free hydro- chloric acid, the absence of lactic acid, and a degree of acidity of 60. On washing out the stomach of the patient in the fasting condition, it was found that it contained no food from the previous day, and the water returned pretty clear. When, however, the wa- ter stopped running and the tube was partly with- drawn, so that its end was in the neighborhood of the cardia, a small quantity of clear blood, mixed with some water, usually ran out. When the upper opening of the tube was closed and the instrument entirely withdrawn, it was found to contain pretty clear blood. Numerous examinations during a j)e- riod of about two months showed the presence of the same condition, especially with regard to the appear- ance of blood at the end of the washing procedure or when withdrawing the tube. The characteristic rest treatment for ulcer did not benefit the patient in the least. The probable diagnosis of cancer of the cardia was made, and the patient died one year afterward in a well-known sanitarium in Germany, in which the diagnosis of cancer had been confirmed. 3. Retention of Food within the (Esophagus. — In most instances of cardiac stenosis some of the food particles remain within the oesophagus above the ste- CANCER OF THE STOXACH. 275 nosed spot. As a rule, they become decomposed and cause an irritation or inflammation of the oesophageal walls. The retention of food within the oesophagus IS an important sign, and can be discovered one hour after the partaking of a small meal, in the following way: A tube of ordinary size (not too narrow) is introduced into the oesophagus until about 1 or 2 cm. above the stenosed spot, and the patient ordered to compress his thorax after a deep inspiration. As a rule, some contents now appears through the tube. The opening is then closed, the tube withdrawn and emptied, and the obtained contents examined as to appearance (macroscopical aspect), reaction, whether acid or not, whether containing lactic acid, hydro- chloric acid, or the ferments. A tube of thinner calibre which can pass the stricture is then taken, and introduced into the stomach. By the ordinary expression method the real gastric contents are now obtained. Their macroscoj)ical ap- pearance, as well as their chemical condition — which again refers to acidity, presence of hydrochloric acids, and ferments — is compared with the portion first ob- tained by means of the thicker tube. In cases of actual retention of food within the oesophagus, the first portion shows the following characteristics: Ee- action, either neutral, alkaline, or slightly acid; hy- drochloric acid and ferments absent; organic acids occasionally j)resent. The particles of food appear un- changed in any way and are in just the same condition as when swallowed. The second portion, obtained from the stomach, presents the appearance of chyme, shows a decided acid reaction, the presence of hydro- 276 DISEASES OF THE STOMACH. chloric acid either in its free state or combined, fre- quently the presence of ferments, especially rennet, and gives the biuret reaction. Ketention of food within the oesophagus is not path- ognomonic of cancer of the cardia, as it is also found in dilatation of the oesophagus, caused either by a benignant stricture of the cardia or by a disturbance of the peristaltic action of the oesophagus. The latter two conditions, however, are quite rare, so that the symptom of retention is of much importance in the diagnosis of cancer of the cardia. 4. The examination with the oesophagoscope often shows a neoplasm. (b) Pylorus. Subjective Signs. — Besides the pains, there exist a decided feeling of fulness and quite fre- quent attacks of vomiting. Objective Signs. — 1. Tumor. A tumor can very frequently be discovered, situated somewhat to the right of the linea alba in the area extending from the navel to the ribs. The methods of diagnosing these pyloric neoplasms have already been described above. 2. Vomited matter. This consists of large quantities of chyme (one to two quarts or more), and, as a rule, contains food which had been taken a day or two before the act of vomiting. 3. Ischochymia. This condition (retention of chyme) is very pronounced. On examining the stomach in the fasting condition of the patient by means of the tube a considerable quan- tity of chyme, containing more or less decomposed food from previous days, is found. Very frequently the particles of food are quite coarse and obstruct the openings of the tube. In such instances it is often very difficult to empty the stomach entirely, even by CANCEK OF THE STOMACH. 277 means of washing. This object can hardly be achieved in one sitting. (c) Stomach Proper. Subjective Symptoms. — 1. Pains. A constant gnawing pain in the scrobiculus cordis radiating to the back is frequently found pres- ent. 2. Anorexia is very marked. Objective Symptoms. — 1. Tumor. The presence of a tumor situated to the left of the linea alba (see page 262). 2. Vomiting of small quantities of food, fre- quently presenting a blackish color. 3. Ischochymia ^^^^Tttfri of a slight degree. The examination by means of the tube of the stomach in the fasting condition reveals the presence of a small quantity of chyme, the parti- cles of food therein being quite minute. Diagnosis. — The diagnosis of cancer of the cardia is made from a study of the above-described symptoms and the results of the examination with the tube. Cancer of the pylorus and stomach proper is diagnosed in the same manner. Although the hope of finding certain pathognomonic characteristics in the chemical condition of the gastric contents with cancer of the stomach has not been realized, still the chemical an- . alysis reveals several points which certainly aid in es- tablishing the diagnosis of the affection in question. Van den Velden,' in 1879, first stated that hydrochloric acid is absent in gastric cancer. "He made use of cer- tain aniline dyes (Congo and methyl violet) for the de- tection of this acid. Cahn and von Mering ^ made use of an exact analytical method, and found that in some cases of gastric cancer the stomach contents revealed 1 Van den Velden : Arch. f. klin. Med., Bd. 22, p. 369. ^ Cahn und von Mering : Berl. klin. Wochenschr., 1885. 278 DISEASES OP THE STOMACH. considerable quantities of hydrochloric acid. Ewald justl}' mentions in his book that the question as to the presence or absence of hydrochloric acid in gastric can- cer had been experimentally broached as far back as 1842 by the English physician Golding Bird.' In a man forty-two years old, with pyloric cancer and dila- tation, this writer determined the relation of hydro- chloric and the organic acids in a series of examina- tions of the vomit. The results of these examinations led Bird to conclude that "during the most irritative stages of the disease free hydrochloric acid is present in the vomit in considerable quantities, but it gradu- ally diminishes in proportion to the patient's loss of strength, and that the organic acids increase pro- portionally as the free hydrochloric acid dimin- ishes." In forty cases of gastric cancer Boas ' found an ab- sence of hydrochloric acid in thirty-five, while in the remaining five free hydrochloric acid was discovered. Among the cases of gastric cancer that I have seen during the last few years, I know of six in which free hydrochloric acid was present, either in normal or in greater quantities. These cases of gastric cancer in which hydrochloric acid is found to exist certainly lessen the value of Van den A-^elden's symptom for the recognition of the disease ; but this symptom loses still more in importance if we consider that absence of free hydrochloric acid is associated with many other ' Golding Bird : " Contributions to the Chemical Pathology of some Forms of Morbid Indigestion." London Med. Gazette, 1842, p. 391. * Boas : I. c. CANCER OF THE STOMACH. 279 conditions besides cancer. Severe forms of gastric catarrh, and esi^ecially achylia gastrica, will undoubt- edly furnish a greater contingent of cases with ab- sence of hydrochloric acid than cancer of the stonaach itself. Lactic Acid. — Although it was known that the or- ganic acids are increased in cancer of the stomach, and that lactic acid frequently occurs, Boas ' must be credited with laying stress upon the presence of lactic acid in this affection ; he even attributed a pathogno- monic value to this symptom. According to this in- vestigator, lactic acid, if not introduced in a pre- formed state with the food, but developing in the stomach, occurs exclusively in cancer of this organ. After a thorough washing of the stomach, Boas gives the patient a test meal, consisting of a plate of barley soup. One hour afterward the gastric contents are obtained and examined, either by the Uffelmann test or by Boas' method, as to the presence of lactic acid. This test meal does not contain any lactic acid, and if the latter is found to be present then it must have been produced in the stomach. Boas does not deny that there are cancers of the stomach which do not show this symptom. As a rule, these are cases in which hydrochloric acid is found to be present. The occurrence of lactic acid, however, is, according to Boas, a specific sign. Many writers have of late in- vestigated the question of the appearance of this acid. Most of them agree that lactic acid exists in large quantities in the majorit}^ of cases of gastric cancer, but that it is by no means a specific sign. Klem- ' J. Boas: Deutsche med. WocheDschr. , 1892, No. 17. •280 DISEASES OF THE STOMACH. perer,' Thayer," Rosenheim/ and myself," have pub- lished cases of non-malignant gastric troubles in which lactic acid was found in the gastric contents. The absence of free hydrochloric acid and the pres- ence of lactic acid, although they are, as we have seen, not pathognomonic, are, however, of importance and frequently help to establish the correct diagnosis, i The diagnosis of cancer can be positively made un- der the following conditions : 1. If particles of tumor are found {in the wash-wa- ter or in the tube), which under the microscope re- veal the characteristic picture of a malignant growth. 2. The presence of a more or less large tumor with an uneven surface, belonging to the stomach and as- sociated with dyspeptic symptoms. 3. The presence of a tumor associated with fre- quent haematemesis. 4. Constant pains, frequent vomiting, ischochymia, emaciation — all these symptoms being quite perma- nent and not extending over too long a period of time (six months to one year). 5. Tumor and ischoch3"mia. 6. Emaciation, ischochymia, presence of lactic acid. 7. Constant anorexia and pains, not yielding to treatment, accompanied by frequent small hemor- rhages (of coffee-ground color). Differential Diagnosis. — In cases in which a tu- mor exists it is necessary to determine whether it 'Kleinperer: Deutsche nied. Woclienschr. , 1895. ^ Thayer : Johns Hopkins Hosp. Bullet. , 1893, No. 31. ^Rosenheim: Berl. klin. Wochenschr. , 1894. No. 39. •• Max Einhoin : " Stenosis of the Pylorus. " Medical Eecord, Jan- uary 19tli, 1895. CANCER OF THE STOMACH. 281 originates from the stomach or some other organ ; and if it has its seat in the stomach, whether it is of benign or malignant character. The first ques- tion, as to which organ a tumor belongs to, has been discussed above. As regards the second question, we shall have to differentiate between a tumor situated within the stomach proper and one at the pylorus. Benign tumors, like fibroma, myoma, and lipoma ' situated within the stomach, or foreign bodies, like a gastrolith or a mass of hair, which may sim- ulate a neoplasm are of extremely rare occurrence and need hardly be taken into consideration when making the diagnosis. In tumors situated at the py- lorus we meet much more frequently conditions of a benign type, such as cicatricial thickening or simple hypertrophy. The size of the tumor, the condition of its surface, whether smooth or nodular, will fre- quently help to decide this question. The tumor in benign processes is usually not very large (about wal- nut size), smooth, and does not grow; while malig- nant growths are larger, frequently present an uneven surface, and increase in size. These points are, how- ever, not enough to form a decisive opinion, and they must be supplemented by such data as can be ob- tained. Thus, long duration of the sickness — two or three years and rqore — speaks in favor of a benign process, while a short duration — six months and so on — rather favors the view of a malignant process. In all instances in which a tumor is absent the ' Syphilitic gummatous tumors of the stomach also belong to this class. I have observed a case of this kind very recently. The \n-es- ence of other luetic manifestations vrill remind us of this possibility. 28-2 DISEASES OF THE STOMACH. differential diagnosis of cancer will have to exclude ulcer, benign stenosis of the pylorus (not palpable), chronic gastric catarrh, achylia gastrica, and very se- vere forms of gastric neurasthenia. 1. Ulcer. — In ulcer there is, as a rule, clear tongue, a circumscribed spot painful to pressure, some con- nection of the pains with the period of gastric diges- tion, intervals perfectly free from pain, very large hemorrhages, not recurring very frequently, and, as a rule, no real anorexia. In cancer, on the other hand,i the tongue is almost always thickly furred, the pain-| ful area generally extends over the greater part of the gastric region, the pains not having much rela- tion with the digestive period, the hemorrhages are rather small and very often recurring, and real an- orexia or aversion for food exists. 2. Tlie benign stenosis of the 2^ylojnis gives a long history of sickness interrupted by intervals of almost perfect euphoria, extending over different periods of time (one year to two or three months) ; the gastric contents generally show the presence of free hydro- chloric acid and an increased degree of acidity. Ma- lignant stenosis of the pylorus gives a short clinical history, no intermissions, and the gastric contents most often do not contain free hydrochloric acid and reveal the presence of lactic acid in considerable quan- tities. The degree of acidity is variable, sometimes being greatly increased through organic acids. 3. Chronic Gastric Catarrh. — A severe form of chronic gastric catarrh may at the beginning give rise to considerable difficulty in establishing the diagnosis between the two conditions. Sometimes this will be CANCER OF THE STOMACH. 283 at first impossible. By keeping the patient under ob- servation for a certain length of time the diagnosis ■will often clear np, the chronic catarrh will improve under rational treatment, while cancer of the stomach will either show no amelioration whatever or only a very slight one, the main symptoms of the disease con- tinuing in the same way as before the institution of the treatment. 4. Achylia Gastrica. — In achylia gastrica the tongue is sometimes clear, the gastric contents show- ing no juice whatever, no mucus, very little fluid of neutral or very slightly acid reaction (acidity, 2 to 6), no ferments, no lactic acid. The particles of food are very coarse. The stomach is empty in the fasting condition of the patient; there are no hemorrhages. In gastric cancer the tongue is always furred, the gas- tric contents, as a rule, include considerable quantities of mucus, and the degree of acidity is much higher, even if there is absence of free hydrochloric acid. The fragments of food are not so coarse as in the former condition, lactic acid is frequently present, and numerous micro-organisms are almost always present in the contents. 5. Severe Form of Gastric Neurasthenia. — A mis- take between gastric cancer and severe forms of neu- rasthenia will not occur frequently. The neurotic condition which can be found in the patient, implicat- ing several other organs besides the stomach, will help to establish the true diagnosis. Duration and Prognosis. — The malignant process usually terminates fatally about one year from the commencement of the symptoms. Cases, however, 284 DISEASES OF THE STOMACH. are met with in which the disease runs a more protracted course, eighteen months to two years. On the other hand, very acute, so-called foudroyant cases are observed which end in death in from four to six weeks. The duration of the disease depends, firstly, upon the situation of the neoplasm, which causes more disturbances and rapid death when oc- cupying and occluding the cardiac or pyloric orifice; secondly, upon the character of the growths (some of which, as, for instance, the medullary form, develop, rapidly) ; and thirdly, upon the complications which arise either from ulceration and hemorrhage or from cancerous metastasis. The prognosis of cancer of the stomach is always hopeless. Oser justly said, the only hope for the pa- tient can be that the physician has made a mistake in the diagnosis. No specific remedy has as yet been discovered for this ailment, and even surgery has not been able thus far to combat this malady successfully. Treatment. — The treatment comprises: A. Surgical interference; B. Medical treatment. A. Surgical Interference. — Owing to the futility of medicinal treatment, surgical intervention has been invoked, and several bold operations have been de- vised, which may be resorted to in appropriate cases. These may be divided into radical and palliative pro- cedures. a. The radical operations mc\\i(\e: (1) Resection of the pylorus;- (2) excision of the tumor. Billroth' was the first to prove the possibility of ex- cision of the carcinomatous pylorus, in 1878. Since 'Billroth. Wiener klin. Wochenschr., 1891, No. 34. CANCER OF THE STOMACH. 285 that time, distinguished surgeons all over the world have been working in this special field of abdominal surgery, and have greatly contributed to the further development of this heroic method of treatment. The aim in total resection of the tumor is to radically cure the patient, i.e., to remove all the cancerous parts of the organ. It will be seen at a glance that the indi- cations for this operation exist as soon as a neoplasm accessible to the knife and operable can be diagnosed. The earlier the diagnosis is made the better are the chances for radical interference. Thus far only very few cases are known in literature in which the excision of the tumor or the resection of the pylorus was followed by a real cure. The reason that these operative procedures have not been so successful as has been expected is that they are resorted to, as a rule, too late. Gastric cancer can rarely be diagnosed before it has contracted adhesions with other organs, or before metastatic deposits have formed elsewhere. Contraindications for these operations are: (1) If can- cerous metastasis can be discovered in other organs (liver, glands, etc.); (2) adhesions, i.e., if the tumor is not perfectly movable and found to be adherent to other organs; (3) the large size of the tumor; (4) the presence of high degrees of anaemia or cachexia ; (5) very old age. h. Palliative Operations. — The palliative operations have two purposes in view : 1. To permit of a better introduction of food into the digestive tract. 2. To remove as much as possible the irritating effect of food upon the affected area. 280 DISEASES OF THE STOMACH. The operations serving this object are : 1. Gastrostomy, in malignant affections of the car- diac orifice or of the oesophagus. 2. Gastroenterostomy, for mahgnant affections of the pylorus or its immediate neighborhood. Gastrostomy consists in establishing an opening be- tween the stomach and the abdominal wall, in order to introduce food by this new passage. The technique of this operation has lately been considerably im- proved, Witzel's ' method accomplishing the best re- sults. The indications for this operation exist as soon as dysphagia is well developed and the patient unable to introduce large enough quantities of liquid and semi-liquid food through his oesophagus in order to maintain his bodily weight. To wait until a time when even small quantities of liquid cannot pass through the cardia into the stomach without discom- fort and pain does not appear to be advisable, for at this period the operation, as a rule, is more dangerous and affords less relief to the patient. Contraindica- tions for this operation are the weakened condition of the system, caused either by advanced cachexia, very old age, or other conditions. Gastroenterostomy consists in the establishment of a new communication between the stomach and the small intestines, in this way allowing the chyme to pass directly into the small intestine without previ- ously passing through the pylorus. The indications for this operation exist as soon as the presence of ma- lignant trouble within the organ has been diagnosed, complicated with symptoms of ischochymia, especially ' Witzel: Centralbl. f. Chiruig., 1891, No. 31. CANCER OF THE STOMACH. 287 if a radical operation does not appear to be feasible. The sooner it is done the better. By means of it life can be considerably prolonged and made much more comfortable than is possible by any other treatment. The contraindications are the same as those given above under gastrostomy. Exploratory laparotomy^ v^hich is often performed in this disease, seems to be permissible only in those cases in which the diagnosis, although not positive, admits of the possibility of undertaking some kind of an operation which will afford either a cure or at least some relief to the patient. To make an explora- tory laparotomy merely for the sake of diagnosis does not seem to me justifiable. B. Medical Treatment. — The medical treatment has the following points in view : To strengthen the or- ganism by a proper mode of nourishment, thereby prolonging life as much as possible, and to alleviate the morbid phenomena. The first point can be achieved by a proper diet. The more food the patient can be made to take and to assimilate the better This should be the most important principle in guid- ing us. Ample variety in the bill of fare and the in- dividual inclination of the patient will have to be con- sidered. Trousseau said that the patient should be allowed to eat what he himself thinks he can best tol- erate. The following may be given as general rules: The diet should consist of milk, kumyss, matzoon ; farinaceous foods ; soups containing leguminous foods in a finely divided state (ground) ; eggs, either raw or soft-boiled, or well beaten up in soup or milk ; small quantities of meat, either raw and well scraped, or 288 DISEASES OF THE STOMACH. broiled; the white meat of a chicken; squab, calf's brain, sweetbreads, oysters, lish, white French bread ; crackers, with the addition of a small quantity of sweet butter; tea and coffee, wine, ale. In the later stages of the disease many articles of the just-de- scribed diet will not appear suitable, and the mainte- nance of nutrition becomes gradually more difficult. Here the artificial foods, the various peptone prepara- tions (Wyeth's beef juice, Kemmerich's or Eudisch's peptone, Mosquera's beef jelly, somatose, Armour's beef peptone), are in place. . Medicinal Treatment. — As yet no specific remedy against cancer has been found. The treatment must, therefore, be a palliative one, and chiefly directed toward combating the more pronounced morbid mani- festations and alleviating pain. In cardiac strictures Boas' recommends the use of potassium_iodide. This author reports a case of oesophageal cancer in which he employed sodium iodide (2 to 3 gm. x>'^'0 die) for over six months. During this whole period the pa- tient remained free from symptoms, and even gained nine pounds in weight. I have also administered this drug in several cases of cardiac stenosis, and frequently obtained transient good results. Arsenic has also been given in this affection (solutio arseni- calis Fowleri, three drops three times daily), some- times with good results. One of the principal reme- dies which is employed in gastric cancer is condurango. This drug was recommended in 1874 by Friedreich,' as a specific against cancer. While, however, further ' Boas : I. c. ■■^Friedreich: Berl. klin. Wochenschr., 1874. CANCER OF THE STOMACH. ' 289 researches did not substantiate this favorable report, but rather proved that condurango has in no v/ay a specific action on cancer, many writers agree that it is an excellent stomachic and as such helps greatly to alleviate some of the gastric symptoms accompanying- malignant affections of the stomach. Ewald, Rosen- heim, Boas, strongl}' advocate the use of this drug. I also administer it in the greater number of cases. Ewald usually employs it in combination with hydro- chloric acid. Condurango may be given in the form of a decoction. 25 to 200 gm. water, one tablesi^oonful every four hours; or in the form of fluid extract, of which twenty drops or even more can be given three to four times daily. Another drug from which I have some- times seen beneficial effects in this malady is methyl blue. I ' was the first to recommend its internal use in cases of cancer. I have employed it in eight cases of cancerous affection of either the oesophagus or the stomach. In three of these cases I was able to note a great improvement of most of the morbid phenom- ena. In one case, in which a considerable tumor oc- cupied the gastric region, this appeared to have become somewhat smaller after the drug had been used for about three weeks. This patient took methyl blue for a period covering eight to nine months uninterrupt edly, being all the time quite free from pain and not losing in weight, the tumor meanwhile not getting any larger. After this period, however, the tumor began to grow again and the patient rapidly succumbed. Methyl blue is best given in gelatin capsules, 0.2 gm. 'Max Einhorn : "Ueber die Anwendung des Methylenblau. " Deutsche med. Wocheuschr., 1891, No. 18. 19 •Z'JU ' DISEASES OF THE STOMACH. once or twice daily. While I do not believe that this drug is able to cure a cancerous disease permanently, I am of the opinion that it seems to exert a beneficial action in some cases of cancer. In all cases in which either decomposition of food or ulceration is taking place, one of the best reme- , dies to alleviate these conditions, and also subduej the discomforts produced by them, is chloral hydrate. I Ewald was the first to advise its use, and I also advo-' cate it highly. It may be given in the form of a three-per-cent solution, one tablespoonful every two or three hours. The remainder of the remedies em- ployed is simply symptomatic; thus, in case of pain, opium, morphine, or codeine must be administered. The combination of an opiate with belladonna is very suitable. If there should be a profuse hemorrhage, this will have to be treated similarly to that produced by ulcer. Obstinate vomiting must be controlled either by opiates or, in instances in which vomiting is due to stagnation of food in the stomach, by occasional lavage. Constipation, which is so frequently present, must be relieved, either by mild aperients (rhubarb, compound licorice powder, cascara sagrada), or by enemata, or glycerin suppositories. Occasionally the following pills may be prescribed : IJ Extr. aloes, Extr. rhei comp., aa2.0 M. f. pil. No. XX. D. S. One to two pills in the evening. CHAPTER IX. FUNCTIONAL DISEASES WITH VARIABLE LESIONS/ H YPEESE CRETION. HypercTilorhydria . Synonyms. — Hyperacidity ; hypersecretion. Definition. — The term hyperchlorhydria is applied to a condition in which the gastric secretion is more acid than normally and richer in ferments. Fre- quently the quantity of juice is also increased, hut it is secreted only during the period of digestion. General Remarks. — ^AVhile the older writers were acquainted, to a certain extent, with digestive disor- ders attended with hyperacidity of the gastric juice, it is but quite recently that these conditions have been thoroughly studied and placed on an exact scientific basis. Formerly it was thought that in most disturb- ances of the stomach the gastric secretion was defi.- cient. Nowadays, since the publications of Riegel,"* Reichmann," Jaworski and Glusinski,* Ewald ^ and others, we know that in almost one-half of all the pa- * This heading comprises affections in which either the secretory or the motor function (prochoresis) of the stomach is at fault, form- ing the principal symptoms. Anatomical lesions here are not al- ■ways present and if present are often of various kinds. 2 Riegel : Zeitschr. f. klin. Med. , Bd. 11 and 12. sReichmann: Berl. klin. Wochenschr. , 1882, No. 40; 1884, No. 48 ; 1887, No. 12. * Jaworski: Zeitschr. f. klin. Med., Bd. 11, Heft 2 und 3. ^ Ewald : I. c. 292 DISEASES OF THE STOMACH. tients suffering with digestive disorders the gastric juice is rather increased. According to my own experience, the gastric disor- ders accompanied with hyperchlorhydria form more than one-half of the number of patients troubled with digestive affections. With reference to this point the following table, which I published in the Medical Record of November, 1895, may be of interest: Table of Private Patients whose Gastric Contents have BEEN Analyzed During 1889 to 1895. T^T 1 ^ .-.•.,, ( in 89 : HCl = 0, acidity = 2 to 40 Number of patients with hy- \ . „. ,,„, „ .,./ .„ , o^ 11 1 J • low i m 31 : HCl = 0, acidity = 40 to 80 pochloihydria, 187, • ] • an Trr-i i •^•/ ^K4. ai\ <. in 67 : HCl +. acidity = 15 to 40 Numbei" of patients with eu- j chlorhydria, 91, . . [ i^ 91 : HCl +, acidity = 40 to 60 Number of patients with hy- i perchloriydria, 286. . \ ^^ ^86 : HCl -f , acidity = 60 to 140 Total number of patients, 564. Thus more than one-half of the cases showed a hy- peracid state of the gastric juice. Whether hyperacidity should be considered as a dis- ease sui generis or not, is difficult to decide. Hyper- acidity certainly describes only one symptom, show- ing that the secretory function is increased without pointing to any definite anatomical lesion ; but this symptom may be of the greatest importance, and very often covers the whole ground upon which is based the subjective suffering of the patient and the ration- al treatment at our command. That is the reason why I think it best to discuss hyperchlorhydria in a special chapter. Does hyperchlorhydria always give rise to digestive disturbances and other symptoms? In order to an- HYPEECHLORHYDRIA. 293 swer this questioD it will be best to determine more exactly where hyperchlorhydria begins — ^.e., to what degree of acidity we may apply this term. According to the experience of Ewald and others, to which I can add my own, the degree of acidity of the gastric con- tents about an hour after Ewald 's test breakfast va- ries, as a rule, in healthy people between 40 and 60. A degree of acidity of 70 and above is therefore con- sidered as hyperacidity. The above question will now be put in the following way : Must people with an acidity of their gastric contents of TO and above al- ways present morbid phenomena '? To this I must answer in the negative. From a very large experi- ence, I can assert that we occasionally meet with per- sons whose degree of acidity of the gastric contents is as high as 100 and even more, without producing any disturbances whatever. This condition need not even be a transient one, but may last for years and still cause no discomfort. This, however, is not the rule, and the greater number of persons with a hyperacid juice are not free from disturbances, but rather pre- sent a ver}^ characteristic train of symptoms. We speak of a pathological hyperchlorhydria whenever this condition is associated with subjective complaints. Etiology. — As has been just stated, hyperchlorhy- dria is of very frequent occurrence. It is met with chiefly in adults, although neither the young nor the old are exempt. In the majority of cases its origin may be traced either to a psychological cause, such as grief or worry, or to mental overwork. It is, as a rule, more frequent among the wealthier and more educated class of people, as lawyers, bankers, etc., al- 294 DISEASES OF THE STOMACH. though hyperchlorhydria may be met with also among the poor. But in addition to this so-called reflex ac- tion of the brain as an etiological factor of the dis- ease, there may also be direct causes; thus, for in- stance, the habit of taking highly spiced dishes, much ice water, and strong alcoholic drinks is liable to pro- duce this trouble. Symptomatology. — This disorder is usually charac- terized by a gradual development. At first the i^a- tient experiences an uneasy sensation about two or three hours after dinner. Later this changes into a feeling of distress in the epigastric region, occurring about two hours after each meal, instead of after din- ner alone. The pain lasts for an hour or two, or even three, and then disappears. Very often pyrosis ac- companies the pain and occasionally regurgitation or water brash takes place. The patients, as a rule, can ease their pain by taking some nourishment, especially one that is rich in albumin ; thus the white of an egg, milk, or meat is capable of dispersing the pain. It also disappears after the ingestion of some alkali, as Vichy water or bicarbonate of soda. The appetite is ordinarily not diminished but frequently rather in- creased. Thirst is generally enhanced. The bowels in most cases are constipated. The composition of the food is frequently of signifi- cance with reference to the character of the pains, which are less intense in people partaking of large quantities of meat and eggs, while they are much more severe in persons living on a chiefly vegetable diet. Besides the attacks of pain, patients affected with hyperchlorhydria very often suffer from severe head- HYPEECHLORHYDEIA. 295 ache or attacks of dizziness, which may appear either independently or accompanied by gastric pains. The patients, as a rule, do not lose in weight except in some rare instances, in which a faulty and insufficient diet has been maintained for quite a long time. Objective Symptoms. — On palpation the gastric re- gion is frequently found tender on pressure, although not actually painful, this tenderness not being limited to one circumscribed spot, but to a larger area cover- ing the greater part of the gastric region. The con- tour and the size of the stomach are frequently found enlarged, although this condition is by no means char- acteristic of the affection in question. A splashing sound can be produced after the ingestion of water or after meals, but not in the fasting condition. On examination of the stomach with a tube in the fasting condition it is found to be empty, or only a few cubic centimetres (five to ten) of gastric juice can be obtained. One hour after Ew aid's test break- fast, or two to four hours after Leube-Eiegel's test dinner, the gastric contents include an abundance of hydrochloric acid and of the ferments, the acidity be- ing, as a rule, much higher than normally (twice or three times as high). A disc of egg albumen becomes digested in the filtrate of these contents in a very short time (sometimes in half an hour). The gastric contents obtained three to four hours after the test dinner show macroscopically that the meat has been perfectly digested, while starchy substances are yet either unchanged or very little altered. The filtrate of the gastric contents, either after the test dinner or after the test breakfast, will reveal the presence of 29G DISEASES OF THE STOMACH. either starch or large quantities of erythrodextrin. The addition of a few drops of Lugol's solution to the filtrate will produce either a blue color or an intense dark red. The high degree of acidity is most commonly caused by free hydrochloric acid. The difference between the amount of free hydrochloric acid (as determined by Mintz's or Toepfer's method) and the total acidity is not great, the figure very frequently being from 10 to 20. The motor faculty of the stomach is usually not im- paired ; in a few instances it is rather increased. Thus two hours after the test breakfast, or six to sev- en hours after the test dinner, the stomach is found to be either empty or to contain but very little food. The salol test likewise shows salicyluric acid in the urine as early as an hour after the ingestion of the salol. The degree of acidity of the urine is frequently di- minished during the digestive period. This, however, is not always the case, for occasionally the degree of acidity of the urine and of the gastric contents may be found increased at the same time. Course. — At the beginning hyperchlorhydria is most frequently intermittent. The patient may suffer from this affection for several days, weeks, or even months, becoming free from the ailment for periods of time which vary from several weeks to months or even years. After this interval the trouble either re- curs spontaneously without any apparent cause, or is evoked by a severe mental shock or worry. Later on the periods of remission may become shorter, the pe- riods of hyperchlorhydria longer, and at last this con- dition may become permanent. HYPERCHLORHYDEIA. 297 The following is a typical case of hyperchlorhydria : N. B. , '2^ years old, complained for the last two and a half years of digestive disturbances which consist in pyrosis, dryness in the throat, drowsiness, and constipation. These symptoms were always pres- ent and became aggravated at certain periods of time. Patient has never lost much in weight. For the last three months patient suffered from pains in the gas- tric region. These appear quite regularly one and a half to two hours after meals, and last for one and a half to two hours. Before meals and shortly after- ward patient feels well. Appetite very good. Present Condition. — Patient looks somewhat pale. Tongue clear, with but a slight coating at the back. Gastric region not painful to pressure; stomach not enlarged. One hour after the test breakfast : HCl -f- ; acidity = 100; free HCl = 88; dextrin + traces; erythro- dextrin + very much. In the fasting condition, the stomach is empty. The following represents an atypical case of hyper- chlorhydria : Patient (M. A ) has been ailing for four or five years with pains in the stomach and frequent vomit- ing. Sometimes she has no pains for two to three weeks, at the end of which time they reappear. The pains occur immediately after meals. She also vom- its large quantities of food. On examination I found that the stomach was only sensitive to pressure; oth- erwise nothing could be discovered. With regard to diagnosis it was questionable whether I had to deal with an ulcer or with some functional disorder of the stomach. The regular treatment for ulcer (milk diet, rest, large doses of bismuth) was instituted, but after 298 DISEASES OF THE STOMACH. a period of three weeks the symptoms had not abated. The pains appeared in the same severity and the vom- iting persisted. The failure of the treatment made it probable that there was no ulcer. Patient was exam- ined one hour after a test breakfast, and the following condition found: HC1-|-; acidity = 100; free HCl = S6. In the fasting condition the stomach w^as empty. Hyperchlorhydria was diagnosed, and the treatment arranged accordingly. The patient now rallied very quickly and recovered entirely. Prognosis. — The prognosis in hyperchlorhydria is, as a rule, quite good, except in some cases of a very protracted and severe nature, in which the prognosis regarding the complete disappearance of this condi- tion is bad, although even then there is no danger of a fatal issue. Diagnosis. — The diagnosis of hyperchlorhydria is made either from the subjective symptoms alone or from these in connection with the results of a chemical examination of the gastric contents. The subjective symptoms characteristic of hyperchlorhydria are : 1. Pain, appearing constantly about two to three hours after meals. Eelief from the pain is felt imme- diately after the ingestion of an alkali, or a little while after the partaking of some food, especially al- buminous. 2. Appetite and thirst are either in a healthy condi- tion or increased. 3. No marked cachexia. 4. Constipation. Although all the symptoms mentioned make the di- agnosis of hyperchlorhydria probable, it can be made HYPERCHLORHYDEIA. 299 with certainty only after repeated examinations of the gastric juice. 1. On examination of the stomach in the fasting condition, the organ is either found empty, or con- tains only a few cubic centimetres of juice. 2. One hour after Ewald's test breakfast the degree of acidity is found greatly increased, owing to the large amount of free hydrochloric acid. Differential Diagnosis. — In making the diagnosis of hyperchlorhydria, we shall have to exclude all con- ditions which are liable to give similar symptoms; for instance, gastric ulcer, permanent hypersecretion, and biliary colic. The characteristic symptoms of ulcer have been described above, and we shall here limit ourselves to the remark that the pain of an ulcer, even if this is accompanied by hyperchlorhydria, does not disappear entirely after the ingestion of large doses of alkalies. Permanent hypersecretion is very frequently accompanied by vomiting, and the most intense attacks of gastric pain appear, as a rule, in the middle of the night or early in the morning. On examination with the tube, the stomach in the fasting condition is found to contain considerable quantities of gastric juice (80 to 100 c.c). Biliary colic, not ac- companied by jaundice or by a considerable palpable swelling of the gall bladder, may give rise to errors as to the real cause of the pain. In biliary colic, how- ever, the pains, as a rule, appear later than in hyper- chlorhydria (four to five hours after a meal), and are not eased by the ingestion of food or by alkalies. An- other means of differential diagnosis is that the pains in biliary colic most commonly extend over the right 300 DISEASES OF THE STOMACH. epigastric and hypochondriac regions, whereas the pains of hyperchlorhydria are felt more in the middle of the epigastrium, although sometimes radiating far- ther to the right. Treatment. — Hygienic Regimen. — In view of the fact that hyperchlorhydria is most frequently caused by too much mental work, the daily life of the patient as to amount of work, bodily exercise, mental rest, and pleasure must be regulated. With regard to this point, the same rules will not apply to all, but it will be necessary to individualize .each case for itself. Thus business men with a great deal of responsibility resting upon them, lawyers, politicians, and physi- cians must be sent away from their work to some country place, so as to relieve their brains temporarily from the strain. Ladies moving in high social cir- cles, and participating in all manner of festivities, will have to be restricted to a more quiet life. Again, there are people with large fortunes and without any occupation whatever, who become sick from paying too much attention to their own bodily functions. Here it will be necessary to occupy the mind of these patients with some kind of work. Cold sponge baths in the morning, bodily exercise of about eight to ten minutes' duration every morn- ing are in most instances of value. Walking once or twice a day for half an hour to an hour, horseback riding, driving, bicycle riding should be highly recom- mended. Diet. — All substances that are liable to excite in- tensely the glands of the stomach must be excluded from the dietary of such patients. Therefore all kinds HYPERCHLORHYDRIA. 301 of acids, including organic acids (citric, tartaric, ace- tic acid) ; all kinds of spices, such as pepper, mustard, horseradish, and the like, must he forbidden. The food should consist of material rich in albumin, while the quantity of starchy substances should be dimin- ished. Thus all kinds of meat (even game), fish, oysters, eggs, milk, should be taken in large quanti- ties. Bread and butter are permitted. Potatoes, spinach, asparagus, green peas, farina, and rice should be taken only in small amounts. Whiskey and wines should, as a rule, be avoided. Cacao, weak tea, weak coffee, and beer can be given in mod- erate quantities. As a rule, it is advisable to have the patient partake of five or six meals daily, three heavy and two or three lighter ones. The heavier meals should not deviate much from the ordinary bill of fare, while the lighter meals should consist either of a glassful of milk or matzoon, with bread and butter or a cup of cocoa and a few crackers, or occasionally a cup of bouillon with an egg beaten up in it, and some bread, or half a dozen oysters, a few crackers, and a glass of beer. The patient must be impressed with the importance of thoroughly masticating the food and eating slowly, be- sides resting fifteen to twenty minutes after each meal. Outline of Diet in Hyperchlorhydria. Calories. 7: 30 A.M., two eggs, 160 wheaten bread, 50 gm., . . .128 butter, 20 gm., 163 milk, 250 gm., .... . 169 3()2 DISEASES OF THE STOMACH. 10: 30 A.M., matzoon or milk, 200 gm., crackers or bread, '60 gm., butter, 10 gm., 1 P.M., broiled meat, 100 gm., mashed potatoes, 50 gm., . bread, 30 gm., butter, 10 gm., . weak tea or Vichy water, 200 gm 3: 30 P.M., the same as at 10: 30 a.m., 6:30 Calories . 135 . 77 . 81 . 210 . 63 . 77 . 81 . 293 soup (with barley or vermicelli), 200 gm., 100 bread and butter (bread, 30 gm. ; butter, 10 gm.), 158 meat (broiled or cooked), 100 gm., . 210 potatoes, baked, 50 gm., . . .60 green vegetables (spinach, green peas), 50 gm., 80 coffee (half milk), 100 gm., . . .31 10 P.M., oysters and crackers, or cold meat sandwich, one glass of beer, . . . . .200 2,519 Medicamenis. — All kinds of alkalies can be used in the treatment of this affection. Where hyperchlor- hydria is not complicated with constipation, bicarbo- nate of soda may be given, either alone or in combina- tion with sugar of milk or peppermint sugar (German Pharmacopceia), in doses of half a teaspoonful to about one teaspoonful three times a day, two hours after meals. Calcined magnesia and magnesia am- raonio-phosphorica neutralize four times as much acid as bicarbonate of soda. The following prescriptions are therefore very serviceable : I^ Sodii bicarbon., Magnes. ust. , aa 20.0 3 v. M. exactissime, f. pulv. D. ad scatulani. S. Half a teaspoon ful to a teaspoonful three times daih", two hours after meals. HYPEECHLORHYDKIA. 303 Or, I^ Sodii bicarbon., ...... 20.0 3 v. Magnes. ust., Magnes. ammoniophospli., '. . . aa 10.0 3 iiss. M. exactissime, f. pulv. D. ad scatulam. S. Half a teaspoon- ful to a teaspoonfiil three times daily, two hours after meals. In cases which are accompaDied by constipation, magnesia usta and some rhubarb can be added, and here I frequently prescribe the following : IJ Magnes. ust., Pulv. rad. rhei, aa 7.5 3 ij. Sodii carbon, exsiccat., Sodii bi carbon., Elseosacch. menth. pip aa 15.0 3 iv. M. exactissime, f. pulv. D. ad scatulam. S. Half a teaspoon- ful to a teaspoonful three times daily, two hours after meals, to be taken in plain water or in Vichy water. Bouveret uses sodium bicarbonate in 2 gm. doses, to be taken two hours after lunch and after supper, and to be repeated after an hour's interval. The al- kaline treatment can be continued for very long pe- riods without an}^ ill effects whatever. In cases in which the nervous element is more disturbed (sleep- lessness, headaches, over-excitability, etc.), we should give a good dose of a bromide salt. I am in the habit of prescribing strontium bromide : I^ Stront. brom. puriss., . . . . 12.0 3 iij. Aq. menth. pip., ..... 60.0 3 xv. S. One teaspoonful twice daily in milk at mealtime. Sodium bromide and ammonium bromide can be em- ployed in the same way. The bromides should, how- ever, be given only for a week or two, and their use then discontinued for a short time, after which they may be resumed for the same length of time. Boas ;304 DISEASES OF THE STOMACH. advises the admiuistration of small doses of morphine or codeine. He frequently j^rescribes the following: 1^ Magnes. ust, 15.0 3 iijf- Morphiiife hydrochlor., .... 0.1 gr. if. M. f. pulv. D. ad scat. S. A point of a knife to a teaspoonful three times daily. I have very seldom seen the necessity of prescribing either morphine or codeine in this affection. Of the watering-places, Yichy and Neuenahr are to be highly recommended. For the treatment of these patients at home these mineral waters are taken most advantageously in small quantities. Electricity. — In cases of a protracted nature, the direct application of the electric current to the inside of the stomach is frequently of the greatest benefit. In most instances the faradic current should be ap- plied, but in cases in which the pains are very severe galvanization should be employed. As to the mode of application of the current and the length of time required for this treatment, see the section on electric- ity. The electric current applied in this manner ex- erts a stimulating tonic influence, not only upon the stomach, but also upon the small and large intestines, I have frequently seen cases of hyperchlorhydria, ac- companied by the most obstinate constipation, per- fectly cured by means of the current, even when no drugs whatever had been given. Gastrosuccorrhcea Continua Periodica (Reichmann). Synonyms. — Gastroxynsis (Eossbach) ; periodic con- tinuous flow of gastric juice. Definition. — Gastrosuccorrhcea continua periodica GASTROSUCCOEKHCEA CONTINUA PERIODICA. 305 is a condition characterized by the acute appearance of a constant secretion of gastric juice giving rise to attacks of vomiting and severe pains. General Remarks. — Organic affections of the pe- ripheral or central nervous system are present in some cases of this disorder, although it may occur in per- sons who are apparently free from nervous troubles. Keichmann ' was the first to call attention to the pe- riodic continuous flow of gastric juice; a few years previously Eossbach ^ had described under the name of gastroxynsis a nervous affection of the stomach, which consists in a sudden appearance of severe head- aches accompanied by gastric pains and vomiting of very acid chyme or gastric juice. In accordance with Boas, I consider gastroxynsis and gastrosuccor- rhoea continua periodica to be one and the same affec- tion, and do not think they should be treated under different headings. Symptomatology. — In the midst of perfect health a sensation of discomfort is experienced in the gastric region, which is associated with restlessness. Soon afterward the discomfort changes into a rather pain- ful sensation, and nausea appears. The patient is compelled to occupy a recumbent position. The symptoms just described continue or rather increase in severity, and in about an hour or two the nausea ends in vomiting of a large quantity of gastric con- tents. The patient may now feel a little relieved for a short time, but soon the same symptoms return. The appetite is entirely lost and instead there is ex- ' Eeichmann : Berl. klin. Wochenschr., 1882, No. 40. 2 Eossbach: Deutsch. Arch. f. klin. Med., 1885, Bd. 35. 20 30G DISEASES OF THE STOMACH. treme thirst. The more the patient drinks the more, as a rule, he has to vomit. If he abstains from drink- ing, the vomiting is less frequent, but persists never- theless. Thus, as a rule, in the middle of the night or early in the morning, the patient has to vomit a large quantity of a watery liquid which is very acid in character, and either quite clear or greenish from the admixture of bile. If this liquid be examined it will be found that free hydrochloric acid is present in large quantities, as are the ferments (rennet and pepsin). No food particles can be discovered in the fluid. It consists of either clear gastric juice or gas- tric juice with admixture of a little bile. After such an attack frequently a constant desire to vomit per- sists, and the patient suffers from very violent and painful retching. Often a quarter of an hour after the last paroxysm, the patient's efforts to vomit cause a small quantity of clear yellow bile to be ejected. Even if the patient absolutely abstains from all kinds of food and drink, a few hours later a largo quantity of gastric juice may again be vomited. The patient in this condition is hardly able to sleep for any length of time, as the pain awakens him soon after he has fallen asleep. The abdomen, as a rule, is sunken. The patient looks extremely pale, and his extremities are fre- quently cold. Severe headaches often accompany this train of symptoms, and constipation is almost a con- stant concomitant. After this condition has lasted for two or three days, or sometimes even longer, the nauseous feeling begins to disappear, the pains sub- side, and the patient experiences for the first time a GASTEOSUCCORRHCEA COXTIXUA PERIODICA. 307 desire for food. He is now able to eat without vom- iting, and in a day or two feels like hiroself again. It is characteristic of this affection that the symjDtoms disappear almost suddenly, and that the patient who seemed to he in a wretched state a few hours before may now appear nearly well. After a period of perfect euphoria, varying from several weeks to a few months or a year or even long- er, a similar attack may occur. The attacks may then either recur after the same period of time, or the intermissions of health may become gradually shorter, so that ultimately the patient has hardly recuperated from his last attack before a new one supervenes. The latter condition forms the intermediary stage between periodic and chronic gastrosuccorrhoea. During the free intervals the gastric secretion takes place either in a perfectly normal manner or hyper- chlorhydria may exist. In either case, however, the stomach remains free from secretion in its empty state. The following cases may serve as good illustrations of this affection : Case I. — R. B. I , aged 37, business man. During 1890 and 1891 patient had several attacks of the then prevailing grippe. In December, 1892, after the third attack of the grijDpe. he was taken ill with a stomach trouble, the nature of which patient describes as follows : "' I was seized suddenly with a fit of vomit- ing, entirely emptying the stomach apparently, but followed by successive spells, at an interval of one to two hours, accompanied by the most intense pain. This would last from twenty -four to thirty-six hours, and sometimes forty-eight, after which the stomach 308 DISEASES OF THE STOMACH. would gradual!}' quiet down so that nourishment in the form of milk — either hot milk or kumjss — could be taken in small quantities at intervals of about two hours, until a normal condition was restored, which usually took from two to three days to accomplish. "The character of the vomit was, first, that of un- digested food, followed by a strong and very acid fluid of a whitish, and finally of a greenish color, consisting principally of bile. After each of the spells men- tioned the intense pain would subside, and I would fall asleep — to be awakened again by a recurrence of the pain — the intervals of sleep and suffering varying from an hour to three as I became better, and contin- uing until vomiting had ceased. "During all these spells I was exceedingly nervous — the slightest noise or vibration causing pain and sometimes causing the vomiting. General condition after becoming able to sit up was one of extreme weakness — having lost from ten to twenty pounds, as the attacks were longer or shorter. "During 1893 I was ill four or five times, in 1894 as often, and in 1895 four times. Weight previous to griiDpe averaged 135 to 138 pounds; since these at- tacks it has varied from 125 to 133." Present Condition. — July 22d, 1895. — Chest organs normal. The palpation of the abdomen does not re- veal any pathological condition. The splashing sound can be easily produced in the gastric region, and ex- tends downward to about two fingers' width below the navel. Knee reflex present. Urine does not con- tain any sugar or albumin. Besides the above-de- scribed attacks of vomiting, patient complains of a feeling of heaviness in his gastric region about one hour after meals, and of slight constipation. July 23d. — Examination of the gastric contents one GASTKOSUCCORRHCEA CONTINUA PERIODICA. 309 hour after Ewald's test breakfast: HCl +, acidity = 100, free HCl = 86. October 8th. — Patient is in bed suffering from one of the attacks mentioned ; he has vomited several times during the day and is suffering from intense pain. On inspection the abdomen is shghtly sunken; on palpation the whole gastric region is found ex- tremely sensitive and painful to pressure. The hands and also the face (particularly nose and forehead) are somewhat cold ; pulse, 110; temperature, 98° F. The vomited matter consists of a pretty clear fluid with an abundant admixture of mucus; no food particles can be discovered in the liquid. On chemical exami- nation free HCl as well as pepsin and rennet are found present in large amount. Patient complains of in- tense thirst. Under the administration of opiates he grew better and was able to leave his bed after three days. Case II. — George N. J , 42 years of age, mer- chant, suffered for five years from frequently appear- ing attacks of pains in the region of the stomach. These attacks were usually accompanied by vomiting of highly acid substances ; they recurred once every three to four weeks and lasted about three days. During the attack the patient felt miserable and down-hearted, suffered from severe pains; was not able to eat anything and vomited frequently. When the attack was over he felt perfectly we]l, except that his sleep was somewhat disturbed. The physical examination shows: Chest and ab- dominal organs intact; the patellar reflex present; stomach not dilated (the site of the stomach having been determined by gastro-diaphany). August 31st, 1891. — One hour after test breakfast, HCl + , acidity = Q6. 310 DISEASES OF THE STOMACH. The patient was directly gastro-faradized for a pe- riod of two months. He had no attack during the time of treatment, nor any thus far after it was dis- continued ;> sleeps w^ell and feels stronger and full of life. Diagnosis. — The diagnosis of gastrosuccorrhoea con- tinua periodica can be made by the above-described symptoms, in connection with the examination of the vomited matter (which is found to consist principally of clear gastric juice without admixture of much food), or with the examination of the stomach in the fasting condition by means of the tube (which results in the withdrawal of a considerable quantity of clear gastric juice). Inasmuch as similar attacks of gas- trosuccorrhoea may occur as a consequence of either an open ulcer or a cicatrix within the stomach, the pylorus, or the duodenum, it will be necessary to exclude such organic affections before making a diag- nosis of continuous periodic gastric flow, which we consider to be a nervous affection. It will also be of importance to exclude organic spinal or cerebral trou- bles, which may cause a similar disorder of reflex origin. Prognosis.— ll]i% prognosis of pure gastrosuccor- rhoea continua periodica is, as a rule, not bad. In many instances it is possible either to make the at- tacks less severe, or in some instances to effect a cure by rational treatment. Treatment. — It will always be advisable to analyze the gastric juice of the patient during the free inter- vals. If hyperchlorhydria is found this will have to be treated (see p. 206), even if there should be no GASTROSUCCORRHCEA CONTINUA PERIODICA. 311 subjective complaints; for hyperchlorbydria is fre- quently, although not always, the cause of such at- tacks. At any rate, a hygienic way of living should he inaugurated by the physician. I am in the habit of prescribing a good-sized dose of bromide as soon as the -patient feels an attack coming on, and find that occasionally it may be cut short at the very beginning. In some instances the attack, although not inter- rupted in its progress, is thereby rendered less severe. When the attack has appeared the patient must be kept in bed. A hot- water bag is placed over the gas- tric region, and if the pains are severe an opiate, either alone or in combination with belladonna, is ad- ministered. During the first day of the attack no nourishment whatever should be given. A teaspoon- ful of cold water or a small ice pill can be adminis- tered from time to time, especially if the patient is very thirsty. The next day small quantities of milk, matzoon, or egg water, one or two tablespoonfuls, are given every hour. On the third day the quantity of nourishment may be increased to half a cupful at a time administered every two hours, and besides the above liquid food the white of a hard-boiled egg chopped up fine may also be given (one or two eggs a day). On the fourth day meat (scraped, raw, or broiled) may be tried, and afterward the diet gradu- ally arranged as for cases of hyperchlorbydria. The system of diet as laid down here for every day from the beginning of the attack will certainly depend upon the condition of the patient, and will have to be modified accordingly. As there is always constipa- tion during the attack, it will be best to move the 312 DISEASES OF THE STOMACH. "bowels on the second or third day, either hy a glycerin supjDOsitory or by a large injection of water (a quart of water and a teaspoonful of salt), or an injection of sweet oil (one pint). Gastrosiiccorrhcea Continua Chronica {Reichmann). Synonyms. — Chronic continuous flow of gastric juice: Reichmann's disease. Definition. — Reichmann,' in 1882, described under the above name a disorder which is characterized by a constant secretion of gastric juice, even in the ab- sence of food in the stomach. Considerable quanti- ties of gastric juice can be withdrawn from the stom- ach in the morning, even in the fasting condition. General Remarks. — In describing this new disease Reichmann in 1887 mentioned that he had observed sixteen cases. An exact scientific diagnosis had been made, however, only in six of them. "In the re- maining cases," says Reichmann, "I was able to find in the stomach in the morning in the fasting condi- tion a large quantity of a liquid containing hydro- chloric acid and pepsin, and exhibiting digestive properties, but also containing much peptone and rem- nants of amylaceous food." Among the six cases which Reichmann considered as typical of gastrosuccorrhoea chronica, I think that only one (Case 3) deserves this name, for the remain- ing five, aside from the constant secretion of gastric juice, presented other important lesions of the stom- ach, which in all probability were rather the cause 'Reichmann-. Berl. klin. Wochenschr. , 1882. No. 40; 1884, No. 48, and 1887, No. 13. GASTROSUCCOREHCEA COXTIXUA CHRONICA. olo than the effect of the coostant gastric flow. In all the cases described by Eeichmann, except in Case 3, the stomach in the fasting condition contained a con- siderable quantity of liquid, consisting of gastric juice, and containing only amylaceous food remnants. When the stomach had been washed out on the pre- vious night, and the patient had abstained from food or drink, the stomach in the morning nevertheless contained clear gastric juice. These cases are then undoubtedly cases of dilatation of the stomach, or, more correctly speaking, of stenosis of the pylorus, in which hypersecretion must be considered as a con- comitant factor. Eeichmann, and following him, es- pecially the French writers Bouveret,^ Debove and Remond,' and among the Germans Eiegel," have laid too little stress upon the distinction between the con- stant flow of gastric juice and dilatation of the stom- ach due to stenosis of the pylorus. On this account the picture given by these authors of the true gastro- succorrhoea chronica bears a closer resemblance in many points to that of dilatation of the stomach than to the picture of the affection in question. Inasmuch as the treatment of cases of stenosis of the pylorus is in most essential points different from cases of gastro- succorrhoea (I need only mention that the most ra- tional treatment for the former is a surgical one), it is absolutely necessary strictly to differentiate between these two conditions. About two years ago Schreiber,^ of Konigsberg, ' Bouveret : "Traite des Maladies de rEstomac. " 2 Debove et Eemond : "Les Maladies de rEstomac." 2 Eiegel : Deutsche med. Worhenschrif t, 1893. Nos. 31 imd 32. ^Schreiber: Deutsche med. Wochenschr., 1893, Nos. 29 und 30. 314 DISEASES OF THE STOMACH. published an extensive paper in which he expressed doubt as to the existence of the new disease, regard- ing all the cases described by Eeichmann as cases of dilatation of the stomach with stagnation of food. Shortly afterward two other important papers ap- peared with reference to this question. Riegel defended Reichmann's views, while Martins' was in- clined to favor Schreiber's opinion. Whether Schrei- ber's view, that the stomach normally secretes gastric juice even while in its empty state, is correct or not, is a question that is quite difficult to decide, although I am personally of the opinion that when there is no food in the stomach there is no secretion. But leav- ing aside this question about the physiology of the stomach, there is no doubt that, as a rule, the stomach in the fasting condition does not contain any con- siderable quantity of gastric juice. Whenever larger quantities are found the stomach must be regarded as affected. Etiology. — Gastrosuccorrhoea chronica is met with much more frequently in men than in women. In some instances there is present besides this affec- tion some other functional neurotic disturbance. In three of my cases the latter was very marked. Thus one of these patients complained of a burning sensa- tion all over his limbs, which lasted for three months and then suddenly disappeared. Like hyperchlor- hydria, gastrosuccorrhoea seems to arise from great mental worry or strain. Symptomatology. — After a more or less prolonged period of different dyspeptic disturbances which are ' Marti us : Deutsche nied. Wochenschrift, 1894. • GASTROSUCCORRHCEA CONTINUA CHRONICA. 315 similar in character to those caused by hyperchlorhy- dria, there ajDpears a pronounced sensation of pain sev- eral hours after and shortly before meals. Very soon vomiting supervenes as a new symptom. At first it occurs only occasionally, but constantly grows more frequent until at last there may be one or several vomiting spells every day. The vomiting appears most frequently soon after breakfast, sometimes also after supper. In only a few cases does it occur in the night, about two or three o'clock, preceded by a long and severe attack of pain. The vomited matter is al- ways very acid and more or less liquid. The night vomit consists, as a rule, of a clear liquid containing hardly any food. The appetite is generally increased, although there are exceptions to this rule. In some cases periods of extreme hunger alternate with periods of pronounced anorexia. In most cases the sensation of thirst is greatly increased. In all of my cases constipation was marked. In some there was loss of weight, but none of my patients was emaciated in any great degree. Diagnosis. — Although the symptoms described might suggest the presence of gastrosuccorrhoea in cer- tain cases, the exact diagnosis can be made only by a repeated examination of the stomach in the fasting condition. By inserting the tube into the stomach, and telling the patient to exert some pressure with his abdominal muscles, more or less liquid (60 to 100 c.c.) is obtained from the stomach. This contains no food particles, but exhibits all the properties of the gastric juice. It may look greenish from the admixture of bile, but this is not an important sign. The filtrate, olG DISEASES OF THE STOMACH. as a rule, shows a somewhat increased degree of acidity. It never contains any starchy products (ab- sence of erythrodextrin, achroodextrin, and sugar). Microscopically no sarcinse or other signs of decom- position are found. Frequently cell nuclei are met with in large numbers. In examining the patient one hour after Ewald's test breakfast, the gastric contents will be found to contain more liquid than usually, and the degree of acidity will be quite high (80 to l!^(i). As a rule, the degree of acidity of the gastric contents is higher than that of the gastric juice when with- drawn from the stomach in the fasting condition. In examining the filtrate of the gastric contents with reference to the starchy products, it will be found that the Lugol solution will produce a deep violet or even blue color, showing that the starch has not been much changed. A thin disc of hard-boiled egg will be digested in the filtrate at blood temperature in about half an hour to an hour. The difference as to the de- grees of digestion of the albuminates and starches (the former being more quickly, the latter much more slowly digested) can be best studied after Leube- Riegel's test dinner. Three to four hours after such a dinner the obtained gastric contents show hardly any meat particles whatever (all being digested), whereas particles of starchy food form the principal part of the mixture. In this way the difference be- tween the digestion of meats and starchy foods exist- ing in this affection is seen at once. Differential Diagnosis. — In making the diagnosis of gastrosuccorrhcea, all organic lesions of the stomach (ulcer and stenosis of the pylorus) which are liable to GASTKOSUCCORRHCEA CONTIXUA CHRONICA. 317 be accompanied with gastrosuccorrhoea will have to be excluded. According to my experience, it is easy to exclude stenosis of the pylorus, but not an ulcer. In stenosis of the pylorus the stomach in the fasting condition is also found to contain a liquid, but this is mix^d with food and the filtrate always shows the presence of starch or sugar products. But the main thing is that food articles can be seen even with the naked eye, whereas the liquid found in the stomach in case of genuine gastrosuccorrhoea does not contain any food particles, as described above. The presence of an ulcer will be suspected if there has been a preceding hsematemesis or melsena or a circumscribed spot in the gastric region very painful to the slightest jDressure. The absence of these symptoms will tend to justify the diagnosis of gastrosuccorrhoea. In this respect I agree with Eeichmann as to the existence of a pathological continuous gastric succor- rhoea, although I restrict this name to cases not pre- senting any organic lesions of the stomach. When- ever the latter exist, I deem it best to look upon the accompanying gastric succorrhoea as a consequence of the main trouble, but not as the cause of the organic lesion. According to my experience, which coincides with that of Ewald, cases of genuine gastrosuccor- rhoea chronica are quite rare. They are less frequent than those of periodic gastrosuccorrhoea. During the last eight years I have met with eight cases of this affection, one of which I * published in 1887. The fol- lowing is the description of one of my recently ob- served typical cases of gastrosuccorrhoea : * Max Einhorn : New Yorker medicinische Presse, 1887. 318 DISEASES OF THE STOMACH. A. S , 21 years old, has suffered since early youth from digestive troubles. As far back as he can re- member, he has felt hungry very soon after meals (one hour). The bowels, although usually regular, were at times very constipated. Patient was always weakly, hut in the last three years he has been troubled to a much greater degree. He felt extremely weak, became dizzy after meals, and was overcome by a feeling of sleepiness. The bowels became consti- pated all the time. During the last six or seven months there was a sensation of extreme weakness in the hands and feet. The appetite was constantly in- creased, and a hungry feeling . appeared very fre- quently. For the past three months there had been a burning sensation in the gastric region, which in- creased in severity about an hour or two after meals. From that time on the patient began to vomit fre- quently. The vomiting, as a rule, occurred very soon after a meal, although occasionally it took place either in the middle of the night or in the morning before breakfast. Patient had lost lately in weight (about ten pounds). Present Condition. — Chest organs intact. On pal- pation, the gastric region is somewhat sensitive to pres- sure. There is, however, no circumscribed painful area. A splashing sound can be produced extending to about one finger's width above the navel. The tongue is thickly coated. The color of the lips and cheeks is quite good, and the patient does not look emaciated. The knee reflex is present, and the urine does not contain anything abnormal. The examina- tion of the stomach one hour after a test breakfast showed the quantity of chyme to be small (about 30 c.c); hydrochloric acid -\-, acidity = 100. The examination of the stomach in the fasting con- dition revealed the presence of a considerable quantity GASTROSUCCOREHCEA COXTIXUA CHRONICA. 319 of pure gastric juice; 120 c.c. of a somewhat turbid liquid, not containing any food reranants whatever, were withdrawn with the tube. This fluid contained free hydi'ochloric acid, had an acidity of SO, gave only weak biuret reaction, while erythrodextrin, dextrin, and sugar were wholly absent. During the first three months of treatment the condition of the stomach in reference to its secretion of juice did not change in any way. Repeated examinations, which had been made in the fasting condition of the patient, always gave the same result: presence of about 100 c.c. or more of pure gastric juice. The treatment consisted at first in regulation of the diet, and in the administration of large doses of alka- lies. Later on washing of the stomach and spraying of the organ with a 1 to 2:1,000 solution of nitrate of silver was instituted. The latter means proved more effective than the former treatment, and after about two weeks it was noticed that the stomach in the fast- ing condition contained considerably smaller quantities of juice. Frequently but 30 or 2f_' c.c. of juice were found. The spraying was continued for two months, after which time the stomach in the fasting condition was usually found empty. This objective improve- ment was connected with a subjective amelioration of all the symptoms: the vomiting ceased, the hunger was much less marked, the dizziness subsided, and the patient felt stronger and could do his work much better. The examination of the stomach one hour after the test breakfast, however, showed that the hyperchlorhydria still persisted. In this case we fre- quently tried to determine the motor (transportation) faculty of the stomach. One and a half hours after Ewald's test breakfast, as a rule, the stomach was found empty, showing that this faculty was rather increased. This is of interest, inasmuch as it shows 320 DISEASES OF THE STOMACH. that continuous hypersecretion need not be associated with sluggishness in the muscular action of the organ, a theory which is accepted by most investiga- tors who have written on the subject. The following is another typical case of continuous hypersecretion. S , 40 years old, has been suffering from diges- tive disturbances since 1893. The principal symptoms consist in pains appearing in the gastric region about three hours after meals and also early in the morn- ing before arising. The appetite was always good. Thirst is frequently greatly marked and with it a sen- sation of dryness in the mouth. The pains are almost always relieved either by food or by bicarbonate of soda. Steady brain work, strain in business, and worry greatly aggravate the condi- tion, while a stay in the country and rest materially diminish the symptoms. There were several inter- missions of the symptoms extending over a period of a few months' duration. But thus far they have always returned. Constipation exists in a high de- gree. On examination the stomach is found to extend to two fingers' width below the navel; the gastric region is not painful to pressure. One hour after test breakfast: Quantity of chyme (consisting of fine pieces of roll and a watery liquid) amounts to 500 c.c. HCl +, acidity = 108, free HCl = 02, erythrodextrin + much. In the fasting condition, the stomach contains 130 c.c. of a watery liquid not mixed with any particles of food. HCl +, acidity = 100, free HCl = 90, ery- throdextrin = 0. Several other examinations gave similar results, and for quite a while the stomach in the fasting con- GASTROSUCCOKKHCEA CONTINUA CHRONICA. 321 dition usually contained from 70 to 140 c.c. of clear gastric juice. The treatment consisted in the ap- plication of intragastric galvanization and spray- ing with nitrate of silver. The symptoms gradually subsided. Prognosis. — According to my experience, the prog- nosis of gastrosuccorrhoea is not bad. As a rule, most patients improve under rational treatment. Frequently, how^ever, there are relapses. Some very obstinate cases are occasionally met v^ith, and the trouble, although yielding somewhat to treatment, may persist for years. There is, however, no danger of a fatal issue resulting from this disease alone. Treatment.' — As we have seen, gastrosuccorrhoea is always associated with hyperchlorhydria. The treatment of the latter condition in reference to diet, drugs, and mode of living will have to be resorted to here also. With reference to diet, I have only to add that it is of great importance not to permit the patient to partake of any large quantities of liquid. In this affection more stress must be laid upon this point than in hyperchlorhydria. Medicaments. — The treatment of gastrosuccorrhoea must be directed toward decreasing the undue amount of gastric secretion. With this end in view, Voinovitch ' recommepds the use of atrojDine in doses of 2 mgm. (gr. ^) daily. Bouveret prefers morphine to atropine. Following the advice of Leubuscher and Schaeffer,' he administered as much as 2 to 3 cgm. (gr. -|-i) of sulphate of morphine three times ^ Voinovitch : La Semaine medicale, April 6th, 1892. 2 Leubuscher imd Schaeflfer : Deutsche med. Wocheuschr., 1892. 21 32-2 DISEASES OF THE STOMACH. daily by subcutaneous injection. This author doubts, however, whether this treatment, which seems to be effective in the initial state of the affection, will prove useful in cases that have progressed further. The use of either atropine or morphine may be tried for a short time, but they should never be administered for a long period. The subcutaneous injections of morphine especiall\' should be avoided, as the patient runs the risk of becoming an habitue of this drug. Large doses of subuitrate of bismuth (:2 gm. or half a drachm in a wineglassful of water three times daily half an hour before meals) seem to have occasionally very good effects. Wolff ' recommends Carlsbad salt or IJ Sod. sulph., Potass, sulph., Sod. clilorat. , Sod. carbon., Sod. bicarbon., M. f. pulv. Half a water three times dailv 30.0 5.0 30.0 25.0 10.0 teaspoonful in half a glassful of lukewarm the first portion to be taken in the fasting condition, the second two hours before the midday meal, and the third two hours before supper. Riegel * likewise speaks highly of this mode of treat- ment. Lavage. — Reichmann, and later Riegel, recommend the use of lavage of the stomach as the best means of improving its condition. While Riegel washes out the stomach in the evening six to seven hours after the heavy meal. Reichmann and most writers administer the lavage in the fasting condition. The latter way is also employed by myself: it has the advantage that, ' Wolff: Zeitschrift f. klin. Med.. Bd. xvi. - F. Riegel: "Die Erkrankungen des Magens, " "Wien, 1896, p. 268. GASTROSUCCORRHCEA CONTINUA CHRONICA. 323 by emptying the stomach in the fasting condition, we are better enabled to judge of the quantity of juice present, at a time when normally there should be none; and also that no food whatever is removed from the stomach. Instead of lavage Boas recommends emptying the stomach by means of a tube in the fasting condition (expression method). In order to combat more effectively the undue secre- tion, Eeichmann recommends adding nitrate of silver to the water used in washing out the stomach. After it has been washed out with plain water, 300 c.c. of a 1 or 2 : 1,000 solution of nitrate of silver is poured into the organ, and left there for about five minutes, when it is withdrawn by siphonage. Spraying the Stomach. — Instead of the latter pro- ceeding I have sprayed out the stomach after wash- ing with a 1 or 2 : 1,000 nitrate-of-silver solution. In two cases I found this method of treatment of great benefit. Direct Galvanization. — The first of my observed cases of gastrosuccorrhcea chronica was a very obsti- nate one, and the affection did not yield much to either the medicinal treatment or to the use of lavage. I empirically tried direct galvanization of the organ, and after a treatmeut of a few weeks the stomach be- gan to be empty in the morning, and has remained so for several years. Since then it has been my custom to make use of this method in this affection, and I must say that the result has been very gratifying. Very often I employ both spraying with nitrate of silver and direct galvanization, applying them alternately. OHAPTEK X. FUNCTIONAL DISEASES WITH VARIABLE LESIONS.— Co«^Mmed. Achylia Oastrica. Synonyms. — Atrophy of the stomach; anadenia ventriculi; phthisis ventriculi. Definition. — This term embraces a class of cases in which there is a permanent absence of gastric secre- tion. General Remarks. — In 1892 I' suggested the term "achylia gastrica" for those conditions in which the stomach apparently secretes no juice and in which clinically the diagnosis of "atrophy of the gastric mucosa" seems to be justifiable. In a paper referring to this subject I endeavored to show that cases of achylia gastrica and cases of pernicious anaemia ought to be kept strictly apart. Whereas the latter, as a rule, end fatally, the former do not necessarily en- danger the life of the patient. As a proof of this view I described a case of achylia gastrica which I had under observation for four years and whose condition had meanwhile somewhat improved, and another case in which the history given by the patient made it prob- able that the stomach had persisted in this state of juicelessness for forty years. In this case there were no subjective symptoms present and the patient used 'MaxEinhorn: Medical Eecord, June 11th, 1893. ACHYLIA GASTRICA. 325 to partake of the heaviest food with perfect impunity. Id all these cases the small intestine acts vicariously and completely replaces the lack of digestion of the stomach. In regard to the literature of " atrophy of the gastric mucosa" I refer to the excellent paper of S. Fenwick,' who first described this condition in cases of pernicious anaemia, and to the work of Lewy/ Ewald/ Henry and Osier/ Kinnicutt/ Nothnagel,' and George Meyer.' In all cases described by these writers (mostly per- nicious anaemia) the autopsy showed the disappearance of the gastric glands. Henry and Osier have given various characteristic drawings illustrating the micro- scopic picture of this condition. In most cases of atrophy of the stomach mentioned in literature the sickness in question is one in which all the functions of the stomach are disturbed and which gradually leads to death. There have been de- scribed, however, a few cases of atrophy of the stomach in which the clinical symptoms, or, more cor- rectly, the chemical analysis of the stomach contents led to the above diagnosis, which by no means seemed 'S. Fenwick : "Ati-ophy of the Stomach." The Lancet, July, 1877. 2 B. Lewy : Berliner klin. Wochenschr. , 1887, No. 4. 3C. A. Ewald: ibid., 1886, No. 32. * Henry and Osier : American Journal of the Medical Sciences, vol. 91, 1886, p. 498. ^F. P. Kinnicutt: American Journal of the Medical Sciences, vol. 94, 1887, p. 419. ^ Nothnagel : Deutsch. Arch, f . klin. Medicin, Bd. xxiv. , Heft 4 und 5. ''George Meyer: "Zur Kenntniss der sogenannten 'Magen- atrophie. '" Zeitschrift fiii- klinische Medicin, Bd. xvi., p. 366. 326 DISEASES OP THE STOMACH. to present such a severe irreparable disease. In these cases no autopsies could be made, and atrophy of the stomach, although it must here be conjectured, is not as yet proven to exist. Cases belonging to this latter grouj) have been described by Grundzach,' Ewald,' Wolff, ^ Jaworski,* Boas," Eosenheim," Litten,'' and myself.* For these cases the name achylia gastrica seems to be best adapted. The recent literature on cases of pure achylia gas- trica (not complicated with pernicious anaemia) is not very extensive. Simultaneously with my article on "Achylia Gastrica" Ewald " published a paper entitled: "A Case of Chronic Disability of Gastric Secretion (Anadenia Ventriculi?)." Ewald 's views are in per- fect accord with mine. The patient reported in the paper had been observed by Ewald for two and a half years. Although this patient improved considerably in every respect and gained forty-two pounds in weight, the chemical examination of the gastric con- tents showed a total lack of juice. In this country Allen A. Jones'" has described under ij. Grundzach: Berl. klin. Wochenschr. , 1887, No. 30. * C. A. Ewald : " Ueber das Fehlen der f reien Salzsaure im Magen- inhalt." Berl. klin. Wochenschr., 1887, No. 30. 3L. Wolff: ihid. ■*Javvorski : Wiener medicinische Wochenschr. , 1886, Nos. 49-52. * I. Boas : Miinchener nied. Wochenschr. , 1887, Nos. 41 und 42. ^Rosenheim: Berl. klin. Wochenschr., 1888, Nos. 51, 52. ' M. Litten und Rosengart : Zeitschr. f. klin. Medicin, 1888, p. 573. 8 Max Einhorn : " Ein Fall von continuirlichem Magensaftfluss und ein Fall von vollstandigera Fehlen der Salzsaure im Magen." New Yorker medicinische Presse, September, 1888. 'Ewald: Berliner klin. Wochenschr., 1892, Nos. 20 und 27. '"Allen A. Jones: New York Medical Journal, May 27th, 1893, p. 573. ACHYLIA GASTRICA. 327 the name of "Gastric Aoacidity" four cases belonging to this class of affections. Eecently D. D. Stewart ' has written a very valuable paper on the same subject. Morbid Anatomy. — There exist but few cases of achylia gastrica in which autopsies have been made. "^''SS^rM^M^ Fig. 47.— a Small Piece of Gastric Jlucusa (from Patient D. S., with Achylia Gas- trica) Found in Wash-water from Stomach. Only few glands visible; empty spaces where glands had previously existed; general small roimd-cell infiltra- tion. X 80. One case, observed by me, showed a complete atrophy of the gastric tubules (see p. 166, Fig. 38). As to the question whether in all cases of achylia gastrica there necessarily exists an anatomical lesion (atrophy of the glands) or not — i.e., whether cases of achylia might not perhaps occur in which the gastric ' D. D. Stewart : American Journal of the Medical Sciences, November, 1895. 328 DISEASES OF THE STOMACH. P?^^^W^ mucosa is not much altered, I must say from my own experience that the latter is frequently the case. This is the reason why a repair of this condition is occasion- ally observed.' Etiology. — According to the views generally enter- tained, achylia gastrica is a sequel to certain severe chronic catarrhal conditions of the stomach. The more recent text-books on gastric diseases (Ewald, Boas, Bouveret) discuss this affection under the head of " Gastritis Glan- dularis Chronica." I certainly believe that such an origin of achylia gastrica is sometimes traceable. The cases of chronic gastric catarrh in which the acidity is pretty low (10 to 20), ^^ and in which no free ^f; ''^■~o^..^T'^ ^^^""^ "' ^^"T^^ ^""T^ HCl exists, but both the (from Patient R. H , with Achylia Gas- ' trica): no glands visible; o, general small jjiin'et reactioU and reU- round-cell infiltration; b, empty spaces where glands had previously existed. X 80. net are prCSent, Speak in favor of this view. They represent, so to say, tlie prodromic stage of ach3'lia gastrica. Notwithstanding this it seems to me more than probable that the affec- tion in question may develop also in some other way (in consequence of nervous disturbances). In such instances the glandular layers of the stomach need not necessarily be greatly altered, although it appears prob- * Max Einhorn : " A Further Report on Achylia Gastrica. " Medi- cal Record, July 6th, 1895. ACHYLIA GASTRICA. 329 able that after a long persistence of inactivity of the glands these may begin to atrophy. Symptomatology . — With regard to their subjective complaints patients with achylia gastrica may be divided into three groups : 1. Patients without any subjective symptoms what- ever and enjoying perfect euphoria: 2. Patients presenting a variety of gastric symp- toms associated with mild intestinal disturbances; 3. Patients without any apparent gastric symptoms, but with severe and obstinate intestinal disturbances. Cases belonging to the first group are quite rare. I therefore do not deem it superfluous to describe here such a case without any gastric or intestinal symptoms, which possesses the further interest that it was com- plicated with rumination. Achylia Gastrica, Combined icith Rumination. — August R , 52 years of age, carpenter, was always well and had not consulted a physician for the last twenty years. Suffered in his boyhood from frequent headaches, cramps in the abdomen, and diarrhoea until his twentieth year. The patient attributes the griping pains in his abdomen at that time to the cir- cumstance of growing up under poor and miserable surroundings ; as a rule he had very little to eat ; from time to time, however, he worked in the country with the peasants, where he had plenty of good things to eat, and here he used to overload his stomach. As a boy the patient partook of hardly any meat from his fifth to his fourteenth year of age ; his main nourishment consisted of potatoes, flour-soup, bread, and water — soup only now and then : of meat he par- took only when occasionally visiting his relatives. He did not like buttermilk or coffee. 330 DISEASES OF THE STOMACH. As long as the patient can recollect he often brought up the food from the stomach into the mouth about half an hour after the meal, chewing it and swallow- ing it again. When eating cherries he w^as in the habit of swallowing the pits also, and afterward, when bringing them up from the stomach into the mouth, he used to spit them out. This bringing up of the food the patient did mainl}- when feeling well. He enjoyed chewing the second time as much as w^hen first masticating the food. Often the food would come up in morsels, although the patient had not been thinking of it at all. He hardly ever vomited, except when he got drunk — which happened twice during his life — and when cross- ing the ocean on a trip to Germany. He eats hastily, and the hard substances he chews w^ell afterwards when they come up from the stomach. The patient can ruminate any time be chooses, ex- cept when the stomach contains but very little or is almost empty. In ruminating he takes care to con- ceal the act from others ; he speaks to no one about it, and even bis wife is not aware of his habit. Present Condition. — Strongly built man of short stature, is well nourished, with good panniculus adi- posus ; chest organs intact ; stomach dilated ; the low^er margin extending to one finger's width above the navel. He has no complaints whatever, enjoys a good appe- tite, his bowels are regular, and he feels well in every respect. The only thing which strikes him as being abnormal, and for which he was treated for some time in Germany and afterward came to see me, is his coated tongue. October 27th. — One hour after the test breakfast: Patient spontaneousl}- brings up a small quantity of the contents of his stomach (about 20 c.c). With the tube likewise only a small quantity can be obtained ACHYLIA GASTEICA. 331 The roll particles are not minutely minced and almost unchanged. HCl = 0; acidity = 2; rennet = 0; pro- peptone = 0; peptone = 0; erythrodextrin = 0. Meltzer's swallowing sounds: Patient drinks water; at the first swallow a sound is heard immediately at the xyphoid process {Durchspritzgerdusch) ; at the sec- ond swallow (one to two minutes later) a sound is heard about eight seconds afterward {Diirclipress- gerdusch) ; at the third swallow the Durchspritzge- rmisch is heard immediately ; and ten seconds later the Dnrchpressgerdusch . I had the opportunity of examining the patient for three months, and always found the stomach contents in the above-described condition, with the same result of chemical analysis. The history of this case seems to indicate that the abnormal condition of the stomach developed in his early youth ; for only at that time the patient had complaints, whereas later on he had no disease what- ever. This would show clearly that achylia gastrica may exist forty years without endangering the vital functions of the organism. The second group, namely, of those presenting gas- tric symptoms, comprises the greater number of cases. The symptoms consist of loss of appetite, of a sensa- tion of fulness or pain in the epigastric and gastric regions, and of vomiting. Occasionally only one of these symptoms ma}^ be present, while in some cases the symptoms mentioned may appear alternately. Headaches are frequently met with, and constipation of a mild character is also more or less the rule. The following may be considered as a typical case of this group ; 332 DISEASES OF THE STOMACH. Mrs. G , aged about -45, has complained of her stomach for the last twelve years. She is almost al- ways troubled after meals with pains in the gastric and epigastric regions. Appetite poor. Bowels in- clined to be constipated. Vomiting appears very sel- dom. Patient had lost considerably in weight during the first years of her ailment; thereafter her weight remained stationary. In 1891 she visited Carlsbad, but her condition did not improve any. Present Condition. — Patient of small stature and quite thin. Panniculus adiposus somewhat thin. Lips and cheeks of a pale color. Tongue not coated. Chest organs normal. Palpation of the abdomen re- veals the absence of any tumor. The epigastric re- gion is sensitive on pressure, but not exactly painful. A splashing sound can be produced to about three fin- gers' width below the navel. The urine does not con- tain either sugar or albumin. October 27th, 1892. — Examination of the stomach one hour after Ewald's test breakfast: HCl = 0; lac- tic acid = ; acidity = 6 ; rennet = ; biuret reac- tion = 0; erythrodextrin = 0; sugar + . The quan- tity of the gastric contents is not large, and there is a very small amount of liquid. The bread particles are not minute. No mucus. October 30th. — When fasting, stomach empty. January 8th, 1893.' — Examination of the stomach one hour after Ewald's test breakfast: HCl = 0; lac- tic acid = ; acidity = 4 ; rennet = ; pepsin = ; biuret reaction = ; erythrodextrin = ; sugar + . During the year 1893 several other examinations of the gastric contents were made, with the same ana- lytical data as just mentioned. The third group, without gastric symptoms but ACHYLIA GASTRICA. 333 with intestinal disturbances, forms, according to my experience, at least one-fifth of all the cases of achylia gastrica. In this group there may be either no gastric disturbances whatever or very slight ones (as, for in- stance, occasionally slight pressure in the gastric re- gion — or belching). The appetite is either normal or somewhat increased. The principal symptom in most of these cases is obstinate diarrhoea, or diarrhoea al- ternating with periods of constipation. Some of these cases present symptoms similar to those met with in diabetes: constant thirst, frequent micturition, extreme weakness, great loss of flesh; in some, how- ever, these symptoms are less marked, or there may exist merely a feeling of weakness and lack of energy. The following case is a good representative of this group. Solomon S , 57^ years of age, always enjoyed good health until August, 1892, when he had a severe attack of dysentery ; he was confined to the bed for over three weeks and felt afterward extraordinarily weak. Since that time the patient has had attacks of severe diarrhoea (much mucus, sometimes blood in the passages) every two to three weeks. This diarrhoea used to alternate with constipation. From August to October, 1892, the patient lost forty pounds in weight. From that time on he felt weak and miserable and complained of thirst. This condition has since re- mained unchanged, and he complains at present prin- cipally of extreme weakness, of intense thirst, and of very weakening diarrhoeal attacks. Present Condition. — Color of lips and cheeks very pale, anaemic. Tongue furred with a whitish coat. Chest organs intact. The stomach extends to one fin- 334 DISEASES OP THE STOMACH. ger's width below the navel. A splashing sound can be easily produced in the gastric region. There is no- where any tumor. There are no sensitive spots dis- coverable in the abdoraen. The knee reflex is present. The in-ine contains neither sugar nor albumin. Patient was treated for some time, at first with in- jections into the bowel (tannic acid 2.0 to a quart of water once daily), thereafter with the administration of peptonate of iron. These means, however, failed to be of any benefit whatever; the tired feeling and weakness persisted, and the frequent attacks of diar- rhoea likewise remained unchanged. November 21st, ISO-i. — Examination of the stomach one hour after Ew^ald's test breakfast : HCl = ; acid- ity = 2 ; lactic acid = ; rennet = ; pepsin = ; bi- uret reaction = ; erythrodextrin = ; sugar + . Quantity of liquid very small ; the bread particles not minute; no admixture of mucus. November 23d, — When fasting, stomach empty. Achylia gastrica is diagnosticated, and the patient treated with intragastric faradization. The diet is ar- ranged in such a manner that it does not contain very much meat, and is instead rich in food taken from the vegetable kingdom. After two weeks of this treatment the sensation of weakness w-as no longer felt. Patient began to look better. His cheeks had a red color, the bowels were regular, and the troublesome sensation of thirst that formerly was so annoying disappeared. December 17th. — Examination of the stomach one hour after Ewald's test breakfast: HCl = 0, of neu- tral reaction ; biuret reaction = ; rennet = ; pepsin ~ ; erythrodextrin = ; sugar + . Small quantity of fluid ; the bread particles not minute; no mucus. Patient asserts that he feels well ; he can walk great distances without feeling tired. ACHYLIA GASTRIC A. 335 December 20th. — One and a half hours after the test breakfast : stomach empty. December 31st. — Patient takes one glassful of milk; one hour afterward he takes a glassful of water, and his stomach is directly faradized for ten minutes. Then the gastric contents are obtained by means of a tube; they consist of uncurdled milk diluted with wa- ter and are of neutral reaction. Patient was examined at various times in January and February, 1895, and there was always found a complete absence of gastric juice. The absoriDtion of the stomach was examined by means of the potassium iodide test, and the iodine could be detected in the sa- liva after a lapse of eleven minutes. Patient's health was and has remained thus far in very good state; his appetite is fair, bowels regular, and stools well formed ; no attacks of diarrhoea. April loth, 1895. — Patient has gained ten pounds in weight. January, 1S96. — Patient is in perfect health and has gained forty pounds in weight. While the subjective complaints are thus of quite a manifold nature and may often be entirely absent, particularly as regards the stomach, the objective symptoms are always alike and show the following peculiarities. One to one and a half hours after Ewald's test breakfast: 1. The pieces of roll are not minutely minced and unchanged. 2. The reaction is very weakly acid or neutral, usually the acidity is 4. 3. Hydrochloric acid is not present. 4. Lactic acid is either absent or present in traces and can be discov- ered only after a thorough shaking with ether. 5. Neither propeptone nor peptone is present. 6. The 336 DISEASES OF THE STOMACH. tests for the pepsin and rennet ' ferments give nega- tive results. 7. The stomach contents do not smell bad, and do not otherwise give the appearance of de- composition. S. Absence of mucus. L». The quanti- ty of liquid found in the stomach of these patients one hour after the test breakfast is remarkably small. Aside from the fluids soaked in and around the parti- cles of bread there is hardly any liquid at all. The gastric contents thereby acquire a peculiar, character- istic appearance, and look different from what they do in other affections of the stomach. The small amount of fluid in the gastric contents of patients with achylia may be explained in the follow- ing way : Besides the water (or tea) ingested into the stomach with the test meal, there is no addition of juice (or liquid) during the stay of food in this organ. As the more liquid chyme, as a rule, leaves the stom- ach quicker than the more solid substances, these latter alone will then, after a while (about one hour after Ewald's test breakfast), be found present. The motor function of the stomach is as a rule not impaired or slackened ; in some of the cases it is rather somewhat hastened (Solomon S ). The absorption faculty of the stomach is, according to my experience, not in any way retarded. Course. — This disease runs a very protracted course; cases in which the stomach resumes secretion after a cessation of several years are very rare. I have had only one case of this kind under observation. As a rule, the subjective symptoms can be greatly amelio- rated or entirely removed by prolonged rational treat- ' The rennet zymogen, however, may still be found present. ACHYLIA GASTRICA. 337 ment, while the objective symptoms of achylia remain unchanged. Diagnosis. — To arrive at a diagnosis of achylia gas- trica repeated examinations of the gastric contents are required for the detection of the above-mentioned characteristic points. The points of differential diagnosis between achylia gastrica and cancer of the stomach have been de- scribed under the latter affection (p. 283) and are therefore omitted. Prognosis. — The prognosis of cases of achylia gas- trica is good quoad vitam, a view which I have repre- sented in several papers and which is now generally accepted by most writers. The small intestine per- fectly replaces the digestive work of the stomach, and the organism is not only enabled to maintain its equi- librium but also to gain in weight. Treatment. — Therapeutic measures will be indicated only in cases presenting subjective symptoms. The treatment w^ill have to be carried out in the two following directions : 1. To stimulate the mechan- ical action of the stomach. 2. To arrange the diet in such a way that the food is easily accessible for the intestinal digestion. The first point is best achieved by stimulating the stomach, as by lavage and, principally, direct faradi- zation of the organ. In some of the cases I have not employed any medicaments whatever, and in others I have administered condurango or nux vomica. In reference to diet, it is of utmost importance to see that the food is broken into very minute particles or can be easily divided by chewing. For, on the one 338 DISEASES OF THE STOMACH. hand, all kinds of meat are in no way altered in the stomach and reach the intestine in the shape in which they entered the cardiac orifice ; on the other hand, the starchy substances contained in the vegetable food cannot become converted into maltose so long as the albuminous membrane occluding them has not been opened. In the stomach of these patients starch, as such, when accessible to the action of ptyalin, undergoes conversion into sugar very rapidly. Vegetable food is, as a rule, here very well borne. Strained pea and bean soups may be highly recom- mended on account of their richness in albumin. Kumyss or matzoon, or sometimes bonny-clabber well beaten with a spoon, or plain milk with the addition of bread or crackers with butter, are highly advan- tageous. Meats are to be allowed only in small quan- tities, best well hashed and broiled, or the white part of chicken. Brain, sweetbread, fish, and raw oysters are very suitable. Id the grave cases it is advanta- geous to administer meat powder ' (two to three table- spoonfuls or even more, pro die, in soup or milk). The usual beverages, as tea, coffee, cacao with milk and sugar, besides small quantities of beer or stout, may be allowed. Outline of Diet in Achylia Gastrica. Calories. 8 A.M. : oatmeal with cream, 150 gm., . . . 395 cacao with milk, 200 gm., . . . .135 ' Meat powder can be prepared in the following manner : Raw lean meat is cut into thin slices and dried on a glass plate on the stove for about two or three hours, then pounded in a mortar and ground twice in a coflFee-mill. ACHYLIA GASTKICA. 339 Calories. toasted bread, 60 gm., . . . . .135 butter, 20 gm., 163 12 M.: pea soup, 200 gm., 190 scraped meat (broiled) or fish, 100 gm., . 213 baked or mashed potatoes, 50 gm., . . 63 spinach or turnips, 50 gm., . . . .82 wheaten bread, 60 gm., .... 135 butter, 20 gm., 163 6 P.M. ; two eggs (soft-boiled or scrambled), . . 160 farina with milk, 200 gm., .... 432 wheaten bread, 60 gm., .... 135 butter, 20 gm., 163 tea, 200 gm, (milk, 30 gm. ; sugar, 10 gm.), 60 9 : 30 P.M. : kumyss, 200 gm. ; crackers, 30 gm. ; butter, 10 gm. ; or, instead, a sandwich with cream cheese or caviar, or sardines and beer, 323 2,9ir Here also, as in all other chronic disturbances of the digestive tract, it will be of importance to pay at- tention not only to the quality but also to the quan- tity of food taken. And the greatest stress must be laid upon the injunction that a sufficient quantity of food is taken. It is always preferable to have the pa- tient partake of too large a quantity, of food rather than too small a quantity, in consequence of which a condition of subnutrition is so often established. When the intestine has adapted itself to the greater amount of work and the nutrition is maintained on a well-regulated basis, achylia gastrica need not cause any trouble whatever, and the patient may enjoy per- fect euphoria. CHAPTER XL FUNCTIONAL DISEASES WITH VARIABLE LESIONS. — Continued. Ischochymia. Definition. — An affection characterized by the con- stant presence of food in the stomach, even in the fast- ing state. There is always a retardation or retention of chyme in the organ. General Remarks. — The term "clinical dilatation of the stomach," as is well known, is applied by the majority of authors to a condition in which there is stagnation of food in the stomach. Taken in its true sense, however, the word "dilatation of the stomach," or "ectasia ventriculi," refers merely to the dimen- sions of the organ. This explains the frequent mis- understandings caused by these expressions. Some speak of dilatation of the stomach as soon as the limits of this organ are found enlarged ; others, however, only in those instances where there are found rem- nants of food in the morning in the fasting condition. Rosen bach,' therefore, suggested the term "motor in- sufficiency of the stomach," to designate that condition in which the transportation of food from the stomach into the small intestine is at fault. In an article re- cently published. Boas* expresses the opinion that the ■Rosenbach: Volkmann's Sammlung klin. Vortrage, No. 153. 1878. 2 Boas: Deutsche med. Wochenscbr., 1894, No. 28, p. 576. ISCHOCHYMIA. oil terms "dilatation of the stomach" and "ectasia ven- triculi" should not be used at all, and suggests the term "gastric insufficiency of the first and second degrees" instead. The first degree corresponds to the atonic condition, the second to the stagnation of food. Al- though, like Boas, I am fully convinced of the impor- tance of differentiating between cases of stagnation of food and those in which the transportation of the chyme is only slightly retarded, I do not, however, be- lieve that we ought to discard the expression "dilata- tion of the stomach," or that the proposed term, " gastric insufficiency of the first and second degrees" is well selected. "Dilatation of the stomach" is a term applied to the condition of the volume of the stomach, and signifies an enlargement of its dimensions. Such conditions not only do exist, but are an every-day occurrence. There is, therefore, no reason for discarding the term "dilatation of the stomach." Whether this enlarge- ment of the dimensions of the stomach has been due to physiological or pathological processes, or whether it creates abnormal conditions or not, will have to be investigated in every individual case. The term "insufficiency" or "mechanical (motor) in- sufficiency of the stomach," signifying a retardation in the transportation of the food from the stomach into the intestine, appears to me ill chosen ; for the word "insufficiency," or "mechanical insufficiency of the stomach," does not clearly point out the condition caused by the transportation of chyme from the stom- ach into the intestines. Moreover, the term "me- chanical insufficiency of the stomach" means that the 342 DISEASES OF THE STOMACH. fault for the non-transiDortation of food lies in the stomach, which is not the case in most instances. Analogous to the expression ^'ischuria/* which sig- nifies an abnormal collection or stagnation of urine in the bladder, without giving the cause of this condi- tion, the word "'ischochymia'- ' might be applied in order to designate an undue stagnation of chyme in the stomach." Thus " ischochymia" will embody a complex of symptoms without stating the cause. The latter will have to be discovered and further deter- mined in each case. Symptomatology. — Ischochymia may last either a short period of time (a few days to one week) or it may become chronic or stationary. Acute ischochymia is occasionally found as a result of an acute inflammatory process of the gastric mu- cosa in consequence of gross errors in diet and the like. Ischochymia, then, although quite rarely, may develop alarming symptoms and may even lead to a fatal is- sue. Several such instances have been reported un- der the heading of acute dilatation of the stomach by Hunter," Frankel," and Boas,^ the case of the latter author ending in recovery. Whether acute ischo- chymia is due to a paralysis of the gastric muscles, or whether it is caused by a spasmodic contraction of the pylorus, is as yet undecided. Probably both condi- tions exist. In these instances it appears that nothing ' Ischochymia, from t(T;i:E(v=detain, and ;fi'(/(5f=chyme. -See Max Einhorn : "Diagnosis and Treatment of Stenosis of the Pylorus." Medical Record, .January 19th, 1895. ' ^Hunter: Medical Record, 1889. ■*A. Frankel : Deutsche med. Wochenschr., 1894, No. 7. ^.J. Boas: Deutsche med. Wochenschr., 1894, No. 8. ISCHOCHYMIA. 343 passes from the stomach into the duodenum; auy- thing which is taken in the way of food or drink col- lects in the stomach and distends it. The presence of gastric juice may still further increase the amount of liquid within the organ, and in this way aggravate the condition. The prolonged stagnation of chyme within the stomach gives rise to manifold processes of decomposition and fermentation. Vomiting usually Fig. 49.— a Specimen of Chyme Obtained from the Stomach in the Fasting Condi- tion (from a Patient with Isehochymia [H.]). showing (a) vegetable ceUs, C6) partly digested muscle fibres, (c) starch grains, (cZ) fat, (e) yeast cells, baciUi and cocci. occurs and brings temporary relief. The direct cause of an eventual fatal issue is quite difficult to state. It may be due to auto-intoxication or to some more direct injury to the vagus nerve. Transient isehochymia may appear in conditions in which the muscles of the stomach are weakened and fail to do their work properly, or in a begin- ning stenosis of the pylorus. In both instances the 344 DISEASES OF THE STOMACH. ischochymia is only slightly marked — that is, while there is a retention of some food in the stomach, the greater part is transferred into the small intestines. In the fasting condition the amount of chyme present in the stomach is not large. In a few days the stom- ach, as a rule, recuperates and by more energetic ac- tion succeeds in accomplishing its work properly, that is, transports all the chyme to the duodenum during the night. Constant ischochymia is always a serious trouble. Processes of fermentation are almost constantly present (Fig, 49). It is here that the occurrence of manifold gases has been described ; as, for instance, sulphu- retted hydrogen, hydrogen, marsh gas, oxygen, and carbon dioxide. In some of these patients the gas eructated burns with a flame if lighted (Ewald). Very often it is possible to hear, when auscultating the gastric region of these patients, a constant bub- bling or sizzling sound, arising from the rapid for- mation of the gas. If the gastric contents of such patients be obtained and put in a cylinder, one can perceive the bubbles of gas rising to the surface. The amount of gas may be determined, according to Kuhn,' by placing small quantities of the filtrate in a fermentation tube which is kept at blood temperature for several hours. Chronic ischochymia is almost always accompanied by the following train of symptoms: The appetite is frequently poor, although at times it may be abnor- tnally increased. The sensation of thirst is usually augmented and in some cases constantly present, and ' Kuhn ; Deutsche med. Wochenschr. , 1892, Nos. 49 und 50. ISCHOCHYMIA. 345 the patient is continually tormented with a feeling of extreme dryness in his throat. A feeling of oppres- sion almost always exists, which at times may alter- nate with more or less intense pains. The eructation of gas, which has a disagreeable odor, is often met with. Vomiting of large quantities of chyme, in which particles of food from previous days may be recognized, is one of the most important symptoms. The vomiting may occur once or twice a day, or once only in two or three days. There are very few cases in which the bowels work regularly ; as a rule, the most obstinate constipation is found. Emaciation is present in almost all instances, and it may occasion- ally reach such a degree that the patient literally looks like a skeleton. In the advanced stages of ischochymia, the quan- tity of urine voided in twenty-four hours is greatly reduced, and may sometimes be less than 600 c.c. Etiology. — Ischochymia is due to a diminished mus- cular work of the stomach, or to stenosis of the py- lorus, or to an open ulcer within or very near the py- lorus. In the latter instances a spasmodic contraction of the pylorus takes place. Course. — The course of ischochymia will materially differ, according to the etiological factors causing this condition. Ischochymia due to muscular weakness of the organ (atony) may occasionally disappear without medical aid and is in most instances amenable to ra- tional treatment. Ischochymia due to stenosis of the pylorus will run a different course, according to the nature of the stenosis. If the latter be of a benign type (hypertrophy of the jDylorus or stricture of the py- 346 DISEASES OF THE STOMACH. lorus due to cicatricial contraction) there are at first ameliorations which are due to an hypertrophy of the muscles of the stomach and to increased compensatory action ; frequently, however, the symptoms of stenosis return as soon as the pylorus has become still nar- rower, until at last sufficient compensation cannot he effected. In this stage the only means of saving the life of the patient is surgical intervention in the way of establishing a larger opening between the stomach and the small intestines, which may be done either by Heinecke-Mikulicz' pyloroplasty or by a gastro-enteros- tomy. In all these cases a radical cure can thus be accom- plished. The patients then gain considerably in weight, have no pain, no digestive troubles whatever, and can attend to their daily vocations in life. They all feel as if "new-born," if I may be permitted to use this expression. In two of these patients I convinced myself, by means of several experiments, of the prompt forwarding of the contents of the stomach into the intestines. The chemical condition was not mark- edly changed; the gastric volume in the two patients was not appreciably lessened six months after the ope- ration. In one of my newly observed cases,* however, there was a marked diminution in the size of the stomach two months after the gastro-enterostomy. If the stenosis is of a malignant type, then the course will correspond to the original disease. However, it is here also possible to relieve the symptoms of is- chochymia by an early gastro-enterostomy. ' Max Einhorn : " A Fuitlier Contribution to our Knowledge of Ischocliymia. " Medical Record, June 19th, 1897. ISCHOCHYMIA. 347 Before taking ujd the diagnosis, we may consider some symptoms which are characteristic of the just- mentioned etiological factors : IscJiochymia due to Atony. — In this condition the residue of chyme found in the stomach in the fasting state consists of some liquid and fine particles of food. Even if coarse particles of food (as, for instance, as- paragus, spinach, rice grains not too well cooked, chestnuts, and the like) have been ingested on the pre- vious day, the residue of these substances is not so very much pronounced, while in ischochymia due to stenosis of the pylorus it will be found that the entire quantity of such coarse particles of food, which under- go no changes in the stomach, will remain within the organ. In atony of the stomach the difSculty merely lies in a deficient peristalsis of the stomach, i.e., the contents are not sufficiently jDushed toward the py- lorus. But whatever reaches this outlet can pass without much inconvenience, whether it be very fine or whether coarser particles be present. This is quite different in stenosis of the pylorus, for here the main obstacle is the narrowness of the canal, which does not permit of the passage of coarser particles of food. The peristalsis of the stomach, even if the muscles work with increased activity, is here without much avail. As cases of ischochymia due to a weakened condi- tion of the muscular action of the stomach are quite rare, the following case, which I have observed very recently, will not be without interest: Patient H — — , aged 46 years, had been suffering for the last three years with an intense burning sensa- 3-t8 DISEASES OF THE STOMACH. tion, beginning at the pit of the stomach and extend- ing all the way up through the oesophagus to the pharynx. There was a feeling of pressure in the gas- tric region, which occasionally alternated with pains. Besides, the patient complained of belching of bad- smelling gases, which were very disagreeable, espe- cially to his wife and immediate family. His appetite was fair, and constipation existed only in a slight de- gree. His weight had steadily decreased during the last three years, so that he had lost over fifty pounds within that period. The examination of the patient revealed that the stomach was quite enlarged; a splashing sound extended to about two fingers' width below the navel, and a succussion sound could be eas- ily produced. The examination of the stomach in the fasting condition revealed the presence of a considera- ble quantity of chyme, which presented all the signs of marked decomposition (almost fetid odor, presence of sulphuretted hydrogen ; microscopically, each speci- men was full of micro-organisms, yeast cells, and sarcinse) ; free hydrochloric acid, however, was pres- ent in quite normal amounts. After a thorough cleansing of the organ, the patient was told to par- take of light (more liquid) food during the day, and for supper of some meat, a liberal amount of rice, not too well cooked, and some bread. On the following morning the patient was again examined in the fasting condition. While some chyme was present in the stomach, the amount of rice found was very small indeed, so that it was rather difficult to recognize its presence with certainty. The result of this observation, combined with the points derived from the history of the disease (the symptoms steadily keeping on and slowly gaining in severity, no decided free intermissions of long duration), seemed to point to an atonic state of the gastric muscles, rather than ISCHOCHYMIA. 349 to stenosis of the pylorus. The beneficial results of the treatment, which was based on this view (regu- lation of diet, four or five meals daily, interdiction of larger amounts of liquids, large doses of bismuth, with the addition of small doses of resorcin, and oc- casional lavage of the stomach), justified the conclu- sion that the diagnosis was correct. The patient after a few weeks felt much better, lost his burning sensation, while the stomach in the fasting condition was now found empty, and only after the ingestion of a very large supper the stomach on the following morning contained a small quantity of chyme, but not smelling badly. After three months the patient had gained twelve pounds iii weight, and is steadily improving. Benign Stenosis ^ of the Pylorus. — Only rarely can the pylorus be palpated as a small oval tumor (of small hen's egg size); in most instances the pylorus cannot be felt. All cases reveal a long period of sick- ness (extending from two to fifteen years), in which the appearance of pain plays the greatest part. Al- though at first, either with or without therapeutic aid, there appear ameliorations, these periods of eu- phoria, however, are again and again interrupted by fresh attacks of sickness. They constantly become more violent and of longer duration, and the pains subside only after an. artificially induced or spontaneous vomiting spell. Still later, when the ischochymia de- velops to a higher degree, not even vomiting brings entire relief, and the patients are subjected to the greatest pain and suffering. They emaciate quickly, and, if there is no radical intervention at this period, death from starvation inevitably eventuates. 350 DISEASES OF THE STOMACH. The following two cases present good instances of a benign stenosis of the pylorus : Case I. — Louis L , 40 years of age, lawyer, be- gan to be troubled with his stomach in the summer of fprmr-x^ FiQ. 50.— Cross-section of a Benign Hypertrophied Pylorus. (From the writer's own observation.) X 60. 1891. The patient was attacked with pains after meals during a period of ten days, when this symptom ISCHOCHYMIA. 351 disappeared suddeDly. There was no vomiting. For six months the patient felt well, not having any pains whatever; he noticed, however, that he became tired quicker than heretofore. In the winter of 1892 (Feb- ruary) he again had an attack of pain, lasting more than a month. During this attack he vomited twice. He felt well until July, when he had a fresh attack of pain extending over two to three weeks, with four vomiting spells. On account of the severe pains he could not lie quietly, but had to walk frequently to and fro in his room. In December, 1892, the patient had another attack, lasting until February, 1893. He then had to vomit frequently (nearly every other day). He had never vomited any blood. Since the begin- ning of the sickness his bowels were constipated. On January 2Tth, 1893, Dr. Charles Simmons called me in for a consultation and kindly entrusted me with the treatment of the patient. When I first saw the patient he presented the pic- ture of a very sick man in agonies of pain. He looked pale and emaciated; he asserted that he had lost about forty pounds in weight since the beginning of his ailment, and complained of a feeling of constric- tion in the abdomen and of shortness in breathing ; he further complained of vomiting large quantities of fluid, and of obstinate constipation. During the last fourteen days the patient had taken large doses of opium ; he was, however, very rarely entirely free from pain. The examination of the chest organs did not reveal anything abnormal. Tongue slightly coated; pulse, 90; temperature, 98° F. The whole abdomen was more or less bloated and quite tense. In the gastric region no splashing sound could be produced. No tu- mor could be felt. The fluid which the patient vom- ited a few hours before showed many blackish flakes 352 DISEASES OF THE STOMACH. floating in it, contained a great quantity of free HCl. gave no reaction for lactic acid, and had an acid- ity = 90. Patient was instructed to have a light meal (well- scraped meat, oysters, milk, crackers) every two hours. The quantity of liquids was reduced, and he was allowed to take only J 50 c.c. at a time. Besides, oil clysmata were administered. Under this treat- ment the patient felt somewhat better, although his ailment, on the whole, did not change. On January 29th he was instructed not to take any food after his eight o'clock evening meal until the next morning. On January 30th, at 8 A.M., when fasting, the tube was inserted into the stomach and two quarts of liquid withdrawn. The stomach was then washed with lukewarm water. Patient felt exceedingly well after this lavage. The withdrawn gastric liquid was analyzed ; in this sample there were the blackish flakes mentioned above. The examination showed : HCl + ; acidity = 88; lactic acid not present; peptone + ; propep- tone + ; rennet and pepsin + ; erythrodextrin -j-. Microscopically, no particles of meat can be found ; amylaceous grains, yeast cells, and bacteria are present in considerable quantity. Teichmann 's test for blood shows the absence of hsemin. Thus the withdrawn liquid consisted principally of gastric juice and of remnants of food taken the pre- vious day. February 1st, 1898, at 10 p.m., the stomach of the patient was thoroughly washed out. During the night he did not partake of anything, and on February 2d. at 8 A.M., the stomach was examined with the tube, and a small quantity of liquid withdrawn (150 c.c). The examination of this gastric liquid showed : ITCl -\- : both ferments present; acidity = 70. ISCHOCHYMIA. 353 The patient was treated with lavage for another week. He felt better and could walk outdoors. The pains, however, persisted, although they were less se- vere, and the stomach was never empty in the morning, but contained more or less liquid with food rem- nants. February 11th, 13th, and 15th. — Intragastric gal- vanization was applied without, however, materially improving the patient's condition. The diagnosis of benign stenosis of the pylorus was made and an oper- ation strongly recommended. Dr. F. Lange undertook the operation on February 22d. The pylorus was found greatly constricted. Heinecke-Mikulicz's pyloroplasty was performed, and after a month's confinement the patient left the clinic. Although he was now able to partake of a more va- ried and coarse diet without vomiting, he nevertheless constantly complained of pains and had to resort to opium. On March 30th the stomach was examined one hour after the test breakfast: HCl + ; no lactic acid; acidity = 120, no remnants of food from the previous day. It was supposed that this high degree of acidity might be the cause of the pains. The patient was therefore instructed to take half a teaspoonful of bi- carbonate of soda three times a day, two hours after meals. This worked like a charm ; the pains entirely disappeared and he began to gain rapidly in flesh After six months' medication with the soda the pa- tient discontinued its use and felt perfectly well with- out it. He now attends to his business and has gained seventy pounds since the operation. Case II. — Mrs. P. L , 43 years of age, mother of three children. Her mother died of cancer. Pa- tient has been suffering for six years. The ailment began with diarrhceal trouble lasting for two years. 23 354 DISEASES OF THE STOMACH. (Patient is unable to state whether the stools were of dark color.) Since four years cramps in the stomach. The pains are extremely severe; there is relief after belching or flatus. Never had any jaundice. For the last two years intense burning in the stomach with frequent vomiting. Never vomited any blood. During the night the jDains are extremely severe and disturb slee^D. Patient during last months lost con- siderably in weight (about thirty pounds). She was referred to me by Dr. Willy Meyer for examination and diagnosis. Present Condition. — Chest organs intact. Palpa- tion of the abdomen reveals a small cylindrical tumor, of the size of an Qgg, situated to the right of the na- vel. This tumor is easily movable in all directions and has a smooth surface. A splashing sound can be produced in the gastric region from one to two fingers' width below the navel. The gastric region is not painful to pressure. The liver is not enlarged. After lavage the patient is examined with the gas- trodiaphane; the stomach is found considerably en- larged and occupying a low position. On the following day the patient is examined with the tube one hour after a cup of tea without bread (the patient being in the fasting condition with the exception of the tea). The stomach contained about 300 c.c. of a slightly greenish liquid (presence of bile), in which were only a few remnants of food (several bread particles) from the previous day. The analysis showed : HCl + ; acidity = 42 ; free HCl = 24; lactic acid = 0. The patient was then treated for a week with lav- age and chloral hydrate at the New York Post-Grad- uate Hospital; there was, however, no material im- provement in her condition. On a subsequent examination one and one-half ISCHOCHYMIA. 355 hours after Ewald's test breakfast: HC1+ ; acidity — 50; no lactic acid. The obtained gastric contents amounted from 300 to 400 c.c. and contained food from previous days; for instance, rice, which had been taken on the previous night, and several grape-skins, which had been taken three days before. This time no bile could be detected. The diagnosis (of benign stenosis of the pylorus) was made and the patient operated on by Dr. Willy Meyer.' After opening the abdomen the tumor, which proved to be the thickened pylorus, was resected. The duodenum was then inserted into the stomach by means of Murphy's button. The patient passed an undisturbed convalescence, evacuated the button in her stools during the third week, and has since been well. She has gained twenty pounds and has had no pains whatever. The resected, highly thickened, and stiff pylorus could not be macroscopically distinguished from a cancerous organ ; the microscopical examination, how- ever, showed that it was merely an hypertrophied py lorus.'^ Malignant Stenosis of the Pylorus or Cancerous Stenosis. — Stenosis of the pylorus due to carcinoma is of frequent occurrence, and is developed sooner or la- ter in the course of most cancers of the stomach appertaining to this region. Cases in which the diag- nosis is made at an early period are most suitable for surgical interference. When possible, the tumor should be resected; otherwise gastro-enterostomy ^ Heinecke-Mikulicz's operation could not be done in this case. (1) on account of suspicion of cancer ; (2) because the lumen was too narrow and the thickening of the walls of the pylorus too con- siderable. 2 The wall of the pylorus, after specimen was preserved in alcohol for about nine months, measured in thickness li cm. 356 DISEASES OF THE STOMACH. should be performed. An operation appears to me to be always indicated when there exists ischochymia for some time, and either a tumor is felt or else the diag- nosis of cancer of the pylorus can be made by other deductions — unless the tumor has assumed too exten- sive dimensions or the patient be too weak to stand an operation. Assuredly one can in many cases give great benefit for a more or less prolonged period of time, and the sooner the greater. Of the considerable number of cases of cancerous stenosis of the pylorus which I have seen during the past five years, eight have been operated upon. In only one was resection of the pylorus practised ; in all others gastro-enteros- tomy was performed by well-known surgeons of this city. One patient died during the first week after the operation. The remaining seven lived from two months to a year. All cases of cancerous stenosis reveal a more or less short period of illness' (five months to one and a half years at the utmost) and show considerable ischo- chymia. In most instances, with but few exceptions, a gastric tumor can be palpated. In some of the cases the position of the tumor can be accurately de- termined with the gastrodiaphane. By means of transillumination, it can be ascertained whether the tumor occupies the greater or lesser curvature of the stomach. I append the drawings of two cases as viewed with the aid of the gastrodiaphane (Figs. 51 and 52). Both patients had been operated on by Dr. ' There are, however, exceptions to this rule. Thus a cancer which has developed on the basis of an ulcer may give a long period of disease. ISCHOCHYMIA. dOY F. Kammerer, at the German Hospital, and the diag- nosis as to position of the tumor was found to be correct. Most cases show the absence of free HCl and the presence of lactic acid, although in some instances free HCl is present in considerable quantities and lactic acid absent, as the following case demonstrates: Fig. 51.— Resiilt of Gastrodiaphany in Patient K X ,-sritti Tumor in the Gastric Region, a, The transilluminated zone; 6, the dotted spot slightly translucent on pressure; c, the black-colored spot remains dark even on pressure. March 9th, lS9i.— Oscar F , 32 years of age, silk manufacturer, always robust and healthy, has been suffering for the past six or seven months from digestive troubles which have been constantly increas- ing. They consist principally of pain, and for the last four months also of frequent spells of vomiting. Pa- tient has lost forty pounds in weight. Bowels not 358 DISEASES OF THE STOMACH. materially impaired. Poor appetite. Patient has never vomited any blood. Present Condition. — Patient looks thin and cachec- tic. Lips and cheeks are extremely pale. Chest or- gans intact. Palpation of the abdomen shows pain- fulness on pressure in the gastric region and an egg-sized tumor somewhat to the right and above the Fig. 52.— Result of Gastrodiaphany in Patient M. R , vith Tumor in the Gas- tric Region, a, The transilhiminated zone; 6, the dotted spot slightly translucent on pressure; c, the black-colored spot remains dark even on pressure. navel. This tumor is not especiall}'" painful on pres- sure, presents a smooth surface, and is easily mova- ble. A splashing sound can be produced in the gas- tric region extending to two fingers' width above the symphysis. March 9th, at 6 p.m. — Patient had taken a glass- ful of milk at 10 a.m. and had had nothing since; it ISCHOCHYMIA, 359 was therefore eight hours after his last meal. Ex- amination by means of the tube revealed the presence of two pints of chyme. The latter showed a brownish color, contained small particles of casein, and various other food -stuffs. HCl + ; no lactic acid; acidity = 118; free HCl = 94. Patient is instructed to take with his supper rice, milk, and crackers. March 10th. — When fasting, two pints of chyme are withdrawn from the stomach. The chyme presents a brownish color and contains food from previous days- — rice, particles of bread, and casein. Microscop- ically: yeast cells, granules of starch, sarcinse, bacte- ria, brown pigment. Chemically : HCl + ; no lactic acid ; acidit}^ = 112 ; peptone + ; propeptone + ; ren- net + ; erythrodextrin + little ; achroodextrin + much. March 12th. — The stomach is examined in the fast- ing condition and the same results are obtained as on the 10th. The high degree of ischochymia and the presence of a tumor in the pyloric region pointed with certainty to a stenosis of the pylorus. It was questionable, how- ever, whether the process was a benign or a malig- nant one. Whereas the chemical condition of the gastric contents pointed toward a benign stenosis, the large size of the tumor and the relatively short period of sickness (six to seven months) answered more to the history of a malignant growth. After a consultation with Dr. F. Lange, we both were of the opinion that we had to deal here with a cancerous stenosis of the pylorus. The high degree of ischochymia appeared to necessitate surgical inter- ference, which should consist in either resection of the pylorus or in gastro-enterostomy. Patient was operated on by Dr. Lange, on March 16th, 1894; the tumor was found (macroscopically) to 360 DISEASES OF THE STOMACH. be a cancer, and conld not be resected on account of the numerous adhesions, principal!}' with the colon. Gastro-enterostomy was established, and in about a month's time patient was able to leave the clinic and partake of a great variety of food. Soon, however, regurgitation of bile into the stomach appeared, and a short while afterward ''peristaltic restlessness'' of this organ also developed. Both conditions made the patient feel very uneasy. April 19th. — Patient was examined one hour after Ewald's test breakfast. There was a considerable amount of bile in the gastric contents, which did not contain any food from the previous day. Chemically: HCl = 0; no lactic acid ; acidity = 22. Diagnosis. — In cases of ischochymia due to stenosis of the pylorus, benign as well as malignant, symp- toms of vomiting ' and pain are almost always pres- ent, in connection witb a more or less considerable loss of weight. This condition, however, is best rec- ognized by the examination of the stomach by means of the tube when fasting. I usually instruct the pa- tient to have at his supper, on the night preceding the examination, besides soup, meat, and bread, some rice, as this latter is very easily recognized and as a rule is retained in the stomach when the pylorus is ' Vomiting may sometimes be absent, notwithstanding that ischo- chymia has already developed. I at present have under observation a patient with carcinoma pjlori (with clearly palpable tnmor), who has been ailing for the last six months. Tlie patient has never vomited nor has he had mucli pain. His complaints merely refer to loss of appetite and obstinate constipation. The examination of the stomacli iu the fasting condition always reveals the presence of chyme (coarse food-stuffs are principally found). Although the patient, living on a more regulated diet, has gained six pounds within the last month, nevertheless the ischochymia remained un- changed. ISCHOCHYMIA. 361 stenosed. For this examination the expression meth- od alone is not always sufficient. Whenever no chyme is withdrawn by this method, it is necessary to wash out the stomach. In these cases food is then continually found in the stomach. Dilatation of the stomach is almost always present ; the organ occasion- ally extends from the margin of the ribs far down to the symphysis. Differential Diagnostic Points. Duration of ill- ness. Course of the dis- ease. Tumor Benign stenosis of pylorus. Long duration of illness (two to fifteen years) . Long intervals without pain, or periods of per- fect euphoria. As a rule absent Malignant stenosis of pjlorus. Short duration of illness (five months to one and one-half years). No periods of perfect eu- phoria, but constant and gradual aggrava- tion of the symptoms. Present in most cases. Condition of Gastric Contents. Benign stenosis of pylorus. FreeHCl Lactic acid Acidity Rennet Present in the great ma- jority of cases. Absent in the great ma- jority of cases. Always increased Always present Odor Unpleasant, disagreeable Malignant stenosis of pylorus. Nearly always absent. As a rule, present. Fluctuates between 30 and 90. Varies. Very frequently fetid. In the following I shall describe several symptoms which, w^hen present, are very valuable, but whose absence does not militate against the existence of py- loric stenosis. These symptoms are : 1, The dilated or abnormally large stomach. 2. The thickened and readily palpable pylorus. 362 DISEASES OF THE STOMACH, 3. The peristaltic restlessness of the stomach, •i. The fermentation products. 1. The abnormal size of the stomach is pathogno- monic only if the organ occupies nearly the entire lower section of the abdomen, and contains over three or four litres of fluid. Such stomachs are frequently met with in old cases of stenosis of the pylorus, and their presence at once awakens the suspicion of a nar- rowing of the pylorus; before this diagnosis can be made, however, the presence of ischochymia must be determined. In this country considerable weight has been placed upon this symptom; yet the absence of this diagnostic sign should not lead us astray, for it is our aim to make the diagnosis of pyloric stenosis as early as possible, while the pronounced, at once per- ceiDtible dilatation of the stomach develops only in the course of time. 2. If it is possible by means of palpation to map out the pylorus as a smooth, oval tumor, and if ischochy- mia is present and the disease has lasted over one and a half or two years, we can with certainty make a diagnosis of benign pyloric stenosis. 3. Peristaltic restlessness of the stomach is fre- quently found in cases of benign as well as of malig- nant stenosis of the pylorus. Inasmuch as the peri- staltic restlessness of the stomach but very rarely occurs as a pure neurosis, this symptom is of great significance for the recognition of stricture of the pylorus, the more so as an examination for this pur- pose (simple inspection of the abdomen in the recum- bent position) is not attended with any difficulty. The presence of this symptom in connection with ISCHOCHYMIA. 363 the existence of ischochymia speaks in favor of nar- rowing of the pylorus, and against simple relaxation of the gastric muscular coat; the absence of this symptom is of no consequence. tt. Fermentation products (formation of lactic acid or gases in the stomach) are observed almost con- stantly in all cases of ischochymia. Commonly, one or the other kind of fermentation is present, that is, either formation of lactic acid or formation of gases. The lactic acid is found in the stomach in cases in which the secretion of hydrochloric acid is consider- ably diminished, while the development of gas is en- countered in cases in which there is an abundant secretion of gastric juice. These points, which have been especially emphasized by H. Strauss,^ I can com- pletely confirm on the ground of my own experience. These fermentation products may be absent, how- ever, notwithstanding the presence of pyloric stenosis, if the stomach has been treated in a rational manner, that is, has been washed out several times. The constant or frequent occurrence of small quan- tities of bile in the stomach does not in my experience militate against the existence of a narrowing of the pylorus; on the other hand, it appears to ine to point to a firm rigidity of this orifice, in consequence of which the latter is never completely closed." Among the more recent auxiliary measures which are available in arriving at a diagnosis, the gastro- scope has been recently employed by Eosenheim and Kelling. In my opinion there is no doubt that this 1 H. Strauss : Zeitchr. f. klin. Medicin, 1895. 2 Max Einhorn : "A Further Contribution to Our Knowledge of Ischochymia, " I. c. 364 DISEASES OP THE STOMACH. instrument has a great future, although at present it has not been generally utilized. A protracted atony of the stomach may at times produce ischochymia; it is then, however, not con- stantly found and disappears soon after the regula- tion of diet and rational treatment. The same may be said of grave forms of chronic gastric catarrh. Here also ischochymia is liable to develop under fa- vorable conditions. The symptom, however, disap- pears after a few washings of the stomach. In this way I believe that these two conditions (atony of the stomach and chronic gastric catarrh) can be distin- guished without difficulty from stenosis of the pylorus, and can give no cause whatever for mistakes. Treatment. — In the treatment of ischochymia it is necessary, first of all, to ascertain the cause of the stagnation of food in the stomach. If this be due to a far-advanced stenosis of the py- lorus, or to a commencing occlusion of this opening malignant in its nature, surgical interference (pyloro- plastic operation, pylorectomy, or gastro-enterostomy) is indicated. If we have to deal, however, with com- mencing benign stenosis of the pylorus, or a genuine relaxation of the muscular coat of the stomach, pal- liative treatment should first be given a trial, and in the event of its failure an operation is demanded. The palliative treatment in the milder cases consists in the employment of a fluid or semifluid diet (milk soups, with finely ground farina, meat broths with eg,g, egg and milk) lavage of the stomach in fasting condition, followed by spraying with a one-per-mille solution of nitrate of silver, and in the administration ISCHOCHYMIA. 365 of medicaments which prevent fermentation. Among these may be used benzonaphthol, salol, bismuth, and resorcin. I frequently give: I^ Eesorcin 4. Bismuth, subnit 20. Aq. dest 200.0 S. One tablespoonful in a wineglassful of water three times daily, half an liour before meals. In severe cases (frequent vomiting, violent pains, intense burning sensations) it is advisable to keep the patients in bed for about three weeks, and to nourish them for five days exclusively per rectum (besides the nourishing enema rectal injections of water, as recommended by Unverricht, are of great benefit when thirst is present and the amount of urine decreased) and then slowly and gradually adopt a miik diet, as in ulcer of the stomach — in this condition, however, much more cautiously and slowly. Thus, for example, on the sixth day I give only two tablespoonfuls of milk every hour, on- the seventh day three tablespoonfuls, on the eighth day four table- spoonfuls, etc., until I have reached 100 c.c. every hour; then I give 200 c.c. every two hours, and in- crease to 300 c.c. On every other morning I de- termine by washing out the stomach in the fasting condition whether it. is empty. In this manner it is frequently possible to adapt the stomach, first to a light, and later to a heavier diet. The patients then increase gradually in weight and appear completely well. Yet they cannot be regarded as entirely healthy, because we must be constantly prepared for a recurrence of the old affection. 366 DISEASES OF THE STOMACH. Moreover, in cases in which it is not possible to remove the ischochymia by palliative measures, the patient may sometimes maintain a comfortable ex- istence under use of regular washings out of the stomach and the maintenance of a light and rather fluid diet. Such patients, however, are menaced by many dangers and can enjoy but few of the luxuries of life, and for this reason the clinician should insist that an operation is to be regarded as the only correct procedure. In benign stenosis of the pylorus the application of massage (ten minutes twice daily) to the gastric region can be warmly recommended. Likewise the admin- istration of alkalies in existing hyperacidity, and the application of the galvanic current when there are severe pains may be profitably tried. Cancerous stenosis of the pylorus hardly admits of any treatment. Condurango given when there is anorexia, and chloral hydrate (a tablespoonful of a three-per-cent .solution every two to three hours) when pains exist, as has been recommended by Ewald, are the most reliable and efficient medicaments. In ischochymia due to atony of the gastric muscles the treatment should consist of lavage, direct faradi- zation of the stomach, and the administration of frequent but light meals. Complications. Tetany. — The occurrence of tonic and clonic spasms in the flexors of the arms, in the muscles of the calf, and in the muscles of the abdomen as a complication of "dilatation of the stomach" (ischochymia) was ISCHOCHYMIA. 367 first pointed out by E, Neumann ' and shortly after- ward by Kussmaul/ Frequently the muscles of the face, of the jaws, and of the neck are likewise affected by the spasmodic contractions. The eyes are turned upward and occasionally emprosthotonus of short dura- tion occurs. The crampy contractions are painful; consciousness is either undisturbed, partly disturbed, or entirely absent. In one of Kussmaul's cases, which was published by Gassner, ^ the attacks had a dis- tinctly epileptiform character. Several cases of this complication, which have been described mostly un- der the name of tetany, have been published by Leven,* Dujardin Beaumetz," Hanot, Miiller,'' Ger- hardt,' Eenvers," Bouveret and Devic,'Ewald," Albu," Boas," and Fleiner.'' Real tetany is characterized by the sudden appearance of mostly bilateral tonic con- tractions of the muscles, beginning at the fingers and toes and progressing thence centripetally. The flexor muscles are principally affected, and the hand usually assumes a position which has been charac- terized by Trousseau as the obstetrical hand. Only ' E. Neumann : Deutsche Klinik, 1861. 2 Kussmaul: Deutsch. Arch. f. klin. Med., 1869, Bd. vi. " Gassner : Inaug. Dissert. , Strassburg, 1878. "* Leven: Gaz. med. de Paris, 1881, p. 646. ^Dujardin Beaumetz : L'Union medic. , 1884, Nos. 15 and 18. "Mtiller : Charite Annalen, Bd. 13, 1886. 'Gerhardt: Berl. klin. Wochenschr., 1886, No. 36, and 1888, No. 4. ^ Renvers : Gesellschaf t der Charite Aerzte, 1887. " Bouveret et Devic : Rev. de medecine, 1892, p. 48. '" Ewald : Berl. klin. Wochenschr. , 1894, No. 2. '^Albu: Berl. klin. Wochenschr., 1894, No. 2. I'Boas: loc. cit., 107. ^^Fleiner: Arch. f. Verdauungskrank. , Bd. i., Heft 3. 368 DISEASES OF THE STOMACH. in rare instances are the extensor muscles also af- fected. As a rule, the knees are bent and the toes turned downward, while the heel is turned upward and somewhat outward (pes equiuus). The muscles of the femur and the thigh are only very rarely in- volved. The duration of the attacks may vary from five minutes to several hours. The following symp- toms, which exist for some time after the attacks, are characteristic of tetany : 1. Compression of the main nerves or blood-vessels of the affected extremities for one to two minutes will produce an attack (Trousseau) ; 2. The electrical irritability of the nerves and muscles is greatly in- creased (Erb) ; 3. The mechanical irritability of many nerves of the extremities, and especially of the facialis, is increased. Tapping with a finger in the region of the facial nerve produces quick contractions of the corresponding muscles. Kneading of the face from top to bottom evokes contractions of the sub- jacent muscles (Chvostek). The prognosis of tetany is quite bad. In the cases collected by Bouveret and Devic there was a mortality of seventy per cent. It seems that this complication is of quite rare oc- currence, for all the cases mentioned in literature scarcely exceed thirty. Tetany -like convulsions and epileptiform attacks with loss of consciousness are met with far more frequently. According to my experi- ence, the latter complications occur not only in cases of chronic ischochymia, but also in other affections of the stomach. ISCHOCHYMIA. 369 . Thus I have observed one case in a man, 28 years old, who suffered for a great many years from a chronic gastric catarrh. In August, 1895, during a hot spell, he was obliged to drink large quantities of ice-water. At that time he began to suffer from attacks of tetany, alternating with epileptiform con- vulsions and loss of consciousness. During an attack of tetany the patient would notice that his arms and legs became contracted against his will and would remain in this condition for about ten minutes, he being perfectly conscious, but unable to change the assumed position of the affected extremities. The epileptiform attacks would begin with a pre- monitory stage of pain in the gastric region and a restless condition which would last only a short while. Thereupon the patient would lose his consciousness entirely and convulsions of all the muscles in the body would ensue. He would remain in this state from twenty to forty minutes, would frequently bite his tongue, and after awakening usually had no idea of what had happened. The patient had such attacks of either tetany or epileptiform convulsions once or twice a week, and felt utterly prostrated for a day or two after their occurrence. He also complained of a very disagreeable taste in the mouth between the attacks. On examining the stomach in the fasting condition, I found that it was perfectly empty. One hour after a test breakfast free hydrochloric acid was present, but the degree of acidity was somewhat diminished. Under lavage and a general tonic treatment, the patient's condition improved and the attacks became milder in form and appeared at much longer inter- vals ; thus for a period of six weeks the patient had no attacks whatever. The attacks sometimes occurred without any apparent cause, sometimes, however, they could be referred to some gross dietetic error; 24 370 DISEASES OF THE STOMACH. thus, for instance, the patient once took a very large piece of salted herring with bread and cheese at twelve o'clock at night before retiring. He awoke at two and called his brother, who slept in the adjoining room, telling him of his restless condition and of the painful sensation within his stomach, and a few min- utes later was seized with a severe convulsive attack, which lasted for half an hour, and during which he again severely bit his tongue. I have observed a similar case of epileptiform at- tacks in which there was likewise no ischochymia, but hyperchlorhydria and erosions of the stomach. In this case, however, the attacks, as a rule, appeared after an accidental overloading of the stomach, alco- holic drinks apparently playing a great part therein. In a third case I likewise noticed epileptiform attacks in a lady of forty years of age, who suffered from chronic ischochymia, due to a benignant stenosis of the pylorus. The prognosis of these epileptiform attacks seems to be far more favorable than that of real tetany, for in none of the three cases mentioned have the at- tacks thus far resulted in a fatal issue. With regard to the etiology of either tetany or the epileptiform attacks accompanying severe gastric dis- orders, three theories have been expounded: 1. One theory has been given by Kussmaul, explaining the symptoms of tetany and similar conditions by the great loss of fluids to which the system has been sub- jected, for this condition is most frequently found in patients who have vomited for a long time and in this way lost a great deal of liquid, in consequence of ISCHOCHYMIA. 371 which the blood has been much thickened, while the nerves and all other tissues have become thoroughly dry. The thirst which is met with in these patients and the greatly diminished urinary excretion speak in favor of this view. This theory has lately gained a warm supporter in Fleiner, who pointed out that in most of these conditions of stenosis of the pylorus, be- sides the slight quantity of liquid which is able to pass from the stomach into the small intestines, there is often a state of hypersecretion, owing to which abundant quantities of gastric juice are poured into its cavity. The latter circumstance increases the great deficiency of water in the system. 2. The second theory, advanced by Germain See,' explains these tonic and clonic convulsions as a reflex action from the nerves of the stomach. Friedrich Miiller is also in favor of this view, for the two follow- ing reasons : First, tetany is occasionally met with in cases in which there is no considerable loss of fluid, as for instance in cases of intestinal worms. Secondly, Miiller was able to produce such an attack of tetany in one of his patients by striking his epigastrium. 3. The third theory explains tetany and similar conditions on the basis of auto-intoxication. In cases of ischochyrnia, many processes of fermentation and decomposition exist, and these give rise to the produc- tion of toxic elements, .which are liable to give rise to the above-described symptoms. Gerhardt, Baginski,^ Paliard,' Loeb,* Bouveret and Devic, Ewald, Heim,' * Germain See : Bull, de I'Acad. de med., ^Bagiuski: Arch. f. Kinderlieilk., Bd. vii., 1886. spaliard: Rev. de medic, 1888, p. 406. ^Loeb: Dentsch. Arch. f. klin. Med., Bd. 46, p. 98. *Heim: Inaug. Diss., Bonn, 1893. 372 DISEASES OF THE STOMACH. Albu, Scblesinger/ and Kulneff ' are all firm believers in tbis auto-intoxication tbeory. Bouveret and Devic, and likewise Kulneff, have been able to obtain from the gastric contents of patients with chronic ischochy- mia by Brieger's method (extraction with alcohol and precipitating with chloride of mercury) toxic products of the diamine group. Ewald and Jacobson, and later Albu, have obtained from the urine of a patient af- fected with tetany an alkaloidal substance (the picrin salt). This substance usually appeared in the urine during the attacks of tetany only and not during the intervals. Bouveret and Devic are of the opinion that the toxic products develop much quicker in cases of hyperchlorhydria if alcoholics have been indulged in. Although the auto-intoxication theory seems to be the most plausible, its verification remains to be demonstrated. ' Schlesinger : Berl. klin. Wochenschr. , 1894, No. 9. 2 Kulneff : Berl. klin. Wochenschr., 1891, No. 44 CHAPTER XII. ABNORMAL CONDITIONS WITH REFEEENCE TO THE SIZE, SHAPE, AND POSITION OF THE STOMACH. Abnormalities in The Size of the Stomach. In the normal state, the size or capacity of the stomach varies within wide limits, and this is more marked in pathological conditions. The following figures of capacity were obtained by Ziemssen ' as the result of a large number of post-mortem examinations of the stomachs of persons of about the same size who during life had never manifested signs of digestive troubles. The largest stomach of these held 1,680 c.c. (or fifty-six ounces) , the smallest 250 c. c. (eight ounces) ; the other figures ranged between these limits. While some years ago any stomach of very large size was considered as diseased, Ewald first pointed out that the organ, no matter how great its capacity, may still be able to work perfectly and satisfactorily. He therefore suggested that an acquired or congenital large stomach with normal functions should be designated as "me- gastria.''^ A very large stomach causing manifest digestive disturbances is generally spoken of as a dilated stomach (dilatation of the stomach, gastrec- tasia). The most extensive degrees of gastric dilata- tion are found in cases of obstruction of the pylorus. ' Ziemssen, cited from C. A. Ewald : "Diseases of the Stomach," p. 110. 374 DISEASES OF THE STOMACH. Angustatio ventriculi denotes an extremely small stomach. In very marked degrees of this condition the stomach may have a capacity of hardly an egg in size, and may appear even narrower than the duode- num (Haller). Angustatio ventriculi is generally found in most cases of oesophageal or cardiac strictures (principally cancerous) ; occasionally, however, it oc- curs alone in cirrhosis ventriculi. Abnormalities in the Shape of the Stomach. The shape of the stomach is occasionally found al- tered, caused by cicatricial changes after extensive ulcers. The hour-glass form is one which gives rise to grave disturbances and can frequently be recognized during life. Inflation with carbonic-acid gas shows the hour-glass shape of the organ ; lavage six to seven hours after a meal will occasionally fail to remove all the contents. After the wash-water has come out clear for a time there may occur a sudden admixture of chyme. Abnormalities in the Position of the Stomach. The abnormal positions of the stomach may be either congenital or acquired. Among the congenital abnormalities we would mention the transposition of the stomach in the thoracic cavity, which occurs if there is a partial or a complete defect at the diaphragm. The stomach is found to be situated on the right side of the abdomen (pyloric portion to the left) in cases of general transposition of the viscera. Both these 'Haller: "Elem. Physiol.," Lib. xix., Sect. 1, §3. ENTEROPTOSIS, OR GLENARD'S DISEASE. 375 anomalies are extremely rare. Among acquired anomalies a vertical position of the stomach is occa- sionally found. The pylorus is then situated much lower and farther to the left than normally. This condition is mostly found in women and can be easily recognized either by the gastrodiaphane or by inflation of the stomach, which reveals a lengthy but narrow configuration, its horizontal diameter not extending to the right of the linea alba. Descensus veyitriculi or gastroptosis (low position of the stomach) is the most frequent anomaly; it usually occurs in connection with a ptosis of several other in- testinal organs, and will therefore be best described under enteroptosis, or Glenard's disease. Enteroptosis, or Glenard^s Disease. Definition. — Downward displacement of the stom- ach, right kidney, and other organs of the abdom- inal cavity, attended with digestive disturbances. General Remarks. — Descent of the stomach as well as of other abdominal organs was described many years ago by Virchow, Leube, Landau, and other au- thors; yet to Glenard ' must be awarded the credit of having first sufficiently emphasized the importance of this condition, of having recognized its clinical signifi- cance, and established it as a distinct affection. The idea which led the French physician to the dis- covery of the disease designated by his name was the fact that the whole digestive tract, which from the mouth to the anus is ten or fifteen times longer than a straight line connecting both points, is arranged in I F. Glenard : Lyon Med. , 1885, p. 450. 370 DISEASES OF THE STOMACH. the form of different baldachiDs suspended on six loops ' by means of ligaments at the posterior wall of the abdomen. The zigzag direction of the loops offers the possibility of too great a bend, sometimes at such an acute angle that it causes obstruction to the passage of the ingesta or secretions at the six main points of fixation. This might occur at the gastro-duodenal, duodeno-jejunal, or transverse/ sigmoid o-rectal curvatures. The ligaments are not all of equal strength and the points of fixation of several of them are especially weak. This is true of the gastro-duodenal and the transverse colon ligaments. Thus, from a theoretical point of view, it is apparent that the possibility exists that the weak ligaments may give way under favor- able conditions, and that a falling of that part of the intestine may result. This would naturally exert in- creased traction on the next fixation point, and might cause an obstruction to the passage of the contents of the intestine, or, in other words, a partial entero- stenosis. In forty autopsies Glenard several times found the colon transversum displaced and stenosed. He recognized that these changes in the anatomical position must give rise to troubles, which should be considered dependent upon this condition. In examin- ing all his patients with digestive troubles, he found that there were many so-called "nervous dyspeptics" in whom he could discover, by a thorough investiga- ' (1) Anse gastrique ; (2) anse duodenale ; (3) anse ileo-oolique ; (4) anse colique transverse ; (4 a) costo sous-pylorique ; (5 c) sous- pylori -costale ; (6) anse colo-sigmoidale. * "Colique sous-costal droit," "colique sous-costal gauche," "sous- pylorique du transverse." ENTEROPTOSIS, OR GLENARD'S DISEASE. 377 tion of the abdomen, that some abnormal position of the intestines existed. He described the following objective points as characteristic of this affection : 1. Splashing sound {clapotement epigastrique) . 2. Pulsation of the abdominal aorta {battement aortique). 3. "Corde colique transverse." 4r. In the right hypochondriac region frequently movable kidney. By the term "corde colique transverse" Glenard means the resistance which is found lying over the aorta 3 to 5 cm. above the navel, running horizontally 6 to 10 cm. on each side of the median line. This gives the impression of a ribbon 1 cm. in width, and was supposed by Glenard to be the displaced colon transversum, for pressure on the right iliac region at the beginning of the colon ascendens produced rum- bling sounds in the "corde transverse." He con- sequently concluded that all the symptoms in these patients were caused by this abnormal position of the intestine. He named this condition "enteroptosis." Etiology. — It is generally accepted that the corset plays a predominant part in the causation of the downward displacement of the abdominal organs; confinement is also believed to be a great factor of this disorder. But besides these two points, which refer only to the female sex, there are some other con- ditions which likewise predispose to enteroptosis and have reference to both sexes, namely, acute diseases of a grave nature and protracted ailments accom- panied by a considerable loss of flesh. Enteroptosis is found quite frequently, especially 378 DISEASES OF THE STOMACH. among women. In order to give a clear illustration of this fact, I take at random the number of patients recorded in my jDrivate day book for the months of January and April, 1896. In the month of January I saw 57 male patients with gastric disturbances; among them were 4 with a distinct enteroptosis and right movable kidney (third and fourth degrees) ; the number of women with the same disturbances amounted to 33, and 13 had distinct enteroptosis with right movable kidney. The month of April showed similar figures: Number of male patients, 84; enter- optosis with movable kidney, 5. Number of females, 69; enteroptosis with movable kidney, 19. The fig- ures of these two months put together show: Number of male patients, 141 ; enteroptosis with movable kidney, 9. Number of female jjatients, 92 1 enterojDtosis with movable kidney, 32. We find the percentage of enteroptosis to be 6.2 among the male patients with digestive disorders, while in the females similarly afflicted we find the percentage to be 34.8. The great frequency of enteroptosis which has been noted by Glenard is fully sustained by the figures just given. Glenard, however, goes too far, when he ascribes all digestive disturbances to this faulty position of the abdominal viscera ; nor is enteroptosis always the only cause of all the morbid symptoms. According to my own experience, pronounced enteroptosis may exist without any manifestations of morbid phenomena. It is also self-evident that all kinds of .gastric affections occur in enteroptosis as well as in other disorders; for enteroptosis does not produce immunity from digee- ENTEROPTOSIS, OR GLENARD'S DISEASE. 379 tive diseases. Id this way it appears that the diagnosis of enteroptosis will often have to be supplemented by the elucidation of some other factors besides the position of the abdominal viscera. I, however, con- cur with Glenard that in many instances enteroptosis, as such, is liable to produce symptoms, and that these symptoms can be materially improved by the out- lined treatment of Glenard which will be described later. Symptomatology. — The first stage of the disease consists in a prolapse of the intestines, particularly of the right part of the colon transversum, due to a re- laxation of the weak ligamentum colico-hepaticum. The colon ascendens and colon transversum, losing their ligamentous suspension, sink down, and thus the colon transversum, instead of running straight across the abdominal cavity, runs obliquely from below up- ward. At the left end the transverse colon is held in place by the strong ligamentum gastro-colicum. The acute angle produced at this point by the prolapse of the other end of the transverse colon causes a partial occlusion of the lumen of the gut (enterostenosis). The transverse colon, therefore, remains contracted and empty, and gives the condition described as "corde transverse. " Coincident with the descent of the trans- verse colon there is a relaxation of the ligaments (mesenteries) of the small intestines, and this produces a dragging down of the stomach, and causes the liver and kidney, through the ligamentum gastro-colicum, to assume a lower position than normal (Jiepatoptosis and nephroptosis). Thus there may be a prolapse of all the intestines — splanchnoptosis. The enteroptosis 380 DISEASES OF THE STOMACH. causes enterostenosis and increases the specific gravity of the intestines, because they do not contain gas, thus diminishing the abdominal tension. A circulus viti- osus is produced which, if not interfered with, grows worse. The subjective symptoms of this disease are: weak- ness and a constant feeling of lassitude ; difficulty in digestion of fats, farinaceous food, acids, jDure wine, pure milk, with an increase in the digestive troubles about three hours after meals ; sleeplessness ; usually constipation or irregularity of the bowels. The objective conditions are : decreased tension of the abdomen ; prolapsus of the abdominal contents (enteroptosis, gastroptosis, frequently movable kidney, movable liver) ; enterostenosis, Glenard distinguishes three different periods of the disease: (1) Atonie gastrique par enteroptose; (2) mesogastrique, gastroptose; (3) neurasthenique, en- terostenose — and describes them as follows : During the first period of the disease (atonie gas- trique par enteroptose) the patient eats everything, but experiences slight somnolence or a burning sensa- tion after meals; about 2 o'clock a.m. the sleep is in- terrupted for a few minutes. Generally there is one evacuation of the bowels in the morning, of some- what diarrhoeic nature; there is a gradual loss of strength. In the second period (mesogastrique, gastroptose) the patient avoids fat, farinaceous food, acids, milk, wine; complains of a sensation of dragging, false hunger, and emptiness about three hours after meals. About 2 o'clock a.m. he remains awake for two or ENTEROPTOSIS, OR GLENARD'S DISEASE. 381 three hours; suffers from constipation, interrupted once in a while by diarrhoeic evacuations ; always feels tired, particularly when arising and about 3 o'clock in the afternoon. In the third period (neurasthenique, enterostenose) the patient has lost about thirty or forty pounds and is not sufficiently nourished ; he has lived on milk diet, on purees, beef tea — on the most improbable meals; complains of a weighty sensation or cramps in the stomach, and is almost constantly suffering. He does not sleep; the constipation is most obstinate; the daily enemata with difficulty effect an evacuation of fatty scybala surrounded by mucus or pseudo-mem- branes from time to time. There is constant com- plaint of great weakness, so that he hardly leaves the room, and lies on the lounge constantly. He pre- sents the most varied nervous symptoms: cerebral, spinal, sympathetic, both psychical and physical. Diagnosis. — As has been shown by Ewald,' the best test for the recognition of enteroptosis is the demon- stration of an existing gastroptosis. This can occasion- ally be elucidated by the splashing sound, which in these cases can be produced on the left side of the ab- domen over an area extending from the navel or some- what above it down to the symphysis. The inflation of air is another means for detecting the position of the stomach. When the stomach is inflated the lesser cur- vature, in cases of gastroptosis, is visible midway be- tween the ensiform process and the navel or just in the neighborhood of the umbilicus. This is the meth- od which Ewald used in his cases. Gastrodiaphany 1 C. A. Ewald : Berliner klin. Wochenschr. , 1890, Nos. 12 and 13. 382 DISEASES OF THE STOMACH. has been recommended by me ' as a reliable means of recognizing gastroptosis, and from my further experi- ences in this line I must say that the picture which the gastrodiaphane produces in this condition is very striking: the stomach is here visible on the abdomen as a red zone lying between the navel and the sym- physis. Movable kidney is another essential symptom of enteroptosis. The recognition of the movable kidney is quite easy. It is only necessary to practise palpa- tion with both hands, putting one hand on the back of patient behind the lumbar region, while the other hand is held flat below the margin of the false ribs covering the lower outside angle of the abdomen. By having the patient inspire deeply, the kidney, if mov- able, is felt to slip between both hands ; slight pressure with the hand on the lumbar region will facilitate the recognition of an existing movable kidney. While Israel is of the opinion that on deep inspira- tion even a normal kidney may be partly felt by this method of examination, Glenard considers all cases in which the kidney can be perceived by palpation as abnormal. This writer distinguishes four degrees of movable kidney : First degree of nejyhroptosis : The lower part of the kidney can be palpated during deep inspiration; during expiration the kidney slips back to its place and it is impossible to arrest it. Second degree : The greater part of the kidney can ' Max Einhom : " On Gastrodiaphany. " New York Medical Jour nal, December 3d, 1892. " Glenard 's Disease." The Post- Graduate. 1893, No. 2. ENTEEOPTOSIS, OR GLENARD's DISEASE. 383 be palpated and it can also be arrested, but its su- perior margin cannot be felt. Third degree : The superior margin of the kidney can be reached on deep inspiration. Fourth degree : The whole kidney is accessible to palpation even during expiration (the movable or wandering kidney of the older writers). Treatment. — As this whole series of symptoms is caused and explained by (1) enteroptosis, (2) entero- stenosis, and (3) deficient nutrition, the fundamental indications for the successful treatment are pointed out by Glenard as follows : 1. The intestines must be raised and maintained in their position ; 2. The abdominal tension must be increased ; 3. The bowels must be regulated ; 4. The secretions of the digestive tract and of the annexed glands must be stimulated ; 5. The alimentation must be regulated and the digestion assisted ; 6. The organism must be stimulated. The first two points are accomplished by wearing a bandage reaching from the symphysis to the navel and exerting a pressure upon the hypogastrium from below upward. This bandage raises the intestines and increases the tension of the abdomen. In order to regulate the bowels Glenard gives his patients, a quarter of an hour before breakfast, sodium sulphate 4.0, magnesium sulphate 3.0, in half a glass- ful of water; or half a glass of Hunyadi Janos; or one-quarter of a glass of Eubinat ; or a teaspoonful of Carlsbad salt; or pills consisting of 0.05 aloes, or 0.05 384 DISEASES OP THE STOMACH. extractum rhei. The fourth requirement must be ac- comphshed by massage, electricity, and lavage of the stomach ; and the sixth by gymnastic exercises. As to alimentation Glenard has given the following table : During the First Stage of the Disease. — Boiled meat, roast game, odorless squabs, brain ; farinaceous vegetables (lentils, potatoes), rice, carrots; grapes, very ripe fruit; fried eggs, oysters, liver (fat); Gerx and Gruyere cheese; red wine diluted with water; sauces, juices, lards, fries, Italian pat^s, salad; pure red wine, creams, undiluted boiled milk, fresh milk. Second Stage of the Disease. — Eoast meat (beef, mutton, veal, chicken), lean ham; fish (sole, white fish, trout); scrambled eggs; fresh vegetables, well- cooked, English style ; cheeses (Brie, Camembert) ; baked apples, preserves, compotes; chocolate, beer, cider (?), white wine (?). TJiird Stage of the Disease. — Raw meat (beef, mutton), raw eggs, stale bread, coffee with milk (one- third milk, two-thirds coffee) ; coffee, tea, water, water with cognac, champagne; broiled meat (roast beef, mutton, lamb chops, tenderloin of beef) ; eggs, bouillon, preserves. I agree with Glenard in regard to the bandage which should support and elevate the intestines, but the medicinal and dietetic treatment must be made dependent upon the result of a chemical analysis of the stomach contents; for, according to my experi- ence, the chemical condition of the stomach in these cases of " enteroptosis" is not always alike. In those ENTEROPTOSIS, OR GLENARD's DISEASE. 385 cases where there is hyperacidity — which is the case with the greater number of this class of patients — GMnard's rules are excellent; but where there is an insufficiency or an absence of HCl, the treatment will have to be modified accordingly. CHAPTER XIII. NERVOUS AFFECTIONS OF THE STOMACH. General Remarks. Deviations from the normal process of gastric di- gestion not based upon pathologico-anatomical changes are considered as gastric neuroses. We are accus- tomed to ascribe the different functions of the stomach to the action of special nerves. Although physiolog- ical experiments have not as yet enabled us to discover special nerves governing secretion, motion, or sensi- bility of the organ, still clinically many facts speak in favor of such an assumption. The neuroses of the stomach are also occasionally designated as "func- tional disturbances." The different gastric neuroses may appear either separately or, occasionally, in com- bination with each other. As a rule, these neuroses occur most frequently in women, especially between the ages of seventeen and forty; in men also the middle period of life shows a predilection for these disturbances. As a predisposing factor for these neuroses the following conditions must be recognized : severe mental exertions, worry, unusual excitement, sexual excesses. The recognition of the neurosis is not always very easy. The principal point of impor- tance is the exclusion of any organic lesion of the organ. The following symptoms, which frequently recur in gastric neuroses, have been especially well NERVOUS AFFECTIONS. 387 described by Boas,' and will facilitate the recognition of the nervous element of the affections in question. 1, The entire nervous system shows more or less deviation from the normal. There may be present headache, insomnia, conditions of depression, or, on the other hand, excitation, increased sensitiveness. Objectively there may be an increase or diminution of the reflexes of the skin and tendons, hypersesthesia at some, parassthesia or angesthesia at other places. Fre- quently there exists constant or intermittent polyuria. The general condition may be good or various degrees of emaciation may be present. 2. The digestive system is characterized by a con- dition of "labile gastric intestinal function." The subjective symptoms are not always necessarily con- nected with the act of digestion. The digestive com- plaints are usually independent of the quality and quantity of the ingested food. Dietetic errors are, as a rule, not followed by any aggravation of symptoms; while the character of food does not have any influ- ence upon the severity of the symptoms, there are occasionally some other factors in the way of climate and surroundings which play an important part in the amelioration or deterioration of the condition. Objectively changes in the condition of gastric secre- tion and of the motor function of the stomach as well as of the intestines frequently occur. Thus complete anacidity may alternate during a short period with normal secretion. The condition of the motor func- tions of the stomach frequently changes. The state 'Boas: "Specielle Diagnostik und Therapie der Magenkrank- lieiten," 2te Auflage, p. 204. 388 DISEASES OF THE STOMACH. of the bowels is also very variable ; thus constipation frequently alternates with diarrhoea, or, at a time when the bowels are regular, an acute diarrhoea may suddenly appear. According to Eosenthal,' the neuroses of the stom- ach are best divided into: (1) Sensory, (2) motor, and (3) secretory neuroses of the stomach. Sensory Gastric Neuroses. For the sake of greater clearness sensory gastric neuroses are best divided into two main groups : (a) Comprising abnormal sensations of a more or less gen- eral character; (6) special sensations emanating from the stomach itself, (a) Abnormal Sensations of a General Character. The need for food makes itself felt through the sen- sation of hunger, the need for drink through that of thirst. The nervous centre for these sensations ap- pears to be located in the medulla oblongata (R. Ewald ' and Rosenthal). The stomach is the organ into which all substances satisfying hunger and thirst are introduced. The act of satisfying the sensation of hunger with relish is called "appetite." Normally there appears in man a slight feeling of hunger at the usual mealtime. A man relishes the food he takes until at the end of the meal a feeling of satiety ap- pears. The latter may be best characterized by noting the point at which the sensation of hunger has en- ' M. Rosenthal : " Magenneurosen und Magenkatarrh," Wien und Leipzig, 1886. ' R. Ewald : Cited from C. A. Ewald, I. c. , p. 380. SENSORY GASTRIC NEUROSES. 389 tirely disappeared. On going beyond this point to any extent — i.e., by continuing to introduce further food into the organ — a sensation of weight and tight- ness around the stomach develops. This can then be hardly considered as a normal process, and is the way the stomach responds to interference with its habitual mode of work. The time at which hunger appears is physiologically variable and depends upon the time persons are accus- tomed to take their meals. On this account there are people who feel hungry only twice a day, as they are in the habit of taking only two meals daily ; others again who feel hungry about every three hours, as they are accustomed to take five meals a day, and so on. Although the ingestion of food may sometimes lead to some variations in the time at which hunger is experienced — so that a man who is in the habit of taking a light meal at a certain period during the day, after having partaken of a much heavier meal than customary, will perhaps not feel hungry at his next meal — this is of less consequence than the influence of the time at which the meals are ordinarily taken. Thus every one knows that if he has been accustomed to take his lunch, for instance, at one o'clock, the hungry feeling will appear at one, and if not satisfied within a certain period of time (half an hour to an hour), then very frequently it will disappear to return at the next mealtime. Pathologically we find that the above-named sensa- tions may exist either in an exaggerated form, or may be greatly diminished or even absent. 390 DISEASES OF THE STOMACH. Bulimia. Bulimia (/3"y^', ox, hiw^, hunger) or cynorexia (y.'jojv^ dog, o>£|{9, appetite), or hyperorexia, denotes a condi- tion in which the feeling of hunger is enhanced, ap- pearing more frequently and in a more intense degree than in the normal state. Bulimia may exist alone as a primary affection or may be associated with various other disorders, and is then considered as a secondary affection. Thus ulcer of the stomach, hy- perchlorhydria, cancer of the stomach, intestinal troubles, tapeworm, Graves' disease, hysteria and neurasthenia, and tumors of the brain are all liable to be complicated with bulimia. Symptomatologij. — Bulimia may appear periodi- cally and last only a short time (a few days) or may exist chronically and last for months or even years. The periodical form is usually characterized by much greater intensity than the chronic. An attack of bulimia may be described as follows : In the midst of perfect euphoria, a feeling of intense hunger over- comes the patient with a persistent desire to satisfy it. This hungry sensation is associated with a gnawing feeling in the stomach, and the utmost fear and anxiety, as if something alarming were going to happen. If the feeling of hunger is not satisfied very quickly, then severe headache and trembling of the body or even fainting spells may occur. The patient in such a condition, as a rule, disregards convention- alities and tries to obtain whatever food he can, in order to overcome this painful craving of his stomach. Generally a small quantity of nourishment is sufficient BULIMIA. 391 to arrest the attack, sometimes, however, large quan- tities of food have to be taken. Thus Peyer ' describes the case of a woman who was suddenly seized with an attack of bulimia, so that she could not return home from the house of a neighbor whom she was visiting. In forty -five minutes she ravenously devoured three pints of milk, twenty-three eggs, and two pints of strong wine. After this meal she became quieter, went to sleep, and awoke perfectly well on the next day. The primary cause of bulimia appears to be a de- rangement of the nervous apparatus for the hunger sensation. This derangement may be either central or peripheral. Hypermotility was found by Leo ' in a patient troubled with bulimia; but although present in some instances it is by no means a constant symptom. Thus Ewald ' reports a case of bulimia in which the motor function of the stomach was perfectly normal. Treatment. — The treatment should always be directed against the primary cause of the trouble. Thus helminthiasis must be removed by extract of male fern. Hyperchlorhydria should be treated by carbonate of soda, diabetes by a meat diet, and so on. Cases of neurasthenia or hysteria will have to be treated as such. The following means at our com- mand may be directed against bulimia as a distinct disorder : Very frequent light meals (every two hours). ^ A. Peyer : " Beitrag zur Kenntniss der Neurosen des Magens und des Darms." Correspondenzbl. schweizer Aerzte, 1888, No. 20. " Leo : " Verhandlungen des Vereins flir innere Medicin, " Berlin, 1889. 3C. A. Ewald: I. c, p. 379. 392 DISEASES OF THE STOMACH. The bromides should be given in large doses, twice daily, as for instance potassium or sodium bromide, in doses of 1.5 gm. (gr. xx.), or bromide of strontium 12 gm. to 60 c.c. peppermint water, one teaspoonful twice daily, or — IJ Amnion, brom., Sodii brom., aa 8.0 3 ij. Aq. menth. pip., 60.0 3 ij. S. One teaspoonful twice daily. Eosenthal ' recommends the use of cocaine in doses of 3 to 5 cgm. twice daily. Opium or codeine, in doses of 3 to 4 cgm. (gr. ss.) three times daily, may be advantageously employed. Arsenic, is also of value. I^ Sol. arsen. Fowleri, Aq. menth. pip., aa 5.0 3 iss. S. Six drops three times daily. A change of climate, sojourn in the mountains or at the seashore, is frequently beneficial. Parorexia {Perversion of Appetite). The appetite is sometimes manifested for special and peculiar kinds of food, and to this condition the name parorexia has been applied. There exist three degrees of parorexia: 1. Malacia : an increased desire for spiced food-stuffs, as for instance mustard, salad, vinegar, green fruits, etc. 2. Pica : the appetite manifests itself for substances which are not in reality foods, thus for coal, ashes, chalk, earth, sand, insects. 3. Allotriophagia : there seems to be a craving for substances which are decidedly disgusting and harm- ful, as for instance faecal matter, needles, pins, etc. 'Rosenthal : /. c. AKORIA. 393 While the first form (malacia) is met with in many disturbances of the stomach or in different neurotic conditions of the system (neurasthenia), the latter two conditions appear only in severe forms of hysteria, and more frequently in idiots and lunatics. Polyphagia. Polyphagia denotes a condition in which excessive amounts of food have to be taken in order to satisfy the feeling of hunger. Polyphagia is met with in the same conditions as bulimia, and especially in the fol- lowing disorders: Cancer of the pancreas or spleen, fistulous opening of the gall bladder, diabetes, and some tumors of the brain. But polyphagia may also be observed as a primary affection in neurotic persons. Like bulimia, polyphagia either appears in the form of attacks of short duration or may exist as a chronic trouble. The amount of nourishment which may be devoured by the patient during such an attack of polyphagia is sometimes enormous. Thus Eosenthal reports the case of a woman, twenty-eight years old, who devoured at one meal an entire large fried goose and a big portion of bread. Bouveret' mentions a case reported by Percy : The patient, Tarare by name, when seventeen years old could partake of one hun- dred pounds of meat in twenty-four hours. Akoria. By akoria is designated the absence of the sensation of satiety (xop^wop.c, I feel satiated). The main symp- tom of this condition consists in the loss of the feeling 'L. Bonveret-. "Traitedes Maladies de I'Estomac," Paris, 1893, p. 654. 304 DISEASES OP THE STOMACH. a person normally experiences at the end of the meal which tells him that he has had enough. The patient with akoria never knows when to stoj) eating. Fre- quently akoria is found combined with polyphagia, hut not always. It is met with in similar conditions as bulimia and polyphagia, neurasthenics and hysterics forming the large majority of cases. Nervous Anorexia. Under the term anorexia ('''>£|t?, appetite) is under- stood a complete absence of the sensation of hunger, combined with loss of appetite. While anorexia is met with in almost all organic as well as functional disorders of the stomach, "nervous anorexia" may at times appear as a primary affection, unassociated with the conditions just mentioned. The cause of this primary anorexia may be either a depressed condition of the hunger centre or, according to Rosenthal, a kind of hypersesthesia of the gastric mucous mem- brane. As etiological factors are frequently found great mental depression, as after a death in the family, worry, anxiety, fright, etc. Symptomatology. — At first the patient complains of loss of appetite and begins to eat less. As a rule, all kinds of meat are first discarded from the bill of fare. Later on bread, butter, and afterwards most solid foods are avoided and the patient subsists only on a small quantity of milk and some soup. For quite a while the patients apparently maintain their healthy appearance and do not even seem to lose in weight. The small quantities of food the patient takes are now NERVOUS ANOREXIA. 395 still further reduced. Even the encouragement on the part of the family to take more nourishment fails to have any effect ; the patient, as a rule, obstinately refusing to do so. It was Sollier ' who laid particular stress upon this symptom, and suggested designating this condition by the name of ^'' sitieirgy''' {tIto-, food, and el'pyoj, refuse). At this stage the patients lose considerably in weight and begin to look emaciated, have cold extremities, a slow pulse (50 to 60) and re- duced temperature (95 to 96° F.); they grow anaemic and weak, and very soon are hardly able to leave their beds. The appearance of such a patient in this stage of the disease is very similar to that of a consumptive. The face is pale, the eyes sunken, the skin dry, the extremities slightly cyanosed, and the abdomen re- tracted. If the patient still continues to refuse food, the condition may terminate fatally. Such cases of nervous anorexia ending in death have been reported by Gull,° Charcot," Eosenthal," and others. Eosenthal's case was as follows: The patient, female, seventeen years old, had suffered for eighteen months from anorexia. After this period she took only 30 to 40 gm. of milk per day. The patient be- came emaciated and looked like a skeleton. She could not sleep and could not leave her bed. Isolation of the patient or forced alimentation could not be em- ployed under the existing circumstances. Symptoms of rapidly progressing inanition appeared, in connec- tion with shortness of breath, dysphagia, and alalia, 'Sollier: Eevue de medecine, aout, 1891. 2 Gull . Lancet, 1868. 3 Charcot: " (Euvres completes, " t. ill., p. 240. * Rosenthal : I. c. 396 DISEASES OF THE STOMACH. all indicating anaemia of the bulbar centres, the case terminating fatally. Diagnosis. — After the development of nervous symptoms no diflBculty is encountered in making the diagnosis of anorexia. It is necessary first of all to exclude organic affections of the stomach. The early stage of tuberculosis may at times be mistaken for nervous anorexia, especially if there exists no cough or if tubercle bacilli are absent in the sputum. One point, which is quite valuable in making the diagnosis of nervous anorexia, is the circumstance that patients with the latter condition are not in any way alarmed about their loss of appetite, while anorexia existing in organic disorders of the stomach, like cancer, etc., evokes fear and anxiety. Treatment. — In the early stage of the disease the treatment is quite easy. It is merely necessary to impress the patient with the idea that he must take sufficient food. The meals should be taken at regu- lated periods. The patient should be given food with- out any previous questioning as to whether he would like it or not. At meal-times he should be encouraged to take his entire portion. A liberal variety of foods is also of importance. In the way of medicines most of the bitter tonics, which stimulate the appetite, are indicated. Thus nux vomica, in the form of the tincture, may be given in doses of ten drops three times daily, or fluid extract of condurango, twenty drops three times daily. Boas recommends fluid extract of Peruvian bark, one teaspoonful three times daily. Orexinum basicum in doses of 2 to 3 dcgra., in wafers three times daily, is also useful. All these stomachics NERVOUS ANOREXIA. 397 should be given about one-quarter of an hour before meals. The longer the disease has existed the more difficult it becomes to combat it successfully. If it is already of long standing, and has led to high degree of ema- ciation and other pronounced symptoms of inanition, then treatment at the home of the patient is hardly ever successful. Charcot first laid stress upon the importance of isolating the patient from his surround- ings. This plan of treatment has been still further advanced by Weir Mitchell ' in this country, and this method is known as the Weir Mitchell rest cure. The principle of this cure consists first in isolation of the patient from his famil}^ ; secondly, in strict supervision by the physician, and by a constant attendant ; thirdly, in ample feeding, so that a state of hypernutrition may be established ; fourthly, in the application of massage and electricity, which may be considered as adjuncts to the above. In cases in which food is absolutely refused, even after isolation, forced alimentation or gavage (feeding by means of the tube) becomes necessary. Frequently after having nourished the patient by artificial means for a few days, he gains the conviction that his stomach is able to digest food and then begins to eat spontaneously. Good fresh air and an organic iron preparation like Gude's peptomangan or Pizzala's or Dietrich's albuminate of iron or Boehringer's ferratin may be advantageously administered, especially after the patient has begun to improve. Arsenic may also be administered, either alone or in conjunction with 1 AVeir Mitchell : "Fat and Blood, " Philadelphia, 1884. 398 DISEASES OF THE STOMACH. the above-mentioned iron preparations; thus Fowler's solution, two to three drops three times daily in water, or Levico or Eoncegno mineral waters may be given, one to two tablespoonfuls daily. As a rule, the patient should not leave the sanitarium until he has regained his former weight. In the latter instance there is no danger of relapses. {b) Special Sensations Within the Stomach Itself. In its normal state the stomach barely transmits any sensations whatever to our consciousness. As a rule we lose track of the food we take as soon as it has passed the palate and has been swallowed. Plain articles of food and the most delicious dishes are equally quickly forgotten. Cold articles of food and warm beverages do not manifest their presence by any special sensations within the stomach. Notwithstand- ing these facts it is certain that the stomach physio- logically is not void of sensation. Thus ice-water taken in large quantities on an empty stomach gives rise to a sensation of slight cold in the gastric region, especially near the scrobiculus. The faradic current applied within the stomach (one electrode within the organ, the other at the back) produces a sensation either of slight burning or of weight in the gastric region, provided the current is sufficiently strong. If it were not for these experiments, we might imagine that the stomach is an organ which normally does not transmit any perception to the brain. This fact, which applies alike to the stomach as well as to the other vegetative organs of our system, is of great im- portance and a wise provision of nature ; for it enables GASTRIC IDIOSYNCRASIES. 399 "US to occupy ourselves with all kinds of brain work without being constantly disturbed by the functional processes and needs of our digestive organs. In contrast to the small degree of sensation which physiologically exists in the stomach, the activitj^ of the sensory apparatus may be pathologically increased and thus give rise to marked discomfort. Gastric Idiosyncrasies. We sometimes meet with persons who manifest an idiosyncrasy toward certain substances, the ingestion of which gives rise to symptoms emanating from the alimentary tract alone or combined with other dis- orders, especially of the skin. The articles most apt to cause these disturbances are certain kinds of fruit, especially strawberries, lobsters, soft-shell crabs, oys- ters, fish ; but besides these substances there are sev- eral other articles of food which may produce dis- agreeable symptoms in certain individuals. Thus I know of several members of one family who betray very unpleasant symptoms (feelings of pressure, pain, belching) if a trace of onion is added in the prepara- tion of the food. In all these instances this is not an imaginary trouble, for even if the substances men- tioned are given in a disguised form, so that the person is unconscious of taking them, he will never- theless suffer from the same symptoms. Generally only gastric symptoms are produced: pressure, pain, belching, rarely nausea and vomiting; sometimes in addition to these there appear eruptions on the skin, either erythema or urticaria. It is remarkable that in these instances the same individual always mani- 400 DISEASES OP THE STOMACH. fests the same symptoms upon taking the respective article against which he has an idiosyncrasy. Talma * described several cases in which there was an idiosyncrasy against hydrochloric acid. The slightest quantities of a highly diluted solution of hydrochloric acid (1 : 750) produced pains within the stomach. I also have observed a case in which severe pains in the gastric region usually appeared one to two hours after meals for a period of over seven years. The analysis of the gastric contents one hour after the test breakfast revealed the presence of free hydrochloric acid and a de- gree of acidity of 40. As the symptoms corresponded to those found in hyperchlorhydria, I administered alkalies, notwithstanding the fact that the acidity in this case was rather diminished. The symptoms dis- appeared at once, and the patient, who was quite ema- ciated, began to gain in weight rapidly. The treat- ment was continued for over six months, and the improvement persisted. Here the pains were probably due to a kind of idiosyncrasy of the stomach against its own hydrochloric acid. In all these cases nothing can be done to rid the stomach of this peculiarity, and the persons affected must abstain from the offending articles, or else suffer for their indulgence. Abnormal Sensations. Sensations of heat or more seldom of cold, of heavi- ness or of a foreign body within the stomach are present in some cases; and these may manifest them- selves no matter whether the stomach be empty or 'Talma: Zeitschr. f. klin. Medicin, 1884, Bd. viii., p. 407. HYPERiESTHESIA OF THE STOMACH. 401 not. They are not due to changes in the chemical condition of the gastric juice, but are merely symp- toms originating from the nerves of the stomach. With these sensations we may also class the feeling of constriction or of cramp within the organ and the "epigastric heating." The latter is sometimes due to an increased pulsation of the abdominal aorta. While in the normal state people never notice these pulsa- tions, in those affected the beating sensation is very tormenting and is sometimes the cause of many sleep- less nights. All these abnormal sensations are usually found in nervous people, neurasthenics or hj^sterics. Nausea also belongs to the abnormal sensations. Besides its occurrence in organic affections of the stomach it is also found alone, and it is then called "nervous nausea." It is met with in diseases of the central nervous system and in both neurasthenics and hysterics. Sometimes it is also caused by affections in distant organs, as for instance the uterus or the ovaries, and must then be considered as a reflex symp- tom. Nausea appears most frequently in the fasting state, sometimes, however, the patient also experiences the nauseous feeling shortly after meals, from half an hour to an hour. The treatment should therefore be directed principally against the general condition. Sometimes the intragastric application of the galvanic current will greatly facilitate the cure. HypercBsthesia of the Stomach. In hypersesthesia of the stomach there is an ab- normal sensitiveness of the mucous membrane even after the ingestion of ordinary food. The patient ex- 26 402 DISEASES OF THE STOMACH. periences a sensation of fulness, of slight burning, sometimes even of pains in the gastric region after meals. Many organic affections of the stomach are accompanied by this condition. As a primary affec- tion it appears most frequently, according to Eosen- heim,' in chlorotic girls and women. Occasionally it is met with in people with a weakened constitution; thus after excesses in baccho et in ve7iere, or after long periods of unsuitable dieting. Symptomatology. — In the mild form of hyperaes- thesia the patient experiences a sensation of weight or fulness after meals. If the disease, however, is more pronounced, real pains occur after meals, and the stomach after a while may become so irritable that the contact of food with the mucous membrane pro- duces vomiting. In the latter instance the food is partly rejected soon after the meal. As a rule only a small quantity of the ingested food is vomited, while the greater part is thoroughly digested. That is the reason why in these instances the patient does not emaciate. If, however, the bulk of the food be ejected, this symptom may soon lead to grave inani- tion. The disagreeable sensations which exist in this affection frequently lead to a diminution of the quan- tity of food taken (a condition develops which may be termed "sitophobia" — fear of food), and in this way again the nutrition may be impaired. Diagnosis. — In addition to the above symptoms an examination discloses that the gastric and epigastric regions are painful on pressure. The secretory and motor functions of the stomach may be found normal ' Th. Rosenheim: Berl. kliu. Wochenschr., 1890. HYPERiESTHESIA OF THE STOMACH, 403 or a slight degree of hyperchlorhydria may exist. In the differential diagnosis we must exclude gastric catarrh, ulcer and erosions of the stomach, before diagnosing hypersesthesia as such. In catarrh of the stomach the sensation of fulness or weight appears, as a rule, not immediately after meals, but some time afterward. Besides there exist in catarrh of the stomach many other symptoms (loss of appetite, a diminished secretion, etc.), which are not met with in this condition. In ulcer of the stomach the pains are more violent. They are also dependent upon the quality of the food ingested, while in hypersesthesia the abnormal sensations are pretty much the same whether coarse substances or very light food be in- gested. In erosions of the stomach the pains are also usually of a light nature, but here, as in ulcer, we find that the pains depend to a certain extent upon the quality and quantity of the food taken. Another point of importance in this condition is the results obtained after the washing out of the stomach in the fasting condition of the patient. In erosions of the stomach, as a rule, several (two to four) small pieces of gastric mucosa are found in the wash-water; in hypersesthesia this does not occur. Treatment. — For the hypersesthesia occurring in chlorotic persons Eosenheim proposed the following treatment: The patient should be kept in bed, and the Priessnitz compress applied to the gastric region. The diet should consist at first of milk, to which small amounts of lime water are added, and which should be taken with a spoon. The addition of small quantities of tea or coffee to the milk is permissible. After a 404 DISEASES OP THE STOMACH. while the yolk of an egg with sugar and small quan- tities of cognac, wine jelly, scraped meat, or toasted bread are given. Of medicaments, Rosenheim advises the internal use of nitrate of silver. IJ Arg. nitr., 0.3 gr. iij. Aq. dest 100.0 | iij. S. Half a tablespoonf ul in a wineglassful of water, three times daily, half an hour before meals. When the stomach has become less irritable, the patient should begin cautiously with solid food and tonics like iron and arsenic, in order to restore the organism to its normal condition. In cases of h5"per9esthesia not originating from chlorosis the best treatment consists in the administra- tion of the bromides for a period of one or two months. Gastralgia. Synonyms. — Cardialgia, gastrospasmus, and gastro- dynia. By the term gastralgia is designated the occurrence of attacks of pains of more or less severity in the gas- tric and epigastric regions. These persist for a certain period and alternate with perfectly free intervals. Symptomatology. — The attacks of pains rarely ap- pear suddenly. As a rule, they are preceded by short periods of various abnormal sensations ; thus a slight feeling of nausea or of tension in the gastric region may exist. Increased salivation is also frequently one of the prodromal symptoms. Headache, feelings of faintness or vertigo may also precede the real attack. Very soon afterward an intense pain appears in the epigastric region, extending especially to the left side. GASTRALGIA. 405 There exist a crampy sensation and a feeling of con- striction, or there may be a feeling of intense burning. These pains and sensations frequently radiate to the back, to the shoulder blades, and over the whole ab- domen. At such times the patient is overcome by a feeling of great anxiety. The extremities often grow cold, and cold perspiration appears on the forehead. The face is extremely pale, and bears the expression of anguish and anxiety. The patient frequently is unable to lie straight, and often assumes a bent posi- tion, so that the abdominal muscles are not stretched, but kept in a curved and relaxed condition. Some- times the patient puts a pillow upon his abdomen and curls himself around it, holding it with his arms. The character of the pulse is variable. As a rule, it is accelerated, sometimes, however, it is rather re- tarded. The gastric region is mostly sunken ; in rare instances protruding. While this region is sensitive to slight palpation, a more profound pressure does not, as a rule, cause any pain, and frequently rather re- lieves the patient's suffering for a moment. The dur- ation of such an attack is very variable ; it may last fifteen minutes only or several hours. At the end of the attack the pains disappear quite suddenly, and the patient now experiences a sensation of hunger. If the attack was of short duration (half an hour or so) the patient does not retain any symptoms of malaise after it, and is able to attend to his usual work. It is quite different with a severe attack that has lasted several hours. The latter leaves a feeling of extreme weakness for several days, during which the patient has to remain abed. 406 DISEASES OF THE STOMACH. The frequency of these attacks is very variable, and different in each case. In some cases the attacks occur once in a few months or once in a year, while in others they appear every week or even every day. The attacks of idiopathic gastralgia do not seem to be dependent upon the quality or quantity of food in- gested, nor to show any relation to the time of its ingestion. EtioJoyy. — With regard to etiology, gastralgia may be divided into the following forms : (1) Gastralgia of stomachic origin ; (2) central gas- tralgia ; (3) neurotic gastralgia ; (4) constitutional gastralgia ; (5) reflex gastralgia. Gastralgia of Stomachic Origin. — Besides occurring in connection with gastric affection, as for instance ulcer, cancer, hyperchlorhydria, peritonitic adhesions, gastralgia may exist as a primary affection of the stomach, either without any visible cause or after the ingestion of certain unusual or unaccustomed articles of food or spices ; thus very strong black coffee or ice- cream may provoke an attack in people not accus- tomed to these substances. Gastralgia of Central Origin. — Diseases of the brain are very seldom accompanied by gastralgia. Spinal disorders are much more frequently associated with the latter condition. In tabes especially gastral- gia frequently occurs. Charcot deserves much credit for having first recognized the dependence of these gastric pains upon the spinal trouble. He described these attacks under the name of "crises gastriques." The pathological basis for tlje latter condition was found to consist in a sclerotic degeneration of the GASTRALGIA. 407 vagus Ducleus or the vagus trunk (Kahler/ Demange/ Landouzy and D^jerine," Oppenheim '). The gastric crises differ but little from the usual gastric attacks. As a rule, they begin with a prodromal period of lan- cinating pains in the limbs or in both upper and lower extremities, and also with excessive vomiting. The attack in many points greatly resembles that of con- tinuous periodic hypersecretion, and lasts just about as long. Examination of the stomach contents before and during the attack has not revealed anything characteristic (Von Noorden' and Ewald "). Besides tabes dorsalis, other lesions of the spinal cord which involve the vagus nucleus may also pro- voke gastralgia. Thus Leyden' describes it among the symptoms of subacute myelitis, and Oser' in a case of pressure myelitis. This type of gastralgia accom- panying spinal troubles appears of special importance, inasmuch as it is frequently one of the first symptoms of the real trouble. The gastric crises may in some instances precede for several years the other symptoms of locomotor ataxia. It is hardly necessary to men- tion that in all cases of periodic gastralgia we should examine the condition of the nerves and of the cord (knee reflex, Eomberg's symptom, sensitiveness of the skin, and reaction of the pupils). 'Kahler: Prager Zeitsch. f. Heilknnde, Bd. ii. ^ Demange : Eevue de medecine, 1882. ^Landouzy et Dejerine : Societe de biologie, 1884. ^Oppenheim: Berl. klin. Wochenschr. , 1885. ^C. von Noorden : "Pathologie der gastrischen Krisen." Charite Annalen, 1880. « C. A. Ewald -.I.e., p. 403. ^E. Leyden: Zeitschr. f. klin. Medicin, 1882, Bd. iv., p. 605. ^O^er : "Die Neurosen des Magens, " Wien und Leipzig, 1885. 408 DISEASES OF THE STOMACH. Neurotic Gastralgia. — Gastralgia often occurs as one of the symptoms of either hysteria or neurasthe- nia. Both conditions are characterized by the peculiar symptoms which, if jDresent in a sufficient number, will make the diagnosis easy. Sometimes, however, the gastralgia may exist for a long time as the only symptom of either neurasthenia or hysteria. It is then more difficult to recognize the real nature of the trouble. Constitutional Gastralgia. — Constitutional gas- tralgia is caused by some abnormal condition of the blood, due either to infection, intoxication, or malnu- trition. Among the infections, malaria is frequently the cause of intense gastralgia. The gastralgia may be associated with other symptoms of this dis- ease, chills, fever, etc., or it may appear alone. It is characteristic of gastralgia of malarial origin to ap- pear either every day, or every other day, or every third day at the same hour. I have frequently seen this form of gastralgia accompanied by intense vomiting and by a condition of hyperaesthesia of the stomach prevailing in the intervals between the attacks. The intoxications causing gastralgia are very nu- merous. Thus chronic lead poisoning, an extensive use of the mercurial preparations, the excessive use of tobacco, frequently evoke typical attacks. Gout is also sometimes found to give rise to gastric attacks. Malnutrition, which is always associated with anaemia, is frequently found complicated with gastralgia, es- pecially in young persons (chlorosis). In these cases it is, as a rule, very difficult to decide whether the GASTKALGIA. 409 gastralgia is due to the ansemia or to a real organic trouble of the stomach, namely, ulcer. Reflex Gastralgia. — This group occurs more fre- quently in women. Eeflex gastralgia may be caused by abnormal conditions in distant organs, such as the uterus, ovaries, or tubes. In men also diseases of the genito-urinary organs give rise to similar troubles. Another frequent cause of reflex gastralgia is an ab- normal position of the abdominal organs. Thus en- teroptosis, gastroptosis, nephroptosis, hepatoptosis are all occasionally the cause of gastric pains. Hydrone- phrosis has also been stated by Eenvers' to be the cause of gastralgia, and I myself have observed one •case of this kind. Diagnosis. — To establish the diagnosis of gastralgia it is of importance to exclude (1) all organic and func- tional diseases of the stomach accompanied by pain, and (2) conditions likewise provoking pains in the gastric region which, however, are not due to the stomach. Among the organic affections of the stomach which give rise to gastralgia, and may occasionally be con- founded with idiopathic gastralgia, are : (a) Chronic gastric catarrh ; (6) cancer of the stomach ; (c) ulcer of the stomach ; {d) stenosis of the pylorus. In chronic gastric catarrh the pains are very seldom intense, they have a more continuous character, and do not appear in paroxysms. In cancer of the stomach the pains may be intense at times, but they are also, as a rule, more steady, never leaving any perfectly free intervals, while in iRenvers: Berl. klin. Wochenschr., 1888, No. 53. 410 DISEASES OP THE STOMACH. idiopathic gastralgia the pains appear in the form of attacks lasting only several hours and alternating with complete euphoria. Ulcer of the stomach occasionally presents much more similarity to the affection under consideration. The characteristic signs of ulcer (a circumscribed spot in the gastric region or to the left of the eleventh to twelfth dorsal vertebra, very painful on pressure, the aggravation of the pains after the ingestion of food, especially of coarse substances, a preceding hemor- rhage) will, if present, make the differential diagnosis between this affection and idiopathic gastralgia very easy. Sometimes, however, all of the characteristic symptoms mentioned are absent, and then it becomes very difficult to distinguish between these two affec- tions, for there undoubtedly exist ulcers of the stomach which give rise to more or less periodic paroxysms. In these doubtful cases it is advisable to institute the Ziemssen-Leube rest treatment of ulcer, and if this proves beneficial it will speak in favor of the affection having been an ulcer ; the failure of this treatment would rather tend to indicate that the affection is nervous gastralgia. Stenosis of the pylorus is accompanied with typical attacks of gastralgia. When frequent vomiting and ischochymia are present, the differential diagnosis is not difficult. If, however, the two symptoms men- tioned are absent, it may sometimes become quite difficult to decide between the two conditions. In diagnosticating nervous gastralgia, it will be still more important to differentiate between some functional disorders of the stomach which may GASTRALGIA. 411 be associated with pains. Such affections are: (a) Hyperchlorhydria ; (b) periodic and chronic continuous hypersecretion ; (c) achyha gastrica. In hyperchlorhy- dria and hypersecretion the pains, as a rule, disappear after the ingestion of food, and even a severe attack may be checked by the taking of some food. In achylia gastrica the pains exist only while there is food in the stomach, but not in its empty condition, while in nervous gastralgia the pains appear independently whether there be food in the stomach or not. Besides these clinical symptoms in all of the functional dis- orders just mentioned, the exact diagnosis can be made by the results of the examination of the gastric contents. There are other conditions which also provoke pains in the gastric region, which are not due to the stomach. Muscular pains of the abdomen, due either to rheu- matism or to overexertion, may give rise to mistakes in diagnosis. The pain in these affections, however, does not appear paroxysmally and disappears if due to overexertion when the patient assumes a recumbent position and the abdomen is relaxed. Neuralgia of the lower intercostal nerves is char- acterized by extreme sensitiveness on pressure in a certain intercostal space, extending forward from the vertebral column ; the pain is more superficial than in gastralgia. Gall stones frequently give rise to attacks of intense pains which may be mistaken for gastralgia. When- ever there is a distinct history of cholelithiasis (a pre- ceding icterus, the appearance of gall stones in the 412 DISEASES OF THE STOMACH. stools, swelling of the liver) the diagnosis is easy When, however, these characteristic symptoms are absent, then it becomes more difficult to differentiate between gastralgia and biliary colic. The following points will help to establish the differential diagnosis. In gall stones the attack of pain is frequently associated with a rise of temperature. The jjains are also felt more intensely to the right of the abdominal cavity (liver). In gastralgia there is, as a rule, no fever and the pains on the right side are not so well marked as in biliary colic. In many instances the diagnosis be- tween gastralgia and biliary colic will remain doubt- ful, and it is then advisable to institute a treatment which would be suitable for gall stones. The success or the failure of the treatment will aid in the estab- lishment of the correct diagnosis. Enteralgia or intestinal colic is characterized by the change of the site of the pains from one place to an- other in the abdominal cavity, while in gastralgia the pain is fixed at one and the same area. Another point in the differential diagnosis between these two condi- tions is the circumstance that in enteralgia the pain is either relieved or disappears entirely after the passage of flatus. Furthermore, enteralgia is very often the result of irregularities of the bowels, and the condition is therefore ameliorated after these have been regu- lated. Eenal calculi may also give rise to colicky pains. These are characterized, however, by radiation along the ureter to the bladder. The passage of a small stone or of gravel or of blood clots with the urine will easily establish the true nature of the condition. GASTKALGIA. 413 Treatment. — In treating a case of gastralgia it is of the utmost importance to recognize the primary cause of this condition. Thus in gastralgia of malarial origin quinine in large doses will be the best remedy, while in that due to chronic nicotine poisoning a cure will be obtained by forbidding the patient to smoke. Gastralgia resulting from chlorosis will have to be treated by the administration of iron, arsenic, bone marrow, and other blood-producing substances. Gas- tralgia due to hysteria and neurasthenia should be treated by hydropathic methods, massage, and large doses of bromides. Primary gastralgia, or gas- tralgia in which no etiological factors can be found, is best treated by the application of the galvanic current, either percutaneously or by the intraventricular method. The latter mode of treatment I consider much superior. I would emphasize that methodical application of the galvanic current intraventricularly, administered for a period of from four to six weeks, rarely fails to relieve the most intense and obstinate cases of idiopathic gastralgia. All the methods of treatment just mentioned have in view the prevention of the attacks. The gastric attacks as such, however, should be treated in the following manner. Pains in the abdomen not very intense in character are frequently relieved by the application of a hot-water bag or a warm linseed poultice, or by the assumption of a recumbent posi- tion, and the taking of warm drinks. Hoffman's ano- dyne (ten to twenty drops) in sugar water or on a lump of sugar, or tincture of valerian (fifteen to twenty drops) may also relieve the pain. If the at- 414 DISEASES OF THE STOMACH. tacks of gastralgia, however, appear in intense form, the administration of an opiate can seldom he avoided. The best and quickest way to relieve the suffering is a hypodermic injection of morphine (one-sixth to one- fourth of a grain) ; sujDpositories of either codeine or opium in combination with belladonna are very use- ful. I frequently prescribe suppositories of two-thirds of a grain of opium and one-sixth of a grain of bella- donna extract, to be taken every two or three hours until the pains cease. Motor Neuroses. Physiologically as soon as food has been swallowed and has passed the pharynx, the further motion of the bolus is accomplished without our consciousness. We know from experience that the peristaltic action of .the oesophagus carries the bolus to the cardia, which has opened during deglutition, and through it to the stomach. The cardia apparently remains closed, if not all the time, then at least when the stomach is at work. The pylorus is also closed during the act of gastric digestion, and opens at certain inter- vals, in order to allow portions of chyme to pass. The cardia and pylorus being closed, the anakinesic work of the stomach can go on without difficulty. If one of the arrangements just mentioned is disturbed, then pathological conditions arise. They may consist either in an exaggerated action or in a marked diminution of the work of one of the above functions. SPASM OF THE CARDIA. 4] 5 Spasm of the Carclia (Cardiospasmus). Cardiospasmus represents a condition in which there is a spasmodic contraction of the cardia and the lower part of the oesophagus, causing pain and d3'sphagia, and not dependent upon an anatomical lesion. Symptomatology. — Although chewing and swallow- ing food is accomplished without difficulty, as soon as a few mouthfuls have heen ingested a feeling of pres- sure is experienced in the region of the upper and middle portions of the sternum. The patient feels as if something had remained in the oesophagus. At the same time he has also a slight sensation of dyspnoea. Instinctively the inspirations now become much deeper and the expirations are performed with much force. The latter act frequently causes a regurgita- tion of the oesophageal contents. As soon as the oesophagus has become empty in this way the patient feels better and the symptoms just described disap- pear. The same phenomena come into play as often as the patient begins to eat. Cardiospasmus may ajDpear in an acute form and last only a very short time (one to two days), or it may, in rare instances, exist as a chronic affection and last for many years. In the latter instance it must always be considered as a grave trouble. The chronic form, although originally based on the same derangements, manifests itself in a somewhat dif- ferent way from the acute variety. The same diffi- culties (dysphagia) are experienced as described above after the swallowing of food. Instead of regurgitat- ing the food, however, the patient instinctively learns 410 DISEASES OF THE STOMACH. to force it down into the stomach, taking a very deep inspiration and compressing the thorax by muscular action while holding his breath. Liquid and semi- liquid foods are easily forced down into the stomach in the manner just described. Most of the patients learn to ingest even coarse substances; they are obliged, however, to take a few mouthfuls of liquid before they can pass the food into the stomach. As a rule, in all these cases of chronic cardiospasmus the upper part of the oesophagus becomes dilated, and can easily hold from 300 to -iOO c.c. That is the reason why patients aJHicted with this trouble perform the act of forcing the food farther down, not after every one or two mouthfuls, but rather after having already taken quite a considerable quantity, as the food meanwhile can easily lodge within the oesophagus. As a rule, three or four intermissions are made by the patient during a meal in order to force the food into the stomach. In some cases the dysphagia is more pronounced on certain days, and less on others. Such patients are occasionally able to take an ordinary meal without the slightest difiSculty. As a rule, however, these good days are not numerous. The explanation for this variable condition lies in the assumption that the spas- modic contraction of the cardia alternates with periods of relaxation. These periods of relaxation, however, are found only in cases which are not of long stand- ing. If the condition has lasted for a considerable length of time (one or two years), a dilatation of the oesophagus is often the result. As soon as this has occurred, the dysphagia becomes permanent, no mat- SPASM OF THE CARDIA. 417 ter whether the cardia be spasmodically contracted or not. The same condition — viz., dilatation of the oesophagus — can also be produced, either by paralysis of the oesophagus or by a lack of reflex relaxation of the cardia (or paralysis of the nervus dilatator car- dise, Oppenchowski). After dilatation of the oesopha- gus has been established it is generally most difficult to decide whether this is a result of a spasmodic contrac- tion of the cardia or of one of the two conditions just mentioned. The following case * well illustrates the latter possibility : J. W , 45 years of age, janitor, had typhoid fever twenty-five years ago, since which time he has enjoyed perfect health. In the beginning of March, 1888, the patient fell dov/n in the street, striking his back against a small projection. He arose unaided, and resumed his work without any annoyance. On the following day he had pains in the upper part of his body, especially in his arms ; these lasted but a few days and disappeared. About fourteen days later the patient began to have a feeling of fulness after eating, and had a pressing sensation above the gastric region. Two or three weeks later he noticed some difficulty in taking his food, and tried to assist it by drinking warm water several times during the meal ; only in this way did he succeed in enjoying a whole meal. In May, on account of this pressing sensation, the patient was compelled to leave the table in the middle of a meal and walk up and down the room, making ' Max Einhorn : " A Case of Dysphagia with Dilatation of the (Esophagus," Medical Record, 1888. Similar oases have been de- scribed by S. J. Meltzer : Berl. klin. Wochenschr., 1888, No. 8, and J. May ban m : Archiv fiir Verdaunngskrankheiten, Bd. i.. Heft 4. 27 418 DISEASES OF THE STOMACH. deep inspirations and expirations; he used to press with his hands upon the front of the lower part of his thorax after having made a deep inspiration and closed the glottis. The patient said that these attacks dur- ing a meal resembled very much a suffocating condi- tion. The described manipulation usually brought him relief, allowing him to eat again, but then the process repeated itself. In the morning he could eat more easily than at noon-time. Since June, 18SS, the patient has been sleeping very badly (at most three hours during the night). When in bed he had often a sensation as if something would go up and down in the interior of his chest, and when this sensation came on he was forced to cough quite often. From time to time it happened that he awoke, his mouth being full of fluid ; also while awake some fluid at times came up into his throat and mouth, this only happening when in the recumbent position. When standing, he was never compelled to empty his throat. The patient became thin, felt weak and miserable, and soon could j^artake only of fluid. The sight of solid food enraged him to such a degree that he threw it away with disgust. Even fluid substances were taken only with great difficulty; he used to throw his arms backward, and, standing erect, his head leaning toward the back, after a deep inspiration and with closed glottis he would press firmly. The condition of the patient became worse and worse ; he lost forty- one pounds during these few months, and went for aid to the German Dispensary on October 23d, 1888. Present Condition. — October 23d, 1888 : Patient tall in stature and lean ; looks pale. The integument can be lifted in large folds. The physical examination of the thorax and the abdomen cannot detect anything ab- normal. The heart sounds are normal. Pulse, To; SPASM OF THE CARDIA. 419 respiration, 20 ; temperature, judging from sensation upon the chest, not increased. The patellar reflex is present, and the patient is able to stand with eyes closed. The urine does not contain any sugar or albumin. The patient complains of not being able to eat any solid food, and of difficulty in taking even fluids, as he cannot get them down. Besides this, he has nearly always a pressing sensation around the chest, coughs very much, and is not able to sleep well. Examination of the Stomach and CEsophagus. — 1. October 2oth, 1888, at 8 a.m. : Patient drank coffee one hour before. As soon as a part of the stomach tube was pushed into the oesophagus a coffee-brown liquid was ejected, in which there were some rem- nants of food and many epithelial cells present. The patient then drank 100 c.c. water. I did not hear any swallowing sound at the ensiform process during the time that the patient drank. On introducing a part of the tube into the oesophagus, water of a neutral reaction came out. Thereupon the tube was pushed farther into the stomach without any resistance, and the patient ejected from his stomach through the tube about YO c.c. of a coffee-brown liquid. Eeaction acid, hydrochloric acid present (phloroglucin-vanillin test), the degree of acidity being 40. 2. November 5th, at 9 a.m. : On account of loss of appetite, the patient had not eaten anything since 2 P.M. of the previous day. The tube was introduced for a length of 46 cm. from the teeth; a pulpy mass (150 c.c.) came out, in which were present small par- ticles of bread; reaction acid, lactic acid present, no hydrochloric acid ; acidity = 4. The patient drank 100 c.c. water, the tube was introduced 45 cm., the water came out somewhat turbid by the admixture of mucus and food remnants ; microscopically there were many epithelial cells and micrococci. After the water 420 DISEASES OF THE STOMACH. had come out, the tube, without being taken out, was pushed farther and with but a slight resistance it passed into the stomach; the patient was told to empty his stomach, but only a few drops of clear fluid were obtained. This proved that the stomach was empty. 3. November 8th : The patient partook of breakfast, and then drank water; he was examined an hour later. The tube was introduced for a distance of 36 cm., when there appeared a fluid containing no hy- drochloric acid; thereupon the tube was pushed, with- out any further resistance, into the stomach, and by expression a fine chyme was obtained containing hy- drochloric acid and peptone. 4. November 13th: The patient took eggs, coffee, and a little softened white bread; then he adminis- tered his method of bringing the food down into the stomach by means of pressing (bringing the muscles of expiration into play, after having made a deep in- spiration, with closed glottis). An hour later, shortly before the examination, the patient was told to press several times again. The tube was introduced to a distance of 48 cm., and during expiration only 8 c.c. of a turbid liquid were obtained ; there were present very minute pieces of bread and many epithelial cells, but no hydrochloric acid ; thereupon the tube was pushed, without any resistance, into the stomach ; now there came out a chymous fluid with hydrochloric acid. The patient drank 200 c.c. water; the tube was introduced about 40 cm., and the water came out with a gush. 5. November 16th: Patient took breakfast at home and administered his method of forcing down his food. The oesophagus was examined an hour later and found empty. The pharyngeal vault was tickled with the finger to induce vomiting, but without sue- SPASM OF THE CARDIA. 421 cess. Thereupon the tube was iutroduced into the stomach, and a fine chymous fluid, containing hydro- chloric acid, was obtained. The stomach was then filled with air by means of a tube and bulb ; the air did not escape along the outside wall of the tube. By keeping the tube open the stomach was emptied of the air; afterwards the lower part of the oesophagus was blown up. A considerable quantity of air could be blown into it without returning, but upon increasing it still more the air began to escape upward through the upper part of the oesophagus, along the outer side of the tube wall. During the inflation of the oesoph- agus there was observed, at both sides of the vertebrae below the inferior margin of the scapulae, somewhat more tympanitic resonance, but that was not very decided. It is evident, from the history of this patient, that the difficulty in bringing the food into the stomach slowly developed a few days after the fall, and finally led to complete dysphagia. The examinations showed that the contents of the stomach were normal. The examinations with the stomach tube show, firstly, that the passage through the oesophagus to the stomach is perfectly free, for the thick tube passed into the stomach without any resistance; secondl}^, that the oesophagus, in its lower third, must be sac- cularly dilated, as the distance from the teeth to the cardia (measured with the tube) is 48 cm. ; whereas in the case of this patient, even taking into considera- tion his large frame, it ought normally to be not more than 40 to 41 cm. In this cavity the tube, leaning on the wall of the oesophagus, was compelled to assume with its lower end the form of a semicircle, and thus produce this high figure. That the patient is really unable, in swallowing, to bring even liquids down to his stomach, except by the pressing action, is proven 422 DISEASES OF THE STOMACH. by the fact that swallowed water could always he taken out from the oesophagus by means of the tube, whereas immediately afterward the tube, pushed into the stomach, brought up part of the stomach contents containing hydrochloric acid. Ewald mentions a similar case, in which the tube passed into the stomach without encountering any resistance at the cardia while the food still remained within the oesophagus. He considers this case as one of spasmodic contraction of the cardia and believes that although no resistance was felt with the tube, still the cardia became contracted during deglutition. I do not think it is necessary to assume that the cardia acts differently during insertion of the tube than while taking food. As I remarked above, the symp- tom of dysphagia exists as soon as dilatation of the oesophagus has been established, no matter whether the cardia be contracted or not, for the dilated oesoph- agus cannot contract sufficiently to carry the food into the stomach. In order to accomplish this, other means will be necessary, consisting, as mentioned above, in the compression of the thorax, after a deep inspiration. Diagnosis. — The diagnosis of the acute form of car- diospasmus is based upon the following points: The existence of dysphagia for a short time, the absence of the swallowing sounds, and the resistance encoun- tered at the cardia on insertion of a tube into the oesophagus — a resistance, however, which can be over- come. It is characteristic of this spasmodic contrac- tion of the cardia that the resistance felt during the introduction of different-sized bougies is the same or SPASM OF THE CARDIA. 423 rather less for those of large calibre, while in organic strictures of the cardia a thick tube is unable to pass and the thin ones encounter either no resistance at all or glide through with some resistance. The diagnosis of the chronic forms of cardiospasmus can be made if the symptom of dysphagia has lasted for long periods of time (three months to two years; and the examina- tion with a bougie reveals the same condition as de- scribed in the acute form. Dilatation of the oesophagus, which is of so frequent occurrence in this affection, and its most important sequelae can be diagnosed in the following way : The patient one to two hours after a meal is examined by means of a tube, which is introduced into the oesopha- gus, and if there be some contents (in the oesophagus) they are withdrawn. The patient now drinks a glass- ful of water (200 to 300 c.c.) and is told not to perform the forcing motions. After an interval of about five minutes the tube is again inserted into the oesophagus. If dilatation of the latter exists, the water will now appear through the tube in about the same condition as when drank, i.e., not mixed with food. On push- ing the tube farther down through the cardia into the stomach, real gastric contents will now appear, showing that the water the patient drank had re- mained all the time within the oesophagus and had not mixed with the food. Prognosis. — The prognosis of the acute form is good. That of the chronic form is good quoad vitam and bad quoad valetudinem completam. Treatment. — The acute form is best treated by large doses of bromides and bv the introduction of large- 424 DISEASES OF THE STOMACH. sized sounds. Opiates and chloral hydrate have also sometimes a beneficial effect. In the chronic form, the treatment will consist in the following; 1. The patient is allowed to take only fluid or semi-fluid foods; 2. After every meal he must perform his press- ing action for a long time ; 3. Every evening, before going to bed, the oesophagus is emptied and washed by means of the tube; -4. The patient introduces the tube into his stomach once every day, in order to relax the cardia. After a while, when the patient feels better, he can begin to introduce greater variety into his diet, and is allowed to eat even solid substances. Eructation. The frequent expulsion of gas from the stomach through the mouth is known as eructation or belch- ing. While this condition may accompany the most varied affections of the stomach, it may also occur alone and is then considered as a neurosis. It is characteristic of the latter that the gas expelled has no particular odor and consists principally of air. The eructations of gas may appear in the form of at- tacks lasting half an hour to an hour or much longer. The intervals between the eructations during an at- tack are sometimes very short, so that there may occur two or three belching spells in one minute. Some- times the expelled gas does not come from the stom- ach, but merely from the oesophagus, and consists of air which has just been swallovv'ed previous to the l)elch- ing. Some people are able to produce this kind of belching voluntarily. Ewald states that he can belch ERUCTATION. 425 at will from the oesophagus. By auscultating himself to the ensiform process, he became conviuced that the air voluntarily eructated did not come from his stom- ach, as no sound whatever was audible at the ensiform process. In view of this fact and of the importance of swallowing of air in the production of belching, Bouveret ' proposed to designate this condition as aei^o- phagia (eating of air) . I am inclined to think that the frequent eructations from the oesophagus, w^hich are always preceded by acts of deglutition and accom- panied by loud sounds, are identical with singultus, and result from a condition of irritation of the phrenic nerves. Attacks of singultus of short duration (ten to fifteen minutes) are of frequent occurrence, while attacks lasting several days without interruption are quite rare. The latter occur either accompanying very grave conditions (cancer of the stomach and some cases of peritonitis) or again as a primary neurosis. Nervous belching may either last several days or exist for years. The patients are never disturbed by the act of belching during sleep, but in the daytime the trouble may sometimes be so annoying as to keep them away from society or even from business. The act of belching is ascribed by some to an increased peristaltic action of the stomach, by some to a decreased contrac- tion or a relaxation of the cardia, and by some to both of these conditions together. Etiology. — Nervous belching is frequently found in hysterical and neurasthenic persons, but also in people not otherwise showing any neurotic symptoms what- ever. It sometimes appears after great mental worry ' Bouveret : I. c, p. 611. 426 DISEASES OF THE STOMACH. or excitement, or also as a sequel of an acute gastric catarrh. Treatment. — In persons with a weakened constitu- tion, in neurasthenics and hysterical persons, this primary trouble must be treated as such. If the con- dition is idiopathic, the administration of the bromide salts is very valuable. The faradic current applied intraventricularly has given me very good results in this class of cases. Diet does not seem to have much influence upon the affection. I deem it very impor- tant to tell the jDatient to try and suppress the belch- ing as often as he can. Very frequently this measure alone suffices to effect a cure. Pyrosis. By the term pyrosis is designated the ejection of chyme from the stomach into the oesophagus. As a rule, a burning sensation is then felt at the pit of the stomach, which is also known under the name of heartburn. While pyrosis is of frequent occurrence in hyperchlorhydria, it may also appear as a neurosis even if the gastric secretion is perfectly normal. It is generally believed that the sensation of heartburn can be produced solely by acid fluids, but the sensa- tion can exist even without the presence of an acid. Thus I have at present under observation a patient with achylia gastrica, in whom the gastric contents are almost always of a neutral reaction and who nevertheless frequently complains of heartburn. REGURGITATION. 42? Regurgitation. Eegurgitation denotes a condition in which either liquids or liquids mixed with solid food particles are ejected in small portions from the stomach into the mouth. These contents are, as a rule, spit out; occa- sionally, however, they are again swallowed. It is generally believed that a relaxation of the cardia is the cause of the trouble. In most instances regurgi- tation takes place involuntarily, in some, however, the patient is able to produce it at will. In nervous regurgitation the ejected matter does not show any abnormal condition (and does not smell or taste bad). This is different if regurgitation is the result of an organic affection of the stomach. Eegurgitation, as a rule, appears soon after meals, and this process may repeat itself quite a number of times in a short period. In most instances this affection does not lead to any serious conditions. Sometimes, however, if regurgi- tation is very obstinate and large portions of chyme are constantl}' ejected, serious complications may re- sult from inanition. The following case, which I have observed, is inter- esting with regard to this point. A boy, 8 years of age, had been suffering, as his mother stated, from obstinate vomiting for about three years. The little patient looked extremely pale and emaciated. He had cold extremities, became dizzy quite frequently, especially on rising, and felt very weak, so that a walk of two blocks tired him out. On further inquiry the mother stated that the boy did not vomit a large quantity at once, but brought up 428 DISEASES OF THE STOMACH. small portions of food from the stomach which he spat out. This occurred fifteen to twenty or even more times after each meal. Physical examination of the chest revealed nothing abnormal. The abdomen was slightly bloated ; the splashing sound could be pro- duced in the gastric region, extending to two fingers' width below the navel. On palpation no painful spots could be discovered. The patient took a small meal and was observed half an hour afterward. Ee- gurgitation took place while he was in ray office. The ejected chyme revealed on examination the presence of free hydrochloric acid in normal amounts. The case was diagnosed as nervous regurgitation, and the extreme degree of anaemia and malnutrition referred to insufficient nutrition on account of the great amount of chyme which was constantly ejected from the stomach and in this way lost to the organism. The little patient was given no medicine, but was told never to spit out the food which came up into his mouth, but rather to swallow it. The mother was told to keep constant watch over the boy, in order to have this rule strictly observed. In about three months the patient began to grow stronger and gained in weight, so that after this time he could hardly be 'considered sick. Moreover, regurgitation now ap- peared quite seldom and was then repeated only once or twice. Etiology. — Eegurgitation may develop either in consequence of great mental worry or nervous strain or as a sequel of an acute gastric catarrh. The prognosis is almost always good. Treatment. — This consists in the application of the faradic current intraventricularly and in the adminis- tration of strychnine. In conjunction with these RUMINATION. 429 remedies, the patient must be told to suppress regur- gitation whenever possible. At first he will often fail to do so. but after a while he will be able to sup- press it, and still later the tendency to regurgitation will entirely disappear. In cases in which regurgita- tion is of frequent occurrence and obstinate, and nutrition begins to be insuflScient, it is of the greatest importance to forbid the patient to spit out the ejected food and to tell him to swallow it again. This treat- ment may occasionally artificially produce the condi- tion which will now be described. Rumination.^ Synonyms. — Merycism, "chewing the cud." By rumination is designated a condition in which the food returns, without nausea, in small portions, from the stomach through the oesophagus into the mouth, some time after meals; here it is chewed anew and swallowed. Etiology. — If we are not inclined to accept as the cause of rumination an anatomical alteration in the upper digestive tract — a hypothesis not demonstrated or even rendered probable — two explanations still pre- sent themselves, namely, heredity and self-acquisition. But as heredity has been met with in only very few cases of rumination, and thus cannot be taken for the main cause of the affection, it appears of importance to lay most stress on self -acquisition. This may arise, firstly, from imitation; secondly, from necessity and custom (adaptation). J The history and literature of this affection can be found in my paper: "Rumination in Man," Medical Record, May 17th, 1890. 430 DISEASES OF THE STOMACH. As the best example of imitation Koerner's ' case may be cited, where a ruminating governess imparted her own affection to her two pupils ; after the gover- ness had been sent away, the two children quickly got rid of their rumination. In many cases of rumination the patients first, be- fore the beginning of the trouble, had for some time suffered from dyspeptic symptoms with regurgitations; thereafter they commenced to swallow what came up by regurgitation, and, finally, were aware of ruminat- ing. In these cases the development of rumination from slight pathological conditions, by necessity and custom, can be plainly seen. Most of the reported cases of rumination (in all the literature, to date, but one hundred and six cases have been described) are of the male sex, and belong chiefly to the professional and more educated classes (physi- cians, philologists, and lawyers) ; of the female sex only a few cases are reported as ruminants (in all nine cases, figured from the paper of Johannessen).' This alone would not prove that rumination, in fact, appears less frequently in men of the lower class and in the female sex; for very often a man of the work- ing class does not deem his condition as a ruminant to be abnormal, and does not make mention of it to his physician. On the other hand, there are several people (especially among women) who would like to conceal their affection, and therefore do not speak about it. In consequence thereof, the correct relation of rumination, in reference to its distribution among 'Koerner: Deutsch. Arcli. f. klin. MediciD, Bd. xxxiii., p. 554. '^ Joliannessen : Zeitschr. f. klin. Medicin, Bd. x., p. 274. RUMINATION. 431 the two sexes and the different social classes, cannot be ascertained from the cases reported in literature. Among the insane and idiots rumination has been found quite frequently. Thus G. Cantarono ' found nine cases of rumination among four hundred male insane; but among three hundred female insane he found no ruminants. Bourneville and Seglas"" like- wise lay stress on the frequency of rumination in idiots, and also in epileptics. Duration. — The duration of merycism is very vari- able ; sometimes there is rumination going on uninter- ruptedly during the whole of life. Often it appears in the forms of attacks, periods of rumination alter- nating with normal periods of varying duration. Sometimes rumination suddenly ceases at the occur- rence of an important change in the life of the mery- cist. Thus a case is on record in which a person ceased to ruminate immediately after marriage. But there is also a report of another case in which rumina- tion made its appearance a day after marriage. These varying circumstances can only prove how deeply rumination is connected with the nervous functions. Chemical Analysis of the Stomach Contents. — The investigations upon the chemical condition of the stomach in merycists have been made only within the most recent period. Johannessen says briefly, in his elaborate paper on rumination, that at the end of rumination the ejected 'G. Cantarono: Neurolog. Centralbl., Bd. iv. , 1885. 2 Bourneville et Seglas : " Du Meryeisme. " Arch, de Neurologie, Paris, 1883. 4:32 DISEASES OF THE STOMACH. materials showed an acid reaction. Alt,' in 1888, was the first to make exact examinations of the stomach contents in a ruminant. As soon as the patient suppressed rumination it was found that the stomach contents, obtained three to four hours after a test dinner, contained free hydrochloric acid, were rather hyperacid, and showed very retarded amylolytic qualities. But as soon as the patient had practised his rumination as usual, the stomach contents were less acid and the amylolysis was much better. Alt presumes that the rumination in his patient had the purpose of correcting the fault made by a deficient salivation of the food and the hyperacidity arising from it. "We would seem to have," he says, "in rumination a process for correcting the hyperacidity caused by a deficient salivation and the bad digestion of amylaceous matters." Acting on this theory, Alt treated his patient with alkalies, with the result that the patient was less inclined to ruminate, and further, could suppress the habit much more easily. In favor of Alt's theory would be perhaps the case of rumination reported by W. A. Hubbard." A farmer, aged thirty-five, consulted Dr. Hubbard for, as he expressed it, " the restoration of his lost cud." This patient had had the habit of ruminating his food since a period beyond his recollection, and had always enjoyed perfect health ; now, for a month the rumina- tion had stopped, and this was immediately followed by dyspeptic symptoms. All medicaments proved to be of no use. Should we look with Alt upon rumina- 'Alt: Berl. klin. Wochenschr., 1888, Nos. 26 and 27. 2W. A. Hubbard: Medical Record, July 31st, 1886, p. 122. RUMINATION. 433 tion as a means of correctioD, it would be very easy to understand why the patient had the dyspeptic symptoms at the cessation of the rumination, and his wish and hope that "his habit mhII return as suddenly as it left him," justifiable. Soon afterward, however. Boas' published a case of rumination in which the chemical analysis of the stomach contents showed the acidity to be markedly diminished. The treatment consisted in giving the patient hydrochloric acid, and the result was a diminu- tion of the rumination and an amelioration of the glandular function of the stomach. In this way by Boas' case Alt's theory has been refuted. Shortly afterward Juergensen' published two cases of rumina- tion, with an absence of the free hydrochloric acid. In considering the figures of the chemical analysis of the stomach contents of merycists I have observed, I must say that no relationship whatever can be found between the chemical condition of the stomach con- tents and rumination. In some of the patients the condition of the stomach was perfectly normal in every respect; the chemical analysis showed the pres- ence of hydrochloric acid in a normal quantity ; the power of motion also proved to be adequate; Ewald's salol reaction appeared after one hour: in others the chemical analysis of the stomach contents varied greatly on different days. There was found once normal acidity (50), once rather subacidity (4:0), and once hyperacidity (100), whereas hydrochloric acid was always present. In some, again, there was hyper- 'Boas: Berl. klin. Wochenschr., 1888, No. 831. ^ Juergensen : Berl. klin. Wochenschr., 1888, No. 46. 28 434 DISEASES OF THE STOMACH. chlorhydria, while in others achylia gastrica prevailed. The conjecture of Ewald is therefore confirmed. This author, in his book on the "Diseases of the Stomach," says in reference to rumination: "I would not be as- tonished, the conditions being the same, if varying degrees of acidity were found in the same patient, be- cause such changeable conditions are in the nature of many neuroses." One of my patients (K ) furnished the best example of such an occurrence, and from this we can infer that no connection exists between rumination and the chemical condition of the stomach. During the last nine years I have observed twenty- two cases of rumination. One of the first cases, which I described in the Medical Record,^ was as follows: March 26th, 1890: G. P , physician, aged 27, had febris gastrica in his childhood, and in 1884 typhoid fever. Since his ninth year the patient has been troubled with his stomach ; at that time, during a period of six months, he usually vomited after par- taking of food, especially of fluid. Sometimes the patient had to vomit at the beginning of the meal, immediately after the soup, but could nevertheless continue to partake of his meal directly afterward. Since then his condition has become ameliorated, and instead of vomiting there appeared rumination. The rumination in this patient appears spontane- ously, about one hour after meals, and continues for about a quarter of an hour. The food comes up in small quantities (in the form of boli). The taste is not sour; in chewing the cud the patient has a pleas- ant sensation. > Max Einhorn: "Rumination in Man," Medical Record, I. c. RUMIXATION. 435 When he partakes of liquid food only (as, for in- stance, beer, bouillon, coffee, milk), there is no rumi- nation. In this patient the rumination appears periodically ; thus, for instance, he ruminated three months, and then Tvas free from the trouble for about a year. Even during the period of rumination the bowels act regularly ; the patient, however, often suffers from belching. He is able to ruminate at will any time there is food in his stomach. The act of rumination proceeds even then without any effort. In order to effect the rumi- nation the patient closes his glottis and exerts slight pressure over the stomach by means of his abdominal muscles; the contents are then ejected in small por- tions into the mouth. Patient is able to do this in any posture; when he is sitting or standing, however, it is done with more ease than in a recumbent position. In the same way the patient is voluntarily able to belch and to vomit; the latter in such a way that all the stomach contents are ejected at once. The patient is thus enabled to cleanse his stomach easily ; he does this by drinking a large quantity of water and ejecting it immediately after. He also has the faculty of stopping the vomiting at any moment he chooses, and in this way he can alternate vomiting with rumi- nation. He has diplojDia and is color-blind in one eye. The father of the patient and several of his brothers and sisters are troubled with the stomach; the main symptom of their ailment is belching; nobody in the family, however, had ruminated. The patient is able to suppress rumination, not feeling any pain in doing so. He does not know what causes the periodical attacks of rumination, although he has noticed that after any excitement he is more liable to have an attack. 436 DISEASES OF THE STOMACH. The physical examination shows no abnormal con- ditions whatever. Patient is of medium height, well developed, somewhat stout. Tongue perfectly clean. The stomach does not seem to he dilated. Seven seconds after swallowing water a rattling sound ap- pears on auscultation at the xyphoid process. Examinations of the Stomach. — 1. During the rumination period, September 15th, 1888. One hour after Ewald's test breakfast: HCl +; acidity = 50; erythrodextrin +; achroodextrin -\-. On the same day the patient took 1.0 gm. salol in a gelatin capsule; the urine showed the salicyluric acid reaction (it be- came dark red on addition of a few drops of liquor ferri sesquichloridi) after one hour. 2. During an interval of freedom from rumination, March 25th, 1890. One hour after test breakfast: HCl + ; acidity = 54 ; erythrodextrin + ; achroodex- trin + . After this examination the patient had an attack of rumination for three days, then it ceased. Treatment. — Formerly hydrochloric acid, alkalies, narcotics, and bitters were tried empirically now and then, with apparent results for a short time, and some- times without any influence whatever. Lately the attempt has been made to remedy the error — if any — ascertained after a chemical examination of the stomach contents, and hydrochloric acid or alkalies have accordingly been given, with good results. Koerner tried giving small pieces of ice immediately after meals, and warmly recommends this method. Washing out of the stomach has been practised by Johannessen, and gavage (feeding through the stomach tube) during fourteen days by Juergensen. but with only temporary relief. All these remedies NERVOUS VOMITING. 437 sometimes effect a temporary amelioration ; a perma- nent cure, however, has never been achieved by thera- peutic means. As an exception to this rule we might perhaps consider the moral treatment — i.e., the pa- tient determines not to ruminate and, as soon as a de- sire to ruminate appears, endeavors to suppress it. Ponsgen' mentions two cases of merycism perfectly cured by this method. This moral treatment can of course be applied more easily in cases in which the rumination can be sup- pressed by the will power of the patient, although even in those in which the rumination is wholly indepen- dent of the will it can also be effected. In treating Dr. G. P., I made use of this method; he was instructed, as soon as he felt any inclination to ruminate, to try with all his power to suppress it. The patient has carried out this rule quite conscien- tiously, and the merycism has since that time occurred only occasionally. In the treatment of several other cases I have applied the same method with the best result. Nervous Vomiting {Vomitus Nervosus). The process of vomiting serves to empty the stomach of its contents by the shortest way, that is, through the oesophagus and mouth. The mechanism of this action is very complicated and a large number of striated and non-striated muscles participate in it. At first the abdominal muscles and the diaphragm contract and compress the abdominal cavity; then ' Ponsgen • " Die motorischen Verrichtungen des menschlichen Magens, " Strassburg, 1882, p. 127. 438 DISEASES OF THE STOMACH. the stomach contracts and the pylorus closes firmly. At the same time the longitudinal fibres of the lower end of the oesophagus contract and open the cardia ; the pressure which is exerted by the stomach upon its contents throws them into the open oesophagus, which becomes wider and shorter by the contraction of its longitudinal fibres. The epiglottis turns upon the larynx and closes up this canal, while the soft palate rises and covers the posterior nares. Both these actions serve to prevent the contents from reaching either the larynx or the nasal cavity. The only canal which remains open is the mouth. From the oesopha- gus, by an antiperistaltic contraction of the same, the contents are quickly emptied through the mouth. It is generally believed that there exists a centre for the act of vomiting in the vagus nucleus. It may even be that the respiratory centre and the centre for vomit- ing are situated at one and the same spot. Vomiting may be a consequence of various patho- logical conditions of the stomach, or may be due to an abnormal state of the food. Nervous vomiting is characterized by the absence of either of the two con- ditions mentioned. The vomiting may be due to some spinal or cerebral irritation, or may originate reflexly from abnormal conditions in other organs (pharynx, oesophagus, larynx, palate, kidneys, liver, peritoneum, genital organs, etc.), or it may be due to neurasthenia or hysteria. Among these different kinds of nervous vomiting juvenile vomiting and the periodic vomiting of Leyden' deserve special consideration. ' E. Leyden : I. c. NERVOUS VOMITING. 439 Diagnosis. — The diagnosis of nervous vomiting has a twofold object in view : (1) To recognize the nervous character of the condition, and (2) to reveal, if pos- sible, its cause. Stiller' gives the following points as characteristic of nervous vomiting : It occurs easily, without anv effort and without any preparatory stage. It is, as a rule, independent of the quality and quan- tity of the ingested food. Other points he mentions are: The capriciousness with which certain kinds of food (sometimes very easily digestible) are ejected, while other indigestible substances are w^ell borne; the faculty which sometimes exists in selecting only one certain substance from the various food -stuffs present in the stomach for the vomiting ; the careless- ness with which the patients bear this condition for a long time; the very slight or hardly marked degree of inanition, notwithstanding the long duration of the ailment. The vomiting is not always dependent upon the meals, but may occur occasionally in the fasting- condition. There exist other neuropathic symptoms, which may be associated with the vomiting or alter- nate with it — the influence which psychical conditions exert upon the vomiting. To these points Boas' adds another one, namely, normal secretory and motor functions of the stomach. I agree, however, with Bouveret that, while this ma}^ be present in some cases, there certainly occur cases of nervous vomiting in which the gastric secretory function is greatly dimin- ished or even absent. Juvenile Vomiting. — This condition occurs in young 1 stiller: "Die nervosen Magenkrankheiten," Stuttgart, 1884. 2 Boas: I. c, p. 238. 440 DISEASES OF THE STOMACH. persons attending school, especially if they are over- worked. Symptoms of cardialgia and vomiting de- velop, the latter appearing either once or twice every day, or presenting a rather periodic character. Oc- casionally there is a train of the following symptoms associated with this vomiting: severe headache, marked pallor, very slow pulse, and dilated pupils. The diagnosis of this form of vomiting is easily made by the symptoms just mentioned. The best treatment is the temporary removal of the patient from school, and a good, strengthening diet. Periodic Vomiting (Leyden). — Leyden first de- scribed periodic vomiting, which is characterized by the following points: 1. It appears in apparently healthy individuals; 2. The paroxysms occur periodically after intervals of equally long duration ; 3. When the attack is over, the patient is perfectly well and no gastric symptoms persist. The attack is very similar to that of acute suc- corrhcea gastrica continua, and may be described as follows: In the midst of perfect health the jDatient experiences for a short time uneasy sensations (slight headache, nausea, slight chilly feeling) which are followed by vomiting. At first the entire gastric con- tents are ejected ; later the vomited matter consists of mucus, alone or with admixture of either bile or shreds of blood. The latter is more frequently found if violent retching has preceded the act of vomiting. Frequently, although not always, there exist an in- tense pain in the epigastric region and a sensation of utter prostration. The abdomen is, as a rule, sunken and the extremities are cold. At this time no food NERVOUS VOMITING. 441 whatever is borne by the stomach ; even a drink of water is very soon ejected. This condition of utter irritability of the stomach and persistent vomiting may last from one to ten days, when suddenly the disturbances disappear, the nausea subsides, and a feeling of hunger returns, which can be satisfied with impunity. All kinds of food are now well borne by the stomach, which but an hour before could not re- tain the lightest food. The periodic vomiting of Leyden is a rare affection, and it does not seem to me that the condition of the gastric secretion plays an important part in its causa- tion. While most of the cases mentioned in literature seem to have been associated with a normal condition of the gastric juice, I have observed a case of periodic vomiting in a patient who was affected with achylia gastrica. This patient (J. S.), thirty-seven years old, had been troubled for the last six years with periodic attacks of vomiting, which appeared once in either six or three months and lasted from four to five days. During the intervals the patient could partake of all kinds of food without much inconvenience. The only complaints referred to were frequent belching and constipation. During the attacks the patient could not ingest anything for the entire five days and as a rule presented the most alarming symptoms. I examined him frequently during the intervals and also during the attacks and never found any traces of gastric juice in the contents. The treatment consists in absolute rest, in the ad- ministration of ice pills, and in the use of morphine (subcutaneous injection) or of opium in the form of 442 DISEASES OF THE STOMACH. suppositories. During the intervals between the attacks a sojourn in the country and hydropathic pro- cedures may prove of value. Reflex Vomiting. — jS^ervous vomiting frequently occurs as a result of derangements of various other organs. Thus abnormal conditions of the pharynx, an elongated uvula, disorders of the genito-urinary organs may be associated with vomiting. The vomit- ing of pregnancy must also be considered as belonging to this group. Floating kidney, hydronephrosis, he- patoptosis may likewise be the cause of vomiting. The treatment of this class of cases will have to be directed toward the seat of the original trouble. An elongated uvula must be amputated, and ptosis of the different abdominal organs must be remedied by keeping them in place by means of a suitable bandage. All the genito-urinary disorders should be treated as such. The vomiting of pregnancy must be considered as a physiological phenomenon as long as it occurs during the first months of pregnancy and appears only once or twice a day, not interfering much with the general nutrition. In this case it is hardly neces- sary to use any therapeutic means. If, however, the vomiting appears more frequently and obstinately, so that the patient begins to lose in weight, then we have the following remedies at our disposal : Bromide of sodium, 1 gm. (gr. xv.), to be taken twice daily; cerium oxalate, 2 dgm. (gr. iii.) three times daily. I^ Menthol, 1.0 Aq. dest., . 100.0 Spir. frument. rectif. , . . . . 50.0 Syr. zingib., . .... 30.0 D. S. One tablespoonful four times daily. NERVOUS VOMITING. 443 Other remedies, such as cocaine, codeine, belladonna, or chloral hydrate, may occasionally be useful. If medicinal treatment fails, then a change of surround- ings, as a sojourn in the country, may be tried. If all these means prove useless and the vomiting con- tinues undiminished, so that the life of the patient is in danger, then as ultimuiii refugium, artificial abor- tion has to be resorted to. Idiopathic Nervous Vomiting. — Besides the above- named two groups of vomiting, namely, the juvenile and the periodic, which appear without any apparent cause, there exist cases of vomiting in adults which do not show any periodicity. The vomiting occurs, as a rule, after meals. Usually only a portion of the meal is ejected; occasionally, however, the wholemeal may be vomited. The vomiting may exist for months and sometimes even for years without remission. The nutrition, as a rule, in these instances is not disturbed. Neurasthenic and hysterical individuals form the greater contingent of sufferers from this form of vom- iting. Sometimes, however, persons with an appar- ently normal condition of their nervous functions may be affected with this trouble, w^hich is by far more frequent in women than in men. The treatment consists in regulating the mode of life of the patient and in advising him to suppress vomiting whenever possible. In neurasthenic and hysterical patients the treatment must be directed against the original trouble; in others change of climate may be tried. Of medicines the bromides play a great part. Arsenic and iron are useful in many instances. In severe cases of vomiting, feeding 44J: DISEASES OF THE STOMACH. through the tube for a period of two weeks may be resorted to. During this time no food is to be taken in any other way. When this period is over, then small quantities of food are administered per os, be- sides continuing the gavage (feeding through the tube). If the food which is taken by tlie mouth is no longer vomited, then after a while gavage may be discontinued and the feeding done in the natural way. Intragastric faradization may also prove useful. Sev- eral cases have come under my observation in which nervous vomiting, after having lasted for many years and resisted the most diverse modes of treatment, has been perfectly cured by the faradic current. Pneumatosis. Under the name gastric pneumatosis are classified a group of cases in which the stomach is distended with gas (air), giving rise to a sensation of marked tension and frequently also to shortness of breath (asthma dyspepticum, Henoch). It is generally believed that a spasmodic contraction of both the cardia and pylorus is partly the cause of this condition. This affection may appear periodically or exist constantly. It is often found associated with other symptoms of neu- rasthenia or hysteria ; occasionally, however, it is met with alone. In typical cases of pneumatosis the epigastric and gastric regions are found greatly pro- tuberant, sometimes the uj^per jDart of the abdomen looks like a balloon. On percussion this area gives a highly tympanitic sound. The patients experience a sensation of distention and marked want of air; some- times a feeling of utmost anxiety is also present. HYPANAKINESIS VENTRICULI. 445 Belching, as a rule, cannot be produced by these patients. In making the diagnosis of this condition, it will be necessary to exclude organic affections of the stomach which may give rise to similar symptoms. In the lat- ter, however, the gas accumulated in the stomach will have a foul odor. The treatment consists in a general tonic regimen of the nervous system and in the administration of the bromide salts. An acute attack of pneumatosis can be checked in the quickest and easiest way by the in- troduction of a tube into the stomach, so that the imprisoned air can find an exit. The symptoms of tension then disappear at once. This procedure must be repeated whenever a considerable quantity of gas has accumulated in the stomach and given rise to the characteristic symptoms. If a tube is not at hand, or its introduction be inadvisable, the attack may be relieved by a subcutaneous injection of morphine (Ewald). The extract of Calabar bean may also be found very useful, Hypanakinesis Ventriculi. I have applied the term hypanakinesis to a condi- tion in which the mechanical function of the stomach is greatly reduced. If tested with the gastrograph there are found only three or four "breaks" and "makes" of the current marked within three minutes. Sometimes no current changes whatever are observed within the same time. I have noticed this condition several times in gastric ulcer, but twice also in persons in which the diagnosis of gastric ulcer could be ex- 4-46 DISEASES OF THE STOMACH. eluded. One of the latter usually complained that he experienced the most disagreeable sensation soon after meals when resting quietly. He felt relieved only when walking about for three-quarters of an hour or an hour after each meal. It may be that the exercise which the patient instinctively resorted to served to supplement the mechanical work of the stomach that was lacking. Hyperanakinesis Ventriculi. In contrast to the above, hyperanakinesis ventriculi denotes a condition of too strong mechanical action of the stomach. The gastrograph shows forty to eighty " breaks" and " makes" of the current within three minutes. This symptom is frequently foand to be present in cases of obstruction at the pylorus, but may occur in other conditions. In several of my cases this symptom was associated with hyperchlorhydria. Peristaltic Restlessness of the Stomach (Kussmaul '), Tormina Ventriculi Nervosa. Under this heading are grouped those cases in which there is not only an increased motor (mechanical) activity of the stomach, but in which the peristaltic movements are distinctly visible. In this condition the peristaltic action of the stom- ach is remarkably active. High waves can be seen moving along the stomach from left to right. The time required for one wave to pass from the extreme left to the pylorus is about one minute. This visible 'Kussmaul: "Die peristaltische Unruhe des Magens. " Volk- mann's Samml. kliu. Vortrage, No. 181, 1880. PERISTALTIC RESTLESSNESS OF THE STOMACH. 44? peristaltic action of the stomach is more pronounced when it is filled with food. In some instances the exaggerated peristalsis is felt by the patient as a slightly painful contraction. In other instances it is not perceptible to the patient. Peristaltic restlessness of the stomach is usually found in dilated stomachs with obstruction of the pylorus. Here it signifies the effort which the stomach makes to overcome the undue resistance which the contents find in passing through the stenosed pylorus. In rare instances peristaltic restlessness of the stomach may occur alone without any obstruction of the pylorus, in that case being a pure neurosis. Kussmaul has described two such cases of nervous origin. I have had the opportunity of observing eight cases of peristaltic restlessness of the stomach in stenosis of the pylorus (seven cases of cancer and one case of benignant stenosis) and only one case of nervous origin. The latter was in a man, forty-two years old, who presented distinct symptoms of neurasthenia and complained of a moving cramp- like sensation, which usually appeared soon after meals in the gastric region and lasted for half an hour or longer. On inspecting his abdomen half an hour after a light meal, small "mountainous waves" could be seen moving from left to right over the gastric region. In this case the greater curvature of the stomach extended to one finger's breadth above the navel (gastrodiaphany) and the stomach was usually found empty one and a half hours after a test break- fast. The treatment of this affection, if associated with pyloric obstruction, must be directed against the latter 448 DISEASES OP THE STOMACH. primary trouble. In cases of neurotic origin, our therapeutic measures will have to be directed against the nervous system. Massage, hydrotherapy, elec- tricity {percutaneous or intragastric faradization), change of climate and surroundings will frequently prove useful. Larger doses of potassium bromide and codeine, either alone or with belladonna, are often beneficial. Antiperistaltic Restlessness of the Stomach. Glax,' Schiitz," and Cahn ^ have described cases in which the waves over the stomach moved from right to left, and they therefore designated this condition as "antiperistaltic restlessness of the stomach." Glax's case was of neurotic origin. In making the diagnosis of peristaltic or antiperistaltic restlessness of the stomach it is of the greatest importance to deter- mine that the visible waves originate within the stom- ach and not in the intestines. Peristaltic and anti- peristaltic movements of the small intestines are frequently observed and can easily be distinguished from motions of the stomach by the forms presented by the waves. If they originate in the small intes- tines, they are of small calibre (sausage-like) and are seen moving in different directions and over different regions, while the waves produced in the stomach are nearly always quite large (hand-size) and always move, if peristaltic, from left to right, if antiperi- staltic from right to left, in the upper part of the abdominal cavity. 'Glax: Pest, med.-chirurg. Presse, 1884. 'Schiitz: Pragermed. Wochenschr., 1882, No. 11. 3Cahn: Deutsch. Arcli. f. klin. Med., 1884, p. 402. IXCOXTINENTIA PYLORI. 449 Incontinentia Pylori {Incontinence of the Pylorus). Incontinence of the pylorus was first described by L. de Sere' and later by Ebstein/ The pylorus may be incompetent, first, when unyielding neoplasms in- volve this portion of the stomach ; secondly, when the pyloric sphincter is in an atonic condition, i.e., when the pylorus is apparently always open by reason of some nervous derangement. Ebstein diagnoses an in- continence of the pylorus if on inflating the stomach with air the latter rapidly passes into the intestines, so that it becomes impossible to fill the organ with gas. Instead of the stomach, the small intestines then become filled with air and give tympanitic sounds on iDercussion. Ewald justly doubts the accuracy of this diagnostic means. He has, indeed, never ob- served this symptom. In all the cases in which he had distended the stomach to its utmost extent with air, he could never demonstrate that the air passed into the intestines. Whenever the tension became too great, the air always escaped upward through the cardia with eructation. My own experience coincides with that of Ewald. Incontinence, or rather relaxa- tion of the pylorus, is a rare condition, and we are able to recognize it, not so much by the fact that food and gas pass from the stomach into the duodenum more rapidly than normally, as by the regurgitation of intestinal contents into the stomach. The presence of the latter condition is shown by the fact that on 'L. de Sere: "Du Eelachement du Pylore." Gaz. des hop., 1864 No. 62. ^Ebstein: Deutsch. Arch. f. klin. Medicin, Bd. 26, p. 295. 29 450 DISEASES OF THE STOMACH. washing out the stomach in the fasting condition, more or less large quantities of intestinal juice and especially of bile almost always appear. While the occasional regurgitation of intestinal secretion into the stomach may occur as a consequence of irritation caused by the tube when lavage is applied, still the quantity of the intestinal juice is always small. In incontinence of the pylorus, the quantity of regurgi- tated intestinal juice and bile is considerable and al- ways present in the fasting condition at each washing of the stomach, and sometimes also if the contents of the organ are withdrawn one hour after the test break- fast or three to four hours after a test dinner. Whether the condition in which the stomach becomes empty more rapidly than normally is to be referred to a relaxation of the pylorus, or to an increased motor function (hyperprochoresis) of the organ, is still undecided. In most instances, however, it seems to me that the latter factor is the more probable. I have observed two cases of relaxation of the pylorus, and both have been treated by intragastric faradization with good results. Occasionally relaxation of the py- lorus is combined with relaxation of the cardia, as the following case well illustrates: Miss Emma M , 24 years of age, suffering for three years from loss of appetite, eructation, consti- pation, and poor sleep; there was no vomiting but belching of acid fluid after meals. One of the worst complaints of the patient was of this highly annoying ructus, which never left her, and in consequence of which she was hampered in her occupation and frequently kept away from society. PYLOEOSPASMUS. 451 Present Condition. — Tongue thickly coated ; splash- ing sound from the stomach to a point two fingers' breadth below the navel : the right kidney is clearly palpable and easily moved. Examination of the stom- ach in the fasting condition by means of a tube shows that there is bile mixed with gastric juice in the stomach ; also after the test breakfast the contents of the stomach were usually found mixed with bile, as will be seen from the following memorandum : One hour after the test breakfast : HCl + ; acidity = Q^ ; admixture of bile. When fasting, the stomach contains 70 c.c. of an in- tensely yellow-colored fluid (bile present) ; HCl +. The treatment consisted in direct gastro-faradiza- tion and once in a while washing of the stomach. During the month of April the faradization was ap- plied every other day, and the lavage of the stomach once a week in the fasting condition. The patient felt better after a few days' treatment; the eructation disappeared almost entirely, and she could eat with good appetite, having no distress afterward. Subsequently the faradization was applied once a week and then discontinued. The patient gained sev- eral pounds during the treatment, and has been pretty free from complaints since that time. Pylorospasmus. A spasmodic contraction of the pylorus without or- ganic disease has been described by Bentejac' He reports the following case : A man, 59 years old, swallowed a glassful of kero- sene by mistake. After this accident he was troubled with intense pains in his epigastric region, but never 1 Bentejac : These de Paris, 1888. 452 DISEASES OF THE STOMACH. vomited blood nor did he pass blood with his move- ments. At the end of eight months there was inces- sant vomiting and the dilated stomach extended below the navel. Stenosis of the pylorus was diagnosed, and Richelot performed an exploratory laparotomy, but found the pylorus perfectly smooth and normal. The result of the examination during the operation proved that the pylorus was only spasmodically contracted. The operation, however, had the result that the pa- tient ceased to suffer from vomiting, which must be ascribed merely to the suggestive effect of the pro- cedure. Pylorospasmus is frequently found in association with ulcer, either of the pylorus or of its immediate neighborhood, and must then be considered as a reflex neurosis. The symptoms produced resemble in most instances a real stenosis of the pylorus; and if several attempts to improve the condition have totally failed, then surgical interference must be resorted to. Bou- veret ' states that pylorospasmus frequently occurs in cases of hyperchlorhydria and especially of hyperse- cretion. The fact that in these cases the pyloric re- gion is sometimes found to be painful and very tender on pressure, Bouveret refers to an undue spasmodic contraction of the pylorus. I must say that this symptom alone is not sufiScient to warrant the as- sumption of pylorospasmus. The pains which are felt more to the right side may be caused by the un- due irritation which too acid chyme exerts during its passage through the pylorus. ' Bouveret : I. c. ATONY OF THE STOMACH. 453 Atony of the Stomach. Synonyms.— Gastvic insufficiency (Eosenbach') ; my- asthenia ventriculi (Boas). Atony of the stomach designates a condition in which the muscular action of the organ is retarded and weakened. It occurs as a frequent complication of many digestive disorders, and also of other diseases which greatly weaken the constitution. Thus we find it accomiDanymg chronic gastric catarrh, hyperchlor- hydria, neurasthenia gastrica, tuberculosis of the lungs, grave heart affections, and the like. Some- times, however, this condition exists as a primary neurosis. Symptomatology. — If atony occurs as a complica- tion to another affection, the symptoms of atony will be overshadowed by those of the principal trouble. If it exists alone, the following characteristics are fre- quently present. An uncomfortable feeling of fulness appears after meals ; often there is eructation of gas ; the appetite is diminished ; headaches and constipa- tion are frequently present. Diagnosis. — ^The diagnosis is based upon the pres- ence of the above-described symptoms and the detec- tion of the following points on examination : 1. The splashing sound is easil}^ produced in the gastric region, even if the stomach contains only a small quantity of chyme or liquid. As a rule, the area over which the splashing sound can be produced extends from the margin of the ribs on the left side to the umbilicus or somewhat below it. ' Rosenbach : Volkmann's Samml. klin. Vortrage, 1878, No. 153. 454 DISEASES OF THE STOMACH. 2. Six to seven hours after Leube's test dinDer, the washing out of the stomach reveals the presence of a more or less considerable quantity of chyme; while the stomach is found empty in the morning in the fasting condition. 3. On filling the stomach with water, the greater curvature will descend lower and lower as water is added. This symptom, however, which has been de- scribed by Pacanowski ' and Boas, is not constant and therefore not reliable. The prognosis of atony of the stomach is not bad, as the affection is quite amenable to treatment. Treatment. — A hygienic way of living and a strengthening regime should be advocated. Too much brain work should be forbidden, and plenty of outdoor exercise and frequent bodily ablutions are to be enjoined. Slow eating and thorough mastication of the food are of the greatest importance. The quan- tity of fluids should be restricted. Not more than from one to one and one-half quarts of liquid, includ- ing tea, coffee, milk, and soup, should be given daily. As a rule it is best to have the patient take five meals a day. The diet should consist of light solid food (bread and butter, eggs, mashed and baked potatoes, farina, hominy, soup with vermicelli), tender meat (tenderloin steak, lamb chops, roast beef, chicken, squab), fish, oysters; spinach, asparagus, green peas, carrots; tea, coffee, or cacao (with sugar and milk) in small quantities; a small quantity of beer or ale. Of medicaments strychnine ranks highest. I fre- quently give tincture nux vomica and fluid extract of ' Pacauowski : Deiitsch. Arch, f . klin. Medicin, Bd. 40. SECRETORY NEUROSES. 455 eondurango equal parts, twenty drops three times daily. The administration of ferratin ^ gm. three times daily may also frequently be found useful. Electricity, especially intragastric faradization, seems to me to be of the greatest value, in order to strengthen the muscular apparatus of the stomach. With regard to lavage, I concur with Boas that its use is not indicated in this affection. The constipation, which is so frequently present, is best treated by having the patient partake of plenty of green vegetables, brown and Graham bread, and plenty of fruit ; he should be instructed to go to the closet in the morning always at the same time. If these means, however, do not suffice, then I frequently order the following pills : i^ Podophyllin, 0.3 Extr. uuc. vom., Extr. fab. calab., . aa0,5 Extr. gentian., Pulv. glycyrrhizge, aa q. s. M. efc ft. pil. No. 30. S. One pill twice a day. Instead of this pill fifteen to twenty drops of the fluid extract of cascara sagrada may be given twice daily. Secretory Neuroses. The existence of secretory nerves governing the glandular secretion of the stomach is generally ac- cepted as a fact, although they have not as yet been demonstrated experimentally beyond a doubt. Sev- eral physiological facts speak in favor of this view : A piece of meat held before the eyes of a dog provided with a gastric fistula produces a flow of gastric juice. 456 DISEASES OF THE STOMACH. The same phenomenon has been observed by Eichet ' in the case of a man with a gastric fistula. Fear and great anxiety have a depressing effect on the gastric secretion. These facts clearly show the influence of nerve centres within the brain upon the gastric secre- tory function. There must, however, undoubtedly exist some nerve mechanism within the stomach it- self which regulates the secretion ; for after section of the vagus and sympathetic nerves supplying the stom- ach, the latter organ wall continue to produce its ordi- nary secretion after the aiDplication of an irritant. As in the neuroses previously considered, conditions of increased and decreased functions exist also in these cases. After having described the functional disorders of secretion under special chapters (Hypersecretion and Achylia Gastrica), we need say here only that in most instances these affections are of nervous origin, either prctopathic or of a reflex nature. This latter theory has been especially advocated by Charles G. Stock- ton,* of Buffalo. Frequently, however, disorders of secretion may secondarily accompany primary neuroses; thus tabes dorsalis and other spinal lesions are frequently associ ated with hyperchlorhydria and also with periodic gastrosuccorrhoea. Neurasthenia and hysteria may be complicated with either hyperchlorhydria or hypochlorhydria or achylia. The symptoms which these secretory disturbances ' Ch . Richet : " Du Sue gastrique chez 1 ' Homme et les Animaux, " Paris, 1878. ■^ Charles G. Stockton : Medical Record, 1894. NERVOUS DYSPEPSIA. 457 evoke are the same as if they were the primary affec- tioDs. Hypochlorhydria of nervous origin is sometimes met with without the association of other nervous symptoms, and it is then quite difficult to establish the diagnosis between this affection and gastric catarrh. Absence of tenderness on pressure in the gastric region and a perfectly clean tongue point rather to the presence of a neurosis. Sudden changes in the condition of the gastric secretion speak likewise in favor of a neurotic character. Nervous Dyspepsia "^ (Leube). Leube* originated the name of nervous dyspepsia (neurasthenia gastrica of Ewald) to describe a condi- tion characterized by manifold subjective symptoms, which appear during the act of digestion, but cannot be referred to any abnormal condition in the organ susceptible of objective demonstration. All cases in which dyspeptic symptoms existed and in which after a test dinner hydrochloric acid was detected and the organ was found empty seven hours after this meal, Leube diagnosed as nervous dyspepsia. Later, w^hen attempts w^ere made to estimate the degree of acidity quantitatively, all the cases of hyperchlorhydria had to be sepai-ated from this condition. For here the subjective complaints of the patients could be referred ' Nervous dyspepsia is in reality a viixed 7ieurosis in which the sensory, motor, and secretory nerve mechanism, either combined or alternately, may play a part. 2 Leube: "Ueber nervosa Dyspepsia." Deutsch. Arch. f. klin. Medicin, Bd. 23, 1879. 458 DISEASES OP THE STOMACH. to the abnormal condition existing in the undue secre- tion. Nervous dyspepsia may best be characterized by the existence of manifold clinical symptoms, with- out any organic lesion whatever. Etiology. — The disease appears more frequently in men than' in women. Although it may occur at the most diverse ages, still the years between thirty and forty-five show the greatest frequency. Many debili- tating conditions give rise to the development of this trouble : chlorosis, lung troubles, grippe, malaria ; ab- normal conditions of the genito-urinary organs, sexual excess, excessive use of tobacco and alcohol predispose to this affection. Organic troubles of the stomach, such as ulcer or chronic gastric catarrh, may also give rise to this complication. It is hardly necessary to say that both neurasthenia and hysteria are often complicated with nervous dyspepsia, or, speaking more correctly, the nervous dyspepsia in reality forms a part of these two conditions. Symptomatology. — The appetite is generally irregu- lar and capricious. Sometimes it is increased, more frequently, however, it is lessened. The tongue, as a rule, is clean and only occasionally slightl}^ coated. Vevy soon after a meal various symptoms appear: slight pains in the gastric region, frequent belching, sometimes an irresistible desire to sleep, occasionally a feeling of burning in the head, especially in the forehead. All these disagreeable sensations frequently last as long as there is food in the stomach. Some- times, when the stomach is empty, a weak feeling and slight dizziness overcome the patient, so that there is really no time whatever during which the patient NERVOUS DYSPEPSIA. 459 feels perfectly well and enjoys the feeling of a healthy person. This explains the marked depression existing in these patients. Most of them look at everything from the darkest point of view, and any small incon- venience, which would hardly be noticed by a healthy iDerson, may give them great anxiety and fear. At first the nutrition of the body appears to be in good condition. But sooner or later the patient begins to lose in weight, the sleep is also very soon impaired, and all the symptoms are aggravated. Besides the gastric symptoms there are also mani- fold symptoms which refer to the intestines. Sensa- tions of fulness or of tension, and sometimes also pain, are experienced in different regions of the abdomen. Frequently these abnormal sensations are caused by an accumulation of gas in the intestinal tract and re- lief is felt after the passing of flatus. The bowels are almost always constipated. The movements some- times appear in the form of small balls and occasion- ally in the form of a very thin long cylinder the size of a quill. The latter is always the result of the spasmodic form of constipation. Diarrhoea is very seldom met with in this disease. Burkhart ' has described the existence of certain points in the abdomen which are painful to pressure, and believes them to be characteristic of this affec- tion. Leven ^ likewise attributes great importance to the appearance of these painful spots, which he ascribes to an irritation of the solar plexus. He de- ' Burkhart : " Zur Patbologie der Neurasthenia gastrica, " Bonn, 1882. ^ Leven: " Estomac et Cerveau, " Paris, 1884. 460 DISEASES OF THE STOMACH. scribes three such painful areas, one immediately be- low the ensiform process, the others near the navel, especially to the left of it. Ewald, Eichter/ and Bou- veret are of the opinion that this symptom is by no means characteristic of nervous dyspepsia, as they have met with cases of the affection in which no such painful points could be found. The condition of the gastric juice does not present anything characteristic of this affection. Frequently the juice will be found normal. Sometimes the degree of acidity will be di- minished and occasionally increased. In many cases the condition of the gastric juice will reveal mani- fold variations from time to time. I agree with Bouveret that more frequently a diminished acidity is met with in this affection. If the affection has lasted quite a while, atony of the stomach is usually present. In w^omen enteroptosis very frequently occurs as a complication. In both sexes, but more frequently in the female, membranous colitis may develop in conse- quence of the high degree of constipation and of the irritation of the colon through scybala. Besides all these symptoms, which refer to the digestive tract, manifold nervous symptoms usually occur: headache, insomnia, pains in the back, frequent emissions, some- times impotence, vertigo, palpitations of the heart after slight exertions or after meals, feeling of ex- treme weakness, loss of energy and ambition, etc. The prognosis of neurasthenia gastrica is quite un- certain. Cases of a slight nature may sometimes re- sist the best kinds of treatment for a long time. On the other hand, cases of a severer nature may readily 'Richter: Berl. klin. Wochenschr., 1882. NERVOUS DYSPEPSIA. 461 yield to rational treatment. The duration of the dis- ease can very seldom be foretold, and although life is not directly endangered, still instances of fatal issue even without apparent complications have been re- ported in literature. Diagnosis. — The presence of symptoms of general neurasthenia, and especially of those attributable to the digestive tract without the existence of a real or- ganic trouble, will establish the diagnosis. The prin- cipal characteristic of this affection is the lack of pro- portion between the multiform complaints and the results objectively found in an examination of the digestive organs. Another point of value is the cir- cumstance that different kinds of food, even indiges- tible substances, do not seem to aggravate the condition, nor does very light food ameliorate it, while changes of climate or surroundings or sometimes pleasant news and the like, may sud- denly check all the unpleasant sensations for a con- siderable time. Differential Diagnosis. — Neurasthenia gastrica may occasionally be confounded with chronic gastric ca- tarrh, ulcer of the stomach, or cancer, the more so as all these organic affections of the stomach are fre- quently associated with nervous symptoms. The fol- lowing points will serve to differentiate between neu- rasthenia gastrica and the affections mentioned: in neurasthenia gastrica the nervous symptoms (refer- ring to the stomach and to other distant organs) play the most important part. While the different com- plaints are connected more or less with the digestive tract, the quality and quantity of food do not seem to 462 DISEASES OF THE STOMACH. be of great importance. Sudden changes in the con- dition of the patient, who feels entirelj' well for a few days and then again utterly disabled, are character- istic of neurasthenia gastrica. Chronic gastric ca- tarrh will be easily recognized by the constancy of the symptoms, which are aggravated by errors in diet, and by the condition of the gastric secretion (diminished acidity, large quantity of mucus, etc.). In ulcer of the stomach we shall always find some of the charac- teristic points (circumscribed painful spot, vomiting, haematemesis or melsena, pains after the ingestion of food, as a rule very intense). As is well known, how- ever, an ulcer may exist without any of these char- acteristic symptoms, and it therefore becomes very difficult to exclude its presence, the more so as neuras- thenia gastrica may complicate this affection. To es- tablish the differential diagnosis between neurasthenia gastrica and cancer of the stomach, it is often neces- sary to have the patient under observation for quite a period of time. Whenever there is a tumor or other distinct symptoms of cancer, it is easy to recognize the cancerous affection. If, however, marked symp- toms are absent (during the first period of the disease), the differential diagnosis is difficult. In cancer of the stomach there will also be some relation between the quality and quantity of the ingesta, and the existing disturbances. Moreover, in cancer of the stomach there is progressive aggravation of the trouble, while in neurasthenia gastrica the condition may remain stationary for a long period of time. Treatment. — In all cases in which some connection can be found between this affection and other existing NERVOUS DYSPEPSIA. 463 ailments, the treatment must be directed against the latter. If neurasthenia gastrica exists alone, then therapeutic means must he resorted to which will strengthen the entire nervous system. Change of cli- mate, outdoor life, entire relief from business cares, are of great importance, and sometimes sufficient to cure the patient. The diet should be amjjle, and it is of importance to impress upon the patient the neces- sity of taking plenty of food. As to the digestibility of different kinds of food in this affection, the patient's own judgment and experience are the best guides to follow. Condiments should be taken moderately and the use of wine, tea, coffee, and beer in small quantities is allowable. In patients who have greatly emaciated, Weir Mitchell's rest cure is often followed by the best results. The direct means which serve to strengthen the nervous system are the following: 1. Hydrotherapeutic measures of a mild nature (wet cold pack, lukewarm sitz bath). '±. Massage of the entire body, to which special massage of the abdomen may be added. 3. Electricity; general faradization of Beard and Eockwell ; * the patient sits barefooted on a large plate electrode, while the other electrode is passed by the physician over the chest, back, and ex- tremities — electric bath. -i. Both sleep and rest should be accorded to the patient in a large degree. While gymnastic exercises are beneficial, they should never be indulged in to such an extent as to tire out the patient. With reference to the local treatment of the stom- ach, the gastric douche has been recommended by ^ Beard and Rockwell : I. c. 464 DISEASES OF THE STOMACH. Malbranc' and lately by Eosenheim/ In a few cases I have applied the gastric spray with similar good results. As regards medicaments, the bromides are of the greatest importance. I^ Ammonii bromidi, Sodii bromidi, aa 1.0 M. f. pulv. D. in chart. No. 20. S. One powder twice daily in milk or in water. The use of the different tonics (iron, arsenic) is fre- quently indicated. Levico or Koncegno water (one- half to one tablespoonful three times daily), ferratin, Gude's peptomangan, Dietrich's peptonate of iron are also in place. In cases in which the anorexia plays a dominant part, tincture of nux vomica (ten drops three times daily) or orexinum basicum (2 dgm. in wafers, three times daily) should be administered. Insomnia will often have to be remedied by the use of either chloral hydrate, sulphonal (1|- to 2 gm.), or trional (1 to 2 gm.). The bowels should be regulated according to the rules given in the chapter en chronic gastric catarrh. A sojourn in the mountains or in some watering-place having mild ferruginous springs, such as Elster, Franzensbad, and Pyrmont, or salines such as Ems, Wiesbaden, and Kissingen, may be recommended, while the purgative waters of Carlsbad and Marien- bad should be avoided. ' Malbranc : I. c. 2Th. Rosenheim: Therap. Monatshefte, 1892, p. 382. CHAPTER XIY. THE CON'DITION OF THE STOMACH IN DIS- EASES OF OTHER ORGANS. There are but few diseases which are not attended to a greater or less extent with gastric symptoms. Every constitutional or local disease, febrile and afe- brile processes, are all more or less complicated with disturbances of the digestive organs. The digestive symptoms in all these conditions, however, are de- pendent upon a general disturbance of the entire or- ganism and are not due to real affections of the diges- tive organs. They are therefore always discussed in the symptomatology of the different diseases. In the following we shall briefly describe the condition of the stomach in several organic diseases of other organs, wherein the gastric symptoms play a predominant part. In fact, in many cases it is quite difficult to recognize the secondary nature of the gastric trouble, the primary disease giving so few and unimportant symptoms that it is easily overlooked. Tuberculosis of the Lungs. — As is well known, in pulmonary tuberculosis the symptoms of the gastro- intestinal tract are frequently very pronounced and very difficult to manage ; often there exist loss of ap- petite, disagreeable sensations after meals, belching, bad taste, constipation alternating with diarrhoea, and last, but not least, severe and obstinate gastralgia as 30 4^66 DISEASES OF THE STOMACH. well as enteralgia. While these gastric symptoms, as a rule, appear when the tuberculous process in the lungs is already quite advanced, occasionally they may exist long before there is any evidence of a real lung trouble. While the pathological anatomy of the stomach in tuberculous patients has been examined by W. Fenwick,' who found well-marked evidence of gastric catarrh in eleven out of fifteen cases of phthi- sis, the functions of the stomach in this affection have been studied by Rosenthal.* Edinger,^ Klemperer' and Schetty,^ Brieger,* Hildebrandt,^ Immermann,* and myself.^ My own conclusions, which harmonize well with those of most of the writers just mentioned, were published in the Medical Record of May 4th, 1889, and are as follows: 1. Among the fifteen cases of phthisis pulmonura examined, free hydrochloric acid was absent in two only (Xos. 14 and 15); in a third patient (Xo. 11) the hydrochloric acid was wanting but once, and was present at two other examinations; in all the other patients the hydrochloric acid was always present. 2. As regards acidity, in five patients (Xos. 6 to 10) it was found normal ; five (Xos. 1 to 5) showed hyper- acidity; and five (Xos. 11 to 15), a diminution in the degree of acidity; among the last group there 'W. Fenwick: Virchows' Arch., 1889, p. 187. SC. Rosenthal: Berl. klin. Wochenschr., 1888, No. 45. sEdinger: Deutsch. Arch. f. klin. Med., 1881. ■*Kleniperer: Berl. klin. Wochenschr., 1889, No. 11. »F. Schetty: Deutsch. Arch. f. klin. Med., Bd. 44, p. 219. *Brieger: Deutscli. med. Wochenschr., 1888, No. 14. 'Hildebrandt: ibidevi, 1889, No. 15. ^Immermann: Verhandl. des Congresses f. innere Medicin Wiesbaden, 1889. «Max Einhorn : Medical Record. Mav 4th, 1889. THE STOMACH IX OTHEE DISEASES. 467 were two with a total absence of free hydrochloric acid. 3. Only one patient (Xo. 4) had in his stomach, after the test breakfast, the remnants of the yolk of an egg which he had eaten on the day previous, and that but once. In all other patients no food whatever was found in the stomach except the fine pieces of the roll. The stomach must have been empty before taking the breakfast, and therefore it can be concluded that the motor power of the stomach was not diminished in a very high degree, 4. In most cases a record of the appetite was kept. A priori, one would be inclined to think that the ap- petite is in a certain degree dependent upon the amount of gastric juice secreted. As the amount of gastric juice secreted is measured b}' the degree of acidity, the appetite ought to be good where hyper- acidity or a normal amount of acidity exists, and bad where there is present a diminished degree of acidity. But this is not true; three patients with hyperacidity (Xos. 1, 3, and i), and two with normal acidity (Xos. 8 and 10), complained of poor appetite, whereas pa- tient Xo. 15 had a good appetite, although there was complete absence of free hydrochloric acid in his stomach. It will be seen that frequently the subjective symp- toms do not harmonize with the objective data found in a thorough examination of the stomach. The point to be gained from this fact with regard to treatment is not to be afraid of giving sufficient food to these patients with markedly disturbed appetite and many other dyspeptic symptoms. In fact, gavage or forced 468 DISEASES OF THE STOMACH. alimentation will often prove very useful. Debove, Peiper, Leyden, and others have obtained the most beneficial results in phthisical patients by this method. The treatment of the gastric symptoms, in which certain functional anomalies of the stomach (as for instance hyperchlorhydria or hypochlorhydria) have been found, will be similar to that described under the head of these latter conditions. The main treat- ment, however, must always be directed against the primary affection, namely, the lung trouble. Tuberculous ulcers of the stomach are occasionally met with, especially in association with tuberculous lesions of other organs. Their occurrence has been de- scribed by several writers (Eppinger, ' Litten,' Musser'). In chlorosis and ancemia the gastric symptoms fre- quently play an important part. They all, as a rule, belong to the neurotic derangements of the stomach. Thus anorexia, gastralgia, hyperaesthesia of the stom- ach, atony, and hyperchlorhydria are frequently met with. Some writers (Hay em ' and others) look upon the gastric disturbances as the primary factor causing the affection of the blood. I concur with Ewald and Rosenheim that in the vast majority of cases the di- gestive symptoms are only sequelae and not the pri- mary cause of the chlorosis. The administration of iron quickly improves the gastric symptoms. Heart lesions are frequentl}^ attended with gastric disturbances. The latter, as a rule, are due to hyper- semia of the gastric mucosa and consist in a feeling of ' Eppinger : Prag. med. Wochenschr. , 1881, Nos. 51 and 52. »Litten: Virch. Arch., Bd. 67, p. 615. sMusser: Philad. Hospital Reports, 1890, vol. 1, p. 170. ^Hayem: Bull, medical, 1891, No. 87. THE STOMACH IN OTHER DISEASES. 469 pressure in the epigastric region, especially after meals, anorexia, belching, etc. Huefler's' assertion that there is an absence of free hydrochloric acid in almost all cases of valvular heart lesions is not correct, as has been shown by myself and later by Adler and Stern." Among twelve patients with heart affections whose gastric contents I have examined, in eight free hydrochloric acid was present, while in four it was absent. Gastric affections not infrequently produce symp- toms simulating a heart lesion. Thus, for instance, arhythmia cordis, tachycardia, and occasionally brady- cardia are met with in chronic gastric catarrh, in ner- vous disorders, and in atony of the stomach. Some- times it is difficult to decide at first whether we have to deal with an affection of the heart or of the stom- ach, A thorough examination of the circulatory ap- paratus and also of the gastric functions will reveal the true nature of the disease. Like affections of the heart, disturbances of the liver are also almost always accompanied by gastric symp- toms, due to a hyperaemic condition of the stomach. Thus in icterus and cirrhosis of the liver the stomach is the first to manifest various symptoms. Here, as in most other diseases, the secretory function of the stomach does not show any constancy ; in some cases the gastric juice may be normal, in some increased, while in the greater number of cases it is diminished. Diseases of the kidney are also frequently associ- ated with gastric symptoms. Thus nausea and vom- ^Huefler: Miinchen. med. Wochenschr. , 1889, No. 33. 2 ]yia,x Einhorn : Berl. klin. Wochenchr., 1889, No. 48. 3 Adler und Stern : Berl. klin. Wochenschr., 1889, No. 49. 470 DISEASES OF THE STOMACH. iting may be the first symptoms. They are caused either by excretion of urea through the gastric mu- cous membrane, or by the retention of that substance in the circulation and the irritation caused thereby upon the brain. Biernacki ' has made a series of ex- aminations of the gastric condition in renal affections and found that in most of them the gastric secretion was greatly diminished. Allen A. Jones " likewise frequently found achylia gastrica among patients with kidney troubles. Stone in the kidney may give rise to similar gastric disturbances. I have observed in a patient suffering with renal calculus, achylia gastrica which had existed for a long time, and given rise to many severe symptoms. After the removal of the stone by operation the gastric symptoms at once dis- appeared. The condition of the stomach in diabetes has been examined by Eosenstein ^ and Gans.^ The gastric functions were found very variable. I have had the opportunity of examining quite a number of diabetics with regard to the gastric functions and must say that they do not show any constancy. Normal and ab- normal conditions of secretion are alike found. In a case of chronic m^tliritis deformans and in two patients with severe gout I found achylia gastrica. In several instances in which only slight symptoms of gout existed, I frequently found hyperchlorhydria. The existence of gastric symptoms in malaria is 'Biernacki: Berl. klin. Wochenschr. , 1891, Nos. 25 and 26. ^ Allen A. Jones: "Gastric Conditions in Renal Disease," New York Medical Journal, January 19th, 1895. =* Rosenstein : Berl. klin. Wochenschr., 1890, No. 13. ^ Edg. Gans : IX. Congress f . innere Medicin, 1890, Wiesbaden. THE STOMACH IN OTHER DISEASES. 471 well known, and Leube ' first described several cases of very severe gastralgia with absence of fever, which were due to malaria, as the successful treatment with quinine clearly proved. The malarial origin of the gastric symptoms will be apparent if they are inter- mittent and appear only at a certain time every day or every other day. I have observed several cases of obstinate vomiting due to malaria, but in most of these instances there have been, besides the gastric symptoms, other manifestations indicating the true nature of the condition. The gastric secretion here also does not show any characteristic feature, and is frequently diminished. Diseases of the Skin. — This subject, although of particular interest, has as yet received but very little attention. Pidoux'' considered all cases of dyspepsia due to a herpetic state of the system. The appearance of eczema, psoriasis, pityriasis, lichen, or acne in any case he considered as outwg^rd manifestations of that constitutional anomaly which he called herpetisme. Nowadays no one will be inclined to accept this theory of a general constitutional anomaly for the origin of these troubles of the alimentary tract. Notwithstand- ing this there is no doubt that occasionally some con- nection is found between some skin manifestations and digestive disturbances. Pemphigus of the mouth has been described under the name of stomatitis neurotica chronica by A. Ja- c()bi,'of New York. I observed this affection present 1 Leube : Deutsch. Arch. f. klin. Medicin, Bd. 33. -Pidoux : "Rapport de I'herpetisme etdes dyspepsies." L'Union medicale, 1866, p. 235. ^ A. Jacobi : Transactions of the Association of American Physi- cians, 1894. 472 DISEASES OF THE STOMACH. in three patients suffering from neurasthenia gastrica and hyperchlorhydria respectively. In two of these cases there was an improvement of the affection of the mouth (also tongue) in connection with the abate- ment of the gastric symptoms. In the third case, however, the pemphigus resisted every kind of treat- ment and persisted even during periods in which there were no complaints referring to digestion. In this case there were frequently present a burning sensa- tion within the oesophagus and slight symptoms of dysphagia. Most probably they were also caused by the formation of vesicular patches along the oesopha- geal wall. Urticaria and erythema due to absorption in the digestive tract of some poisonous substances ingested with the food (especially lobsters, soft-shell crabs, fish, and the like) are well known and have been referred to above under the head of idiosyncrasies. With reference to eczema Hyde' says: "No one, however, can doubt for a moment that many visceral disorders have an influence upon the production of eczema, repeated attacks even following accesses of morbid affections of these organs ; and it is equally cer- tain that many varieties of eczema are directly depend- ent upon several systemic states such as, most effective in the list, gout and rheumatic gout, dyspepsia, con- stipation, and scrofula." Considering the large num- ber of dyspeptics which come under my observation, I must say that the occurrence of eczema among them is very infrequent indeed. This would rather speak against an intimate connection between these ' Hyde : " Twentieth Century Practice of Medicine, " vol. v. , p. 170. THE STOMACH IN OTHER DISEASES. 473 two affections, although I have seen a case of eczema of the scrotum which had resisted the most rational methods of local treatment, in which the skin trouble very quickly disappeared after amelioration of the gas- tric symptoms. Acne simplex and acne rosacea seem to occur more frequently in connection with affections of the stom- ach than eczema. Two patients of mine with acne rosacea and chronic continuous gastric succorrhoea have both shown a decided improvement of the red nose after an amelioration of the gastric symptoms. In one of these patients I frequently noticed that the skin affection became worse as soon as there was an exacerbation of the gastric symptoms, but changed for the better upon improvement of the latter. In some cases of psoriasis, accompanied by digestive disorders, I did not observe that the improvement in the latter condition exerted any direct influence upon the skin affection. INDEX. Abbe, 117 Abelous, 75 Abnormalities in the shape of the stomach, 374 in the size of the stomach, 373 in the position of the stom- ach, 874 Abscess of the stomach, 158 subphrenic, 216 Absorptive function of the stom- ach, 84 Acetic acid, test for, 53 Achroodextrin, test for, 50 Achylia gastrica, 324 definition, 324 course, 336 diagnosis, 337 etiology, 328 general remarks, 324 morbid anatomy, 327 prognosis, 337 symptomatology, 329 synonyms, 324 treatment, 337 Acid, acetic, test for, 52 hydrochloric, combined, es- timation of, 54 hydrochloric, deficit, deter- mination of, 58 hydrochloric, free, estima- tion of, 52 salts, estimation of, 55 Acidity, determination of, 48 Acids, volatile, test for, 51 Acne rosacea, stomach in, 473 simplex, stomach in, 473 Adler, 468 Aerophagia, 425 Akoria, 393 Albu, 367, 371 Algesimeter, 26 Allotriophagia, 392 Alt, 432, 433 Amylopsin, 69 Anadenia ventriculi, 165, 324 Anaemia, stomach in, 468 Anakinesis, 85 Anatomy of the stomach, 1 Anderson, 208 Angustatio ventriculi, 374 Anorexia, nervous, 394 Appetite, definition, 388 perversion of, 392 Armstrong, 237 Arnold, 264 Arnott, 126 Arthritis deformans, stomach in, 470 Aspirator, Boas', 43 Asthma dyspepticum, 168 Atony of the stomach, 453 definition, 453 diagnosis, 453 prognosis, 454 symptomatology, 453 synonyms, 453 treatment, 454 Atrophy of the stomach, 164, 324 Auscultatory percussion, 28 Baginski, 871 Bardet's method of direct electri- zation, 141 Barling, 238 476 INDEX. Beaumetz, Dujardin, 367 Beaumont, 10, 110, 153 Beard, 137, 463 Beck, C, 217 Bentejao, 451 Berthold, 188 Bidder, 11 Biernacki, 469 Bile, action of, 14 test for, 68 Billroth, 284 Bird, 278 Blondlot, 11 Blood, condition of, in cancer of the stomach, 270 tests for, 69 Blood-vessels of the stomach, 3 Blutin, 126 Boas, 26, 27, 39, 70, 73, 75, 76, 78, 132, 133, 269, 278, 279, 288, 289, 293, 305, 323, 326, 340, 342, 367, 387, 433, 439, 453, 454, 455 Boas' aspirator, 43 resorcin-sugar test, 45 test for lactic acid, 47 Bocci, 137, 140 Bouchard, 29 Bourneville, 431 Bouveret, 303, 313, 321, 367, 368, 371, 372, 393, 425, 439, 452, 460 Brieger, 17, 466 Brinton, 165. 187, 196, 205, 217, 218, 248, 250, 251, 252, 258, 259, 260, 261, 263, 264, 265, 268 Brock, 149 Brunton, L. , 15 Bryant, 249 Bucket, stomach, 62 Bulimia, 390 cause, 391 symptomatology, 390 treatment, 391 Bull, 117 Burkhart, 459 Bush, 126 Cahn, 277, 448 Calorie, 98 Cancer of the stomach, 248 definition, 248 diagnosis, 277 differential diagnosis, 280 duration and prognosis, 283 etiology, 248 hydrochloric acid in, 277 lactic acid in, 279 metastasis, 260 morbid anatomy, 254 palliative operations for, 285 radical operations for, 284 secondary changes accom- panying, 260 shape of the stomach in, 259 symptomatology, 262 topographical relations of, 258 treatment, 284 Canstatt, 140 Cantarouo, 431 Cardia, cancer of, 271 spasm of, 415 Cardiospasmus, 415 Catarrh, acute gastric, 151 chronic gastric, 163 Cazenave, 34 Charcot, 395, 397 Chewing the cud, 429 Chlorosis, stomach in, 468 Chvostek, 368 Chyle, definition, 17 Chyme, definition, 13 determination of quantity of, in stomach, 66 Cirrhosis ventriculi, 165 Clapotage, 29 Cloquet, 252 Coley, 254 INDEX. 477 CoHapse in ulcer of the stomach, 233 Constipation complicating chronic gastric catarrh, 184 Cruveilhier, 187, 205, 224 Daetttyler, 189 De Bary, 75 Debove', 30, 196, 216, 223, 224, 251, 313, 468 Deglutition sounds, 30 Dehio, 27 Dejerine, 407 Demange, 407 Descensus ventriculi, 375 Devic, 367, 368, 371, 372 Diabetes, stomach in, 470 Dickinson, 65 Diet, 97 in health, 107 Dietetics in acute diseases of the stomach, 113 in chronic affections of the stomach, 116 in diseases of the stomach, 108 Digestion, definition of, 8 gastric, 13 intestinal, 14 Dilatation of the oesophagus, 416, 423 Dimethylamido-azobenzol, 53 Dittrich, 218 Dobson, 233 Douche, gastric, 132 Duchenne, 140 Dyspepsia, nerTOus, 457 Dysphagia, 415 Ebstein, 449 Eczema, stomach in, 472 Edinger, 466 Eichhorst, 252 Einhorn's method of direct elec- trization, 142 Eisenlohr, 270 Electricity, 136 direct application, 139 intragastric application, 139 percutaneous application, 137 Electrode, deglutable, 143 spiral, 150 Elsberg, 81 Emmerich, 254 Enteric juice, 16 Enteroptosis, 375 definition, 375 diagnosis, 381 etiology, 377 general remarks, 375 symptomatology, 379 treatment, 383 Epigastric beating, 401 Eppinger, 468 Erb, 139, 368 Erosions of the stomach, 238 condition of the gastric juice in, 242 course, 242 definition, 238 diagnosis, 245 etiology, 239 general remarks, 238 symptomatology, 239 treatment, 246 Eructation, 424 Erythema, stomach in, 472 Erythrodextrin, test for, 50 Etat mamelonne, 163 Ewald, C. A. , 86, 39, 54, 86, 108 114, 127, 138, 149, 164, 165, 181 185, 188, 189, 190, 194, 195, 220 332, 239, 253, 260, 268. 278 289, 290, 291, 293, 817, 325 326, 866, 867, 371, 372, 373 381, 391, 407, 422, 424, 434 449, 457, 460, 468 Ewald, R., 888 478 INDEX. Ewald and Sievers' method of testing the motor function, 85 Ewald-Boas expression method, 43 Ewald-Boas' test breakfast, 41 Examination, methods of, 18 physical, methods of, 22 Exploratory laparotomy, 287 Expression method of Ewald- Boas, 43 Fen WICK, S., 325 Fenwick, W. , 466 Ferments, definition of, 9 formed, 9 unformed, 9 Fibroma of the stomach, 281 lleiner. 230, 367, 371 Fleischer, 46 Food, definition of, 97 substances, composition of the most common, 99 utilization of, 107 Foods, animal, 103 liquid, 106 vegetable, 105 Foote, 233, 234 Forster, 97, 224 Fox, Wilson, 194, 224, 251 Fraukel, 342 Frerichs, 28 Friedenwald, 36, 54 Friedreich, 288 Fubini, 137 Fuerstner, 138, 140 Gans, 470 Gassuer, 367 Gastralgia, 404 diagnosis, 409 etiology, 406 symptomatology, 404 synonyms, 404 treatment, 413 Gastrectasia, 373 Gastric catarrh, acute, 151 Gastric catarrh, chronic, 163 course, 173 definition, 163 diagnosis, 173 differential diagnosis, 174 etiology, 166 pathological anatomy, 163 prognosis, 175 symptomatology, 167 treatment, 175 Gastric contents, abnormal con- stituents of, 68 contents, microscopical ex- amination, 72 digestion, 13 douche, 132 idiosyncrasies, 399 insufficiency, 453 juice, constituents of, 11 juice, physiology of, 10 juice, snail-like cells in, 72 mucosa, pieces of, found in wash water, 77 neuroses, sensorj', 388 secretion, different methods of testing, 60 spray, 134 ulcer, condition of the gas- tric contents, 210 Gastritis acuta simplex, 151 diagnosis, 154 etiology, 151 morbid anatomy, 152 prognosis, 155 symptomatology, 153 treatment, 155 Gastritis, acute, 151 definition, 151 synonyms, 151 Gastritis glandularis chronica, 163 Gastritis phlegm onosa, 158 INDEX. 479 Gastritis phlegmonosa, diagno- sis, 159 morbid anatomy, 158 symptomatology, 158 synonyms, 158 treatment, 159 Gastritis, toxic, 159 diagnosis, 161 prognosis, 161 symptomatology, 160 treatment, 161 Gastrodiaphane, the, 35 Gastrodiaphany, 34 Gastro-enterostomy in cancer of the stomach, 286 Gastrofaradization, 144 Gastrogalvanization, 145 Gastrograph, 89 Gastrokinesograph, 91 Gastrolith, 281 Gastroptosis, 375 Gastroscope, the, 34 Gastroscopy, 33 Gastrostomy in cancer ©f the stomach, 286 Gastrosuccorrhoea continua chronica, 312 definition, 312 diagnosis, 315 differential diagnosis, 316 etiology, 314 general remarks, 312 prognosis, 321 symptomatology, 314 treatment, 322 Gastrosuccorrhoea continua peri- odica, 304 definition, 304 diagnosis, 310 general remarks, 305 prognosis, 310 symptomatology, 305 synonyms, 304 treatment, 310 Gastroxynsis, 304 Gerhardt, 238, 239, 367, 371 Germain See's test meal, 41 Gerster, 117 Glands of the stomach, 5 Glax, 448 Glenard, 375, 376, 377, 378, 379, 380, 383, 384 Glenard 's disease, 375 GliicksQiann, 237 Glusinski, 211, 291 Goldschmidt, 149 Goodsir, 77 Gout, stomach in, 470 Gries, 188 Griesinger, 249 Griffini, 189 Gross, M., 133 Gruber, 97 Grundzach, 326 Gull, 395 Giinzburg's method of testing the gastric secretion, 61 phloroglucin - vanillin test, 45 Gurgling sounds, 32 Gyromele, 150 Haeberlin, 248, 252, 270 Haematemesis in ulcer of the stomach, 207 Haller, 374 Hampeln, 268 Hanot, 367 Harada, 138 Harttung, 192, 239 Hauser, 253 Hay em, 11, 59, 468 Hay em and Winter's method of estimating hydrochloric acid, 57 Heart lesions, stomach in, 468 Heartburn, 426 Heat unit, definition of, 98 480 INDEX. Hehner, 59 Hehner and Seemann's method of estimating hydrochloric acid, 56 Heidenhain, 6 Heim, 371 Heinemann, 250 Heller's blood test, 70 Hemmeter, 96, 131 Hemmeter-Moritz's method of examining the motor func- tion, 95 Hemorrhage in ulcer of the stomach, 331 Henoch, 444 Henry, 325 Hepatoptosis, 379 Herschell's method of testing the absorptive function, 84 Heryng, 36 Hildebrandt, 466 Hippocrates, 32, 125 Hirschfeld, 102 Hoffmann, 97, 138 Honigmann, 58, 60 Hubbard, 432 Ruber's modification of salol test, 87 Huefler, 468 Hiihnerfeld, 71 Hunter, 342 Hyde, 472 Hydrochloric acid, combined, estimation of, 54 acid deficit, determination of, 58 acid, free, estimation of, 52 acid, tests for, 44 Hypauakinesis ventriculi, 445 Hyperacidity, 291 Hypereesthesia of the stomach, 401 diagnosis, 402 symptomatology, 402 Hyperaesthesia of the stomach, treatment, 403 Hyperanakinesis ventriculi, 446 Hj'perchlorhydria, 291 course, 296 definition, 291 diagnosis, 298 differential diagnosis, 299 etiology, 293 general remarks, 291 prognosis, 298 symptomatology, 294 synonyms, 291 treatment, 300 Hypersecretion, 291 Hypochlorhydria, 457 Idiosyncrasies, gastric, 399 Immermann, 466 Incontinence of the pylorus, 449 Inflation of the stomach, 28 Ingesta, examination of, 44 hydrochloric acid, 44 reaction, 44 Inspection, 22 InsuflSciency, gastric, 453 Interrogation of the patient, 18 Intestinal digestion, 14 juice, test for, 68 Ischochymia, 340 acute, 342 chronic, 344 complications, 366 constant, 344 course, 345 definition, 340 diagnosis, 360 differential diagnosis, 361 etiology, 345 general remarks, 340 symptomatology, 342 transient, 343 treatment, 362 Israel, 382 INDEX. 481 Jacobi, a., 471 Jacobson, 36, 372 Jaworski, 73, 183, 194, 211, 291, 326 Johannessen, 430, 431, 436 Jones, Allen A., 149, 326, 470 Juergensen, 433. 436 Juice, enteric, 16 gastric, see Gastric juice intestinal, test for, 68 Kahler, 407 Kamraerer, F. , 357 Katzenellenbogen, 259, 263 Kaufmann, 75, 76 KeUing, 363 Key, 193 Kidney, movable, 882 stomach in diseases of, 469 Kinnicutt, 325 Kirkpatrick, 237 Klemperer, 270, 279, 466 KQemperer's oil test, 88 test meal, 41 Koch, 190 Koenig, 122 Koerner, 431, 436 Korczynski, 194 and Jaworski 's blood test, 71 Kroneckei', 30 Kulneff, 371 Kupffer, 6 Kussmaul, 126, 139, 366, 367. 370, 447 Kussinaul's method of direct electrization, 140 Kuttner, 36 Laache, 270 Lactic acid, estimation of, 52 acid, test for, 46 Laker, 33 Landau, 375 Landerer, 237 31 Landouzy, 407 Lange, F., 117, 353, 359 Langerhans, 193, 239 Latent ulcer of the stomach, 211 Lauenstein, 237 Lavage, 126 contraindications for, 132 Friedlieb's apparatus, 129 funnel arrangement for, 126 indications for, 132 Leube-Rosenthal apparatus, 127 rules for its application, 131 with tube d double courant, 131 Lebert, 152, 248, 250, 252, 259, 260 Lente, 138 Leo, 391 Leo's method of estimating acid salts, 55 Leube, 88, 108, 110, 138, 181, 224, 228, 375, 457, 470 Leube-Riegel's test dinner, 40 Leube's method of testing the motor function, 85 Leubuscher, 138, 321 Leven, 367, 459 Lewy, 325 Ley den, 407, 440, 468 Lipoma of the stomach, 381 Litten, 326, 468 Liver, function of, 15 stomach in diseases of, 469 Loeb, 371 Loven, 8 Ludwig, 137 Luettke, 59 Lugol's solution, 50 Lymphatics of the stomach, 7 Macfadyen, 75 Malacia, 392 Malaria, stomach in, 470 Malbranc, 132, 464 482 INDEX. Maltose, test for, 50 Manges, 36 Marcet, 190 Markoe, 236 Marti US: 36, 59, 314 Mathieu, 67, 251 McBuruey, 117 McCosh, 237 Mechanical function, 89 Megastria, 373 Metena, 208 Meltzer, 30 Meltzing, 36 Menetrier, 253 Mering, von, 277 Merycisni, 429 Methods of examination, 18 of physical examination, 22 Meyer, George, 325 Meyer, Willy, 117, 354, 355 Microscopical examination of gastric contents, 72 Mikulicz, 34 Miller, 75 Milliot, 34 Minkowski, 77 Mintzs method of estimating free hydrochloric acid, 53 Mitchell, Weir, 124, 397 Moerner and Boas' method of estimating free hydrochloric acid. 53 Moritz, 96 Motor function, 85 Mucus, test for, 68 Miiller, F., 270, 367, 371 Munk, 98 Murphy, 117 Musser, 468 Myasthenia ventriculi, 453 Myoma of the stomach, 281 Nausea, 401 Neftel, 138 Nencki, 75 Nephroptosis, 379 Nerves of the stomach, 7 Nervous affections of the stom- ach, 386 Nervous anorexia, 394 diagnosis, 396 symptomatology, 394 treatment, 396 Nervous dyspepsia, 457 definition, 457 diagnosis, 461 differential diagnosis, 461 etiology, 458 prognosis, 460 symptomatology, 458 treatment, 462 Nervous vomiting, 437 diagnosis, 461 idiopathic, 443 juvenile, 439 periodic, 440 reflex, 442 Neumau, 366 Neurasthenia gastrica, 457 Neuroses, motor, 414 secretory, 455 sensory gastric, 388 Nolte, 188, 201 Noorden, von, 58, 60, 99, 108, 119, 407 Nothnagel, 325 Nussbaum, 6 Nutritive enema, 114 (Edema fugax in cancer of the stomach, 269 CEsophagus, dilatation of, 416, 423 retention of food in, 274 Oil test, Klemperer's, 88 Oka. 138 Oppenchowski, 417 Oppenheim, 407 INDEX. 483 Oser, 152, 284, 407 Osier, 23, 325 Pacaxowski, 458 Paliard, 371 Palpation, 24 Pancreatic secretion, 16 Panum, 193 Pariser, 36 Park, Eoswell, 117 Parker, 237 Parorexia, 353 Patient, interrogation of, 18 Pavy, 194 Peiper, 468 Pemphigus of the month, stom- ach in, 471 Penzoldt, 27, 102, 104, 111 Penzoldt-Faber's method of test- ing the absorptive function. 84 Pepper, W., 29, 139 Pepsin, test for, 49 Peptone, test for, 49 Peptonuria in cancer, 271 Percussion, 26 auscultatory, 28 Percy, 393 Perforation in ulcer of the stom- ach, 232 Peristaltic restlessness of the stomach, 446 Pettenkofer, 97 Peyer, 391 Pfuhl, 217 Phenolphthalein, 48 Phloroglucin-vanillin test, 45 Phthisis ventriculi, 324 Physiology of the stomach, 8 Pica, 392 Pidoux, 471 Piorry, 26 Pneumatosis, 444 Polyphagia, 393 Ponsgen, 437 Prochoresis, 85 Propeptone, test for, 49 Prout, 10 Psoriasis, stomach in, 473 Ptyalin, definition, 10 Pus, recognition of, 72 Pylorospasmus, 451 Pylorus, cancer of, 276 benign stenosis of, 349 incontinence of, 449 malignant stenosis of, 355 Pyopneumothorax subphrenicus, 216 Pyrosis, 426 Quincke, 189 Rate, 149 Reaumur, 10 Regurgitation, 427 Reichmann, 36, 291, 304, 805, 312, 313, 314, 317, 322, 323 Remond, 30, 67, 196, 216, 228, 224, 318 Rennet ferment, test for, 50 zymogen, test for, 50 Ren vers, 86, 867, 409 Resorcin-sugar test of Boas, 45 Respiratory sounds, 32 Restlessness, antiperistaltic, of the stomach, 448 peristaltic, of the stomach, 446 Richet, 456 Richter, 138, 460 Riegel, 194, 210, 291, 318, 314, 822 Rindfleisch, 193 Ringing sounds, 33 Rockwell, 137, 453 Roentgen rays, 38 Rokitansky, 193 Rose, A., 29 Rosenbach, 81, 840, 453 484 INDEX. Rosenheim, 59, 60, i;«. 133. 149, 196, 219, 230. 253, 280, 289. 326, 363, 402, 403, 404, 464, 468 Rosenstein, 470 Rosenthal, 388. 392, 393. 394, 395 Rosenthal, C. 466 Rossbach, 304, 305 Rumination, 429 chemical analysis, 431 definition, 429 duration, 431 etiology, 429 synonyms, 429 treatment, 436 Runebeig, 28 Sachs, 6, 153 Sahli, 61 Saliva, definition, 10 Salol test. 86, 87 Sarcinte ventriculi, 77 Schaeffer, 321 Schetty, 466 Scheuerlen, 254 Schillbach, 137 Schlesinger, 371 Schmidt, 11 Schneider, 270 Schneyer, 270 Schonbein-Almen's blood test, Tl Schreiber, 314 Schutz, 448 Schwann, 11 Sclerosis ventriculi, 165 Secretory function of the stom- ach, 39 neuroses, 455 See, Germain, 371 Seemann, 59 Seglas, 431 Semmola, 138 Senn, 117 Sensations, abnormal, 400 Sere. L de,449 Silbermann, 190 Simmons, 351 Singultus, 425 Sitieirgy. 395 Sitophobia, 402 Sizzling sounds, 33 Sjcequist, 54. 59 Skin, stomach in diseases of, 471 Snail-like cells in gastric juice, 72 Snow, 252 Sohlern, von, 188 Sollier, 395 Sommerville, 126 Sounds of the stomach, 29 Spallanzani, 10 Spallanzani and Edinger's sponge method of testing the gastric secretion, 61 Spasm of the cardia, 415 diagnosis, 422 prognosis, 423 symptomatology 415 treatment, 423 Spectroscopic test for blood, 70 Splanchnoptosis, 379 Splashing sound, 29 Spray, gastric, 134 Starch digestion, products of, 50 Steapsin, 69 Stenosis of the pylorus, benign, 349 malignant, 355 Stern, 469 Stewart, D. D., 36, 149, 327 Stiller, 439 Stinison, 237 Stockton, 36, 148, 149, 194, 456 Stockton's stomach electrode, 142 Stoehr, 6 Stomach, abnormalities in the position of, 374 abnormalities in the shape of, 374 INDEX. 485 Stomach, abnormalities in the size of, 373 abscess of, 158 absorptive function of, 84 anatomy of, 1 antiperistaltic restlessness of, 448 atony of, 453 atrophy of, 164, 324 blood-vessels of, 3, 7 bucket, 63 cancer of, 248 condition of, in other dis- eases, 467 dilated, 373 electrode, deglutable, 143 erosions of the, 238 examination in the fasting condition, 88 glands of, 5 hour-glass form, 374 hypertesthesia of, 401 in ansemia, 468 in arthritis deformans, 470 in chlorosis, 468 in diabetes, 470 in diseases of the kidney, 469 in diseases of the liver, 469 in diseases of the skin, 471 in gout, 470 in heart lesions, 468 in malaria, 470 in pulmonary tuberculosis, 465 local treatment of, 126 lymphatics of, 7 mechanical function of, 89 methods of inflation, 28 motor function of, 85 mucous membrane of, 4 muscular coat of, 4 nerves of, 7 nervous affections of, 386 peristaltic restlessness of, 446 Stomach, physiology of, 8 relations to neighboring or- gans, 3 secretory function of, 39 situation of, 2 sounds of, 29 structure of, 3 submucous coat, 4 transillumination of, 34 transposition of, 374 tube, contraindications to its use, 60 ulcer of the, 187 vertical position of, 375 Strauss, 59, 60, 363 Structure of the stomach, 3 Subphrenic abscess, 216 Succussion sound, 32 Talma, 400 Teichmann's hsemin test, 71 Test breakfast of Ewald-Boas, 41 dinner of Leube-Riegel, 40 meal of Germain See, 41 meal of Klemperer, 41 Tests for hydrochloric acid, 44 Tetany, 366 etiology, 370 prognosis, 368 symptoms, 368 Thayer, 280 Thompson, W. Gilman, 115 Toepfer, 54 Toepfer's method of estimating free hydrochloric acid, 53 Tongue, inspection of, 23 Transillumination of the stom- ach, 34 Trousseau, 287, 367, 368 Trypsin, 69 Tschelzoff, 183 Tuberculosis, pulmonary, stom- ach in, 465 486 INDEX. Tumor, particles of, 83 Turck, 150 Uffelmann, 46, 98 Uflfelmann's lactic-acid test, 46 Ulcer of the stomach, 187 complications, 213 definition, 187 diagnosis, 219 differential diagnosis, 320 duration, 212 etiology, 187 latent, 211 localization, 222 morbid anatomy, 195 multiple, 201 perforation, 213 prognosis, 223 progress, 201 situation, 196 surgical treatment, 233 symptomatology, 203 synonyms, 187 treatment, 224 Unverricht, 365 Urine, condition of, in cancer of the stomach, 270 Urticaria, stomach in, 472 Van den Velden, 277 Vassale, 189 Vierordt, 102 Virchow, 97, 193, 239, 2481 375 Voinovitch, 321 Voit, 97 Volatile acids, test for, 51 Vomiting, nervous, 437 Waldeyer, 254 Weber, 70, 137 Wegele, 150 Weir, 117, 233, 235, 236, 237 Welch, 201, 250, 251, 259 Wiederhoefer, 251 Wilkinson, 251 Willigk, 248 Winter, 11, 59 Witzel, 286 Wolff, 322, 326 Wyss, 248 ZlEMSSEN, von, 137, 142, 224, 228 i^ COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 C28(63B)MS0 RC816 Ei6 1898 Einhom