Chapter XXXII: Front Matter (32)

Leube's beef-solution[112] is a nutritious, unirritating, and easily-digested article of diet. It can often be taken when milk is not easily or {521} completely digested, or when milk becomes tiresome and disagreeable to the patient. It is relied upon mainly by Leube in his very successful treatment of gastric ulcer. A pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. A tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of Liebig's beef-extract may be added to improve the taste. The bouillon should be absolutely free from fat. Unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time.

[Footnote 112: By means of a high temperature and of hydrochloric acid the meat enclosed in an air-tight vessel is converted into a fine emulsion and is partly digested. Its soft consistence, highly nutritious quality, and easy digestibility render this preparation of the greatest value. The beef-solution is prepared in New York satisfactorily by Mettenheimer, druggist, Sixth Avenue and Forty-fifth street, and by Dr. Rudisch, whose preparation is sold by several druggists.]

Freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. The juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. The meat should, however, remain very rare, and the fat should be carefully removed from the juice.

To the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as Nestle's. Milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk.

For the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. Nothing should be left to the discretion of the patient or of his friends. The treatment should be methodic. It is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared.

In all cases of any severity the patient should be treated in bed in the recumbent posture, and warm fomentations should be kept over the region of the stomach. Mental and physical fatigue should be avoided.

Usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. Meat-broths may be given. Boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. Boiled sweetbread is also admissible. Boiled calf's brain and calf's feet are allowed by Leube at this stage of the treatment.

To these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. This may be superficially broiled with a little fresh butter. Boiled white fish, particularly cod, may also be tried.

It is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. The juice of oranges and of lemons can usually be taken. The food should not be taken very hot or very cold.

For at least two or three months the patient should be confined to the {522} easily-digested articles of diet mentioned. These afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. Transgression in this respect is liable to be severely punished by return of the symptoms. When there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. Should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above.

Medicinal treatment of gastric ulcer, although less efficacious than the dietetic treatment, is not to be discarded. Since its advocacy by Ziemssen the administration of Carlsbad salts or of similarly composed salts belongs to the systematic treatment of gastric ulcer. The objects intended to be accomplished by the use of these salts are the daily evacuation of the contents of the stomach into the intestine by gentle stimulation of the gastric peristaltic movements, the neutralization of the acid of the stomach, and the prevention of acid fermentations in the stomach. Of these objects the most important is the prevention of stagnation of the contents of the stomach. The chief ingredients of the Carlsbad waters are sulphate of sodium, carbonate of sodium, and chloride of sodium. The most important of these ingredients is sulphate of sodium (Glauber's salts), which by exciting peristalsis propels the gastric contents into the intestine, and thus relieves the stomach of its burden, prevents fermentation, and removes from the surface of the ulcer an important source of irritation. The carbonate of sodium neutralizes the acids of the stomach, but the main value of this ingredient and of the chloride of sodium is that in some way they correct the action of the Glauber's salts, so that the latter may be taken in smaller quantity and without the usual unpleasant effects of pure Glauber's salts.[113] The artificial Carlsbad salts are to be preferred to the natural or the artificial Carlsbad water. The natural Carlsbad salts and much of those sold as artificial Carlsbad salts consist almost wholly of sulphate of sodium. It is therefore best to prescribe in proper proportion the leading ingredients of these salts. A suitable combination is sulphate of sodium five ounces, bicarbonate of sodium two ounces, and chloride of sodium one ounce (Leichtenstern[114]). The relative proportion of the ingredients may of course be varied somewhat to suit individual cases. The salts are to be taken daily before breakfast dissolved in a considerable quantity of warm water. One or two heaping teaspoonfuls of the salts are dissolved in one-half to one pint of water warmed to a {523} temperature of 95° F. One-fourth of this is to be drunk at a time at intervals of ten minutes. Breakfast is taken half an hour after the last draught. After breakfast there should follow one or two loose movements of the bowels. If this is not the case, the next day the quantity of the salts is to be increased, or if more movements are produced the quantity is to be diminished until the desired result is obtained. In case the salts do not operate, an enema may be used. Usually, to obtain the same effect, the quantity of salts may be gradually diminished to a teaspoonful.

[Footnote 113: Water from the Sprudel spring contains in 16 ounces 18.2 grains of sulphate of sodium, 14.6 grains of bicarbonate of sodium, and 7.9 grains of chloride of sodium, and 11.8 cubic inches of carbonic acid. Its natural temperature is 158° F. The other Carlsbad springs have the same fixed composition and vary only in temperature and amount of CO_{2}.]

[Footnote 114: The second edition of the German Pharmacopoeia contains a formula for making artificial Carlsbad salts, so that the ingredients are in about the same proportion as in the natural water. The formula is as follows: Dried sulphate of sodium 44 parts, sulphate of potassium 2 parts, chloride of sodium 18 parts, bicarbonate of sodium 36 parts. These should be mixed so as to make a white dry powder. The Carlsbad water is imitated by dissolving 6 grammes of this salt in 1 liter of water (_Pharmacopoeia Germanica_, editio altera, Berlin, 1882, p. 232).

According to a prescription very commonly used in Germany, the Carlsbad salts are made by taking sulphate of sodium 50 parts, bicarbonate of sodium 6 parts, chloride of sodium 3 parts. Dose, a teaspoonful dissolved in one or two tumblers of warm water (Ewald u. Lüdecke, _Handb. d. Allg. u. spec. Arzneiverordnungslehre_, Berlin, 1883, p. 480).]

The Carlsbad salts are directed especially against the chronic gastric catarrh which complicates the majority of cases of ulcer of the stomach. It is well known that the most effective method of treating this morbid condition is the washing out of the stomach by means of the stomach-tube. The propriety of adopting this procedure in gastric ulcer comes, therefore, under consideration. Although the use of the stomach-tube in gastric ulcer is discarded by Leube and by Sée on account of its possible danger, nevertheless this instrument has been employed with great benefit in many instances of this disease by Schliep, Debore, and others.[115] No instance of perforation of an ulcer by means of the stomach-tube has been reported, and in general no evil effects have resulted; but Duguet cites a case of fatal hemorrhage following washing out of the stomach.[116] In view of the great benefit to be secured by washing out the stomach, and of the comparatively slight danger which attends the process, it seems justifiable to adopt this procedure cautiously and occasionally in cases of gastric ulcer with severe gastric catarrh. Of course only the soft rubber tube should be used, and the siphon process should be adopted.[117] The stomach may be washed out with pure warm water or with water containing a little bicarbonate of sodium (one-half drachm to a quart of water). The occasional cleansing of the stomach in this way can hardly fail to promote the healing of the ulcer. Recent or threatened hemorrhage from the stomach would contraindicate the use of the stomach-tube.

[Footnote 115: Schliep, _Deutsch. Arch. f. klin. Med._, Bd. 13; Debore, _L'Union méd._, Dec. 30, 1882; Bianchi, _Gaz. degli Ospitali_, March 26, 1884.]

[Footnote 116: _Gaz. des Hôp._, Apr. 29, 1884. In a case of gastric ulcer of Cornillon severe hemorrhage followed washing out the stomach (_Le Prog. méd._, Apr. 28, 1883).]

[Footnote 117: Soft rubber stomach-tubes are made by Tiemann & Co. in New York, and are sold by most medical instrument-makers. A description of the appropriate tube and of the method of its use is given by W. B. Platt ("The Mechanical Treatment of Diseases of the Stomach," _Maryland Medical Journal_, March 8, 1884).]

Beyond the measures indicated there is little more to do in the way of treatment directed toward the repair of the ulcer. Not much, if anything, is to be expected from the employment of drugs which have been claimed to exert a specific curative action on the ulcer. Of these drugs those which have been held in the greatest repute are bismuth and nitrate of silver. Trousseau[118] devised a somewhat complicated plan for administering bismuth and nitrate of silver in succession for several months in the treatment of gastric ulcer. There are few who any longer cherish any faith in these drugs as curative of gastric ulcer. The same may be said of other drugs which have been thought to have similar specific virtue in the treatment of gastric ulcer, such as acetate of lead, arsenic, chloral hydrate, iodoform, etc.

[Footnote 118: _Clinique médicale_, t. iii. p. 95, Paris, 1865.]

{524} It remains to consider therapeutic measures which may be necessary to combat individual symptoms of gastric ulcer.

The pain of gastric ulcer is generally relieved in a few days by strict adherence to the dietetic regimen which has been laid down. When this is not the case, it may be best to withhold all food from the stomach and to nourish by the rectum. But this cannot be continued long without weakening the patient, and sometimes the pain persists in spite of the rest afforded the stomach. Undoubtedly, the most effective means of quieting the pain of gastric ulcer is the administration of opium in some form. Opium should not, however, be resorted to without full consideration of the possible consequences. When the use of this drug is once begun, the patient is liable to become dependent upon it, and may be inclined, consciously or unconsciously, to exaggerate the pain in order to obtain the narcotic. When prescribing opium in this disease the physician should have in mind the danger of establishing the opium habit. Moreover, opium retards digestion, and is anything but an aid to the proper dietetic regimen, which is all-important. If it is decided to give opium, it does not matter much in what form it is administered, but the dose should be as small as will answer the purpose. Hypodermic injections of morphine over the region of the stomach may be recommended. Codeia often produces less disturbance than opium or morphine. A useful powder for the relief of pain is one containing 8 or 10 grains of subnitrate of bismuth, 1/12 grain of sulphate of morphia, and 1/5 grain of extract of belladonna. Much of the beneficial effect attributed to bismuth is in reality due to its customary combination with a small quantity of morphine. Before resorting to opium in cases of severe pain it will be well to try some of the other means for relieving the pain of gastric ulcer, although they are less effective. Gerhardt thinks that astringents are better than narcotics to relieve the pain of ulcer, and he recommends for the purpose three or four drops of solution of chloride of iron diluted with a wineglassful of water, to be taken several times daily. Although this recommendation is from high authority and is often quoted, sufficient confirmatory evidence of its value is lacking. Other medicines recommended are hyoscyamus, belladonna, choral hydrate, chloric ether, hydrocyanic acid, bismuth, nitrate of silver, and compound kino powder. Sometimes warm fomentations, at other times a light ice-bag over the epigastrium, afford marked relief of the pain. Counter-irritation over the region of the stomach has also given relief. This may be effected with a mustard plaster or by croton oil. I have known the establishment of a small nitric-acid issue in the pit of the stomach to relieve the pain, but such severe measures of counter-irritation are generally unnecessary. The application of a few leeches over the epigastrium has been highly recommended, but this should be done without much loss of blood. The effect of position of the body upon the relief of pain should be determined. When the pain is due to flatulence or to acid fermentation in the stomach, the treatment should be directed to those states.

The most effective means of controlling the vomiting in gastric ulcer are the regulation of the diet and, if necessary, the resort to rectal alimentation. Absolute rest should be enjoined. Whenever small quantities of milk, peptonized or in any other form, cannot be retained, then exclusive rectal feeding may be tried for a while. There have been cases of gastric {525} ulcer when both the stomach and the rectum have been intolerant of food. In such desperate cases the attempt may be made to introduce food into the stomach by means of the stomach-tube, for it is a singular fact that food introduced in this way is sometimes retained when everything taken by the mouth is vomited.[119] The cautious washing out of the stomach by the stomach-tube may prove beneficial. In these cases the attempt has also been made to nourish by subcutaneous injections of food. In a case of gastric ulcer where no food could be retained either by the stomach or by the rectum Whittaker[120] injected subcutaneously milk, beef-extract, and warmed cod-liver oil. The oil was best borne. The injections were continued for four days without food by the mouth or rectum. The patient recovered. At the best, hypodermic alimentation can afford but slight nourishment, and is to be regarded only as a last refuge. If there is danger of death by exhaustion, transfusion may be resorted to.

[Footnote 119: Debore, _L'Union médicale_, Dec. 30, 1882, and _Gaz. des Hôp._, April 29, 1884. For this reason Debore makes extensive use of the stomach-tube in general in feeding patients affected with gastric ulcer. He objects to an exclusive milk diet on account of the quantity of fluid necessary to nourish the patient, which he says amounts to three to four quarts of milk daily. To avoid these inconveniences, he gives three times daily drachm viss of meat-powder and drachm iiss of bicarbonate of sodium (or equal parts of calcined magnesia and bicarb. sod.), well stirred into milk. This is to be introduced by the stomach-tube on account of its disagreeable taste. He believes that the addition of the large quantity of alkali prevents digestion from beginning until the food has reached the intestine. He also gives daily a quart of milk containing grs. xv of saccharate of lime. Debore's method of preparing the meat-powder is described in _L'Union médicale_, July 29, 1882, p. 160. He also uses a milk-powder (_ibid._, Dec. 30, 1882; see also _Le Progrès méd._, July 12, 1884).]

[Footnote 120: J. T. Whittaker, "Hypodermic Alimentation," _The Clinic_, Jan. 22, 1876.

Bernutz practised successfully in two cases the hypodermic injection of fresh dog's blood (_Gaz. des Hôp._, 1882, No. 64).

Krueg (_Wiener med. Wochenschr._, 1875, No. 34) injected 15 cc. of olive oil twice a day subcutaneously without causing abscesses.

Menzel and Porco were the first to employ hypodermic alimentation (_ibid._, 1869, No. 31).]

Of remedies to check vomiting, first in importance are ice swallowed in small fragments and morphine administered hypodermically. Effervescent drinks, such as Vichy, soda-water, and iced champagne, may bring relief. Other remedies which have been recommended are bismuth, hydrocyanic acid, oxalate of cerium, creasote, iodine, bromide of potash, calomel in small doses, and ingluvin. But in general it is best to forego the use of drugs and to rely upon proper regulation of the diet, such as iced milk taken in teaspoonful doses, and upon repose for the stomach.

Hemorrhage from the stomach is best treated by absolute rest, the administration of bits of ice by the mouth, and the application of a flat, not too heavy, ice-bag over the stomach. The patient should lie as quietly as possible in the supine position, with light coverings and in a cool atmosphere. He should be cautioned to make no exertion. His apprehensions should be quieted so far as possible. All food should be withheld from the stomach, and for four or five days after the cessation of profuse hemorrhage aliment should be given only by the rectum. There is no proof that styptics administered by the mouth have any control over the hemorrhage, and as they are liable to excite vomiting they may do harm. Ergotin, dissolved in water (1 part to 10), may be injected hypodermically in grain doses several times repeated if necessary. If internal styptics {526} are to be used, perhaps the best are alum-whey and a combination of gallic acid 10 grains and dilute sulphuric acid 10 drops diluted with water. Fox praises acetate of lead, and others ergot, tannin, and Monsell's solution. If there is vomiting or much restlessness, morphine should be given hypodermically. If the bleeding is profuse, elastic ligatures may be applied for a short time around the upper part of one or more extremities, so as to shut out temporarily from the circulation the blood contained in the extremity. If syncope threatens, ammonia or a little ether may be inhaled, or ether may be given hypodermically. Brandy, if administered, should be given either by the rectum or hypodermically. Caution should be exercised not to excite too vigorously the force of the circulation, as the diminished force of the heart is an important agent in checking hemorrhage. When life is threatened in consequence of the loss of blood, then recourse may be had to transfusion, but experience has shown that this act is liable to cause renewed hemorrhage in consequence of the elevation of the blood-pressure which follows it. Transfusion is therefore indicated more for the acute anæmia after the hemorrhage has ceased and is not likely to be renewed. It should not be employed immediately after profuse hæmatemesis, unless it is probable that otherwise the patient will die from the loss of blood, and then it is well to transfuse only a small quantity.[121]

[Footnote 121: Michel transfused successfully in a case of extreme anæmia following gastrorrhagia (_Berl. klin. Wochenschr._, 1870, No. 49). In a case of profuse and repeated hæmatemesis which followed washing out the stomach Michaelis infused into the veins 350 cc. of solution of common salt. Reaction gradually followed, and the patient recovered. This case, which was one of probable ulcer, illustrates the advantages of infusing a small quantity (_ibid._, June 23, 1884). The dangers are illustrated by a case reported by V. Hacker, who infused 1500 cc. of salt solution in a patient in a state of extreme collapse resulting from hemorrhage from gastric ulcer. The patient rallied, but he died three hours after the infusion from renewed hemorrhage (_Wiener med. Wochenschr._, 1883, No. 37). In Légroux's case of gastric ulcer renewed hemorrhage and death followed the transfusion of only 80 grammes of blood (_Arch. gén. de Méd._, Nov., 1880). In a case quoted by Roussel, Leroy transfused 130 grammes of blood in a girl twenty years old who lay at the point of death from repeated hemorrhages from a gastric ulcer. In the following night occurred renewed hemorrhage and death (_Gaz. des Hôp._, Sept. 22, 1883). According to the experiments of Schwartz and V. Ott, the transfusion, or rather infusion, of physiological salt solution is as useful as that of blood, and it is simpler and unattended with some of the dangers of blood-transfusion. The formula is chloride of sodium 6 parts, distilled water 1000.]

Schilling recommends, when the bleeding is so profuse that the patient's life is threatened, to tampon the stomach by means of a rubber balloon attached to the end of a soft-rubber stomach-tube.[122] The external surface of the balloon is slightly oiled. It is introduced into the stomach in a collapsed state, and after its introduction it is moderately distended with air. When the balloon is to be withdrawn the air should be allowed slowly to escape. Schilling tried this procedure in one case of hemorrhage from gastric ulcer, allowing the inflated bag to remain in the stomach twelve minutes. The hemorrhage ceased and was not renewed. Experience only can determine whether this device, to which there are manifest objections, will prove a valuable addition to our meagre means of controlling hemorrhage from the stomach.

[Footnote 122: F. Schilling, _Aerztl. Intelligenzbl._, Jan. 8, 1884. Schreiber, in order to determine the position of the stomach, was the first to introduce and inflate in this organ a rubber balloon (_Deutsches Arch. f. klin. Med._, June 5, 1877). Uhler recommends in case of profuse gastric hemorrhage to pass a rubber bag into the stomach and fill it with liquid (_Maryland Med. Journ._, Aug. 30, 1884, p. 347).]

{527} The boldest suggestion ever made for stopping gastric hemorrhage is that of Rydygier, who advocates in case hemorrhage from an ulcer threatens to be fatal to cut down upon the stomach, search for the bleeding ulcer, and then resect it.[123] Notwithstanding the great advances made in gastric surgery during the last few years, Rydygier's suggestion seems extravagant and unwarrantable.

[Footnote 123: _Berl. klin. Wochenschr._, Jan. 16, 1882.]

The most effectual treatment of the dyspepsia which is present in many cases of gastric ulcer is adherence to the dietetic rules which have been laid down, aided by the administration of Carlsbad salts and perhaps in extreme cases the occasional and cautious use of the stomach-tube. If eructations of gas and heartburn are troublesome, antacids may be employed, but they should be given in small doses and not frequently, as the ultimate effect of alkalies is to increase the acid secretion of the stomach and to impair digestion. The best alkali to use is bicarbonate of sodium, of which a few grains may be taken dry upon the tongue or dissolved in a little water.

If perforation into the peritoneal cavity occur, then opium or hypodermic injections of morphine should be given in large doses, as in peritonitis. Bran poultices sprinkled with laudanum or other warm fomentations should be applied over the abdomen, although in Germany ice-bags are preferred. Food should be administered only by the rectum. The chances of recovery are extremely slight, but the patient's sufferings are thus relieved. In view of the almost certainly fatal prognosis of perforation of gastric ulcer into the general peritoneal cavity, and in view of the success attending various operations requiring laparotomy, it would seem justifiable in these cases, after arousing, if possible, the patient from collapse by the administration of stimulants per rectum or hypodermically, to open the peritoneal cavity and cleanse it with some tepid antiseptic solution, and then to treat the perforation in the stomach and the case generally according to established surgical methods.[124] This would be the more indicated if it is known that the contents of the stomach at the time of perforation are not of a bland nature.

[Footnote 124: Mikulicz has successfully treated by laparotomy a case of purulent peritonitis resulting from perforation of the intestine with extravasation of the intestinal contents. He says that the operation is not contraindicated by existing peritonitis if the patient is not already in a state of collapse or sepsis. The perforation is closed by sutures after freshening the edges of the opening (abstract in the _Medical News_, Philada., Sept. 6, 1884). Both Kuh and Rydygier recommend opening the abdomen after perforation of gastric ulcer. The borders of the ulcer are to be resected and the opening closed by sutures (_Volkmann's Samml. klin. Vorträge_, No. 220, p. 12).]

It is important to maintain and to improve the patient's nutrition, which often becomes greatly impaired from the effects of the ulcer. This indication is not altogether compatible with the all-important one of reducing to a minimum the digestive work of the stomach. Nevertheless, some of the easily-digested articles of food which have been mentioned are highly nutritious. By means of these and by good hygienic management the physician should endeavor, without violating the dietetic laws which have been laid down, to increase, so far as possible, the strength of his patient. Starvation treatment in itself is never indicated in gastric ulcer. Inunction of the body with oil is useful in cases of gastric ulcer, as recommended by Pepper.[125]

[Footnote 125: _North Carolina Medical Journal_, 1880, vol. v. p. 5.]

{528} In view of Daettwyler's experiments, mentioned on page 514, it is manifestly important to counteract the anæmia of gastric ulcer. Iron, however, administered by the mouth, disturbs the stomach and is decidedly contraindicated during the active stage of gastric ulcer. During convalescence, only the blandest preparations of iron should be given, and these not too soon, lest they cause a relapse. When the indication to remove the anæmia is urgent, and especially when the chlorotic form of anæmia exists, it may be well to try the hypodermic method of administering iron, although this method has not yet been made thoroughly satisfactory. Especially for the anæmia of gastric ulcer would an efficient and unirritating preparation of iron for hypodermic administration prove a great boon. Probably at present the best preparation for hypodermic use is the citrate of iron, given in one- to two-grain doses in a 10 per cent. aqueous solution, which when used must be clear and not over a month old. The syringe and needle shortly before using should be washed with carbolic acid. The injections are best borne when made into the long muscles of the back or into the nates, as recommended by Lewin for injections of corrosive sublimate. A slight burning pain is felt for ten minutes after the injection. This is the method employed by Quincke with good result and without inflammatory reaction.[126] It is well to remember that Kobert[127] has found by experiment on animals that large doses of iron injected subcutaneously cause nephritis. Other preparations of iron which have been recommended for hypodermic use are ferrum dialysatum (DaCosta), ferrum pyrophosphoricum cum natr. citrico (Neuss), ferrum pyrophosphoricum cum ammon. citr. (Huguenin), ferrum peptonatum and ferrum oleinicum (Rosenthal).[128] When it becomes safe to administer iron by the stomach, then the blander preparations should be used, such as the pyrophosphate, lactate, effervescing citrate, ferrum redactum. Leube recommends the following prescription: Ferr. redact. gr. 80, Pulv. althææ gr. 60, Gelatin q. s.; make 90 pills: at first one, and afterward as many as three, of these pills may be taken three times a day. When carefully prepared the pills are about as soft as butter.

[Footnote 126: Quincke, _Deutsch. Arch. f. klin. Med._, Bd. xx. p. 27; Glaenecke, _Arch. f. exper. Path. u. Pharm._, Bd. 17, p. 466.]

[Footnote 127: _Arch. f. exper. Path. u. Pharm._, Bd. 16.]

[Footnote 128: DaCosta, _N.Y. Med. Record_, vol. xiii. p. 290; Neuss, _Zeitschrift f. klin. Med._, Bd. 3, p. 1; Huguenin, _Correspondenzbl. f. Schweiz. Aerzte_, 1876, No. 11; Rosenthal, _Wiener med. Presse_, 1878, Nos. 45-49, and 1884, Jan. 20.]

Various sequels of gastric ulcer may require treatment. Cicatrization of the ulcer is by no means always cure in the clinical sense. As the result of adhesions and the formation and contraction of cicatricial tissue very serious disturbances of the functions of the stomach may follow the repair of gastric ulcer. The most important of these sequels is stenosis of the orifices of the stomach, particularly of the pyloric orifice. Very considerable stenosis of the pylorus may be produced before the ulcer is completely cicatrized. In three instances a stenosing ulcer of the pylorus has been successfully extirpated.[129] The most important of these sequels {529} of gastric ulcer will be treated of hereafter. Here it need only be said that during convalescence from gastric ulcer attention to diet is all-important. For a long time the diet should be restricted to easily-digested food. The first symptoms of relapse are to be met by prompt return to bland diet, or, if necessary, to rectal alimentation.

[Footnote 129: The successful operators were Rydygier (_Berl. klin. Wochenschr._, Jan. 16, 1882), Czerny (_Arch. f. klin. Chir._, Bd. xxx. p. 1), and Van Kleef (_Virchow u. Hirsch's Jahresbericht_, 1882, Bd. ii. p. 383). Cavazzani cut out by an elliptical incision an old indurated ulcer of the stomach adherent to the anterior abdominal walls. The patient died three years afterward of phthisis (_Centralbl. f. Chir._, 1879, p. 711). Lauenstein resected the pylorus unsuccessfully for what appears to have been an ulcer of the pylorus with fibroid induration around it (_ibid._, 1882, No. 9). These four cases (three successful) are all which I have found recorded of resection of gastric ulcer. In my opinion the resection of gastric ulcers which resist all other methods of treatment, and especially those which cause progressive stricture of the pylorus, is a justifiable operation.]

Addendum.

Ulcers of the stomach which do not belong to the category of simple ulcer are for the most part of pathological rather than of clinical interest.

Although miliary tubercles in the walls of the stomach are more frequent than is generally supposed, genuine tuberculous ulcers of the stomach are not common. The most important criterion of these ulcers is the presence of tuberculous lymphatic glands in the neighborhood, and of miliary tubercles upon the peritoneum corresponding to the ulcer. Sometimes miliary tubercles can be discovered in the floor and sides of the ulcer. Tuberculous gastric ulcers, when they occur, are usually associated with tuberculous ulceration of the intestine. In an undoubted case of tuberculous ulcer of the stomach reported by Litten, however, this was the only ulcer to be found in the digestive tract.[130] Tuberculous gastric ulcers generally produce no symptoms, but they have been known to cause perforation of the stomach and hæmatemesis. Many cases which have been recorded as tuberculous ulcers of the stomach were in reality simple ulcers. Cheesy tubercles as large as a pea, both ulcerated and non-ulcerated, have been found in the stomach, but they are very rare.

[Footnote 130: Litten, _Virchow's Archiv_, Bd. 67, p. 615.]

Typhoid ulcers may also occur in the stomach, but they are infrequent. Both perforation of the stomach and gastrorrhagia have been caused by typhoid ulcers, which, as a rule, however, produce no symptoms distinctly referable to the ulcer.

Syphilitic ulcers and syphilitic cicatrices of the stomach have been described, without sufficient proof as to their being syphilitic in origin.

Necrotic ulcers, probably mycotic in origin, may be found in the stomach in cases of splenic fever, erysipelas, pyæmia, etc.

Ulceration occurring in toxic, in diphtheritic, and in phlegmonous gastritis need not be discussed here.

Follicular and catarrhal ulcers of the stomach have been described, but without sufficient ground for separating them from hemorrhagic erosion on the one hand and simple ulcer on the other.

Hemorrhagic erosions of the stomach, to which formerly so much importance was attached, are now believed to be without clinical significance. They are found very frequently, and often very abundantly, after death from a great variety of causes.

{530}

CANCER OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.--Cancer of the stomach is characterized anatomically by the formation in this organ of a new growth, composed of a connective-tissue stroma so arranged as to enclose alveoli or spaces containing cells resembling epithelial cells. The growth extends by invading the tissues surrounding it, and frequently gives rise to secondary cancerous deposits in other organs of the body. The forms of cancer which occur primarily in the stomach are scirrhous, medullary, colloid, and cylindrical epithelial cancer. The disease develops usually in advanced life. Rarely latent, occasionally without symptoms pointing to the stomach as the seat of disease, gastric cancer is usually attended by the following symptoms: loss of appetite, indigestion, vomiting with or without admixture with blood, pain, a tumor in or near the epigastric region, progressive loss of flesh and strength, and the development of the so-called cancerous cachexia. The disease is not curable. After its recognition it rarely lasts longer than from twelve to fifteen months.

SYNONYMS.--Carcinoma ventriculi; Malignant disease of the stomach. Of the many synonyms for the special forms of cancer, the most common are--for scirrhous, hard, fibrous; for medullary, encephaloid, soft, fungoid; for colloid, gelatinous, mucoid, alveolar; and for cylindrical epithelial, cylindrical-celled or cylindrical or columnar epithelioma, cylindrical-celled cancroid, destructive adenoma.

HISTORY.--Cancer of the stomach was known to the ancients only by certain disturbances of the gastric functions which it produces. The disease itself was not clearly appreciated until its recognition by post-mortem examinations, which began to be made with some frequency after the revival of medicine in the sixteenth century. During the seventeenth and eighteenth centuries several instances of gastric cancer are recorded, the best described being those observed and collected by Morgagni (1761). During this period scirrhus was regarded as the type of cancerous disease. It was a common custom to call only the ulcerated scirrhous tumors cancerous.

With the awakened interest in pathological anatomy which marked the beginning of the present century, the gross anatomical characters of cancer and the main forms of the disease came to be more clearly recognized. After the description of encephaloid cancer by Laennec[1] in 1812, {531} and the first clear recognition of colloid cancer by Otto[2] in 1816, these two forms of cancer took rank with scirrhus as constituting the varieties of cancer of the stomach as well as of cancer elsewhere. All that it was possible to accomplish in the description of cancer of the stomach from a purely gross anatomical point of view reached its culmination in the great pathological works of Cruveilhier (1829-35) and of Carswell (1838), both of whom admirably delineated several specimens of gastric cancer.

[Footnote 1: _Dict. des Sciences méd._, t. i. and t. xii., Paris, 1812-15.]

[Footnote 2: Otto, _Seltens Beobachtungen, etc._, 1816.]

During this period of active anatomical research the symptomatology of gastric cancer was not neglected. The article on cancer by Bayle and Cayol in the _Dictionnaire des Sciences médicales_, published in 1812, shows how well the clinical history of gastric cancer was understood at that period.

Cylindrical-celled epithelioma of the stomach could not be recognized as a separate form of tumor until the application of the microscope to the study and classification of tumors--an era introduced by Müller in 1838.[3] Cylindrical-celled epithelioma of the stomach was first recognized by Reinhardt in 1851, was subsequently described by Bidder and by Virchow, and received a full and accurate description from Förster in 1858.[4]

[Footnote 3: _Ueber den feineren Ban, etc., der krankh. Geschwülste_, Berlin, 1838.]

[Footnote 4: Reinhardt, _Annalen d. Charité_, ii. 1, 1851; Bidder, _Müller's Archiv_, 1852, p. 178; Virchow, _Gaz. méd. de Paris_, April 7, 1855; Förster, _Virchow's Archiv_, Bd. 14, p. 91, 1858.]

Until the publication by Waldeyer[5] in 1867 of his memorable article on the development of cancers, it was generally accepted that gastric cancer originated in the submucous coat of the stomach, and that the cells in the cancerous alveoli were derived from connective-tissue cells. Waldeyer attempted to establish for the stomach his doctrine that all cancers are of epithelial origin. In all varieties of gastric cancer he believed that he could demonstrate the origin of the cancer-cells from epithelial cells of the gastric tubules--a mode of origin which had previously been advocated for cylindrical epithelioma by Cornil[6] (1864). Waldeyer's view has met with marked favor since its publication, but there are eminent pathologists who have not given adherence to it in the exclusive form advocated by its author.

[Footnote 5: _Virchow's Archiv_, Bd. 41.]

[Footnote 6: _Journ. de l'Anat. et de la Phys._, 1864.]

It is somewhat remarkable that although in the early part of the present century several monographs on gastric cancer appeared,[7] all the more recent contributions to the subject are to be found in theses, scattered journal articles, and text-books. Of the more recent careful and extensive articles on cancer of the stomach, those of Lebert and of Brinton are perhaps most worthy of mention.[8]

[Footnote 7: Chardel, Benech, Daniel, Germain, Prus, Sharpey, Barras, etc.]

[Footnote 8: Lebert, _Die Krankheiten des Magens_, Tübingen, 1878; Brinton, _Brit. and For. Med.-Chir. Rev._, 1857.]

ETIOLOGY.--The data for estimating the frequency of gastric cancer are the clinical statistics of hospitals, series of recorded autopsies, and mortuary registration reports.

Statistics with reference to this point based exclusively upon the clinical material of hospitals have only relative value, as they do not {532} represent in proper proportion both sexes, all ages, all classes in life, and all diseases. Statistics based upon autopsies surpass all others in certainty of diagnosis, but they possess in even greater degree the defects urged against hospital statistics. Not all the fatal cases in hospitals are examined post-mortem, and gastric cancer is among the diseases most likely to receive such examination. Hence estimates of frequency based exclusively upon autopsies are liable to be excessive. Estimates from mortuary registration reports, and therefore from the diagnoses given in death-certificates, rest manifestly upon a very untrustworthy basis as regards diagnosis, but in other respects they represent the ideal point of view, including, as these reports do, all causes of death among all classes of persons. It is evident that in all methods of estimating the frequency of gastric cancer inhere important sources of error. In general, the larger the number of cases upon which the estimates rest the less prominent are the errors. Such estimates as we possess are to be regarded only as approximate, and subject to revision.

From mortuary statistics Tanchou estimates the frequency of gastric cancer as compared with that of all causes of death at 0.6 per cent.; Virchow, at 1.9 per cent.; Wyss, at 2 per cent.; and D'Espine, at 2½ per cent.[9]

[Footnote 9: Tanchou, _Rech. sur le Traitement méd. des Tumeurs du Sein_, Paris, 1844. These statistics, which are based upon an analysis of 382,851 deaths in the department of the Seine, are necessarily subject to sources of error, but they do not seem to me to deserve the harsh criticisms of Lebert and others.

Virchow, _Verhandl. d. phys.-med. Gesellsch. Würzburg_, 1860, vol. x. p. 49--analysis of 3390 deaths in Würzburg during the years 1852-55.

Wyss, quoted by Ebstein in _Volkmann's Samml. klin. Vorträge_, No. 87--analysis of 4800 deaths in Zurich from 1872-74.

D'Espine, _Echo médical_, 1858, vol. ii.--mortuary statistics of the canton of Geneva, considered to be particularly accurate.]

In 8468 autopsies, chiefly from English hospitals, Brinton[10] found gastric cancer recorded in 1 per cent. of the cases. Gussenbauer and Von Winiwarter[11] found gastric cancer recorded in 1½ per cent. of the 61,287 autopsies in the Pathological Anatomical Institute of the Vienna University. From an analysis of 11,175 autopsies in Prague, I find gastric cancer in 3½ per cent. of the cases.[12]

[Footnote 10: _Loc. cit._]

[Footnote 11: _Arch. f. klin. Chirurg._, Bd. xix. p. 372.]

[Footnote 12: Statistics of Dittrich, Engel, Willigk, Wrany, and Eppinger, in _Prager Vierteljahrschr._, vols. vii., viii., ix., x., xii., xiv., xxvii., l., xciv., xcix., and cxiv. Grünfeld found in 1150 autopsies in the general hospital for aged persons in Copenhagen 102 cancers of the stomach, or 9 per cent. (_Schmidt's Jahrb._, Bd. 198, p. 141).]

I have collected and analyzed with reference to this point the statistics of death from all causes in the city of New York for the fifteen years from 1868 to 1882, inclusive.[13] I find that of the 444,564 deaths during this period, cancer of the stomach was assigned as the cause in 1548 cases and cancer of the liver in 867 cases. Probably at least one-third of the primary cancers of the liver are to be reckoned as gastric cancers. This would make the ratio of gastric cancer to all causes of death about 0.4 per cent. This ratio becomes about 1 per cent. (0.93) if only the deaths from twenty years of age upward be taken: gastric cancer hardly ever occurs under that age. It is probably fair to conclude that in New York not over 1 in 200 of the deaths occurring at all ages and from all causes {533} is due to cancer of the stomach, and that about 1 in 100 of the deaths from twenty years of age upward is due to this cause.

[Footnote 13: These statistics are obtained from the records of the Board of Health of the city of New York. These records are kept with great care and system.]

The organs most frequently affected with primary cancer are the uterus and stomach. In order to determine the relative frequency of cancer in these situations, I have compiled the following table of statistics from various sources:[14]

Primary Cancers. Stomach. Uterus.
------------------------- -------------- --------------
11,131 in Vienna 10 per cent. 31 per cent.
7,150 in New York 25.7 " " 24.2 " "
9,118 in Paris (Tanchou) 25.2 " " 32.8 " "
1,378 in Paris (Salle) 31.9 " " 32 " "
587 in Berlin 35.8 " " 25 " "
183 in Würzburg 34.9 " " 19 " "
1,046 in Prague 37.6 " " 33.3 " "
889 in Geneva 45 " " 15.6 " "
------ ---- ----
31,482 total 21.4 per cent. 29.5 per cent.

From this table it appears that in some collections of cases the uterus is the most frequent seat of primary cancer, while in other collections the stomach takes the first rank. If the sum-total of all the cases be taken, the conclusion would be that about one-fifth of all primary cancers are seated in the stomach, and somewhat less than one-third in the uterus. Even if allowance be made for the apparently too low percentage of cases of gastric cancer in the large Vienna statistics,[15] I should still be inclined to place the uterus first in the list of organs most frequently affected with primary cancer, and to estimate the frequency of gastric cancer compared with that of primary cancer elsewhere as not over 25 per cent.

[Footnote 14: Vienna cases: Gurlt, _Arch. f. klin. Chir._, Bd. xxv. p. 421--statistical analysis of 16,637 tumors observed in the three large hospitals of Vienna from 1855 to 1878. New York cases: see preceding foot-note. Paris cases: Tanchou, _op. cit._, and Salle, _Étiologie de la Carcinose_, Thèse, Paris, 1877, p. 145 _et seq._--fatal cases in Paris hospitals, 1861-63. Berlin cases: Lange, _Ueber den Magenkrebs_, Inaug. Diss., Berlin, 1877--post-mortem material. Würzburg cases: Virchow, _loc. cit._, and _Virchow's Archiv_, Bd. 27, p. 430. Prague cases: reference given above--post-mortem material. Geneva cases: D'Espine, _loc. cit._]

[Footnote 15: That this percentage is too low is apparent from the fact that the number of cases of gastric cancer is only twice that of primary cancer of liver in Gurlt's statistics.]

The liability to gastric cancer seems to be the same in both sexes. Of 2214 cases of gastric cancer which I have collected from hospital statistics, and which were nearly all confirmed by autopsy, 1233 were in males and 981 in females.[16] This makes the ratio of males to females about 5 to 4. This difference is so slight that no importance can be attached to it, especially in view of the fact that in most hospitals the males are in excess of the females.

[Footnote 16: My statistics regarding sex are obtained from _Prager Vierteljahrschr._, vols. xvii., l., xciv., xcix., cxiv.; Lange, _op. cit._; Katzenellenbogen, _Beitr. zur Statistik d. Magencarcinoms_, Jena, 1878; Leudet, _Bull. de l'Acad._, t. 29, p. 564; Gussenbauer and V. Winiwarter, _loc. cit._; Lebert, _op. cit._; Habershon, _Diseases of Abdomen_, Philada., 1879; and _Ann. d. Städt. Allg. Krankenh. zu München_, Bd. i. and ii.

If to these accurate statistics be added collections of cases from heterogeneous sources, including mortuary statistics (Brinton, Louis, D'Espine, Virchow, Gurlt, Welch), there results a total of 5426 cases, with 2843 males and 2583 females, the two sexes being more evenly represented than in the more exact statistics given in the text. In this collection of cases Gussenbauer and V. Winiwarter's cases only up to the year 1855 are included, as the subsequent ones are doubtless in great part included in Gurlt's statistics. According to Brinton, gastric cancer is twice as frequent in males as in females.]

{534} The following table gives the age in 2038 cases of gastric cancer obtained from trustworthy sources and arranged according to decades:[17]

Age. Number of cases. Per cent.
------ ---------------- ---------
10-20. 2 0.1
20-30. 55 2.7
30-40. 271 13.3
40-50. 499 24.5
50-60. 620 30.4
60-70. 428 21
70-80. 140 6.85
80-90. 20 1
90-100. 2 0.1
Over 100. 1 0.05

From this analysis we may conclude that three-fourths of all gastric cancers occur between forty and seventy years of age. The absolutely largest number is found between fifty and sixty years, but, taking into consideration the number of those living, the liability to gastric cancer is as great between sixty and seventy years of age. Nevertheless, the number of cases between thirty and forty years is considerable, and the occurrence of gastric cancer even between twenty and thirty is not so exceptional as is often represented, and is by no means to be ignored. The liability to gastric cancer seems to lessen after seventy years of age, but here the number of cases and the number of those living are so small that it is hazardous to draw positive conclusions.

[Footnote 17: The sources of the statistics for age are--Dittrich (160), _Prager Vierteljahrschr._, vol. xvii.; D'Espine (117), _loc. cit._; Virchow (63), _Virchow's Archiv_, Bd. 27, p. 429; Leudet (69), _loc. cit._; Lange (147), _op. cit._; Katzenellenbogen (60), _op. cit._; Gussenbauer and Von Winiwarter (493 cases up to 1855), _loc. cit._; Lebert (314), _op. cit._; Habershon (76), _op. cit._; Gurlt (455), _loc. cit._; _Trans. N.Y. Path. Soc._, vol. i. (41); and _Trans. London Path. Soc._, vols. i.-xxxiv. (43). The results correspond closely to those of the smaller statistics of Brinton and of Lebert.]

Cancer of the stomach in childhood is among the rarest of diseases. Steiner and Neureutter[18] failed to find a single gastric cancer in 2000 autopsies on children. Cullingworth[19] has reported with microscopical examination a case of cylindrical-celled epithelioma in a male infant dying at the age of five weeks; it is probable that the tumor was congenital. It is not certain whether Wilkinson's[20] often-quoted case of congenital scirrhus of the pylorus in an infant five weeks old was a cancer or an instance of simple hypertrophy. Kaulich[21] cites a case of colloid cancer affecting the stomach, together with nearly all the abdominal organs, in a child a year and a half old, but whether the growth in the stomach was primary or secondary is not mentioned. The case which Widerhofer[22] has reported as one of cancer of the stomach secondary to cancer of the retro-peritoneal glands in an infant sixteen days old seems from the description to be sarcoma. Scheffer[23] has reported a case of large ulcerated encephaloid cancer of the fundus, involving the spleen, in a boy fourteen years old. Jackson[24] has reported an interesting case of encephaloid cancer in a boy fifteen years old in whom no evidence of disease existed up {535} to ten weeks before death. These cases, which are all that I have been able to find in children, are to be regarded as pathological curiosities.[25]

[Footnote 18: _Prager Vierteljahrschr._, vol. lxxxix. p. 77.]

[Footnote 19: _British Med. Journ._, Aug. 25, 1877, p. 253.]

[Footnote 20: _London and Edinburgh Month. Journ. of Med._, 1841, vol. i. p. 23.]

[Footnote 21: _Prager med. Wochenschr._, 1864, No. 34.]

[Footnote 22: _Jahrb. f. Kinderheilk. Alt. Reihe_, Bd. ii. Heft 4, p. 194.]

[Footnote 23: _Jahrb. f. Kinderheilk._, xv. p. 425, 1880.]

[Footnote 24: J. B. S. Jackson, _Extracts from the Records of the Boston Society for Medical Improvement_, vol. v., Appendix, p. 109, Boston, 1867.]

[Footnote 25: Mathien (_Du Cancer précoce de l'Estomac_, Paris, 1884) has recently analyzed, chiefly from a clinical point of view, 27 cases of gastric cancer occurring under thirty-four years of age. Of these, 3 were under twenty and 14 were between twenty and thirty years. He also emphasizes the error of considering cancer of the stomach as exclusively a disease of advanced life.]

Such statistics as we possess would make it appear that gastric cancer, as well as cancer in general, is somewhat less common in the United States than in the greater part of Europe.[26] These statistics, however, are too inaccurate, and the problems involved in their interpretation are too complex, to justify us in drawing any positive conclusions as to this point. It is certain that cancer is not a rare disease in the United States.

[Footnote 26: Of 1000 deaths in New York in 1882, 19.3 were from cancer. The statistics on this point from some of the large European cities are--Geneva, 53 deaths from cancer per mille; Frankfort, 47.6; Copenhagen, 33.2; Christiania, 29; London, 28.7; Paris, 27; Edinburgh, 25.4; Berlin, 22.4; St. Petersburg, 15; Amsterdam, 12. These statistics are obtained from the _Forty-fourth Annual Report of the Registrar-General (for 1881)_, London, 1883; from _Preussische Statistik_, Heft lxiii., Berlin, 1882; and from _Traité de la Climatologie médicale_, Paris, 1877-80, by Lombard, in whose excellent work will be found much information on this subject.

To judge from statistics in this country and in England, the death-rate from cancer is undergoing a rapid annual increase. Whereas in New York in 1868 this death-rate was only 12.6 per mille, in 1882 it was 19.3. In England and Wales in 1858 the deaths from cancer per 1,000,000 persons living were 329, and in 1881 they were 520. It seems probable, as suggested in the above report of the Registrar-General, that this apparently increasing large death-rate is due to increased accuracy in diagnosis. It may be also that decrease in infant mortality and prolongation of life by improved sanitary regulations may account in part for this increase. From this point of view Dunn makes the paradoxical statement that the cancer-rate of a country may be accepted as an index of its healthfulness (_Brit. Med. Journ._, 1883, i.).]

It is said on good authority that in Egypt and Turkey gastric cancer and other forms of cancer are infrequent.[27] A similar infrequency has been claimed for South America, the Indies, and in general for tropical and subtropical countries; but all of these statements as to the geographical distribution of cancer are to be accepted with great reserve, as they do not rest upon sufficient statistical information.

[Footnote 27: Hirsch, _Handb. d. Historisch-geographische Pathologie_, Bd. ii. p. 379, Erlangen, 1862-64.]

I have analyzed the frequency of gastric cancer among negroes upon a basis of 7518 deaths among this race in New York, and I find the proportion of deaths from this cause about one-third less than among white persons.[28] It has been stated that cancer is an extremely rare disease among negroes in Africa.[29] The admixture with white blood makes it difficult to determine to what degree pure negroes in this country are subject to cancer.

[Footnote 28: According to the Ninth Census Report of the United States, in the census year 1870 the deaths from cancer among white persons were 13.7 per mille, and among colored persons only 5.7 per mille; but it is well known that the registration returns upon which the vital statistics in these reports are based are very incomplete and unsatisfactory.]