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I V. 3ia3w do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn snidiosw do Aavaan tvnoiivn 3nidioi»jc IONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONS n' ' ^f ° " ° ^ n siasw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snioiqsw do Aavaan tvnoiivn 3NiDia»» IONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATION; Diasw do Aavaan tvnoiivn 3nidk]3w do Aavaan tvnoiiv THE DISEASES OF THE STOMACH BY Dr. C. A. £WA EXTRAORDINARY PROFESSOR OF MEDICINE AT THE UNIVERSITY OF BERLIN DIRECTOR OF THE AUGUSTA HOSPITAL, ETC. TRANSLATED AND EDITED, IVITH NUMEROUS ADDITIONS, FROM THE THIRD GERMAN EDITION By MORRIS MANGES, A.M., M. D. ASSISTANT VISITING PHYSICIAN TO MOUNT SINAI HOSPITAL LECTURER ON GENERAL MEDICINE AT THE NEW YORK POLYCLINIC, ETC. SECOND REVISED EDITION 1* <\ & NEW YORK D. APPLETON AND COMPANY 1897 E341 \897 ftLm SJB , /L/ f .j. ^ 7I0.Z Copyright, 1897, By D. APPLETON AND COMPANY. PREFACE TO THE SECOND AMERICAN EDITION. The great progress which has been made in our knowledge of the diseases of the stomach since the appearance of the first edition of this work in 1892 has rendered a new edition necessary. This is based upon the last (third) German edition, which was published in 1893, which, as may be learned from Prof. Ewald's preface, was a complete revision of the earlier work. With few exceptions I have followed the author's text and have everywhere presented his views, even where subsequent investigations have since modified them. The current opinions have been appended, attention being at the same time called to the change. In addition, much new matter has been incorporated into the text and footnotes. Al- though I have endeavored to render the revision as complete as jospible, it is probable that I have failed to include everything \ 1 i ?h was worthy of notice. The literature on the diseases of the &4 ~>mach is now so extensive that to have included everything would have been impossible. ,\rew illustrations have been added, so that the present edition r ->r" 'ns thirteen figures which are not in the German edition. A iiu^> er of the other figures has also been redrawn. All the new matter and illustrations have been inclosed in [ ]• An esteemed reviewer of the first edition has taken exception to the naming of special manufactures of drugs and food products. Although I agree entirely with him on this point, yet this was un- avoidable ; for it had only been done wherever Prof. Ewald has recommended specific preparations which were unknown to the iii IV DISEASES OF THE STOMACIL majority of American practitioners. I have referred to this detail because the same custom has also been followed in the present edition. I am indebted to Dr. Albert Kohn for assistance in the prepara- tion of the index. M. Manges. 941 Madison Avenue, New York, Aug. 1, 1896. PREFACE TO THE THIRD GERMAN EDITION. The very favorable reception which has everywhere been accorded to this book * has spurred me on to special exertions in writing the present edition. I have therefore not only added con- siderable new matter, but have also entirely rewritten the work. This was necessary, because, on the one hand, the clarifying process which has been going on in this branch during the past years has enabled us to throw aside much superfluous matter, and, on the other hand, many new facts and observations have accumulated. The arrangement of the chapters has been somewhat changed, so as to correspond more closely to the development and relation of the various diseases. I have not refrained from adding many new personal obser- vations and therapeutic experiences, which I trust may be found useful, although they are thus lost to the current literature, which represents only journal articles or abstracts of them. So far as concerns the general pathological views on which the book is based, there has been little which has required alteration. Taken all in all, my original views have been substantiated by the work which has been done on gastric disorders during the past ten years. It has been demonstrated that, after all, in spite of the stom- ach tube, miracles can not be performed, and that the physician's general knowledge, perspicacity, and judgment are still of primary importance! I would also direct attention to the progress made during the past few years in gastric surgery, which has now passed beyond the * Within a short period three edition? have appeared and translations pub- lished in England (Xew Sydenham Society), Spain, France, Italy, and the United States. v vi DISEASES OF THE STOMACH. stage of a few isolated daring operations. In the discussion of the various diseases I have considered the indications for operative interference, and have presented the pros and cons so far as would be necessary to enable a physician to determine whether in a concrete case the aid of the surgeon might be required. The latter may then consider the indications from the surgical standpoint. To present these details, or to give the technique of the various operative pro- cedures, has been unnecessary, for the operator, be he a surgeon or a general practitioner who is compelled to resort to the knife only occasionally, will not consult a work on clinical medicine for such details. The present book, based upon lectures which were delivered be- fore practitioners and which were subsequently enlarged, has been designed for general practitioners and students; every part has been considered from this standpoint and represents an extensive practi- cal experience. I wish to contrast it with the recent small manuals on this subject, which are " adapted to the needs of the general practitioner." The thorough and earnest physician wishes to obtain the current general views on the subject, and to get advice in diffi- cult cases. I trust that their needs will be fulfilled in the same increasing degree as the personal experience of the author has grown, and that, in spite of its revision, the book has not lost its original freshness. C. A. Ewald. Berlin, April 15, 1893. CONTENTS. Preface to the second American edition.......iii Preface to the third German edition........v CHAPTER PAGE I.—Methods of examination.—Determination of the acidity and acids of the contents of the stomach......1 II.—Methods of examination (continued).—Determination of the di- gestion of albumen and starch.—Absorption and motility.— The technique of the examination of the stomach ... 60 III.—Stenoses and strictures of the (esophagus and of the cardia . 109 IV.—The general relations of the stomach to the organism.—In- flammation of the stomach.—Gastritis glandularis acuta, idiopathica et sympathica.—Gastritis phlegmonosa purulenta. Gastritis toxica...........155 V.—Chronic glandular gastritis.—Chronic catarrh of the stomach . 192 VI.—[Mechanical] insufficiency and dilatation of the stomach . . 254 VII.—Cancer of the stomach.........313 VIII.—Ulcer of the stomach.—Ulcus pepticum seu rodens . . . 377 IX.—The neuroses of the stomach.—The physiological relations of the stomach...........448 X.—The neuroses of the stomach........473 XI.—The neuroses of the stomach (continued).....501 XII.—The correlation of the diseases of the stomach to those of other organs.—The practical value of the modern chemical tests.............563 Index.............583 vii LIST OF ILLUSTRATIONS. PAGE 1. Lower end of Ewald's stomach tube........ 6 2. Boas's aspirator............13 3. Curling over of flexible tube in the stomach......16 4. Curve showing the course of the secretion of hydrochloric acid ... 27 5. Curve showing the course of the secretion of hydrochloric acid as calcu- lated according to different methods.......58 6. [Microscopical appearance of stomach contents]......74 7. Vertical position of stomach and exposure of body of pancreas ... 90 8. [Cast of cylindriform stomach in vertical position].....91 9. [Cast of normal stomach]..........91 10. [Cast of dilated stomach in normal position]......91 11. [Cast of markedly dilated stomach tending to assume vertical position] . 91 12. Contraction of stomach in a case of cancer and stenosis of oesophagus . 94 13. [Einhorn's gastrodiaphane]..........96 14. Gastrodiaphanic picture in normal stomach......97 15. Gastrodiaphanic picture in dilated stomach.......97 16. Gastrodiaphanic picture in gastroptosis.......97 17. Gastrodiaphanic picture in gastroptosis.......97 18. Stand for holding stomach tube.........99 19. [Auto-lavage of stomach]..........100 20. [Hemmeter's recurrent stomach tube]........101 21. Deglutable stomach electrode.........103 22. Cicatricial stenosis of oesophagus in child.......115 23. Localized cancer of cardiac orifice of stomach......122 24. Carcinoma surrounding cardia, side view.......130 25. Carcinoma surrounding cardia, front view.......131 26. Carcinoma of oesophagus just above cardia.......137 27. Section of piece of mucous membrane of stomach found in wash-water during lavage of empty stomach........196 28. Section of mucous membrane of atrophic stomach.....198 29. Section of mucous membrane of stomach ; marked atrophy . . . 201 30. Section of mucous membrane of stomach ; cirrhotic atrophy . . . 202 31. Section of mucous membrane of stomach ; total atrophic sclerosis . . 204 32. [Turck's gyroraele]...........237 ix X DISEASES OF THE STOMACH. PAGE 33. [Tumor caused by dilated stomach, front view, showing increased peri- stalsis] .............256 34. [Tumor caused by dilated stomach, side view]......257 35. [Tumor caused by dilated stomach, front view]......258 36. Vascular, polypoid tumor on posterior wall of stomach .... 270 37. Cancer of pylorus with dilatation of stomach and duodenum . . . 272 38. Cross-section through mucous membrane of dilated stomach . . . 281 39. Total scirrhous cancer of stomach.........32G 40. Stomach contents from a case of cancer of stomach ....•• 332 41. [Boas and Oppler's long bacilli found in cancer of stomach] . . . 333 42. Colloid cancer of lesser curvature of stomach......341 43. Cancerous cell-nest raised through stomach tube.....353 44. Piece of mucous membrane resembling cancerous cell-nest.... 354 45. Perforating ulcer of stomach.........379 46. Sketch of position of viscera in splanchnoptosis......541 DISEASES OF THE STOMACH. CHAPTER I. METHODS OF EXAMINATION.--DETERMINATION OF THE ACIDITY AND ACIDS OF THE CONTENTS OF THE STOMACH. The past few years have witnessed such prodigious activity in the study of the diseases of the digestive tract, and more especially of the stomach, that we may now run some risks of being unable to correctly judge what has been accomplished, as we may be unable to separate the wheat from the chaff. Therefore, while pursuing a branch of study the progress of which is so active, it will unques- tionably be very advantageous if we pause every now and then to take an account of stock, to appraise what is novel at its true worth, and to rearrange what is old ; so that we may retain what has stood the test of experience and discard what has been shown to be mere hypothesis. It affords me considerable satisfaction to point out that the views which I have repeatedly expressed on former occasions on the advances in our knowledge of gastric disorders have generally been correct. For, unlike many other investigators in this field, I have maintained that we ought not to be too one-sided in laying undue stress upon the newly acquired knowledge of the chemical processes of gastric digestion in health and disease, but that, so far as possible, v:e should observe and make use of all the symptoms. Thus, at the conclusion of the previous editions of this work I always urged that the correct diagnosis of a gastric disorder was possible only after the most careful and complete consideration of all the symptoms and the employment of all the diagnostic re- sources. This opinion, which is really self-evident, has been strengthened by my daily increasing practical experience. As always occurs under similar circumstances, our diagnostic 1 2 DISEASES OF THE STOMACH armamentarium has been strengthened by becoming less complicated. This is especially true of the chemical procedures. Hence many things which were formerly discussed in minute details may now be discarded, or dismissed in a few words. On the other hand, I pro- pose to lay more stress than formerly upon the so-called physical methods of examination and upon the fundamental principles of dietetics. Before entering into the discussion of my theme, I may be per- mitted to make a few brief introductory remarks. The methods which have recently enabled us to obtain a better knowledge of the chemical processes in the stomach have thrown a light upon the pathology of dyspepsia and the irregularities of gastric digestion which is analogous, comparing a small matter with a great one, to what the ophthalmoscope did in its day for the retina and the laryn- goscope for the interior of the larynx. It was inevitable that this method should soon be favorably received, and that it should have been very extensively used during the past few years in hospital and general practice. I wish, however, to state that not too much stress should be laid upon these procedures as belonging to a spe- cialty. Throughout this work I will be able to show that the tech- nique of the methods which are in use is by no means difficult to carry out, and is within the scope of every physician who as a stu- dent has learned to titrate, to test acid and alkaline solutions, and to place a test tube in a warm chamber. Naturally, fewer persons are engaged in original investigations; hence the examinations do not require the skill characteristic of a specialty, which can only be ac- quired after continuous occupation with that specialty. But, to obtain and analyze stomach contents does not lie beyond the scope of the dexterity and ability which every physician ought to possess. It may happen that one is consulted especially by patients with stomach troubles because he has occupied himself chiefly with the study of these conditions, and has hence acquired the reputation of possessing a special experience. But this alone is not sufficient. Physicians and the public are here influenced not by the special but by general medical knowledge ; this is certainly not acquired if a physician immediately after graduation sets himself up as a special- THE STOMACH TUBE. 3 ist for stomach diseases. In the course of this book it will be seen how closely the diseases of the stomach are related to those of other organs, how complicated this relation is, how often the symptoms are deceptive, how frequently in an apparent stomach disorder entirely different organs are really involved. Hence it is my firm conviction that it is impossible to find truly profitable and satis- factory special occupation in the treatment of the diseases of the stomach alone, because the field is too small, and the technique is so easily learned and is so limited in its scope. I wished to premise these remarks because such questions are frequently put to me. The diagnosis of the diseases of the stomach is based, as in other organs, subjectively upon the statements of the patient, and objec- tively upon the results of our examination. I shall disregard the former, as this will be discussed in the description of each disease. For the latter we may utilize, first, the so-called methods of physical examination—i. e., inspection, palpation, auscultation, and mensu- ration ; secondly, the analysis of the chemical, absorptive, and motor functions of the organ—in short, the investigation of the digestive activity of the stomach. First of all I shall briefly consider the chemical processes of digestion, since it is obvious that the pathological deviations from the normal can only be recognized and properly treated after the normal conditions have been thoroughly understood. Formerly this was hardly possible, so long as we were restricted to the inade- quate external signs and the subjective complaints of the patients. But now a very important factor in the methods of examination has been supplied, since we have learned how to obtain the contents of the stomach at any time in an easy and rapid way, which is also safe and convenient to the patient. This is accomplished by means of the hard or soft stomach tubes, and with the general use of these instruments the new era in the pathology of the diseases of the stomach began. It is worthy of note that the use of the stomach tube is by no means, as is supposed, a recent acquisition* We may disregard * Leube. Die Magensonde. Die Geschichte ihrer Entstehung und ihrer Bedeu- tung in diagnostischer und therapeutischer Hinsicht. Erlangen, 1879. [A most 4 DISEASES OF THE STOMACH. the crude manipulations of Fabricius ab Aquapendente and Rum- saeus (1059), who invented a " stomach brush" * to remove the mucus from the stomach, " so that at that time there was no beer- company at which some did not apply it themselves after drinking heavily, either the same night if they had taken too much, or on the following morning, if they were distressed with the thick phlegm in the throat, after having snored out their intoxication." f In the latter half of the previous century John Hunter introduced catheters into the stomach, but only to inject irritating substances into it. The English surgeon, F. Bush, was the first to attach a pump to the stomach tube to evacuate the stomach in a case of opium poisoning; this discovery is attributed by others to Weiss, an instrument maker. The stomach siphon was first proposed by Arnott:}: in 1829, and then by Sommerville, but passed into oblivion. Kussmaul# again directed the attention of the profession to the stomach tube in his publications in 1867 and 1861), on the treatment of dilatation of the stomach. Meanwhile it had been occasionally recommended, as in France by Blatin, in 1832, and by Canstatt, || and was also used here and there. It was always a standing though only privately uttered claim of Prof. French's clinic, that the pump had regularly been used long before Kuss- maul's publications. But, as is well known, in disputes as to priority in scientific matters, the time at which the subject in ques- tion is made public is decisive, and hence Kussmaul deserves the credit of having again called the attention of the whole medical pro- fession in an impressive way to the use and benefits of the stomach tube. At the meeting of naturalists at Rostock, in 1871, Leube interesting and very complete history of the stomach tube has recently been published by J. C. Hemmeter. New York Medical Journal, December 28, 1895, p. 819.—Ed.] * [Turck's gyromele is a modern device embodying this idea.—Ed.] f J. Chr. Kundraan. Seltenheiten der Xatur und Kunst, etc., 1737. Quoted by Leube. % Quoted by Alderson, On the Dangers attending the Use of the Stomach Pump. Lancet, January 4, 1879. * Kussmaul, in Bericht iiber die 41. Versammlung deutscher Naturforscher und Aerzte zu Frankfurt a. Main, 1867; and Ueberdie Behandlung der Magenerweiter- ung durch eine neue Methode mittelst der Magenpumpe. Deutsch. Archiv fiir klin. Medicin. Bd. vi, S. 455. | Canstatt, in his Jahresbericht for 1841. THE STOMACH TUBE. 5 asserted the possibility of using it for diagnostic purposes, and, as later developments proved, opened up an excellent means of ex- amination. Yet in his early investigations Leube as well as his predecessors exclusively used a stiff tube, or a rubber tube with an elastic but more or less rigid whalebone stylet. This procedure has many inconveniences and disadvantages. Instead of this, I was the first to show that a very soft tube without any stylet, provided it had a thick wall and a sufficient firmness, could be easily intro- duced into the stomach in the great majority of cases requiring examination.* As occurs so frequently, this was the result of chance. In 1875 a man who had poisoned himself with prussic acid was brought to the Frerich clinic. The stomach had to be washed out at once. None of the stiff tubes which were then in use was at hand, so I cut off a piece of gas tubing, rounded off the sharp end, cut out two eyelets, oiled the tube, and, although the man was unconscious, I easily succeeded in reaching the stomach. A similar procedure was published later by Oser.f It is now quite universal to employ only soft, vulcanized rubber tubes like Nek- ton's urethral catheters. They have been used in France since 1880, and are known as tubes Faucher.\ The expressions oesophageal sound, oesophageal tube, stomach sound, siphon sound, stomach pump, stomach tube, etc., are indis- criminately used by writers, and not in their true meaning. Sounds, strictly speaking, are instruments whose solidity permits the trans- fer of the sense of touch into deep and inaccessible places. Hol- low instruments can only be indirectly used for sounding, if their walls are thick enough, as, for example, the use of a catheter for exploring the bladder. The same is true also of the so-called stiff oesophageal and stomach tubes, which may be used to explore the oesophagus and stomach if they are rigid enough and are rounded * Ewald. A Ready Method of washing out the Stomach. Irish Gazette, August 15, 1874, and Berlin, klin. Wochenschr., 1875, No. 1. \ L. Oser. Die mechanische Behandlung der Magen- und Darmkrankheiten. Wiener med. Klinik, 1875; and Die Magenausspiilung mittelst des elastischen Schlauches. Wiener med. Presse, 1887, No. 1. % [Faucher's tubes are about 60 inches long; the external diameter is f to § inch; the walls are of such thickness that the tube can be bent without effacing its lumen. At one extremity is a lateral eye with two orifices; to the other extremity a funnel holding about a pint is attached. Welch.—Ed.] 6 DISEASES OF THE STOMACH. off at the end. But this use is merelv secondary, as their true function is indicated by their name " tubes "—i. e., to allow the passage of fluids. It is an abuse of language to speak of a siphon sound (Hebei'somfe) instead of a stomach tube or.simply a stomach siphon. In the following pages I shall speak of all solid instru- ments as sounds, and of the hollow tubes with more or less rigid walls as stiff oesophageal or stomach tubes {Scldundrohr or Magen- rohr), and of the flexible tubes (made of silk or rubber) simply as stomach tubes {Magenschlauch).* If the tube is introduced to obtain the contents of the stomach, it is naturally of primary importance that these can easily enter and leave the tube; this is ac- complished by having as many and as large openings as possible in the lower portion. The ordinary stiff tubes, and most of the soft ones in general use till now, have one or two openings— eyelets or fenestrse, as they are called—near the lower end ; this is usually a blind end formed by a closed tip made of a harder material. Un- less the tube is very carefully cleansed, all kinds of organic substances may accumulate here and decompose. To avoid these objections I have the tubes made of different thicknesses, with the lower end open, and, following Schiitz's suggestion, have one large fenestra very low down and a number of smaller openings about the size of a large pin's head (Fig. 1). In this way the contents of the stomach may easily enter the tube from all sides, and can be very Fig. 1. readily obtained. Furthermore, the tubes can * [It is surprising how often the expression, stomach pump, is used by writers where the soft tube is referred to. A very striking example of this fault is afforded by the recently published work of Sidney Martin. (The Diseases of the Stomach, London, 1895). Here the word stomach pump is continually used; only rarely do we encounter the terms stomach tube or siphon, soft tube, etc. This is greatly to be regretted, as such carelessness of expression may tend to keep up the popular dread against the use of all gastric instruments which is now happily disappear- ing.—Ed.] THE STOMACH TUBE. 7 be very easily cleansed after having been used. These tubes are everywhere known as Ewald's stomach tubes.* Tubes made of braided silk varnished over have also been em- ployed ; they are somewhat firmer than the soft rubber tubes, but are much less rigid than the stiff ones. At my suggestion they have been made after the same model as that above. [Such tubes are very delicate, and can be used only a few times before they are ruined]. [Recurrent stomach tubes have been devisee by Hemmeter-f; and others for lavage; the caliber of the outlet tube is usually too small to permit their use for diagnostic purposes.] It is of the utmost importance that all tubes be kept scrupu- lously clean, nor should they be used indiscriminately. I cleanse them carefully with hot water after every introduction, and have them washed with it from time to time. They are kept in a large, flat, covered glass dish—like the large culture dishes which bacteri- ologists use—which contains a solution of borax. This is superior to carbolic acid, thymol, etc., since it imparts no bad taste to the tubes. Tubes which have been used on patients with or suspected of having cancer ought to be specially marked. This can readily be done by branding them with a hot needle. Patients who can afford it, and who require prolonged treatment, may provide their own instruments.^: * Although I had already published an exactly similar description of these tubes in the first edition of this book in 1888, yet Rosenheim, of Berlin, in the Thera- peutische Monatshefte, August, 1892, has described, in almost the same words as above, what he calls his own important modification of the " ordinary tubes " for douching the stomach. The only difference is that he has substituted an addi- tional number of smaller openings for the large lateral fenestrum. No mention is made, however, of my tubes. If Rosenheim really intended to construct the best possible sprinkling douche, he ought also to have closed the lower opening, which he undoubtedly refrained from doing for the same reasons as I had. Many years ago I discarded a French tube which had only small lateral openings; and since I have successfully douched the stomach for a long time before Rosenheim, I con- sider his modification as entirely superfluous for this purpose. f [Hemmeter. N. Y. Med. Jour., December 28, 1895.—Ed.] X [A very convenient sterilizing apparatus for stomach tubes has been devised by Kutner. An illustration of it may be found in Boas' Magenkrankheiten, 3te Auflage. Bd. i, p. 94, or Therapeut. Monatshefte, 1894, p. 397. I have found that keeping stomach tubes in the solutions recommended by Ewald roughens them after a time, and hence I prefer to keep them dry.—Ed.] 2 8 DISEASES OF THE STOMACH. Dangers of Stomach Tube.—It is self-evident that the softer the instrument which is introduced into the stomach and the more rounded the edges of the openings are, the less wdll be the danger of injuring the mucous membrane. This occurs more easily, and has actually occurred, when rigid instruments and the stomach pump were employed. The tearing off of small pieces of mucous mem- brane has frequently been reported, as, for example, by Wiesner,* Yon Ziemssen,f Leube,:}: Schliep,* and others. Cramer || has re- ported a case where this occurred in a simple lavage of the stomach with the soft tube. This writer seems to be unaware of the fact that BoasA has carefully described the exfoliation of the mucous membrane which occurs in chronic gastritis, and has employed the microscopic examination of these particles for diagnostic purposes.^ As I shall show later on, the finding of these bits of exfoliated mucous membrane is by no means infrequent. They are usually imbedded in blood-streaked mucus. No serious consequences, such as bleeding or gastric ulcers, have ever resulted from them. This is probably due to the prompt contraction of the gastric walls, which closes any open vessels and approximates the borders of the dam- aged area. The possibility of such an occurrence, and, in fact, of any severe lesion of the mucous membrane, is reduced to a minimum by the use of the flexible tube; and in this way there has been removed a serious objection which prevailed until quite recently against the internal exploration of the stomach in certain conditions, such as * Wiesner. Ueber der Behandlung der Ectasie mittelst der Magenpumpe. Ber- liner klin. Wochenschrift, 1870, No. 1. f Von Ziemssen. Zur Technik des Localbehandlung des Magens. Deutsch. Archiv fiir klin. Med., Bd. x, p. 66. X Leube. Die Magensonde. Erlangen, 1879, p. 25. * Schliep. On the Stomach Pump in the Treatment of Chronic Gastric Catarrh. Lancet, December 14, 1872. | Cramer. Die Ablosung der Magenschleimhaut durch die Sondirung und ihre Folgen. Miinch. med. Wochenschr., 1891. Cramer erroneously states that Leube is the only author who is quoted on this subject in the newer text-books of Ewald and Rosenheim. All four of the above names were mentioned in the first edition of this work. A Boas. Magenkrankheiten, 3te Auflage, Bd. i., p. 225. Q [An elaborate paper on this subject has recently been published by Cohnheim, Die Bedeutung kleiner Schleimhautstiickchen fiir die Diagnostik der Magenkrank- heiten. Boas' Archiv fur Verdauungskrankheiten, Bd. i, p. 274.—Ed.] THE STOMACH TUBE. 9 cancer and ulcer, where bleeding may readily occur. Regurgitation of food is a very unpleasant complication, as it may even lead to suffocation, aspiration-pneumonia, etc.* This may be guarded against by the local or internal use of cocaine in very nervous pa- tients. The choking sensation is much less marked after the test breakfast (vide infra), since its intensity is manifestly regulated by the amount of the ingesta, and the masses raised are smaller and much less offensive. It ceases, as a rule, after pouring some water into the stomach, since the irritation of the mucous membrane by the tube is thus removed. In most cases, however, the cause is not any irritation of the gastric mucosa, but hyperesthesia of the pharynx, which gives rise to retching and vomiting, and which may readily be lessened by the local use of cocaine. Finally, when the tube is removed it should be withdrawn as rapidly as possible. If the tube is pinched between the thumb and index finger of the right hand nothing can escape during its withdrawal. In this way we may prevent any aspiration of the stomach contents into the bronchi, and at the same time the physician soils neither himself nor the patient. [Another important reason for pinching the tube during its withdrawal is that we thus obtained an additional few cubic centimetres of stomach contents. Indeed, it not infrequently happens that when we have been unable to siphon any stomach contents, enough may be obtained in this way to make a superficial analysis.] I personally have never met with any serious accidents — neither large haemorrhages nor any other mishap—and can agree with Leube's statement that, "taken all in all, the passage of the tube into the stomach is to be considered an operation without risk"; f but I would modify it by substituting for " taken all in all" the expression " if the necessary care be taken." Another advantage of the flexible tubes is that, in introducing them, it is absolutely unnecessary to introduce the finger into the patient's mouth, thereby sparing him the always unpleasant gagging, and obviating the danger of the physician having his finger bitten. * Emminghaus. Einiges iiber Diagnostik und Therapie mit der Schlundsonde. Deutsch. Archiv fiir klin. Med., Bd. ii, p. 304. f Leube, loc. cit., p. 40. 10 DISEASES OF TnE STOMACH. In introducing flexible tubes, it is superfluous, as Oser showed, to apply oil, vaseline, or glycerin to the outside of the instrument. It need only be dipped in warm water, as the abundant secretion of saliva by the patient will lubricate it sufficiently. Let the patient [who is seated in a chair with his head thrown back a little] open his mouth, push the tube on to the posterior wall of the pharynx (the tube is sufficiently rigid to permit this), and then ask the patient to swallow ; the tube is grasped by the muscles of deglutition and passes without any difficulty into the upper end of the oesophagus, its passage through the introitus oesophagi being distinctly felt; then, by gently pushing the tube, it speedily reaches the stomach. At times a slight resistance is felt at the cardia, frequently not. By this method we avoid the manipulations in the patient's mouth, which are unpleasant both to the latter and to the physician. The procedure is much simplified, and the unpleasantness and excite- ment are so much lessened that, among the many thousand patients examined by me, I can scarcely recall a case in which I was unable to introduce the tube, provided, of course, that I had the patient's co-operation. With a little patience on the one hand, and deter- mination on the other, we may succeed even in nervous and anxious subjects. The patients' conduct during this procedure has afforded me an excellent test of the strength of their nerves, and, as the an- cients expressed it, of their sanguine and lymphatic temperaments. In very sensitive persons, the local sensation may be entirely abol- ished by painting the posterior pharyngeal wall with a 10 to 20 per cent cocaine solution a few minutes before introducing the tube. I have hardly ever found this necessary, and furthermore avoid it wherever it is possible, on account of some patients' idio- syncrasy toward the drug. But, even without its use, I may safely assert that this procedure is much less distressing to the patient than a laryngoscopic examination without cocaine, as the latter at first sets up a much greater irritation. Under certain conditions it may be impossible to pass a soft instrument through the oesophagus, even though it be free from obstruction; then there is also the active resistance of the insane, etc.; finally, we may encounter mechanical obstructions, such as unusual narrowing of the entrance of the oesophagus, due to bony THE STOMACH TUBE. 11 protuberances or to a posterior displacement of the hyoid bone or nervous spasm of the oesophagus. In such cases it is necessary to use a more rigid tube, and, according to the resistance to be over- come, we may try either one of the above described silk tubes, or a so-called red English tube made of catgut varnished over. I no longer use the black French bougies, which were formerly so popu- lar, as they wear out too easily. The majority of the above instruments are 75 ctm. [29| inches] long, so that, having been introduced into the stomach, only a small piece is left projecting between the teeth, as we may usually reckon the distance from the incisor teeth to the lowest point of the greater curvature as being 60 to 65 ctm. [23^ to 25^ inches]. For further manipulations, this small projecting piece may be lengthened before or after its introduction by attaching a small piece of glass tubing with a suitable length of rubber tube of the same size; or, if the upper end of the stomach tube is funnel-shaped, we may insert a hard rubber stopcock, one side of which has a conical end with a screw thread, while the other side is a smooth tube over which soft rubber tubing may be slipped. For cases of dilatation of the stom- ach I have had extra long tubes made with a length of 95 ctm. [37-| inches].* All stiff instruments which are introduced into the oesophagus or stomach, as the sponge probang, bougies, etc., ought to be held in the right hand like a pen; the left index finger is passed into the patient's mouth and depresses the tongue, the tip of the finger pass- ing to the epiglottis if possible ; the tube is then passed rapidly along the left index finger to the posterior pharyngeal wall, and then, and not before, by raising the right wrist the point of the in- strument is depressed into the oesophagus. The more quickly and boldly you manipulate the more easily will the tube pass, and the less will the patient be annoyed. The danger of entering the larynx is greatly exaggerated, and the detailed accounts given about it in * These tubes can be obtained at Miersch, Berlin W., Friedrichstrasse 66. [At my request the Davidson Rubber Company have made Ewald stomach tubes with a graduated scale on the tube up to 25 inches ; a special mark is made at the 16th inch to show when the tube enters the cardia. These tubes may be had of J. Camp- bell, 228 Lexington Avenue, N. Y— Ed.] 12 DISEASES OF THE STOMACH. most text-books are quite superfluous. Under normal conditions the entrance to the larynx is at once reflexly closed by the epiglottis. But even in paralysis or anaesthesia of the larynx, and other con- ditions interfering with the functions of the epiglottis, only the greatest clumsiness will cause the tube to enter the larynx instead of the oesophagus. But even if it should occur, the marked dyspnoea and cyanosis of the patient, and the entrance and exit of air through the tube, would at once show that a " mistake " had been made. At the first introduction of any instrument into the oesophagus patients often become markedly cyanotic, because they believe they can not breathe, and therefore hold their breath spasmodically. Such oc- currences must not be confounded with the above. Holding the breath may easily be differentiated from a true dyspnoea by getting the patients to breathe rhythmically while we count for them. Having introduced the tube, our next task is to obtain the con- tents of the stomach. Here, also, the past few years have witnessed a great simplification. Originally, the stomach pump was used ; this instrument consists of a pump with two tubes—one below, the other at the side ; the fluid is drawn up through the former, and then by turning the piston, or by some similar arrangement of the valves, it is evacuated through the latter. Other even more com- plicated apparatus has been devised which, as the proverb reads, make five quarters out of a mile ! They all require such an array of bottles and glass tubes as from the very beginning to preclude their practical use. Aspiration and expression are the methods which we now gener- ally employ for obtaining stomach contents. For the purpose of aspiration we attach the upper end of the tube by means of a con- necting tube of hard rubber or glass to a pear-shaped rubber bag (like a Politzer bag), which has an upper opening about the size of the little finger. The bag is attached after it has been squeezed to- gether ; in expanding, it aspirates the stomach contents so long as subjected to the ordinary atmospheric pressure. This bag may also be used for the reverse ; namely, by filling it with air or water, attaching it to the tube, and then by squeezing it gently we may succeed in dislodging any pieces of food which may obstruct the lumen of the tube, as is recognized by the cessation of the resistance THE EXPRESSION METHOD. 13 caused by the plug. Boas * has suggested the use of a rubber bulb with a short rubber tube on either side ; one of these is attached to the stomach tube by means of a small piece of glass tubing; on the other is a pinchcock (Fig. 2). A vacuum is obtained by compress- Fig. 2. ing the bulb while the cock is open ; when the latter is closed the contents of the stomach will be sucked up into the bulb. The cock is now opened wdiile the tube on the other side of the bulb is com- pressed ; by squeezing the bulb, whatever has been aspirated may be expelled into a vessel held under the free end of the tube with the cock. I have not found this instrument as convenient as the Politzer bag, since both hands are needed to open the pinchcock. Both methods are, however, good. [My own experience is, that Boas' bulb is far superior to the Politzer bag. Its manipulation is exceedingly simple and easy ; with it we may often be able, to start the siphonage where expression fails; and, finally, it is more easily cleaned than the bag can be. Aspiration may also be done by attaching the stomach tube to the vacuum bottle of Potain's as- pirating apparatus, but the caution must be taken of using a low vacuum.] The Expression Method.—But usually all these manipulations are unnecessary. Some time ago Dr. Boas and myself showed that the stomach contents could be obtained at any time by means of the abdominal pressure, since the straining of the patient suffices to drive the contents of the stomach into the tube, provided they are * I. Boas. Allgemeine Diagnostik und Therapie der Magenkrankheiten. 3te Auflage, Bd. i, p. 128. 14 DISEASES OF THE STOMACH. sufficiently fluid, so that the lumen of the tube is not occluded.* It is frequently erroneously stated that the physician must press with his hand upon the patient's abdomen. Since then the method has been tried by many others with excellent results, and has been designated the Ewald Expression Method {Die Ewaldsche. Exjtres- sionsmethode). It is true that some one may now and then have observed that the stomach contents were forced from the tube dur- ing acts of coughing, etc. ; yet Boas and myself may claim the credit of having systematized the method, and by its means of hav- ing greatly simplified the technique. Martius f states that " Ewald's method was the first one with which, without the slightest danger, sufficient stomach contents could be obtained at any time for examination from every stomach case.'1 In fact, the introduction of the tube for diagnostic purposes is being employed more and more by physicians, and is so well known to the laity, that not infrequently patients in whom the chemical ex- amination of the stomach contents is unnecessary reproachfully ask " whether they will not be pumped out." Indeed, with but very few exceptions I should reproach myself if in any doubtful case I had neglected to employ this method, which, when properly applied, is so absolutely free from danger. Epstein ^ has successfully applied the treatment with the stom- ach tube in very small children, even in infants; the tube was, of course, of a corresponding size—i. e., a Nelaton catheter, Nos. 8, 9, and 10 (French). Leo * and others have used this method for the systematic study of the functions of the stomach in suckling infants, where its employment is so very simple. By proper use, as above mentioned, I would have understood that whenever the possibility exists that the, use of the abdominal pressure may produce hcemorrhage from, or even tearing of, the gastric or intestinal mucosa, the tube must not be employed ; or, if * Ewald und Boas. Beitrage zur Physiologie und Pathologie der Verdauung. Virchow's Archiv, Bd. ci, pp. 325-375; ibid., Bd. civ, pp. 271-305. f Martius und Liittke. Die Magensaure des Menschen, 1892, p. 4. X Epstein. Ueber Magenaussptilung bei Sauglingen. Archiv fur Kinderheil. kunde, 1883, Bd. iv, S. 325. * Leo. Ueber die Function des normalen und kranken Magens, etc., im Siiug- lingsalter. Berl. klin. Wochenschrift, 1888, No. 49. THE STOMACn TUBE. 15 it is, only aspiration after preliminary cocainization should be re- sorted to. The diseases in which these rules hold good are ulcera- tive processes in the stomach, severe organic diseases of the heart, aortic aneurisms, haemorrhagic diatheses, etc., concerning which 1 shall speak in more detail later on. Nevertheless here, as in every procedure which is not absolutely a matter of indifference, unfortu- nate accidents may arise for which neither the physician nor the method ought to be held responsible. Such a case I reported to the Berlin Medical Society ; * a number of others have been pub- lished by W. S. Fenwick.f Although such occurrences, which, after all, concern only decrepit patients whose lives hang in the balance, should warn us to be careful at all times, yet they should not make us discard the method, any more than anaesthetics ought to be abandoned because of the occasional deaths under narcosis. It sometimes happens that, although the stomach is full, none of its contents can be obtained by any of these methods. This may be due to an occlusion of the fenestras of the tube, either by a prolapse * Ewald. Ein Fall von Aneurysma Dissecans. Berl. klin. Wochenschr., 1890, p. 694. A man who was suspected of having a cancer of the stomach presented himself to have the stomach tube introduced in order to obtain some of the gastric contents for examination. No tumor could be felt, yet he was emaciated and ca- chectic. Slight tenderness on pressure in the epigastrium. Heart and lungs nor- mal. After introducing the tube very easily, the patient was asked to bear down ; at that instant he suddenly fell back, became pale and cyanotic, and died within a few minutes. There was no haematemesis, nor was there any blood on the tube. During the last few moments of life a rapid increase in the area of cardiac dullness and a loud friction sound over the heart could be made out. The diagnosis made was haematopericardium, resulting from rupture or perforation of an aneurism. The autopsy revealed the presence of a dissecting aneurism at the beginning of the ascending aorta, just above the aortic valves and still within the pericardium, just where the latter is reflected. At this spot the wall of the aneurism was torn, and it was here that the blood had entered the pericardial cavity. The stomach and oesophagus were absolutely intact and were free from any neoplasm. It must re- main an open question whether the introduction of the tube had anything to do with the rupture of the aneurism. If we consider all the factors of the act of bear- ing down, it would appear that it would not produce such a result; however, it would not cause an increase of the blood pressure in the aorta above the semilunar valves, but would rather exert pressure on the exterior of the vessel. At all events the death occurred while the tube was used. f W. Soltau Fenwick. Some of the Dangers of Washing Out the Stomach; Practitioner, April, 1892. Among other cases, Fenwick also speaks of several fatal cases of tetany which occurred immediately after lavage. Had the stagnating stom- ach contents been thoroughly removed at an early period, the tetany would have been prevented. Consequently these cases speak more in favor of lavage than against it. 16 DISEASES OF THE STOMACH. of the mucous membrane, or they may be plugged—both of these occur rarely with my method; or the tube may have been intro- duced too far and has curled around along the greater curvature, and thus the end is above the level of the contents of the stomach, as is shown in Fig. 3. This is easily remedied by withdrawing the tube a little. In rare cases it may also happen that at a time after the test breakfast, when the stomach is usually full, the organ is found empty, and hence nothing can be expressed. In such cases the transfer of the inges- ta into the intestines is unusually rapid ; this is generally due to a hyperkinesis of the muscular fibers, a condition which will be referred to in the discussion of the gastric neuroses. Although this method of expres- sion, as I have called it, can usually be car- ried out very readily after one has acquired a little experience, yet I must not neglect to tell you that in some cases it is not successful. Thus this may happen where the abdom- inal walls are so relaxed that their pressure can not be brought into play; then, there are also some persons who have so little control over their muscles that they can not bear down when they are told to do so. Hence this method of expression may not be successful, or at least not till after several attempts; yet, taken all together, this occurs in scarcely five per cent of the cases. I may dismiss with mere mention the various procedures which have been proposed by Spallanzani, Edinger, Spath, Einhorn, and Kornfeld. Small quantities of stomach contents are obtained by having the patients swallow small balls of compressed elder pith, SUBSTITUTES FOR THE TUBE. If sponges, or silver buckets which are attached to a string. They have no practical value, because the largest quantities of stomach contents which can be obtained with them are too small for a com- plete analysis ; while, on the other hand, the inconvenience which they cause the patient is scarcely less than that due to the introduc- tion of the tube. Giinzburg* and Sahli f have proposed methods by means of which conclusions as to the completeness of gastric digestion are drawn in an indirect way without withdrawing any stomach con- tents. Some substance, like potassic iodide, which is readily ab- sorbed, is introduced into the stomach during digestion after hav- ing been inclosed in a special way in a fibrin capsule. The length of time which elapses until the appearance in the saliva of the potassic iodide which has been absorbed after the digestion of the fibrin capsule is used as a standard for determining the good or bad condition of the digestion in toto. It must be apparent that this method can never give any exact information as to the cause of any particular stage of digestion, nor the relation of the different phases ; it does not even give any absolute indications concerning digestion in the stomach, as there are no criteria whether the capsule was digested in the stomach or intestines. I shall therefore refrain from giving exact details as to the somewhat complicated methods of preparation of these capsules, which even Sahli himself con- siders only as complementary to the exact methods of analysis. The employment of potassic iodide capsules for testing the absorp- tive powers of the stomach will be considered later on4 It is self-evident that in the examination of the contents of the stomach a method which is as uniform as possible should be fol- lowed. The activity of the gastric secretion depends, mutatis mutandis, upon the food eaten. The quantity is abundant if a * Giinzburg. Ein Ersatz der diagnostischen Magenausheberung. Deutsche med. Wochenschr., 1889, No. 41. t Sahli. Ueber eine neue Untersuchungsmethode der Verdauungsorgane und einige Resultate derselben. Schweizer Corresp.-Blat., 1891, No. 3. X [Other indirect methods of studying the changes in the gastric juice have been suggested. These are based upon changes in the acidity of the urine and the amount of indican. See page 163. A good resume of these indirect meth- ods has been given by Boardman Reed, Medical News, January 18, 1896, p. 57.—Ed.] 18 DISEASES OF THE STOMACH. good opportunity is offered for free secretion. An abundance <>1 food calls forth a greater activity of the glands than a scanty diet, till the food present is saturated with the secreted juice. There- fore different results will be obtained if the examinations are made after varying intervals and after different kinds of food. The neglect of this point was the cause of the great discrepancies be- tween the various writers up to a short time ago ; hence it is abso- lutely indispensable that the interval after the meal and the diet should always be the same, if the results are to be of any value for comparison. The question naturally arises, What is the normal course of t/u secretion in human beings f A continuous series of experiments on the successive phases of digestion in animals, as well as in hu- man beings, had never been made till Dr. Boas and myself made ours on the latter some years ago. First of all we corroborated the results of Tiedemann and Gmelin (1826) and others, that there is normally no gastric juice in the stomach when fasting ; that some kind of irritation of the gastric mucous membrane is necessary to produce the secretion, either by the simple introduction of a sound or tube, as in very nervous persons, or by giving some water, pep- per, etc. Thus, for example, Edinger* found that in 13 out of 15 cases there was no trace of hydrochloric acid, and in the other two a " by no means positive " trace of it. He used the old method of Spallanzani, in which the subjects swallowed pieces of sponge com- pressed to the size of a pill, and attached to a silk thread. Con- cerning this it must be stated that, in persons who have not eaten for an unusually long time, the introduction of the tube may not cause a secretion of gastric juice, but instead a regurgitation of bile and other contents of the duodenum. This is not a normal occur- rence, as will easily be perceived from the standards to be given later on. Schreiber f and Rosin, $ after very thorough experiments, * Edinger. Zur Physiologie und Pathologie des Magens. Deutsch. Archiv fiir klin. Med., Bd. xxix, 1881. f J. Schreiber. Die spontane Saftabscheidung des Magens im Niichternen und die Saftsecretion des Magens im Fasten. Arch, fiir experim. Pathologie und Pharmakologie, Bd. xxiv, S. 365. X H. Rosin. Ueber das Secret des niichternen Magens. Deutsche med. Woch- enschr., 1887, No. 47. IS THE GASTRIC SECRETION CONTINUOUS? 19 have recently claimed that the secretion in the stomach is con- tinuous. At all events, it was found that in 11 out of 15 persons examined for this purpose from 2 to 50 c. c. [f 3 ss. to 3 jf] of a fluid containing hydrochloric acid could be expressed from the stomach when free from food; the fluid was usually clear as water, with very little potash and no remnants of food; in a few cases it was colored green or yellow. Likewise, in 10 out of 11 persons who had fasted seven hours, some of them even the greater part of the day, a fluid containing hydrochloric acid could always be ob- tained by expression, repeated at a few hours' interval. In the cases examined by Kinnicutt,* 2 c. c. of stomach contents contain- ing free hydrochloric acid was found in one case, 10 c. c. in another. Leo,f who found hydrochloric acid "almost without exception" in the stomachs of suckling infants, considers it a residue of the previous process of digestion, while Rosenheim:}: and Kinnicutt agree perfectly with my results that normally the stomach contains only traces of hydrochloric acid (never over 0*04: per thousand#). I can not admit that Schreiber\s experiments ■ are convincing, and that the glands of the stomach, unlike all other secreting glands, are active without any specific stimulation, somewhat like a steam engine " going dead slow." I still consider that the simple act of introducing the tube in most persons who have not become accus- tomed to it by long practice causes a reflex from the mouth down- ward, and this reflex action will suffice to call forth a more or less marked secretion of gastric juice. Furthermore, this will occur more readily the longer the person has remained hungry beyond the usual time of eating, exactly as happens in the salivary glands of dogs, which, when a piece of meat is held before them, secrete the more abundantly the longer they have been starved. Proof of this was afforded me in five patients who were accustomed to the * Kinnicutt. Diagnosis of Diseases of the Stomach. Transactions of the Asso- ciation of American Physicians, vol. v, p. 216. f Leo, loc. cit. X T. Rosenheim. Ueber die Sauren des gesunden und kranken Magens bei Einfuhrung von Kohlenhydraten. Virchow's Archiv, Bd. cxi, S. 419. * [0-04 per thousand, or 0*04 pro mille, as it is usually expressed in German, equals 2gft00-. This is a very convenient way of expressing these high fractions in the decimal system. They can easily be converted back into fractions by remem- bering that 1 pro mille (or 0*1 per cent.) equals tsW—Ed.] 20 DISEASES OF THE STOMACH. passage of the instrument. I passed the tube while the patients were in bed a short time before breakfast, but I obtained only small quantities of clear mucus, at times of a yellow color. This mucus, although having a feeble acid reaction several times, never gave a reaction with the tropaeolin or the phloroglucin-vanillin tests. It may be objected that these were patients with diseased stomachs; yet they always secreted gastric juice with hydrochloric acid after taking food. It is self-evident that patients who are suffering from hypersecretion of the gastric juice, whose stomachs, therefore, are never empty, but always contain a certain amount of secretion, ought not to be employed for such experiments; on the other hand, it is wrong to introduce distilled water into the stomach and then aspirate it, because this produces a more or less energetic secretion of hydrochloric acid. At all events, the contradictory results given by the above writers show that idiosyncrasy causes some to react more easily than others, and, as we shall see later on, this may under certain conditions even lead to a pathological increase of the secretion. [There has recently been considerable discussion as to the con- tents of the stomach while fasting, for the reason that the answer to this question is of importance in the condition known as continuous hypersecretion (see Chapter XI). Probably the best results obtained are those of Martius,* who made experiments on 16 healthy soldiers ; while fasting, the tube was introduced and the contents of the stomach were aspirated. In order to eliminate any irritation of the gastric mucosa from the tube the manipulations were per- formed as rapidly as possible. On an average only 5 seconds were needed to insert the tube and 7 to 8 seconds for aspiration. In all cases Martius obtained stomach contents which contained hydrochloric acid; the quantity of the stomach contents varied from 3 to 30 c. c. (3tV-J); tne acidity from 10 to 40 (0-4 to 1-5 per mille HC1). Schule + experimented on 9 subjects, 6 of whom had previously been trained. In 31 out of 34 trials the stomach contained 2 to 23 c. c. (3 £-vj) of acid fluid. Free hydro- * [Martius. Ueber den Inhalt des gesunden niichternen Magens. Deutsch. med. Wochenschr., Aug. 9, 1894, p. 628.—Ed.] f [Schule. Berl. klin. Wochenschr., 1895, No. 52.—Ed.] THE TEST MEALS. 21 chloric acid was only present 7 times; mucus, bile, peptones, and pepsin were occasionally found. The cause of the presence of this fluid must be the saliva and pharyngeal secretions which are swallowed during sleep. He concludes that the presence of hyperacid fluid in amounts over 50 c. c. is pathological.] Test Meals.—For testing the functions of the stomach we give the patients various meals, some of which are simple, others are larger; but, so far as possible, the various meals should be uni- formly prepared. The test breakfast (Probefruhstuck) of Ewald and Boas consists of an ordinary dry roll and a definite quantity— ■J- litre [f § x]—of fluid, either simply warm water or weak tea [without milk or sugar]. (Tea sometimes has a feeble acid reac- tion, depending on the province from which the tea leaves come.) According to Konig's analysis, such rolls contain 7 per cent nitro- gen, 0'5 per cent fat, 4 per cent sugar, and 52*5 per cent non- nitrogenous extractive substances, to which 1 per cent ash must be added. The roll is thus a mixture of the various nutritious ingre- dients, and is made up here [Berlin] of a tolerably uniform weight, about 35 grammes [540 grains]. The test breakfast thus includes albuminoids, sugar, starches, non-nitrogenous extractives, and also salts; the tea belongs to that group of foods which are of consid- erable importance to the gastric secretion. By means of this breakfast we can offer the stomach all the ingredients which are usually taken, with the great advantage that they are liquefied in a relatively short time, or at least they are softened sufficiently to permit their passage through the tube; while if solid food like meat is given, the openings in the tube are very easily plugged. This also explains why many can not dispense with the stomach pump, which naturally gives greater suction power. The test breakfast can be taken by most patients with gastric disorders, many of whom would be unable to eat a larger meal. My method has the additional advantage of great cleanliness. Even should the patient vomit, as occurs occasionally in a very few cases, the vomit does not consist of fatty, offensive, and viscous masses, as when a large meal is taken, but only of comparatively clean morsels of bread. These advantages have caused the method to be very popu- •>•; DISEASES OF THE STOMACH. lar. On the other hand, it must not be forgotten that such a mod- erate meal makes a very slight demand on the action of the viscus, and a stomach which may prove capable of digesting this moderate meal may not secrete enough for a more complicated diet. This objection applies also to the meal of milk and bread which has been proposed by Klemperer,* and with even greater force to the one- sided administration of small quantities of albumen only (the whites of one or two hard-boiled eggs), as proposed by Jaworski. It is for this reason that I deny the value of such a meal to test all the digestive functions of the stomach. If wre have given the test breakfast, and still desire to apply severer tests, nothing forbids the use of another kind of food to ascertain whether the latter is also properly digested, f Larger meals, like the test dinner (Probemittagbrod), to be taken at noon, have been employed by other observers (Leube, Riegel, Germain See). The test dinner consists of an ordinary [German] midday meal of bouillon, barley or flour soup, a moder- ate piece of beefsteak, and some bread. .Naturally a uniform quan- tity should be given at these meals—about 400 grammes [about 13 fl. oz.] of soup, 60 grammes [2 oz.] scraped beef, and 50 grammes [If oz.] wheat bread. This is not so easily carried out, and the same interval should also be allowed to elapse before the examina- tion. With the test breakfast digestion is at its height within one hour after eating, and under normal conditions can be evacuated in a liquid condition ; but in the large meals either no digestion at all, or very little, will have taken place in that time. One must wait at least two to three, and usually four hours, according to the state of the food, or at times upon the condition of the organ, till all the ingredients are digested sufficiently to pass through the tube; and as the fluid portions of the food are absorbed much more rapidly than the solids, the contents of the stomach after a time become more and more like mush, so that it may easily happen that at this time a sufficient quantity of the stomach contents can not be ob- * Klemperer. Ueber die Anwendung der Milch zur Diagnostik der Magen- krankheiten. Charite-Annalen, Bd. xiv. f [The normal amount withdrawn one hour after a test breakfast is between 20 to 60 c. c. [ \ f-ij]; quantities much greater than this are pathological.—Ed.] THE TEST MEALS. 23 tained. The longer period of waiting is of less importance, since, after all, we are looking for comparative results, provided the larger meals would yield more information about the nature and course of digestion in pathological conditions; but this is not the case. Ein- horn,* Jiirgensen,f Loewenthal,^ and many other writers, have shown that in both methods the variations in the results were only differences in the absolute values, but neither had any special pathog- nostic advantages. It is undoubtedly true that inspection of the stomach contents obtained after a mixed diet will at a glance show the degree of digestion of the starches and albuminoids, and espe- cially of the meat; yet the digestive capacity may also be de- termined by the changes in the roll, and whenever it is necessary we can always supplement it with the test dinner. A gastric juice which digests a roll completely will also digest meat; while, on the other hand, any increase in the secretion (hypersecretion and hyper- chlorhydria) may be detected with the simple digestive stimuli as well as with the more complicated one. The gastric juice which can not digest a roll will be still more insufficient when mixed diet or meat is taken. On the other hand, the test breakfast possesses the great advan- tage that we can at once detect old food remnants, such as fragments of meat, vegetables, etc., which have remained in the stomach. Thus there are many pros and cons for both methods, and while it must be admitted that the test breakfast is practically the most use- ful, yet ive can succeed with any meal which is known to stimulate the normal stomach sufficiently. However, the advantages of the test breakfast are so great that I usually confine myself to it. It is especially convenient where large numbers of examinations must be made, and hardly anything else could be used in consultation prac- tice, where the patient's general condition is determined on one day, and early on the following morning he may come for the ex- * Einhorn. Probefriihstiick oder Probemittagbrod? Berl. klin. Wochenschrift, 1888, No. 32. f Chr. Jiirgensen. Probemittagmahlzeit oder Probefriihstiick? Berl. klin. Wochenschrift, 1889, No. 20. 1 M. Loewenthal. Beitrage zur Diagnostik und Therapie der Magenkrankhei- ten. Inaug. Dissertation, Berlin, 1892. 3 24 DISEASES OF THE STOMACH animation of the stomach, and thus the inconveniences of the pro- cedure are reduced to a minimum.* Examination of Stomach Contents.—The filtrate of the stomach contents which is obtained from the test breakfast when digestion is normal, is a clear watery or light to brownish-yellow fluid, which may readily be used for all the various chemical procedures. Upon the filter is left a mushy mass consisting of fine particles of the digested roll, and scarcely any mucus; it should not contain any admixtures, such as old food fragments or blood. At times, when bile has regurgitated into the stomach, the chyme may assume a light-greenish color on standing. If the filtrate contains either the normal or an excessive amount of hydrochloric acid, it will remain as clear as water for days, and during the first few days will scarcely undergo any change in its acidity; but when the amount of hydro- chloric acid is subnormal it soon becomes turbid and moldy. Under ordinary conditions secretion ceases as soon as the chyme has passed into the intestines. The evacuation of the stomach may at times be delayed, and hence the period of secretion may be pro- longed. This condition, however, must be differentiated from that of the continuous secretion of gastric juice, since, during the latter, secretion goes on even when the stomach is empty. Tarious names have been applied to this condition : gastrosuccorrhaia (Magensaft- fluss) by Reichmann, hypersecretio acida continua by Jaworski, acute and chronic continuous secretion of gastric juice by Riegel, while I, for the sake of brevity, simply called it parasecretion [see Chapter XI]. This classification is thus based upon the time, and not the quantity, of the secretion. Hence secretion must not be confounded with acidity; the latter may be normal, increased (su- peracidity), diminished (subacidity), or absent (anacidity). Further- more, the acidity must be distinguished from the percentage of hydrochloric acid, which, as we shall see later on, may vary from an excess (hyperchlorhydria) to an absence of hydrochloric acid (achlorhydria). Determination of Acidity.—The first thing which must be deter- * [It is not advisable to depend upon the results of one examination ; to be at all certain, at least three test meals should be given at different times.—Ed.] DETERMINATION OF ACIDITY. 25 mined in normal stomach contents which have been removed at the height of digestion is the acid reaction; this is due for the most part to the secreted HCl, the balance to other factors, the most important of which are the acid salts which are found in the stomach contents. At this time the acidity is highest; from the beginning of digestion it gradually increases up to this point, and then gradually dimin- ishes. The secretion of HCl begins at the moment when the glan- dular cells are stimulated to activity by the ingested food ; it at once combines wdth the bases which may be present, and forms inorganic and organic salts. These are neutral salts (chlorides), HCl-albu- minates; later on HCl-albumoses and peptones also are formed. Although the combinations of HCl and albuminoids have an acid reaction—i. e., redden litmus—yet the HCl present in them has been deprived of its character of a free acid, and hence the tests for free HCl (which will be described later on) are negative. These HCl combinations, however, are not very stable, since even satura- tion with calcic carbonate at ordinary temperature will decompose them, and naturally they are destroyed by combustion. We may therefore correctly designate this portion the loosely combined IICI. According to the quantity and quality of its food, these bases which combine wTith HCl are saturated sooner or later, and thus, since the activity of the glands still continues, free HCl* appears in the stomach, the quantity of which increases until it reaches its maxi- mum at the height of digestion^ and then diminishes ; but, as far as our present knowledge will allow us to judge, it persists and can always be demonstrated until the stomach is completely evacuated. To put it in other words, we may say that at the height of digestion the chlorine is present in the following combinations : * Recently the free HCl has been designated as "excessive" (ueberschussig). It seems to me that this term has been poorly chosen, since this would indicate that the combined HCl was the chief factor in the physiological process of digestion, although it is undoubtedly true that the free HCl plays an equally important part in the peptic and antifermentative actions of the gastric juice. Furthermore, the term free HCl has been generally adopted by physicians, and has been accepted in the sense I have denned above. At all events, chemically speaking, the loosely com- bined and the free HCl—i. e., the total chlorine compounds, with the exception of the chlorides (the ammonia may be disregarded)—may be designated free HCl; but it would only complicate matters and would give rise to many errors if this nomenclature were employed and recommended for general use, as has been urged by Leo. 26 DISEASES OF THE STOMACH. 1. With hydrogen, as free HCl. 2. Combined with organic substances, as loosely combined HCl. 3. Combined with inorganic bases, as chlorides, which have either been introduced with the food or have been formed in the stomach. Inasmuch as in the various test meals, and especially in the test breakfast, only small and fairly uniform quantities of inorganic chlorides or bases and salts from which chlorides might be formed in the stomach are introduced [i. e. 3], it is evident that the esti- mation of the chlorine contained in them is of no importance in studying the processes of gastric secretion. Accordingly, the general course of the secretion of HCl may be represented by a curve which begins at zero, rises to a maximum, and then descends. The first period, which is a small one, including the formation of chlorides and the loosely combined HCl, is that which extends from the beginning of digestion to the occurrence of free HCl; the second and larger period is that of digestion with combined and free HCl. The maximum secretion of HCl occurs in the second period, and varies as to time and amount, according to the food and the digestive power of the individual. On a frugal diet (test breakfast) this is at the beginning of the second hour ; the amount of free HCl varies approximately between 1*5 and 2*0 per mille ; on an abundant mixed diet this occurs later, as, for example, in Riegel's test meal,* in the third to fourth hour, with values of 2*3 to 3*0 per mille. However, it is natural that these figures are only approximate and not absolutely fixed, and that in each individual patient the general characteristics of the case must be considered in drawing conclusions from these extreme figures. However, results which are much below or above them may at once be considered pathological. Putting, then, the various possible quantitative changes in the secretion of HCl in an ascending scale, we would have : 1. Achlorhydria.f * [Riegel's test meal consists of a plate of soup, 150 to 200 grammes (5-6£ oz.) of beefsteak, 50 grammes (If oz.) mashed potatoes, and a roll. It is evacuated after three to four hours. Its advantage is that the relative digestion of the starches and albuminoids can be determined at a glance; its disadvantage resides in the plugging of the tube by large fragments of meat.—Ed.] f Some authors, for the sake of euphony, speak of anachlorhydria—e. g., Lyon, DETERMINATION OF ACIDITY. 27 2. Hypochlorhydria. 3. Euchlorhydria. 4. Hyperchlorhydria. The curve in the accompanying figure (Fig. 4) may be taken as an example of the course of the secretion of HCl; it was constructed from a patient with a gastric fistula, from whom the stomach con- tents were taken at first every ten minutes, and later every half hour. Free HCl first ap- peared at the point marked with a *. Although the greater portion of the acidity of the stomach contents is due to HCl, yet the acid salts, especially the acid phosphates (sodic and potassic phosphates), which are introduced in variable amounts with the food, also participate in it, al- though to a lesser degree. As a rule, they are unimportant as compared to free HCl, and their significance has never been exaggerated by German writers, as stated by Hay em and Winter; yet it would be a gross error to simply disregard them in calculating the acidity. The presence of small quantities of lactic acid in the beginning of digestion is an entirely different matter. Small quantities of lactic acid may frequently be found at this time, when the lactic acid bacilli which have been introduced with the food have had an " 0 I _ .J f\ , 1 1 n ' 0. 0. 0 1___ 6 0 9 0 1 0 1 0 I___ 1 10 2 f° MINUTES Fig. 4—Curve showing the course of the secretion of HCl after a test breakfast. The cross indicates the time at which free HCl first appeared. L'analyse de sac gastrique; the grammatical term is that given above. [I have retained throughout this work the term chlorhydria—i. e., amount of HCl—on ac- count of the convenience of its compounds in expressing in one word the differences in amount of HCl.—Ed.] 28 DISEASES OF THE STOMACH. opportunity to thrive. This may occur only in the early periods of digestion, as long as large quantities of HCl have not been secreted; for the conversion of starch into sugar, which is essential for their activity ceases as soon as there is 0'3 per mille HCl.* The forma- tion of lactic acid itself ceases, according to Cohn,f and also Hirsch- feld,^: when the amount of HCl is 0*7 per mille ; according to the latter it is markedly lessened when the HCl is between 04 and 0-2 per mille. Hence in a normal stomach this can take place only a short time. In a large number of investigations made long ago by Boas and myself,* we found lactic acid so regularly at the begin- ning of digestion, that we believed 'its presence to be a constant factor, and accordingly described three stages in the digestion of the test breakfast: the first with lactic acid; the second or inter- mediate stage with lactic acid and small quantities of free HCl; the third, which occurred toward the end of the first hour and when digestion was at its height, with only free HCl. Nevertheless, we have always considered the formation of lactic acid an accidental factor which is dependent upon the introduction into the stomach of carbohydrates, especially sugar, and the lactic acid bacilli, although the latter may have already been present in the gastric mucus ; for if a roll or bread is broken up in water and kept for a time at the bodily temperature no lactic acid is normally detected.! Neither did we assume, as claimed by Martius and Luttke,A that HCl is derived from lactic acid. On the contrary, we have shown that no lactic acid is normally formed when pure albu- min has been eaten ; Q yet my present experience convinces me that we had gone too far in assuming that the formation of lactic acid was always the rule after eating bread, and hence also a factor in its * Ewald. Ueber Zuckerbilduug im Magen und Dyspepsia acida. Berl. klin- Wochensch., 1886. No. 48. f F. Cohn. Ueber die Einwirkung der kiinstlichen Magensaftes auf Essigsaure. und Milchsauregahrung. Zeitschr. fiir phys. Chem., Bd. xiv, p. 75. ± E. Hirschfeld. Ueber die Einwirkung der kiinstlichen Magensaftes auf Essig- saure- und Milchsauregahrung. Pfliiger's Arch., Bd. xlvii, p. 560. * Virchow's Arch., Bd. civ, p. 271. || Ewald. Ueber Zuckerbildung im Magen, etc., loc. cit. A Martius und Liittke. Die Magensaure des Menschen, 1892, p. 24. Q " If food be given which contains nothing from which lactic acid may be pro- duced, such as pure egg albumin, only free HCl will be found." Ewald. Klinik, etc., I. Theil, 3te Auflage, p. 80. LACTIC ACID. 29 peptonization. Although the presence of lactic acid was proved by the formation of lactates, and was also confirmed by all subsequent writers—Cahn and von Mering,* Ritter and Hirsch,f Rosenheim,:}: Leo,* Stintzing, | and von Jaksch,A to mention only the German writers—and although some of these writers have even traced the lactic acid to the end of digestion, yet I have repeatedly seen cases in which this acid was entirely absent throughout the entire course of digestion. That Martius and Liittke A should have reached the same conclusion did not therefore surprise me ; careful investiga- tions with their method (see page 51) showed that the acidity had coincided with that of HCl, and that, so to speak, there was no room for any lactic acid. But I have laid no undue weight upon this fact, which, as stated, was long known to me; first, because, in view of what I have already explained, it was by no means striking; sec- ondly, because it is by no means a constant factor ; and, thirdly, and most important for practical purposes, lactic acid is normally always absent at the height of digestion. It is this relation to the typical course of HCl secretion which is of clinical value, and changes in which may indicate pathological conditions. This fact is by no means altered because several of the above writers could with com- plicated and delicate tests demonstrate traces of lactic acid even at a late stage of digestion. J This can not be done in the ordinary lactic-acid tests, such as Uffelmann's (see page 41), which are not so delicate. But in this lack of sensitiveness lies the value of this test. For we have no method by which an excess of lactic acid could be quickly estimated; hence the value of a reaction which, as in the case here, only becomes evident when there is a patho- logical increase of lactic acid in the stage of digestion under dis- * Cahn und v. Mering. Ueber die Sauren des gesunden und kranken Magens. Deutsch. Archiv f. klin. Med., Bd. xxxix, Hefte 3 u. 4. ' f Ritter und Hirsch. Ueber die Sauren des Magensaftes. Zeitschr. fiir klin. Med., Bd. xiii, p. 446. X Rosenheim. Ueber Magensaure bei Amylaceenkost. Virchow's Archiv, Bd. cxi, S. 414. * Leo. Diagnostik der Krankheiten der Verdauungsorgane, 1890. | Stintzing. Ueber den gegenwartigen Stand der Diagnostik der Magenkrank- heiten. Miinch. Wochenschr., 1889, Nos. 8 and 9. A Jaksch. Klinische Diagnostik, 3te Aufl., 1892. Q Martius und Liittke. Loc. cit., pp. 13 and 156. $ I have corroborated this in several cases. See first edition of this work, p. 21. 30 DISEASES OF TnE STOMACH. cussion. I am therefore justified in maintaining the value of this procedure in spite of the objections raised by Martius and Liittke.* [During the past few years much has been written f on the sub- ject of the relations of lactic acid, especially since Boas claimed a diagnostic significance for the presence of large quantities of this acid in cancer of the stomach. By using new methods {vide infra) for detecting lactic acid, Boas found that lactic acid is not produced during any stage of di- gestion, and that bread and all the substances which are usually given in test meals contain lactic acid or lactates ; he therefore pro- posed that in all tests for lactic acid the test meal given should con- sist of an oatmeal soup or gruel, which is made by boiling a table- spoonful of oatmeal flour with a quart of water, the only addition being a little salt. The stomach contents obtained after this gruel contain no lactic acid. On this point, however, Boas has gone too far; for it has been shown by many observers that the amount of lactic acid or lactates in the roll of a test breakfast is so insignifi- cant that it may practically be discarded, since, as he himself ad- mits, in all cases in which lactic acid has any significance it must be present in such large quantities that Uffelmann's test will give us sufficiently reliable results.] The practical outcome of these considerations is, that the simple fact that the stomach contents are acid does not indicate upon what the acidity depends. It is simply a sum total which must be re- solved into several factors, in doing which we must always remem- ber that the height of the acidity does not necessarily coincide with the height of the secretion of HCl, and that secretion, acidity, and chlorhydria must be carefully distinguished from one another. Furthermore, under pathological conditions, the acidity is also de- pendent upon the products of fermentation of the carbohydrates and fats—i. e., lactic, acetic, and butyric acids, and even alcohol. Nevertheless it is always important to ascertain how acid the stom- ach contents are—i. e., to test the acidity with volumetric solutions and the burette (titration). * Loc. cit., p. 56. f [The full literature on this subject may be found in elaborate papers by Langguth, Boas' Archiv, Bd. i, p. 355, and De Jong, ibid., Bd. ii, p. 53. Also see THE TESTS FOR TOTAL ACIDITY. 31 Tests for Total Acidity.—This is ascertained by adding to the stomach contents a sufficient quantity of an alkaline solution of definite composition which will neutralize all the acid contained in them. The question at once arises whether we should employ filtered stomach contents, as has been done heretofore, or whether we should follow the sug- gestion of Martius and Liittke to use them unfiltered. It is self-evident that different results will be obtained according as we make use of the one or the other. But the above-mentioned writers have neglected one very- important fact, that in either case absolute values are never obtained, but only relative ones. Absolute values are never obtained, because in deter- mining the acidity by titration very different results are found with the various indicators employed ; and we must never forget that in all these procedures we are dealing with certain signs whose nature and useful- ness consist in the fact that they may be compared with one another. In measuring unfiltered stomach contents the results will vary with the quantity of larger or smaller fragments of food contained in them, and the titrimetric error will be much greater because the unfiltered stom- ach contents must be strongly diluted in order that they may be used for titration. Experiments with such a complex mixture as the stomach con- tents differ radically from those with pure solutions. The fact that we estimate all results by percentage instead of by absolute values has this advantage, that it suffices to determine the proportional values. It is self- evident that in the unliquefied fragments of food a certain amount of HCl has been imbibed, the absolute amount of which may be determined if we use unfiltered stomach contents. But inasmuch as the course of digestion is such that a corresponding amount of HCl is also in solution (free, or combined with the dissolved albumin), then the estimation of the latter will also give us indications of the amount of the former; in other words, the amount of work accomplished by the stomach. And that is the very thing which we wish to ascertain. But since it is much easier and more convenient to use filtered stomach contents, and since filtration at the same time also offers certain other diagnostic data, I believe that I am justified in adhering to the old method of studying the chemical changes with filtered chyme. The same is true of the suggestion of Geigel and Blass *—to discuss this point at the same time—that we should estimate the total quantity of acid which is present in the stomach at that particular period in order that we may use this as a means of estimating the functional activity of the organ. Concerning this I would say the following : The advantage of percentage estimations is this, that they give us re- sults which are independent of the total quantity and which may be used Friedenwald. N. Y. Medical Journal, March 23, 1895; and Stewart. Medical News, February 16, 1895.—Ed.] * Geigel und Blass. Procentuale und absolute Aciditiit des Magensaftes. Zeit- schr. fiir klin. Med., Bd. xx, Heft 3. Geigel und Abend. Die Salzsauresecretion bei Dyspepsia nervosa. Virchow's Archiv, Bd. cxxx, Heft 1. 32 DISEASES OF THE STOMACH. in comparing different cases. In order to draw general conclusions from a number of details—and it is our task to deduce general laws from the mass of confusing details—it is of no value to know in each individual case the total amount of secretion, which varies every minute ; on the con- trary, it is much more important to know the relation of the case in point to some absolutely fixed standard of comparison. If the grade of a street or railroad is 15 per cent, the relation to all other roads is known, no mat- ter what the absolute length, elevation above the sea level, etc., may be. The results of the very numerous examinations which have been made in the past have convinced me that percentage values remain uniform when the conditions are unchanged, or, to put it in other words, they change in a corresponding manner. They may therefore be employed in estimating the functional powers of the stomach. A priori, it is evident that the percentage value and the absolute amount of the secretion neither can nor must always agree, since both factors are entirely differently in- fluenced by absorption, transudation, emptying of the stomach, etc. Nat- urally tbe absolute amount of HCl will vary with the quantity of the chyme; and also, as I have shown elsewhere,* it may happen that the percentage will remain uniform while the total amount of HCl will vary from minute to minute on account of the evacuation of large quan- tities of chyme into the intestines. Hence from moment to moment dur- ing the course of digestion varying absolute values would be obtained which bear no direct or absolute relation to the total quantity secreted by the mucous membrane. Consequently the determination of normal and pathological conditions would be made much more difficult, instead of being simplified. Our knowledge of gastric disorders has been much advanced, and is dependent upon the estimations by percentages ; while on the other hand, so far as I know, no new diagnostic facts have been gained by the other method. It is therefore advisable to adhere to the old procedures, and the more so because the method of Geigel and Blass is so complicated as to be useless for practical purposes. However, it is not denied that it may be of some interest to know the absolute amount of secretion at any given moment. [These remarks may also be applied to the various methods f which have been suggested to determine the absolute quantity of stomach contents at the time of their withdrawal. These proce- dures are all too complicated for clinical use, nor are the practical results obtained worth the trouble.] Titration % is most conveniently performed with a deci-normal solution of caustic soda, the end reaction being determined with phenol-phthalein. Should the reaction of the stomach contents be * Ewald. Zeitschr. fiir klin. Med., Bd. xx, Heft 4-6. f [They are described in Boas, he. cit., Bd. i, p. 139. Riegel. Erkrankungen des Magens. Nothnagel's Encyclopedia, 1896, Bd. xvi, II. Theil, p. 88.—Ed.] X [The description of the technique of titration and other strictly chemical pro- cedures lies beyond the province of this work. Those who desire further informa- THE TESTS FOR TOTAL ACIDITY. 33 alkaline, the degree of alkalinity may be determined with a deci-nor- mal acid solution. Normal caustic soda solution contains 40 grm. to the litre, so that 1 c. c. deci-normal caustic soda solution is equivalent to 0-003046 grm. HCl or 0*009 grm. lactic acid. Phenol-phthalein, a derivative of benzol, is a buff-colored powder, freely soluble in alcohol, making a slightly opalescent solution, which remains color- less in acid or neutral solutions, but assumes a carmine color in alka- line solutions. The procedure is simple: a Mohr's burette * is filled with the deci-normal solution of caustic soda; 5 or 10 c. c. of the filtered stomach contents are poured into a small glass beaker, and one or two drops of the [one per cent] alcoholic solution of phenol-phthalein are added. The solution in the burette is very gradually added till the red color which appears in the contents of the beaker no longer disappears on shaking, but remains perma- nently. This indicates the moment when all the acids are saturated or neutralized, or, to put it more exactly, it denotes that the reaction has just turned alkaline. The number of cubic centimetres of the solution in the burette which have been used represents the acidity of the quantity of stomach contents which have been employed. A slight turbidity or yellowish color of the stomach contents does not interfere with the delicacy of the reaction; it is also to be noted that the addition of the phenol-phthalein gives a slightly milky appearance to many stomach contents, f As a rule, the acidity of tion than is given in the text will find these methods fully described in the Hand- book of Volumetric Analysis, by Edward Hart; New York, John Wiley & Sons. In all these volumetric methods the metric system is obviously alone employed. —Ed.] * Where titrations are not made daily, Kleinert's burette will be found very con- venient. This burette differs from the ordinary form with glass stopcock in hav- ing the latter at the upper end above the zero mark of the scale, while the lower end is somewhat drawn out, and is ground, to permit its being closed with a glass cover. The burette is filled by dipping the lower end into the standard solution to be used and sucking at the upper end while the stopcock is open. By closing the latter the atmospheric pressure will keep the column of fluid in the burette. To titrate, we simply turn the stopcock above instead of below, as usual. After use, the lower extremity is closed with the well-greased glass cover. In this way we avoid the annoying drying of the stopcock, and also the alteration due to exposure to the air which occurs in the ordinary form in the drops of fluid in the lower end, if the burette is not in continual use ; this change is due to the formation of car- bonates. f In the text I have only described titration with phenol-phthalein. It is a well- known fact, to which Lippmann (Ueber den Sauregrad des Mageninhaltes bei An- 34 DISEASES OF THE STOMACH 10 c. c. of stomach contents obtained one hour after the tost break- fast ranges between 4 to 5 or 5 to 6 c. c.; results above or below these limits are pathological. It is a matter of convenience to ex- press the acidity in percentage according to the amount of the deci- normal soda solution used; thus, for example, 61 per cent acidity would mean that 100 c. c. of filtered stomach contents were neu- tralized by 61 c. c. of a deci-normal soda solution. This prevents any misconception that the acidity depends on free hydrochloric acid. If we are sure that the acidity depends on the latter, and not on salts or any other acids, we may express the value as HCl. Let us take an example: 6 1 c. c. of deci-normal soda solution had to be added to 10 c. c. of stomach contents until the end reaction ap- peared. One cubic centimetre deci-normal soda solution being equivalent to 0-003646 HCl, when 10 c. c. of stomach contents are used, multiply 0-03646 by the number of cubic centimetres added from the burette till the contents of the beaker are neutralized; this will give the percentage of HCl in the stomach contents under examination. Thus in the example the actual percentage of HCl is 0*22 per cent; this result is within the normal limits (0*14 to 0-24 per cent). To determine whether the acidity depends on free acids or acid salts, the aniline dyes will be found the most useful; of these the best is Tropwolin OO—Vorange Poirier of the French. This powder, when dry, has a beautiful orange color; in saturated watery or alcoholic solutions it is a dark yellowish red ; in the presence of traces of free acid—even as little as about 0*25 per thousand [1 in 4,000]—it changes to dark brown, but acid salts make it straw yel- low. Take a small quantity of the reagent and add a few drops of dilute HCl (containing about 0'05 per cent pure HCl); the solution at once assumes a deep dark-brown color. If some acid sodium wendung verschiedener Indicatoren. Inaug. Dissert. Neuwied, 1891) has again directed attention, that the various indicators, rosolic acid, cochineal, fluorescin, litmus, curcuma, etc., give very different values for the so-called point of neu- tralization. Thus the acidity of a specimen of stomach contents was 65-8 with phenol-phthalein, 54-6 with rosolic acid, and 51*8 with litmus. An interesting dis- cussion of this subject has been published by Spitzer (Ueber die Benutzung gewisser Farbstoffe zur Bestimmung von Afflnitaten. Pfliiger's Archiv, Bd. iv, p. 551), Hence it is necessary to always employ the same indicator. THE TESTS FOR FREE ACIDS. 35 phosphate is added to the tropaeolin solution, the color turns not brown, but a light straw yellow. When free acid and acid salts are both present, a turbid, dirty brown color will be obtained according to which of these predominates. Thus tropaeolin enables us to de- termine whether free acids (hydrochloric or lactic) are present. The dye called Congo red, which was introduced by Hoesslin,* has a similar action ; its solutions assume a peach to a brownish-red color. The addition of a free acid changes it to a sky blue. It is more delicate than tropaeolin, and will react to a fluid containing but 0-02 per thousand. Acid salts produce no change. Methyl violet is another dye which may be mentioned ; it is used in an aqueous solution, which is diluted till it has a reddish-violet color. The addition of even 0-024 per cent of HCl to the solution changes the tint to a sky blue, which is a different color than the original, as can readily be determined when both tubes, before and after adding the stomach contents, are held up to the light. In these tests, as well as in all the other reactions to be mentioned later, there must be an excess of the fluid to be tested over the color solution, otherwise delicate changes might escape notice. The best method is to pour 5 to 10 drops of the color solution into a small test tube and then add 1 to 2 c. c. [15 to 30 drops] of the fil- tered stomach contents. TVe may also pour a little of the dye upon a white porcelain capsule, spread it out in a thin layer by shaking the capsule from side to side, and then add a few drops of the fil- trate at the edge of the layer. [The color reaction will then be seen at the place of contact.] Or we may dip ordinary filter paper into a solution of the dye. allow it to dry, and cut it up into narrow strips. [A strip is dipped into the specimen of stomach contents; the moistened place will then assume the characteristic color. Such test papers may be also prepared with many of the dyes to be men- tioned later on. This is the most convenient way of employing these tests.] These are all merely modifications of the same thing. It is to be observed that the test papers are somewhat less delicate than the freshly prepared solutions, and they become even less delicate after they have been kept for some time. Thus Boas and * Von Hoesslin. Ein neues Reagent auf freie Sauren. Miinch. med. Wochen- schr., No. 6, 1886. 36 DISEASES OF THE STOMACH. myself found that the lower limit of delicacy of Congo paper was 0*1 per mille, which is ten times greater than that of the solution of the dye. The delicacy of tropaeolin paper which is a year old is much diminished. The delicacy of all these reactions is markedly affected by the presence of salts and albuminoids, especially albumoses and pep- tones. Certain salts, as, for example, sodium chloride, enter into combinations with the dyes which are very stable even though they are not true chemical compounds, and not even the addition of small quantities of acid suffices to break them up again; on the other hand, albumen and its derivatives form unstable combinations with a portion of the free acid, and thus also disturb the reaction. Yet, at all events, wre can roughly estimate whether we are dealing with free acid or acid salts, and can obtain a rough idea of the amount of free acid by the intensity of the reaction. For example, test whether the specimen, whose acidity is 61 per cent ( =0-2 per cent HCl), contains free acid. First add some to the Congo red solution; it assumes a pale-blue color, but its intensity is much less than this control test with a 0*2 per cent hydrochloric- acid solution. The same difference is observed in the reactions with tropaeolin. Therefore, along with the free acid which is present in this specimen there are also acid salts. How can we determine the nature of the free acids ? For the Determination of Hydrochloric Acid the above-mentioned dyes are of little use, because the reaction of these aniline dyes toward hydrochloric acid is somewhat uncertain, since they are de- colorized by other acids, especially the organic; as I have already shown, their delicacy is also affected by other substances. Unfor- tunately, these substances are the ones which we always encounter in the stomach contents during ordinary digestion—i. e., albumen and its derivatives, saliva (an albuminous and saline fluid), chlorides, and phosphates. What I said while discussing the demonstration of free acid is also true here. They either simulate or prevent the change of color. There has been much discussion on this point, and the attempt has been made to use this as a criterion for the use- fulness of the various reagents. The truth is that they all react only to free acid, and it depends upon the delicacy of the various THE TESTS FOR HYDROCHLORIC ACID. 37 reagents toward the latter whether the reaction will occur in the presence of a definite amount of albumen, etc.; or, in other words, whether enough free acid will be left over to give the reaction after all the compounds have been formed which the acid may enter into in such a mixture. Therefore, in making comparative tests with solutions of acids which exceed the sensitiveness of a reagent, the more delicate the reagent the greater is the amount of the above-named substances [albumen, etc.] which may be added without preventing the reac- tion ; the opposite result will be observed if we are working with solutions which still contain even a trace of acid to act upon the reagent. This enables us to understand the statement made, for ex- ample, by Seeman,* that a combination of equal parts of a i-per- cent peptone solution and a 0'2-per-cent HCl mixture will just give the methyl-violet reaction; while Ivrukenberg f claims that the phloroglucin reagent (see p. 38) will do the same when one part of a 4-per-cent peptone solution is added to two parts of the identical HCl mixture. It simply means that methyl-violet is about four times less sensitive than phloroglucin-vanillin. As early as 1880 I called attention to this,;}: and showed, espe- cially concerning the methyl-violet reaction, that " it was delayed by the presence of even small quantities of blood, and that it was markedly enfeebled or even prevented by solutions of hydrochlorate of leucin and tyrosin as well as by albumen and peptone." The or- ganic acids which have been alluded to above as affecting the color solutions include lactic acid, acetic acid, and butyric acid ; yet, in order to simulate the changes produced by HCl, much stronger solu- tions are requisite than are found in the stomach contents.* Nevertheless, the value of these dyes as reagents for HCl is less- * Seeman. Ueber das Vorhandensein freier Salzsaure im Magen. Zeitschr. fiir klin. Med., Bd. v, 1882. f Krukenberg. Ueber die diagnostische Bedeutung des Salzsiiurenachweises bei Magenkrebs. Inaug. Dissert. Heidelberg, 1888. X Ewald. Ueber das angebliche Fehlen freier Salzsaure im Magensaft. Zeit- schr. fiir klin. Med., Bd. i, S. 022. * A number of other reagents for free HCl, like Mohr's, Reoch's, Kahler's, etc., have also been published, which I have described in former editions, but have now .omitted because they have only a historical value. Mohr employed the reaction which occurs on the addition of free HCl to a 10 per cent solution of sulpho- 38 DISEASES OF TOE STOMACH. ened, especially since the reagents proposed by Giinzburg* and Boas f do not labor under these disadvantages. Both methods have therefore been universally adopted, and are indispensable for the practical, qualitative testing of free LIC1. Giinzburg's Reagent.—The principle of the reaction, which has long been known to chemists, is that a pine needle which has been dipped into a solution of phloroglucin will assume a bright red color when it is brought in contact with hydrochloric acid. Max Singer has shown that this color change is due to the presence of vanillin. The solution is made as follows: Phloroglucin...................... 2'0 [gr. xxx] Vanillin.......................... TO [gr. xv] Absolute alcohol................... 30*0 [f I j] The solution is pale yellow in color, and has a pronounced odor of vanilla or fresh pine wood; on exposure to light it in time assumes a dark golden-yellow color, and it must therefore be kept in black bottles. If a drop of the reagent is put into a small porcelain dish and some concentrated hydrochloric acid is added, a bright red color and the formation of small red crystals will be at once observed. If the acid is weaker, as, for example, only 0-05 per cent or less, or with stomach contents, no change will be observed at first; but if the dish is carefully heated over a flame, so that the fluid does not boil, but simply evaporates slowly, at the edge of the drop a bright red tinge or very delicate red stripes will be observed. These are absolute proofs of the presence of free hydrochloric acid. Blowing on the dish will cause the beautiful red stripes to appear at once. Filtration of the gastric contents is unnecessary; one or two drops in a small dish or on a strip of filter paper with an equal quan- tity of the reagent will suffice. Test papers may be prepared by soaking strips of ash-free filter paper in the reagent and drying them. A drop of stomach contents is placed upon the strip; on cyanide of potassium and acetate of iron; a peach-red precipitate of sulpho-cyanide of iron is thrown down. Reoch used tartrate of sodium ferric oxide for the same purpose. Kahler proposed ultramarine and zinc sulphide. * Giinzburg. Neue Methode zum Nachweis freier Salzsaure im Mageninhalt. Centralblatt fiir klinische Medicin, 1887, No. 40. f Boas. Ein neues Reagens fiir den Nachweis freier Salzsaure im Magensaft. Centralblatt fur klin. Med., 1888, No. 45. [Friedenwald, N. Y. Medical Record, October 6, 1894.—Ed.] r THE TESTS FOR HYDROCHLORIC ACID. 39 heating this in a porcelain capsule a distinct reaction may be ob- tained (Boas). But not even this is necessary. It will suffice to take the minute quantity of stomach contents which is held in the eye of a piece of wire which has been bent over into a loop the size of a pin's head. Hub this upon a porcelain capsule or upon the tip of a porcelain spoon, and add an equal quantity of reagent; on heating, a distinct reaction will be obtained. The reaction has this great advantage over all others, that it is only produced by HCl and not by organic acids, and that it is not simulated by the albu- minates which may be present; neither is it interfered with by salts, provided they are within the usual proportion; nor is it affected by organic acids; but of this I shall speak again later on. It is sufficiently delicate, since a distinct reaction may be obtained with even 0'05 per mille [1: 20000] HCl. The color obtained is always a bright red, but where the amounts are very small it may be a pale rose red, yet it is never brown nor brownish yellow nor brownish red. The presence of such shades indicates overheating and the combustion of organic substances. Characteristic is the appearance of red stripes or of a uniform reddish tinge at the edge of the drop after gentle heating or slow evaporation to dryness. Strong heating and evaporation of any albuminous substance will produce a marked central red colora- tion, yet this is scarcely to be confounded with hydrochloric-acid reaction. If dilute hydrochloric acid is added to solutions of albu- men or peptone, then the above-mentioned reaction of these sub- stances will only occur after their affinity for the acid has been com- pletely satisfied. Boas's Reagent consists of Eesorcin resublimat.............. 5'0 [gr. lxxv] Sacchar. alb.................... 3*0 [gr. xlv] Spiritus dilut................... 100-0 {f 3 iijss.] The reaction is carried out in the same way as with Giinzburg's re- agent ; the color produced is the same, but it is slower in making its appearance, and, in heating, greater care must be taken lest the charring of the sugar lessens the cleanliness of the reaction. The rose-red colored spot which appears on heating the test paper is not decolorized by ether. 4 40 DISEASES OF THE STOMACH. [The only advantages which Boas's test has over that of Giinz- burg are that it is much cheaper and more stable. It may be kept unchanged for a very long time.] [Topfers Test.—Topfer * has recently proposed a test for free HCl which is exceedingly delicate, and which has the additional ad- vantage that it may also be used in quantitative analyses for the vari- ous combinations of HCl (see page 47). His reagent is a one-half- per-cent alcoholic solution of dimethylamidoazobenzol, which turns red even in the presence of ^ per mille (1 to 40,000) HCl. It may be used either in solution or as a test paper, the latter being less delicate than the former. It is used as follows: To a few cubic centimetres of filtered stomach contents in a test tube or beaker add one drop of the test solution ; if free HCl is present it will turn red. The test papers are prepared by dipping strips of filter paper into the test solution ; on drying they turn yellow. On dipping the test paper into stomach contents with free HCl a red color appears. TOpfer and Friedenwald claim that this reagent responds only to free HCl, and not to combined HCl or organic acids. It has been shown, however, by Strauss f and Einhorn,;}: that it also responds to moderately concentrated solutions of acid phosphates and solutions of lactic acid in the concentrations in which it occurs in the stom- ach. Einhorn believes that if lactic acid is shown to be absent by Uffelmann's test we have an excellent means of determining the amount of free HCl. For the use of this test for quantitative work, see page 48.] The Tests for Organic Acids,—i. e., lactic, acetic, and the true fatty acids, especially butyric acid—must now be considered. I have already discussed the occurrence of lactic acid in the earliest stages of digestion. But it is pathological if it or other organic acids are found in such quantities that they may readily be detected by the ordinary tests. It is characteristic of these acids that they are deriv- atives of the substances which occur normally in the chyme— i. e., starches, sugars, fats, and proteids—and that they are produced * [Topfer. Zeitschr. fiir physiolog. Chemie, Bd. xix, Heft 1. Friedenwald. N. Y. Medical Record, April 6, 1895.—Ed.] f [Strauss. Deutsch. Arch, fiir k'in. Med., Bd. lv.—Ed.] % [Einhorn. N. Y. Medical Journal, May 9, 1896, p. 602.—Ed.] THE TESTS FOR LACTIC ACID. 41 from them by fermentation. So far as we know, the only one which is not so formed is sarcolactic acid, which is dissolved from meat in which it is always present. Tests for Lactic Acid.—There are two kinds of lactic acid : fer- mentation lactic acid and sarcolactic acid. They are distinguished not so much by differences in chemical character as by their source. The former is of more importance to us than the latter, yet the tests to be described presently apply to both kinds. The method used by chemists to determine the presence of lactic acid is a very elaborate one, and is too complicated for general use. A very sim- ple and rapid test for medical practice has been proposed by Uffel- mann, Diluted solutions of neutral ferric chloride turn canary yellow or greenish yellow in the presence of lactic acid.* If some ferric chloride solution is diluted till it is almost colorless, and a trace of lactic acid is added, a canary-yellow color will at once appear. Nevertheless, the reaction is somewhat uncertain, or rather difficult of recognition, because we must merely distinguish the intensity of otherwise similar shades of color. Hence the test was modified by adding one or two drops of pure carbolic acid to the above solution ; or a few c. c. of a dilute carbolic acid solution, say 10 c. c. [3 ijss.] of a 2 to 5 per cent solution of carbolic acid—the exact proportions are not essential—are mixed with one or two drops of ferric chloride solution and diluted with water till the solution assumes a beautiful amethyst-blue color. The addition of lactic acid changes the color to the same canary or greenish yellow described above, and a good con- trast is thus obtained. A few drops of even a 0'05 per thousand solu- tion of lactic acid [1 in 20,000] will suffice to change this blue to the characteristic yellow color. The delicacy of the reaction is such that 2 c. c. [3 ss.] of this Uffelmann's reagent will give a distinct re- sult on adding 0*8 c. c. [12 minims] of a lactic acid solution of 0*01 per cent; with 0*6 c. c. [9 minims] of the same solution the color is pale yellow ; but no yellow color is recognizable on adding only 0*3 c. c. [4-£ minims]. The reagent soon decolorizes, and hence must be * [All recent writers lay great stress upon the greenish color of the reaction; when in doubt as to the exact color it is wise to add a drop of lactic acid to a small quantity of Uffelmann's reagent in a test tube and to use this as a standard for comparison.—Ed.] 42 DISEASES OF TnE STOMACH freshly prepared each time before using it. I have found, how- ever, that it may be kept unchanged for some time by adding about 5 per cent chloroform and preserving it in dark bottles. Unfortunately, this test is not entirely free from sources of error, since lactates as well as free lactic acid produce the yellow color. This, however, does not make much difference, for it is immaterial to us whether free lactic acid or lactates are present; we simply wish to ascertain the presence of lactic acid in the stomach. But the reaction can also be caused by alcohol, sugar, and certain salts, especially phosphates, which are frequently found in the contents of the stomach. Thus, a drop of Rhine wine will give a decided yellow color, and even the ethereal extract of a tablespoonful of Rhine wine or claret will do the same. We must therefore be care- ful to ascertain whether the patient has taken any wine or alcohol before making the test. If to Uffelmann's reagent we add some phosphate, as, for example, a little phosphate of soda in solution, its color will change to canary-yellow which is, however, different from the characteristic tinge; but if the stomach contents have a yellowish hue of their own, then the resemblance may be very close. Under such circumstances we are compelled to resort to a modi- fication of the method used by chemists—i. e., we must make an ethereal extract of the fluid to be examined, then evaporate it, and apply the reaction on the residue left after evaporation. This method is very simple. Take some gastric juice with an acid reac- tion, which gives a marked yellow color with Uffelmann's reagent, and which shows no reaction for free acid with Giinzburg's test or tropaeolin, but which does give a reaction with Congo red; we must ascertain whether the yellow color is due to traces of free lactic acid or lactates or acid salts. Lactic acid may easily be ex- tracted with ether from solutions of 0*75 to 0*5 per thousand; hence, if free lactic acid be present, the aqueous solution of the residue left after evaporating the ethereal extract ought to react acid. First, we extract with ether. We may do this by using a so- called " separatory funnel" (Scheidetrichter), or more simply by thoroughly shaking about 5 to 10 c. c. [ 3 j£ to 3 ijss.] of the stom- ach contents in a medicine bottle with alcohol-free ether; let the TESTS FOR LACTIC ACID. 43 ether separate, which usually occurs very rapidly, and pour it off into a small glass beaker. This is repeated with fresh portions of ether till we have used, all told, about 30 to 60 c. c. [f 3 j-ij] of ether. The ether is then evaporated without an open flame by placing the glass beaker in a vessel of hot water. Add a few drops of water to the residue, and with this try Uffelmann's reaction by carefully let- ting one or two drops of the reagent flow from a pipette. The re- agent and the substance to be tested must always bear a definite re- lation to each other. If we add too much, the reaction might be con- cealed. The residue after evaporation was acid, and gave a distinct Uffelmann reaction. Since in this experiment no reaction for free acid was obtained with tropaeolin, it will show how much more delicate Uffelmann's reagent is than tropaeolin. The latter gave no reaction for free acid because it was masked by acid salts, and because only minute traces of lactic acid were present; yet the Congo-red test for free acid was positive, and the Uffelmann test showed that this was lactic acid. [In spite of all the work which has recently been done on the tests for lactic acid, it is generally conceded that, after all, Uffel- mann's test is sufficiently reliable for practical purposes, since the quantities of lactic acid which have any pathological significance must be so large that they can readily be detected with this reagent. Several useful modifications have been proposed. Thus Fleischer* does not evaporate the ether, but adds the freshly prepared Uffel- mann reagent to the mixture of ether and stomach contents, and shakes vigorously; if lactic acid is present a yellow zone appears at the bottom of the test tube. Strauss f has devised a special separatory funnel which is gradu- ated at 5 c. c. and 25 c. c. Five cubic centimetres stomach contents are poured in, and then add 20 c. c. ether; shake well, then allow 20 c. c. to run off by opening the stopcock at the lower end of the funnel; dilute the remaining 5 c. c. by adding 20 c. c. distilled water; then add 2 drops of a 10 per cent aqueous solution of ferric chloride; shake well, and an intense greenish-yellow color will be observed. * [Fleischer. Quoted by Penzoldt, Deutsch. Arch, fiir klin. Med. Bd. ii, p. 544, —Ed.] f [Strauss. Berl. klin. Wochenschr., 1895, No. 37.—Ed.] 44 DISEASES OF THE STOMACII. Boas's qualitative test* for lactic acid is too complicated for clinical purposes; its principle is the oxidation of the lac- tic acid into aldehyde, which is then detected by Nessler's re- agent, f The diagnostic significance of lactic acid will be discussed in the chapter on Cancer of the Stomach.] The fatty acids, and especially butyric acid, decolorize Uffel- mann's reagent; but this occurs only wmen they are present in over 0-5 per thousand [1 in 2,000]. Fat in the stomach contents may be easily recognized by the small oily particles which are to be found in the aqueous solution of the residue left after evaporating the ethereal extract. The butyric acid which is present in this same aqueous solution may be separated in the form of oily drops by adding some small pieces of calcium chloride. Large quantities of fatty acids in the chyme may be recognized by the characteristic acrid, rancid odor. The best practical test for acetic acid is the nose. If present in considerable quantity its odor is unmistakable. It may be de- tected by neutralizing the watery residue of the ethereal extract with carbonate of soda and then adding neutral ferric chloride solu- tion. A beautiful blood-red color is struck, which can only be ob- tained by one other substance—formic acid—but this does not occur in the contents of the stomach. Finally, one other substance—alcohol—is to be mentioned; it is to be found only in the rare cases of marked yeast fermentation in the stomach. It may be detected with the Lieben iodoform reac- tion in the distillate of the stomach contents; but we must be cer- tain that the patient has not taken alcohol for some time, either in beverages or medicines (tinctures, fluid extracts, etc.). The demon- stration of alcohol has no practical value, hence I shall omit giving exact details of the method. [A number of other substances which are the result of abnormal fermentations and putrefaction of the carbohydrates and albumi- noids when there is marked stagnation of the stomach contents are * [See Boas, loc. cit., or Friedenwald, loc. cit.—Ed.] f [An excellent critical resume of the various tests for lactic acid has recently been published by De Jong. Boas' Archiv, Bd. ii, Heft 1, p. 53.—Ed.] FERMENTATION PRODUCTS. 45 acetone, methane, sulphureted hydrogen, and ammonia. The cause is usually bacterial. The fermentation of carbohydrates produces lactic, butyric, and acetic acids, and possibly also hydrogen; furthermore, as the result of yeast fermentation, alcohol and carbonic acid are produced. The putrefaction of albuminoids results in ammonia, sulphureted hy- drogen, and methane. Rosenheim and Strauss * have shown that traces of ammonia may occur normally in the stomach ; carbonic-acid gas may also be regarded as a normal product in the stomach. The relations of sulphureted hydrogen have been studied by Boas and Zawadski. f Boas claims that this gas occurs especially in dilatation of the stomach due to benign stenoses, and that it is not found when the cause of the pyloric stenosis is malignant. It occurs even when HCl is present in normal amounts. Zawadski only found it when the stomach contents had stagnated over 24 hours. It may readily be detected by its characteristic odor of rotten eggs, and also by the blackening of a strip of filter paper moistened with alkaline sugar-of-lead solution, which is hung in a well-corked test tube containing some of the stomach contents. The occurrence of this gas and of methane will be discussed in Chapter VI, where the subject of fermentation and putrefaction will be considered in detail. It is to be noted that Betz and Sena- tor have found ILS in acute gastric catarrh, and Emminghaus has observed it in a case where there was a communication between the stomach and the perforated intestines. Acetone has also been found in stagnating stomach contents by Von Jaksch and Lorenz ; \ these writers also claimed to have found it in other conditions. Penzoldt and Savelieff * maintain that they have never been able to find it. Ptomaines have also been extracted from stagnating stomach con- * [Rosenheim. Centralblatt fur klin. Med., 1892, No. 32. Strauss. Berl. klin. Wochenschr., 1893, No. 17— Ed.] f [Boas. Loc. cit., part i, p. 209. Zawadski. Centralblatt fiir innere Medicin, 1894, No. 50.—Ed.] X [Von Jaksch. Zeitschr. fiir klin. Med., Bd. viii, p. 36. Lorenz. Ibid., Bd. viii, p. 36.—Ed.] # [Savelieff. Berl. klin. Wochenschr., August 13, 1894.—Ed.] 46 DISEASES OF THE STOMACH. tents in gastrectases due to benign and cancerous pyloric stenosis. Ptomaines seem to play an important part in the causation of tetany (see Chapter VI). Strauss f has recently reported a case in which both sulphureted hydrogen and indol were found ; he was able to cultivate the bacil- lus coh communis from the stomach contents. In cultures this bacillus produced H2S.] The Quantitative Determination of Acidity.—The quantitative de- termination of the amount of HCl secreted must determine two things: (1) The amount of free HCl; (2) the amount of HCl which, as explained above (page 25), has combined with bases and organic substances. The sum of (1) and (2) will give the total amount of HCl secreted. This value, however, can only be de- termined if we introduce food into the stomach which is totally free from chlorides, or if the amount of chlorides which has been introduced is exactly known. Both of these procedures would be very difficult, and would scarcely be feasible for ordinary practical work; and, furthermore, for the following reasons they are un- necessary. It is true that with the test dinner, and especially with the test breakfast, we introduce a certain quantity of chlorides and bases, the latter of which are converted into chlorides by the HCl which is secreted; yet we have at present no simple method with which we can distinguish the chlorine of the chlorides which are introduced into the stomach and those which are formed there. On the contrary, in the ordinary methods of analysis the chlorine of the total chlorides is ascertained and is calculated as HCl. But the chlorides which have been introduced do not interest us. The chlorine which they contain has nothing to do with the work of the stomach, and is a variable factor which differs in the various cases, which, for example, varies if the bread or the dinner which is eaten contains more salt than usual. At all events, the bases and weaker salts are converted into chlorides by the secreted HCl, and thus take up a certain quantity of the secreted HCl; yet this is only a very small fraction of the total amount of HCl. Xow, as the * [Kulneff. Berl. klin. Wochenschr., 1893, No. 17. Turck. Toxines of the Stomach, N. Y. Medical Journal, February 22, 1896.—Ed.] * [Strauss, Berl. klin. Wochenschr., May 4, 1896.—Ed.] QUANTITATIVE TESTS FOR FREE HYDROCHLORIC ACID. 47 amount of bases which are introduced with every test breakfast is about the same, and at all events differs to a much less degree than the chlorides, and especially sodium chloride, we may once for all, without committing any great error, eliminate this factor and restrict ourselves to the estimation of the amount of HCl combined with organic substances. This is the more justifiable because the HCl which has combined to form chlorides has been lost for actual diges- tive purposes. Our task is therefore simplified by having to estimate only the amount of the free HCl, and of the HCl which has com- bined with organic bodies—i. e., the physiologically active HCl. I believe the views which have just been enunciated will dispose of the demand made by Martius and Liittke,* that the unfiltered and not the filtered stomach contents be employed; for, as already explained on pages 31 and 32, we are always only dealing with rel- ative values, in which, for practical diagnostic purposes, it makes very little difference whether they are absolutely or approximately estimated. Also in the method of these two writers, as will be shown later on, the chlorine which has combined with the bases is neglected, and therefore no attempt is made to calculate the abso- lute quantity of HCl secreted, even if we disregard the fact that this method also gives by no means accurate results. In order to simplify matters I shall follow the suggestion of Mintz, and designate and tabulate the various factors under discus- sion as follows, because, as shown by the literature of the past few years, there has been much confusion on this subject, not alone among general practitioners, but also among writers. A = Aciditas = Total acidity. L = Acid, hydrochlor. liberum = Free HCl (or the chlorine con- tained in it). C = Acid, hydrochlor. combinatum = Loosely combined HCl (or the chlorine combined with organic bodies). F = Chlorum fixum = Chlorides (or chlorine of the mineral salts). T = Chlorum totale = Total chlorine. The Estimation of Free HCl (L).—This is best made with Mints''s * Loc. cit., p. 30. 43 DISEASES OF TnE STOMACH. method; * deci-normal soda solution is added [from a burette] to 10 c. c. of stomach contents till Giinzburg's or Boas's reaction no longer occurs; here the quantity of alkali corresponds to the amount of free hydrochloric acid which is present. Mintz has estimated the limits of the Giinzburg reaction to be 0*036 per mille HCl (i. e., 1 c. c. deci-normal soda solution to 100); he has also demonstrated by special experiments that even in mixtures of albuminous substances and hydrochloric acid the alkali combines first with the free HCl. For example, if the Giinzburg reaction no longer occurs after add- ing 1-3 c. c. deci-normal soda solution to 10 c. c. stomach contents, and is still positive when only 1-2 c. c. of the soda solution have been added, then the amount of free HCl, as calculated for 100 c. c. stomach contents, equals 13 c. c. deci-normal soda solution (i. e., 12 -f-1); this represents 0*047 per cent HCl.f If Giinzburg's test is used, as described on page 39, the amount of stomach contents used in testing is exceedingly small, even if repeated tests be made, for each time we need only as much as is taken up by a small loop of wire, "j: As soon as the point is reached where Giinzburg's test is nega- tive, a few drops of phenol phthalein solution may be added to the filtrate of the stomach contents, and, as already described, the total acidity may be determined. Thus we may at once determine both the amount of free HCl (L) and the total acidity (A). [The amount of free HCl and the total acidity may also be de- termined with Topfer's reagent (see page 40). At the same time we can also ascertain the amount of loosely combined HCl and that due to the organic acid -\- acid salts. This is accomplished by means of various indicators. * S. Mintz. Eine einfache Methode zur quantitativen Bestimmung der freien Salzsaure im Mageninhalt. Wiener klin. Wochenschrift, 1889, No. 20, and 1891, No. 9. f [13 x 0-003646 (1 c. c. & normal soda solution = 0-003646 HCl) = 0-047398 per cent HCL—Ed.] X Boas (Diagnostik und Therapie der Magenkrankheiten, 2te Aufl., Bd. i, p. 168) has proposed the opposite method, namely, of titrating with deci-normal HCl, to determine the value of the combined HCl. But, disregarding the fact that Mintz has proposed his method only " for the HCl, which is not demonstrable with Giinzburg's reagent," A. Meyer (Inaug. Dissert., Berlin, 1890) has already shown that the combined HCl can not be determined in this way. QUANTITATIVE TESTS FOR COMBINED HYDROCHLORIC ACID. 49 The method is as follows: The reagents required are deci-normal soda solution, phenol-phthalein solution, Topfer's reagent, and 1 per cent aqueous solution of sodium alizarin sulphonate. Place 10 c. c. of the stomach contents in three beakers, A, B, and C. To beaker A add two drops of the phenol-phthalein solution and deter- mine the total acidity by adding deci-normal soda solution until a per- manent red color is obtained. To beaker B add three or four drops of the al izarin sulphonate solution and add deci-normal soda solution until the first appearance of a distinct violet tint. All the factors of the acidity excepting the loosely combined HCl act on alizarin. Hence the difference between B and A = loosely combined HCl. To beaker C add three or four drops of Topfer's reagent and add deci-normal soda solution until the last trace of red has disappeared, leaving only a yellow tint. This gives the amount of free HCl. By subtracting the results of the free and loosely combined HCl from the total acidity we will obtain the acidity due to the organic acids and acid salts.*] Estimation of the Loosely Combined HCl (C).—A great many tests have been proposed for this purpose, of which Martius and Liittke have enumerated and carefully described no less than twelve.f The principle of all these methods is to ascertain the total quantity of * [Leo's Diagnostik der Krankheiten der Bauchorgane, 2te Auflage, p. 319.—Ed.] f In addition to those which will be described in the text these may be briefly recapitulated as follows: 1. Bidder and Schmidt's method for the determination of the total HCl. See Ewald, Klinik, etc., Bd. i, 3te Auflage, p. 81. 2. Jlehner and Seemann's Method.—Incineration after adding enough alkali to neutralize (a); estimation of acidity of the ash (b). Then a — b = free + combined HCl. Zeitschr. fur klin. Med., Bd. v, p. 272. 3. Brauri's modification of this method, described by Leube. Spec. Diagnostik. etc., 2d edition. 4. Cahn and Yon Mering's Method.—After the HCl has been combined with cin- chonin,, it is separated and the amount of chlorine contained therein is estimated. Deutsch. Arch, fur klin. Med., Bd. xxxix, p. 293. 5. Hoffmann's Method.—This is based on the inverting action on sugar of HCl solutions. Centralbl. fiir klin. Med., 1889, No. 46. 6. Jolles's Method.—The spectra of watery solutions of eosin have two absorp- tion bands which disappear when free and combined HCl are present. One fifth normal alkali is added to the stomach contents until the absorption bands appear; the HCl is calculated from the amount of alkali used. Wiener med. Presse, 1890, No. 51. 7. SjoqvisVs Method.—By incineration with barium carbonate the free and com- bined HCl are converted into barium chloride, which may then be calculated ac- cording to different methods. Zeitschr. fiir physiolog. Chem., Bd. xiii, p. 1. See also Katz. Wiener med. Wochenschr., 1890, No. 51. Von Jaksch. Klinische Diag- nostik, 3te Auflage, 1892. Fawitzki. Virchow's Arch., Bd. cxxiii, p. 307; and Bourget. Arch, de med. Experim., 1889, No. 6, p. 844. 8. Winter and Hayem's Method.—Incineration (after the addition of soda) and estimation of the chlorine with deci-normal silver nitrate with three portions of 50 DISEASES OF TOE STOMACH the free and loosely combined HCl (L -f- C), and then by ascertain- ing and subtracting the amount of free IIC1 to obtain the quantity of the loosely combined HCl. The sum L + C is estimated either by direct analysis or by first obtaining the total amount of chlo;-ine (T) and then subtracting the chlorine in the chlorides (F). I have studied and employed all these various methods, but consider it superfluous to enter into a detailed criticism of them; instead, I shall confine myself to a description of two of them, which, on ac- count of their simplicity, may be recommended for practical u.-e. Although they are not free from sources of error, yet their results are sufficiently accurate for practical purposes. If we will only consider upon how many uncontrollable factors the amount of HCl secreted at the time of our examination depends, we will, I believe, refrain from demanding of our analytical procedures a delicacy which can only be deceptive and which leads to false conclusions when the methods are put to practical use. Leo's Method.—This method is based upon the fact that calcium carbonate (CaC03) at ordinary temperatures is converted into cal- cium chloride (CaCl2) by free and combined HCl, whereas it is not changed by acid phosphates. The difference in the acidity before and after adding CaC03 will therefore give the amount of physiologically active HCl (L -4- C), provided no other free acids are present, or if they are there, have previously been got rid of. The acidity after the addition of CaC03 represents the amount of acid salts present. As it has been found that the same quantity of bi- acid-phosphate requires twice as much alkali for neutralization in the presence of CaCl2 as it does when the latter is absent (on ac- count of the formation of monocalcium phosphate), and as CaCl2 is stomach contents by which (a) the total chlorine, (b) the loosely combined and fixed chlorine, and (c) the fixed chlorides are ascertained. All the procedures, especially Nos. 7 and 8, have been frequently discussed, and have given rise to many controversies which need not be discussed here. Critical discussions of them may be found in Martius and Liittke's monograph, and also in Kossler (Zeitschr. fiir physiolog. Chemie, Bd. xvii, p. 91). It has been shown by a number of observers, but especially by Martius and Liittke and also by Sansoni (Berl. Klin. Wochenschr., 1892, No. 43). that the relation between free and com- bined HCl is uncontrollably destroyed by evaporation and incineration. Moreover, F. A. Hoffmann (Schmidt's Jahrbiicher, Bd. ccxxxiii. p. 208) maintains all methods for estimating HCl which necessitate evaporation are to be avoided because the de- composition produced in the fluid by evaporation can not be calculated. LEO'S TEST. 51 formed in the reaction, it is necessary to have an excess of CaCl2 during all the titrations. The method is carried out as follows : After removing and estimating any organic acids which may be present (vide supra), 5 c. c. of a concen- trated CaCla solution are added to 10 c. c. of filtered stomach contents, and the acidity determined [with deci-normal caustic soda solution and phenol- phthalein]. Then some chemically pure * powdered CaCOs is thoroughly rubbed up with 15 c. c. filtered stomach contents which have been poured into a dry glass beaker; the mixture is then passed through a dry filter. Ten c. c. of the filtrate are measured off, air is blown through to drive off the COa which is formed,f 5 c. c. CaCla solution are added, and the acidity is again determined. The difference in the results of the first and second titrations represents the physiologically active HCl. The fundamental principle of this method—i. e., that the phos- phates are not acted upon by calcium carbonate—has been verified by many observers, among whom are A. Meyer, £ Hoffmann and Wagner,* and Leo and Friedheim. || Langermann A has compared this test with several others, and has obtained fairly good results. Later investigations of Kossler Q have shown that the experimental error with solutions of HCl-peptones and of albumen, and with the small quantities of phosphates which are present in the stomach contents, are very slight (between 1 to 3 per cent. HCl), and that; the results obtained are sufficiently accurate for clinical purposes. I fully agree with Kossler, since for practical purposes it is imma- terial whether, in a given case, we find 2*5 or 2-5S per mille LIC1, which is what an error of -4- 3*24 would be equivalent to. Liittke's Method.—This is based on Volhard's well-known method, the principle of which is that all combinations of chlorine are converted by silver nitrate into silver chloride. The latter is titrated according to the usual methods. Therefore, if the total * CaCOs is chemically pure when red litmus is not blued, after rubbing some of it up with water, and when the addition of sulphuric acid to a solution of it in HCl does not cause a precipitate. f This is best done with the double bulb of a spray apparatus. We detach the double bulb and the rubber tube, and insert a small piece of glass tubing into the open end of the latter. X A. Meyer, Ueber die neuesten Methoden, etc. Inaug. Dissert., Berlin, 1890. * Hoffmann and Wagner. Centralblatt fur klin Med., 1890, No. 40. | Leo und Friedheim. Pfliiger's Archiv, Bd. xlviii, p. 614. A Langermann. Virchow's Archiv, Bd. cxxviii, p. 408. Q Kossler. Zeitschr. fiir physiolog. Chemie, Bd. xvii, p. 91. 52 DISEASES OF TnE STOMACH. chlorine is first determined, and then the amount of chlorine after incineration, the difference in the results of the two estimations will give the amount of physiologically active HCl (L+C). If L has been determined according to Mintz's method, then (L + C) — L = C —i. e., the loosely combined HCl. For the method the following solutions are needed : 1. Deci-normal silver nitrate solution, 17 grammes AgNOs to the litre, and containing an excess of nitric acid, so that 1 c. c. exactly equals 1 c. c. deci-normal HCl solution—i. e., 0-00365 HCl. 2. Liquor ferri tersulphatis (U. S. Ph.).* 3. Deci-normal ammonium sulphocyanate solution, containing 7"6 grammes of the salt to the litre, t The silver which is left over after the formation of silver chloride forms silver sulphocyanate on the addition of the ammonium sulpho- cyanate solution. As soon as all the silver sulphocyanate has been formed, the solution assumes a blood-red color, due to the iron sulpho- cyanate. (a) Estimation of the Total Chlorine.—The procedure is carried out as follows: Ten c. c. of the well-shaken unfiltered or filtered stomach contents are poured into a graduated 100 c. c. flask; the small flask in which the stomach contents have been measured must be washed out with water once or twice. Then 20 c. c. of the deci-normal AgNOs solution are added ; the mixture is shaken and allowed to stand for ten minutes. The addition of 5 to 10 drops of potassium permanganate solution (1 to 15) will decolorize the stomach contents if they are strongly tinged; but this is unnecessary in the majority of cases. The permanganate is not to be added until all the chlorine has combined with the silver, otherwise it will act upon the HCl so that the free chlorine will be set free, which will then evaporate and render the results of the analysis doubtful. If the decolorization has been effectual water is added up to 100 c. c, the mixture is shaken, and filtered through a dry filter into a dry vessel. Fifty c. c. of the filtrate are then titrated with deci-normal ammonium sulphocyanate solution. The total chlorine is calculated as follows: The number of c. c. of ammonium sulphocyanate solution used is multiplied by two, and the sum is subtracted from the number of c. c. of silver used (20 c. c). (b) Estimation of the Chlorides.—Ten c. c. of the well-shaken or fil- tered stomach contents are evaporated to dryness in a platinum dish over a water bath. Instead of a platinum dish we may use an asbestos plate * 175 grammes AgN03 are dissolved in about 900 c. c. 25 per cent, nitric acid solution, and 50 c. c. liq. ferri tersulphatis are then added ; water is then added up to one litre, and is exactly adjusted to deci-normal HCl solution. f Eight grammes ammonium sulphocyanate are dissolved in one litre of water, and the titration point adjusted to the above-described silver solution. Thus, for example, if 9-7 c. c. ammonium sulphocyanate solution were used for 10 c. c. silver solution, then 970 c. c. of this solution must be diluted to 1,000 c. c. LtTTKE'S TEST. 53 which is not too thick, and which is heated by a gas flame or alcohol lamp. In this way the evaporation takes place quickly, care being taken that there is no loss of the fluid by splashing. The residue left after evaporation is burned over an open flame until the residue no longer burns with an illuminating flame. Too strong and too prolonged burning is unnecessary, and is to be avoided because the chlorides are volatilized by too high a temperature. The residue left after combustion is rubbed up with moistened charcoal by means of a glass rod, and is then dissolved out with about 100 c. c. of water, and the fluid is then filtered. Experience has shown that this amount of water is sufficient to completely dissolve out the charcoal. But if we are in doubt whether all the chlorides have been washed out we may add a drop of silver solution to a few drops of the last portion of the filtrate. Any turbidity will indicate the presence of chlorine, and will necessitate further washing. The total filtrate is then poured into a beaker, 10 c. c. deci-normal silver solution are added, and titration carried out with the deci-normal am- monium sulphocyanate solution. The amount of the combined chloride is obtained by subtracting the number of c. c. of ammonia sulphocyanate solution used from the amount of silver solution employed (10 c. a). The difference, a—b, multiplied by 0-0365, will give directly the per- centage of the physiologically active HCl. But even this method, which at first glance seems perfect, is not infallible, in spite of the fact that Volhard's method, which is much simpler and rapid than would appear from the above descrip- tion, has been shown by chemists to be absolutely reliable. Kossler * has called attention to the fact that in the presence of calcium and phosphorus compounds, the amount of chlorides (F) must be too 1owt, because in the decomposition f free HCl, which is volatilized during the evaporation, is set free. The amount of physiologically active HCl will therefore be too high, because calcium and phosphorus compounds are always present in the stomach con- tents after the test breakfast. Another source of error may arise from .the presence of ammonium chloride (NH4C1) in the stomach contents. Even Bidder and Schmidt found as much as 0-4T per mille NII4CI in the gastric juice (containing no saliva) of dogs, although they state that there is no NH4C1 in the gastric juice * Loc. cit. t CaCU + KH3P04 = CaHP04 + KC1 + HCL And 3CaCl, + 2KH2P04 = Ca (1*04)3 + 2KC1 + 2HCL Kossler's experiments show that this loss may amount to about 25 to 40 per cent. 54 DISEASES OF THE STOMACH. (containing no saliva) of human beings.* Leo f also found only traces of ammonia in human stomach contents with tests made for this purpose with Schlosing's method; but Rosenheim X states that with this method he could demonstrate ammonia in such quantities that about 10 per cent of the HCl present in the filtrate of the stomach contents examined must have been thus combined. Inasmuch as ammonia does not occur preformed in the food, its presence can only be traced to the secretion of the rennet glands or to putrefaction of the albumens. At all events, the formation of NH4C1 renders part of the physiologically active HCl inert, which, as may be readily perceived, would be considered active in Liittke's method— i. e., the factor C wTould be about 10 per cent too high. These reasons may perhaps explain why in Martius and Liittke's analyses the amount of IIC1 coincides so surprisingly frequently with the total acidity ; this would leave no room for other acids or salts which in my experience are always found in the stomach contents. However this may be, it is evident that Liittke's method is not free from objections; furthermore, another disadvantage is that it needs too many titrations and also combustion. As in the method of Leo, the free HCl must be determined by a separate analysis with Mintz's method. Nevertheless Liittke's method is to be rec- ommended because of its relative simplicity and the reduction of errors to the lowest possible degree. Quantitative Estimation of Lactic Acid.—After having ascer- tained the acidity of 10 c. c. of stomach contents they are repeat- edly shaken up with a large quantity (100 to 150 c. c.) [ § iij-v] of ether, and the acidity of the residue left after the removal of the ether is determined. Multiplication of the difference of the two re- sults by 0-09 will give the approximate percentage of lactic acid which is sufficiently accurate for practical purposes. To carry out this test it is essential that volatile fatty acids, es- pecially butyric acid, be absent. Their presence may be ascertained by pouring some stomach contents into a test tube or a small flask, * See Ewald. Klinik, etc., I. Theil, 3te Auflage, p. 81. f Leo. Deutsch. med. Wochenschr., 1891, No. 41. X Rosenheim. Centralbl. fiir klin. Med., 1892, No. 39. QUANTITATIVE ESTIMATION OF LACTIC ACID. 55 a piece of moistened sensitive blue litmus paper being placed in the neck of the tube. On heating, if volatile fatty acids are present, they will escape with the watery vapor and will redden the litmus paper. If any fatty acids be found they must be removed by a preliminary boiling; the boiling is kept up until the litmus paper is no longer reddened, the water lost by evaporation being re- placed. [Boas * has given us what are undoubtedly the most accurate methods for both the qualitative and quantitative tests of lactic acid ; but for clinical purposes they are too delicate, since it has been shown that even some of. the reagents employed may simulate the reaction given by decomposition products of lactic acid.f The principle of the tests is this : When lactic acid is slowly and carefully heated with oxidizing agents, it splits up into formic acid and acetic aldehyde. The presence and amount of the latter sub- stance can be ascertained by many tests, of which the iodoform test is the best both for qualitative and quantitative purposes. The oxidizing agent used is potassium permanganate and sulphuric acid. If the aldehyde is then conducted into an alkaline solution of iodine, iodoform is formed. Under proper precautions a given quantity of aldehyde decomposes a given proportion of the iodine solution, and hence the amount of the former can be determined. Ketone and alcohol, which give the same reaction, are removed by boiling the fluid to be examined to a sirupy consistency. Carbo- hydrates heated with oxidizing agents also give off aldehyde, so that the lactic acid must first be extracted with ether. The test meal used for this method is Boas's oatmeal soup.] \ Quantitative analyses of the fatty acids will scarcely ever be re- quired in ordinary practice. They can only be performed after repeated extraction with ether or by distillation. Quantitative Estimation of Acid Salts.—This is obtained by sub- tracting from the total acidity the acidity which is obtained in Leo's method after adding CaC03. Inasmuch as most of the acid * [Boas. Loc. cit., p. 179. Friedenwald. Loc. cit.—Ed.] f [Langguth. Loc. cit.—Ed.] X [Boas's oatmeal soup consists of a tablespoonful of oatmeal to a quart of water which is boiled down to a pint. Salt may be added to suit the taste. The advan- tage of this meal is that it does not contain any lactic acid or lactates.—Ed.] 5 56 DISEASES OF THE STOMACH. compounds consist of phosphates the difference must be divided by two (see p. 50). From the methods of analyses described above we may con- struct the following schema for the routine quantitative examination of stomach contents: Stomach Contents obtained One Hour after Test Breakfast.— Color, light yellow ; on filtration, a clear yellow filtrate is obtained; a homogeneous residue is left upon the filter. Reaction to litmus, acid. Tropseolin test, dark brown. Congo-red test, blue. Giinzburg's or Boas's test, carmine red. Uffelmann's test, doubtful. Butyric acid, negative. Estimation of HCl, Leo's method. 1. Total acidity (A) = 55. 2. Acidity after extraction with ether (the ethereal extract gives a positive reaction with Uffelmann's test) = 46. Lactic acid there- fore = 0*018 per cent. 3. Acidity after adding CaCl2 = 56. 4. Acidity after adding CaC03 = 16—i. e., corresponds to acid salts. 5. Therefore acidity due to free acids = 40. From this subtract the amount represented by lactic acid 1) — 2) —i. e., 55 — 46 = 9. Therefore 6. Acidity of physiologically active HCl (L + C) = 31 = 0*113 per cent HCl. 7. Acidity of free HCl (L) by Mintz's method = 14 = 0-05 per cent HCl. Therefore combined HCl (C) = 0*063 per cent. It is self-evident that if we only care to ascertain the amount of HCl the method may be much simplified by adding the CaCG3 directly to the residue left after the extraction with ether. Fur- thermore, when fatty acids are present, they are to be removed as already stated, the acidity must be determined after their removal, and the amount subtracted from the results obtained in 5). It will thus be seen that an exact quantitative analysis of the VALUE OF QUANTITATIVE ANALYSES. 57 stomach contents requires quite a little time and work. The ques- tion naturally arises, do the results obtained pay one for his trouble, or, in other words, could we not obtain practical results for clinical purposes in some simpler way ? Disregarding all abnormal mix- tures of acids, we may encounter one of two varieties of cases : in the one free IIC1 has been secreted and we may do what was formerly generally done—namely, convert the total acidity clinically into that of the physiologically active HCl; we need only bear in mind that this is absolutely too high on account of the presence of the acid phosphates. In the other case no free HCl has been secreted; here large quantities of organic acids are usually present, and the ques- tion arises whether any HCl at all has been secreted. For this pur- pose we must resort to one of the above methods, which, for this purpose, are much simplified because it is unnecessary to estimate the quantity of free HCl, and because it is immaterial whether the analytical error of a few milligrammes or centigrammes is made. We only want to know whether the mucous membrane is still able to pour forth any secretion, and, if so, to gain a rough idea to what extent.* Hence my own opinion is that Leo's method is the best one for clinical purposes. [Topfer's method also promises to be valuable * An approximate estimation of the loosely combined HCl may also be rela- tively easily and rapidly obtained with Sjoqvist's method. Ten c. c. gastric juice are evaporated after adding a tip of a knifebladeful of barium carbonate and incinerated, care being taken lest the temperature be too high; the ash is extracted with water and filtered. To the filtrate, which is as clear as water and which con- tains any HCl which may be present as barium chloride, a few drops of concen- trated sola solution are added. If the fluid remains clear, HCl is absent; if it is present, the fluid will assume a whitish turbidity or will throw down a white pre- cipitate of carbonate of baryta, from the amount of which we may at once infer what the quantity of the loosely combined HCl might be. If it could be proven that after a definite test meal of constant weight the amount of loosely combined HCl would always be uniform, we could follow a sug- gestion of Biedert (quoted by Langermann, loc. cit.), to add deci-normal HCl until free IIC1 appears: then by subtracting the amount of deci-normal HCl used from the known amount of HCl necessary for saturation of the definite test meal, we could estimate the amount of loosely combined HCL But it is evident that such a constant value does not exist, because the quantity of swallowed or secreted mucus in the stomach is always variable, and, furthermore, because the quantity of IIC1 combined with albumen, albumoses, and peptones must then always be constan^ and these latter substances must always be present in that amount at a definite period of digestion. 58 DISEASES OF TnE STOMACH. where the saving of time is important. Hoppe-Seyler, De Jong and Friedenwald * commend it highly.] For the sake of comparison I have charted a series of curves (Fig. 5) of the total acidity calculated as HCl, the total HCl accord- ing to Leo's method, the total HCl according to Liittke's method, and the free HCl according to Mintz's method. They were ob- Fis. 5.—a, HCl calculated from acidity; b, total HCl calculated according to Leo's method; c, total HCl calculated according to Liittke's method; d, free HCl calculated according to Mintz's method. tained from the stomach contents of a woman upon whom gastros- tomy had been performed on account of a cicatricial stenosis of the oesophagus after an ulcus oesophagi; hence at any time stomach contents could be readily obtained through the gastric fistula.f The stomach was affected only in so far that if food remained unduly long in it hyperchlorhydria would occur; this very fact enables us to follow the course of the secretion of HCl unusually well. The meal given for these experiments consisted of 500 c. c. [O j] tea, two eggs, two zwieback, 200 c. c. [f ^ vj-f] milk, and 50 grammes [ 5 j t] meat powder. Free HCl did not appear till after one hour and a half. Lactic acid was only present in traces at the beginning. * [Hoppe-Seyler. Miinchener med. Wochenschr., 1895, No. 50. De Jong, Boas's Arch. Bd. ii, Heft, i. Friedenwald, N. Y. Med. Record, Apr. 6,1895—Ed.] t Ewald. Zeitschr. fiir klin. Med., Bd. xx, Heft 4-6. VALUE OF QUANTITATIVE ANALYSES. 59 These curves show, as has already been said, that the total acid- ity may be calculated as HCl without any great error, especially if at the same time the quantity of free HCl has also been determined. The differences in the two results would then about represent the combined HCl, provided, of course, that the quantity of acid salts is small and organic acids have been removed. Kosenheim * has also urged that the determinations of the total acidity and of the amount of free HCl are perfectly sufficient for all practical purposes. I would like to erase the word " perfectly " from this sentence, be- cause the numerous cases without free HCl would then be insuffi- ciently regarded; yet for general use in all cases where free HCl is present this simplified procedure will suffice, for in the majority of these cases the estimation of the quantity of the loosely combined HCl is relatively unimportant. Thus in the great majority of cases the elaborate quantitative determinations of acidity would be re- duced to a few titrations which take up very little time. * Rosenheim. Ueber die practische Bedeutung der quantitativen Bestimmung der freien Salzsaure im Mageninhalt. Deutsch. med. Wochenschr., 1892, Nos. Vi and 14. CHAPTER II. METHODS OF EXAMINATION {continued).--DETERMINATION OF THE DI- GESTION OF ALBUMEN AND STARCH.--ABSORPTION AND MOTILITY. --THE TECHNIQUE OF THE EXAMINATION OF THE STOMACH. The essence of the digestion of albumen consists in the well- known transformation of the various kinds of this substance, of which I shall only mention the more important varieties—Gi^'j, serum, and plant albumen, fibrin, and casein—into a soluble and easily diffusible form, peptone. In another place * I have already given an exact description of these changes, and now I shall restrict myself to the practical deductions from the facts known to us. It is well known that between albumen at the beginning and peptone at the end of the process of albuminous digestion there exist certain intermediate bodies which are collectively known as the albumoses. Of these we are concerned only with syntonin, the product of neu- tralization, and propeptone or hemialbumosjs. Now, the question arises, What significance have these bodies in the processes of diges- tion, and by what tests may they be recognized ? 1. Temperature.—Fluid albumen and syntonin coagulate on warming—i. e., heating to about TO0 C. [158° F.]. Propeptone and peptone are not coagulated by heat. If propeptone is precipitated from its solutions in the cold and is then heated, the precipitate re- dissolves, but is again deposited on cooling. Temperature has abso- lutely no influence on peptone. 2. Biuret Reaction.—If cupric sulphate is added to propep- tone and peptone in an alkaline solution, an intense purple-red color is observed, the so-called biuret reaction. If caustic pot- ash and dilute cupric sulphate are added to ordinary albumen and * Ewald. Klinik der Verdauungskrankheiten, I. Theil, 3te Auflage, p. 93, etc. [See also Chittenden's Cartwright Lectures on Digestive Proteolysis, New Haven, 1895. This work contains an elaborate and masterly description of this entire sub- ject.—Ed.] 60 REACTIONS OF ALBUMEN, ETC. 61 syntonin without warming, a more or less marked bluish-violet color is struck, which at all events may often be confounded with the biuret reaction. To a solution of peptone add some caustic potash, and then a little dilute cupric sulphate ; a deep purple-red color will be obtained which is distinctly different from this bluish-violet color obtained in a similar way with a solution of pure albumen. The same is true of propeptone, as can be shown with a solution of meat peptone. When the quantity of peptone or propeptone is small, the copper solution must be diluted to a very pale blue and must be added drop by drop ; a rose-red zone will appear about the drops as they fall into the solution; this color will then gradually diffuse through the solution. 3. Precipitation.—Albumen and syntonin are precipitated by saturated solutions of sulphate of soda or common salt in an acetic- acid solution, hot or cold. Syntonin is precipitated from acid solu- tions as soon as it is neutralized. Propeptone in neutral solution is precipitated by a saturated solution of common salt or rock salt on adding strong acetic acid; it is soluble when heated. However, a portion remains in solution, and can only be precipi- tated by the addition of ammonium sulphate in substance or in concentrated solution. Peptones are not precipitated by the above nor by the following reagents which throw down albumen, syntonin, and propeptone: cold or warm nitric acid, acetate of lead, acetic acid with ferrocyanide of potash, metaphosphoric acid, ammonium sulphate. The behavior of the above-mentioned substances may be seen at a glance in the following tables : ( ( Precipitated by saturated solution of sulphate Coagulated by heat; ) Albumen. ) of goda Qr common salt and acetic acid> cold no biuret reaction. ( Syntonin. ( Qr warm> Not coagulated by r propeptone> j Precipitated cold by saturated solution of heat; biuret reac- •< '( common salt and strong acetic acid. tion. ' Peptone. Nitric acid, acetic acid. Acetic acid and ferrocyanide of potash. Acetate of lead. Metaphosphoric acid. Ammonium sulphate. Mercuric chloride. Phosphotungstic acid. Phosphomolybdic acid. Tannin. . Mercuric iodide. Precipitate albumen, syntonin, and pro- - peptone. Precipitate peptone, 62 DISEASES OF TnE STOMACII. Now, what are the practical deductions from these results ? If gastric juice containing pepsin and hydrochloric acid be al- lowed to act on albumen, after a certain time the mixture ought to contain the various modifications of albumen, and, according to the nature and strength of the gastric juice, some or all of them ought to be present. The results of such an examination will give us an indication of the intensity of the digestive processes in the stomach. Accordingly, we first test whether the stomach contents are coagu- lable by heat. If they are, albumen or syntonin, or both, may be present; if not, we may find propeptone or peptone. If the reac- tion is acid, and coagulation occurs on heating, we must neutralize. Should a precipitate be thrown down, it is syntonin. If this is fil- tered out and an equal quantity of concentrated common-salt solu- tion is added to the filtrate, and then acidulated with acetic acid, any precipitate thrown down which is redissolved on heating is due to propeptone, and the biuret action must be positive. The latter pre- cipitate is also removed by filtration; the filtrate is treated with acetic acid and ferrocyanide of potash ; if no precipitate is obtained, and if the biuret test is positive, and if, furthermore, precipitates are thrown down by tannin or the salts of the heavy metals, or by phosphotungstic acid, etc., then peptone is present. Such would be the method of conducting an examination. But the question naturally arises, What is the practical value of such a demonstration of the various transformation products of the diges- tion of albumen, and what conclusions can be drawn in regard to the pathology of the cases in question ? It is a peculiar fact that as soon as the digestion of albumen has begun as the result of the action of pepsin and hydrochloric acid, the biuret reaction may be obtained in a very short time. This may be due either to propeptone or peptone. I shall, therefore, briefly consider the relations of propeptone to digestion. Is it absorbed as such, or is it simply a necessary preliminary stage of peptone ? Concerning the former we know nothing; of the latter we can at least say that propeptone seems to be a very frequent but by no means a constant transformation product in the digestion of albumen by pepsin and hydrochloric acid. On the other hand, by the simple action of hydrochloric acid upon RELATIONS OF PROPEPTONE. 63 albumen at the temperature of the body, syntonin as well as propeptone may be obtained. Since propeptone will give the biuret reaction as well as peptone, the simple application of this test, as has been done heretofore, will give no positive proof of the presence of peptone. The best way is to precipitate the pro- peptone. As the result of investigations conducted in my laboratory, Dr. Boas * has shown that that portion of propeptone which is precipi- tated by rock salt and acetic acid is absent in the digestion of meat, but is present in the digestion of plant albuminates and pure egg albumen. On an ordinary mixed diet the amount of propeptone which is precipitated, as above stated, bears some relation to the activity of digestion, so that from the precipitability and amount of propeptone approximate conclusions may be drawn as to the digest- ive process. It would be much better if this could be determined from the quantitative analysis of the peptones, to which there are two objections. One is that we do not at present possess any con- venient and sufficiently accurate method for estimating the quantity of peptones, since, as has been already shown, the intensity of the biuret reaction is of no use, because it responds to both peptone and propeptone. Secondly, as some investigations of my own f have shown, digestion in the human stomach produces only a very small proportion of true peptone, the greater portion of the albumen being converted into propeptone and the albumoses of Kiihne. Hence under the term "peptone" are included those products of proteid digestion which are not precipitated by ammonium sulphate in neutral solution, rock salt (or concentrated sodium chloride solu- tion), or a saturated solution of common salt in acetic acid; which give the biuret reaction; which remain in solution at any tempera- ture, and are only precipitated by mercuric chloride, tannin, phos- photungstic acid (phosphomolybdic acid), picric acid, and mercuric iodide and potassic iodide solution. Hence it is of considerable value to determine and approxi- * I. Boas. Beitriige zur Eiweissverdauung. Zeitschr. fur klin. Med., Bd. xii, Heft 3. f Ewald und Gumlich. Ueber die Bildung von Pepton im menschlichen Magen. Berl. klin. Wochenschr., 1890, No. 44. 64 DISEASES OF THE STOMACn. mately estimate not alone the end products of proteid digestion, but also the intermediate bodies. Now, we have found that in an ordinary diet, containing an abundance of plant albuminates, and after the test breakfast, the di- gestion of albumen has progressed so far within an hour that that portion of propeptone which is precipitated by concentrated NaCl solution and acetic acid is present only in traces, or usually is not to be detected at all; whereas in abnormally slow digestion it is still abundant at that period. We may also approximately estimate the amount of peptone by the intensity of the biuret reaction provided we always use the same quantities of stomach contents, caustic pot- ash, and cupric sulphate,* and compare it with the reaction given with a peptone solution of known strength. But it has been ob- served that the biuret reaction is equally intense where at the same time there is either no propeptone or where the amount of the lat- ter is very variable. In other words, just as Cahn f found in the digestion of meat in dogs, the formation of peptone remains at a certain percentage, or is kept at that figure by the removal of the peptones over that amount; in such cases the only guide to the rapidity and amount of the transformation of the albumen is the amount of propeptone formed or still remaining. Naturally there are also cases in which the peptone formation does not reach the normal height, being thus entirely insufficient; for this reason it is advisable to make the test for propeptone even where the amount of peptone is apparently normal. However, we not infrequently encounter cases in which a positive biuret reaction is obtained, although no free HCl can be demonstrated. Further analysis will also demonstrate the absence of propeptone (as defined above); in other words, this will show that the proteid digestion is well advanced. How can this be ex- plained, since we know that peptone can only be found in the pres- ence of pepsin and HCl ? There are two possible explanations. * On the addition of caustic potash many stomach contents turn yellow. Spitzer has separated from this a yellowish-brown amorphous substance which assumes an onion-red color on the addition of alkalies. Centralblatt fiir klin. Med., 1891, No. 9. f A. Cahn. Die Verdauung des Fleisches im normalen Magen. Zeitschr. fiir klin. Med., Bd. xii, Hef te 1 und 2. DIGESTION TESTS. 35 One is that all HCl is not absent, but only the free HCl, and further analysis will reveal the presence of loosely combined HCl. But, as was demonstrated many years ago (1882) by me,* and later on also by Salkowski and Kumagawa,f loosely combined HCl and pepsin can peptonize albumen, although the action is a very feeble one. The other possibility is that when all HCl is absent, large quantities of lactic acid are always present; in such cases the lactic acid takes the place of HCl in the peptonizing process, provided pepsin is still secreted. Although the presence of HCl always in- dicates that pepsin will be found, yet conversely the absence of HCl does not prove that pepsin is lacking. For it has been proved by the physiological experiments of Cahn $ and by an observation of my own # that the secretion of pepsin, at least in small quantities, may be independent of HCl. The presence of peptone in the stomach contents can thus be explained when there is no physiologi- cally active HCl (L + C), and when the peptones have not been re- gurgitated from the intestines. Hence, for the reasons given above, the estimation of peptones with the biuret reaction is always doubtful, and it is much more advisable to determine the digestive power of the gastric juice by the rapidity with which coagulated albumen is liquefied (proteo- lysis). Digestion Tests.—Coagulated white of egg is cut into thin lam- ellae with a double section knife [Valentine's knife], and uniform disks are cut out with a cork-borer or some similar instrument with a round, hollow cutting edge. [A short piece of glass tubing will do.] By preserving these disks of albumen in glycerin they are ready for use at any time. In order to determine in a given speci- men of stomach contents whether the pepsin or hydrochloric acid is present in too great or too small amount, an equal quantity of the filtered specimen is placed in four small test tubes and one or two * Ewald. Virchow's Archiv, Bd. xc, p. 333. t Salkowski und Kumagawa. Virchow's Archiv, Bd. cxxii. See also Rosenheim. Centralblatt fiir klin. Med., 1891, No. 39; and F. A. Hoffmann, ibid, No. 42. X Cahn. Die Magenverdauungim Chlorhunger. Zeitschrift fiir physiol. Chemie, 1886, Bd. x. * Ewald. Ein Fall von Atrophie der Magenschleimhaut. Berl. klin. Wochen- schr., 1886, No. 32. 66 DISEASES OF THE STOMACH. disks of albumen put into each. To the first nothing else is added; to the second, enough hydrochloric acid to make a solution of about 0*3 to 0*5 per cent; this is accomplished by adding two drops of hydrochloric acid (Ph. Germ.)* to 5 c. c. [f 3 ji] of stomach con- tents. To the third we add a definite quantity of pepsin, about 0-2 to 0*5 gramme [gr. iij to gr. vijss.] ; to the fourth add both hydro- chloric acid and pepsin. The test tubes are placed in a warm cham- ber kept at about 100° Fahr.; from time to time we [shake the tubes and] look to see how far the liquefaction of the disks of albumen has proceeded. The rapidity of this liquefaction will at once inform us whether digestion would have occurred without having added anything, or whether acid or pepsin or both were necessary. [Pieces of Merck's fibrin may be used instead of the disks of albumen.] In this way we can judge which factor is at fault. But we must not forget that after the amount of peptone has reached a certain per- centage its further production is retarded, or even suspended, so that an apparently slow reaction may be really due to a very active gastric juice. In this, as in all laboratory experiments on digestion, we must never forget the great difference between them and the natural processes, and that in our flasks and test tubes we can never imitate the absorption on the one hand, and the removal to the in- testines on the other, by which the stomach strives to maintain a fairly uniform degree of concentration of its contents; hence all our tests are fundamentally deviations from Nature, and are thus to a certain degree pathological. The question naturally arises, Is it necessary to resort to these somewhat inconvenient digestion tests, and will it not suffice to sim- ply employ the acid tests, since the rule is that the secretion of HCl and pepsin run parallel courses ? Any one who has done much work in stomach analysis will answer this question in the affirmative, since there are many stomach contents in which the amount of free HCl does not stand in a direct relation to the peptic power, and, as has been shown above, proteolysis may occur even in the complete absence of free HCl. Consequently, as has also been stated by * [Acidum hydrochloricum of the German Pharmacopoeia is somewhat feebler than that of the U. S. Pharm.; the former has 25 per cent pure anhydrous acid, the latter 32 per cent.—Ed.] TESTS FOR PEPSIN AND RENNET. 67 Tschlenoff,* the digestive powers of such stomach contents can only be ascertained with the digestion tests. [For quantitative estimation of pepsin Hammerschlag f employs Esbach's tubes (such as are used for quantitative estimations of al- bumen in the urine). Take three portions, 10 c. c. ( § £) each, of a 1-per-cent solution of albumen, which is prepared by dissolving the albumen in a 0*l-per-cent HCl solution; to the first portion add 5 c. c. ( 5 -J-) gastric filtrate; to the second the same and also 0*5 grammes (gr. vijss.) pepsin (this is the standard solution); to the third only 5 c. c. water. Three Esbach tubes are respectively filled with a portion of each solution up to the II mark on the tube, and placed for an hour in a thermostat at 98° F. Then Esbach's reagent is poured into each tube up to the R mark, and the albumen pre- cipitated as usual. After standing 24 hours the amount of precipi- tated albumen is read off the scale on the tube. The difference be- tween the first and third tubes will give the amount of digested albumen. When we wish to be absolutely certain about the absence of pepsin and pepsinogen we may use the method proposed by Jawor- ski4 Into the empty stomach about 200 c. c. [ ^ vjss.] of deci-nor- mal HCl solution are poured through a stomach tube, and aspi- rated after 30 minutes. If the fluid obtained contains no pepsin we may be certain that no ferments are secreted by the stomach (Leo). These pepsin tests are only of value in diagnosticating total atrophy of the stomach, which is the sole condition in which the ferments are absent.*] The gastric glands secrete not alone pepsin but also rennet fer- ment {Labfermen t), which causes the coagulation of milk. Its pres- ence may be detected by taking a small quantity, 10 c. c. [f 3 ijss.], of boiled milk having a neutral reaction, and adding an equal amount * Tschlenoff. Aciditat und Verdauung. Schweizer Correspond. Blat., 1891, No. 22. f [Hammerschlag. Internat. klin. Rundschau, 1894. No. 39.—Ed.] X [Jaworski. Vefhandlungen des VII. Congresses fiir innere Med., 1888, p. 272. —Ed] » [Oppler (Centralblatt fiir innere Med., February 1, 1896) has carefully studied the relations cf pepsin in different diseases of the stomach. He concludes that the quantitative estimations of pepsin are unnecessary.—Ed.] 68 DISEASES OF THE STOMACH of carefully neutralized filtered stomach contents; the mixture is then placed in a warm chamber at 100° Fahr., and after a short time, 10 to 15 minutes on an average, the milk has coagulated and separated into a cake of casein and clear serum. [Leo * uses 10 c. c. of raw milk, and only 2 to 5 drops of stomach contents. On account of the relatively small quantity of the latter, neutralization of the mixture is unncessary. Raw milk is used because it coagulates ten times more rapidly than cooked milk. With this modification it occurs from one minute to several hours after being placed in the warm chamber. Coagulation by rennet produces the characteristic cake of casein floating in clear serum, and is not to be confounded with the flaky or lumpy coagulation by acids.] The rennet ferment or enzyme {lubenzyirb) exists also in a pre- liminary stage as a pro-enzyme or rennet zymogen {Labzymogen); this itself has no action upon milk, but by adding acids, especially hydrochloric acid, and also calcium chloride while warm, it is con- verted into the typical ferment. This will become evident in the filtrate of a gastric juice which either has no spontaneous coagulat- ing action or in which the ferment has been destroyed by adding an alkaline carbonate. If such a filtrate be digested with dilute hydro- chloric acid, or if a 5-per-cent calcium-chloride solution be added, it will curdle milk. In the stomach, while fasting, and at the be- ginning of digestion, the zymogen is only found, but later both it and the ferment are present. An acid reaction or the presence of free acid in the original filtrate of the stomach contents is not abso- lutely necessary for the curdling action of rennet, since it has been demonstrated when free acid was absent, or even when the reaction was neutral. Among the various investigations on rennet in human beings I would call especial attention to the works of Raudnitz, Boas, Johnson, Klemperer, and C. Rosenthal.f * [Leo. Diagnostik, etc., 2te Aufl., 1895, p. 328.—Ed.] f Raudnitz. Ueber das Vorkommen des Labferments im Sauglingsmagen. Prager med. Wochenschr., 1887, No. 24.—Boas. Labferment und Labzymogen im gesunden und kranken Magen. Zeitschr. fiir klin. Med., Bd. xiv, S. 249.—Johnson. Studien iiber das Vorkommen des Labferments, etc. Ibid., S. 240.—Klemperer. Die diagnostischer Verwerthbarkeit des Labferments. Ibid., S. 280.—C. Rosenthal. Ueber das Labferment nebst Bemerkungen iiber die Production freier Salzsiiurc bei Phthisikern. Berl. klin. Wochenschr., 1888, No. 45. DIGESTION OF STARCH AND SUGAR. 69 [Boas* has devised tests for the quantitative testing of both rennet ferment and zymogen. " To test rennet ferment a portion of the gastric filtrate is exactly neutralized, and portions are diluted with distilled water (J^, -J^-, ^, etc.); 5 c. c. of each of these por- tions are placed in beakers and 5 c. c. of milk added to each. The mixtures are then placed in the thermostat. It can easily be deter- mined at what dilution the ferment is no longer active. " Rennet zymogen is tested in a similar way. A portion of the gastric filtrate is made slightly alkaline and portions diluted (y1^, tV- sV* ife) etc.). To 5 c. c. of each of these portions 1 c. c. of a 1-per-cent solution of calcium chloride and 5 c. c. milk. The mix- tures are placed in the thermostat and the point at which the rennet zymogen is no longer active can then be determined." Friedenwald f concludes that normally rennet ferment may be present in dilutions up to y\j, and the zymogen up to y^. The estimations are of no value wThen HCl is present, but may be im- portant when free HCl is absent in differentiating cases of anachlor- hydria due to severe chronic gastritis or cancer from the cases of nervous anachlorhydria. Diastase (ptyalin) is another ferment which is constantly present in the stomach contents ; it is derived from the swallowed saliva or regurgitated intestinal contents. Its presence may be determined by neutralizing free gastric filtrate and adding a few c. c. to an equal quantity of a thin starch solution. The mixture is placed in the thermostat for 1 or 2 hours. The addition of dilute Lugol's solution will show whether all the starch has been converted into sugar, or whether the intermediate dextrins are present.] Digestion of Starch and Sugar.—It will be remembered that in the organism starch is converted into grape sugar (dextrose) by the action of the salivary ferment, ptyalin, and that cane sugar, as shown by Leube, is changed into invert sugar, a mixture of cane and grape sugar. We know that this sugar ferment exists not alone in the saliva, but also in small quantities in very many tissues, and prob- ably also in the mucus which is usually sparingly secreted in the stomach. It was formerly supposed that ptyalin acted on the * [Boas. Loc. cit., part i, p. 187.—Ed.] f [Friedenwald. Medical News, June 22, 1895.—Ed.] 70 DISEASES OF THE STOMACH. amylaceous substances only in the mouth during mastication. At all events, the transformation of starch into sugar by ptyalin occurs very rapidly indeed; yet this would not suffice to allow the ferment to act thoroughly on the more or less compact masses swallowed. The saliva which is swallowed continues its action on the amylace- ous substances even in the stomach, as has been shown by von den Velden.* The only question is, How long does this process con- tinue ? We know that pytalin acts best in neutral or feebly alkaline solutions, but is checked in acid fluids. It has been shown that the formation of sugar ceases as soon as the amount of acid (reckoned for hydrochloric acid—a point of vital importance to us) reaches 0*01 per cent or more; but in smaller quantities the action of the ferment is even somewhat accelerated (Chittenden). With lactic acid the acidity must be much higher, namely, 0*1 to 0*2 per cent, and -with butyric acid or fatty acids may be even higher than this, up to 0*1 per cent.f But, as first shown in pigs and horses by Ellenberger and Hofmeister,*}: and in human beings by Ewald and Boas, the simple taking of raw starch will cause the secretion of hydrochloric acid, to which is later added the lactic acid produced by fermentation. This naturally occurs also in a mixed diet with amylaceous substances. As normally the acidity of the stomach contents gradually becomes more marked as more hydrochloric acid is secreted, we will hence observe an initial stage in which starch is still converted into sugar; but gradually the process becomes feebler, and finally ceases entirely. Thus the conversion of starch into sugar is not a simple uniform process, but, like the digestion of albumen, there are intermediate products, the dextrins and maltose.* The two important varieties of dextrin are erythrodextrin and * R. v. d. Velden. Ueber die Wirksamkeit des Mundspeichels im Magen. Deutsch. Arch, fiir klin. Med. Bd. xxv, S. 105. f According to O. John, Ueber die Einwirkung fetter Sauren auf die Starkeum- wandlung durch den Speichel. Inaug. Dissert., Berlin, 1890. The action of ptyalin is completely checked when lactic acid is 0-5 per cent and butyric acid 1*2 per cent of the total mixture. X Ellenberger und Hofmeister. Arch, fiir wissensch. und prakt. Thierheilkunde, viii, S. 395, and xii, S. 126. Pfliiger's Archiv, Bd. xliv, S. 484. * See Ewald. Klinik, etc., I. Theil, 3te Auflage, S. 55 et seq. Also a detailed account in Ewald. Ueber die Zuckerbildung im Magen und Dyspepsia acida. Berl. klin. Wochenschr., 1886, No. 48. DIGESTION OF STARCn AND SUGAR. 71 achroodextrin. Maltose is to a certain extent an intermediate body between starch and dextrin on the one hand, and grape sugar on the other. Starch is recognized by the familiar deep-blue color struck with iodine or a mixture of iodine and potassium iodide—i. e., Lugol's solution: Iodi.......................... 0*1 [gr. jss.] Potass, iodidi.................. 0*2, [gr. iij] Aq. destillat................... 200*0 [f 1 vj 3 vj] This reaction becomes less marked in proportion to the amount of starch converted into dextrin and sugar. A solution of erythrodex- trin, as its name indicates, no longer gives a blue color, but purple; solutions of achroodextrin, maltose, or dextrose assume no other color than the yellow of the iodine solution. The latter substances have a closer relation to iodine than dextrin, and the latter again more than starch; hence, in a mixture of these bodies, the first drops of iodine solution added cause either no color at all or only a transitory one, and it is only after adding more iodine that the purple of erythrodextrin or the blue tinge of starch is ob- served. As was shown by von Mering in laboratory experiments, and by myself on human beings, in the transformation of starch into sugar by ptyalin, the smaller portion only is converted into dex- trose, the greater into maltose. The latter passes on into the intes- tines, where it is changed into dextrose (Brown and Heron). The practical result of these conditions is the following: If the amylaceous transformation proceeds normally in the mouth and stomach, after a time, within an hour at least, so much starch has been changed into achroodextrin, maltose, or dextrose that the addi- tion of small quantities of Lugol's solution to the filtered stomach contents no longer produces any changes of color. The occurrence of a purple (erythrodextrin) or a blue color (starch) shows that the sugar transformation has been incomplete. This may be due either to a deficiency of ptyalin or to a too rapidly increasing acidity or an original hyperacidity of the stomach. If, then, we should be unable to titrate the gastric contents— supposing, for example, that we had only a very small quantity— 6 72 DISEASES OF THE STOMACH such a result would of itself indicate a hyperacidity of the gastric juice. It seems that a deficiency in the saccharification power of the saliva never occurs. For a long time I have tested the fermen- tative power of saliva in patients with dental caries, inflammatory lesions in the mouth, angina, diphtheria, carcinoma of the tongue, and similar conditions, but never have I found a saliva which could not convert starch into sugar; yet I must not fail to add that no quantitative examinations were made. At my request Schlesinger* has made investigations to fill this gap; he made quantitative analyses of the action of the saliva in twenty-five pathological cases, and compared his results with those obtained in healthy persons. He found that the maximum action in health and in disease was about the same; but the minimum action was higher in healthy in- dividuals by about 50 per cent. At all events, it seems that the saliva does not lose its ferment, although pepsin may occasionally be completely absent from the gastric juice, as occurs in the cases of atrophy of the gastric mucosa. [Kellogg has carefully studied the digestion of starch in the stom- ach by the determination of the relative amounts of maltose, dextrin, and soluble starch found in the stomach contents. He has found that the average amount of conversion of starch into maltose is 80 per cent, the balance of 20 per cent including dextrin and soluble starch. Much higher percentages of maltose are found in hypo- chlorhydria than in hyperchlorhydria. His results also agree with those of Ewald, already stated, that the activity of the saliva does not differ in hyperchlorhydria and hypochlorhydria, and hence the differences in the amount of starch conversion are due to differences in the gastric juice. In anachlorhydria starch digestion is usually complete. The relations of starch digestion are of interest in cases of so- called " buccal or salivary dyspepsia." The name is poorly chosen, but it emphasizes the necessity of attending to the proper mastica- tion of food in many cases of dyspepsia.f] * A. Schlesinger. Zur Kenntniss der diastatischen Wirkung des menschlichen Speichels. Virchow's Archiv, Bd. exxv und exxvi, p. 354. f [Further details may be found in Kellogg's papers in Modern Medicine, Feb- ruary, March and April, 1896.—Ed.] RELATIONS OF SALIVA AND GASTRIC JUICE. 73 According to Wright * and Sticker,f the cessation of the action of the saliva upon the stomach is followed by a diminution or stop- page of the secretion of gastric juice; consequently the digestion both of starch and also of albumen suffers on this account. Biernacki % has attributed this to the carbonic acid and carbonates which are present in the saliva and which have a slight stimulating action on the gastric mucosa. It has long been known that reflex relations exist between mastication and the gastric functions; nevertheless numerous cases of gastrotomy after total cicatricial closure of the oesophagus (as, for example, the well-known case of Richet*) prove that the secretion of gastric juice may occur independently of any action of the saliva. Sugar may always be found in the stomach contents after the various test meals, since a certain amount is contained in them. Finally, I must state that bile may be detected in the contents of the stomach by the greenish tinge it imparts, or by Gmelin's test. It is also characteristic of biliary pigment that the bright yellow debris left upon the filter upon filtering the stomach contents after the test breakfast, and especially that portion at the edge of the filter, assumes a greenish tinge by oxidation after prolonged expo- sure to the air. It is to be noted that stomach contents containing a large amount of IIC1 which have been taken from the stomach while fasting often have a greenish color, yet no biliary pigments can be demonstrated with the ordinary reagents. [Trypsin, urea, blood, pus, and mucin are also found in the stomach contents.] [All of the various procedures ought to be done with the stomach contents which are obtained after test meals. To depend exclusively upon vomited matters is often very misleading, and they should only be employed when for various reasons test meals can not be given. At times important data can be obtained by the passage of the stomach tube while fasting. What the stomach contains at this '■' Wright. The Physiology and Pathology of the Saliva. London, 1841. f (r. Sticker. Wechselbeziehungen zwischen Speichel und Magensaft. Volk- mann's Vortrage, No. 2!»7. t Biernacki. Reviewed in Virchow-Hirsch Jahresber., 1891. * Ewald. Klinik, etc., I. Theil, 3te Auflage, p. 114. 71 DISEASES OF THE STOMACH. time has already been discussed (page 18). Indeed, the diagnosis of continuous hypersecretion and the prognosis of many cases of lessened motility of the stomach are directly based upon what is obtained by the passage of the tube while fasting. The presence of large quantities (over 60 c. c— 5ij) would seem to be pathological. Occasionally intestinal contents may be found in the stomach while fasting; under these conditions the stomach contents may even be alkaline in reaction.] [Microscopic Examination of the Stomach Contents.—This ought not to be omitted, although the results are very varying and often of no great diagnostic value ; yet we may derive benefit from it when least expected. We observe food fragments, starch granules, [Fig. 6.—Microscopic appearance of stagnating stomach contents. 1 and 2, sarcinae vcntri- culi; 3, yeast cells; 4, fatty acid needle crystals ; 5, fat droplets ; 6, starch granules ; 7, partly digested meat iiber. From Kiegel.]- plant cells, fat cells, muscular fibers, elastic fibers, and connective tissues; various forms of flat epithelial cells of the mouth and oesophagus; less frequently cylindrical cells from the stomach and leucocytes (Fig. 6). A few red blood-cells are not pathological. Pus cells may also be observed. Parasites are frequently found; these include yeast cells, mold fungi, sarcinae, bacteriae, and micro- cocci. Among the bacteriae the most important are the lactic acid TESTS FOR GASTRIC ABSORPTION. 75 bacilli and Oppler's long bacilli, the latter of which seem to occur very frequently in cancer of the stomach. The exact details of the microscopical appearances in the various disorders of the stomach will be found in the chapters on these diseases. At times bacteriological examinations of the stomach contents may be of service.* Under normal conditions, after giving sterilized food no bacteria will be obtained.] There are still two factors to be discussed—the absorptive power of the stomach and its motor functions—two points which have recently been underestimated because they have been overshadowed by purely chemical examinations. Absorption by the gastric mucous membrane is tested with potas- sium iodide. Penzoldt f recommends giving it [on an empty stom- ach] in small doses of 0*1 gramme [gr. jss.] in capsules which have been carefully wiped off, so that none of the drug adheres to the outside of the capsule. A capsule is taken, and the moment iodine appears in the saliva is determined by means of the well-known reaction with starch paste. Filter paper is moistened with starch paste and dried ; after the capsule is taken, from time to time, say every five minutes, a little of the patient's saliva is placed upon the dried filter paper ; then, by adding some fuming nitric acid (one or two drops), the appearance of a blue color will indicate exactly when the iodine appears in the saliva. Xormally this occurs in ten to fifteen minutes; but in processes where absorption by the stomach is slow or fails entirely, this reaction occurs much later, being de- layed a half to a whole hour, or even longer. These statements were first tested and in general confirmed by Boas, and later on by Zweifel % and Haeberlein.* However, Boas | * [Turck. N. Y. Medical Journal, November 23, 1895: ibid., February 22, 1896; Medical News, April 4, 1896. Kaufmann. Berl. klin. Wochenschr., 1895, No. 6. —Ed.] \ Penzoldt und Faber. Resorptionfahigkeit des menschlichen Magens. Berl. klin. Wochenschr., 1882. No. 21. 1 Zweifel. LVberdieResorptionsfahigkeitdesmenschlichen Magens,etc. Deutsch. Arch, fiir klin. Med., Bd. xxxix, p. 349. 9 Haeberlein. Ueber neue diagnostische Hiilfsmittel bei Magenkrebs. Deutsch. Arch, fur klin. Med., Bd. xlv, p. 347. || Boas. Loc. cit., p. 179. 76 DISEASES OF THE STOMACH. correctly objects that this test has no specific, differential diag- nostic value, as, for instance, between ulcer, cancer, and dilatation of the stomach. The same is true of Sahli's potassium iodide fibrin capsules, described on page 17. At all events, when the absorption is delayed for 60 to 00 minutes some pathological condition must exist. The method therefore enables us to determine gross changes in the absorptive powers of the gastric mucosa. [Very little practical importance can be placed upon the results of the potassium iodide test, since it has been shown that the results vary when the capsules are taken on an empty stomach or even dur- ing various stages of digestion. The brilliant experiments of Yon Mering * have shown that gastric absorption is a very complex process, for all substances are not equally rapidly absorbed in the stomach; on the contrary, some substances cause the fluids to move in the opposite direction—i. e., excretion. Thus he has found by experiments on animals with duodenal fistulae that as much or even more water flows out of the fistula as was given by the mouth and therefore concludes that water is not absorbed by the stomach. These experiments were confirmed by Moritz.f Yon Mering also found that alcohol, peptones, sugar, dextrin, sodium chloride, and carbonic acid are absorbed. The amount absorbed increases with the concentration of the solution, but along with the absorption of these substances there is a more or less active excretion of water into the stomach, the amount of which increases with the quantity of these substances absorbed. The excretion of water into the stomach occurs when the presence of HCl in the stomach can not be demonstrated. Thus, unlike what occurs in the intestines, absorp- tion in the stomach seems to be a process of diffusion. These results are of the utmost importance in the treatment of dilatation of the stomach. This subject has also been recently studied by Meltzer,"j: who shows how little understood these processes are. His experiments * [Von Mering. Therapeutische Monatshefte, 1893, p. 201.—Ed.] t [Moritz. Miinch. med. Wochenschr., 1893, No. 38 ; ibid., 1894, No. 41. —Ed.] X [Meltzer's paper, which was read before the May (1896) meeting of the Asso- ciation of American Physicians, has not yet been published.—Ed.] TESTS FOR GASTRIC MOTOR FUNCTIONS. 77 demonstrate that the absorptive powers of the stomach have been greatly overestimated.] Another question is, How can we test the motility or motor func- tion of the stomach ? The determination of the normal peristalsis and proper movement of the ingesta in and expulsion out of the stomach is very important, because the timely evacuation of the chyme into the intestines will compensate for a deficiency in the gastric digestion, while, on the other hand, any lessening of the motility gives rise to a series of well-marked disturbances, the nature of which we will discuss later under motor insufficiency of the stomach. To show how completely the absolute absence of any true gastric digestion may be compensated by means of good motor functions, I shall cite the following examples: I had under my observation for four years a gentleman, whom I have since lost track of, whose stomach contents I examined several times yearly, and yet was never able to detect free hydrochloric acid and pep- sin. He went to Kissingen every summer, felt tolerably well, ate large dinners, and pursued his occupation; and yet I must confess that without exception hydrochloric acid and pepsin have been absent in every test made at various intervals after eating different kinds of food, both the test breakfast as well as larger meals. Dr. L. Wolff and myself* have published analogous cases. I have also had a similar experience in a female patient upon whom gastrotomy was performed for carcinoma of the (esophagus. I have published another case which I had watched for three years, and had repeatedly examined at different times after giving various kinds of food. At all times, physiologically active (free and loosely combined) HCl, pepsin, and rennet were absent. In spite of this he felt very well under the systematic use of HCl and gained 46 pounds. From this we may infer that under certain circumstances the secretory function of the stomach is not essential to maintain life, providing that the lesion in the stomach does not of itself imperil life by a general intoxication, but that under these conditions the intestinal digestion seems to vicariously assume the entire burden. This is plausible, since the chemical processes of digestion are doubly provided for: two secretions digest starch—i. e., saliva and the pancreatic juice; albumen may be peptonized at two places, the * L. Wolff und Ewald. Ueber das Eehlen der freien Salzsaure im Mageninhalt. Berl. klin. Wochenschr., 1S87, No. 30; and Ewald, ibid.. 1*87, No. 49, Verhand- lungen des Vereins fur innere Medicin; ibid., 1892, No. 26. 7S DISEASES OF THE STOMACH stomach and intestines ; and fats may be emulsified by the pancreatic juice and bile. The intestines are thus capable of acting vicariously for the stomach, if necessary. Similar conclusions have been reached by other writers. But Jaworski has gone to extremes in maintain- ing that the chemical functions of the stomach play a subordinate part, and that the stomach is nothing more than a storeroom and warming place where the food may enter and be admitted to the intestine as through a sluice. Bunge * has also gone too far in asserting that the HCl acts only as an antiseptic, and has no peptic powers in digestion. This is a wild speculation, which brings us back to the old Hippocratic doctrine of the coctio ciborum, the cooking of the food by the animal heat. The most positive means of determining how soon the stomach evacuates its contents—i. e., the estimation of the propulsive powers of the stomach—are still the methods by which we determine the duration of digestion. The best is Leubds method, in which we give his test dinner and pass the tube 6 or 7 hours later, when normally the stomach ought to be empty ; or, according to Ewald, the stomach ought to be found empty If to 2 hours after the test breakfast. However, ignoring the fact that the introduction of the tube is necessary, the method is nevertheless not absolutely reliable, because the physiological evacuation of the stomach is subject to many variations, and therefore, at best, we can only use the longest periods as standards. Furthermore, we can never be absolutely cer- tain that the stomach is empty unless after repeated washings, since, as is well known, large residues of food may not infrequently be raised just at the conclusion of prolonged lavage. Finally, ab- sorption as well as motility is involved in this test. Salol Test.—For the separate determination of the latter I have proposed the use of salol. f Salol is a compound of phenol and salicylic acid—a phenol ether of salicylic acid which, according to Nencki, is not changed by acids but is converted by the action of * [Lehrbuch der physiol. und patholog. Chemie, 2te Auflage, pp. 143 et seq. Al- though some of the statements made in this chapter are very radical, they will well repay perusal for the comparative chemistry of the gastric juices in the different species.—Ed.] f Sievers und Ewald. Zur Pathologie und Therapie der Magenectasien. Ther- apeutische Monatshefte, August, 1887. SALOL TEST. 79 the pancreas and the intestinal bacteria into salicylic acid and phenol. Dr. Sievers, of Helsingfors, and myself undertook a series of obser- vations which showed that salol is decomposed by relatively feeble alkaline fluids—for example, the saliva—but that it is not decomposed when introduced into the stomach, or when mixed outside of this viscus with acid stomach contents or artificial digestive mixtures with pepsin and hydrochloric acid. This fundamental principle I have again demonstrated recently upon a patient with a gastric fis- tula, who had a mild degree of hyperchlorhydria, and into whose stomach at the height of digestion salol was introduced through the fistula. Consequently, the statements made to the contrary by Reale and Grande * may be attributed to faulty methods. On the other hand, the question arises whether salol may not be directly absorbed by the gastric mucous membrane and subsequently split up in the tissues. According to experiments made by Stein,f in which salol was introduced into the stomach after double ligation of the pylorus from the duodenum, this may occur when the salol is re- tained in the stomach for many hours. My experiments, which were not repeated by Stein, and in which the relations of the salol were studied only for the first two hours, showed the contrary. Conse- quently, the splitting up of salol into salicylic acid and phenol, and the appearance in the urine of salicyluric acid, the product of the decomposition of salicylic acid, will indicate that the salol has actu- ally passed out of the stomach. Salol is a white, tasteless powder, which is best given in capsules to prevent any action of the saliva ; one gramme [15 grains] is given in three capsules, preferably at the height of digestion. Salicyluric acid is easily recognized in the urine by the violet color produced on the addition of neutral ferric-chloride solution. A simple method is to place several drops of urine on a piece of filter paper and then let a drop of a 10-per-cent ferric-chloride solution fall upon the moistened spot on the filter paper. The edge of the drop will assume a violet color in the presence of even the smallest trace of salicyluric acid. * Reale and Grande. Sulla scomposizione del salolo nello stomaco. Rivista clin., October, 1891. f Stein. Ueber die Verwendbarkeit des Salol zur Priifung des Magens. Wiener med. Wochenschr., 1892, No. 43. 80 DISEASES OF THE STOMACH. In the great majority of cases this reaction occurs 00 to 75 min- utes after taking the salol. Unfortunately, in this method the time of the decomposition of the salol depends on the occurrence of the neutral or alkaline reaction of the intestine ; even under normal conditions this may vary, since it depends on the changeable reaction of the chyme and the quantity of bile and pancreatic juice which reaches the intestines. Hence the time of the reaction is subject to variations which some observers consider to be so great as to render the method useless. Huber * has therefore proceeded in the reverse direction, and has estimated the time which elapses from the taking of the salol to the complete disappearance of the reaction in the urine. In healthy persons this excretion lasts 24 hours; in patients with enfeeblement of the motor functions of the stomach it lasted 4S hours, or even longer. Silberstein f experimented with this method on 26 cases of gastric dilatation and 12 cases of atony of the muscular fibers of the stomach; the excretion of salicyluric acid lasted till the second day—i. e., 30 hours or more. The condition of the bowels, diar- rhoea or constipation, appeared to exert no influence. [To carry out Huber's test, one gramme [gr. xv] of salol is given, and the urine is examined 21 to 30 hours later. If salicyluric acid is still present at the latter period, or even later, we may with tol- erable certainty infer a disturbance of the muscular activity of the stomach.] It is self-evident that the objections which may be raised against the original method also apply to Huber's modification. In my opinion, demands have been made upon the method which are im- possible, and which Sievers and myself never claimed for it, since it will only indicate gross changes in the emptying of the stomach. In the experiments of \Yotitzky,*{: the average reaction time in gastric disorders was 132 minutes ; in various other diseases 69 to 90 min- utes. For this purpose it is amply sufficient, and on account of its * A. Huber. Zur Bestimmung der motorischen Thatigkeit des Magens. Miinch. med. Wochenschr., 1887, No. 19. f Silberstein. Deutsch. med. Wochenschrift. 1891, No. 9. X Wotitzky. Ueber der diagnostischen Werth des Salols. Prager med. Woch- enschr., 1891, No. 31. OIL TEST. ^ simplicity is preferable to Leube's method and Klemperer's oil test.* Oil Test.—Klemperer f has proposed another method for deter- mining the motor activity of the stomach. He pours a definite quantity—100 e. c. [f 5 iij 3 ij]—of pure olive oil into the empty stomach, which has previously been washed out, if necessary; two hours later the stomach is aspirated, and whatever oil is left is re- moved as thoroughly as possible till only an insignificant trace re- mains. The difference between the original quantity of oil and that aspirated is used by him as an indication of the motor function of the stomach. However, even Klemperer himself admits that this method can not be always used in general practice, because it is complicated and objectionable to patients. Under certain condi- tions this test may even do harm, since it can not be a matter of in- difference to inflict so large a quantity of fat upon a diseased stom- ach or intestine. [Recently Matthieu^ has proposed a modified oil test, Ten grammes of an oil emulsion are given with a test break- fast, the amount of oil obtained after a definite interval being deter- mined by extracts with ether and weighing. The process is too complicated for clinical use.] [It is no exaggeration to say that the examination of the motor functions of the stomach is equally as important as the testing for 11 CI. In the zealous pursuit of tests for the latter the motility was much neglected up to a short time ago, when it was recognized how essential it was to know exactly the peristaltic powers of the stom- ach. The motility may be lessened, as occurs in atony and dilata- tion of the stomach ; or it may be increased, as shown in peristaltic unrest and in hyperkinesia (see Chapter XI). In the former the emptying of the stomach is delayed for varying intervals; in the latter the food leaves the stomach unduly early, the stomach being often found empty three hours after Leube's test dinner. The general concensus of opinion to-day is that the salol tests * [A death has been reported from the use of this method. See London Lancet, May 23. 1891. Such an accident must be regarded as a very rare event,—Ed.] f Klemperer. Ueber die motorisehe Thatigkeit des menschlichen Magens. Deutsche med. Wochenschr., 1887, No. 47. X [Matthieu. Boas's Archiv fiir Verdauungskrankheiten, Bd. i, p. 345.—Ed.] 82 DISEASES OF THE STOMACH. are too unreliable, and that the best method is that of Leube. Boas has modified this for determining various degrees of stagnation of the stomach contents in atony and dilatation. After cleaning the stomach he gives his test sujtper, wdiich consists of some cold meat, wheat bread and butter, and a large cup of tea. NTormally, on pass- ing the tube early the next morning the stomach ought to be empty. In testing the motility, it is equally important to ascertain the tone of the muscular fibers. This may be accomplished with Dehio's method for determining the size of the stomach {vide supra); the successive areas of dullness reach down lower than n< >rmal on succes- sively percussing the greater curvature (in the upright position) after successively drinking two to three glasses of water (Riegel). In lavage, the force with which the water is expelled or the rapidity with which the fluid enters the stomach is also a good criterion.* To determine the actual peristaltic power of the stomach, Ein- horn has devised his gastrograph,\ an instrument which is not adapted for clinical use and the utility of which the future can alone determine, as the observations thus far published by Einhorn are not yet sufficient to allow one to draw any conclusions. The same may be said of Hemmeter's intragastric bags \ for obtaining records of the motor functions of the stomach on the kymographion.] The physical methods of examination, the second great group of our diagnostic aids, I can only speak of here in so far as they have a direct bearing upon the examination of the stomach, or are con- nected with it in some peculiar manner. I shall refrain from enter- ing into the elementary rules for determining the topography of the stomach, since they may be found in every text-book on physical diagnosis. Moreover, in the description of the various diseases, I shall have many opportunities to speak of percussion, auscultation, * [A good discussion of this subject will be found in Kaufmann, N. Y. Medical Journal, March 28, 1896.—Ed.] t [Einhorn. N. Y. Medical Journal, September 15, 1894; Zeitschr. fur klin. Med.. 1895, Bd. xxvii, p. 242.] X [Hemmeter. N. Y. Medical Journal, June 22, 1895.—Ed.] PALPATION OF ABDOMEN. so inspection, etc., so that I shall now restrict myself to the following points: 1. Palpation.—Of all the various means of examining the ab- dominal organs this is undoubtedly the most important. "Whoever can palpate well, and has a delicate sense of touch, possesses an ad- vantage in diagnosis which is not to be overestimated. Naturally there must always be a combination of the tactile impression and the mental process which will enable the observer at that particular moment to draw upon the whole range of his experience and to use it upon the case in question; or, to use a figure of speech, which will enable him to look through the abdominal walls and direct his fingers. But a proper technique is very important here, and, as I so often see errors committed and examinations rendered difficult and uncertain, I shall be pardoned if I call attention to several very well known points : Never palpate with the hand held perpendicu- larly or obliquely to the abdominal wall; gradually and carefully go deeper by small rotatory movements in a horizontal plane. Place your hands flat upon the abdomen, and only press down gradually and very gently by bending the end phalanges. In this way we not alone prevent the contraction of the abdominal muscles whose edges have caused errors and uncertainty in even very experienced clinicians, but we also obtain a much better per- ception of the site, size, and form of any peculiar conditions beneath the abdominal wall; and, finally, last but not least, we cause a mini- mum of discomfort and pain to the patient. Here the same con- siderations are true as in percussion. As is well know, differences of tone which are perceptible with gentle percussion are overlooked when it is forcible. It is hardly necessary to state that under cer- tain circumstances firmer pressure may be needed in palpation, and a stronger stroke may be required in percussion, yet such cases always have peculiar features which distinguish them from the ordi- nary ones. Sometimes it may be of great advantage to supplement the palpation in the dorsal and lateral posture by examining the patient in the knee-elbow position. Movable tumors will then sink against the anterior abdominal wall, and may be recognized as such. I also wish to direct attention to two points which may easily lead 84 DISEASES OF TOE STOMACH to doubt and error, and upon which, so far as I know, sufficient stress has nowhere been laid. The first point is concerning palpa- tion of the pancreas. Normally, the pancreas lies behind the stom- ach, being covered by the lesser curvature, above which it projects a little. Usually, and especially when the stomach is filled with food, it can not be palpated. It is different, however, when the abdominal parietes are emaciated and relaxed, the stomach empty, and its walls thin. Then an indefinite tumor may be palpated in the epigastric region ; it may be differentiated by a very careful determination of the borders of the liver, by its absolute immobility, by its deep situa- tion, by its flat and extended shape, by distending the stomach, and by the absence of any symptoms which might indicate a neoplasm. Its recognition is much more difficult when the stomach is dislocated downward, as occurs in gastroptosis ; here the pancreas lies uncov- ered to a greater or less extent above the lesser curvature. After distending the stomach, the suspected tumor may be demonstrated above the lesser curvature in the hollow formed by the inner half of the right costal border, the ensif orm process, and the lesser curva- ture ; it may be felt much more readily as the latter sinks more and more toward the umbilicus, the level of which it actually reaches in extreme cases. Under these circumstances we feel a smooth, transversely situated, immovable band, which feels like a piece of contracted gut lying transversely over the vertebral column, and which is tender on pressure, evidently the result of irritation of the nervous plexus. But careful exploration and a knowledge of the pathological conditions will prevent any errors. The second point is the following, which may at times cause much more confusion. A lymphatic gland lies at about the middle of the greater curvature, not in the wall of the stomach, but in the gastro-colic ligament. In inflammatory conditions within or about the stomach this gland enlarges and may become palpable, especially when the stomach, as the result of an axial rotation, is pressed more closely than usual against the abdominal parietes. It may then at times be palpated as a small, movable tumor, about the size of a hazelnut or walnut, and which can be shown to belong to the stom- ach by inflation of the latter (or at times the colon). It disappears or becomes less distinct when the stomach sinks backward, when DISTENTION OF STOMACH WITH GAS. 85 the patient lies on his back, or when the intestines rise in front of the stomach. Furthermore, it may become smaller when the ori- ginal inflammatory process abates and can then no longer be pal- pated. I must confess that, until I had convinced myself of these conditions at autopsies, I have been very much worried by certain obscure cases and have occasionally made an incorrect diagnosis of carcinoma. Hence the importance of laying stress upon this point. On the other hand, I need scarcely caution against the error which is not infrequently committed by novices, of mistaking for a tumor the pulsating aorta which often seems to lie just under the abdominal parietes, when the latter are much sunken in and the vertebral column somewhat arched forward; in such cases it has been supposed that the pulsations are due to transmission to the sus- pected tumor from the underlying aorta, whereas it was only the ves- sel itself which was felt. [See also beginning of Chapter YL] 2. Distention of the Stomach with Carbonic-Acid Gas or Air.—The method of distending the stomach wdth carbonic-acid gas generated in loco was introduced by Von Frerichs, and since then has been in general use. Yon Ziemssen,* following the American method, applied it also to the intestines by administering per rectum bicar- bonate of soda and some organic acid ; we may also employ carbonic- acid gas already generated outside of the body—for example, from an inverted siphon of mineral water (Schnetter and Rosenbach).f These methods suffer from the disadvantages that we have no con- trol over the amount of gas produced after the salts have been intro- duced into the stomach or intestines, that disagreeable accompany- ing symptoms frequently arise from the irritation of the carbonic- acid gas upon the walls of the stomach or intestines, and that, even though varying quantities of gas are needed for different persons, the degree of tension produced can not be regulated at will nor in- creased at a given moment. [A teaspoonful of sodium bicarbonate * Von Ziemssen. Die kiinstliche Gasaufbliihung des Dickdarms zu diagnosti- schen und therapeutischen Zwecken. Deutsch. Arch, fiir klin. Med., Bd. xxxiii, S. 235. f Schnetter. Zur Behandlung der Darmverschliessungen. Deutsch. Arch, fiir klin. Med., Bd. xxxiv, S. 638.—Rosenbach. Berl. klin. Wochenschr., 1890. 86 DISEASES OF TnE STOMACII. and three quarters of a teaspoonful of tartaric acid are each dis- solved in half a tumblerful of water; the tartaric-acid solution is given first, and immediately after it the sodium bicarbonate. Riegel, Osier, Meinert, and many others have never seen any bad effects from this method, which certainly has the great advantage of dis- pensing with the stomach tube. Should the results be unsatisfac- tory we can always resort to the inflation of air.] For these rea- sons it is better to use the method recommended by Runeberg, * which has long been used by Oser + and myself, and which consists in introducing a stomach or rectal tube and then insufflating air with the double bulb of a spray apparatus. Frequently there are also other good reasons for introducing the tube in a given case, and this does away with any objections against a special passage of the tube with its accompanying inconveniences, although the latter are really too insignificant to have any weight. Runeberg says cor- rectly : " In endeavoring, for example, to estimate exactly the size and situation of a markedly dilated stomach it is by no means an easy task to obtain a suitable degree of distention by generating carbonic-acid gas. On the other hand, this may be very conven- iently and easily accomplished by this method of pumping in air." The same is true of the intestines, especially of the transverse colon. Any excess of air pumped in escapes alongside of the tube, or is easily expelled by a reactive contraction of the stomach as soon as the patient experiences a marked tension of that viscus. In using car- bonic-acid gas the reverse usually occurs, since the irritation of the gas causes a spasmodic contraction of the cardia, so that the patient must exert himself more vigorously to expel it; furthermore, the pylorus may relax more readily than the cardia, and the gas may then pass on into the small intestines. I have never observed the condition described by Ebstein as insufficiency of the pylorus, in which the gas generated in the stomach passes rapidly into the duo- denum. I believe that conditions in which the pylorus is not re- laxed at first, but only during the generation of the carbonic-acid * W. Runeberg. Ueber kiinstliche Aufbliihung des Magens und des Diek- darms durch Einpumpen von Luft. Deutsch. Arch, fiir klin. Med., Bd. xxxiv, S. 460. f Oser. Die Neurosen des Magens. Vienna, 1885, S. 10. DISTENTION OF STOMACH WITH WATER. 87 gas, are due to the causes above mentioned. It is true Schiitz* has had just the reverse experience of observing the air pumped in escape rapidly into the intestine, but it seems to me that this was an exceptional case, which does not agree with the experiences of Oser y and of myself. Inflation of the stomach and intestines may be combined. Behrens \\ has called attention to the value of the latter method for detecting tumors which might be present in the abdom- inal cavity. According to my own experience, the quantity of air to be pumped in through the rectum is very variable, and the same is true of the distinctness with which the distended coils of intes- tines may be seen. I have always been struck by the amount of air which could be pumped in through the anus without again escap- ing, providing, of course, that there is no marked accumulation of faeces. Where the latter exists, and in strictures and stenoses of the lower portion of the intestine, the air is soon expelled, together with foul-smelling gases. This feature I have repeatedly found in cases of compression of the descending colon by a neoplasm. If we auscultate the abdominal walls, preferably with a binaural stetho- scope, while the air is being pumped in, we can accurately follow the advance of the air in the various portions of the intestines. 3. Distention of the Stomach with Water.—A somewhat similar but less convenient idea was embodied in the plan proposed by Piorry, but made especially well known by Penzoldt,* to deter- mine the site of the lower border of the stomach by filling that viscus with water. As water sinks to the lowest part of the stom- ach, in a sitting or standing posture, a large quantity of fluid intro- duced into the organ will indicate the course of the greater curva- ture by a curved line of dullness with the convexity downward— providing that the transverse colon contains air; and by pouring in and siphoning out larger quantities, about one litre [quart], we will prevent mistaking it for neighboring organs, tumors, etc., * E. Schiitz. Wanderniere und Magenerweiterung. Prag. med. Wochenschr., January 14, 1885. t Oser. Die Ursachen der Magenerweiterung. Wiener med. Klinik, 1881, S. 4. X 0. Behrens. Ueber den Werth der kiinstlichen Auftreibung des Dickdarms mit Gasen und mit Fliissigkeiten. Gottingener Inaugural Dissertation. Helm- stadt, 1886. * Penzoldt. Die Magenerweiterung. Erlangen, 1877. 7 88 DISEASES OF THE STOMACH. having a dull percussion note. Further details concerning this method, and also a modification proposed by Dehio, wall be dis- cussed while speaking of dilatation of the stomach. [Chapter VI]. In this connection I wish to make some remarks upon the deter- mination of the situation and size of the stomach. A sufficiently good guide for the situation of the stomach is the greater curvature; normally, in men, when the stomach is moder- ately distended, it crosses the median line at about the beginning of the lower third of the xipho-umbilical line—i. e., the distance be- tween the xiphoid process and the umbilicus; in women, it crosses at the middle of this line; * in either case it is above the umbilicus. It is immaterial whether this is determined by inflating the stomach with air or carbonic-acid gas to map out the area of tympanitic resonance, or by gradually filling the stomach with water to obtain the lower zone of dullness which separates it from the air-filled transverse colon; it is also immaterial whether these procedures are carried out while the patient is recumbent or standing up (prefer- ably with the body bent forward), or whether ordinary or auscul- tatory percussion is employed, y The differences which are obtained with these various methods are always less than the great individual variations in the situation and size of the stomach; it is sufficient to remember that the greater curvature ought to lie above the um- bilicus. In a careful study of 81 persons, in which, unfortunately, those having gastric disorders have not been separately classified, Pacanowski % found that the distance of the lower border of the stomach above the umbilicus in the left parasternal line was 3 to 5 centimetres [1-|- to 2 inches] in men and 1 to 7 centimetres [1-| to 2f inches] in women ; when the stomach was moderately distended with carbonic-acid gas the distance between the highest and lowest point in the zone of tympanitic resonance was between 11 to 14 centimetres [4f to 5-| inches] in men and only 10 centimetres [4 * H. Pacanowski. Beitrag zur percutorische Bestimmung der Magengrenzen. Deutsch. Arch, fur klin. Med., Bd. xl, p. 342.—P. Predazzi. La percussione dello stomacco. Rivista clin., 1890, No. 1.—G. Kelling. Ueber die Ermittelung der Magen- grosse. Inaug. Dissert., Leipzig. 1890. t Obrastzow. Zur physikalischen Untersuchung des Magens und Derms. Deutsch. Arch, fur klin. Med., Bd. xliii, p. 417. See Chapter VI for discussion on changes in the percussion in displacements of the stomach (Kernig). X Loc. cit. GASTROPTOSIS, 89 inches] in women ; the greatest width of the tympanitic zone was 21 to 18 centimetres [8| to 7\ inches] respectively. On the other hand, the greater curvature was several centimetres below the umbilicus in a case of gastrectasis and one of atony, and consequently the results were different from the figures given above. My own observations agree quite well with these results, al- though, on an average, I have found the distance between the greater curvature and the umbilicus to be somewhat less—i. e., usually between 2*5 to 4 centimetres [1 to If inches]. At all events, it may be accepted as a rule that pathological conditions exist when the greater curvature lies at or below the umbilicus. The same is true of the method proposed by Pradezzi and others to use the intersection of the ninth rib and the left mammillary line as a guide for the greater curvature, as it is claimed that it is nor- mally subject to fewer variations.* Downward displacement of the lower border, however, does not necessarily indicate an increase in the size of the stomach, since the same thing occurs in downward dislocation of the stomach {gas- troptosis or descensus ventriculi) or when the stomach assumes a more or less vertical position, so that the course of the greater curv- ature is almost parallel with the left border of the body. Both of these conditions will be revealed by distention of the stomach. In gastroptosis the organ looks like a distended air cush- ion which lies across the middle of the abdomen. Superiorly it is flattened out on a concave line which represents the lesser curva- ture ; above this, in the epigastric region, there is a depression which gives a dull note on percussion, and in which, as stated above, the * As the result of a series of very careful investigations, Obrastzow (loc. cit.) comes to the conclusion that the situation of the lower border of the stomach is di- rectly dependent upon the build and general nutrition of the individual. The better these are, the higher will the greater curvature lie; while the poorer these are, and the older the individual, the nearer it will approach the umbilicus. In men as well as in women it may usually be found in the lower third of the xipho-umbilical line. It is displaced downward by pregnancy, diseases in which the diaphragm is pushed downward (emphysema, pleuritis, and pneumothorax), and enlargement of the liver and spleen. The reverse is true of the diseases which lessen the capacity of the abdominal cavity. Acute and chronic diseases of the stomach (excepting gastrectasis from whatever cause) have no influence upon the situation of the lower curvature. 90 DISEASES OF THE STOMACH. pancreas may at times be palpated. Inferiorly, the greater curva- ture may be distinguished below the umbilicus as a curved line with its convexity downward. Transillumination of the stomach {vide infra) will corroborate this. In gastroptosis, the volume of the stomach, as a rule, remains normal; but, according to my ex- perience, when the stomach is vertical a dilatation is always present. This is well shown in the accompanying drawing (Fig. 7). In such FIG, 7.—Vertical situation of stomach and exposure of the body of the pancreas. In this case the dilatation is only moderate; in other cases it may be so marked that the greater curvature reaches the symphysis. cases the lesser curvature may be seen near the middle line, or even to the left of it, while the zone of gastric tympanites may fill the entire left side of the abdomen; consequently there can be little doubt as to the size and situation of the viscus. The absolute size of the stomach is subject to very great differ- ences, even under normal conditions, which are independent of the height of the individual. I have a series of plaster casts of stomachs which were made by filling the viscus with liquefied tallow after it had been removed from the body and tying at both cardia and pylorus. Matrices GASTROPTOSIS. 91 were then taken from the casts thus formed, and the plaster models made from these.* One can most thoroughly be convinced of the well-known fact of the variations in form and size of the stomach by noting that Fig. 8. Fig. 9. Fig. 10. [Fio. 8.—Cast of cylindriform stomach in vertical position. Female. Ziemssen.] [Fig. 9.—Cast of normal stomach. Female. Ziemssen.] [Fig. 10.—Cast of dilated stomach in vertical position. Female. Ziemssen.] eight or ten other models differ a great deal, although all of them were made from persons of about the same size, who had never during life complained of any disturbance of digestion. Besides the simple purse-shaped, we find stomachs which are elongated, al- most, indeed, like a sausage, and others in which—be it remembered, without the action of cicatricial con- traction—a marked exaggeration of the so-called antrum pylori (i. e., the lower portion lying below the pylorus) [see Fig. 10, a] has almost caused the viscus to assume the shape of an hourglass. Just as the [Fm n _Cast of a markedly dilated Btom. form, SO Varies the Capacity of the ach tending to assume vertical position. , , . , . ,, Female. Ziemssen.] stomach, which in these prepara- tions was always determined by filling them with water. The largest * [Figs. 8, 9, 10. and 11 are from photographs of some of these plaster-of-Paris casts. They were all taken at the same distance from the camera, and were placed in the position which they occupied in the body. The differences in form, position, and size have thus been preserved.—Ed.] 92 DISEASES OF THE STOMACH. stomach held 1,680 c. c. [f I xlvj],the smallest only 250 c. c. [f 1 viij] ; between these limits we find all possible variations. From this it can be inferred that there is no absolute standard for the size of the normal stomach, at least within the given limits, and that its capacity by no means bears a fixed relation to the size of the body. We may find a very large stomach in a comparatively small individual, and vice versa, so that clinically one can only speak of a dilatation under the restrictions to be mentioned later on [see Chapter VI]. But it is very easy to determine the capacity of the stomach in the living subject and without distending it with water; it may be done at the same time when we inflate the stomach with air to as- certain its situation. We first learn the size of the compressing bulb of the double bulb of a spray apparatus,* and then count the number of times we must compress the bulb until the patient indi- cates that the pressure of the air upon the gastric walls is painful, and can thus easily calculate the volume of air which has been inflated. Unfortunately, however, researches which have been made under my direction by Dr. Kelling have shown that the capacity of the stomach in one and the same individual is subject to quite consider- able variations at different times ; or, in other words, varying amounts of air must be pumped in at different times to produce the same pressure within the stomach. This may easily be ascertained by attaching a manometer to the stomach tube and double bulb by means of a T tube; we can thus determine in each case how much air had to be pumped in in order to obtain the same pressure, or we can ascertain at what pressure each patient complained of pain or distention. These experiments, which it is self-evident must be performed on an empty stomach, have naturally had very varying results, because the factors upon which they depend— * This calculation is most readily made thus: A tall, graduated cylinder of about 200 c. c. [ § vjss.] is filled to the edge with water, is covered air-tight with the palm of the hand, and is inserted in a vessel of water. The tube of the double bulb is placed under the inverted cylinder; on compressing the bulb, the air will rise in the cylinder and will displace as much water as represents the capacity of the compres- sion bulb. This simple procedure can be carried out at any druggist's shop. The bulbs which I usually employ hold about 150 c. c. [ § v]. THE DEGLUTITION MURMURS. 93 namely, the tone of the gastric muscular fibers, the situation and fullness of the intestines, the tension of the abdominal walls —are different at different times.* However, the results ob- tained with inflation will always enable one to determine whether the stomach is small or large or abnormally large, or whether it is at the same time displaced. [For further details, and exact methods as to size and situation of the stomach, see Chapter VI on Dilatation of the Stomach, and Chapter XI on Gastroptosis.] Finally, the stomach may be so small that it may not be demon- strable, and may eventually completely disappear behind the costal border or left lobe of the liver. This may occur either in total car- cinomatous degeneration of the stomach, which may be so extreme that the organ looks like a loop of intestine, or in obstruction of the oesophagus when the stomach does not have the normal stimulation from the food, and hence contracts itself as much as possible. The accompanying figure (Fig. 12) is a typical example of this con- dition which was found in a case of oesophageal carcinoma. 4. The Deglutition Murmurs {Schluckgerdusche) as diagnostic aids. At another place y I have spoken of the nature and character of * [These results have been disclaimed by Kelling. Volkmann's Sammlung klinische Vortrage, No. 144, February, 1896, p. 29.—Ed.] f Ewald. Klinik der Verdauungskrankheiten, I. "Theil, 3te Auflage, pp. 67-70. [As these murmurs are quite frequently referred to in the following pages, this brief extract of the author's views as to their nature and origin has been added. At the beginning of swallowing, a murmur is propagated from the pharynx into the oesophagus ; this sound has no significance whatsoever. The true murmurs are the Durchspritzgerdusch and the Durchpressgerausch. Ewald thinks it much better to call them simply the first and second murmurs respectively. The first murmur (Spritzgerdusch) occurs almost immediately after the beginning of deglutition, and is a hissing sound, as if the fluid were being directly squirted into the stethoscope. Some time after, usually six to seven seconds, the second sound (Pressgerausch) is heard; this is a series of tones rapidly following one another, either gurgling, cluck- ing, sprinkling, or splashing. These murmurs are heard only near the cardia; the best site is just below the xiphoid cartilage; this at once distinguishes them from the sounds transmitted from the pharynx, which may be heard all along the oesophagus. The first sound is only heard rarely; its occurrence is said to denote a relaxation of the cardia, and the direct passage of the food into the stomach; the second is quite constant, and is absent only when the first is heard. Its nature is not so evident; some (Kronecker) claim that it is due to the audible vibrations of the cardia which are caused by the passage of the food over it; others (Zencker, Quincke, Ewald, Dirksen) assert that it is simply a result of the pressing through of the air which has been swallowed with the food. These sounds were first mentioned in 1864 by Natanson, and were carefully 94 DISEASES OF TEE STOMACH. these murmurs, and shall simply say here that they give no positive indications in the diagnosis of gastric diseases. Meltzer * claimed that the so-called Schluckgerdusch was due to a relaxation of the Fig. 12.—Contraction of the stomach in a case of cancer and stenosis of the oesophagus. cardia, and occurred as a specific symptom of old syphilis, phthisis accompanied by mild vomiting, neuroses of the cardia, etc. The studied by Zencker and also by Meltzer. The literature of the subject may be found in Ewald, loc. cit., p. 92.—Ed.] * Meltzer. Schluckgerausche im Scorbiculus cordis und ihre physiologische Bedeutung. Centralbl. f. d. med. Wissensch., 1883, No. 1. GASTROSCOPY. 95 inconstancy of the phenomenon was shown by Dirksen * and myself. I have never observed any constant and characteristic change in the intensity or quality of these murmurs, either in paralytic spinal lesions or dilatation of the stomach, or in any other condition which at first sight might seem to include this phenomenon. On the other hand, typical and of diagnostic value is the absence of the deglutition murmurs in complete or almost complete closure of the cardia, whether the obstruction be above or below the cardia. Yet this negative proof must be determined positively by repeated ex- aminations, since the murmur is now and then absent in healthy persons. 5. Another method of examination requiring a few words is that inaugurated chiefly through the labors of Mikulicz [and Kosen- heim]—gastroscopy, or the direct visual examination of the mucous membrane of the stomach with a specially adapted instrument, the gastroscope. Unfortunately, the simple mention of this author's name almost exhausts the literature of the subject, for the instru- ment, as constructed by Leiter (of Vienna), is so expensive and at the same time so difficult to manipulate, unless both patient and physician have been well trained, that its use has been very limited. The results which Mikulicz y obtained in carcinoma of the pylorus are of diagnostic interest. In the normal stomach the pylorus ap- pears as a long slit or a triangular, oval, and often a circular open- ing, surrounded by a ring of bright-red folds and projections of mucous membrane, which are in active motion and show an infinite number of changes of form. But in neoplasms at the pylorus this region is smooth, pale, without the above-described folds and pro- jections, and absolutely motionless. This would thus be a valuable aid in diagnosis, had not Pribram % reported a case of pyloric carcinoma—at all events, without gastroscopic examination—in which there were active movements of the tumor; i. e., a change in its size synchronous with active contractions of the whole stomach. * H. Dirksen. Beitrag zur Lehre von den Schluckgerauschen. Inaug. Dissert., Berlin, 1885. t Wiener med. Wochenschrift, 33te Jahrgang, S. 748. X Pribram. Zur Semiotik des Pyloruscarcinoms. Prager med. Wochenschr., 1884, S. 53. 96 DISEASES OF THE STOMACH. [Kosenheim * has devoted much time to perfecting the gastro- scope, and has devised two instruments for this purpose. He claims that this method is of great service in the early diagnosis of cancer ; but, as he himself admits, this method is adapted only for few cases, as much experience and time are required to use the in- strument. It may be of interest to note that the interior of the stomach has also been photographed by Kuttner.f] 6. The gastrodiaphane, which was first suggested by Einhorn,:}: and later by Heryng and Keichmann,* is an entirely different instru- ment from the gastroscope, since the main object of the procedure is to transilluminate the gastric and abdominal walls. This is most readily accomplished with Ein- horn's instrument [Fig. 13], which consists of a flexible rub- ber stomach tube, at the end of which is a small Edison incan- descent light about the size of a small hazelnut. The conduct- ing wires run through the tube and are connected with a switch after they leave it; the lamp is made of strong crystal glass. There is little danger of over- heating the lamp, as the stom- ach must contain some water before the instrument is intro- duced, and, furthermore, the current need be turned on but for a very short space of time. [The instrument should be introduced on an empty stomach, or the stomach should be washed out if it contains food. One or two glasses of water are taken before inserting the [Fig. 13.—Einhorn's gastrodiaphane.] * [Full details on this subject will be found in Rosenheim's Krankheiten der Speiserohre und des Magens, 2te Auflage, 1896, pp. 559-578.—Ed.] f [Kuttner. Deutsch. med. Wochenschr., 1891, p. 1311.—Ed.] X Einhorn. Ueber Gastrodiaphanie, N. Y. med. Monatschr., 1889; Berl. klin. Wochenschr., 1892, No. 51. * Heryng und Reichmann. Ueber electrische Magen- und Darmdurcbleuchtung. Therap. Monatshefte, March, 1892. GASTRODIAPHANY. 97 instrument. Kuttner and Jacobson recommended taking 2 to 3 pints.] The examination is best conducted in a darkened room [and in the standing position]. If the abdominal walls are sufficiently translucent—which, unfortunately, is too frequently not the case— brightly illuminated or rather transilluminated areas will be seen upon the abdominal walls. These areas have various sizes and situ- Fig. 14.—Gastrodiaphanic picture in normal Fig. 15.—Gastrodiaphanic picture in dilated stomach. stomach. Fig. 16.—Gastrodiaphanic picture in gastroptosis. Fig. 17.—Gastrodiaphanic picture in gastroptosis. ations, as may be seen in the accompanying figures (Figs. 14 to IT), which have been reproduced from Einhorn's paper, and may have some diagnostic value. An extended use of this method will be precluded by the difficul- ties incidental to the nature of the apparatus and obtaining the requisite electricity, and especially by the fact that these diagnostic results may be reached by our ordinary methods. 98 DISEASES OF THE STOMACH. [This method has been carefully studied by Kuttner and Jacob- son, Pariser, Meltzing, "Martius, Meinert, and Ivelling.* Kuttner and Jacobson claim that the form and situation of the transillumi- nated area is not alone sufficient to make a differential diagnosis be- tween dilatation and displacement of the stomach. They lay stress upon the absence of respiratory changes in diagnosticating the latter. This is denied by Meltzing; this observer also found that the size of the stomach as shown by transillumination is larger than is shown by percussion; thus he claims that even the empty stomach may reach as low as the umbilicus. Kelling shows that the illu- minated area need not necessarily correspond to the part of the stomach which it overlies, for it may be too small if filled coils of intestines intervene, or if the lamp is too far removed from the abdominal parietes; or it may be too large if adjacent empty coils of intestines are also transilluminated. He also shows by experiments on the cadaver that the light may penetrate the transverse colon obliquely, and thus lead one to suppose that the empty stomach was at the umbilicus, while in reality it was behind the liver. Furthermore, the diagnosis of tumors in the anterior wall of the stomach, as claimed by Einhorn, is considered doubtful by Riegel y and others.] The Technique of the Treatment of Stomach Diseases.—Of the numerous methods from time to time proposed for washing out the stomach or irrigating its mucous membrane, the best is the simple siphon method, concerning which we may speak as of the expres- sion method, simplex veri sigillum. A glass funnel is attached to the free end of the stomach tube by means of a piece of nibber tubing about one metre [one yard] long, and by alternately raising and lowering the funnel the stomach may be filled or emptied. The simple siphon action is all that is needed, since, with very few ex- ceptions, we can undertake the operation at a time, or after such meals, when there is no danger of having the openings of the tube * [Kuttner und Jacobson. Berl. klin. Wochenschr., 1893, Nos. 39 and 40.— Pariser, ibid., 1892, No. 32.—Meltzing. Zeitschr. fiir klin. Med., Bd. xxvii, Heft 3 und 4.—Martius. Centralbl. fiir innere Med., 1895, No. 49.—Meinert, ibid., 1895, No. 49.—Kelling. Volkmann's Sammlung klinische Vortrage, No. 144, February' 1896, p. 16.—Ed.] t [Riegel. Krankheiten des Magens, 1896, p. 37.—Ed.] TECHNIQUE OF LAVAGE. 99 plugged; and even if small pieces of meat and similar substances are aspirated into the eyelets, they can easily be dislodged by hold- ing the funnel high up. I consider it entirely irrelevant whether we use a continuous stream with a double-current tube or Rosen- heim's douche, described on page 7, or whether we fill and empty the stomach alternately; if anything, I prefer the latter, since the rapid raising and depressing of the fun- nel agitates the fluid in the stomach more forcibly, and mucus and other solid substances caught in the folds of the mucosa may be more easily re- moved mechanically. I prefer to use a large glass funnel of about two litres [two quarts] capacity, with a diam- eter of 20 centimetres [8 inches] ; this is attached to a rub- ber tube of suitable length, which is joined to the upper end of the stomach tube [by a small piece of glass tubing].* The funnel rests in a wooden frame (Fig. 18) on the floor and is here filled with the requisite amount of water or other fluid used, and is then raised to a height suitable to ob- tain the amount of pressure desired. The water escapes from the various openings in the tube as from a sprinkler, so that, by * [A small piece of glass tubing, the caliber of which is somewhat smaller than that of the stomach tube, is very convenient for connecting the latter with the tubing attached to the funnel; through it we may also see the nature of the fluid raised from the stomach, and can also readily determine when it comes up perfectly clear. It is quite important to select -the proper rubber tubing for this purpose. The best kind is pure gum tubing, the caliber of which is slightly larger than that of the stomach tube. The advantages of this tubing are, that by stripping the tube outward we may obtain sufficient aspiration to start the siphonage ; or, if the tube is plugged, we may often dislodge the obstruction by stripping the tube in the reverse direction. These minor but nevertheless important details of the use of the tube I have discussed in the Technique of Obtaining Stomach Contents, New York Polyclinic, August, 1894.—Ed.] Fig. 18.—Stand for holding funnel of stomach tube. 100 DISEASES OF THE STOMACH. gradually withdrawing the tube a little, the various portions of the stomach may be successively irrigated. To siphon the water out of the stomach, the funnel is again placed in the wooden frame, and thus any foreign substances that may be present may rise in it, and can be obtained for examination if desired. [To allow the fluid to accumulate in the funnel before throwing it away into a pail is a point that is usually neglected. In this way exfoliated pieces of mucous membrane, bits of tumor tissue, blood clots, etc., may be obtained, when under the ordinary method they would doubtlessly escape observation]. If one is alone, this technique is much more convenient than to work with a small funnel. For consultation practice out of the office, I use a small hard-rubber funnel of about 300 c. c. [f 5 x] capacity. Siphonage of the stomach by elevating and depressing a funnel can not be done by the patient alone. Yet in many cases it is es- sential that the patient should wash out his own stomach; the first requisite is, of course, to learn to introduce the tube himself, a manipulation which most patients acquire very readily. Here, too, the sim- plest method will suffice. For siphonage, the following will be found to be convenient: One extremity of the horizon- tal portion of a glass T tube \_C, Fig. 19] is connected with the stomach tube \_A~\ ; the other extremity is joined to an irrigator by means of a soft- rubber tube \_D],a hard-rubber stopcock * intervening; to the free end of the vertical portion is attached a rubber tube \_H~\ about one metre [one yard] long. The patient sits near the irrigator, which * [This is not essential; it may be replaced by a pinchcock placed on the tub- ing (d); it will also be found convenient to have one upon e.—Ed.] [Fig. 19, -From Pepper's System of Medicine (after Leube).] TECHNIQUE OF LAVAGE. 101 has previously been filled and placed at a suitable height; the tube is introduced into the stomach while the stopcock is kept closed, and the open end of the rubber tube [ pages under the title of Dyspepsie et Ca- tarrhe Gastrique (Paris, 1890); and Germain See,*}* who distinctly describes dyspepsia as an " operation chimique defecteuse" still clings to a purely symptomatic classification, and divides dyspepsias into those with changes in the chemical functions and those with mechanical disturbances. This is about as scientific as it would be to write a chapter on dropsies, although we had long ago advanced from a symptomatic to an anatomical classification. It is only re- cently that Dujardin-Beaumetz % took a decided stand against this view of the dyspepsias, and says : " D'ailleurs cet mot de la dyspep- sia essentielle est appele de disparaitre de la pathologie. II cache en effet notre ignorance." The Germans were the first to destroy this conception of dyspep- sia as a disease, and to recognize it as only a pathological condition ; therefore Lebert properly excluded the chapter on dyspepsia from his treatise on the diseases of the stomach. In fact, such terms as dyspepsia, indigestion, etc., are merely descriptive of a functional disturbance but not of a distinct disease; and hence to-day we ought not to find a physician who considers a disturbance of digestion as a separate disease. In making a historical review of this chapter in the works of the writers in this field, we find that its extent gradually becomes smaller —in other words, that distinct clinical types have been successively separated from this large group. Thus, to give only two examples, irritable and atonic dyspepsias are now included under the gastric neuroses, and we may equally well class some of the cases described by the older writers as pyrosis or heartburn under what we now recognize as acid hypersecretion. I shall revert to this topic while considering the conditions of * F. Damaschino. Maladies des voies digestives. Paris, 1880. f Germain See. Du regime alimentaire. Paris, 1887 ; Des dyspepsies gastroin- testinales. Paris, 1883. X Dujardin-Beaumetz. L'Union Medic, July 22, 1892. 1D4 DISEASES OF THE STOMACH. hyperchlorhydria, which I classify among the neuroses of the stom- ach. I will merely say here that of necessity we must differentiate between a catarrhal (that is, a chronic inflammatory) condition of the glandular coat of the stomach and the nervous affections of the same, be the irritation direct or indirect. The inflammatory pro- cesses are always attended by a lessening of the glandular secretion —i. e., of hydrochloric acid and pepsin—and instead there is pro- duced a more or less alkaline transudate. The sum of these two factors will give the absolute acidity or alkalinity of the stomach contents as produced by the irritation of the ingesta. But the de- gree of acidity is always lessened, and it is therefore a distinct con- tradiction of the pathological meaning of the term inflammation, and especially of chronic catarrhal processes, to speak of an " acid catarrh," as has been done up to recent times, in absolute violation of fundamental medical principles. In spite of the statements of certain authors (Jaworski, Korczynski,* Dujardin-Beaumetz, Hay- em f), I can not force myself to accept the view that we shall desig- nate as "catarrhs" conditions in which there is hypersecretion accom- panying a more or less marked irritation of the mucous membrane. When we find hyperacidity, or, to speak more exactly, hyperchlor- hydria, and also the evidences of inflammation of the mucosa (cel- lular proliferation, cloudiness of the epithelium, etc.), the latter must be regarded as secondary to the former. The hyperchlor- hydria is usually due to some nervous influences which cause an overactivity of the secretory apparatus ; and it exists in spite of the damage to part of the secretory parenchyma as an evidence of the overactivity of the intact portion, but not as the result of a " so- called acid catarrh," as Korczynski and Jaworski have proposed, since the adjective " so-called " shows that this designation is purely arbitrary. It is entirely different, however, with the coexisting production of mucus, which, as in other glands—the submaxillary gland, for instance—does not go hand in hand with the formation of the spe- cific secretion. The longer the stimulation lasts the smaller the * Von Korczynski and Jaworski. Deutsch. Arch, fiir klin. Med., Bd. xlvii. f Dujardin-Beaumetz. Traitement des Maladies de l'estomac. Paris, 1891, p. 227.—Hayem. Gazette hebdom., 1892, Nos. 33 and 34. PATHOLOGY OF CHRONIC GASTRITIS. 195 percentage of the organic constituents of the saliva will be than the inorganic, and probably (although this is not yet absolutely known) the amount of mucus and ptyalin will stand not in the same but in the reverse proportion.* Analogous to this, the secretion of mucus in the stomach may be very abundant, and yet the gastric juice may be absolutely wanting ; such, indeed, is often the case. But all those conditions which are accompanied by an increased secretion of gastric juice must be classified among the neuroses of the stomach, whether it is only an abnormal reaction to a normal physiological stimulation—i. e., occurring only during digestion—or whether a eontinual irritation keeps up a constant secretion of the glands. These are the conditions which we now call hyperchlorhydria and hypersecretion. In accordance with these views, I shall describe these conditions among the nervous disturbances of the stomach. [This view is not shared by Boas, Rosenheim, and others, who main- tain that there are cases of chronic gastritis with increased acidity of the stomach contents. This group of cases is called gastritis acida.) Pathology.—The anatomical features are allied to the conditions described under acute gastritis. For the greater part the mucous membrane has a yellowish-gray or slate-gray color, with insular, vas- cular, deeply injected areas of a scarlet or brownish-red color ; it is usually thickened, on an average, one or two millimetres [^- to j1^ of an inch], and covered with a delicate but firmly adherent layer of mucus ; in many places it is elevated above the tense submucosa, because at these places it has grown more rapidly than the latter, and forms papillary projections, giving rise to the so-called etat mamcloncc, a term which at all events is applied by some authors not to this condition but to the polypoid degeneration of the mucous membrane.f The portion of the stomach usually involved is the pylorus, but it may extend to the fundus and even the entire mu- cous membrane. The submucosa and muscularis may also be thick- ened, and the latter especially at the pylorus may cause hypertrophy with consecutive stenosis. To this condition of well-marked hyper- trophy Brinton has applied the name of cirrhosis of the stomach, * Vidi- Ewald. Klinik, etc., I. Theil, 3te. Auflage, S. 47 and 50 et seq. f Orth. Loc. cit., p. 709. 196 DISEASES OF THE STOMACH. while the French writers * call it hypertrophic sclerosis of the sub- mucosa and muscularis. The minute anatomy of the process is that of a parenchymatous and interstitial inflammation.f The glandular cells are partly de- stroyed, partly granular, and partly shriveled up ; differentiation between the principal {Hauptzellen) and the parietal cells {Belegzel- Fig. 27.—Mrs. St., September 27,1887. From a pale, reddish shred, the size of a grain of sand, which was found between some pieces of mucus in the wash-water after lavage of the empty stomach. J len) is impossible ; in many places, especially in the pyloric region, the ducts have lost their regular order of lying alongside of one another, and show an atypical manifold ramification like glove- * Hanot et Gombauldt. Arch, de physiol., ix, p. 412.—Dubujadoux. Gazette hebdom., 1883, p. 198.—Kahlden. Ueber chronische sclerosirende Gastritis. Cen- tralblatt fiir klin. Med.. 1887, No. 16. t [See also Hayem. Gastritis Parenchymatosa. Wiener Allgem. med. Zeit., 1894, Nos. 2-17. Hayem has published the best histological studies of the gastric mucous membrane.—Ed.] X [Some light has been shed upon the changes in the gastric mucous membrane by the study of the fragments of tissue which are frequently found in the wash- water during lavage, as was originally proposed by Boas. A most elaborate study, with illustrations and complete bibliography, has been published by Cohnheim (Boas's Archiv, 1895, Bd. i, p. 274). Einhorn has also studied this subject in his publication on erosions of the stomach (N. Y. Medical Record, June 23, 1894), in which he has endeavored to construct a new clinical group for this symptom—a grouping which does not seem justified when one considers in how many different conditions these fragments may be found. This has been shown in Cohnheim's paper and also in Einhorn's original paper, and one which has just appeared (The State of the Gastric Mucosa in Secretory Disorders of the Stomach, N. Y. Medical Record, June 27, 1896). How far we are justified in drawing conclusions as to the condition of the other parts of the mucosa must remain an open question. This much seems to be established at present, that as yet we are unable to associate any definite pathological changes in the fragments of tissue with the various diseases of the stomach.—Ed.] PATHOLOGY OF CHRONIC GASTRITIS. 197 fingers. Isolated glands become separated at the fundus and appear at the border of the submucosa as cysts, which are either empty, with a smooth lining membrane, or are filled with the remains of glistening hyaline cuboidal epithelium. There is an abundant small- celled infiltration which is especially marked near the surface of the mucous membrane ; the cells lie between the glands and in places push their ducts far apart. In the hyperplastic form we see pro- cesses of connective tissue which proceed upward between the glands from the submucosa like the branches of a tree. The free surface of the glandular layer is covered with a film of mucus in- closing many leucocytes and nuclei. The superficial layer of the epithelium of the mucosa is loosened, and can be separated in ad- herent shreds which may sometimes be found in the wash-water after lavage of the stomach. In the accompanying drawing (fig. 27) one can readily see the mouths of the glandular ducts and the surrounding epithelium, The epithelial cells of the Vorraum [the short, tunnellike entrance to the cavity of a peptic gland] is for the greater part filled with a pale mucous mass wThich projects sharply against the lumen without any inclosing membrane, as described by Kupffer * in the normal stomach. I have been able to study this and the following conditions in specimens which were obtained immediately after death, or from living persons after resection of the pylorus. In the condition (to be described presently) of mucous catarrh this mucoid degeneration may be observed to extend down to the base of the glands, so that in place of the ordinary principal and parietal cells wre only find cells in the most varied stages of mucoid degeneration. This condition is especially marked in the pyloric region. Isolated 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 mucus 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, where it has been precipi- tated in streaks by the alcohol. This gives rise to very delicate * Kupffer. Epithel und Driisen des menschlichen Magens. Miinchen, 1883. Tafel I. 198 DISEASES OF THE STOMACH. figures, which resemble a row of horseshoes with their openings toward the lumen of the gland. Fig. 28 has been taken from a piece of mucous membrane which was placed in hardening fluid im- Fig. 28.—The specimen from which this figure has been drawn is from a piece of mucous membrane which was placed in alcohol immediately after its removal from the stomach, at an operation for resection of a pyloric carcinoma. It was stained by Heidenhain's method of hematoxylin and bichromate of potash. On the right side of the figure is the upper border of the mucous membrane, showing the epithelium, a few cells of which contain mucin. Directly under the epithelium is a small-celled infiltration which ex- tends across the entire mucous membrane, dipping down to the submucosa between the glandular tubules, separating the latter and obliterating their excretory ducts. The section, being oblique, shows one portion of the glands in longitudinal, the other in transverse, section. In the glandular cells the mucoid degeneration may be seen to extend in even as far as their fundal portion. (Camera lucida.) mediately after excision. Some of the glands are well preserved, while others are irregularly formed, but only in the pyloric region, the cells of which are in various stages of mucoid degeneration. PATHOLOGY OF ATROPHY OF GASTRIC MUCOSA. 199 Some of the cells are still intact; others are filled with granular protoplasm and a large nucleus ; in still others the greater portion of the cell consists of mucus which has crowded the protoplasm and nucleus to one side ; finally, there are others in which the cell mem- brane has burst, the mucus has been poured out into the lumen of the gland, and has been precipitated in streaks by the alcohol. That this is really mucus, and not the isolated formation of vacuoles, as described by Stohr and Sachs, is easily proved by the reaction with acetic acid and the bluish color with heematoxylin; yet, I repeat, these features are only found where the mucous membrane has been placed in alcohol while still warm; in older tissues I have never met them. Thus there is a mucoid degeneration of the protoplasm of the cells, which extends deep down into the fundus of the gland. Whether these changes may retrograde, or whether they are perma- nent, I can not yet decide from the specimens which I have at present. As the disease advances, chronic gastritis finally causes retro- gressive changes in nutrition, which are at first manifested in a pro- gressive fatty degeneration of the glandular cells, and which finally cause complete atrophy of the mucous membrane, a condition to which Lewy * has called especial attention. This led to further in- vestigation on this subject, although it had already been carefully studied and illustrated by Fenwick; f yet these pictures are very incomplete according to our present notions. Freund *{: has also de- scribed this condition in a monograph, rich in historical data, under the name of granular degeneration of the mucous membrane of the stomach. These changes, if a large area, or especially the entire surface, of the mucous membrane be involved, must finally lead to a total destruction of the secreting parenchyma with all its conse- quences. [The correctness of these views on atrophy of the gastric mu- * B. Lewy. Chronische Gastritis mit Atrophie der Mucosa. Ziegler's Beitrage, Heft 1, 1886.—Ewald. Ein Fall von Atrophie der Magenschleimhaut. Berl. klin. Wochenschr., 1886. f L. Fenwick. On Atrophy of the Stomach. London, 1880. X W. A. Freund. Ueber den etat mamelonne und die Granularentartung der Magenschleimhaut. Breslau, 1862. 14 200 DISEASES OF THE STOMACH. cosa have been questioned by Cohnheim,* who quotes Hammer- schlag f and Schmidt % in support of his views. Cohnheim main- tains that in most cases it is only the true secreting portion of the mucosa which is destroyed, but that the excretory duct, i. e., the foveal layer—remains intact, or is even hypertrophied. The rapid post-mortem changes usually lead to the destruction of these super- ficial layers, and hence it is only by the examination of the bits of tissue in the wash-water during lavage that the real condition of the mucosa can be determined.] The process may advance in two different ways:# 1. In the one form, in addition to the above-described degeneration of the gland- ular cells, and a small-celled infiltration of the interglandular con- nective tissue, there is a progressive destruction of the glandular parenchyma, so that finally, as may be seen in Fig. 29, nothing is left but a layer (whose thickness is much less than that of the nor- mal mucosa) of small round cells, between which isolated remnants of the former parenchyma may here and there be found. Toward the cavity of the stomach, what was formerly the gland- ular layer is limited by numerous villi infiltrated with many round cells. Toward the submucosa—i. e., in the deeper layers of the mu- cous membrane—may be found remnants of glandular ducts running obliquely; these are still in the earlier stages of the process, and some of them have been converted into larger or smaller cysts. The latter fact proves that the process has progressed from above down- ward, and has first obliterated the orifices of the ducts. Later, even these remnants of the glands disappear. The muscularis mucosae is much thickened; the submucosa becomes wider, and is drawn out into a network, while its vessels are widely dilated without showing any marked changes in their walls. A peculiar widening of the space between the muscle bundles is very noticeable in the muscu- * [Cohnheim. Loc. cit, pp. 290-294.—Ed.] t [Hammerschlag. Wiener klin. Rundschau, 1895, No. 23.—Ed.] X [Schmidt. Deutsch. med. Wochenschr., 1895, No. 19.—Ed.] * The description of these conditions, based upon specimens which I prepared with Dr. George Meyer, was first given by me at the meeting of the Berliner med. Gesellschaft on November 14, 1888.—Berl. klin. Wochenschr., 1888, No. 49.—[See also G. Meyer. Zur Kenntniss der sogenannten " Magenatrophie." Zeitschr. fiir klin. Med., Bd. xvi, S. 366.—Ed.] PATHOLOGY OF ATROPHY OF GASTRIC MUCOSA. 201 laris. The organ in toto is enlarged; its walls appear thinned and brightly transparent in areas or throughout its entire extent. The whole process seems to be a parenchymatous one which has ex- tended from the surface downward. Fio. 29.—From a case of anadenia of the mucosa, with accompanying dilatation of the stom- ach. Instead of the mucosa we find only round cells, relatively few in number, which still barely indicate the normal villuslike arrangement. The muscularis mucosae is much broader; the submucosa is stretched out, and contains markedly dilated blood- vessels filled with blood-corpuscles. The muscularis, which is not represented in the drawing, presented a peculiar formation of spaces between the individual bundles of muscle-fibers, causing it to look like a network of cavities. (Camera lucida.) 2. The other form is characterized by a marked activity of the mterstitial connective tissue, and leads to its hypertrophic prolifera- 202 DISEASES OF THE STOMACH. tion, which proceeds from the base of the glands upward toward the lumen (Fig. 30). The few fibers which are normally found above the muscularis mucosas are thickened; ascending and branching like a tree between the glands, they surround them and cut them off. Yet, unlike the first form, no cysts are formed, since the parenchymatous cells, hav- ing been deprived of their nutrition, undergo atrophy; so that finally, Fig. 30.—From a case of phthisis ventriculi, with cirrhotic atrophy. Broad bands of con- nective tissue ascend from the submucosa (situated to the right in the figure) upward between the glandular tubules, embrace them and cut them off, thereby causing the destruction of the parenchyma. In many places are to be seen numerous round cells, which surround the base of the glands, and also lie in the meshes of the connective tissue. Toward the free surface of the mucous membrane is a small-celled infiltration. The muscularis mucosa is gone. The submucosa has been converted into a dense fibrous mass of connective tissue, in which a few isolated remnants of ruptured glands may be found. (Camera lucida.) as is shown in Fig. 30, there remains only a meshwork with large interstices whose fibers run parallel to and terminate smoothly at the surface. Isolated remnants of ducts and cells may be found here and there in the form of hyaline inclosures. The muscularis mucosse disappears entirely, the submucosa is traversed by bands of connective-tissue fibers, but the muscularis is apparently unaltered. PATHOLOGY OF ATROPHY OF GASTRIC MUCOSA. 203 The organ is usually not enlarged in toto, but at times, as in a case reported by Nothnagel,* may be small and cirrhotic. I have examined such a stomach, the capacity of which was only 180 c. c. [f ^ vj]. The membrane which has taken the place of the mucous membrane is macroscopically smooth and white, gray, or slate-col- ored. In such cases the sclerotic atrophy involves the pyloric region especially, while the thinning of the walls of the stomach occurs in irregular areas, especially at the fundus, or it may involve the entire organ. To what extent the walls of the stomach may be altered by this process may readily be perceived from the following measurements of the various layers made by Westphalen : Normal stomach. Atrophic fundus. Mucosa.............................. Millimetre, t 060 0-05 0-30 070 Millimetre. 0*05 Muscularis mucosa?...................... o-oi Submucosa................................. 0-20 Muscularis................................ 0-13 On the other hand, there may be a compensating hypertrophy of the muscularis, so that the latter may be twice as broad as usual. This increase, as shown by a case which I have examined, is due to a typical hypertrophy of the muscular tissues. In either form it is a severe, irreparable process which specially involves the glandular layer of the stomach, and which is character- ized by a complete disappearance of the secreting parenchyma. I therefore fully agree with Dr. George Meyer, who wishes to abolish the name of atrophy of the stomach, which conveys a false idea of this process, and proposes as a substitute phthisis ventriculi, gas- tric phthisis {Magenphthise). As an amendment I would propose the name Anadenie des Magens, because the lesion causes a total destruction of the secreting parenchyma. It is hardly necessary to explain that such terms as catarrhus atrophicans or atrophicus are ridiculous. * Nothnagel. Cirrhotische Verkleinerung des Magens und Schwund der Lab- driisen nnter dem kliniscben Bild der perniciosen Anamie. Deutsch. Archiv fiir klin. Med., Bd. xxiv, S. 53. f [One millimetre equals ?V inch.—Ed.] 204 DISEASES OF THE STOMACH. Additional cases of anadenia have since been reported, of which I shall only mention those of Westphalen* Klinkert,f and Ilayem,^ the latter of whom has described no less than 15 cases. In general, the statements which I have just made above are confirmed, and no new facts are presented, with the exception of a few variations in Fig. 31.—Total atrophic sclerosis of the mucous membrane, which has been converted into a long, stretched-out portion of connective tissue, with isolated round cells, and hyaline remnants of former glandular tissues. Toward the free border of what was formerly the mucous membrane (to the left of the figure) the closer packing of the fibrous bands has formed a kind of limiting membrane. The muscularis mucosae has disappeared, the submucosa is thinned, and consists of undulating bands of connective tissue. Cysts may be seen very close to the free border of the membrane. the relation of the interstitial to the parenchymatous inflammation and the proliferation of the interstitial tissue. My own histological studies do not enable me to decide whether in the first form we are only dealing with secondary processes after prolonged catarrhal in- flammation, or whether, as claimed by some writers, like Fenwick and Eisenlohr,* there is a genuine primary atrophy of the gastric mucosa. I believe this question can hardly be decided from the * Westphalen. Ein Fall hochgradiger relativ motorischer Insufficienz des Magens und Atrophie der Magenschleimhaut. St. Petersburg, med. Wochenschr., 1890, No. 37. t Klinkert. De klinische beteekniss van der atroph. Maag-Katarrh. Nederl. Weekbl. v. Geneesk., 1892, No. 5. X Hayem. Resume de l'anatomie pathologique de la gastrite chronique. Gaz. hebdom., 1892, Nos. 33 and 34. * Eisenlohr. Ueber primare Atrophie der Magen und Darmschleimhaut. Deutsch. med. Wochenschr., 1892, No. 49. POLYPI OF STOMACH. 205 histological appearances. It would be much easier to assume clin- ically that a primary atrophy might occur in young individuals with- out an antecedent protracted catarrh in the sense of the latter writers; yet of this also there exist no unequivocal proofs. [Under the name achylia gastrica, Einhorn * includes all cases in which the stomach contents contain no HCl or ferments; in one group there is atrophy of the gastric mucosa; in the other the mucous mem- brane may be intact, the cause of the absence of secretion being nervous.] At all events, there are many intermediate stages between the simple and mucous catarrhs and atrophy, so that at times it may be impossible to differentiate the two processes. So much for these final stages of chronic gastroadenitis. Another change arises from the villous outgrowths from be- tween the small depressions in the gastric mucous membrane ; this gives rise to the polypoid outgrowths [polypi] from it, usually the size of a milium {Hirsekorn) to a pea, and arranged alongside of one another in large numbers, although at times they may assume larger dimensions. Cruveilhier has a drawing of a specimen in which the polypi hang down from the mucous membrane like the teats of a young bitch. Ebstein *f* has studied their structure very carefully, and divides them into the pedunculated and the n on-pedunculated ; those occurring in groups and those which are isolated; those with a smooth and those with a polypoid mucous covering. In the affected areas the connective tissue between the glands is always increased and forces them asunder. The mucous membrane and submucosa are thickened in larger areas. In a case of Lemaitre,*}: carcinoma and polypus were observed together; amyloid degeneration of the vessels was also present.* It is well known that intestinal polypi may not infrequently give rise to a partial or complete intussusception of the intestine, yet a similar condition due to gastric polypi is a very rare occurrence. * [Einhorn. Achylia Gastrica. N. Y. Medical Record. July 6, 1895.—Ed.] f W. Ebstein. Die polypose Geschwulste des Magens. Reichert und Du Bois, Archiv. 1864. S. 94. X Camus-Corignon. Des polypes de l'estomac. These de Paris, 1883. * [An excellent picture of polyposis of the stomach may be found in Martin's Diseases of the Stomach, 1895, Fig. 23, p. 240.—Ed.] 20fi DISEASES OF THE STOMACH. Such a case of intussusception of the stomach, described by Chiari, • therefore deserves especial mention. The patient was a woman, forty-four years old, who had died of ma- rasmus. During life a tumor was felt at the pylorus ; there was emacia- tion, accompanied by vomiting of blood ; the diagnosis was carcinoma of the pylorus with consecutive dilatation of the stomach. At the autopsy a funnel-shaped depression was found on the outer wall of the stomach S centimetres [3 inches] from the pylorus, and into which the middle finger could be passed 6 centimetres [2*4 indies] toward the pylorus. A portion of the greater omentum had been drawn into this intussuscepted part of the stomach, but it was easily replaced. On opening the stomach it was found that the intussusception was due to three large polypi like cauli- flowers, situated at the apex of the prolapsed portion of the wall of the stomach ; together they formed a tumor about the size of an egg, which extended from the stomach through the pylorus into the duodenum, to a distance of 2 centimetres [0*8 inch]. Although this did not cause a com- plete obstruction of the pylorus, since the index finger could still be easily passed through it into the duodenum alongside of the polypi, yet there must have been a serious obstruction to the passage of food from the stomach into the intestines. This explained what was found during life, and justified the error in the diagnosis. The situation of polypi close to the pylorus explains why they can be drawn downward by the strong contractions of this part of the stomach, and thus cause an intussusception. The latter is exceedingly rare, as stated above, when the polypi are situated elsewhere. Etiology.—The causes of chronic gastritis are of a very manifold nature. First, it may result from the acute and subacute forms, as oft-repeated attacks frequently lead to it, especially since the causes of all these forms may be the same. Such irritants can act more readily when the mucous membrane has been altered by changes in the circulation or in the condition of the blood, the mucous mem- brane being thus rendered more sensitive than it normally is. Changes in the circulation may be produced by all processes which lead to venous congestion of the stomach—that is, the affections of the organs of the portal system, especially of the liver and spleen ; also diseases of the heart, and tuberculosis. Among the conditions which probably predispose to chronic gastritis by an altered condition of the blood are chlorosis, scrofula, anaemia after dysentery, typhoid fever, acute exanthemata, preg- * A. Chiari. Ueber Intussusception am Magen. Prager med. Wochenschrift, 1888, No. 23. ETIOLOGY OF CHRONIC GASTRITIS. 207 nancy, and uterine diseases ; also diabetes, gout, and chronic affec- tions of the kidney. Finally, chronic gastritis may also result from direct local irrita- tion, either as a consequence of cicatrices and neoplasms in the mu- cous membrane, or irritating substances which are brought in con- tact for a long time with the gastric mucous membrane, either from without or from the blood. Among the former is the swallowing of large, half-digested, and insufficiently insalivated morsels of food, which irritate the gastric mucosa, either directly or indirectly, by predisposing to fermentation of the stomach contents. Another source of irritation from without may be putrefaction in the mouth from carious teeth or inflammation of the gums ; these putrid prod- ucts are swallowed, and may cause inflammation directly or indi- rectly. To this category also belongs tobacco juice, wdiieh fre- quently produces first a subacute and then a chronic inflammation ; also concentrated alcoholic beverages, and condiments in the food which may cause chronic changes after prolonged abuse ; finally, true toxic substances or parasites like trichinae, worms, larvae, etc. On the other hand, there are also certain toxic substances which circulate in the blood and are excreted in the stomach—e. g., urea in chronic renal diseases, and the products of intestinal putrefaction in constipation. [Turck * has conclusively shown the close relation that exists in many cases between diseases of the mouth and nasopharynx and chronic inflammation of the stomach and intestines. He maintains that "the invasion of the stomach from the infected mouth and phar- ynx is supported by the fact that many of the known pathogenic micro-organisms present identical biological and morphological forms in cases of gastritis as the micro-organisms found in. diseases of the mouths and post-nasal cavities of the same patients." He also urges that the decomposition of the food and the growth of micro-organisms in the stomach lead to the formation of poisons which may be absorbed and produce both general toxic effects and local irritation.] The continual regurgitation of bile into the stomach has been * [Turck. N. Y. Medical Journal. November 23, 1895, p. 648; ibid., February 22, 1896 ; Medical News, April 4, 1S96, p. 373.—Ed.] 20S DISEASES OF THE STOMACH. regarded as a special etiological factor. Although the investigations of Dastre and Oddi* show that even large quantities of bile may have no effect on digestion, yet the results of these experiments of animals are directly opposed to the old views on this subject; and, according to the observations of Von den Velden, Malbrane, Riegel,f Weill,*}: and my own experience, it is beyond any doubt that a contin- ual regurgitation of bile may cause chronic disturbances of digestion. But, as shown by Boas, in such cases the bile merely acts as an ant- acid, since the biliary albumen and mucus combine with the HCl, and it will depend entirely upon the energy of the HCl secretion and the amount of regurgitated bile as to how much the gastric digestion will be disturbed, and to what degree the mucosa will be irritated. The most important of these etiological factors is always the entrance of the above-mentioned injurious substances, and as these are usually taken of the sufferer's own free will, the disease may be classified among those in which the patient's indiscretions play a very important role. But as most persons treat their stomachs badly, and are neither able to resist culinary temptations nor take sufficient precautions at the beginning of their trouble, chronic gas- tric catarrh is one of the " best-nourished " and most prevalent dis- eases in the wrorld. Indigestion is the remorse of a guilty stomach ! Clinical History.—The disease presents itself in two clinical forms, which, when fully developed, are easily differentiated: Chronic simple gastritis {catarrhus gastricus chronicus) and chronic mucous gastritis {catarrhus gastricus mucosus) [Hayem's gastrite parenckymateuse muquese'] ; both of these may finally lead to atrophy of the mucous membrane. Although the symptoms of these different conditions have long been known and described, yet on the one hand they have not been described as independent dis- eases, nor on the other hand has their mutual connection been rec- ognized. Boas,* by using the new methods of examination, deserves * Dastre. Recherches sur la bile. Archives de physiologie, April, 1890, p. 315. t Riegel. Beitrage zur Diagnostik und Therapie der Magenkrankheiten. Zeit- schr. fiir klin. Med., Bd. xi, p. 87. X E. Weill. Du refleux permanent de la bile dans l'estomac. Lyon medicale, December, 1890. * J. Boas. Zur Symptomatologie des chronischen Magenkatarrhs und der Atrophie der Magenschleimhaut. Munch, med. Wochenschr., 1887, No. 42. SYMPTOMS OF CHRONIC GASTRITIS. 209 the credit of having differentiated the atrophic from the mucous form. In the initial stages the subjective symptoms are about the same in the different forms, namely, those of difficult digestion, or of chronic dyspepsia ; it is only after the development of a progressive phthisis (atrophy) of the gastric mucous membrane—and, as it seems, < >nly after it has been established for a long time—that the symp- toms of rapid decline of the organism become manifest. The differ- entiation really depends on the result of the chemical examination of the stomach contents. I shall first consider the local and general symptoms which are common to all. The patients usually complain of a dry, pasty, or salty taste in the mouth, which is also communicated to the food during mastication. There is nothing characteristic about the tongue ; it is seldom clean, but usually coated, either entirely or at the base, where the reddened, swollen papillae project like straw- berries, while the edges bear the impressions of the teeth ; the thick fur which accompanies carcinoma [of the stomach] is usually absent. The tongues of delicate ainemic patients have a more uniform trans- parent coating, giving the organ a bluish-white color. Occasionally aphthae form at the edges and cause the patient much annoyance. In the morning the coat is much thicker than in the evening, be- cause the movements of the tongue serve to keep it clean ; if some teeth are missing, we notice that the coating is thicker on that side, although this is not always to be explained thus. The lips are usu- ally dry and chapped. Belching is very frequent; the gas is either odorless or has an offensive sour smell and disagreeably rancid taste. It is frequently accompanied by the regurgitation of fluid or rem- nants of food from the stomach, having a very sour and disagree- able taste; these regurgitated masses often impart a burning and scratching sensation along the oesophagus—heartburn or pyrosis, the ardor ventriculi of Hoffman. If this sensation is limited to the lower section of the cesophagus, or to the cardia, and is of an intense character, it may be termed cardialgia. Such an exact dis- tinction between pyrosis and cardialgia is usually impossible, even if Cullen, of Scotland, has described, under the name of pyrosis, a peculiar group of symptoms of violent cardialgia occurring, espe- 210 DISEASES OP THE STOMACH. cially among the Scotch country people, paroxysmally in the morn- ing before eating, and which is relieved by the vomiting of a watery fluid. On the other hand, a difference must be made between car- dialgia and gastrcdgia, and they must not be used indiscriminately for each other, as is done by the older writers. The latter is a diffuse pain in the stomach ; the former is a pain limited, as its name denotes, to about the situation of the cardia, at the line of junction between the body of the sternum and the ensiform process at the level of the sternal attachment of the seventh rib. But when the heartburn is especially pronounced, whether along the entire course of the oesophagus or only at the cardia, or whether only sour masses are regurgitated into the mouth without causing any marked burning sensation in the cesophagus, it is always important to en- deavor to ascertain its exact nature, and to distinguish sharply between the sour masses whose acidity is due to the products of fermentation and putrefaction (acetic acid, fatty acids, lactic acid) and such as owe their taste to an exaggeration of the normal acidity of the gastric juice (i. e., to a hypersecretion of hydrochloric acid), and finally from those somewhat paradoxical cases in which, in spite of the symptoms of pyrosis, as shown by MacNaught,* the acidity and condition of the stomach contents are normal. It is only the first of these forms (which had been described by Graves as long ago as 1823) which is to be considered as belonging to chronic gas- tritis ; the other two forms are to be classed with the neuroses of the stomach. In the latter conditions there may sometimes be such an intolerance toward acids that, as Talma *f* has observed, the ad- ministration of solutions of hydrochloric acid of normal or even subnormal acidity may produce the symptoms of pyrosis and car- dialgia in nervous persons. Vomiting is of very irregular occurrence ; the condition of the vomited masses depends on the stage of the disease, so that the amount of digestive and putrefactive products contained in them varies a great deal. Xausea and even trismus usually precede it. The appetite is either slight or may be lacking entirely; yet the * MacNaught. Med. Chronicle [Manchester], January, 1885, t Talma. Ueber Behandlung von Magenkrankheiten. Zeitschrift fur klin. Med., Bd. viii, p. 407. ATONY OF STOMACH. 211 good and bad phases alternate, so that in the former the patients often easily commit dietetic errors and cause fresh irritation. Many patients go to the table with good appetites, but the first few mor- sels satisfy their cravings; others verify the saying, "Happetit vient en mungeantP While in the latter there is just enough irritation to stimulate the glands to secretion, in the former it is too much for the irritable mucous membrane, and may check the secretion by causing an abnormal hyperaemia. Without being really thirsty, most patients crave some sour drink or fluids, especially while eat- ing. Soon after a meal they feel oppressed and bloated; they do not complain of a true spontaneous pain in the epigastrium; it is more of a choking, a vague sensation which only becomes a slight pain on pressure over the stomach. True gastralgiae do not belong to the ordinary symptoms, and their occurrence should al- ways lead us to suspect the presence of other lesions. The patients very frequently have the feeling that the food remains abnormally long in the stomach, and they often describe very effectively the vain efforts of the oppressed viscus to drive the ingesta on into the intestines. In fact, finally, these conditions may be combined with weakness of the gastric muscular wall—atony of the stomach—which in turn causes a lengthened stay of the food in the stomach. As a result, decomposition takes place in the ingesta ; the carbohydrates fer- ment ; the albumenoids putrefy—a condition which Escherich has called "alkaline fermentation." This produces distention of the stomach with gas, eructation of offensive gases, and regurgitation of sour and rancid masses. The distention of the stomach in turn paralyzes its muscular fibers and causes a feeling of tension and pain ; the decomposed or insufficiently digested stomach contents irritate the intestines, and the conditions thus produced are reflected back to the stomach, and thus the vicious circle which is present in all affections of the stomach is completed. I shall show how these conditions may finally lead to dilatation or true gastrectasis (pp. 276 et seq.) ; here I wish to simply add that these decompositions usually occur toward evening ; in the morning they may be absent or only very slight. The conception and the term atony of the stomach have been 212 DISEASES OF THE STOMACH. used so long in the pathology of the stomach that the attempts of Von Pfungen * to describe a new disease under this title do not seem to me to be justifiable. If by the term atony we understand, as its name denotes, a deficiency in the muscular tone, and as a result an insufficient muscular activity, a mechanical or muscular insufficiency of the stomach, then it is not proper for certain writers to also include disturbances of the glandular secretion. Atony arises either primarily or secondarily. Primary atony is, in my opinion, a neurosis, and is always a rarity. Secondary atony is associated with nearly all affections which involve larger areas of the gastric mucous membrane ; in fact, we may say that the first marked objec- tive symptoms are usually due to the atony, since before the tone of the organ is lost the damage done by an insufficient secretion or in- complete absorption is compensated by the muscular fibers of the stomach—that is, the chyme is still properly expelled into the intes- tines. But it also occurs in conditions of general debility which lead to torpor and insufficiency of individual organs as well as of the gen- eral metabolism; hence it is especially frequently observed in the initial stages of rickets and scrofula in children, and also in phthisis, chlorosis, etc. The large, distended abdomens of scrofulous chil- dren are classical proofs of this. Here there is an atony of the stomach and intestines which leads to manifold disturbances of digestion and nutrition, and causes the dilatation of the stomach which occurs sooner or later, as I have already stated. In these cases the atony is never a primary lesion, but is always the result of a general dyscrasia. It is only primary in so far as other diseases of the stomach arise from it. Therefore, atony of the stomach de- serves an important place, as was first shown by Kosenbach,f and still more completely applied in every direction by Von Pfungen in the work cited above ; and the more so because the primary forms with their mechanical changes influence the chemical and other functions as well as those of motion. I will not now enter into an irrelevant discussion to which some investigations have led as to whether there is a separate disturbance of the peristalsis of the fun- * R. v. Pfungen. Ueber Atonie des Magens. Wien, 1887. + Rosenbach. Der Mechanismus und die Diagnose der Mageninsufficienz. Volkmann's Klinische Vortrage, No. 153. CONSTIPATION IN CHRONIC GASTRITIS. 213 dal or pyloric portions of the stomach ; the result is the same, so far as we are now concerned, but I will consider this in greater detail when speaking of atony as a nervous condition. For in the present cases the atony is only a secondary pathological process, and is only to be regarded as a symptom, and not as an independent disease. There are constitutional reasons why it appears early in some and later in others ; why the course is mild or severe, and why its origin may even be traced back to childhood in some cases {vide reports of Wiederhofer, Kundrat, Comby, and others). But whether the atony is primary or secondary, it leads in all cases to a relaxation and distention or even a dilatation of the viscus, which, as Poensgen has observed, other things being equal, occurs the more readily the more relaxed the anterior abdominal wall is and the less support afforded by it to the stomach. [Boas and others group atony of the stomach among the gastric motor disturbances as insufficiency of the stomach. See Chapter VI, on Dilatation of the Stomach. Some authors, such as Boas,* assert that the motor functions are normal or even increased in chronic gastritis, and that rarely, and then only in long-standing cases, is it lessened. He claims that he has never seen a true dilatation follow chronic gastritis. Be this as it may, it is very important to consider the motility of the stomach in all cases of chronic gastritis, especially in reference to treatment.] Constipation exists, as a rule ; exceptionally the evacuations are regular; in a few cases diarrhoea and constipation alternate ; if haemorrhoids are present, as frequently happens, the movements are painful. The stools are sometimes light colored, sometimes dark green, or they may be very offensive and contain undigested food. The patients have the sensation that the evacuations are in- complete, and suffer much from flatulence and rumbling in the abdomen, which is sometimes loud enough to be heard at a distance. Often, instead of true faeces, the stools are watery or slimy, as a re- sult of the irritation of the intestinal mucous membrane by hard scybalae ; for if the rectum of these patients be examined, it will be found full of hard masses, which can not be expelled on account of the paresis of the muscular fibers of the gut. * [Boas. Magenkrankheiten. Bd. ii, 2te Auflage, p. 21.—Ed.] 214 DISEASES OF THE STOMACH. The urine is scanty, deposits urates abundantly, and is at times alkaline from basic salts. Unfortunately, as yet wre have no exact investigations to show how the disturbances of the metabolism are manifested through the kidneys, although in connection with our recent knowledge of the formation of alkaloids in the organism this would seem to be a very promising field for investigation. Emaciation occurs soon, and is the more marked and earlier in its appearance the stouter the patients have previously been ; losses of 15 to 25 kilogrammes [33 to 60 pounds] may often occur in a few weeks. In older patients this may occasion the gravest suspicions as to the nature of the illness, which may only be cleared up by the subsequent course of the disease. Among the general symptoms we notice a diminution of mental activity, disinclination to bodily exertion, languor during the day, especially after meals, headache or a feeling of oppression in the head, and a morose, irritable disposition. In some patients the head- aches are only relieved after vomiting slimy, bile-stained masses ; in others they are accompanied by a burning sensation in the stomach, or " stomach cramps," which may occur periodically for years; such attacks may even date back to early youth. In one of my patients there was a distinct hereditary factor (grandfather, father, brothers, and sisters). The patients frequently complain of a feeling of heavi- ness in every limb, cold extremities, itching, and formication. Sleep is deep and longer than usual, but is not refreshing, and is disturbed by hideous dreams. Yawning is frequent, and is accompanied by an unpleasant sensation of puckering in the mouth and an increased flow of saliva. The patients "hack" very frequently, and expec- torate tenacious mucus containing dark particles. This is the so- called " stomach cough of dyspeptics," which of course has no more to do with the stomach than that the pharyngeal catarrh which causes it is usually due to the same factors as the gastritis—i. e., abuse of irritating substances, especially alcoholic beverages.* At all events, it may happen that the already inflamed pharyngeal mu- * The existence of a true " stomach cough " has not yet been proved—that is, a reflex act starting from the mucous membrane of the stomach and causing acts of coughing. Such eminent authors as Naunyn [Deutsch. Archiv fiir klin. Med., 1879, Bd. xxiii], Nothnagel, and Edleffsen [ibid., 1877, Bd. xx] directly deny it. DYSPEPTIC ASTHMA. 215 cous membrane may be irritated by the regurgitation of the acid stomach contents, and thus may cause cough reflexes to be sent out from the crossing of the oesophagus and bronchi. Such " coughs " usually disappear after neutralizing or lessening the acidity of the stomach contents. The pulse is small and weak, sometimes intermittent, and this irregularity of the heart action is felt by the patient as palpitation. Some patients have a certain characteristic odor which is also com- municated to their underwear, and with each exacerbation this odor becomes stronger. Evening rises of temperature may also be ob- served in this disease, and have indeed required antipyretic treat- ment, and have even been mistaken for typhoid fever [or malaria].* All of the above symptoms will not be found in all cases nor even in the majority of them. Sometimes one, sometimes another symptom will predominate and characterize the clinical picture. Thus some patients complain only of the distention of the abdo- men and marked dyspnoea, and we have the group of symptoms described as dyspeptic asthma {asthma dyspepticum). Others are annoyed especially by the cough, loss of appetite, acid regurgitation, choking and burning sensation in the abdomen. In still others, the irregular heart action, palpitation, irregular and intermittent pulse are especially prominent and may arouse suspicions of organic car- diac disease. These symptoms occur especially during digestion, are complicated by pulsation in the epigastrium, but are less marked when the stomach contents pass into the intestines or when the ten- sion is lessened by belching up gas. A variety of this ccerdiac dys- pepsia, which had already been described by Henoch,f has been especially studied and published by Eosenbach.-j: (See Chapter X, on the Gastric Neuroses.) But common to all patients is the very A case of paroxysmal coughing proceeding reflexly from the gastric mucosa has been published by E. Bull, Deutsch. Archiv fur klin. Med.. Bd. xli, S. 472. [Brun- ton (Disorders of Digestion, p. 40) believes that stomach-coughs are due to the association of mild inflammatory conditions of the upper passages with the pres- ence of some irritant in the stomach.—Ed.] * [On the other hand, cases not infrequently occur in which the dyspeptic symp- toms, gastralgia, and vague fever disappear promptly on the administration of anti- periodic remedies.—Ed.] f Loc. cit., p. 391. X O. Rosenbach. Neurose des Vagus bei Dyspepsie. Deutsch. med. Wochenschr., 1879, Nos. 42 and 43. 15 216 DISEASES OF THE STOMACH. slight tenderness on pressure or spontaneous pain in the epigastrium and the chemical changes in the digestive processes. Here I may also mention that peculiar condition first described by Trousseau as vertigo gyrosa or vertigo e stomacho laeso {vertigo stomachalis), gastric vertigo, and also discussed at about the same time by Briick, of Osnabriick,* as Schwindelangst ("vertigo-fear"), aura vertiginosa; this subject has since been carefully studied by Blondeau, Kiemeyer, Von Basch, Westphal, Cordes, Eyselein, and others. But Trousseau deserves the credit of having first directed attention to the relation of these attacks of vertigo with chronic catarrhal gastritis. They occur without loss of consciousness, begin usually some time after eating, although sometimes they may be checked by taking food, but can not be produced either by rapid circular movements or by inclining the head forward, or similar motions. The attacks pass away after remaining quiet and regu- lating the diet, but are usually followed by severe headaches. Some- times these attacks assrme the form of the agoraphobia, and have been described as such by the writers last mentioned above. Here the patients experience an indefinable terror; they may even be unable to go alone over large open fields, places, or broad streets, either avoiding crossing such places entirely or seeking company even of strangers. Granting that these conditions actually belong to or border upon the mild psychoses, yet they must not be re- garded as neuroses of the stomach in the sense that there is a dis- ease of this organ due directly or indirectly to the nervous system. On the other hand, they must be considered reflexes from an organic disease of the stomach upon the brain, and are thus to be sharply differentiated from the conditions to be presently described as nerv- ous dyspepsia. We may accept the explanation of their origin pro- posed by Mayer and Pribram, that the arterial pressure in the cere- bral vessels is raised by the reflexes from the walls of the stomach, or the assumption of Bernstein and Asp, that they are due to an irri- tation of the splanchnic. The following cases may be cited, since these conditions are not common. The patients were middle-aged men, for it usually occurs * Briick. " Vom Schwindel." Hufeland's Journal, Bd. xvii, St. 5. ATROPHY OF THE GASTRIC MUCOSA. 217 in such patients, although the ages of the 51 cases collected by Cordes * vary between nineteen and forty-seven years. Common to all of them is the chronic catarrhal gastritis, and the disappearance of the agoraphobia after this was cured. The first case was a captain, who, while complaining to me that he suf- fered from mild local gastric troubles and occasional slight headaches, said that for some time he had also experienced real terror when walking or riding over large, open places to such an extent that he was unable to cross the parade ground alone; if be did succeed in riding over it, when halfway across he was seized with such terror that he had to dismount, and that then, while leading bis horse by the bridle, he could proceed without any further trouble. The second case also happened to be a military officer, on duty at the ministry of war, who said that he had the greatest fear of a smooth level area on which there was no resting-place for the eye. Thus he could not go alone through large, empty rooms with hard-wood floors, and that it was especially disagreeable to him to walk on the smooth asphalt pave- ment, so that he either made detours or sought company. The third case was a government employe who had to pass over an open square every day to reach his office; at first, while crossing this, a feeling crept over him that it was impossible to reach the other side, and that the ground shook under him. If he attempted to force his way, after a few steps he was attacked with such vertigo that he feared he would fall, and had to give up the attempt. In all these cases this psychosis disappeared entirely as soon as the gastric symptoms were cured by suitable treatment. In the course of time I have seen a number of such cases in which it has usually been difficult to determine whether the gastric disturbances were the cause or a sequel of a general neurosis. " Theater-fear " {Theaterangst) seems to be a very frequent form of agoraphobia ; it attacks the patients in theaters, concert halls, the circus, meeting places, etc. ; they can only sit close to the door or keep on a level surface, and even then they may be overcome after a little while so that they must rush out into the open air. Such attacks, however, often depend upon the stomach, for not infre- quently they may be checked by eating a piece of bread or chocolate or by taking a swallow of strong wine or cognac. [It is often diffi- cult to distinguish these cases from gastric neurasthenia.] A very interesting feature is the final stage of chronic catarrhal gastritis already spoken of as atrophy of the mucous membrane, or * Westphal's Archiv, Bd. iii, S. 521; also Bd. v. 218 DISEASES OF TnE STOMACH. better, anadenia [avd, without; a^rjv, gland] of the stomach {Ana- denie des Magens), since this is not so much a disturbance of nutri- tion which spares the structure of the tissue ; it is rather a process which causes a complete destruction of the glandular parenchyma, and whose gradual development has been designated phthisis mu- cosae by G. Meyer; it has also been improperly called gastric phthisis. [These cases have been included by Einhorn* under achylia gastrica.'] This process may be partial or complete ; it assumes importance only in the latter case, since the destruction of circumscribed areas in the former may easily be compensated by the rest of the paren- chyma. According to the anatomical details of the lesion already given, we observe a progressive loss of secreting elements which must finally lead to a total abolition of secretion ; and with this the digestive activity of the stomach is gradually and irrevocably de- stroyed. The consequences of this process are self-evident. After a longer or shorter period, marked by dyspeptic complaints, so severe a disturbance of the nutrition is developed that the patient literally pines away " like a lamp the oil of which has not been replenished," and finally dies of marasmus. At all events, we now possess sufficient clinical data to show that the intestines may act vicariously for the stomach, and may assume the entire task of as- similation of the nutrition. During the period of compensation the general condition of the patient will depend entirely upon the extent to wmich the motor functions of the stomach—i. e., its ability to forward its contents on into the intestines—are preserved; in other words, whether the muscular fibers are intact, paretic (dilatation), or have increased power. But this seems to be limited to a definite time, which varies in different individuals ; for sooner or later pathological processes also attack the intestine and abolish its activity, either on account of the extra work imposed upon it, or other accidental causes. As the observations of Jiirgens, Blaschko, Sasaki, and Eisenlohr \ have * Einhorn, loc. cit, and Boas' Arch., Bd. i, p. 158. A careful study of this con- dition, together with exhaustive bibliography, has been given by Stewart, Amer. Journ. Med. Sciences, 1895, vol. ex, p. 560.—Ed.] t Eisenlohr. Ueber primare Atrophie der Magen- und Darmschleimhaut. Deutsch. med. Wochenschr., 1892, No. 49. ATROPHY OF THE GASTRIC MUCOSA. 219 shown, there is finally also an atrophy of the intestinal walls which manifests itself in a degeneration of the muscular layers, the nerv- ous apparatus, and atrophy or fatty degeneration of the mucosa. Now are added the symptoms of insufficient regeneration of blood, a picture which may simulate progressive pernicious anaemia, unless there has been such a gradual failing of the faculties that death may be said to have resulted " from old age." For I have frequently convinced myself at the autopsy table that in many of the cases said to have died from old age there has actually been an extensive ana- denia, usually combined with dilatation of the stomach. When the compensatory action of the intestines suddenly ceases a fresh dis- ease apparently breaks out. I have repeatedly seen such cases after an acute febrile disease, such as influenza, febrile bronchial catarrhs, etc.; they are suddenly followed by a group of symptoms which can only be regarded as the result of anadenia. A number of these cases progressively became worse and died of almost complete an- orexia ; in several of them there were gastralgic symptoms and per- versions of taste (e. g., a continual fecal taste). The diagnosis was confirmed at the autopsies. The conditions which prevail here can not be different than in other viscera ; at least, we know of no associated organs with vege- tative functions which are of great importance to the economy where one could replace the other for an indefinite time. Of course, we know that it can be done for a short period, but not beyond that; it is true of the lungs as well as of the kidneys. The same occurs in the individual sections of the digestive tract, and just as it is impossible to nourish a person indefinitely per rectum, so the stomach can not permanently lie idle ; for it is not merely a place for digestion and disinfection, but it is also an organ of vital im- portance. The association of these atrophic conditions with severe anae- mias indirectly brings them into relation with certain changes in the spinal cord which have been discovered by Lichtheim.* The latter consist of scattered miliary foci, or, when more marked, of extensive degeneration of the posterior columns and other parts of * Lichtheim. Verhandl. des Congresses fiir innere Med., 1887. [See Fleiner, Boas' Archiv, Bd. i, p. 249.—Ed.] 22u DISEASES OF THE STOMACH the cord. The similarity of the symptoms to those of pernicious anaemia has already * been noted by Fenwick,f Bartels,*{; Scheper- len, * and Osier. || RosenheimA has observed two cases which seemed to be pernicious anaemia. Inasmuch as these cases also have marked changes in the blood, alterations in the red corpuscles, relative increase of the white, and the formation of macrocytes and microcytes, the question may arise whether pernicious anaemia is really an independent disease or is the result of anadenia of the stomach; but in the cases of pernicious anaemia described by Quincke, and also by Immermann, the changes found in the stom- ach were insignificant as compared with the intensity of the symp- toms. A striking feature which has been observed by several writers (Fenwick, Ewald, and Nothnagel) is the good condition of the subcutaneous fat, which, however, is not often found in dis- ease of the blood, in consequence of the lessened thoroughness of oxidation. Naturally, this variety of chronic gastritis is especially frequent in older persons, since the compensatory and reconstituent powers of the tissues are greater in the young. Most of the cases have been over forty years of age, and in the two young patients, eighteen and twenty-one years old, reported by Litten {) and Einhorn, the diagnosis was not verified by autopsy. Under favorable conditions—i. e., sufficient compensation—the disease may last many years, as shown in a case described by Ein- * [Austin Flint was the first to call attention to the relation between anaemia and atrophy of the gastric glands. He expressed the opinion that some cases of obscure and profound anaemia are dependent upon degeneration and atrophy of the glands of the stomach. See American Medical Times, 1860; New York Medical Journal, March, 1871; Flint's Practice of Medicine, Philadelphia, 1881, p. 477.— Quoted by Welch, loc. cit, p. 616.—Ed.] f S. Fenwick. Loc. cit. X Bartels. Ein Fall von pernicioser Anamie mit Icterus. Berliner klin. Wochenschr., 1888, No. 3. 9 Scheperlen. Studier angaaende Anasmie. Nord. medic. Arkiv, 1879, Bd. xi, No. 3. || Osier. Atrophy of the Stomach with the Clinical Features of Progressive Pernicious Anaemia. American Journal of Med. Sciences, 1886, No. 4. A T. Rosenheim. Loc. cit. 0 M. Litten und Rosengart. Ein Fall von fast vOlligen Erloschen der Secretion des Magensaftes. (Atrophie der Magenschleimhaut der Autoren.) Zeitschrift fiir klin. Med., Bd. xiv, S. 573. DIAGNOSIS OF CHRONIC GASTRITIS. 221 horn.* [A number of cases of long duration and occurring in per- sons under forty years have since been reported.] But in this case, as in all the other cases which were first described, the observers have only calculated the amount of free HCl, and not the total IIC1 as well; thus we are uncertain whether there was a complete cessation of glandular function exerted or not. [In later reports on this and other cases Einhorn states that combined HCl was also always absent.] Diagnosis.—The objects of the diagnosis are, first, to differen- tiate chronic catarrhal gastritis and its results from other diseases; and, secondly, to distinguish its varieties from one another. The disease occurs so frequently as an accompaniment of the most varied local affections of the stomach that I will disregard its sec- ondary occurrence and restrict myself to the genuine varieties. From the description of the symptoms already given it may readily be inferred that the diagnosis of such a true gastritis can only be made by exclusion—that is, after having shut out all the other or- ganic and functional disorders of the organ. An idiopathic gastri- tis can only be diagnosticated after ulcer, carcinoma, dilatation, neuroses, or any of the acute disorders already described has been excluded. What is left is gastritis; but just as readily as the diag- nosis " chronic gastric catarrh " is made, just so little is such an offhand opinion justified in many cases, for the symptoms of chronic gastritis may at times simulate any of the above-mentioned disorders, and neither the duration, nor the etiology, nor the kind of dyspeptic manifestations will suffice to make the diagnosis at once, but in addition there must be a careful examination with the aid of all our modern diagnostic resources. The diagnosis of chronic gastritis having been made in this way, the next step is to determine which variety we have before us. Our only means for this purpose is the examination of the stomach contents. The re- sults of these may be grouped as follows : 1. Simple chronic gastritis. While fasting, the stomach con- tains only a small quantity of a watery, mucous fluid, frequently * Einhorn. Achylia gastrica. N. Y. Med. Record, June 11, 1892. 222 DISEASES OF THE STOMACH. tinged yellow or yellowish-green by bile, and sometimes mixed with duodenal contents. On standing, it deposits a sediment con- taining epithelial cells of various sizes and shapes, numerous round cells and free nuclei, also small quantities of remnants of food, starch granules, muscle fibrillae, and vegetable cellular tissue. After the test breakfast the acidity is variable but never increased; the quantity of hydrochloric acid is lessened. Pepsin and rennet are small in amount, but form propeptone and peptone even in the stomach; can digest [in artificial digestion] after acidulating. 2. Chronic mucous gastritis. This differs from the simple form by the abundance of mucus in the contents of the stomach while fasting and after taking food, so that acetic acid always gives a marked mucin reaction. Acidity always low. Hydrochloric acid usually absent. Propeptone very abundant, peptone only in traces. Digestion [in the test tube] occurs only after adding hydrochloric acid, and is slow even then. Curdling by rennet is tardy or absent. In the wash-water after lavage small, bloody fragments of the epi- thelial covering of the mucous membrane may occasionally be found. 3. Atrophy. This differs from the two varieties already named in that while fasting the stomach is usually empty, and that the chyme expressed after the test breakfast contains neither mucus, hydrochloric acid, pepsin, nor rennet ferment. [The stomach con- tents obtained after the test breakfast are very characteristic in ap- pearance. The pieces of the roll are unchanged and are not at all digested; the amount of fluid is small, and hence it is often quite difficult to express the stomach contents. Rennet zymogen is some- times found when all other kinds of ferment are absent.] At all events, some caution is required in determining the absence of pep- sin. Jaworski properly calls attention to the fact that the simple addition of a few drops of hydrochloric acid to gastric contents con- taining none of this acid, before trying artificial digestion in the test tube, is not sufficient to determine the presence or absence of pepsin. On the contrary, enough acid must be added till the color tests indicate the presence of free acid; only then will the positive or negative results of the digestion experiments be decisive. For a long time I have used no other method, and I confess that I have always considered the procedure self-explanatory. Now, as hydro- DIAGNOSIS OF CHRONIC GASTRITIS. 223 chloric acid is a decided stimulant for the secretion of pepsin, or rather for the transformation of pepsinogen into pepsin, it is advis- able to follow Jaworski's suggestion in cases of deficient hydro- chloric-acid secretion where we wash to be certain of the absence of this ferment: 200-300 c. c. [f 5 vjss. to x] of diluted hydrochloric acid [decinormal HCl solution] are administered [through the stom- ach tube after having washed the viscus], and half an hour later the stomach is siphoned. The fluid is then tested as to its digestive powers, and by using suitably diluted portions we may obtain an approximate idea of the amount of pepsin present.* Naturally, no tissue elements of the glandular parenchyma are to be found in the contents of a totally atrophied stomach ; a few degenerated round cells and micro-organisms may be all that is found. [Fragments of tissue have been found in the wash-water in lavage by Cohnheim and others.] The absence of haematemesis or of blood in the stomach contents is characteristic of anadenia. I have never encountered the latter. These differences will generally enable us to distinguish the several varieties of the disease. Yet, as already stated, there are intermediate forms, especially between the simple and the mucous, which can not be definitely classified. However, the greatest diag- nostic difficulty is encountered in differentiating atrophy of the stomach from the cases of gastric neuroses and carcinoma, accom- panied by complete loss of secretion. From the neuroses it may be distinguished, as a rule, by the fact that these occur usually in mid- dle-aged or young persons, and that their course is irregular, while atrophy occurs in older persons and is permanent. The chemical differentiation of carcinoma and atrophy is much more difficult—that is, where the ordinary symptoms of the former, tumor, swelling of the lymphatic glands, cachexia, and haemate- mesis, are absent; because in both hydrochloric acid, pepsin, and rennet may be absent. But, as I have already said, atrophy leads to a gradual extinction of the gastric functions without the severe * Jaworski. Zur Diagnose des atrophischen Magenkatarrhs. Verhandlungen des vii. Congresses fiir innere Medicin. Wiesbaden, 1888. [A good description of this method will be found in Stewart, Amer. Jour. Med. Sciences, vol. ex, p. 563.— Ed.] 221 DISEASES OF THE STOMACH vomiting and gastralgia which occur so often in cancer. Another symptom has been of service to me; at all events, it is also a very valuable point in the diagnosis of cancer. I refer to the bloody color of the stomach contents, due to the presence of altered blood pigment, which is frequently observed in carcinoma, even where there has been no haematemesis. So far as I know at present, this never occurs in anadenia of the gastric mucous membrane. Course and Prognosis.—The long duration of chronic gastritis is indicated by its name. This is especially due to its tendency to relapses, or, more properly speaking, exacerbations; for even in apparently cured cases the organ is left in such a sensitive condi- tion that the slightest irritation, or a deviation from a specified diet, may cause a fresh attack. Therefore the prognosis of the dis- ease should not be considered too slightingly, especially as in pro- longed cases atrophy, an incurable and fatal lesion, may be devel- oped. A large number of the cases which are usually said to have died of old age really perish from gastric atrophy; but it is gen- erally not recognized, since its symptoms are as yet not well known, and because the macroscopic changes in the stomach are not marked. Finally, there is another reason why the significance of chronic gastritis is not to be underestimated, namely, the dis- turbances of nutrition and the resulting deterioration of the tissues render the organism less resistant toward, and more susceptible to, a series of other poisons, of which I shall only mention tuberculosis and acute articular rheumatism. As certain as it is, on the one hand, that tuberculosis leads to gastric catarrh, so probable is it, on the other, that even though the latter does not produce the predis- position for the former, yet if the stomach trouble is once present it favors and increases the advance of the tubercular infiltration. Treatment.—Our remedies must be divided into three groups: (1) those which aim to directly replace the deficient supply of gas- tric juice ; (2) those which are to stimulate the depressed functions of the organ ; (3) those which are capable of counteracting the irri- tant substances introduced from without. The first class includes the use of hydrochloric acid, pepsin, and of TREATMENT OF CHRONIC GASTRITIS. 225 the so-called peptogenous substances. The therapeutic employment of the latter depends on the well-known claims of Schiff and Herzen of the effects of certain (peptogenous) substances (bouillon, dextrin, breadcrumbs); * but, as I have already shown, this peptogenous, or rather pepsinogenous, action of these substances depends only on the stimulation of the gastric glands, such as is exerted by all kinds of nutritious substances; the stomach is filled with active digestive substances, the peptic power of which must be of assistance to the ingesta which are swallowed later. Still, Dujardin-Beaumetz f has proposed an elixir peptogene, which consists of 10 parts of dextrin, 20 of rum, and ISO of sugar water; and Labastide \ attributes to peptone enemata the power of at once relieving obstinate anorexia by the administration of peptogenous substances. Hydrochloric acid is of the greatest importance in the treat- ment of chronic gastritis, because it not alone replaces the deficiency in the secretion and forms acid albuminates so essential for pep- tonization, but also because it prevents abnormal fermentation, or lessens it if already present. Apparently in relation to such fer- mentations even Heberden says, uPotus acidi non semper nocent aegris acore ventriculi laborantibus nonnunquam etiam auxilio sunt.'1 * Pemberton says the same. As this checking of fer- mentation is due to hydrochloric acid alone, it is wrong for some writers to recommend lactic or citric acid instead of it, for they have no such antifermentative action. In all cases where a diminu- tion or absence of hydrochloric acid has been determined—i. e., in all cases of chronic gastritis—it is therefore to be given, preferably as the dilute hydrochloric acid of the pharmacopoeia || in large quan- tities, and certainly in larger doses than have thus far been recom- mended. Jaworski was the first to show, what daily experience has since proven,A that considerable quantities of hydrochloric acid * Ewald. Klinik, etc., I. Theil, 3te Auflage, S. 108.—A. Herzen. Altes und Neues iiber Pepsinbildung, Magenverdauung und Krankenkost. Stuttgart, 1885. f Dujardin-Beaumetz. Journal de therap., 1880, p. 828. X Labastide. Gazette d. hopit., 1883, p. 332. * Quoted by Budd, loc. cit, p. 424. || [Acid, hydrochlor. dil. (Ph. Germ.) has 25 per cent pure HCl.—Ed.] A Loewenthal (Berl. klin. Wochenschr., 1892, No. 47) went to the unnecessary trouble of proving this over again. 226 DISEASES OF THE STOMACH. may be introduced into the stomach without harm; therefore, I order it in as concentrated a watery solution as possible—i. e., as sour as the patient's mouth will tolerate—to be taken three or four times, at fifteen minutes' intervals, after the meal; a glass tube should be employed, as the prolonged use of the acid affects the teeth. It is still better to pour 200 to 300 c. c. [ 5 vij—x] of a •1 to -5-per-cent. solution of HCl directly into the stomach tube, provided the patient has become accustomed to the tube. I had repeatedly done this with very good success in obstinate catarrhs.* Pills may also be made with bolus alba (Ph. Germ.) [argilla] and a few drops of dilute muriatic acid; five or six of these may be or- dered at a time, to be taken with a glass of water. But if one has obtained a clear conception of this subject, it will be seen that these small doses are like pouring drops of water into the sea. I have prescribed this remedy for months at a time without any bad effects. Pepsin was for a long time regularly prescribed with the muri- atic acid, with the pernicious idea that even if it did not help, it certainly did no harm. To-day, however, we know that pepsin is present in a very large number of cases even when free hydro- chloric acid is absent, and that, as shown by Jaworski,*f* and as I can corroborate, pepsin can be extracted from the glands of the human stomach by means of this acid. We should therefore restrict its administration to those cases in wdiich its absence can be actu- ally proved—that is, to cases of advanced mucous catarrh and of atrophy. It is then to be given in large doses, 0*5—1*0 gramme [gr. vijss. to xv], preferably dissolved in water acidulated with hy- drochloric acid, fifteen to twenty minutes after eating; for, even though small amounts of pepsin are said to liquefy large quantities of albumen, yet the artificial pepsin preparations contain a consid- erable amount of milk sugar; and further, only a portion of the pepsin is active, because a part of it is soon carried on into the in- * Ewald. Zur Therapie der Krankheiten der Verdauungstractus. Berl. klin. Wochenschr., 1892. t W. Jaworski. Die Wirkung der Sauren auf die Magenfunction des Menschen. Deutsch. med. Wochenschr., 1887, Nos. 36-38.—Also, Methoden zur Bestimmung der Intensitat der Pepsinausscheidung. Miinchener med. Wochenschr., 1887, No. 33. TREATMENT OF CHRONIC GASTRITIS. 227 testines. In cases of complete absence of hydrochloric acid it would seem rational to administer pancreatin or papoid.* How- ever, experiments made under my direction, by Dr. Haafewinkel, showed that the various preparations of pancreatin which were given with the test breakfast had no stimulating effect on its diges- tion. [If pepsin is to be used, the best preparations are the various glycerin extracts which have been placed upon the market. It ought to be prescribed alone, for if combined with HCl and many other substances which have been recommended, such as alcohol (elixirs and wines of pepsin), the activity of the ferment is soon de- stroyed. Pineapple juice contains a proteolytic ferment (bromelin), and hence may be of service in chronic gastritis.f] The object of the second class of remedies is to increase the activity of the glands. Pre-eminent in this group is lavage of the stomach, which, excepting in dilatation of the stomach, has no- where done more good than in chronic gastritis. This is true of the simple, and especially of the mucous, variety. It is well to com- bine the stomach douche with the lavage; this is continued till the wash-water runs off perfectly clear, and then a quantity of water or medicated solution may be left behind in the stomach. At first we use clear warm water, which may be replaced at the conclusion with an alkaline or antiseptic solution, as the case may demand. The former is employed where mucus is abundant, the latter for the fermentative processes. The great advantage of the tube is that we can introduce much larger quantities of unpleasant or irritating substances than would be possible by the mouth, be- cause they can be removed at once. It is best to prescribe the medicament which is to be employed in the lavage in the form of powders, one of which is to be added to a litre [quart] of warm, boiled water. Thus we may order: * [Finkler. Comparative experiments between the action of papoid and pepsin. Therapeutic Gazette, August 15, 1887. Grote. Klinische Erfahrungen iiber die ^Yirkung des Papains bei Magenkrankheiten. Deutsch. med. Wochenschr., Julv 23, 1896.—Ed.] f [Takadiastase is an amylaceous ferment which has been recently recommended to aid in the digestion of starches in cases of so-called " buccal dyspepsia." These cases seem to me to be forms of hyperchlorhydria.—Ed.] 228 DISEASES OF THE STOMACn. Sodii bicarbonas........ 7*5 to 10*0 [ 3 i to £] Sodii carbonas.......... 10*0 [Si] Acid, salicylici.......... 1*0 to 3*0 [gr. xv to xlv] Thymol............... 0*5 [gr. vijss.] Acid, boric............. 10*0 [ I £] Sodii biboras........... 15*0 to 20*0 [ I £ to |] Of the liquid preparations we may use: Liq. argenti nitras, 50 c. c. [5 If] of a 2-per-cent solution may be added to a litre [quart] of distilled water.* We may also employ Aq. chloroformi, 1im)0*0 ; if we wish to prepare it freshly, we may prescribe : 1> Chloroformi................... 50*0 [ I jf] Aq.......................... 1000*0 [Oij] M. Sig. : Shake well several times during the day and use the supernatant liquid for lavage. Kresin may be used in 0*5-l*0-per-cent solution, and is preferable to creolin and similar preparations because its odor and taste are less marked. [Hydrogen peroxide has also been recommended by some. I have obtained no special results with it.] Even after a relatively small number (eight to ten) of washings a marked improvement in the local process and a great relief to the patient may be observed. I could cite a large number of cases to corroborate this, but I shall not do so, because there is nothing characteristic about them; yet I repeat, that cases which have re- sisted the usual methods of treatment for months, and even years, have been greatly relieved and even cured by lavage in a relatively short space of time, this treatment having been of course accom- panied by other suitable therapeutic measures. When the condition of the patient prevents a systematic use of the tube—the patients no longer object to the much-abused " stom- ach pump," now that the public is better informed of the necessity of the modern methods of examination and treatment of gastric disorders—I replace it by ordering large quantities, up to half a litre [pint], of a 1-per-cent solution of common salt at 42° C. [107*5 * [Nitrate of silver may also be applied to the gastric mucous membrane with Einhorn's gastric spray. (N. Y. Med. Journal, September, 1892). The empty stomach is washed out with lukewarm water, and § \ of a -fa to -ft per cent AgNOs is sprayed.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 229 Fahr.], or Wiesbaden Kochbrunnen, or warmed Rakoczy [Kissin- gen] water. The action of lavage consists in the removal from the stomach of remnants of food which have remained there unduly long, and the loosening of the mucus which adheres to its walls, partly chemically, partly mechanically; furthermore, the introduction of the tube, combined with the entrance and exit of the water, in- creases the peristalsis and strengthens the muscular activity, as well as favorably influences the glands, or, as put by Oser, " it produces a healthy reaction." The sodium chloride is certainly not without value, notwithstanding the fact that Pfeiffer has shown that the addition of it in artificial digestion lessens the digestive power. The experiments of Braun and Griitzner, as well as of Boas, agree that the addition of common salt to the blood increases the secretion of gastric juice, and seem to me, for many reasons,* to be more con- vincing than artificial digestion experiments. At all events, the re- sults at Wiesbaden and Kissingen and of daily practice disprove it. As a stimulant of the glandular secretion, we may also employ in- ternal faradization of the stomach (see p. 103), although the tonic ac- tion on the muscular fibers undoubtedly also plays an important part. This much is at all events certain, that I have had perfect success with this method in a number of obstinate cases of chronic gastritis. It must be added, however, that the treatment was faithfully given several times weekly for a long time, together with appropriate drugs and diet; but since the latter had been previously used for a long time without any pronounced good effect, we must accord to the electricity the greater part of the success obtained. The most contradictory views have recently been expressed con- cerning the use and action of the so-called bitters and carminatives. Although these substances formerly enjoyed a high reputation as gas- tric stimulants, yet the experiments of Tscheltzow, Jaworski, Reich- mann, and Stekhoven f show that the bitters only have any specially * Vide Ewald, Klinik, etc., I. Theil, 3te Aufl., p. 99. f W. Jaworski. Experimenteller Beitrag zur Wirkung und therapeutischen Anwcndung der Amara und der Galle. Zeitschr. fur Therapie, 1886, No. 23.— Keichmann. Zeitschr. fiir klin. Med.. 1888, Bd. xiv, p. 177.—Stekhoven. Weekbl. v. Geneesk., 1887.—Tscheltzow, quoted by Tawizki, Deutsch. Arch, fur klin. Med., Bd. xlviii, p. 344. 230 DISEASES OF THE STOMACH good effect upon the secretive and digestive powers of the stomach when they are taken some time before the meal, and even then the effect on the gastric juice is only slight. On the other hand, Terray, Marcone, Tawizki, and Ramm,* partly from experiments on animals, partly from observations on human beings, uphold the old empirical notions that bitters have a decidedly good effect on the motility and secretions of the stomach. Marcone asserts that when intro- duced into the empty stomach they stimulate the secretion of gastric juice; if administered with the food, the period of digestion is short- ened, the gastric juice increased in quantity, and the peristalsis heightened. After section of the vagi in the neck this effect was not obtained; hence there must be a direct action on the mucous membrane of the stomach. However all this may be, all writers agree that there is no marked difference between the various bitters, and that any good therapeutic results which may be obtained must be accepted accord- ing to the views above mentioned. My own belief is that these differences, which also correspond to what is observed in practice, are to be explained according to the intensity and extent of the gas- tritis and the reactive power of the glandular parenchyma. The success of quassia, gentian, kino, calumba, chamomile, vermuth, peppermint, and of condurango bark, has been noted by too many and too good observers than that it should depend upon crude self- deception. I have always been satisfied with quassia and condu- rango, although I usually combine them with hydrochloric acid in such proportion that the solution contains 0*2 per cent of pure hydrochloric acid. The following formulae may be recommended : $ Cortic. condurango............... 30*0 [ 5 j] Macera per horas xij cum aq. 300*0 [f ^ x] Diger. lent, calore ad colatur. 150*0 [f ^ v] Adde Acid, hydrochlor. dilut............ 5*0 [f 3 j£] Syrup, zingiber............... ad 200*0 [f 1 vj 3 vj] M. Sig.: One tablespoonful every two to three hours. * Terray. Wien. med. Wochenschr.. 1891, No. 12.—Marcone. Riforma medica, June 8, 1891.—Ramm, in Kobert's histor. Studien aus dem pharmakolog. Instit. TREATMENT OF CHRONIC GASTRITIS. 231 1$ Tinct. nuc. vomic................. 5*0 [f 3 ji] Resorcin resublimat............... 10*0 [ 3 ijss.] Tinct. gentian................... 25*0 [f 3 vji] Syrup, simpl................. ad 200*0 [f 3 vj 3 vj] M. Sig. : One tablespoonful every two to three hours. An especial action on the muscular tone has always been at- tributed to nux vomica, or its alkaloid strychnine, and belladonna, especially in drinkers and persons with weak nervous systems. This is undoubtedly true, provided we substitute large doses for the customary small ones. I usually prefer to combine the tinctura nucis vomicae with a decoction of one of the above stomachics in such proportin that at least ten drops are in each table- spoonful : Iji Tinct. nuc. vomicae............ 5*0 [f 3 ji] Decoct, condurango............ 150*0 [f § v] M. Sig.: Tablespoonful three to four times daily, half an hour before taking food. Or it may be combined with belladonna, as follows: $ Tinct. belladonnas.............. 5*0 [f 3 ji] Tinct. nuc. vomicae............. 10*0 [f 3 ijss.] Tinct. castor, canadensis *....... 10*0 [f 3 ijss.] M. Sig.: Twenty drops (!) six times daily. We may also follow the English custom and give ipecac in small doses of 2 to 3 centigrammes [gr. ^ to •£] with the extract, nuc. vomicae in the same dose, ordering it in powders thrice daily, half an hour before meals. Alcohol also, according to Klemperer,*!* stimulates the motility, so that the popular belief in the value of " stomach bitters" re- ceives official approval, as it were, although the older investiga- tions, as well as the more recent ones of Klemperer, Hugounang, Georges, Katz, and many others,*}: all agree that it has absolutely no zu Dorpat., Bd. ii, 1890. Here an exhaustive review of the literature of the bitters may be found. * [This preparation was officinal in the U. S. Pharm. of 1870.—Ed.] f Klemperer. Alcohol und Kreosot als Stomachica. Zeitschr. fiir klin. Med., Bd. clxxi, Supplement, p. 324. X Georges. Quelques experiences propres a eclairer la therapeutique de la dys- pepsie gastrique. Arch, de med., 1890, No. 1. 16 232 DISEASES OF TnE STOMACH. stimulating effect upon secretion and the peptic digestion is even retarded by it. [The effect of alcohol on digestion has recently been most elab- orately studied by Chittenden and Mendel.* Their results agree with those of Roberts,f that " in the presence of less than 10 per cent of proof spirit (5 per cent absolute alcohol) there was no ap- preciable retardation of gastric digestion. With 10 per cent of proof spirit retardation was only barely perceptible, while with 20 per cent retardation was quite distinct. Beyond this point the in- hibitory effect of alcohol increased rapidly." In conclusion, they show that the actual effects of alcohol on digestion can not be de- termined from the results of the chemical changes alone, but only when these are combined with the effects on secretion, absorption, and penetration. " JSTot until these points have been thoroughly studied shall we be able to understand fully the action of alcoholic beverages on the whole process of digestion."] Much has been written about orexin, a derivative of chinolin, which Penzoldt has introduced as a true stomachic.*}; Kronfeld # found 101 favorable reports in 176 cases which he could collect from the literature. This does not mean much, because bad results are not published, or, if published, are referred to less than the good ones. Henne || reports that digestion is delayed and even checked by it. Although at the start I had a few unexpectedly good results in improving the appetites of phthisical patients, yet, although I have used it very frequently, I have, unfortunately, found it to be very uncertain ; not infrequently it was a complete failure. Besides this, the patients often complained of severe burning pains in the stomach, " as if they had been poisoned." Why more or less * [Chittenden and Mendel. The Influence of Alcohol and Alcoholic Drinks upon the Chemical Processes of Digestion. Amer. Jour. Med. Sciences, vol. cxl, 1896, pp. 35, 163, 314, and 431 et seq.—Ed.] f [Roberts. Digestion and Diet. London, 1891, pp. 115 and 132.—Ed.] X [Penzoldt. Salzsaures Orexin, ein echtes Stomachicum. Therapeut. Monats- hefte, Bd. iv, 1890, p. 59. Other papers on this subject may be found in this vol- ume, pp. 287, 374, 496, and Bd. v, 1891, pp. 203, 309, 364.—Ed.] * Kronfeld. Wirkungsweise des salzsaures Orexin. Wiener klin. Wochenschr., 1891, Nos. 3 and 4. || Henne. Experimentelle Beitrage zur Therapie der Magenkrankheiten. In- aug. Dissert., Bern, 1891. TREATMENT OF CHRONIC GASTRITIS. 233 prompt effects should be obtained in some cases and absolutely none in others, I can not explain. My own experience shows that the most failures were in cases of nervous anorexia (hysteria, neuras- thenia, etc.). It is administered as orexin hydrochlorate in pills of 0*1 gramme (gr. jss.), 3, 1, and 5 pills of which are taken on three successive days half an hour before the principal meal. [My expe- rience with orexin, both the basic and the hydrochlorate, has been unsatisfactory. The most recent report on it is that of Battistini,* who found it useful in 19 out of 25 cases.] Creosote and guaiacol have undoubtedly an exceedingly good effect on gastric digestion in many cases, which is probably due to the antifermentative effect of these preparations ; but in some cases, either at the beginning or after they have been taken for some time, they are not borne well; the burning pain in the stom- ach and the constant repeating and offensive taste in the mouth ab- solutely destroy the appetite instead of improving it. But accord- ing to my own extensive experience with these drugs these cases are exceptional; they may be explained either by the fact that the dose has been increased too rapidly or the mode of administration has been bad, thus allowing the creosote to come into direct contact with the mucous membrane of the stomach. Creosote is best given in sugar-coated pills or capsules, each containing 5 centigrammes [f grain] creosote with 1 centigramme [gr. |] balsam of tolu, 10 of which may be taken daily. Guaiacol may be taken in doses of 1 centigramme [gr. |] several times daily. Henne f claims that these drugs do not have any effect on the gastric juice, and attributes the good effects which he has had to their antiseptic qualities. The same good effects may be obtained from resorcin, the value of which has so often been urged by Andeer. This is a true antisep- tic, in spite of the statements of Brieger, Gilberti, P. Guttmann, and others to the contrary. I can fully agree with Menche *}: in highly recommending it in diseases of the digestive tract accompanied by fermentation. It is essential that the purified, white resublimated * [Battistini. Therap. Monatshefte, December, 1894.—Ed.] t Henne. Loc. cit. 1 Menche. Das Resorcin als innere Mittel. Centralbl. fiir klin. Med., 1891, No. 21. 234 DISEASES OF THE STOMACH. resorcin which is free from all by-products be prescribed ; it seems to have none of the bad effects which have been observed after ordi- nary resorcin. Nevertheless I have once had a case in which black- ish-brown urine was passed after using it for a short time, but the urine cleared up immediately after the drug was discontinued. Res- orcin is freely soluble in water and alcohol, and may be prescribed with the various infusions and tinctures or as a powder. Some re- cent favorite prescriptions have been : 1$ Tinct. nuc. vomic................ 25*0 [f 3 vjlj Resorcin. resublimat............. 5*0 [ 3 j£] Tinct. cinchon. comp............ 10*0 [f 3 ijss.] M. Sig. : Ten to fifteen drops every two hours. P Resorcin. resublimat., Bismuth, subnitrat.............aa 10*0 [ 3 ijss.] Natrii bicarbonat., Ext. rhiz. calami, Sacchar. alb...................aa 8*0 [ 3 ij] M. Sig. : Teaspoonful every two hours. These prescriptions may be varied by substituting, as may be needed, rhubarb, salicylates, sulphur, etc. [My own experience agrees entirely with the above. Although I have used the drug very extensively, only once did I see the char- acteristic blackish urine which is so familiar after using carbolic acid. I believe such bad effects are due to a decomposition of the resorcin by the alkalies which are so often prescribed with it. It is possible that intermediate bodies, like pyrogallic acid, etc., may be set free. Solutions or powders with alkalies darken after a short time, and hence such combinations ought to be avoided. The great value of resorcin may readily be understood, if we recall that its chemical composition is almost identical with that of carbolic acid. It is val- uable not alone as an antiseptic, but also as a sedative. Few drugs are more valuable in gastric disorders than resorcin. The doses given are usually too small; it may safely be given as high as 5 to 10 grains at a dose, and should be well diluted with water.*] What is true of resorcin may also be said of salicylic acid and * [Manges. Resorcin as a Gastro-intestinal Remedy. New York Polyclinic, June 15, 1895, p. 173.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 235 the salicylates, especially sodium salicylate and bismuth salicylate. The fact that salicylic acid is not used more frequently in gastric catarrhs may be due to the fact that it is strongly irritant to the gastric mucosa and also to the kidneys; while it is claimed—whether rightly or wrongly, I do not know—that bismuth salicylate acts more upon the intestines than upon the stomach. [The decided chola- gogue action of the salicylates renders them peculiarly valuable agents where disorders of the fiver are associated with the gastric disorders. Phenol bismuth and betanaphthol bismuth (dose 15 to 30 grains) are said to be mostly decomposed in the stomach, and have been proposed to replace bismuth salicylate.] I have been much less satisfied with the action of carbolic acid, thymol, benzoic acid, naphthalin, and naphthol; this is probably due to the fact that their disagreeable after-effects prevent the admin- istration of sufficiently large doses. On the other hand, in catarrhs associated with gastralgia, I have found chloral hydrate to be of very great value because it is an anti- fermentative as well as a sedative. The three cases of agoraphobia cited above were all cured with chloral. I order a tablespoonful of a 3- to 5-per-cent solution to be taken every two hours. The same is true of chloroform, the high antiputrefactive value of which has been shown by Salkowski. It is best administered in doses of 2 or 3 drops in a teaspoonful of water or claret every 2 or 3 hours. I wish to call attention once more to the antifermentati/ve action of a systematic use of hydrochloric acid. It is also well known that the symptoms due to fermentation may be relieved or lessened in a short time by sufficient doses of alkalies, as bicarbonate of soda in 5- to 10-grain doses alone or com- bined with rhubarb or bismuth ; but it is simply palliative, and favors rather than opposes the cause of the process. [An excellent antacid for occasional use is the tablet proposed by Roberts.* Each tablet consists of 1$ Calcii carbon at. praecipit............... gr. iijss. Magnes. carbonat...................... gr. ijss. Sodii chloridi......................... gr. j The tablets are to be allowed to dissolve slowly in the mouth, the * [See Sir William Roberts. "British Med. Journal, 1889, vol. ii, p. 373.—Ed.] 230 DISEASES OF THE STOMACH. copious flow of alkaline saliva being thus induced. Concerning the action of bicarbonate of soda in gastric disorders many papers have recently been written ; of these the most important is that of Reich- mann.* After very careful experiments he concludes that it acts as an antacid upon the acid already secreted, but that it in no way influences the secretory power of the stomach, even if used for a long time.] The proper use of antifermentatives also puts an end to the formation of gas, and hence it is unnecessary to have recourse to the use of the more than questionable drugs recommended to absorb gas. The use of charcoal is utterly irrational; it has recently been brought into commerce in the form of " charcoal cakes " ; the char- coal becomes moist in the stomach, and in that condition its absorp- tive powers for gas are entirely lost. [The popular use of charcoal has been ably defended in a recent prize essay by Wild,f who has made a careful laboratory study of it. Although not possessing any antiseptic properties, yet his ex- periments showed that it may be useful either by oxidizing the chem- ical substances formed during abnormal decomposition or the toxins produced by pathogenic organisms. " This action may be direct or indirect through the aerobic processes of putrefaction, and it is pos- sible that a supply of oxygen contained in the charcoal may modify the pathogenic organisms themselves, and render them or their prod- ucts less virulent. The power of charcoal to remove alkaloids from solutions is worth considering, as certain toxins and ptomaines are possibly of this nature. It may thus prevent auto-intoxication from the alimentary canal." It may be given in from 2 to 6 teaspoonfuls or more daily. Wood charcoal absorbs much more gas than animal charcoal.] However, the best treatment of fermentation, if at all pro- nounced, is lavage of the stomach, the details of which will be dis- cussed in the chapter on Dilatation of the Stomach. [Turck X has recently suggested the use of his gyromele (revolv- * [Reichmann. Boas' Archiv., Bd. i, p. 44.—Ed.]| f [Wild. Medical Chronicle, 1896, No. 4, p. 401. Abstracted in N. Y. Medical Journal. 1896, vol. lxiii, p. 463.—Ed.] X [Turck. Wiener med. Wochenschr., 1895, Nos. 1 and 2.—N. Y. Medical Jour- nal, November 23, 1895, p. 648. Medical News, April 4, 1896, p. 373.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 237 ing sound) (Fig. 32) in the treatment of chronic gastritis. The in- strument consists of a stomach tube inside of which is a flexible cable (3); to the lower end of the latter is attached a sponge (1) covering a spiral spring {d) which can be removed and changed ; the sponge may be protruded from or withdrawn into the stomach tube. The [Fig. 32.—Turck's gyromele.] stomach tube and cable are attached to a hand piece by which the latter can be made to rotate very rapidly. The instrument is intro- duced (with the sponge withdrawn up to the tube) just like an ordi- nary stomach tube ; the sponge is pushed out by depressing the long handle and is made to revolve rapidly by turning the crank. Water may be introduced through the small lateral tube which is armed with a pinchcock. The movable gag {b) is placed between the pa- tient's teeth. The revolving sponge catches up any adherent mucus and food fragments and cleanses the mucous membrane just as the ancients sought to cleanse the stomach with their gastric brushes. By changing the position of the tube the various parts of the stom- ach may be cleansed. The instrument may also be used to obtain bacteriological cultures of the stomach contents. Turck claims excel- lent results for his instrument in the treatment of chronic gastritis.] The hydriatic measures—cold rubbings, douches to the epigas- trium (highly prized by the ancients, and known as cataclysmus), and massage—are also useful. Apparently irrational is the use of alkaline waters, for example, as recommended by G. See, half an hour before meals. But since Jaworski has shown that carbonic- acid waters strongly stimulate the chemical activity and absorption, their action may probably be explained in that way; on the other hand, they neutralize where the secretion of acid is marked. How- ever, all these procedures are useless unless they are combined with a careful regulation of the diet. 23s DISEASES OF THE STOMACH. The regulation of the diet of the dyspeptic begins in the moidh. We have already seen, in the etiology of chronic gastritis, that two important factors were the care of the teeth and slow eating—that is, a sufficient disintegration and insalivation of the food in the mouth. Although the care of the mouth is now much more gener- ally observed than formerly, yet only too often do we still find ex- amples of shocking neglect. I will not mention poorly cleansed teeth covered with tartar, caries, diseased alveoli, or inflamed gums with a thick whitish-green coating of desquamated epithelium, fungi, cocci, and remnants of food between the teeth. These are so promi- nent that they are noticed at once ; and we ought always to recom- mend the patients (and healthy persons as well) to brush the teeth after each meal. Less apparent is the layer of filth which covers the plates of artificial teeth, or the broken-off stumps beneath them. Kaczarowski has exaggerated these conditions, but he is certainly right in many cases. Thus, not long ago, a man consulted me for a typical mucous catarrh ; he had a false upper plate, and naively admitted that he never removed his teeth at night, and only cleansed them about every third day. The plate was covered with a dirty- white coating consisting of numerous fungi and masses of cocci, while the hard palate was markedly reddened and dotted with small aphthous ulcers. In the slimy stomach contents there were small brown streaks which consisted of granular blood pigment and num- berless fungi and yeast-cells. The patient's complaints were rela- tively slight, and began only after his treatment by the dentist. In this case the swallowed bacteria unquestionably kept up a constant state of irritation of the gastric mucous membrane. [Attention has already been directed to Turck'swork on the im- portance of the naso-pharynx in the treatment of chronic gastritis (page 207). Hemmeter * has devised a tongue brush for removing the debris which accumulates at the root of the tongue.] The importance of eating slowly has been told thousands of times. A striking example of this is the fact that many people with weak stomachs while on a journey can digest the poor food of the hotels, because they have nothing else to do and stay a long time at the table, yet they suffer from the carefully prepared and selected * [Hemmeter. N. Y. Medical Journal, December 28, 1895, p. 836.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 239 dishes at home, which are rapidly consumed while the mind is occu- pied with business cares. Upon similar psychical grounds is based the observation that many dishes are sometimes well borne by dys- peptics, while at other times they cause great discomfort, according to the mental or bodily condition. Many persons also have a marked idiosyncrasy toward certain dishes, and for others, again, an entirely voluntary and, as it were, unjustifiable tolerance. In the course of practice you will frequently meet patients who assert that they can tolerate rich mayonnaises, pastries, tough or fat meat, as, for exam- ple, lobster or goose, but who suffer intensely after a cup of milk or bouillon. As a result, every physician who has much to do with diseases of digestion sooner or later ceases to forbid individual dishes, but will be guided by the patient's experience. There is a certain amount of truth in the saying of G. See, "Fn France on pent bien soumettre un menu au malade, en Allemagne on Ty sou- met." One can only indicate the fundamental principles of dietetics concerning the form and amount of food.* Still, it is of great im- portance to give the patient a daily bill of fare in which the time of meals and the kind and exact amount of food are explicitly stated.f But in doing this we should follow the patient's tastes as far as pos- sible, and should arrange regular meals at two to three hours' in- tervals. That what is allowed should be given in the most digestible con- dition, is self-evident, Therefore forbid hard-boiled eggs, meat with very tough fibers and tendons, the flesh of too old animals or of those which have just been slaughtered, in which the post-mortem formation of acids has not yet had an opportunity to soften it. For the same reason warmed meat is to be forbidden, also that which contains too much fat, like pork, fat portions of lamb, fat fowl, fish * [This subject is very well discussed in Sir William Roberts's work on Diges- tion and Diet, London, 1891, pp. 160 et seq. A good review of the chapter on this topic will be found in the American Journal of the Medical Sciences, 1891, vol. ci, p. 397.—Ed.] t [Boas has recently protested vigorously against the custom of giving the pa- tient a printed diet list, as too much freedom is thus allowed. Nevertheless, with a little care such lists, if properly prepared, will be found useful. The best set of detachable diet lists which has yet been published is that of J. B. Thomas, Diet Lists and Sick-Room Dietary. Published by W. B. Saunders, Philadelphia, 1895. —Ed.] 240 DISEASES OF THE STOMACH. and mollusks (salmon, carp, turbot, eel, lobster, crabs, oysters*), sausages, smoked fish like flounder, herring, eel, sprats, lamprey, etc. Under the direction of Penzoldt, Gigglberger,f with the aid of the stomach tube, has experimented on himself with various arti- cles of food prepared in as many ways as possible. His results practically agree with those of Beaumont.*{: According to him, meat remains in the stomach between two hours and twenty-five minutes (stewed calf-brain) and five hours and twenty-five minutes (roast mutton). In general, roasted meats remain somewhat longer in the stomach than stewed. It is scarcely necessary to mention that white meats like veal, poultry, and young game, venison, etc., are easy to digest. Eggs, even when raw, are badly borne, much more fre- quently than would be suspected ; scrambled eggs and omelettes are to be excluded at once. Heavy cheeses are also indigestible ; hence the old proverb that they are gold in the morning but lead at night. I also consider that bouillon from red meats is not indicated, not on account of its albuminoids, but because the high percentage of salts may irritate the gastric mucosa; this is not the case wdth bouillons made from white meats. Gelatinous soups and jellies made from calves' feet, calves' heads, ox tails, etc., are bland and nutritious on account of their gelatin, which is easily oxidized and saves the bodily fats from combustion. Among irritant ingesta may also be included strong acids, like vinegar, strong condiments, and alcohol in concen- trated form as liqueurs. Indirectly injurious—that is, by their products of decomposition—are the fats, and hence oils and fatty * R. H. Chittenden. On the Relative Digestibility of Pish Flesh in the Gastric Juice. Amer. Chemie. Jour., vol. vi, No. 5. Chittenden places oysters almost at the foot of his table. This is not absolutely correct. Not long ago I artificially digested some oysters and found that they were digested more rapidly and com- pletely than soft-boiled egg albumin. Raw and not fried oysters should be al- lowed ; they should be chewed, and not swallowed whole. The greater part of an oyster consists, as is well known, of glycogen and a digestive ferment, hepatic dias- tase. In chewing, both substances are brought together, so that the glycogen is immediately converted. By frying, the ferment is destroyed and the usefulness of the glycogen is also lessened, just the same as happens when the oysters enter a stomach which contains too much HCl. Hence oysters are especially well digested when there is a deficiency in the secretion of HCl. Roberts, loc. cit f X. Gigglberger. Ueber die Dauer der Magenverdauung von Fleischspeisen. Inaug. Dissertation. Erlangen, 1886. X Vide Ewald. Klinik. etc. I. Theil. 3te Auflage, pp. 114 et seq. [Elaborate tables are given as to the digestibility of the various articles of diet.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 211 sauces should not be found on the dyspeptic's table. A substitute for meat may be found in the peptone preparations and peptone chocolate ; * the latter is expensive, but may easily be prepared at home by boiling some cocoa free from fat, or even chocolate, and adding some peptone or meat peptone. On the other side of the scale of nutritious substances are the carbohydrates, including everything from pure starch preparations to the nitrogenous flours, vegetables, fruits, and legumes. Their digestion is easy, provided that in their preparation as much starch as possible has been changed into dextrin, and the thick consistency of the dough formed by mixing flour and water has been got rid of by heat and drying in the air. Therefore all freshly baked articles are to be avoided ; on the other hand, it explains the digestibility of the various flours, and soups, jellies, etc., prepared from them; also of vegetables and fruits when they are freed from their cellulose and softened, and in the case of the former when prepared with a mini- mum amount of fat. But all kinds of cabbage are to be avoided, because the carbohydrates contained in them are especially prone to fermentation. This is also true of the legumes, and hence mashed peas and lentils are usually poorly borne. On the other hand, the so-called leguminous flours, which may now be bought in many forms, constitute a good diet, of which, however, the patients usually tire after a time. But it must never be forgotten that all foods with carbohydrates very easily undergo fermentation on account of the sugar which they contain ; consequently they must be used with caution in all atonic conditions of the stomach. Milk occupies an intermediate place among the above-mentioned substances ; theoretically it ought to be the best. But in practice it is either rejected entirely or is borne only for a short time by many patients ; however, it may be given, cooked or raw, sweet or sour, or with soda, lime water, or rum. Koumyss and matzoon are well borne by most persons ; some, however, can only take them for a short time. It must also not be forgotten that an exclusive milk diet is a kind of slow starvation, and that to live on milk alone * [Mosquera's beef cacao is a similar preparation; a tablespoonful of the powder is added to a cup of hot milk, and is boiled five minutes like ordinary cocoa. It is quite palatable. Somatose may also be highly recommended.—Ed.] 242 DISEASES OF THE STOMACH. would require much larger quantities than the capacity of the stom- ach would allow. Still, a high nutritive value can be given to milk by adding the so-called milk powder—i. e., milk which has evapo- rated to dryness and pulverized ; of this, 100 grammes [3* ounces] represent about one litre [quart] of milk. Finally, dyspeptics must not forget the general rule never to fully satisfy their appetite, but to stop as soon as they feel the first sensation of satiation, and to allow sufficiently long intervals to in- tervene between meals. Fluids are not to be taken too hot nor too cold, nor in too large quantities, since they unnecessarily dilute the gastric juice. Dys- peptics should also avoid all strongly carbonated waters and those in which fermentation readily occurs, since the stomach becomes dis- tended and the blood surcharged with carbonic-acid gas ; for there are very few cases in which its stimulating effects neutralize these disadvantages.* According to experiments performed on himself, Eichenberg f claims that small quantities of alcoholic beverages (cognac, alcohol) lessen the time of digestion a little (■£■ to -^ of the total time), just as 50 to 60 drops of the officinal diluted HCl do. As bland beverages we may use the time-honored orgeat, rice water, and decoctions of hops, salep, and barley. It is self-evident that in diet lists we can only give general direc- tions and the maximum quantities beyond which the patients must not go. For the exact selection and preparation of the various arti- cles of diet I would refer to what has already been said, and to Weil's Tisch fiir Magenkranke or Heyl's Kochbuch fiir Kranken- kiiche.*}: Although it is important to regulate the patient's diet, yet it is equally essential to see that the ordinary diet is resumed at the proper time. Most patients are only too glad to resume this as soon * [These remarks apply with even greater force to the use at meals of alkaline carbonated waters like Vichy, Seltzers, etc.—Ed.] f Eichenberg. Ueber die Aufenthaltsdauer der Speisen im Magen bei Zufuhr von Salzsauer, Alkohol, und andere Reizmitteln. Dissert. Erlangen, 1891. (The writer experimented on himself.) X [For additional data upon the dietetics of chronic gastritis, see Thompson's Practical Dietetics, 1896, pp. 496 et seq.; Burney Yeo, Hare's System of Therapeutics, 1891, vol. i, pp. 646 et seq— Ed.] TREATMENT OF CHRONIC GASTRITIS. 243 as possible ; yet there are many anxious patients, of whom we shall speak later when discussing neurasthenia, who allow themselves to run down by remaining unnecessarily long on a restricted diet, so that the original catarrh of the stomach is followed by nervous dyspepsia or a general weakness which can only be combated by an energetic change of diet. That the regulation of the diet must be combined with attention to general hygiene need hardly be mentioned in our tunes. The care of the skin and lungs—in short, the care to obtain pure air— constitutes the most important part not alone of the prophylaxis, but also of the treatment, of nearly all chronic diseases. But it is in cases of chronic gastric catarrh that much harm is done, be- cause most patients think they have done their duty in attending to a few dietetic details, and therefore find no harm in spending night after night in a hot atmosphere contaminated with gas, crowded rooms, smoke-filled saloons, etc. The dyspeptic's pro- gramme should always include active bodily exercise, long walks, horseback riding, baths, sometimes combined with douches, gymnas- tic exercises, especially those which call the abdominal muscles into action ; and as most persons do not carry out these exercises for a long time unless there is some object in view, they should be taken as sport or massage. Rowing is a specially valuable exercise, and with the present sliding seats, as shown anatomically by Mitan,* offers admirable exercise for every muscle. It is to be regretted that women can not indulge in this as much as men, yet home gym- nastics, massage, daily walks and rides can accomplish much good. uMaximequc qua super lores partes moveat, quod genus in omnibus stomachi vitiis ajdissimum est," says Celsus ; yet it would be even better to bring the body into moderate action but not overexertion. [The bicycle has afforded a happy solution of the above problem. Its rational use is followed by the most excellent results in this class of cases.] f * Mitan. Das Rudern, eine heilgymnastische Uebung. Inaug. Dissertation. Berlin, 1882. f [Those who are interested in the medical aspects of the bicycle may consult an exhaustive study by Mendelsohn in Deutsch. med. Wochenschr., 1896, Nos. 18 to 25. An extended discussion of this paper will be found, ibid., Vereinsbeilage, April 2, 1S!)0 et seq.—Ed.] 244 DISEASES OF THE STOMACH. [In some cases it is equally important to prescribe rest ; persons with enfeebled digestion are often benefited by lying down for a short time after eating.] Finally, some special points in the treatment still require dis- cussion. Where gastralgia resist all ordinary forms of treatment with the various opiates they may be temporarily relieved, preferably by a hypodermic injection of morphine. Hyoscyamus, hydrocyanic acid, and belladonna, as well as chloroform water (1 to 200), have also been recommended for this purpose. I have found the following com- bination very useful: 1> Morphinae hydrochloratis........... 0*2 [gr. iij] Cocain. hydrochloratis.............. 0*3 [gr. v] Tinct. belladonnas................. 5*0 [f 3 ji] Aq. amygdalae amarae.............. 20*0 [f 3 v] M. Sig. : Ten to fifteen drops every hour. Where the pains are very severe, three doses of ten drops each within an hour. Budd attributes a sedative action to Fowler's solution, taken half an hour before eating ; while Siebert * has even come to the conclu- sion that with the use of arsenic the pains of nervous or catarrhal gastralgia disappear in a few days, but persist where it is due to an ulcer. Germain See has spoken very highly of the use of calcium and bromide salts and of extract, cannabis indicae in gastralgias of all kinds, and has laid especial stress upon the fact that it acts only locally on the mucous membrane of the stomach, and not upon the general nervous system. I can not agree with this sweeping recom- mendation. It is true, I have obtained analgesic effects from its use in some patients, for I have used it in the form of an infusion for more than twenty years ; occasionally excellent results were ob- tained with the officinal extract, using as much as one decigramme [gr. jss.] at a dose ; others were attacked with severe cerebral symp- toms, like intoxication and headache ; in still others it had no effect whatever. [I can fully agree with Mackenzie's recommendation of canna- * Siebert. Ueber Magenschmerz und Magengeschwiir. Deutsche Klinik, No. 10, 1852. TREATMENT OF CHRONIC GASTRITIS. 245 1 >is indica in the treatment of gastralgia and enteralgia.* The vary- ing reports are due not to the drug but to the preparation employed. .The unpleasant effects due to idiosyncrasies may be avoided by be- ginning with small doses and gradually increasing until the point of tolerance is reached. Mackenzie prefers the tincture for rapid ef- fects, the extract being more suitable for slow and continuous use.] Codeine, especially codeine phosphate,*f* acts much better. I prescribe it either in drops like the morphine drops above mentioned (replacing the morphine by codeine, but in double the quantity, 0*4 [gr. vj], or as powder with bismuth subnitrate, extract of belladon- na, etc. : 9 Codeinae phosphatis......... 0*02-0*015 [gr. i-£] Bismuthi subnitratis......... 0*3 [gr. v] Sacchari lactis.............. ()-2 [gr. iij] M. Sig. : Tal. dos. every two hours. It is superior to morphine because it retards the intestinal peri- stalsis much less, and its use is very rarely followed by nausea. Purgatives.—Irregularity of the bowels plays a very important part in all forms of chronic gastritis. In the early part of this work I have called attention to the close connection between the intes- tines and the stomach, and have repeatedly pointed out that many so-called stomach troubles are really in the intestines. Although I shall reserve a detailed description of these conditions for the por- tion of this work devoted to the diseases of the in testines, % yet the use of purgatives must be considered here, since they not alone re- lieve the intestinal disturbances, but also directly aid the passage of the stomach contents into the intestine by securing prompt evac- uations. In the same way those drugs which act as cholagogues also increase the peristalsis of the intestines, and hence empty the bowels. In the vast majority of cases of chronic gastritis we must combat constipation and not diarrhoea. We may at once eliminate one group of purgatives, the vegetable oils, of which the typical example is castor oil; it irritates the stom- * [Stephen Mckenzie. On some Classes of Cases in which Indian Hemp is of special Service. Medical Week, 1894, p. 457.—Ed.] + [Codeine phosphate is often preferable to codeine on account of its solubility; the ordinary dose is 0*1 [gr. jss.]; the daily dose is 0-4 [gr. vjj.—Ed.] t [This portion of this work has not yet been published.—Ed.] 246 DISEASES OF THE STOMACH. ach and nauseates most patients even when given in an emulsion. Although it has undoubtedly been very useful in many cases of so- called stomach catarrhs, yet it is just in these cases that the real trouble is in the intestines and not in the stomach, and the injurious effects on the latter are more than counterbalanced by its beneficial action on the former. I have even been able to demonstrate experi- mentally the disturbing effect of oil on the chemical processes of digestion.* Saline cathartics are also only to be given when an action on the small intestines is desired ; then the sulphate-of-soda mineral waters are to be used, or, as these are usually insufficient, the salt itself in substance. An excellent remedy is sulphate of soda in combination with rhubarb and carbonate of soda; it is the old solamen hypochondriacum of Kleist which has been recommended by Leube: 1} Pulv. rad. rhei.................. 20*0 [ 3 v] Sod. sulphat.................... 10*0 [ 3 ijss.] Sod. carbonat., Sod. bicarbonat...............aa 5*0 [gr. Ixxv] M. Sig. : At bedtime, \ to \\ teaspoonfuls in a glass of warm water, as may be necessary. According to the individual indication this may be changed and magnesia usta, or tartaric acid, or sulphate of potash may be added; or, as I prefer, it may be combined with bismuth salicylate, benzo- naphthol, and extract, nuc. vomic. (in atony of the stomach with tendency to flatulence from intestinal fermentation): 9 Extr. nuc. vomicae.............. 0*5 [gr. vijss.] Bismuthi salicylatis, Benzonaphthol...............aa 10-0 [ 3 ijss.] Pulv. rad. rhei................. 15*0 [ ^ ss.] Natrii sulphatis., Potassii bitartratis.............aa 8*0 [ 3 ij] Natrii bicarbonatis.............. 5*0 [ 3 j-j] M. Sig. : One teaspoonful every two hours. Here I may also mention cream of tartar, Rochelle salt, or tartrate of soda (Ph. Germ.) ; they may be given in effervescing lemonades, * Ewald und Boas. Zur Physiologie und Pathologie der Verdauung. II. Vir- chow's Archiv, Bd. civ. TREATMENT OF CHRONIC GASTRITIS. 247 in powder with washed sulphur, or in decoctions with the vegetable aperients spoken of in the next paragraph. Vegetable Aperients.—The mildest of these are the various fruits which owe their efficacy to their vegetable acids. The use of stewed prunes at night before retiring is well known ; less known is a mixture of two parts of prunes and one part of dried figs ; the taste is agreeable and the cathartic action is mild. Among the true laxatives rhubarb stands pre-eminent, and in fact in all its various proportions it is a very valuable aid to dyspeptics; yet it has one great disadvantage, that its action is temporary and is followed by obstinate constipation. Next to it stand tamarinds, then senna, buckthorn, European centaury (Herba centaurii, Ph. Germ.), tarax- acum, coriander, fennel, etc., some as extracts, others as teas ; of the latter the best-known preparation is the so-called Hamburg tea. Senna sometimes causes nausea and colic ; this may be avoided by using an alcoholic extract (extract, sennae fluid.), or by adding some aromatic spirits of ammonia or tincture of cardamom. Cascara sa- grada, which has been so extensively used recently (50 to 80 drops of the fluid extract at night), is a mild and at first a certain remedy, but like the rest of this class it loses some of its effects in time.* Extract, fab. calabaric. (Ph. Germ.) [ext. physostigmatis, U. S. Ph.] 0*05 [gr. J-] with 10*0 [ 3 ijss.] of glycerin has been highly praised by some, but according to my experience is very uncertain. Aloes act especially on the large intestines, either alone or com- bined with jalap, colocynth, or scammony. English writers also con- sider it a stomachic and give it especially with calomel, to which, as is well known, a cholagogue as well as a cathartic action has been attributed. But, as Rutherford has shown that podophyllin is also a cholagogue, and as it has the advantage over calomel of having none of its after-effects, I prefer to use it with aloes, etc., instead of calomel. Fnemata also deserve mention ; they may consist of warm water * [This drug may also be used as a stomachic as well as a laxative. 3 Tinct. nucis vomicis.......................... 10-0 [ 3 ijss.] Ext. cascaras sagradae fluidi, Elix. aurantii..............................aa, 40-0 [ 3 x] Aquam....................................ad 120-0 [ % iv] M. Sig.: Teaspoonful fifteen minutes before eating.—Ed.] 17 248 DISEASES OF THE STOMACH. alone or with salt, soap, decoction of senna, castor oil, and the like. It is an old rule, originally given by Trousseau, that they should never be given immediately after a meal, since they may then easily cause severe diarrhceal discharges instead of easy movements; but it is only recently that attention has been called to the fact that no hard-rubber syringes should be introduced into the rectum ; instead, a soft, flexible, thick-rubber tube, with one opening below and sev- eral laterally, should be passed quite high up, and the fluid permit- ted to enter or force its way slowly. Enemata are of especial value where the large intestine is relaxed; they soften the hard faecal masses which accumulate in the sigmoid flexure and descending colon, and they also gently stimulate the muscular fibers of the lower segment of the intestine. Upon the latter also depends the action of the injections of small quantities of glycerin (which con- stitutes the active ingredient of the so-called " Oydtmann's purga- tive ") and of the glycerin suppositories which are made of glycerin and any easily melting substance. Small enemata of about 300-500 c. c. [ § x-xvj] of pure, slightly warmed olive oil often have an ex- cellent, mild laxative action where other forms of injections have no effect at all, or, if they do act, only cause unsatisfactory watery stools with much tenesmus and abdominal pain. I have used them fre- quently, and can indorse the very favorable reports of Kussmaul and Fleiner.* As long as the enemata operate (i. e., as long as we are only dealing with the so-called torpidity of the lower bowel) they are the best and mildest means, and the bad results attributed to their prolonged use, such as causing catarrh of the intestines, occur in very few cases. Dilatation of the rectum after the use of too large enemata is much more to be feared, and patients ought to be warned against this possibility. Although they usually lose their effect after a time, yet I know patients who have successfully used them daily for years. Finally, I must not neglect to state that a number of cases of * Fleiner. Ueber die Behandlung der Constipation mit grossen Oelklystieren. Berl. klin. Wochenschr., 1893, No. 3. [These oil enemata are especially valuable in cases of so-called spastic constipation. Such cases may readily be recognized by the passage of small, very hard scybalae and by the failure of the ordinary cathar- tics. The latter make matters worse, because, instead of relaxing the spasm of the intestines, they only increase it.—Ed.] TREATMENT OF CHRONIC GASTRITIS. 249 chronic gastritis can not be cured with the so-called stomach reme- dies, but require treatment for the primary disease. These are especially the gastric catarrhs which occur in pulmonary, cardiac, and renal diseases, and those appearing during the course of chloro- sis. But, as the gastric symptoms sometimes constitute the most prominent part of the patient's complaints, it not infrequently hap- pens that these persons are for a long time treated for the stomach trouble, till a thorough examination reveals the real condition, and the proper treatment of this relieves the gastric symptoms. Mineral Springs.—The drinking of mineral waters, either at the springs or at home, constitutes an important part of the treatment of chronic gastritis. Drinking the water at home is only an expe- dient, and will never replace the great advantages of a residence at the spa with all its adjuvants; the mental and bodily rest and in- vigoration, the dolcefar niente of life at the springs, the constant warning against dietetic errors—all these are lacking. This is true, even though, so far as these points are concerned, many well-situ- ated people could just as well take the cure at home. But, in spite of every care in filling and sending, bottled mineral waters never have the invigorating freshness nor the strength of the bubbling spring. For the local treatment of stomach troubles the following four classes of mineral waters are of most importance : 1. Pure salines. 2. Salines with a large amount of carbonic-acid gas. 3. Alkaline salines in which the proportion of sodium chloride and carbonic-acid gas is much less than that of intermediate salts. 4. Alkaline and alkaline - muriatic {alkalisch - muriatische) waters.* * The following springs may serve as types of these classes : (1) Wiesbaden (Kochbrunnen). Sodium chloride........................ 6-83 Calcium chloride........................ 0-47 Calcium carbonate...................... 0-42 Carbonic-acid gas....................... 0-5 c. c. to the litre. (2) Kissingen (Rakoczy). Sodium chloride........................ 5-82 Calcium chloride........................ 0-28 Calcium carbonate...................... 1*06 Carbonic-acid gas....................... 13920 c. c. to the litre. 250 DISEASES OF THE STOMACH. Unfortunately, I must confess that we know very little of the action of these mineral waters upon the stomach, because the criteria upon which their effects are judged are based directly upon the in- fluence on the intestmes, and only indirectly take cognizance of the stomach. Just at present this position is rendered still more aggra- vating because the experimental researches of Pfeiffer * and Jawor- ski have strongly shaken our belief in the influence of Glauber's salt on stomach disorders. Jaworski, as is well known, has con- cluded, from his investigations, that Carlsbad water stimulates the gastric secretion only in the beginning, and when taken in small quantities ; but if consumed for a longer time it lessens it markedly, may finally cause it to disappear, and may even lead to atrophy of the glandular parenchyma.*}* At my request, Dr. Sandberg, of Marstrand, has investigated these striking results. Consecutive ex- aminations were made on ten patients during a four to five weeks' treatment at Carlsbad ; the result was that in half of them the acid- ity was somewhat lessened, in the others increased ; and the lessened acidity was just in those patients who had had a high acidity before beginning the treatment. But as we know that the acidity is sub- ject to very great variations in the same persons, too much weight must not be laid upon the above results, especially as an apprecia- ble change was not found in the peptic power nor in the action of rennet. For the influence of common-salt mineral waters on digestion (3) Carlsbad (Muhlbrnnnen). Sodium sulphate...................... 2'39 Sodium carbonate.................... P27 Sodium chloride. ... ................... P02 Carbonic-acid gas....................... P27 c. c. to the litre. (4) Ems (Kcsselbrunnen). Sodium carbonate....................... 1*99 Calcium carbonate..................... 0-22 Sodium chloride....................... 1*0 Carbonic-acid gas....................... 553'2 c. c. to the litre. [For further information concerning these and other springs, see George E. Walton. Mineral Springs of the United States, etc., 1883.—Hayem and Hare. Physical and Natural Therapeutics, 1895.—Ed.] * E. Pfeiffer. Balneologische Studien iiber Wiesbaden. Wiesbaden, 1883, chap- ter on " Kochsalz oder Glaubersalz ? " t W. Jaworski. Ueber die Wirkung des Carlsbader Wassers auf die Magendarm- function. Deutsch. Arch, fiir klin. Med., Bd. xxvii. TREATMENT OF CHRONIC GASTRITIS. 251 I refer to what was said on page 228, and add that Boas* has methodically observed the changes in the secretion of gastric juice while taking warm saline waters; after three to four weeks he noticed a decided improvement in the secretion and a coincident disappearance of the symptoms. The action of the saline waters (sodium chloride) depends chiefly on a stimulation in the secretion and absorption and an increase in the metabolism. This is also true of the alkaline saline waters, yet it seems to be more pronounced in the waters with sodium chloride than those with sodium sulphate. The latter and the alkaline waters have such a high percentage of alkali that they can act as antacids. All possess the property of dis- solving mucus. The saline waters stimulate the stomach's activity, the alkaline saline act principally on the intestines and fiver. The simple mechanical action of washing out the stomach is common to them all. But while it is true of the saline and alkaline springs that they can not have any bad effect on the general system, or, as the layman says, " they are not powerful," yet this is often the case to a marked degree with the sodium-sulphate waters, and, especially in nervous and anaemic persons, they may cause an increase in the irri- tative manifestations or the signs of depression.-j* Therefore we ought never to send patients with pronounced neuroses of the stom- ach to these springs, nor even allow them to drink any of these waters. For them we must recommend a general tonic treatment which may vary with the individual: sometimes only a stay in high mountainous districts; others need the seashore ; others, again, re- quire a hydropathic establishment with all its paraphernalia ; in still others, mud or brine baths, together with small doses of an alkaline muriatic water, are indicated. To this class belong the great group of nervous dyspeptics, the patients with atony of the muscular fibers of the stomach upon a nervous predisposition. In this respect my experience tells me that much harm is done, and every year from a * J. Boas. Verhandlungen des Vereins fiir innere Med. zu Berlin, November 5, 1888. f By way of addition I may observe that I find that so experienced a physician as Cordes (loc. cit., p. 535) expresses himself thus: "On this occasion I wish to warn most emphatically against sending irritable, weak patients to the sodium-sulphate springs ; for they operate badly in every case, because the reflexes proceeding from the stomach and intestines of themselves are very pernicious." 252 DISEASES OF TEE STOMACH. number of patients I hear the same complaint, that they were sent to Carlsbad on account of chronic catarrh of the stomach, but that they had borne the treatment very badly. Carlsbad and Marienbad are frequently these patients' greatest enemies. The high elevation of Tarasp causes it to occupy an intermediate position; Kissingen, Wiesbaden, Homburg, JSauheim, Franzensbad, etc., or the sparkling soda springs like Yichy, Ems, Neuenahr, Bilin, etc., are more indif- ferent, and may at times be beneficial on account of the change of life and the other well-known accessories of watering-place life. On the other hand, experience has shown that the alkaline-saline and the alkaline springs (to say a few words in anticipation on the treatment of the gastric neuroses) are very beneficial in conditions of hyperacidity or hypersecretion. The very successful use of Carlsbad water in ulcer of the stomach is now much more readily understood, since we know that the ulcer is in many cases accom- panied by hyperacidity, and that the mineral water not alone mo- mentarily neutralizes this (just as in cases of hypersecretion), but also that it may actually lessen the activity of the secretion. A similar effect might also be produced by the purely alkaline waters, but they have not yet been used much for this purpose. Finally, the sodium-sulphate waters are to be used in those cases in which the stomach is only secondarily involved from disturbances of the liver and the intestines. However, the saline waters are indicated in all cases of catarrh with lessening of the secretion, either with or without the produc- tion of mucus. Here we may use the simple sodium chloride wa- ters where the patient is otherwise well, and only the gastric and intestinal secretions are to be augmented ; the sparkling sodium- chloride waters are useful where we desire the stimulating effects of the carbonic-acid gas, and where, by moderate catharsis and the use of the brine as such, the metabolism may be increased. Finally, all waters which are to act on the stomach are borne better warm than cold. The stereotyped directions to walk after drinking this or that water in the morning on an empty stomach will do for the majority of patients, but by no means for all. The waters do not agree with some when taken in this way, but will be well borne if taken while still in bed or later in the morning, TREATMENT OF CHRONIC GASTRITIS. 253 provided we do not suddenly upset the patient's routine mode of living. There are still others who can only proceed gradually to take the actual ** cure." Therefore I frequently prescribe a pre- liminary course of some other water at home before the patient goes to the springs ; for example, if Carlsbad has been recommended, I advise taking small quantities—say ^ to ^ litre [quart]—of Wies- baden Kochhrunnen water. In the above I have simply given the general indications for choosing springs; for further details one may consult the text- books on balneology, and to the admirable treatise of Leichtenstern in Ziemssen's Handbuch der allgemeinen Therapie.* I need hardly indicate how much is left for individualizing by noting the equip- ment of the different resorts, such as mud and iron baths, mild effer- vescing iron springs, medico-mechanical [for instance, like Zander's system] and electrical treatment, etc. These details must be attended to, lest a stereotyped method of treatment be employed, and that the individual indications may be properly looked after ; in other words, the treatment must be adapted to the patient, not the pa- tient to the treatment. It is unquestionable that the treatment will be much more suc- cessful if the diagnosis of gastric catarrh is exactly defined into one of the three varieties—simple, mucous, or atrophic catarrhal gas- tritis, f This can only be done by employing the chemical methods, the use and success of which have been greatest in this field where they were at first least expected. Finally, it is of equal importance to both physician and patient that in the selection of a suitable watering-place for the latter, the former should, if possible, know the place recommended from his own personal observation. Here, again, we must individualize, for even if the analyses of two mineral springs are almost identical, yet it does not therefore follow that they are equally well adapted to the same class of patients. The other adjuvants of the place must be considered, and to know the character of the physician to whom we intrust our patients is not unimportant. * [Vol. IV of American translation, New York, 1885.—Tr.] f Ewald. Der chronische Magenkatarrh und seine Behandlung an den Heil- quellen. Deutsch. med. Zeitung, March 3, 1889. CHAPTER YI. [mechanical] insufficiency and dilatation of the stomach. As I have already stated [page 90], there is no absolute stand- ard for the normal size of the stomach, and its capacity stands in no relation whatever to the size of the individual. We can only speak of an absolute dilatation of the stomach when it exceeds the given capacity in round numbers of 1,600 to 1,700 c. c. [53 to 57 fl. oz.]. But the stomach may be actually much smaller and yet be relatively dilated for the individual. Furthermore, as Kussmaul and Rosenbach * have already shown, there are very large stomachs which exert no disturbing influence on digestion, so that they are discovered accidentally while making some other examination. I therefore distinguish between the large stomach, megalogastria, and the enlargement of the stomach, gastric dilatation or gastrectasis, which in turn is to be divided into an acute or subacute and a chronic form. Megalogastria may lead to dilatation, but is not a pathological occurrence. Thus it amounts to an anatomical condi- tion, while the nature of dilatation is that of a functional disturb- ance, combined with a progressive anatomical process. Accordingly, I would define dilatation of the stomach, or gas- trectasis, as that condition of the stomach in which the clinical symptoms of disturbance of the gastric functions proceed from an enlargement of that organ; megalogastria, however, is the congeni- tal or acquired large stomach, the functions of which are compen- sated. Persons with large stomachs may have catarrhal gastritis, etc., but this does not mean that they have dilatation as it is under- stood clinically, although they are more disposed to this condition than are others. * O. Rosenbach. Der Mechanismus und die Diagnose der Mageninsufficienz. Volkmann's Sammlung klinische Vortrage, No. 153, p. 8. 254 DIAGNOSIS OF GASTRECTASIS. 255 Germain See* also distinguishes between simple dilatation, which may exist for a long time, or even permanently, without creating any disturbance and dilatation with dyspepsia—i. e., that condition which we commonly regard as gastric dilatation, by which we do not mean simply a large stomach, but that there is at the same time a morbid disturbance of its function. Megalogastria and gastrectasis have frequently been confounded with each other. An entirely different condition, if I may anticipate, is gastric insuffi- ciency—Westphalen"s relative dilatation, Rosenbach's relative gas- tric insufficiency—which indeed may and frequently does lead to the symptoms of gastrectasis, yet does not have the anatomical basis of the dilated stomach, but is a functional disturbance occur- ring in the most varied conditions of size of the organ, f We possess the following diagnostic aids for the recognition of the large or dilated stomach: *}: 1. Inspection.—With relaxed and thin abdominal walls we fre- quently see the left hypochondriac region and a larger or smaller portion of the right, according to the extent to which the stomach is filled with air or ingesta, bulge out like a hemisphere or balloon, beginning just below the free margin of the ribs. The lower border of this swelling crosses the mid-line on a level with the umbilicus, or below this, between it and the symphysis. At times there is only a lower projection present, with a troughlike depression between it and the free border of the ribs, which is caused, as a rule, by the long axis of the stomach assuming a more or less vertical position; occasionally,however,it maybe produced by the region of the lesser curvature becoming collapsed, while the fundal zone is inflated or filled with ingesta. In the former case the lesser curvature runs parallel to the spinal column in the middle line, or even to the left of it, and in highly marked degrees of this condition it only passes to the right on a level with the umbilicus, so that even the pancreas may be felt between the margin of the liver and the stomach, and may be mistaken for a gastric tumor. Peristaltic * Germain See. Du regime alimentaire. Paris, 1877, p. 280. f [An excellent discussion of this subject will be found in Riegel, Ueber Megalo- gastrie und Gastrectasie, Deutsch. med. Wochenschr., April 12, 1894, p. 333.—Ed.] X [See also p. 80 et seq — Ed.] [Fig. 33.—Photograph showing tumor caused by dilated stomach, and also undulatory waves of peristalsis. The crosses are placed on the three prominent waves. The letter/ indi- cates the depression on the lesser curvature. (Osier.) ] these conditions become still more marked, and the gradual appear- ance of the viscus as it becomes distended produces, as a rule, a very characteristic picture. The epigastrium, which before had been sunken in, now projects forward, so that we may usually, * L. Bamberger. Krankheiten des chylopoetischen Systems. Erlangen, 1855, S. 325. f A. Cahn. Antiperistaltische Magenbewegungen. Deutsch. Archiv f. klin. Med., Bd. xxxv, S. 402. X A. Glax. Ueber peristaltische und antiperistaltische Unruhe des Magens. Pester med. chirurg. Presse, 1884. ' DIAGNOSIS OF GASTRECTASIS. 257 although not always, distinguish dilatation from gastroptosis (see page S(,>). In electric transillumination of the stomach we see a broad illuminated zone extending from the left of the navel down to the suprapubic or left inguinal regions. [See Fig. 15.] In advanced dilatation the body is usually emaciated, the abdominal walls are relaxed and slightly sunken, and the false ribs on the left side are raised like wings. The skin is dry, pale, and somewhat tawny. [Inspection is a means of diagnosis which is very much neg- lected. Its great value may be appreciated by bearing in mind that Osier,* in 10 out of 13 cases of gastric dilatation, was able to make the diagnosis from mere inspection. An excellent idea of what is seen on inspection of the abdomen when the stomach is [Fig. 34.—Profile view of abdomen of woman, sixty-five years old, showing the tumor caused by dilated stomach. From photograph taken during life. (Osier.)] dilated may be obtained from Figs. 33, 31, and 35. The peristaltic waves are well shown in Fig. 33; when present—which occurs much more frequently than is generally supposed—they are a great aid in diagnosis. The force of the waves may be increased by flap- ping the abdomen with a wet towel or rubbing the skin with a lump of ice. They are not visible in Figs. 34 and 35, as the dilata- * [Osier. Lectures on the Diagnosis of Abdominal Tumors, 1895, p. 23. This excellent work should be studied by all who would attain any proficiency in ab- dominal diagnosis.—Ed.] 258 DISEASES OF THE STOMACH tion in this was so great that there was paralytie distention of the stomach.] 2. Percussion.—Should any suspicion of dilatation exist, it is best before percussing to first distend the stomach with air. The double bulb ought to be alone used for this purpose, for I have [Fig. 35.—Anterior view of same case as Fig. 34, showing tumor caused by dilatation of stomach. From photograph taken during life. (Osier.)] seen so many errors arise from the use of carbonic-acid gas that I consider the latter only a poor compromise. I shall cite but one of many examples of this: A colleague failed to recognize a marked dilatation, which extended to midway between the um- bilicus and the symphysis, in spite of his having given a Seidlitz powder to the patient, because the quantity of gas evolved was actually insufficient for the capacity of the stomach.* The percus- sion note over the inflated stomach is always tympanitic and more * [Nevertheless, Osier, Riegel. and many other good observers express them- selves as being satisfied with the carbonic-acid gas method. It possesses the very great advantage over the inflation with air that the introduction of the stomach tube is unnecessary. A teaspoonful of sodium bicarbonate and not quite a teaspoonful of tartaric acid, or the two powders of a Seidlitz powder, are each dissolved in half DIAGNOSIS OF GASTRECTASIS. 259 or less high according to the contents and the tension of its walls. Should the transverse colon be markedly distended and the curva- ture of the stomach lie immediately next it, it may at times emit the same note, and thus render it an impossibility to define the boundary between the two organs by means of percussion. In such a case we must either fill the stomach with fluid, and then percuss in order to contrast its dullness with the tympanites of the colon; or we must force more air into the latter from the rectum, thereby producing either a change in position or a higher tympa- nitic note. Here it is well to remember that delicate differences in sound frequently become more distinct by the use of auscul- tatory percussion when the ordinary method of percussion with the pleximeter leaves us in the lurch, and that therefore this method can also be utilized in doubtful cases. Ferber* has called attention to the fact that the circular, tympanitic " stomach-lung region " {Magen-Lungenraum) formed by the stomach under the lower lobe of the left lung gradually disappears behind the axillary line if the organ be normal, while if it be dilated it may be traced to the vertebral column. Kernig lays stress upon the fact that on examination in the recumbent posture of patients with dilated 6tomachs the dullness in the left lateral region disappears on turn- ing over on the right side, a tympanitic note appearing instead. This does not occur in normal subjects; on the contrary, the dull- ness either persists, or is displaced a little laterally forward, or gives a little less dull note than when recumbent. The same is true if the percussion is done while standing. Yet it is evident, a priori, that this must depend essentially upon the quantity of gas and ingesta in the stomach and intestines; for Kernig also found differences even in healthy persons according to the length of time which had elapsed since taking food, so that there was no distinct dullness in the third to the fifth hour after a meal. On the other hand, I have repeatedly found that when the dilatation is well marked the differences in dullness on postural a goblet of water and drunk in rapid succession. The patient must refrain from belching. If in doubt, we can always resort to inflation with air.—Ed.] * Ferber. Ein Beitrag zur Magenpercussion, etc. Deutsche Zeitschr. f. prakt. Med., 1876, No. 42. 260 DISEASES OF THE STOMACH. changes, as above described, persisted in all stages of digestion and even when fasting. Den-id's method* has been recommended for determining the boundaries of the stomach in normal and pathological conditions. On an empty stomach the patient drinks a litre [quart] of water interruptedly in four portions of \ litre [5viij] each. If, now, after every \ litre we percuss out the resultant lower crescentic limit of dullness against the tympanitic transverse colon, we find in a healthy person, while erect, that the stomach moves downward according to the greater amount of fluid it contains, but that it never extends beyond the umbilicus as a rule, coming only to within a few centimetres [an inch] of the same. In the recumbent posture we get a tympanitic note due to the air swallowed with the water, and this prompt change of the percussion note is a strong proof that we are dealing with the stomach and not perchance with the intestine. I have found, however, that the latter is not time in all cases, for if the transverse colon is markedly dilated and contains watery stools, the same difference in resonance will be observed. Yet this will cause confusion in only a few excep- tional cases. - At the same time, this procedure allows us to recognize the con- ditions of motor insufficiency or atony of the stomach—i. e., its temporary dilatation and its persistent ectasis—which so often is the immediate result of the former; for it is evident that the more re- laxed the gastric walls are, the sooner will the lower boundary of the stomach reach its most dependent position even after the intro- duction of small quantities of fluid, or in cases of marked dilatation it will be found in an abnormally low position at the very com- mencement. [In other words, Dehio's method is an excellent means of determining the tone or contractility of the gastric mus- cular wall.] The conditions which must exist to enable us to use this method of exploration are, of course, that the intestines, and especially the transverse colon, must contain air; that there is no abnormal configuration of the stomach; and, finally, that, the ab- * Dehio. Zur physikalischen Diagnostik der mechanischen Insufficienz des Magens. "Verhandl. des vii. Congresses f. innere Medicin, 1888. DIAGNOSIS OF GASTRECTASIS. 261 dominal walls are not so thick as to entirely prevent the transmis- sion of the more delicate differences in sound. 3. Palpation.—Leube has recommended "palpation of the tip of the tube " in order to recognize dilatation of the stomach. A stiff sound is introduced into the stomaeh until it meets with re- sistance, as far as this is feasible without the employment of undue force. If, now, the point of the sound can be palpated below the level of the umbilicus, dilatation of the stomach is proved to exist. It seems that Leube himself does not value this method very highly; furthermore, it has not become popular on account of the inconveniences connected with it and because the results are doubt- ful. Albutt * is right in saying: "In my opinion palpation of the tip of the sound is unnecessary when the abdominal walls are thin, while in stout persons the instrument can not be distinctly felt." [Boas f has recently called attention to this method and claims excellent results from it. A very long, soft-rubber tube is intro- duced into the stomach', and if the abdominal walls are sufficiently relaxed the tube may readily be palpated along the greater curvature. Experiments made by Schmilinsky *j: show that the tube invariably passes on until it reaches the greater curvature and then glides along it until it reaches the pylorus. According to him, Fig. 3 (page 16) is incorrect. It is to be noted that not the tip, but the tube itself, is palpated. If any doubt exists as to what is palpated, the tube may be withdrawn; while this is being done we may readily feel the tube slip from under the fingers. To avoid errors, the epigastrium ought to be palpated before the introduction of the tube. The examination is made either on an empty stomach or after introducing one to two pints of water. It is best done in the recumbent posture. The instrument moves with respiration, and the position of the pylorus may also be ascertained. The method will not be successful in fat people or patients with rigid abdo- mens. With a little practice the method is easily learned. Boas was * Loc. cit. f [Boas, Centralblatt fur innere Med., February 8, 1896.—Ed.] X [Schmilinsky, Ueber Sondenpalption und die Lage des Magens. Boas's Archiv, Bd. ii, p. 215.—Ed.] 262 DISEASES OF THE STOMACH. successful in 25 out of 30 cases; Schmilinsky failed to feel the sound in only 3 out of 100 cases. My experience with the method is at present rather limited; but, so far as I can now express an opinion, I would say that it promises to be a very useful procedure. Osier* calls attention to the fact that palpation will often en- able us to recognize the position of the pylorus by noting that in following the peristaltic waves the muscular contractions at the pylorus are unusually firm; in some instances the contractions and relaxations remind one of the uterus. Furthermore, in palpating the pylorus region gas may be felt as it gurgles through the pylorus. This is usually marked when the stomach is inflated; but it may also occur spontaneously and at regular intervals. " In doubtful tumors of this region this is a sign to which scarcely sufficient atten- tion has been paid." Another point to which Osier directs attention is that in dila- tation of the stomach the palpation of a pyloric tumor may be very variable from time to time, according to the degree of distention of the stomach. See Figs. 6 and 13 {loc. cit.).] 4. Auscultation.—If we place our hands flat on the region of the stomach and give the abdominal walls a series of rapid consecu- tive shocks, or if we shake the body in toto, we can hear, either at a distance or with the stethoscope, sounds of a splashing character with a faint metallic timbre, the so-called succussion or splashing sounds, the clapotement of the French.f [Succussion sound can usually be brought out best by striking the abdomen with the ulnar side of the hand, care being taken that the abdominal parietes are relaxed as much as possible. By successively striking the abdomen from above downward, and noting where the sounds cease or change in character, we are often enabled to at once determine the solution of the lower curvature. The patient must be in the recum- bent posture.] In themselves they have no pathognomonic signifi- cance. They may arise in the transverse colon as well as in the * [Osier, loc. cit, p. 26.—Ed.] t Audhui. Du bruit de flot ou de clapotage de 1'estomac comme signe de dila- tation de 1'estomac. Gaz. des hopit., 1883, No. 47.—Girandeau. De la dilatation de 1'estomac. Arch, general, de med., 1885, p. 342. Duplay, in 1833, was the first to direct attention to this in France. [Rose, N. Y. Medical Journal, June 15, 1895, p. 739.—Ed.] DIAGNOSIS OF GASTRECTASIS. 263 stomach, and are frequently heard under perfectly normal circum- stances immediately after the ingestion of a large quantity of fluid, when they can readily be produced by short and energetic contrac- tions of the abdominal muscles. They only become pathognomonic (1) when they are present some time after fluid has been taken, and (2) when they are positively produced in the stomach. At times the latter can only be determined by completely emptying (siphon- ing out) the stomach. If, then, the succussion sounds persist, they are to be referred to the intestines. These conditions are frequently disregarded, and a diagnosis of dilatation of the stomach is rashly made. In this way only can we explain the fact that certain French authors (Bouchard and others) find dilatation of the stom- ach not only in every dyspeptic, but that Bouchard finds it present in about 30 per cent of all sick people. This is an exaggeration which is not shared by sober-minded observers like Germain See and Dujardin-Beaumetz. [Bianchi's phonendoscope * promises to be a very useful instru- ment in auscultating the size of the stomach. The method of using it is simple, and my experience with it has been very satisfactory.] Pauli was the first after Penzoldt f to call attention to a sound in the stomach like escaping vapor, similar to that made by uncork- ing a bottle of Selters water, and in fact this can occasionally be recognized on auscultating in the region of the stomach when marked fermentative processes are present. Of a different kind are the sounds called by Kussmaul % " cooing or clapping sounds " {Gurr- oder Klatschger'dusche), which, as I have mentioned above, may be produced in many persons, both with and without dilatation of the stomach, by the active contraction of the abdominal muscles or by rapidly alternating pressure and relaxation on the passive ab- dominal wall. Unlike the succussion sounds, they are best pro- duced in the erect posture. At times we can hear, even at a distance, the heart-sounds re- sounding with a metallic character from the stomach filled with air. * [For details of the instrument and mode of employment, see Schwalbe, Deutsch. med. Wochenschr., July 30, 1896.—Ed.] f Penzoldt. Die Magenerweiterung. Erlangen, 1877. X Kussmaul, in Volkmann's Samml. klin. Vortrage, No. 181. 18 264 DISEASES OF THE STOMACH. Striimpell and Laker* speak of sounds which could be heard at quite a distance and which were isochronous with respiration in a patient with dilatation of the stomach. I have made similar obser- vations, but they are simply to be regarded as curiosities. The note produced in SUibdien-Plessimeter-Percussion f also has a metallic character, and in favorable cases can even be used to define the limits of the organ against the coils of intestine (Leichtenstern). The occurrence of the deglutition murmurs can not be utilized in the diagnosis of dilatation. I have never been able to observe any characteristic change in them, although I have examined every accessible case for this purpose. Rosenbach % has suggested a method which is based upon aus- cultation of air blown through a tube which is introduced into the stomach. If we pour water into a healthy stomach, introduce a tube below its surface, and blow in air, we will then on auscultation hear large, moist, metallic rales, which disappear when the tube is slowly withdrawn as soon as its eye is above the level of the fluid. Therefore the surface of the fluid is assumed to be at the spot where the rales cease to be heard. If, after having thus determined this point, we pour an additional quantity of water, say one litre [quart], into a healthy stomach, we will find that the level of the fluid has become appreciably higher, while in the case of an exist- ing dilatation very little displacement is said to occur. In practice this method is quite difficult to carry out, and may be placed on a plane.with Leube's palpation of the sound, inasmuch as it is un- necessary for the recognition of large dilatations, while in less marked conditions it fails of its purpose. Furthermore, the method is rendered entirely superfluous, because Dehio's method is much simpler. 5. Mensuration of the Stomach.—As already stated on page 92 this may be determined either by ascertaining the volume of air * Berl. klin. 'Wochenschr., 1879, No. 30. Aus den Sitzungsberichten der med. Gesellschaft zu Leipzig.—Laker. Ueber ein rhythmisches Klangphanomen des Magens. Wiener med. Presse, 1889, Nos. 43 and 44. t [This is a form of auscultatory percussion in which the percussion note is elicited by striking a pleximeter with some hard object, as a lead pencil, handle of percussion hammer, etc.—Ed.] X Loc. cit. DIAGNOSIS OF GASTRECTASIS. 265 which can be inflated into the stomach, or by measuring the amount of water which is required to fill it. For this purpose the stomach must be filled as full as possible and then be entirely emptied; but when is it full \ We must either rely on the statements of the patients, who generally experience a distinct sensation when the stomach begins to be more markedly filled, or we must wait till they vomit the superfluous quantity of water. Neither sign can be absolutely depended upon, since the point in question varies with the sensitiveness of the patient and the tone of the gastric muscular fibers, and the capacity of the stomach is so different individually. Therefore the first method is preferable if it is carefully carried out. That the results are variable and not absolute has already been shown (page 92). Ost * has called attention to the fact that even normally a por- tion of the inflated air seems to escape into the intestines; for, after inflation and then emptying the stomach of its air as far as possi- ble, Ost regularly found that the circumference of the abdomen had increased a few centimetres. Kuttner verified this statement by experiments at the Augusta Hospital; in almost every instance the circumference of the abdomen increased 1 to 2 centimetres [f to £ inch]. That gas may readily escape from the stomach into the intestines had been shown in 1SSS by Senn,f in his experiments on dogs into whose stomachs he had inflated hydrogen. But where such gross errors can not be avoided, it is futile to calculate the expansion of the air in the stomach, as proposed by Jaworski, Ost, and Kelling. *J: But, as things stand, we must abstain from laying undue stress upon small differences in measuring the capacity of the stomach, and should only speak positively of an absolutely large stomach when its capacity exceeds 1,500 to 1,600 c. c. [ 51 to liij], although even these figures are not to be taken absolutely, but only as approximate.* * Ost. Beitrage zur Bestimmung der Capacitat des Magens. Inaug. Dissert. Dorpat, 1891. t Senn. Inflation of the Stomach with Hydrogen Gas. Medical News, Aug. 25, 1888. X Kelling. Ein einfaches Verfahren zur Bestimmung der Magengrosse mittels Luft. Deutsch. med. Wochenschr., 1892, Nos. 51-52. * [A very careful study of the mensuration and situation of the stomach, intra- 266 DISEASES OF THE STOMACH. [The use of the gastrodiaphane in determining the size of the stomach has already been discussed on page 96.] Etiology of Dilatation of the Stomach.—Dilatations of the stomach are produced by two etiological factors: (1) mechanical stenoses of the pylorus, (2) absolute or relative weakness of the expulsive forces —in other words, atonic conditions of the muscularis. It is self- evident that in a normally acting stomach the relations between eon- tents, muscular action, and resistance at the pylorus must be in the proper proportion; therefore any change in these factors must lead to a disturbance of function, which in most cases gives rise to dilata- tion of the organ. However, the requisite relationship may be pre- served by compensation, in spite of abnormal change of the indi- vidual factors, and only when this fails do we get functional dis- turbance, just as in cardiac disease there is no circulatory disturb- ance until the compensation of the valvular lesions, etc., becomes inefficient. Oser * has already made use of this explanation as the basis of his discussion of gastric dilatation, and it will also be suffi- cient for us. f For the purposes of compensation the organism has hypertrophy of the muscularis at its disposal; however, it is to be remembered that only rarely does the hypertrophy of the muscular layer manifest itself in an appreciable thickening, but that as a rule it is not recognizable, since the individual fasciculi are separated and at the same time spread out by the dilatation of the organ. How- ever, under such circumstances if it were possible to conceive of the stomach being reduced to its normal size, the amount of muscular tissue remaining the same, we would find this layer quite markedly increased in thickness. In order to gain a satisfactory insight into the nature of dilata- tion of the stomach we must above all recognize the fact that we have always to deal with a consecutive process, a symptom, but not gastric pressure, etc., will be found in Kelling, Volkmann's Sammlung klinische Vortrage, No. 144, Feb., 1896.—Ed.] * L. Oser. Die Ursachen der Magenerweiterung. Wiener med. Klinik, 1881, No. 1. f [Oser has graphically represented this relation in the formula C > I + W, in which C = contractility of the stomach, I = resistance from gastric contents, and W = resistance at pylorus. The results of disturbance of these factors in causing dilatation and the changes which are necessary to maintain the normal relations may be seen at a glance.—Ed.] ETIOLOGY OF GASTRECTASIS. 267 with an independent disease, and that therefore the most varied causes may be involved, as long as they call into existence the pre- liminary conditions soon to be spoken of. To be sure, the clinical picture of dilatation of the stomach, when it is fully developed, is very uniform, and so marked when contrasted with this diversity of the etiological factors, that as a rule it predominates and more or less relegates the original trouble to the background. Yet, for this very reason, it becomes our imperative duty to seek for the cause in every case of dilatation of the stomach, especially since by its recognition the prognosis is by no means immaterially influenced. For, according to the character of this causative factor will there be a transient or permanent condition, a reparable or an irreparable disturbance. We must therefore differentiate, as I have already mentioned at the beginning of this chapter, between functional and organic dilatations; i. e., between those forms of dilatation of the stomach which do not result in a material lesion of the motor appa- ratus together with its nerves—therefore those which can be cured— and those in which the circumstances will not permit such a result because severe degenerative processes have developed in the gas- tric wall. But at times the functional dilatations may even arise acutely; at any rate, they are always of relatively short duration, so that they do not lead at all to the classical symptoms of dilatation of the stomach, or only do so transiently; they run the course rather of dyspeptic conditions peculiar to the special underlying disease of the organ, chronic gastritis, atony, or the neuroses. [Boas and others * have reported cases of acute dilatation of the stomach. This condition may arise either from overloading the viscus, traumatisms, or from central or peripheral nervous causes (see page 290). Rosenheim f also states that he has observed cases in which mechanical insufficiency of the stomach occurred periodically in attacks. The patients in whom he observed this were neuras- thenics.] But it is important not to confound the clinical symptoms of gastrectasis with the anatomical condition of the organ; for the * [Boas. Deutsch. med. Wochenschr., 1894, pp. 155 and 172; Rosenheim, Magen- krankheiten. 2te Aufl., p. 452.—Ed.] f [Rosenheim, loc. cit, p. 453.—Ed.] 268 DISEASES OF THE STOMACH. clinical picture is primarily a series of symptoms caused by fer- mentation and stagnation of the chyme which are usually, but not always, due to a dilated stomach, yet which may arise whenever stagnation and decomposition of the stomach contents occur from any cause. It is well, therefore, to distinguish dilatation proper from the symptoms of gastric fermentation, wdiich may at times be present without any dilatation whatsoever. A case of the latter I shall describe later on. The mechanical factors which lead to the stenosis or occlusion of the pylorus are situated either in the wall of the stomach itself or extend to it from without. Among the most frequent causes of the former class and of prime importance are carcinoma and cica- tricial contraction, whether this be due to direct cicatrization of an ulcer, or produced by inflammatory processes following ulcer or phlegmonous gastritis. Cicatrization is usually due to ulcers situ- ated near the pylorus', the healing of which causes not alone a ste- nosis but also frequently a thickening of the pylorus, which may even be palpated through the abdominal walls, and which may be mis- taken for a malignant neoplasm. As will be shown later, this error may be avoided by the examination of the stomach contents. At all events, cicatrization of ulcers is a quite frequent cause of dila- tation. Neoplasms at the pylorus usually involve the greater part of its circumference, or may surround it entirely like a ring; or they may be situated above the pylorus and have warty or polypoid excrescences, which force themselves into the orifice somewhat like a cork. I observed such a condition in a case in which a very vas- cular polypoid tumor, larger than a walnut, was situated on the pos- terior wall of the stomach, its base being about 3 centimetres \1\ inch] above the pylorus, and which during life must have more or less completely occluded the passage like a ball valve according to its vascularity ; the pylorus, although somewhat narrowed, would easily admit the little finger (Fig. 36). Bernabel * reports a similar case, which is remarkable, however, by the formation of true pe- dunculated polypi. The largest was 6*8 centimetres [2| inches] in * Bernabel. Contribuzione al etiologia del vomito mecanico da polypo gastrico. Rivist. clin. di Bologna, 1882. ETIOLOGY OF GASTRECTASIS. 269 length, and was situated on the anterior wall of the stomach, 5 centi- metres [2 inches] above the pylorus. On the other hand, it is self-evident that all stenoses of the duo- denum, especially of its superior horizontal portion, must also cause dilatation of the stomach. In Cruveilhier * may be found the draw- ing of a tumor, about the size of a potato, situated in the duodenum immediately below the pylorus, which must have had the same effect as a true pyloric stenosis. Unique among such obstructions is the case described by Pertik,f in which a diverticulum shaped like a glove-finger was situated in the duodenum at the level of Vater's papilla, which, according to the degree to which it was filled by the chyme coming from the stomach, must have prevented its passage through the duodenum. Pertik endeavors to explain the origin of this diverticulum as being due to an unusually well developed fold of mucous membrane which was gradually made larger by the pres- sure of the chyme, in the same way as similar semilunar, diaphragm- like reduplications of mucous membrane have been observed by Deiters *{: (Grawitz) at the pylorus and also in other parts of the small intestines. Congenital stenosis of the pylorus may also be included among the mechanical constrictions; such cases have been described by Landerer,* Maier, || and Hirschspring.A There may be either a round or a slit like contraction of the ostium pylori, or the muscu- lar portion of the pylorus may be hypertrophied, and the pyloric portion of the stomach present a spherical or conical appearance, in which latter case it projects into the duodenum like the cervix uteri into the vagina. This hypertrophy, by the way, can readily be dis- tinguished from the form produced by chronic catarrh of the mu- cous membrane. It is very apparent that such stenoses may cause * Cruveilhier. Anatomie pathologique du corps humain. Livr. 4, p. 1. f 0. Pertik. Beitrag zur Aetiologie der Magenerweiterung. Virchow's Arch., Bd. 114, S. 437. X Deiters. Beitrage zur Aetiologie der Magenerweiterung. Inaug. Dissert. Greifswald, 1889. * Ueber angeborene Stenose des Pylorus. Inaug. Diss. Tubingen, 1879. || R. Maier. Beitrage zur angeborenen Pylorus-stenose. Virchow's Arch., Bd. cii, S. 413. A Hirschspring. Falle von angeborener Pylorusstenose. Jahrbiich. fiir Kinder- heilkunde, 1888, Heft 1. 270 DISEASES OF THE STOMACH. Fig. 36.—Very vascular, polypoid tumor, on posterior wall of stomach, H inch above the pylorus. ETIOLOGY OF GASTRECTASIS. 271 the development of a dilatation as soon as the expulsive power of the pyloric portion of the stomach is unable to overcome them —in other words, as soon as the antrum pylori passes from the stage of hypertrophic compensation into that of insufficiency. When this will occur depends naturally upon individual circumstances. While in these cases the obstruction to the emptying of the stomach is manifest, in other cases we find the pylorus patent after death, and yet have dilatation of the stomach, for which the factors of ab- solute or relative muscular insufficiency, soon to be discussed, can either not be applied or are not sufficient to account for it. Kussmaul * has shown by experiments on the cadaver that with great relaxation of the abdominal walls the pylorus may assume a vertical position due to the rotation of the full stomach, and at the same time so twist and compress the horizontal portion of the duo- denum at its junction with the stomach that not a drop of fluid can escape into the duodenum. As can readily be understood, the lumen of the intestine may be occluded by bending, not at the py- lorus, but somewhat below it, where the horizontal curves into the descending portion ; this takes place when the stomach is filled and its ligaments are relaxed, so that it drags the horizontal portion of the duodenum down with it. If, in addition, there exists a constrict- ing stenosis of the pylorus, then dilatations of the duodenum, in the form of ampullae, may be added to the dilatation of the stomach, as is typically depicted in the accompanying drawing, taken from a paper by Cahn,f which at the same time gives a good idea of the position of the stomach in marked dilatation (Fig. 37). An additional factor may perhaps be found in the following: While under the usual circumstances the demarcation of the pylo- rus from the duodenum consists only in a slight constriction or in- cline, but passes perfectly smoothly on to the stomach, we occasion- ally find an actual ring, so that on section of the stomach the pylorus looks as though a cord had been drawn underneath the mucous membrane. A small pouch is consequently formed on the gastric side of the orifice, which may easily become dilated from the pres- * Loc. cit \ Cahn. Ueber antiperistaltische Magenbewegungen. Deutsch. Arch. f. klin. Med., Bd. xxxv, S. 414. 272 DISEASES OF TnE STOMACH. sure of food, and thus gradually lead to a true dilatation. Neces- sarily, an uncommonly firm closure of the pylorus would be requi- site for this to occur—i. e., a spasmodic contraction. Fig. 37.—Cancer of pylorus, with dilatation of stomach and duodenum. Distance of the greater curvature from the symphysis = 4 ctm. [lg inch]. Portion of the oesophagus in the abdominal cavity = 4 ctm. [If inch]. Length of lesser curvature = 10 ctm. [4 inches]. c = carcinoma, p = pancreas ; it has sunk behind the lesser omentum to the level of the second lumbar vertebra, d = horizontal portion of the duodenum; its ver- tical portion descends to the pelvic brim. ETIOLOGY OF GASTRECTASIS. 273 Finally, spastic contraction of the pylorus [pylorospasm] may cause dilatation. Such a condition was very obvious in the case on which Sanctuary * performed an autopsy. The pylorus was quite patent, but above it lay an egg-shaped ulcer, surrounded by normal mucous membrane, 2^ inches long and 1 inch wide, the irritation of which, from the movements of the food, evidently produced a marked spastic contraction of the entire pyloric region. A pro- nounced dilatation of the stomach had been diagnosticated during life. However, of all the causes which have been brought forward to account for dilatation, where there is no tangible narrowing of the pylorus, spastic contraction appears to me to be the most doubt- ful ; for it lies in the very nature of spastic contractions that they do not persist continually, but relax at times—consequently, that they can not produce any lasting obstruction. According to our present experiences, which appear to be pretty generally recognized, spasm of the pylorus is produced by excessive acidity of the stom- ach contents ; according to this, all cases of hyperacidity would finally have to lead to dilatation of the stomach, which, at least as far as our present knowledge goes, is surely not the case.f It is at all events true that many cases of gastrectasis without mechanical obstruction are accompanied by excessive and untimely secretion of II01, yet it remains doubtful whether a spasm of the pylorus or an overloading of the stomach as the result of incomplete diges- tion of carbohydrates is the exciting cause. A well-observed case of this, with reference to the final result, is that reported by Nauwerk : $ A woman, twenty-three years old, had suffered for ten months with slight dyspeptic manifestations. After swallowing some cherry pits symptoms of closure of the pylorus suddenly appeared, continuous, obstinate vomiting, and absolute constipation. Death followed three months later. The muscular layer at the pylorus was found to be 7 millimetres [£ inch] thick, the mucosa 4 to 5 millimetres [4, inch], the serosa 2 millimetres [ ^inch], the pyloric orifice being quite patent. No . * Sanctuary. Notes of Cases of Dilated Stomach, with Remarks. British Med. .Journal, 1883, p. 613. f [Fleiner (Boas's Arch., Bd. i, Heft 4) believes that spasm of the pylorus occurs frequently in the hyperacidity which accompanies ulcer of the stomach, and may even explain the frequency with which ulcers occur near the pylorus.—Ed.] X Xauwerk. Ein Fall hypertrophischer Pylorusstenose mit hochgradiger Ma- generweiterung. Deutsch. Arch. f. klin. Med., Bd. xxi, pp. 573-580. 274 DISEASES OF THE STOMACH. neoplasm could be found either on macroscopic or microscopic examina- tion. There were ten cherry pits still present in the enormously dilated stomach. The causes, situated external to the stomach, which may lead to stenosis or occlusion of the pylorus, are either tumors which exert pressure upon the pyloric orifice (or the duodenum), or which em- brace and grow around it; such neoplasms arise either from the pancreas, the omentum, the retroperitoneal glands, or the liver. Minkowski * reports a rare occurrence of this kind, in which he observed a hard tumor which was considered a cancer of the pylo- rus during life, combined with dilatation of the stomach, but which after death was found to be the gall bladder entirely filled by a large calculus; this compressed the pylorus completely and led to the enormous dilatation. In this case examination for hydrochloric acid would have definitely excluded carcinoma, even though, as we shall see later, this is not positive ; at any rate, it is at times abso- lutely impossible to differentiate between tumors of the liver or gall bladder, or biliary calculi and neoplasms of the stomach. A number of cases have recently been published *f* in which gallstones were either wedged in the orifice of the common duct or stenosed the intestines or produced fistulous tracts with annular cicatricial strictures; or the stones had perforated the intestines directly after adhesions between the gall bladder and the intestines had been formed. Further, if an old peritonitis gives rise to cicatricial bands which surround the pylorus or force it toward the posterior abdominal walls, and make traction upon or bend the pylorus—or the horizon- tal portion of the duodenum—we may also get pyloric stenosis. Rokitanski-j: has seen cases of gastrectasis which were caused by * 0. Minkowski. Ueber die Gahrungen im Magen. Mittheilungen aus der med. Klinik zu Konigsberg in Preussen. p. 163. t Grundzach. Ueber Gallensteine im Magen. Wiener med. Presse, 1891, No. 28. —A. Smith. Some Clinical Points on Gastrectasia. N. Y. Medical Record, February 4, 1888. [Bouveret (Revue de Medecine, January, 1896) reports additional cases of pyloric stenosis due to gallstones. He calls attention to one symptom which is characteristic of stenosis due to fixation of the pylorus by adhesions—i. e., the vomiting and other symptoms of dilatation persist as long as the patient is active and on his feet, but cease as soon as he rests in the recumbent posture. Abstracted in Amer. Journ. Med. Sciences. June. 1896, p. 728.—Ed.] X Rokitanski. Handbuch der pathol. Anatomie, Bd. ii, S. 178. ETIOLOGY OF GASTRECTASIS. 275 large scrotal herniae exerting traction upon the stomach and dislo- cating it (and possibly also bending the duodenum ?). Bartels was the first to call attention to the joint occurrence of wandering kid- ney on the right side and dilatation of the stomach, accounting for the latter by the pressure made by the kidney upon the duodenum; this form can not become marked unless its existence dates from childhood. Malbranc * agrees with him, and Schiitz f reports the case of a woman whose difficulties rapidly disappeared on leaving off her corsets, which were supposed to have exerted pressure on the dislocated kidney. Furthermore, Litten has called special atten- tion to the connection between diseases of the stomach and change in position of the right kidney,*}: and has seen displacement of the right kidney and dilatation of the stomach occurring together in no less than 55 per cent of his cases. This proportion may seem rather high, yet according to Kuttner's researches# it can not be much above the correct figure. But a floating kidney is by no means an indispensable feature in every dilatation of the stomach, since Len- hartz | was unable to find a floating kidney in any of the 16 cases of dilatation which he examined for this purpose. Therefore I agree with Oser, Nothnagel, and Leube,A and wish to emphasize the fact that no causal relation exists in the majority of cases, but that it is a simple coincidence, and that, as has been conclusively shown by Kuttner, in many cases of so-called dilatation with float- ing kidney there is no gastrectasis, but either a megalogastria or a gastroptosis which has deceived inexperienced observers. At all events, Bartel's views are untenable, because any pressure which the right kidney might exert on the duodenum necessarily requires that this kidney be fixed ; but its characteristic is just its mobility; hence it slips away, and it is only necessary to have seen in an animal how energetically the intestinal contents are forced on to appreciate how * Malbranc. Ein complicirter Fall von Magenerweiterung. Berl. klin. Woch- enschr., 1880, No. 28. f E. Schiitz. Wanderniere und Magenerweiterung. Prager medicin. Wochen- schr., 1885, January 14th. t Verhandlungen des Congresses fiir innere Medicin. Wiesbaden, 1887, S. 223. 9 Kuttner. Ueber palpable Nieren. Berl. klin. Wochenschr.. 1890. || Lenhartz. Beitrage zur moderne Diagnostik der Magenkrankheiten. Deutsch. med. Wochenschr., 1890, No. 7. A Loc. cit, S. 225. 276 DISEASES OF THE STOMACH. easily such an obstruction could be overcome. I think Landau * is right when he says that, even for physical reasons, the kidney would be unable to exert the necessary pressure on the gut. The second great group of dilatations of the stomach arises from weakness of the gastric muscle, and differs from that first spoken of in that, as a rule, the stomach is dilated only to a slight degree, while the hypertrophy of the muscularis is absent. I shall describe these conditions as atonic gastric dilatations caused by asthenia or akinesis [a, without, /civea), I move]\ of the stomach. Predisposing factors are: 1. Weakening of the muscular tone, due either to excessive de- mands (perhaps traumatisms ?) upon the muscle and its gradual relaxation, or to insufficient nourishment of the contractile elements of the gastric wall in anaemia, chlorosis, nervous affections, acute and chronic diseases of an exhausting nature, peritonitis, amyloid degeneration of the vessels. Thus we find that chronic gastric catarrh must also be included among the etiological factors of dilatation of the stomach. Since the catarrhal condition causes the ingesta to remain for a longer time than normal in the stom- ach, it is overburdened, and a relaxation of the muscle is pro- duced, which, as we shall see when speaking of atrophy of the stomach, finally leads to separation of the fibers of the submucosa and muscularis; dilatation of the organ is the result, just as the bladder, when affected with catarrh, finally becomes the seat of paralytic dilatation. It is in this sense that we must understand Clozier X when he includes deficient hygiene in combination with continual erect position of the body among the causes of dilatation of the stomach. But some writers believe that dilatation is not caused alone by the chemical insufficiency which is associated with gastric catarrh, but also, on the contrary, by the excess of function, * Landau. Die Wanderniere der Frauen. Berlin, 1881, S. 44. t The ancients called conditions of this kind frigiditas stomachi. Todd was probably the first to use the term atony; Andral introduced the phrase dyspepsie par asthenic de 1'estomac ; Broussais designated it dyspepsie asthenique. The most varied dyspeptic conditions were included under this.term. X Clozier. De la dilatation dite primitive de 1'estomac. Bull, med., 1888, p. 1245. ETIOLOGY OF GASTRECTASIS. 277 hyperchlorhydria, and hypersecretion, which delays the digestion of the starches, the stomach being emptied either not at all or only very late. The weakening of the walls of the stomach is not only brought about by overloading the stomach with improper quantities of solid masses, with which the muscle is unable to cope, but also by the abnormal production of gases in the stomach, together with closure of the orifices; the latter may be of a mechanical nature from the commencement, and due to one of the aforementioned factors, or may be due to the occurrence of an abnormal fermentation of the ingesta, which only leads secondarily to muscular insufficiency. As we know best from our observations upon the intestines, the prod- ucts of fermentation, when absorbed, cause an irritation of the mus- cle, which, as long as the contractility is intact, probably leads also to the simultaneous closure of the sphincters, and in this way causes an abnormally long detention of the fermenting masses in the stom- ach. Later} owing partly to mechanical distention, partly to the venous stasis intimately connected therewith, structural changes are produced in the mucosa and muscularis; also paresis and degenera- tion, and thus, finally, muscular insufficiency of the organ. Thus it is that we find dilatation of the stomach so frequently in gluttons, diabetics, insane patients with polyphagia, etc.; it may also develop from chronic gastric catarrh, or (probably most frequently) it may arise from a combination of both causes. It is especially due to Naunyn,* and his pupil Minkowski, f that these processes have been properly considered. 2. Weakness and paralysis of the motor nerve-fibers of the stomach, or diminished excitability of the nervous apparatus pre- siding over peristalsis, may be caused by local lesions, such as de- struction by ulceration of the branches of the vagus entering the stomach (Traube), or by processes of inhibition arising from other portions of the nervous system—for instance, the paralyzing influ- ence exerted by chronic peritoneal exudations (Bamberger), or even by a simple catarrh of the stomach, just as paralyses of the muscles * B. Naunyn. Ueber das Yerhaltniss der Magengahrung zur mechan. Magen- insufficienz. Deutsch. Arch, fiir klin. Med., Bd. xxxi, S. 225. t Minkowski, loc. cit. 278 DISEASES OF THE STOMACR of the vocal cords are produced by laryngeal catarrh. To this is also due the occurrence of dilatation in general neuroses and gas- troptosis and enteroptosis, conditions which will be described later on. Perhaps it is here that we must include those rare cases of atonic dilatation of the stomach which, quite contrary to the ordi- nary course of events, develop as the result of chronic obstinate constipation, when, as a rule, just the opposite occurs. We know that there is no sharp line of demarcation between the peristalsis of the intestines and that of the stomach, but that, rather, the peri- stalsis of the upper portion of the intestines can be obliterated by the contractions of the stomach, as Braam-Houckgeest * has shown. On the contrary, persistent sluggishness or paresis of the intestines may give rise to diminished peristalsis in the stomach. G. See and Mathieu f have also called attention to this point. I saw a very striking example of this in a lady thirty years of age, who had suf- fered with obstinate constipation since childhood (the trouble, as is not at all infrequent, was hereditary in her family), and who, in the course of my observations, extending over a period of two years, although she had never before complained of stomach trouble, ac- quired a typical dilatation of the stomach, without, it is true, any marked signs of decomposition, but yet without any other referable cause. 3. Finally, the expulsive powers may be weakened by the ex- clusion of a more or less sharply defined portion of the muscular fibers of the stomach. Circumscribed cancerous infiltration and ulcerations which do not stenose the stomach but destroy a portion of its muscle, result at times, if their growth be slow enough, in hypertrophic dilatation of the stomach. [Infiltration of the muscu- lar layers occurs very early in cancer of the stomach, long before there is any stenosis of the pylorus. This early weakening of the gastric motility in cancer, combined with the absence of HCl, ex- plains the early occurrence of lactic acid in this disease.] A simi- lar condition is produced when broad bands of the muscular * Ewald, Klinik, etc. I. Theil, 3te Aufl., S. 192. f G. See et Mathieu. De la dilatation atonique de 1'estomac. Rev. de med., May 10 and Sept. 10, 1884. A. Mathieu. Les phenomenes nervo-moteurs de la dyspepsie gastrique. Gaz. d. hopit., 1888, No. 47. PATHOLOGY OF GASTRECTASIS. 279 layer of the stomach are destroyed by inflammatory or ulcerative processes, and cause partial dilatation behind the site of the ob- struction or complete gastrectasis. Yery instructive pictures of this process may be seen in Cruveilhier's celebrated Atlas of Patho- logical Anatomy.* Pathology.—I have already discussed the gross anatomical changes, the variations in the size of the dilated stomach, and the changes in the position of the neighboring organs produced there- by. At present the changes in the individual coats of the stomach are of special importance. It has been known for a long time that the muscularis may be totally or partially thickened, or apparently normal or thinned; a distinction has thus been made between hy- pertrophic and atrophic forms. Hypertrophy of the muscularis preponderates in the pyloric region, and occurs most frequently with cancerous or cicatricial stricture of the pylorus. Whether in such cases there is a true hypertrophy, or only an apparent thicken- ing of the muscular wall of the stomach on account of infiltration with cancerous elements, can frequently be decided only by care- ful microscopic examination. In the chronic inflammatory forms Lebert f claims to have found an increase in the thickness to 14 millimetres [j7^- inch] ; generally it amounts to 5 to 6 millimetres [£ inch], which is quite considerable. This he regards as the result of a chronic hypertrophic inflammation of the muscularis. There can be no doubt that the hypertrophic form may gradually pass into the atrophic. The former occurs more frequently in youthful in- dividuals, the latter, without exception, in the aged; so that in the numerous cases of dilatation of the stomach in old people on whom I have performed autopsies I have never found hypertrophy of the muscularis, it being much oftener, in fact in the majority of cases, of normal thickness and far less frequently thinned. The individ- ual muscle fibers are normal in appearance; the nuclei stain well with picro-carmine. Since 1S74 I have examined a large number of dilated stomachs microscopically, but I have never found hyper- trophy of the individual muscle cells of which Lebert speaks, nor degeneration of these cells into a gelatinous mass (colloid degenera- * [Anatomie pathologique du corps humain. Paris, 1830-1842, 2 vols.—Ed.] f Lebert, loc. cit, pp. 525 et seq. 19 280 DISEASES OF THE STOMACH. tion), as described by Kussmaul and K. Meyer, and also found by Cahn; frequently there existed a more or less extensive fatty degeneration. The interspaces between the individual muscular fasciculi appear enlarged and traversed by strands of connective tissue. Yery often an infiltration of small cells is present, proceed- ing from the submucosa. The latter forms a wide-meshed tissue studded with numerous round cells with its vessels widely dilated. The mucous membrane presents the picture of chronic gastritis in its different stages. In the glandular cells of the mucosa there is no change at all in many places; in others they are markedly cloudy and granular; in still others they show cystic degeneration, or have entirely disappeared in a round-celled infiltration, which also fills and forces the meshes of the interstitial tissue apart. No- where can we recognize that they are hypertrophied. Neither do they appear to be increased in number. The interstitial tissue is considerably thickened and studded with numerous round cells; those ducts of the glands which are present are forced apart and separated by wide intervals, while normally they lie close together (Fig. 38). I have never found conditions which pointed to new formation or increase (hyperplasia or hypertrophy) of the glandu- lar substance. In the great majority of cases the mucous mem- brane is spread smoothly over the muscularis, and is thinned rather than thickened ; yet in the rare forms of hypertrophic dilata- tion the condition which the French call etat mammelone is developed, owing to the unequal growth of the mucosa and the muscularis, which leads to the former being thrown up into folds. At first the dilatation of the stomach is found specially at the cul-de-sac; later on it involves the whole organ. A pathological curiosity are the rare dilatationlike diverticula which are due to the persistent pressure of indigestible substances (coins, etc.) in the stomach. Symptoms of Gastrectasis.—As a rule, patients with dilatation of the stomach, as may be inferred from the nature of its causes, are middle-aged or more advanced in years. Yet the more extensive my experience becomes, the more am I astonished at the frequency with which it occurs in younger persons, and is not recognized. PATHOLOGY OF GASTRECTASIS. 281 According to Pauli,* stenosis of the pylorus may be congenital and may give rise to dilatation. Andralf speaks of children being born with stomachs which filled the greater portion of the abdominal cavity. Similar observations have frequently been made, and only Fig. 38.—Cross-section through the mucous membrane of a dilated stomach. The ducts of the glands are forced apart, the interstices entirely filled by an infiltration of small cells. The glandular epithelium is unchanged in part, partly fatty, and in some places entirely gone. Single epithelial cells may be seen in the interstitial tissue.—Camera lucida. a short time ago at the Augusta Hospital I found a marked dilata- tion of the stomach in a girl 13 years of age who claimed to have heard succussion sounds (which were very evident at the examina- tion) since her earliest childhood. During the past few years I have frequently seen cases of more or less marked dilatation in young patients between 12 and 17 years old, in none of which could a manifest cause for its origin be discovered. Wiederhofer, % * Pauli. De ventriculi dilatatione. Frankfurt a. M.. 1839. f Andral. Grundriss der pathol. Anatomie. Edited by Becker, 1830, ii, S. 91. X Wiederhofer. Gerhardt's Handb. d. Kinderkrankheiten. Bd. iv, Abtheil. ii, S. 356 et seq. 282 DISEASES OF THE STOMACH. Comby,* Malibran,f and others, have demonstrated and carefully studied dilatation of the stomach in children which they have ascribed to atonic and anaemic conditions. My own experience in the polyclinic of the Augusta Hospital shows that marked dilatation is by no means rare in children, although they are as a rule so well compensated that the symptoms presented are only dyspeptic, and not those due to fermentation. Before discussing the symptomatology of dilatation, I wish to state that we not infrequently see cases which present the typical clinical picture of gastric dilatation and yet in which there is no true dilatation of the stomach. I shall designate such cases, as O. Rosenbach has done, % gastric insufficiency, or better, motor insufficiency, of the stomach. I shall again refer to this later on. [Recently most writers have grouped all cases of gastrectasis under the general heading of mechanical insufficiency of the stomach, and have subdivided them according to the severity of the motor dis- turbance.] The symptoms of dilatation of the stomach always develop slowly. As a rule, dyspeptic troubles are the first to appear, and they may last for years ; indeed, they may be the only symptom of a well-developed dilatation. Thus it is that the latter is discovered only on a very careful examination of the patient. This occurred to me not long ago in a young man whose father, a physician, had given him a letter with an explicit description of the symptoms on which he had based the diagnosis of nervous dyspepsia. In addi- tion to the dyspeptic difficulties—anorexia, pressure and fullness after eating, tension of the abdomen, bad odor from the mouth, coated tongue, epigastric tenderness, malaise, oppression and pain in the head, irregular stool, etc.—we have a characteristic symptom in vomiting. At first this occurs frequently, and comparatively soon after eating, being to a certain extent a therapeutic effort of the organism to relieve itself of the excess of the ingesta, while a * Comby. De la dilatation de 1'estomac chez les enfants. Arch, gener. de med., Aout et Sept., 1884. t Malibran. Contribution a l'etude des ectasies gastriques. These de Paris, 1885. X 0. Rosenbach, loc cit, SYMPTOMS OF- GASTRECTASIS. 283 portion is retained in the stomach, as urine is in a paralyzed blad- der. Later the vomiting occurs less frequently in proportion to the increasing relaxation of the muscle and as the quantity of the collected masses to be evacuated becomes greater; finally—and this is always a bad omen—it ceases entirely. Then either the ob- structing neoplasm has ulcerated, thus again opening the passage into the intestine, or a complete paralysis of the muscle has been developed. A characteristic feature of the vomit is its large quan- tity, which in individual cases has been quite astonishing, and is said to have been as much as 8 kilogrammes [17f pounds]. Portal says that the stomach of the Due de Chausnes, one of the greatest gourmands in Paris, could hold eight pints of fluid ; and even larger figures are given. [Liebermeister * gives the details of the case of a hackman who was noted for the enormous quantities of beer which he could swallow at a single draught. The autopsy which was made after his death from an accident showed that the capacity was 6 litres [13 pints], but otherwise the organ was normal. Characteristics of Stomach Contents.—It is well known that at times more is vomited than has been eaten, since the remnants of former meals which accumulate in the stomach are added. If the vomit, or the masses removed from the stomach through the tube, are allowed to stand in a glass cylinder, they soon separate into three layers, the upper one of brownish foam, a much larger middle layer of yellowish-brown, faintly cloudy fluid, and a lower one consisting of dark-brown, crummy, and slimy masses, chiefly remains of food. From time to time bubbles of gas rise up through the fluid, carrying particles of the deposit with them, while other fragments sink, since they are no longer supported by the carbonic-acid gas. Such a play of bubbles, similar to that which we see in a glass of champagne in which bread crumbs have been placed, always indicates considerable yeast fermentation. Further, we find the morsels of food in the vomit in a more or less softened and digested condition ; we also find varieties of mucor, sarcinae, yeast, and numberless schizomycetes. At Kussmaul's in- * [Liebermeister. Die Krankheiten des Unterleibsorgane, 1894, p. 70. Quoted from Boas.—Ed.] 284 DISEASES OF THE STOMACH. stigation Du Barry* examined these vegetable forms more care- fully, and isolated them in pure cultures, but, it is to be regretted, without obtaining any definite pathognostic result. We are not justified, from the observations made by this author, in inferring a fermentative action from the presence and growth of the fungi. At all events, bacteria, yeast, and probably sarcinae also have a definite typical fermentative action. Sarcinae ventriculi, those pe- culiar colonies of cocci which occur in cubes or as tetrads, were first described by Goodsir in 1842; the extensive literature which has been written about them since then has been collected in detail by Falkenheim.f [See Fig. 41.] It is a matter of regret that the pathognostic significance of the parasite does not deserve the in- terest which was accorded to it by physicians. As early as 1841) Frerichs apologized for speaking about a subject " the literature of which is perhaps more extensive than its importance warrants" ; thus Falkenheim also was unable to add anything new as to their oc- currence or significance, while he established the important fact in the natural history of sarcinae that at times, according to external circumstances, the same cocci may form either irregular masses or typical sarcinae. Usually sarcinae are present in small numbers or are entirely absent, yet at times in conditions favorable to their growth they may appear in large masses, so that every drop of stomach contents is really a pure culture of them; indeed, F. Richter *{; reports a case in which the inspissated masses of sarcinae had led to complete closure of the pylorus. [The relations of sar- cinae ventriculi have recently been studied by Oppler,* who found that they occurred in large numbers only in gastrectases due to benign stenoses of the pylorus ; where the cause of the latter is malignant they are rarely found. Oppler would explain this by the fact that sarcinae only thrive in the presence of HCl.] How- ever, if large numbers of micro-organisms are present in the stom- ach contents in spite of the free hydrochloric acid, or if the reaction * Du Barry. Beitrag zur Kenntniss der niederen Organismen im Mageninhalt. Arch. f. exp. Pathol, u. Pharmacol., Bd. xx, p. 243. t Falkenheim. Ueber Sarcine. Arch. f. exp. Pathol, u. Pharmacol., Bd. xix. X Richter. Verstopfung des Pylorus durch Sarcina ventriculi. Virchow's Arch., Bd. cvii, p. 198. 9 [Oppler. Miinch. med. Wochenschr., 1894, No. 29.—Ed.] SYMPTOMS OF GASTRECTASIS. 285 be neutral, or if the acidity be due to organic acids, there is imme- diately such a development of fungi in the filtrate that the variety of the predominating fermentation may be recognized even by mere inspection. Thus we may find mold fungi—and this even in the presence of the hydrochloric-acid reaction in the filtrate—in the form of a white or gray scum upon the surface; or, after being cloudy at first, yeast may be deposited at the bottom of the vessel ; or a more equally diffused turbidity, together with a strong sour odor, may be produced by the development of the lactic, acetic, and butyric acid bacilli; or, finally, white zooglea masses, which readily fall apart, may form upon the surface. These finally lead to com- plete decomposition of the albumen, and to an alkaline reaction, the process being accompanied by the odor of decay. At times the vomit contains remnants of food, such as pits, fish scales, etc., which, as the patients can prove, had been eaten months before. Werner * found 17 plum and 920 cherry pits in a dilated stomach, which must have stayed there since the previous cherry season—i. e., fully three quarters of a year. But at times such things remain in stomachs which are not dilated. Thus in the stomach contents obtained from a neurasthenic I found a small piece of fish skin, which, according to the positive statements of the patient, must have been in the stomach for three and a half days. The chemical relations of the gastric juice in gastrectasis depend upon the cause of the dilatation. Should a cancer be present, we will find all the anomalies of secretion, which will be explicitly dis- cussed in the chapter on Carcinoma of the Stomach. If, on the other hand, we have to deal with cicatricial contractions of the pylorus, atonic conditions of the muscular fibers, hypersecretion, etc., we find almost without exception either the usual or increased quantities of hydrochloric acid, peptone, and propeptone, and the peptic action is satisfactory, though usually somewhat retarded. But even in the same patient and with the same diet the quantity of nCl may vary on different days, so that variations from 0*07 per cent to 0*28 per cent may be found. It is by no means rare to find * Werner. Zur Casuistik des Magenkrebses, etc. Wlirtemberg. med. Corre- spondenzbl., 1869, 22-24. 2S6 DISEASES OF THE STOMACn. hypersecretion (hypersecretio acida continua), so that after empty- ing the stomach in the evening, on the following morning we may obtain fluid containing HCl sometimes in considerable amounts. In 33 cases Riegel* found 0*10 to 0*46 per cent HCl; in 6S cases which I titrated, the acidity due to hydrochloric acid varied be- tween 50 and 80 = 0*17 to 0*30 per cent of that acid. Fermentations.—However, this picture of the normal condition of secretion is complicated by the fermentations which take place in the stomach, and which cause secondary decompositions of the stom- ach contents. In another place f I have given the schema of the fermentation of carbohydrates, which, depending upon the abnormal decomposition of sugar, appears at times in the form of the so-called oxidation-fermentation, alcohol, aldehyde, and acetic acid being formed from the sugar; or at other times lactic acid fermentation sets in, in which the sugar is first decomposed into lactic acid, and later into butyric acid, carbon dioxide, and hydrogen. Both fer- mentative processes are due to the presence of specific organized fer- ments, among wdiich we can name yeast, oidium lactis, and a num- ber of bacteria, the recognition and isolation of which are to be especially ascribed to Hiippe. Both processes may occur together, and in rare cases may be combined with the products of cellulose fermentation ; though it is questionable whether the latter—namely, methane, and sometimes olefiant gas—are derived from the stomach, or whether they have not rather regurgitated from the intestines into the stomach. The best-known case of this kind is that de- scribed by Ruppstein and myself, *j: of a patient who, according to his own statement, " had at times a vinegar factory and at others a gas factory in his stomach," in whom, therefore, the fermentation was sometimes combined with a predominant production of acid, and at other times caused a collection of gas. When the latter condition was present, he could ignite the eructated gases through a little roll * Riegel. Beitrage zur Diagnostik und Therapie der Magenkrankheiten. Zeit- schr. f. klin. Med., Bd. xi, Hefte 2 u. 8. f Ewald. Klinik, etc. I. Theil, 3te Auflage, S. 125. [See also Boas, Therap. Monatshefte, January and February, 1896, for a good resume of the fermentation and changes in the stomach contents in gastrectases.—Ed.] X Ewald. Ueber Magengahrung und Bildung von Magengasen mit gelb bren- nender Flamme. Reichert's und Du Bois' Archiv, 1874, S. 217. SYMPTOMS OF GASTRECTASIS. 287 of paper or a cigar-holder, by holding a lighted match in front of it; the result was a faintly illuminating flame. In the vomit Rupp- stein demonstrated the presence of alcohol, acetic, lactic, and butyric acids, while I found the gases to be composed of carbon dioxide, hydrogen, methane, traces of olefiant gas, oxygen, nitrogen, and sul- phureted hydrogen. Similar observations have been made by Schultze, Heynsius, and Popoff; a gas-forming bacillus has been isolated from the stomach contents by Miller, the activity of which only ceases in 1*6 per mille HCl. The gas produced contained only Coa and II. A similar case of McNaught's has already been referred to (page 161). The formation of gases in the contents of dilated and catarrhal stomachs has been systematically studied by both G. Hoppe-Seyler and Kuhn.* According to the former, the occur- rence of inflammable gas is by no means a rarity, for in 13 out of 22 cases he could obtain a gas from the stomach which consisted of a mixture of Co„ and H ; the amount of the latter was as high as 60 per cent, and was the result of butyric acid fermentation which may take place even when there is as much as 0*2 per cent HCl. The same conclusions were reached by Kuhn (who studied the gases which developed in the stomach contents after their removal, the organisms of fermentation, etc.). The methods used by both of these investigators are too complicated for general practice. [Strauss has recently shown that the bacillus coli communis produces gas when grown on culture media containing sugar (see page 15)]. But we may easily ascertain whether there are gases in any stomach contents, the intensity of their formation, and whether they consist only of Coa, or of other gases (the most important of which is hydrogen). This is done by filling two ordinary fermentation tubes (the best is Einhorn's fermentation saccharimeter) with stom- ach contents, in the one unfiltered, in the other filtered, putting them aside at ordinary temperature and observing the rapidity of the formation of gas. After this has ceased add some caustic pot- ash, which on account of its weight will sink, and may thus be easily * G. Hoppe-Seyler. Deutsch. Arch, fur klin. Med., Bd. 1, p. 82.—Kuhn. Zeit- schr. fiir klin. Med., Bd. xxi, p. 572 ; Deutsche med. Wocherfschr., 1892, Nos. 49, 50.—[Strauss. Zeitschr. fiir klin. Med., Bd. xxvi and xxvii. See also literature quoted on page 55.—Ed.] 288 DISEASES OF THE STOMACH. introduced into the graduated portion of the apparatus. If the gas disappears after a time and the graduated part of the tube refills en- tirely, then the only gas present is C02. In view of what has already been said, it seems to me to be a strange coincidence that in my former and present investigations I have never seen any hydrogen fermentation. It is also remarkable that the total acidity is not excessive even in cases of very marked fermentation in spite of the intense odor and acridity of the regur- gitated or vomited stomach contents. This is undoubtedly due to the fact that the acids which are formed are immediately converted into neutral or basic salts. Another form of abnormal chemical change leads to the products of decomposition of albumen—amido- acids and ammonia—which are characterized by their peculiar foul odor, and under the microscope by the prevalence of cocci, vibri- ones, and masses of zooglea, some of which may be seen spinning about in the field in a lively manner. Betz, Senator, Ewald, Em- minghaus, Boas * [Strauss, and others] have demonstrated the occur- rence of sulphureted hydrogen in the stomach contents; Boas claims that its presence is quite common where albumens are de- composed. It may be detected with acetate of lead paper moistened with caustic potash. The reaction of the stomach contents is, then, usually neutral ; or, if the basic products of the decomposition of albumen are in excess, it may even be faintly alkaline. Still, as already mentioned, the decomposition of proteids may occur even if HCl is present, or may be absent even when no HCl is found. At any rate, because there is either an absence of hydrochloric acid from the commencement, or because it is neutralized by the prod- ucts of decomposition spoken of, an opportunity is given for pro- gressive decompositions, which combine with the above-mentioned processes of fermentation, and thus may produce very varied clinical pictures. Usually in such cases we have to deal with large degenerating neoplasms. [Boas f and others claim that as a rule the total acidity is considerably increased in most cases of stagnation and decomposition of the stomach contents, the high * Boas. Ueber das Vorkommen von Schwefelwasserstoff im Magen. Deutsch. med. Wochenschr., 1892, No. 49. t [Boas. Op. cit, Bd. ii, p. 99.—Ed.] SYMPTOMS OF GASTRECTASIS. 289 total acidity being due either to free or combined HCl and organic acids. Concerning the presence of acetone, toxines, etc., see pages 45, 46]. While the stagnation of the stomach contents exerts no appreci- able influence upon the secretion of the mucous membrane as long as the secreting elements are intact, it disturbs absorption very seri- ously. This goes hand in hand with the paresis of the motor ele- ments. The tests with iodide of potassium and with salol show the retardation of the absorptive and motor functions. The result of the former may be obtained from half an hour to a whole hour too late, and I have seen the latter absent as long as two and three hours. Nevertheless, it is by no means asserted that, in all or in particular cases of gastric dilatation, these reactions are always typi- cally retarded. It must be borne in mind, however, that they explain only a function, and not a group of symptoms, and that a markedly dilated stomach can very well display normal or nearly normal efficiency in this direction. But, under such circumstances, the disturbances which might otherwise develop tend, as a rule, to be comparatively slight. Thus in fourteen cases of typical dilata- tion of the stomach, in which I used the salol test, I found in five that there was no appreciable delay in the splitting up of the salol. In three of these cases, too, the subjective symptoms of dilatation of the stomach were by no means marked, proving that the ingesta were promptly passed on into the intestine, thus compensating for the dilatation. [In this connection it is well to recall the researches of Yon Me- ring,* who showed that when there is stagnation of the chyme, ab- sorption of liquids is not alone delayed, but that there is also a trans- udation of fluid from the gastric mucosa as the result of the irritation of the latter by the various ingredients of the stagnating food.] It is very apparent that these different disturbances of function react one upon the other. The development of the products of de- composition paralyzes the muscularis, and this paralysis favors the stagnation and with it the further decomposition of the ingesta. * [See p. 76.] 290 DISEASES OF THE STOMACH. The disturbed function of absorption not only delays the removal of absorbable substances, but also interferes with their further for- mation. In view of the experiments of Schmidt-Miihlheim, Calm, and others, we must assume that the power of the gastric juice to form peptone ceases as soon as the percentage of the latter has reached a certain height, just as alcoholic fermentation is suspended as soon as a definite quantity of alcohol has been formed. Now, since the peptones are neither absorbed nor transferred to the intes- tines at the proper time, it follows that the rest of the nitrogenous food is not attacked by the gastric juice ; and hence we find so many wholly or partly undigested masses in the stomach in spite of the excessively long time during which the ingesta remain in the organ. On the other hand, it is evident that all these conditions may be present and may manifest themselves without the existence of a really marked dilatation, but rather of motor insufficiency, or what the ancients called atony of the stomach. They are then, it is true, less marked, yet at times they may reach a high degree of intensity, as the case spoken of above, of the patient " with the gas-factory," proves, in whom, quite contrary to our assumption of a dilatation of the stomach, based, it is true, upon what we would to-day con- sider insufficient examination, there existed an almost concentric hypertrophy of the stomach with a stenosing carcinoma of the py- lorus.* Such cases, therefore, as I have mentioned above must be designated motor insufficiency of the stomaclnf From these con- siderations we can see that very appreciable dilatations of the stom- ach may occur, in which the injurious effects are equalized by effi- cient compensation on the part of the absorptive and motor functions. Thus, some individuals may for years have an abnormally large stomach, which causes them little or no trouble, just as many peo- ple live for years with valvular lesions in ignorance of the existence of their trouble, since compensatory hypertrophy of the ventricle equalizes the defect of the valve. But some day this compensation * A similar anatomical case was described by Diemerbroeck in 1685 (and cited by Penzoldt, Die Magenerweiterungen) in order to prove that a hard drinker must not necessarily have a dilatation. t [Additional cases of mechanical insufficiency in spite of the normal size and situation may be found in Boas, op. cit, Bd. ii, p. 96.—Ed.] SYMPTOMS OF GASTRECTASIS. 291 fails, and then suddenly, or in a surprisingly short time, all the symptoms of dilatation appear. These are the cases in which the dilatation has apparently arisen acutely, and which are spoken of especially in English literature.* [See page 267.] As the disease progresses the nutrition is affected more and more; a highly marked marasmus appears. The hands and feet become bluish-red, cold, and moist; while the face not infrequently becomes reddened by the development of acne pustules and marked ingestion of the capillaries. While vomiting occurs less frequently, the foul-smelling eructations and flatulence are increased. The pressure of the dilated stomach causes displacements of the neigh- boring organs, especially the lungs, heart, liver, and intestines, together with disturbances of their functions. Dyspnoea and pal- pitation are increased according to the extent to which the dia- phragm is forced upward by the stomach filled with ingesta or dis- tended by gases. Obstructions to the portal circulation and their consequences appear. The bowels, as a rule, are sluggish, and can be moved only by enemata or strong drastics; and the stools even then are usually not soft, but consist of hard masses mixed with water and mucus. An unusual symptom, but when present a very conspicuous one, is the peristaltic unrest of the stomach, first de- scribed by Kussmaul. Powerful waves are seen passing slowly over the stomach from right to left, and from above downward; they may also affect the lower sections of the intestines, and even in rare cases take an antiperistaltic course (Cahn). Naturally, this presup- poses a marked obstruction at the pylorus in connection with rela- tively intact muscle or innervation.! Not only is absorption scanty or checked in the stomach, but it must also be markedly diminished in the intestine, which is but insufficiently provided with chyme from the stomach at long inter- vals. This is especially true of the absorption of water, causing an abnormal dryness of the muscular and nervous tissues and of the * For example, Hilton Fagge, On Acute Dilatation of the Stomach, Guy's Hosp. Reports, xviii, pp. 1-22 ; and Albutt, On Gastrectasis, Lancet, 1887. Hood. A Case of Acute Dilatation of the Stomach. Lancet, December 19, 1891. f [According to Osier (loc. cit, p. 25), increased peristalsis is not infrequently seen in dilatation of the stomach.—Ed.] 292 DISEASES OF THE STOMACH. skin; the latter is roughened almost as it is in the last stages of dia- betes, and at times thickly covered with furfuraceous scales. To this dryness Kussmaul* ascribes a nervous phenomenon observed by him which manifested itself by painful spasms of the flexors of the arms, the calves, and the abdominal muscles, with which at times a kind of nystagmus, mydriasis, emprosthotonos, as well as disturb- ances of consciousness, were associated, together with a condition which closely resembled, if it really was not, the tetany which ap- pears after acute infections, rheumatism, conditions of great exhaus- tion, etc. These attacks begin with painful sensations in the stom- ach and other regions of the body, as well as with a feeling of oppression, and may at times last for many hours. The face may also become involved; it then assumes a masklike, rigid appearance. Temperature and pulse are often very high; and in a short time all the symptoms may become so very much aggravated that death speedily results. [The symptoms usually occur in attacks of vary- ing duration which come on at irregular intervals. As a rule they appear after severe vomiting.] According to this, it seems that the disturbed absorption of water and the resultant dryness of the tissues may in individual cases be the cause of an abnormal irritability of the nervous system which may become intensified sufficiently to present the picture of tetany, so that in addition to the symptoms already described we may also find a decided increase in the mechanical and electrical irritability of the nerves and muscles. Trousseau's symptom and the facial phenomenon may also be present. In other cases, however, owing to the absorption into the blood of the products of decomposition, there may appear an auto-infection characterized by nervous de- pression, which has been aptly named coma dyspepticum. Fr. Miiller *f* has reported two cases of the former kind in which, in addition to the symptoms already mentioned, there was a distinct * Kussmaul. Ueber die Behandlung der Magenerweiterung, etc. Deutsch. Arch. f. klin. Med., Bd. vi, S. 455. Also Laprevotte, Des accidents tetaniformes dans la di- latation de I'estomac. Paris, 1884.—Dujardin-Beaumetz et Oettinger. Note sur un cas de dilatation de I'estomac continuee de tetanie generalisee. L'Union med., 1884, Nos. 15 and 18. t Fr. Miiller. Tetanie bei Dflatatio ventriculi und Achsendrehung des Magens. Charite-Annalen, 1888, Bd. xiii, S. 273. SYMPTOMS OF GASTRECTASIS. 293 increase in the mechanical and electrical excitability of nerve and muscle; Minkowski * mentions the occurrence of deep coma in the course of a case of dilatation of the stomach, the patient dying in this state two days later; while Litten observed similar though not such intense conditions in cases of acutely developed dyspepsia, and obtained the ethyl-diacetic-acid reaction [Gerhardt's Burgundy-red reaction] in the urine.f During the last few years quite a number of cases of tetany after gastric dilatation have been reported, so that Bouveret and Devic:}: have been able to present an exhaustive analysis of 23 cases. In their opinion there has usually been a continuous hypersecretion, although at times, and especially toward the end of the disease, this may be absent. Although Miiller was unable to isolate any toxine from the stomach contents, Bouveret and Devic succeeded in producing symptoms of tetany in animals by intravenous injections of the alcoholic extract of the stomach con- tents of such cases, and especially when the chyme contained a marked excess of free HCl. It remains to be seen how far these somewhat surprising statements will be verified. In a case of my own, in which the attack occurred immediately after the introduc- tion of a stomach tube, the amount of HCl, instead of being in- creased, was much diminished. Finally, therefore, the possibility remains that this form of tetany represents a reflex process proceed- ing from the stomach, and for which many analogies, collected by Miiller, could be found, of which I will only mention the convul- sions caused by worms. [Fleiner # has recently published an ex- haustive essay on tetany in which he reports four cases of his own. He objects to the name tetany because the group of symptoms is unlike that disease in many respects, and the symptoms present in different attacks even in the same persons are not always the same. Thus once they may resemble tetany, at another time tetanus, and * Minkowski, loc. cit., p. 163. f M. Litten. Eigenartiger Symptomencomplex in Folge von Selbstinfection bei dyspeptischen Zustanden. Zeitschr. f. klin. Med., Bd. vii. Supplementheft, S. 81 u. ff. X Bouveret et Devic. Recherches cliniques et experimentelles sur la tetanie d'origine gastrique. Rev. de med., 1892, Nos. 1 and 2. An exhaustive bibliogra- phy is given here. * [Fleiner. Boas' Archiv, 1895, Bd. i, pp. 243-262. Contains full bibliography. —Ed.] 294 DISEASES OF THE STOMACH. finally the attacks may be epileptiform. He also denies the assertion of Bouveret and Devic that hypersecretion and hyperchlorhydria are present in all cases of tetany; in one of his cases there was no free HCl. Neither was he able to extract any preformed toxine from the stomach contents, and he believes that the substances extracted by Bouveret and Devic were due to faulty chemical manipulations. He also shows that Kussmaul himself has discarded his original belief that tetany was due to a rapid thickening of the blood and drying of the nerves and muscles. His own views are that the cause is a reflex action and not originally an autointoxication; that the etio- logical factor is not always the same, but that " in most cases of convulsions and tonic muscular spasms of gastric origin which may resemble epilepsy, tetanus, or tetany, there are severe anatomical changes in the pyloric region of the stomach or duodenum which more or less completely prevent the passage of the chyme into the intestines and at times render it impassible, and then produce the condition of so-called hypersecretion."] Tetany is always a severe complication of gastric dilatation, for of the 23 cases collected, 16 were fatal—a mortality of 69*5 per cent. The Urine.—I have never observed the peptonuria spoken of by G. See and found by Bouchard in 7 per cent of his cases, al- though 1 have examined many patients for that purpose. The bodies found were probably albumoses, and not peptone. At times, in the later stages of the disease, the quantity of the urine is dimin- ished, though this is not usual. Perhaps this, like the alkalinity of the urine, which may be observed under certain circumstances,* is to be referred to the regular emptying or washing of the stomach undertaken in the course of treatment. Quincke believes the cause to be the deficient absorption of the acid of the stomach by the gas- tric mucosa, whereby an important factor in the acidifying of the urine is removed. This is quite possible so long as the changes in the chemical functions connected with dilatation are not remedied. On the contrary, it seems to me that the greater the care which is taken to improve the organ by systematic lavage, the more favor- * Quincke. Dilatatio ventriculi mit Durchbruch in das Colon. Eigenthum- liehes Verhalten des Urins. Correspondenzbl. fur Schweizer Aerzte, 1874, No. 1. DIAGNOSIS OF GASTRECTASIS. 295 able must the conditions of absorption become, and that therefore the urine should be acid rather than alkaline. This is also corroborated by an observation of Winkhaus,* who collected the urine in sepa- rate portions at various periods during the day in a patient with a marked gastrectasis ; the urine was alkaline as long as the fermenta- tion in the stomach was not interfered with, but invariably became acid some time after the stomach was washed out. Moreover, it de- pends entirely on the actual cause of the dilatation whether any quantities of hydrochloric acid worth mentioning are secreted by the stomach. Besides triple phosphates, crystals of magnesium phos- phates, i. e., large highly refracting rhombic plates have been found. [In cases of tetany, increased toxicity of the urine has been reported by Bouveret and Devic and others.*f* Albumen, and sometimes sugar, have also been found in this condition.] Diagnosis.—Were I to follow the usual plan and now take up the diagnosis of dilatation of the stomach, I would simply have to repeat what has already been said, for whatever has reference to the diagnosis has been fully discussed. It is just in dilatation of the stomach that the differential diagnosis is relegated more than elsewhere to the background. According to Loreta, catarrhal dila- tation may be distinguished from that after cicatricial stricture of the pylorus by the occurrence of large quantities of undigested food in the wash water in lavage in the former, whereas in the latter the stomach contents are an acid chyme. In the former the appetite may be present; in the latter it is changed.$ In some stages of dilatation, as my own experience shows, this is perfectly true. But the amount of HCl diminishes # as the mucosa becomes more and more involved by chronic inflammatory changes. It is self-evident that we must guard against confounding this condition with distention of the colon, ovarian cysts, sacculated ascites, hydronephrosis, and echinococcus cysts; however, on care- ful examination by the methods given, these can hardly claim our * II. Winkhaus. Beitrag zur Lehre von der Magenerweiterung. Inaug. Diss., Marburg, 1887. f [Loc. cit] X Quoted by Marten, Lancet, August 2, 1890. * In one case I found the acidity as high as 98, although lactic and butyric acids were absent. 20 296 DISEASES OF THE STOMACH. earnest attention. The differentiation of gastroptosis from dilata- tion will be considered while discussing the former condition. On the whole, the tendency of physicians is to make the diagnosis of " dilatation of the stomach " rather too often than too seldom, ex- cept, as I have already mentioned, when it occurs in young persons. It would be of very great importance were we able to sharply dis- tinguish between insufficiency of the stomach and true gastrectasis. This is easy as long as we have to deal with the group of symptoms of a dilatation when no truly dilated stomach is present; under such circumstances it may be extremely difficult to exclude a primary ca- tarrhal condition; yet it is impossible, and the diagnosis can only be made ex juvantibus when, with a relatively short duration of the disease and poorly marked symptoms, a megalogastria exists at the same time, and thus simulates an incipient gastrectasis. In advanced cases we can not remain in doubt even under such circumstances. Course and Prognosis.—Both are intimately connected with the primary cause of the gastric dilatation. If it be due to a malignant tumor, the duration of life is dependent upon the course of the can- cerous disease and the prognosis is always unfavorable; yet we must not forget that remissions may occur in the course of such processes which under the influence of rational treatment may produce a rela- tively good condition for weeks, and even for months. It is to this fact that the majority of the cases reported " cured " can probably be referred. I, however, have never seen such a gastric dilatation cured, but I have repeatedly observed that such periods of improve- ment threw* doubt upon the diagnosis till it was finally confirmed at the autopsy. When the dilatations are caused by constricting cicatrices, or by atonic conditions of the gastric muscle, they run a slower course, and the prognosis is on the whole more favorable. But here too, alas! we must say, " Prcmalabunt fata consiliis ! " Such patients carry their dilated stomachs about with them for years, and under appropriate treatment and diet can lead an endurable life—indeed, one almost free from all difficulties ; but they never dare forget that every " step from the path "—i. e., every dietetic error—which need by no means be gross, but simply a very slight departure from the prescribed diet, entails not only a momentary feeling of sickness PROGNOSIS OF GASTRECTASIS. 297 but usually severe disturbances, which sometimes can not be relieved at all; for it is a peculiar characteristic of all dyspeptic conditions of a severe and chronic nature that they not only may relapse easily, but that these relapses last longer and are worse than the first attack. But it must be specially emphasized that dilata- tions of the stomach when they are recognized early offer us a very grateful field for treatment, unless, which is not unusually the case, they have been treated in the meantime with every kind of purposeless " stomach medicines." We can very safely promise such patients a very marked improvement in their trouble; in fact, were we only to regard the subjective symptoms, we could promise a cure. But. if we did, such a falsehood would be punished in the future. As far as my experience goes, even these dilatations can not be cured, and the final prognosis is always unfavorable; at least, in four cases which I have had the opportunity of watching for years—over 10 and as long as 12 years—I have found the stomach just as large as ever when I distended it, in spite of sub- jective improvements and even apparent cure; the result has been just the same in the many cases of dilatation of the stomach of this category which I have had the opportunity of observing for shorter periods of time. When the stomach is once dilated we are unable to draw it together again like a tobacco-pouch, any more than an eccentrically hypertrophied heart (excepting the isolated cases of acute cardiac dilatation) ever returns to its normal condition. As soon as the muscular and glandular tissues have been forced apart and infiltrated by an abundant proliferation of interstitial tissue; as soon as the muscular fibers have undergone fatty or other degen- erations ; as soon as the ducts of the glands have been destroyed or have undergone cystic degeneration—in short, as soon as atonic atrophy of the walls of the stomach has appeared, the game is lost. Gradually our therapeutic and dietetic measures lose their efficacy, and the patients die of marasmus, and with more or less marked dropsical effusions. We can only expect a decided improvement, or even a cure of the gastric dilatation, when the process is in its earliest stages and is produced by functional disturbances, atony, deficient innervation, or catarrhal conditions of the mucous membrane, or when the ob- 298 DISEASES OF THE STOMACH. struction to the emptying of the stomach is immediately removed by operative procedures, as in the case of Klemperer.* Korcynzski and Jaworski f report a case of dilatation consecutive to gastric ulcer, in which the former disappeared almost entirely and the latter was cured ; they believed that the ulcer caused a marked in- filtration of the mucosa at the pylorus which produced a stenosis of this orifice; on the lessening of the catarrhal condition this stenosis disappeared. In these cases the relaxed muscle may regain its tone and the mucous membrane its normal structure and function, the interstitial exudation may be absorbed, and the organ in toto brought back to its original size. It is very evident that all this is only possible provided the anatomical changes have not exceeded a definite and very limited degree; this is quite analogous to the con- ditions of other organs—the bladder, for instance. Those cases of dilatation of the stomach which arise from a chlorotic or anaemic condition, and which have been described as cured, can not be classed with the true dilatations, as I have defined them above, but belong to the group of gastric insufficiency, which may at times be combined with a megalogastria. [According to Boas,:}: the prognosis may be based upon the con- dition of the stomach after having given his test supper. This consists of two cups of tea, two rolls, and a slice of cold meat. This meal is taken at 8 p. m. On the following morning the tube is passed. If no remnants of food are found macroscopically the prognosis is good; if, on the contrary, food is obtained, the case is much severer. He therefore subdivides the cases of muscular in- sufficiency into two classes, which he calls first and second degree respectively, the former including the cases of simple atony, the latter the gastrectases.] The prognosis of the complications, tetany, coma dyspepticum, * Klemperer. Deutsch. med. Wochenschr., 1889, p. 170. The case was one of cicatricial pyloric stenosis produced by corrosion with hydrochloric acid; consecu- tive dilatation of the stomach (capacity, 2£ litres [Ovss.]). After dilating the ste- nosis by operation, the dilatation became less, so that at the death of the 35-year- old patient two months later from phthisis, the stomach, although large, was not found to be actually dilated. f Korcynzski und Jaworski, Rundes Magengeschwiir und saurer Magenkatarrh. Deutch. Arch, fiir klin. Med., Bd. xlvii, S. 586. X Boas, op. cit, Bd. ii, p. 70. TREATMENT OF GASTRECTASIS. 299 etc., which may occasionally occur, has already been considered. I merely wish to add that several cases of sudden death have been reported in which excessive formation of gas has caused rupture of the stomach.* The treatment f of dilatation of the stomach must fulfill two indications: 1. By means of a carefully regulated diet and appro- priate medication it must ease and assist gastric digestion as much as possible, and even supply nutriment to the organism in another way. 2. It must prevent stagnation of the stomach contents and must expel them either upward or downward, and must also check the fermentative processes which develop in the stomach. 1. The diet in dilatation of the stomach should be as limited as possible. We must restrict the use of fluids as far as we can; thin soups, large quantities of alcoholic beverages, mineral or other waters, and much tea or coffee, are to be entirely avoided. I make use of milk even in only small quantities, and give it in teaspoonful or tablespoonful doses at frequent intervals. When it is possible, it is advisable to substitute peptonized milk, which may be made quite palatable by adding cream. Under such circumstances the most rational course to pursue, if possible, would be to use Schroth's dry diet {Trockenkur).\ But since the treatment must extend not over short periods of time, but over months, and even years, this is not applicable, and we must therefore satisfy ourselves with a modified dry diet. The use of the peptone preparations is to be recom- mended ; for instance, Koch's or Kemmerich's meat peptones, meat peptone chocolate, Maggi's peptone pastilles, [Yalentine's] meat juice, [somatose], etc., which contain much nourishment in a small volume.* I have lately found condensed peptonized milk to be * Matthieu. Rupture of the Stomach due probably to Overdistention by Gases. Chicago Med. Rep., 1887, p. 274. f [See also valuable paper by Oser, Wiener Med. Presse, September 25, 1889. —Ed.] X [This very energetic treatment, as modified by Jlirgensen, consists in giving the patient as many dry rolls as he wishes, and also a third to two thirds of a pound of lean meat and a pint of light claret wine; no other fluids are allowed, except on every third or fourth day, when drinking is permitted. 'Wet packs at night. Before the cure, fluids are gradually withdrawn, and after it they are gradually increased. The treatment lasts about a month.—Ed.] * [Analogous preparations are Rudisch's sarcopeptones, Carnrick's beef pepto- 300 DISEASES OF THE STOMACH. very serviceable; it has an agreeable taste, and can be purchased in small packages as the so-called u Muttermilchpatronen" or of a gelatinous consistence in larger boxes. [Ordinary fresh unsweetened condensed milk will be found equally useful.] The patients also like meat powder,* which can easily be made at home from dried and pulverized meat; it is made into a broth, with the addition of spices. It is evident that all easily fermenting food stuffs, especially amylaceous foods and vegetables and fruits which contain much sugar, are to be absolutely avoided; and it is only as a concession to the imperative necessity for starchy foods that we permit the patients to have a small quantity of bread, say 75 to 100 grammes [ 5 ijss. to iijss.] daily—i. e., two or three stale rolls or toast. The decomposi- tion of the fats evidently takes place late and slowly, for in washing out the stomach six to seven hours after a meal we find the fat floating in large and small globules on the surface of the water, and no intense odor of the fatty acids is noticeable, which is always the case unless the stomach is systematically washed out. However, since the fats seem to exert an irritant action on the mucous mem- brane, their use is to be restricted as much as possible. The strength of the patient may be kept up by means of small quantities of strong wine or strong, unsweetened coffee or tea. Nutrient enemata form an important aid in nourishment; they may be given in the form which I have spoken of, or as suppositories of peptone, the use of which can be continued for weeks or months. By such means nourishment by the mouth may be reduced to a minimum for days—i. e., until the condition of gastric digestion has been im- proved as much as possible; enemata also possess the advantage of preventing the lack of water in the tissues by means of the fluids introduced (Liebermeister). 2. Hydrochloric acid in large doses is an excellent remedy for all gastric dilatations which are not dependent upon pure atony of the muscle. We may commence with ten to fifteen drops of dilute hy- drochloric acid, taken through a glass tube in a tablespoonful of water every hour. Concerning the other disinfectants, I would refer noids, Bush's bovinine, etc. Peptone chocolate is now sold in this country under the name of vigor chocolate.—Ed.] * [Mosquera's beef meal may be used for this purpose.—Ed.] TREATMENT OF GASTRECTASIS. 301 to what has already been said on page 233. Kuhn (loc. cit.) has tabulated the various useful antifermentatives according to their value in checking fermentation, the percentages denoting the con- centration necessary for this purpose : Acid, salicylic.. 0*0025 per cent. Resorcin.. 0*25 per cent. Natriisalicylas. 0*0025 " Creosote.. 0*5 " Natrii benzoas. 0*03 " Acid, boric, over 1 " Saccharin..... 0*05 " Aq. chlori. 5 " Acid, carbolic.. 0*1 " Alcohol... 5 p. c. or more. If carcinoma of the stomach exists, it is best to use a maceration of condurango, with the proper quantity of hydrochloric acid. In case there is much pain in the stomach, I make use of the sedative and antiseptic action of chloral, combined with cocaine, as follows: 1^ Cocain. hydrochlor.............. 0*3 [gr. jvss.] Chloral, hydrat................. 3*0 [gr. xlv] Aq. menth. pip................. 50*0 [f 5 jf ] Aq........................... 100*0 [fSiiji] M. Sig.: Tablespoonful every two hours. Dujardin-Beaumetz speaks highly of introducing large doses of bismuth, 50 grammes, suspended in 500 c. c. of water [ 5 jss. bis- muth to O j water], from which the drug is said to be deposited on the gastric mucous membrane ; * injections of morphine are eventu- ally unavoidable. Atonic conditions of the muscle require the exhibition of strych- nine, as extract or tincture of nux vomica, which had been formerly recommended by Skjelderup and Duplay, f who did not draw this sharp distinction. It can be given without bad effects in large doses —0*1 to 0*15 [gr. jss.-ij^] ! of the extract pro die. Dr. Wolff has proved at my clinic that it also increases the production of hydro- chloric acid. The cathartics and drastics have always played an important part in the therapy of gastric dilatation ; they are really of service, probably by sympathetic stimulation of the gastric peristalsis, not only in evacuating the intestines but the stomach as well, as soon as they have passed the pylorus, or, indeed, have been absorbed at * Bullet, gener. de therapeutique, 1883, No. 1. f Arch, gener. de med., Nov., Dec, 1883. 302 DISEASES OF THE STOMACH. all, neither of which is always the case. Penzoldt was able to directly prove the beneficial effect of Carlsbad salts in lessening the quantity of the stomach contents, for the quantity removed from the organ while the salts were used amounted to 850 c. c. [f^xxviij], while without them, the condition being otherwise the same, they measured 1,525 c. c. [3£ pints]. Kussmaul recommends drastic pills, composed of IjJ Extr. colocynth. spirit. (G. P.)..... 0*5 [gr. vijss.] Extr. rhei comp. (G. P.), Swe Extr. aloes aquos., Extr. scammon................aa 2*0 [gr. xxx] M. Div. in pil. no. xxx. Sig. : One pill before dinner. I have frequently used aloin subcutaneously with good results. 3. To meet the second of the two indications given above, lav- age, the sovereign remedy in the treatment of dilatation, is to be used. I will disregard the many appliances devised for this pur- pose, because, to my mind, they are like carrying coals to Newcastle. The use of the stomach tube, with a funnel attached to it, and the cleansing of the stomach by the alternate introduction and removal of large quantities of water, is the simplest and at the same time an entirely efficient method. We must not stop until the water * returns clear or only very slightly turbid, but by all means entirely free from fragments of food and flakes of mucus. At times, toward the end of the operation, after the water has come back clear for some time, it suddenly becomes turbid again from the presence of large masses of stomach contents; this occurs especially when there are well-marked pouches in the stomach, the contents of which are only stirred up toward the last by the entrance of the water or the bearing down of the patient. We must allow all the time we can for the possible digestion of the food which may be in the stom- ach, and therefore we must only empty the stomach when large ac- cumulations are present—i. e., to wash out only six or seven hours after the principal meal. Besides the actual washing out which is to prevent the mechanical overloading of the stomach, we conclude the operation with irrigation of the mucous membrane with antisep- TREATMENT OF GASTRECTASIS. 303 tic or antifermentative solutions. In cases of very marked fermen- tation we can clean the walls of the stomach more quickly and thor- oughly by washing out the stomach in the morning before breakfast when the viscus is empty, as Naunyn and Minkowski have also ad- vised. I have had patients in whom the morning lavage produced much better results than that done in the evening. Still the time must be adapted to the individual case. Thus in continuous hyper- secretion it is better to wash the stomach in the evening, or even both morning and evening. As antiseptics we may use solutions of salicylic acid 0*3 to 0*5 per cent, or borax 2 to 4 per cent (dissolved in hot water), or sodium subsulphate 10 to 20 per cent, as well as a great number of other disinfectants, such as naphthalin, resorcin, benzoic acid, permanganate of potash, etc. These substances, the efficacy of which is well known, should suffice. The advantages which accrue from this procedure are so appar- ent that it is really incomprehensible why this method should not have been introduced earlier into therapeutics. To avoid repetitions I shall not add anything further on the benefits of lavage of the stomach, for its manifold advantages can readily be recognized. However, of one of these I must speak, for it appears very fre- quently, if not always—namely, the effect on the stools. Many patients who have had to contend with habitual constipation through- out the whole course of their illness have had free passages after the washings, especially at the commencement of the treatment. Kuss- maul,* who has called attention to this effect of lavage, always con- siders its absence an ominous sign ; in other words, he believes that the persistence of obstinate constipation always indicates an irrepar- able disorganization of the stomach and an incurable stenosis of the pylorus. But this much is certain, that in scarcely any other place in the whole range of the therapy of diseases of the stomach can we attain such brilliant results as we can in the treatment of a case of protracted dilatation of the stomach. The disgusting vomiting, the feeling of fullness, the eructations, the dyspeptic difficulties, and the cerebral symptoms either cease entirely or become markedly im- proved. Consequently lavage is being employed more and more, so * Loc. cit, p. 467. 304 DISEASES OF THE STOMACH. that the severe and neglected cases of dilatation which were for- merly encountered are now no longer seen. How often shall we wash out the stomach ? Daily, or at longer intervals, or as often as several times a day ? I consider daily wash- ings at the time specified to be indispensable. But they must be conscientiously continued for a long time—the patients soon learn to do it themselves—and we must not be guided alone by the sub- jective sensations of the patient. Should the latter's apparently good condition induce us to allow longer intervals to intervene, so- called relapses are sure to occur, since stagnation and its conse- quences will always return. The present technique is so simple and safe that less can be said against it than, for instance, against long- continued catheterization in hypertrophy of the prostate. I have as yet never seen any unpleasant accidents occurring after lavage; yet Fenwick * has collected a number of cases which have been re- ported, and from his own practice (seven cases in all), in which per- foration, haemorrhage, convulsions, and death after various intervals occurred after lavage. However, a number of these cases should never have been washed out, or the same thing may have happened here as occurred in a case reported by Martin, f in which death sud- denly occurred six hours after a tube had been introduced into a dilated stomach with stricture of the pylorus. No injury of the viscus was found at the autopsy, and, since sudden collapse and death may occasionally occur in cases of cancer without any cause at all, it appears to me that this was simply a coincidence. [An in- teresting fact concerning the great value of lavage, etc., in gastrec- tasis is the statement of Kussmaul, that in the last ten years he has not seen a single case of tetany, although he was the first to describe it as a complication of this condition. *{: ] Here we must also mention the few cases in which rupture of the gastric mucosa or wall has occurred (usually longitudinally along the lesser curvature) as the result of overloading the stomach with fluids. A. Key-Aberg * has carefully reported a case of this kind * Loc. cit, on p. 15. f Martin. Death after washing out Dilated Stomach. Lancet, 1887, No. 2. X [Quoted by Fleiner. Loc. cit, p. 254.—Ed.] * A. Key-Aberg. Vierteljahrschr. fiir gerichtlich. Med. und offentl. Gesund- heitspflege, 3te Folge, Bd. i, 1891. TREATMENT OF GASTRECTASIS. 305 in which rupture of gastric mucosa and haemorrhage were caused by the water left in the stomach after lavage in a case of opium poison- ing ; the man, although semiconscious, nevertheless retched a great deal. He also cites the few cases of this kind which have been re- ported, some of which are not entirely free from objections.* Other details on the complications of lavage have already been discussed on page 15. Massage and faradization of the stomach I consider adjuvants of lavage. The former, if intelligently applied, forces the contents of the stomach into the intestines, and in this way dilates the py- lorus by means of mechanical pressure. Yet we must avoid forcing masses into the duodenum which are too acid or too acrid, which can not be sufficiently neutralized by the intestinal juices, and which produce conditions of irritation in the mucous membrane of the intestine. Zabludowski,f of Gerhardt's clinic, has published very good results from the use of massage in dilatation of the stomach, together with an exact account of the technique employed. On the other hand, we must not forget that the decided pressure exerted on the stomach will distend and dilate the gastric walls if the chyme is not forced through the pylorus. Faradization of the stomach has already been discussed on page 102. It certainly accelerates the emptying of the stomach. For ex- ample, Brunner *j: demonstrated that a test breakfast disappeared much more rapidly from the stomach when the abdominal walls were faradized. I have so often convinced myself of the beneficial effects of intragastric faradization, and the patients themselves have so decidedly felt that it alone benefited them (for they lost ground as soon as it was discontinued), that I am sure that the results are due to something more than suggestion. Cold douches and applications are said to have a tonic effect upon the muscle fibers of the stomach, as well as the so-called Scotch douche, as recommended by Winternitz and Baum.* * Revilliod. Rupture de I'estomac. Rev. med. de la Suisse Romande, 1855, No. 1. f Zabludowski. Zur Massagetherapie. Berliner klin. Wochenschrift, 1886, S. 443. X W. Brunner. Zur Diagnostik der motorischen Insufficienz des Magens. Deutsche med. Wochenschr., 1889, No. 7. * Wiener med. Presse, 1873, No. 17. [" This consists of a stream of water, the 306 DISEASES OF THE STOMACH. In a few cases of marked dilatation I have obtained good results from wearing an abdominal bandage (as will be described more fully under Gastroptosis), since the relaxed abdominal walls are supported and thus facilitate the movements of the stomach and intestines. Surgical Treatment.—Finally, wre must think of dilatation or ex- cision of the stenosis. I can not do much more than mention these procedures here, and therefore simply call attention to the fact that quite a series of successful operations—i. e., excision of the con- stricting tumor, forcible dilatation of the cicatricial stenosis, and gas- troenterostomy—has been published during the past few years. Thus, Hubert describes two cases of forcible digital dilatation of cicatricial stenosis of the pylorus which were operated upon by Prof. Loreta in Bologna, and apparently were radically cured.* A method which is worthy of special consideration is that proposed by Hei- necke and Mikulicz, of splitting the stricture longitudinally and then passing the sutures transversely ; a number of excellent results have been obtained by this operation. The question of whether resection of the pylorus or gastroenter- ostomy is preferable has been carefully discussed during the past few years by many eminent surgeons, of whom I shall mention only the German operators, Billroth, Liicke, Mikulicz, Hahn, Laueustein, Yon Hacker, etc. The indications and technique have been much improved.*]* Thus, for example, Lauenstein % reports 17 cases of gastroenterostomy, in 13 of which there was cancer of the pylorus. Five cases were fatal and 12 were successful so far as the operation was concerned. Three of the cases which were operated on account of benign stenosis remained permanently well. Of the 13 operated because of pyloric cancer, three died; the others survived on an aver- size of a finger, which is directed against the region of the stomach. The tempera- ture of the water changes every twenty seconds between 80° and 50° Fahr. (26° and 10° C), and is continued for three minutes." Decker, Munch, med. Wochen., May 28, 1889.—Ed.] * Hubert. Jour, de med. de Bruxelles, avril, 1883, p. 309. [Also Loreta, Lancet, April 26, 1884; Bull and Kinnicutt, A Case of Cicatricial Stenosis of Pylorus relieved by Loreta's Operation. New York Medical Record, June 8, 1889. This paper gives the results of twenty cases.—Ed.] t An exhaustive discussion may be found in the dissertation of W. Hellwig. Behandlung der Magenerweiterung mit Gastroenterostomie. Halle, 1892. X C. Lauenstein. Zur Indication, Anlegung und Function der Magendiimdarm- fistel. Centralbl. fiir Chirurgie, 1891, No. 40. TREATMENT OF GASTRECTASIS. 307 age five months, and were free from symptoms for about three months. Halm's * results are still better: 11 operations, of which 6 were fatal; one case survived 5 years (!), another one year, the others survived several months. Hellwig + reports two successful cases which had been operated on by von Bramann, and summarizes the operative indications as follows : " Gastroenterostomy is gener- ally indicated in those cases of dilatation of the stomach in which a demonstrable obstruction exists at the pylorus which can not be removed by a radical operation; otherwise resection of the pylorus ought to be performed. However, the general condition of the patient ought to be at least such that there should be no metastases, and the possible duration of life should not be one of a few months." Yon Bramann urges that gastroenterostomy ought also to be per- formed on severe, primary gastrectases to spare the patients the years of lavage. Birchner,:}: on the other hand, suggests making a fold in the walls of the stomach so as to elevate the greater curva- ture, thereby raising the lowest part of the stomach to such a level that the contractions of the stomach may expel the chyme through the pylorus. This is a less serious operation than gastroenterostomy, and Birchner has already reported three successful cases. Although in the second edition of this book I have already suggested a similar procedure—i. e., to excise a lancet-shaped piece of the wall of the stomach—yet Birchner's operation will probably only be successful in those cases in which the pyloric obstruction is not such that a fresh dilatation will be formed later on. Furthermore, it is very much to be feared in this and similar operations that the patients may subsequently be troubled by the resulting cicatrices. It is not my province to enter into further details of this topic. Enough has been said to show that surgeons are ready to afford * E. Hahn. Ueber Gastroenterostomie. Deutsch. med. Wochenschr., 1891, No. 30. f Hellwig, loc. cit. X Birchner. Eine operative Behandlung der Magenerweiterung. Correspon- denzbl. fur schweizer Aerzte, 1891, No. 23. [Weir. New York Medical Journal, July, 1892. Up to 1894 this operation had been performed seven times; all recov- ered promptly. In five there was complete restoration of the stomach, one died after a second operation; cancer was suspected in this case; another case died from heart failure six weeks after the operation. Quoted from American Yearbook of Medicine and Surgery, 1896, p. 124.—Ed.] 308 DISEASES OF THE STOMACH. relief where our former methods left us in the lurch, and that it is our duty in every case of this kind to consider as early as possible the possibilities of operative relief. Jaworski, Obalinski, and Rydy- gier * have, however, shown what was to have been expected a priori, that in cancer of the stomach, even when these operations of resec- tion and gastroenterostomy are successful, neither the mechanical nor the chemical functions of the stomach return to the normal, but that in general only symptomatic relief is afforded by the removal of the mechanical obstruction. Nevertheless, in these cases decided subjective and objective relief is obtained, in spite of the fact that the presence of a malignant cicatrization in the stomach must also exert a deleterious effect on the functions of the intestines, liver, and pancreas. Thus in Jaworski's case the stools were frequent, soft, and decolorized, and also contained much undigested meat and fat; biliary coloring matter was also absent. So far as I may judge from my own cases—four of resection of the pylorus and three gastroenterostomies—I would only advise re- section in nonmalignant stenoses; in all other cases, gastroenteros- tomy. For, no matter how sharply a cancer may seem to be limited macroscopically, there are always numerous offshoots which often extend a considerable distance; hence,"operating in the healthy tissues" is usually only a delusion (see chapter on Cancer of the Stomach). Senn, one of the most distinguished surgeons in this branch, closes an exhaustive study,f in which he reports 13 gastro- enterostomies, with 8 so-called cures—i. e., death weeks or months after the operation—as follows: " 1. Pyloroplasty, as devised by Heinecke-Mikulicz, is the safest and most efficient operation for cicatricial stenosis of the pylorus. " 2. Pylorectomy in the treatment of carcinoma of the pylorus is a justifiable procedure when the disease is limited to the organ primarily affected and the patient's general condition furnishes no contraindication. " 3. Gastroenterostomy by the aid of large, moist, perforated * Jaworski und Obalinski. Wiener klin. Wochenschr., 1889, No. 5.—Jaworski und Rydygier. Deutsch. med. Wochenschr., 1889, No. 14. t Senn. The Surgical Treatment of Pyloric Stenosis, with a Report of Fifteen Operations for this Condition. New York Medical Record, November 7 and 14, 1891. TREATMENT OF GASTRECTASIS. 309 plates of decalcified bone should be resorted to in the treatment of malignant stenosis of the pylorus as soon as a positive diagnosis can be made, and a radical operation is contraindicated by local or general conditions of the patient." [The present view as to the surgical treatment of dilatation due to pyloric stenoses, either benign or malignant, is decidedly in favor of gastroenterostomy. Thus Rosenheim * reports 8 cases which were operated in this way with no deaths, the improvement in the gastric functions being satisfactory in all of them. Loreta's opera- tion has fallen into disfavor; pyloroplasty and resection of the pylorus have still a high mortality, that of the former being 22*6 per cent., according to Mintz (see also Surgical Treatment of Cancer of Stomach). The use of the Murphy button has not materially changed these indications. According to Fleiner,f operative interference is indicated when the amounts of food and fluid which pass from the stomach into the intestines no longer suffice for the needs of the system, and when these factors and the disturbances of the economy which result from the lesion can not be remedied by medical treatment. Well- marked tetany is a contraindication to operative interference; still, if the tetany can be improved by appropriate treatment, an operation may be attempted. One of the four cases which he reports was successful.] I shall now apply the foregoing remarks to some practical ex- amples ; for this purpose I have not selected hospital cases, with the results of autopsies, but such patients as we meet in daily practice: The first patient is a railroad secretary, fifty-two years of age, whose previous history I shall give in his own words : " Ten months ago, in the beginning of last year, I was taken sick with loss of appetite, constipation, slight malaise, and also a cough, with expec- toration. On the 14th of June, a year ago. I went to Gorbersdorf, in Silesia, at the advice of my physician, and remained there under treat- ment, at the institute of Dr. Rompler, until July 10th. On July 10th I went to Carlsbad, where the diagnosis of dilatation of the stomach was made. I was treated there till August 14th (five weeks); the physician * [Rosenheim, op. cit, p. 485. An excellent resume of this subject may be found here and in Boas, op. cit, Bd. ii, p. 122.—Ed.] f [Fleiner, loc. cit, p. 262.—Ed.] 310 DISEASES OF THE STOMACH. told me that I was at the proper spring. At Carlsbad I drank three half- glasses of Schlosshrunnen daily, and besides took four Sprudel and eight mud baths (one every third day). The action of the baths was always sedative for several hours. In general the treatment at Carlsbad affected my body quite unfavorably, my strength was not correspondingly in- creased, and a slow improvement could only be observed at intervals of from four to five weeks. After the 10th of August I was under the treat- ment of another physician.'' When I first examined this patient, who was sent to me by his family physician on the 24th of October, although he was thin, he by no means looked sick. Lungs and heart normal; liver not enlarged ; its lower edge can be felt distinctly a finger's breadth below the free margin of the ribs. Spleen not enlarged; the stomach, however, showed the following changes: Even on mere inspection of the abdomen, and especially on looking at it against the light, with the patient lying down, I can see a slight protuber- ance the size of a five-mark piece [about the same as a silver dollar] in the region of the umbilicus, and extending to the right; it projects so slightly above the surface of the abdomen that it is only recognizable by the relief given by its shadow. Otherwise the abdominal walls are smooth, not too relaxed, with neither troughlike depression nor abnormal vaulted projec- tion. Palpation reveals a tumor at the place mentioned, about the size of an apple, hard, nodular, easily movable, which does not descend on res- piration, and entirely insensitive to pressure. Tapottement produces loud succussion sounds. No slapping sounds (Klatschgerdusch). The inguinal glands are about the size of a pea, but there are no other adenopathies. The patient has taken a test breakfast. I introduce the stomach tube, and on expression obtain about 100 c. c. [ § iij^] of a thin fluid, which con- tains some remnants of the roll. I now inflate the stomach with the double bulb, and you can see that the tumor is displaced somewhat to the right and downward, and that the contour of the stomach becomes very distinct. By sight alone, but better by means of percussion, I can locate the greater curvature 3 centimetres [14, inch] below the umbilicus. Examination of the stomach contents, which have been filtered, reveals the total ab- sence of hydrochloric acid, faint peptone reaction, large amounts of pro- peptone, erythrodextrin, fatty acids, but no lactic acid. At a former ex- amination I ascertained that the filtrate of the stomach contents did not digest albumen, and from the examination made six hours after a dinner consisting of meat, potatoes, bread, and bouillon the same results were ob- tained. Neither yeast cells, sarcinae, nor cancerous elements are present. The patient took 1 gramme [gr. xv] of salol yesterday, and has brought the urine voided three quarters of an hour, an hour and a quarter, and an hour and three quarters afterward. In the last portion we get an indis- tinct violet coloration on adding ferric chloride, but I must first shake up the urine with ether in order to obtain a positive though only a weak reaction. In view of all this there can be no doubt that the diagnosis is cancer- ous stenosis of the pylorus, with consecutive dilatation of the stomach. It is interesting that in this case the disease began so insidiously, and that it pointed so little to the stomach as its seat, that probably, in connection with a then-existing bronchial catarrh, the suspicion of phthisis could CASES OF GASTRECTASIS. 311 arise, which led to his being sent to Gorbersdorf. I have seen excellent results in the treatment of phthisis in Gorbersdorf, but carcinomata can not also be cured there ! The case is so far a favorable one in that, on the one hand, the bodily strength is relatively good, and, on the other, the tendency to decomposition of the stomach contents is comparatively slight. In the way of treatment the patient has been taking condurango, with hydrochloric acid, and for the past week his stomach has been washed out regularly every second evening, six hours after his dinner ; considerable quantities of stomach contents, brown in color, have always been brought up. I proposed to the patient to have the tumor excised, which, according to competent authority, can be done in this case. However, he feels so much easier and better under the present treatment that he can not decide upon having it done, and thus, as is alas so frequent, the favorable moment for undertaking it will pass by. The second case, which I will deal with at less length, concerns a fifty- two-year-old, large, strongly built, somewhat pale woman. For about a year and a half she has suffered severely with acid eructations. To this has been added a constant loss of appetite, and partly owing to this, partly because she has kept a strict diet, her nutrition has suffered considerably. No difficulties in swallowing. Vomiting has been very infrequent, lately every fortnight, and is said to have consisted of very sour, slimy masses, mixed with but slightly changed remnants of food ; blood has never been present. Stools hard and sluggish. The urine has been repeatedly exam- ined, with negative result. The patient was formerly very healthy, vigor- ous, and active about the house, and has borne nine children. Although I pass over the examination of the other organs, in which there is nothing abnormal, I wish to call attention to the relaxed condition and markedly vaulted projection of the abdominal walls, on which I can at once pro- duce loud succussion sounds. I can not palpate a tumor anywhere, yet I feel the pulsations of the aorta. The patient " expresses " a light-brown fluid—she had some meat and coffee four hours ago; on inflation with air the entire abdominal cavity immediately becomes evenly distended, so that we can see the lower border of the stomach running just above the symphysis ; the whole abdomen appears like an evenly inflated balloon. The salol test does not show any retardation. The filtrate of the stomach contents has an acidity of 48 per cent with a decinormal soda solution, and distinctly contains free hydrochloric acid, peptone; only traces of propeptone ; it also digests well. Lactic acid is present in small quantities. The diagnosis of gastric dilatation, which can not be doubted, does not seem to have been made before. The question arises, To what can the dilatation be referred ? A previous ulcer may be rejected with great probability on account of the absence of pain, and altogether on account of the previous good general condition. Thus, also, tumors of any kind whatsoever may be excluded, and, granted that further observations yield no results different from to-day's, we can only have to deal with a cica- tricial distortion or adhesion, or with a primary atony of the gastric mus- cular fibers. Even though the former could be a result of puerperal peri- tonitis which had run a latent course, yet this is only to be surmised. At any rate, the prognosis is favorable for improvement within a short time in view of the presence of free hydrochloric acid. 21 312 DISEASES OF THE STOMACH. I persuaded the patient, who had come from a distance, to enter the sanitarium, where she could be treated with an appropriate dry diet, sys- tematic lavage, strychnine, and faradization of the stomach. Three weeks after the treatment had been begun, HCl disappeared permanently, and a small tumor, hardly the size of a walnut, was discov- ered in the pyloric region. Operation was proposed but was rejected by the patient, who left the sanitarium and died a few months later of cancer of the stomach. (I wish to direct particular attention to this case, because it is typical of its kind. To-day I would be still more guarded in the diagnosis and prognosis in view of the fact that cancer may develop from an ulcei-, the course of which has been absolutely latent.) The third case is a young student, twenty-one years of age, strong and apparently healthy. He has complained for fifteen months of distention of the abdomen, with pressure and fullness there, capricious appetite, irregular bowels, and, when these symptoms are present, of poor sleep, headaches, brief attacks of dizziness, and conditions of anxiety. He there- fore keeps a strict diet, refrains from all debauches, and tends to hypo- chondriasis. The tongue is clean, eructation and vomiting have never been present, the stomach contents as well as the size of the stomach are normal, and we would be inclined to regard this case as one of nervous dyspepsia, were it not that the iodide of potassium and salol tests both agree in showing retardation of absorption and motion. I therefore do not hesitate in pronouncing this a case of gastric insufficiency, and the result of the treatment adopted seems to justify the diagnosis. For two weeks he has taken 0*03 [gr. $] of extract of nux vomica three times daily, and has been faradized every other day. Since this time the attacks have not appeared. In these three cases I believe I have presented various types of dilatation and insufficiency of the stomach. From this it will be seen how the simple diagnosis of " dilatation of the stomach " does not suffice, and how much treatment and prognosis are influenced by the recognition of the underlying cause. CHAPTER YII. CANCER OF THE STOMACH. Although it may be interesting to learn from the various statis- tics which are published from time to time that between 0*5 and 2*5 per cent of the total mortality is due to cancer of the stomach, and that 35 to 45 per cent of all cases of cancer involve the stomach, yet such facts have only a nosological interest. Of far greater impor- tance is the question, At what age do persons most frequently suc- cumb to gastric cancer ? The various statistics, of which Brinton's, based upon 600 cases, and Welch's, upon 2,075 cases, are the most important, agree tolerably well in proving that three fourths of all cancers of the stomach occur between the fortieth and the seven- tieth years of life. The maximum liability is between the fiftieth and the sixtieth, but, according to Lebert, it lies between the forty- first and the end of the sixtieth year. It is very rare before the thirtieth year; congenitally it almost never occurs, and the case re- ported by Wilkinson* must be regarded as a very great rarity. According to decades, its occurrence is as follows : 10 to 20. 20 to 30. 30 to 40. 40 to 50. 50 to 60. 60 to 70. 70 to 60. 80 to 90. Welch.... Brinton . 2 i 55 11 271 31 55 499 63 96 620 88 95 428 100 61 140 52 13 60 Lebert f. • 3 1 * Quoted by W. Hayle Walshe. The Nature and Treatment of Cancer. Lon- don, 1846, p. 146. [Other very early cases of gastric cancer may be found in Welch's article in Pepper's System of Medicine, vol. ii, p. 534, 1885. Scheffer, Jahrbiicher fiir Kinderheilkunde, Bd. xv. Bibliographies may be found in C. Stern, Deutsch. med. Wochenschr., 1892, No. 22; and Duzan, Du cancer chez les enfants. These de Paris, 1875.—Ed. t Lebert reports 162 cases. 313 314 DISEASES OF THE STOMACH. Thus the frequency in the four decades between the thirty-first and the completed seventieth year is 1)1*6 per cent. Similar results were obtained by Haberlin*, whose statistics are based upon 6,863 men and 4,559 women (1877-1SS6); he found 72 per cent for the period of the fortieth to the seventieth year, and 90 per cent if the seventieth to eightieth years be included. But, as already stated, these figures are only based upon the relative morbidity of the dif- ferent ages to the total morbidity from cancer. If the frequency of the disease were calculated for the total number of people living in each decade, then the ratio would increase in an ascending scale, and would not show a diminution after the sixtieth year. This opinion, which I had expressed some time ago,f has been corrobo- rated by Haberlin. He estimates the yearly number of deaths from gastric cancer per 1,000 persons to be 0*1, 0*46, 1*35, 2*67, 3*31 for each decade from the fortieth to the eightieth year. Thus the con- ditions are the same as in phthisis, the relative frequency of which, as estimated for the total number of people living at that period, steadily increases with advancing age. The disease also seems to be distributed differently in different regions. Griesinger never saw any case of it in Egypt, while Cloquet and Autenrieth found it unusually common in Normandy and the Black Forest [Baden] respectively. Haberlin concludes that twice as many cases of can- cer of the stomach occur in Switzerland as in Berlin and Yienna. Sex appears to exert no influence on the frequency of gastric cancer; at all events, Fox's tabulation of the statements of seven writers shows that, of 1,303 cases, 680 were males and 623 females, in other words, both sexes were about equally affected, if we allow for the coincidences which are unavoidable in such a small series. Ledoux-Lebard,:}: from a study of the mortality statistics of Yienna, announces a mortality which is about the same for both sexes (100 in 25,000 deaths in a city of a million inhabitants). Of Welch's 2,214 cases, 1,233 were men and 981 women. Wilson Fox found the proportion to be 52 per cent in men and 48 per cent in women. * Haberlin. Ueber Verbreitung und Aetiologie des Magenkrebses. Deutsch. Archiv fiir klin. Med., Bd. xliv und xlv. \ Ewald. First American edition of this work, p. 263. X Ledoux-Lebard. Arch, gener. de med., avril, 1885. HEREDITY OF CANCER. 315 Brautigam found the relation to be 3:2 in Bavaria, and Haberlin 7: 5 in Switzerland. It would be very important if we could come to a definite con- clusion regarding the heredity of cancer. Not alone in the diag- nosis of a suspicious case, but also in the prognosis as to the prob- able duration of life of the children of cancerous parents, an im- portant part is played by this question of the heredity of cancer, it being self-evident that cancer of the stomach is included in the general sphere of carcinomatous affections. All authors who have studied the origin of carcinoma, even to the most recent date (a good resume of this discussion will be found in J. E. Alberts's book *), agree that cancer is hereditary in the sense that the predis- position is transmitted from the sufferer to his descendants, and this it is which may develop under certain conditions. But what are these conditions which influence the transmission and subse- quent development of the disease; how often are the subjects attacked—in other words, how frequently do the children of carci- nomatous parents acquire the disease, and what cause may be discov- ered for this ? This is really the practical side of the question ; but, strange to say, it is scarcely broached in these works, while its great importance is manifest, and confronts us daily. But here, with the exception of a few statistics, we are almost exclusively compelled to use more or less subjective (and hence unreliable) opinions, while the information obtained from the relatives of the deceased patients is always interpreted very differently by different physicians, yet nearly always in the view of heredity. Not alone may cancer of the stomach be directly transmitted from parents to children, but more frequently the preceding generation has had a different variety of cancer; in mothers the uterus or mamma has been especially fre- quently involved. The life-insurance companies, which naturally are vitally inter- ested in this question of the heredity of cancer, do not, as a rule, reject a candidate on account of the death of one parent from this disease; yet it is considered to increase the risk, and a higher pre- mium must be paid. This is based upon their practical experience : * J. E. Alberts. Das Carcinom in historischer und experimentell-patholo- gischer Beziehung. Jena, 1887. 316 DISEASES OF THE STOMACH. thus, for example, in a period of fifty years, from 1829 to 1878, the Gotha Life Insurance Company had 334 deaths from cancer; of these, 31—i. e., 9*3 per cent—were hereditary. Lebert found he- redity in 7 per cent of his cases; Haberlin has analyzed 138 cases, and has found positive evidence of gastric cancer in the parents in 8 per cent, in brothers and sisters 2*2 per cent; probable gastric cancer in parents in 4*3 per cent, uncertain in 5 per cent; cancer in other organs, 2*9 per cent. In 178 cases of my own, the his- tories of which were taken as carefully as possible, heredity ex- isted in only 6*7 per cent. Nevertheless, in this and similar statements, no attention is paid to the fact that the disease often occurs in families in which there is no hereditary predisposition. IT. Snow, physician to the London Cancer Hospital,* has an- swered the question, to the effect that in 1,075 cases of carcinoma in different parts of the body, 167—i. e., 15*7 per cent—stated that the disease had already occurred in their families, it being understood that the transmission is not always direct, but that it has affected more than one member of the family. On the other hand, among 175 patients who were under treatment for non- cancerous affections, 46;—i. e., 26 per cent—admitted that cancer had occurred in their families ; and in two other series, of 78 and 79 cases respectively, the former being healthy individuals, the latter patients with pulmonary diseases, the relative percentages were 19*2 and 11*3. It is manifest that statistics of this kind are very uncer- tain, since it can not be demonstrated whether the patients in ques- tion have not or would not have fallen victims to the disease. The statements of Roth f are entirely different; an analysis of the mor- tality records of Laenggries in Bavaria, from 1682 to 1885, shows an inheritance of cancer in more than half the cases. But here the reliability of the data may be questioned, and, moreover, the range of observation is too limited. [Graf % has carefully studied the question of heredity in 4,233 cases of cancer of all kinds which he had collected. He found * H. Snow. Is Cancer Hereditary 1 British Medical Journal, October 10,1885. t Roth. Ueber Erblichkeit des Krebses. Friedreich's Blatter, 1889, pp. 26 to 45. X [Graf. Ueber das Carcinom mit besonderer Beriicksichtigung seiner Aetiologie, Hereditat und seines endemischen Auftretens. Archiv fiir klin. Chirurgie, Bd. 1, Heft i. Contains complete bibliography.—Ed.] » ETIOLOGY OF GASTRIC CANCER. 317 that cancers were decidedly hereditary in certain families, and that it occurred more frequently in some districts than in others. The latter was especially true of cancers of the digestive tract. This was especially noticeable where the population was more exposed than elsewhere to irritative conditions of this tract. Thus we may ex- plain the frequency with which husband and wife or members of certain families are attacked, because they are exposed to the same irritant action of certain strongly seasoned or indigestible articles of food.] Etiology.—In discussing this question of the hereditary transmis- sion of carcinoma of the stomach, I have already encroached upon the question of the individual causes of the disease. In general, it must be admitted that we are just as ignorant of the etiology here as elsewhere. I may enumerate a fist of so-called etiological factors, because in a number of cases we have observed a transient connec- tion, and a more or less evident transition, which is called cause and effect; yet it is not known why these causes are in some cases fol- lowed by a carcinomatous proliferation, and why in others there is no reaction whatsoever. Nevertheless, some of the factors to be mentioned presently occur so frequently that they must exert some influence on the origin of carcinomatous tumors. A discussion of this question is in place in a general consideration of the nature of carcinoma ; this lies within the province of general pathology, and hence is out of place here*. I shall simply limit myself to a brief resume of the possible etiological factors. All of these partake more or less of the char- acter of irritants which may be due to the ingestion of acrid sub- stances, or which may result from acute or chronic inflammatory processes. Among these may be included corrosion by nitric acid and arsenic; of the former, Andral is said to have reported an ex- ample, but the case is not reported in the reference which is copied from one book to another ; the latter is regarded as a causal factor by Dittrich; yet this is at all events doubtful, since Walshe found a large quantity of arsenic encapsulated in the stomach of a patient * An elaborate discussion may be found in Hauser, Das Cylinderepithelcarci- nom des Magens, June, 1890. 318 DISEASES OF THE STOMACH. without any further changes in its tissues.* Traumatisms have been repeatedly cited as causes of gastric cancer. For example, Alberts f reports the following case : A man who up to his fiftieth year had always enjoyed good health stumbled and fell against the handle of his umbrella. Three weeks later gastric symptoms appeared, and after a year the patient died of carcinoma ventriculi. A moment's consideration, however, will show that this and similar observations can not definitely settle this question, since they are not absolutely conclusive. Who can tell whether there was not already a latent cancer, and that the traumatism simply accelerated its growth ? Even in olden times inflammatory conditions of the mucous membrane of the stomach were included among the causes of gas- tric carcinoma. Such views may be found in the writings of Boer- haave and Yan Swieten, and in the older works they are met with more frequently in proportion as the nature of the disease is less known. But not very long ago Schuchardt,:}: in a monograph enti- tled Contributions to the Origin of Carcinoma from Chronic Inflam- matory Conditions of the Mucous Membranes and Skin, claims that a chronic or hyperplastic condition precedes the formation of the neoplasm, and that, while this condition does not necessarily cause the latter, yet it favors it to a high degree. Chronic gastric ulcers may also be classed among the predis- posing factors. Lebert has observed the direct transformation of ulcer into cancer, and Dittrich the simultaneous occurrence of both conditions. Brinton cites cases in which the lesion, macroscopically an ulcer with thickened edges, was accompanied by unquestion- able metastases in the liver and lungs ; and even states that " an unhealed ulcer may at times cause the development of cancerous cachexia." * C. Meyer || describes a case of simple ulcer occurring with carcinoma of which the cell-nests, although only in the imme- diate vicinity of the ulcer, were visible as smooth nodules which * Walshe, Inc. cit., p. 167. t Alberts, loc. cit, p. 195. X Schuchardt. Beitrage, etc. Volkmann's Sammlung klin. Vortrage, No. 257. 9 Brinton, loc. cit., p. 248. | C. Meyer. Ein Fall von Ulcus simplex in Verbindung mit Carcinom. Inaug. Dissertation. Berlin, 1874. ETIOLOGY OF GASTRIC CANCER. 319 had developed from the epithelium of the ducts of the glands. Heitler * reports three similar cases (without microscopic examina- tion), and remarks that the diagnosis carcinoma ven triculi ad basim ulceris rotundi is not at all rare in Yienna. Hauser f has histo- logically demonstrated the transition of ulceration into carcinoma- tous proliferation, and asserts that in one of the cases examined by him he found not only the secondary development of carcinoma in a gastric ulcer of very long standing, but that " occasionally a can- cer may develop from an affection of the gastric glands, even in the sense of the theory proposed for carcinoma by Thiersch and Wal- deyer." Flatow *{: reports a similar case from the Pathological Institute at Munich. This case is important because the patient was only twenty-six years old, and the history of ulcer was beyond doubt. The cancer was near the pylorus, and in its center was an old scar with a smooth base. As the result of his microscopical ex- amination Flatow says, " Evidently there was at first a cicatricial mass, and this facilitated an atypical proliferation of epithelium." Hauser's work has since been corroborated by a number of writers.* The statistics of Haberlin's cases show that 7 per cent of carcinom- ata occurred after ulcers. [Kelynack | reports an interesting case of ulcer of the stomach in a man, 27 years old, who had been ill for four years with symp- toms which were characteristic of ulcer, until an actual tumor and cachexia became noticeable during two months before his death. * Heitler. Entwickelung von Krebs auf narbigem Grunde in Magen und in der Gallenblase. Wiener med. Wochenschr., 1883, No. 31. Kollmar (Zur Differential diagnose zwischen Magengeschwiir und Magenkrebs. Berl. klin. Wochenschr., 1891, Nos. 5 and 6) has collected only 14 cases from the literature. This, however, gives an erroneous idea of the frequency of this occurrence, because all the cases of this well-known fact are not published. f Hauser. Das chronische Magengeschwiir und dessen Beziehung zur Entwick- elung des Magencarcinoms. Leipzig, 1883, S. 70 und 73. Also loc. cit. X H. Flatow. Ueber die Entwickelung des Magenkrebses aus Narben des run- den Magengeschwiirs. Inaug. Dissert. Miinchen, 1887. 9 Stienon. Contribution a l'anatomie pathologique de l'ulcere de I'estomac. Bruxelles, 1889.—Kulcke. Zur Diagnose und Therapie des Magencarcinoms. Inaug. Dissert., Berlin, 1889.—Rosenheim. Berl. klin. Wochenschr., 1889, No. 47. | [Kelynack. On the Occurrence of a Cancerous Development in Simple Ulcer of the Stomach. Brit. Medical Journal. January IS. 1896, p. 142. Contains a com- plete bibliography and references to all published cases.—Ed.] 320 DISEASES OF THE STOMACH. At the autopsy the carcinoma was found to be limited to the ulcer and its vicinity. There were no metastases. Hydrochloric acid persisted almost to the end.] Concerning the other chronic irritants of the mucous membrane which are supposed to favor the development of cancer, the various exceptions are so evident that a discussion on the unreliability of such evidence is superfluous. The same is true of bacterial origin and transmission of cancer, as shown in the experimental and bacte- riological researches of Alberts, Schill, Scheurlen, Adamkiewicz, Sanarelli, and Barbei. Hauser has presented strong arguments against this doctrine ; he directs especial attention to the histological differences in the tissue changes produced by carcinoma and by bac- teria, and also to the primary difference in the histogenetic origin and formation of metastases in each. Furthermore, he has shown that all so-called inoculations of cancers are nothing more than suc- cessful transplantations of living tissues which have proliferated at the point of inoculation. Pathological Anatomy.—After a thorough investigation, Wal- deyer was the first to teach that the disease is developed from the glandular elements of the mucous membrane—i. e., from the peptic glands, and especially from the mucous glands of the pylorus. The process is an atypical glandular proliferation which bursts through the muscularis mucosae, and extends into the submucosa. In the cells of these proliferating glands, as has been shown by Hauser and Hansemann,* numerous karyokinetic figures may be demonstrated. In the deeper layers of the tissues there is formed a richly reticu- lated network with many anastomoses, the outlying branches of which, as I f have demonstrated years ago, penetrate deeply into the apparently healthy tissues in the form of long tubules filled with cu- boidal epithelium. Thus circumscribed cancerous nodules are formed ; these coalesce later on, and thus necessitate the subsequent flattened growth. Coincidently there is an active growth of the connective tissue which soon exceeds the proliferation of the gland- ular elements, and thus at first produces an hypertrophy of the * Hauser, loc. cit.—Hansemann. Virch. Arch., 1890, Bd. cxix, p. 299. t Ewald. Berl. klin. Wochenschr., 1888, p. 995. PATHOLOGY OF GASTRIC CANCER. 321 connective tissue, while the glandular elements still remain nor- mal. Later, it extends along the proliferated glandular tubules and manifests itseK as a small-celled infiltration about the cancer nodules. After Korcynski and Jaworski * had laid much stress upon the relation between carcinoma and catarrhal gastritis, Rosenheim, Mat- thieu, and myself f have, a number of years ago, carefully studied the mucous membrane which was not involved by the carcinomatous process. Their statements have been corroborated and augmented by Fischl,*j: who examined 15 cases, and myself, in two cases in which I was able to make sections from fresh tissue which was cut from the periphery of the cancerous tumor at operations. According to these authors, the mucosa is inflamed far beyond the seat of the neoplasm, being manifested by a more or less pronounced interstitial gastritis with its characteristic granular degeneration of the glandular cells, cystic enlargement of the tubules, and atrophy of the mucosa, as already described on page 200. Varieties.—Any of the various forms of cancer—schirrus, en- cephaloid, colloid, polypoid, and telangiectatic—may occur in the stomach. All authors state that the first is the most common. Ac- cording to Brinton, it occurs in 75 per cent of all cases, while the colloid is found only in from 2 to 8 per cent. If we agree with Waldeyer # that the nature of the disease consists in " an atypical transformation of epithelium," then the above-mentioned individual varieties are one and the same fundamental process, and, as actually occurs, often change into one another. Scirrhus, carcinoma simplex or fibrosum, with its predominant development of dense connective-tissue stroma, and with relatively few cell-nests, has a firm and compact structure. It occurs some- times as large masses or tubercles, sometimes as small nodules ; at times multiple, but oftener as a diffuse infiltration. It creaks when * Korcynski und Jaworski. Deutsch. med. Wochenschr., 1886, Nos. 47-49. f Ewald. Klinik, etc., 1888.—Rosenheim. Berl. klin. Woch., 1881, Nos. 51, 52. —Matthieu. Archiv. gen. de med., avril, 1889. X Fischl. Die Gastritis bei Carcinom des Magens. Prager Zeitschr. fur Heil- kunde, 1891, Heft 3. * Waldeyer. Die Entwickelung der Carcinome. Virchow's Archiv, Bd. lv, S.54. 322 DISEASES OF THE STOMACH. cut, and the section presents an almost cartilaginous tissue of a white, grayish-yellow, or dull yellow color, with yellow or red spots scattered here and there ; it may, however, have a smooth and shining surface, almost like bacon. Where there is a tendency to ulceration we find a rich vascular network, and also an extensive diffuse redness; where ulceration has already begun, an undulating fissured surface is presented by the ulcer, which is covered with ragged greenish-yellow or black detritus. Of frequent occurrence are fatty degeneration and atrophy in some parts, while in others it continues to grow. Firm pressure will cause a small amount of turbid, milky cancer juice to exude. Encephaloid cancer, carcinoma medullare, is soft, has very little connective-tissue stroma, but is very rich in vessels and cells; the growth is spongy, and cuts easily; the cut section is whitish-yellow in color, and resembles brain matter both in color and consistency. It undergoes colloid degeneration more frequently than does the scirrhus. Extravasations of blood are frequent, and are marked by their characteristic discoloration. If the cells in an otherwise well-developed stroma show from the beginning a tendency to undergo colloid degeneration, then the whole growth assumes a gelatinous appearance somewhat resembling glue. Thus arises the colloid carcinoma, carcinoma alveolare or gelatinosum. On cutting and scraping, a true cancer juice does not exude, but instead gelatinous fragments. Villous carcinoma, Zottenkrebs, carcinoma villosum, is produced by villous or papillary outgrowths in the scirrhus or medullary varieties. If the development of blood-vessels predominates, the growth is called a telangiectatic carcinoma or fungus hwmatodes. Finally, if there are numerous haemorrhages into the cancerous tis- sues, any of the varieties of the neoplasm may assume the char- acter of a melanotic carcinoma* As I have already indicated, these various forms may coexist in almost every variety. I shall * [Such discolored cancers ought not to be confounded with true melanotic tumors. Welch could find no record of true primary melanotic cancers of the stomach; all of those cases have proved to be melanotic sarcomata. Welch, h-c. cit, p. 561, footnote.—Ed.] PATHOLOGY OF GASTRIC CANCER. 323 merely add that several varieties of cancer may be found in isolated areas in the same stomach. Thus, for example, we may find a medullary carcinoma at the lower curvature and a scirrhus at the pylorus. In all these types the bundles of muscular fibers are more or less infiltrated, and undergo hypertrophy; the muscularis becomes paler, less elastic, and fragile; at times, however, atrophy may result. Secondary inflammatory processes, with thickening and adhesions to the adjacent organs, are observed in the serosa. Finally, it is to be observed that other neoplasms, such as sarcoma and lymphadenoma, may also occur in the stomach; their clinical course can not be distinguished from that of carcinoma. Lymph- adenomata are exceedingly rare; Pitt * has collected 17 cases, which may be divided into two groups, one in which the new growth begins in the mucosa and submucosa, and forms a soft tumor which projects into the cavity of the stomach; in the other there is a diffuse proliferation under the serosa, which only exceptionally extends into the submucosa and mucosa. Having thus briefly recalled to mind the chief characteristics of the different varieties, I shall now speak more in detail of the topo- graphical features or the localization of cancer of the stomach, and of the results thereof. We must first distinguish between tumors which grow espe- cially on the surface and involve large areas of the mucous mem- brane, and those which attack only a small portion. The former are by far the less common, and are usually of the medullary or colloid variety; they are characterized by a nodular or roughened surface like a grater; they are flattened rather than projecting high above the surface ; other peculiarities are the frequency of assuming the villous form, the occurrence of blood extravasations and ad- hesions to the adjacent organs, especially to the peritonaeum and omentum. In such cases the greater portion of the stomach from the cardia to the fundus may be converted into a carcinomatous mass, vet such an occurrence is a great rarity. Otherwise the * Newton Pitt. Lymphadenoma of the Stomach and Intestines. Transact. Pathol. Soc, London, 1890, vol. xi. 324 DISEASES OF THE STOMACH. greater curvature usually remains free, and the neoplasm preferably extends on the posterior wall along the lesser curvature. Generally the organ is not increased in size, but rather diminished to a firm, sausagelike tumor. I have preserved such a medullary cancer in- volving the entire organ, which I obtained at an autopsy; the capacity of the viscus was scarcely 200 c. c. [f 5 vjss.] of water. The scirrhus variety involves the whole organ much less frequently. I have two specimens of this in which the entire viscus is so infil- trated with a dense scirrhus that it looks like a piece of intestines. In passing, I will say that in these cases the stomach could not be palpated, so that in one of them the diagnosis of the neurasthenia was made by another physician, since there were no marked dys- peptic symptoms; and even up to a short time before his death the patient had to undergo the Weir-Mitchell treatment. Such a case of scirrhus is pictured in Fig. 39, which is taken from Cars- well's Atlas.* Usually scirrhus follows the second of the above courses—i. e., it remains in a circumscribed portion of the stomach, and tends to grow in depth and height as opposed to the superficial extension of the medullary and colloid varieties. This, however, does not exclude its multiple occurrence in several parts of the mucous membrane of the organ, as, for example, at the pylorus and the lesser curvature or the cul-de-sac. Concerning the situation of the cancer, nearly all the statistics agree that in about one half of the cases the pylorus is involved: according to Brinton, 60 per cent; Lebert, 59*6 per cent; Katzenel- lenbogen,f 58*3 per cent; Luton,;}: 57 per cent, etc. In between 10 and 11 per cent (Luton, 7*8 per cent) it is the cardia or the lesser curvature ; in the remainder the lesion is scattered over the greater and lesser curvatures. Of 195 cases of gastric cancer, Israel # found the pylorus involved in 128; the cardia, 26 ; the lesser curvature, 23; the greater curvature, 11; and flat carcinoma of the entire * [Sir Robert C. Carswell. Pathological Anatomy. Illustrations on the Ele- mentary Forms of Diseases, 1833-38.—Ed.] t Katzenellenbogen. Beitrage zur Statistik des Magencarcinoms. Inaug. Dis- sert, Jena, 1878. X Luton. Nouv. dictionnaire de med. Paris, 1871. * Israel. Berl. klin. Wochenschr., 1890, No. 29. PATHOLOGY OF GASTRIC CANCER. 325 stomach, 6. The fundus is attacked least frequently of all; such a case with extension to the spleen was described by Tiingel.* Among the 1,300 cases reported by Welch, 19 were situated in the fundus. At all events, the orifices are the favorite sites—70 to 75 per cent; thus cancer differs markedly from ulcer in this respect, as the latter involves the orifices about five times less frequently—i. e., 16 to IS per cent. The situation and extent as well as the consistency of the neo- plasm influence the shape and position of the stomach in the follow- ing ways: 1. The viscus may become smaller by a concentric contraction, as where a firm tumor involves the stomach in toto—i. e., infiltra- tion of the mucosa and muscularis ; or, finally, even a narrowing of the lumen by extension inward, as shown in Fig. 39. It may also result from tight strictures situated at the cardia; as a consequence of this, the absence of the normal pressure of the contents of the stomach upon its walls causes the organ to contract into the smallest possible volume, since it must yield to its elastic tissues ; its diame- ter may be diminished to that of the large intestines, as occurred in the case which I have already described on page 94 (Fig. 12). While the patient was alive the pancreas and stomach could be palpated through the relaxed abdominal wall as a hard nodular tumor. 2. Dilatation is always the result of a tumor obstructing the pylorus. Here the stenosis may be due to all the various causes which have been fully described under dilatation of the stomach. 3. Changes in the position of the stomach are produced by the weight of the tumor ; this may be so marked that either the fundus or the pylorus, alone or both together, may be dragged down deeply into the pelvis, and may contract adhesions with its organs, the ovaries, uterus, bladder, etc. 4. Distortions, bends, and constrictions of the stomach may be developed as a consequence of the inflammatory adhesions with ad- * Tiingel. Klinische Mittheilungen aus dem Hamburger Krankenhause, 1860, S. 108. 326 DISEASES OF THE STOMACH. Fig. 39.—Scirrhus ventriculi totalis (reduced to one fifth). PATHOLOGY OF GASTRIC CANCER. 307 jacent viscera, or of the extension of the new growth in the stom- ach itself. These different conditions show in what varied ways the shape and situation of the stomach may be altered. Gastric cancer occurs so overwhelmingly frequently as a pri- mary growth that a case like that reported by Cohnheim, in which the primary tumor was situated in the mamma, must always be con- sidered a great rarity. Ely * has, however, collected 13 cases, in which the primary cancer was in the cesophagus in 6 cases, in the mamma in 3, in the testicle in 2, and once each in the leg, supra- renal capsule, and colon. On the other hand, it is not exactly rare to find the disease occurring simultaneously in a remote organ; as, for example, cancer of the stomach may coexist with a similar growth in the uterus or ovaries, and no evidence can be found to indicate a metastasis from either organ. Dittrich has never seen the simultaneous occurrence of the disease in the stomach and uterus. In 38 cases of gastric cancer Haberlin found '* metas- tasis of the uterus mentioned only once." Recently I performed an autopsy in a case in which there was found an immense cysto- sarcoma of the uterus, and a carcinomatous infiltration of the py- lorus. Secondary cancerous metastases are, as is well known, by no means rare ; they may affect any part of the organism in about three out of four cases. The liver is involved in 25*6 to 30 per cent; the peritonaeum in 13*7 to 22*7 per cent; the lungs and pleurae in 0*6 to 6*2 per cent; while in 160 cases collected by Dittrich the rectum was involved only twice, and the ovaries once. However arbitrary such figures may be, according to the cases at the disposal of indi- vidual writers, the evidence as to relative frequency of these metas- tases, as given by Lebert, is as follows : In the liver, 40*9 per cent; peritonaeum, 37*5 per cent ; lungs, 8*3 per cent; ovaries, 4*5 per cent. Lange's f analysis of 210 cases at the Berlin Pathological In- stitute gives different percentages : 30*9, 17*6, 0*71, and 0*14, re- spectively. Of greater practical interest is the simultaneous occur- * [J. S. Ely. A Study of Metastatic Carcinoma of the Stomach. American Journal of the Medical Sciences, June, 1890. p. 584.—Ed.] f Lange. Der Magenkrebs und seine Metastasen. Inaug. Dissert. Berlin, 1877. 22 328 DISEASES OF THE STOMACH. rence of metastases in important organs ; as, for example, in the liver and lungs, which Lange found ten times—i. c., 4*7 per cent. Although Brinton asserts that the occurrence of metastases in the liver naturally lessens the danger of involvement of the lungs, yet it would seem more probable that, with the establishment of two cancerous depots, the chances of infection by transportation through the vascular system would be increased. I must confess, however, that my own experience corroborates Brintoifs statement. That cancer and tuberculosis do not exclude each other, or that both may perhaps be attributed to a scrofulous diathesis, as was formerly supposed, needs no further discussion at present. Dis- regarding statistical data—as, for example, Lange, who found them together in 8*1 per cent of his cases—all doubt on the subject has been removed by the direct observation of tubercle bacilli in the pulmonary deposits in lungs which are also cancerous. It must be confessed, however, that it is at times very difficult to decide whether small cavities are due to softening of tubercular or metas- tatic carcinomatous nodules. In many cases we can explain the path of the metastatic infec- tion by way of the blood or lymph vessels ; in others we must think of direct extension in the continuity or along extra-vascular channels; as, for example, the extension of a pyloric cancer to the edge of the liver or the gall bladder ; the involvement of the colon from a tumor on the greater curvature, or of the diaphragm and lungs from one situated at the cardia (Carsw*ell and Yirchow *). The formation of thrombi in various places remote from the stomach is also to be explained by vascular transportation in so far as they are not due to the cachexia, the altered condition of the blood, and the slowing of the circulation, just as is seen in the veins of the lower extremities. It has been repeatedly asserted that the composition of the blood is altered, especially a lessening of the number of the red blood-cells, and of the solid constituents of the plasma. I shall consider this topic further when discussing the symptomatology. Andral and Gavarett *f* state that the percentage of fibrin is variable. There is nothing characteristic in these * Virchow. Die krankhafte Geschwiilste, Bd. i. S. 54. f Andral et Gavarett. Rech. sur la composit. du sang, p. 238. PATHOLOGY OF GASTRIC CANCER. 329 changes, but they are more or less peculiar to all cachectic con- ditions. The swelling of the lymphatic glands occurs less frequently in this disease than in neoplasms elsewhere which are in close connec- tion with the lymphatic system—for example, the mammary gland. Brinton has observed it in only 23*5 per cent of his cases, although Welch gives a higher figure, 35 per cent. In this connection I would refer to the statements I have already made on page 123. We must, however, distinguish between a simple swelling and can- cerous degeneration of the glands. The latter would be observed much more frequently if attention were not alone paid to the glands which are visible and palpable, but also to the entire lymphatic sys- tem. Lebert gives the high percentage of 54*5, though Katzenel- lenliogen places it lower, 40 per cent. The swelling of the supra- clavicular glands, which was first claimed by Henoch and Yirchow, and later by many others,* to be a pathognomonic symptom, is, in my experience, a rare and by no means constant occurrence. [Le- pine f observed it in only three out of 40 cases of gastric cancer on which autopsies had been performed. He reports one case in which the left supraclavicular gland was larger than a hen's egg, although the gastric tumor could only be palpated with great difficulty.] Ulceration occurs to a very variable extent in gastric cancer, sometimes as simple superficial erosions, sometimes as a single round or oval ulcer, not infrequently having an orifice like a crater with a thick, wall-like edge. Ulceration occurs most frequently in the medullary variety, less often in the scirrhous, and least of all in the colloid. Although the process usually has a progressive tendency, yet sometimes carcinomatous ulcers may be found with the central portion cicatrized (whence the saying that cancer is curable), but in the edges of which new foci continue to be formed. Erosion of the blood-vessels may lead to small or large haemorrhages with their subsequent tissue changes. If the mucous membrane is totally de- stroyed, we then find the submucous connective tissue covered with florid, blackish fragments of the destroyed membrane, or its surface * Troisier. Les gangliones sus-claviculaires dans le cancer de 1'estomac. Gaz. hebdom., 1886, No. 42. f [Lepine. Deutsch. med. Wochenschr., 1894, p. 298.—Ed.] 330 DISEASES OF THE STOMACH. may be entirely bare, excepting here and there a few vascular loops. In a similar way arise the villous fungosities on the surface of an ulcerated carcinoma ; yet these must be carefully distinguished from the benign true polypi of the mucous membrane. Ulceration may lead to -perforation ; this is comparatively infre- quent. Brinton estimates its occurrence at about 4 per cent. The intestines and peritonaeum are most frequently involved, especially the transverse colon; these communications being sometimes of a fairly large size. If an adhesive peritonitis has preceded, the per- foration may at times lead to the formation of an encapsulated sac, which in rare cases may perforate the abdominal wall in the form of an abscess. Altogether sixteen such cases have been reported, according to a compilation by Mislowitzer; * to these must be added another case, which occurred in Gerhardt's clinic. Dittrich has seen a case in which the perforation was into the ileum after com- plete closure of the pylorus had taken place; and thus by natural means a collateral communication between the stomach and intes- tines was established, such as we endeavor to obtain by operation in similar cases. General Clinical History.—Cancer of the stomach is an exceed- ingly insidious disease, and at the outset is not to be distinguished from other affections of the organ which lead to dyspepsia. Brin- ton's epigrammatic description, " Obscure in its symptoms, frequent in its recurrence, fatal in its event," is true even to-day in spite of the great improvement in our diagnostic and therapeutic resources. Irregularity and impairment of the appetite, slowing and disturb- ance of digestion, a feeling of pressure, fullness, and tension in the epigastrium, also regurgitation of food and a tendency to nausea, together with more or less obstinate constipation, open the scene. In Beau's statement that gastric cancer is often preceded by a period of " idiopathic dyspepsia," f the word often ought to be changed to seldom ; for, on the contrary, it is surprising how fre- quently patients assert that they have always had good stomachs, and that they have always been moderate in eating and drinking. * E. Mislowitzer. Ueber die Perforationen des Magencarcinoms nach aussen. Inaug. Dissert., Berlin, 1889. t Beau. Gazette d. hopit., 1859, p. 390. SYMPTOMS OF GASTRIC CANCER. 331 While the gluttons have themselves to blame to some extent for their dilated stomachs, the unfortunate victims of gastric cancer have not even the melancholy satisfaction that in the days of health their stomachs had afforded especial joy and pleasure. It is only gradually that pain in the stomach, local or diffused or cardialgic in character, is added; then vomiting occurs, usually without any great exertion and without marked nausea. The tongue becomes thickly coated, and especially in the morning has a tena- cious white fur, which is scraped off with difficulty and is soon re- newed. Lebert seldom found the tongue coated, and considered this cleanness of the tongue one of the most important paradoxical manifestations of the disease. My experience is, however, different; I have, indeed, seen patients whose tongues remained relatively clean, yet such cases are exceptions. The coated condition of the tongue, either in toto or with the exception of the edges and isolated papillae which project like berries, is, quite on the contrary, to be regarded as an important point in the differential diagnosis from gastric ulcer. A striking repugnance toward meat, and other anoma- lies of taste and appetite, precede complete anorexia. A patient of mine stated that claret suddenly tasted like ink. One of Brin- ton's patients abruptly lost all desire for smoking, although strongly addicted to the habit. This, combined with a cachectic appearance, led the physician to diagnose a cancer which was subsequently dem- onstrated, although the other symptoms did not indicate it. The taste becomes flat and " pasty," bitter or sour, or the mouth may become foul in spite of all attempts at rinsing and cleansing. The pain becomes more intense and at times paroxysmal, and occurs not only after the scanty meals but also between them and at night. Yomiting is more frequent; while at first the vomit consists chiefly of mucus, remnants of food, and watery fluid mixed with bile, in time the food is vomited in a more and more undigested condition. The vomit is sometimes tasteless, sometimes sour, has a pene- trating or offensive odor, and where perforation has occurred into the intestines it may even have a fecal odor. Yarious kinds of epithelium and micro-organisms (Fig. 40) are usually present (see page 304). The vomited matter may often contain blood, either in small amounts as bright-red streaks in the mucus, or in large quan- 332 DISEASES OF THE STOMACH. tities as bright-red or brownish-red clots or brown, chocolate-colored to black coagula and masses—the well-known coffee-ground vomit; these differences are due to the length of time the blood has re- mained in the stomach, and to the extent of the decomposition caused by its contents. Although haematemesis when it does occur in cancer of the stomach is usually a late symptom, yet in rare cases it may take place at the beginning of the disease. Thus, Mey * reports three cases in which profuse haemorrhage from the stomach was the first symptom given by the patients. The autopsy in each case revealed scirrhous cancer of the stomach, the consistency and character of which eliminated the possibility of having arisen from an ulcer. Fig. 40. The vomit from which this drawing was made consisted of a clear, reddish fluid, with a light, flocculent deposit, in which dark-brown par- ticles resembling snuff were suspended. The filtrate contained no free acid, but small amounts of lactic acid were present; has no digestive action unless hydrochloric acid is added. Under the microscope may be seen the outlines of red blood-cells, granular masses stained with blood pigment, epithelium of the cesophagus and stomach, some of which look like peptic cells; others are distinctly cylindrical. There are also yeast- * Edg. Mey. Ueber profuse Magenblutungen und Hydrops Anasarca als initiale Symptome des Magencarcinoms. Dissert., Dorpat, 1891. SYMPTOMS OF GASTRIC CANCER. 333 cells, and also cells of another variety of fungi, probably an aspergillus. A dense network of delicate and coarse fungous filaments (which is merely indicated in the figurej incloses the above-mentioned brownish detritus which is visible to the naked eye. There are also many cocci and drops of fat. The peculiar fibers to the left of the figure, resembling elastic fibers of the lungs, are from the connective tissue of the ingested meat. I have repeatedly observed these fibres, even in the artificial digestion of meat. The patient asserted that he had taken only milk for three weeks. There is no reason to doubt the truth of this assertion; what we find sim- ply proves how long such remnants may remain in the folds of the mu- cous membrane. [Boas * and Oppler f have described certain long bacilli (Fig. 11) which they found in large number in the stomach contents in cases of gastric cancer; they are very long, threadlike bacilli, which have sharp bends, and usually lie at an angle to one another and are immobile. They believe that their pres- ence is diagnostic of cancer of the stomach. Kaufmann and Schlesinger, *j: Riegel,# Strauss, | Manges,A Rosen- heim, and Richter () have also found them in most cases of cancer. They produce lactic acid, and Kaufmann and Schlesinger are inclined to believe that they are the spe- cific cause of the formation of lactic acid which is so frequently found in this disease. This is denied by Rosenheim and Richter, who found there bacilli in the stomach contents of a case of benign pyloric stenosis in which HCl was absent, and also assert that they may occasionally occur in stom- ach contents with free HCl. [Fig. 41.—Boas and Oppler's long bacilli; from the contents of a cancerous stomach. Mag- nification, Leitz I, 7. From Eiegel.] * [Boas, op. cit., Bd. ii, p. 182.—Ed.] f [Oppler. Deutsch. med. Wochenschr., 1895, No. 5.—Ed.] X [Kaufmann und Schlesinger. Wiener klin. Rundschau. 1895, No. 15.—Ed.] * [Riegel. Krankheiten des Magens, 1896, p. 173.—Ed.] || [Strauss. Zeitschr. fiir klin. Med., Bd. xxviii.—Ed.] A [Manges. New York Med. Record, April 27, 1895.—Ed.] Q [Rosenheim und Richter. Zeitschr. fiir klin. Med., Bd. xxviii.—Ed.] 334 DISEASES OF THE STOMACH. Sarcinae are usually absent in gastric cancer, for they require HCl for their growth. After a careful study Oppler * asserts that sarcinae occur only in large numbers when the stagnation of the chyme is due to benign pyloric stenoses, severe gastric atonies, and occasionally in other noncancerous diseases of the stomach. He found that pure cultures of sarcinae when added to cancerous stom- ach contents disappeared in a short time.] The coffee-ground vomit is not, as was formerly supposed, pa- thognomonic of cancer of the stomach; yet it must be admitted that in this disease the blood remains in the stomach for a longer period than in the other diseases of this organ which lead to haem- orrhages and these subsequent changes. In most cases there now appears a palpable (or also visible) tumor, which is most frequently situated in the triangle formed by the free lower border of the ribs and the linea umbilicalis [a hori- zontal line passing through the umbilicus] ; it is somewhat higher in men than in women, in whom the lower situation is due to the downward displacement of the liver. Rather early, and not at all proportional to the subjective feel- ings of the patient, occur marked loss of strength and progressive emaciation; the superficial fat and the muscles rapidly waste away, till the sufferer soon drifts into a state of extreme marasmus and exhaustion. One of my patients, with a distinct tumor but with a surprisingly good subjective condition, complained only at first that his limbs were becoming weak in climbing stairs. Soon the charac- teristic pale-yellow color of the cancerous cachexia makes its ap- pearance. After severe haemorrhages the countenance acquires an anaemic or at times a dropsical puffmess, especially under the eye- lids. The eyes sink in, the cheeks become very prominent, the features pointed, and the patients look much older than they are. Profound depression of a melancholy nature may alternate with restlessness and excitement. The picture may be complicated by neuralgias, headaches, dizziness, and tinnitus aurium. In very rare cases neither anorexia nor emaciation may occur. On April 8, 1891, I performed an autopsy on a patient who was brought into the hospital on April 4th, unconscious and hemiplegic. According to * [Oppler. Miinchener med. Wochenschr., 1894, No. 29.—Ed.] SYMPTOMS OF GASTRIC CANCER. 335 the statement of his friends he had never suffered from any gastric symp- toms ; his general bodily condition was excellent, as was shown by a heavy panniculus adiposus. A tumor was found in the right anterior cen- tral convolution, and a large, broken-down cancer of the greater curva- ture of the stomach, with metastases in the liver. For almost four months I had in my service at the hospital a sixty- two-year-old man who suffered from chronic bronchitis, chronic pleurisy. and pericarditis, with slight symptoms of congestion and moderate gastric complaints. During all that time I watched him until he died of pro- gressive inanition, after having become slightly delirious. At the autopsy, in addition to what was expected, a cancer of the pylorus with slight dila- tation of the stomach was found. Similar cases of pyloric cancers without anorexia and emaciation have been reported by Siredey, and also by Muselier.* Muselier's patient was a man, fifty-eight years old, who, at all events, had oedema, anaemia, and cachexia, with, however, only slight dyspepsia and a good appetite. Severe gastric symptoms did not appear until seventeen days before his death. The metastases in other organs—the liver, intestines, lungs, etc.— the insidious or the acute perforations, may produce a variety of complications which in individual cases are manifested by charac- teristic symptoms. Certain occurrences are especially significant of a fatal termination. Among these is fever, which is neither a marked nor a constant symptom, yet by no means as rare as is commonly supposed. Its course is irregular, ranging usually be- tween 38° and 39° C. [100*4° and 102*2° Fahr.), rarely reaching 40° [104° Fahr.], and may, as I saw in one case, assume a purely hectic character. At times absolutely or almost afebrile periods may alter- nate with such high febrile movements as can only arise from sec- ondary inflammations. Hampeln,*f* in a very interesting paper on the symptoms of obscure visceral carcinomata, has very accurately described two cases of gastric cancer with an intermitting fever, which was so marked that chills followed by fever and sweating were present, and the possibility of the existence of malaria had to be carefully considered. An interesting case of the latter variety came under my observation at the Augusta Hospital. A man, forty-seven years old, was admitted December 6,1888. Present illness began about two years ago with symptoms of dyspepsia. In Sep- * Muselier. Gaz. med. de Paris, 1891, No. 1. f P. Hampeln. Zur Symptomatologie occulter visceraler Carcinome. Zeitschr. fiir klin. Medicin, Bd. viii, S. 232. 336 DISEASES OF THE STOMACH. tember, 1888, had hiomatemesis and also passed blood per anum. He was treated in the hospital during October for " ulcer of the stomach," and was discharged improved. On December 3d, violent vomiting, but no haematemesis. On admission he was placed on a milk diet, it being supposed that a gastric ulcer was present. An irregular fever with evening exacerbations to 396° C. [103*3° Fahr.] soon manifested itself. The pains in the epigas- trium continued, and became variable in their situation, being sometimes more marked to the left, sometimes to the right. The stomach contents contained no free hydrochloric acid. The patient became more and more emaciated, so that finally a small tumor could be palpated in the right hypochrondrium near the border of the liver. Icterus was not present. A diagnosis of cancer of the stomach and liver was made. On January 5, 1889, he had a marked chill, which recurred several times ; the pains in the epigastrium increased, and from now on to the patient's death on February 20, 1889, the fever remained continuous, and a delicate friction sound could be heard near the edge of the liver. A diagnosis was made of. perforation of an ulcerated cancer following an adhesive inflammation and agglutination of the adjacent tissues, and also a localized peritonitis. The autopsy revealed the presence of an ulcerated carcinoma about the size of an apple, which was situated on the lesser curvature, and which reached to and was adherent to the diaphragm. The surface of the liver was studded with numerous slightly elevated white nodules, all of which showed recent adhesions to the parietal peritonaeum. Among the terminal symptoms are dropsical swellings and effu- sions into the serous cavities; in very rare cases these may even occur as initial symptoms ; * inflammatory processes may also occur in the lungs, pleurae, and kidneys. As death approaches, delirium may occasionally be present; this is to be regarded as a delirium due to inanition. Death is due to marasmus ; the agony is brief. Consciousness remains clear for a long time, yet disappears as death approaches, so that a conscious death struggle does not occur, f The condition of the blood deserves especial notice. Laache:}: was the first to describe a lessening of the number of the red blood- cells in this disease ; Lepine * called attention to the temporary oc- * Mey, loc. cit, describes two cases in which no other cause could be found for the oedema and anaemia which occurred even at the beginning of the disease. t [Dyspnoeic coma, as in diabetes, may also occur in the later stages of gastric cancer. Gerhardt's reaction may or may not be present in the urine. See Welch, loc. cit, pp. 534 et seq.-—Ed.] X S. Laache. Die Anaemie. Christiania, 1883. * Lepine et Germont. Note, etc. Gazette med. de Paris, 1877, No. 14 SYMPTOMS OF GASTRIC CANCER. 337 currence of numerous microcytes. Eisenlohr,* Schneider,f and Oppenheimer,X besides the above changes, observed a relative and even an absolute increase in the number of white blood-cells, so that the condition of the blood may resemble that of pernicious anaemia, or even of leucocythaemia; Schneider also says that " these so easily recognized changes in the blood may become a not unim- portant item in the differential diagnosis." Leichtenstern* and Haberlin | believed that the diminution in the amount of haemo- globin was a characteristic symptom, so that the latter would ex- clude the possibility of gastric cancer if the haemoglobin was about 60 per cent. Laker A urged that surgical interference ought to de- pend upon the percentage of haemoglobin. Daland and Sadler, Mouisset,^ and others, have corroborated the diminution in the per- centage of haemoglobin. At my request Ostersprey J studied this subject in reference to differential diagnosis ; in 12 cases he found the number of red cells lessened in 7, an increase in the white cells in 5, a lessening in the amount of haemoglobin in 11. In 2 cases, however, the red cells were increased in number with the formation of microcytes. These changes, although pathological, have unfortunately no diagnostic value, since similar changes, as shown by Ostersprey, occur in ulcer of the stomach, and, as shown by other writers, are found in other wasting diseases like tuberculosis, anaemia, cirrhosis of the liver, chronic perito- nitis, etc. [It is claimed by some $ that there is no digestive leucocytosis in gastric cancer, and attempts have even been made to use this as a * Eisenlohr. Blut und Knochenmark. Deutches Archiv fiir klin. Med., Bd. xxx, S. 495. f G. Schneider. Ueber die morphologischen Verhaltnisse des Blutes bei Herz- krankheiten und bei Carcinom. Inaug. Diss. Berlin, 1888, X Oppenheimer. Deutsch. med. Wochenschr., 1889, No. 42 et seq. 9 Leichtenstern. Untersuchungen iiber den Hamoglobingehalt des Blutes im gesunden und kranken Zustand. Leipzig, 1888. || Iliiberlin. Miinchener med. Wochenschr., 1888, No. 22. A Laker. Wiener med. Wochenschr., 1886, No. 18 et seq. Q Daland und Sadler. Fortschritte der Med., 1891, No. 20.—Mouisset. Carci- nome de I'estomac. Rev. de med., 1891, No. 10. \ Ostersprey. Berl. klin. Wochenschr., 1892. Nos. 12, 13. X [Hartung. Wiener med. Wochenschr., October 3, 1895.—Schneyer. Internat. klin. Rundschau, 1894. No. 39.—Ed.] 338 DISEASES OF THE STOMACH. means of differential diagnosis. At present no reliance can be placed upon such vague signs.] * The Changes in the Metabolism.—That patients with cancer ex- crete very little urea in spite of the ingestion of relatively larger amounts of food, and that there is a chronic deficit in the amount of nitrogen in the body—i. e., a wasting of the bodily albumen—require as little experimental demonstration as does the contrary proposition that the intestines act vicariously in digesting and absorbing food where the bodily weight remains constant and the general condition of the patient keeps good in spite of the deficiency of the gastric digestion. Both are absolute conclusions from the determinations of the loss and gain of the bodily weight. These self-evident rela- tions have nevertheless been worked out experimentally.*!* Of far greater interest is the study of the relation of the urea (i. e., the de- composed bodily nitrogen) to the chlorides in the urine, because both factors are dependent on the energy of the HCl secretion in the stomach. But, as in all investigations of the metabolism, it is self-evident that these analyses are only of value when the ingesta as well as the excreta are determined. This has been neglected by Bouveret; X consequently, in spite of the fact that his results are based upon 28 analyses upon two patients with cancer of the stomach, his conclusion is not free from objection, namely, that the relation of the chlorides to urea in cancer of the stomach with absence of HCl is less than the normal—i. e., is less than 2*3 and may sink to 0*7. Laubenheimer,* acting upon the above postulate, has shown in a careful investigation upon 5 cancerous patients that the disease does not necessarily influence the excretion of the chlorides, and, if reten- tion of the chlorides does occur, that this is due to no characteristic feature of the metabolism in cancer but to some accidental factors, * [For further details upon the blood changes, see the recently published text- books on the blood by Grawitz and by Limbeck.—Ed.] f Rommelaere. Journ. de med., etc., de Bruxelles, 1883-1886.—Rawzier. De la diminution de l'uree dans le cancer. Paris, 1889 (contains full literature).—Fr, Miiller. Zeitschr. fiir klin. Med., Bd. xvi, S. 496.—Klemperer. Berl. klin. Woch- enschr., 1889, No. 40. X Bouveret. Le rapport des chlorures urinaires a l'uree dans l'hypersecretion gastrique et le cancer de 1'estomac. Revue de med.. 1891, No. 7. * Laubenheimer. Ausscheidung der Chloride bei Carcinomatosen. Zeitschr. fiir klin. Med., Bd. xxi, p. 535. DURATION OF GASTRIC CANCER. 339 like the retention of water, etc. Katz,* without making such ex- haustive analyses, but repeating and extending Bouveret's experi- ments upon a large series of other diseases, has also ascertained that in diseases of the stomach the chloride excretion depends upon the general metabolism, and the relation between urea and the urinary chlorides is abnormally high where there is an exudation or reten- tion of fluid in the bodily cavities or in the tissues. As might have been anticipated, this shatters forever the hope that specific pathog- nomonic signs might be obtained from such variable factors as the changes in the metabolism. According to Rommelaere, 10 to 12 grammes of urea ought to be the highest amounts excreted in can- cer. But, as was evident a priori, this hypazoturia by itseK has no significance.f As a rule, the course of cancer is progressive, irresistible, and advancing toward a fatal termination. Occasionally, longer or shorter periods may occur in which the process seems to stand still, in fact even to retrograde. Such occurrences may lead to diag- nostic errors and doubts. Such periods of apparent improvement I have repeatedly observed. Most experienced physicians know of them; they certainly occur much more frequently than the text- books would lead us to suppose. The duration of the disease may vary from between three to six months to two, three, or more years; on an average it lasts between six and fifteen months; a shorter course is at all events exceptional. It always terminates fatally. Cases of cured cancer of the stomach have been repeatedly reported, yet they have never been positively proved. The cases reported by Dittrich, Lebert, Friedreich, and others, may have been mistaken for gastric ulcers or the superficial cicatrices which have already been described. Thus, in one of my cases of cancer of the breast, I found in the stomach a radiating cicatrix with thick, callous edges and a marked atrophy of the mu- cous membrane in the vicinity. It would have been reasonable to * Katz. Ueber die Beziehungen der Chlorausscheidung zu Erkrankungen des Magens. lnternat. klin. Rundschau, 1892. No. 10. f Grasset. Nouveaux elements de diagnostic, differential, etc. Gaz. hebdom., Mav 10, 1889.—Dujardin-Beaumetz, loc. cit. 340 DISEASES OF THE STOMACH. suppose that this was a healed primary carcinoma of the stomach with metastases in the mammary gland. But the microscope showed just the reverse. The base of the scar was formed by firm, dense connective tissue, while in the immediate vicinity of the border in the submucosa scattered cell-nests were found; these could only be regarded as the beginning of a cancerous process. The process was thus a cancer which had developed in the cicatrix left after the healing of an ulcer. The opinion that this was a cicatrized carcinoma was also excluded, because such an abrupt transi- tion from purely fibrous tissue to recent carcinomatous prolifer- ation as was present in this case is never found in a cancerous cicatrix. Frequency of Various Symptoms.—The above clinical picture is only schematic, and in an individual case numerous modifications may occur. Writers have taken great pains to determine the rela- tive frequency of the occurrence of the various symptoms, and in the works of Brinton and Lebert you will find analyses carefully prepared from relatively large numbers of cases. In practice—i. e., in the diagnosis of a suspected case—such statistics have only a rela- tive value, and are more interesting for the nosology of the disease. If we remember our statistics never so well, who will guarantee that a given case is the rule or an exception ? To illustrate the above, I present the accompanying half-sche- matic drawing (Fig. 12) of a case in which a colloid cancer involved the lesser curvature, and, being partially covered by the left lobe of the liver, could not be palpated during life. The patient was a tailor, forty-eight years old, who had never complained of pain, and had never had haematemesis. A probable diagnosis of cancer of the stomach had been made at the clinic of Prof. Frerichs, solely upon the marked anorexia and the progressive cachexia, and by the careful exclusion of other diseases. The fact that haematemesis occurs in 42 per cent (according to Lebert, in only 12 per cent) of the cases, and that a tumor is absent in 20 per cent, wTould have de- cided this case neither positively nor negatively. For the sake of completeness, however, and because it may nevertheless be of some assistance, I shall not withhold the fol- lowing figures. They are based upon an analysis of 250 cases CANCER OF THE STOMACH. 341 |.V*.J$f>"-H Fig. 42.—Colloid cancer of lesser curvature of stomacn. 342 DISEASES OF THE STOMACH. reported by Brinton and 88 and 145 eases respectively collected by Lebert.* Loss of appetite occurs in 45 per cent; often is observed only toward the close of the disease; rarely the appetite is increased. Pain is present in U2 per cent (Lebert, 75 per cent). It is fre- quently absent in old people. Brinton claims that pain between the scapulae indicates a cancer on the lesser curvature. In the case which I have just cited there was no reference to such an interscap- ular pain, and my own experience leads me to consider that the sig- nificance of this symptom has been exaggerated. Vomiting occurs in 88 per cent (Lebert, 80 per cent). It is most frequent where the orifices are involved. Nevertheless, a marked stenosis of the pylorus may exist without the occurrence of vomiting. While in most cases it occurs a considerable time after the meal (one, two, or three hours), yet it may take place much sooner, and in drunkards and very debilitated persons may even be present in the morning when the stomach is empty. There is thus nothing typical in the time of its occurrence. Hematemesis is noted in 42 per cent of Brinton's cases. Lebert distinguishes large haemorrhages from the stomach from true me- laena or melanemesis [the vomiting of black altered blood] ; the fre- quency of the former he estimates at only 12 per cent. A tumor is present in 80 per cent of the cases, according to both Brinton and Lebert. It is seldom palpable before the third to the sixth month; usually it is only distinct in the second half of the course of the disease, or during the last months of the patient's life. The bowels remain regular in only 4 to 5 per cent of the cases. In the vast majority there is constipation, or constipation alternat- ing with diarrhoea; the latter is a manifestation of a catarrhal con- dition of the intestinal mucous membrane, due to the irritation of hard fecal masses, or of products of decomposition which have not been carried off. A gastro-intestinal fistula may be formed, and faeces and gases may reach the stomach, or the stools may * A. Ott (Zur Pathologie des Magencarcinoms, Inaug. Dissert., Zurich, 1807; has added 33 additional cases from Prof. Biermer's clinic, and has obtained substan- tially the same results. DIAGNOSIS OF GASTRIC CANCER. 313 become lienteric—i. e., the presence of undigested food in the faeces. Yet Rampold * has observed a communication between the stomach and transverse colon and an adjacent loop of intestine in a patient sixty-six years of age, who gave no definite symptoms indicating a gastric lesion; it must be noted, however, that the patient also suffered from dementia paralytica. Murchison f has called attention to the fact that stercoraceous vomiting will be absent when the contents of the stomach pass directly into the colon, since there can be no formation of faeces. Finally, we must mention one peculiarity which is observed where the orifices of the stomach are involved by the cancer—i. e., the breaking down of the new tissue may cause the symptoms due to the stenosis to dis- appear, and thus, at times, an improvement may seem to have occurred. Diagnosis.—Although, taking all in all, the diagnosis of the dis- ease may be made from what has already been stated concerning the development, course, and general symptomatology, yet there still remain certain important diagnostic features the consideration of which I must not omit. I shall begin with the one which is of most recent origin, and which has given rise to somewhat too precipitate and exaggerated hopes. I refer to— 1. The absence of free hydrochloric acid in the stomach contents. It was a great triumph of Prof. Kussmaul's clinic to have first methodically investigated the subject. The opinion was originally expressed by R. von den Yelden,*j: that cancer of the pylorus, ac- companied by dilatation of the stomach, leads to a suppression of the secretion of hydrochloric acid. This view was soon indiscrim- inately applied to all varieties of cancers of the stomach. But even the combined labors of numerous investigators, and, not the least, those of the above-mentioned clinic, have shown that this statement can not be maintained in its entirety; yet it has led to results of great diagnostic and therapeutic significance. But historical justice demands that we think of an investigator * Rampold. Hufeland's Journal, 5te Stuck, 1836. f Quoted by Henoch. Klinik der Unterleibskrankheiten. Berlin, 1863. t Von den Velden. Ueber Vorkommen und Mangel der freien Salzsaure im Magensaft. Zeitschr. fur klin. Med., Bd. xxiii, p. 369. 23 314 DISEASES OF THE STOMACH. who, years ago, so thoroughly studied the question of the occurrence of hydrochloric acid in gastric cancer that the knowledge of his conclusions would have spared us much needless discussion. Re- markably, however, his labors, splendid for the age in which he lived, have so absolutely passed into oblivion that even his own countrymen nowhere speak of them. Golding Bird, Physician to the Islington Dispensary, and Professor of Medicine at Guy's Hos- pital in London, in 1812,* in a man forty-two years old, with pyloric cancer and dilatation (verified by autopsy), determined the relation of hydrochloric and the organic acids in a series of examinations of the vomit, the methods employed being faultless even to-day.f In about three weeks three estimations were made, the results of which led Bird to conclude that " during the more irritative stage of the disease free hydrochloric acid is present in the vomit in con- siderable quantities, but it gradually diminishes in proportion to the patient's loss of strength; and that the organic acids increase pro- portionally as the free hydrochloric acid diminishes." It is worthy of note that, by a control experiment on a healthy subject (an emetic dose of sulphate of zinc was given thirty minutes after a moderate dinner), free hydrochloric acid, but only a very small quantity of organic acids, could be demonstrated; another experiment, on a patient with cancer of the liver and dilatation of the stomach result- ing from pressure of the tumor on the pylorus, showed a somewhat lessened amount of free hydrochloric acid but large amounts of com- bined hydrochloric and organic acids. In these investigations it may be possible that a little confusion may exist in the relation of the free to the combined hydrochloric acid and the organic acids, because the diet and the time of the emesis were not precisely determined ; yet Bird's deductions are not to be questioned, and are of great importance. Bird himself was conscious of this, but complains of the amount of time demanded by these studies, and it seems he did not pursue them further. In * Golding Bird. Contributions to the Chemical Pathology of some Forms of Morbid Digestion. London Med. Gazette, 1842, vol. ii, p. 391. f Distillation of the volatile acids, incineration of the residue, boiling with dilute nitric acid, and estimating the silver salt with and without the addition of soda. DIAGNOSIS OF GASTRIC CANCER. 345 this way they passed into obscurity, and it was only recently that this subject was again taken up, but with new methods. The subject has been most thoroughly investigated by a large number of physicians. To show the extent of this discussion I need merely mention in chronological order the names of Yon den Yel- den, Ewald, Kietz, Thiersch, Riegel, Kahn and Yon Mering, Ja- worski and Gluczynski, Bamberger, Kraus, Dreschfeld, Rosenbach, Krukenberg, Rosenheim, and many others. Unquestionably the largest amount of material was collected by Riegel, who reported sixteen cases of cancer of the stomach, in which three hundred and six separate examinations were made.* It will be superfluous to follow the views expressed pro and con by the various writers, espe- cially since it has now been definitely settled that the absence of HCl in cancer cf the stomach has no special significance as such, but has only the value of a secondary symptom. It can very well be main- tained, as I have always done, that carcinoma regarded as a histo- logical neoplasm in no way lessens or destroys the secretion of hy- drochloric acid. This has recently received additional and almost superfluous corroboration by the unearthing of Bird's researches. But, whatever view is taken, it would nevertheless be a valuable di- agnostic criterion, provided other complicating factors did not inter- fere with the determination of the presence of hydrochloric acid— but not of its secretion. Each is correct. When the new growth is confined microscopically and macroscopically (which by no means always correspond) to a limited area, when the accompanying ca- tarrh of the mucous membrane is moderate, and when there is no atrophy, then the secretion of hydrochloric acid may remain ample till it disappears with the approach of death; or it may be much diminished, as occurs in all cachetic conditions. Indeed, as has been specially urged by Rosenheim,*!* if the cancer has developed in the scar of an ulcer, there may be normal or increased amount of HCl at the beginning of the disease. [A number of such cases has been reported in which the presence of free HCl persisted almost to the end of the disease.] However, in the vast majority of cases one of * Riegel. Zeitschr. fiir klin. Med., Bd. xii, p. 430. f Rosenheim. Zur Kenntniss des mit Krebs complicirten runden Magenge- schwiirs. Zeitschr. fiir klin. Med., Bd. xvii, p. 116. 346 DISEASES OF THE STOMACH. the above-mentioned factors plays a prominent part, and the secre- tion of hydrochloric acid is either entirely annihilated or is reduced to so small a quantity as not to be demonstrable with the ordinary tests. This would afford us an exceedingly good diagnostic criterion but for the fact—be it said with regret—that a diminution in this secretion may occur in other pathological conditions of the gastric mucosa. This I have demonstrated both as to the free and the com- bined HCl.* These include atrophy and amyloid degeneration of the mucous membrane ; self-evidently, poisoning or corrosion, in which a large portion of the mucous lining is destroyed; mucous catarrhs and certain neuroses depending upon or associated with a disturbance of the innervation of the gastric glands. It is manifest, as I have already stated, that acute injuries of the gastric mucosa, poisoning, and acute indigestion may cause a loss of glandular ac- tivity, just as in an acute catarrh of the kidney there is a marked diminution of its secretion, or as an injection of atropine into Whar- ton's duct dries up the salivary secretion. Likewise, in my own per- son I found that the stomach contents were absolutely free from hydrochloric acid during a very transitory nicotine poisoning; on another occasion, during a sea voyage, I could obtain no reaction with Congo paper in the food which was vomited one hour after breakfast. Such conditions are only of short duration, and rapidly disappear after the removal of the irritant or under a suitable diet. The experiments of Wolfram f show that, while fever is present in all the acute infectious diseases, the gastric juice contains no hydro- chloric acid and exerts no digestive action either within or outside of the organism. We also know concerning certain chronic dis- eases—for example, Addison's disease, pernicious anaemia, many cases of pulmonary phthisis, valvular diseases of the heart, diabetes, etc.—that the secretion of hydrochloric acid is reduced to a mini- mum, and no free acid can any longer be detected. But even physiologically there are very marked variations in the * Ewald. Ueber Stricturen der Speiserohre. Zeitschr. fiir klin. Med., Bd. xx, p. 562. t Announced by Gluczynski. Ueber das Verhalten des Magensaftes in fieber- haften Krankheiten. Deutsches Arch, fiir klin. Med., Bd. xxxiii. DIAGNOSIS OF GASTRIC CANCER. 347 amount of acid produced. Normally, the amount of HCl secreted is regulated by the amount and kind of food, so that some free HCl is soon present. This does not occur in the vast majority of cases of cancer of the stomach. But this does not depend upon some in- fluence of the cancer on the production of HCl, but is simply due to the accompanying catarrhal, inflammatory, or atrophic conditions of the gastric mucous membrane. If these are absent the acid is secreted abundantly, as in the case reported by Bird, another by Cahn, and still another reported later which had been observed by Yon den Yelden,* or there may even be an excess of HCl as occurs in the cases of carcinomatous degeneration of gastric ulcers.f But if, during our observation of such a patient, one of the above pro- cesses involves the gastric mucous membrane and becomes more marked, or if the organism gradually becomes weaker and weaker, as the result of the carcinomatous intoxication, then the transition from the occurrence of hydrochloric acid to its absence may take place in a relatively short space of time. In this way I explain Bird's case, and also one which came under my own obser- vation : Mr. R, merchant, forty-two years old, was seen in consultation on January 7th. He had suffered for a long time from "chronic catarrh," and had complained of a severe burning sensation in the stomach for several months. He was admitted to the Augusta Hospital, and while there was treated with the stomach tube and was very much benefited by it. He learned to wash out his stomach and did it frequently, especially as he sought in this way to remedy his frequent dietetic errors. The patient was a haggard man, with a dry skin and retracted abdo- men ; he lay in bed on account of weakness. Heart and lungs negative. There was a small movable tumor at the pylorus about the size of a wal- nut, slightly tender on pressure. No succussion sound. The stomach when distended reached to the umbilicus, causing the tumor to move downward and somewhat to the right. During the introduction of the tube by himself he vomited slimy, yellowish-green, offensive masses of neutral reaction ; accordingly, no free acid was present. No glandular swellings. Urine clear and acid. Stools irregular. The stomach contents, after taking the test-breakfast on the following morning, undoubtedly contained a considerable amount of hydrochloric * Cahn. Verhandlungen des vi. Congress, fiir innere Medicin, 1887, S. 362 und 373. t Thus, for example, Waetzhold (Charite Annalen, Bd. ix) has reported a case with 3 per mille HCl. In the two cases of Rosenheim the amount of HCl was 3-9 and 3*4 per mille. 348 DISEASES OF THE STOMACn. acid, and small quantities of lactic acid, peptone, and propeptone. The stomach contents digested slowly. In view of the presence of hydrochloric acid, a diagnosis was made of a non-carcinomatous hypertrophy of the pylorus (cicatrization of an old ulcer ; muscular hypertrophy accompanying a chronic catarrh (?) ). But on the following day the patient vomited bloody masses, and com- plained of severe burning pain in the stomach and an almost intolerable dryness of the mouth, pharynx, and cesophagus. Vomiting recurred very frequently during the next three weeks in spite of a rigorous diet and regular lavage of the stomach. Each time the stomach contents were abundant, of a bloody color, or contained broken-down coagula ; frag- ments of food were also present. Hydrochloric acid was never found ; on the other hand, large quantities of yeast-cells, bacteria, and mucus could be seen. The reaction was usually neutral; if acid, it was due to acid salts or lactic acid. On two different occasions the test breakfast was given lege artis, and each time the absence of hydrochloric acid was noted. The tumor remained unchanged and could be felt more or less distinctly, according to the fullness of the stomach. The patient suffered intensely, lost strength rapidly, and urgently wished the removal of the tumor by operation. In view of the large quantities of " stomach con- tents " which were siphoned through the tube from the patient's stomach —often amounting to four or five litres [nine to eleven pints]—dilatation of the stomach was diagnosed, although a repetition of the distention of the viscus with air again gave no positive evidence thereof. I could not quite explain this peculiar condition, but I expressed to my colleagues the suspicion that the siphoned fluid came from the intestines rather than from the stomach, the fluid having regurgitated into the latter through the rigid and thus incompetent pylorus. At the patient's request, Prof. Sonnenberg resected the pylorus on January 30th—i. e., about three weeks after the first examination. At and surrounding the pylorus was a hard tumor, the size of a walnut, which so narrowed the orifice that the tip of the little finger could be inserted only with difficulty. Several glands in the ligamentum gastro- colicum were enlarged to the size of cherries. The stomach was not dilated. After the operation everything went smoothly, and for the first few days the patient's condition was excellent. On the fourth day there was a slight febrile movement, followed by marked collapse ; the patient died on the evening of the fifth day. At the autopsy I found that some of the sutures (catgut and silk) had suppurated, causing a localized purulent and adhesive peritonitis which may be regarded as the cause of death. The mucous membrane in the line of sutures was hypersemic, but elsewhere was entirely uninvolved. On the other hand, the muscularis as far as the fundus was infiltrated and thickened. A piece of the fresh tumor was immediately placed in absolute alcohol, which was subsequently fre- quently changed ; microscopical examination showed that it was a scir- rhous carcinoma which was almost entirely limited to the muscularis, in- filtrating it in broad bands. The greater part of the mucous membrane ivas entirely normal, or at most only slightly infiltrated by an interstitial proliferation of small cells from the submucosa. In places there was DIAGNOSIS OF GASTRIC CANCER 349 more atypical growth of the glandular tubules, and cysts of various sizes were found toward and in the submucosa. On comparing this section with a preparation from a catarrhal stomach no marked differences could be found. The same was true of pieces of tissue which were taken at the autopsy from the fundal and cardiac portions. In the affected area the submucosa was sharply defined from the mucosa on the one side and from the infiltrated muscularis on the other ; even with the naked eye its wide-meshed fibrous structure could be recognized. The great significance of this case is manifest. It proves that with a localized cancer and an intact mucous membrane the secre- tion of hydrochloric acid may continue up to a short time before death; and under such circumstances conclusions based upon the demonstration of this acid may be erroneous. The hard nodular character of the cancer precludes the possibility of an antecedent ulcer ; so that Rosenheim* is right in urging that the presence of free HCl does not of itself indicate the origin of a cancer from an ulcer, but that other symptoms of gastric ulcer, such as haemate- mesis (at the beginning of the disease !), cardialgia after eating, localized pain in the epigastrium, etc., must have been present. Since the observation of this case a number of careful investiga- tions have been made on the relations of hydrochloric acid to cancer of the stomach ; of these I shall only quote the following: In eight cases of this disease which were carefully studied, both anatomically and chemically, Stienon f reports that four gave no reaction to the color tests, while the other four gave temporary, more or less posi- tive results. In fourteen examinations made on two cases with the method of Cahn and Yon Mering, positive reactions were obtained, the amount of hydrochloric acid varying between 0*4 and 2*3 per thousand, but the color tests gave a negative result every time. The microscopic examination convinced him that the disease is fre- quently, if not usually, accompanied by an atrophy of the glands, and to this may be due the absence of hydrochloric acid. Similar conclusions have been reached by Rosenheim X an(i hy myself in * Loc. cit, p. 135. * L. Stienon. Le sue gastrique et les phenomenes chimiques de la digestion dans les maladies de I'estomac. Journal de Med. de Bruxelles, October 5, 1888. f Th. Rosenheim. Ueber atrophische Processe in der Magenschleimhaut in ihrer Beziehung zum Carcinom und als selbststandige Erkrankung. Berliner klin. Wochenschr., 18tS8, No. 51-52. 350 DISEASES OF THE STOMACH. many examinations which I have not published. It is to be noted, however, that such atrophic processes are not the general rule, be- cause experience teaches us that the accompanying affection of the mucous membrane may restrict itself to a more or less extensive and intense inflammatory process (catarrh). 2. Relations of the Ferments.—For the other ingredients of the gastric juice, the pepsin and rennet ferment are not lessened to the same degree as the hydrochloric acid. The products of the action of pepsin, the peptones, are found almost without exception even where neither free hydrochloric nor lactic acid is present. Hence pepsin must have been secreted, and sufficient free HCl to form peptone must have been present at some time. The majority of these filtered stomach contents form not alone propeptone but also true peptone, if they are acidulated to about two per thousand of free HCl. Boas (loc. cit.) claims to have found rennet ferment even where free HCl was absent. The explanation of this apparent para- dox lies in the fact that the secreted HCl combines with any free bases, weak salts and albumen and its derivatives, while the fer- ments remain free; and of the latter we know that their action only begins to be lessened when the products of fermentation are present in excess. The relation of these three elements [hydro- chloric acid, pepsin, and rennet ferment], and the mode of deter- mining them, will therefore depend very much upon the nature of the food and the energy of the secretion—the effects of the variety and extent of the lesion of the mucous membrane being self-evi- dent. [No practical diagnostic results have thus far been gained by the tests for the gastric ferments in cancer of the stomach. Their absence is only indicative of atrophic conditions of the gastric mucosa. See page 67.] But the important fact remains that free hydrochloric acid is usually absent in carcinoma of the stomach. Unfortunately, the diagnostic value of this circumstance is decidedly affected by the occurrence of this same loss in the other conditions which I have already mentioned. But, granting this, the proposition, which I was the first to announce, is still true, that the demonstration of the presence of hydrochloric acid points with very great probability against the existence of cancer of the stomach ; for the cases of this DIAGNOSIS OF GASTRIC CANCER. 351 disease in which there is a positive reaction to the carefully applied tests are so rare that they have very little bearing on the question.* Under certain conditions (stagnation of the ingesta or the intro- duction of easily fermenting food) the hydrochloric acid may be re- placed, or may be accompanied by lactic acid, .fatty acids and their salts, which may impart an acid reaction and penetrating odor and taste to the contents of the stomach. Of especial interest, however, is the fact, which has been repeatedly observed in this disease, as well as in other affections of the stomach, that, with an absolute loss of the hydrochloric-acid reaction, this deficiency in the digest- ive function has been replaced for a long time by the vicarious action of the intestinal digestion, or by the formation of large quan- tities of lactic acid (or eventually of acetic acid). [3. Significance of lactic Acid.—Boas was the first to lay stress upon the fact that, in most cases of cancer of the stomach, lactic acid is formed in such large quantities that this relation may be used for diagnostic purposes, especially in the early stages of the disease.-f- Boas urges that we must distinguish between the forma- tion and occurrence of lactic acid. The acid occurs in many gastric disorders, especially since it is taken into the stomach with meat, bread, milk, etc. On the other hand, it is formed only in cancer. This is due to the stagnation of the stomach contents which results from the very early and increasing infiltration of the muscular layers by the neoplasm, combined with the absence of HCl. No- where else than in cancer do these two factors occur more often; hence the value of the test. Unless both of these factors are present large quantities of lactic acid will not be formed. Thus we do not encounter it when ulcer undergoes carcinomatous degeneration. Furthermore, the test is of value only from a positive standpoint— i. e., the absence of lactic acid does not indicate that a cancer is necessarily absent. Hence Boas does not claim that it is of service in all cases, but in many of them ; and especially at an early period, * I have given these conclusions exactly as they were stated in the earlier edition of this work. Their correctness has been shown by all researches which have since been published on this subject. f [This relation was first pointed out by Cahn and Von Mering.—Langguth. Boas's Arch., Bd. i, p. 358.—Ed.] 352 DISEASES OF THE STOMACH. before a tumor can be palpated and before the cachexia has become pronounced—a time, in other words, when radical measures can best be carried out. (For the exact details of the tests, see pages 41 and 54.) Boas's claims have been corroborated by a number of writers, among whom we may mention Oppler, Cohnheim, Pariser, Frieden- wald, Hammerschlag, Stewart, Manges, Schule, De Jong, and others. Its value has been more or less recognized, but its claims as a spe- cific denied by Riegel, Thayer, Rosenheim, Klemperer, Strauss, Bial, Langguth, and others. But Boas never claimed that it was abso- lutely pathognomonic of cancer, but only highly suggestive of this disease when combined with other symptoms; that the lactic acid must be formed in large quantities, and that the tests should be tried several times. A number of investigations which have since been published proves that lactic acid may be formed as well as occur in other conditions than cancer, which are accompanied by motor and secretory insufficiency of the stomach. Thus Strauss has reported a case of fat necrosis of the pancreas, and Riegel * one of invagination of the colon, in which large quantities of lactic acid were found. Still, even the opponents of the test admit that large quantities of lactic acid occur in from 78 per cent (Rosenheim) to 91 per cent (Strauss) of cases of cancer of the stomach. It must be added that sometimes instead of occurring early in the disease it does not appear till later on.] f 4. The presence of specific tissue elements in the vomit, or in the masses raised through the stomach tube. I have already spoken in general of the constituents of the vomit; here I need only recapitu- late that in the advanced stages of this malady we may find a very great variety of fungi, yeast-cells, sarcinae, bacteria, pavement and round epithelial cells, with large nuclei, single nuclei, and nucleoli, and large masses of detritus colored brown to a dark green, and mixed with all kinds of remnants of food. But the present question * [Quoted by Riegel, op. cit, p. 137.—Ed.] t [The German literature of this subject may be found in Langguth. Boas's Arch., Bd. i, p. 355. De Jong, ibid.. Bd. ii, p. 53. Hammerschlag, ibid., Bd. ii, pp. 1 and 198. The American literature is given by Manges. New York Medical Record, April 27, 1895.—Ed.] DIAGNOSIS OF GASTRIC CANCER. 353 is, Is it possible to recognize specific cancerous tissue ? This is cer- tainly impossible with isolated epithelial cells. It must be admitted with regret that, in spite of all the time and labor which have been expended, no means have yet been discovered by which we can dis- tinguish specific cancer cells from the ordinary varieties of epithelial cells found in the stomach contents, some of which are derived from the walls of that viscus, while others, from the mouth and oesopha- gus, have been swallowed. Even Brinton said: " But mere isolated cells or nuclei scarcely justify a decision." Lebert, in his Physi- ologie pathologique, pictures cells with six or more concentric layers, which he considers specific cancer cells, " globules cancereux dpuroix concentriques." These cells are nothing more nor less than Fio. 43.—Cancerous cell-nest raised through stomach tube. (From Mr. L., December 11,1886. Sketched with camera lucida.) starch granules. For my part, I only consider conclusive the con- centrically stratified aggregations of cells, true cancer cell-nests, such as are shown in Fig. 43. In the case from which this specimen was obtained it was even of decisive value. Mr. L., about thirty-five years old ; no inherited diseases; has been complaining for the last six months of anorexia, pain in the epigastrium, and frequent vomiting : no tumor nor cancerous cachexia. By means of the stomach tube large masses of mucus were obtained every time; hydro- 354 DISEASES OF THE STOMACH. chloric acid could never be demonstrated. The diagnosis lay between a severe mucous catarrhal gastritis and an occult neoplasm. On renewal of the examinations faint blood streaks were seen, and a small, firm particle was obtained ; from this the above preparation was made. By its means alone the diagnosis was established, and the death of the patient about two months later verified its correctness. But even such specimens as the one in question may give rise to errors. It occasionally happens that very small pieces of the gas- tric mucosa may be detached where the membrane is very vulnerable, even when a cancerous neoplasm is absent. If such a piece is placed on a slide, the pressure of the cover-glass may cause the epithelium surrounding an excretory duct to assume a concentric stratification closely resembling a cancerous cell-nest. The drawing of such a specimen is given in Fig. 44; it, together with a large shred of the epithelial lining of the stom- ach, was found in the wash-water while washing the stomach of a patient twenty-eight years old, suffering from a mucous catarrhal gastritis, with no symptoms of cancer, and whose improvement was continuous. On page 196 I have already given similar but not such deceptive figures. [Cohnheim * reports five cases of gastric cancer in which bits of tumor tissue were found and examined.] 5. The cancerous tumor. Concerning tumors of the stomach, I shall only remark, in passing, that it is self-evident that to be pal- pable they must be situated upon the greater curvature, or at the pylorus, and that neoplasms situated upon the lesser curvature are beyond the reach of the palpating fingers, especially if the growth is along the surface and is overlapped by the liver; such a condi- tion was present in the case from which Fig. 42 was taken; and, finally, that tumors on the lesser curvature can only be palpated when the stomach occupies an abnormal position. It is equally ob- Fig. 44.—A piece of the epithelial covering of the mucous membrane of the stomach, resembling a cancerous cell-nest. (From Mr. K., March 10, 1887. Sketched with camera lucida.) * [Cohnheim. Boas's Archiv, Bd. i, p. 294.—Ed.] DIAGNOSIS OF GASTRIC CANCER. 355 vious that the palpation of gastric tumors may be rendered impossi- ble by the development of ascites from any cause. For a long time it was considered an axiom that movement of gastric tumors with respiration became possible only after adhesions had been contracted with the liver. But even this rule is not without exceptions. I, as well as Fr. Miiller, have repeatedly observed distinct respiratory movement of the stomach, which, as shown by autopsy, was totally carcinomatous, without any adhesions to the adjacent viscera; and yet which, during life, descended with every inspiration, as a result of the flattening of the diaphragm. A similar movement of the tumor may be transmitted from the liver when the neoplasm lies close to the edge of the liver without the formation of any adhesions. At the Policlinic I have repeatedly and carefully examined a pa- tient with such a tumor, the size of a fist, situated on the greater curvature near the pylorus; it was freely movable both with the fingers and by distending the stomach with air; the descent with every movement of inspiration was very noticeable. But such cases are always exceptional; and, indeed, their occurrence as such merely serves to strengthen the general rule above stated. [The present views as to the respiratory movement of gastric tumors may be briefly formulated thus: Neoplasms at the pylorus act differently than those situated on the curvatures. Pyloric tumors move with respiration only after they have contracted adhesions to the liver. Those on the curvatures are movable, as a rule, at all times. A feature peculiar to them has been pointed out by Min- kowski,* that their ascent with expiration may be retarded by fixing them; thus, if we press on the tumor after taking a full inspiration, it will not rise until the pressure is released.* This feature is of value not alone in distinguishing gastric from other tumors, but also in distinguishing those on the curvatures from the growths at the pylorus.] It is also important to bear in mind that most tumors feel much larger to the palpating finger than they really are, and that they may change their position according to the fullness of the stomach or intestines. In like manner a good idea of the size and situation, * [Minkowski. Berl. klin. Wochenschr., 1888, No. 31.—Boas, op. cit, Bd. ii, p. 174.—Ed.] 356 DISEASES OF THE STOMACH. whether in the stomach or in one of the adjacent viscera, is not sel- dom only obtainable after the distention of the stomach or intes- tines ; at times it may be necessary to examine the patient not alone while recumbent, but also by depressing the head deeply and elevat- ing the pelvis, or in the knee-elbow position. To distinguish a de- formity on the lower border of the liver, especially in the left lobe, such as frequently result from tight lacing in women, or a true tumor of the liver, pancreas, or spleen from a new growth in the stomach, may at times be very difficult; at other times it is even impossible.* The reverse may also occur, and a carcinoma of the stomach may be regarded as belonging to the left lobe of the liver. Thus Ott,f after giving a very careful description of such a case, says: The complete degeneration of the entire stomach even to the region of the liver, the rigid infiltration of the greater curvature, the diminution in size and contraction of the organ which enabled one to grasp the greater curvature, and which caused it to feel like the edge of the liver— all of these factors led to this deception. It is equally difficult to decide whether a thickening at the py- lorus is due to hypertrophy of the muscular coat, cirrhosis, foreign body encapsulated in the stomach,*}: wall-like cicatrized ulcer, * local- ized peritoneal exudate, or carcinoma. Carcinomata of the omentum or of the intestines, which may be lying alongside of the stomach, may at times be recognized by a simple distention of the gut with air. Leube very properly calls attention to the possibility of mis- taking the pancreas for a growing tumor of the stomach, since the progressive emaciation of the patient permits the pancreas to be more easily palpated through the relaxed abdominal wall. It is very difficult, and at times even impossible, to positively differentiate a pyloric tumor from carcinoma of the gall bladder or even gallstones which have not been accompanied by the typical symptoms of this condition—colic, icterus, hepatic enlargement, etc.—but which have * [See Osier, op. cit, Lecture II, for an instructive series of cases of cancer of the stomach, showing the various diagnostic features.—Ed.] t Ott. Zur Pathologie der Magencarcinome. Zurich, 1867, S. 60. X [See p. 376.] * Reinhard (Inaug. Dissert., Berlin, 1888) has collected 16 cases. According to my experience its occurrence must be much more frequent. DIAGNOSIS OF GASTRIC CANCER. 357 only given rise to a vague tumor in the neighborhood of the pylorus. Frequently the question can only be decided after prolonged ob- servation by the eventual growth of the suspected tumor, the occur- rence of cancerous cachexia, the formation of metastases, and swell- ings of the lymph glands; but sometimes even these signs may fail, and the autopsy alone can reveal the true condition. In all these cases the examination of the stomach contents is of great importance. If the usual amount of free hydrochloric acid is found after the test breakfast, we may say with tolerable certainty that the stomach is not involved, or at least that no well-marked cancer is present. An excess of HCl would indicate an indurated cicatrix after an ulcer, the possible carcinomatous degeneration of which we can not at once determine with certainty. I shall relate two cases to illustrate how the examinations for HCl established the diagnosis beyond a doubt: On November 24th a colleague, Dr. X., sent to me Mrs. W., thirty- three years old, a small, emaciated woman, who had borne four children. She complained of almost continuous pain day and night in the epigas- trium. The pains were independent of eating, had lasted more than six months, and were temporarily ameliorated by the use of Carlsbad water. The patient belched frequently, but had a good appetite, and had never vomited. The tongue was not coated; the abdomen was somewhat pendulous, and its walls relaxed. Close to and on the right of the median line was an easily movable tumor, which was painful on pressure; to the right and external to this was a second tumor, smaller, and descending with inspiration (gall bladder). Distention of the stomach with air revealed a dilatation and a descent of the greater curvature to midway between the symphysis and umbilicus. The stomach contents contained an abundance of free hydrochloric acid, but no products of fermentation or decomposi- tion. Further questioning revealed that the patient had occasionally suf- fered from gastralgia. Diagnosis: Dilatation of the stomach resulting from a cicatricial stenosis of the pylorus, and hypertrophy of the muscu- laris as a sequel of an ulcer at this point. The proof of this was the con- tinuous improvement and gain in strength after methodical lavage and suitable diet. No cancerous cachexia was present. The diagnosis of this case was possible only by knowing the result of the examination of the stomach contents; and having ascertained this, it was rendered sufficiently certain. It is well known that a hypertrophy of the muscularis in the pyloric re- gion may absolutely simulate a neoplasm; as examples, I refer 358 DISEASES OF TnE STOMACH. to the case reported by Yirchow,* and to another published by myself: f The latter case was as follows: H. S., fifty-six years old, teacher from Salzwedel. The man, of a very large and powerful frame, was much emaciated and cachectic. The abdomen was relaxed and very flaccid, as in a multipara. In the umbilical region close to the surface could be felt a broad, flat, slightly nodular tumor, which reached on the right to the axillary line and on the left to the parasternal line. Deep inspiration gave rise to a feeling of false movement—i. e., the sliding of the abdominal wall simulated the movement of a tumor. The patient was very dyspep- tic, suffered severely from belching, and vomited occasionally. It was self-evident that there was a carcinoma of the omentum ; the only ques- tion in doubt was whether there was also a cancer of the stomach, as was indicated by the dyspeptic manifestations. The examination of the stom- ach contents revealed an abundance of free hydrochloric acid, acidity 50 ■ the filtrate had a digestive action. An involvement of the stomach was thus excluded. The correctness of this diagnosis was verified by the autopsy. In large tumors percussion may reveal a circumscribed area of dullness, yet it is hardly necessary for me to state that the percus- sion note will vary considerably according to the amount of air in the stomach and intestines, and according to the force used. The best results are obtained by very delicate direct percussion with the finger, or by auscultatory percussion.X Small tumors may at times be inaccessible to both percussion and palpation by a twisting of the stomach on its axis, yet they may be rendered demonstrable by in- flation of the stomach or intestines. At times the tumor may pulsate distinctly when it lies upon the aorta and is lifted by it. This pulsation, which may be very marked, and owing to the retraction of the abdominal parietes may seem to be just beneath them, is distinguished from pulsation of the aorta by the fact that a tumor only expands in a vertical direction, while the aorta does so both vertically and laterally. However, this does not always suffice; if the tumor surrounds the aorta, as occurred in Ott's case,* all the symptoms of an aortic aneurism may be present: * Virchow. Wiener med. Wochenschr., 1857, No. 26. t Ewald. Berl. klin. Wochenschr., 1886, No. 32. X [The phonendoscope promises to be very useful in determining delicate dif- ferences of this kind. My experience with this instrument in mapping out changes in the stomach outlines has been very encouraging.—Ed.] 9 Ott. Loc. cit, p. 73. DIAGNOSIS OF GASTRIC CANCER. 359 transverse and vertical pulsation, systolic bruit and distinct thrill over the tumor, smallness of the femoral arteries, even a swelling in the back may be present; we may sometimes also observe symptoms which are exactly similar to those occurring when a calcareous an- nular infiltration has developed in the walls of the aorta and has caused a stenosis of the vessel and a dilatation above the site of the stricture. At all events, a differential diagnosis in such cases is out of the question. Hard fecal masses in the transverse colon or jejunum may simu- late a tumor ; hence the rule, Always previously evacuate the bow- . els thoroughly in every doubtful case. This is so self-evident that I ought scarcely to mention it. Yet in practice I find that this point is very frequently disregarded, in spite of the fact that it is men- tioned in every text-book. In many cases there is continuous pain at the site of the neo- plasm ; its manifold character has already been discussed under the general symptoms. In other cases the pain varies, at times ceasing entirely or being simply manifested as a vague burning sensation or oppression in the epigastrium. The exacerbations of pain are usually due to fresh inflammatory processes or the development of new tumors, or finally to traction on the walls of the stomach, owing to the firm adhesions with the adjacent movable viscera. Propaga- tion of the pain downward into the umbilical and suprapubic regions renders it very probable that the neoplasm is advancing along the peritonaeum ; occasionally distinct friction sounds may be heard, es- pecially in the hepatic region ; sometimes a rubbing may also be felt. 6. The cancerous cachexia. The peculiar condition of patients with cancer, which is called the cancerous cachexia, appears almost without exception sooner or later in the course of the disease, and has afforded various authors an opportunity to write more or less poetical descriptions. Unfortunately, this condition may give rise to errors both positive and negative. The latter are due to the fact that it is usually absent at the beginning or during the first half of the disease, just at the time when it would be of the greatest service to render a diagnosis certain. Some time ago I was called to see a patient in whom I could very easily palpate an immense nodular tumor occupying the entire epigas- 24 360 DISEASES OF THE STOMACH. trium, and also adherent to the liver. The patient claimed to have been well up to two weeks before my visit and to have followed his usual oc- cupation till then ; also that neither his family nor his friends noticed any- thing peculiar about him. The first symptoms observed were jaundice, and cedema of the lower extremities, which appeared suddenly. Even when I saw him there was no trace of a true cachexia, and yet the neoplasm was evidently of long standing. On the other hand, we will not infrequently see persons with a typical cancerous cachexia, and whose history, as well as the results of the examination, point strongly toward cancer, yet after a longer or shorter course of treatment they recover entirely, and thus afford a most striking proof to the contrary. Among these are aged per- sons with chronic catarrhal gastritis who often, especially if they were formerly plump, emaciate to such a marked degree that they look as if they had cancer. Disregarding manifest diseases whose nature may be discovered, it is almost superfluous to say that in this class of patients the most important place is occupied by hysteria in all its varieties. Every physician knows to what extent the emacia- tion and loss of strength of hysterical patients may sometimes reach. Even if we disregard the other characteristic symptoms as a whole, it will be observed that in hysterical cachexia the turgescence of the skin is well preserved, in marked contrast with the condition of the skin in cancer ; this is a valuable diagnostic sign. The differ- entiation is rendered still more difficult in the hysteria of male subjects. Some time ago I was associated with a local colleague in the treatment of a man, forty years old, who had lost thirty pounds in two months; he had quite a marked but not extreme cachexia, and a variety of symptoms, among which were complete anorexia, marked fetor of the breath, and oppression over the epigastrium ; these led to the suspicion of a rapidly growing organic lesion. In addition, the patient also suffered from pal- pitation of the heart and attacks of dyspnoea, apparently of a severe form; he also had strange sensations, especially a very peculiar and annoying feeling as if his limbs were "dead and ice-cold." Other physicians had expressed an unfavorable prognosis, and this had not failed to exert a very depressing effect on his already irritable disposition. He lay in bed for weeks and protested that he was unable to leave it. The latter symp- tom, the cardiac palpitation, the dyspnoea, the peculiar sensations for which we could find no cause either in the circulatory or respiratory sys- tem (there was a moderate dullness on the right side posteriorly, but this proved to have been due to a temporary atelectasis)—all these led us to assume the presence of hysteria complicated with a very severe gastric DIAGNOSIS OF GASTRIC CANCER. 361 catarrh, possibly due indirectly to the latter. We began suitable treat- ment, and its success proved the correctness of our supposition; all of the symptoms disappeared, and the patient was discharged cured, after four weeks' treatment, including washing out the stomach with a watery solu- tion of thymol; the other drugs used were hydrochloric acid, bromide of potassium, and valerian. In this case the patient's age was an important .—Perforating ulcer of stomach, c, cardia ; p, pylorus ; «, perforating ulcer. 380 DISEASES OF THE STOMACH. was a thrombosed and very tortuous vessel, about the diameter of a pin, from which the fatal haemorrhage arose. The margins of the ulcer in the lower and middle portions were thickened, wall-like, and undermined; y in the upper portion they ran gradually into the intact mucous mem- brane. The other ulcers extended only to the muscular layer, or were limited to the mucous membrane. In one of these the remains of a small throm- bosed vessel could be observed. The rest of the mucous membrane was in the usual condition, except that the small greenish points described above as appearing on the serous coat were also seen here. The micro- scope revealed a catarrhal condition in the fundus and pylorus, with marked cellular infiltration and cloudy glandular cells. The "green points " were not due to extravasations of blood, but were produced by the vessels of the submucosa, which were uncommonly enlarged and mark- edly tortuous, and especially by the veins, which were widely distended with blood. There was no amyloid degeneration. In the intestines were found large quantities of thin fluid blood. The remaining abdominal viscera were normal, but anaemic to a high degree. This case presents several deviations from the common type of gastric ulcer, not only in regard to the course of the disease, or rather its latency, but also on account of the not very common form of the ulcer and the perforation, and finally in the uncommon mani- festations to whioh the perforation itself gave rise. I will return to this later on. I shall now describe the clinical picture of the so-called round, but better named chronic eroding gastric ulcer, in contradistinction to the acute ulcers produced by the action of corrosive poisons, which have already been discussed in speaking of toxic gastritis [see Chapter IV]. The name chronic round gastric ulcer is also not quite proper, inasmuch as it is occasionally acute or subacute, and as it is by no means always round, but frequently of various forms. Etiology.—Investigators have zealously endeavored both clinic- ally and experimentally to establish the causes of gastric ulcer. Synchronous with the commencement of the experimental era in medicine is the first careful and comprehensive description of this affection by Cruveilhier, who was the first to raise the gastric ulcer from a curiosity of the autopsy table to the dignity of a definite and recognizable pathological condition. Experiments on Animals.—Gastric ulcers—that is, circumscribed losses of tissue in the mucous membrane, extending to the submu- cous and muscular layers—may be produced in animals by various ETIOLOGY OF GASTRIC ULCER. 3SJ means, which in the end always amount to a local disturbance of nutrition in limited portions of the mucous membrane, lasting a cer- tain time. There is either a shutting off of circumscribed vascular areas with consequent necrosis and sloughing of the tissues, the gastric juice meanwhile attacking the spots deprived of their nor- mal nourishment exactly as, under favorable conditions, it causes softening (digestion) of the dead stomach, but to a greater degree. This is due to emboli artificially produced, ligation of small vessels, or to haemorrhages which result from injury to certain portions of the central nervous system. Or, the ulcer may be referred to direct mechanical, chemical, or thermal lesions of the mucous membrane, the latter being at the same time accompanied by an alteration of the circulation in the parts subjected to irritation. But these losses of substance heal with exceptional rapidity, cicatrization advancing from the margins to the center with restoration of the mucous membrane. According to the investigations of Griffini and Vas- sale,* the mucous membrane of the fundus of the stomach is replaced by the formation of true peptic glands from the superficial epi- thelium which at first covers the wound, this in turn being formed from the glandular epithelium found in the glands situated in the margins of the wound. This replacement, too, is prompt and effi- cient, so that in the very late stages of the process it is difficult to find the situation of the injury, while after ten to fifteen days it has entirely healed, without leaving behind a trace of its presence. Thus, these are fundamentally acute defects of the mucous membrane which can not properly be called ulcers; for these, at least during some portion of their existence, must display the tendency to spread. For the production of chronic ulcers another force must come into play—namely, a disproportion must exist or be created between the secretion of the gastric glands and the nutritive blood, either syn- chronous with or previous to the appearance of the local lesion ; it may be either an increased acidity of the former or a deterioration of the latter, or both factors may be present at the same time. Eb- * L. Griffini und G. Vassale. Ueber die Reproduction der Magenschleiinhaut. Beitrage zur pathologischen Anatomie, etc., von Zeigler und Nauwerck, Bd. iii, Heft 5, p. 4:25. 382 DISEASES OF THE STOMACH. stein* making use of a discovery of Schiff, produced gastric haemor- rhages and corroding ulcers, and even perforation, by injury to the anterior corpora quadrigemina. \Ye may well assume that an ex- cessive production of acid secretion took place here, perhaps due to the cerebral irritation. Koch and Ewald,f by introducing a hyper- acid 0*5-per-cent solution of hydrochloric acid, produced deep ulcers in the stomachs of animals in which gastric haemorrhages had been caused by section of the spinal cord, according to SchifFs method. Quincke and Daettwyler X made the animals anaemic by venesection. Silbermann* caused haemoglobinaemia by means of substances which disintegrate the blood-corpuscles. Under such circumstances the losses of substance produced by the above-men- tioned methods heal but gradually and tardily, or they may go on even to perforation, as occurred in one of Silbermann's experiments. Then only have the experiments on animals borne any analogy to the clinical picture of gastric ulcer. Talma || succeeded in pro- ducing softening of the stomach as well as typical gastric ulcers in rabbits and dogs by ligating the stomach above and below—that is, tying the oesophagus just above the cardia, and the duodenum be- tween the pylorus and the mouth of the common bile-duct. The result of this was a stagnation and fermentation of the contents of the stomach, the quantity of the latter being more or less increased by the persistent secretion of the gastric juice. In this way the walls of the stomach were rendered so tense that sharply localized haemorrhagic infarctions were produced, and from these typical gastric ulcers. Talma also concludes that " a disturbance of nutrition must precede the ulceration, be it either a simple anaemia or a re- tardation in the movement of the nutritive lymph ; or, finally, more profound changes in the tissues themselves." * W. Ebstein. Experimentelle Untersuchungen iiber das Zustandekommen der Blutextravasate in der Magenschleimhaut. Arch, fiir exper. Pathol., Bd. iii, p. 183. f Ewald. Klinik, etc., I. Theil, 3te Aufl., p. 122. I must say that we did not carry on our experiments in the above sense, although they correspond entirely with them. X H. Quincke und Daettwyler. Correspondenzbl. f. Schweizer Aerzte, 1875, p. 101. 9 0. Silbermann. Experimentelles und Kritisches zur Lehre vom Ulcus ven- triculi rotund. Deutsche med. Wochenschr., 1886, No. 29, p. 497. || Talma. Untersuchungen iiber Ulcus ventriculi simplex, Gastromalacie und Ileus. Zeitschr. fiir klin. Med., Bd. xvii, p. 10. ETIOLOGY OF GASTRIC ULCER. 383 In mom, too, if we confine ourselves to the typical ulcer of the stomach, and disregard the secondary ulceration of carcinoma or of phlegmonous gastritis, we have to record a twofold course of gastric ulcer. Constant reference is made to the fact that it is doubtlessly not uncommon for ulcers to occur—that is, in the sense of the de- fects of the mucous membrane described above—which never reach the point of manifesting themselves clinically, or which do not pre- sent the typical picture of ulcer of the stomach, but which give rise only to indefinite symptoms, which do not spread and which do not really cicatrize. To this category belong the haemorrhagic erosions of Rokitanski, which were already regarded by him as the initial steps leading to true gastric ulcer.* Here I might also include the so-called follicular ulcers, which are due to the swelling and con- secutive suppuration of the glandular follicles. The factors enu- merated above often give rise to such processes. We need only think of the frequent occurrence of circumscribed haemorrhages from the mucous membrane in chronic catarrh, especially in drink- ers ; of the irritations of the mucous membrane caused by too hot ingesta, and of the artificial lesions produced in this membrane by the introduction of sounds, to have a full quota of such factors. In proof of this—the transient haemorrhages and follicular suppuration due to irritating ingesta—we possess a classical witness for all time in the Canadian experimented on by Beaumont.f Is it to be ex- pected in the many cases in which sharp objects, such as splinters of bone, knife and dagger blades, etc., are accidentally or purposely swallowed, that they will always pass off without lesion to the wall of the stomach ? And yet ulcers of the stomach are among the * C. v. Rokitanski. Lehrbuch der pathol. Anatomie, 3te Aufl. f W. Beaumont. Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Boston, 1833, p. 108. The passage in these excellent in- vestigations, referred to, reads as follows : " There are sometimes found on the in- ternal coat of the stomach (especially after irritation of the mucosa by food) erup- tions, or deep-red pimples; not numerous, but distributed here and there upon the villous membrane, rising above the surface of the mucous coat. These are at first sharp-pointed and red, but frequently become filled with white purulent matter. At other times irregular circumscribed red patches, varying in size and extent from half an inch to an inch and a half, are found on the internal coat. These appear to be the effect of congestion in the minute blood-vessels of the stomach. There are also seen at times small aphthous crusts in connection with these red patches." 381 DISEASES OF THC STOMACH. rarer results. One of the most remarkable examples of this kind, and at the same time a most striking proof of what the stomach may be subjected to, is the following very curious case of the sailor, John Cumming, reported by Dr. Marcet: * In the year 1799 an American sailor saw a juggler in Havre perform the trick of knife-swallowing. Returning to his vessel somewhat intoxi- cated, he was foolhardy enough to try to swallow his open pocket-knife, and succeeding in this, he " ate" three more. Three passed off in the stool during the next few days, but one could not be accounted for. One evening, six years later, he again swallowed six knives, but this time not without unpleasant though very transient results, on account of which he was admitted to a hospital. He did this frequently, till he had swallowed about thirty-five knives. Finally he was taken seriously ill, and died in Guy's Hospital, in London, in 1809. In the stomach some thirty pieces of blades, in parts markedly corroded, together with handles, were found; two blades in the colon and rectum, which were placed transversely and had perforated the intestinal wall (and that without causing peritonitis), but no recent or old ulcers of the stomach, or any remains of them. It is inconceivable that the man's repeated onslaughts on the . * mucous membrane of his stomach should have passed off without producing any lesion at all; yet he nevertheless acquired no gastric ulcer. Moreover, it is also recorded that to the end he always en- joyed good health, and that he had a very good appetite. If, therefore, gastric ulcer always resulted from the injuries above mentioned, it would appear much more frequently than is observed; in fact, it would be the rule, and its absence the excep- tion. Let us take, for instance, the frequently mentioned occurrence of ulcer in cooks. It is true that their employment affords them ample opportunity to swallow hot morsels. Becker f has succeeded in experimentally producing gastric ulcers in dogs by introducing hot gruel into their stomachs. But, not to speak of cooks, how many persons eat their food hastily, and as hot as possible, without acquiring gastric ulcer; and how small is the percentage of cooks who suffer with ulcer in comparison to the entire number of the members of this honorable craft! On the other hand, we actually know of cases in which ulcers v/ere due to traumatisms. Leube X * Marcet. Med.-Chirurg. Transactions, vol. xii, p. 72. t Becker. Berl. klin. Wochenschr., 1887, p. 369. X Leube. Centralbl. fur klin. Med., 1886, No. 5. ETIOLOGY OF GASTRIC ULCER. 385 describes under the name of ulcus ventriculi traumaticum a typical case of an ulcer developed after a blow upon the epigastrium by the tongue of a wagon, in a man who had always been healthy, and who remained perfectly well after the ulcer was healed. Yanni * also reports the case of a woman, thirty-two years of age, in whom all the symptoms of a typical gastric ulcer developed immediately after a blow upon the epigastrium. The same author has collected fourteen reported cases of round ulcer of traumatic origin. In this category we may also include the cases described by Talma, f in which haemorrhages of the stomach and ulceration resulted from severe general convulsions. But how many persons have had con- vulsions and received blows upon the stomach without developing ulcers! [After having made careful autopsies on three cases of severe internal injuries, Miiller X maintains that traumatisms may cause gastric and duodenal ulcers.] ('hanges in the Blood.—Evidently here, as well as in the examples given above, there must be a second factor in order to render pos- sible the chronic development of the supposed injury and its sequelae —a factor which to a certain extent forms the basis on which the ulcer can /car egoxvv develop. And it is only by means of such a permanent or transient "predisposition" that the much-discussed question, why some ulcers heal and others progress, can be solved. There is no lack of analogies for such a condition. I need only bring forward the example of the tubercle bacilli which is now so familiar to all. Here, too, there is the exciting poison, the bacillus, to which numberless persons are exposed on countless occasions. However, to become tuberculous, the predisposition is requisite, which fortunately is not the possession of everybody. In man this predisposition to gastric ulcer resides in the disj>roj>ortion existing between the composition of the gastric juice and the blood, as we have already recognized it as necessary for the artificial production of chronic ulcer of the stomach in animals. It is not the alkalinity of the blood which prevents the autodigestion of the gastric mucous * Vanni. Sull' ulcera dello stomaco d' origine traumatico. Lo Sperimentale, Juglio, 1889. f Loc. cit X [Miiller. Ulcus ventriculi et duodeni traumaticum. Inaug. Dissert., Leipzig, 1894.—Ed.] 386 DISEASES OF THE STOMACH. membrane and the subsequent development of a round ulcer, as stated byPavy*in his explanation at that time, which, deceptive by its simplicity, was therefore almost universally accepted; for the old teaching that the alkaline condition of the deeper layers of. the gastric mucous membrane prevents its digestion by the gastric juice under normal conditions is untenable. Disregarding the fact that this does not explain why the upper layers of the mucosa (which, as is well known, have an acid reaction) are not digested, Edinger has endeavored to prove that the deeper layers are also acid.f And even if we are unwilling to ascribe much weight to these experi- ments, as I have proved in the place cited below, it is nevertheless true that the alkaline reaction, as such, does not suffice here—alkali albuminates are also digested—because the blood may be made neu- tral by means of acid, as Samuelson X has shown, and yet not lead to autodigestion of the stomach. This investigator gives still more important reasons, and refers especially to the contradiction that the acid formed in the glands is not neutralized when it enters the cavity of the stomach, but that this is supposed to occur when the reverse takes place—i. e., when the acid is brought in contact with the mucous membrane. There- fore, either no free alkali exists in the neighborhood of the acid, or it can no more neutralize the excreted than it can the penetrating acid. Furthermore, Sehrwald # has shown that in a living animal the diffusion of an alkali through the wall of the stomach into an acid solution which had been poured into its cavity proceeds far differently than in a stomach removed from the body, taking place much more energetically in the latter than in the former case. This is a remarkable phenomenon, which can only be explained by the influence of the living cell on the course of the physical process. Further, how is it that an ulcer heals in spite of the damage done to the protecting network of vessels ? Why, for instance, does not the * Pavy. On Gastric Erosion. Guy's Hosp. Reports, xiv, 1868. t Edinger. Ueber die Reaction der lebenden Magenschleimhaut. Pfliiger's Archiv, Bd. xxix, S. 247. See Ewald. Klinik, etc., I. Theil, 3te Aufl., S. 121. X Samuelson. Die Selbstverdauung des Magens. Preyer's Sammlung physiol. Abhandl., 1879. II. Reihe, Heft 6. * E. Sehrwald. Was verhindert die Selbstverdauung das lebenden Magens 1 Miinchener med. Wochenschr., 1888, No. 44 und 45. ETIOLOGY OF GASTRIC ULCER. 387 pancreas digest itself ? This problem still lies before us, for our knowledge of the zymogens can not solve it, and we are no nearer the solution even after recognizing " the vital energy of the cells " or Hunter's " living principle." We must cling to the fact that normal gastric juice and normal blood do not cause the formation of an ulcer from the factors already discussed, nor do they further its course or prevent its healing. The disproportion between the avidity of the gastric juice and the com- position of the blood is always necessary to produce such a result. Modern Views.—The exact grounds for the view proposed above have, it is true, been arrived at only by the more recent investiga- tions. We have known for a long time that corroding gastric ulcers arise from anomalies in the composition of the blood. Suppression of the menses, chlorosis, anaemia after parturition, are seen too fre- quently in connection with gastric ulcer to admit of any doubt as to their etiological relations. Indeed, Miquel * reports cases in which menstruation at first ceased and then returned again; but a reap- pearance of the gastralgia with increased severity was noticed at every menstrual epoch. Crisp, f in his time, collected fourteen cases of perforating gastric ulcer in women, in thirteen of which there was coexisting irregularity or absence of menstruation. On the other hand, W. Fox,*j: supported by the observation of a case of poisoning by hydrochloric acid with perforating ulcer, had already expressed his suspicion that the cause of the formation of an ulcer might be " excessive secretion or excessive acidity of the gastric juice, espe- cially when the stomach was empty." But the exact proof that the ulcers are in many cases associated with hyperchlorhydria of the gas- tric juice was first brought forward by the investigations of Yon den Yelden, Riegel, Ewald, Jaworski, Boas, Rosenheim, and others. The primary cause of the ulcer may then be one of the above-men- tioned accidents. These include traumatic or thermal irritations, violent emesis, haemorrhages due to congested conditions, hyper- aemia and stasis in circumscribed vascular areas of the mucous mem- * Miquel. Hannover. Zeitschr. f. prakt. Heilkunde. t Crisp. On Perforation of the Stomach. Lancet, August 5,1843. X W. Fox. Chronic Ulcer of the Stomach. Reynolds's System of Med., vol. ii, p. 930. 388 DISEASES OF THE STOMACH. brane, haemorrhagic infarctions, spasm of the vessels, and atherom- atous, amyloid, or aneurismal degeneration. But such injuries are undoubtedly of frequent occurrence in the stomach without being followed by ulcer. If, however, a growing ulcer develops, it is due to the existence of one or another of the anomalies men- tioned. Repair begins only when the latter has been removed; then a reactive inflammation of the base of the ulcer and of the surrounding tissues sets in, and its subsequent cicatrization becomes possible. Here, too, lies the natural explanation of the well-known tend- ency of gastric ulcers to relapse. According to my conception, re- lapses always follow in those cases in which the underlying affection is transiently relieved by therapeutic measures, but which returns to the old condition as soon as the effect of the medication wears off. This also corresponds with the well-known fact that the greatest contingent of relapsing gastric ulcers is drawn from those of a nerv- ous or chlorotic nature, whose cure requires a long time, and in whom the tendency to relapse is well marked. Perhaps the objection may be raised that many diseases in which there is alteration of the composition of the blood predispose to gas- tric haemorrhage without the occurrence of typical gastric ulcers. Thus, for instance, in cirrhosis of the liver haemorrhages from the gastric mucous membrane due to obstruction in the portal circula- tion are not uncommon, yet the occurrence of gastric ulcers is only a simple coincidence. My answer is, that these processes reduce the acidity of the secretion by means of the consecutive hyperaemic and catarrhal condition of the mucosa. Consequently, the requisite dis- proportion between the blood and the gastric juice does not exist, even though both components, taken absolutely, are found to be al- tered. As predisposing factors, however, we must recognize hyper- acidity of the gastric juice, produced by hyperchlorhydria, as well as a change in the composition of the blood in the presence of the normal acidity. Riegel and Talma believe that this hyperchlorhydria is the un- derlying cause and efficient agent in the production of gastric ulcers. Korcynski and Jaworski claim that the " acid gastric catarrh " which they have described and which we have already mentioned [page ETIOLOGY OF GASTRIC ULCER. 389 191] is the cause, and maintain that " ulcers are produced as the resuH of the action of the acrid gastric juice upon the altered mucosa of the pylorus." But why should there be circumscribed necroses when the entire membrane is changed ? Riegel's views are much more acceptable : " On account of the hyperchlorhydria an erosion or injury of the mucous membrane, unimportant in itself and tend- ing to rapid repair, attains a greater significance ; its healing is re- tarded and the ulcer spreads." * A second possibility, and one equally justified, is this, that the hyperchlorhydria, and with it the typical ulcer, is only developed in predisposed individuals with great irritability of the nerves of secretion, as the result of some damage, etc., to the mucous membrane. In other words, as Ritter and Hirsch also say, the hyperchlorhydria may just as well be the result as the cause (or, as I should say, the primary predisposing factor) of the ulcer. The idea that the secretion of hyperacid gastric juice is essential for the formation of a round ulcer is by no means new, but, like all the questions with which the pathology of the stomach has recently been concerned, was expressed long ago, even if it was not investi- gated by means of exact methods. It is closely connected with the question of softening of the stomach—gastromalacia—which, unless it be a post-mortem phenomenon, is nothing but a large gastric ulcer running an acute course. Even Rokitanski and Camerer believed that hyperacid gastric juice was secreted in these cases as a result of a paralysis of the vagi. Giinsburgf directly pos- tulated that the existence of a perforating gastric ulcer depended upon the production of a hyperacid secretion. He says, " The (ulcerative) destruction of the gastric mucous membrane depends upon a quantitative irregularity in the secretion of free acid." His chief evidence was the fact that in perforating ulcer he found the mucus of the stomach markedly acid, instead of its having the usual alkaline reaction ; he erred in referring this hyperacidity to lactic acid, in accordance with the view then held as to the nature * F. Riegel. Zur Lehre vom Ulcus ventriculi rotundum. Deutsche med. Woch- enschr., 1SS6, No. 52, S. 931. f Fr. Giinsburg. Zur Kritik des Magengeschwurs, insbesondere des perforiren- den. Arch. f. physiol. Heilkunde, xi. Jahrg., 1852, S. 516. 390 DISEASES OF THE STOMACH. of the acid of the gastric juice. However, it can nevertheless be seen that here, as well as everywhere else, we stand on the shoul- ders of our predecessors, and that the numerous public and private claims for priority, on closer investigation, shrink to very modest proportions. The remarkable coincidence of burns of the skin with ulcers of the stomach and duodenum in young subjects, first observed by Curling,* and later by Dupuytren, Cooper, Erichsen, Wilks, and others, will be no more than mentioned in this place, inasmuch as for the present we possess no knowledge of a possible interdepend- ence of the two processes. In 125 cases of severe burns, Holmes f found the duodenum ulcerated in 16, and other portions of the in- testine in 2. The earliest period of its appearance was from four to six days after the burn. A possible clue to understanding this remarkable phenomenon has been furnished by W. Hunter,X who observed duodenal ulcers surrounding the orifice of the common bile duct after subcutaneous injections of toluylendiamide ; he believes that the ulcers were due to excretion through the bile of substances which may provoke inflammation. It is possible that in burns some similar substances may be produced by decomposition of the blood or by absorption of toxic substances from the burned area which is then excreted in the bile. Ulcers in the stomach, of which Roki- tanski, Low, Wilks,* and Pitt | report cases, seem to be much rarer. And, finally, micro-organisms have also been brought forward as the cause of gastric ulcer. Botticher's observations on this sub- ject were soon shown by KbrteA to be inconstant and not con- vincing. Letulle Q found numerous streptococci in the veins of * Curling. On Acute Ulceration of the Duodenum. Med.-Chirurg. Transact., vol. xxv, p. 260. f Holmes. Syst. of Surgery, vol. i, p. 733. X W. Hunter. The Pathology of Duodenitis. Transact. Patholog. Society of London, 1890. * Wilks. Cases of Death from Burns and Scalds. Case 77, quoted by Falk. Ueber einige Allgemeinerscheinungen nach umfangreichen Hautverbrennungen. Virchow's Arch., 1871, Bd. liii, p. 27. || Pitt. Stomach with Numerous Superficial Erosions following after an Exten- sive Burn. Transact. Pathol. Soc. London, 1887, pp. 38, 140. A Korte. Beitrage zur Lehre vom runden Magengeschwlirs. Inaug. Dissert., Strassburg, 1875. Q M. Letulle. Origine infectieuse de certains ulceres simples de I'estomac ou du duodenum. Compt. rend., torn. 106, No. 25. OCCURRENCE OF GASTRIC ULCER. 391 the submucosa and of the uterus in a case of recent ulcer of the stomach, which appeared during the course of puerperal septicaemia. Pure cultures of these injected into guinea pigs also caused ulcera- tions in the stomachs of the animals, which threatened to perforate the walls of the artificially distended organ. Letulle obtained the same result in four cases with the staphylococcus pyogenes aureus cultivated from various abscesses, and in one case with the microbes of dysentery discovered by Chantemasse and Widal; in this case they were derived from a man who had returned from Cochin-China with chronic dysentery, and was attacked with a gastric ulcer. It was claimed that the process was either embolism or direct invasion of the mucous membrane, leading to necrotic spots and the diges- tion of circumscribed areas. For the present the simple recording of these statements will suffice. [The latest advocate of the microbic origin of gastric ulcers is Martin* The general tendency, how- ever, is against accepting any etiological relation of bacteria. The presence of numerous micro-organisms in ulcers means nothing. On the other hand, there is no doubt that some ulcers are caused by bacteria being transported by the blood and causing thrombosis. Such ulcers may occur in sepsis, acute rheumatism, possibly tuber- culosis and other infectious diseases.*]* (See also page 183.)] So much concerning the presumable cause of ulcers of the stom- ach. I have spoken of these views first because at present they are the center of interest, and because they are naturally of great im- portance in prognosis and therapy. I shall now review the clinical facts. I shall first give a few statistics, which, as they are compiled from the records of autopsies, naturally refer only to the typical perforating or cicatrizing ulcers. Occurrence.—The frequency of ulcer of the stomach seems to vary in different localities. Lebert, it is true, holds that on the average this is between 4 and 5 per cent [of the total mortality] for Europe, and supports this statement by his own statistics as well as those of Brinton and Jaksch ; yet these averages are subject to con- * [Martin. Diseases of the Stomach, 1895, p. 418.—Ed.] f [Rosenheim. Op. cit, p. 350.—En.] 26 392 DISEASES OF TnE STOMACn. siderable variations. Disregarding the fact that the figure estimated by Lebert for Jaksch's statistics at 5*8 per cent is incorrect, and should be 3*2 per cent, we find that Berthold gives 2*7 per cent for Berlin, and Xolte 1*23 per cent for Munich; while, on the other hand, Griess gives 8*3 per cent for Kiel, in Jena it is said to be 10 per cent; according to Starck, it is 13 per cent in Copenhagen.* [Fiedler f states that in 2,200 autopsies, ulcers or scars were found in 1*5 per cent of the men and 20 per cent of the women.] Inas- much as these results are deduced from large numbers, it is to be supposed that the unimportant errors have become fairly well aver- aged, and that a certain regional difference is exhibited. There is nothing surprising in this, for the causes of ulcer of the stomach are in part referable to direct irritation of the gastric mucous mem- brane, and this factor changes with the mode of life and the food supply in the various places. It has frequently been shown that an insufficient diet may cause gastric ulcer, as demonstrated, for in- stance, by Gerhardt's experiences in Thiiringen. Sohlern,:}: pro- ceeding the opposite way, has lately called attention to the fact that in certain districts of Germany, the Rhon Mountains and the Ba- varian Alps, and further in the greater part of Russia (the so-called Grossrussland), gastric ulcer is a rarity, and that, strange to say, the inhabitants of these regions exist almost exclusively on a vegetable diet. Nevertheless, this class of people, especially in Russia and Bavaria, is in general well nourished and strong. Now, as it is well known that much more potassium is added to the blood on a vegetable diet, nearly a third more than on a mixed diet, so this permanently increased addition necessarily brings with it an in- crease in the amount of this metal in the blood ; while, according to other investigations, the red blood-cells are to be regarded as the chief carriers of potassium. Sohlern claims that this increased amount would represent the cause of the relative immunity of the * [As Welch properly says, such statistics are based upon the result of autopsies in which all cicatrices are included as healed ulcers. The ratio of cicatrices to open ulcers has been placed at 3 to 1.—Ed.] f [Fiedler. Sitzungsbericht d. Dresdener Vereins fiir Natur und Heilkunde, 1883.—Ed.] X Von Sohlern. Der Einfluss der Ernahrung auf die Entstehung des Magenge- schwiirs. Berl. klin. Wochenschr., 1889, No. 14. OCCURRENCE OF GASTRIC ULCER. 393 above-mentioned classes from ulcer of the stomach, quite in accord- ance with the rare occurrence of this disease in vegetarians, whose blood, as is well known, is rich in potassium phosphate. On the other hand, diseases accompanied by an impoverishment or change in the red blood-cells, such as chlorosis, anaemia, etc., might tend to the development of ulcer because they produce blood which is poor in potassium. For the present, as Sohlern himself says, these very interesting considerations lack the support of a series of examinations of blood made for the purpose; but even without these the significance of the facts advanced can not be denied. Statistics show great unanimity regarding the remainder of the accessible factors—sea?, age, site of the ulcer, and frequency of per- foration. It is universally found that females are more frequently affected than males, the average proportion being as two to one. Further, on consideration of all the factors involved, it is without doubt that it most commonly occurs between the ages of twenty and forty, while the greatest mortality is found between forty and sixty years. These facts are in no way altered by Griinfeldt * having found scars of gastric ulcers 92 times (20 per cent) in 450 autopsies on old people, or by Chiari's f case of a recent perforation in a man seventy-one years old, or Sedgwick's X similar case in which the man was eighty-two years old, nor by the fact that, according to Birsch-Hirschfeld and Henoch,* ulcers of the stomach are fairly frequent in children, and even in the newborn. The latter, at all events, have nothing in common with typical gastric ulcer, inasmuch as they are probably caused by intra-uterine poisons, or by those connected with parturition, and since they do not last beyond earli- est infancy. At any rate, on reference to the mortality tables, we find that childhood, till the tenth or fifteenth year, is practically entirely exempt. On the other hand, I think it very probable that ulcers of the stomach occur at this age, but that, owing to the more * Griinfeldt. Hospitaltid, 2. R. ix, p. 765, quoted in Virchow-Hirsch's Jahrb., 1878. t Chiari. Fall von Perforation eines Magengeschwiirs. Anzeiger der k. k. Gesellsch. d. Aerzte zu Wien, 1880, S. 161. X Sedgwick. On Perforating Ulcer of the Stomach. Dublin Hosp. Gaz., 1855. * Henoch. Vorlesungen iiber Kinderkrankheiten. Berl., 1883, 2te Aufl., S. 61. 394 DISEASES OF THE STOMACH. active regenerative and plastic powers of the tissues in childhood, the tendency to recovery is greater than at a more advanced age. I have observed at least two cases which I could only regard as gastric ulcer, and in which nothing but haemorrhage was needed to com- plete the typical picture. Unquestionably, however, they are of much rarer occurrence than in later years, because the injurious factors are far less common in childhood. [A number of cases of ulcers in very young children have recently been published, of which I shall only quote the case reported by Colgan,* in a child two and a half years old. The patient was suddenly attacked with convulsions, the temperature rose to 106°, the pulse to 150; death occurred in 13 hours. There were no gastric symptoms. The au- topsy showed a perforation on the posterior wall of the stomach at the cardia and near the greater curvature.] Whether occupation plays any role in the causation of round ulcer, as is frequently accepted, appears more than doubtful to me, according to what I have said at the beginning of this chapter. Nevertheless, I will again mention the well-known fact of its fre- quent occurrence in female servants, and especially in cooks. In English literature insufficient food is more often given among the causes, and we also find a parallel drawn between it and the oc- currence of ulcers of the cornea in cachectic and much enfeebled patients. Pathological Anatomy.—A large number of the ulcers undoubt- edly arise from direct lesions to the vessels and their result, haemor- rhagic infarction, whether it be that the primary cause lies in the obstruction of the smallest arterial twigs which run up between the glands of the mucous membrane from the submucosa, or whether it be that atheromatous, amyloid, or aneurismal degeneration of the vascular walls, cerebral injuries, or even simple and spasmodic con- traction of the muscular layers, predispose to the rupture of the vessels. In a few cases Yon Openchowskif has also observed hyaline degeneration of the walls of the smallest vessels in the * [Quoted by Weir and Foote. Medical News, April 25, 1896.—Ed.] t Von Openchowski. Zur pathologischen Anatomie der geschwiirigen Processe im Magendarmtractus. Virchow's Archiv, Bd. cxvii, p. 347. PATHOLOGICAL ANATOMY OF GASTRIC ULCER. 395 haemorrhagically infiltrated area of the mucosa, and regards them as being the causes of the latter. But these causes are not alone sufficient, because numerous cases occur, especially in youthful individuals, in which no indication either of disease of the vessels or of the other enumerated factors exists. Here we must assume that the ulcers are developed from the follicular haemorrhages and the haemorrhagic erosions of Roki- tanski, which in a small way represent the same thing that haemor- rhagic infarctions do on a large scale, namely, the withdrawal of the normal nourishment from small areas of the mucous membrane. Carswell, in his Atlas,* pictures an exquisite example of follicular haemorrhages with punctate haemorrhages in the mouths of the crypts partly surrounded by a round zone of extravasated blood. In a stomach the mucous membrane of which was suffused with blood, and which I treated very soon after death according to Hei- denhain's method (placing small pieces of tissue immediately in ab- solute alcohol which must be frequently changed, and staining with haematoxylin and bichromate of potassium), I found the ducts of the glands packed full of red blood-cells to beyond the neck—i. e., down into the fundal portions. These could only have had their origin in a haemorrhage on the surface of the mucous membrane, which in its turn could only have come from the fine capillary net- work (Henle) situated close beneath the free surface of the mucous membrane. Such haemorrhages may be due to a very unimportant stoppage of the circulation, or to a traumatism, etc. They develop into haemorrhagic erosions, small streaklike or rounded losses of substance from the size of a millet seed to that of a pea, on which at times a blackish-brown extravasation of blood is found, together with the simultaneous loosening of the mucous membrane. Their number is very variable, being sometimes enormous, especially near the pylorus, so that the stomach appears as if sown with them. From the erosion the typical chronic ulcer is developed. But cer- tainly not from every erosion, which, as Langerhans f has properly claimed, are distinguished from ulcers by the fact that they are * [Carswell. Loc. cit] f R. Langerhans. Ungewohnliche Art der hamorrhagischen Erosion des Ma- gens. Virchow's Archiv, Bd. cxxiv, p. 273. 3<)t; DISEASES OF THE STOMACH. irregularly scattered over the mucous membrane in large numbers and coalesce, whereas ulcers occur singly and in certain localities only. Nevertheless Langerhaus and D. Gerhardt* give carefully described typical examples of such erosions which have been trans- formed into classical ulcers. Gerhardt also shows that we may also include among these the small ulcers which are formed by the swelling and bursting of lymphatic follicles. But whether the causation of the nicer be due to one or the other, it can nevertheless never be regarded as an " ulcer," viewing it from the standpoint of pathological anatomy; it is rather a " progressive necrosis of tissue," in which the characteristic feature of an ulcer, " the proliferation of young cellular elements which always spreads deeper into the tissues, and continually throws more elements to the surface," f is entirely lacking. The ulcer does not grow by an active process in the tissues with subsequent necrosis, but by a passive one. The participation becomes active only on the appearance of the cellular infiltration which leads to cicatri- zation. The gross anatomy of gastric ulcer and its consequences I can dispose of in a few words. Its form, like a funnel or crater, is well known; the margin is at first sharply defined, and only becomes thickened and wall-like later on. There is not a medical student who does not know Rokitanski's classical comparison, that an ulcer looks " as though cut out with a punch," although this can only be applied to old perforating ulcers; while among the others are found linear, oval, insular, or steplike forms. Usually the base of the ulcer is smooth, or with only a few inequalities, but occasionally it is covered with small blood-clots or with tenacious greenish or brownish mucus. The size varies considerably, being usually that of a 10-pfennig piece [5-cent nickel] to a mark [silver quarter-dollar]. Generally the ulcer observed by Cruveilhier, 16 centimetres [6f inches] in length, and 8*5 centimetres [3f inches] in width, is referred to as a prodigy; but I have found a case described by Habershon in which * D. Gerhardt. Ueber geschwiirige Processe im Magen. Virchow's Archiv, Bd. cxxvii, p. 85. f Virchow. Cellular Pathologie, 4te Aufl., p. 537. PATHOLOGICAL ANATOMY OF GASTRIC ULCER. 397 the process involved nearly the entire surface from the pylorus to the cardia. The site is preferably at the pylorus and the greater curvature, corresponding to the most dependent portion of the stomach where the gastric juice collects in the erect posture ; hence Nolte gives the following scale of frequency: At the greater curvature 22, at the pylorus 13, anterior wall 3, posterior wall 2, cardia 1.* Langerhans's statement {loc. cit.) that the typical site of gastric ulcers is " along the lesser curvature " is opposed to these and my own experiences. Xumber.—In the majority of cases only one ulcer is present; more, up to three or over, are rare. However, Lange saw so many of them in one case that " he had to give up the attempt to count them all." f Finally, if in the course of the process the base of the ulcer be- comes thickened and like a plate, and the margins indurated and wall-like, and if its site be such that the spot is appreciable on pal- pation, it can on this account convey the impression of an ulcer- ating malignant neoplasm, as I shall discuss more fully later on. If, however, the ulcer is situated either in the region of the pylorus or of the cardia, the cicatrization may cause stenosis of these open- ings with its clinical sequelae. It is also to be noted that at times several ulcers, which were originally distinct, may coalesce and form one large ulcer. * [Welch, as the result of the analysis of 793 cases, gives the following: Lesser curvature........................... 288 (363 per cent). Posterior wall.............................. 235 (29-6 " ) Pylorus................................... 95(12 " ) Anterior wall.............................. 69(8-7 " ) Cardia..................................... 50(6-3 « ) Fundus.................................... 29(3-7 " ) Greater curvature.......................... 27(34 " ) Pepper's System of Medicine, vol. ii, p. 503. Peptic ulcers may also occur in the lower portion of the oesophagus (see page 115) or in the upper part of the duodenum (see page 432).—Ed.] f Lange. Deutsche Klinik, 1860, p. 90. " In addition to this (i. e., the perfo- rating ulcer) there was not only an immense number of scars of various sizes and depths all over the walls of the stomach, but also such a quantity of uncicatrized ulcers, some extending only into the mucosa, others penetrating even into the mus- cularis, some flat, some in the shape of holes, and others funnellike, that I had to give up the attempt to count them all." 398 DISEASES OF THE STOMACH. In microscopic sections through the margin of a recent ulcer the ducts of the glands are seen to descend troughlike [muldenfbrmig], and as though cut off toward the base of the ulcer. They are sim- ply eaten away or digested as far as the tissues could offer no re- sistance to the digestive power of the gastric juice. It is only in older ulcers that. a reactive inflammation sets in at the periphery, leading to the formation of a callous margin. Here the trabecular between the remaining ducts are thickened and in' part placed ob- liquely, a condition which would appear to be analogous to a dis- covery of Witosowski's, which will be mentioned directly. As much of the glandular epithelium as is present in the f undal por- tions of the remaining ducts has undergone a remarkable change. In the place of the peptic cells we find cuboidal or cylindrical epi- thelium ; they are shrunken so that they are separated both from the membrana propria and from one another; their nuclei can not be recognized by staining, and their contents are of a broken-down, light, glassy appearance, which reminds one most of hyaline degen- eration. Single ducts have undergone cystic degeneration. The submucosa is decidedly broader and thicker, with an abundant infil- tration of small cells, and with a rich vascular network ; the bands of muscular fibers of the muscularis in some portions are separated by connective tissue which is partly fibrillar, partly torn apart in meshes, and in other portions they have been entirely replaced by it. We see, therefore, that the necrotic process is surrounded in its entire extent, both at the margin and the base, by a zone which is the seat of irritative processes, which subsequently lead on to true cicatrization. This always causes the firm attachment of the base of the ulcer to the underlying tissue, and the inversion of the mu- cous membrane at the edge into the substance of the ulcer. Witosowski * claims that the ducts of the glands situated at the margin of the ulcer become bent so that their mouths are turned toward the ulcer, and thus pour their secretion directly into it. He holds that a corroding ulcer, which always develops at the bottom of the furrows produced by the folds of mucous membrane, can only be formed by these means or by a simultaneous process of pro- * Witosowski. Ueber das Verhaltniss der productiv entziindlichen Processe zu den Ulcerosen im Magen. Virchow's Arch., Bd. xciv, p. 542. PATHOLOGICAL ANATOMY OF GASTRIC ULCER. 399 liferation proceeding from the submucosa. The former is for the most part true, and can be explained by the impeded circulation of the parts. I have never seen the latter, and I can not regard the singular theory which Witosowski has founded upon it as being open to discussion. At all events, in old ulcers the ducts of the glands are directed toward the crater of the ulcer, as has been stated by Hauser,* and as I can fully corroborate, but it is only because the elasticity of the muscular coat causes it to retract and draw away under the mucosa; however, from the very nature of things, a secre- tion from these ducts is no longer possible. In the interstices we always find a profuse small-celled infiltra- tion, but there is nothing specially characteristic of ulcer in this, as it is found in all processes leading to inflammatory irritation of the mucous membrane, from a mild catarrh to an acute phlegmonous gastritis. Korczynski and Jaworski f have examined pieces of gas- tric mucous membrane which were removed from the vicinity of an ulcer at operations on three cases, and in one case they studied large pieces which were obtained after death. They were able to demon- strate an inflammatory condition of the interglandular tissue as well as a disappearance of the peptic cells of the gastric tubules, the parietal cells being unaffected ; there was also extensive loss of the superficial epithelium of the mucosa. They therefore conclude that this inflammatory—i. e., catarrhal—affection, which is in many cases accompanied by a coincident overproduction of HCl, is in many cases the primary cause of the ulcer. In my opinion the con- trary would be much more probable ; for mucous membranes sur- rounding the ulcer is liable to be put into an irritable condition which involves it to a variable extent and intensity. The results of the necrotic process are of special interest. We must distinguish between— 1. Cicatrization. Here there exists a marked distinction from the ulcers artificially produced in animals; for, while these heal with restitution of the normal mucous membrane,*}: as Cohnheim * G. Hauser. Das chronische Magengeschwiir. Leipzig, 1883. f Loc. cit. Deutsch. Arch, fiir klin. Med., Bd. xlvii. X After careful investigations this has been corroborated by Griffini and Va- sale. Ziegler's Beitrage zur patholog. Anatomie, Bd. iii. 400 DISEASES OF TnE STOMACH states, and as I, too, have found, in man a fibrous, centrally de- pressed scar is formed, with the well-known tendency to contrac- tion. This leads to radiating scars and to distortion of the gastric wall, especially if a fixed point has been established by previous adhesions to the neighboring organs. Girdlelike constrictions of the viscus occur, giving it the form of an hourglass or a gourd [the hourglass stomach]. In this way, if the scar is situated in the lesser curvature, the pylorus and cardia may be drawn together to such a degree that a lead pencil can scarcely be passed between them. Thus, also, very peculiar cicatricial bands may be formed, which lead to the formation of a complete sac, of which Cruveil- hier * gives an excellent drawing in his Atlas. 2. Progressive necrosis and corrosion. If cicatrization does not occur, the necrotic process continues as long as any gastric juice is secreted, finally causing its own cessation by means of the ensuing complications. These are : {a) Corrosion of the vessels. Vessels of larger or smaller caliber are opened according to the site of the ulcer and to its extension into the tissues. The slight tendency to thrombosis is a character- istic feature, which is probably connected with the digestive action of the gastric secretion. Among the larger vessels most frequently affected are the gastric, splenic, and pancreatic arteries. {b) Adhesions to neighboring organs and perforation. If the necrosis extends to the serosa, it leads either to a reactive inflamma- tion and adhesion to surrounding organs, and consequent spread of the process to them; or, where circumstances will not permit this, to a direct perforation into the abdominal cavity. There may also be secondary perforations into the pleural or pericardial cavities through the corresponding interposed tissues. According to the site of the ulcer, all the neighboring organs, liver, gall bladder, f pancreas, spleen, diaphragm, heart, lungs, and intestines are subject to this possibility. At times it may produce adhesions among or- gans situated near one another in the abdominal cavity, such a case being described by Budd. Finally, tubercular and syphilitic ulcers must be mentioned. * Loc. cit, 20. Livrais, PI. 6. f Habershon. Lancet, June 2, 1883, p. 951. TUBERCULAR ULCER OF STOxMACH. 401 Tubercular Ulcers.—Thus far these have only been found in con- nection with tubercular lesions in other organs. They are charac- terized by their thickened, infiltrated, wall-like margins; the base is for the most part yellowish and granular. They are pale, and, as seen in Eppinger's* cases, they thus present a sharp contrast to their dark-colored surroundings. In the margins and base, tubercu- lar nodules with their characteristic giant-cells are found. There may be one or more ulcers, involving only the mucosa and sub- mucosa, or extending down to the muscularis. In a few cases (Lit- ten f) the serous coat over the base of the ulcer is strewn with mili- ary tubercles. In Litten's case the ulcer was fairly large—1*2x3*3 centimetres [1-7 X 1*3 inch]. The edges were sharp and indurated, and in parts swollen and infiltrated with blood. The rest of the digestive tract was free from tubercular ulcerations, but they were found in the larynx, bronchi, and lungs. A similar case is reported by Talamon-Balzer,*}: another by Gilles-Sabourin,# and Eppinger J has described two others. [An excellent description of tubercular ulcer of the stomach will be found in a paper by Musser,A in which he describes a case, a negro forty-four years of age, with pulmonary phthisis and vague gastric symptoms; on autopsy, an ulcer, 1\ X 3£ inches, was found in the stomach; the ulcer was evidently tubercular, and contained cheesy matter, as well as miliary tubercles in the base and in the submucosa in the vicinity. Tubercle bacilli were found in the cheesy masses; they were also found in some other cases which he mentions. Barbacci () describes a similar case in which there were isolated tubercular ulcerations in the stomach, the primary tuberculosis being in the pharynx. Most of the cases reported by Musser occurred in children.] Nevertheless, these cases * Eppinger. Ueber Tuberculose des Magens und Oesophagus. Prager med. Wochenschr., 1881, No. 51 und 52. f M. Litten. Ulcus ventriculi tuberculosum. Virchow's Archiv, Bd. lxvii, S. 615. X Talamon-Balzer. Phthisie locale; ulcerations tuberculeuses de I'estomac et de l'intestin. Bull. Soc. anatom., 1878, p. 374. *Ibid. I Loc cit. A [J. II. Musser. Tubercular Ulcer of the Stomach. Philadelphia Hospital Re- ports, 1890, vol. i, pp. 117-124.—Also, Barlow. Transactions of Patholog. Society of London, 1887, vol. xxxviii.—Ed.] Q Barbacci. Un nuovo caso di tuberculosi gastrica. Lo Sperimental, 1892, No. 13. 402 DISEASES OF THE STOMACH. are quite rare, since Eisenhardt* found only one case of gastric tuberculosis in 567 cases of tuberculosis of the intestines. Marfan,f in a study of the gastric disturbances of pulmonary phthisis, also presents but few cases, some of them being doubtful. However, all these do not belong to the type of the corresponding ulcer; they are rather true areas of tubercular softening as they occur every- where with central cheesy degeneration of the tubercle tissue. At all events, there is a combination with the corrosive action of the gastric juice on the necrotic tissue elements*}: [see page 418]. The syphilitic ulcer is not marked by characteristic anatomical features. In the majority of the few cases thoroughly observed, the question whether the ulcer was a primary lesion or a broken- down gumma is not broached.* [The relations of syphilis and gastric ulcer are discussed in some detail by Neumann, || who considers their occurrence in this disease by no means as rare as has been supposed. He believes that the ulcers which are found in syphilitic patients may be either true peptic ulcers or broken-down gummata (see page 417).] Symptoms.—As is well known, some gastric ulcers, healing by cicatrization, run their course during life without presenting any symptoms whatever, or only a few which are not at all characteristic; they are then only found accidentally after death. Their occur- rence had already been established by Williams, Abercrombie, and Chambers, and naturally they do not come under clinical observa- tion. [A very interesting case of latent ulcer has recently been published by Dieulafoy.A There were absolutely no symptoms until perforation occurred; and yet there were two ulcers, one of which * Eisenhardt. Ueber die Haufigkeit dar Darmtuberkulose. Inaug. Dissert, Munich, 1891. f Marfan. Troubles et lesions gastriques dans la phthisie pulmonaire. Paris, 1887. X [Full bibliography of tuberculosis of the stomach will be found in W. S. Fen- wick, Dyspepsia of Phthisis, London, 1894, p. 198.—Ed.] * Galliard. Syphilis gastrique et ulcere simple de I'estomac. Arch, gener. de med., 1886, pp. 66 et seq. | [Neumann. Syphilis. Nothnagel's Encyclopaedia, 1896, Bd. xxiii, p. 354.—Ed.] A [Dieulafoy. Presse med., July 25, 1896. Full abstract in New York Medical Journal, August 15, 1896, p. 245.—Ed.] SYMPTOMS OF GASTRIC ULCER. 403 was as large as a half-dollar. According to Stoll,* who has pub- lished statistics based upon 3,476 autopsies, gastric ulcers run a latent course in 27 per cent of the cases.] The various ulcers of the stomach may be arranged, according to their symptoms, into the following groups: 1. Cases in which the symptoms due to irritation predominate, and which result in haemorrhagic erosions, or in corrosion and ex- posure of a larger or smaller portion of the mucous membrane with- out the development of further complications. 2. Cases with these symptoms of irritation, together with haem- orrhages. 3. Cases with symptoms of irritation and perforation, resulting in recovery or death. 4. Cases which remain latent until death occurs by haemorrhage or perforation. The fact that the symptoms of the first three groups may be combined in various ways explains why the clinical picture is so changeable; and if, in addition, the results of cicatrization are also included, it becomes even more complicated. The first stages mani- fest themselves by those conditions of discomfort which we find at the commencement of so many diseases of the stomach,, such as vague sensations of pressure, transient drawing pains, and the ac- companying disturbances of the appetite. However, the tongue is usually clean, or only moderately coated at the base. On strict in- quiry we find that the patients eat very little, and usually keep a fairly strict diet, not on account of lack of appetite, but owing to the dread of having pain after a full meal. For this gastralgia forms a marked feature of the picture, even early in the disease. The accompanying catarrhal gastritis is but rarely sufficiently marked to cause true anorexia, foul taste, belching, bad odor from the mouth, and heavily coated tongue. Only in the rare cases in which a girdlelike ulcer or a cicatrix interferes with the peristalsis of the stomach and causes dilatation, is there marked decomposition of the stomach contents and belch- ing of foul gases. Sluggishness of the bowels is the rule; diar- » [Stoll. Deutsch. Arch, fur klin. Med., Bd. Iii, Hefte 5 und 6.—Ed.] 404 DISEASES OF TTIE STOMACn. rhcea, or a condition in which the two alternate, the exception. The intestinal functions are rarely found to be normal and un- disturbed. Chronic ulcer runs its course without fever, and, should an in- creased temperature be present in conditions of exhaustion toward the end of life, or in certain forms of ulcer running an acute course, they are due to inflammatory processes, such as gastritis, peritonitis, or pneumonic infiltrations. Recent cases are not usually accompanied by disturbances of nutrition ; they may even be absent after the ulcer has existed for some time. Most patients, however, eventually emaciate on account of their scanty diet, and frequently lose weight so rapidly as to cause apprehension, so that losses of 20 kilogrammes [44 pounds] and more in a few months are not uncommon. This depends partly on the previous condition, and occurs more frequently in the strong and stout than it does in lean persons. Gradually the pains become localized to a definite spot corre- sponding to the site of the ulcer, and as this is commonly situated in the lower half of the stomach, and as the painful spot can not be localized with exactness, it is usual to have it referred to the infra- sternal depression. The boring, sharply localized pain, frequently darting from before backward, is characteristic. Some patients complain only of pain in the back, others of " stitches in the side," owing to wmich the disease may be mistaken for intercostal neural- gia. [The pain in the back is usually localized, especially on the left side, at the twelfth dorsal and first lumbar vertebrae. Localized tenderness in this area is very frequently observed.] As a rule, pressure increases it; women can not lace, and men can not pull the band of their trousers tight. In rare cases, on the other hand, pressure eases the pain. It appears in attacks most frequently on mechanical or thermal irritation of the exposed surface of the ulcer. Of course, this is primarily and most frequently the case after eat- ing, the food either causing direct irritation on its introduction, or stretching the wall of the stomach by its weight, or the surface of the ulcer is distorted and its nerves irritated by the contractions accompanying digestion. But this is not the only cause. I have repeatedly seen severe gastralgia in patients with ulcer of the stom- SYMPTOMS OF GASTRIC ULCER. 405 ach, after a drink which was too cold, or a spoonful of soup or tea etc., which was too hot; in these cases, consequently, the pain could not be attributed to the above-mentioned factors, but only to ther- mal irritation. Moreover, according to my experience, ingesta which are too hot are less often the cause than those which are too cold, perhaps because the mouth and throat act as guards to the stomach in the former case, and because the mucous membrane of the stomach is more tolerant of high degrees of temperature than it is of low, and also because smaller quantities of the former are taken than of the latter. The state of the ingesta is also certainly not without influence on the reaction of the mucous membrane. A re- markable example of this is recorded by Dunglison : * Numerous cases of severe acute gastritis occurred among the workmen in Virginia who, becoming overheated under the hot sun, quenched their thirst with large quantities of cold spring water ; these attacks were rap- idly followed by death. On substituting small pieces of ice instead of the water, this disease practically disappeared. To be sure, there are many patients who never have trouble after eating, but, instead, the attacks of gastralgia appear when the stom- ach is empty, and even in the night. Here the cause may be the secretion of hyperacid gastric juice, which is still to be spoken of. On the other hand, gastralgia may be caused by the distention of the walls of the stomach by gases, or by irritation of the nerve fibers due to the progressing process of ulceration, while the attacks of gastralgia caused by colds and excitement, and the increased pain before the menstrual epoch and its cessation on the appearance of the menses, may be regarded as reflex in character. A peculiar symptom occasionally seen is the cutaneous hyperaesthesia and anaes- thesia observed by Traube f and referred by him to a central " irra- diation." The causes of the gastralgias lead to the fact that they usually appear suddenly and with great intensity at once, and as rapidly subside, so that a nearly normal condition is very soon estab- lished ; paroxysms which gradually increase in intensity are less frequently observed. The Changes in the Chemical Functions of the Stomach.—At all * Quoted by Copeland, Dictionary of Pract. Med., article Indigestion. t Traube. Deutsche Klinik, 1861, S. 63. 406 DISEASES OF THE STOMACH events, the appetite of patients with gastric ulcers and their digestive power show that they are not lessened. To Riegel and his fol- lowers* is due the credit of having been the first to attach great importance to occurrence of increased secretion of HCl. Numerous investigations f have shown that this hyperchlorhydria is not con- stant, as was at first supposed by Riegel, but it is nevertheless found in the great majority of cases. The statement long ago made by me,X that "in cases of ulcer the gastric juice always contains HCl, and usually an excess of it," may to-day be generally accepted. Von Korczynski and Jaworski # in a few cases have also observed the untimely occurrence (i. e., on an empty stomach) of continuous acid hypersecretion ; they have noticed that the acidity increased or diminished in the same degree as the patient's subjective symptoms, but it was greatest just before the occurrence of a haemorrhage. But all authorities agree that the acidity due to HCl may reach 90 to 100, and even as high as 108 and 110. It is self-evident that the hyperacidity of the chyme will interfere with digestion, the diges- tion of proteids being more rapid and complete than of the starches. Thus in the stomach contents after a mixed meal one will find that all the meat has been digested, while a larger or smaller residue of starches will be found unchanged. Changes in the Urine.—Such a hyperchlorhydria is necessarily caused by an abnormally large decomposition of the chlorides, which in turn causes a larger amount of the corresponding bases to appear in the urine—i. e., the urine becomes more alkaline. This has been systematically observed by Quincke, Maly, Sticker and Hiibner,|| and Ferrarini.A Gluczynski I) was the first to call attention to the * F. Riegel. Beitrage zur Diagnostik der Magenkrankheiten. Zeitschrift fiir klin. Med., Bd. xii, p. 434, etc.; Volkmann's Sammlung klin. Vortrage, No. 289; Deutsch. med. Wochenschr., 1886, No. 52.—Vogel. Beitrage zur Lehre vom Ulcus ventriculi simplex. Inaug. Dissert., Giesen, 1887, and others. f Rothschild. Inaug. Dissert.. Strassburg. 1886.—Ewald. Berl. klin. Wochen- schr., 1886, No. 23.—Ritter und Hirsch. Zeitschr. fiir klin. Med., Bd. xiii, p. 446 — C. Gerhardt. Deutsch. med. Wochenschr., 1888, No. 18.—Rosenheim. Ibid., No. 22, and others. X Ewald. First American edition of this work, p. 230. * Loc. cit. Deutsch. Arch, fiir klin. Med., Bd. xlvii. | Sticker und Hiibner. Zeitschr. fiir klin. Med., Bd. xii, p. 114. A Ferrarini. Riforma medic, April 24, 1891. Y Gluczynski. Berl. klin. Wochenschr., 1888, No. 52. SYMPTOMS OF GASTRIC ULCER. 40f complete absence of the chlorides from the urine, a fact which can be readily corroborated; hence a high alkaline reaction of the urine and the absence of chlorides indicate marked changes in the func- tional activity of the glands of the stomach. [See page 163.] Condition of the Blood.—Most writers, such as Laache, Leich- tenstern, Reinert, and Ostersprey,* have found changes in the blood which were independent of any haemorrhages ; the number of red cells and the percentage of haemoglobin were diminished, while at times the number of white cells was increased. The contradicting observations of Miiller and Oppenheimer, f however, show that al- though these results are common, yet they are not always found, and hence have not specific relations to gastric ulcer, and therefore depend upon secondary conditions, such as chlorosis, anaemia, etc. Immediately after a haemorrhage we find the usual blood changes after such occurrences—i. e., a diminution of the red cells and haemo- globin and a slight increase of the leucocytes. The next symptom to be considered is vomiting, both of food and of blood. Vomiting usually occurs soon after eating. It is due to the irritation caused by the food, and not to an accumulation of ingesta, as is the case in dilatation of the stomach. The food is brought up only slightly changed and mixed with some mucus, as in the morning vomiting of drunkards. Fermentation fungi and other foreign cellular elements, with the exception of the occasional ad- mixture of blood, are absent, or are (for example, sarcinae) very rare. At other times the vomit is watery, with a light greenish tinge, very acid, and on standing there is a mushy deposit which consists chiefly of starch granules, cellular detritus, and scanty, well digested fragments of meat. There may also be periods in which the vomit is very copious, when the stomach is absolutely intolerant toward food. Haematemesis.—When the blood comes from small vessels, the quantity is usually small; if recent, it appears only as fine bloody streaks in the vomit; but if the gastric juice has had an opportunity to act for a longer time upon the blood while it was accumulating, then it is changed to reddish-brown, granular masses. Small quan- * Ostersprey. Vide supra, p. 327. \ Miiller. Vide supra, p. 327. 27 408 DISEASES OF TnE STOMACn. tities of blood may easily escape observation when no vomiting oc- curs and the blood is carried into the intestines ; here it is altered to such an extent that nothing is noticeable by simple inspection of the faeces. Under such circumstances, as has been shown by Schmauss, the blood in the stool can only be demonstrated by a microscopic, spectroscopic, or chemical examination. However, the detection of small quantities of blood in the stools is always a difficult task, be- cause the red cells are usually so altered in the intestines that they lose their characteristic form. This difficulty, which is not encoun- tered in large bleedings, is increased in small haemorrhages, especially if the patient has taken preparations of mercury [iron, bismuth] and sulphur, which give a dark color to the faeces. In this way the cause of an obscure anaemia may be discovered. In fact, this is possible much more frequently than is generally assumed ; conse- quently repeated examination of the faeces should not be omitted after gastralgic attacks, or indeed in any obscure case of gastric or intestinal diseases. Profuse haemorrhages presuppose the erosion of a larger vessel; the blood acts as an emetic on the stomach, so that it empties itself of its contents. Many patients have a distinct and positive premo- nition in the form of flashes of heat, epigastric pulsation, fullness in the region of the stomach, and great and apparently groundless rest- lessness, as in the case described at the beginning of this chapter. The time during which the blood remains in the stomach varies, and with this, consequently, the appearance of the vomited masses. In some cases we find bright-red clots, in others dark, brownish-red masses, while in the great minority of cases it presents the appear- ance of coffee grounds. The presence of blood in the vomit can, as a rule, be readily established with the naked eye ; it can always be easily discovered with the microscope or spectroscope, or by means of Heller's blood test. We must not forget that confusion may arise if the patient has partaken of red wine, cacao, colored medi- cines, cinnamon, or real coffee grounds ; but a glance through the microscope will readily settle this question. Part of the blood passes into the intestines. This is the rule in the smaller haemor- rhages which do not lead to vomiting ; the blood mingles with the rest of the intestinal contents and is not recognizable in the faeces, SYMPTOMS OF GASTRIC ULCER. 409 or is overlooked. In the case of larger hemorrhages, or if the ulcer is situated in the duodenum, the evacuations consist of tarry, very offensive masses. The estimation that haematemesis occurs in 50 per cent of the cases is rather too high than too low. Brinton gives 29 per cent; Witte, of Copenhagen, found it 100 times in 339 cases; and Ger- hardt saw it in 47 per cent of his cases; so we may assume that considerably more than half the patients do not have haematemesis. In an interesting study of the records of Guy's Hospital from 1870 to 1890, Hood* has shown that the majority of cases of ulcers which occurred under the thirtieth year were women, and that death was extremely rare at this youthful period of life. Of 66 such cases, 29 were under thirty years old, of whom only 2 were men ; whereas 11 of the 21 cases which occurred between the thirtieth and fortieth years were men. All cases recovered. Seven other cases which were fatal immediately after haemorrhage were all over thirty years old; 4 of them were women, aged thirty-three, thirty-five, fifty, and fifty-three years. Although we must not infer that the prognosis of haematemesis suddenly changes with the thirtieth birthday, yet these statistics indicate that the prognosis of haematemesis in youth- ful women is not bad; on the contrary, after such catastrophes we often see a remarkable improvement, lessening of the distressing symptoms, and improvement of the blood. Thus in one of my cases within three weeks after haematemesis, the number of red blood- cells were from 1,900,000 to 3,040,000 and 4,070,000, and the per- centage of haemoglobin from 31 to 51. I have also repeatedly seen similar occurrences. The bloody masses after haemorrhage from ulcer contain no specific elements; and the red blood-cells are so abundant that the cellular structure of the gastric mucous membrane is scarcely or not at all to be seen. When larger haemorrhages have occurred, the danger of their recurrence hangs over the patient's head like the sword of Damo- cles, and in a twofold manner: First of all, repeated haemorrhages occur in the course of the day, even several times during the same * W. Charles Hood. Haematemesis, with Special Reference to that Form met with in Early Female Life. London, J. Bale & Sons, 1892. 410 DISEASES OF THE STOMACH. day, or at short intervals, say, during a week. Then we must assume that there are recurrences from the same vessel which was first opened. Secondly, after a pause of months, or even years, fresh haematemesis appears. Its return may be due to a tendency of the individual to this kind of haemorrhage. In order to form any idea at all why in certain persons extensive ulcers, which must necessarily have involved large vessels in their growth, run their course without haemorrhage, and others are marked by such profuse haemorrhage, we must, in my opinion, assume a certain predispo- sition to a deficiency in the fibrinoplastic power of the blood, and with this an insufficient or ineffectual formation of thrombi. It oc- casionally appears, too, as if the thrombi after being formed were very loosely attached and could be quite easily displaced, as soon as the heart's action exceeded its normal strength. Thus I have twice seen a haemorrhage recur after a long period of quiescence, caused by the patients, who, thinking themselves well, had in- dulged in strong alcoholic beverages, although only in small quan- tities. Small haemorrhages have no influence on the condition of the patient, except psychically; larger haemorrhages, especially if recur- ring at short intervals, lead to a high degree of anaemia and its consequences. Waxy pallor of the skin, small, rapid pulse, slight febrile movements, complete anorexia, ringing in the ears and ver- tigo, transient mild delirium, and even complete loss of conscious- ness, may occur. Subsultus tendinum and convulsions in the ex- tremities have even been observed. In spite of this, as a rule, the patients rally comparatively rapidly, and under appropriate treat- ment soon tend to regain their lost powers. We may also observe oedema of the lower extremities, especially at night, after the patient has been on his legs all day, and also amaurosis, which may occur soon, or some time after the bleeding. According to Fries,* amau- rosis occurs in 65*5 per cent of all cases of bleeding from the in- testinal tract; but its real relation to haematemesis has by no means yet been made clear. Immediately fatal cases of gastric haemorrhage from the vessels * S. Fries. Beitrage zur kenntniss der Amblyopic und Amaurose nach Blutver- lusten. Inaug. Dissert., Tubingen, 1876. SYMPTOMS OF GASTRIC ULCER. 411 of the stomach, especially in youthful persons, as has been shown above, are comparatively rare. In most the cause has been perfora- tion of the ulcer (see page 406), and the involvement of the splenic or pancreatic artery, the portal vein or the left heart. Cruveilhier pictures a case in which the stomach was distended with fluid, brownish-red blood. Budd saw a case in which not only the stomach but also the entire intestinal tract was full of blood, and in which the patient had bled to death into his own body. A case reported by Finny is interesting: * A young man, nineteen years of age, in whom phthisis had been sus- pected, and who for some time had had hectic fever, died suddenly. There were no symptoms of stomach trouble. Yomiting did not occur, not even immediately before death. The stomach and intestines down to the anus were found full of fluid blood. The stomach, diaphragm, pericar- dium, and myocardium had all become adherent to one another. A small cannular communication led into the left ventricle; otherwise its muscle was normal, and was found to have undergone granular degeneration only in the neighborhood of the perforation. The ulcer in the stomach was situated on the anterior wall, and measured one inch and a quarter in length by three quarters of an inch in width. A small aneurism of the gastric artery was the cause of death in a case reported by Powell.f The ulcer was situated near the cardia on the lesser curvature, and in the center was a ruptured aneurism of the size of a pea, the profuse haemorrhage from which caused the death of the patient in a few minutes. Referring to the fourth group mentioned above [page 394], we see that haemorrhages may occur without any previous indication of a gastric ulcer, and in fact these have frequently been observed. I wish to again recall to your memory the case described at the com- mencement of the chapter as belonging in this category. However, in this patient vague symptoms of a grave illness preceded the fatal hemorrhage, while in other cases it has killed apparently healthy persons with alarming and unexpected suddenness. In this connec- tion a case of haemorrhage from the intestines described by Pois- son X is of diagnostic interest; the bleeding appeared during conva- * Finny. Ulcer of the Stomach opening in the Left Ventricle of the Heart. Brit. Med. Jour., 1886, i, p. 1102. f Powell. Transact. Pathol. Soc. [London], vol. xxix, p. 133. \ Poisson. Bull, de la Soc. anat. de Paris, Febr., 1855. 412 DISEASES OF THE STOMACn. lescence from an attack of typhoid, and might have occasioned its being mistaken for a typhoid haemorrhage. Hollevoet * describes a case of ulcer with haemorrhage which was followed by marked purpura haemorrhagica. But, as in this case (which recovered), there were also renal haemorrhages. Scurvy may also have been present. A severe complication of this disease is produced by the perfo- ration of the ulcer and the involvement of the neighboring organs. When the digestive process has reached the serous layer of the gastric wall, and has involved one of the neighboring organs (among which I here include the coils of intestine), it manifests itself occasionally by a localized sensation of pain, referable to the posi- tion of the affected viscus. Most frequently, however, it runs its course without any outward manifestation, so that only when dis- turbances of function appear in the organs involved do we recog- nize the fact that they are similarly affected. Or haemorrhages may occur from the larger vascular trunks, especially in the pan- creas and spleen, which are naturally in no way to be distinguished from those already considered. I do not consider it essential to give a detailed account of the intercurrent affections possible here, and which I have already re- ferred to above, although the literature of the past fifty years is full of reports of all such complications. We can readily conceive of the occurrences in question on calling to mind the topography of the stomach and its relations to the surrounding organs. The most interesting is the perforation through the diaphragm f [sometimes giving rise to diaphragmatic hernia] and pericardium into the left heart,*}: with pneumo-pericarditis, or into the mediastinum, with cutaneous emphysema and collection of inflammable gases. West* describes a case in which the ulcer extended to the portal vein and * Hollevoet. Arch. med. Beiges, 1892, No. 3. t [Pick has recently reported a case of this kind; the true condition was only found at the autopsy. Zeitschrift fiir klin. Med., Bd. xxvi. Bibliography of 27 cases is given.—Ed.] X [Oser has described a case in which, although the left ventricle was eroded, the patient survived two days. The opening was closed during the systole and only open during the diastole; the patient thus gradually bled to death. Addi- tional cases are quoted by Welch (Pepper's System of Med., vol. ii, p. 508).—Ed.] * S. West. Trans. Patholog. Soc, London, 1890, p. 147. SYMPTOMS OF GASTRIC ULCER. 413 caused death from pylephlebitis. Those cases in which encapsulated abscesses containing air have formed beneath the diaphragm have been described under the name of pyopneumothorax subphrenicus. [Subphrenic abscess is by no means rare after perforation of gastric ulcers. Much has recently been written on this subject, especially by Maydl,* Meltzer, f Weir,*}: Beck,* Foote, || and others. In 110 cases of subphrenic abscess collected by Meltzer, 32 occurred after gastric ulcers and 9 after duodenal ulcers. The abscesses frequently con- tain gas, and are by no means easily recognized. Pyopneumothorax will also exist if the diaphragm has been perforated. The diagnosis may be made by the history of the case, the absence of Litten's " diaphragm phenomenon " before perforation of the diaphragm has occurred, the presence of dullness over the lower thorax, not due to the liver or spleen, and the use of the aspirating needle (Weir and Foote). The prognosis is very bad unless the condition is relieved by operation.] Perforation into the pleura A can be diagnosticated if it causes pneumothorax and empyema, or if it leads to direct communication with the lungs, and the coughing up of particles of food, which not only may occur, but actually has been reported. I have already spoken of perforation into the colon and the re- sulting lienteric diarrhoea, in discussing perforation due to cancer- ous ulceration. Perforation into the abdominal cavity may occur in different ways. In fortunate cases there is a preceding adhesive in- flammation between the stomach and the neighboring intestinal wall and omentum, thus forming a cavity representing a sac inclosed in a sac, which prevents the escape of the gastric contents into the abdominal cavity. Then signs of irritation of the peritonaeum appear; circumscribed pain and distention of the upper part of the abdomen, together with fever, and sometimes frequent vomiting. If the adhesions are more extensive they may result—as in the case of Budd, which I have already mentioned—in complete interference * [Maydl. Der Subphrenische Abscess. Vienna, 1894.—Ed.] f [Meltzer. N. Y. Med. Journal, June 24, 1893.—Ed.] X [Weir. Internat. Med. Magazine, February. 1892.—Ed.] # [Beck. N. Y. Med. Record, 1896, vol. i, p. 217.—Ed.] | [Weir and Foote. Med. News, May 2, 1896.—Ed.] A [In a case reported by Muller, lumbricoid worms were found in the pleural cavity. Memorabilien, xvii, October, 1872. Quoted by Welch, loc. cit—Ed.] 414 DISEASES OF THE STOMACH. with the functions of the intestine, thus leading to permanent ob- struction, progressive marasmus, and death. Perforation into the peritoneal cavity is, however, by far the most frequent, either with or without previous adhesions and for- mation of abscess. It may follow slowly and gradually, or, rather, the escape of the gastric contents may be slow. In such cases sac- culated abscesses may form, which remain encapsulated, or burst later on and cause general peritonitis. As a rule, though, the per- foration occurs quite suddenly, without any warning or symptoms referable to it. The patients suddenly experience severe pain in the abdomen, causing them to collapse to a certain extent. This appears without cause, or after a preceding traumatism, such as an accidental blow, or after leaning on the edge of a table or window- sill, after riding, after a hearty meal, or after vomiting. In a short time the clinical picture of peritonitis due to perforation is devel- oped : distention of the abdomen, severe pain even on the slightest touch, vomiting,* singultus, facies Hippocratica. small pulse, and finally death. Yet, as in the case recorded at the commencement of this chapter, the perforation may occur without the appearance of any of these signs. Inasmuch as the patient had practically taken no food for three days previously, the stomach in this case was empty both of food and gas, and consequently the perforation of the ulcer was accompanied only by the symptoms of profound shock —unconsciousness, Cheyne-Stokes respiration, extremely small pulse, cold skin, etc.—while the abdomen was neither markedly distended nor very painful, f Such perforations may also be caused by convulsive contractions of the stomach after vomiting, induced either by drugs or by the introduction of the finger into the throat, as many patients are fond of doing in order to produce vomiting or belching, or after * [Some uncertainty exists as to the existence of vomiting in perforation. Struve found it in two thirds of his cases, and says that it is liable to be absent in large perforations. Weir and Foote found it in 36 per cent of their cases, in 8 per cent it was absent; in the remainder (56 per cent) no reference is made to this symptom. " Certainly the presence of vomiting in no wise argues against the diag- nosis of perforation of the stomach." Weir and Foote. Med. News, April 25, 1896, p. 461.—Ed.] f Even unconscious individuals react still to severe painful sensations. SYMPTOMS OF GASTRIC ULCER. 415 the introduction of the stomach tube. Faber * describes a case of perforation after vomiting brought on by the patient. According to Bouilleaud,f the normal act of defecation may give rise to per- foration. In the practice of one of my colleagues I have myself recently observed a case of perforation of an ulcer which had caused stenosis of the pylorus ; the opening was the size of a cherry pit. This occurred during the even- ing, after lavage of the stomach, which had at one time been recommended by me on account of the marked dilatation of the stomach and accumula- tion of its contents. Immediately afterward the emaciated and miserable patient complained of severe abdominal pain and distention, and died in collapse that very night. At the autopsy, air and blackish-brown stomach contents were found in the abdominal cavity. The stomach was enor- mously dilated, and the pylorus so narrow that a pencil could scarcely be passed through it. Just above this was an ulcer. It was about the size of a 2-mark [50-cent] piece, with wall-like and thickened (carcinomatous ?) edges, and in the center was a circular perforation with very smooth, sharp contour, not at all ragged or torn, and in no way suggesting a recent wound. Inasmuch as my colleague used a soft-rubber tube, taking all necessary precautions, a direct lesion caused by it may be excluded. My explana- tion of the case is rather that a slight adhesion had taken place and was broken up by the marked traction on the gastric or abdominal walls which always accompanies the washing out of the stomach. I have had a similar experience in the case of a young woman, twenty- one years old, with an ulcer about the size of the palm of the hand, which had undergone carcinomatous degeneration. There was a perforation about as large as a 20-pfennig [5-cent nickel] piece on the lesser curvature, below the left lobe of the liver; the edges of the perforation were smooth, and there was no trace of recent inflammation in its vicinity. During the last weeks of her life she had vomited frequently, but the tube had never been introduced. Cases which recover from such perforations are exceedingly rare. [Such a case has been published by Hall.*}: The writer found only six reported cases of recovery after peritonitis from perforating gas- tric ulcer. Three recovered completely; three died in the course of subsequent attacks; autopsies verified the diagnoses. The treat- ment was expectant—i. e., opium and rectal alimentation. The good result was attributed to the fact that the perforation occurred * Faber. Emphysem des Mediastinums und der ausseren Haut in Folge einer Perforation eines Magengeschwiirs. Wurttemb. med. Correspondenzblatt, 1885, No. 40. f Bouilleaud. Arch, de med., i, p. 534. X [Hall. Case of Perforating Gastric Ulcer, Peritonitis, Recovery. Brit. Med. Jour., January 9, 1892.—Ed.] 416 DISEASES OF THE STOMACH. four hours after eating, when the stomach was empty. Pariser * reports 15 authentic cases of recovery after acute perforation, with- out operation. He, too, insists that recovery in all these cases de- pended on the empty condition of the stomach at the time of per- foration.] We really can not speak of recovery in the true sense of the word, for the adhesions of the intestines, which are produced in the most favorable cases, lead to chronic illness, and death occurs in a comparatively short time from progressive disturbance of nu- trition. Sudden perforations have repeatedly caused suspicion of poisoning, and have led to erroneous accusations. [" Gastrocutaneous fistulae are a rare result of the perforation of gastric ulcer. The external opening is most frequently in the umbilical region, but it may be in the epigastric or in the left hypo- chondriac region or between the ribs." " Of the 25 cases of gastrocutaneous fistulae collected by Murchison,f 18 were the result of disease. In 12 of these cases the probable cause was simple gas- tric ulcer. Middeldorpf X says that among the internal causes of the 47 cases of external gastric fistulae which he tabulated, simple ulcer of the stomach played an important role."] The form of the cicatrization is of great importance. It is very apparent that cicatricial contraction may lead to the severest dis- turbances of the functions of the stomach, of which one—dilatation following cicatricial stenosis of the pylorus—has already been dis- cussed. In these cases a well-marked and characteristic clinical pic- ture is developed. In other cases the cicatricial contraction leads to traction on the nerves in the gastric wall, to deformities of the viscus, to the shutting out of larger portions of the muscular coat, or to adhesions with the neighboring organs; the result is gastral- gias, or disturbances of function, which manifest themselves as " dyspepsias" of various kinds. As a rule, the primary cause of these " dyspepsias " is very difficult to discover; a cure is usually or nearly always impossible. I have learned to fear these cicatrices even more than the original ulcer. It is not uncommon for such * [Pariser. Deutsch. med. Wochenschr., 1895, p. 468.—Ed.] t [Murchison. Med.-Chir. Transact., London, 1858, vol. xii, p. 11.—Ed.] X [Middeldorpf. Wiener med. Wochenschr., I860.—Welch, loc. cit, vol. ii, p. 508.—Ed.] RELATIONS OF SYPHILIS AND GASTRIC ULCER. 417 patients to be regarded as " nervous dyspeptics." If the cicatrix is circular and at about the middle of the stomach, forming the hour- glass stomach, or large saccular dilatations may be formed, then it may happen that if for some reason lavage is performed later on, the remarkable phenomenon may appear that the stomach apparently can not be emptied. The water, to be sure, comes away almost clear after a time, but it suddenly becomes turbid again; this may be repeated many times.* In such cases we either have the condi- tion described, or an insufficiency of the pylorus, permitting regur- gitation of the contents of the duodenum into the stomach. Syphilis and TTlcer.—As early as 1838 Andral inquired why syphilitic manifestations could not break out on the mucous mem- brane of the stomach as well as on that of the mouth. Since that time the question has been frequently discussed, and a number of more or less convincing observations have been published by Gold- stein, Hiller, Yirchow, Leudet, Lanceraux, Fauvel, Klebs, and Cornil. Only two cases of the simultaneous appearance of gumma and ulcer have been observed. Other observers (Frerichs, Drozda, Murchison, Chvostek) found scars in the stomach coincidently with general syphilis. Among 100 cases of ulcer, Engel found previous syphilis in 10 per cent, Lang f found it in 20 per cent, while Julien:}: justly expresses himself with great reserve on this subject. It must always remain questionable in two diseases, as common as those under discussion, whether we are dealing with cause and effect or with an accidental coincidence, especially since we are by no means able in every case to avoid confounding it with ulcerating gumma. Here the result of specific treatment can alone be conclusive. A number of such cases has been reported, for instance by Hiller* and by GalliardJ although the latter, who has published the latest monograph on the subject, admits that they can not be positively proved. At any rate, syphilitic ulcers do not show specific symp- toms. Nevertheless, it is advisable to use specific treatment in * G. Scherf (Beitrage zur Lehre von der Magendilatation; Inaug. Dissert., Gottingen, 1879) also observed this. f [Lang. Wiener med. Presse, 1885, No. 11.—Ed.] t Julien. Traite des maladies veneriennes. Paris, 1886, p. 880. 9 Hiller. Monatschr. f. prakt. Heilkunde, 1883. [ Galliard, loc. cit. 418 DISEASES OF THE STOMACH. cases showing the signs of gastric ulcer together with the existence of syphilis [see page 402]. Tuberculosis and Ulcer.—As is wel lknown, tubercular ulcerations of the intestinal canal are common, but they do not occur very fre- quently with ulcer of the stomach ; this may be because the germi- cidal action of the gastric juice prevents the proliferation of the bacilli which may be introduced in swallowed sputum, or in the blood. [Fenwick* believes that the rarity of tubercular disease in the stomach is also due to the small amount of lymphoid tissue which is deeply situated in the mucous membrane.] Tubercular ulcers of the stomach present no specific symptoms. Sudden death from haematemesis due to the involvement of vessels has also been observed in these cases. [Musser f claims that this is the rule. Fenwick X says complete perforation is very rare, on account of the numerous adhesions which are formed about the base of the ulcer. He could find only one case reported, and this he considers doubtful.] Diagnosis.—When all the classical symptoms are present the diagnosis of chronic gastric ulcer is easy and scarcely to be mis- taken ; while if this be not the case it can only be made approxi- mately, or not at all. Where it deviates from its typical course there are practically two other diseases of the stomach, the symp- toms of which resemble those of gastric ulcer—i. e., gastralgia or gastrodynia, occurring as the expression of nervous disturbance, and carcinoma. A good survey of the symptoms of the diseases in question may be obtained by arranging them in parallel columns, as Walshe has done in his celebrated treatise on cancer.* Nervous Gastralgia. Tongue variable, often pale, with indented edges. Frequent belching of odorless gas. Gastric Ulcer. Tongue dry and red, with a white stripe down the middle; or smooth and moist, or lightly coated. Belching rare: or sour re- gurgitation with heart- burn. Gastric Cancer. Tongue pale and furred. Frequent fetid belching. * [Fenwick, op. cit, p. 14.—Ed.] \ [Loc. cit.] X [Fenwick, op. cit, p. 163.—Ed.] * [The Nature and Treatment of Cancer. London, 1846, p. 289.] DIAGNOSIS OF GASTRIC ULCER. 419 Nervous Gastralgia. No change of the taste in the mouth. Frequent dryness in the mouth ; may have salivation. Appetite irregular and capricious. Variable sensations in the stomach, at times hot and at others cold. Pain entirely irregular and not dependent up- on eating; frequently eased by this or by pressure on the stom- ach. Puncta dolorosa. over the intestinal plexus. Chemistry of digestion not essentially altered. Epigastric pulsation. Vomiting variable: some- times only mucus, sometimes more or less digested stomach con- tents ; seldom with bile. No haematemesis, except' ing in unusual acci- dental complications. Gastric Ulcer. Obstinate constipation al- ways present to a great- er or lesser degree. Nor- mal stool very rare. At times watery, mucous evacuations, the so- called pseudo-diarrhoea Taste unchanged. Appetite good between the attacks. Thirst. Burning in the stomach. Circumscribed boring pains, frequently radiat- ing, to the back. Pains rare when the stom- ach is empty; chiefly after eating, or after movements or positions which cause traction on the stomach. Increased by pressure. Digestion of starch foods frequently retarded. Di- gestion of meat normal or even too rapid. Hyper- acidity the rule. Vomiting usually immedi- ately or within a short time after eating; fre- quently the first symp- tom of the disease. Very rarely, hyperacid vomit- ing from an empty stom- ach. Vomiting of clear blood or coffee-ground masses. As a rule, frequently repeat- ed within a short time. At times very profuse, with intense anaemia and collapse. Comparatively rapid recovery. Bloody stools. Stool variable. Diarrhoea due to intestinal irrita- tion not uncommon. Li- enteric diarrhoea after perforation into the colon. Gastric Cancer. Pasty, insipid taste. Appetite diminished or en- tirely absent. Repug- nance to meat shown early in the disease. Feeling of oppression, draw- ing, and pain of variable character. Later, pain in the shoulder. Continuous dull pain, at times becoming paroxys- mal. Frequently produced or increased by pressure. Digestion insufficient; as a rule, deficiency of free hydrochloric acid. For- mation of organic prod- ucts of decomposition. Epigastric pulsation only seen with marked emacia- tion. Violent and frequent vom- iting, often periodic, at times from an empty stomach. Mucous; if acid, it is owing to organic acids. Always appears first in the course of other dyspeptic troubles. Con- sists of slightly digested' food and occasionally can- cer cells. Blood more often decom- posed than recent. Quan- tity usually small. When once commenced, fre- quently recurs and with- out specially long inter- vals. Obstinate constipation al- most constant. Lienteric diarrhoea after perforation into the colon. 420 DISEASES OF THE STOMACH. Nervous Gastralgia. No fever. Complexion pale, rarely. fresh. Cutaneous cir- culation normal. Occurs at all ages. Com- moner in women than in men. Frequently in combination with hys- terical symptoms. No tumor can be palpated unless in the rare and exceptional cases in which foreign bodies, such as hair, etc., are introduced. [Hydrochloric acid vari- able.] No symptoms oiperf^ a- tion. Gastric Ulcer. Gastric Cancer. Slight febrile movement, but only in the presence of adhesive inflammation caused by perforation of the ulcer; or in connec- tion with larger haemor- rhages. Complexion commonly fresh, only anaemic after severe losses of blood. Frequently the visible mucous membranes and even the cheeks are slight- ly cyanotic. Another group of patients is chlo- rotic. Most frequent in middle- aged patients. Rare in children. Spirits varia- ble, frequently much de- pressed. Round, egg-shaped tumor to the right of the mid- line, if the ulcer is situ- ated at the pylorus and is followed by hypertro- phy. In old ulcers with a firm base and thickened border—or in circum- scribed encapsulated per- forations, or in case of adhesions with the head of the pancreas, the left lobe of the liver or the spleen—a tumor may at times be palpated. Posi- tion not changed by re- spiratory movements. Hydrochloric acid present and usually increased in amount. Perforation into the neigh- boring organs, with its characteristic signs ap- pearing even after an ap- parently short duration of the disease, or without so much as a premoni- tion. Fever rare. When present, only seen toward the end of life. Complexion pale and yel- lowish. Skin dry and re- laxed. Marked cachexia. Most frequent between forty and sixty years. Spirits depressed and despondent, but remarkably less de- spairing than in severe cases of ulcer. Tumor variable in size and form : knobbed or smooth; can readily be palpated; usually can be moved without resistance; at times its position changes with respiration. Sec- ondary glandular enlarge- ments. Metastases. [In the majority of cases no hydrochloric acid, but an excess of lactic acid.] Perforation or implication of surrounding organs only after the disease has existed for some time.* * [See also E. Kollmar, Zur Differentialdiagnose zwischen Magengeschwiir und Magenkrebs. Berl. klin. Wochenschr., Bd. xxviii, pp. 119, 146.—Ed.] DIAGNOSIS OF GASTRIC ULCER. 421 This table may be of service in establishing a differential diag- nosis. However, sharp as the distinction between the three pic- tures may appear on paper, we find often enough in practice that just the most important symptoms are absent, or so combined with one another, or so vaguely manifested, that an exact diagnosis can not possibly be made. This applies especially to the early stages of the ulcerative process. Up to the present time it was well-nigh impossible to differentiate these conditions from the many forms of dyspepsia, as long as they presented only more or less marked gen- eral disturbances of nutrition, as long as no typical gastralgic attacks occurred, and especially as long as every trace of haematemesis was absent. I regard the demonstration of increased acidity as a marked advance toward the recognition of this condition, and it enables us to make an early diagnosis. It is just in these cases that I consider it especially valuable, although it must not be forgotten that we undoubtedly find exceptions to this rule. I do not mean by this to belittle the value of positive results, for establishing which Riegel deserves great credit; nevertheless, the simultaneous presence of the three classical symptoms—typical gastralgia, haematemesis, and bloody stools, together with absence of tumor and cachexia—still remains the most positive means of establishing the diagnosis. Yet I have seen cases of undoubted gastric ulcer with great loss of strength, and, on the other hand, cases of cancer of the stomach in which the strength and general condition were unusually good. At times we can only make the diagnosis, as Leube also says, by the success or failure of specific treatment for ulcer. A special diffi- culty in diagnosis may be caused by the above-mentioned tumorlike cicatrization, and where neighboring organs have been drawn into the base of the ulcer, which has become adherent to them and per- forated over them. In the latter case the head of the pancreas and the left lobe of the liver are specially involved, less frequently the spleen. There is also a lymphatic gland in the ligamentum gastro- colicum, and especially a chain of glands situated near by, which under certain circumstances become sympathetically swollen and sensitive on pressure, and which may be detected on palpation as small tumors of the size of a hazelnut at the lower edge of the stomach. These have repeatedly caused me great trouble in diag- 422 DISEASES OF THE STOMACH. nosis. In all these cases, the fact that the tumor remains unaltered, the maintenance of strength, and the presence of hydrochloric acid, speak for the diagnosis of ulcer and against cancer. Further, as may be assumed from what I have already said concerning the du- ration of these processes, a course lasting more than three years, and the absence of typical cancerous cachexia, point toward the presence of the former affection. While discussing cancer of the stomach I have already spoken of the transformation of an ulcer into a cancer. Inasmuch as we know that hyperacidity is the rule in the majority of cases of gas- tric ulcer, we ought not to be surprised to find a persistence of the secretion of hydrochloric acid, sometimes even up to the normal amount, in certain cases of cancer which have developed in this way. It is therefore of importance from a diagnostic standpoint to consider tumors, especially those situated at the pylorus, which are accompanied by the typical symptoms of the cancerous cachexia, but in which hydrochloric acid is present in abundance, as being cancers which have developed from ulcers. I have repeatedly seen such cases. In one of them a tumor at the pylorus reached the size of an apple within a year. At first the patient, a man, twenty-seven years old, presented only the symptoms of an ulcer with hyper- acidity of 104 and 101 per cent; this hyperacidity persisted in spite of the development of the tumor and the presence of well-marked signs of stenosis. Gastroenterostomy was performed ; at the opera- tion inspection of the tumor showed that it was undoubtedly a cancer. Dietrich * has estimated the frequency of such cancers to be 5 per cent of all gastric carcinomas; Rosenheim f places it even higher, 8 per cent. The Diagnostic Use of the Tube in Ulcer.—The question arises whether it is justifiable to introduce the stomach tube for diagnos- tic purposes in gastric ulcer. Many clinicians, of whom I shall only mention Leube among the Germans and Germain See X among the French, condemn lavage and the use of the tube in this con- dition. See cites cases of Cornillon and Daguet in which lavage * Loc. cit f Berl. klin. Wochenschr., 1889, No. 47. X G. See. Hyperchlorhydrie et atouie de 1'estomac. Bull, de l'Acad. de med., 1 mai, 1888. DIFFERENTIAL DIAGNOSIS OF HAEMATEMESIS. 423 was followed by fatal haemorrhages. My own opinion is that the tube may be employed after preliminary cocainization of the fauces, and in connection with the aspiration method; but its use must be restricted to those cases in which a diagnosis can not be established in any other way. For scientific purposes we may risk the possible dangers in a clinic or hospital where the necessary means are at hand in case of emergency; but in private practice and in dispen- sary work I must caution against it most decidedly, otherwise I fear one may at some time find himself in an exceedingly uncomfortable position. It may happen to any one that in introducing the tube we may cause haemorrhage, and may even be so unfortunate as to cause the perforation of an unsuspected ulcer, or of one giving but vague symptoms. This might easily have happened to me in the case reported on page 377, just as it did in the one quoted later on, without giving rise to any justifiable reproach. But this danger must always be borne in mind. It is, of course, greatly lessened by cocainizing the throat before introducing the tube in doubtful cases, and by using the utmost caution in aspirating with the aspirator or the stomach pump; it is equalized, and more than equalized, by the great advantages peculiar to our methods of examination. But, nevertheless, I refrain from introducing the tube in all cases of ulcer in which the diagnosis can be made in another way; and I desist so much the more, since in these cases the examination of the stomach contents does not establish the diagnosis, and since it does not aid us in the treatment. On the other hand, I have ob- served that severe haemorrhages which could not be controlled in any other way have been checked by washing out the stomach with ice-cold water, as will be discussed later on under the treatment. Differential Diagnosis of Haematemesis.—As the expression " vom- iting of blood " is applied not only to gastric but also to pulmonary haemorrhages, we may consider the differences between them—i. e., between haematemesis and haemoptysis. We must remember that in haemoptysis the blood is mixed with a great deal of air and con- sequently tends to be bright red in color, and is ejected by cough- ing, and also that the history points to some chronic pulmonary af- fection. In many cases the patients have a distinct sensation as to 28 424 DISEASES OF THE STOMACH . j whether the blood comes from the lungs or from the stomach; in the former the haemorrhage is preceded by inclination to cough, due to irritation, tickling in the throat, and a sensation of warmth in the chest, while in gastric haemorrhages nausea and a tendency to vomit precede the attack. This holds true also of pharyngeal haemor- rhages, which may possibly come into play here ; but these, as a rule, are not so profuse, their source can usually be easily discov- ered, and the attack generally occurs under circumstances which do not permit their being mistaken. However, gastric haemorrhages may begin very violently, coughing being caused by the aspiration of blood into the respiratory tract, which is expelled not only through the mouth but also through the nose. Thus a pulmonary haemorrhage may be simulated, and even suffocation produced, by blood accumulating and clotting in the throat during syncope. In haemoptysis the patients cough for some time, and the sputa are coin-shaped and brownish or brownish-red in color ; in a recent at- tack we first observe bright-red and then dark blood. There is no sputum after haematemesis, but, as a rule, we find bloody stools (i. e., so-called melaena), which in doubtful cases indicate the occur- rence of gastric haemorrhage. On the other hand, we naturally dare not forget that many gastric haemorrhages occur without bleeding from the intestine, and also that occasionally blood which has been coughed up is swallowed and voided in the stools. The causes, then, which lead to haematemesis, disregarding ulcer and carcinoma, are : 1. Conditions of congestion in the venous vascular system. Thus Dr. Yellowly * reports a case of haemorrhage into the stomach in a man who was hanged (at all events, there was no haematemesis). Similar occurrences are said to take place in epileptic attacks. Cases of haematemesis with cardiac lesions have been described by Carswell and Budd.f H. Jones X has reported a case in acute yel- low atrophy of the liver, and another in cirrhosis of the liver with compression of the portal vein. Debove * has published an exhaust- * Med.-Chirurg. Transactions, 1853. \ Loc. cit, p. 53. X H. Jones. Cases of Haematemesis, with Remarks. Med. Times and Gazette, 1855, vol. ii, pp. 182, 410. 9 Debove. Des hemorrhagies gastro-intestinalcs profuses dans la cirrhose du foie et dans les autres affections hepatiques. Journ. Soc. anatom., 1890, No. 43. I DIFFERENTIAL DIAGNOSIS OF HAEMATEMESIS. 425 ive essay upon the relation between haematemesis and diseases of the liver. Here especial attention must be paid to the haemorrhage from dilated oesophageal veins. In hepatic cirrhosis these vessels, which form a part of the collateral circulation for the blood in the portal vein, are liable not alone to well-marked varicosities but also to rup- tures which may cause profuse and at times even immediately fatal haemorrhages. If the blood flows into the stomach and is then vom- ited, it may simulate haemorrhage from the stomach; if, then, an autopsy be performed on such a case without paying the proper at- tention to the oesophagus, the diagnosis of so-called idiopathic gas- tric haemorrhage will be made. The number of such cases reported has grown remarkably since attention has been called to them. Blume, Stony Wilson, Litten, Sachs, Yoelkel, and Ewald * have pub- lished and described cases of this kind. [At the May (1896) meet- ing of the Association of American Physicians Garland reported a case of oesophageal haemorrhage with cirrhosis of the liver. In the discussion Osier described two cases. Graham mentioned a case of oesophageal haemorrhage in a boy ; at the autopsy oesophageal vari- cosities were found, but no disease of the liver or any other organ. Mitchell added another case of a child who died of unaccountable haemorrhage after scarlet fever. The autopsy showed large " oeso- phageal piles," and also a group of dilated veins in the stomach, but no disturbance of any other organ.f] Sachs's case is particularly- interesting, as its clinical cause was very much like the one I have reported. A sixty-year-old man had for years repeated profuse haemorrhages from the stomach; at first they were in- frequent, later they occurred every half year, and finally every three months. Gastric symptoms, pain on pressure, and, in fact, all signs of any abdominal disease were absent. The haemorrhages were preceded by ver- tigo, cold sweats, etc.; they were followed by a feeling of relief. Finally he became intensely anaemic and weak, and died immediately after a pro- fuse haemorrhage. The autopsy, the very interesting details of which I can only indicate, revealed an aneurism of the hepatic artery which had ruptured into a hepatic vein; thrombosis of the splenic vein, and a rup- tured varix at the cardia. Manifestly the oesophageal veins were the source of the recurrent haemorrhages. * Blume. Om phlebectasia et varices oesophagi, etc. Copenhagen, 1868.— Stony Wilson. Brit. Med. Journ., December 27, 1890.—Litten. Verhandlungen des X. intermit, med. Congresses zu Berlin.—Sachs. Deutsch. med. Wochenschr., 1892, No. 20.—Ewald. Ibid., No. 20, Verhandl. des Vereins f. innere Med. f [Medical News, May 23, 1896, p. 595.—Ed.] 426 DISEASES OF THE STOMACH. In a case of cirrhosis of the liver with fatal hemorrhage, the diagnosis was made during life, because the haematemesis occurred without any nausea or gagging; indeed, there were no premonitory symptoms at all; this, together with the presence of the hepatic cirrhosis, rendered the lia- bility of such an occurrence as rupture of an oesophageal varix very likely. At the autopsy I found a ruptured varicose vein in the lower portion of the cesophagus. Yomiting of blood is also said to occur in intermittent and ty- phoid fevers, but in the cases described the existence of an ulcer is not excluded.* 2. Active hypercemia. An example of this is found in the fre- quently quoted case of Watson,f concerning a woman who ever since her fourteenth year had gastric haemorrhage instead of men- struating, which after her marriage only ceased during pregnancy and lactation, and then became vicarious as before. The following case, which came under my observation, must also be considered among the active hyperaemias: The patient was a married woman, who again became pregnant after having already borne two children, the younger of which was one year old. One evening, in order to bring about a miscarriage, she drank a hot decoction consisting of a bottle of claret, chamomile flowers, juniper berries, and some powerful aromatics, and also took a vaginal injection of soap-water. During the night, while nursing the baby, she suddenly fainted, and vomited large quantities of fresh blood. This was followed by rectal tenesmus and the evacuation of bloody masses. The haemateme- sis recurred twice during the next three days. Although she was greatly prostrated, she made an excellent recovery under appropriate treatment. Strange to say, she did not abort. No gastric symptoms occurred during the following three years. Here, too, the haemorrhages in severe chronic glandular gastritis are to be included, which probably may be regarded as analogous to the bleeding in chronic catarrh of the nose and pharynx. Usu- ally they are so slight that they do not cause vomiting of blood. Finally, we may also include the rarer haematemesis in hysterical subjects, in cholera, yellow fever, scurvy, purpura haemorrhagica, helminthiasis, malaria, and exanthemata, so far as the haemorrhage is * M. Weiss. Magenblutungen bei Typhus abdominalis. Wiener med. Pressei 1887, No. 12.—Millard. L'Union Med.," 1877, No. 12.—Reimer. Jahrb. fiir Kin- derheilkunde, Neue Folge, Bd. x, p. 39. t Cited by Budd, loc. cit, p. 364. DIAGNOSIS OF H^IMATEMESIS. 427 not dependent upon direct lesions to the vessels, or upon changes in their walls. But large haemorrhages undoubtedly occur in the stomach, in which no changes in the blood-vessels can be found. In 1891 a young man, twenty-four years old, was admitted to the medi- cal division of the Augusta Hospital; he complained of moderate dyspep- tic symptoms; there was no fever, vomiting, or sign of a severe acute or chronic disease. On the third day he went into collapse with all the symptoms of internal haemorrhage. At the autopsy the stomach was found distended with fresh and partly coagulated blood, but the most careful examination of the entire digestive tract failed to reveal any cause for the bleeding. Hepatic cirrhosis, typhoid fever, or any general disease which might be associated with the haemorrhage was not present, and hence by exclusion the diagnosis of "parenchymatous" haemorrhage was made. Likewise the diagnosis of the following case is doubtful at least, in spite of repeated haemorrhages, although in my opinion the occurrence of capillary or parenchymatous haemorrhage is the most plausible. The patient was a man, sixty-seven years old, in very good circum- stances, and of a strong and vigorous constitution, who had come to Berlin for consultation on account of severe haematemesis which had occurred a short time previous. His physician wrote : " On January 25, 1890, I was suddenly called to see Mr. Q. on account of severe cardialgia, for which he wished a hypodermic injection of morphine. The latter at once stopped the pain, but be vomited acid stomach contents. In the evening there was coffee-ground vomit; on the next day over a litre of dark, fluid blood was raised. There was no fever ; the pulse was 110 ; systolic mur- mur heard over the cardiac area. On the next day haematemesis occurred once; then the patient recovered so rapidly that he was scarcely a week in bed, and went out riding on February 2d. Soon after, the patient's appearance was excellent. Exactly one year previous he had had similar attacks of profuse haematemesis; went to Carlsbad and Baden Baden, and was perfectly well and exceptionally strong during the whole year of 1889. Every time the bleeding occurred while the patient was per- fectly well after too great exertions, and each time was immediately followed by months of health. There are no alcoholic excesses, but his work is excessive and irregular." On February 14, 1890,1 examined bim and was unable to make a posi- tive diagnosis, for nothing was found except a systolic murmur at the apex of the heart. In my case book I entered the diagnosis ulcer (?) or varicosities (?). At my request his physician sent me the following report on January 3, 1893: ''Since his visit to you the patient has had a number of similar attacks of bleeding without his general condition being in any way 428 DISEASES OF THE STOMACH. affected by them. This is all the more remarkable because he is very reckless. A trip to Italy and back within a fortnight in midwinter is a mere trifle to him. He is now seventy years old, and is apparently in good physical and mental condition. The only restraint he places upon himself is a proper diet and abstinence from alcohol." Hood* has repeatedly observed such haemorrhages with rapid recovery in young anaemic girls and women, without a typical his- tory or symptoms of ulcer. He describes several excellent exam- ples of this kind. In looking over my records I can also find a number of cases which I had diagnosticated as haemorrhage from ulcers, but the histories of which are so little characteristic of ulcer that they may also be interpreted from this standpoint of Hood, provided we accept his views as correct. These cases occurred in anaemic women from eighteen to thirty years old. 3. Direct traumatisms. Hafner f reports the case of a boy who half an hour after a fall from a considerable height on hard ground, without apparent external injury, repeatedly vomited blood, and had bloody stools. The swallowing of pointed objects, and even severe vomiting itself, without any further injury, may lead to gastric haemorrhage. Pointed bodies which have been swallowed may cause severe vomiting and haematemesis without causing any further injury to the stomach. Heilbrunn X reports a case in which blood was vomited after drinking a glass of beer; in the wash-water he found a sharp triangular piece of glass from the bottle, 1 ctm. [0*1 inch] long and 2 mm. [*08 inch] thick. The patient recovered. 4. Alterations in the walls of the blood-vessels. As yet nothing is known concerning the formation of varices or of atheromatous or amyloid degeneration of the gastric vessels, which might lead to haemorrhages. However, where a positive and extensive change in the vessels exists, as, for instance, in the atheroma of old persons, it does not, according to my experience, lead to gastric haemorrhage. As already stated, varicose veins occur in the cesophagus in old per- sons, and also, as stated by Letulle,* in confirmed drunkards; bleed- ing from these vessels may give rise to false haemorrhages from the * Loc. cit. f Cited by Henoch, p. 434. X Heilbrunn. Centralbl. fiir Chirurgie, 1891, No. 6. * Letulle. Varices veineuses de l'cesophage dans ralcoolisme. Jour, des societ. Scient., 1890. DIAGNOSIS OF HAEMATEMESIS. 429 stomach. This will coincide with the above-described haemorrhages in cirrhosis of the liver. I have found two cases reported by Gal- liard * as examples of the only disease which can be classed under this heading, in which small miliary aneurisms were the cause of rapidly fatal and very profuse gastric haemorrhage. Both patients were men, twenty-five and fifty-one years old respectively. Athe- roma, or other diseases of the general vascular system, were said not to be present. Additional cases have been reported by Sachs f and Welch; *}: in a man, fifty years of age, he found a raptured miliary aneurism on a branch of the gastric artery; it was situated in the submucosa, midway between the pylorus and cardia. It is apparent that the recognition of the cause of the haemor- rhage, the difficulties of which I have already discussed (page 407), necessitates different lines of treatment, and that it can not be an indifferent matter, either for the prognosis or the treatment, whether the haematemesis be due to a congestion, or an active hy- peraemia, or a destructive process acting on the mucous membrane. Here I wish to direct attention to an apparently secondary mat- ter, but which to-day plays an important role in the examination of the faeces. I refer to the use of water closets. Many patients, unless confined to bed, are unable to describe their dejecta, be- yond speaking of the vague impression that they are formed or otherwise, or that the quantity is large or normal or small, because they never see their stools. Therefore we can never be positive of a possible bloody evacuation, as well as of many other facts. A striking example of this is the following case quoted from my case book : A man, thirty-eight years old, had suffered for five years with stomach disturbances which at first manifested themselves only in a feeling of full- ness in the stomach after eating, occasional belching, and constipation. Strict diet and medication, together with the use of Carlsbad (Miihlbrun- nen) water, only gave slight relief. True cardialgia never present. One day, a year ago, he had abdominal pains and diarrhoea while at his office, necessitating his using the closet several times during the day. Toward evening he suddenly fainted, and was carried home half dead. He re- * Galliard. Alterations peu connues de la muqueuse de I'estomac. Gaz. d. hopit., 1884. p. 196. f Sachs, loc. cit. X Welch. Johns Hopkins Hospital Bulletin, No. 1. 430 DISEASES OF THE STOMACH mained in bed five weeks, and recovered slowly. Was quite well the fol- lowing summer, complaining only of slight gastric oppression. Now, for about eight weeks, he has had great difficulty, especially marked regurgi- tation and repeated vomiting some time after eating, chiclly during the night between ten and twelve and two and three o'clock. Relief after vomiting. He claims that there never was any blood in the vomit or faeces. Constipated. Feeling of fatigue marked. With the exception of slight sensitiveness on pressure nothing could be discovered either in the epigastrium, or to the right of this in the para- sternal line under the free border of the ribs. The acidity after the test breakfast was 84—i. e., hyperacidity was present. There can be no doubt that this was a case of gastric or duodenal ulcer, and that the apparent " diarrhoea " was the resulting profuse haemorrhage leading to fainting, for the other conditions causing haemorrhage from the bowels, such as tuberculosis, ulcers, diseases of the portal vein and of the liver, etc., could be excluded. Later on the patient remembered that he had seen blood on the closet paper. How often, however, may such haemorrhages occur wdthout coming to the knowledge of the patient or of the physician. Only a short time ago I had another case of this kind in which a man, suffering with gastralgia, after a short sojourn in Carlsbad, had two severe attacks of syncope, which, now that symptoms of a duodenal ulcer have become more plainly developed, can only be referred to severe internal intestinal haemorrhage. Considerable difficulty may arise in making a differential diag- nosis between hepatic and renal colic and gastralgia due to an ulcer at the pylorus or in the duodenum. Naturally, not in the typical cases of either disease. Just as positively as the complete list of symptoms given above shows the presence of an ulcer, we may es- tablish a diagnosis of hepatic colic if we find constantly recurring pain in the right hypochondrium independent of the ingestion of food, possibly mild febrile movements, jaundice, swelling of and pain over the liver, together with a gall bladder which may be pal- pated, possibly with gall-stones, shooting pains along the ureters, haematuria, and the passage of biliary or renal calculi. But very many cases occur in which the symptoms are so shifted about that we can scarcely avoid mistaking one for the other. If in cases of hepatic colic jaundice may frequently be absent or very slight, so, on the other hand, we not uncommonly find cases of gastralgia with DIAGNOSIS OF GASTRIC ULCER. 431 slight icterus, due perhaps to the convulsive contraction of the ab- dominal viscera forcing the bile into the blood, or perhaps because a very transient sympathetic spasm of the hepatic duct has caused a stagnation of the bile. Frequently, too, the patients refer the pain in hepatic colic more toward the mid-line, especially the case in women, in whom lacing has altered the topography of the liver. Should the pylorus be displaced somewhat toward the right, or should the ulcer lie in the horizontal portion of the duodenum, a local differentiation would be wholly out of the question. Thus we may remain in doubt for a long time, or indeed never decide whether we have to deal with hepatic colic or with gastralgia. Here, again, the presence of hyperacidity of the gastric contents offers us a val- uable diagnostic aid. Results in which the acidity amounts to more than 80—i. e., 0*3 per cent of hydrochloric acid—may be regarded as denoting this. Not only is the diagnosis of the existence of an ulcer to be es- tablished, but its site as well. This assertion has frequently been made, only lately even by Gerhardt. According to my conviction and experience, it is only possible in those cases in which the cir- cumstances are unusually favorable, that an ulcer situated at the py- lorus or in the duodenum, or perhaps on the greater curvature, may be made out. On the other hand, proceeding by exclusion, we may surmise that the site of the ulcer is elsewhere. In contrast to this, ulcer of the pylorus can be recognized by a sharply localized pain a little to the right of the middle line. But the element of time as a factor in the causation of the pain now leaves us in the lurch, and I find the assertion that ulcers in the cardiac portion of the stomach are accompanied by pain immediately after eating, while those at the pylorus only cause pain later, to be neither sufficiently proved clinically nor warranted under the circumstances. We really can not conceive, or at least we have no grounds for so doing, that the ingesta are retained at tfie cardia and only reach the pylorus after an appreciable interval. Attempts have also been made to locate the site of the ulcer by the position which some patients assume in order to ease the pain. If the pain is lessened when the patient lies on the left side, the ulcer is said to be situated on the lesser curva- ture, and vice versa. This, too, may be considered a doubtful and 432 DISEASES OF THE STOMACH unreliable symptom—the more so since the majority of patients have no such experience. If the site of the ulcer in the stomach were discovered, it would perhaps be of practical significance in pre- dicting the possible resulting conditions. According to Gerhardt,* " sensitiveness on pressure and a tumor " point " more toward the site being on the anterior wall, pain in the back and haemorrhage more to its being on the posterior wall. Ulcers in the regions of the fundus or the pylorus may often be distinguished by the loca- tion of the pain and by its increase in the lateral posture. Ulcers of the fundus which are adherent to the spleen may lead to chills, owing to splenitis, as I (Gerhardt) have seen in three cases." It need not be specially mentioned that dilatation of the stomach points to the site of the ulcer being at the pylorus or in the duodenum, and that contraction shows that it is at the cardia. However, if one con- siders how vague a symptom sensitiveness on pressure is ; how rare the occurrence of a tumor caused by an ulcer is in comparison with the total number of cases; how little we are able to establish the condition of contraction during life ; and if one will recall the case of perforation of a necrotic carcinoma of the lesser curvature accom- panied by chills, cited on page 335 ; and, finally, if one knows that frequently numerous ulcers are situated in different places, the un- reliability of these signs will be readily appreciated. Duodenal Ulcers.—All that has been said concerning the site of the ulcer in the stomach refers also to its position in the duodenum. In at least 90 per cent of the cases it is impossible to decide posi- tively whether we are dealing with a gastric or a duodenal ulcer; for the duodenum, and especially its horizontal portion, may for this purpose be really regarded as only a continuation or a portion of the stomach; and the ulcerative process is accompanied by the same phenomena in this case as it is in the other. Those factors which indicate an ulcer at the pylorus also speak for the duodenal ulcer, and the more so since the latter at times extends directly from the pylorus into the duodenum. A duodenal ulcer is probably present if the pain does not develop until some time after the in- gestion of food, if the position, together with sensitiveness on pres- Loc. cit. PROGNOSIS OF GASTRIC ULCER. 433 sure, is situated decidedly to the right of the parasternal line, and if possibly there are profuse bloody stools without any haematemesis. The fact that duodenal ulcers often appear after extensive cutaneous burns may in such cases be of service in diagnosis. A point of support, but no more, is offered by the rarer occurrence of ulcer of the duodenum. Thus Willigk reports only 6 duodenal ulcers to 225 in the stomach, and Trier places the figures at 28 to 261. Yet even in this small percentage a number of cases are included in which ulcers existed in the stomach and duodenum at the same time. Gastralgia is said to be less common because, as Budd be- lieves, the duodenum is not subjected to as much traction and change of position as the stomach. Moreover, the very uncommon appearance of jaundice can be of no more aid in diagnosis than the circumstance that, on the whole, intestinal haemorrhages are more frequent here than haematemesis, for we find that ulcer of the stomach also leads to the former, and that duodenal ulcer is also accompanied by the latter. Oppenheimer * reports a case in which Leube made the diagnosis. An absolutely certain case of this kind I have had reported by Keckmann.f Prognosis.—Till within a short time it was customary and proper to give a doubtful prognosis in cases of gastric ulcer, when the diag- nosis could only be made by the established symptoms. But now, since we are able to recognize its early stages, and to differentiate it from other dyspepsias, since the principles of treatment have be- come apparent to us, and we are in the position to apply them at the commencement of the process, the prognosis has become essen- tially better so far as the early stages of the ulcer are concerned. We may now, if the patients subject themselves to a rational course of treatment—i. e., the rest cure—at the proper time, give them well-grounded prospects of recovery ; and even in cases of classical ulcer we may hope for cure or for decided improvement. It is to be regretted that during the earliest stages, which are not very troublesome subjectively, very few patients are either willing or in the position to subject themselves to a course of treatment which is * H. Oppenheimer. Das ulcus pepticum duodenale. Inaug. Dissert., Wiirz- burg, 1891. f Reckmann. Inaug. Dissert., Berlin, 1893. 434 DISEASES OF THE STOMACH. always exacting. However, if we succeed in permanently remedy- ing the anomalies in the composition of the blood or the secretion of gastric juice, we lessen the danger of relapses, which otherwise always threaten us, and only too often appear. But the conse- quences of traction by the cicatrices, especially after the healing of extensive ulcers, always remain to be feared, as well as the accom- panying permanent impairment of the general health which can not be remedied. In such cases, therefore, the prognosis must always be made with great care. But that it is nevertheless not a poor one can be deduced from the well-known fact that the scars of gastric ulcers are found about twice as often as the ulcers themselves. In haemorrhage, if this is not immediately fatal, the prognosis is on the whole favorable. As a rule we are able to control the bleeding by means of appropriate treatment, and even to remedy extreme anaemia in a relatively short time. Treatment.—I know but one form of treatment which holds out prospects of success, and which, if applied in the early stages, can show excellent results. This is the rest cure introduced into Ger- many by Von Ziemssen * and Leube,f by which the stomach is pro- tected from all irritating factors, as a broken bone is immobilized in plaster, with of course the difference that, while this is absolute in the latter instance, it can only be approximately attained in the former. The principle of this treatment, long since recommended in England by Wilson Fox and Balthazar Forster,*}; consists of rest in bed and rectal alimentation, with such nourishment as will cause the stomach the least trouble. As adjuvants we have moist heat in the form of external applications, which quiet the pain [except when there is bleeding] and at the same time diminish the irrita- tion ; and, internally, a course of hot Carlsbad water or a solution of Carlsbad salts. I could quote a large number of cases either cured with surpris- ing rapidity and safety by this method, or at least freed for a long time from all difficulties, but the following will suffice: In October, 1888, I was called in consultation to see Mrs. Fr., aged * Ziemssen. Ueber die Behandlung des Magengeschwiirs. Volkmann's Samml. klin. Vortrage, No. 15. f Leube. Magenkrankheiten, S. 117. X Loc. cit, p. 944. TREATMENT OF GASTRIC ULCER. 435 thirty-seven, a widow who supported her children by working on the machine as seamstress. Typical history of ulcer, haematemesis, gastralgia. Severe pain after each meal, and also at times during the night and morning on an empty stomach. Dieted strictly and lost much flesh. Appeared pale and miserable. Pain on pressure in the epigastrium. No tumor. Abdominal walls soft, strong muscular contraction occurring only on making pressure at the spot mentioned. No floating kidney. Urine negative. Patient treated till the middle of January, 1889, with internal medica- tion—nitrate of silver, bismuth with ext. hyoscyam. and morphine, tinct. opii, etc.—but without success. At last, on January 14th, she applied for admittance at the Augusta Hospital. The typical ulcer cure was insti- tuted, and the patient was treated in the manner soon to be described. Her troubles were rapidly lessened, and then ceased entirely. The sensi- tiveness at the pit of the stomach—a point on which I always lay great stress—disappeared, and on the 20th of February, that is, after six weeks, the patient was discharged cured. Inasmuch as she was very foolish regarding her diet, and during her convalescence took more than was allowed her, and as this propensity was responsible for a renewed attack of gastralgia at about the middle of the treatment, we can really say that she gave us still stronger proof of her recovery. She has also remained free from relapses up to the time of her last report. However, I dare not conceal the fact that such a prompt cure does not always result, and that I have also had cases which as long as they were taking the treatment felt very well, but as soon as they returned to their daily life, even if with all precautions, suffered from fresh attacks and the return of the old difficulties. Neverthe- less, these have always been in the minority. Leube emphasizes the fact that the composition of the Carlsbad salt is both neutralizing and, owing to the sodium chloride which it contains, stimulating in its action; but as we know that the acid- ity is increased in the majority of cases, the latter property may be regarded more as a disadvantage. Depression rather than stimu- lation is indicated. Neither can I ascribe very much importance to the neutralization or diminution of the acidity if this be done but once, and then in a stomach containing no food, which, unless there is continuous secretion (hypersecretion), is therefore empty. The essential indications seem rather to be the reduction of the hyper- secretion by means of neutral salts, as already surmised by Pember- ton and directly proved by Jaworski,* and in the sedative action * Jaworski. Ueber Wirkung, therapeutischer Werthe und Gebrauch des neuen Carlsbader Quellsalzes. Wiener med. Wochenschr., 6-16, 1886. 436 DISEASES OP THE STOMACH. of large quantities of warm water; * and, finally, in the laxative effects of the neutral salts. If the action of the waters of the simple alkaline springs has been found to be less effective than that of the alkaline saline, it is probably due to the failure of supplying the laxative effects by other means. Where this laxative action is absent, as is frequently the case in the Carlsbad waters, we must produce it by the addition of Glau- ber's salt, or, better, by means of vegetable cathartics, preferably rhubarb or senna in watery infusion. Moreover, it is not necessary for us to adhere too narrow-mindedly to one standard; our watch- word is necessity. It is immaterial whether we relieve the pain by hot fomentations, or, if these be ineffectual, by subcutaneous injec- tions of morphine; whether wre give the patient a solution of Spru- del salt or the natural Carlsbad spring water, or that of an effer- vescing soda spring, such as Ems, or Vichy, or Xeuenahr, and sup- ply the laxative action missing in these waters by means of other aperients. We give 300 to 500 c. c. [f ^ x to Oj] of Carlsbad water. It is immaterial from which spring it comes, because there are no essential differences in their chemical composition, while the differences of temperature existing in the wraters of the individual hot springs may be disregarded, for they are always taken only as hot as the patient can bear them ; in other words, at about the same temperature. Of the salt about 15 grammes [one table- spoonful] are dissolved in one half litre [one pint] of [hot] water. This is taken as at the "cure"—i. e., small swallows at short in- tervals. For the first three days I give the patients absolutely no food, and allow them only a nutritive enema three times daily. Then feeding by the mouth is commenced wTith small quantities of milk f and gruels; later on I give leguminous soups, then leguminous vegetables and potatoes in the form of a puree, to which small * [Oser cautions against giving too great amounts of water or anything producing large quantities of gas,'on account of the danger of distending the walls of the stomach and thus opening the ulcer. However, this seems to be theoretical rather than practical.—Ed.] f Cruveilhier was the first to recommend the milk diet. Gruels cooked with milk are preferable to pure milk, because the casein coagulates more flocculently than it does in pure milk. TREATMENT OF GASTRIC ULCER. 437 quantities of meat-broth are added later; also rice [stewed], chestnuts, sago, tapioca, and the like. Later on we may allow raw or lightly boiled eggs, meat solution, calves' brain, finely scraped cold ham, white breast-meat of game or tender saddle of venison, etc. It is to be regretted that milk, the neutralizing action of which on acids is well known, and which has also recently been demonstrated by Leo and Yon Pfungen, is so badly borne by many persons, no matter whether we add sodium bicarbonate, lime water whisky, coffee, etc. In a number of such cases peptonized milk, the taste of which has been corrected with sweet cream, can be tolerated. De Bove* recommends meat powder to which an alkali has been added. Only in the third week is a quantitatively and qualitatively ampler diet permitted, but always with the view of sparing the stomach as much as possible. We must of course individualize, for the patients undoubtedly lose flesh on this diet; but they recover rapidly, the gastralgic attacks remain absent, and now is the time to meet the second indication, to improve the gen- eral condition, f* For this purpose we use the iron preparations, either alone or in combination with arsenic. The former are indicated in cases of pure chlorosis or anaemia, the latter if we have to deal with an en- feebled nervous system and we wrish to exert an indirect action upon it by direct stimulation of metabolism. The scruples formerly existing against the use of iron in cases of gastric ulcer were caused by the experience that this drug is often poorly borne as long as an active process is going on ; but they are not justified as soon as recovery has commenced and is well under way. I can at least fully concur in the experiences which Te Gempt X has published on this subject. He uses Drees's liquor ferri albumin., which, as is well known, is a preparation made by treating albumen with chlo- * Quoted by Matthieu. Ulcere de I'estomac. Gaz. des hopital, 1892, No. 99. t [Da Costa reports three cases of gastric ulcer which he treated successfully with ice cream ad libitum. The ice cream must contain no corn starch or other substances employed for thickening purposes, and it must not be over twenty-four hours old. Medical News, August 8, 1891, p. 155.—Ed.] X Te Gempt. Ueber Behandlung des runden Magengeschwiirs mit Eisenalbu- minat. Berl. klin. Wochenschr., 1886, S. 240. 438 DISEASES OF THE STOMACH. ride of iron, and which is expensive* Inasmuch as all we care for is to introduce the proper proportions of albumen and iron into the stomach, so as to produce an absorbable peptonate of iron, and inasmuch as we know that the power of forming peptones is not extinguished in ulcer of the stomach, I prescribe this medica- ment in a simpler and less expensive manner. I order three times daily a teaspoonful of a 2 to 3 per cent solution of ferri sesquichlor. (Ph. Ger.) [ferri chloridum, U. S. P.] to be added to a wineglassful of egg-water (one part of white of egg to two parts of water) and taken through a glass tube in order to spare the teeth. The ad- vantages of the chloride of iron, as one of the mildest and most easily assimilable preparations of iron, have been extolled by many; with these I also wish to join. However, it is well known that every one has a favorite iron preparation, and if one has more con- fidence in any other and gets good results with it, its use ought not to be discontinued ; for success does not depend upon the prepara- tion, but upon its assimilation, and especially upon its action on the blood. I formerly gave arsenic in the form of Fowler's solution, together with tinct. ferri chlor. According to Liebreich's brilliant investigations, arsenious acid appears to be more effective, and I prescribe it in pills containing 2 milligrammes [gr. ^] of arsenious acid and 2 centigrammes [gr. -J-] of ferri sesquichlor. [Ph. Ger.] Much smaller but decidedly efficacious (as shown by metabolic in- vestigations made by Dronke and myself f) doses of iron and arsenic may be administered with the waters of Levico and Ron- cegno, which are usually well borne.*}: It is advisable to employ in- creasing doses, and to give the drugs after meals. This regimen must be continued for months, during which the use of arsenic is to be discontinued for three to five days every three weeks. The combined use of arsenic and iron may thus be continued for a long time, if we employ the caution of giving the arsenic in increasing and then diminishing doses, say from 3 to 10 pills (!) a day. The diet may gradually become more generous, but must nevertheless * [Dietterich's peptonate of iron and Gude's peptomanganate of iron are more common in this country.—Ed.] t Ewald und Dronke. Berl. klin. Wochenschr., 1892, No. 19 und 20. X [The dose of these waters is to begin with one teaspoonful and increase gradu- ally to one or two tablespoonfuls.—Ed.] TREATMENT OF GASTRIC ULCER. 439 be strictly regulated for months; and those patients who tend to excesses must be made to adhere rigidly to a written bill of fare and a certain allowance of food. This treatment brilliantly confirms the remark of Leube, that " the treatment of gastric ulcer remains a thankful task to the phy- sician because the cures form by far the greater majority of the therapeutic results, if we include those cases in which the patients are freed from all difficulties for a long time, and have relapses only later on " ; * and also, " I am convinced that the more strictly the dietetic directions are carried out at the bedside, the more will the unpleasant medicinal treatment of ulcer of the stomach dwindle away." However, the latter is nevertheless indispensable : first, because there are very many patients who are unwilling or unable to sub- ject themselves to such a " cure" ; secondly, because there are many cases which present urgent symptomatic indications which must be met immediately. Bismuth has enjoyed a very great reputation ever since it was first recommended by Odier, of Geneva, although we have never been sure of its mode of action, as is shown by the great variations in its dosage, from 0*1 gramme [gr. jss.] up to 15 grammes [ 3 ss.]. Given by Odier " enterieurement comme antispasmodique," it was used later, for instance by the English school, for the purpose of remedying an " undue secretion." In our day the remarkable sup- position is frequently advanced that the comparatively diminutive amount of the preparation introduced into the stomach selects the surface of the ulcer on which to deposit itself and form a protective covering. Since we give it chiefly in doses of 0*5 gramme [gr. vijss.] together with 5 to 10 milligrammes [gr. TV to \] of morphine, it can not be said how much of the possible action is to be ascribed to the latter. To me the French method appears to be the most ra- tional, in which large doses, 10 to 15 grammes [ 3 ijss. to 1 ss.], are given suspended in water. However, on account of the expense this is a line of treatment not applicable to all. But bismuth has been successfully used by so many excellent * Leube. Magenkrankheiten, S. 113. 29 440 DISEASES OF TnE STOMACH. practitioners, especially in cases of gastralgia—Budd recommends it just "in gastralgia with increased secretion of the gastric acid" —that all possibilities of illusion seem to be excluded. Neverthe- less, the question whether it possesses a specific action, or whether it can not be just as well replaced by some other preparation of a poorly soluble alkaline salt—e. g., bicarbonate of calcium—must still remain undecided. [The use of very large doses of bismuth has been recommended by Fleiner,* especially for the treatment of ambulatory cases of gastric ulcer. The technique is as follows: 10-20 grammes [ § i-f ] of bismuth subnitrate are suspended in 200 c. c. [f I vjf ] of luke- warm water. This is introduced into the stomach in the early morning after having washed out the viscus, if necessary. Fleiner advises that the bismuth mixture be introduced through the tube; this is, however, not essential, as equally good results may be ob- tained without it. Sixty c. c. [f 5 ij] water are either drank or poured in through the tube to wash down any of the bismuth which may have adhered in its passage to the stomach. The patient then lies down for half an hour in the position in which the bismuth may deposit itself upon the ulcer. Fleiner states that it takes 5 to 6 min- utes for the bismuth to be deposited upon the mucous membrane. The bismuth acts mechanically in protecting the eroded mucosa and in lessening the irritation of the exposed nerve endings, and it also is an antiseptic. A special diet is not absolutely necessary, neither is the patient confined to bed, but he may go about and attend to his ordinary duties. Fleiner has reported excellent results, which have been corrobo- rated by Rosenheim,! Matthes,:}: Savelieff,* Cramer, || and others. I have been well satisfied with the results which I have obtained in a number of cases of ulcer; it has also been serviceable in some cases of obstinate gastralgia. I have not used the tube ; neither have I * [Fleiner. Verhandlung. des Congresses fiir innere Med., 1893.—Ed.] t [Rosenheim. Berliner Klinik, 1894, Heft 71, p. 15.—Ed.] X [Matthes. Centralbl. fiir klin. Med., 1894, No. 1.—Ed.] * [Savelieff. Therapeut. Monatshefte, October, 1894, p. 485. This paper con- tains full bibliography.^ED.] | Cramer. Miinch. med. Wochenschr., June 23, 1896.—Ed.] TREATMENT OF GASTRIC ULCER. 44! withdrawn the supernatant fluid, as recommended by Fleiner. It is surprising how tenaciously the bismuth adheres to the mucous membrane; thus, if the stomach is washed 30 minutes after 15 grammes [ I ss.] have been introduced, and the bismuth which is obtained in the wash-water is filtered out, but 1*5 to 2 grammes [gr. xvij-xxx] can be obtained. If good preparations of bismuth are used, no poisonous effects will be observed. My results agree with all those which have thus far been reported in the absence of all toxic effects. In several cases in which I have given 15 grammes [ I ss.] daily for several weeks, no bad effects were observed from these large doses. Neither need there be any fear of enteroliths from these large doses. Con- stipation is sometimes observed; if it occur, large oil enemata will relieve it. In some cases I have even observed diarrhoea. Savelieff also noted the absence of constipation, and states that it disappeared, if present, during the treatment. The treatment is not to be employed in acute cases, but is to be reserved for the subacute or chronic forms.] Ord * very highly recommends potassium iodide combined with sodium bicarbonate for the catarrh which accompanies gastric ulcer. It may be used thus: $ Potass, iodidi............ 2*0 [gr. xxx] Sodii bicarbonatis........ 5*0 [gr. Ixxv] Acid, hydrocyan. dil...... gtt. iij Inf. rad. gentian......... 3*0 :150*0 [gr. xlv: f § v] M. Sig.: One tablespoonful three times daily. What I have said of bismuth will almost apply to nitrate of silver. Here, too, we are entirely in the dark as to its mode of action, for, as Leube has said, we can scarcely believe in a direct local action of the small doses—0*01 gramme [gr. £]—of nitrate of silver, and it is no more possible that any effective combination with an acid can be formed by it. Notwithstanding this, we also have weighty evidence (I will only mention Gerhardt) in favor of the effectiveness of the drug. In a few cases I have obtained de- cided but also only transient relief of the difficulties with a solution * W. Ord. Gastric Ulcer. American Jour. Med. Sciences, June, 1889. 442 DISEASES OF THE STOMACH. of 0*2 [gr. iij] argent, nitrat. in 150 [f I v] of water, taken every two hours; while in other cases I had to discontinue the drug after it had been used a few times, because increased discomfort in the stomach, nausea, anorexia, coated tongue, and also constipation ap- peared. On the other hand, in one of my cases I had to discard it because just the reverse occurred—namely, watery evacuations always followed almost immediately after taking it. [Boas * praises nitrate of silver very highly, especially in mild cases or in patients who can not undertake a rest cure. He begins with gr. iv to f I iv of water (I ss. t.i.d.), and gradually increases it to gr. vj to f I iv of water.] [Rankin f has reported ten cases in which good results were ob- tained from a combination of pepsin, iron, and cannabis indica, given combined in pill form. On the other hand, Grote *}: has recently published the results of his experiments with papain; he found that this substance was not well borne, and increased the pain in hyper- acidity and ulcerative processes in the stomach.] In my opinion, the dietetic principles given above are also the most serviceable in the treatment of ambulatory cases, and we must endeavor to carry them out, at least as far as the diet is concerned, as fully as possible. Here we must give special consideration to milk. Moreover, I try to blunt the hyperacid gastric juice by the hourly exhibition of small doses of an alkali combined with rhu- barb and cane or milk sugar. The rhubarb acts mildly on the bowels, while the sugar has a decided anodyne action, on account of which it has frequently been recommended. I have seen fairly good results from the following powder : Ijjfc Magnesiae ustae, Sodii carbonatis, Potass, carbonatis...........aa 5*0 [ 3 j gr. xv] Pulv. rad. rhei............. 10*0 [ 3 ijss.] Sacch. lactis............... 25*0 [ 3 vj gr. xv] M. Sig.: A large pinch, dry on the tongue, every hour. Morphine, either by the mouth or subcutaneously, stands first * [Boas. Op. cit, p. 60.—Ed.] + [Rankin. Lancet, February 9, 1895.—Ed.] X [Grote. Deutsch. med. Wochenschr., July 23, 1896, p. 474—Ed.] TREATMENT OF GASTRIC ULCER. 443 for the rehef of severe gastralgia. Solutions of chloroform (1:120, 3 ss. every two hours) have at times an excellent effect, not only on the temporary pain, but altogether on the course of the process. [Stcpp * highly recommends the use of Iji Chloroformi purificati.............. 1-0 [Tftxv] Bismuth, subnitratis................ 3-0 [gr. xlv] Aquae............................ 150*0 [f 5 v] M. Sig. : Tablespoonful, well diluted, every hour.] Among the remaining anodynes I have frequently used lupulin, ext. cannabis indie, ext. hyoscyam., and belladonna experimentally, but I have always been obliged to return to morphine. I have been especially dissatisfied with cannabis indica, which has been so highly lauded by Germain See ; not alone did I repeatedly fail to obtain any analgesic or quieting effects, but, on the contrary, unpleasant con- ditions of excitement [see page 244]. I have no personal experi- ence with strontium bromide, which has been highly praised by the same writer for its good effects in hyperchlorhydria. f [Atropine has also been recommended for the latter purpose ; it may be given in doses of gr. ^ three times daily.] X Formerly leeches were frequently applied over the affected site ; blisters and even the cautery were used. Ice-bags will suffice, or ice-cold or warm applications, or Leiter's coil, which, where circum- stances allow it, is the cleanest and most comfortable way of apply- ing cold. Nothing is more serviceable in vomiting than a carefully regu- lated diet. We may allow the patients to drink large quantities of warm water several times during the day, and also give them pieces of ice with chloroform; but as the vomiting usually ceases with the gastralgia, it is met by the treatment of the latter. Special care is required in haematemesis, not only, as is self- evident, when it is profuse, but also when the haemorrhages are smaller. The first indication under all circumstances is absolute physical and mental rest, and the avoidance of all internal and ex- * [Stepp. Therapeut. Monatshefte, November, 1893, p. 540.—Ed.] f G. See. Sur Faction du bromurede strontium dans les affections de l'estomac. Bullet, de l'Acad. franc.. 1891, No. 42. X [Therapeut. Monatshefte, 1895, p. 384.—Ed.] 444 DISEASES OF THE STOMACH. ternal irritation to the stomach. Even in the smaller haemor- rhages, since they frequently are precursors of larger ones, the pa- tients, if circumstances will permit, ought to subject themselves to this regimen for several days, and the entire plan of treatment should be carried out. We may give small pieces of ice, or table- spoonfuls of ice-cold tea or ice-cold fluid peptone solutions. In the cases in which it is not known whether the patients take milk well, I do not give it, but instead I prescribe for the first day a solution of grape sugar, which is replaced by some bouillon made of meat- peptones taken very cold, or cold thin gruels made of barley or oat- meal. Where it is possible, I order nutritive enemata, which must be given with care. Several times during the day I inject one or two syringefuls * of the following into the region of the stomach: ~fy Ext. seealis cornuti [Ph. Ger.]. .. 2*5 [gr. xxxvij] Glycerini, Aquae......................aa 5*0 [f 3 j TTlxv]. M. [See page 369.] However, I must add that in some persons ergo- tin causes very unpleasant symptoms of oppression and dizziness. I have never been able to convince myself of the reliability of the fluid extracts of hydrastis canadensis or hamamelis virginica. In case the patients are much excited, morphine may be added to this in- jection. As a rule, the haemorrhages, unless they come from too large a vessel, are controlled by this. Formerly, remedies which have the reputation of being styptics, like acetate of lead, chloride of iron, and oil of turpentine, were given internally ; but we do not use them now, since we have a much more effective and rational remedy in ergot. In two of my cases, haemorrhages which recurred repeatedly for several days in spite of the means above mentioned were checked with washing out the stomach with ice water. After preliminary cocainization of the fauces and a small hypodermic injection of mor- phine, the soft tube was carefully introduced and the stomach was washed out a number of times with ice water, when the haemor- rhage at once ceased. In one of these cases this was successfully repeated three times in the course of a few weeks; in the second * [Pravaz syringe ; holds one gramme.—Ed.] TREATMENT OF GASTRIC ULCER. 445 and third haemorrhages this treatment was at once applied. [This treatment has also been highly praised by Minkowski. Operations have also been performed on account of haemorrhage from the stom- ach. This was first done by Mikulicz,* without success, however. Subsequently Kuster f was successful in two cases.] As most of the blood passes on into the intestines and decom- poses there, irritation may be caused there; hence, if there are no spontaneous stools, mild aperients, preferably rhubarb with sulphur, should be given. Should symptoms of collapse appear, we may give hypodermic injections of camphor and ether (1: 6), or enemata of wine or wine and egg or peptone, and also hot applications to the extremities. In threatened death from haemorrhage, with very small pulse, anaemic murmurs heard over the heart, and cerebral anaemia, we proceed to transfusion of blood or infusion of salt solution. The advantages of these two methods have been extensively discussed, but they have not yet been finally decided, although lately there is an increase in the number of cases successfully treated by salt infu- sion. X The best method is subcutaneous infusion with a large can- nula [which is attached to the tube of an ordinary fountain syringe]. The salt solution [0*4 to 0*6 per cent] is heated to the temperature of the body and is allowed to run in simultaneously through two cannulas ; gentle massage being employed, a litre of water can be infused in a short time. I prefer the subclavicular region as the site of the infusion. In favorable cases the blood regenerates quite rapidly. In a twenty-five-year-old patient I found the number of red cells to be 2,100,000 on the day after the infusion ; two weeks later it was 3,560,000, with a slight leucocytosis. Peritonitis due to perforation demands the exhibition of large doses of opium, best given in suppositories or enemata, and also the * [Mikulicz. Verhandlungen d. deutsch. Gesellsch. f. Chir., 1887, p. 337.—Ed.] t [Kuster. Ibid., 1894 ; Centralbl. f. Chir., 1894, No. 51.—Ed.] X For instance, Michaelis, Heftige Magenblutung nach einer Magenausspiilung (wahrscheinlich bei Ulcus). Erfolgreiche Kochsalztransfusion. Berl. klin. Woch- enschr., 1884, No. 25.—I myself have seen three cases of subcutaneous salt-water infusion, in all of which the hematemesis had lasted till the patient was pulseless. All three women, aged twenty-six, nineteen, and twenty-three years, respectively, recovered quite rapidly. 446 DISEASES OF THE STOMACH. use of ice-cold applications to the abdomen. If doubt exists whether the stomach be full, an attempt may be made to empty it by means of the stomach tube, after the patient has as far as possible been rendered incapable of reaction by means of a large dose of mor- phine or by the local application of cocaine. But under all circum- stances we must prevent every attempt at gagging and choking, since this may lead to the enlargement of the perforation. At times this treatment has succeeded in keeping the peritonitis local- ized and causing adhesions.* Laparotomy has been proposed for the cases of perforations, and a successful one has been reported by Parsons, f [Recently many operations have been reported, especially by English surgeons, in cases of acute perforation of gastric ulcers. In an excellent paper, Weir and Foote X have collected and analyzed 78 cases of laparotomy performed for this purpose, and also 9 lapa- rotomies for acute perforation of duodenal ulcers. The average mortality was 71 per cent; great differences, however, were found, according to the time which had elapsed between perforation and operation. Thus the mortality of 23 cases operated within twelve hours was only 39 per cent; while in 17 cases operated within twelve to twenty-four hours it was 76 per cent; and in 32 cases operated after twenty-four hours it was 87 per cent. Successful excisions of ulcers have also been reported by Czerny, Cordua, Keen, Lange, and others.*] Finally, I wish to add my views of the treatment at the mineral springs. For years the hot Glauber salt springs, especially those in Carls- bad, have enjoyed the established and undeniable reputation that the treatment of ulcer there is crowned by excellent results. We can not assert, as we can in other affections and concerning other * Such cases, which were verified by the subsequent perforation of a second ulcer and post-mortem examination, have been reported, for instance, by Hughes, Hilton, and Ray, Guy's Hosp. Rep., vol. iv, and by Bennett, Clinical Medicine, p. 487.— [See page 415.—Ed.] | Parsons. Dublin Med. Jour.. July, 1892. X [Weir and Foote. Medical News, April 25, 1896, contains full bibliography. See also Barling. Brit. Med. Journal, June 15, 1896.—Ed.] * [Weir and Foote. Loc. cit, May 2, 1895, p. 489.—Ed.] TREATMENT OF GASTRIC ULCER. 447 places, that these results would have appeared in spite of Carlsbad; nevertheless, it is my opinion that the same or perhaps more rapid effects would have been obtained in those cases had they taken the rest cure at home, and if after its completion they had sojourned in an invigorating climate under a tonic regimen. For the adjuncts of the medicinal springs—pure air, diversion, and beautiful scenery —which are frequently so effectual, are not requisite in the treat- ment of gastric ulcer. Rest and effective local treatment are the things needed, and these can be had much better at home than any- where else. There is always time, after the disturbances of the digestive apparatus have been quelled, for the patients to seek gen- eral strengthening and invigoration by a stay at Franzensbad, El- ster, Rippoldsau, Pyrmont, etc., in the mountains, or at the sea- shore, but always with the proviso that they are able to procure suitable food, preferably by having the family cook its own meals, In this regard the places along the Baltic are to be recommended, as all opportunities for keeping one's own house are there offered. But very many patients much prefer to go to the baths or springs than to lie in bed at home, and many, too, can devote only from four to six weeks to the treatment; for these Carlsbad is the best place, if for no other reason than that opportunities for dietetic errors are practically excluded there. After Carlsbad, Neuenahr, Ems, Franz- ensbad, and Homburg can be recommended. CHAPTER IX. THE NEUROSES OF THE STOMACH.—THE PHYSIOLOGICAL RELATIONS OF THE STOMACH. Before entering upon the many-sided and uncertain province of the nervous disorders of the stomach, I desire to preface the little which we positively know of the innervation of the stomach. My brother, Dr. R. Ewald, Professor of Physiology at Stras- burg, has written the following chapter at my request, and for this I desire to give him my heartiest thanks.* THE INNERVATION OF THE STOMACH. It was an epoch-making advance when the old vital forces were dethroned and only physical (and also using it in its broadest sense, chemical) manifestations were allowed to explain the operations of the organism. The physical methods of research were adopted and the vital processes were placed on a corresponding basis. This was the first step which absolved physiology from its long bondage as a subordinate part of anatomy and elevated it to an independent science. But the fond hopes which were placed on purely physical explanations even up to a few decades ago have since been proved to be unattainable, and the inevitable reaction has set in after we had in vain waited for the solution of all problems by physical sci- ence. Not that there was a reaction to the old vital forces; not that every attempt at an explanation was rejected in despair; but experimenters beeame convinced that in many, in fact in nearly all the better known phenomena the physical laws did not suffice to give a clear explanation of the mysterious vital phenomena. Un- * [The form in which the following chapter is presented precludes any attempts at revision. Instead, I would refer the reader to the last edition of Foster's Physiology.—Ed.] 448 RELATIONS OF THE STOMACH TO THE NERVOUS SYSTEM. 449 fortunately, we are now nearly everywhere compelled to assume a specific yet absolutely unknown activity of the living, cell. This reaction was very beneficial; it unmasked an apparent knowledge, and brought us nearer to a true understanding of Nature; and even if we must finally admit a mechanical basis, yet we are still infinitely remote from the goal of all natural science. That we can only reach this goal by extending our knowledge of the vital phenomena in the individual cells, is the advance which has resulted from the reaction against purely physical speculations. The same conceptions which elevated physiology to an independent science would merely have converted it into physics and chemistry as applied to vital phenom- ena. Now, however, its character as an independent science is for- ever preserved. While, on the one hand, the activity of the cells can be more and more distinctly differentiated from the processes which we have heretofore considered physical, on the other hand we are compelled to accord to the phenomena of cell life an always greater autonomy —i. e., independence of the nervous system. The nerves regulate the cellular activity, and cause them to act at the right time and with the proper energy ; but in many cases this regulation may be absent without stopping the true activity of the cells. I shall now endeavor to show how far these peculiarities and independence of the cellular phenomenon are concerned in the in- nervation of the stomach. The General Relations of the Functions of the Stomach and the Nervous System.—The functions of the stomach consist mainly of secretion, absorption, and motion. It was once thought that the activity of the glands could be explained by the purely mechanical processes of filtration and diffusion. The chemical and physical changes in the blood circulating about the glands, of which the physical were regulated by the nerves, seemed sufficient to explain why the secretion of one and the same gland may vary in strength and composition. Although Johannes Miiller had long ago called attention to the specific activity of the glandular cells, yet only recently was it posi- tively demonstrated that the mechanical processes of filtration and diffusion do not suffice to explain secretion, and that we must accept 450 DISEASES OF THE STOMACH the existence of a peculiar activity of the cells* Nerves may regu- late this cellular activity, yet secretion is unquestionably possible without them, and in this respect the animal tissues do not differ from the vegetable, which have glands but no nerves. In the process of absorption the specific activity of the indi- vidual cell becomes even more obvious. Here, contrary to physical laws, some substances are taken up while others are rejected. The lymph cells have been observed to wander to the surface of the in- testinal mucous membrane and there incorporate drops of fat; they then creep back even into the lacteals, where they give up these particles of fat. In the face of such occurrences we must naturally avoid physical explanations, since at all events they show that in the processes of absorption peculiar functions of the living cells must coexist with filtration and diffusion. The conditions are no more favorable in the motor function. I disregard entirely the fact that what occurs in a muscle during con- traction is as incomprehensible as what constitutes innervation in a nerve. But the dependence of the contraction upon the nervous impulse, and the invariable result of this impulse, namely—a shorten- ing of the muscle—were formerly regarded as a general and, in a certain sense, physical law. Indeed, for striped muscle it would be difficult to find an exception to this law, if we do not include the direct stimulation of the muscle, which can only occur in an ab- normal way. The striped muscle fiber is always at rest till an impulse reaches it through its nerve ; the result of this impulse is al- ways a contraction, be it a jerk or tetanus. The apparent exception that the heart continues to beat even after all its nerves have been divided, was explained by assuming that the impulses may arise in the heart itself in its ganglion cells, and that these impulses are transmitted to the cardiac muscle fibers through the intracardiac nerves. It was, however, discovered that sections of the heart which positively contained no ganglion cells continued to beat rhyth- mically. The greatest difficulty of maintaining the law of the de- pendence of muscular contraction upon nervous impulses is en- countered in the unstriated muscles. Here we not alone observe * Ewald. Klinik, etc., I. Theil, 3te Auflage, S. 61 und 208 et seq. ANATOMY OF THE GASTRIC NERVES. 451 movements which are independent of any nervous influence, as, for example, in the ureter, but we are not even able in every instance to prove that the result of the nervous impulse is a contraction of the muscle. Thus irritation of the vaso-dilator nerves causes the arte- rioles to relax, and as for many reasons we can not explain this by the longitudinal fibers, we are compelled to assume the paradox that the circular fibers lengthen upon irritation. We must therefore admit that, with the possible exception of the striated muscles, the above law does not always operate, and that consequently the mus- cles may both make spontaneous movements, and may also lengthen upon stimulation. These preliminary remarks will enable us to comprehend more readily the unpleasant fact that we know very little about the secre- tion, absorption, and motility of the stomach. The experiments are very frequently contradictory; many contain conditions which, upon closer examination, preclude a uniform result.* It is evident that the study of the organ has been undertaken with too many physical propositions, whereas here, as in the entire digestive tract, biological laws are more important. It seems that the more highly vegetative the functions of an organ are, the more does its activity depend upon its own cells and the less upon the nervous system. In fact, could we remove every nervous element, nerve fibers as well as gan- glia, from the walls of the stomach without injuring the other tissues, it would still secrete, absorb, and contract quite well. One may ask, Why, then, all these nerve fibers which enter the stomach ? For the same reason that nerves go to the automatic heart—to connect it with the rest of the body. On the one hand, the stomach has these connections with the central nervous system to fulfill the de- mands of the other parts of the body; and, on the other, to enable the entire organism to take cognizance of its condition. Anatomy of the Nerves of the Stomach.—The Vagus Nerve.— Below the neck both pneumogastrics travel along the cesophagus, the left or the smaller being on its anterior aspect, the right or the * Among such conditions we may include, for example, the destruction of sec- tions of the central nervous system when we obtain negative results before complete recovery of the animals. The same applies to all electrical stimulations which can not be confirmed by mechanical irritation, etc. 452 DISEASES OF THE STOMACH. larger on its posterior; they maintain the same relation in passing through the diaphragm. But these are not the only fibers of the vagi which reach the stomach, for as soon as the nerves reach the cesophagus they give off numerous small filaments which form a delicate plexus, invisible to [the naked eye of] experimenters, in the substance of the cesophagus and thus reach the stomach. Hence it will not suffice to simply divide the two vagi upon the cesophagus to sever their connection with the stomach (Brachet), but a circular incision must be made down to the muscular layer in the oesophagus just below the diaphragm (Schiff). The left nerve passes from the anterior surface of the oesophagus to the cardia and lesser curvature, forms the anterior gastric plexus, and divides into terminal fila- ments, which proceed along the anterior surface of the stomach as far as the pylorus, and form many anastomoses with the sympa- thetic. Two thirds of the right nerve pass to the abdominal organs, and only one third reaches the posterior surface of the stomach, where it forms the posterior gastric plexus. The terminal filaments radiate from this over the posterior surface, and, like those of the left nerve, form numerous anastomoses with the sympathetic. The Sympathetic Nerves.—From the cceliac plexus, the cerebrum abdominale of the ancients, in the formation of which the vagi, especially the right, participate, is developed a series of secondary plexuses. Among these is the coronary plexus (plexus coronarius ventriculi azygos), which accompanies the left coronary [gastric] artery of the stomach to the lesser curvature, and communicates with the two plexuses of the vagi. Another secondary azygos plexus is the hepatic, which is also partially formed by the pneumo- gastrics; a branch of this plexus accompanies the right coronary [pyloric] artery of the stomach to the lesser curvature, where it communicates with the coronary plexus. Another somewhat larger branch of the same plexus, which has received the name of inferior coronary plexus (plexus coronarius ventriculi inferior), passes along with the right gastro-epiploic artery to the greater curvature ; com- municating branches to the plexus of the vagi are also given off by this plexus. Ganglion Cells.—The radicles of the two intestinal plexuses may be traced into the stomach; beginning at the lesser curvature, the SECRETION OF THE STOMACH. 453 plexus myentericus has already developed into a thick network at the pylorus, and communicates here with the gastric branches of the vagi (Auerbach). The plexus submucosus (Meissner's) may also be demonstrated even at the pylorus; it probably contains fewer ganglion cells than Auerbach's plexus, just as is the case in the other parts of the intestines. Secretion.—In spite of numerous and careful experiments in stimulating and dividing the nerves communicating with the stom- ach, no definite effects on the secretion have yet been produced. We might even doubt the influence of these nerves on the secre- tion, did we not know from other sources that both stimulating and depressing impulses pass along them to the glands of the stomach. The most important observation on this subject was made by Richet on a man with a stricture of the cesophagus, which necessitated the making of a gastric fistula. It was positively proved that the cesoph- agus was completely occluded, and that not the smallest trace of saliva could reach the stomach. On asking the patient to chew some ferrocyanide of potassium, not a trace of the salt could be de- tected in the stomach ; yet whenever he chewed substances with a strong taste (sugar, slices of lemon, etc.) there was always a copious secretion in the stomach. This interesting case proves that the secretion of the stomach may be reflexly stimulated by centers lying outside of that viscus; * hence, the glands of the stomach are inner- vated by the nerves communicating with it. Like the nerves of taste, the olfactory nerves may also produce this reflex directly— i. e., without the intervention of a psychical process. It is different when the reflex proceeds from the optic nerve ; thus, the mere sight of meat causes a copious secretion of gastric juice in hungry dogs, just as the saliva runs freely from their mouths if they look for a long time at a lump of sugar. However, it is evident that the reflex does not proceed directly from the optic nerve, but that the sight of the food first produces a mental impression, and this it is which causes the secretion. We ourselves all know that we need not even see food, but that simply the thought of savory dishes " makes our * Jiirgens states that this reflex from the mouth disappears completely after division of the vagi below the diaphragm. 454 DISEASES OF THE STOMACH. mouths water." It will not be erroneous to infer that this reflex extends also to the stomach. The secretion of the stomach may be reflexly lessened in the same way that it may be stimulated. The taste, smell, sight, and even thought of disgusting food cause such inhibitions. Usually these various reflexes, whether stimulating or depressing, combine and produce a more marked effect. Having thus seen the effects of visual impressions upon the gastric secretion, it becomes evident that it may also be influenced by psychical processes ; yet this connection becomes more apparent when we consider the effects produced. Taken all in all, their action is inhibitory; the most potent of all is the influence of fear. It dominates the entire digestive tract; it causes the food " to stick in the throat" on account of the stoppage of the secretion of saliva and the refusal of the muscles of deglutition to act. Fear may cause involuntary defecation by increasing the peristalsis of the intes- tines.* In the cases of which we hear that fear caused the food to remain undigested in the stomach for hours and to be finally vom- ited, we will not err in assuming that this is due to an absence of the necessary gastric juice, corresponding to a similar lack of saliva; it can not be due to an increased peristalsis of the stomach, since such a condition would favor gastric digestion. Although it is beyond doubt that both stimulating and inhibi- tory impulses are conveyed along the nerves to the gastric glands, yet the fact nevertheless remains that even after the section of all these nerves the secretion does not cease, f and may even be increased by an irritation of the mucous membrane. It is not improbable that stimuli pass directly or indirectly along sensory paths to the ganglion cells in the wall of the stomach, and that from these the glands are stimulated to activity. This has not yet been proved, and, as Heidenhain has already said, we can not disregard the fact * It has been erroneously supposed that defecation results from the relaxation of the sphincter. But the rectum is normally empty, and under such circum- stances defecation can not result from simple opening of the sphincter. Hence it is absolutely impossible to explain in this way the diarrhoea which results from fear. t Diminution in the secretion as well as changes in the composition of the gas- tric juice, for example, lessening of the amount of pepsin, after low division of the vagi (Jiirgens), have been frequently reported. ABSORPTION OF THE STOMACH. 455 that these stimuli may act on the glandular cells directly without any nervous intervention. It has been demonstrated through gas- tric fistulae that normally even the contact of a foreign body with the mucous membrane causes a circumscribed secretion at the place touched. Only the mechanical stimulation operates in such a case, since the same effect is produced by a pebble or by lightly applying a feather. The amount of the secretion thus produced is very small, but immediately increases and loses its circumscribed character if absorption of even innutritious fluids like water takes place. But the entire stomach becomes active and the secretion reaches its nor- mal strength only when the organ contains absorbable nutritious material. It is by no means essential that these fluids enter the stomach as such, but the liquids produced by the solution and diges- tion of solid food will suffice. It must remain an open question whether this absorbed food acts indirectly by altering the blood, or directly by affecting the nervous elements in the stomach ; yet the reflex character of this stimulation is shown by its extension over the entire stomach. We must therefore assume that normally the contact of food with the mucous membrane causes a local secretion which is possibly produced by a direct stimulation of the glands, and that at the same time the absorption of food reflexly calls the entire secretory apparatus of the organ into activity. Absorption.—A not insignificant portion of the food, both fluid and that liquefied in the stomach, is absorbed by the stomach itself.* As the walls of the vessels and the surrounding portions of the stomach constitute an animal membrane, filtration and osmosis may play an important part. This explanation of absorption appears all the more acceptable because variations in this process which are be- lieved to be of nervous origin may easily be attributed to vaso- motor changes in the blood, and even the lymph vessels. Absorp- tion is also directly influenced by the nervous system. The first decisive experiment on this subject was made by Goltz ; it may be briefly described as follows: In two frogs the heart was removed, thereby rendering circulation impossible; then the brain and spinal cord of one of these frogs were destroyed, in the other they were * [See page 75.] 30 456 DISEASES OF THE STOMACH. left intact. An equal amount of a strychnine solution was then injected under the skin of the hind leg of each of them; after a time it could be demonstrated that the fore leg of the frog with the intact central nervous system contains strychnine, and was poisonous when some of its juices w*ere injected into another frog; but the fore leg was not poisonous in the frog without its central nervous system, and hence contained none of the alkaloid. As there was no circulation of either blood or lymph, the strychnine must have passed from the hind leg to the fore leg by diffusion, or, if we wish to avoid the use of this strictly physical expression, by absorption. The experiment therefore proves that the rapidity of this absorption was influenced by the nervous system. How shall we think of this influence ? Certainly not from a purely physical standpoint, as if the nerves had altered the texture of the parts of the body involved, and in this way changed the ra- pidity of diffusion, just as a tense membrane affects filtration and diffusion differently from a relaxed one. We would rather assume that the activity of the individual living cells had been altered, causing them to absorb and give up the strychnine solution to the neighboring cells more rapidly. The existence of an independent activity of the living cells ought not to surprise us, if we recall the remarkable functions of the white blood-cells mentioned on page 450, or if we remember that some one-celled animalcules only choose certain algae for their food. Absorption may thus take place very easily in the stomach with- out any influence of the nervous system through the individual activity of the cells of the mucous membrane and of the walls of the vessels, and even of the blood itself. It may be changed by the nervous system both quantitatively and qualitatively. It is also, to some extent, affected by the physical laws of filtration and diffusion, which in turn are influenced by chemical and physical changes in the circulation. But the physical relations of the circu- lation are regulated by a direct nervous influence, and in this way the nervous system may exert a double regulating action on absorp- tion. The paths of the direct nervous regulation of the cell activity are still absolutely unknown. I will now discuss those which in- fluence the circulation of the blood. VASO-MOTOR NERVES OF THE STOMACH. 457 Vaso-motor Nerves.—Whenever the glands of a part or of the whole stomach are in active secretion it is constantly observed that the secreting area has an increased blood supply. The arteries dilate, the blood flows more rapidly, and reaches the veins in a less oxidized condition. The object of this heightened circulation is manifestly to bring a sufficient amount of material for secretion. These changes may be recognized by the reddening of the mucous membrane and a marked turgescence and erection of its folds, espe- cially of the large ones near the pylorus. flow does this vascular dilatation occur ? The vaso-motor nerves may be stimulated directly—i. e., either by mechanical irritation produced by the weight of the ingesta, or by their rubbing against the walls of the stomach and the like, or by a chemical stimulation proceeding from the absorbed materials. The extent of the area of dilatation would thus correspond to the area to which the directly stimulated nerves are distributed. But the irritation of the mucous membrane with a feather or a solid body only produces a local red- dening corresponding to the irritated area. This would indicate an immediate influence on the walls of the vessels themselves, and ren- ders the above-described transfer of the stimulation to the vaso- motor nerves very improbable. A similar and even more localized reddening may be produced in the skin by rubbing, or drawing a line on it; chemical irritants (stimulating plasters) also exert a local action. These manifestations are undoubtedly due to a local action on the vascular walls; and the same seems to be true of the stomach. Let it, however, not be inferred that an important part may not be played by the true vascular reflex which follows mechanical, chemical, and thermal stimulation, proceeds along the sensory nerves and acts through the medullary and spinal centers (Schmidt-Miihl- heim) upon the vascular nerves; for we also know that holding a piece of bacon before a hungry dog causes an increase in the tem- perature of the stomach which is analogous to the heightened secre- tion. Possibly the same influences operate here as in secretion. The reflex stimuli are probably associated with the direct local ones, but they differ from the latter by influencing the stomach in its en- tire extent. We are justified in assuming that the path of the vaso-motor im- 458 DISEASES OF THE STOMACH. pulses is along the sympathetic nerves. This is rendered probable by the analogical conditions in other parts of the body as well as by the fact that very moderate vascular changes follow the division of the vagi. Yaso-constrictor nerves probably accompany the vaso- dilators everywhere ; this may explain why in all the experiments to demonstrate the relations of the stomach to the nervous system not alone the various experimenters have differed so among themselves, but also the same observer has obtained such contradictory results on repeating the same experiment. The manifold functions of the nerves distributed to the stomach are indicated by their size; and we also have many undoubted proofs of centrifugal impulses in the effects of fear, in the case of Richet (page 453), and in other similar observations. But why is the result so often absent on stimulating the vagus and sympathetic ? Why do we get one result in some cases and the contrary in others ? I think that these differences are not to be attributed to the longer or shorter interval after the last meal, to the various degrees of fear in the animals, or to the dif- ferent anaesthetics. In my judgment the probable explanation is as follows : If the vagus is stimulated, the inhibitory effect on the heart is so marked that for a long time the presence of accelerating fibers was denied. Had the effect of the accelerating fibers exceeded that of the inhibitory, then probably the former would only have been recognized at first. What would be the result if both sets of fibers were equally powerful ? Stimulation of the vagus might then be followed by inhibition at one time, by acceleration at another, or by no effect at all. Where the stimulation of both sets of fibers is ex- actly equal, the result will be negative. But, on the other hand, slight variations in the point of application of the electrodes, differ- ent conditions of exhaustion of the various groups of fibers, and the like, may cause the result to be positive. The condition of the heart, the organ supplied by the nerve, will also influence the result. This is well shown in the experiment in which the sciatic nerve of a dog is stimulated; if the blood-vessels of the paw have been di- lated by heat, the irritation will cause them to contract; but if they have been contracted by cold, then a dilatation will be the result. Let us, then, suppose that all the inhibitory and stimulat- MOVEMENTS OF THE STOMACH. 459 ing nerves of the stomach are acting equally powerfully; then an explanation would be given why strong impulses may pass along the vagus and sympathetic during life, and yet the functions of these nerves may remain unexplained by our present methods of investigation. The Movements of the Stomach.—When spontaneous movements are observed in an excised organ we very frequently, but not always, find ganglion cells in these tissues; hence we are led to infer that these movements depend upon the ganglion cells. In support of this view I may mention the active peristaltic move- ments of an excised piece of intestine; here we have the gan- glion cells of Meissners and of Auerbach's plexuses. The oesoph- agus executes spontaneous movements twenty-six hours after excision, and here, too, numerous ganglion cells may be found in its walls. The conditions in the stomach are exactly the same, for it, too, manifests spontaneous movements a long time after removal from the body, and in its walls may be found the collections of ganglion cells already described (page 453). These movements differ from those normally observed in being less regular in their direction. The peristaltic and the antiperistaltic movements seem to alternate irregularly, or both may affect various parts of the stomach at the same time. Normally, by means of fistulae or by a very careful exposure of the organ, two distinct varieties of movements have been observed, those of the empty viscus and those during diges- tion. In the former condition the contractions are slower, less fre- quent, and individually less energetic—i.e., the constrictions are not so deep. On the contrary, while secreting they are rapidly executed, much more frequent in occurrence, and each contraction is more vigorous. A great variety of movements has been observed. Most of the waves seem to proceed from the pylorus antiperistaltically to the middle of the stomach, and then run back to the pylorus as peri- staltic waves. This origin of the movements would seem to indicate that most of the ganglion cells are situated at the pylorus. The other half of the stomach also shows various movements, but they are less easily traced. A permanent transverse constriction across 460 DISEASES OF TTIE STOMACH the middle of the organ, the so-called eravate de Suisse* and many similar features, have been described, but I will not enter into further details concerning them, and shall simply mention two im- portant circumstances: First, we must distinguish between move- ments of the ingesta and the visible movements of the organ, as they by no means coincide with each other. The former should be such that the food makes a circuit of the stomach in one or another direction. Secondly, at no time is the peristaltic motion exclusively in one direction, and hence it is impossible to determine from the outside whether or not the chyme is forced through the pylorus. Long pauses may occur in the movements of the empty as well as of the full stomach; they are most marked in the former and may continue for hours, but when full, the periods of repose last only a few minutes. Concerning the object of these movements I may premise that, as there is only a thin layer of muscular fibers, the amount of force generated must be small, and that any mechanical trituration or grinding of the food is out of the question. Such a mechanism is not compatible with a secretory apparatus, since strong pressure would be injurious. Hence, in birds, where such grinding and crushing take place, we observe that this is done in a separate mus- cular stomach, while secretion occurs in another stomach specially arranged for the purpose. Therefore, in mammals the movements of the stomach can only serve the twofold purpose : first, to move the ingesta about so that they may be brought into thorough con- tact with the gastric juice, and to stimulate the secretion of the lat- ter by this mechanical irritation of the walls of the organ; and, sec- ondly, to expel the chyme. The origin and insertion of the muscular fibers at the cardia and pylorus are arranged in a special manner, and also have special functions. While there is very little agreement as to the functions of these sphincters, yet the following facts may be accepted : Both orifices are normally kept lightly closed by the tone of the sphinc- ters. The opening of the cardia constitutes the last part in the act * [This term has been applied to " the layer of oblique muscular fibers which pass from behind the cardia to below the pylorus. By contracting, they form a con- tinuous canal between these two orifices, separate from the fundus."—Ed.] MOVEMENTS OF THE STOMACH. 461 of deglutition. On introducing the finger into the cardia from within the stomach, rhythmical contractions may be felt like those of the sphincter ani after section of the spinal cord. Yet there is no rhythmical opening of the oesophagus, for this would permit the regurgitation of food ; it is simply a " wandering up and down " of the closed orifice of the stomach, for as the cardia relaxes the former closes. At the same time there may also be an active opening of the cardia by muscular contractions through the shortening of the muscular fibers passing from it to the stomach. The pylorus not possessing such bands of muscular fibers must always open pas- sively. This occurs during the later stages of gastric digestion, partly as a result of the increased pressure exerted on it by the food through the heightened peristalsis, and also partly on account of the increased amount of hydrochloric acid in the chyme. The latter does not all pass into the duodenum at once, but intermittently; this may be due to the fact that the pylorus has rhythmical move- ments like those of the cardia. As already mentioned, section of all the nerves distributed to the stomach does not cause the cessation of all its various movements, but only weakens them, and abolishes the slight degree of regularity and co-ordination which they ha dpreviously manifested. In mam- mals, stimulation of the vagus usually causes peristaltic movements of the organ or intensifies those already present. As a rule, the pylorus also contracts powerfully, but a coincident contraction of some duration has not always been observed. The majority of ex- perimenters believe that similar but far less powerful movements follow stimulation of the sympathetic. On the other hand, stimula- tion of the splanchnic nerves in the abdominal cavity is said to stop the spontaneous contractions of the pylorus (Oser, Bastianelli). Probably the action of the different nerves depends upon the condition of the stomach (Contejean). If the stomach is in motion as the result of stimulation from the vagus, the action of the sym- pathetic will be inhibitory; but it will provoke peristaltic action if the stomach is at rest, On the other hand, the stimulation of the vagus has no effect on movements which have been called forth by the sympathetic. Yet all these experimental stimulations in mammals have an in- 162 DISEASES OF THE STOMACH. definite and uncertain character; their success is usually not great and by no means constant.* We know only of the absolutely clear and satisfactory experiment on frogs, and it may indeed be said that it is the only positive experiment on the influence of the nerves upon the movements of the stomach. I refer to Goltz's crucial test with curarized frogs.f In spite of Goltz's warning, this experi- ment is nearly always falsely interpreted. The main point at issue is really a stimulation which results from destroying the brain and cord, and which reaches the stomach through the vagi. The same effect may therefore be obtained by laying this nerve bare and stimulating it. Vomiting.—Magendie thought that vomiting was exclusively due to the action of the abdominal pressure, which is entirely independ- ent of the stomach. As is known, he replaced this viscus with a pig's bladder, and caused the expulsion of its contents by injecting tartar emetic into the blood. But Tantini showed that this experi- ment was no longer successful after the cardia was left attached to the oesophagus. Therefore, during vomiting there must be an active opening of the cardia in the manner already described. At the same time that the cardia is opened the pylorus is tightly closed, and powerful peristaltic and antiperistaltic waves, especially the latter, traverse the organ; the diaphragm descends and becomes less arched; the abdominal muscles exert pressure on the stomach partly directly, partly indirectly, by compressing all the abdominal viscera. The larynx descends, the base of the tongue is depressed, and the upper part of the body is bent forward. All these movements are * There is no lack of recent positive assertions, but confirmation is still wanting; for example, see the review of R. Robert in Schmidt's Jahrbiicher, Bd. ccxi, S. 244. and Bd. ccxv, S. 12. f Vide Ewald. Klinik, etc., I. Theil, 3te Auflage, S. 76. [In brief, the experi- ment is as follows: Two frogs, whose oesophagi and stomachs have been laid bare, are suspended vertically after having been curarized; in addition, in the one frog the brain and spinal cord have been destroyed. A dilute solution of common salt is now poured, drop by drop, into their mouths ; in the normal frog the stomach and cesophagus are distended and full of fluid, almost motionless, with only an oc- casional peristaltic wave, and look just like a distended pig's bladder; in the frog without the central nervous system the gullet and stomach are empty, with active peristaltic waves from above downward, and look like a rosary. The same results are obtained by dividing the vagi, but electrical stimulation of this nerve produces only slight contractions.—Ed.] SENSIBILITY OF THE STOMACH. 453 intended to facilitate the evacuation of the contents of the stomach. Indeed, the abdominal pressure may be said to exert most of the force necessary for the act. This is well shown in the easy vomit- ing of children ; here we may see the entire contents of the stomach ejected from the mouth in a large, continuous stream, such as could never be caused by peristaltic contractions. It should also be ob- served that the ability to vomit lessens with years, especially as fat develops in the abdominal muscles, so that even in one's student days vomiting may only be accomplished by artificial pressure on the abdomen, even though marked nausea be present. Of the nerves participating in the act of emesis we are here only interested in those distributed to the stomach. Mechanical and electrical stimulation of the gastric mucosa easily excises vomiting, since it seems that it is transmitted along the sympathetic to the vomiting center in the medulla. This has not yet been demon- strated with the other sensory stimuli, and it seems that most of the emetics can only act on this center after they have passed into the blood.* The centrifugal impulses which reach the stomach during vomiting proceed along the vagi, and effect the proper co-ordination of the movements of the stomach with the other muscular contrac- tions essential to this act. After section of the vagi this co-ordi- nation is lost, and, although vomiting is not impossible, yet it is rendered very difficult. It will then only occur when by chance the increase in the abdominal pressure and the opening of the cardia happen to be simultaneous. Sensibility of the Stomach.—The stomach is unquestionably sensi- tive both upon the mucosa as well as on the serosa. A hard oeso- phageal bougie is felt the moment it touches the walls of the stomach. So, also, in making a gastric fistula the patient feels the thermo- cautery as it touches the stomach from without. The sensitiveness * Openchewski makes a distinction between central and peripheral emetics. The latter, the most important of which are cupric sulphate and tartar emetic, may produce their effects from any part of the digestive tract. Apomorphine acts cen- trally, but ceases when the corpora quadrigemina are destroyed. The center for the movements of the cardia and the stomach proper has been located here. Open- chewski believes that the inhibitory center for the cardia is situated at the junction of the anterior inferior extremity of the caudate nucleus with the lenticular nucleus. (See Ewald, Klinik, etc., 3te Auflage, I. Theil, p. 77.) 104 DISEASES OF THE STOMACH. is verv limited, and strong stimuli are required to produce these effects. Normally we do not feel our stomachs ; we neither feel the weight of the ingesta nor do we know where the food lies, its tem- perature, or chemical properties, whether acid, alkaline, or bitter; neither do we feel the peristalsis called forth by eating. But the powerful stimuli above mentioned prove that even the healthy stom- ach is not utterly devoid of sensation ; and as all sensory nerves respond to the four different kinds of stimuli, viz., mechanical, electrical, thermal, and chemical, these may also be at once assumed of the sensory nerves of the stomach. The efficiency of the elec- trical and chemical stimuli has also been demonstrated ; this, com- bined with the perception of the bougie and the thermo-cautery mentioned above, demonstrates that, to a certain extent at least, all of these kinds of stimuli are effective. The thinness of the walls of the stomach may at times render it difficult to decide whether the perception has been on its inner or outer surface ; it has indeed been suggested that in some cases, as, for example, the temperature of the food, the sensations are not in the stomach but in the abdominal parietes. Even if this be true under certain conditions, the fact nevertheless remains that the various stimuli mentioned may all be perceived in the mucous membrane of the stomach. Pathologically the sensitiveness may be increased even where the nerves are not exposed, as happens in gastric ulcer, cancer, etc. Under such circumstances irritating ingesta which have been swal- lowed may cause pain, and even touching the wall of the stomach with the bougie may produce unpleasant sensations. To anticipate what will be discussed later on, I will add that, although we do not normally feel whether the stomach is empty or not, yet we do know when it is overfilled ; this may be due to dis- tention and traction on the gastric walls. All these sensations affect consciousness by means of the pneu- mogastric nerves, since the complete division of these nerves will prevent every conscious perception of the stomach.* * [An elaborate study of the sensibility of the stomach and its influence on digestion has been made by Sollier. Kellogg's translation may be found in Modern Medicine, 1895, vol. iv, pp. 142 et seq. This subject is destined to play an impor- tant part in the future investigations on the neuroses of the stomach.—Ed.] HUNGER. 465 Hunger.—The consideration of the causes and localization of the sensation of hunger is best taken up after the above discussion of the sensibility of the stomach. Formerly the stomach was uni- versally regarded as the cause of hunger. Thus, Haller thought it was due to the rubbing together of the walls of the empty stomach. But hunger is unquestionably a general sensation. It is due to the impoverishment of the blood, and has been well called the appeal of the impoverished metabolism to the brain. Such being its cause, it can only be definitely satisfied by supplying the blood with fresh nu- triment. It has been demonstrated in animals that hunger is abol- ished by injecting nutritious substances into the blood. Naturally, the experiment with the corresponding general sensation of thirst is much more easily carried out, since the simple injection of water easily relieves it. Recently there has been no lack of contradictory statements, only the more important of which I will now mention. Thus, it has been said that hunger is due to the emptiness of the stomach. But rabbits, guinea pigs, and. other herbivorae, never have empty stom- achs ; indeed, the organ retains the same degree of fullness which it had after the last meal, till the fresh food which has been taken pushes part of the contents on through the pylorus. Here we can not speak even of a relative emptiness of the stomach which might cause the sensation. In carnivora the viscus is empty hours before hunger is felt, and in newborn infants hunger is only manifested some time after tying the cord, while normally the stomach is empty up to this time without giving rise to this feeling. Furthermore, it has been attempted to make not alone the emp- tiness of the stomach a direct cause, but also the simultaneous in- creased peristalsis or the lessening of the secretion of the gastric juice, or even its accumulation in the gastric glands. But direct observation shows that all these suppositions are not tenable, and therefore can not be advanced in explanation of this feeling. On the other hand, section of the vagi affords important proof that hunger is a universal sensation, since it may be felt even after all the fibers of these nerves have been divided. But, as I have already mentioned, after this has been done no more perceptions can pro- ceed from the stomach to consciousness. 466 DISEASES OF THE STOMACH. The vagi having been divided, reflexes might be transmitted to the brain by the sympathetic. Such a function is generally not ac- cepted ; hence it has been suggested whether, after the suppression of perceptible stimuli from the stomach by division of the vagi, other kinds of excitation of the organ which are not perceived as such by consciousness, may not affect the higher centers, and thus cause the sensation of hunger. But the latter may be felt even after the simultaneous division of both the vagi and sympathetic. There- fore the hunger center requires no connection with the stomach. Where shall we search for the center ? At all events, not in the cerebrum or cerebellum, for monsters born without these organs give undoubted manifestations of hunger. Until recently it was observed that pigeons in which the cerebrum had been extirpated never voluntarily took food ; and as they made no movements which could indicate hunger, even starving to death while quietly resting on a heap of peas, it was naturally supposed that with the destruc- tion of the cerebrum the sensation of hunger had also been lost. But in all experiments on the central nervous system very great care must be exercised and inferences very cautiously drawn. Nearly one year after the destruction of the cerebrum in the usual manner I saw a pigeon again begin to take solid and liquid food voluntarily. This seems to have been the first case of this kind observed. It has also been verified by Schrader, but he asserts that pigeons can only again learn to eat when remnants of the frontal lobes have been left intact. On the other hand, the same writer saw frogs catch and devour flies after complete removal of the cerebrum. Therefore, this center does not exist in the cerebrum, and it has properly been located in the medulla ; the supposition is that it is here stimulated directly without the intervention of peripheral nerves by the blood circulating about it, whenever the percentage of nutritious material in the blood has been sufficiently lowered by giving it up to the tissues. But how can we reconcile this with the fact that most people locate the sensation of hunger in a particular spot ? A comparison with another general sensation which is universally recognized as such—i. e., sleep—teaches us how easily such general sensations may be combined with local perceptions. When we are tired, the feeling HUNGER. 467 of general languor and the desire to sleep is accompanied by a heavi- ness of the eyelids which is often supplemented by itching or burn- ing. Here we distinctly feel that the general fatigue is associated with a localized feeling in the eyelids. But in hunger the gen- eral sensation is so indefinite that it is usually mistaken for the simultaneous local feeling. Hence, hunger is more or less posi- tively located by most persons in a definite part of the body. Yerv interesting in this connection is the statement of Schiff, who asked a large number of soldiers where they experienced the sensation of hunger. Several located it in the chest and neck, twenty-three over the sternum, four did not know where to place it, and only two mentioned the stomach. Marked individual differences undoubtedly exist in the localization as well as the intensity of this sensation. After a long fast many only experience a moderate, vague feeling of oppression, while others regularly have an intense, almost painful sensation before the usual meal hour. Yet in the majority of per- sons who can observe themselves somewmat closely hunger seems to begin merely with a vague oppression in the epigastrium. This localized sensation accompanying the general feeling is really cen- tral—i. e., it results from the stimulation of the centers themselves without any demonstrable intervention of the peripheral nerves. The central irritation is then transferred peripherally—that is, the cause of our perception is falsely referred to the periphery. Such or analogous " eccentric transfers" are of frequent occurrence; thus, if the ulnar nerve is injured, the pain is felt in the little fin- ger. However, in this example the irritant does not act upon the center, as in the sensation of hunger, but only upon the nerve at a place which is more centrally situated than the site to which the sensation is referred ; but otherwise it is an exactly analogous ec- centric transfer of a sensation. Against this interpretation of the localized feeling of hunger as a central perception it might be said that the local irritation of the stomach is often followed by very positive manifestations of hunger. Thus, the first effect of a growing cancer of the stomach may be a ravenous appetite. But why may not an " eccentric sensation " be simulated by one which is peripheral ? Touching the spokes of a rapidly revolving wheel at times causes a sensation like that of the 468 DISEASES OF THE STOMACH. " falling asleep " of a finger. On the other hand, if this feeling of hunger suddenly passes aw*ay, as through disgust, it is highly im- probable that the perception of the existing local irritation should have been suppressed, as such an inhibition usually results only from the most intense psychical excitement. In the heat of a battle the pain of a wound may not be felt even if the attention has been casually directed to it; here stimuli are acting which affect the mind to the highest degree. But if these stimuli be feeble, as, for exam- ple, the receipt of some unexpected, affecting news, be it good or bad, we can nevertheless always positively say whether there is any abnormal sensation in any part of the body ; our judgment will in no wise be different than usual. At all events, in such a case we can remove this inhibition which may finally have resulted from the mental excitement by directing the attention to the part of the body in question. But if through mental excitement we have lost our desire for food—I will rather say the sensation of hunger—we may sit down at the table, we may long to eat, we may concentrate our entire attention upon the appetite, yet this feeling of hunger remains away. What trifling excitements sometimes cause this in many persons—the news that a good friend is coming, the falling of a fly in the soup, or the narration of disgusting stories ! It is cer- tainly an interesting fact that the appetite may be extinguished by psychical influences, in spite of the most strenuous efforts of the eater not to be influenced by these recitals. It will always be futile to use such feeble mental efforts to suppress sensations due to pe- ripheral irritants, even if they be slight or proceed from without or within the body. The abnormal sensation will always return when- ever the attention is directed to one's own body. It is different with sensations of central origin. Continuous self- observation will at times show that a headache may entirely disap- pear as a result of moderate mental excitement; possibly even more convincing is the feeling of fatigue which so often leaves us after slight mental exertion and then is craved back again in vain. I therefore believe that hunger is of purely central orgin, and that it is only indirectly connected with the "rumblings of an empty stomach." Just as we can drive away sleep for a short time by abolishing HUNGER. 469 the sensations by which it manifests itself locally, so can we do the same with hunger. Washing the eyes with cold water will keep one awake. Hunger may be put off by introducing indigestible substances into the stomach or by compressing this viscus with a tight belt, as is frequently done by the common people. But both of these general sensations have only been treated symptomatically, and have not really been suppressed. It is merely using the familiar method of obscuring one sensation by a stronger one at the site of the former, or where this may be referred in the periphery. Even if we thus succeed in removing the manifestations of hun- ger which appeal most powerfully to consciousness, true hunger can nevertheless be satisfied only by introducing nutritious material into the circulation. But it is a well-known fact that when we are very hungry and have waited too long after the usual time of eating, so that the stomach " rumbles," we yawn and feel weak, etc., a few bites will satisfy us and relieve these distressing symptoms. But is it possible that in so short a time sufficient food has been absorbed to satisfy this want ? By no means. Only the more urgent mani- festations have been assuaged, exactly as happens after swallowing indigestible substances and tightening a belt. Eating a meal first satisfies the urgent signs of hunger, but we are not really satiated then ; the true hunger is appeased very slowly during the meal and the period of digestion. The true sign of being sated is that condi- tion of the blood which no longer stimulates the hunger center; hence the latter ceases to send out impulses to the other centers which cause this feeling to be manifested. According to this theory, that satiation denotes a state of quies- cence of the hunger center, the feeling is of a negative character. Hence it might be objected that it would then be impossible to be especially " full" after a large meal, I might almost say over-sati- ated. But in order to show that this is really an objection to the theory, it must first be demonstrated that the sensation is due to an excess of nutrition in the blood above what is needed for satiation. This is evidently not the case. We can not feel whether more nourishment than is necessary is circulating in the blood, just as we are unable to tell whether the sleep from which we have just awakened will suffice for a longer or shorter time. Consequently, 470 DISEASES OF THE STOMACH. after having satisfied' ourselves at a meal, and provided we have no other guide than our sensations, we will not know whether we will feel hungry sooner or later. The real cause of the varying degrees of satiation after a meal is simply the distention of the stomach, for which, as already stated (page 467), we have a distinct perception. Whether the stomach feels especially full or not depends on the usual size of the meal. If we give only meat and wheat bread to an Irish peasant who is accustomed to distend his stomach with potatoes, he will feel sated after having taken a much larger amount of nutriment than usual; in spite of this, he will not feel that he has eaten too much, unless his stomach is unusually distended. On the other hand, if we give innutritious and bulky food to a person whose chief article of diet has been meat, he will feel oversated when his stomach is uncommonly distended, even if he has taken less nourishment than usual. Hence the feeling of oversatiation is really not due to such a condition, but is to be regarded only as a new and positive sensation, resulting from an unusual distention of the stomach, and which to some extent may be regarded as a warn- ing against overloading this organ. Finally, I must discuss the appetite. Let us again use the simile between hunger and general fatigue. H we are tired and wish to sleep, it is essential that certain parts of the brain should not be ex- cited. The absence of such excitement puts us into the condition of sleepiness. Not alone do we wish to sleep, not alone do we feel the need of repose, but we also experience the sensation that we will soon be asleep if we simply keep quiet. The same exertions which have at first tired us may excite us if they are kept up too long. Then we are overtired. In the same way certain mental exertions may be exciting; in both cases, in spite of the fact that we feel a very well marked need of rest, we are yet unable to sleep—that is, we are not drowsy. Appetite bears the same relation to hunger that drowsiness does to sleep. Normally, both sensations, hunger and appetite, precede the taking of food ; but we may be overhungry as we may be over- tired. Of the mental excitements which may suppress hunger I have already spoken. Sensory stimuli act in this same.way upon drowsiness and appetite; a cold sponging may awaken us, and an APPETITE. 471 offensive taste or smell may spoil our appetites. Finally, however, sleep as well as hunger overcome all obstacles and imperatively de- mand their rights. We must therefore assume that the true hunger center, which is influenced by the impoverished condition of the blood, sets into ac- tion a large series of secondary centers, which in their turn produce the manifest signs of hunger ; and upon their activity depends the occurrence of appetite. If we have no appetite, as, for example, when we are overhungry, then these centers are inhibited ; the most pressing and distinct signs of hunger which urge us to eat are absent, and only a vague general feeling tells us that we are nevertheless not sated. How*ever, the nature of appetite consists not alone in a demand for taking food, and a preference for certain articles of diet (if this were the case, then there would be an analogous sensation in the condition of thirst, which, however, does not exist, and for which also there is no word in the language), but the appetite may also exclude certain articles of diet which are relished at another time. The latter lends a special characteristic to this feeling. Of the many instances which might be quoted to illustrate this I will simply recall the striking repugnance toward fats in jaundice. The mere sight of butter may excite disgust even in persons who have been fond of butter or fatty food. I do not know any analogous instances of this regarding thirst—that is, in so far as the fluids are simply to allay thirst, but are not to have any great nutritive value, as milk, chocolate, etc. Here it is only overindulgence which causes a disgust toward favorite beverages. The taking of food brings into action a very large number of special centers. Among these are the centers for taste and smell, the secretion of saliva, the voluntary and involuntary acts of deglu- tition, etc. We also have a very distinct feeling whether a certain article will influence the taking of food favorably or unfavorably. Even the thought of them will act in the same way as the dishes themselves, but, of course, to a feebler degree. If we notice that the smell or taste of a dish is unpleasant, that the secretion of saliva is lessened, and that deglutition is inhibited (a sensation which is characterized in its most marked form as a " zugeschnilrte Kehle "), then this article of food becomes repugnant to us. Such an occur- 31 472 DISEASES OF THE STOMACH rence will explain why this peculiarity does not occur in the analo- gous sensation of thirst, or, if present, is very feebly marked : that is, the act of drinking does not call these centers of salivary secre- tion, and deglutition, etc., into play to the same degree. Naturally, a favorable influence on the above centers will cause a longing for special foods. In my opinion, appetite is due (1) to the excitation of those centers which cause the manifest symptoms of hunger, and the ac- tion of which is regulated by the true hunger center; (2) to the favorable or unfavorable stimulating or inhibitory action of the secondary centers concerned with the taking of food. CHAPTER X. THE NEUROSES OF THE STOMACH. The term neuroses of the stomach includes all those conditions which manifest themselves as disturbances of digestion without demonstrable anatomical lesion in that organ ; or, if such be pres-. ent, they are only secondary ; in other words, the neuroses of the stomach are the functional disturbances as opposed to the so-called organic. Our knowledge of this subject is by no means recent,- for ex- ample, a description which was excellent for the time in which it was written may be found in Comparetti (1790).* Many writers have been engaged on this theme, especially the French and Eng- lish, including Barras, Beau, Trousseau, Chambers, Budd, Fother- gill, Fenwick, and others. Yet since then great advances have been made as the result of the labors of investigators in every land, and in Germany especially by the work of Leube. It must be admitted that our knowledge is chiefly of a descriptive nature, and that the etiology of the disturbances is far from being thoroughly under- stood. However, if we remember that the stomach is the center of a far-reaching plexus whose cerebral and sympathetic fibers have many anastomoses, with the resulting crossing and mingling of both stimulating and inhibitory impulses, it will be easily understood how difficult it is to bring order out of this chaos, and to isolate the separate threads of this entangled meshwork. It will also become evident why writers, among whom I may mention Stiller, Rosen- thal, and Oser,f have endeavored to establish the manifold manifes- tations of the disturbed innervation of the organ upon a basis cor- * Occursus medici de vaga aegritudine infirmitatis nervorum Andreae Com- paretti. Venetiis, 1790. f Stiller. Die nervosen Magenkrankheiten. Stuttgart, 1884.—Rosenthal. Ma- genneurosen und Magenkatarrh. Wien, 1886.—Oser. Die Neurosen des Magens und ihre Behandlung. Wiener Klinik, 1885. 473 474 DISEASES OF THE STOMACH. responding to our present knowledge of its physiology. Yet even to this day our knowledge is so limited and vague that conjecture and hypothesis still play a prominent part, while the actual clinical facts upon which our pathology is based fill only a very small space. How easily, then, can we speculate as to the probable causes and refer everything to higher centers of innervation—e. g., Rosenthal's hunger center, for which Ave may bring as many arguments pro as contra. Classification.—The neuroses of the stomach may arise either directly from diseases of this viscus, or they may be caused reflexly from other organs—the brain, spinal cord, uterus, kidneys, liver, etc.; thus the gastric nervous centers may be called into action, either directly or reflexly. Yet, in the majority of cases, as Oser has shown, a sharp distinction can not be made; as an example he cites the so-called reflex cardialgias in uterine disorders Avhere both affections, the uterine and the gastric, might be considered concur- rent, as well as standing in a causal relation to each other. In the following table of the various neuroses I have followed a classification which is midway between the purely symptomatic and the etiological, in order that a better general idea might thus be ob- tained. THE NEUROSES OF THE STOMACH. a. Sensory. Hyperaesthesia. Nausea. Hyperorexia. Anorexia. Parorexia. Gastralgia. Anaesthesia. Polyphagia. I. Conditions of Irritation. b. Secretory. Hyperchlorhydria. Hypersecretion. (Gastrosuccorhcea.) II. Conditions of Depression. Anachlorhydria. Gastro-intestinal neu- rasthenia (dyspepsia nervosa. III. Mixed Form. Anorexia mentalis. c. Motor. Eructation. Pyrosis. Vomiting. Hyperkinesis. Colic. Tormina ventriculi. Atony or hypokinesis. Insufficiency of the pylorus and cardia. Rumination. Gastroptosis and en- teroptosis. IV. Reflexes from other Organs upon the Gastric Nerves. Reflexes from the brain, spinal cord, kidneys, liver, sexual organs, and intestines manifest themselves in the forms mentioned in I and IL OCCURRENCE AND ETIOLOGY OF GASTRIC NEUROSES. 475 Taken all in all, the above classification, which has since been adopted by other writers,* will suffice. However, in view of the very varying and interchangeable clinical pictures it is often diffi- cult to decide how some are to be classified. Thus, ought rumina- tion to be grouped among the atonic or irritative hyperkinetic pro- cesess ? Where shall mental anorexia be placed ? etc. Still, this is of no significance when compared to the much more important fact to Avhich attention has already been drawn, that all these various con- ditions rarely occur as distinct, independent diseases, but usually in groups, either appearing simultaneously or closely following one another during the course of the malady, passing before us like a panorama with ever-changing scenes. Occurrence and Etiology.—To prevent needless repetitions, let it be said, once for all, that these conditions occur most frequently in women, and especially in the younger rather than those further ad- vanced in years. It is hardly necessary to say that this is due to the greater predisposition of women to the functional neuroses, and to their great frequency before the climacteric rather than after it. In both sexes the middle period of life, from about the twentieth year onward, is most frequently the time of their occur- rence : they are less common before this time, and least of all after the fifties. No such general rules as these for sex and age can be formu- lated for the condition of these patients. Some of them have severe disturbances of nutrition, are feeble, emaciated, anaemic persons, with a faded, pale complexion, through which the veins may be seen; they have languid eyes, a weak voice, feeble movements, and a dragging gait; some are even bedridden ; while, on the other hand, we are astonished to see people enter our offices who are apparently healthy and vigorous, and with red cheeks, yet who complain of a host of nervous disturbances. There are also exceptions to the well- known rule, that the people attacked with the gastric neuroses are usually those who live in large cities, and especially those better situated, whose struggle for existence demands an especial expendi- * Similar classifications have been published ; for example, by Garland, Gastric Neurasthenia, Boston Medical and Surgical elournal, October 3, 1889; Cimbali, Le maladie nervose dello stomaco, Morgagni 1, 1891. 476 DISEASES OF THE STOMACH. ture of labor and mental excitement to keep up with the demands of an " advanced culture." I have seen quite severe neuroses in persons of the lower classes—farmers, working people, female serv- ants, factory girls, and finally, where one Avould least expect it, in sailors. As predisposing factors, it is not difficult to recognize the rela- tions of severe mental exertions of men in their business affairs, and in women the absolute or relative excess of social duties and pleas- ures; and in both sexes the excessive use of the sexual organs. For, not infrequently, we see cases of periodically recurring neu- roses Avhich are due to periodical increase of these causes, inasmuch as the amount of work and of pleasures is greater at some times and is less at others; this increase and diminution is accompanied by a corresponding increase or lessening or even disappearance of the nervous symptoms. Stiller observed an exacerbation of the neuroses in some of his patients in the spring; in my practice the majority of these patients come at the close of the winter. Yet, as the patients usually allow some time to elapse before consulting a physician, this would afford very little information as to the origin of these disor- ders ; but the patients themselves frequently assert that in the quiet season they feel entirely or relatively well. Almost without exception these patients have symptoms of gen- eral neuroses as well as their gastric complaints; naturally these are often not well marked, or are not considered by the patient to be- long to the actual trouble, so that a thorough examination may be needed to bring them to light. We may then discover a so-called nervous temperament, headaches of various location and character, disinclination toward mental exertion, depression, mental sluggish- ness, poor memory, absence of mind, vertigo and its curious mani- festation agoraphobia, insomnia, neuralgias and parasthesiae, espe- cially of the trigeminus and in the lower extremities, pupillary dif- ferences, evidences of spinal irritation, intercostal neuralgias, vesical weakness, and ovarian pains—all of these manifestations relegating such patients to the great class of neurasthenics. If the disturbances of the diseased mind are projected along the most varied nervous tracts—i. e., forming the capricious and confusing picture of hys- teria—another and almost equally frequent class of cases will be HYPERESTHESIA OF THE STOMACH. 477 grouped. Naturally, it is impossible in every case to draw a sharp line between neurasthenia and hysteria. The marked cases of each are easily recognized, but there is a border province in which the judgment, I would like to say the tact, of the physician must decide the diagnosis. For the present it is sufficient to know that the neuroses of the stomach are usually (although not always) only a partial manifestation of general nervousness in the broadest sense of the word—i. e., of neurasthenia and hysteria; the very important deduction from this fact is, that the main object of the treatment is to cure the primary affection, and is not to be directed only to a single symptom, however prominent. This will impart an almost uniform character to the therapeutic measures for these troubles, and hence the essential features of the treatment will always be the group of nervines, including both medical and dietetic measures. I shall therefore consider the treatment of the gastric neuroses col- lectively at the close of this subject (page 548). I. Conditions or Irritation. Proceeding from #these general considerations to the special, I will first mention the mildest disturbances of sensation, hyperesthesia of the stomach, which manifests itself in a feeling of fullness and tension as well as oppression in this region, and nausea. These sen- sations are so closely allied to the normal, and are the daily and con- stant accompaniments of so many digestive disturbances, that they include the entire series of gastric disorders, from the " full stom- ach " after a good dinner and the symptoms of intoxication after a strong cigar, up to the incessant oppression and fullness in the epi- gastrium felt by many patients with cancer, the burning sensation in the abdomen, and nausea which may accompany hysteria, menin- geal irritation, cerebral tumors, and other diseases of the central nervous system. As concomitant manifestations of other diseases they must be disregarded here, for I must limit myself to the gen- uine neuroses. But it is difficult to define the latter exactly, to recognize these symptoms as such—in other words, to group them as hyperaesthesiae of the stomach. Positive information can only be obtained after a careful and thorough examination with all the means for the differential diag- 478 DISEASES OF THE STOMACn. nosis of the various organic gastric disorders. Furthermore, one must not forget that many patients, either through carelessness or because they locate falsely, attribute many painful sensations to the stomach, wdiich really do not exist there, but in the epigastrium (the so-called epigastric pain of Briquet, myalgia of the abdominal mus- cles) ; such pains are usually the result of cutaneous hyperaesthesia or muscular rheumatism, or may even proceed from the spinal col- umn. That the greater number of patients observe themselves very carelessly, and are very reckless in localizing painful sensations, is a daily experience; hence the patient must not alone describe the painful spot, but he must also point it out to me. Oser has fre- quently seen sufferers from locomotor ataxia who referred the site of their troubles to the stomach, although they did not suffer from gastric crises; they had mistaken the girdle sensation perceived in the epigastrium for gastric sensations. The knowledge of hyperaesthetic conditions of the mucous mem- brane of the stomach is very old. Todd * cites examples from Hip- pocrates and Aretaeus ; Schmidtmann f and Barras X knew of them —the latter, strange to say, under the name of dyspepsia. Pember- ton considered it a condition of muscular irritability. J. Johnson describes it as a " morbid sensibility of the stomach " ; while Todd cites cases under the name of " irritable gastric dyspepsia." The characteristic feature of hyperaesthesia is an increased irri- tability of the stomach, the result of which is that the gentlest irri- tants, including even those which are normal, may call forth very painful sensations; the latter may sometimes occur even without the presence of such direct irritants. And yet these same sensory nerve-endings in the mucous membrane of the stomach are other- wise so tolerant! When well, we know nothing of the existence of the stomach, and much less of its functions ; but in these patients there is a continuous sensation of heat or cold, gnawing, pulling, burning in the organ, which may exert such a powerful influence on the physical and mental life of the patients that every sensation, * Loc. cit, p. 633. t J. Schmidtmann. Summa observationum medicarum ex praxi clinica triginta annorum. Berolini, 1819-1826. X Barras. Traite sur les gastralgies et enteralgies. Paris, 1827. HYPERESTHESIA OF STOMACH. 479 and, in fact, anything which attracts their attention, is considered in its relations to their stomachs. " Le principe de tous mes maux est dans mon ventre ; il est tellement sensible, que peine, douleur, plaisir, en un mot toute espece d'affections morales ont la leur prin- cipe. Je pense par le ventre si je puis m'exprimer ainsi." This is what a lady wrote to Pinel; it is a splendid description of a condition which has been called hypochondria; at all events, it is located in the hypochondrium, but it undoubtedly also belongs to the hyperaesthetic conditions of the stomach. The nervous nature of these disturbances is also shown by the fact that, in some cases, taking food moderates them; but they may become worse after the stomach has again become empty ; how- ever, in the majority of cases the reverse is true, and the trouble is aggravated during digestion. Sometimes the sensations described above appear only after taking even very small amounts—as, for example, a glass of water. Then everything which has been taken is vomited, and remedies which are usually well borne now cause severe pain, clammy sweats due to fear, and even convulsions and collapse; mild aperients may be followed by severe diarrhoea. Sometimes the hyperaesthesia is preceded by a tangible cause. Thus, for example, it sometimes follows chloroform narcosis. Such a case I have recently seen : A young woman, twenty-eight years old, suffered from tabes, and also had a carcinoma of the anterior lip of the os uteri; the latter was removed under narcosis. Before the operation her appetite and digestion were excellent. For three days after she remained in a condition in which she complained of severe burning in the stomach and an unquenchable thirst; everything she ate was vomited after a short time. Several times on the day after the operation I examined the vomit, which consisted of weak coffee, and always found hydrochloric acid in it. Small pieces of ice, morphine injections, and large doses of morphine and cocaine inter- nally were useless. The vomiting, which was neA-er spontaneous, ceased only a few days before death. Peritonitis, which had been suspected to be the cause of the obstinate vomiting, Avas not found at the autopsy. For a similar case I am indebted to Dr. Steyerthal, of Bruel: B., nineteen years old, of a large and powerful build, had always en- joyed good health until about six weeks previously, when he began to complain of severe pains in the left hip, which were said to haA'e set in after a wound of the foot which he had received while skating. As ex- tension did not relieve the pains, resection of the hip joint was decided 480 DISEASES OF THE STOMACH upon. The pains were so agonizing that transportation to the hospital was only possible under chloroform narcosis. On February 6, 1HS9. the operation was performed. Only a very slight caries was found in the joint; no osteomyelitis. The prolonged chloroform narcosis was well borne. On February 7th, without any cause, the patient began to vomit all the food and drink which he took. Morphine, ice, antifebrine, and antipyrin had no effect. The vomiting continued until his death, shortly after midnight on February 8th. The autopsy on February 10th shoAved that all the organs Avere absolutely normal excepting a marked dilatation of the stomach. There was no peritonitis. Chemical analysis of the chloral-chloroform Avhich had been used showed it to be absolutely pure. In these cases there was an acute irritation, which could only have arisen from the nerves; here its origin was central. In the chronic form the same may be true of a number of the above-mentioned disorders, while in others the seat of the irritation is peripheral. Among the causes given is insufficient food for a long period, or sudden restriction of diet; thus, prolonged fasting is said to have caused hyperaesthesiae of the stomach in Catholic priests, fakirs, and Brahmans; excesses and an enfeebled bodily condition are said to favor their development. On the other hand, more material causes are also given, as, for example, gastric calculi, the well-known con- cretiones benzoarticae,* and worms. In many cases the causal fac- tors will be sought for in vain. Thus, I have recently had under my treatment a strong man, in good circumstances, thirty years old, who has developed this condition ; as yet I can discover no cause for it, with the possible exception of a transient gastric catarrh. Idiosyncrasies may also be included among the hyperaesthesiae. As is well known, the eating of certain foods by predisposed indi- viduals is followed by peculiar sensations in the epigastrium, mild oppression or burning, and sometimes vague nausea, combined with singular excitation of the cutaneous nerves, pruritus, erythema, and the formation of wheals [urticaria] ; even headache and slight febrile movements which either soon disappear of themselves, or are sub- dued by the strong reflex irritants from the gastric mucous mem- brane, as strong wines, cognac, and the like. This condition most frequently follows the eating of shellfish, crabs, lobsters, oysters, etc., * [These are of very frequent occurrence in the abomasum, or fourth stomach of ruminants. See Lancet, 1888, vol. i, p. 186. For hair tumors of the stomach, etc., vide supra, p. 376.—Ed.] IDIOSYNCRASIES OF THE STOMACH. 481 sometimes also strawberries, or green peas. Here we are surely not dealing with a psychosis, but only with an abnormal sensitiveness of the gastric nerves toAvard these articles of food; for its first occurrence is purely accidental, and it recurs after these conse- quences have long since been forgotten. A very peculiar condition which may also be included among the idiosyncrasies was recently observed by me in a man, fifty-one years old, in whom " the smallest quantities of fat" caused severe migraine, tempo- rary partial amaurosis (Flimmerscotom), flatulence, and the passage of watery and very offensive stools. This condition was said to occur twelve to fourteen hours after taking fatty food; the expression "fatty" is ob- viously very vague, and refers only to the more or less oily additions to the ordinary articles of food. It was characteristic of a neurosis that he could eat pure table butter without any inconvenience, but as soon as he had tasted butter which had been rendered the peculiar attacks came on. Otherwise, this patient, who moved in the best society, had a good appe- tite, was robust, and had no real gastric disturbances. In the intervals between the attacks the bowels were regular. In order to remove every suspicion of an insufficient decomposition or absorption of the fats, the passages were examined on three different occasions after an attack, and the amount of fat was ascertained by means of extraction with ether; but the amount was always found normal in comparison to the small quantity of fat which he consumed. The patient had suffered from this trouble for years, was himself convinced that he was " very nervous," and had de- rived no benefit from living in the mountains or at the seashore, nor from drinking the waters at Carlsbad and Kissingen, nor from the use of preparations of pancreatin and the like. The deviations from the feeling of hunger constitute a second series of sensations which become pathological by a gradual increase of those which were originally normal. As is wTell known, the length of time during which one can endure hunger, or, to express it more properly, during which one need not eat anything, is subject to very extraordinary variations. Some people are satisfied with two meals a day, a good breakfast and a substantial dinner at 6 or 7 p. m. ; while others must eat every three or four hours. Unless this is done they experience the sensation of emptiness of the stom- ach, and faintness, Avhich may even reach such a degree in nervous persons that they lose consciousness; the French call this defailli- ance. I have treated a state official who was utterly unable to take even a glance at a newspaper unless he had had his breakfast ex- actly at his regular time. An exaggeration of this condition is bulimia (6 Xtytto?, hunger. 4S2 DISEASES OF THE STOMACH. o /Sou?, ox *); it is also called cynorexia [o kvwv, dog, 17 opegts, de- sire], or fames canina; hyperorexia, Heisshun ger or Wolfs hunger. Sometimes this condition is only temporary and quite closely allied to the normal sensations; at other times it is permanent; in the latter it constitutes a very obstinate, weakening, and exceedingly unpleasant malady. It may occur alone or may be a symptom of the various diseases of the nervous system, manifest diseases of the brain, hysteria, neu- rasthenia, and psychoses; it may also complicate constitutional dis- orders like diabetes and Addison's disease, and may be of temporary duration in convalescence from acute diseases, after serious opera- tions, profuse loss of fluids, peripheral irritation, for example, worms (Pavy), uterine disorders, and even syphilis. Naturally, the most interesting cases are those in which it occurs as an independ- ent disease. Potton f reports the case of an hysterical girl, eighteen years old, who ate eleven to twelve times a day, and consumed 10 to 12 kilogrammes [22 to 26| pounds]. She drank little, and her sleep was frequently disturbed to satisfy the craving for food. The stools were never diarrhceal, but were frequent and copious; the urine was negative. The patient gained in weight, but her strength began to fail. A cure was effected with in- creasing doses of morphine, up to 0*4 gramme [gr. vj] in twenty-four hours. In a similar case morphine was useless, but it was cured by large doses of opium, up to 3 grammes [gr. xlv]. / Peyer { describes the case of a woman, thirty-two years old, who was suddenly seized with a furious attack of bulimia, so that she could not re- turn home from the house of a neighbor whom she happened to visit. In forty-five minutes she ravenously devoured three pints of milk, twenty- three eggs, and two pints of strong wine which Peyer allowed her to take. Thereupon she became quieter, went to sleep, and awoke perfectly well on the next day. She described the attack as a feeling of hunger accom- panied by an inexpressible pain and suffering in the region of the stom- ach ; she feared that she would die; she did not feel that the food reached the stomach, and it did not relieve her condition; it was only the strong wine which affected her. The attack had been preceded by severe psychical excitement and worry. * This etymology is according to Roth-Gessler's Klinische Terminologie. Er- langen, 1884. f Potton. Etudes et observations sur la boulimie dyspeptique. Gaz. med. de Lyon, juin 1, 1863. X A. Peyer. Beitrag zur Kenntniss der Neurosen des Magens und des Darms. Correspondenzblatt schweiz. Aerzte, 1888, No. 20. BULIMIA. 483 For many years I had under my treatment a young lawyer, the picture of health, normal in every respect, both mentally and bodily, but who was annoyed with continually recurring attacks of bulimy. He was at- tacked whenever he had not eaten anything for two or at most three hours, especially in the morning, when he was frequently aroused from his sleep. He was then utterly unfit to attend to any business, not even to follow a conversation. His whole existence and every thought con- centrated itself on the immediate allaying of his ravenous appetite. A few morsels or a swallow of strong wine sufficed temporarily, but soon the torment returned with renewed vigor. The intervals were longest after severe bodily exertion, so that he suffered little during his service in the army. But a sedentary occupation caused the attacks to be very severe, and so annoying that the patient for months subjected himself to all kinds of treatment, including faradization of the stomach, systematic lavage, etc., but unfortunately all without any visible effect; the best re- sult was obtained with large doses of bromide of potassium, but even this was only temporary. Rosenthal gives other examples associated with migraine, hypo- chondria, and exophthalmic goitre. The disorder also accompanies diseases of the brain. Thus, this author describes a case which oc- curred with cerebral embolism subsequent to mitral insufficiency and cardiac hypertrophy. In another case it was the result of con- cussion of the brain; it appeared after the acute symptoms had dis- appeared, and lasted about three months. Analogous to bulimia are the cases of perverted appetite which occur in pregnancy, children, and mental disorders. Guipon * considers bulimia to be an abnormal increase of the digestive powers, which, in spite of the increased consumption of food, is unable " to repair the deficit in the economy." As I have already said, I do not think it advisable to enter into speculations about the site of this and other neuroses, in so far as the more exact localization is concerned. That we are dealing with central and not peripheral causes is proved by the simple fact that any trifle which is introduced into the stomach—a piece of bread, a cake, a swallow of wine—may momentarily assuage the voracious hunger; yet simple appeasing of the hunger is out of the question; and, furthermore, the feehng may come on Avhen the stomach still contains large quantities of food. This is * Guipon. Des dyspepsies boulimiques et syncopales. Bull, de therap., 1864, 15 aout. 484 DISEASES OF THE STOMACH. also corroborated by the cases already cited, in which the malady followed severe cerebral injury. The cases already narrated show that there are acute and chronic forms of bulimia; but the chief difference between them is that in the latter the attacks are less severe, and may extend over Aveeks, months, and even years. Under these conditions, one would imagine that the stomach is abnormally rapidly evacuated, and that this is the cause of the feel- ing of hunger; but in a typical case of bulimia reported by Leo,* which I had an opportunity of observing for some time at the Au- gusta Hospital, on repeated examinations fifty to ninety minutes after the test breakfast, and more abundant meals, the stomach was by no means found empty, but, instead, the amount of stomach con- tents which could be expressed was normal. On the other hand, in a woman under my care, who for some time was awakened every two hours during the night to satisfy her ravenous appetite, the stomach was found almost empty thirty to forty-five minutes after the test breakfast; the salol test was decidedly hastened, the reaction being present within thirty minutes, and very marked after forty- five minutes. These two cases simply prove that there is no uni- form condition in this respect. But the first case mentioned shows how easily such conditions may become aggravated if the patient is at all liable to psychical changes; for within a few months he was attacked with acute insanity, and committed suicide. I have ob- served another case of bulimia in a man with sexual perversion. Anorexia {■>) opeft?, the desire) denotes a lack of appetite or a re- pugnance toward food. These two conceptions do not correspond exactly, since it is one thing for a person not to have any appetite, or not to feel hungry ; it is something else if there is a repugnance toward food, or even nausea at the sight of it. Yet the latter may be regarded as an exaggeration of the former, and therefore they may be included under the same term. Anorexia accompanies nearly every dyspeptic condition, but naturally the discussion of this variety of it is out of place when speaking of the gastric neuroses. In the latter, the loss of appetite * Leo. Verhandlungen des Vereins fiir innere Med. Berlin, 1889. BULIMIA. 485 may arise spontaneously, or may be due to hyperaesthesia of the stomach; hence, central or peripheral conditions of irritation may be among its causes.' Both combine to produce their effects: the original anorexia, due to a cerebral lesion, and the consequent disturbance of nutri- tion, may cause hyperaesthesia of the stomach; and, on the other hand, the latter may produce changes in the psychical processes. We may therefore, as has been proposed by several writers, make a distinction between mental and nervous anorexia; in the former the primary factor is an abnormally irritable condition of the mind ; in the latter the primary irritation is in the gastric nerves, which is reflected inward toward the central nervous system. But a sharp distinction is hardly feasible, and, moreover, both of these conditions frequently develop into gastric neurasthenia, a neurosis which will be discussed later on. Furthermore, a vicious chain is formed, which may at times lead to the most serious consequences. In the first place, a perverted taste may be manifested in a lack of desire for food, which may at first be overcome by an effort of the will, but may later develop into a decided repugnance and disgust toward food, and an almost absolute refusal to take nourishment. Frequently such pa- tients sit down at the table with a good appetite, or may even be very hungry ; yet the first bite is followed by an insuperable aver- sion toward eating any more. In other cases, absolutely no need of taking food is experienced. " Unless I saw how other people ate, and were I not compelled to go to meals, I would not feel any need of it," is a frequent complaint of these patients. They would like to eat, but every morsel causes them pain. If hungry, there is an un- bearable sweetish taste in the mouth, but if they eat they are annoyed by a sharp, burning sensation. On the tongue we may frequently see smooth, bright red insular areas, or it is traversed by deep fissures, giving it the appearance of a recently plowed field. The organ seems to be too large, and causes the patient to swallow incessantly. Small vesicles, or loss of the epithelium on the edges, cause the patients much annoyance, and make them fear that a cancer is developing. Numbness, or loss of sensation, burning, or dryness, are frequently complained of, although the tongue is 486 DISEASES OF THE STOMACH. smooth and moist. Frequently it seems to be bluish white, as if coated, but in reality it is only anaemic. In other cases Ave see peculiar linear hypertrophy of the epithelium, giving the tongue the appearance of a cornfield. In one of my cases this hairy layer exfoliated from time to time, and then gradually reappeared. Mi- croscopical examination showed that there Avas an epithelial prolif- eration similar to what has been described as " black tongue." * It is inevitable that the nutrition suffers from this, and also that the gastric mucosa becomes pathologically irritable. This brings us to the end of the chain; but then the hyperaesthetic mucous membrane revolts unless the brain causes it to refuse nourishment. We may be con- tented if these patients simply emaciate and look pale and miserable, provided they still maintain their strength ; but in the severe cases the condition of inanition may become very threatening, so that the patients' feebleness may permanently confine them to bed. Marked disquiet and restlessness, which struck Fenwick as being very inconsistent with the emaciation of the patients, did not occur in my cases, yet at times this may constitute a very prominent fea- ture of the disease. Fenwick narrates the case of a lady whose rest- lessness led her to make absolutely unnecessary railway journeys, although she knew that these would be followed by severe exhaus- tion and many days' confinement to bed. Hyperaesthesia of the sensory nerves of the stomach leads to the same result, but in the opposite way; for, on account of this over- sensitiveness, the patients gradually eat less and less solid food. Finally, the general nutrition is disturbed, which also affects the higher centers. Not infrequently this condition may follow pro- found mental disturbances of a depressing nature, so that patients who had previously enjoyed excellent health can positively trace the beginning of their affliction to a definite period, sometimes even to the very day. The cause may be the death of a dear friend, deep grief, crosses in love, loss of fortune, disgust toward some particular article of food, an unappetizing dish, etc. Frequently the condition arises without any discoverable cause. The majority of these patients * Dirkler. Ein Beitrag zur Pathologie der sogen. schwarzen Haarzunge. Vir- chow's Archiv, Bd. cxviii, p. 46. GASTRALGIA. 487 consist of young girls of the better classes; young or adult men are rarely attacked. As chronic anorexia may lead to marked emacia- tion and feebleness, and, as Fenwick * claims, even to death, it may be mistaken for a constitutional disease, especially phthisis. Such errors are frequently made, and may occur very readily, because the enfeebled condition of these patients reduces their powers of resist- ance, and they may therefore be easily attacked by infectious germs; this will explain their predisposition toward pneumonia, pleurisy, acute bronchitis, etc. Hence a thorough examination of the heart and lungs is very important, and should never be neglected. On the other hand, tuberculosis develops much less frequently than one would expect. I have now observed a number of cases of severe nervous anorexia for years; they are in bed during the greater part of the year; there have been fluctuations in the general condition, temporary improvement, either spontaneously or after a sojourn at the spas, or during some new course of treatment; but, taken all in all, the condition is about the same, without any definite cure, yet without any other marked complications. We may dispose of such cases under the generic expression of " hysteria," but this by no means alters the fact that it is a sad affliction for the patients, and especially for their relatives. Gastralgia or Gastrodynia f (^ oBvvn, pain). Although the causes of pain in the stomach are very manifold, yet its manifestation is quite uniform. This is perfectly rational, because the pain is always due to an irritation of the sensory fibers of the vagus, either in its peripheral terminal filaments or nucleus, or in the reflections to it from still higher centers. Hence gastralgia may be due to local causes, or to conditions of irritation in the nerves outside of the stomach. The attacks of pain may be ushered in by a feeling of discom- fort, fullness and tension in the epigastrium, or they may begin sud- denly and reach their greatest intensity almost instantly. Not in- * Fenwick. On Atrophy of the Stomach and on the Nervous Affections of the Digestive Organs. London, 1880, p. 99. f I avoid the expression cardialgia, because it localizes the pain at a definite spot in the stomach without our being able to prove it. 32 4S8 DISEASES OF THE STOMACn. frequently the scene may be opened with a copious secretion of saliva. Oser mentions a case in which the attacks began almost uni- formly with a severe toothache. But the pain in the left ear, which is mentioned by this author among the initial symptoms, is surely to be regarded as a coincidence. The character of true gastralgia is an agonizing boring or cutting pain, sometimes sharply localized, some- times diffuse, or even resembling a girdle sensation; in severe cases the intensity is very pronounced. Instinctively the patients double themselves up to relax the abdominal muscles, breathe superficially, and carefully avoid coughing and speaking aloud. Although there is decided cutaneous hyperaesthesia of the abdominal parietes, yet deep pressure often gives relief. The face is pale, distorted with pain, and covered with cold sweat, and there may be conditions of collapse with an intense sensation of impending death, and attacks of unconsciousness. The abdominal aorta pulsates vigorously, and pains radiate along the spinal column and into the intercostal spaces. At times points of exquisite tenderness may be demonstrated along the spinal column or the lumbar nerves. In its general features and duration the gastralgic attack is very variable; the paroxysms may be either brief and mild or may last for hours, and may torture the sufferer till medical aid or Nature brings relief. As a rule, the attack wears itself out and the normal condition is gradually restored; at other times it terminates sud- denly with vomiting; or the patient, to whom every morsel would have been a horror only a short time before, now experiences sharp hunger and demands food after the attack is over. The urine passed after the paroxysm usually has a low specific gravity. A feeling of marked relaxation and exhaustion is left behind. Happily, these at- tacks do not recur frequently, yet I have seen a case in which there were three or four in one day, causing very profound exhaustion of the patient. The etiology of gastralgia is very varied, and may be classified as follows: 1. Local Causes {true gastralgia).—In the chapter on Gastric Ulcer I mentioned the fact that there are follicular inflammations, haemorrhages, and losses of substance of the mucous membrane which are not manifested by the classical symptoms of ulcer of the GASTRALGIA. 489 stomach, but which give only a single symptom, recurring gastralgia, which, although it does not appear after every meal, yet stands in some relation to taking food. Now, it is characteristic of nervous gastralgia that it has nothing at all to do with eating; therefore, strictly speaking, these cases just spoken of do not belong here; yet we must not classify too strictly on either side, because every experi- enced physician has seen cases in which these criteria could not be applied. The following is an example : Miss Von B., from D----, twenty-one years old; complained of gas- tralgic pains which recurred irregularly for about six months. Some- times they stay away for weeks ; at other times they recur every few days. A relation of these attacks to taking food was at times suspected, but not constantly present. They have frequently occurred very early in the morning, and have aroused her from sleep; the pain was localized in the stomach or the infrasternal depression, and was not very severe. No his- tory of ulcer; never had migraine ; the acidity of the filtrate after the test breakfast was 66 per cent—i. e., just at the upper limits of the normal; contains no abnormal constituents. Physical examination negative. No tenderness over the ovaries, no painful points on pressure. Although the patient did not look bad, yet recently she had lost constantly in weight. The continuous frequency of the attacks during the past few weeks led her to come to Berlin for treatment. Diagnosis: follicular ulceration of the mucous membrane of the stomach. A rest cure ordered. The patient left the sanitarium after four weeks, during which time she had gained four kilogrammes [about nine pounds], and without low- ing had any attacks during the last fortnight. Soon after she was mar- ried, and according to subsequent reports has remained free from attacks eATer since. In cases like the above, in spite of the apparently idiopathic gas- tralgia, there are distinct anatomical lesions. There is another group of gastralgias which, although distinctly neurotic, yet are only indi- rect, since the real lesion is a neurosis which consists in hypersecre- tion of gastric juice, concerning which I will speak later. It is evident that the very acid chyme irritates the gastric nerves and thus causes typical attacks of gastralgia, for which no other cause than this can be found. Thus the class of genuine gastralgias is restricted to a very small group. My own experience leads me to be very sparing of the diagnosis of idiopathic gastralgia, and I believe that many of the cases grouped under this heading would be differently classed if they were examined according to our modern methods. 490 DISEASES OF THE STOMACH. 2. Gastralgias due to Diseases of the Central Nervous System.— Diseases of the brain are manifestly very infrequently accompanied by pains in the stomach ; according to Kosenthal, only a few vague data are given by Kruckenberg. They are much more frequent in spinal diseases. The gastric crises of tabes were first described by Charcot, and, after attention had been drawn to them by this dis- tinguished French clinician, they have frequently been discussed. Although Delamare * (1866) was the first to carefully study these attacks—for analogous cases were reported by Gullf as early as 1856—yet it is due to Charcot and his school that the existence of the affection has been firmly established, and it is therefore no more than right to attach his name to the gastric crises. I can not resist the temptation to give Charcot's classical description of such crises: X " Suddenly, and frequently with an attack of fulgurating pains, the patient complains of pains which begin in the groins, ascend along both sides of the abdomen to the epigastrium, where they become fixed. There are also pains between the shoulders, which radiate like lightning to the buttocks. The heart action is rapid and forci- ble ; but there is no rise in temperature. At the same time there is almost uninterrupted and exceedingly painful vomiting ; the vomit consists at first of food, later of a mucous fluid, which is sometimes mixed with bile or tinged with blood. This is accompanied by marked nausea and vertigo, as well as by cardialgic pains which at times reach a terrible degree of intensity. These gastric pains may continue almost uninterruptedly for two or three days. They may appear at the very beginning of the disease, and then belong to the so-called preataxic symptoms, but they may not disappear even when the disease has reached its full development with complete ataxia." The frequency of the attacks is variable: sometimes there are long free periods, and the occurrence of the crises is irregular ; at other times they recur monthly, weekly, or even at still shorter in- * Delamare. Des troubles gastriques dans l'ataxie locomotrice. These de Paris, 1866. f W. Gull. Cases of Paraplegia. Guy's Hospital Reports, 1856, p. 161. X Charcot. Lecons sur les maladies du systeme nerveux, 1881, tomes i, p. 261, et ii, p. 32.—Des crises gastriques tabetiques, etc. Gazette medic, de Paris, 1889, No. 39. GASTRALGIA. 49! tervals ; they may even seem to assume a certain regular type. A characteristic feature is the sudden transition from the condition of intense pains and complete cessation of all the functions of the stom- ach to one of absolute comfort, so that the patients ask for food a 6hort time after the close of the crisis. Examination of the stomach contents before, during, and after the attack has not revealed anything which is characteristic, since the degrees of acidity which were found were very variable, and stood in no relation to the course of the crisis. Having made nu- merous examinations myself, I can corroborate these facts, which were first announced by Yon Noorden.* [The contents of the stomach during gastric crises have been care- fully studied by Cathelineau,+ whose results agree with those al- ready given. The vomit varied in amount from 800 to 8,600 c. c. [f 1 27 to 87] in the twenty-four hours. Giinzburg's and the biuret tests Avere always positive. After a test breakfast free HCl, ery- throdextrin, and peptones were present. Hayem and Winter's test showed hyperchlorhydria. During the crises the results were not so constant, but free HCl was always present.] Their clinical existence having been established, the pathological basis was found to consist in a sclerotic degeneration of the vagus nucleus or the vagus trunk ; this has been demonstrated in numer- ous recent papers by Kahler, Demange, Landouzi and Dejerine, Oppenheim, and others. In the course of time I have seen quite a large number of cases of gastric crises in tabes. The diagnosis is readily made as soon as the symptoms of locomotor ataxia are well marked. But if the crises are among the initial symptoms we may be in doubt for a long time, and it is possible that the only valuable symptoms present may be changes in the pupils, or Westphal's symptom, anaesthesia of the pharynx, etc. Thus it may happen that a patient who originally consulted us on account of a " gastric catarrh with cramps of the stomach," may finally die of tabes. But gastralgias may be caused not alone by sclerosis of the posterior columns, but also by other lesions which involve the vagus nucleus. Thus Leyden includes * Von Noorden. Pathologie der gastrischen Krisen. Charite Annalen, 1890. f [Cathelineau. Arch. gen. de med., avril, 1894.—Ed.] 492 DISEASES OF THE STOMACH. them among the symptoms of subacute myelitis ; Oser saw them in a case of pressure myelitis following vertebral caries.* These gastralgias would always be interesting to us, even if they were simply symptoms of tabes in the stage of complete devel- opment ; but gastric crises are not infrequently the initial symptom of locomotor ataxia. This lends a peculiar importance to them ; hence in every case of nervous gastralgia a thorough examination should be made in this direction, and frequently enough we may discover other symptoms of the disease which had not been noticed by the patient. 3. Gastralgias from Constitutional Causes.—These include the cases occurring in neurasthenia, hysteria, certain psychoses, and pri- mary anaemia. It is important, not alone for the semeiology but also for the prognosis, that neurasthenia be distinguished from hysteria, and, as this will not be accomplished by the epigram that " neurasthenia includes rational sensations, hysteria those which are irrational," I shall therefore endeavor to distinguish these two conditions in the following, in so far as it is essential for the gastric manifestations. Neurasthenic Gastralgias.—The expression asthenia was intro- duced by Brown, and was later applied by Broussais in the doctrine of irritants ; it denotes a condition of weakness of an organ Avhich is at first manifested by a morbidly increased irritability, and later by a diminution of its functional activity. Therefore, the term neurasthenia indicates an enfeebled condition of the nervous system and the consequences thereof. It is marked by a continuous and advancing course, and seldom occurs without causal factors of an enfeebling nature, mental overexertion, strong emotions, sexual ex- cesses, anaemic conditions, etc. Eosenthal draws a sharp distinction between the irritative and depressive forms, the former being recognized by manifestations which are pre-eminently those of irritation, the latter by symptoms of exhaustion. Both are related to each other by numerous tran- sitional forms, and are characterized as follows by this experi- enced neurologist: " The patients suffering from irritative neuras- * Oser, loc. cit, p. 42. GASTRALGIA. 493 thenia complain of diffuse or circumscribed headache, which is associated (especially in an attack) with local cutaneous hyperalgia and acoustic or optic hyperaesthesia. Marked mental excitability, uncalled-for depression of spirits, and sensations of fear and in- ability to speak or read for a prolonged period, indicate unusual central irritability and exhaustion. Equally annoying to the pa- tients are the periodical pains in the spine, with points douloureux in the nape of the neck, more frequently between the scapulae, less often lower down. Electrical and thermal stimulation also cause a peculiar sensitiveness here, especially over the spinous and trans- verse processes. This secondary condition of irritation in the dis- tribution of the sensory roots may be demonstrated more accurately and positively by means of electricity. Most frequently I found a striking sensitiveness on the left side toward cathodal irritation and the faradic brush which extended like half a girdle over the points douloureux in its path, and over which it was most pronounced. Yague neuralgias or parasthesiae in the upper and lower extremi- ties, becoming easily tired and exhausted after exercise and work, noticeable increase of the cutaneous and patellar reflexes, as well as disturbances of sleep and appetite, constitute many of the patho- logical variations of irritative neurasthenia. When located in the chest, periodical cardialgias are frequently present. We may also often observe that increase of the pain in the back, and of the ten- derness over the cervical and dorsal vertebrae, together with fullness of the head, are the forerunners of the periodically recurring gas- tralgia. Not infrequently there are also localized hyperaesthetic areas on the trunk, and puncta dolorifica may be more prominent as well as more abundant. More or less rapidly these are now fol- lowed by pain in the stomach, the intensity of which gradually in- creases. " The pain is characterized sometimes as ' drawing together,' sometimes as boring, and radiates from the loAver ribs to the epigas- trium ; it is accompanied by the vaso-motor symptoms, and those due to the cerebral anaemia, which have already been described. " The depressive form of neurasthenia presents itself thus: The patients complain, especially after eating, of an oppressive sensation or a dragging which extends from the stomach into the abdomen, 494 DISEASES OF THE STOMACH. without, however, haA'ing the paroxysmal character of the painful gastralgias. The pain in the back is also not so intense, nor is it of so neuralgic a character; on the other hand, the motor exhaustion, sexual weakness, seminal emissions, mental depression, and atonic dyspepsia are especially predominant. The diagnosis of a localized spinal meningitis, which is not infrequently resorted to, may be avoided by observing that in the latter the intense and usually widely distributed pain in the back is ushered in by fever, tonic contractions of the muscles of the nape of the neck and the back prevent any movements,"contractures and partial paralyses may occur in the extremities, and finally pain in the stomach is extremely rare and temporary." To this description I must add Burkart's painfid points* On pressing deeply down to the retroperitonaeum, over the region of the superior hypogastric, aortic, and cceliac plexuses, the patient experiences exceedingly sharp and unpleasant pains, Avhich radiated up to the epigastrium. Burkart claims to have found these points in all cases. In 1884, in the discussion on nervous dyspepsia at the third Congress for Internal Medicine,*!* I stated that in my expe- rience this was not always the case. Kichter X also asserts that, as a rule, pressure over the stomach and abdomen is not painful. Since then, this has been agreed to by others. At that time I said that the same was true of the above-mentioned painful points along the spinal column, upon which so much stress was laid by Rosenthal. They may be present (according to Rosenthal, in 75 per cent of the cases), or they may be absent; but, even if they are present, they have no important bearing on the conception of the disease, and are by no means one of its essential features. On the contrary, I will say that my further experience has been that pain along the spinal column, both on pressure and with the faradic brush, may fre- quently be absent in undoubted cases of neurasthenia. Here I may also classify the condition which Buch* has de- * R. Burkart. Zur Pathologie der Neurasthenia gastrica. Bonn, 1882. t Verhandlungen des Congresses fiir innere Medicin, 1884, S. 232. X Richter. Ueber nervose Dyspepsie und nervose Enteropathie. Berliner klin. Wochenschr., 1882, No. 13. * Buch. Wirbelweh, eine neue Form der Gastralgia. St. Petersburger med. Wochenschr., 1889, No. 22. GASTRALGIA. 495 scribed as a separate form of nervous disorder under the name of "Wirbelweh" [vertebral pain]—i. e., the pains which are produced by pressure made in the epigastrium, or at the level of the umbili- cus, upon the anterior surface of the lumbar vertebrae. They are usually accompanied by a subjective feeling of more forcible pulsa- tion of the abdominal aorta ; they do not, however, occur if pressure is made on both sides alongside ofihe vertebral column. At times, though not always, the spinous processes are also sensitive. Among the accompanying symptoms are nausea, eructation, ravenous appe- tite, with nausea and languor. The stools are variable; constipation is the rule, although diarrhoea may occur. Buch correctly assumes this condition to be a neurosis of the sympathetic plexus which proceeds from the plexus aorticus abdomi- nalis and the plexus hypogastricus, and supplies the bodies of the vertebrae and the intervertebral disks with nerve-filaments. But this condition was recognized long ago,* and is also mentioned by me, on page 493, among the symptoms of gastralgia. It remains ques- tionable wmether these cases ought to be grouped in a separate class. Buch claims to have had good effects from injections of antipyrin in loco affecto; but this is rendered doubtful, because at the same time he also used all the ordinary means of physiatric treatment, in- cluding cold rubbings, douches, baths, gymnastics, diet, etc. The following case may serve as a typical example of this kind: In August, 1885, a merchant, forty-five years old, was brought to me by his family physician. He complained of great fatigue, especially a feeling of heaviness in his legs, disinclination for work, and dullness and confusion of the head, especially after eating. His appetite was capri- cious, and he neArer dared to eat the same thing many times in succession. For the past six weeks he had suffered seATerely from painful attacks of gastralgia, Avhich at first Avere far apart, but later occurred daily, and sometimes even several times a day. Although they did not occur imme- diately after eating, yet he thought that they were caused by eating, and consequently had restricted his diet; as a result he lost over ten pounds in weight. A course of treatment for three weeks at Carlsbad had not alone not benefited him, but had even made him much worse. The bowels were constipated. The patient, a very active person, well nour- ished but pale, was the proprietor of a very large factory employing over * Hornbaum. Ueber die Pulsation in der Oberbauchgegend als begleitendes Symptom der Indigestion. Hildburgshausen, 1836. 496 DISEASES OF THE STOMACH. one hundred people, a number of whom were engaged outside of Berlin ; he had to oversee many of their trips, and consequently was frequently aggravated and worried. The illness of his partner for a time threw the entire responsibility upon him. A year previously he had had a similar attack. The physical examination revealed no abnormalities; all signs of spinal and intercostal neuralgia?, as well as painful points, Avere absent. On the other hand, the tendon reflexes Ave re markedly increased. The chemical processes of the stomach (after the test breakfast) were found normal. At the first glance it was apparent that this was a tolerably clear case of nervous gastralgia, in spite of the absence of the painful points, the symptom upon which so much stress had been laid. The treatment con- firmed the diagnosis. At first bromide of potassium was used ; later, a so- journ for several weeks at one of the resorts on the Baltic Sea caused the cessation of the attacks, and the patient then gained rapidly in weight. The rest was accomplished by a proper diet and hygienic measures (daily sponging and riding). Up to the present time the attacks have not re- curred. I must not omit to mention how difficult it is in such cases to exclude the presence of biliary colic. Even in the above case this point is not definitely settled. Undoubtedly there are cases of biliary colic without icterus, distention of the gall bladder, and fever, and in which the diagnosis between an affection of the liver and the stomach can not be made. Among the cases of pure gastralgia under my care quite a number are marked with an interrogation point. The following may be quoted as an example: A well-nourished woman, thirty years old, the mother of seven chil- dren, had formerly never had pain in the stomach ; five years previously, after the birth of the fifth child, had " biliary colic " ; had been to Carls- bad twice and obtained relief ; for the past year has had painful cramps in the stomach, at first infrequently, lately every fortnight. Physical ex- amination was negative. The uterus was pronounced normal by a gyn- aecologist. Never had belching or vomiting; between the attacks the appetite was good. The bowels are constipated after the attacks, other- wise regular. Although considerable relief was afforded by regulating the diet, drinking the water of the Marienbader Kreuzbrunnen, and taking soda to which small dosesof morphine had been added; yet, dur- ing the two months in which the patient was under my observation, she still had occasional attacks, although less severe in character. I consid- ered the diagnosis doubtful, in spite of the fact that the patient no longer referred the pain to the right hypochondrium as formerly, but to the middle line, and even to the left of it; the reason was, that Ave know that attacks of biliary colic may be followed by inflammation of the gall blad- der, with the subsequent formation of adhesions to the adjacent viscera the stretching of Avhich may produce colicky pains. GASTRALGIA 497 Hysterical Gastralgias.—It is only the peculiar nature of hys- teria which will enable us to recognize as hysterical the attacks of gastralgia which may occur during its course. In the following remarks I do not by any means propose to give a thorough description of the protean picture of hysteria; I simply wish to give a few suggestions, upon the completeness of which I lay A*ery little stress, because the characteristic features of this dis- ease are not difficult to recognize. In this affection, unlike neurasthenia, the psychical factors, per- verse thoughts and sensations, occupy a pre-eminent place. The tend- ency toward extraordinary behavior, the conscious or unconscious longing to be conspicuous by any means whatsoever, the turning away from every serious occupation, the degradation into the peculiar, fantastic existence about which the patient's entire being revokes, the capricious, willful, and impulsive actions are not those of ordi- nary fife, and these are all aberrations from normal thought and sen- sation, denoting profound changes in the psychical processes. As- sociated with them are the manifold, objectively demonstrable nerv- ous disturbances, convulsions, paralyses, pupillary inequalities, hemi- anaesthesiae, and changes in electrical sensibility. The manifestations of transference give additional symptoms. In the affections with gastric disturbances I have been particularly struck by the absence or lessening of the electro-cutaneous sensitiveness of the abdominal parietes; this sign Avas not absent even where other hysterical symptoms were scarcely manifested. A marked example of this is afforded in the following history which I shall relate in the exact words of the physician who sent the case to me : The patient is a lady, fifty-two years of age, the history of whose suf- ferings is a very long one. Soon after marriage she began to be troubled with haemorrhoids ; constipation was always present. For years she had suffered from chronic metritis and endometritis; the menses were very profuse, lasted eight days, and were accompanied by many disturbances. Temporary relief was obtained by douches, sitz baths, local applications to the cervical canal, and evacuants. To obtain better results she was sent to Eister; here the severe haemorrhages lessened, yet now there were very frequent disturbances of digestion combined with pains in the lumbar, inguinal, and umbilical regions. In this year she was sent to Kissingen, on account of the incessant complaints produced by variously located symptoms due to stagnation of the portal circulation. Here, for the first time, there Avere also pains and stitches in the breast, which usually 498 DISEASES OF THE STOMACH. appeared after midnight, and in fact began only at night, very suddenly, and Avith great severity : after lasting for hours they ceased, witli marked eructation. Sometimes these symptoms appeared on several consecutive nights; at other times the patient might be free for a number of nights. The patient appeared to be easily excitable, and, although emaciated, was very Avell preserved for her years; on the back of the left hand and forearm there was an absolutely anaesthetic zone ; patellar reflexes absent; the abdominal parietes were very sensitive, even to delicate palpation; on the other hand, faradic brushing was scarcely felt here, although it was painful on the face, arms, and legs. Undoubtedly this was a hysterical condition accompanying a reflex dyspepsia, proceeding from the uterus, the symptoms of the latter being especially prominent. The alternation with neuralgias or neuroses in other organs is characteristic of hysterical gastralgias. Oser reports a typical case of this kind in which hysterical aphonia alternated with attacks of gastralgia; this case suggests very strongly that the nucleus of the vagus was involved. I have had under my observation for a long time a case in which, together with persistent constipation— the bowels are never spontaneously evacuated—peculiar sensations are experienced in the abdomen, so that the patient thinks that a frog is in her stomach; at other times she imagines she has swal- lowed a needle, or that she has a tumor; at times she also has at- tacks of hysterical hoarseness and aphonia. Occasionally she also has attacks of true gastralgia. Some time ago I had the opportunity of seeing a case of hyster- ical gastralgia, which was so characteristic that it deserves mention here, especially as the treatment renders it remarkable: On April 1,1888, I was summoned to a distant suburb for a consulta- tion. When I arrived there the family physician was not present, because, as I was told, he said that " nothing could be done for the case." I found a small, delicate woman of thirty years, very much retarded in her growth ; she was living with her mother in great poverty, and had been in bed for eight months because she claimed to be too weak to walk. What little nourishment she took was liquid; nevertheless, she was tortured with such severe paroxysms of gastralgia that, as her mother stated, she scraped the chalk off the walls and disturbed the house by her screaming. In her childhood she was said to have had chorea. On physical examina- tion there was pain on pressure over the ovaries and in the infrasternal depression; no anaesthetic areas, patellar reflexes present, tongue clean, no fetor; at no times vomiting, stools very constipated, and like scybalse! The diagnosis of hysteria was beyond doubt. To show the patient that she could walk, I took her out of the bed and. supporting her under the arms, dragged her about the room. As I had thus convinced myself GASTRALGIA. 499 that there were no organic paralyses, I ordered her to visit me the next morning. During my office hours I was disturbed by a loud noise; it was the patient, who had come to my house in a cab after a ride of about forty- five minutes, had been carried upstairs by the coachman, and could go about the room Avhen supported by two persons. I washed out the stom- ach to examine its chemical functions, to reduce the hypersensitiveness, and also to produce a moral effect; while introducing the tube she became very cyanotic. No free hydrochloric acid was found in the wash-water. I prescribed hydrochloric acid, tincture of belladonna, and cocaine. Six days later she came again; but this time she was alone, had walked up the stairs very slowly and with great exertion, yet without any help ; but after that she had a typical attack of hysterical barking cough. The stomach was again washed out; no free acid, and a little peptone was found. Three days later she came upstairs alone. The cough had dis- appeared ; had occasional but only slight pains. Began to have appetite. The stomach was washed out twice more at several days' intervals. On May 31st I recorded that speech was good ; walked without aid, simply by holding her hand lightly; complained still of nausea, pain in abdomen after eating and walking, and heaviness in the legs. The stomach was found empty two hours and a half after the test breakfast. Arsenic and iron were ordered, and she was sent to the country. In the fall the mother reported that with the exception of trivial ailments she had kept well. I do not consider this case at all extraordinary. Similar cases occur every day, although possibly the cure is not so remarkable. It is superfluous to enter into further details on this subject, as such cases occur frequently in practice. The gastralgias constitute only one link in the chain of the manifold group of symptoms; the only point is, not to be deceived about the true nature of the at- tacks, and to recognize the hysterical basis. This is usually easy in most cases, but it may be very difficult, especially when the hysteria is manifested by only one symptom—for example, gastralgic attacks in old women, or even in men. To exhaust all these possible forms would take me far beyond my province. Finally, gastralgias may also occur in psychoses, and, what is es- pecially important, may be among the prodromal symptoms. For a year and a half I treated a young engineer for gastralgia associ- ated with neurasthenia. He finally became melancholic and committed suicide. Psychoses had already occurred in the family, and one brother had died in an insane asylum. In these cases the chemical functions of the stomach were normal, so far as could be determined. On pages 216 et seq., while considering chronic gastritis, I have already discussed the 500 DISEASES OF THE STOMACH. nervous symptoms and psychoses which may accompany or follow well-marked disturbances of the functions of the stomach. The views there expressed have been corroborated by Alt,* who has described a number of excellent examples of agoraphobia, melan- cholia, and conditions of fear which sometimes even became halluci- nations, in which improvement or cure followed suitable treatment directed to the gastric disturbances present. Most of the cases were gastrectases with disturbances of secretion. Alt's observations led him to fully accept my views of agoraphobia. As excessive or perverted sexual intercourse may be regarded among the psychoses, we may also include here the cases in which gastralgias occur after frequent pollutions. I have repeatedly seen examples of this in young men. * K. Alt. Ueber das Entstehen von Neurosen und Psychosen auf dem Boden von chronischen Magenkrankheiten. Arch, fiir Psych, und Nervenkrankheiten, Bd. xxiv, p. 403. CHAPTER XL THE NEUROSES OF THE STOMACH (CONTINUED). I consider hyperchlorhydria and hypersecretion of the gastric juice to be sensory neuroses of the secretory function. Reichmann deserves the credit of having been the first to thoroughly study this subject with our modern methods in 1882 and 1883 ; yet it is an error to suppose that these conditions were unknown formerly. Even Riegel makes this mistake in his last publication,* in spite of what I have already said on this point. On the contrary, they were de- scribed almost fifty years ago by Pemberton, Copland, Todd, Budd, Trousseau, and among the Germans by Hiibner; f but later, as these descriptions were based upon speculation rather than upon direct observation, they passed into oblivion. Recently this subject has been especially investigated by the above [Reichmann], JaAvor- ski, Yon den Yelden, Riegel, Saly, Yon Noorden, and Honig- mann. Hyperchlorhydria is an increase above the normal of the amount of hydrochloric acid secreted ; it is due to the stimulation of the * Riegel. Deutsch. med. Wochenschr., 1892, No. 21. f As early as 1820, Pemberton (Treatise on the Various Diseases of the Abdomi- nal Viscera) speaks of " a morbidly increased secretion from the stomach, analo- gous to a diabetic secretion of urine by the kidneys"; also Copland : " Or in other words, that pyrosis is produced by the continuance of the secretion of the gastric juices after the food taken into the stomach has passed into the duodenum." Budd also says that pains, etc., may arise "from the presence of free acid in the empty stomach." Trousseau (Des Dyspepsies, L'Union med., 1857, p. 306): " Le neuralgie de I'estomac augmente les secretions acides a ce point qu'elles se ferront non plus comme d'habitude au moment de la digestion mais encore en dehors de ces mo- ments." In Hiibner (Die gastrischen Krankheiten monographisch dargestellt, Leip- zig, 1844, S. 209) we find the following : " If the morbidly altered secretion of the gastric juice ... is the cause of the acid, then the patient suffers uninterruptedly from it; he may eat what he will, the symptoms become more marked, and, as the cause persists, it becomes more obstinate than in the formation of acid by fer- mentation." 501 502 DISEASES OF THE STOMACH ingesta, the acidity of which is heightened after being incorporated therewith. Naturally, it is difficult to determine where the normal acidity ceases and the abnormal hyperacidity begins, as a sharp line like the zero point in a thermometer can not be draAvn; on the con- trary, there must always be an intermediate stage in which the quantity of the secretion depends on individual circumstances; here we remain in doubt whether this should be called hyperacidity or not. However, from the average of a very large number of exami- nations after the test breakfast I consider that hyperacidity begins when the amount of acid is between 60 and 70 per cent. I have already spoken of the relation of hyperacidity to gastric ulcer; but it is beyond doubt that this condition may exist as a pri- mary neurosis independently of any organic lesions. Yon Noorden has observed it in melancholia,* Jolly claims that there is an in- creased secretion of gastric juice in hysteria, and Jaworski *f has frequently found it among the Jews of Galicia, who are especially predisposed to nervous disturbances. It may also occur as a reflex symptom of gall stones and renal calculi; and also where all of these factors are absent the neurotic basis of the disorder may be recognized by the want of success in treatment directed toward the cure of a supposed gastric ulcer. In the summer of 1887 I treated a girl of nineteen years for nearly three months for a supposed gastric ulcer, because she had periodical gas- tralgia, and a hyperacidity of 88 per cent. The absolute failure of the treatment, and the constant recurrence of the attacks, in spite of the im- provement in the general condition and the increase in weight, indicated a purely neurotic basis of the disorder, although other symptoms of neur- asthenia and hysteria were lacking. Hypersecretion, or better, parasecretion, gastrosuccorrhcea (the Magensaftfluss of Reichmann), may occur in two forms, the pe- riodic and the continuous. The acidity is not increased, as a rule, in the former, but it is in the latter. In the periodic form it usually occurs after eating, rarely while fasting, yet it does not seem to * Sitzungsbericht der medicin. Gesellschaft zu Giessen. Abstract in Berlin, klin. Wochenschr., 1887, No. 18. t W. Jaworski. Zusammenhang zwischen subjectiven Magensymptomen und objectiven Befunden bei Magenfunctionsstorungen. Wiener med. Wochenschr., 1886, Nos. 49-52. HYPERCHLORHYDRIA. 503 have a direct connection with the introduction of food. Wilkens * reports a typical case of this kind. A musician, thirty-six years old, who led an emotional life, for the preceding three years and a half had attacks of vomiting and pain in the stomach ; during the paroxysms he could neither eat nor drink, and had to go to bed. Similar attacks, which lasted tAventy-seven to thirty-five hours, recurred at intervals of ten to twelve days. He lost in Aveight from 2 to 3| kilogrammes [4-J- to 7f pounds]. Intense hunger between the attacks. The gastric juice vomited Avas about two pounds and a half, and eA-ery time had 012 per cent HCl. Diagnosis, affection of the secretory nerves. All writers agree that the condition is a functional disturbance of the nerves of the stomach, which may occur alone or as part of other neuroses. I can therefore not understand why Riegel f denies the nervous nature of this condition. That it occurs in all classes, as has been correctly claimed by Riegel, is no argument against this, for it is well knoAvn that neuroses occur in all classes of society. In continuous hypersecretion {continuirliche Magensaftfluss) there is a continuous secretion of gastric juice which is usually hyperacid,*}: so that even while fasting the stomach may contain smaller or larger quantities, varying between 100 and 1,000 c. c. [f 5 iijss. to Oij], or more, of a fluid very much resembling ordi- nary gastric juice, but Avithout any remnants of food, and frequently tinged grass-green or bluish-green by the admixture of bile.# The degree of acidity is high, but the amount of free hydrochloric acid which can affect the color reagents is very variable, as has been shown by JaAvorski; | since in cases with the same degree of acid- ity, in some there was much free acid and a feeble biuret reaction; in others, Hke free acid, in spite of the absence of organic acids and * S. A. Wilkens. A Case of Hypersecretion in Intermittent Attacks. Lancet, August 27, 1887. f Riegel. Ueber chronisch-continuirliche Magensaftsecretion. Deutsch. med. Wochenschr., 1892, No. 21. X Jaworski, loc. cit—in 121 cases of hypersecretion, hyperacidity was found at the same time in 115 of them. * Jaworski, loc. cit.—77 times in 222 cases. | Jaworski. Ueber die Verschiedenheit in der Beschaffenheit des niichternen Magensaftes bei Magensaftfluss (Gastrorrhcea acida). Verhandlungen des Con- gresses f. innere Med. Wiesbaden, 1888, S. 280. 33 504 DISEASES OF THE STOMACH. a marked biuret action; finally, in rare cases having a certain degree of acidity no reactions can be obtained, although one would expect a positive result Avith all the color tests. JaAvorski attributes this to the larger or smaller admixture of desquamated tissue elements of the mucous membrane or emigrated white blood cells, or even blood serum, Avhich by forming peptone or acid combinations may com- bine with part or all of the free hydrochloric acid. Swallowed saliva or bronchial secretion may take an active part in this ; they are usually found in stomach contents in the form of greenish masses. It is found that the digestion of starches is delayed, but is very prompt in albuminoids, so that after a meal consisting of meat and amylaceous substances one may find abundant remnants of undi- gested starches, but no trace of meat (Riegel). While fasting, the fluid in the stomach no longer contains the usual varieties of epi- thelium, but instead many nuclei with sharp contours, which Trink- ler * (who first called attention to them in animals), Jawwski, and myself consider to be remains of undigested cells. According to Jaworski, this condition of chronic hypersecretion must be almost the rule, since among 159 cases he found 115 with hyperacid and continuous secretion. Riegel does not go to such extremes, yet he claims that it occurs in about half of all the cases of stomach dis- orders. Other writers, especially among the French, for example, Matthieu, agree with the latter. My own experience would lead me to make the proportion even less, notwithstanding the fact that in the last few years I have examined in reference to this point every patient whose symptoms lead me to suspect this condition. We must leave it a mooted question whether, as claimed by Yon den Yelden, hypersecretion is only a lengthened reaction toward the stimulation of the food, or whether it is continuous, as asserted by Reichmann, Riegel, myself, and others. Under certain conditions, as observed by Talma,f the stomachs of neurasthenics may react ab- normally toward acids. * Trinkler. Ueber den Bau der Magenschleimhaut. M. Schultze's Archiv, Bd. xxiv, S. 195. t S. Talma. Zur Behandlung von Magenkrankheiten. Zeitschrift fiir klin. Med., Bd. viii, S. 407. HYPERSECRETION OF GASTRIC JUICE. 505 The irritation of the mucous membrane by the acid fluid causes hyperassthesia, the results of which are tenderness or pain in the epigastrium, acid eructation, heartburn, vomiting of sour masses, gastralgias, and similar digestive disturbances which constitute the symptoms of a chronic inflammatory condition, which occur not alone during the day, but also at night and morning when the stomach is empty. The absence of the signs of a catarrh is characteristic—i. e., coated tongue, foul breath, and loss of appetite ; on the contrary, the tongue is usually clean, and the appetite is increased rather than diminished. Excessive thirst was common in Jaworski's cases, and (Avhat is by no means wonderful) was said to have been relieved by drinking water and diluting the contents of the stomach. Among the results of this condition Ay,e must consider atony of the muscular coat of the stomach, and the gastrectasis due to it; where the condition has lasted a long time, this is so common that twenty-nine more or less well-marked dilatations of the stomach were found in thirty cases at Prof. Riegel's clinic* But by this time the neurosis has been converted into an organic lesion, and such conditions must, therefore, be considered among the cases of gastrectasis, and not among the gastric neuroses. [The urine is al- kaline, contains few chlorides; but phosphates are often in excess. The boAvels are usually obstinately constipated.] The exact diagnosis of this condition can only be made by exam- ining the stomach contents, and so far as concerns chronic hyper- secretion this examination must be made while fasting. [Reich- mann and Riegel recommend that the stomach be washed out in the evening, after which nothing is to be eaten. The tube is then passed early the next morning, while fasting.] A clew to this state is afforded by the fact that the symptoms are temporarily amelio- rated by eating proteids; this differentiates it from the disturb- ances caused by the pyrosis and gastralgia due to acid fermentation. The alkalies give temporary relief in both conditions of nervous hyperacidity and acid fermentation ; yet the difference is this, that for the former we have no other direct remedy excepting this purely * Honigmann, loc. cit. 506 DISEASES OF THE STOMACH. symptomatic one; but fermentation may be controlled and pre- vented by specific measures. [Much has been written during the past few years on the subject of Reichmann's disease, as gastrosuccorrhoea is sometimes called. In spite of the long and bitter controversy in which Schreiber and Riegel* have been engaged, much uncertainty still prevails as to hoAV much is to be included under this term. Neither is it yet certain whether it is a disease sui generis, or simply a symptom of various gastric disorders, or whether the gastrosuccorrhoea, atony, or gastrectasis is the primary factor of these three conditions which are so frequently associated to- gether. This may readily be appreciated by the fact that Reich- mann states that in years he has seen only 6 cases, while Boas states that in his large experience he has only encountered 10 genuine cases of the chronic f orm.f On the other hand, Bouveret X maintains that he has seen many cases of it, and devotes over sixty pages to its consideration. Riegel, Jaworski, and others also con- sider it a frequent disease. Much of this uncertainty is due to the fact that for a long time we did not really know what the contents of the stomach were while fasting. It is now acknowledged that acid gastric juice may be frequently found at this time (see page 20). Another reason which may be given is that, as above stated, many conditions in which hypersecretion occurs as a complication, as cases of dilatation, atony of the stomach, gastric ulcer, gastric neurasthenia, etc., with hyperchlorhydria, are regarded as examples of Reichmann's disease. Pathologically, some observers, as Hayem,* Korczynski, and Jaworski ||, have found special changes in the gastric mucous mem- brane to which the term gastrite hyperpeptique has been applied; the peptic cells undergo degeneration, but the parietal cells are un- changed. They would also connect this disease with the so-called acid catarrhal gastritis. * [See files of Deutsch. med. Wochenschr., 1893.—Ed.] t [Quoted from Boas, op. cit, Bd. ii, p. 130.—Ed.] X [Bouveret. Traite des maladies de I'estomac. Paris, 1893, ppj. 161-221.—Ed.] * [Hayem. Allgemeine Wiener med. Zeit., 1894, No. 2, etc.—Ed.] || [Korczynski und Jaworski. Deutsch. Arch, fiir klin. Med., Bd. xlvii, p. 578. —Ed.] HYPERSECRETION OF GASTRIC JUICE. 507 The main diagnostic features have already been considered. At present it is not expedient to give any points of differential diag- nosis ; this will only be possible when all are agreed as to what is understood under the term Reichmann's disease. It is also impor- tant to bear in mind the warning given by Boas,* that the find- ing of large quantities of acid stomach contents Avhile fasting is not sufficient to make the diagnosis of chronic gastrosuccorrhoea, but that the patient must also have the clinical symptoms of this con- dition—i. e., heartburn, eructation, occasional vomiting, pain in epi- gastrium and back, increased appetite, constipation, and emaciation; besides, the excessive quantities of hyperacid gastric juice must be of constant occurrence. The treatment, being different than that of the neuroses in gen- eral, Avill be considered separately. Bouveret f divides this into several indications, of which we may mention : 1. To stop the flow of gastric juice. This may be effected by lavage Avith a solution of argentic nitrate, 0*1 or 0*2 per cent as an intragastric spray, or 150 to 200 c. c. [f 5 "v to vjss.] are introduced every other day, and are allowed to remain ten or fifteen minutes; it may also be presented in pill form. Simple lavage has also been recommended. We may also give Carlsbad salts, large doses of alkalies, or atropine. My own experience with atropine has been faA^orable. It may be given in tablets of gr. -jA-g- three times daily after meals. 2. To suppress all causes of excitation of the secretory appara- tus. This includes mental quiet, hydrotherapy, regulation of the diet—i. e. avoidance of salt, alcohol, and highly seasoned food. The diet must be so regulated that small meals are given at frequent in- tervals ; albuminoids should be in excess ; starches and sugars are to be avoided. 3. To combat the effects of the excessive amount of HCl, espe- cially of the pain, vomiting, and the dilatation of the stomach. These have already been considered in the previous chapters.] Among these neuroses I also classify the condition called Gas- troxynsis [yaa-Tijp, stomach, 6fy?, acid] by Rossbach, which differs * [Boas. Zur Lehre vom chronischen Magensaftfluss. Berl. klin. Wochenschr., 1895, No. 46.—Ed.] f [Loc. cit, p. 212.—Ed.] 508 DISEASES OF THE STOMACH. from migraine only in the fact that it does not occur spontaneously as frequently as the latter, but as the result of definite causes, men- tal overexertion or profound emotional disturbances, and that the vomited masses are very acid, containing as much as 3*4 to 4 per thousand. However, the latter is common to both the condition and typical migraine, since I have repeatedly obtained equally high results in the latter. Jiirgensen * and Westphalen have also ob- served very similar states. [Boasf considers that this condition ought to be included among the periodical cases of hypersecretion.] [Dauber X has recently reported a case of chronic continuous se- cretion of mucus—gastrosuccorrhoea mucosa. At first the symp- toms were those of a chronic catarrhal gastritis with a moderate hyperacidity; later on, Avhile expressing the stomach early in the morning, he obtained 60 c. c. [f ^ ij] of a turbid milky fluid which contained a trace of HCl and much mucus. Fragments of food and saliva were absent. Subsequent examinations yielded the same re- sults. Dauber considers this condition a secretory neurosis analo- gous to gastrosuccorrhoea.] Nervous Belching, Eructatio.—It is only in hysterical persons that I have seen this occur alone, for in neurasthenics it is always asso- ciated with other sensations, especially oppression and tension in the epigastrium. I agree with Weissgerber,* who has published a very exhaustive paper on eructation, that in the former [hysteria] there is a heightened contractility of the stomach, together wdth an in- creased tone of the pylorus, provided the other manifestations of hysteria are also considered among the processes of irritation. Since the sphincter at the pylorus is stronger than that at the cardia, it will contract more powerfully even if both are equally stimulated ; hence, when the distention of the stomach is so great that it must * Jiirgensen. Ueber Abscheidung neuer Formen nervoser Magenkrankheiten. Deutsch. Archiv fiir klin. Med., Bd. xliii, S. 9 und 20.—Westphalen. Kopfschmerzen gastrisehen Ursprungs. Berl. klin. Wochenschr., 1891, No. 37. f [Boas, op. cit, Bd. ii, p. 132.—Ed.] X [Dauber. Ueber kontinuirliche Magenschleimsekretion. Boas's Arch., Bd. ii, p. 168.—Ed.] * Weissgerber. Ueber den Mechanismus der Ructus und Bemerkungen iiber den Lufteintritt in den Magen Neugeborener. Berl. klin. Wochenschr., 1878, No. 35. NERVOUS BELCHING. 509 expel some of its gas, this can escape more readily upward than downward. For it can not be doubted that eructation is an active and not a passive process. It may be possible, as claimed by Stiller and Rosenthal, that a relaxation of the cardia may facilitate the exit of the gases from the stomach, and that hence, according to cir- cumstances, eructation may be due either to an increase or a paral- ysis of the muscular action of the stomach. However, in many cases, belching certainly has nothing to do with relaxation of the cardia, as is shown by the numerous patients who try in vain to empty their stomachs of the accumulated gas. There is another kind of belching which is entirely independent of the stomach, in which the gas is raised only from the oesophagus by contracting the muscles of the neck, just as Bristowe * has as- sumed in hysterical vomiting. This form escaped Weissgerber's notice entirely. I myself can belch voluntarily, and I have con- vinced myself by means of the deglutition murmur that the air which is compressed in the cesophagus does not enter the stomach unless additional true movements of deglutition are executed. We may therefore accept the fact that it is possible to belch from the oesophagus alone, and this may explain many cases of hysterical eructation in which the stomach is not distended. Belching may become a very annoying symptom, since it is never noiseless but is usually quite loud. In one attack, of an hour's dura- tion, Cartellieri f was able to count it twenty-five hundred times! The gas is always odorless and tasteless, and thus differs in this re- spect from that raised in true dyspepsia, fermentative processes, etc. It therefore must consist of atmospheric air which, in the opinion of most authors, must have been swallowed, but which may also possi- bly come up from the intestines ; in many cases it is certainly raised only from the oesophagus. Cartellieri says his patient had no time to swallow air during the attack; in such cases the question then arises, Is air really expelled, or is it a manifestation in which this is simulated ? So far as I know, this subject has never been investi- * Bristowe. Clinical Remarks on the Functional Vomiting of Hysteria. Prac- titioner, 1883, p. 161. f P. Cartellieri. Eine seltene vorkommende Magenneurose. Wiener allgemeine med. Zeitung, 1885, S. 3. 510 DISEASES OF THE STOMACH. gated. It is worthy of note that I have observed nervous eruc- tation quite as frequently in men as in women. These cases are always neurasthenics in whom suggestion is of value. Pyrosis denotes the raising of sour masses from the stomach, a symptom which is well known under the name of heartburn. In the nervous forms of this condition at least, the stomach contents are not necessarily hyperacid; on the other hand, severe acrid and burning sensations may be produced by the regurgitation of even normal stomach contents or gastric juice. Here, also, one may be in doubt whether the cause resides in a heightened contraction of the muscular coat of the stomach or in a paralysis of the cardiac sphinc- ter. I have been led to classify this phenomenon among the motor conditions of irritation, because I have in vain searched for the sign of a marked relaxation of the cardia, the occurrence of the first deg- lutition murmur. Next in order is the consideration of a very annoying condition called Pneumatosis, or Tympanites. Here the stomach is filled with gas, and may become so distended that it causes not alone the un- pleasant sensation of marked tension, but even severe nervous symp- toms, by pushing the diaphragm upward and pressing on the heart. The patients are seized with typical attacks of asthma—the asthma dyspepticum of Henoch—in which at first there is only the annoy- ing feeling of being compelled to take deep inspirations after short periods of normal breathing; at the beginning this suffices, but later it develops into an incessant dyspnoea. Now there is also palpitation of the heart, pulsation of the peripheral arteries, fullness of the head, and even the feeling of impending death, or com- plete unconsciousness—in short, such is the condition that I have been repeatedly told by many sufferers that they Avere almost driven to suicide. Relief can only be afforded by bringing up some of the gas, and then the attack rapidly subsides. This condition is probably caused by the air which has been swallowed, together with a spasm of the sphincters of the stomach. The chemical processes were normal in one case which I examined, yet the same state may be produced in dyspeptics by the gas generated in fermentation. The attacks may be relieved instantly by introducing the stom- ach tube and allowing the gas to escape. But it seems that it is NERVOUS VOMITING. 5H very difficult to cure the disease itself where it is nervous in char- acter. In one case of pneumatosis I had no success with— ]pfc Cocain. hydrochloratis........... 1*0 [gr. xv] Aq. amygdal. amarse............ 10*0 [f 3 ijss.] M. Sig.: Ten drops every two hours. Large doses of bromide of potassium had also been given, but without producing any effect. In another case hypodermic injec- tions of morphine into the epigastrium gave immediate relief; a third case was cured by change of climate. The patient was a Bra- zilian, who while at home had suffered very severely from pneuma- tosis, but here [Germany] he was entirely free from it. Nervous Vomiting.—This includes those forms of vomiting which are caused neither by anatomical lesions of the stomach nor by quantitative or qualitative changes in the food. It is pre-eminently reflex, and may be caused either directly by the vomiting center or indirectly from other points in the central nervous system, or from other organs. As far as we know, the causes of this condition may include palpable changes in the brain and spinal cord, kidneys, uterus, liver, and certain organs of sense. These forms of nervous vomiting may be classed among the reflex neuroses. I have had the opportunity of observing two such cases of nerv- ous vomiting in close succession; during their course they seemed to be very much alike, yet the nature of the primary affection caused them to terminate very differently. The first case was a married lady, thirty-six years old, who had been suffering for three weeks with uncontrollable vomiting and a continuous flow of saliva, together with strong fetor from the mouth. This con- dition had come on after an attack of catarrhal jaundice, traces of which were just recognizable in a slight discoloration of the sclerotics at the time I first saw the patient. She had emaciated very little considering that she had taken scarcely any nourishment during this period, for she vomited everything immediately after eating. On examination, nothing could be found anywhere, not even in the liver. The passages were loose and bright yellow. Only temporary relief was obtained by the hypodermic use of morphine with atropine, washing out the stomach with chloroform water, and chloroform internally. Finally, the attacks were controlled by Avithholding all food and drink by the mouth, and using nu- tritive enemata for several days. But the salivation kept up some weeks longer, when it ceased entirely. The condition here was probably a reflex irritation from a gallstone; hysteria was excluded because the patient was otherwise healthy and the mother of several grown-up children. I 512 DISEASES OF THE STOMACH. must not conceal the fact that for a long time the patient caused me a good deal of anxiety on account of the absence of definite points on which to base a diagnosis. The second case was a lady in the fifties, living outside of Berlin ; un- fortunately, I had the opportunity of seeing her only once. In the early part of 1888 she experienced profound emotional disturbances ; since the following summer she had suffered from mild gastric troubles which lasted, with variable intensity, till November. After that every meal Avas regularly folloAved by vomiting, which had continued with few intermis- sions till the beginning of January, when I saw the patient. The woman, who had formerly been strong, was now very much run down ; she had frequent attacks of unconsciousness, and complained of great Aveakness, especially in the legs. Sleep was good. The urine had been repeatedly examined, but albumen and sugar were not found. I found a bedridden patient who was still quite well nourished in spite of the emaciation she complained of ; she could move quite readily in the bed ; she spoke with deliberation : in short, she seemed less affected than was to be expected from her history. On examination I could find noth- ing but a struma, and tachycardia up to one hundred and twenty beats per minute. There was no tumor nor any tenderness in the abdomen. Patellar reflexes normal; pupils reacted Avell; no limitation of the field of vision, and no complaints about sight. Sensation everywhere normal. Heart and lungs negative. In my presence the patient ate two pieces of toast and drank a glass of water without vomiting. The tube was easily introduced and the stomach contents expressed twenty-five minutes after. No hydrochloric acid found ; the fragments of toast were scarcely digested. This result left the diagnosis in doubt between a severe neurosis and an occult carcinoma; yet the absence of true cancerous cachexia favored the former. The rapidity of the pulse was attributed to the struma; tabes accompanied by gastric crises was excluded on account of the absence of its specific symptoms. The condition seemed to improve at first by using nutritive enemata and restricting feeding by the mouth as much as possible ; small doses of digitalis and atropine were also given. But she soon relapsed into the old condition; she gradually grew weaker, till one day she was seized with epileptic convulsions and died several days later. An autopsy was not allowed, yet the whole clinical picture led me to diagnosticate an af- fection of the medulla oblongata, probably a tumor, involving the roots of the vagus, thus causing the persistent vomiting and the rapid pulse. At all events, this presupposes such a situation of the suspected tumor that the nucleus of the fibers of the vagus distributed to the heart was paralyzed or destroyed, while those fibers going to the stomach were kept in a condition of chronic irritation. The soundness of this supposition remains in doubt, although it is by no means without a parallel (Ro- senthal). Both of these cases are typical examples of severe vomiting caused by nervous irritation, and at the same time they show how NERVOUS VOMITING. 513 difficult (sometimes even impossible) it is to make a diagnosis at a given time during life. For a certain group of cases Ave are unable to find this proof, although Ave may suspect the reflex origin. Pre-eminent among these stands the vomiting of neurasthenic and hysterical patients; it is uncommon among the former, but occurs frequently in the latter. It is characteristic of this form of vomiting that it usually occurs without any true nausea, and that the retching is reduced to a minimum. Hysterical vomiting may occur after every meal; some- times it is less frequent. Either all food may be rejected, or only certain kinds or even individual dishes. I made use of this fact in making my first investigations on the course of normal digestion in human beings; my subject was a hysterical girl who could retain all kinds of solid food, but was compelled to vomit whenever she swallowed any fluid. Another young girl, who has now been under my observation for a number of years, regularly vomits nearly all that she has eaten almost immediately after every meal. The gen- eral nutrition suffers surprisingly little from this persistent vomit- ing ; thus the second patient's weight has been almost the same during the past four years ; she has come down from 40*5 to 39*5 kilogrammes (89 to 87 pounds). In other cases the vomiting does seem to affect the weight. Thus Tuckwell * reports that three chil- dren were very greatly emaciated after prolonged vomiting Avhich lasted for months ; it was controlled by sitting the little patients up as soon as any tendency to vomiting occurred (and also, to be sure, carefully regulating the diet). Barras f speaks of a woman who suffered from nervous vomiting, but who ceased to vomit while she was in the bath ; she was cured after her meals were given to her in this Avay. This affection may pursue an acute or chronic course; it may begin spontaneously or may follow some demonstrable cause. One young girl was attacked immediately after the death of her father; another as the result of breaking off an engagement of marriage. As in other neuroses, the female sex is especially liable. I must confess that my experience of the infrequent occurrence * Tuckwell. On Vomiting of Habit. British Med. Journal, March 22, 1873. f Barras. Traite sur les gastralgies et enteralgies. Paris, 1827. 514 DISEASES OF THE STOMACH. of vomiting in neurasthenics does not agree with that of Rosenthal, who claims to have seen it not infrequently in this class of patients. I shall simply content myself with giving the headings of two of his histories: Observation No. 31.—Neurasthenia, hyperaesthesia toward acids, with consecutive gastric colic and vomiting. Cured by local remedies (small pieces of ice, with two to three drops of tincture of nux vomica) and gen- eral invigorating treatment. Observation No. 32.—Neurasthenia following onanism, with frequent vomiting. After the latter had ceased it began again after each coitus, while a heavy meal did not cause any complaints. Neurasthenia and vomiting cured by prohibiting sexual intercourse at the beginning of the treatment, increasing doses of potassium bromide, with some pyrophosph. ferri citronatric. [Ph. Austr.], Neptune's girdle, galvanization of the sym- pathetic, and hydriatic procedures. This difference in observation might appear striking, yet it may be readily explained by the fact that two observers in places at some distance from each other [Berlin and ATienna] deal with dif- ferent kinds of patients. Concerning the multiplicity and intensity of all neuroses it is peculiar that they most frequently attack the easily excitable Southerners, and especially the nationalities living near the military border. Hypersecretion seems also to occur more frequently there than in Germany. Finally, I must speak of a form of nervous vomiting which was described by Leyden.* It may occur as a primary neurosis, or as a secondary spinal affection, or as a reflex form. A peculiarity of this variety is the periodicity of the attacks [whence the name periodical vomiting], which may last from a few hours to a number (ten) of days. They begin with sudden nausea and colicky contractions of the intestines, but the abdominal wall is relaxed. At first the vomit consists of food debris and slimy masses, later of bile and streaks of blood; the attacks accompanied by migraine and tearing sensa- tions in the limbs;' they are followed by obstinate constipation, which is due to a spasm of the intestine. The trouble may last for years, but its origin can only be sought in the directions indicated above. In two of my cases the autopsies gave negative results. * Leyden. Ueber periodisches Erbrechen (gastrische Krisen) nebst Bemerk- ungen iiber nervose Magenaffectionen. Zeitschr. fiir klin. Medicin, 1882, Bd. iv, S. 605. STOMACH COLICS. 515 [Kelling * has recently reported a case of periodical vomiting associated with diarrhoea and vasomotor disturbance which was hereditary; the patient was a woman, forty-two years old, whose grandmother and mother suffered in the same way. The attacks were brought on by emotional disturbances and Avere not relieved by any drug except morphine, which, however, only slightly de- layed and lessened the attacks. The urine passed during the parox- ysms was more acid and toxic than that passed afterward.] Stomach colics are usually included among the gastralgias. In fact, they frequently occur together, since stomach colic is accom- panied by severe pains. But, as indicated by the name, the pains are colicky, and are due to a spasmodic contraction of the viscus; but they are not boring and shooting, as in genuine gastralgias. The causal factors are the same as those which have been described under the gastralgias. Localized spasms may occur at the cardia and pylorus. While introducing the stomach tube we sometimes experience the sensation as if the instrument were spasmodically gripped at the cardia. It would be difficult to ascertain whether this is due to a contraction of the lower segment of the oesophagus or of the cardia. Spasm of the pylorus seems to be due, disregarding the irritation from local changes, to gastric juice which is either too acid or which has been secreted at improper times. This is the only way of explaining hyperacidity and hypersecretion, as has been sug- gested by Boas and myself. Hanssen f describes a case of spastic stenosis which produced a palpable tumor at the pylorus the size of a thumb, and which disappeared under a soothing treatment. In distention of the stomach with gas, its escape upward or downward can only be prevented by an abnormally tight closure of the gastric sphincters. Peristaltic Unrest of the Stomach {Peristaltische Unruhe, Tor- mina ventriculi nervosa).—This was first described by Kussmaul X as being caused by an increased peristalsis, which is so intense and * [Kelling. Zeitschr. fur klin. Med., Bd. xxix, p. 421.—Ed.] f Hanssen. Quoted in Virchow-Hirsch's Jahresber. fiir 1890, p. 241. X Kussmaul. Volkmann's Sammlung klinische Vortrage, 1880, No. 181. [Also Boas, Deutsch. med. Wochenschr., October 17, 1889.—Ed.] 516 DISEASES OF THE STOMACH. so well marked that it may readily be perceived through the relaxed abdominal parietes, and which may at times be accompanied by gurgling and rumbling loud enough to be heard at a distance. This affection, by itself, is not painful, yet it may torture the sufferer to extremes. " It is just as if the intestines were twisted around in- side my abdomen," was told to me recently by a female patient, forty-six years of age, in whom the noises in the gut were so marked that they were audible as soon as she entered the room. They are most intense after meals, yet they do not disappear entirely between them; and, like other neuroses, they hav^e the characteristic pecul- iarity that they sometimes suddenly cease when the patient becomes excited—for example, during the doctor's visit—although a moment before they were present in full intensity. Kussmaul's earliest cases were persons with gastrectasis, and the majority of the cases which have since been observed have been such patients. The reA*erse of this condition, antiperistaltic unrest of the stom- ach, has been observed by Glax * as a pure neurosis. His was a typical case; the examples which had previously been published by Schiitz and Cohn Avere not free from criticism. Glax's case was a man, thirty-two years old, who had formerly suffered from dyspep- tic disturbances and a slight dilatation of the stomach ; the writer describes his condition as follows : A shallow but distinct constriction could be seen passing vertically downward over the stomach from the right sternal border. Suddenly to the left of this the fundus A^entriculi appeared hard and tense, and grad- ually expanded to the size of a child's head; this swelling slowly went down, then appeared to the right of the constriction, and then began almost immediately to the left again. Often, however, the movement distinctly passed from the right back to the left in an antiperistaltic direction. I then distended the stomach with carbonic acid gas, which caused the movements to become very active. Errors may arise from the not infrequent occurrence of peri- staltic unrest of the intestines; this may also assume an antiperistaltic form. That this may actually happen is shown by the cases of Bri- quet, Jaccoud and Fouquet, and Rosenstein, in which scybalse and discolored enemata were evacuated through the mouth.f In many * Glax, loc. cit, p. 190. f [A case of habitual defecation by the mouth has been reported by Desnos (Wiener med. Presse, 1891, No. 51, S. 1958). The case was that of a man who POLYPHAGIA. 517 persons stroking the finger nail rapidly and sharply across the epi- gastrium Avill produce distinct peristaltic movements. Here we must also include the cases of hyperkinesis of the stom- ach—i. e., increased motor activity—which causes the chyme to pass on into the intestines too soon. In such cases the stomach is found absolutely empty one hour after the test breakfast, and water which is introduced through the tube returns practically without any frag- ments of the roll. The same is true of the larger test meals. This is usually associated with an increased secretion of HCl. Leo * and Weinert f haA*e endeavored to construct a new disease out of these cases. Such cases I have seen and described years ago4 It is an open question whether the cause is only an increase in the motor functions and an abnormally rapid solution and absorption of the food, or whether it is due to an insufficiency of the pylorus. II. Conditions of Depression. Concerning the conditions of anaesthesia of the stomach we know very little, or rather it would be truer to say, practically nothing. In Chapter IX attention was drawn to this point; and as we nor- mally have no perception of the processes going on in and about our stomachs, Ave can not, therefore, gain any distinct conceptions of a pathological lack of sensitiveness. Polyphagia, or acoria [a, without, Kopew, I satiate], the want of the feeling of satiation, is best regarded as a result of anaesthesia of the stomach. If in the discussion on bulimia and anorexia I have made it evi- dent that these conditions are due to an OArerexcitation of centers in the brain, then satiation must be considered an inhibition of hunger, was found on the street in an epileptic attack; the saliva which flowed from the mouth was apparently mixed with fecal matter. Upon inquiry, the patient said that for two years he had not passed his stools per anum, but at six o'clock each evening he passed a stool by his mouth. The man was under observation only two days, but his statement was corroborated. At times the evacuation took place without any effort; at others they occurred during a nervous attack, with slight convulsions and pain in the cesophagus.—Ed.] * Leo. Ueber Bulimie. Deutsch. med. Wochenschr., 1889. f Weinert. Ein seltener Fall von Hyperkinese des Magens. Inaug. Dissert., Berlin, 1892. X Ewald. Diseases of the Stomach. Translated by Manges, p. 435. 518 DISEASES OF THE STOMACH. and the absence of this sensation a negative phenomenon—i. e., either the hunger center is no longer under the influence of the nervous paths passing to it, or the latter are defective. But I have already shown the vagueness and uncertainty of all such deductions, Avhich still lack a tangible and well-established basis, and I believe this is also true of the above suggestions. Purely nervous polyphagia is a very rare occurrence ; naturally I exclude those gluttons of whom the old and new books on " gas- trosophy " are full; but I mean those really morbid conditions which usually follow tangible lesions, and in the discussion of Avhich these cases Avill be found. Nervous anacidity (or anachlorhydria) of the gastric juice is not as rare as it would appear after searching through the literature. I have repeatedly found it in hysterical persons (see the case of hys- terical gastralgia, page 498). I have also observed it in neurasthen- ics in whom there was no reason for suspecting an organic disease of the stomach. I shall restrict myself to the following case : Mr. P., landed proprietor in Culm, a powerful man of Herculean build, forty-three years of age, said that he had been very nervous since the death of his wife; he imagined that he had a cancer of the stomach; there were also abnormal sensations in the urethra and impaired sexual pow- ers. His appetite was absent; the stools were constipated, hard, and dry. His disposition was exceedingly melancholic. On examination, nothing could be found except a very marked sensi- tiveness of the spinal column on pressure against the spinous processes and with the faradic brush. The stomach and urinary tract (catheteriza- tion) were found normal. Examination of the test breakfast after ex- pression revealed the absence of free acid. He was admitted to the sani- tarium, where he slept after taking potassium bromide. Hydrochloric acid was also given, as well as lukewarm baths in the morning and warm rub- bings in the evening. He was kept under observation nearly two months, and in that time the stomach contents, after the test breakfast, Avere ex- amined five times at about weekly intervals. They were always neutral, and contained the breakfast almost without any changes, but there was no mucus. Gradually the condition improved, after all kinds of sensations in the soles of the feet, loins, larynx, and urethra had in the meanwhile ap- peared. He was advised to go to the hydriatic establishment at Elgers- burg, where he stayed several weeks. Later on I received a report from there that " Mr. P., the neurasthenic, who leaves here to-day, has been generally improved by the use of lukewarm half- and sitz-baths,. elec- tricity, and massage; yet, in spite of this, his old complaints have re- turned, etc." NERVOUS ANACHLORHYDRIA. 519 Recently I heard again from this patient. Although a year and a half ha\-e elapsed, his symptoms are about the same. There are no signs of real loss of strength. We may therefore exclude organic diseases, car- cinoma, mucous catarrh, etc. I have observed quite a number of similar cases of even longer duration, one of which which was of particular interest, I have pub- lished.* The following is another case which is also a good example of the relation between nervous dyspeptic conditions to the true psychoses (see page 499). Mr. K., an actor, twenty-eight years old : slender figure. Previous history good ; no organic diseases can be discovered. He was always in good health, and lived quietly and regularly. In the winter of 1884-'85 he had to play a very exciting part several hundred times in succession at one of the local [Berlin] theatres. He felt exhausted and languid till in the following summer his condition became as follows, to use his own words : " It seemed to me as if my entire abdomen was constricted with a cord, so that suddenly I Avas attacked with a feeling of anxiety ; there was also oppression which extended high up into the chest and caused a torment- ing dyspnoea. I could not take a long, deep breath, on account of the feeling of undue fullness in the abdomen. This condition persisted even when I had eaten nothing—e. g. on aAvakening early in the morning. I can not complain of any real pains, yet I have never felt really well since. The pressure in the abdomen and the oppression following it con- tinually reminded me that my health was shattered. Although I fre- quently had a good appetite and relished food, yet not alone after eating, but even during the meal, severe disturbances set in, combined with end- less belching and eructation, and great fatigue ; in the beginning there Avas also vomiting, but after a few times this did not return. At times I was suddenly seized Avith a ravenous appetite, after the satiation of which the above attacks did not fail to appear. " The family physician's remedies were all of no avail, and this condi- tion persisted till the winter of 1886. Then the discovery that I had a tape-worm gave me hope that with its removal I would be cured. But, alas ! even after that, the old state persisted, and, if anything, became worse. My arduous duties in the winter of 1886-'87 did not cause the trouble to be less marked. Since then eA^ery part of my body feels very tired and languid, and in spite of careful rest and forbearance this has persisted up to the present time. The pressure from the distended abdo- men, oppression (frequently also stitches in the side), and dyspnea still persist. In spite of this I still have an appetite, sometimes a very large one. I usually relish food, but after meals, as a rule, though not always, the unpleasant symptoms make their appearance, and are more marked at some times than at others."' * Ewald. Ein Fall chronischer Secretionsuntuchtigkeit des Magens. Berl. klin. Wochenschr., 1892, No. 26. 34 520 DISEASES OF THE STOMACH. I haATe treated this gentleman a long time, and have tested his gastric juice for hydrochloric acid twenty-nine times, at the most varied intervals after the test breakfast, and also after a more abundant dinner. A small amount of free acid could be detected only three times. Propeptone was always present in relatively large quantities, but the peptone reaction was only faint, and the digestive power of the filtered gastric contents was negative, except in two tests, unless hydrochloric acid and pepsin were added. The rennet action could be demonstrated in half of the tests, and that, too, in the absence of free hydrochloric acid, but at the same time lactic acid was present; at other times the tests for lactic acid and peptone were positive, although free muriatic acid, pepsin, and rennet were all absent. Much mucus were never present in the wash-water except the first time, when the patient had evidently swallowed large quantities, which were due to the irritation of the tube. On the other hand, on two occasions I found small shreds which differed from those usually present in the wash-water, by sinking rapidly in the funnel. They con- sisted of the adherent epithelial cells of the gastric mucous membrane already described (see Fig. 27). Although I consider this pathological, yet such abrasions continually occur in the mucosa of the stomach as well as in other mucous membranes, though they are usually not found, since the acid gastric juice digests them. Strychnine was first given in small doses ; then later on his stomach was washed out and douched every sec- ond day with good results. In this case there was surely no mucous ca- tarrh ; an atrophy of the mucosa was also absent, since this occurs only as the consequence of a long-standing catarrh, or at a much more advanced age. None of the symptoms indicate cancer; what is, therefore, left but to assume that we are dealing with a neurosis ? The subsequent course of the case proved the correctness of my diag- nosis. The patient went to a well-known establishment for nervous dis- eases, and then spent a long time in Switzerland. On his return the gastric symptoms had completely disappeared, and in his own eccentric way he could not say too much in favor of his cure. But he now frequently had attacks of melancholia. The following summer he went to the country near a large lake. One evening he left the house and never returned. His body was found in the rushes at the border of the lake; he had evidently committed suicide by drowning. The case was thus a neurosis which had at first attacked the vegeta- tive functions, and finally had involved the mind. I have already given my opinion on the significance of the ab-- sence of free hydrochloric acid [p. 343 et seq.]. Relaxation of the cardia and of the pylorus must be considered conditions which resemble paralysis. Paresis of the cardia may give rise to the annoying and trouble- some nervous eructation (see above, under Eructation, page 508). If fluids or remnants of food are raised, as well as gas, the condition is called regurgitation. In very many persons small quantities of RUMINATION. 521 chyme having a very sour taste are raised after eating, but they are swallowed at once; this condition can be called neither pathological nor very annoying. But if it occurs frequently, and if larger quan- tities are regurgitated, then they are no longer swallowed again but are expectorated; true rumination, such as occurs in animals, does not take place. This condition is very annoying and may lead to serious changes in nutrition, yet it may also exist for years without any bad results. At times will-power may succeed in repressing it; yet I have seen a young man in whom neither will-poAver nor large doses of bromide of sodium had any effect. Regurgitation also occurs in diverticula of the cesophagus; here it may be due either to the filling up of the diverticulum and its overflowing into the mouth—this occurs most frequently when there is a stricture below the site of the diverticulum—or the contents of the pouch may voluntarily be raised, or rather pressed upward, by the patient. At my lectures I have frequently presented a patient with a diverticu- lum who was able to raise its contents at will by taking a deep inspiration and bearing down. As he restricted himself to fluids, the material which he raised contained no solid substances; the greater part of it was mucus, and by its smell one could ascertain Avhether he had pre- viously taken coffee, alcoholic drinks, etc. The reaction was alkaline or neutral. At first there was no odor, but recently the patient has ob- served that what he regurgitates has a slight foul smell. An entirely different thing, is Rumination, Merycismus [/j-wpv/cdfa, I ruminate], which has attracted the attention of laymen and phy- sicians ever since antiquity, and has given rise to the strangest theories. Some supposed that ruminators were necessarily de- scended from parents with horns; * thus Fabricius says, " Ex quo forte datur nobis intelligi parentis semen aliquam habuisse affini- tatem cum cornigeris animalibus neque mirum fuisse genitum filium simile quid a parente contraxisse" (that is, the father is said to have had a horn on his forehead); others imagined that these persons—at least as infants—must have suckled ruminating ani- * I have taken these data from the following treatises: Bourneville and Seglas, Archiv de neurologie, 1883, p. 86; Schmidtmann, loc. cit, p. 183; Schneider, Das Wiederkauen beim Menschen, Heidelberger med. Annalen, 1846, xii, S. 251; A. Johannesen, Ueber das Wiederkauen beim Menschen, Zeitschrift fiir klin. Med., Bd. x, S. 274. 5*22 DISEASES OF THE STOMACH. mals *; or even that " they had sinful intercourse Avith a coav." For a long time the opinion prevailed that these persons certainly had stomachs Avith different compartments, like ruminants, till it was finally shown by autopsies that in the majority of cases there were no changes in the stomach or oesophagus. As time passed by these negative results became more frequent; but Schneider [1846] was able to report the case of a court coun- cilor from Fulda who had died at the age of seventy years, at the end of the previous century, after having ruminated all his life. In this case it was found that the cardia was wide enough to easily ad- mit five fingers, and that the stomach was enormously dilated. Arnold (1838) observed three cases of rumination in which a sac- culated dilatation of the oesophagus was found above the cardia in the antrum cardiacum. Bourneville and Seglas f (1883) came to the conclusion that there was no real anatomical change. In fact, the manifestations of rumination are especially liable to attract attention. JSTot alone is it remarkable that, a shorter or longer interval after eating, the food returns to the mouth in sep- arate morsels, unchanged in taste, to be chewed and swallowed a second time, yet it is still more wonderful that they should come up in a definite order, and that they should taste even better than the first time ; X or that the taste may be so unchanged that, as re- ported by Peter Frank, a patient could distinguish the food in the reverse order in which he had eaten it on the previous day. It is also stated by Darwin that any particular dish which had been -eaten could be regurgitated at pleasure. This certainly seems to be almost superhuman. No light is shed by the explanation of Gallois # that the regurgitated masses at first consist of an indis- tinguishable mixture of fluid and solid ingesta; but when rumina- tion occurred during the later stages of digestion they would then contain only solids, and finally merely indigestible remnants of * Daniel Perinetti, an eight-year-old child, was said to have been nourished by a goat for two years, and to have ruminated later on in imitation of it. t Archiv de neurologie, 1883. X Anthony Rechy said, " Indeed, it is sweeter than honey, and accompanied by a more delightful relish." * P. Gallois. Merycisme et etude physiologique de la digestion stomacale. Revue de med., 1889, No. 3. RUMINATION. 523 food, like tendons, leaves of salad, etc. A simple explanation, is that during gastric digestion the fluidified ingesta are removed from the stomach; hence, the regurgitated masses gradually con- tain more and more solid substances which can not be attacked by the stomach, and finally consist of nothing but the latter. Hence, the condition of the regurgitated food does not depend on the wishes of the patient, but upon the phase of digestion in which rumination occurs. Rossier * asked one of these subjects to keep a record of the number of the regurgitated morsels. After break- fast there were six to twelve; dinner, eleven to twenty-one; supper, seven to sixteen. Rumination must not be confounded with the condition in which healthy persons may at will regurgitate the contents of the stomach; this is simply due to their ability to expel food from the stomach in the same manner as in my method of expression. It was this fact, for example, which led Montegre f to make his in- vestigations on digestion. That rumination is due to a neurosis is beyond doubt. This is corroborated by the well-authenticated cases of heredity—e. g., Windthier's case of a Swede, forty-five years of age, who had ruminated since his thirtieth year; his son also began it in his twenty-fourth year. Rossier describes a father and son, sixty-five and twenty-four years old respectively. Another factor, imitation, may play an important part; this is shoAvn in the case reported by Korner,*j: where a ruminating governess gave it to her two pupils. Additional weight is lent by its relatively frequent occurrence in nervous persons suffering from neurasthenia, hysteria, epilepsy, and idiocy, and its cessation when the patients experience profound emotional disturbances—passion, anger, etc. The case of Ducasse # also confirms this; this was a young man who had been afflicted Avith this disorder from his sixth to twenty-eighth year; it was * Rossier. Mercycisme hereditaire dependant d'une epilepsie. Annal. de la Soc. de med. d'Anvers, avril-mai, 1867. f Montegre. Experiences sur la digestion. Paris, 1814. X 0. Korner. Beitrage zur Kenntniss der Rumination beim Menschen. Deutsch. Archiv fiir klin. Med., Bd. xxxiii. * Ducasse. Mem. de l'Acad. royale de Toulouse, tome iii. Quoted by Schnei- der, loc. cit. 521 DISEASES OF THE STOMACH. lessened on the first day after his marriage, and disappeared one Aveek after; in other cases the reverse has occurred ; there are still others in whom the malady is made worse by sexual excesses. The state of nutrition of the patients is very variable. The dis- ease may occur in all classes of society and at all ages. Haste in eating and the swallowing of large morsels seem to be of very fre- quent occurrence in this disorder. Rumination may take place voluntarily or involuntarily, but its suppression causes pain. The most varied speculations have been indulged in as to its cause: first a central lesion was suggested; then a peripheral one; some thought it was due to a relaxation of the cardia; others re- ferred it to a heightened sensibility of the mucosa and stronger mus- cular contractions of the stomach, or even to some peculiar forma- tion of the latter or of the antrum cardiacum of the cesophagus. We must confess that we really know nothing of the true etiology of the affection, and it would simply be a circumlocution to follow the example of Dehio,* who designates it a " perverse and com- bined act of motion " or a reflex functional neurosis. A study of the murmurs of deglutition shows that there can be no permanent relaxation of the cardia. Dehio heard in his patient a distinct second deglutition murmur " which, according to the generally ac- cepted view of the origin of this murmur, can not be present when the cardia is paralyzed" [see footnote, p. 93]. Distention of the stomach with carbonic-acid gas also showed that the cardia was competent. In two cases of my own in which, at all events, rumi- nation was not very marked (possibly eructation would be the proper name), repeated examination failed to reveal the normal deglutition murmurs. According to the prevailing views, this would also speak against a permanent relaxation of the cardia; on the other hand, no further proof is needed to show that at the time of rumination the tone of the cardiac sphincter must be relaxed, and that there must be a paresis, or, better, an unusually easy yielding of the cardia. [Singer f believes that the relaxation of the cardia is due to the mechanical dilatation of the lower portion of the cesoph- * K. Dehio. Ein Fall von Ruminatio humana. St. Petersburger med. Woch- enschr., 1888, No. 1. t [G. Singer. Deutsch. Archiv fiir klin. Med., Bd. 1.—Ed.] RUMINATION. 525 agus Avhich results from swallowing too large morsels. This dilata- tion can be demonstrated with the cesophagoscope.] Unfortunately, in the patient who was able to swallow two live goldfish, respec- tively 6£ and 5^ centimetres [2| and 2^ inches] long, and to regurgi- tate them alive twenty minutes after, Alt * neglected to study the murmurs of deglutition; yet this performance would seem almost impossible without a relaxation of the cardia and oesophagus, since it is scarcely possible that the delicate fish could have been squeezed through the narrow passage alive. Decker reports five cases in which the stomach was repeatedly inflated; as the cardia was always found to be competent, the possibility of a permanent paraly- sis or paresis of the cardia is excluded. The chemical processes in the stomach have been studied by Alt, Boas, Jiirgensen, Sievers, Leva, Decker [and Runge].f The variable results obtained—all degrees of acidity, from hyperacidity to anacidity, were found—agree with the statement I made that " the changes in the chemical processes of the stomach are not an essential but only an incidental feature in the symptomatology of rumination ; hence 1 would not be at all surprised if in one and the same patient varying degrees of acidity were found under otherwise identical conditions, since such a variable relation is characteristic of many of the neuroses." This latter supposition has since been verified by Leva, who found all the various degrees of secretion of HCl in a ruminant. Nevertheless, among the cases just referred to relief was ob- tained by the treatment which was indicated by the results of the chemical examinations; alkalies were given in one case of Alt and three cases of Sievers, where there was hyperacidity, and acids in Boas's case with subacidity. These results should be appreciated still more, since every kind of treatment which had previously been tried Avas unsuccessful. The only exception to this was Rossier, who * K. Alt. Beitrage zur Lehre von Meryeismus. Berl. klin. Wochenschr., 1888, Nos. 26 and 27. f Alt, loc. cit.—Boas. Berl. klin. Wochenschr., 1888, No. 30.—Chr. Jiirgensen. Ibid., No. 36.—Sievers. Finske Lakares Allskapt, 1889.—Leva, Munch, med. Woch- enschr., 1890, Nos. 20. 21.—Decker. Ibid., 1892, No. 21.—Freyhan. Deutsch. med. Wochenschr., 1891, No. 41.—Einhorn. Medical Record, May 17,1890.—[Runge. St. Louis Medical Review, August 18, 1894.—Ed.] 526 DISEASES OF THE STOMACn. gave relief in one case by the internal administration of morphine in increasing doses up to 4<> centigrammes [gr. vj] a day; in another patient in whom this drug was powerless he succeeded with large doses of opium, 1*5 gramme [gr. xxi jss.]. In general, the best treatment seems to be that given in a case described by lY-nsgen—an energetic will, and swallowing the food at once when it regurgitates, without chewing it a second time. Expectoration of the regurgi- tated food may lead to serious disturbance of nutrition, as occurred in the case reported by Sauvage, of a patient who had been afflicted for thirty years, but whose confessor had ordered him to spit out the regurgitated masses. Two weeks later he had emaciated very much, but he did not improve till, at the advice of a physician, he returned to the old habit. If the existence of paresis of the cardia in rumination is an as- sumption rather than a demonstrated fact, this is even more appli- cable to incontinence of the pylorus, which was considered a special nervous affection, first by L. de Sere,* and more recently by Eb- stein. y It is true that the latter has positively demonstrated that the pylorus may be incompetent when unyielding neoplasms involve this portion of the stomach; this was naturally to be expected, but unfortunately we have no diagnostic criteria by which we may es- tablish the existence of this condition as dependent upon atony of the pyloric sphincter—i. e., as a pure neurosis—for an occasional incontinence of the pylorus is a normal phenomenon. An extensive experience will demonstrate to any one what was first observed by Kussmaul, that, after introducing the tube into the stomach while fasting, intestinal contents or bile may be obtained ; this occurs most frequently when the patients have gone without eating for a longer period than usual. The natural inference from this is that the pylo- rus was not firmly closed; consequently it will be very difficult to distinguish its pathological occurrence from the physiological. Fur- thermore, Ebstein's diagnostic test, the rapid passage into the intes- tines of the carbonic-acid gas which has been artificially generated * L. de Sere. Du relachement du pylore. Gaz. des hop., 1864, No. 62. t Ebstein. Ueber Nichtschlussfahigkeit des Pylorus (Incontinentia pylori). Volkmann's klin. Vortrage, No. 155.—Einige Bemerkungen zu der Lehre von der Nichtschlussfahigkeit des Pylorus. Deutsch. Archiv fiir klin. Med., Bd. xxxvi, S. 295. ATONY OF STOMACH. 527 in the stomach, is unreliable, and is subject to many errors. First, the inflation of the stomach may displace some coils of intestines up against the abdominal wall, just as if they had been distended by the passage of gas into them from the stomach; secondly, different per- sons require very varying quantities of effervescing powder to dis- tinctly inflate their stomachs; finally, the gastric contents may com- bine Avith more or less of the gas as it is generated. Hence the pylorus may be competent, in spite of the negative result of this test. At all events, incontinence of the pylorus is a very rare occur- rence. In the numerous cases in which I have distended the stom- ach to its utmost with air, I could never distinctly demonstrate such a condition; instead of that, the air always escaped upward with ex- plosive eructations Avhenever the tension became too great. Never- theless, I believe that some dyspeptic disturbances are due to pyloric incontinence ; yet many more are the result of regurgitation of the intestinal contents into the stomach rather than a too early passage of the chyme into the duodenum. On the other hand, I agree fully with Ebstein and Zeckendorf,* that the acute intestinal tympanites of hysterical persons may be largely due to the rapid passage from the stomach into the intestines of air which has been swallowed ; hence the pylorus must necessarily have been incompetent. Atony of the stomach is an important neurosis to which sufficient attention has not yet been paid. We have already encountered this condition and its results as an accompanying symptom of manifold dyspeptic' disturbances ; but atonic states of the gastric musculosa may undoubtedly occur as a primary neurosis, as an inde- pendent disorder of the innervation of the nerve centers regulating the peristalsis of the stomach ; these may occur either in loco affec- tionis or in the central nervous system, and are frequently the cause of the dyspeptic troubles resulting therefrom. It is superfluous to speak in detail about the origin of this condition as a result of in- sufficient or too tardy movement of the chyme, since we have already frequently observed this reciprocal relation of cause and effect. I simply wish to distinctly state once more that I consider " atony " to include a disturbance of the gastric motor function only, not of * Zeckendorf. Ueber die Pathogenese der Bauchtympanie. Dissertation, Got- tingen, 1883. 52S DISEASES OF THE STOMACH. its secretory ; in other words, it is a lack of agreement between the muscular force of the stomach and the task to be accomplished by it—i, e., it is an insufficiency of the stomach (Rosenbach). Other- wise we may, hke Yon Pfungen,* include three fourths of all the lesions of the stomach under this title, and yet not obtain a clear conception of its relations. Atony may be partial or complete, depending upon the involve- ment of the fundus or pylorus or the entire stomach. I consider this classification premature, for it is based upon the independence of the several portions of the stomach, which has recently been re- peatedly maintained. I will admit the value of the experiments of Schiff, von Hofmeister, and Schiitz upon the movements of the stomach,*}* and also the observations of Yon Pfungen X upon a pa- tient who had undergone the operation of gastrotomy; according to these experiments, the motor power of the body of the stomach is about one third as great as that of the antrum pylori ; while the function of the latter is especially to expel the chyme, that of the former is the trituration of the ingested food. But I maintain that we know so little about the movements of the stomach in patho- logical cases that we may be happy to be able even to recognize the existence of these disturbances as such. Furthermore, I can not see what is gained by such a distinction between atony of the pyloric portion and of the body of the stomach; for, so far as clinical effects are concerned, the latter will always be the more important and causal factor. Where there is no movement in the body of the stomach its absence can not be replaced by the peristalsis of the an- trum pylori, be the latter ever so powerful; but if a normal or even heightened peristalsis of the fundus be associated with an atonic condition of the pyloric portion, there can be no obstruction to the expulsion of the chyme; on the other hand, this "must be more easily accomplished than normally, since an atonic state of this portion of the musculosa of the stomach would be inconceivable without a co- incident diminution of the tone of the true pyloric sphincter Avhich * R. Freiherr v. Pfungen. Ueber Atonie des Magens. Klinische Zeit- und Streitfragen. Vienna, 1887. t Vide Ewald. Klinik, etc., I. Theil, 3te Auflage, S. 78. X Loc. cit, p. 261. NEURASTHENIA GASTRICA. 529 is so closely associated AA*ith it; consequently, the muscular power of the remainder of the stomach can easily overcome the resistance of the " inert channel " thus formed. In such cases we might possibly suppose that Avhere this relaxation of the pyloric portion begins a closure of some kind might be effected by the contraction of the adjacent circular fibers of the stomach, and thus none of the chyme will pass on into the intestines in spite of the apparently vigorous peristalsis. This is how Yon Pfungen attempts to explain a case of this kind Avhich had been reported by Kussmaul.* Such suppo- sitions, however, lead us into the broad field of speculation, from which we must keep aloof as far as possible. III. Mixed Foeai of Gastric Neuroses. Neurasthenia Gastrica (Nervous Dyspepsia).—The condition Avhich, under the name of nervous dyspepsia, has recently been the subject of so much discussion, is, in my opinion, only a complex form in which the neuroses already described in the preceding pages take a more or less prominent part, but which is at the same time charac- terized by an active participation of the entire gastro-intestinal tract. According to Leube,*f* nervous dyspepsia is a group of symptoms essentially of a cerebral nature, Avhich are due to an abnormal irri- tability of the sensory nerves of the stomach toward the normal digestive processes, and which are especially manifested by the symptoms which I have already grouped together among the sen- sory phenomena caused by irritation. On the other hand, Stiller includes under this title of nervous dyspepsia all those conditions in which there is a predominance of digestive disturbances which are reflected back upon the stomach from and by means of the central nervous system and the sym- pathetic respectively, and which may incidentally cause definite changes in its functions. Whereas the former writer proceeds from the center of the circle to the periphery, the latter goes in the re- verse direction, from the periphery to the center. Furthermore, while the former claims that the true peptic activity of the stomach * Kussmaul. Deutsch. Arch, fur klin. Med., Bd. vi, p. 470. f Leube. Ueber nervose Dyspepsie. Deutsch. Arch, fiir klin. Med., Bd. xxiii, 1879. Also Spec. Diagnostik der innerer Krankheiten. 3te Auflage, 1891, p. 265. 530 DISEASES OF THE STOMACH. is unchanged, the latter maintains that it is altered under certain conditions, and, in fact, in the majority of cases. In this dilemma it would be difficult to follow the usual course and say that the truth lies midway between these two views, for in a certain sense, or rather with certain restrictions, both of them may be correct. There are some cases—i. e., the rarer cases of Leube— which correspond to the picture of nervous dyspepsia ; but I believe that this group will gradually grow smaller and smaller with the increasing delicacy of the methods of investigating the peptic pow- ers of the stomach. After a careful study of the digestive pro- cesses, I have found changes in the chemical functions in quite a large number of cases in which the nervous symptoms were the prominent feature. Furthermore, we must not forget that our pres- ent methods of chemical examination are still relatively crude, and give us absolutely no information concerning the amount of pepsin secreted, and very little about the intensity of absorption and the strength of motion. Hence, we can only ascertain certain gross changes, Avhile there is surely quite a large number of alterations which escape us because they lie beyond our present limits. The same may be true of anatomical changes. Important discoveries of this kind have been reported by Jiirgens, Blaschko, and Sasaki. Jiirgens* has made an important contribution upon this point. In forty-one patients who, while alive, had complained of vague dys- peptic disturbances, a complete degeneration of Meissner's and Auerbach's plexuses was discovered ; in this way he gave a tangible anatomical basis to these cases of dyspepsia, many of which had been diagnosticated as "reflex dyspepsia." Furthermore, "where the disturbance was more of a sensory character," he found " a de- generation of the muscularis mucosas of the stomach and of the intestines also, and a pronounced formation of varices in the intes- tinal walls, the exact examination of which revealed a degeneration not alone of the muscular fibers of the veins, but also of the sensory nerves and of the branches of Meissner's plexus in the vicinity." Inasmuch as severe forms of anaemia are also accompanied by gas- trointestinal symptoms which are unusually pronounced, especially * Jiirgens. Verhandlungen des iii. Congresses fiir innere Medicin, S. 253. NEURASTHENIA GASTRICA. 531 at the beginning of the disease, and may thus simulate nervous dys- pepsia, the findings of Blaschko and Sasaki are of importance. In severe anaemias both of these observers have found marked degener- ation of the nervous plexuses of the intestines, and at times also fatty degeneration of intestinal muscular layers and atrophy of the mucosa. On the other hand, in the majority of cases we can discover no changes in the nerves outside of the stomach, of a direct or reflex nature, which may be referred to this viscus, or may give rise to immediate disturbances of the gastric digestion. In either case the clinical symptoms of this condition will always consist of the manifestations which I have already described as those of irritation or paralysis, a mosaic in Avhich now one stone, now another, will be lacking; sometimes one, sometimes another, will be especially prominent; but they will never be firmly fixed to- gether, and, like man himself, will always present a kaleidoscopic picture. There is only one characteristic feature, that, taken all in all, the symptoms are usually mild, and severe forms of gastralgia and cramps, nervous vomiting, polyphagia, and bulimia do not occur. In all these patients the symptoms of imperfect intestinal diges- tion will always be found associated with those due to changes in the gastric functions. In some cases the symptoms of imperfect intes- tinal digestion are not well marked, and are restricted to the conse- quences of lessened or increased peristalsis—usually constipation, less frequently diarrhoea—or the stools may be normal but absorption is disturbed; such patients will emaciate continuously in spite of a good appetite, etc. Not very long ago attention was directed to these cases by Mobius.* In other cases the intestinal symptoms are so well marked that one might be tempted to group them into a dis- tinct class, as was done by Cherchewsky.f Here, along Avith mild gastric disturbances, we observe anorexia, repugnance toward taking food, coated tongue, mild nausea—in short, symptoms which might * P. Mobius. Ueber nervose Verdauungsschwache des Darms. Centralblatt fiir Nervenheilkunde von Erlenmeyer, vii. Jahrgang, 1884. No. 1. f Cherchewsky. Contribution a la pathologie des nevroses intestinales. Revue de medecine, 1884, No. 3. 532 DISEASES OF THE STOMACH. not inaptly be designated those of visceral neuralgia. The bowels are usually constipated, and there are severe pains in the abdomen, either spread diffusely or recognizable as separate painful spots. Rarely the abdomen is retracted ; as a rule, it is quite distended and tympanitic, sometimes even to a marked degree, while the free es- cape of flatus causes great torture to the sufferer. The gas which may escape either by mouth or by rectum has caused this condition to be called flatulent dyspepsia. In addition there are also general nervous symptoms like those observed in the gastric form, except that they are usually more severe and even at times alarming.* If one will recall what was said in the introduction to this part about the innervation of the stomach and intestines, the mutual transition of the symptoms of these viscera ought to occasion no surprise. The close connections of the numerous plexuses of the intestines and the fibers of the vagi, splanchnics, and the various sympathetic ganglia, necessarily cause the involvement of the one to be followed by a disturbance of the other, no matter whether the cause is located centrally or peripherally. Therefore I have proposed the name neurasthenia gastrica, or vago-sympathica, for this entire group of symptoms. It may be sub- divided into a gastric and an intestinal form, according to the viscus which is especially involved.f I consider this name is much better than the expression " nervous dyspepsia," because it corresponds more closely to the nature of the affection, and my liking for the latter designation has by no means been lessened by the reasons given by Leyden \ in a splendid paper on this theme. But we must not forget that the term " nervous dyspepsia " is so expressive and in such general use that it may safely be retained. As I have already said, gastric neurasthenia is a complex of the various nervous disturbances already described, and therefore these can give no specific and characteristic data. The same is true of the etiology. Undoubtedly there are cases * One of my patients wrote to me that " I must complain most of a feeling of oppression while walking, bitter taste in the mouth, and obstinate constipation." The bitter taste in the mouth is frequently replaced by an exceedingly annoying dryness and burning sensation. t Ewald. Verhandlungen des iii. Congresses fiir innere Medicin. X E. Leyden. Ueber nervose Dyspepsie. Berl. klin. Wochenschr., 1885, No. 30. NEURASTHENIA GASTRICA. 533 in which no cause can be discovered—Fenwick * claims this for the majority of his observations—but surely there are very few patients indeed in whom the characteristics of a nervous disposition can not be discovered. Either nervous diseases are hereditary in the family, or the nervous system has been very severely taxed in some way or another—profound emotional excitement, business cares, severe mental exertion, sexual excesses—or the condition which we call cerebral or spinal irritation, or any other affection of the nervous system bordering upon hysteria, has preceded it. Thus, I have had under my treatment for a long time a young man, eighteen years old, whose father suffered from pronounced spinal irritation. An- other case was an old gentleman Avho had all the symptoms of a well-marked neurosis of the intestinal tract, after having suffered for years from peculiar nervous symptoms, which were always asso- ciated with irregularities of intestinal digestion. There are also some cases—their number is very limited—in which intestinal neu- roses are developed without these prodromata. By watching such patients for a longer period we will usually be able to observe other neurasthenic symptoms. I have frequently seen a young lady in whom the condition which at first could only be called gastric neur- asthenia was aggravated on account of the cessation of men- struation, and finally became hysteria, with especial prominence of the signs of gastralgia and enteralgia. However, such an occurrence is manifestly very rare, and warrants the suspicion that it was hys- teria from the beginning ; in fact, all these conditions now under discussion Avere formerly included under this disease. Naturally, they have been known for a long time, but their exact description, and the chemical demonstration of the integrity of the gastric juice, is an achievement of recent times, due especially to the labors of Leube. At this place, however, I should like to state that the same nerv- ous conditions which constitute the prodromata of the dyspeptic condition may also become very prominent during the course of the latter. Not alone are there pains in the head and back, weariness of the limbs, etc., but these patients are very gloomy and pessimis- * Fenwick. On Atrophy of the Stomach and on the Nervous Affections of the Digestive Organs. London, 1880. 534 DISEASES OF THE STOMACH. tic, worry unnecessarily, and lose Avhat little ambition they still pos- sess. One of my patients complained of a weak memory and in- ability to concentrate his thoughts; another suffered very severely from vertigo during every exacerbation of his dyspepsia. At the same time the pulse became small and rapid, the hands and feet were cold and livid, and trembled, there was palpitation of the heart with oppression and dyspnoea, which became worse on getting up or walking; these symptoms increased to a most intense fear of impending death, till suddenly relief was brought by the passage of flatus. Although the patient, who was a well-educated gentleman, moving in the highest circles, kneAv how the attack would end, he was nevertheless utterly unable to overcome the feeling of impend- ing death. A description by Freud * is quite typical, and agrees very well with my own experiences : A patient, who was originally healthy, committed the usual sexual errors at puberty, overworked while a student, acquired a gonorrhoea, and was then suddenly attacked with dyspepsia accompanied by obstinate constipation. He was relieved of the latter after months, and then had oppression in the head ; was moody, and unable to do any work ; the char- acter changed, he grew intensely egotistical, and finally became a great burden to his family. Here we continually encounter fresh surprises and apparently the most wonderfully various moods of the stomach. Many patients can only retain ice-cold fluids, but at once vomit the same fluids if they are slightly warmed. Others have peculiar idiosyncrasies to- ward special articles of diet which cause them the most intense pain. Thus one of my patients, a young man eighteen years old, was completely absorbed in regulating the choice and quantity of his food: About midday he became so weak that he could not eat, and the very thought of food caused palpitation and cold sweats. He continually had the sensation of a lump in his stomach. For days weakness compelled him to lie on the sofa. In the evening he ate (as he thought) too much. He was always constipated, and every cathartic made him feel very weak. He kept a voluminous diary about himself. As a youth masturbated a great deal, and overworked himself mentally. Was cured, although the condition had lasted a number of years. * S. Freud. Ein Fall von hypnotischer Heilung, etc. Zeitschr. fur Hypnotis- mus, 1892, Heft 3, p. 102. NEURASTHENIA GASTRICA. 535 I have already called attention to the fact, which I shall empha- size once more, that many of these patients gradually weaken them- selves to such a degree by adhering too long to a rigorous diet which Avas necessary for a gastric catarrh, etc., but which was not dis- continued at the proper time, that very energetic measures are neces- sary to restore the normal tone of the weakened nervous system. In all these cases I wish to state emphatically that the lesions are dyspeptic conditions upon a neurotic basis, never concomitant symp- toms of really demonstrable injuries of the central nervous system— e. g., gastric crises of tabes dorsalis, diffuse and localized cerebral lesions, ailments of the peripheral nerves, etc.; or what may occur as reflex neuroses in chlorosis, menstrual disorders, uterine and ovarian diseases, and intense psychical excitement (Avhen they are manifested as nervous diarrhoea or constipation). As opposed to the chronic and, if I may so express it, the milder character of gastric neuras- thenia, these conditions take the shape of acute, rapidly developed attacks, accompanied by very intense symptoms, Avhich may either occur once or return periodically. Such attacks are described in Richter's monograph.* Leyden + has also published a series of very well marked examples. In my opinion the only relation Avhich they bear to neurasthenia gastrica is that they can not be grouped Avith the forms of psychoses or neuroses in Avhich anatomical lesions of the central nervous system can not be demonstrated Avith the meth- ods thus far at our disposal. Although we can not positively say that real pathological ana- tomical changes are lacking, yet we can usually exclude great altera- tions in the chemical functions, even though this is not always justi- fiable. Leube X divides the cases of nervous dyspepsia into those with normal, excessive, and lessened secretion of HCl. I do not wish to argue with this distinguished clinician who Avas the first to direct attention to nervous dyspepsia, yet I would state that in so doing * Richter. Ueber nervose Dyspepsie und nervose Enteropathie. Berliner klin. Wochenschr., 1882. No. 13. f Leyden. Ueber periodisches Erbrechen (gastrische Krisen). Zeitschr. fiir klin. Med., Bd. iv, 1882, X Leube. Spec. Diagnose der innerer Krankheiten. 3te Auflage, 1891, pp. 265 et seq. 35 536 DISEASES OF THE STOMACH. he has become untrue to his original definition, the chief feature of which was this very absence of marked changes in the chemical functions of the stomach. It has therefore seemed proper to me to separate and classify as independent conditions or neuroses some of the cases which Leube includes under the head of " nervous dys- pepsia." In many cases an indigestion of short or long duration, a mild catarrh, frequently recurring hyperaemia, and the like, have surely been the primary cause of the manifestation of the nervous symp- toms in the digestive organs. Indeed, such injurious conditions may recur during the course of the disease, and may produce a tempo- rary aggravation thereof, because they are added to the factors already existing. But if we encounter leucorrhcea or dyspeptic disturbances during chlorosis, or if we see retinal changes in Bright's disease, Ave will never consider these conditions as anything but symptoms of a general malady. In my opinion there can be no doubt that these dyspeptic con- ditions are the manifestations of general neurasthenia. In rare cases this may be developed only in the nerves of the stomach and intestines, and apparently the lesion is in one of the peripheral nerves. In the vast majority of cases these local symptoms are com- bined with others of a nervous nature, and among which they oc- cupy a pre-eminent place. For the diagnosis of dyspeptic neurasthenia there are no single characteristic symptoms. Therefore it can not be made simply from the results of one examination, and the complaints of the patient at that time ; the more so since not infrequently organic lesions may go hand in hand with neurasthenic conditions. A correct diagnosis is possible only after a prolonged observation of the course of the disease, discovery of the causal factors, the failure of all measures directed toward suspected organic diseases of the stomach and intes- tines, and a proper estimation of all the signs of neurasthenia which may be present. As Burkart has rightly suggested, particularly great value is to be laid upon the peculiar character of the indi- vidual symptoms, on account of their mutual relations to one an- other, and their changeable occurrence. This is also true of R. Burkart's painful points in the abdomen, NEURASTHENIA GASTRICA. 537 which have already been described [page 494]. There is nothing about them which is characteristic of gastric neurasthenia. Thev can not be mistaken for gastralgias, enteralgias, and the painful sensations in the abdominal parietes ; the latter not infrequently radiate from the infrasternal depression as lancinating pains, and might well be called epigastralgic, as proposed by Briquet. I would also like to direct attention to the following: First, the gastralgic pains are, as a rule, diffuse, and do not have that distinct, sharply localized character observed in ulcer or cancer of the stom- ach. They are also much less dependent upon taking food, although this relation is also very variable in carcinoma. Secondly, vomiting occurs very rarely in gastric neurasthenia. AVhen it does occur, it consists of mucus mixed with bile and rem- nants of food in various stages of digestion, but never of bloody or decomposed masses. It is distinguished from hysterical vomiting by the ease and regularity with which the latter usually occurs. The taste of the vomit is not offensive, but bitter. I am inclined to agree Avith Liebreich, that the taste in these cases is due not to bile but to peptones, which are well known to have a very sharp and bit- ter taste. In belching, with the regurgitation of acrid masses, this is undoubtedly the case. Thirdly, the stools—of which I have examined a large number in the course of time—have the usual changeable character described by Lambl, and later by Nothnagel.* In no case did I find an un- usual quantity of undigested remnants of food or mucus, or even of blood. The form of the faeces is also very variable. I have ob- serAred nothing of a typical character. Of not infrequent occurrence are, however, the membranous, flattened, vermicelli-like or tubular masses, sometimes grayish white, at others brownish in color, Avhich at times are passed in enormous quantities in the stools. This con- dition has incorrectly, I believe, been described as membranous en- teritis and colitis, because these products have nothing to do Avith an inflammatory condition of the intestinal mucosa. On the con- trary, as has also been shown by Kitagawa.f they consist of numer- * Nothnagel. Beitrage zur Physiologie und Pathologie des Darmes. Ber- lin, 1884. f Kitagawa. Beitrage zur Physiologie und Pathologie des Darmes. Berlin, 538 DISEASES OF THE STOMACH. ous broken-down cells and brownish fragments and detritus, Avhich are imbedded in a fibrinous and somewhat tenacious basement-sub- stance, in which remnants of organized tissue can never be detected, but which, on the contrary, on adding acetic acid give the charac- teristic reaction of mucin. In all probability they are formed from an overproduction of intestinal mucus. Concerning the differential diagnosis, I shall not speak of the neoplasms, ulcers, strictures, etc., which may be recognized by pal- pation, inspection, or by very characteristic symptoms, but instead I shall state that the initial stage of a neoplasm in the stomach may simulate a neurosis, and, on the other hand, that a chronic, distinc- tive process like phthisis or carcinoma may be diagnosticated where really only a neurosis exists. It may happen that a long time may be required before a positive diagnosis can be made. Indeed, we should endeavor to realize the fact that in very many cases it is impossible to recognize a neurosis at the first glance, and that only prolonged observation, a very carefully taken history, and a consideration of the general condition will strengthen the diag- nosis and exclude other conditions. Intercostal neuralgia has also given rise to errors ; and although I have never met such a case, which must necessarily be rare, it should nevertheless always be borne in mind. Where the diagnosis is doubtful concerning the possibility of a gastric ulcer, there is an additional factor to which I always pay attention—i. e., for the reasons given on page 422, I am afraid to introduce the stomach tube, and I thus avoid the risk of causing a perforation for the sake of information which may be doubtful; therefore it seems much more important to me to treat the sus- pected ulcer with appropriate remedies, and let the diagnosis depend upon the results of such a course of treatment. The prognosis is as uncertain here as it is in all neurasthenic affections. Some cases are quite rapidly cured by suitable treat- ment, and may remain well permanently or temporarily ; but there are others which for years resist all the efforts of rational thera- peutics. The course which an individual case will pursue can not 1884. [This subject has been carefully studied by Akerlund. Boas's Archiv 1896 Bd. i, p. 396.—Ed.] GASTROPTOSIS. 539 be predicted in advance. It is natural to suppose that the chances are best where the symptoms have been mild, and vice versa; but on this very point I have repeatedly erred. Apparently very severe cases are cured in a relatively short space of time, while seemingly simple ones persist for years. In general, only this much can be premised, that at best the trouble is one of long duration, lasting for months at least, and that the external appearance of the patient affords no clew to the severity of the neurasthenic symptoms. I haAre frequently treated young men who were the picture of health, and whose complaints Avere therefore ridiculed. There are other cases in which the patients decline very much, emaciate, and become so miserable that some English writers have even described extreme conditions of weakness, with terminal oedema, fever, and death. Possibly this is the best place to discuss a group of symptoms which, unlike nervous dyspepsia, is due to a distinct pathological cause; I refer to the condition described by Glenard as enteroptosis and gastroptosis [see p. 89]. In this condition, which I have studied very carefully,* there is a relaxation of the ligaments of the abdominal viscera, especially of the stomach, intestines, and the large abdominal glands, which allows these organs to descend, and thus produces changes in the circulation with their consequences. The clinical picture is well known to all; it consists of distinct dyspeptic disturbances combined with nervous symptoms which may arise sympathetically in the en- tire organism. The digestive symptoms are disturbances of appetite, anorexia or false sensations of hunger, a sense of fulness in the epigastrium, belching, acid taste and dryness of the mouth, burning or shootmg pains in the epigastrium after eating. Constipation alternating with so-called false diarrhoea is common, scybalse, which are almost as hard as stone and frequently coated with mucus, being passed after severe straining and after taking strong purgatives or enemata; large fragments of membrane, as in membranous enteritis, are often observed. At the same time the abdomen, especially its lower por- * Ewald. Ueber Enteroptose und Wanderniere. Berl. klin. Wochenschr., 1890, No. 13. A full bibliography is given in this paper. 540 DISEASES OF THE STOMACH. tion, is somewhat distended; dragging pains and abundant flatus are complained of. The general nervous symptoms include general weakness, change- able and depressed moods, headaches and fulness of the head, ver- tigo, heaviness of the limbs, the hands and feet feel cold, palpitation, disturbance of sleep and frequent pains in the back which are re- ferred to definite localities. Further general symptoms are emacia- tion, rapid loss of weight, pallor, falling out of hair, eczema, and the like. The loss of weight may at times be so marked that the patient or his friends fear cancer or malignant diseases. [On the other hand, there are many cases of gastroptosis which give rise to no clinical symptoms. When symptoms are present, they need not always be constant but may occur in paroxysms. Chlorosis is said by Meinert to be a constant symptom of this condition; indeed, he maintains that gastroptosis is the chief cause of chlorosis in women (see p. 571).] On examination we find a more or less marked mobility or dis- placement of the kidneys, sometimes of the liver, and downward displacement of the stomach, i. e., gastroptosis, a symptom which may readily be demonstrated. If the stomach be distended by means of the methods described on page 85, it will project on the anterior wall hke an air cushion so that the upper border may be seen in the middle line a little above the umbilicus, the lower border being be- tween the latter and the symphysis. Besides this there is also usu- ally a dislocation of the liver and transverse colon, while the small intestines sink deeply into the pelvis. Arguing from a theory which need not now be discussed, because it has no sufficient pathological basis and because it is not verified by clinical observations, Glenard * assumed that these various dis- placements were caused by a bending of the transverse colon near the ligamentum colico-hepaticum. As the result of this the colon, lying to the other [left] side of this place, collapses and becomes con- tracted into a sausagelike mass which can be felt extending from the left to the right. Glenard lays great stress on this symptom, * Glenard. De l'Enteroptose. Paris, 1885, and numerous articles and theses by Trastour, Fereol, Cuilleret, Cheron, Raoult, Blanc-Champagnoe, Ott, Meinert, Chlapowski, etc. GASTROPTOSIS. • 5^ which he calls the corde oblique. As the result of this the mesen- teries become relaxed so that the small intestines sink into the pelvis and drag doAvn the stomach, kidneys, and sometimes even the liver itself. However, my own experience is that in the majority of cases the contracted colon can not be palpated; on the contrary, what is Fig. 46.—Sketch of positions of abdominal viscera in splanchnoptosis, a, liver ; c, stomach ; d, pancreas; e, e, duodenum ; /, transverse colon ; g, descending colon ; h, small intes- tines : u, umbilicus. felt is the pancreas, the horizontal portion of which, as is shown in the accompanying sketch (Fig. 46), can be felt above the lesser curvature because it is now no longer covered by the stomach, as occurs under normal conditions. 1 shall cite the folloAving instructive case to demonstrate these relations. It, together with the sketch (Fig. 46), is taken from a dissertation by Poltowicz,* of Prof. Roux"s clinic in Lausanne. The sketch is of especial value because it is drawn from the condition found at a laparotomy. The patient was a fifty-year-old woman who gradually became ill with dyspeptic symptoms accompanied by vomiting (at times it was black and * Poltowicz. Contribution a l'etude de la maladie de Glenard, etc. Inaug. Diss. Lausanne, 1892. 542 DISEASES OF THE STOMACH. once consisted of two tablespoonfuls of blood), obstinate constipation, and marked emaciation. Dislocation and dilatation of the stomach could be made out, but no tumor was palpable ; but as a neoplasm was suspected, after a time an exploratory laparotomy was performed. The operation must have been very '* thorough " as the following report will show : " The liver is completely dislocated and is somewhat rotated on its axis, so that the gall bladder lies in the axillary line. The right kidney lies below the liver in its normal situation. The stomach is slightly filled, has thin walls, is but little distended in the pyloric region, but is enormously dilated at the fundus, which has sunk down into the pelvis. The same is true of the duodenum. The omentum and small intestines are in the pelvis. The pan- creas is about the lesser curvature. Nothing but the mesentery and ab- dominal aorta lie on the lumbar vertebrae. The transverse and descend- ing colon are strongly contracted, the former being in the form of a cord which runs across the abdomen below the umbilicus." In spite of this somewhat extensive laparotomy, as must he confessed, the patient was discharged " cured " at the end of five weeks, and was re- ported to be feeling well and having a good appetite. It is inconceivable how simple manipulation, etc., of the abdom- inal viscera should cure such marked symptoms, a point which the writer does not discuss. The description, however, which he gives of the situation of the viscera is an excellent picture of splanchnoptosis. I myself have observed a similar very typical case in a corpse in which the kidneys were also movable and in which absolutely nothing in the way of old inflammatory adhesions could be discovered ; I shall refrain from describing it, as the above case will suffice. Meinert * has photographed a number of typical cases of gastroptosis; Krez,f of Leube's clinic, has also published a typical case with a detailed account of the autopsy; the interesting feature of the case was that the pancreas was palpated during life, as de- scribed above, and the finding was corroborated at the autopsy. The fact that such displacements of the intestines may possibly occur even during foetal life, or may be predisposed to during child- hood, can not be denied; X yet in this connection we must distin- guish two classes of cases: * Meinert. Dresdener Jahresbiicher, 1891-92. [A large number of photo- graphs of cases of gastroptosis will be found in Meinert's monograph. Volkmann's klinische Vortrage, Nos. 115 and 116, January, 1895.—Ed.] t L. Krez. Zur Frage der Enteroptose. Munch, med. Wochenschr., 1892:, No. 34. X [Thus, according to Meinert, a long and narrow thorax predisposes phthisical patients to splanchnoptosis. Rickets also predisposes even young children. See Figs. 10-14 in Meinert, loc. cit—En.] GASTROPTOSIS. 543 1. This group includes those cases in which the displacement of the viscera is the demonstrable result of antecedent inflammatory processes, especially such as proceed from the genital organs in women. Such conditions have formerly been repeatedly described, and Yirchow, in discussing my paper on enteroptosis, stated that these changes were known long ago. It Avas equally well known that such conditions could be followed by the above-mentioned sub- jective symptoms to a greater or less degree. But the disorder does not consist so much in an exclusive downward displacement of these viscera, as it does in the distortion and displacements which may at times also lead to the sinking down of the organs. 2. However, splanchnoptosis as regarded by Glenard and myself has nothing to do with these cases; it includes a group of cases which are entirely independent. In the dislocations after old in- flammatory processes, only isolated coils of intestmes or organs are involved, but in Glenard's disease, as splanchnoptosis is sometimes called, there is a general descent of all the abdominal organs above mentioned, and in the histories of these cases there is absolutely no reference to any such antecedent inflammation. If any etiological factors can be discovered at all, they Avill be severe bodily exertion, concussion of the abdominal viscera, protracted and frequent labors, tight lacing, and, finally, antecedent prolonged dyspepsias which have occasioned the enteroptosis as the result of the change in the pressure and tension. Thus enteroptosis may cause dyspepsia or vice versa. Enteroptosis occurs far more frequently in Avomen than in men. In Glenard's 404 cases, 306 Avere women. [Tight lacing and preg- nancy are the chief causes of this great difference in the two sexes.] I would not be understood as having stated that only true enter- optosis can lead to the aboATe-mentioned symptoms. For the sec- ondary displacements of the abdominal Auscera, and especially of the stomach and intestines, may give rise to exactly similar clinical pic- tures, in which it is natural that the chief place should be occupied by the primary causal factor. Concerning the relation between floating kidney and dilatation of the stomach, I would refer to what has already been said on page 275. 544 DISEASES OF THE STOMACH. Here it Avill suffice to say that the existence of gastroptosis and enteroptosis has now been corroborated by many writers,* and that the simple method of distending the stomach and intestines, com- bined with palpation of the abdominal organs, have enabled us to isolate from the great mass of cases of nervous dyspepsia a group of cases in which palpable anatomical changes which can be demon- strated during life are the causal factors. In discussing the treat- ment, I shall be able to show that we are now able to treat these conditions better than formerly. [On the other hand, many cases of gastroptosis exist which give absolutely no symptoms at all; but if, however, for some reason or another, the general health is impaired, the compensation which has been established will be disturbed and the examination will then re- veal the displacement of the viscera.] TV. Reflex Gastric Neuroses from other Organs. Under this heading I include palpable changes in organs other than the stomach, whose effects are observed in the gastric nerves; in other words, those morbid manifestations to which, like all other reflex conditions, the axiom Ablata causa cessit effectus has a spe- cial significance. Too frequently is the cause of the cases sought, not in the real primary area, but incorrectly in the place second- arily involved; therefore, a brief resume of the reflex symptoms known to us may serve to remind you what organs and morbid processes are to be especially considered. The reflexes manifest themselves as (1) mild disturbances of digestion; (2) gastralgias; (3) vomiting; the latter occurs espe- cially in acute affections, the former in those of a more chronic na- ture. But just as these three types may very frequently be inter- changeable, and even occur in combination, so may chronic proc- esses give rise to the symptoms of an acute gastric disorder, if they exacerbate suddenly or invoke specially predisposed nervous plex- * Ott. Ueber die Glenard'sche Krankheit. Prager med. Wochenschr., 1892, No. 46, and the works already quoted. [This subject is fully discussed in the recent monographs of Meinert, op. cit.; Kelling, Volkmann's klin. Vortrage, No. 144, Feb- ruary, 1896; Fleiner, Ueber die Beziehung der Form und Lageanderung des Magens. Miinch. med. Wochenschr., 1895, Nos. 42-45.—Ed.] REFLEX GASTRIC NEUROSES. 545 uses, etc., in their course. This is well shown, for example, in the crises of locomotor ataxia. The fact has been repeatedly mentioned that the stomach is the center of a nervous plexus whose branches have very wide connec- tions, and directly or indirectly involve nearly every organ in the body; hence, an irritation which is manifested at any point in this plexus will reach the stomach, just as in any peripheral end-appa- ratus. Of especial importance are the reflexes from the central nervous system, the great glandular organs in the abdomen, the in- testines, genital tract, and, finally, the heart and lungs. The cerebral disorders—meningitis, haemorrhages, abscesses, tu- mors—are usually accompanied by vomiting of a transitory or more permanent character, and frequently by hypersecretion of the gas- tric juice, as was already known to Andral.* This abundant secre- tion of gastric juice during life will therefore explain the rapidity with which post-mortem softening of the stomach may take place in these cases. Yomiting usually occurs during the course of the disease, or it may usher it in and thus cause great misconceptions, as is well known in meningeal inflammation, especially of children, and in tumors. Therefore, every case of long standing, or even un- yielding vomiting, must be considered from this standpoint. The vomiting of seasickness, migraine, and the beginning of psychical affections, may also be included in this variety of reflex vomiting. Of the latter occurrence I have tAvo examples in which, appar- ently from a gastric catarrh, very obstinate vomiting was developed, which, after having lasted several weeks, was followed by a psycho- sis. Lesions in the cervical and dorsal portions of the spinal cord cause gastralgia, sometimes with vomiting, as soon as the centers or nerve-roots concerned are involved. Such "gastric crises" occur not alone in the gray degeneration of the posterior columns (tabes), but also in insular lesions of disseminated sclerosis. Yomiting is also of frequent occurrence in abscesses and calculi in the liver and kidneys, especially when they pass into the excretory ducts and thus irritate their sensory nerves. I will recall the vomiting of pregnancy not alone to indicate a * Quoted by Budd, loc. cit. 546 DISEASES OF THE STOMACH. very common reflex upon the stomach, but also a not infrequent source of diagnostic doubts and errors. How frequently has ap- parently serious vomiting, which simulated some grave disorder of the stomach, simply proved to be the first manifestation of a preg- nancy ! It occurs in the early part of gestation, Avhile the uterus is still in the pelvis, since this variety of vomiting is due to the press- ure of the enlarged womb upon the sympathetic nerves. The dis- order may reach such a degree that all remedies are useless, if the uterus is unusually large or is misshapen, or if its muscular fibers are inflamed, or if it is misplaced. But acute injuries or maltreat- ment of this organ may also cause vomiting—e. g., snaring a polyp at the fundus uteri preparatory to its removal. Dr. Daumann had such a case in which pain in vomiting set in every time the loop was tightened, while the latter ceased as soon as the ligature was loos- ened. The same thing has been observed in operations on the blad- der, urethra, etc. Chronic disorders of the female as well as of the male sexual organs may be followed by chronic dyspeptic conditions. I would here remind you that the normal process of menstruation causes retardation of gastric digestion, or even complete absence of free hydrochloric acid in the stomach contents, as was first demonstrated by Kretschy,* and later confirmed by Fleischer,f and Boas and myself.X How much greater reflexes will be referred to the stom- ach and intestines by amenorrhoea and dysmenorrhoea, the climac- teric period and chronic disorders of uterus which are associated with an irritability, or even with a direct excitation of its nerves 1 Hence we can understand why Kisch* found "dyspepsia uterina " most frequently in retroflexion of the enlarged uterus, then in mal- positions in general, myomata, pelvic exudations with traction on the uterus and its adnexa, follicular or carcinomatous ulcers of the cervix, and ovarian tumors ; but it was absent in simple and mild * F. Kretschy. Beobachtungen und Versuche an einer Magenfistelkranken. Deutsches Archiv fiir klin. Med., Bd. xviii, S. 257. f E. Fleischer. Ueber die Verdauungsvorgange im Magen unter verschiedenen Einfliissen. Berl. klin. Wochenschr., 1882, No. 7. X Ewald und Boas. Zur Physiologie und Pathologie der Verdauung. Vir- chow's Archiv, Bd. civ. * H. Kisch. Dyspepsia uterina. Berl. klin. Wochenschr., 1883, No. 18. REFLEX GASTRIC NEUROSES. 547 endometritis, chronic catarrhs, and small perimetric and parametric exudations. Such dyspeptic conditions which may have persisted for years have been cured in a surprisingly short time by appro- priate local treatment. I have recently observed a peculiar and rare example of a reflex of this kind which first involved the salivary glands and indirectly the stomach— i. e., sialorrhea with dyspepsia resulting therefrom. An unmarried lady, forty-one years of age, was said by her physician to have suffered for two and a half months from loss of appetite, bitter taste in the mouth, consti- pation, feeling of oppression over the stomach, and for several weeks very severe salivation. She Avas much emaciated, felt very weak, and had the greatest repugnance toward exerting herself, although she Avas formerly very actiA^e. She lived upon her estate, and had already taken Carlsbad water, condurango, nitrate of sibber, and small doses of quinine ; cold rub- bings and suitable diet had also been tried, but all without success, On the patient's admission to the sanitarium the amount of saliva secreted daily Avas found to be about two litres [4| pints]; this was examined in Prof. Kossel's laboratory and found normal. No great changes discovered in the gastric chemical functions; acidity 48. No other anomalies found; the mouth was free from any special disease. E\ery kind of poisoning by the coating of mirrors, mouth Avashes, hair dyes, and the like, was ex- cluded. After a fortnight's trial of pills of atropine, and hypodermic in- jections of morphine and atropine, with only temporary effect on the symptoms, I discoArered a retroflexion of the uterus. With the introduc- tion of a pessary the obstinate ptyalism and the dyspeptic condition very soon disappeared. Reflex gastric neuroses from the generative organs occur in men as well as in Avomen, a relation which occurs much more commonly than is usually supposed. I have already referred to the effects of sexual errors (onanism, sexual perversion, and excesses). At present I refer to local affections, such as chronic urethritis, urethral stric- tures, spermatorrhoea, pollutions, etc., with reflex gastric neuroses. These include any of the conditions already described, i. e., gastral- gia, vomiting, eructation, cramps, bulimia, gastrosucchorea, etc. ; but far more frequent than any of these is nervous dyspepsia. In these cases the relation between the genital lesion and the gastric symp- toms is established by the fact that after the treatment and cure of the former, the latter often—but, alas! not ahvays—disappear. In the course of months I have seen quite a number of these cases, but, as I have already hinted, the relief of the gastric trouble by no means always follows the cure of the local disease, as might easily 548 DISEASES OF THE STOMACH. be inferred from the excellent monograph of Peyer; * on the con- trary, the gastric neurosis may persist long after the disappearance of the local disease. In conclusion, I must mention the reflexes from the intestines, such as are caused by worms, enteroliths, and neoplasms in and about the gut. The parasites, especially, play an important part here. I shall not go into details about the serious disturbances of nutrition which may be caused by the distoma and strongylus varie- ties, neither shall I speak of the disease of tunnel workmen and brickburners.f It will suffice to mention the ordinary ascarides and taenia, and recall the fact that many a long-standing " nervous dyspepsia " has been terminated by the expulsion of a tapeAvorm! Treatment of the Neuroses of the Stomach. In all the nervous diseases of the stomach the treatment will depend upon the question whether they are of an irritative or de- pressive nature. The conditions of increased irritability must be separated into those in Avhich the hyperaesthesia is local and those which are cen- tral in origin. For local hyperaesthesia, opium and its derivatives—morphine, codeine, and narceine—have been invaluable for ages. In general, morphine is best administered in watery solution, or in bitter-almond water, since it is not dissolved in the stomach if given in substance, or has little or no action. The most rapid effects may be obtained by hypodermic injection in loco affecto; I usually follow the English custom of adding one tenth part of sulphate of atropine, partly to counteract any possible nauseating effects of the morphine, partly to obtain the relaxing effects of the atropine. This is an excellent combination, which may be very useful in patients who have inva- riably had nausea and vomiting after the simple morphine solution. For example, in bulimia, Rosenbach has recommended the hypoder- * A. Peyer. Ueber Magenaffectionen bei mannlichen Genitalleiden. Volk- mann's Samml. klin. Vortrage, No. 356. t [The Tunnelkrankheit or Bergkachexie is a form of anaemia caused by the anchylostomum duodenale. It has also been called Gothard Tunnel disease. The same parasite is the cause of brickburner's anaemia.—Ed.] TREATMENT OF GASTRIC NEUROSES. 549 mic use of extract, opii which has been dissolved in glycerin, filtered and diluted with water; but I have had no occasion to use it. If the general sedative effect on the entire nervous system is desired, and if there are reasons Avhy it should not be given by the mouth, or subcutaneously, it may be administered in suppositories of 0*03 to 0*05 [gr. £ to f] each, or 0*1 to 0*15 [gr. ji to ij£] per day. The action of opium and morphine may be assisted by hydrocyanic acid, in small doses, in the form of aqua amygdalae amarae. Hydrochlo- rate of cocaine may be unhesitatingly given internally, in doses of 0*05 to 0*1 gramme [gr. £ to jss.] ; yet one must not forget that, in some individuals, even the first dose may be followed by unpleasant symptoms of irritation—sleeplessness, restlessness, pulsation of the arteries, and oppression and pain in the head. For prolonged use and where the symptoms are mild, coca Avine may sometimes be valuable. As an antispasmodic Ave may use the preparations of belladonna, either pills of extract of belladonna or atropine, or the tincture. In hysterial hyperaesthesiae, gastralgias, vomiting, and even in spasmodic conditions, I have been very well satisfied with the fol- lowing combination of the remedies mentioned above: $ Morphinae hydrochloratis.... 0*2 [gr. iij] Cocainae hydrochloratis...... 0*3-0*5 [gr. ivss.-vijss.] Tincturae belladonnae........ 5*0-10*0 [f 3 ji-ijss.] Aquae amygdalae amarae..... 25*0 [f 3vj£] M. Sig.: Ten to fifteen drops every hour. However indispensable morphine may be, the fact of its subcu- taneous use being a two-edged sword in all chronic forms of disease is well knoAvn; and it is just in neuroses now under discussion that both physician and patient should ahvays keep before their eyes the terrible dangers of the morphine habit. This need not be feared with chloral in 3 to 5 per cent solution, sometimes in combination with cocaine, to be taken at one and one haK to two hours' intervals; it has a good sedative action. The feeblest and not always reliable analgesics are the preparations of bismuth, either alone or in combination with morphine or extract of hyoscyamus or—in mild cases, and especially in children—rhu- barb. 550 DISEASES OF THE STOMACH. # Codein phosphatis.............. <>^ [gr- «.]'] Pulv. rad. ipecacuanha.......... 0*5 [gr. vijss.] Bismuth subnitratis.............. 10*0 [ 3 ijss.] Natrii bicarbonate, Sacchari albi..................aa 15*0 [ I ss] M. Sig.: One teaspoonful every two hours. Swallowing small pieces of cracked ice with three to five drops of chloroform, may be recommended for rapidly allaying pain ; the same is true of chloroform-water, Avhich may be prepared by shak- ing water with an excess of chloroform, decanting and diluting Avith half the quantity of an aromatic water; the dose is a tablespoonful at intervals during the day. H. Hirschberg claims that cane sugar in large doses (40 to 50 grammes [ 3 j*J- 5 jl] dissolved in water) has temporary analgesic properties. Rosenthal, Leube, Yizioli, and Rosenbach have repeatedly ob- served the lessening and even disappearance of gastralgias by the anodal action of the constant current. [Einhorn* has called especial attention to the value of intragastric galvanization in gastralgia. This method has also given me excellent results. The intragastric electrode is the anode, the current strength being about 8 to 15 mil- liamperes. The sittings last 5 to 10 minutes, and are daily at first, the intervals being made longer as the pain abates.] A sedative effect is also claimed for the continuous use of the "galvanic chain " (zinc [negative] pole on the lumbar portion of the spinal column, the silver [positive] pole upon the stomach). Surprising results may sometimes be obtained by local treatment with the internal stomach douche, which was first recommended by Malbranc f (see p. 99). This " massage of the stomach " seems to exert a quieting influence on the hypersensitive gastric nerves, just as ordinary massage often unexpectedly relieves painful neuroses. Malbranc has formulated Kussmaul's experience and opinion in ex- planation of the beneficial effects of the stomach douche in the fol- lowing conclusions, although in the case quoted below only the last * Loc. cit f M. Malbranc. Ueber Behandlung von Gastralgien mit der inneren Magen- douche nebst Bemerkungen iiber die Technik der Sondirung des Magens. Berl. klin. Wochenschr., 1876, S. 41. TREATMENT OF GASTRIC NEUROSES. 551 mentioned are concerned: (1) Removal of stagnant remnants of food from the stomach ; (2) relief from acid, acrid masses (products of decomposition) and mucus; (3) the quieting effect of the warm water bath; (4) stimulation of the peristalsis by the impact of the stream of water; (5) the mildly anaesthetic as well as the stimulat- ing effects on the muscular fibers of the stomach from the carbonic- acid gas; (6) the increase in the peristalsis of the intestines by the last two factors. As an example of the beneficial effects of the douche I wish to describe the folloAving case : A married woman, thirty-six years old, the mother of one child, came ten days before, complaining of intense gastralgia, complete loss of appe- tite, and great lassitude. She was of a slight build and her appearance was bad; her ey,es especially were dull and languid, as they are after sleepless nights. Her illness began five months previously with cramps in the stomach. For the preceding eight weeks the attacks had occurred several times a day; sometimes they were almost uninterrupted and were present at night quite independently of eating. Nothing abnormal was found in the stomach and abdomen; heart and lungs were normal. While fasting, about 30 c. c. [ § j] of a neutral turbid yellow liquid, which was not slimy, were expressed from the stomach. This was undoubtedly regurgitated fluid from the duodenum. After the test breakfast the acid- ity was very feeble, with only a trace of hydrochloric acid. She had a large batch of prescriptions of various narcotics and sedatives which she had taken without any benefit. The result of four douches was that only traces of the attacks occurred during the daytime; the appetite returned, and greater quantities of food were consumed. Recently, Rosenheim has also given several examples of this kind (see page 7). Cases have also been reported by Everett,* in which incessant pains were relieved by lavage of the stomach. I myself have also reported similar cases. Undoubtedly, as in elec- trical treatment, a large part of the good effect is due to suggestion. A similar change of tone in the nervous apparatus may explain the effect of the introduction of the stomach tube and feeding through it in severe reflex vomiting, especially in the vomiting of pregnancy ; many successful examples may be found in English literature. On the other hand, I must agree with Oser,f that washing or douching the stomach has no permanent effect in hy- * Everett. New York Medical Record, 1891, No..25. f Oser. Wiener Klinik, 1875, S. 257. 36 552 DISEASES OF THE STOMACH. pochondriacs. They feel well as long as the treatment is kept up, but as soon as the physician or the patient stops it, the old condition again returns. Among the remedies with a local action are also included moist compresses upon the epigastrium, either in the form of the simple Neptune's girdle or sedative cataplasms of chamomile, valerian, etc. The bromides are the most important of the agents which act centrally ; we may use either the salts of potassium, sodium, ammo- nium [or strontium], but the dose must be large to obtain a good effect. The limit is about two to three grammes [gr. xxx-xlv] tvvo or three times a day; these doses are usually well borne, although some patients bear even small doses badly ; the head is confused, the limbs feel heavy; the characteristic smell may be detected in the breath, and sometimes there is even incontinence of urine. It is therefore advisable to begin with small doses; and in every case where the drug has been used for long periods it is wise to make small intermissions in its administration for three to eight days. Erlmeyer's bromide water is also useful here. Antipyrin, phenac- etin, salicylic acid, and salol, in doses of 0*5 to 1*0 gramme [gr. vijss.-xv] are beneficial only for the hemicrania occurring among the other gastric symptoms ; but otherwise they have no direct effect on the nervous apparatus of the stomach. Rosenthal employed pilocarpine subcutaneously in the spastic forms of vomiting, inferring this use from the antispasmodic action of the drug in obstinate singultus. From a similar theoretical standpoint we may recommend physostigma, the central paralyzing power of which is well known, and which was recently tried by Riess and G-. Meyer. In several cases in which I employed this remedy no special benefit was obtained. I may also speak here of the valerianate and the natrio-salicylate of caffeine—in doses of 0*1 [gr. jss.] two to three times daily—also of caffeine chloral and of nitroglycerin, which Talma valued so highly. The former have more of a general action on the ex- hausted nervous system, and are at the same time cardiac. In chloral caffeine the sedative and analgesic effect of the chloral is marked; it also has the advantage of being suitable for subcutaneous use. I have discarded nitroglycerin on account of the frequent oc- TREATMENT OF GASTRIC NEUROSES. 553 currence of unpleasant after effects, headaches, and vascular excita- tion. It may be used in doses of 0*5 milhgramme [gr. ^] in oil or in tablets. In nearly all the conditions under discussion, a general toning of the constitution by improving the metabolism and the composi- tion of the blood is indicated, as well as an excitation or quieting of the nervous system. The preparations of arsenic and iron are the best for this purpose. Although I formerly used Fowler's solution most frequently, yet now, in accordance with Liebreieh's recommendation, I employ arsenous acid almost exclusively, either in solution : Ijfc Acidi arsenosi.................... 0*02 [or. -§] Aquae menthae piperitae............ 20*0 [f 3 v] M. Sig.: Ten drops t. i. d., and increase. It may also be administered in granules of one milligramme [gr- *&]» or m tne form of Asiatic pills : [9 Acidi arsenosi.................. 0*075 [gr. j£] Pulveris piperis nigri............ 6*0 [ 3 jss.] Gummi arabici................. 1-5 [gr. xxiij] Pulveris radicis altheae.......... 2*0 [gr. xxx] Aquae q. s. ut fiat pil. no. c. M. Sig. : One to three pills t. i. d.] If the precaution be taken of avoiding any irritation of arsenic upon the mucous membrane by giving it only when the stomach is full, and if the above preparations be employed, then the drug can be used for a long time and in larger doses than is usually possible —i. e., up to 10 to 15 milligrammes [gr. | to £] per day—Avithout any bad effects. [Sawyer * has also highly commended the use of arsenic in gastralgia ; he prefers to use it in pills of arsenous acid, gr- Yt-> wifh 2 to 3 grains of extract of gentian, three times daily betAveen meals.] The mineral waters of Roncegno and Levico in South Tyrol are excellent means of giving iron and arsenic. Even very weak and delicate persons may continue their use for a long time, provided they begin Avith small doses—a tablespoonful once daily, half an * [Sawyer. London Lancet, July 4, 1896.—Ed.] 554 DISEASES OF THE STOMACH. hour after the midday meal, and gradually increase up to two to three tablespoonfuls (see page 438). Iron is also usually well borne Avhen combined with a purgative. I frequently use Dr. Saundby's formula : 9 Ferri sulphatis................... gr. ij [0*12] Acidi sulphurici diluti............ ui xv [0*75] Magnesii sulphatis...............gr. xj [0*55] Aquae menthae piperitae.......... 5 j [30*0] M. Sig.: Tal. dos. thrice daily. If we disregard the iron waters, the best way of administering this metal is in combination with albuminates, as albuminate of iron. Ferruginous preparations are as abundant as the sand on the shore, and every form has found its panegyrist; but the preference of one above the other depends mostly upon individual experience and co- incidences. I use almost exclusively the chlorine compounds of iron, to the ease of the absorption of which I have repeatedly called attention—i. e., the tincture of the chloride of iron; the sesqui- chloride of iron in substance (combined with arsenic or quinine or chinoidin in pills) ; or liquor ferri sesquichlorati (Ph. G.) [liquor ferri chloridi, H. S. P.] mixed together in 2 to 5 per cent solution, and given in teaspoonful doses with wliite-of-egg water (1 part of white of egg, 5 parts water). This makes an albuminate of iron which is very well borne, almost without exception, even by very sensitive stomachs, and may replace the expensive liq. ferri album. Drees (Ph. Germ.).* The haematogenous remedies may be com- bined with the so-called tonics, cinchona bark, and the other bitters. The various hydriatic procedures must be considered among those methods which have a strengthening as well as a soothing in- fluence. These include the methodical use of lukewarm half-baths, washing the whole body with lukewarm sprinkling douches—the so- called Scotch douches y—packing with tepid water, and cool sitz- * [Other organic iron preparations are also useful; they may be given alone or in combination with Fowler's solution, detannated tinct. nuc. vomica?, etc. See also Goodhart, Rest and Food in the Treatment of Anaemia and Anorexia Nervosa. Amer. Jour. Med. Sciences, September, 1891, p. 238.—Ed.] t [The Scotch douche consists of a stream of water, about the size of a finger, which is directed against the epigastrium. The temperature of the water is rapidly alternated, 30° C. (86° F.) and 12° C. (54° F.), every ten to twelve seconds. It lasts TREATMENT OF GASTROPTOSIS. 555 baths. I would warn against the use of too cold water, which fre- quently has an exciting and irritating effect; for this reason cold river and sea baths may sometimes be badly borne. To make an error of this kind in a feeble and anaemic person is of less impor- tance than it would be in the by no means insignificant number of neurasthenics who apparently have, or imagine that they have, a strong constitution, and hence believe that the more the cold water causes them to shiver the greater will be its healing influence. At this place I wish to add a few words about the treatment of gastroptosis and enteroptosis. The object of the treatment is two- fold, mechanical on the one hand and medicinal and dietetic on the other. The former indication is met by means of a properly con- structed support which will lift up and hold the displaced organs in place. According to Glenard, the indication for such supports is given by the immediate cessation of the symptoms and a decided feeling of relief which follow when the abdominal viscera are lifted up even momentarily. This is accomplished by standing behind the patient, grasping the abdomen with both hands, and exerting pressure from below upAvard and inward. This often occurs, and is especially marked in cases of pendulous abdomens, but it may also be observed in others who are not stout. For the latter it is often difficult to obtain a comfortable support, because as the re- sult of their leanness the abdomen is usually sunken in while the peMc bones are very protuberant. Kuttner and myself have de- vised a supporter which consists of a slightly curved tin shield, the size of which varies according to that of the abdomen; this is pad- ded heavily in such a way that the thickness diminishes from below upward. This truss is retained by means of suitable springs and thigh and abdominal strips ; the lower border is about two centi- meters [0*8 inch] above the symphysis pubis, the sides the same dis- tance from the iliac crests, the pressure being exerted obliquely two to three minutes, and mayor may not be followed by a warm pack. The alter- nation of heat and cold is very stimulating to the entire neuro-muscular apparatus of the digestive tract. At the same time it causes hyperoamia of the abdominal parietes and viscera. Both of these actions, the stimulating and the vascular, are increased by the mechanical effects of the impaet of the stream of water against the skin. Thus, it is a powerful adjuvant to electricity and massage of the abdo- men. Ziemssen, Klinische Vortrage, No. xii, 1888.—Ed.] 556 DISEASES OF THE STOMACH. from below upward. The tension of the abdominal walls is in- creased, and thus the peristalsis of the stomach and intestines is ren- dered easier by the increased support Avhich is thus afforded to them. "We can thus easily explain the surprising improvement which is often seen after wearing such supporters; a good proof of this is the fact that the patients never do without them, for as soon as they do so the old symptoms return. [Treves * has recently reported the complete cure of a very severe case of gastroptosis by laparot- omy and stitching the stomach.] In the way of drugs, we may use mild vegetable aperients and the neutral salts [Mittelsalze] to secure proper evacuation of the bowels, and as intestinal disinfectants, creosote, benzo-naphthol, and bismuth salicylate. Furthermore, we may employ the general tonic, dietetic, and gymnastic measures and electricity, all of which have already been discussed. By means of these measures excellent results may frequently be obtained in suitable cases. In a certain group of patients with nervous stomach troubles, in whom persistent anorexia has led to \*ery profound disturbances of nutrition, marked emaciation, and enfeeblement of the body, the use of the rest-cure {Mast-kur) is to be recommended. This method, as is well known, was first introduced by "Weir Mitchell, and modified by Playfair, of London, and Burkart, Leyden, and Binswanger, in Germany; its object is to introduce and cause the absorption of a quantity of food which the patient under ordinary circumstances is able neither to take nor to assimilate. "With this purpose, the treatment consists of two parts—a psychical and a vegetative or dietetic. The object of the former is to remove the patient from the injurious influences which his surroundings and his usual habits of daily life exert upon him, these being adapted to his complaint; therefore, he is kept isolated from these deleterious fac- tors, so that he is completely under the control of his physician, whose orders he must obey even to the smallest, apparently trivial, details. For this, it is absolutely essential to separate the patient * [Treves. British Med. Journal, January 4, 1896, p. 1.—Ed.] REST-CURE IN GASTRIC NEUROSES. 557 from his family and keep him at a sanitarium. I must confess that I did not formerly lay as much stress on treatment in a sanita- rium as I do now, after having had a much more extended expe- rience. This is not alone true in cases of the rest-cure, but also in many other neuroses, which offer far greater chances for cure when they are under the direct care of the physician and are removed from the disturbing influences of home fife. I therefore insist more and more upon treating these cases away from home. I also lay stress upon the cure being supervised or carried out by only one physician. Two doctors, no matter how well they harmonize, may in giving orders easily disagree on trivial details which, how- ever, appear to be very important to the anxious and distrustful pa- tient, and may thus occasion doubts and uncertainty. It is just in this class of cases that absolutely consistent, certain, and unerring lines of treatment are essential. The object of the dietetic measures is to overfeed the patient— i. e., at least during the early part of the treatment, to give more nourishment than is required to satisfy his subjective wants. Rest in bed is essential to prevent, as far as possible, the conversion of the food for heat production and muscular work; but at the same time the circulation is improved by passive muscular exercise through massage and electricity. The treatment is carried out as follows: The first step is to iso- late the patient and place him in charge of a male or female nurse, whose duty it shall be to manage the feeding and the above-men- tioned mechanical procedures; the nurse ought also to have the pleasant quality of not being personally unsympathetic to the pa- tient. For the first few days the cure consists in giving milk in small quantities at two or three hours' intervals, so that one or two litres [quarts] are taken daily; the milk may be raw or cooked, skimmed or fresh from the cow, warm or cold, and may have vari- ous additions according to the caprice and taste of the patient. After three or four days the food is made more substantial and is given in small amounts every two hours. This consists of milk, meat, farinaceous food, butter, and coffee or tea; the daily quantity should be about 2| litres [six pints] of milk, 420 grammes [ 3 xiv] of meat, about 150 grammes [ 3 v] of vegetables or stewed fruit, 558 DISEASES OF THE STOMACH. and the equivalent amount of wheat bread, toast, and butter. If the stomach rebels against this rigorous diet and reacts Avith an acute gastric catarrh—i. e., dry, coated tongue, belching, heartburn, pains in the stomach and head—then it must be suspended for a few days. Great attention must also be paid to the regulation of the stools. In favorable cases improvement is shown as early as the second or third week. After the third or fourth week the patients may leave the bed, and may attempt to walk. Corresponding to the progressive improvement the massage and faradization are gradu- ally lessened till they may be stopped entirely. If no improve- ment has been manifested by this time, it is advisable to refrain from carrying this treatment on any further. As an example, I may mention a case of hysterical anorexia in a girl, sixteen years old, wLrich had developed after an attack of scarlet fever eight years previously. The patient was emaciated to a skeleton, and suffered from headaches, tinnitus aurium, color-blindness, and photophobia, which was so intense that she had to sit in the dark, and was unable to read a line ; great lassitude and trembling after every exertion ; incontinence of faeces. At the beginning of the treatment she weighed 25*6 kilogrammes [56*3 pounds] ; the conversion of nitro- gen as calculated for albumen was 37*19 grammes [573 grains]. At first she received as food 114*42 grammes [1765 grains] of albumen, which was gradually increased in four weeks to 195*77 grammes [3020 grains]. She was kept isolated from December 5th to January 26th ; on that day the conversion of albumen was 124*06 grammes [1914 grains]—i. e., a gain of 71*71 grammes [1106 grains], and her weight was 33*05 kilogrammes [72*7 pounds]—i. e., an increase of 7*45 kilogrammes [16*4 pounds]. I have had the opportunity of watching the patient three months longer; she is with her nurse at the house of her parents, gains steadily in weight, eats well, goes ont walking, and is free from her old symptoms! This splendid result was obtained only because during the entire course of treatment she was free from all kinds of gastric and intestinal disturbances, except those of a very slight and transient nature. The important factors which have already been mentioned above, and which have also been emphasized in the various pub- REST-CURE IN GASTRIC NEUROSES. 559 lications of Burkart (who has undoubtedly had the largest expe- rience in this field of any one in Germany), are the psychical effect on the patient and the latter's firm determination, or at least his consent, in favor of the proposed treatment. If both of these are present, we may dispense with isolation in a hospital, which above all has a psychical effect, provided the patient's family judiciously co-operate Avith the method. I have frequently and successfully carried out such cures at the patients' homes, and know that others have also done so. Nevertheless, I adhere to what I have already said about the great advantage of treatment in sanitaria. But one must not imagine that all the rest-cures, even in sanitaria, run so smoothly and favorably as the case above mentioned. Many pa- tients, in spite of the best intentions, are unable to take the amount of food prescribed ; for they either vomit it or they may even be unable to swallow solids. In such cases peptone enemeta also are of no avail, and it is often a riddle how and from what the patients manage to survive. Treatment by suggestion (see page 561) I have always found useless. Other patients look strong, have good com- plexions, and gain correspondingly in weight; and yet in spite of all this they have the same lack of physical and mental strength as before. One of my patients reported as follows : " Every mental relation, for example, the writing of this letter, is a Arery severe ex- ertion, and Avalking is a torture to me on account of the weakness of my spine." Others keep up by using all their energies, but, nevertheless, make no real progress. Another patient wrote to me : " Your orders that I should not yield to the moods of my stomach are my best aid. I force myself to eat, and eat my beefsteak with resignation and shudders, in order to keep up my strength until I shall feel better." * In connection with this therapeutic measure I Avish to call atten- tion once more to the importance of systematic weighing in the nervous affections as well as in all lesions of the organs of absorp- tion. Important criteria for judging the course of a disease and the success of our treatment may be obtained by the increase or loss shown by the scales ; the latter (loss) must also frequently include a * [For further details, see Weir Mitchell, Fat and Blood; J. M. Mitchell, Hare's System of Therapeutics, vol. i, p. 227; Thompson's Dietetics, p. 578.—Ed.] 560 DISEASES OF THE STOMACH. stationary condition of the weight according to the axiom, " Stand- still is retrogression." The only precaution necessary is not to be deceived nor influenced by small and inconstant variations in the bodily weight. After systematic weighing for months of naked persons who have been kept on a uniform diet and surroundings, I am convinced that differences of 1 to 1£ kilogramme [2| to 3£ pounds], from one day to another, or in the course of a few days, may be considered normal occurrences. Even continuous consider- able losses do not necessarily indicate a bad prognosis, at least as long as the correct treatment has not yet been discovered. At all events, it is true that all malignant organic structural changes are also accompanied by constant loss of weight, with possibly small transient fluctuations, and accordingly always have an unfavorable significance ; but nervous dyspeptics, neurasthenics, patients with haemorrhoids, and the like, may lose 15 to 20 kilogrammes [33 to 44 pounds] within a few months. The test of a proper and successful treatment consists in the gradual increase of the bodily weight which is sometimes manifested Avithin a short time after the beginning of the new regimen, but at other times may not begin till after a period of continual loss which may even last three or four weeks. There- fore, the scales ought always to be employed in all kinds of stomach diseases, but especially in the neuroses. Surely all should imitate the proposition made long ago by the late Benecke, that every one should keep a regular record of his weight. Prof. Thomas tried it practically on himself, with excellent results for regulating his diet.* Finally, the treatment of the gastric neuroses should include the use of all those adjuvants which improve the general condition and the mind by the effect of a change of climate, the stimulating and quieting influence of the air of mountains and plains, sojourn at the seashore, the tonic springs like the alkaline waters of Franzensbad, Ems, and Neuenaar; even the salines, "Wiesbaden and Kissingen; the mild chalybeate water of Eister, Franzensbad, Pyrmont, Rip- poldsau, and the like; and, last but not least, the mud baths. Probably these are nowhere better nor more comfortably prepared * See Transactions of the Naturforscherversammlung zu Berlin, 1887. TREATMENT OF GASTRIC NEUROSES. 561 than at Franzensbad, where, as even Frerichs said, in the last pub- lication which came from his pen, there is an abundant supply of material for their preparation, Avhich, having been carried on for years, is attended to with the utmost care. Once more do I warn against the pernicious practice of ordering nervous patients to use the Glauber's salt waters, especially those of Carlsbad and Marienbad, because these waters are Arery slowly and imperfectly absorbed in these cases—" they lie heavily in the stom- ach," and exert a decidedly enfeebling effect; the latter is due to the fact that they involve still more the already altered metabolism, that they saturate the blood with neutral salts, wThich are improperly excreted, and that not alone do they not improve the nutrition of the nervous system, but actually injure it. At the end of every summer I regularly see numbers of such patients who haATe returned from these springs with a decided deterioration of their condition. To-day it is impossible to conclude the treatment of neuroses without reference to suggestion therapy. Among the strict adher- ents of this method I have the reputation of being an outspoken antagonist because I endeaATored years ago to estimate the proced- ures at their true value, and therefore was led to deny to hypno- tism and suggestion the qualities of remedial agents as understood in scientific medicine. I did this because their successful applica- tion demand the active cooperation of the patient to a far greater degree than is usually required in prescribing a remedy, and, fur- thermore, because we all make more or less use of psychotherapy without the procedures of hypnosis and suggestion. I have never denied that occasionally, after an unusual expenditure of such psychical influences, we may obtain unusual effects, but such effects are usually only of transitory duration. Nevertheless, I have em- ployed suggestion in so many cases, either trying it myself or Avith a competent " hypnotiseur," that I have formed a practical opinion. This is, that just in the cases of severe hysteria in which we have the greatest need of suggestion we are left in the lurch, as is also admitted by Binswanger,* after a A^ery large experience, because hys- terical subjects can only be suggested insufficiently or not at all. At * Binswanger. Congress fiir innere Medicin, Leipzig, 1892. 562 DISEASES OF THE STOMACH. times they apparently can be brought into the first stages of hyp- nosis, but, as may easily be ascertained by careful observation, they never relinquish their own wills, the autonomy of their minds does not cease, and the suggestion fails to accomphsh its object. In other nervous patients, however, without resorting to hypnosis we can succeed, with the good will of the patient, by employing that part of suggestion which consists in energetic and firm action, and may thus dispense with this procedure, which always is scarcely edifying to an earnest man. Still, I will not deny that occasionally sugges- tive influences may be of value; but, as I have already said, these results are not permanent in the majority of cases, and then, as I have also observed, a second and third suggestion no longer pro- duces any effect. CHAPTER XII. THE CORRELATION OF THE DISEASES OF THE STOMACH TO THOSE OF OTHER ORGANS.--THE PRACTICAL VALUE OF THE MODERN CHEMI- CAL TESTS. The relations which exist between the disturbances of digestion and other diseases, as I need scarcely mention, are of the greatest importance. There is hardly any internal disorder in which gastro- intestinal digestion may not also be affected to a greater or less degree; or it may be associated with them by functional disturb- ances, the treatment of which is to be conducted upon the lines already laid down. However, my present aim is not to discuss the changes which accompany febrile and afebrile, localized and consti- tutional processes, but rather those cases of disease which depart from the ordinary course, in which the gastric symptoms are the earliest manifestations, or which, at least on superficial observation, seem to be the prominent features of pathological processes which are situated outside of the stomach. Here it is of the utmost im- portance to discover the real cause of the digestive disturbances, to distinguish the secondary features of the disease from the primary, and to recognize them as such. The effect of diseases of other organs upon the stomach and their reciprocal action as manifested in structural changes in this organ have been carefully studied by "W. Fenwick.* But as these investi- gations are concerned with the pathological-anatomical changes in the stomach rather than with the clinical features of these processes, I shall here simply state that Fenwick calls special attention to the relation between advanced atrophy of the gastric mucosa and perni- cious anaemia, and also of carcinomatous tumors of other organs, * W. Fenwick. Ueber den Zusammenhang einiger krankhafter Zustande des Magens mit anderen Organerkrankungen. Virchow's Archiv, 1889, Bd. cxviii, S. 187. 563 564 DISEASES OF THE STOMACH. especially the mammary gland and intestines; as, for example, the occurrence of severe anaemia after the excision of relatively insig- nificant tumors of the breast.* However, as I have already shown, Henry and Osier + and other writers have already called attention to this fact. "W. Fenwick also found more or less marked catarrh of the mucous membrane of the stomach in nearly all the diseases which were studied by him—i. e., diseases of the kidney, pulmonary phthi- sis, chronic bronchitis, emphysema, various valvular lesions of the heart; it was least marked in acute pneumonia and typhoid fever; and not at all in diseases of the brain (tumor, epilepsy, softening, apoplexy). He also states that Handheld Jones,*]; in a study of over 100 cases of " affections of the glands of the stomach," only once found disease of the brain. If, therefore, the gastric symptoms, and especially vomiting, which occur in diseases of the central nerv- ous system, are manifestly reflex nervous symptoms, then the dis- turbances of the digestive tract which occur in other disorders must undoubtedly depend upon anatomical and functional changes. The most important of the latter will now be discussed. The most prominent place in the consideration of this subject is occupied by tuberculosis, which indeed most frequently gives rise to errors. It is only too well known that the course of phthisis may be marked by dyspeptic symptoms' which may vary from a simple loss of appetite to severe anorexia and vomiting, and may go hand in hand with the febrile movement. But, as Louis, Andral, and Bourdon pointed out long ago, there are many cases of tuberculosis in which the first symptom to attract attention is dyspepsia. Hutchinson # has analyzed a large number of cases and calcu- lated that in 33 per cent dyspeptic symptoms precede the onset of the tubercular manifestations. "W. Fenwick found well-marked evidences of gastric catarrh in 11 out of 15 cases of phthisis— * Samuel Fenwick. Atrophy of the Stomach. London, 1880, p. 49. t Henry and Osier. Atrophy of the Stomach with the Clinical Features of Pro- gressive Pernicious Anaemia. American Journ. of Med. Sciences, April, 1886. X Handheld Jones. Diseases of the Stomach. * Hutchinson. The Morbid States of the Stomach and Duodenum. London, 1878. GASTRIC SYMPTOMS IN TUBERCULOSIS. 565 i. e., 73 per cent. Marfan* considers this figure too high, and quotes the Avell-known and universally accepted observation of Quenu that many patients disregard the period of short, dry cough which precedes the onset of expectoration, so that the begmning of the disease must be placed at an earlier period than is given by them. In 61 cases he claims to have found only five in which the gastric preceded the pulmonary symptoms. Yet the point at issue is not so much these objections to the patient's previous history as the fact that persons frequently consult us complaining only about their digestion, which they consider the cause of all their troubles; yet careful examination will either reveal the presence of a phthisi- cal process, or will cause us to entertain suspicions of such a condi- tion, the correctness of which is confirmed by the subsequent course of the malady. As a rule, these patients are delicate and anaemic; they begin to complain of loss of appetite, oppression, and fullness after eating, and irregularity of the bowels; they suffer from regurgitation and a foul taste in the mouth ; they feel feeble and languid. For a long time they are treated for chronic catarrhal gastritis; but both physi- cian and patient wonder Avhy all the apparently rational remedies are of no avail; then a careful examination is made, and chronic pulmonary disease is either discovered or at least strongly suspected. A true dullness is not present, yet the apices do not expand prop- erly, or the whole of one side may expand someAvhat tardily on inspiration; the respiratory murmur has a soft, moist, interrupted character; the movements of the entire thorax are not sufficiently deep; the manometer shows that inspiration and expiration are feeble; expiration is prolonged. Careful questioning will now reveal that the patient has " hacked " for a long time without pay- ing any attention to it; that he was scrofulous as a child; that he perspired very easily, although there are no true night-sweats; and, finally, that there is a hereditary predisposition. If we can obtain some of the sputum—which, Avhen the expectoration is scanty, the patient frequently disregards or swallows—we may often succeed in finding a few tubercle bacilli, and thus at once corroborate our diag- * B. Marfan. Troubles et lesions gastriques dans la phthisie poulmonaire. Paris, 1887. 566 DISEASES OF THE STOMACH. nosis. Under these circumstances a diseased condition of the stom- ach is at all events present, yet it is merely the manifestation of a venous hyperaemia and congestion, which in its turn is due to the disturbance of the pulmonary circulation. It was, therefore, important to study the chemical processes of the stomach in pulmonary phthisis. Some incidental communica- tions were made on this subject by Edinger, and also by myself; yet systematic examinations were first made by C. Rosenthal,* Klemperer,*}* Schetty,*}: O. Brieger,* Hildebrand, || and Immer- mann ; A their results, which agree tolerably well, are best expressed in the following propositions, formulated by Brieger: " In severe cases of phthisis a normal condition was found in only 16 per cent of the cases, in the rest more or less marked in- sufficiency was found; in fact, in 9*6 per cent of all the cases there was a complete absence of all the normal products of secretion. " In moderately severe cases the gastric juice was normal in only 33 per cent; in the remainder its strength varied, the disturbance being, as a rule, well marked; while in 6*6 per cent the normal secretory products were absolutely lacking. " In the initial stages the cases of normal and disturbed secretion were about evenly divided." Absorption and peristalsis seem to be impaired to a degree cor- responding to the disturbance of the chemical functions. It is self-evident that the above percentages, which are based upon 64 cases, give an approximate and not an absolute idea of the relative frequency of the conditions under discussion. After care- ful study, with reliable methods, Grusdew () and Bernstein J also * C. Rosenthal. Ueber das Labferment. Berliner klin. Wochenschr., 1888, No. 45. t Klemperer. Ueber die Dyspepsie der Phthisiker. Ibid., 1889, No. 11. X Schetty, loc. cit 9 0. Brieger. Ueber die Functionen des Magens bei Phthisis pulmonum Deutsche med. Wochenschr., 1888, No. 14. || H. Hildebrand. Ibid., 1889, No. 15. A Immermann. Verhandlungen des Congresses fiir innere Medicin. Wies- baden, 1889. v [Grusdew. Wratsch, 1889, Nos. 15, 16. Centralblatt fiir klin. Med., 1890, S. 92.—Ed.] J Iwan Bernstein. Die Dyspepsie der Phthisiker. Inaug. Dissert. Dorpat, 1889. GASTRIC SYMPTOMS IN TUBERCULOSIS. 567 come to the conclusion that " hydrochloric acid is either absent or reduced to very small quantities." In testing the motor functions Immermann found no marked changes in 53 out of 54 trials—i. e., the stomach was found empty six hours after taking Leube's test meal; on the other hand, Klem- perer used his oil method (page 81), and found a marked enfeeble- ment of the motility. Furthermore, Immermann states that he found free hydrochloric acid in 38 out of 44 trials, even where the high fever and cachexia of the terminal stages of phthisis were pres- ent ; Brieger observed it only in 16 to 33 per cent. This discrep- ancy can be explained by the former having used Jaworski's test breakfast (the whites of two hard-boiled eggs and 100 c. c. [f ^ iij 3 ij] of water), which is notoriously inadequate for this purpose. At all events, the occurrence of gastric disturbances depends on what stage of phthisis may be present. Thus, Hutchinson states that in 9 cases dyspepsia was found after the pulmonary symptoms had began; in 10 it appeared at the same time, and in 33 it pre- ceded them. Although all these investigations give us important information, yet their value would have been greatly enhanced had the observers laid more stress on the comparison betAveen the subjective com- plaints and the results of the objective examinations. It is beyond doubt that the so-called phthisical dyspepsia is not due to a tubercu- lar affection of the gastric mucous membrane, but, as already stated, is only a complication of this disease due to disturbance of the cir- culation. But it is equally certain that a very large proportion of the successful results of the treatment in pulmonary phthisis de- pends on the nutrition of the patient and the possibility of main- taining it. The French method of overfeeding {sur-alimentation) —the experiences of Dettweiler, Peiper, Riihle, Liebermeister, Ley- den, and others—are the best proofs of this. Our therapeutic efforts Avill have a greater effect and will be more certain if we have ascertained the functional activity of the digestive organs by means of a chemical examination independently of any of the patient's subjective complaints. True, it is self-evident that the first object of treatment is the primary disease, with the improvement or cure of Avhich the dyspeptic symptoms will disappear; yet we must not 37 568 DISEASES OF THE STOMACH. lose sight of the fact that the improvement of the functions of the stomach with the resulting better state of nutrition Avill react favorably upon the local process hi the lungs. Here it should be observed that the specific stomachics are un- successful, if not injurious, for they irritate the already congested mucous membrane, and thus increase the hyperaemia. It would be much more advisable to lessen the irritating effects of the food, as far as possible, by ordering a simple, easily digestible diet, or by giving in each individual case the drugs A\diich may seem to be indi- cated by the results of the examination of the gastric functions, pro- vided pronounced dyspeptic disturbance should render this necessary. A general rule for these remedies can not be given, as is at once evident after a careful consideration of the changeable factors here concerned. Thus, in a large number of examinations on one patient at the Augusta Hospital, Rosenthal could never find free hydro- chloric acid during the summer, yet when he returned to the hospi- tal in the winter it Avas present in abundance; Hildebrand observed the same thing during shorter periods. Only this much is certain, that the subjective complaints of the patient do not by any means ahvays correspond to the results of the objectiAre examination, and that therefore the former should be investigated before they are allowed to weigh against methods of treatment which (like the ali- mentation force of the French) aim to improve the general nutrition by giving larger quantities of food. Concerning the milk diet, Ave should remember that its power of combining with acids surely comes into play in the cases or stages of hyperacidity which have been mentioned above. But, to return to the question under discussion, these cases of pretubercular dyspepsia—if we may use this short but improper expression—may be readily recognized, provided sufficient care be exercised. The diagnosis is not so easy if the dyspeptic symptoms are due to a centrally located miliary tuberculosis with slight feb- rile movement. If this is associated with a moderate enlargement of the spleen, of recent or old origin, it may readily be mistaken for typhoid fever, especially the ambulant variety. I recently saw an example of this in a gentleman from St. Petersburg, who thought his stomach was at fault. He presented the group of symptoms GASTRIC SYMPTOMS IN TUBERCULOSIS. 569 just described: there was a moderate irregular febrile movement, with slight evening exacerbations, which was said to have existed for some time, since quinine, antipyrine, and hydrochloric acid had been prescribed for him. Inasmuch as he said that he had been suddenly taken ill some weeks previously after a journey in a fever district, and had nevertheless not gone to bed, but instead had attended to his business, I naturally thought of the last stage of a "walking typhoid fever" with an irregular febrile movement; all doubt was dispelled during about the fourth week, when the symptoms of acute miliary tuberculosis became more and more prominent. He died of undoubted pulmonary tuberculosis after having been a feAv weeks at Gorbersdorf. [Fenwick * has made a very careful study of the condition of the stomach in pulmonary phthisis. He distinguishes a prodromal, initial and final dyspepsia of phthisis, and has presented data con- cerning the forms as he found them in an analysis of a large num- ber of cases. The prodromal dyspepsia he subdivides into the atonic and irritable varieties, the former occurring usually in young females from thirteen to twenty-five years of age, the latter in men from twenty-five to forty years old. The atonic form usually follows convalescence from some acute febrile disorder, or may begin insidi- ously. The difference in the symptoms in the two groups is suffi- ciently expressed by their names. The initial dyspepsia is that which ushers in and accompanies the first stage of pulmonary phthisis, and is that which is usually known as the dyspepsia of phthisis. It seems to be much more com- mon in women than in men. Pain is a very constant feature, since it was noted in 92 per cent of the cases ; vomiting also occurs fre- quently ; the appetite is distended, especially toward evening. There is a marked repugnance toward fat. Other symptoms are flatulence, acidity, constipation, large, flabby, indented tongue, and profound anaemia. The symptoms stand in a direct relation to the condition of the lungs, and may even be arrested if the pulmonary disease is cured. The final dyspepsia is that which occurs after the formation of * [W. Soltan Fenwick. The Dyspepsia of Phthisis, its Varieties and Treatment. London, 1894.—Ed.] 570 DISEASES OF THE STOMACH. cavities in the lungs. Here also women seem to be more frequently attacked, the ratio being 62 per cent in Avomen, 25 per cent in men. The chief symptoms are anorexia, thirst, painful sensations in the epigastrium, and nausea. Yomiting and flatulance are not constant as in the other forms. The boAvels are irregular. Fenwick lays great stress on the fact that the stomach is not alone involved, but the entire intestinal tract as well. It is really a gastro-enteritis which begins in the chronic interstitial form, which is due to the absorption of certain toxic substances. Later on the glands are also involved. This condition can always be demon- strated after cavities have been formed in the lungs. For further details, this excellent monograph may be consulted. For tubercular ulcers of stomach, see pages 401 and 418]. The changes in the digestive tract in anaemia and chlorosis are closely allied to the above. They undoubtedly play an important part, which, up to the present time, has been very much neglected ; hence, in the treatment of anaemia, efforts should first be made to improve the condition of the digestive organs, and then the compo- sition of the blood. As has long been known, and as Hayem,* Gluczinsky,f Pick,*}; and others have shown by direct examination of the gastric juice and the functions of the stomach, a true insuffi- ciency of the latter exists. [OssAvald # has recently examined 21 chlorotic patients ; free HCl Avas present, usually in excess ; at times the percentage was as high as 160. The motor functions were normal]. But some writers, especially Hayem, go too far when they consider that the changes in the stomach and intestines are the pri- mary cause. In my opinion, it is one-sided to claim that chlorosis can be cured by the relief of these disturbances; for it is by no means certain that these changes in the digestive tract are not sec- ondary, and can only be relieved after the composition of the blood * Hayem. Des alterations du chimisme stomacal dans la chlorose. Bulletin medic, 1891, No. 87. f Buczlygan und Gluczinsky. Ueber das Verhalten des Magensaftes bei den verschiedenen Formen der Anaemie und besonders der Chlorose. Internat. klin. Rundschau, 1891, No. 34. X Pick. Therapie der Chlorose. Wiener med. Wochenschr., 1891, No. 50. * [Osswald. Ueber den Salzsauregehalt des Magensaftes bei Chlorose. Miinch. med. Wochenschr., 1894, No. 27.—Ed.] GASTRIC SYMPTOMS IN HEART DISEASE. 571 has been improved by appropriate treatment. The histories of many patients attest the truth of this. [Meinert * maintains that many cases of chlorosis are due to gas- troptosis. He does not include all young Avomen with chlorosis, as has been generally supposed, but only such girls who up to the time of puberty had been apparently in good health. In all of these cases Meinert states that inflation of the stomach has always demonstrated the presence of gastroptosis. The prolapse of the stomach produces a stretching of the gastric nerves, which in turn irritates the solar plexus. The latter giving off sympathetic branches to the spleen, may disturb the blood formation which occurs in the latter organ. The most fruitful cause of gastroptosis is tight lacing. Meinert's monograph is most elaborate, and contains many typical examples of this condition. This subject has been studied by Kelling, f Bruggemann,*{: and Meltzing,* all of whom agree that Meinert is too sweeping in his assertions, and that gastroptosis is not present in all cases of " typical chlorosis," as described by him. They agree, however, that down- ward displacement of the stomach is of frequent occurrence in chlo- rosis, and seems to be found more frequently in these subjects than in non-chlorotic girls.] The next group of diseases includes the valvular affections of the heart. Here, also, the nature of the lesion causes a venous con- gestion and the symptoms of a chronic catarrh of the stomach. Careful examination is required to reveal incompetency of the valves, enlargement of the heart, latent pericarditis, pericardial ad- hesions, or chronic myocarditis. In such cases cures can only be effected in the early stages ; unfortunately, these therapeutic meas- ures usually afford temporary and not permanent rehef; yet some- times, by using digitalis and other members of this group for a short time, we may succeed in completely removing the catarrhal mani- festations, and thus secure a period of relative or absolute relief. * [Meinert. Volkmann's klinische Vortrage, Nos. 115 and 116, January, 1895.— Ed.] t [Kelling. Ibid., No. 144. February. 1896.—Ed.] X [Briiggemann. Ueber den Tiefstand des Magens bei Chlorose. Inaug. Dissert. Bonn. 1895.—Ed.] 9 [Meltzing. Wiener med. Presse, 1895, No. 30.—Ed.J 572 DISEASES OF THE STOMACH A priori, there can be scarcely any doubt, for the reasons above given, that the secretory activity of the stomach is lessened as soon as compensation is disturbed, not alone in true valvular lesions, but also in other processes which, directly or indirectly, cause functional disturbances of the cardiac muscle. Hiifler* thought that he had proved this, since, in 10 cases of the above kinds, mostly valvular lesions, total absence of hydrochloric acid and almost negative di- gestion of albumen were found 9 times, in spite of the fact that most of the patients were still in the clinical stage of complete com- pensation. In the single patient (moderate mitral insufficiency) in whom hydrochloric acid was present, he is inclined to assume " hy- peracidity." But concerning this apparently exceptional case it may be stated that it is by no means certain that congestion of the gastric mucosa and its consequences always occur under these cir- cumstances, for there may also be a compensation in the stomach. Therefore, the assumption of hyperacidity seems unnecessary to me in the explanation of this exception. I also have had a patient with mitral insufficiency at the Augusta Hospital, the acidity of whose stomach contents was 62 ; the acidity was entirely due to HCl. But it appears that insufficiency of the gastric secretion is not as constant as Hiifler supposed ; for, in 20 patients with heart dis- ease, Adler and Stern y found that free hydrochloric acid was always present in 16, variable in 2, and always absent in 2 cases. Nat- urally these writers are inclined to believe that this discrepancy is due to the difference in the methods employed, for Hiifler gave Leube's meal in the morning—i. e., a very unfavorable time—while Adler and Stern gave the test breakfast. However, it is also prob- able that the degree of compensation is also of importance in this question, for the clinical picture alone does not enable us to judge it properly. The diseases of the kidney also involve the stomach if the excre- tory products of the metabolism are retained in the organism early in the course of the affection; if excreted in the stomach and intes- * Hiifler. Ueber die Functionen des Magens bei Herzfehlern. Miinch. med. Wochenschr., 1889, No. 33. t Adler and Stern. Ueber die Magenverdauung bei Herzfehlern. Berl. klin. Wochenschr., 1889, No. 49. GASTRIC SYMPTOMS IN RENAL DISEASES. 573 tines, they will irritate these viscera. Such cases are by no means common; the vomiting and other symptoms of disturbances of gas- tric digestion occur long before the distinct signs of dropsy or other manifestations which would lead to the correct diagnosis; hence, these cases are thought to be independent lesions, whereas they are really only due to chronic uraemia. They may also occur Avithout any disease of the renal parenchyma where there has been a long- standing retention of urine from obstruction of the urinary passages. Fenwick * assumes that the mucous membrane of the stomach can excrete certain poisons, including also urea; the result of this irri- tation is an acute catarrh of the gastric glands. Degenerative pro- cesses, for example, fatty degeneration of the glandular epithelium and amyloid of the mucosa, may also occur, as well as gastritis in the true sense of this term. Biernacki f lays stress upon the retention of metabolic products which lessen the secretion of the gastric juice by means of nervous influences. He has actually demonstrated this in a number of cases of nephritis which were investigated for this purpose. Therefore, he agrees with me X in recommending pep- tonized milk in these cases. [Zipkin # and Alapy || have recently studied the condition of the stomach in renal diseases. The former found no constant relation between the tAvo organs; Alapy, on the contrary, asserts that the results of treatment show that the stomach suffers in chronic ne- phritis, probably through the excretion of the retained nitrogenous substances through the gastric mucosa. He therefore advises the examination of the urine of all patients over fifty years of age Avith chronic gastric symptoms.] Renal tumors, especially carcinoma of the kidney, may for a long time cause only disturbances of digestion, anorexia, vomiting, and emaciation; in fact, in a case reported by Colleville,A up to the * Fenwick, loc. cit f Biernacki. Ueber das Verhalten des Magens bei Nierenentziindung. Berl. klin. Wochenschr., 1891, Nos. 25, 26. X Ewald. IX. Congress fiir innere Medicin zu Wien, 1890. * [Zipkin. Ueber das Verhalten des Magenverdauung bei Nephritis. Inaug. Dissert. Wtirzburg, 1894.—Ed.] | [Alapy. Verdauungstorungen bei der ch-ronischen Harnretention. Wiener klinik, 1894. No. 9.—Ed.] ^ Colleville. Progr. med., 1883, No. 20. .* 574 DISEASES OF THE STOMACH. patient's death these were the only symptoms. Finally, without suffering any changes in the [renal] secretory capacity, the kidneys may cause disturbances and pain in the stomach on account of their unusual site or mobility; these effects of floating kidneys, etc., have been considered while discussing gastroptosis, gastrectasis, and gas- tralgia. The liver stands in such close relationship to the stomach [as has already been discussed in Chapter IY] that serious functional disturb- ances of the one are without exception reflected on the other; this close connection, and the fact that so many of the noxious substances introduced from without act on both viscera at once—I will only mention alcohol—render it very difficult to say which is affected first. For example, in the very great majority of cases, cirrhosis of the liver is accompanied by chronic gastritis, yet, even if we observe that the symptoms of a doubtful hepatic cirrhosis have for a longer or shorter time preceded a chronic gastric catarrh, we are utterly unable to tell whether the two stand in a causal relation or are simply coincident. Nevertheless, we should never forget the fact that many cases of hepatic cirrhosis for a long time run their course as chronic gastritis, and that the same is true of cancer of the liver. Although I have frequently called attention to the relations of the diseases of the central nervous system with those of the stomach, yet I must not neglect to take this subject up once more at this place. On account of its great importance, I shall only specially discuss the relation of the gastric disturbances to sclerosis of the posterior columns of the spinal cord (tabes). This includes not only the classical attacks of gastralgia and gastric crises [see page 403] which occur in cases well advanced and recognizable, but also vaguer sensations—slight boring and radiating pains, a permanent feeling of gnawing and burning in the stomach, or even more marked perceptions which occur among the prodromata, or as the first symptoms of locomotor ataxia, but which at the time in ques- tion have not yet acquired any typical characteristics. It is self- evident that it is impossible to make an exact diagnosis under such circumstances, and that even if the gastralgia continue for years their true origin would not be recognized. GASTRIC SYMPTOMS IN NERVOUS DISEASES. 575 Such a case has been described by "Werner; * an induration was found at the pylorus in a patient who had been for a long time con- sidered hysterical; gastroenterostomy was performed for supposed stenosing cicatrix of an ulcer at the pylorus; but it proved to be simply a muscular hypertrophy. As the operation proved unsuc- cessful, the ovaries were subsequently removed (Hegar's method); nevertheless, the gastric symptoms, which were chiefly manifested as gastralgia, persisted ; and it was only five years later that distinct symptoms of tabes appeared, the existence of which was confirmed at the autopsy. Unfortunately, the early symptoms of tabes do not readily permit a positive diagnosis; thus, for example, the absence of the patellar reflex occurs independently of this disease so fre- quently that the simple coincidence of this symptom and gastralgia in a suspicious case would not justify a diagnosis of locomotor ataxia. [A case has recently come under my observation in which gas- tralgic attacks existed for eight years before the real nature of the disease was discovered. At present the symptoms of tabes are ab- sence of patellar reflexes, Argyll-Robinson pupils, Romberg's symp- tom, occasional shooting pains in the lower extremities, and attacks of severe gastralgia, which come on at varying intervals and last from a few hours to a few days. Repeated examination of the stomach contents shows normal conditions in the intervals between the at- tacks, but during them there is marked subacidity. For a long time the only other symptom present was the myosis, which caused her to be unjustly regarded as a morphinist. "Wolff f has also carefully described three cases of tabes which had been under his observation for a long time, in which the gastric crises were not alone the initial but also were the most prominent symptoms throughout the disease. At all times, both during and between the attacks, he found either lessening or absence of HCL] Among the constitutional diseases diabetes gives rise to errors most frequently. For years many diabetics are considered to be suffering from some stomach trouble until the urine is examined, * G. Werner. Gastrische Krisen als Initialsymptora einer Tabes dorsalis. In- aug. Dissert. Berlin, 1889. f [L. Wolff. Abstract in Boas's Arch., Bd. i, p. 110.—Ed.] 576 DISEASES OF THE STOMACH. either accidentally or on account of the development of the specific symptoms of emaciation, pruritus, etc. [Gastric crises, Avhich are at times very painful, have also been reported in this disease.*] In well-developed cases of diabetes, as shown by Rosenstein f and Gans,:J: the gastric functions are very variable, and stand in no relation to the amount of sugar, acetone, and diacetic acid in the urine. Rosenstein concludes from his investigations that in some cases free hydrochloric acid may be absent; Avhere this is temporary, it is to be referred to a gastric neurosis ; but, when it is permanent, the cause is atrophy of the mucosa in consequence of interstitial inflammation. The relations of gout to disturbances of digestion have been especially discussed in English medical literature. According to some writers, there is a specific gouty disorder of the stomach re- sulting from the uric acid diathesis, or from contamination with the products of incomplete metabolism, or their insufficient excretion —i. e., disturbed retrograde metamorphosis. Thus, not long ago, Burney Teo * claimed that one of the prominent manifestations of this condition was dyspepsia in all its forms. Other authors, like Brinton, Pavy, etc., do not recognize a specific gastric disorder, and may therefore be considered to take a view more closely allied to our own. The same is true of the rheumatic diathesis, which has played quite a prominent part in French literature. Although I have not met a single case of true gout with coincident gastric dis- turbances, yet I have seen numerous such examples in chronic artic- ular rheumatism, in which they were so marked that the pains in the joints were comparatively insignificant. Whether there is any close connection between these conditions I shall refrain from saying, just as I shall do in the similar relations of affections of the skin and the stomach, to which Pidoux || has paid particular attention. Finally, I consider that there is a much better * [Leube. Miinch. med. Wochenschr., 1895, No. 7.—Ed.] f Rosenstein. Berlin, klin. Wochenschr., 1890, No. 13. X Edg. Gans. Ueber das Verhalten der Magenfunctibnen beim Diabetes mellitus IX. Congress fur innere Medicin. Vienna, 1890. 9 Burney Yeo. On the Treatment of the Gouty Constitution. British Med. Journal, January 7 and 14, 1888. || Pidoux. Rapport d l'herpetisme et des dyspepsies. Union med., 1886, No. 1. THE PRACTICAL VALUE OF THE CHEMICAL METHODS. 577 established as well as a more practical connection between the digest- ive disturbances and the various forms of malaria (i. e., the manifest and especially the latent forms of intermittent fever) and typhoid fever, particularly its ambulant variety. Malarial poisoning may be manifested as an intermittent car- dialgia (Leube *) or in the form of the various neuroses of the stom- ach, which will be characterized by a certain regularity (Rosenthal, Glax f), and which, according to the latter observer, can be relieved only by quinine as long as the patient remains in the malarial dis- trict. Kisch*}: in Marienbad, and Glax in Rohitsch [an alkaline saline spring in Steiermark, Austria], both observed that it was most striking that, after the use of the waters of these places, the neuroses first occurred in true intermitting attacks and then finally disappeared altogether. Formerly I not infrequently had the oppor- tunity of treating such cases of marked intermittent dyspepsia. [These various manifestations are quite common in New York, and should always be borne in mind in obstinate cases. The routine use of the thermometer will occasionally aid in recognizing these cases. In the treatment, "Warburg's tincture will be found to be especially useful.] Conclusion.—The Practical Value of the Modern Chemical Tests.— In the course of this book I have ahvays brought forward the experiences which have been gained by the new methods of investi- gation, especially of the chemical functions of the diseased stomach, and I have thus been enabled to combine the old well-known noso- logical facts Avith the diagnostic and therapeutic results recently gained. The task still remains to mention what place is occupied by the chemical methods of investigation in the individual affections of the stomach, and how far they warrant drawing absolute conclu- sions upon the nature of the disease under consideration. Do the stomach and the test tubes enable us to discover specific, character- istic functional disturbances which belong invariably and exclusively * Leube. Beitrage zur Diagnostik der Magenkrankheiten. Deutsch. Archiv. fiir klin. Med., Bd. xxxiii. f Glax. Ueber die Neurosen des Magens. Vienna, 1887, S. 206. X Loc. cit 578 DISEASES OF THE STOMACH. to an individual case, and thus establish the diagnosis like the presence of tubercle bacilli in the sputum and hyaline casts in the urine ? Or, are they simply the signs of a more general significance which have nothing to do with a specific morbid process ? It is known that some recent authors have gone so far as to classify the diseases of the stomach into those Avith an increase, diminution, and absence of hydrochloric acid, and possibly some may regret that I " have not followed the fashion " and arranged the subject-matter from this standpoint. I have as remote an idea of doing this as I would have of writing a text-book on special pathology in which the diseases are classified according to the presence or absence of dropsy, jaundice, albuminuria, etc. On the contrary, if Ave wish to adhere to facts and avoid exaggerations, our present knowledge may be summed up in the following propositions: There are two great groups of results in the chemical examina- tions of the gastric juice which differ from the normal: 1. The untimely occurrence of organic acids. 2. The changes in the gas- tric juice itself (i. e., the secretion of hydrochloric acid, pepsin, and rennet), and the absorption and motility of the organ. 1. The occurrence of organic acids, especially lactic acid, during a stage of digestion in which they can not be demonstrated normally by the tests already known to you. This is always characteristic of definite pathological conditions, the manifestations of which are also perceived subjectively by the patient. These acids are due to ab- normal processes of decomposition or fermentation, whose causes may be manifold but which are always combined with a morbid state, provided the latter expression be made to include not only an abnormal chemical result, but also more or less well-marked disturb- ances in the affected individual. This explains the significance of the demonstration of lactic and the fatty acids. Now, since these products of fermentation are always associated with a prolonged stay of the ingesta in the stomach, and usually with an absolute or relative lessening of the secretion of hydrochloric acid, a diag- nosis may be ventured in this direction from a knowledge of these facts. 2. Much more complicated are the conditions concerning the significance of changes in the gastric juice. Since the secretion of THE PRACTICAL VALUE OF THE CHEMICAL METHODS. 579 pepsin and rennet ferments goes hand in hand with that of hy- drochloric acid—excepting trifling variations which have no prac- tical meaning—what is said of the latter may serve as a statement for all. It has always been my belief, as I have stated in the earlier editions of this book that increase or diminution in the amount of the hydrochloric acid secretion is a sign which is related to the various types of disease only in so far that some tend to cause its increase, while others its diminution or even absence; but this de- pends entirely upon the anatomical or functional disturbances which accompany these morbid types. Naturally, these cause the changes in the production of hydrochloric acid; hence it is their extent in the course of the disease which will determine how much the secretion of acid will be affected. At all events, we may say that one group will never cause an increased secretion of acid—i. e., all those forms in which an extensive organic destruction or change in the secreting parenchyma has taken place. So far as we know, there is no vicarious increase in the activity of the remaining glan- dular cells. This group, therefore, includes carcinoma, chronic gastritis and its sequelae, atrophy of the mucous membrane, mucous degeneration of the gastric glands; possibly, also, certain chronic vascular lesions—as, e. g., amyloid degeneration of the blood vessels [of the stomach]. We must also add other chronic enfeebling morbid processes which may cause the disappearance of HCl, such as profound anaemia, tuberculosis, cardiac diseases, dia- betes, etc. But, if we reverse this statement, and say that certain kinds of disease cause an increased secretion, we would be going too far. An increased secretion is ahvays functional, a sign of irritation. But, as is well knoAvn, every such overproduction may cause exactly the opposite condition; I refer not only to the result of exhaustion following overexcitation, but also to the condition of depression from the very beginning. Thus it may happen that we some- times encounter an absence of hypersecretion in a condition which is usually accompanied by a strong stimulation of the secreting ele- ments, as gastric ulcer. A neurosis may manifest itself at one time by an overproduction of acid during the period of digestion (hyper- 580 DISEASES OF THE STOMACH. chlorhydria) ; at another time by a continuous secretion (hypersecre- tion). Other cases also exist in which there is such a diminution in the secretion of hydrochloric acid that the amount is permanently reduced to a minimum. Undoubtedly, the normal process of digestion is accompanied by so copious a secretion of hydrochloric acid that not alone are various combinations formed Avith the different foods present, but there is also a certain excess of free acid which seems to be indis- pensable for the completion of normal gastric digestion. But we must not forget, as I showed some time ago in the digestion of albu- men,* and as has since been corroborated by Salkowski, Rosenheim, and others, that peptonization, even though it is slight, may take place without any free acid; that normally, as in menstruation, no free acid, or only a Arery small quantity, is secreted; and that the human organism manifestly possesses in no insignificant degree the capacity of compensating for an absence of hydrochloric acid, pep- sin, and rennet by driving the chyme out of the stomach much sooner, and relegating it for digestion to the intestine. After all this I think all will agree with me if, in general, I attribute no positive diagnostic value to the simple fact that the acidity is increased or diminished or apparently normal, provided this is referred to no other acids than free hydrochloric acid ; and if I consider such results only as a supplementary although very important feature in completing and establishing the entire clinical picture. On the other hand, I do not wish to be misunderstood, and I therefore say emphatically that this statement is in no way intended to detract from the value of our examinations ; on the contrary, they are indispensable to us, and in all cases where cir- cumstances will not permit them we feel in doubt, and " somewhat at sea." At every step in the preceding discussions it will have been ob- served the proof of the extent to which our knowledge has been extended and amplified by the new methods of investigation ; but, on the other hand, in view of many recent events, I believe it is my * C. A. Ewald. Ueber den " Coefficient de partage " und iiber das Vorkommen von Milchsaure und Leucin im Magen. Virchow's Archiv, Bd. xc, S. 349. THE PRACTICAL VALUE OF THE CHEMICAL METHODS. 581 duty to warn against a one-sided overestimation of their value. As I have already stated in Chapter I, time has since shown the cor- rectness of my views. We have gradually sailed into smoother waters ; indeed, a reaction has already set in, so that the results of the chemical examinations are even valued less than they ought to be. This negative view is just as erroneous as the one-sided over- valuation of these methods. Only the most careful and thorough consideration and weighing of all the symptoms which can be ob- tained with all the diagnostic resources will enable us to recognize the existing disease. Not even the most careful chemical examina- tion of the functions of the stomach will put within our grasp the divining-rod which will magically call forth the fountain of knowl- edge from the adamantine rocks of obscure symptoms! Even to- day the old saying is true that— *' Ubi ratio sine experimentis mendax, Ita experientia sine ratione fallax." INDEX. Abelous, 187. Abercrombie, 127, 402. Abscess of stomach, 181. Absorption in stomach, 60, 75, 455; char- acter of, 75 ; test of, 75. Achlorhydria, 24,26. See Hydrochloric Acid, Absence of. Achylia gastrica, 205, 221. Acid, acetic, tests £or, 44. butyric, tests for, 44. hydrochloric. See Hydrochloric Acid. lactic, in stomach contents, 27, 29 ; in cancer, 30, 351; fermentation-, 41; meat-, 41; quantitative estimation of, 54; tests for, 29, 30, 41, 44, 55; varieties of, 41. salicyluric, test of, in urine, 79. sarcolactic, 41. Acid salts, 25 ; quantitative estimation of, 55 ; tests for, 34. Acidity of gastric juice, cause of, 27; variations of, 24, 580; determination of, 24. of stomach contents, 25 ; stages of, 25 testing of, 30, 47. percentage of, 34. total, tests for, 31. quantitative determination of, 46. Acids, fatty, in stomach contents, 44; tests for, 44. free, tests for, 34. organic, in stomach, 44, 578; tests for, 40. See also Contents of Stomach. Acoria. 517. Adamkiewicz, 320. Adenopathies in gastric cancer, 329. Adler, 572. Agoraphobia in chronic gastritis, 216. in gastric neuroses, 476. Air, distention of stomach with, 85, 87. Akerlund, 538. 38 I Akinesis of stomach, 276. Alapy, 573. Albertoni, 375. Alberts, J. E., 315, 317, 318, 320. Albu, 159. Albumen, digestion of, 60. disks, 65. putrefaction of, in stomach, 288. reaction on aniline dyes, 36. reactions of, 60, 61. Albumoses, 60. Albutt, 261, 291. Alcohol in contents of stomach, 44. Alderson, 4. Alimentation, rectal, 150, 434, 436. Alt, 500, 525. Anachlorhydria, 26, 518. See also Hy- drochloric Acid, Absence of. Anacidity of gastric juice, 24, 343, 579. nervous, 518. See Hydrochloric Acid, Absence of. Anadenia of stomach, 203, 217; diag- nosis, 221 ; from cancer, 223; lav- age in, 223 : pathology, 199: relation to pernicious anaemia, 220, 563; stomach contents in, 222; treatment, 224. Anaemia, condition of stomach in, 570. pernicious, condition of stomach in, 220, 563. Anaesthesia of skin in gastric ulcer, 405. of stomach, 517. Andeer, 233. Andral, 181, 276, 281, 317, 328, 417, 545, 564. Aniline dyes in stomach analyses, 35. objections to, 36. Anorexia, 484. in cancer of stomach, 331. in catarrh, 172. in dilatation, 282. in phlegmon, 183. 584 DISEASES OF THE STOMACH. Anorexia in tumors of kidney, 573. in tuberculosis, 487, 564. in ulcer of stomach, 403. nervous, 484. Antiperistaltic unrest of stomach, 516. Antrum pylori, 91. Apepsia, 192. Appetite, 470. in gastric cancer, 331. lack of. See Anorexia. perverse, 483. ravenous, 482. See Bulimia. Ardor ventriculi, 209. Aretams, 478. Arnold, 522. Arnott, 4. Asiatic pills, 553. Asp, 216. Aspirator, stomach, 12 ; Boas's, 13. Asthenia of stomach, 276. Asthma, dyspeptic, 215, 510. Atony of stomach, 192, 527. in chronic gastritis, 211. in dilatation, 276. Atrophy of stomach. See Anadenia. of muscularis of stomach, 203. Audhui, 202. Auerbach's plexus, 453, 459. Aura vertiginosa, 216. Autenrieth, 314. Autointoxication, intestinal, 159. Autoscope, Kirstein's, 125. Bacillus coli communis in stomach con- tents, 46. Bacillus gastricus, 185. Bacteria in acute gastritis, 166. in gastric cancer, 75, 331, 333. in gastric phlegmon, 181. in gastric ulcer. 390. Bamberger, 255, 277, 345. Baraduc, 104. Barbacci, 401. Barbei, 320. Barlow, 401. Barnes, 117. Barras, 473, 478, 513. Barry, Du, 284. Bartels, 220, 275. Basch, Von, 216. Bastianelli, 461. Battistini. 233. Baum, 305. Beatson, 161. Beau, 330, 473. Beaumont, 164, 240, 383. Beck, 413. Becker, 384. Behrens, 87. Belching, nervous. 508. Belladonna in cancer of stomach, 370. Benecke, 560. Benedict, 102. Bennet, 446. Bernstein, 216, 566. Berrez, 115. Berthold, 392. Best, 376. Betz, 45, 288. Bial, 187, 352. Bianchi, 263. Bidder, 49, 53. Biedert, 57. Billroth, 306. Biernacki, 73, 573. Bile, cause of chronic gastritis, 208. in stomach contents, 73. taste of, 172. test for, 73. Binswanger, 556, 561. Birchner, 307. Bird, Golding, 344, 347. Birsch-Hirschfeld. 393. Bismuth in gastric ulcer, 439. Bitters, 229. Biuret reaction, 60. - Blaschko, 218, 530, 531. Blass, 31, 32. Blatin, 4. Blondeau, 216. Blood, condition of, in cancer of stom- ach, 336. condition of, in ulcer of stomach, 385, 407. in stools, 408, 409, 411, 424. vomiting of. See Haematemesis. Blume, 425. Boas, 7, 8, 13, 14.18, 21, 28, 30, 32,35.38, 39, 44, 45, 48, 63, 68, 69, 70, 75, 153, 195, 196. 208, 213, 229, 239, 246, 261, 267, 288, 290, 298, 333, 350, 351, 352, 387, 442, 506, 507, 508, 515, 525, 546. reagent of, 28. Bocci, 105. Boerhave, 318. Bollinger, 376. INDEX. 585 Botticher, 390. Bouchard, 159, 203,294. Bouilleaud, 415. Bourdon, 504. Bourneville, 521, 522. Bouveret, 274,293, 294, 295,338,506, 507. Bovis, De, 192. Braam-IIouckgeest, 278. Briiutigam, 315. Bradypepsie, 192. Braun, 49, 229. Bramann, Von, 307. Brieger, 233, 566, 567. Brinton, 112, 121, 181, 184, 195, 313, 318, 321, 324, 328, 329, 330, 331, 340, 342, 353, 391, 409, 576. Briquet, 478, 516, 537. Bristowe, 509. Brochet, 452. Brock, 106. Bromide-water, 552. Broussais, 192, 276, 492. Brown, 71, 492, Brown-Sequard, 178. Briick, 216. Bruggemann, 571. Brunner, 305. Brunton, Lauder, 157, 173. Brush, stomach, 4. Buch, 494, 495. Buczlygan, 570. Budd, 244, 400, 411, 413, 424, 426, 433, 440, 473, 501, 545. Bukler, 183. Bulimia, 481; etiology, 483; forms, 484; occurrence, 482; peristalsis in, 484; treatment, 483, 548. Bull, E., 215. Bull, W. T., 306. Bunge, 78, 160. Burettes, forms used in titration, 33. Burkart, 106, 494. 536, 556, 559. Bush, F., 4. Bussel, 376. Cachexia, in gastric cancer, 334, 359. in hysteria, 360. Cahn, 29, 49, 64, 65, 118, 180, 255, 271, 280, 290, 291, 347, 349, 351. Calculi, gastric, 480. Callow, 185. Oamerer, 389. Camus-Corrignon, 205. Canstatt, 4. Cancer of stomach. See Carcinoma. Canula, permanent, of cesophagus, 143. Caragiosiadis, 105. Carbcnic acid gas, distention of stomach with, 85. Carcinoma of stomach, 313. bacteria in, 75, 331, 333. blood in, 336. course, 339. diagnosis, 343; absence of hydrochlo- ric acid, 343; cachexia in, 359 : can- cerous tumor, 354; from atrophy, 223; lactic acid in, 30, 351; pieces of tissue obtained by washing out stomach, 352. differential diagnosis, 361 ; between gastric nicer and cancer, 331, 362, 363, 418. etiology, 317. ferments in, 350. localization, 323. lymphadenitis, 329. metabolism, changes in, 338. occurrence, 313 ; age, 313; duration, 339; heredity, 315; locality, 314; primary or secondary, 327; rela- tions to gastric ulcer, 318; sex, 314. pathological anatomy, 320; varieties, 321. perforation, 330. position of stomach in, 324. prognosis, 339. propagation, 327. sarcina?, absence of, 334. shape of stomach in, 325. site, 324 ; sequelae of, 325. symptoms, 330; anorexia, 331; bowels, 342 ; cachexia, 334; pain, 331; pres- ence of tumor, 334; tongue, 331; vomiting, 331, 332, 334; vomiting of blood, 331. thrombosis, 328. treatment, 366; analgesics, 369; con- durango, 366; diet, 371; mineral waters, 373; of constipation, 370; of haematemesis. 369; of vomiting, 368; surgical, 373. tuberculosis occurring with, 328. ulceration, 329. Cardia, cancer of, 121,152; stomach con- tents in, 153. closure of, 460; in rumination, 524. 586 DISEASES OF THE STOMACH. Cardia, contraction of, spastic, 116. function of, 460. neoplasms of, 120; cause of, 121. paresis of, 520. relaxation of, 509, 520, 524. spasm of, 116, 515. stenosis of, 109. stricture of, 109; dilatation of, 132; feeding in, 149 ; gastrostomy in, 146; organic, 114; pain in, 116; passage of bougies in, 124, 141; symptoms, 109; treatment, 140. Cardialgia, 209, 487. in gastric cancer, 231. in stricture of cardia, 116. Carlsbad water, action of, in chronic gastritis, 250; in gastric neuroses, 561; in ulcer, 434, 435. Carron, 116. Carswell, 324, 328, 395, 424. Cartellieri, 509. Catarrh, acute, of stomach, 163. See Gastritis, Simple Acute. subacute, 181. chronic, 192. See Gastritis, Chronic Glandular. Catarrhus atrophicus, 203. Cathelineau, 491. Chlapowski, 540. Chambers, 402, 473. Chantemasse, 391. Charcot, 490. Chemical tests, value of, 577. Cherchewsky, 531. Churon, 540. Chiaje, Delia, 145. Chiari, 115, 206, 393. Chittenden, 60, 70, 232, 240. Chlorine. See Contents of Stomach. Chlorosis, condition of stomach in, 570. relation to gastroptosis, 571. Chomel, 193. Chovstek, 184, 417. Cimbali, 475. Cirrhosis ventriculi, 195. Clapotement, 262. Cloquet, 314. Clostrydium butyricum, 161. Clozier, 270. Cohn, 28, 160, 161, 516. Cohnheim, 8, 155. 169, 180, 196, 200, 223, 327, 352, 354, 399. Coin, 116. Cold-water treatment. 108. Colgan, 394. Colleville, 573. Colloid cancer of stomach, 321, 322, 323. Colic, biliary, 430. stomach, 515. Coma dyspepticum, 292. dyspnceic, 336. Comby, 213, 282. Comparetti, 473. Concretiones benzoartices, 480. Condurango in gastric cancer, 366. Congo red, 35. Contejean, 461. Contents of stomach, 6. acetic acid in, 44. acetone in, 45. acidity of, 36, 37, 47, 387, 406, 580. alcohol in, 44. ammonia in, 45. bacteria in, 46, 75. See Bacteria. bile in, 73. butyric acid in, 44. carbonic acid in, 45. chlorine, estimation of, 52. chlorides, estimation of, 52. examination of, 24. fatty acids in, 44. filtration of, 31. fungi in, 185. in acute gastritis, 167. indol in, 46. in gastric crises, 491. in gastric cancer, 343. in gastric catarrh, 221. in gastric dilatation, 283. in gastric ulcer, 387, 406, 422. in mucous gastritis, 222. intestinal parasites in, 187. lactic acid in, 44. larvae in, 181. marsh gas in, 45. methods of obtaining, 12. micro-organisms in, 187. See Bacteria. microscopical examination of, 74. olefiant gas in, 45. organic acids in. 44. pepsin in, 66, 67, 226, 350. ptomaines in, 45. reaction of, 25. rennet in, 67, 350. routine examination of, 56. sulphuretted hydrogen in, 45. INDEX. 5S7 Contents of stomach, sugar in, 73. taste of, 172. while fasting, 73. Contraction of stomach, 325. Cooper, 390. Copland, 192, 405, 501. Cordes, 216, 217, 251. Cordua, 446. Cornil, 417. Cornillon, 422. Cough, stomach, 214. Couteret, 193. Cramps of stomach, 477, 515 ; in gastric dilatation, 292. Cramer, 8, 440. Cravate de Suisse, 460. Crises, gastric, 490, 535, 574. Crisp, 387. Cruveilhier, 181, 205, 269, 279, 380, 396, 400, 411, 436. Cuilleret, 540. Cullen, 209. Cure, rest, 434, 556. Schroth's dry, 299. Curling, 390. Cynorexia, 482. Depressive neuroses of stomach, 474. Desnos, 516. Dettweiler, 567. Devic, 293, 294, 295. Dextrin, 70. varieties, 70. test for, 71. Diabetes, condition of stomach in, 575. Diarrhoea due to terror, 454. Diastase, 69; taka diastase, 227. Diemerbroeck, 290. Diet in gastric cancer, 371. in gastric catarrh, 238. in gastric ulcer, 437. Dietrich, 123, 422. Dieulafoy, 402. Digestion of albumen, 60; test of, 65. of starch and sugar, 60, 09. effect of alcohol on, 232. in absence of hydrochloric acid, 102. reflex disturbances of, 544. test in gastric neuroses, 530. Dilatation of cesophagus, 111, 132. Dilatation of stomach, 211, 254. atonic, 276. course of, 296. diagnosis of, 255, 295; Boas's method, 261 ; auscultation, 262 ; Dehio's method, 260; inspection, 255; Leu- be's method, 261; measuring capacity of stomach in, 264; murmurs of deglutition in, 264; palpation, 261; percussion, 258; peristalsis in, 256, 257 ; use of phonendoscope in, 263 ; Rosenbach's method in, 264; suc- cussion, 262. etiology, 266 ; atony of stomach, 276 ; exclusion of limited areas of muscu- lar fibres of stomach, 278 ; feebleness of motor nerves, 277; polyphagia, 277 : stenoses of pylorus, 268; wan- dering kidney, 275. occurrence, 280; with biliary calculi, 274. pathology, 279. physical signs, 255. prognosis, 296. symptoms, 280: acidity, 288; chemical functions of stomach, 285; coma, 292; constipation, 291; delayed ab- sorption, 289; dryness of tissues, 291; fermentations, 277, 283, 286; inflammable gases, 286; peristalsis, Da Costa, 437. Daettwyler, 382. Daguet, 422. Daland, 337. Damaschino, 193. Danger of stomach tube, 8, 127, 422. Darwin, 522. Dastre, 208. Dauber, 508. Daumann, 546. Debove, 424, 437. Decker, 525. Defecation by mouth, 516. Defailliance, 481. Degeneration, colloid, of stomach, 279. Degeneration of nervous plexuses of in- testines, 530. Deglutition murmurs, 93. in dilatation of stomach, 264. in rumination, 524. Dehio, 82. 88, 260, 524. Deininger, 184, 185. Deiters, 269. Dejerine, 491. Delamare, 490. Demange, 491. 588 DISEASES OF THE STOMACH. 291 ; sarcinae and bacteria, 283; stagnation of stomach contents, 283; sulphuretted hydrogen in, 45; teta- ny, 292; urine, state of, 293, 294; vomit, 283; vomiting, 282. treatment, 299; dry diet, 299; resec- tion of pylorus, 306 ; use of cathar- tics, 301; faradization, 305 ; hydro- chloric acid, 300; massage, 305 ; size of tube for, 11; strychnine, 301; washing out stomach, 302. Dimethylamidoazobenzol, 40. Diphtheritic gastritis, 166, 180. Dirkler, 486. Dirksen, 93, 95. Distention of stomach, with air, 85, 87. with carbonic-acid gas, 85. with water, 82, 87. Dittrich, 181, 317, 318, 327, 330, 339. Diverticula of cesophagus, 119. Douche, Scotch, 305, 554. stomach, 99, 550. Dreschfeld, 345. Dronke. 438. Drozda, 417. Dubujadoux, 196. Ducasse, 523. Dujardin Beaumetz, 193, 194, 225, 263, 292, 301, 339. Dunglison, 405. Duodenum, ulcer of, 390, 430, 432. Duplay, 262, 301. Dupuytren, 390. Duzan, 313. Dyspepsia, 156. asthenique, 276. atonic, 192. buccal, 72. cardiaca, 215. flatulent, 532. habitual, 192. in gastric cancer, 331. in gastric dilatation, 282. in stricture of cardia, 110. irritable, 192. nervous, 529. peristalsis of stomach in, 162. reflex, 530, 546. salivary, 72. uterina, 546. Also see Gastritis, Chronic Catar- rhal. Dyspnceic coma in gastric cancer, 336. Dyspeptic asthma, 215, 510. Eating, slow, 238. repugnance toward, 484. Ebstein, 80, 169, 188, 205, 381, 526, 527. Edleffsen, 214. Edinger, 16, 18, 169, 179, 386, 566. Egeberg, 146. Eichenberg, 242. Einhorn, 16, 23, 40, 82, 96, 97, 98, 102, 103, 106, 134, 196, 205, 218, 220, 221, 525, 550. Eisenlohr, 204, 218, 337. Eisenhardt, 402. Electrization of stomach, 102, 305. effect on muscular fiber, 104. effect of, 105. Electrode, stomach, 103. Elixir peptogene, 225. Ellenberger, 70. Ely, 327. Emrainghaus, 9, 45, 288. Emptiness of stomach, 481. Engel, 417. Enemata in chronic gastritis, 206. Enemata, nutritive, 150, 151, 436. Enteroliths after bismuth, 441. Enteroptosis, 539. treatment of, 555. Eppinger, 401. Epstein, 14. Eras, 115. Erichsen, 390. Ergot, in haematemesis, 369, 444. Erlmeyer, 552. Erosions of stomach, 196; haemorrhagic, 335. Eructation, foul-smelling, 286. hysterical, 508. nervous, 508. Escherich, 211. Etat mammelone, 280. Ether, extraction of stomach contents with, 42. Euchlorhydria, 27. Everett, 551. Ewald, C. A., 5, 7, 8, 14, 21, 28, 32, 37, 54, 58, 60, 63, 65. 70, 72, 73, 77, 78, 79, 93, 94, 111, 116, 150, 152, 158, 161, 162, 169, 178, 190, 195, 220, 225, 226, 229, 240, 246, 253, 278, 286, 288, 320, 321, 345, 346, 358, 371, 382, 386, IXDEX. 589 387, 406, 425, 438, 450, 462, 463, 517, 519, 528, 532, 539, 546 573, 580. Ewald, R., 448. Expression, Ewald's method of, 12. contraindications to, 15. Eyeselein, 216. Faber, 75, 415. Fabricius ab Aquapendente, 4, 521. Fagge, Hilton, 291. Falk, 160. Falkenheim, 284. Fames canina, 482. Fauvel, 417. Favus of stomach, 185. Fawizky, 49. Feeding by rectum, 150, 151, 436. Fenwick, S., 199, 204, 220, 304, 418, 473, 486, 487, 533. Fenwick, W. S., 15, 169, 179, 402, 563, 564, 569, 570. Ferber, 259. Fereol, 540. Fermaud, 187. Fermentation (alkaline) of albuminoids in stomach, 211, 288. in stomach, 167, 235, 299. lactic acid, 41. Ferrarini, 406. Fiedler, 392. Finkler, 227. Finny, 411. Fischl, 321. Fistula of stomach, making of, 146. Fistula? after perforation of gastric ulcer, 416. Flatow, 319. Fleiner, 248, 273, 293, 304, 309, 440, 441, 544. Fleischer, 43, 546. Flint, 220. Food, taking of, 471. refusal of, 484. Foote, 394, 413, 414, 446. Forster, 434. Fothergill, 473. Fouquet, 516. Fox, Wilson, 314, 387, 434. Frank, 522. Frankel, E., 186. Frerichs, von, 4, 85, 127, 284, 417, 561. Freud, 534. Freund, 199. Freyhan, 525. Friedenwald, 31, 40, 44, 58, 69, 352. Friedheim, 51. Friedreich, 339, 366. Fries, 410. Full stomach, 477. Fungus haematodes of stomach, 321, 322. Furstner, 106. Fungi in stomach contents, 285. Gaertig, 123. Galliard, 402, 417, 429. Gallois, 522. Ganglion cells of stomach, 452. Gans, 576. Garland, 425, 475. Gastralgia, 210. genuine, 488. hysterical, 497. diagnosis from ulcer and cancer, 418. differential diagnosis between gastral- gia due to ulcer and colics, 430. in diseases of central nervous system, 490. in gastric cancer, 331. in gastric ulcer, 403, 404. in gastric neurasthenia, 492. in nervous dyspepsia, 537. in psychoses, 499. reflex, 544. treatment of, 369, 443, 548, 549. Gastrectasis. See Dilatation of Stom- ach. Gastric crises, 490, 535, 574. Gastric fever, 173. Gastric juice. See Juice, Gastric. Gastric neurasthenia, 529. Gastrite hyperpeptique, 506. Gastritis acida, 195. Gastritis, simple acute, 165; glandular, 165; idiopathic, 165; sympathetic, 178; acidity in sympathetic, 179. diagnosis, 174; etiology, 165; fatty acids in, 167, 173; fermentation in, 167; hydrochloric acid in, 173; lac- tic acid in, 167, 173; micro-organ- isms in, 166; occurrence, 165; pa- thology, 168: psychical factor in, 166; stomach contents in, 167; symptoms, 171; treatment, 176; varieties, 172. chronic glandular, 192; agoraphobia in. 216; anadenia in, see Anadenia; antifermentatives in, 227, 235; ano- 590 DISEASES OF THE STOMACH. dynes in, 244; atrophy of mucous membrane in, 199; bitters in, 229; bromelin in, 227; constipation in, 213 ; course, 224; diagnosis, 221 ; diet in, 238 ; drugs in, 233, 234; dys- peptic asthma in, 215; electricity in, 229; enemata in, 247; etiology, 206; hydriatic treatment of, 237 ; exfolia- tion of mucous membrane in, 8,196; hydrochloric acid in, 221, 225, 235; hygiene in, 243; lavage in, 200, 227; mineral waters in, 249; minute anat- omy of, 197; orexin in, 232; papoid in, 227; pancreatin in, 227; pathol- ogy of, 195; pepsin in, 226; prog- nosis of, 224; pulse in, 215; purga- tives in, 245; stomach cough in, 214; symptoms, 208; synonyms, 192; tongue in, 209; treatment, 224; urine in, 214; varieties, 200; vertigo in, 216 ; vomiting in, 210. diphtheritic, 166, 180. emphysematous, 186. membranous, 166, 180. mucous, 208, 222; lavage in, 222. mycotic, 185. parasitic, 185. parenchymatous, 169. purulenta phlegmonosa, 181; diag- nosis, 184; etiology, 181; occurrence. 181; pathology, 182; symptoms, 183; treatment, 185; varieties, 181. toxic, 188; diagnosis, 189; symptoms, 189; treatment, 189. Gastroadenitis, 164. Gastrodiaphane, 96. Gastrodynia, 487. Gastroenterite, 192. Gastrograph, 82. Gastroliths, 376. Gastromalacia, 389. Gastroptosis, 89, 539. treatment of, 555. Gastroscope, 95. Gastroscopy, 95. Gastrostomy, 146. feeding after, 152. technique of, 148. Gastrosuccorrhoea, 24, 502. mucosa, 508. Gastroxynsis, 507. Gavarett, 328. Geigel, 31, 32. Gempt, Te, 437. Georges, 231. Gerhardt, 187, 330, 392, 396, 406, 409, 431, 432, 441. Germont, 336. Gersung, 144. Gigglberger, 240. Gilles-Sabourin, 401. Girandeau, 262. Glaser, 184. Glax, 181, 255, 516, 577. Glenard, 539, 540, 543, 555. disease of. See Gastroptosis. Gluczinsky, 345, 346, 406, 570. Gmelin, 18, 73. Goldschmidt, 108. Goldstein, 417. Goltz, 455, 462. Gombault, 196. Goodhart, 554. Goodsir, 284. Gothard Tunnel disease, 548. Gout, condition of stomach in, 576. Graf, 316. Graham, 425. Grande, 79. Grasset, 339. Graves, 210. Griesinger, 314. Griess, 392. Griffini, 381, 399. Grote, 227, 442. Grtinfeldt, 393. Grutzner, 229. Grundzach, 162, 274. Grusdew, 566. Giinsburg, 389. Giinzburg, 17. 38. reagent, 38. Guipon, 483. Guiteras, 115. Gull, 490. Gumlich, 63, 371. Gussmann, 174. Guttmann, 233. Gyromele, Turck's, 4, 236. Haafewinkel, 227. Habershon, 181, 396, 400. Haberlin, 75, 314, 316, 319, 327, 337. Hacker, Von, 115, 306. Haematemesis, 407, 423. causes of, 424. INDEX. 591 Haematemesis, diagnosis from haemop- tysis, 423. in cardiac diseases, 424. in cholera, 420. in direct traumatism, 428. in diseased gastric blood-vessels, 428. in epilepsy, 424. in fever, intermittent, 426. in fevers, exanthematous, 426. in gastric ulcer, 407. in gastritis glandularis chronica, 426. in helminthiasis, 426. in hysteria, 426. in liver, acute yellow atrophy of, 424. in liver, cirrhosis of, 424. in miliary aneurism, 429. in oesophageal varix, 425. in progressive anaemia, 428. in purpura haemorrhagica, 426. in scurvy, 426. parenchymatous, 427. treatment of, in cancer, 369; in gen- eral, 429 ; in ulcer, 443. Haemoptysis, 423. Hafner, 428. Hahn, 300, 307, 374. 375. Hair tumors in stomach, 370, 480. Hall, 415. Haller, 465. Hamburger, 160, 161. Hammerschlag, 67, 200, 352. Hampeln, 335. Hanot, 121, 196. Hansemann, 320. Hanssen, 515. Hart, Ed., 33. Hart, Wheatley, 133. Hartung, 337. Hasselmann, 114. Hauser, 317, 319, 320, 399. Hayem, 27, 49, 169, 194, 196, 204, 208, 250, 506, 570. Heart, condition of stomach in diseases of, 571. Heart-burn, 209, 510. Heberden, 225. Heddaeus, 119. Helmer, 49. Heidenhain, 170, 395, 454. Heilbrun, 428. Heinecke, 306, 308. Heintz, 181. Heitler, 319. Hellwig, 306, 307. Hemialbumose, 60. Hemmeter, 7, 82. Henle, 395. Henne, 232. Henoch, 175, 215, 329, 343, 393, 428, 510. Henry, 564. Heredity of cancer, 315. Heron, 71. Herpes labialis in acute catarrhal gas- tritis, 172. Herschell, 163. Heryng, 96. Herzen, 225. Heynsius, 287. Hildebrand, 187, 566, 568. Hiller, 417. Hilton, 446. Hippocrates, 478. Hirsch, 29, 389, 406. Hirschberg, 550. Hirschfeld, 28. Hirschspring, 269. Hoesslin, von, 35. Hoffmann, F. A., 49, 50, 51,164,165, 209. Hofmeister, 70, 528. Hollevoet, 412. Holmes, 390. Hood, 291, 409, 428. Hoppe-Seyler, 58, 178, 287. Honigmann, 501, 506. Hornbaum, 495. Huber, 80, 151. Hubert, 306. Hiibner, 406, 501. Hiifler, 572. Huppe, 286. Hufeland 366. Hughes, 446. Hugounang, 231. Hunger, 465. causes of, 405. center of, 466, 471. feeling of, 466; deviations from, 481; inhibition of, 468; localization, 467; voracious, 481. Hunter, 4, 387, 390. Hutchinson, 564, 567. Hydrochloric acid, absence of, in Addi- son's disease, 346; in amyloid de- generation of gastric mucosa, 346; in anadenia, 222: in fever, 179; in gastric cancer, 345; in gastric neuro- 592 DISEASES OF THE STOMACH. ses, 340: in menstruation, 546; in mucous catarrh of stomach, 340; permanent, in healthy persons, 579 ; in pulmonary phthisis, 346, 507: in valvular diseases, 346. antiseptic action of, 160. free and combined, 25, 26, 47. free, estimation of, 47. influenced by electricity, 105. in fever, 179; in phthisis, 566. loosely combined, method of deter- mining, 4!'. percentage of, 24, 31. permanent lessening in gastric neu- roses, 580. relation to acidity of urine, 162. relation to indican in urine, 163. secretion of, 25, 27. tests for, 36, 37, 47. use of, 221, 225, 235, 300. Hydrops in gastric cancer, 336. Hydrotherapy, 108, 554. Hyperacidity, 24, 27, 194, 501, 502. in gastric ulcer, 387, 406. in nervous disorders, 502. occurrence, 502. test of, 36. treatment, 507. Hyperaesthesia of stomach, 477. after chloroform narcosis, 479. Hyperchlorhydria. See Hyperacidity. Hyperkinesis, 16, 517. Hyperorexia, 482. Hypersecretion of gastric juice, 501, 502. diagnosis, 505. forms of, 502. in cerebral disorders, 545. periodical, 502. symptoms of, 505. Hypersecretio acida, 24, 501, 502. Hypochlorhydria, 27. Hypochondria, 483. Hysteria, 365, 477, 487, 492, 497. Idiosyncrasy of stomach, 480. Immermann, 220, 367, 368, 566, 567. Indigestion, 192. Innervation of stomach, 448. Insufficiency of stomach, 254. See Py- lorus and Cardia ; see Dilatation. Invert sugar, 69. Iodoform reaction, Lieben's, 44. Intestines, disturbed digestion of, 531. Intestines, electrization of, 105. haemorrhage in, 408, 411, 424. in diseases of stomach, 157. tympanites of, 527. vicarious action of, 77, 351, 218. 580. Irritative gastric neuroses, 474, 477. Israel, 324. Jacobson, 97, 98. Jaksch, von, 29, 45, 391, 392. Jaccoud, 510. Jaworski, 22, 24, 07. 78. 194, 222, 223, 225, 220, 22!), 237, 250, 205, 298, 308, 321. 345, 387, 388, 399, 406, 435, 501, 502, 503, 504, 505, 506, 567. Johannessen, 521. John, 70. Johnson, 68, 478. Jolles, 49. Jolly, 502. Jones, A., 105. Jones, H., 424, 564. Jong, De, 30, 58, 352. Juice, gastric, acidity of, 19, 24. acidity while fasting. 20. changes in, significance of, 578. flow of, 501; continual, 503; in cere- bral affection, 545 ; periodical, 502. hyperacidity of, 501, 502. hypersecretion of, 501, 502. in gastric catarrh, 221. in gastric cancer, 343. in gastric dilatation, 285. in gastric ulcer, 387, 406. in rumination, 525. parasecretion, 502. secretion of, 19, 24. Julien, 114, 417. Jung, De, 44. Jiirgens, 218, 453, 454, 530. Jiirgensen, 299, 508, 525. Kabrehl, 160. Kaczarowski, 238. Kahlden, 196. Kahler, 37, 38, 491. Kahn, 345. Kalmus, 180. Kast, 189. Katzenellenbogen, 324, 329. Kaufmann, J., 75, 82, 161, 187. Kaufmann, W., 333. Keen, 446. INDEX. 593 Kelling, 93, 98, 120. Kellog, 74, 404. Kelynack, 319. Kering, 259. Key-Aberg, 304. Kidney, condition of stomach in dis- eases of, 564, 572. Kietz, 345. Kinnicutt, 19, 306. Kisch, 546, 577. Kitagawa, 537. Klebs, 159, 185, 417. Kleinert, 33. Kleist, 246. Klemperer, G., 22, 68, 81, 119, 123, 179, 231, 298, 338, 352, 566, 567. Klinkert, 204. Robert, 462. Koch, 382. Kocher, 148, 374. Kollmar, 319, 420. Konig, 21. Korte, 390. Kooyker, 376. Korner, 118, 120, 523. Korczynski. 194, 298, 321, 388, 399, 406. Kornfeld, 16. Kossel, 547. Kossler, 50, 51, 53. Kraus, 32, 345. Kretschy, 546. Krishaber, 143. Kronecker, 93, 115. Kronfeld, 232. Kronlein, 374. Krukenberg, 37, 345, 490. Kriiger, 375, Kuhn, 287, 301. Kulcke, 319. Kulneff, 46, 159. Kumagawa, 65. Kundmann, 4. Kundrat, 185, 213. Kunze, 375. Kupffer, 197. Kuttner, 7, 96, 97, 98, 265, 275. 555. Kussmaul, 4, 106, 150, 248> 254, 263, 271, 280, 283, 291, 292. 294, 302, 303, 343, 515, 516, 526, 529, 550. Kiihne, 63. Kuster, 445. Laache, 336, 407. Labastide, 225. Lab-enzyme, 68. Lab-ferment, 67. Lab-zymogen, 68. See Rennet. Labastide, 225. Laboulbene, 189. Lactic acid. See Acid, Lactic. Laenggries, 316. Laker, 264, 337. Lambl, 537. Lanceraux, 417. Landau, 276. Landerer, 269. Landouzi, 491. Lang, 417. Lange, 327, 328, 397, 446. Langebach, 162. Langerhans, 395, 396, 397. Langermann, 51, 57. Langguth, 30, 55, 352. Laprevotte, 292. Large stomach, 255. Laubenheimer, 338. Lauenstein, 306. Lavage of stomach, 98, 200, 227, 302. dangers of, 304. Lebert, 165, 172, 173, 183, 193, 279, 313, 316, 318, 324, 327, 329, 331, 339, 340, 342, 353, 373, 391, 392. Ledoux-Lebard, 314. Leichtenstern, 133, 253, 264, 337. 407. Lemaitre, 205. Lenhartz, 275. Leo, 14, 19, 25, 29, 49, 50, 51, 54, 55. 56, 67, 68, 437, 484, 517. Lepine, 329, 336. Lesser, 189. Lesshaft, 117. Letulle, 390, 391, 428. Leube, 3, 4, 5, 8, 9, 22, 69, 77, 80.100,150, 168, 184, 246, 261, 275, 350, 384, 421, 422, 433, 434, 435, 439, 441, 473, 529, 530, 533, 535, 530, 550, 567, 572, 577. Leucin, reaction of, 28. Leudet, 417. Leury, 199. Leva, 525. Lewin, W., 183, 184. Lewy, 318. Leyden, 143, 491, 514, 532, 535, 556, 567. Lichtheim, 219. Liebermeister, 283, 300, 567. Liebreich, 438, 537, 553. 594 DISEASES OF THE STOMACH. Lienteric stools, 186, 250. Lindeman, 182. Lippman, 33. Lische, 169. Litmus-paper, 22. Litten, 220, 275, 293, 401, 413, 425. Liver, action on peptones, 158. condition of stomach in diseases of, 574. relation of diseases of stomach, 157. Lorenz. 45. Loreta. 295, 306. Loewenthal, 23, 225. Loftier, 160. Losch, 169. Louis, 564. Low, 390. Loye, 105. Lublinski, 114, 187. Lucke, 306. Lugol's solution, 71. Lung, haemorrhage from, 423. Luschka, 110. Luton, 324. Liittke, 14, 28, 29, 30, 31, 47, 49, 50, 51, 54, 58. Lymphadenoma of stomach, 323. Lyon, 26. Macfadyen, 161, 187. Mackenzie, 111, 141, 143, 147, 244. Macleod, 183. MacNaught, 210, 287. Magendie, 462. Maier, 269. Malaria, condition of stomach in, 577. Malbranc, 208, 275, 550. Malibran, 282. Maltose, 71. Malvoz, 375. Maly, 406. Manges, 99, 234, 333, 352. Marcet, 384. Marcone, 230. Marfan, 169, 402, 565. Marten, 295. Martin, 6, 186, 304, 391. Martin, St., 152. Martius, 14, 20, 28, 29, 30, 31, 47, 49, 50, 54, 98. Massage of stomach, 108. Matthieu, 81, 163, 278, 299, 321, 437, 504. Matthes, 440. Maydl, 413. May em, 180. Mayer, 216. Mazotti, 113. McNaught, 161. Meat-juice, 300. Meat peptone, 299; chocolate, 300. Kemmerich's, 299. Kochs, 299. solution, Leube's, 114. Medullary carcinoma of stomach, 321, 322. Megalostria, 254. Meinert, 86, 98, 540, 542, 544, 571. Meissner's plexus, 453, 459. Melama, 424. Melaenemesis, 332. Melanotic carcinoma of stomach, 322. Meltzer, 76, 94, 107, 115, 117, 413. Meltzing, 98, 571. Menasse, 376. Menassein, 169, 178. Menche, 233. Mendel, 232. Mendelsohn, 243. Mering, von, 29, 49, 71, 76, 289, 345, 349, 351. Merycismus, 521. Meschede, 187. Methyl violet, 35. Mey, 332, 336. Meyer, A., 48, 51. Meyer, C, 318. Meyer, E., 125. Meyer, G., 169, 200, 203, 218, 552. Meyer, John, 183, 184. Meyer, R., 280. Meyer, W., 148, 368. Meyerhof, 114. Michaelis, 445. Middeldorf, 416. Mikulicz, 95, 306, 308, 445. Milk diet, 241. peptonized, 299, 371. Millard, 426. Miller, 160, 161, 287. Mineral springs, treatment at. in gastric cancer, 373. in gastric catarrh, 249. in gastric neuroses, 561. in gastric ulcer, 446. Mineral waters in gastric neuroses, 553. INDEX. 595 Minkowski, 160, 274, 277, 293, 303, 355, 445. Mintz, 47, 48, 54, 58, 184, 309. Miquel, 160, 387. Mislowitzer, 330. Mitan, 243. Mitchell, J. M., 559. Mitchell, Weir, 324, 425, 556, 559. Mobius, 531. Models of stomach, 91. Mohr, 33, 37. Montegre, 523. Moritz, 76, 107. Mosetig-Moorhof, 368. Motility, 60. See Movements of Stomach. Mouisset, 337. Movements of stomach, 77, 459. in bulimia, 484. in chronic catarrhal gastritis, 212. tests of, 78, 81. Mucous gastritis, 208, 222. Mucous glands of stomach, 171. Mucous membrane of stomach, atrophy of, 199, 563. degeneration of, granular, 199. fungi of, 185. haemorrhage in, 395. polypi of, 205. structure of, 163. vacuoles in cells of, 199. Mucus, excessive secretion of, 508. Miiller, Fr., 123, 292, 293, 338, 355, 385, 407, 413. Miiller, Joh., 449. Murchison, 343, 416, 417. Murmur, deglutition, 93, 264, 525. absence of, 95. aids to diagnosis, 93. gurgling, 118. nature of, 93. press, 93. splash, 262. squirt, 93. succussion, 262. Muscularis of stomach, atrophy of, 203, 279. feebleness of, 276. hypertrophy of, 279. paresis of, 218. Muselier, 335. Musser, 401, 418. Myalgia of abdominal muscles, 478. Natanson, 93. Xaunyn, 214, 277, 303. Nausea, 477. Nauwerck, 180, 273. Nencki, 78. Neptune's girdle, 514, 551. Nerves of stomach, 451. Nervous system, condition of stomach in diseases of, 574. Neschaieff, 153. Neumann, 114, 402. Neurasthenia, 492. irritative, 492. depressive, 493. gastric, 529. gastro-intestinal, 532. vago-sym pathetic, 532. Neuroses of stomach, 448. 473. conditions of depression in, 474, 517. conditions of irritation, 474, 477. classification of, 474. etiology, 475. mixed form, 474, 529. occurrence, 475. reflex, 474, 544. relations to other neuroses, 474. treatment, 477, 548. Nicaladoni, 133. Niemeyer, 216. Nolte,*392, 397. Noorden, Von, 162, 372. 491, 501, 502. Normal soda solution, 33. Nothnagel, 32, 203, 214, 220, 275, 537. Obalinski, 308. Obrastzow, 88, 89. Oddi, 208. Odier, 439. Oesophageal sound, 125. Oesophageal tube, 127. ffisophagoscope, 124. CEsophagus, cancer of, 118, 120. symptoms, 123, 124. CEsophagus, dilatation of, 111, 132. diverticula of, 119. neoplasms of, 118, 120. permanent canula of, 143. sounding of, 125. stenosis of, 109. stricture, cicatricial, 111; feeding in, 149; gastrostomy in, 146; rectal feeding in, 150. spasmodic, 116. 596 DISEASES OF THE STOMACH. CEsophagus, ulcer of, corrosion, 115; syphilitic, 111; tubercular, 113. Oettinger, 292. Oil test, 81. Openchowski, Von. 394, 463. Oppenheim, 491. Oppenheimer, 337, 407, 433. Oppler, 67, 75, 284, 333, 334, 352. l'orange Poirier, 34. Orexin, 232. Organic acids. See Acids. Ord, 441. Orth, 185, 186, 195. Oser, 5, 86, 87, 229, 266, 275, 299, 367, 412, 436, 461, 473, 474, 478, 488, 492, 498, 551. Osgood, 306. Osier, 86, 220, 257, 258, 262, 291, 356, 425, 564. Ost, 265. Ostersprey, 337, 407. Osswald. 570. Ott, 342, 356, 358, 364, 540, 544. Overloading of stomach, 168. Pacanowski, 88. Pain, epigastralgic, 537. epigastric, 478. in cancer, 331, 359, 364. in catarrh of stomach, febrile, 172; chronic, 210. in hyperaesthesia of stomach, 478. in hypersecretion of gastric juice, 505. in hysterical gastralgia, 497. in nervous dyspepsia, 536. in neurasthenic gastralgia. 493. in stricture of the cardia, 116. in ulcer of stomach, 404. Palpation of stomach, 83. of pancreas, 84, 90. of stomach tube, 261. Parasecretion, 24, 502. Pariser, 98, 352, 416. Parsons, 446. Pauli, 263, 281. Pavy, 386, 482, 576. Peiper, 507. Pemberton. 225, 435, 478, 501. Penzoldt, 43, 45, 75, 87, 232, 240, 263, 290, 302, Pepper, 106. Pepsin and hydrochloric acid, digestion by, 65. Pepsin and hydrochloric acid, in chronic catarrhal gastritis, 226. quantitative estimation of, 67. Pepsinogen, 67, 223. Peptone, 60. action of liver on, 158. artificial, 371. chocolate, 371. enema, 150. pastilles, Maggi's, 299. reactions of, 60, 01. Peptonuria in gastric dilatation, 294. Perforation in gastric cancer, 330; in gastric ulcer, 412. Perforation peritonitis, 414. Peristalsis of stomach, 77, 459. Pertik, 269. Peyer, 482, 548. Pfeiffer, 229, 250. Pfungen, Von, 212, 437, 528, 529. Phenolphthallein, 32, 33. Phlegmon, gastric. See Gastritis phleg- monosa. Phloroglucin-vanillin test, 38. Phonendoscope, 203, 358. Phthisis ventriculi. See Anadenia. Pick, 412, 570. Pidoux, 576. Pinel, 479. Piorry, 87. Pitt, 323, 390. Playfair, 556. Pneumatosis, 510. Points, painful, Burkart's, 494, 536. Poirier, l'orange, 34. Poensgen, 213, 526. Poisoning, 188. with alcohol, 188 ; caustic alkalies, 188, 189; hydrochloric acid, 188; nitro- benzol, 188 ; oxalic acid, 310 ; phos- phorus, 188 ; sulphuric acid, 188. Poisson, 411. Poltowicz, 541. Polyphagia, 517. Polypi of stomach, 205. Polypoid cancer of stomach, 321, 322. Pomper, 187. Popoff, 287. Portal, 283. Position, vertical, of stomach, 90. Potton, 482. Powell, 411. Power, 117. 1NDI Pradazzi, 88, 89. Prazmowski, 161. Pribram, 95. 216. Probefriihstiick. See Test Breakfast. Probemahlzeit. See Test Meal. Probemittagbrod. See Test Dinner. Proenzyme, rennet, 68. Propeptone, 60. reactions of, 61. relations of to digestion, 62. Proteolysis, 65, Ptyalin, 69. quantitative examination of, 72. Ptyalism, reflex, 547. Pump, stomach, 4, 5, 12. Puncta dolorosa. See Points, Painful. Purgative, Oydtmann's, 248. Purgatives, 245. Pylorus, cancer of. See Carcinoma of Stomach. appearance of, in neoplasms, 95. closure of, 460. functions of, 460. hypertrophy of muscularis at, 357, 362. incontinence of, 526. palpation of, 202. relaxation of, 520. spasm of, 515. spastic contraction of, 273. stenosis of, cicatricial, 268 ; congenital, 269; hypertrophic, 269 ; mechanical, 269; causes of stenosis, external to stomach, 274. Pyrosis, 209, 510. Quenu, 565. Quincke, 93, 115, 130, 220, 294, 382, 406. Ramm, 230. Rampold, 343. Rankin, 442. Raoult, 540. Raudnitz, 68. Rawzier, 338. Kay. 446.. Reaction, ethyldiacetic acid (in urine), 293. (For other reactions see under individual headings.) Reagent, Boas's, 38, 39. Giinzburg's. 38. Lieben's, 44. Nessler's, 44. Topfer's, 40, 48. ex. 507 Reagent, Uffelmann's, 41. source of errors, 42. Reale, 79. Recklinghausen, Von, 180. Reckmann, 433. Reed, 17. Reflex dyspepsia, 530, 546. Reflexes from other organs on the stom- ach, 544. Regnard, 105. Regurgitation, 520. in diverticula of cesophagus, 521. in stricture of cesophagus and cardia, 111. Reichmann, 24, 96, 229, 236, 501, 502, 504, 505, 506, 507. Reinert, 407. Relations, mutual, of stomach, liver, and intestines, 155 ; and nervous system, 574 ; other organs, 563. Renal colic, 430. Rennet ferment, 67; quantitative test for, 69 ; proenzyme, 68 ; zymogen, 68. Reiraer, 426. Reinhard, 356. Renvers, 143. Reoch, 37, 38. Resorcin, 234; test, 39. Rest cure, Leube-Ziemssen, in ulcer, 434. Weir Mitchell, 556. Retzius, 367. Rheumatism, condition of stomach in, 576. Richet, 152, 453, 458. Richter, 284, 333, 494, 535. Riegel, 22, 24, 26, 32, 74, 82, 86, 98, 107, 153, 161, 208, 255, 258, 286, 333, 345, 352, 387, 388, 389, 406, 421, 501, 503, 504, 505. 506. Rieger. 102. Riess, 366, 367, 552. Ritter, 29, 389, 406. Roberts, 232, 235, 239. Rockwitz, 375. Rolleston, 120. Rokitanski, 114, 121, 181, 274, 383, 389, 390, 396. Rosch, 375. Rose, 262. Rommelaere, 338, 339. Rosenbach. 85, 212, 215, 254, 255, 264, 282, 345, 528, 548, 549. 598 DISEASES OF THE STOMACH. Rosenheim. 7. 8.19, 29, 45, 59, 95. 96, 99, 120, 124, 142, 185, 195, 220. 207. 309, 319, 321, 333, 345. 347, 349, 352, 374, 387, 391, 406, 422, 440, 551, 580. Rosenstein, 516, 576. Rosenthal. 150, 473, 474, 483, 490, 492, 494, 509, 514, 550, 552, 566, 568, 577. Rosenthal, C, 68. Rosin, 18. Ross, 192. Rossbach, 507. Rossier, 523, 525. Roth, 316, 382. Rothschild, 406. Rowing in chronic catarrhal gastritis, 243. Ructus. See Eructation. Ruhle, 567. Rumination, 521. Rumpel, 189. Rumsaeus, 4. Runeberg, 86. Runge, 525. Rupture of stomach, 189. Ruppstein, 286, 287. Rutherford, 247. Rydygier, 308. Sabel, 115. Saccharification, 69. by saliva, 70. Sachs, 169, 171, 199, 425, 429. Sadler, 337. Sahli, 17, 76. Salkowski, 65, 235, 580. Salol test, 78. Saly, 501. Samuelson, 386. Sanarelli. 320. Sanctuary, 273. Sansoni, 50. Sarcinae ventriculi, 284, 334. Sarcoma ventriculi, 323, 375. Sasaki, 218, 530, 531. Sassezky, 178. Satiation, feeling of, 469. lack of, 484. Saundby, 554. Sauvage, 526. Savelieff, 45, 440, 441. Sawyer, 553. Scheperlen, 220. Scherf, 417. Schetty. 179, 566. Seheuerlen, 320. .Schonlorn, 376. Schiff, 225, 381, 452, 467, 528. Schill, 320. Sehillbach, 105. Sthirrous cancer of stomach, 321, 324. Schlesinger, 72, 333. Schliep, 8. Schlosing, 54. Schluckgerausch. See Murmur, Deglu- tition. Schmauss, 408. Size of stomach, 88. Situation of stomach, 88. Schmidt, F., 49, 53,173, 200. Schmidt-Miihlheim, 290, 457. Schmidtmann, 478, 521. Schmilinsky, 261, 262. Schneider, 337, 521, 522. Schnetter, 85. Schneyer, 337. Schrader, 466. Schreiber, 18, 19, 142, 506. Schroth's dry diet, 299. Schuchardt, 318. Schule, 20, 352. Schultze, 161, 287. Schiitz, 6, 87. 275, 516, 528. Schwalbe, 169. Scirrhus of stomach, 321, 324. Secretion of stomach, 453. Sedgwick, 393. Sedillot, 147. See, Germain, 22, 193, 237, 239, 244, 262, 278, 294, 422, 443. Seemann. 37, 49. Seglas, 521, 522. Sehrwald, 386. Senator, 45, 142, 159, 187, 288. Senn, 265, 308. Sensibility of the stomach, 463 ; morbid, 478. Sere, De, 526. Shape of stomach, changes in, 91. Sialorrhcea, 547. Sieber, 160. Siebert, 244. Sievers, 78, 79, 80, 106, 525. Siewecke, 362. Silbermann, 382. Silberstein, 80. Silberti, 233. Silver nitrate, 271. Simon, 103. Simple gastritis, 165. Singer, 38, 524. Siphon, stomach, 4. Siphonage in washing out stomach, 98. Siredey, 335. Sjoqvist, 49. 57. Skin, anaesthesia of, in gastric ulcer, 405. hyperaesthesia of, in gastric ulcer, 405. condition of stomach in diseases of, 576. Skjelderup, 301. Skoda, 173. Smirnow, 166, 180. Smith, A., 274. Snow, 316. Soda solution, normal, 33. Sodium chloride, reaction of, 36. Sohlern, Von, 392, 393. Sollier, 464. Sommerville, 4. Sonnenberg, 143. Sounding of stomach, 10. Sounds, oesophageal, 5. siphon, 5. stomach, 5. Spallanzani, 16, 18, 160. Spath, 16. Spitzer, 34, 64. Splanchnoptosis, 542. Spray, gastric, 102. Springs, mineral, treatment at, in gastric cancer, 373; catarrh, 249; neuroses, 561; ulcer, 446. Stabchen plessimeter percussion, 264. Starch, digestion of, 60, 69. test for, 71. Starck, 392. Status gastricus, 192. Stein, 79. Stekhoven, 229. Stepp, 443. Stern, 313, 572. Stewart, D. D., 31, 223, 352. Stewart, Grainger, 183. Steyerthal, 479. Sticker, 73, 406. Stintzing, 29. Stienon, 319, 349. Stiller, 473, 476, 509, 529. Stintzig, 169. Stohr, 199. Stoll, 403. 39 index. 599 Stockton, 104, 106. Storck, 366. Stomach, anadenia of. See Anadenia. atony of. See Atony. atrophy of. See Atrophy. capacity of, 91; to determine, 92. carcinoma of. See Carcinoma. catarrh of. See Gastritis catarrha- LIS. contents of. See Contents of Stom- ach. dilatation of. See Dilatation of Stomach. distention with air or carbonic acid, 85. haemorrhage in. See Haematemesis. inflammation of, purulent. See Gas- tritis phlegmonosa. Inflammation of, toxic. See Gastritis, Toxic innervation of, 448. large, 255. measurements of, 89. models of, 91. motility of. See Movements of Stom- ach. mucous membrane. See Mucous Mem- brane. neuroses of. See Neuroses of Stom- ach. physical examination of, 82. phthisis of. See Anadenia. relation to liver and intestines, 155. secretion in, 19. shape of, 91. size of, 90 ; test, 82, 85. topography of, 88. ulcer of. See Ulcer of Stomach. Stools, in gastric cancer, 343; catarrh, 213 ; dilatation, 291; dyspepsia ner- vosa, 537; phlegmon, 184; ulcer, 408. in stricture of cardia, 113. lienteric, 343, 413. tarry, 408. Storer, 362. Strauss, 40, 43, 45, 46, 161, 187, 287, 288, 333, 352. Stroh, 162. Striimpell, 264. Struve, 414. Subacidity, 24. Sugar, digestion of. 69. Suggestion in neuroses, 561. Superacidity, 24. 600 DISEASES OF THE STOMACH. Surgery of stomach, 157, 373, 440. See individual diseases. Swieton, Van, 318. Switzer, 143. Symonds, 143. Sympathetic nerve, course of, 452. Syntonin, demonstration and reactions of, 60. Tabes, gastric crises in, 490, 535, 501. Talamon-Balzer, 401. Talma, 210, 381, 385, 388, 504, 552. Tantini, 462. Taste in gastric cancer, 331; ulcer, 403; gastritis catarrhalis chronica, 209; in rumination, 522. Tawizki, 230. Teeth, care of, in diseases of stomach, 238. Telangiectatic carcinoma of stomach, 321, 322. Terray, 230. Test breakfast, 21. of Ewald and Boas, 21. of Klemperer, 22. dinner, of Leube, 22. meal, 21. of Riegel, 26. supper, 82, 298. Tetany after washing out stomach, 304. in gastric dilatation, 292. ptomaines in, 46. Thayer, 352. Thiersch, 319, 345. Thoman, 182. Thomas, 239, 560. Thompson, 242. Thrombosis in gastric cancer, 328. Tiedemann, 18. Tilger, 375. Titration, method of, 30, 32. Todd, 192, 276, 478, 501. Topfer, 40, 48, 57. Tongue in diseases of stomach, 174. in nervous anorexia, 485. in gastric cancer, 331, 364; catarrh, acute, 175; chronic, 209; dilatation, 282 ; hypersecretion of gastric juice, 505; neurasthenia, 531; ulcer, 364, 403,418; phlegmonous gastritis, 183; stricture of cardia, 113. Torminae ventriculi, 515. Transformation of gastric ulcer into can- cer, 422. of starch, 00, 69. Trastour, 540. Traube, 277, 405. Treheux, 163. Trendelenburg, 152. Treves, 556. Trier, 433. Trinkler, 504. Troisier, 329. Tropaeolin, 34. Trousseau, 216, 248, 292, 373, 473, 501. Tschdzoff, 344. Tschelzow, 229. Tschlenoff, 67. Tube, Faucher's, 5. oesophageal, 5. stomach, 3; dangers of, 8, 127, 422; care of, 7; introduction of, 9, 10,11, 12; recurrent, 7; sterilization of, 7; obstruction to passage of, 10 ; length of, 11; use of, in children, 14; in chronic gastritis, 200, 227; neuroses, 550; ulcer, 422; tympanites, 510. Tuberculosis, condition of stomach in, 564. Tuckwell, 513. Tiingel, 324. Tumor in gastric cancer, 334. hypertrophy of muscularis at pylorus, 357,362. mediastinal, 118. retroperitoneal, 118. Tumors, non-carcinomatous, of stomach, 375. Turck, 4, 46, 75, 101, 104, 207, 236, 238. Tympanites, 510. Typhoid fever, condition of stomach in, 564. Uffelmann, 29, 30, 40. Ulcer of duodenum, 390, 430, 432. Ulcer of stomach, follicular, 383; round, 377. adhesions in, 400. age in, 393. anatomical characters of, 394. base, 396. bloody stools in, 408. bowel's, 403. cicatrization of, 399, 416. composition of blood in, 385, 407. INDEX. 601 Ulcer of stomach, corrosion of vessels in. 400. diagnosis of, 418. differential diagnosis, 418, 430. diet in, 437. emaciation, 404. etiology, 380. excision of, 446. fever in, 404. fistulae after, 416. form, 396. haemorrhage in, 407. treatment of, 443. hyperacidity of gastric juice in, 387, 406. in cutaneous burns, 390. micro-organisms in, 390. microscopic appearance, 398. necrosis, 400. occurrence, 391. operative procedures in, 446. pain in, 403, 404. treatment of, 443. pathological anatomy, 394. perforation of, 412. perforation peritonitis, 414; treat- ment, 415. prognosis, 433. relapsing, 388. rest cure in, 434. results of,-399. sex, 393. site, 397, 431. size, 396. skin in, 405. symptoms of, 403. syphilitic, 402, 417. tongue in, 403, 418. treatment of, 434 ; at mineral springs, 446; rectal feeding in, 434, 436 ; use of Carlsbader water in, 434, 435; use of iron in, 437 ; use of nitrate of sil- ver in, 442. tube in, 422. tubercular, 401, 418. urine in, 406. Unrest of stomach, antiperistaltic, 516. peristaltic, 291. 515. Vagus, course of, 451. Value of chemical tests, 577. Vanillin, phloroglucin, 38. Vanni, 385. Vaso-motor nerves of stomach, 457; re- lations of, in gastric secretion, 457. Vassale, 381, 399. Velden, Von den, 70, 208, 343, 345, 347, 387, 501, 504. Verneuil, 152. Vertigo gyrosa, 216. stomachalis, 216. e stomacho laeso, 216. Villous carcinoma of stomach, 322. Violet, methyl, 35. Virchow, R, 114, 121, 169, 188, 328, 329, 358, 396, 417, 543. Vizioli, 550. Voelkel, 425. Vogel, 366, 406. Voigt, 120. Volhard, 51, 53. Vormagen, 111. Vomit, coffee-grounds, 332. taste of, 172, 537. Vomiting, 462. faecal, 516. hysterical, 513. in abscess of liver, 545. in diseases of brain, 545; spinal cord, 545. in gastric cancer, 331, 334; catarrh, acute, 172; chronic, 210; in gastric crises, 490; dilatation, 282; ulcer, 407. in hyperaesthesia of stomach, 479. in hypersecretion, 505. in injuries to uterus, 546. in neurasthenia, 513, 537. in operations on bladder, 546; urethra, 546. in stricture of cardia, 72. in phlegmonous gastritis, 183. in phthisis, 564. in poisoning, 189. in pregnancy, 545. in renal abscess, 545; colic, 545; dis- eases, 573. in seasickness, 545. nervous, 511. of blood. See Haematemesis. periodical, 514. reflex, 544. Waetzhold, 347. Wagner, 51. Waldeyer, 125, 319, 320, 321. OF THE STOMACH. 602 DISEASES Wilson, 425. Windthier, 523. Winkhaus, 295. Winter, 27, 49. Winternitz, 305. Wirbelweh, 494. Witosowski, 398. Witte, 409. Wolff, J., 575. Wolff, L., 77, 162, 301. Wolfram, 346. Wolffler, 374. Wotitzky, 80. Wright, 73. Yeast cells in stomach contents, 187. Yellowly, 424. Yeo, Burney, 242, 576. Zabludowski, 305. Zawadski, 45. Zeckendorf, 527. Zenker, 93, 94, 111 Zesas, 147. Ziegler, 181, 376. Ziemssen, Von, 8, 85, 105, 106, 111, 434. Zipkin, 573. Zweifel, 75. Zymogen. See Pepsin and Rennet. Walshe, 313, 317, 418. Walton, 250. Washing of stomach, 98. in poisoning, 190. Water, filling stomach with, 82, 87. Watson, 426. Wegele, 104. Weighing, systematic, 559. Weill, 208. Weinert. 517. Weir, 307, 394,413, 414, 446. Weiss, 4, 426. Weissgerber, 508, 509. Welch, 313, 314, 322, 325, 329, 336, 375, 392, 397, 412, 413, 429. Werner, 285, 575. Wesener, 160. West, 412. Westphal, 216, 491. Westphalen, 169, 203, 204, 255, 508. Widal, 391. Wiederhofer, 213, 281. Wiesner, 8. Wild, 236. Wilkens, 503. Wikinson, 313. Wilks, 390. Williams, 402. Willigk, 433. THE END. PRACTICAL DIETETICS, IVITH SPECIAL REFERENCE TO DIET IN DISEASE. BY W. OILMAN THOMPSON, M. D., Professor of Materia Medica, Therapeutics, and Clinical Medicine in the University of the City of New York; Visiting Physician to the Presbyterian and Bellevue Hospitals, New York. LARGE OCTAVO, EIGHT HUNDRED PAGES, ILLUSTRATED. Prices : Cloth, $5.00; sheep, $6.00. SOLD BY SUBSCRIPTION ONLY. THE subject is one which does not receive proper attention either in med- ical colleges or in the standard works upon the Theory and Practice of Medicine; the directions given in the latter being of a very general and vague character, and in the former it is dismissed in one or two lectures. In hos- pitals and in the training of nurses too little attention is paid to the subject, while in works on food and dietetics the practical application of dietetics to disease receives but slight notice. This work is intended to remedy these shortcomings and to furnish to the practitioner a text-book containing in- structions as to the appropriate diet in diseases which are influenced by right feeding. 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