Ixxv (5.0); sacchari lactis, drachms viss (26.0). Of this half a teaspoonful
(2.0) is taken dry on the tongue every 3 hours.
Silver nitrate has been recommended by Gerhardt. According to his
reports the distressing symptoms will often cease directly upon its adminis-
tration, while in other cases it has no influence whatever and in still others
it seems to aggravate the symptoms. He believes that this drug is useful
in patients who suffer pain when the stomach is empty, on account of its neu-
tralizing effect upon the hydrochloric acid. His method is to give this agent
in doses of from y^- to ^ a grain (0.006 to 0.03) in solution several times in
the 24 hours upon an empty stomach.
Boas considers silver nitrate useful especially in the less severe cases of ulcer
and in those for whom it is impossible to institute a rest cure. He starts the
treatment with ^ an ounce (15.0) of a i grain (0.065) to i ounce (30.0) solu-
tion of the nitrate in aqua menth. pip. three times a day on an empty stomach.
Later he increases the strength of the solution to 1.2 grains (0.07) to the
ounce (30.0) and still later to 1.6 grains (o.i) to the ounce (30.0). In con-
nection with this treatment the diet must be carefully regulated and the patient
should remain as quiet as possible.
Numerous other drugs have their advocates in the treatment of ulcer.
GASTRIC ULCER. 35 1
among which may be mentioned chloroform. Stepp considers that this
agent given in connection with bismuth — chloroform, i part; bismuth sub-
nitrate, 3 parts, distilled water, 150 parts — exerts a favorable influence.
Condurango bark, in the opinion of Gerhardt, acts well especially in old
vilcers in poorly nourished patients.
Fuchs believes that the action of bismuth in ulcer is not alone due to its
neutralizing effect upon the hydrochloric acid and to the fact that it is mechan-
ically a protective biit that the subnitrate is reduced to an oxyhydrate which,
being dissolved, is absorbed by the granulating tissue and here acts specific-
ally. It also increases the secretion of mucus which has a considerable
protective action. Bismuthose, a combination of bismuth and albumin
is more astringent than bismuth, more insoluble, and has a greater acid-
combining power. Eisner reports good results from its use. Its great dis-
advantage, however, is the influence of its astringency upon the co-existent
constipation. It is particularly useful in combating hyperacidity.
The treatment of the excessive acidity often present in ulcer has received
much attention and various methods have been recommended as applicable
to the reduction of this manifestation. Ewald uses the alkalies mixed with
powdered rhubarb and sugar. Others advocate the use of sodium bicarbon-
ate, which according to chemical principles directly defeats the object with
which it is given. Riegel, in uncomplicated cases, advises the following
formula: I^ sodium bicarb., magnesias ponderosae, aa, drachms ii (8.0); sac-
char, lactis, drachms iii .(12.0). To this a small amount of powdered rhubarb
may be added if the constipation is marked. Of this J teaspoonful (2.0) after
meals is prescribed. In cases where the increased acidity is continuous the
alkali should be given more frequently and in smaller doses.
Atropine has a decided influence in diminishing the secretion of the gastric
juice and consequently it and belladonna have their places in the treatment
of hyperchlorhydria.
The treatment of the pain is to a certain extent that of the hyperchorhydria
since the former is the result of the latter. Usually the administr?.tion of anal-
gesics is unnecessary, for as a rule the pain disappears within a day or two
after the institution of the ordinary treatment. In severe cases at the beginning
the hypodermatic use of morphine is indicated; however, according to recent
investigators, this is likely to cause an increase in the secretion of gastric juice
and consequently is to be avoided if possible. Codeine or its phosphate
are sanctioned by certain high authorities. Cannabis indica while acting as a
hypnotic to a very slight degree is likely to cause disagreeable mental phenom-
ena. Strontium bromide is recommended. Orthofqrm (a methyl aether of
benzoic acid) is said to have a marked effect upon the pain of ulcer and
Murdoch believes that gastric pain which is relieved by this drug augurs the
existence of ulcer.
352 DISEASES or THE DIGESTIVE SYSTEM AND PERITONEUM.
Local applications such as poultices of flax seed may afford relief but the
Priesnitz umschlag — flannel wrung out in hot water and covered with oil-silk —
will usually be found to act as weU. Sharply localized pain due to peritonitis
may be relieved by the ice bag or coil.
Vomiting seldom needs special treatment since it usually ceases upon the
institution of the ordinary course of treatment directed toward the cure of the
ulcer. If this symptom continues to distress the patient cracked ice may
be given and various antiemetics such as cerium oxalate, grains v to x (0.30
to O.J56), chloretone, grains x to xv (0.66 to i.oo), dilute hydrocyanic acid,
minims ii to vi (0.13 to 0.4) in water, chloroform, minims i to ii (0.065 to
0.13) in water, etc., may be used.
Hmmatemesis should be treated by absolute rest and the application of an
ice coil to the epigastrium. Cracked ice is allowed by some authorities,
while others insist that nothing should be given by the mouth. If the haemor-
rhage has been considerable a tube should be very carefully introduced. For
this a skilled hand is necessary for the tube must be passed only a very short
distance beyond the cardia. A pint (500.0) of water at 120° F. (48.9° C.) is
now introduced and allowed to remain. Later the clots should be siphoned
out so as to allow the organ to contract and a small amount of water containing
about ten grains (0.66) of heavy magnesia is put into the stomach and allowed
to remain. Lavage of the stomach with ice water has given good results in a
few cases, according to Ewald. The hypodermatic use of morphine sulphate
in dosage of J of a grain (0.016) will quiet the patient, relieve the air hunger
and stimulate the heart action. Ergotal, 20 to 30 minims (1.66 to 2.00), hypo-
dermatically is recommended by Hemmeter as an excellent haemostatic. Sub-
cutaneous injections of ergotine, 5 to 10 grains (0.33 to 0.66) in equal parts of
glycerin and water may be found effective. Certain authorities mention
hydrastis, hamamelis (witchhazel), lead acetate, iron chloride and other haemos-
tatic drugs in this connection but it is probable that the irritation caused by
their entrance into the stomach more than counteracts their power over the
haemorrhage. Adrenalin chloride in doses of from 10 to 30 drops (0.66 to 2.00)
of the I to 1000 solution given in a drachm (4.00) of water has seemed to act
well in certain cases of gastric haemorrhage and it will be interesting to observe
the results of its administration under the skin.
Excessive gastric haemorrhage with its accompanying symptoms of heart
weakness, pallor, and general collapse calls for immediate and energetic treat-
ment. The usual means employed in haemorrhage from any source m.ust be
instituted at once. Hypodermatic stimulation by means of camphor and
aether or camphor and oil, strychnine sulphate, etc., is indicated. The so-
called bleeding of the patient into his own tissues which consists in applying
snug bandages to the limbs and thus forcing the blood into, the trunk, is an
excellent resource as is the administration of copious high rectal enemata
GASTRIC ULCER. 353
of normal (0.9 percent.) solution of sodium chloride, at a temperature of
io5°-ii2° F. (40.4° to 44.5° C). Intravenous infusion of saline, or, what
may be much more rapidly performed, the giving of the solution under the
skin of the fleshy parts of the back, chest or thighs may be advised. For
this procedure the only necessary apparatus is a fair sized aspirating needle, a
few feet of rubber tube and a funnel. The funnel is filled, the solution al-
lowed to flow through the tube and the needle, and the last is plunged into
the subcutaneous tissue of the part selected. If the part is massaged as the
fluid is flowing in a pint (500.0) or more of the solution may be given.
A necessary precaution in connection with this as with other methods of
stimulation is to take care lest the vascular tension be raised to such an extent
as to excite further haemorrhage and thus defeat our object. The tension
shoifld be aUowed to remain low lest this accident take place.
Feeding in Gastric Ulcer. During the progress of the treatment most
approved by the author — i.e., that of bismuth subnitrate combined with
heavy magnesia — the patient is fed entirely by rectum. A nutrient enema,
preceded by a high rectal irrigation of about a quart (litre) of normal saline so-
lution at about 105° F. (40.5° C.) to cleanse the intestinal mucous membrane
and facilitate absorption, is administered every 4 hours. The enema preferred
by the author consists of one-half to one ounce (15.0 to 30.0) of starch paste
with 2 to 3 ounces (60.0 to 90.0) of beef e:!ttract, liquid peptonoids or pano-
pepton.
Rectal feeding should usually be continued for about two weeks.
Other enemata useful in this disease may be chosen from the following
formulas :
1. Milk, 4 ounces (120.0); the yolks of two eggs; salt, i drachm (4.0);
claret, i ounce (30.0); aleuronat flour, one-half ounce (15.0). (Boas.)
2. Two or three eggs beaten with a little water; i ounce (30.0) of dextrinized
flour boiled with 4 ounces (120.0) of 20 percent, solution of lactose; one wine-
glass (30.0) of claret, a little salt. The eggs shoifld not be mixed with the
other ingredients until the latter have cooled so that their temperature will
not coagulate the albumin of the former.
3. Bouillon, 8 ounces (240.0); wine, 2 ounces (60.0); the yolks of two eggs;
dry peptone i to 5 drachms (4.0 to 20.0). (Jaccoud.)
4. Milk, 8 ounces (240.0); two to three eggs; a little salt. (Riegel.)
5. Milk, 8 ounces (240.0); liquid peptone, i ounce (30.0); yolk of one egg;
laudanum, 5 drops (0.33); a small quantity of sodium bicarbonate for chem-
ical neutralization if the peptone is acid. (Dujardin-Beaumetz.)
6. Two eggs; whiskey, one-half ounce (15.0); starch paste, one-half ounce
(15.0); milk up to 8 ounces (240.0).
Other formulae may be made up as occasion requires. In quantity nutrient
enemata, according to most authorities, should not exceed 3 or 4 ounces
23
354 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
(90.0 to 120.0), and the proper interval for their administration is about every
four hours. Four enemata during the 24 hours will be found to be sufl&cient.
When enemata larger in quantity than the above are weU borne it may be
wise to give as a routine three daily injections of a pint (500.0) of food each.
This procedure relieves the patient of too frequent disturbance and allows
his sleep to be unbroken. The enema may consist of the whites of two eggs,
a teaspoonful (4.0) of salt, i^ ounces (45.0) of a saturated solution of glucose,
and milk up to a pint (500.0). Such a mixture contains carbohyhrates,
fat, prc^eid and salts in approximately proper proportions.
Nutrient enemata, particularly those of considerable size, are better given
from a fountain s}Tinge than by means of the piston variety, since the force
and tendency of the latter to sudden spurts may cause irritability of the bowel.
Food given per rectum will be more readily absorbed and assimilated if
peptonized and not only the milk but the other constituents of nutritive
enemata should undergo this process. Preparations for the convenient
peptonizing of food substances are obtainable at any apothecary's. In certain
cases nutrient enemata may not be well borne or may be difficult of retention
on account of irritability of the bowel. Such a complication may be obviated
by preliminary cleansing of the bowel by a saline enema and, if this procedure
fails, by the addition of a small dose of the tincture of opium to each enema.
Nutrient enemata should be thoroughly mixed and administered warm.
100° F. (37.8° C), under moderate pressure and very slowly through a soft
rubber rectal tube passed as high into the bowel as possible. Care should
be taken lest the tube turn on itself and its extremity, instead of being
in the sigmoid flexure, be just inside the anus. The best position for the
patient to assume while receiving the enema is upon the left side. After
about 30 minutes he should turn to the right side and a pillow shoiild be placed
under his hips. These positions facilitate the flow of the enema through the
colon.
At intervals it may be necessary to give a high enema of clear water for the
relief of the thirst.
After the cessation of rectal feeding the return to ordinary diet must be
very gradual. The first foods allowed by mouth may be equal parts of milk
and Hme water, beef bouillon to which such substances as plasmon, nutrose
or somatose may be added, and albumin water. These fluids must be given
at a neutral temperature — neither hot nor cold. Sugar solution (20 percent.)
may also be allowed. Dextrose is the preferable form of sugar, but cane sugar
is allowable. Lactose is least desirable. After about ten days a more liberal
diet may be instituted consisting — according to v. Leube — of boiled sweet-
breads, calf's brain, white meat of chicken, various gruels and vegetable
puree soups, tapioca with milk, oatmeal and finely scraped raw beef. After
a week scraped raw ham, finely chopped rare broiled beef steak, toast or
GASTRIC ULCER. 355
zwieback and mashed potatoes are allowable, as also are stewed fresh non-
acid fruits. Further extension of the diet shotdd be postponed as long as
possible, but when this becomes necessary the patient may eat broiled chicken
and veal, rare roast beef, fish, plain meat soups, etc.
All irritating foods, such as vegetables containing an excess of ceUulose,
breads with hard crusts, fruits with tough skins, together with alcoholic bever-
ages should be refrained from until all the symptoms have disappeared and
have remained absent for a long period of time. Cold and hot, sour or highly-
spiced foods and drinks should be avoided for many months after the cure
is apparent.
The anaemia so frequently accompanying gastric ulcer should never be
neglected. To combat this important factor in the disease iron and arsenic
are our chief rehance. It is needless to say that their administration should
not be begun until all the symptoms of gastric irritation have disappeared.
Ewald is accustomed to give a 2 or 3 percent, solution of iron sesquichloride
three times a day in teaspoonful (4.0) doses in an ounce (30.0) of albumin
water. This should be taken through a tube. The various forms of organic
iron which have lately been put upon the market should be useful in this
connection particularly iron viteUin in half ounce (15.0) doses given three
times daily after meals.
Arsenic may be given in the form of Fowler's solution or arsenic tri oxide.
The various mineral waters containing and arsenic will be found useful.
The Surgical Treatment of Gastric Ulcer may be divided into:
a. The treatment of the ulcer by excision.
b. The treatment of haemorrhage.
c. The treatment of perforation.
d. The treatment of gastro-peritonaeal adhesions.
e. The treatment of the various resulting gastric deformities such as
stenosis of the pylorus, hour-glass contraction, etc.
It is conceded by most surgeons that acute gastric ulcer is a medical condi-
tion but chronic ulcer with obstinate and persistent emesis and pain may be
treated surgically by excision or cauterization. In multiple ulcer excision of
all the ulcerating points is, however, impossible. Ulcers situated near the
pylorus and associated with pylorospasm may be relieved and even cured by
the operation of gastroenterostomy. In ulcers of other regions of the stomach
this operation may also afford relief.
Repeated haemorrhage, unless the patient is too anaemic to withstand the
shock of operation, probably constitutes an indication for surgical treatment.
If possible the bleeding point should be cauterized or excised. If these
are multiple, gastroenterostomy should be performed.
Perforation should be treated surgically as soon as the diagnosis is made,
unless it is an absolute certainty that adhesions shutting off the site of the
356 DISEASES OP THE DIGESTIVE SYSTEM AND PEEITONiEUM.
perforation from the general peritonaeal cavity, have been formed. The longer
operation is postponed after the contents of the stomach have been emptied
into the peritonaeal cavity the less the likelihood of the recovery of the patient.
Adhesions about the stomach which cause pain and other unpleasant
symptoms may necessitate surgical interference. Hour-glass contraction
and other post-ulcerous deformities of the organ are also amenable to oper-
ative treatment.
-» CANCER OF THE STOMACH.
Synonyms. Gastric Cancer; Carcinoma of the Stomach; Carcinoma
Ventriculi.
.Etiology. The direct setiology of cancer is unknown. Heredity plays '
some part in its causation and gastric ulcer is undoubtedly a predisposing
cause. Cancer of the stomach is rarely seen before middle age and is more
common in males than in females. It not infrequently occurs in individuals
who have had apparently healthy stomachs during their earlier years.
Pathology. Cancer of the stomach is usually primary. AU varieties of
carcinoma may occur in the stomach but the most frequently seen are:
a. The scirrhus which is an infiltrating growth, hard and dense in struc-
ture; it usually involves a considerable portion of the submucosa and may
spread through its whole extent.
b. The meduUary type develops rapidly, is likely to ulcerate and is prone
to extend directly or by metastasis to other structures.
c. The coUoid variety grows to a larger size than do the other types and
frequently spreads by direct contiguity to neighboring tissues, making with
them a mass of considerable size.
The majority of gastric carcinomata begin near the pylorus and from this
point tend to extend along the curvatures, involving chiefly the submucous
coat. The growth, as a rule, originates in the tubules, it progresses, infiltrating
and causing induration of the remaining tissues of the organ, and results in
a nodular tumor which may ulcerate. The neighboring lymphatic glands
become hardened and enlarged and may themselves become the seat of car-
cinomatous growth. When the tumor is at the pylorus stenosis results which
causes dilatation of the organ, otherwise the stomach tends to diminish in
size. Ulcerations infrequently perforate the stomach waU but often erode a
blood-vessel and cause haemorrhage.
Symptoms. Before gastric cancer is suspected the patient is prone to in-
definite symptoms referred to the stomach, such as loss of appetite, distress,
eructations of gas and constipation, but it must be remembered that the growth
may exist for considerable time without giving rise to any symptoms which call
attention to the stomach. The cancerous cachexia, with its characteristic
CANCER OF THE STOMACH. 357
color of the skin, anaemia, and loss of flesh and strength becomes sooner or
later apparent and palpation of the stomach may or may not reveal the pres-
ence of a tumor which is rarely observed in the normal region of the pylorus.
It is more likely to be near the umbilicus but may be found much lower.
The reason for this displacement is that the weight of the tumor drags the
stomach downward. The tumor varies in size and in consistency and may not
be nodular, it may be either fixed or movable; a pyloric growth is not likely
to change its position on respiration but the contrary is true of tumors upon
the curvatures. At times when situated over the aorta the tumor may seem
to pulsate, but this pulsation is non-expansile.
It is not very imusual for no tumor to be palpable even in the latest stages
of the disease.
As the disease progresses the vomiting usually becomes more distressing.
The vomitus consists of food particles and at times contains blood or " coffee-
ground" material — the result of the admixture of the gastric secretion and
blood; it may be of foul odor and if particles of food are detected which have
been eaten a number of hours previously, we may, in the presence of other
suggestive symptoms, diagnose a malignant pyloric stenosis. Vomiting is
less frequent when the growth is situated in portions of the organ other than
the pyloric region. In the later stages there may be lymphatic enlargements
in the clavicular and inguinal regions, enlargement of the liver, jaundice,
oedema of the lower limbs and an irregular febrile movement. Albumin
may be present in the urine, and the presence of metastatic growths, partic-
vdarly in the liver, may be detected. Blood examination shows a diminution
in the red ceUs, seldom, however, below 2,000,000, and a corresponding
decrease in haemoglobin; the haemoglobin index is low, a point which is of
assistance in the differential diagnosis from pernicious anaemia. The white
blood cells are, as a rule, increased to a moderate degree — 20,000 or there-
abouts — the increase being confined primarily to the polymorphonuclear
neutrophils. In advanced stages of the disease nucleated red cells and
myelocytes have been observed.
The Stomach Contents. Chemical examination of the gastric contents
withdrawn after a test-meal typically reveals an almost total or an entire
absence of free hydrochloric acid and an excessive amount of lactic acid.
While absence of free hydrochloric acid and an excess of lactic acid may occur
in other lesions, if repeated gastric analyses after test-meals show these condi-
tions to be constantly present and the clinical symptoms point toward malignant
neoplasm, the probability is strongly in favor of the existence of gastric cancer.
The microscope should always be employed in the examination of the result
of the test-meal and significant findings are blood, the Boas-Oppler bacillus
and fragments of the growth. The Boas-Oppler bacillus is said to be present
in gastric cancer almost without exception and if a piece of the tumor can
358 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
be demonstrated to be carcinomatous tissue the diagnosis is established
beyond doubt.
Rontgen ray examination may reveal the presence of a tumor in certain
cases but this means of diagnosis is as yet hardly trustworthy.
The prognosis is distinctly unfavorable, medical treatment offering no
hope. Radical surgical intervention, early in the course of the disease, may
be attended with good results, but the diagnosis is seldom made before sur-
rounding structures are involved, rendering entire removal of the malignant
neoplasm impossible. The disease is usually fatal within a year but under
siirgical treatment this period may be slightly lengthened.
Treatment. Medical treatment is merely palliative and consists in reliev-
ing the pain, improving the digestion and keeping up the patient's nutrition.
By attention to these factors life may be prolonged and made more comfor-
table.
The pain may be controlled by means of hot or cold applications to the
epigastrium. When it is apparently due to retained and fermenting food it
may be effectually relieved by gastric lavage and removal of the exciting cause.
Sodium chloride in 30 grain (2.0) doses well diluted thrice daily will often
relieve pain. The narcotics should be used with care; belladonna extract,
gr. ^ (o.oi), may prove effectual and codeine may be employed; hydrated
chloral should rarely be used because of its liability to cause heart weakness;
morphine may be given hypodermatically when all else fails.
The appetite may be improved by the administration of various stomachics.
Of these condurango has been exploited as a specific in gastric cancer. While
exerting no effect upon the course of the disease it does increase the appetite
and aid digestion. It may be given with hydrochloric acid which also acts
as a tonic upon the organ, in the following formula: ^fluidextract condur-
ango, 5ii (60.0); strychninse sulphatis,gr. ^(0.02); acidi hydrochlorici diluti 3iv
(15.0); fluidextracti gentiani q.s. ad §iv (120.0); misce et signa, one teaspoonful
in a wine-glass (60.0) of water through a tube, after meals. Lavage with plain
water or with infusions of the vegetable bitters cleanses the stomach and acts
favorably upon the appetite.
Vomiting may be controlled by lavage since it is frequently due to the stag-
nation and decomposition of food in the stomach. When the vomitus is of