Transcriber Note
Text emphasis denoted as _Italics_.
=== THE ===
Cleveland Medical Gazette
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_VOL. I._ _FEBRUARY, 1886._ _No. 4._
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ORIGINAL LECTURES.
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ULCER OF THE STOMACH.
A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA.
[Translated for the Cleveland Medical Gazette by Dr. C. Rosenwasser].
Gentlemen! The disease which we intend to study to-day is one, the
traces of which are found much oftener at post-mortems than the disease
itself in the clinic. A great many cases are overlooked and improperly
diagnosed for reasons which I shall state hereafter.
It has been called by various names. Round ulcer, perforating ulcer,
chronic ulcer, corroding ulcer and simple ulcer are only different
designations for one and the same condition. I prefer to call it
_peptic ulcer_, as it is always the result of self-digestion of a part
of the walls of the stomach, but is not always round, nor perforating,
nor chronic, nor corroded; nor is it always simple, several ulcers
having occasionally been found in one and the same stomach.
Pathologists have not yet come to a positive decision on the _modus
operandi_ of its origin, but several conditions are mentioned as
necessary for its development.
1. The self-digestion of a part of the stomach by the gastric juice.
2. Disturbances of the circulation of the blood in the walls of the
stomach.
3. The alkalinity of the blood circulating in the walls of the stomach
prevents the digestion of the mucous membrane. If this action on the
walls of the stomach is prevented in any way, the development of an
ulcer is aided. This clause has been accepted until recently, when
it has been rendered somewhat doubtful by the results of certain
experiments.
The first clause is sustained by the fact that the peptic ulcer is only
found in those parts which are brought into direct contact with the
gastric juice. It is further proven by the softening of the stomach so
frequently found at post-mortem. But as long as the circulation of the
blood in the walls of the stomach is normal, ulcers do not form. The
formation of an ulcer in the stomach presupposes a local disturbance
of the circulation. It is usual to find thrombi and diseases of
the bloodvessels in cases where ulcers of the stomach occur. For
this reason the latter is more common in anaemic persons where the
circulation is retarded and the bloodvessels frequently subject to
fatty degeneration.
Virchow regards embolism of a small vessel as the origin of ulcer of
the stomach. Cohnheim disproved this beyond doubt by showing that there
is an abundant circulation in the walls of the stomach by which the
parts affected are again quickly supplied with blood. Klebs takes for
granted a spasmodic contraction of single bloodvessels as the cause
of the retardation of the circulation, while Rindfleich attributes
it to the poor anastomotic connection of the gastric veins. He calls
attention to the frequent coincidence of ulcer and hemorrhagic
infarct in the walls of the stomach. Cohnheim injected chromate of
lead into the gastric branch of the splenic artery in animals, and
when he succeeded in cutting off the arterial supply of the mucous
and submucous layers _only_, he found as a result large ulcers with
sharp, well-defined margins and a circular base. If the animals were
examined in the second week after the experiment, they showed several
small ulcers in place of the larger one. In the third week the ulcers
were found to have healed. From these experiments you can see that
the gastric ulcer has a natural tendency to heal when not interfered
with. By experiments such as these it has been proven beyond doubt that
disturbances of circulation of a small part of the stomach may lead to
ulcer. But the causes of these disturbances, and the reasons why some
ulcers do not heal, are still disputed questions.
Pavy claims that the alkalinity of the blood prevents the gastric juice
from acting on the walls of the stomach. When he introduced acids into
the stomach and allowed the circulation of the blood to continue,
no ulcers resulted; if he impeded the circulation, the stomach was
digested by its acid contents. Samelson instituted experiments to
test the statement of Pavy. He introduced large quantities of various
acids into the stomach of his animals without observing ulceration as
a result; he also neutralized the blood by the injection of weakened
acids into the bloodvessels, but no ulceration followed. But he did
not impede the gastric circulation in his experiments, while Pavy did,
hence the difference in their results. Clinical experience, however,
favors Pavy's views. We can prevent the further progress of the gastric
ulcer by the use of alkalies, while acids only favor its growth. These
questions still need additional research before they are definitely
solved.
Gastric ulcer may occur in any part of the digestive tract which is
exposed to the action of the gastric juice; hence it is found in the
lower part of the œsophagus, any part of the stomach and the upper part
of the duodenum. It is found most frequently in the pyloric end of the
stomach, because this part is most frequently subjected to mechanical
irritation and to the action of the gastric juice.
The shape of the ulcer is usually conical or terraced, its diameter
being largest in the mucous membrane and smallest at its base, in the
deeper structures.
The gastric ulcer must be very common. In about five per cent of all
cadavers we find ulcers in the stomach or else scars as traces of
former ulceration. Ulcer of the stomach is frequently passed over
without recognition, because most physicians do not decide upon this
diagnosis, unless hæmatemesis occurs. Gastric hemorrhage, however, is
not necessarily a concomitant feature of every gastric ulcer, and the
hemorrhage may occur without vomiting, the blood being either digested
and absorbed or passing on into the bowel and causing dark stools.
Thus occasionally the only symptom of hemorrhage of the stomach is the
appearance of darker stools, a symptom of doubtful value when taken
alone, but of some importance when in connection with others.
A few years ago an elderly lady was admitted into the hospital on
account of severe pain in the stomach and the appearance of dark
stools. While in the hospital vomiting of blood set in, continuing
three days, and then the patient died. At the post-mortem we found
that an ulcer of the stomach had burrowed through the diaphragm and
pericardium into the wall of the left ventricle, perforating finally
with a small opening into the left ventricle. I can only explain the
length of the time between perforation and death (three days) by
assuming that part of the gastric fistula leading through the walls of
the heart was firmly closed during systole, and only allowed a small
quantity of blood to ooze through during each diastole.
_Symptomatology._ If you were to rely upon the occurrence of gastric
hemorrhage in making your diagnosis, a great many blunders would
necessarily occur, as this symptom is present in but one quarter of
all the cases. I can give you an exact picture of the symptoms from
experience on myself, having repeatedly been a sufferer from gastric
ulcer and having studied every phase of the question carefully upon
myself, frequently experimenting to get at various truths.
One of the most important and characteristic symptoms is the _localized
pain or soreness_ which is felt in a small, well defined area, and
either originates or is increased by chemical or mechanical irritation.
This spot always was sensitive both to warm and cold food. Salty food,
alcoholic or sour articles brought on pain. I could feel when the
food passed the spot. It was always more sensitive about an hour or
two after a meal, when the process of digestion was most active. My
ulcer was on the anterior wall of the stomach, so that I could greatly
ease the pain after meals by lying upon my back, while lying upon
the abdomen greatly aggravated it, as the food then came in contact
with the ulcer. I was a student yet when first suffering from this
trouble, and was treated by one of our prominent professors for heart
disease. He even gave me a certificate stating that I was suffering
from beginning hypertrophy of the left ventricle. I was not improving
under this treatment, and was taken one day with violent pain in the
stomach, followed by vomiting of a large quantity of blood. Now the
state of things was cleared up, and under the proper treatment (for
ulcer of the stomach) I soon regained my health. I remained well for
a long time, but in the course of the last twenty years have passed
through several relapses. One of these, I distinctly remember, occurred
while I was making a tour through the Alps. I had walked quite a
distance that day and being very thirsty drank three glasses of water
in quick succession. I immediately felt a pain in the stomach, and
could distinctly feel how one of the old scars was again rent asunder.
During these repeated attacks I found that the painful sensation
was really divisible into three distinct periods, that of constant
increase, during which the ulcer is developing and extending, that of
remaining at one height, and that of gradual decrease during the period
of healing. I could distinctly tell from these various changes how my
ulcer was getting along.
Two different kinds of pain are felt, the one constant and the other
occasional. The _constant pain_ is usually present where the ulcer has
extended deeper into the tissues or when the surrounding tissues are
implicated. This pain is increased during digestion or when pressure is
made on the parts from without. The _occasional pains_ are either of
a dyspeptic type, caused by the catarrh which usually accompanies the
ulcer, or of a cardialgic (neuralgic) type, the result of irritation
of the exposed nerve-endings with the ulcer. These cardialgias are
acute attacks of very severe, excruciating pain, which occur during
or between the periods of digestion and are felt in the epigastrium
and back mostly, but sometimes radiate over the entire abdomen, into
the chest and even into the limbs. These attacks differ in no respect
from those occurring in some diseases of the gall bladder, kidneys,
peritoneum or uterus, and are consequently not characteristic of
gastric ulcer. The dyspeptic pain partakes more of the character
of feeling of fullness, a sense of oppression in the epigastrium,
heartburn, etc., such sensations as occur in catarrh of the stomach and
are felt during digestion.
_The characteristic pain in ulcer of the stomach is a localized feeling
of soreness._ It is not always prominent. Chemical or mechanical
irritation of the ulcer brings it on, or if already present, aggravates
it. Especially acids, both mineral and vegetable, have this effect,
while alkalies allay it. This pain only occurs during the process of
digestion, when the food or gastric juice comes in contact with the
ulcer, or when the stomach is distended with gas, and tension exerted
on the tender spot. During the periods when the stomach is at rest it
does not occur.
_Vomiting_ occurs in about three-fourths of all cases of gastric ulcer;
vomiting of blood, however, only in about a quarter of all the cases.
The latter occurs oftener where the ulcer is deep. In cases where the
stomach is dilated, the amount vomited may be enormous, and contain
food which has been retained in the dilated portion for several days.
As a result, also, of the accompanying catarrh of the stomach and the
consequent diminished absorption of fluids, we find _constipation_ and
_diminished secretion of urine_ in cases of ulcer of the stomach.
Perforation of the stomach is most frequently caused by gastric
ulcer, and may be said to be a characteristic symptom; but it usually
occurs too late to be made use of in the treatment of the ulcer. It
is occasionally the first symptom which calls the patient's attention
to the fact that his stomach is and has been seriously diseased. By
the agglutinations of the base of the ulcer with neighboring organs,
through inflammatory processes, perforation can take place into these
organs. The most frequent forms of perforation under such conditions
are those into the liver, spleen or pancreas, but cases have occurred
where perforation into the colon or pleural cavity has taken place,
or even into the pericardium, the heart or lungs. Some time ago I saw
a case of gangrene of the lung, the result of the perforation of a
gastric ulcer into this organ.
A few days ago I saw an interesting case, where an acute gastritis
culminated in the vomiting of a large quantity of pus. The patient had
been having high fever for a few days, with incessant vomiting and
great tenderness in the epigastrium. Evidently an abscess had formed in
the neighborhood of the stomach, and finally opened into this organ,
with the given result.
_Diagnosis._ There are two classes of characteristic symptoms--those
originating from the exposure of nerve-endings, and those caused by
ulceration into bloodvessels. The first class includes the painful
sensations, the characteristic soreness, which occurs in about
four-fifths of all the cases; the second class, the hemorrhages,
occurring in only one-fourth of all the cases. You can readily see
why pain occurs more often than hemorrhage. Even a very superficial
abrasion may expose nerve-endings to the irritation of the food, while
it takes a deeper ulceration to lay open a larger bloodvessel. In order
to make a positive diagnosis, these two symptoms should be present.
Vomiting of blood alone need not necessarily be caused by a gastric
ulcer. There are a great many other conditions which may cause it. It
should, however, put you on the guard, and can, in a great many cases,
justify a diagnosis of probable ulcer of the stomach.
The localized pain occurs, according to my experience, only in cases
of ulceration of the stomach; that is, in gastric or peptic ulcer
and in cancer of this organ. In order to differentiate between these
conditions, it becomes necessary to observe whether the patient is
cachectic or emaciated or not, and whether a tumor can be felt in
the region of the stomach. But even these symptoms can be deceptive,
as an abnormal hardness or resistance--the result of perigastritic
infiltration--may occur in cases of simple ulcer, making the diagnosis
almost impossible. This is true especially in cases of ulcer of the
pyloric regions, while ulcers of the anterior wall of the stomach are
rarely accompanied by such infiltrations.
The pylorus is the most sensitive part of the stomach, and frequently
the seat of pain, when no lesion can be detected post-mortem. The other
parts of the stomach only become painful when attacked by ulcerative or
other pathological processes. Another point worthy of consideration
is that all forms of pain in the stomach are usually referred to the
pyloric region by the patient, even if they originate in other parts.
From all this you can see that no positive diagnosis can be made where
any one of these symptoms is presented unaccompanied by the others. A
careful consideration of the symptoms present will frequently, however,
be of aid in making a diagnosis. Intelligent patients will tell you
that they have a feeling of oppression, a feeling of distress in
dyspepsia, but will describe their feeling as that of distinct pain in
ulcer. Pure neuralgic pain is not always localized, but radiates into
distant parts, is not constant, but sets in all at once and disappears
with equal celerity, sometimes intermitting for days and weeks, and
then again setting in on the slightest nervous excitement. Such pain is
not aggravated by local pressure, shows no relation to the digestive
functions, does not depend upon the quality or quantity of food taken,
and may as well occur during a fast as during a feast. Often such
patients will tell you that their pain does not cease until they have
taken a hearty meal.
In cases of peptic ulcer, you will find that the pain is in direct
relation to the amount and quality of food taken; that the patient
has little or no pain when the stomach is at rest; that coarse foods
as well as acids cause or aggravate the pain, and that indifferent
foods, such as milk, do not bring it about, though they may sometimes
cause a sense of fullness or oppression. Some patients with ulcer will
tell you that the position of their body has an influence on their
pain. If they are so placed that the food, by its gravity, lies on the
ulcer, the pain is brought on or increased, while if the patient under
such circumstances then changes his position, he is relieved of his
pain partially, or even entirely. Yes, some such patients must assume
abnormal positions while their stomach is active, in order to avoid
this suffering. Some patients with gastric ulcer cannot digest _any_
food without great pain, and frequently live on a very scanty diet,
rather than risk taking more food and enduring these excruciating pains
again.
_Anomalous Cases._ Occasionally cases will occur in which the symptoms
presented do not justify the diagnosis of ulcer of the stomach, only
those of dyspepsia or else of gastric catarrh being present, while we
are still compelled to assume the diagnosis of ulcer from the result of
the treatment. Such cases resist all kinds of treatment based upon the
diagnosis of dyspepsia or catarrh, and can only be cured by a strict
"ulcer cure."
Another class of cases only presents gastralgic pain without any other
symptom. Such are frequently patients who have had gastric ulcer
before. Others will come to you with intercostal neuralgia on the left
side. They have, perhaps, tried all the usual anti-neuralgic remedies,
have gone through a course of treatment by electricity, and spent a
large amount of time and money, without obtaining permanent relief,
until some physician puts them on a strict milk diet and cures them in
this way in a short time.
Some cases of ulcer of the stomach present the queerest symptoms.
For instance: they complain of pain after drinking milk, or even
after taking a morphine powder, while they can eat the coarsest food
without any harm. Others run along without presenting any symptoms at
all, until they, as well as their physicians, are surprised by the
perforation of a gastric ulcer.
All these abnormal cases, which form about one-fifth of all the cases
occurring, are so indistinct that they frequently remain unrecognized
throughout their entire course, and baffle the skill of the best
diagnosticians.
In order to be able to make a sure diagnosis, there must be a localized
pain, together with tenderness on pressure from without on the
painful spot. A great many persons in good health are tender in the
epigastrium, so that you have to be on your guard in this direction,
too. From the occurrence of hæmatemesis in an otherwise healthy person
you can, with great probability, diagnose ulcer of the stomach.
_Differential Diagnosis._ In order to differentiate _between catarrh
and ulcer_, it is simply necessary to keep in mind the difference in
the character of the pain, the fact that local pressure is more liable
to aggravate the pain in ulcer than in catarrh, and the occurrence of
hemorrhage in the former. The two conditions, however, frequently occur
in the same patient.
The differentiation between _ulcer and neurosis_ has already been
discussed. The direct connection of the attacks of pain with the
introduction of food, and the character of the pain will soon clear up
the matter. Should you still be in doubt, a course of treatment, such
as an ulcer would demand, will soon clear up the matter. If the case is
one of ulcer, it will have been cured or materially benefited, if it
was a pure neurosis the patient will if anything feel worse than before.
By far the most difficult question to decide in making a diagnosis is
whether the case is one of _ulcer or cancer_ of the stomach. Here close
attention to several points will usually clear up the diagnosis. Cancer
sufferers always have a sallow complexion, a worn, emaciated, cachectic
appearance, no matter what or how much they eat. Ulcer patients
frequently have a robust, healthy appearance, and are emaciated or run
down only after repeated hemorrhages, or when other grave diseases,
such as heart disease, chlorosis, tuberculosis, etc., are also present.
The _presence or absence of a tumor_ is a very important aid to the
diagnosis, though as I have already stated, not always reliable.
Sometimes an ulcer may be covered with granulations, and its
surroundings so infiltrated and hardened, that even post-mortem the
naked eye can not tell whether it is cancer or simple ulcer, and the
question has to be decided by microscope. Such are likely the cases
which form the bases of cancer cures which are reported from time to
time to have been effected by the use of various remedies.
_Vomiting of blood_ is a symptom common to both cancer and ulcer of
the stomach, but is usually more copious in the latter. If the absence
of acid in the gastric juice of cancerous stomachs proves to be as
reliable a symptom as has been recently asserted, this will be an
important feature in the differentiation from ulcer.
You will frequently be astonished by the success of your treatment if
you think of ulcer in doubtful cases of stomach trouble, such as occurs
in young girls with chlorosis and institute a strict milk diet with
the measures adopted for the cure of ulcer.
_Prognosis._ From what has been said you can see that in general the
prognosis of ulcer of the stomach is good, that with proper avoidance
of all irritation, the ulcer has a tendency to heal of itself. This
tendency has been observed even in large ulcers, where death was
perhaps the result of some intercurrent disease.
Ulcers of the anterior wall of the stomach are more dangerous than such
as occur on the posterior wall, for the reason that in the latter case
adhesion with the neighboring structures are more easily formed, and
thus fatal perforation prevented. The anterior wall takes a much more
active part in the peristaltic movement of the stomach, and as a result
does not enter so easily into adhesion with its surroundings. Even
after an ulcer has healed it always remains a weak point, and cases of
rupture of the stomach in old cicatrices are described by Chiari.
_Treatment._ The pain is the most important criterion as a guide
during the treatment. It is the signal by which I judge of the present
condition of the ulcer. According to the variation of its character
and intensity, I can judge whether the ulcer is healing, is remaining
stationary, or is spreading and increasing in size or depth in spite of
the treatment. If the pain has been removed permanently the ulcer has
been healed. From the relation of this symptom to different kinds of
food you can also judge of a progress or improvement of the ulcer.
Theoretically considered, that form of treatment would seem the best
which gives the stomach absolute rest, entire abstinence from food, a
fast of several weeks. But this can not be carried out in practice.
The patient could be nourished per rectum, you might say, by means of
nutrient enemata. In my opinion this method of nourishment does not
amount to much. I believe that very little water is absorbed by the
rectum, the patient would suffer from thirst and you would then be
compelled to allow him to drink water at least.
Luckily we do not need to resort to such extreme measures in the
majority of cases. With the exclusive use of the proper bland, liquid
food, we usually attain the same results. In the treatment of gastric
ulcer I lay the main stress on the restriction and regulation of the
diet, and put the patient on an exclusive milk diet. Milk contains all
the constituents necessary for the nourishment of the human body.
I begin by giving every half hour to one hour a small quantity of
skimmed, boiled milk, which has been cooled on ice. The patient must
rest in bed or on a lounge, as he is weakened by the treatment, and can
not follow his usual avocation. I forbid all other articles of food.
With this diet a patient with ulcer should have no pain and usually
has none. Should there be pain it is necessary to find out whether the
feeling described as such be not simple oppression, or a feeling of
weight in the stomach. Some patients do not seem to digest milk well.
It ferments, forms gases and then they have this feeling of oppression.
Some drink the milk too fast and take too much at a time, swallowing a
lot of air with the milk, thus distending their stomachs unnecessarily.
The patient must be instructed to drink the milk slowly, and only take
a small quantity at a time (about one or two ounces). Some patients can
not stand iced milk but bear luke warm milk much better. Others seem to
prefer milk which has slightly soured.
The patients should adhere to this strict diet as long as possible,
regulating the length of time according to the duration and intensity
of the disease. They have to observe the above rules one or two weeks
at least, several weeks if possible.
Often you will meet with the reply: "I have already tried this diet,
I was put on milk diet once before by Dr. ---- and it did not help
me any, I even felt worse afterwards." If you inquire more closely,
however, you will find that they drank milk several times a day,
but ate bread with it, soaking this in the milk. This is what is
understood to be a milk cure. Gentlemen! I am sorry to say that this
misunderstanding is not confined to the general public, but that some
physicians even do not know better, and consider such a course of diet
a milk diet. I cannot impress it upon your minds any too strongly
not to allow yourselves to be diverted from your purpose by any such
assertions, but to order another course of milk diet, wherever you
find it indicated, and see to it that it is carried out properly this
time. You will thereby occasionally meet with excellent success where
a previous wrong attempt in the same direction failed.
After the patient has been free from pain from eight to ten days, I
then add to his diet soft boiled eggs with a slight addition of salt,
beginning on the first day with one half of an egg. If this is well
borne I gradually allow more day by day, until he is able to digest
four or five a day without difficulty. Eggs do not agree with some
patients. In such cases I pass on the use of meat. I have beefsteak
chopped fine, roasted in little meat cakes of the size of a silver half
dollar. One of these is given to begin with, and if well borne repeated
every two or three hours as long as there is no pain. When eggs agree
I prefer to give them for a few days before beginning with the meat,
waiting until such patients can digest four or five eggs a day. After
the meat has been borne well in small quantities for a while, I
gradually increase the quantity taken per day until it reach a pound or
two.
You cannot be too careful and should instruct the patient to return to
the strict milk diet as soon as any pain is felt, no matter how nicely
he may have been getting along up to the time. Not until the patient
has been entirely free from pain for several weeks is it advisable to
allow the use of cereals boiled in milk, such as rice or tapioca. Then
he can also be allowed to take a quarter of a biscuit (well baked) at
each meal. A full meal, however, in the sense in which it is ordinarily
understood, a large quantity of food taken at one time, is still to
be avoided. It is better to give small quantities of food oftener, in
order not to distend the stomach, and thus run the danger of too great
a strain upon the newly healed ulcer.
These meat cakes made of beef can be taken for a week or so, and then
if well borne other kinds of meat may be occasionally substituted.
_Wine and alcoholic liquors in general_ are to be avoided for several
months.
_Beer_ should never be taken by one who has suffered from gastric
ulcer. In fact it is well for all who have stomach trouble to avoid the
use of beer, especially such as have had ulcer. Such patients have to
be on their guard in matters of diet through the remainder of their
lives, and must avoid excesses both in eating and drinking. You will
occasionally come across persons who can not stand a milk diet in any
form whatever. They frequently do not bear eggs well. In such cases I
proceed at once, but with great care, to the use of meat in very small
quantities, finally chopped and roasted, and have it taken several
times a day. You will frequently have to try one article of food and
then another, and experiment for awhile before you reach that form of
diet which suits the case best.
There are a number of _substitutes_, some of which are really good,
while others are worthless. Of them all I prefer the fresh meat juice
_ext. carnis recent. pressum_, and have it prepared in the following
manner: The meat (beef should be used) is cut into thin slices, placed
between pieces of tissue paper, and pressed in a hydraulic press. The
juice thus obtained is given in teaspoon doses every half hour or so,
just as though it were medicine. In the majority of cases I have the
meat juice made by the druggist, so that a large number of the patients
think it is medicine. It has a rather pleasant taste and is well borne
by the stomach. There are a great many _peptones_ in the market, a
large number of which ought not to be used, as they are not fresh and
more likely to do harm than good. Of them all the English make is the
best, as it is usually well preserved, being packed dry.
Patients who can only take a small quantity of nourishment by the
stomach can be materially aided by the use of nutritious enemata given
luke warm once or twice a day. When the rectum is very irritable a
suppository containing one-half to one grain of ext. opii given a half
hour before the enema is very serviceable. There are a great many
_other remedies_ recommended in the text books, but I would advise you
not to rely too much on them. Lay your main stress on the dietetic
part of the treatment, and use remedies only where they are absolutely
necessary to support this. Among the remedies used the alkalies are the
most valuable. Bicarbonate of soda alone, or in combination with ext.
belladonna when the stomach is very irritable.
℞ Sod. Bicarb., ʒiss.
Ext. Belladon., gr ii. Misce et div. in pulv. XVI.
Sig. One in the morning and one in the evening.
Or I sometimes substitute atropia sulph. (1/120 gr. pro dosi) for the
belladonna. At any rate the use of alkalies is the most plausible
treatment. But the permanent alkalization of the contents of the
stomach by the frequent use of large doses of alkalies, as has been
recommended in Paris by Debove is not plausible, as by this the process
of digestion would be checked entirely.
It is also good to give a dose of Carlsbad salts in the morning every
two or three days, in order to correct the constipation usually
attendant upon such a course of diet. These salts also aid in rendering
the contents of the stomach more alkaline, and in this way aid the plan
spoken of before.
I do not think it advisable to send patients with gastric ulcers to
_health resorts_ or watering places. They can only regain their health
by a strict enforcement of dietetic measures, and these can be carried
out just as well at the patient's home as at the health resort. For
the treatment of such cases _after the ulcer_ has healed, these health
resorts can be of great benefit, but the patient must be cautioned not
to commit excesses in eating or drinking, especially to the latter must
their attention be called, as it is customary in most resorts adapted
to such cases, to drink large quantities of the medicated waters in the
morning. It is also well to caution the patients with regard to their
diet before sending them away. This should be unirritating, bland and
easily digestible. Among the European health resorts, Carlsbad is the
most suitable for such cases.
There are unfortunately some patients who are not benefited by any
method of treatment hitherto thought of, but luckily they are few, and
if you will follow the rules I have laid down you will in a great many
cases meet with splendid results.
One important question still remains to be answered, namely: "What
should be done in case of hemorrhage of the stomach?" Here the patient
must be left quiet just where he happens to be--placed in a horizontal
position on his back if possible. Ice bags should be applied to the
region of the stomach, small pieces of ice swallowed, and hypodermic
injections of ergotin given. This is all that can be done with benefit
in such cases. The patient should not be transported for several hours.
Monsel's solution can be of no service, as it cannot be introduced into
the stomach in a sufficient concentration to be of benefit.
In cases of perforation of an ulcer all that can be done is to
give anodynes to ease the pain and make the patient's condition as
comfortable as possible. Schlipp recommends that when perforation is
threatened on account of gaseous distention of the stomach, the stomach
tube should be used to evacuate the organ.
The mechanical treatment, washing out the stomach with the stomach tube
or stomach pump is contraindicated in cases of ulcer, as more damage
can be done by such procedure than good.
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ORIGINAL ARTICLES
THE RECOGNITION OF MORTIFIED BOWEL IN
OPERATIONS FOR THE RELIEF OF
STRANGULATED HERNIA.
By REUBEN A. VANCE, M. D., CLEVELAND, OHIO.
The medical practitioner who has been hastily summoned to operate
upon a patient with strangulated hernia finds himself confronted with
problems, the gravity of which can alone be appreciated by those who
have frequently met them. The medical treatment to be adopted, the
extent to which taxis should be employed, and the time it is prudent to
delay operative interference when other measures have proved fruitless,
are grave questions upon the solution of which the life of the patient
depends. The operation decided upon, the particular method to be
employed and the manner of dealing with the stricture--with or without
opening the sac--are matters of minor consequence, and affairs that
should be settled in the mind of every practitioner by a reference to
sound surgical principles and the teachings of experience. There are
questions connected with the condition of the parts strangulated that
must be solved by the surgeon during the progress of the operation,
about which much less is said in works on surgery than their importance
warrants. These pertain to the vitality of the part that has been
strangulated, and the duty of the surgeon in the premises. If the
part is still living, it matters not how much damaged by compression,
it should be returned at once into the abdomen; upon this step the
patient's life depends. If the part is mortified and dead, to return it
within the cavity of the belly is to insure the patient's destruction;
if he is to have a chance for life, other measures must be adopted.
Again, the decision of the operator can but rarely be guided or aided
by aught but the conditions revealed by his knife during the operation.
The state of the patient and the history of the case may indicate the
imminence of mortification of the bowel; in the end the appeal is to
the senses of the surgeon, and upon the conclusion at which he then
arrives will depend the fate of the patient.
Under these circumstances it behooves every man who may be placed in
position to make such a momentous decision to at least go to the task,
sustained by every aid that can be derived from the experience of
those who themselves have been placed in this dilemma and compelled to
act with such lights as they then possessed--whose records, next to
personal experience, become the best guide for those forced to follow
in their footsteps.
The history of the case may throw some light upon the state of the
intestine. This is especially so in those cases in which the severity
of the symptoms suddenly subsides without the rupture having been
reduced. The pain is violent, the abdomen distended and singultus
and stercoracious vomiting present; suddenly the patient's suffering
cease, and were it not for the cold extremities, flickering pulse and
persistent tumor--but above all, the teachings of experience--the
surgeon could not but acknowledge that all tangible appearances
portended a change for the better. Yet, almost invariably gangrene of
the gut has taken place, and the fallacious evidences of improvement
above noted are in reality its best clinical exponent. Certain almost
as these signs are, when present, yet it comparatively seldom happens
that the surgeon has their aid in guiding him in the measures he
must adopt; they form, but infrequently, a part of the history of
cases submitted to operation. If present, the surgeon is reasonably
sure of what he will find when he operates; they may be absent and
mortification yet exist. The patient's chance of life depends upon the
surgeon's ability to recognize mortification of the bowel when he sees
it, and his promptitude and skill in dealing with it when present.
It scarcely need be said that mere darkening in color of the bowel,
effusion of fluid into the sac, or exudation of lymph about the
stricture are of no special significance in this connection, and bear
in no way upon the presence or absence of mortification. It has been
again and again repeated in manuals treating of hernia operations
that a deep, purplish discoloration of the bowel and absence of
circulation indicate mortification; that when these physical signs
are present the surgeon should press upon the strictured part, and
if the color remains unchanged when the finger is removed, the bowel
is dead. It requires but little practical experience in dealing with
these cases to appreciate the fallacious character of these signs; the
gut may be fairly black from congestion and yet alive; the color may
remain unchanged under pressure and still that fact have no bearing
on the question of mortification, for a band of stricture, as yet
unappreciated, may be the sole cause of the persistent hyperæmia.
It is quite different as regards certain other signs, especially when
two or more of them are seen in conjunction. _If the bowel be dark and
mottled with grayish spots, of contracted and shrivelled aspect, with a
slight amount of discolored fluid surrounding the gut, and a cadaveric
odor apparent when the sac is opened_, mortification is certainly
present, and the return of the strictured part within the abdominal
cavity dooms the patient to certain death. The surgeon's duty is to
open the sphacelated gut, apply a poultice and favor the relief of the
obstructed bowel by a free discharge of the intestinal contents through
the outlet thus formed. An artificial anus is thus established, and the
patient, for a time, must be content with this deformity; fortunately
it is a condition susceptible of relief, and the surgeon may ultimately
free his patient of even this defect.
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JABORANDI AS A GALACTAGOGUE.
JOHN H. LOWMAN, M. D.
Professor of Materia Medica in the Medical Department of the Western
Reserve University.
There is a decided difference of opinion among therapeutics as to the
effect of jaborandi on the mammary gland. Some claim that it has no
effect upon the gland. Some claim that it assists in increasing the
secretion of milk.
This note is made to show the action of jaborandi as a galactagogue in
the recent puerperal state. The preparation used was the fluid extract
obtained from Squibb & Co.
M. S., age thirty-five years, a multipara, of fair health, not well
nourished. The babe was two weeks old at the time of this observation,
and in good condition. The secretion of milk by the mother began
gradually to fail until not one-third the average quantity was
produced. The child was then nourished artificially. The fluid extract
of jaborandi was given to the mother. The dose was eight minims every
three hours. About fifty minims were taken in twenty-four hours. On
the second day of the administration of the drug the milk increased
in quantity. By the third day it had increased still more, so that
the child had nourishment from the mother sufficient to satisfy it.
Increased salivary and cutaneous secretions led to a discontinuance
of the drug. The milk flowed in good quantities for eight days,
and then rapidly diminished. Jaborandi was again used. The plan of
administration was the same. Increase of the milk was again noted. The
renewed activity of the mammary glands continued for five or six days
only. For a third time the drug was used, and its use followed by good
effects. In the meantime the nourishment of the mother had been pushed.
Iron, quinine and mineral acids were also given. The general health of
the patient improved. After the last increased activity the secretion
of the gland remained normal for three weeks, after which the patient
passed from observation. During the last two weeks no jaborandi was
used.
Whereas in this case the improved condition of the individual was
responsible for the permanent increase in the supply of milk, the use
of the jaborandi and the temporary increase were apparently more than
coincidental. During the first two stimulations the quality of the milk
deteriorated; the quantity of cream diminished; the specific gravity
fell; no microscopic examination of the milk was made. After the last
increase in the activity of the glands the quality of the milk was good.
Two similar cases were noted. B., aged nineteen years, primipara, had
a tedious labor. She recovered slowly. She was well nourished and has
previously been well. At the end of the second week of convalescence
the milk began to fail. Jaborandi was used as in the case just cited.
Marked improvement in the milk was noticed the second day the drug was
given. On the fourth day the medicine was omitted. The milk continued
to flow in sufficient quantities for ten days. The quantity then
gradually and rapidly diminished. The medicine was again given for four
days with the desired effect, which remained for the following ten days
that the patient was under observation.
D., age twenty-five years, a multipara, was a poorly nourished person,
the mother of two children. The confinement was normal. The milk
failed soon after its appearance. Following the use of jaborandi the
milk increased rapidly in quantity, but diminished in three days on
withdrawing the drug. The milk continued to respond to the jaborandi
for the four weeks that the patient was under observation, but no
permanent result was obtained.
On three other cases the jaborandi was used with scarcely perceptible
effect or no effect at all. From a few cases it is impossible to
generalize with expectation of a truthful conclusion. We can, however,
know that the jaborandi has an effect on the mammary gland, and causes
an increase of the milk in puerperal women. This effect is by no means
a constant sequel to the administration of the drug. As far as my
observation is concerned the effect of jaborandi is temporary, and
can be useful only where there is a tendency in the gland to assume
its normal function. This tendency may at times be subordinated to
general influences and even entirely subdued. In such conditions a
timely stimulation of the gland may tide over the threatening arrest of
function. Variation in the activity of the mammary gland, especially
in the early puerperal state, is not unusual. The close relation of
the increase of milk and the use of jaborandi justifies, however, the
assumption of effect and cause.
No effect was observed on the children. Jaborandi is excreted by
the mammary glands, and it was consequently withheld as soon as
practicable, lest the child should feel its presence.
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INDICATIONS FOR OPENING THE MASTOID
PROCESS.
BY A. R. BAKER, M. D., CLEVELAND, OHIO.
The operation of opening the mastoid process is said by some to have
been first performed by Riolan in 1649; according to others, by Petit
in 1750, and later by Jasser, in 1776. During the latter part of the
eighteenth century the operation was performed frequently without
definite pathological indications. But after the unfortunate death
of the Danish physician Berger (1791) the operation was very seldom
or never performed until 1864, by Mayer, following the suggestions
made by Tröltsch some years previous. Berger, for chronic deafness
without suppuration of the middle ear, had the operation performed upon
himself, and died on the twelfth day from meningitis. During the past
twenty years the operation has taken its place as one of the recognized
surgical proceedings owing to the work of the German physicians Moos,
Jacobi, Hartman, Bezold, Schwartz and others, who have laid down the
real indications for the operation from their extensive clinical
observations and pathological researches. The American otologists,
Roosa, Agnew, Buck and others were among the very first to perform the
operation, and have done much to establish its claim to recognition.
And yet it is somewhat remarkable that some of our text books barely
mention the operation; and as short a time ago as 1883, Strawbridge, at
the meeting of the American Otological Society, said that he had seen
over four thousand cases of purulent middle ear disease within twelve
years, and yet had not trephined in a single case; and several other
authorities looked upon the operation as a questionable one. Knapp
took decided grounds in favor of the operation, and cited three fatal
cases in which he believed an operation would have saved life. Kipp had
seen quite a number of fatal cases in which the post-mortem had shown
the mastoid cells filled with pus, which had given rise to cerebral
abscess. Dr. C. H. Burnett reported a fatal case which died from
pyemia, and he thought if his patient had been operated a year before
his life would have been saved.
Gruening said surgery has established that wherever there is a focus of
purulent discharge it should be removed. This, (removal of the focus)
is a life-saving operation and should be done under all circumstances.
Dr. Roosa said that he believed the revival of this operation of
opening the mastoid process has saved many lives. Since his first
operation not a year has passed that he has not found it necessary to
repeat it several times. He says further that "it is true that we shall
seldom need to open the mastoid if an experienced practitioner sees a
case of acute aural disease early in its course. It is an operation for
neglected cases, where suppuration has been allowed to advance from the
tympanic cavity in consequence of not having a free outlet through the
drum-head. But purulent inflammation of the mastoid may occur in acute
cases that have been thoroughly treated by leeching, poultices, rest,
etc., from the start."
The most recently stated indications for opening the mastoid process
are:
1. Purulent inflammation in the mastoid process appearing in the course
of suppuration of the middle ear when persistent severe pain in the
bone cannot be subdued by the application of the ice-bag, leeches, or
by Wilds' incision. (Schwartz).
2. Painful inflammation in the mastoid process occurring in acute
and chronic suppuration of the middle ear, in consequence of growths
filling up the external meatus or the tympanic cavity. When attempts
to remove the obstacle to the free escape of pus have failed, the
operation is imperative. (Grüning). The operation is indicated even
though the soft parts over the mastoid are not swollen or infiltrated.
(Politzer).
3. When the posterior superior wall of the meatus is bulging, and when
after incision the abscess is not emptied and the symptoms of retention
of pus continue. (Toynbee, Duplay).
4. Persistent pain and tenderness in the mastoid process lasting for
days or weeks, in which there is probably an osseous abscess not
communicating with the tympanic cavity. (Politzer).