lead colic with gastric ulcer, and the points in their differential
diagnosis are sufficiently apparent to require no description here. The
diagnosis of duodenal ulcer from gastric ulcer will be discussed
elsewhere. The different causes of gastric hemorrhage, a knowledge of
which is essential to the diagnosis of gastric ulcer, will be
considered in the article on HEMORRHAGE FROM THE STOMACH.
PROGNOSIS.--Although a decided majority of simple ulcers of the stomach
cicatrize, nevertheless, in view of the frequently insidious course of
the disease, the sudden perforations, the grave hemorrhages, the
relapses, and the sequels of the disease, the prognosis must be
pronounced serious.
The earlier the ulcer comes under treatment the better the prognosis.
Old ulcers with thickened indurated margins containing altered
blood-vessels naturally heal with greater difficulty than
recently-formed ulcers.
Profuse hemorrhage adds to the gravity of the diagnosis. It usually
indicates that the ulcer has penetrated to the serous coat of the
stomach. A hemorrhage may exert a favorable influence, in so far as to
convince the patient of the necessity of submitting to the repose and
the strict dietetic regimen which the physician prescribes.
The severity of the pain is of little value as a prognostic sign.
Vomiting and dyspepsia, if uncontrolled by regulation of the diet, lead
to a cachectic state which often ends in death.
Little basis as there is to hope for recovery after perforation into
the general peritoneal cavity, there nevertheless have been a very few
cases in which there is reason to believe that recovery has actually
taken place after this occurrence.[108]
[Footnote 108: The most convincing case of recovery after perforation
of gastric ulcer is one reported by Hughes, Ray, and Hilton in _Guy's
Hosp. Rep._, 1846, p. 332. A servant-girl was suddenly seized with all
of the symptoms of perforation. Fortunately, she had eaten nothing for
four hours before the attack, and then only gruel. She was placed at
once under the influence of opium, was kept in the recumbent posture,
and was fed by the rectum. She was discharged apparently cured after
fifty-two days. Two months afterward she was again suddenly seized with
the same symptoms, and she died in fourteen hours. Shortly before the
second perforation she had eaten cherries, strawberries, and
gooseberries, which were found in the peritoneal cavity. The autopsy
showed, in addition to a recent peritonitis, evidences of an old
peritonitis. There were adhesions of the coils of the intestines with
each other and between the stomach and adjacent viscera. In the stomach
were found a cicatrix and two open ulcers, one of which had perforated.
Other cases in which recovery followed after all of the symptoms of
perforation of gastric ulcer were present, but in which no subsequent
autopsy proved the correctness of the diagnosis, have been reported by
Redwood (_Lancet_, May 7, 1870); Ross (_ibid._, Jan. 21, 1871); Tinley
(_ibid._, April 15, 1871); Mancini (_La Sperimentale_, 1876, pp. 551,
665); and G. Johnson (_Brit. Med. Journ._, March 26, 1870).
Frazer's two cases, reported in the _Dublin Hosp. Gaz._, April 15,
1861, are not convincing. The case reported by Aufrecht (_Berl. kl.
Wochenschr._, 1870, No. 21) and the one by Starcke (_Deutsche Klinik_,
1870, No. 39), which are sometimes quoted as examples of recovery, were
cases of circumscribed peritonitis following perforation.
In an interesting case from Nothnägel's clinic reported by Lüderitz,
the patient lived sixteen days after perforation into the peritoneal
cavity, followed by all of the symptoms of diffuse perforative
peritonitis. Death resulted from pneumonia secondary to the
peritonitis. At the autopsy were found adhesions over the whole
peritoneal surface and streaks of thickened pus between the coils of
intestine. The perforation in the stomach was closed by the left lobe
of the liver (_Berl. kl. Wochenschr._, 1879, No. 33).]
In estimating the prognosis one should bear in mind the possibility of
relapses; of a continuance of gastric disorders, particularly of
gastralgia, after cicatrization; of the formation of cicatricial
stenosis of {519} the orifices of the stomach; and of the development
of dilatation of the stomach.
After the worst has been said concerning the unfavorable issues of
gastric ulcer, it yet remains true that the essential tendency of the
ulcer when placed under favorable conditions is toward recovery, and
that in many cases the treatment of the disease affords most excellent
results, and is therefore a thankful undertaking for the physician.
TREATMENT.--In the absence of any agent which exerts a direct curative
influence upon gastric ulcer the main indication for treatment is the
removal of all sources of irritation from the ulcer, so that the
process of repair may be impeded as little as possible.
Theoretically, this is best accomplished by giving to the stomach
complete rest and by nourishing the patient by rectal alimentation.
Practically, this method of administering food is attended with many
difficulties, and, moreover, the nutrition of the patient eventually
suffers by persistence in its employment. In most cases the patient can
be more satisfactorily nourished by the stomach, and by proper
selection of the diet, without causing injurious irritation of the
ulcer.
At the beginning of the course of treatment it is often well to
withhold for two or three days all food from the stomach and to resort
to exclusive rectal feeding. In some cases with uncontrollable vomiting
and after-hemorrhage from the stomach it is necessary to feed the
patient exclusively by the rectum.
The substances best adapted for nutritive enemata are
artificially-digested foods, such as Leube's pancreatic meat-emulsion,
his beef-solution, and peptonized milk-gruel as recommended by
Roberts.[109] Beef-tea and eggs, which are often used for this purpose,
are not to be recommended, as the former has very little nutritive
value, and egg albumen is absorbed in but slight amount from the
rectum. Expressed beef-juice may also be used for rectal alimentation.
The peptones, although physiologically best adapted for nutritive
enemata, often irritate the mucous membrane of the rectum, so that they
cannot be retained. It has been proven that it is impossible to
completely nourish a human being by the rectum.[110] Rectal
alimentation can sometimes be advantageously combined with feeding by
the mouth.
[Footnote 109: Leube's pancreatic meat-emulsion is prepared by adding
to 4-8 ounces of scraped and finely-chopped beef l-2½ ounces of fresh
finely-chopped oxen's or pig's pancreas freed from fat. To the mixture
is added a little lukewarm water until the consistence after stirring
is that of thick gruel. The syringe used to inject this mixture should
have a wide opening in the nozzle; Leube has constructed one for the
purpose (Leube, _Deutsches Arch. f. klin. Med._, Bd. x. p. 11).
The milk-gruel is prepared by adding a thick, well-boiled gruel made
from wheaten flour, arrowroot, or some other farinaceous article to an
equal quantity of milk. Just before administration a dessertspoonful of
liquor pancreaticus (Benger) or 5 grains of extractum pancreatis
(Fairchild Bros.), with 20 grains of bicarbonate of soda, are added to
the enema. This may be combined with peptonized beef-tea made according
to Roberts's formula (Roberts, _On the Digestive Ferments_, p. 74,
London, 1881).
Preparatory to beginning the treatment the bowels should be emptied by
a clyster, and this should be occasionally repeated. About three to six
ounces of the tepid nutritive fluid should be slowly injected into the
rectum. The injections may be repeated at intervals of from three to
six hours. If necessary, a few drops of laudanum may be occasionally
added to the enema.]
[Footnote 110: Voit u. Bauer, _Zeitschrift f. Biologie_, Bd. v.]
There is universal agreement that the dietetic treatment of gastric
ulcer is of much greater importance than the medicinal treatment. There
is {520} hardly another disease in which the beneficial effects of
proper regulation of the diet are so apparent as in gastric ulcer.
Those articles of food are most suitable which call into action least
vigorously the secretion of gastric juice and the peristaltic movements
of the stomach, which do not cause abnormal fermentations, which do not
remain a long time in the stomach, and which do not mechanically
irritate the surface of the ulcer. These requirements are met only by a
fluid diet, and are met most satisfactorily by milk and by Leube's
beef-solution.
The efficacy of a milk diet in this disease has been attested by long
and manifold experience. By its adoption in many cases the pain and the
vomiting are relieved, and finally disappear, and the ulcer heals. In
general, fresh milk is well borne. If not, skimmed milk may be
employed. If the digestion of the milk causes acidity, then a small
quantity of bicarbonate of soda or some lime-water (one-fourth to
one-half in bulk) may be added to the milk. Large quantities should not
be taken at once. Four ounces of milk taken every two hours are
generally well borne. Sometimes not more than a tablespoonful can be
taken at a time without causing vomiting, and then of course the milk
should be given at shorter intervals. It is desirable that the patient
should receive at least a quart, and if possible two quarts, during the
twenty-four hours. The milk should be slightly warmed, but in some
cases cold milk may be better retained. In some instances buttermilk
agrees with the patient better than sweet milk. Although many suppose
that they have some idiosyncrasy as regards the digestion of milk, this
idiosyncrasy is more frequently imaginary than real. Still, there are
cases in which milk cannot be retained, even in small quantity.
For such cases peptonized milk often proves serviceable.[111] The
artificial digestion of milk as well as of other articles of food is a
method generally applicable to the treatment of gastric ulcer. The main
objection to peptonized milk is the aversion to it that many patients
acquire on account of its bitter taste. The peptonization should not be
carried beyond a slightly bitter taste. The disagreeable taste may be
improved by the addition of a little Vichy or soda-water. Peptonized
milk has proved to be most valuable in the treatment of gastric ulcer.
[Footnote 111: Milk may be peptonized by adding to a pint of fresh
milk, warmed to a temperature of 100° F., 5 grs. of extract pancreatis
(Fairchild Bros. and Foster) and 20 grs. of bicarb. sodii dissolved in
4 ounces of tepid water. The mixture is allowed to digest for about an
hour at a temperature of 100° F., which may be conveniently done by
placing the milk in a bowl in a pan of water maintained at this
temperature. It is then boiled, strained, and placed on ice, or when
the milk is to be taken immediately it is better not to boil it, in
order that the partial digestion may continue for a while under the
influence of the pancreatic ferment in the stomach. The milk without
boiling may be kept on ice without further digestion; and this
procedure has the advantage that the pancreatic ferments, although
inactive at a temperature near that of ice, are not destroyed. The
degree of digestion aimed at is indicated by the production of a
slightly, but not unpleasantly, bitter taste. When the digestion is
carried to completion, milk has a very bitter and disagreeable flavor.
Peptonized milk-gruel, mentioned on page 519, may also be employed.]
Leube's beef-solution[112] is a nutritious, unirritating, and
easily-digested article of diet. It can often be taken when milk is not
easily or {521} completely digested, or when milk becomes tiresome and
disagreeable to the patient. It is relied upon mainly by Leube in his
very successful treatment of gastric ulcer. A pot of the beef-solution
(corresponding to a half pound of beef) is to be taken during the
twenty-four hours. A tablespoonful or more may be given at a time in
unsalted or but slightly salted bouillon, to which, if desired, a
little of Liebig's beef-extract may be added to improve the taste. The
bouillon should be absolutely free from fat. Unfortunately, not a few
patients acquire such a distaste for the beef-solution that they cannot
be persuaded to continue its use for any considerable length of time.
[Footnote 112: By means of a high temperature and of hydrochloric acid
the meat enclosed in an air-tight vessel is converted into a fine
emulsion and is partly digested. Its soft consistence, highly
nutritious quality, and easy digestibility render this preparation of
the greatest value. The beef-solution is prepared in New York
satisfactorily by Mettenheimer, druggist, Sixth Avenue and Forty-fifth
street, and by Dr. Rudisch, whose preparation is sold by several
druggists.]
Freshly-expressed beef-juice is also a fairly nutritious food, which
can sometimes be employed with advantage. The juice is rendered more
palatable if it is pressed from scraped or finely-chopped beef which
has been slightly broiled with a little fresh butter and salt. The meat
should, however, remain very rare, and the fat should be carefully
removed from the juice.
To the articles of diet which have been mentioned can sometimes be
added raw or soft-boiled egg in small quantity, and as an addition to
the milk crumbled biscuit or wheaten bread which may be toasted, or
possibly powdered rice or arrowroot or some of the infant farinaceous
foods, such as Nestle's. Milk thickened with powdered cracker does not
coagulate in large masses in the stomach, and is therefore sometimes
better borne than ordinary milk.
For the first two or three weeks at least the patient should be
confined strictly to the bill of fare here given. Nothing should be
left to the discretion of the patient or of his friends. The treatment
should be methodic. It is not enough to direct the patient simply to
take easily-digested food, but precise directions should be given as to
what kind of food is to be taken, how much is to be taken at a time,
how often it is to be taken, and how it is to be prepared.
In all cases of any severity the patient should be treated in bed in
the recumbent posture, and warm fomentations should be kept over the
region of the stomach. Mental and physical fatigue should be avoided.
Usually, at the end of two or three weeks of this diet the patient's
condition is sufficiently improved to allow greater variety in his
food. Meat-broths may be given. Boiled white meat of a young fowl can
now usually be taken, and agreeable dishes can be prepared with milk,
beaten eggs, and farinaceous substances, such as arrowroot, rice,
corn-starch, tapioca, and sago. Boiled sweetbread is also admissible.
Boiled calf's brain and calf's feet are allowed by Leube at this stage
of the treatment.
To these articles can soon be added a very rare beefsteak made from the
soft mass scraped by a blunt instrument from a tenderloin of beef, so
that all coarse and tough fibres are left behind. This may be
superficially broiled with a little fresh butter. Boiled white fish,
particularly cod, may also be tried.
It is especially important to avoid all coarse, mechanically-irritating
food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty
substances, pastry, acids, highly-seasoned food, vegetables, fruit, and
all kinds of spirituous liquor. The juice of oranges and of lemons can
usually be taken. The food should not be taken very hot or very cold.
For at least two or three months the patient should be confined to the
{522} easily-digested articles of diet mentioned. These afford
sufficient variety, and no license should be given to exceed the
dietary prescribed by the physician. Transgression in this respect is
liable to be severely punished by return of the symptoms. When there is
reason to believe that the ulcer is cicatrized, the patient may
gradually resume his usual diet, but often for a long time, and perhaps
for life, he may be compelled to guard his diet very carefully, lest
there should be a return of the disease. Should there be symptoms of a
relapse, the patient should resume at once the easily-digested diet
described above.
Medicinal treatment of gastric ulcer, although less efficacious than
the dietetic treatment, is not to be discarded. Since its advocacy by
Ziemssen the administration of Carlsbad salts or of similarly composed
salts belongs to the systematic treatment of gastric ulcer. The objects
intended to be accomplished by the use of these salts are the daily
evacuation of the contents of the stomach into the intestine by gentle
stimulation of the gastric peristaltic movements, the neutralization of
the acid of the stomach, and the prevention of acid fermentations in
the stomach. Of these objects the most important is the prevention of
stagnation of the contents of the stomach. The chief ingredients of the
Carlsbad waters are sulphate of sodium, carbonate of sodium, and
chloride of sodium. The most important of these ingredients is sulphate
of sodium (Glauber's salts), which by exciting peristalsis propels the
gastric contents into the intestine, and thus relieves the stomach of
its burden, prevents fermentation, and removes from the surface of the
ulcer an important source of irritation. The carbonate of sodium
neutralizes the acids of the stomach, but the main value of this
ingredient and of the chloride of sodium is that in some way they
correct the action of the Glauber's salts, so that the latter may be
taken in smaller quantity and without the usual unpleasant effects of
pure Glauber's salts.[113] The artificial Carlsbad salts are to be
preferred to the natural or the artificial Carlsbad water. The natural
Carlsbad salts and much of those sold as artificial Carlsbad salts
consist almost wholly of sulphate of sodium. It is therefore best to
prescribe in proper proportion the leading ingredients of these salts.
A suitable combination is sulphate of sodium five ounces, bicarbonate
of sodium two ounces, and chloride of sodium one ounce
(Leichtenstern[114]). The relative proportion of the ingredients may of
course be varied somewhat to suit individual cases. The salts are to be
taken daily before breakfast dissolved in a considerable quantity of
warm water. One or two heaping teaspoonfuls of the salts are dissolved
in one-half to one pint of water warmed to a {523} temperature of 95°
F. One-fourth of this is to be drunk at a time at intervals of ten
minutes. Breakfast is taken half an hour after the last draught. After
breakfast there should follow one or two loose movements of the bowels.
If this is not the case, the next day the quantity of the salts is to
be increased, or if more movements are produced the quantity is to be
diminished until the desired result is obtained. In case the salts do
not operate, an enema may be used. Usually, to obtain the same effect,
the quantity of salts may be gradually diminished to a teaspoonful.
[Footnote 113: Water from the Sprudel spring contains in 16 ounces 18.2
grains of sulphate of sodium, 14.6 grains of bicarbonate of sodium, and
7.9 grains of chloride of sodium, and 11.8 cubic inches of carbonic
acid. Its natural temperature is 158° F. The other Carlsbad springs
have the same fixed composition and vary only in temperature and amount
of CO_{2}.]
[Footnote 114: The second edition of the German Pharmacopoeia contains
a formula for making artificial Carlsbad salts, so that the ingredients
are in about the same proportion as in the natural water. The formula
is as follows: Dried sulphate of sodium 44 parts, sulphate of potassium
2 parts, chloride of sodium 18 parts, bicarbonate of sodium 36 parts.
These should be mixed so as to make a white dry powder. The Carlsbad
water is imitated by dissolving 6 grammes of this salt in 1 liter of
water (_Pharmacopoeia Germanica_, editio altera, Berlin, 1882, p. 232).
According to a prescription very commonly used in Germany, the Carlsbad
salts are made by taking sulphate of sodium 50 parts, bicarbonate of
sodium 6 parts, chloride of sodium 3 parts. Dose, a teaspoonful
dissolved in one or two tumblers of warm water (Ewald u. Lüdecke,
_Handb. d. Allg. u. spec. Arzneiverordnungslehre_, Berlin, 1883, p.
480).]
The Carlsbad salts are directed especially against the chronic gastric
catarrh which complicates the majority of cases of ulcer of the
stomach. It is well known that the most effective method of treating
this morbid condition is the washing out of the stomach by means of the
stomach-tube. The propriety of adopting this procedure in gastric ulcer
comes, therefore, under consideration. Although the use of the
stomach-tube in gastric ulcer is discarded by Leube and by Sée on
account of its possible danger, nevertheless this instrument has been
employed with great benefit in many instances of this disease by
Schliep, Debore, and others.[115] No instance of perforation of an
ulcer by means of the stomach-tube has been reported, and in general no
evil effects have resulted; but Duguet cites a case of fatal hemorrhage
following washing out of the stomach.[116] In view of the great benefit
to be secured by washing out the stomach, and of the comparatively
slight danger which attends the process, it seems justifiable to adopt
this procedure cautiously and occasionally in cases of gastric ulcer
with severe gastric catarrh. Of course only the soft rubber tube should
be used, and the siphon process should be adopted.[117] The stomach may
be washed out with pure warm water or with water containing a little
bicarbonate of sodium (one-half drachm to a quart of water). The
occasional cleansing of the stomach in this way can hardly fail to
promote the healing of the ulcer. Recent or threatened hemorrhage from
the stomach would contraindicate the use of the stomach-tube.
[Footnote 115: Schliep, _Deutsch. Arch. f. klin. Med._, Bd. 13; Debore,
_L'Union méd._, Dec. 30, 1882; Bianchi, _Gaz. degli Ospitali_, March
26, 1884.]
[Footnote 116: _Gaz. des Hôp._, Apr. 29, 1884. In a case of gastric
ulcer of Cornillon severe hemorrhage followed washing out the stomach
(_Le Prog. méd._, Apr. 28, 1883).]
[Footnote 117: Soft rubber stomach-tubes are made by Tiemann & Co. in
New York, and are sold by most medical instrument-makers. A description
of the appropriate tube and of the method of its use is given by W. B.
Platt ("The Mechanical Treatment of Diseases of the Stomach," _Maryland
Medical Journal_, March 8, 1884).]
Beyond the measures indicated there is little more to do in the way of
treatment directed toward the repair of the ulcer. Not much, if
anything, is to be expected from the employment of drugs which have
been claimed to exert a specific curative action on the ulcer. Of these
drugs those which have been held in the greatest repute are bismuth and
nitrate of silver. Trousseau[118] devised a somewhat complicated plan
for administering bismuth and nitrate of silver in succession for
several months in the treatment of gastric ulcer. There are few who any
longer cherish any faith in these drugs as curative of gastric ulcer.
The same may be said of other drugs which have been thought to have
similar specific virtue in the treatment of gastric ulcer, such as
acetate of lead, arsenic, chloral hydrate, iodoform, etc.
[Footnote 118: _Clinique médicale_, t. iii. p. 95, Paris, 1865.]
{524} It remains to consider therapeutic measures which may be
necessary to combat individual symptoms of gastric ulcer.