adherence to the dietetic regimen which has been laid down. When this
is not the case, it may be best to withhold all food from the stomach
and to nourish by the rectum. But this cannot be continued long without
weakening the patient, and sometimes the pain persists in spite of the
rest afforded the stomach. Undoubtedly, the most effective means of
quieting the pain of gastric ulcer is the administration of opium in
some form. Opium should not, however, be resorted to without full
consideration of the possible consequences. When the use of this drug
is once begun, the patient is liable to become dependent upon it, and
may be inclined, consciously or unconsciously, to exaggerate the pain
in order to obtain the narcotic. When prescribing opium in this disease
the physician should have in mind the danger of establishing the opium
habit. Moreover, opium retards digestion, and is anything but an aid to
the proper dietetic regimen, which is all-important. If it is decided
to give opium, it does not matter much in what form it is administered,
but the dose should be as small as will answer the purpose. Hypodermic
injections of morphine over the region of the stomach may be
recommended. Codeia often produces less disturbance than opium or
morphine. A useful powder for the relief of pain is one containing 8 or
10 grains of subnitrate of bismuth, 1/12 grain of sulphate of morphia,
and 1/5 grain of extract of belladonna. Much of the beneficial effect
attributed to bismuth is in reality due to its customary combination
with a small quantity of morphine. Before resorting to opium in cases
of severe pain it will be well to try some of the other means for
relieving the pain of gastric ulcer, although they are less effective.
Gerhardt thinks that astringents are better than narcotics to relieve
the pain of ulcer, and he recommends for the purpose three or four
drops of solution of chloride of iron diluted with a wineglassful of
water, to be taken several times daily. Although this recommendation is
from high authority and is often quoted, sufficient confirmatory
evidence of its value is lacking. Other medicines recommended are
hyoscyamus, belladonna, choral hydrate, chloric ether, hydrocyanic
acid, bismuth, nitrate of silver, and compound kino powder. Sometimes
warm fomentations, at other times a light ice-bag over the epigastrium,
afford marked relief of the pain. Counter-irritation over the region of
the stomach has also given relief. This may be effected with a mustard
plaster or by croton oil. I have known the establishment of a small
nitric-acid issue in the pit of the stomach to relieve the pain, but
such severe measures of counter-irritation are generally unnecessary.
The application of a few leeches over the epigastrium has been highly
recommended, but this should be done without much loss of blood. The
effect of position of the body upon the relief of pain should be
determined. When the pain is due to flatulence or to acid fermentation
in the stomach, the treatment should be directed to those states.
The most effective means of controlling the vomiting in gastric ulcer
are the regulation of the diet and, if necessary, the resort to rectal
alimentation. Absolute rest should be enjoined. Whenever small
quantities of milk, peptonized or in any other form, cannot be
retained, then exclusive rectal feeding may be tried for a while. There
have been cases of gastric {525} ulcer when both the stomach and the
rectum have been intolerant of food. In such desperate cases the
attempt may be made to introduce food into the stomach by means of the
stomach-tube, for it is a singular fact that food introduced in this
way is sometimes retained when everything taken by the mouth is
vomited.[119] The cautious washing out of the stomach by the
stomach-tube may prove beneficial. In these cases the attempt has also
been made to nourish by subcutaneous injections of food. In a case of
gastric ulcer where no food could be retained either by the stomach or
by the rectum Whittaker[120] injected subcutaneously milk,
beef-extract, and warmed cod-liver oil. The oil was best borne. The
injections were continued for four days without food by the mouth or
rectum. The patient recovered. At the best, hypodermic alimentation can
afford but slight nourishment, and is to be regarded only as a last
refuge. If there is danger of death by exhaustion, transfusion may be
resorted to.
[Footnote 119: Debore, _L'Union médicale_, Dec. 30, 1882, and _Gaz. des
Hôp._, April 29, 1884. For this reason Debore makes extensive use of
the stomach-tube in general in feeding patients affected with gastric
ulcer. He objects to an exclusive milk diet on account of the quantity
of fluid necessary to nourish the patient, which he says amounts to
three to four quarts of milk daily. To avoid these inconveniences, he
gives three times daily drachm viss of meat-powder and drachm iiss of
bicarbonate of sodium (or equal parts of calcined magnesia and bicarb.
sod.), well stirred into milk. This is to be introduced by the
stomach-tube on account of its disagreeable taste. He believes that the
addition of the large quantity of alkali prevents digestion from
beginning until the food has reached the intestine. He also gives daily
a quart of milk containing grs. xv of saccharate of lime. Debore's
method of preparing the meat-powder is described in _L'Union médicale_,
July 29, 1882, p. 160. He also uses a milk-powder (_ibid._, Dec. 30,
1882; see also _Le Progrès méd._, July 12, 1884).]
[Footnote 120: J. T. Whittaker, "Hypodermic Alimentation," _The
Clinic_, Jan. 22, 1876.
Bernutz practised successfully in two cases the hypodermic injection of
fresh dog's blood (_Gaz. des Hôp._, 1882, No. 64).
Krueg (_Wiener med. Wochenschr._, 1875, No. 34) injected 15 cc. of
olive oil twice a day subcutaneously without causing abscesses.
Menzel and Porco were the first to employ hypodermic alimentation
(_ibid._, 1869, No. 31).]
Of remedies to check vomiting, first in importance are ice swallowed in
small fragments and morphine administered hypodermically. Effervescent
drinks, such as Vichy, soda-water, and iced champagne, may bring
relief. Other remedies which have been recommended are bismuth,
hydrocyanic acid, oxalate of cerium, creasote, iodine, bromide of
potash, calomel in small doses, and ingluvin. But in general it is best
to forego the use of drugs and to rely upon proper regulation of the
diet, such as iced milk taken in teaspoonful doses, and upon repose for
the stomach.
Hemorrhage from the stomach is best treated by absolute rest, the
administration of bits of ice by the mouth, and the application of a
flat, not too heavy, ice-bag over the stomach. The patient should lie
as quietly as possible in the supine position, with light coverings and
in a cool atmosphere. He should be cautioned to make no exertion. His
apprehensions should be quieted so far as possible. All food should be
withheld from the stomach, and for four or five days after the
cessation of profuse hemorrhage aliment should be given only by the
rectum. There is no proof that styptics administered by the mouth have
any control over the hemorrhage, and as they are liable to excite
vomiting they may do harm. Ergotin, dissolved in water (1 part to 10),
may be injected hypodermically in grain doses several times repeated if
necessary. If internal styptics {526} are to be used, perhaps the best
are alum-whey and a combination of gallic acid 10 grains and dilute
sulphuric acid 10 drops diluted with water. Fox praises acetate of
lead, and others ergot, tannin, and Monsell's solution. If there is
vomiting or much restlessness, morphine should be given hypodermically.
If the bleeding is profuse, elastic ligatures may be applied for a
short time around the upper part of one or more extremities, so as to
shut out temporarily from the circulation the blood contained in the
extremity. If syncope threatens, ammonia or a little ether may be
inhaled, or ether may be given hypodermically. Brandy, if administered,
should be given either by the rectum or hypodermically. Caution should
be exercised not to excite too vigorously the force of the circulation,
as the diminished force of the heart is an important agent in checking
hemorrhage. When life is threatened in consequence of the loss of
blood, then recourse may be had to transfusion, but experience has
shown that this act is liable to cause renewed hemorrhage in
consequence of the elevation of the blood-pressure which follows it.
Transfusion is therefore indicated more for the acute anæmia after the
hemorrhage has ceased and is not likely to be renewed. It should not be
employed immediately after profuse hæmatemesis, unless it is probable
that otherwise the patient will die from the loss of blood, and then it
is well to transfuse only a small quantity.[121]
[Footnote 121: Michel transfused successfully in a case of extreme
anæmia following gastrorrhagia (_Berl. klin. Wochenschr._, 1870, No.
49). In a case of profuse and repeated hæmatemesis which followed
washing out the stomach Michaelis infused into the veins 350 cc. of
solution of common salt. Reaction gradually followed, and the patient
recovered. This case, which was one of probable ulcer, illustrates the
advantages of infusing a small quantity (_ibid._, June 23, 1884). The
dangers are illustrated by a case reported by V. Hacker, who infused
1500 cc. of salt solution in a patient in a state of extreme collapse
resulting from hemorrhage from gastric ulcer. The patient rallied, but
he died three hours after the infusion from renewed hemorrhage (_Wiener
med. Wochenschr._, 1883, No. 37). In Légroux's case of gastric ulcer
renewed hemorrhage and death followed the transfusion of only 80
grammes of blood (_Arch. gén. de Méd._, Nov., 1880). In a case quoted
by Roussel, Leroy transfused 130 grammes of blood in a girl twenty
years old who lay at the point of death from repeated hemorrhages from
a gastric ulcer. In the following night occurred renewed hemorrhage and
death (_Gaz. des Hôp._, Sept. 22, 1883). According to the experiments
of Schwartz and V. Ott, the transfusion, or rather infusion, of
physiological salt solution is as useful as that of blood, and it is
simpler and unattended with some of the dangers of blood-transfusion.
The formula is chloride of sodium 6 parts, distilled water 1000.]
Schilling recommends, when the bleeding is so profuse that the
patient's life is threatened, to tampon the stomach by means of a
rubber balloon attached to the end of a soft-rubber stomach-tube.[122]
The external surface of the balloon is slightly oiled. It is introduced
into the stomach in a collapsed state, and after its introduction it is
moderately distended with air. When the balloon is to be withdrawn the
air should be allowed slowly to escape. Schilling tried this procedure
in one case of hemorrhage from gastric ulcer, allowing the inflated bag
to remain in the stomach twelve minutes. The hemorrhage ceased and was
not renewed. Experience only can determine whether this device, to
which there are manifest objections, will prove a valuable addition to
our meagre means of controlling hemorrhage from the stomach.
[Footnote 122: F. Schilling, _Aerztl. Intelligenzbl._, Jan. 8, 1884.
Schreiber, in order to determine the position of the stomach, was the
first to introduce and inflate in this organ a rubber balloon
(_Deutsches Arch. f. klin. Med._, June 5, 1877). Uhler recommends in
case of profuse gastric hemorrhage to pass a rubber bag into the
stomach and fill it with liquid (_Maryland Med. Journ._, Aug. 30, 1884,
p. 347).]
{527} The boldest suggestion ever made for stopping gastric hemorrhage
is that of Rydygier, who advocates in case hemorrhage from an ulcer
threatens to be fatal to cut down upon the stomach, search for the
bleeding ulcer, and then resect it.[123] Notwithstanding the great
advances made in gastric surgery during the last few years, Rydygier's
suggestion seems extravagant and unwarrantable.
[Footnote 123: _Berl. klin. Wochenschr._, Jan. 16, 1882.]
The most effectual treatment of the dyspepsia which is present in many
cases of gastric ulcer is adherence to the dietetic rules which have
been laid down, aided by the administration of Carlsbad salts and
perhaps in extreme cases the occasional and cautious use of the
stomach-tube. If eructations of gas and heartburn are troublesome,
antacids may be employed, but they should be given in small doses and
not frequently, as the ultimate effect of alkalies is to increase the
acid secretion of the stomach and to impair digestion. The best alkali
to use is bicarbonate of sodium, of which a few grains may be taken dry
upon the tongue or dissolved in a little water.
If perforation into the peritoneal cavity occur, then opium or
hypodermic injections of morphine should be given in large doses, as in
peritonitis. Bran poultices sprinkled with laudanum or other warm
fomentations should be applied over the abdomen, although in Germany
ice-bags are preferred. Food should be administered only by the rectum.
The chances of recovery are extremely slight, but the patient's
sufferings are thus relieved. In view of the almost certainly fatal
prognosis of perforation of gastric ulcer into the general peritoneal
cavity, and in view of the success attending various operations
requiring laparotomy, it would seem justifiable in these cases, after
arousing, if possible, the patient from collapse by the administration
of stimulants per rectum or hypodermically, to open the peritoneal
cavity and cleanse it with some tepid antiseptic solution, and then to
treat the perforation in the stomach and the case generally according
to established surgical methods.[124] This would be the more indicated
if it is known that the contents of the stomach at the time of
perforation are not of a bland nature.
[Footnote 124: Mikulicz has successfully treated by laparotomy a case
of purulent peritonitis resulting from perforation of the intestine
with extravasation of the intestinal contents. He says that the
operation is not contraindicated by existing peritonitis if the patient
is not already in a state of collapse or sepsis. The perforation is
closed by sutures after freshening the edges of the opening (abstract
in the _Medical News_, Philada., Sept. 6, 1884). Both Kuh and Rydygier
recommend opening the abdomen after perforation of gastric ulcer. The
borders of the ulcer are to be resected and the opening closed by
sutures (_Volkmann's Samml. klin. Vorträge_, No. 220, p. 12).]
It is important to maintain and to improve the patient's nutrition,
which often becomes greatly impaired from the effects of the ulcer.
This indication is not altogether compatible with the all-important one
of reducing to a minimum the digestive work of the stomach.
Nevertheless, some of the easily-digested articles of food which have
been mentioned are highly nutritious. By means of these and by good
hygienic management the physician should endeavor, without violating
the dietetic laws which have been laid down, to increase, so far as
possible, the strength of his patient. Starvation treatment in itself
is never indicated in gastric ulcer. Inunction of the body with oil is
useful in cases of gastric ulcer, as recommended by Pepper.[125]
[Footnote 125: _North Carolina Medical Journal_, 1880, vol. v. p. 5.]
{528} In view of Daettwyler's experiments, mentioned on page 514, it is
manifestly important to counteract the anæmia of gastric ulcer. Iron,
however, administered by the mouth, disturbs the stomach and is
decidedly contraindicated during the active stage of gastric ulcer.
During convalescence, only the blandest preparations of iron should be
given, and these not too soon, lest they cause a relapse. When the
indication to remove the anæmia is urgent, and especially when the
chlorotic form of anæmia exists, it may be well to try the hypodermic
method of administering iron, although this method has not yet been
made thoroughly satisfactory. Especially for the anæmia of gastric
ulcer would an efficient and unirritating preparation of iron for
hypodermic administration prove a great boon. Probably at present the
best preparation for hypodermic use is the citrate of iron, given in
one- to two-grain doses in a 10 per cent. aqueous solution, which when
used must be clear and not over a month old. The syringe and needle
shortly before using should be washed with carbolic acid. The
injections are best borne when made into the long muscles of the back
or into the nates, as recommended by Lewin for injections of corrosive
sublimate. A slight burning pain is felt for ten minutes after the
injection. This is the method employed by Quincke with good result and
without inflammatory reaction.[126] It is well to remember that
Kobert[127] has found by experiment on animals that large doses of iron
injected subcutaneously cause nephritis. Other preparations of iron
which have been recommended for hypodermic use are ferrum dialysatum
(DaCosta), ferrum pyrophosphoricum cum natr. citrico (Neuss), ferrum
pyrophosphoricum cum ammon. citr. (Huguenin), ferrum peptonatum and
ferrum oleinicum (Rosenthal).[128] When it becomes safe to administer
iron by the stomach, then the blander preparations should be used, such
as the pyrophosphate, lactate, effervescing citrate, ferrum redactum.
Leube recommends the following prescription: Ferr. redact. gr. 80,
Pulv. althææ gr. 60, Gelatin q. s.; make 90 pills: at first one, and
afterward as many as three, of these pills may be taken three times a
day. When carefully prepared the pills are about as soft as butter.
[Footnote 126: Quincke, _Deutsch. Arch. f. klin. Med._, Bd. xx. p. 27;
Glaenecke, _Arch. f. exper. Path. u. Pharm._, Bd. 17, p. 466.]
[Footnote 127: _Arch. f. exper. Path. u. Pharm._, Bd. 16.]
[Footnote 128: DaCosta, _N.Y. Med. Record_, vol. xiii. p. 290; Neuss,
_Zeitschrift f. klin. Med._, Bd. 3, p. 1; Huguenin, _Correspondenzbl.
f. Schweiz. Aerzte_, 1876, No. 11; Rosenthal, _Wiener med. Presse_,
1878, Nos. 45-49, and 1884, Jan. 20.]
Various sequels of gastric ulcer may require treatment. Cicatrization
of the ulcer is by no means always cure in the clinical sense. As the
result of adhesions and the formation and contraction of cicatricial
tissue very serious disturbances of the functions of the stomach may
follow the repair of gastric ulcer. The most important of these sequels
is stenosis of the orifices of the stomach, particularly of the pyloric
orifice. Very considerable stenosis of the pylorus may be produced
before the ulcer is completely cicatrized. In three instances a
stenosing ulcer of the pylorus has been successfully extirpated.[129]
The most important of these sequels {529} of gastric ulcer will be
treated of hereafter. Here it need only be said that during
convalescence from gastric ulcer attention to diet is all-important.
For a long time the diet should be restricted to easily-digested food.
The first symptoms of relapse are to be met by prompt return to bland
diet, or, if necessary, to rectal alimentation.
[Footnote 129: The successful operators were Rydygier (_Berl. klin.
Wochenschr._, Jan. 16, 1882), Czerny (_Arch. f. klin. Chir._, Bd. xxx.
p. 1), and Van Kleef (_Virchow u. Hirsch's Jahresbericht_, 1882, Bd.
ii. p. 383). Cavazzani cut out by an elliptical incision an old
indurated ulcer of the stomach adherent to the anterior abdominal
walls. The patient died three years afterward of phthisis (_Centralbl.
f. Chir._, 1879, p. 711). Lauenstein resected the pylorus
unsuccessfully for what appears to have been an ulcer of the pylorus
with fibroid induration around it (_ibid._, 1882, No. 9). These four
cases (three successful) are all which I have found recorded of
resection of gastric ulcer. In my opinion the resection of gastric
ulcers which resist all other methods of treatment, and especially
those which cause progressive stricture of the pylorus, is a
justifiable operation.]
Addendum.
Ulcers of the stomach which do not belong to the category of simple
ulcer are for the most part of pathological rather than of clinical
interest.
Although miliary tubercles in the walls of the stomach are more
frequent than is generally supposed, genuine tuberculous ulcers of the
stomach are not common. The most important criterion of these ulcers is
the presence of tuberculous lymphatic glands in the neighborhood, and
of miliary tubercles upon the peritoneum corresponding to the ulcer.
Sometimes miliary tubercles can be discovered in the floor and sides of
the ulcer. Tuberculous gastric ulcers, when they occur, are usually
associated with tuberculous ulceration of the intestine. In an
undoubted case of tuberculous ulcer of the stomach reported by Litten,
however, this was the only ulcer to be found in the digestive
tract.[130] Tuberculous gastric ulcers generally produce no symptoms,
but they have been known to cause perforation of the stomach and
hæmatemesis. Many cases which have been recorded as tuberculous ulcers
of the stomach were in reality simple ulcers. Cheesy tubercles as large
as a pea, both ulcerated and non-ulcerated, have been found in the
stomach, but they are very rare.
[Footnote 130: Litten, _Virchow's Archiv_, Bd. 67, p. 615.]
Typhoid ulcers may also occur in the stomach, but they are infrequent.
Both perforation of the stomach and gastrorrhagia have been caused by
typhoid ulcers, which, as a rule, however, produce no symptoms
distinctly referable to the ulcer.
Syphilitic ulcers and syphilitic cicatrices of the stomach have been
described, without sufficient proof as to their being syphilitic in
origin.
Necrotic ulcers, probably mycotic in origin, may be found in the
stomach in cases of splenic fever, erysipelas, pyæmia, etc.
Ulceration occurring in toxic, in diphtheritic, and in phlegmonous
gastritis need not be discussed here.
Follicular and catarrhal ulcers of the stomach have been described, but
without sufficient ground for separating them from hemorrhagic erosion
on the one hand and simple ulcer on the other.
Hemorrhagic erosions of the stomach, to which formerly so much
importance was attached, are now believed to be without clinical
significance. They are found very frequently, and often very
abundantly, after death from a great variety of causes.
{530}
CANCER OF THE STOMACH.
BY W. H. WELCH, M.D.
DEFINITION.--Cancer of the stomach is characterized anatomically by the
formation in this organ of a new growth, composed of a
connective-tissue stroma so arranged as to enclose alveoli or spaces
containing cells resembling epithelial cells. The growth extends by
invading the tissues surrounding it, and frequently gives rise to
secondary cancerous deposits in other organs of the body. The forms of
cancer which occur primarily in the stomach are scirrhous, medullary,
colloid, and cylindrical epithelial cancer. The disease develops
usually in advanced life. Rarely latent, occasionally without symptoms
pointing to the stomach as the seat of disease, gastric cancer is
usually attended by the following symptoms: loss of appetite,
indigestion, vomiting with or without admixture with blood, pain, a
tumor in or near the epigastric region, progressive loss of flesh and
strength, and the development of the so-called cancerous cachexia. The
disease is not curable. After its recognition it rarely lasts longer
than from twelve to fifteen months.
SYNONYMS.--Carcinoma ventriculi; Malignant disease of the stomach. Of
the many synonyms for the special forms of cancer, the most common
are--for scirrhous, hard, fibrous; for medullary, encephaloid, soft,
fungoid; for colloid, gelatinous, mucoid, alveolar; and for cylindrical
epithelial, cylindrical-celled or cylindrical or columnar epithelioma,
cylindrical-celled cancroid, destructive adenoma.
HISTORY.--Cancer of the stomach was known to the ancients only by
certain disturbances of the gastric functions which it produces. The
disease itself was not clearly appreciated until its recognition by
post-mortem examinations, which began to be made with some frequency
after the revival of medicine in the sixteenth century. During the
seventeenth and eighteenth centuries several instances of gastric
cancer are recorded, the best described being those observed and
collected by Morgagni (1761). During this period scirrhus was regarded
as the type of cancerous disease. It was a common custom to call only
the ulcerated scirrhous tumors cancerous.