incompressible hard-rubber tube like that employed with the
stomach-pump, but by far the simplest, most convenient, and safest form
of stomach-tube is the soft, flexible, red rubber tube, resembling the
Jacques catheter, but of course larger and longer.[31] This soft tube
can inflict no {606} injury, and in most cases it is readily
introduced. Generally, the patient himself can best manipulate the
introduction of the tube. After the tube is introduced into the
pharynx, the patient, who should be in a sitting posture, makes
repeated acts of swallowing, by means of which, accompanied by
directing and gently pushing the tube with the fingers, the tube passes
along the oesophagus into the stomach. Often at first the nervousness
and inexperience of the patient occasion some trouble, but after a
little practice he generally succeeds in introducing the tube without
discomfort or difficulty. Before its introduction the tube should be
anointed with a little vaseline or some similar substance. In an adult
the tube is introduced for a length of at least 20 to 25 inches, and in
cases of dilatation of the stomach of course for a greater distance.
Whatever form of stomach-tube be used, it is important that the tube
should be at least 30 inches long, and should be provided with one, and
preferably with two, large eyes at its distal extremity.
[Footnote 31: Such a tube (marked 19 A) is made by Tieman & Co. of New
York, and is to be had of most surgical instrument-makers. (For a
fuller description of the tube and the mode of its employment see
article by W. B. Platt, "The Mechanical Treatment of Diseases of the
Stomach," _Maryland Medical Journal_, March 8, 1884.)
Oser's tube is 2 meters long, and is made of mineralized rubber. There
are two sizes. The smaller has a lumen of 8 mm. The thickness of the
wall is 2½ mm. In the larger tube the lumen is 10 mm., and the
thickness of the wall 3 mm. He generally uses the smaller tube.
Faucher's tube is 1½ meters long. The external diameter of the tube is
10 to 12 mm. The walls are of such thickness that the tube can be bent
without effacing its lumen. At one extremity is a lateral eye with two
orifices. To the other extremity is adapted a funnel with a capacity of
about 500 grammes.]
Although the stomach-pump has the advantage of more completely
evacuating the stomach and of removing coarser solid particles than is
possible with the siphon, nevertheless its disadvantages--namely, the
possibility of inflicting injury to the mucous membrane of the
stomach,[32] the expense and greater complexity of the instrument, and
the circumstance that it should be used only by the physician--in
contrast with the advantages of the siphon--namely, its cheapness,
simplicity, safety, and possible employment by the patient or his
attendants--have led to the general adoption of the latter process.
Only the soft-rubber stomach-tube should be left to the employment of
the patient.
[Footnote 32: A number of cases have been recorded in which pieces of
the mucous membrane of the stomach have been detached by the
stomach-pump. Although as yet no serious effects have followed this
accident, the possibility of its occurrence can certainly not be
regarded with equanimity.]
Sometimes the flow through the siphon is interrupted by occlusion of
the eye of the stomach-tube by a solid mass or by some cause not always
clear. As already mentioned, it is desirable that there should be two
openings at the gastric extremity of the tube. When the flow is {607}
interrupted the position of the tube in the stomach may be changed, or
the patient may be directed to cough or to exert the pressure of the
abdominal muscles, or more water may be allowed to run into the stomach
in order to displace an occluding mass in the tube. It is, however,
well for such cases to have, if possible, a stomach-pump and an
incompressible tube in reserve. Moreover, as is apparent from the
foregoing statement of the advantages of the stomach-pump, there are
cases in which this instrument is much more useful than the siphon, so
that one cannot decide unconditionally in favor of one instrument over
the other.
The stomach-tube should be secured so that there can be no possibility
of its being swallowed entirely. A string may be attached to the distal
end of the tube. Leube[33] has reported an instance in which the whole
tube disappeared into the stomach, and Jackson[34] has also narrated a
case in which an insane patient swallowed the stomach-tube. In both
cases the tube was subsequently rejected by vomiting.
[Footnote 33: _Deutsches Arch. f. klin. Med._, Bd. 33, p. 6.]
[Footnote 34: _Extracts from the Records of the Boston Society for
Medical Improvement_, vol. vi. p. 261.]
For washing out the stomach after the greater part of the contents have
been withdrawn, about a pint of tepid fluid is allowed to slowly run
into the stomach, and is then siphoned out. This process is to be
repeated several times. In general, tepid water suffices for washing
out the stomach, but it is often better to use, at least a part of the
time, a 1 to 2 per cent. solution of bicarbonate of sodium, which
facilitates the removal of mucus. The artificial and the natural Vichy
and Carlsbad waters are also excellent for this purpose. Various
additions are also made to the water with the view of counteracting
fermentative changes in the stomach. For this purpose perhaps the best
agents are salicylate of sodium (1 per cent. solution) or resorcin (2
per cent. solution). Other substances which have also been recommended
are carbolic acid, permanganate of potassium, hyposulphite of sodium,
creasote, benzine. Simple water, however, accomplishes about all that
is possible, and many are satisfied to use it without any medication.
As regards the frequency with which the stomach is to be washed out,
one is to be guided by the symptoms and the effect obtained by the use
of the stomach-tube. As a general rule, it suffices to wash out the
stomach once a day, and often the process need be repeated only every
second or third day.
Opinions are divided as to the best time of day to select for washing
out the stomach. Kussmaul recommends the morning before breakfast, and
the majority have followed his advice; others prefer the evening. There
is much, however, in favor of washing out the stomach about half an
hour before the principal meal of the day. The best opportunity has
been offered for the digestion and absorption of the food taken at the
previous main meal, and the stomach is placed in the best possible
condition for the reception of more food.
The habitual washing out of the stomach is not without its drawbacks.
We often remove, as has been pointed out especially by Leube, not only
noxious substances from the stomach, but also the completed products of
digestion. To withdraw from the nourishment of the body this chyme
which the stomach has laboriously manufactured cannot be a matter of
indifference. Still, with the weakened absorptive powers of the
stomach, {608} and its inability to properly propel its contents into
the intestine, it is a question how much of this chyme would eventually
be utilized for nutrition. Another point is worthy of attention. The
relief which the patient experiences when his overloaded stomach is
freed of its burden, and the knowledge that this method of relief is
always at hand, may make him careless in the observance of the dietetic
rules which are of great importance in the treatment of this disease.
It is well, therefore, not to wash out the stomach oftener than is
necessary, nor to continue the habitual use of the stomach-tube longer
than is required.
There are contraindications to the use of the stomach-tube. In very
rare instances the attempt to introduce the tube causes the patient so
much distress, produces such violent spasm of the pharyngeal and
adjacent muscles, or induces so much retching and vomiting, or is
attended with such prostration or even syncope, that this method of
treatment has to be abandoned. Great weakness, recent gastric
hemorrhage, ulcer of the stomach in most cases (see page 523), often
cancer of the cardia or of the oesophagus, and aneurism of the aorta,
are contraindications to the use of the stomach-tube.
If we group together the results obtained by the use of the
stomach-tube in gastric dilatation, we shall find cases in which no
benefit results; cases which are benefited, but are obliged to continue
the use of the stomach-tube throughout life; cases in which recovery is
slow and gradual; cases with more or less speedy relief or apparent
cure, but followed by relapses; and cases of prompt relief and
permanent cure.
The regulation of the diet is never to be neglected in cases of
dilatation of the stomach. Here the guiding principles are that little
fluid should be taken, and that the food should be small in bulk,
nutritious, easily digestible, and not readily undergoing fermentation.
The patient should drink as little water as possible, and should
therefore avoid whatever occasions thirst. It is hardly practicable to
carry out the plan of giving water mostly by the rectum, as has been
proposed. In most cases milk is useful, but an exclusively milk diet is
not generally well borne on account of the quantity of fluid required.
Leube's beef-solution is often serviceable. Soft-boiled eggs and tender
meats are to be allowed, particularly the white meat of fowl and rare
beefsteak, especially that prepared from scraped and finely-chopped
beef, as recommended in the treatment of gastric ulcer (page 521).
Fatty, saccharine, and amylaceous articles of food--hence most
vegetables and fruits--are to be avoided on account of their tendency
to undergo fermentation in the stomach. Alcohol in any form is usually
detrimental. If gastric symptoms, particularly vomiting, be very
urgent, or if food introduced into the stomach affords little or no
nourishment, as in some cases of tight pyloric stricture, then rectal
alimentation is to be resorted to.
An important indication is to restore the tone and contractile power of
the muscular coat of the stomach. For this purpose electricity, in the
form both of the constant and of the faradic current, has been
beneficially employed. The best results are reported from the use of
the faradic current. Both poles may be applied over the region of the
stomach. The application of electricity to the inside of the stomach by
means of electrodes attached to stomach-tubes or bougies is a more
{609} difficult procedure, but has its advocates. Uniformly good
results are not obtained by the use of electricity in gastric
dilatation, but there can be no doubt that in some cases decided
benefit follows this method of treatment.
Nux vomica, particularly its alkaloid strychnia, has been much employed
with the view of stimulating the muscular power of the stomach.
Strychnia is given either internally or hypodermically. Hypodermic
injections of ergotin have also been used for the same purpose. It has
been hoped to increase the contraction of the stomach by cold
applications to the abdomen, as by ice-bags applied immediately after
washing out the stomach. The benefit derived from these various
attempts to increase the tonicity of the gastric muscle is not very
apparent.
A belt or bandage around the abdomen in order to support the stomach
sometimes makes the patient feel more comfortable; in other cases it
aggravates the symptoms.
In many cases digestion is promoted by giving dilute hydrochloric acid
with or without pepsin. About ten drops of dilute hydrochloric acid may
be given half an hour to an hour after each meal.
When the stomach is systematically washed out, the individual symptoms
of dilatation of the stomach will rarely require special treatment. The
sensation of fulness and weight in the stomach, the eructations, the
vomiting, and the constipation are generally relieved, at least
temporarily, by washing out the stomach. The appetite is improved, and
an increase in weight is usually soon noticeable.
If heartburn and eructations of gas continue troublesome, an antacid,
such as bicarbonate of sodium or prepared chalk, will be found useful.
Leube, in order to relieve constipation and to increase the peristalsis
of the stomach, administers Carlsbad water (see page 522). Not more
than five or six ounces of the water need be given, and this should be
taken slowly in divided doses. A laxative pill containing rhubarb may
be given occasionally.
If anæmia be the cause or a prominent accompaniment of dilatation of
the stomach, iron may be administered in a form as little disturbing
the digestion as possible, as the effervescing citrate or the lactate,
or arsenic in the form of Fowler's solution may be tried. In general,
however, all drugs which impair the appetite or digestion are to be
withheld. The digestion and the general condition of the patient are
often benefited by massage.
Resection of the pylorus in cases of cancerous and of cicatricial
stenosis of this orifice has been performed in several instances. The
subject, as regards its medical in distinction from its surgical
bearings, has already been discussed in connection with cancer of the
stomach (see page 577). Here it may be added that the propriety of
resection is less open for dispute in cases of non-cancerous pyloric
stenosis than it is in cancer of the pylorus.
Remarkable results have been reported by Loreta in cases of cicatricial
stenosis of the pylorus. After performing gastrotomy he inserts his
fingers through the constricted pyloric orifice and forcibly dilates
the stricture.[35] To judge from experience in divulsing strictures in
other parts of {610} the body, it does not seem probable that a
permanent cure can be often effected by this bold and dangerous
procedure.
[Footnote 35: Loreta has performed this operation successfully no less
than nine times (_The Lancet_, April 26, 1884).]
Acute Dilatation of the Stomach.
Under the name acute dilatation of the stomach[36] have been described
cases in which it has been supposed that a more or less suddenly
developed paralysis of the muscular coat of the stomach exists. But the
propriety of the term acute dilatation, and the very existence of an
acute paralysis of the stomach, are, to say the least, questionable.
[Footnote 36: The literature pertaining to the subject of acute
dilatation of the stomach is to be found in Poensgen, _Die Motorischen
Verrichtungen des Menschlichen Magens_, Strasburg, 1882, p. 95.]
As causes of this so-called acute dilatation of the stomach have been
assigned injuries, particularly those affecting the abdomen, surgical
operations involving the peritoneum, acute inflammations of the mucous
and of the peritoneal coats of the stomach, acute fevers, especially
during convalescence, and overloading the stomach with food or with
liquids.
The symptoms which have been chiefly emphasized are severe abdominal
pain, tympanitic distension of the stomach, and absence or cessation of
vomiting if this has previously existed. It will be noted that
inability to vomit under these circumstances implies not only paralysis
of the stomach, but also that of the abdominal muscles.
The prognosis depends on the character of the primary disease causing
the alleged paralysis.
If there be acute distension of the stomach with inability of the organ
to expel its contents either externally or into the intestine, the
stomach-tube may be employed to evacuate the gas and other material
present.
In a case described by Hilton Fagge[37] as acute dilatation of the
stomach the symptoms of dilatation appeared suddenly and ran an acute
course, but the autopsy showed that the dilatation was doubtless of
much longer development than the symptoms indicated. In a case reported
by Nauwerk[38] of extreme dilatation in consequence of hypertrophic
stenosis of the pylorus, after ten months of insignificant dyspeptic
symptoms there suddenly appeared, after excess in eating, symptoms of
dilatation of great severity, which continued until a fatal termination
at the end of three months. Thus it appears that chronic dilatation of
the stomach may cause little disturbance for a considerable time and
then run a rapid course.
[Footnote 37: "On Acute Dilatation of the Stomach," _Guy's Hosp. Rep._,
xviii. p. 4, 1873.]
[Footnote 38: _Deutsches Arch. f. kl. Med._, Bd. xxi. p. 573.]
{611}
MINOR ORGANIC AFFECTIONS OF THE STOMACH.
(CIRRHOSIS; HYPERTROPHIC STENOSIS OF PYLORUS; ATROPHY; ANOMALIES IN THE
FORM AND THE POSITION OF THE STOMACH; RUPTURE; GASTROMALACIA.)
BY W. H. WELCH, M.D.
CIRRHOSIS OF THE STOMACH.
DEFINITION.--Cirrhosis of the stomach is characterized by thickening of
the walls of the greater part or of the whole of the stomach in
consequence of a new growth of fibrous tissue, combined usually with
hypertrophy of the muscular layers of the stomach. The cavity of the
stomach is usually contracted, but sometimes it is of normal size or
even dilated.
SYNONYMS.--Fibroid induration of the stomach; Hypertrophy of the walls
of the stomach; Chronic interstitial gastritis; Sclerosis of the
stomach; Plastic linitis.
HISTORY.--The writings of the seventeenth and eighteenth centuries
contain many records of extremely contracted stomachs with uniformly
and greatly thickened walls (Butzen, Löseke, Storck, Portal, Lieutaud,
Pohl, etc.). In the works of Lieutaud and of Voigtel may be found
references to many such cases.[1] Doubtless, some of these cases were
examples of cirrhosis of the stomach, but in the absence of
microscopical examination it is not possible to separate these from
cancer.
[Footnote 1: Lieutaud, _Historia anat.-med._, t. i. p. 8, Venet., 1779;
Voigtel, _Handb. d. Path. Anat._, Bd. ii. p. 450, Halle, 1804. Here it
may be mentioned that Diemerbroeck's case, which is so often quoted to
prove that polyphagia instead of causing gastric dilatation may produce
hypertrophy of the muscular coat of the stomach, with contraction, was
probably an instance of cirrhosis of the stomach.]
Andral[2] was the first to describe fully and systematically
hypertrophy of the walls of the stomach. He attributed the lesion to
chronic inflammation. He erroneously supposed that scirrhus of the
stomach was only hypertrophy of the gastric walls. Cruveilhier[3]
distinguished between scirrhous induration and hypertrophy, which he
considered to be a final result of the irritation accompanying chronic
diseases of the stomach. Rokitansky's[4] description of fibroid
induration of the stomach, although brief, is accurate. He says that
the process usually involves the whole {612} stomach, and that it
originates in an inflammation of the submucous connective tissue. This
inflammation may occur either independently or in combination with
gastritis mucosa. Rokitansky emphasizes the error of confounding the
disease with scirrhous cancer. Bruch[5] made an elaborate study of
hypertrophy of the walls of the stomach, which he considered to be the
final stage of various chronic diseases of the stomach. Fibrous or
scirrhous cancer he considered to be nothing but this hypertrophy.
[Footnote 2: _Précis d'Anat. path._, Paris, 1829.]
[Footnote 3: _Anatomie pathologique_, Paris, 1830-42.]
[Footnote 4: _Lehrb. d. Path. Anat._, Wien, 1855-61.]
[Footnote 5: _Zeitschr. f. rat. Med._, Bd. vii., 1849.]
The best descriptions of cirrhosis of the stomach have been furnished
by English writers, by most of whom it is properly regarded as an
independent disease. Brinton[6] first employed the names cirrhosis of
the stomach and plastic linitis. Excellent descriptions of the disease
have been given by Hodgkin, Budd, Brinton, Habershon, H. Jones, Wilks,
Quain, and Smith.
[Footnote 6: _Diseases of the Stomach_.]
While in former times cirrhosis of the stomach was confounded with
cancer, in recent times it has not been separated by many from chronic
catarrhal gastritis. In German systematic works the disease receives,
as a rule, only passing mention in connection with chronic catarrhal
gastritis.
ETIOLOGY.--Cirrhosis of the stomach is rare, but it is not so
exceptional as to be without any clinical importance. I have met with
three cases at post-mortem examination.
The disease is more frequent in men than in women. A considerable
number of cases have occurred between thirty and forty years of age,
but the greatest frequency is after forty. At an earlier age than
twenty the disease is very rare.
The causation of cirrhosis of the stomach is obscure. Nearly all
writers upon the subject have emphasized the abuse of alcohol as an
important cause in this as in other diseases of the stomach.
Intemperance cannot, however, be the only cause; and here, as
elsewhere, it is not easy to say what importance is to be attached to
it as an etiological factor. In only one of the three cases which I
examined post-mortem could it be determined that the patient was an
immoderate drinker, and in one case intemperance could be positively
excluded. Other cases have been recorded in which the abuse of spirits
could be positively excluded. In one of my cases syphilis existed, as
was established by the presence of gummata in the liver. In some cases
the disease has been attributed to cicatrization of a gastric ulcer. In
a case reported by Snellen the disease followed an injury to the
epigastric region.[7]
[Footnote 7: _Canstatt's Jahresbericht_, 1856, iii. 302.]
Cirrhosis of the stomach, as well as cancer, ulcer, and most other
chronic structural diseases of this organ, is usually associated with
chronic catarrhal gastritis. There is, however, no proof of the
prevalent idea that chronic catarrhal gastritis is the cause of the
enormous new growth of fibrous tissue which characterizes typical cases
of this disease.
SYMPTOMATOLOGY AND DIAGNOSIS.--The symptoms of cirrhosis of the stomach
are not sufficiently characteristic to warrant a positive diagnosis.
Sometimes the disease pursues a latent course. Like cancer of the
stomach, it may put on various disguises. Thus, in a case of cirrhosis
of the stomach reported by Nothnägel[8] the symptoms were {613}
typically those of progressive pernicious anæmia. Association with
ascites or with chronic peritonitis may lead to a false diagnosis.
Thus, in one of the cases which I examined after death, and in which
there was chronic peritonitis with abundant fluid exudation, the
disease during life was diagnosticated as cirrhosis of the liver. Most
frequently, however, cirrhosis of the stomach is mistaken for gastric
cancer, from which, in fact, it can rarely be positively
diagnosticated.
[Footnote 8: _Deutsches Arch. f. kl. Med._, Bd. 24, p. 353.]
The symptoms are usually those of chronic dyspepsia, which sooner or
later assumes a severity which leads to the diagnosis of some grave
structural disease of the stomach, usually of cancer.
Indigestion, loss of appetite, oppression in the epigastrium, vomiting,
are the common but in no way characteristic symptoms of cirrhosis of
the stomach. There may be severe gastralgia, but in general the disease
is less painful than either ulcer or cancer of the stomach. The
inability to take more than a small quantity of food or of drink at a
time, with the sense of fulness which even this small quantity
occasions, has been considered somewhat characteristic of cirrhosis of
the stomach, but this symptom is too inconstant, and occurs in too many
other affections of the stomach, to be of much service in diagnosis.
The symptoms of dyspepsia are often of much longer duration than in
cancer, existing sometimes for many years (up to fifteen years), but on
the other hand there have been cases in which the clinical history of
gastric cirrhosis was as rapid in its progress as cancer. Moreover,
cancer may be preceded by dyspeptic symptoms of long duration, but long
duration is the exception with cancer and the rule with cirrhosis of
the stomach.
As the disease progresses the patient loses flesh and strength, and
usually dies in a condition of marasmus. Blood is rarely present in the
vomit, but in a few cases the vomiting of coffee-ground material has
been noted.