STAFF THIS BOOK WAS DONATED DISEASES OF THE DIGESTIVE SYSTEM MODERN CLINICAL MEDICINE DISEASES DIGESTIVE SYSTEM EDITED BY FRANK BILLINGS, M.D. PROFESSOR OF MEDICINE, UNIVERSITY OF CHICAGO, AND PROFESSOR OF MEDICINE AND DEAN OF FACULTY, RUSH MEDICAL COLLEGE AN AUTHORIZED TRANSLATION FROM "DIE DEUTSCHE KLINIK 1 UNDER THE GENERAL EDITORIAL SUPERVISION OF JULIUS L. SALINGER, M.D. WITH FORTY-FIVE ILLUSTRATIONS IN THE TEXT NEW YORK AND LONDON D. APPLETON AND COMPANY 1910 \ UO COPYRIGHT, 1906, 1909, 1910, BY D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS NEW YORK, U. 8. A. S\P INTRODUCTION THE advances of chemistry in the last few decades have placed the diagnosis and treatment of Digestive Diseases upon a firm foundation. Much that was formerly purely theoretical and based upon hypothesis has now become almost absolute knowledge. The study of metabolism has lifted the veil of mystery from much that was obscure. In the investiga- tion of diseases of digestion, in which physiology, chemistry, and pathology are so intimately connected, the practitioner has received valuable aid in relieving suffering humanity. In practice, perhaps the greatest benefits may be conveyed by the correction of even the most insignificant alimentary errors. In no organ of the abdominal cavity, and perhaps of the entire body, are the functions so manifold and diverse as in the pancreas. Text-books dating back a few decades scarcely mentioned the name of the organ, not to speak of a reference to its diseases. Thanks to the labors of investigators quite a literature is to-day extant, and the search-light of diagnosis is beginning to be thrown upon maladies of this important digestive organ. This volume treats not only of these subjects, but a new study has been opened, or, more properly, revived; namely, the investigation of the feces. What the examination of the sputum is to disease of the lungs, what the examination of the urine is to disease of the kidney and to disorders of metabolism, what the analysis of the gastric contents is to the diagnosis of disease of the stomach, the macroscopic, microscopic, bacteriologic and chemical investigation of the feces is to disease of the intestines. Abdominal surgery has aided much in the elucidation of many of these problems, and although we have reached but the first step of the ladder in the ascent of the tree of knowledge, much has been learned and still more may be expected. INTRODUCTION TO THE SECOND EDITION THK need for a second edition of this volume in a brief space of time is an evidence not only of the appreciation, but also of the necessity for the study of diseases of the digestive tract. It is with a certain degree of satisfaction that we are able to state that the material contained in this book is so abreast of the times that but very few changes could be made in the new edition. Some recent points have been added in symptom- atology and in treatment. It is to be hoped that future editions will meet with the same favorable reception as that accorded to the original volume. JULIUS L. SALINGER. EDITOR'S PREFACE TO-DAY diseases of the Digestive Tract stand in the forefront of sub- jects which interest the practitioner and the surgeon. Many of the diseases included in this volume lie on the borderland of medicine and surgery. This volume includes articles from many of the most eminent men of Europe, specialists in internal medicine and in diseases of the digestive tract. The subjects are treated very fully and at the same time in a concise and practical manner. The modern methods of examination, including physical and chemical measures, are clearly set forth, which will enable the practitioner to apply them with the same ease that he may make a physical examination of the chest and a chemical and microscopic uran- alysis. The diagnosis of the various diseases is fully discussed and the treat- ment, including the dietary, is satisfactorily full and complete. Indeed, the subjects are so fully treated that the editor found it inexpedient to add to or to modify the. text to any important extent. The translator has done the work well, with the result that the text is smooth and interestingly readable. FRANK BILLINGS. 100 STATE STREET, CHICAGO. LIST OF CONTRIBUTIONS Stenosis of the Esophagus. By TH. ROSENHEIM, Berlin. The History and Clinical Indications of Gastric Lavage. By W. FLEINER, Heidel- berg. Functional Diseases of the Stomach. By H. LEO, Bonn. The Diagnostic and Therapeutic Significance of Secretory Disturbances of the Stomach. By H. STRAUSS, Berlin. Diagnosis and Treatment of Gastric Dilatation. By F. RIEGEL, Giessen. Gastric Ulcer and Gastric Hemorrhage. By C. A. EWALD, Berlin. Gastric and Intestinal Carcinomata. By J. BOAS, Berlin. Displacements of the Abdominal Viscera and of the Heart. By F. HIRSCHFELD, Berlin. Symptomatology of the Diseases of the Pancreas. By L. OSER, Vienna. Jaundice and Hepatic Insufficiency. By O. MINKOWSKI, Cologne. Chronic Inflammation of the Liver. By E. STADELMANN, Berlin. Neoplasms of the Liver and Biliary Passages. By FR. KRAUS, Graz. Echinococcus of the Liver. By E. STADELMANN, Berlin. Gall-stones. By E. NEUSSER, Vienna. Acute Diffuse Peritonitis, Appendicitis, and Perityphlitis: I. Diffuse and Circumscribed Peritonitis. By O. VIERORDT, Heidelberg. II. Chronic Perityphlitis. By J. BOAS, Berlin. Examination of the Feces. By J. STRASBURGER, Bonn. Diarrhea, Intestinal Catarrh, and Intestinal Tuberculosis. By W. FLEINER, Heidel- berg. Constipation and Hemorrhoids. By J. BOAS, Berlin. Mucous Colic and Membranous Intestinal Catarrh. By G. HOPPE-SEYLER, Kiel. Intestinal Constriction and Intestinal Occlusion. By H. NOTHNAGEL, Vienna. CONTENTS DISEASES OF THE ESOPHAGUS AND OF THE STOMACH PAGE STENOSIS OF THE ESOPHAGUS 1 Etiology 1 Symptoms 2 Diagnosis 10 Treatment 19 THE HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE ... 32 The History of Gastric Lavage 32 The Clinical Employment of Gastric Lavage 46 FUNCTIONAL DISEASES OF THE STOMACH 63 To Test the Function of the Stomach 63 Examination of the Gastric Contents 66 Dyspepsia 69 Neuroses of the Stomach 70 THE DIAGNOSTIC AND THERAPEUTIC SIGNIFICANCE OF SECRETORY DISTURB- ANCES OF THE STOMACH 87 Gastric Secretions 88 Subacidity (Apepsia Gastrica) 94 Hyperacidity 103 Hypersecretion 113 Supplement 119 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION 122 Clinical Forms 122 Pathology 131 Symptomatology 132 Differential Diagnosis 143 Course of the Disease 144 Diagnosis 146 Prognosis and Treatment 149 GASTRIC ULCER AND GASTRIC HEMORRHAGE 159 Etiology 159 Pathological Anatomy 163 Symptoms 168 Diagnosis 188 Prognosis 199 Treatment 201 Literature . . . 216 xii CONTENTS PAGE GASTRIC AND INTESTINAL CARCINOMATA 221 Etiology 222 Chemical and Microscopical Investigation of the Gastric Contents . . 230 Gastric Carcinoma 234 Carcinoma of the Intestines . ... . 240 Treatment of Carcinomata of the Stomach and of the Intestines . . 251 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND OF THE HEART . . . 263 Displacement of the Stomach. (Gastroptosis) 265 Displacement of the Kidneys Wandering Kindey Nephroptosis . . 281 Displacement of the Liver Wandering Liver (Hepatoptosis) . . . 290 Displacement of the Spleen Wandering Spleen 292 Displacement of the Colon (Coloptosis) 294 Displacement of the Heart Wandering Heart, Cor Mobile . . . 295 SYMPTOMATOLOGY OF THE DISEASES OF THE PANCREAS 303 History 303 Anatomy and Physiology 304 Symptoms 306 DISEASES OF THE LIVER AND BILIARY PASSAGES JAUNDICE AND HEPATIC INSUFFICIENCY 325 Jaundice 325 Hepatic Insufficiency 340 Acute Yellow Atrophy 342 CHRONIC INFLAMMATION OF THE LIVER 361 A. The Various Forms of Chronic Hepatic Inflammation .... 363 B. Cirrhosis Hepatis Laennec's Cirrhosis Granular Atrophy of the Liver 371 C. Hypertrophic Hepatic Cirrhosis 385 D. Biliary Hepatic Cirrhosis 388 E. Syphilis of the Liver 389 Literature 393 NEOPLASMS OF THE LIVER AND BILIARY PASSAGES 396 1 . Neoplasms of the Gall-bladder 397 _'. Obstructions of the Common Gall-duct by Tumors . . . . . 406 3. Neoplasms of the Liver 438 ECHINOCOCCUS OF THE LlVER 454 A. Echinococcus Cysticus 455 H. Echinococcus Multilocularis Seu Alveolaris 460 GALL-STONES 464 Symptomatology 464 Prognosis .... 503 Treatment 504 Etiology 506 CONTENTS xiii DISEASES OF THE INTESTINES PAGE ACUTE DIFFUSE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS . . . 513 I. Diffuse and Circumscribed Peritonitis 513 Acute Diffuse Peritonitis . . . . 513 Circumscribed Acute Peritonitis with Particular Reference to Peri- typhlitis . . . . . . . 540 Circumscribed Peritonitis, Particularly Perityphlitis .... 564 II. Chronic Perityphlitis . 573 Etiology 574 Anatomical and Histological Changes 575 Clinical Picture 578 I. Residual Perityphlitis . 578 II. Chronic Relapsing Perityphlitis 581 Complications 588 Diagnosis and Differential Diagnosis 589 Prognosis 595 Treatment 597 EXAMINATION OP THE FECES 605 Test Diet 607 Test for Occult Blood 633 DIARRHEA, INTESTINAL CATARRH, AND INTESTINAL TUBERCULOSIS . . 635 I. Diarrhea .............. 635 Intestinal Bacteria 637 Etiology 644 Symptoms 647 Diagnosis 650 II. Intestinal Catarrh 654 Acute Intestinal Catarrh 654 Chronic Intestinal Catarrh 668 III. Intestinal Tuberculosis 687 Pathology . . 689 Symptoms . . 691 Diagnosis 697 Treatment .698 CONSTIPATION AND HEMORRHOIDS . . . 704 Constipation 704 Etiology of Habitual Constipation 705 Etiology of Hemorrhoids 708 Symptoms of Habitual Constipation 709 Symptoms of Hemorrhoids 711 Diagnosis of Habitual Constipation 713 Diagnosis of Hemorrhoids 715 Treatment of Habitual Constipation 716 Treatment of Hemorrhoids . , 730 Mucous COLIC AND MEMBRANOUS INTESTINAL CATARRH .... 735 Etiology and Pathogenesis 736 Pathologic Anatomy 738 Symptoms and Course 739 xiv CONTENTS PAGE Prognosis 746 Diagnosis 746 Treatment 747 INTESTINAL CONSTRICTION AND INTESTINAL OCCLUSION 751 I. Intestinal Constriction 751 Symptomatology 751 Etiology 754 Prognosis 762 Treatment ' 763 II. Intestinal Occlusion 765 Pathology 765 Symptoms 767 Diagnosis 775 Treatment 780 INDEX OF AUTHORS 787 INDEX OF SUBJECTS 797 LIST OF ILLUSTRATIONS (FOUR IN COLORS) FIQ - PAGE 1. The Sippy Dilator 25 2. Terminal piece of a soft stomach tube 49 3. Terminal piece of a soft stomach tube with lateral and central openings. 49 4. Terminal piece of a soft stomach tube with a central and numerous lateral openings 50 5 and 6. Terminal piece of soft tubes with rounded openings .... 50 7. Complete apparatus for washing the stomach. (After Kussmaul) . . 53 8. Hard rubber ring on which to bite, drawn over the sound .... 54 9. Inserted piece of hard rubber with cock 55 10. Case of gastric dilatation with low position of the stomach in a woman aged 59 148 11. Normal position of the stomach 268 12. Gastroptosis of the first degree 269 13. Gastroptosis of the second degree 270 14. Gastroptosis of the third degree 271 15. Constriction of right lobe of liver and pylorus 272 16. Displacement of the liver 291 17. Displacement of the liver 292 18. Pericardium with vessels. (After Henke) 295 19. Frontal section through the trunk 297 20. Constriction of the cecum 556 21. Temperature curve in perityphlitic exudate 592 22. A fragment of a grain from bread. (Magnified 250 times) . . . .611 23. Potato cells. (Magnified 250 times) 612 24. Fragment of peas. (Magnified 250 times) 612 25. (Colored). Carrot cells with crystals of carrotin. (Magnified 250 times) . 613 26. A portion of a leaf of lettuce. (Magnified 250 times) 613 27. Two stippled vessels in juxtaposition. (Magnified 250 times) . . . 613 28. Elongated cells from stalks of asparagus. (Magnified 250 times) . . . 614 29. Spores from truffles in an ascus. (Magnified 250 times) 614 30. Mildew spores of wheat. (Magnified 250 times) 614 31. Spores of lycopodium clavatum. (Magnified 250 times) 614 32. Stone cells (core) from the pulp of pears. (Magnified 250 times) . . . 615 33. Elastic fibers. (Magnified 250 times) 615 34. Connective tissue. (Magnified 250 times) 616 35. Muscle fibers in various stages of digestion. (Magnified 250 times) . . 617 36. Fermentation tubes with contents. (One-fifth natural size) . . . .621 37. Soap crystals and soap granules. (Magnified 500 times) .... 623 38. Same as Fig. 37, but after heating with dilute sulphuric acid. (Magnified 500 times) 624 39. (Colored). Normal feces from a test diet. (Combination picture) . . 627 xvi LIST OF ILLUSTRATIONS FIO. PAOE 10. (Colored). Pathologic constituents in feces after a test meal. (Combina- tion picture) 628 4 1 . Connective tissue from the feces. (Natural size) 629 42. Mucus from the feces. (Natural size) 630 43. Mucus with isolated disintegrated epithelia. (Magnified 250 times) . . 630 44. Same after thorough admixture with dilute acetic acid. (Magnified 250 times) 631 45. (Colored). Mucus with numerous red blood-corpuscles in process of de- struction, together with crystals of triple phosphates. (Magnified 250 times) . 632 DISEASES OF THE ESOPHAGUS AND OF THE STOMACH STENOSIS OF THE ESOPHAGUS BY TH. ROSENHEIM, BERLIN ETIOLOGY DISEASES of the esophagus are, as a rule, infrequent. Almost invaria- bly, however, they are of great importance, as an essential function of the organ is rapidly influenced, and because these processes occur in the immediate vicinity of the most vital organs, so that a dangerous trans- mission of the disease may readily take place. As the organ in question is one of the least sensitive ones, pain in disease of the esophagus is rare. In the main, there is but one symptom: disturbance of deglutition. This occurs in varying degrees of intensity in all esophageal affections, yet the severity of the causal process has no decisive influence upon the degree; for the hindrance in deglutition may be slight in carcinoma, and, on the contrary, it may be high-graded in small erosions, or in derangement of innervation. The basis for most disturbances of deglutition is a stenosis of the lumen, which may arise from manifold causes, and to which this article will be exclusively devoted. The majority of diseases occurring in the esophagus must be more or less considered; this will broaden our theme to a great extent, but we shall confine ourselves well within the required limits if we emphasize only the most important features from a diagnostic and therapeutic standpoint. The researches of the last few years, and especially since the introduction of esophagoscopy, have revealed much that is new and important. The most frequent and, practically, the most significant cause of steno- sis of the esophagus is cancer; other diseases are rarely mentioned, at most, here and there, stricture due to swallowing of caustics. But the forms of stenosis are by no means exhausted with this, and the spastic stenoses, particularly, call for more thorough consideration than was formerly de- voted to them. Disturbances in innervation play an important part in the origin of derangement of deglutition. Yet it is often extraordinarily diffi- cult accurately to measure the part which they play in the causation of the symptoms of the disease, as they rarely occur alone, but usually are combined with other pathologico-anatomical changes in the esophagus or adjacent organs. We must, however, always endeavor to analyze as accu- 1 2 STENOSIS OF THE ESOPHAGUS rately as possible the genesis of the difficulty in swallowing, as this is of decisive importance in the therapy. In reviewing the morbid processes in the esophagus which come into question under the picture of stenosis, the enormous amount of material may be divided into two groups: In the first group we are dealing with abnormal processes which have their seat in the organ itself, i. e., they arise directly from the organ, and thus narrow its lumen; in the second group we consider the cases in which stenosis is due to compression. Here may be mentioned tumors of the mediastinum, of the vertebral column, goiter or enlarged lymph-glands, aortic aneurysm, peri-esophageal abscesses, and, finally, filled diverticula which produce stenosis by pressure. To the first group belong: (a) neoplastic stenoses; (b) inflammatory and cicatricial stenoses; (c) spastic stenoses; (d) hereditary stenoses, and, lastly, (e.) the obstruction to the propulsion of the ingesta which may be produced by the esophagus, in which sense foreign bodies that have been swallowed, polypi with long pedicles, and aphthous stomatitis may act. SYMPTOMS Let us now describe the subjective and objective symptoms of stenosis of the esophagus in the various forms of the disease which are to be here considered, and let us observe the differences in the manifestations pre- sented by the several types. For this purpose it is best to analyze the symptoms of cancer of the esophagus, the affection that most frequently causes stenosis of the esophagus. How frequent carcinoma is can be defi- nitely seen from statistics which show that about 60 per cent, of all diseases of the esophagus are of a malignant nature, according to other compila- tions even 90 per cent. ; but from my own experience I think the latter figure somewhat too high. It may be remarked in passing that cancer of the esophagus occurs in different countries with variable frequency. For example, in Moscow unquestionably the cases are more numerous than in Berlin. Difficulty or an impediment in deglutition, therefore dysphagia, is the most constant symptom of cancer of the esophagus. It is usually the first, also, which makes the patient anxious, and leads him to consult a physician. The disturbance in swallowing appears gradually as mild pressure, some- times behind the corpus sterni and behind the larynx, sometimes in front of the stomach and noted upon swallowing solid food; later, solid masses, even if well masticated, pass only with the greatest difficulty or only simul- taneously with fluid; often they are arrested; then comes a stage in which watery, pappy food can be forced into the stomach only with effort ; it must be swallowed in small portions, slowly and carefully; finally, the passage is entirely occluded, transitorily or permanently, so that the patient faces starvation. Besides this gradual, insidious, progressive development of SYMPTOMS 3 dysphagia, which is the usual course, we observe in some cases in the midst of the best of health and without prodromes a sudden and decided impedi- ment to deglutition. At other times, decided variation in the degree of passability of the esophagus may be noted. On some days the patient can apparently swallow anything, on other days there is an obstacle. Doubtless the condition of the nervous system here plays an important role, for I have repeatedly observed this in very nervous patients with carcinoma of the esophagus. With a prolonged course of the affection, amelioration may come by the purulent softening and ichorous decomposi- tion of prominent cancer proliferations; the patient again becomes hope- ful, but this improvement is only the precursor of the final catastrophe. The following fact is also remarkable: The patients complain of in- creasing difficulty in deglutition, so that even fluids fail to pass, or only with great effort, but, in this condition it is always possible to pass esopha- geal bougies into the stomach. This disproportion between the natural power of deglutition and the results of probing is found in all the varied affections of the esophagus, but chiefly in compression of the organ and in neuroses; occasionally, however, it is also observed in flat carcinomata situated in the wall of the organ and not distributed in annular form, since these offer no marked resistance to the sound, which readily passes them, and they disturb the active deglutition only in a reflex manner. Thus spasms are caused especially at the upper portion of the diseased area, but they may also occur in normal portions of the canal. For example, as not in- frequent complications, we may have spasms behind the larynx, provided the tumor is situated in the cardia, and, in addition to this, very disagreeable sensations of constriction are felt at the boundary line between the pharynx and esophagus, and these necessitate continued efforts at swallowing on the part of the patient ; this forms a very usual complication in the various diseases of the esophagus, and particularly in carcinoma, immaterial what its situation. The reports of the patient as to the region in which he feels constriction and pressure are often inaccurate and misleading. Frequently he will state that the bolus is arrested in the neck, while the cancer is situated in the cardia, or vice versa; the distress is sometimes localized in the epigastrium, when the neoplasm has developed in the upper half of the esophagus. Therefore, the origin of disturbances of deglutition is the combination of a series of factors. At one time, mechanical obstruc- tion such as is presented by the infiltration of the wall of the esophagus plays an important role; at another, we observe increased sensitiveness of the nerves of the muscular apparatus which, as soon as the food reaches the inflamed area, readily show abnormal reaction. This reaction is the result of irritation, and is usually manifest as a spasm at the seat of the affection or in distant areas. Added to this are disturbances due to inflam- matory processes in the mucous membrane of the areas surrounding the cancer, alone or in combination with an atonic-ectatic condition of the organ 4 STENOSIS OF THE ESOPHAGUS above the neoplasm. In regard to the last point, it must be remembered that hypertrophy, and also dilatation, may develop above the stenosed area, that the latter, however, only rarely is decided, as a prolonged and perma- nent stagnation of food does not readily take place. On the contrary, when the bolus is arrested, it is usually soon regurgitated. This regurgitation naturally occurs the more promptly the greater the disproportion between the narrowness of the stricture and the consistency of the food, as well as between the local sensitiveness and irritability of the food. As a rule, regurgitation occurs immediately after swallowing, or from a few minutes to a quarter of an hour after, rarely later. When delayed, however, dilata- tion is usually present. In this case, if the esophageal sound be used, masses of food may be brought up in which the absence of peptonization shows clearly that they have never reached the stomach. It is obvious that processes of decomposition must arise when the food remains for a long time in the esophagus; consequently the patients not rarely complain of a fetid odor from the mouth. But these processes may occur in an advanced stage of the disease even without a decided retention of food owing to the decomposition of the cancer, and thus give rise to offensive breath. Besides food, and even independently of its introduction, a foamy, mucoid fluid having a fetid odor, is often ejected, and not rarely shows traces of blood. This is the product of the inflammatory process which accompanies cancer of the esophagus, and which sometimes also extends to the pharynx and larynx. The combined effect of these irritative factors is cough., which often increases to extremely severe paroxysms which natur- ally distress the patient ; added to this is the fact that bronchitis and tuber- culous changes in the lungs commonly coexist with cancer. Apart from the unpleasant sensation of pressure mechanically caused by the arrest of the bolus, the affection may be painless for a long time or even permanently, for the esophagus is one of the least sensitive organs, and in this malady only an implication of the mediastinum, the pleura, and the pericardium, the compression of important nerve plexuses in the vicinity, the implication of the vertebral column and the spinal cord, will he productive of pain. Then boring, burning, lancinating pains set in which accompany the act of deglutition or follow it, but may come on independ- ently of the introduction of food, particularly at night. The pains are felt in the intercostal spaces, between the shoulder blades, in the epigas- trium, in the throat and head ; for example, frequently in the ear and in the extremities. It is obvious that by the metastatic distribution, and by the further growth of the cancer, manifold symptoms may be produced. I shall here mention, for example, vasomotor and trophic disturbances in the naih; also the occurrence of inequality of the pupils; almost always the left pupil is contracted. Paralysis of the recurrent laryngeal nerve, above all, deserves special mention. Unilateral paralysis of the vocal cord is a quite common symptom. As this may not cause any change in voice production, SYMPTOMS 5 it can be detected only by a laryngeal examination, and thus is frequently overlooked. Often, however, it is an early symptom, and may even be present when as yet the stenosis is scarcely obvious. Dyspnea and attacks of pain resembling angina pectoris arise in the course of the disease either because the neoplasm posteriorly presses imme- diately upon the trachea, or upon both recurrent laryngeal nerves, or impli- cates the posterior plate of cricoid cartilage and its surroundings, in which case the nerve and the muscular substance of the dilators of the vocal cords are directly destroyed. Perforation of the esophageal wall may take place without producing special symptoms, and this is true even if the formation of a fistula between the esophagus and the trachea or the bronchi has already occurred, provided that the opening is small and the esophageal stricture slight, so that food may pass the organ without being arrested ; otherwise, severe paroxysms of cough and marked dyspnea upon the ingestion of food are the character- istic signs of this last-named complication. The paroxysms of cough cause the ejection of mucus stained with blood simultaneously with particles of food which have found their way into the respiratory apparatus; sooner or later, upon continued nutrition by the mouth, pneumonia or pulmonary gangrene occurs. If the fistulous passage is very narrow, and the stricture still relatively permeable, it is sometimes noted that thin fluids cause parox- ysms of cough, while more compact food passes with ease. Decided spontaneous hemorrhages from cancerous ulcers in the esophagus which cause hematemesis are rare symptoms of carcinoma. More frequent are fatal internal hemorrhages due to the erosion of a vessel with the ad- vance of the process. Concerning the difficulties on the part of the gastrointestinal canal and the general condition: At the onset of the affection the patients usu- ally have a good appetite, and in some pitiable cases this continues until death. In the further course of the disease, as a rule, hunger becomes less pressing, while burning thirst almost invariably persists. Stubborn con- stipation is common. In advanced cases, after the food has reached the stomach, it sometimes produces a continuous dull pain in the epigastrium, not rarely accompanied by eructations and nausea. These dyspeptic symp- toms have no direct significance in cancer of the esophagus. They are to be attributed to secondary inflammatory atrophic processes in the mucous membrane of the stomach which are sooner or later added, and the more rapidly, the closer the cancer lies to the stomach, and the sooner it impli- cates this organ. It is obvious that inanition and cachexia will early develop in the clinical picture, according to the nature of the disturbances which the affection produces. At first the loss in strength is parallel with the dura- tion of the disease and the degree of obstruction to deglutition. If it is possible to diminish, or even to remove, the latter, although only tern- 6 STENOSIS OF THE ESOPHAGUS porarily, the patients, as a rule, rapidly recover and increase in weight. Exceptionally carcinoma of the esophagus, without any functional disturb- ance, causes extreme debility by a deleterious and toxic influence upon proteid metabolism. Examination of the patient in the various stages of the affection fur- nishes results which are further modified according to the seat of the diffi- culty and the complications. Inspection and palpation frequently permit us to recognize enlargement of the lymph-glands in the supraclavicular and cervical regions; but the utilization of this finding necessitates caution, since quite marked enlargement of the glands is also found in scrofulo- tuberculous individuals, a moderate enlargement not infrequently in syphi- lis and catarrhal affections of the organs of the throat; it may even be present without a recognizable disease. If the cancer is situated in the upper portion of the esophagus it may be externally palpated as a tumor beside the trachea and the larynx, and if it attack the cricoid plate or the pharynx it may even be seen by the laryngoscope. When the cancer is deeply located, and cannot be thus recognized, we must investigate by means of the sound. We should first determine that no disease is present which contraindicates the use of the sound, and then attempt to pass the stricture with a thick instrument (10 to 12 mm. in diameter). After it is within the esophagus it should be slowly and care- fully forced ; if resistance is met with, it must be overcome by gentle means, but boring should be avoided; upon withdrawal the length of the narrow portion from the teeth should be carefully noted. It will frequently hap- pen that the figures gained in this manner will vary several centimeters upon different days this is explained by the fact that the sound enters to a different depth, or the point is embedded in the stricture nevertheless, in spite of these variations, they enable us to locate the constriction, but give us no idea of its extent. The resistance that the sound meets may be in the upper, in the middle, or in the lower part of the malignant neoplasm. It is a valuable diagnostic aid carefully to examine the fenester of the sound. In this we frequently find remains of food, blood, pus, mucus, and sometimes even shreds of tissue which under the microscope permit the exact recognition of the disease. If it be impossible to recog- nize the characteristic cancer cell nests in the investigation of the fresh preparation, then the suspicious portion may be examined by the stroma preparation of sections after hardening in alcohol, or, a more rapid process, the frozen section with the microtome and its staining (for example, with picro-carmin). After the presence of a stenosis has been determined by means of a thick sound, we should attempt to pass through the narrow passage with more xlrnder instruments; frequently it will be impossible to reach the stomach with the finest instruments, although pappy and, occasionally, even solid food still pass the stricture. The explanation of this is either that SYMPTOMS 7 the point of the sound is caught in a diverticulum above the narrowed area, or the canal of the stricture is not straight but follows an irregular, spiral course. On the other hand, the patients may complain of difficulty in swallowing food in a certain area of the esophagus, yet the largest sound finds no resistance in its entire course to the stomach ; in cases of beginning cancer formation, particularly, the results of examination may be negative. Here the latter course must explain the case, or, if an early diagnosis is desired, we must investigate by means of the esophagoscope. The nar- rowed area which has been revealed by the sound, even in advanced cases, may be entirely unrecognizable if extensive ulceration and rapid destruc- tion have occurred; but here also the esophagoscope gives the desired information. The esophagoscopic pictures show great variations, which certainly de- pend upon the stage of development of the neoplasm, and, above all, the nature of the growth. The picture which presents itself is entirely differ- ent when cauliflower-like proliferations enter into the lumen, or, on the contrary, when only an induration of the wall has occurred, when ulcer formation has taken place, when the mucous membrane is still retained, when the narrowing is very decided, or when it is very slight. The cancerous protuberances which narrow the space, if accurately investigated, cannot be confounded with anything else; there is no process in the esophagus except carcinoma that runs its course with the formation of these prominent, whitish-grey to greyish or dirty greyish-yellow nodules permeated by punctiform hemorrhages. The finding of a prominence cov- ered with mucous membrane, however, may be of varying significance. Even in advanced cases of carcinoma the stenosis is generally not due to cancerous masses which have proliferated into the lumen, but is due to infiltration, and this, viewed from above, presents itself as a swelling or a round tumor about the size of a cherry with well-retained mucous membrane, while ulceration or splitting of the surface cannot be detected because it occurs only toward the inner wall, therefore, arises in the lumen of the stricture. Frequently, above these protuberances the mucous mem- brane appears paler than normal, sometimes more yellow or, cyanotically, bluish-red, occasionally even loosened and markedly reddened. Worthy of note are the epithelial thickenings in different forms (streaks, flakes, etc.), which resemble leukoplakia of the tongue, and are found in the immediate surroundings of the morbid focus. At other times whitish, papillary ex- crescences, resembling pointed condylomata, or papillae consisting of several whitish papillary proliferations, are met with in front of the narrowed area, frequently situated upon a perfectly normal mucous membrane. These last mentioned changes are not pathognomonic of carcinoma; we also meet with them in other conditions. Not rarely the wall is deeply infiltrated only in the cancerous mass; then the formation of the above-mentioned one-sided protuberance does 8 STENOSIS OF THE ESOPHAGUS not occur, but frequently there is an annular narrowing, with increasing constriction downward. We can then pass the tube as far as this rigid area, but no farther, and we descry from above a funnel-shaped passage with mucous membrane folds converging downward. Sometimes the en- trance into the stricture may be distinctly perceived, even in the deepest area, occasionally, however, the folds so overlap that this is impossible. A similar picture is sometimes presented to us by strictures due to caustics, and the previously mentioned protuberances with well-retained mucous membrane may also be produced by the bulging of the wall of the esophagus in consequence of compression from without. Therefore, the proof of ulceration or of a cauliflower-like proliferation entering into the lumen is of the greatest importance. Sometimes it is possible to recognize the line of demarcation where the healthy mucous membrane terminates, having an eroded appearance, or the transition to the ulcerating part, the surface of which can no longer be recognized, betrays itself here and there by free, floating shreds of mucous membrane. We may distinguish the ulcerated portion by the dirty, greyish-yellow, purulent coating under which and beside which the greyish-red, uneven cancer surface can sometimes only be brought to view by cleansing, and which is characterized by its tendency to continuous capillary hemorrhages. Sometimes after the introduction of the tube, blood oozes continuously from the ulcerated surface, and, in spite of careful cleansing with cotton, nothing more can be seen. In other cases foaming, muco-purulent, bloody fluid becomes visible, and with every ex- piration is forced up through the narrow passage with a gurgling murmur. If we are certain that no injury has been done with the esophagoscope at the point of lesion, the expulsion of hemorrhagico-purulent secretions from the stenosis confirms the diagnosis of carcinoma. The pulsating motion of the esophagus, which is synchronous with the dilatation of the aorta, disturbs the investigation, particularly if the focus of the disease be situated at the point of bifurcation. But, with some prac- tice, we become accustomed to this rhythmic motion of the picture. The respiratory displacement of the organ, by which its walls approximate one another in expiration, scarcely interferes, provided breathing is not too deep and rapid ; it is absent, or almost so, when the cancer has infiltrated the walls of the organ; it may, therefore, be absent upon one side or in the entire circumference. On the other hand, there may be a disagreeable disturbance due to severe cough, which, in spite of cocain and morphin, is a common consequence of the existing laryngitis or trachitis. It is impor- tant that the patients be examined upon an empty stomach. If the field of vision is obscured by remains of food, such as portions of milk, particles of egg and the like upon the mucous membrane, and particularly over the narrowed areas of the rough cancerous surface, mistakes are readily made; in other cases it is easily possible to mistake these whitish masses for cancer. A single inspection will not always suffice for us to recognize the SYMPTOMS 9 carcinoma. In cases in which the diagnosis is uncertain, small particles of tissue may be extracted and later microscopically eiamined, but great care is necessary in this procedure. The esophagoscope should never be used immediately after sounding with a rigid tube. If the sound has been introduced into the esophagus to determine a stricture and to measure its distance from the teeth, even with careful manipulation the field of vision may be obscured with blood. It is well, therefore, to wait a few hours. The results furnished by auscultation of the esophagus are in the main meager. If the patient takes fluid, swallow by swallow, he himself will frequently notice, as do those about him, a gurgling sound which is some- times heard for a few seconds and is produced at the narrowed area by the checking and regurgitation of the fluid stream. By auscultation at the previously designated area, these deglutition murmurs give us diagnostic points of support, which, although not absolute proof, are nevertheless auxiliary, particularly in those cases in which, for example, upon suspicion of aneurysm, it is unwise to introduce instruments into the esophagus. No importance is to be attached to the rarity of the murmur in question (press- ing-through murmur) or its absence; if it be present, however, and conspicu- ously prolonged, an impediment in the upper portion of the esophagus is indicated. //, however, the pressing-through murmur is invariably absent, simultaneously with the first sounds an occasional absence is without im- portance this is in favor of a pathologic process which limits the muscula- ture in its function at the cardia, and which, according to experience, is, as a rule, of a carcinomatous nature; for only very exceptionally are both murmurs absent under normal conditions. Earely does the esophageal bougie, even when it does not pass into the stomach, fill itself with fluid or pappy or compact remains of food which must have lodged in that portion above the carcinoma ; they betray their origin by the absence of hydrochloric acid, pepsin, bile, and peptone, and by their alkaline or neutral reaction, which, however, may occasionally be acid, and is then due to organic fer- mentative acids. The gastric function must suffer sooner or later, and earliest if the cancer be situated in the vicinity of the cardia. The hydrochloric acid secretion is therefore not rarely found to be absent. The urine is scant owing to the limited ingestion of fluid, and, in advanced stages, frequently shows the products of proteid decomposition (indican) and those of patho- logic albumin decomposition (acetone, aceto-acetic acid, oxybutyric acid). Examination of the larynx, lungs and pleura should never be neglected. This often gives valuable aid in judging our cases. 10 STENOSIS OF THE ESOPHAGUS f DIAGNOSIS The most important point in the diagnosis of carcinoma of the esophagus is the recognition of a stenosis of the esophagus. If we deter- mine this by the aid of the bougie in a previously healthy person, between the ages of forty and seventy, the affection having arisen without a recog- nizable cause, and steadily increased from weeks to months, nothing is more likchj than that we are dealing with a carcinoma of the esophagus. Yet a stenosis that has developed in this way, and under these conditions, may occasionally be of a non-malignant nature, and on account of the impor- tance of this point for the patient, this possibility should first be excluded. It must be borne in mind that the history and the subjective symptoms, as well as most of the objective symptoms, may lead us astray. It some- times happens, for I have myself observed and described such cases, that in benign dilatations and with the formation of a diverticulum as well as in spasm of the esophagus and atony, dysphagia may begin without assignable cause, and increase in a few months to a threatening degree, rapidly undermining the strength. On the other hand, in consequence of the chronic nature of disease of the esophagus, we must by no means per- mit ourselves to give a relatively favorable prognosis, and to exclude car- cinoma. I have seen patients in whom difficulty in deglutition had existed from four to ten years prior to death, and due to carcinoma at the seat of the obstruction. These cases may be explained by the hypothesis that the cancer formed secondarily upon a base which had long been in a state of irritation, and had been well prepared. We know that ulcers due to a variety of causes (to tuberculosis, to caustics, or to digestive processes) in cicatrices, in inflammatory, irritative areas, therefore, wherever me- chanical obstruction causes local irritation, prepare a soil suitable for the formation of cancer. A second factor in the history, which can only be applied after thor- ough investigation, is the age of the patient. It is true cancer usually develops at an advanced age; but I have seen a number of cases of cancer of the esophagus in persons between 30 and 40 years of age, and hardly a year passes in which I do not see at least one case in early youth. Another point which may mislead us is the cachexia. This is mani- fest in all diseases of the esophagus, provided they form a hindrance to the ingestion of food; in nervous disturbances and in dilatation of the esophagus, it may even be excessive. It must be remembered that a steady increase of dysphagia for months, or oven for years, occurs in various affections of the esophagus, namely, in simple inflammatory processes, in dilatation, and in diverticulum. A conspicuous change in the power of swallowing is present in nervous dis- turbance* of the esophagus; but nervous influences may also occasionally appear in carcinoma. DIAGNOSIS 11 Resistance to the passage of the esophageal sound is objective proof of importance in diagnosis, but this does not demonstrate with absolute certainty that there is an anatomical obstruction. Spasm may arrest the bougie, and it may be impossible to overcome this either by prolonged wait- ing or by attempts at swallowing on the part of the patient (see below). More important is the recognition of an admixture of blood, of pus, or of the products of decomposition which have lodged in the opening of the tube during probing, but it must be borne in mind that ulcerative processes and decomposition may be present in dilated portions of the organ with- out the presence of a carcinoma. Only when we are fortunate enough to find shreds of tissue, which unquestionably demonstrate the carcinom- atous character of the affection, is this positive result a decisive proof; and this can only occur in exceptional cases; in the early stages of the disease when the diagnosis is still doubtful it rarely happens. A positive and early diagnosis may be made most frequently by the esophagoscope. The esophagoscopic picture is generally the determining factor; in the majority of cases it may be readily obtained; in a minority this is unsatisfactory, i. e. it does not give a positive result; and this may be readily understood when we consider the fact that we are able to inspect only the upper border of the diseased area, and the later course of the affection and the consideration of all its accompanying circumstances can alone clear the situation. From this it is evident that the positive determination of the character of a constriction of the esophagus is by no means easy. Although the ma- lignant form predominates, many others must be considered which furnish a similar symptom-picture, and well deserve the interest of the physician. We should, therefore, avoid making a positive diagnosis of cancer of the esophagus, as is very commonly done, without certain indications such as dysphagia and resistance upon probing. Based on these criteria, no positive diagnosis is possible, and, when we consider how much is at stake for the patient, we should be somewhat more thorough in our differential diagnosis and more cautious in our prognosis. We shall now describe the other manifold processes which cause obstruc- tion to the passage of food, and, therefore, present the picture of stenosis of the esophagus. These are to be minutely discussed, and are best con- sidered according to the classification given above. As benign neoplasms (myoma, fibroma, and cysts) are great rarities, and scarcely ever give rise to clinical symptoms, we may at once direct our attention to the second group of stenoses, those which originate from inflammatory ulcerative processes. Stenoses of the lumen of the esophagus due to the action of caustics stand first in practical importance. These, as is well known, are not rare, and in regard to the symptoms it is immaterial whether acids, alkalies, 12 STENOSIS OF THE ESOPHAGUS or other chemical agents, which have been swallowed either for purposes of poisoning or by accident, produce alterations in the mucous membrane. We shall not describe the stage of the acute, florid, inflammatory process and the phenomena to be attributed to this. We are more interested in the conditions which result in the course of weeks and months in consequence of infiltrations of the wall, formation of cicatrices, and narrowing of the lumen. The strictures which originate in this manner, if very narrow, annular or tubular, are limited to certain areas of the esophagus, and this is generally the upper portion, the region of the bifurcation, and the area of the foramen cesophageum. If we are dealing with long, tubular strict- ures, their centers are at these points, whence they distribute themselves upward or downward or in both directions. There may be strictures at several points of the esophagus, and by the coalescence of several, the con- striction becomes extensive, and finally total. The difficulties in deglutition are not specially characteristic. They are permanent, and vary in intensity according to the degree of the con- striction and the local irritation, as is true of all stenoses. An aid in diagnosis is the circumstance that from the history alone the nature of the disease may l)e determined with some degree of certainty. But the anatomic condition of the organ caused by caustic we can only ascertain by an exact investigation, and here our first question is: Are we dealing with one or more strictures? In this respect, the reports of the patient regarding the act of deglutition permit some deductions. However, this information must be utilized with necessary reserve, as it is frequently shown to be erroneous. Moreover, we desire to know: Are inflammatory, ulcerative processes still present in the mucous membrane, or has definite cicatriza- tion occurred in all parts? Is dilatation present? Finally, the question must be answered whether carcinoma has developed in consequence of the changes which are to be here considered. Information in regard to all these points is given us by the sound and the esophagoscope. Soft tubes, firm English and French bougies, also the metallic spirals which I prefer- ably employ when it is necessary to find a passage, may be repeatedly used in order to acquaint ourselves with the situation and to enable us to form a correct opinion. The esophagoscope gives us accurate knowledge; strict- ures due to caustics form very characteristic pictures. In the neck and in the suprabi furcating area of the esophagus frequently striated, elongated, and flaky white cicatrices are outlined sharply against the rose-red mucous membrane; the nearer the stricture the more numerous the cicatrices upon the mucous membrane. The ring form, or the beginning of an annular stricture, manifests itself either as a cicatricial funnel at the apex of which a more or less circular or oval lumen is noted, or it resembles the portio vaginalis, from the fact that the region of the esophagus above it is dilated, and with the tube is uniformly forced downward above the invaginating stricture. Only with a very superficial cicatricial formation does the nar- DIAGNOSIS 13 rowed area, whose lumen is often eccentrically layered from contraction of the cicatrix and frequently resembles a folded diaphragm, still show respira- tory movement and radial folds; the deeper the effect of the caustic, the more rigid and immotile is the area of the stricture. The whole portion looks like a canal partly or entirely covered with white cicatricial tissue. At other times the mucous membrane up to the point of stricture is a deep, dark red, and shows a tendency to bleed readily; in the earlier stages of the disease, and even later, or as the result of improper treatment, we find ulcerative areas between the cicatrices. If the caustic action has been slight, the secondary cicatricial formation may be of little extent, and after the acute symptoms have passed away no difficulty in deglutition remains; but in several cases of this kind I have observed that 10 to 20 years later difficulties in deglutition may reappear, particularly if the food is very coarse; larger, poorly masticated particles may be arrested. Thus, in adults, I have twice been obliged to extract coarse pieces of meat, about the size of a thumb- joint, which were arrested in the upper third of the esophagus. In both cases slight corrosive strict- ures were present which had been formed in earliest childhood. Up to that time the patients had ingested their food without any difficulty, and scarcely remembered the early disease of the esophagus. In both instances, the esophagoscope revealed a marked injection in that portion of the esopha- gus in which the bolus was arrested. Only in one of the patients was there a distinct cicatrix. With care further consequences were averted. Stenoses due to other ulcerative processes are very rarely multiple. Mostly limited to a portion of the wall, the contracting cicatrix draws the corresponding portion of the retained mucous membrane toward it, and thus the stenoses cause diverticuli and valve formation. It may then hap- pen that if the bougie is caught in the narrowing, it may appear of great extent, while, at other times, quite a large tube may be passed with ease. The differentiation of cicatricial strictures according to the nature of the ulcerative processes to which they are due is very difficult, and even impos- sible except in the case of the ulcer due to caustics. We consider chiefly syphilitic, tuberculous, peptic, and diphtheritic ulcerations. In doubtful cases the presence of syphilis and tuberculosis will aid in the diagnosis; peptic ulcers occur only in the lower third of the esophagus, and there are usually accompanying symptoms which point to gastric ulcer. I treated successfully a case of stricture of the esophagus following scarlatinal diph- theria. Naturally here also the preceding disease is a guide to the diag- nosis. In conclusion we must consider cicatricial constrictions which have their origin in peri-esophageal processes which start from the lymph-glands, secondarily producing ulceration of the esophagus, which, in case healing occurs, results in stenosis of the lumen. The finer differentiation of cicatricial strictures according to their gen- esis is not of practical importance. It is, however, always an advantage 14 STENOSIS OF THE ESOPHAGUS to obtain a clear picture of the anatomic condition by aid of the esophago- scope, and thus determine whether or not florid inflammatory processes are present, and whether carcinoma, especially, can be excluded. Of great import is the recognition of stenosis due to spasm of the esophagus. By the pathologic contraction of a layer of the annular fibers of the musculature, a segment of the esophagus becomes impermeable, or can only be passed with difficulty. The obstruction to deglutition resulting from this is of varying duration and intensity, and occasionally is also accompanied by painful sensations. The spasm may be transitory or per- manent; sometimes the affection persists uninterruptedly for weeks or months or even for years, occasionally it is intermittent, and at other times only occurs after a definite irritation from food. In many cases this esophagismus accompanies hysteria and neurasthenia, epilepsy, chorea, and tetanus; it is an invariable and most important symptom of hydrophobia. Occasionally it is one of the manifestations of disease of the central nervous system ; very frequently it is reflex. Thus, a spasm may prevent the ingress of our instrument, even of a soft tube; foreign bodies, coarse food, irrita- tive fluids, anything that produces decided retching, may give rise to stub- horn spasm. Above all, spasm is frequently a concomitant symptom of other diseases of the esophagus. Every anatomical process in the esophagus may be accompanied by spasm. Diseases of other organs may produce the spasm ; affections of the pharynx and larynx, of the stomach and intestine, of the male and female genital organs, may be its etiologic basis, and trauma, which directly affects the head of the thorax, may cause reflex spasm. The appearance of spasm in certain intoxications (from bella- donna, from strychnin, from sausage, etc.), following refrigeration with or without rheumatic affection of the joints and muscles, and with or with- out catarrhal affections of the larynx and pharynx, is worthy of mention. This neurosis shows itself chiefly by dysphagia. The nature of the difficulty in deglutition is often not characteristic; the symptoms are the same as those complained of by patients with stenosis of the esophagus from other causes. Occasionally the spasm is accompanied by dull pressure in the chest, by a painful feeling of constriction, by lancinating or burning pains in the neighborhood of the esophagus, for example, in the shoulder or the neck, or it follows these symptoms. Spasm of the muscles of the pharynx, of the larynx, of the trunk, and of the extremity may coexist and alternate with esophagospasm, particularly in those cases in which a gen- eral neurosis is the foundation of the affection. The degree of hindrance in deglutition varies greatly. Only rarely is the esophagus absolutely, or almost wholly, impermeable for a long time; in these cases severe inani- tion may result, and the patient finally perish from the neurosis. This dysphagia may appear in dissimilar forms. Sometimes the patients ex- perience only the sensation of an arrest of the food, and by the aid of a DIAGNOSIS 15 few deep inspirations, or by swallowing some fluid, the bolus finally reaches the stomach; or the first food is regurgitated while that subsequently taken passes without difficulty. In some cases the spasm shows itself only upon abnormal irritation, for example, during probing or when certain foods are taken, usually coarse food or solid food in general; but we some- times meet a patient who finds fluids more difficult to swallow than solid food. Occasionally the spasm occurs only at certain times of the day, or during the course of prolonged meals. In spite of the fact that some of these disturbances we have mentioned certainly arise only under the influence of a derangement of innervation, positive proof that we are dealing only with a nervous affection can never be attained in the given case by the history and the subjective observation of the patient. The diagnosis of spasm is rarely easy. The most useful points of support for the recognition of the neurosis from the subjective and objective symptoms will now be briefly described. The sudden appearance of difficulty in deglutition, particularly of fluid food, indicates the presence of spasm, and still more so the intermittence of the attacks, which may be quite irregular or be produced by very definite influences, partly nervous, the intensity and duration of which vary. Dif- ferences in the degree of permeability of the esophagus is a conspicuous symptom favoring spasm ; the first food may be arrested, the succeeding may pass, or, the first masses of food may pass readily, and then, without assign- able cause, a sudden stoppage occurs. More important is a variation in the seat of the constriction, so that, for example, on one day the upper, and upon another day the lower, third of the esophagus becomes impermeable. But this is a very rare symptom, and is only found as an accompaniment of severe nervous affections. An absolute diagnosis of this condition can only be made by means of the bougie and the esophagoscope. The first sounding should take place with a rigid instrument, as this will more cer- tainly pass the axis of the organ than a soft one, which is easily bent. If we probe during a time when the difficulty in deglutition exists, a resist- ance must be objectively noted. After a short pause, or on moderate pressure, it may disappear, for there are many mild forms of spasm, but it must positively be present. It is worthy of note that the resistance may be caused to disappear by probing, by means of which we force the patient repeatedly to swallow very rapidly, and this brings about a more decided innervation of the longitudinal muscles of the esophagus, therefore, the dilators, and thus we overcome at least moderate grades of spasm. More- over, probing may reveal a variation in the degree of permeability and in the seat of the constriction which is often of decisive import. By means of the esophagoscope we are enabled to recognize other esopha- geal diseases, and positively to diagnosticate spasm; for this, as a rule, usually gives a characteristic picture, sharply rising folds of mucous mem- brane which converge toward a point in the middle of the lumen and form 3 16 STENOSIS OF THE ESOPHAGUS a rosette-like, more or less rigid closure. The lumen, if it can be recognized at all, is narrow. Only upon deep inspiration or on coughing are fluids (mucus, gastric contents) and air regurgitated through the narrow open- ing, not rarely accompanied by a hissing or gurgling murmur. The mucous membrane of the contracted portion of the esophagus shows abnormal, in- tense reddening. Occasionally the mucosa is found eroded, particularly in the region where regurgitation or stagnation has occurred. If an examination be made during a time free from attacks, all the previously mentioned criteria may be absent, but a negative finding, in particular, is of diagnostic value. The determination of the previously mentioned causes of spasm is an important aid: The proof of another affection of the esophagus coexisting, the recognition of a local affection of which the spasm of the esophagus may be the reflex symptom. Above all, we must consider the status of the nervous system; but even if dis- ease of this region be unquestionably present, it does not permit a con- clusion regarding the character of a coincident difficulty in deglutition. This must be borne in mind if we would avoid falling into gross error. Inversely, we should observe that in true spasm also the difficulty in deglutition may progressively increase, that extreme cachexia may also develop, and that more or less complete impermeability of the esophagus may persist stubbornly for months and years. Congenital stenoses of the esophagus, from the onset, either make life impossible, or they manifest themselves by a difficulty in deglutition which appears in early youth; it must be remarked here that congenital dilatation of the organ (anterior stomach) may give rise to symptoms similar to those of stenosis. If it is possible to demonstrate that considerable masses of food are retained in the esophagus, this is proof that dilatation at least is present; whether beneath this a constriction also exists can only be determined by the sound and the esophagoscope. Occlusion stenoses, to the description of which we now turn, are due to impaction by foreign bodies which are arrested in the esophagus; they occlude the passage more or less completely, irritate the mucous membrane, and eventually may produce phlegmons and perforation. Even very small objects, for example, small fish bones, by giving rise to local irritation and spasm, may cause pain and symptoms of stenosis; and, even if the foreign body is not arrested but reaches the stomach, erosions and fissures which it produces in the mucous membrane may cause the same symptoms. On the contrary, it will be observed that not only small but also comparatively large foreign bodies, for example, a plate of false teeth, may be arrested in the esophagus without giving rise to decided subjective, or even marked objective, symptoms. For example, as I myself have seen, a plate of false teeth larger than a silver half-dollar may be arrested in the upper third DIAGNOSIS 17 of the esophagus below the larynx, and lie with its convex surface in the concavity of the anterior wall of the esophagus, so that the organ gapes, and thus not only food but thick bougies may pass the large foreign body without difficulty. In this case, it had been supposed that the plate of false teeth was no longer in the esophagus, and the symptoms still present had been referred to lacerations in the mucous membrane; the true state of affairs was revealed by the esophagoscope. Foreign bodies, almost without exception, are arrested in the upper, narrower parts of the esophagus; when they are found in the lower por- tions they have usually been forced down by instruments. With a pre- viously existing stenosis even a small foreign body, for instance, a fruit kernel, may bring about complete obstruction of the esophagus, and abso- lute impermeability arises when a spastic process of the musculature holds a small foreign body. If foreign bodies have been swallowed, the patient is generally aware of it, and reports the circumstance; where no history can be utilized, the acute appearance of stenosis at once leads us to think of obstruction; but also when the stenosis is due to foreign bodies, the variation in permeability occasionally favors this hypothesis. Temporarily the closure is complete, then the foreign body, in consequence of a paroxysm of coughing, or by retching, changes its position, and food now passes, perhaps also a bougie. But the sensation of a foreign body being lodged in the esophagus mostly remains, and after a short time difficulty in deglutition again becomes noticeable. The examination with the bougie in doubtful cases will scarcely show the nature of the obstruction. By the introduction of instruments, we are at most only able to determine that a mechanical obstruction is present, and this is not even certain in all cases; for the probe may pass alongside of the foreign body through the lumen of the esophagus. On the other hand, esophagoscopy always enables us to make a positive diagnosis. By the aid of the eye we can extract the foreign body, or force it down, and readily cure any existing lesions in the mucous membrane by cauterization. The stenoses due to compression of the esophagus are of the greatest practical importance. Any tumor formation in the neighborhood of the organ may sooner or later lead to compression of the tube. The esophagus is naturally motile, and may deviate. If, however, it is completely sur- rounded, or only adherent on one side, symptoms of stenosis appear. Goiter itself most readily causes difficulty in respiration, but rarely dis- turbs the function of deglutition; this will occur if it be very large, or if it surround the esophagus with greatly developed processes, or show ma- lignant degeneration. Carcinoma of the larynx or of the vertebral column often interferes with the act of deglutition, and very early. In the thoracic cavity, as well as in the neck, the esophagus may deviate lg STENOSIS OF THE ESOPHAGUS from compression. Cancer of the lung, of the pleura, or of the vertebral column must first proliferate into the peri-esophageal tissue before produc- ing marked dysphagia. Enlargement of the tracheobronchial or mediastinal lymph-glands from cancer, tuberculosis, or syphilis more frequently dis- turbs the act of deglutition; as the result of purulent liquefaction of the glands, broncho-esophageal fistula may form, and later, upon cicatrization, true stenosis or traction diverticulum may develop. A massive pericarditis or a cor bovinum scarcely ever produces dysphagia, and only exceptionally will the pressure of an aortic aneurysm narrow the lumen of the esophagus. These patients more frequently complain of constriction and difficulty of respiration upon swallowing than of actual difficulty in forcing their food downward. The disturbances in deglutition from the presence of a diverticulum of the esophagus are due to various causes, and compression of the organ by the filled sac is only one of the most important, but, neverthe- less, must be taken into consideration. The filled diverticulum may un- questionably completely occlude the passage into the stomach. If it is empty, food as well as the sound will often pass. This variation in the permeability has a certain diagnostic importance. The differentiation between compression stenosis and other forms of narrowing of the esophagus is frequently not easy. Of utmost consequence here is the differentiation of compression of the esophagus by disease of the neighboring organs from cancer of the esophagus. In the esophagoscope the picture of compression stenosis may resemble that which we observe where there are infiltrating tumors of the organ. From one side a tumor with smooth, reddened mucous membrane protrudes into the lumen, and does not change its position upon respiration. The lumen of the organ deviates toward the side and is recognized as a small semilunar space, or it shows a funnel shape gradually tapering downward. This finding is not uniform; it may also occasionally be noticed in carcinoma. For the diagnosis of compression stenosis the examination of the thorax often reveals exact grounds of support; a retardation of one-half of the thorax upon respiration, the conspicuous appearance of veins upon the skin of the chest, dulness or abnormal pulsations, are important factors; expectoration, par- ticularly if hemorrhagic, true hemoptysis, the signs of infiltration of the lung, exudation into the pleura, painful points upon the vertebral column, all aid us in the recognition of the underlying condition. Finally, in stenosis of the lumen by compression, the nature of the dysphagia and the result* of probing may be characteristic. Occasionally, a crass disproportion may be determined between the results of probing and the ability to swal- low. Such a disproportion is also found in atony and paralysis of the esophagus, in tumors developing in the walls of the organ, occasionally also when foreign bodies are present, and in hyperesthetic conditions, but in compression this symptom is of special import. While with atony and paralysis of the esophagus the sound invariably passes unarrested into the TREATMENT 19 stomach, in compression we note resistance whenever the instrument is passed; this is usually slight, and may be overcome with comparative ease by the use of moderate force; even a very thick tube may pass under these circumstances, while the patient is scarcely able to swallow thin fluid. The muscles lack the power to do what the pressure of the hand which guides the sound can achieve. Moreover, it is noteworthy that in these cases of compression forced probing, provided an aneurysm is not present, is not dangerous and is well borne; traces of blood are scarcely ever noted upon the bougie or in the fenestra of the tube, which, without exception, is always the case in carcinoma if the esophagus be energetically sounded. Where such a result of probing is combined with the esophagoscopic finding sketched above, carcinoma of the esophagus may be certainly excluded, for with a carcinomatous infiltration of the esophagus producing a prominent tumor, such as we have described above, the lumen of the organ must, under all circumstances, be decidedly narrowed, and we find it is impossible to pass a thick sound. The differentiation from one another of the various kinds of stenosis which we have here separately analyzed is of the utmost practical value; it is naturally not always possible to make an exact diagnosis, but much is already gained if we are able positively to exclude carcinoma. If it be doubtful whether cancer is present or not, and in my opinion this is frequently the case, in the interest of the patient all possibilities should be carefully investigated and treatment be directed accordingly. Thus, in the last few years, I have been able by energetic iodin treatment to keep alive two cases of suspected carcinoma of the esophagus, because I made a correct diagnosis of compression stenosis of the esophagus, and was right in assuming syphilitic enlargement of the glands to be the cause of the obstruction. In many cases, even by the aid of the esophagoscope, it is impossible absolutely to define the difficulty, but this must not prevent us from mak- ing every effort to clear the complicated situation. Certainly the great majority of cases of stenosis of the esophagus are incurable, but, in the minority in which the affection is recognized, therapeutic success is possible, and, even if we do not cure the others, we can benefit them by treatment, and, by the clear insight which we have obtained of the character of the disturbance, can bring about a decided amelioration. TREATMENT In the treatment of all stenoses of the esophagus some general thera- peutic rules are operative concerning hygiene and dietetics. As the total intake of food is frequently lessened on account of the difficulty of degluti- tion, such patients emaciate, even in cases in which there is no malignant process. Accordingly a leading and important object of treatment is to 20 produce a favorable influence upon nutrition. Nourishment should always be plentiful, and, under some circumstances, it should be calculated to in- crease flesh. It need scarcely be mentioned that in the solution of this problem great, frequently insurmountable, difficulties are opposed, yet even here much may be attained by the proper choice of food, and by the utiliza- tion of all auxiliary methods for artificial nutrition. We should make it a rule that the patients take only such food as we know will pass easily through the narrow space; for it is possible to take sufficient food even though it be in the thinnest of fluids. Trials with coarser food, in many cases, only increase the local irritation, and thereby make it more difficult to swallow liquid food. Large particles may be arrested, and thus render the stenosis completely impermeable; connective tissue shreds, in particu- lar, which adhere to particles of fat and meat, obstruct with extraordinary ease a lumen which is already narrowed. For this reason we must exercise the greatest care to have the particles of meat, vegetable, etc., as small as possible, and where we are not certain that the patient masticates the food thoroughly with his teeth, these, so far as permitted, should only be given in a crushed form. That foods with skin, stems, kernels, and husks are forbidden is self-evident, but even highly seasoned or spiced food (mustard, etc. ) , concentrated alcohol, or very acid foods, are to be avoided on account of their irritative effect. The same is true of extremes of temperature. Lukewarm or slightly cooled fluids are easiest to swallow, and this does not contradict the fact that occasionally, where there is marked congestion and swelling, ice may be well borne; food of a low temperature is not suitable for prolonged use, as it unfavorably influences gastric activity. Naturally, the food in its composition should contain all the important nutritive elements, and as we are able to administer not only salts and carbo- hydrates but even fats and proteids (the latter, for example, in the form of artificial foods) in a form soluble in water, it is quite possible to nourish the patient sufficiently in those cases in which only a thin fluid passes. I attach especial importance to the administration of fat in the form of melted butter, or olive oil, or cream. Apart from the high combustion value by which it is distinguished above all other food, it is particularly advisable because it makes the bolus soft and slippery, and because, adhering to the mucous membrane, it protects the same, thus diminishing the irrita- bility of the inflamed parts; sometimes it will trickle through a stricture when even water is regurgitated. The arrangement of meals and the manner in which they are eaten is of vital importance. All over-exertion of the diseased organ should be avoided. The patients are therefore advised to swallow slowly, with pauses between; where compact food is taken, the ingestion of thin fluid after each bite will facilitate its passage. Each meal, therefore, should consume a comparatively long time, even when only small amounts of food are eaten, but this does not matter; such patients should be encouraged to eat very TREATMENT 21 often. That mental rest and bodily relaxation are beneficial here is true, all the more so as unfavorable nervous influences very readily aggravate the disturbance in swallowing, even in those cases in which a carcinoma is present. The avoidance of all unnecessary exertion is absolutely essen- tial for the purpose we have in view, namely, to improve the nutrition. Not rarely we observe that with complete rest in bed the power of swallow- ing improves. It need hardly be mentioned that everything that stimu- lates the appetite and increases the power of assimilation (fresh air, massage, wine, etc.) will aid in the treatment. Further curative measures in patients with stenosis of the esophagus depend upon the nature of the underlying process. Let us first consider the treatment in the cases which are in the majority, in carcinoma. The object in cancer is this, to maintain the patient in such a condition that he is able to ingest fluid or pappy food readily, or, at least, without decided difficulty. We attempt to keep the stenosis from becoming impermeable, but it is not our aim to extend our therapeutic endeavors beyond the limit just mentioned, and to bring about greater ease in swallowing more com- pact food no matter at what cost. If it is clear to us to what the dysphagia in cancer of the esophagus is due, the two possibilities which are present here, and to which I have already called attention, will, above all else, prevent this. In the first place the disturbances in deglutition are pro- duced by a mechanical obstruction, by infiltration of the walls, or by the proliferating neoplasm. The second factor of no less consequence is the damage to the nervous and muscular apparatus of the esophagus, which, in some of the cases, is in an extremely irritable condition, and reacts abnormally as soon as food reaches the ulcerated, inflamed area. This reaction frequently manifests itself as spasm, during which not a drop of fluid will pass the stricture, yet the same patient, after a preceding hypodermic injection of morphin, may readily swallow solid food. At other times atonic conditions react unfavorably upon deglutition in that portion above the cancer, and even in the areas in which there is no dilatation. From hyperesthesia of the inflamed parts, by over-exertion, etc., irregularity and weakness of function may arise and lead to an interruption, or, at least, to a disturbance of peristalsis which manifests itself by an unfavorable influence on the muscles, sometimes the longitudinal, at other times the annular, the final result, however, being the same, namely, a disturbance of deglutition. If we observe these points, we must distinguish the treatment of me- chanical obstruction from that of irritative conditions and atony. The former is a very unsuitable point toward which to direct our treatment; in general more harm is done here than good, yet all the more must we attempt to relieve the local irritation and weakness. Besides a bland diet, we must prohibit any food that does not pass easily, anything that may 22 STENOSIS OF THE ESOPHAGUS cause regurgitation, and must consider an anesthetic process. Morphin administered internally is often beneficial; the objections to its prolonged use (becoming accustomed to the poison, and loss of appetite) are naturally not slight. Morphin may be administered alone, or in combination with cocain or antipyrin or menthol in the form of compressed tablets, which are slowly dissolved in the mouth; I use these very frequently in high- seated carcinomata which are near the larynx and pharynx, or which attack these organs (for example, morphin muriate 0.0025, cocain 0.0025, anti- pyrin 0.1, sacch. 0.3. M. f. tabl. compr. dos. 30; one tablet several times daily, immediately before eating) . Where morphin fails of success, I resort to local anesthesia. With the aid of the esophageal syringe devised by me (a simple syringe with a capacity of about 3 grams, and to which a fine tube of about 25 to 35 cm. in length is attached) I inject, reaching the point of the affection, a three to five per cent, eucain solution, at first twice daily, later less frequently: doses of from 2 to 3 grams of the solution per day are well borne and do not give rise to symptoms of intoxication. There are also cases in which cauterization of the hyperesthetic inflamed mucous membrane with a 1-3 per cent, silver nitrate solution may prove beneficial. The improvement is sometimes remarkable, even though, for the most part, only transitory; hut, nevertheless, this process assists materially in attaining the object sketched above, namely, the retention of the patient's ability to swallow fluid and pappy food. The process of injection is quite simple, and may be employed by any physician; it can never do harm, but only good. The same may be said of mild measures to combat atonic and ectatic conditions here, above all, mild lavage of the esophagus with the same instrument which we employ for the stomach is advisable and readily carried out; mucous masses, obstructing coagula, remains of food, foreign bodies, products of decomposition, etc., are thus removed, and, simultaneously, this cleans- ing process acts also as a kind of massage, and has a tonic effect upon the muscle. All of these auxiliary measures are more worthy of trial in the treat- ment of the carcinoma than probing, by which the mechanical obstruction which causes the disturbance is increased. In my experience the majority of all malignant neoplasms are unsuitable for treatment by the sound, and only in a few cases have I been convinced of an improvement in degluti- tion by this process. So long as the patients are able to swallow fluid and pnppij food, I avoid every process which dilates mechanically. In such cases we must be content with the existing condition, for the probability of attaining anything more satisfactory by sounding is very slight. If the ability to swallow is markedly disturbed, so that deglutition of thin fluids is only accomplished with extreme difficulty, if anesthetics do not relieve the condition, if lavage simultaneously is without result, we can no longer refrain from dilating the stricture. It must be borne in mind that sound- TREATMENT 23 ing is never an insignificant procedure; it increases the irritability of the organ, the tendency to hemorrhage and ulceration, and adds to the danger of perforation. In probing, the hollow, fenestrated, hard rubber instruments may be used with advantage after being previously softened in warm water, but, nevertheless, by bending in the stricture, or even before they reach it, these are soon worn out. Solid bougies of the same material with a button-shaped or pointed end are more satisfactory, although they are not much more dura- ble. I have for years frequently employed bougies which were manufac- tured for me after Crawcour's method. They are made from rolled sheet metal, cut into spirals, the flexible part, 40 cm. long, making up the coils ; they terminate in a button-like attachment about l cm. in length, the upper part consisting of a solid steel handle 10 cm. in length. They are very flexible, find their way into the stricture even if it is excentrically situated more readily than other sounds, and are almost indestructible if kept clean (a diluted lysol solution and subsequent drying by heat are sufficient for cleansing purposes). In carcinoma we must be extremely cautious in the passage of the sound, and never employ the slightest degree of force. The sound, which will barely pass, is allowed to remain for a few minutes ; it should be introduced every other day, not oftener, for the diseased mass reacts to every irritation, bleeds readily, and thus edema and pain are rapidly produced. Often it is difficult to reach the narrow canal from the dilated portion above the stenosis, especially as this passage is not always straight; portions of the tumor may occlude the opening, or the sound may bend and be pressed against the wall of the organ, where even slight pressure may be followed by the most serious consequences. If the open- ing into the canal is not readily found, further manipulation should be stopped for a time; if, however, we succeed in passing an instrument of considerable size, at the next trial we should try most carefully to pass one a size larger. If we succeed in this, a still larger one may later be used. In the main, we must be careful to use no force in this method of treat- ment, but should rather be content with moderate success, and avoid too frequent and too prolonged soundings. It will not rarely surprise us that although, for example, No. 5 passes readily, at the next attempt No. 2 can hardly be passed through the obstruc- tion; acute swellings have appeared, or the tumor, in consequence of irrita- tion, shows a more pronounced growth into the lumen of the canal. On the other hand, it may happen that the narrow passage will suddenly become permeable for compact food and thicker bougies owing to the removal of obstructions by ulcerative decomposition on the part of the tumor masses. If it is impossible to introduce a bougie in the usual manner through the narrowed esophagus, the attempt may be made with the patient in the recumbent posture, eventually with the aid of the esophagoscope; instead of working in the dark we may occasionally find the entrance to the canal 24 STENOSIS OF THE ESOPHAGUS immediately, and we may sometimes succeed in cases where we have pre- viously failed. For this purpose I employ spiral bougies (see above) or English bougies with a solid metallic guiding staff. For dilatation of esophageal stenosis, still other instruments have been employed. Senator was the first to introduce laminaria tents of varying thickness into the carcinomatous stricture to attain a dilatation by their gradual swelling. The laminaria tent was fastened by a screw to a thin, flexible bougie. I have entirely abandoned this method in the treatment of carcinoma; but the idea may be well utilized in the dilatation of other strictures if the laminaria tents armed with a silk thread under the direc- tion of the eye and by the aid of the esophagoscope are introduced into the narrow passage, and are permitted to remain from three to ten hours, perhaps even longer, and the tents are then drawn up by the silk threads. Dilatation may thus be promoted with extraordinary rapidity. We may soon convince ourselves that there is no danger in this process, and in des- perate cases I have obtained from it excellent results (see below). To produce a slow and careful dilatation, Schreiber advises a dilator consisting of an ordinary, thin, non-fenestrated stomach-tube, at the esophageal end of which a rubber tube 2 to 3 cm. in length is attached, which again terminates in a smooth firm point. At the opposite end of the sound there is a metallic attachment which is connected with a suitable syringe having a capacity of from 10 to 30 c.c. The sound is introduced through the narrow passage, water being injected into the sound so that the rubber piece fills and expands. The tense, elastic balloon we now attempt to withdraw through the narrow passage. This, in fact, is ex- tremely difficult, but with great care quite decided pressure is exerted upon the internal walls of the stenosed area. This process I very rarely employ in carcinomatous strictures, as they are generally too unyielding to respond to the pressure. But the method is well adapted to soft, recent, cicatricial tissue, and to overcoming spastically stenosed areas. [Professor B. W. Sippy, of Chicago, has invented an instrument for the dilatation of spasmodic and other strictures of the esophagus, especially canliospasm (see Fig. 1). The instrument is especially applicable in hypertrophic stenosis of the cardia due to long standing cardiospasm. It has been successfully employed in several patients. In two patients under my charge the result was notable. In one, a woman with long standing canliospasm and apparent hypertrophy of the circular fibers due to the spasm of the cardia. and with considerable dilatation of the esophagus, three applications of the instrument resulted in complete relief. Other methods 1 ailed after a trial of several months. The instrument is applicable in cases of organic stricture, but should then be used with extreme caution. ED.] In conclusion I must mention the treatment with a permanent cannula which was so strongly advised in foreign countries, was tested by Leyden and Renvers, and has been of late especially praised by Curschmann. The TREATMENT 25 cannula employed for this purpose is best manufactured from elastic ma- terial, it should be 10 to 12 cm. in length, and have at its point a width FIG. 1. The Sippy Dilator. [The dilator consists of a rubber bag 3 inches long and 1J inches wide when col- lapsed. At an upper corner of the bag a firm, piece of rubber tubing about 20 inches long is attached. Another piece of rubber tubing 3 inches long is secured in the center of the inside of the rubber bag. The lower end of this piece of tubing is closed; the upper end remains open and is secured air tight in the wall of the rubber bag. The tip of a whalebone bougie introduced into this compartment guides the bag into the seat of the stricture. The essential feature is a bag made of thin firm cloth which encloses the rubber bag, and limits accurately the degree of dilatation. The length of the cloth sac should be about 3 inches. Its width determines the degree of dilatation. In dilating strictures due to spasm the width of the cloth sac should be about 6 or 7 cm. for adults. Smaller sizes must be constructed for children and for dilating strictures due to malignant growths and cicatrix. The cloth sac must be uniform in width. When ready to introduce, a rubber condom is slipped on over the collapsed dilator and tied loosely about the rubber tubing and bougie. The distance of the stricture from the teeth is measured and the collapsed dilating bag guided well into it. A firm rubber bulb such as accompanies an ordinary Paquelin cautery may be used as an air-pump. The dilating force that may be applied directly to the stricture is enormous, but limited accurately by the size of the cloth sac. ED.] and lumen of about 5 mm. and above of about 12 mm. Such a cannula is introduced by means of a whalebone stylet with two ivory buttons; the lower button serves as an obdurator. The upper is larger, and permits 26 STENOSIS OF THE ESOPHAGUS the introduction of a tube which is held by means of a silk thread. After the stylet has been withdrawn the thread is fastened upon the cheek. The advantage of this process is that nourishment, either fluid or pappy food, may be introduced in quite large amounts without difficulty. It is also said to prevent the decomposition of the cancer, as the food does not come in contact with the tumor. My experience with the use of permanent cannulas is not particularly favorable. The retention of the silk thread in the mouth is uncomfortable to the patient ; if it is drawn through the nose, it irritates the epiglottis and the pharynx, and is most unpleasant to some patients, for example, if catarrh of the larynx or of the pharynx, which is so frequent, is present. The mechanical irritation of the carcinoma is also not to be underestimated. Encircling of the tube by its growth, and clogging of the same, are not rare. The most unpleasant feature, how- ever, is this, that occasionally in withdrawing the cannula the thread breaks, and we are then compelled to remove it with the esophagoscope, and this may be a very difficult operation. Above all it must be remembered that this cannula treatment is only adapted to patients in whom a tube of from 5 to (i mm. still passes the obstruction. There are, however, patients in whom for some time sufficient nourishment may be introduced according to the method I have first described, without subjecting them to particular discomfort. The methods with laminaria tents and with the rubber ball sound presuppose a certain permeability of the stricture, although not to the extent necessary for the cannula, but this is evidently one of the reasons why these methods have not been more frequently resorted to in the treat- ment of carcinoma. If the stricture is too narrow, so that probing with and without the esophagoscope gives no results, and the local application of drugs to com- bat the hypcresthesia and the spasms affords no material relief, when, there- fore, the condition is such that, in spite of all endeavors, no fluids, or only slight amounts, trickle through the esophagus, and the patients rapidly emaciate, in my opinion the time has arrived for surgical interference. But before deciding upon this, I would urgently advise the simple trial of putting the patient to bed for a few days, with absolute rest, and to nourish him by the bowel, entirely refraining from the introduction of food by the mouth. Hunger and thirst may be allayed by small doses of cocain (O.Ov! per dose, two or three times daily), and the mouth and pharynx should be frequently rinsed with ice water. A favorable change is often noted in that the local condition improves decidedly. After these few days of rest, the passage is likely to be decidedly more free than it formerly was, and the introduction of the tube or the injections may be resumed should this appear advantageous; sometimes it is unnecessary, for we find that if such patients are nourished with enemata on one or two days in the week they are able to swallow quite well during the remaining period, particu- larly if small doses of morphin are simultaneously administered. In this TREATMENT 27 stage of the disease we have little hope of long averting the catastrophe, but whether in this crisis gastrostomy will greatly avail appears to be very questionable. In my opinion, only in the most unfavorable cases is the production of a gastric fistula indicated. This operation is, in truth, for me the ultima ratio, notwithstanding the fact that the operation, through the successes of prominent surgeons, has become a relatively safe one, and that the fistula functionates perfectly for a long time. Gastrostomy appears to be abso- lutely indicated when broncho-esophageal fistulce cause the continuous passage of food into the wrong channel, when imperfect permeability of the esophagus for any kind of food exists, and, finally, when in an early stage of the disease impassibility occurs and causes a rapid loss of strength. In well-advanced cases, with decided stenosis of the lumen, a marked pro- longation of life, a noticeable improvement in the general nutritive con- dition, and a decided amelioration of the dysphagia is not to be expected from the operation. As a prophylactic measure there is not the slightest reason for early operation while there is still sufficient permeability of the esophagus. The radical treatment of cancer of the esophagus by extirpa- tion could only come into question with high-seated tumors ; up to this time not a single case of recovery has been reported. This is partly due to the great difficulties which the surgeon must combat, but partly also to the fact that the diagnosis is not made early enough. The more thorough use of the esophagoscope may, perhaps, be productive of better results inr the near future. Of other symptomatic treatment, I shall only mention the irrigation of the esophagus with disinfectant solutions (thymol 0.5-1000, salicylic acid 1-1000, silver nitrate 1-1000, etc.) to remove the symptoms due to stagna- tion (fetid odor, eructations). For the catarrh of the pharynx, of the larynx, and of the bronchi, which so frequently accompany the condition, I employ Ems water, morphin, etc.; the salts of iodin, also, bring about amelioration by thinning the tough mucus. The many neuralgic pains are relieved by our reliable antirheumatics. The therapy of cicatricial strictures must be constructed on principles entirely different from those that come into question in carcinoma. Here there is a possibility of preserving life, under favorable circumstances of permanently curing the local lesion, and here dilatation of the stricture is the most important aim of the treatment. The results depend very much upon the methods of procedure. We shall first describe the simplest process, that of sounding. It is generally admitted that slight pressure is permissi- ble in shoving the instrument through the narrowed cicatrized area, and that it may be permitted to remain for some time (from three to fifteen minutes). Daily probing is not always advisable; often a certain amount of forbearance gives better results, so that the method is only employed 28 STENOSIS OF THE ESOPHAGUS every second day. If we are dealing with an excentrically layered canal, or with a somewhat circular narrow pass, the metallic spiral probes such as I advised many years ago, appear to me to be the most suitable in- struments. If the way into the stricture may be found more easily, it is quite immaterial of what the dilator is made. Sounds with a button of whalebone, or English or French bougies, may be employed. If it is impos- sible to attain our end by the usual sightless method, before we conclude upon further surgical procedures (esophagotomy, gastrostomy) we should always make an attempt to probe with the aid of the esophagoscope. In apparently quite desperate cases I have at last succeeded in finding the entrance to the stricture, and in passing it with a fine instrument. The process is laborious, but the results are sometimes brilliant. For dilatation with the esophagoscope, I am partial to the use of metallic spiral sounds, or so-called " director sounds," i. e., narrow bougies of impregnated tissue which terminate in a quite long metal staff that permits of firm direction. Occasionally I have also employed with advantage fine lead and zinc staffs to direct the passage through the obliterated organ. After finding the way a few times with the esophagoscope, I frequently succeed in attaining my purpose upon simple probing in the recumbent posture without the intro- duction of the esophageal tube, and if the canal has been at all dilated I resume the trial in the sitting posture with the ordinary sound. A number of little artifices, which I do not care to describe here, may facili- tate this process in difficult cases. If the cicatricial tissue is not too firm, and the narrowed pass not too long, I find Schreiber's sound, cautiously used (see above), particularly useful in producing dilatation with comparative rapidity. The treatment of cicatricial strictures by bougies should be begun as early as possible. This treatment should be carried out every day, and should be continued for a long time, for, even after extensive stretching, the tendency of cicatricial tissue to contract continues. Although we may attempt decidedly more in this affection of the organ than in carcinoma, cautious manipulation is 'nevertheless necessary, and it must be borne in mind that, besides cicatrices, ulceration may also be present, that the mucous membrane above the narrowing is frequently irritated and in- flamed, so that here, as well as in cancer, the disturbance in degluti- tion does not necessarily depend upon the mechanical obstruction alone, but may be due also to nervous disturbance, to a tendency to spasm, and to atony. There are, however, cases where the most persistent use of the bougie, even if it really pass through the constricted area, produces no noteworthy dilatation; and we often meet with cases in which it is impossible to pass the stricture with any of our instruments. In difficult cases of this kind, and sometimes in almost desperate situations, an attempt must be made to dilate in the esophagoscope with sounds or by the introduction of laminaria TREATMENT 29 tents at the starting point of the stricture. The latter process, which Ebstein has advised as a modification of the earlier Senator method (which see), I have repeatedly tested. For the introduction of the stylets into the stricture I employ forceps with smooth, concave, internal surfaces; if the entrance to the stricture is extremely small, the lower end of the tent is pointed, and cautiously pressed into the narrow canal. During this treat- ment the patient must be very carefully watched. At first the tent should be allowed to remain only for three to eight hours, provided there is no pain or fever, and later, for a longer time. Withdrawal is usually easy by the aid of the silk thread. In elongated strictures the process with the laminaria tent is an arduous one, and gives only very slow results. In these cases we should always try to attain our end by the introduction of long thin bougies by the aid of the esophagoscope. After we have found a passage, according to v. Hacker and Ebstein, dilatation may be facilitated under some circumstances by employing drains which are placed over a thin metallic introduction rod of about 2 mm. in size; if the staff is withdrawn the tension lessens, the drain contracts, and thus exerts decided pressure upon the wall, particularly if it is allowed to remain for a longer time, up to 24 hours. In my own experience the process is somewhat painful and not absolutely harmless; even with close watching of the patient, the jerking back of the rubber may occasionally cause a laceration in the wall of the organ. If we do not succeed by these methods, if the results are unsatisfactory in that deglutition is not facilitated, and the patient's nutrition now suf- fers, gastrostomy should not be too long delayed. By producing a gastric fistula, we need no longer be anxious about the nutrition, we may influence favorably the irritation and inflammatory condition created in the esophagus by the inactivity of the organ, and may devote ourselves to the object of restoring its permeability. For this time is often necessary, much time. Besides, there is the added advantage that through the wound produced by gastrostomy we may attack the focus of the disease in the esophagus. Primarily this is possible by means of bougies, and cases have been reported where dilatation has been produced from below at a point which could not be reached by sounding through the mouth. This presupposes that the fistula is located in such an area that from it we may with comparative ease reach the cardia. This, unfortunately, is not the case with the fistulas commonly produced by Witzel's method; their advantage consists in their permitting an excellent occlusion, but manipulation with sounds from the gastric opening is exceedingly difficult. There are methods, however, which, even under these circumstances, may be quite well employed for dilatation. The simple experiment, after Socin, with silver balls which are fastened to a silk thread should first be tried. A very small one may be swallowed by the patient in the evening, and we are sometimes surprised to find that in the course of the night it has found its way into the stomach. Various 30 STENOSIS OF THE ESOPHAGUS processes have been devised for securing through the fistula the silver thread which has been fastened above through the cheek. The stomach may be filled with water or soup, and these fluids are then permitted rapidly to How off through the tube : not rarely the thread will be carried with them. Or slightly curved instruments (dressing forceps) must be introduced into the stomach and an attempt be made to catch the thread while the patient assumes different positions, and to draw it into the fistulous canal. If this is successful the ends of the silk thread are fastened together, the ring is closed, a fine rubber drain is inserted within it, and an effort is made to draw this through the stricture. Then larger drains may be employed, and the stricture be thus dilated. But we must not be too hasty, and too forci- ble pulling upon the thread must be avoided, as this causes great tension in the narrow pass, and the danger of injury is not inconsiderable. It must be mentioned that csophagotomy may also be occasionally em- ployed if it can be carried out below the obstruction. Nutrition is possible through the fistula, and, under some circumstances, dilatation may be attempted at the opening in the neck. Here, however, it must be observed that a stricture in the opening at the neck of the esophagus may be diag- nosticated positively, but it is by no means certain that there are not also other impermeable ones in the lower part of the organ. Then we have to deal with a new obstruction. This we may occasionally remove from the wound in the neck by probing, or cutting, but such a process is always protracted, and, in the meantime, the exhausted patient may perish. Therefore in all doubtful and difficult cases it is wise to assure ourselves of the nutrition by the production of a gastric fistula. In the treatment of compression stenoses, sounding is also useful, and generally still more so than in cicatricial constriction, for we may manipulate the organ to a greater extent, the mucous membrane being everywhere intact. We are soon convinced that a decided improvement in deglutition is not to be brought about by bougies; but if, at regular intervals, we intro- duce sounds with fenestrated openings into the stomach the nutrition of the patient may be carried on satisfactorily, and thus inanition be prevented. This is all that we can really accomplish in patients with compression stenosis, if the treatment does not diminish the size of the tumor which causes compression or remove it. The latter, unfortunately, is only excep- tionally possible; for example, in syphilitic lymphomata by potassium iodid or an inunction treatment, in diverticulum by cleansing or extirpation of the sac. In spastic contracture of the esophagus, soundings may occasionally be of use; I have frequently brought about a lessened tendency to spasm at tin 1 cardia by over-distention -of the esophageal orifice of the stomach, for which Schreiber's rubber balloon sound serves the purpose best. This in- strument is carefully introduced into the cardia, perhaps by the aid of several attempts at deglutition, or by local anesthesia, when the balloon is TREATMENT 31 distended, and pulled through the cardia. Above all, however, we must endeavor to ascertain the cause of the spasm, whether inside or outside of the esophagus, whether produced by local disease, or whether the general condition produces the tendency to spasm. The etiological therapy which results from this is of vital importance, but, for this reason, the importance of the local symptomatic treatment is by no means to be undervalued. Be- sides sounding, the injection of remedies that produce anesthesia (eucain, 3 per cent.) or electricity by the aid of a simple esophageal electrode, such as I have proposed, may be of decided benefit. Where the spasm, particu- larly at the cardia, has produced secondary changes (dilatation, inflamma- tion), the resulting conditions are naturally to be also considered in treatment. In conclusion, a few remarks may be in order concerning the treatment of obstruction stenosis; polypus (an extraordinarily rare occurrence) should be removed surgically; in obstruction due to masses of thrush, irrigations and the use of borax (3 per cent, solution, a tablespoonful every two hours) internally, are very serviceable. When foreign bodies are lodged in the esophagus, we must above all things refrain from at once employing the sound. We must first endeavor to remove the object which has entered the esophagus by the mouth, particularly if it has pointed or sharp edges, for, if forced downward, these may give rise to dangerous symptoms in the stomach and in the intestines. Smooth bodies, for example, coins, even if large, are not very dangerous in their journey through the digestive apparatus. It is, however, of the utmost importance that (if possible) a foreign body be speedily removed, provided we may extract it under the direction of the eye. Esophagoscopy enables us to achieve this in many cases by a bloodless process, where formerly an operation was necessary; small pointed objects, particularly, are thus rapidly removed and without danger. Instead of the manifold instruments which were formerly neces- sary (coin catchers, hooks, esophageal probangs) we now, in most cases when employing the esophagoscope, use only a simple forceps. Combined with this an instrument constructed according to the principles of the Leroy curette may sometimes be useful. That a small foreign body which causes disturbance of deglutition may sometimes be removed by the admin- istration of an emetic must be also mentioned. Fissures and erosions which subsequently cause difficulty are best treated by the application of caustic under the direction of the eye, provided rest of the organ and morphin do not bring about rapid recovery. If the foreign body reaches the stomach, the old efficacious potato treat- ment for its expulsion per anum is still the best method: For three or four days the patient is given daily 3 or 4 pounds of potatoes prepared in different ways, constipation being induced by the administration of the tincture of opium; then the bowel is cleansed by enemata or the adminis- tration of castor oil. 4 THE HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE BY W. FLEINER, HEIDELBERG AT the turning point of the century the treatment of gastric diseases has reached a high degree of development. This progress has taken place upon the fruitful soil of an exact method of diagnosis based upon precise indications, and the seed was the ingenious idea of Kussmaul promulgated about a lifetime ago : Introduce a tube into the stomach, remove the ab- normal contents by washing, and treat locally the diseased gastric mucous membrane. Up to the middle of the previous century, but few of the pathologic changes of the stomach could be recognized with certainty, not even those for which pathologic anatomy had already furnished an explanation. Our knowledge of functional disturbances of the stomach was even more obscure. Digestive disturbances whose organic foundation was unrecognizable were attributed, according to the views of the time, to pathologic processes of the stomach, and were thus treated. Naturally empiric treatment of an assumed affection could only produce unsatisfactory results such as we sometimes attain even to-day when a greatly eulogized remedy is used to relieve a prominent symptom in a clinical case. The modern physician who has been trained to employ his therapeutics according to definite indications and with clear ideas possesses also, with- out effort on his part, an advanced technic which is the fruit of the labor of his predecessors; he can scarcely realize the conditions in that time when modern auxiliary measures did not exist, yet in these we have not advanced to the fullest extent. And he will correctly measure and fully appreciate the value of his inheritance only when he studies its historical development and considers the labor that has brought to completion so great a work. THE HISTORY OF GASTRIC LAVAGE At the close of the sixth decade of the preceding century, dilatation of the stomach, particularly that advanced form developing from narrowing and closure of the pylorus, was reckoned among the diseases most difficult to treat. " Only exceptionally," says Kussmaul, " did we attain any results 32 THE HISTORY OF GASTRIC LAVAGE 33 in the treatment of this distressing affection. As a rule, little could be done to ameliorate the sufferings, and nothing to cure." Cases of this kind were looked upon as hopeless, and for this reason were not welcomed in hospitals and clinics. Thus Kussmaul, at that time Director of the Freiburg Medical Clinic, was disinclined to admit to his Clinic, which was then greatly overfilled, a country girl, Marie Weiner, from Heimbach, aged 25, who sought admittance upon April 15, 1867. She had been suffering from a gastric affection since her eleventh year, having an extreme dilatation of the stomach due to pyloric ulcer, hypertrophy of the pylorus, and chronic catarrh of the stomach ; she was greatly emaciated and suffered besides from peculiar spasmodic attacks which are now known and dreaded under the name of gastric tetany; however, at the repeated urgent entreaty of the patient, Kussmaul relented and admitted her to the Clinic. This patient suffered almost daily from gastric pain and vomiting, and passed sleepless nights of suffering unless relieved by the administration of morphin; her pitiful condition gave Kussmaul the idea of employing the stomach-pump. His considerations and reasons were as follows: " Quite frequently, when I observed the patient in the miserable pro- dromal stage of vomiting, the thought had occurred to me that I might ameliorate her sufferings by the employment of the stomach-pump, as the removal of large masses of decomposed acid gastric contents should cause the agonizing burning and retching at once to cease. The introduction of the esophageal sound was naturally not difficult, for where a gastric dilata- tion has existed for so long a time the esophagus also is usually dilated. The artificial emptying of the stomach by the pump could be no more painful or distressing than her condition before and during vomiting. At all events, it would be more rapid and complete than the natural emptying of the stomach by the act of vomiting, with its prolonged prodromal stage of nausea, pain and retching. Eepeatedly, even after vomiting, palpation and percussion revealed that the stomach still contained considerable masses. This condition reminded me of the so-called ischuria paradoxa, in which large amounts of urine flow daily from the dilated urinary bladder with- out its actually becoming empty and without reducing its circumference. By means of the pump we must succeed in emptying the stomach completely, and, if its elastic and contractile power have not been entirely exhausted, perhaps even give to it the tone to contract to its smallest extent, just as the catheter occasionally brings about recovery in ischuria paradoxa. " In our patient the gastric dilatation was due to constriction of the pylorus. At the autopsy of cases of extreme gastric dilatation I had repeat- edly observed that the stenosis which caused them would still permit the passage of a small finger from the stomach into the duodenum, although toward the end of life there had appeared to be complete closure of the pylorus. In such cases I had occasionally noted at the bedside through 34 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE the abdominal covers active movement in the stomach. A paresis of the gastric musculature might be present, but certainly not complete paralysis. It appeared to me as though the excessive distention, the filling and over- loading of the stomach itself, produced a mechanical action which increased the constriction of the pylorus to complete closure, and this condition I hoped to remove by emptying the stomach and decreasing its size. " Finally, it appeared that the employment of the stomach-pump would permit a more active topical treatment of the diseased gastric mucous mem- brane than was formerly possible. In the case of our patient this organ had for years been continuously irritated by extremely acid contents. The retention, stagnation, and decomposition of masses of food in the stomach because of pyloric stenosis is certainly often the only cause of the catarrh of the mucous membrane; as, for example,, in cases in which originally there was but an ulcer or a cicatrix at the pylorus, the stomach being other- wise intact ; in all other cases it probably maintains and increases a catarrh already present. This is probably why we note so constantly, in constric- tion of the pylorus, that the mucous membrane about the pylorus, where the gastric contents especially accumulate, shows most intense disease. The stomach-pump, I hoped, would not only make it possible completely to evacuate these acid, irritating masses, but would also permit the washing and cleansing of the diseased mucous membrane which had been irritated by acid and alkaline fluids, as, for instance, with Vichy water or with an artificial soda solution." In pursuance of these considerations Kussmaul, upon July 22, 1867, for the first time, pumped and washed out the stomach of his patient. " The introduction of the stomach-tube, the pumping out, and the wash- ing with Vichy water were unexpectedly easy. We withdrew three liters of acid, dirty-grey, sarcina-containing fluid, with particles of food of all kinds undergoing softening and decomposition. " Even the immediate result of the first emptying and washing of the stomach with Vichy water was a surprisingly beneficial one. The patient, who was previously always exceedingly disagreeable, and of such a whining disposition that she well bore out her name, 'Weiner' (crier), appeared a few hours later as if completely transformed. For the first time she was agreeable and appeared comfortable in her bed, and she declared that for years she had not been in such good spirits. She at once digested and slept much better, and for two days was entirely free from depressing sen- sations in the stomach. After repeated employment of the pump, at the cud of fourteen days the patient had a more healthy appearance, and had become another being. She who had always been disagreeable, had lain in bed or reclined in an arm-chair, was up the whole day, was very friendly, and attempted to make herself useful about the room, and soon in other parts of the house. In the first three months of her stay in the hospital, and before the employment of the pump, she had gained at most about 5 35 pounds in weight ; two months afterward she had gained at least 16| pounds, and in not quite six months, 24 to 25 pounds. For two years recovery has been complete, although the patient is by no means in easy circumstances." The first communication regarding this new method of treatment of gastric dilatation was reported by Kussmaul at the first meeting of the Section of Internal Medicine of the Forty-first Congress of German ]STatu- ralists and Physicians in Frankfort-on-the-Main in September, 1867. Fur- ther observations and experience regarding this treatment, which, in the meantime, had become a method of gastric dilatation, were communicated by Kussmaul in his Freiburg pro-rector oration on the 9th of September, 1869, and in his classic treatise in the Deutsches Archiv filr Klinische' Medicin, vol. vi, 1869, which has become widely celebrated : " On a New Method of Treatment of Gastric Dilatation by means of the Stomach Pump." Besides the new method of treatment, this epoch-making work of Kuss- maul's furnished such an enormous amount of clinical material and so many new points of view for pathology, diagnosis and treatment that it became the foundation, and even a treasury, for most of the later investi- gations in gastric disease. Besides benign constriction of the pylorus from ulcers, cicatrices, hypertrophy, and malignant constrictions from cancer, here was found the complete clinical investigation of the simple dilatations of the stomach not dependent upon stenosis of the pylorus or of the duo- denum, those due to atony of the muscularis in consequence of too great weight and extension of the stomach beyond its elasticity from polyphagia, or paralytic weakness in convalescence from exhausting diseases, for exam- ple, enteric fever, or which had been produced in nervous anemic condi- tions, as well as paresis of the gastric musculature in consequence of fatty and choloid degeneration of the muscular fibers. The definite mechanical factors were also considered which occasionally during life had caused symp- toms of complete closure of the pylorus while in the cadaver a small finger could readily be passed through the narrowed pylorus into the duodenum. The descent in gastric dilatation of the pyloric portion of the stomach which is most bulged out and implicated, and the formation of the fetal (vertical) position of the stomach were also discussed, as well as the possibility of a reflex tonic spasm of the hypertrophied pylorus, which is manifest to a decided degree in consequence of the irritation of the sensory nerves of the pyloric region produced by the acid contents which cause increased peristalsis in this neighborhood. That this increased irritation of the gastric mucous membrane from stagnating gastric contents produces reflexly an increased, even continuous secretion of fluid, and not only of HCl-containing gastric juice, was at that time unknown to Kussmaul. It did not. however, escape the sharp eye of the investigator that in his patient suffering from tonic muscular spasm the amounts of fluid ejected by vomiting and brought up with the 36 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE stomach-pump were much greater than those introduced; he also noted the decidedly diminished amounts of urine in such patients. Kussmaul believed for a long time, as I know from his personal communications, in a kind of transudation into the stomach, but he was unable to furnish exact clinical proof of such an influx of fluids; as is well known, this ex- perimental success was achieved only a few years ago (1893) by v. Mering. On the other hand, the significance of the marked, and often rapidly occurring, losses of water in some cases of gastric dilatation was quite clear to Kussmaul; he considered the tonic muscular spasms which were first described by him (so-called gastric tetany) to be the consequences of rapid inspissation of the blood and a drying of the nerve and muscle, and con- sequently, at that time, he laid great stress upon the introduction of fluid in the form of meat, broth, and wine enemata, which were absorbed in the intestine with beneficial effect. As an additional therapeutic resource which we obtained simultaneously with the stomach-pump, we must mention Kuss- maul 's experience that the dilated stomach which is no longer capable of retaining large amounts of fluid or food is still able to force into the intestine small portions given at stated intervals, and, finally, the employ- ment of the liypogastric bandage to prop up the descended and dilated stomach. Kussmaul, in his classic work, refers at different points to the variation of the stagnant contents of dilated stomachs in regard to amount, and to the appearance, the composition, and the degeneration of the gastric juice, in such a manner as to sound like a challenge to investigators to attack these questions. In truth, all of the clinical laboratories, particularly in Kussmaul's Clinic, were actively at work on this line, but were interrupted by the Franco-Prussian war and, later, by the great clinician's removal from Freiburg to Strassburg. The contents of diseased stomachs and, later, those also of healthy stomachs, were subjected to chemical, physiologic, and subsequently also to bacteriologic, investigations. Normal and patho- logic processes of digestion attained more and more prominence, both from a clinical and a professional standpoint. With an eagerness without parallel, the tube was introduced into the stomach and gastric contents were brought up as if buried treasures were being restored to daylight. Thanks to these eager investigators, we gradually became aware of the importance in diagnosis and prognosis of the presence or absence of hydro- chloric acid, not only in gastric dilatation but also in gastric affections in general. Simple color reactions were found which, even at the bedside, showed the qualitative presence of hydrochloric acid and of organic acids, whilo analytical methods by measure and weight were formulated in great numbers to determine quantitatively the gastric acids. In connection with physiologic experiments in digestion to show the activity of the enzymes of the gastric juice, and their presence or absence, these quantitative analyses also made it possible to test the function of secretion of the gastric mucous THE HISTORY OF GASTRIC LAVAGE 37 membrane and the digestive power of the gastric juice. We learned to recognize an amylolytic and a proteolytic stage of gastric digestion, also the difference between combined and free hydrochloric acid. Gradually a period dawned in which we believed that the activity of the stomach and the degree of its digestive disturbance could be definitely measured accord- ing to the amount of hydrochloric acid present, and the other functions of the stomach, especially its motor activity, were not sufficiently appre- ciated. A reaction took place. In the meantime, however, the number of methods for estimating free and combined hydrochloric acid became enormous, and the literature of this subject has become so extensive that it can scarcely be reviewed; the future will determine what portion of this is necessary, useful, and of permanent value. But, to return to our theme of gastric lavage, we must first mention the instrument which Kussmaul used to empty and wash out the stomach. Kussmaul first employed the stomach-pump of the American physician, Wyman, which, according to Bowditch's reports (1852), was also utilized in draining empyemata. Then, however, he had pumps manufactured by the instrument maker, Fischer, in Freiburg, after Wyman's drawings, and these were also made use of by Reich in Stuttgart who designated them as Fischer's stomach-pump, without any mention of Kussmaul's authorship. v. Ziemssen later ascertained that the honor of inventing this very use- ful instrument belongs neither to Wyman nor to Bowditch, but to a German instrument maker by the name of Weiss, who lived in London in the second decade of the last century. Ziemssen therefore proposed in 1870 that "the instrument which, by Kussmaul's brilliant discovery, rapidly attained such great distinction in the treatment of gastric diseases, should hereafter be designated as the Weiss stomach-pump." At first Kussmaul, after once emptying and cleansing a dilated stomach, only employed the gastric pump when new difficulties arose, such as burning in the stomach, acid eructation, pain, a tendency to vomit and similar symptoms. In consequence, the daily employment of the stomach-pump, particu- larly in severe cases, became more and more obvious, and it was also ascer- tained that for emptying and washing the dilated stomach, the time when the stomach was still empty, therefore, the early morning, was the best time. As long as the patients remained in the hospital, this operation could be easily and regularly carried out early in the morning upon an empty stomach. After discharge from the hospital, however, the patients are unfortunate, " for a busy physician cannot find time to use the pumps for such patients for weeks or even for many months with the desirable regularity." These reasons induced Kussmaul to teach the patients them- selves to introduce the stomach-tube, and to wash out their stomachs. His patients who had learned to introduce the stomach-tube and the stomach- pump for themselves as the clinical histories of the year 1869 show left the Freiburg Clinic with these instruments in their possession. It is very 38 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAV AGE interesting to note the use which a patient of Kussmaul's, a wool-spinner by occupation, made of the stomach-pump as soon as indigestion appeared. This patient by no means adhered to the directions which he had received in the Clinic, but, nevertheless, he improved steadily. If the foods which were forbidden, pastry, bacon, poor beer, or others, caused any great diffi- culty, he used the pump and washed them out often twice daily. " In comparison to this refined behavior of the Black Forest wool-spinner, how insignificant," says Kussmaul (1. c., page 498) "is the classic con- suetudo vomitandi of Vitellius and other celebrated gourmands of ancient Rome, who had at command only the maneuver of the palate-tickling finger or the feather." But, from the onset, Kussmaul was not content with the simple evacua- tion of the stagnating gastric contents. On the contrary he sometimes also employed the stomach-pump for irrigating the diseased gastric mucous membrane with suitable fluids, designed to have a curative effect, or to limit processes of decomposition and the proliferation of fungi (sarcina). First, natural alkaline waters were employed, Vichy and Vals, which, however, were gradually replaced by corresponding artificial soda solutions. For the latter purpose, borax solutions (4--iOO), phenyl acid solutions (25.0 creosote water to 400 of water), solution of sodium hyposulphite (4 to 8 grams to 400 of water), which, il was expected, would cause the formation of disinfecting sulphurous acid in the stomach, also lign. quassia amar. raspat., of which 30 grams were covered with 400 grams of cold water, and, after macerating for twelve hours, the colature was employed. The action of stomach washing was assisted by dietetic treatment, which com- prised the ingestion of small but frequent meals consisting of food which could be easily digested and contained nothing that might produce abnormal acids; also the employment of soda-containing mineral waters (Vichy, Vals) given in amounts of a ^ schoppen, one-half to one hour before breakfast or before the first meal, for the purpose of dissolving the tough mucus which had formed in surplus, to neutralize the abnormal acid, and to stimulate the secretion of normal gastric juice; finally, keeping the bowels open by means of sour milk, buttermilk, simple warm water enemata, and rhubarb. The great enthusiasm aroused by the first communication of Kussmaul before the Frankfort Naturalist Congress, and, even more, the general recognition in all professional circles of the world of the wonderful suc- cess of his method of treatment, when compared with other modes, as detailed explicitly in the Deutsches Archiv fur Klinische Medicin, led to the rapid introduction of the stomach-pump into hospital and private prac- tice. With the publication of Kussmaul's method of treatment, voluminous literature of the subject rapidly appeared which at first brought only novelty in regard to technic, various processes being described which permitted the non-employment of the stomach-pump, as this could not always be readily obtained. THE HISTORY OF GASTRIC LAVAGE 39 In Kiel, Dr. Schorer, the assistant of Bartels, in the absence of a Wyman pump used the ordinary laboratory air-pump. Jiirgensen, at that time professor in Kiel, inserted between pump and stomach a two-necked Woulff's bottle, in order to meet. the objection that all fluids discharged from the stomach passed through the metal boot, and thus corroded and damaged the pump which was very difficult to clean. Jiirgensen, however, soon noticed that the stomach-pump was only neces- sary until the tube was filled which led from the stomach to the low-lying Woulff's bottle : From that time on the indications for emptying the stomach by the action of a lever were given. Jiirgensen obtained the latter just as well by abdominal pressure as by the suction pump. For this reason the use of the stomach-pump was discontinued,, the stomach was no longer pumped out but evacuated. In his article : " An Addition to the Local Treatment of Gastric Dis- eases " (in the Deutsches Archiv fur Klinische Medicin, vii, 1870), Jiirgen- sen describes the simplest method embodying the lever principle, which he advises for the busy practitioner as the most serviceable, in the following: " By the aid of the tube which is introduced into the stomach the lat- ter, if empty, is filled with a fluid to be utilized in washing; naturally, if the stomach contains sufficient fluid this is unnecessary; then by means of a glass tube or a hard rubber and glass tube (1.5-2 meters long, and one centimeter in diameter) an ordinary rubber tube is attached to a sound. " The patient now stands upon a chair, and either coughs or retches. The flow from the stomach immediately begins. The emptiness of the stomach is indicated by a sudden jerking of the rubber tube; and the stream of outflowing water at once becomes thinner. " Thus, in a brief time, a large amount of fluid may be forced through the stomach. To be certain that my lever may actually be filled without difficulty by the prelum abdominale, I fill the stomach with water, and pay no attention to the slight inconvenience which the patient appears to experience." ( Jiirgensen. ) Compared with gastric lavage as practised to-day, this method described by Jiirgensen as the simplest appears to require considerable assistance from the patient who must get upon a chair with a sound in his stomach. Never- theless, we owe it to Jiirgensen that the pump was proven to be unnecessary. Jiirgensen did us the further service of attempting to substitute soft rubber sounds for the stiff French and English stomach sounds which were then in use. These stomach sounds were of very small caliber, and had upon their anterior end two or four small fenestra, in consequence of which they very readily became clogged with the remains of food and even with mucus. A very disagreeable feature for the patient was that, as soon as clogging occurred, the sound was taken from the stomach, cleansed, and reintro- duced. This process was improved by Jiirgensen who obtained from the 40 factory of Galante in Paris an excellent tube having a length of 70 cm., the walls being 2 mm. in thickness, and 10 mm. in diameter. This he tied with a silk thread over an acorn-shaped ivory button 2 cm. long in such a manner that the tube nowhere extended aboVe the level of the acorn. In the base of the lumen of the tube the ivory button had an indenta- tion 3 mm. deep, which was intended to receive the anterior end of a whalebone sound acting as a director to prevent its lateral deviation. Laterally, 2-2f cm. above the ivory button, a hole was cut in the tube corresponding to its lumen. Jiirgensen preferred one opening to several, chiefly because of the durability of the tube. If he poured water into one opening of the sound this flowed from it in a full stream, while the sound itself, owing to the well-known phenomenon of " rebound," would move with great rapidity in the direction opposite to the outflow. By this lateral deviation of the tube, Jiirgensen believed, especially by turning the sound on its longitudinal axis, that he was able to douche the stomach by the instreaming water. When it was desirable to prevent the lateral motion of the sound in the stomach, a second small opening, opposite the outlet, was sufficient for this purpose. The tube-sound was so prepared that the stylet was at first introduced into the hollow orifice of the acorn-like attachment, then the tube was drawn over it and stretched, and, finally, a clamp was attached at the end of the tube opposite the acorn, over the tube and the directing staff. " When the sound equipped in this manner has been inserted about 5 cm. into the esophagus, the clamp is removed, the whalebone staff (man- drin) may be withdrawn, and the soft tube is passed down into the stomach and held so that it cannot be forced up by the retching" (Jiirgensen). A further simplification of the technic of gastric lavage was the inser- tion, by Rosenthal, of a T-shaped tube with a cock into the apparatus, which, being placed in different positions, might be connected with the vessel containing the water, with the descending outflow tube, or the stomach-tube with the outflow tube, or the vessel containing water with the stomach-tube. A similar technic was recommended by Schiffer. Then experiments were made with double stomach sounds, first by Dr. Auerbach in the Clinic at Kiel, then by Ploss, Hodgen, Apolant and others. Hodgen (St. Louis) invented a simple hard rubber pump in which the ball valves were so arranged that the mere turning of the hand in a con- trary direction was sufficient to reverse the stream. Hodgen even simplified the 1 method of emptying the stomach by connecting a rubber tube with the gastric sound, and filling it with water before introducing the sound into the stomach. According to whether the vessel containing the end of the rubber tube is higher or lower than the stomach, fluid may be allowed to flow into the stomach or may be withdrawn from it. THE HISTORY OF GASTRIC LAVAGE 41 Extreme simplicity seemed to be attained in the apparatus employed by Th. Biedert ; it consisted of a stomach-tube, a glass tube 6 to 8 cm. long, which was inserted into the former, and which at its other extremity was connected with a long rubber tube, and, finally, with a funnel into which the water could be poured (1873). To permit the water to flow from the stomach, Jiirgensen, as mentioned, still believed it necessary that the patient with the full, or even distended, stomach get up on a chair. In 1875, Holland Cotton thought it sufficient for the patient to stand during the lavage; Biedert filled and emptied the stomach by raising and lowering the funnel. A fortunate advance in the technic of gastric lavage was the introduc- tion of soft stomach-tubes by Jiirgensen. These instruments had the dis- advantage that their flexibility was soon lost, from the fact that a mandrin of whalebone or rattan was introduced into them, to stiffen them until the larynx was passed. It is greatly to Ewald's credit to have shown (1874) in a case of nitrobenzol poisoning that even a very soft rubber tube, or an ordinary smooth gas tube, may be introduced into the stomach and utilized for gastric lavage. In a discussion of Oser's communication (" Die Magen- spiihmg mittels des elastischen Schlauches," Wiener med. Presse, 1877, 1), Nothnagel, however, emphasizes (in Virchow-Hirsch's Jahresberichten) that he also, without any knowledge of Ewald's publication, employed in his Clinic for some years a smooth rubber tube with a funnel for simple gastric lavage. Ewald's gas tubing was the prototype of the improved tube which later came into use, stomach-tubes which were open below, i. e., with one cen- tral opening only. Jiirgensen's ivory knob at the end of a soft tube fell into disuse when, with the technical improvement in the rubber industry, closed, rounded tubes, with one or two lateral openings, stomach-tubes pat- terned after the Nelaton catheter, were then manufactured. Such tubes were first employed by Leube ; by and by, however, they came into general use, and have been exclusively employed in gastric lavage. The technic of the introduction of the sound in gastric lavage which was carefully constructed and practised in Kussmaul's Clinic, had then to be learned and practised by others who desired to utilize this new method of treatment. It goes without saying that in such mostly autodidactic handling of the sound the patients must have been obliged to bear a great deal. I do not believe I am far wrong in assuming that the widely prevalent fear of the stomach-pump which still exists in the minds of many patients originated in that period when physicians were learning to use the stomach sound and the stomach-tube. Eecognizing these evils, v. Ziemssen was the first to advise care in the employment of the stomach-pump (1872). Then Biermer (1874) pub- lished a communication concerning inflammation of the esophagus and 42 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE of the peri-esophageal connective tissue following injuries from the sound. This author was later followed by Leube and others. In the introduction of the stomach sound, as well as also in the use of the stomach-pump, and in withdrawal of the sound from the stomach, now and then injuries occurred which, under some circumstances, made these procedures danger- ous. It repeatedly happened that portions of the mucous membrane were torn off by the sound, sometimes fragments from 1 to 3 cm. long and 3 to 5 nun. in breadth, therefore presenting quite a surface. In none of these cases of injury to the gastric mucous membrane were serious consequences noted ; now and then more or less decided hemorrhage and syncope followed, l)ii t recovery was rapid and so complete that even in those cases in which there was an opportunity later to hold a necropsy no visible cicatrices were found in the stomach. Besides these lacerations in the mucous membrane of the stomach, there are reports in literature of injuries to the pharyngeal and esopheageal mucous membranes, perforations of aortic aneurysms, hem- orrhages from esophageal varices, of erosions and superficial excoriations of the gastric mucous membrane. Moreover, the mucous membrane has been perforated by using hard sounds, and the overfilling of the stomach with fluid has caused decided ruptures of continuity in the gastric mucous membrane. The number of accidents of this kind noted in literature is exceedingly small when we consider the extensive and world-wide use of the stomach- tube. However, in the opinion of a celebrated author (Ebstein) they do not exactly represent actual conditions. For instance, the tearing away of particles of the gastric mucous membrane with a stomach sound is even now said to be much more frequent than might be assumed from the publications. In the year 1872 Ziemssen also advised us to be careful in the use of certain sounds, particularly the black ones (French), and of such as had friable borders at their openings. Emminghaus did the same. Luube com- pared the action of a sharp opening in the sound with that of a hollow chisel, and he believed the central opening in the sound to be dangerous. as had previously been stated by Emminghaus. Ziemssen (1872) gave minute directions for preventing injuries with the sound as follows: 1. Measure the distance between the epigastrium and the teeth with a sound before its introduction, and mark upon the latter a line so that the instru- ment will not be forced so deeply into the stomach as to damage the greater curvature : 2. Xever begin to pump out the stomach before previously inject- ing warm water (at least half a liter), unless a short time previously large amounts of fluid have been ingested; otherwise, the gastric mucous mem- brane may be drawn by suction into the opening of the tube, and thus be torn away. \\ ith the general introduction into practice of the soft stomach-tube these dangers have been almost obviated. Gastric lavage may now be THE HISTORY OF GASTRIC LAV AGE 43 regarded as a harmless procedure provided the cases are suitable for lavage and the instruments correctly chosen, and that we adhere to the technical rules primarily given by Kussmaul, which are still to be explicitly discussed. The greater certainty which has resulted from this manner of handling the stomach-tube no longer limits the employment of lavage to the dilated stomach. Kussmaul advised the employment of lavage as early as possible in reflex spasm, in stenosis of the pylorus, and in pathologic conditions lead- ing to degeneration of the gastric walls. In consequence of this Reich in Stuttgart (1869 and 1870) and Schliep in London treated chronic dis- eases of the stomach, catarrh, ulcers, and digestive disturbances from other causes with the stomach-pump, and also employed the remedies advised by Kussmaul in irrigating the affected gastric mucous membrane, solutions of sodium bicarbonate, potassium permanganate (1 to 100, of this 2 to 4 ounces in a vessel filled with water), carbolic acid, chloralum (an English preparation), boric acid and tincture of myrrh. In an article from Kuss- mauPs Clinic, " On the Treatment of Gastralgia with the Internal Stomach Douche, and Remarks Regarding the Technic of Sounding the Stomach," Malbranc (1878) described the anodyne effect of sprinkling the gastric wall with warm water, and particularly with warm carbonated water (100.4 F.). Rosenheim, in 1892, advised a particular sound with many small lateral openings for douching the stomach. In the same year Lowenthal suggested in the treatment of hyperchlorhydria and gastralgia spraying the gastric mucous membrane with solutions of silver nitrate (1 to 1000) and Einhorn employed the spray in various gastric affections. The communications of Cahn, from Kussmaul's Clinic, upon the treat- ment of intestinal obstruction .by gastric lavage (1884), received merited attention. In many cases of ileus, the results of repeated, even of a single, irrigation of the stomach, as I later had abundant opportunity of convinc- ing myself, were remarkable. The benefit was brought about by the removal of gas and fecal masses lodged above the stenosed area. This removes ten- sion and the limitation of space. Decided peristalsis and vomiting cease, and food may then be introduced. I must also attribute to Kussmaul's initiative the method, which I have systematically described and practised, of covering with bismuth the ulcer- ated and bleeding surfaces in the stomach, these having first been cleansed (1893). The beneficial effect of gastric lavage upon the bowels in dilatation of the stomach, Kussmaul mentioned in his article to which we have so often referred. This was noted in all cases in which gastric lavage was at all serviceable, and he looked upon it as a suspicious sign if, after prolonged gastric lavage, amelioration took place, and the gastric symptoms improved, but constipation stubbornly persisted. In conjoined labor with the venerable master for almost ten years, / have availed myself of the benefits of gastric lavage in intestinal disturb- 44 ance to an enormous extent, not only when constipation existed, but even more frequently when prolonged diarrheas were present which so often have their origin in disturbances of gastric function and organic disease of the stomach. Here I cannot refrain from mentioning the favorable effect of gastric lavage in many diseases of the liver, in diseases of the gall-bladder combined with jaundice, in chlorosis and anemia, in many disturbances of metabolism, and in intoxications. Gastric lavage has not only a local effect, but, in those cases where the pylorus opens during lavage, also a general effect in that the water which streams into the small intestine, if not regurgitated into the stomach, and not expelled externally, reaches the blood and the liver, washes out the blood and the vessels, and. in particular, cleanses and washes out the kidneys just as effectually as the best mineral spring cures. Furthermore, I must call attention to the value of gastric lavage in diagnosis; this was evident from the beginning and has become still more apparent in the course of time. " We first empty the stomach, and then the palpating finger may detect tumors which cannot be made out when the stomach is filled. Secondly, lavage is a very valuable means by which to differentiate dilatation of the stomach from dilatation of the transverse colon; this was formerly very difficult, so much so that, as I know from my own experience, the greatest clinicians occasionally made gross mis- takes " (Kussmaul, 1869). Finally, gastric lavage enables us to arrive at conclusions regarding the motor condition of the stomach, and Leube did us a lasting service in utilizing gastric lavage to estimate the time necessary for gastric digestion and for the diagnostic determination of the motility of the stomach. By systematic washing out of the stomach a certain time after the ingestion of various foods and drinks Leube, and, following him, Penzoldt, gained absolute knowledge concerning the activity of the stomach, and the gastric digestibility of food. The results obtained became the basis of scientific dietetics. This was the origin of the well-known diet schemes of Leube, as well as the tables of Penzoldt, which are so useful in practice, showing the gastric digestibility of ordinary food and drink. The motor function and the activity of the stomach were considered by Leube as sufficiently good if, in the course of from five to seven hours, after a test-meal at midday consisting of soup, meat and a roll, an evening washing of the stomach showed it to be almost or entirely empty. If, at this time, considerable quantities of the midday meal are still found in the stomach, digestion is slow or imperfect. Such a stomach, however, as is taught by clinical experience, will during the night rid itself of its con- tents and become empty by the morning even if another meal has been eaten in the evening before complete emptying. I, therefore, regard a stomach which does not become empty during the night, and in which early in the morning remains of food from the previous day are still present, THE HISTORY OF GASTRIC LAV AGE 45 as deficient in a motor respect only. A flaccid or atonic stomach is occa- sionally not empty early in the morning on account of an error in diet, either by overloading and over-distending it, or because of improper food and an improper mode of life, while it may be quite capable. of digesting and assimilating suitable food. On the other hand a dilated stomach in consequence of moderate stenosis of the pylorus may, for a long time until improved by washing show motor insufficiency, but in severe cases it is permanently in this condition, in which case it is never empty early in the morning, and is therefore incurable by gastric lavage. At this point I shall mention what Kussmaul found to be the limita- tions of his method in the treatment of gastric dilatation. He was able to cure dilatation of the stomach by gastric lavage when no, or only mod- erate, constriction of the pylorus or duodenum was present. No cure, but amelioration only, could be brought about by gastric lavage in the follow- ing conditions: 1. In malignant stenosis of the pylorus, 2. In very decided cicatricial narrowing of the pylorus, and 3. In moderate narrowing, when the gastric wall, in consequence of chronic gastritis, had suffered such extreme degeneration as no longer to be capable of retrogression. For the cases which at that time (1869) were looked upon 'as incurable, gastric lavage was evidently_a remedy that, if employed early, would decid- edly prolong life and markedly improve the nutrition. " Naturally, a cicatricial narrowing which cannot be dilated even to the extent that a goose quill may pass through the pylorus, can never be cured by gastric lavage." With keen discernment, the great master con- tinues: " Whether in the most daring ages of a distant future, an attempt may be made to produce radical results by gastrostomy, and to form a gastric fistula and dilatation of the stricture by the Tcnife or sound, no one can to-day positively assert. We fear that even the proposal of such a method of relief may expose us to silent or expressed ridicule." Kussmaul, Deutsch. Archiv fur Klin. Medicin, vi, p. 485. Perhaps it was the inspiration of this ingenious thought of Kussmaul's which stimulated his friend Billroth (who was, unfortunately, too early removed from his sphere of activity) to attempt the cure of heretofore incurable gastric diseases, in which internal treatment had been of no avail, O by operative procedures. But this was by no means left to a later race of surgeons; by means of antisepsis and asepsis the contemporaries of Kussmaul have been enabled to operate on diseased organs within the cavities of the body. Since that time surgery of the abdominal organs and, by no means least, gastric sur- gery has had a brilliant and wonderful success. At the turn of the cen- tury the realms of internal medicine and surgery are no longer, as a few decades ago, sharply, almost diametrically, opposed to each other, but, in 46 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAV AGE united labor, such as Kussmaul saw with his mind's eye or hoped for, the physician and the surgeon are working hand in hand to reach the same high goal : To cure ! THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE Owing to the results achieved by gastric lavage and diet, the treatment of diseases of the stomach has become one of the most grateful tasks of the internal clinician. In the interest of the practising physician it is to be greatly deplored that this realm, which is constantly extending, threatens to become the domain of specialists. For the peculiar sense of satisfaction which springs from the consciousness of having relieved the sick from distress, and which richly compensates the physician for many weary hours of his professional life, can scarcely be greater after a fortunate version or forceps extraction, after the curative removal of pus from a con- cealed abscess, after the removal of an obstruction to respiration by the aspiration of a pleural exudate or of ascites, or after the instrumental relief of an over-distended bladder difficult to reach than after a gastric lavage. which frees from his painful condition an unfortunate whose stomach has no longer the power to empty itself. The dread of disagreeable consequences which the first trial of gastric lavage brings to the physician as well as to the patient, and also the possible danger of certain unfortunate errors in technic for which we are responsible, may restrain some physician,, whose position in regard to his patient is often very difficult, from employing this otherwise most useful method. Nevertheless, particularly in severe disease, the value of gastric lavage carried out at the right time is so great, and the injury which ensues from neglecting the necessary emptying of the stomach may be so considerable, that personal considerations must be set aside. Besides, with the methods in vogue to-day it is quite possible to use the stomach- tube for diagnostic and therapeutic purposes in such a way that harm to the patient may be absolutely avoided. The technic of gastric lavage has become of such vast practical impor- tance, for the physician as well as for the patient, that I am led minutely to detail some old, well-tried rules which I learned and constantly used in association with my highly honored teacher, Kussmaul. The stomach-tube, as is well known, serves for diagnostic and therapeutic purposes. We test the function of the stomach to aid us in the diagnosis of a gastric affection or in the correct decision as to the part which the stomach performs in a complex of pathologic phenomena. This test com- prises two parts: A test of the gastric contents at the height of digestion, and a test lavage. A test of the gastric contents is made a certain time after the admin- istration of a test-meal, usually from three to three and a half hours after THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 47 a meal consisting of gelatinous soups (250), roast beef (200), and mashed potatoes (200), or one hour after a trial breakfast consisting of tea and a roll. By means of the stomach-tube a sufficient quantity of the gastric contents is obtained for chemical, physiologic and microscopic investiga- tion, so that we may examine the secretory and fermentative processes in the stomach. The trial lavage of the stomach takes place early in the morning, the stomach of the patient being empty, and enables us to form conclusions regarding its motor activity, as well as also in regard to many pathologic conditions, such as catarrh, secretory irritative phenomena, continuous secretion of gastric juice, and stagnation and decomposition of food. In the trial lavage of the stomach, which naturally should be empty, we must not neglect to secure separately the stagnating contents or the first fluid which comes from the stomach, and these should be examined chemi- cally and microscopically at least, with litmus paper and with Congo paper. If circumstances permit, a test of the gastric contents should first be made, and then the trial lavage should be attempted; there should be "a day of rest between these procedures. How these results assist in the diagnosis and indications for treatment will be described later. The therapeutic indications obtained by the aid of the gastric tube are manifold. Frequently the stomach-tube is used for the purpose of emptying and washing the stomach. Such stomach washings are indicated in all cases in which the stomach, early in the morning, is not empty, but in which are found remains of food from the preceding day (or even earlier), mucus or gastric juice containing hydrochloric acid such as occurs in chronic gas- tric catarrh, and a continuous flow of gastric juice in consequence of perma- nent irritative conditions of the gastric mucous membrane. Even if the stomach early in the morning is quite empty, gastric lavage is often performed. Washing or spraying the gastric wall with the stomach- douche may be designated as the best remedy to stimulate the appetite, the flaccid gastric musculature and the secretory glandular apparatus, and also to relieve irritative conditions and pain or vomiting. All of the symptoms just mentioned are indications for the employment of the stomach-douche. Instead of water of varying temperature (usually from 86 to 95 F.) saline solution, mineral water and diluted drugs of various kinds are em- ployed, according to circumstances. Gastric lavage is also frequently and successfully employed in disturb- ances of function and in diseases of the intestine and of the liver, in con- ditions of abnormal blood-mixture, in renal diseases, and in acute poison- ing, as well as in chronic states of intoxication, for example, uremia. The indication for gastric lavage in ileus (intestinal obstruction) deserves special mention. 5 48 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAV AGE Before each introduction of the stomach-tube or of the sound the patient must be carefully examined, since this alone makes it possible to discrim- inate in the choice of patients, and to exclude those in whom gastric lavage might be dangerous. In deciding what cases are suitable for gastric lavage it must be remem- bered that the first introduction of the stomach-tube almost invariably produces excitement, retching, and nausea, sometimes also difficulty in respiration and cardiac palpitation. Some patients, in consequence of psychic stimulation, hold the breath, become cyanotic, and, by a mighty exertion of the prelum abdominale, bring about a decided rise in blood- pressure. In irritable and anxious patients, all these symptoms appear more rapidly and reach a higher degree than in persons of more quiet temperament who are able to control themselves. The same is true of those who suffer from diseases of the respiratory and circulatory organs. For this reason persons who, on account of diseases of the respiratory passages, the lungs or the pleura, can only complete their respiratory inter- change of gases with difficulty, are markedly disturbed by gastric lavage, and, under some circumstances, to them it even becomes dangerous. The effect is similar in those who have a disease of the heart, whose myocardium is weakened or degenerated, or whose valvular disease is so defectively compensated for as to be unable to withstand great variations in blood- pressure. Therefore, we refrain from stomach washing and also stomach evacuation to promote the diagnostic investigation of the stomach contents when severe pulmonary and cardiac affections are present. If, however, the conditions are such as to necessitate the introduction of a gastric tube, and if it is believed that the value of this procedure will outweigh the possible danger from its use, the expert, relying upon the accurate handling of the stomach-tube while carefully regarding the rules of the technic, will, nevertheless, attempt to introduce the instrument. If the first trial is successful, with like caution others may follow, for a sensible patient soon becomes accustomed to its use. Many a phthisical patient by the washing out of the stomach has gained an appetite, acquired new strength, and prolongation of life. I even believe that incipient phthisis in many per- sons may be arrested with the removal of the anorexia by gastric lavage and subsequent plentiful feeding, and that in this way a cure may be brought about. As a rule, we avoid the use of the stomach-tube if we have reason to suspect that the walls of the vessels in any part of the body are not able to withstand a rise in blood-pressure brought about by the introduction of the sound, which is apt to produce retching, vomiting, or decided action of tlu 1 abdominal press. Preceding hemorrhages (hemoptysis, hematemesis, melena. apoplexy) or a tendency to hemorrhage still present, also atheroma- tons a rt erics, valvular disease of the heart demonstrable by percussion and THE CLINICAL EMPLOYMENT OF GASTRIC LAV AGE 49 auscultation, and even suspected aneurysmal dilatation of the aorta, are valuable guides. Recent and profuse hemorrhages from the stomach or from the lungs, high-graded atheroma, severe cardiac disease, and aortic aneurysm are always contraindications to the employment of the stomach-tube. Capillary hemorrhages from the inflamed, perhaps also eroded, gastric mucous membrane, and parenchymatous bleeding from ulcerated, decom- FIG. 2. Terminal piece of a soft tube as found in the instruments usually on the market. posing growths in the gastric wall, may, under sOme circumstances, also be contraindications ; usually, however, they are not ; but such hemorrhages generally cease if, after the discharge of accumulated and decomposed masses, the stomach is again able to contract. In hemorrhages of any kind, even during the menstrual period, I only very exceptionally make a gastric examination with the stomach-tube and perform gastric lavage. During menstruation the gastric mucous membrane of many women is somewhat inclined to hemorrhage. For this reason I interrupt the treatment by gas- tric lavage, and resume it only two or three days after the menstrual period. According to experience, women during menstruation digest food less well, and they secrete a weaker gastric juice than at other times, therefore it is well to defer the investigation of the gastric contents. To obtain the gastric contents and for gastric lavage we employ exclu- sively soft stomach-tubes, and preferably those of English manufacture (Jaques's esophagus tube) on account of their smooth surface and great flexibility. However, these English tubes have glaring defects which for FIG. 3. Terminal piece of a soft tube with a lateral opening, and a central opening in the longitudinal axis of the tube. This tube appears to me to be most dangerous to the mucous membrane of the pharynx, of the esophagus, and of the stomach. some unaccountable reason the manufacturers do not remedy. Their open- ings are frequently not large enough, and the margins of the openings, with- out exception, are so sharp that they readily injure the mucous membrane, particularly the mucous membrane of the stomach, as may be seen from Figures 2, 3, and 4, which show the configuration of the tubes in natural size. This defect may be remedied by burning out the openings, and round- ing off the edges with a hot darning needle or a hot glass rod, as may be seen in Figures 5 and 6. But, after this treatment of the margins of 50 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE the openings, the rubber is rough for a time, and must be rubbed down with pumice stone. Besides, the tube has for days an odor of burnt rub- ber, and, sooner or later, small rents appear in the edges which have been burnt and soon render the tube unfit for use. It is to be hoped that the FIG. 4. Terminal piece of a soft tube with a central and numerous lateral openings, and said to be more suitable for irrigation of the stomach than tubes with only two large lateral openings. manufacturers will speedily place on the market more serviceable tubes with rounded, polished edges that will meet practical requirements. The introduction of a staff or mandrin into a soft stomach-tube is decidedly objectionable, for, with a mandrin inside, the soft tube again becomes a hard sound with all of its defects and dangers. They are only required in gastric lavage and artificial nutrition when it is necessary to overcome an obstruction in the front of the stomach, in narrowing of the esophagus, or in deep-seated dilatations of the esophagus, for example, in some ante-stomachs. Preparation of the Patient. Before the first introduction of the stomach-tube I have never failed minutely to inform patients who are at all intelligent regarding the purpose and utility of the proceeding, to call their attention to its harmlessness, and to teach them how to conduct them- selves during the operation. Whenever possible, I have always allowed FIGS. 5 and 6. Terminal piece of soft tubes whose openings have been rounded off by a hot glass rod and thereby rendered harmless. nervous patients an opportunity to see how willingly other patients with practice swallow the tube themselves and permit lavage. The patient now sits erect in a chair, or, if in bed, sits upon the edge of the bed. A basin is given him in which to catch the saliva which flows from the mouth, or the vomited material, and which he holds with both 1 lands, so as not to disturb the physician by making motions to oppose him. If dealing with patients who have very sensitive pharyngeal mucous mem- branes, such as smokers who retch easily and show a tendency to vomit, THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 51 the introduction should be preceded by gargling with a watery solution of potassium bromid, or by painting the pharynx with cocain, when the sensi- tiveness and reflex irritability of the structures of the pharynx may be so controlled that we may proceed with the introduction of the tube. Arti- ficial teeth must, naturally, be removed. The patient should be allowed to drink some water before the lavage, so that the mucous membrane of the mouth, tongue, palate, pharynx and esophagus may be moistened and more readily permit the passage of the tube. Where there is a very irrita- ble stomach and a great tendency to vomit, the patient should even be made to swallow a considerable quantity of water before the introduction of the tube, so that this will not reach an entirely empty stomach and, by direct contact with its walls, produce great irritation. Naturally, if we desire to obtain the gastric contents for the purpose of analytical examination, water is not permitted before the introduction of the tube. In this case the prevention of retching and a tendency to vomit are not at all necessary for, under these circumstances, the evacua- tion of the gastric contents is only facilitated, In this latter operation in case it is done without a pump or aspiration apparatus injury to the gastric wall is unlikely, since the stomach is not empty, and the tube can hardly come in contact with the walls of the stomach. Preparation of the Stomach-Tube. According to Luschka's plates, the ninth spinous process of the thoracic vertebrae corresponds exactly to the position of the cardia, provided the location of the abdominal organs is normal. Before the first introduction of the tube we count on the patient's back the spinous processes of the vertebral column up to this point, to which we apply the upper opening of the tube, and measure along the vertebral column, passing alongside the ear to the incisor teeth, and mark this point upon the tube with a waxed silk thread which we tie around the tube, or with a colored pencil. If the tube is now introduced up to this point it is certainly in the stomach, provided this organ is in its normal situa- tion, and it is unnecessary to shove the tube up and down to ascertain whether it is in its proper position, as this will cause retching and a ten- dency to vomit. Before the introduction is begun the end of the stomach- tube is moistened in luke-warm water. While the patient sits erect in a comfortable position, with the head raised, the mouth open wide, and the point of the tongue placed against the lower incisor teeth, the rounded end of the stomach-tube is pushed over the dorsum of the tongue up to the posterior pharyngeal wall. The moment the tube reaches this point, the patient slowly bends his head for- ward and simultaneously attempts to swallow. The sound glides along the posterior wall of the pharynx, along the vertebral column to the cricoid cartilage, often even beyond this. Now we pause for a moment, ask the patient to breathe deeply and regularly, and then to swallow again, when the tube will slide downward behind the larynx, and with a slight push t COLLEGE Ol r OSTEOl 2 \-\l\ t-l Ci :;N'S-c^-Ul\ 52 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAV AGE on the part of the physician the instrument is rapidly introduced up to the required mark. When this is accomplished the tube is held firmly until the patient breathes quietly and regularly, and, in the meantime, a ring of hard rubber which encircles the tube, is put between his teeth, and upon this ring he may bite. The further procedure depends upon the purpose for which the tube has been introduced. To Test the Gastric Contents. If it is desirable to obtain some of the gastric contents for a test of the chemism of the stomach, we direct the patient, after the tube has been introduced and is in the right position, to contract his abdominal muscles as if he were having an evacuation. By this exertion of the abdominal press, the gastric contents are brought up through the tube and may be caught in a vessel held for the purpose. It may happen that, on pressing, only air comes up through the tube and none of the ingesta. The tube is then gently pushed further down, and after a few deep respirations renewed attempts at expression arc made. With very flabby abdominal walls, the result may sometimes be brought about by pressing a hand upon the back and one upon the abdomen to assist the abdominal press, or by raising the protruding abdomen so as to bring the descending stomach and its contents nearer the vicinity of the tube. // tli esc manipulations are futile, either the stomach is empty or the tube is clogged by insufficiently masticated particles of meat of the test- meal which have not yet been dissolved in the stomach and are too large to pass. It is not always easy to determine which of these two possibilities is the case. If, on repeated attempts at pressing, only air comes up through the tube and this may be recognized by the sound which accom- panies it this is in favor of the stomach being empty. If, on the other hand, upon attempts at pressure nothing or only the sound of air is heard, which suddenly ceases, or if the stream of stomach contents suddenly stops flowing from the tube and does not again flow when pressure is made, the tube is clogged. It may be that the tube is not clogged by particles of food, but that a fold of the gastric mucous membrane is sucked into the opening of the tube and thus closes the opening. The latter possibility must be borne in mind if, upon pressure, neither air nor stomach contents come forth. In such cases there is danger, by rapid displacement of the tube, of injuring the gastric mucous membrane, or of tearing off a fold of the mucous membrane which has been sucked into the opening of the tube. (Jreat care is necessary in moving or in withdrawing the tube. To be assured of the results when gastric contents are not brought up through the tube, hold it firmly, connect it with the other parts of the lavage apparatus, and permit a measured quantity of lukewarm water to flow into the stomach. If this water, upon lowering the funnel, regurgitates quite THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 53 pure, the stomach has passed the test-meal into the intestine, and the tube may now be removed with the observance of the necessary precautions. The attempt to obtain the gastric contents has, under such circumstances, failed, and if we desire to obtain further insight into the chemism of the stomach the test-meal must be repeated at some other time, and at an earlier hour. At all events, the operation gives proof of a nor- mal, even increased, motor activ- ity (hypermotility) which com- pensates for secretory disturb- ances. A proof that the tube has been clogged, and that the stom- ach is not empty, is the fact that water poured into the stomach reappears mingled with gastric contents when the funnel is low- ered. Qualitative investigation for hydrochloric acid, at least with Congo paper, may be made in the fluid thus obtained, but no quantitative results are fur- nished. Under these circum- stances, therefore, another test- meal must be given, the attempt be repeated another day, with due care that the meat has been fine- ly chopped so as to avoid clog- ging of the stomach-tube. In the first attempt, I do not have the meat for the test-meal chopped, for it often aids us in the etiology and treatment of many digestive disturbances to know how the patient chews. Gastric Lavage. For stomach washing we require an apparatus (Fig. 7) which is composed of the already mentioned stomach-tube and the ring which is placed over it and held between the incisor teeth (Fig. 8) for biting, a glass funnel holding from one-half to three-quarters of a liter, and a rubber tube one and one-half meters long interrupted in its lower third by a short glass tube which is connected with the funnel, also an inserted piece by which the rubber tube is readily attached to the stomach- tube. This enclosed piece (Fig. 9) is made of hard rubber, and is of the form and size depicted in the illustration. The round end, a, is placed toward the funnel and attached to the rubber tube. At & there is a faucet which is usually firm and air-tight, but, under certain conditions which we FIG. 7. Complete apparatus for washing the stomach. (After Kussmaul.) a, funnel; b, rubber tube, one and one-half meters long; c, glass connecting piece; d, enclosed piece of hard rubber with cock; e, stomach-tube; /, ring of hard rubber on which to bite. 54 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE will learn to recognize, may be removed for a short time. The conically narrowing end, c, of the inserted piece answers the purpose of connecting the tube with the stomach-tube and, on account of its shape, fits a tube of any caliber. If the stomach-tube has been introduced according to the directions given, the biting ring is between the incisor teeth, and everything else in position, we fill the lowered funnel with lukewarm water, and then raise it so that the water flows into the stomach. When proper assistance is given I permit the funnel to be filled as soon as the tube has passed the larynx and before it is introduced and elevated. The rapidity with which the water flows into the stomach depends upon the pressure of the column of water, i. e., upon the elevation of the funnel, upon the degree of contraction of the gastric muscula- ture, and upon the pressure of the prelum abdomi- nale. Under some circumstances, as in retching or coughing, nothing flows into the stomach, and even when the funnel is raised very high either the water for washing or some of the gastric contents returns through the tube. On the other hand, if the stom- ach walls are flaccid, on deep inspiration and in consequence of the diminished intra-abdominal pres- sure the water is aspirated into the stomach and actually streams into this organ. It may then occur, if the funnel is raised high, that a bubble arises and by means of this, simultaneously with the water, air is aspirated into the stomach and causes an over- distention of the organ. A simple artifice, namely, slanting the funnel, may prevent this difficulty. Before the funnel becomes quite empty, it must be rapidly lowered so that no air can pass into the tube, and the continuous flow of water through the tube is not interrupted. On lowering the funnel, a siphon action takes place, and the water regurgitates into the funnel. It may now be collected, examined, its reaction tested with litmus or Congo paper, and we should carefully observe whether as much water flows out of the stomach as has been poured in. By this precaution, it is quite impossible to damage the stomach by over-filling it with fluid. In the stomach-tube and in the wash-tube, even after emptying the funnel, a column of fluid remains. A glance at the glass tube within the stomach-tube will show of what this fluid column consists. If it is clear, or but slightly turbid, we should continue the lavage. The lowered funnel is refilled with water, is raised and low- ered again, the water used for washing is collected and emptied, as before. FIG. 8. Ring on which to bite (of hard rub- ber) drawn over the sound, and readily moved about upon it. THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 55 If, however, the fluid in the tube is quite turbid, or decidedly mixed with mucus, remains of food or the like, the faucet at the inserted piece is removed for a moment so that air enters the tube and the contents flow toward the funnel. When this is done, the faucet is reintroduced, the washing is continued, the faucet is again removed, and if the water returned a second or third time through the funnel is not yet clear, this process is continued until the water flows clear. Without the enclosed piece with the faucet which, by the way, is the invention of an artillery officer who was treated in Kussmaul's Clinic for dilatation of the stomach the soiled water is again forced through the tube and returns to the stomach. The process is then unnecessarily prolonged, and this is an evil of some consequence in debilitated patients, one which is obviated by the introduction of the en- closed piece, which is as simple as it is ingenious. The stomach, as a rule, is washed until it is clean, provided the' patient is able to bear it. In very irritable patients we must reckon upon their resistance, and, particularly in the first lavage, we may be obliged to desist FIG. 9. Inserted piece of hard rubber with cock. before this end is attained. Even with patients whose activity and self- control is only slightly diminished, days frequently pass before the remains of food from former meals can be removed from a dilated stomach. Besides, a return flow of clear water does not always indicate that the stomach is actually clean. For example, mucus, which often thickly coats the gastric walls, dissolves but slightly or not at all in pure water; the water may, therefore, flow off clear while a mucus coat, rich in microbes and fer- ments, may still adhere to the gastric mucous membrane. If, in such cases, alkaline waters or solutions of soda and table salt are used for washing, it is frequently astonishing to see the amounts of mucus brought up. The conditions are somewhat different in a flaccid and dilated or abnormally-formed stomach. When the patient is in a sitting posture, the fluid reaches only the lower segment of the flaccid sac, and sprays the pos- terior gastric wall and the small curvature, also the region of the cardia and the fundus, slightly or not at all. If the patients with gastric dilata- tion who have become accustomed to the sound are made to lie down after an apparently satisfactory washing carried out in a sitting posture, and 56 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE lavage is continued while in the recumbent posture, surprisingly large quan- tities of mucus and remains of food are brought up with the water. Those who have become accustomed to lavage in the recumbent posture bear it very well, so that, after the stomach is filled with water, this fluid may be moved to and fro in the stomach by movement of the trunk. The gastric wall is thus thoroughly washed up to the small curvature, which is par- ticularly important since this area is the preferable seat of the severest gastric diseases. In hour-glass stomachs, those with deep diverticulum-like sacs formed by cicatrices, also in such as have a markedly developed antrum pyloricum and antrum cardiacum, we sometimes observe that, after an apparently thor- ough gastric lavage, turbid gastric contents which have been enclosed in a sac suddenly pour into the funnel. The symptom may frequently be utilized in diagnosis. In removing the stomach-tube when the washing is finished, we will note that, with a lowered funnel, a column of fluid remains in the tube because the gastric wall contracts firmly around the lower end of the tube and closes the opening. By the siphon action, folds of mucous membrane may even be drawn into the opening of the tube, and, should this occur, the flow of water will cease suddenly with a jerk which may often be felt throughout the entire tube. If, at this moment, the stomach-tube should be rapidly withdrawn, there is great danger of injuring the mucous mem- brane, or even of tearing off a portion of it that has been sucked into the tube. This danger may very readily be averted by holding the tube without moving it, pouring a little water into the funnel which is raised, and then slowly withdrawing the tube, when water will again flow into the stomach, and the mucous membrane be forced away from the opening of the tube. When the tube is so far withdrawn that the opening is above the cardia we compress it in order to prevent any fluid from entering the air passages while the tube is passing over the epiglottis. Immediately after lavage the patients should have some breakfast and then rest for a little while; they should make no exertion whatever for at least an hour afterward. Individualization and Interruption of Gastric Lavage. Individuality of character and will power exert quite an influence upon the course of operations, which, like most stomach washings, necessitate some assistance on the part of the patient. Where this influence is a deleterious one, the physician, by his personality and skill, may be able to overcome it after a time. Moreover, there are definite pathological conditions to be considered in the case, the influence of which upon the course of the operation cannot be foreseen nor always prevented, and, under some circumstances, they may be so great that lavage must be discontinued. We refer particularly to THE CLINICAL EMPLOYMENT OF GASTRIC LAV AGE 57 the danger of extraordinary irritability of the gastric mucous membrane and the danger of hemorrhage. According to experience lavage is best borne by patients with gastric dilatation, therefore by those to whom this operation is most necessary. The mucous membranes of the stomach and esophagus are so benumbed by the intense irritation of the stagnating gastric contents and by vomit- ing that they do not react to the irritation of the tube and the cleansing fluid. Hence the danger of injury to the mucous membrane by the stomach- tube in gastric dilatation is very slight. The condition is different in irritable stomachs which are not dilated, which are sometimes even decreased in size (contracted or concentrically hypertrophied), which react by a decided, sudden contraction, by retching and vomiting, or by cough, to the least irritation ; for example, to the slight- est movement of the introduced stomach-tube, to a touch of the latter against the stomach wall, to the inflow of the fluid, or to the temperature or com- position of the same. Vomiting in such cases often has a peculiar expulsive character. The water suddenly gushes from the mouth with great force so that care is necessary in handling the stomach-tube. In such irritable stomachs another grave danger is that, after a sudden attack of retching with severe vomiting, or after an attack of coughing, the gastric wall is forced against the stomach-tube, and consequently the mucous membrane is rubbed against the opening of the tube and becomes excoriated, or a fold of the mucous membrane is sucked into the opening and torn off, or, if the stomach-tube has not been adjusted carefully enough, it is forced out of the stomach. These stormy reactions of extremely irritable stomachs frequently cease if the patient obeys the command to breathe deeply and regularly. In other cases, the stream of luke-warm water flowing from the funnel held as high as possible quiets the irritable gastric walls. If this is not the case, it is risky to continue the lavage. It is wise to observe all pre- cautions; we, therefore, slowly withdraw the stomach-tube, and defer the operation until another morning. Before attempting it again, we should never neglect to call the attention of the patient to the mistakes of the last washing, to caution him to breathe deeply and regularly, and to avoid this or that bad habit. If catarrh of the pharynx is present, this also should receive the necessary treatment. In another category of gastric affections, lavage is disagreeable, and even dangerous, because of the great tendency of the gastric mucous mem- brane to hemorrhage. In the accidents during lavage which have heen described above, hemorrhages may also occur, but only in consequence of previous gross mechanical injuries. Here we are dealing with hemor- rhages which occur without such injuries. There are certain catarrhs of the stomach in which the mucous mem- brane, particularly at the height of its folds, is enormously hyperemic. 58 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE The dilated capillaries of the mucous membrane mostly show such an extreme permeability that quite insignificant variations in pressure are sufficient to cause mucous membrane hemorrhages. Among many thousand cases of lavage, I have known about ten such hemorrhages to occur. Al- though they were slight they necessitated the interruption of the opera- tion and, because they recurred with every attempt, I was compelled to discontinue lavage entirely in these cases. In hysterical patients vomiting of bloody masses and of pure blood occasionally occurs without any loss of substance of the mucous mem- brane. Therefore, in such patients also, we may be forced to withdraw the stomach-tube on account of the hemorrhagic staining of the water; the same is true of gastric crises of spinal origin. Hemorrhages from esophageal varices must also be referred to. They are more profuse than the previously mentioned form, and closely resem- ble the hemorrhages originating from gastric ulcers. In a noteworthy case of this kind which was at first believed to be ulcer of the stomach, in which, however, this diagnosis was abandoned on account of the absence of all other symptoms of ulcer, the hemorrhages ceased entirely under the influence of lavage. Here, apparently, the introduction of the tube com- pressed the ectatic veins of the esophagus. Similar conditions are seen in hemorrhage from the ureter, where catheterization or sounding acts as a potent curative factor. If, during lavage, congealed blood is found in the stomach such as is observed in ulcerating carcinoma, in old ulcers of the stomach, and, par- ticularly, where there is a stenosis of the pylorus with a spastic closure of the pylorus caused reflexly, producing hypersecretion, there is no reason for interrupting the operation. On the contrary, in cases of this kind, the thorough emptying and cleansing of the stomach is an exceedingly bene- ficial measure, and well calculated to check an old hemorrhage and pre- vent a new one. The empty and clean stomach is again able to contract properly, and by contraction the bleeding surface becomes smaller, the borders of the ulcer are approximated, and the gaping lumina of the ves- sels closed. The fresh, and often not inconsiderable, losses of substance caused by the tearing off of particles of mucous membrane by the tube most distinctly show the mighty styptic influence of the muscular con- traction of the stomach. In the cases that have been reported, the hemor- rhage has ceased rapidly and no ulcer formation has taken place apparently for the reason that the margins of the wound, in consequence of muscular contraction, have approximated at once, have closed and healed, like opera- tive wounds of the stomach, by first intention. If, therefore, during lavage, a fresh hemorrhage should unexpectedly appear and be indicated by the red discoloration of the water, the physi- cian must have the presence of mind not to withdraw the sound at once; lie must very gently, even though with some force, allow the stomach THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 59 to empty itself, and thus make it possible for it to contract completely. Naturally the patient in whom this has happened must be treated for a time after his hemorrhage as in the case of ulcer. The remedies used in lavage vary with the requirements of the indi- vidual case. For simple cleansing of the stomach, lukewarm water is sufficient (at about the temperature of 86 F.) ; if, however, we wish to act upon the diseased gastric wall, additions must be made to the fluid, above all, soda for gastric catarrh, and table salt for deficient hydrochloric acid. A mix- ture of these salts is most serviceable : ^ Sodium carbonate part 1 Sodium chlorid " 2 M. D. S. : To be dissolved in water (2 to 5 per 1000). But even water alone may act in different ways upon the gastric wall ; lower temperatures (less than 86 F.) stimulate and irritate; higher than 86 F., lessen irritation, have a soothing effect and relax. Under the influence of warm washings the pylorus opens, even when spastically closed, more quickly than under the influence of cool washings. If in the individual case, lavage of the stomach requires a long time, it is better for the patient not to have the water too cool, as thus too much heat may be withdrawn from him. Debilitated persons for this reason bear warm washings better than cool ones. The pressure exerted during lavage has no inconsiderable influence upon the diseased gastric wall. In all the diseases in which lavage must be car- ried out cautiously, therefore in gastric ulcer and in corrosion of the stomach after poisoning with a tendency to hemorrhage and extreme irritability, the funnel must not be held too high, not above the height of the patient's head. When we wish to produce a stimulating effect by the gastric washing (gastric douche), it should be held as high as possible. After cleansing the stomach, bitter tonics are sometimes sprayed upon the mucous membrane, and are allowed to remain in the stomach in con- tact with the gastric mucous membrane for a few minutes; among these quassia amara (30 grains in half a liter of cold water, macerated overnight, and filtered early in the morning), hop tea and infusion of dried hops, and condurango are most recommended. I employ one to two teaspoonfuls of the fluid extract of condurango to half a liter of lukewarm water. Abnormal fermentative decomposition in the stomach is best combated by thorough and regular lavage. We possess no reliable remedy for the relief of abnormal decomposition, fermentation and other processes of de- composition, which, without danger to the organism, can aseptically change the digestive processes in the stomach and intestine. In an abnormal pro- duction of organic acids in the stomach I have most often employed wash- ings with a 1-1000 salicylic acid solution. 60 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE Where there is an immoderate excretion of hydrochloric acid (hyper- chlorhydria), and in gastric ulcer, some authorities recommend spraying the stomach with a 1-1000 silver nitrate solution. In severe, old, gastric ulcers particularly, excellent results have been obtained, after all internal remedies had failed, by pouring bismuth into the previously cleansed stom- ach. With an approximately exact diagnosis of the seat of the ulcer, or after a few attempts with the patient in a suitable posture, it is possible to introduce into the adult stomach, by sedimentation, a mixure of bismuth in suspension (10 to 20 bismuth subnitrate to 200 of water) so that a precipitate of bismuth completely covers the ulcerated surface. That a coating of bismuth remains upon the rough or sinuous ulcerated surface, and irritation by the gastric contents is thus prevented, I have concluded from numerous clinical observations; for, after a few applications of bis- muth in the cases in question not only the sensory but also the secretory and motor irritative phenomena (pains, hyperchlorhydria and hypersecre- tion, peristaltic unrest and spasm of the pylorus) were lessened, and often entirely ceased, and with the continuance of the bismuth treatment of the gastric ulcer for several weeks cure finally took place. In fresh gastric ulcers and in hemorrhage, which do not permit lavage, I have had good results by letting the patient drink bismuth in suspension after the stomach had been cleansed in a natural manner by the drinking of an alkaline water half an hour previously. (Here the remark may be permissible that min- eral water cures, in fact, the drinking of natural mineral waters, may be designated as natural gastric lavage in contrast to the artificial, that is, gastric lavage performed with the stomach-tube. For obvious reasons the latter is much more effective than the former.) The best time for gastric lavage may be seen from the indication: // the stomach early in the morning is not empty, it must be washed out. At this time the stomach washing is least exhaustive, is completed most rapidly, and is most useful to the organism. The cleansed stomach- wall, refreshed by the washing with water, is ready for new and thorough activity (similar to the mouth after brushing the teeth). It is, true it is very difficult for the busy practitioner so to divide his time that his gastric patients may have regular treatment early in the morning and at the same hour daily. Yet it is not right that lavage should be performed at any time during the day when our visiting list brings us to the patient. If, for example, we wash out the stomach at a time when the labor of digestion is not yet completed, added to the abrupt interruption of the digestive processes is the disadvantage that, besides the digestive juices, larger and smaller quantities of unused chyme are washed out of the stomach. Besides, gastric lavage at an improper time is much more exhausting than when the stomach is empty. The expulsion of the insufficiently split- up food is very difficult, the washing, therefore, takes a long time, large THE CLINICAL EMPLOYMENT OF GASTRIC LAVAGE 61 quantities of fluid are necessary to cleanse the stomach, much heat is thereby withdrawn from the patients and they are often exhausted before the stomach is clean; organ and organism therefore suffer injury by lavage at an unsuitable time. The stomach becomes worse instead of better, the gen- eral condition of nutrition falls instead of rises; in spite of patience and labor the treatment is unsuccessful, and the criticism is made, " Even lavage did not help him." Moreover, the ordering of a test-meal and the later removal of the gastric contents should not occur at any arbitrary time. The stomach is not a retort into which, at any time, something may be put, or from which something may be taken to see what process it has undergone in the meantime. I do not deny that in the treatment of diseases of the stomach our adherence to the most useful methods and to a definite time is a hindrance to the general employment of gastric lavage, and to a certain extent limits its utility in practice. It is due to these circumstances, and not to the knowledge of the practising physician, that the results of local treatment of the stomach in well conducted institutions are usually better than in private practice. Where it is at all possible, therefore, if the stomach-tube is to be employed for a long time, the patient should at once be taught to use it for himself. Besides, the essential point in treatment of the stomach is not alone the correct use of the stomach-tube: Much more difficult than this is the art of nourishing the patient. If nothing injurious is introduced into the stomach, less will be brought up by lavage; by a proper diet, therefore, we may limit lavage and in many cases make it unnecessary. Naturally, dietetic treatment in institutions in which food is prepared under the direction of the physician is easier than in private practice. Only definite symptoms should cause us to deviate from the general rule of washing out the diseased stomach early in the morning when empty. There are cases of mechanical insufficiency of the stomach in which secre- tion of hydrochloric acid (hypersecretion), the formation of organic acids, and, under some circumstances, the production of gas is so great and the difficulties arising from these conditions so decided that by a rapid empty- ing of the stomach not only are the sufferings of the patients relieved but danger is averted. If, in cases of this kind, examination by the physician at any hour of the day makes it appear that the stomach should be emptied immediately, it is best to choose for lavage a late evening hour; by lavage at nine or ten o'clock, or even later in the evening according to the time when food was last taken, the patient is relieved for the night from his discomfort, and secures a very necessary and grateful night's rest. Evening lavage, however, if continued for a long time, is not well borne, not nearly so well as that of the morning, and in cases in which both morning and evening 62 HISTORY AND CLINICAL INDICATIONS OF GASTRIC LAVAGE lavage are necessary the patient soon loses strength, the intestine no longer receives sufficient fluid and nourishment from the stomach, the require- ments of the economy of the body can no longer be met, even although we use supplementary rectal alimentation, and unless an operation is per- formed in such cases the patients slowly succumb to exhaustion. FUNCTIONAL DISEASES OF THE STOMACH BY H. LEO, BONN. THE stomach differs from other organs in that it frequently presents subjective and also objective symptoms of disease which are not due to any organic change, or, at least, not to any which are recognizable by our present methods of investigation. In this respect, only the heart, that is, the circulatory apparatus, and the intestines show similar conditions. These clinical pictures may be grouped under the term, functional diseases of the stomach. One of these groups presents well-developed anomalies of the gastric contents which are not, however, due to disease of the stomach wall, but to the ingestion of tainted food, or to the invasion of microbes which in themselves cause the decomposition of the ingesta in the stomach. These morbid conditions have been designated dyspepsia. The second group is distinguished by clinical pictures which present either subjective symptoms dependent only upon alterations of the stomach or, combined with this, disturbances of gastric activity which may be ob- jectively recognized. The majority unquestionably depend upon abnormal functions of the nervous apparatus, and these affections are therefore desig- nated neuroses of the stomach, in spite of the fact that a direct relation to diseases of the nervous system does not always exist. The differential diagnosis of individual diseases belonging to this group from one another and from other organic diseases of the stomach is not always easy. To accomplish this an investigation of the entire organism is, as a rule, necessary, and of the various disturbances which uncommonly often disturb the gastric activity, or may be due to abnormalities of the latter. Naturally the chief stress is to be laid upon the special examina- tion of the stomach, in an anatomical as well as functional respect. On account of the increased importance of this in the last few years, it appears advisable to discuss somewhat minutely the best method of examination. TO TEST THE FUNCTION OF THE STOMACH Of the three functions of the stomach, the motor, the secretory and the absorbent, the motor, i. e., the intimate admixture and mechanical prepa- ration of the food and its timely removal through the pylorus into the intestine is unquestionably the most important. The disturbances of this 6 63 64 FUNCTIONAL DISEASES OF THE STOMACH function, manifested by an increased or, usually, by a decreased action, and which appear in the most varied diseases, are then conspicuous to a high degree. To differentiate them, besides other complicated and less definite methods, it is sufficient to prove by the Leube-Riegel test-meal (see below) or by the Ewald-Boas test-breakfast (see below) that .the duration of digestion deviates from the normal. As a decrease in the motor function (insufficiency of the stomach) primarily occurs in gastric dilatation, I shall forego a full explanation of the test for this, and instead refer the reader to the article by Riegel. It is sufficient to state here that six hours after a test-meal, and, at the latest, two hours after a trial-breakfast, the stomach normally propels its contents into the intestine. If, therefore, at this time, by sounding or by lavage ingesta are still found, the motility of the stomach is diminished. On the other hand, experience teaches us that the stomach, under normal circumstances, three hours after a test-meal and one hour after a test-breakfast, still contains remains of food. If, at this time, it is already empty, we have proof of an increase of its motility. While a test of the absorbent function of the stomach has, up to the present time, produced no results which are of value in the diagnosis of gastric disease, the study of the secretory function by an examination of the constituents of the gastric secretion or of the admixture of the same with the intaken ingesta, and also of the normal and abnormal products of decomposition, is of great practical importance. Only since the exam- ination of the gastric contents was incorporated into the diagnosis of gas- tric diseases have certain well-characterized clinical pictures (hypersecre- tion, hyperacidity, achylia) become known. Their results in many cases determine the diagnosis, either because we find changes in the gastric con- tents which are characteristic of certain diseases, or because changes of this kind are absent; that is, normal conditions exist, and we are thereby justified in excluding some diseases which come into question in the differ- ential diagnosis. In regard to the indications for the examination of the gastric contents, this procedure, that is, lavage of the stomach, aside from the contraindica- tions to be at once named, is absolutely harmless and, as a rule, may be carried on without difficulty, but is occasionally unpleasant to very sensi- tive patients, and, naturally, not in place when other diagnostic aids per- mit us to make a positive diagnosis. The artificial removal of the gastric contents is now only performed with a soft rubber tube, but is absolutely contraindicated if hemorrhages have occurred even although a long time have elapsed since the last one. Otherwise, a fresh hemorrhage might readily be produced. The stomach contents are withdrawn either when the stomach is empty, therefore, as a rule, early in the morning, or during the period of diges- tion ; if we suspect hypersecretion (see below) it is done at the time first named. In these cases, we find a considerable amount of clear fluid while TO TEST THE FUNCTION OF THE STOMACH 65 the stomach normally should be empty. Only when ingesta reach the stomach, that is, when present there, both in the healthy and in the sick, do we find besides hypersecretion a secretion of the gastric juice. In the examination of the empty stomach the proof of gastritis may also be valua- ble on account of the mucus present in the opening of the tube, and which contains profuse amounts of leukocytes and epithelium. This is also the case with the proof of insufficiency of the stomach, in which the stomach that should normally be empty in the morning still contains ingesta. In all other cases, we examine the gastric contents during the time of digestion. During this process two objects must be borne in mind : First, the deter- mination of abnormal processes of decomposition in the gastric contents, and secondly, the determination of the properties of the gastric secretion. To determine the first, that is, the presence of abnormal products of decomposition or causes of decomposition, it is often sufficient if we obtain the gastric contents for examination upon the first visit to the patient, immaterial when and what the patient has last eaten. But it is advisable to do this only when we desire qualitative proof of the composition of the gastric secretion (hydrochloric acid and pepsin). This, however, is unwise when an exact estimation of the activity of the gastric parenchyma is to be made, particularly if we wish to determine the proportion of the constituents of the secretion, and, especially, of hydrochloric acid. The composition of the gastric contents, which repre- sent a mixture of the gastric secretion and the food that has been consumed, is dependent upon the amount and nature of the ingested food and upon the time which has elapsed since the food was eaten. Therefore, if we desire to ascertain the deviations of this composition from the normal, these deviations not being dependent upon accidental variations in the intake of food, but upon anomalies of secretion, we must be sure, in the first place, that the composition and amount of the introduced ingesta are always alike, and that the stomach contents are always obtained after the same lapse of time following the ingestion of food. For this purpose it is, above all, necessary that the stomach be empty before the foods which are to cause a secretion of gastric juice are eaten. The best time for the so-called test-meal is, therefore, early in the morn- ing, or in the course of the morning, several hours after breakfast has been taken. When it is doubtful whether the stomach is empty it must be washed out before the test-meal is given. Of the many test-meals which have been advised to stimulate gastric secretion, I shall here mention only the two which are in most common use, which are the best, and quite suffi- cient for all practical purposes. Test-meal according to Leube-Biegel. Toward midday the patient partakes of a plate of beef -soup, 150 to 200 grams of beefsteak, 50 grams of mashed potato and a roll. Four hours later, as a rule, the stomach is empty, but it is occasionally advisable to empty the stomach somewhat 66 FUNCTIONAL DISEASES OF THE STOMACH sooner or later. This method has the advantage that the gastric mucous membrane is stimulated in a normal manner, because all necessary foods are contained in the meal. It should, therefore, always be employed when the simpler Ewald method gives a negative result in regard to hydrochloric acid and pepsin. In such cases we often note that the more intense and prolonged stimulation of Leube's test-meal gives a conspicuously positive result; its disadvantage lies in the fact that, because of the complexity of the components of the meal, complete uniformity of the same in every case can only be obtained with difficulty, and gastric patients in particular are frequently unable to consume it entirely. In office practice it is most unpleasant, but sometimes necessary, to evacuate the stomach a long time after the meal, at a late afternoon hour. Test-meal according to Ewald and Boas. Early in the morning, or at another time when the stomach is empty, the patient receives one or two rolls of wheat bread (35 to 70 grams) and one or two cups of tea without sugar or milk. Water may be taken instead of tea. After an hour or an hour and a quarter (according to whether the single or double quantity has been taken) the stomach is evacuated. This test-meal has the advantage of great simplicity, and the masses which are evacuated do not have the smeary composition which they have by Leube's method. As the evacuation may occur comparatively soon after the intake of food, the administration of the trial breakfast and the evacuation of the stomach contents may be undertaken during the office hour. [The shredded wheat biscuit makes an excellent test-meal. It is free from yeast and contains the entire food elements of wheat. Two biscuits, thoroughly masticated, and a glass or two of water form an ideal Ewald meal. ED.] EXAMINATION OF THE GASTRIC CONTENTS A. MACROSCOPIC AND MICROSCOPIC EXAMINATION The odor of the gastric contents normally and also in most pathologic cases, provided the stomach is empty before the test-meal is administered, is not distinc- tive. In stagnation of the ingesta ( gastrectasis, dyspepsia, gastritis) we find, as an expression of decomposition, the odor of fatty acids, acetic acid or butyric acid (like rancid butter). Blood is occasionally admixed with the stomach contents as a small, bright red streak; it originates from retching, and is therefore of no pathognomonic impor- tance. If, however, the entire contents have a distinct hemorrhagic discoloration, the presence of an ulcer, carcinoma, or stasis in the portal vein system is proven, and all further sounding is to be avoided. IHlc, characterized by its yellow or greenish color, is very frequently found in the gastric contents and is of no diagnostic significance. Mucus in small amounts may also be found in the normal gastric contents if the quantity of hydrochloric acid present is slight. Larger amounts, particularly thick coagula, denote gastritis, unless the mucus originates from the respiratory passages. In the case of gastritis, the microscopic examination of the mucus as well as of the EXAMINATION OF THE GASTRIC CONTENTS 67 stomach contents evacuated from the empty stomach is of importance. The micro- scope reveals numerous well retained leukocytes and epithelia; in acid gastritis in which the protoplasm of the leukocyte is digested, numerous cell nuclei are found while these normally are present in only slight numbers (A. Schmidt). The macroscopic composition of the ingesta is of special significance. If, after Leube's test-meal, the particles of meat are split up, the production of hydrochloric acid is sufficient, perhaps even increased. On the contrary, if they appear un- changed there is a deficiency of hydrochloric acid, perhaps of acidity. Insufficient maceration of the fragments of bread favors hyperacidity as a greater amount of HC1 inhibits the saccharifying action of the diastatic salivary ferment which nor- mally occurs in the stomach. The microscopic examination of the gastric contents may be of diagnostic weight on account of the previously mentioned formed elements in gastritis. The presence of large numbers of microorganisms denotes stagnation of the ingesta, but it must be remembered that the yeast cells may be due to the ingested bread. B. CHEMICAL EXAMINATION The gastric contents to be examined must be undiluted ; except in an examination for ferments, it is unnecessary to filter them. The examination primarily is for the acids, particularly hydrochloric acid, vola- tile fatty acids, and lactic acids. In most cases this is sufficient. Under some cir- cumstances (if achylia be suspected), an examination of the ferment, perhaps also of the products of digestion, is expedient. ACIDS (a) Qualitative Tests Reaction. The evacuated contents of the empty stomach may normally have a neutral or even an alkaline reaction (the presence of bile and intestinal juices in the stomach). If, after a test-meal, blue litmus paper is not reddened, the con- dition is one of insufficient or absent hydrochloric acid secretion. Hydrochloric Acid. The test is first made with the Giinzburg reagent (two grams of phloroglucin, one gram of vanillin, thirty grams of alcohol) ; a few drops of this with an equal quantity of gastric contents are placed in a porcelain dish and heated over a small flame. If a beautiful red margin appears, the presence of hydro- chloric acid is proven. If, however, the red color does not appear, the absence of hydrochloric acid is by no means certain, as its presence, even in decided amounts, may be obscured by other combinations. This error cannot occur in the test with CaCo 3 ; therefore, this test must always be used if the reaction with the Giinzburg test is negative. For this purpose, we mix in a watch-glass some of the gastric contents with a pinch of powdered CaCo 3 . The reaction of the mixture is tested with blue litmus paper, and this is compared with the original reaction of the gastric contents. If the redness of the litmus paper after treatment with CaCo 3 is less intense than before, or if no reaction occurs, the stomach contents ( in the presence of volatile fatty acids and of lactic acid) contain hydrochloric acid. If the reddening is the same, before and after, no hydrochloric acid is present. For further confirmation of this test the digestion test may be employed (see below ) . Volatile Fatty Acids. Several c.c. of the gastric contents are heated in a test- tube to boiling, while a piece of blue litmus paper is held over the test-tube. If 68 FUNCTIONAL DISEASES OF THE STOMACH the paper redden, the presence of volatile fatty acids is proven: if no redness appear, they are absent. Lactic Acid. About 10 c.c. of gastric contents are shaken up with about the same quantity of ether, and the ether which has taken up the greater part of the lactic acid present is poured off. To the ethereal fluid a few c.c. of a very dilute ferric chlorid solution are added (one drop of an officinal ferric chlorid solution to a test-tube full of water). Even if only minute quantities of lactic acid are present, upon shaking a distinct yellow color appears in the ferric chlorid solution. (b) Quantitative Estimation We must always remember that, in spite of many methods for this estimation, we do not determine the absolute amount of acids excreted in a certain time by the quantitative estimation of the acids, but we measure relatively the secretory func- tion of the stomach, for the reason that we never know how much of the gastric contents has entered the intestine during the time in which we are evacuating the contents, and this, therefore, cannot be calculated. As, normally, there is consider- able variation in the secretion of hydrochloric acid in the same and in different persons, we should only regard marked and constant deviations as pathologic. If the presence of HC1 and the absence of volatile fatty acids and lactic acids have been proven in the manner described above (which is the case in the majority of tests), this is sufficient to determine the total acidity for practical purposes. On the other hand, if we desire to learn the exact proportion of acids present, their esti- mation must be included. Upon the whole, although the qualitative proof of organic acids in fermentative processes is so important, their quantitative estimation is of no great practical utility. Total Acidity. To a definite quantity (5 to 10 c.c., although we may do with less) of gastric contents, to which a few drops of an alcoholic solution of phenol- phthalein solution are added, a decinormal solution of caustic soda is added drop by drop from a graduated pipette until a red color appears and remains. The figure which is expressed by the amount of decinormal soda solution used in 100 c.c. rep- resents the degree of total acidity of the gastric contents. The normal values of total acidity usually vary between 20 and 60. If constant values below 20 are found, there is subacidity. If upon repeated examination values above 70 are noted, we are dealing with hyperacidity. Hydrochloric Acid. Of the many methods advised for the quantitative estima- tion of HC1 I shall describe only the one proposed by myself which, among other advantages, possesses that of great simplicity, and has shown itself, both in my hands and in those of others, to be absolutely reliable. To 10 c.c. of gastric contents, a few c.c. of a concentrated CaCl 2 solution are added, and after the addition of a few drops of an alcoholic phenolphthalein solu- tion the mixture is triturated (as above) with a decinormal soda solution until a permanent red color appears. Then, about 15 c.c. of gastric contents are mixed in a dry vessel with about 1 gram of dry powdered CaCo 3 , and, after stirring, nrp filtered through a dry filter, 10 c.c. of the filtrate are measured off, and the CO, which has formed is evaporated by a current of air, when CaCl 2 solution and some phenolphthalein are again added, and the acidity is calculated by means of a decinormal soda solution. If the sum of the decinormal soda solution obtained in this tritration (calculated upon the basis of 100 c.c. of gastric contents) be subtracted from the number of c.c. required in the first tritration, the difference corresponds to the amount of normal soda solution required for the neutralization of free HC1 present in 100 c.c. DYSPEPSIA 69 of gastric contents. If the reaction for volatile fatty acids and lactic acids (see above) is negative (as is the case in the overwhelming majority of instances), the figure obtained corresponds to the amount of HC1. This figure multiplied by 0.00365 gives the percentage in grams of HC1 in the gastric contents. If organic acids be present, 10 c.c. of gastric contents are again measured and shaken in a beaker with about 50 c.c. of ether; the ether is then poured off, and this shaking and pouring off of ether is repeated five times. If the acidity of the residue of the stomach contents be then determined the difference shows the amount of the organic acids. This is subtracted from the total acidity previously obtained, and the remainder equals HC1. FERMENTS The presence of digestive ferments (pepsin and lab) may greatly assist us in the diagnosis of achylia (see below). The test for pepsin consists in placing 10 c.c. of filtered gastric contents in each of two beakers, and also a flake of washed blood fibrin ; to one of these a few drops of diluted HC1 is added, and both beakers are placed in an incubator at blood temperature (98.6 F. ). If, after several hours, the flakes are still present, in spite of repeated shaking of the beaker, pepsin and pepsinogen are absent from the gastric contents. To determine the presence of the lab ferment about 10 c.c. of raw milk are mixed with 2 to 5 drops of gastric contents. Lab coagulation either occurs at once, or (at the temperature of the body) after a longer period. If the lab ferment is eventually absent, its prior stage, lab zymogen, may be recognized by adding 2 c.c. of a CaCl 2 solution to the previously mentioned mixture. DYSPEPSIA We employ the designation, dyspepsia, which in common parlance means " deficient digestion," to only a limited extent in that we restrict it to gastric digestion. But, even here, it is still further limited in that we exclude from this category organic diseases of the gastric walls which give rise to digestive disturbances. In the term " dyspepsia " we include only those alterations of the stomach which are not due to an organic affection. It is true the ordi- nary conception of dyspepsia is;.decidedly more extensive, for we speak of dyspeptic difficulties:. when referring to abnormal sensations in the stomach without an anomaly of gastric activity being conjoined to them. This .is especially true of sorealled "nervous dyspepsia" (see below), the especial characteristic of. which is that gastric digestion is quite normal. The con- tradiction in this is quite obvious, and although the designation which has become firmly rooted in our language is very difficult to displace, I never- theless believe it to be correct *n a systematic description to speak only of such conditions as dyspepsia in which gastric digestion is, in fact, disturbed. By this classification, cases of dyspepsia are greatly limited. Since the gastric mucous membrane is too sensitive to retain for any length of time contents which have been subjected to decomposition without 70 FUNCTIONAL DISEASES OF THE STOMACH reacting in a short time by irritative processes, i. e., by catarrh, only acute conditions belong in this category. Under dyspepsia, therefore, and in a restricted sense, we consider only acute dyspepsia, i. e., the digestive disturbances which the busy physician meets with daily, which are due to the ingestion of tainted food or to generators of fermentation. As pure dyspepsia, without organic implica- tion, these disturbances will be considered only in their initial stages, that is, before a consecutive catarrh has as yet been produced. To determine that only acute dyspepsia, and not gastritis, is present, an investigation of the gastric contents is always necessary. The presence of products of decomposition, especially organic acids, volatile fatty acids, and lactic acid is not sufficient for this purpose. For even a primary gastritis, usually in consequence of anomalies of secretions, causes an abnormal change in the ingesta which become subject to acid fermentation. True dyspepsia, however, is favored by the absence of decided amounts of mucus, which, in acute gastritis, is always present in the gastric con- tents, especially in the later stages; a microscopic examination permits the recognition of numerous leukocytes and epithelial cells. The effect also of a single, thorough gastric lavage, which is the best and most certain therapeutic remedy in acute dyspepsia, aids in the diag- nosis; for if, after this little operation, and without other remedial meas- ures, restoration to health is immediate, we may feel assured that the gastric mucous membrane was not implicated, and that the primary affec- tion consisted in a decomposition of the gastric contents. NEUROSES OF THE STOMACH Neuroses of the stomach, with comparatively rare exceptions, are purely idiopathic. As a rule, they are caused by a general anomaly of consti- tution, or, reflexly, are dependent upon disease of another organ. In these cases, strictly speaking, we are therefore dealing only with a symptom of another disease which affects the stomach; the disturbances of gastric activity are, however, frequently so prominent and characteristic that they dominate the clinical picture, and for this reason alone they merit a com- prehensive description. The most important etiologic factor is neurasthenia, next hysteria, as well as chlorosis and other anemic conditions, diseases of the sexual ap- paratus (especially in females), wandering kidney and affections of the intestines, and these by no means exhaust the series of diseases in the course of which functional disturbances of the stomach appear. As a rule, they occur secondarily in cerebral and spinal cord affections, in pulmonary tuberculosis, in peritonitis, in severe renal disease, etc. Nevertheless, in making a diagnosis, we must consider their occurrence in very different diseases. NEUROSES OF THE STOMACH 71 SENSORY NEUROSES Anomalies of the Sensation of Hunger. These consist in a decrease (anorexia), an increase (bulimia), and perversions of the normal appetite (parorexia) . Anorexia, which is a distinguishing symptom in almost all gastric dis- eases, may also be autochthonous, and here, above all, psychical influences such as care, sorrow, pain, disgust, etc., which dispel the sensation of hun- ger for a longer or shorter time, play a part. Naturally, before making the diagnosis, the existence of an organic gastric affection must be excluded. Parorexia, in which there is a tendency to eat impreper things, such as sharp condiments, vinegar, iron filings, chalk, etc., while natural foods are declined, occurs particularly in women who suffer from chlorosis or who are pregnant, but these abnormalities may also occur in other hysterical and neurasthenic persons. The treatment is that of the fundamental con- dition. In bulimia we are dealing with a pathological augmentation of the normal sensation of hunger. This varies extraordinarily under different physiologic conditions, and, particularly in growing persons, is frequently intensified ; and, since food not only serves to maintain the healthy condi- tion of the body but also to promote growth, we can only regard excessive increase of the appetite as pathologic. This is shown by an abnormal hunger which appears soon after profuse amounts of food have been taken, and, besides the unconquerable desire to eat, it is accompanied by numer- ous distressing symptoms. Among these are lassitude, numbness of the head, sometimes actual headache, specks before the eyes, tinnitus aurium, general sweating, and tremor as well as general weakness. In some patients local abnormal sensations, as in the region of the stomach, are prominent ; these are sometimes designated as pressure, sometimes as actual pain. As the sensation of hunger is produced by direct action upon the hun- ger center (central disease and chemical irritation of the center by an abnormal condition of the blood) as well as by reflex causes which may originate from the periphery, it is evident that the causes of bulimia may be extremely numerous. Besides neurasthenia the following must be men- tioned : Organic diseases of the brain and psychoses, Graves's disease, diar- rhea, helminthiasis, menorrhagia, pregnancy, diabetes mellitus, etc. Those cases of bulimia are especially interesting which depend upon other func- tional diseases of the stomach, particularly upon hyperacidity (see below) and, above all, upon hypermotility (see below) ; in the former case it is apparently the abnormal irritation of the hyperacid gastric juice, in the latter the abnormally rapid emptying of the stomach after the inges- tion of food, whereby a stimulation of the hunger center is caused cen- tripetally. 72 FUNCTIONAL DISEASES OF THE STOMACH The therapy of bulimia, on account of the great difference in the etiologic factors, must naturally be adapted to the underlying affection. The measures in the individual case are indicated in what has been pre- viously said; in fact, in the case of helminthiasis, diarrhea, diabetes mel- litus, and menorrhagia, a rational treatment of the underlying affection will in most instances suppress the bulimia, or, at least, decrease it. In hypermotility of the stomach it is wise to administer small quantities of food very frequently, and to alternate with fluid and solid food. In all cases in which there is hyperirritation of the nervous system, and these form the majority, besides the general regime suited to this, the adminis- tration of preparations of bromin as well as belladonna and similar reme- dies is of value. Gastralgia (cardialgia, gastrodynia) . This affection which, under the picture of gastric crises, forms such a prominent symptom in tabes dorsalis and other central diseases, may also appear in consequence of the above mentioned affections as a substantive disease. Yet, upon the basis of my experiences, the cases in which typical and marked attacks of pain in the gastric region are observed, may only in an insignificant percentage be considered as gastric neuroses; even then the diagnosis is extremely ques- tionable, for the positive exclusion of cholelithiasis and gastric ulcer (some- times also pancreatic calculi) is very difficult, and when we consider the great frequency of the two first mentioned affections, we had better, in a doubtful case, incline to these, and adjust the treatment in conformity. Gastralgias of moderate degree, which cannot be referred to an organic affection, are, on the other hand, quite frequent. In these cases the pain or sensitiveness is referred to the entire epigastrium, and this circumstance, as well as the patient's frequent statement that the pains are lessened by pressure, is of value in the differential diagnosis between ulcer and chole- lithiasis; in regard to ulcer, the independence of the quality of the food and of the time elapsed since the last ingestion of food also aids in the diagnosis. Gastralgia is not infrequently combined with liyperesihesia of the gas- tric walls, which is particularly observed in anemic and nervous individuals, and which shows itself by a more or less decided sensitiveness directly associated with the intake of food. This sensitiveness may reach a. very high degree, and cause severe irritative symptoms, such as convulsions and cataleptic spasms. The main point in the treatment is to quiet the nervous system. Be- sides other measures, the constant current may be useful. MOTOR NEUROSES The disturbances of motility of the stomach consist in an increase or diminution of this function, affecting the entire stomach, or only the cardia or the pylorus. There are, however, pathologic pictures which are dim- NEUROSES OF THE STOMACH 73 cult to explain otherwise than as a combination of irritative and depress- ing influences. Atony (insufficiency) of the stomach, which appears so frequently in organic disease of the stomach (dilatation and gastrectasis), is one of the most important functional disturbances ; it often occurs in anemia and other nutritive disturbances without demonstrable anatomic change in the gastric walls. In this condition we are dealing with atony of the muscu- lature as well as a decrease in its elasticity and consequent impairment of the property of propelling the ingesta from the stomach at the proper time. As the abnormal tension of the gastric walls which results is usually only a transitory extension of the organ, I shall omit its consideration at this point, and refer the reader to the excellent article by Kiegel. Insufficiency of the Cardia. While flaccidity of the musculature of the pylorus, causing an insufficiency of the pylorus, has only been described in isolated cases as a neurogenous affection (Ebstein), insufficiency of the cardia is an anomaly which may frequently show itself under different clin- ical pictures. Where there is a moderate degree of atony and a simultaneous tendency to voluminous collections of gas which are sometimes increased by decided swallowing of air (Quincke), we also observe eructation (ructus, eructatio) of gases, which may vary in intensity, and be transitory or habitual; in the latter case this becomes very distressing to the patient. As the same symptom is conspicuous in almost all organic gastric affections, errors in diagnosis can only be avoided with care. Besides hysteria, a circumstance in favor of the purely nervous character of the affection is that the gas which is discharged is odorless and tasteless, and the eructation may volun- tarily be suppressed by the impulse of the will. Besides general tonics, the treatment must be designed to influence the psychical element, and we must endeavor to strengthen the will power. Occasionally gastric lavage is of use. Another typical clinical picture, which is attributable to incontinence of the mouth of the stomach, due not only to atony of the cardia but also to a flaccidity in opening and to antiperistalsis of the esophagus, consists in rumination (ruminatio, merycism). In persons affected by this con- dition, the ingested food rises from the stomach a short time after it has been swallowed, and returns to the mouth (regurgitation), where it is again chewed and swallowed. This process usually occasions no disgust, and since regurgitation. as a rule, occurs soon after eating (rarely later than an hour), the food has no sour, or even unpleasant, taste. Many patients are unconscious of any disagreeable sensation, while others are keenly alive to their repulsive condition. Not rarely they are able to sup- press the regurgitation which they have voluntarily produced, but only temporarily, for this afterward recurs to an increased extent. I know sev- eral patients who have had this affection for decades, and who can pre- 74 FUNCTIONAL DISEASES OF THE STOMACH vent regurgitation by lying down immediately after their meals, but if, after some time, they rise, the regurgitation at once appears. The cir- cumstance that psychical alterations, fatigue, menstruation, etc., cause an increased and more frequent appearance of the affection is in favor of its nervous character. The treatment, in the main, must be directed toward increasing the energy of the will and suppressing the pathologic process. Gastric lavage should be tried as well as preparations of bromin. Unfortunately, we rarely succeed in bringing about a cure. So-called nervous vomiting may also be included in this class of affec- tions. Vomiting is caused by increased muscular activity, but a paroxysmal contraction of the diaphragm and of the abdominal muscles only causes immediately a compression of the stomach, that is, an expulsion of its contents, and it is unquestionably true that the forcing of the stomach contents upward occurs all the more readily the less resistance there is on the part of the cardia. Nervous vomiting is characteristic because of the particular ease with which it appears (prodromes, especially nausea, are frequently absent), and it is obvious that flaccidity of the cardia plays an important role. This affection is prone to occur in hysterical persons, also in chlorotics, more rarely in neurasthenics. The idiopathic form of nervous vomiting described by v. Leyden, which is characterized by its periodic appearance (periodical vomiting), must be here included. Nerv- ous vomiting may exist for years without the nutritive condition of the patient suffering. [Regurgitation of food due to stenosis of the esophagus, especially at the cardia, may be mistaken for vomiting. This is especially true of cardio- spasm. General nervous conditions may be the cause of the cardiospasm, and at the same time a nervous dyspepsia or a gastric ulcer may exist. A close attention to the character of the symptoms, especially of the act of so-called vomiting and an examination of the expelled food, will make the case plain. ED.] In the diagnosis, an unusually large number of general affections and diseases of the most varied organs, intoxications and autointoxications, as well as organic gastric affections in which vomiting is a symptom, must be excluded, and furthermore, particular stress must be laid upon the etiologic factor of hysteria. Besides combating hysteria, local treatment of the stomach by lavage or irrigation and electricity are in place. Hypermotility. Hypermotility is a condition in which the motor ac- tivity of the stomach, by means of which its contents are propelled into the intestine, is increased. In consequence the stomach is empty during a time in which, normally, ingesta should still be present. Whether in- sufficiency of the pylorus also plays a causative role cannot be determined. FTvpermotility is by no means rare. It occurs particularly in neuras- thenics, and shows itself by the appearance of bulimia (see above). In NEUROSES OF THE STOMACH 75 the diagnosis, the proof that the stomach one hour after the Ewald, or three hours after a Leube, test-meal is empty or contains but few particles of food is necessary. In regard to treatment, see that indicated for bulimia. Peristaltic Unrest (tormina ventriculi). This anomaly is distinguished by increased peristaltic movement of the stomach (and frequently also of the intestine), and is accompanied by more or less loud rumbling which, with a thin abdominal wall, is distinctly audible. In making a diagnosis stenosis of the pylorus, above all, must be excluded. The treatment consists in the use of sedatives; occasionally lavage of the stomach acts favorably. Spasm of the Cardia. In contrast to the descriptions of this occurrence which are variously given, we must fully understand that the isolated spastic closure of the cardia may, primarily, cause difficulty in deglutition. We therefore have the symptoms of a deeply situated stenosis of the esophagus. This anomaly is purely functional, particularly in hysteria, but it also occurs in marked anemia without other nervous irritative phenomena. It may run its course with or without pain, it may occur paroxysmally, par- ticularly in connection with the act of deglutition, or be permanent. Cases have been described in which the spasm had existed for years, and had given rise to a sac-like dilatation of the esophagus above the stenosis (Leichten- stern, Dinkier). Whether, however, in these cases an ulcer of the cardia did not originally exist would be very difficult to decide. For the diagnosis, examination with the gastric sound is decisive. Upon its introduction, if a spasm at the height of the cardia exists, resistance is met with which, as a rule, is readily overcome. This procedure may be accompanied by pain or occur without it. In the absence of pain the diagnosis is easy. In a dif- ferentio-diagnostic respect, carcinoma, in the usually youthful patient, need scarcely be considered. But with a painful course of the affection, care must be taken not to confound the condition with ulcer of the cardia. The successful introduction of the sound would exclude the latter, while, on the other hand, treatment similar to that for ulcer is to be instituted. Besides general remedial measures, sounding the esophagus is indi- cated. Sometimes a single sounding is sufficient. If this is not the case it is well to apply cocain by moistening the lower end of the tube with a solution; or, still better, after introducing the gastric tube to the depth of the cardia, a few cubic centimeters of a not too concentrated cocain solution may be poured into the tube, which is allowed to remain in situ for a few minutes. Spasm of the Pylorus. This frequently occurs in organic diseases of the stomach, and is said to be also purely functional, particularly in hyper- acidity. The consequences are stagnation of the ingesta and tympany of the stomach, and the latter may be particularly severe when combined with spasm of the cardia. Asthma dyspepticum, so designated by Henoch, is due to a combination of this kind. 76 FUNCTIONAL DISEASES OF THE STOMACH NEUROSES OF SECRETION The anomalies of secretion are less numerous than those of sensation and motion. They consist in a decrease or increase of the secretion. Achylia Gastrica. While the achylia observed in connection with car- cinoma and chronic gastritis depends upon an atrophy of the gastric mucous membrane, we observe in neurasthenic, and especially in anemic, persons, a decrease or complete absence of the secretory activity of the stomach with- out a causative anatomical change, and whether or not due to a purely functional disturbance is doubtful. Martius quite properly states that the ready vulnerability of the mucous membrane, so obvious in cases of this kind upon the introduction of the tube, raises the suspicion of the exist- ence of slight degenerative or inflammatory processes. Besides, the sub- jective symptoms of achylia affecting the stomach are, as a rule, few, and their action upon the entire nutritive condition is slight, or may be wholly absent, for the absence of gastric digestion with intactness of the motor function is not of importance in utilizing the ingesta. A diagnosis of achylia can only be made when repeated examination of the gastric contents, possibly after a previous irritation of the mucous mem- brane by the introduction of a salt solution, shows an absence of acid reaction or only very low values of the total acidity (at most ten or less). In the differential diagnosis carcinoma and gastritis must be excluded. In the treatment, besides general strengthening therapy, the absent secre- tion must be substituted for by the administration of hydrochloric acid and pepsin at every meal, and the maintenance of the motor activity of the stomach must be provided for. The former, as has been remarked, is unnecessary for the sufficient utilization of the ingesta. There is, however, no doubt that by the absence of hydrochloric acid in the stomach there is danger of the further development of pathogenic microorganisms which have gained entrance there, and this danger may be averted by the admin- istration of hydrochloric acid. Hyperacidity (hyperchlorhydria, gastroxynsis) . Hyperacidity repre- sents one of the most important disturbances of function of the stomach, and it may also be combined (see below) with hypersecretion (gastrorrhcea acida). It is chiefly noted in young, anemic individuals, particularly chlorotics, and also in neurasthenics, but by no means exclusively in these conditions. Psychical irritation is unquestionably an important etiologic fac.tor, but it is also observed in persons whose nervous system is, in general, quite normal. Of organic gastric affections, which we shall not minutely consider here, the anomaly is most often associated with ulcer. We find it, too, in motor insufficiency of the stomach, in gastrectasis, in gastroptosis and purely functional atony (see above), probably due to the abnormally long presence in the stomach of the ingesta which causes the secretion. Cases of hyperacidity have also been described (acid gastritis) NEUROSES OF THE STOMACH 77 in chronic gastritis which, as a rule, runs its course with a decrease in gastric secretion, and in the amount of acid. On account of the extreme difficulty of excluding these organic affections, we must admit that abso- lutely certain cases of purely functional hyperacidity are by no means frequent. The subjective symptoms, combined with a normal appetite, are pyrosis, which may be increased to gastric pain, pressure in the gastric region, and acid eructations. Vomiting of decidedly acid masses is rare; thirst and bulimia are frequent. These symptoms appear in very different degrees without a parallel degree in the amount of acid. The sensitiveness of the gastric mucous membrane to the irritative action of hydrochloric acid is apparently very variable in the same and in different individuals, and the relation in time of these difficulties to the intake of food shows many variations. Sometimes they are nearly continuous with occasional exacer- bations attributed to the food consumed, at other times they occur only paroxysmally after meals. Sometimes also certain foods which are invar- iably not well borne are responsible for the difficulty. The diagnosis of hyperacidity depends upon an examination of the gastric contents. If, upon repeated examination, we find an amount of 0.25 per cent, of HC1 or more, hyperacidity is proven. If upon the ab- sence of organic acids the total acidity is more than 70, the same condition is proven. The circumstance that particles of bread are less broken up than normally is also characteristic of a high degree of acid. It must also be borne in mind that, just as under physiologic conditions, variations in the amount of acid frequently occur, yet the diagnosis of hyperacidity is not superseded by the fact that occasionally normal amounts of acid are found. While the proof of hyperacidity, as a rule, is simple, the exclusion of an organic disease of the stomach and the proof of a purely functional disturbance combined with hyperacidity may be most difficult. Here, in the first place, gastric ulcer must be mentioned. On account of its great frequency, and that, as a rule, it runs its course with hyperacidity, and also that, in this affection, the symptoms usually appear some time after eating, we cannot be too careful in the differential diagnosis. When there is well developed gastric pain besides the other mentioned symptoms, in my experience a purely functional hyperacidity should be excluded and the treatment should be based upon the hypothesis of a gastric ulcer. If positive factors for the development of an acid gastritis have been proven, in the differential diagnosis we must also consider this affection. Contrary to the reports of some authors, the absence of mucus in the evacuated masses favors the assumption of the purely nervous character of the malady, if the evacuation have occurred at the usual time after the test-meal, for the mucus secreted in consequence of catarrh is very rapidly digested by the acid gastric juice, which has a strong, peptonizing action. More signifi- 78 FUNCTIONAL DISEASES OF THE STOMACH cant, on the other hand, is the fact that toward the end of digestion, upon microscopic examination of the remnants in the opening of the tube, large numbers of cell nuclei are found, since, normally, but few nuclei of this kind are present. Another circumstance that favors an existing catarrh is that upon withdrawal of the tube from an empty stomach adherent par- ticles of mucus containing large numbers of leukocytes are found. The views in regard to the best treatment of hyperacidity have under- gone decided change. The fact that an increased amount of HC1 in the gastric contents unquestionably disturbs the saccharification of the food- containing starch by the salivary ferment which is swallowed made it appear rational to limit starchy food in the diet of the patients suffering from hyperacidity (to the utmost), and to place them upon animal food. Experience has, however, shown that a diet of this kind does not always lessen the difficulties, but not infrequently they increase, and this coincides with the fact that objective investigations of the gastric contents show no decrease in the amount of acid. In the first place, a meat diet is generally not well borne by patients with gastric disease, and, above all, a diet rich in albumin causes a greater secretion of acid (Hemmeter, Fleiner, Jiir- gensen and others). It is, therefore, rational to prescribe for the patient a mixed diet which possesses the property of combining acids, which in- creases acid secretion to the slightest degree, and is as little irritating as possible. These indications are best fulfilled by milk, and by milk rich in fat, since fats have an extremely slight influence upon the gastric juice. If milk is declined, or not well borne, as is unfortunately often the case with these patients, lime water may be added to it. Sbft, pappy rice, maizena, stewed calves' brains, sweetbreads, etc., are given. Toasted wheat bread, and tea with a plentiful addition of cream, are likewise permitted. We also prescribe soda bicarbonate, magnesia (hydrated), Carlsbad salt and other alkalies, besides narcotics (especially belladonna). In some cases there is a favorable influence from takadiastase, whose saccharifying prop- erty is less disturbed by hydrochloric acid than that of ptyalin. In addi- tion, stimulating measures are not to be neglected. Hyperacidity is a very stubborn disorder, and we must, therefore, be guarded in the prognosis. Hypersecretion (flow of gastric juice). This affection is characterized by an abnormally profuse secretion of the gastric juice, which occurs with- out the stimulation of the ingesta. It may be continuous or periodic, and may run an acute or chronic course. The amount of HC1 of the secre- tion may be increased (gastrorrhcea acida) or normal. In the former case the symptoms are those of hyperacidity; but, even when HC1 is not increased, the patients complain of pyrosis and acid eructations. Vomiting of a more or less profuse, watery, acid fluid while the stomach is empty of food is characteristic of the condition. The diagnosis depends upon the last mentioned symptom and upon NEUROSES OF THE STOMACH 79 the results obtained by the stomach-tube while the stomach is empty; that is, whether by this procedure large amounts (100 c.c. to 1 liter) of an almost clear fluid having an acid reaction and containing HC1 and pepsin are evacuated. The treatment must be directed to the removal of the probable under- lying affection, neurasthenia, anemia, etc. ; the preparations of bromin, narcotics (codein, belladonna, cocain, etc.), are in place as well as irriga- tion of the gastric mucous membrane. NERVOUS DYSPEPSIA (GASTROSIS) Among the gastro-neuroses, so-called " nervous dyspepsia " occupies a peculiar position. Leube, who accurately portrayed the clinical picture after it had been described by others, particularly by English authors (Beard and Eockwell), defines it as a pathologic condition in which sub- jective symptoms of chronic dyspepsia, analogous to those of chronic gas- tritis are present, but in which objectively demonstrable anomalies of activity, as well as organic changes of the stomach, are absent. It is evident that, in a pathological condition the basis of which is subjective difficulties, the negative results of investigations of the anatomi- cal and functional disturbances of the stomach create a difference of opinion among authors in regard to the definition and the limitation of the affection, and that many deny that there is any justification for con- sidering a symptom-complex of this kind as a. disease, sui generis. In fact the number of authors who are opposed to the pathologic conception of " nervous dyspepsia," in Leube's sense, is quite considerable. We would digress too far, and in entire opposition to the character of this article, were we minutely to consider the comprehensive literature of this subject. Some of these explanations bear a remote date, and it may be assumed that not a few of the opponents of " nervous dyspepsia " have, in the course of time, made subsequent observations, and have changed their former opinions. According to my experience which coincides with that of others, there is no doubt of the existence of a clinical picture as described by Leube and others. Far be it from me to maintain that, in such cases, an organic change can always be excluded. We are unable, however, to demonstrate it, and we may often convince ourselves that no organic disease known to us is the cause of the affection. Shall we therefore deny the existence of this clinical picture ? With as much right as we could eliminate many other affections, such as migraine, neuroses of the heart and of the intestines, flittering scotoma, pruritis, etc., from pathology. For in these conditions also we are unable at present to detect any anatomical anomaly which is certainly the cause of the symptoms or to exclude it. The justification and the necessity of limiting " nervous dyspepsia " as a disease, sui 80 FUNCTIONAL DISEASES OF THE STOMACH generis, as well as the previously mentioned functional disturbances, simply depend upon experience, in consequence of which the symptoms mentioned and those still to be discussed appear, and must be considered, as the expression of this affection of the stomach. Objections have been raised to the description of the clinical picture, as well as to its name. This is quite reasonable. Since objective dis- turbances of digestion are absent in the disease it would naturally follow that the name "nervous dyspepsia" would provoke discussion. It might also be added that the nomenclature does not correspond to the actual conditions, since the dyspeptic difficulties are, without exception, to be attributed to an implication of the nervous apparatus. In many, perhaps in a majority of the cases, this origin may be at once admitted; namely, for those in which the disease depends upon neurasthenia, hysteria or organic disease of the nervous system, or where it appears as a reflex neurosis, particularly from the sexual apparatus. Even where the causa- tive factor is looked for in intoxications or infections, such as the abuse of nicotin, alcoholism (here it is true there is usually chronic gastritis), syphilis, malaria, etc., which usually exert a damaging influence upon the peripheral nerves, we are justified in ascribing to the primary cause the development of the gastric symptoms. On the other hand, it must be remembered that the symptom-complex peculiar to this group also appears in consequence of anemic and general debilitative conditions, such as chlorosis, the puerperium, improper and insufficient food, etc. It would seem far-fetched to look for the cause of the morbid sensations in *the nervous system. This would be more obvious in an insufficient nutrition of the parenchyma of the stomach which is undoubtedly present, which, however, as the actual causal factor, has as yet shown no gross pathologico-anatomical changes of the organ. For this reason, the desig- nations neurasthenia dyspeptica orvgastrica (Burkart, Ewald) are not to be regarded as improvements; for, as v. Leyden quite properly remarks, the chief disturbances are not in the stomaqji, as should be the case. Of the other names which have been proposed, the beet appears to be " com- bined gastroneurosis," which, it is true, is somewhat complicated, and does not emphasize the sometimes non-nervous nature of the affection. Perhaps it would be wise to choose a more indifferent designation, which would, however, permit us to recognize that we are dealing with a functional anomaly of the stomach. As such I propose the name: Gastrosis. The designation nervous dyspepsia has become so firmly rooted in our minds that it will not readily be eradicated, but the name is of subordinate significance provided we are unanimous as to what it signifies. Among the etiologic factors which have been mentioned there is one which is important because of its comparative frequency. This is an abnormal state of nutrition due to the fact that the periods between the NEUROSES OF THE STOMACH 81 individual meals are too long. There are some persons who, like dogs, take only once a day a meal which really deserves the name, and yet they continue in the best of health. In spite of the latter circumstance, there can be no doubt that this habit is irrational. It is contrary to the laws regulating the function of the stomach as a reservoir of food, and it cannot be an advantage to the stomach to remain empty for several hours during the day and then suddenly to become excessively loaded. The effect of this is particularly noticeable in persons who do not voluntarily or from habit make these long pauses between meals, but are forced to it by the stress of circumstances. This occurs in very busy physicians, particularly surgeons, in merchants, in lawyers, etc. According to my experience, this category of occupations furnishes the main contingent of the cases of gastrosis. The circumstance that the digestive disturbances of the patients improve when they change their mode of life and take more frequent but smaller meals, is proof of the etiologic importance of this improper mode of nutrition. The symptoms of nervous dyspepsia, as already stated, are in the main subjective. The patients complain chiefly of a feeling of pressure and distention in the gastric region, and of eructations which sometimes become exceedingly severe and loud. The appetite, as a rule, is disturbed. The patients have more or less repugnance to food, and not rarely complain of nausea. Tendency to vomit and actual vomiting also occur, but not so frequently as in gastritis. The loss of appetite in some cases depends upon autosuggestion. The patients fear that by eating their distress will be increased, and therefore refrain from food as far as possible. On the other hand, even bulimia occurs; the patients then are tormented by a voracious appetite which causes them to crave food. As a rule, as soon as they begin to eat, the bulimia not only disappears, but also all desire for food. They can only -take small amounts, and are unable to satisfy the existing hunger. Perverse anomalies of taste are also frequently ob- served. Acids and other foods difficult of digestion are especially pre- ferred, and in the circumstance that, after their use, the preceding dis- comfort often lessens, this clinical picture differs from other organic affections. Among the abnormal sensations which originate from the gastric region, besides fulness and eructation, pyrosis must be mentioned. This symptom, which is an almost invariable accompaniment of actual dyspepsia, of " sour stomach," is not always found hand in hand with an increase in the acidity of the gastric contents, nor need this be the case in nervous dyspepsia. There are, however, instances in which the degree of acidity exceeds the normal limits. Actual pain in the stomach is but rarely complained of, and, even then, it is not the pain upon pressure which is so characteristic of ulcer. The gastric region may be sensitive to the pressure of palpation, but often this 82 FUNCTIONAL DISEASES OF THE STOMACH is only an indefinite, disagreeable feeling, which is also observed in other sensitive patients whose stomach and other abdominal organs are perfectly normal. The condition of the bowels varies. Constipation exists in many cases, as in other chronic gastric affections. Diarrhea is rare, and often no anomaly is present. The disturbances of the general condition may be manifold and corre- spond to the varied etiologic bases of the affection. From the symptoms of neurasthenia (such as numbness in the head, lassitude, depression, hypochondriasis, even melancholia, on the other hand frequently slight irritability, cardiac palpitation, vertigo, etc.) it is not always easy to de- cide whether we are dealing with coordinated symptoms of the same cause of the disease or with the sequels of the gastric affection. The general nutrition may also vary according to the causal factor. In most cases the patients are well nourished, and there is no external sign of suffering. But we also see patients who are hollow-eyed and more or less emaciated with no malady save one of the stomach to account for the disturbance. The history then reveals that the emaciation is due to insufficient food. These patients, partly from fear of distress, partly in obedience to unwise professional advice, have for a long time taken only a minimum of food, and have actually undergone a starvation cure. It cannot be wondered at that, in consequence of this limited diet and the resulting loss of resistance of the walls of the stomach, the symptoms instead of decreasing have been decidedly aggravated. These are the most hopeful cases for treatment; the physician who clearly recognizes the affection and acts upon this knowledge, helped by the previous error, may, with ease, bring about what seems a miraculous cure. In the diagnosis of nervous dyspepsia, which should be made with great care, we must first decide whether the complaints' of the patient are actually attributable to gastric activity, or whether the difficulties referred to the stomach are not due to a disease of other parts of the organism, or whether they do not at least owe to it their origin. In this connection we cannot be too skeptical, since such so-called dyspeptic symptoms as were empha- sized above may occur in a number of different affections which cannot be minutely described at this point. The presence of well developed neurasthenia or hysteria, and the proof that these anomalies existed prior to the dyspeptic symptoms, are of importance in the diagnosis. It is obvious that these will aid us only in the diagnosis, as neurasthenic and hysterical persons may also suffer from organic disease of the stomach, and as gastrosis .ilso occurs in persons who, in Hie main, show no functional disturbances of the nervous system. Tlio coincidence of dyspeptic disturbances belonging to the symptom- complrx of nervous dyspepsia, with functional disturbances of the heart without organic disease, is also important in diagnosis. Cardiac palpita- NEUROSES OF THE STOMACH 83 tion and irregularity of the cardiac action in connection with gastric affec- tions are, therefore, symptoms which must be considered in the diagnosis. The report of the patient that the digestive symptoms vary, that, in- stead of the usual disturbances, there are times when the disease seems to have almost disappeared, particularly when the mind is diverted by pleasant company, may be of value. With Eosenheim I admit this fact, but it rarely occurs, and is not absolute proof that other gastric patients, for example, those suffering from chronic gastritis, occasionally will forget their dyspeptic disturbances when in interesting society, at the theatre, etc. Nevertheless this occurs, although less frequently. The objective examination of the stomach is chiefly important because conspicuous anomalies are not found. I am of the opinion that the mod- erate grades of gastroptosis which prevail so commonly in women without giving rise to symptoms, cannot annul the diagnosis: Nervous dyspepsia. In regard to the functional test, Leube, as remarked above, has laid special stress upon the fact that the motor function is intact. According to my experience, we must in general agree with him, and the cases in which there is a well developed slowing of motion should not be consid- ered as nervous dyspepsia. Moderate grades of atony, or the presence of small remains of food two hours after a test breakfast and seven hours after a test-meal, belong to the same clinical picture, particularly if this condition is not constant. In testing the functions of the stomach these frequently great variations are characteristic, and this is true of a higher degree of secretion. In this respect I entirely agree with Boas and Rosen- heim. It is true that while the degree of acid is usually within normal limits we occasionally note surprising variations of the acidity below and above the normal. On account of this variability of the symptoms, and the difficulty of limiting exactly the clinical picture, we should never fail to consider the possibility of organic disease of the stomach before we make a positive diagnosis. The condition may be mistaken for gastric ulcer, for this affection does not always present the well known classical symptom of typical pain occurring a short time after the intake of food, but it may develop with- out any pain, and an examination of the gastric contents may reveal no characteristic differences. If there is actually well developed pain, the case is not one of nervous dyspepsia. Marked tenderness and a drawing sensation in the gastric region, however, are observed, and the report that these sensations are not increased by external pressure but are rather re- lieved is decidedly against ulcer. The manner in which the sensitiveness of the gastric region shows itself upon palpation is important. If it be localized to a circumscribed area this favors ulcer, while a diffuse, painful sensitiveness of the entire epigastric region points to the nervous character of the affection. If hysteria is present we not rarely observe, especially 84 FUNCTIONAL DISEASES OF THE STOMACH in thin patients, painful pressure areas upon both sides of the vertebral column. But a confusion of this previously mentioned pain upon pressure with simultaneous gastroptosis is not impossible. Even if there is no marked sensitiveness of the gastric region, we can- 7iot at once exclude ulcer, particularly when dealing with young anemics. As the examination of the gastric contents permits no positive conclu- sions, it is wise in cases of this kind to proceed as if ulcer were present, therefore, to prescribe absolute rest, fluid diet, and silver nitrate. If by this means the affection is not favorably influenced, the assumption of gastrosis is justified. Gastric carcinoma may be excluded with certainty provided the dys- peptic difficulties have existed for a long time without any diminution of the body-weight. We must, however, remember that carcinoma may run a very slow course without producing symptoms other than those of dys- pepsia, anemia, and slight emaciation. In elderly individuals we must be very cautious in the diagnosis of an affection of this character, existing for a short time, perhaps only for a few months. If well developed symp- toms of neurasthenia or hysteria have preceded, they favor the diagnosis of nervous dyspepsia, although, of course, patients of this kind may be attacked by carcinoma. A normal hydrochloric acid reaction and the ab- sence of lactic acid in the stomach contents are factors which decidedly favor nervous dyspepsia. Absolute certainty, however, can only be attained when regular weighings of the body, under sufficient nourishment, show no loss in weight. Well developed gasireciasis presents such a characteristic clinical pic- ture that this disease can scarcely be mistaken for another. But this may readily occur when the symptoms depend upon a simple atony of the gas- tric walls. Here definite conclusions are reached by the examination of the motor function. The proof that there is no stagnation of the ingesta, that, on the contrary, the stomach discharges its contents normally, ex- cludes this anomaly. Naturally, we should not be content with a single examination, for, as has been stated, variations in the motor function occur in nervous dyspepsia. But the existence of this affection is not disproven if, transitorily, a prolonged retention of the ingesta in the stomach is observed. Chronic gastritis must be specially borne in mind in the differential diagnosis, as the subjective symptoms of this condition completely coincide with those of nervous dyspepsia. The absence of a coated tongue, and the non-appearance of mucus in the vomit and evacuated gastric contents, particularly when the stomach is empty (see above), favor the latter. If gastritis is present, upon microscopic examination of the contents of the tube we find profuse formed elements, leukocytes and epithelium. The chemical examination of the gastric contents after a test-meal is not unim- portant, for, as a rule, the secretion of HC1 is deficient in gastritis. This NEUROSES OF THE STOMACH 85 is, of course, not always the case, for in so-called acid gastritis, which is rare, it may even be increased. Therefore, in cases of this kind, the circumstance that the affection occurs in neurasthenics or hysterical persons, as well as the modification of the disease hy treatment, is of significance. The prognosis is always doubtful. By proper treatment many cases are favorably influenced and even complete recovery ensues. But it some- times happens that, at the onset, decided improvement takes place, and the easily excited patients are enthusiastic regarding the result ; then, how- ever, relapses occur which affect the entire nervous system, and reproduce the former gastric disturbances. In other cases all endeavors favorably to influence the condition are without avail. These cases test the patience of the sufferer and the physician. In therapy the psychical treatment is hardly less important than the somatic. It is true we will only rarely be successful if we represent to the patients that the affection is a very slight one, which may yield to a little exercise of the will. As a rule the patients resent a suggestion of this kind. It is in crass contrast to their discomfort, and, as a matter of fact, the mere determination not to be ill rarely suffices to cure the disease. But there are instances, as stated before, in which a mere change in the diet, i. e., a return to the usual home living, is sufficient to restore the patient to health. These are, however, not cases due to neurasthenia or hysteria, but those which at the onset were very insignificant gastric diffi- culties, but excessive carefulness and a fear of the injurious effect of whole- some and plentiful food has limited the diet to such uniform and insuffi- cient food that it has not conduced to improvement; hence, in consequence of imperfect nutrition of the walls of the stomach and of the entire organ- ism, a steady aggravation of the dyspeptic symptoms has been brought about. A., a manufacturer, aged 45, as a young man had disease of the left pulmonary apex, which, however, entirely disappeared and there is no trace of it at present. After this illness, the patient became extraordinarily careful and anxious about his health. The slightest deviation from the normal made him fear the onset of disease. According to report, several years ago he began to have a sensation of fulness and pressure in the epigastrium after his principal meal, accompanied by eructa- tions and constipation. Gastritis was diagnosticated, and the patient, whose appe- tite was always normal, limited to an extreme the quantity and quality of his food. By this means and the use of Carlsbad water, his condition is said to have at first improved, but gradually there was an aggravation, and, although pressure in the region of the stomach was no longer especially noticeable, the eructations continued, and to these vertigo, headache and palpitation of the heart were added. Appetite was lost, and not infrequently the monotonous diet caused repugnance. Neverthe- less, the patient continued upon this diet through fear of injuring himself by a change. The examination of the powerfully built, but pale and poorly nourished patient, revealed no anomaly of the stomach (total acidity upon repeated examination 30 to 60, Giinzburg's test positive, motility normal) or any other part of the organism. 86 FUNCTIONAL DISEASES OF THE STOMACH I explained to the patient that there was no disease of the stomach, nor, in fact, any organic affection, and that his symptoms were due to an injudicious mode of life, particularly to monotonous and insufficient food. I, therefore, advised him not only to take the " easily digested foods " but to return to his former favorite foods. No restrictions, whatever, in diet were necessary. The patient at first was some- what incredulous but followed my advice and at once ate some peas with sour kraut and pickled meat. As the symptoms which he looked for did not appear he gained confidence, again ate and drank like a healthy man, and after three weeks presented himself to me completely cured. His weight steadily increased (about 21.9 pounds) and except for constipation, which still existed, all symptoms had disappeared. Cases of this kind are, however, infrequent, and, particularly when dealing with nervous persons, treatment such as above described is not in order. Here, above all, it is necessary to tone up the entire nervous system. Bodily and mental rest, removal from the ordinary occupation, are usually the first requirements, but by no means always. Patients who have previously passed their time in idleness, with hypochondriac thoughts dwelling upon their stomach affection, should be advised to take up a stimu- lating occupation, strengthening and even fatiguing bodily exercises. But the diet must be regulated. In severe cases, particularly in debilitated women, complete isolation and rest in bed, at least for the greater part of the day, and forced feeding, will be beneficial. In other cases a change of air, i. e., residence in pure fresh air (medium altitude in the woods) is sufficient. Special stress must be laid upon the stimulation of the skin by baths, massage and electricity. Above all, the diet must be regulated. Food difficult of digestion, and particularly that which causes flatulence, must be avoided, but the fact should be emphasized that the diet should be varied as much as possible, and the intervals be- tween the meals are not to be too long. Drug treatment, compared with these general dietetic rules, is of de- cidedly secondary importance, but it is frequently necessary to support the latter mode of treatment. Here stomachics such as rhubarb, tincture of quinin and bitters, iron and Fowler's solution, perhaps also quinin as a tonic, then sodium bromid and valerian, as well as various remedies for the usually stubborn constipation, are beneficial. THE DIAGNOSTIC AND THERAPEUTIC SIG- NIFICANCE OF SECRETORY DISTURB- ANCES OF THE STOMACH BY H. STRAUSS, BERLIN THE significance in diagnosis and therapy of the secretory disturbances of the stomach is unquestionable, and is important from a scientific as well as a practical standpoint. This will be admitted even by those who hold the certainly justifiable view that the nosological significance of disturb- ances of secretion was greatly over-estimated in the first few years of the new departure in functional diagnosis of the stomach. But there is no reason for under-estimating it to-day. Though we must acknowl- edge from actual observation that a person absolutely without secretion in the stomach may not only live for years but even decades without showing noteworthy disturbance of nutrition, we know, nevertheless, that the result of marked secretory insufficiency of the stomach as, for instance, diar- rhea may damage nutrition to a marked extent, and that, on the con- trary, excessive secretion continuous secretion of the gastric juice by causing chronic under-nutrition, dryness of the tissues, and perhaps also withdrawal of chlorin may induce conditions which threaten life. It is not my object to describe in detail these conditions in which disorders of secretion play a role, but I shall consider secretory disturbances only in so far as they represent subjects for diagnostic and therapeutic consideration. If this manner of presenting the subject is a priori unfamiliar to the reader accustomed to regard definite clinical pictures as nosological entities, it cer- tainly will facilitate the description, and the physician who understands also other disturbances of the stomach, their importance, and the methods for their recognition, will not be led by such a description to a too one-sided conception of the subject, or allow himself as a therapeutist to drift into errors of omission. As a rule, the careful physician will have already grasped the knowledge that, as a basis for the erection of pathologic pictures in gastric pathology, the clinical symptom-complexes which we meet to-day in gastric pathology frequently do not equal the pathologico-anatomical changes with which we have long been familiar. Following 0. Eosenbach, almost all investigators in this realm have come to the conclusion that for the purpose of treatment the interests of our patient demand not only a thorough investigation of the symptoms of anatomical, change (position, form, and size of the stomach, production of mucus and pus, superficial 87 88 SECRETORY DISTURBANCES OF THE STOMACll lesions), but, in every case also an accurate study of the individual disturb- ances in function. In many instances our method of treatment will only enable us to reach the goal by a test of function (secretion, motility, etc.). GASTRIC SECRETIONS Among the different secretions of the stomach (hydrochloric acid, pep- sin, lab-ferment, steapsin, water) the secretion of hydrochloric acid occu- pies the first place in our present clinical description, as the disturbance of other secretions, such as pepsin and lab-ferment, the secretion of steap- sin, and of the diluting secretions, either is so far parallel with disturb- ances in the production of hydrochloric acid that for clinical purposes it requires special consideration only in particular cases, or, according to the existing state of our knowledge, it is to be regarded as of so little practical value that, for our present purpose, we need not enter upon its detailed description. When we refer to a disturbance of secretion as an object for diagnosis and treatment, the first question that arises is in regard to the normal or pathologic limits of the secretion. This question can be no more accurately answered than we can determine by a simple, fixed formula the boundary between health and disease; for the relation of gastric juice secretion in individual persons not only varies within wide limits but also in one and the same individual at different times; just as in every other function, this has an intimate connection with the nervous system. This has been shown conclusively by the clinical study of cases and by experimental physiology I refer here, above all, to the classical investigations of Paw- low. Moreover, investigation of the gastric contents in the individual case may reveal an extreme increase or diminution of gastric juice secretion without the person in question presenting the slightest subjective sign of disease. Regional differences in the realm of gastric juice secretion may also be recognized, as I demonstrated some years ago in my experiments at Gies- sen and Berlin. If the production of hydrochloric acid be taken as a test object for gastric juice secretion, in a stomach acting normally, one hour after taking a test breakfast, that is, three to four hours after the ingestion uf a test-meal, we may expect to determine free hydrochloric acid in the gastric contents, and that in a test breakfast, as a rule, the total acidity will l>o not higher than about 60, and in a test-meal not higher than about 100. The lowest computation of total acidity in a trial breakfast under normal circumstances will rarely exceed from 35 to 40, and in a test-meal from (i() to TO. 1 I have here quoted figures, but, in spite of this, I must 1 From what has been said it is at once evident that, if we desire to form an opin- ion regarding the secretory activity of a case, a single examination is insufficient, but repeated examination of the gastric contents is necessary. GASTRIC SECRETIONS 89 premise that the determination of the total acidity represents only the final act in the test of the secretion of the stomach. We do not begin the examination of the heart with auscultation, neither do we introduce the test of the secretion with titration, but we necessarily assign the first place to close inspection of the gastric contents. As I do not desire to become involved to any great extent with the question as to which tests are to be preferred for daily practice, I shall only state here that many roads lead to Rome. I, myself, am of the opinion that although the introduction of the test-meal has deepened our insight into the mechanism of gastric digestion, and that in many respects and even to-day, in a concrete case, it is sometimes calculated to enlarge our knowl- edge, nevertheless, in the majority of cases, the test breakfast suffices for a practical test of function, provided it is carried out lege artis, and its results are subjected to examination from all points of view. The last requirement must, however, be particularly emphasized if we assign to the test breakfast the position just indicated; and here it must be remembered that in some cases of hyperacidity, and under some circumstances after ad- ministering the test breakfast, a comparative test with a test-meal may be de- sirable, and also that there are rare cases of "perverted secretion "(Riegel). Inspection. On inspection of the test breakfast, the consistency of the sediment, which resembles flour soup, or puree without the appearance of coarser particles in the expressed contents, shows normal or increased gas- tric juice secretion, while a gross, fragmentary appearance in the evacuated gastric contents leads us to suspect insufficiency of gastric juice secretion. The " amylorrhexis," so designated by me (in contrast to amylolysis), is only a function of proteolysis, and, as such, an indication which may be well utilized in studying the secretion of tHe gastric juice. Any one accus- tomed systematically to regard the test breakfast from the point of view of the degree of " amylorrhexia " may, even from the macroscopic examina- tion of the evacuated contents, determine the presence of subacidity and although with less certainty also assume the existence of hyperacidity. Under certain circumstances, the microscopic examination of the secretion may give us valuable aid. Thus, as a rule, in extreme subacidity, net-like formations are found which I some time ago described as " structure sub- stance," because they consist of the adhesive structure giving the histo- chemical reaction of albumin in which granules of starch are embedded. Such structures are found particularly in " apepsia gastrica." Further- more, in those cases in which leukocytes are admixed with the gastric con- tents, a high-graded secretory insufficiency may also show the retention of the protoplasm ring of the leukocytes which is absent in all those in- stances in which a more marked production of acid is present according to my experience, even the presence of free hydrochloric acid may be un- necessary. For practical purposes the methods which are to be considered in the 90 SECRETORY DISTURBANCES OF THE STOMACH investigation of the products of secretion of the gastric mucous membrane have been detailed to a great extent in the article by Professor Leo, " Func- tional Diseases of the Stomach " (page 66). I shall not consume time with their description, but shall allow myself only a few critical remarks based upon personal experience. At the close of this article I shall enumerate a few methods not given in the previously mentioned treatise. Test for Hydrochloric Acid. For the test of free hydrochloric acid I see no reason to reject Congo paper, since this permits in the simplest man- ner the sufficiently positive recognition of its presence. The dimethyl- amidoazobenzol paper recently advised for this purpose by Einhorn I did not find superior to Congo paper when I conducted investigations about eight years ago in Kiegel's Clinic. Only when Congo paper gives indefinite results, should the Giinzburg reagent be employed. For the quantitative estimation of free hydrochloric acid I still advise dipping with Congo paper according to the processes of Riegel, Morner and others perhaps also the utilization of dimethvlamidoazobenzol as an indicator. With Linossier's reagent, which also contains phenolphthalein and dimethylamidoazobenzol, 1 have not always obtained a definite result. The question in which cases free hydrochloric acid should be determined quantitatively can, in my opin- ion, only be decided in practice in the individual case, since the physician who frequently investigates the gastric contents learns in the course of time, from the combination of values for total acidity, from the Congo reaction, as well as from other signs in the gastric contents, what practical conclusions are to be drawn in the majority of cases. From my own expe- rience I maintain this in regard to the determination of combined hydro- chloric acid, and I have only rarely found a strict necessity for its quanti- tative estimation at least for practical purposes. In the overwhelming majority of cases in which there is a deficiency of free hydrochloric acid and the absence of lactic acid, the comparative estimation of the propor- tion of total acidity and the degree of digestion in the evacuated contents enable us to form an opinion sufficiently clear for practical purposes as to the amount of secretion and the measure of the peptic labor of the stomach, provided we start with the assumption' that when large quantities of com- bined hydrochloric acid are present in the evacuated contents, a good degree of digestion may, as a rule, be recognized, while this is absent when there are only slight quantities of combined hydrochloric acid. I cannot, however, strongly recommend the complicated methods which are advised for deter- mining combined hydrochloric acid, as their adoption into practice is beset with great difficulty, and the exactness of their results is often not com- mensurate with the complexity of their use. If we desire to know the amount of secretion while excluding the phosphates, we may titrate with phenolphthalein and tincture of cochineal (see later), or Leo's process may be employed, or a trial may eventually be made with a method recently advised by Cohnheim and Kriiger. In my experience, however, the latter GASTRIC SECRETIONS 91 necessitates the utmost care, and gives only approximate, not always abso- lutely exact, values for combined hydrochloric acid if, as I found when working with Dr. Cahn, at the same time, investigations are made of the gastric juice for free hydrochloric acid, utilizing Leo's process. The pre- vious method, advised by v. Noorden and Honigmann, for "hydrochloric acid deficit," is simple but does not always give similar values in regard to the amount of combined hydrochloric acid in a test-meal at the height of digestion, as I determined after numerous investigations of the gastric con- tents for free hydrochloric acid with Leo's process, and with Congo titra- tion ; Ehrmann determines it at from 0.05-0.07 HC1 particularly in cases of stagnation with good secretion and also higher values are observed. Total Acidity. The total acidity of the gastric contents, as is well known, is determined by the aid of phenolphthalein which reacts upon all three of the acid components of the normal gastric contents (free and com- bined hydrochloric acid as well as acid phosphates). For the determina- tion of the " physiologically active " hydrochloric acid alone this property of phenolphthalein is unsatisfactory, especially in the cases in which, by a diminution of the production of hydrochloric acid, the amount of acid phosphate in proportion to the total quantity of the "physiologically active " hydrochloric acid increases. The acid phosphates, as I am in a position to prove, form no inconsiderable part of the total acids. In 14 investigations (according to Leo's process) I found that the total quan- tity of acid phosphates in the empty stomach, that is, in the secretion free from food, amounted in value to 7.5 (maximum 10, minimum 5) ; in 19 test breakfasts with free hydrochloric acid, an average value of 11 (maxi- mum 15, minimum 8) ; and in 14 test-meals with free hydrochloric acid, an average value of 22 (maximum 38, minimum 9). Therefore, another indicator would be desirable which, without reacting upon the phosphates in the absence of lactic acid, would show exactly what acid factors of the gastric contents might be referred to hydrochloric acid production. With this in view I have attempted the comparative titration of about 30 gastric contents with methylene orange and tincture of cochineal, and in the inves- tigation of 7 cases of typical " apepsia gastrica " with phenolphthalein, I found upon an average an increase of about 16 in the value of the total acidity in comparison with the values obtained with cochineal tincture. In 15 cases in which stagnation was present the differences were even greater; they amounted to between 18 and 21. In about half the cases these differences were compensated for by the values which I obtained with Leo's process, in the other half this difference was increased to a slight extent, and therefore we may say that among the conditions found in the stomach the cochineal tincture does not reveal acid phosphates. In my opinion, the influence of acid phosphates also deserves mention because of the values for total acidity which we obtain after administering a test breakfast and test-meal at the height of digestion, and because, as I was 92 SECRETORY DISTURBANCES OF THE STOMACH able to demonstrate by special investigations, the acid phosphates of meat present in the evacuated contents at a test-meal may have caused an in- crease in the total acidity. I have permitted myself these brief remarks in order to show that some of the findings in gastric pathology which we have been accustomed to look upon as conclusive, in some points still admit of critical investigation. Pepsin. In definite cases of extreme subacidity, the quantitative esti- mation of pepsin may, under some circumstances, serve a practical purpose in diagnosis notwithstanding the fact, according to my own experience, that a strict parallelism between the production of pepsin and hydrochloric acid does not exist. Nevertheless as I have seen in numerous investiga- tions with complete absence of hydrochloric acid secretion, appreciable quantities of pepsin are so rare their entire absence is exceedingly rare that in practice we will hardly fall into error if, in cases of high-graded subacidity in which the pepsin value of the gastric contents is but slightly above zero, we assume an " apepsia gastrica." From my own knowledge of the various methods employed to determine pepsin I advise only Mett's method, which for simplicity and exactness is preferable to all others, and which I myself used for more than three years. Even H&mmerschlag's method, a modification of which I employed to increase the amount of albumin of the solution using a Puro-solution in order to prepare a test- fluid and the employment of specially chosen Esbach tubes which exactly equal one another, I have found neither more simple nor more exact. As the preparation of Mett's tubes as practised by me differs somewhat from the method given in the last publication on this subject, it is detailed some- what more minutely in the footnote. 1 Lab-Ferment. Quantitative estimations of lab-ferment are very rarely necessary in practice, after making an examination for pepsin. Never- theless, they serve a certain purpose (see later) and thus acquire some im- portance. Lab-ferment is either estimated according to the well known methods or, in the absence of an incubation oven at least one suitable for 1 A part of the white of an egg is filtered through a piece of gauze into a small beaker glass or into a short, wide-mouthed test-tube, after which glass tubes about 2 1 /., ccm. in length and about 2 mm. in breadth are slowly dipped into the filtered albumin. Air bubbles which rise in the glass tubes are permitted to disappear; this may be facilitated by slight tapping with the point of the finger upon the glass, which causes the air bubbles to rise. Then the beaker or test-tube with the tubes containing the albumin solution are placed in a perpendicular position in a large vessel of boiling water, and allowed to boil from five to ten minutes to coagulate the albumin. The flame is then removed and the glasses are permitted to cool slowly for a few hours. Now the test-tube is broken, or the coagulated albumin is cut out of the beaker glass, the tubes are freed from the albumin which adheres externally, and are preserved either in glycerin or in chloroform water. Prior to use the tubes are washed with water. After use the remainder of the albumin is removed, and the lubes may be filled as before with albumin. GASTRIC SECRETIONS 93 the purpose in the following manner: The patient is permitted to drink half a liter of milk, this is removed from the stomach one-half to three- quarters of an hour later, when the evacuated contents will show whether or not the milk is coagulated. Steapsin. The test for steapsin is up to the present of no practico- diagnostic importance; I can, however, absolutely confirm Volhard's re- sults from my own researches. The test of the diluting secretion proposed by Eoth and myself is as yet of no value in practice. The method I proposed for employing Gerber's acidbutyrometric test in the quantitative investigation of the diluting secretions and of resorption is only suitable for extreme grades of subacidity of the gastric contents. In regard to the method recently proposed by Sahli for testing the function of the stomach, v. Koziczkowski, under my direction, has shown sources of error, a fact which has, in the meantime, been confirmed by Lang and by Boeniger. Other constituents of the gastric contents dependent upon the condi- tion of the secretion have more of theoretic than practical interest, and, although not accurately developed in each individual case, are nevertheless worthy of brief mention. I have shown by means of systematic investi- gations that in high-graded subacidity the filtrate on the addition of a solution of iodin usually shows no change in color, or at most turns slightly to a yellowish-brown color, while in hypersecretion or hyperacidity the mass not rarely turns to a bluish-violet or blue color. Normal conditions are indicated by a Burgundy-red color which, in extreme cases, may have more of a violet, at times more of a brownish-red, tint. These peculiarities of the gastric contents have lately been confirmed by Bakman. The specific gravity, as I have shown in cases of subacidity, is usually increased although not invariably while in cases of hyperacidity and hypersecretion it as a rule but by no means constantly shows a decrease. According to my experience and even with some reserve which is especially empha- sized because exceptions occur this is also true of the presence in the gastric contents of a dextro-rotary substance which may be determined with Pulf rich's refractometer called " refraction difference." I shall not enter here upon a discussion of the osmotic concentration of the gastric contents, although it has certain relations to secretion. In the meantime, I have also made numerous tests of the electric conduction of the gastric contents, and will only remark that these, as was to be expected, denoted a close relation to the amount of chlorin therein. Passing from these preliminary remarks to the clinical consideration of disturbances of gastric secretion, we deal either with a decrease, that is, a loss, or an increase of secretion. In referring to hydrochloric acid secretion we speak of subacidity. that is anacidity (hypochlorhydria or achlorhydria), of hyperchlorhydria (hyperacidity 1 ), and of hypersecretion 1 From usage this term is applied especially to hyperaciditas anorganica. 94 SECRETORY DISTURBANCES OF THE STOMACH (gastrosuccorrhea). Expressions such as hypochylia and hyperchylia, which are formed from achylia, as little convey the true meaning as does the word achylia, since chyle is entirely different from the gastric juice. The term lieterochylia is quite misleading as it does not describe a substantive patho- logic picture. On the other hand, it would be well to retain expressions like hypopcpsia, apepsia and hyperpepsia for the reason that they clearly express the effect of gastric digestion without revealing more in regard to the nature of the secretory disturbance than terms which denote the state of hydrochloric acid secretion. This is self-evident when we reflect that the amount of hydrochloric acid contained in the gastric juice is the impor- tant and decisive factor for gastric digestion, because even a gastric juice rich in pepsin is incapable of producing a corresponding digestive activit}' without a large amount of hydrochloric acid. These designations are also suitable for the reason as I have already remarked that special disturb- ances of pepsin, lab-ferment, steapsin and the diluting secretion have as yet not been so fully recognized as to evoke any special therapeutic interest. SUBACIDITY (APEPSIA GASTRICA) In occupying ourselves first with cases of hypochlorhydria and achlor- hydria, that is, hypopepsia and apepsia, we observe that they portray no comprehensive clinical picture, but, instead, a series of peculiarities com- mon to the gastric contents. Among these the absence of free hydrochloric acid is the most important. 1 Other peculiarities, such as the coarse, frag- mentary character of the evacuated gastric contents which, in cases of apepsia, reveals only traces of oral cavity digestion not gastric digestion showing low values for total acidity, usually a high specific gravity, high values for the dextro-rotary substance, the absence of staining products of amylolysis as well as the appearance of shreds of structure substance upon microscopic examination of the gastric contents, are as consequences of (ho decreased secretion merely of s} f mptomatic importance, but may occasionally be of value in a clinico-diagnostic sense. Of pepsin and lab- ferment production we may say in general that they are more permanent than hydrochloric acid secretion, but, like the steapsin production in com- plete insufficiency of secretion, these may also be decidedly decreased or 1 Naturally there are also cases with abnormally low total acidity in which free hydrochloric acid is still present, and also cases (rare) with normal total acidity and absence of free hydrochloric acid without lactic acid. As in the latter cases they an- usually associated with disturbances of motility in patients whose secre- tion is decreased to only a slight degree the secretory energy of the stomach is inxuflicient for the production of the physiologic plus of free hydrochloric acid, these cases are looked upon as instances of "relative" subacidity, because every normal stomach at the height of digestion must show a physiologic plus of free hydrochloric acid. SUBACIDITY (APEPSIA GASTRICA) 95 entirely absent. According to Glaessner, only in carcinoma of the pylorus with complete or almost complete absence of pepsin may the distinct pres- ence of lab-ferment be observed. That we miss a constantly recurring parallelism between acid values and pepsin is, in my opinion, explained from the fact that, besides other causes according to the experimental investigations of Pawlow, Schiff, Herzen and others, there are various stimuli which promote in a one-sided way hydrochloric acid or pepsin production in examining the total acidity we have considered too little the influence of phosphates, whose amount depends only partially upon the energy of secretion of the affected stomach. To this may be added that in former researches with the Hammerschlag process, the inac- curacy of the method has not been sufficiently taken into account in judging the results. In apepsia gastrica, at a time in which individ- ual authors found different values for pepsin, I employed the Hammer- schlag process with my own modifications, and in 4 instances I twice found the peptonizing ferment positively absent, and twice a property of peptonization of from 10 to 12 per cent., while on using the Mett process in 8 cases of apepsia gastrica, I found the property of peptonization only twice and then respectively 2 and 4 mm. In regard to the " diluting secre- tion," I proved in earlier investigations of the specific weight, and in more prolonged studies of the osmotic pressure of the gastric contents, as well as in quantitative estimations of the excretion of water by the gastric walls, that even in extreme secretory insufficiency, and especially in apepsia gastrica, it was still present, although apparently in diminished amounts. In regard to the degree of total acidity in apepsia gastrica, I must reiterate what I have previously stated of the importance of phosphates in an estimation of the total acidity of the gastric contents. Although, as a rule, the majority of my cases of apepsia gastrica showed values for total acidity between 3 and 7 in a few cases I found the gastric juice neutral with phenolphthalein I have, nevertheless, repeatedly observed cases with an acidity of 10 and 12, which possessed no property of peptonization, and at most showed only traces of combined hydrochloric acid (Leo's process). I have, therefore, made it a rule in suspicious cases of apepsia always to titrate with litmus and with tincture of cochineal. As apepsia gastrica represents the highest grade of subacidity, so this affection distinctly demonstrates the clinical expressions of subacidity, its effects upon gastric and intestinal digestion, and upon metabolism; hence, in this description, I shall enumerate the causative factors and also the therapeutic indications which arise when a secretory insufficiency of the stomach is determined. SYMPTOMS The clinical signs which we observe in the higher grades of subacidity vary greatly. Often symptoms are entirely absent. At other times we 8 96 SECRETORY DISTURBANCES OF THE STOMACH meet with indefinite complaints of sensations of pressure or fulness, or of eructation, partly of loss of appetite, partly of intestinal disturbance particularly of diarrhea or of more or less painful sensations in the abdomen. The great variety of clinical pictures in which we find sub- acidity as a symptom is not surprising when we consider that subacidity in a mild or severe degree accompanies or follows in the train .of many maladies. Thus we find it not only in numerous local gastric affections among which carcinoma and alcoholic gastritis are probably the most fre- quent, but also not rarely in nervous and organic general affections, par- ticularly in cardiac and renal disease, in pulmonary tuberculosis, and in the various disturbances of metabolism. For example, in the clinical his- tory of 30 cases of persistent and " uncomplicated " apepsia gastrica which I observed for a long time, and of which I possess accurate notes, there were 8 cases of chronic alcoholism, 4 of pernicious anemia, 5 of advanced pulmonary tuberculosis, 3 of chronic nephritis, 1 of Graves' disease, 2 of well-developed chronic hysteria, 1 of trauma, 2 of severe erosion of the gastric mucous membrane (in both cases there were simultaneously symp- toms of stenosis of the esophagus leading to a " stenosed " form of gastritis) . In 5 cases no especial etiology could be discovered. I have also observed transitory forms of apepsia gastrica in neurasthenics, above all, in a series of cases of delirium tremens. When I refer to an " uncomplicated " form of apepsia gastrica, in contrast to a " complicated " form, I have particu- ' larly in mind that prognostically ominous form which is an accompaniment of malignant neoplasm. DIAGNOSIS As it is especially important in the absence of a recognizable tumor and metastasis (if necessary, palpation per rectum and X-ray examination of the mediastinum) 1 to base the differential diagnosis on the condition of the gastric contents, I shall briefly include in this description the different diagnostic criteria, above all, the significance of an admixture of blood with the stomach contents, and the possibility of evacuating blood by lavage when the stomach is empty. In more than 6 cases which, by prolonged observation, were positively recognized as non-carcinomatous apepsia gas- trica, I found blood in the stomach empty of food, and in some cases I detected shreds of tissue; therefore, I maintain that only the combination of blood and pus indicates carcinoma. As to the diagnostic inferences from the presence of shreds of tissue, I agree with Kuttner. In several cases in which I repeatedly found shreds of tissue upon lavage of the empty stomach, the patients complained of a gnawing sensation, sometimes of pain, and, upon taking food, of even more severe symptoms. I have con- 1 Ola n dill a r tumors of the mediastinum have been actinographically determined by Weinberger (see his Atlas) and others. SUBACIDITY (APEPSIA GASTRICA) 97 sidered hemorrhagic erosions which, in common with Ewald and Boas, and in opposition to Einhorn, Parish, and others, I found in. various gastric conditions, but I am not inclined to believe in the uniformity of a special clinical condition in hemorrhagic erosions. An increased vulnerability of the gastric mucous membrane I have quite often observed in cases of apepsia gastrica as a consequence of chronic nephritis, or as an accom- paniment of chronic alcoholic intoxication. As apepsia gastrica may also be observed as a secondary accompaniment of true pernicious anemia, the differentiation of the forms of apepsia gastrica occurring in connection with carcinoma may, under some circumstances, be of practical significance. Here it must be borne in mind that pernicious anemia going hand in hand with apepsia gastrica, in contrast with carcinoma ventriculi, will, in spite of the severe anemia, usually present a well maintained panniculus adiposus, and that a thorough examination of the blood will generally reveal decided differences between these affections. For those cases of pernicious anemia in which there is no profusion of megaloblasts in the blood, I especially advise the minute observation of the leukocytes ; for, in my numerous stud- ies of pernicious anemia, I have found that with a diminution in the total number of leukocytes, which is quite usual, there is a relative increase of the mononuclear cells, while in the majority of cases of carcinoma, leuko- penia is more rare, and the multinuclear cells are perceptible in normal or even increased amounts. Anemia without severe cachexia it is true this is scarcely ever observed with the typical blood picture of pernicious anemia may also occur in carcinoma of the lesser curvature which leaves both ostia of the stomach intact. In cases of this kind the nutrition of the patient is often but little disturbed, although hemorrhage from the ulcerating tumor may produce the picture of anemia (often to only a slight extent the picture of cachexia). In my experience cases of this kind are by no means so rare as we might suppose from the reports of various authors; for, among the cases of carcinoma which for several months I had opportunities of examining in the Clinic, in the majority of cases, up to the time of death or of the operation, more than one-third ran their course without symptoms of stenosis, and especially without the finding of lactic acid. Practical interest particularly therapeutic is also elicited by those chronic intermittent diarrheas which, in my experience, are noted in about one-third of all cases of apepsia gastrica. We have long been familiar with these diarrheas, as well as with their relation to severe forms of sub- acidity, the condition having been lately described by Einhorn, Oppler, and others. In some instances they represent the most striking and unpleas- ant expression of the secretory disturbance, and they chiefly require ob- servation for the reason that they may decidedly damage the nutrition. In my opinion, the tendency to diarrhea depends to a great extent upon the fact that the coarse ingesta, on which the stomach exerts no digestive 98 SECRETORY DISTURBANCES OF THE STOMACH effect whatever, mechanically irritate the intestine, and also upon the fact that a larger number of bacteria with noxious influence upon the intestine have reached this organ than is the case with a normal secretion in which the virulence of one or the other of these bacteria has been attenuated. Moreover, the diarrhea may cause an injury to the general nutrition, since a disturbance of motility is associated with apepsia gastrica, and makes the ingestion of food insufficient because of vomiting, etc. The effect of a disturbance of motility combined with apepsia gastrica, that is, with a high degree of subacidity, becomes apparent when we examine the gastric contents from the fact that lactic acid may appear in such great amounts as to be easily recognized by the method I have indicated, with which, as is well known, we can only determine pathological amounts of lactic acid in the test breakfast or in the residue of the stomach before food is taken. That the absence of pepsin, as was first maintained by Hammerschlag, is necessary for the development of lactic acid, besides the combination of subacidity and motor insufficiency, I regard as not only unproven at the present time, but as most unlikely ; for, under my direction, v. Aldor showed that in the artificial conditions of experiment, and under circumstances otherwise favorable for the production of lactic acid, pepsin by no means inhibits the appearance of lactic acid fermentation. Only lately I have had an opportunity of observing three cases of apepsia gastrica with temporary but undoubted lactic acid. Two of these cases occurred in perigastritis following cholelithiasis, and were confirmed by operation. The third case occurred in an elderly colleague who, since he was first examined two years ago, has continued in the best of health. I formerly made similar observations in a case of complete erosion of the stomach with the forma- tion of numerous cicatrices and " stenosing pyloric hypertrophy," in a case of duodenal stenosis in consequence of tubercular peritonitis, as well as in a case of fat necrosis of the pancreas. Notwithstanding this, I am quite ready to admit that the finding of lactic acid in non-malignant con- ditions is so rare that, if continuously found for weeks, I consider an ex- ploratory laparotomy to be not only justified but sometimes even absolutely necessary, provided we cannot certainly exclude carcinoma. In fact, my own observations of the frequent occurrence of lactic* acid in carcinoma differ from the ordinary in that I succeeded in demonstrating its presence in only about 60 per cent, of my cases of gastric carcinoma, and I must particularly emphasize that among these cases were a large number in which an autopsy was conducted. In regard to the cases in which an absolute cessation of hydrochloric acid secretion did not occur, the presence of combined hydrochloric acid, even without a quantitative estimation as I have previously remarked, may be assumed in all cases in which the total acidity, without lactic acid being present, reaches a certain amount; i.e., with the employment of phenol- phthalein it exceeds 20, and, at the same time, the gastric contents reveal SUBACIDITY (APEPSIA GASTRICA) 99 positive signs that gastric digestion is present. If, after a test breakfast, the gastric contents without free hydrochloric acid show an acidity which exceeds 30, and if the examination for lactic acid, which should never be omitted in any case of subacidity, gives a negative result, we are probably right in assuming the presence of combined hydrochloric acid. As I have repeatedly observed in cases of stagnation combined with slight subacidity, in rare cases without the presence of lactic acid, higher values of total acidity values from 50 to 60 may be found. I noted this particularly in cases in which ulcer of the pylorus gradually underwent carcinomatous degeneration, but also in non-carcinomatous cases of pyloric stenosis with a secretion which was not quite sufficient. In these cases, the gastric con- tents did not show the symptomatologic and simultaneous increase of the long bacilli which indicates lactic acid. Cases of this kind have not only confirmed my view that combined hydrochloric acid may inhibit lactic acid fermentation, but by their excellent chymification, as well as by their amount of erythrodextrin, they have proven that where large amounts of combined hydrochloric acid are present, notwithstanding the absence of free Irydrochloric acid, we have the objective signs of proteolysis and of disturbed amylolysis. In regard to chymification, I must here remark that occasionally, even when large amounts of lactic acid were present, I suc- ceeded in recognizing a slight degree of chymification in the gastric contents. TREATMENT OF SUBACIDITY Since it is my intention in describing the treatment of subacidity to consider the diminution of the secretory energy of the stomach only as a symptom of definite affections, I shall not fully discuss the treatment of these maladies, but shall limit myself in the main to the therapeutic indi- cations necessary to combat this condition. Diet. Beginning with the dietetic treatment, we find, fortunately, en- tire unanimity between theory and practice. This is first shown by the requirement that the food be finely divided, and of such a character that it will pass the pylorus as under normal circumstances. The importance of this therapeutic principle, so long established in practice, we can appre- ciate after we understand that the reduction of bread and pastry to a fine, pappy mass is not only the function of mastication in the oral cavity, but also that of proteolysis in the stomach. As I have demonstrated by micro- scopic investigations, a small portion of bread (consisting of gluten albu- min) may be compared to tissue or a sponge in whose meshes the starch granules are deposited. To secure this reduction of food with defective proteolysis, good teeth are absolutely necessary, therefore in many cases of extreme subacidity the examination of the teeth by a dentist and the correction of defects form the first part of the treatment. The thorough cleansing of the oral cavity is also necessary, for the reason that the stomach of the patient in question can offer but slight resistance to the bacteria 100 SECRETORY DISTURBANCES OF THE STOMACH descending from the mouth. In patients suffering from subacidity thor- ough mastication is also necessary for another reason. Recent investiga- tions (Pawlow, Schiile, Troller, Riegel and Schreuer, as well as the ex- periments conducted by Martin Cohn under my direction) have shown that, in cases in which the property of secretion has not been entirely lost but is capable of increase upon decided stimulation, thorough chewing will, in fact, increase the production of acid. Therefore, slow eating and thor- ough mastication are to be especially insisted upon with those patients who suffer from subacidity. As a rule, crisp bread and pastry which are well ground up by the tee,th, such as crackers, zwieback, toast, etc., are the best. The more tender varieties of meat are given, such as poultry, veal, etc., in place of that containing coarse fibers held together by a tough connective tissue network (beef, lamb), and we should see that the food is so prepared in the kitchen as to facilitate its mastication. According to the investiga- tions of A. Schmidt, in which I entirely concur, too thorough cooking of meat, that is, broiling which hardens the connective tissue which is not subsequently dissolved in the intestine in apepsia gastrica, may irritate the intestinal wall and thus produce diarrhea. Raw meat should not be given to the patient suffering from subacidity. Gelatinous foods (gelatin) are very useful since gelatin dissolves into fluid in the stomach. In those cases in which it is impossible to administer sufficient nourishment in the manner described, as well as by the contingent use of artificial foods, the employ- ment of means for disintegrating food, for example, Collin's apparatus, or masticators, or small meat choppers, are advisable, and it is well for the patient to use the apparatus himself since food brought upon the table in a broken-up condition is less stimulating to the appetite than that served in its original form and then finely divided by the patient himself. This point, in my opinion, is all the more worthy of consideration because the preparation of food and its appetizing appearance are important matters to a patient suffering from subacidity. Pawlow has shown that the appear- ance of food has a stimulating or depressing effect upon the appetite which materially influences the intensity of the secretion of gastric juice. We may truly say that the sight of appetizing food not only makes the mouth water, but also causes the gastric juice to flow, and to the joy of every gourmand, we maintain that food eaten with zest is half digested. For this reason, in all cases of subacidity in which the glandular parenchyma still reacts to stimulation by a secretion of gastric juice, great weight must be attached to the attractive and appetizing preparation of the food, which is obvious from the fact that many of these patients already suffer from loss of appetite. Therefore spices, meat sauces, and the other condiments of the kitchen within certain limits are just as necessary here as the stomachics of the apothecary. In regard to the latter, I must mention in passing that they act upon the nerves of smell and taste and thus produce a feeling of desire which reflexly influences gastric secretion. It is evi- SUBACIDITY (APEPSIA GASTRICA) 101 dent from the foregoing that not only bouillon but even the so-called appe- tizers should be advised as overtures to a meal in all cases of this kind. When the auxiliary measures here mentioned do not sufficiently break up the ingesta, and also stimulate the gastric secretion, we must at the onset dissolve or very finely pulverize the greater part of the food. As to albu- min, milk and eggs are to be utilized in different ways prior to or simul- taneously with artificial foods. In the use of milk, it is true that great care is necessary in patients who show a tendency to diarrhea, and the advice of A. Schmidt to administer to such patients only the salicylated milk particularly in summer is especially valuable. In cases in which there is a tendency to diarrhea I have repeatedly seen favorable results from well-sterilized diabetic milk (almost free from sugar), which I used chiefly in cases of diarrhea. Of artificial food preparations thanks to the zeal of busy manufacturers a large number are at our disposal, so that in the choice in a given case we pay more attention to the taste, or, in other cases, to the price of the article. These food preparations are best given in soups, in milk, or in puree. The various meals should not be large, and we should rather adhere to the law, " Little and frequently " than to " Much and rarely." Of fats I prefer the easily digested milk fats (milk, cream, but- ter), whose secretory, inhibitive influence in severe forms of secretory in- sufficiency is no longer of much importance. Physical Treatment. Physical treatment generally aids us but little in controlling subacidity. In so far as my own experience and investiga- tions permit an opinion, neither hydrotherapeutic measures, nor massage, nor electricity of the stomach can claim a positive influence upon the secre- tion of gastric juice. Gastric lavage may also be tried in subacidity when there are large quantities of mucus in the empty stomach, although in the majority of such cases the use of alkaline mineral waters upon an empty stomach is sufficient (washing in the direction of the pylorus), and also when a disturbance in motility is combined with subacidity. In regard to the balneotherapeutic treatment of subacidity, I prefer the waters con- taining sodium chlorid (Kissingen, Homburg, Wiesbaden, etc.), but ex- periments to demonstrate the relation in such spa cures of the sodium chlorid in the organism to the secretion of hydrochloric acid lack a satis- factory scientific basis. The secretion of hydrochloric acid can nowise be increased b\ the rectal introduction of sodium chlorid, as I have proven in a number of patients suffering from subacidity. This is the result I ex- pected inasmuch as, in the patients who here come into question, the secre- tory insufficiency is to be attributed more to the pathological condition of the secreting cells and the nerves which stimulate them than to a deficiency of sodium chlorid in the organism. In cases in which a general neurosis is the cause of eubacidity, the elements of physical treatment may, under certain circumstances, indirectly act favorably upon the production of hydrochloric acid. (_ L.-E L i-~ i? T II i-N M r k' N CMU 102 SECRETORY DISTURBANCES OF THE STOMACH Drug Treatment. Drug treatment of subacidity represents on the one hand a substitution therapy, and on the other hand an attempt to increase the diminished secretion. Substitution therapy aims to supply hydrochloric acid and the ferments which have been lost particularly pepsin from without, and probably represents, so far as the introduction of pepsin is concerned, the oldest form of organotherapy upon an exact basis in man. If we study the consequences of subacidity from the introduction of hydro- chloric acid and of pepsin, a critical judge will not place a high estimate upon the effect of such treatment; for, as the investigations of Pfungen, Schiile and others have demonstrated, the amount of hydrochloric acid combined by the proteids compared with the quantity of hydrochloric acid therapeutically administered by the mouth is so great that the introduced hydrochloric acid can hardly be looked upon as a substitute for the secre- tion which has been lost. Moreover, in regard to pepsin it must be stated that, with adequate quantities of hydrochloric acid, even slight amounts of pepsin are enough to produce a satisfactory proteolytic effect ; that, how- ever, the introduction of pepsin is useless if, during the entire duration of digestion, a sufficient quantity of hydrochloric acid is simultaneously present in the stomach. Benefit from the various wines of pepsin, therefore, is prob- ably because of the stomachics they contain. In cases with complete loss of secretion it is far wiser to use the pancreas preparations which act upon a neutral or alkaline floor and permit digestion of the small intestine to begin in the stomach; that is, where gastric digestion is lacking, intestinal digestion is aided by the administration of proper preparations. Among these preparations pankreon has been most serviceable in my hands, while from papain, which is said to be active in an acid media, I have seen no remarkable results nor have Grote, Hirsch and others. In regard to a special form of substitution therapy, the administration of canine gastric juice, which was first advised by Pawlow and subsequently by Kussian and French investigators in Germany this has only been employed by Paul Meyer I have no personal experience. I do not believe, however, that this method is often absolutely necessary, nor, the material being so difficult to obtain, that it will come into general use. Great value was formerly attached to certain products that increased secretion, and Pawlow by masterly investigation and technic has now made it possible for us accurately to study this question experimentally. Pawlow found that raw meat, meat juice, meat broth, Liebig's meat extract, milk, gelatin, certain peptones and large quantities of water stimulate the gastric juice. Herzen compared dextrin (not chemically pure) and Liebig's meat extract, and found that the combination of large doses of these (25 to 50 grams) in a dog with gastric fistula stimulated the gastric secretion and formed pepsin. Employed alone, dextrin particularly influenced pepsin formation, while Liebig's meat extract chiefly acted upon the gastric juice. Alcohol proved a mighty stimulant to the gastric secretion but had abso- HYPERACIDITY 103 lutely no effect upon the production of pepsin. Alcohol administered per rectum also showed itself a stimulant to the gastric juice, as Metzger deter- mined in Kiegel's Clinic. Herzen reports that he produced favorable re- sults in man with a mixture of Liebig's meat extract and dextrin in a pala- table form. Another preparation, inulin, after the administration of which Herzen found a marked amount of pepsin in the gastric juice if he simul- taneously administered alcohol, I have employed in a few cases in the form of a tea containing inulin (25 grams in 300 c.c. of the tea for a trial break- fast). Although I have in a few cases seen a slightly stimulating effect upon the gastric juice, yet, considering the expense of inulin, this was not so marked as to tempt me to make very extensive experiments. It may be urged in opposition to the explanations given here that there are cases of apepsia gastrica which run their course for years and even decades without any marked disturbance, and we may conclude from this that it is not always necessary in cases of subacidity to follow the outlined treatment here suggested. In reply it may be maintained that no proof has yet been furnished that the persistent functional over-exertion of those glands of the intestine which furnish the proteolytic ferments and their combinations will never produce injurious effects. What we have stated of the relation of certain forms of diarrhea to apepsia gastrica, and the favor- able influence upon them of measures hqre described, by no means strength- ens the arguments of those who declare these measures to be unnecessary; and even if we could adduce no positive facts in support of the fundamental principles here developed, the purely theoretical assumption that prophy- laxis is the best therapy is sufficient reason and justification. This is par- ticularly true of the suggestion of small and frequent meals, since these, more than any other means, conserve the motility of the stomach, the weak- ening of which at once disturbs the equilibrium of the patient's metabolism. A disturbance of motility in cases of apepsia gastrica soon changes the stomach from a natural disinfectant apparatus into an incubation apparatus for various microorganisms under some circumstances, also the pathogenic and, from a teleologic point of view, a reason may be discerned in the facts that the stomach in apepsia gastrica usually empties itself more rapidly than under normal circumstances, that it is unable to digest its contents, and also that it has no power upon micro-parasites, but rapidly propels them into the small intestine, in which a great number of micro- organisms appear to perish. HYPERACIDITY In the description of an immoderate secretion of acid we must sharply differentiate those conditions in which gastric juice abnormally rich in hydrochloric acid is excreted only by the stimulation of the ingesta from those in which gastric juice is excreted with a permanent secretion one independent of the introduction of food. We must, therefore, sharply dis- 104 SECRETORY DISTURBANCES OF THE STOMACH tinguish hyperacidity (superacidity, peracidity) from hypersecretion (su- persecretion, parasecretion, gastrosuccorrhea). As in the former the stom- ach reacts only to the stimulation of the ingesta present, and produces a secretion powerful in digestion, in the second case a secretion takes place without stimulation, and, as to cause and effect, the stomach in the former case bears the same relation to the latter as a pump or open well to an artesian well. But since it is not my purpose here to discuss the ques- tion in how far hyperacidity is a substantive disease or is merely a symptom of other affections, I shall at once define our chemical conception of hyper- acidity. To express this in figures is very difficult, for, on the one hand, the amount of secretion varies greatly under physiological conditions in one and the same individual as well as in different persons, and, on the other hand, the sensibility of individual persons to an excess of hydro- chloric acid in the stomach shows extraordinary variations. In practice, tliis latter factor merits special consideration because only that patient suffering from hyperacidity seeks a physician who suffers discomfort on account of his disturbance in secretion. In my opinion, therefore, a de- scription of hyperacidity necessitates the simultaneous delineation of all those factors which produce a more or less marked acid hyperesthesia. Be- sides, our conception of the condition, that is, whether we base the chem- ical conception of hyperacidity on the total acidity, or make free hydro- chloric acid most prominent, varies greatly. Among those who adhere to the first theory, Ewald estimates hyperacidity in a total acidity between GO and 70, and Eosenheim above 60; Johnson and Behm consider a gastric juice with a total acidity of 70 as hyperacid, and Boas regards in the same light a gastric juice with an acidity of over 2 per thousand. Kiegel, besides laying much stress upon the total acidity, also attaches great significance to the proportion of free hydrochloric acid. " The most important point is the free hydrochloric acid. Only where this is increased are we justified in speaking of an actual hyperaciditas hydrochlorica. Values of 60, 70, 80 and more after a test-meal, of 50 to 60 and upwards after a test breakfast are frequently found here." Schiile considers the gastric juice to be hyper- acid when it reaches a height of 0.22 per cent, more than free hydrochloric acid, and shows a total acidity of more than 70. Schneider maintains that a gastric juice with more than 0.25 per cent, of free hydrochloric acid is to be looked upon as hyperacid, and that we may also regard as hyperacid a gastric juice which still gives a reaction for free hydrochloric acid with a dilution of more than ten times its bulk. Although it must be admitted without more ado that gastric contents which with a total acidity of 70 give an intense reaction for HC1 may be called hyperacid, yet, in doubtful cases I should be reluctant to diagnosticate hyperacidity of the gastric juice upon this single symptom of the gastric contents, but only upon the sum of peculiarities which the test breakfast or the test-meal enable us to recog- nize. For we may examine gastric juice in which titration shows no ab- HYPERACIDITY 105 normally high degree of total acidity, while, notwithstanding this, certain peculiarities of the gastric contents and also the clinical symptoms of the patient may correspond to the condition which we are accustomed to find in hyperacidity. Cases of this kind which Schiile under my direction de- scribed by the name of hyperaciditas larvata or hyperaciditas occulta are not extremely rare and, in a certain sense, are the antitheses of those cases of hyperacidity running their course without symptoms in which the exam- ination of the gastric contents reveals the distinct characteristics of hyper- acidity while the patient presents absolutely no symptoms. The typical peculiarities of the gastric contents in hyperacidity are the following: The thin fluidity of the gastric contents, the tendency rapidly to form two layers, an upper one consisting of fluid and a lower one of a finely pul- verized, starchy sediment, and, especially prominent, its conspicuous chymi- fication. In regard to the layers, we find that if the gastric juice is placed in a graduated test tube for two hours after its withdrawal, and spontane- ous sedimentation is permitted, the " layer quotient," i. e., the figure which the height of the sediment shows divided by the total amount of gastric contents collected for sedimentation, is frequently although not invariably below 50 per cent. Sedimentation contrasted with that of many sub- acid gastric contents not only occurs very rapidly but most completely. Besides amylorrhexis of the hyperacid gastric contents, amylolysis also merits some consideration. As I showed years ago in a large number of cases of hyperacidity, relatively low values for the dextro-rotary substance were found in the majority, and (particularly dependent upon this) also a low specific gravity of the gastric contents, 1 as well as frequently a Bor- deaux red or violet in rare cases also a blue reaction of the iodin test. In some cases I detected an abnormally low molecular concentration of the gastric contents. As to the proportion of free hydrochloric acid to total acidity, in a comprehensive examination of my cases of hyperacidity in which the total acidity amounted to more than 60, more frequently than otherwise I found the free hydrochloric acid equalled two-thirds and more of the total acidity. In nine cases of hyperaciditas larvata in which the total acidity did not exceed 50, I only twice saw the acidity value of free hydrochloric acid fall below 50 per cent, of the total acidity, while in other cases in which the total acidity was not over 50 the value for free hydro- chloric acid was more often below than above 50 per cent, of the total acidity. These conditions, however, are not so characteristic in the indi- vidual case as to be of direct diagnostic use. The relation of the total amount of the gastric contents here calls for consideration, and all the more so because in various places erroneous views have been promulgated 1 I am unaware that either Schiile or I have given a specific gravity of over 1.020 as a " positive " sign of subacidity, as has recently been alleged by Illoway, nor can this statement be proven. 106 SECRETORY DISTURBANCES OF THE STOMACH as to the influence of motility in hyperacidity. For a long time it was remarked that one hour after administering the test-breakfast in cases of hyperacidity, and upon the evacuation of the gastric contents, an increased amount was not rarely evacuated. This fact was long known to those who only recently relinquished the antiquated method of estimating the total amount of gastric contents solely by expression, that is, by aspiration, with- out subsequent lavage. For more than eight years, after every investiga- tion of the gastric contents I have made an exact estimation of the residue of the gastric contents by the aid of a mathematical formula which is based on the relation of the specific gravity of the undiluted gastric juice to that of the gastric juice diluted with 100 c.c. of water, this principle, as I learned subsequently, having been previously employed by Jaworski in his scientific investigations. I still employ this mode of calculation because the estimation of acidity according to the method of Mathieu and Remond in cases of anacidity leaves us in the lurch ; that is, only by the employment of a complicated modification given by Cohnheim are we enabled to reach a conclusion. It may be interesting to note here that the amount of gastric contents I have obtained in a great number of investigations in normal persons one hour after a test breakfast reached on an average the figure of 150 c.c., while in 40 cases of hyperacidity I obtained an average figure of 210 c.c. (the lowest being 124 c.c., and the highest 400 c.c.). Con- trary to numerous authors, I do not believe this increase in the amount of gastric contents one hour after the administration of the test breakfast at least in uncomplicated cases to be the consequence of a so-called "atony" (an expression which had best be eliminated from the nomencla- ture of gastric pathology since it is not only superfluous but, in consequence of the dissimilar significance attached to it by different authors, is liable to cause confusion) but to be the product of an increase in the secretion of the gastric juice of a hyperacid stomach. In numerous researches in un- complicated cases of hyperacidity I was unable to detect any sign of motor insufficiency either by the currant test, by the fermentation test, or by micro- scopic examination of the evacuated gastric contents. Perhaps the fact, which has already been alluded to, that the " layer test " of hyperacidity usually gives a lower layer quotient than in subacidity, and that occasion- ally a conspicuously low value for the molecular concentration of the gastric contents is found ( " hydrorrhcea gastrica") may be utilized in the same sense as my explanation. The view that the increase of the gastric contents in hyperacidity is to a great extent the consequence of an increased secre- tion is somewhat favored by the experience that, in contrast to the condi- tion, just described, of the test breakfast (rich in starch), upon utilizing the test-meal relatively rich in albumin and poor in carboh} r drates, an extremely rapid emptying of the stomach may frequently be observed; this phenomenon may be satisfactorily explained by the theory that the test breakfast, by the too early interruption of amylolysis (" Secretio celer et HYPERACIDITY 107 alta"), and the disturbed liquefaction of the introduced starches, promotes an increase of secretory stimulation. Johannes Miiller admits that the digestion of bread is generally delayed by a decidedly acid secretion, and that the inhibition of amylolysis appears to be influenced more by the rapid- ity than by the intensity of the acid secretion. SYMPTOMS As already indicated, the clinical manifestations of hyperacidity vary in individual cases to an extraordinary degree. One case will run its course without symptoms, and another with excessive pain which occasionally reaches such a degree and is so frequent that signs of chronic under-nutri- tion and loss of strength may appear. Complications such as erosions, fissures with consecutive pylorospasm, ulcer of the stomach, and especially ulcer of the pylorus, may in isolated instances impress their stamp upon the case. However, except for such " complications/' in the great majority of cases of hyperacidity we may construct a clinical picture which, although not applicable to all cases, nevertheless applies in a great many. The patients are usually thin but not always are, as a rule, between 20 and 40 years of age, the majority of them belong to the erethismic type, they complain of gnawing, painful sensations of pressure in the gastric region, and state that these unpleasant symptoms occur as a rule several hours after eating after the midday meal, or in the late afternoon hours they con- tinue for a time and then disappear. The mechanical state of the food is said to be unimportant, and the pains to disappear frequently by the in- gestion of milk or by a large dose of sodium bicarbonate. The appetite is good, but the patients refrain from eating through fear of pain (cibo- phobia). Vomiting is rare, but eructations are frequent, as well as nausea and retching. The patients usually complain of chronic constipation. Provided complications or other diseases which, according to experience, play a role in the etiology of hyperacidity (pyloric stenosis, gastroptosis, hernia epigastrica, etc.) are not present, objective investigation in most cases reveals only slight diffuse sensitiveness on pressure. Frequently even this is absent. Hyperacidity is observed in different countries in varying frequency. According to Jaworski it occurs in Lemberg in 51.8 per cent., according to Einhorn in New York in 51 per cent., according to Johnson and Behm in Stockholm in 36.4 per cent., according to Kb'vesi in Budapest in 30.4 per cent., according to Mathieu and Eemond in Paris in 29 per cent., accord- ing to Bouveret in Lyons in 25 per cent, of all cases of gastric disease which come under observation. In my own experience it is noted in Berlin in scarcely more than one-third of all gastric cases. At all events, among the clinical cases received at the Charite in Berlin, the disease is decidedly less frequent than it was in the Clinic in Giessen, as I had an opportunity of observing. 108 SECRETORY DISTURBANCES OF THE STOMACH ETIOLOGY The causes of hyperacidity also vary in the individual cases, and are partly of a local, partly of a general, nature. Among the local factors chemic, thermal and mechanical irritants play a role which, upon prolonged action, may perhaps also lead to parenchymatous changes in the gastric mucous membrane. I believe it very likely that the constant use of food rich in spices and the generous consumption of alcohol especially of sour Rhine wine play a role in the etiology of hyperacidity, and I also take cognizance of the thermic factors because hyperacidity is relatively com- mon among bakers, who, as is well known, frequently eat hot pastry. Moreover it is by no means certain that the frequent drinking of ice cold fluids upon an empty stomach does not predispose to hyperacidity. In addition there is a large group of local and general neuroses essential, toxic (tobacco!), or arising reflexly 1 and, what I believe to be worthy of serious discussion, the chronic constipation so often noted in hyperacidity. With their removal the symptoms of hyperacidity frequently disappear. By some authors (Hemmeter) continuous over-stimulation with a meat diet is considered of special etiologic importance, and Westphalen even discrim- inates a congenital predisposition attributable to the predominant meat diet of preceding generations. Cloetta has also shown that in dogs of the same litter, those nourished with meat show free hydrochloric acid after a meal while in dogs fed with milk it is absent. Although Cloetta could find no absolute difference in the histologic structure of the mucous mem- brane of these dogs on different foods, I believe it at least possible that organic changes may be produced in the gastric mucous membrane by hyperacidity. There is, as I have proven in several of my cases, a true acid gastritis, i. e., a combination on the part of the stomach of the pro- duction of mucus with that of hyperacidity. Such cases upon lavage of the empty stomach not only show more mucus than in the norm the lavage water of a normal stomach before food is taken is grey, has a turbid appear- ance, and resembles the water after cleansing the mouth but the micro- scopic examination of the peculiar mucus plugs from the test- breakfast also shows a conspicuous number of glistening nuclei of leukocytes with com- pletely digested protoplasm. The conclusion is obvious that the increase of acid production in such cases is not only functional but, perhaps, also anatomical, especially in the cases of hyperacidity running their course with motor insufficiency, and in which the autopsy reveals proliferation of the glandular parenchyma. 1 Some cases of hyperacidity and gastroptosis, hernia epigastrica, and local peri- tonitis may also be of more or less neurogenic origin. HYPERACIDITY 109 TREATMENT OF HYPERACIDITY In the treatment of hyperacidity diet occupies the first place. Its im- portance is evident from the fact that, probably, in no branch of the treat- ment of gastric affections are the fundamental laws of nutrition so warmly disputed as in this instance. The question chiefly resolves itself into this, whether preference should be given to albumin which readily combines acids, or to starches which are less stimulating to the production of hydro- chloric acid in the patient suffering from hyperacidity. To-day, when the waves of discord have become somewhat smoother, we may say that occa- sionally in this discussion the point of view has been too one-sided, inas- much as it has been overlooked that in the dietetic treatment of the patient the entire organism is to be considered as well as the stomach, and that in the consideration of dietetic experiments and experiences, meat and albumin have often been regarded as synonymous with carbohydrates and vegetables. In some of the earlier researches, too, the importance of the employment of " equicaloric " amounts of ingested food, and differences in the composition of the food, have not been sufficiently taken into account in the individual experiment, as is apparent from the special preparation of the food, its volume, and the labor necessary in masticating it. Finally, in my opinion, the varying etiology of hyperacidity from the basis of nutri- tion has been too little considered in the individual cases. A certain bias of observation has until recently been manifest, for, in the question under discussion the cry has almost always been " here albumin " or " here carbo- hydrates " while of fat we have only been told that patients suffering from hyperacidity " may " have good butter, or that large quantities of fat should be avoided for the reason that they readily disturb intestinal digestion by the hyperacidity of the gastric juice. Fat, at the present time, not only occupies a position of equal importance with the two other nutritive prod- ucts in the diet of the person suffering from hyperacidity but even a pre- ferred position, for the reason as we know from the pioneer experiments of Pawlow upon the dog, and those which I simultaneously carried out with Akimow Perez, and the subsequent ones of Backman and others in man that fat inhibits gastric juice secretion, and therefore is utilized normally in the intestinal canal of the patient with hyperacidity, yet does not inhibit the motility any more than an equal quantity of other caloric food prod- ucts. The curative power of large quantities of milk fat in the dietary of hyperacidity thus appears to be proven, accordingly fat, especially milk fat, has been accorded a permanent place in the treatment of hyperacidity. In earlier investigations which I made regarding the relation of the dextro- rotary substance in the human gastric contents, I found in concentrated solutions of sugar another dietetic measure to diminish gastric juice secre- tion. Similar researches have recently been made by v. Aldor in man. and by Clemm in the dog, with gastric fistula, and the results have been con- 110 SECRETORY DISTURBANCES OF THE STOMACH firmed. For the removal of the acid symptoms, concentrated sugar solu- tions are most effective if administered to the patient only upon their appearance. Instead of sugar solutions we may use honey, although, as Clemm has shown, levulose lacks the powerful, inhibiting secretory effect of dextrose. For the rational treatment of hyperacidity, however, dietetic measures to diminish gastric juice secretion are by no means sufficient, but we must simultaneously remove from the diet all those articles which in themselves possess the property of increasing the secretion of the gastric juice. As food and dainties in this respect have already been discussed in the description of subacidity, I desire only to urge the utmost care in the free use of extracts of meat (concentrated bouillon, sauces), and the spicy preparation of food in general, above all, such food products as require prolonged mastication. A rational arrangement of the meals also appears to be highly important in hyperacidity. It is directly opposed to the true conception of the nature of hyperacidity that a patient with this affection should take frequent but small meals. The essential feature of hyperacidity consists in an abnormal irritability of the secretory apparatus of the stom- ach, the expression of which is not manifest during the period when the stomach rests, but only during its time of labor. For this reason I main- tain, with A. Schmidt, that but a few and provided there are no definite factors to the contrary somewhat larger meals are indicated. In regard to the mixture of individual food products, I agree with those who have lately recommended a vegetable or a lacto-vegetable regime in the treatment of all those cases of hyperacidity in which this appears to be the consequence of a functional neurosis, or in which the symptoms of the latter at least dominate the clinical picture. According to my experience, in the remaining cases, the administration of a mixed diet is best, one which, in a normal calory amount, contains considerable fat (from 150 to 180 grams) especially milk fat, such as cream, butter, Jaworski's " kraftmilch," or Gaertner's fat milk, fat cheese, oil (according to Walko, even by the stomach-tube), emulsions of almond oil, etc., but not bacon and beef fat as well as a normal quantity of albumin (amount- ing to about 120 grams) only a small part of which should consist of meat, preferably broiled meat, or of fish. Starches had best be administered in the form of thick soups, gruels (mashed potatoes, flour, rice, etc.), and tender, well-cooked vegetables dressed with considerable butter; it is ad- visable in general not to give more than 250 or 300 grams, but the amount permissible depends very much upon the form in which it is given. As soups rich in extracts are usually unsuitable for patients with hyperacidity, carbohydrates, if not fluid or also taken in other ways, may be given in flour soup, milk soup or fruit soup. Bread, whenever possible, should be rich in albumin (aleuronat, roborat or casein breads) or fat containing, as bread and butter or Eademann's nutritive toast (Nahrtoast), etc. Some- times foods containing oil (sardines in oil) may be permissible, or a dose of HYPERACIDITY 111 emulsion of almond oil before meals, or a not too strong fatty cheese, as, for example, the creme double de Normandie, which gourmands even eat with sugar, or with whipped cream and sugar. The effect of the latter, as has already been stated, justifies the use of sweets, such as fruit jellies, creams, sweet stewed fruits, and fruit syrups, such as raspberry syrup, grape juice, etc. also in the form of Nectar and Pomril as well as malt extract, malt beer, porter, and honey; in this respect the particular idiosyn- crasy of the patient suffering from hyperacidity is to be considered. Among wines, as a rule, red wine is preferable, which had best be diluted with an alkaline mineral water. Among the Ehine wines, the acid varieties must be avoided; white Bordeaux wine and white Burgundy are preferable to Moselle wine. The tolerance of beer varies greatly in the individual case; in general, those rich in carbohydrates are preferable to those defi- cient. Coffee is usually badly borne; tea and cocoa frequently agree well with the patient, particularly if given with large quantities of cream. Physical Treatment. The curative factors of physical therapy from a symptomatic standpoint may aid us greatly; moist, warm compresses as well as dry heat (thermophore, Japanese stove) are particularly effective for the unpleasant sensations produced by hyperacidity. Simon maintains the favorable influence of sweating upon the gastric juice secretion, which coincides with the researches Edel made in Riegel's Clinic. I have been unable to find these so frequent as to make the method worthy of general acceptance. However, other hydrotherapeutic measures are not rarely in- dicated in those cases going hand in hand with neurasthenia or attributable to this. Drug Treatment. Drug treatment is employed in hyperacidity for various purposes. For the hyperacidity itself subcutaneous injections of atropin were advised by Riegel as valuable on account of the experiments which he made in dogs with fistula, and from his own clinical experience. Unfortunately, however, the dose required decidedly to inhibit secretion is so great that atropin can only be employed for relatively brief periods daily, unless we wish to run the risk of poisoning from atropin. For this reason atropin in doses of one milligram is particularly indicated in the treatment of acute exacerbations of hyperacidity. Whether bismuth and silver nitrate also possess the power to inhibit secretion is not certain. In systematic investigations of the gastric juice secretion prior to and after treatment with bismuth and silver nitrate lasting for several weeks, I have personally been unable to determine any absolute decrease of the gastric juice secretion. Nevertheless, these drugs at least deserve mention. Alkalies for a long time quite properly played a role in the symptomatic drug treatment. It is wise to give the alkali or the alkaline mixture usually a mixture of various alkalies is given to which, in cases compli- cated with constipation, a laxative salt is, as a rule, added to the patient only on special indications, i. e., only when acidity becomes noticeable, and 112 SECRETORY DISTURBANCES OF THE STOMACH then not in small, divided doses but at once in a decided dose (at least what will cover the tip of a knife, and, if necessary, from one-half to one tea- spoonful). The immediate effect of the alkaline treatment upon the symp- toms in hyperacidity proves more absolutely than any theoretic considera- tion that a causal relation must exist between the excess of acid and the manifestation of the symptoms. It appears that by the administration of alkalies this plus of hydrochloric acid which has a disagreeable effect upon the patient is neutralized. The prompt action of alkalies may very well be explained by the assumption that a pyloric spasm and its consequences (painful contraction, retention of gases, etc.) are arrested by neutralizing the acid, or that in hyperesthesia gastrica the acid irritation is removed. That the alkaline therapy is injurious is neither maintained by those who have had great experience in this treatment of hyperacidity, nor by other observations such as have been made, for example, in the treatment of acidosis with large doses of an alkali. An excess of alkali is removed from the body with relative rapidity. In numerous original experiments, on the administration of 10 grams of sodium bicarbonate, alkalinity of the urine usually occurred in from ten minutes to an hour and a half, and rarely lasted longer than sixteen hours. The administration of alkalies to patients with hyperacidity may, under certain circumstances, even in- crease amylolysis, which in practice is all the more striking since in the treatment of hyperacidity the resistance of saccharifying ferments accom- plishes but little. In association with Stargard I determined this for the remedy last advised, takadiastase. The treatment of hyperacidity naturally remains incomplete so long as only the irritative condition of the gastric mucous membrane is com- bated, and not the cause which produces the condition. Although this is not the place in which to consider this subject minutely, nevertheless it must be here emphasized, above all, that in a great number of cases of hyperacidity the simultaneous constipation largely demands our thera- peutic interest, for, in fact, it almost gives us the impression that hyper- acidity may often be more readily cured by attacking the intestine than the stomach. In a certain sense the relations are here inverted, as in the diarrhea of apepsia gastrica. Therefore, at least in all cases of hyper- acidity in which the bowel action is not perfectly normal, a systematic Carlsbad cure either with natural Carlsbad water or Carlsbad salts is indicated, and all the more so as in cases of hyperacidity without constipa- tion we occasionally observe very decided improvement under the influence of Carlsbad salt or Carlsbad water. In every individual case of hyper- acidity we should, however, as therapeutists, reflect upon the limits of our differential diagnosis, which in this affection are not infrequently revealed when a case which we have believed to be " only " hyperacidity proves to be an ulcer of the stomach, and demands of us special consideration in the treatment. HYPERSECRETION 113 HYPERSECRETION In contrast to hyperacidity, hypersecretion (parasecretion, gastrosuc- chorrhea, Reichmann's disease, etc. ) is distinguished by a continuous " flow of gastric juice," therefore is a condition in which the stomach, even with- out the stimulus of the ingesta, secretes gastric juice. Although hyper- secretion is a substantive condition, nevertheless it is not an etiologic unity, for it arises under varying circumstances. Its recognition depends upon the proof of greater or less amounts of secretion in the stomach devoid of food, and we will therefore first consider the question, what conditions, under normal circumstances, promote secretion in the empty stomach? As investigations of this point by various authors I shall mention here Riegel, Rosin, Martius, Schreiber, Gintl and others have furnished results in part contradictory, in answering this question I shall primarily relate my own observations. Years ago, in experiments which I made in Ewald's wards of the Augusta Hospital in Berlin, I found in 38 persons that note- worthy quantities of actual gastric juice were not present in the normal stomach, but I noted the same condition in several hundred observations which I had an opportunity of making in the course of years while intro- ducing the stomach-tube into the stomach empty of food partly for diag- nostic, partly for therapeutic, and partly for clinico-experimental purposes. Therefore, I agree with Riegel, Ewald, and numerous other authors even more fully to-day than formerly in believing that the presence of appre- ciable quantities of fluid which presents all the peculiarities of gastric juice is abnormal, and that in cases in which this fluid reaches a certain amount, say exceeding 30 c.c., we have a pathologic condition. What are the properties which lend to a fluid the characteristics of the gastric juice? , The fluid which usually flows in a stream from the tube is, as a rule, clear as water or turbid, of a light grey color, or may also show a greenish discoloration. The latter change is readily produced in the fluid from the fact that during the act of expression the pylorus occasionally opens and bile regurgitates from the small intestine into the stomach. In numer- ous observations which I had an opportunity of making, the closure of the pylorus during the act of expression is more readily overcome when fluid is present in the stomach than when it contains a thick, pappy mass. The pure secretion of the empty stomach, compared with the " residue " which represents remains of food containing chyme without a distinctly recognizable admixture of the remains of food, filters rapidly as a thin fluid, either clear as water, or occasionally slightly opalescent, or somewhat greenish (in the latter case after standing a few days the green color is frequently increased on admixture with air). If the fluid which has be- come turbid from admixture with leukocytes and remains of epithelia, as well as from shreds of mucus occasionally resembling the water with which 114 SECRETORY DISTURBANCES OF THE STOMACH the mouth has been cleansed is allowed to stand, a sediment forms which in more than fifty examinations of this kind I have rarely found to be higher than 4 to 5 per cent, of the total fluid. This sediment consists almost exclusively of mucus flocculi and nuclei of leukocytes whose proto- plasmic ring has been digested, but also contains esophageal and gastric epithelia which produce the turbidity. Now and then a few starch granules are noted, their amount being slight, so that in a test-tube, and on the addition of a few drops of Lugol's solution, the sediment in pure cases does not show a blue color. The specific gravity of the filtrate is, as a rule, abnormally low (about 1.004 to 1.008). The addition of iodin solution to the filtrate produces no change of color. Trommer's test is also negative, but the biuret test is, as a rule, positive. Upon polarization a rotation to the left of 0.2-1.0 per cent, is shown. That true gastric juice must con- tain hydrochloric acid is self-evident; the values for total acidity and for free hydrochloric acid, however, vary greatly. The amount of combined hydrochloric acid is, as a rule, not very high, and the amount of acid phos- phates is usually less than in a trial breakfast. These are the conditions, provided there is simultaneously no obvious motor insufficiency. When this is not present in the " secretion from an empty stomach," we find no sar- cinae nor sprouting yeast, and in the incubation oven the fermentation test is also negative. In pure cases of the disease we find these conditions, immaterial whether the stomach has been thoroughly washed out the even- ing before or whether we have limited ourselves to prohibiting the patient from taking food after his supper. As Riegel emphasized, and as I demonstrated in quite a number of cases of hypersecretion, upon introduc- ing the stomach-tube and removing the contents of the stomach at inter- vals of an hour or every two hours, we invariably observe a decided amount of secretion in the stomach although the patient in question has, in the meantime, entirely abstained from alimentary stimulation. SYMPTOMS From this peculiarity hypersecretion is accorded a special clinical posi- tion, as is its due also in a clinico-symptomatologic aspect, because the symptoms which bring the patient to the physician often present more or less uniformity. The patients upon prolonged duration of the disease and in spite of a good appetite are usually emaciated with tissues deficient in fluid (dry skin!), they complain of gnawing and painful sensations in the gastric region which are generally persistent, and what is symptom atolog- ically worthy of remark these are present both night and morning, and are relieved by vomiting. The vomitus itself is usually a thin fluid, of acid taste, and often without admixture of food. In consequence of the loss of large amounts of gastric juice, there is, as a rule, thirst and con- stipation, and the urine on account of an increase of its alkalinity fre- HYPERSECRETION 115 quently shows a phosphate sediment (gastrogenous phosphaturia) . In typical cases the test breakfast reveals certain peculiarities which are con- spicuous to the expert. There is a large amount (400 c.c. and more) of very thin, fluid, stomach contents which show relatively slight sediment (the layer quotient rarely amounts to more than 20 or 30 per cent. ) . The sedi- ment has an extraordinarily fine, puree-like appearance, in consequence of the excellent amylorrhexis due to prolonged contact of the gastric contents and gastric juice. The trial breakfast generally filters very rapidly, and the watery filtrate upon addition of an iodin solution (in consequence of disturbed amylolysis) usually assumes a violet or more or less bluish color. The values for total acidity and for free hydrochloric acid vary. Not rarely but by no means always hyperacidity is present. In several cases of hypersecretion with simultaneous disturbance in motility I have noticed the peculiar circumstance that a few hours after the ingestion of one-half to one liter of milk into a stomach which was previously washed clean, an opalescent, turbid fluid without casein flocculi (which are otherwise pres- ent but here are digested with enormous rapidity) was obtained and at the upper border of the fluid sometimes a thin, at other times a thicker, coat- ing of cream accumulated so that a well developed intermediary layer con- sisting of fluid and fat was formed. DIAGNOSIS In the diagnosis of hypersecretion the introduction of the stomach- tube upon an empty stomach is absolutely necessary, and in the diagnostic judgment of the contents which are evacuated from the empty stomach the constituents of the secretion which have here been described are important for the reason that the " residue " of the empty stomach may easily be confounded with the " secretion " of the same. The finding in the empty stomach of an appreciable " residue " which constantly shows a higher layer quotient than that of the " secretion " from the empty stomach, is always a sign of motor insufficiency. In those cases in which we must decide the question whether pure hypersecretion or hypersecretion combined with disturbance of motility is present, I advise as the first step in the differential diagnosis the administration of a teaspoonful to a tablespoon ful of currants, the stomach having been washed out the evening before, also the microscopic examination of the gastric contents for micro-parasites, finally, the fermentation test conducted in an incubation oven. 1 A minute 1 In the microscopic examination of the contents of the stomach in cases of hypersecretion with disturbance of motility, at a time when it should have been empty, I have occasionally found a remarkably slight amount of yeast present, and subsequently, a few times, chains of a delicate, thin, elongated variety of bacteria, as well as once distinct fungi mycelia which I also found in two cases of subacidity, and to which I attach no particular diagnostic significance. 116 SECRETORY DISTURBANCES OF THE STOMACH investigation of gastric motility by the objective method of the currant test, and microscopic examination and fermentation in the incubation oven, appear to me to be particularly important because in the investigation of cases of hypersccretion the proofs whether a disturbance in motility is present or absent must be established. This differentiation is of vital im- portance for the clinical, especially for the theoretic, conception of cases, much more so than the otherwise justifiable classification of cases of hyper- secretion into acute or chronic, into intermittent or relapsing, forms. PATHOGENESIS Disputes have arisen as to the pathogenesis of hypersecretion. The controversy above all has revolved about the question whether every case of hypersecretion is the result of pyloric stenosis expressed functionally or whether it is motor insufficiency. In truth, a number of authors look upon hypersecretion merely as a retention of secretion produced by motor insufficiency, basing their views upon the fact that the finding of motor insufficiency in cases of hypersecretion is not unusual, but even very fre- quent. Nevertheless, various authors (Riegel, Wilkens, Martius, Licht- hcim, Gintl and others) have observed undoubted cases of chronic hyper- secretion in which no objective symptoms of motor insufficiency could be detected, and I have reported two cases of this kind which led me to look upon hypersecretion as the expression of a chronic irritative condition of the secreting parenchyma in the etiology of which various factors play a part. The hypothesis that every hypersecretion is a simple retention of secretion, therefore, appears to me to be insufficient, because other authors as well as I have observed cases of motor insufficiency in which, after the disturbance in motility had been removed, the symptoms of hypersecretion persisted for days and weeks before they disappeared, 1 and because in a series of researches which I have not as yet published I demonstrated (in contrast to Boas) that under rectal nutrition therefore when local stimu- lus from the stomach contents was entirely absent the amount of secre- tion obtained from the empty stomach was just as profuse as during the time when food was introduced by mouth. For this reason I consider the nature of continuous hypersecretion to be a persistent irritability of the secreting parenchyma which itself may be due to a number of causes, among others the irritation of stagnant masses of food. However, as Riegel has emphasized there is in the latter a disproportion between the amount of irritation and the amount of secretion, therefore a special irritability of 1 That such an irritation of the parenchyma may exist for some weeks after a successful gastroenterostomy I recently saw proven by the cure of a case of motor insufficiency due to perigastritis, which should be of deep interest because the peri- gastritis was the consequence of a laparotomy performed to recover a stomach-tube which had been swallowed by the patient (not while in the hospital). HYPERSECRETION 117 the secreting parenchyma must be presupposed if the symptoms of hyper- secretion become prominent. In regard to the etiologic importance of spasm of the pylorus which is occasionally observed in ulcer of the stomach not rare in chronic hypersecretion I limit myself to the remark that such spasms of the pylorus, under some conditions, may certainly lead to a retention of secretion in the stomach free from food, namely, if they have begun during a time in which the stomach contained no food. With the exception of ulcer of the stomach, which is frequent in hypersecretion, the pathologic anatomy of cases of hypersecretion has as yet taught us little regarding the pathogenesis of this morbid condition; for, in so far as exact investigation of the various areas of the stomach is concerned, the number of cases studied is quite scant. In a case reported by Myer and myself a few years ago there was but slight tortuosity and dissemination of the glands, also but slight change in the interstitial tissue. These find- ings were absent in a second case which I clinically observed. The litera- ture, too, of the anatomical findings in cases of hypersecretion, which I cannot here describe, is contradictory. Nevertheless, in discussing the anatomy, I cannot refrain from stating that in cases of hypersecretion I have repeatedly observed gastroptosis, which, however, was usually the mechanical consequence of habitual overloading of the stomach with secre- tion, and also that, in those cases of hypersecretion in which an ulcer of the stomach existed, a permanent secretory irritation was perhaps due to the fact that exposed nerves upon the floor of the ulcer were irritated by the gastric contents or the gastric juice, and this, perhaps, produced inflam- matory changes. Of the neurogenous type of hypersecretion those cases observed during gastric crises are the best examples. To-day, when we have learned from Pawlow's classical investigations to appreciate the rela- tion of the nervous system to the secretion of the gastric juice, it hardly appears remarkable that hypersecretion may be of neurogenic origin. It is interesting, too, to note that hypersecretion is chiefly a disease of middle life, that it occurs more often in men than in women, and that it is more frequent in countries in which ulcer and hyperacidity are common than in other regions. TREATMENT The treatment of hypersecretion, primarily, is identical with the treat- ment of the underlying cause. Where there is a disturbance in motility, this must be combated with all the measures at our command. In those cases in which no disturbance of motility exists which are decidedly the rarer all the points come into question which have already been described under the treatment of hyperacidity, and here the plentiful administration of fat appears to be in order, since other authors, as well as I, have seen improvement and even cure follow its use in cases of hypersecretion. Con- centrated solutions of sugar must be avoided, because the stomach in hyper- 118 SECRETORY DISTURBANCES OF THE STOMACH secretion, in consequence of habitual overloading with secretion, already has a tendency to myoparesis. The latter factor, in combination with our purpose of frequently introducing acid-combining material into the stom- ach, shows the wisdom of administering small and frequent meals. For several reasons, those substances which increase the secretion of the gastric juice should not be employed as food. Alkalies are advisable when a hyper- acid secretion causes spasm of the pylorus, as in the case of hyperacidity. Frequently, however, the pains are mitigated by the administration of other acid-combining substances, for example, eggs or milk. In the general diet, the amount of albuminous food, on account of the acid-combining proper- ties of the albumin, should not be too small. If the palliative measures just mentioned are not sufficient, amelioration may often be produced by the subcutaneous administration of atropin, and Reichmann advises also the internal administration of not too minute doses of silver nitrate. In well developed cases of long duration we cannot get along without the introduction of the stomach-tube, which serves a particularly useful pur- pose in evacuating the surplus amount of secretion present at an improper time. Lavage of the stomach with water is only necessary when there is simultaneous disturbance of motility. When this becomes expedient, Rie- gel advises the use of an alkaline water, and Rosenheim, as well as Rost, praises irrigations with a 1-1000 solution of silver nitrate. Only when the measures that have been described prove inadequate, and absolute rest of the stomach for some time by rectal alimentation is ineffectual, does gastroenterostomy come into question. In those cases in which there is no disturbance in motility this operation has a curative effect by promoting the discharge from the stomach of irritating and burdensome secretions which prevent the healing of wounds that may be present, and by prevent- ing the vomiting of food and gastric juice protects the patient from under- nutrition and losses of chlorin. In some cases the treatment must also take into consideration the consequences of hypersecretion, for example, the gastroptosis, as well as the general loss or general dryness of tissue, but this is not the place in which to outline the treatment of these special pathologic conditions. In reviewing what is here stated of the diagnosis and treatment of secretory disturbances of the stomach, the conclusion will be reached that the last quarter of the preceding century, in particular, has very materially added to our knowledge of these affections and broadened our sphere of action. Our present methods have been built upon a firm foundation, which may be more readily reviewed than was formerly the case. This development of an important diagnostic and therapeutic branch of gastric pathology is due not only to a generally recognized impetus given to medi- cine in the second half of the preceding century, to the methods of research and the exact results of scientific investigations, but, above all, to the SUPPLEMENT 119 acumen and well-directed, energetic labors of those men who have made the stomach-tube the common property of the clinic and the practising physician (Kussmaul, v. Leube and others). The introduction of the stomach-tube, and particularly the introduction of the soft stomach-tube into medical practice due to Ewald was an event of almost historic importance, as is pointed out in another article in this volume. To ac- knowledge this, and to express it, can nowhere be more fitting than in con- cluding a description of a branch of medicine in which accurate knowledge and full comprehension have been made possible only by the use of the stomach-tube. SUPPLEMENT In this article on the analysis of clinical symptoms of individual secre- tory disturbances, it has been repeatedly intimated that an actual relation between definite, clinical symptom-complexes and definite disturbances of secretion cannot always be demonstrated. Therefore, it is still a mooted question in which cases the practitioner is justified in making an exact investigation of the gastric juice secretion by evacuating the gastric con- tents. This question can only be answered in a general way by the state- ment that a test of the gastric contents appears to be indicated in all those cases in which, without such examination, the diagnosis remains uncertain, and in which there are contraindications (in regard to this point see the article by Fleiner, pages 48 and 49) to the introduction of the gastric tube. As nothing of importance in the macroscopic investigation of the contents removed from the stomach can here be added to what was men- tioned in the preceding articles, the method of chemical examination shall be briefly described : In each individual case we begin with dipping a piece of Congo paper in the filtered (and also in the non-filtered) gastric con- tents. The result of this examination indicates what further steps are to be taken in the investigation, since, according to what was said in the preceding article, if free hydrochloric acid is absent we ascertain by test- ing with litmus paper whether the gastric contents have an acid reaction, and, if this be the case, we examine for lactic acid. For the latter pur- pose I advise my modification of Uffelmann's process, since only pathologic amounts of lactic acid can be demonstrated after a test breakfast. This is carried out by using a graduated test-tube specially constructed for this purpose, which may be shaken, so that 5 c.c. of filtered gastric contents are shaken up with 20 c.c. of ether; the gastric juice and 15 c.c. of ethereal extract are allowed to flow off, and the remaining 5 c.c. of ethereal extract with 20 c.c. of water are shaken up with 2 drops, of a 1 per cent, iron chlorid solution (liquor ferri sesquichlorati, 1-10). If lactic acid is present in a proportion of 5 to 1000 or more, the water turns decidedly green. If any doubt exists in regard to. the lactic acid test, it is always advisable to investigate the gastric contents microscopically for an increase 120 SECRETORY DISTURBANCES OF THE STOMACH of bacteria, especially the long bacteria commonly found therein. In those cases in which we are unable to obtain much material with the stomach- tube, the latter process should never be omitted, because the microscopic finding of numerous long bacteria in the gastric contents, as well as the presence or absence of the protoplasmic ring of leukocytes in those cases in which a chemical examination of the gastric contents cannot be made for want of sufficient material, may give us valuable information concern- ing the gastric juice secretions. The total acidity is ascertained by the method Prof. Leo described in his article (which see), and phenolphthalein is generally used. When we suspect apepsia this may be advantageously supplemented by a compara- tive titration with tincture of cochineal (or with tincture of litmus). In the few cases in which we desire to determine the combined HC1, Leo's method is advisable. If, for any reason, we wish to ascertain the quantita- tive amount of free hydrochloric acid, a few drops of a one-half per cent. alcoholic solution of dimethylamidoazobenzol is added to a measured quan- tity (10 c.c.) of filtered gastric contents and titrated with a decinormal solution of soda until the red color disappears; or we may use the dipping method with Congo paper. When employing the latter the platinum loop is advised for withdrawing small amounts (Ewald), and the best way of proceeding is to compare the drop taken from the gastric contents with a drop of water of the same size placed upon Congo paper. In case Linos- sier's reagent is not used from the onset (dimethylamidoazobenzol 0.25, phenolphthalein 2.0, alcohol 100.0), after the amount of free hydrochloric acid has been obtained a few drops of an alcoholic solution of phenol- phthalein is added, and the total acidity is determined by the same test. Mett's process for the quantitative estimation of pepsin, which may under some circumstances be of practical use in the diagnosis of apepsia gastrica or for the topical diagnosis of gastric carcinoma, is best carried out in daily practice in the following way: 10 c.c. of the filtered anacid or subacid gastric contents, to which one c.c. of a 2 per cent, solution of hydro- chloric acid which is kept on hand should be added, are placed in a small glass bottle with a beveled cover, or in some other low and proportionately wide glass vessel closed with a glass stopper. With an albumin tube, prepared according to the method described upon page 92, well washed for iM- hours before use, and with the aid of a magnifying glass, we deter- mine the total amount of albumin digested during this time. According to my experience (and when the test is made in the manner described), in the normal person this rarely amounts to less than 5 mm., sometimes, how- ever, to decidedly more (occasionally to double this amount). Schorlem- nier (An-liir fur VerdauungskranTcheiten, Bd. VIII, Heft 3 und 4) has re- cently advised an ingenious modification of Mett's method of examination, Imt it would be well first to decide by comparative investigations whether the additions to improve the process are absolutely necessary in daily prac- SUPPLEMENT 121 tice. The dilution recently proposed by Nirenstein and Schiff (Archiv fur Verdauungskrankheiten, Bd. VIII, Heft 6) with a l-20th normal hydrochloric acid solution in the proportion of 1 to 16 for those cases in which we have pronounced the estimations of pepsin as valuable cases of extreme subacidity is unnecessary, as in these cases, particularly, the results of the diluted and non-diluted test appear to be almost exactly alike. The estimation of lab-zymogen in accordance with the method proposed by Boas is best made in the following manner: 2 c.c. of gastric juice (with high-graded secretory insufficiency a neutralization of the acid by alkalies is only necessary when lactic acid is present and to prevent a greater dilu- tion this is best done with a normal, not a decinormal, soda solution) are placed in a small measuring glass and diluted with 8 c.c. of water and 5 c.c. of milk (this must not be of acid reaction) mixed in a test-tube (dilution of 1 to 10). The remaining 5 c.c. are mixed with 5 c.c. of water so as to produce 10 c.c., and 5 c.c. of this mixture are added to 5 c.c. of milk (dilution of 1 to 20). The 5 c.c. remaining from this test are added as before to 5 c.c. of water, and one-half of this is poured off and mixed with 5 c.c. of milk (dilution of 1 to 40). By repeating this process we produce dilutions of 1 to 80, 1 to 160, and 1 to 320. After the addition to each of one c.c. of a one per cent, calcium chlorid solution, the entire series is placed in the incubation oven, heated to 37 C., and allowed to remain for half an hour. Under these conditions the nitrate from a stom- ach which functions normally will coagulate milk in a dilution of 1 to 80 or even 1 to 160. Glassner (Berliner klin. Woclienschr., 1902, NT. 29), reports that the normal amount of lab-ferment in the gastric juice obtained by a test breakfast is 1 to 100, i. e., 0.1 c.c. of neutralized gastric juice will, within half an hour, caseate 10 c.c. of milk at a temperature of 30 to 40 C. For further details of the methods of examination, the reader is referred to recent text-books upon the diagnosis and therapy of gastric diseases, especially to those of Boas, Ewald, Fleiner, Eiegel, and Rosenheim, as well as to the text-books upon microscopico-chemical diagnosis by v. Jaksch, Lenhartz and others. A critical compilation of the literature up to the year 1892 concerning the various methods of examination of the gastric juice is found in the monograph by Martius-Liittke : " Die Magensaure des Menschen," Stuttgart, F. Enke, 1892. DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION BY F. RIEGEL, GIESSEN CLINICAL FORMS WHEN a patient presents himself to us and states that he suffers from frequent vomiting of large residua of food, and that he repeatedly finds remains of food that he had consumed several days before, when, upon examination of the patient, the lower boundary of the stomach is found below the umbilicus with an approximate normal position of the upper, and when, throughout this entire region, a loud succussion sound can be produced, the suspicion of dilatation of the stomach is obvious. If, in such a case, seven hours after a test-meal, profuse quantities, a liter or more, are evacuated from the organ, and if an evaluation in the morning upon a presumably empty stomach shows profuse remains, we speak of gastric dilatation, or gastrectasis. Two factors are necessary for the diagnosis of gastric dilatation a decided increase in the size of the organ and an insufficient motor activity, a so-called motor insufficiency. I do not agree with those modern investigators who recently have re- peatedly declared that the terms " ectasis " and " dilatation of the stomach " are no longer expressive of present scientific views, if they intend to elim- inate the term " gastric dilatation " from pathology, and to put in its place " mechanical insufficiency, myasthenia gastrica, ichochymia, motor gastric debility " or the like, which denote exclusively insufficient motor activity. These authors are certainly correct when they declare that the size of the stomach is no measure of its motor activity. A stomach may he larger than normal, yet, notwithstanding, have sufficient motor power, nnd another stomach may be well within the usual physiologic limits, and, nevertheless, show motor insufficiency. Boas is, therefore, certainly right when he says that we drift from a positive foundation in diagnosis when we make the limits and size of the stomach a criterion in deciding upon an existing gastric dilatation. But no conscientious physician will to-day diagnosticate gastric dilatation upon the basis alone of a large extension of the gastric limits. The stomach may have suffered in its elasticity, may be more distensi- ble, yet, nevertheless, still be capable of propelling its contents at the proper 122 CLINICAL FORMS 123 time. If such a stomach be inflated with air or carbonic acid, it reaches far beyond the normal limits; such a stomach is abnormally elastic; never- theless, it may be able to propel the ingesta at the right time like a normal stomach. This condition is designated megalogasiria. Such cases are discovered purely by accident; for megalogastria, as such, does not give rise to symptoms. The conception of ectasis demands more than an increase of size, more than abnormal elasticity; above all, it is necessary that the stomach should be unable to propel its contents at the proper time, that during the long period in which a normal stomach receives no food, more or less profuse contents are still within its walls. We are forced to admit that the designation "gastric dilatation" pri- marily implies only a larger extent of space. Nevertheless, this same term " dilatation," in a certain sense, also indicates a condition of motor insuffi- ciency, for, from what other cause has the patient with gastrectasis a dilated stomach, wherein is the root of his difficulties except in this, that the stomach is incapable of propelling its contents, and is, therefore, constantly overfilled ! Even the older physicians in their conception of gastric dilata- tion not only held the view of an abnormally large extension, but also that the stomach lacked the power of timely propulsion of its contents. That stomach alone is permanently dilated which cannot empty itself at normal periods. If this view of gastric dilatation be accepted and formerly it was uni- versal there is absolutely no reason for discarding the old, established designation " gastric dilatation." It is true that the determination of the size of the stomach alone is not sufficient, it is also necessary to ascertain the motor activity of the dilated organ. At the bedside it is never satis- factory to determine the physical changes only of the diseased organ; we must also picture to ourselves the disturbed function. Similarly, we speak of a dilatation of the heart; but as, in the heart, the determination merely of an increase in size is not sufficient, so, in every case, we study the effect of this dilatation upon the circulation, both in the arterial and venous system, since increase in size is by no means always of like importance; this is also true of the stomach. In the con- ception of dilatation, a decrease in the motor power is included as well as increase of size. At the onset, however, it is clear that it makes a decided difference whether a stomach shows only decreased motor power, or whether it simultaneously shows a decided and permanent increase in size. It must be admitted that formerly the error was frequently made of diagnosticating gastric dilatation solely because of an increase in size. But to-day no conscientious physician, upon suspicion of gastric dilata- tion, will limit himself only to determining the boundaries of the stomach. This would be just as one-sided and wrong as to make a diagnosis of gas- tric disease from the determination of the acidity alone, or to diagnosticate carcinoma from the absence of free hydrochloric acid alone. The increase 124 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION in size primarily awakens the suspicion of dilatation, but this is insuffi- cient warrant for a diagnosis. When there is a decided distention of the stomach combined with sub- jective symptoms, the physician should not neglect to introduce the stomach- tube, to determine the functions of the stomach in regard to motion and secretion. The name " motor insufficiency " indicates only a disturbance in func- tion which may occur in the most varied diseases, and is manifest when the gastric contents are not expelled at the proper time. This may occur in a dilated stomach, in a normal one, and even in a stomach decreased in size. The designation " motor insufficiency " in place of " dilatation " can- not be regarded as correct, for the reason that motor insufficiency is possi- ble without any enlargement of the stomach. It is, however, a matter of consequence, whether, in the given case, the motor insufficiency has led to a permanent abnormal distention of the stomach or not, but only in the latter case do we speak of dilatation. Atony is a special form of motor insufficiency. By this we mean a condition in which the tonus of the gastric musculature is diminished, in consequence of which there is delay in propelling its contents, without the boundaries of the stomach having exceeded their normal limits. Atony may lead to dilatation, but need not necessarily. When the latter is the case, we speak of atonic dilatation. The atonic stomach propels the gastric contents more slowly than is normal, but does finally propel them. We must, therefore, differentiate between motor insufficiency, atony (a special variety of motor insufficiency), and dilatation. Megalogastria does not here come into question. Before proceeding to the clinical picture of dilatation and I purposely speak of the clinical picture of dilatation, and not of the disease " eotasis," for it is not a disease, sui generis I thought it necessary to explain the conception of the term. On this point, as a glance at the literature of recent years will show, there is a great difference of opinion. 1 An attempt has been made to substitute a different designation for the term in general use, " dilatation." If the conception " gastric dilatation " is considered in the above mentioned sense, there is no reason for the introduction of new terms, as they have no advantage over the old. Natur- ally, in determining a dilatation we must not limit ourselves to the mere estimation of the size, but we must endeavor to investigate the intensity of the disturbance in function in connection therewith. There are varying degrees in the nature of the clinical picture which we designate by the term " ectasis," but no well-defined limit from which we may speak of dilatation and from which we should speak of motor 1 I refer particularly to Hesse, " The Conception of, and the Term, ' Gastric Dilata- tion,' in German Literature since 1875." Berliner klin. Wochenschr. 1900, Nos. 23 ,jid 24. CLINICAL FORMS 125 insufficiency and atony. The diagnosis of gastric dilatation is easy when the stomach permanently contains decided residue of food, and when its boundaries, therefore, far exceed the normal limits. In milder cases the condition is different. No stomach, not even a normal one, constantly shows the same dis- tention ; its boundaries vary, we may almost say hourly. The same is true of the dilated stomach, and also of the stomach with motor insufficiency, which, although it finally expels the ingesta, does this decidedly more slowly than the normal organ. The stomach with motor insufficiency is relatively dilated in so far that it still retains ingesta at a time when a normal stomach has already expelled it. In this sense we speak of relative dilatation if a stomach, seven hours after a test-meal, still contains considerable remains of food, while its limits do not exceed the normal boundaries. For, at this time, the stomach should be empty and markedly contracted. In such cases we do not make a diag- nosis of gastric dilatation, but only when the lower and lateral borders of the stomach permanently exceed the normal boundaries, and when the stomach permanently retains ingesta. In spite of this, in the first men- tioned case, there is a relative and temporary increase in size, and there can be no doubt that, upon prolonged duration and long-continued action of these deleterious causes in such a dilated stomach, true dilatation may gradually develop. It is, therefore, evident that there is no sharp dividing line between dilatation and motor insufficiency. Dilatation naturally includes motor insufficiency, for the stomach can only be dilated when its contents are not entirely expelled at the right time. Every true dilatation, therefore, must be accompanied by motor insufficiency ; but not every insufficiency need lead to true ectasis. It is obvious, therefore, that in discussing dilatation we also consider motor insufficiency and atony. As to the causes of dilatation, it must be remembered that this can only develop upon a basis of motor insufficiency. If the stomach cannot dis- charge its contents fully and at the proper time, it must be distended longer than is normal, it must remain abnormally weighted. Gradually, decided distention occurs, and, finally, true ectasis. Motor insufficiency can only arise where there is a disproportion be- tween requisite labor and the capacity for labor, where requisite labor and power of labor no longer, as in the norm., maintain an equilibrium. When the motor power of the stomach is no longer commensurate with the de- mands made upon it, the work is only imperfectly done or after a long period; i. e., the stomach will expel the ingesta only partially or after a pro- longed period of time. The causes of this diminished motor activity are various, and may be expressed as follows : 1. The amount to be propelled is abnormally large, as, for example, in acute, or prolonged, or frequently re- peated over-distention of the stomach; 2. The expelling power, the muscular 126 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION power of the stomach, is deficient; 3. There is an abnormal resistance to the expulsion of the ingesta from the stomach. While, in the group first mentioned, we are dealing with a direct dam- age or diminution of the motor power, in the third group, that of mechan- ical hindrance to the expulsion of the ingesta, we often find the muscular power increased, the muscularis even hypertrophic the same as in stenosis of a valve of the heart, that portion of the heart anterior to the stenosis is not only dilated but, at the same time, it becomes hypertrophic. Never- theless, it is incapable of increased labor. This group represents by far the greatest number of dilatations, and includes the stenoses of the pylorus and its surroundings, Much rarer is insufficiency, the atony and atonic dilatation which go hand in hand with flaccidity of the muscularis. Moderate degrees of atony are not rare. Such an atony may arise when the stomach either temporarily or for a long time has an unusual amount of work to perform. Thus, we see atony as an accompanying symptom of various affections of the stomach. We observe it particularly after acute distention of the stomach with food difficult to digest, we see it in persons who eat hurriedly and abundantly, and chew their food insufficiently. True dilatation may arise in conse- quence of such over-distention ; in children,, particularly, acute dilatation not rarely occurs in this manner. Occasionally it increases to an extreme, and not seldom such acute dilatations have a lethal outcome. In the latter case, other factors besides an acute distention of the stomach may play a role. Thus Kussmaul * many years ago called attention to the fact that in gastric dilatation all the symptoms of complete closure may occasionally appear and continue until large amounts of the stomach contents are ex- pelled by vomiting or by lavage. As Kussmaul pointed out, such cases cannot be due to a paralysis of the muscular wall* by immoderate distention, for peristalsis of the stomach is seen to be markedly active when the stomach contents can no longer be propelled. Kussmaul believes that in cases of this kind a narrowing from tug and tension occurs at the point where the horizontal portion of the duodenum leads into the vertically fixed part at the vertebral column. This conception of the combined action of a mechanical hindrance has gained decided support by the recent investigations of Albrecht 2 regard- ing " Arterio-Mesenteric Intestinal Occlusion at the Duodenal Jejunal Boundary and its Causal Relation to Gastrectasis." Albrecht has proven that the cases of acute gastric dilatation, above all with symptoms of ileus (intestinal obstruction), often have their origin in an arterio-mesenteric invagination of the inferior transverse portion of the duodenum, in that the stomach, as it dilates more and more, forces the transverse colon and the 1 " Peristaltic Unrest of the Stomach." Volkmann's Samml. klin. Vortr. Nr. 181. 2 Virchow's Archiv, CLVI. CLINICAL FORMS 127 loops of the small intestine downward toward the pelvis, the mesentery, and particularly the' arched fold under which the duodenum enters into the jejunum, becomes tense, and thus a constriction is caused in the mesenteric artery at the duodeno-jejunal boundary. Albrecht quite properly states that the vicious circle which is formed by the downward sinking of the folds of the small intestine causes tension in the mesentery which completes the compression of the duodenum. Thus the contents of the duodenum be- come more and more engorged, and the stomach constantly more full and dilated. The horizontal portion of the duodenum becomes still more over- loaded, and the downward displacement of the colon and the small intes- tine still further increased. That an acute atony of the stomach, an acute gastric dilatation, may favor the development to a high degree of an arterio-mesenteric duodenal incarceration is clear. In other cases, the compression of the duodenum by the mesentery of the small intestine may have been the beginning of the disastrous chain. In incomplete closure, and with an incomplete dis- location of the duodenum, there may be chronic dilatation with vomiting of bilious masses. In cases of this kind recently reported, the symptom-complex was ob- served after chloroform narcosis preceding various operations, among them some upon the biliary passages. Baumler, 1 in reports of two cases belong- ing to this category, has recently stated that numerous factors favor this form of intestinal immobility, and he groups these as follows: 1. Greater length of the mesentery of the small intestine; 2. Gastroptosis ; 3. En- teroptosis in its influence upon the position of the duodenum and upon the root of the mesentery ; 4. The position of the duodeno-jejunal boundary in relation to the vertebral column; 5. Marked lumbar lordosis; 6. High- graded emaciation and debility from preceding disease; 7. Chronic gastric dilatation in consequence of congenital or acquired stenosis of the pylorus; 8. Prolonged dorsal decubitus after operations ; 9. Very complete emptying of the intestine prior to an operation. Further predisposing factors for the development of atony in general are preceding severe infectious diseases, general constitutional affections, anemia, chlorosis, and the like. Those who are poorly nourished, or debilitated by sexual excess or other causes, are highly susceptible to atony. Abnormal position of the stomach, gastroptosis, enteroptosis, extreme flaccidity of the abdominal walls may be designated as predisposing factors, even although they do not in them- selves cause atony. In some cases, the so-called weak, atonic stomach is hereditary. Fre- quently, the nutrition habitual from childhood may here play a role. Like every muscular organ, the stomach, from childhood, should be accustomed 1 Munchener med. Wochenschr. 1901, Nr. 17. 10 128 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION to proper food, as this develops its muscular activity. Monotonous diet which is deficient in residue may so weaken the stomach that when, under unusual circumstances, demands are made upon it which can hardly be designated as harmful, its muscular tonus suffers and reacts by becoming ilaccid. At the onset, we might suppose that disturbances in the secretion of the gastric juice would decidedly influence the propulsion of the gastric contents, and thus indirectly cause disturbances of motor activity. Clinical observation shows that this is not the case to the extent, and in the manner, that we might be inclined to assume. Such a reaction we should most look for in pure acliylia in which the secretion of gastric juice is entirely absent. But here, particularly, such a disturbance does not appear; on the con- trary, the motor power is good throughout, and even increased. This is best explained by studying the remarkable results of the experiments of Pawlow l in which he proved that the duodenal mucous membrane regulates the propulsion of the gastric contents into the intestine, regardless of the condition of fulness in the latter, from the fact that it depends upon the reaction of the gastric contents and their acidity. Alkaline contents usu- ally pass from the stomach very soon. On the other hand, after the intes- tine has received a portion of the acid gastric contents, it causes by reflex action a temporary closure of the pylorus. The acid food mass, which the pylorus has permitted to pass through, causes an increased secretion of pancreatic juice, and by and by becomes neutralized. Only after this has occurred is the expulsion of further acid masses from the stomach per- mitted, and, accordingly, the quickened motor activity of the stomach in achylia is readily understood. On the other hand, in cases of increased gastric juice secretion, par- ticularly in hypersecretion, we not infrequently see disturbances of the motor activity in the form of delayed expulsion of the ingesta, and not rarely also of ectasis. The connection between these is a varying one. Many authors regard hypersecretion in all cases as secondary, as the conse- quence, not the cause, of ectasis. That hypersecretion and ectasis are fre- quently observed in combination is certain; which is primary, and which secondary, cannot be so readily decided. Even where an organic pyloric stenosis can be determined, this does not prove that the mechanical obstruc- tion is the cause of the hypersecretion. Pyloric stenosis in which there is a sufficient secretion of gastric juice by no means always leads to hyper- secretion. That hypersecretion often rapidly disappears after gastro- enterostomy, which so greatly facilitates the flow of the secretion, cannot be regarded as a proof that the latter is a consequence of the stasis. Pro- longed stasis may keep up the irritative condition, its disappearance may " Das experiment als zeitgemasse und einheitliche Methode medicinischer For- schung." Wiesbaden, 1900. CLINICAL FORMS 129 remove it, and facilitate the outpouring of the secretion; but stenosis in itself does not explain the prolonged secretion of gastric juice. The secretion of gastric juice normally is not continuous, but periodic. As Pawlow x first showed by conclusive experiments, the normal stomach, empty of food, does not secrete gastric juice. It only secretes it upon digestive, not upon mechanical, stimulation. For this reason, therefore, it is not to be expected that stenosis in itself will cause a continuous secretion of gastric juice. If the stomach of a patient suffering from hypersecretion is washed perfectly clean, and is evacuated after a few hours, during which time the patient has taken no food, a greater or less amount of secretion is nevertheless found. The stomach therefore, despite the absence of any digestive stimulation, has spontaneously secreted gastric juice. This cer- tainly favors abnormal stimulation. On the other hand, we also see, although not so frequently, cases of hypersecretion without pyloric stenosis and without actual dilatation. It is true these cases are readily overlooked. Hence it follows that pyloric stenosis in itself is not the primal, and not the only, cause of hypersecretion. Inversely, however, it is doubtless true that hypersecretion alone may lead to dilatation by limiting the transforma- tion of the amylacea to such a degree that upon prolonged retention fer- mentation of gas is produced, and, finally, if this continue for some time causes dilatation. According to Pawlow's investigations, the abnormally acid contents and the profuse amount of acid-secretion remain in the stom- ach a much longer time than the gastric contents which are normally acid. The transformation of the acid gastric digestion to the alkaline intestinal digestion by the pancreatic juice must be slow and difficult in those cases in which a much higher degree of acidity and a" much larger amount of acid gastric juice is present than in the normal, as is the case in hyper- secretion. Particularly in the case of hypersecretion, spastic processes at the pylorus are observed which inhibit the exit of the acid ingesta; this, accordingly, can only be regarded as a proper preventive, as a protection against a dis- turbance of digestion of the small intestine. These factors are calculated to produce a long stagnation of the ingesta even without the existence of a stenosis. Hypersecretion in itself must cause stasis, and may, therefore, in itself finally produce dilatation. Hence it cannot appear strange that, particularly in the case of hypersecretion, a change in the symptoms is observed, sometimes improvement, sometimes aggravation, sometimes an increase of the motor insufficiency. It has been maintained that marked psychical influences give rise to such atonies. That psychical influences may affect the secretion of the gastric juice and also the motility of the stomach is no doubt true. But these are only transitory disturbances. It has not yet been proven that chronic ectasis may develop upon a purely nervous basis. 1( 'Die Arbeit der Verdauungsdriisen," 1898. 130 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION Whether, and in how far, diseases of the central nervous system lead to atony and dilatation has not yet been determined with certainty. Iso- lated, recent observations appear to favor the possibility of the develop- ment of gastric dilatation from central influences. The cases are not rare in which patients with gastrectasis refer the beginning of their disturbances to a single trauma in the gastric region. As is shown by careful analysis of these cases, many of the ectases are caused by a stenosis of the pylorus or in its vicinity. This stenosis in a number of cases originates in a cicatricial narrowing brought about by necrosis and ulceration due to trauma; in other cases the trauma first causes a perigastritis, and, in consequence of this, adhesions to the neighbor- ing organs; when these adhesions in their further course affect the region of the pylorus, they also lead to stenosis. These traumatic stenoses have the peculiarity that the stenotic symptoms never develop at once, but often only a long time after the trauma. Simple atony may also develop after trauma; it has been noted after operations upon the abdomen. In contrast with the form just mentioned, atonies after traumata mostly develop suddenly and soon after the injury; they may even themselves prove fatal, as in a case recently reported by Grundzach. 1 Not only a single trauma, but also frequently repeated ones which affect the gastric region play a role in the etiology of ectasis. Many occupations necessitate that the labor be performed in a position which causes the body to be bent forward, that the epigastrium be exposed to the pressure of tools which are stemmed against it, and thus subject it to long-continued pressure. This may cause circulatory disturbance, a pressure ulcer, but also cicatricial stenoses or perigastritis, and thus lead to gastrectasis. But we cannot assume a cicatricial stenosis in every case of gastrectasis; even active peristalsis of the stomach is no positive proof. At all events, in a number of dilatations developed in this manner, we note decided variation in the symptoms, and, under some circumstances, even complete retardation, so that the assumption that spasms of the pylorus are chiefly the cause does not appear unjustifiable. It has been maintained that some narcotics, such as alcohol and tobacco, have a relaxing and paralyzing effect upon the muscularis of the stomach. No eases developing in this manner have as yet been determined with certainty. Although it cannot be denied that gastrectasis may develop upon the basis of atony, nevertheless, at the onset, in every dilatation of extreme degree the suspicion is justified that a mechanical hindrance, or an organic stenosis either at the pylorus or in its vicinity, is the cause of the dilata- tion. Mechanical hindrances are ~by far the most frequent causes of ectasis, 1 Revue de Medecine, Mars, 1899. PATHOLOGY . 131 and the most important of these are cicatrices from ulcers, carcinoma, and cicatrices from caustics. The consequences of dilatation will naturally also appear when the obstruction which causes stenosis is situated somewhat lower down, below the pylorus and in the beginning of the duodenum. Foreign bodies which find their way into the pylorus, cherry stones, medlar stones, invaginated gall-stones, have caused dilatation there or in the duodenum. Quite ex- ceptionally, cases of tuberculous stenosis of the pylorus have been observed. Jacobi l has recently reported such a case. Very rare causes of pyloric stenosis are benign tumors, pediculated polypi, connective tissue hyper- trophy of the pylorus, external tumors pressing upon the pylorus (large gall-stones in the gall-bladder, Minkowski). Pyloric stenosis is rarely congenital; nevertheless, quite a series of reports are at hand in which a decided hypertrophy of the pylorus caused marked symptoms of stenosis in nurslings. It is true a number of cases of supposed congenital pyloric stenosis admit of a different explanation. Pfaundler, 2 particularly, has called attention to the fact that recently in examining cadavers of nurslings, in about every third case the stomach was found in a peculiar state of persistent, muscular rigidity. The pylorus itself, in consequence of the permanent contraction, was very narrow, and frequently did not permit the passage of a medium thick sound. Pfaundler believes that many cases reported as congenital pyloric stenosis correspond minutely with the findings in systolic stomachs of this kind. However, he does not deny that there are actual clinical pictures among nurslings which point to an existing pyloric stenosis. These are the most important causes of dilatation and motor insuffi- ciency. The degree is a varying one. High-graded ectasis is observed in organic stenosis, among which by far the most frequent causes are car- cinoma and cicatrices from ulcers. PATHOLOGY Anatomically, the picture presented by ectasis is in proportion to the cause and duration of the dilatation, the degree and nature of the stenosis. Motor insufficiency, as such, so long as it does not give rise to dilatation, is not susceptible to anatomical diagnosis, or, at most, only in the rare cases with cirrhotic change or diffuse malignant degeneration of the stomach. The degree of dilatation varies; primarily, and chiefly, the fundus and the greater curvature which bear the brunt of the affection are involved in the dilatation. But, in severe grades, the dilatation is more general, chiefly lateral, as may often be determined intra vitam. 1 Wiener klinische Wochcnschrift, 1900, Nr. 48. 3 Ibid., 1898, Nr. 52. 132 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION In isolated cases of ectasis the walls of the stomach are very differently affected; sometimes they are thinned, in other cases they show decided thickening. This variation depends primarily upon the cause of the dila- tation, and, secondly, upon the duration of the affection. Decided hypertrophy, particularly of the pylorus, is seen chiefly in stenoses of the pylorus and of its surrounding areas. The muscularis is often three or four times thicker than the norm. In other cases there is no hypertrophy of this kind; on the contrary, the muscularis appears thin and atrophic as in the case of atonic dilatation; not infrequently atrophy, and fatty and other forms of degeneration of the muscularis are noted in the later stages of long-existing ectasis. The relation of the sub-mucosa and mucosa depends much less upon the dilatation itself than upon the underlying causes of the ectases. But in regard to these points we must refer the reader to the individual forms of disease which produce dilatation. SYMPTOMATOLOGY In the description of the clinical picture, " ectasis," I shall limit myself entirely to the symtomatology of dilatation. It would be too great a digression if I were to consider all varieties which might secondarily cause dilatation, such as carcinoma, cicatrices from ulcers, perigastric adhesions, chronic gastritis, hypersecretion and the like. Here we will consider only the clinical picture of dilatation as we meet it in daily practice. It is true the diagnosis, " ectasis," is an imperfect one ; it tells us only that the stomach is dilated, and that motor insufficiency is present ; our object must be to determine the cause, and, as a rule, this offers no insurmountable difficulty. The cases are comparatively rare in which the special diagnosis of the cause of the dilatation is difficult. Often the examination of the patient not only suffices for this but enables us to determine the underlying affec- tion which produced it. Naturally, there are cases in which prolonged observation and the most minute investigation of the course of the disease and of the results of treatment are necessary; but at the bedside we should first determine the dilatation; and then seek for its cause. The symptomatology naturally varies with the degree of the dilatation. Mild grades of ectasis produce less prominent symptoms than higher grades. As I have already stated, there is no sharp division between motor insuffi- ciency and dilatation, in spite of many attempts to define it. It is impossi- ble to draw a line, from which point the stomach may be regarded as dilated. This might be feasible in an organ always of absolutely the same size, but not in an organ which, like the stomach, shows a varying exten- sion at different periods. Naturally there are extreme degrees of dilatation which enable us to say, without more ado, that the stomach is decidedly SYMPTOMATOLOGY 133 dilated. Slighter degrees are designated by one author only as motor in- sufficiency, by another, as dilatation. In estimating the size of the stomach, we must consider the period as well as the absolute degree of distention. In no group of diseases is the time of the physical examination so important as in gastric affections. It is by no means immaterial at what time of the day we examine a patient suffering from gastric disease. If, early in the morning before food is taken, we can elicit a distinct splash- ing sound, and so prove that large quantities of fluid and air are still in the stomach when it should be empty, we decide at once that motor insufficiency is present. In a certain sense we may also consider this stomach to be dilated although its lower boundary does not extend below the umbilicus. For it is at least temporarily dilated ; i. e., more than nor- mally distended; early in the morning it should be empty and contracted. We may, therefore, speak of relative dilatation in contrast to absolute and extreme dilatation. In practice, however, it is necessary not only to deter- mine the extreme grades, but also the slighter forms of dilatation and motor insufficiency. The earlier the stage in which the diagnosis is made the greater the chances of controlling the malady. But, as I should like to emphasize at this point, to obtain a clear insight we must employ all methods in the examination. A well-trained practitioner will sometimes, on first observing the abdomen, be able to diagnosticate gastric dilatation just as we diagnosticate tabes dorsalis from the gait, and aortic insufficiency from the pulse. But no conscientious physician would be content with this. For the name, alone, of the disease, does not suffice, but, at the bed- side, we must fully comprehend the nature and intensity of the physiologic disturbance of function, and for this purpose we require numerous methods of investigation. If this had always been borne in mind in making the diagnosis of ectasis, we should not have erred by regarding the size of the stomach as of most importance, and of considering this alone the decisive factor. But it is just as partial and extreme to determine the degree of ectasis from the amount of material evacuated or from the amount, of residue, and to consider the size, of the organ as entirely secondary. They are related to each other, and still further methods of investigation must be resorted to if certainty in diagnosis is to be assured, as well as a full understanding of the nature and intensity of the disturbances in a given case. To begin with the subjective symptoms, it must be remarked that these vary not alone according to the degree of the dilatation, but also ac- cording to the cause and the manner of its development. As a rule the first symptom of which the patients complain is a feeling of tension, fulness, and pressure after meals. Some experience abnormal sensations of this kind even after light meals ; some report that they feel better in the recum- 134 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION bent posture than when standing, particularly after a somewhat heavier meal. Others complain of eructations and pyrosis, others again of a sensation of active unrest in the stomach which sometimes increases to actual spasmodic pain. Occasionally these disturbances are relieved by vomiting. This is observed chiefly in pyloric stenosis with sufficient or increased secre- tion of gastric juice; but spastic conditions of the pyloric ring may also of themselves produce painful spasmodic attacks. The appetite is capricious; as a rule it is decreased; only rarely, in mild cases is it normal or increased. Often the patients have a feeling of satiety after partaking of small amounts of food; bulimia occurring par- oxysmally is rarely complained of. The thirst is more important than the state of the appetite. In almost all well marked cases there is complaint of thirst. The more extreme the degree of dilatation and motor insufficiency, the more markedly is thirst increased. The stomach itself does not absorb water, but, on the contrary, a more or less active excretion of water occurs in the stomach with the absorption of many substances, such as sugar, dextrin, alcohol, peptone, etc. ; with well marked dilatation of the stomach the propulsion of fluid be- comes exceedingly difficult. This remarkable increase in thirst is readily explained; and the fact that in dilatation more fluid is frequently found in the stomach than is consumed is comprehensible. The decreased absorp- tion of water corresponds with the decreased excretion of urine, to which we shall recur in describing the objective symptoms. The state of the tongue is not characteristic; in the more marked cases there is a noteworthy tendency to dryness. In general, the appearance of the tongue varies; but it is by no means, as was formerly supposed, a reflection of the stomach. An important and, probably, the most important symptom of dilatation is vomiting. In the milder grades of motor insufficiency it may be en- tirely absent; in well marked ectasis it is almost always present, naturally, in varying frequency. In some cases its peculiarities at once suggest dila- tation. Thus, if the quantity of the vomited material exceed the quantity of the last meal, if remains of food which had been taken previously, often some days before, be detected in the vomitus, motor insufficiency is in- dicated. The patients are usually decidedly relieved by vomiting. For this reason they often attempt to produce it voluntarily. Vomiting may be repeated daily; frequently it occurs at very irregular intervals. The appearance of the vomited material varies greatly; the differences depend chiefly upon the underlying affection which causes the dilatation and upon the secretion of gastric juice. The vomitus in dilatation with hypersecretion has a different appearance from that due to carcinoma of the pylorus. In the former case we observe the well known three layers; SYMPTOMATOLOGY 135 the lower layer consisting of fine remains of starch, the next of a decidedly acid fluid, and the upper layer being frothy as the expression of gas fer- mentation; in the latter case coarse remains of food are seen, particularly remains of meat, with an absence of free hydrochloric acid, and a decided reaction for lactic acid. I cannot here describe the special peculiarities of the vomited material, which differ according to the underlying affection that causes the dilatation. I must refer the reader to the individual dis- eases themselves. An admixture of blood in the vomitus is not rare; this is most fre- quently seen in carcinoma, but it also occurs in other processes. Naturally this finding has nothing to do with the dilatation as such. Moderate degrees of motor insufficiency often exist for a long time without impair- ing the general condition. Patients with high-graded ectasis, however, as a rule, are feeble, weak, and incapable of exertion. We commonly meet with complaints of numbness in the head, of headache and of vertigo. The bowels, as a rule, are constipated, occasionally not. Very rarely do the patients complain of diarrhea; this is most frequently observed in stenoses with marked gaseous fermentation. These most important symptoms of the patients, as will be noted, show but slight peculiarities. The objective symptoms are much more impor- tant, and are alone decisive in diagnosis. Naturally they also differ accord- ing to the degree of the dilatation. Slight grades of atoay and motor insufficiency at first, that is, if the duration has not been too prolonged, do not materially affect the general condition and nutrition. It is different in high-graded, long-continued dilatation. Here the nutrition suffers de- cidedly. The patients are more or less emaciated; the fatty layer has dis- appeared, the skin is dry and withered, it may be raised in large folds and desquamates; the muscles are thin and atrophic. This picture is met with not only in cases of dilatation due to carcinoma, but is also observed in dilatation occurring in benign affections, and, naturally, it depends upon the duration of the disease. Carcinomatous dilatation leads more rapidly to loss of strength than the benign forms. But, in any given case, the appearance, the degree of emaciation, cannot be taken as positive indica- tions of the nature of the stenosis. Any one who has seen many patients of this kind will admit that the external habitus is not decisive. The nature of the stenosis can only be determined by a study of the entire condition. The examination of the diseased organ must be made systematically, and. in every case of gastric disease, should begin with inspection. I expressly emphasize this method of examination because in practice it is often neglected. As, in the examination of the heart, the sequence of the investigation is essential, so is it in the stomach. Inspection often gives us important knowledge ; naturally, not in very fat persons. On the other hand, in slender persons, poor in fat, with thin flaccid abdominal walls, 136 we often see the contours of the protruding and dilated stomach without other aid. This, of course, depends upon the time of the examination. If we examine immediately after the stomach has rid itself of the greater part of its contents by vomiting or by lavage, inspection usually reveals nothing. If the stomach, however, is still quite full, we can frequently trace its boundaries; the upper portion of the epigastrium, perhaps still somewhat sunken, is seen lower down extending far below the navel, where a protuberance is noted, inside of which there is often active peristaltic movement from left, to right. Upon superficial investigation these peristal- tic movements may perhaps convey the impression of being irregular; on closer examination, however, a certain regularity is observed, and eleva- tions and depressions may be recognized. The boundaries of the stomach are not only sharply defined, but at the same time we conclude that we are not dealing with a simple flaccidity. In atony such active peristaltic movements are never observed. By inspection alone, we can, under some circumstances, determine the presence of an ectasis, but also simultaneously that the stomach labors with increased force. The latter circumstance favors stenosi-s ; of course, this need not be an organic obstruction, for even a functional disturbance, a spasmodic contraction of the pylorus, may tem- porarily make the outflow difficult, and produce an increase of peristalsis. For a positive diagnosis of dilatation it is absolutely necessary to observe accurately not only the lower but also the upper boundary. As is well known, marked dilatations frequently, even as a rule, accompany gastroptosis, i. e., the whole stomach is displaced downward. The disloca- tion of the lower border alone to a point more or less below the navel does not prove dilatation, for this also happens in gastroptosis ; therefore, the upper boundary must be accurately located. Normally this is invisible; if it be displaced downward, we note in the epigastrium a slight flatten- ing, and below this a prominence gradually increasing as it descends, and with its convexity directed downward. I shall not here discuss the results of electric illumination. Apart from the fact that this method can only be utilized in isolated instances, it gives no results which may not be obtained in other and simpler ways. Inspection is to be followed by palpation. By this means we confirm the results of inspection and also gain other valuable knowledge. In thin patients, provided the stomach is not empty, we may often distinctly pal- pate the organ under the flaccid abdominal walls, particularly if the hand is laid flat with the ulnar surface next the abdomen, and, lightly stroking, glides downward. The practised hand frequently traces the boundaries of the stomach accurately. Simultaneously the proof of a tumor in the pyloric region sometimes complements the diagnosis of such cases. Less importance is to be attached to the method formerly so much prac- tiscd of palpation ~by means of a sound. Although it is true that we frequently succeed in feeling the end of the sound through the abdominal SYMPTOMATOLOGY 137 walls, we find at most only the lower boundary of the stomach, and noth- ing showing its total extension; moreover, a bend in the sound may very readily lead to errors. Another symptom that may be determined by palpation is the splash- ing sound which we elicit by tapping the abdominal coverings with the finger. Splashing sounds only permit diagnostic conclusions when we simultaneously consider the time and the extent of their development. In themselves they only show the presence of fluid and air in a hollow organ. Splashing sounds may, under some circumstances, also be produced in healthy persons, but only when the stomach contains air and fluid, and even when this is the case not beyond the normal boundaries of the stom- ach. If we find splashing sounds extending beyond these, if we find them within abnormal limits at a time when a healthy stomach should be empty, that is, seven hours after a meal or in the morning before food is taken, diagnostic significance may be attached to them. Such a splashing sound proves that the stomach still contains more or less profuse amounts of fluid, and it further proves that the stomach is more decidedly dilated than the normal. Naturally, if the latter con- clusion is justified, gastroptosis must be excluded. To determine the boundaries and position of the stomach it is best to inflate it by means of air or carbonic acid, and the choice between these two methods has been much discussed. We would digress too far to enumerate all the objections which have been made against inflation by carbonic acid. I believe, however, that these objections are entirely unfounded. I have never seen deleterious effects, or even danger from it, although I have used this method daily for many years. But doses suffi- ciently large must be given, a heaping teaspoonful of sodium bicarbonate and a correspondingly large dose of tartaric acid; less than this is in- sufficient. Distention by means of bellows, and autodistention, such as has lately been advised by Spirack x have the disadvantage that a stomach-tube is necessary. The administration of the effervescing mixture is easier and more readily carried out. If the abdominal walls are not too tense and fat we usually succeed, without more ado, in tracing the contours of the stomach; where this is impossible, its boundaries are frequently revealed by the uniformly elastic sensation and by percussion. In stenosis of the pylorus, after the administration of an effervescing mixture, the peristaltic movements of the stomach usually show a marked increase in activity. Percussion of the stomach serves to confirm and emphasize the pre- viously mentioned results; primarily it only aids us in tracing the boun- daries of the stomach, therefore in gauging its size, but does not prove a simultaneously existing motor insufficiency. But it does confirm the lat- 1 Deutsche med. Wochcnschr., 1900, Nr. 23. 138 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION ter if we succeed in ascertaining the presence of fluid in the stomach at a time when it should be empty. For this purpose it is advisable to examine the patient while in the erect and the recumbent postures alter- nately. If, when standing, we percuss downward, and if the upper areas of the stomach are first filled, we find a tympanitic zone which is bounded at the height of the navel, or somewhat below or even somewhat higher, by a horizontal dull line, which lower down terminates in a more or less convex curve, but which in the recumbent posture again clears up. To guard against errors, it is advisable in such cases to evacuate the stomach and thus control it. An evacuation of this kind is, eo ipso, advisable in all cases where there is the slightest suspicion of disturbance of the motor activity of the stomach. The Penzoldt-Dehio method, which consists in administering to the patient early in the morning upon an empty stomach two or three glasses of water in succession, and determining after each glass the extent of the gastric dulness while the patient stands erect, is more useful for ascertain- ing the lower border of the stomach and its tonus than for the proof of dilatation. It may be dispensed with in cases of high-graded ectasis in which the stomach is never entirely empty. Only in mild grades of motor insufficiency is it worthy of trial, and even here it is superfluous since a diagnostic evacuation will give us much more positive proof of the exist- ence of motor insufficiency, and, at the same time, acquaints us with the degree of the same. Some of the other numerous methods for determining the size and capacity of the stomach are very complicated, have no advantage over those just mentioned, and, for this reason, may be ignored. The same is true of the method recently proposed by Queirolo. 1 If the methods of examination described have given any evidence of the existence of a dilatation of motor insufficiency of mild degree, we produce a diagnostic evacuation. This evacuation, a definite time after a meal, enables us to decide whether or not the stomach has fulfilled its task of propelling the food at the right time into the intestine. As a test of motor activity, the test-meal is unquestionably more satisfactory than the test breakfast, for the reason that, in consequence of the greater labor put upon the stomach, we get a better idea of its activity. However, the trial-breakfast may also be utilized to test the motor activity. A healthy stomach is empty six to seven hours after the intake of a test-meal. If, after this time, remains of food are present, its motor activity is impaired. The greater the amount of food still present in the stomach, the greater the degree of motor insufficiency. We may, of course, differentiate vary- ing degrees of motor insufficiency according to the amount of the residue 1 Verhandlungen des XVIII. Congresses fiir innere Medicin, 1900. SYMPTOMATOLOGY 139 and the time it remains in the stomach. Usually it is sufficient to differ- entiate two degrees, in one of which the stomach is not yet empty seven hours after a test-meal but is so in the morning; in the second, a more advanced stage, in which, after a simple evening meal, the stomach is not empty on the following morning. My usual method is this : In the evening, seven hours after the midday meal, I evacuate the stomach. If there are profuse remains of food motor insufficiency is proven. I then wash out the stomach and permit the patient to take a simple evening meal. The stomach is evacuated the next morning before any food is taken. If it is empty, this shows that the stomach which was unable to digest a test-meal in seven hours is, never- theless, able to digest a smaller meal, the evening meal, in a longer period in about twelve hours. If the stomach is not empty upon the succeed- ing morning, a higher grade of motor insufficiency is evident. Another method is to wash the stomach clean in the evening, after which the patient is permitted to take the evening meal, and the stomach is evacuated the next morning before any food is taken. The next day, without a previous evening washing, the supper is eaten, and the follow- ing morning the stomach is again washed out before any food is taken. In the latter case we will often see, before food is taken, that the stomach still contains remains of food, while, upon the day before, when an evening washing preceded, it contained none. This shows that the evening washing has benefited the condition of the stomach. Naturally this method may be modified in various ways. Higher grades of motor insufficiency wherein the stomach, even over- night, cannot completely get rid of its contents, as a rule are associated with an increase in size, and this is not surprising. Evidently, the dura- tion of the motor insufficiency has a causative influence in the development of this increase. In connection with gastric evacuation, there must be an exact examina- tion of the gastric contents. This also occasionally aids us in the diagnosis of motor disturbance, for, very frequently, remains of ingesta which had been consumed days, even weeks, prior, are evacuated, substances such as cherry-stones, seeds of cranberries, of cucumbers, of pears, currants, etc. Marked gas fermentation also presupposes a prolonged stagnation. The three characteristic layers of the gastric contents (the upper or foamy layer, the medium or fluid layer, the lower or finely distributed starchy sedi- ment) proves stagnation and at least a sufficient HC1 secretion. For an exact estimation of slight disturbance in less developed cases Strauss * gives valuable advice, which is to take the unfiltered gastric contents, place them in a fermentation tube with grape sugar, and permit them to stand for some time; by this means we get an idea of the rapidity and intensity of 1 Zeitschrift fiir praktische Aerzte, 1896, Nr. 6. 140 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION the gas formation, of the retained causes of fermentation. The further examination of the gastric contents does not aid so much in the exact estimation of motor insufficiency as in the question of the nature and final cause of the dilatation, that is, of the underlying affection. Although by this process only can we understand the nature of the transformation of the ingesta, and from the gastric juice only can draw conclusions regard- ing the underlying affections which have caused the dilatation and motor insufficiency, nevertheless we obtain from this, particularly when taken in connection with the other symptoms, important points of support. Thus coarse undigested remains of food, particularly of meat, absence of free HC1 and profuse amounts of lactic acid primarily indicate carcinoma, while a profuse residue consisting only of fluid and remains of starch with decided yeast fermentation, the presence of large amounts of yeast cells which are beginning to germinate, as well as sarcinae and an abundant amount of hydrochloric acid, favor benign dilatation. A constant admixture of bile in the material vomited or evacuated from the stomach points to a deeper seat of the obstruction, to an infrapapillary duodenal stenosis. In the majority of cases, we may content ourselves with testing the motor activity by simple lavage, and, perhaps, as a control, a subsequent lavage may be performed. If, one hour after a test breakfast, and six to seven hours after a test-meal, a plentiful residue of half a liter and more is found, motor insufficiency is certainly present. This method is satisfactory in practice. For exact estimation and scientific purposes it is insufficient. Here the method must, at the same time, show us what residue remains in the stomach. Formulas for deter- mining the residue have been given by Mathieu and Remond, 1 Strauss, 2 Goldschmidt, 3 Sorensen and Brandenburg. 4 We cannot enter into the de- tails of these processes. In practice they may all be dispensed with. Any one who desires to employ still other methods of examination for purposes of control finds a number of such at his service. One is Strauss' currant test, in which the patient is given in the evening a tablespoonful of currants or cranberry jelly, and upon the succeeding morning, the stomach is evacuated after a test breakfast or a test-meal, and an exam- ination is made to determine whether, and how many, seeds are still present in the evacuated contents. In a normal person these are no longer found. Other tests are by the salol method and Klemperer's oil method. These tests are all inferior to the old process, first employed by Leube, for testing the duration of digestion. The iodipin method, lately advised, 1 Soc. de biolog., 1890. 2 Therapeutische Monatshefte, 1895. 8 Miinchener mrd. Wochenschrift, 1897, Nr. 13. 4 Archiv f. Verdauurnskrankheiten, Bd. III. SYMPTOMATOLOGY 141 which depends upon the fact that the gastric juice is incapable of freeing iodin from the iodin fat, and that the iodin is first set free in the intes- tine, can, if necessary, be employed as a substitution method, which is not quite free from objection in those cases in which absolutely no use can be made of the stomach-tube. This method has the disadvantage that it consumes more time than lavage, while the latter is superior in that it enables us to form conclusions in regard to the motor activity, and also shows us the secretory condition. These are the objective signs which indicate gastric dilatation and motor insufficiency. Before we ask what aids we have at command to assist us in determin- ing the nature of the dilatation and the motor insufficiency, a few symptoms may be briefly mentioned which are directly connected with the disturbed motor activity of the stomach. That disturbances of intestinal activity are not rarely observed in dila- tation of the stomach is not surprising. Patients with this affection fre- quently have a tendency to constipation; much more rarely they suffer from diarrhea. This constipation may, to a great extent, be due to insuffi- cient absorption of water; the excretion of water from the stomach and the difficult propulsion of the ingesta into the intestine may be the cause of this. In cases of high-graded dilatation the dryness of all the tissues is the reason why more water is withdrawn from the intestinal contents than in the norm. This readily explains the conspicuously hard and dry composition of the feces so often observed, and the difficulty of their propulsion. The diminution in the amount of urine noted in extreme dilatation is due to the decreased absorption of water. The amount of urine voided is a fair measure of the activity of the stomach. In very marked cases, the daily excretion of urine is often decreased to a few cubic centimeters. An increase in the amount of urine is an infallible sign of improvement; the slighter the amount, the more concentrated it naturally is, and the higher its specific gravity. In dilatation with a plentiful HC1 production, the urine often shows a neutral or alkaline reaction, and also when, in consequence of profuse vomiting or by frequently repeated lavage, much acid gastric juice is removed. Occasionally we note an action upon the heart shown by a slowing of the beat. However, this occurs not only in dilatation, but also in many other gastric affections, and, therefore, may in nowise be designated a pathognomonic peculiarity of dilatation. More important than the previously mentioned effects are certain de- rangements of the nervous system. Among these the symptom-complex designated as tetany is especially interesting. This, as is well known, manifests itself particularly by tonic muscular spasms in the hands and arms, occurring intermittently, and an increased irritability of the nerves. 142 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION Fortunately, tetany is not among the frequent sequels of dilatation. Most cases of tetany in gastric dilatation observed up to the present have occurred in benign pyloric stenoses, mostly in such as were accompanied by hyper- acidity and acid fermentation; however, cases of tetany have also been observed in carcinomatous pyloric stenosis, in absence of HC1 secretion, and in lactic acid fermentation. How tetany is produced in these cases is still a mooted question. With Kussmaul, some attribute it to a deficiency of water in the organism; in another theory, the development of the attacks of spasm is attributed to a reflex irritation of the nerve center from the irritated nerves of the gastric mucous membrane; in a third theory, gastric tetany is regarded as the consequence of an intoxication of the organism by abnormal products of metabolism in the diseased gastrointestinal canal. So far as I am able to judge, the last theory has found the most adherents. A discussion of these various theories would lead us too far from our sub- ject; and, naturally, I must decline to enter upon a special description of the symptoms of tetany. (See volume " Diseases of the Nervous System.") Headache and vertigo are not rarely the sequels and accompanying symptoms of dilatation; usually these are not very intense. In the ter- minal stages of marked dilatation the patients are sometimes observed to become soporose, and finally succumb to coma. Such a case, in which sopor and general spasms occurred and terminated fatally after a few days, has recently been reported by Jiirgensen. 1 In this case the fact was note- worthy that during the soporose condition the secretion of urine ceased entirely. The supposition of an autointoxication in such cases is certainly very reasonable. The appearance of curious drumstick-like changes in the fingers and toes in a case of gastrectasis due to benign pyloric stenosis must be men- tioned. This case, recently reported by Dennig, 2 is interesting for the reason that after a successful operation (pyloric resection) there was a complete retardation of the drumstick-like changes. If, after an examination by the methods detailed, gastrectasis and motor insufficiency have been determined, we then inquire what has pro- duced the condition, whether a mechanical obstruction at, or in the neigh- borhood of, the pylorus, or simple flaccidity. The question may sometimes be decided at a glance, or immediately upon palpating the abdomen, in other cases only after minute consideration of all the symptoms and after prolonged observation. If the condition were as simple as has recently been maintained, that every chronic dilatation is due to a hindrance in passage or to a local process at the outlet of the stomach, the diagnosis of cctasis, and also of " pyloric stenosis " could be at once made. But the conditions are not so simple, although it is true that the most marked 1 Deutsches Archiv f. klin, Medicin, Bd. LX. 3 Munchener med. Wochenschrift, 1901, Nr. 10. DIFFERENTIAL DIAGNOSIS 143 grades of dilatation occur in pyloric stenosis. In practice, however, we must diagnosticate not only the marked grades of ectasis, but also the milder grades, the earlier stages. Such forms are due to an atonic condition. But spastic processes also, without an organic stenosis being present, occasionally, as we have before stated, play a role in the etiology of dilatation. Atony, as we have seen, occurs in persons whose nutrition has suffered, and in those with flaccid abdominal walls; not rarely, gastroptosis and enteroptosis exist simultaneously. Such an atonic stomach, as a rule, has a flaccid feeling with but little tension. In spite of a sufficient secretion of gastric juice, as shown by lavage, we frequently find coarse particles of food, especially fibers of meat. The latter are probably due to a loss of energy of the muscularis which prevents an intimate admixture of the ingesta with the gastric juice. A successful treatment, in such cases, often confirms the diagnosis. If, by suitable diet and by improving the nutrition, briefly, by methods which strengthen the tonus of the muscularis and improve the general nutrition, we can remove the symptoms of motor insufficiency, this result favors the view that we are not dealing with an organic stenosis. DIFFERENTIAL DIAGNOSIS In the differential diagnosis between atonic and mechanical dilatation, the history is important. When symptoms of ulcer have previously existed, when in connection with this the picture of dilatation has gradually devel- oped, our first thought is that a cicatrix of the pylorus has produced stenosis. If examination reveal a uniform resistance in the pyloric region, if the secretion of gastric juice be normal or increased, if we observe active peristaltic movements, a cicatrix from ulcer is indicated. When, upon in- flation, we find that the thickened area remains immobile at the same place in which it appeared while the stomach was empty, this we assume to indi- cate a simultaneous perigastric adhesion. The diagnosis is more difficult in cases in which hypersecretion and dilatation exist simultaneously. I have already discussed the varying pos- sibilities of this combination. Active peristalsis favors a mechanical ob- struction, although not necessarily an organic hindrance. Preceding gas- tric hemorrhage favors ulcer, and, possibly, a cicatricial stenosis, although this is by no means absolutely proven. The results of therapy often indi- cate that the cause which brought about the dilatation could not well have been an organic stenosis. Probably the most positive sign of mechanical obstruction at the pylorus is active peristalsis. It is never absent except in the terminal stages and in those instances in which secondary degeneration of the hypertrophic musculature has occurred. Yet the obstruction is not necessarily an organic 11 144 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION one. As is well known, spasms. of the pylorus play a part in many forms of disease of the stomach as well as in dilatation, and are particularly prom- inent in those which run their course with increased secretion of gastric juice. According to Serejukow, acids cause the sphincter muscle to contract. A factor not without significance in the differential diagnosis between the.se forms of dilatation is the rapidity of the influx and outflow of the gastric contents; that is, of the water used for lavage. The stronger the tonus of the stomach, the more powerful the musculature in an obstruction at the outlet of the stomach, the greater the force with which the organ will empty itself. The more slowly the water used for lavage flows in, the more rapidly will it flow out. The conditions are the reverse of this witli very flaccid, thin, atrophic gastric walls. Here the gastric contents are discharged very slowly and incompletely; the water poured in, however, rushes with force through the tube, so that swirls develop, and air is readily aspirated into the stomach. An admixture of bile is not infrequently observed at the termination of a washing of the stomach, especially in atonic dilatation. If other signs of stenosis exist, the permanent regurgitation of bile favors an infrapapil- lary seat of the stricture. The most important sign of stenosis, however, is always the demonstra- tion of a tumor at, or in the vicinity of, the pylorus. The tumor, in itself, does not prove a stenosis, for we must be certain that it belongs to the stomach or to the adjacent portion of the duodenum. When a tumor has been diagnosticated, the question to be next decided is whether it be benign or malignant. We would digress too far if we entered upon this differential diagnosis. This point can only be established by considering the duration of the disease, the condition of the gastric contents, the secretion of the gastric juice and the like. That the results of treatment may be utilized to a certain extent in diagnosis, particularly in differential diagnosis, whether stenosis, or atony, or only functional spasm be present, is clear. Eapid relief of the dilata- tion by suitable treatment favors the atonic form or spastic stenosis. Xaturally, in a temporary improvement, we should not at once permit our- selves to make this diagnosis. Ectases due to organic stenosis are also ameliorated by methodical lavage, by diet, and other remedies; but this improvement is not permanent. COURSE OF THE DISEASE Having described the symptoms of motor insufficiency and dilatation, it is next expedient to describe their course. In the majority of cases the clinical picture of dilatation develops gradually; rarely does it happen that a single deleterious effect, brief in duration, suddenly causes dilatation. COURSE OF THE DISEASE 145 In the course, as in the development, we must differentiate between acute and chronic dilatation. The acute varieties, as a rule, are rapidly cured by appropriate treatment; yet, repeatedly, cases with a fatal termination have been observed. In explanation of these, Albrecht's previously men- tioned investigation of arterio-mesenteric intestinal occlusion at the duodeno-jejunal boundary might well be considered. Whether, in all cases of acute gastric dilatation running a fatal course, mechanical factors of this kind play an important role, cannot, naturally, be subsequently decided. The symptoms of severe acute dilatation have several times appeared without any demonstrable cause. In a few cases the clinical picture developed directly after anesthesia; in several cases a severe infectious disease immediately preceded the condition. It is worthy of note that in a number of these cases vomiting was absent during the entire course; this is probably to be explained by the high-graded, over- distention and loss of tonicity of the walls of the stomach. Such severe, rapidly fatal cases are very rare. Much more frequently mild and moderately severe forms are observed, the origin of which is traced to gross errors in diet. A marked, painful swelling of the abdomen soon occurs and is associated with nausea, vomiting, and great thirst. In mild cases the symptoms disappear in a few days, particularly if thorough lav- age is performed, and we must be careful to see that the stomach is abso- lutely emptied. In other cases the symptoms do not yield so readily. The earlier and more energetic the treatment, the more favorable and rapid, as a rule, is the course. In private practice, we more frequently deal with chronic cases dila- tation which develops gradually. The course of these varies greatly, and depends upon different factors : the underlying cause, the mode of life, and numerous other conditions. Not infrequently we notice a change in the symptoms, sometimes amelioration, at other times aggravation; this is observed, above all, in cases of non-organic stenosis. Organic stenosis, on the other hand, generally shows a progressive increase in the symptoms. The most marked degrees of dilatation are met with in pyloric stenosis; atonic dilatation, in the majority of cases, is extremely slight. Yet it appears to me that we are not justified in denying absolutely the occur- rence of atonic dilatation, as some writers do. At all events, it is rare, and usually not of marked extent. It is unfortunate that the test by physicians of the motor activity has not everywhere been regarded as of equal value with the test of the secre- tory activity. Nevertheless, we must admit that the disturbances of motor activity are often of the greatest importance, even more so than the varia- tions in the secretion of the gastric juice. If in every serious gastric disturbance the same importance were attached to the motor as to the secretory activity, many a case which is now recorded under the name " chronic catarrh " or " nervous dyspepsia " would be recognized as motor 146 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION insufficiency or as dilatation, although not of extreme degree. I have met with a considerable number of such moderate dilatations which, under appropriate treatment, proper diet, rest, forced feeding, methodical lavage and the like, were entirely cured. These patients with atony, even after relatively light meals, have a sensation of satiety, of pressure or fulness in the stomach; they feel indisposed to follow their occupations; they are listless. As a rule there is no complaint of actual pain. If gas- troptosis goes hand in hand with atony, as it frequently does, the dis- turbances are increased. The patients, after eating only a little food, have very disagreeable sensations, they lose their appetite, and gradually the nutrition suffers. Such atonies are very often disregarded, or erroneously diagnosticated, and if they do not early come under suitable treatment they rapidly increase in severity. Only a minute objective examination and the aid of an accurate history make an early diagnosis possible. The more promptly suitable treatment is instituted, the easier is the cure. It can be readily understood that these forms show frequent changes, a tendency to relapse, and that periods of amelioration and aggravation alternate. A much more uniform course is generally observed in motor insufficiency and dilatation due to organic stenosis. Here, also, transitory improve- ment may occur; but it cannot last long unless we succeed in remov- ing the obstruction which causes the stenosis; however, this is hardly possi- ble except by surgical interference. We cannot enter into details of the modifications of these forms on account of the great variety of their causes. DIAGNOSIS In discussing the diagnosis of motor insufficiency in dilatation, I may be brief. This is based solely upon the objective examination, upon the proof of prolonged digestion, and upon an increase in the size of the stomach. Among the methods that have been mentioned, the most certain one for determining motor insufficiency is to wash out the stomach six to seven hours after a test-meal, or two hours after a test breakfast. Splash- ing sounds heard at a period in which the stomach should be empty assist the diagnosis, but never render the diagnostic washing out unnecessary. The latter has the advantage that it simultaneously enables us to form conclusions in regard to the secretory activity, and also to determine what processes cause the dilatation. The degree of motor insufficiency is readily estimated from the amount of retained material and the period of its retention in the stomach. Considering the diagnostic criteria which have been mentioned, con- fusion with other affections is hardly possible. Megalogastria could only be mistaken for dilatation if we should neglect the washing out of the stomach which is absolutely necessary to test the motor activity. Still loss would it be possible to confound the condition with chronic gastritis DIAGNOSIS 147 or with nervous dyspepsia. This confusion is impossible if diagnostic lavage be performed. However, atony and motor insufficiency may occur simultaneously with chronic gastritis and nervous dyspepsia; motor insuffi- ciency is only a disturbance of function which may develop in various ways. In practice confusion of gastrectasis with gastroptosis occurs. This error is not rare, for the reason that with a low position of the greater curvature of the stomach and a succussion sound developed below the navel dilatation is assumed without further investigation. This is not justified by the facts. The proof of displacement of the lower boundary of the stomach is not sufficient to determine dilatation; its total extension must be determined, not only that of the lower, but also of the upper and the lateral borders. The investigation of the latter is interesting. As Michaelis * has shown in cases of enlargement of the stomach in which the gastric motility was severely disturbed, the right border, as a rule, is found much farther removed from the median line than in a stomach with normal motility. On the other hand, we must remember that motor insufficiency and dila- tation are often combined with gastroptosis. It is quite natural that a permanent over-weighting of the stomach should lead to a sinking, to gastroptosis. In fact, in almost all extreme dilatations, we find more or less sinking of the lesser curvature. An extreme case of decidedly low position of the stomach which may readily be recognized (with a high grade of dilatation) may be seen in the accompanying illustration (Fig. 10) in the case of a woman, aged 59, who had carcinomatous stenosis of the pylorus. Simple atonic dilatations very frequently are combined with gastrop- tosis. This combination is not difficult to recognize, provided we make use of the previously mentioned diagnostic aids. By what means atonic dilatation is to be distinguished from that caused by mechanical obstruction has been stated. This question can often only be decided after prolonged observation, under some circumstances only by studying the results of treatment. Much more difficult is it to decide as to the nature of the constriction. Whether we are dealing with benign or malignant stenosis is a most im- portant question, and, in the majority of cases, not difficult to decide. A hard, nodulated tumor in the pyloric region, abundant coarse residue with frequent hemorrhagic admixture in the form of coffee-ground masses, ab- sence of free HC1, lactic acid fermentation, and rapidly increasing cachexia, naturally favor malignant stenosis. But, in malignant stenosis, particu- larly in such as develops from an ulcer, we often find a normal secretion of gastric juice. It must be borne in mind that no single symptom is decisive, but the combination of all the symptoms is necessary to a diag- *Zeitschr. f. klin. Med. XXXIV. FIG. 10. TREATMENT 149 nosis; whether one or the other is absent is not conclusive. But a diag- nosis can never be looked upon as certain which does not combine all the symptoms. PROGNOSIS As has been shown, the importance of motor insufficiency and dilata- tion varies greatly in the individual case ; it may run an acute or a chronic course. At one time it represents a transitory atonic condition, at another time it depends upon a mechanical obstruction, which in one case may be benign, and in the other malignant. The prognosis of motor insuffi- ciency in dilatation, therefore, also varies strikingly in the individual case. Some forms are cured in the briefest time by proper management, others only after months or even years of treatment; some in the briefest time terminate fatally, others again are not susceptible to internal treatment, and surgical measures alone will cure the affection or moderate its con- sequences. The earlier treatment is begun, and the more systematically it is car- ried out, the more rapidly do acute dilatations improve. Under some cir- cumstances threatening symptoms may intervene, and the cases even ter- minate fatally. Generally no prognosis is possible in chronic dilatation. Many factors influence the prognosis in a given case; thus, the duration of the affection and the degree of motor insufficiency. Moderate degrees of motor insufficiency which have not existed for a long time naturally lead to a more favorable prognosis than long-existing, high-graded dilata- tions. But, above all, the prognosis depends upon the underlying cause of the dilatation. If we succeed in removing the causative factor, as a rule we also succeed in ameliorating the dilatation. Mild and medium grades of atony under suitable treatment are often cured in the briefest time. Where the cause of the dilatation is an organic obstruction in the pylorus or its vicinity, improvement can only be brought about by surgical means. Internal treatment in such cases produces apparent, but in reality transitory, results. Unfortunately many cases are no longer suitable for operative interference, such as extensive carcinomata, or those in which metastases are present and the like. The dilatation alone does not per- mit a positive prognosis, but this depends, above all, upon the underlying affection; that is, upon the cause which has produced the dilatation. TREATMENT We now come to the main question: How shall we treat dilatation? Naturally it is not my object to explain here all the methods of treatment and the other procedures which may be necessary on account of the causa- tive factor, carcinoma, cicatrix from ulcer, perigastric adhesions, and sim- ilar conditions; we should digress too far from our actual theme. But 150 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION we shall consider only the treatment of motor insufficiency and dilatation as such. Acute dilatations which have been brought about by over-loading the stomach with food difficult to digest require immediate and thorough empty- ing of the stomach and an absolute rest of the organ for some time. When debility necessitates the administration of food or fluid, rectal alimentation should be resorted to. Under all circumstances, however, the stomach must have absolute rest in the days succeeding. How long this treatment is to be pursued naturally depends upon the severity of the symptom- complex. In acute dilatation in which symptoms of obstruction appear, it is not enough merely to empty the over-filled stomach, and to suspend for some time the administration of food and fluid by the mouth ; we must also attempt to relieve the coils of the small intestines at their mesenteric roots, which, by a drawing process, have been forced down into the pelvis. For this purpose, the patient must be placed in such a position that the small intestine may find its way out of the pelvis, and the tension of its mesentery be quickly relieved. Therefore the knee-elbow position, or lying prone upon the stomach, is most effective. Cases of this kind ending in recovery have recently been reported by Miiller. 1 Where this method does not bring relief, eventually surgical measures only can avail. The conditions are different in the much more frequent chronic forms of dilatation and motor insufficiency with which the physician must chiefly concern himself. Although our object varies according to whether we are dealing with simple atony, with atonic dilatation, or with dilatation caused by a mechanical obstruction, nevertheless, certain therapeutic rules are equally operative in all these forms. In these groups, prolonged stagna- tion, and all abnormal weighting of the stomach, must be avoided as much as possible, that is, combated, and the diet must be so ordered that it will necessitate the least possible exercise of the motor activity of the stomach, and can by no possibility be injurious. Our primary object in dilatation is to regulate the diet. We must in- variably consider first, the kind of food, and, secondly, much more impor- tant in dilatation, the form in which it is administered. In modern prac- tice the majority of physicians advise a dry diet in dilatation; fluids are to be refrained from as much as possible, for they load the stomach by their weight, are badly absorbed, and, in pyloric stenosis are expelled from the stomach with difficulty as is proven by the over-distention of the stomach with fluid. A dry diet, therefore, with the greatest possible limitation of fluids, is advisable. In every form of dilatation, whether it depend upon atony or upon mechanical obstruction, the motor activity of the stomach is insufficient, either absolutely or relatively insufficient, according to the amount of labor 1 Deutsche Zeitschrift filr Chirurgie, Bd. LVI. TREATMENT 151 required of it. We must reckon with this motor weakness; i. e., we must choose a diet which necessitates but slight exertion on the part of the motor power, which does not require over-exertion, but one that prevents it. For, by means of the motor power, the fragments of ingesta are split up in the stomach, reduced in size, liquefied, and, finally, propelled from the stomach into the intestines. v. Mering, by his well known researches, has proven that the healthy stomach possesses only very slight power of absorption, and that its labor consists chiefly in propelling the fluid gastric contents into the intestines. Moritz, too, has demonstrated by investigations that fluid food is more rapidly propelled into the intestine than pappy food, and this again in a shorter time than solids. Therefore, above all, in motor insufficiency and dilatation we must choose a diet which is readily forced onward into the intestine. This is true, however, only of fluid and pappy food. In opposition to the almost universal practice of employing a dry diet, I have for years advised fluid and pappy forms of food in dilatation. This method appears to have recently gained many adherents. In the choice of the diet we must always reckon with the weakened motor power, and, therefore, so far as possible, choose a food that may be broken up into fine particles. One objection has been raised to fluid diet, namely, that the nutritive value of fluid food, in proportion to its volume, is but slight. This argu- ment may, however, be met by choosing a food as nutritious as possible. Such a nutriment is represented by milk, which may be given pure, or as buttermilk, as cream, as milk-custard, and as gruel with various additions of grits, rice, and the like. The taste may be varied by the addition of aromatic substances by brandy, lime-water, by the addition of cocoa, vanilla, cinnamon, lemon, etc. We can generally succeed, in almost all patients, in administering larger or smaller amounts of milk, even when they express a dislike for it. Eggs may be variously prepared and, in addition to other foods, take a place in the diet of the patient. The addition of tropon, nutrose, plas- mon and similar preparations to fluid and pappy food increases their nutritive value. Meat, in so far as the underlying affection permits its use, had best be given scraped or chopped. Calves' brains and sweetbreads, on account of their pulpy consistence, are very suitable for such patients. Game must be avoided, as well as goose, duck, and fat pork. Of fish the most suitable are giant pike, pike, perSh, and shell fish. Vegetables are to be given only very finely split up or in the form of puree, of asparagus the heads, of cauliflower the tops, and mashed potatoes. Fat, especially milk-fat, is also suitable for patients with disturbances of the gastric motility, particularly for such forms as are combined with 1 IE 1- 152 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION hyperacidity. Formerly the opinion prevailed that large amounts of fat lie heavy in the stomach 1 and that in disturbances of its motility they should he avoided. The researches of Strauss, 2 Bachmann, 3 Wolkowitsch * and others, show that too much cream will diminish the secretory power of the stomach, and even in the stomach showing motor insufficiency it is subjectively better borne than a large quantity of carbohydrates. In hypersecretion, and particularly when disturbance of motility is simul- taneously present, the profuse ingestion of undissolved carbohydrates in- creases hypersecretion. For these cases of disturbance of motility with well maintained HC1 secretion, it, therefore, seems more rational to substitute for the carbohydrates as far as possible the fats which are readily and thor- oughly broken up. Here the albumin fat diet for several weeks is advisable. It is well known that some patients cannot digest fat, particularly cream. In these cases of motor insufficiency and dilatation, the opinion previously maintained that fat must be prohibited and that, at most, but small quantities of butter should be permitted, is no longer in accordance with our clinical experience. A definite diet list for patients with dilatation cannot be given; it is clear that wealthy patients may have a more varied dietary than the poor, but for both the rules given above, which primarily enjoin a rest for the stomach, are alike operative. Another self-evident rule is that such patients should never take too much food at one time. The custom of eating only two meals a day is not suitable for patients with gastrectasis. The meals are to be small, but they should be frequent. Under some circumstances, the method of Albu 5 of giving the patient fluid, concentrated food through the stomach-tube ini mediately after the morning and evening stomach washing may be adopted; but this would come into consideration only in the nutrition of very debilitated patients with marked anorexia. In very emaciated persons, to improve the nutrition and' to rest the stomach as much as possible, a portion of the fluid food may be given by the rectum. If we are only endeavoring to combat the decrease of water in the organism, enemata of water with the addition of salt (1 teaspoonful of table salt to a liter of water) or a small quantity of brandy, or wine bouillon enemata ( |- bouillon and -J. Rhine wine) may be given. It is advisable to give nutritive substances admixed with the enema. For this 1 In regard to the question of the part played by the stomach in the digestion of fats, I refer to the investigations of Volhard upon "Absorption and Fat Splitting in the Stomach," recently published from my Clinic. (Miinchener med. Wochenschrift, 1!)0(), Nr. 5 u. 6. und Zeitschr. f. klin. Med., XLII.) - ZcitKdi rift fiir diiitetische und physikalische Therapie, III. 3 Archiv fiir Verdauungskrankheiten, V. 4 WmiM-fi, 1898, Nr. 13, in Archiv fiir Verdauungskrankheiten. 5 Deutxche med. Wochenschr., 1900, Nr. 11. TREATMENT 153 purpose a peptone-enema (50 to 60 of peptone to 300 of milk), milk and egg enemata (3 eggs with the addition of 3 grams of table salt, in 300 of milk) and starch enemata (50 starch to 300 of milk) may be employed. Solutions of sugar are liable to produce irritation of the mucous mem- brane of the rectum. If they must be employed, not more than 15 or 20 grams of sugar to 300 of fluid should be used. Nutritive enemata of this kind must of course only be given in extreme dilatation, and for a short time; as complete substitutes for the administration of food by the mouth, they naturally fail. Subcutaneous injections of fat may, under some cir- cumstances, be given for nutritive purposes. Alcohol is generally to be avoided in dilatation. It is true the stom- ach will absorb alcohol, but, with its absorption, a plentiful excretion of water from the stomach occurs, which is the greater the larger the amount of alcohol absorbed. Although these diet rules apply in general to every form of dilatation, whether it run its course with normal or defective secretion of gastric juice, nevertheless, this secretion of gastric juice should be considered in the choice of food. Where it is more or less decreased, milk -foods, strong soups, and the most, tender meats are indicated, the meat to be finely chopped or divided. But in hypersecretion and hyperacidity, the, carbohydrates must be limited, and a meat-fat diet is preferable. In cases of this kind where the secretion of gastric juice is due to pyloric stenosis, where, therefore, notwithstanding dilatation, gastric peristalsis is still active, it may be expected that the stomach is still able to digest meat divided less finely. At all events we need not be so careful in this respect as in the cases with diminished secretory power and simultaneous atony. As with every damaged or weakened organ, so in the case of the stom- ach it must be our first object to give it rest. The diet should be light, but, nevertheless, sufficient food must be taken. Eest of the organ is facilitated if the patient with dilatation is kept as much as possible in a recumbent posture. That an upright position of the body is more unfavorable for the dilated stomach than a recumbent one is clear. After eating, the patient should lie down for a long time. Lying upon the right side after eating has frequently been recommended to facilitate the propulsion of the food mass into the duodenum. It is self-evident that such patients must eat slowly and masticate thoroughly. If the dilatation and the motor insufficiency are due to the difficulty of expelling the gastric contents, we must resort to measures that will assist in this expulsion. ^ For this purpose systematic massage has been advised. Massage of the stomach, however, also serves the further purpose of strengthening the gastric musculature. If we intend the massage merely to produce a more rapid propulsion of the ingesta into the intestine, it should not be given 154 immediately after a meal but a considerable time later. Massage is con- traindicated in cases of decided fermentation, which must first be re- moved. In the majority of cases the results of massage are not very satisfactory. We cannot describe the technic. Massage of the stomach, however, should always be given by the physician. In atony the faradic current is useful to strengthen the muscularis of the stomach ; this, as a rule, is employed extraventricularly, more rarely intraventricularly. Certain hydropathic procedures, douches, the fan- douche, and, particularly, the so-called Scotch douche, are beneficial. From my experience I cannot advise internal douches; in extreme dilata- tion I do not consider them free from danger, and in milder forms more simple methods may be substituted. To promote more rapid propulsion of the gastric contents into the intestine in cases of organic or spastic stenosis of the pylorus, the use of olive oil has recently been recommended. Cohnheim * advises 50 grams one hour before meals three times daily. Not only in cases of spasm of the pylorus, but also in cicatricial stenoses of the same, he claims to have had good results. In several of these cases, there was scarcely a hope of recovery except by surgical interference. All of these methods are designed to rest and strengthen the stomach; they may suffice in mild grades of motor insufficiency and atony, but not in the severe forms of dilatation in which the stomach is never per- fectly empty, but even in the morning, before taking food, portions of that consumed the previous day are still present. Here it is necessary to re- lieve the stomach of its abnormal contents by gastric lavage. In all severe forms of motor insufficiency and dilatation, gastric lavage is an extremely valuable and indispensable aid. The degree of motor insufficiency which necessitates methodic lavage is a disputed point. All authors are unanimous that, in the extreme forms in which the stomach in the morning before breakfast contains food from the day previous, it should be washed daily. It is different in slighter dilatation. In my opinion, even mild forms of dilatation indicate regular lavage. The normal stomach acts only periodically, not continu- ously. Six to seven hours after the midday meal it is empty, and four to five hours after a simple evening meal it should no longer contain food. In consequence of this, the stomach has certain periods of rest. The dis- eased stomach with motor insufficiency should have no greater work, and no longer hours of labor, than correspond to the norm. If the stomach in the evening, before supper, still contains larger or smaller quantities of food, it must be washed out. If this is not done it is abnormally taxed, and if the debilitated and distended stomach with motor insufficiency is not to be still further stretched and taxed, naturally no more labor must 1 Archiv fur Verdauungskrankheiten, Bd. V. TREATMENT 155 be exacted from it than from a normal organ. This would, however, be the case, if we expect an evening meal to be digested besides the remains of the midday meal which is still in part undergoing fermentation. This would not ensure to the diseased organ the rest which is of such primary importance. If the stomach that has been washed before supper is empty upon the following morning, this evening lavage alone will be sufficient ; if not, it must be performed in the morning in addition. This is not only neces- sary to relieve the stomach, but because abnormal fermentation and decom- position occur upon prolonged stagnation of the ingesta. Many recommend lavage in the morning before breakfast. They be- lieve that if the stomach is not empty at this time it should be washed out, and that this is the best time for the procedure. They also believe that at this hour the washing can be most rapidly performed, and is the least exhausting. I do not coincide with this reasoning. Lavage should relieve the stomach by removing its decomposed products of abnormal fermenta- tion. It is undeniably true that lavage is most easily performed in the morn- ing, and more rapidly because the stomach before breakfast contains rela- tively the slightest residue of food. But this method gives little relief to the stomach; it has no periods of rest as in the norm. It is better, as others advise, to carry out the lavage late in the evening between 9 and 10 o'clock. This gives absolute relief and an actual period of rest follows. To me it appears most rational to use lavage immediately before the evening meal. If, after seven hours, much residue is still present, which must, under any circumstances, have begun to ferment, it is wiser to remove this and to introduce fresh food into the cleansed stomach than, as the exponents of lavage in the late evening recommend, to add an even- ing meal to the fermenting remains and evacuate the stomach two or three hours later. If, after evening lavage, the stomach is not empty upon the following morning, it must, in addition, be washed in the morning. Therapeutic washings should be as thorough as possible, not only to empty the stomach, but to remove as well the causes of fermentation. This should be done first with lukewarm water; medications may be necessary in subsequent washings on account of special individual conditions, because of acid, abnormal fermentation, and the like. The latter, especially, often renders the use of drugs necessary, such as salicylic acid (1-1000), boric acid, resorcin, and similar antiferments. A thorough cleansing of the stomach is more rapid when there is rela- tively increased gastric tonus*, such as we meet with in pyloric stenosis rather than in the atonic forms. Naturally, lavage must be continued until the stomach is thoroughly cleansed, or until we have convinced our- selves of the uselessness of further effort. 156 DIAGNOSIS AND TREATMENT OF GASTRIC DILATATION To the physical aids which play but an indirect role in the therapy of dilatation, bandages may be added. They do not reduce the dilata- tion, but they give the dilated stomach a firm support; they not only assist in producing subjective amelioration, but to a certain extent they relieve the condition. They are particularly valuable in those numerous cases in which, besides dilatation, there is also gastroptosis, or where there is, at the same time, a marked degree of flaccidity of the abdominal walls. These are the chief remedies and methods to which we resort in dila- tation of the stomach. Actual drug medication for dilatation does not come into question. It has been maintained of some remedies, such as strychnin, that they stimulate the tonus and peristalsis of the stomach, which has also been claimed for creosote, brexin and other drugs. But 1 have observed no remarkable action of this kind from any of the remedies applied. A few words must be devoted to the belladonna preparations and to s. At this point I cannot refrain from expressing my belief that deficiency of water in the organism, brought forth so prominently by Kussinaurs adherents, is the causative factor in only a small number of SYMPTOMS 171 cases. Other authors, as well as I, have observed cases of tetany in which there were no signs of gastrectasis and its consequences, but the cause was to be sought for in the increased reflex irritability due to abnormal decomposition of the ingesta and the formation of toxins thereby. In nearly three-fourths of all cases of gastric disease, there is an " epi- gastric pressure point" i. e., an area in the scrobiculus cordis sensitive to pressure, and this is also present in most patients suffering from ulcer. That this has nothing in common with the localization of the ulcer is a well known fact and experience. To be distinctly differentiated from it is a point lower down and to the left which upon pressure also very frequently, but not so often as the first mentioned one, is sensitive to pressure, and in its position corresponds to the solar plexus. In fact in most persons, with and without ulcer, a decided sensitiveness to pressure may be observed in this area, provided the pressure is exerted obliquely toward the median line, and thereby the solar plexus is forced toward the bony vertebral column. That in thin persons with rigid abdominal walls a distinct epi- gastric pulsation is felt in this area hardly requires mention. Only rarely is the accompanying gastric catarrh so prominent that actual anorexia, a pappy taste, eructations, a disagreeable odor to the breath, and a coated tongue are observed. On the contrary, the latter organ is usually of fair appearance, smooth, moist, and distinctly red, so that the findings just mentioned in patients with severe, colicky, gastric disturbance should at once awaken our suspicions of ulcer. What of the chemical processes going on in the stomach? Here we are forced to touch upon the question so often discussed whether it is permissible, with a certain or suspected ulcer, to introduce the sound or the stomach-tube for diagnostic or therapeutic purposes. Absolutely yes ! In many hundreds of patients with ulcer I have intro- duced the stomach-tube, or have had it introduced, thousands of times, and have never seen deleterious effects. This is maintained by all authors of great experience. Of course, this manipulation is not to be undertaken immediately after a profuse hemor- rhage. But we shall see later on that during decided bleeding it is very beneficial to wash out the stomach with ice-water. That in a majority of the cases the chemism is not decreased is evident from the fair appetite of patients with ulcer. Yet the early view that an increased production of hydrochloric acid is a necessary or, at least, an almost invariable accompaniment of gastric ulcer can no longer be maintained, being contrary to the comprehensive observations of the last few years. In my cases I found hyperacidity in only 34.1 per cent., normal acidity in 56.8 per cent, and subacidity in 9 per cent. ; I must admit that these results surprised me greatly. It must be remarked, however, that in the last mentioned group there were five cases in which the acidity on repeated investigations was found to be either 14 per cent, or 24 per cent., 172 GASTRIC ULCER AND GASTRIC HEMORRHAGE while the presence of a typical gastric ulcer without carcinomatous degen- eration was made certain by an operation and the subsequent microscopic investigation of a resected portion of the tissue. It is true that in the other cases of this category we were dealing with persons in whom a more or less advanced degeneration was either assumed or was determined posi- tively by operation. Rheinwald tested the chemistry of the stomach in 66 cases, and found hydrochloric acid in 84.5 per cent., hyperchlorhydria in 65.5 per cent., an absence of hydrochloric acid in 7 per cent., lactic acid 5 times. The fre- quency of non-increased, and even subacid, values has also been noted by other authors. In 38 cases of ulcer Schneider found hyperacidity in only 18 to 19 per cent. The reason he assigns for this is that simultaneously complica- tions of various kinds arose, such as ectatic conditions, chronic peritonitis, more or less severe anemia, etc. Kohler, who observed the cases in Gerhardt's Clinic from 1890 to 1895, found among 165 tests for hydrochloric acid 65 per cent, of positive, and 34.7 per cent, of negative results. It is true the extreme proportion of lactic acid, namely, 33.3 per cent., forces us to conclude that in many of his cases there was already well advanced carcinomatous de- generation. According to these experiences, the opinion that all gastric ulcers during the time of their existence cause a typical increase of acidity, must at all events be rejected as incorrect. On the contrary, here as in many other points in the diagnosis of gastric disease we must be very cautious in utilizing the chemical findings. Increased acidity favors ulcer, its decrease does not positively exclude it. In fact, upon repeated examinations the values for acidity show de- cided variations. In 35 cases, in which I was not content with a single test but made repeated examinations, sometimes six or seven, the values in some respects differed widely from each other. Thus, in a woman, aged 25, who several times suffered from hematemesis, and in whom the gastric contents after a test breakfast frequently showed small quantities of blood, the values for acidity varied between 28 and 44; in a patient aged 26 between 36 and 78 ; in a man with repeated hematemesis, and who per- ished from perforation, between 38 and 54; in another patient, in whom resection was performed for ulcer at the pylorus, between 29 and 71, etc. Treatment, and particularly the diet, influences these variations, but they are especially important because these are usually the cases in which we resort to the stomach-tube to obtain a positive finding, if possible. Kohler also states that in some cases of undoubted ulcer of the stomach a number of tests are apt to be negative until free hydrochloric acid is produced in large quantity, and sometimes no hydrochloric acid can be found with SYMPTOMS 173 any tests. Riegel's statement that hyperacidity is a constant sign in ulcer of the stomach must, therefore, be accepted with limitations. Gluczinsky has called attention to the fact that chemism changes when a correct diet is instituted, that is to say, changes with the food. For example, in the first week on a mixed diet an acidity value of 30 (hydro- chloric acid) was found after a test breakfast, in the second week upon a milk diet 8, in the third week upon mixed diet 25, and in the fourth week upon a milk diet 5. In the cases which I cited it is unnecessary to consider this circumstance; for, during the entire time the patients were under observation, they were kept upon the same bland diet. In a certain group of cases, however, an increase in the excretion of hydrochloric acid is unquestionably present, and these are the cases desig- nated as gastrosuccorrhea or hypersecretion (parasecretion, Ewald). For- merly relegated by many authors to the true neuroses, they are now re- garded as the consequences of ulcer running a latent course. Soupault operated upon 28 cases of typical gastrosuccorrhea, and in each instance found an ulcer of the pylorus. In 48 cases of gastrosuccorrhea Mathieu and Laboulais found hematemesis or melena six times, and eleven times very severe pains were referred to spasm of the pylorus. Gluczinsky at- tributes all cases of gastrosuccorrhea to ulcer with stenosis of the pylorus. This, in my opinion, is to act without discrimination. The outpouring of gastric juice is occasionally irregular and unsteady. It is unreasonable to assume in each case a newly formed ulcer, but in all of these instances we must consider nervous irritation as a cause, as well as the fact that these cases cannot be strictly separated into " retention secretion " and " hypersecretion" nor do they belong exclusively to one or the other cate- gory. Every one of extensive experience knows that transitions occur, and that the same case may at certain times show the characteristics of a pure neurosis, and at other times may present the picture of deranged stasis. Therefore, explicit descriptions to show that either the one or the other condition was alone decisive and causative appear to me to be quite superfluous. Yet this is now a secondary question. I desire only to show that certain cases of ulcer positively present increased secretion of hydro- chloric acid, and, disregarding the limitations mentioned above, the latter, i. e., hyperchlorhydria, is unquestionably of great diagnostic value. I go a step further, and maintain that in all cases in which the course points with more or less likelihood to gastric ulcer, the chemism of the stomach, however, showing insufficiency of hydrochloric acid secretion and of peptic digestion, the view of a carcinomatous transition of the ulcer is well founded. This is particularly true in young persons. In this respect I have recently seen a most typical case: A woman, aged 26, had a large, freely movable tumor situated upon the greater curvature and toward the pylorus, the mucous gastric contents showing undigested remains of a roll but without free hydrochloric acid. Operation revealed two flat 174 GASTRIC ULCER AND GASTRIC HEMORRHAGE ulcers the size of a twenty-five cent piece, one close to the pylorus, the other toward the fundus, in the surroundings of which the submucosa, the muscularis and serosa were markedly thickened. The floor of the ulcers was almost smooth, of a light flesh color, the margin was slightly raised, Imt not undermining the neighboring, greatly swollen mucous membrane. Microscopical investigation showed a carcinomatous neoplasm extending into the muscularis, which only in quite isolated areas had left some glandular tissue. In this case the history revealed no former symptoms of ulcer, but the age of the patient was against a primary carcinoma. In other similar cases, however, typical signs of an old ulcer could be gleaned from the history. The hemorrhages are either from small vessels and slight in amount, and then are only accidentally observed in the form of fine hemorrhagic streaks when freshly admixed with the vomited material, or they are seen as reddish-brown, granular masses after the gastric juice has for some time acted upon the accumulated blood. Upon superficial examination small hemorrhages of this kind may be entirely overlooked, for the blood is not vomited at all, but passes into the intestine, and is there so decomposed that the appearance of the feces is not decidedly altered. Slight admix- ture of blood to the gastric contents does not give it a characteristic appear- ance, but often only a dirty gray color, which does not at once awaken the suspicion of hemorrhage. On the other hand, it need hardly be stated that cocoa, chocolate, strawberry wine, bilberry wine, and the like may lead to errors upon superficial examination. In such cases, as Schmauss has shown, we must occasionally make microscopic, spectroscopic, or chem- ical examinations in order to detect the presence of the smallest quantities of hemoglobin or of blood in the gastric contents or in the feces, and to recognize them as the cause of so-called essential anemia. Occult Hemorrhage. In latent gastric ulcer Rossel, and subsequently Boas and I, repeatedly made the diagnosis of ulcer from the proof of " occult " blood in the feces, naturally, when other sources of hemorrhage were excluded, and the food administered prior to the examination did not contain large amounts of blood. The chemical examination of the feces for blood is best made either with the resin of guaiac or with aloin. In either case a quantity of feces about the size of a hazelnut is rubbed up with water (or a corresponding quantity of fluid feces is taken), and, after the addition of some glacial acetic acid, is shaken up in a test-tube with ether (the previous removal of fat from the feces by shaking with ether is proper, but is by no means always necessary). The hemoglobin which may be present is changed into hematin (methemoglobin) by the acetic acid, and taken up by the ether. To the clear, over-lying ether which is poured off resin of guaiac which has been dissolved in alcohol is added (or the dry powder which is readily soluble in ether), and finally about a cubic centimeter of the SYMPTOMS 175 resin of turpentine or Hiihnerfeld's reagent. 1 When larger quantities of blood are present, a blue color at once appears ; when smaller quantities, this change takes place after a few minutes. The test is made in the same way with aloin, of which a freshly prepared alcoholic solution should be used. In a few minutes the ethereal mixture changes to a beautiful, cherry- red color, and the hemoglobin forms a uniform layer of precipitate at the bottom of the test-tube. According to Boas, the test may be made in the same way as for the reaction of indican; the addition of a few drops of chloroform will make the reaction more distinct, but in my opinion this is superfluous. No matter how the reaction for blood is produced, in those cases which present no other characteristic sign of gastric ulcer the difficulty will be to prove that the blood found is actually from the stomach and not from other portions of the digestive tract. It is self-evident that no blood or hemoglobin should be given with the food. The microscopic proof of small quantities of blood in the feces is al- ways very difficult, because the blood-corpuscles in their migration through the intestine are usually so distorted that they lose their characteristics. In profuse hemorrhages there is no danger of this, but in lesser ones, especially when mercurial preparations or those containing sulphur have been administered, it must be considered. Copious hemorrhages presuppose the erosion of a large vessel, and they act upon the stomach like an emetic, so that this organ rids itself of its contents. Many patients have distinct premonitory symptoms, flashes of heat, epigastric pulsation, a sense of fulness in the gastric region, great, and apparently groundless, internal disquietude which to a great degree produces depression and anxiety. In other patients the only preceding symptoms are an unusual feeling of illness and complete loss of appetite. The time which the blood remains in the stomach varies greatly, and this also changes the appearance of the vomited material. Sometimes the coagu- lated blood is light red and lumpy, at other times it forms dark red masses, and sometimes, in a minority of cases, the vomited material resembles coffee-grounds. Large quantities of blood in the vomited material may even be noted with the naked eye, certainly by the aid of the microscope, perhaps by the spectroscope, or by the various chemical tests for blood. As mentioned above, a portion of the blood finds its way into the intestines. If a profuse hemorrhage has occurred, or if the ulcer is in the duodenum, the evacuations have a tarry appearance, and consist of very offensive masses in which the presence of blood may be detected. In most cases the hemorrhages occur suddenly without an assignable cause. Occasionally they are preceded by circumstances either of a psychic or a physical nature which accelerate the cardiac action, such as joy, fright, unusual exertion, external trauma (blow, fall, pressure, etc.), or i Acid, acetic., Aq. destill. aa. 2.0, 01. Terebinth., Spirit, dilut. aa. 100.0. 13 176 GASTRIC ULCER AND GASTRIC HEMORRHAGE strain upon evacuation. Improper food, for example, hard tendinous meat, fibrous vegetables, such as beans or asparagus, may cause hemorrhage by direct mechanical lesion. One of my patients, who up to that time had never vomited blood, had a severe hemorrhage after taking, on the advice of Cohnheim, 200 grams of oil by the mouth to relieve pyloric spasm. Nausea, retching, and hematemesis were the consequences of this form of medication which is greatly praised by its author. The frequency of hematemesis is reckoned at 50 per cent., but this is too high rather than too low. Brinton gave 29 per cent., Witte in Copen- hagen found it 100 times in 339 cases ( 29.4 per cent.), Gerhardt saw it in 47 per cent, of his cases, so that we may safely assume that more than half of the patients do not suffer from hematemesis. Among 556 cases v. Leube found it in 46 per cent. I observed it in 54.5 per cent. In 187 cases Joslin found no less than 81 per cent, showing gastric hemorrhages, from which we may see how unreliable and how dependent upon accidental conditions these so-called statistics are. In an interesting compilation based upon the records of Guy's Hospital from 1870 to 1890, W. Charles Hood reports that in the majority of cases of gastric hemorrhage in the course of ulcer occurring in patients under 30 years of age women are chiefly affected, and that during this period of life fatal hemorrhage is extremely rare. Of 66 cases of this kind 29 were under thirty, among these only 2 men. On the other hand there were 11 men among 21 cases between thirty and forty years of age. All recov- ered. Seven other cases in which death occurred immediately after the hemorrhage were all over 30 years of age, among them 4 women, respect- ively 33, 35, 50 and 53 years of age. Although we can hardly assume that the prognosis of gastric hemorrhage changes particularly with the critical age of thirty in women, nevertheless this report indicates that gastric hemorrhages in younger women present a less unfavorable prog- nosis, since a conspicuous improvement, the cessation of the distressing symptoms and regeneration of the blood, is often observed after such an event. In one of my cases the number of erythrocytes within three weeks after the hemorrhage increased from 1,900,000 to 3,040,000, and the amount of hemoglobin from 31 per cent, to 51 per cent. Similar observa- tions have bee.n repeatedly made. The hemorrhagic masses from a bleeding peptic ulcer are free from specific elements, and the blood-corpuscles preponderate to such an extent that the cellular elements of the gastric mucous membrane are either scant or do not appear at all. When a copious hemorrhage has once occurred the danger of a repeti- tion is always present and hangs, like the sword of Damocles, over the patient's head in a two-fold manner. In the first place, at brief intervals in the course of a day, or even several times a day, or, perhaps, at brief intervals during a week, hemorrhages repeatedly occur. We must then SYMPTOMS 177 assume that we are dealing with relapses from the same vessel which was first eroded. Secondly, after longer intervals, months or even years, hem- atemesis may be renewed, and then, in consequence of the tendency of the individual to hemorrhages of this kind, repetitions are likely. Occa- sionally it appears as though the thrombus formed is not adherent, and that it readily sloughs off when the cardiac action becomes stronger, as under normal conditions. Twice I saw a hemorrhage occur after a long interval when the patient, from a mistaken idea that it would be beneficial, took strong alcoholic liquors, although only in small quantity. Slight hemorrhages, aside from their psychical effect, have no influence upon the condition of the patient; copious hemorrhages, particula ly when in rapid succession, lead to extreme anemia and its consequences. Wax- like pallor of the skin, a small frequent pulse, slight fever, tinnitus aurium and vertigo, loss of consciousness, transitory mild delirium, and total anorexia follow. Subsultus tendinum and spasms in the extremity like those of cholera have been observed. Nevertheless, the patients recover with comparative rapidity, and under suitable treatment the lost strength is regained. Edema of the extremities, which is observed particularly in the evening if the patient has been upon his feet during the day, and amaurosis which sometimes occurs immediately, perhaps some time after the hemorrhage (but which, according to Fries, occurs in 65.5 per cent, of all hemorrhages in the intestinal tract), show an internal relation to hematemesis which as yet has not been clearly demonstrated. As has al- ready been stated, cases of gastric hemorrhage with fatal outcome, particu- larly in youth, are comparatively rare. Here also the reports of authors differ widely, and the results vary between 8 per cent. (Eodman) to 0.8 per cent. (Bramwell). My own statistics, based upon 360 cases observed in the hospital, give 1.2 per cent. Usually death is due to the rupture of the ulcer and corrosion of the splenic or pancreatic artery, the portal vein, or the left heart, as will soon be described. A case of chronic gastric ulcer with fatal hemorrhage from an eroded left renal vein has lately been reported by A. Markel. A small aneurysm of the coronary artery was the cause of death in a case described by Powell. The ulcer was situated in the lesser curvature close to the cardia ; in its center was an aneurysm about the size of a pea which had ruptured, and by profuse hemorrhage had caused death in a few moments. A similar case was described by Sachs. Here a small artery of the submucosa was implicated. The hemorrhages which take place by the perforation of an aortic aneurysm into the stomach or into the esophagus are of a more indirect nature. Gastric hemorrhages have also been observed (Naunyn) in chole- lithiasis. Minkowski reported a remarkable case at the Congress of In- ternal Medicine in 1902. It was thai of a small aneurysm at the arch of the aorta which had ruptured through the walls of the esophagus. 178 GASTRIC ULCER AND GASTRIC HEMORRHAGE Thence the blood found its way to the cardia and to the floor of an ulcer in the stomach. Any of these hemorrhages may occur without preceding symptoms of an ulcer of the stomach. Fatal hemorrhages are usually preceded by indistinct signs of a severe disease; in other cases, however, the hemorrhage may occur suddenly like lightning from a clear sky, attacking a person apparently in the best of health, and bringing about a fatal termination. At this point we must call attention to other forms of " gastric hem- orrhages," which, because less familiar, may tend to grave diagnostic errors. First, are the hemorrhages from varicose veins of the esophagus. Here the condition is such that occlusion of the hepatic circulation takes place, and the blood in the portal vein attempts to force its way through the venous plexus formed by the combination of the gastric veins with the osophageal veins. The blood then takes a retrogressive course, and, as the esophageal veins cannot withstand the force of such large amounts of blood, they become enormously dilated. The least resistant areas dilate and form varices, which, with the great pressure of the blood, readily rupture and cause profuse hemorrhage. The blood at first flows into the stomach and is vomited as a " gastric hemorrhage." Only a thorough investigation and the consideration of the just mentioned possibility will furnish a clue to the true situation. Frequently this is revealed only at the autopsy. I have seen a great number of cases of this kind in which grave errors were made. Only recently a gentleman from the provinces was sent to me with the diagnosis " hematemesis from an ulcer of the stomach"; examination revealed a decided enlargement of the spleen and a hard, enlarged liver. In the gastric contents there was a mar.ked decrease of free HC1 ; no en- larged glands. The patient had twice suffered from a decided gastric hemorrhage which had appeared without prodromes. Typical symptoms of ulcer were never present. Under these circumstances a diagnosis was made of hepatic cirrhosis with hemorrhage from the esophagus, and this was soon confirmed by the development of marked ascites. In this group we must include the hemorrhages from varices of the gastric mucous membrane (Sachs, Letulle, A. Cohn), which often recur in close succession, and " are combined with venous stasis phenomena of the abdominal organs, often with hepatic cirrhosis, and almost invariably with decided enlargement of the spleen." In regard to the splenic tumor in these cases, it must be borne in mind that, under some circumstances, as has been previously stated, thrombosis of Hie splenic vein from a corroding ulcer of the stomach may cause acute enlargement of the spleen. If the thrombus be simultaneously affected, and if, in consequence, a septic fever develops, the diagnostic perplexity is less great. Another form of gastric hemorrhage not originating from ulcer is the SYMPTOMS 179 so-called "parenchymatous gastric hemorrhage." There is also a group of hemorrhages which are not limited to the stomach, but attack the entire intestinal tract, and occur as the consequence of venous stasis in diseases of the heart, the liver, and the lungs, particularly in thrombosis of the portal veins, and in infectious diseases, such as enteric fever, yellow fever, cholera, etc. As a rule, they do not lead to typical hematemesis, and scarcely ever simulate gastric ulcer. The condition is quite different when the bleeding appears suddenly, as a single or repeated attack of hemorrhagic vomiting, and the most minute investigation fails to reveal the source of the hemorrhage. As many cases of gastric ulcer run a latent course prior to the appearance of severe hematemesis or melena, we will not err in such cases, after excluding the previously mentioned causes of hemor- rhage here, in my experience, hepatic cirrhosis take^ precedence if we assume a gastric ulcer, and in the further course this view is confirmed by the fact that, soon or late, the classical picture of gastric ulcer develops. Now and then, however, the course is exactly the opposite of this. The hemorrhage soon ceases; for a few days or weeks, although great debility remains, the patient feels perfectly well, and shows no gastric symptoms. On the other hand, repeated hemorrhages may lead to collapse and death. At the autopsy, except for the occasional but by no means invariable superficial erosions of the mucosa, no pathological changes are found which are either directly or indirectly related to the hemorrhages. There are quite a number of such cases in literature I have seen five such, some of which were published by Eeichard in which the most careful microscopic examination did not show the origin of the bleeding. In a case of Ham- peln's, a few erosions of the mucosa were found near the pylorus and the lesser curvature, but, upon injecting the gastric artery, no fluid passed through the eroded areas of the mucosa. In one of my cases the hemor- rhage was due to extreme irritation of the gastric mucous membrane, the drinking of a hot infusion of red wine, chamomile, thuja, and various spices. Under some circumstances nothing remains but the assumption of a special permeability of the vessels which are unable to resist the local hyperemia. A case described by Hirschfeld occurred in an old, cachectic woman in whom no change except a very marked arteriosclerosis of the vascular system could be found. Minkowski reports a case of amyloid degeneration of the heart and gastrointestinal vessels without a similar change in the large glandular organs (liver, spleen, kidneys) leading to parenchymatous gastric hemorrhage. Menstrual gastric hemorrhages, and those occurring vicariously in place of menstruation which sometimes may appear intermediately between two periods, usually belong to the group of so-called occult hemorrhages. Actual hematemesis is not observed. On the contrary, -the blood is dis- covered accidentally, or is found while evacuating the gastric contents (Kuttner). Therefore, this condition may very readily be overlooked; 180 GASTRIC ULCER AND GASTRIC HEMORRHAGE nevertheless, it exists, and v. Schrotter, ST., only placed his tempera- mental ignorance on record when he chose to designate my report at the Congress of Internal Medicine (1902) as a canard (" Raubergeschichten ") ! Whether simple stenosis of the pylorus may be the cause of the hemorrhage, as was assumed by Lambotte and subsequently by Moser (retention of gas- tric contents, venous hyperemia of the mucous membrane, and muscular contractions) appears to me very doubtful when we contrast this with the munerous cases of pyloric stenosis without hemorrhage. The cases re- ported by Lambotte certainly do not permit us to exclude the possibility of ulcer. At this point, too, the occurrence of profuse initial hematemesis in gastric carcinoma must be mentioned (E. Mey). In such cases the assumption is obvious that an ulcer originally existed which must have undergone carcinomatous degeneration. In the 4 autopsy reports commu- nicated by Mey, the nodular character of the neoplasm favors a primary carcinoma, for, in the transition of an ulcer into carcinoma an infiltration of the tissue is much more likely to occur. At all events, in such cases the possibility of this must be considered. The circumstances are different when hemorrhages occur as complica- tions of severe purulent processes or marked circulatory disturbance in the intestinal vessels. Surgeons, for example, v. Eiselsberg, have for a long time called attention to the fact that after abdominal operations, particu- larly for strangulated hernia, gastric hemorrhages may occur. These are attributed to displaced thrombi from the point of operation. But I ex- plain the condition in the following case differently: A man, aged 47, was suddenly attacked with severe pain in the umbilical region ; there was absolute constipation. After twenty-four hours an operation was per- formed, at which a diagnosis of internal incarceration was.piade. Prior to the opera- tion the stomach was washed out, and large quantities of a dark, brownish-red fluid were evacuated; this proved to be almost pure blood. At the operation a portion of the small intestine amounting in length to 1 meter and 30 cm. was found to be constricted by a band reaching from the sigmoid flexure to the root of the mesentery. The constricted intestine was enormously distended, and dark bluish-red in color. The circulation was not reestablished in the constricted portion of the intestine, hence it was resected. The patient lived only twenty hours after the severe opera- tion. The autopsy revealed a greatly distended stomach; the leaflets of the dia- phragm were forced up to the fourth rib. " In the stomach countless erosions of the mucous membrane of the size of a pin's head were found. Some of these were round, others angular or elongated; in isolated cases, they extended to the sub- mucosa : at other points they were more shallow. Some contained greyish-red blood, particularly about the borders and at the base; other erosions contained no blood. A true rascular lesion was nowhere to be found. The peritoneum near the gastric region showed no abnormalities." (From the autopsy report of Dr. Oestreich.) But little muco-hemorrhagic contents were found in the intestine; the vessels were mark- edly injected. The abdominal cavity contained about 200 c.c. of a hemorrhagico- serous fluid. In this case we probably find the cause and anatomical foundation for the hemorrhage in the altered circulation of the abdominal cavity, and in the erosions of the mucous membrane which were apparently of an earlier date. SYMPTOMS 181 Severe hemorrhages into the stomach and the intestine occurring in the course of septic processes which affect the abdominal organs without an apparent anatomical lesion, and which cannot be attributed to the formation of thrombus, have until recently been observed only in isolated cares. Dieulafoy mentions them in perityphlitis, and regards them as the result of toxin infection of the gastric mucous membrane, the latter, in his cases, showing no ulceration in the region of the pylorus. Guyon has reported a case of sepsis in the urinary passages without any injury to the urinary organs. Such cases may present insurmountable difficulty in the diagnosis, as will be noted from a case which I recently observed. A man, aged 37, who had been ill for four days, was awakened during the night with pain which soon spread over the entire abdomen. He stated that he had pre- viously suffered from gastric difficulty, and that upon the second day of the disease a chill with rise in temperature to 103.2 F. had taken place; except for this there was no fever during the entire course of the disease. I found the patient with all the signs of diffuse peritonitis, slight dulness in the right and left inguinal regions. The pains varied, being both spontaneous and upon pressure, and were said to have first appeared in the pit of the stomach. During the night the patient vomited large quantities of a blackish-brown mass containing blood. The vomiting recurred in the course of the day and also during the lavage with ice-water which was later undertaken, the water each time evacuated containing blood. The slight quantity of feces discharged from the large intestine after enemata showed no blood. Con- sequently, I diagnosticated a perforating gastric ulcer, and rejected the possibility of a perforative perityphlitis on account of the hemorrhagic gastric contents and the original seat of the pain in the scrobiculus cbrdis. The surgeon called in con- sultation was of the same opinion, but, on account of the advanced peritonitis, re- fused to operate. The man succumbed on the third day of my observation, and upon the sixth of the disease. The autopsy revealed general peritonitis starting from a perforating gangrenous appendix. The gastric mucous membrane was entirely in- tact. But the intestinal mucous membrane in some areas showed a bright red injection, a velvety swelling, and hemorrhagic contents were still present in the intestine itself. Composition of the Blood. Most authors I mention Laache, Leich- tenstern, Reinert, Osterspey (Ewald), and also recently Rencki and Dol- matow have found the composition of the blood (and this quite inde- pendently of a possible hematemesis) so changed that a decided alteration in the number of red blood-corpuscles, and in the hemoglobin, and, occa- sionally, an increase of the leukocytes, was present. But these changes are due to secondary conditions, chlorosis, anemia, etc., and are not typical of ulcer. For well known reasons, the composition of the blood immedi- ately after a hemorrhage will invariably be found changed, i. e., the red cells and the hemoglobin are decreased, and the leukocytes slightly increased. Vomiting. The next symptom of importance is vomiting. Vomiting usually occurs after eating. It is caused by an irritation of the walls of the stomach, particularly of the exposed ulcer surface, from the food, that is, the hyperacid gastric contents. This is partly due to 182 GASTRIC ULCER AND GASTRIC HEMORRHAGE the fact that the strong acid causes a spasmodic contraction and closure of the pylorus, and thus not only pains but an increased and even anti- peristaltic action of the stomach is produced. The food is often but little changed, and is vomited admixed with mucus as is the case in the so-called vomitus matutinus of alcoholics. Fungi of fermentation and other foreign cellular elements, with the exception of occasional admixtures of blood, are either rare or absent (sarcinse). At other times the vomitus is a thin fluid, of slightly greenish color, and very acid, which upon standing forms a pappy precipitate consisting of starch granules, cellular detritus, but only a few markedly digested remains of meat. Periods occur in which there is an increase of the vomiting, and the stomach absolutely rejects food. It is quite apparent even from the external appearance of the vomitus, particularly if it is ejected a considerable time after the ingestion of food, that the gastric contents are decidedly acid. Upon standing two layers form : The upper is a thin fluid, clear, not foaming, and containing a finely granular precipitate consisting of slightly altered remains of starch, plant cells, and the like, in which, however, there are no, or very few, muscle fibers, that is, remains of meat. The test with Congo paper gives a strong reaction for free hydrochloric acid. As a rule spontaneous vomit- ing is not frequent. It is most prone to occur when the ulcer is situated at the pylorus. Perigastritis. When the ulcer has extended to the serosa, and before complete rupture takes place, an inflammation of the external layer of the serosa with the formation of a plastic exudate and perigastritis occasion- ally occurs. This may be limited to a definite area, or may extend into adjacent parts, or may change to hard, indurated masses of exudate which upon examination resemble tumors. Associated with this are local irri- tative phenomena, retching, and even mild fever. Distortion of the stom- ach may take place and, under some circumstances, it may be very difficult or even impossible to recognize the true nature of these conditions. From their character, they are insusceptible to internal treatment, and form a permanent source of perplexity. (See also p. 185 in the description of cicatrization.) Perforation. A severe complication of the disease and, perhaps, of the clinical picture is produced by the rupture of the ulcer and the implication of neighboring organs. When the peptic process reaches the external layer of the gastric wall and attacks one of the neighboring organs, this is occasionally manifested by a localized sensation of pain in the region of the organ attacked. As a rule, however, it runs its course without any external sign, so that only when we test the disturbance of function of the organ in question can we recognize that it has been implicated in the process. As previously mentioned, there may be hemorrhages from the larger vascular trunks. The various conditions which arise for consideration may be readily SYMPTOMS 183 reviewed if we remember the topography of the organs surrounding the stomach. A most interesting complication is a rupture through the dia- phragm and pericardium into the left heart followed by pneumopericar- ditis, also into the mediastinum with emphysema of the external skin and the accumulation of combustible gas. West describes a preparation in which an ulcer had attacked the portal vein and led to a fatal pylephlebitis. Cases are described as pyopneumothorax subphrenicus in which an encap- sulated abscess containing air had formed below the diaphragm. Osier has described a very unusual case in which rupture into the left heart occurred; nevertheless, the patient lived two days, for the perforation closed during every systole and opened during the diastole. Thus the patient gradually bled to death. Kupture into the pleural cavity may be diagnosticated when it leads to pneumothorax and empyema or to a direct communication with the lungs, and, as has happened, particles of food may actually be coughed up. In a case reported by Miiller nematodes were found in the pleural cavity. Kupture into the colon and subsequent lientery are rare. When, in a favorable case, the ulcer ruptures into the abdominal cavity, the preceding adhesive inflammation between the stomach and the neighboring intestinal wall and the omentum forms a cavity which is a sac within a sac, and prevents the propulsion of the stomach contents into the abdominal cavity. After this peritoneal irritative phenomena appear, with circumscribed pain, distention of the upper abdominal region, and fever, perhaps also severe vomiting. If the adhesions are very" extensive, there may be complete stoppage of intestinal activity which, with permanent obstruction and in- creasing marasmus, leads to death, as in a case reported by Budd. Perforation into the free peritoneal cavity is by far the most frequent complication, and happens either after preceding adhesion and abscess formation or without these. It may appear slowly and gradually or, on the contrary, the exit of the stomach contents may be slow. Adhesive abscesses then form which may later become encapsulated, or may rupture and produce general peritonitis. Usually perforation occurs suddenly without prodromes or, at least, without symptoms which point to such an accident. Without any cause or after a preceding trauma, such as an accidental blow, or pressure against the edge of a table or when leaning over a window-sill, in riding, after they have eaten heartily, or after or during vomiting, the patients suddenly feel severe pains in the abdomen which cause a feeling of collapse and, in a brief time, the picture of perforative peritonitis develops : Distention of the abdomen, obliteration of liver dulness, on even the slightest touch excruciating pain which may have a colicky or paroxysmal character, vomiting, singultus, facies hippo- cratica, small pulse, and with these symptoms the patient succumbs. Spontaneous pain is usually referred to the gastric region ; the ileo-cecal region is mentioned, that is, is sensitive to pressure, only in duodenal 184 GASTRIC ULCER AND GASTRIC HEMORRHAGE ulcers. According to the exhaustive compilation of Brunner, in about 90 per cent, of all cases of perforation the history discloses the symptoms of a preceding ulcer, which, upon the average, had been first noticed about 3 years before. These may, however, be absent, and I remember a case in which a young girl, previously always healthy, collapsed at night while dancing, succumbing -to a perforating ulcer. Such perforation may also be caused by spasmodic contractions of the stomach either from vomiting after medication, or from introducing the finger into the pharynx, as is done by many patients to produce eructation and vomiting, or it may occur after introducing the stomach-tube. Faber describes a case of perforation after vomiting induced by the patient. The normal act of defecation is said by Bouillaud to have also been a cause. The youngest female patient was nine years old, the oldest seventy-one. The youngest male was seventeen, the oldest seventy-two (Brunner). The seat of perforation in the gastric wall is usually the greater or lesser curvature, very rarely the pylorus or the cardia. The lesion is cir- cular, with smooth, non-elevated borders, and surrounded by a more or less extensive zone of smooth, cicatricial tissue, which is usually friable so that at operation the suture will not hold but tears through, and the healing of the wound is exceedingly difficult. Cases of such perforation that have recovered without operation are among the greatest rarities. Brunner collected from literature the records of 17, all of whom were treated with opium, ice, and rectal alimentation. Almost invariably the perforation occurred a few hours after eating, while the stomach was empty. In these cases there is a justifiable doubt as to the correctness of the diagnosis. In a case described by Harland, as the author himself reports, an ulcer with a simultaneously existing gastrectasis simulated perforation. In this category I must also include the case reported by Spicker of the spontaneous cure of perforative peritonitis in ulcer of the stomach, which was probably nothing but an acute gastric dilatation. It is certain that the symptoms mentioned above may be absent, yet perforation may have occurred. I have seen two cases in which there was at first no marked distention of the abdomen, no shock or collapse, the pulse was regular, the temperature normal. It was obvious, however, that perforation had occurred. In both instances the stomach contained neither food nor gas, the patient for three days previously having re- frained almost entirely from food, and, therefore, the rupture of the ulcer was accompanied only by the signs of intense shock loss of consciousness, Cheyne-Stokes respiration, absence of pulse, cold skin, etc. while the abdomen was neither greatly distended nor very painful. The " disappearance " of liver dulness, in particular, is a very uncer- tain sign, as this may also be produced by the distended transverse colon SYMPTOMS 185 that extends high above the liver, or in very rare cases by a dilated stomach adherent to the liver. Musser and Wharton calculate that perforation occurs in about 7 to 18 per cent, of all cases. If this includes the most marked cases only, even this low figure is, in my opinion, much too high. I have not observed more than 1.2 per cent, of perforations. Greenough and Joslin saw perfora- tion in 3.2 per cent, of all cases. Those serious accidents in which several isolated ulcers in different areas of the stomach simultaneously rupture, usually in the anterior and posterior walls (Lovell-Keays and others), are very rare. Occasionally a gastrocutaneous fistula forms with an opening into the epigastric or left hypochondriac region or between the ribs. This is a very rare occurrence; nevertheless, Murchison collected 12 reports of such cases. Sudden perforation has repeatedly awakened a suspicion of poison- ing and led to unjust criminal trials. The nature of the cicatrization is of great importance. It is obvious that cicatricial distortion may lead to the severest disturbance of the gastric functions, one of which, dilatation of the organ with cicatricial pyloric stenosis, has already been described; this produces a limited pathologic picture. In other cases, cicatricial contraction causes torsion of the nerves of the gastric wall or deformity of the organs, or the function of large portions of the muscularis is lost, or adhesions with neighboring organs form and lead to gastralgia or to functional disturbances which appear under the guise of " dyspepsia " of different kinds, the original cause of which is usually difficult to recognize and from which recovery without operation is, as a rule, impossible. In the course of years I have learned to dread this cicatrization even more than the primary ulcer. Not rarely such patients are erroneously considered as "nervous dyspeptics." If the cicatrix is circular and at about the middle of the stomach, the various forms of hour-glass stomach or large sac-like dilatations of the same are produced. In washing out the stomach the curious symptom then appears that the stomach apparently cannot be evacuated. After some time the water injected for washing returns clear, suddenly, however, again becom- ing turbid and admixed with gastric contents, and this phenomenon may be repeated several times. This indicates either the condition just de- scribed or an insufficiency of the pylorus, the contents of the duodenum being regurgitated into the stomach. Hemorrhagic Erosions. Einhorn has lately devoted much attention clinically to the previously mentioned " hemorrhagic erosions/' which have long been known anatomically, and frequently described. They do not present the classical picture of ulcer of the stomach but dyspeptic symp- toms, even decided pain, which increases soon after taking food, and con- tinues from one to two hours; emaciation and weakness appear. The chemism is not specially characteristic. Yet almost always in the water 186 GASTRIC ULCER AND GASTRIC HEMORRHAGE used for lavage and authors lay particular stress upon this constancy small reddish-white flocculi are present which, upon minute examination, prove to be desquamated portions of the mucous membrane. They show well retained glands with small cell infiltration and an accumulation of red blood-corpuscles between them. These reports have been several times discussed (Pariser, Hemmeter, Platter, Evvald and others). That no positive diagnostic value can be at- tached to these mucous membrane particles which appear in the water after lavage, i. e., that they do not reveal histologic changes characteristic of a definite pathologic type, Leuk proved in my wards after thorough and careful investigation. His conclusions have been confirmed by Cohn- hehn, Lubarsch, Hari and others. Eisner examined 35 cases in which inflammatory symptoms attributable to the stomach with a decrease or cessation of the gastric juice secretion were determined only 12 times, i. e., in 35 per cent., and found exfoliations of the mucous membrane either transitorily or permanently in the water used for lavage. Only four of these complained of difficulties such as Einhorn described. I have, however, elsewhere expressed my opinion (Transactions of the Twentieth Congress for Internal Medicine, Wies- baden, 1902) that a well characterized pathologic picture of hemorrhagic erosions does not exist,, and that every author who has attempted to por- tray this has presented a type differing from that of his predecessors. Not only the differential diagnosis of true ulcer, but also that between neuroses with hypersensitiveness of the gastric mucous membrane and spas- modic conditions of the pylorus, occasions perplexity. A positive diagnosis in such cases cannot be made from the course and the results of treatment ; the methods of treatment which, under various authors, have resulted in a cure of " erosions," for example, lavage of the stomach with a one per cent, silver nitrate solution, will also cure an underlying gastric catarrh or the ulcer, which, as some observations invariably prove, may develop from such erosions. Henschen, in his autopsy reports, mentions erosions in 3 cases of tuberculosis, in 2 cases of nephritis (which I can corroborate, Ewald), twice in mental diseases, once in pneumonia and only once in gastritis, and these circumstances raise the question whether the erosions arc not rather the consequence of a general affection than the expression of a local disease. In any case, the diagnosis "erosion" is very con- venient, and will therefore probably maintain its position. Fissures of the Mucous Membrane. Here a change in the mucous membrane which is said to have its seat at the pylorus must be mentioned : Fissures of the mucous membrane which produce pyloric spasm, just as anal fissures give rise to rectal spasm. In his report upon the curative effect of large doses of olive oil in gastric disease (see under Treatment) Cohnheim discusses these fissures extensively without positively demon- strating their existence. He considers a fissure to be present from the SYMPTOMS 187 fact of the rapid recovery, i. e., the cessation of pains, and maintains that the patients' symptoms could not be relieved in such a few days if they were due to well developed ulcer. In my opinion this argument does not warrant a positive diagnosis. For he has neither seen these hypothetical fissures himself, nor does he construct from them a characteristic symp- tom-complex, nor, finally and this is certainly remarkable are there any reports or proofs to justify this in the literature cited by him. In the many hundreds of autopsies in which I have examined the stomach with the closest attention, I have never seen such a fissure. Now, I will n6t deny that an ulcer may occasionally bear a certain resemblance to a fissure a fissure is really nothing more than an ulcerated lesion of the mucous membrane although, as the name implies, it must have more of a lacer- ated appearance than the ulcer which develops evenly but it remains to be proven that these fissures are so frequent as Cohnheim believes, that among 24 cases (I exclude the 6 cases of undoubted carcinomatous ulcer) he made this diagnosis four times, therefore in 16.6 per cent, of the cases. Syphilis and Ulcer. In 1838 Andral propounded the question, Why do not syphilitic manifestations appear upon the mucous membrane of the stomach as well as upon the mucous membrane of the mouth? Since then this question has been much discussed, and more or less positive cases have been reported by Goldstein, Hiller, Yirchow, Leudet, Lan- cereaux, Fauvel, Klebs, and Cornil. The simultaneous occurrence of gumma and ulcer of the stomach has been reported in only two cases. In others (Frerichs, Drozda, Murchison, Chvostek) cicatrices were found in the stomach and simultaneously general syphilis. Among 100 cases of ulcer, Engel found a preceding syphilis in 10 per cent., Lang in 20 per cent. Julien, in his great " Traite des maladies veneriennes," quite properly, is very conservative. In diseases so frequent as the two in question it must always be doubtful whether cause and effect or mere coincidence is before us, particularly as confusion with ulcerating gum- mata can by no means be always excluded. Only the result of specific treatment is decisive. Several such cases have been reported, for example, by Hiller and Gaillard, but the latter, who has written the most recent monograph upon this subject, admits that we have no certain proof. Spe- cific symptoms are certainly not peculiar to syphilitic ulcers. Neverthe- less, with coexisting syphilis and the signs of gastric ulcer it is advisable to institute specific treatment. Tuberculosis and Ulcer. Tuberculous ulcerations of the intestinal canal occur frequently, as is well known, but they are not often combined with ulceration of the stomach, perhaps for the reason that the dissolving gastric juice prevents the propagation of bacilli, whether introduced with swallowed sputum or with the blood. Typical symptoms are not peculiar to tuberculous ulcers of the stomach. Sudden death from hematemesis in consequence of eroded vessels has also been observed. 188 GASTRIC ULCER AND GASTRIC HEMORRHAGE DIAGNOSIS The diagnosis of chronic ulcer of the stomach is easy, and, when all of the classical symptoms are present, can scarcely occasion perplexity. When this is not the case it is exceedingly difficult or even impossible. Important diagnostic factors have already been indicated; we may, there- fore, be brief. Two other diseases of the stomach, gastralgia, or gastro- dynia (as the expression of a functional nervous disturbance), and car- cinoma resemble the symptom-picture of ulcer when ulcer deviates from its typical course. It seems advisable to tabulate their important points of difference as follows: NERVOUS GASTRALGIA. ULCER. CANCER. Tongue varies, often pale, and fissured at the borders or upon the surface. Tongue dry, red, with white streaks in the center, or smooth and moist, or slightly coated. Tongue pale, furry, in rare cases very red, dry. Frequent eructation of odor- less gas. Eructations either rare or acid eructations with py- rosis. Frequent fetid eructations. Taste unaltered. Dryness of mouth frequent, sometimes salivation. Taste unaltered. Pappy, insipid taste. Appetite irregular, capri- cious. Appetite good in the inter- vals. Thirst. Appetite decreased or ano- rexia. Early repugnance to meat. Varying sensations in the stomach, sometimes heat, sometimes cold. Burning sensation in the stomach. Circumscribed boring pain, often radiat- ing posteriorly. Sensation of weight; draw- ing pains of varying char- acter, perhaps pain in the shoulder. Spasmodic, burning pain, in- dependent of food, often ameliorated by the latter or by pressure upon the stomach. Pressure points over the intestinal plex- uses. Pains gnawing, rare upon an empty stomach, usual- ly appearing after eating or upon motion and on assuming positions which dilate the stomach ; in- creased upon pressure. Pressure points upon back. Continuous dull sensations of pain, periodically in- creasing to paroxysms, of- ten produced by pressure or increased by it. The ohemism of digestion not especially altered. Digestion of starches fre- quently slow ; that of meat normal, or even acceler- ate 1 : usually hyperchlor- hydria. Digestion insufficient; usu- ally absence of free HC1; formation of organic prod- ucts of decomposition. DIAGNOSIS 189 NERVOUS GASTRALGIA. ULCER. CANCER. Epigastric pulsation. Epigastric pulsation only with marked emaciation. Vomiting irregular, some- times mucus only, some- times more or less'digested 'gastric contents, rarely ad- mixed with bile. Vomiting, as a rule, imme- diately or shortly after eating, and frequently the first symptom of the dis- ease ; very rarely without taking food, vomitus hy- peracidas. Severe and frequent vomit- ing, often periodical, occa- sionally also before the ingestion of food ; mucoid ; when acid, due to organic acids ; only occurring dur- ing the course of other dyspeptic symptoms; vom- itus shows but slight di- gestion ; sometimes cancer cells present. No hematemesis, except as accompaniment of very rare complications. Vomiting of light red blood or coffee-ground masses; usually repeated in a brief space of time, occasion- ally very profuse, followed by extreme anemia and collapse. Compensation with comparative rapid- ity. Blood in the feces. Occult hemorrhages. Decomposed blood more fre- quent than fresh ; quan- tity usually slight, but, having once appeared, re- curring frequently at short intervals. Almost invariably stubborn constipation; normal evac- uations very rare; occa- sionally fluid mucoid de- jecta, the so-called pseudo- diarrhea. Mucous colic, that is, colitis mucosa membranacea. Bowel discharges vary, not infrequently diarrhea in consequence of intestinal irritation. Lientery after perforation into the colon. Almost invariably bowels stubbornly constipated. Lientery after perforation of the colon. No fever. Mild fever only with adhe- sive inflammation after rupture of the ulcer, or following profuse hemor- rhages. Fever rare, and only toward the termination of life. Initial fever quite rare. Skin pale, rarely ruddy. Skin of normal turges- cence. Skin usually of ruddy ap- pearance, anemic only af- ter profuse hemorrhages. Frequently the visible mucous membranes, and even the cheeks, slightly cyanotic. Patients some- times present the chlo- rotic type. Skin sallow, yellowish, dry, and flaccid. Marked ca- chexia. Often conjoined with hys- terical symptoms. Occurs at all ages, more frequently in women than in men. Most frequent in middle life ; rare in children. Ac- companied by a varying psychical condition, fre- quently great depression. Most frequent between the fortieth and sixieth years. Psychical condition that of depression ; melan- cholia, but, strange to say, less profound than in se- vere cases of ulcer. 190 GASTRIC ULCER AND GASTRIC HEMORRHAGE NERVOUS GASTRALGIA. ULCER. CANCER. No tumor on palpation, When the ulcer is situated Tumor of varying size and unless, as rare exceptions, at the pylorus with con- shape, nodular or smooth, when foreign bodies, hair, secutive hypertrophy, an distinctly palpable: as a etc., have been swallowed. ovoid, smooth tumor at rule, passively moved, oc- Chemism varies; absence the right of the median casionally also in respira- of lactic acid. line may be palpated. Oc- casionally in old ulcers tion. In the majority of cases no HC1 ; absence of with a hard base and cal- pepsin digestion ; lactic lous borders a palpable acid. Lab-ferment some- tumor with circumscribed times absent (cancer of the encapsulation, perforation pylorus), sometimes pres- or adhesions with the head ent (cancer of the fund us). of the pancreas, the left Secondary glandular en- lobe of the liver, the spleen largement. Metastases. or omentum, and does not move with the expiratory excursion. HC1 present, and usually increased. No symptom of perforation. Perforation into neighbor- Perforation ; implication of ing organs with character- neighboring organs only istic symptoms, frequently after prolonged existence after apparent brief dura- of the disease. tion of the disease even occurring without pro- dromes. Nevertheless, distinct as these three clinical pictures may appear to be upon paper, in practice the most prominent symptoms are often so ill-developed or so merged into one another that a precise diagnosis is impossible, as, for instance, in the onset of the ulcerative process. So long as the symptoms indicate only general digestive disturbances, so long as there are no typical gastralgic attacks, and especially so long as there is no trace of hematemesis, we have no clue by which to dis- tinguish this condition -from the great category of dyspepsias. An im- portant aid in the recognition, which makes an early diagnosis possible, is the proof of hyperchlorhydria, although we should not forget that rare exceptions to this occur, and that chemically slight hemorrhages into the gastric and intestinal contents cannot be macroscopically recognized. The diagnosis is most positive when we find the symptoms of typical gastralgia, vomiting of blood, blood in the feces, absence of tumor and cachexia. In such cases it is unnecessary to examine the patient with the stomach-tube; for this may be a serious procedure, and it had better be avoided. On the other hand, in indefinite cases the investigation of the chemism is absolutely necessary, but all precautions must be ob- served. The proof of hyperchlorhvdria or of gastrosuccorrhea with a large amount of hydrochloric acid is then decisive, and indicates, par- ticularly the latter occurrence, that the seat of the ulcer is at the pylorus, DIAGNOSIS 191 and there is consequent stenosis. I have seen patients with undoubted ulcer of the stomach with extreme loss of strength, and, on the other hand, cases of gastric cancer with unimpaired strength, appetite, and the general habitus. Occasionally, as Leube also states, the diagnosis can be made solely by the efficacy or fruitlessness of a specific treatment for ulcer. Extreme difficulty in the differentiation may be caused by the above de- scribed tumor-like cicatrization, which draws the neighboring organs toward the base of an ulcer to which they are adherent, or which forms above a perforated ulcer. In the latter case the head of the pancreas, the left lobe of the liver, or, more rarely, the spleen, may be involved. In the gastrocolic ligament there is a lymph-gland, or a band of closely situ- ated glands, which under some circumstances enlarge and become sensitive to pressure; they may be palpated as small tumors the size of a hazelnut at the lower boundary of the stomach, and have repeatedly caused me the greatest perplexity in diagnosis. In all of these cases the persistent size of the tumor, the maintenance of strength, and the presence of hydrochloric acid, favor ulcer in opposition to cancer, just as a course lasting more than three years and the absence of a typical cancerous cachexia favor the first named affection. Since we know that hyperacidity exists in numerous cases of ulcer, it is obvious that those distinct tumors of the stomach, particularly those situated about the pylorus, which in spite of typical signs of malignant cachexia run their course with profuse excre- tion of hydrochloric acid, may be referred to the fact that cancer has developed upon the foundation of a gastric ulcer. I have repeatedly observed such cases. In several instances in which a tumor of the pylorus while under observation and within a year developed to the size of a walnut, the acidity amounted to 104 and 101. Gastroenterostomy was performed, and at this time the tumor was inspected and subsequently removed; it proved to be an unquestioned carcinoma. A test of the chemism, as advised by Gluczinsky, is valuable for the early recognition of beginning carcinomatous degeneration of an ulcer and may be carried out upon one and the same day, first upon an empty stomach, secondly, after a test breakfast, and, finally, after a midday meal. In a florid ulcer all tests give normal values; decrease or absence of one or more favors a beginning carcinoma. In 17 cases in my wards Dr. Sigel has put Gluczinsky's results to the test, and, although not in every case, in the main he confirmed them. Diagnosis of Perforation. The diagnosis of perforation of an ulcer is based upon the above described symptoms, and only those features will be discussed which may lead to error. Here we must consider perforation of a gastric carcinoma (a relatively rare occurrence), of the gall-bladder, that is, by a gall-stone, of the appendix, of an intestinal ulcer, and acute diffuse peritonitis caused by rupture of the spleen, of a pyosalpinx, or of an ovarian tumor. The greatest differentio-diagnostic perplexity may 14 192 GASTRIC ULCER AND GASTRIC HEMORRHAGE arise from the rupture of a gastric cancer, which, however, as has already been mentioned, is extraordinarily rare because the neoplasm is prone to attach itself by inflammatory adhesions to the surrounding organs. The other possibilities enumerated may be excluded by a careful examination and the history. But there are other diseases which, without producing per- foration and peritonitis, may simulate these conditions. Here are to be mentioned : Gall-stone and renal colics, torsion of pedicles, torsion of the ureters in -movable kidney, severe gastralgia, poisoning, embolism and thrombosis of the mesenteric arteries, and, finally, even pleurisy and pneumonia, the latter affection occasionally, i. e., in a few cases, being complicated by a similar symptom-complex. I can only call attention to these occurrences; the diagnosis will be in part described in the follow- ing pages. Unfortunately, we have no means of recognizing a threatening perfora- tion because there is nothing to indicate whether, in a given case, we are dealing with a superficial or deeply invading ulcer. Symptoms per- sisting for a long time may, perhaps, be utilized in the latter sense, but the uncertainty of such a conclusion is obvious, and the great majority of cases of ulcer run their course for years without perforation. The diagnosis may be very obscure when we are deciding between cholelithiasis, renal colic, and gastralgia occurring in the course of ulcer of the pylorus or ulcer of the duodenum; of course, not in typical cases of either disease. Recurring pain in the right hypochondrium independent of the ingestion of food, slight fever, jaundice, enlargement of the liver, pain over the liver, a palpable gall-bladder perhaps containing stones, drawing pains along the ureter, hematuria, the passage of gall-stones or renal stones are just as typical of gall-stone colic or renal colic as the total complex of the symptoms previously described is of ulcer. But in many cases the symptoms are so indefinite that confusion can scarcely be prevented. If in gall-stone colic jaundice is frequently absent or very feebly developed, there are, on the other hand, not seldom cases of gas- tralgia which run their course with mild jaundice, either because bile is forced into the blood-vessels from spasmodic contraction of the abdominal organs or because a rapid, transitory, sympathetic spasm of the hepatic duct occurs, and with this biliary stasis. The patients with gall-stone colic are apt to locate their pain in the median line, particularly women, in whom the topography of the liver has been changed from lacing. Fink even makes the very remarkable statement that among 403 cases of gall- stone colic which he observed in Carlsbad, in 380 =. 94.3 per cent., gastric spasm occurred alone without pain in the hepatic region ! If the pylorus is displaced somewhat to the right, or if the ulcer is situated in the hori- zontal axis of the duodenum, there can be no question of a local difference. Hence, it may for a long time, or perhaps always, be a mooted question whether cholelithiasis or gastralgia is present. But here hyperchlorhydria DIAGNOSIS 193 of the gastric juice, if present, gives us a valuable clue. Acidity over 80, i. e., 0.3 per cent. HC1, may be utilized in this way. A tuberculous ulcer is recognizable by its reaction to tuberculin, ac- cording to Petruschky's method. I should like to remark in this connec- tion that we must never be content in such cases with one test if this be negative, but several injections, in increasing doses, must be given. Re- peatedly I had no reaction with 1 and 2 mgm., but obtained a typical one after employing 3 and 5 mgm. Position of the Tumor. Only an unusually favorable combination of circumstances will enable us to recognize the position of an ulcer at the pylorus or in the duodenum, perhaps even in the greater curvature. On the other hand, by exclusion we may decide that the ulcer is situated elsewhere. An ulcer at the pylorus is characterized by sharp, localized pain a little to the right of the median line. Fleiner attaches great weight to the symptom of pyloric spasm. But the significant factor of pain cannot here be reckoned upon, and the assumption that ulcer situated in the cardia of the stomach is accompanied by sensations of pain immedi- ately after eating while those at the pylorus produce pain only later has, I find, neither been sufficiently proven clinically, nor is it justified by the actual conditions. An attempt has been made to locate the seat of the ulcer from the position which some patients assume to alleviate their pain. If the pain is less in the left lateral position, the ulcer is said to be situ- ated at the lesser curvature, or vice versa. This also is a very doubtful and uncertain symptom, inasmuch as it does not accord with the 'experi- ence of the majority of patients. According to Gerhardt : " Sensitiveness to pressure and tumor favor the seat of the ulcer upon 'the anterior wall, pain in the back and hemorrhage its seat upon the posterior wall. The seat of the pain and its increase in the latter position often permit the differentiation of ulcer of the fundus or of the pyloric region. When an ulcer at the fundus is adherent to the spleen it may by producing splenitis give rise to chills, as I (Gerhardt) have seen in three cases." That gastrectasis indicates the seat of an ulcer at the pylorus or in the duodenum and contraction at the cardia, requires no special emphasis. When we reflect how vague is the symptom of pressure sensitiveness, how rare is the appearance of tumor due to ulcer in proportion to the total number of cases, how very difficult is it in these cases to determine the constriction of the stomach intra vitam since we do not inflate the organ or introduce the stomach-tube, and, lastly, when we remember that often several distinct ulcers are situated in different areas, no great weight will be attached to this symptom. But, in my experience, the most reliable of the symptoms which have been mentioned is the pain, often spasmodic, in the region of the pylorus, therefore, in the right mammary line, localized below the border of the liver. As, however, the pylorus is occasionally very movable, and may 194 GASTRIC ULCER AND GASTRIC HEMORRHAGE frequently be found even at the left of the median line, it is clear that pain in the latter region cannot always be referred to the greater curva- ture or even to the f undus. v. Leube very correctly remarks : " We must beware of such diagnoses. They are at least uncertain, as well as all diagnoses based upon the subjective symptom, pain, even when some spe- cial condition is pointed out by this; for instance, when pain is developed only on displacing the gastric contents from a particular position, there- fore only appearing when the patient assumes the right lateral position." Xor must we forget the well known fact, to which Schiitz has recently again called attention, that there are inflammatory conditions in the trans- verse colon associated with pain which may readily but erroneously be referred to the stomach. It would materially aid us in the comprehension of this condition if we possessed a really good gastroscope, but, at present, this does not appear to be the case. It need hardly be stated that the same consideration which deters us from introducing a stomach-tube or a soft sound in ulcer is more strongly deterrent in the case of a rigid metal tube. It is true that a stenotic gastric ulcer at the pylorus with consecutive gastric dilatation, and, vice versa, the same condition at the cardia with resultant contraction of the stomach, are readily recognized, the latter, perhaps, requiring the aid of the esophagoscope ; but, even with this, we get little further knowledge, and to the cases mentioned by Gerhardt I may oppose another where the perforation of a broken-down carcinoma of the smaller curvature manifested itself by chills and intense pain, espe- cially upon the left side. We are in an extremely difficult position when several ulcers are simultaneously present, and this condition is not rare. Exact knowledge of the location is, therefore, for many and perhaps for most cases, very desirable, and the more important because accurate loca- tion of the seat of the ulcer is of the utmost significance in the treatment, and particularly for operative intervention when hemorrhage occurs. How difficult this determination is may be understood from the fact that Schloffer was unable to find it in 2 of 5 cases even at the operation. But even if we were so fortunate as almost to grasp the ulcer with our hands, i. e., to detect tumor at the pylorus, and although other factors, particularly the chemism of the stomach, the age of the patient, his general condition and strength, were of such a nature as to exclude car- cinoma, an absolute diagnosis could not be made. Hence the following con- ditions come into view, and these we must discuss for a few moments: I. Pylorospasm. II. Muscular hypertrophy, that is, cicatricial thickening of the pyloric region. III. Carcinomatous neoplasm. Of the first it must be remarked that although its most frequent cause is an ulcer at or in the immediate vicinity of the pylorus, cases have been DIAGNOSIS 195 undoubtedly observed in which pylorospasm occurs without any alteration in the mucous membrane that can be detected. Here the observations of surgeons are of great weight. Both Schloffer and Alberti have reported such cases. The case of the first author was that of a woman, aged 44, in whom the gastric contents showed no hydrochloric acid, but lactic acid. At the operation an oval, slightly diagonal, extraordinarily hard, circumscribed resistance of about 2 cm. in length and 1 cm. in breadth, which prolonged investigation showed to be nowise altered, was found at the greatly nar- rowed pylorus, and on its posterior wall. The area in question was re- sected, and, most astonishing to relate, absolutely no pathological changes were found. Histological examination merely showed a slight hypertrophy of the musculature in this area, and Schloffer assumes the case to be one of circumscribed spasm of the musculature of the pylorus in its pos- terior wall. The case of Alberti is interesting from the fact that at the laparotomy a pyloric tumor was found which was of uniform hardness, sharply de- marcated toward the duodenum, but toward the stomach and particularly at its posterior wall it showed merely a coarse and firm wedge-shaped swelling amounting to about 4 cm. in length. Alberti looked upon it as a neoplasm, and concluded to perform pylorectomy, the more so since no adhesions or metastases were apparent. When, however, the lesser and greater omentum were detached, all signs of tumor suddenly disappeared, and the stomach, that is, the pylorus, became soft and perfectly normal. Pyloroplasty after Heinecke-Mikulicz was performed, and the pylorus was found to be narrowed but no firm cieatrix could be detected. The attacks of intense pain were arrested, and the patient, in spite of the continuance of symptoms of stenosis of the pylorus for five years, showed very slight dilatation of the stomach. This case appears to leave no room for doubt. Here marked reaction for hydrochloric acid was always present. On the other hand, in the light of our experience in the Augusta Hospital, the case of Schloffer may be regarded as questionable. We have observed two such cases in which resection was apparently performed on account of a benign pyloric tumor, and the most minute histologic examination of the resected tissue not only by us but also by our pathologists showed no change characteristic of carcinoma. The first case was that of a woman, aged 47, who had been suffering for several months from a gastric affection, and complaining of vomiting and eructa- tion; examination showed a moderate gastric dilatation and a pyloric tumor causing stenosis. Free HC1 was repeatedly found to amount to 0.5-0.6 per cent., albumin digestion to about 75 per cent. Lactic acid and blood were never present. The gastric tumor was resected and gastro- enterostomy performed. In 20 sections from the resected tissue nothing 196 GASTRIC ULCER AND GASTRIC HEMORRHAGE characteristic of cancer could be found. For five years the woman re- mained in good condition, then ascites developed combined with abdominal symptoms which pointed to a tumor of the abdomen. An indistinct re- sistance could be palpated both by the vagina and by the* rectum. Operation performed in the summer of 1901 revealed extrauterine pregnancy and, simultaneously, a neoplasm of both ovaries which, at the histologic examination the patient died soon after the operation proved to be an adenocarcinoma. There can be no doubt that this was a metas- tasis from the stomach. The other case occurred in a man, aged 37, who, six weeks prior to Christmas of 1897, was suddenly attacked by diarrhea which continued until the time of his admission upon the 9th of March, 1898. Fourteen days previously he began to vomit brownish masses, but had never suf- fered from pain in the stomach; he felt quite strong, and had a good appetite. After inflation of the stomach a tumor the size of a small apple was found in the epigastric region upon the right below the border of the liver. The stomach was slightly enlarged; no glandular enlarge- ment. Acidity was 58 upon the empty stomach and lactic acid 25. In the test breakfast, acidity was 54, lactic acid 16 (0.058 per cent.). Pepsin digestion was barely 10 per cent. Laparotomy upon the 14th of May disclosed a tumor of the greater curvature extending to the pylorus, and in its middle a deep ulcer. About two-thirds of the stomach was resected, and on the remainder of the stomach gastroenterostomy antecol. anter. was performed. The patient was discharged cured upon the 7th of April. Although the diagnosis of carcinomatous ulcer was made from the macroscopic appearances, histologic examination did not reveal a charac- teristic picture. The man has just been readmitted to my ward with a large, undoubtedly malignant tumor of the greater curvature. We see, therefore, that in the differentiation of these so-called spastic tumors and muscular hypertrophies of the pylorus we must be very cau- tious. It is not surprising that, in spite of resection of an apparently healthy organ, metastases should develop. Years ago I stated that typical, cancerous nests might be found in the submucosa and muscularis far beyond the macroscopic, visible portions of a malignant tumor. Tumors due to muscular hypertrophy are generally differentiated from spasm by their consistence. The same cause which generates them always produces stenosis of the pylorus, whether they originate from the cicatrix of an ulcer causing stricture, or from reflex contraction, from the irrita- tion of a fresh ulcer by the ingesta, or, finally, from a malignant neoplasm. I must also mention that occasionally a gall-stone is incarcerated in the pylorus (Naunyn, Eisner) or tumors from hair or trichobezoar may be present. In how far dilatations of the stomach occur in connection with these conditions, and how far they may be attributed to it, depends upon the duration of the affection, upon the permeability of the stenosis, and DIAGNOSIS 197 upon the degree of the compensatory muscular hypertrophy of the stomach. Here, however, there are marked gradations in the condition. We meet with convincing proof of the fact that ulcer of the pylorus frequently merges into carcinoma of the pylorus and here, as in other areas, persistent mechanical irritation from the chyle which presses through the pylorus performs an active part. These are the cases in which hydrochloric acid secretion and the peptic function of the stomach are long retained, al- though they finally decrease from the norm. With these also belong some of the cases which I first mentioned, cases in which, on account of the chemism of the stomach, the diagnosis of a benign tumor of the pylorus was made, while operation or autopsy revealed that we were dealing with a more or less carcinomatously degenerated old ulcer. It always appears to me that the general condition of such patients suffers but little provided high-graded pyloric stenosis does not occur, and this is another factor which may lead to diagnostic errors. In conclusion we must consider the last of the three groups mentioned, namely, carcinomatous tumors situated at the pylorus or in other portions of the watt of the stomach. Here, of course, we are only dealing with those cases in which the age, the patient's strength, the chemism, the gastric contents, and the objective condition raise doubts as to whether we have before us a carcinoma, the old cicatrix of an ulcer, or an epi- gastric process. In my opinion, during the short or long course of the disease a cer- tain grouping of the symptoms may sometimes entirely preclude our making a diagnosis at the time, because neither the individual symptoms nor their totality are sufficiently clear to lead in any direction to a de- cision. This is particularly true of two symptoms to which we otherwise, quite justly, attach great significance: The pain and the emaciation. Here I entirely leave out of consideration those cases in which gas- tralgia occurs at the initial stage of pulmonary phthisis in young, chlorotic and anemic persons or where these attacks occur in the so-called preataxic stage of tabes dorsalis (locomotor ataxia), because these may be easily differentiated by a minute examination which, in women, should include also the genitalia. A number of years ago Aufrecht called attention to cases of severe gastralgia without anatomical findings which even showed a family rela- tionship. I have never seen cases of this kind, and must say that Aufrecht's brief report does not appear to me convincing : " At the autopsy nothing was found in the stomach, the biliary passages, or the duodenum to make clear the cause of the disease." In old gastric ulcers the typical pain beginning at a definite time after the ingestion of food is either absent, or it is so irregular that it does not differ from cardialgia due to other causes; therefore, it does not differ from the pain produced by perigastric adhesions and carcinoma, 198 GASTRIC ULCER AND GASTRIC HEMORRHAGE either typically, or by its seat, or by the frequency of its appearance. Here we must also consider the typical pains due to a hernia of the linea alba. In general these may be readily demonstrated, but it is necessary to bear them in mind, for, in my experience, they lie somewhat beyond the pale of the experience of most practitioners. By proving that the condition was hernia, and by a slight operation, I have succeeded in promptly curing many a case diagnosticated as gastric ulcer. If, however, there are no well developed attacks of pain, and we are dealing only with more or less decided discomfort, a sense of pressure, and fulness after eating, we know that these may exist for a long time and, even until death, be the only symptoms in patients with cancer. It is true that in ulcer emaciation is usually much less marked than in cancer, and that the color of the skin characteristic of malignant cachexia is usually absent. Where, however, an ulcer forms in debilitated, nervous, hysterical persons or, vice versa, in the robust who, from a fear of pain, limit for a long time the amount of their food, rapid and striking losses of weight occasionally occur and lead us to consider seriously the exist- ence of carcinoma. But the condition of the peripheral lymph-glands should give us relia- ble information on this point ! Long ago, in 1886, Dietrich proved, after a careful examination of normal persons, that is, those not suffering from malignant disease, the great frequency of slight glandular enlargement thus, for example, the inguinal glands in 92 per cent, and the axillary glands in 64.9 per cent, were swollen to the size of a bean. But decided tumefaction must be present for this to, be of any importance. Tarchetti lays special stress upon enlargement of the supraclavicular glands which he met with in 18.4 per cent, of cases of cancer. But in my experience statistics of glandu- lar enlargements are not very reliable. In 125 cases of positive ulcer of which I have notes regarding this, sixty times the inguinal glands were enlarged to the size of a bean, and twenty-four times the glands of the axillary cavity to the size of a pea. Nevertheless, I must admit that the condition of the lymph-glands, particularly the enlargement of the left- sided supraclavicular glands, is of some significance. Still greater weight must be attached to the state of the tongue, which in ulcer especially in recent ulcer is red, moist, glistening, while in cancer it has a white coating and is usually dry, in nervous disturbances it is deeply fissured, particularly upon the sides, so that the tongue resembles a freshly ploughed field, or, to use a more striking comparison, a glacier with its clefts. And this, fortunately, again brings us -to the symptom per tot ' discrimina rerum to which the ancients, without any knowledge of our modern methods, attached so high a diagnostic value ! Duodenal Ulcer. What is true of the seat of ulcer of the stomach is also true of the seat of ulcer of the duodenum: in at least 90 per cent. PROGNOSIS 199 of the cases it is impossible to decide positively whether we are dealing with ulcer of the duodenum or ulcer of the stomach. Leo adds an addi- tional symptom in the diagnosis of duodenal ulcer. Upon lavage there is a profuse subacid fluid. The gastric contents show large amounts of organic acid, and there is a constant green discoloration from the admix- ture of bile and pancreatic juice. As a rule there is no vomiting. Factors which favor ulcer of the pylorus are also operative for ulcer of the duo- denum, all the more so as the ulcer sometimes directly attacks the duode- num from the pylorus. A duodenal ulcer is likely when the pains only set in some time after the ingestion of food; their seat, as well as a passive sensitiveness to pressure, is decidedly to the right of the parasternal line, and profuse hemorrhagic dejecta and hematemesis may appear. Jaundice and peritonitis have been repeatedly observed. The fact that ulcer of the duodenum frequently occurs in old persons after extensive cutaneous burns may in a given case be of value in the diagnosis. A point of support, but no more than this, is the rare occurrence of duodenal ulcer, for, according to Willigk, to 225 cases of gastric ulcer there are only 6 ulcers of the duo- denum, according to Trier only 28 to 261. Moynihan has recently empha- sized the seriousness of this condition. In the last seventeen years he has operated upon 114 cases. In 107 of these the ulcer was near the pylorus. There were 91 recoveries. Gastralgia is said to be not so frequent as Budd believes, because the duodenum is exposed to less distention and less change of position than the stomach. Jaundice, which is very rare in ulcer of the duodenum, can be little utilized in the diagnosis from the circumstance that, in the main, intestinal hemorrhage is more frequent and hematemesis rarer, but gastric ulcer also leads to hemorrhage from the intestines, and ulcer of the duodenum may be accompanied by hematemesis. PROGNOSIS Until recently, and quite properly, a doubtful prognosis was given in gastric ulcer when it was differentiated by the signs which have been mentioned. Since we have become able to make an early diagnosis, and to separate it from the forms of dyspepsia, since the principles of treat- ment have been clearly established, and we are in a position to use them at the onset of the process, the prognosis in at least the early stage of ulcer has decidedly improved. If the patient is subjected to rational treatment at the proper time, i. e., if a rest cure is instituted, well founded hopes of recovery may be entertained, and even in classical ulcer recovery or decided improvement may be looked for. Unfortunately, during the first stages, which subjectively do not occasion great difficulty, very few patients are inclined, or are in a position, to submit to such treatment. If, however, we succeed in curing the ulcer by permanently changing the abnormal composition of the blood or the secretion of the gastric juice, the fear of relapse is also removed, which, otherwise, always threatens 200 GASTRIC ULCER AND GASTRIC HEMORRHAGE and only too frequently occurs. Invariably, however, and particularly in the healing of extensive ulcers, there is danger of a permanent damage to the health from the consequences of cicatricial tissue formation, and this cannot be lost sight of. In such cases the prognosis must be made with great caution. That it is not bad is, nevertheless, evident from the well known fact that cicatrices from gastric ulcers are found about twice as frequently as open ulcers. In hemorrhage, provided it is not immediately fatal, the prognosis is, as a rule, favorable, and it is better the younger the individuals in question. By suitable treatment we usually succeed in mastering the hemorrhage, and even extreme anemias are improved in a relatively short time. At the Surgical Congress in Berlin (1897), v. Leube gave the following statistics of his cases: Of 424 hospital patients 314, = 74 per cent., were cured after a treatment of four weeks, 93, = 32 per cent,, were improved, 10, = 2.4 per cent., died, 7, = 1.6 per cent., were unimproved. Therefore, in only 4 per cent, was careful treatment without result. This coincides with my reports of 233 hospital patients, in which I had 76 per cent, of recoveries. But it cannot be denied that in these statistics the factors, which have often been mentioned, of unlike circumstances and insufficiently long ob- servation play a part. The surgeon reaches other results than the physi- cian, and thus it comes to pass that v. Mikulicz gives a mortality of from 20 to 30 per cent,, while Leube has only 4.1 per cent. It is obvious that the brief period of observation in the hospital can only be regarded as corresponding to the "healing" of the ulcer; it does not strictly apply to the period after the patient's discharge from the hospital, and tells us nothing of the mortality. The latter depends upon accidental con- ditions, and can only be arrived at with some degree of certainty from the reports of many autopsies. But the " statistics of cures " are also open to doubt from the fact that groups denominated as ulcer include many cases in which true ulcer was not present, as is evident from the nature of these cases. For this reason I have refused to utilize my statis- tics in this way. J. Schulz has decidedly cleared the situation. He analyzed 291 cases, 184 from the Breslau Clinic, and 107 from the Eppen- dorf Hospital, all of which were recognized as ulcer by the appearance of hemorrhage. Of course under these circumstances a diagnostic error was not absolutely excluded, but, nevertheless, it was scarcely possible. Questions were sent to all of these patients from which deductions were to be made regarding the results of treatment. One hundred and fifty- seven answers were received, and the accurate investigation of these justi- fied the conclusion that internal treatment of ulcer of the stomach accord- ing to the method instituted by v. Ziemssen and Leube gives a perma- nently good result in 64 per cent. In 18 per cent, relapses occurred, but, nevertheless, most of these patients were finally cured. It might be as- sumed that under renewed proper treatment the others would decidedly TREATMENT 201 improve. In 18 per cent, the treatment was without result, and of these 7.6 per cent. died. If, therefore, we count those who were not benefited among the unsuccessful cases, 64 per cent, were cured, in 13 per cent, there was temporarily either no result or a relapse, and in 23 per cent, absolute failure. TREATMENT Whenever possible, gastric ulcer should be treated by the rest cure in- augurated by v. Ziemssen and v. Leube, in which all irritation of the stomach is to be prevented, just as a fractured bone is immobilized by a plaster dressing, naturally with the difference that in the latter case this rest is absolute while in the former it is only approximate. Eest in bed and nutrition by the rectum or by food which burdens the stomach as little as possible are the foundations of this treatment which, in England, was long practised by Wilson Fox and Balthazar Forster. As adjuvant, anodyne remedies, and at the same time calculated to lessen irritation, moist heat in the form of hot compresses and the drinking of hot Carlsbad water or a solution of Carlsbad salt which neutralizes acid,, are recom- mended, v. Leube administers the Carlsbad water lukewarm; the com- presses, however, should be as hot as they can be borne; according to his latest reports, he no longer uses nutritive enemata. To the latter, how- ever, I attach the greatest importance, while I have discarded the hot compresses, chiefly because they leave an ugly pigmentation upon the abdo- men. It is astonishing how well the majority of patients will bear exclu- sive rectal alimentation for three, four or more days, the nutritive property of which, according to all recent investigations (Eichhorst, Ewald, Huber, Kost and others), and in spite of several attempts to depreciate its practical value (Plantenga, v. Mering), admits of no question, particularly if small quantities of a 5 per cent, solution of cocain upon pellets of ice be given by the mouth. Whether nutritive enemata, as Zierko maintains, actually diminish the acidity of the gastric juice, has not yet been positively determined. Acting upon Kussmaul's advice, I have for some time administered large doses of bismuth in suspension (about 15 to 20 grams in 200 of water daily, divided into three doses, well shaken, and given before meals) which, according to the experimental reports of Matthes, forms a protec- tive coat over the exposed, ulcerated surface. This treatment, according to universal experience, gives excellent re- sults where the ulcers do not invade too deeply, or where the condition resembles that of a florid ulcer, while, in truth, other affections peri- gastric adhesions, neuroses, cholelithiasis, renal stones and the like are the causative agents. Bourget has lately declared that rectal alimentation is rather harmful than beneficial (why?) ; on the other hand, he admin- isters rice soups and milk and rice, and, therapeutically, washes the stomach OOLLEl OF OS TIE 01= 202 GASTRIC ULCER AND GASTRIC HEMORRHAGE with a 2 per cent, solution of iron chlorid, to which ^ per cent, of potassium chlorate is added; so far, I have had no occasion to test his method. Leube attaches weight to the fact that Carlsbad salt has a neutralizing, and, on account of the sodium chlorid it contains, also a stimulating effect; but the latter might rather be looked upon as deleterious, since we know that in many cases the acidity is greatly increased, and there- fore a depressant rather than a stimulant is indicated. As to the neutral- ization, or decrease, of the acidity, I do not attach much importance to this if it is observed but a single time in an empty stomach, provided there is not always a secretion in the stomach when it should be empty. On the contrary, the diminution of the hypersecretion and the laxative effect of the neutral salts, as well as the soothing influence of large quan- tities of warm water, appear to me to be of the utmost importance. If the water of simple alkaline springs has been found to be less effective than that of the saline alkaline springs, it is only because we have for- gotten to produce the desired laxative effect by other means. Where there is no laxative effect from Carlsbad water, as is frequently the case, it must be brought about by the addition of Glauber salt or, still better, by vegetable laxatives, preferably rhubarb or senna. It is unnecessary to adhere rigidly to a formula, the principle alone is impor- tant. Whether the pains are relieved by warm fomentations or, in case these are ineffectual, by small doses or subcutaneous injections of mor-. phin, whether the patient is given a solution of Sprudel salt or the natural spring water from Carlsbad, or, for example, Ems, Vichy, or the Neue- nahr Spring, and the absent neutral salt be supplied by the addition of other aperients, is immaterial. Of the Carlsbad spring water 300 to 500 c.c. should be given. But which spring? This is unessential since there are no important differences in the chemical combination, and the differ- ences in temperature of the individual Carlsbad springs are of little con- sequence because these waters can only be taken as hot as the patient can bear them ; therefore are all taken quite hot. Fifteen grams (about one tablespoonful) of the salts should be taken daily, small quantities dis- solved in half a liter of water at intervals, with corresponding pauses between. For the first three days absolutely no food is to be adminis- tered by mouth, but a nutritive enema is given three times daily; subse- quently, besides the enemata, milk, or milk in flour soup, in tablespoonful doses, or bland pigeon or chicken broth. The milk, on account of its fine floccular coagulation, has some pegnin added. If this diet is well borne, it is added to in a manner soon to be described; otherwise, absolute rectal nutrition is again instituted. If no pain follows the careful admin- istration of milk, we may permit somewhat larger quantities (up to a flat plateful, i.e., about 180 c.c.), leguminous flour soup, then legumes, later pappy food made of chestnuts, sago, tapioca, Kufeke's flour, hygiama and others, and later small quantities of meat. Among nutritive sub- TREATMENT 203 stances cow's milk takes the first place; it was first advised for this pur- pose by Cruveilhier. It is suitable because it contains all of the nutritive elements in solution, that is, finely divided, is free from irritating sub- stances, because the acid is neutralized, and because the coagula which forms from the action of the gastric juice remains soft. The patient, however, must drink it very slowly and lukewarm. To prevent the floccu- lent coagulation of the milk, and the irritation of the ulcerative surfaces due to this, I now add pegnin (lab-ferment), which produces a very fine flocculent coagulation, v. Mering advises lab cheese for patients who cannot take milk. Besides pigeon or veal soups, the yolk of an egg, and beaten-up egg albumin, pulverized meat or leguminous soups may, per- haps, be given. We must limit ourselves to these foods until the severe symptoms have disappeared. In the third week a food richer than this, both quantitatively and qualitatively, is permissible, and we should then carefully try food of somewhat greater consistence, such as scraped raw ham, raw or very soft boiled eggs, scraped venison or the breast of fowl, rolls or zwieback softened in cocoa, but milk is always preferable, and we should always be ready to return to a simpler diet as soon as symptoms, or even pains, appear. Even small portions of coarse bread, legumes, fruit, cabbage, salad, pickles, mushrooms, high spices, fatty foods or those prepared with vine- gar, liver, fatty acids, confectionery, alcohol and coffee are to be strictly prohibited. In regard to the diet in hyperchlorhydria., the article by Strauss, " The Diagnostic and Therapeutic Significance of Secretory Disturbances of the Stomach" (see this volume), which embodies the latest views on this subject, should be consulted. It is absolutely necessary that the patient take but little food at a time but somewhat more frequent meals, that he eat slowly, avoiding all hot food; after recovery he should never overload the stomach, but must re- frain from foods difficult of digestion or highly spiced, so as to prevent any lesion of the cicatrized area. Lenhartz proposes quite a different dietetic treatment. Starting from the fact that hyperchlorhydria, chlorosis and anemia frequently develop in the course of ulcer, he permits his patients from the start to take concentrated foods rich in albumin. The patients, even when hemorrhage has occurred immediately before treatment, receive doses from a spoonful up to 300 c.c. of iced milk in which as many as 3 eggs have been beaten; from the third day sugar is allowed, and from the sixth day scraped meat, then milk, rice, and fine bread; from the tenth day raw ham and butter. Rest in bed, applications of ice, one to two grams of bismuth daily and, perhaps, iron with arsenic are ordered. In sixty cases treated in this way the results are said to have been very good; one case proved fatal, seven cases of relapsing hematemesis remained in the hospital. 204 GASTRIC ULCER AND GASTRIC HEMORRHAGE The pains ceased almost immediately after the ingestion of food rich in albumin, and the patients recovered more rapidly than those on the preceding diet. Of 25 patients who were subsequently questioned, 18 (72 per cent.) were entirely free from symptoms. The editor of the Fortschritte der Medicin quite properly remarks of these reports that the results are no better than with the old, reliable diet, and that there are very few who would risk the employment of such food in the stomach of a patient with ulcer. The reason given by Lenhartz- Wagner in favor of this coarse diet, that the patients recover more quickly, does not appear to me to be justified. Patients with ulcer recover very rapidly when the pains cease, and this takes place the more quickly when the gastric mucous membrane is allowed absolute rest instead of being stimulated to greater activity. It is true that patients on this diet are at first debilitated and lose weight, but even here we must individualize. To attempt to regulate the diet in these cases according to calories is a form of play under a scientific cloak which to-day is much in vogue. As soon as the patients are able to eat at all they are prone to eat so much, even without calory force, that they soon recover from the former undernutrition. Convalescence is rapid, gastralgia ceases, and the time arrives when we must consider the second indication, the strengthening of the constitution. For this purpose iron preparations,, either alone or in combination with arsenic, are serviceable, the former in cases of pure chlorosis or anemia, the latter when we are combating a weakened nervous system, and it is desirable indirectly to influence this by the direct stimulation of metab- olism. The old opposition to the employment of iron in ulcer of the stomach was founded on the experience that iron is frequently badly borne while the florid process is present; this, however, does not hold good when improvement sets in. Which iron preparation is to be employed depends largely upon personal preference; each day brings forth a new one, and in one case this, in another that, is the better tolerated. Of late, I have frequently employed triferrin which, without exception, was well borne. I formerly used arsenic in the form of Fowler's solution with tinctura ferri chloridi. After Liebreich's investigations arsenious acid appeared to be more serviceable and I now employ this in pill form, 1.5-2 mgm. of arsenious acid, 2 cgm. of ferri sesquichlorat. Considerably smaller but decidedly active doses of iron and arsenic, as has been proven by investigations in metabolism conducted by Ewald and Dronke, are given in the waters of Levico and Eoncegno and the Guber Spring, which are excellently borne. The remedy should be given in increasing doses and after meals. This regime must be continued for months, and then the administration of arsenic must be interrupted for three to five days about every three weeks. The diet may gradually become more liberal but, nevertheless, must be strictly regulated for months, and patients who show TREATMENT 205 a tendency to exceed their allowance must be given a written diet list indicating the amount of food permitted. It is sometimes impossible to carry out the rest cure mentioned above because there are many patients who are unwilling, or not in a position, to undertake it, and in many cases it is necessary to fulfil a stringent indicatio symptomatica. Under these circumstances treatment with large doses of bismuth is recommended. Kussmaul (Fleiner) advised that this in suspension be introduced in large doses into the stomach previously washed out, and that the patient then, according to the suspected seat of the ulcer, assume for some minutes such a position as will enable the drug to sink to the lowest area ; therefore, for example, in ulcer of the pylorus the right lateral position. Since, as a rule, I avoid lavage in ulcer, and because I know that the stomach is usually empty early in the morning, and also that by a previous drinking of water the gastric juice present may be diluted and more rapidly propelled into the intestine, and since, moreover, it is scarcely possible so to cleanse the gastric mucous membrane as to remove particles which may possibly be adherent to the ulcerated surface, and this, at all events, would necessitate the use of many liters of water, therefore I omit the washing and permit the patient to drink the bismuth suspension upon an empty stomach. The beneficial results I have obtained prove the reliability of this modified process. Indeed, the patient's tolerance of the drug and the ensuing freedom from pain are quite remarkable, although not so invariable nor so prompt as would appear from Fleiner's report. This is quite natural; the conditions are occasionally much more compli- cated than we assume and the method presupposes to be the case. The dose is large, apparently unlimited, and may be given for an indefinitely long period. In one of my cases the patient received over 800 grams in the course of a few weeks without the slightest inconvenience, not even constipation resulting. In this case, however, considering the size of the dose, the result was not very satisfactory. The same may probably be inferred from the large quantities employed by Fleiner (up to 1,000 grams). In place of bismuth, Pariser advises equal parts of the cheaper white chalk and talcum, one to one and a half teaspoonfuls in water in the morning upon an empty stomach, and in the evening three hours after the full evening meal. Under this treatment the feces remain light in color, and small hemorrhages are much more readily recognizable than in the dark bismuth feces. In place of bismuth subnitrate, bismuth subcarbonate (Boas) and bismutose have been advised. If all proceeds as we anticipate, and a protective covering of bismuth forms over the ulcer, this has not only a symptomatic but a curative effect. Under this protection the ulcer has time to heal, and, as Matthes has shown, the formation of granulation tissue at the base of the ulcer and the proliferation of glandular and other epithelia take place. 206 GASTRIC ULCER AND GASTRIC HEMORRHAGE Under thorough treatment which is long enough continued, in my ex- perience for at least four weeks, recent ulcers promptly heal. In some cases a single treatment is not sufficient, but a repetition is necessary. The result of this treatment, however, is generally so uncertain that with an unsuccessful issue we may at once assume either that an incorrect diagnosis has been made (particularly the pure neuroses lead to errors) or that we have old, deeply invading ulcers with broken down, excavated borders, that malignant degeneration has begun or induration has devel- oped. In such cases other curative measures are indicated, gastric lavage, tonics, and stomachics, small doses of mild narcotics, aperients, and the like. The indications for the employment of these remedies must be obtained by testing the functional activity of the stomach. Of additional remedies silver nitrate has also been advised, best in solution, and in decided doses (0.2 silver nitrate to 200.0 of water, a table- spoonful every two hours). With this remedy I have sometimes seen decided amelioration of the symptoms, and even a complete cure; in other instances, after a little time the remedy had to be stopped because in- creased disturbance of the stomach, nausea, anorexia, coated tongue, and derangement of the intestinal activity, diarrhea or constipation, appeared. In one of my cases, every time a spoonful of the silver solution was taken watery dejecta accompanied by severe abdominal pain followed. In my opinion the dietetic principles enunciated above are also im- portant in the treatment of ambulatory cases, and the diet should, at least, be followed as far as possible. As the patients digest meat better than starches and vegetables, they instinctively eat less of the latter, and event- ually, therefore, suffer from a monotonous meat nutrition, i. e., they ema- ciate, and become nervous and irritable. This must be counteracted as much as possible, and larger quantities of fat in the nourishment are not contraindicated because, as I showed some years ago, fat has the effect of decreasing acidity. I endeavor to modify the hyperacid gastric juice by repeated small doses of alkali combined with rhubarb and cane sugar or milk sugar. Rhubarb has a mild action upon the intestines, the sugar has a decided anodyne effect, and for this purpose has been repeatedly advised. I use a powder of about the following composition: 3^ Magnes. ust., "j Natr. carbon., I aa 5.0 Kalii carbonic., j Pulv. rad. Rhei 10.0 Sacch. lactis 25.0 M. D. S. : Every hour enough to cover the tip of a knife. This is to be taken dry; I have seen good results from its use. Patients who know by experience the beneficial effects of alkalies, particularly of TREATMENT 207 soda, are usually afraid of taking too much. In this respect their minds may be easy. I have never yet observed a deleterious effect from the too long-continued use of an alkali, particularly of sodium bicarbonate. For the catarrh which accompanies ulcer, Ord advises potassium iodid with the addition of sodium bicarbonate in about the following formula:. ^ Kalii iodat 2.0 Natrii bicarbonic 5.0 Acid, hydrocyan. dil. (m. 2 per cent, acid) gutt. tres Inf. rad. Gentian 3.0 : 150.0 M. D. S. : A tablespoonful three times a day. It is well to remember the advice of Pariser that women who have suffered from ulcer, even after treatment is discontinued, should be kept in bed during the next two or three menstrual periods and on almost the same diet as while suffering from ulcer. For the severe gastralgia, morphin internally or subcutaneously ranks first. Chloroform solutions (1-120, a tablespoonful every two hours) or chloroform in drops (5 to 6 in a teaspoonful of water or on a pellet of ice) occasionally produce excellent effect, not only upon the momentary pain but upon the course of the process in general. For a long time I have been in the habit of administering bismuth in suspension with a one per cent, addition of chloroform, or, instead of using distilled water, I employ chloroform water. Tincture of iodin, 5 drops, three times daily in water, occasionally acts as an anodyne. Of other sedatives I have occasionally employed lupulin, extract of cannabis indica, extract of hyos- cyamus, and extract of belladonna, but have always been compelled to return to morphin or codein. Cannabis indica, in particular, which is so greatly praised and was advised by G. See, has in my hands repeatedly failed to show any anodyne or quieting effect, but, on the contrary, has produced an unpleasant irritation. Formerly leeches were applied at the seat of the affection, and also blistering plaster ; it was painted with strong solutions of iodin, and even the actual cautery was used. We are content to-day with the ice bag, or the application of ice-cold or warm compresses, or Leiter's coil which, where the circumstances permit, is the most cleanly and convenient mode of employing cold. Treatment with Oil. Treatment with oil (linseed oil or olive oil) has been praised by various authors. Cohnheim, in 1889 and later, was the first to report surprisingly good results. The oil is to be given in grad- ually increasing doses from a tablespoonful to a wineglassful or may be poured in through a stomach-tube. Ageron advises the admixture of 10 grams of dermatol with 200 of the finest linseed oil or poppy seed oil. Walko adds bismutose or bismuth. The oil is best taken while the patient is in the recumbent posture, and Ageron has the patient assume the dorsal 15 208 GASTRIC ULCER AND GASTRIC HEMORRHAGE decubitus, raising the pelvis after taking the remedy to relieve the greater curvature. Aside from the fact that the stomach-tube should not be intro- duced in cases of ulcer without very clear indications which I think do not include the pouring in of oil I have previously cited a case in which the oil caused such great nausea and retching that it was the immediate cause of a severe gastric hemorrhage. Cohnheim, however, in about 30 cases, even with irreparable organic changes at the pylorus as well as in functional disturbances, has seen no unpleasant secondary effects but usu- ally a very favorable influence upon the pain, the spasm, the general nutritive condition and the degree of acidity of the stomach. Even cases in which operative interference had been advised by others were cured by this treatment. According to their nature, cases of the first category can only be symptomatically influenced, while permanent results have actually been attained in spastic stenosis of the pylorus, in ulcer, in fis- sures (?), in erosions of the pylorus, in pyrosis hydrochlorica with acid gastritis, and similar conditions when a pure neurosis formed the founda- tion of the difficulties, and provided no complicating perigastric processes existed. Instead of oil, an qmulsion of almond milk (about a tablespoonful of sweet almonds ground up in about 200 of water) also has a quieting, but not a nutritive, effect. The oil has the following merits: It quiets spasm, it lessens friction, it decreases the acid secretion, and it assists in the nutrition. Cohnheim, in his last publication (1904), remarks that it is strange that his reports have been confirmed only by Walko. This may be for two reasons. Either the process has been generally satisfactory, and only by accident others have failed to praise it, or the results lauded by Cohn- heim have not been attained by others, and judgment has been suspended. The latter describes my own position. Ever since Cohnheim's first pub- lication I have repeatedly employed the oil treatment in my private prac- tice, in the Hospital, and in the Clinic, and I have observed some beneficial, and also some very ill, effects. The oil was so repugnant to many of the patients that it was impossible for them to take it, and in others it subse- quently caused complete loss of appetite, eructations and vomiting, no matter whether given by the mouth or introduced through the stomach- tube. Fischl in a study of 19 cases arrived at the same conclusion. As the poor results were observed chiefly during the first trial, I must ac- knowledge that no extensive test was made by me, so that a definite state- ment regarding the method is at this time impossible. Cohnheim's last publication may induce me methodically to test the oil treatment anew. But at present, on the basis of my previous experience, I must maintain that in this treatment we possess no panacea for the symptoms in question, Xeroform, one of the newer remedies (0.5 gram four times daily) has been much praised. Jaworski advises, under the name of aq. alcalina effervescens, a solution of sodium bicarbonate (8 or 5), sodium salicylate TREATMENT 209 (2 or 2), and sodium biborate (2 or 1) in a liter of water, one-third to one-half of a tumblerful several times daily. For the vomiting nothing is better than a carefully regulated diet. Large quantities of hot water may be taken several times daily, also pellets of ice with chloroform. Tincture of iodin (15 drops in 150 of water) has been advised by some authors. Special care is necessary if hematemesis appear; when very profuse this is self-evident, but it is also enjoined when smaller hemorrhages take place. Under all circumstances, the first requirements are absolute bodily and mental rest and the avoid- ance of all internal and external irritation of the stomach. Even in smaller hemorrhages, if circumstances permit, the patient should be re- stricted to this regime for several days, and the fullest precautions should be taken because these small hemorrhages are very frequently only the precursors of more profuse ones. Small pellets of ice, ice-cold tea, or ice-cold solutions of peptone in spoonful doses may be given. I do not give milk in such cases unless I know that the patient takes it well, but for the first day order either a solution of grape sugar to which some meat peptone bouillon is added and given ice-cold, or I administer cold, gelat- inous soups of barley or oatmeal gruel; where the circumstances permit, nutritive eneinata are cautiously given. The fluid extract of ergot, 2.5 to 5 of water and glycerin in equal parts, is subcutaneously injected in the gastric region, one to two syringefuls several times daily, but it must be remarked that ergotin in some persons gives rise to very unpleasant symp- toms of constriction and vertigo. I have been unable to convince myself of the reliability of the fluid extracts of hydrastis canadensis and hama- melis mrginica, which have lately been much used. When there is great irritability of the stomach, the injections of ergot should be combined with injections of morphin. This will usually arrest hemorrhage, provided large vessels are not implicated. Formerly lead acetate, iron chlorid, and oil of turpentine were employed internally because of their presumable styp- tic influence, but these are no longer used because we possess a more rational and active remedy in ergot. In some instances in which hemorrhages recurred for several days and the above measures were futile, the bleeding ceased upon lavage of the stomach with ice water. After preceding cocain- ization and the injection of a small quantity of morphin, the stomach-tube was carefully introduced, and the stomach wall repeatedly sprinkled with ice water, large amounts of hemorrhagic gastric contents being first washed out, whereupen the hemorrhage immediately ceased. Before proceeding to operate in such cases, this maneuver should always be first tried. It is occasionally astonishing to see what large quantities of hemorrhagic fluid are evacuated from the stomach. As some blood usually passes into the intestine and is there decomposed, and perhaps may set up irritative phenomena, it is advisable, if there is no spontaneous passage, to employ mild evacuants, preferably rhubarb with sulphur, or enemata; if symptoms 210 GASTRIC ULCER AND GASTRIC HEMORRHAGE of collapse appear, injections of camphorated oil (1:6), enemata of wine, or wine with egg or peptone, and hot applications to the extremities. With threatening hemorrhage, a very small pulse, anemic murmurs over the heart, or cerebral anemia, normal saline infusions are indicated. Sub- cutaneous infusions are best given by employing a rather large Pravaz cannula. If the salt solution (7.5:1,000) warmed to the temperature of the body is injected simultaneously through two needles, and the fluid introduced is disseminated by gentle friction, one liter of water may be introduced in a very short time. We prefer the subclavicular region as the point in which the needle should be introduced. In favorable cases the blood is rapidly regenerated. In a patient, aged 25, who had received an infusion, the blood upon the next day showed 2,100,000 erythrocytes, two weeks later 3,560,000, with a slight increase of the leukocytes. Adrenalin or suprarenal extract has also been advised for gastric hem- orrhage. Fenwick employs 1.3 grams of the dry glandular substance boiled in 230 of water. Internally or subcutaneously it is more rational to em- ploy adrenalin hydrochlorid in solutions of 1 : 1,000, 20 to 30 drops in- ternally three to four times daily, subcutaneously 0.5-1 c.c. several times daily. There are quite a number of reports (Roussel, Renon and Louste, Mills, Kirch, Mamlock and others) in praise of its action, and authors are at least unanimous on the point that no unpleasant sequelae (glyco- suria, marked increase of blood pressure) appear even after its use for weeks. Up to the present, I have employed the remedy internally in two cases, and it failed entirely. I must also say the same of gelatin, of which I gave a 10 per cent, solution up to 100 c.c. by mouth twice daily (it may also be used by enemata). G. Klemperer, of Berlin, advises the employment of escalin (an aluminum-glycerin paste), 10 grams to be given daily for four days for the hemorrhage of gastric ulcer. This author, as well as others, reports excellent results from this method of treatment. Perforative peritonitis necessitates opium in large doses in the form of a suppository or as an enema, and the use of cold in the form of ice-cold compresses about the abdomen. If we suspect that the stomach is full, we must first try to empty it by the tube after either giving the patient a large dose of morphin or by applying cocain locally. But here it is necessary, under all circumstances, to keep the patient from retching, which may perhaps even enlarge the perforative opening. By this treat- ment it has sometimes been possible to limit the peritonitis locally, and to bring about adhesions. Operative measures have lately been advised for such cases, and several successful laparotomies have been reported (see below). Surgical Measures. For the florid ulcer, as well as for those with recent cicatrices, surgical aid has been invoked. Among the first to TREATMENT 211 favor this were Eossoni in Rome, Nissen in St. Petersburg, and v. Miku- licz in Breslau. At the Surgical Congress (1897) the last author enu- merated the indications as follows: " 1. When the life of the patient is directly or indirectly threatened by hemorrhage, perforation, inanition. 2. When continuous treatment produces no, or but a temporary, relief, and the sufferings of the patient make his life miserable." These indications may be somewhat more accurately denned, and opera- tive measures resorted to under the following circumstances: 1. In stenoses of the pylorus and hour-glass stomach due to cicatricial contraction, or when continuous internal treatment is powerless to remove the symptoms. This presupposes the consideration that all internal reme- dies have been thoroughly and exhaustively employed. At the Interna- tional Congress at Moscow in 1899 I gave the preference to this method of treatment in the but slightly developed field of gastric surgery rather than to operations for cancer, and ascribed to it the most satisfactory and the most lasting results. 2. In perigastric adhesions of the stomach to the surrounding organs. Here those adhesions of the greater curvature and at the pylorus are espe- cially to be considered which by volvulus and torsion of the organs and the neighboring structures produce unbearable pain, all anodynes being ineffectual, while an operation at once removes the difficulties which may have existed for years. It is very surprising to see how delicate these adhe- sions sometimes are. In a case of ours recently operated upon the thin layers of the greater curvature led to the transverse colon, and could be almost completely detached without hemorrhage. Notwithstanding this, they must have been the cause of pains for months, since the patient had no symptoms after the operation. 3. In gastric hemorrhage. While the previously mentioned indications are clear and beyond question, provided the diagnosis is positive, in hemate- mesis it is extremely difficult to say whether and when operative measures are indicated. For even very threatening and very massive hemorrhages are apparently promptly arrested by proper internal treatment. Throm- bosis appears with decreasing cardiac power, and it is astonishing to see how rapidly these exsanguine patients recuperate, v. Leube found uncon- trollable hemorrhage to be the cause of death in 1 per cent, of his case^. Personally I have never seen 9, patient succumb immediately to hemor- rhage. When Brinton claims 5 per cent, of fatal cases in ulcer due to hemorrhage, only the subsequent consequences, but not immediate death from hemorrhage, can be meant. This makes the decision as to operation difficult, as the results of surgery are by no means brilliant. Often it is impossible to find the bleeding vessel at the operation, and there are cases in which this cannot be discovered even at the autopsy. Statistics are always -very unreliable, for, according to the nature of the case, the successful operations, but not all of the unsuccessful ones, are 212 GASTRIC ULCER AND GASTRIC HEMORRHAGE published. Kaupe, the most recent author, collected 16 cases up to 1902 in which operation was performed because of acute life-threatening hemor- rhage, and 10 of these were discharged as cured; this gives a mortality of only 37 per cent., which figure decidedly differs from the actual facts. The prospects would, perhaps, be more favorable if it could be proven, and to this surgeons have recently called attention, that gastroenterostomy arrests the hemorrhage, that is, prevents its recurrence, without reaching the actual source of the bleeding. Of course those cases only can be considered in which operation was performed during the hemorrhage, for, under other circumstances, we can never be sure that the hemorrhage did not cease spontaneously. Petersen and Machol actually state : " We have reached the positive conclusion that gastroenterostomy with Murphy's button might save many a patient with severe gastric hemorrhage who would be lost under conservative treatment as well as by any other method of operation." The decision whether Murphy's button is actually a con- ditio sine qua non for the successful result of the operation I must leave to the surgeons. But, as this technic has been mentioned in the words quoted, I cannot refrain from raising the question (although from prin- ciple I do not interfere in the technic of surgical treatment, and do not usually permit myself an opinion) whether, for example, in the case in question, gastroenterostomy antecolica or gastroenterostomy retrocolica is indicated. During the last few years, i. e., while Murphy's button was still made use of by our German surgeons, I witnessed many operations with and without it, and I am convinced that its advantage of a more simple, and therefore more rapid, technic does not compensate for its well known dis- advantages. We are never sure that the button will not fail back into the stomach, and in pyloric stenosis its fate is indefinite; we do not know whether the narrow opening will functionate sufficiently, whether the but- ton has actually passed or has remained in the intestine (its passage may have been overlooked by the nurses), and, provided everything goes well until then, it may even happen that the button is passed some weeks later accompanied by very alarming symptoms which cause the greatest anxiety to the patients and also to the physician not sufficiently familiar with those conditions (for example, after the patient has left the hospital). All of this is obviated in a simple suture anastomosis which, in skilful hands, consumes but little more time than the use of the Murphy button. 4. A further indication for operative relief, and particularly for gas- troenterostomy, is given by persistent hyperacidity, especially if combined with dilatation of the stomach and weakness of the expelling musculature; of course, only in those cases in which internal remedies have proven ineffectual after a thorough trial. Tin's occurs in connection with the sequels of gccstroanastomosis which may influence the function of the stomach in various ways. We might TREATMENT 213 suppose, a priori, that when anastomosis is produced in the deepest area of the stomach a perfectly regular propulsion of the food would result. Some authors, for example, Rosenheim, go so far as to assume the former tion of a new sphincter. The latter, however, as Petersen correctly re- marks, must first be anatomically proven, and this has never yet been done. The possibility of closure of the anastomosis, which has been ob- served by Rosenheim, Carle and Fantino, or, more correctly, the fact that either water or air is retained in the stomach, merely proves that occa- sionally a valve-like closure of the opening occurs, not, however, that a sphincter is formed. On the other hand, the consensus of opinion is, and I have often seen convincing proof of this, that the propulsion of the gastric contents after operation is more rapid than before. Certainly if this were not so the result of the operation would be most unfortunate! Whether this is due to an increase of motility or to a freer outflow can hardly be decided. The absence of engorgement of the duodenum has been regarded as indicating an increased motility, for, according to Hirsch and v. Mering, normally, when the duodenum is full, it exerts an inhib- itive reflex upon gastric movement. In this theory the fact has been over- looked that in by far the majority of cases in which gastroenterostomy is performed, stenosis of the pylorus occurs as well as a decrease or even a suspension of the propulsion of the ingesta from the stomach into the duodenum. Whether it is advisable in an open pylorus, as Kelling pro- poses, to close the passage from the stomach into the duodenum by the artificial production of stenosis, and thus prevent the conditions which have just been pointed out, can only be learned from surgical experience, reports of which are still lacking. There is no doubt that, in many cases, improvement in the chemism of the stomach has been brought about. The acidity value, more accu- rately the value for the excretion of hydrochloric acid, decreases, perhaps less in consequence of decreased secretion than because the bile which regurgitates into the stomach, possibly also the pancreatic juice, neutralizes the acid gastric contents. But that such a decrease of acidity does not take place in all cases may be adduced from my own experiences, which, un- fortunately, are not yet published, as well as from the reports of numerous other authors, Dunin, Oderfeld, Kausch, Rosenheim, Rencki, Petersen and others. ISTevertheless, the decrease of acidity is so frequent that the above indication for gastroenterostomy in hyperacidity must be mentioned. The regurgitation of bile and pancreatic juice into the stomach which, under the present method of performing enterostomy between the loops leading to and away, is now usually prevented gives rise to but slight, if any, diffi- culty, and this is only perceptible by a bilious taste. Experiments which Joslin undertook in the year 1897 at my suggestion revealed decreased fat digestion, but this, as Nikolaysen later found, is only immediately after the operation, and then is replaced by normal conditions. The ex- 214 GASTRIC ULCER AND GASTRIC HEMORRHAGE periments at that time, however, were made upon patients who had not been operated upon; what the results would be after this operation is still to be determined. 5. In case of perforation, operation whenever possible should be per- formed in the first twenty-four hours; the later, the worse the chances. Tn 1895 Pariser could report only 43 cases. In the year 1896 Weir and Foote compiled a table of the cases of perforating gastric ulcer which had been operated upon, and this showed 78 cases with 23 recoveries, =. 29 per cent. In 43 cases the perforative opening was situated upon the anterior wall of the stomach, 11 times upon the posterior wall, and 6 times on the lesser curvature. Accordingly, in the majority of cases this opening may be found and sutured. In 92 per cent. of the cases the history pointed to the diagnosis of gastric ulcer. The importance of early operation is very evident, for in the cases that had existed less than twelve hours the mortality was 39 per cent., in those of twelve to twenty-four hours 76 per cent., and in those over twenty-four hours 87 per cent. The number of such cases rapidly increased. In 1900, Mayo Robson published statistics compiled from reports of English and American hos- pitals, comprising 429 cases with a mortality of 55 per cent.; Brunner, however, declares that some cases were counted twice. In the year 1903, Brunner compiled the statistics of 466 cases upon whom operation for gastric perforation had been performed, which gave a mortality of 50 to 64 per cent. ; here also the advantage of early operation was clearly demon- strated, for, among the cases in which operation was performed in the first twelve hours, 75 per cent, recovered ! It is well known that the chances of recovery for the patient are much better if the stomach at the time of perforation is empty. Unfortunately, under some circumstances, we cannot determine whether in the case in question we are dealing with a perforative peritonitis due to ulcer of the stomach or not. I have seen a case of this kind terminate in recovery, yet during its course and even later no positive diagnosis was possible. Brunner collected reports of 17 cases recovering without operation, as against 466 who were operated upon in the same period of time. This number, 17, has been increased by a recent English report of a few cases (British Med. Journal, Feb. 20, 1904, H. Whiteford), which, however, is not quite trustworthy. 6. By some authors the pure, uncomplicated ulcer has also been desig- nated as suitable for surgical treatment. I do not agree with this. An uncomplicated ulcer heals readily under internal treatment; if healing does not thus take place the ulcer is not uncomplicated, but is combined with changes which resist the regenerative process. Under such circum- stances, the indication for operation has been assumed from the fact that TREATMENT 215 an ulcer may occasionally undergo malignant degeneration. This is anal- ogous to the proposition to operate upon every appendix in which there are signs of inflammation, because subsequently perforation might result. But in the one instance, as in the other, this is but a remote possibility, and in the case of ulcer the danger is very slight, for the number of cases cured decidedly preponderates over those of uncured ulcer of the stomach. As shown above, this proportion is about 2 : 1, but in reality only a small fractional part of unhealed cases undergo malignant degeneration. Finally, as a general indication for operative interference, immaterial which of the conditions enumerated comes into question, it must be borne in mind that operation only removes the existing pathologic focus, not the predisposition to future relapses. Therefore, the appearance of a new ulcer, another hemorrhage, fresh adhesions, is by no means impossible after a successful operation, and Braschr has described a case in which fatal hemorrhage occurred immediately after gastroenterostomy had been performed. Consequently those surgeons are right who proceed to operate only when all the remedies of internal treatment have been exhausted, that is, when the condition of the patient permits no further delay. That cases of acute perforation are exceptions to this is self-evident. In his opinion, and also in the warning against exaggeration of the indications for operation, as expressed by Sahli before the Twentieth Congress of Internal Medicine in 1902, I concur almost absolutely. It should never be forgotten that the process of healing after these operations is not always smooth and unbroken. I do not refer to the danger of the so-called vicious circle, i. e., the regurgitation of the gastric contents into the false intestinal loop in gastroenterostomy, because this perhaps is avoided by the simultaneous enterostomy, but I must call atten- tion to the occasional development after operation of peptic intestinal ulcers which are a new source of difficulty and danger to the patient. Neumann has recently reported a very instructive case of this kind, and in my opinion given very valuable advice, which is, that in gastric dilata- tion with pylorospasm and hyperacidity we should first perform jejunos- tomy and then allow the stomach to rest. Later, if necessary, and under favorable circumstances, gastroenterostomy may be performed. Mineral Spring Treatment. Since remote times the hot Glauber Salt Springs, particularly those of Carlsbad, have enjoyed a well deserved repu- tation, and there is no doubt that the treatment of ulcer at this resort, when carefully conducted and too large quantities of water at one time are not consumed, is frequently crowned by the best results. When the disturbances on the part of the digestive apparatus are relieved, the pa- tient should endeavor to recuperate and gain strength by a sojourn at Franzensbad, Elster, Eippoldsau, Pyrmont, etc., in the mountains or at the sea, with the proviso that he can secure suitable food, which is best when the family does its own cooking. Since, however, many patients 216 GASTRIC ULCER AND GASTRIC HEMORRHAGE prefer a mineral spring cure to going to bed at home, and many can only avail themselves of the short period of four to six weeks, Carlsbad for these is always the best place, because the opportunity there for dietetic sins is less than elsewhere. After Carjsbad, Neuenahr, Ems, Franzensbad, Homburg and Vichy are to be recommended. LITERATURE Ageron, " Diagnostisch-therapeutische Bemerkungen zum Magengeschwiir." Miinch- ener mcd. Wochenschr., 1902, Nr. 30. Alberti, Deutsche Wochenschr., 10. Januar, 1901, Vereinsbericht. 0. Ashe, "Excision of a Perforated Gastric Ulcer; Recovery." Brit. Med.Joum., December 15th, 1903. Backmann, "Verbreitung des runden Magengeschwiirs in Finnland." Zeitschr. /. klin. Med., Ed. XLIX. F. Blumcnsath, "Statistisch-klin. Mittheilungen iiber das runde Magengeschwiir." 1 naug. -Dissert., Kiel, 1902. Boas, "Ueber occulte Magenblutungen." Deutsche med. Wochenschr., 1901, Nr. 20. Borrmann, "Das Wachsthum und die Verbreitungswege des Magencarcinoms." Jena, 1901, G. Fischer. L. Bourget, "Therapie des Ulcus ventriculi." Therap. Monatsh., Juli, 1901. Brinton, "Die Krankheiten des Magens." Uebersetzt von H. Bauer, Wiirzburg, 1862. Fr. Brunner, "Das acut in die freie Bauchhohle perforirende Magen- und Duoden. algeschwiir." Deutsche Zeitschr. f. Chir., Bd. LXIX, p. 101. Byrom Bramwell, "On Gastric Ulcer." Lancet, March 9th, 1901. Cabot, "Indications for Operation in Gastric Ulcer." Boston Med. Journ., 1902, Nr. 9. Carle und Fantino, "Beitrage zur Pathologic und Therapie des Magens." Arch. /. klin. Chir., 1898, Bd. LVI. P. Cohnheim, "Heilwirkung grosser Dosen von Olivenol." Zeitschr. /. klin. Med., Bd. LII, Heft 1 und 2. Cesaris Deniel, " Syphilitisches Magengeschwur." Wiener med. Presse, 1900, Nr. 8. Dolmatow, "Zur Frage iiber den Werth der Verdauungsleukocytose bei Magen- carcinom." (Polish.) Jahrber., 1900. M. Einhorn, "Beitrag zur Kenntnis und Behandlung der Erosionen des Magens." Berliner klin. Wochenschr., 1895, Nr. 20, und Arch. f. Verdauungskrankh., Bd. V, p. 317. //. Eisner, "Zur Frage der hamorrhagischen Erosionen des Magens." Deutsche med. Wochenschr., 1903, Nr. 41. Eppinger, "Ueber Tuberculose des Magens und Oesophagus." Prager med. Wochenschr., 1881, Nr. 51 und 52. C. .1. Eirald, "Diagnose und Therapie des Magengeschwiirs." XX. Congr. f. innere Med., Wiesbaden, 1902. Ibid., Nr. 23, p. 347. "Ueber die Djagnose des Ulcus ventriculi mittels Nachweises occulter Blutanwesenheit in den Faces." Deutsche med. Wochenschr., 1903, Nr. 47. Berliner klin. Wochenschr., LITERATURE 217 1888, p. 396. "Zur Diagnose des Sanduhrmagens." Deutsches Arch. f. klin. Med., Bd. LXXIII, p. 152. Eysenhardl, quoted by. Struppler. Fenwick, "Suprarenal Extract in Gastro-intestinal Haemorrhage." Brit. Med. Journ., November 30th, 1901. Frz. Fink, "Erfolge der Karlsbader Cur u. s. w." Wien und Leipzig, 1903. L. Fischl, "Zur Therapie der Hyperaciditat des Magens." Prager med. Woch- enschr., 1903, Nr. 11. Fleiner, "Therapie des Magengeschwiirs." XX. Congr. f. innere Med., Wies- baden, 1902. Friedenthal, " Ernahrungsschwierigkeiten bei Ulcus ventriculi." 1 naug. -Dissert., Berlin, 1899. Futterer, "Treatment of Chronic Round Ulcer of the Stomach." Journ. Amer Med. Association, January, 1902. Gaillard, "Syphilis gastrique et ulcere de Testomac." Arch, gener. de mid., 1886. D. Gerhardt, "Ueber geschwiirige Processe im Magen." Virchow's Arch., Bd CXXVII, p. 85. Gluczinsky, "Ueber die Behandlung des peptischen Magengeschwiirs." Wiener klin. Wochenschr., 1900, Nr. 49. Greenough and Joslin, "Gastric Ulcer at the Massachusetts General Hospital." Amer. Journ. of Med. Sciences, August, 1899. Hampeln, " Gastro-intestinale Blutungen." St. Petersburger med. Wochenschr., 1891, Nr. 8. Harttung, "Ueber Faltenbildung und hamorrhagische Erosionen." Deutsche Wochenschr., 1890, p. 847. Hemmeter, "Zur Histologie der Magenschleimhaut." Arch. /. Verdauungskrankh., Bd. IV, p. 24. A. Hirsch, "Beitrage zur motorischen Function des Magens." Centralbl. f. klin Med., 1892, Nr. 47. P. Hirschfeld, Discussion. XX. Congr. f. innere Med., Wiesbaden, 1902. W. C. Hood, " Hsematemesis with Special Reference to that Form met with in Early Adult Female Life." London, 1892. Kausch, "Ueber functionelle Ergebnisse nach Operationen am Magen." Grenz- gebiete, Bd. IV, p. 347. G. Kelling, " Sympathischer Reizzustand bei Magengeschwiir." Wiener med. Wochenschr., 1902, Nr. 48. Kocher, " Indicationen zur Operation bei Ulcus ventriculi." Correspondenzbl. f. Schweizer Aerzte, 15 October, 1898. G. Kohler, "Beitrag zur Kenntnis der Symptomatologie bei Ulcus ventriculi sim- plex." I naug. -Dissert., Berlin, 1895. Korte, " Chirurgische Behandlung des Magengeschwiirs." Arch. /. klin. Chir., Bd. LXIII, p. 1. Krafft, "Beitrag zur Pathogenese des Ulcus ventriculi." Hosptialstidende, 1900. Kronlein, "Ueber Ulcus und Stenosis des Magens nach Trauma." Arch. f. Chir. L. Kuttner, " Magenblutungen und deren Beziehungen zur Menstruation." Ber- liner klin. Wochenschr., 1895, Nr. 7. Lange, Deutsche Klinik, 1860, p. 90. 218 GASTRIC ULCER AND GASTRIC HEMORRHAGE Langerhans, " Ungewohnliche Art der hamorrhagischen Erosionen des Magens." Virchow's Arch., Bd. CXXIV, p. 373. Letulle, Compt. rend., 1888, Vol. CVI. v. Leube, "Ueber die Erfolge der internen Behandlung des Magengeschwiirs und die Indicationen zum chirurgischen Eingreifen in dieselbe Grenzgebiete," Bd. II. Referat auf dem XXVI. Chirurgen-Congress, 1897. Leuk, " Untersuchungen zur pathologischen Anatomic des menschlichen Magens," etc. Zeitschr. /. klin. Med., 1899, Bd. XXXVII. Litten, "Ulcus ventriculi tuberculosum." Virchow's Archiv, Bd. LXVII, p. 615. L. Lorell-Keays, "A case of Double Perforating Gastric Ulcer." Brit. Med. Journ. December 15th, 1903. Lnxenburg und Jawadzki, " Ein Fall von Ulcus ventriculi rotundum auf Grund syphilitisoher Gefasserkrankung." Wiener Med. Presse, 1894, Nr. 50 und 51. J. N. Marshall, " Two Gases of Gastric Ulcer in which Symptoms arose suggesting Perforation of the Stomach." Glasgow Med. Journ., February, 1890. A. Mathieu, "Traite des maladies de 1'estomac et de 1'intestin." Paris, 1901. Mathicu et Roux, "Sur un cas d'ulcerations uremiques de 1'estomac et de 1'intestin grele." Arch. gen. de med., Janvier, 1902. r. Mering, "Zur Function des Magens." Congr. f. innere Med., Berlin, 1897. H. Merkel, "Ein Fall von chron. Magengeschwiir mit todtlicher Blutung aus der arrodirten linken Nierenvene." Virchow's Archiv, 1903, Bd. CXXIII. E. Mey, " Profuse Magenblutungen und Hydrops anasarca als initiale Symptome des Magencarcinoms." 1 naug. -Dissert., Dorpat, 1891. Michailow, " Ein Fall von erfolgreichem chirurgischen Eingriff bei Blutungen aus einem Magengeschwiir." Grenzgebiete, 1901, p. 535. v. Mikulicz, "Die chirurgische Behandlung des chron. Magengeschwurs." Ber- liner klin. Wochenschr., 1897, Nr. 23. Minkowski, Discussion. XX. Congr. f. innere Med. zu Wiesbaden, 1902. 8. Mintz, "Hamorrhagische Magenerosionen." Zeitschr. /. klin. Med., Bd. XLVI, Heft 1 to 4. Marfan, "Troubles et lesions gastriques dans la phthisie pulmonaire." Paris, 18S7. William Murrell, "The Value of Age and Sex as Etiological Factors," etc. Med. Press and Circular, October 23d, 1901. /. H. Musser, "Tubercular Ulcer of the Stomach." Philadelphia Hosp. Reports, 1S90, Vol. I. 0. Miiller und Hccker, quoted by Struppler. \amrerk, "Mykotisch-peptisches Magengeschwiir." Munchener med. Wochenschr., 1895, Nr. 38 und 39. r. Opcnclioicski, "Zur pathol. Anatomic der geschwiirgen Processe im Magen- Darmtractus." Virchow's Archiv, Bd. CXVII, p. 347. Jr. Ord, "On the Diagnosis and Treatment of Gastric Ulcer." Amer. Journ. of Med. Sci., June, 1889. Osterspey, "Die Blutuntersuchungen bei Magenkranken." Berliner klin. Woch- enschr., 1892, Nr. 12 und 13. Parixrr, " Discussionsbemerkungen im XX. Congr. f. innere Med. zu Wiesbaden. Ueber hamorrhagische Erosionen der Magenschleimhaut." Berliner klin. Wochenschr., 1900, Nr. 43. LITERATURE 219 Paulicki, Virchow's Archiv, Bd. XLIV. Petersen und Machol, "Beitrage zur Pathologie und Therapie gutartiger Magen- krankheiten. " v. Bruns' Beitrage zur klin. Chir., Bd. XXXIII, p. 297. Petruschky, "Zur Diagnose und Therapie des primaren Ulcus ventriculi tubercu- losum." Deutsche med. Wochenschr., 1899, Nr. 24, und 1901, p. 394. N. Platter, "Ueber Erosionen der Magenschleimhaut." Inaug. -Dissert., Zurich, 1901. Reichard, "Freie Vereinigung der Chirurgen Berlins." Deutsche med. Wochen- schr., 1890, p. 327. R. Reinhard, "Ulcus ventriculi simplex mit Tumoren." Inaug. -Dissert., Berlin, 1888. R. Rencki, " Diagnostische Bedeutung der mikroskop. Blutuntersuchung bei Car- cinom und Ulcus ventriculi." Arch. f. Verdauungskrankh., 1901. "Ueber die functionellen Ergebnisse nach Operationen am Magen bei Ulcus und gutartiger Pylorusstenose." Grenzgebiete, 1901, Bd. VIII. Rheinwald, "Die Behandlung des einfachen Magengeschwiirs mit Karlsbader Curen." Inaug. -Dissert., Tubingen, 1898. F. Riegel, "Beitrage zur Diagnostik der Magenkrankheiten." Zeitschr. /. klin. Med., Bd. XII, Heft 5. Mayo Robson, "A Clinical Lecture on the Complications of Gastric Ulcer and Its Treatment." Brit. Med. Journ., February 2d, 1901. Rosenheim, "Ueber seltene Complicationen des runden Magengeschwiirs." Ber- liner klin. Wochenschr., 1889, p. 1031. "Ueber die chirurgische Behandlung der Magenkrankheiten." Deutsche med. Wochenschr., 1895, Nr. 1. Schloffer, "Operationen bei gutartiger Magenerkrankung." v. Bruns, Beitrage zur klin. Chir., Bd. XXXII, Heft 2. A. Schmidt, "Pathogenese des Magengeschwiirs." Verhandl. XX. Congr. f. inner e Med., Wiesbaden, 1902. Schiitz, "Zur Differentialdiagnose des Ulcus ventriculi." XVII. Congr. f. innere Med., Wiesbaden, 1899. J. Schulz, "Ueber Dauererfolge der internen Therapie des Ulcus ventriculi." Grenzgebiete, 1903, Bd. XI. Schwarz, " Beitrage zur Pathologie und chirurgischen Therapie des penetrirenden Magengeschwiirs." Grenzgebiete, 1900. J. Sigel, "Zur Diagnose des Magencarcinoms." Berliner klin. Wochenschr., 1904, Nr. 12 und 13. / M. Silbermark, "Rundes Magengeschwiir nach Trauma." Wiener med. Woch- enschr., 1902, Nr. 21 und 22. Simmonds, "Ueber Tuberculose des Magens." Munchener med. Wochenschr., 1900, Nr. 10. v. Sohlern, "Einfluss der Ernahrung auf die Entstehung des Magengeschwiirs." Berliner klin. Wochenschr., 1889, Nr. 13 und 14. Spicker, "Spontan geheilte Perforationsperitonitis bei Ulcus ventriculi." Deutsche med. Wochenschr., 1903, Nr. 1. Stepp, "Zur Behandlung des chron. Magengeschwiirs." Festschr. d. Nilrnberger drztl. Vereins, 1902. Stern, "Ueber traumatische Erkrankungen der Magenschleimhaut." Deutsche med. Wochenschr., 1899, Nr. 23. 220 GASTRIC ULCER AND GASTRIC HEMORRHAGE H. Strauss und Bleichroder, " Untersuchungen iiber den Magensaftfluss." Grenz- gebiete, 1903, Bd. XII, Heft 1. Struppler, "Ueber das tuberculose Magengeschwiir." Zeitschr. f. Tuberculose und Heilstdttenwesen, Bd. I, Heft 4. Talamon-Balzer, "Phthisie locale; ulcerations tuberculeuses de 1'estomac et de 1'intestin." Bullet. Soc. Anatom., 1878, p. 374. S. Talma, "Untersuchungen iiber Ulcus ventriculi simplex." Zeitschr. f. klin. Med., Bd. XVII, Heft 1 und 2. M. Tiegel, "Beitrag zur Casuistik todtlicher Magenblutungen." Miinchener med. Wochenschr., 1902, Nr. 47. Dalla Vedova, " Experimenteller Beitrag zur Kenntnis des Ulcus ventriculi." Arch. /. Verdauungskrankh., Bd. VIII, Heft 3. Walko, "Ueber die Behandlung des Ulcus ventriculi mit Olivenol." Centralbl. f. inner e Med., 1902, Nr. 45. M. Weiss, " Magenblutung bei Typhus abdominalis." Wiener Med. Presse, 1887. Frz. Warnecke, " Indicationen zur operativen Behandlung des Ulcus ventriculi." Preisschr., Gottingen, 1903. van Yzeren, "Die Pathogenesis des chron. Magengeschwiirs." Zeitschr. f. klin. Med., Bd. XLIII, p. 181. (Also see the literature in Ewald's article "Magen- krankheiten," Eulenburg's Real-Encydopadie, 1897, Bd. XIV.) GASTRIC AND INTESTINAL CARCINOMATA BY J. BOAS, BERLIN WHEN a case of gastric or intestinal carcinoma presents itself before us to-day, we judge it by very different standards from those employed about twenty years ago. At that period, i. e., in the days of Billroth, Pean and Rydygier, our chief endeavor was to make the diagnosis, and at that a diagnosis of general visceral cancer. Whether the cancer was located in the stomach and in what part of the same, whether in the small or large intestine, whether in the omentum or the liver, in the gall-bladder or the pancreas, was of scientific but not of therapeutic interest. In every case the patient was doomed; to him accurate proof that this or that portion of his viscera showed malignant degeneration was of no avail. In the last two decades our views concerning these affections have undergone a complete change the influence of which no physician, however pessimistic he may be regarding carcinoma in general, can withstand. This change, as is well known, has been brought about by surgery, and no genius has yet appeared to teach us how to cure by internal remedies. The knife alone can permanently remove the difficulty, or, although very rarely, bring amelioration which lasts for years. This advance, which is largely due to the high development of anti- sepsis and asepsis, but also to an enormous impetus to the technic of abdominal surgery, imposes upon internal medicine new obligations. The diagnosis must be made early. It must accurately define the seat of the affection, it must when possible embrace the consideration whether the malignant focus is circumscribed or already generalized. It must de- cide whether or not any complications are present which may influence the course of the operation, and, finally, it must determine whether at the given moment the patient's strength will warrant surgical interference. If it were possible in a case of gastric or intestinal carcinoma to decide all these points with certainty, the results of operative treatment would be decidedly more favorable than they are at present, and this would doubt- less influence strongly our decision as to conservative or active treatment. Although, in fact, this goal is still remote, our chief endeavor must be to arrive as near as possible to the previously mentioned postulates. For this purpose not only a comprehensive diagnosis, but also the earliest recognition of the affection from all points of view is necessary. 221 222 GASTRIC AND INTESTINAL CARCINOMATA After these preliminary remarks I shall describe a typical case of gas- tric carcinoma, the delineation of other less typical forms will follow this, and I shall then describe a case of carcinoma of the large intestine and of the rectum; for cancer of the small intestine, on account of its rarity, a brief description will suffice; in conclusion I shall summarize the treat- ment of gastrointestinal carcinomata. ETIOLOGY In examining the history of this patient it will be noted that he is about 50 years of age, and up to the time of his present affection he has usually been well ; above all, he has had no gastric affection. Until within the last few months he could eat anything and digest it. His present illness dates from this period* Let us here pause for a moment, since these data are of great importance as indicating the character of the affection. When a patient, who has reached the age at which cancer is likely to occur, tells us that he has never been ill, while his appearance denotes the existence of a serious malady, we must primarily think of a malignant disease. Not that this report is in itself of vital importance, but it indicates the direction in which we must search for the underlying affection. We have heard from this patient how his ailment gradually developed to its present extent. We are especially interested in learning what the first symptoms were, and whether these gave any indication of the gravity of the condition. His report, in brief, is the following: On taking food, he has now and then a sensation of pressure which is not actual pain in the pit of the stomach, occasionally there is eructation of gas but not of food, and with this a gradually increasing loss of appetite. This is about all. We see the justification of Brinton's expression in regard to the onset of gastric carcinoma : " Obscure in its symptoms." Nevertheless, any one who has had much experience in the realm of visceral carcinomata will not escape the conviction that this latent and indefinite onset forms the rule- to which there are, however, numerous exceptions of practical importance. Among these belongs the sudden onset with severe symptoms: In the midst of apparently normal health the patient begins to vomit, and to the surprise of those about him, even of the physician, this continues and steadily becomes more copious so that in a few days, or at most in a few weeks, the patient emaciates markedly, loses his appetite, and becomes feeble and debilitated; briefly, he shows such extreme emaciation that, provided no severe functional or central affection is present in this connection I refer particularly to the gastric crises and the periodical vomiting described by v. Leydon without more ado the suspicion of malignant disease is aroused. Another mode of onset of practical significance is when gastric car- ETIOLOGY 223 cinoma is most surprisingly ushered in by decided and threatening hema- temesis or melena. This naturally leads us to think of a simple ulcer of the stomach or of the duodenum, and if etiologic factors are favorable, per- haps also of cirrhosis of the liver or some other form of disease leading to stasis of the portal vein; but the further course shows that a scarcely avoidable error has been made. In connection with the hemorrhage isolated symptoms occur, or all the symptoms of a malignant course may be re- quired to make the diagnosis of cancer more positive from day to day. Practically we may easily assume that a gastric ulcer is undergoing malig- nant degeneration, but it has been proven with certainty (by May, Ewald and others) that such a course by no means always permits the conclusion of a preceding ulcer. I shall refer to this again in the description of carcinomatous ulcer. But such occurrences as have been mentioned are usually exceptional. The typical onset, as we unfortunately know, is usually so slightly charac- teristic that the last thing the patient and his relatives think of is the development of a malignant, incurable disease. And thus it happens that at first, according to their degree of education, they become their own physicians and employ all sorts of home remedies and occasionally purga- tives up to a period when every effort at internal or surgical treatment is hopeless. But with careful and comprehensive professional treatment from the first, all concerned will have an expectant attitude. The wise physician will reckon on the possibility of a beginning malignant affection, but because of the absence of definite symptoms, he will refrain from expressing his fears, and not cause unnecessary fright and distress. At the onset, I purposely mention the difficulties in the recognition of the disease. It will be seen that the demand of many surgeons for an early diagnosis is scarcely justified, for we cannot make a diagnosis before we have the patient. In the chapter upon treatment we shall also consider the fact that, even with an early diagnosis, rapid surgical intervention is sometimes prevented by the stress of circumstances. After this brief digression, we return to the further course of the dis- ease as described by our patient. He states that in addition to the slight difficulties at the onset disturbances of more serious nature now and then occurred; there was pressure, also pain in the pit of the stomach which occasionally extended from the left side posteriorly into the back, radiating also to the shoulder-blade. Sometimes the patient mentions a symptom that, so far as known to me, is nowhere recorded a peculiar grating in the gastric region as of two surfaces rubbing against each other. I have heard this symptom described in the same manner by several patients, so that in enumerating the subjective disturbances it appears to me to be of consequence. Now and then vomiting occurs, at first rarely and in slight amount, in the last few weeks more frequently and more copiously. The vomitus consisted of the ingested food which, in the first stages, 16 224 GASTRIC AND INTESTINAL CARCINOMATA showed no alteration in appearance, but lately it has now and then been somewhat brownish. After vomiting the patient is temporarily relieved. At first he lost some flesh; in the last few weeks the weight has declined rapidly, and hand in hand with this there has been a marked decrease in strength; the appetite is wholly lost. This is the stage in which patients with carcinoma of the stomach usually present themselves to the physician. Clear as the course of the development appears, and strongly as the individual points favor a malig- nant disease, we must not forget that other severe but not actually ma- lignant processes may have the same or a very similar course of develop- ment. I refer, for example, to the cases, recently so accurately studied, of hypertrophic stenosis of the pylorus, the symptoms of which closely resemble those just described. Cicatricial stenosis of the pylorus also may remain latent for a long time, and only when, by a sudden and occa- sional cause, the musculature is insufficient, may show symptoms which very closely resemble in severity and extent closure by a malignant process. Only an accurate clinical analysis of the case will decide whether the very suggestive reports of the patient find their explanation in the objective examination. While the patient was undressing it was noted that the extraordinary extent of the disturbance in nutrition was most obvious from the upper to the lower extremity. The musculature was soft and flabby, the subcutaneous connective tissue thin, atrophic and without fat, the skin itself could readily be lifted in folds. The tongue was coated at the tip and borders. From the present stand of gastric pathology too much im- portance cannot be attached to the condition of this organ. Various factors here come into consideration (tobacco and alcohol, their use and abuse, fissures, inflammation of the tonsils and pharynx, greater or less cleanliness of the oral cavity) so that the relation between gastric diffi- culties and the tongue cannot be accurately determined. In contrast to Leser, I do not attach much importance to the small miliary and sub- miliary angiomata which this patient also showed, for, in my experience, which coincides with that of Gebele, this is not rare in non-carcinomatous cases, particularly in the aged. After the patient had removed his clothes he was systematically ex- amined in the usual manner. To avoid taking up unnecessary time I shall state at once that the examination of the heart and lungs revealed normal conditions. In the examination of the abdomen I must promptly emphasize the importance of inspection of the abdomen,, for this method furnishes a ful- ness of diagnostic aids which can only be recognized by experience. First, the configuration of the abdomen must be noted, and the deviations in both its halves carefully compared. To the right of the median line a relief-like projection is then noted, a slight prominence, which on deep inspiration descended, and upon expiration rose again to its old position. ETIOLOGY 225 I shall revert {o this later. But another very remarkable phenomenon was noted ! From time to time a second relief was seen in the left hypo- chondrium, rising suddenly and prominently, almost like a mound, from the level of the abdomen, and after a brief time sinking to its old position of rest. While inspecting the abdomen carefully, and at the conclusion of this phenomenon, a peculiar gurgling murmur was heard. What does this phenomenon mean? It will perhaps be said that it denotes peristaltic unrest of the stomach, as was first described in a classical manner by Kussmaul, or, as the French term it, " peristaltism." But if this sign which was found to recur at brief intervals and always to run the same course be more accurately examined, we may convince ourselves that it is not from true peristaltic action. On the contrary, it resembles a tonic contraction which does not develop further but remains localized. The picture is so fascinating that when the phenomenon is at its height we cannot refrain from grasping the prominence with the hands. We feel a hard, contracted mass which resembles the uterus during a pain. No doubt this is the fundus of the stomach. We designate this process "gastric rigidity" and this is analogous to the nomenclature Nothnagel proposed for similar processes in the intestine, to which we shall refer later. This sign, to which I have recently again called attention, 1 was ob- served about fifty years ago by no less a one than Cruveilhier, 2 and I cannot refrain from quoting what he says of this symptom in his great " Traite d'anatomie pathol. generale," as follows : " La dilatation hypertrophique de 1'estomac s'observe dans les cas ou 1'ampliation de Festomac se faisant graduellement, la contractilite et la force elastique de Porgane n'ayant pas ete vaincues, il y a resistance a la distension de la part de la tunique musculeuse, qui se contracte energique- ment sur les aliments, les boissons et les gaz, qu'il contient. Cette con- traction qui se manifeste d'une maniere intermittente est facile a recon- naitre pendant la vie par un durcissement douloureux analogue aux legeres contractions uterines, qui precedent les grands douleurs de I' accouchement. Pendant toute la duree de cette contraction la forme de 1'estomac se dessine a travers les parois abdominales et chez les sujets amaigris on peut en suivre tous les contours a I'oeil et au doigt. C'est a mon avis un grand moyen de diagnostic." In this description the process of gastric rigidity is so masterfully portrayed that little of importance can be added. My own experience has taught me that several stages of gastric rigidity may be differentiated : 1. Slight contractions extending only to small areas 1 Boas, Deutsche med. Wochenschr., 1902, Nr. 10. 2 Cruveilhier, " Trait6 d'anatomie pathol. ggngrale," 1852, T. II, p. 857. 226 GASTRIC AND INTESTINAL CAECINOMATA of the fundus, which are felt as increased tonicity lasting but a few seconds (abortive gastric rigidity) ; 2. Distinct contractions conveying the sensa- tion of marked increase in tonicity, becoming visible as globular prom- inences, being contractions of a greater or lesser area of the fundus, and terminating with a distinct pressure murmur which is felt by the patient as a more or less painful contraction; 3. Decidedly marked, visible and palpable contractions in the entire extent of the gastric fundus, which continue for a long time, terminate with a distinct gurgle, and produce active pain. This gastric rigidity is apparently the precursor of peristaltic unrest. Its relation to the latter is that of tonus to tetanus. Occasionally, par- ticularly when the stomach is overloaded, both may be observed side by side. Gastric rigidity is in my opinion of very decided diagnostic importance. It indicates at a relatively early stage that there is an obstruction at the pylorus. Of what nature this is, whether purely functional (spastic contraction of the pylorus) or organic, whether an ulcer, a neoplasm, a gastrolith, an adhesion of the pylorus to neighboring organs, volvulus, etc., can only be decided by continued objective analysis of the individual case. But the fact alone that the patient is suffering from an obstruction at or near the pylorus is not only of great import in the diagnosis but also in the prognosis, and even in treatment. For this purpose I wish to add a few remarks of practical significance to the discussion of the symptom of gastric rigidity, which is not suffi- ciently considered in medical literature. " Gastric rigidity," for obvious reasons, may be "best noted when the organ is full and it may then be best palpated; but, even then, it can occasionally only be observed with marked friction of the gastric region, preferably with a cool hand or a hand that has been dipped in ice-water. As gastric rigidity does not always occur even under these conditions the examination must be frequently repeated. A slight degree of gastric rigidity can only be determined by much practice, and I therefore advise that the students practise first with cases in which the rigidity is well developed, so as to determine the increased gastric tonus. I have purposely dwelt upon this phenomenon at some length, for with- out a complicated apparatus it at once gives the physician reason to sup- pose that something is out of order in the motor apparatus of the stomach. We have then a certain foundation upon which to proceed, and we know what further steps must be taken to clear the situation. We shall now recur to the previously mentioned visible prominence. We note that it shows inspiratory and expiratory motion, and we shall proceed to palpate it. As may be readily determined, we are dealing with a hard tumor of uneven surface and about the size of *. small orange. Apparently this completes the diagnosis. We have before us a tumor ETIOLOGY 227 of the pylorus. But we must investigate still further to ascertain the nature of this tumor. Is it movable or adherent? Can it be fixed upon expiration or not? The movability of a pyloric tumor (for only these can be decidedly moved manually) is so readily proven that we really need say nothing further in regard to it. But only a very few pyloric tumors are movable in all directions like the head of a child in the uterus; in the majority of cases there are some adhesions, and it is then necessary to determine the degree of movability. If we are in doubt, it is well to inflate the stomach with carbonic acid or air, when it will be possible to determine the position of the stomach, especially that of the greater curvature. If while inflated by air the tumor is still movable, certain locomotor excursions downward and to the right will occur, occasionally also upward and to the right. Under this method in the case in question we note that inflation by C0 2 (which we prefer on account of its simplicity and particularly because the patient has not yet become accustomed to the prolonged presence of the stomach-tube) affects the position of the tumor but little. Therefore, it is probably adherent to the surroundings. At this point we must consider an important difference between the expiratory relation of tumors of the pylorus and tumors of the small cur- vature. The latter, as was first determined by Minkowski, 1 are charac- terized by expiratory immovability. By this sign tumors of the small curvature may readily be differentiated from tumors belonging to other organs, and on the other hand it is also an important factor in differen- tiating them from tumors of the pylorus. Yet, tumors of the small curva- ture may lose their expiratory immovability when they become adherent to neighboring organs, but in this case they either do not ascend with inspiration, or they slightly descend. Judging from the previously mentioned findings the tumor in this case proves to be a tumor of the pylorus, and since it is hard to the touch and the other symptoms also point to a malignant course, we can hardly be wrong in deciding that we have before us a carcinoma of the pylorus. Nevertheless, although we feel quite certain of our opinion, we shall complete as far as possible the physical examination of the organ, as well as of the other abdominal organs. Previously, on inflating with C0 2 and simultaneously ascertaining the movability of the pyloric tumor, we observed the position of the greater curvature. It was noted under these circumstances that it extended above the horizontal umbilical line about a handbreadth. We were then unable to determine the position of the smaller curvature as this is only possible on inflating the stomach with air to the extreme limit. These methods, 1 Minkowski, Berliner klin. Wochenschrift, 1888, Nr. 31. 228 GASTRIC AND INTESTINAL CARCINOMATA therefore, do not permit us to ascertain whether the stomach is enlarged or descended, or whether both conditions are present. If we desire accurate knowledge, we must resort to maximal inflations with air, filling with water, or, eventually, the illumination of the stomach. These tests may perhaps have a scientific value, but are of little practical importance. It is more serviceable to investigate the organs adjacent to the stomach, especially the liver, the intestines, and the mesentery. As the metastases of carcinoma are principally found in the liver, we should convince ourselves of an enlargement of this organ, or of the pres- ence of nodules therein, and should also palpate the entire intestines and the mesentery, in so far as they are susceptible to the palpating finger; above all we must not fail to ascertain whether or not free fluid is present in the abdominal cavity. Finally, we must palpate for a moment the left supraclavicular region for the possible presence of a so-called Virchow's gland. The occurrence of such glands, sometimes ranging in size from that of a hazelnut to that of a hen's egg, according to the opinion of most authors (v. Leube, Ewald, Riegel, Rosenheim, Mathieu, Hayem and Lion, Hemmeter, Einhorn, Flciner) with whom I coincide, belongs to the greatest rarities. In regard to the fact that enlargement of the supraclavicular glands (Tarchetti and others) unquestionably belongs to a late period of carcinomatous develop- ment, complete unanimity does not exist even among the few authors who ascribe great importance to this symptom. That enlargement of the supraclavicular glands is not peculiar to gas- tric carcinoma alone, but to all intestinal carcinomata, need hardly be mentioned. The condition may throw light upon the cases in which the clinical signs of an intestinal carcinoma are obscure. Such instances have been reported in literature, and every one of experience will remember similar occurrences. Under these circumstances, glandular enlargement of the supraclavicular region may aid in the diagnosis. The same is true of another variety of glandular enlargement which has been observed for a long time, especially in France and also in Ger- many, but in the main has received but little consideration: The enlarge- ment of the peri- and para-umbilical glands. Simultaneously, but even alone, the umbilicus may also show metastasis, 1 so that we then speak of umbilical carcinoma. This complication, which Quenu and Longuet 2 a few years ago made the subject of a comprehensive study, is exceedingly rare. Nevertheless, in the course of years I have seen about half a dozen 1 Cases of primary carcinoma of the umbilicus have been described in literature ; they are, however, exceedingly rare. -Quenu et Longuet, "Cancer secondaire de 1'ombilic." Revue de Chirurg., 1896, T. 10, p. 1897. ETIOLOGY 220 of these metastases. That which has been mentioned as clinically impor- tant in enlargement of the supraclavicular glands is, cceteris paribus, also true of carcinoma of the umbilicus and its surroundings. This exhausts the leading points of the physical examination. They are sufficient, as we have seen in the case in question, not only for the diagnosis but also, so far as this be possible, to decide whether or not complications are present. From an examination of the vomited material and from its nature a conclusion, although not an exhaustive one, may be drawn in regard to the gastric functions, and it will be apparent that in classical cases of carcinoma of the stomach other methods of examination, particularly an examination of the gastric contents, in a strict sense, are superfluous. In my opinion these are only necessary when other methods yield insufficient or contradictory results. As this is often the case, the examination of the gastric contents will be included with the physical examination of the patient in question, although not for the purpose of a strict indication, but for didactic reasons. The patient was prepared for this by withholding food from about eight o'clock of the preceding evening to the following morning. This method of procedure, i. e., the examination of the empty stomach, is very valuable in daily practice, as by this means without further prepa- ration not only the secretory, but, above all, the motor activity of the stomach may be investigated. In the majority of cases, if the stomach proves to be empty, we may at once administer a trial breakfast and an hour after its introduction the gastric contents may be obtained. In the case in question the trial breakfast is unnecessary, as the patient's stomach, even early in the morning, contains about one-half liter of residue. We must first examine the residue carefully. It consists of a grayish, thin fluid, a mucus-containing mass, as may be noted by pouring the material from one vessel into another, and has an acid but not disagreeable odor. If a portion of the fluid be poured into a test-tube there .is no obvious change except that the solid constitu- ents fall .to the bottom, but true gas formation which occurs so often in other cases of stagnated gastric contents, is not here visible. If the attempt be made to observe gas .formation in a ferment- tube, no actual production of gas is noted. Occasionally in the gastric contents or in the vomited material one or several particles of the tumor may be admixed, and if microscopic examination reveals characteristic signs of an atypical neoplasm the diag- nosis is virtually certain. It need hardly be stated that macroscopic exami- nation alone under no circumstances suffices, since particles resembling tumor may upon accurate investigation prove to be fragments of mucous membrane, coagulated blood, etc. 230 GASTRIC AND INTESTINAL CARCINOMATA CHEMICAL AND MICROSCOPICAL INVESTIGATION OF THE GASTRIC CONTENTS With this external investigation we now include the chemical and microscopical examination of the gastric contents. As may be noted from the color reaction (tropaeolin paper, Congo paper) as well as from the results of the phlorogluein, vanillin and resorcin tests, free hydrochloric acid is not present in the gastric contents. It was, however, found that litmus paper was decidedly reddened. The gastric contents must contain either much combined hydrochloric acid or acid salts or organic acids, or all of these combined are found. Of these we are chiefly interested in lactic aoid, especially as its presence may be most easily determined. In fact, as was demonstrated by the iron chlorid test, lactic acid was present in large amounts. Besides lactic acid, other volatile fatty acids are probably present, but their exact determination is difficult and they are of little practical importance. On the other hand, further to determine the secretory insufficiency of the stomach, the proof that enzymes, that is, proenzymes of the gastric contents, pepsin and pepsinogen, as well as lab-ferment and lab-zymogen, are absent is necessary. As was shown by the tests which were made, the previously mentioned enzymes are absent from the gastric contents of the patient in question. We conclude the chemical examination by testing a portion of the gastric contents for blood, using the guaiac test modified by Weber. Test for Blood. As this test has been but little employed in practice I shall at this point briefly describe it. About 10 c.c. of unfiltered gastric contents are mixed in a test-tube with about one-third as much of glacial acetic acid, and the mixture is repeatedly shaken. We then add to it the same quantity of sulphuric ether, after which we shake it, and subse- quently note whether the mixture shows any change in color. If much hemoglobin be present in the gastric contents the ether soon changes to a yellowish-brown color somewhat like diluted Tokay wine. This yellowish-brown discoloration strongly indicates the presence of hematin. The ether is carefully decanted, and ten drops of guaiac tinc- ture freshly prepared each time and thirty drops of old, strong oil of turpentine are added. If hematin is present, upon long standing at first a grayish and later a decidedly marked violet color develops in the mixture. We add to the mixture a few cubic centimeters of distilled water and from ten to twenty drops of chloroform. This rapidly takes up the blue coloring matter, and the reaction soon becomes markedly distinct. From the intensity of the blue or violet discoloration we may draw conclusions as to the amount of dissolved hematin present in the gastric contents. The test made in the case of our patient revealed an extraordinarily profuse amount of hematin in the gastric contents. MICROSCOPICAL INVESTIGATION OF THE GASTRIC CONTENTS 231 Finally, a microscopic examination of the gastric contents should be undertaken. Under the microscope numerous immotile rods, partly iso- lated, partly in clumps or forming angles, were observed; these are lactic acid bacilli, which were first described by me, later by Oppler, and accu- rately studied by Kaufmann and Schlesinger. Furthermore, numerous transverse, striped muscular fibers were noted of which a part were still well retained, now and then starch bodies, also fatty acid crystals and fatty acid needles. Occasionally yeast colonies, isolated or beginning to sprout, are noted, but, on the other hand, the sarcina3 so frequently present in these conditions were absent. Pus in the gastric contents is a significant finding, and its presence is often revealed by the odor. If the gastric contents are spread out thin upon a black pus basin and carefully examined, as a rule particles of pus will be discovered which may be verified by microscopic examination. In the preceding I have described the most important macroscopical, chemical and microscopical findings in the gastric contents of the case under discussion. Let us now consider the collective importance of the' individual findings. The least weight is to be attached to the macroscopic investigation; it is true the coffee-ground appearance may strengthen the suspicion of car- cinoma, yet it is not absolutely proven. But the previously mentioned particles of tumor tissue unquestionably are in favor of a malignant neoplasm. More valuable is the chemical finding, and here primarily the absence of free hydrochloric acid and enzymes, the fact of abnormal lactic acid fermentation, and the presence of blood and pus in the gastric contents are significant. The absence of free hydrochloric acid (which, as is well known, was discovered in Kussmaul's Clinic in the year 1879 by van den Velden), even to-day is looked upon as a relatively certain and decisive sign. It is of very frequent occurrence in gastric carcinoma; it was present in 77.5 per cent, of my cases, and other observers give even higher figures. But gastric carcinoma is not the only affection which shows the absence of hydrochloric acid. This symptom is observed in maladies of an entirely benign character: In chronic gastritis, in amyloid degeneration, in severe forms of anemia, in poisoning by sulphuric and hydrochloric acids, in so-called achylia gastrica, in hypertrophic pyloric stenosis, and in rare cases of ulcer of the stomach; moreover,, deficient hydrochloric acid is found in carcinoma of other organs, for example, of the esophagus, of the uterus, of the breast, and of the rectum. Inversely, free hydrochloric acid is occasionally found even in con- spicuous excess in well developed cases of gastric carcinoma. An excess of hydrochloric acid is especially frequent in carcinomatous ulcer, to which we shall refer later. But also in undoubted gastric carcinoma, particu- 232 GASTRIC AND INTESTINAL CARCINOMATA larly of the pylorus and at the onset of the disease, we quite often find hydrochloric acid. Of greater decisive importance is the occurrence of large amounts of lactic acid. Arthur Schiff 1 compiled the figures of Hammerschlag, Strauss, Schlesinger, Kaufmann and Ekehorn, which show that 84.4 per cent, of gastric affections running their course with lactic acid fermenta- tion are gastric carcinomata. According to the same compilation, the in- vestigations of Boas, Hammerschlag, Kosenheim, Lindner, Kuttner, Eobin, Strauss, Kaufmann and Schlesinger show that lactic acid occurs in 73 per cent, of all gastric carcinomata. Higher figures were given by Croner, 2 that is, 78.5 per cent., and Riitimeyer, 3 75 to 80 per cent. On the other hand, it cannot be denied that lactic acid fermentation in the stomach occurs in quite a number of non-malignant gastric affec- tions; for example, in hypertrophic pyloric stenosis, gastritis gravis (Rosen- heim), in pernicious anemia with gastric atrophy (Ewald), and in other rare cases which, however, do not clinically present the picture of gastric carcinoma. As the presence of lactic acid occurs only with stasis of the gastric contents and the absence of hydrochloric acid, it is obvious that deficiency in lactic acid by no means excludes gastric carcinoma. The positive finding only is of importance, not the negative. Besides the chemical changes previously mentioned the absence of pepsin and lab-ferment is to be emphasized, to which Hammerschlag, Ewald, Kuttner and others attach great value. This, however, always occurs when the presence of lactic acid is combined with the absence of hydrochloric acid, so that proof of the absence of enzymes at most only confirms the previously mentioned anomalies or complements them. Occult Gastric Hemorrhage. In my experience some weight must be attached to the evidence of occult gastric hemorrhage. This may be de- tected in the gastric contents or, if for any reason not thus perceptible, may be demonstrated in the feces by means of the previously mentioned method (page 230). Since Ewald and Kuttner called attention to the occurrence of these slight, hemorrhages, I have recently had an opportunity to study this sub- ject carefully, and in numerous cases of gastric carcinoma have deter- mined that in these diseases occult hemorrhages are exceedingly common. Thus, associated with my assistant, Dr. Kochmann, in 67 cases of gastric carcinoma we found 65 hemorrhages, and in the overwhelming majority of cases the bleeding was occult. 1 Arthur Schiff, " Die Diagnose des Magencarcinoms," " Sammelreferat nach den Arbeiten dt>r Jahren 1894-1898." Centralbl. f. die Grenzgebiete der Medicin u. Chirurgie, 1898, Nr. 12 and 13. 2 Croner, Mittheilungen aus den Grenzgebieten, 1899. Bd. V, p. 405. 3 Itiitinicycr, Correspondenzbl. f. Schweizcr Acrzte, 1900, Nr. 21. MICROSCOPICAL INVESTIGATION OF THE GASTRIC CONTENTS 233 However, this finding is not pathognomonic. We have noted the con- dition in a large series of observations, most numerously in cases of benign dilatation, also in hypertrophic pyloric stenosis and in ulcer of the stomach, but not, however, in positive cases of chronic gastritis and achylia. Natu- rally, even in these cases, fresh visible hemorrhages may appear as capillary hemorrhages which, however, as a rule, are of artificial origin. Continu- ous hemorrhage in chronic achylia or gastritis without conditions of stasis belongs to the greatest exceptions; in carcinoma, however, it forms the rule. The differentiation of a benign from a malignant pyloric stenosis by demonstrating the presence of blood is not readily made. But we may state that under these conditions the reaction in carcinoma is decidedly more marked (saturated blue) than in benign processes (delicate violet). Microscopic examination has a certain importance inasmuch as it re- veals the thread bacilli of lactic acid fermentation, and thus confirms the presence of the latter. Sarcince, in my experience, are of no diagnostic significance in gastric carcinoma. They are absent, as a rule, but not invariably, in marked lactic acid fermentation, and, vice versa, with the finding of free hydrochloric acid and marked stagnation they are almost always present in carcinoma. Pus in the gastric contents is by no means a rare symptom; usually it is found admixed with blood. Although pus may occur in the stomach from various causes (gastritis phlegmonosa, abscesses) and is especially prone, to originate from the , upper air passages, the continuous finding of amounts of pus, particularly if the conditions mentioned may be ex- cluded, is a valuable sign of carcinoma. Besides the gastric contents, the composition of the blood in gastric carcinoma has received considerable attention; in the main, however, the results are unsatisfactory. We often find, but not constantly, a marked diminution of hemoglobin and of the erythrocytes. The opinion promul- gated a few years ago by Schneyer * that there is an absence of digestive leukocytosis in gastric carcinoma was found to be incorrect after further examination (by Hassmann, Hoffmann, Sayler and Taylor, Chadbourne, Dolmatow, Marchetti, Eencki and others). From this description it follows that absolute proof of the presence of a gastric carcinoma, aside, perhaps, from the very rare finding of particles of the tumor which is only possible in well advanced cases, cannot be obtained from the investigation of the gastric contents. Only most careful consideration of all the clinical signs, among them the phys- ical, particularly the tumor, can protect us from an erroneous diagnosis. With this we reach the important and difficult chapter of the diagnosis of gastric carcinoma. 1 Schneyer, Internationale klin. Rundschau, 1894. 234 GASTRIC AND INTESTINAL CARCINOMATA GASTRIC CARCINOMA DIAGNOSIS So long as we are dealing with cases similar to the one just described, the diagnosis of gastric carcinoma is one of the easiest in the realm of internal medicine. Difficulties beset us only when the onset is indistinct and the course atypical, when the symptoms differ in important points from those just described, when important objective factors are either absent or indistinctly developed. We may differentiate two categories of atypical development: First, those in which a tumor in the stomach is not palpable at the moment of examination; secondly, if the tumor be present, it does not have the char- acteristic properties of a gastric tumor, and particularly of a malignant gastric tumor. We shall now concern ourselves with the first class of cases. Daily observation gives us many examples of this kind. We see, for instance, a patient who for a short time has complained of dyspeptic symptoms: Gastric oppression, anorexia, now and then draw- ing pains in the epigastrium or in the fundus, occasionally also in the back, eructations, emaciation, a feeling of diminished dynamic activity, etc. Palpation may perhaps reveal slight sensitiveness to pressure, but other than this no objective signs are observed. The suspicion of a pernicious disease is aroused, but we may also be dealing with a severe form of chronic gastritis or even with one of those not infrequent forms of nervous dyspepsia which in the course of time lead to an extreme degree of marasmus, and thus very closely simulate the picture of carcinomatous cachexia. In another series of carcinomata we observe an entirely different course. The disease begins suddenly as a severe gastritis, or like an acute gastric dilatation : In the midst of health the patient begins to vomit, or, after a more or less obvious cause, once or several times large or small amounts of ingesta are ejected; but notwithstanding careful regulation of the diet and the use of all remedies calculated to ameliorate the condition, the symptoms do not yield but even increase. The patient permanently loses his appetite, cannot take even the most carefully prepared food, and in a few weeks shows a threatening state of inanition. Or after indistinct prodromes the patient is suddenly attacked with profuse hematemesis or melena. We first think of a latent ulcer and in- stitute appropriate treatment; the hemorrhage ceases but the patient does not recover his health, he rejects his food, repeatedly vomits, sometimes food but occasionally also fresh blood, and the case begins to assume a serious aspect. In other cases, the patient shows indistinct dyspeptic symptoms with fever which is not characteristic, nor does it conform to any of the well- GASTRIC CARCINOMA 235 known types. We think of cryptogenetic pyemia or an irregular attack of enteric fever, of malaria, of tuberculous peritonitis, etc., and finally section shows the presence of a gastric or intestinal carcinoma which was insusceptible to palpation. This shows but a few forms under which carcinoma may be masked. If we undertook to enumerate them all we should 'lose ourselves in a chaos of conditions which could not be examined. Somewhat less intricate but still obscure is the second category of cases in which a tumor is present but in which doubts arise as to whether it belongs to the stomach, or in which the history or malignancy is uncertain. We mention, for example, the difficult differentiation of an old ulcer with thickened borders from a carcinoma or a carcinomatous ulcer, further- more, the recognition of a callous, indurated perigastritis, a hypertrophic thickening of the pylorus, a hard gall-bladder filled with stones, a gastro- lith, a lipoma, a papilloma or myoma, not to speak of sarcoma of the stomach. In these and numerous other cases which cannot be mentioned here all methods of diagnosis, particularly the examination of the gastric con- tents, must be utilized, and, as I must admit, frequently without success, to clear up these doubtful conditions. But, nevertheless, cases remain in which nothing but the further course of the disease, and often not even this, but only laparotomy or the autopsy, will decide the question. To proceed, we must mention some other methods which now and then are employed in complementing the diagnosis. First among these is the examination of the patient under anesthesia. By this means doubtful tumors whose presence in the various abdominal organs cannot be determined with certainty may be better recognized or localized. However, in consequence of more thorough technic in palpa- tion, examination under an anesthetic has in the last few years fallen into disuse. It is best reserved for the cases in which active tension of the abdominal walls from marked meteorism, etc., makes it impossible to obtain a clear idea of the condition of the viscera. The second method is gastroscopy which, however, up to the present time has secured no permanent place in the diagnosis of gastric pathology. Invented by v. Mikulicz, and further developed by Eosenheim, Kuttner and Rewidzoff, this method has been chiefly employed in the last few years by G. Kelling. Kelling is of the opinion that gastroscopy enables us to make the diagnosis in doubtful cases of gastric carcinoma, and in other instances to make it early (see below). We must wait and see what the technic and possibilities of gastroscopy achieve in the future, before we can look upon this method as positive and decisive. So-called exploratory laparotomy has also been employed as a diag- nostic aid. As a matter of fact every laparotomy is an exploratory incision, as only this gives us accurate knowledge as to the seat of the tumor, its 236 GASTRIC AND INTESTINAL CARCINOMATA physical composition, its relation to neighboring organs, the existence of complications, etc. In this respect, exploratory incision is in truth the best and most cer- tain diagnostic method. But this opinion is not generally held nor the fact recognized, above all among the laity. Although with the great develop- ment in technic as well as in antisepsis and asepsis the risk is not great, nevertheless the method is rejected even at the cost of a positive diagnosis. In these instances laparotomy is frequently begun as a therapeutic meas- ure and ended as an exploratory operation. I believe an exploratory incision to be unjustifiable when the diagnosis is wholly obscure or when we entertain the suspicion of a malignant process but cannot possibly determine the organ affected. Here from a simple exploratory incision a lengthy, severe, and occasionally ineffectual operation may result. In describing the indications for the operative treatment of gastric carcinoma we shall again revert to this subject. From what has just been stated the impression will be given that in the majority of cases of gastric carcinoma a clear diagnosis can be made. Much more perplexing is it to determine at the onset with certainty or probability the exact seat, the extent of the process, the presence of metas- tasis, a beginning ascites or other complications. In so far as we are deal- ing with objectively demonstrable changes a careful examination will natu- rally assist us. Other very frequent occurrences, such as metastasis of the liver, or of the mesentery, etc., sometimes escape recognition. A diag- nosis entirely comprehensive in this respect is impossible. Intimately related to these difficulties is the much discussed question of the early diagnosis of gastric carcinoma. Even the prior question, " What do we understand by early diagnosis ? " is not easily answered. It has been said "that a diagnosis is made early if no palpable tumor is present." This is generally true. But the facts show that even in Bill- roth's time radical operation was attempted for gastric carcinoma, which proves that this requirement was not absolutely a prior condition for successful surgical treatment but also, inversely, what every one of ex- perience knows, that the impossibility of feeling a tumor is no proof of conditions favorable to operation. Neither will the time which has elapsed since the onset of the disease furnish us any clue to the distribution of the process, as groups of tumors which grow rapidly and also such as grow very slowly have been observed. The chemical findings, particularly the triad, stagnation, absence of hydrochloric acid, and presence of lactic acid, will in some of the indi- vidual cases enable us to make an early diagnosis even although the tumor elude discovery, although isolatedly there are benign processes with the same chemical finding, and, notwithstanding the fact that the presence of this triad of symptoms indicates conditions already very unfavorable for the removal of the tumor. GASTRIC CARCINOMA 237 Nevertheless, in the points above mentioned, collectively at least, and so long as no better criteria exist, these factors in a large number of cases permit an early diagnosis. The usually very decided period of latency forms the greatest obstacle in the discrimination of gastric carcinoma. In this stage the patients have but relatively few symptoms, do not consult a physician, and resort to home remedies. Certainly most of the carcinomata which we meet are already well advanced and manifest conspicuous symptoms, above all, a palpable tumor. In this condition gastroscopy even should the technic become more simple will not materially aid us. Nothing is easier than the diagnosis of rectal, uterine or mammary carcinomata, and yet in these we hear of precisely the same perplexities on the part of the surgeons and gynecologists as in the case of gastric carcinoma. Nevertheless it would be a great mistake to allow these obstacles to daunt us, and to relinquish our endeavors to make an early diagnosis. The marked successes reported in literature resulting from early operation after an early diagnosis of gastric carcinoma should encourage us, even with the basis of our present methods, always to attempt to diagnosticate the disease as soon as possible. A special form of carcinoma still to be described is carcinomatous ulcer. Previously investigated by Eokitansky and Dittrich, carcinomatous ulcer has recently been thoroughly studied by Hauser. Opinions as to the frequency of the transformation of a simple ulcer into carcinoma are to-day widely asunder. According to Lebert, 9 per cent, of all gastric cancers are due to this cause. Rosenheim found it only in 5 to 6 per cent., and Ewald has lately declared carcinomatous ulcer to be far more fre- quent than has up to this time been assumed. According to my experience a positive diagnosis of carcinomatous ulcer intra vitam is impossible. The chemical examination of the gastric contents utterly fails us. The excess of hydrochloric acid which Rosen- heim previously believed to be decisive is found, as we now know, also in carcinoma without ulcer. I have repeatedly observed in carcinomatous ulcer severe, rapidly succeeding gastric hemorrhages. Yet even these are not decisive. We should always think of carcinoma ex ulcere if positive symptoms of ulcer have for a long time preceded the process. COURSE The course of gastric carcinoma depends upon various factors, primar- ily upon the nature and seat of the tumor. Experience has shown that there is a gliding scale for the malignancy of carcinoma; that, for exam- ple, adenocarcinomata grow more slowly and less frequently develop me- tastasis than the rapidly growing, speedily decomposing medullary carci- nomata which readily promote the carrying of carcinomatous products. 238 GASTRIC AND INTESTINAL CARCINOMATA Scirrhus is again characterized by its tendency to advance rapidly and cause stenosis, colloid carcinoma by its unlimited growth. Possibly the seat of gastric carcinoma is of even greater significance in the course. It was formerly assumed that the point of predilection was the pyloric region. More recent experience, as well as operations and autopsies, shows this to be no longer true. Carcinomata of the smaller curvature are not less frequent than those of the pylorus, and it is even likely that, similar to the course in ulcer, the smaller curvature is the preferred seat for carcinoma. No matter how this may be, the fact is generally accepted that the nearer the carcinoma to the pylorus the more rapid and more serious the course of the disease. Under these circumstances the malady may set in with elementary force and in an exceedingly short time, even a few weeks, cause death (acute carcinoma). In opposition to this are the slowly growing carcinomata with numerous variations which are clinically ill-defined, and, according to whether improvement or aggravation appear, keep the patient and the physician wavering between hope and fear. The cause of this latency is easily recognized if we remember that in carcinomata not situated in the pylorus vomiting is absent or only present to a slight extent, that hemorrhages also are but moderate, and that, finally, the ingestion of food and its assimilation are far less damaged than in the first mentioned group. Under such circumstances the patients may for a time gain in weight and subjective activity; nevertheless, the outcome shows that the physician was correct in his grave prognosis. It need scarcely be mentioned that the course of the pathologic process is influenced to a decided extent by the most varied complications, such as ascites, proliferation into the peritoneum, external rupture or rupture into the intestine, metastatic pleurisy, etc. We see from this that in a given case the determination of the duration of the course is beset with great difficulty. However, it may be estimated on the average at a year to a year and a half. If this period has elapsed we will rarely go astray in excluding a malignant process. COMPLICATIONS AND SEQUELS The complications which may occur in the course of gastric carcinoma are numerous. Some of these are due principally to the nature of the affection, and for this reason are not of great clinical interest. Others, however, require a brief description. I must first call attention to the fever which occurs in carcinoma; this was mentioned by Wunderlich in his well-known text-book, and has been more accurately described by Hampeln (1884). Carcinomatous Fever. According to Freudweiler, who made a thor- GASTRIC CARCINOMA 239 ough study of carcinomatous fever in 475 cases of carcinoma in the Zurich Clinic, this symptom was present in 117 cases (i. e., in 24.6 per cent.), and was not due to complications; rarely (that is, in 1.5 per cent, of all cases) the fever was almost continuous, usually it was remittent or intermittent (in 10 per cent, of the total number of cases) ; much more rarely it was typically intermittent and resembled malaria (in 3.6 per cent, of all cases, in 14.5 per cent, of febrile carcinoma) ; in the latter case, the fever was not so typical as in malaria, often it was of an inverse type, the time of its appearance varying on different days as did the duration of the febrile period; in a number of cases the temperature rose but gradually instead of suddenly as in malaria. With relative frequency (in 38.5 per cent, of the fever cases and in 9.3 per cent, of all cases of carcinoma) there were isolated rises in temperature which did not last longer than three days. In the majority of the patients the condition was that of ulcerative carcinoma so that the fever was attributed to secondary infection; in the minority, however, no ulceration could be detected at the autopsy. There- fore, carcinoma in itself, similar to tuberculosis and lympho-sarcoma, has pyrogenetic properties. Inversely, as Freudweiler has shown, carcinoma may also run its course with subnormal temperature. In 47.8 per cent, of his cases temperatures below 96.8 F. were repeatedly found. Coma Carcinomatosum. A second important complication is coma car- cinomatosum which was first described by v. Jaksch, then by Senator, Riess, G. Klemperer and others. Acetone was first found by v. Jaksch in the distillate from the urine, and Klemperer later detected oxybuiyric acid. Coma carcinomatosum resembles diabetic coma except that, in my experi- ence, its course is not so rapid. In one of my patients with rectal car- cinoma, in whom a few months previously colostomy had been performed, the comatose condition lasted very nearly two months. Whether in these cases, as is exceedingly likely in diabetes, there is an acid intoxication, or whether specific toxins generated by the carcinomatous poison are opera- tive, is not yet known. Tetany is very much more rare than the two complications just men- tioned. This form of tetany does not differ from that occurring in benign pyloric stenosis. In conclusion we must mention the dropsical symptoms in carcinoma (edema and ascites), venous thrombosis and metastases in the liver which, according to Lebert, occur in 50 per cent, of all the cases, also metastases of the pleura and of the lungs, and finally the appearance of multiple neuritis. PROGNOSIS The prognosis, as I need hardly mention, is very unfavorable provided surgical intervention does not soon interrupt the course for a time (un- 17 240 GASTRIC AND INTESTINAL CARCINOMATA fortunately, however, not for a very long time). As we shall show in the chapter upon therapy, internal treatment may bring about ameliora- tion of many of the symptoms and increase the strength, but the unfavor- able outcome cannot be averted. When no complications are present, the prognosis depends mainly upon the nature and seat of the tumor. As I have already mentioned, carcinomata which do not implicate the pylorus run a much slower course, I might almost say a more benign course, than carcinomata which cause stenosis. As regards danger to life, such car- cinomata may be prognostically designated as more favorable, but with the limitation that under a radical operation the chances of success are even less than in those of the pylorus. CARCINOMA OF THE INTESTINES Proceeding downward from the stomach we meet with carcinomata everywhere but and this is of great importance by no means with the same frequency. While carcinomata of the small intestines are extremely rare, carcinomata of the rectum are about as numerous as those of the esophagus. Between these, carcinomata of the large intestine are found; and here also the curvatures are the points of predilection. From this it is evident that, a fact to which Virchow called our attention, those por- tions of the digestive canal through which the contents move but slowly and sluggishly are particularly predisposed to the development of malig- nant tumors. SYMPTOMS I shall first describe a typical case of carcinoma of the large intestine, then one of the rectum, and in connection with these shall briefly delineate the symptomatology of carcinoma of the small intestine. The patient was a man in the forties and, except for the diseases of childhood and other mild affections, he had up to the present time always been well. In particular he had never complained of gastrointestinal disturbance. Here we observe the abrupt onset in the midst of perfect health to which I called attention when describing carcinoma of the stomach. The patient stated that the first symptom was stubborn constipation, so that at the onset of the affection he was compelled to resort to active. purgatives to regulate the function of his bowels. Following the consti- pation attacks of severe colic soon appeared, first at long intervals, and later every two or three days. Finally, he complained of marked loss of weight, lassitude and inability to follow his occupation. It is evident here that the onset of the affection was but slightly characteristic. At first a mild coprostasis, a flatulent colic appears, such as we are CARCINOMA OF THE INTESTINES 241 accustomed to see every day. But, under these circumstances, it is well not to be too optimistic, even in cases in which there is no serious indica- tion of a malignant affection, particularly when an obvious loss of weight cannot be attributed to alimentary processes. In every case it is well to bear the patient in mind. Repeated weigh- ings should be made, and the physician should not be content until he has decisive evidence whether a mild, or, vice versa, a very serious malady is present. Too great pessimism will do no harm, especially if it should later give way to positive optimism. So much as to the onset of the disease. Let us now discuss its further development. In the last few weeks the intestinal cramp increased to an unbearable degree. The patient was compelled to take narcotics. Purga- tives which at first had been active were now ineffectual even in large doses. Stronger drugs were all the time taken, and finally drastics were employed, without relief. The feces no longer appeared in solid, cylindrical masses as formerly, but in the shape of small scybala, frequently admixed with mucus or as a small quantity of thin fluid, or, finally, in this or that form. The patient has not noticed blood in the dejecta. Upon being questioned he reports that he frequently noted simultaneously with the attacks of pain, but often also without these, a distinct, intestinal rumbling similar to the dripping of a fluid, and that this was even audible at some distance. Very observant patients will occasionally state, upon being asked, that occasionally, especially if active pains are present, the prominence of some portions of the intestines has been perceived. Although these symptoms are by no means positive signs of the nature of the affection, nevertheless it is wise not to place too low an estimate upon them. I can positively state that, from a history of this kind all the details of which have been taken into consideration, I have made a diagnosis of carcinoma of the large intestine even before the patient un- dressed himself for a physical examination. Absolute certainty, above all, is furnished by the clinical findings. I shall not allude to the general symptoms, which were discussed in the previous chapter on visceral carcinoma, but shall only consider what may be demonstrated locally. In intestinal carcinoma the finding of a well-characterized tumor is unquestionably the most positive and decisive symptom. Let us discuss the local findings in the patient in question. As was readily observed, there was an apparently hard but slightly movable tumor about the size of a mandarin in the cecal region, and this could be palpated. Does the tumor belong to the intestine, and to which part? Are we dealing with a malignant tumor? What is its degree of movability? As these questions arise in every case that is not absolutely clear, their immediate investigation is imperative. The fact that the tumor belongs to the intestinal canal may, as a rule, 242 GASTRIC AND INTESTINAL CARCINOMATA be determined without great difficulty from the history in connection with the other clinical findings. Nevertheless, sometimes perplexities arise which greatly annoy the diagnostician. A displaced lobe of the liver, hepatoptosis, with a gall-bladder full of stones or showing carcinomatous degeneration or dropsy, normal but low-lying kidneys, renal tumors, tu- mors of the omentum, and even tumors of the pylorus may, under some circumstances, simulate neoplasms of the large intestine. In the chapter devoted to diagnosis I shall enter upon these details more minutely. To prove whether a benign or a malignant process is present is by no means always easy. Chronic perityphlitis with decided induration, tuberculous thickening of the cecum, not to speak of other benign tumors (fibromata, lipomata, myomata, etc.), may resemble malignant neoplasms to such an extent that the true condition is recognized only after pro- longed observation, often only at the operation or at the post mortem. In regard to movability, the law generally obtains that in intestinal tumors this should exist to a high degree. This general rule does not coincide with my experience. I can only admit that the most extreme grades of movability are observed in carcinomata of the large intestine; yet, when a great number of cases are studied, we find only slight, passive locomotion to be present. In the development of the tumor adhesions to neighboring organs very soon form. For distinct passive movability in inflation of the rectum with gas we have a method which is usually serviceable, but the intestines must not be too greatly distended with gas for, if this be the case, the tumor is covered by the intestines and is palpated with great difficulty. In the case in question it was readily determined that the tumor was hardly movable, and I may add that upon repeated investigation its posi- tion was unchanged. The inflation of the intestines per rectum gave no other results. Where there is undoubtedly a hard tumor of the large intestine, as well as other points in the clinical history, the clinical picture of carcinoma of the large intestine is sufficiently characteristic; there can be no doubt of the diagnosis. Other factors which we shall later consider at most serve to complement the pathologic picture. Very frequently, however, the symptoms are complicated. A tumor is absent. There are signs of a malignant intestinal affection but without positive indications as to its nature. Frequently we note a symptom which we also find in the case under consideration : The picture of chronic intes- tinal stenosis. As we have in this volume a masterly description by Noth- nagel of chronic intestinal stenosis (which see) I limit myself to a few salient points which relate particularly to carcinoma of the intestine. Intestinal Rigidity. In this condition the severe attacks of obstruc- tion accompanied by severe colic, occasionally by vomiting, which have already been described are subjectively decisive. Objectively, we must CARCINOMA OF THE INTESTINES 243 consider meteorism, suprastenotic succussion, and the visible, tetanic, in- testinal contractions to which Nothnagel has given the appropriate name of " intestinal rigidity" In well-developed cases of intestinal stenosis meteorism is rarely absent, but is present in varying degree according to the individual case. Sometimes it is localized, and permits a somewhat accurate recognition of the seat of the intestinal stenosis, or it may be general in the stage of intestinal paralysis, that is, of threatening ileus, and may then be indistinct or obliterated. Intestinal rigidity is the clearest and the most objective symptom of intestinal stenosis. In well-developed cases we note from time to time that the coils of the intestine above the stenosed area contract tetanically with sensations of actual pain, they become hard and stiff, and remain in this condition for some time. With a distinctly audible murmur that I have designated a pressure murmur, this contraction suddenly relaxes, or to a certain extent remains permanent^. These are the classical types of intestinal rigidity, but there are numerous deviations. The intestine may contract, for example, but not tetanically, it may become hard and only show an increase of tonicity similar to what we have observed in the stomach, or it rises slightly in the abdominal wall and rapidly sinks without producing acoustic phenomena in its state of relaxation. The extent of the stiffened intestinal areas varies greatly, according to the seat and the extent of the stenosis. Where stenosis is very marked and provided the seat is in the cecum or in the ascending colon, although rarely when deeper, we note how the small intestines rise one above another like the pipes of an organ, covering the entire abdominal surface, as has been graphically described by Nothnagel. It is scarcely possible to confound this intestinal rigidity with the in- distinct peristaltic motion which we meet with physiologically in well- developed diastasis of the recti, or in motility neurosis of the intestine (tormina ventric. nervosa, Kussmaul). The absence of pain, of rigidity, of constipation, of intestinal splashing, of a pressure murmur, indicates without further consideration the marked difference. Although intestinal rigidity points only to the existence of stenosis, and only exceptionally to its seat, we are frequently able to make a diag- nosis of intestinal carcinoma as well as from the remaining clinical course even in the absence of a tumor. Naturally, this is not always an early diagnosis but, under some circumstances, the conditions may be so favor- able as to permit a radical operation which may bring relief to the patient for a long time. In another group of intestinal carcinomata we find no symptoms of intestinal stenosis; these are the cases which from the onset show no annular band formation with cicatrization, but in which diffuse, infiltrat- ing, ulcerating tumors are found, as in the curvatures of the stomach. 244 GASTRIC AND INTESTINAL CARCINOMATA The symptoms in these cases provided a well-developed localized tumor be absent vary greatly, according to the stage, the seat, and the extent of the process. It may happen that for weeks and even for months positive intestinal symptoms are entirely lacking. Or, if they are present, they point to a severe intestinal affection the nature of which for a long time cannot be discerned. In such cases periodic, persistent investigation of the feces may in the course of time show the true nature of the condition. The investigation of the feces in intestinal carcinoma has not the same clinical importance as the examination of the gastric contents in the diag- nosis of gastric carcinoma. But a few factors are, nevertheless, significant. Among these is the single or repeated admixture of blood with the feces. This may introduce intestinal carcinoma, or may appear in its course, or may form the terminal symptom. The hemorrhages may be copious, or may appear as small specks which are hardly visible, or, finally, they may be occult and only detected by chemical examination (guaiac test) or by the spectroscope. Kochmann and I observed such occult hemorrhages in two cases of carcinoma of the colon, and greater attention will, therefore, subsequently be devoted to this symptom. In the main, however, copious intestinal hemorrhages are not common symptoms of intestinal carcinoma. Such an experienced investigator as Treves * calculates their frequency at only 15 per cent. Whether, however, smaller hemorrhages which readily escape recognition by the patient and the physician are not more frequent is yet to be determined. Besides pure hemorrhages, admixtures of blood and pus have been observed by other authors as well as by myself. I have repeatedly noticed these in deep-seated intestinal carcinomata (in the sigmoid flexure) which offer more favorable conditions for the retention of pus corpuscles than, for instance, the cecum or even the small intestine. That mucus also is sometimes admixed with the feces is readily con- ceivable if we remember that the carcinomatous neoplasm produces in a large portion of the intestinal tube a condition of catarrhal inflammation. In a case of carcinoma of the ascending colon near the cecum, deter- mined at the autopsy, I observed even a well-developed membranous colitis. In regard to the form of the feces, it has previously been briefly stated that various deviations from the normal may be observed. Thin, flattened, tape-like feces have been designated as typical of steno- sis. We know to-day that this is untrue, not because normal feces may temporarily appear in stenosis nor because the changes mentioned indicate tlio formation of stenosis. Only one condition of the feces is never found 1 Treves, " Intestinal Obstruction," London, 1899. CARCINOMA OF THE INTESTINES 245 in carcinoma causing stenosis, namely, a persistently well-formed, cylin- drical shape. In very isolated cases of intestinal carcinoma, just as in gastric car- cinoma, shreds of the tumor are found in the feces. The few observations at hand do not permit a conclusion as to the clinical value of this symp- tom; nevertheless, this much is certain, that sequestration only occurs in well advanced cases. In this description I have considered mainly the high-seated carci- nomata of the large intestine. The deeply-seated ones, therefore those from the flexura colico-lienalis downward, are marked by certain peculiar- ities which I must briefly indicate. Here tenesmus, which we must consider in detail under the descrip- tion of carcinomata of the rectum, becomes prominent, not only tenesmus recti alone but combined with tenesmus vesicae. Rectal Carcinomata. Occasionally the latter may be so prominent that we are inclined to think of an affection of the bladder. If a tumor be present it is situated either in the region of the sigmoid flexure or closely adjacent to the bladder where it may be felt below or beside this organ. In one of my cases the tumor was situated at the right side of the bladder, and was therefore thought to be a cecal tumor. Occasionally, however, carcinomata of the sigmoid flexure, as Kb'rte correctly remarks, are not susceptible to palpation, that is, when their situation is intermediate, or just above the rectum. They cannot be reached by digital examination either from above or below, and offer great difficulty in diagnosis as well as in surgical operations. Carcinomata of the sigmoid flexure lead imme- diately to the description of the most deep-seated intestinal carcinomata, those of the rectum. We shall proceed to consider these by quoting a concrete case. The patient, as was at once apparent, showed no cachexia, nevertheless the history denoted that we were dealing with a serio^us affection. He was 52 years of age. He stated that his mother perished after several operations for a tumor of the uterus, his father died from apoplexy. The patient gave an excellent history of himself up to the time of the present disease, which began about five months ago with a slight sensation of pressure and inability to evacuate the bowels naturally. The feces were. very frequently admixed with mucus, gradually tenesmus became more marked, and every three or four hours the patient was compelled to seek the toilet, frequently without other result than thin fluid feces admixed with mucus, and even then showing traces of blood. Thinking he had intestinal catarrh he resorted to a diet consisting of non-irritating gruels and soups with the result that tenesmus was produced and his strength and weight decidedly decreased. Among the symptoms tenesmus became prominent and this at once indicated that the seat of the affection was in the rectum. Of course in all 246 GASTRIC AND INTESTINAL CARCINOMATA cases in which this symptom is mentioned we do not invariably at once think of carcinoma, as the same is complained of by patients with hemor- rhoids, with acute and chronic proctitis, with ulceration in the rectum, with prolapse of the rectum, with so-called fecal impaction, and even in purely nervous spasm (proctospasm) this symptom is by no means rare. Nevertheless, whenever we have the symptom of tenesmus a careful digital or ocular exploration of the rectum should at once be made. Before describing the patient's condition we shall first determine whether physical examination of the thoracic organs and external palpation revealed any anomaly. This was not the case except for one suspicious point. We found that the liver was decidedly enlarged. It projected beyond the border of the ribs about three fingerbreadths, and the border was con- spicuously hard to the touch but not otherwise painful. Digital examina- tion confirmed our suspicion. High up in the rectum a hard, nodulated, scarcely movable tumor was felt, and, as was observed when the finger was withdrawn covered with blood, an ulcerative tumor. This made the diagnosis in our case positive. The only question which remained was whether the enlargement of the liver was connected with this carcinoma of the rectum. I believe we must answer this in the affirmative as rectal carcinoma is especially prone to cause metastatic processes by means of the hemorrhoidal veins. To complement the examination of the tumor we may view the morbid focus directly by means of a speculum which is frequently employed for this purpose. However, I regard digital examination as decisive and usu- ally sufficient. The conditions are different with high-situated tumors which are difficult or impossible to palpate with the finger. Here, as I have convinced myself, the diagnosis may sometimes be made by an exam- ination with the speculum. If this also fails, examination under an anesthetic should never be omitted. In carcinoma of .the rectum in which a tumor can be palpated exam- ination of the feces is of secondary importance. Where the tumor is located high, and inspection and palpation give no result, careful and systematic examination of the feces may guide us to a correct diagnosis, from the fact that very frequently or constantly blood, mucus and pus, and occasionally desquamated shreds of tumor, are found. At all events we should not rest until we have satisfactorily explained these very conspicu- ous changes. Various deviations from the condition just described may mislead the physician who is not familiar with these symptoms. I can quote a few from my own rich experience without by any means exhausting them. Jn some patients the disease sets in with decided hemorrhage which, having once occurred, is soon repeated. The patient believes that the bleeding is from a hemorrhoid, and, assisted by popular literature or by his physician, is content with his "golden vein." In other cases marked diarrhea or CARCINOMA OF THE INTESTINES 247 actual tenesmus do not point to the rectum but to higher portions of the intestine. In still other instances I have observed how accidental compli- cations such as minor genital affections (in one case uterine retroflexion) so engrossed the attention of the physician that the affection of the rectum was entirely overlooked. In three of my cases pregnancy was present, and the patient's symptoms were attributed to this until digital examination revealed the existence of a rectal carcinoma. In two of these, fortunately, extirpation was possible. Simple as the condition appears, the recognition of a carcinoma of the rectum is difficult when the affection has not developed along normal lines, and when it can only be recognized by careful digital examination, which is necessary in every such case of intestinal disturbance. Cancer of the Small Intestine. In carcinoma of the small intestine we are on much more uncertain ground. Carcinoma of the duodenum shows such similarity to the clinical picture of gastric carcinoma that a differentiation between them is simply impossible. At all events, in car- cinomata situated below the papilla of Vater with the constant regurgita- tion of bilious masses, we may assume a stenosis in the region of the pars descendens duodeni and not beyond this unless, exceptionally, a clearly localized, easily palpable, and otherwise characteristic tumor points to the nature of the affection. The recognition of so-called papillary carcinomata, i. e., those situated and growing around the papilla, is extremely perplexing. Jaundice devel- ops very rapidly, but it is simply impossible to determine its cause on account of the many conditions which are here present. If a tumor can be palpated, sometimes even without this, the diagnosis of a malignant affection may be more or less accurately made from the course of the disease. The determination of its seat is, however, always accidental. In all carcinomata of the duodenum gastric disturbances are the most promi- nent, particularly vomiting, while symptoms attributed to the intestine are of a secondary nature. What is true of papillary carcinomata is, in the main, true of the exceedingly rare carcinomata of the jejunum and ileum, especially as these only exceptionally lead to the formation of a tumor. When a tumor is present it is distinguished by its great movability. Occasionally, when symptoms of stenosis develop with constant vomiting of fecal or fecaloid masses, we may diagnosticate the seat of the tumor as in the jejunum. The appearance of intestinal hemorrhages may then be a further indica- tion of the nature of the disease. The subjective symptoms, in the main, do not differ from those of deeply situated duodenal carcinomata. 248 GASTRIC AND INTESTINAL CARCINOMATA DIAGNOSIS The diagnosis of intestinal carcinomata, as is evident from the fore- going, meets with great and occasionally insurmountable obstacles. We shall not refer to these again, nor shall we enumerate all the errors which may diagnostically come into question, as it is impossible to exhaust the list. We hold that the decisive and most important symptom is the finding of a tumor in the intestine, and even this, aside from the difficulty of its positive localization, does not confer absolute certainty. Thus, for exam- ple, a frequent source of error which has lately been much discussed is found in inflammatory tumors of the cecum. Here, primarily, the differentiation of intestinal carcinomata from tu- bercular ulcers comes into question. Obrastzow l mentions the following points in the differential diagnosis of these conditions: In carcinoma of the cecum the intestines themselves cannot be palpated, but the tumor with the cylindrical mass attached to it and extending downward as well as the ascending colon passing upward is palpated. In contrast with this, in tuberculosis of the cecum the intestine with its characteristic peculiarities is for the most part susceptible to palpation, but its walls appear thickened and infiltrated. Moreover, pal- pation usually shows the tumor of carcinoma to have sharply defined borders, while in tuberculosis the infiltration more or less gradually dis- appears. Finally, in carcinoma of the cecum stenosis very soon occurs. These points may be unquestionably looked upon as auxiliary factors, but it is doubtful whether in the majority of cases they enable us to reach a positive decision. The constant finding of tubercle bacilli in the feces without simul- taneous pulmonary tuberculosis, as mentioned by Obrastzow, is far more decisive. If this is confirmed we will have an additional diagnostic cri- terion. Besides this, the age, the duration of the disease, the state of the lungs and the course of the fever will aid in the diagnosis. Collectively in isolated cases they make a definite opinion -possible, in others this will be tentative, and will remain so until later clinical signs (ascites, etc.) or laparotomy remove all doubts. Besides cecal tuberculosis other inflammatory processes from the vermi- form appendix, and occasionally also from the typhlon, may assume a tumor-like character so that in deciding as to their nature certain doubts arise. Errors in diagnosis are frequently made in surgical cases from the fact that malignant tumor has been assumed where a simple exudate is present, and vice versa. But by careful clinical observation these errors, as a rule, may be avoided. The same is true of the exceedingly rare cases of benign tumors in the 1 Obrastzow, Arch. f. Verdauungskrankheiten, Bd. IV, 1898. CARCINOMA OF THE INTESTINES 249 cecum (myomata, lipomata, fibromata, etc.), while the differentiation from sarcomata is only possible under very favorable clinical circumstances. Benign infiltrations may occur in the sigmoid flexure as well as in the cecum (sigmoiditis) ; occasionally they are of the consistence of a neoplasm and thus make the diagnosis difficult or impossible. Spastic contractures of the colon must here be referred to; they are frequently associated with obstinate habitual constipation, and are found particularly in the transverse colon, in the cecum, and are occasionally very conspicuous in the descending colon and the sigmoid flexure. As a rule, however, it is possible at once to determine a functional spasm by inflation or by filling the intestine with water. By this means the spasm completely disappears to develop anew after a short time. We are here upon more positive ground than in the diagnosis of tumors of the rectum. In so far as they may be reached by the finger or the speculum, they rarely cause confusion, and above all, benign neoplasms and syphilitic strictures here come into question. In regard to the first, with the exception of polypi, which are extremely rare, we observe that benign tumors of the rectum never produce ulceration, while these as a rule occur very early in carcinomata of the rectum; nor does stenosis occur, at least not the very characteristic, rigid stenosis of carcinoma. I must not fail to mention, however, that benign tumors of the rectum, particularly polypi and papillomata, not rarely in later years lay the foundation for carcinoma. I have observed a case of this kind. Well developed syphilitic stenoses present an 'entirely different appear- ance from carcinomatous ones. As Kraske x correctly states, syphilitic ulcerations never have the coarse, tumorous border of the malignant, and, unlike these, are usually multiple and separated from one another by areas of normal or cicatricially altered mucous membrane. In doubtful cases the diagnosis may also be made by microscopic examination of a small excised particle or a portion that has been detached by the finger. Diagnosis of Cancer of the Small Intestine. The diagnosis of carci- noma of the small intestine, even when tumor is present, is most difficult. So long as we are dealing with the upper portion of the duodenum and on account of the identity of the clinical course, the differentiation from gastric carcinoma, as has already been mentioned, is simply accidental. Lower down, particularly in the descending part of the duodenum, the conditions are somewhat more favorable, as the permanent regurgitation of bile is a valuable point in regard to the seat of the tumor. Still further down, however, the clinical symptoms again become indistinct, and only exceptionally permit a well-founded opinion. The nearer the carcinoma of the small intestine is to the ileo-cecal 1 Kraske, " Erfahrungen iiber den Mastdarmkrebs." Volkmann's Sammlung klin. Vortrdge. 1883-84, p. 789. 250 GASTRIC AND INTESTINAL CARCINOMATA valve, the more closely does the clinical picture resemble that of carcinoma of the large intestine, and it becomes impossible positively to diagnosticate the condition. All this is true of intestinal carcinomata with determinable tumor for- mation. Where this is absent the conditions, as a rule, are still more com- plex. Not that the diagnosis under these circumstances is impossible; on the contrary, for example, stenosed carcinomata of the large intestine, even without palpable tumors, may furnish typical cases. In others at least as far as the determination of a stricture of the large intestine and, proceeding from this fact, a reflection of the entire clinical picture a probable and even a positive diagnosis of carcinoma of the intestine may be made. Nevertheless, complicating factors frequently mislead the diag- nostician, so that great care is necessary. We waver, however, in our opinion when a palpable tumor and symp- toms of stenosis are absent. In this case the clinical impression can at most only indicate the correct direction, and this impression is further strengthened by certain episodes, for example, the onset of severe hemor- rhage, the discharge of particles of the tumor, the appearance of palpable metastases, ascites and edema, perforation into neighboring organs which usually occurs at a very late stage, and is unfavorable for " operative " treatment. Examination of the feces may mislead us, especially as the finding of blood and pus is susceptible of many explanations, and does not permit, for example, a differentiation from ulcerative colitis. COMPLICATIONS AND SEQUELS The complications and sequels of carcinoma of the intestine in many respects resemble those of carcinoma of the stomach. In one as in the other febrile conditions may appear, usually in the advanced stages of the affection. Coma carcinomatosum has also been observed in cancer of the intestine. Metastasis of the liver, ascites, pleurisy, peritoneal carcinosis, external or internal ruptures occur particularly into the peritoneum, the bladder and the female genital organs. Other sequels belong to the realm of casuistics, and therefore do not need especial mention at this place. The chief complication of stenotic carcinoma requires a thorough de- scription: The transition of partial into complete obstruction. This may increase slowly and gradually to total occlusion, or it occurs suddenly in a previously permeable intestine and may astonish the patient as well as the physician. The latter may be due to several causes : Either the power of the hypertrophied suprastenotic musculature, which has functioned well, ceases suddenly and completely, or in and immediately above the stricture obstructing fecal plugs or a residue of food have accumulated which, not- withstanding sufficient muscular power, make propulsion impossible, or, finally, a quantity of stagnating fecal masses may produce volvulus. TREATMENT OF CARCINOMATA 251 In these cases a fulminant intestinal occlusion occurs with threatening danger which can only be averted by an early operation. Pseudo-ileus may, however, also be present. The patient presents the severe picture of absolute intestinal occlusion. Internal treatment is entirely without result but, nevertheless, contrary to our expectations, the intestines may again become open, the patient may pass gas and feces, and is for the moment saved. But only for the moment ! For the next or a succeeding obstruc- tion may become complete and, in spite of medical treatment, pursue its fatal course unless surgery again intervene at the proper time. PROGNOSIS The prognosis of cancer of the intestine, as need scarcely be reiterated, is in the main just as grave as that of other carcinomata. But, in the opinion of numerous surgeons, the tendency to the formation of metastasis is not so great as in cancer of the stomach, so that operation performed at the right time offers in the main better chances than in the latter affection. And, as we shall point out in the chapter devoted to treatment, the possibility of total extirpation, for example, in carcinoma of the colon and of the rectum, is more frequent than in carcinoma of the stomach; the circumstance also that in carcinoma of the colon and of the rectum the nutrition is relatively but little affected makes the prognosis somewhat more favorable than in carcinoma situated higher up. TREATMENT OF CARCINOMATA OF THE STOMACH AND OF THE INTESTINES This combined description of the treatment of carcinomata of the stomach and intestines has not been without a purpose. The fundamental laws of internal as well as of operative treatment present in both such numerous points of contact that a collective presentation is by far the best to answer didactic requirements. Complete cure of a gastric or intestinal carcinoma is unknown, not even by means of the knife. The latter by radical or palliative procedures may decidedly prolong life, not, however, or at least very exceptionally, up to the normal, probable duration of life of the individual in question; but even with the highly developed surgical technic of to-day and the popularity of operations on the intestinal canal, this prolongation of life occurs only in a small fractional number of the patients. 'According to the statistics of G. Heimann 1 made in Prussian hospitals in the years 1885 and 1886, 14.4 and 15.9 per cent, respectively of patients with cancer of the stomach were treated by operation, and even in cancer of the rectum in the same years only 45 per cent., at most 50 per cent., of i 0. Heimann, Arch. f. klin. CMrurgie, Bd. LVII, p. 4. 252 GASTRIC AND INTESTINAL CARCINOMATA the cases were operated upon. We cannot be far wrong in assuming that the remaining number were already in such a hopeless condition that operation appeared to be useless. Therefore, the majority of patients with cancer of the stomach, even to-day, must be treated by internal means and in no inconsiderable num- ber of those operated upon this is necessary after the operation (palliative or radical). Internal Treatment. The objects of internal treatment depend in gen- eral upon the following considerations: As an actual cure is impossible it becomes necessary, just as in other internal conditions (gall-stones, dia- betes) to keep the affection latent as long as possible, and to ameliorate or remove the subjective and objective disturbances which arise. This may suffice for a certain time but permanently it is inadequate, and the reasons for this are manifold. Primarily, we must consider the mechanical disturbances which fre- quently arise in gastrointestinal carcinoma, then certain toxic products which are produced by the carcinoma, subsequently the hemorrhages which mediately or immediately are caused by the carcinoma, also metastasis, and, finally, the disturbances of metabolism which, even though not wholly, are nevertheless in great part the consequence of carcinoma. Tn regard to the latter, the accurate investigations of F. Kraus, Fr. Miiller, and Klemperer, to which those of v. Noorden-Gartig must be added, have given us full information. They have unanimously shown that a number of patients with cancer, notwithstanding plentiful food and a high amount of albumin, permanently lose N. Fr. Miiller found that on increasing the administration of food the conditions remained unchanged. The N-excretion was invariably greater than the N-intake. The increase of acetone observed by F. Blumenthal in severe carcinomatous cachexia points to an increased decomposition of albumin. The more these products increase, the more marked and persistent is the loss of strength, and vice versa. It is, therefore, evident that the nourishment of patients with cancer is extremely difficult. In addition to this, the appetite in the course of carcinoma is very frequently, although fortunately not always, decidedly decreased, chiefly so in carcinoma of the stomach and small intestine, and to a somewhat slighter degree in carcinoma of the colon and rectum. We must always bear in mind the importance of nourishing patients with cancer as plentifully as possible. Our individual points of view must depend upon the position and the nature of the carcinoma, and the stage in which the patient comes under professional observation. Let us begin with cancer of the stomach. We find the conditions vastly different according to whether the carcinoma runs its course with or without very decided motor disturbance, or, vice versa, severe symp- toms of stagnation are present; in the latter case, as a rule, vomiting TREATMENT OP CARCINOMATA 253 dominates the scene. In the former case, a decided limitation of diet is not indicated, or to but very slight extent. Albumin, carbohydrates, and fat, naturally most carefully prepared, are permissible, and above all milk and milk preparations in the most varied form and according to the indi- vidual circumstances and the wishes of the patient. With a fairly good appetite and the careful combination of foods, it may be possible to keep the patient for weeks and months in good condi- tion, and now and then even to increase his weight. Occasionally the patients are subjectively better, and their courage revives, a fact to which the gain in weight conduces not a little. It is unfortunate that most patients with cancer of the stomach have a distinct repugnance to meat and meat derivatives (therefore to bouillon and meat extracts). Hence the administration of meat cannot be insisted upon, but an attempt should be made to administer other albumin bodies, with eggs, carbohydrates rich in albumin, dishes prepared with milk, etc. After a prolonged abstinence from meat an attempt may be made again to administer it in some form, but usually without success. The nourishment of the patient is much more difficult in carcinoma at or near the pylorus. Here, as a rule, we are limited to fluid food, and often but small quantities will pass through the pylorus. Above all, milk preparations, soup with the yolk of an egg, the various leguminous vege- tables, and cereals in convenient form, may prove serviceable. That only small quantities should be administered will be understood. From the quantity of urine voided, and by comparing the amount of material found in the stomach by lavage in the early morning with the amount of fluid introduced, we can practically estimate the amount absorbed. It is perhaps well at this point to touch upon the value of artificial food preparations in cancer of the stomach. We may to-day regard it as certain that they have no beneficial effect on the nutrition. Their value consists solely in the fact that the patients who have no appetite for food, but actual repugnance, regard the intake of these sub- stances mixed with nutritive preparations as a duty to which they submit as willingly as to that of taking medicine. From this standpoint it is quite immaterial what artificial food we administer to cancer patients. The individual taste will best decide. According to my personal experi- ence the most suitable preparations are : Puro, meat jelly, somatose, sanato- gen, roborat. These products will also furnish a sufficient variety. Luxuries, substances which tempt and stimulate the appetite (v. Ley- den), are just as important as nutritive preparations. What has been said above is also true of these. By their aid it is often possible for a long time to keep the patient away from the cliffs of inanition. What is advisable in the individual case depends upon the social position, upon the habits, and finally upon the wishes of the patient. At all events by being too strict we may do more harm than good. 254 Among the auxiliary dietetic measures belong artificial, or, as it has lately been called, extra-buccal nutrition. For the technic and other details we must refer to von Leube's excellent description. It only remains for us briefly to mention the value of this in carcinoma of the stomach. Unquestionably the mere introduction of fluid to prevent a too dry con- dition of the organism may also prevent threatening tetany and the accu- mulation of toxic products, and the intake of even a few calories is a gain which should never be undervalued. No one will claim that extra-buccal nutrition decidedly prolongs the life of the patient with cancer. The simplest method and the one most in use is by means of nutritive enemata; subcutaneous methods (oil-sugar solutions), no matter upon what scientific principle they are based, have, as yet, not found general acceptance. What is true of cancer of the stomach is also true of carcinoma of the small intestine. In carcinoma of the large intestine other points of view arise, and, above all, it is here an absolute law that we should avoid everything in diet which may obstruct or delay the passage of the feces. Avoidance of all substances with skins containing residue unsuitable to the gastric and intestinal juices is therefore a leading principle. Then the nutrition must be calculated directly to stimulate intestinal peristalsis. This may be attained by physiologic aperients: Honey, milk sugar, sour milk, stewed fruit, lemonade, wines made from fruit, marmalade, and fruit jellies. Other foods may be given in the form and manner mentioned under the consideration of cancer of the stomach. In ulcerating carcinomata which do not run their course with the formation of stenosis, we must be particularly careful of the diet. The most suitable articles here are milk and milk preparations, soups made from leguminous vegetables, soups containing eggs, meat jelly, etc. In extreme stenosis from obstruction the introduction of food is most difficult on account of the mechanical hindrance to the passage of feces. Under these circumstances we must limit ourselves to small amounts of highly concentrated food. The artificial introduction of food in carcinoma of the large intestine is only permissible provided the neoplasm does not extend lower down than the cecum or the flexura colico-hepatica. Below this it will irritate rather than benefit the nutrition. In carcinoma of the sigmoid flexure there can naturally be no question of rectal alimentation. Reports in regard to subcutaneous nutrition, which is here indicated, are not to my knowledge at hand. Drug Treatment. To ameliorate the sufferings which carcinomata of the stomach and intestines bring in their train drugs are often useful, occasionally even indispensable. One of the most -frequent causes of distress in gastric and occasionally TREATMENT OF CARCINOMATA 255 also in intestinal carcinoma is loss of appetite. Often this can be relieved for a time by the so-called stomachics, by condurango as well as by other bitters; as a rule, however, they fail. In so-called achylia gastrica, which, as before stated, very frequently occurs in gastric cancer, we may employ hydrochloric acid and also pancreatic preparations to improve the digestion. Eecently pankreon has been much employed in the form of tablets each containing one gram. Pain in the region of the stomach and particularly of the intestine also calls for relief. In gastric pain, as a rule, mild narcotics (codein, dionin) suffice. In severe cases of obstruction, in intestinal carcinoma, the most powerful narcotics are necessary. First among these is opium in the form of the tincture of thebain, or pure opium (0.03-0.05) perhaps in combination with belladonna (extract of belladonna 0.01-0.03), then morphin as a powder, in solution, by suppositories or subcutaneously. Obstinate constipation by no means contraindicates the administra- tion of opium; on the contrary we frequently see that after complete in- testinal rest normal intestinal peristalsis again sets in. Opiates act remarkably well in the severe rectal and vesical tenesmus which we have learned to recognize as regular accompaniments of deep- seated carcinoma. By the influence of these drugs the patients may be spared these distressing symptoms for many hours during the day or during the night. Purgatives play an important role in the treatment of gastric and intestinal carcinomata. In the former purgatives will only rarely be administered, preference being given to lavage. If aperients are indi- cated, fluids or substances readily soluble in water are preferable to pills and also to tablets which are frequently dissolved with difficulty or not at all. In the stage of intestinal rest in carcinoma of the intestine, purgatives are usually indispensable, and here also purgatives that are easily soluble yet at the same time are mild and act quickly are the best. As most suit- able remedies for this purpose I advise: Fluid extract of cascara, com- pound licorice powder, castor oil, magnesium, rhubarb, flowers of sulphur and, finally, mineral waters in small doses. In intestinal carcinoma it is wise to keep the bowels regulated by the continuous use of a suitable purgative and thus avoid being surprised by the sudden cessation of peri- staltic action. Mechanical Treatment (gastric lavage). Gastric lavage in cancer of the stomach and small intestine may prove useful and palliative, but even here we must individualize strictly. This should not be resorted to so long as the motor activity of the stomach is unimpaired. It is true that lavage acts favorably upon the pain, also occasionally, when stagnation exists, upon the appetite. But even when this is the case, the nature of the carcinoma, its stage, 18 256 GASTRIC AND INTESTINAL CARCINOMATA and the strength of the patient must be carefully considered. In stagna- tion not too far advanced lavage may be employed, provided pain, a sensa- tion of pressure, nausea, vomiting and anorexia are present. Stagnation itself, in my experience, does not necessitate the employment of lavage. In the course of years I have seen numerous patients with cancer of the stomach who, in spite of moderate stagnation, remained in fair condition for quite a long time. With severe stagnation and coffee-ground contents I no longer employ gastric lavage, because I have observed that the patients are much worse after this treatment than before. If it be necessary to remove the stagnant masses, an expression limited to a few minutes is sufficient. But even in incipient cases I believe it wise to resort to gastric lavage as little as possible. With care in the diet we are frequently able to prevent abnormal collections of material. Indications for, and Results of, Operative Treatment. The physician is to-day in duty bound carefully to study the indications for, and the results of, abdominal surgery. In advising or rejecting operation, he is often held responsible both for what is done and what remains undone. He will base his opinion, in the first place, upon statistics of large groups of cases, and then upon personal experience. In any event, no matter how the individual case may present itself, the following questions are sure to arise: 1. Is surgical interference indicated in the stage in which this patient presents himself? 2. If this be the case, what operation is indicated, and what are the probabilities of success? In some individuals the answer to the first question is easy, in others difficult or even impossible. The decision may be quickly made in dealing with very cachectic individuals, also in those cases in which diffused edema, ascites, diabetes, hepatic metastases, or serious complications on the part of the heart, the lungs or the kidneys exist. Under these circumstances, naturally, any surgical interference will only hasten the end. Nor will we resort to operation if, for example, there is a very circumscribed carci- noma of the small curvature, which neither subjectively causes severe symptoms, nor objectively produces serious motor disturbance. Experi- ence teaches us that in such cases the duration of the patient's life is no less than after operation, provided that exceptionally a radical removal is indicated by the position of the growth. According to my experience the prognosis is very serious in those cases of carcinoma (usually at the pylorus) in which the vomited material or the evacuated gastric contents resemble coffee-grounds. The results which I have seen after even pallia- tive operation can scarcely be called good. In carcinoma of the large intestine and rectum the conditions are quite similar, but the lower down the growth is situated, the more favor- TREATMENT OF CARCINOMATA 257 able are the prospects of a radical operation. We shall revert to this later. In regard to the second question, if there are no centra-indications such as have been mentioned, surgical interference becomes necessary and we must now consider the question: What operation is to be performed, shall it be the radical removal of the tumor or merely palliative treatment, i. e., the removal of the motor disturbance ? Let us begin with the stomach. In the first place, we must confess that an absolutely positive decision as to whether extirpation or gastro- enterostomy is indicated is most difficult to answer prior to the laparotomy. No matter how favorable the location of the tumor, laparotomy may show such a general extension of the carcinoma that a radical removal of the tumor is simply impossible, v. Mikulicz and Kausch 1 therefore very properly remark that every operation is primarily an exploratory laparot- omy, and a definite plan of operation depends upon what is found on opening the abdominal cavity. In many cases we may at once exclude the possibility of total extirpa- tion, for example, when the tumors are large and immovable or when the tumor is movable but the patient has not sufficient strength. In non-palpable tumors the decision is still less possible prior to ex- ploratory incision. When we have reason to assume that a pyloric car- cinoma causes stenosis, a radical operation is at least possible. In other cases, however, even with a positive diagnosis, such an operation can hardly be advised. Besides gastroenterostomy, as a palliative procedure we should also consider jejunostomy which is particularly advised by v. Maydl. He introduced this operation for the cases of gastric disease in which a great portion of the stomach was destroyed, and in which it was impossible to supply sufficient nutrition. Recently this surgeon has advised us to employ jejunostomy in place of gastroenterostomy, as the former is much more thorough, and, besides, meets the important requirements of the case by sparing the diseased organ and protecting the neoplasm from all irritation. However, this operation has been employed by surgeons only to a limited extent, chiefly for the reason that, like all operations for fistula, cosmetically it is not fully satisfactory. The prolongation of life, too, is less than after gastroenterostomy. As a very thorough operation, total extirpation of the stomach, the union of the upper duodenum and the cardia, or the lowest portion of the esophagus, which was first successfully performed by Schlatter in Zurich, comes into question. Although to-day quite a number of favor- 1 v. Mikulicz und Kausch, " Handbuch der praktischen Chirurgie," Separatab- druck, p. 147. 258 GASTRIC AND INTESTINAL CARCINOMATA able results are reported in surgical literature, nevertheless, as v. Mikulicz and Kausch * state, metastatic lymph-glands are rarely absent in any case of gastric carcinoma, and, therefore, we should not indulge in too great expectations of the results of this heroic treatment. On the other hand, it must be admitted that some remarkable successes for instance, the last case operated upon by Fedor Krause favor the radical removal of the neoplasm. At the present time, however, the definite results, the failures and successes, cannot he positively recorded. In the main, gastroenterostomy and resection of the pylorus are the operations at this time most frequently performed. With the results of these methods we are comparatively well acquainted, a large number of statistics being available, as well as the individual reports of eminent surgeons. Thus, Terrier and Hartmann have collected the statistics of abdominal operations performed by distinguished surgeons (Czerny, Kronlein, Carle, v. Mikulicz, Kocher, and Hartmann) and from 127 resections of the pylorus have calculated a mortality of 26 per cent.; but this varies greatly. For example, Lindner has lately estimated the mortality at 50 per cent. In the main, however, the results of resection in the course of the last twenty years have gradually improved, v. Miku- licx 2 computed the total of radical cures at 17 per cent. If this estimate is compared with the total number of cures of other carcinomata we are by no means hopeless. According to v. Mikulicz, the cases of carcinoma of the breast permanently cured amount to from 10 to 15 per cent., with curettage of the axillary cavity to 25 to 30 per cent., in carcinoma of the uterus 30 to 35 per cent., in carcinoma of the rectum 10 to 20 per cent., in carcinoma of the tongue 10 to 20 per cent. If we compare these with the results of gastroenterostomy, the latter, on account of a more complete technic, and, above all, by the avoidance of the so-called vicious circle, are decidedly better. While, according to the last great statistical report of Chlumky, the mortality from 1881 to 1885 was still 75 per cent., from 1886 to 1890 it decreased to 48.4 per cent., and from 1890 to 1896 declined to 36.61 per cent.; for the past five years v. Mikulicz estimated his operative loss at only 28 per cent, (in his last report v. Mikulicz computes these fatalities at 26 per cent.). In gastroenterostomy, however, not only the immediate results of the operation but the prolongation of life as well as the functional results must also be considered. As to the former, the average results are not very satisfactory. Life was prolonged for five or six months; now and then there must have been brilliant exceptions to this. Nor is the functional effect in all cases satisfactory. Frequently the 1 L. c. 2 v. Mikulicz, 73. Yersammlung deutscherNaturforscher und Aerzte in Hamburg, 1001. Referat. TREATMENT OF CARCINOMATA 259 pains and vomiting recur, jaundice, ascites and edema appear, and a persistent anorexia leads to early loss of strength. Even in favorable cases, in spite of an increase in weight, the patients do not gain in strength, and are unable to follow their usual occupations. In other words, the prolongation of life is frequently nothing more than a prolongation of suffering. It is true some strikingly favorable results occur, but in the overwhelming majority of cases, after a brief improvement a progressive downward course is noted. It follows from this that, although the immediate results of gastro- enterostomy are relatively beneficial, for the duration of life as well as for the general bodily condition and functions, after gastroenterostomy there is still much to be desired. Under these circumstances surgeons as well as physicians frequently raise the question whether gastroenterostomy should not be limited in favor of total extirpation. After I had formulated this conclusion based upon my own experience, 1 v. Mikulicz, in the article cited above, and from his far greater experience, arrived at the same opinion. If from this standpoint we make a strict choice, the number of cases suitable for resection will not be great, perhaps will even be less than before, but the patient will have the benefit of not only an apparent but an actual result which may in some cases prolong life for many years. At the present time, our conclusions amount to this, that in cases in which total extirpation cannot be performed we should under special cir- cumstances advise gastroenterostomy; for example, when there are very marked disturbances (pain, vomiting), a fair degree of strength, and when the use of internal remedies has been futile. Occasionally, at the urgent desire of the patient and his relatives, to whom, for personal reasons, even a brief prolongation of life is a boon, we are constrained to consent. When the question of total extirpation arises, and the surgeon considers the patient's strength sufficient, this operation should be performed. Often enough, in such cases, we will be convinced of the futility of total extirpa- tion and content ourselves with gastroenterostomy, but now and then the constellation of conditions appears so favorable that radical procedures are undertaken. We now turn to carcinoma of the intestines, and in the case of carci- noma of the small intestine the laws and indications are the same as those which have just been described. The higher the situation of the carcinoma the more difficult is its total removal, as the duodenum nor- mally is so fixed that the total extirpation of a tumor is not only extremely difficult and attended therefore with great loss of time but is combined with great danger for the patient. Lower down, as is proven by a few successful sarcoma operations, complete success has been attained. But 1 Boas, " Diagnostik und Therapie der Magenkrankheiten," II, 4, Auuage, p. 222. 260 GASTRIC AND INTESTINAL CARCINOMATA the decision as to the most suitable time for operation meets with many obstacles. The conditions are more favorable in carcinomata of the large intes- tine and rectum. Whenever possible the radical method is here to be preferred to the palliative. Generally speaking, the conditions for total extirpation in the previously discussed carcinoma varieties are decidedly better than in carcinoma of the stomach ; for, as we have stated, metastases usually occur late, the tumor being for a long time movable, and less technical difficulty is encountered at the operation. In spite of this the results fall far below our expectations. According to Wolffler-Schloffer, up to the year 1896 the mortality in resections of carcinoma of the large intestine still amounted to 50 per cent. Yet the prognosis in regard to prolongation of life appears to be decidedly better than in high-seated carcinomata. Cases are on record of cure lasting seventeen years (Martini-Gussenbauer), of ten years (Czerny, a case of sarcoma), of eight and nine years (Korte), etc. I have a patient who had carcinoma of the cecum (adenocarcinoma) and whose recovery has lasted over five years. Nevertheless, up to the present time such recoveries are rare. Most cases, even after a radical operation, perish in the next two years. In case a radical operation cannot be performed two palliative methods of treatment remain : Entero-anastomosis and anus praeter naturam (colos- tomy). Unquestionably the first method is preferable to the other for obvious reasons. It also gives relatively good results according to Wolffler-Schloffer the mortality is 20 per cent. and prolongs life from a year to a year and a half. But here we must bear in mind not only that the patients live, but how they live. Although there are very favorable functional results, I have repeatedly observed, soon after the entero- anastomosis, renewed attacks of severe colic, marked loss of weight which had at first been increased, edema, and ascites. In conclusion, colostomy will only come into question when, on ac- count of the general condition, an immediate operation is necessary, there- fore either when the strength is markedly reduced in the early stages of obstruction, or where debility has more fully developed. These conditions will usually be found associated. The indications for colostomy are closely related to the situation of the carcinoma. For example, in carcinoma of the cecum the production of a fistula of the ileum is a questionable proceeding, both from a cosmetic and a nutritive standpoint. The true domain of colostomy is found in carcinoma of the sigmoid flexure and of the rectum, for here the feces have acquired a consistence which makes it possible readily to remove them. We now turn to the operative treatment of carcinoma of the rectum. According to the seat, the development, the movability of the tumor, and the presence of metastases, the following procedures must be considered: TREATMENT OF CARCINOMATA 261 Extirpation of the tumor, curettage, and the production of an artificial anus. The ideal method is, naturally, the radical removal of the tumor (amputatio recti or resectio recti), but, only when the tumor is sufficiently movable, and when there are no metastases of distant organs, especially of the liver, is this possible. Enlargement of regional lymph-glands, how- ever, forms no contra-indication to total extirpation. Since the perform- ance of resection of the sacrum by Kraske (1882) high-seated carcinomata of the rectum have also been radically removed. The results of these operations at the hands of different surgeons are far asunder, but in the last ten years they have become decidedly more favorable. According to Czerny's comprehensive statistics of the Heidel- berg Clinic, which have the advantage of originating with him and which cover a long period of time, 152 rectal carcinomata were observed in the years from 1878 to 1891 and 109 radical operations were performed. Among 83 cases which were operated upon by the perineal method 3 died, = 3.6 per cent. ; of 66 according to the sacral method, 9 perished, giving 13.64 per cent. The total mortality of 10 deaths in 109 cases is 9.1 per cent. Of 99 in whom radical operation was performed followed by a cure, 21 lived two years and more after the operation, 15, three years and longer, 13, four years and longer, 8, five years and longer; among these one case lived for 18 years, one case for 16 years, four cases re- spectively thirteen years and nine months, eleven years and six months, eight years and nine months, and six years and nine months. The fre- quency of relapse after extirpation is calculated differently by different authors. The figures vary between 41.6 and 73.3 per cent. Czerny main- tains that 20 to 25 per cent, of those in whom radical operation is per- formed continue free from relapses for two years, and the majority of them are permanently cured. The sacral method in particular diminishes the danger of relapse, as the lymph-glands situated in the excavatio sacralis are likewise removed. The functional results vary according to whether the sphincter is re- tained or removed. In the former case, the functional results, quoad continentiam recti, are very satisfactory. In the latter, the condition of the patient is most unpleasant, as he can retain neither gas nor fluid feces, and it is therefore necessary by diet and drugs to make the feces compact. Where a radical operation is impossible, as is unfortunately often the case, there are two methods, curetting and the production of an artificial anus the one direct, the other indirect by which we diminish or arrest the symptoms of stenosis. The curetting which may be performed with instruments, or, still better, with the hands, is best adapted to deep-seated carcinomata with special implication of the posterior wall of the rectum. When the tumor is high-seated it is best not to use this method as, under 262 GASTRIC AND INTESTINAL CARCINOMATA some circumstances, more harm than good is done. The same is true of deep-seated carcinomata in the anterior wall of the rectum. The most suitable and, relatively, the least dangerous measure for the removal of the symptoms of stenosis is unquestionably colostomy. This method most certainly relieves the irritation of the tumor, and cases are on record of prolongation of life for two or three years after the produc- tion of an artificial anus. In regard to the indications for colostomy the opinions of physicians and surgeons are wide asunder. While colostomy is frequently employed in England and France, in Germany, like all fistulous operations, it appears to have lost favor in the last few years. We may here speak of a relative and an absolute indication for its performance. The indication is relative if, while a fair intestinal passage remains, the patient steadily loses in weight and strength, is tormented by pain, and passes much pus and blood. In such cases we are decidedly in favor of operation, provided internal remedies have proven ineffectual. As long as evacuations at all sufficient are brought about by mild dietetic measures or by purgatives, we do not advise colostomy. With a suitable diet I have kept well advanced cases of carcinoma of the rectum alive just as long as by the production of an artificial anus. Colostomy is absolutely indicated when complete intestinal occlusion occurs or is threatened. In this case it is best not to wait so long that the patient's strength is diminished by vomiting, pain, and high-graded meteorism. The functional results of colostomy are satisfactory, provided we are careful to produce compact feces and the fistulous opening is kept well closed with a hernia bandage. We must consider, too, that many patients naturally find the daily manipulation of their intestines and of the dejecta exceedingly repugnant. It is, therefore, the duty of the physi- cian and the surgeon, in order to prevent subsequent regret, to explain to the patient in no uncertain manner before the operation the light and shade aspects of the anus praBternaturalis. DISPLACEMENTS OF THE ABDOMINAL VISCERA AND OF THE HEART BY F. HIRSCHFELD, BERLIN. INTRODUCTION UNTIL about twenty years ago a displacement of the viscera was gen- erally regarded as a rarity. It is true that at the beginning of the nine- teenth century celebrated clinicians such as Esquirol had devoted much consideration to displacements of the abdominal viscera, and had even recognized the connection between displacement of the colon and the devel- opment of mental disease; but, toward the middle of the century, these views were no longer considered tenable, as appears from the works of Griesinger, Wunderlich, Canstatt and others. Displacement of the colon was looked upon as unimportant, that of the stomach could not be de- tected by the ordinary clinical methods of the day, and only that of the kidneys was considered, this, however, being regarded as a rare occurrence since it was only occasionally noted by anatomists. The reason for this may be found in the technic of autopsies, as well as in the fact that in most cadavers the organs have regained their normal position by the bodily rest which usually precedes death. It is true that in isolated reports abnormal movability was occasionally pointed out, but general attention was directed to this only about in 1880, in Germany, by the labors of Landau, Leube, Ewald, L. Kuttner, Litten and Meinert, and in France by Glenard, Fereol and Cuilleret. In 1890, Virchow demonstrated that a change in the position of the abdominal viscera, and particularly of the intestines, could be detected in the majority of persons. Glenard did much to promote the recognition of these changes in position as a pathologic condition by creating the name, enteroptosis. His investigations, however, soon led him to a path on which he could no longer be followed. His orig- inal view that enteroptosis is a sharply characterized substantive disease (entite morbide) was not at once generally accepted, but in the main was considered justifiable. It was admitted that in many persons a moderate degree of downward displacement of the stomach, a unilateral movability of the kidney, and a displacement of the colon could be demonstrated, 263 264 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART and the embodiment of these phenomena in one clinical picture appeared all the more warranted since they presented themselves in nervous, weak females, usually anemic, therefore in persons who in their external appear- ance already presented the same type. Glenard believed that downward displacement of the colon, particularly of the right portion of the trans- verse colon, was chiefly responsible for the production of these disturbances. On the other hand, in the development of displacement of these organs, he was but little inclined to take into consideration mechanical conditions, flaccidity of the abdominal walls, the disappearance of fat in the abdom- inal spaces, the influence of external pressure from lacing, etc. The im- portance of these factors in the etiology of enteroptosis was especially demonstrated by Landau, Meinert, and Dennig, and was proven by the fact that in many persons, and under certain conditions, a loosening of the attachments and the descent of one or more organs was possible. The anatomical prior condition may be favorable to a displacement in one case, still more so in another, but it is difficult to regard this weakness of the ligaments as the foundation of a disease, particularly as it occurs in most persons without producing symptoms. Thus we see floating kidney appear in one person by the development of asthma and emphysema, because of the disappearance of fat in the abdominal cavity, and, perhaps, because the flaccidity of the abdominal walls which increases with age diminishes pressure in the abdomen, and thus the firm position of the kidneys is so far weakened that under the influence of shock to the abdominal cavity (as in prolonged paroxysms of coughing) they finally descend ; in other cases, however, we note particularly how the heart is limited in its movability by the formation of empyema in the lungs, and subsequently the phenomenon of " displaced heart " disappears. Only the minute consideration of all the mechanical conditions will enable us to understand clearly the genesis of these changes in position and their influence upon the functions of the various organs. By some clinicians, such as Stiller and Obrastzow, enteroptosis or splanchnoptosis is to a certain extent regarded as the sign of degeneration. The imperfect cartilaginous attachment of the tenth rib to the thorax (costa decima fluctuans), frequently found in such persons, is looked upon as proof. A certain justification must be admitted for this view, since, undoubtedly, a displacement of the abdominal viscera is found in a greater percentage of persons predisposed to nervous affections than in the nor- mally strong. On the other hand, we must bear in mind that in nervous persons a lessened muscular activity, a weaker muscular structure, and probably a more flaccid ligamentous apparatus, are generally to be expected. Therefore, that a displacement of the internal organs may readily occur does not appear remarkable, and this circumstance naturally explains the greater distribution of enteroptosis among the nervous. Whether, in addi- tion, a certain, and perhaps also a hereditary, predisposition can be as- DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 265 sumed is extremely difficult to decide. Very likely a feeble ligamentous apparatus in the internal organs and certain peculiarities in the structure of the same may be hereditary, as well as a special predisposition of the bony skeleton; but, for the development of enteroptosis, perhaps, just as in the development of kyphoscoliosis of the vertebral column, a number of external influences are necessary. Therefore, we do not agree with Glenard who, in accepting the French views regarding Farthritisme, pro- pounds a theory according to which most diseases are related to enterop- tosis, and a disturbance in the activity of the liver which is not described (1'hepatisme) is the most significant symptom. 1 Although certain uniform factors are decisive in the development and treatment of the various displacements of the organs, it appears to be most necessary for the correct understanding of the subject un- der discussion to describe the displacement of each individual organ separately. Most important are the displacements of the stomach and the kidneys. Displacements of the spleen and of the liver are generally rare, those of the colon and heart more frequent but of less clinical importance. DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) Reports vary as to the frequency of gastroptosis. According to Meinert, 2 in Dresden the majority of women have a displacement of the stomach while, by estimation, only about 5 per cent, of men show an alteration in the position of this organ. Similar proportions have been reported by Dennig 3 in the population of Wiirttemberg. From his figures it is very evident in which years of life gastroptosis is specially prone to appear. Among 2,000 persons who presented themselves at a Stuttgart Poly- clinic on account of various ailments not connected with disease of the stomach, in 29.7 per cent, of the men, in 75.4 per cent, of the women, a displacement of the stomach was determined. iThe views of Glenard, except those in his earlier publications (Lyon medical, 1885 et 1887), are found in his comprehensive work: " Les ptoses visce"rales. Diag- nostic et nosographie." Paris, 1899, 962 pages. Compare also Le progres medical, 1899, I, page 320; 1900, I, page 225; 1902, I, No. 2. 2 Meinert, Sammlung klin. Tortrdffe. N. F., Nr. 115 u. 116, Leipzig, 1895; Cen- tralblatt f. innere Med., 1895, Nr. 43 und ebenda, 1896, Nr. 13 u. 14. s A. Dennig, Wiirttembergisches med. Correspondenzbl., 1903, Nr. 18. 266 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART In regard to age, gastroptosis was present IN MEN. IN WOMEN. Fi- ona 14-20 yet 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-70 irs of a ge in Per cent. 16 27 26 28 37 29 38 34 34 32 Per cent. 62 79 81 92 96 92 85 97 100 It was determined in girls from 10-15 years, in 20 per cent., " 16-20 " " 57 From this it can be distinctly seen that gastroptosis is much more frequent in females than in males. This displacement probably occurs even at the age of puberty as a consequence of wearing a corset, and under the influence of pregnancy in the following decades flaccidity of the abdominal walls becomes more common until, finally, almost all elderly women show gastroptosis. According to Dennig the same deleterious in- fluence as that of the corset is ascribed to a habit very common among the female rural population of Wiirttemberg of tying the skirts around the waist and drawing the strings very tight. When the hips have not as yet attained the growth characteristic in woman, tightness about the waist is especially desired to prevent the skirt from slipping down. Sus- pension of the clothes from the shoulder, as is the rule with children, is seldom seen in girls over fifteen years of age. The correctness of these conclusions is proven by the results of investi- gations in males. Here the injurious effects of wearing a belt to fasten the trousers instead of suspenders from the shoulder is distinctly recog- nized, for of 172 men with marked gastroptosis, 72 wore narrow belts around the waist, while among 406 men with a normal position of the stomach only 16 used the belt; the remainder wore suspenders. In children, as a rule, the stomach lies in a horizontal position. Meinert declares it to be true that every child is born with a vertically lying stomach, the pylorus of which is therefore deeply situated, but that after a few weeks this position is changed. The lower curvature of the stomach forms an almost horizontal line above the umbilicus. The conspicuously frequent occurrence of gastroptosis in Saxony, which was first pointed out by Meinert, has given rise to much speculation. Some investigators reject the entire theory, and believe that the large DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 267 amounts of gases developed from the carbonic acid employed for distend- ing the stomach abnormally displace this organ, and probably also give no well-defined idea of the size of the stomach so inflated. According to Meinert, in the above investigations 8 grams of sodium bicarbonate, 6 " of tartaric acid, were employed; this was dissolved in a little water and taken at once or in divided doses rapidly succeeding each other. Gastroptosis was assumed whenever the pylorus could not be recognized at the scrobiculus cordis, or was situated more deeply ; the greater and lesser curvatures of the stomach must have descended at the same time. As large doses of this mixture will produce nearly 3 liters of carbonic acid, the criticism is justifiable that the normal stomach which, as a rule, has merely a capacity of about 1 liters, is immoderately distended and perhaps also is drawn somewhat downward. Dennig employed a large double bellows with which he inflated the stomach after introducing the stomach-tube. With this method, as I have fully convinced myself, par- ticularly with tense belly walls, it is necessary to exert considerable pressure if the boundaries of the stomach are to be sharply defined. We must, however, remember that neither in powerful men nor in children does this downward displacement of the distended stomach ever take place. We are thus forced to conclude that this property of the stomach or, rather, of the pylorus, to descend upon immoderate inflation, is a pathologic devia- tion, and to a certain extent indicates a predisposition to gastroptosis. In the description of the development of gastroptosis from the influ- ence of gastric catarrh, general weakness of the stomach, etc., I shall attempt to show that, to a certain extent, the same process takes place as in the downward displacement of the organ artificially inflated by carbonic acid gas. The purely mechanical course may best be understood by some illus- trations. 1 In Fig. 11 we see a stomach in its normal position. The pylorus is situated at a point almost directly behind the right arch of the ribs, where this is crossed by the tip of the ensiform process upon a horizontal plane (Meinert). The axis of the stomach more nearly approaches the horizontal than the vertical. The pyloric portion of the stomach is in the main situated in the scrobiculus cordis. In Fig. 12 we see the so-called vertical position of the large normal i These illustrations have been taken from the " Diagnostic Lexicon " of A. Bum and ScJinirer, Vienna, 1884, III, p. 111. Presentation of gastric examination by Rosenheim. My description of the individual figures differs somewhat from that given by Rosenheim. 268 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART stomach when inflated. The pylorus can no longer be detected in the pit of the stomach. The greater curvature is decidedly lower than the umbili- cus. The axis of the stomach is in a vertical rather than a horizontal position. Fig. 13 shows a somewhat later stage. The greater curvature has de- scended lower. The cardia may be recognized in about the same area as FIG. 11. Normal situation of the stomach; dotted line, ....... shows the margin of the liver. in the normal stomach. Especially noteworthy is the great bulging of the pyloric portion of the stomach downward and to the right. As the muscles of the stomach which chiefly propel the chyle are situated around the pylorus, an enlargement of the stomach to the right, which may be dis- tinctly demonstrated by percussion, clearly denotes a weakness of the muscular apparatus and beginning insufficiency of the same, 1 although gastric dulness appears, in the main, to be but slightly increased. In Fig. 14 we see a decidedly enlarged stomach. Such a condition may have been caused by gastroptosis and subsequent insufficiency as well as by a mere descent from gastrectasis. A decision cannot be based alone upon these pictures; for this purpose the consideration of all the points necessary in an examination is called for. 1 Rosenheim, " Krankheiten der Speiserohre und des Magens," I. Aufl. 1891 ; Leo, Deutsch. med. Wochenschr. 1896; und W. Michaelis, Zeitschr. f. klin. Med., XXXIV. DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 269 A somewhat different condition is shown by Fig. 15, which is taken from Bellinger's book. 1 This illustration of Bollinger, first of all, shows distinctly how the vertical position of the stomach with constriction of its pyloric portion occurs from the external pressure of tight lacing, just as this acts upon the liver. A vertical position of the stomach without dilatation is fre- quently not considered pathologic by the anatomist, and therefore we often see illustrations of a vertical stomach in books upon normal topographic anatomy. How do the effects of a downward displacement of the pylorus, of gas- troptosis, become noticeable during life? In a normal person this occurs by downward pressure on the liver and pylorus in consequence of tight lacing around the waist, and, except for slight discomfort which, perhaps, is only due to pressure upon the skin, the activity of these organs is usually but slightly affected. It is true FIG. 12. Gastroptosis of the first degree. the passage of the chyle from the stomach into the duodenum is probably impeded, but we know that the smooth muscles of the intestine rapidly hypertrophy after the addition of obstructions in the intestinal canal, and thus by increased labor bring about compensation. The majority of healthy i O. Bollinger, " Atlas und Grundriss der pathologischen Anatomic," I., page 193, 2. Aufl. Miinchen, 1901. 270 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART young girls, therefore, notice no immediate, injurious effect from the wearing of a constricting corset which simultaneously presses down the liver and the pylorus. It is different, however, if the stomach of the FIG. 13. Gastroptosis of the second degree. person in question has previously shown a tendency to disturbance, or if a general weakness of the system exists. These disturbances most frequently occur in young, anemic, poorly nourished, growing girls. Under these ' circumstances, the stomach cannot so readily compensate the obstruction to the propulsion of chyle by the unfavorable position. Decided insufficiency readily takes place. The symp- toms of the patient all distinctly point to the fact that the corset is the disturber of the peace, for, after discarding it, decided amelioration is noted. Gradually the gastric catarrh disappears, and, on resuming the corset, the patient readily becomes accustomed to her instrument of torture. In these cases, therefore, a slight gastroptosis persists which usually cannot be determined by the ordinary clinical methods of examination, unless it be by decided inflation of the stomach. As a rule, symptoms appear only when an error in diet produces an acute gastric catarrh. While the consequences of such a gastric disturbance in patients with a normal stomach soon disappear under suitable treatment, in those with a latent gastroptosis a high-graded insufficiency of the stomach occasion- ally develops. A loud, splashing sound most distinctly reveals the enlarge- DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 271 ment of the stomach. The greater the distention of the stomach in the course of the affection, the more difficult, naturally, is the propulsion of chyle into the duodenum. The affection, therefore, spontaneously forms a vicious circle. An immoderate dilatation of the stomach is also promoted when the belly wall is very flaccid. Even in young girls who are unac- customed to bodily labor, the muscles exerted in the abdominal press form only a flaccid, thin wall. The activity of the abdominal muscles is still further impaired in women by successive labors, the consequent pen- dulous abdomen described by Landau 1 becoming particularly noticeable. The persistence of gastric catarrh or gastric insufficiency in gastrop- tosis, however, leads to other dangers. Being insufficiently nourished the organism is forced by metabolism to the combustion of its body substance, the fat in the abdomen and the mesentery being first utilized for this purpose. Here we note the well known fact that in an antifat treatment FIG. 14. Gastroptosis of the third degree. a decrease in the circumference of the waist is most perceptible. The loss of fat accumulated in the abdominal cavity makes itself felt in the same way as a weakening of the abdominal walls. The position and attach- ment of the organs are no longer secured by simultaneous pressure, but these depend upon the suspensory ligaments which may readily yield. In 19 Landau, Terhandl. der Berl. med. Gesellschaft, 1890. 272 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART severe diseases, such as gall-stone colic, gastric ulcer, or gastric cancer, this dilatation of the prolapsed stomach becomes noticeable much more frequently than after simple gastric catarrh. Its manner of development is interesting, and is as follows: I have repeatedly heard young persons who have recovered from an appendicitis operation state that in the first FIG. 15. -Constriction of the right lobe of the liver and of the pylorus. few days after they had left their beds they observed an increase in the circumference of the abdomen, which was confirmed by the objective ex- amination of the physician. In these cases there was no abdominal hernia, but an enlargement and displacement of the stomach was evident without any symptom of gastric disease. This was explained by the marked dis- appearance of fatty tissue in the abdominal cavity, since the persons in DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 273 question had lost from 11 to 16| Ibs. in weight. A few days after getting out of bed, and being in an upright position, they were well enough to take large quantities of food, and this had caused the over-burdened and distended stomach with all of the other viscera to descend. That occasionally a decided displacement of the stomach may be de- termined in kyphoscoliosis is readily comprehended. In these cases, also, the prolapse usually occurs without producing any disturbance in gastric activity ( Fleiner 1 ) . Lordosis of the vertebral column, which sometimes develops to a de- cided degree in women predisposed to it if they wear high heels, produces a condition in which the pressure of the viscera dilates the abdominal walls downward and anteriorly, and the internal organs themselves drop (Cserv, Kon'myi, and Meltzing 2 ). In some diseases, for instance, tuberculosis, the effect of mechanical shock makes itself felt in the abdominal cavity. The paroxysmal shock to the thorax and abdominal wall produced by cough must assist this process, particularly when the factors we have mentioned which favor the descent of the stomach have already been active. From these descriptions it is obvious that gastroptosis may be looked upon as a disease in only a small number of cases when, from any com- plication, the compensation is lacking which would otherwise be produced by increased activity of the muscular structure of the pylorus. In regard to the frequency of these disturbances, no absolute general rules can be laid down. Gastroptosis and enteroptosis are most frequently met with in patients suffering from gastric disease. Thus Einhorn 3 reports that within a few months he found 9 cases among 141 male patients with gastric disease, and among 92 women he found these changes 32 times. It is true that the more vigilantly we search for changes in position, the more frequently we will diagnosticate them in a greater or less degree. Often the appear- ance of hysteria or neurasthenia leads us to suspect gastroptosis. It may then be doubtful which affection existed first. SYMPTOMS Symptoms of gastroptosis may be entirely absent. In young girls who press the pylorus down by wearing a corset, possibly because of the in- creased difficulty with which the chyle is propelled into the duodenum, eructations will often occur, and the peculiar rumbling or gurgling fre- quently heard in women who lace very tight is declared by Fleiner to be 1 Fleiner, Miinch. med. Wochcnsclir. 1895. Xr. 42-44. *Kor6nyi, Berl. kl. Wochenschr., 1890. Xr. 31: Meltzing, Volkmann'sche Vortr. 1896; Csery, Wiener med. WochenscJir., 1901. Xr. 28. *M. Einhorn, "Die Krankheiten des Magens," Berlin, 1898, page 270. 274 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART a murmur of stenosis due to compression of the stomach. In most cases, however, as has been stated, symptoms are either absent, or these mild signs are regarded by healthy persons as due to a disturbance of gastric movement. In weak, anemic persons with a tendency to chlorosis the constriction of the stomach may exert such a deleterious effect that not only the signs of gastric catarrh but also manifold nervous disturbances may present themselves. The symptoms due to gastroptosis are then closely intermingled with those of chlorosis, of general debility, and of nervous- ness, but are, in the main, attributed to chlorosis; they may continue for weeks, months, or even for years. Quite properly Meinert attributes the old axiom, founded upon experience, that marriage is the remedy for chlorosis to the fact that when pregnancy occurs the growing uterus forces the distended stomach upward again. The symptoms which subsequently arise, provided no intercurrent dis- ease suddenly produce marked insufficiency of gastric activity, as in the manner I have described, resemble those which generally appear in per- sons suffering from gastric catarrh. A conspicuous symptom in such patients is the great weakness and debility which cannot be accounted for by any preceding error in diet. In the horizontal position, especially in the right lateral, the symptoms ameliorate, for then the propulsion of food goes on under the most favorable mechanical conditions. Vomiting is rarely mentioned in the history, but is most frequent at the onset, and very rare in the later course. Incessant vomiting throughout the entire period of the disease might therefore be utilized as excluding gastroptosis. The patients almost invariably complain of marked constipation, for which various causes are assigned. In the first place, a displacement of the colon, particularly of the mesocolon in which the thin, fluid feces first become more compact, may cause kinking and, naturally, a retardation of the feces. However, too much stress is not to be laid upon this cir- cumstance, since, after the removal of other causes, and in spite of the persistently abnormal course of the colon, regular fecal discharges almost always take place. It is significant that these women and with such we usually deal in gastroptosis generally prefer easily digested food which leaves but little residue in the intestine. We know from physiology that with food consisting chiefly of meat and wheat bread the fecal mass in twenty-four hours amounts to only 100 to 130 grams of moist, and from 20 to 30 grams of dry, substance, while with a diet rich in cellulose, there- fore with the ingestion of much rye bread, the feces amount to 400 to 600 grains of moist, and 60 to 80 grams of dry, substance. As the intake of food in gastric affections is generally even less, and accordingly there is less residue, a fecal evacuation every two or three days appears quite natural. Moreover, a pendulous abdomen decidedly decreases the force of the ab- dominal press, so that small fecal masses formed from easily digested food are only evacuated by great effort. Finally, in my experience, the lack DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 275 of muscular exercise on the part of most women adds much to torpidity of the bowels, which therefore cannot be looked upon as entirely the consequence of gastroptosis, coloptosis or enteroptosis. Among the objective symptoms, a loud splashing sound in the umbili- cal region is noted by the physician. This sign is so characteristic that when absent in repeated examinations one or two hours after the ingestion of fluid, insufficiency of the displaced stomach may be denied. The im- portance of the succussion sound in judging of the gastric activity has lately been the subject of much controversy. Although I am willing to admit that this symptom may occasionally be observed in thin, healthy persons, nevertheless I coincide with Stiller and Kuttner x in the view that, under these circumstances, the gastric wall is incapable of contract- ing strongly enough about its contents. In gastroptosis the splashing sound is usually detected around the umbilicus, often, however, below this region. Among other signs epigastric pulsation, which is emphasized by Gle- nard, must be considered. It is not of the same diagnostic import as the succussion sound, for, in the first place, when the abdominal walls are thin and the pylorus is situated in the scrobiculus cordis, the pulsation of the vessels may sometimes be felt through the gastric walls, and sec- ondly, when the abdominal walls are rich in adipose tissue, pulsation is unrecognizable notwithstanding the existence of gastroptosis. Another symptom, a feeling as of the pressure of a girdle in the gastric region, the " corde colique," leaves us completely in doubt. Glenard be- lieves this band to be the colon, while, according to Ewald, the area of resistance, which, however, can rarely be felt, is to be looked upon as the pancreas. This fact is not generally known ; it is, however, occasionally of great practical value, for, otherwise, upon palpation in this region, and when there is a disturbance of gastric activity, we might mistake this resistance for a neoplasm. I know of a case in which such an error led to a laparotomy being performed a state of things naturally not very desirable, yet not so serious as the inverse assumption that a neoplasm is only the head of the pancreas. The most signal proof of gastroptosis, or that the disturbances present are chiefly due to displacement of the stomach, is furnished us by the movability of other abdominal organs, particularly of the kidneys. In how far it is possible to palpate the kidneys will be discussed later. In almost every marked case of gastroptosis it is possible distinctly to palpate the kidneys, at least the right one, upon the posterior wall of the abdomen. Often one or both kidneys are movable in the abdominal cavity, or they are shown to be fixed in certain areas. i Berliner klin, Wochenschr., 1901, Nr. 50. 276 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART DIAGNOSIS Naturally the diagnosis is assisted when the walls are very flaccid. In the majority of cases of gastroptosis the distention of the stomach is so marked that the findings appear to be entirely out of proportion to the symptoms, which have usually existed but a short time. In gastrectasis which develops in consequence of some other gastric affection, derangement of the activity of the stomach has gradually become marked. Finally, we must remember that a displacement may have occurred secondarily from the cicatrix of an ulcer or a neoplasm which had narrowed the stomach, and that dilatation had subsequently occurred. In practice, therefore, the proof of a displacement is naturally much less significant than the recognition of some other obstruction to the propulsion of the ingesta ib rough the pylorus. For this reason, in the examination of a patient suffering from gastric disease, I must advise against a great inflation of the stomach, provided we desire only to determine gastroptosis or the tendency to displacement. In my experience, only in hysterical, very nervous persons, or in those debilitated from disease of some other organ, in'// gastroptosis cause a decided disturbance in nutrition. On the con- trary, examination should reveal the cause of the compensatory disturb- ance in the activity of the displaced stomach. According to the age, the sex, and the general appearance of the patient, we must search for gastric nicer, for malignant disease of the gastrointestinal canal,, for cholelithiasis, or for pulmonary tuberculosis. TREATMENT In the treatment, prophylaxis plays the first role. By prohibiting lacing the chief cause of the development of gastroptosis, as well as dis- placement of other organs, will be removed. Probably every woman will assure the physician that she does not lace too tight, although an exam- ination of the skin will reveal distinct lines about the waist due to the constricting corset. In regard to these views there is little unanimity between physicians and their women patients. A corset of stiff material worn by those anemic women, weak in muscle, who form the majority of the well-to-do classes, may have the advantage that it gives a certain support to the weak vertebral column which is lacking in strength of muscle and will remedy defects in the carriage of the body. But, as a rule, the physician must insist that the corset be not worn too tight, nor the skirts suspended from the waist. This danger is greatest in girls from fourteen to sixteen years of age whose hips have not yet sufficiently developed. The skirts must be suspended from the shoulders like the trou- sers of men, and a belt must not be worn. It is well known that the " dress reform," which has already become somewhat general in Germany, is directed toward this purpose. Unfortunately, stout women refuse to DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 277 abandon the corset, because without it the waist appears to them to be too large, and the bust is not sufficiently supported. It is to be hoped, although it is by no means certain, that in this respect common sense will finally prevail over vanity and the present standards of beauty. On account of the tendency of the vertebral column to marked lordosis, the wearing of high-heeled shoes should be prohibited, the height of the heel being limited to 2 or 3 cm. The formation of a pendulous abdomen in consequence of childbirth may be prevented by maintaining the recumbent posture as long as possible after labor, and on rising from bed the flaccid abdominal walls should be firmly supported by a well-fitting bandage. The most effectual means to prevent the displacement of organs prob- ably lies in the education of the female from infancy as to the value of physical exercise. With this we might hope that the abdominal, as well as all the other muscles of the body, would attain their fullest develop- ment, and that the wearing of sensible clothing by the majority of women would prevent many other disabilities of civilized people. If a displacement of the stomach has already occurred, yet no symp- toms are present, treatment may appear to be superfluous. Nevertheless, in such cases I must advise prophylactic interference and the interdiction of tight lacing, especially if occasional symptoms, such as loud gurgling in the intestines, have already been noted. If there are distinct signs of insufficiency of the stomach, a binder which supports the lower parts of the abdomen is serviceable. An abdominal bandage lately advised by Ostertag 1 is especially valuable for this purpose. In women the symp- toms sometimes disappear immediately on its use. In advising an abdominal binder it must be borne in mind that it would be the height of folly to forbid, on the one hand, the constricting corset, and then, for the opposite effect, to recommend an abdominal bandage which compresses the organs from the waist downward. According to the statements of Landau and Bardenheuer, there are stays supplied by instrument makers which exert no special pressure about the waist, and to this the abdominal bandage for the lower parts of the abdomen is already attached. I advise these corsets in antifat cures even if there is no gastroptosis, since in hyponutrition, as already re- marked, fat disappears from the abdominal cavity with comparative rapid- ity and, therefore, the condition for displacement of organs is already present. Bial 2 has lately proven by the illumination of the organ that a prolapsed stomach cannot be supported by a bandage. He also relates , his experiences, according to which the desired result may be attained by suitable hydrotherapeutic and dietetic measures. Nevertheless I advise 1 Ostertag, Monatsschr. f. Geburtsh. u. Gyn., XV. 2 Rial, Verh. d. Congr. f. innere Med., 1897, p. 521. 278 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART the employment of these abdominal supporters. In the first place, in women the weakened abdominal wall is strengthened, and thereby the danger of a marked displacement of the abdominal organs is averted. Moreover, it is quite clear to me that not only does the motor activity of the stomach improve, but the action of the bowels is decidedly facili- tated. The descent of the diaphragm, which by the abdominal press forces the abdominal viscera downward, encounters a stronger resistance in the abdominal bandage than in the flaccid belly walls, which, when strong pressure is exerted, invariably become more distended. Dietetic rules form an important part of the treatment. From a purely mechanical standpoint the difficulty of propelling the ingesta from the stomach is at once obvious, v. Mering * has lately pointed out that in the right lateral position the stomach is most rapidly emptied, and, under the conditions here discussed, we should utilize this fact. In debilitated persons, a rest of one or two hours in the right lateral position after the principal meal should certainly be advised. Furthermore, it is unwise to permit too copious meals. At least while active symptoms are present, several small meals must take the place of the chief meal. Oertel and Schweninger's advice to the obese not to drink while eating, which they erroneously regarded as an important law, is, on the contrary, well adapted to gastric patients, and particularly to those suffering from gastroptosis. Under some circumstances we may attempt to hasten the evacuation of the stomach by massage. In most cases I believe this effect is to be attributed to autosuggestion. Nevertheless, I have several times seen such favorable results that I frequently advise it, and the more so since it may be readily practised by the patients upon themselves. The hand rests upon the left arch of the ribs, and about this point rotary motions are made from the left below to the right upward. Massage by another person I do not advise, because, particularly with movable kidneys, there is danger that these may be irritated a danger which cannot be excluded. I am, therefore, decidedly opposed to the advice given by some authors to treat gastroptosis by a course of massage of from six to eight weeks, in which the massage is given one or two hours before eating. This will not bring about a true cure of gastroptosis, and a temporary insufficiency of the musculature of the stomach may more certainly be made to disap- pear by other means. In the choice of food the same rules are operative which are applicable to all patients suffering from gastric disease. When there is marked dis- turbance of gastric digestion small quantities of milk may first be per- mitted, and are very serviceable as easily digested, rich, nutritive products. It is not advisable to give more than one liter of milk in the course of 1 v. Mering, Therapie der Gegenwart, 1902, Heft 5. DISPLACEMENT OF THE STOMACH (GASTROPTOSIS) 279 the day; more than this will over-burden the stomach. If there is repug- nance to milk, cream may be given, more or less fatty according to the severity of the condition, and some tea. Zwieback, wheat bread, lean meat, eggs, green vegetables are the foods which next come into question. We must be careful with those foods which readily generate fermentation and gas in the stomach, therefore those especially rich in sugar. Naturally, the individual taste and the experience of special patients must here be taken into consideration. In regulating the bowels we must always con- sider whether a food shows a strong tendency to generate gas. In consti- pation we are generally inclined to advise foods rich in cellulose, conse- quently bread rich in gluten. The cellulose of gluten at first mechanically stimulates the intestine, subsequently it undergoes decomposition in the intestine by the activity of bacteria, and thus volatile acids and gases are formed. In gastroptosis, on account of the pendulous belly which usually coexists, gas production is probably already present and very disagreeable to the patient, so that, under these circumstances, the physician must be cautious. Here fruit, stewed fruit, and acid fruit wine, buttermilk or milk sugar lemonade are frequently preferable to the coarser varieties of rye bread. As in all displacements of organs we must consider in each individual case whether it is wise to attempt a " fattening cure " by profuse nourish- ment, so that the fat which has disappeared from the abdominal cavity may again accumulate there. I believe that this question should generally be answered in the affirmative. Patients with an affection of the stomach are usually so debilitated that even a gain in weight of a few pounds is worth our efforts, because this furnishes the best proof of the retardation of the pathologic phenomena. In all cases of hypernutrition prolonged rest is absolutely necessary, for we must never forget that the displaced stomach, even more than the normal stomach, is burdened by the ingested food. The more food, therefore, the patient eats, the less should the stomach labor under unfavorable mechanical conditions. As already stated, it is not enough that the patient assume the lateral position for some time after eating, but for the whole day, uninterruptedly, or at least for the greater part of the day, he should remain in bed or upon a lounge. The too free consumption of milk over three liters daily, according to the advice of Weir Mitchell as was formerly and is even now the general rule, can only aggravate the insufficiency of the displaced organ by over- burdening the stomach. On the other hand, easily digested fats, such as cream, butter, bacon, or some carbohydrates, such as milk sugar and man- nite, should be employed. Alcohol 1 can rarely be dispensed with in the form of brandy, good wine, or even as beer. But only slight quantities 1 Compare F. Hirschfeld, " Die Uebererniihrung und die Unterernahrung," Frank- furt, 1897, p. 43 u. f. 280 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART of the last named stimulant should be allowed, and never more than 200 e.c. at a meal. Brandy may be advantageously given with milk, or even with cream provided it be not too fat. Not only the property of alcohol as a nutrient, but also its stimulating effect upon the gastric activity, is especially desirable (G. Klemperer). In gastroptosis I have made but little use of drugs to improve the nutri- tion. Sodium bicarbonate or magnesia, about as much as will cover the tip of a knife, frequently lessens the gastric symptoms. Hydrochloric acid, as a rule, unquestionably has a deleterious effect. A favorable influ- ence is usually obtained by the employment of bitters; and I have fre- quently used the following prescription: ty Tinct. Cinchona comp 20.0 Tinct. Nucis Vomica? 5.0 30 drops in water or brandy three or four times daily. In gastroptosis a mineral spring treatment is naturally not advisable. Even in Carlsbad, particularly in young, nervous persons, such treatment of these cases is often ineffectual. A residence in a place of high altitude is more beneficial, and care must be taken, especially at first, to avoid too great bodily exertion, or to see, at least, that it corresponds with the strength of the patient. In nervous patients it is easily understood that rest in a sanatorium, or a residence with surroundings of beautiful scenery, will have a favorable effect. Sea baths, also, on account of their stimula- tion of the appetite, are worthy of consideration in some cases, but the physician should always be consulted in these instances. In Germany, bathing in the Baltic Sea is generally more beneficial to such patients than in the North Sea. Finally, in gastroptosis, as in so many other diseases, hydrotherapy may be employed, and is particularly adapted to the many nervous symp- toms which develop in connection with all gastric affections. Buxbaum 1 and Winternitz advise quick, cool Sitz baths, while others (Matthes, Boas 2 ) have seen favorable results from a needle douche which may be used either cold or, like the so-called Scotch douche, cool and warm alternately. In this treatment, other measures may occasionally precede the local douche, as a lukewarm full bath, or general friction of the entire body. For the sake of completeness I shall only mention that electrical treat- ment of the stomach, the faradic as well as the galvanic current, is occa- sionally employed in gastroptosis. I saw favorable results in a case in 1 liu.rbaum, " Festschrift fiir Winternitz," 1892. "Mut this. " Klinische Hydrotherapie," Jena, 1900, p. 226; Boas, Internat. klin. ulxchriu, 1894, Nr. 6. DISPLACEMENT OF THE KIDNEYS 281 which almost all other remedies had proven ineffectual. The patient was a lady, exceedingly nervous, who complained of spasmodic pain several hours after taking food. In the treatment of all cases of gastroptosis the following must be remembered : We may relieve and improve a state of insufficiency of the gastric musculature which develops in consequence of an unfavorable position of the stomach, and brings about severe nutritive disturbance in the patient. The low position of the pylorus, however, remains, and, as is the case with a damaged cardiac valve, only hypertrophy of the cardiac muscle produces compensation; in the same way greater labor is demanded of the muscu- lature of the pylorus on account of its unfavorable effect upon the pro- pulsion of the chyle. The efforts of the physician must be directed, on the one hand, to removing the disturbance of compensation which has occurred, and he must subsequently try to prevent such a condition. This part of his work is practical and of the utmost importance. An attempt should also be made to strengthen the abdominal walls and, in so far as possible, to prevent the patient from over-burdening his stomach. In how far this may be done in the individual case by giving minute directions in regard to the food can be ascertained only by careful observation. The surgical treatment of gastroptosis rarely comes into question, be- cause the continuance of the symptoms, notwithstanding careful treat- ment, must probably be attributed to a disturbance of the nervous system. Duret and Eowsing have proposed to attach the gastric wall to the anterior parietal peritoneum. Bier x advises us to shorten the gastrohepatic liga- ment by folding and stitching it, and in four cases he had favorable results by this means. The previous nutritive condition, which was very poor, the cachexia of gastroptosis, and the nervous symptoms were said to be relieved by this treatment. DISPLACEMENT OF THE KIDNEYS WANDERING KIDNEY NEPHROPTOSIS While displacement of the stomach almost invariably develops after puberty, displacement of the kidneys is often observed in children. This anomaly was even noted in a nursling. 2 A male nursling, a few days after birth, was attacked by serious vomiting and symptoms of collapse. Physical examination revealed a small oval tumor at the right arch of the ribs which could be moved over the entire abdomen. The other kidney was also movable, but not to the same extent. The attacks recurred in the next few days, spasms simultaneously taking place. There was marked constipation. 1 Bier, Zeitschr. f. Chirurgie, 1901. *Rees Phillips, The Lancet, 1903, p. 731. 282 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART A case of this kind shows that displacement of the kidneys may be congenital. In by far the great majority of cases, however, it develops gradually, as is evident from the following statistics of L. Kuttner. 1 The age in 326 cases was as follows: 1-10 10-20 20-30 80-40 40-50 50-60 60-70 years. 6 32 82 123 49 26 8 The right kidney is most frequently displaced. According to Ewald and Kuttner, we may assume that the right kidney is seven or eight times more frequently displaced than the left kidney. Often the position of both kidneys is changed, and in the majority of cases greater movability may be determined in the right than in the left. E. Hahn 2 attributes this to the firm attachment of the left kidney to the descending colon (which is little inclined to displacement) and to the pancreas and the spleen, while the right kidney possesses but one point of fastening, the hepatorenal ligament. The sexes are affected by this anomaly in about the proportion of ? or 8 to 1 ; among 97 cases of nephroptosis Landau 3 found 10 to occur in men and 87 in women. Hahn, it is true, assumed that floating kidney was 20 times more frequent in women than in men. In regard to the absolute proportion of cases showing change of posi- tion it is difficult to give a positive opinion. From investigations in the living subject, Ewald and Kuttner assume 15 per cent., and with this the reports of anatomists coincide. In the reports of the seventh decade of the preceding century, among the autopsies of the pathological institutes of Berlin, Vienna and Kiel, movability of the kidney was found in only 0.1 : 0.4 per cent., but the more recent investigations of Fischer-Benzon, in Kiel, show from 17 to 22 per cent. According to the degree of movability of the kidney we differentiate various grades. Under physiologic conditions, the kidneys move slightly from their position with each respiration, descending on inspiration, and rising on expiration. Some clinicians, such as Israel, Litten, Lennhof and Becher, maintain that this movability may be determined by palpation even during life, while the majority of authors deny this. At all events, therefore, in the normal person this movability must be very slight, and in the majority of healthy adults the kidney cannot be palpated from the abdomen. In the minority this is to some extent possible, but only the lower third of the organ can be felt. Of course, thin, flaccid abdominal 1 L. Kuttner, Berl. klin. Wochenschr., 1890, p. 364; compare in the same journal Ewald's lecture before the Berlin Medical Society, March, 1890, and the discussion in connection with it. (Virchow, Litten, Landau, P. Guttmann, Senator, Israel and others.) 1 /:. Hulin, Zritachr. f. Chirurgie, LXVII, p. 356 et seq. * L. Landau, " Die Wanderniere," Berlin, 1881. DISPLACEMENT OF THE KIDNEYS 283 walls will extraordinarily facilitate the examination. Becher and Lenn- hof 1 point to a special structure of the body which lends itself to palpa- tion. Although tall persons usually form the bulk of this group, a definite bodily proportion is decisive, and this may be found in individual persons and in various races under different conditions. The greater the distance from the manubrium sterni to the symphysis pubis, the greater the portion of the kidney susceptible to palpation. If the slight physiologic movabil- ity of the kidney is increased, it is possible during palpation of the abdo- men not only to feel a small portion of the kidney but two-thirds, or even the complete extent, of the organ; under the influence of the respira- tory movements the displacement becomes particularly prominent. In a later stage of abnormal movability, the kidney can no longer be recognized in its normal position upon the posterior wall of the abdominal cavity, but may be felt in some other area of the abdomen, and thence it may either be readily moved or it becomes adherent to this region so that it can only be displaced in connection with other abdominal viscera. ETIOLOGY A primal cause of abnormal movability is probably a congenital pre- disposition. In the normal person the kidneys are usually situated in a groove in the posterior abdominal wall, anterior to and alongside the trans- verse processes of the vertebrae, and extending from about the height of the twelfth cervical to the third lumbar vertebra. Two Eussian investi- gators, Wolkow and Delitzin, 2 have especially called attention to the im- portance of the formation of this paravertebral niche for holding the kidney. If this niche is markedly flattened, the kidney, naturally, will much more readily slip out. Besides this congenital flatness of the groove, which is readily seen, scoliosis of the vertebral column adds to the condi- tion. We must also consider that in intra-uterine life the kidneys are low down in the abdominal cavity in the sacral hollow of the pelvis. Gradually they move up higher. This shows at once that the kidneys are not supplied with very tense suspensory ligaments; they are partially held by their ligamentous apparatus, but are also supported by the peri- toneal layers and the fatty capsule; on the other hand, the kidneys main- tain their position by the pressure of all the abdominal viscera. Accord- ingly, by a sundering of various links, this girdle which supports them may become slack or broken. A flattening of the niche simultaneously with a loosening of the ligamentous apparatus seldom causes a displacement of the kidney. Eigid abdominal walls, such as are found in most young, 1 W. Becher und 7?. Lennhof, Deutsche med. Wochenschr., 1898, Nr. 32, und Verh. d. XVIII. Congr. f. inn. Med., p. 476. 3 Wolkow und Delitzin, "Die Wanderniere," Berlin, 1899; compare also M. Zondek, " Die Topographic der Niere," Berlin, 1903. 284 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART robust persons, usually hold the abdominal organs in their natural position. This explains the rarity of floating kidney in persons under twenty years of age. When, from any circumstance, pressure in the abdomen is less- ened, this favorable influence is lacking. Lacing is the most frequent among: the deleterious factors which must here be considered, because the O ' liver is thereby pressed downward, and the right kidney, which is inti- mately connected with the liver, also has pressure exerted upon it. This explains the fact that the right kidney shows abnormal displacement so much more frequently than the left. We, however, are under the im- pression that lacing is here not so predisposing as is the case in gastrop- tosis. Repeated pregnancies which markedly diminish the support of the abdominal wall mostly have a decided effect in that a portion of the abdom- inal contents, usually the intestines, bulge forward and downward, so that lateral pressure upon the kidneys is diminished. The greatest decrease in pressure occurs when the abdominal cavity suddenly becomes smaller, as after the operative removal of large tumors. 1'nder such circumstances, Israel noted that, before his very eyes, the kidneys became abnormally movable. A gradual decrease in pressure may also be expected when from general emaciation considerable adipose tissue disappears from the abdominal cavity. Other deleterious effects may also be operative, such as shock to the abdominal wall. Thus I would explain the wandering kidney which 1 several times saw develop in emaciated patients in the course of pulmo- nary disease. In emphysema and asthma floating kidney may easily be produced, because, from the emphysematously distended lung, pressure is exerted upon the diaphragm, and then referred to the liver and the right kidney. Repeated shock to the abdominal wall from paroxysms of cough may gradually loosen the kidneys. In one case of wandering kidney caus- ing abdominal symptoms the patient attributed it to prolonged laughter. In a similar manner straining during a difficult fecal evacuation, or in lift- ing a heavy load, may be the cause. Under such circumstances traumatic origin of wandering kidney is quite possible, while in a normal, well-fastened kidney this theory is scarcely plausible. Just as the stomach may subsequently be displaced by a neoplasm which adds to its weight and dilates it, so may this condition result in the kidney from hydronephrosis or pyonephrosis. Such cases, of course, are not wandering kidneys in the usual acceptation of the term. SYMPTOMS Symptoms of wandering kidney may be entirely absent. The patients, in this instance, are usually strong, plethoric persons otherwise quite well, whose kidneys, one or both, have descended into the abdomen without causing any symptoms. Occasionally abnormal sensations are noted which DISPLACEMENT OF THE KIDNEYS 285 incidentally make known to the person in question that he has a movable kidney. Some patients report after unusual exertion a sensation of rum- bling or one like the gliding about of a heavy substance. It is difficult to decide whether these reports depend merely upon auto-suggestion, or to what extent indefinable sensations, due to the influence of already ex- istent factors, may subsequently be explained. It is still more difficult to assign vague nervous symptoms, whatever their nature, to nephrop- tosis. While we cannot doubt that all varieties of nervous symptoms may appear in persons whose kidneys are normally attached, yet, when people are predisposed to nervous affections, we are justified in assuming a mov- able kidney to be the cause of various painful sensations such as sciatica, intercostal neuralgia, or similar affections. Sensitiveness in the region of the iliac fossa may be attributed to the kidney. In any case the physician is wise not at once to communicate the fact that during an examination he has accidentally discovered a wandering kidney. The precautions yet to be considered, such as wearing a bandage, refraining from lacing, etc., can also be insisted upon when we speak to the patient merely of " a predisposition to wandering kidney," and the first duty is to prevent the production of a floating kidney. Symptoms on the part of the stomach are most frequently noticed, and these usually simulate a chronic gastric catarrh; acute attacks, designated as gastric spasm, are very rare. As a rule, we note loss of appetite, eruc- tations, and pressure in the gastric region, less frequently vomiting. We know from numerous observations that in diseases of other organs, and particularly in those of the abdomen, the stomach is likely to become implicated. A heavily coated tongue is almost invariably present in dis- ease of the gall-bladder, of the urinary bladder, and in inflammation of the renal pelvis, and the appetite is always decreased. It must be borne in mind that nephroptosis is often combined with gastroptosis. These pa- tients are usually pale and weak young persons in whom gastric difficulties are prominent; stout, elderly women, even when a pendulous abdomen has developed, are more rarely affected. According to statistics, the implica- tion of the stomach in nephroptosis is about as follows: In 89 cases of movable kidney Kuttner found the position of the stomach normal in only 10, that is, the greater curvature of the stomach was situated normally in the median line between the umbilicus and the ensiform process. In 79 cases the greater curvature was 3 to 4 cm. below the navel, occasionally even lower than this; in 15 of these cases, by inflation of the abdomen with air by means of a double bellows, a true prolapse of the stomach could be observed. Dyspeptic symptoms were present in 70 of these persons, hence this symptom may be designated as the most important and most common in floating kidney. 286 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART A peculiarity of the gastric symptoms in nephroptosis is their increase after muscular exertion and their disappearance, or at least improvement, after prolonged rest. As a rule, the majority of these female patients suffer most during the menstrual period. In nephroptosis, just as in gastroptosis, constipation is important and is due to the same causes weakness of the abdominal walls, insufficient nourishment or food poor in residue, often kinking of the colon, etc. Symptoms on the part of the kidneys are rare. It might readily be supposed, and would seem likely, that torsion and kinking of the ureters would occur frequently. As a matter of fact such an accident is very rare. Dittl, Landau, Lindner and others have, it is true, described attacks which resembled renal colic and which were mistaken for this. Occasionally it was believed that spasmodic contraction of the ureter could be felt through the abdominal walls. Some patients are attacked so suddenly with sensa- tions of nausea, vomiting, and severe pain in the renal region, the ureters and the bladder, that the physician must assume severe peritoneal irrita- tion, for the pulse also is small and increased, the skin is cool, cold sweat appears, etc. But such intermediate attacks which probably depend upon kinking of the ureter or of the vessels, or torsion of the renal nerves, are rare; I have only once seen a case of the kind. Albuminuria and hematuria are infrequent, as are also so-called intermittent hydronephro- sis, pyonephrosis, and pyelitis. Up to the present time but little attention lias been given to the latter complication, therefore I shall briefly relate my own experience in regard to it. [These attacks are the so-called " Dittl's crises."] Pyelitis as a Complication of Hydronephrosis. The patients, usually women about forty years of age, who for ten or even twenty years have had no symptoms of their wandering kidney, are suddenly attacked with acute pains in the abdomen. The pains, as shown by palpation of the abdomen, are chiefly located in the displaced kidney, and radiate along the course of the ureter to the region of the bladder. Strangury fre- quently occurs. There is fever from 100.4 to 102.2 F. which is re- mittent in type. The urine is turbid, usually of acid reaction, and micro- scopically is composed almost exclusively of pus corpuscles. Chemical examination, of course, reveals albumin, but decided amounts (up to 5 per 1,000) are also found in the filtered urine or in the clear urine after sedimentation has occurred. After one or two weeks the inflammatory symptoms subside. The temperature becomes normal, but the pulse for some time continues to be accelerated. The sensitiveness of the kidney gradually passes away. The albumin decreases so rapidly that after two or three weeks none can 1)0 detected in a clear layer of urine; but the excretion of pus and the turbidity of the urine due to this may continue for months and, occasion- ally, even for years. For a long time the patients are able to take but DISPLACEMENT OF THE KIDNEYS 287 little exercise and must avoid all exertion. Prolonged sitting is impossible. A slight tenderness of the urinary organs upon pressure continues to exist for some time, and makes the wearing of bandages or corsets irksome. Slow recovery from pyelitis and floating kidney is characteristic. In the treatment warm drinks, warm baths, hot poultices, etc., are most effective; among drugs salol, urotropin, uva ursi and the like. In one case, eight days after a very movable right kidney had become affected I saw the left kidney also attacked, this, so far as could be ascer- tained, being in its normal situation. The fever, which had declined, again rose, and all of the symptoms returned. The sudden appearance of pyelitis without other symptoms may be attributed to an acute infection; but the nature of the infection is not clear. If gonorrhea or cystitis have not previously been present, it is very likely due to an emigration of bacteria from the intestine (Posner). But such complications are rare, for Kuttner saw only 4 among his 89 cases, and among 93 cases operated upon by Kiister 1 only two displaced kidneys showed the development of pathologic processes. DIAGNOSIS The diagnosis of floating kidney is in some cases very easy. Even upon superficial palpation of the abdomen, we feel an organ of the size and consistence of the kidney which either moves about or is fixed in some area. In the majority of cases the organ is situated upon the right side of the body, which confirms the opinion that the right kidney is by far the most frequently displaced. The diagnosis becomes difficult when the kidueys still retain their position in the posterior abdominal wall. Bimanual examination then becomes necessary. As already stated, only in those persons who are tall and thin is it possible to feel a portion of the normally situated kidney, that is, about one-third of the organ, and this is most readily perceptible in the deeper situated right kidney. To over- come the marked tension of the abdominal walls which is often present, Becher and Lennhof advise an occasional examination in a warm bath. A simpler method which I found serviceable was the employment of a moist, hot poultice about the abdomen. 2 For the examination, the patient is placed in a horizontal position, the legs are flexed somewhat, and abducted and rotated outwardly to ensure a comfortable position, then one hand is placed upon the back at the 1 P. Gets, "18 Jahre Nierenchirurgie," Marburg, 1900. 2 The relaxation of the tension of the abdominal walls is naturally also of value in the consideration of other pathologic processes. For diagnostic purposes in peri- typhlitis, the occasional employment of the hydropathic poultice to determine the presence and extension of the exudate is especially useful. The enlarged appendix can then occasionally be palpated. 20 288 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART height of the eleventh or twelfth rib while the other gradually makes deep pressure from above downward. An accumulation of fat, as well as marked tension of the abdominal walls, renders this examination dif- iicult, and even with abundant practice it often gives a doubtful result. If upon respiration the kidney seems to be movable we may draw the con- clusion that it has descended somewhat, since, under normal circumstances, this movability is hardly perceptible. Another method of examination, percussion, often leaves us absolutely in the dark. Renal Dystopia. In considering the findings, we must first answer the question: Is not the displacement a congenital change, a so-called renal dystopia? Miillerheim 1 has recently taught us by his special investiga- tions that this renal dystopia depends upon an embryonal inhibitive for- mation, and is by no means rare, for he succeeded in finding 200 cases reported in literature. The characteristics of renal dystopia are, as a rule, the change in form, the fixation of the position, the abnormal vascu- lar supply, and the shortness of the ureters. Some of these character- istics, such as the abnormal vascular supply, cannot be recognized during the life of the patient. More significance is to be attached to the change in form detected by palpation. Frequently the kidneys still show fetal tabulation, or they have coalesced and formed the so-called horseshoe kidney. Sometimes, the dystopic kidney lies in the pelvis. If, however, the assumption of a congenitally displaced kidney is already likely from the fixation, the proof may be found, according to Miillerheim, by meas- uring the ureters. Normally, these have a length of about 25 cm., but in a dystopic kidney there is often a difference of 10 cm. Unfortunately to take these measures is a very complicated procedure; it can only be done by catheterization of the ureters, and, with a tortuous ureter, this is often deceptive. The diagnosis " floating kidney " naturally receives some support from the appearance of the person in question. In a patient with a tendency to anemia there must also be either a pendulous abdomen or a somewhat flaccid abdominal wall. A certain degree of "nervousness" or hysteria is significant of this affection. The presence of Stiller's sign, abnormal movability or deficient chondrification of the tenth rib, gives a view of this kind an objective basis. The presence of kyphoscoliosis strengthens the diagnosis of wandering kidney. Naturally, we must remember that many women show a moderate degree of kyphoscoliosis. In men, and in a left-sided floating kidney, the greatest care in the diagnosis is presup- posed. The fact that in floating kidney the stomach rarely is normal in position and size may also be utilized in the diagnosis. Finally, an ex- amination of the patient in various positions of the body (upon the side 1 R. Miillerheim, Verhandl. der Medicin. Gesellschaft in Berlin, November, 1892; see also its ensuing discussion. DISPLACEMENT OF THE KIDNEYS 289 and upon the back) must be made, the alteration in position of the movable organ must be followed and investigated, and we must observe whether it is connected with other organs. According to J. Israel, 1 the proof that the kidneys are out of their normal positions is alone decisive, since con- striction of the right lobe of the liver, 2 carcinomatous and tubercular tumors of the ascending colon and of the flexure of the colon, carcinomata of the pylorus, small ovarian tumors with long pedicles, and enlarged gall-bladder have been mistaken for floating kidney. (For confusion with wandering spleen see page 293.) TREATMENT The treatment of floating kidney must be limited in most cases to the application of a suitable bandage, to preventing the formation of a pendu- lous belly, and, in case this is already present, preventing its further enlargement. It is easy to understand that the symptoms of wandering kidney are not so readily removed by a bandage as those of gastroptosis. If pyelitis has preceded, such a bandage is often intolerable to the patient. Occasionally a corset specially designed is useful, yet often this fails to have any effect. Then we are compelled to resort to strips of adhesive plaster. Eose 3 advises the following : " Three strips as wide as the hand and of varying length are used, the longest being applied firmly around the belly; the entire abdominal mass is firmly pressed upward from below, and the two ends of the adhesive strip are brought together at or over the vertebral column. The crest of the ilium should remain free, but the plaster must be applied imme- diately above, and adjacent to, this bone. The propping of the abdominal wall is strengthened by the application of two additional lateral strips which also meet at the vertebral column, running upward and backward from Poupart's ligament." If these bandages do not at once relieve the discomfort of the patient, we should insist upon a few weeks of rest in bed. Plentiful nourishment and prolonged bodily rest will, as a rule, re- move the symptoms which appear in very nervous patients who suffer from floating kidney. By this treatment fat will perhaps be deposited in the belly and the capsules of the kidneys, and thus a cause of abnormal movability will be removed. The nervous symptoms, too, are usually re- lieved by a rest cure in suitable environment and by the employment of hydrotherapeutic measures. But, in the end, the results do not entirely 1 J. Israel, " Chirurgische Klinik der Nierenkrankheiten." Berlin, 1901, p. 20. *Penzoldt, Miinchener med. Wochenschr., 1903, Nr. 10. 'Rose, Zeitschr. f. prakt. Aerzte, Sept., 1901 ; quoted from B. Presch, " Die physi- kalisch-diatetische Therapie in der arztlichen Praxis." Wiirzburg, 1903, p. 170. 290 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART correspond with our hopes. After a short time, the old complaints of a wandering kidney are again heard. The inefficacy of treatment indicates that operation for the removal of the symptoms should be considered. The excision of the kidney has been proposed and carried out, but, fortunately, this is no longer advised by any surgeon. The knowledge that when one kidney is very movable the other organ often shows the same disability, although to a less extent, should have prevented such a method of procedure. Even when the opera- tion of suture, yet to be touched upon, would be useless, extirpation must be rejected, for, no matter how great the nervous symptoms, the most important disease is in the nervous system, so that, as a rule, the removal of the kidney brings no permanent improvement. The dangers of this operation may best be seen from E. Hahn's * report of 42 extirpations for wandering kidney, with the result that 11 patients succumbed to sepsis, peritonitis and uremia. The operation usually employed at the present time is suture of the kidney to the abdominal wall (nephrorrhaphy), introduced by E. Hahn. The kidney is exposed by excision in the lumbar region, the fatty capsule is partly removed and fastened to the muscles by a few stitches through the capsula propria and the substance of the kidney. According to Israel, under some circumstances, the repetition of nephrorrhaphy, perhaps by another method, may be necessary. Objections have been raised to this operation. In the first place, Hahn himself emphasizes that it is not quite devoid of danger. The mortality is said to be from 2 to 3 per cent. Furthermore, the cure is often not permanent, the difficulties being, in fact, not alone due to the kidneys, but also to a simultaneously present gastroptosis, and symptoms referable to the stomach and to the nervous system are combined. According to the reports of various surgeons, the cures may be estimated at 50 to 60 per cent. From this the conclusion is obvious that the operation is advisable only in such cases of floating kidney as present also renal symptoms, therefore, symptoms of constric- tion, of hydronephrosis or pyonephrosis, or a stubborn, distressing pyelitis. This, as has been stated, is only the case in a minority of the patients. DISPLACEMENT OF THE LIVER WANDERING LIVER (HEPATOPTOSIS) Displacement of the liver is comparatively rare, provided we mean the complete descent of this organ from its usual position. Slight de- grees of displacement, however, are comparatively frequent, as has been shown when the abdominal cavity has been opened during life. Kehr, therefore, maintains that a somewhat movable liver is found in all women 1 E. Hahn, Zeitschr. f. Chirurgie, LXVII, p. 363. DISPLACEMENT OF THE LIVER 291 who have borne children. When the liver descends into the lower abdom- inal cavity, we naturally first attribute it to an abnormal weakness of the suspensory ligaments, and, secondly, repeated pregnancies which weaken the abdominal walls are frequently held responsible. Thus Landau 1 found a very marked displacement of the liver into the lower abdominal cavity in a woman, aged 28, who in three years had passed through four preg- nancies. Cantani 2 was the first to describe such a change of position, and other cases were subsequently reported by various authors. In 1885, Landau published a comprehensive mono- graph, " Ueber Wanderleber und Hangebauch," in which these altera- tions in the position of the liver are accurately described as well as their mechanical effect upon the position of the abdominal organs. Among 31 cases of floating liver which Landau collected from litera- ture, 27 occurred in women and 4 in men; 14 of these cases were his own patients, and he expressly points out that most authors underestimate the frequency of wandering liver because the liver is rarely examined while the patient is in the erect posture. The age of the person affected is usually over forty years. Hepatoptosis is recognized by the absence of liver dulness in the usual area, and by the discovery of a movable tumor of the size and consistence of the liver in the lower abdominal cavity; movability generally occurs when the body changes its position. In many cases, displacement of other organs can also be determined; Landau, for instance, among his 14 cases of wandering liver found a floating kidney in 4. The position of the liver is best shown by the accompanying illustrations taken from Landau's book. Confusion with cancer of the stomach, tumors of the omentum, and ovarian cysts may occur if we do not bear in mind displacement of the liver, and thus fail to trace the boundaries of the liver in the right hypo- chondrium. FIG. 16. Displacement of the liver. 1 L. Landau, "Die Wanderleber und der Hangebauch der Frauen," Berlin, 1885, comprehensive compilation of the literature. 2 Cantani, Schmidt'sche Jahrbiicher, CXLI. 292 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART SYMPTOMS Symptoms of wandering liver are usually manifest, for the organ is so large that, when in an unusual position, its pressure upon other organs could not be unnoticed. A sensation of fulness, rumbling in the abdomen, ill-defined pains which sometimes extend over the entire abdomen/ to the chest, to the small of the back, and to the right shoulder are, according to Landau, the most frequent signs. As in displacement of other organs, the patients complain most after exertion ; on prolonged rest in the recum- bent posture the symptoms disap- pear. Some patients are annoyed by the pulsation of the abdominal aorta and other large abdominal vessels which is distinctly felt. Sometimes it is impossible to trace an intimate connection between the nervous symptoms and the abdo- men. Disturbances of gastric di- gestion and of bowel action are often noted, as in displacement of all other abdominal organs. .. TREATMENT FIG. 17. Displacement of the liver. The treatment generally con- sists in applying a binder to sup- port the pendulous abdomen. Schott x has constructed a shield resembling the human hand to hold the liver in its normal position, but, like all other apparatus to support the abdomen, the results are not very satisfactory. DISPLACEMENT OF THE SPLEEN WANDERING SPLEEN A displacement of the unenlarged, normal spleen is very rare. Glenard reports that he found it only twice in 160 cases of enteroptosis. The loca- tion of the spleen near the diaphragm is such that in all pathologic proc- esses which dilate the left thoracic cavity it is forced downward, and 1 hereby is more readily reached by the palpating finger; but there is no greater permanent movability than in the normal organ. A displacement of the spleen is also observed when it becomes enlarged by pathologic processes (by uncompensated valvular lesions, hepatic cirrhosis, malaria, leukemia). But, even in this case, the movability is usually not great. Finally, those cases remain in which extreme movability of the spleen is 1 Schott, " D. Medicinalzeitg." 1882, Nr. 21 und 22. DISPLACEMENT OF THE SPLEEN 293 noted in some area of the abdominal cavity, most frequently in the left iliac fossa. The cause of this displacement is unknown. Flaccidity of the abdominal walls or shock naturally favors its occurrence; but only in a very slight number of persons, and these mostly women, are the ligaments of the spleen so feebly developed as to permit a marked displacement. DIAGNOSIS In the diagnosis, a differentiation must be made between wandering spleen and the far more frequent floating kidney. The spleen frequently shows upon its anterior border one or more incisures which are lacking in the kidney. The entire configuration of the spleen is different from that of the kidney. It must be remembered, too, that the right kidney is most likely to be displaced, and this is generally detected, although not always, upon the right side of the abdomen. When the spleen is absent from its normal area on percussion the diagnosis is certain, but this is a proof naturally very difficult to obtain in the obese and in very old persons. The kidneys should either be palpable in their normal position, or their absence decided upon. In conclusion, they may be confounded with very movable ovarian cysts having long pedicles. SYMPTOMS Symptoms of wandering spleen may be entirely absent; occasionally there are pains of very indefinite nature. The turning of the pedicle and consequent compression of the splenic vessels may cause atrophy or even gangrene in the surroundings of the organ or in the stomach. In one case the spleen steadily decreases in size, the disturbances gradually disappear, and recovery takes place; in another, peritoneal processes may develop. But these are probably great rarities, always current in medical literature. 1 TREATMENT In the treatment, the employment of an abdominal bandage must first be considered; then, by the administration of arsenic, quinin, and iodin, we must attempt to decrease the size of the spleen; finally, the nervous symptoms should be combated by hydrotherapy. Among surgical measures, fixation of the" spleen, splenopexy, which was first proposed by Eydygier 2 is prominent. Litten 3 quite properly 1 It is quite remarkable how few reports there are in the literature of the last few decades regarding wandering spleen, which is a proof of the rarity of the affec- tion, for the obverse conclusion that everything relating to this condition has been ascertained, and that, therefore, further reports would be superfluous, is unjustifiable. "Rydygier, Verhandl. der deutschen Gesellschaft f. Chirurgie, Berlin, 1895. 8 Litten, " Die Krankheiten der Milz," Wien, 1898, p. 37. 294 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART raises to this the objection that permanent fastening of an organ which to so great an extent takes part in the respiratory excursus of the dia- phragm can hardly be expected. When the spleen is decidedly enlarged, however, its total removal may be considered. It is self-evident that this is by no means a simple operation 1 and that it should never be advised when nervous symptoms only are present. DISPLACEMENT OF THE COLON (COLOPTOSIS) In 1853 Virchow 2 called attention to the fact that displacement of the eolon was of frequent occurrence, and attributed this to local chronic peritonitis and to acute, infectious, intestinal diseases, especially dysen- tery. Displacement of the colon is due to the same causes as general splanchnoptosis, to a weakness of the ligamentous apparatus and a de- cidedly pendulous abdomen. The greatest deviation in course is shown by the transverse colon, particularly by the right flexure, which occasion- ally forms a sharp angle whose vertex is situated below the umbilicus, the entire large intestine resembling in shape the letter M. Under these circumstances, particularly in aged persons, portions of the intestine packed with feces are felt in the right iliac fossa, a finding which led me to regard peritvphlitis as the consequence of fecal stasis, whereas we now know with certainty that the feces above the ileo-cecal valve are still fluid in composition, the solidification chiefly taking place in the trans- verse colon. Displacement of the colon may be proven by inflation from the rectum. Such a process, however, is usually superfluous, because valueless in treat- ment. For although displacement of the colon may hinder the propulsion of the intestinal contents, as has been stated, an obstruction in the intes- tinal canal is easily compensated for by a greater activity producing hyper- trophy of the smooth musculature of the intestine. The causes of consti- pation may be readily found in weakness of the abdominal muscles, in the composition of the food which leaves too little residue, and often also in gastric disturbances. Nervous symptoms may usually be attributed to a general splanchnoptosis and to neurasthenia rather than to coloptosis. 3 The most effective treatment in displacement of the colon as well as any other part of the intestines consists in the application of a well-fitting abdominal binder, and the regulation of the diet and the entire mode of life, in the manner already described. .hist as in gastroptosis, Bier attempted the surgical treatment of colop- 1 Compare Vitlpins, Beitrage zur klin. Chirurgie, XI, 1894; Kirchhoff, Therapeut. Monatsh.. 1898. 2 Virchow's Archiv, V, 1853. 3 Blocher, Zeitschr. f. Chirurgie, LVI. DISPLACEMENT OF THE HEART 295 tosis. In a patient who suffered from constipation accompanied by pain in the left side of the abdomen,, the mesocolon of the transverse colon, which was extremely tortuous, was straightened by silk sutures. From the description just given, which shows that the symptoms de- pend only in small part upon displacement of the colon, it is evident that such surgical treatment is not advisable. DISPLACEMENT OF THE HEART WANDERING HEART COR MOBILE 1 Under physiologic conditions the heart is held in position by the aorta and the pulmonary artery which are firmly adherent to the pericardium, and also by its attachment to the diaphragm in the thorax; it is still further supported by the large veins which empty into the heart. As is shown by the illus- tration (Fig. 18), taken from Determann's 2 work, the heart is attached at such points on its right and upper side as will permit to the apex of the heart the greatest possible movability in conformity with the movements of the thorax, and this position is most dis- tinctly revealed by the apex beat. As is the case with the abdominal organs, the heart is also maintained in position by the pressure of the adjacent organs. Thus the lungs completely surround the heart and exert pressure which, in the case of pleural effusion or any other process which decreases the space in the thorax, may increase to such an extent as to force the heart away from its normal position. The heart is also held in place by its attachment to the diaphragm, and particularly to the central tendon, by means of which every variation in pressure within the abdominal cavity is transmitted to the heart (see Fig. 19, taken from C. Toldt's 3 Anatom- ical Atlas). FIG. 18. Pericardium with vessels. Henke.) (After 1 The term employed by some authors, cardioptosis, does not appear to me to be happily chosen, in which opinion A. Hoffmann coincides, since it is too suggestive of a low position of the cardia, therefore of a portion of the stomach. 2 Determann, Deutsche mcd. Wochcnsclir., 1900, Nr. 5; compare also the discus- sion following this. s C. Toldt, Anatom. Atlas, III, Aufl., IV, Liefer., p. 482, Berlin und Wien., 1903. 296 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART To a certain degree every heart is movable; this has been known to clinicians ever since the introduction of percussion. It has also been known that the heart could be displaced 1 or 2 cm. to the left, and, to a somewhat slighter extent, also to the right. But the investigations of Kumpff, Determann, A. Hoffmann, Cherchewski, 1 L. Braun, Leusser and others have given us more accurate information. Determann, in particu- lar, deserves great credit for having widened our knowledge of this process hv a large number of researches, in which the results of percussion were subjected to a subsequent test by X-rays. These results, later confirmed by other investigations, are as follows: In a normal person in the left lateral position displacement of the heart takes place, upon the average 2 to 3 cm. to the left, and in the right lateral position about 1 cm. A displacement is rarely absent, but occasionally it may be very slight. In some healthy persons, however, this displacement is decided, and amounts to 6 cm. to the left and 4 cm. to the right. Generally, these extreme degrees of displacement are found in middle-aged persons who are poorly nourished and have a weak mus- cular system, in whom, therefore, an abnormally great displacement of the abdominal organs is also most frequently found. This coincides with the opinion that in women the heart is generally much more movable than in men. In the newborn, cardiac displacement is almost unknown, and in children it is very slight. A deviation from the normal state of the abdominal viscera is found when, in the aged, the movability of the heart does not increase but decreases, probably because, by augmentation of the emphysema, the pressure exerted by the lungs upon the heart be- comes greater. But the pressure from the abdominal cavity influences the movability of the heart still more than pressure from the lungs. During pregnancy the heart is forced upward, and rests upon the diaphragm in such a way that hypertrophy is simulated; yet the heart is but slightly movable. Soon after labor, however, the highest grades of cardiac displace- ment may be noted, as a rule, to the left and upward, so that the apex beat appears near the axillary cavity. A similar influence is exerted by all other processes in the abdomen, such as ascites, meteorism, by a pendu- lous belly, or enteroptosis. Emaciation, as a rule, intensifies the movability. In the first place, the layers of fat normally surrounding the heart and which reach their greatest development (Gerhardt) in the obese occasionally disappear; the 1 Cherchewski, Gaz. med. de Paris, 1887, No. 53; Rumpff, Verhandl. d. VI. Con- firrftsrs f. inncrc Med., 1888; Deutsche med. Wochenschr., 1902, Nr. 31, und 1903, Xr. 3: .1. Hoffmann, also, 1900, Nr. 19; L. Braun, " Ueber Herzbewegung und Herz- stoss," Jena, 1898 u. Centralbl. f. innere Med., 1902, Nr. 35; Leusser, Miinchener med. Wochenschrift, 1902, Nr. 26; Pick, Wiener klin. Wochenschr., 1889, p. 747; .1. Schmidt. Deutsche med. Wochenschr., 1901, Nr. 16. I have also made investiga- tions in a small number of cases. Venous angle \ Trachea Innominate artery Internal jugular vein Arch of the aorta / Subclavian vein Coracoid process Superior medias- tinal or cardiac 1 y in p h a t i c glands Ascending aorta - Superior vena cava Serailunar or sig- moid valves of the aorta Mitral or bicus- pid valve Right lung Orifice of the coronary sinus Eustachian valve Branches of the hepatic veins Phrenocostal or diaphragmatico- costal supple- mental pleural space Branches of the portal vein with Glisson's cap- sule Gall-bladder Hepatic flexure of the colon Clavicle Body or shaft of the first rib --' Mediastinal pleura - Costal pleura Left lung Pulmonary artery Pericardia! cavity Pericardium Pleural cavity Left ventricle Apex of the heart Diaphragm Left lobe of the liver Body or shaft of the seventh rib Spleen (inferior extremity) Body of the stomach Transverse colon Pyloric portion of the stomach Duodenum Pylorus (superior portion or first part) FIG. 19. Frontal section through the trunk. 298 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART abdominal fat is largely decreased also in hyponutrition. This, therefore, favors a loosening of the viscera from their attachments, a downward displacement of the diaphragm, and, thereby, leads to a decrease of pres- sure in the thorax. Movability of the abdominal organs and of the heart is also observed in chlorosis. Hoffmann considers this the explanation of the passive dilatation after exertion so frequently reported by some investigators (probably from erroneous observations), but he is probably incorrect. For as we know that the chlorotic has a flaccid muscular system, and that under these circumstances a displaced stomach readily dilates, so the same may be assumed of the heart. In this case we would have a complication of abnormal displacement and dilatation. We have little definite knowledge of the pathologic processes which are influenced by the amount of space in the thorax and abdominal cavity. Some clinicians (Curschmann, Braun, and Cherchewski) maintain, from their experience, that arterio-sclerosis particularly involving the aorta in- creases movability, while Determann was unable to confirm this. It is easily understood that just as a neoplasm burdens the stomach, or hydronephrosis produces a tendency to displacement, so the same conditions arise in a hypertrophied heart. An enlargement of the left ventricle may become so extensive that dilatation of the right ventricle escapes observation (Frankel). Individud influences play a great role, and often a hypertrophied heart shows no displacement. As a rule, displacement is readily proven by palpation and percussion. SYMPTOMS As to the symptoms, there is no unanimity among clinicians. Some, such as Rumpff and Leusser, incline to the view that certain symptoms distinctly indicate cardiac displacement, wandering heart. Persons with marked displacement of the heart cannot sleep for any length of time upon the left side without distress arising. Symptoms become noticeable, such as palpitation, oppression, difficulty in respiration, attacks of syncope, fear, irregularity of the pulse, etc. Other clinicians, such as Braun and Homberg, deny this, and quite properly emphasize that many persons have a greater or less displacement of the heart without any symptoms. More- over, the persons who usually suffer from wandering heart are exceedingly nervous, and often complications are present, such as alcoholism, cardiac asthenia, etc., to which the symptoms are attributed; this makes an opinion exceedingly difficult. In the main, I agree with the latter view, and in this connection I wish to reiterate what I have said regarding floating kidney. A healthy person will usually feel no discomfort from the displacement of a kidney or of the heart, although it cannot be denied that displacement of these DISPLACEMENT OF THE HEART 299 organs, when made known to him, and particularly at the onset, may give rise to symptoms. The rarity of cardiac symptoms in healthy women after labor, during which the heart is especially prone to be displaced, favors this view. Moreover, I recently saw a marked displacement of the heart during an obesity cure, while, simultaneously, the symptoms refer- able to it disappeared. The case was that of a woman, aged 32, having a height of 1.7 meters, and weighing 98 kilograms; the obesity had particularly increased during the last few years. The heart at first re- vealed normal dulness, the pulse ^during rest in the sitting posture was from 80 to 88, but upon the slightest exertion it rose to 130, and at the same time decided dyspnea appeared. Questioning elicited the report that, for many years, the patient had slept only upon her back or in the right lateral position. I instituted a moderate hyponutrition, and assured the lady that after the loss of 16^ to 22 pounds she would be able to sleep upon the left side. When, after six weeks, she had lost 20 pounds, quite a decided displacement of the heart to the left could be determined, about 4 to 5 cm., which had not previously been noticeable. Of course, I did not tell her this. General bodily activity, as well as that of the heart, had increased, the pulse during rest did not exceed 80, and even upon exertion dyspnea did not so rapidly appear. Above all, the lady assured me that she could now sleep the entire night upon her left side without any inconvenience. Here, therefore, the antifat cure produced such an improvement in the circulation that possible abnormal sensations due to displacement of the heart were unnoticed by the patient. In this respect erroneous opinions may easily be formed because under- nutrition is not well borne by nervous patients. In men who work under mental strain, and in women who have many household cares, it is apt to produce nervous disturbances, while, after they are relieved from their burdens and pressing duties, and are sent away to a pleasant environment, most of them bear a loss in weight of from 11 to 16^ pounds without the consequent displacement of the heart having any unpleasant effect. Upon the basis of these views, the removal of the symptoms of wander- ing heart by plentiful nutrition might be supposed the correct treatment. But, generally speaking, this is not the case. We must not forget that in some persons blood formation is immoderately increased by plentiful nutrition, and thus higher blood pressure arises. We do not know under what circumstances cardiac hypertrophy occurs, but it must all the more be reckoned with since the development of this affection usually escapes observation. It is quite likely that disturbances regarded as " cardiac neuroses " mark its onset, usually designated cardiac hypertrophy follow- ing " luxury consumption." In practice, even after minute investigation of the heart, we may sometimes doubt whether certain symptoms are due to an increased displacement or to a beginning hypertrophy. Only in 300 DISPLACEMENTS OF THE ABDOMINAL VISCERA AND HEART thin, debilitated individuals does hypernutrition appear to be justified. The efforts of the physician must be chiefly directed to combating the nervous symptoms by means of rest, a proper regulation of the muscular activity, plentiful amounts of fresh air, and, perhaps, also the employment of hydrotherapeutic measures. In some cases the binder advised by Abee in Xauheim, a so-called heart brace or heart bandage, may be advised. The chief value of the apparatus is, however, merely suggestive; at all events, unlike the advantage from the employment of the binder in dis- placement of the abdominal organs, it js impossible to explain by purely mechanical laws the benefits from its use. DISEASES OF THE PANCREAS Till 1 !- SYMPTOMATOLOGY OF THE DISEASES OF THE PANCREAS BY L. OSER, VIENNA HISTORY ALTHOUGH physiology and experimental pathology were busy in the last third of the preceding century with a study of the pancreas which has led to a better understanding of the various vital functions of this organ, practical medicine has utilized this knowledge to but very slight extent. Hospitals and medical colleges, especially the departments of surgery, have devoted increasing attention to the pancreas within the last few years, and it has come to pass that, in making a diagnoses of digestive disturb- ances from certain alterations of metabolism, the pancreas also has been considered, yet in the popular current of professional life, diseases of the pancreas have been almost ignored. Eegrettable as this apparent apathy is, its cause is easily understood when sought for. Chief among the reasons is the fact that, until recently, this indifference was manifest also in the schools, in the clinics, and in the laboratories. Even to-day, adequate attention is not devoted to the pan- creas, as is evident when we consider the manifold and complicated ques- tions brought up for consideration, questions which often relate to ele- mentary but most significant processes. Even pathologic anatomy has added little to our knowledge of the pancreas; at autopsies, the pancreas frequently is not considered at all, or but superficially investigated, and a cursory examination of this organ is usually without value. It is true the difficulties are great. An apparently normal pancreas will, upon careful microscopic investigation, frequently show changes which are ex- ceedingly difficult to interpret correctly for the reason that the organ, during the death agony and, perhaps, also for some time after death, undergoes change from continued self-digestion, and this may very readily be mistaken for a pathologic alteration which had occurred during life. In the last few years a decided change for the better has taken place, as is shown by the increasingly rich literature. Since the important re- searches of v. Mering and Minkowski, which point with certainty to the connection between diabetes and the pancreas, an active interest in this 21 303 304 DISEASES OF THE PANCREAS organ has been awakened and, owing to the victorious advance of surgery, following the initiative of Gussenbauer, the pancreas has become the border-land between internal medicine and surgery, and incontrovertible proof has been furnished of the great practical importance of this organ. The pancreas to-day, on account of individual causative observations, is not only the subject of discussion in inaugural dissertations, but promi- nent exponents of theoretical and practical medicine in different countries have devoted their best endeavors to the development of a positive founda- tion for the study of diseases of the pancreas. Naturally we are still far from the goal but a few important facts have been ascertained, which are not only interesting to the practical physician, but the knowledge of these he cannot and dare not ignore in his professional work. This is our justification for calling close attention to the present status of clinical knowledge concerning diseases of the pancreas. This article will be devoted to a description of the symptoms by which we are enabled to make a diagnosis of disease of the pancreas. ANATOMY AND PHYSIOLOGY Before entering upon my actual theme, I desire to emphasize a few points in the anatomy ^and physiology of the pancreas which have a direct bearing on our subject. First in importance, the gland, as a rule, has two ducts, a fact which is not always borne in mind, even by physiologists, since in the animal usually experimented upon the dog two ducts are invariably present. The tying of one duct, or the introduction of a can- nula into one duct, may lead to error. In the dog as recently reported by Helly these ducts are always distinctly separated, which in man is the exception. Helly, under the direction of Zuckerkandl, has recently studied this subject thoroughly. He examined 50 cases, and among these he only once found the ductus Santorini and no ductus Wirsungianus ; in all of the other cases he found the ductus Santorini connected with the ductus Wirsungianus, or the duct existed alone, the latter condition being much the rarer. Of the 50 cases, Santorini's duct had free passage into the intestine in 40 cases, and was obliterated in 10. The relations between the pancreas and the ductus choledochus are of the utmost practical importance; the latter enters a groove upon the side of the gland, bends toward the duodenum, and, as Zuckerkandl- reports, embeds itself, but soon terminates in a canal. Helly, in his investigation of 70 cases, confirmed these reports of Zuckerkandl. He found that the terminal portion of the ductus choledochus is always closely connected with the head of the pancreas to the extent of from 2 to 7 cm. Pawlow made some interesting experiments in regard to innervation. According to this author, the vagus is the secretory nerve of the pancreas, but this nerve also carries fibers which have an inhibitive secretory func- ANATOMY AND PHYSIOLOGY 305 tion; in the sympathetic Pawlow also determines secretory and vaso- constrictory fibers. More recent investigations by Wertheimer and Lepage have demonstrated that, after the severing of all nerve centers, secretion does not cease ; that, therefore, there must also be an automatic nerve appa- ratus present in the gland. These investigations permit us to conclude with certainty that in pathologic cases disturbances in secretion may also be caused by disturbances of innervation. The incessant labors of physiologists in the last few decades have fre- quently demonstrated the great importance of the physiological functions of the pancreas. Undoubtedly the pancreas is one of the most important organs of the body; in digestion and in metabolism perhaps the most important. The pancreatic juice is the only glandular secretion which is capable of converting all substances that can be at all digested into that form which is necessary for their complete utilization as food. It is more active than any other ferment (trypsin) in the splitting of the albumin bodies; it emulsifies and splits the fats so that they are capable of absorption (steapsin) ; it transforms the carbohydrates into sugar (pan- creatic diastase) and also possesses a milk-coagulating ferment. The secre- tions of the other digestive glands also possess these properties, but they are not combined in the secretion of any single organ. The specific property of the pancreas, which belongs to it alone, is the splitting up of fat. In the intestine, it is true, a certain degree of fat-splitting is possible, but only by bacteria. The enormous importance of the pancreatic juice in digestion has been decisively proven by animal experiments, to which we shall later revert. But its digestive function is, however, not the only activity of the gland. It also performs an important part in the human economy by the transformation and preparation of sugar. We attribute this func- tion to the internal secretion, the conclusive, experimental proofs of which we shall later discuss minutely. This sketch indicates the great importance of the pancreas in the human economy. Disease of this organ must, naturally, produce severe disturb- ances, and we might suppose that, in consequence, such marked symptoms would appear that the recognition of a disturbance in function would present no difficulty, but the contrary is the case. How can this fact be explained? The most significant reason is this that only very ex- tensive or complete destruction of the organ and the occlusion of both ducts will cause characteristic symptoms. In partial disease, or the occlu- sion of one duct, as we shall see, the internal as well as the digestive function may remain intact, and the normal remainder of the gland, although with only one duct, and perhaps vicariously, may compensate for the functions of the neighboring organs. Total or very extensive dis- ease is certainly much rarer than partial, and the latter usually gives rise only to doubtful symptoms which are but uncertain points of support for 306 DISEASES OF THE PANCREAS its recognition. The symptoms are interesting, because, as a rule, it is not only the pancreas that is diseased, but a simultaneous disease of the neighboring organs may be the cause, or consequence, of disease of the pancreas, and its physical signs be much more distinctly and obviously apparent than those of the diseased pancreas. If, for example, chronic pancreatitis develops in the course of gall-stone disease, cholelithiasis forms the most prominent symptom, and the signs of disease of the pancreas may be completely disguised. The symptoms of absence of function, therefore, are of paramount importance in diagnosis, and to these we shall devote our attention. SYMPTOMS First among these are diabetes and alimentary glycosuria. Autopsy findings long ago directed attention to the relation between I he pancreas and diabetes. The oldest, most reliable report was in 1788 bv Cowlcy, who, in a diabetic, found numerous calculi in the substance of the pancreas. Chopart later made a similar observation. Bright, in 1S.S3, saw, in a diabetic, aged 19, a hard, nodular tumor at the head of the pancreas while the gland itself was atrophic. Since that time, similar cases have been frequently mentioned in literature. The frequent coincidence of diabetes and disease of the pancreas caused Frerichs, Seegen, and Friedreich to assume a causal connection between the clinical and anatomical findings; but it was still questionable whether disease of the pancreas was the cause or the consequence of diabetes. French authors above all, Bouchardat took a more decided stand; they proposed a clinical type, diabete maigre, and looked for its foundation in a disease of the pancreas. This assumption was enticing, and was also frequently confirmed by conclusive reports of cases; nevertheless, it re- mained but a hypothesis until by animal experiment v. Mering and Min- kowski finally furnished the incontestable proof that by removing or de- stroying the pancreas in a dog severe diabetes occurred. A radical change in opinion was the result, and it is now believed beyond all doubt that diabetes in man is caused by disease of the pancreas. The results obtained by these authors were soon confirmed by many others, and in an entire scries of animals diabetes was produced by extirpating the pancreas. But diabetes occurred only by removal of the entire gland, or, at least, of its (jrcatcr portion; partial extirpation gave varying results. If one-fifth to one-fourth of the gland were allowed to remain, v. Mering and Minkowski frequently found no glycosuria. But severe diabetes might also be pro- duced. This depended particularly upon the composition of the portion of the gland remaining. If this was subsequently destroyed by consecu- tive inflammation or atrophy, diabetes developed; cases of diabetes of medium severity, or only a transitory or more or less permanent alimentary SYMPTOMS 307 glycosuria arose; or, as already mentioned, in the great majority of cases no form of sugar excretion took place. Sandmeyer found, in a patient in whom severe diabetes developed 13^ months after partial extirpation of the pancreas, that diabetes persisted for eight months and until death occurred. In the experiments in partial extirpation conducted by Katz and myself, it was impossible to produce severe diabetes, but only transi- tory and alimentary glycosuria; in some cases, sugar was absent from the urine. Minkowski definitely proved that the cause of diabetes in extirpation of the pancreas could be found neither in a lesion of the nerves nor in injuries, and that it could not be attributed to the absence of the pan- creatic secretion. This was demonstrated in an indisputable manner by the transplanta- tion of portions of the pancreas under the abdominal skin, first by Min- kowski and later by Hedon. A portion of the pancreas may be detached and, without injuring the vessels which supply it, may be transplanted under the skin of the abdomen. If the portion remaining in the abdominal cavity is removed, no glycosuria occurs, not even the alimentary form; if the section underneath the abdominal skin is subsequently removed, severe diabetes is produced. If the transplanted portion is badly nourished, mild diabetes may occur. If complete atrophy takes place in the grafted por- tion, severe diabetes develops. The mere tying of the ducts never leads to diabetes, except when such a change due to these processes subsequently occurs in the glandular substance that it is completely destroyed. It is absolutely true that removal of the pancreas in quite a number of animals has produced diabetes. Besides its digestive function, the pan- creas unquestionably has another which is related to sugar metabolism. We do not err when we refer this function tb a secretion quite distinct from the digestive juice; this is called the internal secretion, or, following Hansemann, the positive function. In what manner this internal secre- tion exerts its activity is still doubtful. Minkowski, and also most authors, assume that the pancreas in the preparation of sugar also generates a prod- uct which acts in the organs. A series of hypotheses have been proposed in explanation, but no defi- nite proof of the correctness of one or the other is yet at hand. The hypothesis of Lepine is most interesting; he assumes a glycolitic ferment which is normally produced in the pancreas. This glycolitic fer- ment reaches the lymph, thence the blood, particularly the white blood- corpuscles, and carries on the preparation of sugar in the tissues. If this ferment is absent, hyperglycemia and diabetes result. Lepine later modi- fied this hypothesis, no longer referring the point of attack of the glycolitic ferment to the blood but to the tissues. In consequence, as Minkowski points out, the assumption of such a ferment is no longer impossible, although we have no actual proof. 308 DISEASES OF THE PANCREAS Other hypotheses, such as those of Chauveau and Kaufmann, in which an increase of sugar formation in the liver is assumed to be the basis, and also the views of the brothers Cavazzani are flisproven by the experi- ments of Minkowski, who demonstrated that in experimental pancreatic diabetes not an increase of the sugar production, but a decrease in its consumption, occurs. We only know, therefore, that the pancreas has a function which regulates the consumption of sugar, but we do not know the nature of this function. An attempt has lately been made to discover the region in which this internal secretion is found. Langerhans in 1869 described structures in the pancreas which differ from the pancreatic tubules. These so-called intertubular cell clumps are also found in man and in various animals, and have different forms. Recently the property of furnishing the internal secretion has been ascribed to these intertubular cell clumps. Laguesse as well as Diamare some years ago expressed the view that these cell clumps bear some relation to the internal secretion. Recently Walter Schulze has attempted to solve this question experi- mentally. He ligated small portions of the pancreas in guinea pigs, and studied the changes which followed. After a few days an atrophic process developed in the glandular elements which continually increased even after 80 days, at which time the tubular area was completely atrophied, being replaced by delicate connective tissue; the cell clumps had taken no part in this atrophy, but, on the contrary, showed not the slightest change. Schulze concludes from this that these cell clumps are substantive structures independent of the glandular system of the pancreas. It is true this does not prove that they have any bearing on sugar metabolism. It had long been believed that these structures were in their nature different from the secreting glandular elements. Langerhans himself regarded them as nervous elements; other authors have looked upon them as lymphatic tissue. Some authorities believe them to be embryonal remains, and they have also been considered in connection with the secretion of the diastatic ferment. Walter Schulze's experiments are evidently of importance, but the proof that these structures do not belong to the glandular system and are related to the internal secretion must be furnished by further investigation. Szobolew recently undertook to prove by chemical and microscopical in- vestigations that Langerhans's cell clumps have some relation to sugar metabolism, and decided this to be a fact. In two cases of pancreatic dia- betes the disappearance of these cell clumps was confirmed. Opie arrived at the same conclusion; in 11 cases of interlobular pancreatitis in which form of the disease Langerhans's cell clumps are visible only when the process is very far advanced, he noted mild diabetes only once, and at that in a case in which the sclerosis had also attacked Langerhans's cell clumps. In three cases of interacinous pancreatitis in which form also the previ- SYMPTOMS 309 ously mentioned cell clumps were implicated, diabetes was present twice, and in the fourth case of diabetes there was complete hyaline degeneration of Langerhans's islands. If we succeed in proving positively that these cell clumps are con- cerned in the internal secretion, important knowledge as to the true cause of pancreatic diabetes will have been gained. The demonstration in animals of an experimental pancreatic diabetes enables us to understand much more fully than was previously possible the numerous autopsy reports in literature of changes in the pancreas in the diabetes of man. All doubts disappear, and it is certain that in a large number of cases disease of the pancreas was the cause of the diabetes. At the necropsy of diabetics various changes were found in the pancreas, most frequently atrophy, but often also induration, calculi formation, carcinoma and fatty degeneration. Doubtless, some of these changes in the pancreas are not the cause of diabetes; in many cases they are either its consequences or are in no way related to it. Atrophy has often been demonstrated to be the cause of the marasmus which occurs in diabetes. Hansemann reports a characteristic form of diabetic atrophy with well developed symptoms of an active process added to the process of the secre- tory cells; this belongs to the varieties of interstitial inflammation, similar to that in certain forms of granular atrophy of the kidneys. Hansemann describes early stages of these processes, and designates them as anatomical individualities which must necessarily lead to diabetes. If, in many cases of diabetes, no changes are found in the pancreas, not even upon minute microscopic examination, this is additional proof that there are other causes of diabetes than disease of the pancreas a view now generally accepted. Lanceraux in the last Congress at Paris maintained the unity of diabetes, and of its origin in disease of the pan- creas. He assumes that there are anatomical determinable changes or functional disturbances of the pancreas which lead to diabetes. Lan- ceraux formulates a hypothesis against which weighty objections may be raised, and which cannot be sustained at this present time. A vulnerable point in the theory of pancreatic diabetes in man is the fact that total destruction of the pancreas has been found without diabetes haying existed during life, Hansemann's hypothesis does" not .sufficiently explain the -fact that in' cases of total destruction of th.6 panc'reas "by diffuse carcinoma, carcinomatously degenerated cells nlay perhaps '.furnish the internal secretion of the pancreas, as there are also other varieties of total destruction of the pancreas without diabetes. Perhaps future inves- tigation of the anatomical findings revealed in Walter Schulze's experi- ments will clear up the situation. N"o matter what the conclusion may be, this loop-hole cannot alter the fact that in man diabetes is due to the absence of the pancreatic function. Not only permanent diabetes but also transitory and alimentary glyco- 310 DISEASES OF THE PANCREAS suria may be caused by changes in the pancreas; this is shown by animal experiments, as well as by the facts demonstrated in the disease in man. After various injuries of the pancreas, even although slight, transitory glycosuria may occur. In 15 out of 32 cases of partial extirpation, Min- kowski saw transitory glycosuria. Minkowski, as well as myself, demon- strated alimentary glycosuria in the previously mentioned experiments. In one of these there was a transitory excretion of sugar after every operation upon the pancreas. Upon an exclusive meat diet, on the admin- istration of 10 grams of grape sugar slight glycosuria occurred, and after 50 grams it was marked. In an interesting article Wille has furnished proof that alimentary glycosuria in man is also connected with changei in the pancreas. In 800 patients in the Hamburg General Hospital, Willc made feeding experiments, administering 100 grams of grape sugar in each case, and, with a positive result, this was repeated once weekly. In 47 cases he found alimentary glycosuria. In 77 of the 800 cases an autopsy was held; in 15 of these alimentary glycosuria had been recog- nized during life, and at the autopsy high-graded changes in the pancreas were invariably found. Ten doubtful cases still remained in which during life alimentary glycosuria had been proven, and at the autopsy marked changes in the pancreas were found. Alteration in the pancreas was also observed at the autopsy in cases which, during life, had given no evidence of alimentary glycosuria. Wille arrived at the conclusion that the regular appearance of alimentary glycosuria is an important diagnostic sign of existing disease of the pancreas, that in a periodically appearing alimentary glycosuria the suspicion of disease of the pancreas should not be at once rejected, but that, in the absence of this symptom, the pancreas cannot be looked upon with certainty as normal. These reports of Wille are noteworthy ; they show that cases of constant alimentary glycosuria may be the result of changes in the pancreas. But the relatively small number of positive reports prevents our proving with certainty that this is always the case. Alimentary glycosuria also the constant form is frequently found associated with various diseases, par- ticularly those of the nervous system. In these numerous cases but few autopsy reports relating minutely to the pancreas are at hand, and it may be assumed that there are cases of alimentary glycosuria not caused by changes in the pancreas. It may be true, as in permanent diabetes, that constant alimentary glycosuria occurs witho.ut changes in the pancreas. In spite of these objections, we may maintain, on the basis of our present knowledge, that the proof of permanent diabetes as well as of constant alimentary glycosuria justifies us in including changes of the pancreas in our diagnostic calculations. A second group of symptoms develops from the absence or by the destruction of the digestive function. We know that the pancreas has a SYMPTOMS 311 fat-emulsifying and fat-splitting, a proteolytic and an amylolytic, function. Disease of the pancreas or its destruction must necessarily lead to disturb- ances of this kind. The fact is also operative that a large portion of the gland, or almost all of it, must be incapable of performing its function, hence symptoms due to the absence of function must appear. Add to this the circumstance that, as a rule, two ducts are affected, in some animals even more, and it -becomes clear that if only one duct be occluded, provided that in the other the secretion is sufficiently active, no digestive disturbances may follow. This explains why we so rarely observe disturbances of diges- tion as a result of disease of the pancreas. Let us first consider the absence, or the disturbance, of fat digestion. This is shown either macroscopically, or only microscopically or chemically in the changed condition of the feces. For a long time isolated clinical observations have pointed out the connection between impaired assimilation of fat and changes in the pan- creas, and an attempt was made to prove this experimentally in animals. Even Claude Bernard was of the opinion that pancreatic juice splits the neutral fats, emulsifies them, and is therefore necessary for the absorption of fats. Among those who differed with him was Schiff. Opinions varied until the discovery of experimental pancreatic diabetes by v. Mering and Minkowski, and the digestive disturbances following the removal of the pancreas were studied. Although even to-day there are diversities of opin- ion and many doubts concerning these points, nevertheless the view that, in the absence of the pancreatic function, disturbances arise in the absorp- tion of fat is generally accepted. Abelmann, a pupil of Minkowski, found that with an absence of the pancreas non-emulsified fat is not ab- sorbed at all, and emulsified fat only to a slight extent; only in the case of cream was the absorption more complete. With partial extirpation, 50 per cent, of emulsified fats was absorbed and 80 per cent, of milk. Upon the addition of pancreas to the food, digestion improved. Fat-splitting, even with a total absence of the pancreas, was undisturbed. Similar re- ports were made by Sandmeyer, Cavazzani, and Baldi. Very different results were obtained by Hedon and Ville who raised objections to Abel- mann's method of research, and in this they were supported by Pfliiger. Hedon and Ville found that after total extirpation of the pancreas, fat absorption continued, although to a lessened extent; in a case of severe diabetes it amounted to about 18 per cent. ; fat-splitting remained about normal, principally free fatty acids, but also small amounts of soap. In more extensive investigations Siegfried Eosenberg ascertained that in ex- perimental, gradual destruction of the parenchyma of the gland, fat ab- sorption still showed almost normal -values ; that, however, upon increasing glandular destruction, it is damaged. In regard to fat-splitting, which Rosenberg attributes mainly to bacterial action, he believes that the low fat-splitting figures found with increasing glandular destruction are due 312 DISEASES OF THE PANCREAS to the frequent evacuations, and are caused by the undigested material which passes through the intestine. In complete unanimity with the results of animal experiments, clinical experience teaches us that frequently, but by no means always, in disease of the pancreas, in chronic inflammation, in the case of neoplasms, of cysts, of stones in the ducte, and in atrophy, a deficient digestion of fat can be proven. The first undoubted report is by Kunzmann in 1820; lie saw a profuse discharge of fat in the feces of a man who suffered from induration of the pancreas with obliteration of Wirsung's duct, chronic jaundice and dropsy. A report by Fles is very interesting. A diabetic who had eaten considerable bacon and fat meat discharged ounces of fat in liis feces that could be separated from the stool. If the patient took with his food an emulsion prepared from the pancreas of a calf, the fat disappeared. At the autopsy high-graded atrophy of the pancreas was found. In a case of carcinoma of the head of the pancreas observed by me, , there were present for months uncommonly copious, thick, pappy, fecal discharges which were always profusely admixed with fat. In both cases jaundice was absent a fact which must be particularly emphasized, for, according to the excellent researches of Friedrich Miiller, if the bile is absent from the intestine fatty stools are quite normal. The forms of disturbance of fat digestion which are combined with disease of the pancreas vary considerably. They are sometimes recognized macroscopically, and are then designated as true steatorrhea. In this con- dition large quantities of oily or fluid, yellow and yellowish-brown, fatty masses are discharged with the evacuations, or even independent of them. In the cold these become compact, resembling butter, grease or wax; the hardened fat may then completely envelop the feces contained within it. Pribram, in a case observed by him, closely analyzed these fatty discharges, and proved their similarity to the varieties of fat ingested. Chemical examination of the fatty masses which are visible to the naked eye shows neutral fats and fatty acids. In diseases of the pancreas the stools are of the consistency of clay, grayish-white, or colorless, occasionally asbestos-like, and the increased amount of fat can only be recognized by chemical and microscopical processes. Unquestionably there are many transitional stages between true steatorrhea and the previously mentioned fatty stools, so that the difference between the two forms of dejecta may be assumed to be a graduated one. The chemical investigation of these feces chiefly reveals neutral fats, fatty acids and soaps. Such dejecta, rich in fat, are found by no meana exclu- sively in diseases of the pancreas, but may also occur normally in persons who have eaten such a great amount of fat that the intestine is incapable of absorbing it; in the majority of cases, however, the condition is observed when bile is absent from the intestine, in certain diseases of the intestine, in anryloidosis, in tuberculosis of the intestine, in distributed atrophy of SYMPTOMS 313 the mucous membrane of > the small intestine, in caseation of the mesen- teric glands, in chronic tubercular peritonitis, and perhaps to which also Xothnagel calls attention in intense catarrhal processes. It is evident from this fact that a high percentage of fat in the stools does not prove disease of the pancreas, and we must first exclude all other causes of insufficient fat absorption before we can regard an affection of the pancreas as the cause of the disturbed fat digestion. Miiller, who was positively unable to determine a greater amount of fat in the stool upon the absence of pancreatic juice from the intestine, designated diminished fat-splitting as a factor of disease of the pancreas. Miiller excised the pancreas of a dog, and, under antiseptic precautions, placed it in sterilized milk in the incubator for 24 hours. Fatty acids amounting to from 42 to 45 per cent, were present. In a control experi- ment in which the pancreatic ferment was destroyed by boiling, no fat- splitting occurred. After Miiller had previously proven by experiment that intestinal bacteria had but a slight influence upon fat-splitting, he concluded that the important factor for fat-splitting in the intestine is contained in the pancreatic juice, and the absence of the pancreatic func- tion is expressed by disturbed fat-splitting. In a series of cases of pan- creatic disease, Miiller proved the disturbed fat-splitting with certainty, his reports being confirmed by several authors, but denied by others. The question has been most thoroughly studied by Katz. He formu- lated an expeditious method which enables us to determine the degree of fat-splitting in 24 hours. In the examination of a number of cases ob- served in my hospital, in which during life reduced fat-splitting, and at the autopsy pathologic changes in the pancreas, were determined, he came to the conclusion that a diminution of fatty acids and soaps to below 70 per cent, of the total amount of fat in the fatty stool favors a diminished or even completely arrested function of the pancreatic juice; but in nurs- lings, and in profuse diarrhea, this decrease had no significance. Other authors have also noted disturbed fat-splitting in pancreatic disease, for example, v. Noorden, Rosenheim, Anschiitz. Diminished fat-splitting in disturbed pancreatic function may, there- fore, be considered as proven, and the validity of this proof does not suffer from the fact that there are undoubted cases perhaps many in which no disturbance of fat-splitting can be determined ; even in widely distributed disease of the organ, a healthy portion of the gland may serve the excre- tory ducts, which may discharge a sufficiency of pancreatic juice into the intestine. Where a disturbance of fat-splitting has been found without disease of the pancreas being determined, the circumstances are different. Katz specified that in nurslings and in profuse diarrhea reduced fat-splitting might be found without coexisting disease of the pancreas. Certainly in all cases in which an increased peristalsis rapidly propels the contents 314 DISEASES OF THE PANCREAS through the intestine, the pancreatic juice, normal in amount, will not have sufficient time to split the fat to such an extent as is possible under normal circumstances. Zoja, who recently published a comprehensive study of fat absorption, mentions two cases of reduced fat-splitting without changes being found in the pancreas or in the excretory ducts. In one case there was stenosis of the large intestine, and in .the other carcinoma of the gall-bladder. 1 Zoja recognizes in deranged fat digestion an important indication of an affection of the pancreas, but, on account of the great number of reported cases he arrived at the conclusion that the disturbed fat-splitting is not the most important symptom, but the small amount of soaps which he invariably demonstrated in diseases of the pancreas. Deucher had pre- viously called attention to the importance of this factor. The demonstra- tion in the feces of a decided quantity of neutral fats, or of a great amount of fatty acids, particularly, however, of a deficiency in soaps, according to Zoja. points with great likelihood, if not with positive certainty, to the absence of pancreatic juice from the intestine. The main stress is placed by Zoja upon the lessened quantity of soaps. The greater the percentage of soaps, the more certainly may an occlusion of the pancreatic ducts be excluded; the less the quantity of soaps in proportion to the neutral fats and fatty acids, the more readily may occlusion of the pancreatic duct be assumed. The less the amount of pancreatic juice which flows into the intestine, the slighter is the amount of alkali, and, therefore, also the smaller the amount of soaps. In this reasoning Zoja finds no difference between the animal experiment and observation in man, which has also been emphasized from the standpoint of fat-splitting, since Abelmann, as well as Rosenberg, found smaller amounts of soaps. We cannot enter here upon a criticism of the work of Zoja. I shall only mention that Abelmann reported the frequent finding of quantities of soaps which reached the normal. Miiller previously objected to this method of determining soaps and the combined fatty acids, and designates the proportion of free fatty acids to the soaps in the feces as an inconstant one which depends upon accidental conditions. I must also state that in a case of Zoja's of recognized pancreatic affection, normal values for soaps were found. The relative value of the factor emphasized by Zoja, the lessened soap figures in proportion to the large amount of neutral acids and fatty acids, cannot be denied; but more complete investigations are neces- sary finally to solve the important question of the diagnosis of diseases of the pancreas. We can only state positively that disturbed fat digestion is an important symptom in pancreatic disease. An increased amount of fat in the stools is alone not a basis for the assumption of a pancreatic allVction. If no jaundice exists, and no disease of the intestine is present, if increased peristalsis by which the ingesta are rapidly propelled through the intestine does not explain the insufficient fat digestion, then the sus- SYMPTOMS 315 picion of disease of the pancreas is certainly justified. Some forms of altered fat digestion, true steatorrhea, in which larger, even macroscopi- cally recognizable, amounts of fat are passed with or without the stool, which show diminished fat-splitting with a certain increased amount of fat in the stools, and low quantities of soaps in proportion to the fatty acids and neutral fats, are factors which point with great likelihood to disease of the pancreas. It can only be positively proven, however, when other symptoms due to absence of function, such as diabetes or insufficient nitrogen absorption, or certain clinical symptoms, such as tumor, bronzing of the skin or pancreatic colic, are present. Equally important is the absence or disturbance of albumin digestion, which is observed experimentally and clinically in diseases of the pancreas. Abelmann found that when the pancreatic juice is absent, only a portion of the proteids is absorbed; this averages 44 per cent, in animals in whom the pancreas was removed, and 54 per cent, in the cases of partial extirpation of the pancreas. If, on meat diet, pig's pancreas was simul- taneously given, the absorption of nitrogen was decidedly increased, and 74 to 78 per cent, was absorbed. After a meat diet the presence of numer- ous macroscopically recognizable undigested muscle fibers was conspicuous. Similar results were obtained by de Kenzi, Cavazzani, Sandmeyer, and Harley. In an instance of total extirpation of the pancreas performed by Katz and myself, and which was followed by diabetes, after meat was taken for the first time, large portions of undigested meat were macro- scopically found in the feces. Under microscopic investigation numerous muscle fibers with distinct transverse striae were detected. Eosenberg's investigations were most thorough; after tying the excre- tory ducts, injecting into them an acid solution, and subsequently tying again, as is done for the gradual destruction of the glandular parenchyma, he found at once that the absorption of nitrogen was but slightly altered, even before he could determine any disturbance in the absorption of fat and carbohydrates. Later, after the removal of the degenerated glands, nitrogen metabolism fell to 33 and 35 per cent., while 41 per cent, of fat and 50 per cent, of carbohydrates were still being absorbed. Quite as positive is the clinical proof based upon numerous observations that in man disease of the pancreas causes disturbances of albumin diges- tion. Deficient meat digestion is most conspicuous. In the feces there are numerous undigested muscular fibers, as may sometimes be recognized with the naked eye, but microscopic examination shows them very dis- tinctly. In the case of a diabetic, reported by Fles, the dejecta contained uncommonly numerous, undigested, quite distinct, transverse muscular fibers. If the patient took calf's pancreas with his other food, the meat was again perfectly digested, and the muscle fibers again appeared in the stool when no pancreas was added to the food. Harley recognized a similar condition in a case of pancreatic abscess, v. Ackeren noted impaired 316 DISEASES OF THE PANCREAS digestion of meat in carcinoma, Kiister in a case of cyst, and Lichtheim in a case of calculus formation in the pancreas. In a case of carcinoma of the pancreas that came under my observation, I noted numerous remains of transverse, striped, muscular fibers with distinct muscular structure. Zoja recently reported a case of carcinoma of the head of the pancreas with occlusion of Wirsung's duct and of the common gall-duct, in which numerous fibers of meat were found in the feces with distinctly devel- oped transverse striation. A similar condition was observed by Auerbach in a case of carcinoma of the pancreas, and by Cipriani and Giudiceandrea in pancreatic calculi. The insufficient nitrogen absorption in pancreatic disease has also been proven by exact researches in metabolism. Hirschfeld conducted a series of thorough analyses in diabetes. He found that 32 per cent, of the nitrogen substance ingested could be found in the feces, while 5 to 6 per cent, corresponds to the norm. It is true this was not proven by autopsy findings. But this proof was present in a case of Weintraud's; 45.2 per cent, of the albumin of the food, and 22.2 per cent, of the fat, were lost. At the autopsy a markedly contracted, indurated pancreas with decided increase of the connective tissue was found, and in this only iso- lated glandular globules could be seen. Weintraud, in agreement with the results of Rosenberg's animal experiments, lays the principal stress upon the fact that in diseases of the pancreas proteid absorption is more de- cidedly, or at least as greatly, disturbed as fat absorption; while in intestinal diseases, in which the intestinal apparatus for the absorption of fat functionates insufficiently, as in amyloid disease of the intestine, etc., the absorption of fat is comparatively as much affected as that of the albumin. The conditions were similar in a previously mentioned case reported by Zoja, of carcinoma of the pancreas with occlusion of Wirsung's duct. More than 70 per cent, of the nitrogen of the food was excreted, and hardly 30 per cent, absorbed. Unfortunately, but few reports of experi- ments are at hand; but even with the data we have, there can be no doubt that this is a positive method for the recognition of diseases of the pancreas. Recently Sahli has proposed another method for testing the digestive function of the pancreas for proteids. He determined by exact experiments that gelatin capsules hardened with formaldehyd he calls them glutoid capsules after reaching a definite degree of hardness, are soluble neither by water nor by hydrochloric acid pepsin digestion, but only so by pancre- atic juice (by trypsin). If these capsules are filled with a substance which can be recognized in the saliva or in the urine best with iodoform in cases of arrested pancreatic digestion a reaction for iodin does not occur at all, or only very late. With normal motility of the stomach and suffi- ciently good pancreatic function the iodin reaction in the saliva shows itself in from 4 to 8 hours. According to Sahli, from the absence or from SYMPTOMS 317 the delayed appearance of the iodin reaction we may determine a disturb- ance of the pancreatic function, provided the motility of the stomach is not reduced. These reports of Sahli are very interesting, and if, in a large number of tests, the absence or the late appearance of the " glutoid reac- tion " coincides with anatomical proof of a pancreatic disease and arrested secretion, we have a positive and infallible sign of disease of the pancreas. There can be no doubt that the digestion of carbohydrates suffers when the pancreatic function is absent or disturbed. Eosenberg has considered this in his animal experiments. So long as the pathologic process in the pancreas is not too far advanced, normal or almost normal absorption was i found; when the process had made further progress, the figures de- creased decidedly, so that, in this case, digestion was already seriously damaged. In an experiment at the conclusion of which the degenerate glandular remains were removed, carbohydrate absorption as well as fat- splitting sank rapidly and decidedly, with a loss in the absorption of nitrogen and fat ; on pancreas feeding, in all the experiments a conspicuous improvement was noted. Clinical reports in regard to this factor are very few. In recent isolated cases, as, for example, by Auerbach and Edoardo Italia, it is expressly stated that considerable starch was found in the stools. When the pancreatic function is either absent or disturbed, impaired digestion occasionally produces conspicuous symptoms that are often noted by the patient himself. The stools have a massive appearance which is out of proportion to the amount of food ingested. I have seen a number of cases in which this symptom led me to suspect a disease of the pancreas, and the further course of the affection justified this assumption. Much of the food passes through the digestive tract without being utilized. In spite of plentiful food, there is constant loss of weight, and conspicuously massive, thick,, pappy or compact dejecta, whose amount appears to be decidedly greater than the ingested food, and this is an important symp- tom which calls for the closest attention of the physician. Exact micro- scopic and chemical analysis explains this massiveness ; muscle fiber as well as fat and carbohydrates are excreted without being assimilated. The symptoms due to absence of function unquestionably furnish the most important aid in the recognition of an affection of the pancreas, and must therefore be first described. There are, however, a few symptoms which cannot be regarded as denoting absence of function, which, never- theless, enable us to recognize that the pancreas is diseased. Among these we must consider the following: Bronzing of the skin, peculiar colic and pains of a definite character in the epigastrium; tumor or resistance in . this region, and certain forms of jaundice. These signs, with the excep- tion of tumor formation, only become important when they are combined with permanent or transitory symptoms of absence of function of the gland. 31g DISEASES OF THE PANCREAS French authors were the first to direct attention to a peculiar form of diabetes with deposition of pigment in the skin diabete bronze. This pigment formation is the expression of hemochromatosis, which develops in the skin as well as in the different organs. The color of the skin is brownish, brownish-black, or somewhat grayish, the discoloration is diffused over the entire body, and nowhere are pigmented areas observed, not even upon the mucous membrane, and this differentiates the condition from Addison's disease. The cases reported up to the present time are few in number. In the book I published in 1898 I mentioned 22, Anschiitz, in 1899, 24 cases. In most instances changes were found in the pancreas. It was sclerotic, rusty-brown, the excretory ducts were patulous. Jeanselme had already declared diabetes to be due to sclerosis of the pancreas which develops as a result of deposition of pigment. Anschiitz recently studied an undoubted case. During life, besides the symptoms of diabetes, there were also signs of disturbed secretory function: distinct fat-splitting and fatty stools. For this reason a diagnosis of disease of the pancreas was made. At the autopsy, a chronic, indurated pancreatitis with general hemochroma- tosis was found. The deposition of pigment caused chronic inflammation of the pancreas, and this in turn the diabetes. A similar report and explanation were furnished by Opie. Bronzing of the skin diffusely distributed, from which hemochromatosis may be concluded, absence of pigment areas in the skin and in the mucous membranes, and simultaneously diabetes, warrant the assumption of dis- ease of the pancreas, particularly if, at the same time, secretory disturb- ances, fatty stools, deficient digestion of fat and albumin can be deter- mined. From the pain alone no matter what form it may assume disease of the pancreas can never be diagnosticated. In pancreatic affections pain may be of many varieties and degrees, it may be persistent or paroxysmal. The former., sometimes remittent or paroxysmal, or gradually becoming more severe, is found in abscess, in hemorrhage, in acute and chronic pancreatitis, and in tumor. In carcinoma the pain may, under some cir- cumstances, be of extraordinary intensity, so that the patient anxiously avoids any movement, shrinks at a loud word, and rejects food. In combination with a feeling of extreme weakness and marked prostration, this pain shows certain peculiarities such as are very rare in other tumors of the abdomen. Whether pressure upon the celiac ganglion or torsion of the same causes this peculiar pain has not been proven, but it is unques- tionably a characteristic feature, and we are justified in entertaining the suspicion that the seat of the affection is the pancreas. The paroxysmal pains may resemble sharp colic limited chiefly to the epigastrium, and, under certain circumstances, may also point to disease of the pancreas. By some authors special stress is laid upon this pain. SYMPTOMS 319 Epigastric colic, as such, naturally proves nothing, not even that, for ex- ample, as in the case described by Miinnich and Holzmann, its main point of concentration is under the left arch of the ribs. We know that renal colic or gall-stone colic, colic of the appendix, and a beginning pericolitis may cause similar pains in the region of the splenic flexure. We are, then, only justified in diagnosticating a disease of the pancreas if pancreatic concrements are found in the feces, or if, after prolongation of the disease, symptoms due to absence of function appear, such as dia- betes, or insufficient digestion of proteid or fat. We may conclude from this that the same process that gives rise to prolonged colic also brings about changes in the parenchyma of the pancreas, and gradually disturbs or arrests the function of the organ. In calculi formation there are chronic inflammatory changes with connective tissue proliferation, and these gradually displace and replace the gland substance. Not only in stone formation does colic occur, but also in all cases of occlusion of the excretory ducts and of the secretory passages in the in- terior of the gland, as from cicatrices, neoplasms, indurated inflammations or hemorrhages. In cysts of the pancreas these colics play a particularly important role. In 104 cases operated upon Takayasu found colic a symp- tom in 64 cases. As this form of pain is evidently very much more rare in other cysts of the abdomen, its presence, as Leube emphasized, is an important sign of pancreatic cysts. It may be asserted that these colics are much more frequent than is to-day assumed. How many so-called nervous gastralgias may depend upon pancreatic colic ! Minute inves- tigations in metabolism and absorption may, perhaps, show transitory or permanent anomalies which occur in the course of a pancreatic affection. A feeling of resistance or a tumor in the region of the pancreas forms a significant symptom. Naturally we must be certain that this resist- ance, or the tumor, actually springs from the pancreas. This proof, on account of the concealed position of the organ, is difficult to establish. Primarily we must consider carcinoma, cysts, and indurative inflamma- tion, as the acute processes, acute hemorrhagie pancreatitis, abscess, hemor- rhage and necrosis are evidently much rarer occurrences. In a small number of cases of carcinoma, in about -J- to , a tumor can be felt, but even then the differentiation from carcinoma of the duo- denum, from carcinoma of the choledochus and of the porta hepatis, from lymph-gland tumor, from aneurysms of the hepatic artery, from products of inflammation of a tuberculous nature, even from carcinoma of the colon or pylorus, is very difficult, occasionally impossible. The differentiation from tumors of the colon or pylorus is most readily made since pancreatic carcinomata are, as a rule, fixed, while carcinomata of the colon and pylorus are frequently movable. By artificial inflation of the stomach and colon, by the demonstration of symptoms of stenosis in the stomach or 22 320 DISEASES OF THE PANCREAS intestine, by the chemical and microscopic investigation of the gastric and intestinal contents, as well as by other clinical signs referable to disease of the stomach, the intestine, or of the pancreas, the diagnosis may occa- sionally be made with certainty. Much more difficult, almost impossible, is the differentiation of tumors of the duodenum or the biliary passages. Here the appearance of symptoms which indicate absence of function of the pancreas may clear the situation. The appearance of a cystic tumor in the region of the pancreas does not at all prove that we are dealing with a pancreatic cyst. Echinococcus of the liver, of the spleen, of the mesentery and of the peritoneum, hydronephrosis, dropsy of the gall-bladder, cysts of the omen- turn or the mesentery, the spleen, the kidney or the adrenals, soft sar- comata of the liver, accumulations of fluid in the bursa omentalis, etc., mav give rise to confusion. It would lead us too far afield to enter upon the details of the diagnostic factors; frequently the diagnosis can only be made with certainty at the operation. The inflammatory tumor is rarely recognized during life; usually it is confounded with neoplasms. Often, however, at the operation it is not quite clear whether an indurative inflammation or a neoplasm is present, and only from the gradual disappearance of the tumor, as, for instance, after the operative removal of gall-stones, do we recognize that a chronic inflammation of the pancreas was present, and this appears to be a by no means rare occurrence. One of the most frequent symptoms of disease of the pancreas is jaundice. The intimate relations existing between the head of the pan- creas and the common gall-duct sufficiently explain this. Unfortunately there is no characteristic form of jaundice which indicates disease of the pancreas. The form in which the jaundice slowly but steadily increases and finally leads to complete occlusion by compression of the common gall-duct, is also found in tumors of the duodenum, of the hilus hepatis, and in lymph-gland tumors, all of these causing a similar development of the jaundice as well as the Bard-Pic syndrome: Intense, chronic, grad- ually increasing jaundice with enormous dilatation of the gall-bladder, rapid emaciation and cachexia with usually subnormal temperature, and the absence of decided enlargement of the liver are not confirmatory, even although it cannot be denied that this symptom-complex occurs more fre-- quently in carcinoma of the head of the pancreas than in tumor of the neighboring organs, or in stone formation in the biliary passages. The relatively rare appearance of the cardinal symptoms, of diabetes, of in- sufficient fat and albumin digestion, may, it is true, here also indicate the correct diagnosis. Much less convincing are other symptoms which are observed in dis- ease of the pancreas : Emaciation, digestive disturbances, salivation, vomit- ing, constipation, hemorrhagic stools, intestinal occlusion, fever. It is true SYMPTOMS 321 a proof of a sequestrating pancreas, or of pancreatic concrements in the stools, may undoubtedly lead to the diagnosis of disease of the organ. The acute inflammations, hemorrhagic pancreatitis, pancreatic apo- plexy and necrosis continually appear with severe symptoms: Sudden, severe and paroxysmal pain in the gastric and umbilical region, nausea, vomiting, immediate and severe collapse, great anxiety, enormous increase in the pulse rate, and not infrequently the picture of acute intestinal occlusion. The differential diagnosis between internal incarceration and the previously mentioned processes is exceedingly difficult, and usually can only be made at the operation or at the autopsy. In disease of the pancreas some authors lay special stress upon certain changes in the urine which enable us to make a diagnosis of involvement of the pancreas, such as an insufficient excretion of indican and the proof of pentosuria or maltosuria ; unfortunately, these views have not been con- firmed. During pancreatic digestion, as is well known, indol, the mother substance of indican, develops. For this reason we formerly, with a suspicion of disease of the pancreas, first directed particular attention to the urine. In a case of occlusion of the small intestine Gerhardi con- cluded from the fact that indican was not increased that disease of the pancreas was the cause of the occlusion; the autopsy confirmed Gerhardi's view. The animal experiments of Pisenti appear to confirm this opinion. In our animal experiments, at my suggestion, my assistant, Dr. Katz, invariably examined the urine for indican and always found this sub- stance increased. Reports are at hand showing that, in the course of dis- ease of the pancreas in man, the amount of indican was also increased. Just as little has the appearance of maltose or pentose in the urine proven itself characteristic of pancreatic disease. In reviewing the important symptoms which have been mentioned in this article, it is apparent that the most reliable aids in the diagnosis are the symptoms due to absence of function of the gland, and the proof of resistance or of a tumor having its seat in the pancreas. In a detailed description of the individual forms of the disease, we are convinced by the careful consideration and investigation of the different symptoms in a number of cases that the diagnosis may be made with certainty, or with more or less likelihood. In many probably in the great majority of cases, if we go beyond an assumption we find ourselves upon the wrong track. If any result be obtained it is only possible by persistent, tireless investigation. Such a result is not only of theoretic, but also of great practical value, as has been shown by the efforts of surgeons, who, inter- fering at the right time, have cured many affections which had endangered life, such as chronic and acute inflammatory processes, and neoplasms of the pancreas. We are now at the dawn of rational treatment of disease of the pan- creas, and undoubtedly internal therapy will also produce practical results 322 DISEASES OF THE PANCREAS \vhen we are able to diagnosticate the by no means rare and curable affec- tions of the pancreas. On account of the intimate relation between the biliary passages, the liver, and intestines on the one hand, and the pan- creas on the other, the consecutive changes in the pancreas will un- questionably I might say will unwittingly be cured by internal treat- ment. When we gain a deeper insight into the pathology of the pancreas, and are able to recognize clearly the pathologic changes in this organ, it will perhaps often be possible not only to prevent the implication of the pancreas, but to restore to the normal the already diseased organ in so far as this is at all possible. DISEASES OF THE LIVER AND BILIARY PASSAGES JAUNDICE AND HEPATIC INSUFFICIENCY BY O. MINKOWSKI, COLOGNE JAUNDICE GENERAL CONSIDERATIONS WHEN a patient with jaundice presents himself to our notice, certain peculiarities are conspicuous at the first glance. In a yellow, artificial light the yellow discoloration of the skin may easily escape observatioD, but in broad daylight this is strikingly obvious, and we then perceive the yellow discoloration of the conjunctive^ sclerce; the transudation of the tis- sues of the lips and the mucous membrane of the mouth with the same yellow coloring matter also becomes visible if we render the tissues blood- less by pressing upon the mucous membrane. This yellow color is readily recognizable upon the hard palate where the greater tension of the mucous membrane makes it pallid. The yellow discoloration is, in fact, due to an overflooding of the organ- ism with biliary coloring matter., as is proven by the composition of the urine which, with its brownish tint like the color of beer and the yellowness of its foam, shows the presence of bilirubin. The intense staining power of this coloring matter is immediately perceptible on dipping a piece of filter paper into the urine, and is also manifested by the yellow stains which may appear upon the linen of the patient. Certain proof of the presence of biliary coloring is obtained by the positive reaction of Gmelin's test, which is as follows: We place a specimen of the suspected urine in a test-tube, and with a glass pipette introduce beneath it a layer of concentrated nitric acid to which nitrous acid has been added. The nitric acid should have only a faint yellow color. Chemically pure nitric acid is just as useful as the fuming acid. We obtain an excellent reagent by adding to a larger quan- tity of pure nitric acid a few drops of the fuming acid, or by heating the pure acid for a short time with a splinter of wood. The continuous oxida- tion of the biliary coloring matter will then produce at the point of contact of the urine and acid the characteristic green zone of biliverdin which, upon allowing the test-tube to stand, is gradually disseminated upward and is subsequently followed by a ring of blue, violet, red and yellow, which slowly rises. 325 326 JAUNDICE AND HEPATIC INSUFFICIENCY Even with a great dilution of the urine, these bands of color may be distinctly seen if the test-tube is held against a moist piece of filter paper or a plate of ground glass and examined in a clear light. If we put a drop of nitric acid upon the filter paper through which the urine has been filtered, the characteristic colors will develop in con- centric rings. By adding chloroform to some of the urine in a test-tube a yellow color is produced. We may also obtain the Gmelin reaction with chloroform extract by adding commercial nitric acid or bromin water. The method proposed by Marechal and Rosin, of covering the urine with a dilute tincture of iodin, will also produce at the point of contact a play of greenish colors which denotes the presence of biliary coloring matter. Besides biliary coloring matter other constituents of the bile are cer- tainly contained in the urine, chiefly bile acids. Complicated chemical methods are necessary to isolate these by Pettenkofer's test. The urinary sediment obtained by centrifugation shows under the mi- croscope hyaline casts which, in the case to be described, were stained a distinct yellow. The presence of albumin in this urine could not be demonstrated by ordinary reagents, nor was sugar present. The overflooding of the organism with biliary coloring matter is be- trayed also by the intense yellow staining of the blood serum, which may be recognized in a thin layer of the blood in a glass capillary pipette, par- ticularly on comparison with normal blood serum. In the patient under observation the blood was obtained by means of a capillary pipette after pricking the lobe of the ear, and a Gruber-Widal agglutination test was made with serum which was negative in typhoid cultures as well as in those of paratyphoid. The serum may also be tested by Gmelin's method. With nitric acid, characteristic colored rings will be observed at the point of contact with the precipitated albumin. In the case under consideration this accumulation of biliary coloring matter in the organism was coincident with the absence of bile from the intestine. The peculiar, whitish gray color and clayish consistency of the feces are often noticed by the patient. Yet such appearance in normal feces is not proof of the absence of hi liaiy coloring matter or its reduction products, hydrobilirubin and uro- bilin. On the contrary, it is demonstrable that the grayish white color is duo to a large quantity of fats and soaps in the dejecta. Under the microscope we may discern many fat globules and long fatty acid crystals, also a large number of fine needles of sodium, calcium and magnesium soaps. These soaps give to the feces their peculiar glistening appearance. If the feces are rendered acid by an addition of acetic acid, and are then shaken up with alcohol and ether, many of these colorless masses JAUNDICE 327 may be dissolved, after which the residue shows a dark brown discolora- tion due to the undigested remains of meat. Neither bilirubin nor uro- bilin can be demonstrated in the pale yellow ethereal extract, and, in fact, an occlusion of bile from the intestine may be assumed. The abnormally large amount of fat in the feces is unquestionably the consequence of absence of bile from the intestine, although it is possible that an obstruction to the flow of the pancreatic juice may be simultane- ously operative. The constipation and flatulence of which the patients complain must be referred to an inhibition to the flow of bile. Primarily, the normal stimulation of intestinal peristalsis by the bile is lacking. Whether the absence of the inhibitive effect of bile upon decomposition may be regarded as the cause of the marked production of gas and the somewhat unusual odor of the feces is questionable. Bidder and Schmidt have assumed that the bile exerts an influence upon intestinal decomposi- tion. Nevertheless there can be no doubt that the bile itself may readily decompose, and it certainly exerts no powerful antiseptic effect. Yet we may reasonably suppose that the absence of bile from the intestine favors the development of certain varieties of bacteria, and thus diverts the processes of decomposition into definite tracts. It may be that the altera- tion in the composition of the intestinal contents from the lack of bile, for instance, the greater proportion of fat, is the sole cause of the abnormal processes of decomposition in the intestine. The probability that increased decomposition may occasionally result from biliary occlusion is favored by the increased excretion of ethyl sul- phuric acid in the urine which has been noted by various authors (Brieger, Biernacki, Eiger, Schmidt, Bohm). But this is apparently not an invari- able finding, since other investigators, such as Kohmann, Pott, and v. Noorden, found no marked variation from the normal in the ethyl sul- phuric acid contents of the urine in jaundice. The symptom-complex of jaundice is met with in very unlike but more or less serious affections: In occlusion of the biliary passages from gall- stones, in neoplasms of the biliary channels and in the head of the pan- creas, in various cases of diffused and circumscribed disease of the liver, especially in certain forms of hepatic cirrhosis. Icteroid discoloration of the skin and mucous membranes of less intensity is observed in other affections, in general circulatory disturbances, in those produced by dis- ease of the heart, in some cases of pneumonia, in general sepsis, and in other infectious diseases. In all of these cases jaundice appears only as an accompanying symptom in contradistinction to the typical symptoms of the disease by which we determine the character of the affection and its probable course. The circumstances are different in the case under consideration. Here markedly developed icterus dominates the entire clinical picture, and forms 328 JAUNDICE AND HEPATIC INSUFFICIENCY the salient feature of the pathologic condition. Here we are dealing with simple essential jaundice, with icterus simplex. This diagnosis corresponds with what we glean from the history of (lie following case: The patient, a strong man, 26 years of age, and pre- viously healthy, states that about fourteen days ago upon the occasion of a festivity he suffered from a stomach disturbance. The symptoms which appeared within the next few days did not, as on similar occasions, soon pass away, but continued; a sense of discomfort in the gastric region, a disagreeable taste, loss of appetite, a tendency to nausea, as well as general malaise, lassitude, psychical depression, headache, and mild vertigo per- sisted. At first there was some fever, also slight diarrhea followed by constipation, but no colicky pain. After about a week the yellowness of the patient became noticeable to those about him. Subsequently he re- membered that his urine, even for a few days before, was extremely dark and had stained his linen yellow. Until the present time the patient has been able to follow his occupation, but has felt very weak and has emaci- ated decidedly. Solid food, particularly fatty food, has been repugnant io him, but he has had increased thirst and a special desire for cool and acid drinks. Further examination revealed no marked change except the jaundice; a fc'w scratches upon the skin showed that the patient was annoyed by itching. There was no elevation of the temperature, which was, on the contrary, somewhat subnormal, 97-98.1 F. ; the pulse was slow, 64 to 68. There was nothing abnormal in the thoracic organs. The abdomen was slightly distended, the hepatic region somewhat sensitive to pressure. The liver showed some enlargement just below the border of the ribs, but was not particularly hard to the touch. The gall-bladder could be distinctly palpated below the border of the liver, and apparently was slightly dis- tended. Splenic dulness seemed somewhat increased, but the spleen could not be palpated. We therefore recognized the clinical condition known as " catarrhal " jaundice, which in typical cases, as a rule, runs a benign course. We have refrained from the use of this designation because, in its conception, a definite mode of development of the jaundice has been assumed, and this has by no means been proven in all cases. The term is 1 in SIM! on the assumption that the jaundice is caused by a catarrhal in- flammation of the mucous membrane of the gall-ducts, or of the duodenum at the mouth of the gall-ducts, which mechanically inhibits the outflow <>f b\lc. The finding of a plug of colorless mucus at the mouth of the common bile duct and the difficulty of forcing the contents of the gall- bladder into the intestine by pressure have, since the time of Virchow, been regarded as the anatomical foundation for this view. To-day the plug of mucus is no longer considered to be the actual ob- struction to the flow of bile. From the evident lack of biliary imbibition JAUNDICE 329 which the mucus reveals, we conclude that, at most, there was an actual impediment to the flow of bile during life. The mechanical obstruction is revealed by the inspissation of the bile itself as well as by the catarrhal swelling of the mucous membrane in the narrow biliary passages. It is true that little of this swelling is to be seen at the autopsy, but the observa- tions of those who have inspected the mucous membranes during life have taught us that swelling, due to marked hyperemia, is not recognizable after death. Nevertheless, this assumption does not sufficiently explain the develop- ment of jaundice in all of the cases which are included under the term catarrhal jaundice; at least, it does not coincide with our ideas of catarrh of the biliary passages, of cholangitis catarrhalis. The symptoms of such a cholangitis are often found in cases in which icterus was never present, and are frequently absent when the clinical picture exactly corresponds to essential jaundice. It is true there are few opportunities for the anatomical investigation of typical cases of this affection, since, as a rule, their course is benign. But their purely clinical investigation, the nature of their appearance, their frequent occurrence under certain conditions, their relation to other forms of jaundice and to diseases of the liver and biliary passages, taken in connection with the results of experimental, physiologic and pathologic investigation, have recently led to other hypotheses which, although by no means clear, are in many respects far in advance of earlier conceptions. This change of view not only embraces the nosologic position of this special form of jaundice but also explains the processes brought about in these cases by the transference of biliary constituents into the blood and the fluids of the tissues. ORIGIN Before discussing further the subject of jaundice, we must express our present opinions in regard to the development of jaundice in general. At this time we may maintain that all jaundice is of hepatogenous origin, i. e., that general jaundice cannot occur without an implication of the liver. Every case of jaundice, therefore, is due to absorption of bile which is formed in the liver. The old teaching of " obstructive jaundice" the development of jaun- dice by an inhibited excretion of coloring matter formed outside of the liver and which can be regarded only as an excretion product, has been completely disproven by the investigations of Stern, ISTaunyn and Min- kowski. But the opinion also that the icterus in " hematogenous " jaun- dice is " anliepatogenous" is no longer tenable. There can be no doubt that hematoidin (or bilirubin) may be formed from hemoglobin outside the liver, for example, in extravasations of blood. It is also certain that processes which run their course with a massive dissolution of red blood- 330 JAUNDICE AND HEPATIC INSUFFICIENCY corpuscles and an increased destruction of hemoglobin may lead to jaun- dice, but in such cases, as in hemoglobinemia after poisoning with arseni- ureted hydrogen, toluilendiamin and other poisons, the transformation of hemoglobin into biliary coloring matter takes place in the liver (Stadel- mann, Affanassiew), and its presence there causes the outbreak of jaundice (Naunyn and Minkowski). The latest observations of loannovics do not alter the fact that by hemolysis the spleen plays an especial role in the production of jaundice, since this organ is actively implicated in the de- struction of damaged blood-corpuscles. The designation of such forms of jaundice as " hematogenous " or " hematohepatogenous " is even less justi- fiable, as the material for the production of biliary coloring matter is normally furnished by the hemoglobin. If we desire to indicate the special mode of development of this form of jaundice, the designations " cythemo- lytic " and " hemolytic " are certainly preferable. The most likely cause for the absorption of bile in the liver is a mechanical impediment to the flow of bile in the biliary passages. There- fore, in all cases of jaundice an attempt should first be made to ascertain the nature of this mechanical obstruction. Naturally it is easy to assume a " stasis icterus " when either the lumen of one of the large biliary passages is occluded or there is external compression of the biliary passages. When, however, the impermeability of the excretory passages cannot be certainly demonstrated, more or less hypothetical explanations of the ob- struction to the flow of bile may be suggested. The fact has been pointed out that the secretory pressure of the bile is comparatively low (according to Heidenhain in the dog about 200 mm., according to Biirker in the rabbit 75 to 80 mm.) ; therefore even a slight obstruction to the flow of bile is sufficient to cause the absorption of biliary constituents by the blood. Hence it was believed, as has been stated, that the development of simple jaundice could be referred to catarrhal swelling of the mucous membrane and to the accumulation of mucus at the mouth of the common bile duct. Jaundice in infectious diseases was attributed to complicating intestinal catarrh and was also regarded as " catarrhal/' When jaundice occurred in pneumonia it was assumed that, in consequence of a decrease in the respiratory excursus of the diaphragm, an important adjunct for the pro- pulsion of bile was absent. Jaundice in cardiac disease was referred to a decrease of blood pressure, or to compression of the finer biliary channels by the dilated blood capillaries. In the case of icterus neonatorum, the condition was thought to be due to the altered circulatory relations after birth, to a patulous ductus arantii, and the like. Hepatic cirrhosis was at one time attributed to a compression of the finest interlobular biliary channels by constricting connective tissue, at another time to a catarrhal affection of the finest biliary passages or the occlusion of their lumen by granular pigmented masses, by desquamated and swollen epithelium and the like. Some authors sought for the explanation of the obstruction JAUNDICE 331 to the flow of bile in the morphologic changes, the swelling and displace- ment of the hepatic cells, and the " dislocation of the hepatic cell tra- beculae." " Hemolytic " jaundice from the effect of blood poisoning was first referred by Stadelmann to an inspissation of the bile caused by the in- creased destruction of blood-corpuscles in the liver, which thus formed coloring matter. Naunyn and Minkowski therefore employed for this form of jaundice the designation "jaundice from polycholia" and Stadelmann proposed as a more concise expression, " pleiochromia." It did not escape the attention of these authors that the increased formation of coloring matter was not the only cause of the obstruction to the outflow of bile, but, as Stadelmann emphasized, besides an increased secretion of mucus, the occlusion of the biliary capillaries with decomposed epithelia and hepatic cells destroyed by the poison might also impede the outflow of bile, as well as, perhaps, the compression of the finer biliary passages by swollen glandular cells or dilated blood capillaries which had been sub- jected to toxic influence. Although a conception of this kind relegated " polycholic " jaundice to the ranks of jaundice due to mechanical obstruction, many authors have regarded "polycholia" as a welcome adjunct by which to explain the different varieties of jaundice whose development from biliary stasis could otherwise scarcely be proven. Above all, icterus neonatorum was ascribed to a suddenly increased formation of biliary coloring material brought about in the first few days after birth (Hofmeier, Silbermann, Hayem) by a massive destruction of the red blood-corpuscles. The development of jaundice from polycholia was also assumed by many authors (Rosenstein, Chauffard, Girode, Banti and others) in certain forms of hepatic cirrhosis as well as in the different varieties of "infectious" jaundice. This was based upon the observation that in such cases, notwithstanding the jaundice, there is usually an intense biliary staining of the feces. Grawitz found that in chronic circulatory disturbances free hemoglobin was demonstrable in the blood serum; he therefore believed that jaundice in cardiac disease might be attributed to polycholia. G. Hoppe-Seyler declared icterus in pneumonia after injections of tuberculin and in Graves' disease to be polycholic, because in these conditions he demonstrated a simultaneous increase of urobilin in the urine and in the feces. In those forms of icterus in which there could be no doubt of a mechan- ical obstruction to the flow of bile, some authors went so far as to ascribe the jaundice to the polycholia which caused a destruction of red blood- corpuscles. Browicz, to whom we are indebted for very valuable investi- gations into the histology of the liver, attempted to prove that a polycholia of this kind was the foundation of all forms of jaundice ; even in occlusion of the common bile duct he believed that only a mediate influence upon the development of jaundice could be ascribed to the mechanical factor. These 332 JAUNDICE AND HEPATIC INSUFFICIENCY theories, however, did not prove satisfactory. On the one hand, the purely mechanical explanations were incomplete. In some cases the intensity of the jaundice was entirely out of proportion to the demonstrable obstruc- tion ; in many others, no obstruction of this kind could be determined, and, finally, in the liver itself signs of biliary stasis were frequently absent. When these signs were present there was undoubtedly a mechanical ob- struction to the flow of bile : Dilatation and flooding of the biliary passages, the accumulation of bile in the intralobular bile capillaries, and the de- posit of biliary pigment in the hepatic cells. On the other hand, the mere assumption of polycholia or pleiochromia did not sufficiently explain the entrance of bile into the blood and into the fluids of the tissues, unless it wore assumed that occasionally the liver ceased to excrete bile normally, while at the same time bile formation was increased. Thus it came to pass in the last few years that a new view received recognition and a new factor entered into the pathogenesis of icterus; for an attempt was made to attribute the appearance of biliary constituents in the blood to special functional disturbances of the hepatic cells. 1 was probably the first definitely to express this thought, for in a discussion at the Congress of Internal Medicine in 1892 I made the fol- lowing remarks: "The special function of the hepatic cell, which enables it to introduce certain products into the bile channels, others into the blood-vessels or lymph channels therefore biliary coloring matter and bile acids into the biliary passages, and sugar and urea into the blood is appar- ently dependent upon the normal nutrition and normal function of the cell itself. Disturbances of this function may exist without mechanical hindrance to the outflow of bile, and may result in the transmission of biliary constituents to the blood/' I compared the disturbance in func- tion of the hepatic cells here described with the disturbance in, function of the renal cells which occurs in albuminuria, and pointed to the analo- gous appearance of these forms of disturbance in infectious diseases, in intoxications, in lesions of the nervous system, in circulatory disturbances, and in parenchymatous implication of the organs. Liebermeister followed a similar train of thought when, a year later, he described " acathectic " jaundice, which was said to be due either to a marked change in the liver cells or because in the process of destruction they could no longer retain the bile or hinder its diffusion into the blood and lymph. Later E. Pick voiced the same opinion when he declared most varieties of jaundice to be essentially due to " paracholia," a disturb- ance of the flow of bile in a much more general form. For the cases under consideration I proposed the designation " parape desis of bile" in differentiating the close analogy with hemorrhage per rhexin and per the so-called Gerlach valve, the recent interesting inves- tigations of v. Hansemann x show that its power of closure bears an inti- mate relation to the presence or absence of fecal concrements. The same is to a certain extent true of regurgitation into the cecum. The anatomical changes in chronic relapsing perityphlitis are mani- fold, and, corresponding to the nature of the case, they are relatively slight. According to Federmann, 2 whose description we shall follow, the mucous membrane is more or less thickened. In the mucosa we find a plentiful accumulation of round cells or connective tissue proliferation with swelling, bulging and polypoid excrescences (appendicitis polyposa). In other cases the decrease of the glandular tissue leads to atrophy or may cause partial or total obliteration of the lumen. In other instances the appendix is more or less thickened, rigid, or erect, as Talamon expresses it, often abnormally adherent or firmly agglu- tinated to its surroundings. Frequently, however, it is absolutely free. The lumen of the rigid structure gapes, and is filled with a smeary, mu- coid, or hemorrhagico-purulent mass admixed with portions of feces or fecal concrements of disagreeable odor. The mucous membrane is thickened, moderately tumid, injected, and in many cases is covered with ulcers. The muscular layer is distributed partly by inflammatory infiltration, partly by true labor hypertrophy. The surroundings of the process are 1 v. Hansemann, Mittheilungen aus den Grenzgebieten der inneren Medicin und Chirurgie, XIT, p. 514, u. f. 2 Federmann, in Sonnenburg, " Pathologie und Therapie der Perityphlitis." 5. Aufl., Leipzig, 1905, p. 48. 578 ACUTE PERITONITIS, APPENDICITIS, AND PERlTYPHLlTIS also implicated. The appendix is more or less adherent to the cecum, to the neighboring intestinal coils, and to the parietal portion of the peritoneum, and this leads to stasis of secretion, and the accumulation of mucus and fecal constituents. If obstruction occurs during a time in which the cavity of the vermi- form process is empty, and if no virulent microbes are present in the obstructed area, inflammatory processes do not arise but the cavity becomes more or less distended, and so-called dropsy of the vermiform process sets in. The glandular apparatus undergoes a gradual retrogressive change, the epithelium is desquamated, the mucous membrane loses its original character, and all of its constituents undergo hypertrophy. The extent of the dropsy may attain the size of a fist. If during the time in which adhesions are forming many virulent bacteria are present, empyema of the vermiform process results, or a dropsy empyema may subsequently arise from secondary infection. THE CLINICAL PICTURE OF CHRONIC PERlTYPHLlTIS I. RESIDUAL PERlTYPHLlTIS We have already stated that every acute attack of perityphlitis leaves traces in the vermiform appendix or in its surroundings. Nevertheless in a clinical sense the affection may be regarded as having run its course provided there are no subsequent attacks or other sequela?. Such a cure, however, does not occur in the majority of cases, and we must always count upon the possibility and even likelihood of a relapse soon or late. Daily experience teaches us that the greater the lapse of time after the first attack the less the danger of a relapse. This, however, is by no means absolutely true, for under some circumstances relapses more or less severe may develop years after the first attack. Some authors incline to the opinion that this is not a true relapse but a new attack; yet from the fact that small' pus foci may remain for years encapsulated in the surroundings of the appendix as well as that numerous mechanical changes in the appendix (obliteration, inflammatory thickening, adhesion, exu- dates, dropsy, empyema) follow an acute attack, the view of an acute relapse seems more likely. A relapse following an acute attack may develop in three different ways, as follows: 1. Acute attacks occur after certain intervals and these may differ entirely from the first in severity and intensity. It must here be empha- sized that a mild, primary attack may be followed by very severe and rapidly fatal, secondary relapses. To this category belongs the following case which I observed a few years ago : S. B., a merchant, aged 24, was attacked in the spring of 1902 with mild peri- typhlitis and moderate fever. Against my advice the patient made a long foot tour THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 579 of Switzerland in the following summer. Upon the 3rd of September, following an angina follicularis, possibly also after an error in diet, severe pain appeared in the abdomen, especially in the ileo-cecal region. The temperature rose to 101.3 F. When I saw the patient the next day with the family physician the general con- dition was good. The temperature was 101.1 F., the pulse 92 and of good tension; he had slept well during the night. Above Poupart's ligament on the right there was a moderately dull, tympanitic zone which was sensitive to pressure. Upon the 5th of September, 1902, there was jaundice and repeated vomiting occurred, the vomitus being distinctly hemorrhagic (guaiac test positive). Slight meteorism was present. The pulse was 96, the temperature 102 F.; the hepatic region was insensitive to pressure, and the same condition was present in the ileo- cecal region as on the previous day. Considering the severity of the case operation upon the same day was advised. The surgeon was E. Hahn. Finding: Gangrenous appendix with suppuration into the surroundings. Collapse and death upon the 7th of September, 1902. Here we were dealing with one of those quite rare cases designated by Dieulafoy 1 as vomito negro. On the other hand, after an exceedingly severe case, one or several mild relapses may follow. The assumption is obvious that relapses are the immediate result of mechanical conditions (trauma, too great bodily exertion, acute indiges- tion, etc.), but there are also cases in which the most scrupulous care in questioning will elicit no clue to the cause. 2. The sequels of an acute attack are of exceedingly chronic character. Among them are chronic exudates or indurations, adhesions about the vermiform process, empyema or dropsy, thickening or kinking of the appendix, and other similar affections of the appendix or in its sur- roundings. The clinical course in this group of cases is, as a rule, the same as that of chronic relapsing perityphlitis (see below). 3. The clinical picture of chronic relapsing perityphlitis may already exist but suddenly more or less severe acute symptoms develop. These are probably to be attributed to purulent residues or ulcers upon the mucous membrane of the appendix, but even sudden perforation may be the cause. The case now to be described, which at the same time proves that even after repeated rupture through the intestine with discharge of pus recovery may occur, is an illustration of this form. Miss L., from W., aged 22, whose parents are living and well, and who states that she has always been healthy. Toward the end of February, 1903, she was attacked by pain in the region of the cecum with vomiting, constipation, and a temperature of 102.2 F. An abscess formed, and after ten days an incision was made from the rectum and a tampon introduced. On incision a large amount of pus was discharged. Following this the patient remained in bed for three weeks but did not recuperate; she emaciated so greatly that in the spring she was sent to Pyrmont. Here, eight days later, she i Dieulafcy, Bullet, de I'academie de mcdec., 1901, No. 6. 580 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS was again attacked by symptoms of perityphlitis, and for the second time pus was discharged through the rectum. Notwithstanding this the pain persisted for some time, and the patient was confined to bed for eight weeks. She gradually recovered, but continued very weak. Upon September 7th, 1903, she entered a sanatorium. The patient did not complain of pain, her bowels moved regularly, and she was clinically treated merely to improve her nutrition; she was carefully watched. Status Prrrnens: The patient is small, undeveloped, and emaciated, with scanty musculature and a delicate frame. No edema, no eruption, no enlargement of glands. Patella reflex increased, pupillary reflex normal. Lungs normal. Heart: Uulness normal; the second sound markedly accentuated but pure. Abdomen : Only a small circumscribed area midway between the navel and the spinous process of the right ilium shows slight sensitiveness to pressure. No abnor- mal dulness. Urine contains neither albumin nor sugar. Bowel movement well formed with no admixture of pus or mucus. \Yeight 43.5 kilograms. Treatment: Alcohol compresses over the region of the appendix, rest in bed, stimulating diet. Under this treatment there was decided improvement and a marked increase in weight. The patient left her bed for the first time on the 3rd of October, 1903. Her weight was then 47 kilograms. About half-past seven in the evening the patient suddenly complained of severe pain in the region of the cecum. The temperature was 98.2 F. Cold compresses were applied, and suppositories of codein and belladonna were given; at midnight, on account of increasing pain, 0.01 of morphin hypodermically. The temperature was normal. October 4th, 1903. The pains had been less severe after the use of morphin, but in the morning they increased. Treatment: Morphin 0.01 subcutaneously and ice- bags. In the ileo-cecal region there was an area of resistance about the size of a plate and markedly sensitive to pressure. The note upon percussion was very dull. The temperature in 'the morning was 99.1 F., in the evening 100.6 F. An ice-bag was ordered, also fluid diet, and 15 drops of tincture of opium every three hours. A consultation with Prof. Korte was held on the evening of the same day. On considering the danger of an immediate operation and the fact that the temperature was but slightly elevated, the pulse 90 and strong, the decrease of the pain and the absence of peritoneal symptoms, it was decided to postpone operation and to wait until the acute symptoms disappeared. October 5th, 1903. In the morning the condition was somewhat better; the tem- perature was 98.8 F., the pulse 108. There was still sensitiveness upon pressure, especially in the region of McBurney's point, and, although to a lesser extent, to the left of the navel. The resistance in the region of the cecum was apparently some- what less, the percussion note rather dull, but normal in other areas. There was no singultus, no vomiting. The treatment was continued. Afternoon: Condition less good; pulse 120, temperature 100.2 F. Toward evening llie general condition worse, pulse 128, temperature 100.6 F. The pains in the region of the cecum and also upon the left side had become very severe. Flatus was passed twice; there was no eructation, no vomiting. On account of the danger of perforation Prof. Korte operated at 10 o'clock at night, the patient being under chloroform anesthesia. The posterior surface of the colon was covered with purulent coating, the remain- ing serosa of the intestine being smooth and glistening. The vermiform process was found deep down below the colon and was elevated. A point from which pus was THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 581 discharged could be recognized. The appendix was about 6 cm. in length, and greatly swollen; it was extirpated in the usual manner. Course: Without complications. The patient was discharged cured upon the 14th of November, 1903, weighing 50.5 kilograms. H. CHRONIC RELAPSING PERITYPHLITIS > In contrast with residual perityphlitis, chronic relapsing perityphlitis is of much milder and more benign type. Yet it is often characterized by such an enormous number of individual points, variations and com- plications as to make it an extraordinarily interesting affection. In the chronic relapsing form of perityphlitis two distinctly different varieties may be diagnosticated: First, that running its course without an acute attack, or, more correctly, acute exacerbation, and secondly, that in which the chronic process is interrupted by mild attacks now and then occurring. In very rare cases (Rosenheim *) of these forms perforation is said to occur suddenly. However, it is doubtful whether in these instances we are not dealing with abortive cases of residual perityphlitis. At all events a favorable and benign course in chronic relapsing perityphlitis is so much the more frequent that practically we need not consider the previously mentioned serious eventualities. In a study of chronic relapsing perityphlitis we meet with a number of forms whose clinical symptoms are so well characterized that their recognition is of great practical importance. We shall begin with latent perityphlitis. (a) Latent Perityphlitis. Although this form is not technically the subject of professional treatment, we particularly desire to discuss it, primarily because it plays an important role in the prophylaxis of peri- typhlitis. These cases may occur either in persons who years before passed through a positive attack of perityphlitis or in those who have never shown any of its symptoms. The patients who consult us for other disturbances present absolutely no symptoms referable to the ileo-cecal region, but careful and repeated examinations reveal a very characteristic sensitive- ness to pressure in this area. Among 106 cases of chronic perityphlitis that I observed a year ago I noted this latent perityphlitis in 23. It is true the differentiation of such cases is difficult for, according to the reports of Keith, 2 McBurney's point is normally sensitive to pressure, but, like Lennander (loc. cit.), I emphatically deny this. It may be admitted that McBurney's point is tender on exaggerated pressure, but a comparison of this sensitiveness with that caused by pres- 1 Rosenheim, Deutsche med. Wochenschr., 1905, Nr. 27. 2 Keith, quoted from Lennander, " Meine Erfahrungen iiber Appendicitis." Hit- theilungen aus den Grenzgebieten, 1904, Bd. XIII, p. 326. 582 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS sure in the homologous area upon the left side will at once indicate whether we are dealing with a physiologic or an abnormal zone sensi- tiveness. An interesting question is involved in the decision whether acute or chronic perityphlitis will in the course of time develop from such latent eases. In so far as I have been able to review the literature, such transi- tions have not been described, but we must not overlook the fact that these abdominal diseases have been recognized only in the last few years by careful palpation of the cecal region. The analogous occurrence of a latent cholelithiasis or cholecystitis, which I have not infrequently ob- served, strongly favors a latent perityphlitis. Here I have several times noted the appearance of acute inflammation or typical attacks. It is highly desirable that clinicians and physicians should devote more attention to the occurrence and the significance of latent perityphlitis than has ihus far been the case. (b) Typical Cases of Chronic Relapsing Perityphlitis. Probably most cases of chronic relapsing perityphlitis set in very insidiously and without prodromes, and gradually the symptoms become more severe. If the patients are asked from what period of time they date their disease but few can give a satisfactory answer, for the disease is of chronic type from the onset. The symptoms vary greatly in intensity. Sometimes drawing pains in Hie ileo-cecal region are caused by any motion, or by bending or lifting, or by prolonged sitting ; in other cases there are only sensations of pressure and weight in the right abdominal region which are annoying to the patient; sometimes it is merely a sense of fatigue after prolonged walk- ing; sometimes the disturbances are more or less dependent upon defe- cation, which in such cases is usually irregular; occasionally there are also more or less typical bladder symptoms (tenesmus, painful passage of urine, etc.). The previously mentioned disturbances now show distinct exacerba- tions and remissions which are probably to be attributed to the factors of bodily rest and avoidance of exertion of any kind. The occupation t of the patient of course here plays an important role. Those who are able to take care of themselves sometimes have intervals of fair or even normal health while the symptoms almost invariably increase in those whose circumstances compel them to labor. I have a patient whose case is interesting because his appendicular symptoms were increased after each coitus. In their objective signs, there is a marked difference between residual perityphlitis and the pure, chronic form. This is shown by the fact that in the residual form and during the interval we not infrequently find distinct traces of inflammation which has run its course by palpating exudates, strands, or thickening in the ileo-cecal region. It may be re- THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 583 garded as a rule with but few exceptions that when such plastic changes in the region of the appendix can be determined an acute inflammatory process has always preceded. Only under rare circumstances are these plastic changes found in the true, chronic, relapsing form. Therefore, I do not concur in the views of H. Herz, 1 who has published an otherwise excellent article concerning the condition under discussion and who states that the exudate or the tumor is the unmistakable sign of chronic perityphlitis. Here I wish to call attention to the fact that the possibility of demon- strating thickening, adhesions, etc., at or around the appendix, is often greatly overestimated. Such adhesive changes may be suspected in the residual processes of an acute perityphlitis. Since they occur with relative frequency they are not rarely met with at a laparotomy, but under such circumstances the diagnosis is merely an accidental one. If honest, we must admit that only a distinctly palpable tumor or resistance permits conclusions in regard to residual processes. In my opinion there is rarely a doubt as to whether or not resistance is present, especially in the ileo- cecal region; but there may possibly be a question as to its character (exudate, malignant tumor, ileo-cecal tuberculosis, or induration). In the overwhelming majority of cases of the chronic relapsing form, we find as an objective expression of perityphlitis the presence of a painful pressure zone in the region of McBurney's point. This can be easily found by drawing upon the body two imaginary lines one of which connects the anterior superior spine of the ilium upon the right side with the umbilicus, and the other outlines the external margin of the right rectus muscle. The point where these lines intersect each other coincides with McBurney's point. The importance of McBurney's point in the diagnosis of perityphlitis will be more fully discussed in the section devoted to diagnosis. Here I shall only add that the point, or, more correctly, McBurney's zone, is nothing more than a convenient landmark. There can be no doubt that in chronic perityphlitis McBurney's point is usually sensitive to pressure, and it would be a misrepresentation of facts if we were to ignore this painful zone; in its intimate relation to the other symptoms it is naturally a clinical aid. When the processes in typical cases of chronic relapsing perityphlitis show acute increase, this is of limited extent. The temperature is but moderately elevated (100.4 to 101.3 F.), and upon the next or the succeeding day falls to the norm. Corresponding with the temperature the pulse remains normal as to quality, it shows no intermissions, and is only moderately rapid. Except for the increase of the ileo-cecal pain the general condition is but slightly disturbed. Signs of peritoneal irri- i H. Hers, Therap. Monatshefte, 1905, H. 3 u. 4. 584 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS tation arc absent (vomiting, meteorism, facies peritonealis, singultus). The ileo-cecal region itself is more sensitive to pressure upon the first or second day of the disease than during the interval, but under suitable treatment this tenderness upon pressure either disappears in from twenty- four to forty-eight hours or ameliorates to the degree present in the inter- vening period. (c) Atypical Cases of Chronic Relapsing Perityphlitis. There are numerous variations from the type above described. To enumerate and to describe these would be to include an enormous number of histories. Nevertheless, among the irregular forms there are certain pathologic groups with common and easily recognizable features, and these are the more important in practice because a failure to observe them leads to erroneous therapeutic measures. APPENDICULAR COLIC. Among the atypical cases colica appendicu- laris (coliquc appcndiculaire, Talamon) must primarily be mentioned. Under this name Talamon was the first to describe in a publication, 1 which is even to-day a masterpiece, a form of chronic perityphlitis distin- guished by the following characteristic symptom-complex: The patients, frequently without a recognizable cause, or occasionally, as they report, in consequence of an error in diet, are attacked by severe colic which extends over the entire abdomen (not, as is stated in some text-books, limited to the ileo-cecal region). This is extraordinarily severe and lasts from 6 to 8 hours or longer. During the attack the entire abdomen is more or less sensitive and tense, just as in the case of flatulent colic, but after the attack has passed a sensitiveness in the ileo-cecal region appears and lasts for several days and this is the most important feature in the entire symptom-complex. This subjective tenderness which becomes noticeable on active movements and even in walking and bending over corresponds to the extreme tenderness in the region of the appendix. But the subjective sensations and the objective sign of tenderness on pressure disappear after a few days, until a renewed attack produces the same symptoms. Fever and other changes referable to inflammation are absent, as a rule, in the ordinary form of colica vermicularis. What is the cause of these peculiar attacks? Most authors quite prop- erly attribute them to spasmodic contractions of the appendix which result from the attempt of the organ to expel foreign bodies, fecal concrements, or other substances which have found their way into the appendix from the ceeuni. A very interesting case of this kind from Wolfler's Clinic was de- scribed by Goldbach. 2 i Talamon, " Appendicite et Perityphlite." Bibliothdque medicale, Chwcot- Debovc. Paris, 1892. - doldbach, Prager med. Wochenschr., 1898, Nr. 16. THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 585 A student, aged 16, had for a year following jaundice severe colicky pains under the right arch of the ribs. During the attack of pain there was never vomiting or fever, but obstinate constipation was present. Later the pains reappeared, particu- larly in the evening ; there was no pain in the morning. At the time of examination the pains were felt in the ileo-cecal region, the pain being definitely localized in McBurney's point. Calculi were never found in the feces. Palpation revealed an oval, .somewhat soft tumor (cecum), upon which an elongated, cylindrical body was distinctly palpated. This, as a whole, appeared to be movable, and was sometimes found in the hepatic region, at other times in the lower abdominal region. The liver was not enlarged. At the operation two small stones were found in the cecum. If the stones were forced toward the vermiform process they readily slipped into tli is organ and just as readily were returned to the cecum, which was absolutely normal. Extirpation of the appendix. Recovery. Among the atypical cases, MASKED (Treves) and LARVAL PERITYPH- LITIS (Ewald) must be enumerated. Under the name of " masked perityphlitis " Treves J has described a number of cases in which there were absolutely no signs of perityphlitis, and in which the ileo-cecal region was free from pain. In one of these cases the symptoms were chiefly those of pylephlebitis, while the necropsy showed small hepatic abscesses and (as a primary infection) a completely transformed appendix filled with pus. I recently observed a case, in many respects similar to this, which caused great perplexity in diagnosis. Mr. O. F., a merchant, aged 22, from Antwerp; his parents were healthy. As a child the patient had measles, diphtheria, and whooping-cough, and five years ago enteric fever. From childhood he had a tendency to diarrhea in consequence of dietetic errors. In June, 1903, while in New Orleans and after a slight alcoholic excess, the patient had a mild attack of fever accompanied by pain in the gastric region and the back and also diarrhea; the attack lasted for a few days and then yielded. In the beginning of August, 1903, a " mild attack of colic " with pains in the abdomen and diarrhea occurred very suddenly (without known cause). In the following months he frequently had diarrhea without pain. In March, 1904, the patient had an attack of jaundice. Prior to the outbreak there was slight malaise for a few days and some fever ("like an influenza"). Pain was not present. After the jaundice had existed for three weeks, pains were felt in the anus and also periodic pains in the genitalia which radiated to the anus. These attacks always lasted from fifteen to thirty minutes. During this time the patient could void his urine only in drops. After a few days the pain passed away, and micturition was normal. The jaundice also gradually disappeared, and in the spring of 1904 the patient completely recovered at Baden-Baden. In July, 1904, diar- rhea and vomiting appeared suddenly in the night ; at first without pain, but toward morning pains were felt in the entire abdomen, passing away in a few hours. The patient is said to have had no fever. Three weeks later there was sudden severe pain in the "gastric region" (left side of the abdomen), which later radiated to the right lotrer side of the belli/; there was mild fever. The physician suspected perityphlitis. After three days the patient was able to resume his occupation. In August there was diarrhea with the passage of mucus and tenesmus. Early in Sep- tember, 1904, he was again suddenly attacked by chills and fever with severe pains . ^- i Treves, " Perityphlitis and Its Varieties," London, 1897, p. 37. 586 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHL1TIS in the gastric region (epigastrium) which radiated to the lower abdominal region, also vomiting. An injection of morphin soon relieved the pain, but for a few. days there was marked sensitiveness below the right arch of the ribs which to a slight extent had existed since the attack of jaundice in the spring. Since the last attack there has been a tendency to diarrhea alternating with constipation, occasionally mucus in the dejecta, and sometimes mild pain in the right abdominal region (be- tween the hip and the right border of the ribs). The patient, who had made a journey from Antwerp to Berlin without difficulty, was suddenly attacked the first night with severe pain in the abdomen (in the middle of the belly somewhat above the navel) which soon radiated to the right lower side and the region of the bladder, this being accompanied by bilious vomiting and, toward morning, by chills. The temperature rose to 101.7 F., the pulse was 104. but regular, full, and of good tension. The abdomen was retracted; the walls showed only moderate tension. Just above the navel the belly was very sensitive to pressure. The ileo-cecal region and the other parts of the abdomen were moder- ately tender to ordinary pressure. The liver and gall-bladder were not palpable, nor painful on pressure. The splenic dulness was normal, the organ could not be palpated. The urine was clear and free from albumin and sugar. Digital rectal examination was very painful, the prostate gland slightly enlarged ; otherwise nothing abnormal could be palpated. Lungs and heart normal. The fever continued for several days; the pulse was always regular and full, the greatest rapidity being 108. After the 2nd of November the abdomen was mod- erately distended. Above the navel and also in the region of the sigmoid flexure there was extreme tenderness both spontaneously and on pressure, but pressure in the ileo-cecal region evoked no actual pain, nor was there pain upon pressure in the region of the liver and gall-bladder. The pains above the navel radiated downward to the bladder region. Up to the 4th of November neither feces nor flatus were passed. After intestinal irrigation there was a slight fecal evacuation accompanied by vomiting. Pain was everywhere produced on pressure, and was most marked above the navel. Upon the 5th of November the bowels moved freely; the abdomen was no longer distended but soft, although painful upon pressure above the navel, and somewhat less so in the region of the sigmoid flexure; other areas not painful. The temperature returned to the norm and remained so for a few weeks except for a transitory rise in consequence of catarrhal tonsillitis. The patient constantly had fleeting pain in the abdomen which radiated from the middle of the epigastrium down to the bladder and the ileo-cecal region. Upon pressure in the latter area there was but little pain, but this pressure invariably produced pain in the epigastrium and sometimes in the region of the bladder. At the end of urination also there was frequently slight pain in the bladder. The urine was somewhat turbid; the sedi- ment contained sodium urate and isolated bladder epithelia. The bowels moved daily, the dejecta were formed, and on rare occasions were admixed with a little mucus (immediately after the attack the mucus was considerable). The patient recovered within the next week, gained 5 kilograms in weight, was out of bed, and had taken two carriage drives when, upon the morning of the 12th of December, there was sudden severe pain in the bladder region and in the radix penis accom- panied by bilious vomiting. The temperature rose above 100.4 F. The abdomen was retracted, tense, and everywhere painful on pressure, particularly in the bladder region over the symphysis. Pressure over the liver and gall-bladder was not espe- cially painful. At the termination of urination there was intense pain in the blad- der which radiated to the epigastrium. The urine showed nothing abnormal. The pulse was 124, and full and strong. Rectal examination and palpation revealed nothing abnormal. After an injection of morphin the pains ceased for a short time. 587 The temperature continued high for the next few days, the abdomen tense and pain- ful, especially in the bladder region, more so upon the right side than upon the left, and very tender upon pressure. Nothing abnormal could be palpated. The pulse was invariably full and strong, the pulse rate as high as 132. Up to Decem- ber loth, notwithstanding oil enemata and the introduction of an intestinal tube, neither feces nor flatus were passed, and upon the 14th vomiting and eructations were frequent. Upon the 15th of December, after two profuse intestinal irrigations with soap-suds a large amount of feces and flatus was discharged. The abdomen became soft. The bladder region was still painful upon pressure. The temperature fell to normal. Sensitiveness in the epigastrium (spontaneous and on pressure) con- tinued, as well as severe pain on pressure immediately over the symphysis, and more marked upon the right than upon the left side. The ileo-cecal region and the region of the liver and gall-bladder showed no tenderness. The abdomen revealed nothing abnormal upon palpation or rectal examination. At the termination of micturition, as well as prior to defecation, there was still occasional pain in the bladder region. A tentative diagnosis was made of appendicitis, the appendix being displaced down- ivard and adherent to the bladder. Operation was advised. Upon the 25th of De- cember there was another slight rise in temperature. On the 27th the -patient was admitted to Prof. Korte's Clinic, where, in an examination under an anesthetic, noth- ing abnormal could be found. Operation was performed by Prof. Korte upon the 2nd of January, 1905. Under chloroform anesthesia an incision was made in the median line above the navel and extending two fingerbreadths above the symphysis. The omentum was found to be adherent to the pelvis, the cecum adherent to the bladder, the appendix was displaced downward into the pelvis behind the bladder and there adherent to the bladder. The adhesions of the omentum to the bladder were broken up as well as the adhesion of the omentum to the sigmoid flexure. Upon loosening the appendix, perforation occurred at the base of the organ and a fecal cal- culus exuded. Amputation of the appendix. In the pelvis a small abscess was opened in loosening the adhesions. Coils of the small intestine adhered to each other, and their dissolution was impossible on account of the extent of the adhesions. The serosa of the intestines was reddened; in some areas there were small whitish nodules (tubercles?). Gall-bladder: No adhesions; no stones could be palpated. In the liver, so far as it could be palpated, there was nothing abnormal. The abdominal walls were sutured with drainage. Near the base of the appendix which was opened an ulceration the size of a pea was found, and this had perforated when the organ was removed. The appendix contained purulent feces. The muscularis and sub- mucosa were thickened. Recovery was slow, but there was no complication except a suture abscess. The highest temperature range was from 98.6 to 100.4 F. Upon February 18th, 1905, the patient was discharged well. The intestinal function was somewhat torpid but otherwise normal. According to Treves, in numerous other cases there are no symptoms which point to perityphlitis, but they chiefly indicate general dyspepsia (loss of appetite, constipation, occasional vomiting). The abdomen is somewhat distended, feels tense, and is frequently the seat of indefinite colicky pains. Fever is either absent or is but slight. Upon deep pressure in the right iliac fossa there may possibly be some sensitiveness. The swelling may be in the impacted cccum, the intestinal contours being sharply defined. The cases run an indefinite course until the diagnosis is confirmed by the detection of an abscess. 588 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS As is obvious, the group last described bears a certain similarity to the cases designated by Ewald 1 as PERITYPHLITIS LARVATA. In this form also there are atypical gastric and intestinal symptoms of varying nature and intensity but, in contradistinction to the masked cases of Treves, in perityphlitis larvata there is an evident sensitiveness to pressure in the ileo-cecal region. Such atypical cases are by no means rare, and can be correctly diagnosticated only when, as already remarked, the area of the appendix is carefully palpated in every case of visceral disease. In my article quoted above 2 I have called attention to another variety of atypical perityphlitis distinguished by this feature: That the patients complain little of distress in the ileo-cecal region but, on the contrary, refer their symptoms to the hepatic region, while here objective examina- tion reveals normal conditions, but extreme sensitiveness to pressure at McBurney's point. COMPLICATIONS OF CHRONIC PERITYPHLITIS In the residual as well as in the relapsing forms of perityphlitis com- plications frequently set in. In the former they may under some circum- stances so completely dominate the pathologic picture that the actual focus of the disease is masked. To this category belong the dreaded hepatic abscess and pyopneumothorax subphrenicus, secondary pleurisy and pneu- monia, and the embolic processes in the lungs which develop in the course of, or after an operation for, acute or residual perityphlitis. This by no means exhausts the number or the varieties of the com- plications; were we to attempt at this point to give a comprehensive description of this grave disease which so frequently threatens life, it would be necessary to describe the entire pathology of acute perityphlitis. We shall lirnit ourselves to mentioning a restricted number of the complications of chronic perityphlitis. Here two groups are alike interesting: Chronic catarrh of the colon and (in women) diseases of the right-sided adnexa. In regard to the first, catarrh of the colon in its various forms and manifestations is among the most frequent and, we may almost say, daily accompanying symptoms. Here we must discuss the question in how far colitis is the cause or the effect of chronic perityphlitis. "We must admit that catarrh of the colon precedes as well as follows perityphlitis, and in such a manner that the bland diet necessitated and the lack of sufficient bodily exercise leads to habitual constipation and gradually to true catarrh. The second group of complications relates to diseases of the female genital organs, especially of the right-sided adnexa. It is not within my 1 Firald, " Die Krankheiten des Darnies und des Bauchfells," Berlin, 1902, p. 237. x, Deulsche nicd. Wochenschr., 1905, Nr. 27. THE CLINICAL PICTURE OP CHRONIC PERITYPHLITIS 589 province to describe minutely these serious affections. Those who desire detailed information are referred to the instructive and exhaustive mono- graph of Th. Landau, which is a critical analysis of extraordinary merit. According to Th. Landau, besides the true diseases of the adnexa, the ovarialgia, the retroflexioversio uteri mobilis, and the dislocated right kidney may be combined with perityphlitis, and thus mask the actual underlying affection. Besides these most common maladies, there are many others which may accompany perityphlitis. First to be mentioned here are calcareous processes of the right kidney and of the gall-bladder, which, more fre- quently than we are prone to believe, cause errors in diagnosis. Further- more, as already stated, there may be a dislocated right kidney as well as perityphlitis, and if the symptom-complex be not typical this may make a differential diagnosis either perplexing or impossible. We shall discuss these difficulties more minutely in the section devoted to diagnosis. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF CHRONIC PERITYPHLITIS The diagnosis of chronic perityphlitis may be easy, even to the novice, or, inversely, may present to the most experienced great and occasionally even insurmountable difficulty. Starting from the principle, which has been reiterated, that residual perityphlitis and chronic relapsing perityphlitis are two clinically different forms, we shall enunciate the fundamental laws regarding the first men- tioned group. Here, primarily, the history must be regarded as the decisive factor. The more clearly this reveals the occurrence of a prior typical attack the more readily can we decide as to the nature of the possible acute relapse. Nevertheless, experience shows that milder attacks are frequently forgotten by the patient, especially if they have occurred a long time previously. If the patient is a very young person, we frequently find that such mild attacks have not been recognized by the physician owing to the insignifi- cant symptoms, hence in a given case an existing attack may not be re- garded as a relapse but as a primary attack. Aside from this, in all essential points the diagnosis of residual peri- typhlitis in its acute form is evolved as in the primary attack. Besides this, however, as mentioned before, the chronic residua must be consid- ered. In the discrimination of these the prior history of the patient is the best guide. The occurrence of fever and of the febrile movement, the duration and severity of the attack, and possible complications are especially valuable aids to the recognition not only of the nature but also of the intensity of the process. These are the cases also in which, following the acute attack, objective symptoms persist which can be demonstrated with more or less accuracy. 590 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS The region of McBurney's point is probably sensitive to pressure, but in its surroundings we find at the same time a certain amount of thick- ening which may be demonstrated even on very slight percussion. In some cases an exudate may be felt. According to Ewald * and Sonnenburg * this is said to become prominent after inflation of the colon. Sometimes the differentiation between an exudate and a neoplasm is extremely difficult, and casuistry furnishes a number of instances in which laparotomy or the necropsy has revealed numerous fundamental errors and confusions. Among the most serious conditions leading to mistakes are carcinoma of the cecum and ileo-cecal tuberculosis. In fact these affections, provided positive symptoms and a clear history do not guide the physician, run their course with manifestations which closely resemble chronic perityphlitis. In the following we will present a few principles for the differentiation of these clinical pictures the prognosis of which varies so greatly, but in which, however, we cannot deny that no differentiating factors will invari- ably protect us from error. Cecal Tuberculosis. Cecal tuberculosis usually occurs in comparative youth (from the second to the fourth decade), runs an exceedingly chronic course, and frequently, although by no means always, is accompanied by tuberculous processes in the lungs. As Obrastzow correctly points out, the cecum does not form an actual tumor, but has the appearance of a rigid, irregular, nodular infiltration. Cecal tuberculosis invariably runs its course with symptoms of stenosis which in such cases are revealed in a typical manner (well developed intestinal peristalsis, alternation between constipation and diarrhea, attacks of obstruction). Blood and pus are rarely present in the feces, but tubercle bacilli may be frequently found. Fever is rare. Carcinoma of the Cecum. As a rule, in carcinoma of the cecum which usually occurs late in life the tumor is sharply limited. Symptoms of stenosis may be absent, or may be present in a greater or less degree. Fresh or occult blood (Boas 3 ) appears in the feces in from 10 to 15 per cent, of all cases; pus is either not found or is exceedingly rare. Fever may occur in carcinoma of the cecum, but only in advanced stages of the affection. Where there is no thickening, tumor formation, or even symptom of stenosis, the only objective sign is sensitiveness to pressure in the ileo- cecal region. Tn rare cases, to find at the autopsy an inflammatory or even malignant i Eicahl. " Die Krankheiten des Darmes und des Bauchfells," Berlin, 1902. - Sonnenburg, " Pathologie imd Therapie der Perityphlitis," 5 Aufl., Leipzig, 1905. s Boas, " Ueber occulte Magen- und Darmblutungen." Volkmann's Sammlung klin. Vortruge, 1905, Nr. 387. THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 591 tumor instead of the expected perityphlitis is an experience from which even the most skilful diagnostician is not exempt. In these and other doubtful cases I must call attention to a factor that aids materially in the diagnosis of residual perityphlitis: This is a regular temperature record continued for weeks, and especially the com- parison of temperatures taken simultaneously in the axilla and in the rectum. A copy is here presented of a temperature curve which clearly portrays these differences. I have been several times convinced that, under some circumstances, these more or less high elevations of temperature, and especially the simul- taneous rectal and axillary temperatures, form the only guiding and determining symptom. The following case may serve as an example: A girl, aged 4, daughter of a manufacturer from G. Following a doubtful acute perityphlitis she complained of periodic abdominal pains which lasted but a few seconds and occasionally ceased after vomiting. Localization of the pain was impos- sible. The objective finding was entirely negative, the region of the cecum being painless upon pressure. Regular and continuous records of the temperature showed occasional falls or elevations of brief duration. A diagnosis of residual perityphlitis was accordingly made and the child was operated upon by Prof. Korte. The opera- tion revealed the following : In the mesentery a swollen gland which was extirpated. The appendix was about 10 cm. in length, contained semisolid feces, and in the center a mucous membrane cicatrix. The cecum and ascending colon were palpated and found to be normal. Course normal ; discharged cured. While in residual perityphlitis the prior history will usually give us valuable data for the diagnosis, in the chronic relapsing form we must depend principally upon the clinical course. Frequently this ensures a diagnosis; but there are also cases so faintly characterized that only repeated and thorough examinations will enable us to come to a decision. Among the diagnostic factors which favor chronic perityphlitis the most prominent are the characteristic subjective symptoms : The persistent pains starting from the ileo-cecal region and centrifugally radiating to the thigh, to the lumbar and the hepatic regions. Among the objective symptoms, as already mentioned, there is frequently nothing but the sensitiveness at McBurney's point. In some cases another phenomenon appears upon palpation, which at this point must be described somewhat more explicitly since it is fre- quently and variously referred to in literature: This is palpation of the diseased vermiform process. The American surgeon, Edebohls, deserves credit for having called attention to the possibility of palpating the dis- eased vermiform process, and in 1894 he made the statement that this organ could be recognized in every case of perityphlitis. That this assumption is not borne out by the facts can to-day scarcely be doubted by physicians of experience. In cases of acute perityphlitis the swelling of the mesentery, the appearance of the exudate, etc., make the conditions for palpating the diseased appendix extremely unpropitious. 39 IIK3II IIIIIE liiiiiiiii mii ^ ni 1 THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 593 The circumstances are somewhat more favorable for palpating the appen- dix in chronic perityphlitis, a fact to which some authors (Ewald, Haus- mann) have attached a certain diagnostic significance. In these instances we may admit that now and then when the vermi- form process is in a favorable position it may be felt as a round, painful organ, sometimes with surprising distinctness. Nevertheless, dozens of cases of chronic perityphlitis may be observed in which the result of palpation is not only once but repeatedly negative. In other cases in which we think that something is palpated, the body that is felt cannot be clearly recognized, and we waver in opinion between the assumption of a contracted portion of the colon, of a coil of the ileum, of adhesive intestines, or of the rolled-up mesentery, etc. At all events, in my experience palpation of the diseased appendix is only of diagnostic importance if we constantly find in the ileo-cecal region a distinctly palpable body which is sensitive to pressure, and which is of the same form and thickness as the vermiform process. In such isolated cases, of course, the diagnosis may be much more readily made. The actual difficulties in the diagnosis of chronic perityphlitis depend upon our distinguishing this from other chronic forms of colitis, as well as upon the differentiation from chronic disease of the uterine adnexa. In the great majority of cases the condition in the former is such that we must decide whether merely colitis is present or whether this coexists with chronic perityphlitis. The differentiation is extremely difficult when the chronic colitis has its seat in the cecum, i. e., when a true chronic typhlitis exists. Then a symp- tom picture may develop which nowise differs from chronic perityphlitis. As a matter of fact the diseases may exist simultaneously. The condition is somewhat more favorable when the colitis occurs in a more peripheral section of the colon, and when a severe but circum- scribed pain upon pressure is produced in the ileo-cecal region. If the clin- ical picture of perityphlitis is simultaneously present, we can hardly doubt their coexistence. The diagnosis is facilitated if acute, mild, febrile exacerbations appear similar to those which occur in the course of chronic relapsing perityph- litis; this impresses the stamp of certainty upon the previously doubtful case. Nevertheless it cannot be denied that in a not inconsiderable percentage of cases doubts will arise which cannot be removed even by careful investi- gation and observation. To this category belong, for example, the apparently not rare cases of so-called pseudo-perityphlitis to which Nothnagel 1 first called attention, and which all experienced physicians have met with. iNothnagel, Wien. klin. Wochenschrift , 1899, Nr. 15; compare also G. Singer, " Pseudoappendicitis und Ileococalschmerz," Wien und Leipzig, 1905. 594 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS We are not always in a position to verify our diagnosis by operation, as was the case with Nothnagel. Nevertheless, there are some symptoms which may be looked upon as landmarks in the differential diagnosis be- tween true and pseudo-perityphlitis. Paramount among these is the course: At certain irregular intervals the patients suffer from pain in the ileo-cecal region, but this is not associated with rises in temperature and is not increased by active or passive movements. The region of the appen- dix is either insensitive to pressure or the sensitiveness is only referred to the skin, and it is not circumscribed but diffuse. Occasionally cutaneous hyperesthesia alternates with normal sensation upon pressure. I recently had an opportunity of observing a very instructive case of well-developed typhlopholia. In a family which was well known to me for years a fatal case of severe acute perityphlitis had occurred in a near relative. This case was for weeks the subject of conversation in the family, and one of the two daughters of the house, a girl aged fourteen, became especially concerned and uneasy. A short time afterward she complained of severe pain in the region of the cecum, lost her appetite, remained away from school, became anxious, and caused her mother a great deal of worry. The history showed that the child had never had fever. Exami- nation of all parts of the abdomen revealed absolutely no sensitiveness nor resistance, and the adduction of the thigh which was several times at- tempted produced no pain. This proved that there could be no question of perityphlitis. I quieted the anxious patient, and advised her to return to school the next day and to consider herself as well. From this moment the child was well and remained so. Besides organic and neuralgic intestinal affections, in the female the differentiation of diseases of the adnexa may come into question in a diag- nostic respect. We have already indicated the possibilities which exist, and at this point attention must be called to the necessity of considering these syrnptomatically with chronic perityphlitis, for these genital affec- tions may be quite analogous. In the diagnosis of inflammation of the adnexa a considerable degree of practice and experience is a prerequisite, therefore in cases at all doubtful the opinion of a gynecologist should be sought. Besides these factors which dominate the differential diagnosis of chronic perityphlitis, there are still others which now and then come into question. Ainong these are cases of calculus in the right kidney or of the uric arid diathesis. The regular finding of abnormal amounts of uric acid combined with small amounts of albumin in the urine, the appearance of typical attacks with their characteristic urinary changes, the demonstra- tion of a gouty substratum in characteristic areas of the body, and the palpation of the kidney itself will in many cases reveal the correct diagno- sis. Nevertheless, the ensemble of the previously mentioned symptoms is THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 595 not always so favorable that the underlying condition can be clearly dis- cerned. With reference to the kidney, its dislocation, at least so far as sub- jective factors are concerned, may produce symptoms which to a certain extent resemble those of chronic perityphlitis. But no actual attacks are observed, there is no typical pressure point in the ileo-cecal region, and the characteristic localization of the pains is also lacking. Atypical cases of cholelithiasis and of cholecystitis may be confounded with chronic perityphlitis, particularly as they are not infrequently com- bined in the same individual. To this must be added another source of error, the not rare coexistence of cholelithiasis and colitis. An accu- rate history combined with cautious and repeated examinations of the liver and the region of the gall-bladder and the occasional finding of biliary coloring matter in the urine will often clear the complicated picture. Finally, we must mention the not infrequent possibility of error from the presence of ill-defined hernia, particularly of right-sided in- guinal and crural hernia. I have several times seen cases of supposedly chronic perityphlitis which were permanently cured by wearing a hernial truss. This by no means exhausts the number of perplexities which may arise in differential diagnosis, but from what has been stated it is obvious that in some cases the diagnosis of chronic perityphlitis requires considerable acumen, practice, and experience. One factor in particular must not be omitted from consideration, namely, that chronic perityphlitis may appear simultaneously with or inde- pendently of diseases of other organs. Sometimes we are inclined to fol- low an old rule and to substitute one or more pathologic varieties for each other. But nature does not sanction such a method, and we must there- fore consider not only whether one or the other affection is present but this is often the most difficult problem whether they do not exist inde- pendently of each other. PROGNOSIS OF CHRONIC PERITYPHLITIS In this article we have repeatedly called attention to the fact that the prognosis in residual and in chronic perityphlitis presents fundamental differences. This is evident from the etiology of both forms of the dis- ease. While, as is shown by the fitting designation of Sahli, in acute perityphlitis there is always " a purulent nucleus," the changes in the chronic form are referred more to the mechanical realm, and consist of kinking, thickening, adhesions and obliterations. This is the reason why the process in acute perityphlitis may heal functionally, for example, by self -drainage (Sahli), or by rupture into ,196 ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS the intestine or into other organs. The conditions are, however, different in the cases with a chronic beginning and running a chronic course. Here mechanical disturbances when once developed to such a height as to produce symptoms rarely or never heal. From the fact that even when acute perityphlitis terminates in recovery it leaves residua of varying extent and absolutely unlike quality, it follows that the prognosis of resid- ual perityphlitis precludes any a priori judgment. Experience also teaches us that the primary attack may yield without any difficulties and compli- cations while the second attack may develop in an extremely fulminant manner, and if timely surgical aid is not at hand may cost the life of the patient. And, vice versa, the first attack may be exceedingly dangerous while the following ones may run a smooth, mild course. In such cases, any attempt to lay down definite rules and to institute a plan of treatment in accordance with these, in opposition to the ex- pressive voice of practical experience, must be unwise and even dangerous. Here and there, it appears as if certain laws in the course of residual perityphlitis were decisive, but this is nothing more than an accidentally favorable sequence in the individual cases, and with some patients it col- lapses like a house built of cards. The prognosis of chronic relapsing perityphlitis is much more certain than that of the residual form. With few exceptions the prognosis of the latter, in so far as life is concerned, may be regarded as favorable. This is true of the intervals as well as of the attacks which occur period- ically. Although I am well aware that no conclusive significance attaches to a single observation, nevertheless the following clinical history may be here in place because it shows how even extensive and chronic disease of the vermiform process may set in yet not decidedly impair the organ. The case was that of a lawyer, aged 25, who in the year 1904 began his voluntary service as a soldier in the army. In 1905 he presented himself to me for treat- ment showing all the signs of chronic relapsing perityphlitis. Besides this there was an obstinate habitual constipation with colitis. Although I warned the patient of the incompatibility of military duty with his disease, he insisted upon continuing his service in the army. He passed energetically through the difficult period of his recruit service; gradually, however, his symptoms increased so that in April, 1905, I strenuously advised operative removal of the appendix. Even then his condition was still bearable, and only the fear that in all probability he could not serve his time induced him to consent to the ^operation, which was successfully performed by Prof. Korte upon the 21st of May, 1905. The appendix was long, its end thickened, and it contained fecal concrements. Microscopic finding: Appendicitis ulcerosa. Notwithstanding the strenuous corporeal exertion to which the patient was exposed during his military career, and although he punctiliously performed all of his duties, no true attack supervened, which is certainly ;i forcible illustration of what has been said above that chronic relapsing cases show no tendency to a severe course. THE CLINICAL PICTURE OF CHRONIC PERITYPHLITIS 597 The prognosis in regard to a cure is quite different. While in an acute attack, even when most severe, a cure in the ordinary sense ensues and may be permanent, in the chronic relapsing form, for reasons previously mentioned, the result is quite different. Since in this form the symptoms at the onset are frequently very slight, it cannot be denied that by imme- diate and suitable remedies which will be described in the chapter upon treatment the disturbances may be so lessened as to constitute a cure; but a true cure which under observation lasts for years I am not cognizant of, 1 and in such a case I should be inclined to doubt the correctness of the diagnosis. The most characteristic feature of chronic perityphlitis, not only in its course but also in its prognosis, is the fact that under favorable ex- ternal conditions (bodily rest, lessening of tension, mineral spring cures, etc.), distinct remissions occur. But this somewhat subjective euphoria is in sharp contrast with the objective investigation which shows that a distinctly recognizable sensitiveness to pressure is constanfly present in the ileo-cecal region. TREATMENT OF CHRONIC PERITYPHLITIS In the borderland between internal and operative treatment, the treat- ment of chronic perityphlitis most frequently lies. It is everywhere rec- ognized that the most radical and relatively the least dangerous method of cure of chronic perityphlitis consists in the extirpation of the appendix in the afebrile stage. Upon superficial observation any further discussion as to the best mode of treatment of chronic perityphlitis would appear to be superfluous. But upon accurate weighing of the conditions they are found to be not quite so simple, and it is therefore necessary most carefully to investigate this question. In the first place, in the therapeutic indications and centra-indications there is a fundamental difference between those of residual and chronic perityphlitis. As we have seen, an acute attack may result either in complete recov- ery (in a functional sense) or the residua may generate chronic symptoms, "or, finally, may lead to a subsequent attack. The more resultless the investigation of the anatomical relations the more positively is therapeutic treatment indicated. We must, therefore, decide to what extent the changes after an attack i Albu, in an article recently published, " Zur Diagnose und Therapie der chro- nischen Perityphlitis" (Deutsche med. Wochenschr., 1905, Nr. 25 u. 26), mentions two apparently cured cases of residual perityphlitis. But in both cases the period of observation was too brief to permit a definite opinion. ACUTE PERITONITIS, APPENDICITIS, AND PERITYPHLITIS arc perceptible, and in how far we may prognosticate with probability the type of subsequent relapses. Considering first the residua, the presence of an exudate may be cer- tainly determined and its growth or retardation demonstrated by continu- ous observation. On the contrary, exact knowledge of the condition of the vermiform process and its immediate surroundings is much more difficult to acquire. It may still contain pus, a tendency to perforation and ulcera- tion may still be present, the mesenteriolum may be inflamed or gangre- nous, yet there may be no marked or grave symptoms to indicate the gravity of the condition. Inversely, a slowly progressive healing may take place,, but whether this is permanent is a question to be answered only with the greatest reserve. As we have already emphasized, the prognosis in a second or third attack is most perplexing. We have only to consult one of the numerous clinico-surgical reports upon appendicitis to be convinced that here every rule finds its paradigm in the inexhaustible variations of the clinical course of peri typhlitis. Only ripe experience, as has often been demonstrated, warrants the following prognosis: The longer the interval after the first attack the less the danger of subsequent and severe relapses. But even here, as every one who has followed the literature of perityphlitis knows, exceptions now and then occur. To find the proper indication for our therapeutic procedure, we must consider impartially what internal medi i\ i COLLIESE 01" 07. evacuation of, 119, 229, 230. examination of, 54, 64, 66, 77, 96, 139. bacteriologic, 36. chemical, 67, 119. chemical and microscopical, 47. microscopical, 115, 119, 231, 233. expulsion of, 153. extreme subacidity of, 93. hydrochloric acid in, 67, 78. hyperacid, peculiarities of, 105. inflow and outflow of, 144. methods of testing, 140. microorganisms in, 67. osmotic concentration of, 93. propulsion of, 128. qualitative tests of, 67, 68. reaction of, 67. removal of, 61, 64. specific gravity of, 93. stagnation of, 91, 99, 129, 139. subacidity of, 89. sudden discharge of, 56. test of, 52. total acidity of, 68, 91. Gastric crises, 117. Gastric digestion, 94. amylolytic and proteolytic stage of, 37. marked disturbance of, 278. Gastric dilatation, 57, 122, 163. acute, 126. acute and chronic, 145, 150. causes of, 125, 149. chronic, 145. clinical forms of, 122. course of, 144. diagnosis of, 122, 132, 133, 146. diet in, 150. differentiation of, from other affections, 143. general condition and nutrition in, 135. in children, 126. nervous symptoms of, 141. objective symptoms of, 135, 141. prognosis of, 149. subjective symptoms of, 133. surgical treatment of, 156. symptoms of, 132. treatment of, 35, 144, 149, 150. INDEX OP SUBJECTS Gastric disease, advantages of institu- tional treatment in, 61. malignant, 236. physical examination in, 136. treatment of, 32. Gastric douche, 59. Gastric fistula, formation of, 45. in dogs, 102, 109. in man, 109. Gastric hemorrhage, 178. cavises of, 175. composition of blood in, 181. fatality of, 177. indications for operation in, 211. menstrual, 179. occult, 232. parenchymatous, 179. repetitions of, 176. vicarious, 179. Gastric insufficiency, 271. Gastric juice, acidity of, 104. changes in, 36. characteristics of, 113. composition of, 65. continuous flow of, 113. diminution of, 109. during menstruation, 49. hyperacidity of, 71. hypersecretion of, 60, 87. influence of sweating on, 111. inhibiting of, by drugs, 111. irregular outpour of, 173. layer quotient of, 105. microscopic examination of, 67. peptonizing action of, 77. residue of, estimation of, 106. Gastric lavage, 101, 118, 136, 139, 140. apparatus for, 53. at evening, 61, 155. benefits of, 34, 46. Biedert's method of, 41. by patients themselves, 37. clinical use of, 46. contraindications of, 48. effect of, in the debilitated, 59. findings of, 114. for eructation of gas, 73. former methods of, 39. hemorrhage during, 57. history of, 32. Hodgen's method of, 40. in cancer of stomach and intestine, 255. in dilatation, 145, 146, 154. in diseases of liver and gall-bladder, 44. in mucous membrane erosions, 180. in recumbent posture, 56. in the debilitated, 55. individualization of, 56. interruption of, 56. Jiirgensen's method of, 39. Kussmaul's directions for, 43. rebound in, 40. solutions used for, 59. suitable cases for, 48. suitable time of day for, 60. technic of, 41, 46. Uffelmann's process of, 119. Gastric lavage, with ice water, 209. with iron chlorid solution, 202. with silver nitrate solution, 186. Gastric motility, disturbance of, 94, 226. Gastric mucous membrane, excoriation of, 57. fissures of, 186. hypersensitiveness of, 186. injuries of, 42, 56. irritability of, 57. Gastric musculature, atony of, 35. fatty and choroid degeneration of, 35. paresis of, 35. Gastric necrosis, 160. Gastric perforation, act of defecation a cause of, 184. percentage of, 185. poisoning simulated by, 185. self-induced vomiting a cause of, 184. Gastric rigidity, 225. detection of, 226. Gastric secretion, 88. absence of acid in, 76. discharge of, 118. disturbances of, 128. independent of food, 103. insufficiency of, 89. retention of, 116, 173. substitution for, 76. variations of, in health, 88. Gastric tetany, 142. Gastric tumor, position of, 193. Gastric ulcer, 83, 117, 159, 276. acute and chronic forms of, 159. age of occurrence of, 168. ambulatory cases of, 206. at fundus, 194. bismuth treatment of, 43, 201, 205. carcinomatous, 237. carcinomatous degeneration of, 191. carcinomatous transition of, 173. chronic diagnosis of, 188. cicatrization of, 165, 185. combination of, with gastrectasis, 184. with gumma, 187. confounding of, with gastralgia, 72. diet in, 202. differentiation of, from hyperacidity, 77, 112. from gastralgia and carcinoma, 188. emaciation in, 198. etiology of, 159. bacteria, 161. circulatory disturbance, 160. endarteritis of smallest vessels, 160. hemorrhagic erosions, 160. trauma, 162. vascular lesions, 160. frequency of hemorrhages in, 176. healing processes of, 215. hemorrhage from, 58. hydrochloric acid in, 172. indications for operation in, 215. in Finland, 163. irritative symptoms of, 168. latent, 174, 179, 234. literature of, 216. INDEX OF SUBJECTS 809 Gastric ulcer, localization of, 164, 193, 194. malignant degeneration of, 223. microscopic section of, 164. mineral spring treatment of, 202, 215. mortality in, 211, 212. normal type of, 168. obscure development of, 163. oil treatment of, 207. operation for, 194. operative statistics of, 214. pain in, 81, 169. pathological anatomy of, 163. perforation of, 165, 167, 214. while dancing, 184. perigastric adhesions of, 211. prognosis of, 199. proportional affection of the sexes in,168. pure, uncomplicated, 214. rectal nutrition in, 201. relapses of, 200. relation of nervous system to, 162. relation of, to cancer, 167. round, 161. rupture of, 177, 182. sequelae of, 168. size of, 164. solitary, 161. statistics of, 200. surgical results in, 211. surgical treatment of, 210. symptoms of, 168. syphilitic, 167. the lesion in, 184. transition of, into carcinoma, 180. treatment of, 60, 84, 201. triad of 'symptoms of, 169. tubercular, 166. vomiting in, 181. with latent course, 168. Gastric ulcers, isolated, simultaneous rup- ture of, 185. usual number of, 164. Gastric wall, atony of, 84. degeneration of, 43, 45. necrosis of, 162. torsion of nerves of, 185. Gastritis, acid, 76, 77, 85, 108. acute phlegmonous, 165. chronic, 83, 84, 146. denoting of, by mucus coagula, 66. differentiation of, from dyspepsia, 70. proof of, 65. Gastritis gravis, 232. Gastritis phlegmonosa, 233. Gastroanastomosis, sequels of, 212. Gastrodynia, 72. differentiation of, from gastric ulcer, 188. Gastroenterostomy, 128, 157, 191, 195, 196, 215, 257, 258, 259. antecolica and retrocolica, 212. indication for, 118. Gastrogenous phosphaturia, 115. Gastrohepatic ligament, shortening of, 281. Gastrointestinal canal, malignant disease of, 276. Gastrolith, 235. Gastroneurosis, combined, 80. Gastroptosis, 107, 118, 127, 146, 265. boundaries of stomach in, 136. combination of, with enteroptosis, 143. confounding of, with gastrectasis, 147, diagnosis of, 276. diet in, 274. drug treatment of, 280. gastrectasis a cause of, 268. hyperacidity in, 76. in hypersecretion, 117. in women, 83. proof of, 275. prophylaxis of, 276. relation of, to chlorosis, 274. statistics of, 265. surgical treatment of, 281. symptoms of, 273. treatment of, 276. Gastrorrhoea acida, 76, 78. Gastroscope, 194. Gastroscopy, 235, 237. Gastrosis, 79. causes of, 80. infrequency of meals, 80. diagnosis of, 82. of reflex sexual origin, 80. symptoms of, 81. Gastrostomy, 27, 28, 29, 45. Gastrosuccorrhea, 94, 104, 113, 173, 190. Gastroxynsis, 76. Gelatin in treatment of gastric ulcer, 210. Genital organs (female), diseases of, 588. Girdle sensation, 275. Glands, para-umbilical, 228. peri-umbilical, 228. supraclavicular, enlargement of, 198, 228. Glandular parenchyma, proliferation of, 108. Gluczinsky's test, 191. Glycosuria, alimentary, 306, 309. constant, 310. occurrence of, after use of suprarenal extract, 210. statistics of, 310. transitory, 307, 309. Gmelin's test, 325. Gnawing sensation, 114. Goiter, 2, 17. Grape cure, 732. Grating sensation in gastric region, 22S Growths, esophageal, 7. Guaiac test, 174, 244. Gumma, syphilitic, 167. Giinzburg reagent, 67, 90. Giinzburg's test, 85. Gurgling, intestinal, 273, 277. Gurgling sound in esophagus, 9. Gymnastics, Schreber s curative, 724. Swedish curative, 724. Hamamelis virginica, 209. Hammerschlag's test, 92, 95. Head, numbness in, 82, 135. Headache in gastric dilatation, 142. 810 Heart, amyloid degeneration of, 179. corrosion of, from gastric ulcer, 177. dilatation of, 123. displacement of, 263, 264, 295. causes of, 296. symptoms of, 298. in women, greater movability of, 296. neuroses of, 79. normal position of, 295. rupture of, from gastric ulcer, 183. slow action of, 141. valvular disease of, 48. wandering, 295. Heart brace, 300. Heat, application of, 111. Heels, high, effect of, 273. Helminthiasis, bulimia in, 72. Hematemesis, 172, 203, 234. as symptom of carcinomata, 223. fatal, 187. frequency of, 176. in gastric ulcer, 169. in jaundice, 494. Hematin in gastric contents, 230. Hematuria, 286. Hemicrania dyspeptica, 650. Hemicrania intestinalis, 650. Hemoglobin in gastric contents, 230. Hemorrhage, capillary, 8, 49, 233. from mucous membrane, 13. from old gastric ulcers, 58. from stomach, 159, 174; see also Gastric Hemorrhage. gastric, 57, 143, 162, 208. controlled by lavage, 58. recuperation after, 211. treatment of, 210. by bismuth, 60. by ice water, 209. internal, 5. intestinal, 244. occult, 174, 179, 633. punctiform, in esophagus, 7. tendency to, 48. vicarious, 179. vicarious gastric, 713. Hemorrhagic pancreatitis, 321. Hemorrhagic stools in pancreatic disease, 320. Hemorrhoidal pessaries, 734. Hemorrhoidal prolapse, 716. Hemorrhoids, 704. catarrh of rectum a complication of, 715. cholelithiasis a factor of, 708. cold applications to, 732. complication of, 715. treatment of, 732. diagnosis of, 715. diet in, 731. differential diagnosis of, 715. digital examination of rectum in, 715. due to circulatory disturbance, 708. elevation of buttocks in, 731. etiology of, 708. external, 715. grape cure of, 732. hemorrhages of, 712. Hemorrhoids, hepatic congestion in, 712. hereditary predisposition to, 708. in childhood, 709. in pregnancy, 708. internal, 715. itching and burning in, 712. mineral water cures for, 731. mixed, 715. prolapse of, treatment of, 734. symptoms of, 711. treatment of, 730. combined with constipation, 731. enemata in, 731. exercise in, 731. incarceration of, 734. laxative, 730. suppositories in, 732. ulceration of, 712, 716. vicarious gastric hemorrhage in, 713. with incontinence of rectal sphincters, 716. Hepatargy, 341. Hepatic abscess due to gall-stones, 505. Hepatic artery, compression of, 487. Hepatic colic due to simple adhesions, 475. Hepatic duct, sympathetic spasm of, 192. Hepatic dyspepsia, 341. Hepatic insufficiency, 340. hemorrhagic diathesis in, 341. symptoms of, 341. Hepatic region, auscultation of, 487. Hepatoptosis, 290. distinguished from other diseases, 291. symptoms of, 291, 292. Hereditary jaundice, 348. Hernia epigastrica, 107. Hernia of the linea alba, 198. Hernia, strangulated, 180. Heterochylia, 94. Hop tea as gastric spray, 59. Hiihnerfeld's reagent, 175. Hunger, anomalous, 71. artificial relief of, 26. Hunger center in brain, 71. Hydrastis canadensis, 209. Hydrochloric acid, absence of, 140. from stomach contents, 76. cessation of, 98. combined, 90, 114. deficiency of, 84, 91. experiments in dogs, 108. free, quantitative estimation of, 120. increase of, in stomach, 169. in gastric contents, 68, 231. in gastric juice, 65. in stomach, 36. qualitative estimation of, 53. secretion of, 9, 88. test for, 90. Hydronephrosis, 286. Hydroparacumaric acid, 352. Hydropathy, 154. for diseases of stomach, 154. Hydrorrhrca gastrica, 106. Hydrotherapy in gastroptosis, 280. Hygiene in esophageal disease, 19. Hyperaciditas anorganica, 93. INDEX OF SUBJECTS 811 Hyperaciditas hydrochlorica, 104. Hyperaciditas larvata, 105. Hyperaciditas occulta, 105. Hyperacidity, 76, 89, 93, 103. as cause of gastric ulcer, 160. as sign of gastric ulcer, 173. chemical conception of, 104. drug treatment of, 111. etiology of, 108. functional, 77. gastric, 64. in different countries, 107. in gastric ulcer, 171. of stomach, 67, 75. persistent, 212. suitable diet for, 78. symptoms of, 107. treatment of, 78, 109. Hyperchlorhydria, 60, 76, 93, 172, 173, 190, 192. diet in, 203. treatment of, 43. Hyperchylia, 94. Hyperesthesia gastrica, 112. Hyperesthesia of gastric walls, 72. Hyperglycemia, 307. Hypermotility, gastric, 53. of stomach, 71, 74. Hypernutrition, 279. Hypersecretion, 76, 78, 113, 128, 129, 173. chronic, 116. combined with dilatation, 143. diagnosis of, 115. gastric, 60, 61, 64. neurogenous, 117. pathogenesis of, 116. symptoms of, 114. treatment of, 117. Hypertrophic pyloric stenosis, 232. Hypertrophy, stenosing pyloric, 98. Hypochlorhydria, 94. Hypocholia, 340. Hypochondriasis, 82. Hypochondrium, peculiar phenomenon in, 225. right, pain in, 192. Hypochylia, 94. Hypopepsia, 94. Hysteria, as cause of eructations, 73. as cause of gastric neuroses, 70, 74. combined with gastrosis, 82. gastric hemorrhage in, 58. painful pressure areas in, 84. significant of floating kidney, 288. with esophagismus, 14. Ice, application of, in gastric ulcer, 207. in esophageal disease, 20. use of, in gastric ulcer, 209. Ice cold fluids, effect of, 108. Ichochymia, 122. Ictere hemaphe'ique, 341, 410. Icterus. See Jaundice. Icterus gravis, 341. Icterus neonatorum, 331. Ileum, carcinoma of, 247. Ileus, dynamic, 765. Ileus, mechanical, 765. paralytic, 517, 765. treatment of, by gastric lavage, 43, 47. Iliac fossa, sensitiveness in, 285. Inanition, 14. in esophageal disease, 5. prevention of, 30. Indican in urine, 9. Indican excretion insufficient in pancre- atic disease, 321. Indigo reaction, 502. Indol, 636. Infarct, hemprrhagic, 160. Infiltration ligneuse, 489. Infiltration, small cell, 165. Infusions, subcutaneous, in gastric ulcer, 210. Ingesta, abnormal decomposition of, 171. expulsion of, from stomach, 125. hot or cold, as cause of pain, 170. permanent retention of, in stomach, 125. propulsion of, 73. stagnation of, 75. Innervation, disturbances of, 1, 15. Inspection in gastric disease, 135. Inspection of esophagus, 6. Intestinal activity, disturbance of, 141. Intestinal canal, tuberculosis of, 187. Intestinal carcinoma, 240. complications and sequels of, 250. diagnosis of, 248. distinguished from other conditions, 242. movability of, 242. prognosis of, 251. symptoms of, 240. Intestinal constriction, 751. abdomen in, palpation of, 760. alteration of fecal movements in, 751. anatomical nature of, 760. bowels in, regulation of, 764. carcinoma the cause of, 761. caution in diagnosis of, 761. cicatricial strictures causing, 761. colon the seat of, 758. constipation in, 752. course of, 762. diagnosis of, 753, 761, 762. diarrhea in, 752. diet in, 764. digital rectal examination in, 759, 760. due to benign tumors, 756. to carcinomata, 755. to chronic peritonitis, 757. to internal cicatricial strictures, 756. to pressure of tumor-like masses, 757. to sarcomata, 755. to tuberculomata, 755. duodenum in, chronic stenosis of, 759. etiology of, 754. external, by peritoneal processes, 757. feces in, 752. hernial rings, examination of, 759, 760. insidious onset of, 762. intestinal stiffening of, 753. diagnostic value of, 754. Japarptomy in, 762. 812 INDEX OF SUBJECTS Intestinal constriction, leading to occlu- sion, 763. pain in, 752, 759. pelvic peritonitis preceding, 761. peristalsis increased in, 753. prognosis of, 762. seat of, 762. seat of obstruction in, 758. small intestine seat of, 759. stenosis of rectum in, 760. symptomatology of, 751. treatment of, 763. by operation, 763. non-surgical, 764. symptomatic, 764. treatment of colic in, 764. of occlusion in, 764. tumors in, 759, 760. vaginal examination in, 759, 760. Intestinal immobility, 127. Intestinal obstruction, treated by gastric lavage, 43. Intestinal occlusion, 751, 765. abdomen in, 780. anatomical changes in, 765. arterio-mesenteric, 126. blood in, intoxication theory of, 772. reflex theory of, 772. bowels in, 780. cardiac activity in, 782. causes of, 773. obstruction, 774. circulatory apparatus in, 772. collapse in, 780. course of, 773. development of, 766. diagnosis of, 775. diarrhea in, 772. differentiation of, from peritonitis, 776. due to internal incarceration, 779. to invagination, 779. to obstruction by foreign bodies, 779. to paralysis of intestine, 779. to volvulus, 779. electrotherapy in, 786. fecal vomiting in, 767, 775. feces of, 778. gall-stones in, 781. hernial rings in, 777, 779. impermeability of intestine in, 775. in pancreatic disease, 320. indicanuria in, 778. ingestion of food in, 785. initial pain of, 770. insidious, 778. meteorism in, 769, 771, 775, 778. local, 766. stasis, 766. pain in, 780. paralysis of intestine in, 774. pathologic anatomy of, 779. pathology of, 765. peristalsis in, 772. rectal examination in, 777, 779. seat ot, 777. spontaneous cure of, 781. strangulation in, 766, 769, 778. Intestinal occlusion, strangulation in, symptoms of, 770. treatment of, 781. non-operative, 782. symptoms of, 766, 767. tetanic intestinal stiffening in, 772. treatment of, 780. by atropin, 785. by enemata, 783. by gastric lavage, 784. by massage, 784. by operation, 782. by opium, 784. by purgatives, 783. by rectal irrigation, 783. urine in, increased constituents of, 769. vaginal examination in, 777. volvulus in, 771. vomiting in, 771, 775, 778,, 780. Intestinal rumbling, 75. Intestinal stagnation, 712. Intestinal tract, hemorrhage from, 179. Intestine, carcinoma of, 240, 259, 755. catarrh of, 631. See also Diarrhea, constriction of, 180. disorders of gastric lavage in, 43. foods which stimulate, 718. increased activity in, 635. irrigation of, 714. irritability of, 642. mucous membrane of, increased secre- tion of, 635. sarcomata of, 755. small, cancer of, 247, 254. .traumatic contusion of, 533. Intoxication, "septic," 521. Inulin, use of, in subacidity, 103. lodipin test, 140. Iron-preparations in gastric ulcer, 204. Irrigation, ice-water, 171. of stomach, 38. therapeutic, 155. Ischuria paradoxa, 33, 671. Jaques's esophagus tube, 49. Jaundice, absence of, in gall-stone colic, 192. acathectic, 332. amido-acids in urine of, 351. anhepatogenous, 329. appearance of feces in, 326. catarrhal, 328, 330, 336. causes of, 328, 329, 331, 332, 333. composition of urine in, 325. constipation in, 327. cythemolytic, 330. epidemic, 338. flatulence in, 327. Gmelin's test of serum in, 326. hematogenous, 329. hemolytic, 330, 331. hyaline casts in urine of, 326. in disease of the pancreas, 317, 320. in duodenal ulcer. 199. infectious, 331, 338. obstructive, 329. post-operative, 467. INDEX OF SUBJECTS 813 Jaundice, prognosis of, 353. simple, diagnosis of, 351. simple essential, 328. symptom-complex of, in various dis- eases, 327. symptoms of, 335, 336, 337. treatment of, 354, 355. alkaline waters in, 356. by drugs, 360. by injection of water into colon in, 3jj7. cholagogues in, 356. electricity in, 356. food in, 357, 358. lavage in, 360. massage in, 356. yellow color of blood serum in, 326. Jaundice and hepatic insufficiency, 325. Jejunostomy, 215, 257. Jejunum, carcinoma of, 247. Jennerization, 698. KJilbersterbe, 637. Kidney, examination of, while in warm bath, 287. extirpation of, 290. floating, diagnosis of, 288. treatment of, 289. lying in pelvis, 288. suture of, 290. unilateral movability of, 263. wandering, 281. See also Nephroptosis, predisposition to, 285. Kidneys, benefits to, from gastric lavage, 44. change of form in, 288. displacement of, 281 . See also Nephrop- tosis. Klemperer's oil test, 140. Knee-elbow position in gastric dilatation, 150. Kussmaul's treatment of gastric diseases, 32, 38. for gastric dilatation, 35. Kyphoscoliosis, 273. in women, 288. vertebral column, 265. Lab, coagulation of, 69. Lab ferment, 69, 88, 94, 232. tests for, 92. Lab-zymogen, 121. Labor, displacement of heart after, 299. Lacing, tight, a cause of gastroptosis, 266, 269, 270, 273, 276. a cause of nephroptosis, 284. Lactic acid, absence of, 90. in gastric contents, 68, 119, 140, 230, 232. in the stomach, 172. increase of, 98. Lactic acid fermentation, 142, 232. Laennec's cirrhosis, 371. Laminaria tents, 24, 26, 28, 29. Langerhans' islands, degeneration of, 309. Laparotomy, exploratory, 235. Laryngitis, 8. Larynx, carcinoma of, 17. catarrh of, 27. Lassitude in neurasthenia, 82. Laughter, prolonged, as cause of nephrop- tosis, 284. Lavage, control of hemorrhage by, 58. gastric, 32, 185, 504. for peristaltic unrest, 75. of esophagus, 22. with ice-water, 181. "Layer test" of hyperacidity, 106. Leeches, in gastric ulcer, 207. Leo's test for hydrochloric acid, 90. for total acidity, 120. Leroy curette, 31. Leube, diet schemes of, 44. Leub's digestion test, 140. Leukocytes, 84. in gastric contents, 67, 70, 78, 97, 113. protoplasmic ring of, 89. Leukocytosis, digestive, 233. Levulose for hyperacidity, 110. L'h6patisme, 265. Lientery, 183, 651. amylum, 652. Life, prolongation of, in carcinoma, 259.' Linossier's reagent, 90. Linossier's test, 120. Lipoma, 235. Liver, abscess of, 480. acute yellow atrophy of, 342. course of, 345. decrease in excretion of urea in, 352. diagnosis of, 351. etiology of, 342, 343, 347. increased excretion of ammonia in , 352. leucin and tyrosin in urine in, 345. pathology of, 345, 349. profuse diuresis in, 345. symptoms of, 343, 344. adenoma of, 443. carcinoma of, 443. nodulated, 447. chronic inflammation of, 361. etiology of, 363-371. pathology .of, 361-371. varieties of, 363-371. cirrhosis of, 371. ascites in, 375. biliary, 388. etiology of, 388. pathology of, 388. symptoms of, 389. treatment of, 389. collateral circulation in, 375. complications in, 379. diagnosis of, 380. differential diagnosis of, 380. duration of, 380. etiology of, 371. 372. hypertrophic, 385. diagnosis of, 387. i etiology of, 387. pathology of, 385. prognosis of, 387. symptoms of, 386. treatment of, 387. by calomel, 387. levulosuria in, 379. 814 INDEX OF SUBJECTS Liver, cirrhosis of, metabolism in, 377. pathology of, 372, 373. peritoneal tuberculosis and, 379. primary carcinoma and, 379. prognosis of, 381. pulse in, 376. respiration in, 376. symptoms and course of, 374-379. treatment of, 381-384. surgical, 384. urine in, 378, 379. displaced lobe of, 242. displacement of, 290. See also Hepatop- tosis. downward pressure upon, 270. echinococcus of, 454. alveolaris, 460. cystic, diagnosis of, 459. pathology of, 455. perforation of, into neighboring organs, 457-459. treatment of, 459-460. multilocularis, 460. diagnosis of, 462. prognosis of, 463. symptoms of, 462. treatment of, 463. symptoms of, 456-459. enlargement of, 178. connected with rectal carcinoma, 246. granular atrophy of, 371. melanosarcoma of, 441. symptomatology of, 441. metastases of, 228, 236. neoplasms of, 396, 438. clinical forms of, 438-447. diagnosis of, 450-452. hemorrhages in, 446. malignant, 440. massive cancer in, 447. treatment of, 452, 453. non-parasitic cysts of, 440. syphilis of, 389, 390. clinical course of, 391. diagnosis of, 392. symptoms of, 391. treatment of, 392. topographical changes in, 192. wandering, 290, 486. Liver dulness, disappearance of, 184. Lung, cancer of, 18. Lumbar lardosis, 127. Luschka's plates, 51. Luxury consumption, 299. Lymph-glands, cancer of, 18. enlargement of, 2, 6. peri-esophageal processes from, 13. peripheral, 198. Lymphatic follicles, rupture of, 161. Lymphomata, syphilitic, 30. Lympho-sarcoma, 239. Maltosuria in pancreatic disease, 321. Mandrin in stomach-tube, use of, 50. Massage in gastric dilatation, 153. in gastroptosis, 278. of stomach, 153. Massive stools in pancreatic disease, 317. Mastication, importance of, 100. Meals, frequent, value of, 103. infrequency of, 81. light, benefits from, 152. rational arrangement of, 110. small and frequent, 118. Meat, aversion to, 253. proper cooking of, 100. use of, in gastric disease, 151. Meat diet, over-stimulation from, 108. Meat extracts, use of, 110. Mediastinum, rupture of gastric ulcer into, 183. tumors of, 2. Megalogastria, 123, 124, 146. Melena, 173, 179, 234. as symptom of carcinomata, 223. in cholelithiasis, 499. Menorrhagia, bulimia in, 72. Menstruation, tendency to gastric hemor- rhage in, 49. Menstruation in cases of gastric ulcer, 207. Mental disease, association of, with dis- placement of the colon, 263. Merycism, 73. Mesentery, abnormal length of, 127. metastasis of, 236. Metabolism, investigations in, 204. sugar, 308. Metastasis, ovarian, 196. Meteorism, 243. local, 766. peritoneal, 536. stasis, 766. Methemoglobin, 174. Methylene orange test, 91. Mett's test, 92, 95, 120. Microorganisms in stomach, 76. Microtome, 6. Migraine, 79. due to diarrhea, 650. Milk, coagulation of, 121. free consumption of, 279. free from sugar, 101. in the diet, 78, 101. effect of, 78. in gastric disease, 151. salicylated, 101. use of, in gastric ulcer, 203. Milk fat, curative powers of, 109. Morphin in esophageal disease, 22. in gastric ulcer, 207. Morphinism, cause of intermittent fever, 482. Motility of stomach, 117. Motor insufficiency, 146. Mucosa, gastric disease of, 160. Mucous membrane, desquamation of, 186. gastric, atrophy of, 76. erosions of, 180. irritation of, 35, 179. laceration of, 42. nutrition of, 159. toxin infection of, 181 varices of, 178. vulnerability of, 97. INDEX OF SUBJECTS 815 Mucous membrane, in esophageal disease, 7, 8. purulent, 8. vulnerability of, 76. Mucus, gastric, 78. in gastric contents, 55, 66, 77. in stomach, 87. microscopic examination of, 67. Murmur, abdominal, 225. pressing-through, 9. Murmurs, deglutition, 9. Murphy's button, 212. Musculature, hypertrophic, degeneration of, 143. Myasthenia gastrica, 122. Myoparesis of stomach, 18. Nahrtoast, 110. Nails, vasomotor and trophic changes in, 4. Narcotics, paralyzing effect of, 130. Necrosis of gastric mucous membrane, 160. Nematodes in pleural cavity, 183. Neoplasm, carcinomatous, 167. benign, 249. of trachea, 5. Nephrolithiasis, 550. Nephroptosis, 281. age liable to, 282. combination of, with gastroptosis, 285. diagnosis of, 287. etiology of, 283. operative treatment of, 290. slow recovery from, 287. statistics of, 282. symptoms of, 284. Nephrorrhaphy, dangers of, 290. results of, 290. Nerves, esophageal, sensitiveness of, 3. recurrent laryngeal, 5. paralysis of, 4. Nervous disturbances from under-nutri- tion, 299. Nervous hepatic colic, 473. Nervous system, central, diseases of, 130. derangement of, from gastric disease, 141. hyperirritation of, 72. Neuralgia, intercostal, 170. Neurasthenia, a cause of gastric disease, 79. accompanied by esophagismus, 14. predisposing to gastric neuroses, 70. Neurasthenia dyspeptica, 80. Neurasthenia, gastrica, 80. Neuroses, cardiac, 299. gastric, 70. predisposing causes of, 70. treatment of, 74. motor, of stomach. 72. of secretion, 76, 509. sensory, of the stomach, 71. Niche, paravertebral, for kidney, 283. Nicotin as cause of gastrosis, 80. Nitrogen absorption insufficiency of, in pancreatic disease, 316. Nodules, miliary, in stomach, 166. Nourishment by rectum, 62, 152. Nourishment in carcinoma, 252, 253. Nurslings, fat-splitting in, 313. feces of, 605, 631. nephroptosis in, 281. pyloric stenosis in, 131. Nutrition, artificial, 20. artificial or extra-buccal, 254. disturbance of, from gastroptosis, 276. faulty, 127. general, damaged by diarrhea, 98. in esophageal disease, 20, 29, 30. Obesity cure as cause of displacement of heart, 299. Obstruction, intestinal, 242. Occlusion, arterio-mesenteric intestinal. 145. of hepatic circulation, 178. of intestine, 492. Odor, fetid, from decomposition of food, 4. treatment of, 27. of gastric contents, 66. Oil, ingestion of, as cause of hemorrhage, 176. in the diet, 110. Oligocholia, 340. Olive oil for gastric ulcer, 207, 208. in gastric dilatation, 154. in gastric disease, 186. Operation in gastric ulcer, mortality in, 214. Operations on stomach, results of, 213. Opium in treatment of carcinoma, 255. Oral cavity, bacteria in, 99. cleansing of, 99. infection from, 224. Orexin for gastric dilatation, 156. Ovaries, neoplasm of, 196. Oxyacids, 352. Oxybutyric acid, 9, 239. Oxymandelic acid, 352. Pain, distribution of, in esophageal dis- ease, 4. epigastric, 5. following ingestion of food, 169. gastric, 77, 134, 163, 183. gastric and intestinal, 255. in gastric ulcer, 169. pyloric, 193. typical, in gastric ulcer, 197. Palpation, facilitating of, by structure of body, 283. of esophagus, 6. Palpitation, cardiac, 82. Pancreas, absence of function of, 306. anatomy and physiology of, 304. atrophy of, 312. chemistry of, 315. destruction of, 305. digestive function of, 305. disease of, 301. combined with diabetes, 306. symptoms of, 304, 625. 816 INDEX OF SUBJECTS Pancreas, diseases of, histoiy of, 303. obscure knowledge of, 303. surgery in, 304. extirpation of, 306, 310. head of, carcinoma of, 312. induration of, 312. innervation of, 304. internal secretion of, 305, 307. nerve apparatus of, 305. of dogs, excision of, 313. experiments in, 308. relation of, to fat-splitting, 313. secretion of, 305. total destruction of, without diabetes, 309. transplantation of portions of, 307. two ducts of, 304. tying of ducts of, 307. Pancreatic apoplexy, 321. Pancreatic artery, corrosion of, 177. Pancreatic colic, 317, 318. Pancreatic duct, occlusion of, 305. Pancreatic juice, increased secretion of, 128. regurgitation of, 213. Pancreatic necrosis, 321. Pancreatic pain, 318, 319. Pancreatitis, gall-stones a cause of, 505. hemorrhagic, 321. interacinous, 308. interlobular, 308. Pankreon, 255. for subacidity, 102. Panniculus adiposus, 485. retention of. in pernicious anemia, 97. Papilloma, 235. rectal, 249. Paquelin cautery, 25. Paracholia, nervous, 469. Parasecretion, 104, 113, 173. Parenchyma, secreting, 116. Paresis of gastric musculature, 34. Parorexia, 71. Pastry, hot, effect of, 108. Pathology, gastric, symptom-complexes of, 87. Pedatrophia, 673. Pedicles, torsion of, 192. Pentosuria in pancreatic disease, 321. Penzoldt-Dehio method, of evacuating stomach, 138. Pepsin, 94. absence of, 98. for subacidity, 102. in gastric contents, 232. estimation of, 120. Mett's test for, 92. secretion of, 88. tests for, 69, 92. Peptic ulcer, 159. Peptones in acute yellow atrophy, 352. Poracidity, 104. Perforation, gastric, operation after, 214. of stomach from self-induced vomiting, 184. Periappendicitis, 533. purulent, circumscribed, symptoms of, 553. Pericarditis, 18. Pericholecystitis, 549. Peri-esophageal processes, 13. Perigastritis, 98, 130, 165, 182, 235. Perihepatitis in gall-stones, 486. Peristalsis, active, 143. disturbance of, 21. due to gases, 636. gastric, 156. increased, 60, 636. Peristaltic unrest, 75. Peristaltism, 225. Peritoneal collapse, 515. Peritoneal irritation, 534. Peritoneal sepsis, 523. Peritoneum, constriction of, 762. inflammation of, bacteriological findings is, 529, 530. pyogenic organisms in, 529. Peritonism, 539. Peritonitis, acute diffuse, 513. abscess formation in, 518. adhesions in, at point of rupture, 519. formation of, 532. rupture of, 532, 533. air in peritoneal sac in, 536. albuminuria in, 518. bacterial infection in, 520. bowels in, condition of, 517. chemical form of, 519. clinical history of a case of, 513-516 coli bacilli in, presence of, 516. collapse in, 535. treatment of, 563. colon in, evacuation of, 563. diagnosis of, 538. diet in, 561. differentiation of, from gall-stone colic, 538. from intestinal obstruction, 538. exploratory laparotomy in, 560. exudation in, 518. gas in abdominal cavity in, 537. indicanuru in, 518. internal treatment of, 560, 561. indications for, 561. laparotomy in, 521. local symptoms of, 536. meteorism a symptom of, 536. omentum in, 525. operative measures in, 559. opium in, effect of, 519. opium in treatment of, 562. pain in, 517. pain upon pressure in, 537. pathology of, 534. perforation into abdominal cavity in, 522. peritoneal meteorism in, 537. peritoneum in, changes in, 531. prophylaxis of, 558. pus foci in uterus in, 523. recovery after operation in, 560. rupture of pus into intestine in, 519. septic intoxication in, 536. stomach in, rupture of, 521. streptococci in, presence of, 516. INDEX OF SUBJECTS 817 Peritonitis, acute diffuse, surgical treat- ment advisable in, 560. symptoms of, 535. in course, 518, 519. in onset, 517. temperature in, 517. treatment of, 536. unfavorable for operation. 560. urinary complications in, 537. vomiting in, 517, 537. appendix, position of, in relation to, 540. attenuated general, 525. bacterial and chemical, discrimination of, in prophylaxis, 559. chemical, 531, 533, 534. from circumscribed periappendicular abscess, 533. plastic exudates of, 534. plastic form of, 533. circumscribed, 540. clinical picture of, 540. origin of, 557. gastric ulcer, 557. infection of biliary passages, 557. perforating typhoid ulcer, 557. pathology of, 540. purulent, points of preference for, 558. confounded with uremia, 538. diaphragmatic respiration in, 537. diffuse, 181. circumscribed and, 513. due to puerperal suppurative proc- esses, 557. etiology of, 528, 529, 530. general, from perforating, gangrenous appendix, 181. in acute articular rheumatism, 529. malarial, 529. origin of, 537. from neighboring organs in perito- neum, 557. from the vessels, 528. pelvic, 761. perforative, 167, 183. spontaneous cure of, 184. symptoms of, 553. periappendicular abscesses in, 558. progressing rapidly after consolidation of a local perityphlitis, 525. palpation valuable in, 525. progressive purulent, 524, 525, 533, 554. plastic inflammation in, 525. puerperal 523. bacteriological findings in, 531. diarrhea in, 523. early collapse in, 523. purulent, bacteriological findings in, 530. sero-fibrinous, 533. severity of, 534. simulated by fecal accumulation, 538. simulating cardialgia, 538. typhoid, 529. Perityphlitis, 513. abscesses in duration of, 555. acute, fecal calculus in, 576. inflammatory process in, 575. Perityphlitis, adhesions in, causing pain, 556. indications of, 554. chronic, 573. anatomical and histological changes in, 575. anatomical changes in, 577. bath cures in, 600. catarrh of the colon in, treatment of. 600. clinical picture of, 578. colitis a cause of, 575. complications of, 588. confounded with cholecystitis, 595. with cholelithiasis, 595. constipation a cause of, 575. diagnosis of, 589. diet in, 599. dislocation of kidney resembling symptoms of, 595. empyema of vermiform process in, 578. etiology of, 574. extirpation of appendix in, 597. exudation in, 598. Gerlach valve in, 577. habitual constipation in, treatment of, 600. indigestion a factor in, 599. internal medicine in, 573. intestinal catarrh a cause of, 575. laparotomy in, 573, 575. mineral spring cures in, 600. new attacks in, prevention of, 598. obstruction of vermiform process in, 578. occurrence of, with other organic dis- eases, 595. operation at puberty in, 602. causes of failure of, 603. dangers of, 602. results of, 602. origin of, 574. prognosis of, 595. prognosis of subsequent attacks of 598. relapse after operation in, 603. remissions in, 597. simulated by hernia, 595. therapeutic considerations in, 597. traumatic influences in, 575. treatment of, 597. uterine adnexa, disease of, a cause of, 575. with chronic catarrh of colon, 588. with diseases of right-sided adnexa, 588. chronic relapsing, 574, 581. atypical cases of, 584. diagnostic factors in, 591. differentiation of, from colitis, 593. from disease of uterine adnexa 593, 594. from renal calculus, 594. McBurney's point, 591. importance of, in diagnosis of, 583, pain in region of, 583. 818 INDEX OF SUBJECTS Perityphlitis, chronic relapsing, palpation of vermiform process in, 591. prognosis of, 596. removal of appendix in, 601. symptoms of, 582. temperature in, 583. treatment of, 599. typical cases of, 582. varieties of, 581. circumscribed, 540. acute, localization of, 541. differential diagnosis of, 549. fever in, 547. pain a symptom of, 546. symptoms of, 545. tumor of, 548. urine in, 549. vomiting in, 548. confounded with tuberculosis and ac- tinomycosis of cecum and appen- dix, 549. course of, 554. dangers of non-operation in, 567. of operation in, 567. diagnosis of form of, 550. diet in treatment of, 572. differentiation between true and pseu- do-, 594. of from acute intestinal occlusion, 549. from fecal tumor, 549. from other conditions, 549. due to chronic appendicitis, 556. to fecal calculus, 556. empyema of appendix in, symptoms of, 553. fecal calculi in, 564. fecal discharges of, 572. latent, 581. transitions from, 582. malignant affections in, 554. masked, 585. massage in, treatment by, 573. moderate circumscribed, 526. obliteration of appendix following, 527. non-operative treatment of, 569. operation in, absolute indications for, 566. after attack, 569. during attack, 568. operative considerations in, 565. opium in, misuse of, 571. use of, 570, 571. prognosis of, 566. prophylaxis of, 534. purgation in treatment of, 573. pus in, significance of, 551. symptoms of, 553. relapses in, 554, 572. due to pus, 556. resembling neoplasms of cecum or colon, 549. residual, 574, 578. diagnostic factors in, 589. differentiation of, from carcinoma of cecum, 590. from cecal tuberculosis, 590. Perityphlitis, residual, forms of develop- ment of, 578. McBurney's point in, 590. operative treatment of, 599. prognosis of, 596. recovery after repeated rupture in, 579. temperature a diagnostic factor in, 591. vomito nigro in, 579. rupture of abscess of, 545. suppurative, 541. surgical indications in slowly progres- sive cases of, 569. treatment of, 565. tumor in, palpation of, 583. Perityphlitis laryata, 585, 588. Pernicious anemia, 97. Pettenkofer's test, 326. Petruschky's test, 193. Pharynx, catarrh of, 27. Phenol, 636, 640. Phenolphthalein, 90, 91, 98, 120. Phenyl acid, irrigations with, 38. Phosphates, acid, in gastric contents, 91. influence of, 95. Phosphaturia, 115. Phosphorus poisoning, 346. Phthisis, incipient, gastric lavage in, 48. pulmonary, 166. Physical therapy, 111. Physostigmin, 786. Pleiochromia, 331. Pleura, cancer of, 18. Pneumopericarditis, 183. Poisoning, acute, gastric lavage in, 47. by atropin, 111. corrosive, 59. Polycholia, 331. Polypi, pediculated, 131. rectal, 249. Portal vein, corrosion of, 177. stasis of, 223. Posture, importance of, in dilatation, 153. Potatoes for removal of foreign body, 31. Poultice to abdomen, 287. Pregnancies, repeated, a cause of hepatop- tosis, 290. as cause of nephroptosis, 284. Pregnancy, extrauterine, 196. parorexia in, 71. relation of, to chlorosis, 274. Prelum abdominale, 48. Press, abdominal, 271, 274. Pressure, sensation of, in stomach, 222. Pressure in gastric region, 77. Pressure of fluid in gastric lavage, 54. Pressure point, epigastric, 171. in gastric ulcer, 170. Probes, metallic spiral, 28. Processes of fermentation and decomposi- tion in intestine, 640. Proctitis, 659. Proctitis hspmorrhoidalis, 715. Proliferations, cauliflower-like, into esoph- agus, 7, 8. Proteid decomposition in colon, 638. INDEX OTF SUBJECTS 819 Proteid producing peristalsis, 636. Proteolysis, 37, 89. Proteorrhea, 652. Pruritus, 79. Pseudo-ileus, 251. Pseudo-peritonitis, 539. clinical picture of, 539. diagnosis of point of origin of, 539. hernial rings in, examination of, 539. rectal examination in, 539. rectal temperature of importance in, 539. vaginal examination in, 539. Pseudo-perityphlitis, 593. Psychical irritation, 76. Psychical stimulation during gastric lav- age, 48. Ptomains, 643. Ptyalin, 652. Pulmonary phthisis, 197. Pulsation, epigastric, 171, 275. Pulse of aortic insufficiency, 133. Pupils, inequality of, 4. Purgatives, 223, 241. in intestinal carcinomata, 255. Purin substances in acute yellow atrophy, 352. Purulent processes with hemorrhage, 180. Pus as indication of gastric carcinoma, 96. Pus in esophagus, 11. in gastric contents, 231, 233. in stomach, 87. Pyelitis, 286. slow recovery from, 287. treatment of, 287. Pyemia, cryptogenetic, 235. Pylephlebitis, 183, 480. Pylethrombosis, 480. Pylorectomy, 195. Pyloric stenoses, benign, 142. congenital, 131. organic, 145, 146. without hemorrhage, 180. Pyloric ulcer, 190. Pyloroplasty, 157, 195. Pylorospasm, 107, 169, 194, 195, 215. Pylorus, benign and malignant tumors of, 147. benign constriction of, 35. cancer of, 35. carcinoma of, 95, 197, 227, 256. carcinomatous tumor of, 197. cicatricial and hypertrophic stenosis of, 224. cicatricial narrowing of, 45. cicatricial thickening of, 194. cicatrix of, 35, 143. closure of, from mechanical causes, 35. constriction of, 33, 34. contraction of, 131. digital divulsion of, 157. flaccidity of, 73, 142. hypertrophy of, 33, 35, 131, 132, 196. insufficiency of, 74, 185. necrosis of, 130. obstruction of, 226. open, 213. Pylorus, organic stenosis of, 128. resection of, 142, 258. spasm of, 60, 70, 112, 117, 118, 144. from nervous influence, 162. spastic processes of, 129. stenosis of, 43, 45, 126, 127, 130, 137, 142, 211. malignant, 157. surgical treatment of, 157. stricture of, surgical dilatation of, 45. temporary closure of, 128. tuberculous stenosis of, 131. tumor of, 136, 144, 226. ulcer of, 99, 107, 130, 164, 170, 172, 173. traumatic, 163. Pyopneumothorax subphrenicus, 183. Pyosalpinx, rupture of, 191. Pyrosis, 77, 78, 81, 134. Pyrosis hydrochlorica, 208. Quassia amara as gastric spray, 59. Rademann's nutritive toast, 110. Rectal alimentation, 118. in gastric ulcer, 201. Rectal carcinoma, mortality in, 261 occurring in pregnancy, 247. operative results in, 261. Rectal nutrition, 116. Rectum, carcinoma of, 245, 260. catarrh of, 715. curetting of, 261. diastasis of, 243. digital or ocular exploration of, 246. stenosis of, 760. tuberculosis of, 702. tumors of, 249. Refraction difference, 93. Reichmann's disease, 113. Renal colic combined with gastric ulcer, 192. Renal disease, gastric lavage in, 47. Renal vein, erosion of, 177. Resorts for mineral spring treatment, 215, 216. Respiratory interchange of gases, 48. Rest in cure of nephroptosis, 289. in treatment of esophagus, 26. Rest cure, in gastric ulcer, 199, 201, 205. Retching, 33, 57. cause of hemorrhage, 66. during gastric lavage, 54. in esophageal disease, 14. Rheumatism, acute articular, peritonitis in, 529. Rhubarb, action of, 206. for gastric ulcer, 209. Rigidity, gastric, 225. intestinal, 242, 243. Rokitansky, hemorrhagic erosions of, 160. Rumbling, abdominal, 285, 292. intestinal, 241. Rumination, 73. Sacrum, resection of, 261. Sahli's glutoid test, 316. Sahli's test of gastric function, 93. 820 INDEX OF SUBJECTS Salivation in pancreatic disease. 320. Salol test of gastric contents, 140. Sarcinse in gastric contents, 140, 223.. in stomach, 38. in vomit, 182. Sarcoma, operations for, 259. Satiety as a symptom, 146. Saxony, gastroptosis in, 266. Schmidt's tests for all nuclei, 625. Schreiber's rubber balloon, 30. Schreiber's sound, 28. Schul/e's experiments on the pancreas, 308. Scirrhus, 238. Scotch douche, 280. Scotoma, flittering, 79. Sea baths, advantage of, in gastroptosis, 280. Secretion, diluting, 95. neuroses of, 76. of hydrochloric acid, 93. Secretory apparatus of stomach, irrita- bility of, 110. Secretory disturbances, diagnosis and therapy of, 87. Secretory insufficiency, extreme, 121. Senator method of dilating esophagus, 29. Sepsis, peritoneal, 523, 535. Sexual excess as cause of atony, 127. Shield to support abdomen, 292. Shock as cause of 'wandering spleen, 293. Shock, "reflex" or "nervous," 521. Shoulder, right, pain in, 170. Shredded wheat biscuit, value of, 66. Sigmoiditis, 249. Silver nitrate for gastric ulcer, 60, 206. in hypersecretion, 118. Simon's test for dissolved albumin, 626. Singultus in cholelithiasis, 494. Sippy dilator, 25. Sitz baths, 280. Skeatol, 636. Skin, dryness of, 114. Skirts, suspension of, from shoulders, 276. Skolikoiditis, 541. Sleep on left side, impossibility of, 298. Soaps, amount of, in pancreatic disease, 314. Sodium chlorid for subacidity, 101. Sodium hyposulphite, irrigations with, 38. Solar plexus, sensitiveness of, 171. Sound, esophageal, 6, 27. introduction of, 30. passage of, 3, 4. resistance to, 19. use of, 22, 23. varieties of, 12. gastric, dangers in use of, 42. rubber ball, 26. splashing, 146. in stomach, 133, 137, 270, 275. succussion, 122, 147. Sounds, director, 28. esophageal, English and French, 28. for stomach, double, 40. soft-rubber, 39. Soups in the dietary, 110 Spasm, esophageal, 14. causes of, 14. diagnosis of, 15. therapy of, 31. gastric, 192. of stomach, 43. pyloric, 193. pyloric circumscribed, 195. rectal, 186. Spasm as a neurosis, 14. Spasms, esophageal, 3. reflex, 14. from poisoning, 14. of the extremities, 177. tonic muscular, 141. Sphincter, new, formation of, 213. Sphincter muscle, contraction of, 144. Spine, pain in, from gastric ulcer, 170. Splanchnoptosis, 264, 294. Spleen, displacement of, 265, 292; see also Gastroptosis. drug treatment of, 293. enlargement of, 178. in cholelithiasis, 496. extirpation of, 294. fixation of, 293. hemolysis of, in jaundice, 330. rupture of, 191. wandering, 292. diagnosis of, 293. symptoms of, 293. treatment of, 293. Splenopexy, 293. Sputum, deglutition of, 167. swallowing of, as cause of tuberculosis, 187. Stagnation of gastric contents, 256. Starch, saccharification of, 78. Starches in food, 78. in the diet, 110. Starvation cure, 82. Stasis, gastric, 128. of portal vein system, 66. Stasis icterus, 330. Steapsin, 88, 305. tests for, 93. Steatorrhea, 652. true, 312, 315. Stenosis, cardiac, 126. chronic intestinal, 242. compression, of esophagus, 30. differentiation of various forms of, 19. infrapapillary duodenal, 140. intestinal, feces of, 752. malignant, of pylorus, 45. obstruction, 31. occlusion, of esophagus, 16. of esophagus, 1, 6. acute appearance of, 17. congenital, 16. from caustics, 11. from compression, 2. symptoms of, 2, 14. treatment of, 19. pyloric, 107, 116, 136. spastic, 1. syphilitic, 249. INDEX OF SUBJECTS 821 Stenosis, value of history in, 12. varieties of, 2. Stomach, abnormal acidity of, 129. abnormal fermentation in, 155. abnormal formation of, 55. abscess of, 233. absence of secretion in, 87. absorbent function of, 64. absorption of, 151. acidity of, 34, 83, 88, 123. activity of, 44. test of, 145. acute atony of, 127. adhesion of, to neighboring organs, 165. anatomical changes in, 87. anomalous activity of, 79. atony of, 45, 73, 124, 169. autodistention of, 137. boundaries of, 136. cancer of, 163. carcinoma of, 191. carcinomatous neoplasm of, 194. carcinomatous ulcer of, 196. catarrh of, 34, 57, 70. chemism of, 185, 194, 197, 213. chemistry of, 172. conservation of motility of, 103. constrictions in, 165. continuous secretion of fluid in, 35. corrosion of, 59. decrease in motor power of, 123. descent of pyloric portion of, 35. diagnostic evacuation of, 138. digestive stimulation of, 129. dilatation of, 32, 33, 55, 73, 122, 129. cure of, 45. dilated, adherent to liver, 185. diseases of, laboratory investigation of, 36. nutrition in, 61. displacement of, 263, 265. distention of, as cause of gastroptosis, 267. by gas, 169. with water, 228. distortion of, 182. douching of, 40, 154. drawing sensation in, 83. electric illumination of, 136. electricity to, 101. enlargement of, 268. erosion of, 98. evacuation of, 129, 138. extirpation of, 257. fermentative decomposition in, 59. fetal, position of, 35. flaccidity of, 55, 162. flaccidity of muscularis of, 126. functional diagnosis of, 87. functional diseases of, 63. functional disturbances of, 32, 88. functions of, 63. habitual overloading of, 117. hemorrhage from, 49, 64, 165, 175. treatment of, 60. hour-glass, 56, 165, 185, 211. hypermotility of, 643. 53 Stomach, illumination of, 228, 277. implication of, in nephroptosis, 285. increased size of, 122, 139. inflation of, 270, 276. with air, 227. with air or carbonic acid, 137. insufficiency of, 64, 65, 270. irrigation of, 38. with drugs, 59. irritable, 57. massage of, 153. mechanical insufficiency of, 61, 122. microbes and ferments in, 55. motility of, 72. diagnostic determination of, 44. motor activity of, 123, 128. motor function of, 84. motor insufficiency of, 45, 76, 116, 122, 124, 125, 138, 154. motor irritative phenomena in, 60. motor power of, 125. necrosis in, 162. nervous apparatus of, 63. neuroses of, 70, 206. normal motility of, 64. normal position of, 267. organic acids in, 61. organic disease of, 82, 83. over-distention of, 45. during gastric lavage, 54. overfilling of, with fluid, 42. over-loading of, 34. palpation of, 81, 83, 136. paralysis of muscular wall of, 126. peptic labor of, 90. percussion of, 137. perforation of, 165, 182. peristalsis of, 126, 130, 137. permanent secretion of, 103. perverted secretion of, 89. position of, 147. production of gas in, 61. progressive corrosive necrosis of, 165. prolapse of, 273. prolapsed, dilatation of, 272. rapid emptying of, 71, 106. relative dilatation of, 125. retention of ingesta in, 84. rigidity of, 131. sarcoma of, 235. secretory activity of, 76. secretory and fermentative processes in, 47. secretory disturbances of, 53, 87. secretory function of, 64. size of, 133, 137. sour, 81. spasmodic contractions of, 184. structure substances in, 89. subacidity of, 92. syphilis of, 187. test of function of, 46, 83. tissue necrosis in, 163. transudation of fluids into, 36. trial lavage of, 47. tuberculous ulcers of, 187. tumors of, 191. 822 INDEX OF SUBJECTS Stomach, tympany of, 75, 138. ulcer of, 107, 117, 533. vertical position of, 266, 269. washing of, 34. Stomach-pump, 34. origin of, 33. use of, 36, 37. various forms of, 37. Stomach-sound, rules for introduction of, 42. Stomach-tube, clogging of, 52. dangers of use of, 42. defective varieties of, 49. different forms of, 41. injury to mucous membrane by, 52. introduction of, 115, 124, 193. in gastric ulcer, 171. into medical practice, 119. method of using, 50. modern form of, 41. preparation of, for use, 51. use of, by patient, 61. with ring on which to bite, 54. Stomach-tubes, soft, 41, 49. Stomachs of dogs, experiments in, 108, 161, 162. Stools, fatty, 312. Strangury, 286. Strauss' currant test, 140. Stricture, annular, of esophagus, 12. corrosive, of esophagus, 13. from caustics, 8. internal cicatricial, 756. of esophagus, treatment of, 27- ring form of, 12. syphilitic, 249. tuberculous cicatricial, 756, 762. Strychnin, for dilatation of stomach, 156. Stylet in stomach-tube, 40. Stylets, introduction of, 29. Subacidity, 94. as symptom in various diseases, 96. diagnosis of, 96. diet in, 100. drug treatment of, 102. extreme, 121. relative, 94. specific gravity of, 105. symptoms of, 95. treatment of, 99. Substances, bactericidal, 639. Substitution therapy, 102. Subsultus tendinum, 177. Sugar, by rectum, 153. decreased consumption of, 308. formation of, 308. in liver, 308. in the diet, 111, 117. transformation of, 305. use of, in hyperacidity, 110. Superacidity, 104. Supersecretion, 104. Supraclavicular region, palpation of, 228. Surgery, advance in, 221. gastric, 45. in esophageal disease. 26. in gastric diseases, 157. Suture anastomosis in pyloric stenosis, 212. Swallowing in esophageal disease, 18. Sweating, accompanying bulimia, 71. influence of, upon gastric juice, 111. Syncytiolysins, 348. Syphilis of stomach, 187. Syringe, esophageal, 22. Tabes dorsalis, 197. gastralgia in, 72. Tabes mesenterica, 673. Takadiastase, 78, 112. Taste, sense of, perversion of, 81. Teeth, correction of defects irf, 99. false, arrested in esophagus, 16. Tenesmus, rectal and yesical, 245. Tenesmus in hemorrhoids, 712. Tension, gastric, after meals, 133. Test, corrosive sublimate, of the feces, 626. fermentation, of feces, 618, 620. Gmelin's in the feces, 628. of gastric function, 88. Teichmann's hemin, 633. Weber-van Deen, 633. Test breakfast, 83, 89, 99, 138, 140. Ewald-Boas, 606. in hypersecretion, 115. Test-diet, in examination of feces, 607. Test-meal, 61, 138. best time for, 65. of Ewald-Boas, 64, 66. of Leube-Riegel, 64, 65, 606. Tetanus, esophagismus in, 14. Tetany, 170, 239. as sequel of dilatation, 142. cause of, 156. from gastric disease, 33, 36, 141, 142. Thirst, accompanying gastric disease, 134. artificial relief of, 26. in esophageal diseases, 5. in gastric neuroses, 77. in hypersecretion, 114. Thorax, examination of, 18. Thrombosis of splenic vein, 178. venous, 239. Thrombi, displaced, 180. Thrombus formation in stomach, 165. of gastric ulcer, 177. Thrush, 31. Tincture of iodin test for bile in urine, 326. Tinnitus aurium, 177. accompanying bulimia, 71. Tissue, dryness of, 87, 118, 141. esophageal, examination of, 6. microscopic examination of, 9. shreds of, 11. Tobacco, effect of, on stomach, 130. Toes, drumstick changes in, 142. Tongue, coated, significance of, 84, 171. in gastric disease, 134. in gastric ulcer, 198. in visceral carcinomata, 224. leukoplakia of, 7. Tormina ventriculi, 75. Tormina ventriculi nervosa, 243. Torsion of abdominal organs, 211. INDEX OF SUBJECTS 823 Tonus, gastric, increased, 155. Toxins, bacterial, 643. Trachitis, 8. Transudation of fluids into stomach, 36. Trauma, a cause of gastric ulcer, 162. as cause of spasm, 14. of stomach, 130. Triferrin in gastric ulcer, 204. Trypsin, 305. Tubercle bacilli in the feces, 248. in stomach 166. Tubercular ulcer of stomach, 166. Tuberculin, 193. Tuberculoma of intestinal walls, 755. of intestine, 762. Tuberculosis, cecal, 590. gastric, in children, 166. intestinal, 635, 687. chronic intestinal catarrh in, 691. constriction of intestine in, 690. diagnosis of, 697. diagnosis injestion of tuberculin in, 697. diarrhea in, 692. ethyl sulphuric acid in urine in, 698. etiology of, 687. general clinical picture in, 695. hemorrhage in, 693. offensive odor of feces in, 697. pathology of, 689. prophylaxis in, 698. rigidity in. 695. symptoms of, 691. symptoms in ulcerative, 691. treatment of, 698. adrenalin in, 701. bismuth in, 701. food in, 703. opium in, 701. surgical, 702. symptomatic, 700. tuberculin in, 699. miliary, 696. of stomach, 187. pharyngeal, 166. pulmonary, 276. Tumor in greater curvature of stomach, 173. in disease of the pancreas, 317, 319. of esophagus, 6. of gall-bladder, 487. of greater curvature, 196. of intestines, 241. pyloric, 194, 226. Tumors, benign, 131. benign intestinal, 756. from hair, 196. from trichobezoar, 196. spastic, 196. Tnssis hepatica, 483. Typhlon, inflammatory processes from, 248. Typhlophobia, 594. Typhoid, bilious, 347. Ulcer, carcinomatous, 196. corrosive, 166. Ulcer, diphtheritic, 13. gastric, 528. cicatrices of, 131. bismuth treatment of, 43. hyperacidity in, 76. florid, 201. intestinal, 528. perforation of, 191. of cardia, 75. diagnosis of, 75. of stomach, 159. See also Gastric Ulcer. peptic, 13, 162. pyloric, 33, 35. round, 159. syphilitic, 13, 187. in stomach, 167. tuberculous, 13, 193. in stomach, 166. as cause of cancer, 10. of esophagus, 5, 7, 8. Uremia, gastric lavage in, 47. Ureter, hemorrhage from, 58. Ureters, measurements of, 288. torsion and kinking of, 286. torsion of, in movable kidney, 192. Urinary tract, sepsis in, 181. Urine, alkalinity of, 141. diminution of, 141. in gastric disease, 36. in pyelitis, 286. suppression of, 142. Urobilin, increase of, in jaundice, 331. Urobilin icterus, 341. Urobilinuria, 340. Uterus, septic infections of, 528. Vagotomia subdiaphragmatica in rabbits, 162. Valve formation in esophagus, 13. Varices, esophageal, 58. hemorrhages from, 42. Vegetables in the diet, 110. Vein, golden, of hemorrhoids, 246, 712. Veins, hemorrhoidal, 246. varicose, in esophagus, 178. Venous stasis, 179. Vertebral column, carcinoma of, 17. kyphoscoliosis of, 265, 273. lordosis of, 277. scoliosis of, 283. tumor of, 2. Vertigo, 82. in ectasis, 135. in gastric dilatation, 142. Vessels, erosion of, 5. of stomach, 165. Vicious circle, formation of, 127. Vitellius, mode of, for emptying stomach, 38. Vocal cords, destruction of, 5. unilateral paralysis of, 4. Voice production, 4. Volvulus, 762, 771. of intestines, 211. Vomit, coffee-ground, 147. 824 INDEX OF SUBJECTS Vomiting, acid, 77. as symptom of visceral carcinomata, 222, 223. bilious, 127. expulsive, 57. fecal, 767, 775. in dilatation with hypersecretion, 134. in gall-stone disease, 490. in gastric dilatation, 122. in gastric disease, 134. in gastric ulcer, 181. in pancreatic disease, 320. nervous, 74. of blood-stained mucus, 5. of gastric ulcer, 209. periodical, 74. spontaneous, 182. Vomito negro in residual perityphlitis, 579. Vomitus, containing three layers, 134. in hypersecretion, 114. Vomitus maturitus, 182. Waist, change in circumference of, 271, 272. compression of, a cause of gastroptosis, 266, 270, 273, 276. Water, deficiency of, in organism, 170. insufficient absorption of, 141. Weight, increase of, after gastric lavage, 35. of body, 84. Weil's disease, 338, 339. symptoms of, 339. Weiss' stomach-pump, 37. Wines tolerated in hyperacidity, 111. Woulff 's bottle, employment of, for lavage, 39. X-rays, examination of heart by, 296. Xeroform, 208. Yeast fermentation, 140. (3) THE END Date Due PRINTED IN U.S.A. CAT. NO. 24 161 A 000 51 1 633 o ' EEEEEEEEEI CO 08 WI 100 B598d 1910 Billings, Frank. Diseases of the digestive system, COLLEGE AND SURG WI 100 B598d 1910 Billings, Frank. Diseases of the digestive system. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664