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 THE 
 
 1} 
 
 DISEASES OF THE STOMACH^ 
 
 BY 
 
 t 
 
 . WILLIAM W. VAN VALZAH, A.M., M.D. 
 
 PROFESSOR OF GENERAL MEDICINE AND DISEASES OF THE DIGESTIVE SYSTEM IN THE 
 NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL, 
 
 J. DOUGLAS NISBET, A.B., M.D. 
 
 ADJUNCT PROFESSOR OF GENERAL MEDICINE AND DISEASES OF THE DIGESTIVE SYSTEM 
 IN THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL. 
 
 1Illustrate& 
 
 PHILADELPHIA 
 W. B. SAUNDERS 
 
 925 WALNUT STREET
 
 
 Coi'YRioiiT, 1898, BY W. B. Saundkrs.
 
 CONTENTS. 
 
 SECTION I. PAGE 
 
 Introduction and Classiptcation, 17 
 
 SECTION II. 
 
 Diagnosis and Diagnostic Methods, 21 
 
 Chapter I. Clinical History, 25 
 
 Chapter II. The Physical Signs, 48 
 
 Chapter III. The Functional Signs, 81 
 
 1. Secretion, 82 
 
 (l) The Hydrochloric Acid, 98 
 
 (2| The Ferments, 119 
 
 (3) Mucus, or the General Secretion, 128 
 
 2. The Motor Function, 130 
 
 3. Absorption, 140 
 
 4. Digestive Work, 141 
 
 Chapter IV. The Bacteriological Signs, 142 
 
 Chapter V. The Anatomical Signs, 158 
 
 SECTION III. 
 
 General Medication, 161 
 
 Chapter I. Digestive Hygiene, 162 
 
 Chapter II. Diet, 165 
 
 I. Selection of a Diet in Diseases of the Stomach, . . 167 
 II. Signs of Correctness of the Prescribed Diet, .... 223 
 
 Chapter HI. Physical Remedies, 227 
 
 Chapter IV. Symptomatic Treatment, 251 
 
 Chapter V. Physiological Treatment, 253 
 
 Chapter VI. Bacteriological Treatment, 258 
 
 Chapter VII. Chemical Treatment, 259 
 
 SECTION IV. 
 
 The Dynamic Affections of the Stomach, 262 
 
 Chapter I. The Sensory Dynamic Affections, 266 
 
 I. Bulimia, 266 
 
 II. Acoria, 269 
 
 HI. Parorexia, 270 
 
 IV. Anore.xia Nervosa, 271 
 
 V. Gastralgia Nervosa, 275 
 
 VI. Hyperesthesia Gastrica, 281 
 
 5
 
 6 CONTENTS. 
 
 PAGIi 
 
 Chai'TKR II. The Dynamic Affections of Secretion, 285 
 
 1. Adenohyperstlienia Gastrica, 286 
 
 (a) Ilyperclilorhydria, 287 
 
 (b) Di<;;estive Ilypercliylia Clastrica, 295 
 
 (c) Paroxysmal Ilypercliylia (jastrica, 299 
 
 2. Adenasthenia Gastrica, 301 
 
 Chapter III. The Motor Dynamic Affections, 304 
 
 I. Spasm of the Cardia, 304 
 
 II. Spasm of the I'ylorus, 31 1 
 
 III. Gastrospasm, 314 
 
 IV. Tormina V'entriculi Nervosa, 315 
 
 V. Kructatio Nervosa, 316 
 
 VI. Habitual Regurgitation, 321 
 
 VII. Rumination, or Merycism, 322 
 
 VIII. Nervous Vomiting, 325 
 
 I. Symptomatic Vomiting, 326 
 
 2 Nervous Vomiting 327 
 
 IX. Incontinence of the I'ylorus, ^ii 
 
 X. Gastroplegia, 335 
 
 Chatter IV. Neurasthenia Gastrica, 336 
 
 Chapter V. Myasthenia Gastrica, 347 
 
 1. Myasthenia with Stagnation, 349 
 
 2. Myasthenia with Retention, 364 
 
 SECTION V. 
 The Anatomical Dise.\ses ok the Stomach, 378 
 
 Chapter I. Gastritis, 378 
 
 Acute Gastritis, 378 
 
 I. Acute Simple Gastritis, 378 
 
 II. Mycotic Gastritis, 382 
 
 (a) The Fermentation Form of Mycotic Gastritis, . 383 
 
 (b) Infectious Forms, 386 
 
 (1) Purulent Gastritis, 387 
 
 (2) Gastric Fever, 389 
 
 III. Acute Toxic Gastritis, 391 
 
 Chronic Gastritis, 398 
 
 I. Gastritis Catarrhalis Chronica, or Chronic Asthenic 
 
 Gastritis 402 
 
 II. Gastritis Glandularis Proliferans, or Chronic Hyper- 
 sthenic Gastritis, 414 
 
 III. Gastritis Glandularis Atrophicans, or Atrophy of the 
 
 Gastric Glands, 430 
 
 Chapter II. Ulcer of the Stomach, 442 
 
 Chapter III. The Neoplasms of the Stomach, 5^* 
 
 Cancer of the Stomach, 5*2 
 
 Chapter IV. The Displacements of the Stomach, 554 
 
 1. Upward Displacement 555 
 
 2. Vertical or Lateral Displacement, 557 
 
 3. Gastroptosis, 5^4 
 
 Chapter V. Obstruction of the Orifices, 57^ 
 
 1. Obstruction of the Cardia 577 
 
 2. Obstruciion of the Pylorus, 5^4
 
 CONTENTS. 7 
 
 SECTION VI. PAGE 
 
 The Vicious Circles of the Stomach, 6io 
 
 Chapter I. Other Organs in the Diseases of the Stomach, or the Stomach 
 
 in the Causation of Disease, 6lo 
 
 I. Influence on the Intestines, 6il 
 
 II. Influence on the Liver, 614 
 
 III. Influence on the Blood, 615 
 
 IV. Influence on Nutrition, . , . . . 617 
 
 V. Influence on tlie Heart and Circulation, 621 
 
 VI. Influence on the Nervous System, 624 
 
 VII. Influence on the Skin, 629 
 
 VIII. Influence on the Kidneys, 630 
 
 Chapter II. The Secondary Diseases of the Stomach, 631 
 
 I. Diseases of the Intestines, 632 
 
 II. Diseases of the Liver, 633 
 
 III. Diseases of the Heart and Arteries, 634 
 
 IV. Diseases of the Blood, 636 
 
 V. Diseases of Nutrition, 638 
 
 VI. Diseases of the Kidneys, 639 
 
 VII. Spinal Diseases, 640 
 
 VIII. Cerebral Diseases, 641 
 
 IX. Diseases of the Mouth, Nose, and Throat, 643 
 
 X. Diseases of the Respiratory Organs, 645 
 
 Index, 651
 
 DISEASES OF THE STOMACH. 
 
 SECTION I. 
 INTRODUCTION AND CLASSIFICATION. 
 
 The chief excuse for the existence of a book is its indi- 
 viduality. While it is true that the definitive features of a 
 book are the individual views of the author, the great mass 
 of a complete work on the diseases of the stomach must con- 
 sist of the results of research gathered all along the course 
 of medical history. A complete book on this, subject for 
 the use of students and physicians should contain what of 
 knowledge there is of practical value in the past, what of 
 truth there is in the literature of to-day, and what of informa- 
 tion the author may have to contribute. An outline of the 
 evolution of our knowledge of the diseases of the stomach 
 would be a just tribute to the original workers of the past. 
 Possibly narrow and individual conceptions should be rounded 
 with a critical estimate and statement of the opinions of living 
 authorities. But it is our chief endeavor to make this book 
 simple, clear, practical, and complete in useful information. 
 We have consequently decided to have as little as possible to 
 do with history, to omit unnecessary references to literature, 
 and to rearrange the best that others have said and done in 
 unison with what we ourselves have learned during years of 
 special study and practice. 
 
 The classification of the diseases of the stomach should be 
 simple and practical, and embody the data of physiology and 
 pathology. It has become the custom, as exemplified in 
 many text-books, to describe as distinct diseases what are in 
 reality only the functional signs of disease or what are merely 
 inconstant accompaniments. Another common error, in our 
 opinion, is the mistaking of a condition for a disease. It will 
 be observed, consequently, that separate chapters are not 
 
 17
 
 1 8 DISEASES OF THE STOMACH. 
 
 devoted to hyperchlorhydria, to hypochlorhydria, to anachlor- 
 hydria, to acliylia, to gastrosuccorrhea, to erosions of the 
 gastric mucosa, and to dilatation. 
 
 The abnormalities of secretion have been classified as 
 chemical types, and described as distinct diseases with a special 
 causation, special evolution, and special medication. But 
 these abnormalities of secretion are signs of disease and 
 nothing more, — be the disease functional or be it organic. 
 Tiie secretory signs are so constant and characteristic in the 
 various anatomical diseases of the stomach that they are of 
 very great positive and negative ciiagnostic value. Hut the 
 abnormalities of secretion may not depend on a lesion of the 
 mucous membrane, but on abnormal glandular activity, which 
 may be excessive or diminished. These two dynamic affec- 
 tions of secretion we describe as adenohypersthenia gastrica 
 and adenasthenia gastrica. The occurrence of achylia as a 
 dynamic affection without an anatomical lesion of the mucous 
 membrane may well be doubted, for adenasthenia gastrica 
 rarely, and then only temporarily, advances to this stage 
 represented by complete loss of glandular power. Achylia 
 is a sign of the terminal period of asthenic gastritis, a 
 symptom of atrophic glandular gastritis, and it is sometimes 
 met with in advanced carcinoma. 
 
 Gastrorrhea was first described minutely by Parker (1838), 
 although the condition is sometimes known as Reichmann's 
 disease (1882). This symptom-group may occur in the 
 course of chronic glandular (hypersthenic) gastritis, of ob- 
 struction to the evacuation of the contents of the stomach, or 
 of myasthenia. The continuous secretion is the result of the 
 retention or of the gastritis or of both ; it is a condition, a group 
 of signs and symptoms which may develop in the course of 
 well-known diseases of the stomach, and it never appears 
 to be a primary disease. 
 
 Erosions of the gastric mucosa occur in acute and chronic, 
 primary and secondary, gastritis. They may rarely result 
 from cerebral lesions, but are then ordinarily insignificant. 
 We see no good reasons for classifying this epiphenomenon 
 as a distinct disease of the stomach. 
 
 The causes of so-called " dilatation of the stomach " are 
 obstruction to the evacuation of the contents of the stomach 
 into the intestines, deformities and adhesions of the stomach, 
 displacements of the stomach, and myasthenia gastrica. The 
 condition has three characteristics : the stomach has become 
 larger, it does not completely empty itself during the twenty- 
 four hours, and it does not retract when it is empty. Some
 
 INTRODUCTION AND CLASSIFICATION. 1 9 
 
 authors regard " dilatation of the stomach " as synonymous 
 with enlargement of the stomach : some consider the presence 
 of food in the stomach in the early morning before breakfast 
 as its pathognomonic sign : some think that loss of tone and 
 elasticity is its chief characteristic. The normal stomach may 
 be large or small, and its size has no relation to its motor 
 sufficiency. A stomach which does not empty itself under ordi- 
 nary circumstances during the twenty-four hours, may be large 
 or small, strong or weak, thick or thin. A stomach which has 
 lost its tone and elasticity and its power to retract when 
 empty is a myasthenic stomach. We shall not describe 
 " dilatation " as a disease; and we deem it best to employ the 
 words " stagnation " and " retention " to denote the degree of 
 motor insufficiency, and to emphasize the fact that motor 
 insufficiency is a functional sign and not a morbid entity. 
 The word " dilatation," like the word " dyspepsia," has no 
 precise meaning, and embodies false notions. These words 
 impede medical progress and should become obsolete. 
 
 It is also a mistake, we think, to describe, as so many 
 authors do, all the dynamic affections of the stomach as " neu- 
 roses." Some of these troubles are purely muscular. Some 
 of them are exclusively glandular. Some are auto-intoxica- 
 tions. Some are psychic, and some are dependent upon dis- 
 eases of the central nervous system and of the various 
 important organs of the body. A very {^w are possibly 
 " neuroses " in the proper sense of the word. All these affec- 
 tions are dynamic. Such is their nature, and there is nothing 
 else palpable in their manifestations. We shall, consequently, 
 devote a section to the dynamic affections of the stomach, 
 and we believe that this classification embodies a doctrine 
 which is in close conformity with the truth. 
 
 The displacements of the stomach are frequent. The 
 trouble is a purely physical one. The organ is forced to do 
 its work in an unfavorable position. It maybe contended that 
 a displacement is not a disease, — /. e., a morbid process in evo- 
 lution, — that it is only a condition, a result, an accident. But 
 it is not a condition, which, like " dilatation," forms a stage 
 in the orderly evolution of a disease of the stomach. It is 
 the primitive trouble of the stomach. It has its own causa- 
 tion and proper evolution, and can not be understood apart 
 from them. 
 
 The book is divided into six sections. The first section is 
 introductory. 
 
 The second section treats of diagnosis and diagnostic 
 methods, the signs of disease being arranged and classified in
 
 2Q DISEASES OF THE STOMACH. 
 
 the order in which they are obtained during the chnical ex- 
 amination — viz., the chnical history, the physical signs, the 
 functional signs, the bacteriological signs, and the anatomical 
 signs. No chapter will be devoted to the diagnostic value of 
 the alterations of the blood, of the qualities of the stools, and 
 of the properties of the urine. The changes in the blood, the 
 feces, and the urine will be given in the clinical description of 
 each disease. E.xperience with the more direct and exact 
 methods of investigation renders one very cautious in going 
 back from the changes in the blood and excretions to a par- 
 ticular disease or chemical type. It will not be denied that 
 these deviations possess some confirmatory diagnostic value ; 
 but if we attempt to go back to the stomach from the changes 
 in the blood and urine and stools, the conducting thread is 
 soon lost in a network of possibilities. The chance of error 
 is too great. 
 
 The third section is devoted to general medication. The 
 principles of therapeutics are discussed and therapeutic 
 methods are described. The first chapter treats of h\-gienic 
 and physical remedies. The other ciiapters are based on the 
 information obtained by the examination of the patient, the 
 kind of treatment corresponding with the variety of disease- 
 signs — .symptomatic treatment, mechanical treatment, chemi- 
 cal treatment, physiological treatment, and bacteriological 
 treatment. 
 
 These three sections constitute the general or first part of 
 the book. The second or special part of the book is devoted 
 to particulars, which represent results and conclusions. It 
 gives what the physician at the bedside discovers with the aid 
 of the methods of examination ; and it applies the general 
 principles of therapeutics to the treatment of the particular 
 diseases. The fourth section (the beginning of the special 
 part of the book) treats of the dynamic affections of the 
 stomach, while in the fifth section are described its anatomical 
 diseases. Departing from the classical methods, a clinical 
 description of each disease is followed by a discussion of its 
 diagnostic signs in the order given in the second section, 
 which is the natural method of examination. 
 
 The stomach is an organ which rarely escapes undisturbed 
 when the body or any part thereof is seriously diseased ; and 
 the diseased stomach may play a part in the causation of dis- 
 ease of other organs. Be the stomach trouble a dynamic 
 affection or an anatomical lesion, a knowledge of its reciprocal 
 relations is e.xceedingly important. The sixth and last section, 
 will describe the vicious circles of the stomach.
 
 SECTION II. 
 DIAGNOSIS AND DIAGNOSTIC METHODS. 
 
 The object of the interrogation and examination of the 
 patient is the revelation of a disease. This detective work is 
 known as the diagnosis, which forms the basis of a well- 
 regulated plan of treatment. 
 
 The diagnosis includes the recognition of the clinical group 
 to which the disease belongs, and the discovery of its nature, 
 stage, associations, and complications. 
 
 The diagnosis of a disease of the stomach includes more 
 than a knowledge of the pathological chemistry of digestion. 
 The unhealthy variations of the gastric juice, the perversion 
 of the motor function, the little variations in the quantity of 
 the hydrochloric acid secreted or left free, occupy too much 
 and too exclusively the minds of some practitioners. Our 
 knowledge of these troubles rests on as sure and broad a 
 foundation as does our knowledge of any other class of 
 internal diseases, and includes all the truth revealed by all the 
 methods of investigation that give a new or an additional 
 light. The theory should be constructed out of all the signs 
 and symptoms and not be made dependent on the functional 
 signs alone, or chiefly. Under the glare of novelty the older 
 methods have become too much neglected, and what is new 
 is given too great value and employed too exclusively and 
 indiscriminately. 
 
 Each new method of investigation destroys and creates, 
 and modifies profoundly the theory of particular branches of 
 internal medicine. This was the case with the diseases of the 
 chest after the adoption of the method of L^nnec. Such was 
 also the effect of the introduction of the ophthalmoscope, and 
 the laryngoscope, and the cystoscope in a less degree. Each 
 method that reveals the interior of one of the cavities creates 
 a revolution. 
 
 Only a few years ago the subjective sensations gave the 
 greatest part of the information utilized in diagnosis con- 
 cerning the diseases of the stomach. The clinical examina- 
 
 21
 
 2 2 DISEASES OF THE STOMACH. 
 
 tion was nearly resultless, and was confined to the detection 
 of gross abnormalities of size, form, location, density, and 
 sensitiveness. More recent methods reveal the functional 
 power, while the older methods have been made more exact 
 and technical, and the precision and definiteness of all the 
 diagnostic signs have been correspondingly increased. 
 
 The diagnostic methods are both special and general. 
 Some of the procedures are such as are employed in the 
 diagnosis of all internal diseases, while others are used only 
 in the diagnosis of the diseases of the stomach. 
 
 The direct investigation of the digestive functions is a 
 modern procedure. It has yielded a new set of signs of the 
 very greatest value at the bedside. The stomach-tube has 
 also enriched clinical medicine, by adding to it the bacterio- 
 logical and anatomical signs of the diseases of the stomach. 
 
 To the methods peculiar to the diagnosis of the diseases of 
 the stomach should be added the more common procedures 
 of physical diagnosis and their modifications in the examina- 
 tion of the digestive organs. The modified technic and 
 special devices will receive a careful and exact description in 
 order that the fullest information of diagnostic value may be 
 rapidly obtained. 
 
 The revealing signs and symptoms are subjective and objec- 
 tive, or such as are perceived and related by the patient and 
 are detected by the physician. The one constitutes the clini- 
 cal history; the other the clinical examination. 
 
 The clinical history and examination give the data from 
 which, by induction, the diagnosis is drawn. The logical pro- 
 cess is an inductive one, but the analysis is supplemented 
 by synthesis, or the orderly arrangement of the salient and 
 valuable points of the clinical history, and the physical, the 
 functional, the bacteriological, and the anatomical signs. After 
 the clinical history and the examination are completed, the 
 symptoms and signs are arranged in the order of their evolu- 
 tion and in their proper causal relations. The symptom-group 
 is next compared with known clinical types and the disease 
 classified according to its clinical expression. Following the 
 thread found in the modification of function and the evolution 
 of unhealthy variations, we arrive in a natural way at the 
 clinical, functional, and anatomical diagnosis. The more 
 exact and complete the data, the surer is the conclusion 
 reached in this way. The result is dependent on the skill of 
 the physician, the truthfulness and intelligence of the patient, 
 and the exactness and efficiency of the methods. 
 
 The constructed symptom-group rarely corresponds in
 
 DIAGNOSIS AND DIAGNOSTIC METHODS. 23 
 
 every detail with a special clinical type, but may be the ex- 
 pression of more than one disease. By exclusion the diag- 
 nosis is made exact, and the precision essential to purposive 
 treatment is attained. This process is commonly known as 
 differential diagnosis, and is reached by deduction, comparison, 
 and exclusion. The exclusion of the disease suggested by 
 the symptom-group may be dependent on the absence of a 
 cardinal symptom or sign. The result, though based on a 
 negation, is none the less sure. 
 
 After the symptom-group is classified and given a particu- 
 lar name, a comparison is then made with the typical clinical 
 form of the malady, and an explanation is sought for the 
 variations of type. The individual and medical constitution 
 are thus brought prominently into view, and a complication 
 or an associated disease may be revealed. If the situation is 
 thus found to be complex, a further problem is the discovery 
 of the relations of the parts, or the associated morbid enti- 
 ties. As a rule, one disease is the primary and predominant 
 one. But the presence of a complication which may be ex- 
 plained as a result is not conclusive of such a mode of origin, 
 and may lead to a false conception of the supposed causative 
 disease. Accidental independent associations are not rare. 
 That a disease may be explained as a complication does not 
 exclude the possibility of its independent existence and de- 
 velopment. Two possible explanations of a symptom-group 
 may be equally plausible, and precision in the diagnosis may 
 be impossible. In such cases a supposition should not be 
 mistaken for and defended as the truth. 
 
 A disease may have no characteristic sign or symptom- 
 group. The expression maybe irregular, indefinite, formless. 
 The deductive method may then be of use. 
 
 No mistake is more common than to leave out of consider- 
 ation the stage of the disease. The symptom-group of an 
 advanced disease is markedly modified by the constitutional 
 state. The organism suppresses or modifies the expression 
 of the disease, and the former salient features are lost. This 
 is particularly true of the final stages of a disease, when the 
 diagnosis is more clearly revealed by the clinical history than 
 by the present state. The death agony so changes the ex- 
 pression as to suggest often the possibility of an erroneous 
 diagnosis. The mode of death is the same in many widely 
 different diseases. The nature of a disease is revealed by its 
 life history. 
 
 Diagnosis is a logical method, proceeding by analysis, syn- 
 thesis, comparison. The mode of reasoning employed has
 
 24 DISEASES OE THE STOMACH. 
 
 been described. Diagnosis is also a methodical procedure. 
 In taking the clinical history and making the clinical exami- 
 nation, in order to avoid error and loss of time we should 
 adhere strictly to a general plan. The clinical examination 
 begins with the medical constitution, the strength, and the 
 state of nutrition. Then look over the skin and visible mu- 
 cous membranes and search for enlarged glands. This is to be 
 done in every case. The next step is the examination of the 
 organ — the stomach, for example — indicated by the clinical 
 history as the seat of the disease. This being completed, we 
 go on to the examination of the other organs, neglecting in 
 no case to examine the liver, the nervous system, the heart 
 and the blood-vessels, the lungs, and the kidneys. An exami- 
 nation of the blood and the urine, and of the stools, should 
 never be neglected ; and the female genital organs, if not 
 functionating properly, should also be examined. The pres- 
 ence of a causative or associated disease may make the treat- 
 ment of a disease of the stomach a failure. 
 
 A complete diagnosis of a disease of the stomach is not a 
 simple or an easy matter. In the clinical history are found 
 such symptoms as point to this organ as the location of the 
 trouble. The process of reasoning by which the nature of 
 the disease and its clinical form are detected has just been 
 outlined. But a complete practical diagnosis of a trouble of 
 the stomach includes much more. In the first place, the 
 clinical form should be recognized, when our attention is 
 limited to the predominant characteristics revealed in the 
 manner of the manifestations. The grand clinical character is 
 dynamic, and is either hypersthenic or asthenic. These are 
 the two clinical forms, and are the clinical expression of ex- 
 cessive or of insufficient activity. The diagnosis of the clinical 
 form characterizes in a general manner the treatment, be it 
 sedative, indifferent, or excitant. 
 
 The physical examination yields the physical signs, or 
 those obtained by inspection, palpation, percussion, ausculta- 
 tion, inflation, and electric illumination. 
 
 The functional signs maJ<e clear the actual work done by 
 the stomach, and form the basis of physiological treatment. 
 
 The pathological stomach may become the breeding-place 
 of micro-organisms which destroy the food, rob the body of 
 its nutriment, irritate the stomach, and poison the system. 
 The bacteriological signs possess an intense practical interest. 
 
 Special therapeutic indications are given by the anatomical 
 lesions, the determination of the nature of which is often 
 facilitated by the anatomical signs.
 
 THE CLINICAL HISTORY. 2$ 
 
 These signs and the clinical history combined reveal the 
 nature and stage and probable evolution of the disease, and 
 suggest the treatment. 
 
 We shall describe them in the following order, which is the 
 one most natural at the bedside : 
 
 1. The Clinical History. 
 
 2. The Physical Signs. 
 
 3. The Functional Signs. 
 
 4. The Bacteriological Signs. 
 
 5. The Anatomical Signs. 
 
 CHAPTER 1. . 
 THE CLINICAL HISTORY. 
 
 The revelations of the modern methods of examining the 
 stomach have so deeply engaged the attention of the medical 
 world that the diagnostic value of the clinical history has 
 been almost forgotten. The improved technic of physical 
 diagnosis, the more exact and the more frequent clinical study 
 of the functions of the stomach, the more intimate knowledge 
 of the conditions and the effects of fermentation and putre- 
 faction, the search for anatomical signs in the contents of the 
 stomach, and the recent advances of pathology, have dimin- 
 ished the obscurity which has so long concealed the nature, 
 the genesis, and the evolution of stomach diseases. But 
 notwithstanding the increase of knowledge, notwithstanding 
 the great precision of modern diagnostic methods, the clin- 
 ical history still maintains all its old utility. The diagnostic 
 value of the subjective symptoms has only been enhanced by 
 our more exact knowledge of their genesis and their evolu- 
 tion. 
 
 Unfortunately, many practitioners do not accept this view, 
 but deem the time wasted which is spent in obtaining the 
 subjective history. Many of the constitutional symptoms, it 
 may be readily admitted, are common to all forms of gastric 
 trouble, and are of little value in clinical investigation. 
 Many symptoms, also, are in no fixed relation to the cause, 
 or to the chemical pathology, or to the anatomical lesion ; 
 and the complaints of the patient may be so general as 
 to be meaningless. The numerous and different diseases
 
 26 DISEASES OF THE STOMACH. 
 
 of tlie stomach may have a similar group of subjective symp- 
 toms. No one symptom is pathognomonic, and even the 
 collections of symptoms, although more characteristic and 
 more suggestive, are hardly less likely to lead to an erroneous 
 diagnosis. Taken singly or combined, the physician may 
 only be able to conftrm the patient's statement that he is 
 suffering from a " bad stomach " ; and this does not lead very 
 far toward a rational diagnosis or a purposive treatment. 
 
 It is quite true that the bundle of sensations or perceptions 
 is often valueless in the naked abstract ; and, therefore, a 
 thorough search must be made for the individualizing char- 
 acteristics and the definitive features. 
 
 To search out and keep before the mind the useful subjec- 
 tive symptoms is essential to the proper utilization of the 
 clinical history. The chief importance attaches not to the 
 gross symptom, but to its characteristics. The diseases of the 
 stomach are not silent, and they commonly speak distinctly. 
 Rarely, it may be otherwise. A disease of the kidneys, a com- 
 pensated heart lesion, a disease of the liver, may long exist 
 without creating a suspicion. This may also happen with a 
 disease of the stomach, and the first revealing sign may be 
 given by the disturbance of the function of some other organ, 
 or the patient may be so accustomed to a " bad stomach " as 
 to consider its existence meaningless, and may consult the 
 physician for some other trouble — insomnia, palpitation, loss 
 of strength, emaciation, cerebral fatigue. But in the large 
 majority of cases the voice is more distinct, and is heard 
 where it is produced. It is quite proper to speak of an ulcer 
 history, a gastritis history, a cancer history, a myasthenia 
 history, a history of neurasthenia gastrica, or a history of 
 any of the clinically well-defined diseases of the stomach ; 
 but to be of value, the history must be compiled by the 
 physician out of the material furnished by his purposive ques- 
 tioning of the patient. 
 
 The interrogation of the patient demands tact and experi- 
 ence, and a knowledge of human nature and of the " dyspep- 
 tic." The " dyspeptic " is a poor student of himself, but a 
 lover of criticism. Unguided, his story consists chiefly of the 
 numerous drugs he has taken, and the many physicians whom 
 he has consulted without benefit. Acrimonious, full of 
 opinions, he remembers vagueU' and relates unwillingly the 
 facts concerning his digestive trouble, except in the light of a 
 preconceived opinion. The physician, who is supposed to be 
 familiar with the clinical pictures of the different diseases of 
 the stomach, should, by well-chosen questions, concentrate the
 
 THE CLINICAL HISTORY. 2/ 
 
 inquiry and the attention on the distinctive and characteristic 
 symptoms and the symptom-groups. The most detailed de- 
 scription by the patient is much less valuable than a clinical 
 history made out on broad schematic lines. Seize at once the 
 most important points in the patient's story, and follow with 
 questions so formed as to define more clearly the relations of 
 the symptoms. 
 
 It must not be supposed that the clinical history suffices, 
 alone, to make a diagnosis. The atypical and the secondary 
 diseases of the stomach, without the signs revealed by an 
 examination, are likely to be overlooked. Even when the 
 clinical history of the stomach disease is most typical, the 
 possibility of associated diseases must be remembered, and 
 there may be complications. 
 
 The clinical history opens up the way for further and more 
 exact investigation. The interrogation is an introduction and 
 a guide to the clinical examination. The interrogation, how- 
 ever, should not be made the basis of a diagnosis ; for such 
 a course may lead to serious errors. The following case 
 illustrates and emphasizes this principle : A patient, aged 
 thirty-eight, nervous temperament, was severely shocked by 
 the sudden and accidental death of his wife. The appetite 
 began to fail, the stomach, after meals, felt uncomfortably full, 
 and the period of digestion was accompanied by restlessness, 
 nervousness, but by no pain. Liquids produced more distress 
 than solid food, and a full meal increased his discomfort and 
 his mental despondency. The patient had lost a few pounds 
 in weight during the four months since the beginning of the 
 attack, but the diet was less than supporting. Myasthenia 
 gastrica was suspected, and the trouble was supposed to be 
 dynamic. The examination revealed the functional signs of 
 carcinoma, and an elongated, ridge-like, hard tumor could be 
 felt just below and to the left of the ensiform cartilage, moving 
 with respiration, but with difficulty fixable on expiration. 
 The subsequent history proved the diagnosis of carcinoma 
 ventriculi to be correct. 
 
 The story, as told by the patient, is a bundle of uninter- 
 preted or mistakenly interpreted sensations. The nature of 
 the disease may often be revealed by the manner in which 
 the history is gathered up and related. But, as a rule, neither 
 the nature nor the location of the disease is revealed in this 
 way. The trouble may be in the stomach, the colon, or 
 the gall-bladder, or in some other abdominal organ. The 
 subjective symptoms of a benign or a malignant disease are 
 frequently alike. The clinical history may, but does not often.
 
 28 DISEASES OF THE STOMACH. 
 
 suffice; }-et it may reveal the location and the ori<^in, and even 
 the nature, of the trouble. To amass information on these 
 three points is one of the objects in questioning the patient. 
 
 The first problem is the location of the disease. This, at 
 first glance, may seem very easy of solution ; but here mis- 
 takes are very often made. It has been often urged that the 
 specialist is too prone to locate disease in the particular 
 organ or organs which he exclusively treats. It has long 
 been the custom to attribute all the gastro-intestinal and the 
 nervous symptoms of enteroptosis to a displacement or a 
 version of the uterus. The eye and the nose have been no 
 less pretentiously forced upon our attention ; and the stomach 
 and the intestines, on account of their wide s\-mpathies and 
 relations, are no less apt to monopolize our study. 
 
 It is a mistake to direct the questioning solely to the diges- 
 tive function. There are diseases of the stomach that present 
 no local subjective sign. These diseases may express them- 
 selves at a distance, and do their marauding far away from 
 their home — in the head, or the heart, or the lungs, or the 
 kidneys, or the liver, or the sympathetic or central nervous 
 system. There are also diseases of other organs, the only 
 subjective manifestation of which is a disorder of the stomach. 
 The two following cases illustrate what is meant : A patient 
 with a very violent headache came for consultation ; there 
 was no syphilitic history, and no malaria, no neurasthenia, 
 no disease of the kidneys, and no uricemia were found. The 
 headache was at times periodical, at times remittent, at times 
 accompanied at night by insomnia and irritable temper, at 
 times most violent during the day ; there was no fixed rela- 
 tion to the period of gastric digestion, or to constipation, or 
 to excesses ; it was without definitive features, and the patient 
 was not conscious of any abdominal symptoms. The exami- 
 nation revealed a prolapsed myasthenic stomach, with stag- 
 nation and fermentation. Again, a young married woman 
 came complaining of very troublesome vomiting. There 
 were no other subjective or objective gastric symptoms. The 
 uterus was normal and non-pregnant. Upon further ques- 
 tioning it was learned that the vomiting was always preceded 
 by coughing, and an examination revealed an incipient pul- 
 monary tuberculosis, the primary disease. Gastric trouble is 
 so commonly a companion of the diseases of other organs 
 that the physician, cognizant only of the abdominal symptoms, 
 is likely to form a false conclusion. Study the wliole man, 
 and learn to know him in every part. 
 
 The general history should always precede that of the
 
 THE CLIXICAL HISTORY. 29 
 
 abdomen. The local phenomena being next studied, and a 
 provisional diagnosis formed, the known effect of the disease of 
 the stomach on the organism should be looked for as a con- 
 firmation of the hypothesis. The general history in its grand 
 lines, the local phenomena in every detail and relation, the 
 minute search for the usual effects of the suspected disease, 
 is the natural method of conducting the preliminary exami- 
 nation. The following case illustrates the simplicity of this 
 natural method : A young clerk had always enjoyed excel- 
 lent health before an attack of typhoid fever, three years ago. 
 Convalescence was slow, but his appetite and occupation 
 forced him to eat ravenously and rapidly. For the two 
 following years he was conscious of having a bad stomach, 
 intolerant of large quantities of fluid and of large meals. 
 Moderation would cause the headache, insomnia, mental de- 
 pression, and gastric uneasiness and heaviness to disappear. 
 Six months ago, the morning after a heavy, indigestible 
 dinner and several drinks, he had a severe attack of headache, 
 nausea, sour and foul vomiting, which continued for several 
 days. Since that time he has been worse, and vomits large 
 quantities of fluid — sour, brown, sometimes foul, containing 
 food, etc., eaten the day before. During the past six months 
 he has rapidly emaciated ; the skin is dry and rough, the 
 urine is scant, feet and hands are cold, there are cramps in 
 the calves of the legs, " the hands and feet often go to sleep," 
 and the nodosities of Bouchard are very plain. These are 
 retention symptoms. The stomach is not empty in the morn- 
 ing, the vomit " three layer," and contains sarcina^. Test- 
 breakfast, after frequent lavage, gives free HCl. Diagnosis — 
 myasthenia gastrica, with retention. 
 
 The disease being located and classified, it is natural that 
 we should next search for its cause. This may be found in 
 the alimentation, the profession, the home life, the family 
 history, or in a past disease. It is specially valuable to know 
 the beginnings of the trouble ; for at this early period we are 
 nearest to the cause, and the disease is yet central, undiffer- 
 entiated, and uncomplicated. The surroundings of the 
 patient at this time, his habits and diet, should be carefully 
 looked into. The patient, if intelligent, may know the cause, 
 and his opinion should be patiently heard. 
 
 Such is the value of the clinical history. Such is the proper 
 and natural method of obtaining it and of using it in diag- 
 nosis. The subjective symptoms are the manifestations of 
 the disease, and often reveal its nature when their evolution
 
 30 DISEASES OF THE STOMACH. 
 
 and diagnostic features are discovered. The clinical history 
 includes : 
 
 1. The general history of the patient before the beginning 
 of the present trouble. In his past we may see the shadows 
 of coming events. Diseases of other organs are selective in 
 their influence on the stomach, and may give a clue to the 
 genesis and the nature of the present trouble. 
 
 2. The history of the present trouble. 
 
 3. The present condition of the patient, which is most sat- 
 isfactorily revealed, under the guidance of the physician, by 
 his own relation of the history of a single day. 
 
 I. The Previous History. — A disease of the stomach, both 
 in its nature and its evolution, is conditioned, among other 
 things, by the cause and the medical constitution. It has 
 been contended that the pathological anatomy bears no rela- 
 tion to the nature of the disease, and that the symptoms are 
 not an expression of the lesion. In neither the primary nor 
 the secondary diseases of the stomach is this contention true. 
 In the sixth section — on the vicious circles of the stomach — it 
 will be made clear in how intimate a relation a secondary dis- 
 ease of the stomach stands to the disease which has caused 
 it. It is on the reality of this relation that the diagnostic 
 value of the previous history depends, and, consequently, 
 much of the information amassed in that section will aid in 
 the detection of the nature of the particular disease of the 
 stomach. 
 
 The older clinicians laid great stress on the medical consti- 
 tution, and it is to be regretted that the diagnostic, prognos- 
 tic, and therapeutic rules dependent thereon have been allowed 
 to drop into oblivion. The medical constitution, be it inher- 
 ited or acquired, is the soil in which the disease is to grow, 
 and consequently conditions both its evolution and the char- 
 acter of its results. The physician at the hospital overlooks 
 it ; but the physician who knows the individual and the 
 family detects the unique and persistent force revealing itself 
 successively by troubles very various, but one in causation 
 and treatment — this concealed unitv'^ of which the arthritic 
 and neuropathic groups of diseases are the simplest examples. 
 What is true of a diathesis is also true of a temperament, 
 and of the new and special adaptations necessitated by dis- 
 ease and environment. One who studies the present condi- 
 tion ma\' detect the functional trouble, the anatomical lesion, 
 and its seat ; he will see nothing of this individual peculiarity 
 revealed in the evolution and the mode of expression and
 
 THE CLINICAL HISTORY. 3 I 
 
 formation of family disease-groups, and demanding long- 
 continued patience, courage, and a treatment of the morbid 
 individual life. The study of the previous history reveals the 
 individual medical constitution, and the probable nature of 
 the secondary and diathesic diseases of the stomach. We 
 come now to the history of the present trouble — its prelude, 
 the manner and date of its beginning, and its evolution. 
 
 2. The History of the Present Trouble. — The prelude to 
 the development of a disease of the stomach contains the 
 exciting and often the remote cause. This period of the 
 medical history should be very closely studied, with a view to 
 first locating the cause in the organism, or in alimentation 
 and the material introduced into the stomach. At this time 
 the cause and the constitution together will suggest more 
 definitely the nature of the trouble than at a period more 
 remote from the beginning. These causes, be they mechani- 
 cal or vital, act through the five functional factors — the 
 nervous system, the circulation and quality of the blood, 
 secretion, muscular action, and absorption. 
 
 The age at which the trouble began may suggest the prob- 
 ability or the absence of certain diseases. Cancer is very 
 rare before the middle third of life. Myasthenia is more 
 and more frequent with advancing years. Adenohyper- 
 sthenia gastrica diminishes from manhood to old age. Ulcer 
 is somewhat rare before twenty. The hypersthenic motor 
 and sensory affections accompany puberty and youth. Ano- 
 rexia nervosa, nervous vomiting, and gastralgia are most 
 frequent in young girls and middle-aged women. 
 
 The symptoms of the beginning often reveal at once the 
 nature of the affection. The acute inflammations, and often 
 the dynamic affections, begin suddenly, with characteristic 
 symptoms. Chronic diseases, when so from the start, begin 
 slowly and quietly. Ulcer may announce itself by a hemor- 
 rhage, or by an unheralded perforation, but more frequently 
 by digestive irritation in strict relation with the physical action 
 of the food. Myasthenia is usually insidious in its beginning, 
 but may progress with a bound after an excessive meal. 
 Cancer most frequently begins in the midst of seemingly good 
 health, with symptoms due to, and increasing with, the motor 
 insufficiency, the facility with which the food taken ferments 
 and taxes the peristaltic and evacuating power. The displace- 
 ments begin with traction symptoms ; a completed displace- 
 ment may long remain symptomless, but it becomes a con- 
 scious disease when abdominal tension diminishes or myas- 
 thenia gastrica, particularly with fermentation, supervenes.
 
 32 DISEASES OF THE STOMACH. 
 
 When all tlie physiological factors of digestion are more or 
 less implicated, the symptom-group of the beginning is com- 
 monly more characteristic than that of a later period. The 
 disease of the stomach may be displayed more characteris- 
 tically, if not more intensely, in the phenomena which attend 
 its origin. 
 
 The evolution of the subjective symptoms may be inter- 
 mittent, remittent, or progressive. The course of many dis- 
 eases of the stomach is marked by periodicity and by parox- 
 ysms. These qualities may be inherent in the nature of the 
 trouble, the attacks seeming to recur spontaneously or as the 
 expression of accumulated incompetence, each day the organ 
 becoming more exhausted or irritated under the strain of ex- 
 cessive work. In the interval, digestion is unconscious, and 
 an ordinary mixed diet is well borne. Most of the dynamic 
 affections may be periodical or paroxysmal, the attacks often 
 being excited by errors of diet, physical excesses, or mental 
 and moral strain. 
 
 In other cases, the course is characterized by remissions. 
 The interval is a period of improvement, but not of health. 
 The disease continues, but is not uniform in the intensity of 
 its expression. Without these exacerbations, the patient 
 would not consult a physician. During the period of 
 remission, the capability of the diseased stomach is better 
 adapted to the work demanded of it. During the exacerba- 
 tion, this compensation is disturbed by mental, moral, or 
 physical influences, or by bad hygiene, improper diet, and 
 injurious remedies. This is the course most characteristic 
 of the anatoinical diseases of the stomach. Both the re- 
 missions and the exacerbations may be due to " little acci- 
 dents." Another organ may become insufficient, and include 
 the stomach in the vicious circle. The offending matter may 
 be vomited, or may be evacuated into the intestine. After a 
 hemorrhage, the subjective symptoms of a gastric ulcer may 
 subside. 
 
 But, be the course intermittent, remittent, or continuous, 
 progression in spite of proper treatment is a suggestive evo- 
 lution sign. The obstinacy is due to the character of the 
 lesion itself This malign tendency is most constant in car- 
 cinoma, the gross subjective symptoms of which may often be 
 controlled or mitigated by judicious treatment, but each day 
 the disease burns more and more of the albumin of the body, 
 and brings the patient nearer to the grave. 
 
 The evolution of a disease of the stomach may be slow or 
 rapid. The clinical period of cancer does not last longer
 
 THE CLINICAL HISTORY. 33 
 
 than twelve to eighteen months. The dynamic affections may- 
 continue for years, or may suddenly begin, run a rapid course, 
 and just as suddenly end. The constitution, the moral atmos- 
 phere, and the mode of life have much to do with the per- 
 sistence of these troubles. Acute gastritis and ulcer may 
 soon heal, but the displacements and anatomical diseases of 
 the stomach have a tendency to persist. Expectant treatment 
 has no ally in an inherent tendency to get well, and the dis- 
 eases of the stomach recur more frequently than those of any 
 other organ. 
 
 Some diseases are also accompanied by diminished power 
 of the organism to repair its losses, or to recuperate after 
 triflmg accidents. In ulcer, the effects of a hemorrhage may 
 rapidly disappear, because the disease is a local one, and the 
 motor power of the stomach is good. The emaciation is due 
 to voluntary starvation, unless the food be lost by vomiting 
 or by retention from pyloric swelling or stenosis. After a 
 hemorrhage in cancer, the patient sinks more rapidly under 
 the auto-intoxication and the inanition. This diminished re- 
 cuperative power also characterizes the uncompensated dis- 
 eases of the stomach. 
 
 The evolution of a dynamic affection of the stomach may 
 end, eventually, in a destruction of a large part of the noble 
 elements of the organ. The different stages are links of one 
 chain. Adenohypersthenia gastrica may terminate in gas- 
 tritis and atrophy, and the early hypersthenia may develop 
 into the most complete asthenia. The symptom-group is 
 correspondingly changed by the substitution of the signs of 
 depression for those of irritation. Pain is no longer com- 
 plained of, and vomiting may occur only as a result of over- 
 distention, or as a pressure symptom reflected from an adja- 
 cent abdominal organ. In cancer, for example, vomiting is 
 rare in the beginning, may become uncontrollable, and then 
 disappear entirely as the disease progresses. Retention marks 
 a turning-point in the history of a disease of the stomach. 
 The delay in evacuation becomes greater and greater, until 
 finally the stomach never empties itself completeh' ; this 
 condition robs the system of its nutriment, and forms a 
 persistent culture-soil for micro-organisms, since the stomach 
 always has something in it. The clinical picture becomes 
 modified by the little accidents without the natural evolution 
 being interrupted. The morbid unity is preserved beneath 
 the play of expression. These changes of type develop in so 
 orderly a manner as to be of value in determining the nature 
 of the anatomical disease following the dynamic affection. 
 3
 
 34 DISEASES OF THE STOMACH. 
 
 The effects of treatment on the evolution of the disease 
 may reveal its nature. In cancer, the treatment, however 
 purposive, only relieves the gross symptoms of stagnation or 
 retention. The effect of alkalies is of differential value. If 
 large doses of the alkaline waters or drugs give relief, adeno- 
 hypersthenia (excessive secretion) is the most probable 
 functional disturbance; similar doses in myasthenia make 
 matters worse. Lavage is useful chiefly where there is stag- 
 nation or retention, be it with or without a trouble of secre- 
 tion. Only the mild dynamic affections are rapidly influenced 
 by hydrotherapy. The magical effects of a properly-fitting 
 bandage are only obtained in displacements, before myasthenia 
 develops. An ulcer-cure may reveal quickly a suspected ulcer, 
 or, rather, may confirm the probable diagnosis. The thera- 
 peutic test, be it positive or negative in its influence on the 
 evolution of the disease or of the symptoms, is a valuable aid 
 in the diagnosis of difficult cases. 
 
 The state of nutrition is a revealing sign of great value. 
 The dynamic affections, in spite of their violent expression, 
 may run their course under the appearance of perfect health, 
 without cachexia or loss of weight or strength. The health 
 is preserved in its bloom. But in the painful diseases of the 
 stomach, emaciation may be so pronounced as to present a 
 special cachectic appearance. This is the rule when nutritive 
 waste remains active, instead of sharing — as in anorexia ner- 
 vosa — in the restraint of other functions. The emaciation of 
 cancer is progressive. In chronic gastritis the weight is pre- 
 served so long as the motor power of the organ is intact and 
 the intestines are healthy. Should emaciation occur, in spite 
 of a suitable and sufficient diet, there is stagnation, or reten- 
 tion, or a complication. Inanition, with its emaciation, weak- 
 ness, and often discoloration of the skin, may be due to a motor 
 insufficiency or to frequent vomiting. The food is not util- 
 ized, but destroyed or lost. Rarely can it be said that the 
 emaciation is the direct expression of the disease. But this is 
 not all. The emaciation may be due to an unsuitable or a 
 starvation diet. Nothing is more common than to see large 
 quantities of fluid — soups, drinks of all sorts — poured into 
 a myasthenic stomach, with the result of increasing the stag- 
 nation, or of producing retention. As soon as retention be- 
 gins, emaciation sets in. The diet may be suitable to the 
 disease, but insufficient to maintain the balance of nutrition. 
 A diet which produces emaciation should be temporary, 
 purposive, and imperatively demanded ; otherwise it is in- 
 jurious.
 
 THE CLINICAL HISTORY. 35 
 
 3. The Present Symptoms. — The history of the present 
 trouble being thus clearly marked out in its main lines, the 
 object of further questioning is to obtain a knowledge of the 
 present subjective symptoms. The special history has refer- 
 ence to the past and to the present — the genesis and the 
 evolution on the one hand, and the present condition or stage 
 of the disease on the other. We have, then, the past symp- 
 toms and the present symptoms. 
 
 To obtain a knowledge of the present subjective symptoms 
 in their natural relations and characters it is a very good 
 plan to ask the patient to tell the history of an entire day, 
 beginning in the morning with the empty stomach, and 
 recounting the symptoms as they appear — what he did, what 
 he ate and drank, and what he felt. The symptoms should 
 be grouped according to their existence during the period of 
 digestion or of functional rest ; and their relations to the 
 evolution of digestion, more particularly of the chief meal, 
 should be carefully noted. 
 
 For the stomach, the periods of activity and repose are 
 quite clearly marked physiologically ; but it should not be 
 forgotten that the intestmes also begin work soon after a 
 meal. There is great danger of confounding intestinal and 
 gastric symptoms. On account of the mode of suspension 
 and fixation of the intestines, traction symptoms are often 
 referred to the epigastrium. The colon passes above the 
 umbilicus, and the duodenum, with coils of the small intes- 
 tine, is found in the epigastric region. Many so-called 
 stomach pains, occurring during the period of gastric diges- 
 tion, are located in a diseased colon. The subjective symp- 
 toms due to diseased intestines, and occurring when the 
 stomach should be at rest, may be referred to this organ by 
 the patient. The interpretation of the patient should not be 
 implicitly accepted, and we should be sure that the symptoms 
 are gastric. The neglect of this precaution may lead to 
 error. 
 
 The adoption of a special set of questions as a routine is 
 best, in order to assure a well-grouped picture. During the 
 patient's recital of the subjective history of the day, our 
 questions should bring out all the diagnostic features of the 
 important symptoms. 
 
 In this history of the full day we learn the diet — its compo- 
 sition, quality, mode of preparation ; the relation of the 
 symptoms to the taking of the food, to the physiological 
 action of the aliment and drinks, to the periods of functional 
 activity and repose of the organ, to the periods of activity
 
 36 DISEASES OE THE ST0AE4C//. 
 
 and of repose of the bocl^^ We note also the time of 
 appearance and the evolution of the symptoms in relation 
 to the process of digestion ; the time of appearance and the 
 evolution of the symptoms as regards exercise, work, and 
 repose. 
 
 The condition of the patient before breakfast may be of 
 diagnostic value. The most characteristic symptoms of some 
 diseases appear at this period — such as the early morning 
 nausea, the vomiting of mucus and bile in alcoholic gas- 
 tritis, and the morning sickness of pregnancy. In gastric 
 stagnation and retention, in morbid sensibility of the sympa- 
 thetic centers, the person arises tired, and in a state of irri- 
 tability and of mental and moral depression. If there be no 
 retention and no neurasthenia, the period before breakfast 
 is the best during the day. To make these rules valid, an in- 
 testinal trouble should first be excluded. The morning nau- 
 sea, vomiting, vertigo, headache, and diarrhea, are frequently 
 the symptoms of an intestinal disease. 
 
 The traction sensations in the displacements begin with 
 rising, continue throughout the day, and subside with the 
 evening repose. 
 
 The digestive symptoms may or may not begin with the 
 breakfast, depending on the nature and the stage of the disease 
 and the physiological action of the food. This small meal 
 may be without bad effect, and may be taken as a rough 
 measure of the severity of the trouble, according as the action 
 is positive or negative. The digestive symptoms are more 
 marked after a full meal, and may occur during the period of 
 the rise, persistence, or fall of hydrochloric acidity. 
 
 The most common immediate symptoms are the variations 
 of general sensations. The patient becomes conscious of di- 
 gestion. There may be only a feeling of unrest, discomfort, 
 heaviness, pressure, as in gastric neurasthenia, gastritis, or 
 cancer, or the uneasiness may be the beginning of a parox- 
 ysm of severe pain, which may slowly develop side by side 
 with the evolution of secretion, — as in hyperchlorhydria, — or 
 which may become suddenly violent, as in hyperesthesia, or in 
 a fresh or a sensitive ulcer. Whether these severe pains are 
 nervous or symptomatic of ulcer, they are most frequently 
 encountered in anemic girls. Vomiting as an immediate 
 symptom, unpreccded by nausea or pain, is a reflex motor 
 nervous affection. When developing as a sequence of pain 
 or nausea there is usually a pathological state of the mucous 
 membrane. Nervous vomiting is most frequent in women. 
 The motor disturbances of the stomach, and also its secretory
 
 THE CLINICAL HISTORY. 37 
 
 troubles, are very frequently due to the setting in motion of a 
 diseased intestine from which the reflex proceeds. 
 
 During the stationary period of hydrochloric acidity, two 
 characteristic symptom-groups may present themselves — the 
 one is accompanied by severe pain, the other by a sensation 
 of heaviness, of pressure, or of unrest. To the one belong 
 gastric neurasthenia, chronic asthenic gastritis, myasthenia ; 
 to the other, superacidity, ulcer, cancer, and hypersthenic 
 gastritis. Fermentation may complicate either form. In 
 the asthenic group, to the unrest, pressure, w^eight, mental 
 and moral depression, are added meteorism, acid reguvgita- 
 tion, and pyrosis, or heartburn, if fermentation be present. 
 The symptoms are very variable in degree and in duration. 
 The hypersthenic form is accompanied by severe pain, and 
 by other signs of reaction and irritation. The burning sensa- 
 tion, heat, and drawing together of the stomach develop into 
 a cramp, which may become intolerable. The paroxysm is of 
 variable duration, and ends with the passage of the contents 
 into the duodenum, or with their removal by vomiting. In 
 this form there may be in the stomach a moderate degree of 
 fermentation, which may be the cause of the state of irrita- 
 tion ; though if the stomach be cleansed and a test-meal 
 given, the quantity of organic acids is very small. In the 
 majority of these cases the fermentation and decomposition 
 are in the intestines, and the gastric symptoms are due to 
 auto-intoxication. 
 
 The gastric symptoms occurring only during the period of 
 decline may be motor, secretory, or sensory. In the first 
 there is stagnation or retention ; in the others there is abnor- 
 mal secretion or fermentation. 
 
 Many of the gastric symptoms mentioned in the one-day 
 history related by the patient are common to several different 
 diseases of the stomach. Individually and out of their proper 
 relations they possess very little diagnostic or differential 
 value. But some of these symptoms occur only in partic- 
 ular diseases of the stomach, and often have features so char- 
 acteristic that their genesis is made clear. The meaning of 
 the more frequent of these symptoms, particularly when 
 endowed with special qualities, will now be briefly discussed. 
 
 Dysphagia. — In dysphagia the trouble may be in the power 
 of swallowing or in the permeability of the esophagus. The 
 loss of power to swallow is due to paralysis of the muscles of 
 deglutition ; paralysis of the esophagus alone is not known. 
 The obstruction of the esophagus may be due to a defect in 
 development, to certain diseases of its walls, and to pressure
 
 38 DISEASES OF THE STOMACH. 
 
 exerted at some point along its course. The only two dis- 
 eases of the stomach that produce trouble in the swallowing 
 of food, or, more explicitly, that interfere with its passage 
 into the stomach, are spasm and organic obstruction of the 
 cardia. 
 
 Heartburn. — Heartburn is due to excessive acidity of the 
 contents of the stomach, to hyperesthesia of the cardiac 
 region of the stomach, or to the regurgitation of the irritant 
 contents of the stomach into the lower part of the esopha- 
 gus. It w'as long supposed to be a pathognomonic sign of 
 fermentation in the stomach, and it is indeed most frequent 
 in fermentation accompanied by the formation of organic 
 acids in considerable quantities. When due to fermentation, 
 it is most commonly excited by butyric acid, the other forms 
 of fermentation rarely producing it. It is common in myas- 
 thenia, cancer, and in the other diseases of the stomach accom- 
 panied by stagnation or retention. Heartburn may also be 
 due to excessive hydrochloric acidity. When not produced 
 by eating rancid food, it is a sign of either fermentation or of 
 excessive hydrochloric acidity, hyperesthesia and the regur- 
 gitation of the normal contents rarely causing it. Its frequent 
 presence in a particular case possesses some negative value, 
 and aids in the exclusion of the diseases of the stomach in 
 which fermentation and excessive secretion do not occur. 
 
 Uncomfortable Sensations. — A sensation of weight and full- 
 ness in the stomach is a very common symptom. The sensation 
 of traction is also frequent, and the three sensations are often 
 present together, and confounded by the patient. These 
 sensations possess no definite diagnostic value. In some 
 cases they are present for only a short period after the meal ; 
 in others, their evolution is progressive throughout the period 
 of digestion. Without possessing an absolute meaning in 
 such a case, the sensations of weight and fullness which are 
 often associated indicate varying degrees of myasthenia. 
 The symptoms often disappear when the sleepy muscle 
 awakes to its work, and the stomach gets rid of its contents 
 by absorption and peristalsis. When the symptoms persist 
 through the unusually long digestive period, the atony is more 
 pronounced. Gastric neurasthenia is frequently accompanied 
 by the same sensations, which may be due in part to the in- 
 creased sensitiveness of the nerve-centers during the period 
 of physiological activity. The patient becomes conscious of 
 sensations connected with the state of the gastric muscle, 
 which in health go unperceived. The neurasthenic sensations 
 are not so intimately connected with the quantity and the
 
 THE CLINICAL HISTORY. 39 
 
 quality of the food as are those of myasthenia and gastritis. 
 These sensations may persist during the period of physio- 
 logical rest. There is then prolapse, a marked myasthenia, or 
 even retention. When the abdominal wall is atonic, the 
 symptoms are frequently due to coprostasis. In both copro- 
 stasis and prolapse of either the stomach or colon, marked 
 relief is at once given by support. These sensations, in a 
 general way, point to myasthenia, gastritis, or to displacement 
 of the stomach or colon ; they are due to the overdistention 
 of the muscular layer, to the stretching of the nerves or 
 the supporting ligaments, to compression of the sensitive 
 nerves against adjacent organs, and they are intensified by 
 neurasthenia. 
 
 Pain. — Abdominal pain is a symptom of great diagnostic 
 value, provided its qualities and associations be clearly defined. 
 Pain in the abdomen only indicates the probable location of 
 some sort of disease in this region ; it is a revealing sign of a 
 particular disease only when its individuality is exactly and 
 clearly defined. The first problem is to fix its location in the 
 stomach; and then, through its qualities and associations, we 
 can reason back to its particular cause. 
 
 Neuralgia or rheumatism of the abdominal wall may be 
 mistaken for pain in the intestines or in the stomach. In 
 muscular rheumatism the pain is relieved by immobilization, 
 excited by muscular contraction, and is often accompanied by 
 a slight rise of the temperature. The muscle is then often 
 contracted. Neuralgia follows the course of the nerves, and 
 has its painful points. Neither are in any relation to the 
 taking of food, although neuralgia may be increased, or even 
 relieved, by the activity of the stomach ; the neuralgia is then 
 associated with the other signs of neurasthenia. Pressure 
 may locate the trouble; in neuralgia, the skin is sensitive; in 
 rheumatism, deep pressure with the flat hand does not increase 
 the pain, which is then also diffused, corresponds in distribu- 
 tion to the muscle or the muscles affected, and is never cir- 
 cumscribed and limited to a very small area. The pains of 
 neuralgia and rheumatism are continuous, and are subject to 
 exacerbations. Both may be associated with pains in other 
 regions. 
 
 A pain located in the stomach is not always due to a dis- 
 ease of this organ, which is often the seat of referred pain. 
 Examples of referred pain are met with in the gastric and the 
 intestinal crises of tabes, subacute myelitis, compression 
 myelitis, and aneurysm of the abdominal aorta. The pain 
 of the central lesion — of irritation by pressure — is referred to
 
 40 D/S EASES OF THE STOMACH. 
 
 the peripheral area of distribution, in accordance uitli a well- 
 known law. In all cases of severe abdominal pain care 
 should be taken to exclude these causes before attributing 
 the pain to a disease of the stomach. 
 
 A pain which has the stomach for its seat, and which is 
 not produced in the foregoing manner, is often erroneously 
 accepted as a sign of a local disease of this organ. Pain 
 in the area of distribution of one branch of a nerve may 
 have its origin in the periphery of another branch of the 
 same nerve. This is especially true of the pneumogastric 
 with its innumerable connections with the abdominal sym- 
 pathetic. The pain is often in the stomach, when the disease 
 is in the intestines or elsewhere. It is a good rule to sus- 
 pect the colon whenever the stomach is the seat of a so-called 
 colic. 
 
 When hepatic colic is attended b\' its typical sj'mptoms, 
 such as the paroxysmal pain, icterus, distention of the gall- 
 bladder, peritoneal friction, fever, and enlarged or tender liver, 
 and when calculi have been discovered in the stools, there is 
 no difficulty of diagnosis. But in the atypical or abortive 
 attacks, the differentiation may be more difficult. There are, 
 however, many minor signs which may reveal the origin and 
 location of the pain. 
 
 The pain of biliary colic is located over the gall-bladder, 
 at a point three fingers' breadth to the right, and the same 
 distance above the umbilicus. Here the pain begins, and 
 radiates to the right into the back and shoulder, and to the 
 left into the epigastrium, and over the whole abdomen. 
 Pressure over the liver is painful; pressure over the uncovered 
 area of the stomach, if care be taken to avoid the left lobe of 
 the liver, is not so. The dorsal painful-pressure point is to 
 the right and not to the left of the vertebral column, as is 
 the rule in ulcer. Hepatic colic may be excited by a dietetic 
 error, and is not altogether independent of digestion. But 
 it does not appear with regularity after each meal, or neces- 
 sarily during the digestive period, and is not dependent on 
 the physiological action of the food. The paroxysms of 
 hepatic colic are separated by intervals during which all 
 foods are equally and perfectedly digested. The causes 
 which excite the attack are not so palpable as in the diseases 
 of the stomach, but the attacks seem to recur almost acci- 
 dentally. In hepatic colic there is no typical alteration of gas- 
 tric secretion, but the vomit is often superacid. The diagnosis 
 may be very difficult when both a painful hepatic disease and 
 a gastric disease are at the same time present, without char-
 
 THE CLINICAL HISTORY. 4 1 
 
 acteristic symptoms. The attacks of hepatic colic are rarer, 
 and recur irregularly, and often suddenly, without being 
 accompanied by the emptying of the stomach. Nor is he- 
 patic colic ever relieved by food, alkalies, or fluids. Intestinal 
 colic, beginning in the hepatic flexure of the colon, may 
 simulate hepatic colic. 
 
 A large number of diseases of the stomach are painless, or 
 can run their course without distinct pain. This is the case 
 in chronic asthenic gastritis, in many of the dynamic affec- 
 tions involving only the motor functions, and in the milder 
 cases of myasthenia. Under these conditions notable pain is 
 exceptional. Consequently, when pain is a prominent symp- 
 tom, these diseases may be excluded. 
 
 In other diseases the pain is an accident. Such is the case 
 in myasthenia, and in the milder cases of retention, when the 
 pain is the result of fermentation more dependent on the 
 quality of the diet, or on an excessive quantity of food, than 
 on the condition itself. These accidental pains are the result 
 of overdistention, or of local irritation by the products of 
 fermentation. 
 
 In other cases the pain is periodical, and it then appears 
 either during the period of functional activity, or is indepen- ' 
 dent of digestion. In adenohypersthenia the pain develops 
 with the increase of free hydrochloric acid, appears after each 
 meal, and is relieved temporarily by the ingestion of proteids 
 (milk, meats, eggs) and water. In hyperchlorhydria pain is 
 not always present ; when it is present, there must be an 
 increased irritability, in addition to the excessive formation 
 of the hydrochloric acid ; or there must also be hyper- 
 esthesia of the mucous membrane. 
 
 Gastric pain may be cojitimious. Such is the rule with 
 ulcer and advanced cancer. The lesion may allow no periods of 
 entire freedom from pain, while a combination of circumstances 
 increases the pain during the period of digestion. The pain 
 of pyloric carcinoma is often severe, but is even more per- 
 sistently severe on account of the lactic acid formation and of 
 fermentation. Of all the diseases of the stomach, ulcer and 
 pyloric cancer are the most constantly painful. 
 
 Gastric pain may be entirely independent of abnormal 
 nerves. The pain is then due to compression by muscular 
 contraction, when the pain is acute, and subsides with the re- 
 laxation of the muscle ; or it is due to the overdistention with 
 gas, in which case it is dull, aching, heavy^ and disappears 
 with the escape of the gas. The pain is the expression of 
 the motor affection.
 
 42 DISEASES OF THE STOMACH. 
 
 The favorite site of gastric pain is the pyloric region, even 
 when the disease is not confined to this part of the stomach. 
 If this symptom be carefully studied as regards its gene- 
 sis, evolution, duration, intensity, location, diffusion, relations 
 to digestion and to the period of functional repose, to the 
 quality of the food, to the repose or activity of the body or 
 the mind, there is no other gastric symptom that possesses so 
 great a diagnostic value. Its distinctive features in the various 
 painful diseases of the stomach will be found in the fourth 
 and fifth sections of this volume. 
 
 Nausea. — Nausea is a frequent symptom of the diseases of the 
 stomach. It sometimes accompanies a dynamic affection of the 
 stomach, in which case, on close investigation, the cause will 
 often be found to be a reflex or an intoxication expression of an 
 associated intestinal disease. In acute and chronic gastritis 
 nausea mayappear after each meal ; often also during the night, 
 or early in the morning. In the gastric troubles of the anemias 
 it is also frequent. Nausea may occur when the stomach is 
 empty or during the period of gastric digestion. In its nature 
 it is a subjective sensation of disordered peristalsis reflexly 
 produced through the vasomotor nerves, or it is an expression 
 of auto-intoxication, or of irritation of the stomach or the 
 intestines. The symptom is most frequent in the anatomical 
 diseases, and in motor troubles accompanied by fermentation 
 and putrefaction. In cancer it is a more frequent symptom 
 than vomiting. It should be noted whether the nausea is 
 constant or occurs only when the stomach is empty, or only 
 during digestion, and particularly with what symptoms it is 
 associated. It is a rare symptom in many of the diseases of 
 the stomach, and is often present when the stomach is not 
 diseased. 
 
 Flatulency. — Flatulency, or the gaseous distention of the 
 stomach, 'is a frequent symptom. It may be produced in two 
 ways : by the presence of an abnormal quantity of gas in the 
 stomach, or by myasthenia gastrica. 
 
 Myasthenia is the most frequent cause of flatulency, 
 the atonic wall yielding to the natural expansibility of the 
 contained gas. This form of flatulency may be quickly re- 
 lieved by a few eructations, which, however, it may be very 
 difficult to produce voluntarily. There may or may not be 
 an excessive quantity of gas in the stomach, but gas readily 
 accumulates in the myasthenic stomach. 
 
 The gases found in the stomach are swallowed, generated 
 in the stomach by chemical decomposition or by fermen- 
 tation, or are regurgitated from the intestines. Flatulency
 
 THE CLINICAL HISTORY. 43 
 
 may consequently be a sign of excessive swallowing, or too 
 much saliva (carbonates) may find its way into the acid 
 stomach, or there may be too great a quantity of carbonates 
 in the food and drinks. Effervescing drinks also furnish a 
 quantity of gas. The gas regurgitated from the intestines 
 may be formed by fermentation and putrefaction or by the 
 action of the acids of the chyme and of the organic intestinal 
 acids on the carbonates of the pancreatic and intestinal juices. 
 Carbonic acid gas may also be set free in the stomach from 
 the pancreatic juice when it flows back into the stomach. 
 But the most frequent cause of the excessive formation of gas 
 in the stomach is fermentation. So-called gastro-intestinal 
 respiration may be entirely neglected. The excessive quantity 
 of gas may accumulate in the stomach in spasm and obstruc- 
 tion of the pylorus. Clinically, daily recurring flatulency (not 
 belching simply) is a sign of either myasthenia, pyloric spasm, 
 or of obstruction, or of gas-forming fermentation. This guide 
 is more trustworthy if care be taken to keep the bowels freely 
 open and to exclude effervescing drinks and carbonates. 
 
 Regurgitation. — In regurgitation the contents of the stomach 
 are brought up into the mouth, usually involuntarily and with- 
 out effort. When the stomach contents are returned to the 
 mouth to be again masticated and swallowed, the condition 
 becomes a distinct affection known as rumination. 
 
 Regurgitation occasionally occurs as a mere accident or 
 episode of normal digestion, particularly after a heavy meal. 
 Pathologically, regurgitation may be a symptom of a disease 
 of the stomach, or, when it is habitual, constitute an idio- 
 pathic dynamic affection of the stomach, described in the 
 fourth section of this volume. 
 
 Regurgitation is most frequent during the period of diges- 
 tion, but may occur during the period of repose. Occurring 
 during the period of repose of the stomach, the regurgitated 
 matter is usually insipid or slightly acid, and it consists of- 
 saliva mixed with exudation and mucus from the gastric 
 mucous membrane, and sometimes also it is composed in 
 part of the unevacuated remnants of the previous meal. 
 This form of regurgitation is most frequent in myasthenia 
 with stagnation, and in mild cases of gastritis. 
 
 Digestive regurgitation is produced by overdistention of the 
 stomach, and by excessive hydrochloric and organic acidity. 
 It is most frequent in myasthenia and in gastritis or gastric 
 irritation. If the flavor of the regurgitated matter is both 
 bitter and acid, so as to set the teeth on edge, hydrochloric 
 superacidity is most likely the cause. If only bitter, the
 
 44 DISEASES OF THE STOMACH. 
 
 taste may be due to altered bile or to peptones. If the regur- 
 i^itated matter both tastes and smells sour, there is probably 
 fermentation. In cancer of the esophagus or stomach, and in 
 esophageal retention, it ma}' be foul. It should not be for- 
 gotten that regurgitation may be esophageal, and the matter 
 consist of food and saliva collected above a constriction, in a 
 pocket, or above a spasm or obstruction of the cardia. 
 
 In pyloric incontinence, myasthenic retention, gastroptosis, 
 neurasthenia gastrica, and in many of the dynamic affections, 
 regurgitation rarely or never occurs, and the symptom pos- 
 sesses a negative diagnostic meaning. 
 
 Vomiting. — Vomiting may be a symptom of a large number 
 of diseases, and does not necessarily imply that the stomach 
 itself is abnormal. Vomiting is almost as frequent a symptom 
 of the diseases of the intestines as of the diseases of the 
 stomach itself. All the forms of vomiting should be carefully 
 separated from the vomiting symptomatic of a disease of the 
 stomach. Nervous vomiting as a morbid entity is rarer than 
 is commonly supposed. For the discussion of this symptom, 
 and of hematemesis, the reader is referred to the chapters on 
 Nervous Vomiting and Ulcer, respectively. 
 
 Appetite. — The variations of the appetite, to be of diagnostic 
 value, must be the expression of a disease of the stomach. 
 Fatigue, the change from an active to a sedentary life, a hot 
 climate, old age, monotonous diet, moral strain, physical 
 pain, are all accidental causes of a diminished appetite. The 
 appetite may be very variable, and not in relation to the state 
 of the stomach, but to that of the brain. The general or local 
 cry for food, or the protest against it, is too composite to be 
 utilized to point to the location and the nature of the disease 
 except under a particular condition. The variations are 
 not infrequently due to the coating, the laying bare, or the 
 alteration of the nerves of taste, in the diseases of the mouth. 
 The appetite is influenced by the environment, the mental 
 and moral conditions, the state of nutrition, and by many 
 organic and general diseases, but particularly by intestinal 
 auto-intoxication and by severe pain. The appetite, however, 
 when associated with symptoms pointing clearly to a disease 
 of the stomach, becomes of use in diagnosis. 
 
 A false hunger may appear at the end of the period of 
 digestion, and is then due to the continuance of secretion after 
 the stomach is empty. 
 
 In all the secondary and the complicated diseases of the 
 stomach the character of the appetite possesses little diagnostic 
 value, and does not indicate the form of trouble present.
 
 THE CLINICAL HISTORY. 45 
 
 The appetite also does not vary with the changes of secretion. 
 In simple subacidity without fermentation the appetite is nor- 
 mal. In simple superacidity, however, the appetite is normal 
 or increased. In the dynamic affections, not assuming a fixed 
 character like bulimia and anorexia, or in the anatomical 
 diseases growing in a neuropathic soil, the appetite is often 
 rapidly variable, extremely perverted, or easily changed by 
 mental impressions or by a few mouthfuls of food. But these 
 are only presumptive signs that demand control, and possess 
 no characteristics which can be considered as certain or abso- 
 lute. The rules admit of many exceptions because of the 
 many associations and the wide relations of this special sensa- 
 tion. 
 
 Anorexia, when the expression of gastric trouble, is either 
 nervous or organic. The nervous form occurs in the neuro- 
 pathic girl, is commonly complete for all food, and gives no 
 concern to the patient. Long-continued anorexia, due to 
 organic disease of the stomach, is a very grave sign. The 
 patient makes every effort to overcome it, but without suc- 
 cess. 
 
 In cancer, and in other anatomical diseases attended by bac- 
 terial decomposition of the food, the appetite is diminished and 
 may develop into disgust for particular classes of food. The 
 appetite grows less and less as the intervals when the stomach 
 is empty become shorter and shorter. The food against 
 which the appetite is directed belongs to that class which is 
 undergoing fermentation or putrefaction. In ulcer the appe- 
 tite is maintained, though the quantity of food eaten may be 
 markedly diminished on account of pain or the fear of pain 
 associated with the entrance of food into the stomach. In the 
 latent form of ulcer the appetite is, as a rule, uncommonly 
 good. 
 
 Thirst. — Thirst is a less valuable diagnostic sign. It is 
 augmented in fermentation, and in diseases attended by a 
 marked diminution of absorption. An increased desire for 
 fluids is often present, also, in the secondary gastritis of both 
 alcoholism and Bright's disease. Thirst is also a sign of 
 poverty of the fluids of the body, caused by increased elimi- 
 nation, by loss in hemorrhage, and by vomiting. In super- 
 secretion, the desire may be almost irresistible. Thirst is 
 sometimes diminished in the nervous affections. 
 
 The gastric symptoms which have been thus far described 
 are primary, being generated and expressed in the stomach 
 itself. But there are also secondary symptoms, which are 
 very frequent, and are very valuable guides in the search for
 
 46 DISEASES OF THE STOMACH. 
 
 the existence of a stomach disease. The secondary symp- 
 toms may be the only manifestations, the primary symptoms 
 sometimes bein<j altogether absent. 
 
 The secondary symptoms are generated in three ways: 
 some of them are reflex and nervous; some are due to gas- 
 tric auto-intoxication ; others are the result of inanition. 
 
 Emaciation and loss of strength are symptoms of only a 
 {t\y of the simple diseases of the stomach. The inanition is 
 often wholly due to an insufficient diet, the little that is eaten 
 bein^ well digested and utilized. This form of inanition is 
 seen in anorexia nervosa, in ulcer, and in the other painful dis- 
 eases of the stomach. The insufficient diet may be self- 
 infficted by the patient, or mistakenly or properly prescribed 
 by the physician for a definite purpose. In other cases, the 
 inanition is the result of excessive vomiting, or of the malig- 
 nant nature or the advanced stage of an anatomical disease. 
 There is no doubt that long and severe suffering may produce 
 emaciation and loss of strength, a fact well expressed by the 
 phrase " the disease is wearing me out." But the most 
 frequent causes of inanition of gastric origin are obstruction 
 of the pylorus and myasthenic retention. The food is im- 
 perfectly digested, is often periodically lost by vomiting, 
 and undergoes fermentation in the stomach, and putrefaction 
 and fermentation in the bowels. The pernicious effects of 
 auto-intoxication result, and the intestines, being disordered 
 by the vicious chyme, are unable to establish digestive com- 
 pensation. Inanition is also marked in uncompensated gastric 
 atrophy. Whenever emaciation and loss of strength are 
 associated with a disease of the stomach, we should first 
 ascertain whether a sufficient quantity of food is being eaten 
 and retained, and whether the intestines are healthy. If 
 such be the case, marked inanition is most likely due to 
 carcinoma, or to some of the causes of gastric retention. 
 Long-continued retention and cancer inevitably produce 
 inanition. Anorexia nervosa, vomiting, ulcer, and hyper- 
 sthenic gastritis may result in inanition. The other dis- 
 eases of the stomach do not directly affect nutrition. Con- 
 sequently, the symptom has both a negative and a positive 
 diagnostic value. 
 
 The refle.x nervous symptoms are very numerous, and are 
 dependent for their existence and their intensity on the sensi- 
 bility of the nervous system and on the irritation of the 
 gastric nerves. The irritable weakness of the nerve-centers 
 is produced by the numerous causes of neurasthenia. The 
 gastric nerves are irritated by the contents of the stomach-
 
 THE CLINICAL HISTORY. 4/ 
 
 products of fermentation, irritant foods and drinks, prolonged 
 digestion, as in retention, stagnation, and intemperate eating 
 — by an anatomical lesion like ulcer, hypersthenic gastritis, 
 cicatrices, adhesions, and cancer, and by the nerve stretching 
 incident to developing displacements of the stomach. 
 
 The gastric irritation is transmitted by the vagosympathetic 
 to the spine, to the medulla, to the brain, and directly also to 
 the heart, lungs, and intestines. In this manner the functions 
 of these parts become disturbed. 
 
 Gastric is much less frequent than intestinal auto-intoxica- 
 tion, because in the stomach putrefaction is rare, and absorp- 
 tion is slow or absent. A healthy liver is usually able to pro- 
 tect the system against gastric intoxication, but the functions 
 of the liver are, unfortunately, often insufficient. The barrier 
 against gastric intoxication is then removed, provided the 
 poisons are there formed in sufficient quantity. That poison- 
 ous doses are formed in the stomach is by no means certain. 
 
 It is well known that chronic putrefaction is rare in the 
 stomach. Sometimes hydrosulphuric acid is formed in benign 
 retention, but in no greater quantities than occurs in the 
 intestines without giving rise to intoxication. It is certainly 
 true that acute gastric putrefactive auto-intoxication does 
 occur, but usually only when the poisons have been formed 
 before the food enters the stomach. In every case of chronic 
 putrefactive poisoning that has come under our observation 
 it has proven to be of intestinal origin, even where associated 
 with gastric retention. It would be rash to deny that tox- 
 albumins are formed in the pathological stomach in sufficient 
 quantities to produce auto-intoxication, but a theory built on 
 such a supposition is based on our ignorance. 
 
 Gastric fermentation, however, is very common, but the 
 gases and the organic acids formed by fermentation are not 
 very poisonous. The most injurious are the fatty acids. The 
 others have only a local effect. 
 
 The secondary symptoms are very numerous, but are of 
 very little utility in the diagnosis of a particular disease of 
 the stomach. Certain mental symptoms, disorders of sensa- 
 tion, disorders of the special senses, disturbances of the heart's 
 action, cough, dyspnea, vertigo, drowsiness, stupor, coma, 
 headache, neuralgia, tetany-like cramps, extreme and inter- 
 mittent muscular weakness, etc., may be due to a disease 
 of the stomach. These symptoms are described in the sixth 
 section.
 
 48 DISEASES OF TJIE STOMACH. 
 
 CHAPTER II. 
 THE PHYSICAL SIGNS. 
 
 The physical signs are those obtained by the physician 
 through the special senses, and include inspection, palpation, 
 percussion, inflation, auscultation, and electric illumination, 
 aided by special devices. These objective signs reveal the 
 physical deviations from the normal, and instruct us concern- 
 ing the size, the form, the position, the distensibility, the mus- 
 cular activity, the neoplasms, and the sensibility of the stomach, 
 as well as some of the physical properties of its contents. 
 
 The physical examination of the stomach is a very old 
 procedure, but during the past decad it has been improved 
 in technic, and the precise meaning of each sign has been 
 sought with tireless energy. The physical examination is no 
 less important than the more modern f^^nctional exploration, 
 and has the unique advantage of being universally appli- 
 cable. 
 
 The physical examination of the stomach is based on a 
 knowledge of its practical anatomy, and the clinician should 
 be well grounded in this branch. Many of the finer anatomi- 
 cal details may properly be neglected at the bedside, and 
 only those which have a practical bearing need here be 
 recalled to mind. 
 
 The digestive tube is a permeable canal, developed from 
 the tegumentary layer, beginning with the mouth, and curling 
 irregularly through the body it ends with the rectum. The 
 mouth and esophagus, and their connecting cavity, the 
 pharynx, lie above the abdominal cavity, which extends from 
 the under surface of the diaphragm to the rim of the true 
 pelvis. The rectum, the lowest division, lies in the cavity of 
 the true pelvis ; the other anatomical divisions — the stomach, 
 duodenum, jejunum, ileum, cecum, colon, and the sigmoid 
 flexure — are situated in the abdominal cavity. 
 
 Fixed points on the abdominal wall should be taken as 
 the surface landmarks to be used in the investigation of the 
 physical changes and relations of the abdominal organs and 
 viscera. The division of the abdomen into regions, by arbi- 
 trary and imaginary lines, is not free from objections. We 
 shall take the easily accessible points of the skeleton and the 
 umbilicus as the basis of abdominal localization. Of these, 
 the umbilicus is the only movable and variable point. In the
 
 THE PHYSICAL SIGNS. 49 
 
 perfectly normal abdomen, the umbilicus is in the median 
 line in front and on a level with the tip of the spine of the 
 third lumbar vertebra, a little below the center of a line join- 
 ing the ensiform process and the symphysis, and about one 
 inch above a line drawn across the abdomen between the 
 highest points of the iliac crests. Thus is found the normal 
 umbilicus or umbilical point. 
 
 The skin over the epigastrium is supplied by the sixth and 
 seventh intercostal nerves, the region about the umbilicus by 
 the ninth and tenth, and the iliac regions by the upper lumbar 
 nerves. The lateral cutaneous nerves (branches of the lower 
 seven dorsal and two upper lumbar nerves) supply both the 
 skin and the muscles of the abdomen. Pathological irritation 
 of these nerves contracts the abdominal muscles and pro- 
 duces pain about the umbilicus. 
 
 The sensory nerves of the abdomen are in communication 
 with the thoracic sympathetic ganglia, from which arise the 
 greater and the lesser splanchnics. It is through these 
 nerves, which are connected with the cord and the abdominal 
 ganglia, that the skin becomes very sensitive, and the abdom- 
 inal muscles become contracted, in the painful diseases of the 
 abdomen. The hyperesthesia of the skin, and the muscular 
 contraction, may be general or localized, with the diffusion or 
 localization of the internal disease. 
 
 Digestion proper begins in the stomach — a dilatation of 
 the digestive tube, between the lower end of the esophagus 
 and the beginning of the duodenum ; in form it is irregular, 
 pear-shaped, somewhat flattened anteroposteriorly ; and it is 
 lined with an exceedingly rich, glandular, internal membrane. 
 In this viscus the action of the saliva is continued, the trans- 
 formation due to the gastric secretion begins, and a second 
 function, that of absorption, probably commences. The ab- 
 normal physical variations of the stomach are numerous 
 and, clinically, very important. A description of its normal 
 anatomical relations and its surface landmarks has a practical 
 bearing. 
 
 Three-fourths of the stomach lies to the left of the median 
 line, in the upper part of the abdominal cavity, in contact 
 and close union with the under surface of the diaphragm. 
 The remaining one-fourth crosses the median line in the epi- 
 gastrium. The stomach lies in a nest formed by the liver, 
 diaphragm, spleen, pancreas, suprarenal capsules, intestines, 
 liver, and abdominal wall. 
 
 The stomach is suspended and held in position by its con- 
 tinuation with the esophagus and duodenum, and by its close 
 4
 
 50 DISEASES OF THE STOMACH. 
 
 union with the diaphragm (gastrophrenic ligament), and with 
 the peritoneal folds connecting it with the liver (gastrohepatic 
 omentum), and with the spleen (gastrosplenic omentum). 
 The greater curvature is free, and rests on the lesser omen- 
 tum and on the intestines, which form for it a sort of support. 
 The contact of the colon and the stomach may partly explain 
 the association of their peristaltic movements. The investing 
 peritoneum hangs in two layers from its movable lower bor- 
 der, and forms, with the inclosed vessels and the fat, a more 
 or less complete covering of the intestines. A few coils of 
 the intestines are left uncovered in the left iliac fossa, but the 
 greater omentum may be shortened, rolled up, deformed, or 
 imperfectly developed. It is attached to the transverse colon, 
 and forms the gastrocolic ligament, often associating the 
 colon and the stomach in their displacements. 
 
 The stomach moves up and down with respiration, which 
 act serves to keep its contents in motion. Except when there 
 are abnormal adhesions, the associated movement is not so 
 close that the stomach can not be fixed, on expiration, by the 
 pressure of the examining finger. This peculiarity is made 
 use of in the differential diagnosis of the tumors of the 
 stomach. 
 
 The direction of the long axis is from the left in front and 
 above, to the right downward and backward, and corresponds 
 approximately with a line slightly curved downward and 
 joining the left nipple with the tip of the right eleventh rib. 
 Pathologically, the acute angle formed by its axis with a 
 transverse line across the abdomen may be increased, and with 
 the vertical stomach becomes nearly a right angle. In the 
 deformities of the stomach the axis is a very irregular line. 
 In the adult, it varies in length from ten to fourteen inches, in 
 health. 
 
 The size of the stomach is variable and is dependent on 
 the age, and is largely influenced by the dietetic habits 
 of the person. An arbitrary standard is valueless as a 
 diagnostic criterion. The absolute size has no definite re- 
 lation with the maintenance or loss of functional power. 
 A change of size between two dates of examination is of 
 value. The size can also be of diagnostic use when taken 
 into consideration with other signs and symptoms. An 
 inference as to the tone or the muscular power of the stom- 
 ach, drawn from its size or from its capacity, is illogical 
 and may be false. The greatest diameter, measured from 
 the cardia, is about six inches ; the greatest anteroposterior 
 diameter about 45^2 inches ; and the pyloric end is about i^/z
 
 THE PHYSICAL SIGNS. 5 I 
 
 inches through. The normal capacity varies from 300 to 
 2000 c.c, in round numbers. 
 
 The descriptive anatomy of the stomach has a practical 
 bearing on pathology and diagnosis. The viscus has two 
 openings, two ends, two surfaces, two curvatures, two divi- 
 sions of the cavity, and two localized, sac-like dilatations. 
 
 The two orifices are the cardiac, or esophageal, and the 
 pyloric,, or duodenal. The cardiac opening is situated on a 
 level with the spinous process of the ninth dorsal vertebra, 
 one inch below the diaphragm, between the lesser curva- 
 ture and the beginning of the upper division of the fundus, 
 behind the cartilage of the seventh left rib, about one inch 
 to the left of its union with the sternum, and is covered 
 by the left lobe of the liver. This orifice is fixed and held 
 firmly in position by the esophagus, by the union of the 
 peritoneal coverings of the stomach, by the diaphragm, and 
 by the gastrophrenic ligament. It is inaccessible to palpa- 
 tion. The pylorus is on a level with the twelfth dorsal ver- 
 tebra and the ensiform process, lower but to the right and 
 over the lumbar attachment of the diaphragm, about two 
 inches below the cartilage of the right seventh rib, and on a 
 line drawn parallel to and midway between the median line 
 of the sternum and the right border of this bone. It touches, 
 below, the pancreas and the transverse colon ; above, the 
 liver and the gastrohepatic omentum ; and posteriorly, the 
 portal vein and the hepatic artery. It has no proper liga- 
 ment or mesentery, is slightly movable, normally, and its 
 displacement draws on the second part of the duodenum, 
 which is firmly attached to the posterior abdominal wall. 
 Pathologically, it may be found in almost any part of the ab- 
 dominal cavity. 
 
 The anterior surface is directed obliquely from before and 
 above, backward and downward, and is in relation with the 
 left lobe of the liver, the diaphragm, and the abdominal wall. 
 When the viscus is distended, the greater curvature rotates 
 forward, and the plane of the anterior surface is correspond- 
 ingly displaced. 
 
 The posterior surface faces backward and downward, rests 
 upon the mesocolon, and is in relation with the third part of 
 the duodenum, with the superior mesenteric vessels, and with 
 the pancreas. Further behind are the aorta, the pillars of the 
 diaphragm, and the posterior abdominal wall. The lesser 
 curvature lies beneath the left lobe of the liver, is grasped by 
 the gastrohepatic omentum, faces with its concavity above or 
 posteriorly, as the stomach revolves on an axis corresponding
 
 52 DISEASES OF THE STOMACH. 
 
 quite closely with a line joining the cardia with the begin- 
 ning of the second part of the duodenum, and is on a level 
 with the upper border of the first lumbar \-ertebra, and curves 
 around the lobus Spigelii, the celiac trunk, and the solar 
 plexus. Normally, it is inaccessible to palpation. On it, 
 near the pylorus, and about four inches from the cardia, is the 
 pyloric tubercle, the most frequent starting-point of carci- 
 noma of the stomach. 
 
 The greater cur\'ature begins at the cardia, curves upward 
 beneath the left lung to the upper border of the fifth rib, and 
 turns rapidly downward along the anterior border of the 
 spleen. It emerges from beneath the false ribs between the 
 cartilages of the ninth and tenth ribs, runs nearly horizon- 
 tally to the median line, forming a curve which marks the lo- 
 cation of the lesser cul-de-sac on its way across the lineaalba 
 to the pylorus. The upper part of the fundus, marked out by 
 this line, is covered by the left lung ; the second part is cov- 
 ered by the false ribs and by the abdominal wall. The full 
 stomach thus extends from the fifth rib to i ^2 inches above, 
 or even below, the umbilicus. 
 
 The greater curvature approaches the lesser when the 
 stomach is empty, and the pylorus moves to the left and lies 
 beneath the median line of the abdomen. The empty organ 
 lies deep within the concavity of the diaphragm, away from 
 the abdominal wall, and is comparatively inaccessible to physi- 
 cal examination. 
 
 The size and form of the stomach are changed by the 
 pressure of the surrounding organs, by the quantity and the 
 quality of the contents, and by the tonicity and the patholog- 
 ical condition of its walls. In the physical examination, the 
 relation of the viscus to the heart, the lungs, the liver, the 
 spleen, the intestines, and the abdominal wall should be re- 
 membered. 
 
 The normal stomach is accessible to physical examination 
 only over a limited area. This area is bounded on the right 
 by the left lobe of the liver, above by the heart and the left 
 lung, on the left by the spleen and the colon, below b\' the 
 colon. The line of demarcation begins on the lower border 
 of the left lobe of the liver, follows the greater curvature, or 
 the upper border of the colon, to the cartilage of the ninth 
 rib ; proceeds upward, along the anterior border of the spleen, 
 to the lower border of the sixth rib in the anterior axillary 
 line, and to the right of the cartilage of the seventh rib. The 
 area bounded by this line, and h'ing to the left of the left 
 costal border, is known as the half-moon-shaped space of
 
 THE PHYSICAL SIGNS. 53 
 
 Traube. Only a small triangular area of the stomach lies 
 in contact with the muscular abdominal wall, and is bounded 
 by the left costal border, by the greater curvature, and by the 
 lower border of the left lobe of the liver. 
 
 The appearance of the abdomen varies with the position 
 of the body, the age, the muscular development of the pa- 
 tient, and the state of the contents of the abdominal cavity. 
 Besides, the previous contents of the abdomen leave their 
 markings on the front of the abdomen, so that we may read 
 on the abdominal wall, in addition to the present state, the 
 history of gross physical changes in the contents of the ab- 
 dominal cavity. The abdomen of a child — on account of the 
 large size of the liver and the stomach, and the smallness of the 
 pelvis and the crude muscular development — presents a dif- 
 ferent appearance from that of an adult. In a child the bladder 
 and rectum are higher in the abdomen, and the stomach is cov- 
 ered to a greater extent by the left lobe of the liver. 
 
 The abdomen of the healthy and well-developed adult 
 presents prominences and depressions corresponding to the 
 bellies and ligaments of the abdominal muscles. The de- 
 pressions are the median furrow (linea alba), between the 
 ensiform cartilage and the lower fourth of the abdomen, and 
 the right and left lateral furrows along the outer borders of 
 the recti muscles. The recti muscles are inclosed in sheaths, 
 and when strongly contracted present four prominences, 
 marked off by transverse depressions, on a level with the 
 eighth and ninth costal cartilages and the umbilicus. Neither 
 these prominences nor the localized contraction of the bun- 
 dles of fibers composing the muscles should be mistaken for 
 physical changes in the contents of the abdominal cavity. 
 
 I. Inspection. — The inspection signs are remarkably true in 
 their signification, but they are, unfortunately, also very few 
 as regards the diseases of the stomach. But in exceptional 
 cases inspection may rapidly reveal the nature and the 
 severity of the disease. 
 
 In order to give unity and method to the work, we go from 
 the general surface examination of the body to the inspec- 
 tion of the mouth and the throat, the general inspection of 
 the abdomen, and, lastly, to that of the stomach itself. 
 
 The sharp and quick glance of the old clinician is a power 
 well worthy of cultivation. It takes only a few moments to 
 note the state of nutrition, the color of the mucous mem- 
 branes, the character of the patient's expression, the condi- 
 tion of the skin, and the glandular swellings — which may all 
 be connected with diseases of the stomach.
 
 54 DISEASES OF THE STOMACH. 
 
 The relaxation of the muscular system may be a revealing 
 sign. The languid, tired, expressionless face of the niyoneu- 
 rasthenic is well known. 
 
 In the dynamic affections of the stomach the general con- 
 dition may be satisfactory, and the vivacity, the rotundity of 
 form, and the rosy hue of health may be in vivid contrast 
 with the nervous, restless, melancholy complaints. In ano- 
 rexia nervosa and in myasthenic retention, however, emacia- 
 tion may be as great as in carcinoma. 
 
 In severe diseases the adipose layer may be lost, the 
 abdomen sunken and flabby, the viscera rolling down into 
 the sides, away from the vertebral column, when the patient 
 is on the back, and the skin may be peculiarly discolored, in 
 keeping with the causative troubles. Obstruction of the 
 cardia and pylorus, carcinoma, hypersthenic gastritis, uncom- 
 pensated glandular atrophy, and hemorrhagic ulcer are the 
 most common anatomical diseases, which may be accom- 
 panied by cachexia. The sunken eye of exhaustion and the 
 pinched and furrowed features of the painful diseases should 
 not escape notice. An extreme pallor of the skin and 
 mucous membranes suddenly developing in a painful disease 
 of the stomach, accompanied by restlessness but not by 
 nausea and vomiting, is a valuable clinical sign of a concealed 
 hemorrhage in an ulcer. The intensity and the association of 
 these general inspection signs give some information con- 
 cerning the severity and the possible nature of the trouble. 
 
 The inspection of the mouth, the nose, and the throat 
 should include the state of the teeth and the tongue, and of 
 the mucous membranes and the glands. The cause of the 
 gastric trouble may often be found here. 
 
 The bacteria of the mouth enter the stomach through 
 the swallowed saliva and the food. A foul tooth is a breed- 
 ing nest. The teeth should be clean and the cavities filled, 
 and losses should be replaced by artificial teeth. Even when 
 the teeth are good, mastication and insalivation may be badly 
 performed. The carbohydrates, when mixed with saliva, ex- 
 cite the secretion of the stomach more freely than when they 
 are swallowed immediately or when they are introduced into 
 the stomach through the tube. This result is due chiefly to 
 the physiological action of the sugar (developed by the saliva) 
 on secretion. The motor work is also more easily and more 
 rapidly performed when the food is finely divided. Decayed 
 teeth and imperfect insalivation may be the primitive and the 
 sole causes of gastric symptoms. Correction of these defects 
 may be all the etiological treatment that the patient requires.
 
 THE PHYSICAL SIGNS. 55 
 
 The tongue is not a mirror of the stomach, as the ancients 
 supposed. A clean tongue is an index of local cleanliness, 
 local health, and the state of the secretions of the mouth. 
 The coating is a layer of morbid secretion or degenerated 
 cells, and of bacteria. The secretions of the mouth are 
 altered, in many conditions, by the diseases of the stomach, 
 but not in a known, a constant, and a particular manner. The 
 tongue is a local mirror, which reflects only that which comes 
 over its surface. A heavily coated tongue may be a cause of 
 loss of appetite. 
 
 The character of the secretions of these parts is of more 
 practical value. These pathological changes are excited by 
 external or by constitutional causes. Among the many in- 
 ternal causes, the diseases of the stomach form one. The 
 nose and throat changes will be described in the special sec- 
 tion on the vicious circles of the stomach. For the present 
 it need only be emphasized that the vicious circle is com- 
 pleted by the purulent, decomposing, irritating secretions 
 from these cavities finding their way into the stomach and 
 exciting trouble there. A chronic irritable sore throat may 
 produce reflex nausea and vomiting. An inspection of the 
 mouth, the nose, and the throat may reveal the source of a 
 hemorrhage. 
 
 We begin the inspection of the abdomen after the patient 
 has been placed in the proper position and light and the 
 abdomen and the greater part of the chest have been laid bare. 
 
 The person lies on the back, with the spine in contact all 
 along with the lounge, the head comfortably raised, the extrem- 
 ities symmetrically extended, and the whole muscular system 
 relaxed. To hold the legs flexed on the abdomen requires 
 effort, and makes complete muscular relaxation impossible. 
 And what is equally objectionable is that in this position 
 they are in the way of the examining physician. The light 
 should fall horizontally from over the feet of the patient. In 
 this position the patient is requested to breathe quietly and 
 regularly, and to relax all the muscles. 
 
 The whole abdomen should be inspected, and all the devia- 
 tions from the normal should be noted. But we must here 
 limit our description to the inspection signs due to the con- 
 ditions of the stomach. 
 
 It need not be expected that more than gross ph}'sical 
 changes will be revealed by this method. 
 
 As regards the stomach, we may discover by inspection : 
 (i) Distention of the viscus ; (2) contraction; (3) displace- 
 ments; (4) tumors; and (5) peristalsis.
 
 56 DISEASES OE THE SlOMACJl. 
 
 1. The distended stomach ma)' be clearly and visibly out- 
 lined on the abdominal wail, if the wall is relaxed and suf- 
 ficiently thin. This condition may be normal after a heavy 
 meal, but is also frequently pathological and due to reten- 
 tion of food and secretions, swallowed air, and, at times, 
 to gas generated by fermentation. Grooves, marking the 
 sweep of the greater and lesser curvatures, may be seen, 
 and both the size and the location of the viscus may be 
 thus truly revealed. During the period of functional repose 
 the stomach is found distended in myasthenia with retention, 
 and in pyloric obstruction. In the latter condition, the 
 prominence is usually much greater than in the former, on 
 account of the associated hypertrophy of the muscular layer. 
 Self-inflation of the stomach by the gases of fermentation may 
 be observed, but is of rare occurrence. The stomach fills, 
 and then suddenly collapses as the gas escapes through the 
 pylorus. The absence of visible distention at the moment of 
 examination, naturally does not exclude the diseases which 
 produce it. The form and position of the stomach are most 
 easily seen when the stomach is full, but the significance of 
 the distention is determined by the time after the last meal 
 when the examination is made. 
 
 2. The contracted stomach is less easily recognizable by 
 inspection than is the distended or displaced organ. In 
 obstruction of the esophagus and in cancer of the cardia, 
 the stomach may be very small and retracted. The alinost 
 empty, collapsed abdomen, with its thin covering, presents 
 a slight prominence, which extends about as far as the 
 lower border of the left lobe of the liver. During the 
 paroxysms of adenohypersthenia also the abdominal wall and 
 the stomach may both be strongly contracted ; but the face 
 displays deep lines of suffering. The stomach may be norm- 
 ally very small, and the accompanying emaciation may be 
 due to diseases elsewhere than in the stomach. The stom- 
 ach is often very small in scirrhus, in cirrhosis ventriculi, and 
 in chronic starvation. 
 
 3. Inspection may give very truthful information concern- 
 ing the location of the stomach. The small corset-waist, 
 with the rounded epigastrium, suggests a deformed liver and 
 a stomach pressed into a vertical position. The lesser cul- 
 de-sac may then be the lowest part of the stomach, and the 
 region just to the left of the median line and down to the 
 umbilicus may be prominent after meals. If the stomach be 
 prolapsed and full, the displacement maybe easily recognized 
 by inspection — the epigastrium is depressed, the abdomen
 
 THE PHYSICAL SIGNS. 57 
 
 about the umbilicus — and chiefly to the left of it — is promi- 
 nent, and the grooves of the greater and the lesser curva- 
 tures may be seen moving slightly with the diaphragm. 
 If the stomach be empty, the displacement may not be notice- 
 able, or may be less evident. 
 
 4. A visible neoplasm of the stomach is, almost without 
 exception, carcinoma, and may often be seen moving up and 
 down with the diaphragm. The visible neoplasms are com- 
 monly located on the lesser curvature, and are easiest seen 
 when so located, while the stomach is empty. 
 
 It must not be imagined that a visible tumor in the epigas- 
 trium, which moves with respiration, is always a tumor of the 
 stomach. Indeed, the visible moving prominence may not be 
 a neoplasm. The transverse colon, when filled or distended, 
 may often be seen moving up and down as a prominence on 
 the thin abdominal wall, in the lower third of the line joining 
 the ensiform process and the navel, and to the left or the 
 right of the median line, or both. This ridge is often mis- 
 taken for the lesser curvature, and a gastroptosis is supposed 
 to exist; or it is mistaken for a gastric neoplasm. The 
 respiratory movement of the abdominal organs is not depend- 
 ent solely on an attachment to the diaphragm, but all of 
 them move which are caught in the swing between the dia- 
 phragm and the abdominal wall, or are influenced by the 
 increase or the decrease of intra-abdominal pressure. The 
 closer, however, the union is with the diaphragm, the greater 
 is the difficulty of fixation on expiration. 
 
 5. The peristaltic movements of the displaced or obstructed 
 stomach are often visible. These peristaltic waves come out 
 from beneath the left false ribs and roll across the abdomen 
 to the pylorus. When most violent, the peristalsis may be 
 followed by a visible antiperistalsis. The peristalsis may be 
 excited when the organ is moderately filled with cold water, 
 by ether sprayed over the epigastrium, by faradization, by an 
 effervescent drink, or, more conveniently, by a {&\v gentle 
 strokes with the tips of the fingers. Visible peristalsis results 
 from the strong efforts of the stomach to overcome an ob- 
 struction to its evacuation. It is most common in pyloric or 
 duodenal obstruction, in gastroptosis with angular constric- 
 tion of the duodenuin, and it exists rarely as a particular dy- 
 namic affection of the stomach. In cancerous obstruction 
 of the pylorus it is much rarer than in benign obstruction 
 with excessive secretion. 
 
 The loss of tone of the abdominal muscles plays an impor- 
 tant part in the pathology of the stomach. In health, the
 
 58 DISEASES OF THE STOMACH. 
 
 elasticity of these muscles subjects the abdominal contents 
 to a limited degree of pressure, and affords them a certain 
 amount of support conducive to their nutrition and to the 
 performance of their functions. Abdominal tension also 
 regulates the lymph and venous circulations of the abdomen. 
 The flabby wall e.xerts no pressure, and the weight of the 
 unsupported stomach drags on its attachments. Inspection 
 may at once reveal this half-filled bag-like abdomen, which 
 is an inspection sign, not properly of the stomach itself, but 
 is often associated with the displacement of this viscus and 
 with a poor abdominal circulation. The inspection of the 
 abdomen yields both positive and negative information. 
 Some diseases of the stomach display no visible physical 
 changes; some are made manifest by particular inspection 
 signs. A negative result of inspection excludes with proba- 
 bility the latter class of diseases, and limits investigation to 
 those diseases which yield no inspection signs at any period 
 during their evolution. 
 
 The stomach may also be inspected during its illumination. 
 For this purpose the stomach-lamp and the gastroscope may 
 be used. 
 
 2. Electric Illumination of the Stomach. — A simple and prac- 
 tical method of illuminating the stomach was first devised and 
 employed for the purpose of diagnosis by Einhorn. Other 
 cavities of the body had already been successfully illuminated, 
 and Milliot had employed the electric light to illuminate the 
 stomach of the cadaver and of animals. But for a simple 
 method of illuminating the human stomach during life for the 
 purposes of diagnosis, we are indebted to the inventive genius 
 of Einhorn. The instrument consists of an ordinary stomach- 
 tube with a small Edison lamp, which is inclosed in a thick 
 glass capsule at the lower extremity (Fig. i). The conduct- 
 ing wires run in the lumen of the tube and connect with a 
 storage battery. Some of the instruments now in use have 
 openings for the introduction and withdrawal or continuous 
 circulation of water. The lamp can be kept cool without the 
 use of a continuous current, and cleanliness demands the use 
 of a tube without openings. The electric illumination of the 
 stomach has been thoroughly studied by Einhorn. by Heryng 
 and Reichman, by Kuttner and Jacobson, and b\' Meltzing, 
 and others. Some of these writers claim for this method of 
 examination greater accuracy and utility than, in our opinion 
 and experience, it possesses. 
 
 Before the e.xamination. which should be made in a dark 
 room, the stomach is thoroughlv washed out, unless it be
 
 THE PHYSICAL SIGNS. 
 
 59 
 
 already empty. Two or three glasses of water are adminis- 
 tered, or introduced through the tube before it is withdrawn. 
 The electric lamp is next introduced in the same manner as 
 the ordinary stomach-tube. The patient usually stands during 
 the examination, but may also lie on the back. The current 
 is turned on and broken at short intervals in order to avoid 
 heating the lamp. When the light is turned on, the illumi- 
 nated stomach is displayed as a bright area on the abdominal 
 wall, shaded by the recti muscles, crossed by the veins, and 
 
 Fig. 1. — Ewald's Eiiihoni stomach-lamp. 
 
 bounded in part and at times by the curvatures of the stomach. 
 After the general illumination, the lamp may be pushed 
 further on toward the pylorus and made to wander along and 
 to locate the greater curvature as the tube is slowly with- 
 drawn. The water may be left in the stomach. 
 
 The information obtainable by the electric illumination of 
 the stomach is of both positive and negative value. By it 
 some of the diseases of the stomach can be excluded, while 
 others, particularly gastroptosis, may be revealed by it. But
 
 60 DISEASES OF THE STOMACH. 
 
 the utility of the method is limited in practice, and the infor- 
 mation obtained by it is very liable to be misinterpreted. It 
 is only practicable when the patient quietly tolerates the 
 presence of the tube. It naturally e.xcites some fear, and 
 many patients accustomed to the use of the stomach-tube 
 reluctantly consent to the em[)l(:)yment of the lit^ht. There 
 is very little, indeed, of the information obtained by it that 
 is not given with greater accuracy by other and simpler 
 methods. That the instruments are expensive and the 
 method of using them is but little understood, can not be 
 considered valid objections. At present, however, electric 
 illumination is properly used to confirm or control our con- 
 clusions or suspicions, and is most likely to be valuable in 
 obscure cases where it is advisable to avail ourselves of 
 every possible source of information. It may be employed 
 to determine the position and size of the stomach, the loca- 
 tion of the pylorus, and the existence, origin, and location of 
 tumors. 
 
 The illuminated area visible on the abdominal wall does 
 not always represent the size or form of the stomach. The 
 left lobe of the liver .shuts off a part of the light, and, when 
 enlarged, may be misleading. The transverse colon, when 
 filled with gas, may also be illuminated. The general illumi- 
 nation of the stomach possesses a negative value when the 
 bright area corresponds with the size and position of the 
 normal stomach. In gastroptosis and in vertical displace- 
 ment of the stomach, the form and position of the illumi- 
 nated area may be so clear and characteristic as to admit of 
 no doubt. The result can be confirmed by allowing the lamp 
 to wander with intermittent flashes, as recommended by 
 Meltzing. 
 
 The electric lamp may also be used to locate the pylorus, 
 the point where the wandering light stops or turns its course 
 backward along the lesser curvature being noted. 
 
 It is exceedingly rare that a tumor of the stomach origi- 
 nates on or extends to and involves the anterior wall, without 
 being revealed by inspection, palpation, and inflation. But 
 the electric light may be used to confirm a diagnosis of a 
 tumor of the anterior wall, or to prove that the anterior wall 
 is not thickened by a neoplasm or by infiltration. It should 
 not be forgotten that fecal masses may get between the 
 stomach and anterior abdominal wall, or that new growths 
 originating in other parts may obstruct the light, or that a 
 localized dark spot may have its cause in the abdominal wall 
 itself Dark spots due to fecal masses are not constantly
 
 THE PHYSICAL SIGNS. 6 1 
 
 present, and- may, by manipulation, be removed from their 
 position in front of the stomach. We have had no experi- 
 ence with Rontgen's rays. 
 
 The Gastroscope. — By means of the gastroscope constructed 
 by Leiter, the interior of the stomach may be inspected. 
 Mikulicz studied clinically a number of cases of carcinoma 
 and of ulcer with this instrument. The use of the costly 
 and complicated metallic instrument is a severe operation. 
 Rosenheim has recently modified the gastroscope, but has 
 not succeeded in increasing its utility in private practice. 
 
 3. Palpation. — The value of the information obtained by 
 palpation is conditioned by the proper performance of the 
 work by fingers which have been educated for this special 
 purpose. Each palpable organ, in health and disease, im- 
 parts to the hand particular sensations, which enable us to 
 separate one organ from another, and to detect changes in 
 form, in size, in location, in sensitiveness, and sometimes in 
 texture. By palpation of the stomach and intestines it is also 
 possible to obtain some information concerning the quantity 
 and the physical qualities of their contents. 
 
 The general palpation of the abdomen should be made 
 with the hand open, all hand and arm muscles being in repose. 
 In this natural and easy position of the hand the fingers are 
 slightly flexed, and the sense of touch is most delicate. The 
 warm hand is next placed on the abdomen, preferably with the 
 fingers lying crosswise in relation to the axis of the body so as to 
 appreciate the respiratory movements of the abdominal organs. 
 The pressure should be light at first, and then somewhat 
 firmer — the hand remaining still while the patient breathes 
 naturally without effort. The hand may next be slightly 
 moved back and forth over the different regions of the abdo- 
 men and in a direction at a right angle to the long axis of the 
 part of the digestive tube contained therein. In the palpation 
 of the particular organs or of their parts the palmar surface 
 of the fingers is used. Both hands should be educated to do 
 the palpation, but one must frequently be employed to bring 
 a part within reach, to fix it, or to relax the abdominal wall. 
 Gentleness, ease, method, and the use of the most sensitive 
 part of the hand — these are the requisites of palpation. A 
 brutal thrusting of the tips of the fingers would cause pain, 
 would excite contraction of the abdominal muscles, and 
 would, possibly, produce injury; while hard pressure would 
 destroy all delicacy of touch. 
 
 The conditions under which palpation is done also modify 
 the results. The intestines, particularly the transverse colon,
 
 62 DISEASES OF THE STOMACH. 
 
 should always be empt\', wlien the exploration is concerned 
 with the stomach alone. The lowered abdominal tension 
 produced by evacuation of the digestive tube and the bladder 
 facilitates the examination of the abdomen ; but the artificial 
 evacuation of the stomach and intestines ma)' not aid in 
 the discovery of their pathological states, and the search for 
 the cause of a digestive trouble is never complete until after 
 the careful palpation of both these divisions of the digestive 
 tube. Consequently, the fir.st examination should be made 
 without preparation, the patient not being under the imme- 
 diate influence of or recovering from the effects of drugs. 
 After the first examination the bowels, if necessary, should be 
 thoroughly evacuated. To acquire all the information possible 
 by palpation of the stomach, the exploration should be made 
 under low abdominal tension and complete relaxation of the 
 abdominal muscles — while the organ is digesting, while it is 
 empty, and after inflation. Rarely, it may be necessary to 
 conduct the examination under anesthesia. 
 
 The physician should be comfortably and securely seated 
 at the right of the patient, facing the patient's head, and with 
 the arms and the warm hands free. The usual position of the 
 patient is that occupied during inspection — straight, relaxed, 
 flat on the back. Other special positions may be advan- 
 tageous in particular cases. A very useful position for pal- 
 pating the pylorus and the part of the stomach lying beneath 
 the left costal border, is on the left and right side respectively, 
 with the chest slightly elevated and with or without the legs 
 flexed on the abdomen. The knee-chest position and the 
 erect position (when the lower part of the abdomen should be 
 supported) may also be employed in special cases. If the 
 patient be placed on the back, with the chest raised and sup- 
 ported, and with the legs strongly flexed on the abdomen and 
 supported in this position, the deep palpation of the abdomen 
 is wonderfully facilitated. Whatever position the patient 
 assumes during the examination, his abdominal muscles must 
 be inactive and relaxed. 
 
 The palpation of the abdomen should proceed methodically, 
 by regions and by organs, and the resistance, the tenderness, and 
 the physical abnormalities of each area and each organ should 
 be noted. After the general palpation of the abdomen, each 
 important abdominal organ should be examined. At the bed- 
 side we adopt the following order: the large bowel, the 
 kidneys, the liver, the spleen, and, finally, the stomach. The 
 position and the excursion area of the diaphragm should be 
 determined by observing its line of movement on the chest-
 
 THE PHYSICAL SIGNS. 6 1 
 
 wall, and by percussion and auscultation of the heart and 
 lungs. We thus begin the examination of the stomach with 
 a great deal of important information concerning the location 
 and physical properties of the organs around it. 
 
 Tlie palpation of the stomach will be discussed under the 
 following divisions : (i) Palpation during digestion, during the 
 period of repose, and after inflation ; (2) Palpation of the 
 tumors of the stomach ; (3) Tenderness. 
 
 1, The stomach, on palpation, may not be found empty 
 during the period of normal physiological rest. This condi- 
 tion is always pathological, and is due either to myasthenia 
 or to obstruction, or to excessive secretion. 
 
 The palpation of the stomach during digestion may afford 
 some information concerning its position and the state of its 
 muscle. The hand, gently placed over the digesting organ, 
 may often feel it alternately contracting and relaxing, in the 
 performance of its churning and evacuating functions. Per- 
 sistent contraction is a sign of continuous muscular excita- 
 tion. The resistance to the hand may be continuous, and 
 associated with stormy peristaltic efforts in obstruction. The 
 myasthenic organ may be found flaccid and non-resistant. 
 
 Palpation of the moderately full or the distended stomach 
 may also locate its position, and may reveal a displace- 
 ment. Two methods of palpation are useful in locating the 
 position of the stomach : The organ and its lower limit, or 
 both its upper and lower limits, may be felt by the full hand 
 moved from the most prominent part of the stomach toward 
 its upper and lower limits. Sometimes the stomach can be 
 felt moving up and down beneath the hand during respira- 
 tion. The second method is often very exact, and is useful 
 both when the stomach is empty and when it is moderately 
 full. To locate the lower border, the palmar surfaces of 
 the fingers of both hands are placed on the abdomen, and lie 
 in the direction of the long axis of the body and on either 
 side of the linea alba. The patient is told to breathe deeply 
 and regularly. Near the end of inspiration the fingers are 
 gently and firmly pressed downward so as to compress what- 
 ever lies between them and the vertebral column. During 
 expiration the depressed fingers are all simultaneously drawn 
 down toward the symphysis. The procedure is repeated, now 
 higher and now lower, until the point where the lower edge 
 of the stomach is felt to slip up beneath them during ex- 
 piration is reached. The same method may be employed 
 while the diaphragm is at rest. To locate the upper border 
 when it is made accessible to palpation by gastroptosis,
 
 64 DISEASES OF THE STOMAL//. 
 
 the fingers should point toward the symphysis and be 
 drawn toward the ensiforni process while the abdomen is in 
 repose. The edge may thus be felt to slip suddenly from 
 beneath the fingers ; or the fingers may be placed as in the 
 method of locating the lower border, and gently but rapidly 
 drawn from their point of pressure on the spinal column 
 toward the symphysis pubis, during expiration. The ridge 
 of the lesser curvature may sometimes be detected in this 
 manner. When the stomach is empty, the examination is 
 facilitated by the administration of an effervescent drink. 
 The differentiation of the stomach from the pancreas and 
 from the transx'erse colon presents no difficulty to one con- 
 versant with anatomy and experienced in abdominal palpa- 
 tion. The pancreas, if accidentally felt (apart from its location 
 and its small width and thickness), can be easily differen- 
 tiated by its immobility and absolute stillness during respira- 
 tion. Whenever one border of the transverse colon can be 
 felt, the other border can be felt also, and the colon is nearly 
 always narrower than the stomach. In case of doubt, the 
 other methods of locating the lower border of the stomach 
 and of differentiating the colon from the stomach can be used. 
 One of the surest is the palpation of the tube when introduced 
 into the stomach. 
 
 Leube introduced a method of locating the lower border 
 of the stomach which, however, he now no longer employs. 
 A stiff sound is introduced into the stomach, and pushed on 
 until the resistance of the lower curvature is felt. By palpa- 
 tion through the abdominal wall the lower end of the sound 
 is located. Meltzing allows the electric light to wander along 
 the curvatures of the stomach, and its visible line of march is 
 thus located. Turck uses a revolving sponge, which is pal- 
 pable and sometimes visible along the line of its march in the 
 same manner. Boas recommends the employment of the 
 stomach-tube, the position of which is located by j)alpation as 
 it glides and lines itself along the greater curvature. These 
 methods, on account of the distensibility and easy displace- 
 ment of the borders of the stomach by pressure, may give too 
 large an area, but are sufficiently accurate for all practical 
 purposes, and, when the tube is tolerated, are most excellent 
 control methods. The spiral stilet pyloric sound of Kuhn 
 (Fig. 2) is better than the simple stomach-tube; and both of 
 these instruments, when they are employed for locating the 
 greater curvature, the pylorus, and the tumors of the stomach 
 by palpation, and for differentiating the tumors of the stom- 
 ach from the tumors of adjacent organs, should be about
 
 THE PHYSICAL SIGNS. 
 
 65 
 
 100 cm. long. It is rarely necessary to introduce more than 
 75 cm. of the tube ; and the examination should be made 
 when the stomach is empty and when it is full, when the 
 
 Fig. 2.— A, Kuhn's pyloric sound. The spiral metallic stilet (a) is to be introduced into 
 the stomach-tube {b), made of Jacques' rubber ; B, Kuhn's balloon sound. The stilet (jr) 
 fits into the rubber tube and inflatable bulb (jc). 
 
 patient is lying flat on his back and when in the erect 
 position. 
 
 2, Not all the palpable tumors of the stomach are malignant. 
 They may be due also to ulcer, with adhesions and exudation 
 
 5
 
 66 DISEASES OF THE STOMACH. 
 
 to simple hypertrophy of the pylorus, and, very rarely, to 
 benign neoplasms. A very valuable differential sign of a 
 gastric tumor is that it may be fixed by the palpating fingers 
 during expiration. But when adhesions have been formed to 
 the diaphragm, or to the organs closeU' bound to it, this differ- 
 ential characteristic is lost. The ga.>;tric tumors, like those 
 of all organs attached to the diaphragm, move up and down 
 with this muscle, in respiration. The tumors of the stomach 
 always feel much smaller than they are, and, though fixable 
 on expiration, readily slip up when the pressure of the fingers 
 is lessened. 
 
 A negative result of palpation in a case of suspected gastric 
 tumor means very little. The tumors of the cardia can not 
 be felt. The same is true when they are small, wherever 
 situated, and when the conditions are not favorable to a 
 thorough examination. Cancer may be diffused, and may 
 thus escape detection. Tumors situated posteriorly are 
 never palpable, unless the viscus be empty. The tumors of 
 the lesser curvature are turned back, out of reach, when the 
 stomach is distended, and may be drawn up beneath the bony 
 thora.K by adhesions to the diaphragm. The tumors of the 
 pylorus may just as often be felt elsewhere as at the point 
 marking the situation of the normal pylorus. These tumors 
 may move only with the diaphragm, or may, rarely, be carried 
 by the fingers into almost any part of the abdomen. 
 
 It is often difficult to decide whether the tumor belongs 
 to the pylorus. Inflation of the stomach may clear up the 
 difficulty. A better and simpler way is to give the patient a 
 glass of water, and to liold the fingers gentl\' on the pylorus, 
 when the part will grow alternately soft and resistant, except 
 when the pylorus is converted into a hard ring by an infil- 
 trating scirrhus, and the water can be felt bubbling through. 
 A spurting sound, somewhat like that at the cardia on swal- 
 lowing, may also be heard with the stethoscope, and is loudest 
 directly over the pylorus. Or the pylorus may be located by 
 Kuhn's pyloric sound. 
 
 The palpation and localization of the tumors of the stomach 
 may be wonderfully facilitated by the employment of Kuhn's 
 or Schreiber's balloon sounds, which are useful, also, for 
 locating the stomach and the cardia, and for detecting 
 the bilocular stomach and the incomplete division of the 
 stomach into two cavities by deformities or by compression. 
 The little balloon is inflated to a suitable size after the pas- 
 sage of the cardia or after the passage of the constriction of 
 the body of the stomach, and the cardia or the constriction
 
 THE PHYSICAL SIGNS. 6y 
 
 is detected and located in the manner employed for the de- 
 tection and location of a urethral stricture. 
 
 3. Epigastric tenderness may or may not be due to gastric 
 disease. 
 
 It is very common to find the abdominal muscles sore after 
 straining or unwonted use of them. The soreness corres- 
 ponds with the area of the muscle, and not with the distribu- 
 tion of the cutaneous nerves. 
 
 Increased sensibility of the skin over the epigastrium, and 
 corresponding with the distribution of the cutaneous nerves, 
 reflects a morbid sensibility of the gastric mucous membrane, 
 and is a very valuable palpation sign. The route of the 
 reflected hyperesthesia passes through the vagosympathetic 
 ganglia and the cord. 
 
 Epigastric tenderness is frequently due to the sensitive 
 left lobe of the liver, the whole of which, or only its border, 
 may be painful on pressure. The tender area or line will be 
 found to correspond with the size and the form of the left lobe, 
 and will at once suggest its cause. The other lobes of the 
 liver may be tender ; the area of the stomach itself is not so. 
 Epigastric tenderness may be due to an irritable solar plexus. 
 The pain on pressure is somewhat dull, unnerving, and con- 
 siderably affects the circulation. The tenderness of the plexus 
 is greatest during digestion, and may disappear during the 
 period of repose. 
 
 The tenderness may be in the duodenum. This is the case 
 in duodenitis, duodenal ulcer, and duodenal stagnation. The 
 point is near the middle of the right costal border, and 
 gentle but firm pressure should be exerted upward and out- 
 ward and backward. Phillip located this tender point in the 
 pylorus. Glenard places it in the quadrate lobe of the liver. 
 It may also be in the head of the pancreas or in the choleduct. 
 In gastroptosis, under favorable circumstances, the pancreas 
 may be felt as a flat, thin, immobile, transverse body, which 
 should not be confounded with the transverse third part of the 
 duodenum, which is lower. Pressure on the pancreas, when 
 thus found, is often painful. Here the tender point of Phillip 
 may also have its seat. 
 
 The colon passes along the lower border of the stomach, 
 and the pain on pressure located therein should not be con- 
 founded with that of the stomach. 
 
 Diffuse gastric tenderness maybe muscular, as after gastric 
 spasm, or may be due to anatomical disease of the lining mem- 
 brane, to cancerous infiltration, to perigastritis, and, possibly, 
 to gastralgia. This diffuse gastric tenderness possesses a very
 
 68 DISEASES OF THE STOMACH. 
 
 indefinite meaning. Tliis is not true of the very sharply 
 limited, small, often exceedingly tender spot located on or 
 near the median line, below the xiphoid process, and associ- 
 ated with a circumscribed tender spot to the left of the twelfth 
 dorsal vertebra. These palpation signs are most common in 
 ulcer, but they may also be due to tender adhesions, and, 
 rarely, to carcinoma. The ulcer pain may be excited by a 
 pressure of one or two pounds; that of the other painful dis- 
 eases of the mucous membrane of the stomach requires from 
 three to ten pounds. The algesimeter of Boas is a very use- 
 ful in.strument for measuring this difference with exactness. 
 
 Gastric carcinoma may also be exquisitely painful on press- 
 ure, and this quality may aid us in differentiating it from 
 painless tumors, true or false. 
 
 Palpation, like inspection, yields both positive and negative 
 information, which may reveal a disease or a group of diseases 
 of the stomach. 
 
 4. Percussion. — The area of the stomach which can be 
 marked out by percussion is dependent not only on the size, 
 the position, and the contents of the stomach, but also on 
 changes in the surrounding organs, the liver, the lungs, the 
 iieart, the pleura, the spleen, andthe colon. Large abdominal 
 tumors would alter its percussion boundaries. Consequently, 
 the abnormal percussion signs should be used with circum- 
 spection in implicating the stomach as the diseased part. 
 
 In percussing the stomach, we locate successively the upper, 
 lower, right, and left borders, and note the occurrence of 
 pathological sounds within this area. The percussion limi- 
 tation of the stomach should be attempted only when the 
 stomach is moderately full of gas. If the stomach be empty 
 and normal, it is withdrawn into the concavity of the dia- 
 phragm, and the transverse and splenic fle.xure of the colon 
 occupies the vacated spot in the epigastrium. If distended, 
 the stomach limits will be too high or too low. 
 
 The location of the upper border is found by moderately 
 deep percussion from above downward. According as the 
 percussion is deep or shallow will the result be slightly 
 different, and the transition from pulmonary resonance and 
 from dulness to gastric tympanicity will be more or less 
 abrupt. 
 
 If the organs of the thorax are healthy and the stomach is 
 moderately distended with gas, the normal superior percus- 
 sion limit is appro.ximately the following : In the left para- 
 sternal line, behind the fifth rib; in the clavicular line, in the 
 fftli intercostal space; in the anterior axillary line, which is
 
 THE PHYSICAL SIGNS. 69 
 
 the furthest extension of the stomach to the left, in the seventh 
 interspace. 
 
 The sh'ght displacements of the upper border are of little 
 value in the diagnosis of the diseases of the stomach. The 
 only diseases of the stomach which modify greatly the posi- 
 tion of the upper border are gastroptosis, upward displace- 
 ment, and left subphrenic abscess complicating an ulcer or a 
 malignant growth. In gastroptosis, the lesser curvature 
 descends simultaneously with the fundus and with the greater 
 curvature. The limit may be lowered by left pleurisy with 
 effusion, pneumonia, emphysema, or pneumonia of the left 
 lower lobe. It may be raised by conditions causing ascent of 
 the left cavity of the diaphragm. The upper percussion 
 border is also modified by changes in the size of the left lobe 
 of the liver, and by the gaseous distention of the stomach. 
 
 The location of the lower limit of the stomach by percus- 
 sion is more difficult than the location of the upper bound- 
 ary. We begin with very light percussion (the patient lying 
 on the back, as usual) in the prolongation of the left para- 
 sternal line near the symphysis, and gradually move upward, 
 noting, if possible, the transition from the sound over the 
 colon to that over the stomach. There is often a narrow 
 transition area over which the two sounds are mixed, and 
 may be separated and different notes produced by closing or 
 extending the gently percussing fingers at the moment of 
 contact with the one resting on the abdominal wall. The 
 supposed gastric sound should then be followed to the left 
 and right, to see if it corresponds with the form and the 
 location of the stomach or the colon. 
 
 Special devices have been found useful and necessary in 
 the delimitation of the lower border by percussion. One 
 consists of the introduction of fluid or gas into the stomach 
 or colon, so as to produce a corresponding difference in the 
 percussion note. If, for example, the stomach and the colon 
 give a clear and a similar tympanitic sound, we first note this 
 fact in the erect and in the recumbent position. We next 
 give the patient a glass of water, and mark in the erect 
 position the area or line of diminished clearness, which again 
 becomes clear in the recumbent position. Or a quart of water 
 may be introduced into the stomach through the tube, the 
 area of dulness produced thereby located, and, in order to prove 
 that the dulness is due to the contents of the stomach, the 
 water is again removed by expression (Piorry, Penzoldt). 
 Some notion of the tonicity of the stomach in myasthenia 
 may be gained by giving the water in successive half-glass-
 
 JO DISEASES OF THE STOMACH. 
 
 fills, and by noting the descent of the line of diminished 
 cle.irness (Dehio, Boas). Whatever devices may be employed, 
 the percussion signs are not so markedly changed as we 
 should anticipate, and often leave us in doubt. The descent 
 of the normal lower boundary means that the stomach is 
 enlarged, distended, myasthenic, or displaced. Two or more 
 of the conditions may be combined in a particular case, and 
 the differentiation must be made by other methods. 
 
 The right limit of the percussion area of the stomach may be 
 most easily marked out by proceeding with light percussion 
 from over the tympanitic stomach, along parallel lines, to the 
 right. The points of beginning dulness mark the right bor- 
 der accessible to percussion. The position of this border 
 varies with the size of the liver. 
 
 If the liver be normal in size or small, a small area of gas- 
 tric resonance may be located across the median line, below 
 the left lobe. In myasthenia, or in enlargement from obstruc- 
 tion, the lesser cul-de-sac may extend downward, and further 
 to the right. In vertical displacement, the percussion area 
 does not cross the median line. 
 
 The left percussion border is displaced chiefly by enlarge- 
 ment of the spleen. 
 
 The changes in the percussion note over the normally 
 tympinitic area of the stomach, uncovered or unoccupied by 
 a healthy or a diseased adjacent organ, may be due to the 
 contents of the stomach, or to a tumor. 
 
 It is quite characteristic of the moderately filled myasthenic 
 stomach that the percussion sound should vary greatly, both 
 with the position of the patient, and with the peristalsis of 
 the organ. The well-toned normal muscle contracts on its 
 contents, and maintains a notable degree of intragastric pres- 
 sure. The normal tonicity tends to maintain the form, de- 
 spite changes of position of the body. The flabby, myas- 
 thenic stomach alters its form, in obedience to the laws of 
 gravity, and to the slight pressure of neighboring parts. 
 These variations may be noted during digestion, or during 
 the period when the stomach should be empty. 
 
 During digestion there is more or less dulness over the 
 fundus, from one to five hours after a meal, in accordance 
 with the quantity and quality of the food taken. In the 
 strong stomach, the left or upper boundaries move to the 
 right or downward, as the patient rolls to the right side or 
 stands erect. Under the same circumstances, the fundus of 
 the myasthenic stomach becomes tympanitic, but in the erect 
 position the lower boundary sinks notably.
 
 THE PHYSICAL SIGNS. /I 
 
 The percussion note may vary without change of the 
 position of the patient. A point now dull becomes, after a 
 {q\v minutes, tympanitic, and vice versa. The phenomenon is 
 due to peristalsis, usually in a flabby, myasthenic stomach 
 partly filled with fluid and gas. 
 
 Before dismissing the subject of percussion, we wish to 
 make an emphatic protest against the too great value as- 
 cribed to the mere size and to the percussion limits of the 
 stomach. Much of the time spent in the exact location of 
 its borders is wasted. The capacity of the stomach bears no 
 relation whatever to its functional efficiency. The location 
 of the borders may enable us to say whether the stomach 
 is larger or smaller than the average ; but we can not say 
 whether the size is or is not normal for the individual under 
 examination. The limits of the stomach are changed by a 
 few of the pathological conditions of the stomach itself, such 
 as displacement, obstruction, distention, stenosis of thecardia, 
 and, sometimes, myasthenia. Concerning these, percussion 
 may only give vague suggestions that must be controlled 
 and complemented ; but often the limits of displaced organs 
 may be located with precision, as when the lesser curvature, 
 on account of gastroptosis, emerges from beneath the left lobe 
 of the liver, or when the wandering pylorus is dragged down 
 by a neoplasm. 
 
 The percussion signs when negative are valueless, in this 
 respect differing from those obtained by inspection and pal- 
 pation. When positive, they are inaccurate. The lower bor- 
 der, being distant from the abdominal wall, is always lower 
 than percussion places it. The right and left borders can not 
 be even approximately determined. The contraction and 
 thickness of the abdominal wall modify the percussion note. 
 These signs are approximately accurate only when the 
 stomach is just full of gas without distention. Of more 
 importance than the mere position of the borders are the 
 difference in their location when the stomach is empty and 
 when it is full, and the variations in the distance separating 
 the upper and the lower borders measured on the parasternal 
 line. 
 
 The distance from the cardia to the greater curvature may 
 be measured fby the method of Purjesz. The external end 
 of the stomach-tube is connected with a manometer. The 
 passage of the tube through the cardia and its entrance into 
 the stomach are marked by a sudden change from negative 
 to positive pressure. At this moment a mark is made on the 
 tube where it crosses the incisor teeth, and it is then pushed
 
 72 DISEASES OF THE STOMACH. 
 
 on until the resistance of the greater curvature is felt. The 
 length of the tube required to extend from the cardia to the 
 greater curvature measures the distance between them. 
 
 More accurate than simple percussion is auscultatory per- 
 cussion, which may be performed in two ways : The binaural 
 stethoscope may be fixed over the triangular space where the 
 full stomach comes in contact with the abdominal wall, and 
 percussion may be performed along eccentric lines running 
 in ever}' direction until the sound is lost ; or the stethoscope 
 may be moved along these lines while the percussion is being 
 performed over the triangular space. Combined percussion 
 and auscultation are not likely to be employed except in ob- 
 scure cases, when percussion signs are more likely to deceive 
 than to instruct. 
 
 5. Inflation. — Inflation of the stomach is a device which 
 may render much more exact the results of inspection, of 
 palpation, and of percussion. 
 
 The older method consists in the administration, succes- 
 sively, of tartaric acid and of bicarbonate of soda, the COo 
 set free in the stomach distending the organ. Some use as 
 much as one dram of the acid, and a little more of the bi- 
 carbonate of soda. These large doses ma\' produce discom- 
 fort, but may be required to fill stomachs of more than aver- 
 age capacity. It is seldom advisable to use more than one- 
 half a dram of tartaric acid, dissolved in one-third of a glass 
 of sweetened water, and 35 grs. of the bicarbonate, also 
 dissolved in a small quantity of water, when the object is to 
 determine the boundaries of the stomach by percussion. But 
 to render the stomach visible and easily palpable, the large 
 doses of the tartaric acid and soda are necessary. The pa- 
 tient drinks the acid solution, waits about one-half of a min- 
 ute until it has all been emptied into the stomach, and then 
 swallows the solution of the bicarbonate of soda, closes the 
 mouth, lies flat on the back, and breathes quietly. The acid 
 requires about one-ninth more of the bicarbonate of soda 
 for saturation. 
 
 The second method consists in the introduction of air into 
 the stomach through the tube. Bouveret suggests that the 
 physician apply his mouth to the end of the tube and thus 
 inflate the stomach, but this method of inflation is objection- 
 able on grounds of cleanliness, and the physician's mouth is 
 in danger of becoming filled with regurgitated stomach-con- 
 tents. The tube being introduced, the bellows part of a 
 double-bulb atomizer is attached to it by means of a piece 
 of glass tubing, and the stomach of the. patient (who lies on
 
 THE PHYSICAL SIGNS. 
 
 73 
 
 the back) is then very slowly and watchfully distended with 
 air. The inflation should be at once stopped if the patient 
 show signs of distress, even though the stomach has not 
 been well distended. 
 
 Each method has its advantages and disadvantages. The 
 inflation with air is under the control of the operator, and 
 the air can be increased or diminished and the operation sus- 
 pended or repeated at will. But the method is greatly limited 
 by the necessity of employing the tube, and the operation 
 should never be attempted before the patient has lost all fear 
 
 Fig. 3. — Strauss' apparatus for lavage and inflation. 
 
 and has learned by experience to tolerate the tube. The dis- 
 tention with generated gas is more universally applicable, but 
 is uncontrollable, and may be unsatisfactory. Both methods 
 may be rendered useless by the rapid evacuation or passage 
 of the gas or air into the duodenum. When the pylorus is 
 incontinent, the gas bubbles through it rapidly and con- 
 tinuously. The cause of the failure of the pylorus to close 
 properly (atony, paresis, infiltration, particularly by cancer, 
 and peripyloric adhesions) may not be revealed by this 
 method and may be left an open question to be answered by
 
 74 DISEASES OF THE STOMACH. 
 
 Other signs and by the clinical history. More commonly the 
 gas is rapidly evacuated by peristalsis, when its intermittent 
 passage through the pylorus may be felt and heard. 
 
 Inflation should not be used, unless valuable information 
 in the particular case is likely to be gained by it. But a more 
 important contraindication is furnished by the liability to do 
 injury. It should not be employed in ulcer nor in advanced 
 carcinoma, nor where the clinical history makes it likely that 
 perigastritis and peritoneal adhesions exist. The carbon- 
 dioxid method should not be used when flatulency produces 
 great distress or gastric spasm, or when there is gastric re- 
 tention. Tiie other contraindications are those against the 
 use of the tube. It is unnecessary to say that neither method 
 should be employed during the period of physiological ac- 
 tivity of the stomach. If the acid and soda method of infla- 
 tion be selected, it is a good plan to have a stomach-tube 
 ready for the removal of the gas whenever (as almost never 
 happens) the gaseous distention produces much discomfort. 
 
 Inflation gives the best results with thin abdominal walls, 
 when the limits of the stomach may be plainly seen, felt, and 
 marked out by percussion. It may reveal, as no other method 
 does, vertical displacement, total descent, and enlargement of 
 the stomach ; or it may exclude these conditions. The tumors 
 of the lesser curvature may be turned back out of reach, 
 those of the pylorus may be revealed, while those of the 
 greater curvature and of the anterior wall may become less 
 distinct and less sharply limited. The tumors of the posterior 
 wall are further removed from physical examination. 
 
 The inflation is useful not only in determining the loca- 
 tion, size, and form of the stomach, but also the presence of 
 adhesions and the size and origin of tumors. To reveal the 
 capacity of the stomach and to determine the strength of 
 its muscular layer the method is worthless clinically, even 
 though the quantity of air used be measured, inasmuch as 
 part of it may escape through the pylorus or cardia ; and the 
 reflex muscular activity and the degree and ease of disten- 
 tion do not measure the retraction power of the stomach. 
 Schreibcr, Jaworski, Kelling, and Ost have described meth- 
 ods for estimating the cajjacity of the stomach. The prin- . 
 ciple embodied in all these methods is the same, but different 
 means are employed for measuring the quantity of air that 
 can be introduced into the stomach before the distention be- 
 comes |)ainful. These methods are not sufficiently accurate 
 nor simple to be of much clinical value. The information 
 given by any method concerning capacity is of little value.
 
 THE PHYSICAL SIGNS. 75 
 
 6. Auscultation. — Gastric sounds have not been studied 
 with the care that the subject deserves. The information 
 obtained by the sounds produced at the orifices and in the 
 body of the stomach may aid in the discovery of abnormal 
 conditions. These auscultation signs are the deglutition 
 sounds heard at the cardia ; the pyloric and perforation 
 evacuation sounds ; the peristaltic, cardiac, aortic, respiratory, 
 and fermentation sounds ; succussion and percussion splash- 
 ing- 
 
 The deglutition sounds may be changed in the diseases of 
 
 the cardia, but not, however, by diseases of the cardia only. 
 The esophagus also plays an important part in their produc- 
 tion. But apart from diseases of the esophagus, the degluti- 
 tion sounds may be given a negative diagnostic value in that 
 their presence and their normal qualities exclude certain 
 disorders of the cardia. 
 
 The deglutition noises are two in number: The first fol- 
 lows immediately after the patient swallows the mouthful 
 of water, and is forcible, spurting, quick ; the second follows 
 in from five to fifteen seconds, and is dull, labored, and 
 bubbling. When both these signs are normal we may give 
 them a negative meaning, with great probability, and may 
 exclude organic and spasmodic obstruction of the cardia. 
 Both deglutition sounds, particularly the first, may be absent 
 at times in health, but their constant absence is evidence of 
 the complete, or almost complete, obstruction of the esopha- 
 gus or of the cardia. In spasm of the cardia both sounds 
 are often delayed. The delay and prolongation of the sec- 
 ond sound is a sign of stenosis of the cardiac orifice, the two 
 sounds being often separated by an interval of about one 
 minute. The sounds are best heard to the left of the ensi- 
 form process, in front; or on a level with and to the left of 
 the spinous process of the ninth dorsal vertebra, behind. It 
 seems, after careful study, more than probable that the two 
 sounds mark the noisy beginning and ending of the same 
 process, the interval between them being occupied by the 
 entrance of the water into the stomach. The test should be 
 made with a full swallow of water. 
 
 The pyloric evacuation sound is of a quick, spurting, bub- 
 bling, metallic character. This auscultation sign may become 
 very important in special conditions, and is of very much 
 greater diagnostic value than the cardiac deglutition sounds. 
 The pylorus may be auscultated during digestion, or when 
 the stomach should be empty, or after the patient has taken 
 a glass of water. During the period of repose of the normal
 
 76 DISEASES OE THE STOMACH. 
 
 Stomach no sound is heard in tlie pylorus. If a glass of 
 water be given, the sound, recurring at intervals of about one 
 minute, may be very plainly heard with the stethoscope 
 placed over the p\'lorus. The pyloric evacuation sound may 
 be utilized to locate the pylorus when it can not be felt, and 
 also to identify it when displaced. It is also a measure 
 of peristaltic activity. In myasthenia, the beginning of peri- 
 stalsis after a meal is delayed, the peristaltic intervals are 
 long, and the pyloric evacuation sound may be heard when 
 the stomach, if normal, would be empty. In compensated 
 obstruction, the peristalsis is often quick and powerful, and 
 accompanied by a regurgitation sound, which is different in 
 character from the firm pyloric spurt. Though peristalsis be 
 active, the sound is absent during pyloric spasm. It is never 
 heard in complete obstruction of the pylorus. 
 
 In perforation of the stomach, cases have been reported in 
 which the intermittent escape of the contents into the peri- 
 oneal cavity could be heard. This auscultation sign is rarely 
 sought, and has not been so clearly defined as to be employed 
 in diagnosis. 
 
 The fermentation sounds in the stomach may often be heard 
 in stagnation and retention, with active formation of gas. 
 They are very fine crackles, like the bursting of numerous 
 bubbles in a partly filled vessel, and can be artificially pro- 
 duced by the administration, separately, of a little tartaric acid 
 and soda. They may be most easily found if, after the patient 
 has remained perfectly motionless on the back, breathing 
 quietly and regularly for a few minutes, the stomach be 
 slightly agitated while the stethoscope is placed over it. If 
 these sounds are heard during the period when the stomach 
 should be empty, they denote that the stagnation or reten- 
 tion, as the case may be, is accompanied by gas-forming fer- 
 mentation. 
 
 Sounds are also produced in the stomach by peristalsis. 
 These gentle, flowing, rushing, bubbling sounds occur nor- 
 mally during the period of digestion, and are usually loudest 
 near the pylorus. If heard during tiie period when the stom- 
 ach should be empty, they denote either stagnation or reten- 
 tion. 
 
 In abnormal conditions, the heart sounds may be heard 
 over the region of the stomach, and may possess metallic, 
 resonant qualities. This physical sign may be due to disten- 
 tion of the stomach with gas, to upward displacement of the 
 stomach, to pericardiac adhesions, or to subdiaphragmatic 
 abscess. It denotes an abnormal condition of the heart, or
 
 THE PHYSICAL SIGNS. yj 
 
 of the stomach, or of their relations; and when it is constant, 
 a search for the significance should be made. 
 
 The respiratory murmur of forced breathing may sometimes 
 be heard over the stomach in perigastritis, in pleurodia- 
 phragmatic adhesions, in peritonitis, and in ascites. The 
 pulsations of the aorta may rarely produce intragastric 
 sounds, and an aortic bruit may be transmitted and its quali- 
 ties modified by the contents of the stomach. These auscul- 
 tation signs are of no value in the diagnosis of the diseases of 
 the stomach. 
 
 Intragastric noises are very frequent and important aus- 
 cultation signs. For diagnostic purposes, they may be sepa- 
 rated into gurgling, clapping, and splashing, the other intra- 
 gastric sounds having been already described. 
 
 Gastric gurgling may be respiratory, or may be elicited 
 by the physician alternately compressing two compartments 
 of the stomach, or by the gliding method of Glenard. Its 
 production requires the presence of very special conditions — 
 a flabby stomach containing gas, or gas and liquid, separated 
 by a constriction or by compression into two cavities, the 
 contents of one of which are forced into the other. A certain 
 relation must exist between the properties of the contents of 
 the compressed cavity, the size of the communicating canal, 
 and the tension of the receiving cavity, otherwise gastric 
 gurgling can not occur. 
 
 Respiratory gurgling is more frequent in women than in 
 men. The corset or the belt, the left arm laid across the 
 abdomen while the person lies on the back, the colon, the 
 enlarged spleen, the enlarged left lobe of the liver, a tumor, 
 adhesions, or constricting bands deforming the stomach and 
 dividing it into two pouches, may induce constriction or 
 compression. In the majority of cases the stomach is dis- 
 placed and myasthenic. The compression of the cavity from 
 which the contents are driven is made directly by the de- 
 scending diaphragm, or indirectly by the ascent of the dia- 
 phragm. A double respiratory gurgle is not rare. The 
 respiratory gurgle is pathological, and indicates myasthenia, 
 displacement, deformity, or abnormal compression. If it 
 occurs at a period when the stomach should be empt)^ 
 it reveals stagnation or retention ; for the non-functionat- 
 ing stomach should retract and contain no fluid and little 
 or no gas. 
 
 Under suitable conditions, gastric gurgling may be pro- 
 duced by the gliding method of Glenard. The stomach 
 is gently compressed against the vertebral column by the
 
 78 DISEASEii OF THE STOMACH. 
 
 border of the hand transversely placed across the abdo- 
 men — at the end of inspiration — in such a manner as to 
 shut off a pouch from the general cavity of the stomach. 
 The line of compression is moved downward during ex- 
 piration, and the gurgle is produced. Glenard regards this 
 as one of the signs of the descent of the pylorus, and claims 
 that the intragastric pressure is lower than normal, and that 
 the stomach is small, the gurgle always being above the 
 umbilicus. This very e.xact meaning the sign does not 
 possess, for it may be produced also in myasthenia, in the 
 prolapsed as well as in the vertical stomach, when the bor- 
 der of the stomach is below the umbilicus, and may even 
 be produced to the right of the median line, when the lesser 
 cul-de-sac is flabby and displaced downward to the right — it 
 being only necessary so to locate and shape the line of compres- 
 sion as to shut off a pouch containing gas. or gas and fluid. By 
 the gliding method, the lower border of the stomach may 
 sometimes be felt to slip from beneath the hand. It is un- 
 necessary to state that this gastric palpation sign should not 
 be confused with the movable gurgling ribbon. The gliding 
 gurgle and the gliding palpation may be used to locate the 
 lower limit of the stomach, when the very particular condi- 
 tions for the realization of the signs are present. 
 
 Gastric clapping is produced by bringing the walls of the 
 stomach separated by gas into contact by a simple, quick de- 
 pression of the epigastrium in the median line. A somewhat 
 similar sound may be elicited by clapping the anterior wall 
 of the stomach against the surface of the liquid from which it 
 is separated by a layer of gas : but in this condition gastric 
 splashing may also be heard. As the word implies, it differs 
 in its qualities from gastric splashing which, unlike clapping, can 
 not be generated when the patient is standing. It is unneces- 
 sary to state that succussion can only yield splashing sounds. 
 Gastric clapping, engendered during the period of physiologi- 
 cal repose, is a sign which suggests, but does not establish, 
 myasthenia. When it can be produced below the umbilicus, 
 the clapping denotes that the stomach is either enlarged and 
 mj'asthenic or is displaced. 
 
 Gastric splashing occurs in a stomach containing gas and 
 fluid — it matters not whether the wall be flaccid or rigid. 
 The sound may be generated in many ways — by motion of the 
 trunk, by the rapid movements of the diaphragm, by the con- 
 traction and relaxation of the abdominal muscles, by alternat- 
 ing depression at two points, by compression at one point 
 and tapping at another, or by three or four rapid depressions
 
 THE PHYSICAL SIGNS. 79 
 
 over the stomach (particularly at the end of expiration) with- 
 out raising the fingers from the abdominal wall. One method 
 may succeed when the others fail to elicit the sound. The 
 patient should lie fiat on the back, with the muscles relaxed, 
 and the stomach should not be distended. Gastric splashing 
 may occur during the period of digestion. The stomach 
 may then be normal. But constant splashing during the di- 
 gestion of a meal should excite suspicion. The sign may be 
 produced when the stomach should be empty, and is then 
 always pathological, and reveals, according to the moment 
 when the examination is made, either excessive secretion or 
 stagnation or retention. Splashing may be absent during the 
 period of physiological rest, and be elicited by none of the 
 methods employed, even at the end of expiration. If half a 
 glass of water be now given, and the sign be present, suspi- 
 cion should be excited. After an interval of half an hour if 
 the examination is again positive, there is myasthenia. If, 
 after the use of the half-glass of water, none of the gastric 
 noises can be elicited, the motor power of the stomach is 
 normal. The area over which the splashing can be produced 
 is also useful in locating the stomach and in detecting its dis- 
 placement. But we must first be sure that the sound is 
 intragastric. 
 
 Either a splashing or a clapping sound may be produced in 
 the colon, containing a mixture of gas and fluid, or only gas. 
 Constipation, so frequent in myasthenia, would make it prob- 
 able that the sound is intragastric. Palpation of the colon 
 may at once clear up the difficulty, for it is narrow and rib- 
 bon-like or cord-like, and rarely its contents may be solid. 
 The area of distribution might correspond in location and 
 somewhat in form with either the colon or the stomach. 
 The sound first produced, after the drinking of the half- 
 glass of water, is intragastric. In doubtful cases, the empt)-- 
 ing of the stomach by the tube might locate the noise, but it 
 is better to repeat the examination on the following day if 
 the source of the sounds is not made clear. But the possi- 
 bility of the colon and the stomach at the same time yielding 
 clapping or splashing sounds should not be forgotten. 
 
 The area of the splashing, which should be marked out by 
 using gently one or two fingers in producing the rapid, suc- 
 cessive, vertical, and slight depressions in order to localize the 
 effect, may reveal the size and the location of the stomach, 
 and may thus enable us to discover or to exclude a di.«;place- 
 ment, a large myasthenic, or an obstructed organ. We may 
 proceed in either of two ways. The splashing is most easily
 
 So DISEASES OE THE STOMACJI. 
 
 excited and most constant o\er the triangle of contact of 
 the stomach with the abdominal wall, bounded by the me- 
 dian line, the left costal border, and a line uniting the carti- 
 lages of the ninth rib. The cartilage of the ninth rib, which 
 is one of the landmarks of the stomach, may be readily found 
 by passing the finger, from below, along the costal border. 
 The first notch is between the very movable tenth cartilage 
 below and the less movable ninth cartilage above. Over this 
 area the gastric splashing will be found. We proceed from 
 this area downward and to the right, and unite points where 
 the splashing disappears ; or proceed from below, along 
 parallel vertical lines, and from the right, along parallel hori- 
 zontal lines, toward the region of the stomach, and mark and 
 unite the points where the splashing begins. The lower 
 limits may be more easily marked, when the patient's shoul- 
 ders are slightly raised, and the physician steadies the stomach 
 by gentle pressure over the pyloric region. To find the right 
 limit, the patient may be turned very slightly on the right 
 side. In the attempt to locate the stomach by direct percus- 
 sion splashing it often happens that the sound is not produced 
 immediately beneath the fingeVs, and the lower boundary of 
 the stomach may be placed too high or too low. The sound 
 is produced where the gas and fluid mix, and the lower part 
 of the stomach may contain only fluid, or the fluid may all 
 gravitate backward into the greater cul-de-sac, and leave only 
 gas in the part of the stomach beneath the epigastrium ; or, 
 again, the finger agitation may be transmitted to the stomach 
 through the medium of an adjacent organ. The tapping 
 should be light, and the result controlled, where possible, by 
 the gliding method of Glenard. To avoid the error due to 
 the distribution of the contents of the stomach, the depres- 
 sions with the fingers should be made near the line of the 
 greater curvature, at the end of a deep inspiration, and, also, 
 while the other hand of the physician, which is laid flat on 
 the epigastrium, gently compresses the upper part of the 
 stomach. It is a useful precaution to ascertain whether the 
 boundary of splashing is changed after the administration of 
 half a glass of water. 
 
 The constant absence of gastric .splashing during the 
 period when the stomach would be normally empty ex- 
 cludes myasthenia with certainty. The strong, healthy 
 stomach does not splash during the period of digestion, or 
 only splashes intermittently as the stomach momentarily re- 
 laxes. The complete absence of splashing occurs only when 
 the stomach is verv strong.
 
 THE FUNCTIONAL SIGNS. 8 I 
 
 CHAPTER 111. 
 THE FUNCTIONAL SIGNS. 
 
 The clinical history and the physical examination may en- 
 able us to form a correct diagnosis without further explora- 
 tion. The clinical history may be typical and the physical 
 signs may be characteristic. But disease does not develop in 
 grooves and yield always clear-cut types. We may even go 
 further and truthfully say that in the large majority of the 
 cases these methods leave us in doubt. How often, after a 
 most painstaking history and a most exhaustive physical ex- 
 amination, we must be content with a probable diagnosis, or a 
 mere guess at the truth. 
 
 This additional knowledge, so sorely needed, may be fur- 
 nished in part by the functional signs. These signs possess 
 both positive and negative value, inasmuch as certain persistent 
 pathological variations may reveal a particular disease ; and 
 normal functions, or a particular functional anomaly, may 
 exclude a disease suggested by the previous questioning and 
 the physical examination. 
 
 But the functional signs are even more valuable in treat- 
 ment, and have the great advantage of being direct and pre- 
 cise. They form the only scientific basis of the dietetic treat- 
 ment, which has for its object the nourishment of the body 
 and the favoring of the diseased organ. The stomach must 
 work, and, this being the case, we must know what it is 
 capable of doing before we ever can favor it in its duties or 
 avoid overtaxing it. But this is not all. The functional 
 signs display the dynamic variations, be they hypersthenic or 
 asthenic, and consequently suggest and control the physiolog- 
 ical treatment. Whether our remedies be foods or drugs, or 
 of other nature, we must select them in accordance with the 
 commanding physiological indications — excitation or seda- 
 tion. But still more ; a diagnosis made without a knowledge 
 of the functional signs is always incomplete. The clinical 
 history and the physicj^l signs, in a small number of the cases 
 of stomach troubles, may reveal the particular disease, such 
 as ulcer, carcinoma, gastroptosis, gastritis, or one of the 
 dynamic affections. The anatomical diagnosis, however, is 
 insufficient. To treat the stomach well, its functional power 
 must be known. Without such knowledge there can be no 
 
 intelligent and organized effort to preserve, restore, and com- 
 6
 
 82 DISEASES OF THE STOMACH. 
 
 pensatc its functions. And we hold it a mistake in practice to 
 substitute an inference, a mere guess, for the definite knowl- 
 edge obtained by the functional exploration. 
 
 The functional signs are also helpful guides in prognosis, 
 revealing how serious the trouble is when the first examina- 
 tion is made, and making clear, when the exploration is re- 
 peated, the gains and losses and the general tendency of the 
 evolution of the disease of the stomach. It is correct practice 
 to make a functional examination whenever this can be done 
 without danger, and the functional signs are likely to prove 
 valuable in diagnosis, prognosis, or treatment. 
 
 The stomach has three functions — general and special se- 
 cretion, the churning and evacuating movements, and absorp- 
 tion. It also serves as a reservoir, the filling and emptying 
 of which is roughly self-regulating. 
 
 The contents of the stomach, obtained during the period 
 of functional activity and during the period of functional 
 repose, yield functional, bacteriological, and anatomical signs. 
 The functional signs reveal the functional power and activity 
 of the stomach. They may be conveniently treated under 
 the following divisions : (i) Secretion ; (2) the motor function ; 
 (3) absorption ; (4) digestive work. 
 
 I. SECRETION. 
 
 The specific secretions of the stomach are three in number 
 — the acid, and two ferments. The other ferments claimed 
 to exist by some physiologists possess at present no clinical 
 importance. The general secretion of the stomach is the 
 mucus. The secretions of the stomach are formed by its 
 glandular lining membrane, which displays numerous longi- 
 tudinal folds. Slightly magnified, the lining membrane ap- 
 pears reticulated, the little pits (several millions in number) 
 being the mouths of the glands. 
 
 The surface is paved with a single layer of cylindrical 
 epithelial cells, which also extend to a variable distance into 
 the necks of the special secretion glands. Into the pyloric 
 glands they extend four or five times deeper than into the 
 glands of the fundus. The mucous glands are lined through- 
 out with the cylindrical epithelium. These cells are long, 
 thickly packed, and sharply limited, except at their concealed, 
 deep extremities. The basal end is filled with a finely gran- 
 ular protoplasm up to near the central part where the nucleus 
 lies. From the nucleus outward to the free or surface ex-
 
 THE FUNCTIONAL SIGNS. 
 
 83 
 
 tremity, the cells contain clear mucus. This differentiation 
 of the intracellular contents is made very clear by staining. 
 During functional activity more and more protoplasm is 
 transformed into mucin, the free extremity swells and bursts 
 and discharges the mucus into the stomach. The cell retains 
 
 Fig. 4. — A, Cross-section ot a mucous gland, X 325. B, Cross-section at the mouth of 
 a peptic gland, X 325. C, Cross-section at the neck of a peptic gland, X 325: i, border 
 cell ; 2, chief cells. 
 
 I 1 
 
 § B 
 
 Fig. 5. — A, Surface epithelium, X 530. B, Border cell, X 530. C. Chief cells in repose (i) 
 and in activity (2), X 530. 
 
 Fig. 6. — Cross-sections of the body ot a peptic gland in repose (A) and in activity (B), 
 
 X325- 
 
 the unconverted protoplasm and the nucleus, and, presenting 
 a goblet shape, begins its work anew. Mucus secretion is 
 greatest in catarrhal gastritis, when the goblet cells are also 
 found in large numbers. The mucus, which is the general 
 secretion of the stomach, is formed by the cylindrical cells.
 
 84 
 
 DISEASES OF THE STOMACH. 
 
 The special secretion glands contain two kinds of cells — the 
 chief (adelomorphous) and the border (delomorphoiis) cells. 
 The chief cells are small, cuboidal, mononuclear, badly defined, 
 and filled with granular protoplasm, which has little affinity for 
 the anilin dyes. The chief cells predominate in the base of 
 the gland, are less numerous in the fundus, and are very few 
 in number near the neck of the gland. They lie next to the 
 lumen of the gland, are most numerous during the period of 
 functional repose, and almost disappear at the height of secre- 
 tory activity. The border cells are large, roundish, well de- 
 fined, and stain deeply with the anilin dyes. The border- 
 cells predominate near the neck of the gland, are found in 
 
 Fig. 7.— Cross-section of normal mucosa through the necks of peptic glands one hourafter 
 the test-breakfast, X 240 (authors' specimen). 
 
 about equal number as the chief cells in the fundus, and 
 only here and there along the base. They lie near the 
 membrana propria, and form only a small part of the wall of 
 the lumen. The border cells are most numerous during se- 
 cretory activity, and are very few in number after long fasting. 
 In the glands of the pyloric region, the chief cells are nu- 
 merous, but only here and there is a border cell found. The 
 border cells in the area about the junction of the pylorus 
 and the body of the stomach differ slightly in their staining 
 affinities from the border cells found in other parts of the 
 stomach. The glands also 'vary in their size and form in the 
 different parts of the stomach, some being tubular and some 
 branching, some long and others short. The secretion of
 
 THE FUXCTIONAL SIGNS. 85 
 
 the pyloric region is less acid, but contains more pepsin than 
 that of the fundus of the stomach. But it is more than prob- 
 able that the chief cells do not form the ferments exclusively, 
 nor do the border cells form acid alone. The border cells 
 undoubtedly form both acid and ferments, and it seems very 
 likely that the border cells are developed from the chief cells. 
 A study of development and of cell life, and the data of 
 physiology and of pathology, make this theory plausible. 
 
 To test the secretory functions of the stomach we require : 
 (i) A method of obtaining the contents of the stomach ; (2) 
 a test-meal to excite secretion in a normal manner, and (3) 
 reagents and apparatus necessary for the analysis of the re- 
 moved contents. 
 
 I. Methods of Obtaining the Stomach=contents. — Many 
 efforts have been made to save the patient the disagreeable 
 sensations associated with the use of the stomach-tube. Na- 
 ture sometimes imperfectly does the work for us, when the 
 patient vomits at the right moment during the digestive 
 period, or in the early morning before any food or drink has 
 been taken into the stomach. But the vomit may consist 
 largely of the secretions accompanying or preceding the act, 
 and manifestly can not be taken as an index of the specific 
 secretion or the digestive activity conditioned by the disease 
 alone. The vomit usually consists of the contents of the 
 stomach mixed with mucus, with bile, with pancreatic juice, 
 with duodenal secretion, and with saliva. Its analysis may 
 give some valuable information, particularly if it occurs when 
 the stomach should be empty, or at a certain interval after a 
 meal. Continuous secretion, excessive secretion, the power 
 and the degree of secretion, and the motor activity, may be 
 suggested by the properties of the vomit when the vomiting 
 occurs under certain conditions. But the information thus 
 obtained must be complemented and confirmed by the usual 
 functional tests. In no case can the examination of the 
 vomit render unnecessary the test-breakfast, the test-dinner, 
 the test-supper, or the morning expression and lavage. 
 The examination of the vomit is valuable, but the act can not 
 be agreeably produced at the will of the patient or of the 
 physician, and it occurs under exceptional circumstances. 
 
 Some of the very laudable endeavors to avoid the employ- 
 ment of the tube show a good deal of ingenuity. Einhorn in 
 i8go proposed as an easy method the use of a little silver, 
 olive-shaped stomach-bucket attached to a strong thread. The 
 thread is attached to an internal valve-like lid, which closes 
 the mouth when the thread is tight, and leaves it open when
 
 86 DISEASES OF THE STOMACH. 
 
 the thread is relaxed by the bucket reaching the gastric con- 
 tents. The inventor, however, now attaches the thread to a 
 ring on the inside of the bucket, and claims that on account 
 of the bucket being full when withdrawn, the contents are not 
 like!}' to become mixed with other secretions. The bucket is 
 carried into the stomach by a big swallow, remains there 
 a while, and is then drawn out by the thread and pulled over 
 the larynx while the patient makes an effort to swallow. 
 The small amount of contents is tested for free HCl and for 
 ferments. 
 
 Edinger had already (1880-81) proposed a similar method, 
 the principle of which is as old as Spallanzani. Small pieces 
 of sponge are freed from alkaline carbonates by treatment 
 with hydrochloric acid, and by washing with distilled water 
 until tlie reaction is neutral. The dried compressed sponge, 
 to which a silk thread is attached, is inclosed in a gelatin cap- 
 sule, the thread being drawn through a perforation in the 
 cover. The capsule is next smeared with a little butter, 
 swallowed, and washed into the stomach with a bite of bread 
 and some water. The capsule is dissolved in the stomach, 
 the sponge is uncovered, and after fifteen minutes it is quite 
 rapidh' pulled out, saturated with the gastric contents. The 
 four or five drops thus obtained were tested for free HCl. 
 The capsule may be swallowed, according to our object, 
 while the stomach is empty, or at a certain time after a 
 meal. 
 
 Spath (1887) recommended a little bulb of elder pith, satu- 
 rated with a solution of Congo-red, to be swallowed, and thus 
 dipped into the contents, and withdrawn, the blue coloration 
 revealing the presence of free acid. 
 
 The methods of Spath, of Edinger, and of Einhorn are 
 hardly more pleasant than the employment of the stomach- 
 tube. Einhorn's bucket furnishes enough contents for a 
 limited qualitative analysis. 
 
 The Sahli-Giinzburg method (1889-91) was extensively 
 used. About three grains of iodid of potash are tied water- 
 tight in a very small, thin piece of rubber tissue by means 
 of a thread of fibrin. Giinzburg made the knot with the 
 fibrin thread, while Sahli brought the two ends of the fibrin 
 filament together and tied them close up with a fine thread. 
 Giinzburg administered the capsule one hour after the test- 
 breakfast; Sahli gave it with the te.st-breakfast. The trimmed 
 packet is inclosed in a gelatin capsule, swallowed at the 
 desired moment, and the saliva is frequently tested for iodin 
 with strongly acidulated starch paper, which is absorbed
 
 THE FUNCTIONAL SIGNS. 
 
 87 
 
 after the digestion of the fibrin string, and is ehminated by the 
 salivary glands. The packet may be opened by the intestine 
 instead of by the stomach, or in the stomach by organic 
 acids, or even by chlorids or salines. 
 
 Compared with the use of the tube, none of these ingeni- 
 ous but very limited methods can be seriously deemed more 
 than an elegant amusement. The functional tests should be 
 thorough, sufficient, and as free as possible from error, or 
 
 Fig. 8. — The extremities and openings of several stomach-tubes now in use: a, Ewald ; 
 b, Riegel ; c, Hay em ; d, e. Van Valzah and Nisbet. 
 
 they should be omitted altogether. For the proper explora- 
 tion of the functions of the stomach, the stomach-tube is 
 absolutely necessary. 
 
 The stomach-tube has long been employed in therapeutics 
 to wash out the stomach, or to introduce food or remedies. 
 As a diagnostic instrument, it is used to detect obstruction 
 of the cardia, to locate the lower border of the stomach by 
 palpation of its extremity when it is introduced, to inflate
 
 88 DISEASES OF THE STOMACH. 
 
 the stonicich with air, to determine the duration of gastric 
 digestion, and to remove tlie contents of the stomach at any 
 desired moment. The employment of the stomach-tube as 
 an instrument of diagnosis and research lias made the once 
 obscure subject of gastric pathology one of the longest and 
 the clearest of internal medicine. 
 
 Many varieties of tubes are now in use. A good one 
 should be soft, perfectly smooth, with a closed, well-rounded, 
 somewhat conical lower end, and stiff enough to allow the 
 slight resistance to its introduction to be overcome with- 
 out its curling up. It should possess one velvet-eye 
 opening of the same size as the caliber, and another very 
 small one with similarly depressed or rounded edges. The 
 large and lower opening should be as near the extremity as 
 possible, and the caliber of the tube should end with it. The 
 small upper opening, on a level with and opposite the upper 
 border of the large opening, diminishes the chances of the 
 tube becoming obstructed or tearing away a piece of the 
 mucous membrane by aspiration. With two large holes 
 the risk of obstruction is twice as great, and the closing 
 of the upper hole cuts off the outflow. The two large 
 openings weaken the tube, and the stomach can be emptied 
 no lower than the higher one ; but the mucous membrane is 
 prevented from being caught by suction during aspiration or 
 siphonage and is thus protected against injury. 
 
 The caliber of the tube should be as large as it is possible 
 to make it, and yet retain the essential elasticity and stiffness. 
 The length should be 75 to 90 cm., the longer ones 
 being useful in cases where the greater curvature of the 
 stomach is low. It should be kept as scrupulously clean 
 as a catheter, and each patient with syphilis, tuberculosis, or 
 cancer, should have one for his exclusive use. 
 
 The Indications for the Use of the Tube. — Experience alone 
 can point out those cases in which an exploration of the func- 
 tions of the stomach is likely to prove of most value. The 
 tube should be used in every case where the clinical diag- 
 nosis can not be made without it, and where no contra- 
 indication to its employment exists. Without the use of 
 the tube the functional power of the stomach can only be in- 
 ferred, and the inference is usually far from the truth. An 
 exploration of the functions of the stomach is never useless 
 and is rarely unnecessary, but we are frequently able to treat 
 cases successfully, although not in the best manner, without it. 
 
 1. The tube may be used to make the diagnosis. 
 
 2. The tube mav be used to confirm the diagnosis.
 
 THE FUNCTIONAL SIGNS. 89 
 
 3. The tube may aid in reaching a diagnosis by exclusion. 
 
 4. The tube may be used to obtain valuable information in 
 prognosis and treatment, and to determine what progress has 
 been made. 
 
 Contraindications to tlie Use of the Tube. — The introduction 
 of the tube is a little operation which may need to be aban- 
 doned on account of the general condition of the patient, or 
 on account of the presence of some particular disease render- 
 ing it dangerous or injurious. The contraindications may 
 be multiplied by the timidity or the prejudices of the phy- 
 sician. The contraindication is absolute when the operation 
 is a menace to life; it may be advisable or best to avoid it 
 under other exceptional conditions.- The common sense and 
 the experience of each physician should form rules for his 
 own guidance. 
 
 In the severe acute diseases of the throat and the stomach, 
 in general peritonitis and in perigastritis, its employnient is 
 contraindicated. Advanced soft carcinoma and ulcer, on 
 account of the danger of hemorrhage or perforation, prohibit 
 absolutely the introduction of the tube, as do also a sim- 
 ilar condition of the esophagus and the existence of aneur- 
 ysm of the aorta. It is best to defer the operation in all cases 
 of recent hemorrhage. Old age, adynamic diseases, uncom- 
 pensated valvular disease of the heart, degeneration of the 
 heart muscle, arteriosclerosis with a past hemorrhage, ad- 
 vanced renal disease, cyanosis, and all troubles in which in- 
 jury is likely to result from a slight shock, from increase of 
 blood pressure, or from obstructed respiration, certainly make 
 it advisable to avoid the use of the tube, except in very 
 unusual circumstances. When in doubt, it is best to give the 
 patient the benefit of it. The tube should rarely be intro- 
 duced during pregnancy, and never if there is a history of 
 previous abortion. These general rules may sometimes be 
 violated without inflicting injury, and the refusal of the patient 
 to permit the use of the tube may render a search for contra- 
 indications unnecessary. 
 
 Introduction of tlie Tube. — {(i) The Difficulties of Introduction. 
 — The first difficulty most likely to be met with is an 
 irritable throat, a very frequent accompaniment of chronic 
 gastritis. If the patient by intelligent co-operative effort and 
 regular breathing can not overcome the choking, the pharynx 
 should be anesthetized with cocain. 
 
 An obstruction may be encountered in the esophagus, due 
 to stricture, pocketing, compression, tumor, swelling, spasm, 
 or to a foreign body.
 
 90 DISEASES OF THE STOMACH. 
 
 The most common difficulties, however, are faulty manipu- 
 lation on the part of the physician, and the resistance of the 
 patient, who should be told what to do. A little knowledge 
 may dissipate all fear. It is useless to try to force a soft tube 
 throu<^h a contracted pharynx, and an effort to do so is very 
 likely to result in the curling up of the tube in the throat, or 
 in its passage into the larynx. 
 
 (J)) The Methods of Introduction. — The finger method is the 
 older one, but it is better suited to the introduction of bougies 
 or of stiff esophageal sounds. The index- and the middle 
 fingers of the left hand are introduced into the right side of 
 the mouth, and the base of the tongue is pressed downward 
 and forward. The tube, held as a pen, and grasped by the 
 right hand about six inches from its extremity, is pushed 
 along the left index-finger and directed slightly to the right 
 side of the throat, so as to avoid irritating the epiglottis. 
 The tube is next pushed on, as the right hand is elevated 
 by the side of the posterior pillar into the esophagus. 
 The operation is done rapidly and gently. As soon as the 
 tube is well inserted in the esophagus, the fingers are taken 
 out of the mouth and the instrument is pushed rapidly into 
 the stomach, the patient being told to breathe deeply. It is 
 far better to let the patient direct the tube into the esophagus 
 by swallowing. The fingers commonly excite choking, re- 
 sistance, and fear. 
 
 The technic of the swallowing method is very simple: 
 The patient sits erect, and bends the head sliglitly forward, 
 with the chin a little elevated ; all the clothing is loose, and 
 both hands are left free or engaged in holding the receptacle 
 for the contents. The tube, wet simply in warm water, is held 
 in the right hand, as a pen, while the index-finger and the 
 thumb of the left hand protect the lips and steady the tube 
 in the median line. The tube is now placed on the tongue as 
 far back as the base, the patient is told to swallow, and as the 
 pomum adami rises, the progress of the tube is aided by a 
 gentle push. The procedure introduces the tube into the 
 esophagus, and as the patient breathes quietly the instrument 
 is pushed rapidly on into the stomacli. The sudden yielding 
 of the slight resistance offered by the cardia marks the en- 
 trance of the tube into the stomach. 
 
 But this resistance may not be felt, and it may be wise to 
 locate the cardia before beginning the introduction of the tube. 
 This can be done by marking on the tube the average dis- 
 tance of the cardia from the incisor teeth. The esophagus 
 in the adult is about 25 cm. long, and extends from the
 
 THE FUNCTIONAL SIGNS. 9 1 
 
 lower border of the inferior constrictor muscle of the phar- 
 ynx behind the cricoid cartilage and on a level with the fifth 
 cervical vertebra to the cardiac orifice of the stomach. From 
 its beginning it turns to the left of the trachea, and passes 
 behind the left bronchus on its way to the abdominal cavity 
 through the esophageal foramen, ending about three cm. below 
 the diaphragm in the cardiac orifice of the stomach. The 
 distance of the cardia from the incisor teeth is about 40 cm. 
 — 15 cm. to the beginning of the esophagus, 5 cm. cervical, 
 17 cm. thoracic, and 3 cm. abdominal. About 5 cm. more 
 should be added so as to bring the tube well within the cavity 
 of the stomach ; or the distance from the incisor teeth to 
 the cardia may be measured by placing the lower end of the 
 tube over the tip of the process of the ninth dorsal vertebra, 
 and running the tube along the spine and the side of the 
 neck to the front teeth. To express the contents, the open- 
 ings of the tube should be placed just within the cardia, or 
 below the level of the contents. To remove the contents by 
 siphonage, the internal end of the tube should extend to the 
 greater curvature. 
 
 After the tube is introduced, it should always be held in 
 position, in order to prevent its accidental complete entrance 
 into the stomach. To remove the tube, first draw it through 
 the cardia, compress it tightly between the thumb and index- 
 finger of the right hand, and complete the removal as the 
 thumb and index-finger of the left hand catch the internal 
 extremity. 
 
 The Removal of the Stomach=contents. — The contents of the 
 stomach may be obtained in three ways: (i) by suction ; (2) 
 by self-expression; (3) by position and gravity. 
 
 I. Suction is the oldest method (Jukes). For this purpose 
 the pump is antiquated and the modified Politzer bag of 
 Ewald or the aspirator of Boas (Fig. 9) should be used. 
 
 The aspirator of Boas consists of a compressible rubber 
 bulb, terminating at each end in a short rubber tube, which 
 may be compressed by the fingers or closed by clamps. One 
 end is attached, by means of a short piece of glass tubing, to 
 the stomach-tube. The end communicating with the stomach- 
 tube is clamped and the air driven out through the other 
 end by compressing the bulb; the outer end is next clamped 
 and the communication with the stomach-tube re-opened, or 
 the end may be fitted with a valve. The contents of the 
 stomach are drawn into the bulb, and expelled by compres- 
 sion, after clamping the stomach-tube end, into the receiving- 
 glass. Strauss recommends a very excellent apparatus. It
 
 92 
 
 DISEASES OF THE STOMACH. 
 
 consists of three pieces of rubber tiibinf^ fitted with clamps, 
 attached to the extremities of a T-sliaped piece of <;lass tub- 
 ing. One of the tubes is attached to the stomach-tube, 
 another to a funnel, and the third to two bulbs like those of 
 a double bulb atomizer. By proper manipulation the stomach 
 can be washed out, inflated with air, or emptied. Gross in- 
 serts a glass bulb between a rubber bulb and the stomach- 
 tube; the glass bulb receives the contents, and to it is attached 
 a manometer. 
 
 An attempt to completely em[)t)'*the stomach by suction 
 should not be made, but only enough of the contents should 
 
 Fig. 9. — Boas' aspirator. 
 
 be removed to serve for an examination. The suction should 
 be let off, and some water allowed to flow in, before the re- 
 moval of the tube. This method should be used whenever 
 the contents of a degenerated or ulcerated stomach are re- 
 moved, or when the patient is weak or has advanced disease 
 of the lungs. Expression would here be more dangerous. In 
 cases, also, where there is so much mucus in the stomach as 
 to prevent expression, aspiration ma)' be employed. 
 
 2. Expression is quick, and requires no additional instru- 
 ment except a glass to receive the contents. The patient has 
 only to take a deep inspiration, hold it, and contract the ab- 
 dominal muscles, or make efforts to cough, or to strain as at
 
 THE FUNCTIONAL SIGNS. 93 
 
 Stool. If the patient can not or will not co-operate, the tube 
 may be moved back and forth through the cardia, so as to 
 excite an effort to vomit. 
 
 3. In many cases the contents of the stomach can be more 
 easily and completely removed by placing the patient in the 
 horizontal or knee-elbow position. There is then no uphill 
 curve to the tube, and the fluid contents are easily voided 
 with a little increase of abdominal tension. The tube should 
 be just through the cardia, and held in the mouth so as to 
 prevent its dragging forward on the larynx. The method is 
 very valuable in completely emptying the stomach, and is 
 very easy and efficient when the patient is accustomed to the 
 tube. 
 
 Sometimes no contents can be obtained. The failure may 
 be due to several causes : The tube may be obstructed : in 
 this case it can sometimes be opened by forcing a little air 
 through it. But the obstruction may not be removable by 
 this procedure, and the tube must be withdrawn, and again 
 introduced after its canal is opened. The tube may be intro- 
 duced too far, and its extremity may be curled up above the 
 level of the stomach-contents : This fault may be remedied by 
 withdrawing the tube a few inches. The stomach-contents 
 may be too thick or too coarse for removal, or the stomach 
 maybe empty: The situation maybe cleared up by intro- 
 ducing a little water and then withdrawing and analyzing the 
 fluid obtained. 
 
 2. The Test=meals. — The exploration of the functions of 
 the stomach should be made under conditions as nearly alike 
 as possible to those under which the viscus 'ordinarily does 
 its work. Food is the physiological excitant of these func- 
 tions, and a test-meal furnishes a natural, simple, practical, 
 and agreeable excitant. 
 
 Gastric secretion maybe excited by electricity, but it is not 
 practicable to use this agent at the bedside to test even secre- 
 tion. Thermal and chemical excitants once met with some 
 favor, when it was an object to obtain the secretion of the 
 stomach unmixed with food. Leube, after washing out the 
 stomach, introduced 50 c.c. of a three per cent, solution of soda, 
 and allowed it to remain in the stomach twelve minutes. At 
 the expiration of this period 50 c c. of lukewarm water were 
 introduced, and the mixed contents were withdrawn. The 
 reaction of the mixture should, normally, be neutral. If the 
 reaction is alkaline, the degree of alkalinity represents the 
 degree of insufficiency of secretion. Leube also introduced 
 the ice-water method. One hundred c.c. of ice-water were
 
 94 DISEASES OF THE STOMACH. 
 
 introduced through the tube, and at the end of ten minutes 
 300 c.c. of water were introduced, and the wliole contents 
 immediately witlidrawn. The liquid was tested with litmus 
 and tropasolin for acids, and for ferments by artificial diges- 
 tion. Jaworski improved the method by introducing 200 c.c. 
 of ice-cold distilled water and removing it without dilution. 
 The method is no longer employed by the great clinician who 
 first used it. 
 
 The test-meals proposed are very numerous. The white-of- 
 ^gg test-meal was recommended by Jaworski. The patient is 
 put on an albuminous diet for a few days before the testing is 
 begun. In the meantime, the state of the stomach in the 
 morning before breakfast is learned by aspiration with the tube. 
 If the exploration is negative and the stomach is found empty, 
 100 to 300 c.c. of distilled water are introduced and with- 
 drawn. The fluid withdrawn is saved for analysis. 
 
 The evolution and phenomena of digestion are ne.xt studied, 
 after the patient has taken into a clean and empty stomach 
 the white of one or two hard-boiled eggs, with 100 c.c. of 
 distilled water at the temperature of the room. After the 
 patient has remained quiet for forty-five minutes, he is allowed 
 to drink lOO c.c. of distilled water, and five minutes later the 
 contents are aspirated through the tube. This is saved for 
 analysis. The stomach is further washed until all the white 
 of Q.^'g is removed and the undissolved part is recovered by 
 filtration and compared with the quantity eaten. On a 
 second morning the test is repeated, but the aspiration is 
 made after ninety minutes. The normal stomach contains no 
 white of egg after the expiration of seventy-five minutes, all 
 having been digested or evacuated undigested into the duo- 
 denum, except, possibly, a few pieces caught in the folds of 
 the mucous membrane. The maximum of digestive activity 
 is attained in thirty to forty minutes. The first aspirations 
 from the fasting and digesting stomach are tested for reaction, 
 free HCl, digestive power, mucus, syntonin, and for pep- 
 tones, both qualitatively and quantitatively. Morphological 
 elements are looked for with the microscope. 
 
 The method of Jaworski is an excellent one, but it also has 
 its disadvantages. The white of &^g appeals directly to the 
 unique secretory work of the stomach, but it constitutes a 
 very restricted meal. Klemperer recommended a pint of 
 milk and two small rolls. Bourget recommends 20 gm. of 
 well-browned dry toast, 150 c.c. of weak tea without sugar, 
 and a teaspoonful of essence of peppermint. But the test- 
 breakfast of Ewald and Boas, the test-meal of Germain See,
 
 THE FUNCTIONAL SIGNS. 95 
 
 and the test-dinner of Riegel have best stood the test of 
 time. These three test-meals meet all requirements. 
 
 The Test=breakfast of Ewald and Boas. — The patient is given 
 in the morning on an empty stomach, one roll (about 70 
 gm.) and 350 c.c. of water or weak tea (about i^ glasses). 
 It is recommended that the bread be taken into the mouth 
 dry, be thoroughly masticated, and, after insalivation, washed 
 down with the water or tea. Incomplete mastication delays 
 the digestion of the crust, and the particles are very liable 
 to obstruct the tube. One hour after the beginning of the 
 breakfast the contents are removed. 
 
 This breakfast contains albumin, starch, sugar, fat, extrac- 
 tive matter, and inorganic salts, is rarely repulsive, easily ex- 
 pressed, and suitable for chemical analysis. The roll weigh- 
 ing 70 gm. contains about 5 gm. of proteids, 39 gm. of 
 carbohydrates, i^ of a gm. of fat, and ^ of a gm. of ash. 
 Normally, at the end of an hour we obtain from 30 to 50 
 c.c. of a yellowish-tinged, homogeneous mixture, filtering 
 with ease. The total acidity is about 55, the acid albumin 
 acidity about 45, and the free HCl acidity about 10. These 
 figures represent the number of cubic centimeters of a deci- 
 normal solution of potash or soda required exactly to neu- 
 tralize 100 c.c. of the stomach-contents. The digestive power 
 of the filtrate (Hammerschlag's test) is about 90 per cent. 
 The filtrate, in a dilution of i : 3000 with ^V normal HCl solu- 
 tion, digests albumin after remaming in the thermostat at 37° 
 C. for twenty-four hours. Labferment coagulates milk in dilu- 
 tion of I : 40, and labzymogen in dilution of i : 160. Free 
 HCl appears in thirty minutes, reaches its height in about 
 one hour, and, diminishing, continues to the end of gastric 
 digestion. Acetic acid and ferrocyanid of potassium give a 
 little cloudiness after the first half-hour, and the reaction is 
 demonstrable to the end of digestion. The biuret reaction 
 (rose) runs the same course. Fehling's solution is reduced dur- 
 ing the first hour, and then the reaction is less pronounced, and 
 disappears entirely in one-half to three-quarters of an hour 
 before the end of digestion. Lugol's solution gives a brown- 
 ish-purple color during the first one and one-half hours. 
 The contents contain no blood, a small quantity of mucus, 
 possibly a little bile forced through the pylorus during the 
 expression, and a small number of micro-organisms. No 
 organic acids are present, unless they have been swallowed 
 or set free from their salts by the HCl of the gastric juice. 
 The total acidity is equal to the HCl-albumin-acidity, plus 
 the free HCl, plus the small quantity of acid phosphates
 
 96 DISEASES OF THE STOMACH. 
 
 which are usually present. The stomach is empty in from 
 two to two and one-half hours after the beginning of the break- 
 fast. The following table displays the evolution of the hy- 
 drochloric acidity during the normal digestion of the test- 
 fa reakfafst : 
 
 Total acidity, 
 HCl-all)umin, 
 Free IlCl, . 
 
 Thiriv 
 
 MlNUTKS. 
 
 Sixty 
 Minutes. 
 
 NiNHTV 
 
 Minutes. 
 
 20 to 30 
 20 to 30 
 
 
 
 50 to 60 
 40 to 50 
 10 to 15 
 
 30 to 40 
 
 25 to 35 
 
 5 to 10 
 
 The Test=meal of Germain See. — The test-meal of Germain 
 See consists of 60 to 80 gm. of chopped beef, free from fat 
 and fibrous tissue, lOO to 150 gm. of white bread, and a 
 glass of water. It is best to give definite quantities, and we 
 use the smaller quantities in order to get a meal which de- 
 mands more work of the stomach than does the test-break- 
 fast and much less than does the test-dinner. This meal 
 contains about 20 gm. of proteids, i^/^ gm. of fat, 56 gm. 
 of carbohydrates, and one gm. of ash. The contents are 
 removed two hours after the beginning of the meal, which 
 should not be eaten rapidly. 
 
 After the test-meal of Germain See, about 40 to 60 c.c. of 
 grayish-yellow contents are obtained at the end of two hours. 
 The total acidity ranges between 50 and 70, the free HCl 
 between 10 and 20, and the HCl-albumin between 40 and 50. 
 With Hammerschlag's test the digestive power of the filtrate 
 is about 90 per cent. In dilution of the filtrate (1 : 3000) with 
 4^ normal HCl solution, albumin is digested after standing 
 twenty- four hours in the thermostat at 37° C. ; labferment is 
 active in dilution of i : 40. and labzymogen in dilution of i : 160. 
 Lugol's solution gives a brownish-violet coloration. Acetic 
 acid and ferrocyanid of potash produce a light cloud. Feh- 
 ling's test reveals a moderate quantity of sugar. Very few 
 muscular fibers and starch granules are discoverable. Free 
 HCl first appears in one and one-fourth to one and one-half 
 hours, and is present in a mere trace near the termination 
 of gastric digestion. The biuret reaction is positive (rose- 
 colored) between the first and third hours, and then disap- 
 pears. During the same period acetic acid and ferrocyanid 
 of potash produce cloudiness. Both these tests are negative 
 during the last fourth of digestion. Fehling's solution is 
 negative during the last half-hour of digestion. The stomach 
 is empty in three and one-half hours after the beginning of 
 the meal. The following table di.splays the acidity at the 
 end of each hour :
 
 THE FUNCTIONAL SJGNS. 97 
 
 Onk Hour. Two Hours. Three Hours. 
 
 Total acidity, 30 to 40 50 to 70 30 to 40 
 
 HCl-albumin, 30 to 40 40 to 50 25 to 35 
 
 P>ee HCl, o 10 to 20 o to 10 
 
 The Test=dinner of Riegel. — The test-dinner of Riegel con- 
 sists of a plate of beef soup, 150 to 200 gni. of beefsteak, 
 50 gm. of puree of potatoes, and a small roll. For uniformity 
 and accuracy, we prescribe 300 c.c. of clear beef broth, 150 
 gm.* of beefsteak (fillet), 50 gm. of mashed potatoes, and 
 35 gm. of white bread. This meal contains about 36 gm. 
 of proteids, 3.5 gm. of fat, 30 gm. of carbohydrates, and 
 5 gm. of ash. The food should be thoroughly masticated, 
 and the tough, fibrous pieces of the steak should be removed. 
 The contents are obtained either three or four hours after 
 the beginning of the meal. 
 
 The quantity of contents obtainable ranges from 40 to 70 
 or 80 c.c. The total acidity varies between 60 and 80, 
 the HCl-albumin between 50 and 60, and the free HCl 
 between 10 and 20. Free HCl first appears in about two 
 and one-half hours, continues about two hours, and disap- 
 pears about twenty minutes before the stomach becomes empty. 
 The biuret reaction (rose) and the cloudiness with acetic acid 
 and ferrocyanid of potassium begin near the end of the 
 first hour, and disappear during the last fourth of the period 
 of gastric digestion. Very few striated muscular fibers can 
 be found. The stomach should be empty at the expiration 
 of five hours from the beginning of the meal. The ferments 
 and the starch products are present in the same strength as 
 in the test-meal of Germain See. The following table makes 
 clear the evolution of hydrochloric acidity : 
 
 Two Hours. Three Hours. Four Hours. 
 
 Total acidity, 40 to 50 45 to 70 60 to 80 
 
 HCl-albumin, 40 to 50 45 to 60 50 to 60 
 
 PVee HCl, o o to 5 10 to 20 
 
 The test-breakfast, the test-meal, and the test-dinner reveal, 
 accurately and fully, the secretory activity and the digestive 
 work of the stomach. They also afford a rough estimate of 
 its motor activity. But each one of the tests has its advan- 
 tages and disadvantages. The test-breakfast requires only 
 one hour's delay, and, furnishing the stomach a light task, 
 displays the secretory activity of the stomach in an ideal 
 manner. The chemical analysis of the contents after the test- 
 breakfast is easy. But it does not fully test the digestive 
 power of the stomach, and the demands made on the stomach 
 7
 
 98 DISEASES OF THE STOMACH. 
 
 are much less than those of the usual daily meals. To test 
 the functional sufficiency of the stomach, the test-meal of See 
 or the test-dinner of Riegel is necessary. Indeed, it is wise 
 to use two or three of these tests in order to avoid errors, and 
 we employ them, in the study of our cases, in the order of 
 the increasing demands which are made by them on the func- 
 tions of the stomach. The information obtained in this man- 
 ner suggests to the experienced clinician what further tests 
 are advisable, and whether it is necessary to search for a 
 disorder in the normal evolution of digestion. 
 
 I, THE HYDROCHLORIC ACID. 
 
 Before proceeding to study the gastric contents, a very 
 important physiological and practical question must be an- 
 swered — viz.. Is hydrochloric acid formed by the cell and 
 given out in a free state? 
 
 All authors do not give the same answer to this question. 
 Some maintain that it is secreted in organic combination with 
 leucin or pepsin. Others believe that the hydrochloric acid 
 is formed by lactic acid out of the chlorids. These theories 
 may be dismissed without further consideration. 
 
 Recently another theory has been advocated, which main- 
 tains that the free hydrochloric acid found in the gastric con- 
 tents is a by-product of digestion. The chlorids, according 
 to this theory, are the physiologically active constituents of 
 the secretion, these being formed in the cells and given out 
 by them chiefly as the chlorid of sodium. Working in 
 unison with the pepsin they combine with the proteids, 
 and in so doing may form free hydrochloric acid. According 
 to this theory of Hayem, the free hydrochloric acid in the 
 contents is not a cellular but a chemical and digestive by- 
 product. This view we can not accept. 
 
 The almost universally accepted theory — and in our opinion 
 the true one — claims that the hydrochloric acid is formed and 
 given out in a free state by the border cells. This secreted 
 hydrochloric acid unites with the mucus, the exfoliated cells, 
 the saliva found in the stomach, and the inorganic car- 
 bonates, etc., of the food and saliva; and this part, for the 
 digestion of the food, is lost; another part unites with the 
 proteids of tiie food and converts them into acid compounds, 
 which, with the aid of pepsin, are built up into albumoses 
 and peptones. After the affinities of the proteids are satis- 
 fied, the secreted lu'drochloric acid remains free. The hydro- 
 chloric acid, then, is secreted free, and remains free only after
 
 THE FUNCTIONAL SIGNS. 99 
 
 it is in excess. This excess is limited by the normal stomach, 
 and when this limit is exceeded or not reached within the 
 proper time for the particular test-meal, the acid secretion is 
 abnormal. 
 
 Is it possible to estimate the quantity of HCl secreted ? 
 If it be remembered that this secreted acid combines almost 
 immediately with inorganic bases, with organic bases, and 
 loosely with proteids ; that the stomach discharges its 
 contents into the duodenum intermittently throughout the 
 period of digestion, forms a variable quantity of mucus, 
 exfoliates a variable number of cells, has received a variable 
 amount of bases capable of being drawn away from their 
 union by this strong nascent mineral acid ; that the stomach 
 also probably absorbs sufficiently to vitiate the results — it 
 will be seen that the estimation of the total amount of HCl 
 secreted is surrounded by many difficulties. Moreover, the 
 quantity of saliva secreted in twenty-four hours varies from 
 200 to 2000 gm.; this is all swallowed and enters the stom- 
 ach. The saliva contains inorganic salts in the proportion 
 of 2.24 to 1000, nearly all of which are composed of the 
 chlorids and carbonates in the proportion of about four 
 parts of the former to one of the latter. The gastric secre- 
 tion also contains 0.2 per cent, of chlorids, and a variable 
 quantity is introduced with the test-meals. Of the inorganic 
 chlorids found in the gastric contents after a test-meal, a 
 variable part is formed of combinations with the secreted 
 HCl and a variable part comes from other sources. It is 
 not practicable to estimate the total quantity of HCl secreted 
 during the digestion of a meal, but it is possible to estimate 
 the total quantity found at a particular ' moment in the 
 stomach which is physiologically active, and, knowing the 
 total acid-combining power of the proteids in the particular 
 test-meal, to estimate roughly the total quantity of the se- 
 creted HCl which has been used in the digestive transforma- 
 tion of the food. 
 
 The secreted HCl in inorganic combination is lost to gastric 
 digestion, but it protects and influences intestinal digestion. 
 The union of the acid with these substances is strong, and all 
 these affinities are satisfied before the HCl combines loosely 
 with the proteids, before its digestive work begins, before it 
 remains free. Consequently, the HCl which combines with 
 the proteids and that which remains free together roughly 
 represent the activity of acid secretion. The albumin- 
 combined HCl represents the actual digestive work. We 
 know that the combined and unused HCl should be found in
 
 lOO DISEASES OF THE STOMACH. 
 
 certain quantities in the normal stomach in the very par- 
 ticular conditions in which the test is made. We therefore 
 conclude that the quantity of HCl loosely combined with 
 albumin, together with the quantity remaining free in the 
 contents withdrawn at the end of a particular time after the 
 eating of a particular meal, is a practical and clinical meas- 
 ure of the secretory activity of the peptic glands, and of the 
 digestive work of the acid of the stomach. 
 
 The variations from this clinical standard can not be attri- 
 buted exclusively to disease of the border or chief cells, 
 which may or may not be normal. The healthy stomach 
 possesses what may be designated as its acid sense, by which 
 the hydrochloric activity is held fast to a line marking the 
 normal evolution of acid secretion in keeping with the physi- 
 ological action of the contents. This special sense may be 
 disordered ; the nerve-centers concerned with the secretion 
 may generate, and receive or send out morbid impressions ; 
 the circulation may not be good; the blood may be impure or 
 poor ; the border cells themselves may be diseased — and one or 
 all of these conditions may be expressed by the hydrochloric 
 acidity. The acid signs are of great value in detecting an 
 anomalv ; but only with the greatest circumspection should 
 they be made the revealing signs of a particular disease. 
 
 To estimate the hydrochloric acidity of the stomach- 
 contents, removed either during fasting or during the diges- 
 tion of a test-meal, is not very difficult. The details of the 
 methods can be mastered by study and practice. No very 
 great skill is required ; neither is it necessary nor expected 
 that the clinician should be an expert chemist. But if it 
 be necessary to appeal to chemistry, the analysis should be 
 exact and possess a precise meaning. 
 
 Some of the many methods proposed for the chemical ex- 
 amination of the gastric contents are fit only for the laboratory. 
 Their finer distinctions and greater exactness make them 
 preferable in scientific research. But a clinical method must 
 be simple and short ; otherwise the demand upon the skill 
 and the time of the practitioner will prevent its general use, 
 and will deprive it of practical value. Any long and compli- 
 cated method will fall into disuse, or will, at best, be gener- 
 ally deemed a mere whim, peculiar to a few doctors. A 
 description of the more complete and exact methods should 
 find a place in a special work of this kind. The useless or 
 erroneous methods require no mention. The simple clinical 
 methods which require little time or skill will usually be 
 found sufficiently exact and complete.
 
 THE FUNCTIONAL SIGNS. lOI 
 
 We have seen that the hydrochloric acid secreted by the 
 cells of the glandular lining membrane of the stomach may 
 be found in four states in the contents of the digesting 
 stomach : 
 
 I. Free, when secreted in excess of the affinities of the 
 organic and inorganic matter found in the stomach. 
 ■ 2. Combined with the proteids — a loose, acid-reacting, 
 digestive combination. 
 
 3. Combined with organic bases. 
 
 4. Combined with inorganic bases, forming chlorids. 
 These inorganic chlorids subtract from the acidity due to 
 secretion just so much as the chlorin contained in them repre- 
 sents. The inorganic chlorin, drawn from the hydrochloric 
 acid secreted, escapes estimation, and is lost to digestion. 
 
 The general acidity of the contents of the digesting stom- 
 ach is not fully represented by the acidity due to the hydro- 
 chloric acid, which is free and combined with albumin. Other 
 factors enter and make it more complex. The general 
 acidity may be due to — 
 
 1. Free and albumin-combined hydrochloric acid, 
 
 2. Free organic acids, which may also be in acid-reacting 
 combination with proteids, provided no free and stronger acid 
 is present. 
 
 3. Acid inorganic salts, chiefly the acid phosphates. 
 
 The last two factors of general acidity are introduced into 
 the stomach or are formed there without the aid of the 
 specific secretion. The organic acids are chiefly the products 
 of micro-organisms in the stomach, and will be carefully 
 studied with the bacteriological signs. The functional diag- 
 nosis is concerned only with the first of these factors — the 
 hydrochloric acidity. We will now describe how the free 
 and albumin-combined hydrochloric acid in the mixture repre- 
 sented by the gastric contents can be detected and estimated. 
 The analysis is qualitative and quantitative. 
 
 Qualitative Tests. — The qualitative analysis, which often 
 suffices for practical purposes, is made v/ith color-reagents. 
 
 The gastric contents may be alkaline, neutral, or acid. If 
 they are neutral or alkaline, further testing for hydrochloric 
 acid would naturally be useless. Consequently, as a first 
 qualitative test we use a reagent sensitive to all free acids, 
 organic acid combinations, and acid salts. The best reagent 
 of this kind is a good quality of litmus. The red litmus 
 paper is rarely required in this analysis, as an alkaline re- 
 action of the contents of the digesting stomach is exceed- 
 ingly rare. The blue litmus paper is so sensitive that a neg-
 
 I02 DISEASES OF THE STOMACH. 
 
 ative result is at once final. A good quality gives a plain 
 reaction with 0.006 per cent. h\-drocliloric acid, 0.0 1 per cent, 
 lactic acid, and 0.02 per cent, butyric acid. This blue dye, 
 united with an alkali, is soluble in water, and is sensitive to 
 the hydrochloric acid combined with albumin, this mineral 
 acid having a stronger affinity for the alkaline base of the dye 
 than for albumin. The blue litmus is consequently reddened 
 by all the factors of general acidity. 
 
 The second acid qualitative test is made with Congo-red. 
 This is a red dye, soluble in water, and is colored blue by all 
 free acids. It is three or four times more sensitive to free 
 hydrochloric acid than to the free organic acids of the gastric 
 contents. The intensity of the blue coloration increases with 
 the percentage of free acid, and organic acids produce a 
 muddy grayish-blue or purple, in contradistinction to the 
 pure blue of the mineral acid. But even a very extended 
 e.xperience should not permit these slight distinctions to be 
 valued as more than suggestions. The hydrochloric acid and 
 other acids combined with albumin or organic bases, do not 
 alter the color of Congo-red. Acid phosphates, in very con- 
 centrated solution, produce a brownish coloration ; but in such 
 quantities as are found in the stomach after a test-meal, pro- 
 duce no change of color. Consequently, the Congo-red is 
 turned blue by the free hydrochloric and the free organic 
 acids. The acid salts and the acid organic combinations are 
 without influence. A positive reaction means the presence of 
 a free acid. Congo-red may be used in aqueous solution or in 
 the more convenient form of paper. The latter reacts plainly 
 with 0.0 1 per cent, free hydrochloric acid and with three 
 times the quantity of lactic acid. The solution is about ten 
 times more sensitive than the paper, which is made by satur- 
 ating fine filter paper with an aqueous solution of Congo-red. 
 After it is dry, the paper is cut into narrow strips of convenient 
 length. The test may be made with the solution by spread- 
 ing a few drops over a white ground, — as in a watch-glass, on a 
 piece of white paper, or in a porcelain crucible, — and allowing 
 a drop of the gastric contents to flow over it from the edge; 
 the area of contact becomes blue. Or the paper may be dipped 
 into the mixed contents, after the ordinary manner of using 
 test-papers. 
 
 The third qualitative test, in case the Congo-red gives a 
 positive result, is for free hydrochloric acid. The surest and 
 most sensitive reagents for this purpose are those of Giinz- 
 burcf and Boas.
 
 THE FUNCTIONAL SIGNS. IO3 
 
 The reagent of Giinzburg is an alcoholic solution of phloro- 
 glucin and vanillin : 
 
 Phloroglucin, 2 gm. 
 
 Vanillin, I gm. 
 
 Alcohol (absolute), 30 gm. 
 
 This reagent is uninfluenced by all acid salts and combina- 
 tions and by free organic acids. As hydrochloric is the only 
 free mineral acid present in the gastric contents, unless other 
 mineral acids have been swallowed, a positive reaction with 
 phloroglucin-vanillin is proof of the presence of free hydro- 
 chloric acid. This regeant is also very sensitive. With a 
 solution of I : 10,000 the very fine crystals appear, while a 
 solution of I : 20,000 gives a red coloration. If there be 
 much organic matter in the contents, the red is mixed with 
 the pasty, dry, yellowish residue. The test is best made by 
 placing three or four drops of the reagent in a porcelain 
 crucible, and spreading it by causing it to flow in different 
 directions over the surface. A like quantity of the filtered 
 gastric contents to be tested is now added, and spread over the 
 same area. With a small flame the crucible is slowly warmed, 
 never allowing it to become too hot to be comfortably borne 
 on the back of the hand. After several seconds a clear red 
 coloration appears, or the fine, bright-red crystals may be 
 seen if free hydrochloric acid be present. The phloroglucin- 
 vanillin paper, recommended by some writers, we do not em- 
 ploy. A few drops of the gastric contents are placed on 
 the paper, which may be more rapidly heated in the crucible 
 than with the solution test. 
 
 The following solution of Boas' is used in the same manner 
 as the Giinzburg reagent: 
 
 Resorcin (resublimed), 5 gm. 
 
 White sugar, . . 3 gm. 
 
 Alcohol (95 per cent.), IC)0 gm. 
 
 The coloration is a bright rose-red. This reaction of the 
 gastric contents is characteristic of free hydrochloric acid. It 
 is very sensitive, and may be even clearer than the Giinzburg 
 reaction when the contents contain much soluble albumin. 
 
 Dimethylamidoazobenzol, methyl-violet, and tropasolin 00 
 are also employed as free hydrochloric acid reagents. 
 
 A very sensitive reagent for HCl is a ^ per cent, alco- 
 holic solution of dimethylamidoazobenzol. This yellowish 
 solution changes to a reddish color on the addition of a mere 
 trace of free HCl. The reaction is positive with an HCl
 
 I04 DISEASES OE THE STOMACH. 
 
 solution of I : 20,000. The reaction is also produced by 
 concentrated solutions of acid phosphates and lactic acid, but 
 such concentrations occur so rarely and in such particular 
 conditions as to allow little chance for an error to be made 
 by any one who is familiar with the analysis of the tjastric 
 contents. 
 
 Methyl-violet is changed to a sky-blue color by free HCl. 
 The intensity of the blue color produced varies with the 
 strength of the hydrochloric acid solution — i : 10,000 gives 
 a bluish tinge, and i : 5000 a clear reaction. But the 
 reagent is not so sensitive when the gastric contents are em- 
 ployed instead of an aqueous solution of HCl. Lactic acid, 
 in a solution of i : 300, produces also a bluish tinge. Chlo- 
 rids also vitiate the results, and the methyl-violet, conse- 
 quently, is not altogether satisfactory as a free HCl test. The 
 test, which is a very pretty one, is performed in the following 
 manner: A test-tube full of a very dilute solution (1:500) 
 in distilled water is prepared (a clear violet color), and two 
 small test-tubes are about half filled with it. To one is added 
 one to three c.c. of the filtered gastric contents, and to the 
 other the same quantity of distilled water. By comparing 
 the two tubes, the change of color is beautifully displayed. 
 
 Tropaeolin 00, in concentrated aqueous solution, is an 
 excellent reagent for detecting free acids, but it is not quite so 
 sensitive as Congo-red. The yellow solution is changed to 
 a deep red by free acids. Used in the following manner, it is 
 a sure reagent for free HCl (Boas): Three or four drops of 
 a saturated alcoholic solution are spread thinly in a porcelain 
 crucible, and over the same area an equal quantity of the 
 filtered gastric contents is allowed to flow. Next, heat slowly 
 over a small flame. If free HCl is present, lilac streaks 
 appear near the border, which, on further heating, become 
 blue. 
 
 Whenever free HCl is present in the gastric contents, it is 
 useless to make a test for HCl in combination with proteids, 
 since the HCl remains free only when the acid affinities of 
 the proteids have already been satisfied. The presence of 
 HCl free proves that HCl in combination with proteids is 
 also present. 
 
 But it often happens in the diseases of the stomach that 
 no free HCl can be detected. Under such circumstances, if 
 the reaction of the contents is acid, HCl in proteid combina- 
 tion may be present. To detect it, qualitatively, two tests 
 may be made, one of which is a chemical and the other a 
 color test. A small quantity of the filtered contents is ex-
 
 THE FUNCTIONAL SIGNS. IO5 
 
 actly neutralized, boiled, treated with acetic acid and sodium 
 chlorid, again boiled, and filtered after cooling. Any albu- 
 min left in the filtrate is digested albumin combined with 
 HCl. A positive biuret reaction (rose) on treating the fil- 
 tered contents with liquor potassa and cupric sulphate shows 
 the presence of propeptones. These chemical tests also give 
 roughly the degree of peptonization. The color test is made 
 by employing a one per cent, aqueous solution of alizarin. 
 Three or four drops of the solution of the dye are added to 
 a small quantity of the filtered contents, and decinormal 
 alkaline solution is added until a pure violet color appears. To 
 a second portion of the filtered contents the same quantity of 
 the alkaline solution is added. If the mixture still reacts acid 
 to litmus, HCl in proteid combination is present. For prac- 
 tical qualitative purposes the biuret test is sufficient. 
 
 The Quantitative Analysis. — On account of its bearing 
 on the diagnosis and treatment of the diseases of the stomach, 
 an easy and an accurate method of differentiating and esti- 
 mating the different factors of the acidity of the gastric con- 
 tents is very desirable. For a long period the chemical 
 analysis was confined to the detection of free hydrochloric 
 acid. Hayem and Winter (1888) proved the insufificiency of 
 this method,! and gave their very valuable, but long, chloro- 
 metric analysis. A new light was turned on the chemical 
 pathology of the stomach. Many other quantitative methods 
 have since been given, but none of these seem completely to 
 satisfy the requirements of practice. The busy physician in 
 his daily work demands a quantitative method at once easy, 
 accurate, and rapid. 
 
 It would seem that the practical value of very slight quan- 
 titative variations in the factors of general acidity has been 
 overestimated, and that the simpler color methods reveal with 
 sufficient exactness all the deviations from the normal chem- 
 ism which possess a distinctive practical meaning. The in- 
 accurate laboratory methods need not be mentioned. The 
 more complete and chemically accurate methods — which 
 may sometimes be used with advantage in practice, and 
 which should always be employed in original research — will 
 be given. Rut for daily needs coloration-titration procedures 
 usually suffice. 
 
 [a) The Color Methods. — The Method of Mint.':. — This method 
 estimates the quantity of free HCl, or H, by means of Giinz- 
 burg's reagent. To ten c.c. of the filtered contents, the deci- 
 normal alkaline solution is added from the buret until the 
 reaction of a droplet (platinum loop) of the fluid with the
 
 I06 DISEASES OF THE STOMACH. 
 
 reagent of Giinzburg becomes negative. If the reaction is still 
 positive with 0.9 c.c, but is negative with i .0 c.c. of the titration 
 alkali, tiie free HCl acidity in 100 c.c. of the gastric contents 
 is represented by 10 c.c. of the decinormal solution of caus- 
 tic soda or potash. One c.c. of a decinormal alkaline solution 
 represents 0.00365 HCl ; consequently, the 100 c.c. of the 
 gastric contents contain ten times that amount. The strong 
 free HCl in the contents is first completely neutralized by the 
 alkali before any of the other factors of the total acidity are 
 affected. The method consumes less time if the platmum 
 loop, wet in the solution, is brought in contact with Congo- 
 paper. When the Congo-red is no longer made markedly 
 blue, the use of the more trustworthy reagent of Giinzburg 
 may be begun. 
 
 The Method of Boas. — The object of this method is the 
 quantitative estimation of the free hydrochloric acid, or H, 
 Five c.c. of a watery solution of Congo-red are added to an 
 equal quantity of the filtered contents. The mixture becomes 
 blue. The titration is made with the decinormal solution of 
 caustic potash or soda, and contin ueduntil the original Congo- 
 red color is restored. As a control color, five c.c. of the Congo- 
 red solution may be added to an equal quantity of distilled 
 water. The titration should be slow near the end, as the 
 restoration of the red color does not take place rapidly. 
 
 The value thus found represents free HCl ; or, more accur- 
 ately, free HCl and the quantity office organic acids present, 
 or H + O. The author of the method claims that the quan- 
 tity of organic acids in the contents after the test-breakfast is 
 practically seldom worth considering when free HCl is pres- 
 ent, but that if the organic acids are present in notable quan- 
 ity, they should be removed by repeated shaking with ether 
 before the titration. 
 
 Method of Topfer. — The method of Topfer requires the fol- 
 lowing color reagents: (i) One-half per cent, alcoholic solu- 
 tion of dimethylamidoazobenzol ; (2) one per cent, aqueous 
 solution of alizarin ; (3) one percent, alcoholic solution of 
 phenolphthalein. 
 
 I. To ten c.c. of the filtered contents are added a few drops 
 of the alcoholic solution of phenolphthalein, and the total 
 acidity is titrated with a decinormal solution of caustic potash 
 or caustic soda. The alkali is to be added until the rose-red 
 coloration is permanent, and drop by drop so long thereafter 
 as the rose color does not become deeper. The end reaction 
 of the color indicator is used. This gives the total acidity, 
 or A.
 
 THE FUNCTIONAL SIGNS. IO7 
 
 2. To ten c.c. of the filtered contents are added three or 
 four drops of a yi pei' cent. alcohoHc solution of dimethylam- 
 idoazobenzol. This yellowish solution is changed to red 
 by a trace of free HCi, being as sensitive as the reagent of 
 Giinzburg. Organic acids (free) produce the red color when 
 in a concentration of 0.5 per cent, and in the presence of 
 mucin and albumoses require even a greater concentration. 
 Such a quantity of organic acids is probably never present 
 in the free HCl-containing contents (qualitative tests) of the 
 test-breakfast, given on a clean and an empty stomach. The 
 titration is made with the decinormal alkaline solution until 
 the original light orange (not lemon yellow) replaces the red 
 color produced on the addition of the dimethylamidoazobenzol 
 to the contents. The value thus obtained represents the free 
 HCI, or H. 
 
 3. To ten c.c. of the filtered contents are added three or 
 four drops of the one per cent, aqueous solution of alizarin. 
 This reagent is sensitive to all the factors of gastric acidity 
 except the organic combined HCI, or C ; or, in other words, 
 the alizarin solution becomes pure violet on the addition of 
 the solution of caustic alkali after all the factors of gastric 
 acidity have been neutralized except C, which does not pre- 
 vent the transformation of color. This solution, which is 
 yellowish, becomes brownish, and then pure violet, as the 
 titration proceeds. As soon as the p2ire violet color — which is 
 the same as that produced by a one per cent, solution of 
 sodium carbonate — appears, the titration is complete. This 
 value gives the free HCI and the acidity due to the acid salts 
 and the organic acids, or H + P + O, A — (H + P + O) 
 = C. A — (H + C) = O -f P. (A, total acidity ; H, free 
 HCI ; P, acid salts ; O, free organic acids ; C, HCI com- 
 bined with proteids.) The quantity of the decinormal alkaline 
 solution used in each titration is multiplied by 10 to bring 
 all to the standard, which is lOO c.c. of the gastric contents ; 
 or it is better to use only five c.c. of the filtered contents, and 
 to multiply the results by 20. The method, after practice, 
 gives good results, but the proper use of the alizarin as an 
 indicator requires care and experience. 
 
 Combination Color Method. — The color methods may be 
 combined in such a manner as to make the quantitative esti- 
 mate of the factors of acidity of the gastric contents suffi- 
 ciently complete and accurate for the requirements of prac- 
 tice. 
 
 I. If the qualitative tests have revealed the presence of free
 
 108 DISEASES OF THE STOMACH. 
 
 hydrochloric acid in the gastric contents, we may proceed as 
 follows : 
 
 A qualitative test for free volatile organic acids should be 
 made. An acetic or a rancid odor would create suspicion. 
 A small quantity of the contents is put into a test-tube, and 
 a strip of moistened blue litmus paper is held in the end of 
 the tube while its contents are gently warmed. The litmus 
 paper will be reddened if a volatile acid is present. Lactic 
 acid in the contents of the stomach containing free hydro- 
 chloric acid has no distinctive pathological significance, and 
 if found was probably introduced as such, or was set free by 
 decomposition of lactates in the test-breakfast or in the 
 saliva. On the other hand, acetic and butyric fermentations 
 are frequent in the presence of free hydrochloric acid. 
 
 Ten c.c. of the filtered or well-mixed unfiltered contents 
 are placed in a beaker, and the titration, with a decinormal solu- 
 tion of caustic potash or of caustic soda, is begun. The level 
 of the solution in the Mohr buret is noted on a piece of 
 paper after reading the mark of the lowest part of the menis- 
 cus, the finger being placed just below the point so as to make 
 the demarcation clearer. The decinormal alkaline solution is al- 
 lowed to flow until, after shaking, a drop taken out (conveni- 
 ently with a platinum loop) gives a negative reaction with a few 
 drops of a i^ per cent, alcoholic solution of dimethylamido- 
 azobenzol or with Giinzburg's reagent. The point where 
 the reaction with these color reagents disappears gives, 
 when read on the buret, the quantity of decinormal alkaline so- 
 lution req.uired to neutralize the free HCl contained in the ten 
 c.c. of the contents. A memorandum of this reading is made 
 on a slip of paper. This gives H. or the quantity of free HCl. 
 
 A droplet of the contents (platinum loop) is now brought 
 into contact with a few drops of an aqueous solution of Congo- 
 red. If the reaction is positive (grayish-blue), free organic 
 acids are present. The titration is continued with the solu- 
 tion of Congo-red as indicator. As soon as the reaction fails, 
 the reading of the buret is again taken, and the additional 
 quantity of decinormal solution used represents the quantity 
 of free organic acids. Thus O is obtained. 
 
 A droplet of the contents (platinum loop) is next brought 
 into contact with a few drops of a one per cent, aqueous solution 
 of alizarin. If the reaction is negative, the titration is con- 
 tinued with the alizarin as indicator. The point where the 
 pure violet reaction begins marks the disappearance; of the 
 acid salts. The reading on the buret is again taken, and a 
 note is made of it. This gives P.
 
 THE FUNCTIONAL SIGNS. IO9 
 
 The remaining acidity is titrated after the addition of a few 
 drops of a one per cent. alcohoHc solution of phenolphthalein. 
 The decinormal alkaline solution is added until there is no 
 longer an increase of the rose-red color; not the beginning 
 but the end reaction is taken to indicate the completion of 
 titration. The level of the solution is again read on the 
 buret. The additional quantity of decinormal solution used 
 represents the acidity due to HCl in organic combination. 
 This is C. 
 
 The total quantity of the decinormal solution used repre- 
 sents the total acidity of the ten c.c. of the analyzed contents. 
 
 It only remains to calculate the acidity represented by each 
 factor in 100 c.c. of the gastric contents — the quantity taken 
 as the convenient standard of comparison. Ten c.c. being 
 used in the analysis, the results are all multiplied by ten. This 
 gives the total acidity and the different factors of it, expressed 
 in so many cubic centimeters ot decinormal solution. 
 
 After experience with the color reagents, the analysis can 
 be done rapidly without using, in making the repeated tests, 
 a sufficient quantity of the contents materially to falsify the 
 results. The procedure may be easily controlled by repeating 
 the analysis, or part of it, on a fresh specimen. 
 
 2. If there be no free HCl but free organic acids in the 
 contents, as indicated by the Congo-red, tlie test is made as 
 before for volatile acids. If the volatile acids are absent, the 
 free acidity is due to lactic acid. If volatile acids are present 
 and Uffelmann's reaction is negative, the free acidity is due to 
 acetic or butyric acid, or to both. The reactions for lactic and 
 volatile acids may both be positive, as in obstructive retention 
 in carcinoma, with absence of free HCl. The titration is 
 begun with Congo-red as the indicator, and completed with 
 alizarin and phenolphthalein as before. This gives O, P, 
 and A. C may be incorrect, on account of the possible union 
 of organic acids with the proteids. 
 
 3. If no free acid is present, as indicated by Congo-red, the 
 titration begins with alizarin and is completed with phe- 
 nolphthalein. This gives P, C, and A ; C being again pos- 
 sibly incorrect. 
 
 If the contents contain no free HCl, the deficiency of HCl 
 secretion may be roughly determined by the method of von 
 Noorden and Honigmann. Decinormal solution of HCl is 
 added to ten c.c. of the filtered contents until the reactions for 
 free HCl appear. The quantity of the decinormal solution 
 of HCl represents the deficiency in the secretion of hydro- 
 chloric acid. This test is of more value when made on the
 
 I lO DISEASES OF THE STOMACH. 
 
 unfilteied contents. Congo-red and Giinzburg's reagent 
 slioiild be used as the indicators. If free organic acids are 
 present, these should be estimated first and neutrahzed. The 
 test is then made by using ten c.c. of the unfiltered contents 
 whose free acidity has been neutralized. The decinormal 
 solution of HCl is added until dimethylamidoazobenzol (drop- 
 let method) or Giinzburg's reagent reveal the appearance of 
 free HCl. The quantity of the decinormal HCl added has 
 been used in the formation of acid proteid compounds and in 
 the displacement of organic acids. Consequently, after the 
 free HCl reaction becomes positive, the quantity of organic 
 acids set free must be estimated by further titration with a 
 decinormal alkaline solution until Congo-red no longer gives 
 a reaction. The quantity of alkali used should be subtracted 
 from the quantity of decinormal HCl obtained in the first 
 part of the titration. If no HCl has been secreted and com- 
 bined with proteids, the two titrations will give the same 
 quantities, all the decinormal HCl being utilized in the dis- 
 placement of organic acids. 
 
 {l>) The Chemical Methods. — The Method of Brmin. — The 
 method of Braun is one of the simplest of the chemical 
 methods. The general acidity (A) of ten c.c. of the filtered 
 contents is estimated by titration with a decinormal potash 
 or soda solution, using phenolphthalcin as the indicator. 
 
 To a second ten c.c. of the filtered contents, in a platinum 
 crucible, is added a decinormal solution of potash or soda in 
 excess of the general acidity as given by the first analysis, 
 and this quantity is noted. The alkaline fluid is ne.xt evapo- 
 rated carefully on an asbestos plate, and the residue is incin- 
 erated, care being taken not to heat the crucible beyond a 
 dull red glow, and to stop as soon as no more points are in 
 ignition. The ashes are next dissolved with a quantity of 
 decinormal H2SO, (or HCl) solution equal to that of the 
 decinormal potash or soda solution added before evapo- 
 ration. The solution is next warmed to drive off the CO2, 
 and titrated with phenolphthalcin and decinormal KOH, or 
 NaOH. This gives the total acidity, with the exception 
 of that due to the burnt organic acids, or H -}- C + P. A — 
 (H -f C -j- P) = O. For example, ten c.c. of the filtered 
 contents require six c.c. of the decinormal K(OH) to neutral- 
 ize it. or 60 per 100 c.c. This gives A = 60 decinormal 
 K(OH). To a second ten c.c. of the contents are added seven 
 c.c. decinormal K(OH); this is then evaporated, incinerated, 
 and seven c c. decinormal HoSO, (or HCl) added, and the dis- 
 solved ash, after heating, requires five c.c. decinormal K(OH)
 
 THE FUNCTIONAL SIGNS. 1 1 I 
 
 for neutralization. C + H + P = 50 decinormal K(OH); 6o 
 — 50 = 10 = O, or the organic acids converted into alkaline 
 carbonates by incineration and combined, with the equivalent 
 acid added. This method gives O (C + H + P) and A. 
 
 The Mctlwd of Hayein and Winter. — The method of tlayem 
 and Winter is very long, but when well carried out is also 
 very accurate for H + C. 
 
 In three porcelain capsules, a, b, and c, are placed five c.c. 
 of filtered gastric contents. 
 
 To the capsule a is added an excess of pure carbonate of 
 soda, and then the contents of the three capsules are slowly 
 evaporated to complete dryness on the water-bath. The 
 capsule a, to which the carbonate of soda was added, con- 
 tains all the chlorin of the gastric juice in the form of inor- 
 ganic chlorids. The capsule a gives the total chlorin, or T. 
 The capsule is next brought to a low red heat, slowly and 
 frequently stirring with a glass rod, so as to avoid loss by 
 little explosions. As soon as no more points are in ignition 
 and the carbonate of soda begins to fuse, the incineration is 
 completed. After cooling, the residue is taken up with dis- 
 tilled water, to which a little pure nitric acid has been added. 
 The solution, which should be clear, is next boiled to 
 drive off the CO2. It is then completely neutralized, or ren- 
 dered slightly alkaline with pure carbonate of soda. Heat 
 until an abundant precipitate falls, taking down the carbon 
 with it. Then filter, wash the precipitate with boiling water, 
 unite all the washings, and estimate the quantity of chlorin 
 with decinormal AgNOa in the presence of neutral chromate 
 of potash. One or two drops of a concentrated solution of 
 neutral chromate of potash are added to the filtrate, and the 
 decinormal solution of nitrate of silver is allowed to flow 
 into it from the buret until the red coloration, after shaking, 
 remains permanent. All the chlorin is now combined, 
 and the silver begins to unite with the chromic acid. The 
 titration is complete. The number of cubic centimeters of the 
 decinormal silver solution multiplied by O.073 (20 X O.OO365) 
 expresses in terms of HCl the quantity of chlorin contained 
 in 100 c.c. of the gastric contents. 
 
 The capsules band c, by the prolonged and complete 
 evaporation at 100° C, have been deprived of their HCl (free). 
 To the capsule b we add an excess of carbonate of soda, and 
 fix the remaining chlorin. We proceed as with the first 
 capsule, and estimate the quantity of chlorin : a — b = H, or 
 free HCl. 
 
 The contents of the capsule c are incinerated without the
 
 112 DISEASES OF THE STOMACH. 
 
 addition of carbonate of soda. The process is rapidly done 
 by heating on a wire gauze while breaking the coal with a 
 glass rod. As soon as the coal is dry and friable, the process 
 is complete. After cooling, treat as capsule a. This capsule 
 contains only the fixed inorganic chlorids. The free HCl 
 has been driven off and the combined HCl (C) destroyed by 
 heat : b — c = C, or organic combined HCl ; a = T ; a — 
 b = H; b — c = C; c^:=:F, or inorganic combined chlorin. 
 
 This is a chlorometric method. The values found may be 
 converted into their HCl equivalents, or multiplied by 20 to 
 give the equivalent quantities of decinormal A gNO.j required to 
 combine each chlorin factor in 100 c.c of gastric contents. 
 
 In the analysis of Hayem and Winter, the quantity obtained 
 for b (C + F) is incorrect. Not all the free HCl is driven 
 off by evaporation, and the heating causes more of the free 
 HCl which is present to combine with the proteids. But a 
 (= T) and c (^ F) are correct. T — F = H -f- C. In 
 case no free HCl is present, T — F = C. If the contents 
 contain free HCl, the quantity should be estimated by Giinz- 
 burg's reagent, or by Topfer's dimethylamidoazobenzol, which 
 would give H. 
 
 The Method of L'uttke. — Like that of Hayem and Winter, 
 the method of Liittke is chlorometric. The total chlorin 
 (T) and the chlorin combined with inorganic bases (F) are 
 quantitatively estimated. The difference, or T — F, repre- 
 sents the physiologically active chlorin (H + C) — i.e., the 
 quantity of secreted HCl left free (H) and combined with 
 proteids (C). 
 
 The chlorin is estimated by the method of Volhard. For 
 this purpose are needed : (i) A decinormal acid solution of 
 pure nitrate of silver and (2) a decinormal solution of ammo- 
 nium sulphocyanid. 
 
 The decinormal acid silver nitrate solution is prepared by 
 the following formula: 
 
 Argenti nitras (c. p. ), 17.5 gm. 
 
 Acidiim sul|iburicum {25 ]>er cent, solution), 900. c.c. 
 
 Liquor ferri sulplniiici oxidati, 50. c.c. 
 
 Mix and dissolve in the above order, and add enough distilled 
 water to make one liter. Correct by using a standard deci- 
 normal solution of HCl. Ten c.c. of the silver solution are 
 measured and diluted to 100 or 150 c.c. with distilled water. 
 This dilution is titrated \Vith the decinormal solution of HCl. 
 If, for e.xample, 9.5 c.c. of the HCl solution are required 
 to exactly combine the silver in the 10 c.c. taken, 950 c.c. of
 
 THE FUNCTIONAL SIGNS. I I 3 
 
 the acid silver solution are diluted to lOOO c.c, and the cor- 
 rection is confirmed by a new titration. 
 
 The decinormal solution of the sulphocyanid of ammo- 
 nium is prepared by adding eight gm. of NH4CNS to a liter 
 of distilled water, and the solution is corrected by means of 
 the decinormal silver solution. If, for example, 9.8 c.c. of the 
 decinormal silver solution are required to produce the first 
 light rose color, persisting after shaking, 980 c.c. of the solu- 
 tion are diluted to lOOO c.c, and the correction confirmed by 
 titration, until the quantity of CNS in one c.c. of the one is 
 just sufficient exactly to combine the quantity of Ag in one 
 c.c. of the otl'^er. 
 
 If the acid silver solution is added in excess to the gastric 
 contents, only so much of the silver is precipitated as chlorid 
 of silver as there is chlorin present to combine with it. The 
 unchanged nitrate of silver is estimated by titration with the 
 decinormal solution of ammonium cyanid, after removal of 
 the precipitated chlorid of silver by filtration. When the 
 cyanid is added to the acid solution containing the nitrate of 
 silver and sulphate of iron, cyanid of silver and the cyanid 
 of iron are formed. 
 
 AgNO^ + NH.CNS = AgCNS + NH^NO^. 
 Fe,(S6j3 + 6NH,CNS = Fe.,(CNS)e + 3lNHJ,SO,. 
 
 The cyanid of iron colors the solution blood-red, but so 
 long as AgNOs is present, Fe2(CNS)c is decomposed and 
 AgCNS formed, and the red color disappears. The first per- 
 sistence of a rose color indicates that all the nitrate has been 
 converted into the cyanid of silver, and the quantity of the 
 decinormal solution of ammonium sulphocyanid used rep- 
 resents the quantity of silver nitrate unconverted into the 
 chlorid of silver. 
 
 I. The Analysis. — Ten c.c. of the ivcll-inixed 7in filtered gas- 
 tric contents are placed in a 100 c.c. graduate, a, and the 
 measure graduate is washed out a number of times with dis- 
 tilled water, the washings being poured into the large gradu- 
 ate. Twenty c.c. of the decinormal acid solution of nitrate of 
 silver are added, the mixture is well shaken, and left standing 
 for ten minutes. All the chlorin contained in the specimen 
 combines with the silver and forms the insoluble chlorid. 
 Other combinations of silver are prevented by the presence of 
 the H2SO4. Next, add enough distilled water to make the 
 mixture measure exactly 100 c.c, and filter, using dry paper, 
 a dry funnel, and a dry beaker. Fifty c.c. of the filtrate are 
 titrated with the decinormal solution of ammonium sulpho-
 
 I 14 DISEASES OF THE STOMACH. 
 
 cyanid, tlie titration bein<^ complete as soon as tlie reddish 
 color persists after shaking. The reading on the buret is 
 taken, and gives one-half of the silver nitrate added in excess. 
 The reading, multiplied by two and subtracted from 20, gives 
 the total quantity of chlorin present in the ten c.c. of the 
 gastric contents. If, for example, six c.c. of the titration fluid 
 have been used, six multiplied by two and the product sub- 
 tracted from twenty, gives eight c.c. to represent the total 
 chlorin, or T; 0.00355 multiplied by eight, or 0.0284 gm. of 
 chlorin, in the ten c.c. of gastric contents, or 0.00365 X 8 = 
 0.0292 gm. of HCl. Thus T is estimated. 
 
 2. A second ten c.c. of the mixed unfiltered contents are 
 placed in a platinum crucible, b, and evaporated (best on an 
 asbestos plate). The residue of evaporation is incinerated by 
 holding the crucible directly in the flame until the organic 
 matter no longer burns and there is a dull red glow. The 
 incinerating should be done rapidly and without overheating, 
 as high, prolonged heat would also decompose the inorganic 
 chlorids. The free and combined HCl (H + C) has been 
 driven off by the evaporation and incineration, and the ash 
 contains only the inorganic chlorids. 
 
 Pathologically, large quantities of ammonium chlorid (as in 
 uremia, putrefaction, etc.) and, normally, traces of this salt, are 
 found in the contents of the stomach. The ammonium chlorid 
 is decomposed and driven off by incineration, and thus es- 
 capes estimation. The quantity of inorganic chlorids will be 
 just as much too small, and the remainder, T — F or H + 
 C, too great, the ammonium chlorid being included in the 
 estimate of T. This is a possible source of error, which does 
 not exist with T and F in the method of Hayem and Winter. 
 
 The ash is next dissolved by rubbing repeatedly with hot 
 water, the extraction fluid being emptied upon a filter. About 
 200 c.c. of hot water are required, and a small quantity of the 
 last washing should give no precipitate with the silver solu- 
 tion. The whole of the filtered washing, after the addition of 
 ten c.c. of the decinormal silver solution and filtration, are 
 titrated with the decinormal solution of ammonium cyanid, 
 and the value found is subtracted from ten. The remainder 
 is the value for the inorganic chlorids (except chlorid of am- 
 monium, if it should have been present). Thus F is estimated. 
 If, for examjile, seven c.c. of the titration fluid were used, 
 seven subtracted from ten gives three : O.OO355 X 3 = 0.01065 
 gm. chlorin, or 0.00365 X 3 == O.OIO95 gm. free HCl in the 
 ten c.c. of gastric contents. 
 
 The total acidity, A, is estimated by phenolphthalein. The
 
 THE FUNCTIONAL SIGNS. II5 
 
 free acidity, B, is estimated by using a ten per cent, solution 
 of tropaeolin in dilute alcohol as the indicator, in the same 
 manner as phenolphthalein, the yellow mixture changing to 
 red as soon as the titration is completed. T — F = H -f" C. 
 A— (H + C)=0+P. If A =T — F, then B=H. If 
 A > T — F, organic acids are present. If B =: A — (T — F), 
 all the HCl is combined, and all the organic acids are free. 
 IfB<A — (T — F), all the HCl and a part of the organic 
 acids are combined; the free acidity, B, consists wholly of 
 free organic acids. If B > A — (T — F), free organic acid and 
 free HCl are present, all the organic acids being uncombined. 
 
 Many other chemical methods have been employed. These 
 either have only a historical interest, or possess no advan- 
 tages over the three methods already given. We recommend 
 the method of Braun for the estimation of the organic acids, 
 or O. The method of Hayem and Winter gives the most 
 accurate results for T and F, and consequently for T — F, or 
 H -t- C. The free HCl, or H, should be directly estimated by 
 Giinzburg's reagent. The total acidity, or A, is estimated by 
 using phenolphthalein as the indicator. 
 
 The knowledge of the percentages of HCl in the contents 
 is usually sufficient. But the total quantity of physiological 
 HCl, or H -|- C, in the stomach at a given moment gives 
 some further information concerning the activity of secretion 
 and of the motor and absorptive functions. The absolute 
 quantity of HCl in the stomach at the time of the removal of 
 the contents may be easily calculated from the analysis of 
 a part, provided the whole quantity of the contents is known. 
 The total quantity of the contents can be determined by the 
 acidity method of Mathieu and Remond or by the specific 
 gravity method of Strauss. 
 
 TJie Diagnostic Value of the Variations of HCl. — By some 
 students the chemical types revealed by the analysis of the 
 gastric contents after a test-meal have been considered dis- 
 tinct diseases. These diseases have been carefully described, 
 and each of them has been supplied with a characteristic 
 etiology, symptomatology, evolution, and treatment. Others 
 give the chemical types a place among the complications, and 
 speak of the various anatomical diseases complicated by this 
 or that chemical variation. Neither of these opinions can be 
 successfully defended, as the cheniical types are only reveal- 
 ing signs or symptoms. 
 
 Furthermore, these chemical signs have no pathognomonic 
 meaning. Neither a dynamic affection, nor cancer, nor ulcer, 
 nor gastritis, are constantly associated with a particular varia-
 
 Il6 DISEASES OF THE STOMACH. 
 
 tion. Hayem contends that in all gastric troubles with per- 
 sistent chemical types there are anatomical changes, and 
 often serious lesions of the mucous membrane; that the work 
 of the stomach is compromised, like that of other organs, only 
 when there is an anatomical disease. That the persistent 
 chemical types have often a physical basis in histological 
 pathology is. without question, true. That such a basis always 
 exists is more than doubtful, for normal secretion depends 
 not on the integrity of the gastric glands only, but also on a 
 normal nerve- and blood-supply, on a normal motor function, 
 and on normal absorption. The mucous membrane may be 
 perfectly normal, and the secretion of HCl be abnormal and 
 this abnormality may be the symptomatic expression of a dis- 
 ease which is not located in the stomach. But Hayem has 
 rendered an inestimable service in searching for the physical 
 basis of the chemical types, and by controlling the functional 
 chemical signs by the revelations of autopsies. 
 
 That none of the chemical signs are pathognomonic, is no 
 evidence against their diagnostic value, which may be both 
 positive and negative. 
 
 I. The analysis of the gastric contents removed after a test- 
 meal may give a normal quantity of free and combined HCl 
 (H -f- C), or the quantity may be variable, notably increased or 
 diminished, or the physiological HCl may be entirely absent. 
 
 If the quantity is normal, and if this has been proven by 
 two, or, better, by three t^sts, made with two or three days' 
 intervals, there is no anatomical disease of the glands of the 
 stomach. The condition of the blood, of the nerve-cen- 
 ters controlling secretion, and of the secreting glands, is such 
 as to allow the performance of the normal work. There may 
 be myasthenia or neurasthenia gastrica, but it is more proba- 
 ble that the trouble of which the patient complains is located 
 in the intestines or some other organ. Normal digestive 
 chemistr}' excludes with certaint}' an extensive disease of the 
 mucous membrane of the stomach, and may be an important 
 sign in the differential diagnosis of the diseases of other 
 organs from one another and from the diseases of tlie stomach. 
 These may be autotoxic, reflex, cerebral, spinal, or may be 
 due to disorders of the circulation or to the quality of the 
 blood. Under the circumstances, the acid secretion will at 
 times be normal, and at other times abnormal. Variable ab- 
 normal types are common in chronic gastritis, with acute ex- 
 acerbations. Any form of variable chemism may be found in 
 complicated myasthenia. 
 
 Excessive secretion of HCl is a sign of adenohypersthenia
 
 THE FUNCTIONAL SIGNS. WJ 
 
 gastrica, and indicates the employment of sedative medica- 
 tion and the protection of the mucous membrane against the 
 irritating contents. This is a frequent symptom of chronic 
 glandular gastritis, or it may be associated with a complicated 
 myasthenia. In myasthenia it may exist as an expression of 
 the irritation produced by the prolonged sojourn of the con- 
 tents in the stomach ; in a further stage of the same trouble 
 there may be continuous secretion, and the stomach may be 
 unable to obtain physiological rest. In the irritative stage of 
 acute mycotic gastritis, and during the acute exacerbations of 
 chronic gastritis, excessive acidity maj^ manifest the glandular 
 irritability. It is also the most common chemical sign of 
 ulcer, or of its associated gastritis. Excessive secretion may 
 occur as a dynamic affection, as in the crises of cerebrasthenia, 
 tabes, myelitis, intestinal auto-intoxication, and uricemia, and 
 may rarely be a symptom of carcinoma engrafted on an old 
 ulcer. 
 
 Hydrochloric subacidity is a common sign of stages or 
 forms of acute and chronic asthenic gastritis, of carcinoma, 
 sometimes of ulcer, and of a large number of diseases of other 
 organs, of the blood, and of disorders of the circulatory sys- 
 tem. It is an asthenic sign, and may indicate the employ- 
 ment of excitant treatment. 
 
 Hydrochloric anacidity is exceedingly rare as a symptom 
 of a dynamic affection of the stomach, but is somewhat com- 
 mon in forms of gastritis and in atrophy. Carcinoma rarely 
 runs its course without the appearance of this sign. 
 
 The analysis of the acidity of the contents removed at the 
 acme of digestion of the test-meals reveals one form of the 
 quantitative variations of the hydrochloric acid secretion. But 
 secretion may also be disordered in its evolution. 
 
 In order to detect the abnormal evolution of gastric diges- 
 tion, it is necessary to extract the contents at various intervals 
 during the digestion of the test-meal. For the test-breakfast, 
 the intervals should not be longer than half an hour, while 
 the extraction should take place from hour to hour when the 
 test-meals of See and Riegel have been given, removing each 
 time, preferably by aspiration, only enough of the contents 
 for analysis ; or the same test-meal may be given on succes- 
 sive days and the contents be removed, by expression, after 
 increasing intervals, until the evolution of digestion is com- 
 pletely displayed. A test-meal should never be given when 
 the stomach is not empty, and gastric retention renders it 
 imperatively necessary to first employ thorough lavage, which 
 may have to be repeated for several days in succession until
 
 Il8 DISEASES OF THE STOMACH. 
 
 the secretorx' irritation due to retention subsides. This 
 stringent rule must be observed with special care when inves- 
 tigating the evolution of digestion. 
 
 The evolution of secretion maybe more rapid than normal. 
 Expression after one hour may give only a small quantity of 
 contents advanced in digestion and a somewhat less than 
 normal acidity. The stomach is almost empty and digestion 
 is in its decline. The evolution has been more rapid than 
 normal, and the tube, introduced twenty minutes after the 
 test-breakfast, or one hour after the test-meal of See, or two 
 hours after the test-dinner of Riegel, will show that at this 
 early period the secreted h}'drochloric acid remains free. This 
 rapid evolution of secretion is the expression of a morbid irrita- 
 bility or excitability of the glands, accompanied by the rapid 
 evacuation of the contents of the stomach ; or the rapid evolu- 
 tion of digestion may be due solely to the rapid empt\-ing of 
 the stomach, as may occur in incontinence of the pylorus, in 
 forms of scirrhus, in some cases of chronic asthenic and 
 chronic atrophic gastritis, and in hypermotility. Secretion 
 ceases too soon because the stomach becomes empty too 
 rapidly. Consequently, the too rapid evolution of digestion 
 may be accompanied b\^ hyperchylia. by h\-pochylia, or by 
 achylia, but the abnormally rapid evolution of secretion is 
 the expression of morbid activity of the glands and it may be 
 manifested by hyperchlorhydria or by hyperchylia. Abnor- 
 mally rapid secretion never occurs in adenasthenia.but it may 
 occur when the duration of digestion is short, or normal, or 
 long. 
 
 The evolution of secretion may be prolonged, and the pro- 
 longation may be due to excessive secretion, to continuous 
 secretion, to myasthenia, or to obstruction of the pylorus or 
 duodenum. All three stages of digestion may be prolonged, — 
 the rise, the stationary period, and the decline, — being long, but 
 regular, in their general characters. This disorder of evolution 
 is due to excessive secretion ; or the period of decline may 
 be abnormally long on account of the failure of secretion to 
 subside as the stomach evacuates its ingested contents, the 
 lines representing the evolution of digestion being regular: 
 the first two stages of digestion may be long or short, and 
 accompanied by normal or excessive hydrochloric acidity. 
 This disorder of evolution which is manifested by prolonged 
 or continuous secretion is due to chronic proliferating glan- 
 dular gastritis. Prolonged digestion may be due to excessive 
 or to continuous secretion ; it is never produced by adenas- 
 thenia ; or prolonged digestion may be due to motor insufifi-
 
 THE FUNCTIONAL SIGNS. I 1 9 
 
 ciency, and the evolution of digestion will show sudden rises 
 and falls, which display the irregularity of the evacuation of 
 the contents of the stomach. (For the disordered evolution 
 of secretion and digestion due to myasthenia and to obstruc- 
 tion, see the chapters on these diseases.) The lower the 
 specific gravity of the contents, the greater is the proportion 
 of gastric juice in the mixture. The specific gravity of the fil- 
 trate of the normal contents, one hour after the test-breakfast, 
 varies from loioto 1015 ; and the specific gravity of the gastric 
 juice is 1004 to 1006. In excessive secretion, the specific gravity 
 of the contents is less than loio; and when secretion is dimin- 
 ished, the specific gravity of the contents one hour after the 
 test-breakfast, provided there be no myasthenia, is near 1020. 
 
 The evolution of secretion may be delayed. The contents 
 removed after one hour show no free HCl, or a mere trace of 
 it. After the expiration of two hours (test-breakfast), the 
 quantity of the contents removed is larger than normal, di- 
 gestive products are comparatively abundant, and the free 
 HCl and combined HCl are both greater than given by the 
 standard after one hour. There is myasthenia, or obstruc- 
 tion, with irritation from stagnation. 
 
 The functional signs furnished by the variations of the acid 
 secretion should not in themselves be given too distinct a diag- 
 nostic meaning, but should be considered in connection with 
 the other diagnostic signs. Used in this way, their diagnostic 
 and therapeutic importance and value become at once appar- 
 ent. 
 
 2. THE FERMENTS. 
 
 The gastric juice contains two ferments, the quantity and the 
 quality of which vary in the diseases of the stomach. These 
 variations can only be roughly detected and estimated, but 
 when there is an extreme and constant deficiency or excess 
 the examination gives most valuable information concerning 
 the anatomical state of the glandular layer. Slight persistent 
 quantitative variations may suggest the direction in which the 
 disease is making its inroads. 
 
 The great diagnostic value of the quantitative estimation 
 of the labferment and of labzymogen, and of pepsin and 
 pepsinogen, is not admitted nor utilized by all clinicians. 
 As a result of careful clinical study, we wish to emphasize 
 the great practical utility of a knowledge of their quantita- 
 tive variations. 
 
 The secretion of hydrochloric acid is, probably, the work 
 of the border cells ; but this biological work is conditioned
 
 I20 DISEASES OE THE STOMACH. 
 
 and intluencctl by so many circumstances as to make it im- 
 possible and erroneous to attribute the variations of this se- 
 cretion to diseases of the cells themselves. The quantitative 
 variations of the hydrochloric acid may be as great in the 
 dynamic affection as in the anatomical diseases. This secre- 
 tion is, besides, intermittent, and called forth by special 
 excitation at recurring intervals. 
 
 The chief cells perform their biological work in a different 
 manner. The secretion of the mother substances of the two 
 active ferments displays the activity of the cell itself The 
 formative work, being continuous, is less directly the expres- 
 sion of digestive influences. Consequently, we do not find 
 clinically, at least with the tests now employed, notable and 
 persistent variations which are purely dynamic, or which are 
 due to a disturbance of the circulation, like passive conges- 
 tion. Clinically, a persistent deficiency and an excess, re- 
 vealed by the tests now in use, are found only when the cells 
 are diseased. 
 
 The form, however, in which the ferments are found is due 
 to circumstances. The conversion of the mother substance 
 into the active ferment is dependent on the presence, in the 
 stomach, of the chemical reagents capable of producing the 
 change. Consequently, it would be a mistake to attribute 
 the variations of the quantity of pepsin and labferment to im- 
 perfect work of the chief cells. But we must consider the 
 deficient formation of the mother substances, of which the 
 ferments are the converted products, as evidence of disease of 
 the cells, which are concerned in their production. The fer- 
 ments may be absent when their prototypes are present in 
 normal quantity. In such a case we must look for an ex- 
 planation of the abnormality elsewhere than in the ferment- 
 secreting cells. 
 
 {a) The Labferment and Labzymogen, — Labzymogen is 
 probably a specific secretion of the chief cells, which bj' the 
 action of weak free acids and of calcium chlorid is con- 
 verted into the active labferment. The ferment is rapidly 
 destroyed in alkaline fluids, but the mother substance remains 
 intact. The presence of calcium salts promotes and seems 
 essential to the milk-curdling action of the ferment. 
 
 The labferment coagulates milk by the disintegration of 
 the casein. The coagulation differs widely from that of acids, 
 and takes place in the presence — but independently — of any 
 free acid in the stomach. The coagulation which is produced 
 eii )iiassi\ and without change of the reaction of the mixture, 
 occurs when the medium is neutral or weakly acid. The
 
 THE FUNCTIONAL SIGNS. 121 
 
 ferment coagulum contracts on standing, and separates the 
 whey, which contains the ferments, and can produce coagula- 
 tion in a fresh specimen. The most favorable temperature 
 for the action of the ferment is between 33° C. and 44° C, 
 but in the presence of chlorid of calcium it may take place 
 at 20° C. A temperature of 70° C. destroys the ferment, but 
 not the mother substance. Boiled milk is coagulated more 
 slowly than uncooked milk. 
 
 The Qualitative Tests. — To five c.c. of sweet milk (Leo), three 
 or four drops of the unfiltered and unneutralized gastric con- 
 tents are added, and the covered glass is placed in the ther- 
 mostat at blood-heat. If the labferment is present, the co- 
 agulation occurs in ten or fifteen minutes. A negative result 
 with this method, on account of the very small quantity of 
 the gastric contents used, should not be considered conclu- 
 sive. In the short interval, coagulation by micro-organisms 
 is hardly possible. But the following test is more conclusive : 
 
 Five c.c. of the filtered contents are exactly neutralized by 
 the decinormal alkaline solution, always at hand, and added 
 to an equal quantity of sweet neutral, or amphoteric milk. 
 The glass is then placed in the thermostat at blood tempera- 
 ture. In from five to twenty minutes coagulation will demon- 
 strate the presence of the labferment. 
 
 The qualitative test for labzymogen requires a special 
 preparation of the gastric contents. Five c.c. of the filtered 
 contents are made very slightly alkaline with a one per cent, 
 solution of sodium carbonate, or with the decinormal alkaline 
 solution and about two c.c. of a one per cent, solution of cal- 
 cium chlorid are added to it. This is next mixed with an equal 
 quantity of sweet milk, and placed in the thermostat. The 
 alkalinization has destroyed the ferment, and the calcium 
 chlorid will convert the labzymogen, if present, into labfer- 
 ment, and the coagulation will take place in the usual time. 
 
 The Quantitative Tests. — The quantitative estimation of the 
 labsecretion is roughly done by dilution, an excellent clinical 
 method, given by Boas. If the qualitative test for the labfer- 
 ment has been positive, we exactly neutralize the filtered 
 contents, and make four dilutions with distilled water : i : 10, 
 I : 20. I : 30, and i : 40. To five c.c. of each of the dilutions 
 we add five c.c. of milk, place all in the thermostat, and note 
 the weakest dilution in which the ^agulation occurs. 
 
 For the quantitative estimation of the labzymogen, the 
 neutralized contents are made slightly alkaline, and dilutions 
 prepared of i : 10, i : 20, i : 40, i : 80, and i : 160. To five c.c. 
 of each add two c.c. of the one per cent, calcium chlorid
 
 122 DISEASES OF THE STOMACH. 
 
 solution, and five c.c. of milk, and place all in the thermostat, 
 and mark the weakest dilution in which the coagulation 
 occurs. 
 
 Normally, the end dilutions i : 40 (labferment) and 1:160 
 (labzymogen) should give a positive result. 
 
 If the gastric contents contain no free acid, before basing a 
 conclusion on a negative result we should introduce — and 
 withdraw half an hour later — a glass of -^^J normal MCI in the 
 morning, when the stomach is empty. When there is no 
 free hydrochloric acid in the contents, this method is abso- 
 lutely necessary, in order to confirm or control a negative 
 result after a test-meal. 
 
 If the gastric contents be neutral, labferment is absent, but 
 labzymogen may be present exen in normal quantity. 
 
 The Practical Value of the Labferment Signs. — Practically, we 
 may find three conditions: the labsecretion may be normal, 
 variable, or persistently diminished. 
 
 1. The constant presence, after a test-breakfast, of the lab- 
 ferment and its mother substance in normal quantity, does 
 not always exclude an anatomical disease. Rut in a very 
 large majority of cases this sign speaks distinctly in favor of 
 a dynamic affection, and this rule is without exception when 
 the acid secretion and the motor function are also normal. 
 But in continuous excessive HCl secretion, due to glandular 
 gastritis, the test-meal contents show usually an increase of 
 labsecretion, and labferment is often present in greater quan- 
 tity than labzymogen. In gastritis, associated with excessive 
 HCl secretion, the labferment is above normal, although the 
 quantity of labzymogen in the contents removed at the end 
 of one hour may be diminished. If the contents be removed 
 sooner, the quantity of mother substance will be found at 
 least equal to that of health, and the quantity of the con- 
 verted ferment is usually normal or above normal through- 
 out the evolution of digestion. The rule which claims that 
 a normal milk-curdling power of the gastric contents excludes 
 all but the dynamic affections does not obtain in many cases 
 of glandular gastritis, of ulcer, and of complicated myasthenia. 
 
 2. A variable labsecretion is a common sign of incipient 
 and mixed forms of gastritis, or of myasthenia and obstruc- 
 tive stagnation or retention. The quantity varies because 
 the interstitial inflammation varies, and because the evacua- 
 tion of the contents of the stomach is irregular. 
 
 3. The labsecretion may be persistently diminished. If 
 this sign be established — and ouk conclusions should not rest 
 on a single examination — there is glandular disease, and the
 
 THE FUNCTIONAL SIGNS. I 23 
 
 degree of deficiency indicates the degree and diffusion of 
 the gastritis, or it indicates glandular degeneration. Conse- 
 quently, the functional sign may make the exact diagnosis 
 indicate the prognosis, and dominate the treatment. 
 
 {b) Pepsin and Pepsinogen. — Pepsinogen, the mother sub- 
 stance of pepsin, is formed continuously and, in all proba- 
 bility, by the chief cells of the gastric glands, and is stored 
 in these cells to be poured out under the influence of diges- 
 tive stimulation. The chief cells are at once the factory and 
 the storehouse of pepsinogen, which, when given out as one 
 of the elements of the specific secretion, comes in contact 
 with the hydrochloric acid or the secreted chlorids, and is 
 rapidly converted into the active pepsin. The quantity of 
 pepsinogen converted is conditioned by the percentage of 
 free hydrochloric acid, about 2.5 parts a looo being the 
 most favorable strength. The organic acids also possess this 
 power of conversion. 
 
 In the contents after a test-meal, the presence of pepsin is 
 demonstrated by a positive biuret reaction. But the exist- 
 ence of pepsin-hydrochloric acid products is no proof of the 
 secretion of pepsinogen in sufificient quantity, although the 
 sufficiency of this secretion is suggested by the disintegra- 
 tion and solution of the bread and meat; but acid and water 
 may accomplish this solution without the aid of pepsin. 
 Consequently, not only when there is no free HCl in the 
 contents, but also when this acid is present in normal or 
 in excessive quantity, the quantitative estimation of pepsin 
 should be made by testing the power of the properly acidu- 
 lated filtrate to convert the normal quantity of albumin into 
 albumoses within the proper time. The following methods 
 have been used : 
 
 Method of Schiff (1868). — Brucke(i859) added to the gastric 
 contents a small piece of hard-boiled white of Q^^, or of 
 fibrin, and made the digestive power proportionate to the 
 rapidity of the solution of the fibrin or the white of ^%^. 
 Schiff estimated the quantity of albumin or fibrin dissolved 
 in Briicke's experiment, after the lapse of a certain interval, 
 by the increase in specific gravity. The specific gravity of 
 the fluid before and after the artificial digestion is taken, and 
 from the difference the quantity of substance dissolved is 
 aclculated. 
 
 Method of Qriitzner (1874). — Griitzner stained a mass of fibrin 
 with ammonia-carmin for twenty-four hours, washed thor- 
 oughly with water, and poured over it a 0.2 per cent, solution 
 of HCl. One-half gm. of the stained fibrin, in flakes, is
 
 124 DISEASES OF THE STOMACH. 
 
 placed in the digestive solution, and the coloration, after 
 various intervals, is compared with a standard carmin scale. 
 
 Method of Leube. — Two tests are made, the one with the 
 gastric contents alone, and the other after the addition of 
 pepsin. If the latter dissolves an equal quantity of albumin 
 more rapidly than the former, the pepsin is deficient. Boas 
 compares the rapidity of the solution of albumin by the gas- 
 tric contents to be tested with the rapidity of the solution of 
 the same quantity of albumin by the normal contents. 
 
 Method of Jaworski (1887). — Twenty-five c.c. of the clear or 
 filtered gastric contents are divided into two equal parts, 
 which are placed in separate glasses. To one, a drop of con- 
 centrated officinal HCl is added. A piece of hard-boiled 
 white of &<g^ (1.5 mm. thick, ten mm. in diameter, and weigh- 
 ing six centigrams) is placed in each glass. The two pre- 
 parations are put into the thermostat at 40° C, the time 
 is noted when the &oa cylinders are dissolved, and the solu- 
 tion is then tested for peptone. Three c.c. of a five per cent, 
 solution of KOH are added, and into the strongly alkaline 
 solution a one per cent, solution of CUSO4 is let fall, drop by 
 drop, out of the buret. The solution of copper is added until the 
 reddish coloration is no longer increased thereby. The greater 
 the quantity of peptone, the later the peptone reaction begins 
 and the later it reaches its greatest intensity. The quantity 
 of peptone present is indicated by the intensity of the color : 
 Hardly perceptible pale rose, mere trace ; rose, trace ; reddish, 
 plain trace ; red, moderate quantity ; and dark red, large 
 quantity. Syntonin and propeptones do not interfere with 
 the reaction. 
 
 If, after twenty-four hours, the egg cylinders have not 
 disappeared and the peptone reaction is negative, the test 
 specimen possesses no digestive power. Normally acidulated 
 specimens of the gastric contents, obtained at the height of 
 gastric digestion, completely dissolve the qs^^ cylinder within 
 one hour. 
 
 Method of Hammerschlag ( 1894). — Three gm. of commercial 
 egg-albumin are dissolved in 150 c.c. of a solution containing 
 four parts of HCl per looo. The solution, after standing 
 twenty-four hours, is filtered, and the filtrate contains about 
 one per cent, of albumin. With this preparation three tests 
 are made. 
 
 Ten c.c. of the acid albumin solution are mi.xed with five 
 c.c. of the gastric contents, and an Esbach tube, a, is filled to 
 the mark U with the mixture. 
 
 To another ten c.c. of the preparati<Mi five c.c. of distilled
 
 THE FUNCTIONAL SIGNS. 1 25 
 
 water are added, and with this a second Esbach tube, b, is 
 filled to the mark U. 
 
 A third tube, c, is filled to the mark U with a mixture con- 
 sisting of ten c.c. acid albumin solution, five c.c. gastric con- 
 tents, and 0.5 gm. pepsin. 
 
 All the tubes are placed in the thermostat at 37° C. for one 
 hour, removed, and filled to the mark R with Esbach's reagent. 
 
 After standing twenty-four hours the quantity of sediment 
 is read, and the diminution of the sediment in the tubes rt and 
 c is compared with the sediment in the tube b. The peptoni- 
 zation is represented by the unprecipitated albumin products. 
 If, for example, tube a contains three per cent, precipitated 
 albumin and the control tube b contains six per cent., the 
 digestive work is 50 per cent. 
 
 Method of Klug (1895). — Tube peptonization, according to 
 this writer, is most active in a preparation containing 0.5 per 
 cent, to 0.6 per cent, free HCl and o. i per cent, pepsin. A 
 greater or less percentage than o. i per cent, pepsin diminishes 
 peptonization. 
 
 The test may be made in the following manner: Twenty- 
 five c.c. of the filtered contents, in order to eliminate the 
 influence of the hydrochloric acidity, are brought to a free 
 HCl acidity of 0.5 per cent. To this acidulated specimen are 
 added ten gm. of finely divided hard-boiled white of egg, and 
 the mixture is placed in the thermostat at 40^ C. for twenty- 
 four hours. After this period no more of the &^^ is utilized, 
 and the further process consists in the transformation of the 
 syntonin and albumoses into peptones. 
 
 For the differential estimation of the quantity of synto- 
 nin, albumoses, and peptones in the test mixture, Klug uses 
 the biuret reaction, the intensity of which is measured by the 
 spectrophotometer of Glan. The color extinction coefficient 
 is obtained in the usual manner, that part of the spectrum 
 between D 75 E and D 100 E being used. 
 
 The digestive mixture is boiled and filtered ; the filtrate 
 contains all the utilized albumin. To ten c.c. of this filtrate 
 add five c.c. of a concentrated solution of caustic soda and six 
 drops of a ten per cent, solution of cupric sulphate; shake 
 and carefully filter to remove the excess of CUSO4. The 
 coefficient is then taken (E). 
 
 The remainder of the filtrate is exactly neutralized with a 
 solution of caustic soda and filtered. The syntonin is thus 
 removed: Ten c.c. of the filtrate are treated as before and the 
 coefficient taken (E^). Ten c.c. of the syntonin-free filtrate 
 are next boiled with an excess of pure sulphate of ammonium
 
 126 DISEASES OF THE STOMACH. 
 
 and filtered after cooling. The albumoses, except possibly 
 dciitero-albuniose, are thus removed : To one c.c. of the 
 filtrate free from albumoses are added five c.c. of concentrated 
 solution of NaOH and three drops of the ten per cent, solution 
 of CUSO4. Filter repeatedly before taking the coefficient 
 (£3). E2 — £3 = albumoses. E^ — E^ = syntonin. £=^ 
 = peptones. 
 
 Method of Oppler (1896). — Oppler's method is correct in 
 principle, but it is long and tedious in practice. It is the best 
 research method, but the method of Hammerschlag is suffi- 
 ciently accurate for clinical purposes. 
 
 A neutral two per cent, solution of egg-albumin, preserved 
 by the addition of 5 : 1000 chloroform, is mixed in definite 
 proportion with a dilution of the gastric filtrate of a definite 
 HCl (77, or 0.281 per cent.) acidity and placed in the ther- 
 mostat for three hours. The quantity of nitrogen — and conse- 
 quently of albumin — is estimated in the solution of dried egg- 
 albumin, in the diluted contents filtrate, and in the mixture 
 (placed three hours in the thermostat at 37.5° C.) after the 
 removal of the undigested albumin. According to Oppler's 
 investigations, 50 c.c. of the total (one hour after the test- 
 breakfast) ga.stric contents, after dilution to the following 
 quantities, digests during three hours the following percent- 
 ages of the albumin in 20 c.c. of the two per cent, solution 
 of commercial egg-albumin. 
 
 Wlien diluted to I liter, about 70 per cent. 
 
 " " 2 " " 67 " " 
 
 " " " 5 " " 60 " " 
 
 " " " 10 " " 50 " 
 
 " " " 20 " " 45 " " 
 
 A I : 1000 solution of pepsin (pepsin, one; acid hydro- 
 chloric, 20; aq., 1000) digests in three hours about 35 per 
 cent, of the albumin in the solution. 
 
 The test of digestive power is made in the following man- 
 ner : The £wald-Boas test-breakfast is given on an empty 
 stomach, and one hour later the contents are removed ; the 
 stomach is washed with repeated small quantities of distilled 
 water until the return fluid is clear and the mixed wash-water 
 and expressed contents arc diluted to one liter (or two) and 
 brought to an acidity of ^J (0.28 1 per cent.) by the addition 
 of dilute HCl. Fifty c.c. of this acidulated dilution are mixed 
 with 20 c.c. of the two per cent, solution of egg-albumin, and 
 the mixture is placed in the thermostat at 37.5° C. for three 
 hours. The mixture is removed from the thermostat, exactly 
 neutralized by the addition (quantity necessary being pre-
 
 THE FUNCTIONAL SIGNS. 12 J 
 
 vioLi.sly determined) of NaOH, boiled, acidified with acetic 
 acid, five c.c. saturated solution of NaCl are added, and the 
 mixture is again boiled, washed with enough distilled water 
 to make 1 50 c.c, and filtered after it has become cool. (Oppler 
 makes a control test at the same time.) The quantity of 
 n-itrogen is estimated in 50 c.c. of the filtrate by the Kjeldal 
 method, and the result is multiplied by three. The quantity 
 of nitrogen in the dilution of the contents — and in the H2SO4 
 used as a reagent — is deducted. The remainder is the quantity 
 of digested albumin. If, for example, the solution of egg- 
 albumin contains 2.1 per cent, albumin, and 50 c.c. of the 
 diluted (one liter) total gastric contents contain 77.5 milli- 
 grams of N, and the 50 c.c. of the test digestion filtrate contain 
 22.4 milligrams of N, then 22.4 X 3, or 67.2 milligrams of N 
 have been digested. Of this quantity 17.5 milligrams are 
 already present in the gastric contents. Consequently, the 
 remainder, after this is subtracted, when multiplied by 5 
 (20 c.c. being used), is equal to the quantity of the albumin 
 in 100 c.c. of the test albumin solution which has been 
 digested. The 248.5 milligrams of N are equal to 1.55 gr. 
 of albumin, which is 74 per cent, of 2.1. That is, the digestive 
 power is a little greater than normal (70 per cent.), or a little 
 more than twice as great as the digestive power (3.5 per cent.) 
 of the I : 1000 solution of pepsin. 
 
 The Practical Value of the Pepsin Signs. — Pepsin may be 
 formed in normal, in excessive, or in subnormal quantity. 
 A continuous normal pepsinogen secretion is a good sign of 
 the integrity of the glandular layer; but a mild anatomical 
 disease of the stomach may be present without causing a 
 noteworthy change in the quantity of pepsin. 
 
 Pepsin, contrary to the common belief, may be secreted in 
 excessive quantity. This excessive secretion is often met 
 with in chronic hypersthenic (glandular) gastritis. The early 
 morning contents of continuous secretion often digest more 
 rapidly than the contents obtained after a test-meal given to 
 the same individual. The fluid of gastric retention with free 
 HCl usually digests better when diluted and acidulated with 
 HCl. But if the irritation and continuous secretion and the 
 accumulation of ferments be controlled for a few days by 
 diet and lavage, the actual diminished power of secretion may 
 be made clear in some cases of gastric retention. Conse- 
 quently an excess of pepsin may be due to the secretion of a 
 ga.stric juice which is excessively rich in it or to its accumu- 
 lation in the stomach. In both instances the tests of Ham- 
 merschlag and Oppler give an increase of digestive power.
 
 128 DISEASES OF THE STOMACH. 
 
 and the dilutions likewise digest more albumin than do simi- 
 lar dilutions of the test-breakfast contents. Whenever the 
 filtrate of the early morning contents possesses greater diges- 
 tive power than the filtrate of the test-breakfast contents, 
 there is motor insufficiency. In simple continuous secretion, 
 the early morning contents possess no greater digestive 
 power than the contents after the test-breakfast, and the 
 specific gravity is that of the gastric juice — 1004 to 1006. 
 
 In still another condition the pepsin tests are valuable, as 
 when there is persistent and progressive diminution of the 
 specific elements of secretion. This is a physical sign of 
 chronic asthenic gastritis, of atrophy of the gastric glands, 
 or of carcinoma. But pepsin secretion is commonly dimin- 
 ished in chronic inanition, and variations of quantity occur in 
 consequence of nervous influences, particularly in hysteria 
 and in adenasthenia gastrica. Consequently, not even a great 
 diminution of the secretion of this ferment should be consid- 
 ered pathognomonic of severe glandular disease without 
 other corroborative signs. The diminution of pepsin is not 
 characteristic of any particular disease of the stomach, and 
 its quantity varies in very close relation with the quantity of 
 total HCl. Consequently, its increase or decrease or its 
 presence in normal quantity in the contents after the test- 
 breakfast possesses about the same significance as like states 
 of HCl secretion. But there is no doubt that the diminution 
 and the loss of labferment secretion are very grave signs and 
 are much less frequent than the diminution and loss of hydro- 
 chloric acid and pepsin secretion. 
 
 3. Mucus, OR THE General secretion. 
 
 The general secretion of the stomach is mucus, a product 
 of the cylindrical cells which thickly line the surface and 
 extend a short distance into the peptic glands and line com- 
 pletely the mucus glands. This secretion forms a very 
 important protection to the delicate structures which it nor- 
 mally covers as a thin layer. In catarrh, the quantity of the 
 mucus may be greatly increased, and forms, particularly about 
 the pylorus, very thick masses, either clear and tough with a 
 pale membrane beneath or tinged with blood and mixed with 
 the exudate from the hyperemic blood-vessels. 
 
 The mucus which is .secreted by the normal cylindrical 
 surface c[)ithelium contains only a trace of mucin, and no 
 cloudiness is produced by the addition to it of either distilled 
 water (dilution) or acetic acid. It is readily dissolved and
 
 THE FUNCTIONAL SIGNS. 1 29 
 
 digested by the gastric juice. Consequently, the chemical 
 test of normal gastric mucus is worthless, and the search for 
 excessive mucus secretion should be made, not in the test- 
 meal contents, but in the early morning wash-water. In the 
 morning before breakfast 3^ of a pint of water is allowed to 
 flow in and out of the stomach (siphonage) several times, 
 and this wash-water is examined for mucus. The stomach 
 mucus will then appear in shreds and in flocculent masses 
 mixed with a few fat droplets, starch granules, and cylindrical 
 epithelial cells. It stains but faintly with methj'l-green and 
 thionin, and it swells, instead of coagulating and contracting, 
 on the addition of acetic acid. The gastric mucus, however, 
 which is formed after the transformation of the cylindrical 
 into goblet cells (gastritis), contains more mucin, and conse- 
 quently stains more intensely and precipitates on the addition 
 of acetic acid. The presence of much mucus in the wash- 
 water or in the stomach-contents delays filtration, and large 
 quantities of it may be left on the filter. The greatest quan- 
 tities of mucus are found in asthenic and atrophic gastritis 
 and in carcinoma. It accumulates because it is secreted in 
 excess, contains more mucin, and is not dissolved by diges- 
 tion. The quantity of undissolved mucus is in inverse 
 proportion to the quantity of HCl and pepsin. The per- 
 sistent secretion of mucus in excess is a distinctive sign of 
 gastritis — be the gastritis primary or secondary, acute or 
 chronic, asthenic or hypersthenic, or atrophic. 
 
 The mucus removed from the stomach may have been 
 swallowed. The swallowed mucus forms glairy lumps, mixed 
 with squamous epithelium and often with pus cells, and it 
 frequently floats on the surface. The stomach mucus occurs 
 in shreds or flocculent masses, is mixed with starch granules, 
 contains cylinder or beaker cells or their nuclei, and only a 
 few leukocytes. The collection of mucus in the stomach may 
 in reality be an accumulation of saliva. The saliva may be 
 detected by the reaction of the sulphocyanid of potassium 
 which it contains with iron. A dilute solution of chlorid of 
 iron is added, drop by drop, until the red color which is pro- 
 duced no longer increases in intensity. The coloration re- 
 mains after the addition of hydrochloric acid and is not dis- 
 charged by bichlorid of mercury, otherwise the red color is not 
 produced by saliva.
 
 130 DISEASES OF THE STOMACH. 
 
 2. THE MOTOR FUNCTION. 
 
 The gastric muscle plays an exceedingly important part in 
 the pathology of the stomach. Motor insufficiency is a 
 serious primary trouble, and likewise a serious complica- 
 tion. The cardiac muscle has recently been given its proper 
 place in the pathology of the heart. For a long period 
 attention was directed chiefly to the valves and to the peri- 
 cardium ; the heart muscle was neglected. But the involun- 
 tary muscular system deserves a more prominent place in inter- 
 nal pathology. Attention has been directed too exclusively to 
 the mucous membrane. But the uterine muscle is no more 
 important in labor, nor the heart muscle in the circulation of 
 the blood, than is the gastric muscle in digestion. The integ- 
 rity of the muscle cells is no less important than that of the 
 cells which secrete. 
 
 When the general strength and nutrition are affected in an 
 unfavorable manner bj' a disease of the stomach, this result 
 can usually be attributed to a motor defect, which, unlike 
 secretory insufficiency, can not be compensated. The chemi- 
 cal work of the stomach may be null without affecting nutri- 
 tion if the integrity of the motor function is maintained and 
 the contents of the stomach are given over to the healthy 
 intestines for digestion and assimilation. The intestinal 
 juices are much more powerful and active than the gastric 
 secretion. This is the teaching of operations on the stomach 
 which simply secure the passage of the food into the intestines ; 
 such is also the teaching of experiments on animals and of 
 pathology. 
 
 The movements of the stomach are two — the evacuating 
 and the churning. The movements are in all probability due 
 to the excitation of the ganglia in its walls, through which 
 the vagosympathetic branches which go to the stomach 
 probably also exert their influence. The stimulant of these 
 movements is not HCl only ; the movements continue when 
 the reaction is neutral, but are excited by the various elements 
 of the contents. 
 
 The movements of the stomach during digestion and the 
 process by which the organ empties itself have long been 
 the subject of careful study. The character of these move- 
 ments is no less a matter of controversy than is their explana- 
 tion. The philosophy of the subject may be left out of account 
 in a clinical work and only the results of observations need 
 be fjathered.
 
 THE FUNCTIONAL SIGNS. I3I 
 
 Viewed from the results, the contraction of the muscular 
 layer of the stomach produces a twofold effect — the increase of 
 intragastric pressure and the motion of the contents. The iibers 
 the contraction of which causes these results may act con- 
 temporaneously and in union or separately and independently. 
 
 During the first period of digestion, the duration of which 
 is dependent upon the physiological action of the food, the 
 tonic contraction predominates, and the motionless gastric 
 wall applies itself closely to the gastric contents. This period 
 of high intragastric pressure may last a few minutes or two 
 or three hours, the duration being determined by the physical 
 and chemical qualities and the physiological action of the 
 contents and by the power of those fibers which have to do 
 with the result. 
 
 The second period is that of the worm-like movements, 
 which are cardiac, pyloric, or total, according to the location 
 and extent of their visible expression. 
 
 The movements of the cardiac portion begin at the cardia, 
 are slow and weak, and lose themselves in the middle of the 
 organ. These peristaltic movements may be contempora- 
 neous with those of the pylorus or they may be alternating. 
 Observation has established between them no law. 
 
 The movements of the pyloric end are more complex. 
 Two forms have been observed and may be accepted as 
 physiological : First, those which begin on the cardiac side 
 of the pylorus and become stronger as they pass forward and 
 disappear in the duodenum ; second, those which begin on 
 the descending portion of the duodenum and move backward 
 on to the stomach, in the middle third of which they are 
 lost, soon to reappear with greater power along the pylorus 
 to the duodenum. The character of these movements forms 
 the basis of a theory which maintains that the opening of 
 the pylorus is due to a cause which has its origin in the 
 duodenum. 
 
 The total movements are exclusively peristaltic, and begin 
 at the cardia and move slowly toward the pylorus, near which 
 the wave becomes higher and more rapid. The effect of the 
 peristalsis is more visible along the greater curvature, the 
 thick longitudinal bundle along the lesser curvature serving 
 as the fixed line of attachment. These lesser curvature 
 longitudinal fibers extend to the duodenum, over the upper 
 and anterior surfaces of which they spread. Their con- 
 traction would tend to straighten the line between the cardia 
 and the more immovable duodenum, and, if not counteracted 
 by contraction of the ring fibers, it would open the pylorus.
 
 132 DISEASES OF THE STOMACH. 
 
 The excitation of the splanchnic in the thorax, according 
 to Oser, opens tlie p}'lorus and stops its rhythmic contrac- 
 tions. Oppenheinier explains this result by the contractions 
 of the intestinal arterioles and by intestinal contraction on 
 account of the consequent anemia. Such an anemic condi- 
 tion is present when the intestines are enipty and at rest. 
 The intestines become shortened in inanition, and all condi- 
 tions that increase absorption and nutritive change also cause 
 the stomach to empty itself more rapidly. Such is likewise 
 the effect of purgatives which act on the intestines. This 
 would suggest the possibility of the opening of the pylorus 
 through the contraction of the longitudinal fibers of the 
 duodenum extending on to the stomach. 
 
 The movements of the stomach are excited and controlled 
 by the ganglia in its walls; these ganglia are brought into 
 activity by the properties of the gastric contents and by the 
 impression received through the vagosympathetic nerves. 
 Particular centers or areas in the central nervous system are 
 connected with the gastric muscle. The vomiting center is 
 the same as that of respiration (Grimm); or, according to 
 Thomas, is a single center in the posterior part of the medulla 
 oblongata, beginning two mm. before and ending three mm. 
 behind the calamus scriptorius. The centers for the contrac- 
 tion of the cardia are located in the corpora quadrigemina, 
 the fibers from which run partly in the cord (to the eighth 
 cervical vertebra, and thence to the stomach in the splanchnics) 
 and partly in the vagi : the centers for the movements of the 
 wall are in the same bodies, but the fibers run exclusively in 
 the cord and the thoracic sympathetic (Openchowski, Hlasko). 
 The dilator centers of the cardia are situated near the an- 
 terior commissure in the vicinity of the union of the nucleus 
 caudatus and nucleus lentiformis : the fibers from these 
 centers run in the cord to the fifth cervical vertebra and also 
 in the vagi (Knaut) on their way to the cardia. 
 
 The normal motor function is dependent on a j^roper nerve 
 supply, on a healthy muscle, and on a physiological excita- 
 tion. Consequently, the motor function may be deranged 
 through the central and sympathetic nerves, by a badly nour- 
 ished, weak, or diseased gastric muscle, and by improper con- 
 tents in the stomach. The muscle may be hindered in its 
 work by adhesions, deformities, displacements, and obstruc- 
 tion to the evacuation of the stomach. Several methods 
 have been given for testing the motor function. 
 
 Some valuable information concerning the motor function 
 may be obtained from the quantity of the contents after a
 
 THE FUNCTIONAL SIGNS. 1 33 
 
 meal given to test the secretory activity of the stomach. 
 Normally, the total quantity of the contents of the stomach 
 after the test-breakfast is about 125 c.c. ; after the test-meal of 
 See, about 175 c.c. ; and after the test-dinner of Riegel, about 
 200 c.c. If these values are increased more than 25 c.c, there 
 is motor insufficiency; or if they are decreased more than 25 
 c.c, the evacuation of the stomach is too rapid — provided the 
 increase or decrease is not produced by supersecretion or sub- 
 secretion respectively. The total quantity of the contents 
 must be estimated by the method of Mathieu and Remond 
 or by the method of Strauss. 
 
 The method of Mathieu and Remond is based on the prin- 
 ciple that the acidity of the contents before removal from the 
 stomach is equally diffused. Enough of the contents is first 
 removed by expression for analysis, and the vessel containing 
 it is set aside. Two hundred c.c. of distilled water (or a 
 particular quantity) are next introduced into the stomach 
 through the tube and well mixed with the contents by alter- 
 nately lowering and raising the funnel so as to allow the 
 mi.xture to flow back and forth between the stomach and the 
 funnel. The diluted contents are then removed by expres- 
 sion and received in a special vessel. The quantity of the 
 undiluted contents (p) and its total acidity are known. The 
 quantity of water used (w) and the acidity of the diluted con- 
 tents (a^) are also known. Hence: ax = a^w -f- a^x 
 
 .-. X = — ^. The total contents are consequently equal to 
 
 p -I ^J^- This method, commonly ascribed to Mathieu and 
 
 a — a^ 
 
 Remond (1890), was first published by Jaworski (1882). 
 Strauss estimates the total quantity from the specific gravities 
 of the diluted and undiluted contents. If x represents the 
 quantity left in the stomach after the first expression, s and 
 s^ the specific gravity of the undiluted and diluted con- 
 tents respectively, and w the quantity of distilled water used, 
 
 X — ^-^-^^-^JlL. The total quantity is consequently equal to 
 
 p + — ^ ^— . Goldschmidt employs only 50 c.c. of distilled 
 
 water for diluting the unexpressed contents, and adds dis- 
 tilled water to the undiluted contents until the specific gravity 
 is reduced to that of the diluted contents. The quantity of 
 distilled water which is required for this purpose represents 
 the quantity of contents left in the stomach after the first 
 expression, which should be as complete as possible.
 
 134 DISEASES OF THE STOMACH. 
 
 The bacteriological as well as the functional signs give 
 some information concerning the motor work done by the 
 stomach, as stagnation and retention are two of the conditions 
 favorable to germ development. But methods have been 
 devised for testing the motor function more directly. Before 
 describing these direct methods the ingenious method of 
 Ewald and the old plan of Chomel will be discussed. 
 
 Method of Ewald and Sievers (1887). — The salol test of 
 Ewald, as this great clinician himself admits, is onl)' a very 
 crude one. Salol is insoluble in the normal gastric juice, and 
 is decomposed in the intestine into carbolic and salicylic acids. 
 The latter undergoes absorption, and is eliminated as salicyluric 
 acid in the urine. If about 15 grs. of the salol be given in 
 capsules at the height of digestion by the normal stomach, the 
 salicyluric acid may be detected in the urine in about sixty 
 minutes, sometimes in thirty minutes, and sometimes its elimi- 
 nation begins in seventy-five minutes. The longer the lapse 
 of time before its appearance in the urine, the greater is the 
 motor insufficiency. 
 
 The test for the salicyluric acid in the urine is a very simple 
 one. A few drops of the urine are allowed to fall on a piece 
 of filter paper, and three or four drops of a ten per cent, 
 solution of neutral chlorid of iron are placed so near the 
 edge of the wet spot as to mingle with it. The violet color 
 formed reveals the presence of salicyluric acid. A mere trace 
 may be detected by first strongly acidulating a portion of the 
 urine with HCl and testing, with the chlorid of iron, the resi- 
 due of the evaporation of an ether extract. 
 
 Huber claims that the time of disappearance of the sali- 
 cylic acid from the urine is a better measure of the motor 
 insufficiency than the moment when it can be first detected. 
 In health, the salicylic acid should all be eliminated in twenty- 
 seven hours, and the persistence of the reaction beyond this 
 period is proportionate to the motor insufficiency. This brings 
 in the very uncertain factors of absorption, elimination, and 
 the rapidity of the decomposition of the compound ; and clin- 
 ically the liability to error is greater than in the simpler test 
 of Ewald. 
 
 The saliva decomposes salol, and this may occur in the 
 stomach if it contain much alkaline mucus or exudate. Bac- 
 teria decompose it in the stomach. The myasthenic or in- 
 completely obstructed stomach does not empty itself all at 
 once, and at a particular moment, but intermittently through- 
 out the period of digestion, either too slowly (stagnation) or 
 never completely (retention). These facts would suggest the
 
 THE FUNCTIONAL SIGNS. I 35 
 
 fallacies of the method. But theoretical considerations are 
 of little value when the practical test can be made. The 
 application of the method at the bedside reveals the very 
 limited value of the test and the inconstancy of the results. 
 The necessity of urinating every ten minutes until the salicyl- 
 uric acid appears in the urine renders the method inconvenient 
 for men and impracticable for women. Fleischer gives a 
 grain and a half of iodoform at the beginning of a meal, and 
 notes the moment of the appearance of iodin in the saliva. 
 The information obtained through the salol and iodoform tests 
 is comparatively insignificant. 
 
 Method of Chomel. — The splashing sounds give some in- 
 formation concerning the state of the gastric muscle during 
 digestion, and concerning the time which the stomach re- 
 quires for the complete evacuation of its contents. A strong 
 and healthy stomach splashes but little or intermittently, or 
 it does not splash at all during the digestion of an ordinary 
 meal. Splashing throughout the period of digestion and which 
 is demonstrable from day to day, is a sign that the stomach 
 muscle does not properly contract on its contents and per- 
 form its churning work. This test of the tonicity of the 
 muscle may be made during digestion, or after the ad- 
 ministration of a glass of cold water during the period of 
 functional repose. The splashing sounds are also used to 
 test the evacuating power of the stomach. Splashing can 
 not be produced when the stomach is empty, and it always 
 denotes that the stomach contains fluid and gas. If splashing 
 can be elicited when the stomach should contain none 
 of the previous meal, the evacuation of the stomach is de- 
 layed. If it can be produced just before the second and third 
 meals of the day, stagnation of the second degree is present. 
 If the splashing can be produced in the morning before 
 breakfast, it is a sign of retention. The validity of these 
 signs depends on two conditions — namely, no fluid must be 
 swallowed during the period between the end of the meal 
 and the examination, and excessive or prolonged or continu- 
 ous secretion must be excluded. The method of Chomel is 
 valuable as a rough preliminary test. 
 
 Method of Leube. — The method of Leube, with the modi- 
 fication of Boas, is a most excellent and complete test of the 
 evacuation sufficiency of the stomach. The patient is directed 
 to eat a plate of soup, one roll, and a beefsteak. Seven hours 
 later the stomach should normally be empty. If the stomach 
 is washed out at this time, and a notable residue of the meal 
 is obtained, the stomach has failed to evacuate itself within
 
 136 DISEASES OF THE STOMACH. 
 
 the proper period. This failure may be due to myasthenia 
 or to obstruction, or to both, or to excessive secretion. 
 Leube's metliod estabHshes an evacuation insufficiency, but 
 not tlie decree of it. 
 
 To determine the degree of motor insufficiency. Boas 
 recommends that an evening meal consisting of two cups 
 of tea, two small rolls, and a cold meat be given at 8 o'clock, 
 after thorough lavage, unless the stomach is already empty 
 and clean. No visible (macroscopic) remnants of this meal 
 should be in the stomach on the following morning before 
 breakfast, unless motor insufficienc}' of the second degree 
 (Boas) exists. Naturally, other meals than those of Leube 
 and Boas may be given ; but whatever meal is prescribed, the 
 moment of its complete evacuation by the normal stomach 
 should be known, and used as the measure of motor suf- 
 ficiency. 
 
 In practice it is best to learn how the stomach conducts 
 itself with reference to the usual meals — breakfast, lunch, and 
 dinner, or breakfast, dinner, and supper; for in dietetics it is 
 categorically imperative that the stomach should be empty at 
 the beginning of each meal, and we accordingly recognize 
 three degrees of motor insufficiency : In mild stagnation the 
 evacuation of the stomach is delayed, but the stomach empties 
 itself completely between each meal ; in severe stagnation 
 the stomach is found empty only in the early morning before 
 breakfast; in retention the stomach is not empty at any 
 moment during the twenty-four hours, and in the morning 
 before breakfast it contains food and digestive products, the 
 contents being more acid than the contents removed at the 
 acme of the digestion of a test-meal, and of a higher .specific 
 gravity than the gastric juice (1004 to 1006). If the stomach 
 be found empty before each meal, and if the evacuation of the 
 stomach be delayed, as revealed by abnormal splashing, or by 
 too large a quantity of contents after the test-meals, or by 
 the pre.sence of contents at the moment after a particular 
 meal when the stomach should be empty, there is mild stag- 
 nation or excessive secretion, or possibly the two conditions 
 coexist. If the stomach be empty only in the morning before 
 breakfast, there is severe stagnation or prolonged digestion 
 due to excessive secretion, or the two conditions may coexist. 
 If the stomach is not empty before breakfast, there is reten- 
 tion or continuous secretion, or both conditions may be 
 present. The differentiation of excessive and continuous 
 secretion from myasthenic and obstructive stagnation and 
 retention is discussed in Sections IV and V.
 
 THE FUNCTIONAL SIGNS. I 37 
 
 But how can it be determined that the stomach is empty 
 before meals or at a particular moment after meals ? If the 
 stomach splashes it is not empty ; if contents can be ex- 
 pressed or aspirated, it is not empty ; but when no 
 splashing can be elicited and when no contents can be 
 expressed or aspirated the stomach may not be empty. If 
 the tube be introduced into the stomach until its tip touches 
 the greater curvature, and if air be forced through the tube 
 by compressing an attached bulb, the ear, applied over the 
 stomach, will detect bubbling when the stomach is not empty. 
 Or if lOO c.c. of a one per cent, solution of sugar be intro- 
 duced into the stomach, the percentage of sugar will be 
 diminished through dilution by the contents. The exact 
 quantity of the contents can be estimated by dividing lOO by 
 the percentage of sugar in the expressed or aspirated dilution 
 (determined by the ammonia and copper mixture) and sub- 
 tracting lOO from the result. 
 
 Method of Mathieu. — The method of Mathieu and Hallot 
 is an excellent one. It is a very great modification of the old 
 oil method of Klemperer. A test-meal containing a certain 
 quantity of emulsionized oil is given, the tube is introduced 
 after a stated interval, and the contents are removed. The 
 entire quantity of oil in the removed contents is estimated. 
 The part of the oil evacuated represents the motor work. 
 
 The test-breakfast, which is eaten in the morning on an 
 empty stomach, has the following composition : 60 gm. of 
 bread ; an emulsion of 10 gm. of oil of sweet almonds, 5 
 gm. of powdered gum arabic, 30 gm. of simple syrup, and 
 enough weak tea to make 250 cm. One hour after the be- 
 ginning of the meal the contents are removed and the total 
 contents estimated by his dilution (200 cm.) and acidity 
 method. Twenty-five cm. of the undiluted contents are 
 finely divided in a mortar, neutralized with NaOH solution, 
 mixed with sand, and evaporated on a water-bath. The oil 
 is extracted with ether, the ether is driven off by evaporation, 
 and the quantity of oil is weighed. The total quantity of oil 
 is easily calculated, the total quantity of the contents being 
 known. Normally, at the end of one hour about four gm. 
 of the ten gm. of oil are recovered. 
 
 The author of this method uses it also as a secretion test, 
 and saves a part of the undiluted contents for chemical 
 analysis. From the data he also calculates the part of the 
 removed total contents which consists of saliva and gastric 
 secretions, and the part which consists of the administered 
 test-meal. Suppose, for example, after one hour four gm. of
 
 138 DISEASES OF THE STOMACH. 
 
 oil are recovered. Four-tenths, or 100 cm., of the test-meal, 
 consequently, were left in the stomach. This quantity, sub- 
 tracted from the total quantity of contents, gives the portion 
 of the contents which consists of gastric secretion and swal- 
 lowed saliva. 
 
 The Water=test. — None of these motor tests give the cause 
 of the motor insufficiency. The stagnation or retention may 
 be due either to obstruction or to myasthenia. The stagna- 
 tion of myasthenia is a stagnation of liquids. In obstruction 
 (incomplete), liquids are evacuated much more readily than 
 semi -solid food. The normal stomach evacuates 500 cm. of 
 water (just cold enough to be refreshing) in one to one and 
 one-half hours. If the tube introduced after the expiration of 
 one and one-half hours recovers a notable quantity of water 
 there is motor insufficiency which is in all probability due to 
 myasthenia, unless obstruction is so great as to cause almost 
 complete retention. If food stagnates or is retained, and 
 the water is evacuated within the normal period, the trouble 
 is obstruction. If the quantity of the contents after a test- 
 meal is abnormally large and the specific gravity below loio, 
 and if the water is evacuated within the normal period, there 
 is excessive secretion, or excessive secretion with obstruction. 
 The water-test is useful in detecting myasthenia (first and 
 second degrees of stagnation) and in distinguishing obstruc- 
 tion from myasthenia during their stagnation stages. 
 
 Methods of Dehio and Rosenbach. — Some information 
 concerning the elasticity of the stomach may be obtained by 
 the methods of Dehio and Rosenbach. 
 
 The method of Dehio was intended for the purpose of 
 locating the lower border of the stomach; but, as indicated 
 by Boas, it may also give some information concerning the 
 distensibility of the stomach. Normally, after one glass of 
 water has been swallowed, the lower border of the dull area 
 (the patient standing) is about 1 1 cm. below the tip of the 
 ensiform process. Each succeeding glass carries the limit 
 of the dulness about two cm. lower, until after the fourth 
 glass the lower border is near the level of the umbilicus. If 
 the glasses of water be given in succession, a more rapid de- 
 scent of the dull area than normally occurs would indicate 
 that the stomach wall yields too readily to pressure. 
 
 The method of Rosenbach is based on the same principle 
 as the method of Dehio, but the change in the upper level 
 of the water is determined by means of air blown through the 
 introduced stomach-tube. One hundred c.c. of water are in- 
 troduced into the empty stomach, and the distance of the level
 
 THE FUNCTIONAL SIGNS. I 39 
 
 of the fluid from the incisor teeth is determined by placing 
 the ear over the stomach while air is slowly blown into the 
 stomach through the tube by compressing an attached bulb. 
 The cessation of the bubbling indicates that the eye of the 
 tube (a tube with one opening should be employed) has 
 emerged from the water. If a glass of water be introduced, 
 the change in the level of the fluid is again determined. 
 The less the rise in the level of the fluid, the greater is the 
 distensibility of the stomach. 
 
 Some idea of the tonicity of the stomach wall may be ob- 
 tained by attaching a manometer to the funnel end of the 
 tube before its introduction into the stomach to withdraw 
 the contents after a test-meal. The greater the intragastric 
 pressure, the more strongly is the stomach contracted on its 
 contents. The gastrograph of Einhorn and the apparatus of 
 Hemmeter are of little clinical interest, although a practical 
 method of accurately displaying the peristalsis of the stomach 
 would be of very great value. One of the best practical indi- 
 cators of the tonicity of the stomach is the difference in the 
 size of the organ when it is moderately full and when it is 
 empty. A stomach which does not retract when it is empty 
 has lost its tone — its elasticity. The stomach retracts about 
 the line of the fixed lesser curvature. Consequently, the 
 change in the position of the greater curvature displays the 
 change in the size of the organ produced by its retraction. 
 Instrumental methods may be used to make known this change 
 of position, but the physical signs ordinarily suffice for the 
 purposes of practice. 
 
 The motor signs display either normal muscular activity and 
 work or reveal some pathological variation of the motor func- 
 tion. The negative diagnostic value of the normal function 
 should not be forgotten. When the functions are found to be 
 right, as much information is obtained as when they are found 
 to be wrong. 
 
 The pathological variations are excessive activity and insuf- 
 ciency. Excessive activity is manifested by spasm — cardio- 
 spasm, gastrospasm, spasms of the pylorus, peristaltic unrest. 
 Insufficiency is due either to a diminution of muscular power 
 or to inability to overcome some mechanical interference — 
 gastroplegia, myasthenia, displacement, inflammatory or can- 
 cerous infiltration of the muscular coat, pyloric or duodenal 
 obstruction, perigastric adhesions, deformity of the stomach. 
 
 In regard to the evacuation of the stomach, it may be too 
 rapid or too slow. Too rapid evacuation occurs in pyloric 
 incontinence, which may be a dynamic affection, or a symptom
 
 I40 DISEASES OF THE STOMACH. 
 
 of an organic disease, particularly cancer (scirrhus), which 
 has converted the pylorus into a rigid, open canal. 
 
 Delayed evacuation is most commonly the result of myas- 
 thenia, the forms and causes of which are discussed in the 
 fourth section of this book. The other causes of delayed evac- 
 uation, when it is not a mere temporary condition or due 
 to excessive secretion, are the anatomical diseases already 
 mentioned, and which are described in the fifth section of 
 this volume. It is important to remember that motor insuf- 
 ficiency may be absolute and relative, temporary and per- 
 sistent, dynamic or anatomical, simple or complicated. The 
 motor signs are all symptoms — not one of them is a disease. 
 
 3. ABSORPTION. 
 
 Little is known concerning the physiology and pathology 
 of absorption by the human stomach. It is uncertain whether 
 absorption, which occurs to a very small extent, is a physical 
 process of diffusion or is the work of the cells which cover the 
 mucous membrane. It is known that no water and fat are 
 absorbed by the human stomach, but that alcohol, the sugars, 
 and albumoses are absorbed in small quantity. In the ex- 
 periments made on man in health and in disease, it has not 
 been possible to tell how much the results obtained have been 
 affected by gastric secretion and evacuation. 
 
 Jaworski (1883) determined the relative absorbability by 
 the human stomach, of a number of salts, acid carbonate of 
 magnesia beine the most absorbable. These results mav be 
 thus brieflv presented: H.,Mg (CO.O2 > HNaCOa > Na^SO, > 
 MgSO, > H.XaPO^ > KCl > FeCU > NaCl. These results may 
 be incorrect for those salts which, like NaCl, exist in the 
 gastric juice. 
 
 During the past two years (method and results described 
 in a lecture at the Polyclinic in October, 1886) we have em- 
 ployed the following test of absorption : The yolks of four 
 eggs are thoroughly beaten and mixed with 200 c.c. of dis- 
 tilled water, in which 25 gm. of dextrose (Merck) has been 
 dissolved, and 30 c.c. of whisky are added. Two hundred c.c. 
 of the mixture are given on an empty stomach, the balance 
 being utilized for the estimation of the percentages of fat (ether 
 extract) and dextrose (ammonia and copper solution). After 
 one hour the contents are expressed and the total quantity of 
 contents is estimated by the total acidity method of Mathieu.
 
 THE FUNCTIONAL SIGNS. I4I 
 
 The percentages of fat and dextrose in the contents are esti- 
 mated and a qualitative test (liquor potassa and iodin solu- 
 tion) is made for alcohol. From these data it can be readily 
 determined how much fat has been evacuated and conse- 
 quently the proportion of the contents, how much of the 
 contents consists of secretion, how the relative percentages 
 (not affected by evacuation nor by dilution) of fat and dex- 
 trose have been altered, and consequently how much of the 
 dextrose has been absorbed. 
 
 The old method of Penzoldt and Faber is of no clinical 
 value. Three grains of pure iodid of potassium are admin- 
 istered in a capsule while the stomach is empty, and the 
 moment of the appearance of iodin in the saliva is detected 
 by using starch paper and fuming nitric acid. Normally, the 
 reaction in the saliva is positive in fifteen minutes. In some 
 diseases its appearance may be delayed ; but these diseases 
 (cancer, retention) are precisely the ones in which motor 
 insufficiency occurs and free HCl is often absent. Little is 
 known about the many circumstances which delay the 
 absorption of the iodid, and the test has proved almost 
 worthless at the bedside. 
 
 4. DIGESTIVE WORK. 
 
 The chemical transformation of the food, which is pro- 
 duced in the stomach by the saliva and by the gastric juices, 
 represents the digestive work done in this organ. The 
 digestive work which is performed in the stomach after a 
 test-meal is displayed by the digestive products and by the 
 portion of the meal that remains undigested. The diges- 
 tive work is expended on the carbohydrates and on the 
 proteids. 
 
 The carbohydrates are not digested by the gastric juice, 
 but the transformation by the saliva is modified by the dis- 
 eases of the stomach. The inspection of the expressed con- 
 tents may show that the starch remains for the greater part 
 unchanged, or has been normally digested, or has been 
 rapidly and completely dissolved. The normal contents are 
 a finely divided or nearly homogeneous mixture. If the 
 starch digestion is arrested too early by excessive gastric 
 secretion, the bread, or bread and potato, are only partly dis- 
 solved ; Lugol's solution gives a blue or brownish coloration. 
 If starch digestion is very active (subacidity), the solution 
 and transformation is more complete ; Lugol's solution gives
 
 142 DISEASES OF THE STOMACH. 
 
 a reddish or no coloration, and Fehling's solution is posi- 
 tive. The accumulation of the products of starch digestion 
 increases the specific gravity of the filtrate of the contents 
 obtained after the test-meals, unless secretion is excessive. 
 Normally, the specific gravity of the filtrate after the test- 
 breakfast is loio to 1015; after See's meal, 1015 ; after 
 Riegel's dinner, 1015 to 1020. If a large quantity of starch 
 products is present, either the evacuation of the stomach is too 
 slow or absorption is diminished, or both conditions are pres- 
 ent. Digestive products do not accumulate in the normal 
 stomach. 
 
 The digestion of the proteids is revealed by inspection and 
 by chemical tests, and is displayed best by the Riegel or See 
 meals. The proteids may be rapidly digested as in active or 
 excessive secretion ; or they may remain undissolved and 
 untransformed in anacidity. The methods of distinguishing 
 syntonin, albumoses, and peptones is described elsewhere, 
 but the biuret test gives a rough idea of the activity of 
 peptonization. The products of proteid digestion accumu- 
 late in the stomach only when there is motor insufificiency. 
 
 The digestive work done by the stomach in the various 
 diseases is described in the fourth and fifth sections. By 
 mere inspection of the physical properties of the contents, 
 information concerning the functional power of the stomach 
 may be obtained, which is very valuable both in diagnosis and 
 in the dietetic treatment. 
 
 CHAPTER IV. 
 
 THE BACTERIOLOGICAL SIGNS. 
 
 It is a remarkable clinical fact that the micro-organisms 
 of the stomach are quite constant, and are characteristic of 
 the qualities of the contents and of the motor function of the 
 stomach in which they grow. As a rule, germs do not thrive 
 in an acid medium so well as in an alkaline or a nearly neu- 
 tral culture. Consequently, a large number die rapidly or 
 degenerate, or form the more resisting spores when they 
 remain in the acid stomach. The germicidal power of the 
 gastric juice is important, but it is incomplete, both in health 
 and, to a greater degree, in disease. The germs swallowed
 
 THE BACTERIOLOGICAL SIGNS. 1 43 
 
 during the period of functional rest and during the period 
 when no hydrochloric acid is free in the stomach, may escape 
 uninjured into the intestines and find there a persistent and 
 favorable soil. Their passage through the stomach may be 
 too rapid to allow time for their destruction. The healthy 
 stomach may fail to protect the organism against invasion 
 even by the pathogenic germs. The diseased stomach may 
 become a breeding receptacle, particularly for the saprophytic 
 germs. The hydrochloric acid influences only the quality 
 of the germ growth which occurs in the d4seases of the 
 stomach accompanied by motor insufficiency. 
 
 But apart from the acid reaction, the composition of the 
 diet exercises a great influence on the development of the 
 lower forms of life. Each germ has its own peculiar habitat, 
 its favorite culture soil, and dies when it can not adapt itself 
 to the sudden changes which occur in the contents of the 
 stomach. On the other hand, their increase is rapid in a 
 favorable soil. 
 
 But of more influence than either the acidity and the com- 
 position of the contents of the stomach are the intermittence 
 of the food supply and the complete emptiness of the resting 
 organ, which, when normal, evacuates the germs along with 
 the chyme into the duodenum. Thus the normal stomach is 
 intermittently empty and clean and without a culture soil. 
 Consequently, in the normal organ germs do not have time, 
 during the short digestive period, to manifest their very active 
 powers of growth and proliferation. The churning move- 
 ments of the stomach also help. to keep its contents sweet. 
 Constant motion is very destructive to some forms of germ 
 life. 
 
 Naturally, the flora of the stomach is dependent upon the 
 number of germs which obtain entrance there. The supply 
 of these is abundant, — from food and drink, from the mouth, 
 the nose, and the throat, and probably from the intestines. 
 The opportunities afforded by pathological conditions are 
 readily used. 
 
 The prevailing classification of bacteria is based on their 
 form — cocci, bacilli, spirilli. Besides these, we have other 
 germs — the molds and the yeasts. The particular kind of 
 germ found, with but few exceptions, is of little diagnostic 
 value. It is probable that a more complete study and a 
 more exact control of the conditions would extend this short 
 limit. 
 
 The quantity of germs found denotes more favorable con- 
 ditions of growth. This may be referred to the quality of
 
 144 DISEASES OF THE STOMACH. 
 
 the soil, but the richness and the active growth of the flora is, 
 also, directly and closely dependent on the delay or the failure 
 of the stomach to empty itself. 
 
 The germs of the stomach under consideration are not 
 pathogenic, but live on and in dead matter. Consequently, 
 their existence is made manifest by changes in the contents 
 on which they live. The acids, the gases, and the toxins of 
 fermentation and putrefaction are thus developed. 
 
 The bacteriological signs consist of the kind and the num- 
 ber of the micro-organisms, and of the products which they 
 form by fermentation and putrefaction. The products which 
 are of practical importance are the organic acids, the gases, 
 and the toxins. 
 
 Fig. lo.— Sarcinae veniriculi from stomach-contents, X 530; stained with methylene blue 
 (authors' specimen). 
 
 I. The Kind of Germ. — The many kinds of germs found in 
 the healthy stomach and in the pathological stomach have 
 not. been isolated and studied; but it will not be denied by 
 those who frequently make a microscopical examination of 
 the stomach-contents that the individual forms are very 
 numerous. Only sarcina. }'east, and the bacillus geniculatus 
 have a definite pathological meaning. And tl'.is is true of 
 these three only when they are persistently present in large 
 quantities and in active growth. 
 
 Many forms of sarcinae exist in the air, and they may find 
 their way into the stomach, and, under fa\orable conditions, 
 may there proliferate. Oppler, who has best studied these 
 cocci in the stomach-contents, succeeded in isolating five 
 varieties, presenting distinct color and culture peculiarities. 
 The cultures possess only a scientific interest ; practically, we
 
 THE BACTERIOLOGICAL SIGNS. 
 
 145 
 
 are concerned only with their persistent presence in large 
 quantities in the contents of the stomach. 
 
 These cocci are about 2.5 // in diameter and appear in 
 small cubical groups of eight, the packages or bales being 
 marked by lines running at right angles. Larger packets 
 may be formed. They may be found very loosely united or 
 separated, and are small when undergoing degeneration. 
 
 Sarcinee in large quantities are only found in benign forms of 
 gastric stagnation or retention with free HCl. They can not 
 live in the lactic acid contents of carcinoma. In small num- 
 ber they may be found in cancer, during the free HCl stage, 
 in gastritis, in ulcer, in gastroptosis, and in the dynamic 
 affections. Their presence in these diseases is inconstant and 
 rare. Their persistent growth in large numbers is character- 
 
 Fig. II. — Yeast from stomach-contents; X 530 (authors' specimen). 
 
 istic of retention due to myasthenia and to non-malignant 
 obstruction. 
 
 Yeast, which grows by budding and occurs in single cells, 
 or in strings of cells, clear and bright, and staining yellow 
 with iodin, is often found in the stomach-contents; but it 
 only grows and flourishes there when there are motor insuffi- 
 ciency and a suitable soil. The acidity of the contents of the 
 stomach has little influence on the growth of the yeast. It 
 matters little whether the reaction is alkaline, neutral, or 
 strongly acid. Even excessive hydrochloric acidity does not 
 arrest its growth, nor does carcinoma prevent its development. 
 Whenever there is motor insufficiency yeast may be found, 
 but it is not very vigorous except in gastric retention, when the 
 yeast accumulates in large quantity, and the microscope shows 
 that the plants are growing rapidly. The proliferation of the
 
 146 
 
 DISEASES OF THE STOMACH. 
 
 yeast is proportionate to the motor insufficiency and to the 
 richness of the diet in fermentable matter. Yeast is often 
 present in small quantity in all the diseases of the stomach, 
 except simple ulcer. 
 
 The bacillus g:eniculatus (Fig. 12) is present in very large 
 numbers in carcinoma (Boas), and is sufficient to render a case 
 suspicious. This bacillus consists of cells a little smaller than 
 the bacillus subtilis, arranged often in a zigzag line, or in pairs, 
 joined end to end so as to form an angle. It does not color 
 with iodin, but colors homogeneously with fuchsin. It is 
 large, devoid of motion, may be easily seen without staining, 
 and is always present in carcinoma when the contents contain a 
 notable quantity of lactic acid. It develops in acid-sweetened 
 bouillon and produces lactic acid (Kaufmann). 
 
 Fig. 12. — Bacillus geiiiculatus from stomach-contents ; X 730: a, spore-formation ; oval 
 spores in center, ends pale and indistinct: ^, niultiplication by cell-division ; c, normal 
 cell arranged in a zigzag line ; length, 4 to 8 /x ; width, about 0.7 fi (authors' specimen). 
 
 These are the only varieties — viz.: sarcina ventriculi, yeast, 
 and the bacillus geniculatus, whose simple growth in the 
 stomach signifies that the organ is diseased. The sarcinae, in 
 large quantities, are almost exclusively found in benign reten- 
 tion with free HCl. Yeast finds a most favorable soil in 
 stagnation or retention, regardless of the kind or the degree 
 of acidity. The bacillus geniculatus is constantly present in 
 cancerous obstruction of the pylorus which produces reten- 
 tion. It is sometimes absent in other forms of carcinoma, 
 but its persistent presence in large numbers is almost charac- 
 teristic of malignant disease of the stomach. 
 
 2. The Number of Germs. — The quantity and the general 
 character of the micro-organisms present are of diagnostic 
 value. The normal stomach is a bad medium for bacterial
 
 THE BACTERIOLOGICAL SIGNS. 1 4/ 
 
 growth, and the presence of germs here is seemingly tolerated 
 only under the condition of quiescence; some forms are 
 equal to this struggle for life, but are incapable of thriving. 
 In motor insufficiency the conditions are more favorable, and 
 the rapidity of development and the many varieties of germs 
 are often remarkable; but possibly the many kinds may be 
 only stages in the development of a few germs, and may 
 be a sign of the rapid proliferation of a smaller number of 
 distinct kinds than at first sight would appear to be the case. 
 This lively pathological proliferation may be evident at a 
 glance through the microscope and is a sign of gastric reten- 
 tion. Whenever the stomach completely evacuates* its con- 
 tents within the normal period, the number of germs found 
 in it is never large. 
 
 3. Qerm=Products. — The zymogenic and putrefactive bac- 
 teria are the most important in the pathology of the stomach. 
 These, by their existence or growth, cause and perpetuate 
 such changes in the chemical composition or constitution 
 of the complex matter that the resulting substances become 
 simpler and have a less force value. 
 
 This fermentative and putrefactive power is not without 
 limitations, and the soil becomes exhausted and the process 
 ceases. It is probable that all bacteria in the proper medium 
 are zymogenic, and some are capable of producing both fer- 
 mentation and putrefaction; but comparatively few possess 
 these powers to such a degree as to form notable quantities 
 of germ products in the stomach. Fermentation is much 
 more common in the stomach than is putrefaction. The 
 forms of fermentation of practical importance are lactic, bu- 
 tyric, acetic, and alcoholic fermentation. 
 
 [a) Lactic Acid Fermentation. — This form of fermentation is 
 produced by a variety of germs, and is often followed by 
 butyric acid fermentation, CeHi^Og (glucose) = 2(C3Ho03) (lac- 
 tic acid) = C4HSO2 (butyric acid) -\- 2CO2 + H4. The process 
 is not so simple as represented by the equations, for other in- 
 termediate acids and gases are formed. Lactic acid may be 
 destroyed by oxidizing germs. 
 
 The bacillus acidi lactici (Hueppe) is short, — about four 
 times longer than it is thick, — motionless, builds spores, and is 
 aerobic. It is very active at the temperature of the stomach, 
 and converts glucose and lactose into lactic acid with the 
 evolution of CO2. It does not liquefy gelatin, and it forms 
 colonies. Many other bacteria produce the same result. 
 Among these are the bacillus geniculatus and two cocci 
 found in the saliva. The bacterium coli commune, some-
 
 148 DISEASES OF THE STOMACH. 
 
 times fouiul in the stomach, is capable of producing lactic 
 acid. Lactic acid may also be introduced into the stomach 
 with the food and be separated from the lactates by the 
 stronger HCl of secretion. The introduced and the liberated 
 acid have no pathological significance. 
 
 Lactic acid possesses a definite diagnostic value. In many 
 diseases of the stomach lactic acid may be formed in small 
 quantities; but in few diseases is it produced in notable quan- 
 tity, after the stomach has been thoroughly washed out in the 
 evening and a lactic-acid-free test-meal has been given on the 
 following morning. The formation of lactic acid takes place 
 in the human stomach only in very special conditions, and 
 these conditions are rarely fulfilled, except in carcinoma. In 
 the first place, secretion must be dimini.shed, and, indeed, to 
 such an extent that no free HCl exists in the contents obtained 
 at the usual time after a test-meal. The lactic acid bacilli are 
 quickly rendered inactive by free hydrochloric acid, and even 
 hydrochloric acid in organic combination suffices, when in 
 notable quantity (o. 1 2 per cent, or 35), to arrest lactic acid for- 
 mation. Whenever lactic acid coexists with free hydrochloric 
 acid, it has either been introduced into the stomach or formed 
 in the stomach by the decomposition of lactates. In the second 
 place, retention or malignant stagnation must exist. Even in 
 achylia, lactic acid is not formed by germs in the stomach 
 whenever the stomach completely evacuates its contents within 
 the normal period. This rule is without exception, if the 
 stomach be thoroughly washed out and a test-meal, like the 
 oatmeal test of Boas, be given. The time such a meal re- 
 mains in a stomach whose motor function is sufficient is too 
 short for lactic acid to be formed by bacilli ; but the motor 
 insufficiency need only be slight, if it be associated with 
 arrested peristalsis of a portion of the wall of the stomach. 
 This localized arrested peristalsis may be due to adhesions or 
 to a localized perigastritis, or to a new growth. Practically, 
 however, the uncontrollable formation of a notable quantity 
 of lactic acid in slight motor insufficiency occurs only in 
 cancer, which pernn'ts the accumulation of germs and the re- 
 tention of food upon its surface. Lactic acid fermentation may 
 occur in cither benign or malignant retention, accompanied by 
 achylia. But the association of benign retention with achylia 
 is very rare. Finally, the formation of lactic acid is depend- 
 ent on the presence of lactic-acid-forming germs in a suitable 
 culture soil. Any of the test-meals form a suitable soil, and 
 the saliva may furnish the proper germs, which grow and 
 accumulate in the stomach under special circumstances. The
 
 THE BACTEKIOLOGICAL SIGNS. 149 
 
 activity of lactic acid formation is partly dependent on the 
 richness of the contents in ptyalin digestive products. 
 
 The essential conditions of lactic acid formation make clear 
 the diagnostic value of this bacteriological sign. Boas con- 
 tends that the persistent uncontrollable formation of lactic 
 acid in noteworthy quantity during the digestion of a saucer 
 of lactic-acid-free oatmeal is a specific sign of cancer. This 
 contention is almost universally true, the exceedingly rare 
 exceptions occurring in diseases which usually possess other 
 characteristic symptoms and signs, and which do not show 
 the essential clinical characters of carcinoma. 
 
 Persistent, uncontrollable, and noteworthy formation of 
 lactic acid may be an early sign of carcinoma. It is not a 
 pathognomonic sign, but it is one of value, which should 
 be confirmed by the presence of other symptoms of the same 
 disease. It may not appear until late in the development of 
 cancer. A malignant disease of the stomach may run its 
 entire course without lactic acid formation. We have seen 
 almost the entire gastric wall and the pylorus infiltrated, 
 without the appearance of lactic acid in the repeatedly 
 examined contents up to within a few days of death. The 
 stomach, however, in this case was very small, and evacuated 
 the test-breakfast completely in less than one hour. The 
 absence of lactic acid formation does not exclude cancer. Its 
 presence means that the conditions of its formation are real- 
 ized. Its persistent formation in noteworthy quantity (0.05 to 
 0.2 per cent.) after thorough lavage, during the digestion of 
 Boas' oatmeal test or of the Ewald-Boas test-breakfast, is 
 an almost certain sign of carcinoma, for in achylia accom- 
 panied by benign retention the stomach can and would be 
 cleansed. The grave suspicion should be confirmed by other 
 evidences of cancer, and by the absence of the signs of a 
 disease which might be accompanied by the conditions essen- 
 tial to lactic acid formation. 
 
 Lactic acid formed by bacilli in the stomach is always 'a 
 pathological product, and its detection is consequently very 
 important in diagnosis. Two tests are commonly used — viz., 
 the iron test of Uffelmann and the oxidation aldehyd test 
 of Boas. The reaction of Uffelmann, which is qualitative, 
 usually suffices. When this reaction has been repeatedly 
 positive it may be confirmed by the test of Boas, which is 
 qualitative and quantitative. A quantity of lactic acid which 
 does not give the Uffelmann reaction has very little diagnostic 
 significance. It is a waste of time to make either test when 
 free hydrochloric acid is present.
 
 150 DISEASES OF THE STOMACH. 
 
 Uffelniainis Method. — UfTelmann recommended a clear, 
 amethyst-blue solution containing carbolic acid and chlorid 
 of iron. The reagent may be prepared by adding ten c.c. of 
 a four per cent, aqueous solution of carbolic acid to 20 c.c. 
 of distilled water containing one drop of the official solution 
 of the chlorid of iron ; or it may be prepared by dissolving 
 four drops of pure liquefied carbolic acid in 20 c.c of dis- 
 tilled water and adding one drop of the solution of the per- 
 chlorid of iron. The reagent must always be prepared at 
 the moment when the test is made. The blue only serves as 
 a contrast color, and the reagent may be prepared by omitting 
 the carbolic acid, the characteristic reaction being the 
 yellowish-green color produced by the formation of the 
 lactate of iron. It is recommended that the reagent be pre- 
 pared by adding five drops of a ten per cent, dilution of 
 liquor ferri chloridi (chemical reagent) to 50 c.c. of distilled 
 water. This solution is clear and its color is imperceptible. 
 
 The test is made by using either the filtered contents or 
 an ether extract of the same. When the filtrate is employed, 
 the method of Kelling is to be preferred. Five c.c. of the 
 filtrate are diluted to 50 c.c. by means of distilled water, and 
 one or two drops of a five per cent, solution of sesquichlorid 
 of iron (better, two drops of the ten per cent, dilution) are 
 added. The yellowish-green tinge indicates the presence of 
 lactic acid ; or the reaction may be made by employing the 
 solution containing two drops of the ten per cent, dilution of 
 the official liquor ferri chloridi in 20 c.c. of distilled water. 
 Five c.c. of the filtrate are added to 20 c.c. of the reagent, 
 and the coloration is noted. 
 
 The liability to error is diminished by first extracting the 
 lactic acid from the filtered contents with ether, and by 
 testing the ether extract. Two methods may be employed. 
 Five c.c. of the contents are shaken with five times their 
 quantity of ether. After separation, the clear ether is 
 decanted. Five c.c. of the ether extract are shaken with 20 
 c.c. of the iron reagent (containing two drops of the ten per 
 cent, dilution). If lactic acid is present in the ether extract, 
 the lactate of iron formed colors the water the characteris- 
 tic straw-green. Or the method of Strauss may be used : 
 A glass cylinder, graduated at 5 and 25 c.c. and fitted with 
 a stop-cock, is used. Five c.c. of the filtered contents are 
 first added, and thoroughly shaken with ether which has 
 been added until the level of the fluid has been brought to 
 the 25 c.c. mark. After standing until separation takes 
 place, the stop-cock is opened, and the filtered contents and
 
 THE BACTERIOLOGICAL SIGNS. I5I 
 
 the ether are let run out until the ether is lowered to 
 the 5 c.c. mark. The cylinder is next filled with distilled 
 water to the 25 c.c. mark. Two drops of a ten per cent, 
 dilution of liquor ferri chloridi are added, and the coloration 
 is noted. 
 
 The method of de Yong is simple and excellent. One or 
 two drops of HCl are added to five c.c. of the filtered gastric 
 contents, which is slowly evaporated to a syrupy consistency, 
 permitted to cool, and extracted with ether. Five c.c. of dis- 
 tilled water are heated to the boiling-point, and the ether 
 extract is slowly added. The ether is driven off by the heat 
 of the water, and the extracted lactic acid is left in solution 
 in the same quantity of distilled water as the quantity of 
 gastric contents originally employed. One drop of a five per 
 cent, solution of chlorid of iron is added after the solution has 
 become cold, and the intensity of the greenish-yellow color- 
 ation is compared with that produced by adding one drop of 
 the iron solution to five c.c. of solutions of lactic acid varying 
 in strength from 0.5 to 4.0 : looo. 
 
 All these methods, when properly followed, give trust- 
 worthy results. The yellowish-green coloration is slight when 
 lactic acid is present in i : 3000; but it is very clear when 
 I : 1000 lactic acid is present. The reaction is, conse- 
 quently, sufficiently sensitive for practical purposes, for a 
 smaller quantity of lactic acid than is revealed by the test 
 possesses very little diagnostic significance. It is strongly 
 recommended, for the purpose of a comparison, that the same 
 relative quantity of contents (five c.c.) be always employed, 
 and that the reagent contain the same quantity of the iron 
 chlorid (two drops of a ten per cent, dilution of the liquor 
 ferri chloridi to 20 c.c. of distilled water). The peculiar 
 yellowish-green coloration only is characteristic of lactic 
 acid. It is advisable to make a control test with five c.c. of a 
 solution of lactic acid (i : lOOo), using the same reagent in 
 both tests. 
 
 A number of substances give a similar coloration to that of 
 lactic acid — cyanid of potash in the saliva (color remains after 
 the addition of HCl but is discharged by corrosive sublimate), 
 alcohol, sugar, phosphates, carbonates, oxalic acid, tartaric 
 acid, butyric acid, etc. The coloration, when these sub- 
 stances are present in sufficient quantity, resembles, but is 
 not the same as, that of lactic acid. It is always best to use 
 the ether extract, and to make a control test. Under the 
 proper precautions, the Uffelmann reaction is thoroughly trust- 
 worthy, and suffices, ordinarily, for all practical purposes.
 
 152 J)/S/iASl<S OF THE STOMACH. 
 
 The Method of Boas. — The principle of Boas' method, which 
 is both qualitative and quantitative, is very simple. The 
 lactic acid is converted by oxidation, under the necessary pre- 
 cautions, into acetaldehyd and formic acid. The acetaldehyd 
 is tested for and estimated by using Lieben's reagent. The 
 process is very long and tedious, and had better be submitted 
 for its performance to an expert chemist. The qualitative 
 analysis requires about two hours, and the quantitative about 
 three hours, for its completion. It is an e.xcellent method of 
 research, which we find it rarely necessary to employ in 
 practice. 
 
 {b) Butyric Acid Fermentation. — There are several bacteria 
 which produce butyric acid out of carbohydrates : The 
 bacillus butyricus (Prazmowski) is a very common form, and 
 is very active in its movements, anaerobic, and builds central 
 spores, around which the cell swells and lets the spore escape 
 at the end, after enveloping it like a capsule. In starch and 
 sugar solutions, and out of lactates or lactic acid, it forms 
 butyric acid, hydrogen, and carbonic acid. With iodin, like 
 starch (" amylobacter"), it stains — except in sugar solutions — 
 deep blue. It does not liquefy gelatin. The bacillus butyricus 
 (Hueppe) also builds central spores, but is aerobic, and lique- 
 fies gelatin and coagulates milk without changing its reac- 
 tion. Out of lactates and lactic acid it builds butyric acid. 
 
 2(C3lIe03) == C.HgO., + 2(C0,) + 4(H). 
 (Lactic Acid) (Butyric Acid) 
 
 The o'idium lactici is abundantly present in some cases of 
 retention with no free HCl. It forms butyric acid and 
 hydrogen. The formation of hydrogen in the stomach dis- 
 appears with the germ, and it also forms hydrogen in the 
 fermentation tubes. Butyric acid may be split from fat by 
 the secretion of the stomach (probably a ferment), or may be 
 introduced into the stomach from without. The accumulation 
 of the acid in the stomach is due to stagnation or to retention. 
 The formation in the stomach is conditioned by stagnation 
 and by a diet which furnishes the germs with a proper soil. 
 It occurs often in association with lactic acid fermentation, 
 the butyric acid being formed out of the lactic acid. Butyric 
 acid is also formed in stagnation accompanied by normal or 
 excessive HCl secretion. The butyric fermentation is not 
 determined by the disease, but by the stagnation, by the 
 supply of germs, and by a proper soil. It occurs in the mild 
 form of stagnation and in retention, and regardless of the 
 degree and the form of acidity. It is most common in
 
 THE BACTERIOLOGICAL SIGNS. 1 53 
 
 chronic gastritis, cancer, myasthenia, and pyloric obstruction. 
 Butyric acid is a very strong irritant to the stomach, and is 
 also toxic. Butyric is the most frequent form of acute gastric 
 fermentation, but the formation of butyric acid is dependent 
 upon the diet and upon little extraneous accidents rather than 
 upon any particular disease of the stomach. 
 
 Butyric acid may be detected by its characteristic odor, 
 which presents the most delicate test for it. Like the other 
 volatile acids of the contents, it reddens a moistened blue 
 litmus paper held in the end of a tube in which some of the 
 contents are being boiled. It may be detected by distilla- 
 tion or by extraction with large quantities of ether, and by 
 adding to the distillate or residue a large quantity of chlorid 
 of calcium powder. Oil-drops are thus formed having the 
 peculiar rancid odor. 
 
 {c) Acetic Fermentation. — Acetic fermentation is commonly 
 due to the mycoderm aceti, which forms only surface colo- 
 nies, and below a temperature of 35° C, and, consequently, 
 can not take place in the stomach. But this form of fermen- 
 tation does occur in the stomach, and is produced by other 
 germs. 
 
 Acetic fermentation is quite frequent in alcoholism, espe- 
 cially when new, incompletely fermented drinks have been 
 taken. The conversion of ethyl alcohol into acetic acid is an 
 oxidation process, aldehyd being a middle product. 
 
 C2H5OH + = CH3C0H -f- HjO. 
 CH3COH -f O = CHjCOOH. 
 
 This form of fermentation may occur whenever there is 
 stagnation or retention or when the stomach is kept supplied 
 with alcohol. Acetic acid is also a by-product of yeast fer- 
 mentation, and is often found in the stomach-contents which 
 contain an excessive quantity of free HCl. 
 
 The acetic acid may be detected by its peculiar odor; or 
 the distillate may be tested by exact neutralization with soda 
 solution, the acetate formed producing a blood-red color in a 
 dilute solution of chlorid of iron. This reaction is not suffi- 
 ciently sensitive to be often positive in testing the gastric 
 contents. In the absence of butyric acid, the reddening of the 
 moistened litmus paper held in the end of a tube in which 
 some of the contents are being heated may be attributed to 
 acetic acid. 
 
 (^) Alcoholic Fermentation. — Alcoholic fermentation is due 
 to the action of particular forms of yeast, which make alcohol 
 (2C2H6O) and carbonic acid (2CO2) out of glucose (C6H12O0).
 
 154 DISEASES OF THE STOMACH. 
 
 This form of fermentation, accompanied by tlie production of 
 acetic acid, tartrates, etc., takes place in the stomach not 
 altotjether reijardless of its acidity. It is ahnost arrested by 
 one per cent, acetic acid, 2.5 per cent, lactic acid.o. i percent, 
 butyric acid, or 0.2 per cent, free HCl ; and one-half of these 
 percentages arrest the growth and begin to influence the action 
 of the ferment. In the stomach the influence of the acidity 
 is almost null. 
 
 Yeast fermentation may occurs in any disease of the 
 stomach, accompanied by motor insufifiiciency, be the acidity 
 of the contents what it may. But the yeast is most active in 
 retention. The alcohol yeasts consume oxygen, and, when 
 this is not free in the fluid, they remove it from the sugar 
 molecule. The fermentation is purest when air is excluded, 
 but the yeast loses in vitality. The by-products are formed 
 in greatest quantity when the yeast begins to degenerate and 
 to die. The following equations represent this deoxidation 
 process : 
 
 CgH.A = Celli^O, + 4(0) = 2C,HgO + 2CO,. 
 
 Dextrose, maltose, and levulose are directly fermentable. 
 Cane- and milk-sugar are first converted into one of these 
 substances by a ferment produced by the yeast. Starch 
 must first be converted into maltose or dextrose by a dias- 
 tatic ferment or by acids. 
 
 Alcohol may be detected by adding to the filtered contents 
 a few drops of saturated solution of iodin in a solution of 
 iodid of potash in distilled water, and by dropping in a solu- 
 tion of caustic potash until the brown coloration entirely 
 disappears. The test-tube is then placed in a vessel contain- 
 ing hot water, and both are allowed to cool slowly. After a 
 few hours a yellow precipitate of iodoform falls, which may 
 be recognized by its odor and by the regular hexagonal 
 crystals. Acetone gives the same reaction. Or the alcohol 
 may be extracted from the filtrate by alcohol-free ether, and 
 the test made with Lieben's reagent. 
 
 Putrefaction. — Putrefaction is a reduction process. It is 
 due chiefly to anaerobic bacteria, and to such as extract their 
 oxygen from the chemical compounds of the culture soil, 
 from the fats and the albumins. The products of this germ 
 reduction are not so simple as those of ordinary decom- 
 position, which is an oxidation process. These reduction 
 bacteria, which produce stinking products, are not uncommon 
 in pronounced degrees of motor insufficiency. 
 
 Putrefaction may be accompanied by the formation of a
 
 THE BACTERIOLOGICAL SIGNS. 1 55 
 
 number of gases — NH3, HoS, N, PH3, CH4, etc.; a number 
 of acids — butyric, acetic, formic, lactic, oxalic, etc.; a number 
 of basic substances — leucin, tyrosin, skatol, ptomains, toxal- 
 bumins, etc.; and a number of ammoniacal compounds. The 
 acids may be combined with organic bases. 
 
 The formation of HoS, which seldom occurs in cancer, and 
 only in some of the cases of retention, is the most important 
 diagnostic product of gastric putrefaction. The H2S is 
 formed by reduction of the organic sulphur-containing com- 
 pounds. It may also be formed by reduction of the sulphates, 
 when it has no pathological significance. It is found in 
 benign retention, regardless of the HCl and lactic acid percent- 
 ages, after a diet rich in the organic sulphur compounds. A 
 number of germs which find their way into the stomach may 
 produce it, and among these germs is the bacillus coli com- 
 munis (Lesage, Strauss). It may be detected by its odor or 
 by means of alkaline acetate of lead. The lead papers are 
 made by saturation in an alkaline solution of sugar of lead. 
 The paper, previously wet in an alkaline solution, is hung 
 free in a stoppered bottle containing the gastric contents ; 
 and, after a variable interval, it becomes brownish-black. 
 If the action be too prolonged, the white sulphate of lead 
 may be formed, and the re'kction may be no longer apparent. 
 Or the sugar-of-lead-cotton method of Schrank may be used. 
 
 Putrefaction without HoS formation may be recognized by 
 the stinking odor of the contents, and rarely occurs in the 
 human stomach except in retention. Leucin, tyrosin, indol, 
 and similar putrefaction products maybe formed in the stom- 
 ach when this organ contains pancreatic juice which has been 
 regurgitated through the pylorus, or which has found its way 
 into the stomach through a pancreo-gastric fistula. Nearly 
 all the germs of putrefaction are gas-builders, and live prefer- 
 ably on the carbohydrates when the stomach contains them, 
 although fermentation and putrefaction may coexist. Con- 
 sequently, gastric putrefaction is conditioned by the existence 
 of retention and by the presence of albuminous food and 
 putrefactive germs. Putrefaction is increased by albumin 
 digestive products, by fermentable matter, by small quantities 
 of hydrochloric and lactic acids, and by pancreatic juice. 
 
 4. Qas=formation. — A number of gases are formed in the 
 stomach by fermentation and putrefaction ; but the flatulency 
 thus produced can not be distinguished by the physical ex- 
 amination and the subjective symptoms from flatulency pro- 
 duced in other ways. Clinically, it is impracticable to measure 
 the exact quantity of gas in the stomach, and to determine by
 
 156 DISEASES OE THE STOMACH. 
 
 its chemical analysis whether we have to deal with swallowed 
 air, with chemically generated gas, or with gas formed by 
 germs. The most rapid and the easiest method is to make a 
 test of the gas-forming power of the contents of the stomach, 
 whenever and however obtained. For this purpose the 
 vomit or the contents removed during digestion and during 
 the period of repose of the stomach may be used ; but in 
 retention the contents removed before breakfast in the morn- 
 ing should be preferred. 
 
 The gas-formation is dependent upon the composition of 
 the medium or soil. Peptones and other digestive products 
 increase it, and it does not occur, at least to a notable 
 extent, without carbohydrates. Consequently, on account 
 of the possible exhaustion of the nutritive material in the 
 contents, dextrose and peptones should be added to the tube 
 cultures. 
 
 The cause of the gas-formation in the tubes is a living 
 germ. The filtrate does not produce it. The sterilized 
 precipitate added to the filtrate is also inactive. The un- 
 filtered contents should always be employed in the tests. 
 In the three-layer contents of retention, the gas production 
 is most active in the bottom layer containing the numerous 
 germs. 
 
 The activity of the gas-formation is dependent on the 
 vitality and on the number of the germs which accumulate 
 in the stomach. Gas-formation is moderate in stagnation, 
 and often does not begin in the tubes until the end of one to 
 four days. Flatulency is liable to be one of the symptoms in 
 all the diseases of the stomach accompanied by stagnation ; 
 but in retention the gas-formation is active and rapid, and 
 often the tube is nearly full of gas at the end of twenty-four 
 hours. This is an important sign of retention, whether it 
 be due to myasthenia or to obstruction. 
 
 Gas-formation is not prevented by the hydrochloric or 
 lactic acidity of the contents ; consequently, it occurs in 
 both benign and malignant retention. It is impossible to 
 say whether the excessive secretion favors gas-formation or 
 whether the e.xcessive secretion is a result of irritation. The 
 germs seem to be virulent forms adapted to the acid medium. 
 They progressively neutralize the cultures acidified with HCl, 
 again become very active on the exhaustion of the HCl, and 
 finally degenerate and become very sensitive to the anti-fer- 
 mentative influence of the acid. In estimating the diagnostic 
 value of the fermentation tests, the diet of the patient should 
 be taken into account. A meat or proteid diet may almost
 
 THE BACTERIOLOGICAL SIGNS. 1 57 
 
 completely arrest it, unless putrefaction occurs ; but the gas- 
 forming fermentation recommences with the resumption of a 
 mixed diet. A diet rich in carbohydrates increases the fer- 
 mentation. The test should be made while the patient is on a 
 mixed diet, is taking no germ-destroying drugs, and is em- 
 ploying no remedies to control the fermentation. The vitality 
 of the germs and the degree of stagnation or of retention 
 will thus be displayed most clearly. 
 
 The fermentation test may be made by using a Dunbar 
 tube, a urine saccharometer, a Botkin bottle, or the stoppered 
 test-tube of Moritz. The apparatus of Moritz is simple, 
 easily cleaned, and readily filled. An ordinary test-tube is 
 fitted with a perforated rubber cork. Through the perfora- 
 tion a glass tube, which is bent at two right angles or in a 
 half circle, passes to the interior of the test-tube. The 
 sterilized test-tube is filled with the well-mixed, unfiltered, 
 and sweetened contents containing peptones or albumoses, 
 the cork is pushed in, and the glass tubing is thereby filled 
 with the displaced contents. The apparatus is inverted in a 
 beaker and placed in the thermostat at 37° C. The gas, as 
 it forms, collects in the test-tube. The mixture of gases 
 may be analyzed chemically, but the quantity and the rapidity 
 of its formation have a much greater diagnostic significance 
 than has the composition of the mixture of gases. Some 
 information as to the nature of the germ-growth may be 
 obtained by examining a hanging drop prepared from the 
 contents of the test-tube, and by comparing the result with 
 the predominant forms of germs found in the contents soon 
 after their removal from the stomach. 
 
 The other products formed by germs in the stomach have 
 no diagnostic value. The study of the toxicity of the con- 
 tents is of great interest in the pathology of the stomach, 
 and the bacteriological examination is a fruitful field for orig- 
 inal research. The ordinary methods of bacteriology may 
 be readily modified so as to meet the special requirements.
 
 I 58 DISEASES OF THE STOMACH. 
 
 CHAPTER V. 
 THE ANATOMICAL SIGNS. 
 
 The direct anatomical sii^ns of the diseases of the stomach 
 are very few. They may be found in the vomit, in the ex- 
 pressed contents after a test-meal, ancF in the water used to 
 wash out the stomach. These anatomical signs are blood, 
 epithelia, leukocytes, pieces of the mucous membrane, and 
 small fragments of neoplasms. 
 
 The presence of blood in the contents or in the washings of 
 the stomach may very readily lead to false conclusions. A 
 small quantity signifies very little (unless it is present per- 
 sistently or very frequently), and may be due to retching, to 
 the introduction of the tube, to a temporary or a chronic con- 
 gestion. Gastric hemorrhage occurs also in severe anemias 
 and in cirrhosis of the liver. But the hemorrhagic diseases 
 of the stomach are ulcer and carcinoma. Small quantities of 
 blood are often found mixed with mucus in cases of gastritis, 
 and this occurs so frequently as to be of some diagnostic 
 value. 
 
 If the macroscopic and microscopic examinations of the 
 contents do not make the presence of blood clear, it is neces- 
 sary to use special tests. Spectroscopic examination is not 
 clinically practicable. The two best tests for blood in the 
 stomach-contents are those of Weber and Jaworski. It 
 should not be forgotten that blood may be eaten with the 
 food, or that iron (as a drug or as a compound of the food) 
 may be swallowed. 
 
 Weber's test is a modification of Van Deen's. To ten c.c. of 
 the filtered contents about three c.c. of glacial acetic acid are 
 added, and the coloring matter of the blood is extracted by 
 shaking with about five c.c. of ether. If blood is present, the 
 ether extract is brownish ; if the ether extract is uncolored, there 
 is no blood. The separation of the ether may be facilitated by 
 the addition of a few drops of alcohol. Add to the brownish 
 decanted ether extract ten drops of fresh tincture of guaiac 
 and about 20 drops of old spirits of turpentine or a small 
 quantity of peroxid of hydrogen. After \'igorously shaking 
 the mixture for a while it becomes dark blue if blood is pres- 
 ent. If there is no blood present, the mixture often becomes 
 reddish-brown with a tinge of green. When the reaction is 
 not clear, a little water should be added, and the coloring
 
 THE ANATOMICAL SIGNS. I 59 
 
 matter extracted with chloroform. If blood is present, the 
 chloroform extract is colored blue. 
 
 The iron test of Korcynski and Javvorski is made in the 
 following manner : A small piece of the colored and sus- 
 pected sediment is placed in a porcelain capsule, with a pinch 
 of chlorate of potash and one or two drops of concentrated 
 HCl, and is slowly and gently heated to drive off the chlorin. 
 The procedure is repeated, after the addition of another drop 
 of HCl, until the residue of evaporation is decolorized. The 
 addition of one drop of a one per cent, solution of potassium 
 ferrocyanid gives a Prussian-blue color if blood is present. 
 
 In the morning washings of the normal stomach are found 
 a few single cylindrical cells, and, rarely, a few lymphocytes. 
 If the fasting stomach contain free hydrochloric acid, which 
 is a pathological sign, the spiral bodies of Jaworski and 
 groups of the nuclei of leukocytes may often be found. In 
 gastritis with excessive secretion these cell nuclei are num- 
 erous, and are mixed with the mucus, with the chief cells, and 
 with mononuclear leukocytes. In asthenic and atrophic gas- 
 tritis no spiral bodies are found, and no nuclei of cells the pro- 
 toplasm of which has been digested, but numerous cylindrical 
 cells and mononuclear leukocytes and sometimes beaker cells. 
 Rarely, groups of cancer cells are detected. In suppurative 
 gastritis and in perigastric abscess, large numbers of poly- 
 nuclear leukocytes in the morning washings or in the vomit 
 may reveal the nature of the trouble. 
 
 Exfoliated pieces of the mucous membrane are sometimes 
 found in the morning washings, and this anatomical sign is 
 most frequent in ulcerative gastritis (erosions). Pieces of the 
 mucous membrane or of tumors may sometimes be found in 
 the expressed contents, having been scraped off by the tube. 
 This regrettable accident occurs very rarely when the velvet- 
 eye tube is used, but the little fragments should always be 
 searched for in the contents, and should be utilized for diag- 
 nostic purposes. The fragments rarely extend through 
 the glandular layer, but sometimes do so, and, when hard- 
 ened, cut, stained, mounted, and examined with the micro- 
 scope, may give the anatomical diagnosis in a manner which 
 leaves no room for doubt ; but it should be remembered 
 that a normal piece of the mucous membrane does not ex- 
 clude anatomical disease of another part of the stomach, and 
 that different forms of gastritis may coexist in the same 
 stomach. The functional signs must make clear the predomi- 
 nant features of the inflammation, which may be asthenic or 
 hypersthenic. Gastritis may also be a complication of ulcer 
 or of cancer.
 
 l6o DISEASES OF THE STOMACH. 
 
 Bile and pancreatic juice are sometimes found in the con- 
 tents, whether vomited or removed after a test-meal, and in 
 the morning washings before breakfast. This may occur when 
 the stomach is normal. Pathologically, the regurgitation of 
 bile may recur persistently, and this would make obvious the 
 easy passage of the pylorus and suggest the possibility of 
 an obstruction of the duodenum below the opening of the 
 common duct; but under such circumstances it should not 
 be concluded that the pylorus is not the seat of an anatomical 
 disease, for the pylorus may remain patent, like a rigid tube, 
 in cancer, in cases of ulcer, and in cicatricial deformity. 
 
 The anatomical or dynamic or exact nature of a disease of 
 the stomach may often be made plain by the results of treat- 
 ment, even when all other signs fail to clear away the ob- 
 scurity. This constitutes the therapeutic diagnostic test, 
 which is applicable to both the primary and the secondary 
 diseases of the stomach. The principles of the test are very 
 simple. If the h\'pothetical diagnosis be correct, certain 
 results should be obtained by a particular method of treat- 
 ment, which would not give the same results in another 
 disease ; or the effects of treatment may be better or may 
 be worse than would be obtained if the hypothetical diagnosis 
 were true.
 
 SECTION III. 
 GENERAL MEDICATION* 
 
 The revelations of the diagnostic methods, together with 
 our knowledge of the genesis and evolution of the diseases 
 of the stomach, furnish the indications to be met by medica- 
 tion. Corresponding to the modern methods of diagnosis 
 are the modern methods of treatment. The more accurate and 
 complete knowledge of physiology, of pathology, and of the 
 action of remedies has increased our ability to do good or to 
 avoid doing harm. The pathology of the stomach, it is true, 
 seems to have a greater charm for the lover of research than 
 has the treatment of its diseases ; but the interest of the 
 patient begins with the medication intended to cure or to 
 give relief. 
 
 The combination of remedies to meet the special indica- 
 tions of the particular diseases will be considered in Sections 
 IV and V. The general medication consists in the use of 
 remedies suggested by the condition of the patient and by the 
 information given by the various diagnostic methods. The 
 subject will be discussed under the following divisions : 
 
 1. Digestive hygiene. 
 
 2. Diet. 
 
 3. Physical remedies. 
 
 4. Symptomatic treatment. 
 
 5. Physiological treatment. 
 
 6. Bacteriological treatment. 
 
 7. Chemical treatment. 
 
 All curative treatment demands the removal or the control 
 of the cause of the disease. This general principle of thera- 
 peutics has a very extensive application in the treatment of 
 the diseases of the stomach ; for a large number of these 
 diseases are secondary, and the particular cause or causes of 
 the primary diseases are often revealed by the clinical history. 
 A man's stomach is no better and no worse, as a rule, than 
 he himself makes it. 
 
 '^ 161
 
 1 62 DISEASES OF THE STOMACH. 
 
 CHAPTER I. 
 DIGESTIVE HYGIENE. 
 
 Digestive hygiene should begin at birth and continue with- 
 out a break throughout life. In this manner the primary- 
 diseases of the stomach could be prevented and life be 
 made longer, more useful, and more comfortable. A strong 
 stomach is not only a valuable possession, but it is a preven- 
 tive against disease, and good digestion often decides the 
 final result of a struggle against a dangerous disease. Diges- 
 tive hygiene consists in giving to the stomach proper pro- 
 tection, proper repose, proper exercise, and proper work 
 to do at regular periods. The history of the human stom- 
 ach is, ordinarily, a long story of abuse, and pathologists 
 rarely find a healthy stomach when the patient has died after 
 the middle of life. However important digestive hygiene 
 may be in the prevention of disease, it is absolutely essential 
 to the cure of the diseases of the stomach. 
 
 In the general management of the diseases of digestion 
 there is nothing more essential than a suitable environment — 
 physical, moral, and social. These patients are very sensi- 
 tive to cold, and become very languid and bilious in warm 
 climates. Their bodies magnify every change of tempera- 
 ture. As a general rule, a moderately cold, dry location, of 
 medium elevation, is very suitable, giving fresh air and sun- 
 shine and permitting outdoor life. The abdomen sliould at 
 all times be well protected by the clothing, and left free to 
 enjoy unimpeded the movements of the diaphragm. 
 
 The moral atmosphere is magnified in its gloom and de- 
 creased in its brightness by the delicate senses of these 
 patients. The mind is particularly sensitive to the dark colors 
 of life. There is nothing more depressing or injurious to 
 such patients than the companionship of pessimists. The 
 moral atmosphere should be sustaining, dissipating forebod- 
 ings and inspiring contentment, hope, and courage. 
 
 The social atmosphere is another element of help or of 
 injury. The slavery of the social life ma\' offset all remedial 
 influences. The performance of social duties under strain or 
 exhausting excitement may leave no energy for digestion. 
 It is often essential to place those suffering from a disease of 
 the stomach where they can be free and can get rest and
 
 DIGESTIVE HYGIENE. 1 63 
 
 adhere strictly to a proper diet. In these respects treatment 
 in a sanitorium presents many advantages. 
 
 Rarely is the stomach injured by non-penetrating wounds 
 of the abdomen; but diseases of the stomach, particularly 
 ulcer, may be caused by traumatism — by a blow or by re- 
 peated or prolonged and strong compression. In this 
 manner disease of the stomach is sometimes produced in 
 shoemakers and in others who use the abdomen for holding 
 objects or instruments in position ; but more frequently the 
 movements of the stomach are impeded or the stomach is 
 displaced by prolonged compression and constriction of the 
 waist. In this respect modern fashions are a curse to women. 
 During the treatment of the diseases of the stomach, the 
 action of these causes of disease must be excluded and the 
 stomach be protected against external injury and compres- 
 sion. This hygienic rule is imperative during the digestive 
 period. 
 
 " A person digests as much with his legs as with his stom- 
 ach," wrote Chomel. Exercise facilitates nutrition, increases 
 the bodily waste and needs, promotes the appetite, and, under 
 proper conditions, is an aid to digestion. The healthy manual 
 laborer awaits with impatience the hour of his meal, and 
 eats all the more on account of his hard work ; but if he 
 becomes greatly fatigued, the appetite is lost. Sedentary 
 habits may cause disease. On these points there is no differ- 
 ence of opinion. 
 
 When there is a serious disease of the stomach the matter 
 is not so simple, and the prescribing of even moderate 
 exercise during the period of digestion may be a grave error. 
 Exercise creates a new demand for nutriment, and is bene- 
 ficial on the condition that this demand be met easily and 
 without injury. Patients with diseased stomachs are often 
 unable to do this. 
 
 The action of exercise on the functions of the healthy 
 stomach during digestion is positive. Moderate exercise 
 hastens digestion, the stomach completes its evacuation a 
 little' earlier, digestive products do not accumulate in the 
 stomach, the acidity of the contents is normal, and the 
 movements of the intestines are more active. Violent exer- 
 cise and hard labor are more decided in their action and 
 the acidity of the contents is ordinarily below normal. 
 In health it makes little difference whether a person take 
 moderate exercise or rests, for neither is likely to derange 
 digestion. Rest, in health, increases the acidity of the con-
 
 164 DISEASES OF THE STOMACH. 
 
 tents, the digestive products accumulate in the stomach, and 
 the motor function is less active than during moderate exer- 
 cise. In sleep these variations are greater than in rest. 
 
 The influence of exercise, of rest, and of sleep is much 
 greater in the diseases of the stomach than in health, and no 
 rule can be formulated which is applicable to all these diseases. 
 Individualization is the best plan. 
 
 The gastroneurasthenic should rest after his meals; for 
 otherwise what is needed by the stomach may be used by 
 other parts of the body and b\' the mind. The weak and the 
 nervous should rest both before and after their meals, and the 
 greater the weakness and the irritability, the more stringent 
 should be the rule. 
 
 Myasthenic patients may or may not demand rest. If 
 the myasthenia is not of a high grade (complete evacuation 
 between meals) and if the organ has not been overloaded, 
 the erythrism of the nervous system produced by exercise 
 may be an aid to digestion ; but observation proves that the 
 highly myasthenic stomach commonly empties itself soonest 
 under the gentler influence of repose. E.xercise and the 
 erect position increase the motor insufficiency, and may 
 produce complete retention and an acute attack of pain, nau- 
 sea, and vomiting. In all conditions, the digestion of a 
 heavy meal should be begun with half an hour's rest; con- 
 sequently, we almost invariably prescribe, in myasthenia, rest 
 half an hour before and at least one hour after meals, and 
 allow the exercise, in keeping with the individual indica- 
 tions, to be taken when the heavier work of digestion is 
 over, and preferably in the open air. Some fondly imagine 
 that they obey the laws of hygiene by promenading in their 
 apartments or places of business. The exercise during the 
 intervals of digestion should never produce greater fatigue 
 than can be completely dissipated by twenty minutes of rest. 
 
 In many of the anatomical diseases rest during digestion is 
 advisable. Gastroptosis, ulcer, hypersthenic gastritis, ad- 
 vanced carcinoma, and all diseases of the stomach accom- 
 panied by irritability of the mucous membrane or by emacia- 
 tion and loss of strength, should be treated by repose, which 
 should, in severe cases, be absolute. 
 
 The use of the voice immediately after meals is no less in- 
 jurious than may be that of the muscles. The digestive tube 
 is deranged by the unnatural respiration and by tlie compres- 
 sion between the diaphragm and the abdominal muscles. 
 The abdominal tension is increased and the breathing per- 
 forms a kind of massage. This rule is most often violated
 
 DIET. 165 
 
 by orators, professors, lawyers, ministers, and singers. There 
 is no more pernicious habit than that of going directly from 
 the table to the piano. 
 
 Cerebral is no less injurious than muscular fatigue : there 
 are reasons to believe that it is more so. The overworked 
 mind does not cry out in pain, but produces insomnia — it re- 
 fuses to stop work. The strained muscle hurts, and muscular 
 fatigue brings its natural cure — rest. The tired man is 
 drowsy. The thinker should carefully select his food, let 
 his brain rest while his stomach is hardest at work, and take 
 regular and moderate exercise in the open air, so that the 
 body will aid in demanding nutrition and rest for the brain. 
 Nothing can equal the wisdom of these hygienic rules, except, 
 perhaps, their perfect uselessness. Genius has long been 
 condemned to live with a diseased stomach and will probably 
 continue so to do. 
 
 CHAPTER 11. 
 DIET. 
 
 " The best, the only good, the only suitable, diet," wrote 
 Trousseau, " is the one which the patient knows by experience 
 best agrees with him." So notable has been the progress in 
 the use of a diet in the cure and prevention of disease within 
 the past twenty years that this proposition, though always 
 false, is surely no longer tenable. The healthy man does not 
 know how to feed himself, and the diseased man is far less 
 likely to know. 
 
 A rational diet in the diseases of the stomach, through our 
 more accurate and complete knowledge of digestion and nutri- 
 tion, and of the various foods, is to-day possible. It is only 
 within the past two decads that the great work of determining 
 the functional power and the rich flora of the diseased stomach 
 has been pushed on steadily to exact practical results. Dur- 
 ing the same period a flood of light has been thrown on the 
 chemical pathology of nutrition, and on the utilization of 
 food by the intestines in health and in disease. 
 
 But in addition to the increased knowledge of the functions 
 and diseases of the stomach, and their relations to the work 
 done by the intestines and to the state of nutrition, we are also 
 in possession of more accurate knowledge of food. To-day
 
 1 66 DISEASES OF THE STOMACH. 
 
 it no longer suffices to order a fluid, or light, or easily diges- 
 tible, or nutritious diet ; the physician must prescribe precisely 
 and fully what the patient should eat. What is digestible 
 and light and nutritious is unknown to most persons, who 
 when left to follow blindly their diseased appetites and dis- 
 ordered sensations are very likely to eat too much, or too 
 little, or the wrong things, or only a few articles, and to be- 
 come morbidly introspective. The physician should select 
 the diet in accordance with the indications furnished by the 
 individual case, and should watch and control the effects. 
 
 The influence of the diseases of the stomach on nutrition 
 is in practice a matter of very great importance. The clinic 
 teaches, in a more trustworthy manner than experiments on 
 animals, that the chemical work of the stomach, though very 
 useful, is not necessary to the organism. The cases in the 
 practice of every physician are very numerous in which the 
 strength and weight of the patient are maintained, in spite of 
 loss of nearly all digestive aid from the stomach. The utili- 
 zation of the albuminous foods, starches, sweets, and fats may 
 be complete in spite of the chemical inactivity of the stomach ; 
 but this is not because the stomach is useless, but because 
 the organism is rich in resources. 
 
 There is no doubt that the intestines are capable of es- 
 tablishing complete digestive compensation when the stomach 
 is insufficient, but on condition that a proper diet be given. 
 The food will then be absorbed in an assimilable form, and 
 will not be lost by fermentation or putrefaction ; but this 
 does not render it highly probable, as is claimed by some 
 authorities, that the inanition in the diseases of the stomach 
 (except in cancer) is due exclusively to deficient alimentation. 
 Carefully selected diets may be well utilized, when the some- 
 what indiscriminate alimentation of health is not. 
 
 In a disease of the stomach without stagnation or exces- 
 sive secretion there is little difficulty. The intestines, if the 
 diet be correct, are fully equal to the possible extra work, 
 when they are permitted to do it without hindrance ; but where 
 there is excessive secretion, duodenal digestion is interfered 
 with and the action of the saliva is quickly curtailed. The 
 fat which reaches the intestines is well digested and ab- 
 sorbed, but the carbohydrates and proteids are partly lost 
 through fermentation and putrefaction, as the clinical diet 
 guides indicate. In the diseases of the stomach with disturb- 
 ance of the motor function, the stomach exerts its greatest 
 power of doing harm. It may deliver to the intestines a chyme 
 hardly fit for food, or it may reject the best kinds of food, or
 
 DIET. 167 
 
 withhold from the organism much of the food that is eaten; 
 but if care be taken to secure delivery to the intestines of 
 the right kind of food, in many of the cases nutrition may 
 be well maintained, for the intestines may not have lost their 
 compensating power. Disease of the stomach produces 
 emaciation partly because the alimentation is improper. 
 
 Still, unquestionably in a large number of cases, the chronic 
 inanition is due to deficient alimentation, the diet being too 
 exclusive or too reduced in quantity through fear and 
 ignorance. 
 
 In the dietetic treatment of the diseases of the stomach 
 every effort should be made to keep the body well nourished ; 
 but food is not only nutriment, it is also a remedy. Not only 
 must it meet the demands of nutrition and be appropriate to 
 the digestive power of the stomach and intestines, but its 
 physiological action must be such as to produce no harm, or 
 to exert a remedial influence, or to give the diseased organ 
 the appropriate exercise or rest. In the treatment of the 
 diseases of the stomach, food is the most powerful and valu- 
 able physiological remedy. Consequently, a food should be 
 selected, not on account of its nutritive value only, but also 
 on account of its physiological action. Without a knowledge 
 of the uses and action of food it is not possible to prescribe 
 a rational diet. 
 
 In the first part of this chapter the rules for the selec- 
 tion of a diet in the diseases of the stomach will be deduced 
 from the basic principles of alimentation. In the second 
 part will be described the clinical evidences of a proper diet, 
 or the clinical correction or confirmation of the diet as given 
 by the reasoning of the physician. The first is a deduction 
 from principles and from the subjective and objective signs 
 revealed by the examination ; the second is the testing of the 
 conclusions by the daily observation of the individual case 
 and the use of certain clinical methods of control. 
 
 1. SELECTION OF A DIET IN DISEASES OF THE 
 STOMACH. 
 
 The grand aim of alimentation in disease is the restoration 
 of the patient to a normal state of nutrition and to health. The 
 object, then, is twofold — the nourishment of the patient and 
 the exertion of a remedial influence on the disease, A diet 
 which leaves either the one or the other out of consideration 
 is fundamentally wrong. 
 
 The use of food as a remedy does not mean necessarily the
 
 1 68 DISEASES OF THE STOMACH. 
 
 adoption of an exclusive diet, or so-called diet-cure. Dieting 
 is sonietinies made synonymous with slow starvation. A diet 
 incapable of maintaining nutrition is a compromise enforced 
 by very particular circumstances and endangers life when 
 adhered to for a long time. 
 
 There is no general dietetic cure of the diseases of the 
 stomach. Not only should the diet be suitable for the par- 
 ticular disease, but it should also be proper for the particular 
 patient. Each case is a law unto itself, and demands as a 
 basic principle of treatment individualization. No two pa- 
 tients are alike, either in the details of the disease or in their 
 customs, habits, constitution, and state of nutrition. Neither 
 is the dietetic treatment of a particular disease of the stomach 
 fixed and invariable. In some cases it is advisable to change 
 the accustomed diet, though it be improper, slowly and tenta- 
 tively. Changes — and great changes — may be necessary, 
 but they should be gradual and proportionate to the patient's 
 power of adaptation. This matter demands special attention 
 when the patient is old or weak. The same care is often 
 necessary in making radical changes of the diet, as in going 
 from a restricted diet to a more liberal one. The dietetic 
 habits and digestive adaptations are sometimes too rudely 
 disregarded. 
 
 Apart from the management of exceptional cases there 
 are certain general indications to be met by the selection of a 
 diet. These will be first briefly enumerated and then more 
 fully discussed. 
 
 1. The quantity of the food should be sufficient to supply 
 the needs of nutrition, and the composition of the diet should 
 approach as nearly that of the normal diet as the variety of 
 the disease of the stomach will permit. 
 
 2. Those foods should be selected which can be best di- 
 gested and utilized, and which are least likely to ferment or 
 decompose. 
 
 3. The physiological action must be such as to favor or to 
 remedy the disordered functions and the anatomical lesions. 
 
 4. Not only the disease of the stomach but the state and 
 power of other organs must be borne in mind. 
 
 5. The finances, habits, and peculiarities of the patient 
 should be considered. 
 
 6. The directions should be complete and explicit, and 
 should be changed to meet the dail)' indications. 
 
 I . The quantity of the food should be sufficient to supply the 
 needs of nutrition, and the composition of the diet should approach
 
 DIET. 169 
 
 as nearly tliat of the normal diet as the vaiiety of the disease of 
 the stomach ivUl permit. 
 
 Food converted into nutriment and absorbed by the blood- 
 vessels, lacteals, and lymphatics is utilized in nutrition and 
 in the production of force and of animal heat. But what is 
 meant by nutrition ? and how much food does the organism 
 require ? 
 
 The first theory formulated was that of oxidation or com- 
 bustion. Soon after the great Lavoisier discovered oxy- 
 gen and its properties were made known, and Regnault and 
 other physiologists studied the formation of carbonic acid in 
 the organism, it seemed almost sure that oxygen was carried 
 by the hemoglobin of the red corpuscles to the tissues, and 
 thus by combustion, more or less complete, produced urea, 
 uric acid, carbondioxid, etc. This seemed to be a grand 
 triumph for biological chemistry, and the great processes of 
 nutrition and respiration were reduced to a simple chemical 
 equation. Here is life revealing itself in its essence in the 
 form of a chemical reaction. But further discoveries only 
 produced confusion. The circulating albumin is the first to 
 be destroyed, then the sweets, and lastly the fats. If nutri- 
 tion be oxidation, the reverse should be true; and such 
 easily oxidizable substances as alcohol and pyrogallic acid 
 pass through the organism and appear unchanged in the 
 urine. Moreover, the quantity of oxygen eliminated in com- 
 bination with carbon, in the form of carbondioxid, is not in 
 relation with the quantity of oxygen introduced. On the 
 other hand, with an excess of food there is more oxygen 
 absorbed and more urea eliminated. Also, when there is 
 quite rapid loss of body fat, more oxygen enters. Again, 
 oxygen alone is without action on albumins, sweets, and fats. 
 The intervention of a third power is necessary. 
 
 The second theory is that of fermentation, and represents 
 a transition stage. Nutritive exchange is not due to the intro- 
 duction of oxygen into the system and to its action on the 
 circulating nutriment, but is the result of the action of non- 
 figured ferments in solution. Not only digestion but life 
 itself is conditioned by the presence of ferments, since nutri- 
 tion is cellular life, and cellular life makes up the life of the 
 organism ; but it is possible that the ferments widely dis- 
 tributed in the organism are the ferments absorbed from the 
 digestive tube and the associated glands. 
 
 The third and probably true theory is that nutrition is the 
 life and the function of the cell. Of this cellular theory there 
 are two forms. Some contend that only the organized albu-
 
 I/O DISEASES OF THE STOMACH. 
 
 niin undergoes transformation. In order that this view may 
 be maintained in the light of recent discoveries, its supporters 
 are forced to assume the partial regeneration of the albumin 
 by the utilization of the analogous carbon and hydrogen 
 elements of the sweets and fats. It is thus supposed that 
 nutrition is somewhat like fatty degeneration. This theorj' 
 is false, in that it contains only a part of the truth and is sup- 
 ported or supplemented by an untenable hypothesis. The 
 dissociation, of which nutrition is the expression, affects both 
 the protoplasm of the cells and the nutriment in circulation. 
 Moreover, it is the circulating nutriment that is chiefly trans- 
 formed, and for this reason the tissues are stable. Let this 
 matter, on account of its great practical bearing, be examined 
 more closely. 
 
 The fixed, organized " protoplasm " is changed only to a 
 very slight degree in normal nutrition when the supply of 
 nutriment is sufficient. When too few proteids, for instance, 
 are introduced, the quantity of urea diminishes at once and if 
 the condition continues the organism begins to li\'e on itself; 
 but this is unphysiological, and normally the quantity of or- 
 ganized matter varies but little. On the other hand, the quan- 
 tity of circulating nutriment varies with the number of cells 
 (for these are the active agents analogous to ferments), with 
 the rapidity of the circulation, with the increase or decrease of 
 the temperature, and also depends on the degree of special 
 activity proper to each cell. 
 
 The life of the cell expresses itself in the ceaseless move- 
 ments of its constituent elements. What are these elements ? 
 and what is the nature of these movements ? 
 
 The arrangements, association, and constitution of the 
 molecules of a cell endow it with its distinctive attributes and 
 properties. It is in this moving molecule of protoplasm that 
 the nutritive changes incident to life are expressed in their 
 simplest form. It is in this " primordial basis," as Huxley 
 has happily named it. that we shall hope to detect the inti- 
 mate nature of nutrition. Simple and primitive in its life, 
 the protoplasmic molecule is complex in its chemical compo- 
 sition and its constitution. First are the albuminous substances, 
 with their four or five sorts of atoms, C, H, N,S,0,and some- 
 times also Fe or P ; then come also the ternary, or C, H, O 
 compounds, and lastly water and inorganic salts. 
 
 It has already been stated that the interior of this elemen- 
 tary molecule is in ceaseless motion ; but motion presup- 
 poses force, and the regeneration of force means transforma- 
 tion, and transformation predicates a pre-existing substance.
 
 DIET. 171 
 
 Hence, the existence and continuity of cellular movements 
 — or, in other words, cellular life — is dependent on the recep- 
 tion and transformation into living protoplasm, and on its util- 
 ization in the evolution of heat and force and in the removal of 
 the by-products, of material fitted to undergo these changes. 
 This received substance is called " nutriment," its appropria- 
 tion by the living cell is known as "assimilation," and the 
 expulsion of the waste is called "elimination." Assimilation, 
 utilization in the formation of heat and force, and elimination 
 constitute the nutritive changes, which are seen in their 
 simplest form in the proper life of the cell. It will be noted 
 that there is no suggestion of oxidation. The changes take 
 place in the presence of oxygen as in the presence of water, 
 but are the work of the cell itself. 
 
 Apart from its proper life the cell has a function to 
 perform in nutrition. The one concerns itself alone; the 
 other chiefly concerns the organism. This function is the 
 transforming of the circulating nutriment into force and 
 heat. This is, for the organism, the important work of 
 the cell, producing by transformation of the circulating nu- 
 triment the force that is used in the performance of function. 
 It is widely different from cellular nutrition, in that assimila- 
 tion for the cell by the cell is absent. The one is continuous, 
 persistent, innate ; the other is intermittent, variable, pro- 
 duced by external excitation. Many cells, in addition to this 
 general, have a special, work. The power to perform this 
 special function is furnished by the organism; but the per- 
 formance of each of these functions engenders force and 
 animal heat. It is so with muscular contraction; it is also 
 true of respiration, circulation, and digestion, and of the 
 changes undergone by the nutriment in the liver and in the 
 mesenteric glands before it reaches the general circulation. 
 
 Each cell, then, of the body may be considered as a center 
 for the transformation, generation, and manifestation of force, 
 being endowed with an impulsive movement which is its 
 life. The new force is stored in its constituent elements, 
 and is added to the unvarying radical and active force of 
 the organism. It is in this way that the nutriment is util- 
 ized in nutrition, in the general meaning of the word, in- 
 troducing into the body the potential food of life. But po- 
 tentiality made active means transformation and disintegra- 
 tion. This is true regardless of the end of the generative 
 power, be it used in cellular nutrition, in the interest of the or- 
 ganism, or in the performance of specialized work. Conse- 
 quently, the nutritive process includes two grand results — the
 
 172 DISEASES OF THE STOMACH. 
 
 formation of tissue and the evolution of force and heat ; and the 
 food, whicii is the source, has two corresponding destinies. 
 Tlie power of the organism to convert food into some form 
 of force is Hmited. Only one class of foods — proteids — to 
 even a limited degree increases dissimilation when intro- 
 duced into the circulation in excess. When more food is 
 assimilated than the organism requires, the excess is stored or 
 organized. Be the excess proteids, sweets, or fats, the storage 
 is practically almost exclusively in the form of body fat; but 
 be any organ at the same time exercised or given, within 
 limits, more work to do, that organ is strengthened and, if a 
 muscle, also grows. On these observed sequences depends 
 the possibility of improving and strengthening the organism 
 by a fortifying diet. 
 
 In the dietetic treatment of the diseases of the stomach 
 it is never an object to reduce the weight and strength. A 
 starvation or an insufficient diet may be made temporarily 
 necessary by very special circumstances, and it may be very 
 difficult to decide, in the interest of the patient, how much is 
 to be ultimately gained by injuring the organism in order to 
 favor the stomach. There can be no question that the nutri- 
 tion of the body must be improved, or as nearly maintained 
 as the disease will permit. Consequently, except when forced 
 to make a compromise, a primary necessity is the upholding 
 or fortifying of the organism. To do this the quantity of 
 food that the organism daily requires must be known. But 
 this is not all. To select the quantity of food to be adminis- 
 tered a knowledge of the nutritive value of food in the par- 
 ticular disease is also necessary. 
 
 The human organism as a unit may be considered a col- 
 lection of centers for the transformation of force. This force 
 comes from the outer world, and chiefly in the form of poten- 
 tial energy in the food. The difference between the force- 
 value of the food as it enters the body and its remnants on 
 their exit, represents the potential energy appropriated by the 
 organism for the production of work and heat. It is not 
 possible to measure directly the work done by the cell in the 
 performance of its functions, which have to do with the pres- 
 ervation, perpetuation, and movements of the body, and with 
 the mental and moral life ; but by estimating the heat-value 
 of the food as it enters and leaves the body we can obtain 
 the quantity of force utilized by the organism, and expressed 
 as so many units of heat; or by observing and analyzing the 
 quantity of food necessary to maintain the equilibrium of the 
 body, the daily needs of the organism may be expressed in
 
 DIET. 173 
 
 the alimentary principles. The results thus obtained serve as 
 a basis for the quantity of food to be ordered, whether it be 
 for the purpose of maintaining or of restoring the balance of 
 waste and of repair or whether it be our object to reduce the 
 body, to support life, or to force alimentation. 
 
 {ci) The Daily Needs of the Organism estimated in Units 
 of Heat. — To supply the daily needs of the organism and to 
 maintain the balance of nutrition, enough potential energy in 
 the form of food must be received to cover the consumption 
 in the form of work and of animal heat. Such a quantity of 
 food represents the diet of support. Under such a regimen 
 as much is added to the body as is taken from it. The poten- 
 tial energy introduced and appropriated is exactly equal to 
 the work and heat developed. The nutritive value of this 
 merely supporting diet represents the daily needs of the 
 organism, and affords for it an exact measure. 
 
 The amount of potential energy consumed by the body 
 when at rest may be called the biological coefficient. The 
 voluntary movements by which the body is placed in relation 
 with external objects is not included in this conception. The 
 store of potential energy is only drawn upon for internal work 
 and for the supply of animal heat. 
 
 The quantity of potential energy necessary to maintain the 
 dynamic equilibrium of the body in repose is dependent on 
 the number of the noble elements of the body, and on their 
 work in the maintenance of life. Each living cell is in con- 
 tinuous motion, and motion is an expression of transformed 
 or liberated force. When these cells are more numerous, the 
 consumption of potential energy is greater. 
 
 Not only the number of cells, but also the activity of the 
 cellular protoplasm, which varies at different ages, must be 
 considered. The adult requires more food than the child, 
 and the needs of the body diminish with the degeneration of 
 old age. The weight of the body is no measure of this 
 need. The greater part of the body framework, the deposit 
 of fat and other tissues endowed with little activity, neither 
 consume nor liberate much force in their existence. A man, 
 when emaciated, consumes less than when well nourished, 
 because the number of noble elements — of cells which do a 
 work for the organism — is diminished. The same individual 
 on becoming fat, needs and consumes little more, because the 
 fat cells have no active altruistic work to do. 
 
 The second factor of the biological coefficient is the poten- 
 tial energy consumed by the circulation, respiration, and the 
 cells concerned in digestion and nutrition. One part is repre-
 
 174 DISEASES OF THE STOMACH. 
 
 sented by muscular work and the other by glandular activity, 
 and both are under the control of the most highly endowed 
 dynamic cells of the body. 
 
 The smaller the mass, the greater is its relative surface 
 area. Consequently, small animals lose more heat in propor- 
 tion to their size than larger ones in a similar environment. 
 The same law obtains with adults of different size, and applies 
 also to the variations due to the growth of the infant into 
 manhood. The consumption and the cellular activity are 
 relatively greater in order to meet the proportionate by greater 
 loss. Nothing can be more important than the protection of 
 the body against the loss of heat in emaciated and in adynamic 
 conditions. 
 
 The moisture of the climate is without influence, inasmuch 
 as the diminished loss by evaporation is compensated by the 
 increased loss by radiation and conduction. Heat pro- 
 duction in the properly protected body in repose is constant. 
 This is regulated through the nervous system by which 
 heat production, established through the law of survival at a 
 minimum, is transmitted as a fixed peculiarity embodied in a 
 biological law. 
 
 The biological coefficient no longer represents the total 
 work of the organism, as soon as the state of repose is 
 broken. The amount of potential energy consumed is in- 
 creased by the taking of food and by the process of digestion, 
 by mental and muscular work. 
 
 The quantity of nutriment consumed is not proportionate, 
 as was once thought, to the quantity of food introduced. 
 The body is not a furnace that burns immediately and unceas- 
 ingly everything combustible introduced into it. Digestion 
 requires, through its muscular and glandular activity, an addi- 
 tional amount of activity, which varies with the digestibility 
 and the physiological action of the constituents of the meal. 
 Zuntz estimates that the amount of oxygen consumed is in- 
 creased 15 per cent, during the digestion of a moderate meal, 
 and a man digesting enough food to maintain the organism 
 increases the consumption for twenty-four hours of rest and 
 fasting by about ten per cent. The total production of animal 
 heat is in like proportion increased. 
 
 This principle is of the highest practical importance. Mere 
 excitants of the alimentary canal destroy potential energy. 
 Food easily digested and quickly absorbed produces hardly a 
 perceptible increase of nutrition waste. Only by a correctly 
 selected diet can the reduced organism be restored to a good 
 nutritive state. The introduction of food increases the waste
 
 DIET. 175 
 
 by its action on the alimentary canal, and not directly by 
 being itself consumed. A rich diet may mean a loss, as there 
 is no luxurious consumption. The excess is undigested, un- 
 absorbed, or incompletely oxidized. Alimentation is most 
 economical when the nutriment introduced is the exactamount 
 required. An excess is stored or wasted, and when too little 
 food is taken the body lives on itself. 
 
 Muscular work is the cause of the greatest expenditure of 
 force above that of the biological coefficient. The increased 
 consumption of oxygen in very slight movements and its de- 
 mand in strained work illustrate how close and great is the 
 influence of muscular work on the consumption of potential 
 energy. Zuntz estimates the daily consumption by hard work 
 at 25 per cent, above the expenditure in repose. 
 
 In the performance of muscular work, much more potential 
 energy is consumed than is expressed by the useful work 
 performed. Rubner's researches give a loss of nearly four- 
 fifths. This loss is not a constant one, and is not so great 
 when the man is fresh and trained to use his muscles. 
 Fatigue, a relatively great effort, and a lack of training involve 
 great loss and excessive consumption. 
 
 The following table gives in round numbers the daily con- 
 sumption by an adult weighing 65 kilograms, the figures 
 representing looo heat units : 
 
 Rest in bed, 1800 Cal. , or 28 Cal. per kilo. 
 
 In repose, 2100 Cal., or 32 Cal. per kilo. 
 
 In light work, 2300 Cal., or ^iZ Cal. per kilo. 
 
 In moderate work, 2600 Cal., or 40 Cal. per kilo. 
 
 In strained work, 3100 Cal. , or 48 Cal. per kilo. 
 
 The estimation of the needs of the organism in units of 
 heat does not correspond with the actual uses of food in nu- 
 trition. Only a part of the food assimilated is used in the 
 production of heat. Again, although the end-products of 
 the fats and carbohydrates are the same in the calorimeter 
 as in the body, those of albumin are different. The calor- 
 imetric value of animal albumin is 5.7 Cal., that of vege- 
 table albumin is 5.6 Cal.; but the nutritive value of albumin 
 is represented by the number of heat units liberated by its 
 oxidation and conversion into the compounds which repre- 
 sent the forms in which it is eliminated from the body, and, 
 according to Rubner, is 4.2 Cal. and 4 Cal., respectively, for 
 animal and vegetable albumin. The nutritive value often gm. 
 of fat is equal to 23 gm. of albumin or carbohydrates; or — 
 
 I gm. albumin or carbohydrates = 4. 1 Cal. 
 I gm. fat = 9.3 Cal.
 
 176 DISEASES OF THE STOMACH. 
 
 The conversion of the older estimate of the needs of the or- 
 ganism, in so man\' grams of albumin, fat, and carbohydrates, 
 into the newer calorimetric equivalent is an easy process of 
 multiplication ; but the new method is clinically a great ad- 
 vance on the old one. The alimentary principles can, within 
 limits, be substituted for one another, and in the treatment of 
 the diseases of the stomach the substitution is usually and 
 necessarily made. The calorimetric method renders a com- 
 ple.x problem simple and easy. The force-\-alue of the diet 
 is revealed at a glance, and it is quickly seen whether it is 
 insufficient, supporting, or strengthening. 
 
 (/;) The Daily Needs of the Organism as represented by 
 the Alimentary Principles. — The amount of force daily 
 needed by the organism, both in a state of repose and in 
 internal and e.xternal activity, can thus be accurately esti- 
 mated in units of heat. The measure of the oxygen con- 
 sumed, the difference between the heat-value of the food and 
 that of the waste products eliminated, minus the amount re- 
 tained and organized or stored in the body, and the estima- 
 tion of the heat-value of the food necessary to preserve the 
 body for a long period in nutritive equilibrium, have re- 
 vealed with sufficient precision the needs of the organism. 
 Turn we now to a short study of the available material for 
 the supply of these demands. The daily needs of the organ- 
 ism must be supplied by that which is of nutritive value in 
 the food. 
 
 The value of the food to the organism is dependent on its 
 chemical composition, on the combination of the alimentary 
 principles, and on its digestibility and utilization. 
 
 Not all the chemical constituents of a food are of nutritive 
 value. A part ma}' be insoluble in the digestive fluids, and 
 may either become the food of micro-organisms or pass into 
 the feces. A part may be absorbed, onlj^ to be eliminated 
 on account of its worthlessness in nutrition. A part may 
 waste as much potential energy in its digestion and assimila- 
 tion as it supplies in its products. A part may be absorbed 
 unchanged, and may be useful or essential to nutrition with- 
 out directly contributing potential energy to the organism. 
 These are only important on account of their chemical and 
 physiological action. A part may be absorbed after prelimi- 
 nary transformation and be utilized in supplying the needed 
 force and heat. 
 
 Food, then, contains {a) material which maintains the 
 nutritive equilibrium and furnishes heat and force. The most 
 important of the members of this class are the proteids, fats,
 
 DIET. 17 J 
 
 and carbohydrates. Alcohol and the organic acids are also 
 capable of furnishing some force and animal heat in their 
 consumption. Fat and albuminous foods may be either of 
 vegetable or of animal origin, and possess nutritive values 
 according to their qualities and chemical constitution. The 
 carbohydrates are products of the vegetable kingdom. All 
 these foods are organic. 
 
 The second class contains {b) inorganic compounds, or 
 mineral matter. The chief of these inorganic elements are 
 H, O, Na, K, CI, Ca, Mg, Fe, Mn, P, and S. These elements 
 are in various combinations as salts, and are as essential to 
 the organism as are the members of the first class. There 
 exists for each a minimum quantity, without which inanition, 
 and even death, may result. These inorganic compounds are 
 present in excess in all the foods employed in diet prescrip- 
 tions. This is not the case with water or common salt ; 
 these will receive further consideration. 
 
 These compounds exist in all three kingdoms, but give no 
 force or heat to the human body. Their function is almost 
 exclusively a chemical one. 
 
 The remaining compounds {c) are organic, and owe their 
 value to their physiological action. This value may be due to 
 their odor or taste, and to their local action on the stomach 
 or intestines, or on nutrition, or on one or more organs of the 
 body. Some of them also furnish a very small quantity of 
 energy, which may be consumed in the work of the body, as 
 the alkaloids and glucosids. This class exists in all food 
 that is not insipid. They give the pleasant odor and taste to 
 food. Their physiological action is essential to good diges- 
 tion and to nutrition. 
 
 A fourth part of the food {d), important for its local physi- 
 ological action, is the indigestible residuum. 
 
 The Uses of the Albumins. — Albumin may be absorbed with- 
 out having been transformed by the digestive ferments. Al- 
 bumins are, however, rarely eaten raw or in a fluid state, 
 except in milk, and this fluid rapidly becomes a solid in the 
 normal stomach under the coagulating power of the labfer- 
 ment. In health very little albumin is absorbed without trans- 
 formation, although this may occur when a very large quantity 
 is eaten. A part of it then appears in the urine, as also 
 occurs when the albumin is introduced directly into a vein. 
 
 The only chemical work performed by the formed elements 
 of the gastric juice is the digestion of the albumins. This 
 transformation is a progressive one. The albumin is con- 
 verted into syntonin, albumoses, and finally peptones — which
 
 178 DISEASES OF THE STOMACH. 
 
 differ from one another in their degrees of solubility and 
 diffusibility through an animal membrane and in their chemi- 
 cal properties. The transformation is in all probability a 
 change of the chemical constitution of the molecule, while 
 the chemical composition is not altered. Recent investigations 
 would indicate that the albumin molecule is split up into 
 smaller ones with the same chemical composition. Water 
 here, as in all chemical processes, plays an essential part. 
 Very little albumin is converted by the gastric juice into true 
 peptone, the process not going further than the albumoses. 
 With the pancreatic juice, however, this is otherwise. The 
 intermediate compounds are rapidly changed into the end- 
 products of albumin digestion, and so powerful is this fer- 
 ment that a part of the peptones may be decomposed, and 
 the greater part of the potential energy of the molecule may 
 be wasted. 
 
 According to the generally accepted ideas of Kiihne and 
 his followers, the albumin molecule is split into two series of 
 compounds of different qualities, to wliich the names anti- 
 and hemi-albumose and anti- and hemi-peptone have been 
 given. The following diagram represents this view : 
 
 Albumin. 
 
 Hemi-albumose. Anti-albumose. 
 
 i j 
 
 Hemi-peptone. Anti-peptone. 
 
 Leucin. Asparaginic acid. 
 
 Tyrosin. Protein-chromogen. 
 
 These distinct and double but contemporaneous methods 
 of division were first demonstrated by Kiihne in the diges- 
 tion of fibrin, and the same principle has been shown to ob- 
 tain for other forms of albumin, such as gluten, legumen, 
 vitellin, casein, myosin, etc. 
 
 The products of gastric and pancreatic digestion are not 
 the same, even with the same form of albumin. In the 
 stomach, albumoses are formed in far larger quantities. In 
 the intestines the peptones predominate. 
 
 The nutritive value of these products of albumin digestion 
 is variable. Consequently, the form of albumin prescribed, 
 the location of its transformation, and the rapidity of its 
 absorption are of practical importance. This is most evident 
 in disease. In health, selected and digestible nitrogenous
 
 DIET. 179 
 
 food is nearly all absorbed, only three to five per cent, being 
 lost in the feces. But the percentage of utilization varies 
 widely with different articles of food in the disorders and 
 diseases of the digestive tube. 
 
 The greater part of the products of the digestion of albu- 
 min are absorbed before the ileocecal valve is reached, only 
 about one-fifth reaching the large bowel. This is the work 
 of the cell, which pours these products into the blood-vessels 
 exclusively. The lymph-vessels receive none. 
 
 The products of the digestion of albumin are taken up, on 
 their passage through the wall of the alimentary canal, by 
 the white blood corpuscles. None of these products are 
 received free into the serum of the blood. This digestive 
 leukocythemia is only present during the digestion of albu- 
 minous foods, when the number of white corpuscles in the 
 veins is enormously increased. These products are absorbed 
 by the epithelial lining of the stomach and intestines, and are 
 taken up out of the alimentary wall by the white corpuscles 
 and reconstituted into albumin. The white corpuscles assimi- 
 late albumin. 
 
 All the products of the digestion of albumin down to the 
 true peptones are received by the white corpuscles and re- 
 constituted into cellular protoplasm. The albumin thus be- 
 comes endowed with life and loses the personal identity it 
 possessed before digestion and absorption. Out of this re- 
 constituted albumin all the protoplasmic cells of the body 
 receive the food which is to supply the wear and tear of life. 
 The albumin of food is also used in other ways, and reap- 
 pears in the albuminous constituents of the secretions. The 
 casein of milk is a product of cell activity, as is likewise 
 hemoglobin. The last is a synthetic compound of hemo- 
 chromogen and of globulin. The mucin is a compound of 
 albumin and of carbohydrates under the influence of the 
 epithelial cells. In like manner many of the other cells build 
 special forms of albumin out of the albumin of the food. 
 The albumins constitute about one-eleventh of the weight of 
 the body, and nearly one-half of the total quantity is con- 
 tained in the muscular system. 
 
 The dissimilation of albumin is a complex process, which 
 is best and almost e.xclusively known in its end-products. 
 This constitutes the chief use of albumin, the disintegration 
 liberating force and heat and demanding replacement by 
 nitrogenous food. It is only when the assimilation of albu- 
 min is greater than its dissimilation that the excess becomes 
 organized.
 
 l8o DISEASES OF THE STOMACH. 
 
 The quantity of albumin daily disintegrated by a well- 
 nourished person weighing 70 kilograms is about 60 gm. when 
 fasting. The quantity of albumin in a well-compounded diet 
 should never be less than this amount. One gm. of fat is 
 equal to about 2.4 gm. of albumin or carbohydrates, and the 
 albumin can, within a wide range, be replaced by and replace 
 the other two large classes of food ; but the caloric value 
 of the albumin should never be greater than one third nor 
 less than one-sixth of the caloric value of the other two 
 combined. The albumin required by the body for organiza- 
 tion can be replaced by no other kind of food. 
 
 On an exclusive diet of lean meat, about two and one-half 
 or three times as much albumin as is disintegrated and elimi- 
 nated from the body in hunger (50 to 60 gm.) is required 
 to establish nitrogenous equilibrium. The average quantity 
 is about 1200 gm. of lean beef. But while the nitrogenous 
 equilibrium may be maintained on an exclusively meat diet, 
 no increase of weight and strength can be produced, for the 
 dissimilation becomes greater as the quantity of albumin is 
 increased, and the equilibrium is re-established b\^ more active 
 metabolism. The increased ingestion of albumin renders the 
 fluid which surrounds the cells richer in albumin, but no 
 albumin is organized and the development of new cells is not 
 stimulated. On an e.xclusive nitrogenous diet man neither 
 fattens nor organizes albumin after the balance of nutrition is 
 established. Consequently, a healthy body may be main- 
 tained, but a weak or emaciated person can not be made 
 stronger. The first effect of an exclusive meat diet is loss 
 of weight and strength. The body fat is utilized and burned, 
 and the increased albuminous waste is greater than the quan- 
 tity of albumin digested and assimilated. To establish good 
 nutrition so large a quantity of meat is required that even the 
 most tender and palatable meats become disgusting. The 
 normal excitation of intestinal peristalsis is removed and the 
 acidity of the contents of the small intestine disappears. 
 Constipation, putrefaction, uric acid precipitation, and auto- 
 intoxication become the prominent symptoms, and to prevent 
 injury the body must be placed in repose, non-nitrogenous 
 food must be administered with the meats, and eliminative 
 treatment must be employed. Gradually, under rest, laxatives, 
 and large quantities of water, the symptoms are relieved and 
 the repugnance overcome. Eventually, nitrogenous equili- 
 brium may be established as more and more meat is eaten ; 
 and the individual then becomes stronger, but no fat or albu- 
 min is orgfanized.
 
 DIET. 151 
 
 Carbohydrates. — The carbohydrates, found only in traces in 
 the animal body, exist chiefly as the sugars, organic acids, 
 and starches in vegetable food and fruit. The starches must 
 first undergo digestive transformation before absorption and 
 utilization. Some of the sweets are already absorbable in the 
 form in which they are taken into the alimentary canal. 
 
 Starch, when finely divided and liberated from its inclosing 
 capsule of cellulose, is rapidly transformed by the ptyalin of 
 the saliva, when the medium is alkaline, neutral, or slightly 
 acid, into soluble starch, erythrodextrin, achroodextrin, and 
 maltose. The starch which escapes salivary digestion, and 
 the ptyalin products unabsorbed by the stomach, are delivered 
 to the intestines for the completion of the digestive transfor- 
 mation by the diastase of the pancreatic juice. Theoretically, 
 the end-product of starch digestion is maltose, but in the 
 digestive tube the transformation rarely goes beyond the dex- 
 trin stage, maltose being found rarely and only in traces in 
 the portal vein. 
 
 Milk-sugar probably requires and undergoes no digestion. 
 Cane-sugar is inverted by the HCl of the gastric juice, and 
 also by the intestinal secretion, Levulose, a digestive pro- 
 duct of cane-sugar, and also found in fruits and honey, is 
 absorbable. The sugars may nearly all be absorbed as such, 
 and their digestive transformation increases their absorb- 
 ability and liability to ferment. 
 
 The sugars introduced with the food and formed by the 
 digestion of starch are absorbed by the radicals of the portal 
 vein, and undergo further changes fitting them for utilization. 
 If the analysis of the stools alone be taken in evidence, the 
 carbohydrates are almost completely digested and absorbed, 
 when properly prepared and not taken in excessive quantity. 
 But practically and clinically, both in health and in disease, a 
 Considerable quantity undergoes fermentation. The products 
 of fermentation may possess some nutritive value, and the slight 
 acidity of the intestinal contents produced by the fermentation 
 is a safeguard against albuminous decomposition. The gases 
 of fermentation interfere, when in excess, with the functions of 
 the bowel, and the organic acids may produce irritation and 
 inflammation. 
 
 The absorbed products of carbohydrate digestion are as- 
 similated, and are either stored as glycogen in the liver, mus- 
 cles, and white blood corpuscles, or are burned as grape-sugar 
 in the production of force and heat. There is also no doubt 
 that the organism can and does, in certain conditions, trans- 
 form the carbohydrate products into fat to be stored in the
 
 1 82 DISEASES OF THE STOMACH. 
 
 body. The carbohydrates diminish nitrogenous waste, and, 
 in very large quantities, reduce the daily nitrogenous loss 
 below that of tasting. Fat is also protected by the carbo- 
 hydrates, 240 gm. being isodynamic for this purpose with 
 100 gm. of fat taken as food. The amount of fat can be com- 
 pletely protected if with lOO gm. of albumin about 600 gm. 
 of carbohydrates are digested and utilized. If the quantity 
 of carbphydrates be increased, the body may become fatter 
 and some of the albumin ma}' be organized, but in order to 
 insure the latter the quantity of albumin should also be in- 
 creased. If fed exclusively on carbohydrates man would 
 starve, through the uncovered loss of albumin, unless carried 
 off earlier by the diarrhea and enteritis produced by excessive 
 fermentation. 
 
 Fats. — The digestion and absorption of fat begin in the in- 
 testines. In the stomach only small quantities of fatty acids 
 are normally found, and are either introduced as such or are 
 separated from the triglycerid molecule by bacteria — and 
 possibly by a special ferment. A special ferment of the pan- 
 creatic juice splits a part of the fat into fatty acids (93 per 
 cent.) and glycerin (7 per cent.), the fatty acids combining 
 with alkalies (of the bile, chiefly) to form soaps, and with 
 the aid of these products, and of the bile and the pancreatic 
 juice, the remaining fat is emulsified. Only about one-eighth 
 of the fat is decomposed, but the relative proportion of the 
 fatty acids and soaps increases as the lower end of the bowel 
 is approached. This is due partly to the action of the split- 
 ting bacteria, but chiefly to the rapid absorption of the emul- 
 sion of neutral fat by the epithelium covering the intestinal 
 follicles, and possibly by wandering leukocytes. The ab- 
 sorbed fat reappears in the lymph as neutral fat, and is util- 
 ized in the production of heat, of force, and of adipose tissue, 
 which latter constitutes from 5 to 25 per cent, of the weight 
 of the body. No other tissue is subject to such wide quanti- 
 tative variations. 
 
 Fat alone is unable to check the waste of nitrogenous 
 tissues, and only prolongs the period of starvation. A 
 fasting man wastes more than twice as much fat as albumin, 
 but protection against loss of fat can be given either by 
 albumin, by fat, or by carbohydrates ; both a loss of fat 
 can be prevented and a gain of fat insured most economically 
 by a judicious combination of the three alimentary prin- 
 ciples. As a protective against loss of fat, lOO gm. of fat are 
 equivalent to about 225 gm. of albumin. Large quantities of
 
 DIET. 183 
 
 fat can prevent loss of body fat, or even increase its quantity 
 in spite of simultaneous albuminous emaciation. 
 
 The more fat is given, other things being equal, the more 
 is found in the stools. But the total quantity of fat absorbed 
 increases until the quantity administered is about 300 gm. 
 This seems to be the limit of digestive power. 
 
 Gelatin. — Gelatin is a very valuable force- and heat-produc- 
 ing food. It is never organized into fat or iBesh, and in very 
 large quantity can not completely cover albuminous waste ; 
 but with gelatin the quantity of albumin needed can be reduced 
 to a minimum, even below the amount of albuminous waste 
 during fasting. As a protector of body albumin, 100 gm. of 
 gelatin is equivalent to about 35 gm. of food albumin, or 200 
 gm. of carbohydrates. On the other hand, gelatin does not 
 protect against loss of fat as well as do either fat or the carbo- 
 hydrates, 100 gm. being equivalent to about 25 gm. of the 
 dissimilated fat of the body. 
 
 Combinations of the Alimentary Principles. — When fats are 
 combined with albumins, a little less than half as much albu- 
 min is required to maintain nitrogenous equilibrium as in an 
 exclusively albuminous diet. If, after the combination is 
 found which in an individual case exactly maintains the 
 nutritive equilibrium, more albumin is given with a propor- 
 tionately large quantity of fat, both albumin and fat will be 
 organized and deposited. If carbohydrates be substituted 
 for the fats, increase of albumin causes a slight increase in 
 both the albumin and the fat of the body ; increase of both 
 results in bodily gain of flesh and fat. In protection against 
 albuminous waste the carbohydrates are more powerful than 
 the fats, but 100 gm. of fat are equal to 240 gm. of carbo- 
 hydrates in the protection against loss of fat. 
 
 The body can be most economically nourished by a judi- 
 cious combination of the three alimentary principles. The 
 proportion of the caloric value of the albuminous to the non- 
 albuminous foods, and of the fats to the carbohydrates, should 
 be I to 3 or 5. 
 
 The following average estimates of the quantities of the 
 combined alimentary principles required to maintain nutritive 
 equilibrium are taken from the works of Uffelmann, Voit, 
 Camerer, and others :
 
 1 84 
 
 DISEASES OF THE STOMACH. 
 
 Age. 
 
 I week, . 
 
 1 •' 
 
 2 weeks, . 
 3 
 
 4 " . 
 
 5 " 
 
 2 months, 
 
 3 
 4 
 
 6 " 
 
 1 year, 
 
 2 years, 
 3-6 
 7 
 7-15 
 
 9 
 
 10-15 
 
 Adult (man, repose), . . 
 
 << (( C( 
 
 " (man, light work), 
 
 " (woman, " " ), 
 
 " (man, hard work), 
 
 " (man, forced work), 
 
 Weight. 
 
 Per kilo. 
 
 Total 
 Per kilo. 
 
 Total 
 
 Per kilo. 
 
 Total 
 Per kilo. 
 
 Total 
 Per kilo. 
 
 Total 
 
 Per kilo. 
 
 Total 
 
 Per kilo. 
 Total 
 
 Albl'.min. 
 
 Fat. 
 
 Carbohy- 
 drates. 
 
 3-7 
 
 2-5 
 
 4-4 
 4-8 
 5.6 
 7-2 
 4-5 
 9.2 
 4-2 
 
 10.3 
 4- 
 4-1 
 3-6 
 
 55- 
 
 28. 
 
 60. 
 
 61. 
 
 75- 
 
 100. 
 
 no. 
 
 90. 
 
 no. 
 
 145- 
 
 43 
 10.2 
 
 7-4 
 
 5-6 
 22.4 
 28.5 
 
 5-2 
 36.6 
 
 4.6 
 40.7 
 
 4- 
 
 4- 
 
 3- 
 25- 
 
 2. 
 
 44- 
 47- 
 30. 
 0.8 
 56. 
 56. 
 40. 
 80. 
 100. 
 
 4-4 
 
 17-5 
 10. 
 
 5-7 
 3S.6 
 49.2 
 
 5-4 
 63.2 
 
 5- 
 
 70.3 
 
 8-5 
 
 S. 
 
 10. 
 
 180. 
 
 10. 
 
 150. 
 
 200. 
 
 250. 
 
 7-5 
 400. 
 500. 
 400. 
 500. 
 500. 
 
 Mother's 
 Milk. 
 
 250 gm. 
 
 550 gm. 
 700 gm. 
 
 900 gm. 
 
 1000 gm. 
 
 The following table gives the quantity of the alimentary 
 principles in the foods most frequently ordered in the treat- 
 ment of diseases of the stomach : 
 
 Food. Albumin. Fat. 
 
 Lean beef, 20.7 1.7 
 
 Beef-pulp free from fat, 20. 0.5 
 
 Medium beef, 21. 5.4 
 
 Fat beef, 16.7 29.3 
 
 Fat hind quarter, 20.8 23.3 
 
 Fat (steer) tenderloin, iS.S 16.7 
 
 Fat (heifer) tenderloin, 19.2 5.8 
 
 Boiled beef (medium),' 34.1 7.5 
 
 Roast beef (medium), 34.2 8.2 
 
 Fat veal, 18.9 7.4 
 
 Lean ve.ll, 19.9 0.8 
 
 Veal chop, . 20.2 6.4 
 
 Broiled veal chop, 29. 12. 
 
 Fat lamb (quarter), 9.7 35.8 
 
 Lean mutton (quarter), il.i 25.4 
 
 Mutton chop, 14.3 8.6 
 
 Breast of young chicken, 19.4 2.8 
 
 Lean chicken, 23.3 3. 1 
 
 Pheasant, 25.3 1.4 
 
 Pigeon 22.1 I. 
 
 Ham, 24.7 36.5 
 
 Scraped raw ham (lean), 23.5 1.5
 
 DIET. 
 
 185 
 
 Food. Albumin. Fat. Carbohydrates. 
 
 Bouillon, 0.4 0.6 
 
 Expressed beef juice, 7. 0.5 
 
 Veal extract (bottle), 2.8 ... 
 
 Beef " " 1.8 ... 
 
 Oysters, 10. 1.5 
 
 Barley meal, 12. 5 i. 
 
 Flour, 13.6 I. 
 
 Oatmeal, II.6 5. 
 
 Rice, 7.5 0.6 
 
 Bread, 6.8 1.5 
 
 Dry toast, 9.5 i. 
 
 Crackers, 7-5 5- 
 
 Potatoes, 1.5 2. 
 
 Mashed potatoes (milk), .... 3.1 0.9 
 
 Cauliflower, 2.5 0.4 
 
 Asparagus, 1.5 0-3 
 
 Ripe grapes, 0.6 ... 
 
 Prunes, 2.4 0.5 
 
 Sole, II. 9 0.3 
 
 Brook trout, 19.2 2.1 
 
 Carp, 21.9 I. 
 
 Mackerel, 19.4 8. 
 
 Pike, 18.4 0.5 
 
 Cod, 16.2 0.3 
 
 Spinach, 2.5 0.6 
 
 Apples, 0.4 0.8 
 
 Grapes, 0.6 0.8 
 
 Strawberries, I. 0.9 
 
 Honey, 1.2 ... 
 
 Cane-sugar, 0.3 ... 
 
 Beet-sugar, 2.3 . . . 
 
 Macaroni, . . 9. 0.3 
 
 Wheaten grits, 10. 4 0.4 
 
 Graham bread, 9. I. 
 
 Albumin. Carbohydrates. Alcohol. 
 
 Beer, 0.5 5.2 
 
 Bordeaux, 0.3 
 
 Rhine wine, 0.5 
 
 Tokay, 15-22 
 
 Champagne, 8.5-II-5 
 
 Cognac, ... 
 
 Brandy, ... 
 
 3-5 
 10-15 
 10-15 
 16-18 
 12. 
 60. 
 45- 
 
 A knowledge of the quantity of food required to meet the 
 demands of nutrition is of value in many respects. It is the 
 basis of a diet selected with a view to support, or to reduce, 
 or to increase the weight and strength. It reveals by com- 
 parison the cause of emaciation in many cases of disease of 
 the stomach — viz., an insufficient diet. It makes it possible 
 to avoid excessive eating and overtaxing the digestive organs, 
 and the oft-resulting myasthenia, stagnation, and fermenta- 
 tion.
 
 1 86 DISEASES OF THE STOMACH. 
 
 There is no doubt that a strong, well-nourished body pos- 
 sesses a greater resistance and healing power than one which 
 is weak and starving ; but in the treatment of the diseases of 
 the stomach an insufficient diet must often be prescribed. 
 Short abstinence and the consequent complete repose of the 
 stomach is an essential indication in the treatment of acute 
 gastritis. Ulcer may also compel the use of an insufficient 
 diet. Even the dynamic affections may render a more or 
 less complete temporary withholding of food imperative or 
 advisable. Myasthenia may demand a reduction in the quan- 
 tity of food below what is necessary to support ; for. as a 
 general rule, the larger the quantity the longer is the sojourn, 
 and it is always imperatively necessary, whenever possible, 
 that the stomach should completely empty itself between 
 meals. 
 
 The result of an insufficient diet is subnutrition, which 
 renders it necessary for the body to live in part on itself. 
 More than twice as much body albumin is dissimilated in 
 proportion to the body fat when the patient is lean (1:4) than 
 when the patient is fat (1:9). The total quantity of the 
 blood is decreased, and the serum becomes poorer in albumin. 
 The cells of the body do not lose their power of multi- 
 plying. This innate and vital function of the cells is only in 
 abeyance, and again becomes active in proportion to the in- 
 creased ingestion of food. This principle is well illustrated 
 by the renewal of the body during convalescence from severe 
 acute diseases. Subnutrition produces no injury if the latent 
 recuperative powers of the patient are not lessened, and the 
 diseased stomach may be favored without fear of permanent 
 injury by subnutrition provided digestion and assimilation 
 are so improved thereby as to render it easy to restore, at any 
 moment, the loss of weight and strength. 
 
 It is often difficult to make the choice between reducing 
 the body and injuring the stomach, for a blow aimed at one 
 may strike both. The difficulty may often be overcome by re- 
 ducing the nutritive demands to a minimum by absolute rest 
 in bed, and by supplementary rectal feeding. But stomach 
 rest usually means the selection and diminution of the quan- 
 tity of the food so as to support the body in repose and to 
 demand the least possible functional activity of the stomach. 
 In some cases, on account of pain, or loss of appetite, or 
 vomiting, it is difficult to obtain the ingestion or retention 
 of enough food to maintain nutrition. In others, moral 
 suasion and tonics will fail to secure the eating of enough 
 food, or of the right kind, to build up the weight and strength.
 
 DIET. 187 
 
 The only valuable resource then left is artificial and forced 
 feeding. 
 
 This is a very valuable method of alimentation in some of 
 the diseases of the stomach. In anorexia nervosa forced ali- 
 mentation may be employed with the prospect of obtaining 
 excellent results. Whenever, in organic disease, the patient 
 persistently eats too little food, the additional quantity should 
 be introduced through the tube, if there be no danger in its 
 employment and if there exist no reason why the additional 
 food can not be digested and absorbed, as would be the case 
 in myasthenic and in obstructive retention. Pain is another 
 cause of inanition in the diseases of the stomach, the patient by 
 gradual exclusion adopting a starvation diet. This is com- 
 monly the case in hypersthenic gastritis and the diseases 
 which it complicates. In neurasthenia gastrica the digestive 
 discomfort may produce a dread of food. Artificial feeding 
 will, under these circumstances.be found a valuable remedy. 
 The use of tube feeding may also be advisable in ulcer, where, 
 on account of pain, the fear of food is great, or where vomiting 
 becomes uncontrollable. If the stomach-tube be introduced 
 to the lower third of the esophagus, or even just through the 
 cardia, the food may be introduced through it without danger 
 in ulcer, and with a good prospect of its retention. 
 
 It is a curious fact that food introduced through the tube 
 is often retained when, if swallowed, it is invariably rejected 
 by the stomach. In nervous vomiting artificial feeding is a 
 valuable remedy, and may be the only means of obtaining 
 the digestion and absorption of enough food to maintain 
 nutrition. 
 
 Excellent preparations for the administration of food by 
 the tube are combinations of milk, expressed meat juice, 
 meat powder, raw eggs, sugar of milk, and bouillon. The 
 following combinations are often well borne : 
 
 Milk, 500. 
 
 Meat powder, 30. 
 
 Milk-sugar, T 20. 
 
 Or— 
 
 Bouillon, 300- 
 
 Meat juice, 50. 
 
 Or— 
 
 Meat powder, 30. 
 
 Two raw eggs. 
 
 2. Those foods should be selected zvJucJi can be best digested 
 and utilized and are least likely to ferment or decompose.
 
 1 88 DISEASES OF THE STOMACH. 
 
 Each individual lias his own opinion of the digestibility of 
 the various foods. Physicians themselves are as much at 
 variance about the matter as are the patients. Such a state is 
 regrettable. False impressions and narrow theories, as they 
 always do, have led either to bigotry or to agnosticism. The 
 one rejects all investigations as useless ; the other bends all 
 facts to one theory. Both methods are equally disastrous to 
 the patient. 
 
 The point of view has been wrong. The digestibility of 
 food must be defined and studied from the point of view, not 
 of hygiene or physiology, but of the physician. The value 
 of food as a remedy is dependent upon its physiological action 
 and upon the ease and certainty with which it undergoes trans- 
 formation and absorption. In order to use food rationally as 
 a remedy it must be known in a particular manner. 
 
 The duration of the sojourn of a food in the stomach is no 
 full measure of its digestibility. The investigations of Gorse, 
 Spallanzani, Beaumont, Richet, Busch, and Kiihne only show 
 the work of the stomach as a motor organ in certain patho- 
 logical conditions. Gorse and Spallanzani (1785) made their 
 observations on a ruminating patient. Merycism is a neuro- 
 muscular affection of the stomach, and the rapidity with which 
 a food is passed through the pylorus gives no indication of 
 the ease with which it undergoes digestion in health. 
 
 Beaumont (1838) made his observations on Alexis St. Mar- 
 tin, through a gastric fistula resulting from a gunshot wound. 
 Gastrostomy had been performed by Verneuil on Richet's 
 patient for a benign stricture of the esophagus. The adhe- 
 sions of the stomach always disorder its movements, and the 
 duration of the sojourn of a food in a pathological organ is 
 no index of the influence of a given food, even on the motor 
 function, in health. The investigations of Busch and Kiihne 
 were made through a duodenal fistula. In this case the 
 motor function of the adjacent stomach could not be uninflu- 
 enced. Likewise, the experiments upon gastrostomized dogs 
 show the action of food on the pathological stomach of a car- 
 nivorous animal, and are not applicable to the normal or the 
 diseased human stomach. All these investigations throw 
 some light on the action of certain articles of food on the 
 movements of the stomach in certain pathological condi- 
 tions. The tables of digestibility constructed out of such 
 data are almost valueless to the physician and give, except 
 when the guess is a happy one, altogether false results. The 
 end of alimentation in health or in disease can never be 
 attained so longf as the influence of a food on the movements
 
 DIET. 189 
 
 of an unhealthy stomach is taken as a full measure of digesti- 
 bility. 
 
 Still more valueless are the results obtained by artificial 
 dicfestion, which grive a false idea even of the resistance of 
 the food to digestive transformation. The stomach is not a 
 dry, motionless receptacle with impermeable walls. 
 
 The way to scientific results was opened by Leube. The 
 digestibility of food in disease of the stomach is displayed by 
 the manner in which the food is borne by the patient, by the 
 influence of the diet on the progress of the disease, and by 
 the complete evacuation of the food before the expiration 
 of seven hours. Leube, in the determination of the digesti- 
 bility of food in disease, began with patients who were able 
 to comfortably digest but little food within the period of seven 
 hours. Beginning with these few articles of most easily 
 digested food, a table of decreasing digestibility was made by 
 studying cases of disease of less and less severity. Conse- 
 quently, Leube includes in the conception of digestibility in 
 disease not only the duration of the sojourn of a food in the 
 stomach, but also the sensations which it excited and the in- 
 fluence which it exerted on the progress of the disease. The 
 stomach-tube was used to determine whether the stomach was 
 empty at the expiration of the arbitrary seven hours. The 
 following progressive diet of Leube is extensively prescribed, 
 and has proved very valuable : 
 
 I. Bouillon ; Leube-Rosenthal meat solution ; milk ; soft- 
 boiled or raw eggs ; dry toast or crackers ; water or natural 
 indifferent effervescent (CO2 ) water. 
 
 IL Boiled calf's brain ; boiled sweetbread (thymus of calf) ; 
 boiled young chicken ; boiled squab ; cereal soups ; tapioca 
 cooked in milk ; boiled calf's feet. 
 
 III. Sirloin pulp steak ; grilled sirloin steak ; scraped raw 
 ham ; mashed potatoes, baked, with a little milk and butter; 
 a little white bread ; try coffee or tea with milk. 
 
 IV. Roast beef; roast chicken, venison, partridge, and 
 veal; boiled lean fish; macaroni; bouillon or rice soup; 
 spinach ; a little wine. 
 
 V. Baked apple ; all common foods ; finally, salads, vege- 
 tables, and stewed fruits. 
 
 The method of Leube was improved and employed by 
 Penzoldt, but under better control and under precautions 
 against error. The results are comprehensive and valuable, but 
 were obtained by the study of digestion in health. The stom- 
 ach-tube was used to determine the progress of digestion and 
 the exact moment when the stomach is completely empty after
 
 190 
 
 DISEASES OF THE STOMACH. 
 
 the eatinf^ of a definite quantity of a particular food. The 
 table of Penzoldt, which in its chief articles is as follows, is a 
 table of digestibility in health. The time represents the 
 period within which the food leaves the stomach. The quan- 
 tity is given in grams: 
 
 One to Two Hoirs. 
 100-200 water. 
 200 tea \ 
 
 " coffee V plain. 
 
 " cocoa J 
 
 " beer. 
 
 " liyht wine. 
 100-200 sterilized milk. 
 200 meat tea (pure). 
 100 soft-boiled egg;. 
 
 Two TO Three Hours. 
 200 coffee with cream. 
 
 " cocoa with milk. 
 300-500 water. 
 
 " " beer. 
 
 " " boiled milk. 
 100 raw egg or omelet. 
 250 calfs brain, boiled. 
 
 " sweetbread, boiled. 
 
 70 raw oysters. 
 200 boiled carp. 
 
 " " pike. 
 
 Two TO Three Hours. 
 
 (Continued.) 
 150 cauliflower (boiled 
 
 or salad). 
 150 asparagus (boiled). 
 
 " potatoes (mashed). 
 
 " cherry compote. 
 
 " raw cherries. 
 
 20 white l)read. 
 
 •' zwieback. 
 
 50 Albert biscuits. 
 
 Three to Four Hours. 
 230 stewed young 
 
 chicken. 
 230 partridge, broiled. 
 240 stewed pigeon. 
 195 roast " 
 
 250 beef (raw or boiled). 
 
 " calf's foot, boiled. 
 160 ham boiled. 
 100 roast veal. 
 
 " beefsteak. 
 
 Three jo Four Hours. 
 
 (Cutiiinued.) 
 100 beefsteak pulp. 
 
 ''' roast beef. 
 200 Rhine salmon. 
 
 70 caviar. 
 150 black bread. 
 
 " white bread. 
 100 .\lbert biscuits. 
 150 boiled rice. 
 
 " " spinach. 
 
 Four to Five Hours. 
 210 roast pigeon. 
 250 " tillet. 
 
 " beefsteak, grilled. 
 
 " smoked tongue. 
 
 " hare. 
 240 roast partridge. 
 250 " goo.se. 
 2S0 " duck. 
 150 mashed lentils. 
 200 mashed garden peas. 
 150 snap beans. 
 
 Penzoldt has constructed a progressive diet which is based 
 on the digestibility of food by the normal stomach and which 
 agrees in its main features with that of Leube, which has 
 already been given. Each diet consists of a combination of 
 various foods and demands more and more work of the 
 stomach. 
 
 First Diet. — Cup of lean beef broth without salt; glass of 
 sterilized milk, pure or with one-third lime-water ; one or 
 two boiled eggs, or one or two raw eggs stirred in hot meat 
 broth; 30 to 40 gm. of Leube-Ro.senthal meat solution; 6 
 crackers (Albert) ; li of a glass of plain or charged table 
 water. 
 
 Second Diet. — One hundred gm. of boiled calf's brains; 
 100 gm. of boiled sweetbread (thymus gland of calf); I 
 boiled .squab ; i boiled chicken (partridge size) ; lOO gm. of raw 
 scraped or chopped beef with crackers ; 30 gm. of tapioca in 
 milk. The meats should be freed from fat and fibrous tissue, 
 and had better be stirred in meat broth before serving. 
 
 Third Diet. — One pigeon broiled with fresh butter ; one 
 broiled chicken ; 100 gm. of rare roast beef ; loogni. of scraped
 
 DIET. 191 
 
 raw ham ; 50 gm. of zwieback or French roll ; 50 gm. of 
 mashed or mealy potatoes ; 50 gm. of cauliflower (bloom) 
 cooked in salt water. 
 
 Fourth Diet — One hundred gm. of roast venison ; i roast 
 partridge ; lOO gm. of rare roast beef (hot or cold) ; lOO gm. of 
 roast veal cutlet ; lOO gm. of boiled lean, fresh fish ; 50 gm. of 
 Russian caviar; 50 gm. of thoroughly cooked rice gruel; 50 
 gm. of boiled asparagus (tips) ; 2 scrambled eggs with a little 
 fresh butter and salt or omelette souffle ; 50 gm. of sauce of 
 stewed fruit; lOO gm. of warm claret (Bordeaux). 
 
 A table of digestibility to be of clinical value must rest on 
 a broader basis. Not the influence of the food on the 
 motor function and on the other functions of the stomach 
 in health, but the ease and surety of the useful and un- 
 conscious transformation of food into assimilable nutriment 
 by the digestive tube is the clinical measure of digestibility. 
 This clinical conception includes the following four elements : 
 
 1. The food must be easily soluble in the digestive juices. 
 
 2. Its physiological action must be such as is most favor- 
 able to its digestion and absorption, and such as exerts a 
 remedial influence by favoring or exciting the diseased part. 
 
 3. It must not be liable to undergo fermentation or decom- 
 position before it reaches the point of digestion and absorp- 
 tion. 
 
 4. Its digestive products must be easily and quickly ab- 
 sorbed after their formation, or must resist superdigestion and 
 destruction by micro-organisms. 
 
 5. The digestion must be accomplished without pain or dis- 
 comfort. 
 
 From a clinical point of view, the digestibility of a food is 
 not absolute, but individual and variable. The food and its 
 palatable properties are the only fixed elements in the problem. 
 The stomach and the intestines are as variable in power as is 
 the general strength of men, and are as individual as the 
 human face. Often touched by hereditary taint, on both the 
 stomach and intestines are written the biography of their 
 possessor, the record of past diseases, and the salient points 
 in the mode of life. Both become adapted to their environ- 
 ment, which is composed, on the one hand, of the matter in 
 contact with the mucous membrane, and, on the other, of the 
 state and characteristics of the organism. The food and its 
 associations, the products of digestion, fermentation, and de- 
 composition, the flora of the stomach and intestines, are, for 
 no two persons, exactly the same. Secretion is variable, 
 movement is variable, and all of these are individual. Con-
 
 192 DISEASES OF THE STOMACH. 
 
 sequently, individualization is a commanding principle of 
 dietetics and a modifying factor of digestibility. A knowl- 
 edge of food, of its general digestibility, of the state and 
 needs of the organism and of its parts, can serve only as 
 guiding threads. The course is zigzag, but the variations in 
 health are limited, and the variations in disease are quite 
 constant. An average or sweeping curve, however, can 
 be marked out as a clinical guide. 
 
 From this point of view the chief foods of interest to the 
 physician in the treatment of the diseases of the stomach 
 will be studied in their physiological action, the degree of 
 resistance which they offer to digestive transformation, and 
 their liability to undergo destructive or injurious changes; 
 and in this study must be included the action on the stomach, 
 both in health and in disease. 
 
 Meats. — The physiological action of the meats is dependent 
 on their mechanical and chemical influences, and on the asso- 
 ciations of the albumin with the other alimentary principles 
 and with the products which appeal to the palate. Conse- 
 quently, their physiological action is determined by the fol- 
 lowing factors: 
 
 1. Physical state. 
 
 2. The preparation for the market. 
 
 3. The preparation for the table. 
 
 4. The associated products, of which the chief one is fat. 
 
 5. The quantity eaten. 
 
 Meat is the natural stimulant of gastric secretion, an adap- 
 tation, through use, of the activity of a part to the special 
 work which it is intended to perform. The means and the 
 end are fitted to each other, and special opportunity excites 
 purposive activity. The chemical work of the gastric secre- 
 tion is expended on the albumins, and in the ordinary diet 
 these consist chiefly and most universally of the meats. Meat 
 is thus the chief natural excitant of gastric secretion, and as 
 secretion is so greatly influenced by the movements of the 
 stomach, in the course of nature normal and suitable muscu- 
 lar action has become associated with the natural secretion. 
 So, likewise, with the other functions of the organ. The 
 meats, then, excite the stomach to the fullest normal activity. 
 The process and evolution of the digestion of meat represent 
 fully and truthfully the functional work of the stomach, pro- 
 vided the meat is palatable to the individual and does not 
 break too rudely his diet habits. Here, again, the personal 
 element enters and destroys exactness in the detailed ordering 
 of a diet. The physician is the judge, and it is his duty to
 
 DIET. 193 
 
 apply the general laws and precedent to the individual case, 
 under the guidance of experience. 
 
 To represent the comparative evolution of the digestion 
 of meat and of bread and milk, a piece of the round of a 
 properly-fattened two-year-old steer, after hanging, may be 
 selected, the fat and fibrous tissue cut away, and the pulp, 
 separated by a non-cutting chopper, made into masses about 
 an inch thick and two inches in diameter and quickly cooked 
 on a hot griddle so as to leave the center rose-red. Two of 
 these may be taken with a cup of weak tea. 
 
 Comparatively, the gastric secretion is more intense and the 
 evolution of digestion is longer than with either milk or the 
 ordinary roll test-breakfast. The digestion of a glass of milk 
 is near its end at one and a half hours, that of bread at two 
 hours, but that of the beef pulp at three and one-half hours. 
 
 The total hydrochloric secretion is greater with the meat, 
 but it is sufficient and not excessive. At the height of diges- 
 tion there is always a trace of free HCI, but only a trace. 
 The HCI is utilized, but there is no excessive secretion, as 
 with the digestion of bread, and the trace of free HCI con- 
 tinues to the end. 
 
 The evolution of the digestion of a beefsteak or roast 
 beef is not the same as that of the beef pulp. The excitation 
 is more intense; less hydrochloric acid is combined, even if 
 the analysis be made on the unfiltered contents ; more hydro- 
 chloric acid remains free ; the duration of digestion is pro- 
 longed ; and between the third and fourth hours the quantity 
 of digestive products is greater. The difference is due to the 
 presence of fat and of fibrous tissue, to the larger particles, 
 entailing more intense excitation, to diminished utilization of 
 the secreted HCI, to accumulation of stimulating digestive 
 products, and to delayed evacuation. 
 
 The action of the meats on secretion is dependent also on 
 the quantity which is eaten, for the greater the quantity the 
 longer the sojourn in the stomach. In this respect the table 
 of Penzoldt gives very exact and valuable information. Some 
 of the meats are digested much more slowly and others more 
 rapidly than the beef pulp. The greater the quantity of fat 
 and the less minutely divided the meat, the longer is its so- 
 journ, the slower its digestion, and the more out of propor- 
 tion is the quantity of secretion to that which is required for 
 its transformation. Young chicken, veal, calf's brain, squab, 
 and sweetbread are more digestible when boiled, while the 
 older and red meats are better borne when grilled or roasted. 
 The meats are among the best utilized foods. In health, only
 
 194 DISEASES OF THE STOMACH. 
 
 from three to five per cent, of the total quantity of albumin 
 ingested is unabsorbed ; little is destroyed in the digestive 
 tube and little is eliminated in the feces. But this is true 
 only while the functions of the intestines and pancreas remain 
 normal. To e.xcite these functions physiologically and to 
 maintain the balance of nutrition, other kinds of food should 
 be combined with the meats. The action on intestinal peris- 
 talsis is altogether insufficient, but the decomposition products 
 may produce irritation and putrefaction rf favored by the ad- 
 ministration of meats exclusively and in larger quantity than 
 in the normal diet. 
 
 Meat furnishes one of the best means of supplying the 
 nitrogenous needs of the organism, but should not be selected 
 when the object is to give the stomach physiological rest. 
 Its gastric digestion is an example of energetic purposive 
 work without waste. In all diseases of the stomach accom- 
 panied by a diminution of the hydrochloric acid secreted, 
 the quantity of meats in the diet should be reduced to a 
 minimum. The white meats are preferable when it is desired 
 to favor the stomach, because they contain less extractive 
 matter, less hemoglobin and iron, and, when of the proper 
 kind, also less fat. The red meats are to be preferred when- 
 ever intestinal putrefaction exists and whenever it is desired 
 to stimulate the stomach gently and to exercise it. 
 
 Where there is excessive hydrochloric secretion the meats 
 should be given in increased quantity, in order to combine 
 the acid and to secure for the organism the advantages of the 
 digestive and secretory disorder. Here it seems to make 
 little difference chemically whether the best of the white or 
 the red meats be given, so long as both are very finely divided. 
 
 In the dynamic affections of the stomach which are not 
 accompanied by a disorder of secretion, the meats, if properly 
 selected, are usually borne. Some cases of morbid sensibility 
 of the stomach form an exception to the rule. The meats, 
 like all other foods which act energetically on the stomach, 
 should not be prescribed in the anemias associated with 
 vascular disturbances. Their digestion is then often accom- 
 panied by a very rapid pulse, and sometimes excites a bruit de 
 galop, or reduplication of the second sound of the heart, or 
 cardiovascular dyspnea. Here a milk diet, if there be no 
 contraindication, combined with rest in bed, is most suitable. 
 
 Gastric putrefaction is very rare, except it occur as an acci- 
 dent ; but intestinal putrefaction is quite frequent, and it may 
 be necessary temporarily to withhold all meats in order to 
 control this condition. Gastric fermentation is common
 
 DIET. 195 
 
 enough, and is often accompanied by intestinal fermentation. 
 An exclusive but temporary meat diet (with, when possible, 
 a little dry toast and lemon-juice) is then by far the best 
 treatment. Some little temporary injury to nutrition may be 
 done thereby, and the emaciation should not be allowed to go 
 too. far; but cases of this kind are noi rare where no other 
 diet has any permanent or curative effect. Carcinoma is a 
 formal contraindication to an exclusive meat diet. When 
 using meats in the dietetic treatment of diseases of the 
 stomach, lean meat should be selected and the fat should 
 be carefully removed. The fat alters the digestibility and the 
 physiological action of the muscle pulp, prolonging digestion 
 and increasing excitation. 
 
 The most digestible meats are beef, mutton, fowl, some kinds 
 of game (grouse, pheasant, quail, venison), calf's sweetbread, 
 and calf's brain. Goose and duck are too fat, and stay in the 
 stomach about five hours. Pork should never be permitted, 
 but lean boiled ham is often well borne. Roast and broiled 
 chicken and squab are digested in about three and one-half 
 hours. The young meats, and brain, and sweetbread, should 
 not be roasted or grilled. Raw meat is no more easily 
 digested than when it is cooked and finely divided. 
 
 The commercial preparations of meat are very numerous, 
 and their extensive manufacture is sufficient evidence of their 
 great consumption. Convenience and concentration are their 
 chief advantages. Some of them, when fresh, are valuable 
 ■both as food and as remedies. The use of most of them in 
 the treatment of the diseases of the stomach can be easily 
 dispensed with if a good cook is at command, and some of 
 them are veritable irritants and purgatives. 
 
 The commercial albuminous preparations which contain 
 large percentages of mineral and extractive matter excite 
 gastric secretion and irritate the mucous membrane of the 
 alimentary tract. Their transformed albumins easily putrefy 
 in the bowels, and are no better utilized than the albumins 
 of the ordinary foods when in solution or in a state of fine 
 division. They possess no greater nutritive value than is 
 represented by the caloric value of the alimentary principles 
 which they contain, and they can be administered only in very 
 small quantity without disordering digestion. The following 
 table shows the nutritive value of some of the prepared foods 
 in comparison with that of expressed beef juice, meat powder, 
 eggs, milk, and beef:
 
 196 
 
 DISEASES OF THE STOMACH. 
 
 Soluble 
 Albumin. 
 
 Extractive Mineral 
 Matter. Matter. 
 
 Caloric 
 Value. 
 
 Valentine's meat juice, .... 6.7 
 
 Liebig's meal extract, .... 20.5 
 
 Johnston's beef extract, ... 36.7 
 
 Somatose, 80. 
 
 Nutrose, 90. 
 
 Eucasin, 85. 
 
 Expressed beef juice 3. 
 
 Meat powder, 69.5 
 
 Egg (white) 
 
 One egg, 
 
 Milk, 
 
 Beefsteak, 
 
 * 22 
 
 8 
 
 .18 
 
 
 8 
 
 
 
 
 
 ; 
 
 
 
 
 
 ^ 
 
 
 J 
 
 
 11.4 
 
 27. 
 
 23- 
 
 84- 
 
 9- 
 
 150. 
 
 6.7 
 
 320. 
 
 0. 
 
 369- 
 
 0. 
 
 348. 
 
 i.S 
 
 12. 
 
 13- 
 
 285. 
 
 
 53- 
 
 
 70. 
 
 Somatose, nutrose, and eucasin are excellent preparations, 
 but not more than 50 gm. of either can be administered dur- 
 ing the twenty-four hours without disordering digestion. 
 Consequently, little more than one-half of the nitrogenous 
 needs of the body can be supplied by these foods, and they 
 furnish only about one-fifteenth of the quantity of nutriment 
 which is required daiU'. 
 
 Bouillon, meat broths, meat teas, expressed meat juice, 
 meat powder, etc., have their special uses and action on the 
 stomach. The indications for them in the particular diseases 
 will be given in Sections IV and V. 
 
 Fish. — On account of the high percentage of fat, few fish 
 can be employed in the treatment of the diseases of the 
 stomach ; but when these few can be obtained fresh, a very 
 delicate, digestible, and valuable albuminous food is at our 
 command. The lean, fine-meated, perfectly fresh and boiled 
 or baked fish are the only varieties permissible. Among 
 these the following may be named: sole, weakfish, bass, 
 trout, Ger.man carp, chicken halibut, flounder, sheepshead, 
 pike, the lean parts of bluefish and of shad. 
 
 The action of lean fish on the stomach is much less ener- 
 getic than that of meat. Secretion is not so active, and when 
 fish is eaten alone is hardly suflficient for its digestion. In this 
 respect it more closely resembles the white than the red 
 meats. Digestive transformation is quite rapid, and the 
 stomach is empty in about two hours after a breakfast of a 
 small piece of sole, a little lemon-juice, and a cup of tea. 
 
 The albumin of the lean fish is well utilized, only about two 
 per cent, being lost. About ten per cent, of the fat, how- 
 ever, is recovered in the stools. 
 
 Fish of the kind recommended may be prescribed to give
 
 DIET. 197 
 
 a little variety to the diet, and in larger quantity where meats, 
 on account of their comparatively high price, can not be 
 secured. It is a food which is useful in favoring the stomach, 
 but it can not be employed as a physiological remedy where 
 it is desirable to stimulate secretion. 
 
 Milk. — Milk is one of the most widely used and important 
 foods. The only complete and natural food in infancy, in 
 later life milk and its products are also largely consumed. 
 
 Konig gives as a daily average consumption for each indi- 
 vidual, ^ of a liter of milk, ten gm. of butter, and ten gm. of 
 cheese, statistics based on the consumption in large cities. 
 In small towns and in the country the consumption is notably 
 greater, and may be attributed to its cheapness, nutritive 
 value, palatableness, and easy digestibility in health. Its 
 fluid form and its eliminating properties have won for it a 
 very general use in therapeutics. 
 
 From a clinical point of view, this complete fluid food is 
 not without its imperfections. The subjective symptoms fol- 
 lowing its use may to some persons be so disagreeable and 
 peculiar as to reveal a so-called idiosyncrasy, and may be so 
 pronounced as to preclude its use. It also forms a good 
 culture fluid for many germs, under whose influence it rapidly 
 undergoes destructive changes. 
 
 The figures of Freudenreich demonstrate the high value of 
 milk as a culture soil, and the influence of the temperature on 
 germ growth. On arrival in the laboratory, one c.c. con- 
 tained 9300 germs : 
 
 At 15° C. At 25° C. At 35° C. 
 
 Three hours later, .... 10,000 18,000 39,000 
 
 Six hours later, ..... 25,000 172,000 12,000,000 
 
 Twenty-four hours later, .57,000,000 577,000,000 50,000,000 
 
 The nutritive value is not only markedly diminished by 
 these germs, but the products of germ activity are injurious 
 and modify its physiological action. The most common 
 fermentation products are lactic and butyric acids, and tyro- 
 toxicon is formed by its putrefaction. The germs of fermen- 
 tation and putrefaction may be introduced into the body with 
 it, or may be found awaiting its arrival in the stomach or 
 intestines. The first imperfection may be partly remedied by 
 sterilization when fresh, and this procedure is always advisable 
 in order to avoid the introduction of pathogenic bacteria. 
 Sterilization may be done in the ordinary way with an appa- 
 ratus like that of Soxhelet. But a better plan is pasteuriza- 
 tion. The milk is kept at a temperature of 70° C. for five
 
 198 DISEASES OF THE STOMAC/f. 
 
 minutes, then rapidly cooled by placing it in the ice-box. It 
 is then kept lukewarm for about two hours, and a^ain heated 
 to 70° C. The disadvantages of a high temperature are thus 
 avoided, and the resistant spores are germinated and killed, 
 whereas by the ordinary method the spores are usually not 
 killed. The milk should be sterilized or pasteurized immedi- 
 ately after the milking, while it is perfectly sweet; or in hot 
 weather it should be kept cold until the procedure can be 
 employed. 
 
 For the adult, another disadvantage is its small nutritive 
 value in comparison with its total mass. To suppU' the num- 
 ber of heat units represented by the biological coefficient for 
 the adult of average weight, about four liters are required 
 daily. In any other condition than rest the balance of nutri- 
 tion can not be maintained at the normal level on an absolute 
 milk diet, and its exclusive use by the adult constitutes a 
 starvation-cure. 
 
 The average composition of milk is : 
 
 Cashin and 
 Albumin. Fat. Milk-sugar. 
 
 Durham and Ayrshire, 3.4 3.5 5.5 
 
 Jersey, 3.3 4.2 5.7 
 
 Guernsey 4.0 5.1 4.4 
 
 Mixed, 3.5 3.7 4.9 
 
 Four liters, 1400 148.0 196.0 
 
 Repose ration, . . . loo.o 50.0 400.0 (carbo- 
 hydrates) 
 
 Tiiree liters, .... 105.0 lll.o I47-0 
 
 Theoretically, four liters daily should maintain the nutri- 
 tion of the adult; but a large proportion of the milk-sugar 
 may be lost in disease, and about five per cent, of the fat and 
 ten per cent, of the casein are unabsorbed. The milk is 
 markedly diuretic, and increases, when given alone, the urea 
 elimination about one-third (Chibret). An exclusive milk 
 diet, except when the patient is kept warm in bed, produces a 
 marked loss of strength, though the body may lose little 
 weight. 
 
 As an ideal food, its combination of the alimentary princi- 
 ples is defective. The carbohydrates are deficient and the fat 
 is excessive; and until it be proven that the form of albumin 
 is of no consequence, its almost exclusive casein may be 
 considered a defect. 
 
 Yet another imperfection is in its digestion and utilization. 
 Contrary to the general belief, a large percentage of its ali- 
 mentary principles, when given as an exclusive diet, reappear 
 in the stools or are lost bv fermentation.
 
 DIET. 199 
 
 The following table of average percentages shows this loss 
 and its increase with the quantity daily administered : 
 
 Casein. Butter. 
 
 Two liters, . . 5 per cent, in stools. 3 per cent, in stools. 
 
 Three liters, . 8 " '• " " 5 " " " " 
 
 Four liters, . . 12 " " " " 6 " " " " 
 
 The percentage of loss in disease may be greater, and the 
 milk-sugar (none of which is found in the stools) may serve 
 entirely as food for bacteria. The caloric value of the casein 
 and the butter which are utilized in three liters is 1450 Cal. 
 
 One feature in its digestion is clinically of very great im- 
 portance — the products formed by its coagulation by organic 
 and mineral acids, and by the labferment, differ materially in 
 their digestibility and in their physical and chemical proper- 
 ties. The acids form a clot which is the same as clabber. 
 The casein is split by the labferment into two products, one 
 of which is casein- albumin and is held in solution by the 
 phosphate of lime, and the other is precipitated in combina- 
 tion with calcium as a base, and is digested in the intestines. 
 It is practically important that the curdling be produced by 
 the labferment and not by an acid, as is often the case when 
 the stomach is diseased. 
 
 The physiological action of milk on the healthy stomach is 
 very slight. With a glass of milk the height of secretion 
 occurs in about forty minutes, and at the expiration of one 
 and one-half hours the stomach is empty. During its diges- 
 tion there is no free hydrochloric acid, or the merest trace of 
 it. The HCl in organic combination reaches its height sooner 
 than with the test-breakfast, and the acidity due to it is com- 
 monly a fraction greater. As compared with the digestion 
 of the test-breakfast the digestion of milk is more rapid and 
 the acid is more rapidly and completely utilized. If a large 
 quantity of milk be taken the total acidity increases, and 
 there is often an appreciable quantity of lactic acid, because 
 the sojourn in the stomach has been longer. 
 
 1. Gastric excitation is less than with bread. 
 
 2. The hydrochloric acid is completely and rapidly com- 
 bined. 
 
 3. In small quantity it is evacuated in a short time ; and 
 there is no sign of irritation left, such as a tendency of secre- 
 tion to continue. 
 
 4. In large quantity the secretion of hydrochloric acid is 
 insufficient, lactic acid is formed and inhibits the rapid evacu- 
 ation of the chyme. If a notable quantity of lactic acid be
 
 200 DISEASES OF THE STOMACH. 
 
 present, the stomach often " splashes " about two hours after 
 the beginning of digestion. 
 
 The ph\'siological action of milk on the diseased stomach 
 is variable. In excessive secretion with the motor function in- 
 tact it acts as a sedative, relieving irritation ; but in diminished 
 secretion and in motor insufficiency, whatever be the state of 
 secretion, it undergoes imperfect digestion and ferments, pro- 
 ducing sometimes but)'ric and sometimes lactic acid. Butyric 
 acid formation is frequent when the hydrochloric acid is se- 
 creted in excess. These acids produce great irritation and 
 delay the evacuation of the contents of the stomach. 
 
 When milk is perfectly digested it exerts little action on 
 the intestines; the utilization is almost complete ; there is no 
 excessive flatulency, the urotoxic coefficient is markedly 
 diminished, and there is less than the normal quantity of 
 indican found in the urine after the healthy digestion of a 
 mixed meal. The lower half of the bowels is given almost 
 complete rest. The action on the motor function is insuffi- 
 cient, and constipation is a very troublesome result. 
 
 But the intestinal digestion of milk is not always so perfect. 
 The lactose may ferment ; the lactic acid formed is irritating 
 and constipating, or the butyric acid is even more irritat- 
 ing and is likely to produce catarrh with sometimes diarrhea 
 and an intense headache. The bowel may be distended 
 with gas, which is chiefly hydrogen. Even when the milk 
 undergoes these changes and produces these results, the 
 uroto.xic coefficient remains constantly low. If fermenta- 
 tion becomes active with an exclusive milk diet, inanition is 
 rapid. The water, the lactose, and some of the germ products 
 are actively diuretic, and the urea eliminated is increased. 
 The loss of nutritive equilibrium produces increasing loss of 
 strength. 
 
 A very serious objection to the employment of an exclusive 
 milk diet is the almost constant activity of the stomach as a 
 consequence of its frequent administration. An exclusive 
 milk diet, when digested, demands no very great work of the 
 stomach at one time, but it gives the organ no rest. 
 
 The indications and contraindications to the use of a milk 
 diet may now be formulated. The diet is indicated, not 
 when it is possible, but when it is better than any other. 
 
 The milk diet is valuable in the treatment of ulcer of 
 the stomach. Indeed, when in ulcer the motor function is 
 normal and milk does not produce intestinal indigestion, 
 an exclusive milk diet is the sovereign remedy, combining 
 the excessive hydrochloric acid secreted and making little
 
 DIE T. 20 1 
 
 demand on the functions of the stomach. But it does not 
 give the stomach functional rest, and if there be gastric stag- 
 nation or intestinal fermentation or morbid sensibility of the 
 duodenum, it will have to be discarded in favor of another 
 diet. 
 
 Milk is also the best food in the irritative stage of acute 
 gastritis, provided it is borne well by the intestines. But it 
 rarely agrees in acute gastritis when the contents are neutral 
 or very slightly acid or when there is fermentation. 
 
 A milk diet acts most happily in adenohypersthenia gas- 
 trica associated with intestinal putrefaction and an excessive 
 quantity of indican in the urine. In this special condition a 
 milk diet is remarkable in its effects, soothing the irritability 
 of the gastric glands, arresting intestinal putrefaction, reduc- 
 ing the congested liver, and relieving the auto-intoxication by 
 free diuresis. 
 
 A milk diet is contraindicated in all the diseases of the 
 stomach expressed functionally by a notable diminution in 
 the quantity of hydrochloric acid secreted. Consequently, 
 in all cases of chronic asthenic gastritis, and in many cases of 
 acute gastritis, milk should be prohibited. It is the worst 
 possible food in carcinoma with retention. Milk should be 
 prohibited in all the diseases of the stomach accompanied by 
 retention. In some forms of stagnation it maybe proper and 
 valuable if it agrees well with the intestines. The morbid 
 glandular irritability which often accompanies myasthenic 
 stagnation may be relieved by a milk diet. If the myasthenic 
 stagnation be relative, the stomach is often strong enough to 
 evacuate a glass of milk within the normal period, but be- 
 comes insufficient when a larger meal is given. Milk may be 
 made the basis of the liquid diet appropriate in obstructive 
 stagnation. A milk diet is often curative in prolonged diges- 
 tion due to excessive secretion, but in all forms of motor 
 insufficiency milk must be forbidden whenever it undergoes 
 or produces fermentation. 
 
 But even when suited to the stomach, a milk diet may be 
 contraindicated by its action on the intestines and on nutrition. 
 When the bowel is sensitive in its upper third, or is myas- 
 thenic, or is the theater of active fermentation, a milk diet 
 should not be prescribed. Harm may also be done by pre- 
 scribing a milk diet when the patient is already weak and 
 emaciated as a result of disease of the digestive tube. 
 
 There is no diet that requires more careful watching and 
 selection than one of milk. Its indiscriminate and routine 
 employment in the diseases of the stomach gives, in the suit-
 
 202 DISEASES OF THE STOMACH. 
 
 able cases, most excellent results, but in the remaining cases 
 either does no good or produces serious injury. 
 
 Preparations of Milk. — Kcfyr (so-called koumiss of com- 
 merce). — Tiie most valuable preparation of milk in the treat- 
 ment of diseases of the stomach is kefyr, which is the product 
 of special fermentation of cow's milk. It is a household 
 drink in the Russian Caucasus, and is claimed to be a gift 
 from Mohammed to the people. 
 
 The kefyr ferment in the dry state preserves its activity 
 unimpaired for one or two years, and is sold by the Russian 
 pharmacists, often adulterated, at a high price in the form of 
 yellowish-white, dry, brittle granules. Kefyr contains essen- 
 tially two germs, one of which, the dispora caucasica of 
 Kern, converts milk-sugar into lactic acid and partly into 
 an isomeric form which is easily transformed by the other 
 yeast-plant (saccharomyces cerevisiae) into alcohol and car- 
 bonic acid. Other ferments and bacilli have nothing to do 
 with the formation of the characteristic product, but often 
 have to be picked out from the kefyr ferment or killed by a 
 weak solution of salicylic acid. The writers who have studied 
 the process advise a thorough cleansing of the ferment, after 
 each use, by stirring in a one per cent, solution of soda for a 
 few hours, picking out the slimy grains, and leaving the fer- 
 ment for twenty-four hours in a i : 5000 solution of salicylic 
 acid m water. The preparation of kefyr, as described by 
 Biel. consists of two distinct parts — the preparation of the fer- 
 ment and the transformation of the milk. 
 
 The dry ferment is soaked for about half an hour in water 
 at 30° to 35° C.,and the water is then poured off and replaced 
 by fresh water at 20° C, in which the yeast is left for twenty- 
 four hours. The white ferment is next washed on a sieve 
 with warm water, and then added to a liter of sweet sterilized 
 milk, in which it is left and occasionally shaken for twenty- 
 four hours, when the cleansing is repeated and new sterilized 
 milk again used as the culture fluid. After ten or twelve days 
 of this treatment the yeast rises to the surface of the milk on 
 account of the fermentation excited, the cheesy odor is no 
 longer present, and the milk shows a slight coagulum at the 
 end of twenty- four hours. The yeast is now ready for use in 
 the preparation of the kefyr. 
 
 A glassful of the prepared yeast is added to a glass vessel 
 containing a quart of fresh sterilized and cool milk, corked 
 with clean cotton, and set aside in a light, airy room at a tem- 
 perature of about 20° C. 
 
 After about twenty-four hours, during which the vessel,
 
 ■DIET. 203 
 
 without uncovering, has been frequently shaken, the milk 
 becomes creamy and has a sharp and sweet taste. The prep- 
 aration is now strained and bottled. A champagne bottle is 
 filled about one-third full with the prepared milk, and enough 
 sweet sterilized milk (preferably skimmed milk, as the fat is 
 liable to be decomposed) is added to almost fill the bottle, 
 which is then corked, fastened, and stationed, top down, in 
 a room at 15° C. The bottles should be shaken every two 
 or three hours, but never uncorked. The alcoholic fermenta- 
 tion should continue three or four days, and when it stops 
 the bottles should be kept on ice. For medicinal purposes 
 it is not advisable to use the kefyr until the fermentation has 
 spontaneously stopped and a lasting foam forms on shaking. 
 It is more palatable than koumiss or matzoon, should be 
 more generally used than it now is in the United States, and 
 when well prepared has the following average composition : 
 
 Kefvr. Casein. Svntonin and Butter. Milk-sugar. Lactic Acid. Alcohol. 
 Albumoses. 
 
 100 2.5 I 2-3.5 2 I I-I.5 
 
 Physiological Action. — The physiological action of kefyr is 
 very different from that of milk, and this difference is due to 
 the fact that it contains, in addition to the usual ingredients 
 of milk, a notable quantity of alcohol, lactic acid, and the. 
 kefyr bacillus and yeast. In virtue of these ingredients the 
 excitation is more pronounced than that of milk, the gentle 
 action of which both on the secretory and motor functions of 
 the stomach is so well known. As compared with milk, the 
 evolution of secretion is more rapid but more prolonged, and 
 the curve of acidity rises higher. The total quantity of HCl 
 secreted is greater, and a moderate quantity of free HCl is 
 present during the second hour. The stomach seems to 
 empty itself more slowly. At the end of two hours ordi- 
 narily a small quantity of contents can be withdrawn, the 
 hydrochloric acidity of which is still high. In a word, the 
 secretory excitation is more intense and more persistent than 
 with sterilized milk, and its digestive transformation is much 
 more rapid and complete. 
 
 The physiological action on the intestines is not marked in 
 health. Kefyr is better utilized than milk, and only a very 
 small percentage is found in the stools. The small percentage 
 of alcohol promotes both gastric and intestinal absorption. 
 
 The very small and infrequent stools reveal its inactivity 
 on intestinal secretion and movements. It constipates, but 
 rests the lower part of the intestines.
 
 204 DISEASES OF THE STOMACH. 
 
 Clinically, the contraindications to the use of kefyr are 
 formal. In all forms of irritative gastric trouble it should not 
 be prescribed. It gives temporary relief in adenohypersthenia 
 gastrica. as all albuminoid foods do ; but the excessive secre- 
 tion of hydrochloric acid is either increased or not controlled 
 after long use. Alone, it is capable of producing a catarrh 
 in this disease, when both the total acidity and that due to 
 free HCl may disappear, or the partial neutralization b\' the 
 inflammatory exudate may lead to an erroneous and too 
 favorable opinion. In stagnation with fermentation it is injuri- 
 ous. In hyperesthesia of the gastric mucous membrane the 
 sensations of the patient will soon call the attention of the 
 physician to the increased discomfort. It is a valuable 
 remedy in all intestinal diseases except myasthenia. 
 
 In acute or subacute alcoholic gastritis, kefyr is most 
 valuable. It is especially useful after a debauch. In case 
 there exist no forced contraindication to its use, on account 
 of an associated condition, its employment in acute alcoholic 
 gastritis during one to three days gives very remarkable re- 
 sults and is much better in this disease than ordinary milk. 
 
 Another condition in which it may be used with benefit is 
 in subacidity, whether associated or not with a lesion of the 
 mucous membrane. It often acts very happily in these cases, 
 provided there is neither myasthenia nor morbid sensibility 
 of the mucous membrane. The treatment may be begun 
 and continued for three or four days with kefyr alone. 
 
 Again, in diarrhea, accompanied by' fermentation and irri- 
 tation, associated with organic or functional gastric subacidity, 
 kefyr may at times be used with advantage. The results are 
 more satisfactory when the diarrhea is due to putrefaction. 
 As a food, it is easily digested and rapidly absorbed in the 
 stomach and upper part of the small intestine. As a remedy, 
 it acts chiefly by suddenly changing the culture soil of the 
 germs to the action of which the persistence of the diarrhea is 
 due. To change the flora of the intestines it should be used 
 as an exclusive diet for a few days. 
 
 Kefyr was introduced as a means of inducing superalimen- 
 tation in the treatment of tuberculosis. In the Russian es- 
 tablishments it is given as a supplement of a richer diet in a 
 quantity varying from one to six liters a day, as tolerance be- 
 comes established. The quantity for the day is divided into 
 three parts : One portion is taken before the meat-breakfast. 
 The second portion is begun half an hour after breakfast and 
 finished an hour before dinner. The third portion is begun 
 two hours after dinner and finished an hour before supper.
 
 DIET. 205 
 
 It is to be taken slowly in sips, a short promenade preceding 
 each glass. Given according to this method, it may be used 
 with advantage as a supplementary food in affections of 
 the stomach when there is no atony of the muscular layer. 
 During the cure no other fluid should be permitted. The 
 results of its use as a surplus food in the gastric troubles of 
 phthisis are most excellent. 
 
 Koumiss. — Koumiss is a preparation of milk similar to kefyr, 
 but, properly speaking, is made out of mare's milk. It is 
 a drink of the ancient Scythians, and is very popular in 
 southern Russia, whence its use as a remedy and a food 
 has spread over the civilized world. It is valuable on account 
 of its easy digestibility. Koumiss, outside of Russia and 
 Siberia, is made of cow's milk through a double lactic acid 
 and alcoholic fermentation. There may be little difference 
 between koumiss and kefyr, but koumiss is properly made from 
 a combination of ferments, and not from a pure culture, as is 
 kefyr. An additional quantity of milk-sugar is often used — 
 or cane-sugar with maltose may be used in its preparation by 
 the yeast of beer — and it is ripened at a lower temperature. 
 Consequently, the preparation is less constant, often too acid 
 or incompletely fermented, and the associated germs are very 
 variable and not unimportant in the possible modifications 
 of its physiological action. Kefyr is preferable unless the 
 koumiss be prepared in a like manner and given the wrong 
 name in commerce. 
 
 The third-day koumiss, made of cow's milk with added 
 sugar, which is the form used in diseases of the stomach, has 
 the following average composition : 
 
 Syn.tonin 
 
 AND Milk- Lactic 
 
 Casein. Albumoses. Butter, sugar. Acid. Alcohol. 
 
 Unskimmed milk, . . 2 1.5 3-5 3 i 1-5-3 
 
 Skimmed milk, ... 2 1.5 3 i 1-5—3 
 
 The quantity of fat contained in milk seldom constitutes 
 an objection to its use as a remedy. Its presence interferes 
 little with the chemical changes which milk undergoes in the 
 stomach, but fat in large quantity, like all sweets, dimin- 
 ishes the already slight action of milk on the muscular layer, 
 or, like the fatty acids, if decomposed produces an intense 
 congestion of the mucous membrane. 
 
 The fat rises to the top because it is lighter, and not on 
 account of any change in the milk. But the cream also con- 
 tains casein, albumin, sugar, and salts, which the fat-globules 
 have carried along with them. The upper layer, however, in
 
 206 DISEASES OF THE STOMACH. 
 
 whicli the larger fat-gtobules collect, is not so rich in these 
 nutritive ingredients. 
 
 The method used in skimming the milk and obtaining the 
 cream is important. The milk, after being drawn in a clean 
 place, by clean hands, from clean udders, into clean vessels, is 
 immediately sterilized by the spore-killing process and kept 
 for twenty-four, forty-eight, or seventy-two hours at a tem- 
 perature of io° to 15° C. The cream can then be poured or 
 siphoned off just before drmking. The skimmed milk is in 
 this way perfectly sweet and sterilized. When the machine 
 can be obtained, the milk before sterilization may be sepa- 
 rated by the aid of a centrifugal apparatus. The skimmed 
 milk obtained in this way is too poor in fat, as much as pos- 
 sible of which should be introduced with this already insuffi- 
 cient food. It is well established that the emulsionized fat in 
 milk is never contraindicated by a disease of the stomach 
 when milk-sugar can be given. The effort to e.xclude the fat 
 of milk in the treatment of the diseases of the stomach is a 
 mistake. Consequently, no trial should be made of skimmed 
 milk when sweet sterilized milk is not well borne. Also 
 buttermilk, clabber, whe\', and peptonized milk, and all the 
 sweet condensed preparations, in our experience are value- 
 less in the treatment of the diseases of the stomach. 
 
 The cream separated from the milk in the preparation of 
 skimmed milk is a very rich, digestible, fatty food, the use of 
 which may be advisable during the course of the treatment 
 of some of the diseases of the stomach when a concentrated 
 diet must be ordered. Its richness in nutriment is variable. 
 
 Eggs. — The egg, a secretive and formative product of the 
 reproductive organs of the female bird, is a ver\' valuable and 
 widely-used aliment in both health and disease. The compo- 
 sition of the eggs of all birds is nearly the same. 
 
 The Qgg of the hen varies in weight between 45 and 70 
 gm., and is equal in nutritive value to about 40 gm. of meat, 
 and contains about the same quantity of albumin and fat as 
 150 c c. of milk. It is often considered a complete food, but 
 it is no more so than fat meat. The physiological action is 
 modified by the preparation, and that of the white alone is 
 very^ different from that of the whole egg. 
 
 The hard-boiled white of egg rapidly excites secretion, and 
 the height of digestion falls between thirty and forty-five 
 minutes, when the quantity of combined and free HCl is 
 greater than that of the test-breakfast. In seventy-five min- 
 utes after eating the white of one egg the stomach is empty, 
 secretion promptly ceases, and the products of digestion do not
 
 DIET. 207 
 
 accumulate. If the hard-boiled egg be very finely divided 
 before it is eaten, secretion is less rapid and less intense, and 
 the free HCl is less than when the &^^ is simply masticated. 
 The stomach is empty in one hour and enters at once into 
 repose. The digestion of egg-water is like that of the pul- 
 verized white of &%z. 
 
 The digestion of the whole soft-boiled or poached egg is 
 modified by the increase of fat and of salts. Secretion is 
 slower in its evolution, digestive products are more plentiful, 
 the curve of free HCl is slower in its descent, and the stom- 
 ach is not empty until near the end of two hours. 
 
 The percentage of utilization in health is very high. Only 
 about three per cent, of the albumin and five per cent, of the 
 fat escape absorption. Both the white and the yolk putrefy 
 much more readily than meat. 
 
 The whole q^^ constitutes a very fat food, and very much 
 of the yolk is unsuitable in myasthenia. The white should 
 be lightly coagulated or in solution when rapidity of digestion 
 is an object and excessive excitation is to be avoided. The 
 white agrees well in adenohypersthenia, and also in myas- 
 thenia, but in both of these functional states much of the 
 yolk is likely to do harm. In gastric retention and intes- 
 tinal putrefaction eggs should be excluded from the diet. In 
 some persons one egg may be sufficient to initiate intestinal 
 putrefaction, and to produce a few colicky movements and an 
 abundant formation of hydrosulphuric acid gas. Egg stirred 
 in bouillon just hot enough to coagulate the white is as easily 
 digested as the soft-boiled Q-'g^, but the salts in the bouillon 
 slightly increase the hydrochloric acidity. A soft-boiled &^^ 
 is digested in less than two hours, a raw or a scrambled ^^^ 
 in two and a half hours, but a fried q^^ or an omelette 
 requires nearly three hours. 
 
 Cereals. — The cereals are very variable in their digestibility 
 and action on the digestive tube. Practically, only a few of 
 them are useful in the treatment of the diseases of the stom- 
 ach, but these few, on account of the digestible starch which 
 they contain, possess a unique and commanding value. Of 
 these, the preparations of wheat, rice, hominy, and oatmeal 
 are the most important. 
 
 The physiological action of common bread on the healthy 
 stomach is well known, forming the only solid constituent of 
 the Ewald-Boas test-breakfast. The action on secretion is 
 somewhat in excess of the requirements of its digestion. 
 At the end of half an hour, traces of free HCl may he 
 found unutilized, and at the expiration of one hour this
 
 208 DISEASES OF THE STOMACH. 
 
 free liydrochloric acidity is increased to a considerable quan- 
 tity, and is represented by a decinormal acidity of lo to 15, 
 which persists until the stomach is empty. The evacuation 
 of the stomach is complete in about two hours, and there is 
 no great accumulation of digestive products. The motor 
 function is sufficiently stimulated. 
 
 The intestinal digestibility and action are very different from 
 those of any of the foods which have been thus far considered. 
 A very large percentage of the albumin and fat is unabsorbed. 
 A much greater quantity than of the meats or fish or milk 
 or eggs is used in feces formation, and intestinal peristalsis is 
 more regular and efficient. This action on the movements of 
 the bowels is an advantage, but the loss of unabsorbed nutri- 
 ment is very great. From i to 20 per cent, of the albumin 
 and nearly half of the small quantity of fat are recoverable in 
 the stools. The starch is utilized to within one per cent, in 
 health, and though in disease the quantity found in the stools 
 is not much increased, the clinical guides often show a large 
 loss by fermentation. 
 
 In disease, the physiological action of bread on the diges- 
 tive tube is remarkably modified if the starch undergoes fer- 
 mentation. The lactic, butyric, and other acids formed may 
 produce extreme irritation. The starch itself, in excessive 
 secretion, is incompletely digested by the saliva, and often 
 increases the glandular irritation and activity. 
 
 The bread used in the treatment of the diseases of the 
 stomach should be made of very finely-ground white flour. 
 With the whole wheat bread the utilization is much lower, 
 and the gastric excitation in health somewhat greater than 
 with white bread. About 30 per cent, of the albumin of 
 the whole wheat bread is recoverable in the stools, and from 
 five to ten per cent, of the starch escapes absorption and fer- 
 mentation. Clinical experience and the use of the clinical 
 guides prove that the crust of bread or dry toast browned 
 through and through is well borne in the diseases of the 
 stomach. 
 
 The wheaten grits are, when thoroughly cooked, suitable 
 for the treatment of the diseases of the stomach. In their 
 digestion the hydrochloric acid is better combined, as a 
 rule, than with the test breakfast. They contain also more 
 gluten, which is utilized, when thus separated by the cooking 
 with water, as well as the albumin of meat. The starch is also 
 more freely liberated. Consequently, a greater percentage of 
 nitrogenous matter is absorbed than with bread. The wheaten 
 grits ferment more readily than the crust of roll and dry toast.
 
 DIET. 209 
 
 Rice is another cereal which contains starch in a digestible 
 form, when properly cooked by prolonged steaming. It con- 
 tains very little fat, and less albumin than wheat, but does not 
 differ materially in its digestibility and physiological action 
 from wheaten grits. Its composition constitutes it the best 
 of the whole-grain cereals for obtaining the proper quantity 
 of starch, which is very digestible when the rice is thoroughly 
 cooked and passed through a fine sieve. Its starch is nearly 
 all utilized, but its albumin is less easily digestible than that 
 of wheat or corn bread. " Flaked rice " is a very digestible 
 and palatable preparation. 
 
 Oatmeal contains a large quantity of fat, and more albumin 
 and less starch than rice. Its high percentage of vegetable 
 and badly-utilized fat constitutes a serious objection. It 
 remains longer in the stomach than does rice or wheaten 
 grits ; it produces greater excitation and is more likely to 
 undergo fermentation. 
 
 Cornmeal contains less fat than oatmeal, and in the form of 
 thoroughly cooked " mush " or " flaked hominy " is better 
 utilized than any of the other cereals. More than 90 per cent, 
 of both its albumin and fat are absorbed. It remains a little 
 longer in the stomach than the preparations of wheat and 
 rice. Its action on the stomach differs little from that 
 of rice, but its intestinal digestion and absorption are 
 better. 
 
 The cereals are not suitable for furnishing the body with 
 its albumin and fat. From 10 to 75 per cent, of the albumin 
 of the cereals is recoverable in the stools, but only two to five 
 per cent, of the albumin of meats, fish, and eggs is lost. An 
 exception should be made of the gluten preparations, which 
 are valuable when a digestible form of albumin which resists 
 putrefaction is required. Animal albumin, except cheese, 
 putrefies much more readily than vegetable albumin. But 
 these cereals contain the best form of starch. 
 
 In excessive secretion accompanied by fermentation these 
 foods are imperfectly digested and the physiological action of 
 their fermentation products is injurious. They should also 
 be excluded in gastro-intestinal fermentation. In simple 
 myasthenia, and in all diseases where the motor function is 
 preserved, or where there is no excessive fermentation, they 
 may be properly prescribed. They are sometimes not well 
 borne when the stomach is morbidly sensitive. Intestinal 
 putrefaction is no contraindication to their employment ; and 
 they combine rapidly large quantities of HCl, and leave the 
 stomach early and easily. 
 14
 
 2IO DISEASES OF THE STOMACH. 
 
 Potatoes. — Anotlier food uliich is sometimes prescribed, but 
 which is rarely useful in the treatment of the diseases of the 
 stomach, is the Irish potato. Only when steamed or baked 
 and mealy, or boiled and mashed and again baked, with a 
 little milk and butter, should it be permitted, until late in 
 convalescence. 
 
 The potato excites a very active gastric secretion, the hydro- 
 chloric acid being left free very early in the evolution of diges- 
 tion. The free acidity at the end of forty-five minutes is 
 nearly double that of the test-breakfast at one hour. The 
 motor function is also aroused, and the evacuation of the 
 stomach is more rapid than with the cereals. The starch is 
 badly utilized by the intestines, fermentation is favored and 
 often initiated, and the small quantity of nitrogenous matter 
 easily putrefies, so that the stools are foul, acid, and ferment- 
 ing. The potato is valueless as a remedy in any digestive 
 trouble, although it is a nutritious food when digested. The 
 starch of the potato (seven per cent, lost) is not so well util- 
 ized as that of the preparations of wheat (one per cent, lost), 
 rice (one to five per cent, lost), and cornmeal (three per cent, 
 lest). One-third of the albumin of the potato, unless de- 
 stroyed by putrefaction, is recoverable in the stools. 
 
 Fats. — The fats are not digested by the stomach, but they 
 exert a decided action on this organ. The diseases of the 
 stomach, except gastric retention, have no influence on the 
 utilization of the fats, which is the work of the bile, pancreatic 
 juice, and intestines. In large quantities, fat irritates the 
 stomach, delays evacuation, and interferes with the digestion 
 and utilization of albumin and the carbohydrates. The irri- 
 tation, according to Leven, may be so great as to produce 
 intense congestion of the mucous membrane. In small quan- 
 tity, the best fats are without notable action on the healthy 
 stomach when taken with other foods. 
 
 The action on the intestines varies with the kind and quan- 
 tity of fat employed. By far the best utilized fats are butter, 
 bone-marrow, cod-liver oil, pure olive oil, and cream. No 
 other kinds of fat should be permitted in the diseases of the 
 stomach. The products formed by germs out of fat are 
 extremely irritating, and may produce auto-intoxication and 
 enteritis. 
 
 As a physiological remedy, fat has no place in the treatment 
 of the diseases of the stomach. The quantity should always 
 be moderate, and in excessive secretion, in fermentation, and 
 in many cases of myasthenia, it should be reduced to a mini- 
 mum and the effect controlled by the clinical guides.
 
 DIET. 211 
 
 Sweets. — Like the fats, the sweets can not often be utilized as 
 physiological remedies. Their action as such on the stomach 
 and intestines is one of excitation of secretion and peristalsis. 
 The action on the stomach varies according to the quantity 
 and concentration. Large quantities produce a hydragogue 
 effect, the secretion being poor in hydrochloric acid and fer- 
 ments. In disease, their digestibility is greatly modified, and 
 their easy fermentation constitutes the most serious objection 
 to their employment. Concentrated solutions of sugar con- 
 geal or may even inflame the mucosa. 
 
 In the diseases of the stomach with excessive secretion, all 
 sweets must be prohibited, as they only do harm, and are 
 eventually lost as food where there is fermentation. 
 
 If the digestive tube is sweet, the motor function efficient, 
 and the stomach is not morbidly sensitive or inflamed, sweets 
 should be permitted. Their action in adenasthenia gastrica 
 may be beneficial. Milk-sugar is a better remedy than the 
 dextrinized cereals of commerce. It is very nutritious (tea- 
 spoonful or lo gm. furnishes 41 Cal.), excites secretion but 
 little when given well diluted and in small quantity, and is a 
 valuable laxative food. 
 
 Green Vegetables. — Green vegetables, finely divided, tender, 
 and thoroughly cooked, may be permitted in the diseases of 
 the stomach where there is no excessive secretion nor reten- 
 tion. Given alone, they excite more gastric secretion than is 
 required for their digestion, and remain a long time in the 
 stomach. Their large indigestible residue and their resistance 
 to fermentation make them valuable where constipation is 
 troublesome. The best of these are spinach, tender string- 
 beans, carrots, and lettuce as a salad. Asparagus and toma- 
 toes, on account of their acids and the small seeds of the 
 latter, may irritate a sensitive mucous membrane. The nutri- 
 tive matter in the green vegetables is badly utilized. 
 
 Fruits. — Fruits, on account of their acid or sugar and their 
 tendency to ferment, should be excluded in all diseases of 
 the stomach where there is excessive secretion, morbid sensi- 
 bility, and fermentation. As a rule, baked apples, ripe peaches, 
 grapes, and prunes (which are among the most suitable) can be 
 permitted in such diseases only when convalescence is well 
 advanced. 
 
 The digestibility of food in health is modified by the dis- 
 eases of the stomach. The digestive power of the stomach 
 in each of its diseases will be discussed with the different 
 diseases. It may here be once more emphatically stated 
 that the digestibility of food in health is not the same as in
 
 212 DISEASES OE THE STOMACH. 
 
 disease. It is only one guiding thread in the search for a 
 proper diet. 
 
 3. The physiological action of the food and of its digestive 
 products sJiould be such as to reuiedy or favor the disordered 
 functions and anatovdcal lesions. Food, in the treatment of 
 the diseases of the stomach, should be used not only as a 
 source of nourishment, but as a remedy exercising a special 
 action on sensation, secretion, peristalsis, absorption, and the 
 local circulation. The functional and bacteriological signs 
 are guides in the selection of a digestible diet in the treat- 
 ment of the diseases of the stomach ; but the general digesti- 
 bility of food in health is not so important as its digestibility 
 in the particular diseases. Fortunately, the functional power 
 in the well-defined diseases of the stomach is quite constant, 
 and the diet should conform to this capability. 
 
 The functions of the stomach are germicidal, digestive, and 
 absorptive. The germicidal activit)' seems to be dependent 
 on the acid-secreting power, and whenever secretion is inac- 
 tive special care should be taken to have the food and drinks 
 sterile and sweet. No other dietetic indication is furnished 
 by this protective function. Very little is known about the 
 disorders of gastric absorption apart from its diminution in 
 certain diseases. The acute diseases of the stomach are 
 manifested by phenomena of irritation and demand a diet 
 which gives protection and all possible functional rest. In 
 the chronic diseases of the stomach the digestive function 
 may be asthenic or hypersthenic. Asthenia may affect secre- 
 tion or the motor activity and power of the stomach. Hy- 
 persthenia may affect sensation, secretion, and motor activity, 
 and it is manifested by pain, nervous unrest, excessive or 
 continuous secretion, and by spasm. The various functions 
 may be separately affected or combinedly affected in the same 
 manner, or one function may be asthenic and another may 
 be hypersthenic. Whatever be the character of the abnor- 
 mal variations, the diet should be appropriate to the disorders 
 of sensation, of secretion, and of the motor function, and to 
 the accompanying fermentation and putrefaction. 
 
 Morbid sensibility of the stomach is either a dynamic 
 affection or a symptom of an anatomical disease. The hyper- 
 esthesia of organic disease is best treated by a bland, non- 
 irritating diet. All alcoholic drinks should be excluded. 
 Sour foods and acids are also pernicious, and no condiments 
 except a small quantity of salt should be permitted. The 
 temperature of the diet is also important, and the food and
 
 DIET. 213 
 
 drinks should be neither very hot nor cold. The fats, if 
 perfectly fresh, are well borne, but the contrary is true of the 
 sweets, particularly in large quantities. Meat broths and 
 coffee should be excluded, and milk often disagrees. The 
 meats should be finely divided and the young white meats 
 rich in gelatin are to be preferred. To these should be 
 added the finely-ground and thoroughly-cooked cereals and 
 some of the green vegetables. 
 
 There is no fixed rule for the selection of a diet in mor- 
 bid sensibility of the stomach (hyperesthesia and neuras- 
 thenia) as a dynamic affection. Here we have to deal with a 
 neurosis extremely capricious in its likes and dislikes. Con- 
 trary to what seems reasonable, a soothing, indifferent diet 
 often disagrees. This is particularly true of a milk-cure. 
 Nothing but a trial can here guide us, and it is a good plan 
 to begin with a non-irritating diet, and if this does not im- 
 prove the symptoms, to substitute therefor, without hesitation, 
 a diet physiologically more active and stimulating. Exclu- 
 sive diets are rarely well borne in the nervous affections of 
 the stomach, and an insufficiency of food is a grave error. 
 
 In excessive secretion, either of an organic or of a functional 
 nature, the diet should be non-irritating, easily evacuated, 
 and should possess a high acid-combining power. In adeno- 
 hypersthenia gastrica all condiments and mechanically stimu- 
 lating foods should be excluded. Adenohypersthenia gastrica 
 may be converted by useless irritation into a gastritis. If the 
 patient be anemic, exciting food is often sufficient to disturb 
 the rhythm of the heart's action or to cause an attack of 
 dyspnea; or, if weak, the overexcitation may produce tachy- 
 cardia and induce an extreme state of depression. Under the 
 circumstances, only harm can result from an excitant diet. 
 On the contrary, the food should be non-irritating and as indif- 
 ferent in its physiological action as it is possible to make it by 
 minute division, solution, or suspension, by the removal of 
 indigestible particle's, and by the omission of condiments. 
 The action of the food on the stomach should be reduced 
 to a minimum in order to meet the physiological indica- 
 tion — which is sedative. The same rule applies to hyper- 
 sthenic gastritis and to ulcer. In excessive secretion, of 
 both organic and functional nature, the starches should be 
 reduced to a minimum, and in severe cases be excluded, for 
 the digestion of no other class of food leaves so much hydro- 
 chloric acid free. But functional and organic excessive secre- 
 tion should not be treated in the same manner. In adeno- 
 hypersthenia gastrica three moderately large meals should
 
 214 DISEASES OF TJIE STOMACH. 
 
 be given daily, for a large proteid meal will leave less hydro- 
 chloric acid free and will produce less chemical irritation. 
 Ulcer and hypersthenic gastritis, on the other hand, are 
 properly treated when four or five small meals composed of 
 bland, finely-divided food are ordered daily, for it is abso- 
 lutely necessary to reduce mechanical as well as chemical 
 irritation to a minimum. A milk-cure combined with alkalies 
 may agree well, combining the acid rapidly and, without 
 having produced irritation, leaving the stomach after a short 
 sojourn ; but milk, on account of the necessity of giving it 
 at. short intervals, allows the stomach little repose, and is 
 often badly borne by the intestines. Consequently, a diet 
 composed of a large quantity of finely-divided, lean, red 
 meats, eggs, and a minimum of non-irritating cereals and fats 
 may be more suitable. The sugars increase the quantity but 
 not the acidity of the gastric juice. In small quantit\- and 
 well diluted they should be permitted in organic and functional 
 adenohypersthenia, pro\'ided the increase of secretion does 
 not injuriously prolong digestion. Naturally, all irritants and 
 stimulants should be excluded, and the diet made sufficient in 
 quantity to support nutrition, aided, if need be, by absolute 
 rest and rectal feeding. The two commanding indications are 
 the control and utilization of the secretion and the protection 
 of the sensitive mucous membrane against irritation. The 
 object is not necessarily the diminution of the digestive work 
 required of the stomach, but the regulation of the diet so that 
 the stomach may painlessly perform such work as it is fitted 
 to do. 
 
 In cases of simple subacidity, the greater part of albuminous 
 digestion must be done by the intestines. The conditions are 
 most favorable for the digestion of the starches. The diges- 
 tion of the fats is but little interfered with. Consequently, 
 the fats need not be diminished, and the decrease of the 
 albumins should be made up for by a larger quantity of 
 starches. The diet may be composed of meats, fish, cereals, 
 vegetables, fruit, and digestible fats. No class of food need 
 be excluded. Evidently, with the exception of the starches, 
 nearly all the work of digestion is thrown on the intes- 
 tines, and this necessitates very fine division and thorough 
 cooking of the food. The diet should be digestible by the 
 intestines, not prone to putrefaction like eggs, and should 
 be so regulated in quantity and bulk as to preserve the 
 motor function of the stomach. Milk is not well borne. 
 The fats (butter, cream) should not be given in such large 
 quantity as to produce diarrhea. Gastric stimulation, in
 
 DIET. 215 
 
 keeping with the cause of the subacidity, is advantageous, and 
 consequently coffee, condiments, sweets, and alcoholic drinks 
 in moderation may be beneficial. 
 
 The diet in the motor disorders is extremely important, 
 and in this respect resembles the motor function itself. 
 The chemical and absorptive work of the stomach can be 
 performed by the intestines, and the compensation can be 
 so complete as to maintain the organism in perfect health. 
 The stomach must, however, do its own motor work, and the 
 disorders of this function demonstrate in a striking manner 
 the great harm which a diseased stomach can do. 
 
 In morbid muscular irritability of the stomach a bland diet 
 is usually indicated, be the trouble vomiting or the too rapid 
 evacuation of its contents into the intestines. But this is by 
 no means always true, and a slightly stimulating diet may be 
 best tolerated. 
 
 Myasthenia demands a very special diet — nutritious in 
 small bulk, resisting fermentation, non-irritating, finely 
 divided, soluble," sufficient in quantity, and exerting the 
 proper physiological action. The quantity of water taken 
 during the meal and during the period of gastric digestion 
 should not exceed one glassful, for myasthenia is a " dyspepsia 
 of liquids." 
 
 In myasthenia gastrica, if the patient is young and of 
 strong constitution, and there is no contraindication, the 
 excitant diet should be employed to awaken the muscular 
 layer and to contract reflexly the abdominal muscles and 
 increase abdominal tension. When the myasthenia is associ- 
 ated with excessive hydrochloric acidity, no starches should 
 be permitted ; and " peptones " and albumoses will be useful 
 when hydrochloric acid secretion is diminished. If, on the 
 other hand, the muscle is so exhausted as to be both weak 
 and irritable, and if the muscular relaxation is due to inflam- 
 mation of the mucous membrane, ex.citation would only 
 cause tonic contraction or be ineffectual. Excitation would 
 act on the stomach as does digitalis on a heart too weak to 
 support it. Consequently, a bland diet is indicated in the 
 treatment of the irritable and myasthenic stomach. It enables 
 the nervous and neurasthenic to live without discomfort and 
 without disordering reflexes. It relieves spasm and the stasis 
 of contracture. The stomach churns and evacuates its con- 
 tents, the bowels become regular, and the colon resumes its 
 normal caliber. These effects are not theoretical, but can 
 be demonstrated by clinical observation and abdominal palpa- 
 tion.
 
 2l6 DISEASES OF THE STOMACH. 
 
 Tlie disorders of absorption affect chiefly the utilization of 
 alcohol and the absorbable sweets, which, when this function 
 is in abeyance, remain too long in the stomach and produce 
 irritation and undergo fermentation. Alcohol, however, 
 stimulates this function in a state of health. Very little is 
 known of the disorders of gastric absorption apart from its 
 diminution in certain diseases, and, fortunately, the intestines 
 are capable of doing all this work. 
 
 Gastric fermentation is a very common condition, and may 
 require a very special diet or very rapid changes of exclusive 
 diets. When this condition exists as a result of disease of the 
 stomach and not of an improper diet alone, the treatment 
 should be begun after very thorough lavage. Meats, gelatin, 
 and dextrinized bread should form the basis of the diet. 
 Green vegetables, fats, starchy foods, sweets, and fruits may 
 be progressively added as the disease of which the fermenta- 
 tion is the result is improved by proper medication. Gastric 
 putrefaction is very rare. It necessitates the careful selec- 
 tion, and sometimes the exclusion, of albuminous food. Fer- 
 mentation and putrefaction are produced by certain germs 
 in suitable soils. The dietetic treatment consists in making 
 the contents of the stomach a bad medium for the growth of 
 the particular germs which are found. It is a good rule of 
 practice temporarily to exclude the food on which the germs 
 are living. In rebellious ca.ses we strongly recommend 
 stomach washing and exclusive rectal feeding for a few days. 
 
 Gastric digestibility is the correlate of the digestive power 
 of a particular stomach. The impairment of one or more of 
 the functions in a particular manner affords so many guiding 
 threads to the selection of a proper diet. In the dynamic 
 affections it may be that the diet must be so regulated as to 
 favor the stomach in every possible way, gentle or negative 
 in its influence, or it may be that one or more of its functions 
 need excitation. The indications for the use of diet as a 
 remedy capable of soothing or exciting, are furnished by the 
 subjective and functional signs. The stomach requires appro- 
 priate exercise and rest in order to regain lost power. Always 
 to prescribe a favoring diet indifferent in its physiological 
 action is a very serious mistake. 
 
 Not the dynamic affections only necessitate the selection of 
 the diet with a view to its physiological action ; the anatomi- 
 cal diseases of the stomach also demand either stimulation 
 or rest. Chronic asthenic gastritis furnishes a good illustra- 
 tion of the value of an exciting diet, provided glandular 
 deizeneration is not so far advanced as to render stimulation
 
 DIET. 217 
 
 useless. On the other hand, acute gastritis imperatively 
 demands temporary functional repose and the use of the 
 blandest, most non-irritating foods. Ulcer and carcinoma 
 should receive the most careful protection. In Sections IV 
 and V the value and applications of the rule will be fully 
 illustrated. The physiological action of the food and of its 
 digestive products should be well considered in the selection 
 of a diet, in order to avoid doing injury and to secure its 
 full remedial influence. 
 
 The use of food as a remedy often consists in the ordering 
 of a diet which exercises or even excites the functions of the 
 stomach, or which excites one of the functions of the stomach 
 and favors another. But not rarely gastric intolerance, or a 
 gastric lesion, or gastric weakness makes it necessary to 
 favor the stomach or to give it absolute functional rest. 
 
 The stomach may be favored by diminishing the nutritive 
 needs of the organism, by throwing the burden of digestion 
 on the intestines, and by rectal feeding. 
 
 By absolute rest in bed the nutritive needs of the organism 
 may be diminished by about one-fifth, and the work required 
 of the digestive organs is made just so much less. The 
 diminution of the required digestive work may be necessitated 
 by the inability of the digestive organs to utilize enough 
 food to support nutrition, or by the desirability of protect- 
 ing the stomach when it is the seat of a severe lesion, or by 
 weak digestion, combined with great emaciation and debility. 
 
 The healthy intestines are capable of digesting enough 
 food to maintain nutrition, and the stomach may, conse- 
 quently, be favored by selecting an intestinal diet. The food 
 should be very finely divided, liquid, concentrated, and bland, 
 and it should be administered every two to four hours in 
 small quantity. Milk, when it agrees, serves as an excellent 
 basis for the diet. But by proper preparation many other 
 kinds of food can be used. Expressed meat juice, meat pow- 
 der, calf's foot jelly, meat jelly, cereals very finely ground 
 and thoroughly cooked, are a few examples. Butter may 
 be given with the cereals, or cream, and "vigor chocolate" 
 and almond milk may furnish the requisite quantity of fat. 
 The almond milk is prepared by making an emulsion of 20 
 almonds in a pint of hot water, and in proportion of one to 
 two of milk is a palatable and nutritive liquid food. The 
 prepared cereals and the albumoses of commerce are some- 
 times valuable. In this connection somatose and panopep- 
 tone merit special mention. But when peptones are prescribed, 
 the total quantity of nitrogenous food for the twenty-four
 
 2l8 DISEASES OF THE STOMACH. 
 
 hours must be reduced to a niiniuuini in order to avoid pro- 
 duciii<; diarrhea. Some of the peptones of commerce might 
 be appropriately called purgative poisons. 
 
 Rectal feeding may be employed to favor and protect the 
 stomach. Whenever it is not possible to nourish the body 
 by the mouth, or whenever food administered by the mouth 
 is liable to produce injury or to interfere with the cure of a 
 disease of the stomach, complementar\' or exclusive rectal 
 feeding should be tried. 
 
 The large bowel does very little digestive work, but it pos- 
 sesses the power of converting small quantities of starch and 
 cane-sugar into grape-sugar. However, it absorbs water, 
 sugar, dissolved albumin, albumoses, and emulsified fat. The 
 absorption is not very rapid nor very great, and it is rarely 
 possible to nourish a patient in even absolute repose for more 
 than a few weeks by exclusive rectal feeding. Exceptionally, 
 a patient with healthy digestive organs, and with a disease 
 which kills only by starvation (as cicatricial obstruction of the 
 esophagus), may be kept alive for about one year. In such 
 cases it is prolaable that the enema is carried by antiperis- 
 talsis into the small bowel and there digested and absorbed. 
 
 Indeed, the investigations of Griitzner make it probable 
 that a part of a nutrient enema is absorbed by the small intes- 
 tine. This antiperistalsis is favored by a weak salt solution 
 (less than one per cent.), and explains satisfactorily the 
 increased absorption and utilization of an enema which 
 contains a pinch of salt. 
 
 Not enough nourishment can be introduced by the rectum 
 to supply fully all the demands of nutrition ; consequently, 
 the body can be nourished b)' rectal feeding only imperfectly, 
 and, usually, only for a short time. Enough water and salts 
 can be absorbed by the colon, but the quantity of organic 
 nutriment is altogether insufficient, except in very excep- 
 tional cases. Emulsionized fats, dissolved albumins, and their 
 digestive products, alcohol, starch, and the absorbable sugars, 
 may all find their way from the large bowel into the circula- 
 tion, and be utilized in nutrition. The dissolved raw albumin, 
 to which a little common salt is added, is as readily absorbed 
 as albumoses and commercial peptones. Digested enemata 
 possess no greater nutritive value than when undigested, and 
 are prone to decomposition. They are not well tolerated, 
 and often make the patients extremely restless and mentally 
 and morally depressed. But however the nutrient enema be 
 constituted, rectal feeding is likely to produce intolerance, 
 and when too frequently repeated, and composed of pan-
 
 DIET. 219 
 
 creatized milk, may excite an acute colitis. Some patients 
 resist this method of feeding, and are often unable to retain 
 the enema. For these reasons rectal feeding is not popular, 
 and is usually restricted in practice to cases of necessity. 
 The method is employed much less frequently than it 
 should be. 
 
 The valuable enema of Leube is prepared by mixing 
 thoroughly — 
 
 150 gm. of beef pulp (no fat). 
 50 gm. of pulp of the fresh pancreas of the cow (no fat). 
 100 gm. of lukewarm water. 
 
 This mixture is warmed and injected slowly two or three 
 times daily into the large bowel one hour after employing a 
 cleansing enema of 250 gm. of lukewarm water. It does not 
 irritate, the digestion taking place in the bowels. But the 
 fresh pancreas is not easy to get, and the nourishment thus 
 afforded is too exclusively albuminous. For 50 gm. of the 
 beef pulp should be substituted the yellow of one ^%%, one 
 tablespoonful of dextrinized (heat) flour, and one gm. of 
 common table-salt. These should be stirred thoroughly into 
 the lukewarm water. 
 
 The following preparation of Boas is well tolerated and is 
 usually absorbed : 
 
 Milk, 250 gm. 
 
 Yolk of two eggs, 
 
 Salt, 2 gm. 
 
 Claret, Tablespoonful. 
 
 Prepared cereal food, Tablespoonful. 
 
 Use one to three in twenty-four hours. 
 
 The preparation recommended by Ewald is also excellent. 
 Two or three eggs are beaten up with a tablespoonful of 
 cold water. About a tablespoonful of a prepared cereal 
 (dextrinized) is boiled with one-half of a glass of a 20 per 
 cent, solution of grape-sugar, and a wineglassful of claret is 
 added. Let it stand until nearly lukewarm and slowly stir in 
 the beaten eggs. Add one gm. of salt. Use two or three 
 enemata a day. 
 
 These three excellent preparations may be employed in 
 turn. If the contents of the large bowel become acid, both 
 the milk and the sugar should be omitted, and as a substitute 
 therefor beef tea may be used. 
 
 Practically, the greatest obstacle to rectal feeding is the re- 
 bellion of the bowel against the procedure. The rectal in- 
 tolerance, by proper care and co-operation, may usually be
 
 220 DISEASES OF THE STOMACH. 
 
 avoided. The enema should be warm, of the consistency of 
 a thick soup, non-initating, not larger than 250 gm., and 
 given after careful cleansing of the bowel. One hour before 
 the administration of the enema an injection of not more 
 than 300 gm. of lukewarm water should be used; or, if the 
 colon is already empty, the rectum should be simply washed 
 out by the funnel-siplionage method. The nutrient enema 
 is slowly introduced under low pressure, the tube is removed, 
 and a soft towel is held for a short time gently but firmly 
 pressed against the anus, while the patient remains quiet on 
 the left side. A soft tube with a rounded end-opening should 
 be used and introduced high up, or only above the sphincter 
 if the effort to introduce the tube above the sigmoid flexure 
 produces pain, resistance, and irritation. The enema intro- 
 duced properly into the rectum will soon be carried by 
 antiperistalsis, excited by the salt, high into the colon. 
 Where the rectum is very irritable, a few drops of laudanum 
 should be added to the enema. A nutrient enema should 
 never be given oftener than three times daily. 
 
 In extreme conditions, a small quantity of nourishment 
 may be given hypodermically. A few ounces of sterilized oil 
 may be introduced in this way during the twenty-four hours, 
 and, combined with whisky hypodermically, may aid rectal 
 feeding in carrying the patient safely over a period of danger. 
 
 Rectal feeding may be employed to maintain nutrition and 
 to give the stomach rest or protection. In cardiac and pyloric 
 obstruction or stenosis it may be impossible completely to 
 nourish the body by the mouth. Too little food reaches the 
 intestines, and it may not be advisable to resort to surgery for 
 relief. Whether the obstruction be malignant or benign in 
 nature, life can be prolonged by the employment of nutrient 
 encmata. 
 
 Rectal feeding is very valuable in the treatment of myas- 
 thenic retention. In this condition the body suffers both 
 from lack of food and of water, and the slow starvation can be 
 arrested by nutrient enemata, which compensate the gastric 
 insufficiency. Rectal feeding is not only valuable on ac- 
 count of the support which it gives to nutrition, but also on 
 account of the diminution of the functional work of the 
 stomach. The favoring of the organ may be all that is re- 
 quired to relieve the retention and to give the stomach a 
 short interval of repose. The complete evacuation also 
 breaks the continuity of the germ growth. Even more effec- 
 tive is complete gastric rest for a few days. In myasthenic 
 retention with active fermentation, if the patient be put to
 
 DIET. 221 
 
 bed, the stomach thoroughly washed out and daily douched 
 internally, all food prohibited by the mouth, and the body 
 nourished exclusively by nutrient enemata for from three to 
 five days, the result is often remarkable. With this plan of 
 treatment should be combined the daily use of the hot and 
 cold needle-spray for one minute over the abdomen and 
 lower extremities, external cathodal galvanization with large 
 plate-electrodes, and faradization of the abdominal muscles. 
 If the stomach does not retract, strychnin in full doses will 
 prove, in some cases, a valuable aid. This short systematic 
 medication, in which rectal feeding plays an essential part, 
 rarely fails to control the fermentation and to relieve or dimin- 
 ish the retention. The same treatment is very valuable in 
 myasthenic stagnation. 
 
 In the treatment of the dynamic affections where the stom- 
 ach is morbidly sensitive and irritable, a few days of exclusive 
 rectal feeding may be advisable. A good result is often thus 
 obtainable in uncontrollable vomiting, in hyperesthesia, and 
 in adenohypersthenia gastrica, the rectal feeding acting as a 
 remedy by giving absolute rest to the stomach and furnish- 
 ing some nourishment to the body. 
 
 In the treatment of obstinate and complicated ulcer of the 
 stomach, rectal feeding may be used to supplement or to 
 supplant feeding by the mouth. Hemorrhage and local 
 peritonitis and perforation are stringent indications for exclu- 
 sive rectal feeding. So great, indeed, are the advantages of a 
 few days of gastric repose that even in simple, uncomplicated 
 ulcer, in the beginning of the treatment, or intermittently 
 during the cure, rectal feeding might be more frequently 
 employed with benefit and without the least danger. 
 
 In severe acute gastritis and in the hypersthenic form of 
 chronic gastritis, the incalculable value of gastric rest for a 
 few days demands the employment of rectal feeding. Also 
 in the diseases of the stomach which are not compensated 
 by the intestines, and when too little food is digested and ab- 
 sorbed, rectal feeding aids in the maintenance of nutrition, 
 particularly where the large bowel is healthy. Some good 
 may also be done by this method of feeding in arresting the 
 progressive inanition of carcinoma. 
 
 4. Not only the diseases of the stomach, but the pozver and 
 state of other organs, should be kept in mind. The stomach 
 decides the selection of the diet in only one condition — viz., 
 when it is the only organ diseased. The dietist will here ex- 
 perience little difficulty in formulating his prescription in keep- 
 ing with the indications given by the careful application of
 
 222 DISEASES OF THE STOMACH. 
 
 the methods of investigation. Unfortunately, it is rare that 
 the problem is so simple and easy of solution. 
 
 The intestines establish digestive compensation in the 
 diseases of tiie stomach. Consequently, be the intestines 
 healthy or diseased, they are never silent in the selection of 
 a diet. The diet in a diseased stomach with normal in- 
 testines is, so far as the intestines are concerned, prophylactic. 
 The food should be finely divided and free from abnormal 
 chemical, physical, or living irritants. The meats should 
 be palatable and freed from indigestible matter; the cereals 
 should be finely pulverized and thoroughly cooked, and the 
 fats sweet, and those most digestible should be selected. No 
 food should be given that is likely to undergo fermenta- 
 tion in the stomach, or to throw extra work on the intestines, 
 or to force them to work at a disadvantage. The intestines 
 should be as closely watched and favored and protected as 
 the heart-muscle in valvular lesions, for the intestines stand 
 between the diseased stomach and inanition. 
 
 When the intestines, as well as the stomach, are diseased, the 
 diet should be regulated in accordance with the digestive 
 and assimilative power of the alimentary canal. The diet 
 should favor the weakest point; what can not be digested 
 need not be prescribed ; the foods should be selected which 
 have the best chance of escaping destructive changes, the 
 physiological action of which on the diseased digestive 
 tube is most favorable to their digestion and absorption, and 
 the therapeutic effect of which is most likely to be beneficial. 
 The task of the dietist is here a hard one, and can only be 
 done by precise and correct directions, by close observation, 
 and by free use of the clinical guides. 
 
 The diet in the diseases of the stomach should also be 
 modified so as to be appropriate to any other organ that may 
 be diseased. The diseases of nutrition, particularly gout and 
 diabetes, should not be overlooked, and nephritis often forces 
 a compromise. The waste products of the carbohydrates and 
 fats no doubt give the kidneys less work to do than those of 
 albumin, which latter may be retained in the blood in poison- 
 ous quantities. But the normal products of albuminous 
 catabolism are much less injurious than the absorbed pro- 
 ducts of gastro-intestinal decomposition and some forms of 
 fermentation. The first requisite of any diet is that it be 
 digested and absorbed, and, consequently, the stomach and 
 intestines, when diseased, always exercise a controlling influ- 
 ence in the selection of a proper diet. Other diseases may 
 so modify a diet as to destroy its value as a physiological
 
 DIET. 223 
 
 remedy in the treatment of the diseases of the stomach. 
 The remedial influence of food should then be replaced by 
 other forms of appropriate medication. 
 
 5. The finances, habits, and peculiarities of the patient should 
 be considered. In selecting a diet for the rich, with all the 
 luxuries and comforts at their command, the foods which are 
 to furnish nourishment and aid in the cure may be chosen 
 from the best in the market. But many feel the sting of 
 poverty, and must live on what is cheap. The practical physi- 
 cian will order the foods which are best and most suitable 
 under the circumstances. 
 
 A man's stomach is often what he makes it. It readily 
 becomes the slave of habit, and is often endowed by circum- 
 stances with peculiar capabilities and weaknesses. Foods 
 agree and disagree contrary to what would rationally be 
 expected. These results of training and these individual 
 peculiarities should not be rudely disregarded, and the patient 
 ordered to eat what agrees with most men afflicted with the 
 same disease ; a man is too prone to order others to eat 
 what he himself best digests. 
 
 6. The directions should be complete and explicit, and shojild 
 be changed to meet the daily indicatio)is. It is only when it is 
 carefully and minutely regulated, and changed from day to 
 day to meet the new conditions, that the value of the dietetic 
 treatment of the diseases of the stomach becomes so striking. 
 If the physician be content with writing a list of permitted 
 and forbidden foods and drinks, and does not keep the patient 
 under control and observation, no permanent benefit is likely 
 to be conferred. It is necessary to watch the evolution of 
 the disease, so as to be able and ready at the right moment to 
 make the suitable changes in the diet. 
 
 In writing a prescription, it is usual to select the best drugs 
 for the special case, to regulate the doses according to the 
 effects desired, and to order them to be taken in a particular 
 manner at regular intervals, until it is evident that the effects 
 are obtained. The principles of prescribing a diet are the same. 
 As a remedy, the diet should be used in the same manner as 
 any article of the materia medica. 
 
 11. SIGNS OF CORRECTNESS OF THE PRESCRIBED 
 
 DIET. 
 
 The diet being rationally selected in accordance with the 
 rules already given, it should next be prescribed and con- 
 trolled by the clinical guides.
 
 224 DISEASES OF THE STOMACH. 
 
 If the diet is correct, the discomfort of which the patient 
 complains will be relieved. There is soniethini^ radically 
 wrong with a diet which increases the subjective symptoms, 
 and the patient will be the first under the circumstances to 
 protest. When the diet does not diminish or relieve the dis- 
 comfort of which the patient is conscious, all that can be said 
 is that the diet is doing no harm. The correctness of the 
 diet is proportionate to the relief afforded. It is not expected 
 in every case that the trouble will be relieved as if by magic, 
 but the sensations of the patient, where no indulgences are 
 taken, form a rough but trustworthy clinical guide. 
 
 A correct diet will usually cause no loss of weight and 
 strength; otherwise the first requisite of a diet — which is the 
 maintenance of the nutrition of the body — is not fulfilled. 
 But not rarely, even in the simple diseases of the stomach, 
 the diet must be insufficient. The injury done to the organ- 
 ism must not be carried so far as to outweigh the benefit de- 
 rived from the favoring and repose of the stomach. The 
 diseases of the stomach with a tendency to emaciation, par- 
 ticularly the motor insufficiency of carcinoma, should never 
 be treated by a reducing diet, for here the organism has no 
 power to regain what is lost. 
 
 If the symptoms disappear without loss of weight, the 
 diet is correct, and should not be changed unless it is neces- 
 sary or advisable to force alimentation in order to improve 
 the state of nutrition. If there is no loss of weight or 
 strength, but no improvement of the symptoms, the diet is 
 sufficient but not remedial. If the patient feels better, but 
 weight is being lost, the diet, except in cases of obesity, is 
 proper but insufficient. A diet which does not improve the 
 symptoms, and also reduces the weight, should be considered 
 as radically wrong. In retention and carcinoma it may not be 
 possible to arrest the emaciation ; the symptoms may, however, 
 be improved by proper diet and medication. These simple 
 rules are excellent clinical guides. 
 
 In addition to the sensations of the patient and the gain 
 or loss of stren";th and weight, there are also other clinical 
 guides to the correctne.ss of the dietetic treatment. Among 
 these are certain physical, functional, and bacteriological signs. 
 
 The abnormal physical signs, in so far as they are depen- 
 dent on the diet, should improve, although they are often the 
 expression of the lesion only. An increase or decrease of 
 myasthenia can be recognized. Gastric flatulency, occurring 
 immediately after a meal, when there is no gastric retention, 
 is due to swallowed air, and if the stomach is much distended
 
 DIE7\ 225 
 
 is often a sign of myasthenia. Under these circumstances, 
 if the diet is suitable to myasthenia, the flatulency is not a 
 revealing sign of a dietetic error ; but in the absence of gastric 
 retention and colonic stagnation and fermentation, flatulent 
 distention, occurring immediately after a meal, is a sign of 
 myasthenia, and it should be at once considered whether the 
 diet is not physically too heavy, or too large, or too exciting. 
 Overstimulation of a myasthenic stomach produces irregular 
 and often painful peristalsis or complete relaxation. The 
 flabby wall yields readily to the expansibility of the contained 
 gas. 
 
 Gastric flatulency, coming on some time after a meal, may 
 be due to myasthenia, to gas-forming fermentation, or to 
 putrefaction. Gastric putrefaction, except as an accident, is 
 almost unknown, except in carcinoma and in gastric reten- 
 tion, and then it is always accompanied by fermentation. 
 The gas in the stomach is either swallowed, regurgitated 
 from the intestines, or formed in the stomach by fermentation. 
 (The chemically-decomposed carbonates and exhaled gas 
 from the blood may be disregarded.) The cause of the 
 flatulent distention may be readily determined by using the 
 stomach-tube or by giving an exclusively meat meal. If it 
 be found due to fermentation, the diet must be so regulated 
 as to avoid or control this abnormal process. 
 
 Flatulency is more often in the intestines, and when abnor- 
 mally increased is a sign of increased gas formation by putre- 
 faction and fermentation, or of this process combined with 
 myasthenia, or of myasthenia alone. The stools and urine 
 should be examined for signs of putrefaction ; if negative, 
 test the acidity of the stools and prescribe an exclusive meat 
 diet as a trial. If either fermentation or putrefaction is 
 found, the appropriate diet and medication should be pre- 
 scribed. If neither exists in excess, the diet and medication 
 are directed against the myasthenia. 
 
 The influence of the diet as a remedy is revealed by the 
 functional signs. If the gastro-intestinal functions are im- 
 proved thereby, the diet is correct. If the functional signs 
 are made worse, and the other medication is not responsible, 
 the diet is either wrong or, as regards the intestines, an en- 
 forced compromise. The intestines compensate a diseased 
 stomach, and their functional activity requires careful preser- 
 vation. A diet which does not maintain the functions of the 
 intestines in their integrity is always regrettable, but is some- 
 times advisable in. order to favor a diseased stomach tempo- 
 raril\^ If there is no change in the functional signs, the diet 
 15
 
 226 DISEASES OF THE STOMACH 
 
 is either a failure or inactive as a remed)-, but may be the 
 best tliat is possible if it is in conforniit)- with the other 
 clinical guides. 
 
 The bacteriological signs are useful not only in diagnosis, 
 but also in the selection and control of tlie diet. As a 
 clinical dietetic guide, not only the bacteriology of the 
 stomach, but also the evidences of excessive germ activity in 
 the intestines, should be sought in the stools and urine. The 
 diet should be so managed as to control the excessive germ 
 growth in the digestive tube. 
 
 Naturally, the curative treatment is directed against the 
 conditions which favor the excessive germ growth ; but 
 much can also be accomplished by a proper selection and by 
 sudden changes in the diet so as to form an unfavorable cul- 
 ture soil. Fermentation and putrefaction reveal themselves in 
 the odor, reaction, and composition of the stools. In the urine 
 are found the products of the putrefaction, and of these pro- 
 ducts the one of most importance is indican. 
 
 The value of the quantity of the aromatic sulphates in the 
 urine as a clinical guide is unquestionable. The quantity of 
 indican — which may be taken as an indicator — is not always 
 proportionate to the activity of intestinal putrefaction, but is 
 also dependent on absorption. Only when absorption is 
 good is it a guide. A negative result should not be given a 
 positive meaning. 
 
 Intestinal putrefaction is most active in the ileum and colon 
 and is greatly influenced by the acidity of the contents. 
 This acidity is due to two factors — the secreted hydrochloric 
 acid and the organic acids of fermentation. 
 
 To the dietist, the two most important circumstances which 
 influence intestinal putrefaction are the acidity of the gastric 
 secretion and the composition of the diet. 
 
 If intestinal and gastric fermentation or intestinal putrefac- 
 tion be produced or increased by the diet, a mistake has been 
 committed, and the proper correction should be made at 
 once. Putrefaction is more injurious than fermentation, for 
 it produces not only local trouble, but also serious systemic 
 intoxication. Where these processes already exist, their de- 
 crease is the clinical sign of the correctness of the diet. 
 
 By the daily use of these clinical guides the diet, rationally 
 selected, is controlled and made appropriate to the individual 
 case. In order to obtain the full remedial influences of food 
 no indulgences should be permitted, and other forms of 
 appropriate medication should be employed at the same time.
 
 PHYSICAL REMEDIES. 22/ 
 
 CHAPTER 111. 
 PHYSICAL REMEDIES. 
 
 The physical remedies which are used most extensively in 
 the general treatment of the diseases of the stomach are 
 water, electricity, and massage. To these should be added 
 the abdominal belts which are employed to give proper sup- 
 port to the stomach. 
 
 The Uses of Water. — In the treatment of the diseases of 
 the stomach, water may be used internally — as a drink, or to 
 wash out the stomach or to spray the mucous membrane of 
 the stomach ; or it may be employed externally. 
 
 Water is continuously eliminated by the kidneys, the skin, 
 the lungs, and the secretion and excretions of the digestive 
 system. This loss is constantly supplied by absorption. In 
 health, elimination and absorption are so balanced as to main- 
 tain the percentage of water in the body at a constant 
 standard. The excessive drinking of water only raises the 
 percentage temporarily. Elimination rapidly reduces it to 
 the normal percentage, which is about 63. This vital 
 law renders it possible to wash out the system by the 
 ingestion and absorption of large quantities of this solvent. 
 The use of very large quantities of hot water is not indicated 
 by disease of the stomach. Uricemia, gout, rheumatism, and 
 auto-intoxication, may demand the eliminating action of water, 
 and these troubles may be associated with gastric disease. 
 Before ordering such treatment we must know the motor 
 power of the stomach, which determines the manner of 
 administration, and may prohibit the use of excessive quanti- 
 ties of water. 
 
 A diminution of the quantity of water causes the fat 
 deposit to be utilized (Oertel), while an increase may have the 
 opposite effect. In water insufficiency, as in all other forms 
 of starvation, the body is forced to live on itself. The in- 
 creased nitrogenous elimination after the ingestion of water 
 in excess is temporary, and has been attributed solely to the 
 more thorough removal of waste tissue products. 
 
 The action of plain drinking water on the stomach is 
 dependent on the quantity and the temperature. Mineral 
 waters are employed as physiological and chemical remedies, 
 and are considered in the fifth and sixth chapters of this 
 section of the book. Cold water is an intense excitant of
 
 228 DISEASES OF THE STOMACH. 
 
 secretion when taken on an empty .stomach, and tlie action 
 of water within limits becomes less intense with the increase 
 of the temperature. Cold water remains longer in the 
 stomach than water at spring temperature, while hot water is 
 evacuated very rapidly by the normal stomach. The greater 
 the quantity of water taken, the longer it remains in the stom- 
 ach ; but large quantities may be drunk, without propor- 
 tionately delaying evacuation, by drinking it in sips. The 
 quantity of water absorbed from the stomach is exceedingly 
 small. Hot water excites less gastric secretion, is more 
 rapidly evacuated by the normal stomach, increases the flow 
 of bile, is a better solvent, and, consequently, is the form of 
 water most useful in the internal hydrotherapy of certain 
 gastric troubles. 
 
 The soothing effects of hot water are sometimes useful in 
 allaying the irritability of the stomach, and are a valuable 
 means of arresting forms of vomiting. In excessive secretion, 
 and in digestive superacidity associated with normal motor 
 activity, a glass of hot water, sipped slowly an hour before 
 meals, is a simple and excellent remedy. 
 
 In myasthenia it is necessary to avoid overloading the 
 stomach, and the quantity of food and drinks required to 
 maintain the balance of nutrition must be so introduced as to 
 favor the weak muscle as much as possible. The action of 
 the diet must be such as not to delay or make difficult its evac- 
 uation. In addition to selecting food, finely divided, rapidly 
 evacuated, and nutritious in small bulk, the quantity of water 
 taken with the meal must be limited. The remainder of 
 water required to supply the needs of the organism may be 
 so given as to secure a therapeutic effect. In myasthenia 
 with normal or diminished secretion, a single glass, or less, 
 of cold water, slowly sipped an hour before each meal, often 
 exerts a tonic influence. In myasthenia associated with 
 glandular irritation or delayed evolution of secretion, a 
 single glass, or less, of hot water, an hour before each 
 meal, has an undoubted beneficial action, but the hot water 
 must be sipped slowly and the stomach be completely 
 empty before the time for the meal. In myasthenia the total 
 quantity of water allowed should be strictly limited to that 
 required by the organism. The stomach must always be 
 empty at the beginning of a meal and never overloaded with 
 fluids. In gastric retention, due to whatever cause, a drink- 
 cure of any kind whatsoever is absolutely contraindicated, 
 and the administration of hot water before meals is obviously 
 worse than useless. Neither should very hot drinks ever be
 
 PHYSICAL REMEDIES. 229 
 
 given in continuous supersecretion, in ulcer with a tendency 
 to hemorrhage, or in cancer with hemorrhage or with 
 retention. 
 
 The chief indication, however, for the drinking of hot 
 water — natural or artificial — is gastritis. The use of hot 
 water in gastritis should be more accurately limited, and 
 should be confined to cases with the motor function still 
 intact and capable of evacuating in one hour a glass of hot 
 water slowly sipped on an empty stomach. It removes the 
 excess of mucus and exerts a healing and soothing influence 
 directly on the glandular layer. It is also claimed that it 
 prevents excessive fermentation, but so long as there is no 
 motor insufficiency there is no other organic disease of the 
 stomach with so few germs as are found in gastritis. Where 
 the fermentation is due to stagnation or retention, the drink- 
 ing of hot water is contraindicated. 
 
 Stomach washing is "a mechanical remedy that demands 
 very special indications and has fallen somewhat into dis- 
 repute through its too frequent use in cases where it can serve 
 no good purpose. 
 
 The employment of this remedy should be limited to three 
 conditions: (i) Retention or stagnation of food and of di- 
 gestive products ; (2) retention of excessive secretions ; (3) a 
 rich and active germ growth. 
 
 I. There can be no question as to the value of the remedy 
 when there is retention. A stomach which never completely 
 empties itself never rests, and is placed in a most unfavorable 
 condition for regaining its lost power. The retention may 
 be due to obstruction or to a high degree of myasthenia. 
 
 In simple myasthenia with stagnation, lavage is worse 
 than useless where there is no gastric fermentation. If em- 
 ployed before the stomach is empty it robs the organism of the 
 nourishment which without interference would be delivered 
 eventually to the intestines. If employed afte-r the evacua- 
 tion is complete, it is evident that no advantage is gained. In 
 both cases it only stretches and irritates a weak muscle with- 
 out improving the condition of the mucous membrane. The 
 morning washing, too, is here useless, for the stomach is 
 clean and empty and is retracted ; the evening washing does 
 no good and relieves no symptoms. 
 
 In myasthenia with stagnation of the severe type (the 
 stomach emptying itself during the night, but not between 
 meals), accompanied by fermentation simply, the stomach 
 should be washed out before going to bed and left empty until
 
 230 DISEASES OF THE STOMACH. 
 
 morning; but if accompanied by fermentation and excessive 
 secretion, it is best to wash out the stomach before the even- 
 ing meal. 
 
 In myasthenia with retention the circumstances are altered. 
 The stomach never empties itself completely, and is too ex- 
 hausted to retract. Germs find a rich and persistent culture 
 soil. The nervous system is continuously excited and the 
 secreting cells accumulate neither energy nor products. The 
 most important indication is to give the organ rest by arti- 
 ficially emptying and cleaning it. In our opinion, the even- 
 ing washing, as a rule, is decidedly best in nnasthenic 
 retention, on account of the rest which is thus secured for 
 the organ and the patient and the long break made in the 
 germ growth. The evening meal must then be light, such 
 as is quickly digested and emptied by the normal stomach 
 into the duodenum. Between four and five hours later the 
 stomach may be washed out and left completely empty until 
 morning; but if there be little fermentation it is better to 
 do lavage in the morning and enable digestion and absorption 
 to proceed during the night. The operation should be per- 
 formed daily until the bacterial growth is checked and the 
 fermentation controlled, never introducing more than a pint 
 of water before allowing it to flow out, continuing the opera- 
 tion until the stomach is clean, making sure that the water 
 does not accumulate by comparing the quantity withdrawn 
 each time with that introduced, and leaving the stomach com- 
 pletely empty. After the first week lavage ever\' second 
 evening will often suffice. 
 
 In myasthenic retention accompanied by excessive secre- 
 tion and fermentation, the stomach should be washed out 
 twice daily — before the evening meal and in the morning 
 before breakfast. This plan controls the fermentation and 
 enables the system to utilize the greatest possible quantity 
 of food. If the body, however, is well nourished, the stom- 
 ach should be washed out before retiring and left empty 
 so as to give the organ functional rest and protection from 
 irritation during the night. 
 
 In obstructive retention there is uncompensating muscular 
 hypertrophy. The muscle has become stronger and then 
 failed. There is the same stringent indication for washing out 
 the stomach as in myasthenic retention. The best time for 
 performing the operation varies. If the obstruction be such 
 that it can be overcome by increased muscular power, — as is 
 frequently the case in gastric displacement, in traction con- 
 striction, and in relative muscular insufficiency, — the operation
 
 PHYSICAL REMEDIES. 23 I 
 
 should be perfoniied in the evening. In obstructive retention 
 due to an organic lesion the operation can only be palliative, 
 and it may be wisest to secure as much nourishment as possible 
 for the body by making the stomach work at night. The 
 stomach should then be washed out in the morning ; or if 
 there be active fermentation or excessive secretion, lavage 
 should be done both before the evening meal and before 
 breakfast. 
 
 2. The retention of excessive secretion is a condition which 
 may be rationally treated by lavage. The retained secretion 
 may be the product of the general or specific activity of the 
 glands of the stomach. 
 
 Specific secretion, normally intermittent, may become con- 
 tinuous. This by no means rare trouble is usually associated 
 with myasthenia. The muscle seems often inactive rather 
 than weak, and the condition is analogous to the motor in- 
 sufficiency associated with excessive lactic acid formation in 
 malignant disease. The glands of the organ get no rest and 
 are continuously irritated by their own products. It is a 
 good plan to wash out such a stomach with plain warm water 
 until clean, in the morning before anything has been eaten, 
 and then with a i : 1000 solution of nitrate of silver, the 
 stomach being left empty for at least an hour after the opera- 
 tion. 
 
 The general mucous secretion may be excessive and may ac- 
 cumulate in the stomach in large quantity. A coating of mucus 
 is normal and is a necessary protection, but when the mucus 
 accumulates, be it swallowed or excessively secreted by the 
 stomach, removal is necessary in order to avoid the chemical 
 and physiological disturbance caused by it. The stomach 
 should be washed clean and prepared to offer fresh secretions 
 to the ingested food. It is well to wash out the stomach 
 in the morning before breakfast with a warm alkaline solution. 
 
 3. Lavage may be employed to get rid of a very active 
 germ growth even when there is no retention. Through 
 survival of the fittest, a particular micro-organism, or a par- 
 ticular class of them, as revealed by the bacteriological signs, 
 may become established in the stomach in virulent activity. 
 Washing the stomach in the evening with large quantities of 
 water (medicated, if desired) will aid in rendering it sweet. 
 Lavage is most frequently required for this purpose in car- 
 cinoma and in acute indigestion associated with fermentation. 
 
 The technic of stomach washing is very simple. Two 
 methods are in common use. A funnel, to which is attached 
 a piece of rubber tubing about 2j/ feet long, is connected by
 
 232 
 
 DISEASES OF THE STOMACH. 
 
 a short glass tube with the previously introduced stomach- 
 tube, or the whole instrument may be made in one piece. 
 A pint of warm water is poured into the funnel, which is 
 raised above the mouth, and the water gently flows in. 
 Before the funnel is completely empty it is quickly lowered 
 below the level of the stomach, and by siphonage the fluid 
 is withdrawn. The quantity of fluid withdrawn is noted 
 and compared with the quantity introduced, and the solid 
 constituents should also receive our attention. The fluid is 
 then emptied into the receptacle and the procedure repeated 
 
 Fig- 13-— The simi>le apparatus of Somervail (1823). 
 
 until the viscus is clean. The last drop possible must be 
 removed from the stomach by expression before the tube is 
 withdrawn, so as to leave the organ empty. The introduc- 
 tion of a small quantity of water at a time, the avoidance of 
 a strong inflow and of the accumulation of water in the 
 stomach, and as complete evacuation as possible at the end 
 are common rules which become imperative when there is 
 myasthenia. 
 
 The second method is with a receptacle placed above the 
 head. This receptacle is graduated and contains the water,
 
 V "" ^ 
 
 Fig. 14.— Friedlieb's apparatus for lavage and expression. 
 
 233 
 
 Fig. 15.— The Leube-Rosenthal apparatus for lavage.
 
 ^34 
 
 DISEASES OF THE STOMACH. 
 
 and from tlie bottom runs a soft rubber tube to connect with 
 one prong of a Y-shaped connecting glass piece. A second 
 piece of rubber tubing is attached to the second correspond- 
 ing prong, and ends in a graduated receptacle. On each of 
 these tubes is fastened a clamp. The apparatus is connected 
 with the introduced stomach-tube, and is then ready for use. 
 The water is allowed to flow into the stomach in the desired 
 quantity, while the outflow tube is closed. This is next 
 
 ecl-jon . 
 
 Fig. 16. — Rosenheim's intragastric douche tube. 
 
 opened and the feeding tube cut off. The contents of the 
 stomach are aspirated automatically, and the procedure is 
 repeated until the stomach is clean, when the tube may be 
 withdrawn after the stomach is completely emptied by ex- 
 pression. If expression alone be inefficient, it must be aided 
 by the position method. 
 
 The intragastric douche or spray is more beneficial in some 
 of the diseases of the stomach than lavage. The spray
 
 PHYSICAL REMEDIES. 235 
 
 (Einhorn) possesses the advantage of distending the stomach 
 so that the plain or medicated water can be brought into 
 contact with all parts of the mucous membrane. The douche 
 is the form which we prefer, but after the introduction of the 
 tube the stomach should be moderately inflated with air 
 before the water is allowed to flow in. The tube employed 
 is the ordinary stomach-tube, which is, however, provided 
 with a small end-opening and nine smaller openings on the 
 sides. The edges of the openings should be rounded, and 
 their combined caliber should be a little less than the caliber 
 of the tube. 
 
 The douche is of service to arouse peristalsis (cold water), 
 to increase secretion (teaspoonful of salt to a quart of water), 
 to diminish secretion and allay irritability (nitrate of silver, 
 I : 2000-5000), to excite the appetite (weak quassia infusion), 
 and to disinfect the mucous membrane (permanganate of 
 potash, I : 5000). The douche is employed when the stomach 
 is clean and empty, and plain water is used before and after 
 the introduction of the medicated solution, which should all 
 be removed from the stomach. 
 
 Water may be used externally to exert an action on the 
 nervous system, on nutrition, on the temperature of the body, 
 and on the various functions. Indirectly, many of these 
 procedures influence digestion favorably, but the description 
 must be brief and limited to the uses of water in the treat- 
 ment of the diseases of the stomach. This constitutes a 
 special and important division of hydrotherapy. 
 
 The employment of any means as a remedy is based on 
 its physiological action. Hydrotherapy, in addition to its 
 general uses, may be employed to produce particular effects 
 on particular organs. It is our object to describe how the 
 action of water may be utilized in the treatment of the dis- 
 eases of the stomach, be it our purpose to produce a par- 
 ticular effect on the nerve supply, on peristalsis, on the blood 
 supply, or on secretion. In private practice the available 
 methods are few and we seldom advise more than two — 
 varieties of the compress and of the douche. 
 
 The compress may be used hot, cold, or of the tempera- 
 ture of the body. 
 
 The action of combined heat and moisture applied over 
 the stomach is sedative — soothing the nerve supply, quieting 
 peristalsis and spasm, and, when used for a long period, pro- 
 moting the resolution of chronic inflammation. The hot 
 compress is very beneficial in cardialgia, in spasm of the 
 orifices and of the body of the stomach, in hyperesthesia
 
 236 DISEASES OF THE STOMACH. 
 
 gastrica. and in similar conditions where sedation is indicated. 
 The prolonged use of hot applications over the stomach is 
 also beneficial in ulcer (no recent hemorrhage) and in chronic 
 gastritis, but these applications do harm in acute gastritis 
 and are dangerous in ulcer accompanied by hemorrhage. 
 The digestion of very weak and emaciated patients is im- 
 proved by moderately hot applications over the stomach 
 during the digestive period. 
 
 The methods of employing combined heat and moisture 
 are numerous. Towels wrung out of hot water and hot 
 poultices are most commonly ordered ; but the loss of heat 
 and the necessit\^ of frequent re-applications render these 
 methods uncertain in their action and inconvenient. It is 
 best to use an abdominal coil through which hot water flows 
 constantly. Beneath the coil, over the abdomen, is placed a 
 piece of flannel wrung out of hot water, evaporation being 
 prevented by covering the whole with an impermeable tissue. 
 
 The cold-water application is antiphlogistic, and, when 
 long continued, is also sedative. The most important uses 
 of cold applications are to control acute inflammation (peri- 
 gastritis) and to aid in the arrest of gastric hemorrhage. 
 The cold compress is a most efficacious remedy in the treat- 
 ment of digestive vomiting, and it is also beneficial in both 
 acute and chronic gastritis. 
 
 The cold-water may be applied by means of wet towels or 
 an ice-bag over a wet towel, or by means of ice-water run- 
 ning through an abdominal coil. To obtain the beneficial 
 action of the cold compress it is necessar\' that the local 
 action produce an active hyperemia of the skin. In the neu- 
 rasthenic and anemic, and in very weak patients, the severe 
 cold often produces passive congestion of the skin, and the 
 action is injurious. To avoid this injury and action it is often 
 necessary to place a rubber tube across the abdomen and 
 beneath the coil, and through this tube hot water is kept 
 constantly running (Winternitz). Whenever the disturbances 
 against which the compress or local applications are directed 
 are digestive, the applications should be made half an hour 
 before meals, and should be continued during the period of 
 digestion. 
 
 The Priessnitz compress, while applied cold or warm, is in 
 reality a method of using water at the temperature of the 
 body. It is sedative, soothing, antiphlogistic, and hypnotic 
 in its influence, and it may be employed with a good prospect 
 of benefit in all the painful diseases of the stomach. 
 
 The Priessnitz compress may be applied in several ways.
 
 PHYSICAL REMEDIES. 237 
 
 One end of a piece of flannel which is broad enou<jh to cover 
 the abdomen and long enough to go around the body and 
 twice over the abdomen is wet in water of the desired tem- 
 perature, and the bandage is applied and pinned in place. Or 
 a towel may be wrung out of cold water, placed over the 
 abdomen, covered with an impermeable tissue, and held in 
 position by a flannel bandage encircling the body. The im- 
 permeable tissue prevents drying and lessens the chilling 
 action of the cold. The compress may be worn day and 
 night, and should be changed twice during the twenty-four 
 hours. 
 
 In many of the diseases of the stomach the abdominal 
 sympathetic is depressed and irritable. Neurasthenia gastrica 
 is a disease which affects chiefly the nerves of the stomach. 
 Many other diseases of the stomach, both organic and dy- 
 namic, can be favorably influenced by giving tone to the nerve 
 supply, and hydrotherapy furnishes the most active remedy 
 for the realization of this object. We refer to a special form 
 of the needle-spray. 
 
 The intensity of the action of water on the nervous system 
 is dependent on the temperature of the water, on the impres- 
 sionability of the patient, on the mechanical excitation of the 
 nerve endings, and on the location, extent, and duration of 
 the application. The further the temperature of the water is 
 above or below the indifferent point, the greater is the ex- 
 citation. Consequently, a fine needle-spray momentarily ap- 
 plied under moderately high pressure, consisting alternately of 
 hot and cold water, and extended over the area of distribu- 
 tion of all the nerves connected with the centers controlling the 
 stomach, exerts a most powerful action on this organ. The 
 needle-spray, applied in the manner which is here recom- 
 mended, increases the activity of blood circulation in the 
 spinal centers and in the mucous membrane of the stomach, 
 and thus relieves their congestion and improves their nutri- 
 tion, excites peristalsis and causes the stomach to contract 
 firmly on its contents, and restores normal secretion and tones 
 the abdominal sympathetic, as does no other single remedy. 
 
 The needle-spray should be used in the following manner, 
 varying the temperature of the water, the hydrostatic pres- 
 sure, and the duration of the bath so as to be appropriate to 
 the individual case. The chest should be protected during 
 the application, which should not extend above the level of 
 the lower end of the sternum. The temperature of the water 
 maybe as high as 95° F. and as low as 60° F. The hot 
 water is first used, and then, rapidly changing without gradua-
 
 238 
 
 DISEASES OF THE STOMACH. 
 
 tion, the cold water is employed. The application is made 
 with the hand nozle, revolving the spray for ten to twenty 
 seconds over the abdomen, and then for the same time over 
 the front and then the back of the lower extremities. The 
 hot and the cold spray require only one-half to one minute 
 each for their application. The douching is followed by 
 rapid drying, brisk rubbing, and immediate dressing. The 
 stomach should be emptv when the bath is taken. 
 
 The Uses of Electricity. — Electricity is one of the most 
 useful of the physical remedies in diseases of the stomach. 
 
 Fig. 17. — A, Rosenheim's intragastric electrode; B, VVegele's spiral electrode covered 
 with rubber tubing, to be used in the ordinary stomach-tube. 
 
 Each physician has his own favorite methods of employing 
 it. Only those will be described which in our own hands 
 have given the best results. 
 
 Electricity may be applied internally or externally. The 
 internal use is advisable in one disease and one condition — 
 myasthenia — when the patient is accustomed to the use of the 
 tube. Here the internal application would seem to be more 
 powerful than the external ; how much of the additional benefit 
 is due to the more vivid impressions and suggestions it is very 
 hard to estimate. The intrasfastric electrode of Rosenheim is
 
 PHYSICAL REMEDIES. 239 
 
 a very good instrument. Einhorn has invented a capsule 
 electrode which is to be swallowed. The best intragastric 
 electrode is the one recommended by Wegele. It consists of 
 a stomach-tube through which runs a removable spiral con- 
 ductor. The instrument can be kept clean and can be used 
 to wash out the stomach, to introduce the water which serves 
 as the intragastric electrode, and to remove the water after 
 the sitting. The external method consists in the use of one 
 or more forms of electricity in a particular manner — general 
 faradization, central galvanization, and the local use of the two 
 currents. Each method has its effects and its indications. 
 
 The effect of the galvanic and faradic currents on the secre- 
 tions of the stomach may be considered well established by 
 
 Fig. iS. — Einhorn's cajisule electrode. 
 
 experiments, first on the dog and then on man, and by the 
 analysis of the gastric secretion thus excited and obtained 
 by the aid of the stomach- tube. After the use of a moder- 
 ately strong current for about ten minutes, 20 or 30 c.c. of 
 gastric juice may be obtained, rich in all the elements of 
 specific secretion. Secretion may be excited both by external 
 galvanization and by internal faradization. The motor func- 
 tion may also be notably excited — the contractions being 
 tonic or peristaltic according to the strength of the current 
 and the mode of application. Some deny that electricity 
 excites contractions of the stomach. Meltzer laid bare the 
 stomach of an animal and applied the electrode directly to its
 
 240 DISEASES OF THE STOMACH. 
 
 wall. Faradization produced tonic contraction only when the 
 electrode was near the pylorus; over the fundus the result 
 was negative. With one electrode over the stomach and with 
 the other either over the spine or within the stomach, no 
 contraction of the stomach could be excited ; but these ex- 
 periments were made on anesthetized animals during shock. 
 In spite of the denials of some clinicians, there is no doubt 
 that electricity does produce tonic contraction and peristalsis 
 of the human stomach. We have seen both galvanization 
 and faradization cause gastric splashing to cease. When 
 patients have thin abdominal walls, we have seen and felt the 
 peristaltic contractions of the stomach produced by external 
 galvanization, and these patients were not affected by peris- 
 taltic unrest (tormina ventriculi). A glass of water, the test- 
 breakfast, and the test-dinner are evacuated earlier than 
 normal by the electrified stomach. The effects of faradiza- 
 tion and negative polar galvanization are greatest, both on 
 secretion and on the movements of the stomach, after they 
 have been employed for several successive days. 
 
 Electricity may also promote absorption, and is the one 
 direct remedy which e.xcites this function through its influ- 
 ence on the vasomotor nerves and the cells under the control 
 and activity of which the process goes on. 
 
 But electricity is not only valuable on account of its 
 action on the secretory, motor, and absorptive functions of the 
 stomach. It can exert a favorable influence on the general 
 sensations of the stomach, while it is ver\- doubtful whether 
 it has any direct action on the special sensations or the 
 appetite. 
 
 This remed}' also possesses an undoubted trophic action, 
 which may be utilized in the treatment of the chronic ana- 
 tomical diseases of the stomach. 
 
 Contraindications. — The contraindications to the employ- 
 ment of electricit)' in any form do not seem to have attracted 
 much attention. The remedy may be harmful or useless. 
 
 1. It can only do harm in acute gastritis. It disturbs the 
 organ when rest is imperatively demanded. 
 
 2. Electricity of high density does no perceptible good in 
 severe degrees of mj-asthenia. It acts in the same manner 
 as an excitant diet would under the circumstances. 
 
 3. The remedy should not be used during the active period 
 of digestion. Theoretically, it would seem plausible that the 
 functions of the stomach might be aided in the performance 
 of digestive work ; but practically the result of the combined 
 action of the contents and of the remedy can not be con-
 
 PHYSICAL REMEDIES. 24I 
 
 trolled. Electricity may, however, be given in myasthenia 
 near the end of the digestive period. 
 
 4. A recent gastric hemorrhage is a contraindication. 
 Neither should it be employed in diseases of the stomach 
 commonly associated with hemorrhage. Chronic indolent 
 ulcer may, however, form an exception where hemorrhage is 
 not favored by the light hyperemia which accompanies the 
 gentle electrization of the vagosympathetic with a view to 
 obtaining a trophic influence. 
 
 We do not believe in the nihilism which claims that elec- 
 tricity acts solely through suggestion, or not at all. This 
 may be true when the remedy is used without selection, 
 method, or purpose. The physiological action of electricity 
 and therapeutic experience should guide us in the choice and 
 manipulation of the electrodes and in the determination of 
 the form, strength, and density of the currents and of the 
 duration and frequency of the sittings. 
 
 The best electrodes are the nickel-plated ones, with a half- 
 inch thickness of sponge covered with linen. The electrodes 
 are moistened in warm water. The supply should be large 
 enough to enable us to use the requisite current strength and 
 density and to apply them in the proper manner — continuous, 
 interrupted, stable, or mobile. 
 
 The density of the current is represented by a fraction, 
 the numerator of which is the current strength in milliam- 
 peres and the denominator, the surface area of the active 
 electrode in square centimeters. The "active electrode " is 
 the one over the point of greatest excitation, or over the central 
 nervous system. If both the electrodes be over indifferent 
 points, the mean surface area of the electrodes is taken. A 
 current density of 2^ should not be exceeded in the electric 
 treatment of the diseases of the stomach, and when the active 
 pole is over the spine or neck it should not be greater 
 than 3^0". The selection of the poles in the employment of 
 faradism is of no consequence ; but galvanism possesses a 
 decided polar difference, the negative pole being exciting and 
 the positive pole sedative. To obtain the pure polar influence 
 of the anode, only mild currents should be used, and care 
 should be exercised in turning on and off the currents. Begin 
 at zero and gradually and slowly increase to the desired 
 strength ; and at the end of the treatment the strength of 
 the current must be decreased to zero in the same manner 
 before the firmly-held electrodes are removed. 
 
 The duration of the sittings should be regulated according 
 
 to the effect desired. Short applications are most generally 
 16
 
 242 DISEASES OF THE STOMACH. 
 
 useful, and should never be so prolonged as to fatigue the 
 excited part. Exhaustion is no remedy. 
 
 The frequency of the sittings is variable. In the painful 
 affections the quieting influence of the anode may be required 
 several times a day, and in the chronic diseases daily or 
 weekly, and the electric treatment should be continued as 
 long as it is beneficial. 
 
 Electricity may be used to produce: (i) Excitation; (2) 
 sedation ; and (3) a trophic influence. It may consequently be 
 employed in the treatment of: (ij Asthenia gastrica ; (2) hy- 
 persthenia gastrica ; and (3) forms of gastritis and of ulcer. 
 
 1. The Electrical Treatment of Asthenia Gastrica. — Neuras- 
 thenia gastrica may or may not be associated with general 
 neurasthenia, and, consequently, the treatment may be both 
 local and general or local only. 
 
 The controlling indication is gentle excitation of the vago- 
 sympathetic. For this purpose two local methods may be 
 employed — the one indirect, through the connections of the 
 sympathetic with the spinal ner\es, and the other more direct, 
 through the cervical sympathetic vagi connections and the 
 gastric fibers running in the cord from the cranial cavity. 
 For this purpose local galvanization or central galvanization 
 may be employed. 
 
 A favorite method is a modification of the one recom- 
 mended by von Ziemssen. Two large plate electrodes are em- 
 ployed with a surface area of 300 sq. cm. each. One is placed 
 over the epigastrium, and e.xtends from the pylorus across 
 the abdomen to the left, covering the triangular area of the 
 stomach in contact with the abdominal wall, which is marked 
 by the lower border of the left lobe of the liver, the left 
 costal border, and the line of the greater curvature. This 
 electrode is attached to the negative pole, the object being to 
 obtain the polar e.xciting influence. The other electrode, 
 attached to the positive pole, is placfed over the fundus, and 
 extends to the left, toward, but not over, the vertebral column. 
 The edges of the electrodes should be about an inch apart. 
 The current strength should never exceed 15 milliamperes, 
 which gives an electric density of tj^j. The electrodes sliould 
 be well moistened and held in firm contact with the body. 
 The current should be turned on rapidly, allowed to flow 
 constantly for about ten minutes, and should be shut off" 
 suddenly. It is not advisable to begin with a stronger cur- 
 rent than five milliamperes (D = -gJ^), nor to continue the 
 strongest permissible current (15), when it is used, more than 
 a few minutes.
 
 PHYSICAL REMEDIES. 245 
 
 A second local method, which may be alternated with the 
 above, is with the roller attached to the negative pole. The 
 100 sq. cm. anode is placed to the left of the dorsal spine. The 
 current strength should be just sufficient to excite painless 
 contractions of the abdominal muscles, and is usually about 
 three milliamperes. The roller is moved, in firm contact, 
 about 25 times from the fundus to the pylorus, along the 
 axis of the stomach, and back again without lifting it from 
 the abdomen, and about 25 slow strokes are made from above 
 downward over the area of the stomach. 
 
 The first method influences the large sympathetic ganglia 
 and the second excites more strongly the intramural ganglia 
 of the stomach. These methods should be employed once or 
 twice a week. The object will be defeated by meddlesome 
 activity. If there be general neurasthenia, cervicogastric gal- 
 vanization may be used at the same sitting. An electrode of 
 100 sq. cm. is placed over the triangular contact area of the 
 stomach and attached to the negative pole. The other elec- 
 trode, of 50 sq. cm., and attached to the positive pole, is placed 
 over and between the fifth and seventh cervical vertebrae. The 
 moist electrodes are firmly held in this position and the current 
 is very slowly turned on ; it should never exceed one milli- 
 ampere in strength. The positive electrode is now slowly 
 moved to the side of the neck, while firm contact is main- 
 tained, the upper border passing just below the mastoid pro- 
 cess, and the electrode momentarily arrested when it has 
 reached the anterior border of the sternocleidomastoid. 
 From this location it is moved downward to the clavicle and 
 along its upper border back to the starting-point. The same 
 circuit is then made on the opposite side, each consuming 
 about one minute, which, with one minute over the spine, 
 makes the sitting last about three minutes. The current 
 should be slowly turned off, unless spinogalvanization is to 
 be employed. In this case, the anode is moved slowly down- 
 ward to the end of the spinal cord and back again, consuming 
 about three minutes, and the current is slowly turned off. 
 In this method the density of the current should never be 
 greater than -^-^, the electrodes should be held in firm contact 
 with the body, the duration of the sitting short, the applica- 
 tions should be separated by several days' intervals, and great 
 care should be used to turn the current on and off slowly. 
 
 In the treatment of neurasthenia gastrica, a sitting may 
 be given daily, and the sittings should be diminished in 
 frequency as improvement takes place. In the electric 
 treatment of the stomach and its connected ganglia, we
 
 244 DISEASES OF TflE STOMACH. 
 
 are decidedly in favor of small doses given in appropriate 
 ways. 
 
 In myasthenia gastrica electricity may be used internally 
 or externally. Internally, either faradism or galvanism may 
 be employed. The stomach must be clean and resting, and 
 about one pint of water is introduced or swallowed. A large 
 plate electrode (200 sq. cm.) is placed over the epigastrium and 
 the gastric tube electrode is introduced and connected with 
 the negative pole and a current of from five to ten milliam- 
 peres is turned on. The external electrode may be moved 
 during the sitting to the left and over the dorsal spine. The 
 current is slowly turned off. Faradism, however, is prefer- 
 able to galvanism, the external electrode being smaller (100 
 sq. cm.) and the current strong enough to produce painless 
 muscular contractions. The external electrode may be held 
 still, moved or stroked over the stomach, or held over the 
 beginning of the dorsal spine. Intragastric electrization is 
 rarely practicable. It can only be used after the patient has 
 become accustomed to the tube, and this rarely happens 
 except in conditions demanding frequent lavage, where elec- 
 tric treatment is often useless. The possible additional 
 benefit derived from it is outweighed by the punishment 
 inflicted ; but the fatal objection is that the method is uncon- 
 trollable and the density of the current can not be regulated. 
 
 Another method of internal electrization of the digestive 
 tube is more practicable, and may be often used in myasthenia 
 gastro-intestinalis with excellent results. This is recto- 
 abdominal galvanization. The rectal electrode, consisting of 
 a short, rather stiff tube, is so arranged that the mucous 
 membrane is protected against direct contact, and the water 
 can be introduced through it. A very good electrode of this 
 sort is that of Rosenheim. The tube is introduced and half 
 a pint of warm water is allowed to flow in and to fill the 
 rectum, in which the electrode terminates. To this is at- 
 tached the positive pole. A plate electrode of 100 sq. cm. is 
 placed over the epigastrium and connected with the negative 
 pole. The current is turned on, and should not exceed five 
 milliamperes (D = -j^-) ; it is allowed to flow continuously for 
 a short period and then should be interrupted a number of 
 times. The external electrode is allowed to rest over the 
 solar plexus and on either side of the umbilicus for about 
 one minute. The whole sitting lasts about five minutes. A 
 current strength of three milliamperes is generally sufficient. 
 An application may be made every four or five days. Before 
 the treatment the colon should be thoroughly emptied by a
 
 PHYSICAL REMEDIES. 245 
 
 saline or by an injection, and the rectum should be washed 
 out before the introduction of the electrode. 
 
 A second method of treating myasthenia gastrica is with 
 the faradic current. This current is very valuable when the 
 abdominal wall is flabby. The proper external application 
 of faradism excites secretion, peristalsis, and absorption and 
 exercises the abdominal muscles. The current should be 
 strong enough to produce painless contraction. One elec- 
 trode of 100 sq. cm. is held to the left of the dorsal spine and 
 another of 50 sq. cm. is applied over the epigastrium and the 
 bellies of the abdominal muscles, with frequent interruptions. 
 The sitting should last about ten minutes and may be repeated 
 daily. 
 
 Adenasthenia gastrica without an anatomical lesion is very 
 rare, but it may be met with as a result of shock or of hys- 
 teria. Spinogastric galvanization with the negative pole 
 over the stomach may be beneficial, and should be combined 
 with general galvanization of the spine or with general faradi- 
 zation. In the application of galvanism to the spine, the posi- 
 tive electrode of 50 sq. cm. is placed over the back of the neck 
 and the negative electrode is moved from the upper dorsal 
 region to the lower end of the cord. Acurrent strength of two 
 milliamperes ; slow increase from and decrease of the current 
 to zero in the beginning and end of the sitting, which should 
 last about two minutes and may be repeated daily, should be 
 recommended. 
 
 2. Electricity in Hypersthenia Gastrica. — In hypersthenia gas- 
 trica the controlling indication is sedation, and we wish to 
 obtain the quieting influence of electricity. The galvanic is 
 the proper current, and should be so applied as to get the pure 
 polar action of the anode. One plate electrode of lOO sq. cm. is 
 placed over the upper part of the dorsal spine, and is connected 
 with the negative pole. The other, of the same size, is held 
 firmly over the stomach. The current strength shulod not 
 exceed two milliamperes, and the current must be very slowly 
 turned on and off. The sittings should be given daily, and 
 should last five or ten minutes. This method of using elec- 
 tricity often gives most excellent results, and is employed in 
 gastrospasm, in spasm of the orifices, in gastralgia, in habitual 
 vomiting, and in excessive secretion, when not excited by 
 irritant contents or by inflammation. 
 
 3. Electricity in Chronic Gastritis. — In chronic gastritis there 
 may be either a state of irritation or of depression, according 
 to the form and stage of the process. When the irritation is 
 the expression of the lesion and not the result of irritant gas-
 
 246 DISEASES OF THE STOMACH. 
 
 trie products, the sedative pure polar influence of the galvanic 
 anode is very valuable. It is applied in the manner recom- 
 mended in the treatment of hypersthenia gastrica, of which 
 this is the inflammatory form. 
 
 If depression of function exist and the process, as indicated 
 by the functional signs, is not so far advanced as to make 
 •excitation useless, either galvanism with both large plate 
 electrodes over the stomach or spinogastric galvanization 
 with the negative pole over the epigastrium should be used. 
 The two methods are described under the electric treatment 
 of neurasthenia gastrica. 
 
 The faradic brush mildly applied on the dry skin increases 
 cutaneous sensibility and acts on deeper parts as a revulsive. 
 It may be used to modify the circulation of the stomach. A 
 plate electrode is held over an indifferent part, and the brush, 
 with a current sufficiently strong to excite hyperemia but not 
 much pain, is applied for a few minutes over the surface be- 
 tween the left sixth and tenth ribs, the median line, and the 
 spinal column. 
 
 Electricity is a valuable remedy in the treatment of the dis- 
 eases of the stomach when employed in a definite manner for 
 a definite purpose. Its use, regardless of the form, strength, 
 density, polar effect, points, and duration of the application, 
 and in the fond hope of thus accomplishing something, is a 
 waste of time. 
 
 Massage. — The physiological action of exercise differs in 
 important particulars from that of massage, the first being 
 voluntary, and the component parts of the body furnishing 
 the source of power, while in massage the patient receives 
 passively and is under the influence of force which has its 
 origin in the well-directed efforts of another person. The 
 voluntary muscular system furnishes about 45 per cent, of the 
 total weight of the body, and while in action draws to it the 
 arterial and drives out the venous blood. General exercise, 
 built up into a system in the gymnasium, is a powerful revul- 
 sive, and draws away the blood from the internal congested 
 organs ; but it uses stored force and fills the blood with waste 
 products. The weak may not be able to stand it, and it puts 
 additional work on the eliminating organs. It excites chiefly 
 the cerebrospinal nerves. 
 
 Abdominal massage uses little of the patient's force, forms 
 little waste matter, and excites chiefly the abdominal sym- 
 pathetic. It forces the lymph and the venous blood from 
 the abdominal cavity and raises arterial pressure by filling the
 
 PHYSICAL REMEDIES. 247 
 
 arteries with the pressed-out fluids. It consequently purifies 
 the tissues subjected to it. 
 
 Abdominal massage is decidedly an excitant remedy, and 
 is contraindicated in all forms of gastric hypersthenia, of acute 
 inflammation, of ulcer, of morbid sensibility, and of chronic 
 inflammation associated with functional excitation. Massage 
 can only cause cancer to grow and to spread more rapidly. 
 It should never be performed while the stomach contains 
 fermenting food, for it can do no good and disorders the 
 intestines. 
 
 A great deal of harm can easily be done by routine abdomi- 
 nal massage, and the physician must prescribe the form and 
 employ persons with special training to give it. The remedy 
 may be used: (i) To empty the stomach; (2) to relieve an 
 associated myasthenia intestinalis ; (3) to strengthen the 
 abdominal wall ; and (4) to improve the abdominal circula- 
 tion. 
 
 I. To empty the stomach by massage, procedures may be 
 used which act reflexly or mechanically. The reflex-acting 
 method utilizes the connection of the cutaneous nerves with 
 the abdominal sympathetic, the gentle excitation of 4:he skin 
 being transmitted to the muscular layer of the digestive tube. 
 The tip of the thumb rests lightly on the abdomen, between 
 the symphysis and the navel, and the ends of the fingers 
 rapidly circle about the umbilicus. No pressure is exercised, 
 the tips of the fingers being brought in mere contact with the 
 skin. A second circle maybe made, more directly and exclu- 
 sively over the stomach, with its central point over the left 
 costal border half way between the ensiform process and the 
 cartilage of the ninth left rib. Twelve or fifteen circles are 
 made about each central point, and repeated after an interval 
 of five minutes. The procedure is very useful to empty the 
 stomach in myasthenia without retention. The patient soon 
 learns how to do it intelligently. It should be employed 
 after each meal, at the time when the stomach should 
 normally be empty, the patient lying on the back with all 
 clothing loose. 
 
 Reflex excitation of peristalsis may also be employed to 
 strengthen the muscular layer in myasthenic retention. The 
 stomach should previously be emptied by lavage, and a 
 glass of cold water should be administered. 
 
 Zabludowski has recently described a good method of 
 emptying the stomach mechanically. The mechanical method 
 is used in the treatment of myasthenia, gastroptosis. and 
 obstructive retention where the gastric muscle is insufficient
 
 248 DISEASES OF THE STOMACH. 
 
 and quiet. If the muscular layer is hypertrophied, tonic, 
 and powerful, massage can do no good. Tiiis muscular con- 
 dition exists where there is obstructive retention, and is indi- 
 cated by the increased resistance, by the higher percussion 
 note, by the peristaltic sounds, and by the absence of splashing. 
 The massage is intended to restore muscular compensation 
 and to stretch the stricture of the pylorus due to non-malig- 
 nant disease, the compressed contents acting as the instrument 
 of dilatation. Manifestly, the massage expression through 
 the pylorus should be employed only in special conditions. 
 The stomach should be thoroughly washed out before the 
 evening meal, which should consist of food in a state of fine 
 subdivision. Four hours later massage expression may be 
 employed and the stomach left retracted under the influence 
 of circular cutaneous excitation. 
 
 The method recommended by Zabludowski follows the 
 direction of the natural peristalsis from the fundus to the 
 pylorus, and the manipulations are, briefly, as follows: 
 
 {a) A large fold of the abdominal wall and stomach is 
 grasped between the thumb and fingers of the right hand as 
 far to the left of the median line and as deep as possible ; 
 the contents thus caught up are thrown against the pylorus ; 
 this manipulation can be done successfully only when the 
 abdominal wall is thin and flabby. The method of Cseri is 
 better : The ulnar border of the left hand is pressed deep 
 into the abdomen along the greater curvature of the stomach 
 as it runs upward toward the pylorus ; the pyloric end of 
 the stomach lies in the palm of the left hand ; the extended 
 fingers and thumb of the right hand sink deep into the body 
 of the stomach and with a pushing stroke force the contents 
 toward the pylorus. 
 
 {b) Where the abdominal wall is thin and flabby, the 
 stomach may be divided into two cavities by the fingers 
 pressed with a kneading movement deep against the verte- 
 bral column. The contents of the p)'loric division are pressed 
 through the pylorus by moving the fingers to the right and 
 upward, dilating the orifice like a bougie. 
 
 {c) The finger-tips of both hands are pushed deep into the 
 abdomen along the left costal border over the stomach and 
 the oscillating hands knead the contents toward the pylorus, 
 while the fingers are kept constantly in vibration. This pro- 
 cedure is a powerful excitant of peristalsis. 
 
 {d) The stomach is grasped like the uterus in the placenta- 
 expression method of Crede, and the contents are squeezed 
 through the pylorus.
 
 PHYSICAL REMEDIES. 249 
 
 The procedures should be alternated. The massage should 
 never be painful and should be performed only while the 
 muscles are relaxed. The treatment should never continue 
 longer than ten minutes, the patient lying half the time on the 
 back, and the other five minutes on the right side. 
 
 2. Myasthenia intestinalis is often associated with myas- 
 thenia gastrica. The massage of the stomach should then 
 always be preceded by the mechanical emptying of the colon. 
 The methods described by Reibmayer accomplish this object 
 well. If the contents of the colon are fluid, the massage may 
 begin with the cecum ; but if, as is commonly the case, there 
 are solid fecal collections, the massage should begin with 
 the descending colon. The manipulations are the following : 
 
 The right hand is laid flat over the descending colon, with 
 the fingers outstretched and strengthened by the finger-tips 
 of the left hand over the metacarpo-phalangeal joints. The 
 hand is moved downward and inward, avoiding pressure 
 against the iliac bone, the fingers following the dip of the 
 sigmoid flexure into the pelvis. 
 
 The right hand, completely extended, is next placed over 
 the cecum, the fingers covering the umbilicus, and the ulnar 
 border is pressed deeper than the radial. In this position, 
 and under slight pressure of the balls of the little finger and 
 thumb (the other fingers remaining passive), the hand is 
 moved along the ascending colon to the right costal border, 
 across the abdomen in the course of the transverse colon, 
 along the left costal border, and over the remaining part of 
 the colon. Care must be used to avoid causing pain by pres- 
 sure against the bony prominences. 
 
 To empty the cecum, the masseur turns his left side to the 
 patient and places the right hand, with distended fingers 
 directed toward the symphysis pubis, over the right iliac fossa. 
 The fingers are strengthened by the tips of the fingers of the 
 left hand applied over the metacarpo-phalangeal joints. The 
 movement, with gentle pressure, is upward over the cecum 
 and the ascending colon until the fingers reach the right costal 
 border, and then inward, gradually relaxing the pressure as the 
 fingers pass near the umbilicus, to the starting-point. 
 
 The mechanical emptying is completed by repeating the 
 massage of the transverse and descending colon, and peri- 
 stalsis is excited by the reflex-acting cutaneous circles around 
 the umbilicus. Later, as the case improves, the solar and 
 splanchnic plexuses may be vibrated, and the contents of the 
 abdomen rolled between the vibrating hands. 
 
 3. To strengthen the abdominal wall the massage is limited
 
 250 DISEASES OF THE STOMACH. 
 
 to the abdominal muscles, and a systematic series of active, 
 passive, and resisted Swedish movements, aided by faradiza- 
 tion, is employed. 
 
 Abdominal Belts. — The object of mechanical treatment by 
 an abdominal belt is to increase abdominal tension and to 
 support or hold in replacement the dislocated abdominal 
 origans. In this way the vagosympathetic irritation is relieved 
 and the disturbed blood and lymph circulations are restored. 
 
 The abdominal viscera are hung to the posterior abdominal 
 wall and to the diaphragm above the plane in which they lie 
 when the body is erect. Consequently, pressure or constric- 
 tion at a higher point in the abdominal cavity than their 
 location maintains and increases the downward displacement. 
 It is, therefore, absolutely essential that the constrictions above 
 the umbilicus and over the hypochondria should be removed. 
 The stomach must be able to make room for itself on its own 
 level as it becomes more and more distended with food, and 
 not be forced to make room for itself by pressing and distend- 
 ing downward. No mechanical treatment can be of any avail 
 so long as this supra-umbilical constriction exists, and an effort 
 to support the abdominal organs will only result in the pro- 
 duction of excessive abdominal tension and in the compres- 
 sion of the stomach. 
 
 The bandage must exert a proper degree of pressure from 
 below upward and backward and hold the organs in reposi- 
 tion. The support should be very firm at the symphysis and 
 lose itself on the normal level of the transverse colon. 
 
 There are many varieties of abdominal belts or bandages. 
 The pelvic belt of Glenard is simple and sustains the abdo- 
 men. The modification of Montuuis is more suitable for 
 some cases. The abdominal corset of Landau is excellent for 
 increasing abdominal tension and for supplying an artificial 
 abdominal wall. The bandages of Teufel, of Boas, of Rosen- 
 heim, and of Bardenheuer embody useful principles and often 
 do well ; but it is best to have the bandage made to measure 
 so as to fit properly, and to choose the form which best meets 
 the mechanical indications of the particular case. 
 
 It is useless to apply a bandage with the organs in uncor- 
 rected displacement. The patient should assume the knee- 
 chest position and the displacements should be corrected. 
 The bandage is then tightened in place. If the organs are 
 very movable, — floating, — they must first and always be 
 replaced by one who knows how to do it. To attempt sup- 
 port without replacement is like fitting a truss on an unreduced 
 hernia.
 
 S } MP TO MA TIC TREA TMENT. 2 5 I 
 
 The bandage of support should be fitted on in the morning 
 while the stomach is empty, and may be removed at night, 
 while in the recumbent position, if abdominal tension is not 
 very low. 
 
 The belt constitutes an artificial abdominal wall, and should 
 be more and more elastic toward the upper border. The 
 natural abdominal wall should be strengthened by mas- 
 sage and electricity and by very gentle active movements. 
 The abdominal belt is an essential part of the treatment of 
 gastroptosis. 
 
 CHAPTER IV. 
 SYMPTOMATIC TREATMENT. 
 
 The object of the symptomatic treatment is the relief of 
 the manifestations of the diseases of the stomach which give 
 the patient special concern or discomfort. The most impor- 
 tant of these symptoms which require relief are loss of ap- 
 petite, pain, vomiting, and flatulencj^. 
 
 Loss of appetite, where there is no anatomical disease of 
 the stomach, is often relieved by orexin. The basic orexin 
 in fine powder should be given in a gelatin capsule in a single 
 dose of from three to five grs., preferably during luncheon, or, 
 as Penzoldt recommends, with a cup of bouillon at 10 a.m. 
 The drug should not be continued longer than a week, and 
 should never be given when there is an anatomical disease 
 of the stomach or when the kidneys are not healthy. All 
 medication which improves digestion increases the appetite, 
 particularly the remedies which excite secretion and arrest 
 fermentation or putrefaction. The appetite is also better 
 when nutritive exchange is active, and proper exercise in the 
 open air is one of the best means of increasing it. 
 
 Gastric pain may often be best relieved by the removal of 
 its proximate cause. Neutralization or combination of the 
 excessive hydrochloric acid may give relief, or the removal 
 from the stomach of its irritating contents may be required. 
 The latter is the only proper method when the pain is due 
 to retention and fermentation. Gastric pain is often neuralgic 
 in character. Antipyrin or one of the coal-tar analgesics 
 will then give relief; aconite and gelsemium and also arsenic 
 sometimes act well in the obstinate cases, and the specific
 
 252 DISEASES OF THE STOMACH. 
 
 action of quiiiin in malarial neural<^ia should be remembered. 
 The quinin is best given combined with small doses of mor- 
 phin. In hyperesthesia of the mucous membrane, nitrate of 
 silver is both a symptomatic and curative remedy, but should 
 be given only when the stomach is empty. Carbolic acid is 
 a good temporary substitute, and bromid of strontium before 
 meals is sometimes beneficial. The pain of the anatomical 
 diseases is relieved by nothing so rapidly and completely as 
 by morphin administered hypodermically. Codein is less 
 efficient, but possesses some advantages. The method of 
 administration is not a matter of indifference. Morphin 
 given hypodermically is eliminated by the mucous membrane 
 of the stomach, and about one-half of the injected dose can 
 be recovered in the water used in the performance of lavage 
 during the first two hours after the injection. The long-con- 
 tinued use of opiates diminishes the secretion of both the 
 hydrochloric acid and the ferments, and leaves the mucous 
 membrane hyperesthetic. A full dose of an opiate, however 
 administered, diminishes secretion, delays the digestive trans- 
 formation of the food (particularly starch), and decreases 
 peristaltic activity and the tonicity of the stomach wall. 
 The functions of the stomach are less disturbed by codein 
 than by any of the other anodyne derivatives of opium, and 
 the phosphate of codein (by mouth or hypodermically) is 
 the best preparation. Belladonna diminishes starch diges- 
 tion and prolongs the digestive period, but it controls 
 excessive gastric secretion. Coca is an excellent gastric 
 sedative when the pain is due to hyperesthesia of the niucous 
 membrane, but it is inferior in this respect to nitrate of silver. 
 A good preparation of cannabis indica is sedative and does 
 not disturb digestion. Menthol is unreliable and we have 
 often obtained no analgesic action from resorcin. The follow- 
 ing tablet is an excellent gastric analgesic, to which codein 
 may be added when the pain is spasmodic or very severe : 
 
 R . Kxt. belladonna.' ale. , 
 
 Ext. cannaljis indica.' (Squibbs). . . aa . . gr. y'j 
 Ext. cocx gr. iij. 
 
 In the treatment of all forms of gastric pain except that 
 produced by a local irritant in the stomach, the soothing 
 effect of hot external applications should be utilized. The 
 neuralgic cases are sometimes relieved by anodal sedative 
 galvanization. 
 
 The large number of remedies recommended for vomiting- 
 is good evidence of their inefficiency. Revulsion externally.
 
 PHYSIOLOGICAL TREATMENT. 253 
 
 ice internally, sips of champagne, sips of hot water, cocain, 
 carbolic acid, menthol, oxalate of cerium, small doses of 
 ipecac, and sometimes opiates hypodermically or by rectum — 
 all have their advocates. It is better to modify the treatment 
 according to the cause. When due to gastric irritation, it is 
 well to give large drafts of tepid water to wash out the 
 stomach, or, when possible, use lavage. After the stomach is 
 thoroughly emptied, an opiate should be administered hypo- 
 dermically or by rectum. The vomiting of food may some- 
 times be controlled by applying the compress of Winternitz 
 during digestion, or by the introduction of the food through 
 a tube, or by Merck's resublimed resorcin. The treatment of 
 this troublesome symptom is considered in the special part of 
 this book, and most of the remedies likely to prove of value 
 are given in the chapter on Habitual Vomiting. 
 
 The treatment of gastric flatulency is dependent on its 
 cause. The gas may be formed by fermentation, or by decom- 
 position of carbonates in the stomach, or may be swallowed 
 with the food. Gaseous drinks and waters containing car- 
 bonates should be excluded. The amount of air swallowed 
 with the food produces no disturbance unless the stomach 
 is myasthenic. The treatment of flatulency thus reduces 
 itself to the treatment of the fermentation or of the myas- 
 thenia. In either case, a glass of hot water will often enable 
 the stomach to expel the gas. Abdominal massage will also 
 cause the relaxed or distended stomach to contract and over- 
 come the expansibility of the gas. Strychnin, however, is 
 the sovereign remedy unless fermentation is the only cause. 
 Stimulants and nervines of various sorts are advocated with- 
 out good reason, and are administered with but little benefit. 
 This chapter will be ended without apology, for we have a 
 feeling akin to scorn against the symptomatic treatment of 
 diseases of the stomach. 
 
 CHAPTER V. 
 
 PHYSIOLOGICAL TREATMENT. 
 
 Physiological treatment is based on the functional state ot 
 the diseased organ. It has to do with potency, with force ; 
 with an increase or decrease of vital power ; with the ab- 
 normality displayed by the cell in the performance of its
 
 254 DISEASES OF THE STOMACH. 
 
 special or its general work. Physiological treatment is 
 directed against the quantitative or qualitative variation in 
 the normal activity of the cell; against the excessive or the 
 insufficient functional activity. 
 
 The abnormal functions, therefore, are either hypersthenic 
 or asthenic, and the aim of medication is the correction of 
 this or that state. A third possibility is the combination of 
 the two; or, rather, lawless, variable, uncontrollable activity. 
 The organ no longer works rhythmically. With the stomach 
 this lawless activity is clinically a dynamic affection. In all 
 cases the inconstant expression is due to the variable local ex- 
 citation, and can not be considered a distinct pathological 
 type. These variable conditions, consequently, do not demand 
 special consideration. The physiological treatment is directed 
 against the two states — hyperstheniaand asthenia. The treat- 
 ment, then, is either sedative or e.xcitant. 
 
 Hypersthenia Qastrica. — The physiological treatment of 
 this functional state is sedative, and is determined by the par- 
 ticular factor disordered, — sensation, secretion, motility, — by 
 the genesis of the trouble, and by its dynamic or organic 
 nature. 
 
 The indications maybe thus enumerated: (i) Protection 
 against irritation; (2) diminution of functional work; (3) 
 sedative medication. 
 
 I. The irritants against which it is necessary to protect 
 the hypersthenic stomach may be introduced with the food, 
 or they may be formed in the stomach, or they may be pre- 
 scribed as remedies. We have often emphasized the princi- 
 ple that the diet must be selected according to its physiologi- 
 cal action. In hypersthenia the diet must be so compounded 
 as to be as indifferent in its action as possible, and to combine 
 the free hydrochloric acid. 
 
 Another source of gastric irritation is the accumulation 
 of digestive products and secretions. Peptones e.xcite free 
 secretion, but the most excitant of digestive products are the 
 sugars. Consequently, the accumulation of these products 
 in myasthenia and in diminution of absorption should be 
 controlled. Germ products are even more irritating than the 
 digestive compounds. The protection of the stomach against 
 irritation requires careful selection of the diet and of the drugs 
 prescribed, prevention of stagnation and retention, and control 
 of the germ growth. 
 
 On the same principle which requires the exclusion of 
 irritants in the foods and drinks, and the prevention of stag- 
 nation and fermentation, all irritant drugs must be avoided.
 
 PHYSIOLOGICAL TREATMENT. 255 
 
 The neglect of this precaution often leads to failure. Medi- 
 cine is too frequently introduced into the stomach for some 
 particular purpose, it may be, but in total disregard of its 
 local action. 
 
 2. The diminution of the work of an excited organ is one 
 of the fundamental principles of therapeutics. The irritable 
 stomach deserves all the partiality that can be shown it. This 
 indication may be met by an indifferent diet of mere support, 
 including, in the severe cases, rectal feeding and absolute rest 
 in bed. 
 
 3. The sedative medication may be internal or external. 
 The uses of water and electricity have already been discussed, 
 but a few drugs, also, are valuable gastric sedatives. Opium, 
 coca, bismuth, aconite, veratrum viride, belong to this class. 
 The prolonged use of the alkaline mineral waters in large 
 doses is often beneficial, but the most reliable gastric seda- 
 tive in the chronic diseases of the stomach is nitrate of silver. 
 
 The effect of the nitrate of silver is most manifest when 
 the interior of the stomach is douched with a i : 2000 or 
 I : 5000 solution. In the morning, when the stomach is 
 empty, a pint of the solution is allowed to flow in through 
 the stomach douche, and is then withdrawn after a momentary 
 delay. To secure thorough removal the stomach may be 
 afterward douched with plain warm water, and the residue 
 after aspiration may be expressed. The application may be 
 made once or twice a week until the morbid sensibility and 
 excessive secretion subside. In supersecretion with stagna- 
 tion, the douching should be preceded by lavage. The use of 
 salt as a chemical antidote after the douching destroys the 
 sedative action of the silver. The nitrate of silver may be 
 administered by the mouth in solution, but is much less effi- 
 cient and its local effect is accidental. Very little is likely to 
 escape transformation into the inert chlorid or albuminate. 
 Given in pill, it is rendered thus inert before it can come in 
 contact with more than a very limited part of the mucous 
 membrane. The stomach douche presents the most efficient 
 and the only controllable method of using the drug as a local 
 sedative. 
 
 The physiological treatment of hypersthenia gastrica is not 
 the same in all its forms. When the excessive activity affects 
 secretion or the muscular layer in a constant manner, it con- 
 stitutes a particular dynamic affection or it is a sign of a par- 
 ticular anatomical disease of the stomach. The physiological 
 treatment constitutes a part of the treatment of the different 
 diseases and will be discussed in detail in the fourth and fifth 
 sections.
 
 256 DISEASES OE THE STOMACH. 
 
 Asthenia Qastrica. — The physiological treatment of asthenia 
 gastrica has for its aim the restoration of the depressed func- 
 tions ; but not every asthenic state is to be treated in this 
 way. Tiie restoration must be proven possible before it is 
 undertaken. Where disease has destroyed the noble ele- 
 ments such treatment would be useless. Where the depres- 
 sion is the result of active inflammation, excitation would 
 only do harm, 
 
 A very valuable remedy in asthenia gastrica is the stomach 
 douche. The douche should be given in the morning when 
 the stomach is empty, the funnel being raised about three 
 feet above the head of the patient so as to get a forcible rain 
 douche. Plain water, physiological salt solution, or carbonic- 
 acid water may be used. This is an excellent method of 
 exciting the functions of the stomach in myasthenia, in aden- 
 asthenia, and in neurasthenia gastrica. The stomach should 
 be left empty and quiet for half an hour afterward. 
 
 Food is one of the most powerful physiological remedies 
 for the treatment of this condition. The diet is so selected as 
 to exert by its action a stimulating effect on the motor, glan- 
 dular, or nervous function. Instead of favoring the stomach, 
 we push it on to its highest degree of capability. 
 
 The drugs employed in the physiological treatment of 
 asthenia are commonly known as tonics. These prepara- 
 tions are often prescribed indiscriminately, with a view to 
 building up the organism, but are indicated only in the cura- 
 ble states of depression, where a little excitation would do no 
 harm. 
 
 The simple bitters have a very doubtful effect on the func- 
 tions of the stomach. Given in large doses in health for a 
 period of several weeks, they sometimes derange digestion. 
 Their bad effect is rarely noticeable with small doses. The 
 action on secretion is slight, possibly increasing it when it is 
 normal or diminished. The motor function is uninfluenced 
 or possibly stimulated. The excitant action of the simple 
 bitters is more marked when they are combined with aro- 
 matics. The three most useful of the simple bitters are 
 gentian, columbo, and condurango. Columbo acts more 
 strongly on the movements of the intestines than do the other 
 two, but all diminish the decomposition products in the urine. 
 Condurango is also a sedative to the mucous membrane. 
 In myasthenia with delayed evolution and excessive secre- 
 tion, the fresh infusion, combined with nux vomica, is very 
 valuable. Clinically, it is well established that the bitters 
 sharpen the appetite and increase the secretion of saliva; and
 
 PHYSIOLOGICAL TREATMEN7\ 2^7 
 
 it may often be observed that under their influence nutrition 
 and the formed elements of the blood improve. The bene- 
 ficial effects of the bitters are best obtained by administration 
 a half hour before meals. It is probable that their effect is 
 greater on the stomach after they are out of it, or the stomach 
 is left by them in a state more susceptible to excitation. 
 While in the stomach their action on secretion, according to 
 well-conducted experiments, is no greater than that of dis- 
 tilled water. 
 
 Strychnin, on account of its more pronounced action, is of 
 more value than the simple bitters. It increases muscular 
 tone and excites secretion. Ipecac in very small doses has a 
 similar action on the stomach, and the wine of ipecac may 
 often be combined advantageously with the tincture of nux 
 vomica ; but when full doses of strychnin are desirable it 
 is best to give the alkaloid alone. We frequently prescribe 
 with excellent results in simple myasthenia and in adenas- 
 thenia gastrica a combination of these remedies in tablet 
 form : 
 
 R . Quininje, S^- ^ 
 
 Ipecac, • gr. j-L 
 
 Hydrastinin. niuriat., 
 
 Ext. nucis vomicae, aa gr. ^V- 
 
 All hypersthenic states are contraindications to the employ- 
 ment of these drugs. Neither should they be prescribed in 
 the anatomical diseases when excitation would do harm or 
 be useless. A third contraindication is often overlooked. In 
 neurasthenia gastrica they are badly borne, and in pro- 
 nounced myasthenia they may convert a painless into a pain- 
 ful affection. Anything more than the mildest excitation is 
 often injurious in myasthenia. In myasthenia of the colon a 
 purgative and even a laxative dose of cascara will often leave 
 an enterospasm which may continue for several hours. The 
 descending and transverse colon, on palpation, may be then 
 often felt as hard cords, which again dilate as the excessive 
 irritation ceases. The myasthenic stomach may become con- 
 tracted under the same influence as the intestine. Treatment 
 which makes myasthenia painful is too stimulating, and the 
 pain is the revealing sign of the injury being done. 
 
 Common salt and the bicarbonate of soda may be made to 
 exert a very beneficial influence on the depression of the 
 functions of the stomach. The bicarbonate of soda only acts 
 as an excitant of secretion when given in very small doses 
 before meals; five grs. in a wineglassful of water half an hour 
 17
 
 -'3< 
 
 DISEASES OF THE STOMACH. 
 
 before meals is sufficient. The salt should likewise be given 
 in very small doses (three grs.), in about Y^ per cent, solution, 
 on an empty stomach. The small quantity of the weak 
 solution acts after several days as a very energetic excitant. 
 Large doses or strong solutions after short use will produce 
 gastric catarrh. The sodium chlorid also stimulates peri- 
 stalsis. A wineglassful of Saratoga Kissingen or Vichy 
 sometimes give very satisfactory results, or other alkaline 
 saline waters will do as well. 
 
 CHAPTER VI. 
 BACTERIOLOGICAL TF^ATMENT. 
 
 The indications furnishetl by the bacteriological signs may 
 be variously met by: (i) Chemical antisepsis; (2) removal 
 and exclusion of the germs; (3) change of the culture soil 
 and removal of the pathological conditions which favor germ 
 growth. 
 
 Chemical antisepsis is with some practitioners a very 
 popular method of treating gastric fermentation, but it is the 
 least efficient and most injurious. The fermentation, not being 
 an accident, but developing in consequence of the existence 
 of favorable conditions, can be controlled only while the anti- 
 fermentatives are present in the stomach. Antiseptics are 
 also antipeptic, and irritate the mucous membrane, which in 
 fermentation is already in a state of excitation. This method 
 of treatment ordinarily deserves all the condemnation which 
 can be heaped upon it, but at times some benefit is derived 
 from the use of resubiimed resorcin (Merck), of salicin 
 (Merck), and of creosote. 
 
 The removal of the germs is more than a palliative meas- 
 ure, for it places the stomach in a position to perform its 
 functions unmolested. For the safe and efficient removal of 
 the germs there is no method comparable to stomach wash- 
 ing. As a remedy against excessive fermentation the opera- 
 tion should be thoroughly done according to the rules given 
 in the chapter on Physical Remedies. Thus the continuity of 
 germ development is rudely broken, and leaves comparatively 
 few germs to struggle for existence on a much decreased 
 amount of food. The exclusion of germs from the stomach
 
 CHEMICAL TREATMENT. 259 
 
 is an impossibility, but by most careful cleansing of the mouth 
 and throat, and by selection of well-preserved and freshly- 
 cooked food, much can be done to diminish the number 
 which find entrance. The mouth should always be made 
 sweet after the stomach washing. 
 
 A very valuable method of controlling fermentation is by 
 sudden and complete change of the culture soil. The 
 patient is placed for a day or two on an absolute nitrogenous 
 diet, and then this diet is suddenly changed for one consist- 
 ing of thoroughly cooked cereals, and again changed to a 
 proper mixed diet. This method is more applicable in acute 
 cases, where vomiting has partly emptied the stomach, a 
 meat and &^^ diet being most suitable to begin with. In all 
 cases the diet should be composed of such foods as are least 
 liable to undergo the form of fermentation prevailing in the 
 stomach. 
 
 Chemical antisepsis, lavage, and diet will prove only pallia- 
 tive if no change has been produced in the conditions which 
 permit the excessive fermentation. The most common condi- 
 tion is motor insufficiency, and the promotion of the churning 
 and evacuation of the stomach is one of the surest methods 
 of keeping it clean. The fermentation will return as soon as 
 the palliative remedies are stopped, provided the pathological 
 conditions — such as motor insufficiency and excessive secre- 
 tion — have not been discovered and successfully treated. 
 
 CHAPTER VII. 
 CHEMICAL TREATMENT. 
 
 The chemical treatment has to do with the treatment of 
 special symptoms by means of alkalies, acids, and the digestive 
 ferments. The alkalies are employed to neutralize the exces- 
 sive acidity of the contents of the stomach during digestion, 
 while hydrochloric acid and the digestive ferments are very 
 generally prescribed when the gastric juice is deficient. Con- 
 sequently, chemical treatment maybe required in hyperchylia 
 and in hypochylia. 
 
 Hyperchylia. — In hyperchylia the chemical treatment is 
 directed against the excessive hydrochloric acidity, which 
 may irritate the gastric mucosa and may disorder intestinal
 
 26o DISEASES OF TJJE STOMACH. 
 
 digestion. The excessive hydrochloric acidity is neutralized 
 by the administration of alkalies at the right moment an din 
 proper doses. 
 
 The alkalies have for a long time been employed enijiiri- 
 cally in the treatment of the diseases of the stomach, and their 
 universal use would indicate the great esteem in which they 
 are held by the profession. Their value in clinical medicine 
 is due to their physiological action on secretion and on nu- 
 trition, more than to their properties as antacids. As antacids 
 their effect is temporary and without permanent benefit, and 
 unless they be given properly, they may be injurious. 
 
 The alkalies most in vogue are the sodium, magnesium, and 
 calcium salts. The choice of the antacids is not arbitrary ; 
 for their neutralizing power and their action and the action 
 of their chemical products on secretion and on the bowels 
 may be important. Bicarbonate of soda combines less than 
 half its own weight of HCl, and forms common salt and 
 carbonic acid. Calcined magnesia combines nearly twice its 
 weight of HCl, and forms magnesium chlorid. Ammonio- 
 magnesium phosphate combines about its own weight of 
 HCl, and forms magnesium and ammonium chlorids and 
 phosphoric acid. The chlorids of soda and of magnesium 
 are much less energetic in their action on secretion and are 
 much less irritating than are the chlorids of calcium and of 
 ammonium. From the ammonio-magnesium phosphate is 
 liberated phosphoric acid, which is nearly as strong as HCl. 
 As antacids in the treatment of hyperchylia, we consequently 
 prefer magnesia usta and bicarbonate of soda; prescribing 
 enough of the magnesia to regulate the bowels, and correct- 
 ing its overaction by combining bismuth subnitrate with it. 
 Only enough of the antacids should be given to neutralize 
 the excess of HCl and to control the pain of hyperchylia. 
 The small doses may be repeated during the free HCl stage 
 of digestion, but it is rarely advisable to attempt to neutralize 
 the gastric contents completely. The HCl which is combined 
 with albiitiiin should not be neutralized. 
 
 Hypochylia. — Hypochylia is very common, and it may be 
 beneficial to supply the deficiency of secretion by the admin- 
 istration of hydrochloric acid and pepsin during digestion. 
 This method of treatment is very popular. Physicians 
 encourage it, it seems very rational to the laity, and drug- 
 gists flood the market with digestive mixtures. We assert 
 with emphasis that this supplementary chemical treatment 
 has no curative value, is of restricted temporary utility in 
 even suitable cases, and it may do positive harm.
 
 CHEMICAL TREATMENT. 26 1 
 
 Hydrochloric acid administered during the period of gas- 
 tric digestion disappears very rapidly from the stomach, and 
 it should always be given in combination with pepsin. Both 
 pepsin and hydrochloric acid are necessary for the peptoniza- 
 tion of albumin, and the acid and ferment are administered 
 proportionately, or nearly so, in hypochylia. 
 
 The acid-pepsin combination should be given only when 
 secretion is deficient and during the period of gastric diges- 
 tion. The time of administration and the dose should be 
 regulated by the functional signs and by the quantity and 
 quality of the diet. The greater the quantity of albumin in 
 the meal, the larger should be the doses and the sooner 
 should their administration begin. If the meal consists 
 largely of non-nitrogenous food, the smaller should be the 
 doses and the later they should be given. The supply thus 
 meets the physiological demand, and an opportunity is given 
 for salivary digestion. 
 
 In our experience the best results are obtained by repeated 
 doses during the period of gastric digestion. This period 
 has no fixed length, but varies with the character of the meal. 
 After a light meal that remains in the stomach about three 
 hours two doses will usually suffice — half an hour and an 
 hour after eating. After the chief meal, one or two more 
 doses may be given, an hour apart. In our experience it is 
 unnecessary to give enough pepsin and acid to completely 
 digest all the albumin in the meal. 
 
 The supplementary chemical treatment may be employed 
 when the disease of the mucosa permits a certain amount of 
 excitation. When the mucous membrane should be given rest 
 and protection, the administration of acid and pepsin and of 
 predigested foods is injurious. The supplementary chemical 
 treatment may be used when the work of the intestines, on 
 the efficiency of which the maintenance of the balance of 
 nutrition depends, must be lightened; but acid and pepsin, 
 and the vegetable ferments which act independently of the 
 presence of free hydrochloric acid, often disorder intestinal 
 digestion and increase intestinal putrefaction.
 
 SECTION IV. 
 THE DYNAMIC AFFECTIONS OF THE STOMACH. 
 
 All the disorders of the stomach which present no char- 
 acteristic patholoi^ical anatomy are classified as dynamic 
 affections. The displaced stomach may become diseased, or 
 the diseased stomach may become displaced, and it matters 
 not whether the disease of the stomach be anatomical or 
 dynamic. It may be thought preferable, when a displacement 
 of the stomach exists, to consider, for the sake of simplicity, 
 the dynamic affection as a complication or as an accidental 
 association. In like manner an anatomical disease of the 
 stomach may coexist with a dynamic affection, and the 
 anatomical disease may develop either before or during the 
 course of the dynamic affection. The symptoms are then the 
 expression of the dynamic affection combined with the symp- 
 toms and signs of the anatomical lesion. These complex cases 
 should receive recognition, and they are not rare, for disease 
 often defies simplicity and exclusiveness. The dynamic 
 affections have no characteristic pathological anatomy, but 
 their existence is neither destroyed nor excluded by the pres- 
 ence of anatomical lesions of the stomach. The anatomical 
 lesions may coe.xist with the dynamic affection, but they con- 
 stitute a separate and distinct disease. Some of the dynamic 
 affections may be described as " neuroses of the stomach " ; 
 some of them are " functional disorders"; but the dynamic 
 affections of the stomach may be in their nature neither the 
 one nor the other. 
 
 Practically, this is one of the most important sections of the 
 pathology of the stomach. Here disease presents itself in its 
 genesis, and the subsequent evolution, unless arrested by 
 proper treatment, may be represented by an inverted pyramid. 
 The trouble grows along deviating lines, and becomes more 
 and more irresistible. The physiological functions, one after 
 the other, are enlisted with the forces which make for disease. 
 The disease should be recognized and crushed in its pre- 
 anatomical stage if permanent damage is to be avoided. This 
 is the period when treatment will show its greatest power and 
 give the most brilliant results. 
 
 262
 
 THE DYNAMIC AFFECTIONS OF THE STOMACH. 263 
 
 A general characteristic of these affections is the speciahza- 
 tion of the unhealthy variation. The disease dissociates the 
 functions of the stomach and affects some one of them persis- 
 tently and in a particular manner. Now it is a disorder of secre- 
 tion or a motor trouble ; now it is a painful increase of general 
 sensibility or a particular sensation of the stomach which 
 demands attention. Digestion may be chemically perfect or 
 the stomach may churn and evacuate its contents uncon- 
 sciously, the appetite being good. One function is persistently 
 disordered ; the others remain intact. The affection may 
 be paroxysmal or intermittent, but the variation from the 
 normal always recurs in a particular case in the same manner. 
 In the course of the disease, however, the tendency is to 
 spread to the other functions, and the primary dynamic affec- 
 tion may be supplanted or overshadowed by another. The 
 true dynamic affections of the stomach never appear " like a 
 panorama with ever-changing scenes." Such disorders are 
 symptoms and nothing more. To consider the variable gas- 
 tric expression of a disease of another organ as a distinct 
 morbid entity is manifestly erroneous. The gastric disturb- 
 ances cease when the exciting disease is cured. A true 
 dynamic affection is capable of an independent existence, be 
 it primary or be it secondary. 
 
 The manner of development is often peculiar. Suddenly 
 beginning, without any dietetic error, and persisting for a vari- 
 able length of time, the end may be no less sudden ; or slow 
 in its commencement, progressing by leaps, the termination 
 comes when least expected. The unhealthy variation is not, 
 or may not be, persistent, but intermittent. Rapid changes 
 for better or for worse, without a perceptibly adequate cause, 
 are characteristic. This obscure peculiarity is generally a 
 contribution from the abdominal sympathetic, or from the 
 brain, or from the general but temporary state of the body. 
 
 The dynamic affections may be in no close relation with 
 the digestive act or with the alimentation. The symptoms 
 may exist only or chiefly during the digestive period in some 
 of the cases; but it is also true that the symptoms may occur 
 when the stomach is empty. Digestion as a chemical process 
 may be perfect, and the digestive disorder may exist only 
 because the patient suffers and complains during the period 
 of functional activity of the stomach. A large, a small, a 
 mixed, and a simple meal may be equally well or badly 
 digested. The physical state of the food maybe of no greater 
 influence than in health. There may be no constant relation 
 between alimentation and digestion on the one hand and the
 
 264 DISEASES OF THE STOMACH. 
 
 symptoms on the other. Nutrition may be well preserved, 
 and sometimes even in spite of insufficient alimentation, 
 although subnutrition (pain, vomiting, starvation) is some- 
 times as marked as in the grave anatomical diseases of the 
 stomach. These peculiarities are often due to the existence 
 of a trouble in some other part of the body which selects the 
 stomach as the center of its manifestation. 
 
 The dynamic affections of the stomach develop preferably 
 in a particular soil. This is the neurotic or nervous tempera- 
 ment or constitution. Some persons are born with a delicate 
 and overwrought nervous system, and others acquire it by the 
 mode of life, by bad habits, and by too exclusive and exces- 
 sive mental or moral development. The resulting condition is 
 unstable nervous equilibrium — the forerunner often of the 
 nervous affections of the stomach. 
 
 Most of these affections are more frequent in women than 
 in men, the proportion being about one to ten in youth, and 
 gradually changing until the sexual difference becomes much 
 less (about one to two) during the last third of life. The 
 chief exciting causes in men are mental overwork and the 
 reverses of fortune. The dynamic affections are common 
 among women near the end of the social season in large cities, 
 but are infrequent among country girls; for in spite of the 
 pure air and sunshine of the country and the freedom from 
 the withering touch of " culture," anxiety and sorrow and 
 disappointment, and disorders of menstruation, of reproduc- 
 tion, and of lactation, have the same influence in the hut as 
 in the palace. The predominance in women may be explained 
 in part by their mode of life, their delicate organization, and 
 their peculiar diseases. 
 
 The marked influence of the mind and feelings on the func- 
 tions of the stomach is a fact long established by observation. 
 Physiology and anatomy have given no satisfactory e.xplana- 
 tion of this intimate relation of the central and sympathetic 
 systems; but the recent studies of Koiliker and others have 
 thrown some light on this obscure matter. The sympathetic 
 is a richly ringed chain of unipolar and multipolar cells con- 
 necting with each other and directly and indirectly with the 
 central cells of the cerebrospinal system. The units of both 
 systems have psychic and somatic functions. As regards 
 the central nervous system, the sympathetic cells are of two 
 kinds — the dependent and the independent. The independent 
 ganglionic cells are chiefly motor, and innervate the whole 
 involuntary muscular system, giving tonicity, producing con- 
 tractions of the muscular fibers, and probably regulating also
 
 THE DYNAMIC AFFECTIONS OF THE STOMACH. 265 
 
 the caliber of the blood-vessels. Some of these cells are prob- 
 ably sensory, and influence secretion. The dependent cells 
 are in part sensory, and convey, particularly in disease, the 
 indistinct visceral impressions to consciousness ; and in part 
 are motor, and enable the central system to influence indirectly, 
 through the ganglia, both the involuntary muscles and the 
 secreting glands. This discloses, in brief, the anatomical basis 
 of the fact long known to the clinician — the influence of the 
 mind and feelings on the functions of the stomach. 
 
 In many of the dynamic affections of the stomach the 
 nervous system is disturbed out of all proportion to the local 
 trouble, and insomnia, disorders of sensation, tachycardia, 
 faintness, dilatation of the pupils, hot flushes, and blushing 
 are very common. In health the organ does its work silently, 
 but when the sympathetic is irritable, digestion produces an in- 
 definable discomfort, and distant associated disorders develop. 
 The symptoms are not characteristic, and they may be 
 very similar in the anatomical diseases to the manifestations 
 of the dynamic affections. In the one, however, is the con- 
 stant and controlling and palpable anatomical lesion, and in 
 the other is the invisible abnormality, recognizable only by its 
 effects.
 
 CHAPTER 1. 
 THE SENSORY DYNAMIC AFFECTIONS. 
 
 I. BULIMIA. 
 
 The nervous affection of the stomach characterized by a 
 sudden, imperative desire for food, and occurring in par- 
 oxysms and more frequently than in health, and greater than 
 the needs of nutrition, is known as bulimia {^ouq = ox, and 
 Mfxaq = hunger). Other names for the same affection are 
 hyperorexia {u-ip = excessive, and ope^iq = appetite) and 
 cynorexia [x'jiov = dog, and opt^iq =: appetite). 
 
 Etiology. — Bulimia is most frequent between the ages of 
 fifteen and forty, and in the female sex. It occurs as a 
 symptom or association of some cases of ulcer, of functional 
 adenohypersthenia, of hypersthenic gastritis, and, very rarely, 
 of carcinoma and of obstructive and myasthenic retention. In 
 mental diseases, and in organic cerebral troubles, a noteworthy 
 percentage of the cases occur. Hysteria and neurasthenia 
 are responsible for some of the cases. Disease of the male 
 and female sexual organs may excite the affection. Syphilo- 
 graphers report some cases occurring during the third and 
 sixth months of syphilis. Basedow's disease, intestinal worms, 
 pulmonary tuberculosis (first and second stages), and preg- 
 nancy are found among the causes. Rupture of the thoracic 
 duct, tuberculosis of the mesenteric glands, menorrhagia, 
 intestinal fistula, and intestinal hy^permotility may cause 
 excessive hunger; but it is not evident that the desire for 
 food is out of proportion to the needs of nutrition. Bulimia 
 may be central, reflex, nutritive, symptomatic, and idiopathic. 
 As an unassociated affection of the stomach, it is most com- 
 mon in the neuropath. 
 
 Pathology. — The pathology of the affection is obscure. 
 Irritation of the encephalic hunger-center seems a plausible 
 explanation of the cases due to diseases of the brain and of 
 nutrition. Other cases appear to be due to the irritation 
 of the nerve-endings or centers of the vagosympathetic. 
 Hunger is normally excited by the action on the medullary 
 hunger-center of the changed quality or quantitv of the blood. 
 
 266
 
 THE SENSOR Y D YNAMIC AFFECTIONS. 267 
 
 It would seem that bulimia is not excited in this manner, for 
 it may be quelled by food in the stomach before there has 
 been time for its absorption, and the attacks are in no relation 
 to the composition of the blood or to the needs of nutrition; 
 but it should be remembered that sensations in the stomach 
 may inhibit the hunger-center or they may excite it. There 
 is nothing against the supposition that either peripheral or 
 central causes may be present and active. Clinically, there 
 is no doubt that this pathological, excessive, imperative 
 hunger is expressed by sensations located in the stomach, 
 and it may be accompanied by the very rapid evacuation of 
 the contents of the stomach into the duodenum. 
 
 Clinical Description. — In the mild form, a sudden, strong 
 desire for food may occur at any moment during the day or 
 night, while the stomach is full and active, or in repose. 
 There is a little discomfort and uneasiness, possibly a little 
 headache or vertigo, a slight burning or gnawing sensation in 
 the stomach, but the desire for food is not imperative, although 
 it is exaggerated, and the attack passes off after a little food 
 or drink is taken into the stomach, and, after intervals of very 
 variable length, may return suddenly, unexpectedly, and 
 inexplicably. 
 
 The severe form is a much more serious affection. The 
 beginning is sudden, inexplicable, and violent, occurring soon 
 after a meal, while the stomach is empty, during the day or 
 night. The affection may be continuous, the only relief being 
 obtained during a short period after eating; this clinical form 
 may be accompanied by violent exacerbations, which are 
 most frequent in the forenoon. 
 
 The attacks may also be irregular or periodical, and the 
 course intermittent, with short or with very long intervals. 
 This lawlessness, or absolute disregard for all rules, is a dis- 
 tinctive characteristic. If the desire is not satisfied, the 
 peculiar, indefinable visceral sensations become more and 
 more unbearable, there are burning and pain in the stomach, 
 and there may be headache, ringing in the ears, and vertigo ; 
 or the face may become pale, the extremities cold, and the 
 patient may faint. The desire may become so strong as to 
 overpower the moral sense, and food be taken regardless of 
 its quality or ownership or of the surroundings. After the tak- 
 ing of food the sensations subside, but the effect is inde- 
 pendent of the quantity, the quality, and the nutritive value 
 of the food. The attacks may be quelled by eating a little 
 food, or very large quantities may be required to still the 
 hunger. But often the bulimia soon returns, imperative in
 
 268 DISEASES OF THE STOMACH. 
 
 its sti"enL;;th, and without apparent reason. In the intervals 
 between the attacks tlie appetite may be normal, or the severe 
 attacks may be followed by loss of appetite, the hun<jer-center 
 beini^ apparently exhausted or completeU' inhibited. 
 
 The functions of the stomach may be normal or the evacu- 
 ation of the contents may be too rapid. The affection is fre- 
 quently associated with excessive hydrochloric acidity, but 
 this functional adenohx-persthenia may alternate with normal 
 secretioti. At least one important functional disturbing influ- 
 ence is irregular and immoderate eating. The course of the 
 affection is variable, and it may terminate in spite of the per- 
 sistence of the causative disease or condition. It is rebellious 
 when due to encephalic disease, and it may disappear spon- 
 taneously in hysteria. Bulimia is sometimes the cause of 
 myasthenia gastrica. of gastritis, and of intestinal disease. 
 
 Differential Diagnosis. — Acoria, polyphagia, and bulimia 
 are often confounded. In acoria, the food eaten does not sat- 
 isfy; the patient never feels that he has enough, while the 
 desire for food may be normal or less than normal. In pol)'- 
 phagia there is a good appetite associated with a delayed 
 feeling of satisfaction; or, at least, the sensation of having 
 eaten enough does not become so strong as to interfere with 
 the enjoyment of eating more — this is common gluttony. 
 In bulimia there is strong, imperative, often unbearable 
 hunger, which may be satisfied. From the form of gastralgia 
 which occurs only when the stomach is empty it is distin- 
 guished by the strong and imperative appetite which accom- 
 panies the pain, and by the occurrence of some of the attacks 
 when the stomach still contains food. 
 
 Treatment. — The etiological treatment is no less essential 
 in bulimia than in the other nervous affections of the stom- 
 ach. The hysteria or neurasthenia may demand a combined 
 systematic cure, consisting of isolation, rest, diet, massage, 
 electricity, hydrotherapy, and suggestive moral control. The 
 other causative diseases require particular medication, a mere 
 outline of which would here be out of place. 
 
 Antipyrin, or a similar analgesic, may moderate the sever- 
 ity of the attack. Opium or codein may also be used. Both 
 of these drugs are valuable in the diabetic form. The bromids 
 of strontium and arsenic are palliative, and sometimes rapidly 
 curative, remedies. Fifteen grs. of the strontium salt may be 
 given three or four times a day, half an hour before eating, or 
 tablets of the arseniate of soda (Jjj- of a gr.) should be given 
 during the period of gastric activity. We have obtained the
 
 THE SENSORY DYNAMIC AFFECTIONS. 269 
 
 best results from a combination of codein, extract of coca, and 
 extract of hyoscyamus. 
 
 The intragastric douche may be of some service, and several 
 glasses of hot water, given in the same manner as in the treat- 
 ment of chronic gastritis, are sometimes beneficial. 
 
 The diet is determined in part by the associated disease, and 
 should be sufficient to supply the needs of nutrition. Milk, 
 finely-divided cereals, lean fish, the soft part of small, fresh 
 oysters, the least excitant meats, dry toast, indifferently acting 
 vegetables, etc., may be combined, and ordered in small and 
 frequent meals. Sweets should be excluded, but enough fresh 
 butter (unsalted) should be ordered to furnish the needed 
 quantity of fat. The patient should live and exercise in the 
 open air, and whenever subnutrition exists a very nourishing 
 diet is absolutely essential. 
 
 11. ACORIA. 
 
 Acoria (a, privative, and -/.opiw^vin, I have enough ; or y.6jt<iq, 
 satiety) is a rare nervous affection of the stomach, characterized 
 by loss of the special sensation of satiety. The patient never 
 feels that he has eaten enough, whether the meal be small or 
 very large. The appetite is no sharper than in health, indeed, 
 it is often diminished, and the proper quantity of food to be 
 eaten in order to avoid overloading the stomach must be esti- 
 mated by reasoning. 
 
 Nature and Causation. — Some authors claim that the affec- 
 tion is a peripheral anesthesia, while others, whose views are 
 upheld by autopsies, have found the trouble to be due to 
 compression of the pneumogastrics and to softening of the 
 nuclei of origin of their posterior roots. Acoria may be 
 encountered in diabetes, but the large majority of cases occur 
 in the neuropath, particularly after shock and depressing 
 emotions (neurasthenia and hysteria). It may be produced 
 by the crushing influence of a great sorrow. Acoria is an 
 asthenic affection, and it is never associated with bulimia. 
 
 The sensation of satiety is not a mere negative sensation, 
 as some contend, signifying the entrance of the hunger-center 
 into a state of repose Acoria may coexist with anorexia. 
 Neither is acoria a mere continuance of the hunger-center in 
 a state of excitation, for the desire for food may, in this affec- 
 tion, disappear during the course of a meal in spite of the fact 
 that the patient does not feel that he has had enough. Some 
 of the patients with acoria have no sensation of fullness and
 
 2/0 DISEASES OF THE STOMACH. 
 
 weight from overloading the stomach with food or from 
 strongly inflating it with air, but others complain of pain as 
 well as fullness and heaviness in the abdomen. In one of 
 our cases we were able to locate these latter sensations in the 
 colon. It seems probable that the sensation of satiety is 
 identical with a particular state of the gastric " muscular 
 sense," and may be intensified by certain associated sensations, 
 as weight, fullness, discomfort, and cessation of the appetite. 
 Acoria, in keeping with this view, is a special gastric anesthe- 
 sia, which may be central or peripheral in origin. 
 
 Diagnosis. — The diagnosis consists in the detection of the 
 symptom, and, when possible, also of its cause, the etiology 
 serving as a guiding thread in the search. The only mani- 
 festation of acoria is the loss of the sensation of satiety, and 
 the patient is exposed to myasthenia and gastritis from over- 
 eating. 
 
 Treatment. — The treatment of acoria consists chiefly in 
 moral management, hygiene, and excitant hydrotherapy. The 
 intragastric cold douche may be tried, and the hot or cold 
 needle-bath should be used to tone the nervous system. Gal- 
 vanization of the vagosympathetic, the cathode over the 
 stomach, and the anode moved over the cervical centers, in 
 the manner described in the chapter on electric treatment, 
 should be tried. Less active are intragastric and epigastric 
 electrization. Strychnin is valuable, and it should be given 
 in increasing doses to the full physiological effect, and then 
 continued for some time in ordinary doses. Frequent and 
 small meals should be given, for the anesthesia is not likely 
 to be relieved by overdistending the stomach. The treatment 
 must also be causative, and a systematic cure may be required 
 by the neurasthenia or by the hysteria which so frequently 
 accompanies acoria. 
 
 ill. PAROREXIA. 
 
 Parorexia {7raf)d, aside, and of^e^ie;, appetite) is a nervous per- 
 version of the appetite. Bulimia, anorexia, and acoria are 
 quantitative variations of the special sensations of the 
 stomach ; but parorexia is qualitative. 
 
 The appetite may be selective, and there may be a craving 
 for special articles of the ordinary diet — pickles, sweets, ices, 
 spices, condiments (malacia). This common perversion hardly 
 deserves consideration in itself, unless accompanied by ex- 
 clusion of the more nutritive foods; but it may play an im-
 
 THE SENSORY DYNAMIC AFFECTIONS. 2'J I 
 
 portant part in the etiology of the diseases of the stomach. 
 The appetite may be more seriously perverted, and non- 
 alimentary, injurious, even disgusting articles may be eaten 
 (pica). This form is common among the little plantation 
 negroes of the South, — the so-called " dirt-eaters," — and 
 seems to be more prevalent in the spring and in malarial 
 regions. It may be associated with bulimia, and the immediate 
 prevention of the pernicious habit may cause great suffering, 
 which is relieved by the administration of food. It is a popular 
 belief that "dirt-eating" is a sign of intestinal worms, and 
 the association often exists. The habit may seriously affect 
 digestion and nutrition, and is a cause of gastro-enteritis. 
 
 Parorexia is most common in the chlorotic or neurotic 
 girl, particularly during the menstrual period. It frequently 
 accompanies pregnancy, and may be caused by sexual 
 excesses. 
 
 The insane and the hysteric may swallow all sorts of 
 things — pins, needles, urine, feces ; but this is a disease of 
 the mind, and not a perversion of the appetite. 
 
 Treatment. — It is difficult to formulate a general treatment 
 of parorexia. It is an irritative affection, and sedation is the 
 controlling indication, which should be combined with good 
 digestive hygiene and with the management of the associated 
 condition. The stomach of the "dirt-eater" should be 
 thoroughly washed out, and the complicating excessive 
 secretion, bulimia, hypersthenic gastritis, malaria, intestinal 
 worms, enteritis, anemia, or inanition should be given proper 
 attention. 
 
 IV. ANOREXIA NERVOSA. 
 
 Complete loss of appetite may be a symptom of a large 
 number of diseases, and does not constitute anorexia nervosa, 
 which is a very serious nervous affection of the stomach. 
 The appetite in this disease may be completely lost, but the 
 loss is associated with a systematic refusal to take food for a 
 particular reason or motive. The mind is up in arms, and 
 with rare composure excludes all but a little food, and seems 
 satisfied with' the result. The loss of appetite is the "only 
 gastric symptom. The other symptoms are mental and those 
 that result from the voluntary starvation. 
 
 Etiology. — Anorexia nervosa is a disease of the adult neu- 
 ropath, but it may also develop in persons who are neither 
 neurotic nor nervous. It is most frequent between fifteen
 
 2/2 DISEASES OF THE STOMACH. 
 
 and twenty, and cases are very rare before this age and 
 after thirty. Most commonly met with in young girls; 
 it may also occur in young men. It is almost unknown 
 in the active, outdoor-living country girl, and develops more 
 frequently in the nervous, delicately constituted girl who is 
 brought under the withering influences of enforced culture 
 and imprisoned inactivity. It is sometimes, but rarely, en- 
 grafted on a painful affection of the stomach, and is frequently 
 associated with displacements of the abdominal viscera ; but 
 no causal relation of this kind can be established, and the 
 association is accidental, the deforming effects of the corset 
 being very common. 
 
 The insane sometimes persistently refuse to take food ; 
 and hysteria seems able to mimic everything, and includes 
 anorexia. This is the symptomatic form. 
 
 The primary form has been attributed to anesthesia, or to 
 perversion of the sensibility of the gastric nerves (Fenwick), 
 which prevents the starving tissues from giving expression to 
 their need of nutriment. This theory is plausible, and the 
 condition seems almost essential to the successful and com- 
 placent carrying out in practice of the steadfast and wilful 
 refusal to take sufficient nourishment. 
 
 The adoption of a very insufficient diet maybe self-imposed 
 for a variety of reasons. The developing distaste for food is 
 encouraged, and one article after another is excluded " because 
 I do not like it," or " because this food increases my discom- 
 fort, and it is useless and harmful to eat what you can not 
 digest." In some cases the conduct resembles closely hys- 
 terical posing, and is a plea for sympathy and for attention. 
 The solicitude of family and friends only encourages the patient 
 to persist in the voluntary starvation. Shock, grief, great 
 sorrow, disappointment in love, and all causes of moral depres- 
 sion may mark the beginning of the disease. In many cases 
 there is no explanation of the affection to be found in the 
 habits, the circumstances, or the surroundings. 
 
 Clinical Description. — The clinical history of anorexia ner- 
 vosa is that of slow, progressive inanition occurring under 
 peculiar circumstances. In the beginning, digestive power is 
 normal, and the insufficient diet is not enforced by a digestive 
 disease but is adopted and maintained for certain motives or 
 reasons known to the patient. 
 
 In the early stage, for a short while, the weight and the 
 strength may be preserved. Great activity is sometimes 
 shown by patients in order to prove the correctness of their 
 conduct, and they often show a peculiar nervous restlessness.
 
 THE SENSORY DYNAMIC AFFECTIONS. 273 
 
 The loss of color and the appearance of ill health may be 
 hardly noticeable. This stage lasts longer in hysteria, of 
 which the anorexia nervosa may be monosymptomatic, and 
 seems to bemade possible by the diminished nutritive activity, 
 which is common enough in hysteria. 
 
 The inanition progresses and becomes more evident — in 
 diminution of strength and weight, in the slow pulse, the cold 
 extremities, constipation, scant and cloudy urine. The sleep 
 is restless, disturbed by dreams, and there is commonly in- 
 somnia. The ankles may swell, the patient grows weaker, 
 and excessive activity produces exhaustion. The family and 
 friends become alarmed ; but the patient, irritable and moody, 
 is satisfied, and makes no effort to take more food, which, if 
 forcibly or authoritatively given, may be rejected by vomiting. 
 
 If the slow inanition is not arrested, the condition becomes 
 more and more serious. Pale, emaciated, weak, haggard, the 
 patient stands on the verge of exhaustion, which is the second 
 stage. The temperature is usually subnormal, but may be 
 normal, or there may be at times slight fever. Inanition- 
 delirium, with hallucinations, develops. All food may be 
 refused. The digestive power is correspondingly depressed 
 and the stomach may be intolerant. Constipation is obstinate, 
 and the hard, lumpy stool consists of the secretions of the 
 digestive tube. There may be periodical diarrhea, accom- 
 panied by the discharge of false membrane. The abdomen is 
 sunken and the anterior abdominal wall is nearly in contact 
 with the vertebral column when the patient lies on the back. 
 The skin is rough, dry, and hangs like a bag around the flabby 
 muscles and the prominent bones. The features are wasted, 
 and the sunken eyes, with dilated pupils, are surrounded 
 with dark rings. Bedsores develop, and the exhaustion may 
 end in collapse, rapid fall of temperature, and death ; or a 
 fatal termination may occur earlier through pneumonia or 
 some other complicating affection, the half-starved body fall- 
 ing an easy prey to bacterial invasion. 
 
 The urine diminishes in quantity, and in the stage of exhaus- 
 tion is very scant, and only four to six gm. of urea are passed 
 in the twenty-four hours. Albuminuria is exceedingly rare. 
 
 The blood is that characteristic of simple inanition. The 
 percentage of red cells divided by the percentage of hemo- 
 globin is equal to one The fresh specimen of the blood 
 examined with the microscope may be much better than the 
 appearance of the patient would lead one to expect. The 
 number of red corpuscles in the cubic millimeter may be 
 nearly normal, the volume of the blood being probably 
 18
 
 274 DISEASES OF THE STOMACH. 
 
 diminished, and this vital fluid suffers only after most of the 
 stored fat and muscles have been eaten away. The number 
 of white corpuscles in the cubic millimeter of blood is very 
 small, fallinf^ as low as 2000. 
 
 Diagnosis. — A complete loss of appetite, the absence of 
 any serious organic disease, the mental condition, the charac- 
 teristic genesis and evolution, the slow progressive inanition 
 due to an insufficient diet, — leave those who have seen the 
 disease in little doubt as to its nature. 
 
 Differential Diagnosis. — A large number of diseases are 
 accompanied by loss of appetite and by emaciation. The 
 appetite is diminished or lost in most of the febrile diseases. 
 Diseases of the blood, cachectic conditions, severe intestinal 
 diseases, the painful diseases of the abdomen, chronic malaria, 
 and some cases of tuberculosis, are accompanied by loss of 
 appetite. Opium, alcohol, tobacco, digitalis, and many other 
 drugs, when used for a long time, destroy the appetite. 
 Chronic asthenic gastritis, gastric retention and carcinoma 
 are usually accompanied by loss of appetite ; but in all 
 these diseases the patients are alarmed at their condition, 
 and are willing to eat, and do all in their power to get well. 
 The causative disease will be discovered on examination. 
 When the loss of appetite is symptomatic, symptoms are 
 present which do not belong to the symptom-group of ano- 
 rexia nervosa, the blood and urine changes of which may 
 also be valuable differential signs. In the early stage, the 
 gastric functions will be found normal, and even in the stage 
 of exhaustion the digestive power may be good. There are 
 no functional signs of an organic or functional disease of the 
 stomach. 
 
 Tubercular meningitis and tubercular peritonitis may be 
 difficult to exclude. The somnolence, and the delirium in 
 the advanced stage, if the patient be then seen for the first 
 time, and the progressive character of the trouble, may well 
 excite suspicion. But other signs of these diseases may be 
 present, and the wilful and dogged refusal of food, in spite of 
 the integrity of gastric digestion, is characteristic of anorexia 
 nervosa. 
 
 Treatment. — The indications in the management of a case 
 of anorexia nervosa are: (i) To restore the balance of nutri- 
 tion ; (2) to treat the gross symptoms ; (3) to improve the 
 mental and nervous condition. 
 
 In the early stage it is difficult to secure the co-operation 
 of the family and friends, who often fail to see the necessity 
 of firm and absolute control of the patient. The digestive
 
 THE SENSORY DYNAMIC AFFECTIONS. 2/5 
 
 power is still good, and in order to meet the first indication it 
 is only necessary that a sufficient quantity of food be given. 
 To do this, while surrounded by the family and friends, may 
 tax all the resources of the physician. 
 
 It is unnecessary to prescribe a restrictive or exclusive diet. 
 The articles may be selected from the diet of health, and the 
 taste of the patient should be taken into consideration. But 
 the physician who accepts suggestions runs the risk of losing 
 his authority, and without moral control his efforts will prove 
 useless. A bitter tonic may be given, — strychnin, quinin, 
 columbo, etc., — but this alone will do little good. Fowler's 
 solution combined with an aromatic bitter may be tried; or 
 the interior of the stomach may be douched with a ^ per cent, 
 salt solution or with a bitter infusion (Kussmaul, Fleiner). 
 Penzoldt recommends orexinum basicum (four grs. in a cap- 
 sule or wafer at ii a.m., with a cup of bouillon). The con- 
 stipation will disappear with the increased amount of food ; 
 and warm clothing, moderate exercise, hydrotherapy, and 
 other measures to tone the nervous system should not be 
 neglected. The physician must assume complete control, and 
 regulate minutely the mode of life, and strictly enforce a 
 sufficient diet and proper hygiene. 
 
 In the advanced stage the patient should be isolated, and 
 given a gentle but firm nurse. If the stomach is intolerant, 
 rectal nourishment should be used ; and milk, eggs, and meat 
 juices, etc., should be given by the mouth as soon as the 
 vomiting, which is a rare complication, is under control. 
 Absolute rest in a warm bed, systematic feeding, using 
 authority rather than the stomach-tube, massage, electricity, 
 hydrotherapy, are the elements of the combined rest-cure. 
 Few symptoms require drugs for their control, and it is a bad 
 plan to get these patients accustomed to their employment 
 and dependent upon them. Supplementary chemical treat- 
 ment with pepsin and with hydrochloric acid may be of some 
 aid in securing the digestion of a sufficient quantity of food 
 in the beeinniner of the treatment. 
 
 V. GASTRALGIA NERVOSA. 
 
 Gastralgia is an intermittent, painful affection of the stom- 
 ach, occurring in paroxysms independent of the period of 
 functional activity or of the existence of another disease of 
 the stomach. It is in its nature the gastric cry of an irritated 
 nerve-ending or nerve-center — a pneumogastric neuralgia.
 
 276 DISEASES OF THE STOMACH. 
 
 Etiology. — Paroxysmal gastric pain may be symptomatic, 
 reflex, central, or nenralgic. 
 
 Symptomatic paroxysms of gastric pain occur in ulcer of 
 the stomach, in cancer, in obstructive and myasthenic reten- 
 tion, in acute (toxic or mjxotic) and chronic (h}-persthenic 
 and atrophic) gastritis, in adenohypersthenia gastrica, in gas- 
 tric spasm and spasm of the orifices, in perigastritis and peri- 
 gastric adhesions, and in gastroptosis. The paroxysms of pain 
 associated with these diseases should not be confounded with 
 gastralgia nervosa, nor should painful gastric cramps be 
 described, as is done by some authors, under the heading 
 " gastralgia," which is a neuralgia of the stomach. 
 
 Reflex gastric pain is usually spasmodic and not neuralgic. 
 Gastralgia, however, is very seldom caused reflexly by dis- 
 eases of the generative organs, of the liver, of the spleen, of 
 the pancreas, and of the bladder. 
 
 Painful gastric crisis may be produced by diseases involv- 
 ing the nuclei of origin of the pneumogastrics (tabes, multiple 
 sclerosis, myelitis, and tumors), by compression of the trunks 
 of the pneumogastric nerves, and by irritation of the periphe- 
 ral endings of the pneumogastrics or of the sympathetic 
 ganglia. 
 
 Idiopathic gastralgia nervosa is not a frequent disease, and 
 is due to the same causes as other neuralgias. Neurasthenia, 
 malaria, syphilis, chlorosis, oligocythemia, uricemia, and auto- 
 intoxication are the most common causes, and masturbation 
 and sexual excesses are often associated, seemingly in a causal 
 relation, with the trouble. Chlorosis and oligocythemia fre- 
 quently cause adenohypersthenia gastrica, sometimes hyperes- 
 thesia, and, rarely, gastralgia. The abuse of tobacco is respon- 
 sible for some of the cases in men, but gastralgia ner\'osa is 
 most common in women between the fifteenth and thirtieth 
 years who belong to neuropathic families. It sometimes fol- 
 lows typhoid fever and influenza. Malarial gastralgia maybe 
 periodical, accompanying the chill or taking its place. 
 
 Clinical Description. — At the bedside, gastralgia is easily 
 separable into two forms — the mild and the severe. In the 
 mild form the pain is bearable, closely limited to the re- 
 gion of the stomach, and of short duration. There is little 
 or no prodromal nausea or salivation, but only a slight feeling 
 of distention, to usher in the attack. There is no fermen- 
 tation, and the variations of secretion do not get bej-ond the 
 normal limits. There may be a small quantit)' of gastric juice 
 containing a trace of free hydrochloric acid in the stomach, 
 if the attack should occur during the period of gastric repose;
 
 THE SENSORY DYNAMIC AFFECTIONS. 277 
 
 and its presence may be best explained as the result of the 
 vasomotor dilatation that is frequent in parts affected by- 
 neuralgia. During the attack the stomach is but little dis- 
 tended or contracted, and the organ, apart from a slight 
 sensitiveness on pressure, yields no abnormal physical signs. 
 The attack is usually unassociated with heartburn, or pyrosis, 
 and ends with a moderate sensation of hunger, slight drowsi- 
 ness, and a free discharge of clear urine of low specific grav- 
 ity, of slight acidity, and which precipitates the earthy phos- 
 phates on heating. This is the mild form. 
 
 The duration of the mild attacks is short — seldom longer 
 than a few hours. The pain is often moderated by strong 
 pressure over a large area of the epigastrium, and it may be 
 rapidly and completely relieved by the pure sedative influence 
 of anodal galvanization. 
 
 The paroxysms of the severe form usually begin with a 
 well-marked sensation of distention of the stomach and with 
 loss of appetite. The beginning is violent, sudden, without ade- 
 quate local cause, and independent of the functional activity 
 of the stomach. Then the severe, tearing, cutting, throbbing, 
 aching, or burning pain appears in the epigastrium and radi- 
 ates through the abdomen, behind into the back, along the 
 intercostal nerves, and under the sternum into the lower part 
 of the esophagus. The irradiated pains may be very severe 
 and accompanied by a pinched, anxious, perspiring face, cold 
 extremities, retracted abdomen, and a small, jerky pulse, 
 usually frequent, sometimes slow, with pulsation of the 
 abdominal aorta. Or the patient may be doubled together 
 with contracted abdominal muscles, the breathing being thor- 
 acic and shallow. After a variable duration the pain subsides, 
 and the exhausted patient may fall asleep. During the attack 
 the urine is of high specific gravity and but little is secreted. 
 The paroxysm may last several hours and may end in vomit- 
 ing; or the pain may gradually cease with the discharge of a 
 large quantity of clear, or sometimes slightly clouded, urine 
 of the same character as in the mild attack. 
 
 The violent attacks may last one or two days, or only a {^vj 
 hours, and may recur after long, short, or irregular intervals. 
 The pain is calmed by neither alkalies nor albuminous food, 
 and the paroxysms occur regardless of the functional activity 
 or repose of the stomach. If they occur during the period of 
 digestion, the attack may end with critical vomiting; but the 
 attacks recur in relation with the exacerbations of the causa- 
 tive disease and are most frequent after cerebral or physical 
 fatigue.
 
 2/8 DISEASES OF THE STOMACH. 
 
 Diagnosis. — Intermittent paroxysmal attacks of gastric 
 pain, beginning suddenly, becoming rapidly intense, in no 
 constant relation with the taking of food or with the evolution 
 of gastric digestion, unassociated with abnormal functional 
 and bacteriological signs, occurring in the absence of any 
 other disease of the stomach, separated by intervals of normal 
 painless digestion, are so characteristic that the diagnosis may 
 be easily made. But the etiological diagnosis may present 
 great difficulties, and a careful search should be made, and 
 the diseases mentioned under etiology should be excluded, 
 before the gastralgia is pronounced to be primary and idio- 
 pathic — a form which close study will prove to be rare. 
 
 Differential Diagnosis. — The differentiation of gastralgia 
 from other painful paroxysmal diseases must often be made 
 by exclusion. It may be confounded with some of the pain- 
 ful gastric diseases or with painful diseases of other abdominal 
 organs. It may also be confounded with intercostal neuralgia 
 and rheumatism of the abdominal muscles. 
 
 Intercostal neuralgia may be due to the same causes as 
 gastralgia, and is frequent in anemic girls, and is most common 
 on the left side. The intercostal neuralgic pain may be 
 severe and may resemble in location and intensity that of gas- 
 tralgia. The neuralgia of the lower intercostal nerves may 
 be concentrated in the epigastrium. The area of the radia- 
 tions is different; the patient locates the intercostal pain in 
 the thoracic and the abdominal walls, and the whole course, 
 or special points of the intercostal nerve, or nerves, are painful 
 on pressure. The intercostal neuralgia, being superficial, is 
 more readily relieved by sedative galvanization. The inter- 
 costal pains of spinal disease are bilateral and constricting, 
 and are associated with the special signs of the spinal trouble. 
 But it should not be forgotten that the pain of gastralgia may 
 radiate along the intercostal nerves. 
 
 Myalgia may be localized in the epigastrium and the left 
 hypochondrium. In myalgia and gastralgia the abdominal 
 muscles are contracted, and the pain may be paroxysmal and 
 similar in location. The myalgia is relieved or increased, 
 respectively, by relaxation or contraction of the affected 
 muscles. The painful area corresponds with the location of 
 the muscles, and the extension of the trouble to the lumbar 
 or other muscles outside of the gastric area would be a dis- 
 tinctive characteristic. Muscular rheumatism, as Leube has 
 shown, may be accompanied by fever, and there is no increase 
 of temperature in gastralgia. 
 
 Gall-stone colic, which may be itself the cause of gastralgic
 
 THE SENSORY DYNAMIC AFEECTIONS. 279 
 
 crises, probably through irritation of the solar plexus, may 
 be mistaken for gastralgia. In cholelithiasis the pain is to 
 the right of the median line ; radiates sometimes also to the 
 right and to the region of the right scapula ; a painful pres- 
 sure-point to the right of the twelfth dorsal vertebra is com- 
 mon ; the liver maybe enlarged and tender; the epigastric 
 tenderness corresponds to the area and the form of the left 
 lobe; the gall-bladder may be distended, and may present a 
 visible and palpable tumor, and give rise to friction-sounds 
 during the movements of the diaphragm ; there may be 
 jaundice and fever, and gall-stones may be found in the 
 feces. The attacks of hepatic colic are often closely related to 
 dietetic excesses. In atypical cases all these differential 
 characters may be absent, and a seemingly typical gastralgia 
 may later prove to be a no less typical gall-stone colic. 
 
 Intestinal colic is not likely to be be mistaken for gas- 
 tralgia, except when located in the transverse colon. There 
 may be signs of chronic lead-poisoning or a history of con- 
 stipation. The abdomen is fuller than in gastralgia ; the 
 intestine can be felt distended with gas, or it rolls like a 
 hard cord under the finger. The radiation is into the lumbar 
 region or over the sacrum, and the paroxysm ends with the 
 evacuation of the bowel, which often contains mucous shreds 
 or hydrosulphuric acid gas. The intestinal pain is also dis- 
 tinctly peristaltic, or spasmodic, and the point of the greatest 
 intensity follows the course of the bowel. 
 
 Hyperesthesia gastrica is easily differentiated from gastral- 
 gia. The pain of hyperesthesia is not spontaneous, is excited 
 immediately by the contact of the ingested food, and it sub- 
 sides with the evacuation of the stomach. 
 
 Adenohypersthenia gastrica and chronic hypersthenic gas- 
 tritis are frequently mistaken for gastralgia. The hyper- 
 chlorhydria, or hyperchylia, at once excludes gastralgia. 
 The paroxysms begin and develop more slowly, after the 
 ingestion of food, and in close relation with the evolution of 
 secretion. The pain is moderated by alkalies, by water, and 
 by albuminous food, and it is digestive. The functional 
 signs, however, in all doubtful cases, are absolutely conclu- 
 sive, for hyperchylia and hyperchlorhydria exclude gastralgia. 
 Paroxysmal pain characterizes a clinical form of chronic 
 atrophic gastritis; but the achylia, which always accompanies 
 this disease, is never found in gastralgia. 
 
 The differentiation of atypical ulcer and gastralgia may be 
 difficult or impossible. The typical, painful paroxysms of 
 ulcer, excited by food and digestion, and relieved by the 
 evacuation of the stomach, present no difficulty. Neither can
 
 28o DISEASES OF THE STOMACH. 
 
 there be any doubt when there are strictly circumscribed 
 and painful epigastric and dorsal pressure-points, and when 
 the pain is increased by the movements of the body and is 
 relieved by rest in a particular position. But the ulcer may 
 be atypical in its expression, and may leave the physician in 
 doubt after all the etiological, subjective, and objective signs 
 have been weighed. In the absence of the possible conclusive 
 functional signs, the case should be treated as ulcer until more 
 light can be obtained. Such a course protects the physician 
 and gives the patient the benefit of all doubt. 
 
 Epigastric pain may be caused by small herniae in this 
 region, by cysts or carcinoma of the pancreas, by pancrea- 
 titis, by pancreatic calculi, by duodenal ulcer, and by peri- 
 gastric adhesions. When the pain is due to adhesions of the 
 stomach, it recurs with greater regularity than in gastralgia, 
 and it may be produced by inflating the stomach or by over- 
 loading it with food. 
 
 Treatment. — The treatment of gastralgia is etiological and 
 symptomatic. To relieve the pain, anodyne and sedative treat- 
 ment is indicated. In the mild form, ten grains of antipyrin 
 often promptly relieve the pain. If the pain be very severe, it 
 is best to give at once the sovereign remedy, which is a pre- 
 paration of opium, — morphin or codein, — administered hypo- 
 dermically or by the mouth. Hot poultices (or a hot-water 
 coil over wet flannel) should be placed over the stomach, and 
 hot drinks should be given by mouth. The deodorized tinc- 
 ture of opium is also a good preparation. Belladonna, 
 Hoffman's anodyne, and chloroform water have also been 
 reconmiended, but are not trustworthy. In the recurring 
 mild attacks, aconite and gelsemium may prove serviceable, 
 and act best when given simultaneously in small, repeated 
 doses. We usually order a combination of codein (^ of a gr.), 
 ext. cannabis indica (y^^ of a gr.), atropin (^^ of a gr.), and 
 aconitia {-^\^ of a gr.). If malaria be tlie cause, the attacks of 
 gastralgia are periodical. Quinin cures these cases promptly. 
 We prefer the muriate when the drug is given by mouth, and 
 it should be administered in a single dose (lo to 15 grs.), five 
 hours before the time for the recurrence of the attack. Or 
 the quinin may be given by rectum, the following formula 
 being a good one : 
 
 li • Quininre muriat., grs. x-xx 
 
 Morphina; muriat., gr. yi—% 
 
 Sodii chloridi, grs. v 
 
 Aq. amyli, ^ ij. 
 
 M. et ft. sol. 
 
 SiG. — Inject slowly into the rectum three hours before the attack.
 
 THE SENSORY DYNAMIC AFFECTIONS. 281 
 
 Or the bimuriate of quinin (grs. xxx to aq. dist. 5j) may- 
 be given hypodermically, the muriate of morphia being 
 combined with the quinin if it be desirable. Administer 
 15 to 20 minims two hours before the time for the attack. It 
 is our custom to combine with the quinin, during the time of 
 the administration of full doses (three to five days), either 
 morphin or codein, which act as synergists. 
 
 Galvanization often gives prompt relief, and is indicated 
 where it is advisable to avoid the use of morphin. The anode 
 (100 sq. cm.) is placed over the stomach, and the cathode, of 
 the same size, is held to the left of the dorsal spine. A cur- 
 rent of three to five milliamperes is slowly and gradually 
 turned on, is allowed to flow from five to ten minutes (until 
 the pain ceases), and is slowly reduced to zero before remov- 
 ing the electrodes, in order to obtain the pure sedative polar 
 influence of the anode. Intragastric galvanism may be tried 
 by those who prefer this method of using it. It matters 
 little whether intragastric or epigastric galvanism is em- 
 ployed, provided it be administered so as to get a sedative 
 influence. During the intervals, sedative galvanism and 
 aconitia give excellent results, and the special indications 
 furnished by the etiology of the neuralgia should be met — 
 forbidding the use of tobacco and sexual excesses, building 
 up the blood and nutrition and the nervous system, curing 
 the malaria, and preventing auto-intoxication. 
 
 VI. HYPERESTHESIA GASTRICA. 
 
 Like gastralgia, hyperesthesia may be only a symptom or 
 it may be a primary affection of the stomach. In health a 
 person is unconscious of the contact of the normal contents of 
 the stomach with the gastric mucous membrane. In simple 
 hyperesthesia gastrica the mucous membrane is excessively 
 sensitive without the presence of either an anatomical lesion 
 or of a disorder of secretion. The patient becomes conscious, 
 often painfully conscious, of the contact impressions, which 
 in health are unperceived. The disease is analogous to 
 hyperesthesia of the skin, and differs essentially from gas- 
 tralgia, which is a pneumogastric neuralgia. 
 
 Etiology. — Hyperesthesia gastrica may be a symptom of 
 ulcer and of both adenohypersthenia gastrica and chronic 
 hypersthenic gastritis. As a distinct, unassociated affection 
 of the stomach it occurs in diseases of the central nervous
 
 282 DISEASES OF THE STOMACH. 
 
 system, in chlorosis, in anemia, in the artliritic, and in the 
 neuropath. Gastric hyperesthesia may be the first and only 
 symptom of uremia. It may be a monosymptom of hysteria 
 or may coexist with other manifestations of this psychosis. 
 It may be excited by irritant foods and drinks, by tea, coffee, 
 tobacco, excesses in venery, onanism, and masturbation. It 
 is a common sign of narcotic drug habits, and may be pro- 
 duced by chloroform narcosis. It is a symptom of absinthe 
 alcoholism, is not rare during convalescence from exhausting 
 diseases, sometimes precedes and sometimes follows gastralgia 
 nervosa, and may be induced by prolonged fasting and by the 
 protracted use of an exclusive and insufficient diet. Hyper- 
 esthesia gastrica is a common result of an insufficient or ex- 
 clusive diet, but the basis of the trouble is most frequently a 
 neuropathic or an arthritic soil. 
 
 Clinical Description. — In the mild form, immediately after 
 the introduction of food there is a peculiar uneasiness and 
 discomfort, a feeling of local irritation, and tingling, shooting 
 pains. These symptoms continue throughout the period of 
 digestion, and disappear with the evacuation of the stomach. 
 
 In the well-developed form the contact of food produces 
 immediate pain, which, when severe, may excite nausea and 
 vomiting. The symptoms are excited alike by fluids and by 
 solids; indeed, fluids containing an excitant seem to produce 
 a more diffused pain. The pain, often preceded and accom- 
 panied by a sensation of weight and fullness, continues 
 throughout the period of gastric activity; and nausea, a sen- 
 sation of cold and heat, conscious gastric arterial pulsation, 
 and vomiting convince the patient of the existence of a very 
 serious organic disease. When water is introduced through 
 the tube into the stomach, retching and vomiting are imme- 
 diately and almost invariably excited. Through fear of pain, 
 one article of food after another is refused ; through vomiting 
 the supply of nutriment may be reduced below the needs of 
 nutrition, and emaciation may become progressive. There 
 may be no emaciation, or there may be emaciation propor- 
 tionate to the quantity of food lost by vomiting and to the 
 insufficiency of the diet. Gastric hyperesthesia is the fore- 
 runner of anorexia nervosa and of habitual vomiting. 
 
 During the period of gastric repose there is often a sensa- 
 tion of emptiness, often decidedly unnerving and unbearable, 
 and associated with slight vertigo and faintness. A peculiar 
 form of hyperesthesia gastrica is manifested by short, painful 
 paroxysms (fifteen to thirty minutes), which occur as soon as 
 the stomach becomes empty. The pain may be relieved by
 
 THE SENSORY DYNAMIC AFFECTIONS. 283 
 
 food, but it is not relieved by soda, the sodium chlorid formed 
 increasing the pain and often exciting nausea. It is probable 
 that the pain is produced by the action of free HCl on the 
 oversensitive gastric mucosa, secretion continuing after the 
 evacuation of the contents of the stomach into the duodenum. 
 In some cases sensation is dissociated, either in the periphery 
 or in consciousness. There may be a morbid sensibility to 
 slight changes in the temperature of the food, the painful im- 
 pression of contact being momentarily less pronounced; or 
 the gastric contents may produce now a sensation of cold, 
 now burning, now pain, and these sensations are sometimes 
 spontaneous and perceived when the stomach is empty. 
 
 In hyperesthesia gastrica the skin over the epigastrium is 
 often very sensitive. Deep pressure reveals the morbid sen- 
 sibility of the whole stomach, there being no circumscribed 
 painful points. The area of diffused tenderness is sharply 
 limited and corresponds closely with the size and form of the 
 stomach. By moderate vertical pressure with the fingers the 
 size and position of the stomach may frequently be deter- 
 mined with exactness. 
 
 The secretory function of the stomach is normal. The 
 contents, after the test-breakfast, reveal normal chemical, 
 microscopical, and bacteriological signs. There may be in- 
 constantly a small excess or a slight diminution of free HCl, 
 which may be plausibly explained by the accompanying vaso- 
 dilatation. 
 
 Diagnosis. — The pain due to contact, and occurring imme- 
 diately and invariably after the ingestion of food, or as soon 
 as the stomach is empty, and with the associations detailed in 
 the clinical history, and with the normal functional signs, leave 
 little room for doubt as to the nature of the trouble. The 
 etiology may also aid in the diagnosis. The pain is excited 
 by the contents of the stomach — the food, digestive products, 
 and the free hydrochloric acid. Consequently the symptoms 
 are digestive, occur regularly, and for a number of days or 
 weeks after meals, or at the moment when the stomach first 
 becomes empty. Hyperesthesia gastrica, consequently, dif- 
 fers widely from the paroxysms of gastralgia nervosa. 
 
 Differential Diagnosis. — The only diseases likely to be 
 confounded with hyperesthesia gastrica are atypical ulcer, 
 adenohypersthenia gastrica, and hypersthenic gastritis. In 
 adenohypersthenia and in the hypersthenic form or stage of 
 gastritis, the pain does not occur so soon after the ingestion 
 of food, and the stomach only becomes intolerant toward 
 the height of secretion. The pain is also in strict relation
 
 284 DISEASES OF THE STOMACH. 
 
 with the quality of the food, and is reheved by albuminous 
 foods and by alkalies. In hyperesthesia the pain is imme- 
 diate, and is due to contact and not to functional excitation, 
 and is produced by all sorts of food. The abnormal chemi- 
 cal si<^ns characteristic of functional and organic adenohyper- 
 sthenia are absent. 
 
 Ulcer may be manifested only by pain, but the ulcer pain 
 has distinctive features. Cases where the pain does not occur 
 immediately after taking food present no difficulty. But 
 hyperesthesia may be a complication of ulcer. Even in the 
 absence of the characteristic relations of the pain of ulcer to 
 the quality of the food, to the evolution of secretion, to the 
 movements and repose of the body, and even in the absence 
 of the characteristic circumscribed epigastric and dorsal pres- 
 sure-points the abnormal functional signs of ulcer would still 
 be conclusive. Both diseases are frequent in the same class 
 of patients, and if there is doubt after weighing all the signs, 
 the case should be treated as ulcer. 
 
 Treatment. — It is best to put these patients at once to bed. 
 The more absolute the repose of body and mind, the more 
 rapid will be the cure. Sedative galvanization, applied as in 
 the treatment of gastralgia, but with the current of very low 
 density — as two milliamperes with an electrode lOO sq. cm., 
 daily sittings. A cold compress (Winternitz's compress is the 
 best) should be kept constantly over the abdomen. Nitrate 
 of silver is the best medicine, and often acts with remarkable 
 efficiency. One grain shouldbe dissolved in two ounces of 
 distilled water, and one or two teaspoonsful should be given 
 three times a day on an empty stomach. It is often unnec- 
 essary to continue the drug longer than two or three days. 
 A more efficient method is to spray or douche the stomach 
 with a solution of nitrate of silver. In our experience, the 
 bromids do no good. 
 
 The diet should be non-e.xciting and indifferent in its physi- 
 ological action on the stomach. For a short period a pure 
 milk diet or milk and lime-water should be employed ; as 
 soon as the pain is controlled, cereal gruels, soft-boiled or 
 poached eggs, and meats, vegetables, and other foods should 
 be added, in the order given in the chapter on Diet (Section 
 III, chap. 11). Or it may be best to employ e.xclusive rectal 
 feeding for a few days. 
 
 The etiological treatment will demand attention, and con- 
 sists in medication directed against the hysteria, anemia, 
 chlorosis, neuropathic or arthritic constitution, and the cor- 
 rection of excesses and of bad habits.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 285 
 
 CHAPTER II. 
 THE DYNAMIC AFFECTIONS OF SECRETION. 
 
 Some authors deny the existence of persistent disorders of 
 secretion which are not produced by an anatomical lesion of 
 the gastric mucosa, and the majority of writers consider all 
 the dynamic affections of secretion to be neuroses. In our 
 opinion both these contentions are erroneous. There is no 
 doubt that persistent abnormalities of secretion are frequently 
 functional signs of the anatomical diseases of the stomach. 
 No one will deny that secretion may be disturbed through 
 the nerves which control it. Prolonged study and careful 
 investigation have led us irresistibly to the conclusion that 
 the disorders of secretion are not always due to an alteration 
 of the mucosa or to a neurosis of the vagosympathetic 
 system. 
 
 It is, furthermore, the custom to describe a very special 
 condition of the stomach as a distinct disorder of secretion, 
 or neurosis of the stomach. This condition has been named 
 " continuous secretion," or gastrosuccorrhea, or Reichmann's 
 disease, and it may be either periodical (gastrosuccorrhea 
 periodica) or continuous (gastrosuccorrhea continua chronica). 
 We are unable to convince ourselves that continuous gastro- 
 succorrhea exists as a dynamic affection. This condition of 
 secretion may be met with as an episode in obstruction of the 
 pylorus, in myasthenia with secretory irritation due to the 
 retention of the contents of the stomach, or in the hyper- 
 sthenic form of chronic gastritis. It is not a distinct morbid 
 entity, but is a special symptom — a mere complicating condi- 
 tion. Continuous secretion, in our opinion, is not a severe 
 form of supersecretion without an anatomical lesion of the 
 mucous membrane, nor is it a delayed reaction of the secre- 
 tory nerves to the excitation produced by the meals. The 
 normal stomach does not secrete when it is empty, and, at 
 most, only 10 to 20 c.c. of gastric contents can be removed 
 when the tube is introduced into the normal stomach in 
 the early morning before breakfast; but sometimes when 
 the tube is introduced at this time (even when the stomach 
 has been thoroughly washed out the evening before and 
 left empty) it will be found that the stomach contains much 
 more than 20 c.c. of a liquid rich in hydrochloric acid
 
 286 DISEASES OF THE STOMACH. 
 
 and the digestive ferments. This is considered the char- 
 acteristic functional sign of continuous secretion. The sign 
 exists, but we maintain that its interpretation is wrong. 
 The secretion has merely accumulated in the stomach 
 (myasthenia, pyloric obstruction), or it has been formed as a 
 result of hypersthenic gastritis, or, in case the stomach has 
 not been washed out, it may have been excited by retained 
 food and digestive products. The evening lavage, or lavage 
 followed by a few days of rectal feeding, or the water test, 
 considered in combination with the clinical history and with 
 the other objective signs, will reveal the cause of the gastro- 
 succorrhea and demonstrate its non-existence as a dynamic 
 affection of the stomach. It is always due to retention, or to 
 hypersthenic gastritis, or to both. 
 
 Unfortunately, the words in common usage are unsuitable 
 for designating the dynamic affections of secretion. Super- 
 acidity (or the mongrel word, hyperacidity) denotes abnormal 
 increase of the acidity of the contents, whether it be due to 
 hydrochloric or to organic acids. Hydrochloric superacidity 
 is more exact, but the term is also used to denote the func- 
 tional sien of certain anatomical diseases of the stomach. 
 The same objections apply to subacidity. Supersecretion 
 denotes an increase of the quantity of secretion, whether it 
 be a particular morbid process or a functional sign. Hyper- 
 chlorhydria and hypochlorhydria denote a pathological in- 
 crease or decrease of hydrochloric acid in the filtrate of the 
 gastric contents at the acme of digestion, and do not embrace 
 all the secretory disturbances which are found in the two 
 classes of the dynamic affections. In order to avoid con- 
 fusion and to embody an exact conception of their nature, we 
 shall divide the dynamic affections of the stomach into two 
 large classes, and describe them, in keeping with references in 
 other parts of this book, as adenohypersthenia gastrica {aSijv, 
 gland, urAp, excessive, and a<U-^o<;, strength ; excessive glan- 
 dular activity) and adenasthenia (a^'jV, a, and (rMvoq) gastrica. 
 These terms denote the morbid processes which are mani- 
 fested by the disturbances of secretion, and stand in clear 
 relief with the similarly formed terms, myasthenia gastrica 
 and neurasthenia "-astrica. 
 
 I. ADENOHYPERSTHENIA GASTRICA. 
 
 Adenohypersthenia gastrica is a dynamic affection charac- 
 terized by the secretion of a gastric juice which is abnormally
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 28/ 
 
 rich in hydrochloric acid or which is excessive in quantity. 
 The hyperchlorhydria {urAp, -^Xiupuq, and vdiop) and the hyper- 
 chylia {p-ip, excess, and /6»A<>?, juice) gastrica are due neither 
 to an anatomical lesion of the mucosa nor to motor insuffi- 
 ciency. Achylia (a lack of juice) gastrica has recently been 
 employed by Einhorn to denote a permanent absence of 
 gastric secretion, and the similarly formed terms, hyperchylia 
 gastrica and hypochylia gastrica, may be used t<5 denote a 
 pathological increase or decrease of gastric secretion. Hyper- 
 chylia gastrica is here employed to designate the dynamic 
 affection of the stomach which is characterized by super- 
 secretion. 
 
 Hyperchlorhydria and hyperchylia gastrica are closely 
 related in their etiology, and hyperchlorhydria may be the 
 forerunner of hyperchylia ; but this does not establish the 
 identity of the two affections. The one may be a sequel of 
 the other, but hyperchylia gastrica may be milder than the 
 severe cases of hyperchlorhydria, and may not be accom- 
 panied at the acme of the digestion of a test-meal by hydro- 
 chloric superacidity. The one is only a qualitative modification 
 of secretion, and the other is essentially a quantitative disturb- 
 ance. The two affections differ in their subjective manifesta- 
 tions, in their physical, functional, and bacteriological signs, 
 and in their treatment. Hyperchlorhydria is always diges- 
 tive; hyperchylia gastrica may be digestive or paroxysmal. 
 
 (A) HYPERCHLORHYDRIA. 
 
 The causes of hyperchlorhydria are those common to a 
 large number of other diseases of the stomach, and are as 
 often found in the constitution and temperament as in the 
 mode of life and the alimentation. The abuse of condi- 
 ments, the eating of large quantities of red meats, and imper- 
 fect mastication are common causes. The disease is most 
 frequent in youth and manhood, most of the cases occurring 
 between the ages of fifteen and forty. Sex seems to be with- 
 out influence. Like other dynamic affections, it is most fre- 
 quent in the arthritic and the neuropath : in neurasthenia, in 
 hysteria, and in melancholia. According to our observation, 
 it is quite frequently associated with intestinal auto-intoxica- 
 tion. It is common in cholelithiasis, in renal lithiasis, in 
 chlorosis, and in chronic tobacco-poisoning. It is frequent in 
 chronic malaria, even before quinin has been taken. 
 
 Mental and moral causes play an important part. Cerebral 
 fatigue may mark the beginning of the trouble, and illustrates
 
 288 DISEASES OF THE STOMACH. 
 
 the close relations existing between the brain and the abdomi- 
 nal sympathetic, on which Leven has laid so much stress. 
 It is very frequent among students. Prolonged excitement, 
 worr}% and excesses of all sorts are other causes. There is 
 no distinct relation between the disorder of secretion and the 
 nature of the cause. 
 
 Clinical Description. — Ilyperchlorhydria may be latent, re- 
 sembling in this respect many other diseases of the stomach, 
 or the subjective manifestations may occur intermittently, in 
 spite of the unbroken continuity of the digestive secretory irri- 
 tation. The trouble may begin suddenly after a particular meal ; 
 or it may develop more gradually, a meal composed chiefly of 
 starches, cereals, sweets, vegetables, fruits, and fat causing 
 discomfort and pain at the height of gastric digestion. 
 
 The symptoms are digestive, and are in strict relation to 
 the evolution of secretion. In a mild attack, which is the rule 
 after a small meal, such as a breakfast composed of a cereal, 
 eggs or meat, and cafe an lait, there is slight discomfort 
 and uneasiness in the stomach, which usually begin with the 
 appearance of free HCl in the contents ; and, later, there may 
 be acid eructations, heartburn, or even severe pain — all of 
 which disappear with the evacuation of the stomach. The 
 severe attacks, which occur chiefly after a meal the action 
 of which is somewhat irritating and leaves a large quantity 
 of hydrochloric acid free or which was eaten when tired, 
 are accompanied by uneasiness, heartburn, eructations of a 
 bitter, sour fluid, severe pain, and sometimes vomiting. The 
 intensity of the symptoms keeps pace with the evolution of 
 secretion and of digestion. The evacuation of the stomach 
 marks the end of the attack. The pain is most intense dur- 
 ing the course of digestion, when free HCl is greatest, and is 
 temporarily relieved by nitrogenous food, and, more perma- 
 nently, by a full dose of an alkali. The appetite is good 
 and thirst is almost invariably intense. In some cases the 
 local digestive symptoms are accompanied by the symptoms 
 of general neurasthenia, which are most prominent during 
 digestion. The disease is a predisposing cause of ulcer, and, 
 unless arrested early, is likely to end in hypersthenic gastritis. 
 
 The subjective manifestations, which are exclusively diges- 
 tive, may be continuous, remittent, or intermittent, with 
 intervals during which digestion is painless. The digestive 
 secretory irritation continues from day to day, with occasional 
 exacerbations ; but in the early period of the affection, under 
 the influence of rest and a bland diet, secretion may inter- 
 mittent! \' become normal.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 289 
 
 The functional signs are characteristic. The motor function 
 is usually normal after a test-meal ; after a large meal, accom- 
 panied by severe pain, pyloric spasm may delay evacuation. 
 The motor function is excited by the excessively acid con- 
 tents, and the stomach should become empty more rapidly 
 than in health ; but the hyperesthesia of the pylorus and of the 
 duodenum may prevent the rapid evacuation by producing 
 spasm of the pylorus. There is no morning splashing, and 
 usually there is no splashing half an hour after drinking a 
 glass of water on an empty stomach. If splashing can be 
 elicited duruig the digestive period it is circumscribed, and 
 never extends beyond the normal limits of the stomach. 
 There is no motor insufficiency, except the occasional and 
 slight stagnation which may result from pyloric spasm. After 
 the water-test the stomach will be found empty within the 
 normal period, and the stagnation, if it occurs, is, con- 
 sequently, not due to myasthenia. 
 
 The resting stomach will be found empty. Albumins are 
 digested with unusual rapidity. At the end of two hours the 
 meat of the test-meal of Germain See is almost completely 
 dissolved, and the few fibers found with the microscope are 
 undergoing disintegration; propeptones are abundant, and 
 the biuret and Almen reactions for peptones are plainly posi- 
 tive. Starch is not so well digested as in health. The inhibi- 
 tion of salivary digestion occurs so much earlier than in health 
 that Lugol's solution gives a blue or purplish-red coloration 
 when added to the filtered contents. The contents obtained 
 one hour after a test-breakfast are excessively acid (normal, 
 60), composed of both free (H) and (C) combined HCl. Free 
 HCl appears much earlier (ten minutes) in the contents after the 
 test-breakfast than in normal secretion (twenty to thirty nu"n- 
 utes); and also about twice as early as in health after the See 
 and after the Riegel test-dinners. Albumin digestion is very 
 active and rapid, and combined HCl may be excessive, even 
 though there should be no obstructive stagnation and conse- 
 quent accumulation of digestive products. The hydrochloric 
 acidity is excessive during the decline of digestion. Conse- 
 quently secretion may be rapid, and very rich in both hydro- 
 chloric acid and digestive ferments. There are no organic acids, 
 or only unimportant traces. The filtered contents are rich in 
 ferments and possess very high digestive and milk-coagulating 
 powers. The tube digestions are very rapid — the acidulated 
 50 per cent, dilution often digesting as rapidly as the filtrate of 
 the normal contents. Labferment and labzymogen are both 
 very active. The mucus, and the epithelium, and the germ 
 19
 
 290 DISEASES OF THE STOMACH. 
 
 growtli are not excessive nor abnormal. The tube fermenta- 
 tion tests are negative. 
 
 The epigastrium is painful on pressure during the digestive 
 attacks, and more markedly so over the pylorus. The skin 
 may be hyperesthetic. During the interval while the stomach 
 is empty there is much less tenderness and hyperesthesia. 
 
 The urine formed during the period of gastric digestion is 
 poor in chlorids, nearly neutral, and precipitates the earthy 
 phosphates on heating, and sometimes on standing. The 
 diminution of the acidity of the urine secreted during gastric 
 digestion is a rough measure of the increase of the hydro- 
 chloric acidity of the gastric juice. 
 
 The bowels are constipated, but in spite of the excessive 
 acidity of the chyme the starches and fats may not exist in 
 abnormal quantity in the stools, and the balance of nutrition 
 may be maintained. The weight, and the strength, and the 
 color may be those of health, but moderate emaciation is 
 frequent. The appetite is preserved, or it ma\' be very sharp, 
 and a meal taken later than usual will be preceded by hunger. 
 
 Diagnosis. — The diagnosis should present little difficulty if 
 the examination has been complete. The following diagnostic 
 signs should be clearly fixed in the mind : 
 
 The general health, the weight, and the strength are well 
 preserved if the diet has not been restricted. The food being 
 well digested, and not destroyed by fermentation, nor lost by 
 vomiting or by diarrhea, there is no reason why the balance 
 of nutrition should not be maintained. The good appetite 
 will secure the ingestion of a sufficient quantity of food, un- 
 less the diet be reduced on account of fear of pain or in con- 
 sequence of improper treatment. 
 
 The symptoms are all digestive and gastric. During the 
 period of repose of the stomach there is no complaint. The 
 symptoms do not begin immediately after the ingestion of 
 food, but develop in relation with the evolution of secre- 
 tion, and are most intense during the period of greatest free 
 hydrochloric acidity. The severity of the attack is dependent 
 upon the action of the food, upon the power which it has of 
 combining the secreted HCl, upon the activity of hydrochloric 
 secretion, and upon the irritabilit}' of the nervous system at 
 the moment when the food i* eaten. The pain is calmed by 
 albuminous food and alkalies ; it is uninfluenced or made 
 worse by electricity, and disappears with the evacuation of 
 the stomach. The symptoms may appear only after the chief 
 meal. A glass of milk taken alone is usually rapidly and 
 comfortably digested.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 29 1 
 
 The objective signs are even more characteristic. The 
 stomach is normal in position and in size, the motor function 
 (unless there is spasm of the pylorus) and absorption are 
 normal, and there are no bacteriological nor anatomical signs. 
 The resting stomach is empty. During digestion an exces- 
 sively acid gastric juice, rich in both ferments, is secreted. 
 
 Differential Diagnosis. — The differential diagnosis, in spite 
 of the clear-cut features of the disease, may present some 
 difficulties, and in some cases only a probable decision can be 
 made. 
 
 Myasthenia with supersecretion presents a very similar 
 group of symptoms, which are digestive, increase with the 
 evolution of digestion, and may attain their climax with par- 
 oxysms of pain. The objective signs can alone differentiate 
 the two diseases. These signs are those of myasthenia, which 
 are never present in hyperchlorhydria. After the test-breakfast 
 the quantity of contents is normal in hyperchlorhydria ; the 
 emulsion-meal of Mathieu shows that the contents are evacu- 
 ated into the intestines with normal rapidity ; after a Leube- 
 Riegel or a Germain See meal the evacuation of the stomach 
 is not delayed, and digestive products do not accumulate in the 
 stomach. In myasthenia there is splashing when a glass of 
 water has been given on an empty stomach, after the normal 
 interval has elapsed ; and the stomach during digestion is often 
 flabby. Two glasses of water taken on an empty stomach are 
 not evacuated within one and one-half hours, for myasthenia is 
 a " dyspepsia of liquids." The motor insufficiency revealed by 
 the water-test is the most characteristic sign, and the super- 
 secretion increases or decreases with the increase or decrease 
 of the myasthenia. The free HCl may appear early in myas- 
 thenia, but the acme of hydrochloric acidity is postponed, and 
 the decline of secretion is delayed. If the myasthenia is asso- 
 ciated with retention, the differentiation is easy. The digestive 
 subjective symptoms, which in myasthenia with stagnation 
 extend over a longer period than in hyperchlorhydria, be- 
 come confused with the retention symptoms occurring during 
 the period of normal gastric repose. The retention of food 
 excludes hyperchlorhydria, in which affection there is never 
 found in the stomach in the early morning before breakfast 
 either retained food or accumulated digestive products, or 
 an excessive quantity of gastric juice. 
 
 The displacements of the stomach may manifest the same 
 subjective symptoms — uneasiness, acid eructations, heartburn, 
 and gastric pain two to four hours after meals. The pain, 
 however, is peristaltic, and is due to the violent efforts to
 
 292 DISEASES OF THE STOMACH. 
 
 overcome the duodenal traction-produced obstruction, and 
 these strong contractions may be felt by the palpating hand 
 (they are sometimes also visible) over an abnormal area, and 
 reveal the displacement of the stomach. The pain is not 
 relieved by albuminous food, and milk may be badly borne. 
 The physical and functional signs make the differentiation 
 clear. Intlation reveals the displacement of the stomach, 
 which is often associated with a deformed liver, a movable 
 right kidney, and prolapse of the transverse colon. The 
 chemical signs, in case the displacement is complicated by 
 glandular gastritis, or by supersecretion produced by irrita- 
 tion of the stagnant contents, are never the same as are found 
 in hyperchlorhydria. The water-test will exclude or reveal 
 the myasthenia, but we would emphasize the fact that the 
 displaced stomach is subject to the same disorders and dis- 
 eases as the stomach in its normal position. The effect of a 
 properly fitting abdominal belt and of myasthenic medication 
 may be suggestive. But in many of the cases of gastroptosis 
 an excessively rich gastric juice is not secreted, and there is 
 stagnation, often fermentation, and accumulation of digestive 
 products in the stomach. In hyperchlorh\'dria there is never 
 displacement (unless the displacement be a primary or acci- 
 dental association), nor motor insufficiency, nor fermentation, 
 and during the digestive period secretion is always exces- 
 sively rich, but is never abnormally large in quantity. 
 
 Hyperchlorhydria may easily be confounded with ulcer. 
 A hemorrhage, large or small (not due to retching), would 
 exclude the functional trouble. The subjective and the 
 functional signs may be almost the same in the two diseases, 
 but hydrochloric acid is not ahvaj's in e.xcess in the gastric 
 contents of ulcer. The pain of ulcer is not relieved by tak- 
 ing albuminous food ; it is not purely digestive, is increased 
 by movement, may be relieved by rest in a particular position, 
 and does not always develop in relation with the evolution of 
 secretion and of digestion. The exquisitely painful epigas- 
 tric and dorsal points of ulcer may exist even when the 
 stomach is empty. Hyperchlorhydria is a predisposing 
 cause of ulcer ; and when doubt exists, an ulcer cure should 
 be prescribed. 
 
 Hypersthenic gastritis resembles hyperchlorhydria even 
 more closely than does ulcer, but the differentiation is never 
 diflficult. A large number of the cases of chronic hyper- 
 sthenic gastritis, primary and .secondary, are easily excluded 
 by the associated stagnation, displacement, fermentation, or 
 supersecretion. But a notable percentage of the cases of
 
 THE DYNAMIC AFFECTIONS OF SECKETJON. 293 
 
 primary hypersthenic gastritis, particularly in the early stage 
 of the disease, are expressed by the objective and the func- 
 tional signs of digestive secretory irritation. The gastritis is 
 more directly traceable to dietetic errors and to alcoholism, 
 an adequate cause for its existence being thus found. The 
 contents, after the test-meal, contain a large quantity of 
 mucus, cell nuclei, exfoliated and unseparated epithelium, 
 chief and border cells and blood; and misfortune may conclu- 
 sively reveal the anatomical nature of the disease in a piece 
 of scraped-off mucous membrane. Hyperchlorhydria may 
 be intermittent in its manifestations, and in closer relation 
 with the state of the nervous system than with the alimenta- 
 tion. Some of the enumerated differential signs differ only 
 in degree, and not in kind, and it would be impossible to say 
 where hyperchlorhydria ends and hypersthenic gastritis 
 begins, if it were not for the excessive mucus and the dis- 
 tinctive anatomical signs of gastritis. 
 
 Treatment. — Both on account of the suffering which it 
 produces and on account of the serious diseases for which it 
 prepares the way, hyperchlorhydria should receive careful 
 treatment. 
 
 The two ruling principles of its treatment are sedation and 
 the improvement of the condition of the nervous system. 
 The irritable nervous system demands rest, which must be 
 obtained at any cost. It may be sufficient to lighten the 
 daily burdens, to correct excesses, or to send the patient 
 away from home cares to lead a pleasant outdoor life. In 
 severe cases it may be necessary to prescribe a rest-cure, for 
 a few weeks, in bed. 
 
 Electricity, which does not relieve the pain, should be used 
 with care ; and only sedative anodal gastric or epigastric 
 galvanization of the empty stomach should be employed. 
 Hydrotherapy should be used to tone the nervous system, 
 and the hot compress during digestion exerts a soothing in- 
 fluence on the stomach. Penzoldt recommends lavage in the 
 evening, sometimes daily, sometimes less frequently, but we 
 rarely employ stomach washing in this affection. 
 
 The diet is indicated by the functional signs, and should 
 be chemically and mechanically non-irritating, leaving as 
 little HCl uncombined as possible. The albumins of the 
 various foods do not possess the same acid-combining equiva- 
 lents, and the albumin digestive products combine more HCl 
 as the digestive transformation proceeds. Thus, antipeptone 
 combines, in percentage, twice as much HCl as hetero-albu- 
 mose, and hetero-albumose combines double the quantity of
 
 294 DISEASES OF THE STOMACH. 
 
 HCl that is combined b\' proto-albumose. As a result of 
 experiments, we find that lOOi^m. of the following foods, when 
 cooked, require, at '})'j° C, the addition of about the following 
 quantities of a three per thousand solution of HCl before 
 the HCl remains free: Lean beef, 650 c.c ; veal, 710 c.c. ; 
 mutton, 630 c.c; milk, 120 c.c; roil, 105 c.c; wholewheat 
 preparations, 2Cxd c.c; rice, 230 c.c; chicken, 640 c.c; fish, 
 250 c.c; cheese, 300 to 800 c.c; lean ham, 720 c.c; eggs, 
 400 c.c. The physiological action of the various foods on 
 secretion, in addition to their acid-combining power, should 
 guide in the selection of the diet. The diet must be largely 
 albuminous, and must be neither physically nor chemically 
 e.Kcitant. Milk, lean and fine-fibered fish, lean meats reduced 
 to pulp, the soft part of small and fresh o\'sters, plainly 
 cooked game, slightly cooked eggs, are all suitable articles. 
 The cereals, — rice, wheat, oatmeal, — very thoroughly cooked 
 and fresh, possess a high acid-combining power, and may be 
 added to the diet list ; but it should be remembered that the 
 cereals and bread contain starch also, and the starchy foods 
 e.Kcite the secretion of more HCl than they can combine. 
 Vegetables and fruits must be avoided, and only enough fat 
 in the form of fresh (unsalted) butter or cream to supply the 
 needs of nutrition should be permitted. Spices, condiments, 
 acids, oils, and alcoholic drinks should be absolutely prohib- 
 ited. Sweets increase the quantity but diminish the acidity 
 of the gastric juice, and in moderate quantity are beneficial 
 in hyperchlorhydria. Milk, an alkaline mineral water, or 
 plain water are the beet drinks. Very weak tea and coffee 
 may sometimes be permitted, but cocoa and " vigor choco- 
 late " (Hauswaldt) are better. Dry food is \txy injurious, 
 and about two glasses of fluid may be permitted with each 
 meal. An hour's repose after each meal is obligatory. It is 
 best, in our opinion, to permit only three meals a day. 
 
 In the treatment of hyperchlorhydria the alkalies have 
 long held a prominent place. Bicarbonate of soda and cal- 
 cined magnesia may be given during the period of free acidity 
 in repeated doses, as recommended in the chapter on Chemi- 
 cal Treatment. If the pain be very severe, belladonna (J^ to 
 ■5L. of a gr. ext.) and codein {\ of a gr.), or opium (y'-jj of a gr. 
 aq. ext.), may be given before each meal. Our favorite pre- 
 scription is the extract of belladonna combined with two 
 grs. of extract of coca before each meal. Opium, if it is 
 ever advisable, should be given in full doses, as small doses 
 of opium excite secretion and the nervous system. Cannabis 
 indica rarely proves useful, and the bromids do no good.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 295 
 
 We sometimes use nitrate of silver (by mouth or by means of 
 the intragastric douche), and large doses of bismuth, em- 
 ployed as does Fleiner in the treatment of ulcer, are some- 
 times beneficial. Under the influence of this treatment the 
 constipation and the pain may rapidly be relieved. If the 
 constipation requires additional attention, an injection (to 
 which a teaspoonful of glycerin may be added) should be em- 
 ployed, or gluten suppositories, or glycerin suppositories, or 
 anodal sedative galvanization of the colon may be tried. 
 Purgatives repeatedly given by the mouth destroy any good 
 effects derived from the other remedies. The stomach must 
 be consistently and thoroughly protected against all forms of 
 irritation. 
 
 (B) DIGESTIVE HYPERCHYLIA GASTRICA. 
 
 Supersecretion in response to the physiological action of 
 food is a distinct dynamic affection of the stomach. The 
 gastric juice, as a rule, is abnormally rich in acid and fer- 
 ments ; but it may be normal in quality, and, exceptionally, 
 it contains a diminished percentage of hydrochloric acid and 
 ferments. There is no anatomical lesion of the mucosa, and 
 the motor function is normal. Digestion is prolonged because 
 secretion is excessive in quantity. 
 
 Etiology. — The causes of digestive hyperchylia are the same 
 as those which produce hyperchlorhydria, and no complete 
 explanation has yet been given of the genesis of either affec- 
 tion. The underlying condition may be a direct or indirect 
 disturbance of the nerve-centers which control secretion, or 
 excessive vital activity of the chief and border cells, or an 
 impure blood, or a vasomotor disturbance. These patients 
 are most frequently neurotics, or neurasthenics, or young 
 persons guilty of excesses which, directly or indirectly, affect 
 the brain, the central nervous system, or the abdominal sym- 
 pathetic. 
 
 Clinical Description. — Digestive hyperchylia may be a 
 latent disease, or the patient may intermittently pass a number 
 of comfortable days. Most frequently the symptoms recur 
 daily, sometimes after each meal, or, as the rule, only after 
 the second and third meals of the day, the patient having an 
 attack of eructations, belching, heartburn, pain, sometimes 
 vomiting, and headache during the course of the afternoon 
 and another in the evening. Vomiting and headache are more 
 frequent than in hyperchlorhydria, the pain is often severe and 
 spasmodic, and all the symptoms occur in relation with the
 
 296 DISEASES OF THE STOMACH. 
 
 evolution of secretion and digestion. Tiie foods which excite 
 secretion most and remain long in the stomach produce the 
 greatest discomfort. The appetite is usualh' good, and thirst 
 is excessive. Emaciation is more frequent than in hyper- 
 chlorhydria, and the digestive and motor functions of the 
 intestines are disturbed by the large quantity of chyme, which 
 may be superacid and fermenting. 
 
 More characteristic than the clinical history are the phj-sical, 
 functional, and bacteriological signs. The abdomen is tender 
 over the region of the stomach. Splashing and gurgling 
 (gliding method) can be produced at a time after a meal when 
 the normal stomach would be empty. One hour after the 
 test-breakfast the stomach contains more than 150 c.c. of 
 ch\'me ; two hours after the test-meal of See more than 175 
 c.c. of contents can be expressed or estimated b}' the dilution 
 and total acidity method ; after the Riegel dinner more than 
 200 c.c. may be obtained. Consequently, the quantity of the 
 contents is abnormally large. The specific gravity of the fil- 
 trates of the contents after the test-meals is below normal : 
 After the test-breakfast, below loio; after the test-meal of 
 See, below 1015; and after the test-dinner of Riegel, below 
 I020- The ferments are present in normal quantity or in 
 excess. There mayor may not be hydrochloric superacidity, 
 and the quantity of combined HCl is frequently diminished. 
 The albumins are well digested, but starch digestion is 
 decreased, Lugol's solution producing a blue or purplish 
 color. Fehling's test for sugar is negative, or a small quan- 
 tity of the copper may be reduced. There is never an abnor- 
 mal quantity of gastric mucus. The evacuation of the chyme 
 is always delayed, digestion being prolonged in proportion to 
 the supersecretion. The prolongation of digestion is propor- 
 tionately greater after Riegel's test-dinner than after the test- 
 breakfast. When the patient eats his customary three daily 
 meals, the stomach may or may not succeed in emptying 
 itself between the meals. Two glasses of water are evacuated 
 within the normal period. Secretion is inactive while the 
 stomach is empty. There is no stagnation of solids or of 
 liquids, but the physical properties of the contents are such 
 as would be produced by supersecretion during the evolution 
 of digestion. The quality of secretion may be estimated and 
 supersecretion recognized by the emulsion-meal of Mathieu 
 or the authors' meal for testing absorption. 
 
 The prolongation of digestion favors the development of 
 fermentation. The most common form of fermentation in
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 297 
 
 digestive hyperchylia is acetic fermentation. The urine 
 changes are of the same nature but more pronounced than 
 its changes in hyperchlorhydria. 
 
 Diagnosis. — The chnical history of hyperchylia gastrica 
 is not distinctive, but the subjective symptoms possess some 
 diagnostic features. The symptoms all occur during the 
 period of digestion, although the duration of this period is 
 abnormally long. While the stomach contains no food, there 
 are no subjective symptoms and secretion ceases. The 
 symptoms are intensified by large meals, and by foods which 
 remain long in the stomach and which excite free secretion. 
 Albuminous food may temporarily diminish the pain, but the 
 attack is prolonged by eating food. The functional signs are 
 characteristic. The contents are too large in quantity, of 
 abnormally low specific gravity, usually rich in acid and 
 ferments. Digestion is prolonged without motor insufficiency, 
 and mucus is not secreted in excess. Fermentation may or 
 may not B^e present. 
 
 Differential Diagnosis. — Hyperchylia gastrica closely re- 
 sembles hyperchlorhydria in many respects, and after what 
 has already been said its differentiation from ulcer and chronic 
 gastritis may be omitted. Digestive hyperchylia is most 
 frequently confounded with hyperchlorhydria, myasthenia, 
 and pyloric obstruction. The functional signs, the prolon- 
 gation of digestion, the relation of the symptoms to the 
 quantity and quality of the food, and sometimes the occur- 
 rence of fermentation distinguish it readily from hyperchlor- 
 hydria. 
 
 In both myasthenia and digestive hyperchylia the period 
 of digestion is prolonged — in the one, on account of motor 
 insufficiency; in the other, on account of supersecretion. In 
 myasthenia the stomach is flabby, easily distensible, slightly 
 retractile, and the line representing the acidity of the con- 
 tents during the evolution of digestion is irregular. In 
 digestive hyperchylia the stomach possesses its normal 
 tonicity, retracts when it is empty, and the evolution of 
 digestion is abnormal but regular. One and one-half hours 
 after the administration of two glasses of water the stomach 
 is empty in hyperchylia, but in myasthenia it contains a 
 quantity of water proportionate to the motor insufficiency. 
 The quantity of water which it contains may be exactly de- 
 termined by introducing 100 c.c. of a one per cent, solution 
 of sugar into the stomach, mixing it thoroughly with the 
 contents, and subtracting 100 from the result obtained by 
 dividing lOO by the reduced percentage of sugar in the ex-
 
 298 DISEASES OF THE STOMACH. 
 
 pressed dilution. In myasthenia tlie delay in the evacuation 
 of the contents is proportionate to the fluidity and the quan- 
 tity of the food and to its action on the motor function. In 
 hyperchyUa the stomach empties itself most rapidly when 
 the diet is fluid and e.Kcites little secretion. By means of our 
 meal for testing absorption, or of the emulsion-meal of 
 Mathieu, the portion of the total contents which is due to 
 secretion can be estimated. This portion is abnormally 
 large in supersecretion, and normal in quantity in myas- 
 thenia. Expression of the contents is easy in hyperchylia; 
 in myasthenia it is always difficult and incomplete. 
 
 In the absence of a palpable tumor of the pylorus, or of 
 the history or signs of a disease which is liable to produce 
 obstruction of the pylorus or of the duodenum, the differen- 
 tiation of hyperchylia and obstruction may require close 
 study. The evolution and the grouping of the symptoms 
 may be distinctive. Obstruction is persistent, obstinate, often 
 progressive, and obstructive stagnation is a stagnation of 
 solid and coarse food. Hyperchylia yields rapidly to appro- 
 priate treatment, and the prolonged digestion is due to the 
 continuous dilution of the contents by supersecretion. The 
 evolution of digestion is irregular in obstruction ; but it is 
 regular, although abnormal, in hyperchylia. The functional 
 signs may be similar or they may be distinctive of the one or 
 the other disease. Two glasses of water are evacuated within 
 the normal period in both diseases, unless the obstruction is 
 so great as to produce the severe form of stagnation ; but a 
 glass of a ten per cent, solution of sugar is evacuated much 
 earlier in obstruction than in hyperchylia gastrica. 
 
 Treatment. — The treatment of digestive hyperchylia gas- 
 trica consists in the removal of the cause, when this can be 
 accomplished, and in the employment of remedies to tone 
 and quiet the nervous system and to improve the general 
 health. Rest, open-air exercise, electricity, massage, and 
 appropriate baths are usually beneficial. Bismuth, bella- 
 donna, and ergot are the drugs which we have found to exert 
 a controlling influence on the supersecretion. The bismuth 
 should be given in a single large dose (one dram) before 
 breakfast, and the belladonna and ergot may be ordered in 
 small doses before each meal. 
 
 But the special treatment of digestive hyperchylia gastrica 
 is dietetic. No foods should be permitted which greatly 
 excite secretion and which remain a long time in the stomach. 
 Sweets should be prohibited, and the red meats increase the 
 supersecretion. Condiments, tea, coffee, and alcoholic drinks
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 299 
 
 are injurious. The meals should be small, chiefly fluid, and 
 separated by intervals long enough to allow the complete 
 evacuation of the stomach. Milk, cream, cereals, eggs, calf's 
 brain, young chicken, squab, green vegetables thoroughly 
 cooked and passed through a sieve to insure fine division, 
 are appropriate articles of food. The diet of hyperchlorhydria, 
 which is chiefly albuminous, is badly borne and injurious in 
 hyperchylia. Exclusive rectal feeding is rapidly curative, and 
 it should always be employed for a few days in the beginning 
 of the treatment of the severe cases. 
 
 (C) PAROXYSMAL HYPERCHYLIA GASTRICA. 
 
 Paroxysmal hyperchylia gastrica — gastroxynsis (Ross- 
 bach), gastroxia (Lepine), intermittent or periodical gastro- 
 succorrhea — is a dynamic affection of the stomach character- 
 ized by severe headache, by vasomotor disturbances, and by 
 the supersecretion of an excessively acid gastric juice, rich 
 in ferments; it recurs in paroxysms, separated by intervals 
 of perfect health. It is a cerebrogastric trouble, due to the 
 reaction of an irritable and exhausted brain on the solar 
 plexus (Leven); or to excessive secretion excited by an irrita- 
 ble cortex, the wide-spread vasomotor disturbances proceed- 
 ing from the gastric mucous membrane (Rossbach); or it is 
 due to a primary disturbance of the vasomotor center in the 
 medulla, of which the gastric and cerebral symptoms are 
 expressions (Rosenthal). The affection is very closely re- 
 lated to migraine, of which it is probably a form. 
 
 Etiology. — Gastroxynsis is a disease of school-children, of 
 students, and of brain-workers, and appears to be almost 
 exclusively met with in the male sex. The attacks occur 
 periodically, being excited by mental overwork. Abuse of 
 tobacco is said to be another cause. The disease is some- 
 times met with in persons who can not be accused of mental 
 overwork, and it may be excited by intestinal auto-intoxica- 
 tion and by biliary and renal colic. It occurs as a symptom 
 of sclerotic bulbar lesions. 
 
 Clinical Description. — The attacks begin suddenly, without 
 prodromal symptoms, unexpectedly, either during digestion 
 or during the period of gastric repose, but most frequently 
 during the second half of the night, with severe, colicky gastric 
 pains which may or may not be accompanied by headache. 
 The pain may radiate over the abdomen and into the back and 
 shoulders, and be so severe as to produce collapse. Vomiting
 
 300 DISEASES OF THE STOMACH. 
 
 soon follows, but it affords only partial and temporary relief, 
 and recurs again and again after short intervals. The vomit 
 consists of the accidental contents of the stomach and of a 
 gastric juice rich in h\-drochloric acid and ferments and 
 tinged green with bile. If food be in the stomach when the 
 attack begins, the vomit is strongly acid, the acidity being due 
 to an excess of free and a large quantity of combined hydro- 
 chloric acid. After the stomach is emptied secretion con- 
 tinues; and the vomit consists of a greenish fluid of a total 
 acidity of 20 to 40 and a specific gravity of about IO06, 
 and containing the ferments of the stomach. The acidity 
 is due almost entirely to acid phosphates (6 to 12) and to 
 free hydrochloric acid. There is no noteworthy increase 
 of gastric mucus and no blood, but a few cell nuclei are 
 present. The quantity of fluid vomited is largely in excess 
 of what has been swallowed. Secretion is active and con- 
 tinuous. Headache may be the predominant symptom, and 
 it is sometimes agonizing, or it may be but slight. Appetite 
 is lost and the patient complains of great thirst. During 
 the interval betweert the attacks the well-nourished patient 
 experiences no discomfort during digestion, the appetite is 
 good, and the functional signs are normal. 
 
 Diagnosis. — Paroxysmal hj'perchylia gastrica is character- 
 ized by intermittent painful attacks of supersecretion and 
 vomiting, separated by intervals of normal gastric digestion. 
 Locomotor ataxia and multiple sclerosis maybe accompanied 
 by similar paroxysms, and in every case the signs of these 
 diseases should be sought. Paroxysmal supersecretion may 
 be the initial symptom of tabes dorsalis. 
 
 Treatment. — The patient should be put to bed in a darkened 
 room, and hot water administered. If given in the beginning 
 of the attack, the hot water may abort it, and later it will 
 excite profuse vomiting and afford relief (Rossbach). Phena- 
 cetin, antipyrin, or antifebrin may also be administered. 
 Caffein may give relief if administered early in the attack. 
 The Winternitz compress is beneficial. The best treatment 
 in the beginning of the attack is a thorough stomach wash- 
 ing, followed by a purgative dose of calomel, and by mor- 
 phin and atropin hypodermically. During the attack food 
 should not be given by mouth, but the patient should be 
 nourished exclusively by enemata. 
 
 The preventive treatment consists in the avoidance of men- 
 tal fatigue and of intestinal stagnation and decomposition, 
 in digestive hygiene, and in attention to the general health. 
 Errors of refraction should be corrected h\ glasses.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 3OI 
 
 2. ADENASTHENIA GASTRICA. 
 
 A dynamic affection of the stomach, characterized by a 
 diminished and a poor secretion without an anatomical lesion 
 of the mucous membrane, is known as adenasthenia gastrica 
 (subacidity, anacidity, hypochlorhydria, hypochylia). 
 
 Etiology. — The disease is less frequent than adenohyper- 
 sthenia gastrica, and may be met with as a particular form of 
 neurasthenia gastrica and in hysteria and the psychoses. 
 But the trouble may develop in those who are neither neuro- 
 pathic nor neurasthenic, and may be a consequence of railway 
 shock, of fright, of sorrow, of depressing moral influences, 
 or of chronic subnutrition. It is sometimes found in the 
 severe anemias and in chlorosis, and is a symptom of many 
 of the acute febrile diseases. Adenasthenia gastrica predis- 
 poses to intestinal diseases. 
 
 Clinical Description. — Gastric subjective symptoms may be 
 entirely wanting or may consist in slight digestive discomfort. 
 The appetite is often poor, but if the intestines are healthy 
 and enough food is taken the general nutrition is well 
 maintained. The urine is often highly acid, the diminution 
 of its acidity during digestion does not occur, and uric acid 
 frequently precipitates after the urine stands for a few hours. 
 There may or may not be diarrhea, which is as frequent in 
 adenasthenia as constipation is in adenohypersthenia gastrica. 
 
 The patient feels unfitted for work, and no adequate cause 
 can be found for the mental depression. It is usually difficult 
 to persuade the adenasthenic that there is nothing serious 
 the matter, the thoughts and feelings, it would seem, taking 
 all their color from the depressed function of the stomach. 
 
 The functional signs are the distinctive characteristics of 
 the disease. The filtrate of the contents obtained after the 
 test-breakfast contains no free HCl (H), the albuminoid 
 affinities for acid are not satisfied, and in some cases the 
 combined hydrochloric acid (C) is present in mere traces or 
 is altogether wanting. The ferments may be present in pro- 
 portionately greater quantity, but, as a rule, the pepsin is 
 diminished in proportion to the diminution of the total HCl, 
 but not of the free HCl alone. If hydrochloric acid be 
 administered ten minutes before the expression of the test- 
 breakfast contents, both tube peptonization and milk curdling 
 are sometimes as active as in health, for the mother substances 
 of the ferments are present in greater quantity than are the 
 converted ferments. Another characteristic is the influence
 
 302 DISEASES OF THE STOMACH. 
 
 of electricity. Cathodal dorsogastric galvanization for ten 
 minutes, with a current of five to ten milliamperes and a cur- 
 rent density oi 4^, during the second half hour of the diges- 
 tion of the test-breakfast, improves, or even removes, the 
 secretorj' depression. In the gastric contents after the test- 
 breakfast, or after the test-meal of Germain See, there is only 
 a moderate quantity of syntonin and propeptones, a large 
 quantitt' of the albumin remaining undissoh-ed. The acidu- 
 lated tube pepsin tests give a digestive percentage less than 
 normal, and the dilution is always less active than the undiluted 
 test. There is no motor insufficiency in spite of the absence 
 of the motor stimulation exerted by hydrochloric acid, the 
 test contents being less liquid than normal. There is little 
 mucus, no excess of formed elements, and no fermentation, 
 except, irregularly, there may be a strong odor of butyric 
 acid. Starch digestion is greater than in the normal stomach. 
 The specific gravity of the contents is abnormally high, and 
 the total quantity of secretion is frequenth' diminished. 
 
 Differential Diagnosis. — The functional signs, the genesis, 
 the vague subjecti\'e s\'mptoms, and the absence of a dis- 
 coverable disease of any organ are the salient features of 
 adenasthenia. It may be confounded with carcinoma, with 
 asthenic gastritis, and with atrophy of the gastric glands. 
 
 In carcinoma the secretory signs may be similar, but here 
 the resemblance ends. The disgust for certain foods, the 
 relation of the gastric symptoms to the quality of the food, 
 the progressive character in spite of the purposive treatment, 
 the bacteriological signs, possibly the physical signs of a 
 tumor, the motor insufficiency, gastric pain, excess of mucus, 
 etc.. do not exist in adenasthenia. Confusion is not likely to 
 occur unless an attempt be made to base the diagnosis on 
 the narrow and misleading hydrochloric subacidity alone. 
 
 The differentiation of the functional disorder and asthenic 
 gastritis is not difficult. In asthenic gastritis there is always 
 an excess of mucus, and the secretion can not be excited 
 so readily by stimulants and b}' electricity. The subjec- 
 tive symptoms of gastritis are in relation with the physical 
 qualities of the food. The causation and the mode of begin- 
 ning may suggest the nature of the trouble. In gastritis there 
 may be symptoms, such as nausea and vomiting, which are 
 not found in adenasthenia. In asthenic gastritis the ferments 
 are persistently diminished, which may be the case in aden- 
 asthenia. The dynamic affection is very rare. 
 
 Treatment. — The treatment is excitant, the aim being to 
 restore the secretory power and to tone the nervous system.
 
 THE DYNAMIC AFFECTIONS OF SECRETION. 303 
 
 The first object is to reduce the life of the patient to a physi- 
 ological basis and to restore tone and vigor to the whole 
 system by the use of tonics and of hygienic remedies suited 
 to each individual case. 
 
 As a chemical remedy, hydrochloric acid with pepsin may 
 be given in two or three doses during the period of diges- 
 tion, but with no hope of producing directly more than a 
 purely chemical action. The effect of the acid on intestinal 
 digestion should be watched. Peptones may, however, be 
 administered before meals to excite secretion, acting in this 
 respect as physiological remedies. 
 
 The local treatment is physiological and excitant — the 
 Scottish douche, electricity, the intragastric chlorid of sodium 
 douche, in the manner recommended in the chapter on 
 General Medication. 
 
 The diet should not vary much from that of health — meats 
 in moderate quantity and finely-divided cereals (since the 
 digestion must be done by the intestines), vegetables, sweets, 
 and fats. The starchy foods are well digested and they 
 should be particularly recommended. Sweets not only are 
 useful as food, but as a physiological means of exciting secre- 
 tion. Beer, wines, ale, cider, tea, and coffee may be recom- 
 mended in moderation. Fine physical division of all of the 
 food is demanded by the intestines, on which the brunt of 
 digestion falls. The food to be taken during the twenty-four 
 hours should be divided into three or four equal portions. 
 
 Calumba, gentian, cinchona, and nux vomica may be com- 
 bined with aromatic tinctures, and administered half an hour 
 before meals. The effect of the excitant treatment should be 
 carefully watched and not pushed too vigorously, and should 
 be stopped as soon as the secretory activity is restored. Three 
 grains of orexinum basicum may be given in a gelatin cap- 
 sule daily, in the morning at 10 o'clock, with a cup of 
 bouillon, but the remedy should not be continued longer than 
 five days without an intermission. A powder composed of 
 common salt and chlorid of calcium, taken in a wineglassful 
 of a mildly alkaline water half an hour before meals, is an 
 excellent stimulant of secretion.
 
 304 DISEASES OF THE STOMACH. 
 
 CHAPTER III. 
 THE MOTOR DYNAMIC AFFECTIONS. 
 
 I. SPASM OF THE CARDIA. 
 
 On the introduction of the stomach-tube a sh'ght resistance 
 is felt by the experienced finger just before the entrance of tlie 
 tube into the stomach. Tiiis spasmodic contraction of the 
 cardia is physiological, and is often manifest to a person when 
 a large or somewhat irritating bolus is swallowed. It is on 
 account of this spasm that swallowed corrosive poisons are 
 arrested, and are so energetic in their action on the lower 
 portion of the esophagus. Even a full swallow of water 
 occupies about twelve seconds in passing through this normal 
 point of constriction, as indicated by the interval separating 
 the two deglutition sounds. 
 
 Pathologically, the normal constriction or contraction of 
 the cardia may be increased both when the cardia is and is not 
 the site of organic disease. In esophagitis, ulcer of the cardia, 
 and sometimes in carcinoma, the stenosis of the cardia is partly 
 spasmodic. Spasm of the cardia occurs also as a dynamic 
 affection without a local anatomical lesion. The stricture of 
 the cardia is in such cases characterized by the ordinary signs 
 of simple spasm, in association with the stagnation or reten- 
 tion of the swallowed food and the secretions above it, and 
 with the accumulation of gases in the stomach below it. 
 
 Etiology. — Cardiospasm (sometimes called esophagismus) 
 is not a (requent disease. It may occur at any age, and is 
 most common in the neurotic and the arthritic. Cerebral ex- 
 citement is sometimes the occasion of its generation, but the 
 origin of the reflex spasm may be in any of the organs 
 closely connected with the nerves of the cardia. Frequently 
 the abuse of tobacco is the most active factor in its causa- 
 tion. It is sometimes produced by hyperesthesia of the 
 cardia, which may be engendered by very hot or very cold 
 drinks, and by the abuse of condiments. Spasm of the cardia 
 sometimes results, by reflex action, from the habitual swal- 
 lowing of air, and we have seen two cases developing as a 
 result of arteriosclerosis, there being at the same time erosions 
 of the gastric mucosa.
 
 THE MOTOR DYNAMIC AFFECTIONS. 305 
 
 Clinical Description and Objective Signs. — Spasm of the 
 cardia may be acute, paroxysmal, or recurrent, or it may be 
 chronic. The acute attacks last only a few days, and are 
 characterized by dysphagia, by absence or delay of the swal- 
 lowing sounds, and by strong, but eventually yielding, resist- 
 ance to the introduction of the large and moderately stiff 
 stomach-tubes. The food accumulates in the esophagus, and 
 after a 'i^\N mouthsful an effort to force it into the stomach 
 becomes necessary to relieve the pressure behind the sternum. 
 The cardia, however, does not always yield, and the food may 
 be regurgitated into the mouth, and attacks of dyspnea, 
 resembling so-called asthma dyspepticum, may occur. In 
 the chronic form, which is fortunately rare, the dysphagia 
 and other symptoms occur after each meal, but its long 
 course, running often for months and years, may be inter- 
 rupted by periods of marked improvement. 
 
 Clinically, three degrees of the chronic affection may be 
 distinguished, two being characterized by esophageal stagna- 
 tion and the other by esophageal retention of the swallowed 
 food. The form with food retention occurs, with few excep- 
 tions, only where the lower end of the esophagus is dilated; 
 the tube introduced in the morning before breakfast with- 
 draws remnants of food eaten the previous day. 
 
 In the stagnation form the esophagus is either found 
 empty in the early morning or it contains a noteworthy quan- 
 tity of mucus and saliva. The stagnation form may be mild 
 or severe. In the mild form the spasm occurs chiefly during 
 the meal ; in the severe form the spasm is more persistent 
 and obstinate. In the mild form the entrance of food into 
 the stomach is delayed and difficult, but is effected before the 
 next meal ; in the severe form the food is forced into the 
 stomach only after special efforts and devices, and the swal- 
 lowed secretions and the secretion of the esophagus accumu- 
 late between meals, and particularly at night. In the mild 
 form the patient feels the food stop before entering the 
 stomach, but after a few more mouthsful or a few moments' 
 delay the spasm yields and the food enters the stomach, to 
 the relief of the patient. In the severe form the mere delay 
 is not sufficient, but the accumulated food must be forced 
 through the cardia, often after drinking a glass of water. A 
 deep inspiration is taken, and an expiratory effort is made or 
 the thorax is compressed by the hands, while the glottis is 
 kept closed, sometimes during repeated acts of deglutition. 
 
 In the mild form the trouble ends with the swallowing of the 
 20
 
 306 DISEASES OF THE STOMACH. 
 
 meal. In the severe form the accumulation of the secretions 
 may manifest itself by non-alimentary esophageal vomiting. 
 
 In the retention form the spasm can not be completely 
 overcome, either involuntarily or by voluntary effort, and 
 more or less of the swallowed food remains in the esophagus, 
 which is usually dilated. The dilatation is nearly always 
 symmetrical, though it may be unilateral, irregular, or saccu- 
 lated. Retention produces much more serious symptoms 
 than simple stagnation, such as dyspnea, palpitation, fermen- 
 tation, putrefaction, and esophageal alimentary vomiting. 
 The dyspnea occurs not only during the meals but also after 
 moderate exercise or effort, or it may be paroxysmal and 
 nocturnal. The palpitation occurs intermittently in relation 
 with the filling of the dilated pouch, and is rapidly relieved by 
 its evacuation. The fermentation is usually butyric or lactic, 
 and putrefaction is rare. The vomiting often occurs without 
 effort or warning, and may take place during sleep. The un- 
 fortunate patient sometimes awakens with dyspnea, cyanosis, 
 and palpitation, and with the UKuith already full of the regur- 
 gitated material. 
 
 In all forms of the affection the cardia may show favoritism 
 in permitting the passage of the various sorts of food : now 
 hot, now cold, now solid, now fluid food being arrested. 
 The patient must stop eating once, twice, or several times 
 during the meal to allow the cardia to relax, or he must 
 force the food which has accumulated in the esophagus 
 through the resistant cardia into the stomach. In the mild 
 stagnation form it is only necessary, as a rule, to wait for a 
 few minutes, but in the severe stagnation and in the retention 
 varieties of the affection active and voluntary efforts must be 
 employed, and the frequency of these forcing efforts is pro- 
 portionate to their inefficiency and to the smallness of the 
 capacity of the esophagus. If the esophagus is largely 
 dilated but empty when the meal is begun, the patient may 
 be able to eat an ordinary meal before forcing the food into 
 the stomach. The patient, after the meal, commonly retires 
 to a private corner, takes a glass of water, inspires deeply, 
 closes the glottis, contracts the thorax by means of the 
 e.xpiratory muscles, or by compressing with the hands, and 
 repeats the procedure until the contents of the esophagus are 
 completely or in part forced onward into the stomach or 
 backward into the mouth. Patients often feel water pass the 
 lump of retained food and hear it gurgle into the stomach. 
 The spasm may be excited in some cases only by the act of
 
 THE MOTOR DYNAMIC AFFECTIONS. 307 
 
 swallowing, the sound or tube passing into the stomach with- 
 out resistance. 
 
 In addition to the esophageal stagnation and retention, the 
 spasm of the cardia may often cause very distressing tympan- 
 itic distention of the stomach. The distention may be pro- 
 duced by swallowed air or by the gases of chemical decom- 
 position or of fermentation in the stomach, the cardia again 
 closing after being forced by the swallowed food, or con- 
 tracting as a result of the irritation of the mucous membrane 
 of the stomach. This reflex spasm of the cardia may exist 
 without dysphagia. The distention of the stomach produces 
 discomfort, dyspnea, palpitation, and sometimes painful gas- 
 trospasm, the attacks lasting from a {q.\\ minutes to several 
 hours, the pylorus being also simultaneously closed. 
 
 Although the clinical expression of spasm of the cardia is 
 quite well defined, the exploration with the sound furnishes 
 the most exact information. The very soft, flexible tube 
 passes in easily for about 14 inches, removing the con- 
 tents of the esophagus, but it is rarely possible to force it 
 through the spasmodic stricture. With the tube in this posi- 
 tion, a glass of water can be introduced into the esophagus 
 and withdrawn by siphonage before it enters the stomach, 
 particularly where the esophagus is dilated. The stiff English 
 or German stomach-tubes can usually be introduced into the 
 stomach after gentle pressure is patiently employed for one 
 or two minutes, but the flexible English esophageal sounds 
 of large caliber pass easily into the stomach. Sometimes a 
 sound or stiff tube may be introduced without a perceptible 
 resistance at the cardia, the spasm being excited only by acts 
 of swallowing. In the majority of the cases of esophagismus 
 gagging is produced by the use of the tube, and the patient 
 often gives a history of spasm in other parts than the cardia. 
 The effect of bromids, combined with atropin hypodermi- 
 cally, is so marked in the relief of spasm of the cardia that 
 the ease with which the tube can be introduced while the 
 patient is under their influence is of value in the differential 
 diagnosis. If the tube introduced before the evening meal 
 removes no food from the esophagus, there is the mild stag- 
 nation form. If food be removed at this time, and if the 
 esophagus is empty in the morning before breakfast or con- 
 tains only mucus and saliva, the severe stagnation form exists. 
 If the esophagus contains food in the early morning before 
 breakfast there is esophageal retention, and if a noteworthy 
 quantity of contents is removed the esophagus is also dilated. 
 The dilated esophagus may hold a pint or more. When the
 
 308 DISEASES OF 77/ E STOMACH. 
 
 esophagus is not empty in tlie early morning it is our custom 
 to wash out the esophagus and then to introduce a glass of 
 milk, after first pushing the tube well into the stomach. The 
 tube is next withdrawn and the patient is given a glass of 
 water and directed to try to force the water into the stomach. 
 Ten or fifteen minutes later the tube is introduced, and the 
 degree of obstruction of the cardia, and of dilatation of the 
 esophagus, is proportionate to the quantity of water which 
 is recovered. The tube may then be pushed on into the 
 stomach, and the obvious inferences may be made from the 
 withdrawal of milk. Before the entrance of the tube into the 
 stomach it is not possible to inflate the stomach by pumping 
 in air. 
 
 The deglutition sounds are either modified or absent. The 
 first sound is usually delayed, and the second sound, if heard 
 at all, is deferred several minutes or longer. Swallowing is 
 followed by complete silence if nothing enters the stomach, 
 and the deglutition sounds ma)' be heard only after the patient 
 voluntarily presses the arrested food or fluid through the 
 cardia. _ 
 
 Differential Diagnosis. — Obstruction of the cardia may be 
 organic or spasmodic. The non-spasmodic obstruction may 
 be due to compression by tumors of the mediastinum, to 
 Pott's disease, or to neoplasms arising from the vertebral col- 
 umn, or to aortic aneurysm. The symptoms incident to these 
 diseases should be sought for in the obscure cases. Organic 
 strictures may be produced by cancer, ulcer, sacculation, 
 the cicatrization after burns or after the swallowing of corro- 
 sive poisons, and varicose esophageal veins. 
 
 There are signs which distinguish organic from spasmodic 
 stenosis. Organic stricture is persistent : spasmodic stenosis 
 may be intermittent. Atropin and the bromids are without 
 noteworthy influence on organic stricture, but often relax the 
 spasm. Stiff sounds pass a spasmodic stricture more readily 
 than the soft tubes, while the re\'erse is true of organic stric- 
 ture. But spasm may coexist with organic diseases of the 
 cardia, and by the disappearance of inflammatory swelling the 
 spasm may be diminished ; improvement is, consequently, 
 no distinctive criterion. The differentiation should be based 
 on the group of symptoms or signs. 
 
 Carcinoma is most frequent between thirty and fifty, and is 
 regularly progressive. Hemorrhage is not rare, and the blood 
 is unlike that which has been blackened or browned by the 
 acid of the gastric juice. Blood, however, may be vomited after 
 its entrance into the stomach. The cardia is involved in eight
 
 THE MOTOR DYNAMIC AFFECTIONS. 309 
 
 per cent, of all cancers of the stomach, but the neoplasm 
 almost invariably extends to or originates in the stomach or 
 esophagus ; consequently, the functional and bacteriological 
 signs of cancer of the stomach are usually present, and are 
 valuable aids in making a decision. The esophageal contents 
 are usually offensive, and blood and particles of the neoplasm 
 may be removed with the tube. Soft tubes enter the stomach 
 more readily than stiff sounds, and the caliber of the stricture 
 may be rapidly enlarged by ulceration, or diminished by 
 swelling and by the growth of the tumor. Cancer is the 
 most frequent disease of the cardia, and the emaciation and 
 loss of strength are greater than should be produced by the 
 patient's diet. 
 
 Ulcer involving the cardia is most common in men who 
 have passed the fortieth year. It is manifested by nausea, 
 vomiting, and a raw, tearing pain excited immediately by 
 swallowing, and located behind the sternum near the left sixth 
 intercostal space ; from this point the pain may radiate into 
 the epigastrium, back, and shoulders. Hemorrhage is fre- 
 quent, and the introduction of the sound is very painful, always 
 injurious, and often impossible. Cicatricial stenosis, persistent 
 or progressive, is more readily passed by small sounds, and is 
 preceded by the signs and symptoms of destructive inflam- 
 mation. The gastric juice in ulcer of the cardia is usually 
 excessively acid, and many of the signs and symptoms of 
 gastric ulcer accompany it. 
 
 Sacculation of the lower end of the esophagus is exceed- 
 ingly rare, this trouble being located usually at its upper ex- 
 tremity or in its central third. The esophageal contents 
 often contain pus and sometimes blood, and often ferment, or 
 sometimes putrefy. The fermentation is usually butyric or 
 lactic. Both the tube and the sound pass readily when the 
 sac is empty, but, as a rule, only then. No abnormality of the 
 functions of the stomach is produced by sacculation. 
 
 Varicose esophageal veins are accompanied by cirrhosis of 
 the liver, or by other causes and signs of obstruction of the 
 portal circulation. 
 
 Spasm of the cardia, rarer than either cancer or ulcer, oc- 
 curs at all ages, but most frequently in neurotic and arthritic 
 patients. The course is long, intermittent, or remittent. The 
 spasm is palpably relieved by antispasmodics; stiff sounds 
 pass easier than the soft tubes, and no change in the func- 
 tions of the stomach takes place. Consequently, normal 
 functional and bacteriological signs are against ulcer and
 
 3IO DISEASES OF THE STOMACH. 
 
 cancer. Tliere is no spontaneous bleeding, nor blood in the 
 opening of tiie tube. The other signs and symptoms of 
 spasm of the cardia have been enumerated in its clinical 
 description. 
 
 Treatment — The valuable remedies in the treatment of 
 spasm of the cardia are few. The etiological and constitu- 
 tional treatment should not be neglected, and electricity may 
 be tried. Cervico-esophageal sedative polar galvanization is 
 the preferred form, but it is no more and no less valuable than 
 intragastric anodal galvanization. 
 
 The use of the esophageal sound is in itself sometimes 
 curative, and is the mainstay of any plan of treatment. A 
 large fle.xible sound should be passed through the cardia and 
 left in place for several minutes. The sound should be used 
 once a day in the stagnation form, preferably before break- 
 fast. If esophageal retention is present, the sound should be 
 introduced before each meal. The lower end of the tube 
 may be smeared with an ointment of cocain (Rosenheim), or 
 a small piece of sponge attached to a silk thread running 
 through the tube may be placed within the eye of the tube, 
 saturated with a solution of cocain, which is squeezed out 
 after the tube is against the cardia by introducing a tube- 
 guard (Penzoldt). If the esophagus is dilated, its contents 
 should be washed out at bedtime. It is a most excellent plan 
 to introduce all the food through the stomach-tube. 
 
 Bromid of potassium is often palliative, but sometimes does 
 little good unless given in large doses. The spasm often 
 returns after the bromism subsides, but the remedy is in- 
 dicated as a palliative, unless there is excessive hydrochloric 
 acidity of the gastric contents. Nitrate of silver is then 
 much better, and in the simple cases also it often proves of 
 more service than do the bromids. The extracts of coca 
 and of hyoscyamus washed down with chloroform water are 
 very beneficial. These remedies should be given half an 
 hour before meals. It is very important to control excessive 
 hydrochloric secretion and to prevent butj'ric acid fermenta- 
 tion both in the esophagus and stomach. 
 
 The diet is often too restricted. The one essential is 
 that it should not be irritating, and condiments and acids 
 and half-mastication of the food should not be permitted. 
 All the food and water should be taken in three meals, noth- 
 ing being permitted during the intervals. The diet should 
 also satisfy any peculiarity of the spasm, which sometimes 
 shows a repugnance for certain foods. In other respects, the
 
 THE MOTOR DYNAMIC AFFECTIONS. 3II 
 
 diet is selected in reference to the condition of the stomach 
 and the intestines, the needs of nutrition, and also to the con- 
 dition of other organs when diseased, and coarse or solid food 
 may sometimes be employed as a means of dilating the cardia. 
 
 II. SPASM OF THE PYLORUS. 
 
 The pylorus is physiologically the most important sphinc- 
 ter of the digestive tube, exceeding in the variety and value 
 of its work not only the cardia and the anus, but also the 
 ileocecal valve and the duodenojejunal constriction. It con- 
 trols gastric digestion by regulating the time during which 
 the food is subjected to the churning movements, to the 
 transforming gastric juice, to the absorbent surface of the 
 stomach, and to the action of the saliva. It regulates the 
 supply of nutritive material to the intestines without the in- 
 terference of the will. It separates the two chief divisions 
 of the digestive tube, protecting both the stomach and the 
 intestines. Normally, there is no reflux through it to disturb 
 the stomach, and no harm should come through it to the 
 intestines. It controls the gateway to nutrition. But its 
 work is not done without favoritism, for it often protects the 
 intestines at the cost of slow starvation and of injury to the 
 stomach. While acting normally it may not do harm, and 
 the disturbance produced by it when diseased corresponds to 
 the importance of its work in health. One of its chief func- 
 tional disorders is spasm. 
 
 Spasm of the pylorus is either primary or secondary. The 
 secondary spasm of the pylorus is common in ulcer, in cancer, 
 in hypersthenic gastritis, in adenohypersthenia gastrica, and in 
 excessive secretory activity accompanying stagnation and re- 
 tention. It consequently plays an important part in the evolu- 
 tion and in the genesis of the symptoms of acute and chronic 
 hypersthenic gastritis, and of complicated forms of myasthenia. 
 The disease produces the spasm, and the spasm causes or 
 increases stagnation or retention, with consequent irritation of 
 the mucous membrane of the stomach, excessive peristalsis 
 or gastrospasm, and often vomiting. A vicious gastric circle 
 thus becomes established. 
 
 But spasm of the pylorus occurs frequently as a primary 
 dynamic affection — a morbid entity with a distinctive expres- 
 sion and with a proper rational treatment. Its existence can 
 be established only by clinical observation, and its frequency 
 by the recognition of the vicious circle of which it forms a
 
 312 DISEASES OF THE STOMACH. 
 
 part, and by observing the method b}- which this same circle 
 is broken. 
 
 Etiology. — Like spasm of the cardia, spasm of the pylorus 
 is most common in neurotic and arthritic patients, and it may 
 be occasioned by shock, anxiety, worrj', or prolonged 
 mental or moral strain. It may occur as an accident, the mere 
 manifestation of a dietetic error, or the effect of very cold 
 drinks, the protection of the intestines necessitating an acute 
 disturbance of digestion. Spasm of the pylorus is an almost 
 constant accompaniment of gall-stone colic and of pyloric 
 hyperesthesia, and it may produce complete occlusion for 
 several days. It is common in the acute diseases of the 
 intestines, particularly when nausea and vonfiiting are present. 
 When the body of any of the hollow organs that are closed by 
 sphincters becomes relatively weak, the antagonistic sphincter 
 muscle may remain contracted. This is very likely the 
 genesis of pyloric spasm occurring in old age, and during 
 convalescence from severe diseases. 
 
 Clinical Description. — Pyloric spasm, like spasm of the 
 cardia, is digestive and periodical, or it is more persistent. 
 Consequently, it produces either stagnation or retention and 
 their respective consequences. 
 
 One of the most common symptoms is gastric flatulency. 
 The swallowed air and the gases of chemical decomposition 
 and of fermentation when it is present, accumulate in the 
 stomach, and are got rid of by belching or finally by 
 the relaxation of the pylorus and their rapid escape into the 
 duodenum. This sudden relief by the rapid and perceptible 
 evacuation of the stomach is characteristic. 
 
 In the severe cases there are often painful gastric peristal- 
 sis and agonizing pyloric colic, which may end suddenly 
 with the relaxation of the pylorus, or may recur intermit- 
 tently until the stomach is empty, or cease after copious 
 alimentary vomiting. 
 
 There is no discomfort when the stomach is empty, but 
 the pain may continue as long as the food and digestive or 
 fermentative products remain in the stomach. In retention 
 the symptoms may become continuous and the stomach may 
 ultimately reject everything introduced into it. 
 
 The objective signs are much more characteristic than the 
 subjective symptoms. In some cases the pylorus can be 
 felt as a firm cylinder moving up and down with the dia- 
 phragm. During digestion there is no intermittent palpable 
 bubbling through it, nor does it become alternately hard and 
 soft. The intermittent pyloric spurt is not heard either after
 
 THE MOTOR DYNAMIC AFFECTIONS. 313 
 
 a glass of water or during the digestion of a meal. The 
 pyloric evacuation sound may be absent when there is visible 
 or distinctly palpable gastric peristalsis. These abnormalities 
 disappear, either spontaneously or intermittently, under the 
 influence of antispasmodic treatment. 
 
 Artificial inflation of the stomach is easy and the viscus re- 
 mains distended much longer than when it is normal. The gas 
 or air can not be massaged into the duodenum as in health. 
 
 In the simple cases gastric absorption is normal. Secre- 
 tion may be normal or may be excessive, but the abnor- 
 mality usually disappears with the restoration of the motor 
 function. The characteristic functional sign is intermittent 
 stagnation or retention. After the test-breakfast there is an 
 excessive quantity of contents of high specific gravity (above 
 1015) and containing an excessive quantity of digestive pro- 
 ducts. There may be mild or severe stagnation or retention, 
 but the motor insufficiency in a particular case, whatever be 
 its degree, may spontaneously and suddenly disappear, or 
 may be rapidly improved by sedative and soothing medica- 
 tion. This distinctive sign is never met with in myasthenia. 
 If stagnation, as a result of pyloric spasm, occur in adeno- 
 hypersthenia gastrica, it is rapidly relieved by a milk diet with 
 large doses of the alkalies, but the excessive secretion is more 
 rebellious. In stagnation or retention due to myasthenia the 
 excessive secretion may be controlled, but the motor insuffi- 
 ciency disappears very slowly and gradually. 
 
 Treatment. — The treatment of primary spasm of the 
 pylorus is very simple, but not always rapidly successful. 
 Measures to improve the tone and strength and to allay the 
 irritability of the nervous system are naturally in place. If 
 retention be present, the stomach should be daily washed out, 
 but in stagnation only when there is fermentation. 
 
 The diet should be soothing, mild in its action on secre- 
 tion, and easily evacuated, and should also be selected with 
 a view to its resistance to fermentation if the motor insuffi- 
 ciency be pronounced. Consequently no particular diet will 
 suit every case. 
 
 Of the physical remedies, cervicogastric galvanization and 
 the Winternitz or a hot compress (coil over moist flannel) 
 may be employed during digestion. Nitrate of silver is valu- 
 able if the stomach is morbidly sensitive or secretes exces- 
 sively, or when there is hyperesthesia of the pyloric mucous 
 membrane. The extracts of coca and belladonna should be 
 given before each meal, and if there is much pain codein 
 phosphate should be given hypodermically, or chloral hydrate
 
 314 DISEASES OF THE STOMACH. 
 
 may be given bv rectiuii. It is bad practice to give these 
 remedies by mouth for the relief of painful p)'loric spasm. 
 Hot drinks may be given and heat may be applied externally, 
 or the stomach may be washed out and left empty. 
 
 III. GASTROSPASM. 
 
 Tonic spasm of the stomach may be a symptom or, rarely, 
 a distinct morbid entity occurring without any organic 
 change in the mucous membrane. 
 
 Etiology. — Symptomatic gastrospasm occurs in pyloric 
 obstruction, at times during the digestive period, and at 
 times during the period of normal repose, on account of the 
 effort of the stomach to evacuate the retained chyme. But 
 the stomach when empty again relaxes. In hypersthenic 
 gastritis and in adenohypersthenia gastrica the stomach 
 may be resistant and rigid, and also small when it is not 
 full. The spasm of the stomach in these diseases and in 
 ulcer, like pyloric spasm, is due to the irritation or hyper- 
 esthesia of the mucous membrane. The chronic asthenic 
 gastritis which occurs in advanced arteriosclerosis may be 
 accompanied by paro.xysms of painful gastrospasm. and these 
 attacks may occur either when the stomach is empty or 
 during digestion. Tabes may rarely be manifested by crises 
 of gastro-intestinal tonic spasm. A small, contracted, hyper- 
 trophied stomach in a permanent form is a sequel of long 
 rumination. In cases of chronic and periodical vomiting, 
 with complete gastric intolerance, the stomach is contract- 
 ured, and the same condition is a result of acute nicotin- 
 poisoning and probably occurs in meningitis. 
 
 Clinical Description. — Primary gastrospasm may or may 
 not be painful, or may be only periodically painful, and par- 
 ticularly so after the ingestion of food. The sensation of 
 constriction of the stomach, often felt and complained of by 
 the patient, is not always relieved by empt\'ing the stomach. 
 The capacity of the stomach, and consequently its surface 
 area also, is small. If there be vomiting or discomfort, or 
 even severe pain, a quantity of food that is large as regards 
 the size of the stomach always produces these symptoms, 
 but small meals may be well borne. Inflation of the stomach 
 excites nervousness, local distress, and pain. When the 
 stomach is empty the epigastrium is depressed, and may 
 become prominent after meals. Above the depression, and 
 well up under the left costal border, the rigid contractu red
 
 THE MOTOR DYNAMIC AFFECTIONS. 315 
 
 Stomach can sometimes be felt moving up and down with 
 the diaphragm. The epigastric prominence is produced by 
 the hard, smooth stomach, manifesting no palpable peristaltic 
 movements. In neither case is the stomach tender. There 
 is no chemical abnormality of the test-breakfast contents if 
 the bread has been thoroughly masticated. The stomach 
 may be too rapidly evacuated, but more frequently the py- 
 lorus is also tightly closed. 
 
 Diagnosis. — The diagnosis of the dynamic affection — the 
 course of which may be long or short, remittent or intermit- 
 tent, beginning and ending suddenly without apparent cause — 
 must be made by exclusion and by the presence of its physical 
 signs. The gastrospasm can only be rightfully considered 
 primary in the absence of the diseases of which it may be a 
 symptom. Fortunately, the signs of these diseases are dis- 
 tinctive. 
 
 Treatment. — The treatment is almost exclusively dietetic. 
 The bromids only act as palliatives, cannabis indica is uncer- 
 tain, and belladonna is of no benefit. Aconitia and codein 
 are of the greatest value, and in combination have a marked 
 influence on the trouble. Sedative galvanization and a hot 
 compress may be tried. Vigorous massage is also beneficial. 
 
 The diet in the beginning should be soothing and small in 
 quantity, and when well borne nothing is better than hot 
 milk. The quantity of the milk should be gradually increased, 
 and after a week cereals, and, later, meats, should be added to 
 the diet, the object being gradually to render the stomach 
 tolerant of larger and larger quantities of food which excites 
 it little and leaves it rapidly. 
 
 IV. TORMINA VENTRICULI NERVOSA. 
 
 Excessive and visible peristalsis of the stomach as a simple 
 dynamic affection is very rare. The phenomenon is nearly 
 always a symptom either of pyloric or duodenal obstruction 
 or of gastroptosis. 
 
 Peristalsis may infrequently be palpable or visible during 
 normal digestion. Pathologically, gastric peristalsis may also 
 occur periodically, or persistently during the period of nor- 
 mal repose. It is then either a symptom, the stomach con- 
 taining either food or gas, or possibly it is a distinct morbid 
 entity. 
 
 The dynamic form occurs in neurotics and neuropaths — 
 particularly in hysteria and in neurasthenia. It may then
 
 l6 DISEASES OF THE STOMACH. 
 
 exist alone, or ina)' be associated with excessive intestinal 
 peristalsis. 
 
 The visible and palpable peristalsis nia}- occur when the 
 stomach contains no food, but it is most active during diges- 
 tion. It may also be excited by gently stimulating the skin 
 over the epigastrium with the tips of the fingers, or by cold, 
 or, better, by introducing food or cold water into the stomach. 
 It seems, at times, to be a mere effort to rid the stomach of gas, 
 and often ceases with its evacuation. Excitement may either 
 stop or start it. 
 
 As the patient lies quietly on the back, the peristaltic wave 
 emerges from beneath the left costal border, rises prominently 
 into view, and falls beneath the linea alba, to rise again slightly, 
 and finally to disappear at the pylorus. The wave may also 
 be antiperistaltic, and the circuit may be traversed several 
 times in a minute. The agitation may be accompanied by 
 churning and gurgling noises, but the peristalsis is never pain- 
 ful. It may continue day and night, and produce insomnia. 
 Seldom nausea and vomiting and belching occur. There are 
 no secretory or bacteriological signs. The patient com- 
 plains of the perceptible movements in the abdomen and 
 of the peculiar uneasiness which accompanies them. 
 
 The diagnosis is readily made by inspection and palpation, 
 and it is not difficult to locate the trouble in the stomach by 
 the aid of the physical signs. The affection may exist without 
 the peristaltic waves being visible, the subjective sensations 
 described by the patient first directing attention to it. The 
 dynamic affection occurs in nervous persons in the complete 
 absence of signs of obstruction to the evacuation of the 
 stomach and in the absence of gastroptosis, and is relieved 
 by codein, electricity, and rest. On careful study, the simple 
 dynamic affection will be found exceedingly rare. 
 
 The treatment consists of rest in bed, an indifferent diet, 
 and strong intraventricular or epigastric faradization, or, 
 preferably, anodal sedative galvanization. The general ner- 
 vous system should be given tone and strength by hydro- 
 therap}% good hygiene, and reconstituent medication. 
 
 V. ERUCTATIO NERVOSA. 
 
 Belching is common both in health and disease, and occurs 
 or is voluntarily induced in order to relieve the stomach of 
 accumulated gas which has been swallowed with the food or 
 drinks or saliva, or which has been generated in the organ
 
 THE MOTOR DYNAMIC AFFECTIONS. 317 
 
 chemically or by germs, or which has been regurgitated from 
 the intestines. This simple or symptomatic belching ends 
 with a few easy eructations of the gas contained in the 
 stomach. 
 
 Eructatio nervosa is a dynamic affection of the stomach 
 characterized by periodical and paroxysmal attacks of rapidly 
 repeated and often very noisy belching. It is essentially a 
 reflex effort, aided sometimes by volition, to relieve a domi- 
 nant and peculiar sensation. The affection is composed of 
 two factors — the sensation associated in consciousness with 
 the accumulation of gas in the stomach, and the effort to 
 relieve it by belching. The stomach actually may or may 
 not contain an excess of gas. 
 
 It is claimed by some that, in this affection, the stomach 
 draws in and drives out forcibly atmospheric air, after the 
 manner of a Politzer inflator, the suction and expulsion 
 being produced by relaxation and contraction of the muscu- 
 lar layer. Oser notes its occurrence in individuals who 
 manifest in other ways excessive peristaltic activity, and 
 maintains that the cardia is not relaxed, as very great in- 
 crease of abdominal pressure does not expel the gas. In 
 Stiller's opinion, paresis of the cardia is the essential condi- 
 tion, but aided by some expulsive force, it being impossible 
 to exclude contractions of the stomach. He notes, in support 
 of this theory, that the affection is often associated with 
 paresis or spasm of the throat, esophagus, or stomach. Both 
 Oser and Stiller consider eructatio nervosa distinct from 
 esophageal belching. 
 
 Bouveret thinks that the essential factor is clonic spasm of 
 the pharynx, and is more than inclined to consider the affec- 
 tion a neurosis of the pharynx, or aerophagia. As a result of 
 close observation, he separates the belching into two parts — 
 the swallowing and the expulsion of air. The convulsive 
 swallowing is accompanied by tight closure of the lips and 
 mouth, by elevation of the larynx, and by a single short but 
 audible sound. The expulsion is produced by the contrac- 
 tions of the esophagus, and is accompanied by a long, loud, 
 vibratory, and characteristic noise. Some of the swallowed 
 air may enter and accumulate in the stomach and aid in the 
 production of the second sound by its occasional expulsion. 
 
 None of these explanations is satisfactory, and least of all 
 the one which makes the affection a simple aerophagia. A 
 part of the seemingly hysterical effort does not constitute the 
 disease, which is the reflex and sometimes partly voluntary and 
 repeated employment of the usual means of getting gas out of
 
 3l8 DISEASES OE THE STOMACH. 
 
 the stoiiiacli.aiul in eiiictatio nervosa, also in order to relieve a 
 peculiar and uncomfortable <^astric sensation. It is the sensa- 
 tion that bothers the patient more than does the belching, 
 and that distinguishes the affection from the nervous and 
 usually hysterical swallowing and noisy expulsion of air from 
 the esophagus. Aerophagia nervosa is an imitative affection, 
 a play to an audience or a plea for sympathy — a simple 
 psychosis. The attacks are immediately arrested by holding 
 the mouth open, thus rendering the swallowing of the air 
 impossible. 
 
 If a tube be introduced into the esophagus, air is drawn in 
 during each ins[)iration. The same phenomenon is noticeable 
 if, by muscular action or relaxation, either end of the esopha- 
 gus becomes open during respiration. In voluntary esopha- 
 geal belching the mechanism is very simple. During an 
 inspiratory act while the glottis is closed, the larynx is lifted 
 upward and forward, and the air rushes in, sometimes with 
 an audible sound. The larynx is allowed to fall back, and 
 expiratory effort while the glottis is closed forces the air out 
 with more or less noise. In aerophagia nervosa the procedure 
 is the same, but is involuntary, and the contractions of the 
 esophagus chiefly, or unaided by expiration, force out the air. 
 If the cardia be open, the opening of the pharyngeal end of 
 the esophagus by lifting the larynx upward and forward 
 enables the gas to escape, provided (as is nearly always the 
 case when the stomach is distended with gas or contracted 
 on its contents) that it is subjected to a suf^cient pressure to 
 overcome the resistance of the atmosphere. If the cardia is 
 not open it may yield to the slight aspiratory suction exerted 
 during the expulsion of the esophageal air by the full cur- 
 rent of a forced expiration, or to the suction exerted by an 
 expiratory act while the glottis and the pharyngeal end of the 
 esophagus are closed; or it would seem that the cardia is 
 sometimes opened by some of the air being carried by esopha- 
 geal peristalsis into the stomach, furnishing an opportunity 
 for gas subjected to a higher pressure to escape. These are 
 only the occasions of gastric belching, the expulsive force 
 being furnished by the contractions (or elasticity if the 
 stomach is distended) of the stomach or by intra-abdominal 
 pressure. The peculiarity of eructatio nervosa is that 
 these aids to belching are in whole or in part repeatedly and 
 paroxysmally employed to relieve a distressing gastric sensa- 
 tion which may or may not be actually associated with an 
 excess of gas in the stomach, and which may be relieved by 
 the escape of gas or may persist even after the stomach
 
 THE MOTOR DYNAMIC AFFECTIONS. 319 
 
 empties itself or has been emptied by a tube. Such is the 
 double nature of the affection. 
 
 Etiology. — The affection is most common in introspective, 
 nervous, and impressionable people. It develops in the same 
 soil as do hysteria and neurasthenia, and hysterical and 
 neurasthenic forms might justly be described, the attacks 
 sometimes degenerating into feeble efforts to excite sympathy 
 or to attract attention. Shock, anger, misfortune, great sor- 
 rows, and depressing emotions are given by patients as the 
 occasions or causes of it. Masturbation, excessive venery, 
 and other abuses are sometimes associated with it; indeed, 
 many of the individuals are habit-forming neurotics or neuro- 
 paths. It is somewhat more frequent in women than in men. 
 
 The affection is sometimes associated with other diseases of 
 the stomach, particularly, in our experience, with the displace- 
 ments of the organ. In one case the attacks seemed to be 
 associated with and dependent upon the accumulations of 
 gas in the dilated splenic flexure of the colon. It is some- 
 times accompanied by gastric and intestinal " peristaltic un- 
 rest." It would seem that, apart from the displacements of 
 the stomach, its association with other diseases of the stom- 
 ach is accidental. 
 
 Clinical Description. — The affection often develops and 
 terminates suddenly and without evident cause. The appetite, 
 digestion, and nutrition may all be normal, but it is quite 
 common for these patients to be emaciated and asthenic, and 
 to complain of fullness and constriction of the stomach after 
 meals. 
 
 The occurrence of the paroxysm has no constant relation 
 with the taking of food or with its quantity or quality ; but 
 anger, fear, intense emotions of any kind, pressure on hys- 
 terical zones, may induce the attacks, and the peculiar causa- 
 tion defines a cerebrogastric group of cases. In other in- 
 stances the paroxysms seem to be the quiet and natural effort 
 to empty a displaced and flatulent stomach, or one whose 
 pylorus is spasmodically or organically obstructed. The 
 belching, in keeping with the genesis of the attacks, may or 
 may not give relief. 
 
 The paroxysms recur periodically, sometimes after regular 
 intervals, but more commonly suddenly and unexpectedly. 
 They may continue during meals, begin after meals, or only 
 when the stomach is in functional repose ; but, as a rule, they 
 cease at night, and never continue during sleep. An attack 
 may begin at night. The eructated gases are chiefly those 
 found in expired and swallowed air.
 
 320 DISEASES OF THE STOMACH. 
 
 The paroxysms vary in intensity and duration. There 
 may be a number of noisy eructations separated by a few 
 moments of quietude ; or the paroxysms may last several 
 minutes, with ten to twenty eructations or efforts each minute ; 
 or the attacks may be severe, lasting, with short remissions, or 
 intermissions, for several hours, or, rarely, one or two days, or 
 even months. 
 
 The paroxysms are noisy, embarrassing, often banishing 
 the person from society and interfering with work, uncontrol- 
 lable by the will, sometimes distressing and accompanied by 
 excitement and by an.xiety, and are exceptionally followed by 
 depression. The mild attacks have none of these serious 
 features, and a few free eructations give complete relief 
 
 Diagnosis. — The periodical, paroxysmal attacks, when 
 clearly described by the patient or once observed by the 
 physician, are characteristic. The patient is also most com- 
 monly a neurotic or a neuropath. 
 
 The complete absence of signs of organic disease of the 
 stomach is of very great negative value. The peculiar gas- 
 tric sensation, with the induced efforts to relieve it, when dis- 
 sociated with other functional trouble of the stomach, is 
 characteristic; but the discovery of abnormal functional and 
 bacteriological signs does not necessarily exclude eructatio 
 nervosa. 
 
 It is useless to analyze the belched gas, as this will always 
 contain the constituents of expired air. Easier and more 
 practical is the search for bacteriological signs — organic acids, 
 excessive or peculiar germ growth, and gas formation in the 
 fermentation tubes. In simple and symptomatic belching 
 the eructated gas may be swallowed air or gas formed by fer- 
 mentation or by chemical decomposition. The absence of 
 bacteriological signs and of gastric flatulency during the 
 paro.xysm reveals the nervous nature of the trouble ; but 
 their presence does not exclude it. 
 
 Treatment. — The treatment is chiefly constitutional and is 
 directed toward building up the nervous system. Change of 
 scene, rest, hydrotherapy, electricity, and strong moral con- 
 trol and suggestion are valuable remedies. The individual 
 himself, as well as any associated or causative disease, should 
 be appropriately treated. 
 
 Few drugs are of value. In the non-neurasthenic cases, 
 the bromids sometimes do good. Arsenic is seldom bene- 
 ficial. Opium, belladonna, and similar drugs have proved 
 useless in our hands. 
 
 The intragastric spray is the most valuable single remedy.
 
 THE MOTOR DYNAMIC AFFECTIONS. 32 1 
 
 Warm water alone may be used, or warm water followed 
 immediately after its removal by cold water, or a solution of 
 nitrate of silver (five grs. to the pint of distilled water). The 
 prolonged paroxysms may be cut short by 20 grs. of chloral 
 hydrate per rectum. 
 
 VI. HABITUAL REGURGITATION. 
 
 During the course of normal digestion some of the con- 
 tents of the stomach may be regurgitated into the throat or 
 mouth. Food is then commonly brought up, in company with 
 swallowed air or gas, and relieves a sensation of fullness in the 
 stomach ; but the regurgitated matter may also be entirely 
 fluid. This form of regurgitation is often voluntary, or it 
 may be a mere accident or episode of normal digestion. Patho- 
 logically, regurgitation may be a symptom of a disease of the 
 stomach, particularly when such disease is accompanied by 
 stagnation or retention ; but regurgitation exists also as an 
 idiopathic dynamic affection of the stomach, as a distinct 
 morbid entity. 
 
 Clinical Description. — Habitual regurgitation is easy, in- 
 voluntary, effortless, without nausea or increased salivary 
 secretion, not preceded by conscious contraction of the stom- 
 ach, and always occurs during the normal period of gastric 
 digestion. The matter regurgitated is never solid, but always 
 fluid or liquid, and of such a composition and taste as would 
 be expected of the contents of the normal stomach at the 
 moment when it occurs. The liquid rises into the throat or 
 mouth, and not simply into the esophagus, and is either ex- 
 pectorated or is swallowed again through natural feelings of 
 delicacy. It is never remasticated with enjoyment and again 
 swallowed, as in rumination. 
 
 The regurgitations recur quite regularly after each meal, 
 are several times repeated, and are noteworthy in quantity. 
 Rarely, the quantity of food lost by spitting it out is so great 
 as to produce inanition and to confine the weak patient in 
 bed. This severe form is likely to be confounded with habitual 
 vomiting. 
 
 The regurgitation may often be suppressed by a strong 
 effort of the will or by swallowing at the moment when it 
 begins. Occurring, when not resisted, without discomfort, 
 when voluntarily prevented it is usually accompanied by a 
 sensation of fullness or distention in the lower part of the 
 esophagus.
 
 322 DISEASES OF THE STOMACH. 
 
 Diagnosis. — Regurgitation will not be confounded with 
 habitual vomiting when the distinctive characters already 
 given are noticed ; but it may be mistaken for esophageal 
 regurgitation, particularly in esophageal pocketing and the 
 stagnation or retention of esophageal stenosis. The matter 
 regurgitated from the esophagus has never entered the 
 stomach, and consequent!)^ contains neither free nor organic- 
 ally combined IlCl.nor gastric ferments, nor products of gas- 
 tric digestion. The esophageal regurgitated matter often con- 
 tains pus, and consists largely of mucus, sometimes foul or 
 fermenting; the gastric contents, having markedly contrast- 
 ing and characteristic properties, can be obtained through a 
 tube introduced into the stomach. The differentiation is 
 easy after suspicion is once aroused and the proper explora- 
 tions are made. 
 
 Treatment. — The treatment of habitual regurgitation is 
 both general and local. Any associated trouble should re- 
 ceive attention, and an attempt should be encouraged to 
 break the habit by force of will and by its voluntary sup- 
 pression. The general health should be improved, and the 
 nervous system particularly should be strengthened by 
 hygienic and physical remedies. The bromids may prove to 
 be of some value. Strychnin is more trustworthy. Intragas- 
 tric faradization is beneficial, or cervicogastric galvanization 
 may be employed, particularly when the regurgitation is due 
 to insufficiency of the cardia. More important is the regula- 
 tion of the diet, selecting those articles of food which leave 
 the stomach earliest and excite its functions least. All the 
 food should be most minutely divided. Constipation, rapid 
 eatintr, and fatigfue increase the trouble. 
 
 Vll. RUMliNATlON, OR MERYCISM. 
 
 Rumination is a motor disorder of the stomach character- 
 ized by the easy, quiet, effortless, sometimes voluntary, some- 
 times involuntary, regurgitation into the mouth of food which 
 is (according to its taste and to the mental peculiarities of the 
 patient) at times spit out, and at times reswallowed after a 
 second mastication, which, instead of exciting disgust, is 
 performed with pleasure. Pyrosis, regurgitation, and rumina- 
 tion differ more in degree than in nature — out of the volun- 
 tary act the habitual and involuntary may develop. Remas- 
 tication is a distinctive and essential characteristic of rumina- 
 tion, but it is not present at all times in a particular case. In
 
 THE MOTOR DYNAMIC AFFECTIONS. 323 
 
 merycism man really "chews the cud," as do the rumi- 
 nants, but only a part of the food regurgitated may be 
 remasticated and swallowed, the remainder being spit out ; or 
 remastication may be only occasionally performed. It is the 
 second mastication of the food which distinguishes rumina- 
 tion from reei-irgitation, and without its detection the exist- 
 ence of the affection can not be established. Habitual regur-. 
 gitation may be just as obstinate and persistent. 
 
 Pathogenesis. — Various explanations of the nature of 
 rumination have been given. It has been supposed to be due 
 to paresis of the cardia ; but the deglutition sounds are nor- 
 mal, the gas and air do not escape when the stomach is in- 
 flated, and it is hardly probable that the cardia is paretic 
 while the rest of the stomach is normally or excessively 
 active, or that it can be made paretic by irritation. The re- 
 gurgitation has been explained as being produced by irritation 
 of the vagus (periphery or center) and by the active opening 
 of the cardia through Openchowski's dilator fibers of the 
 cardia ; or by reflex relaxation of the cardia ; or it has been 
 supposed to be produced in the same manner as voluntary 
 belching. It would seem at times that the regurgitation is an 
 uncontrollable habit, which was voluntary in its beginning. 
 
 This motor dynamic affection of the stomach occurs in all 
 sorts and conditions of men. It is very frequent among 
 idiots and the insane. Indeed, the remastication without 
 shame and with even positive enjoyment presupposes a 
 certain degree of mental weakness. The ancients, not with- 
 out some show of shrewdness, supposed that a remasticating 
 man had in some way become possessed of the nature and 
 instincts of the cud-chewing animals. Rapid eating, habitual 
 regurgitation, and imitation are occasions of the ruminating 
 habit. The motor function of the stomach becomes subser- 
 vient to a perverted head. It often stands in close relation 
 with the mental affection, developing and declining with it 
 and disappearing during lucid intervals. Merycism is more 
 frequent in men than in women, and may or may not be 
 associated with other diseases of the stomach. 
 
 Clinical Description. — The regurgitation is confined to the 
 period of gastric digestion. During the period of repose it 
 is rare that the gases and the small quantity of secretions in 
 the stomach are voluntarily or involuntarily brought up into 
 the mouth. Water or coffee taken into an empty stomach 
 is not regurgitated, but wine, beer, and other alcoholic 
 drinks are frequently brought up and reswallowed. This 
 rule is, however, not without exceptions. The regurgitation
 
 324 DISEASES OF THE STOMACH. 
 
 is often selective, tlie unmasticated solids being usually 
 brought up — making plausible the opinion of one of our 
 patients who spoke of rumination as a " beautiful provision 
 of nature for the protection of the digestive organs against 
 rapid eating." The regurgitation occurs without noise, effort, 
 or discomfort, and the remastication continues as long as the 
 contents of the stomach have a pleasant taste. 
 
 The procedure usually begins immediately after the meal, 
 and is continued as long as any pleasure or supposed advan- 
 tage is derived from it. The regurgitated food is either spit 
 out or resvvallowed as soon as it is perceived to be sour or 
 unpalatable. Consequently, remastication is most frequent 
 during the first half hour of digestion, but may continue 
 longer or begin later, particularly where secretion is inactive 
 and the food eaten is such as remains long in the stomach. 
 
 The body is usually well nourished, but emaciation occurs, 
 and may become extreme where much of the regurgitated 
 food is not resvvallowed. The state of nutrition is largely 
 dependent on the functional integrity of the intestines, the 
 meats and albuminous foods being often imperfectly digested 
 by the stomach in rumination. Salivary digestion, on the 
 other hand, is unusually active. 
 
 The duration of the affection is indefinite, sometimes 
 beginning suddenly and unexpectedly ceasing, sometimes 
 intermittent, but more frequently obstinate and persistent 
 from early youth to old age. 
 
 Rumination may occur independently or may be associated 
 with other diseases of the stomach. It usually ceases when 
 a painful affection or a severe disease of the stomach de- 
 velops, and the gastric symptoms which follow its disappear- 
 ance are due, not to the suppression of the rumination, but 
 to the disease of the stomach which caused its cessation. In 
 one of our cases it ceased with the sudden development of 
 pyloric incontinence following a heavy financial loss. Hydro- 
 chloric acidity may be normal, increased, or diminished, and 
 delayed hyperchlorhydria is frequent ; the evacuation of the 
 stomach may be normal, delayed, or too rapid. There 
 appears to be no fixed relation between rumination and the 
 states of secretion and of the motor function. The stomach 
 may be normal in size, enlarged, or very small. In a case of 
 the authors' the stomach was very small, holding about twelve 
 ounces when full, indistensible, the greatest transverse diam- 
 eter being about 2^ inches. The mucous membrane was 
 atrophied. The patient had ruminated persistently for fifty 
 years. In still another case the rumination began farther
 
 THE MOTOR DYNAMIC AFFECTIONS. 325 
 
 back than the memory of the aged patient could go, and the 
 rumination suddenly ceased two years before the death of 
 the patient, which was due to a disseminated hard cancer 
 that converted the pylorus into an incontinent ring or open 
 canal. 
 
 Rumination has one pathognomonic sign — the remastica- 
 tion of the regurgitated food. It is always digestive, which is 
 not true of esophageal regurgitation. In habitual gastric 
 regurgitation and in vomiting the food is never remasticated. 
 The beastly enjoyment of cud-chewing is definitive, and 
 without this sign habitual regurgitation and rumination can 
 not be differentiated. In merycism the regurgitated food, on 
 account of its unpleasant taste, may be spit out or reswallowed. 
 
 Treatment. — The treatment of rumination is sometimes 
 successful. The patient should be persuaded, if possible, of 
 the disgusting unnaturalness of the habit, and the will 
 should be engaged in an effort to suppress the regurgitation 
 or to reswallow immediately the regurgitated food without 
 a second mastication. Thorough mastication of the food 
 and the selection of a diet that rapidly leaves the stomach 
 are prophylactic measures. The administration of hydro- 
 chloric acid, or, in suitable cases, of alkalies, may be beneficial. 
 Strychnin and quinin destroy the insane delight of remasti- 
 cation, and may be used if they will induce the patient to 
 reswallow the regurgitated bitter food. Electricity and 
 strychnin may be employed in the treatment of the second- 
 ary paresis of the cardia and the secondary dilatation of the 
 lower part of the esophagus which sometimes exist. 
 
 Vlll. NERVOUS VOMITING. 
 
 Every act of vomiting is nervous, but the incrimination of 
 the nervous system would be manifestly unjust when it is 
 responding to excitation in a normal manner. Vomiting as a 
 dynamic affection of the stomach is not only produced by the 
 nervous system, but is also the expression of a particular 
 state of the nerve-centers that govern the movements of the 
 stomach. From the influences of these centers on the vom- 
 iting center located in the medulla result the co-ordinated 
 contractions of the voluntary muscles concerned in the pro- 
 duction of the overt act. 
 
 The vomiting center is supposed to be represented by a 
 distinct nucleus of one of the roots of the vagus, and is in 
 close eccentric relation with the centers that transmit motor
 
 326 DISEASES OF THE STOMACH. 
 
 impulses to the muscles of the thorax, abdomen, diaphragm, 
 larynx, pharynx, esophagus, and stomach. Through this 
 center the complex act of vomiting is excited and performed. 
 The contracted abdominal muscles and diaphragm compress 
 the stomach. The stomach, particularly the pyloric part, 
 contracts, antiperistalsis begins, the pj'lorus closes, the cardia 
 opens, the esophagus is shortened by contraction of its longi- 
 tudinal fibers, the glottis is closed, the pressure is removed 
 from the esophagus by expansion of the thorax, the soft 
 palate shuts off the rhinopharynx, and the contents of the 
 stomach are forced in successive streams through the mouth. 
 All these parts are not essential to vomiting. The stomach 
 may be passive, as in gastroplegia. The pylorus may be 
 open, as in pyloric incontinence. Vomiting may be effortless, 
 and may occur at the end of expiration and before either the 
 glottis or the rhinopharynx is closed. It may occur in spite 
 of strong voluntary effort to suppress it. But, however per- 
 formed, the act is excited and controlled by the center of 
 vomiting in the medulla. 
 
 Very complex indeed are the relations of this center to the 
 various parts of the organism, and correspondingly numerous 
 are the causes of its activit>\ It may be directly irritated by 
 disease of the medulla, or indirectly by disease of associated 
 cerebrospinal centers, by an abnormal blood or blood-supply, 
 and by impressions reflected from various organs. All these 
 forms of vomiting are symptomatic, and must be excluded 
 before the diagnosis of nervous vomiting can be made. 
 
 I. SV.N\PTO.n.ATIC VOMITING. 
 
 Ce)itral Vomiting. — The morbid causes of central vomiting 
 may be located in the brain, medulla, or cord and in their 
 membranous or bony coverings. It is a common symptom of 
 meningitis, embolism, thrombosis, apoplexy, abscess, trau- 
 matism of the brain, h\'drocephalus, and cerebral tumors. 
 The last is one of the common causes of cerebral vomiting. 
 Irritative lesions of the medulla and exophthalmic goiter, 
 multiple sclerosis, compression myelitis, and particularly 
 tabes dorsalis, may also produce it. In all cases of recur- 
 ring or persistent vomiting without apparent cause the signs 
 of organic disease of the central nervous s\'stem should be 
 diligently sought, and an ophthalmoscopic examination should 
 be made. 
 
 Hematogenous Vomiting. — The activity of the vomiting 
 center may be e.xcited by a deficiency of blood or by toxemia.
 
 THE MOTOR DYNAMIC AFFECTIONS. 327 
 
 Anemia, fainting, and prostration are sometimes accompanied 
 by vomiting. Tobacco, opium, chloroform, ether, and other 
 narcotics exert a toxic action on the medulla, as do also 
 forms of uremia, of sepsis, and of intestinal auto-intoxica- 
 tion. The sudden entrance of bacterial poisons into the 
 system may also excite vomiting, and in this respect the 
 poisons of cholera, of malaria, and of scarlet fever seem to 
 be particularly active. Vomiting should not be called ner- 
 vous until these causes have been excluded. 
 
 Reflex Vomiting. — Reflex vomiting is the most common 
 form and is produced by a very large number of diseases of 
 the various organs. It is a symptom of disease of the laby- 
 rinth and, rarely, of the middle ear. Nasal and pharyngeal 
 tumors may cause it. It is quite common in whooping-cough 
 and in laryngeal tuberculosis. Disease of the lungs, and, 
 more rarely, of the pleura, may cause it; it is sometimes very 
 obstinate in pneumonia, and it is almost a clinical axiom that 
 one who coughs after eating and vomits after the coughing 
 is a consumptive; but the most frequent sources of reflex 
 vomiting are the abdominal organs. The diseases of the 
 stomach need only be mentioned. Cholelithiasis is often an 
 obscure cause. Nephritis, pyelitis, calculus, and displacement 
 of the kidney should not be forgotten. Pregnancy and dis- 
 eases of the uterus and its appendages are frequent causes 
 of reflex vomiting in women. The diseases of the intestines 
 probably produce vomiting even more frequently than those 
 of the stomach itself. Among these may be mentioned en- 
 teritis, colitis, appendicitis, ulcer, obstruction, constipation, 
 neoplasms, and intestinal worms. Peritonitis is still another 
 abdominal cause of reflex vomiting. 
 
 Before the diagnosis of purely nervous vomiting is made, 
 the diseases of which vomiting is a symptom should be ex- 
 cluded as far as possible by a thorough and complete exami- 
 nation. And if such disease be discovered, the diagnosis is 
 not sure, for the question whether vomiting is an associated 
 dynamic affection or a symptom of an associated disease of 
 the stomach remains to be answered. 
 
 2. Nervous Vomiting. 
 
 Nervous vomiting as a dynamic affection occurs in three 
 distinct clinical forms — hysterical, psychic, and periodical. 
 
 Hysterical vomiting is rarely encountered except in the 
 female sex, and is very variable in its clinical characters. 
 Occasionally, the nervous vomiting is the only manifestation
 
 328 DISEASES OF THE STOMACH. 
 
 of the hysteria, or it may follow or alternate with other 
 sym})toiiKs of this protean affection. Its nature is often 
 revealetl by the conduct of the patient (posing, longing for 
 sympathy or for attention, perfect freedom from anxiety), by 
 the irregularity of its occurrence, and by its peculiarities in 
 regard to the quality and quantity of the food. It is alway.s 
 digestive and the vomit is always alimentary. It comes and 
 goes intermittently without evident cause. Only solids, or 
 only liquids, or only a particular food may be vomited. 
 There is no other discoverable disease. The evacuation of 
 the stomach is ordinarily incomplete, and there may be but 
 slight loss of weight and strength. 
 
 A more common form of hysterical vomiting is associated 
 with inactivity of all the vegetative functions. Less oxygen 
 is consumed, less carbonic acid exhaled, and less heat is 
 formed than in health. The skin is dry. The quantity of 
 urea and of all the other excrementitious constituents of the 
 urine eliminated during the twenty-four hours is notably 
 diminished. There may be almost complete anuria. The 
 nervous symptoms of uremia are absent, and there are no 
 signs of disease of the kidneys and no obstruction of the 
 ureters. The body, in spite of the vomiting and of the 
 apparently serious insufficiency, remains well nourished, on 
 account of the inhibition of nutritive exchange. There may 
 be urea or ammonia in the vomit, the gastric intolerance may 
 be complete, but the system shows no other signs of self- 
 poisoning. The trouble may last for days, and may disappear 
 as suddenly and unexpectedly as it began, or may be followed 
 by other hysterical manifestations. 
 
 Psychic vomiting is the most common of the tiiree clinical 
 forms of the dynamic affection, and is either mild or severe. 
 It is usually the result of emotive shock or of mental over- 
 work — intense fright, anxiety, sudden misfortune. It is most 
 frequent among pale and overworked school-children, but 
 may be encountered in all walks of life and in all occupa- 
 tions. It sometimes affects men suddenly thrust into respon- 
 sible positions. 
 
 In the mild form more or less of the food eaten is periodic- 
 ally vomited, or the incomplete vomiting may occur after 
 each meal. The loss of food is not sufficient notably to 
 impair nutrition. Long or short in duration, it usually ends 
 suddenly after the cause has been removed. 
 
 The severe form is also characterized b\' alimentary vomit- 
 ing, copious but often capricious. Inanition is the result of 
 the inability to retain sufficient food, and, exceptionally, the
 
 THE MOTOR DYNAMIC AFFECTIONS. 329 
 
 disease may be fatal. But an intercurrent disease usually cuts 
 the thin-spun thread before death from starvation occurs. The 
 uncontrollable vomiting and the resulting inanition are the 
 only symptoms, the disease getting its name from its mode 
 of origin. 
 
 Periodical vomiting is a rare but a sever'e form of the 
 dynamic affection. It is characterized by periodical attacks 
 of complete gastric intolerance, which are separated by in- 
 tervals of perfect health. The intervals in the same case are 
 always of nearly the same length, during which time no 
 disease of the nervous system nor of the stomach nor of any 
 other organ can be recognized. Theattacks represent periodi- 
 cal breaks in the course of good health, and begin and end 
 suddenly and in an apparently causeless manner. The dura- 
 tion of the interval is from several days to several months, 
 and that of the attack from several hours to several days, but 
 both the interval and the attack have a definite and constant 
 duration in each particular case. 
 
 The disease begins with vomiting, frequently in the morn- 
 ing before breakfast, and without warning, or preceded by 
 a slight headache and gastric discomfort, and sometimes 
 nausea. The vomiting occurs repeatedly, both spontane- 
 ously and after the ingestion of food, drinks, or drugs. The 
 intolerance of the stomach is complete, the vomit in the 
 beginning consisting of the contents of the stomach, and 
 thereafter of the secretions of the stomach and of the duo- 
 denum and its accessory glands, — mucus, bile, pancreatic and 
 gastric juice, — mixed with saliva and whatever has been intro- 
 duced into the stomach. There may be no pain except that 
 due to retching, but severe cramps sometimes occur, along with 
 muscular pains in the lower extremities. The patient soon be- 
 comes anxious and prostrated. The abdomen is depressed, but 
 the abdominal muscles are often soft. Beneath lie the contrac- 
 tured stomach and intestines, alike intolerant of distention or 
 of interference. Constipation is obstinate, and an enema is 
 badly taken, and the little water introduced is quickly ex- 
 pelled. The end of the attack is as sudden and causeless as 
 its beginning. There is no constant nor characteristic dis- 
 order of gastric secretion. 
 
 The periodicity is not a pathognomonic sign, as vomiting 
 often occurs periodically as a sj^mptom. Periodical symp- 
 tomatic vomiting may be the first and only sign of locomotor 
 ataxia, or the expression of any of the forms of central, of 
 hematogenous, and of reflex vomiting. The periodicity, the 
 character and evolution of the attack, the absence of any
 
 330 DISEASES OF THE STOMACH. 
 
 disease that could cause tlie vomiting, the intervals of perfect 
 health, are the distinctive features. Emaciation is the result 
 of frequent and severe attacks, and the disease may be fatal. 
 
 The diagnosis of this rare form of nervous vomiting should 
 be made only after the most exhaustive and repeated ex- 
 aminations. Time only can exclude incipient tabes. The 
 vomiting of migraine marks the end of the attack, whereas 
 periodical vomiting begins without warning. 
 
 Diagnosis. — The diagnosis of the cause and of the par- 
 ticular form of vomiting may be easy or very difficult. It is 
 best always to proceed with the investigation in a methodical 
 manner. Is the vomiting due to a disease of the stomach ? 
 If not, is the vomiting symptomatic or nervous ? And if 
 nervous, what is the particular form ? 
 
 If the vomiting is due to a disease of the stomach it will 
 be accompanied by the usual symptoms and signs of that 
 particular disease ; consequently, the clinical history and 
 the physical, functional, bacteriological, and anatomical signs 
 obtained by the thorough examination of the stomach may 
 at once reveal the particular disease. Or, in case the result 
 of the examination is negative, it remains to be determined 
 whether the vomiting is symptomatic or nervous. But the 
 decision is not to be based on the result of the examination 
 of the stomach only, for there are other symptoms and signs 
 which positively suggest or reveal the symptomatic or ner- 
 vous character of the vomiting. There may be subjective and 
 objective evidences of disease of another organ clinically 
 known to cause vomiting, having the same distinctive features 
 as the case under investigation. The vomiting may occur 
 easily, painlessly, and without discoverable gastric cause, 
 when the stomach is empty; or may be dependent on the 
 state of the feelings or of the mind — in both of these condi- 
 tions the vomiting is not likely to be due to disease of the 
 stomach. Food may be tolerated that is known to be borne 
 with difficulty, or may be vomited when it would be rationally 
 expected to agree better than food that is retained. Diet 
 alone, in symptomatic and nervous vomiting, is likel}- to be 
 of little benefit, but a correct diet often arrests at once the 
 vomiting due to a disease of the stomach, and in both symp- 
 tomatic and nervous vomiting the exclusively gastric medica- 
 tion is of no value. The indifference of the patient and the 
 maintenance of good nutrition, in spite of the absorption of 
 but little nutriment, would reveal its nervous character. 
 
 After excluding a disease of the stomach, it may be diffi- 
 cult or impossible to decide whether the vomiting is sympto-
 
 THE MOTOR DYNAMIC AFFECTIONS. 33 I 
 
 matic or nervous. Symptomatic vomiting is caused by dis- 
 ease, and on careful examination this disease can, as a rule, be 
 detected. If the disease is such as usually excites vomiting, 
 if the gastric disturbance is greatest during the period of 
 functional activity of the diseased organ, and if the vomiting 
 is benefited by the proper treatment of this disease, it is fair 
 to conclude that the vomiting is symptomatic. Nervous 
 vomiting is always afebrile. Hysterical, psychic, and peri- 
 odical vomiting possess certain clear-cut features that often 
 sucfeest at once the correct diagnosis. There is no doubt 
 that nervous vomiting, in the proper and limited meaning of 
 the word, is much rarer than is commonly supposed, and 
 becomes less and less frequent as our methods of investiga- 
 tion gain in completeness and precision. 
 
 Treatment. — The treatment of all forms of vomiting is 
 dominated by three principles — the control or removal of the 
 source of excessive irritation ; the prevention of the action of 
 the cause on the medullary center of vomiting or the arrest 
 of impressions sent out from it; and the maintenance of the 
 repose of the stomach. Or, more briefly stated, the three 
 objects of medication are to control or remove the cause, the 
 transmission, and the expression. The treatment of nervous 
 vomiting is based on the same principles. 
 
 The cause of nervous vomiting is not always palpable, but 
 the influence of the mind and of the moral environment is 
 often very evident. The physician can do a great deal, by 
 gentle authority and by assuring suggestions, to relieve the 
 general demoralization. The hysterical should be controlled 
 by a firm and skilfully directed hand, and moral and mental 
 repose and balance should be restored by whatever means a 
 knowledge of human nature will suggest as most applicable 
 to the individual case. Isolation, change of scene, and ces- 
 sation of study are often necessary. Absolute and continuous 
 rest in bed may be demanded for the restoration of nervous 
 strength and the equalization of the circulation, and the 
 patient should be kept in bed at least during the attack. 
 Massage, electricity, and hydrotherapy, in forms suitable for 
 the particular case, may often be employed with benefit. By 
 these means and by attention to all the vegetative functions, 
 the nervous system may be given new vigor and tone and the 
 transmission of the cerebral impulses may be prevented. 
 
 Something may also be accomplished by gastric medica- 
 tion. Electricity, hydrotherapy, and a proper diet are our 
 best remedies. During the intervals or during the best 
 moments a simple, nutritious, and mixed diet should be
 
 332 DISEASES OF THE STOMACH. 
 
 ordered, and in suitable cases gavage (overfeeding by means 
 of the stomacli-tiibe) may be employed. 
 
 The foregoing medication is the basis of the curative treat- 
 ment. Tlie vomiting itself, however, often requires palliative 
 remedies. 
 
 Menthol, chloroform, iodin, and the bromids are rarely of 
 much value. Oxalate of cerium, in five-grain doses dry on 
 the tongue, is trustworthy and sometimes efficient. The 
 dried alcoholic extracts of coca (three grs.), of kola (five 
 grs.), and of belladonna (y^^ of a gr.) sometimes act effi- 
 ciently when in combination. A tablet may be allowed to 
 melt on the back part of the tongue or the mixed powder 
 may be placed there. Neither these drugs nor the oxalate 
 of cerium act so efficiently when swallowed with water. 
 Suppositories of asafetida (five grs.) and powdered extract of 
 valerian (three grs.), repeated every two hours, exert a very 
 soothing and quieting influence. If there be much prostra- 
 tion, strychnin hypodermically is the best palliative; or, 
 if there be much excitement, the phosphate of codein may 
 be given hypodermically, or chloral hydrate by rectum, or 
 morphin may be at once used, without trial of less trust- 
 worthy remedies. Nitroglycerin may be useful to equalize 
 the circulation. 
 
 Sedative galvanization is a remedy well worthy of trial in 
 the obstinate cases. Large electrodes should be placed over 
 the stomach (anode) and over the cervical spine, and a cur- 
 rent of low density should be slowly turned on and slowly 
 cut off after being allowed to flow uninterruptedly for from 
 ten to twenty minutes. Or sedative polar cervicogastric 
 galvanization may be used, or even intragastric faradization. 
 
 An excellent remedy is cold or heat applied to the spine 
 and to the epigastrium. The rubber coils are most conveni- 
 ent, and through them either ice-cold or hot water may be 
 allowed to flow. Heat is best in prostration and cold in ex- 
 citement ; but the idiosyncrasy of the patient should be con- 
 sidered. The ether spray may be used along the spine and 
 over the epigastrium when a quick effect is desired. A blister 
 (canthos plaster) over the back of the neck and over the 
 epigastrium is sometimes accompanied by the cessation of 
 the vomiting. 
 
 If the stomach is intolerant, the patient should be kept 
 perfectly quiet, in the recumbent position, and neither food 
 nor medicines should be given by mouth ; rectal feeding is 
 then our best resource. Hysterical intolerance is often re- 
 lieved by the introduction of the food into the stomach
 
 THE MOTOR DYNAMIC AFFECTIONS. 333 
 
 through the tube, the food thus introduced being generally 
 retained. In suitable cases overfeeding with the tube (gavage) 
 may be tried. 
 
 In the milder cases the diet must be selected by clinical ex- 
 perimentation, there being in the absence of digestive disease 
 no contraindication to any food, and the foods difficult of di- 
 gestion are sometimes best borne. Often in severe attacks 
 small quantities of dry, solid food can be retained when 
 liquids are at once rejected. If there be much prostration 
 the patient should be kept strictly and persistently in the 
 recumbent position. The treatment, as it thus appears, varies 
 with each individual case, and many of the foregoing reme- 
 dies are generally applicable. 
 
 IX. INCONTINENCE OF THE PYLORUS. 
 
 Contrary to the common opinion, the pylorus is, in all 
 probability, lightly closed during the period of repose of the 
 normal stomach ; for gas remains in the viscus in spite of its 
 retraction, and reflux of bile and duodenal secretion does not 
 occur. The passage is more easily forced by gentle pressure 
 from the duodenal than from the gastric side (Oser). Stimu- 
 lation of the sympathetic relaxes, but that of the vagus closes 
 it. But it is more likely that normal contraction and relaxa- 
 tion of the pylorus during the period of gastric digestion 
 are automatically regulated through the ganglia in its walls. 
 
 The pylorus is incontinent when it is insufficient during 
 digestion, neither controlling nor preventing the too rapid 
 evacuation of the stomach. The trouble may be organic or 
 functional. 
 
 Pathogenesis. — The organic form occurs in cancer, ulcer, 
 and duodenal obstruction. Carcinoma, particularly scirrhus, 
 may convert the pylorus into a rigid tube with an unob- 
 structed lumen, or the canal may be made by ulceration of 
 the neoplasm, or the ring muscle may be rendered stiff and 
 functionless by cancerous infiltration. Ulcer, when either 
 lateral or circular, may also destroy the contractility of the 
 muscle, or a cicatrix or a cicatricial band or adhesion (peri- 
 gastritis) may hold the canal open. In duodenal stenosis, or 
 even in stenosis of the jejunum, the pylorus may be mechani- 
 cally dilated by the material that accumulates above the 
 obstruction. Gastroptosis with angular constriction of the 
 duodenum may be associated with pyloric dilatation. But 
 either the history or signs of ulcer or of cancer or of duo-
 
 334 DISEASES OF THE STOMA CI/. 
 
 denal obstruction will reveal the organic nature of the pyloric 
 incontinence. 
 
 Very rarely incontinence of the pylorus is a dynamic affec- 
 tion. Quite frequently the stomach empties itself with 
 abnormal rapidity, but most commonly on account of exces- 
 sive peristalsis. When the rapid evacuation is due to the 
 insufficiency of the pylorus, it is not prevented by drugs that 
 control peristalsis. 
 
 Clinical Description. — Pyloric incontinence, except when 
 due to duodenal obstruction, is manifested by a few symptoms 
 that maybe somewhat characteristic. It is sometimes noticed 
 that the abdomen, previously flat, suddenly becomes tympan- 
 itic after eating; but this symptom occurs in hysteria, and 
 may be explained in other ways. On artificial inflation the 
 stomach does not fill and distend and outline itself on the 
 abdominal wall, but with each pressure of the bulb, or con- 
 tenijioraneously with the generation of carbon dioxid, pyloric 
 bubbling can be palpated and heard, and the limitation of the 
 stomach by percussion becomes impossible. Eventually the 
 stomach may be distended with the air, but its limits can not 
 be determined by percussion. The inflation test is of more 
 value when it is made during digestion, when the stomach is 
 easily inflated if the pylorus is not insufficient ; if gas bub- 
 bles through the pylorus, the bubbling occurs in relation 
 with the compressions of the inflating rubber bulb, the latter 
 sign, under the circumstances, being characteristic of pyloric 
 incontinence. In hypermotility inflation is easy and the evacu- 
 ation of the stomach is peristaltic. These positive or negalive 
 peculiarities of inflation are distinctive when they occur with 
 regularity and in association with the following signs. 
 
 The stomach persistently empties itself too rapidly after 
 the test-breakfast, after the test-dinner, after a glass of milk, 
 and after two glasses of water have been taken. Contrary to 
 the distinctions that exist normally, one food leaves the 
 stomach about as rapidly as another. As a consequence of 
 this phenomenon, lienteric diarrhea is common when the diet 
 is exciting and unsuited to the intestines. A bland food like 
 milk rapidly cures this particular form of diarrhea. Intuba- 
 tion of the pylorus is less difficult than when the pylorus 
 normally contracts. 
 
 The reflux of bile and pancreatic juice, as would naturally 
 be expected, is easy, but it does not occur constantly. Previ- 
 ous eructation, regurgitation, rumination, and vomiting usually 
 cease when the pylorus becomes incontinent; but this is not 
 always so.
 
 THE MOTOR DYNAMIC AFFECTIONS. 335 
 
 Diagnosis. — The diagnosis is made by the foregoing group 
 of signs and symptoms in the absence of all evidence of ulcer, 
 cancer, or hypermotility. The trouble is not dangerous, as 
 is conclusively proven by the results of pyloroplasty and 
 pylorectomy. 
 
 Treatment. — The treatment is chiefly dietetic, such food 
 being prepared and selected as is readily digested by the intes- 
 tines. Diarrhea and intestinal colic may necessitate frequent 
 small meals. Strychnin and hydrastinin may be of some 
 use, but intragastric faradization is more rational. In cancer 
 and ulcer the incontinence of the pylorus is an advantage. 
 
 X. GASTROPLEGIA. 
 
 Paralysis of the stomach is rare and has usually been con- 
 founded with "dilatation." It is a distinct affection, charac- 
 acterized by the sudden loss of the contractile power of the 
 muscular layer. In myasthenia the muscle is weak and has 
 lost more or less of its normal elasticity and tone. In gas- 
 troplegia the muscle is paralyzed and the power to contract 
 is lost. The stomach is a motionless sac that passively 
 yields to mechanical stretching. 
 
 The chief cause of gastroplegia is traumatic shock. After 
 an accident, or particularly after a laparotomy, the stomach 
 is found to be paralyzed. The same condition may occur in 
 hysteria and as a result of moral shock during the digestion 
 of a meal. Still another cause is acute gastritis, and it may 
 occur in multiple neuritis. 
 
 The beginning is sudden and the duration variable. After 
 a few days the muscle may gradually regain its power, or the 
 loss of contractility may be permanent. After laparotomy 
 and traumatism it may be accompanied by collapse. 
 
 The chief sign is absolute gastric retention. Food and 
 secretions and gases accumulate in the stomach and render 
 the epigastrium prominent. The distention of the stomach 
 is painful, and the contents are often partly removed by 
 expression and by overflow through the pylorus. 
 
 The stomach should be kept clean and empty by lavage 
 and the body should be nourished by rectum. A part of 
 the treatment is that of shock and of the causative disease — 
 hysteria, peritonitis, neuritis, etc. The ordinary means should 
 be employed to restore the paralyzed muscle or prevent its 
 atrophy. The sovereign remedy of traumatic gastroplegia 
 is strychnin, administered hypodermically in large doses.
 
 336 DISEASES OF THE STOMACH. 
 
 CHAPTER IV. 
 NEURASTHENIA GASTRICA. 
 
 Neurasthenia {>eupov, nerve, and aaOtvda, weakness) gastrica 
 is a dynamic affection characterized by excessive irritability 
 and marked weakness of the nerves which supply the stomach, 
 branches of the pneumogastric and of the solar plexus. It 
 is a particular kind of morbid sensibility of the stomach, 
 developing in a fit constitution after the excessive expen- 
 diture of nerve force. It is digestive discomfort without 
 noteworthy modification of the process of digestion and 
 without an anatomical lesion of the mucous membrane. 
 
 Gastric neurasthenia is not limited to the cases where the 
 uncomfortable sensations and the other symptoms of which 
 the patient complains are referred to the stomach. The mani- 
 festations of the irritable weakness of the nerves supplying 
 the stomach may occur in distant parts of the body. It is 
 not the localization of the expression, but that of the weak 
 and genetic point which defines the affection. It is essen- 
 tially a dynamic sensory affection, and, more definitely, an 
 affection chiefly of the abdominal sympathetic. 
 
 The solar plexus, receiving all the impressions from the 
 abdominal and thoracic organs, is very intimately associated 
 with the cerebrum. Through it sensation, thought, and emo- 
 tion influence digestion. Through it and the pneumogastric 
 nerves digestion affects the activity of the brain. Through 
 it most of the distant nervous symptoms of the diseases of 
 the stomach are transmitted. It is the connecting link be- 
 tween the moral, the intellectual, and the vegetative life. 
 And this is best seen not in health, when its working is silent 
 and invisible, not in experimentation, when its action is imper- 
 ceptible or unphysiological, but in disease, when its morbid 
 action rises into consciousness and is expressed by certain 
 symptoms and signs. It is this highest and greatest assem- 
 blage of sympathetic centers which unites the nervous symp- 
 toms of neurasthenia gastrica. 
 
 Strictly localized in the beginning, the irritable weakness 
 extends to the connected cerebral and spinal centers, or, 
 originating in them, secondarily affects the solar plexus. The 
 vicious circle thus becomes established. The clinical picture
 
 NEURASTHENIA GASTRICA. 337 
 
 varies accordingly as the cerebrospinal or abdominal centers 
 control the generation of the manifestations ; but even when 
 the gastric symptoms predominate, their variation, with the 
 mental and moral changes, may be easily observed. 
 
 The peculiar discomfort of neurasthenia gastrica is not due 
 to any anatomical lesion of the mucosa, and is out of all pro- 
 portion to the disturbance of the digestive functions. This 
 is one of its cardinal and distinctive characteristics. Not all 
 gastric symptoms are neurasthenic — not even when they are 
 of the same character and grouping as in this affection. 
 Digestion often becomes uncomfortably perceptible in other 
 diseases, but the effect stands in a natural proportion to its 
 cause. When the irritation is abnormal a corresponding 
 effect should naturally follow. The harmony is preserved 
 between the activity of the external cause and the intensity 
 of perception. In neurasthenia, on the other hand, this har- 
 mony is lost, and the effect is many times multiplied. The 
 nerve-centers are feverishly active. The perceived and actual 
 effect is excessive — too intense and too prolonged. While 
 the action is excessive, the total energy is less ; but the ex- 
 cessive action is not sufficient to produce gastric spasm, nor 
 does the weakness amount to paresis. Secretion may remain 
 normal, the mechanical work may be efficient, or both may 
 be excessively active — but digestion rises painfully into con- 
 sciousness. Secretion may diminish slightly, the motor func- 
 tion become insufficient, or both may continue needlessly long 
 — still digestion is distressing. The patients suffer, be the 
 evolution of digestion normal, hastened, or delayed. The want 
 of harmony between cause and effect exists ; the impressions, 
 normally unfelt, are multiplied and built up into conscious 
 sensations on account of the irritable weakness of the nerve- 
 supply of the stomach. 
 
 Etiology. — Neurasthenia gastrica is common in both sexes 
 during adult and middle life. A large number of the cases 
 occur among students, musicians, and teachers, and among 
 those on whom the cares of life and the reverses of for- 
 tune have fallen heavily. Worry and overwork lay the 
 foundation for a majority of the cases. Prolonged and ex- 
 cessive expenditure of nerve force, particularly by sexual 
 excesses and abuses, and by unsatisfied sexual excitement, 
 exhausts and overexcites in a marked manner the abdominal 
 sympathetic. 
 
 The irritable weakness of the nerve-supply of the stomach 
 may be developed in a number of ways. A nervous tem- 
 perament and constitution, inherited or acquired, predispose
 
 338 DISEASES OF THE STOMACH. 
 
 to it. Neurasthenia gastrica is often associated as cause and 
 effect witli general neurasthenia. The exhausting and irri- 
 tating impressions may come from the brain or may be 
 reflected from other organs. The neurasthenia maybe partly 
 caused by a blood state, as uricemia, uremia, diabetes, auto- 
 intoxication, or by a blood disease. The anatomical diseases 
 of the stomach often produce it, but it is then only secondary 
 and symptomatic, and not a distinct affection. The excita- 
 tions which occasion the outbreak when the nervous system 
 is already weak may originate in the mucous membrane of 
 the stomach, from irritant foods, drinks, and drugs; but the 
 most important factors in the genesis of neurasthenia gas- 
 trica, in our experience, are disease of the intestines, sexual 
 excesses, self-abuse, worry, and overstudy. 
 
 Clinical Description. — All the symptoms of neurasthenia 
 gastrica are referable to the irritable weakness of the nerve- 
 supply of the stomach. These nerves and their centers may 
 be alone involved, and may produce the whole clinical picture, 
 or they may be affected in common with the general nervous 
 system, and may directly cause only a part of the manifesta- 
 tions. In four-fifths of the cases of all forms of neurasthenia 
 the gastric symptoms become prominent at some moment in 
 its evolution. So frequently do the symptoms of neurasthe- 
 nia, be the affection primary or secondary, cluster about the 
 solar plexus. 
 
 The affection is variable in its severity and in its evolution. 
 The course maybe intermittent, remittent, or stationary; or it 
 may rapidly progress from a very mild beginning to a mental, 
 moral, physical, and nutritive state sufficiently severe to 
 excite alarm. In the mild cases the patients are only diseased 
 because they complain, there being no objective signs of 
 trouble. The nutrition, strength, and appearance of health are 
 preserved, the digestion and utilization of food are normal, 
 all the organs, including the stomach, perform their functions 
 physiologically. The affection may be purely subjective, the 
 patients searching in vain for words strong enough to des- 
 cribe their sensations and to persuade others of the reality of 
 their sufferings. In the very severe cases, however, the ob- 
 jective signs may alarm the physician. Emaciation and loss 
 of strength may suggest a severe anatomical disease. The 
 appetite may be lost, the diet restricted and insufficient, insom- 
 nia obstinate, and the secretory and motor functions of the 
 stomach and intestines may be depressed. The subnutrition 
 is the result not of an insufficient diet alone, but of the influ- 
 ence of the peculiar discomfort and of the mental, moral, and
 
 NEURASTHENIA GASTRIC A. 339 
 
 physical state of the patient on the functions of the stomach. 
 Between the mild and the severe cases all grades of the affec- 
 tion exist, some simple and o^thers complicated. 
 
 The symptoms differ during the period of digestion and the 
 period of gastric repose, are markedly influenced by the men- 
 tal and moral state, are commonly associated primarily and 
 eventually with some of the signs of general neurasthenia, 
 and the suffering, shorn of all acuteness, is moderate, unnerv- 
 ing, and sympathetic. The characteristic symptoms are sen- 
 sory, cerebral, muscular, and circulatory. 
 
 The sensory symptoms are the hyperesthesia and neuralgia 
 and the indefinable discomfort due to the excitation and 
 irritable weakness of the abdominal sympathetic. During 
 digestion, and not rarely when the stomach is in repose, 
 there is a sensation of fullness, heaviness, or weight. What- 
 ever touches the mucous membrane — food, gas, drinks, secre- 
 tions, contact of the two surfaces — may produce distress. 
 Belching is common, and the patient often complains of a ball 
 in the throat or gullet and of heartburn which is due to an 
 excess of neither hydrochloric nor butyric acids. Or the pa- 
 tient complains chiefly of a peculiar digestive uneasiness and 
 discomfort, which may begin as soon as food enters the 
 stomach, or after a short period of exaltation and well-being, 
 or which may be confined to the period of free acidity. This 
 free acid discomfort may develop into severe pain, which is 
 immediately relieved by bland nitrogenous food of a high 
 acid-combining power, like milk. There is no excessive 
 acidity and the appetite is not increased, but often diminished, 
 thus distinguishing the symptom from adenohypersthenia gas- 
 trica and bulimia. The skin over the stomach, both before 
 and behind, is often abnormally sensitive. The hyperesthesia 
 is over the area supplied by the cutaneous sensory nerves 
 connected with the irritated part of the sympathetic system. 
 There are often epigastric, dorsal, and intercostal neuralgia 
 and painful pressure-points. The sensitive points correspond, 
 usually, with the large sympathetic ganglia and with the sen- 
 sory branches of the spinal nerves along either side of the 
 dorsal spine. The hyperesthesia of neurasthenia gastrica is 
 characterized by its beginning over the stomach, where it is 
 most constant, and extending to the sides and thorax, neck, 
 and shoulders, and often to the head. It is often confined to 
 the upper part of the l^ft side of the body or head. 
 
 Normally, during the digestion of a full meal there is a 
 desire for repose and isolation, but the depression of the 
 cerebral functions may be prevented by stimulants like coffee,
 
 340 DISEASES OF THE STOMACH. 
 
 tobacco, and entertaining companionship. Digestion physi- 
 ologically enforces cerebral inactivity. But in neurasthenia 
 gastrica the natural depression may be supplanted by a short 
 period of well-being, or may be immediately followed by dis- 
 ordered cerebral activity and unhealthy sensations. The 
 head is heavy or light, the thoughts ramble, ideas follow one 
 another in disorder, and the consciousness of this confusion 
 produces anxiety, gloom, and fear. The anxiety has no exter- 
 nal cause and the fear no e.vternal object — both are centrally 
 excited. Study and concentration of attention and control of 
 thought are difficult, and often become impossible after a 
 short effort. The mind is rapidly drawn aside in spite of 
 the will. There is no repose of mind or spirit, but a con- 
 stant internal unrest. The patient is made anxious and 
 pessimistic by little accidents which would have no effect in 
 health. The physician's assurance that there is no serious 
 disease is as nothing when weighed against the suffering, 
 unrest, and utter lack of energy and will-power. These cere- 
 bral symptoms are often accompanied by headache, insomnia, 
 and vertigo, are worse during digestion, and subside slowly 
 after digestion is finished if there be no secondary sources of 
 irritation. 
 
 The contents of the stomach irritate the oversensitive 
 nerves of the mucous membrane, and these impressions are 
 transmitted to the solar ple.xus and the medulla. From these 
 centers the heart's action and the vasomotor nerves often 
 become disturbed. Tachycardia, palpitation, bruit dc galop, 
 arrhythmia, intermittent pulse, hot flashes, and cold hands and 
 feet result. The involuntary muscles become weak and irri- 
 table, and the voluntary muscles may be easily exhausted. 
 
 All these symptoms vary in their intensity from day to day, 
 and are rarely all present in the same case. Neurasthenia 
 gastrica may be monosymptomatic in its expression — diges- 
 tive discomfort, or disturbance of the action of the heart, or 
 neuralgia, or pessimism, or headache, or other cerebral symp- 
 toms. Their intimate relation to digestion is a distinctive 
 characteristic of these neurasthenic symptoms. 
 
 In some cases the discomfort and flatulency are excited by 
 certain articles of food, particularly acids and sweets, in con- 
 tradiction to the general rule that in neurasthenia gastrica 
 one food is digested about as comfortably as another — no 
 better and no worse. Guided by experience, one food is 
 excluded after another, until some patients become meat 
 eaters, or vegetarians, or half starve themselves. 
 
 The functions of the intestines are rarely normal in neuras-
 
 NEURASTHENIA GASTRICA. 34I 
 
 thenia gastrica, because the whole abdominal sympathetic is 
 often in the same state of irritable weakness as the solar 
 plexus and the ganglia in the gastric wall. The abdomen is 
 sometimes sunken and the intestines contracted and empty, 
 particularly in the severe form with subnutrition. Sometimes 
 there is nervous diarrhea, sometimes general gaseous disten- 
 tion of the intestines ; but the most characteristic condition 
 is localized contractions and isolated gaseous distention of 
 individual knuckles of the intestines. The most frequent sites 
 of this gas accumulation are in the cecum, the lower end of 
 the ileum, and in the transverse colon near the splenic flexure. 
 The patient complains of the gas remaining still, not easily 
 passing either up or down. These distended knuckles are 
 always tender, and the gas gurgles under moderate pressure 
 and does not return to the point after the removal of the 
 pressure. After the gas is pressed out the tenderness disap- 
 pears. Massage restores, in this condition, the normal peri- 
 staltic flow of the contents more rapidly and efficiently than 
 in any other intestinal affection, and is of great utility in 
 relieving the radiated nervous symptoms and in establishing 
 the diagnosis. 
 
 In the majority of the cases of neurasthenia gastrica secre- 
 tion is normal, but in the remainder of the cases the acid, 
 and rarely the ferment, secretion, may vary slightly from the 
 normal. There is, exceptionally, mild supersecretion ; there is 
 more frequently simple diminution of secretion, as more or 
 less all of the organic functions are in abeyance. But the 
 most frequent variation of secretion is a disorder of its evolu- 
 tion. It is often normal for a short period (during the first 
 twenty to forty minutes after the test-breakfast), and thereafter 
 is insufficient, constituting, when the examination of the con- 
 tents is made only at the end of one hour, one group of the 
 cases with diminished activity. In another group of cases 
 the evolution of secretion is delayed, and acid first remains 
 free after more than an hour has passed. There is no per- 
 ceptible diminution of ferment secretion, unless there be sub- 
 nutrition. In adenasthenia gastrica, on the other hand, which 
 is an independent dynamic affection, secretion of the acid, and 
 often of the ferments, is deficient throughout the period of 
 digestion, and there is none of the peculiar discomfort and 
 irritable unrest. The disorders of secretion are neither per- 
 sistent nor characteristic, and are in probability caused by 
 vasomotor disturbances. 
 
 In neurasthenia gastrica the stomach usually empties 
 itself within the normal period, and the motor function has
 
 342 DISEASES OF THE STOMACH. 
 
 consequently been supposed to be normal ; but this is not 
 always a just conclusion. The stomach is often tonically, but 
 not painfully, contracted. Swallowed air accumulates in it, 
 and is often only got rid of by belching, the cardia yield- 
 ing before the firmer pylorus. If the accumulated air does 
 not escape, it may eventually cause anxiety, shortness of 
 breath, palpitation, and sometimes a sense of impending 
 death. The stomach, on physical examination, is then found 
 contracted on the contained air, which can not be expelled 
 by pressure ; but after proper massage for a short time it 
 escapes into the intestines, with relief of the s}-mptoms. The 
 most common motor disturbance, however, is simple relaxa- 
 tion, with splashing during the digestive period. Its inde- 
 pendence of the quality and quantity of the food, its associa- 
 tion with the nervous irritable weakness, the imperceptible 
 delay in the evacuation of the stomach resulting from it, and 
 the intolerance of remedies which do good in myasthenia 
 gastrica, distinguish this motor disorder of neurasthenia gas- 
 trica from myasthenia, which is a distinct dynamic affection. 
 
 There are no anatomical signs of disease, and no bacterio- 
 logical signs (except incidentally, as may occur in the nor- 
 mal stomach). It should be remembered that neurasthenia 
 gastrica may terminate in myasthenia gastrica. and often 
 becomes associated with chronic colitis, particularly with 
 enteritis membrnnacea. 
 
 Differential Diagnosis. — Whenever the symptom-group 
 of neurasthenia gastrica is met with in practice a most 
 thorough examination of the whole body should be made. 
 In this manner only can the idiopathic and secondary forms 
 be separated. The signs of general neurasthenia should be 
 sought ; the blood should be examined for idiopathic anemia 
 and for the amceba malariae, and the urine for signs of chronic 
 nephritis, of gout, and of diabetes ; cholelithiasis should be ex- 
 cluded ; the genital organs should be examined for disease, 
 and the intestines examined particularly for chronic colitis. 
 All these diseases may be accompanied by the digestive dis- 
 comfort and uneasiness, or by the cerebral symptoms of 
 neurasthenia gastrica. It is only by careful exclusion and by 
 particular attention to the distinctive features of the symp- 
 toms as already described that the idiopathic affection can be 
 defined as a morbid entity. 
 
 Some of the diseases of the stomach may be confounded 
 with neurasthenia gastrica. Indeed, it maybe a complication 
 of most of the chronic diseases of the stomach which occur 
 in nervous, weak, and anemic people. Practically, the
 
 NEURASTHENIA GASTRICA. 343 
 
 independent form of neurasthenia gastrica may have to be 
 differentiated from chronic asthenic gastritis, ulcer, gastrop- 
 tosis, atypical forms of cancer, and myasthenia gastrica. 
 
 If the clinical expression of chronic asthenic gastritis and 
 neurasthenia gastrica be carefully studied, it will be seen that 
 the two diseases resemble each other only when the symp- 
 toms are shorn of all distinctive features. The symptoms of 
 this form of gastritis are digestive, in relation with the solidity 
 of the food and proportionate to its physiological action, and 
 the cerebral, circulatory, and distant sensory signs (including 
 the tender points) of neurasthenia gastrica are absent. A 
 proper diet, strictly followed, in gastritis relieves the symp- 
 toms, but the same diet is of little value in neurasthenia gas- 
 trica. The anatomical signs of chronic asthenic gastritis 
 are of absolute differential value — large quantities of mucus 
 in the test-meal contents, and of gastric epithelium and of 
 leukocytes in the early morning washings of the stomach, 
 and the diminution of the ferments. Normal secretion and 
 the normal digestive transformation of the food, common in 
 neurasthenia, exclude gastritis; and rapid but slight secretory 
 variations, not due to local irritation of the mucous mem- 
 brane, are in favor of the dynamic affection. Both clinical 
 forms of chronic gastritis, after healing, may leave the nerves 
 which supply the stomach abnormally irritable. 
 
 Ulcer of the stomach not accompanied by severe pain, 
 hemorrhage, or vomiting may be confounded with neuras- 
 thenia gastrica. The differentiation is not always possible. 
 The discomfort is alike digestive in both, but it is not so ex- 
 clusively and invariably excited by taking food in neuras- 
 thenia. The nerve-supply is in both alike oversensitive, but 
 the circumscribed tender points of ulcer are epigastric and 
 dorsal ; the tender neurasthenic points are present also in 
 other parts of the body. Digestive superacidity is the rule 
 in ulcer ; it is, however, rare, and is not persistently present 
 in neurasthenia gastrica. In the one, secretion is normal or 
 nearly normal ; in the other, secretion is normal or increased. 
 In the one, the motor function is normal or the stomach 
 splashes during digestion ; in the other, it is normal, or 
 signs of obstructive retention may be present. There 
 may be symptoms of general neurasthenia, or the discom- 
 fort may be more closely related to the state of the mind 
 and of the spirits, and these relations would be in favor of 
 the dynamic nature of the trouble. Each individual case 
 may present symptoms found chiefly or exclusively in the 
 one or the other disease ; but the differentiation, even in the
 
 344 DISEASES OF l^HE STOMACH. 
 
 presence of the somewhat distinctive features of the coninion 
 symptoms and signs, is a mere balancing of probabiHties. 
 Tlie diagnosis should often be left to the subsequent evo- 
 lution of the case or be inferred from the results of appro- 
 priate treatment. The continuance of the discomfort and 
 digestive unrest, in spite of rest in bed and a strict milk diet 
 combined with alkalies, is strongly in favor of neurasthenia. 
 
 E.xceptionally, atypical or latent forms of carcinoma may 
 present, particularly in the early period, a symptom-group 
 somewhat like that of neurasthenia gastrica, which may also 
 be accompanied by emaciation ; but after thorough study 
 of the case, its etiology, evolution, symptoms, and signs, 
 doubt is rarely permissible. 
 
 Gastroptosis and neurasthenia gastrica may be readily 
 confounded. The displacement of the stomach is easily 
 detected on examination. The causal relation or indepen- 
 dence of the two diseases can only be made out with proba- 
 bility from the history and from the results of appropriate 
 treatment. It matters little, for when both are present both 
 must be treated. 
 
 Neurasthenia may also be mistaken for myasthenia gastrica 
 — both infrequently being expressed chiefly by slight diges- 
 tive discomfort and by flatulenc\% The absence of stagnation 
 or retention often decides at once in favor of neurasthenia 
 gastrica. In neurasthenia gastrica the motor function may 
 also be insufficient, but this is seldom true except in the 
 severe cases with emaciation and loss of strength ; and 
 the state of nutrition and of the mind and spirits, and the 
 nervous disorders are out of all proportion to the slight 
 motor insufficiency. In neurasthenia liquids are tolerated 
 and evacuated more readily than in myasthenia, as is made 
 clear by the water-test. Myasthenia is also constant, is 
 greatly influenced by the quantity of the food, and is with- 
 out tender points and cerebrasthenia and circulatory disturb- 
 ances. The two affections may coexist, and only a knowledge 
 of their order of development can suggest the causal rela- 
 tions of the one to the other. The typical cases of the two 
 affections bear little resemblance if the distinctive features 
 are closely studied. 
 
 Prognosis. — Neurasthenia gastrica is not a fatal disease, 
 but it often proves very obstinate to treatment. It creates a 
 predisposition to the development of congestion and inflamma- 
 tion of other organs through the vasomotor and circulatory 
 disorders e.xcited by it. The resistance of the organism to 
 invasion is notably weak.
 
 NEURASTHENIA GASTRICA. 345 
 
 The benefits of treatment are conditioned by the ability 
 of the physician completely to control the patient. The 
 common sense, desires, and will must be united in one effort 
 to get well under the strict employment of the proper reme- 
 dies. The life — mental, moral, physical, and social — must 
 be controlled and regulated in the severe cases. The mild 
 cases may recover under gentler restrictions. When properly 
 rested and fed, and firmly led into optimism by the physician, 
 the prognosis is good and the duration of the treatment is 
 shortened. 
 
 Treatment. — The treatment of neurasthenia gastrica should 
 be methodical and consistent. Failure is often the result 
 of a lack of unity and plan in the employment of remedies. 
 Nothing is more important than the combination of all means 
 which make for the repose and strength and conservation of 
 the nervous system. Rest alone will do little good. Isola- 
 tion alone will not accomplish much. Diet alone is often of 
 little benefit. Drugs unaided often-fail even to relieve symp- 
 toms. Repose of mind and body and good digestive hj-giene 
 are of little value when combined with excitant remedies. 
 All sources of excessive irritation should be cut off, and all 
 excessive waste avoided. The irritable weakness can be best 
 relieved by suitable repose, by the conservation of energy, 
 and by enough exercise and functional activity to develop 
 tone and strength in the individual case. Aimless manage- 
 ment without method either does harm or no good. 
 
 In order to control the patient in every particular it is 
 necessary to possess his confidence and the sympathetic aid 
 of those in communication with him. Under no other cir- 
 cumstances can his mind and spirits be controlled and utilized 
 by suggestive therapy to influence the abdominal sympa- 
 thetic. This mental and moral guidance is all the more 
 imperative when the affection is cerebrogastric. 
 
 The nutrition must be good and the sleep sufficient and 
 restful before any improvement can be expected. To this 
 end hygienic remedies and diet are most conducive. 
 
 A warm and sunny climate, proper clothing, change of 
 scene, rest from business and other cares, electricity, massage, 
 active exercise, and hydrotherapy have the same value as in 
 the treatment of general neurasthenia. These physical and 
 mechanical remedies are most beneficial when mild and 
 soothing. The amount of excitation to be produced varies 
 with each individual case, but the after-effect should never 
 be exhaustion or restlessness. The right method has been 
 found when it increases the desire for food, secures sound
 
 346 DISEASES OF THE STOMACH. 
 
 sleep, and relieves the unrest. The contrary effect is a sign 
 of too niuch or too prolon^^ed excitation. 
 
 The quantity of the food is regulated by the state of nutri- 
 tion, but the diet is selected by its physiological action on 
 the sensibility of the stomach, provided there be no associated 
 disease or complication. Rationally, a diet that has but little 
 action on secretion would be exoected to be most suitable, 
 and this is usually the case. Milk is, consequently, in neu- 
 rasthenia gastrica, an appropriate food, and the finely-divided 
 and thoroughly cooked cereals may be combined with it. 
 Fats, of which the best is unsalted butter, are commonly well 
 borne, and fulfil an essential purpose in nutrition. Fish and 
 stewed white young meats agree better than the roasted and 
 broiled red meats. Nothing is more disastrous than a dry 
 diet composed of meats, unless it be a mixture of acids, 
 salads, sweets, pastry, pies, alcohdlic drinks, and highly sea- 
 soned dishes. Green vegetables can be sparingly used, while 
 ripe and not very sweet nor acid but soft and juicy fruits can 
 often be prescribed as nutriment and as remedies against the 
 constipation. The diet should always be sufficient to sup- 
 port or improve nutrition in the particular case, and other 
 articles should be added to it as more and more excitation 
 of the mucous membrane is likely to be beneficial. The 
 supreme clinical control of the rationally selected diet in 
 neurasthenia gastrica is furnished by the subjective sensations 
 of the patient. If the discomfort is relieved, the diet is right 
 in its action; if the unrest be increased, the diet is wrong, 
 unless some other error is being committed. Often the 
 proper diet is more exciting than would be rational!}' expected. 
 
 A valuable local remedy in many cases is the intragastric 
 douche, employed before breakfast or at bedtime, particu- 
 larly in the severe and in the cerebrog^stric cases. The tem- 
 perature of the water should be regulated according to the 
 irritability of the particular case. In the obstinate cases, with 
 gre it digestive discomfort, the stomach may be first douched 
 with water, and then one-half to one pint of a i : 2000 solution 
 of nitrate of silver may be allowed to flow into the empty 
 stomach through the douche-tube, and then be immediately 
 withdrawn. After its removal the stomach is again irrigated 
 with i)lain water. The nitrate of silver douche may be used 
 once, or at most twice, a week. 
 
 A large quantity of tonics and nervines is usually given, 
 sometimes with benefit but often with injury. No .salines, no 
 alkalies, and no antiseptics should be employed. Iron, in its 
 least irritant and least constipating forms, or well-diluted
 
 MYASTHENIA GASTRICA. 347 
 
 arsenic may be required by anemia. The infusion of condu- 
 ranG;;o seems to be the most beneficial bitter. Small doses 
 of the bromids (sodium or strontium) often undoubtedly do 
 good for a short time. It may be advisable or necessary to 
 use soporifics. The constipation is best treated by massage, 
 oil or glycerin injections, electricity, and a proper diet. The 
 common practice of frequently irritating the stomach with so- 
 called reconstituent drugs can not be too strongly condemned 
 in the management of neurasthenia gastrica. 
 
 The etiological treatment should receive careful considera- 
 tion. Enteritis, intestinal irritation (tape- or other worms), 
 enteroptosis, movable kidney, anemia, disease of the genital 
 or urinary organs, associated gastric troubles (particularly 
 gastroptosis), and whatever has prepared the soil or occa- 
 sioned the genesis and aided the evolution of the affection, 
 should have proper attention, in keeping with a fundamental 
 principle of therapeutics. 
 
 CHAPTER V. 
 MYASTHENIA GASTRICA. 
 
 Myasthenia {jm<z, muscle, and aaOsvsia, weakness) gastrica is 
 a dynamic affection of the stomach, characterized by dim- 
 inution of the elasticity and strength of its muscular layer. 
 The stomach does not empty itself within the normal period, 
 and is distended more easily by its contents, on which it re- 
 tracts with less than its normal force. Myasthenia is prim- 
 arily and essentially an independent dynamic affection of the 
 stomach. Pathologically, many claim for it a place among 
 the nervous affections of the organ. The nervous system 
 may play a part in its genesis, but essentially it is a muscular 
 affection. The muscle is everything, and is insufficient be- 
 cause it is weak or degenerated. 
 
 In its course the disease may pass through all degrees of 
 motor insufficiency, varying from a slight deviation from 
 health to absolute gastric retention. Clinically, the evolu- 
 tion of the disease may be divided into two periods : the one 
 being characterized by stagnation, the stomach slowly empty- 
 ing itself completely between meals or during the night only ; 
 the other by retention, the stomach always containing food.
 
 34^ DISEASES OF THE STOMACH. 
 
 Etiology. — Myasthenia is the most frequent dynamic affec- 
 tion of the stomach, occurring regardless of sex and at all 
 ages. 
 
 The predisposition to the disease may be hereditary, per- 
 sons being born with weak muscles as with weak nerves or 
 mucous membranes. Whole families may have it, yet it 
 may be impossible to attribute it to a common dietetic error 
 or mode of life or to other common pathogenic influences. 
 The causes of myasthenia are exceedingly numerous, and it 
 is very difficult to determine precisely its relation to heredity. 
 The very frequent occurrence of the disease in families pos- 
 sessing an undeniable hereditary taint — the neurotic, the 
 arthritic, and in families afflicted with the series of diseases 
 characterized by slow and imperfect catabolism — would seem 
 to indicate that a myasthenic predisposition may be inherited. 
 
 The disease is more frequently acquired, and it is rare that 
 a myasthenic person can pose with much show of reason as 
 a victim of heredity. A mild, and often a temporary, form 
 is produced by mental fatigue and by depressing moral 
 causes. The shock of fear, of accidents, or of grave mis- 
 fortune may be the cause of the relaxation of the voluntary 
 and involuntary muscular systems; and myasthenia gastrica 
 can be thus produced, particularly if the shock comes during 
 gastric digestion. Prolonged mental and physical fatigue 
 can have the same result. But myasthenia gastrica pro- 
 duced in this acute manner is most frequently mild in degree, 
 and recovery may be rapid; but under conditions favorable 
 to its further development the disease may become progres- 
 sive and serious. 
 
 Myasthenia gastrica is an almost constant sequel of severe 
 acute diseases. During convalescence, when the appetite 
 represents more closely the needs of nutrition than the func- 
 tional power of the stomach, the weak organ is often over- 
 loaded, and the gastric myasthenia frequently persists in 
 spite of the improvement in the general strength and in 
 nutrition. Typhoid fever, influenza, and diphtheria deserve 
 particular mention in this connection, though many other 
 adynamic diseases leave the stomach in the same condition. 
 
 Many chronic diseases are predisposing or efficient causes. 
 It is one of the gastric affections of the initial stage of pul- 
 monary tuberculosis. Diseases of the heart, of the lungs, and 
 of the liver, accompanied by congestion of the portal circula- 
 tion, often cause myasthenia gastro-intestinalis. It is very 
 common in gout, in uricemia, in biliary lithiasis, in diabetes, 
 in severe anemias, and after severe hemorrhages. All dis-
 
 MYASTHENIA GASTRICA. 349 
 
 eases accompanied by malnutrition or subnutrition are predis- 
 posing causes. 
 
 Myasthenia may be a complication of many of the diseases 
 of the stomach, and its development renders the situation 
 much more serious. Among the many causative gastric dis- 
 eases maybe mentioned chronic gastritis (chiefly hypersthenic 
 form), displacements of the stomach, and carcinoma. 
 
 The disease may also be caused by dietetic errors, partic- 
 ularly intemperance in eating and drinking, the overtaxed 
 gastric muscle becoming fatigued, insufficient, and less retrac- 
 tile. Very large and bulky meals, large quantities of effer- 
 vescent drinks, large drafts of water in summer, rapid 
 and excessive beer-drinking, and the drinking of large quan- 
 tities of hot water or of mineral waters are common errors, 
 which, repeated often, may directly produce myasthenia. 
 Myasthenia, according to its severity, may be accompanied 
 by stagnation or by retention of the gastric contents. 
 
 I. Myasthenia with Stagnation. 
 
 Clinical Description. — Myasthenia with stagnation is very 
 variable in its severity. The degree of stagnation measures 
 precisely the degree of myasthenia. The period of gastric 
 digestion (which naturally varies with the quality and the 
 quantity of the meal) may be but slightly prolonged, or the 
 stomach may get a short rest only in the early morning. 
 Two forms should be clearly separated, the one being mild 
 and the other severe. In the mild form of stagnation 
 myasthenia the stomach is empty later than it normally 
 should be, but the evacuation of the contents of the stomach 
 is complete between meals. In the severe form of stagna- 
 tion myasthenia the stomach is not empty before the mid- 
 day nor before the evening meals, but is empty for a short 
 period before breakfast. The inability of the stomach to 
 evacuate its contents during the twenty-four hours character- 
 izes the retention form of myasthenia, in which form the 
 stomach always contains food under the circumstances im- 
 posed by ordinary dietetic customs. Both mild and severe 
 stagnation myasthenia may be latent, the disease being ex- 
 pressed only by its physical signs. The stomach empties 
 itself later than in health, remains flaccid, as evidenced by 
 splashing, throughout the digestive period, and distends 
 excessively under the weight of a moderate quantity of con- 
 tents. The balance of nutrition is maintained, but it is im- 
 possible to increase the weight of the body. The patient
 
 350 DISEASES OF THE STOMACH. 
 
 does not complain, but is exposed to digestive disorder when 
 a very large meal is eaten, or when the usual quantity of 
 food is taken while the body and mind are fatigued. 
 
 This latent period may last a number of weeks, or even 
 years, before the clinical period develops. This is the com- 
 mon mode of development when the predisposing cause is 
 heredity, or when the myasthenia follows acute or chronic 
 disease, or when it is due to faulty digestive hygiene. The 
 clinical period may appear suddenly, after shock or depress- 
 ing emotions, or physical or mental fatigue, or after a dietttic 
 error or excess. 
 
 The symptoms of the clinical period are digestive, the 
 short intervals when the stomach is empty being passed 
 without discomfort. Soon after food is taken the stomach 
 feels full and heavy, and the air swallowed and the carbon 
 dioxid set free from the carbonates of the food and the 
 saliva by the secreted hydrochloric acid distend the stomach, 
 often to such a degree that the clothing must be loosened. 
 The gas is removed by frequent belching, bringing with it 
 often a little fluid into the esophagus or mouth; and this is 
 one of the most constant symptoms of the trouble. The 
 distention of the stomach is thus diminished, but the sensa- 
 tions of weight and fullness only gradually disappear as the 
 stomach lazily empties its contents into the duodenum. If 
 the meal be large the gastric distress may become greater 
 and greater, until the stomach empties itself by copious vom- 
 iting, after which there is no more trouble until another meal 
 is eaten. The duration and the intensity of the symptoms 
 are dependent on the quantity of food eaten, and in the mild 
 cases the symptoms may appear only after the chief meal. 
 In the severe form the muscular elasticity is still further 
 diminished, and the discomfort may occur after each meal, 
 and may, indeed, sometimes be produced by drinking a glass 
 of water. The appetite, which is usually good before meals, 
 may be quickly satisfied. A symptom of differential value 
 is the relation of the gastric symptoms to the quality of the 
 food, the symptoms being excited by both fluid and solid 
 food, fluids often producing as much distress as an ordinary 
 mi.xed meal. This symptom is exceedingly rare in any 
 other uncomplicated disease of the stomach. Such is the 
 simple form of stagnation myasthenia, characterized by di- 
 gestive symptoms in close relation with the quantity and 
 the fluidity of the food; by belching and regurgitation ; by a 
 mere maintenance of the balance of nutrition; by physical 
 and mental exhaustion after moderate exercise or effort ; and 
 by the physical and functional signs of myasthenia.
 
 MYASTHENIA GASTKICA. 35 I 
 
 But the disease does not always remain so mild and sim- 
 ple. The stagnation is a favorable condition for fermentation, 
 and the regurgitations may have the odor and taste of organic 
 acids ; but we would particularly emphasize the fact that fer- 
 mentation is rare even in the severe form of stagnation myas- 
 thenia. In some cases, however, it does occur irregularly and 
 intermittently. To the symptoms already enumerated may 
 be added gastralgia, pain, often nausea and vomiting, head- 
 ache, sometimes insomnia, and mental, moral, and physical 
 depression, vertigo, peripheral and central disorders of the 
 circulation, erythema, urticaria, slow and labored action of the 
 heart, with a reduplication of the second sound. 
 
 In consequence of the prolonged sojourn of the contents in 
 the stomach (and, rarely, of fermentation), the gastric glands 
 may become irritable, and secretion may continue for a short 
 time after the evacuation of the chyme into the intestines, or 
 there may be simple hyperchlorhydria. This condition is ex- 
 pressed by gastric pain, hydrochloric heartburn and pyrosis, 
 thirst, and sometimes a sharp appeiite and headache. In 
 still other cases the secretion may become continuous during 
 the day, and the uninterrupted irritation may produce the 
 hypersthenic form of chronic gastritis, which is a most seri- 
 ous sequel of myasthenia. 
 
 In stagnation myasthenia the bowels are usually consti- 
 pated, but when myasthenia intestinalis (a common complica- 
 tion or association) becomes well marked, the whole clinical 
 aspect of the case is changed. The nervous and constitu- 
 tional symptoms (attributed wrongly by some authors to 
 gastric auto-intoxication) appear; and there is constipation, 
 insomnia, headache, neurasthenia, oligocythemia, chlorosis, 
 disorders of the circulation, and hepatic congestion. The 
 intestinal myasthenia may become the most prominent 
 trouble and be manifested by periodical colalgia, localized 
 colitis, spasm alternating with localized dilatations, intestinal 
 supersecretion, and the discharge of muco-albuminous mem- 
 branes infected with bacteria. When the intestines become 
 involved malnutrition begins, and may lead to extreme 
 emaciation and intestinal cachexia. 
 
 The preservation of the strength, the weight, and the ap- 
 pearance of good health is a marked characteristic of simple 
 myasthenia gastrica with stagnation. The disease itself has 
 no influence on general nutrition, the food being eventually 
 as well utilized as in health. If emaciation occurs, it is 
 due to an insufficient or an improper diet or to a complica- 
 tion. The symptoms being digestive, and increasing in pio-
 
 352 DISEASES OF THE STOMACH. 
 
 portion to the quantity of food, and the appetite, even in the 
 mild cases, being often satisfied with a \&\v niouthfuls, the 
 patient is very Ukely to eat less than is necessary to supply 
 the nutritive demands of the body. It is not rare, also, for a 
 myasthenic to adopt an exclusive monotonous diet, as the 
 consequent diminution of the quantity of food gives relief. 
 Whenever, in myasthenia with stagnation, emaciation exists, 
 starvation, or a gastric complication, or an associated disease 
 of another organ will be found. The urine, both in its quan- 
 tity and qualit}', is unchanged, except when there is an asso- 
 ciated secretory disorder or an insufficient quantity of fluids 
 is taken. 
 
 The objective signs are more characteristic than the sub- 
 jective symptoms. These signs are conditioned by the state 
 and the degree of efficiency of the muscular layer, which 
 distends easily and retracts imperfectly on the contents. The 
 stomach empties itself slowly but completely, and even in 
 the severe stagnation form no food is found in the stomach 
 in the morning before breakfast. 
 
 A great deal of time may be spent, and partly wasted, in 
 the endeavor to determine with exactness the size of the 
 stomach by percussion, by the limits of the splashing sounds, 
 by distention with gas or air, and by electric illumination. 
 The size of the stomach bears no relation to its motor power, 
 but an extension of the average limits of the stomach would 
 suggest the presence of a ph)'siologically large stomach or 
 of one of a group of the diseases of this organ, of which 
 group of diseases the stagnation form of myasthenia is a 
 member. 
 
 In myasthenia with stagnation inspection is negative — no 
 visible peristalsis, no particular changes of the form of the 
 abdomen, but at times the distended stomach may produce a 
 visible prominence. 
 
 On palpation the stomach will never be found firmly con- 
 tracted and resistant, but flabby and flat, unless distended 
 with a very large quantity of contents, when its form, size, 
 and position may be sometimes determined. 
 
 Percussion gives some signs of diagnostic value. The 
 pyloric portion may extend beyond the normal limits to the 
 right; but it may be impossible to demonstrate this if the 
 hepatic flexure of the colon is filled with gas. The lower 
 border may often, but by no means always or necessarily, be 
 below the line joining the umbilicus and the tip of the car- 
 tilage of the ninth rib. During digestion, if the time be 
 taken to search for the sign, the percussion note over the
 
 MYASTHENIA GASTRIC A. 353 
 
 uncovered triangle changes with the peristaltic movements, 
 and it changes also over the area of the stomach accessible 
 to percussion when the position of the patient is altered. 
 
 Myasthenia, however, can not be detected by inspection, 
 palpation, and percussion, nor by inflation and electric illumi- 
 nation, for the object is not the determination of the size, 
 form, and position of the stomach, but the estimation of the 
 tone and strength of its muscular layer. The methods of 
 Penzoldt and Dehio are of more value if used with the 
 proper precautions. The liver and the stomach are first 
 mapped out by palpation and percussion, while the patient is 
 recumbent and fasting. The position of the left lobe of the 
 liver and of the greater curvature of the stomach should be 
 next determined as accurately as possible while the patient 
 stands erect. It is necessary to do this while the patient is 
 standing in order to make allowance for the descent of the 
 abdominal viscera produced by the erect position. This 
 descent varies from a fraction to two or three inches, and the 
 greater curvature would be displaced downward, not by re- 
 laxation of its walls, but by total descent. After the new 
 boundaries have been marked, half-glasses of water are ad- 
 ministered after short intervals, during which the change in 
 the location of the greater curvature is determined by per- 
 cussion, the patient being erect. The distance of the dislo- 
 cation is directly proportionate to the myasthenia, and the 
 quantity of water required to produce the greatest descent 
 is inversely proportionate to the myasthenia. Generally, a 
 liter of water does not cause the greater curvature of the 
 normal stomach to descend below the umbilicus. Many 
 difficulties exist in the practice of these methods, and we 
 rarely employ them. 
 
 The most valuable physical sign of myasthenia with stag- 
 nation is percussion splashing located in the stomach, and 
 this alone is sufficient to establish the diagnosis of motor 
 insufficiency when the proper precautions are taken. These 
 splashing sounds are usually absent in the healthy, vigorous 
 stomach at all moments of the digestive period except toward 
 the end of the digestion of a very large meal. The myas- 
 thenic stomach splashes throughout the digestive period, and 
 also later than the moment when the normal stomach should 
 be empty, the evacuation of the stomach being delayed. Two 
 glasses of water given on an empty healthy stomach are passed 
 into the duodenum without its being possible (or, rarely, for 
 a period of a few minutes) to elicit gastric splashing. The 
 myasthenic stomach, under the same circumstances, splashes 
 23
 
 354 DISEASES OF THE STOMACH. 
 
 for two hours, or even longer. In the mild form, and in some 
 of the cases of the severe form of stagnation myasthenia, an 
 examination may give intermittent splashing (during a meal or 
 after the administration of water). The stomach has enough 
 tone to retract during peristalsis, but it relaxes completely 
 during the periods of peristaltic inactivity. If a glass of 
 water be given on an empty stomach, the gliding method of 
 palpation shows the nearly empty stomach to be flabby, non- 
 retracted, e.xtending over a large area and the greater cur- 
 vature, caught between the compressing fingers and the pos- 
 terior abdominal wall, offers little resistance to fixation during 
 expiration. 
 
 While the splashing sounds give valuable information con- 
 cerning the tone and power of the muscular wall, the stomach- 
 tube may be used to determine the motor insufficiency with 
 great exactness. Seven hours after a Leube-Riegel meal 
 the stomach should contain no food. After the test-break- 
 fast the quantity of contents, determined exactly by the 
 methods of Mathieu or Strauss, is greater than normal, the 
 increase above the 150 c.c. revealing the motor insufficiency. 
 The increased quantity of contents may, however, be due to 
 supersecretion or to swallowed saliva. The emulsion meal 
 of Mathieu, or our absorption test-meal, would eliminate this 
 possible source of error. The stomach before breakfast or 
 the morning after the administration of Boas' evening test- 
 meal, contains no food in the stagnation form. 
 
 We commonly adopt the following method of procedure, 
 the existence of motor insufficiency having been revealed by 
 the splashing sounds or by the excessive quantity of contents 
 one hour after the Ewald-Boas test-breakfast. If the stom- 
 ach splashes in the early morning before any food or fluid 
 has been taken, a Boas evening meal is ordered, and the 
 stomach is examined the ne.xt morning for retained contents. 
 If the stomach contains no food, retention does not exist. A 
 breakfast consisting of two soft-boiled eggs, one roll, a little 
 butter, and a cup of weak tea or coffee (milk and sugar 
 allowed) is ordered at 8 o'clock, and at i o'clock the stomach 
 is examined. If it be found empty the severe form of stag- 
 nation does not e.xist. If it contains remnants of the breakfast 
 there is severe stagnation, which may be due to myasthenia 
 or to obstruction. Two glasses of water are given on the fol- 
 lowing morning before breakfast. One and one-half hours 
 later the stomach is examined. If the stomach is empty there 
 is no myasthenia, but there is obstructive stagnation. If the 
 stomach is not empty, the myasthenia is proportionate to the
 
 MYASTHENIA GASTRIC A. 355 
 
 quantity of water which is found in the stomach. The quantity 
 of water may be exactly determined by introducing lOO c.c. of 
 a one per cent, solution of dextrose or sugar, mixing it with 
 the stomach-contents, and subtracting lOO from the result 
 obtained by dividing lOO by the estimated percentage of sugar 
 in the expressed dilution. If the stomach secretes excessively, 
 the analysis of the liquid withdrawn will reveal it. This pro- 
 cedure constitutes the important water-test, which not only 
 reveals the myasthenia (a " dyspepsia of liquids "), but dis- 
 tinguishes myasthenic from obstructive stagnation. 
 
 In stagnation myasthenia the stomach is empty in the early 
 morning before breakfast, but digestion and secretion are 
 prolonged. The stomach works longer than it should and 
 secretes longer than it should; but myasthenia does not pre- 
 sent a constant chemical type, for secretion displays irregular 
 variations. The three stages of digestion — rise, continuance, 
 and decline — may be simply prolonged, with no noteworthy 
 quantitative variations of the total hydrochloric acid from the 
 normal type. More frequently free HCl appears abnormally 
 early and the combined HCl gradually increases, and during 
 the latter stage of digestion is abnormally high, for the 
 secreted HCl is not rapidly utilized and the digestive pro- 
 ducts accumulate. The period of decline of digestion is 
 prolonged like the other stages, and it does not end suddenly, 
 as often happens in obstructive stagnation. The lines repre- 
 senting the evolution of the free HCl and of the combined 
 HCl may be irregular, with sudden rises and falls, for the 
 evacuation of the contents may be irregular and in spurts; 
 but these lines may also be irregular in obstructive stagna- 
 tion. In stagnation myasthenia the total HCl (H -f- C) may 
 be less than normal, the combined HCl gradually increasing 
 as digestion proceeds. If the HCl secreted is greatly and 
 constantly diminished, the co-existence of stagnation should 
 arouse suspicion, for this combination of functional signs is 
 rare in myasthenia; but it is frequent in carcinoma, in chronic 
 gastritis with infiltration of the muscular layer, and in the 
 complicated cases of pyloric obstruction. In adenasthenia 
 gastrica and in simple chronic asthenic gastritis the stomach 
 empties itself with normal or abnormal rapidity, for its motor 
 power is good and the digestive work which it is capable of 
 doing is quickly finished. To detect these abnormalities of 
 the evolution of secretion it is necessary to remove and ana- 
 lyze the contents of the stomach thirty, sixty, and one hun- 
 dred and twenty minutes after the beginning of the test- 
 breakfast. With the exception of these evolution disorders
 
 356 DISEASES OF THE STOMACH. 
 
 tliere are no abnormal secretory signs in stagnation myas- 
 thenia. We would particularly emphasize the almost invari- 
 able absence of abnormal bacteriological signs. There is no 
 excessive germ growth, no fermentation, and no gas forma- 
 tion in the fermentation tube tests. Very rarely there are a 
 few yeast cells. 
 
 The evolution of nu'asthenia with stagnation is variable. 
 Developing as the sequel of an acute disease, it may rapidly 
 disappear under proper treatment. It may be arrested at 
 any stage, whatever be the cause. When a hereditary pre- 
 disposition exists it may last from childhood to old age, 
 but be controllable by proper digesti\'e hygiene. However 
 caused, the form with stagnation may rapidly or slowly grow 
 into the form or period characterized by retention. Its 
 course may be broken by latent periods, characterized only 
 by physical signs, or by exacerbations due to physical, 
 mental, or nervous exhaustion, or to dietetic excesses. 
 
 Diagnosis. — The- diagnosis of myasthenia gastrica is easy 
 if the modern methods of examination be emplo}'ed. The 
 restriction of the symptoms to the prolonged digestive period 
 and their relation witli the quantity and fluidity of the food ; 
 the delayed evacuation of the flabby, easily distensible, and 
 slightly retractile splashing stomach ; the absence of food in 
 the fasting morning stomach ; the absence of a characteristic 
 germ growth or secretory deviation ; the mode of develop- 
 ment and the usual maintenance of nutrition — are suflficiently 
 characteristic. 
 
 Differential Diagnosis. — The diseases most likely to be 
 confounded with the stagnation form of myasthenia gastrica 
 are neurasthenia gastrica, displacements of the stomach, 
 pyloric obstruction, cancer, chronic gastritis, and myas- 
 thenic gastric retention. 
 
 In both neurasthenia and myasthenia the subjective symp- 
 toms are digestive, and may be similar; but in neurasthenia 
 the subjective symptoms are not proportionate to the quan- 
 tity of the food, and are commonly more pronounced with 
 solids than with fluids. In myasthenia the symptoms are 
 greatest after large meals, and are least after small meals of 
 finely-divided solid food with little fluid. Gastric excitants, 
 particularly condiments and irritant drugs, increase greatly 
 the uneasiness and discomfort of neurasthenia, and are com- 
 paratively well borne in the mild form of myasthenia. In 
 neurasthenia the abdominal plexuses are sensitive, and pres- 
 sure, particularly during the period of functional activity of 
 the digestive tube, over the four points situated a little below
 
 MYASTHENIA GASTRICA. 357 
 
 the ensiform process, to either side of the umbilicus, and 
 above the symphysis pubis, produces an indefinable discom- 
 fort. Care should be taken to exclude a tender left lobe of 
 the liver, a filled or an inflated colon, and a distended bladder, 
 tenderness over which may be mistaken for sensitive sympa- 
 thetic ganglia. With these may be found other signs or 
 symptoms of neurasthenia, as neuralgia, spinal points, head- 
 ache, and insomnia ; but none of the signs enumerated are 
 conclusive, as neurasthenia may generate or may be asso- 
 ciated with myasthenia. The functional signs, however, are 
 distinctive. In neurasthenia gastrica both the mechanical 
 and the chemical functions of the stomach are normal, and 
 consequently the presence of gastric splashing under the con- 
 ditions already given, and the evidences of constant motor 
 insufficiency furnished by the tube and by test-meals, exclude 
 simple neurasthenia gastrica with certainty. 
 
 The vertical displacement and the prolapse (gastroptosis) 
 of the stomach may be confounded with myasthenia. The 
 dislocations of the stomach may be symptomless until some 
 complication develops, and the most frequent complications 
 are m3'asthenia and motor insufficiency, due to partial ob- 
 struction. In vertical dislocation the pyloric portion is dis- 
 placed downward and to the left; the percussion area of the 
 stomach does not cross the median line, and remains high, as 
 in health. In gastroptosis the lesser curvature descends, and 
 other abdominal viscera are usually also displaced. In both 
 forms of displacement the stomach may splash. The infla- 
 tion of the stomach and the other physical methods of ex- 
 amination usually reveal clearly the position of the stomach. 
 It should not be forgotten that the displaced stomach is 
 often myasthenic. The abdominal belt and the water-test, 
 and possibly visible peristalsis and a palpable, firmly con- 
 tracted stomach, furnish the only means of distinguishing 
 myasthenic stagnation from the obstructive stagnation pro- 
 duced by displacements of the stomach or by enlargements 
 of the liver. 
 
 The differentiation of myasthenia from pyloric obstruction 
 may be difficult. In making this distinction the clinical his- 
 tory may be very valuable when it gives a group of symp- 
 toms characteristic of a disease which is likely to produce an 
 obstructing deformity. The most common diseases of the 
 stomach which produce obstruction are ulcer and carcinoma. 
 If there be a history of gastric hemorrhage, of epigastric 
 pain bearing the character of that of ulcer, and other gastric 
 symptoms in the characteristic relation to the ingestion and
 
 358 DISEASES OF THE STOMACH. 
 
 the qualities of the food, it is very probable that the motor 
 insufficiency is due to obstruction. The motor insufficiency 
 of the stomach may be due to other diseases than that of tiie 
 stomach itself, such as duodenal stenosis, perigastric and 
 duodenal adhesions, the pressure of tumors and of displaced 
 organs. The obstructed stomach contracts on its contents 
 and retracts when it is empty. In marked contrast is the 
 weak, easily distensible, slightly retractile stomach of myas- 
 thenia. During the performance of lavage in myasthenia 
 the water flows in rapidly and continuously, a suction whirl- 
 pool may be produced by holding the funnel high, and the 
 outflow is slow and steady ; but m obstruction the inflow is 
 slow and may temporarily stop, and the outflow is strong and 
 often in spurts. In myasthenia expression is difficult and 
 always incomplete ; but in obstruction the greater portion of 
 the contents can be easily removed by expression. The mus- 
 cular layer of the obstructed stomach, in the effort to estab- 
 lish compensation, becomes hypertrophied, stronger than 
 normal, and the moderately filled organ may be felt by the 
 educated fingers rounded, sharply limited, resistant, alter- 
 nately relaxing and contracting. The method of Dehio 
 shows no increase of normal distensibility. Splashing, if it 
 exist, is limited to a small area during the digestion of a 
 meal. After a glass of water taken on an empty stomach, 
 splashing is often difficult to produce, is limited to the area 
 of the uncovered triangle, and the gliding method of Glenard 
 is impracticable, or reveals a firm stomach within the normal 
 boundaries and with walls brought in contact with difficulty. 
 In favorable cases with thin and relaxed abdominal walls, 
 peristalsis, and sometimes antiperistalsis, may be visible dur- 
 ing the digestive period. Unless the stomach is displaced or 
 is physiologically large, it remains within its normal bounda- 
 ries, both when full and when emj^ty. The healthy and 
 physiologically large stomach secretes, digests, and empties 
 itself in a normal manner. [For a full discussion of the differ- 
 entiation of obstructive stagnation and myasthenic stagnation 
 see the article on obstruction of the pylorus, where the differ- 
 ential value of the water-test is also made clear.] 
 
 Motor insufficiency is one of the earliest and most constant 
 signs of carcinoma of the stomach. It may be due to pyloric 
 obstruction, to infiltration of the muscular layer, to edema 
 and malnutrition from obstruction of the venous and lym- 
 phatic circulation, and, probably, also to reflex nervous in- 
 fluences. Myasthenia is very slow, often stationary, in its 
 course, occurs at all ages, is amenable to treatment, when
 
 MYASTHENIA GASTRICA. 359 
 
 simple is without deleterious influence on nutrition, and pre- 
 sents a normal series of secretory and bacteriological signs 
 in marked contrast with those of carcinoma. Cancer is rap- 
 idly progressive ; is most frequent after forty ; is only tempo- 
 rarily influenced by treatment ; causes progressive emaciation 
 and loss of strength, with blood and urine changes; may be 
 accompanied by transient edema of the lower extremities; 
 by enlargement of the inguinal and supraclavicular glands, 
 by secondary nodules in the liver, and by a palpable tumor. 
 If the cancer involves the stomach, the chemical and bacteri- 
 ological signs are distinctive ; but these are absent if the 
 motor insufficiency is due to compression by cancer of a 
 neighboring organ, such as the pancreas or the gall-bladder. 
 In cancer, particularly in the early and obscure stage, the 
 stomach is neither flabby nor easily distensible as in myas- 
 thenia. 
 
 Chronic asthenic gastritis is rarely accompanied, except 
 in the advanced stage of some cases, by motor insufficiency. 
 Consequently, none of the physical and functional signs 
 of myasthenia exist in this disease. The stomach is normal 
 in size; there is no abnormal splashing; the hydrochloric 
 secretion and the ferments are constantly diminished ; there is 
 always an excess of mucus; after a test-breakfast the con- 
 tents are thick and contain little fluid, and two glasses of 
 water are evacuated from the stomach within two hours. 
 Cases of chronic asthenic gastritis which have become com- 
 plicated by motor insufficiency do not differ materially from 
 myasthenia which has become complicated by asthenic gas- 
 tritis, except in their etiology and evolution. 
 
 A stomach of any size may become myasthenic, but a 
 large stomach will not be confounded with a myasthenic 
 stomach, except when the diagnosis is based on the position 
 of the greater curvature, a mistake which is sometimes made' 
 by the inexperienced. Myasthenic stagnation is easily dis- 
 tinguished from both myasthenic and obstructive retention 
 by the presence of food in the stomach before breakfast after 
 the Boas evening meal and by the active fermentation which 
 exists in retention. 
 
 Treatment. — The prophylaxis of myasthenia is very im- 
 portant. During convalescence from acute diseases, and dur- 
 ing the course of exhausting diseases, the diet should always 
 be regulated so as to favor the weak gastric muscle, and 
 means should be adopted to preserve and to revive its power. 
 If there be a hereditary predisposition, digestive hygiene 
 should be regulated so as to require no extraordinary
 
 360 DISEASES OF THE STOMACH. 
 
 mechanical work of the stomach, and the neuromuscular 
 system should be developed by a properly regulated life. 
 The same prophylactic measures are an essential part of the 
 treatment of all diseases of the stomach likely in their course 
 to become complicated by myasthenia, the development of 
 which marks a danger-point in their evolution and often 
 necessitates a complete change of the treatment. 
 
 The treatment of the established disease is simple, and the 
 object is clearly defined by its pathology. The weak muscle 
 must be fcivored in its work, its strength must be developed, 
 and enough food should be taken to keep the body well 
 nourished. 
 
 A proper diet is consequently a matter of the first impor- 
 tance. The food should be nutritious, in small bulk, and 
 indifferent in its action on the stomach. Some authorities 
 claim that a dry diet is essential and best, and recommend 
 frequently repeated meals ; but in our experience a glass of 
 fluid is an advantage, and the stomach regains its tone more 
 rapidly when allowed as long an interval of rest as possible. 
 In the severe form it is not advisable to give frequent meals ; 
 the stomach should be given time to empty itself before intro- 
 ducing more food into it. An increased number of meals 
 necessitates an approximation of the meals, and this disad- 
 vantage may outweigh the benefit derived from the diminu- 
 tion of the quantit)^ of each meal. The one or the other 
 method may suit a particular case best, and it may be wise 
 to control the plan of feeding adopted by daily examinations 
 and by the frequent use of the stomach-tube. It is best, 
 however, when the food is badly utilized by the intestines, or 
 when the stomach is capable of managing only a small quan- 
 tity, to divide the total quantity of food required for the 
 twenty-four hours into four equal parts, to be given five 
 hours apart. Overtaxing the stomach is thus avoided and 
 an interval of repose is secured between the meals. 
 
 An excess of sweets and fats is injurious in myasthenia. 
 The one increases the quantity of secretion and is liable, 
 on account of the stagnation, to induce fermentation ; and 
 the other delays the evacuation of the stomach. But fat 
 in the form of fresh butter should be given in sufficient quan- 
 tity to meet the requirements of nutrition, and for theoretical 
 reasons is too often forbidden, for exi)erience shows that it 
 may be well borne, and this rich force-producing and nerve- 
 building food is essential in moderate quantity. It is custo- 
 mary to exclude sweets, but the exclusion of this valuable 
 class of foods is also an error, for it is only necessary to limit
 
 MYASTHENIA GASTRIC A. 36 1 
 
 the quantity and to select the most digestible of the foods 
 which contain sugar. The fear of fermentation in stagnation 
 myasthenia is not well founded, and it is rarely necessary to 
 do more than to select the fats and sweets and to forbid their 
 excessive consumption. 
 
 The diet should not be exclusive, but mixed, and should 
 consist of a combination of finely-divided, tender, and lean 
 meats ; fish ; the more nutritious and easily digestible cereals, 
 such as rice and the preparations of wheat and h6miny or 
 cornmeal mush, thoroughly cooked; a small quantity of 
 vegetables which do not possess a great deal of waste matter ; 
 fresh butter ; and some sweets. Preparations of eggs may 
 also be allowed, but too much of the yolk will not be 
 well borne. An exclusive or chiefly milk diet is often pre- 
 scribed, but is an experiment, and, on account of the large 
 quantity required to support nutrition, is very objectionable; 
 but milk, when well borne, may be permitted as a drink. A 
 cup of coffee once or twice a day may not be injurious. 
 Tea, cocoa, and chocolate should be prohibited, but Haus- 
 waldt's " Vigor Chocolate " may be tried. A small quantity 
 of alcohol, if the patient is accustomed to its use, may be 
 permitted at meal-time, and will usually promote both absoi"p- 
 tion and the evacuation of the stomach. A little pure old 
 whisky or brandy may be taken, well diluted, or a light wine 
 may be permitted ; but often no drink will be found to agree 
 better than a glass of plain water, just cold enough to be re- 
 freshing. A small quantity of ripe, seedless fruit should 
 not be injurious. 
 
 This is the diet of simple myasthenia with stagnation : 
 Small in bulk and nutritious ; finely divided ; mixed ; very little 
 fruit and vegetables ; a moderate quantity of sweets and fats ; 
 nitrogenous foods and cereals as freely as in health ; and a 
 limited quantity of fluid. We are not advocates of a dry 
 diet in myasthenia, and at least three pints of fluid should be 
 taken in the twenty-four hours. The gastric splashing has 
 led logically to the recommendation of a dry diet. This we 
 believe to be a mistake, and consequently permit a glass of 
 fluid (water, coffee, meat broths, possibly milk, or "Vigor 
 Chocolate") with each meal. Two or three more glasses of 
 fluid must be given during the twenty-four hours, at such 
 times as will interfere the least with digestion, or it may be 
 advisable to give part of the required fluid by rectum. 
 
 In the erect position the contents of the myasthenic stom- 
 ach weigh down and distend the pyloric portion, and may 
 produce an incomplete obstruction of the duodenum at its
 
 362 DISEASES OE THE STOMACH. 
 
 point of attachment to the vertebral column. It is not the 
 liquid alone, but the weight of the total gastric contents and 
 the erect position which add to the labors of the weak mus- 
 cle. The myasthenic who overloads his stomach and goes 
 to work or exercise immediately after meals is not likely to 
 do well. If the mechanical work required of the stomach in 
 a particular case is greater than it can perform, the insuffi- 
 ciency will increase and retention will result. One or two 
 hours' rest after meals is wise and beneficial. 
 
 Where the myasthenia is complicated, the chemical and 
 bacteriological signs will require consideration in selecting 
 the diet. These complications or accidental associations are 
 fermentation, excessive secretion (adenohypersthenia), gas- 
 tritis, and intestinal diseases. It is still, however, the func- 
 tional power of the stomach and intestines and the physio- 
 logical action of the food which decide the diet after the 
 possible excessive or peculiar germ growth is arrested, A 
 diet so regulated as to support nutrition and to diminish the 
 mechanical work of the stomach places the organ in a favora- 
 ble condition for regaining its lost muscular power. But 
 other remedies may also be employed to strengthen the weak 
 muscle. The most important of these are exercise, massage, 
 electricity, hydrotherapy, and a few drugs. 
 
 The principle which should regulate the strength and dose 
 of these remedies may be the contrary of that which usually 
 guides practice. The greater the myasthenia, the milder and 
 less excitant, in some cases, should be the remedy. The 
 weak gastro-intestinal muscle may be excessively irritable, 
 and overexcitation or stimulation does harm. This injuri- 
 ous action is clearly demonstrated by the effect of a strong 
 purgative m well-marked myasthenia of the colon, producing 
 colic and localized contractions persisting for hours. No 
 remedy which strains or exhausts a weak muscle can increase 
 its strength. The dose of the muscular excitant must fall 
 short of producing irritable spasm and exhaustion. 
 
 The exercise, which is best taken in the open air, should 
 not begin earlier than one hour after meals, and should always 
 be moderate, so that the slight sense of fatigue disappears 
 after a few minutes' rest. 
 
 Abdominal massage is a remedy of value. If the stagna- 
 tion is pronounced, it may be employed late in the evening — 
 four hours after meals — to empty the stomach, the organ being 
 left contracted under the influences of the skin reflexes ex- 
 cited by circular movements of the tips of the fingers around 
 the umbilicus and over the stomach. It is often advisable to
 
 MYASTHENIA GASTRICA. 363 
 
 massage the abdominal muscles, but the intestines should be 
 left alone to digest and to absorb their contents during the 
 night. The general abdominal massage, if indicated by in- 
 testinal stagnation, should be performed in the morning, fast- 
 ing or after the administration of a glass of water. The best 
 methods of using water in the treatment of myasthenia are 
 the intragastric spray and the Scottish douche, in the manner 
 recommended to tone the abdominal sympathetic. If the 
 patient tolerates the tube, the intragastric douche with plain 
 water will be found valuable, particularly in the cases where 
 suggestion is likely to prove a remedy of value. The tonic 
 influence of a shower-bath is thus brought directly to the 
 gastric wall. The intragastric spray may be employed twice 
 a week, in the morning before breakfast, care being taken to 
 avoid overloading the stomach with water and to leave the 
 organ empty. There is in the stagnation form of myasthenia 
 no indication for stomach washing. 
 
 Electricity may also be often employed with advantage, 
 strong currents of low density being most beneficial. Intra- 
 gastric faradism and cathodal galvanism are the best methods, 
 and minute directions for using electricity to tone the stomach 
 will be found in the section on General Medication. 
 
 A few drugs are of great value in the treatment of myas- 
 thenia. Of these, strychnin deservedly holds the first place. 
 Ergot is also valuable when well borne. Hydrastinin muri- 
 ate is often beneficial. Quinin (alkaloid preferable to its 
 salts) is almost as valuable as strychnin. The prolonged 
 use of ipecac in very small doses is also beneficial. Two or 
 more of these drugs may be given combined. The other 
 medicines are those commonly used to control gross symp- 
 toms. 
 
 Constipation may be a troublesome association, but is usu- 
 ally relieved by a proper diet, by massage, by electricity, by 
 gluten suppositories, by glycerin suppositories, and by the 
 general hygienic remedies directed against the gastric myas- 
 thenia. An occasional injection of water, or water and a 
 teaspoonful of glycerin, may be required. Cascara sagrada 
 in barely efficient doses (combined with hyoscyamus or bella- 
 donna) may be prescribed. A pinch of Turkish rhubarb 
 after the evening meal may be all that is needed. But the 
 time required for the patient to get well is prolonged by the 
 use of purgatives, and no good is done the myasthenic stom- 
 ach by the frequent employment of laxatives.
 
 364 DISEASES OF THE STOMACH. 
 
 2. MYASTHENIA WITH RETENTION. 
 
 Stagnation myasthenia may remain stationary for a long 
 period, but its inherent tendency is to increase. Retention 
 niN'asthenia is, consequently, the natural sequence of the 
 stagnation form. The prolongation of digestion, which neces- 
 sarily results from stagnation myasthenia, increases the 
 mechanical work which the stomach has to perform and 
 requires abnormal endurance of its weak muscle. The nor- 
 mal stomach would hypertrophy under the increased work 
 demanded by the prolongation of digestion and of secretion, 
 but, unfortunately, the myasthenic stomach does not ; its 
 task must be lightened before the weak muscle will begin to 
 recuperate. Furthermore, the myasthenic stomach creates 
 new difficulties for itself. Normally, the pyloric end of the 
 stomach, as it becomes distended by the contents of the 
 stomach forced into it by peristalsis, extends downward and 
 to the right, and is elevated by rotation forward and upward, 
 thus relaxing the gastrohepatic ligament and making it easy 
 for fluids to pass. In myasthenia the enlarged pyloric antrum 
 simply descends in the abdomen, tightens the gastrohepatic 
 ligament, and produces an angular constriction, which renders 
 the evacuation of the stomach more difficult. If the patient 
 be emaciated, or if abdominal tension is low, the production 
 of the duodenopyloric constriction is facilitated. In spite of 
 this difficulty, and in spite of the increase of mechanical work, 
 the stagnation myasthenia may persist for a long time without 
 progressing to a severer stage, or retention may eventually 
 result. The advent of retention is favored b\' a ver}' large 
 meal, by excesses, by fatigue, by enlargement of the liver, 
 and by acute or chronic exhausting diseases. 
 
 Clinical Description. — When the myasthenia becomes so 
 great that the stomach never completely evacuates its con- 
 tents into the duodenum, the symptomatology changes. To 
 the digestive symptoms proper to myasthenia are added those 
 due to the retention and the fermentation. 
 
 The appetite is usually poor, and decreases with the activity 
 of fermentation. Thirst may become intense, but is in direct 
 relation with the sy.stem's loss of fluid by retention and by 
 vomiting. The patient, after a restless night, awakes in the 
 morning, commonly with a headache, depressed and tired. 
 Immediately after meals the stomach feels heavy and full and 
 the abdomen becomes flatulent and distended. The flatu- 
 lency increases with the movements of the digestive tube, and
 
 MYASTHENIA GASTRICA. 365 
 
 large quantities of gas are removed by repeated belching, 
 often bringing a small quantity of a sour and bitter fluid into 
 the mouth. There is constant nausea, and sometimes vertigo, 
 if there is butyric fermentation or putrefaction. The products 
 of fermentation produce sometimes a burning, local pain, 
 and if active fermentation continues in the intestines it pro- 
 duces also colic, and, rarely, diarrheal movements ; but ob- 
 stinate constipation is' the rule in myasthenia with retention. 
 During the digestive period the headache and nervous 
 symptoms increase. The symptoms diminish after a number 
 of hours, but there is no interval of gastric repose or comfort. 
 From meal to meal the retained contents, in active fermenta- 
 tion, accumulate in the stomach, until about every second or 
 fourth day the overloaded organ is relieved by copious, effort- 
 less vomiting, occurring often without nausea. The system 
 is thus robbed of its nourishment by vomiting, and by fer- 
 mentation beginning in the stomach and extending to the 
 intestines, and is also slowly poisoned by germ products. 
 
 Vomiting, however, is not so common a symptom of myas- 
 thenic retention as of that due to pyloric obstruction, and is 
 usually incomplete, less copious, and more apt to occur three 
 or four hours after a meal than at night. The vomit consists 
 of a brownish mixture of a bad odor, like that of "dead" 
 yeast fermentation, very acid, often bitter, containing mucus 
 and sometimes blood and bile, and separates, on standing, into 
 three distinct layers, the upper being fatty and foamy, the 
 middle fluid and cloudy, and the lower consisting of solid 
 residue of food mixed with germs and giving off bubbles of 
 gas, often carrying with them on their way to the top layer 
 little particles of food. The vomiting becomes less and less 
 frequent as the myasthenia increases, but when it occurs tem- 
 porary relief follows. 
 
 Emaciation is a constant symptom of myasthenia with re- 
 tention, and is due partly to enforced inanition. The intes- 
 tines can not compensate the inefficient stomach, because the 
 fermenting mass, in part delivered to it, is neither digestible 
 nor nutritious, and disorders the functions of the intestines. 
 Gastric absorption decreases with the overdistention of the 
 stomach, and many of the so-called auto- intoxication symp- 
 toms are due to the deficient supply of food and water. 
 
 The functions of the intestines are always disordered in 
 myasthenic retention. If the vomiting is complete it is often 
 followed by improvement of the intestinal fermentation and 
 of flatulency ; but the constipation continues obstinate and 
 the movements are rare, dry, and scybalous. In some cases
 
 366 DISEASES OF THE STOMACH. 
 
 the stomach, irritated by the products of active fermentation, 
 empties its contents into the intestines and produces a fer- 
 mentative diarrhea. Often the intestines are also myasthenic, 
 and, as a consequence, enteritis membranacea may eventually 
 develop. 
 
 The urine is always diminished in quantity in proportion 
 to the insufificient absorption and to the loss of water, and it 
 is of high specific gravity. Consequently, the quantity of 
 urine passed in the twenty-four hours may be taken as a 
 rough measure of the degree of retention, notice bein<j taken 
 of the quantities of water ingested and vomited or, rarely, 
 eliminated by diarrhea. The chlorids are diminished and 
 the phosphates are increased and precipitated in large quan- 
 tities on heating. If there be excessive secretion, the urine 
 may present all the characteristics found in hypersthenic gas- 
 tritis. Rapid or severe emaciation may be accompanied b\' 
 acetonuria. 
 
 A large number of general symptoms and diseases of 
 other organs results directly and indirectly from gastric reten- 
 tion. Some find a convenient explanation of these in refle.x 
 action ; others attribute them to the subnutrition, the defi- 
 ciency of water, the disordered metabolism, and the dimin- 
 ished power of resistance of the organism ; and still others, 
 adopting the theory of Bouchard, explain their genesis by 
 auto-into.xication. The germ products absorbed from the 
 digestive tube doubtless play an important pathogenic part, 
 and produce directly many of the general sj'mptoms, but it 
 can not be shown that more than a part of these products 
 are formed in the stomach. 
 
 The list of these secondary troubles is a ver\' long one. 
 The liver is frequently periodically congested. There may 
 also be attacks of icterus without alteration of the color of 
 the stools. Palpitation, arrhythmia, tachycardia, reduplication 
 of the second sound, are common heart disorders, the action 
 of this organ (right ventricle) being also at times mechani- 
 cally interfered with by the presence of the distended stomach 
 and by contraction of the pulmonary arterioles. Bronchitis 
 occurs as frequently as inflanmiation of other mucous mem- 
 branes. Urticaria, acne, pityriasis versicolor, erythema, and 
 eczema are some of the skin affections associated with myas- 
 thenic retention. The nervous symptoms are very numerous 
 — disorders of the special senses and of speech, affections of 
 memory, hypochondriasis, tetany, muscular cramps; attacks 
 beginning with restlessness, jactitation, slight general convul- 
 sions, and accompanied b\' d\-spnea and somnolence, ending in
 
 AIYASriJENIA GASTRIC A. 367 
 
 coma. Some claim rickets to be the result, while Bouchard 
 describes an enlargement of the second phalangeal joints as a 
 nutritive disorder which exists only in association with gastric 
 retention. That auto-intoxication may be the possible cause 
 of these numerous troubles may be admitted ; but a possible 
 explanation is not necessarily always the true one, and it is 
 certain that they have not been proven to result from gastric 
 retention. 
 
 The Objective Signs. — The signs furnished by the examina- 
 tion are those of myasthenia, of retention, and of fermentation. 
 The signs of myasthenia have been given in the description 
 of the stagnation form or period of the disease. The second 
 clinical form or period is characterized by the signs of reten- 
 tion and of fermentation. 
 
 The patient is emaciated, the skin is dry and rough, and 
 the secretions are thickened; the extremities are often cold, 
 and the fingers may show the nodosities of Bouchard. 
 
 The physical examination usually reveals a flabby stomach 
 of large size. If the organ is filled, the epigastrium and the 
 left hypochondrium are prominent, and the greater curvature 
 may often be seen and felt running lower and to the right of 
 the normal limits, splashing always under the same conditions 
 as in myasthenia with stagnation. A normal size of the 
 stomach does not exclude either form of the disease. Infla- 
 tion may be employed to locate and to define more accurately 
 the boundaries of the stomach, revealing or excluding a dis- 
 placement. An important inspection sign is self-inflation of 
 the stomach, when the viscus may be seen slowly to distend 
 with gas and somewhat abruptly to collapse with the escape 
 of gas through the pylorus. Peristalsis is visible only when 
 there is obstruction to the evacuation of the stomach, and is 
 not a sign of myasthenia. On placing the stethoscope over 
 the stomach, intragastric bubbling can often be heard. Both 
 the self-inflation and the crackles are signs of gas-forming 
 fermentation, and when present in the morning before break- 
 fast are pathognomonic of retention and of fermentation. 
 
 Another physical sign of retention is gastric splashing in 
 the morning before anything has been taken into the stomach. 
 This sign is never absent in myasthenic retention, but is also 
 found in continuous secretion. 
 
 The pathognomonic sign of gastric retention is the presence 
 of a noteworthy quantity of food in the stomach in the morning 
 after a test-supper (Boas). To measure the degree of motor 
 insufficiency the stomach should be washed out before the 
 supper is eaten. The quantity of food in the stomach on the
 
 368 DISEASES OF THE STOMACH. 
 
 following morning is, then, proportionate to the motor insuf- 
 ficiency. 
 
 The contents of the stomach, removed by vomiting or by 
 the tube, present physical, chemical, and bacteriological pro- 
 perties characteristic of retention. The odor is sour, dead, 
 often rancid. The total acidity is always high, consisting of 
 the free and the combined acids of secretion and fermenta- 
 tion. On standing, it separates into three layers, with visi- 
 ble gas formation. The gases consist of those of swallowed 
 air, of fermentation, and of putrefaction, including some- 
 times H and HoS. Sarcinae, yeast, and numerous bacteria 
 are found. If the stomach is washed out and a test-break- 
 fast given, we may obtain the secretory and digestive signs 
 of hyperchylia or of a complicating gastritis, plus fermenta- 
 tion. Lactic acid is frequently found in the contents where 
 no free HCl is present; but lactic acid is not formed under 
 the conditions of the Boas cancer test. Gas formation is active 
 in the fermentation tubes filled with the unfiltered and sweet- 
 ened contents of the stomach. 
 
 Diagnosis. — The objective signs of gastric retention are so 
 characteristic that the diagnosis of the condition is easy. It 
 is often confounded with the stagnation form of the disease, 
 both possessing in common the signs of myasthenia; but 
 on account of the different treatment and prognosis it is 
 practically important that the two forms should be sharply 
 separated. The one is benign, local, unaccompanied by ema- 
 ciation or auto-into.xication, the stomach always succeeding 
 in completely empt\'ing itself and in delivering to the body 
 the required quantity of nutriment of all sorts. The other 
 is a starving and poisoning disease, accompanied by emacia- 
 tion, auto-intoxication, morning retention, and actix'e gastric 
 fermentation, the stomach withholding the amount of both 
 food and water necessary to maintain nutrition. The physi- 
 cal, functional, and bacteriological signs render it possible to 
 determine accurately where the one begins and the other 
 ends. But gastric retention is not synonymous with myas- 
 thenic retention ; consequently, myasthenic retention must 
 be distinguished from the other diseases which are accom- 
 panied by gastric retention. 
 
 Differential Diagnosis. — Motor insufficiency of the .stom- 
 ach may be due to increased resistance to the evacuation of 
 the stomach, to diminution of the evacuating power of the 
 stomach, or to an abnormal amount of work to be accom- 
 plished. Increased resistance to evacuation is the result of 
 obstruction. Diminution of the evacuating power may be
 
 MYASTHENIA GASTRIC A. 369 
 
 produced by myasthenia, by cancerous or inflammatory infil- 
 tration of the muscular layer of the stomach, and by gastro- 
 plegia. The amount of work may be made abnormal by the 
 eating of a very large meal. 
 
 Now, gastroplegia occurs suddenly, and is usually the result 
 of severe shock or of peritonitis. It is hardly possible to 
 mistake this rare disease for retention myasthenia. Acute 
 retention may be produced by a very large meal, but the 
 stomach recovers its motor sufficiency in a few days after the 
 large meal is evacuated into the duodenum or is expelled by 
 vomiting. Very rarely death may occur, if the greatly dis- 
 tended stomach can not evacuate the semi-solid contents, 
 the whole mass acting as one body. Acute retention pro- 
 duced in this manner is not likely to be confounded with 
 myasthenic retention. 
 
 Gastric retention due to myasthenia is, then, to be distin- 
 guished from retention due to obstruction, and to cancerous 
 or inflammatory infiltration of the muscular layer. In only 
 one other disease of the stomach is a noteworthy quantity of 
 contents found persistently in the stomach in the morning 
 before breakfast, and this disease is hypersthenic gastritis with 
 continuous secretion, which may be accompanied by pyloric 
 obstruction, or by myasthenia, or by myositis, while the motor 
 insufficiency may be so great as to produce retention, or some- 
 times only stagnation. 
 
 It may be very easy to exclude hypersthenic gastritis with 
 continuous secretion. This usually painful disease has many 
 <;haracteristic symptoms, as may be seen by reading its clinical 
 description. Anatomical signs may be found in the contents 
 of the stomach in this disease, such as blood, a large quan- 
 tity of mucus, nuclei of white corpuscles, and sometimes 
 pieces of inflamed mucous membrane. To distinguish it 
 from myasthenic retention it is only necessary to establish 
 the morbid continuity of secretion, for myasthenia with 
 secondary hypersthenic gastritis and continuous secretion 
 does not differ from hypersthenic gastritis accompanied by 
 myasthenia and continuous secretion except in their preced- 
 ing history and evolution. Now, in continuous secretion 
 the stomach may or may not retain food. If it does not retain 
 food (coarse, finely divided, or in digestive solution), a note- 
 worthy quantity of digestive fluid (more than twenty c.c.) in 
 the stomach before breakfast makes it clear that secretion is 
 continuous. If it does retain food, it is necessary to wash out 
 the stomach most thoroughly in the evening. It maybe very 
 difficult to cleanse the stomach thoroughly, and it is some- 
 24
 
 370 DISEASES OF THE STOMACH. 
 
 times wise to wash out the stomach in the evening and twice 
 on the following day, during which time the patient is nour- 
 ished exclusively by rectum, water only being permitted by 
 mouth. On the following morning before breakfast the con- 
 tents of the stomach are removed. If there is continuous 
 secretion, the stomach will contain more than twenty c.c. of 
 gastric juice. The total contents of the stomach should be 
 estimated by the acidity method of Mathieu or by using the 
 one per cent, solution of sugar. The properties of the morn- 
 ing contents may sometimes make the differentiation clear 
 without the employment of lavage, as stated in the following 
 propositions : 
 
 1. If lavage has not been practised after dinner on the pre- 
 ceding evening, and if the morning contents contain no visible 
 remnants of food, nor deposit a flocculent sediment which the 
 microscope shows to be composed of particles of food, nor 
 give on analysis a noteworthy quantity of combined HCl, — 
 there is no myasthenic retention, nor food retention from any 
 cause ; but if the stomach contains more than twenty c.c. of a 
 digestive fluid there is continuous secretion. 
 
 2. The morning contents in uncomplicated continuous 
 secretion are never more acid than the contents after the 
 test-breakfast. If the acidity (H -f C) of the morning con- 
 tents is greater than that of the digestive contents there is 
 retention. 
 
 3. If the lines which represent the quantity of free (H) and 
 of combined (C) hydrochloric acid during the evolution of the 
 digestion of the test-breakfast undergo sudden rises and falls, 
 there is motor insufficiency, for the rises and falls are due to 
 the irregular evacuation of the contents (obstruction) or to 
 the infrequency of evacuation efforts (myasthenia). If con- 
 tinuous secretion is not associated with motor insufficiency 
 during the period of decline of the digestion of the test- 
 breakfiist, the liquid contents are excessive, and contain free 
 HCl and chlorids, but very little combined HCl. 
 
 4. Whenever, in the ordinary course of events and without 
 previous evening lavage, the stomach contains in the morning 
 before breakfast a very large quantity of secretion but no 
 coarse particles of food, the continuous secretion is accom- 
 panied by motor insufficiency, due to weakness or disease of 
 the muscular layer, unless the examination has been made 
 during a " secretory crisis." 
 
 5. In continuous secretion without food retention, the 
 morning accumulated secretion does not produce gas forma- 
 tion when tested (unfiltered and sweetened) in the fermenta- 
 tion tubes.
 
 MYASTHENIA GASTRIC A. 37 1 
 
 When continuous secretion exists — and its existence is 
 proven by the continuance of gastric secretion after the stom- 
 ach has been completely relieved of all food by lavage, aided, 
 if need be, by fasting — to such a degree of activity as to per- 
 mit the accumulation of a pathological quantity of gastric 
 juice in the stomach before breakfast, there may or may not 
 be food retention. If there is retention of food, the disease 
 can not be simple myasthenia with retention, and the diag- 
 nostic problem which remains for solution is the detection of 
 the cause of the retention which is associated with the con- 
 tinuous secretion of hypersthenic gastritis or of paroxysmal 
 hyperchylia gastrica. 
 
 If continuous secretion does not exist, the retention of food 
 and digestive products may be due to myasthenia, to obstruc- 
 tion, or to secondary disease (inflammation, cancerous degen- 
 eration, atrophy) of the muscular layer. Consequently, the 
 myasthenic retention must be distinguished from obstructive 
 retention, from carcinomatous retention, and from the motor 
 insufficiency which complicates and results, very infrequently, 
 from chronic gastritis. 
 
 Myasthenic retention is comparatively rare ; obstructive 
 retention is frequent. A history of ulcer, or of toxic gastritis, 
 or of gall-stones is in favor of obstruction. A history of 
 myasthenic stagnation, or of an acute or chronic exhausting 
 disease, and the coexistence of phthisis are in favor of myas- 
 thenic retention. The presence of a pyloric tumor removes all 
 doubt of the cause of the retention. 
 
 The evolution of myasthenia is ordinarily slow, the symp- 
 toms are comparatively mild in character, and the quantity of 
 food retained is proportionate to the duration of the disease 
 of the stomach. Obstructive retention may develop rapidly, 
 is ordinarily a very painful disease, and the quantity of food 
 retained is proportionate to the degree and not to the age of 
 the obstruction. 
 
 If there is gastroptosis, the retention may be obstructive or 
 myasthenic. If the retention is due to traction on the duo- 
 denum, support of the stomach by an abdominal belt and rest 
 in the horizontal position during digestion will relieve the 
 retention. Displacement of the stomach is much more fre- 
 quent in pyloric obstruction (neoplasms) than it is in myas- 
 thenia. In pyloric obstruction the displacement of the 
 stomach begins with the pyloric end, and the fundus of the 
 stomach, as a rule, does not descend. In gastroptosis the 
 whole stomach descends in the abdomen, and the lesser curva- 
 ture and the upper border of the fundus are displaced down-
 
 372 DISEASES OF THE STOMACH. 
 
 ward in proportion to the gastroptosis. The obstructed 
 stomach retains its general form, which is lost in myasthenia. 
 
 The obstructed stomach is enlarged and hypertrophied ; 
 reflex peristalsis and contraction are strong and are easily 
 excited ; expression of its contents presents no difficulty, but 
 it is very hard to remove all the coarse particles of food from 
 the stomach by lavage. In myasthenic retention the stomach 
 may be large or small; its wall is thin and flabby; reflex peri- 
 stalsis can not be excited and is never visible ; contraction is 
 weak ; expression of its contents is so difficult that siphonage 
 or suction must usually be employed to obtain the contents 
 for analysis ; and after prolonged lavage it is hardly possible 
 to get the stomach clean and empty. 
 
 In myasthenic retention there are no peristaltic pains and 
 no cramps, and vomiting is infrequent (overflow), copious, 
 liquid, and incomplete. In obstructive retention, peristaltic 
 pains and cramps are ordinarily severe, vomiting may be fre- 
 quent, retching, and complete, and the vomit is thick and 
 contains plenty of coarse food, and sometimes blood, nuclei 
 of white corpuscles, much mucus, and possibly pieces of a 
 tumor or of the inflamed mucous membrane may be found in 
 the vomit, in the expressed contents, or in the wash-water. 
 
 In myasthenic retention the empty stomach does not re- 
 tract, and emaciation is usually not rapid nor very great so 
 long as the stomach can furnish the system with the required 
 quantity of water. In obstruction the empty stomach retracts, 
 and emaciation may develop very rapidly. The enlarged, 
 hypertrophied, and obstructed stomach may not completely 
 retract when it is empty, and the administration of half a 
 glass of water may make it possible to produce splashing over 
 a very small area. The splashing can not be produced when 
 the stomach is full, for it is then firmly contracted on its con- 
 tents, except during the short intervals of peristaltic repose. 
 In myasthenic retention the splashing sounds may be pro- 
 duced at all hours, day ami night, and. as the rule, after most 
 painstaking efforts to empty the stomach completely with the 
 tube. 
 
 The evolution of the digestion of the test-breakfast is dif- 
 ferent in the two forms of retention. The test-breakfast 
 should be preceded by thorough lavage, and the stomach 
 should be left as nearly empty as possible. In myasthenia 
 the first two stages of digestion may be prolonged or free 
 HCl mav appear earlier than in health, but the quantity of 
 combined HCl gradually accumulates, and at the end of two 
 hours the stomach contains about as much, and sometimes
 
 MYASTHENIA GASTRIC A. 373 
 
 more, fluid than was taken with the test-meal. Some of the 
 contents are evacuated, but the slowly evacuated fluid is 
 replaced by secretion during the first two hours. In obstruc- 
 tion the first two stages of digestion may be nearly normal, 
 but free HCl is excessive usually after the first hour, and at 
 the end of two hours the stomach contains a thick mixture of 
 coarse and fine particles of bread, and usually an excessive 
 quantity of physiological hydrochloric acid (H -f C). Ob- 
 structive retention is a retention preeminently of solids, and 
 myasthenic retention is a retention preeminently of liquids. 
 Consequently, if two glasses of water are given on an empty 
 stomach in myasthenic retention, the greater part of the water 
 will still be in the stomach after the lapse of two hours, but 
 in obstructive retention the stomach will be empty. For the 
 same reason, in obstructive retention there is much coarse 
 food in the early morning contents, but in myasthenic reten- 
 tion there is some food and a comparatively large quantity of 
 fluid. In myasthenic retention a moderately dry diet is best 
 borne ; in obstructive retention the diet should be fluid. 
 
 In myasthenic retention physical and mental fatigue in- 
 crease the motor insufficiency but have no effect on obstruc- 
 tive retention. Myasthenic retention may be relieved by 
 favoring and toning the stomach muscle. Obstructive reten- 
 tion is persistent without surgical intervention. 
 
 The differentiation of myasthenic retention from retention 
 due to carcinoma and to advanced chronic gastritis will pre- 
 sent no difficulty when the characteristic signs and symptoms 
 of these disorders are kept in memory. The persistent 
 functional, bacteriological, and anatomical signs of carcinoma 
 and of the terminal period of chronic gastritis exclude readily 
 the retention due to myasthenia ; but chronic gastritis and 
 myasthenic retention (complicated) may terminate, like carci- 
 noma, in the complete destruction of the functions of the 
 stomach. 
 
 Prognosis. — The prognosis of myasthenia with retention 
 varies according to the duration, the degree, and the compli- 
 cations. If the retention is not great, and general nutri- 
 tion can be maintained by the establishment of digestive 
 compensation by the intestines, the chances for a complete 
 cure are favorable. In many cases it is only possible to 
 convert the retention into the stagnation form of the disease 
 and to maintain the body in a fair nutritive condition by 
 persistent and carefully regulated digestive hygiene. The 
 prospect is darker where gastritis coexists, particularly the 
 hypersthenic form. The prognosis is worse where the intes-
 
 374 DISEASES OF THE STOMACH. 
 
 tines are also diseased, for the insufficiency of the intestines 
 determines, to a large extent, the future. The quantity of urine 
 passed in twenty-four hours and the quantity of food retained 
 in the morning after the test-supper are also prognostic guides. 
 The situation is all the more serious where secondary diseases 
 exist, due to auto-intoxication, or where there is a serious 
 independent trouble. It is safe to give a guarded prognosis 
 in all cases, and watch the results of treatment for encouraging 
 signs. 
 
 Treatment. — The objects sought by treatment are : (i) The 
 improvement of the motor function ; (2) the prevention of 
 starvation; (3) the control of fermentation ; (4) the treatment 
 of the gross symptoms, of auto-intoxication, and of the com- 
 plications. 
 
 To increase the power and the efficiency of the muscular 
 layer, the same remedies which are valuable in the treatment 
 of myasthenia with stagnation may be used, including mas- 
 sage, electricity, hydrotherapy, strjxhnin, quinin, and ergot. 
 Massage should not be used to evacuate the stomach until the 
 excessive fermentation is under control, and it may then be 
 employed regularly four hours after the evening meal. The 
 proper time to employ electricity is after lavage, the cervico- 
 gastric.spinogastric.and von Ziemssen methods, with cathodal 
 excitation, low density, and strong currents, and with short 
 sittings, being preferred. Electric treatment may also be 
 given with advantage one or two hours after breakfast, the 
 action of the remedy on the secretion and on the movements of 
 the stomach being used to promote digestion and the evacu- 
 ation of the stomach. In addition to the uses of water 
 directed against the myasthenia, stomach washing must be 
 employed against the retention and the fermentation. Another 
 remedy, required by the thin and weak abdominal walls and 
 the overweighted stomach, is a snugly fitting abdominal ban- 
 dage, to give mechanical support. All constriction about the 
 waist should be removed. The mechanical support and the 
 removal of compression are valuable aids to the evacuation of 
 the stomach and the bowels. 
 
 One of the most difficult objects to attain is the nourishment 
 of the patient. To maintain the balance of nutrition all our 
 resources, if necessary, should be brought to bear; including 
 a proper diet, whose utilization is protected and aided, and 
 supplemented, when necessary, by rectal feeding. The reme- 
 dies which control fermentation and which aid the evacuation 
 of the stomach contribute to this end. 
 
 The diet of retention myasthenia should be nutritious, in
 
 MYASTHENIA GASTRIC A. 375 
 
 small bulk, resistant to fermentation, sufficient to support 
 nutrition, and capable of utilizationby the intestines. Digestive 
 compensation is dependent largely on the integrity of the 
 functions of the intestines, the retained gastric contents being 
 unabsorbed and serving only as food for the large quantity of 
 germs. 
 
 Sweets should be excluded, and fat (only in the form of 
 fresh butter) should be given in moderation. Oil rubbings 
 may be employed to furnish part of the fat required to support 
 nutrition. Meats, fish, and the whites of eggs form the staple 
 articles of diet, and should be given freed from all indigestible 
 matter and finely divided. The meat jellies, resisting fermen- 
 tation and filling a deficiency created by the sweets, are very 
 valuable. Rice and the preparations of wheat are the best 
 cereals, and dry toasted bread may be allowed. Dry meat 
 powder and " somatose " are very concentrated foods, and 
 where too little food is eaten they may be introduced into the 
 stomach through the tube at the end of the morning lavage. 
 Fruits of all kinds should be excluded, and cases are hardly 
 known where milk agrees. A glass of water should be allowed 
 with each meal, and a little old whisky or brandy may be 
 permitted if the disease is not so far advanced that gastric 
 absorption is reduced to zero. Alcohol is absorbed by the 
 normal stomach, and promotes also the absorption of other 
 food products. 
 
 As a rule, it is best to furnish only three, or at most four, 
 meals a day. The frequent administration of small quantities 
 of food robs the stomach of the possibility of repose, and is a 
 good way to make sure of gradual gastric retention. But in 
 a few cases the stomach is capable of evacuating small quan- 
 tities of fluid food, and retention may be avoided by giving 
 the nourishment frequently and in small quantities. This power 
 and peculiarity of the stomach is more often met with in the 
 beginning of myasthenic retention, and where the stomach is 
 not sensibly enlarged. All the food should be given in a state 
 of fine division, so as to favor its evacuation by the stomach 
 and its utilization by the intestines, and to facilitate thorough 
 lavage. 
 
 Since its recommendation by Kussmaul, stomach washing 
 has become a classical remedy in gastric retention. The 
 technic of the procedure has already been described. In the 
 treatment of myasthenic retention the most favorable time 
 for its employment is in the early morning before any food 
 has been taken. This is usually sufficient to control the fer- 
 mentation ; it protects the intestines, removes but little food
 
 376 DISEASES OF THE STOMACH. 
 
 that is likely to prove of nutritive value, and the stomach 
 begins the work of the day fresh and clean. The contents of 
 the stomach should be expressed and the stomach should be 
 thoroughly washed out with warm boiled water, to which an 
 alkali or one of the many antiseptics recommended may be 
 added. The following are the antifermentative solutions most 
 often used : Salicylic acid (i : 1000), boracic acid (i : 100), 
 borax (five per cent.), benzoate or salicylate of sodium (one per 
 cent.), permanganate of potash (i : looo). After thoroughly 
 washing out the stomach with warm boiled water, a pint 
 of a borosalicylic solution (acid boracic, oj ; acid salicylic, 
 grs. XX ; aq., Oj) should be allowed to flow in, be brought 
 thoroughly in contact with the mucous membrane by lower- 
 ing and raising the funnel several times, and should then be 
 allowed to flow out. This is a very efficient solution. The 
 stomach should be left empty. In a few cases, in order to 
 secure sleep, to give a long rest to the stomach, and to control 
 obstinate fermentation, it is necessary to perform lavage in 
 the evening — as late as possible after the evening meal. The 
 stomach may be washed out thoroughly (the contents being 
 previously e.xpressed) with a warm alkaline solution, and 5ss 
 each of salicylate and bicarbonate of soda, dissolved in a few 
 ounces of water, may be left in the stomach during the night. 
 This alkaline antifermentative solution readily destroys yeast 
 and sarcinne. On the following morning the intragastric 
 douche ma\' be employed, using then, also, the borosalicylic 
 solution. The excessive fermentation will soon be controlled 
 by this method, a daily morning lavage being thereafter suffi- 
 cient to check the germ growth. Rarely, it may be neces- 
 sary to combine with the lavage functional repose of the 
 stomach and rectal feeding for a few da\'s. 
 
 With some authors the administration of antifermentative 
 drugs is in great favor. Of these drugs the following may 
 be mentioned, and given without much hope of benefiting the 
 patient: Resorcin resublimat. (Merck's), grs. iij to v; bismuth 
 salicylate, grs. v ; salol, grs. x ; beta-naphthol, grs. iij ; sodium 
 salicylate, grs. v ; salicin, grs. x ; creosote, gtt. iij ; sodium 
 benzoate, grs. v ; ichthyol, gr. j ; aq. chloroformi, ^ss. These 
 drugs may be prescribed in the above doses, three times a 
 day after meals, in various combinations. 
 
 The treatment of myasthenic retention by the systematic 
 use of these remedies often gives relief, and may produce a 
 complete cure. But the result is not always so satisfactory, 
 and, even at the price of their continued daily employment, 
 the patient may be insufficiently nourished and unrelieved of
 
 MYASTHENIA GASTRICA. 377 
 
 his sufferings. As a last resource, the aid of a surgeon may 
 be invoked. 
 
 The operation of Bircher is yet in its infancy, but where 
 the motor power is not completely destroyed it would seem 
 to be worthy of further experimentation. The object of the 
 operation is the diminution of the size of the stomach, the 
 elevation of the greater curvature by infolding the anterior 
 wall in the line of the long axis of the stomach, and the union 
 of the peritoneal edges of the infolded part along the lesser 
 curvature. From this line of union hangs the anterior wall, 
 the stomach being unopened by the operation. Prof Weir 
 also employed the same method to reduce the size of a 
 " dilated" stomach in a patient suffering from retention, some 
 time after the performance of gastro-enterostomy, making 
 several folds in the direction of the long axis of the stomach. 
 The preferable operation is gastro-enterostomy.
 
 SECTION V. 
 THE ANATOMICAL DISEASES OF THE STOMACH. 
 
 CH AFTER 1. 
 GASTRITIS. 
 
 Inflammation of the internal glandular lining membrane 
 of the stomach may be acute or chronic. 
 
 ACUTE GASTRITIS. 
 
 Acute gastritis presents three distinct clinical and patho- 
 logical forms, each possessing a characteristic genesis and evo- 
 lution, and demanding special treatment. These three forms 
 of acute gastritis are : (i) Simple gastritis ; (2) mycotic gas- 
 tritis ; (3) toxic gastritis. 
 
 Acute simple gastritis is an afebrile inflammation of the 
 mucous membrane of the stomach excited by neither micro- 
 organisms nor poisons. A gastritis excited by germs develop- 
 ing in the cavity of the stomach or in its walls is mycotic. 
 Toxic gastritis is an inflammation of the internal layer of the 
 stomach, excited by the accidental or intentional administra- 
 tion of a poison. Many of these poisons are included among 
 the articles of the materia medica. 
 
 I. ACUTE SIMPLE GASTRITIS. 
 
 Acute simple gastritis is a very frequent disease ; it may 
 be very mild and transient, and may pass away after a few 
 meals have been digested with difficulty and discomfort; or it 
 may be expressed by signs of greater irritation, such as nausea, 
 vomiting, and depression. It is often described as indigestion 
 or as acute gastric catarrh. 
 
 Etiology. — Two factors play a more or less important part 
 in its causation : bad alimentation and a diminished resistance 
 
 378
 
 GASTRITIS. 379 
 
 to disturbing influences on the part of the organ. One or 
 both of these morbific causes may be active, the inflam- 
 mation being the result of excessive irritation or of a morbid 
 sensibiHty of the mucous membrane to even normal excita- 
 tion. 
 
 The soil may be prepared for the development of the disease 
 in many ways, all of which act through a derangement of one 
 or more of the physiological factors of digestion. The influ- 
 ence of heredity has been frequently asserted without con- 
 clusive reasons ; common family dietetic faults constitute a 
 stronger predisposition. " I inherit my bad stomach, and my 
 family as far back as I can go has been dyspeptic." There 
 may be some consolation in posing as the victim of uncon- 
 trollable circumstances, but a man's stomach, as regards its 
 primary diseases, is what he has made it. We readily admit, 
 however, the inheritance, and also the influence of the catarrhal 
 and the uric acid diatheses. Exposure to excessive heat or 
 cold during the period of digestion, mental or physical fatigue, 
 intense moral anxiety or depression, etc., may render the 
 stomach relatively incapable, and may create the morbid op- 
 portunity. 
 
 The inflammation may often be attributed to very palpable 
 errors of diet — the food and drinks, on account of their quan- 
 tity or quality, or their delayed evacuation, producing exces- 
 sive stimulation. The disease begins frequently after a rela- 
 tively rich and rapidly eaten meal. The chemical irritants 
 may be proper to the food or drinks, or may be developed in 
 the uneaten food by fermentation, or added by the cook with 
 an excessive desire to please the palate. Or the excitant may 
 be thermal, the food or drinks being too hot or too cold. The 
 most common cause is the irritant quality of the diet — 
 mechanical, chemical, and thermal. Alcohol may often be 
 incriminated, and cold beer seldom fails to produce the disease. 
 Many articles of the materia medica in therapeutic doses are 
 capable of producing the inflammation — arsenic, the iodids, 
 the bromids in strong solution, salines, and excessive quanti- 
 ties of common salt. 
 
 Pathological Anatomy. — Acute simple gastritis not being 
 a fatal disease, an opportunity to study its pathological an- 
 atomy is very rare. The inflammation is superficial, and the 
 signs are soon effaced by postmortem changes. The circula- 
 tion phenomena may be very different after death from those 
 present during life, and nothingmay be left except ecchymoses 
 to recall the intense, active hyperemia. But observations 
 through a gastric fistula, experiments on animals, and a few
 
 380 DISEASES OF THE STOMACH. 
 
 cases examined soon after death due to intercurrent accidents, 
 enable us to describe the morbid anatomy. 
 
 The lining membrane is covered with a layer of tough 
 mucus, which may be here and there tinged a rose color. 
 The mucous membrane is red in patches, studded here and 
 there with punctate superficial hemorrhages, and swollen. 
 Beaumont described small vesicles, separated by patches of 
 deep congestion, in the stomach of Ale.xis St. Martin during 
 an attack of acute gastritis. These appearances are most pro- 
 nounced in the region of the pylorus, and spread to a variable 
 extent over the internal surface. The surface cells are swollen 
 and distended with mucus, desquamated, and mixed with leu- 
 kocytes in the mucus covering the surface. The chief cells 
 are granular, stain deeply, are often shriveled, and may be 
 seen lying free in the lumen of the glands, which may be 
 filled with degenerate granular matter and a fluid resembling 
 mucus. The border cells appear unchanged. The capillaries 
 are enlarged and distended, and there is small-cell infiltration, 
 particularly along the venous radicles, and extending even into 
 the submucosa. After the acute inflammation has lasted a 
 few days, the infiltration of the interglandular spaces with 
 small lymphoid or embryonic cells may be greater ; and the 
 infiltration may be diffuse, or it may be limited to the super- 
 ficial or to the deeper parts of the mucous membrane ; or it 
 may occur in small, sharply limited nodules, very rich in small 
 cells ; or in larger patches which are gradually lost in the 
 adjacent healthy parts. These infiltrating embryonic cells 
 stain lightly, and contain a very large nucleus. Mi.xed with 
 these small cells is a large or small number of wandering 
 leukocytes, accordingly as the inflammation is more or less 
 intense. The endothelium of the lymphatics may be cloudy, 
 swollen, and undergoing desquamation. It is more than 
 probable that the histological changes may be confined to the 
 surface cells in very mild cases, and the exudation and the 
 desquamation may be accompanied simply by active hyper- 
 emia. In some cases the inflammation may be almost exclu- 
 sively parenchymatous, when the most marked lesion is 
 degeneration of the chief cells. In other cases the inflam- 
 mation may be interstitial and characterized by infiltration 
 with embryonic cells and leukocytes. Rarely, the inflamma- 
 tion may be diffuse. 
 
 Clinical Description. — The disease begins during the period 
 of digestion, without chill, pain, or fever. The patient feels 
 dull, uncomfortable, weak, and indisposed to work. The 
 stomach is heavy and full, the respiration shallow, and the
 
 GASTRITIS. 381 
 
 pulse may be large and compressible or small and slightly 
 increased in frequency. There is slight nausea, often a dull 
 frontal headache ; and there may be ringing in the ears, or 
 vertigo, increased by movement or by the upright position. 
 The face is pale, the expression haggard, and the extremities 
 cold. The stomach may empty its contents into the intestines, 
 and these symptoms subside ; or the nausea may increase and 
 lead to vomiting, which the patient may instinctively excite. 
 During the period of digestive rest there is physical and men- 
 tal depression, the appetite is lost, and there may be disgust 
 for the usual food, and the patient may long for sour or spicy 
 articles. The mouth is sticky, and the large white tongue 
 possesses a brownish, thick coating of mucus, bacteria, and 
 epithelium over its base, while the reddened edges bear the 
 imprint of the teeth. The sleep is broken, the bowels con- 
 stipated, or there may be one or two diarrheal movements 
 containing mucus and producing burning and tenesmus. 
 The urine is small in quantity and deposits urates on stand- 
 ing. The trouble may subside in a few days under the influ- 
 ence of rest and a small quantity of non-irritating food ; or 
 the disease, under improper treatment, may become compli- 
 cated with gastric fermentation and be transformed into my- 
 cotic gastritis ; or the subjective digestive symptoms may 
 recur with diminishing intensity until recovery is complete. 
 
 Throughout the course of the disease there is no gastric 
 pain, but diffuse tenderness, and no fever, except a slight pos- 
 sible increase of temperature over the stomach during the 
 period of digestion. But children may show a rise of about 
 one degree in the general temperature. 
 
 The vomit is copious and consists of undigested food, par- 
 ticularly meat, mixed with mucus; it may contain no free 
 HCl, and it may be neutral or alkaline in reaction, or slightly 
 acid on account of the hardly noticeable fermentation. The 
 organic acid is usually butyric. Or the vomit may be exces- 
 sively acid (H + C), and contain bile and mucus stained with 
 fresh blood. The special secretion of the stomach may be 
 suppressed on account of the congestion and the degeneration 
 of the chief cells. The excessive secretion of mucus and the 
 inflammatory exudation diminish the quantity of free HCl, 
 if any is secreted. Or secretion may be active as an expres- 
 sion of the irritation, the inflammation being then probably 
 superficial or interstitial. 
 
 Diagnosis. — The beginning during the period of digestion, 
 the short duration without fever or noteworthy pain, the 
 subsidence of the symptoms after the evacuation of the
 
 382 DISEASES OE THE STOMACH. 
 
 Stomach or the digestive tube, and the characteristics of the 
 vomit, — leave little doubt as to the nature of the disease. 
 
 Treatment. — The treatment of simple acute gastritis is 
 best conducted without the use of drugs. 
 
 If the patient is seen before the stomach has been emptied 
 by vomiting, a glass of water at 90° F. may be administered 
 and vomiting excited by the finger in the pharynx. It is 
 seldom necessary or advisable to use an emetic or lavage. 
 The stomach, once empty, is left completely at rest for several 
 hours, a little barley water, lemonade, or egg water, being 
 used to quench thirst. 
 
 For twenty-four to thirty-six hours the stomach should be 
 given functional rest. At the end of this time a little thor- 
 oughly cooked cereal, or meat juice, or preparation of milk 
 may be ordered; then the more digestible finely-divided 
 meats, a little dry toast or cracker, or crust of roll. At the 
 end of two or three days the patient can be given an ordinary 
 mixed diet composed of the foods which have little physio- 
 logical action on the stomach. To the cereals and meats, 
 butter, vegetables, and, last of all, sweets, may be added in 
 relation to the rapidity of recovery and the return of the 
 functional power of the stomach, which, after the first day or 
 two, may be improved by small doses of strychnin or of nux 
 vomica. 
 
 Recovery may be hastened and the nausea controlled by 
 the cold compress, applied according to the method of Win- 
 ternitz. 
 
 The constipation should be relieved by an enema of warm 
 water, to which a teaspoonful of glycerin may be added. If 
 the irritant has passed into the intestines, a dose of calomel 
 may be given with benefit. The evacuation of the stomach, 
 the compress, the functional rest, the protection of the stomach 
 against irritation, and the relief of the constipation by injec- 
 tions are the remedies most conducive to rapid and complete 
 recovery. 
 
 II. MYCOTIC GASTRITIS. 
 
 Mycotic gastritis may exist in three forms. In one the 
 characteristic sign is acute gastric fermentation, the result of 
 which is an inflammation of the mucous membrane. Acute 
 gastritis may also be produced by eating food which has 
 undergone putrefaction. The attacks begin like acute poison- 
 ing, with headache, vertigo, nausea, vomiting, dyspnea, col- 
 lapse, delirium, and with other symptoms which vary according
 
 GASTRITIS. 383 
 
 to the dose and the nature of the putrefaction poisons. But 
 these cases are not cases of gastric putrefaction, which never 
 occurs except as a result of gastric retention. Putrefaction 
 poisons may produce, however, no inflammation of the mucous 
 membrane of the stomach, acting in this respect like alkaloid 
 poisons. These cases of acute food poisoning are not pro- 
 duced by acute gastric putrefaction, and do not constitute a 
 distinct clinical form of gastritis, like the inflammation excited 
 by acute gastric fermentation. Gastritis may also be excited 
 by bacteriological products brought to the stomach by the 
 blood. The stomach may eliminate the poison, and the 
 anatomical changes may begin on the surface, as in simple 
 acute gastritis ; or the lesions may develop from the capil- 
 laries and involve secondarily the tissues fed by them. Fur- 
 thermore, mycotic gastritis may be caused, not by germs 
 developing in the contents of the stomach nor by bacterial 
 products brought to it by the blood, but by bacteria which 
 invade and inflame its proper tissues. This latter form is 
 infectious. Consequently the two varieties of primary acute 
 mycotic gastritis are : {a) The fermentation form ; and (^) the 
 infectious forms. 
 
 In regard to the fermentation form, it may be contended 
 that the fermentation is the distinctive and predominant 
 characteristic, and that the trouble should be properly named 
 " acute gastric fermentation." The force of this contention may 
 be readily admitted; but the fermentation is the expression 
 of the conditions which permit it — a mere sign. In the 
 genesis of the gastritis it forms the connecting link, and may 
 serve to define it. The morbid evolution has passed into 
 the anatomical stage which is accurately described by acute 
 cfastritis due to fermentation. 
 
 (A) The Fermentation form of Mycotic Gastritis. 
 
 Etiology. — Gastritis due to fermentation is more frequent in 
 infancy, on account of the peculiar and exclusive alimentation, 
 than at any other period of life. The two extremes of life 
 agree in this respect — that both are more liable to the disease 
 than is the middle period. In old age the stomach has been 
 made slow in action and incapable, or in the course of nature 
 has grown to be so. 
 
 Thus we have the two conditions of the active fermentation 
 in the stomach which is the exciting cause and the distinctive 
 characteristic of the gastritis — a diet forming a good culture 
 soil richly infested with germs, and stagnation due to acute
 
 384 DISEASES OF THE STOMACH. 
 
 motor insufficiency of the stomach. The disease is most fre- 
 quent in summer, when the germs of fermentation are most 
 plentiful and virulent, digestion torpid, and the stomach often 
 overloaded with drinks. 
 
 Pathological Anatomy. — The anatomical changes do not 
 differ materially from those of acute simple gastritis, but may 
 be more intense and diff"use, in keeping with their production 
 by irritants in solution. Consequently the surface cylindrical 
 epithelium degenerates and desquamates to a greater extent 
 than in simple acute gastritis, while the changes in the glands 
 and in the interglandular tissue are variable. 
 
 Clinical Description. — This form of acute mycotic gastritis 
 maybe febrile or afebrile. Where the disease runs its course 
 without fever it may present two clinical types — a mild and 
 a severe form. 
 
 The mild form may begin suddenly during the night or 
 may be preceded for a day or two by slight headache, belch- 
 ing, and regurgitation of a fluid which is sometimes without 
 pronounced taste, is sometimes sour, and sometimes has an 
 odor of acetic or butyric acid. These premonitory symptoms 
 occur during the period of digestion, and are made worse by 
 fermentable food. Then comes the attack, which usually 
 occurs at night or three or four hours after the chief meal. 
 The stomach is distended, contains an excess of gas, is tender 
 on pressure, but in the mild form there is rarely distinct pain. 
 Nausea is common, with frontal headache, which may be 
 severe, and no relief is obtained until the stomach is evacuated. 
 The vomit is like that of simple gastritis plus fermentation, 
 and is more fluid on account of the more active secretion. 
 The symptoms may subside with the vomiting or the intes- 
 tines may have received a portion of the fermenting chyme to 
 eliminate by a few diarrheal movements. Convalescence may 
 be complete in four or five days under proper treatment, or 
 may be prolonged by a persistence of the conditions which 
 led up to the attack. 
 
 In the severe form the local symptoms are more intense 
 and the constitutional symptoms are more pronounced. But 
 the severe form is not simply the mild form magnified. In 
 addition to the fermentation and the gastritis excited by it, 
 there is also auto-into.xication, and the intestines and the liver 
 become secondarily involved. 
 
 The severe form may be preceded by the mild form, or 
 may develop as a sequel of acute simple gastritis, or, more fre- 
 quently, suddenly, during the digestive period, with premon- 
 itory symptoms. There is commonly a slight chill, with little
 
 GASTRITIS. 385 
 
 or no fever, intense headache, nausea, dull or severe pain, and 
 epigastric tenderness proportionate to pressure. These symp- 
 toms are increased by additional food or drinks. The stomach 
 is distended, the respiration shallow, the pulse small and fre- 
 quent, and often hard, and the patient is agitated, anxious, and 
 prostrated. The appetite is completely lost ; thirst is often 
 intense. The vomit consists of food, of secretion, of exuda- 
 tion, and of the products of fermentation. The attack is not 
 cut short by vomiting, but the gastric symptoms are tempo- 
 rarily relieved. The vomiting may be frequently repeated, 
 and may be accompanied by severe and painful retching and 
 slight capillary hemorrhage. The stomach evacuates part of 
 its contents into the duodenum, and intestinal irritation and 
 fermentation are added, leading to several large fermenting 
 stools, which may smell musty. The liver is enlarged and 
 congested, the spleen is normal in size, and the slight icterus, 
 which is not rare, is probably the result of the duodenitis 
 extending into or obstructing the common duct, or producing 
 spasm of its sphincter. The severe form may last a few days 
 or one or two weeks, in keeping with the extent and the 
 intensity of the excited inflammation ; or it becomes not 
 infrequently subacute and chronic. 
 
 The disease begins with active fermentation in the stomach, 
 producing irritation and gastritis, and, extending to the in- 
 testines, becomes associated with intestinal irritation or with 
 enteritis. 
 
 Diagnosis. — The diagnosis of the fermentation form of my- 
 cotic gastritis is dependent on the grouping of the subjective 
 and the objective signs as detailed in the clinical history, and 
 on the detection in the gastric contents of the signs of acute 
 inflammation and of active fermentation. In addition to the 
 chemical and the microscopical examination of the vomit, the 
 fermentation tube test should be made. 
 
 The differential diagnosis may present some difficulties ; 
 and simple acute gastritis, and the gastric crises announcing 
 the commencement, or occurring in the course of other dis- 
 eases, may be confounded with it. But active gastric fermen- 
 tation developing proportionately with the evolution of the 
 symptoms is a definitive sign. 
 
 Prognosis. — The prognosis of the mild form is good. 
 The severe form may do lasting injury, and leave chronic 
 gastritis or enteritis as a legacy. In very old or weak patients 
 and in advanced diseases of other organs the prostration 
 may be fatal. It is not the disease itself, but the disease 
 aided by its associations, which kills. 
 25
 
 386 DISEASES OF THE STOMACH. 
 
 Treatment. — The indications as to the plan of treatment 
 are three: (i) Control the fermentation; (2) reHeve the 
 gross symptoms ; (3) treat tlie lesion. 
 
 To control the fermentation it is absolutely necessary that 
 the stomach shall be completely emptied. This may be 
 imperfectly done by vomiting and by copious drafts of 
 warm water — the vomiting being excited by the disease or 
 artificially. But where it can be used, stomach washing is 
 certainly the most efficient method of cleansing the stomach. 
 In the severe form the. intestines are also infected, and there 
 may be auto-intoxication. A dose of Epsom salts, or of the 
 effervescing citrate of magnesia, will remove both these com- 
 plications. Afterward, the large bowel should be washed out. 
 The digestive tube being clean, there may be given to quiet 
 the irritation a large dose of bismuth (j^ to I dram), with 
 which maybe combined an anodyne — the deodorized tincture 
 of opium or the phosphate of codein. The stomach should 
 be kept free from food, which would serve as a germ culture 
 soil, for from twelve to twenty-four hours. 
 
 To relieve the gross symptoms — the nausea and vomiting, 
 pain and prostration — much will already have been done by 
 cleansing the digestive tube and by the administration of the 
 bismuth and the opiate. But pain may require the earlier 
 hypodermic administration of morphin, and, if the prostration 
 be v^ery great, camphorated oil (i gr. in 10 minims of oil of 
 sweet almonds) or strychnin should be given hypodermi- 
 cally. After the copious vomiting, dry champagne may be 
 ordered with benefit. 
 
 The treatment of the lesion consists in the use of the same 
 remedies as in acute simple gastritis — functional rest and 
 favoring of the stomach, rest in bed, the compress, and the 
 administration of strychnin as the reparative process ad- 
 vances. 
 
 (B) INFECTIOUS FORMS. 
 
 Acute gastritis may be produced by pathogenic germs 
 which grow on the surface of the mucosa, or which develop 
 in the structures that compose the gastric wall. Growths 
 of favus, of thrush, and of the larvae of insects on the mu- 
 cous membrane of the stomach are curiosities of medicine. 
 Trichinosis and actinomycosis may affect the stomach. Acute 
 gastritis, with sometimes pseudomembranous formation, may 
 occur in scarlatina, variola, typhus, pyemia, and septicemia. 
 The bacillus of anthrax, the streptococcus erysipelatosus, and 
 the bacillus of influenza may produce their peculiar tissue
 
 GASTRITIS. 387 
 
 alterations in the gastric mucosa. Diphtheric gastritis is very- 
 infrequent, and is always secondary to diphtheria of the 
 upper air-passages. But only two forms of infectious gastritis 
 are of practical interest : purulent gastritis and gastric fever. 
 
 (l) PURULENT GASTRITIS. 
 
 Gastritis accompanied by diffuse or circumscribed suppura- 
 tion, due to the invasion of the gastric wall by the pus- 
 forming bacteria, is a rare disease. In going through the 
 literature of the subject, only 65 well-authenticated cases 
 have been found. 
 
 Etiology. — The disease is due to the development within 
 the gastric wall of the pus-forming bacteria. The majority of 
 the cases have occurred as secondary infections — in pyemia, 
 puerperal fever, gastric ulcer, gastric carcinoma, purulent 
 meningitis, variola, and scarlatina. In other cases ordinary 
 lesions of the stomach, such as traumatism and gastritis, have 
 afforded the opportunity for bacterial invasion. About 
 five-sixths of the reported cases occurred in men. 
 
 Pathological Anatomy — The pathological anatomy is that 
 of purulent cellulitis, the pus being diffused or collected in 
 the submucosa, particularly about the pylorus. The process 
 extends along the lymphatics and the blood-vessels to the 
 peritoneum and to the mucous membrane. The gastric wall 
 is swollen four or five times thicker than normal, and is infil- 
 trated with inflammatory products. The pus may be diffused, 
 or may be collected in a single abscess, or in multiple ab- 
 scesses. As a rule, there is only one abscess, which may vary 
 in size, and is usually situated near the pylorus. The involved 
 peritoneum may be covered with a thick, fibrinous false 
 membrane, or adhesions may be formed with adjacent parts, 
 or the peritoneum may be but slightly or not at all inflamed. 
 The mucous membrane may be but little changed, or may be 
 intensely red, hemorrhagic, ulcerated, or perforated by many 
 small openings, extending through the interglandular con- 
 nective tissue down to the pus-infiltrated submucosa. On 
 pressure, pus oozes through these openings as from a satu- 
 rated sponge. The mucous membrane may be deprived of 
 its blood supply, and the slough, falling away, may leave large 
 or small ulcers. The interglandular tissue is infiltrated with 
 embryonic cells and wandering leukocytes. There may be, 
 rarely, thrombosis of the gastric, hepatic, and pulmonary 
 veins. The muscular layer may be but little involved, but 
 the connective tissue is infiltrated with pus, the bundles of
 
 388 DISEASES OF THE STOMACH. 
 
 fibers are separated, and the muscular fiber is degenerated or 
 disintegrated. The abscess may open into tlie stomach, or 
 the peritoneal cavity, or the pleural cavity; or may burrow 
 through adhesions into adjacent organs. 
 
 Clinical Description. — The disease usually begins suddenly, 
 with a se\ere chill, though in some of the cases there have 
 been, for two or three days preceding the commencement, 
 symptoms of digestive disorder or symptoms of the primary 
 disease of which the purulent gastritis is a secondary infec- 
 tion. The chill is accompanied by high fever, which is usu- 
 ally remittent, ranging from 102° to 105° F. ; and the rigor 
 may be several times repeated during the evolution of the 
 disease. There are great prostration and extremely severe 
 epigastric pains, which may not be increased by pressure; and 
 the stomach may be retracted in the commencement, but soon 
 relaxes, and is distended with gas. There is nausea, repeated 
 vomiting, pinched countenance, prostration, and the symptom- 
 group may suggest acute poisoning. Sooner or later peri- 
 tonitis develops and adds its local and general signs to those 
 given by the intense cellulitis. The peritonitis may remain 
 localized or may become general, and in the pyemic cases 
 the pericardium and the pleura may also be affected. The 
 brutal beginning is sometimes followed by a short period of 
 calm, after which the symptoms become continuous or remit- 
 tent, and usually subside again before the fatal termination in 
 collapse or in coma. Vomiting may not appear until the second 
 day; it becomes frequent, and finally diminishing in frequency, 
 subsides during the calm preceding death. The vomit con- 
 sists of undigested food, mucus, inflammatory products, blood, 
 and bile, but little or no pus, except toward the end, when 
 the abscess may have opened into the stomach. The bowels 
 may be obstinately constipated, but diarrhea is more common. 
 Where circumscribed, the abscess may present a palpable 
 tumor, which is usually tender on pressure. In the circum- 
 scribed form the pain and fever may subside for a few days 
 when the tumor appears, to be followed a few days later by 
 hectic fever and the signs of peritonitis or of perforation into 
 the stomach or into some other cavity. 
 
 The general symptoms are even more intense than the local 
 signs — extreme prostration, anxious and pinched countenance, 
 frequent, small, irregular pulse, delirium with suicidal im- 
 pulses. Tetany may also develop. 
 
 The duration of the disease varies from three or four days 
 to as many weeks. Where the suppuration is circumscribed, 
 the local and the general symptoms are less intense, the fever
 
 GASTRITIS. 389 
 
 becomes ultimately hectic, and the duration is much longer 
 than in the violent, rapid, and diffuse form. The average 
 duration is about one week. 
 
 The disease ends fatally in 95 per cent, of the cases. That 
 complete recovery is possible has been demonstrated by 
 anatomical preparations (Dittrich, Deininger). 
 
 Diagnosis. — The disease has no characteristic sign ; the 
 evolution and the combination of symptoms are not distinc- 
 tive. The diagnoses of intestinal obstruction, of peritonitis, 
 of abscess formation in other parts of the abdomen, have been 
 made. Epigastric resistance to palpation or a tumor which 
 becomes less and disappears after the vomiting of pus may 
 be supposed to be characteristic ; but this combination of 
 signs is rare, and might be due to an abscess which had bur- 
 rowed and opened into the stomach. Corrosive poisoning is 
 easily excluded by the absence of the distinctive effects of 
 such poisons on the mouth and throat. 
 
 The development of the symptoms in the course of one of 
 the infectious diseases which it sometimes complicates may 
 create a suspicion. It may be confounded with acute pan- 
 creatitis or pancreatic abscess, with perigastritis developing 
 in the course of perforating ulcer of the stomach, with hep- 
 atic abscess, and with purulent cholelithiasis. 
 
 Treatment. — The treatment is purely symptomatic so far 
 as the medical management is concerned. Where the disease 
 is suspected and attributable to pus formation and to local 
 peritonitis, an exploratory laparotomy is indicated. Surgical 
 treatment might be successful where the pus is collected in 
 abscesses, and a tumor, developing with the symptoms of 
 acute purulent inflammation, should be explored with a 
 needle, with a view to operative intervention. 
 
 The disease usually goes undiagnosed before death, and 
 the treatment has been that of the disease for which it was 
 mistaken. Functional rest, opium to relieve pain, control of 
 the excessive fever, stimulants — summarize the symptomatic 
 treatment. Some recommend quinin. 
 
 (2) GASTRIC FEVER. 
 The existence of this form of infectious gastritis is denied 
 by some authors, who do not admit that the disease is specific, 
 but contend that the cases reported as such are either food 
 intoxications, severe forms of common gastritis, or abortive 
 attacks of well-known infectious diseases, such as typhoid 
 fever and cholera.
 
 39© DISEASES OF THE STOMACH. 
 
 While the specific nature of the disease avvaits.the discovery 
 of its pathogenic germ, clinically the gastritis is neither simple, 
 nor fermentative, nor toxic; but in its patholog\- and evolution 
 is distinct, and analogous to the bacterial infections. It occurs 
 in persons who have already been affected with typhoid fever, 
 from which it is clinically clearly distinct. The fever is con- 
 tinuous, the spleen is not palpable, and the course is unin- 
 fluenced by quinin, the administration of which increases 
 the gastric symptoms — which is not the case where the Plas- 
 modium malariae exists in the blood. It bears a close resem- 
 blance to the gastric form of influenza, but in our experience 
 usually occurs isolated in families and is not contagious. The 
 disease is more frequent in spring and in autumn, and occurs 
 more often in the middle period of life than in infancy, child- 
 hood, and old age. It occurs isolated, and endemics have 
 been reported. 
 
 Clinical Description. — The beginning is like that of most 
 infectious diseases of mild type — general discomfort, a slight 
 chill, fever, headache, and pains in the extremities, in the 
 back, and in the epigastrium. The general precede the gastric 
 symptoms, and develop independently and out of proportion 
 to the gastritis. Several hours after the commencement there 
 are pains in the stomach, epigastric tenderness, nausea, and 
 vomiting. The vomit consists of an alkaline fluid containing 
 mucus, and, incidentally, sometimes bile and undigested food. 
 The bile is usually absent, except after retching, and the de- 
 velopment of the gastric symptoms is in no relation with the 
 diet or with the period of digestion, and there is no gastric 
 fermentation. 
 
 The fever attains its highest point within forty-eight hours, 
 and oscillates between ioo° and 103° F., with a morning remis- 
 sion of about 1° F. ; it continues, uncontrolled by quinin, for 
 ten or twelve days, and drops, with a greater morning remis- 
 sion, in two or three days to the normal point. 
 
 In addition to the initial chill, slight rigors may occur in 
 the course of the disease. The bowels may be constipated, 
 but there are usually a few diarrheal movements, which have 
 none of the characteristics of the typhoid stool. The pulse 
 is rapid, the patient restless, and delirium may occur in the 
 course of the disease. Insomnia is the rule. The nervous 
 symptoms, apart from the often severe initial pains, continue 
 more or less throughout the disease — headache, restlessness, 
 insomnia, vertigo, tinnitus aurium, prostration, and, with the 
 high temperature, sometimes delirium. 
 
 Diagnosis. — This form of infectious gastritis may be con-
 
 GASTRITIS. 391 
 
 founded with typhoid fever. But the step-like rise of the 
 temperature during the first week, and its slow remittent de- 
 cline during the third or fourth week, the enlarged spleen, 
 the characteristic stool, the ileocecal stagnation and gurgling, 
 the Widal serum sign, and the eruption are all absent. A 
 few bronchial rales may exist, as in typhoid fever ; but the 
 gastritis is an essential and distinctive sign, and the spleen is 
 never palpable. 
 
 From the fermentation form of gastritis and the severe 
 form of simple acute gastritis it differs in the absence of fer- 
 mentation and of a relation with alimentation and digestion, 
 and in the predominance of the general symptoms. In gastric 
 fever the disturbance of the system is much greater than the 
 disease of the stomach would naturally produce, and the gen- 
 eral and the local symptoms bear no close relation to each 
 other. The evolution of the disease, which is in itself dis- 
 tinctively characteristic, is not controlled by treatment. 
 
 Treatment. — The treatment is that of an infectious disease 
 the course of which can not be abridged by drugs. Tepid 
 sponging, the compress, and a fluid diet are indicated to con- 
 trol the fever and the gastric symptoms. Calomel may be 
 given in the beginning, and often exercises a good influence 
 on the symptoms and the temperature. The nervous symp- 
 toms may require phenacetin, but it is best not to disturb the 
 stomach with drues oftener than can be avoided. 
 
 III. ACUTE TOXIC GASTRITIS. 
 
 Acute toxic gastritis is an inflammation of the mucous 
 membrane of the stomach excited by the action of certain 
 poisons introduced into the stomach from without. 
 
 The poisons which produce an injurious effect on the 
 stomach may be formed within the body or may be intro- 
 duced from without. The endogenous poisons are brought to 
 the stomach by the blood. We have nothing to do here with 
 the diseases of the stomach (among which may be gastritis) 
 due to the retention or the excessive formation of normal 
 nutritive or secretory products, or due to the abnormal sub- 
 stances formed by disease or by bacteria within the body. 
 
 Acute toxic gastritis may be produced by alcohol, by 
 tobacco, and by many of the drugs extensively used in the 
 treatment of disease. The essential oils and resins, the 
 iodids, the preparations of mercury, the bromids, the salicy- 
 lates, arsenic, purgatives, iron and its compounds, and a large
 
 392 DISEASES OF THE STOMACH. 
 
 number of other drugs, when given improperly, or for a long 
 time, produce gastritis. But it would not be wise to say more 
 of the serious injury which is often done while conscientiously 
 endeavoring to do good. Acute toxic gastritis is, however, 
 often produced by poisons which have been taken by acci- 
 dent or for suicidal purposes, or which have been adminis- 
 tered with forethought and malice. Some of the most common 
 forms of it will be briefly described. 
 
 All poisons are not capable of exciting an acute gastritis. 
 As regards their action on the stomach, poisons may be 
 divided into three classes. 
 
 1. Those which enter into chemical combination with the 
 tissues, either dissolving the cells, as do the caustic alkalies, 
 or coagulating the protoplasm, as does alcohol, or uniting 
 with their constituents, as do phosphorus and the mineral 
 acids. These are chemically destructive poisons. 
 
 2. Those which irritate and excite inflammation of the 
 glandular layer. 
 
 3. Those which produce no anatomical change in the 
 mucous membrane perceptible during life or visible after 
 death. This class consequently plays no part in the etiology 
 of toxic gastritis. 
 
 (a) Poisonous Acids. — The stronger acids brought in con- 
 tact with the mucous membrane of the stomach directly, 
 produce death of the tissues by dehydrating, coagulating, or 
 combining with the constituents of the cells, for which they 
 have strong chemical affinities ; and by irritation of the adja- 
 cent parts they excite inflammation, which may be so intense 
 as to lead to local death. The separation of the necrosed 
 tissues is a reactive process, which may be followed by cica- 
 tricial healing, or by regeneration, if the action has been 
 superficial. 
 
 Pathological Anatomy. — The stomach is the center of the 
 destructive changes produced by swallowing corrosive acids, 
 being the place where they are first arrested, and where they 
 long remain. The action on the .stomach is conditioned by 
 the quality, the concentration, and the chemical affinities of 
 the acid, and by the quantity and the nature of the contents 
 of the stomach at the time when the poison is swallowed. In 
 small quantities the action is most intense and may be con- 
 fined to the region about the cardia and the lesser curvature, 
 along which the acid flows to and around the pylorus. Con- 
 sequently a very small quantity, after recovery by cicatriza- 
 tion, is likely to leave serious and obstructive deformity of 
 the orifices. In larger quantity, the action is more difl"used
 
 GASTRITIS. 393 
 
 and general, but is deepest along lines marked by the tops of 
 the folds into which the mucous membrane is thrown by the 
 strong contortions of the stomach. The depth of the direct 
 destruction varies according to the quantity, the nature, and 
 the duration of the action of the poisons. The coagulation 
 necrosis may extend rapidly through the entire thickness of 
 the wall, may undergo dissolution, and thus produce perfora- 
 tion. The coagulation of the blood may extend far into the 
 veins, reaching the liver, the right heart, and the lungs. Such 
 direct and extensive destruction and coagulation are rapidly 
 fatal. Where the violence is less brutal, the direct chemical 
 necrosis is more superficial, and the reactive inflammation may 
 separate the slough, and, with granulation formation, accom- 
 panied by free suppuration and by bacterial infection, may 
 ultimately end with a cicatrix which may inclose the remains 
 of glands. Or the inflammation, intense and hemorrhagic, 
 may end in local death and an extension of the loss of sub- 
 stance. The necrosis may be superficial, but may occur in 
 patches; and recovery may leave a deformed stomach, with 
 preservation of more or less of its glandular structure. 
 
 Clinical Description. — The symptoms are due to the local 
 action of the poison on the tissues with which it comes in 
 contact, to the diminished alkalinity of the blood, and to the 
 toxic nephritis. 
 
 The local symptoms develop immediately, and are ex- 
 tremely violent. The pain is burning and horrible in the 
 mouth, throat, the beginning of the esophagus, at the point 
 where it passes the left bronchus, immediately above the 
 cardia, and in the stomach. The stomach is in tonic spasm, 
 and the excruciating pain radiates over the abdomen. The 
 patient writhes in agony, the pulse is small and weak, and 
 the body covered with a cold perspiration. A brownish 
 saliva flows from the mouth, and intense dyspnea may be 
 present if some of the acid has entered the larynx or if there 
 is a rapidly developed edema of the glottis. Saliva, which 
 may be colored with altered blood, flows from the mouth; 
 and vomiting, aided by unquenchable thirst, dysphagia, in- 
 testinal pain, mucous and bloody diarrhea, and tenesmus, adds 
 to the miseries of the patient, who sinks rapidly into collapse, 
 and dies within from two to twenty-four hours. 
 
 The local symptoms may be less violent, and the patient 
 may live long enough for the blood and renal symptoms to 
 develop. If the stomach is not already empty, the vomiting 
 may be delayed. The vomit consists of the contents and 
 mucus, colored with hematin, and of the acid swallowed.
 
 394 DISEASES OF THE STOMACH. 
 
 The urine, which is passed with pain, contains serum albumin 
 and globulin, hematin, and casts. 
 
 The diminished alkalinity of the blood may add to the 
 nervous symptoms. If a large dose of an acid be given to a 
 herbivorous animal, it falls at once into a stupor, and dies 
 before the blood becomes acid. Carnivorous animals and 
 man have a greater power of neutralization ; but the dimin- 
 ished alkalinity of the blood will produce somnolence, stupor, 
 or coma, in proportion to its degree. 
 
 The symptoms due to the renal lesion are those of acute 
 parenchymatous nephritis with intense irritation, but no 
 edema develops. 
 
 The subsequent course is marked by the combined local, 
 nervous, and renal symptoms. The temperature, subnormal 
 in the beginning, rises a few degrees. The dangers do not 
 end with recovery, for the deformities which result from 
 cicatrization may compromise e.xistence. 
 
 Diagnosis. — The sudden beginning, and the violence of the 
 symptoms in the midst of health, would suggest poisoning. 
 But the patient may already have been ill before the acid 
 was swallowed. The excessive acidity of the vomit would 
 create suspicion. The diagnosis of corrosive poisoning 
 will be given by inspection of the mouth, and the color of 
 the necrosed spots may suggest the particular acid. The 
 SN'mptom-group, and the examination of the urine and the 
 vomit, reveal the particular acid to which the gastritis and its 
 treatment stand in direct relation. 
 
 In sulphuric-acid poisoning the local action is very de- 
 structive, and grayish-brown eschars are found, which e.xtend 
 deep into the tissues, the surface being hard and parchment- 
 like ; the toxic nephritis is likewise intense, and the duodenum 
 and the small intestine may be inflamed and ulcerated in spots. 
 The cicatrices are large, and the prognosis must be guarded. 
 Even after resolution the strictures offer little hope of relief 
 by surgical operations. The fatal dose, on an empty stomach, 
 is about five grams. Perforation is frequent. 
 
 Nitric acid produces lesions similar to those produced by 
 sulphuric acid, but perforation is less frequent, and the eschars 
 are brown on account of the formation of xanthoproteinic 
 acid. The fatal dose is six to eight grams. 
 
 Hydrochloric acid produces a grayish eschar on the mu- 
 cous membrane and no cauterization in the corners of the 
 mouth, or but rarely. The eschar may be yellowish, like that 
 of nitric acid. The toxic nephritis is rare, and strictures are 
 not so frequent with hydrochloric and nitric as with sul-
 
 GASTRITIS. 395 
 
 phuric acid. But the nervous symptoms are more promi- 
 nent, and death may occur in collapse, in convulsions, or in 
 coma before vomiting sets in. Perforation is very rare. 
 Lavage is permissible. 
 
 Chromic acid and its salts are very destructive caustics, and 
 the toxic dose is very small — less than ^ of a grain. The color 
 of the eschar on the skin and the mucous membrane is yel- 
 lowish-white, becoming grayish-brown, and the vomit, which 
 is rapidly produced, is colored yellowish-red or, by oxidation, 
 may be green. It produces severe abdominal pain, diarrhea, 
 cramps, collapse, cyanosis, and death ; or the patient may 
 recover after showing yellow sclerotics, toxic nephritis, and 
 anuria. The temperature may rise and the uremia may be 
 the cause of death. The nephritis often becomes chronic. 
 The alkalies neutralize the chromic acid, but form poisonous 
 salts. Acetate of iron is the best antidote. The stomach 
 may be washed out with a -^-^j per cent, solution of nitrate of 
 silver, as the silver chromate is insoluble. The intestines are 
 more involved than in other acid poisonings, and with the 
 gastritis is associated enteritis, often with large ulcers, par- 
 ticularly in the colon. 
 
 Acetic acid may also produce gastritis, and is of special 
 interest on account of its wide-spread use as a condiment and 
 its production in the stomach by fermentation. Concentrated, 
 it is as destructive as the strong mineral acids, and produces 
 a white eschar, cicatricial deformities, and, in large doses, 
 nephritis. It is oxidized and eliminated as carbonates, ren- 
 dering the urine neutral or alkaline. Like tartaric and lactic 
 acids, long continued in small doses, it produces chronic 
 gastritis. 
 
 Oxalic acid produces a whitish eschar, surrounded by a 
 zone of intense inflammation, which separates with difficulty. 
 The vomit is seldom colored, and there is no hemorrhage. 
 This acid has been found in the stomach as a bacterial 
 product. It produces, in addition to the local symptoms, 
 violent convulsions and rapid death, through its action on 
 the nervous system. It excites also toxic nephritis, anuria, 
 colitis, and enteritis, with punctate hemorrhages and ulcer- 
 ation. 
 
 Formic acid excites, locally, an intense inflammation, and 
 in sufficient concentration is also a caustic. It is an oxidation 
 product of gastric fermentation, and consequently is of double 
 interest to the practitioner. It excites nephritis, and is a 
 selective poison for the kidneys unless oxidized into car- 
 bonic acid before elimination.
 
 396 DISEASES OF THE STOMACH. 
 
 Treatment. — The immediate treatment consists in the 
 administration of the chemical antidote. This is not the 
 same for all acids. Magnesia usta is the best antidote 
 for the mineral acids, but other alkalies may also be used. 
 The carbonates of the alkalies should be avoided, on 
 account of the danger, in severe cases, of rupture of the 
 necrosed stomach. But delay is dangerous, and may be 
 fatal, and whatever is at hand should be given — as soup, milk, 
 white of &^g, chalk, scraping from plaster walls, or soap. 
 
 The aftertreatment consists in the employment of remedies 
 to cure the local inflammations and to control the symp- 
 toms. The nourishment and water may have to be given 
 exclusively per rectum. Food given by the mouth should be 
 fluid and non-stimulating, as milk or cereal gruels. Opium 
 may have to be freely used, and healing of the ulcers may 
 be favored by large doses of bismuth. The collapse may 
 be treated with camphorated oil and strychnin, and the coma 
 by increasing the alkalinity of the blood by free hypoder- 
 mic or intravenous injections of sodium carbonate. 
 
 {b) Caustic Alkalies. — The caustic alkalies, like the caustic 
 acids, produce local death and reactive inflammation. The 
 acids coagulate the protoplasm, and form dry, hard, parch- 
 ment-like eschars, sharply limited beneath ; the alkalies 
 liquefy the protoplasm, and extend very deep into the tissues, 
 and the eschar is softer and like false membrane. The mus- 
 cular tissue is rapidly disintegrated; the connective tissue is 
 but little affected; and the nerves, except the end plates, are 
 left chemically intact, to undergo degeneration. They do 
 not act, like the acids, on the kidne\'S and the blood ; the vomit 
 is alkaline; the urine, neutral or slightly alkaline ; and the re- 
 active inflammation is more diffuse. Cicatricial deformity is 
 a legacy of both forms of poisoning. The treatment consists 
 in the neutralization of the alkali by vinegar or by tartaric 
 acid, and in the employment of medication to relieve the 
 local inflammation and the complications and to control the 
 symptoms. 
 
 The symptoms are intense pain, vomiting, collapse, death 
 in convulsions, or from a terminal perforation peritonitis; or, 
 if the acute stage is safely passed, the symptoms are those of 
 the intense reactive inflammation. The vomit is brownish from 
 altered blood, intensely alkaline, tough, and ropy. Ammonia 
 is, in contradistinction to caustic potash and soda, a respira- 
 tory stimulant, and may produce a toxic nephritis. 
 
 The inspection of the mouth, the symptom-group, and 
 the properties of the vomit give the diagnosis.
 
 GASTRITIS. 397 
 
 [c] Metallic Poisons. — Arsenic, phosphorus, and antimony 
 do not belong to the caustic poisons. The gastritis excited 
 by them is not in itself characteristic, but all of them lead to 
 fatty degeneration of the parenchyma of the various organs 
 of the body, including the glands of the stomach. Arsenic 
 may produce an intense hemorrhagic gastritis, with the forma- 
 tion of ulcers; phosphorus may excite little inflammation; 
 antimony may cause more intense irritation than arsenic, 
 the epithelium being destroyed or raised here and there in 
 numerous vesicles and pustules. 
 
 The gastric symptoms of phosphorus-poisoning are usually 
 delayed several hours, unless the stomach contains fat in some 
 form, and may be very slight. After six or eight hours there 
 may be nausea and vomiting ; the vomit is seldom bloody, and 
 contains phosphorus. During the first week the liver en- 
 larges, the spleen remaining normal in size. With the fatty 
 degeneration of the liver icterus also appears, and sometimes 
 fever. During this stage death may occur suddenly from 
 cholemia. A sequel, should recovery take place, is more or 
 less complete gastric atrophy. 
 
 Arsenical poisoning is accompanied by more pronounced 
 symptoms, beginning, after an interval of an hour or two, 
 with burning in the mouth, vomiting, and cholera-like stools, 
 cramps in the extremities, and collapse. The vomit is not 
 colored with blood, but contains the poison. If the patient 
 survive the initial stage, nervous symptoms may appear — 
 paralysis of the sympathetic or neuritis. Anuria may result 
 from a toxic nephritis. Recovery is likely to leave perma- 
 nent effects, from the action of the poison on the abdominal 
 sympathetic and from gastro-intestinal atrophy. 
 
 Antimony leaves its trace in the inflammation and vesicles 
 of the mouth, but its gastro-intestinal symptoms are very 
 much like those of arsenic. Influence upon the nervous 
 system, like that exercised by arsenic, is not found in anti- 
 monial poisoning. 
 
 The diagnosis is dependent on the symptom-group, and on 
 the detection of the poison in the vomit, the stools, or the 
 urine. 
 
 Treatment. — The indication in the treatment of phosphorus- 
 poisoning is to remove the phosphorus before its absorption 
 takes place. The only means of doing this thoroughly is with 
 the stomach-tube. The stomach should be thoroughly washed 
 out with warm water; then with a one per cent, solution of 
 sulphate of copper, followed by the introduction of magnesia 
 usta. The stomach is further washed out with water, and a
 
 398 DISEASES OF THE STOMACH. 
 
 full dose of Epsom salts is left therein. After the action of 
 the saline, the colon should be thoroughly washed out. In 
 this manner the poison is removed from the digestive tube. 
 Fats must be carefully excluded from the diet. The after- 
 treatment is that of the symptoms and the complications. 
 
 Arsenical poisoning is treated also by immediate lavage, to 
 which calcined magnesia is added. The usual antidote (the 
 freshly magnesia-precipitated subsulphate of iron) is then 
 introduced and left in the stomach. The same .precaution 
 should be taken to evacuate the whole bowel with a clyster 
 to which glycerin may be added, and followed by lavage of 
 the colon. The aftertreatmcnt is that of the gastro-enteritis, 
 the gross symptoms, and the complications. 
 
 The treatment of antimonial poisoning is conducted on the 
 same principles. The lavage water should contain about 
 one per cent, of tannin. The evacuation of the intestines 
 should also receive attention, and the gastro-enteritis should 
 be treated in the usual manner. 
 
 CHRONIC GASTRITIS. 
 
 The anatomical and clinical conceptions of chronic inflam- 
 mation of the mucous membrane of the stomach are widely 
 different. If all the cases are to be classified as chronic gas- 
 tritis in which marked anatomical changes (which assume the 
 characteristics of chronic inflammation) are found at the 
 autopsy, then this is unquestionably the most frequent of all 
 the diseases of the stomach. Chronic gastritis is the almost 
 constant accompaniment of the last stages of all chronic dis- 
 eases. This terminal gastritis should be placed among the 
 vicious circles of the stomach, along with all cases secondary 
 to a disease of another organ than the stomach, and present- 
 ing anatomical or clinical peculiarities. 
 
 Gastritis is often a complication of a chronic disease of the 
 stomach; and neither ulcer, nor carcinoma, nor pronounced 
 myasthenia, nor obstructive retention, completes its evolution 
 without the development of gastritis. The clinical conception 
 excludes this complicating gastritis. But ulcer, carcinoma, 
 obstructive retention, and motor insufficiency may appear in 
 the course of chronic gastritis, and only a knowledge of the 
 development of the particular case could enable us to decide 
 which is the primary and which is the complicating disease. 
 Many of the diseases of the stomach are links in the evolu- 
 tion of one process.
 
 GASTRITIS. 399 
 
 Chronic gastritis, as a distinct clinical disease, is a chronic 
 inflammation of the glandular coat of the stomach, not devel- 
 oping in the course or as a consequence of any other chronic 
 disease of the stomach. Before the clinical disease can be 
 established, the characteristic symptoms, the evolution, and 
 the objective signs must be demonstrated, and a chronic 
 associated and causal disease must be excluded. Some 
 authors also exclude from the clinical conception of this 
 disease all cases accompanied by a persistent, excessive, 
 specific secretion. A well-marked clinical form of chronic 
 gastritis (hypersthenic form) is classified and described among 
 the " neuroses " in nearly all the text-books. This is an error. 
 
 Etiology. — Chronic gastritis is most frequent in the middle 
 period of life. It is no less common in old age, but is then 
 more often latent. 
 
 If it be remembered how many morbific influences have a 
 special afifinity for this organ, it will be no wonder that path- 
 ologists so rarely find a healthy stomach after the beginning 
 of adult life. Chronic gastritis frequently follows the acute 
 disease. All the infectious fevers and inflammations affect 
 the stomach, and often produce anatomical changes in the 
 mucous membrane. There exists no serious disease of an 
 important organ of the body, or of nutrition, that may not 
 in itself be the efficient or predisposing cause of gastritis. It 
 may become a complication of another anatomical disease of 
 the stomach, or may develop as a consequence of the chronic 
 dynamic affections. But if all these causes were inactive, 
 chronic gastritis would not be a rare disease, on account of 
 the irritants which are introduced into the stomach or which 
 develop in it. All the causes of acute gastritis, acting with 
 moderate violence during a long period, — the products offer- 
 mentation, coarse food, excess of condiments, abuse of alcoholic 
 drinks, prolonged use of the bitter aromatic drinks, swallow- 
 ing saliva impregnated with nicotin or tobacco juice, abuse 
 of purgatives and irritating drugs, — are so many directly act- 
 ing causes of the chronic disease. 
 
 Pathological Anatomy — The pathological anatomy of 
 chronic gastritis is extremely complex and variable. There 
 is no constant relation between the cause and the morbid 
 anatomy. During the initial period, it is true, the inflamma- 
 tory lesions due to the irritation of the contents are more 
 pronounced in the superficial part of the mucous membrane, 
 whereas those excited by blood or by circulation changes 
 are most marked in the interglandular tissue and in the sub- 
 mucosa. But the evolution of the pathological anatomy soon
 
 400 
 
 DISEASES OF THE STOMACH. 
 
 conceals any relation that may have at one time existed with 
 the natural mode of action of the exciting cause. The fol- 
 lowing diagram shows clearly and at a glance this conception 
 of the evolution of chronic gastritis. 
 
 Every case of chronic gastritis displays the common signs 
 of this form of inflammation — disordered circulation, small 
 round-cell infiltration, cell proliferation, and cell-degeneration. 
 Hemorrhagic erosion and superficial ulceration may be asso- 
 ciated with any of the forms. The ulcers may be few or innu- 
 
 Fig. 19. — The evolution of chronic gastritis. 
 
 merable, and vary in size from a pin-head to a small hand. 
 The grayish-brown, thickened mucous membrane may be 
 marked by fine ramifications of dilated blood-vessels. But the 
 inflammatory changes may predominate in particular compo- 
 nents of the mucous membrane, and thus produce correspond- 
 ing pathological forms. Three anatomical varieties of the 
 disease might be described — the catarrhal, the glandular, and 
 the interstitial. Any one of these varieties may terminate in 
 atrophy of the gastric glands.
 
 GASTRITIS. 401 
 
 But this anatomical classification does not represent the 
 clinical forms of the disease, for interstitial gastritis has no 
 characteristic clinical expression and no characteristic func- 
 tional signs. The diagram which illustrates the evolution of 
 gastritis makes clear the fact that interstitial gastritis may 
 produce catarrhal gastritis, or it may produce proliferating 
 glandular gastritis, or, finally, it may terminate in anadenia 
 gastrica as a result of granular or mucoid degeneration of the 
 chief cells of the gastric glands. Moreover, interstitial gas- 
 tritis nearly always accompanies both chronic gastric catarrh 
 and glandular gastritis. Interstitial gastritis will, conse- 
 quently, not be described as a distinct clinical form. 
 
 It requires no very great ingenuity to multiply the ana- 
 tomical forms of chronic gastritis, for the primary forms do 
 not preserve their identity throughout their development. 
 The characteristics of one stage lose their predominance at a 
 further stage of the evolution of the disease. Nature mixes 
 the anatomical forms at various stages, and produces numerous 
 varieties. Furthermore, the gastritis does not develop with 
 equal rapidity over the whole surface of the mucous mem- 
 brane, nor is it of the same character everywhere. It 
 becomes necessary, therefore, to introduce some general 
 characteristic which displays the predominant condition of 
 the whole mucous membrane. The predominant condition of 
 the mucous membrane is displayed by the functional signs 
 and by the clinical expression. 
 
 In a large group of cases the special secretion of the 
 stomach is constantly diminished. The contents of the test- 
 breakfast contain less hydrochloric acid (H + C) and less 
 ferments than normal. Mucus is secreted in excess. There 
 is no spasm of the pylorus, and the stomach empties itself in 
 a normal manner. The appetite is diminished or lost. Pain 
 is rare. There may be nausea, and after meals the stomach 
 feels overloaded. The signs and symptoms are those of de- 
 pression. The manifestations are not violent. There is no 
 show of strength, but everything is dull and weak. The 
 special acid- and ferment-secreting cells are inactive and de- 
 generate, and there may be active connective-tissue produc- 
 tion. Only the cylindrical cells are irritable and secrete a 
 large excess of mucus. The gastritis is catarrhal in its be- 
 ginning and evolution, and the dynamic expression is 
 asthenic. 
 
 Another group of cases are violent in their manifestations. 
 All the signs are those of great irritabilit)^ General gastric 
 sensation is acute, and the appetite, when not dulled by pain, 
 26
 
 402 DISEASES OF THE STOMACH. 
 
 is sharp. Secretion is excessive — excess of acids and fer- 
 ments and a more than normal quantity of mucus. Tlie 
 pylorus may be closed by spasm, and there may be gastric 
 cramps. The inflammation is glandular and productive in its 
 predominance and evolution. The dynamic expression is 
 hypersthenic. 
 
 A third group of cases is characterized b\' a special 
 causation and by a peculiar evolution. The clinical expres- 
 sion is, unlike that of the two other groups, sometimes latent, 
 sometimes violent. The mucous membrane is exceedingly 
 vulnerable, and gastric secretion progressively diminishes 
 until it almost disappears. The process is atrophic, and the 
 glands and the cylindrical surface cells disappear, and leave a 
 layer composed of connective tissues infiltrated with em- 
 bryonic cells and leukcoytes. 
 
 We recognize, therefore, three distinct clinical and ana- 
 tomical forms of chronic gastritis — viz : (i) Gastritis catarrh- 
 alis chronica, or chronic asthenic gastritis ; (2) gastritis 
 glandularis proliferans, or chronic hypersthenic gastritis; (3) 
 gastritis glandularis atrophicans, or progressive atrophy of 
 the cfastric crlands. 
 
 I. GASTRITIS CATARRHALIS CHRONICA, OR CHRONIC 
 ASTHENIC GASTRITIS. 
 
 Pathological Anatomy. — The mucous membrane, in chronic 
 asthenic gastritis, is covered with a thick layer of tough 
 mucus mixed with a large number of cells, which are in part 
 desquamated cylindrical cells, in part wandering leukocytes, 
 and in part blood-corpuscles. The color may be reddish- 
 brown, or gray, or darkly pigmented. The coloration of the 
 pyloric region is usually diffuse, while that of the rest of the 
 mucous membrane is mottled. The coloration is due to more 
 or less altered blood pigment and cells mi.xed with mucus. The 
 mucous membrane is swollen, and the swelling is the result 
 of edema, of infiltration of the connective tissue, and of en- 
 larged, obstructed glands. The round-cell infiltration of the 
 connective tissue may be limited to the superficial or mucous 
 division of the mucosa ; or to the interglandular and the sub- 
 glandular connective tissue; or it ma\- extend to the sub- 
 mucosa and to the muscular layer. The infiltration and 
 swelling is most intense in the pyloric region, and may 
 diminish the size of the pyloric opening. In old cases the 
 mucous membrane may become mammellated, and the prom-
 
 GASTRITIS. 
 
 403 
 
 inences may resemble polypi. The surface may be studded 
 with little vesicles on the villosities, or there may be hemor- 
 rhagic erosions, catarrhal ulcers, or very small ulcers with 
 the opening of a gland in the center. 
 
 The microscopic appearance of a transverse section of the 
 mucous membrane is very interesting. On account of the in- 
 filtration of the interglandular connective tissue only about 
 one-half the number of ducts appear in the field, as can be 
 seen in a cut of the normal mucous membrane made parallel 
 to the surface through the mucous layer of the mucosa. The 
 
 ■'• ,*V; 
 
 
 Fig. 20. — Gastritis clironica catarrhalis. X 240. (Authors' specimen.) 
 
 connective tissue is infiltrated with small, round, nucleated 
 embryonic cells, and, although the intensity of the infiltration 
 varies, and may be diffuse or in patches, it always becomes 
 less and less as the eye goes from the surface to the sub- 
 mucosa. Mixed with the embryonic cells are wandering 
 leukocytes and hyaline bodies. The hyaline bodies are the 
 granules of disintegrated leukocytes. Many of the leuko- 
 cytes possess oxyphile granules, and they wander between 
 the cylindrical cells to the surface, or into the mucous 
 division of the ducts of the glands. Some of them worm
 
 404 
 
 DISEASES OF THE STOMACH. 
 
 their way directly through the cylindrical cells, and may 
 be recognized therein by their form, by their structure, and 
 by their affinities for stains. The cylindrical cells, which 
 cover the villosities and line the ducts of the glands down to 
 the necks of the tubules, desquamate, reproduce rapidly, 
 become striated along their free ends, and degenerate into 
 beaker cells. The border cells are very few, which is in keep- 
 ing with the functional inactivity of the glands. The nuclei 
 and the cytoplasm of the young cells stain deeply, and are 
 readily distinguishable from the older and paler cells. The 
 
 »'^**^ .^ 
 
 
 ■'S 
 
 
 
 Fig. 21.— Gastritis chronica catairhalis et iiilerslitialis. X 115. (.\iitliors' specimen.) 
 
 nuclei of some of the cylindrical cells may be seen in the 
 process of nuclear division, and the division may be asym- 
 metrical or typical. Three or four such cells may be seen in 
 the duct of a gland and here and there along the surface of 
 the mucous membrane. Beaker cells are not found in health, 
 but are common in gastric catarrh. The gastric glands may 
 be elongated and dilated as a result of obstruction of their 
 ducts by swollen and desquamated cylindrical cells. The 
 chief cells may undergo mucoid degeneration and vacuola- 
 tion. The degenerated chief cells may be replaced by cylin-
 
 GASTRITIS. 405 
 
 drical cells, the regeneration proceeding from the cells lining 
 the necks of the glands, which are thus changed from peptic 
 into mucous glands. Catarrhal gastritis, in its evolution, be- 
 comes a mixed gastritis, and may terminate in anadenia gas- 
 trica. The excessive secretion of mucus and the diminished 
 secretion of acid and ferments are the natural consequences 
 of the anatomical lesions — viz., the irritable hyperplasia and 
 excessive activity of the cylindrical cells, the degeneration 
 and reversion, respectively, of the cylindrical cells into beaker 
 cells and into striated (ciliated) columnar cells, the infiltration 
 of the mucous division of the mucosa, and, to a lesser degree, 
 of the interglandular and subglandular connective tissue. 
 The chief cells may remain normal or degenerate, and the 
 border cells are very few in number, in keeping with the 
 inactivity of glandular secretion. The peptic glands may be 
 converted into mucous glands, or they may disappear; the 
 glandular division of the mucosa being transformed into an 
 infiltrated layer containing, here and there, the remains of a 
 peptic gland, or invaded by the growth and elongation of the 
 portion of the duct which is normally lined with cylindrical 
 cells. Eventually the mucous division of the mucosa may 
 undergo atrophy. 
 
 Clinical Description. — The symptoms of chronic asthenic 
 gastritis are very variable. It may be latent for months, or 
 even throughout its anatomical evolution. In its simple form 
 it is a painless disease, and the gastric discomfort, fullness, or 
 weight are the only abnormal sensations of which the patient 
 complains. The other gastric symptoms are belching and 
 sometimes nausea and vomiting. The belching is not a re- 
 sult of gas formation in the stomach, but it is induced, re- 
 flexly or voluntarily, to relieve the sensation of fullness. The 
 appetite may be normal, but is more often diminished or 
 easily satisfied. Sometimes sour, spicy, and highly seasoned 
 dishes are preferred, and in a small number of the cases there 
 is disgust for meat. The other symptoms commonly ascribed 
 to chronic asthenic gastritis are due to complications. 
 
 On awakening in the morning there may be nausea, and 
 a small quantity of mucus and bile and saliva may be vom- 
 ited. After the meals the stomach feels full and heavy, 
 and there may be nausea and, very seldom, vomiting. The 
 vomit is thick, ropy, contains no free, but possibly a little 
 combined, HCl, and unchanged food. The digestive discom- 
 fort is, with only a few exceptions, worse after meals of solid 
 food, liquids being well borne. There is often repeated 
 belching of swallowed air, bringing with it sometimes into
 
 406 DISEASES OF THE STOMACH. 
 
 the inoutli a little non-acid fluid. Throughout the day, and 
 particularly during the period of gastric digestion, the patient 
 feels vaguely uncomfortable, and indisposed to mental or 
 physical work. 
 
 The failure of digestive compensation occurs early among 
 the poor, on account of tli€ coarseness and the bad quality of 
 their food. The stomach, with its diminished acidity, or even 
 neutral or alkaline contents, is no longer a barrier against the 
 invasion of the intestines by germs. Those who obtain fresh 
 and nutritious food, and protect the intestines by cleanliness, 
 — pure food, pure drinks, sweet mouth and throat, — may live 
 a long period with nutrition perfectly preserved. Whenever 
 malnutrition exists in chronic asthenic gastritis, the cause 
 should be sought for in the alimentation or in the intes- 
 tines. 
 
 Many of the symptoms attributed to asthenic gastritis are 
 due to complicating intestinal trouble. Many of the so- 
 called gastric refle.x disorders of the heart and of the capil- 
 lary circulation have their origin in the intestines. The flatu- 
 lency, often so great as to force the patient to unloosen the 
 clothing, is in the intestines and not in the stomach, which is 
 pushed up and compressed by the distended transverse colon. 
 The belching of the swallowed air relieves the increased 
 abdominal tension, but the stomach is perfectly free from fer- 
 mentation and its products. 
 
 The course of chronic asthenic gastritis is very slow ; at 
 first intermittent, with periods of good health and comfort ; 
 it then becomes more continuous, and more rapidly progres- 
 sive as intestinal compensation fails. Malnutrition now 
 begins, the muscular layer becomes involved in the inflam- 
 mation or undergoes fatty degeneration, the mucosa has 
 been converted into an infiltrated layer without peptic glands, 
 and the atrophied, flabby stomach may be the seat of severe 
 lancinating pains. Often, however, these pains, which are 
 most common during the period of gastric repose, are located 
 in the colon, the stomach being sweet and empty. 
 
 Symptomatology. — The physical signs of chronic asthenic 
 or catarrhal'gastritis possess chiefly a negative value — no 
 tumor, no abnormal splashing, normal in size and position, 
 but usually sensitive to pressure. 
 
 The functional signs are very important in the diagnosis, 
 the prognosis, and the treatment of the disease. The secretion 
 is characterized first by diminution and then by disappearance 
 of the free and the combined HCl, by diminution and disap- 
 pearance of the ferments, and by persistent excess of mucus.
 
 GASTRITIS. 407 
 
 The terminal atrophy is never so complete as to give no se- 
 cretion ; but there is a small quantity of fluid containing 
 mucus, no acid, and no traces of the mother substances of the 
 ferments. After a test-breakfast, during the pre-atrophic 
 stage, less than the normal quantity of contents is obtained, 
 thick and ropy, and of high specific gravity; the bread is for 
 the most part unchanged ; occasionally the mucus is tinged 
 with blood. There is always less fluid in the contents than 
 normal, for secretion (except mucus) is less in quantity, and 
 the motor function is active. There are no organic acids, or 
 mere traces (except where butyric fermentation is active but 
 transient and accidental), no free HCl, and combined HCl may 
 also be completely absent, and the reaction of the contents 
 may be neutral, or even alkaline. The small quantity of HCl 
 secreted is combined with inorganic bases, or is neutralized 
 by the alkaline exudate from the blood-vessels. The acidu- 
 lated tube digestions show in the beginning diminution of the 
 pepsin, and the labferment and the labzymogen are also less 
 active than in the normal contents. The ferments, however, 
 may not be so deficient as we should expect from the very 
 small free hydrochloric acidity, and they show the destruction 
 or degeneration of the peptic glands with greater exactness 
 than does the acid secretion. There is no excessive or char- 
 acteristic germ growth, and the tube fermentation tests are 
 negative. After the test-meal of Germain See, less than the 
 normal quantity of contents is obtained, the food being but 
 slightly changed. There is no peptone, and the propeptones 
 and syntonin are present in very small quantity. The tests for 
 achroodextrin and for maltose are positive, ptyalin digestion 
 being active. The contents are thick, for there is less than 
 the normal quantity of fluid in the stomach. The secretory 
 signs display the pathological changes in the mucosa. The 
 excessive secretion of mucus is persistent. The free HCl 
 diminishes and disappears, and the diminution of combined 
 HCl becomes greater and finally disappears. The pepsin 
 diminishes in proportion to the total hydrochloric acid 
 (H + C). But before the chief cells are degenerate, the acid' 
 secretion — and with it the secretion of the ferments — may be 
 improved by soothing medication to control the secretion of 
 mucus and to relieve the subacute interstitial gastritis. The 
 improvement is in inverse proportion to the degeneration 
 and destruction of the peptic glands. But mucus is actively 
 secreted even after the peptic glands have been transformed 
 or destroyed. 
 
 The motor function is intact, the stomach emptying itself
 
 408 DISEASES OE THE STOMACH. 
 
 in the normal time. Expression is easy, unless the contents 
 are very coarse or thick; it is never difficult for the same 
 reason that it is difficult in myasthenia — viz., the unretracted, 
 flabby condition of the stomach. There is no serious dis- 
 ease of the stomach in which the germ growth is less tlian 
 in chronic asthenic gastritis. But butyric fermentation occurs 
 intermittently in a majority of the cases. In the morning, 
 fasting, the stomach is empty, or contains a small quantity of 
 mucus and saliva. The sediment of the morning contents 
 contains a large quantity of single and of exfoliated masses 
 of cylindrical cells and leukocytes, mixed with mucus. Ab- 
 sorption is diminished in proportion to the diminution of 
 secretion. The functional signs are constant and do not 
 rapidly change, either spontaneously or under the influence 
 of diet or remedies, except in the manner and for the reasons 
 already stated. 
 
 The urine presents no characteristic change, but the diges- 
 tive fall in acidity is less marked than in health, and the 
 acidity of the twenty-four hours' urine is high, and there is 
 often a deposit of urates and of uric acid. In the production 
 of these changes the intestines often play as important a 
 part as does the stomach. 
 
 Prognosis. — Chronic asthenic or catarrhal gastritis is a 
 serious disease which may be arrested by proper treatment, 
 and may be completely compensated by healthy intestines. 
 Consequently, the prognosis is dependent largely upon the 
 condition of the intestines and upon the ability of the patient 
 to obtain the proper food. It is always more serious in 
 malarial and warm regions, on account of the frequency of 
 hepatic and intestinal diseases. A perfect cure is possible 
 even after degeneration of the peptic glands has begun. 
 But the greater the proliferation of the cylindrical cells, the 
 greater the degeneration of the peptic cells, the greater 
 the number of beaker and of ciliated cells, the greater the 
 mucous transformation, the greater the diminution of the 
 total hydrochloric acid, of the ferments, and of the quantity of 
 secretion — ^just so much less will be the probability of the 
 restoration of normal secretion. The e.xamination of a piece 
 of the mucous membrane is an important aid alike in diag- 
 nosis and prognosis. But too much weight should not be 
 given to this kind of information, for the gastritis may not be 
 general, nor in the same stage in all parts of the stomach. 
 
 Asthenic gastritis may also be complicated by motor insuf- 
 ficiency, but this complication is rare and occurs late, when 
 the muscular layer becomes infiltrated. The terminal period,
 
 GASTRITIS. 409 
 
 with inanition and gastro-intestinal atrophy, is often accom- 
 panied by pernicious anemia. 
 
 Differential Diagnosis. — Chronic catarrhal or asthenic 
 gastritis is liable to be mistaken for adenasthenia gastrica, 
 neurasthenia gastrica, myasthenia gastrica, and carcinoma. 
 
 In a general manner the dynamic affections are excluded 
 by the gastric symptoms of asthenic gastritis being so closely 
 related to the digestive period and to the taking of food, and 
 being excited also by solid food, particularly meats, much 
 more than by fluids. In gastritis the symptoms are more 
 closely connected with the alimentation ; in the dynamic 
 afifections they are more intimately connected with the state 
 of the nervous system. In gastritis the functional signs are 
 constant : in the dynamic affections the functional signs may 
 be normal, or, if pathological, they may vary from day to day 
 under petty and seemingly inadequate influences. Gastritis 
 is most frequent after, and the dynamic affections before, the 
 thirtieth year. 
 
 In adenasthenia gastrica nausea and vomiting do not occur. 
 There may be diminution and even absence of HCl, but 
 there is no excess of mucus, nor active epithelial exfoliation, 
 nor traces of blood in the contents ; and the ferments, though 
 often are not always continuously diminished. The func- 
 tional disorder often begins suddenly, after shock, injury, or 
 moral depression ; chronic gastritis develops slowly, or fol- 
 lows the acute disease. In adenasthenia the diet is without 
 influence on the slight local discomfort; in asthenic gastritis 
 the local symptoms are made worse by an improper diet. 
 The treatment suitable to adenasthenia is without benefit in 
 asthenic gastritis, which demands a special diet and local 
 remedies much less excitant. 
 
 In neurasthenia gastrica the abdominal symptoms are di- 
 gestive, and are excited by the simple activity of the stomach, 
 somewhat regardless of the quality of the diet. One article 
 of food is digested little better or worse than another. In 
 neurasthenia gastrica the patient is " dyspeptic " because he 
 suffers and complains, there being no marked and constant 
 chemical insufificiency. The secretory signs are in vivid con- 
 trast with the hypochlorhydria, excess of mucus, and con- 
 stant diminution of the ferments found in asthenic gastritis. 
 
 In myasthenia gastrica the signs of the motor insufficiency 
 at once make the differentiation, except in the rare cases 
 where motor insufificiency is a complication of the asthenic 
 gastritis. Fluids are worse borne than a dry solid meal, the 
 contrary being true in gastritis. The chemical signs of myas-
 
 410 DISEASES OF THE STOMACH. 
 
 thenia — secretion being rarely constantly diminished — are in 
 contrast with those of i^astritis. But asthenic gastritis may 
 develop as a complication of myasthenia ; and, apart from the 
 presumption being in favor of the myasthenia as the primary 
 trouble when the two diseases are found associated, only a 
 knowletlge of the development of the case could clear up 
 the difficulty. 
 
 There is little chance of confounding gastritis with carci- 
 noma, if the case has been well studied. The secretory signs 
 in the two diseases may be alike, for in both they are pro- 
 duced by catarrhal or asthenic gastritis ; but there the resem- 
 blance ends. There may be motor insufficiency in carcinoma, 
 and this occurs late (terminal period) in asthenic gastritis. 
 Not one sign, but the two groups of signs, in the two dis- 
 eases, should furnish the reasons for the decision. For the 
 differential diagnosis, see the chapter on Carcinoma. 
 
 Treatment. — It is much easier to prevent chronic gastritis 
 than to arrest the disease when it is fully developed. For 
 this reason the functional disorders of the stomach should 
 receive careful treatment, and the stomach should be guarded 
 and favored in all diseases of other organs which play a part 
 in the causation of gastritis. The prophylaxis consists in 
 strict digestive hygiene, a proper diet, and, what is more 
 often disregarded, but is equally important, in the avoidance 
 of all drugs which disturb its functions and injure the 
 mucous membrane. Dietetic abuses have become so firmly 
 fi.xed in the customs and habits of the people that there is 
 little danger of the disease disappearing, or of its becoming 
 easy to find a healthy stomach more than forty years old. 
 15ut probably some good may be done by recommending, to 
 tiiose who most need the advice, temperance in eating and 
 drinking, and by correcting gross violations of digestive 
 hygiene. 
 
 The treatment of secondary gastritis is in part the proper 
 treatment of the disease which caused it. The management 
 of the disease of the stomach is modified by the necessity of 
 controlling or of removing its cause. This subject is dis- 
 cussed in the section on the Vicious Circles of the Stomach. 
 
 The most important indications to be met by the treatment 
 of chronic asthenic gastritis are:(i) To protect and to favor 
 the inflamed organ ; (2) to maintain intestinal compensation; 
 (3) to excite the deficient secretion of the stomach by physio- 
 logical remedies; (4) to remove the excess of mucus when it 
 is thought best to do so ; (5) to treat gross symptoms and 
 complications.
 
 GASTRITIS. 411 
 
 The most valuable principle of affording the greatest possi- 
 ble protection to a diseased organ should guide us in the 
 treatment of the anatomical diseases of the stomach. The 
 proper treatment of chronic gastritis is an embodiment of 
 protection and of favoritism. A great deal of injury can be 
 done by trying to force the stomach to do its full chemical 
 work, and by filling the organs with antifermentatives and 
 antiseptics to drive out an imaginary evil. 
 
 A diet properly regulated is our most important remedy in 
 asthenic gastritis, and is often capable alone of suppressing 
 the symptoms and of arresting or curing the gastritis. The 
 chemical work of the stomach being very much reduced on 
 account of the diminished secretion, the disintegrating and 
 solvent work of the gastric juice should be as far as possible 
 done by the preparation and the thorough mastication of the 
 food. The motor power of the stomach must be carefully 
 nursed and guarded, for the maintenance of the balance of 
 nutrition depends on the delivery to the intestines of food 
 in sufficient quantity, and capable of digestion and utiliization 
 by the part of the digestive tube below the pylorus. The 
 disease is in the stomach, but the intestines have the most 
 to do with the selection of the diet. 
 
 Before and after each meal the mouth and the teeth should 
 be cleaned, and all the food eaten should be perfectly fresh. 
 The intestines being no longer protected by the acid gastric 
 secretion against bacterial invasion, every precaution should 
 be taken to have the food pure and sweet. 
 
 The gastric acidity is not sufficient to arrest the action of 
 the ptyalin, and the starches should be most thoroughly 
 chewed and insalivated, and the work of the intestines thus 
 made lighter. 
 
 Physical and chemical irritants should be excluded from the 
 diet. Alcohol is particularly injurious, irritating the inflamed 
 mucous membrane, by which it is not actively absorbed as in 
 health, and a large part of it is consequently conveyed into 
 the intestines. The food should contain only a moderate 
 quantity of salt, and should never be highly seasoned. A 
 small quantity of mild sauce may be used to appeal to the 
 palate. Fat in excess, as demonstrated by Leven, is also a 
 gastric irritant, and diminishes motor activity. More than 
 a very small quantity of cane-sugar must be prohibited, as an 
 intestinal prophylactic measure. Milk-sugar is not objection- 
 able if the small intestine is healthy. But all forms of sugar 
 are hydragogue, and in excess and in concentrated solutions 
 are irritant, and unless rapidly absorbed are liable to ferment in
 
 412 DISEASES OF THE STOMACH. 
 
 the intestines. It is a rule established by clinical experi- 
 ence that sweets and fats must be reduced to a minimum in 
 the treatment of asthenic gastritis, but moderate quantities of 
 fresh butter should always be given, and are usually well 
 borne. 
 
 The sweets may be partly replaced by gelatinous foods, 
 which possess a high force value, resist fermentation, and are 
 rapidly digested and utilized by the intestines. Calf's- and 
 pig's-foot jelly and calf's head (milk sauce) may be utilized 
 for maintaining nutrition. 
 
 The albuminous foods escape gastric digestion, but this 
 affords no reason for diminishing the quantity of this class of 
 food. But the quality and the preparation must be favorable 
 to intestinal digestion and utilization. The meats should be 
 tender, lean, finely divided (chopped or scraped), and as 
 free as possible from indigestible tissue (skin, tendon, blood- 
 vessels, fascia). No fried or greasy dishes should be per- 
 mitted, and all the meats, poultry, and game should be either 
 stewed, broiled, or grilled. 
 
 Milk is well borne in some cases, and should then be per- 
 mitted as a drink and in the preparation of vegetables, sauces, 
 with cereals, etc. It should never be given in the exceptional 
 cases with gastric fermentation, nor where there is stagnation 
 in the small intestine; on the appearance of the first signs 
 of gastric or intestinal fermentation it should be immediately 
 excluded. 
 
 Not more than one glass of fluid should be allowed with 
 a meal. The starch-containing foods should be thoroughly 
 masticated and insalivated before being washed down with 
 water or swallowed. No alcoholic drinks should be per- 
 mitted. Plain water and very weak tea are the most suitable 
 drinks ; chocolate and cocoa are better borne than coffee, and 
 in e.xceptional cases may be permitted, particularly Haus- 
 waldt's " vigor chocolate." 
 
 The following articles should form the staple foods, and 
 should be given in combination and quantity in keeping 
 with the principles of dietetics, so as not only to maintain, 
 but, if need be, to improve nutrition. But where a trouble 
 of the intestines is associated with the gastritis, it may be 
 necessary to restrict and to lower the diet temporarily below 
 the requirements of nutrition until the intestinal disease is 
 under control and digestive compensation is reestablished. 
 All tender lean meats, beef, mutton, calf's-brain, sweet- 
 bread, young chicken, squab, animal jellies, lean and fine- 
 meated fish, soft part of oysters in season, whites of eggs
 
 GASTRITIS. 413 
 
 cooked just enough to hold together, and the yolks of eggs 
 (when there is no intestinal putrefaction), and milk, when well 
 borne (which is not the case if there is intestinal fermenta- 
 tion); preparations of rice and wheat, thoroughly cooked, 
 spinach passed through a sieve, cooked tender sprigs of 
 celery, mashed French peas, tender string beans passed 
 through a colander, and tender sprigs of lettuce with a little 
 salt, white bread toasted through and through, or the crust 
 of roll; and in some cases thoroughly cooked mashed pota- 
 toes or a mealy boiled potato may be permitted. 
 
 All other articles are prohibited until the disease is arrested, 
 as indicated by the functional signs, and until digestive com- 
 pensation is well established. But the deficient chemical work 
 of the stomach will necessitate the observance of hygiene, 
 and the continuance of a diet favoring and nursing the motor 
 power of the stomach, and maintaining strict intestinal pro- 
 phylaxis. It may be necessary to prescribe a fluid diet for a 
 short time, to give four or five small meals a day, and to per- 
 mit only such foods as are evacuated by the normal stomach 
 in about three hours. Select, in the beginning of treat- 
 ment, such foods as leave the stomach rapidly, such as have 
 little action on its mucous membrane, and such as are utilized 
 by the intestines in sufficient quantity to support or to improve 
 nutrition. 
 
 This is the rule when it is necessary to protect and favor 
 the stomach ; but such is not always the proper course. The 
 diet may be used as a physiological remedy to excite secre- 
 tion when excitation is desirable. The meats are strong ex- 
 citants of secretion ; the green vegetables, fruits, and sweets 
 act in a similar manner ; and peptones and albumoses may be 
 prescribed for the same purpose, and condiments may be per- 
 mitted in moderation. It is better to use food as an excitant 
 remedy than to prescribe drugs for the same purpose; but 
 the intragastric douche with a physiological salt solution is a 
 valuable synergist. 
 
 The bowels should be kept regulated by massage, elec- 
 tricity, and injections to which glycerin may be added. If 
 intestinal fermentation becomes active, a dose of calomel 
 should occasionally be given. 
 
 The appetite may be so diminished as to require special 
 treatment, the increase of the appetite improving also the 
 psychic state of the patient. An infusion of condurango or 
 calumba may be given with a tablet of strychnin. 
 
 The general restorative and hygienic remedies — physio- 
 logical living, hydrotherapy, electricity, etc. — should not
 
 414 DISEASES OF THE STOMACH. 
 
 be neglected, and every means should be used to maintain 
 and to impio\e nutrition, to tone and to rest the nervous 
 system, to protect and to favor the stomach, and to secure 
 digestive compensation by the intestines. Stomach wash- 
 ing may be employed to remove the very large quantity 
 of mucus, but we rarely employ it in asthenic gastritis 
 unless there is butyric fermentation. Lavage should be done 
 at bedtime or in the morning before breakfast, using plain 
 warm water, or a little lime-water (i to lo) may be added. If 
 the patient is not accustomed to the tube, a glass of hot water 
 maybe slowly sipped an hour before breakfast. The addition 
 of a few grains of sodium chlorid and calcium chlorid to the 
 hot water usually controls the butyric fermentation. We 
 rarely prescribe mineral waters and so-called mucus-solvents 
 in asthenic gastritis. Indeed, the good motor function and 
 the traversing food and water, aided, if need be, by lavage, are 
 sufficient to remove the excess of mucus ; and it would seem 
 wise to leave enough sweet mucus on the surface of the stom- 
 ach to protect the mucosa. The long preservation of the glan- 
 dular division of the mucosa in health and repose is due to the 
 non-injurious and protecting coat of thick mucus. Some aid 
 may be rendered the intestines in their digestive work by sup- 
 plementary chemical treatment, using hydrochloric acid, and, 
 in the advanced stage of the destructive process, also pepsin, 
 or papoid alone. When the In-drochloric acid is used as a di- 
 gestive agent, two doses of the dilute acid (about 20 drops) 
 should be given during the functional activity of the stomach, 
 about si.xty and ninety minutes after the beginning of the meal. 
 Pepsin should always be combined with it. In the few cases 
 with gastric fermentation, a dose of the acid may be given as 
 an antizymotic, half an hour before each meal. Papoid may 
 be employed without the acid when the stomach is atrophied 
 or when a complicating nephritis exists. But supplementary 
 chemical aid should never be employed until the period has 
 arrived for excitant treatment, for, while it may aid the intes- 
 tines, it may injure the stomach. 
 
 II. GASTRITIS GLANDULARIS PROLIFERANS, OR CHRONIC 
 HYPERSTHENIC GASTRITIS. 
 
 Pathological Anatomy. — In chronic asthenic gastritis the 
 cylindrical cells which cover the surface of the mucous mem- 
 brane and line the mucous ends of the ducts of the glands 
 proliferate, and may replace the degenerate chief and border
 
 GASTRITIS. 
 
 415 
 
 cells, thus converting many of the peptic into mucous glands. 
 Or the fundus of the degenerate gland disappears and noth- 
 ing is left but the elongated duct of the gland, lined with 
 cylindrical cells, with beaker cells, and with ciliated columnar 
 epithelium. In this process the proliferation and infiltration of 
 the connective tissue may play a more or less important part. 
 In chronic proliferating glandular gastritis the pathological 
 process is different and in bold contrast. There may be the 
 same infiltration and proliferation of the connective tissue, and 
 
 
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 Fig. 22. — Gastritis glandularis prolifcrans. X 240. (Authors' specimen.) 
 
 the same wandering of leukocytes, which are, as a rule, oxy- 
 phile. But the proliferation affects the cells of the peptic 
 glands ; the cylindrical mucus-secreting cells remain n'formal, or 
 degenerate and disappear over large areas of the surface of 
 the mucous mfembrane, and many of the pyloric glands be- 
 come lined with cells resembling the chief and border cells of 
 the peptic glands (Fig. 22). 
 
 The mucous membrane is covered with mucus, which is 
 stained with blood and is ordinarily thin and mixed with the 
 nuclei of partly digested cells. The surface of the mucous
 
 41 6 DISEASES OE THE STOMACH. 
 
 membrane is very vulnerable ; it is not, orciinarily, niammel- 
 lated, but the little villosities may be jirominent, and the 
 mucous membrane is firm and thick. Large areas of the 
 mucous membrane are denuded of epithelium, and a peptic 
 (round) ulcer is not rare. The surface epithelium is usually 
 destroyed by postmortem digestion, but it may be found 
 well preserved in small pieces of the mucous membrane ob- 
 tained through the tube; there are no beaker cells, no re- 
 verted ciliated columnar epithelia, no mucoid degeneration 
 of the cylindrical cells, but rarely a very ievj cylindrical cells 
 may show mitosis (normal). In old cases the superficial 
 layer of the mucosa may be richly infiltrated, and the nutri- 
 tion of the surface epithelia may be cut off and their reproduc- 
 tion arrested. The positive characteristic of the gastritis is 
 the proliferation of the border and the chief cells. Some cases 
 show few border cells, and some few chief cells, and the pre- 
 dominance of the one or the other cell may depend on the 
 functional state of the gland when the specimen is obtained — 
 in the morning, when the stomach is in repose and has been 
 empty for some time, or during digestion, or during the period 
 when the stomach still has stagnant or retained food in it. 
 But the glands are ordinarily in a state of functional activity, 
 and the chief cells greatly diminish in number. It is possible 
 that autodigestion and their normally low vitality have some- 
 thing to do with their disappearance. Under the microscope 
 the glands appear lined with cells which are well preserved 
 and closely packed, and some of the younger ones stain in- 
 tensely. The lumen of the glands is filled with granular mat- 
 ter, a few leukocytes, and the remains of chief cells. Many 
 of the cells contain more than one nucleus. The swelling of 
 the mucosa is due to the active proliferation of connective tis- 
 sue in the first anatomical stage of many cases, but the inflam- 
 mation may be interstitial in the beginning, or the interstitial 
 inflammation may develop in the course of the evolution of 
 the case. Proliferating glandular gastritis rarely ends in ana- 
 denia gastrica, though many of the glands may be compressed 
 and deformed, and even destroyed, by the interstitial inflam- 
 mation, and in old cases many of the cells undergo granular 
 and mucoid degeneration and vacuolation. Some of the 
 pyloric glands contain a few border cells, and these glands, as 
 Hayem first discovered, may be converted into true peptic 
 glands. The rich and excessive secretion is the natural se- 
 quence of the pathological alterations of the glandular layer. 
 Clinical Description. — The symptoms of hypersthenic or 
 proliferating glandular gastritis may be confined to the nor
 
 GASTJUTIS. 417 
 
 mal digestive period, and they cease entirely after the stom- 
 ach has emptied itself unless secretion is continuous. Like 
 chronic asthenic gastritis, the disease may be perfectly latent 
 for a long period ; or it may manifest itself by distant, and 
 not by local, subjective symptoms. 
 
 The appetite is good, and often greatly increased, but there 
 is no selective desire for spicy articles or for sour food. Soon 
 after the meal the stomach may feel full, and there is for a 
 short time a sense of well-being; but as digestion proceeds, 
 heartburn, eructations, and pain begin. Thirst is usually 
 strong, and the pain and the burning are relieved by drink- 
 ing water. There is no nausea and no vomiting. The local 
 pain increases with the evolution of digestion, but is relieved 
 by fluids, albuminous foods, and alkalies. The intensity of 
 the symptoms is proportionate to the physiological action of 
 the food on secretion, to the state of the nervous system, to 
 the activity and richness of secretion, and to the time during 
 which it remains undigested in the stomach. Starches, sweets, 
 and fats are not so well borne as is albuminous food, and a 
 glass of milk may be digested with but little discomfort. 
 This is the simplest and the mildest type of chronic hyper- 
 sthenic gastritis, which may have begun suddenly with an 
 attack of acute gastritis, or have been preceded, for a variable 
 period of a few months or years, by adenohypersthenia, or 
 which may have long remained latent or manifested itself 
 intermittently by subjective symptoms. 
 
 Where acetic or butyric fermentation is associated with 
 the glandular gastritis and morbid sensibility, the preceding 
 symptoms are intensified ; and during the period when, nor- 
 mally, digestion would be in the stage of decline, the pain 
 may become paroxysmal, and radiate from the stomach over 
 the abdomen and into the back. The symptoms are incom- 
 pletely relieved by water, by albuminous foods, and by alkalies. 
 There is often headache and nausea, which may terminate with 
 vomiting. But the symptoms maintain the same relation to 
 the evolution of digestion, and to the quantity and composi- 
 tion of the diet, as in the simple form. 
 
 In other cases the symptoms are not confined to the nor- 
 mal digestive period, but encroach upon the period of gastric 
 repose. The local symptoms then become more continuous, 
 with digestive exacerbations, and with nocturnal attacks of 
 pain and nausea, and sometimes vomiting. The glandular gas- 
 tritis is complicated with prolonged digestion produced by 
 supersecretion. Stagnation may end in retention, and the 
 stomach may never completely evacuate through the pylorus 
 27
 
 4l8 DISEASES OE THE STOMACH. 
 
 the food taken into it; or secretion may become continuous, 
 and the organ never get rest from irritation. 
 
 The simple type with digestive symptoms, at any moment, 
 through dietetic errors or through fatigue, may become 
 marked by periods when fermentation is active ; or stagna- 
 tion or retention may occur for a few days. The progress of 
 the disease is then characterized by periods during which all 
 the symptoms are exaggerated and accompanied by nausea and 
 vomiting, lasting a number of days; and by periods lasting a 
 week or a month or longer, during which the patient is com- 
 paratively comfortable. 
 
 The emaciation becomes greater and greater as the suffer- 
 ing, the loss by vomiting, the destruction of food by fermenta- 
 tion, and its waste in intestinal putrefaction increase. The 
 disease now becomes a menace to life. Continuous secretion 
 and retention, with fermentation, excite more and more the 
 inflammation, which becomes more and more interstitial 
 and the destruction of the glands and the muscular fibers 
 begins. The patient, who is generally a man between twenty 
 and forty, is now emaciated, sallow, with long suffering traced 
 in all his features. The appetite is irregular and sharp, and in 
 order to satisfy it food is taken irregularh^ and frequently. 
 As the rule, the morning is the most comfortable part of the 
 day, but in the afternoon the accumulated contents — consist- 
 ing of the foods and fluids ingested, the secretions, and the 
 products of fermentation and digestion — may so irritate the 
 mucous membrane as to produce a severe paroxysm of pain, 
 nausea, and vomiting. The vomit consists of a greenish or a 
 grayish fluid, mi.xed with undigested starch, ropy, acid, and 
 separating into three layers on standing. The dinner is taken 
 with appetite, and from four to si.x hours later a second par- 
 oxysm, like that of the afternoon, may rob the patient of all 
 but a few hours' sleep. There may be only one paroxysm 
 during the twenty-four hours, and the vomiting may be re- 
 placed by diarrhea. Ulcer may develop at any stage of the 
 evolution of the disease, from the simple digestive form to its 
 terminal period — supersecretion, stagnation, fermentation, and 
 finally retention being the intercurrent episodes. 
 
 The stage of hypersthenic gastritis characterized by con- 
 tinuous secretion and motor insufficiency constitutes a symp- 
 tom-group sometimes described as Reichmann's disease. The 
 same symptom-group may characterize a stage in the evolu- 
 tion of myasthenia, of gastroptosis, and of pyloric obstruction. 
 
 Symptomatology. — The a]:)petite in the hypersthenic form 
 is well preserved, and although often diminished during the
 
 GASTJwns. 419 
 
 paroxysms of pain and vomiting, it is never completely lost, 
 as may be the case in anorexia nervosa, in cancer, and in 
 asthenic gastritis, and in myasthenia with retention and fer- 
 mentation. On the other hand, during the periods of im- 
 provement the appetite is unusually sharp, and may become 
 as imperative as in bulimia. « 
 
 Thirst is also a common symptom, and may become very 
 strong during the height of digestion and after profuse vomit- 
 ing and diarrhea. The patient soon learns that the pain is 
 moderated by drinking water, and in the beginning of par- 
 oxysms may take it in very large quantities. 
 
 Pain is a characteristic and frequent symptom, and varies in 
 intensity and in its qualities in the different stages. So long 
 as the motor power is normal and there is no fermentation 
 the pain is digestive, and is most intense when the quantity of 
 free hydrochloric acid is greatest. But in this stage of the 
 disease, after a small non-irritating meal, it may be replaced 
 by discomfort and heartburn. When motor insufficiency 
 appears as a complication, the pain recurs in paroxysms, due 
 to the accumulation of the irritant contents. It is located in 
 the epigastrium, and radiates to the left and over the abdo- 
 men and into the back, burning and unbearable. It is relieved 
 by albuminous foods, such as meats, milk, and eggs, and, more 
 completely, by large doses of alkalies. It subsides also after 
 vomiting (if complete) and lavage and after the evacua- 
 tion of the stomach into the duodenum. 
 
 Nutrition in the beginning is well preserved, but emaciation 
 develops with the increase of fermentation, of vomiting, of 
 retention, and of disturbance of the functions of the intestines. 
 In the advanced stages it may become extreme, and may be 
 associated with cachexia as pronounced as in cancer. 
 
 The physical signs are not characteristic, and reveal a 
 complication — such as ulcer, stagnation, and retention — more 
 often than they reveal the gastritis itself. 
 
 The functional and bacteriological signs not only aid in 
 making the diagnosis, but also indicate the stage which the 
 disease has attained in its evolution, and are valuable guides 
 in the treatment. As regards the functional signs, the dis- 
 ease may be divided into three stages or periods: (i) 
 Initial period ; (2) period of prolonged digestion; (3) terminal 
 period. 
 
 During the initial period the motor function is sufficient, and 
 the stomach empties itself in the normal time. The resting 
 stomach contains no remains of undigested food nor digestive 
 products. The tube, introduced in the morning before break-
 
 420 DISEASES OE THE STOMACH. 
 
 fast, withdraws possibly a few cubic centimeters of fluid, slic^htly 
 acid, and containing mucus, and sometimes saliva; the sediment 
 contains spiral cells, nuclei, sometimes a few wandering leuko- 
 cytes, bacteria, but no yeast or sarcinae. After the test-break- 
 fast about the normal quantity of contents is obtained, gra)ish 
 or greenish, with a peculiar acid odor. The bread (except 
 starch) is well digested, but the mixture is not so homogeneous 
 as in health, and contains an excess of mucus. There are no 
 organic acids. The total hydrochloric acidity is very high 
 (70 to 120), of which part (C) is combined (10 to 40) and part 
 (H) is free (20 to 60). The tube digestions are very active, 
 the acidulated 50 per cent, dilution digesting as rapidly as the 
 undiluted filtrate in health. The labferment and the lab- 
 zymogen are both very active. The contents obtained two 
 hours after the test-meal of Germain See contain nearly all 
 the meat in solution, only a few fibers already undergoing 
 disintegration being discoverable with the microscope. Syn- 
 tonin and propeptones are abundant, and both the biuret and 
 Almen's reactions for peptones are plain. The starch is not 
 difjested as well as in health, and there is no accumulation of 
 pt)'alin products. The tube fermentations are negative, and 
 the total quantity of the contents obtained after the test-meals, 
 as estimated by the method of Mathieu or of Strauss, is some- 
 times normal, but is ordinarily excessive, on account of the 
 usually excessive activity of secretion. The hydrochloric 
 acidity (H -\- C) is excessive, and the excess may be due to an 
 excess of both (H) and (C), or to an excess of (H) chiefly, or 
 of (C) chiefly. The free (H) hydrochloric acid may appear 
 too early in the evolution of digestion (before thirty minutes), 
 and the acme of hydrochloric activity may occur during the 
 second hour of the digestion of the test-breakfast. The line 
 which represents the evolution of (H -f- C) displays no sud- 
 den rises and falls, although it runs abnormally high. Se- 
 cretion ceases with the evacuation of the stomach, which 
 occurs within the normal time. 
 
 During the period with prolonged digestion, two conditions 
 may be found. In the one, the signs are the same as in the 
 initial stage, with a few differences. The contents are exces- 
 sively rich in (H + C) hydrochloric acid and the ferments. 
 The albumin digestion is rapid, and starch digestion is dimin- 
 ished. The evolution of secretion is exi)osed to the same 
 disorders. But the quantity of the contents is greater than 
 normal, and the excessive quantity is due to supersecretion 
 or to spasm of the pylorus. The stomach contains remnants 
 of the roll, and products of pepsin digestion. After the acme
 
 GASTRITIS. 421 
 
 of digestion too much free HCl is always found, and, as 
 digestion proceeds toward its termination, the percentage of 
 free hydrochloric acid increases and that of the combined 
 hydrochloric acid diminishes. The stomach may contain some 
 of the test-breakfast at the end of three hours. In the ordinary 
 course of events the stomach may succeed in emptying itself 
 between each meal, or the digestion of one meal may not be 
 completed when another is begun. But when the prolon- 
 gation of digestion is due to supersecretion, the stomach al- 
 ways empties itself during the night unless secretion is con- 
 tinuous. The stomach is empty one and one-half hours after 
 the water test, or it contains a variable quantity of se,cretion, 
 rich in acid and ferments. There is no myasthenia; diges- 
 tion is prolonged because secretion is excessive, and secretion 
 ceases soon after the stomach is empty. The second con- 
 dition is characterized by continuous secretion. The signs 
 are nearly the same as in the first form with supersecretion, 
 but the tube, introduced in the morning, before breakfast, 
 withdraws a greenish or grayish ropy fluid, without or with 
 alimentary residue, varying from 50 to 250 c.c. or more in 
 quantity, containing free hydrochloric acid (5 to 20 or 50), 
 possibly a small quantity of combined HCl (digested cellular 
 protoplasm), digesting albumin actively in the tubes, and pos- 
 sessing a sp. gr. of 1004 to 1006. About the same quantity 
 of secretion may be obtained after the stomach has been 
 washed out the previous evening, nothing (food, water, nor 
 saliva, etc.) having been ingested or swallowed during the 
 night. The glands continue to secrete throughout the twenty- 
 four hours. In continuo«s secretion the starches undergo no 
 change. There may be slight fermentation — a small quan- 
 tity of organic acids in the contents, a moderate amount of 
 budding yeast, sarcinae, bacteria, particularly cocci, and, pos- 
 sibly, a little gas formation in the fermentation tubes. 
 
 Secretion during the terminal period may remain excessively 
 rich and be less than normal in quantity. The evacuation of 
 the stomach is then abnormally rapid, unless the motor func- 
 tion is made insufficient by a complication. Or, again, the 
 hydrochloric acidity (H -\- C) may be less than in health, and 
 secretion may be about normal in quantity, or it may be 
 excessive, or it may be continuous. Consequently, digestion 
 may be finished too rapidly, in the normal time, or it may be 
 prolonged. But the prolongation is the result of the exces- 
 sive secretion and is not due to motor insufficiency. The 
 secretory signs reveal the progress of glandular destruction 
 by compression. There is, however, a possibility of being
 
 422 DISEASES OF THE STOMACH. 
 
 badly deceived in this matter, for secretion may be reduced 
 in quantity and in richness at any period of the evohition of 
 chronic proliferating glandular gastritis by acute interstitial 
 gastritis. But the suppressed hyperchlorhydria will reappear 
 if the complicating acute condition is relieved by protecting 
 the stomach against all irritation and b\' favoring it in its work 
 or by giving it functional repose for a few days. Sedation 
 and rest produce — or, better, restore — excessive glandular 
 activity, and this sequence occurs in no other disease of the 
 stomach. 
 
 Hypersthenic gastritis may be complicated by m\'asthenia, 
 by pyloric obstruction, and, possibly, by motor insufficiency 
 due to infiltration of the muscular layer. Great difficulty 
 may be experienced in distinguishing these complicated cases 
 with stagnation or retention from the simple cases of Inper- 
 sthenic gastritis with prolonged digestion. 
 
 In the contents, or in the vomit, or in the wash-water, signs 
 of gastritis may be found — blood, altered cylindrical cells, 
 leukocytes or their nuclei, and sometimes small pieces of the 
 vulnerable mucous membrane. The pieces of the mucous 
 membrane show the nature and characters of the pathological 
 process in evolution at the point from which they come, which 
 is nearly always the same as the process which predominates 
 in other parts of the stomach. But gastritis is not always of 
 the same character and stage and intensity at all points of the 
 mucosa. 
 
 The urine easily precipitates the earthy phosphates, but the 
 total quantity of phosphoric acid eliminated in the twenty- 
 four hours may be above or below the normal. The total 
 quantity may reach as high as five gm. or may fall as low as 
 one or two gm., the average elimination being 2^ gm. in the 
 twenty-four hours. But, be the total quantity large or small, 
 the urine, as a rule, is cloudy when voided, and the earthy 
 phosphates are precipitated by heat because the urine is nearly 
 neutral or alkaline. The diminution of the acidity of the urine 
 is proportionate to the amount of acids found in the stomach. 
 The sum total of the acidity of the urine and of the gastric 
 juice in health is a constant quantity, and this inverse re- 
 lation is only disturbed in disease by fermentation and by 
 increased or diminished secretory activitx', chiefl)' of the intes- 
 tines and its annexed glands and of the skin. In hypersthenic 
 gastritis the acidity of the urine is markedly diminished during 
 digestion ; and when digestion is prolonged by e.xcessive or 
 by continuous secretion, the reaction of tlie urine passed dur- 
 ing the twenty-four hours is nearly neutral or alkaline, and it
 
 GASTRITIS. 423 
 
 may be milky with precipitated phosphates. The quantity 
 of urea is increased and the increase is often absolute. This 
 is due in part to the excessively albuminous diet, to the in- 
 creased alkalinity of the blood, and, probably, to the excessive 
 formation of peptones. The increased relative percentage of 
 urea is due to the concentration of the urine by diminished 
 absorption or by increased loss of water by the stomach and 
 intestines in vomiting, retention, lavage, and diarrhea. 
 
 The chlorids are constantly and absolutely diminished in 
 proportion to the vomiting, retention, lavage, and activity of 
 gastric secretion. The urine formation, being continuous, 
 shows at each moment the chlorid percentage of the blood. 
 The blood, during the excessive gastric secretion, is poorer 
 than normal in chlorids. Consequently, the excessive quan- 
 tity of chlorin removed from the blood by the stomach 
 would, without any other disturbance, diminish the total 
 quantity of chlorids eliminated in the urine during the 
 twenty-four hours, and, to a greater degree, during gastric 
 secretion. 
 
 Diagnosis — The slow evolution, the subjective and the 
 objective signs of hypersthenic gastritis, are so characteristic 
 that the diagnosis is not often difficult. The symptom-group 
 presented at any stage would fix the mind on hypersthenic 
 gastritis as one of the probabilities. The differential diagnosis 
 may be a hard problem. 
 
 Differential Diagnosis. — Hypersthenic gastritis may be 
 primary, or it may be a complication developing in the orderly 
 evolution of other diseases of the stomach, such as myas- 
 thenia, displacements, ulcer, pyloric obstruction, and, seldom, 
 carcinoma. Without the functional and bacteriological signs, 
 and careful attention to the evolution of the case, the differ- 
 entiation is only a lucky or an unlucky guess at the truth. 
 If the case be incompletely studied, carcinoma may be easily 
 confounded with hypersthenic gastritis. Pain, slow evacua- 
 tion of the food, emaciation, and cachexia are symptoms 
 common to the two diseases. But a comparison of the dis- 
 tinctive features of the pain would place in our hands the 
 guiding thread which would lead to a correct conclusion. It 
 is useless to recall vague and slight variations when the func- 
 tional and the bacteriological signs are so widely different in 
 the two diseases. The excessive hydrochloric acid in the one, 
 and its diminution (little or no H, little or no C) in the other ; 
 the active and rapid albumin digestion in the one, and its slow- 
 ness, and incompleteness, and possible absence in the other; the 
 absence of lactic acid fermentation in the one, and its frequent
 
 424 DISEASES OF THE STOMACJL 
 
 active formation, after stringent precautions, in the other ; the 
 almost constant cliaracter of the germ growth in the one, and 
 its rapid changes and special character, in keeping with the 
 quick changes in the chemical properties of the more and 
 more stagnant contents of the other — are so many signs which 
 place the two diseases in vivid contrast. The api)etite, the 
 effects of food, the urine, the blood, and the evolution, present 
 other important differences. Very rarely carcinoma may be 
 engrafted on an old ulcer, and the differentiation may be ex- 
 ceedingly difficult, and may demand a close and complete 
 study of every little symptom and sign. 
 
 Myasthenia may become accompanied by fermentation, 
 which might produce secretory irritation, and present a symp- 
 tom-group closely resembling the stage of hj'persthenic 
 gastritis associated with prolonged digestion and fermentation. 
 Or the stagnation of the food in myasthenia might produce 
 supersecretion. A knowledge of the evolution of the case up 
 to the moment of examination would clear up the difficulty 
 and reveal the primitive character of the myasthenia or of the 
 gastritis. The therapeutic test gives valuable information. 
 If the stagnation-caused fermentation in myasthenia is con- 
 trolled by diet and by lavage, and if the treatment suitable to 
 myasthenia is adopted, the excessive and rich secretion due 
 to irritation rapidly subsides ; but hydrochloric superacidity 
 would continue unabated during the prolonged digestive 
 period in hypersthenic gastritis. The anatomical signs of 
 the gastritis would be absent in the particular stage of my- 
 asthenia under discussion. Myasthenia and hypersthenic 
 gastritis resemble each other only when both are accompanied 
 by delayed evacuation of the food and by hydrochloric super- 
 acidity. The existence of continuous secretion excludes 
 simple myasthenia, and the hydrochloric superacidity of my- 
 asthenia is quickly relieved by protecting the stomach from 
 irritation and by giving it functional rest. The lines repre- 
 senting the evolution of secretion in myasthenia show sudden 
 rises and falls. The water test gives different results in the 
 two diseases, for myasthenia is accompanied by stagnation of 
 liquids due to motor insufficiency, and hypersthenic gastritis 
 may be accompanied by prolonged digestion due to superse- 
 cretion. Moreover, in myasthenia expression is difficult, the 
 stomach is flabby, loses its form, does not retract as it becomes 
 empty, and splashes whenever it contains fluid and gas. 
 Contrary signs are present in hypersthenic gastritis with 
 prolonged digestion. For other differential signs, see Myas- 
 thenia. But myasthenia may become complicated by
 
 GASTRITIS. 425 
 
 hypersthenic gastritis, and nothing except a knowledge of 
 the development of the case could make the differential 
 diagnosis. The link belongs to either of the two chains, and 
 the treatment is practically the same when both diseases are 
 present. 
 
 Pyloric obstruction, gastroptosis, and vertical displacement 
 of the stomach may be complicated by hypersthenic gas- 
 tritis, and the history may give the primary trouble ; the 
 gastritis is most frequent in men and the displacement of the 
 stomach in women. For the differential signs, see Myas- 
 thenia, Displacements of the Stomach, and Obstruction of the 
 Pylorus. 
 
 Treatment. — The treatment is not the same in all the 
 stages of hypersthenic gastritis, and each of the periods 
 characterized by special functional signs presents particular 
 indications to be met. 
 
 I. The Initial Period The disease gathers more and more 
 
 force and violence as it progresses, and each day the lesions 
 become more and more extensive and incurable; and hence 
 comes the stringent necessity for correct and consistent treat- 
 ment during the initial period. 
 
 No more striking instance can be found in pathology of 
 the danger of neglecting a disorder of the stomach and of 
 not curing it while in its early stage. The prophylactic treat- 
 ment — so important on account of the part which every disease 
 of the stomach plays in pathogenesis — should not be neglected. 
 Prophylaxis is particularly important in the hypersthenic dis- 
 eases, for they possess a strong inherent tendency to extend 
 and to progress. After the initial period is established the 
 indications are : {a) To protect the mucous membrane against 
 all forms of irritation ; {b) to maintain the balance of nutrition 
 by a suitable diet; (r) to control or utilize the excessive 
 secretion ; {d) to treat the gross symptoms ; {e) to prevent 
 stagnation or retention. 
 
 The mucous membrane may be irritated by drugs, by the 
 diet, and by the excessive hydrochloric acidity. Tonics, 
 nervines, purgatives, and all drugs which act as local irritants 
 and excitants of secretion should be avoided ; indeed, not 
 only avoided, but absolutely prohibited. 
 
 The physiological action of the diet should be indifferent, 
 non-excitant — no condiments, spices, vinegar, highly seas- 
 oned sauces, fermenting or decomposing foods, or alcoholic 
 drinks. Such foods and drinks should be selected as do not 
 excessively excite secretion, and which utilize the secretion 
 which is formed. Consequently, all articles of food which in
 
 426 D/SEASES OF THE STOMACH. 
 
 health leave during their digestion a noteworthy quantity of 
 hydrochloric acid free, should be prohibited. The excessive 
 h)-drochloric acidity of the contents irritates the mucous 
 membrane, which in hypersthenic gastritis may be particu- 
 larly sensitive to the action of free hydrochloric acid. The 
 diet is selected by the needs of nutrition, by the functional 
 activity of the stomach, by the imperative necessity of avoid- 
 ing secretory irritation, and by the state and functional power 
 of the intestines. The diet should also be so regulated as not 
 to tax the motor function of the stomach too heavily, the de- 
 velopment of motor insufficiency rendering the disease much 
 more serious and dangerous. 
 
 During the initial period nutrition is commonly well pre- 
 served, if the good appetite has been heeded. If emaciation 
 exists during this period it is the result not of the disease, but of 
 faulty alimentation, or possibly of a too free use of purgatives, 
 or of intestinal disease. Consequently, the demands of nutri- 
 tion are met by maintaining its equilibrium. An exclusive 
 weakening diet is improper, and it is dangerous to weaken 
 by inanition the voluntary and the involuntary muscles, thus 
 favoring myasthenia and prolapse of the stomach, diminution 
 of abdominal tension, intestinal stasis, and inequality of the 
 circulation. Guided by the active peptonization which is one 
 of the functional characteristics of this disease, the mistake 
 is often committed of prescribing an exclusively albuminous 
 diet incapable of maintaining the balance of nutrition, except 
 possibly at a very low level. The balance of nutrition can 
 be maintained and the functional power of the stomach re- 
 spected by a diminution and a careful selection of the carbo- 
 hydrates and fats in combination with an increased quantity 
 of proper albuminous foods. 
 
 Physiologically, the meats are powerful excitants of secre- 
 tion, and their digestive products are even more active, and the 
 red meats require a long time for their digestion. Conse- 
 quently the meats are not itleal foods in hypersthenic gas- 
 tritis ; but they are of great nutritive value and combine 
 large quantities of HCl. The meats and the other albu- 
 minous foods which are evacuated rapidly by the normal 
 stomach should be preferred. In the initial period there is no 
 objection to milk, which is very soothing in its action on the 
 mucous membrane, which combines the free HCl rapidly, and 
 which leaves the stomach quickly. If milk is suitable to the 
 intestines it is wise to begin the treatment with rest in bed, a 
 milk diet for a few days, gradually adding eggs, "vigor 
 chocolate," stewed or broiled young chicken, squab, lean and
 
 GASTRITIS. 427 
 
 fresh fish, and cereals thoroughly cooked and finely ground 
 or mashed after cooking and eaten with milk or with cream, 
 or with broth or milk soup. Rice, the preparations of wheat, 
 oatmeal, hominy, and cornmeal mush are all suitable cereals. 
 The red meats may next be permitted, but they should be 
 free from fat and from fibrous tissue, finely divided, properly 
 hung, and fresh. Next come the purees of green vegetables, 
 mashed starchy vegetables, fruit, sweets, and salads, in the 
 order named. But the intestines may force an exclusion of 
 milk from the diet, and the prescription of a diet almost 
 exclusively albuminous (fermentation), or a diet composed of 
 cereal-thickened soups, meat juice, cereals, milk-sugar, and 
 possibly green vegetables and fruit (putrefaction). Butter 
 should be given in moderation, and always fresh, and prefer- 
 ably unsalted. Whatever diet is prescribed, its action on 
 secretion and on the motor function should be watched, and 
 it should not cause intestinal putrefaction or fermentation. 
 
 With each meal — composed of food which is finely divided, 
 contains no chemical or mechanical irritant, is nutritious in 
 small bulk, combines large quantities of HCl, and does not ex- 
 cite secretion (in the normal stomach) more than it requires for 
 its digestion, which leaves the stomach rapidly, and is sufficient 
 in quality and composition to maintain the balance of nutrition 
 — there should be given one or two glasses of fluid, either 
 plain water, or a slightly alkaline water, or milk. A dry diet 
 is very injurious, the water not only serving as a diluent, 
 diminishing the physiological action of the contents on 
 secretion, but also promoting the evacuation of the fluid con- 
 tents into the duodenum. The prolonged sojourn of the food 
 in the stomach is a disadvantage, exciting and prolonging 
 secretion unduly, and predisposing to the development of 
 continuous secretion, and to the prolongation of digestion 
 through excessive secretion. 
 
 The hyperchlorhydria will be greatly influenced by the 
 protection of the mucous membrane against avoidable irrita- 
 tion. The condition of the nervous system may also be a 
 causative factor in the production of the hyperchlorhydria and 
 every means should then be employed to enforce mental and 
 moral repose. The usual remedies for toning the nervous 
 system should be prescribed, one of the most powerful being 
 the Scottish douche. Gastrospinal and cervicogastric seda- 
 tive galvanization may be given a trial. 
 
 To control the excessively acid secretion no remedies are 
 more efficient than the alkaline-sulphate waters, of which 
 Carlsbad water is the type. The many Carlsbad springs vary
 
 428 DISEASES OF THE STOMACH. 
 
 but little in the quantity of sodium sulphate, of sodium bicar- 
 bonate, and of salt which they contain, the chief differences 
 bein;4 in the temperature of tlie water as it comes from the 
 various springs. Some claim advantages for the natural water 
 or natural salts, but this superiority of the natural over the 
 artificial product may be doubted, although we sometimes 
 employ the "natural" Sprudel salts. The quantity of salt 
 (NaCl) in the Carlsbad water is objectionable, and it is the 
 large quantity of this ingredient in the Saratoga waters which 
 makes them injurious in the treatment of hypersthenic gas- 
 tritis. The salt either excites secretion (in small doses and 
 weak solutions), or it produces a diminution of HCl secretion 
 by causing acute gastric catarrh. But in small quantity and 
 in combination with an alkali it promotes peristalsis and 
 possesses some other advantages. We ordinarily prescribe 
 artificial salts in the proportions : 
 
 Sodium sulphate, 50 50 
 
 Sodium bicarbonate, 40 or 20 
 
 Sodium clilorid 10 5. 
 
 The first proportion (50:40: 10) is more strongly ant- 
 acid, and the second (50: 20: 5) acts more decisively on the 
 bowels, A level teaspoonful of the mixed salts should be 
 taken, by sips, dissolved in a glass of hot water, one hour 
 before breakfast. The dose should be increased (propor- 
 tionate increase of hot water) or decreased until only one 
 full soft movement of the bowels results. The cure should 
 be continued for three to four weeks, the patient taking but 
 little exercise. The Carlsbad cure should not be ordered for 
 the old and the weak, or for patients with valvular heart 
 disease. 
 
 A very valuable remedy, both to influence secretion and 
 to allay the excessive irritability and the morbid sensibility 
 of the mucous membrane, is the nitrate of silver (i : 2000) 
 douche, employed once a week. Or a tablespoonful of a 
 solution of one grain to two ounces of distilled water may 
 be given every morning on an empty stomach. Theoreti- 
 cally, belladonna, on account of its inhibitory action on 
 secretion, and its diminution of reflexes, is indicated; and, 
 practically, it is of very great value when given in small 
 doses (-\j to Tj^jj- of a gr.) before meals. Subnitrate of bismuth 
 is very valuable when given in the large doses and manner re- 
 commended by Kleiner. Small doses ofergot control the exces- 
 sive flow of blood to the mucous membrane during digestion. 
 
 Pain, vomiting, and constipation may require special atten-
 
 GASTRITIS. 429 
 
 tion. To relieve the pain, no remedy is so effective as the 
 aqueous extract of opium, which may be combined with a 
 good extract of cannabis indica and extract of belladonna, 
 j^Q- of a grain of each being employed. Codein is not so effi- 
 cient, but does not increase the constipation. These anodynes 
 should only be used when alkalies, diet, rest, the warm com- 
 press, belladonna, ergot, Carlsbad salts, nitrate of silver, and 
 bismuth fail to give relief. It is useless to treat the vomit- 
 ing with a symptomatic remedy, the act being conservative 
 and protective. Better encourage it by giving lukewarm 
 water, or wash out the stomach. 
 
 In addition to the remedies directed against the conditions 
 which underlie it, during the periodical attacks of gastric 
 intolerance a Winternitz or Priessnitz compress should be 
 placed on the stomach half an hour before the meal, and 
 kept there during the period of gastric digestion ; and in 
 all cases the compress should be worn at night. The con- 
 stipation is commonly relieved by the prescribed mineral 
 water, but the bowels may exceptionally require evacuation 
 by a warm water enema, to which a teaspoonful of neutral 
 glycerin may be added, or by gluten or glycerin supposi- 
 tories. 
 
 2. During the second period digestion is prolonged. The 
 evacuation of the stomach is delayed, and with the delayed 
 evacuation is associated excessive or continuous secretion, 
 and sometimes fermentation. The remedies used in the first 
 period may also now be useful, but the excessive or continu- 
 ous secretion must be relieved and the diet changed, so as to 
 avoid producing or increasing the fermentation, and to make 
 the demand on the motor function as light as possible. 
 
 Milk must be removed from the diet list and the butter 
 reduced to a minimum quantity. The fermentation may be 
 controlled by an exclusive meat diet for twenty-four or forty- 
 eight hours ; but the fermentation will begin anew with the 
 addition of the carbohydrates, provided the long period of 
 gastric digestion has not been shortened. But often with this 
 temporary change in the diet, combined with rest, hydro- 
 therapy, massage, and gastrospinal galvanization, the fermen- 
 tation may be controlled. A glass of hot water should be 
 slowly sipped every morning an hour before breakfast, during 
 the intervals when the Carlsbad cure is not in progress. 
 This soothing and cleansing remedy is far preferable to 
 stomach washing, as long as the morning fasting stomach is 
 empty and there is no fermentation. The diet during this 
 stage must not be reduced below the needs of nutrition, and
 
 430 DISEASES OF THE STOMACH. 
 
 during the temporary employment of an exclusive diet to aid 
 in suppressing the fermentation a nutrient enema should be 
 given daily. Stomach washing is more beneficial than in the 
 initial period, and it may be employed before the evening 
 meal, or at bedtime, or in the morning before breakfast, as 
 there may be, respectively, continuous secretion, or excessive 
 secretion, or continuous secretion and fermentation. What- 
 ever diet be adopted, it is absolutely necessary that the 
 stomach should be empty when a meal is eaten. Conse- 
 quently it may be best to allow only two meals a day, 
 separated by a long interval, and to use the tube twice a day 
 when secretion is prolonged and does not cease with the 
 evacuation of the stomach, or when secretion is continuous. 
 If the supersecretion is exclusively digestive, it may be best 
 to give a liquid and non-excitant diet, the frequent small 
 meals being separated by intervals long enough to permit the 
 evacuation of the stomach. If secretion is continuous, rectal 
 feeding is the best remedy. All forms of excessive secretion 
 are benefited by belladonna, ergot, nitrate of silver, and bis- 
 muth. 
 
 3. During the terminal period the treatment embodies the 
 same general principles which have regulated the plan of 
 medication in the other stages. The gastric secretion may 
 not be excessively rich, and the diet may be made more 
 liberal. Interstitial inflammation is the new factor with which 
 we have to deal, and it may require, for the relief of its acute 
 exacerbations, even more careful protection of the mucous 
 membrane against irritation, and temporary but complete 
 functional repose. It may be necessary to confine the patient 
 to bed, and to employ rectal feeding for a few days. When 
 secretion becomes diminished in quantity and richness, 
 it may be advisable to douche the interior of the stomach 
 with a physiological salt solution, or to administer five grains 
 of salt in a glass of hot water before breakfast, adding enough 
 sodium sulphate to regulate the bowels; for the intestines 
 demand the same solicitude and watching as in the other 
 stages of chronic hypersthenic gastritis. 
 
 III. GASTRITIS GLANDULARIS ATROPHICANS, OR ATROPHY 
 OF THE GASTRIC GLANDS. 
 
 Complete primary atrophy or degeneration of the secreting 
 structure of the stomach is not a frequent disease. It does 
 not embrace all cases in which there is prolonged absence of
 
 GASTRITIS. 43 1 
 
 gastric secretion, for this condition may occur in severe 
 adenasthenia gastrica complicated by interstitial inflammation, 
 and as a termination of other forms of benign and of malig- 
 nant gastritis. It does not embrace all cases of anadenia ven- 
 triculi. The pathological process is atrophic — a progressive 
 parenchymatous degeneration. 
 
 Glandular atrophy may be secondary. The severe infec- 
 tious and the chronic diseases which run a very long course 
 and are accompanied by great emaciation and loss of strength, 
 produce more or less parenchymatous degeneration of the 
 glandular membrane of the stomach, as do also cancer of the 
 breast, of the uterus, and of the intestines. This result is not 
 constant, but is common in the advanced stages of malignant 
 neoplasms of other organs than the stomach. 
 
 Diseases of the stomach itself may destroy its glandular 
 membrane. This is specially true of carcinoma of the stomach. 
 The destruction is either direct, the secreting cells not being 
 regenerated, or indirect, the glands being destroyed by com- 
 pression and by cellular degeneration. 
 
 But atrophy of the gastric glands may be primary and not 
 due to any other local or distant disease, or it may represent 
 the terminal period of other forms of gastritis. It is frequent 
 in the marasmus of old age, but is then rarely complete. 
 Chronic inanition may also produce it, and typical forms 
 result from phosphorus-poisoning and from arteriosclerosis. 
 It may be due also to the chronic toxemia of nutritive 
 troubles, or, at least, for unknown reasons, the parenchyma 
 of organs at times degenerates and dies instead of becoming 
 inflamed. The mucous membrane of the stomach is not 
 exempt from this sort of degeneration, and, in spite of its 
 usual great resistance, exceptionally and more markedly and 
 sometimes exclusively becomes affected by it. 
 
 Pathological Anatomy. — Glandular atrophy may be pri- 
 mary or it may represent the terminal period of catarrhal and 
 interstitial gastritis. 
 
 Interstitial gastritis may be present in catarrhal gastritis 
 and in proliferating glandular gastritis, and its degree influ- 
 ences the evolution of these forms of gastritis. It may de- 
 velop before the productive inflammation of the mucous 
 division of the mucosa (catarrhal gastritis), or it may begin 
 during the evolution of catarrhal gastritis. It rarely precedes 
 proliferating glandular gastritis, but is common in the terminal 
 period. It is the only productive process which occurs in 
 gastritis glandularis atrophicans. But in some cases the inter- 
 stitial inflammation dominates the pathological changes, and
 
 432 
 
 DISEASES OF THE STOMACH. 
 
 destroys the glands by compression. The changes in the 
 secreting cells are partly degenerative and partly irritative 
 and productive. It is the interstitial inflammation which 
 causes change of form during the evolution of gastritis, and 
 produces atypical clinical cases. If the interstitial inflamma- 
 tion is primary and dominates the evolution of the morbid 
 process, during the period of ad\'anced compression-atrophy, 
 the mucous membrane becomes grayish, smooth, and hard. 
 Here and there, imbedded in the newly-formed connective 
 tissue, may be seen the remains of the gastric tubules. The 
 compression-atrophy is most marked in the pyloric region. 
 The submucosa is thickened and infiltrated, and the infiltra- 
 tion often extends to the muscular layer. The wall of the 
 
 Fig. 23.— Gastritis chronica catarrhalis (terminal atrophy). X 115. (Authors' specimen.) 
 
 stomach is hard, thickened, and the stomach is reduced nota- 
 bly in size. Catarrhal gastritis, in the manner already de- 
 scribed, may end in complete destruction of the glandular 
 layer. 
 
 Glandular atrophy also occurs as the expression of a pri- 
 mary cellular degeneration. The stomach is then usually 
 small and its wall is very thin. The inner surface is smooth 
 and of a pale yellow or reddish color, or sometimes waxy. 
 Gastritis glandularis atrophicans is characterized by degen- 
 eration of both the cylindrical cells and the cells wliich line 
 the glands. Consequently, both the mucous and the glandular 
 divisions of the mucosa are affected by the cellular degenera- 
 tion. The cylindrical cells are converted into goblet cells
 
 GASTRITIS. 
 
 433 
 
 and into columnar cells with striated ends. Some are short 
 and indistinct in outline. The protoplasm loses its affinities 
 for stains, and falls into a pale granular mass. The chief and 
 the border cells can not be distinguished, or only here and 
 there can be seen a cell which preserves its identity. The 
 cells lose their form, diminish in size, yield to the pressure 
 due to the accumulation of degenerate cells, and their cyto- 
 plasm loses its affinities for stains and falls into a pale granu- 
 lar mass. The nuclei also undergo chromatosic degenera- 
 tion. Finally, the mucosa is converted into a soft mass of 
 embryonic cells, mixed with granular masses and hyaline 
 
 y. ' i^te 
 
 •^r:-:-*. ^;<:/,^ •Z:'^^^:-. ,/.>.•• 
 
 •*"* * •■ ' 
 
 
 Fig. 24. — Gastritis glatidiilaris atropliicans. X 115. (Authors' specimen.) 
 
 bodies, which represent degenerated secreting cells and degen- 
 erated wandering leukocytes. Here and there may be seen 
 fragments of partly preserved glands, and in other parts of the 
 mucosa may be found glands whose cells are undergoing 
 degeneration. The surface of the mucosa is without folds, 
 vulnerable, without prominences or depressions, and covered 
 with blood-stained mucus and coagulated protoplasm. The 
 interglandular and subglandular tissues are infiltrated with 
 embryonic cells, with disintegrating leukocytes, with esino- 
 phile cells, and with irregularly outlined, flattened, or elon- 
 gated nucleated cells with granular protoplasm. The sub- 
 
 mucosa is somewhat thickened, and the walls of the arterioles 
 
 28
 
 434 DISEASES OF THE STOMACH. 
 
 in some cases undergo amyloid degeneration. Tlie muscular 
 layer is commonly left intact in the earlier stages, but it may 
 become infiltrated and lose its power. The morbid process 
 is essentially a cellular degeneration without reparative effort, 
 which is accompanied by interstitial inflammation. The final 
 result is complete glandular destruction. Such is atrophy of 
 the gastric glands — a primary and distinct form of gastritis. 
 
 Clinical Description. — The evolution of glandular atrophy 
 may be divided into three periods of variable duration : the 
 periods of compensation, of gastric symptoms, and of inani- 
 tion. The patient is usually in the last third of the normal 
 course of life, but gastric atrophy may occur at an early age. 
 
 The period of compensation may be short or may extend 
 over a number of \'ears. During this period there are no 
 digestive symptoms, and the body remains well nourished. 
 The intestines do perfectly the chemical work of the stomach, 
 the integrity of the motor function of the stomach being pre- 
 served. The secretion of the stomach is diminished, or even 
 completely lost. The hydrochloric acid and the ferments are 
 all about equally decreased or lost. The quantity of mucus 
 in the test-meal contents and in the lavage water may be in- 
 creased or it may be diminished. Nutrition is maintained by 
 the intestines without digestive disturbance. 
 
 The period of gastric symptoms is also variable in duration, 
 and may exist from the beginning of the disease. These symp- 
 toms are often ill-defined, but sometimes characteristic. There 
 may be a little heaviness, or fullness, or flatulency after meals, 
 attended by discomfort, occasionally by bilious or alimentary 
 vomiting, sometimes by diarrhea, but more frequently by 
 constipation. In cases of glandular atrophy, diarrhea is easily 
 produced by dietetic errors and excesses. The vomit some- 
 times contains blood, particularly when grave oligocythemia is 
 present. The appetite is diminished, often lost, a disgust for 
 meats may e.xist, but the cereals, fish, milk, vegetables, and 
 fruits are eaten more readily, without, however, relieving ma- 
 terially the distress. During short intervals of two or three 
 weeks the symptoms may disappear, but again return. More 
 characteristic is the digestive pain, which sometimes continues 
 until the stomach is empty, and often begins as soon as the 
 food, or even water, enters the stomach. The pain is almost 
 invariably e.xcited when the stomach is distended with food 
 or by inflation. The pain is sometimes very severe, and when 
 associated with the functional signs of atrophy is of very great 
 diagnostic value. During the period of gastric repose par- 
 oxysmal peristaltic pains may develop in the colon. The
 
 GASTRITIS. 435 
 
 epigastrium may be very sensitive. Vomiting is an occa- 
 sional symptom, and the stomach may become intolerant. 
 
 The gastric and the inanition periods are not clearly separ- 
 ated. The two may begin together, or the inanition may 
 commence with intestinal disturbance, particularly diarrhea, 
 and the gastric symptoms appear later. Sometimes the gastric 
 symptoms may never become prominent, or they may only 
 appear periodically after days of comfort. 
 
 The inanition is usually progressive, and, unless due to a 
 temporary disturbance of the intestines or to improper diet, 
 it produces death by starvation in six or eight months. The 
 patient becomes weak, pale, cachectic, and sometimes neuras- 
 thenic. Dyspnea and palpitation occur on the least effort. 
 The mind becomes quickly tired, and insomnia is often obsti- 
 nate. But emaciation may not be great, as the bloodless and 
 inactive patient burns but little of the body fat. Nearer to the 
 fatal termination, the fat in the food is better absorbed by the 
 intestines than is any other food. Inanition delirium and 
 sometimes coma, precede the death of the prostrated, blood- 
 less, cachectic, and starved patient. 
 
 Symptomatology. — The loss of appetite, the vague diges- 
 tive symptoms, vomiting, constipation, and diarrhea are com- 
 mon to a number of severe chronic diseases of the stomach, 
 and have little diagnostic value. Of more importance are the 
 pain and inanition. Severe paroxysms of pain, usually diges- 
 tive, but rarely occurring when the stomach should be empty, 
 and then, as a rule, excited by a reflux of bile, associated with 
 greatly diminished or lost gastric secretion, and with preser- 
 vation of the motor function, should arouse suspicion of 
 glandular atrophy. Pain, in association with nearly lost 
 gastric secretion, occurs in carcinoma, but is very rare in 
 chronic asthenic gastritis and adenasthenia gastrica. 
 
 The inanition may become very pronounced, be even 
 fatal, and characterizes one of the stages of the disease. Its 
 coexistence with motor sufficiency of the stomach, and with 
 the employment of a diet containing nutriment enough to meet 
 the requirements of the body, and its increase and decrease in 
 relation with the digestive and absorptive work done by the 
 intestines, are distinctive features. It may be progressive in 
 spite of every effort to nourish the patient, and may be accom- 
 panied by the usual signs of grave oligocythemia. Emacia- 
 tion does not occur until intestinal digestion and absorption 
 begin to fail, unless the diet is insufficient. The body fat may 
 be preserved even when the patient is almost bloodless. 
 
 The severe anemia is generally secondary. The total
 
 436 DISEASES OF THE STOMACH. 
 
 quantity of the blood is diminished, but there are often no 
 hemic murmurs, and the hemoglobin percentage is less reduced, 
 as a rule, than that of the red corpuscles. There is leuko- 
 penia, but the polynuclear white cells largely predominate, and 
 there are megalocytes, poikilocytosis, and microcytes, but no 
 megaloblasts. Lymphemia and nucleated red corpuscles of 
 normal (normoblasts) or of abnormal (microblasts, megalo- 
 blasts, gigantoblasts) sizes are rarely found in the secondary 
 grave oligocythemia of atrophy of the gastric glands. As a 
 result of the disease of the blood there may be hemorrhages 
 in the retina, from the mucous membranes, and in the structure 
 of the various organs. In a case of the authors, with hemor- 
 rhages but no megaloblasts, the liver and kidneys contained 
 no accumulation of iron, and the stomach was small, thin, and 
 the gastric glands were completely atrophied. The glands of 
 the stomach may undergo fatty degeneration in grave oligo- 
 cythemia due to other causes, just as do the kidneys and the 
 heart muscle. The anemia caused by atrophy of the gastric 
 glands is simply a grave secondary inanition anemia, accom- 
 panied by an altered plasma which becomes hematocytolytic, 
 and by diminished resistance and insufficient development of 
 the red and white corpuscles. 
 
 The physical signs are of little diagnostic value. The 
 stomach is usually small and does not splash abnormally. 
 The epigastric tenderness may create a false suspicion of 
 ulcer or of carcinoma. The physical signs po-ssess chiefly a 
 negative diagnostic value. 
 
 The functional signs of atrophy of the gastric glands con- 
 stitute, clinically, its chief distinctive features. The motor 
 function is normal, and if the food be fluid and finely divided 
 it usually leaves the stomach even earlier than in health. But 
 motor insufficiency does not necessarily exclude glandular 
 atrophy, as the motor insufficiency may be an accidental asso- 
 ciation, produced by other causes, but never by the glandular 
 atrophy. There is no dclaj'ed evacuation of the stomach 
 produced by excessive secretion, or by continuous secretion, 
 or by obstruction, or by spasm of the pylorus, or by weak- 
 ness or infiltration of the muscular layer. The stomach 
 grows small as its wall becomes thin. 
 
 After the test-breakfast the contents contain neither HCl 
 (free or in organic combination), nor pepsin, nor labferment, 
 nor the mother substances of the ferments. There may be 
 little or no excess of mucus, unless it be swallowed, and only 
 a few c.c. of water or secretion fluid. Such is the almost 
 total absence of secretion when the atrophy is complete.
 
 GASTRITIS. 437 
 
 When incipient or partial, all the products of secretion simply 
 diminish more or less. 
 
 In the expressed contents — small in quantity, thick, contain- 
 ing little water, with the roll, as swallowed, unchanged physi- 
 cally, covered with mucus or mixed with a little slimy fluid — 
 are found none of the products of pepsin-hydrochloric diges- 
 tion. Starch digestion is normal, and the reaction with Fehl- 
 ing's solution is positive. 
 
 There are no characteristic bacteriological signs. The 
 germs that are found have been swallowed. There may be a 
 trace of lactic acid (ether extract), but never after previous 
 lavage. Sometimes there is a little butyric acid. The total 
 acidity may vary from zero to 8 or lo. The sweetened 
 contents yield no gas in the fermentation tubes. 
 
 Blood is sometimes vomited, and usually comes from con- 
 gested vessels about the cardia. An important anatomical 
 sign of differential diagnostic value is the absence of well- 
 preserved gastric epithelium in the morning washings from 
 the stomach. The tube is rarely used without obtaining a 
 little bloody exudate, and, frequently, pieces of the degener- 
 ated mucous membrane, goblet cells, and leukocytes from 
 the interglandular tissues. 
 
 Neither digestive leukocytosis nor the diminished acidity of 
 the urine secreted during the period of functional activity of 
 the stomach occurs. Digestive leukocytosis, however, occurs 
 during the stage of compensation and before inanition and 
 anemia develop. 
 
 Differential Diagnosis. — Atrophy of the gastric glands 
 may be confounded with adenasthenia gastrica, chronic as- 
 thenic gastritis, and carcinoma. 
 
 Adenasthenia gastrica is most common in hysterical or neu- 
 rasthenic women, between the ages of fifteen and thirty-five. 
 Gastric atrophy is more common in men after the thirty- 
 fifth year. The dynamic affection is often remittent in its 
 course, being accompanied by rapid changes in secretion. 
 Atrophy of the gastric glands, after digestive compensation is 
 lost, often runs a rapid and progessive course to a fatal termi- 
 nation within a year. Secretion once lost is never recovered. 
 In adenasthenia gastrica the acid secretion varies from a 
 slight decrease of the normal quantity to a total temporary 
 loss. There may be little or no free HCl in the contents after 
 the test-breakfast, or only combined hydrochloric acid, or 
 none whatever. The secretory activity of the stomach now 
 drops, now rises rapidly, and may nearly always be excited so 
 as to give plain ferment tests. The secretion of mucus in
 
 438 DISEASES OF THE STOMACH. 
 
 adenasthenia gastrica is never increased, and may not be even 
 altered when the acid secretion is completely suppressed. 
 The morning washings of the stomach contain well-preserved 
 and perfectly staining gastric epithelium, which is never found 
 in glandular atrophy. In the dynamic affections there is no 
 vomiting, no paro.xysmal pain, or, if the diet is sufficient, there 
 is no emaciation, inanition, grave anemia, nor cachexia, nor 
 signs of an anatomical disease of the mucous membrane. 
 Indeed, the two diseases are not likely to be confounded, 
 except during the compensation stage of glandular atrophy. 
 Moreover, adenasthenia gastrica never produces persistent 
 achylia. The disproportion between the glandular destruc- 
 tion in cases of so-called "simple achylia" and the complete 
 suppression of secretion is no proof of the nervous nature of 
 "simple achylia." There may be complete suppression of 
 secretion in severe asthenic gastritis accompanied by acute or 
 subacute interstitial inflammation. Interstitial gastritis may 
 reduce the excessively rich secretion of hypersthenic gastritis 
 to hypochylia. In both cases the chief and border cells may 
 be in perfect preservation, and this condition is, consequently, 
 out of harmony with the depression of secretion. The nervous 
 system may be highly toned without influencing secretion in 
 so-called nervous or "simple achylia." Where pieces of 
 mucous membrane, in our experience, have shown the par- 
 tial preservation of the peptic glands and cells, there has been 
 marked interstitial infiltration, and, usually, advanced changes 
 in the mucous division of the mucosa; or other pieces ob- 
 tained from the same cases have shown the characteristics of 
 glandular atrophy. We can not admit, therefore, the exist- 
 ence of persistent achylia as a dynamic affection. Secretion 
 may sometimes be restored by treatment when the achylia 
 is due to interstitial gastritis. 
 
 Some cases of carcinoma of the stomach may be readily 
 mistaken for glandular atrophy. Cancer nearly always pro- 
 duces motor insufficiency and an active bacillary germ growth. 
 This is a valuable differential sign, and is conclusive when 
 associated with lactic acid formation. But motor insufficiency 
 may not develop until late in the evolution of some cases of 
 cancer, and may never develop in some cases of scirrhus. 
 The ferments do not completely disappear until late in the 
 cachectic stage of cancer. The blood changes are unlike 
 those of gastric atrophy. Hemorrhage is more frequent, pain 
 is more constant, and a tumor can often be detected. Mucus 
 in large quantity, and cancer cells or exfoliations, may be 
 found in the vomit, in the morning washings, and in the ex-
 
 GASTRITIS. 439 
 
 pressed contents after a test-breakfast. The clinical history, 
 particularly the state of the health of the patient when the 
 trouble began, may often give weight to the one or the other 
 side. Both diseases may be progressive and may rapidly 
 terminate in death by inanition, the inanition being toxic 
 (protoplasm poison) in the one and intestinal in the other. 
 The differentiation must be made by a careful study of all the 
 circumstances, symptoms, and signs. Some are found only 
 in the one or the other disease ; some are more common in 
 the one than in the other. The ill-defined atypical cases of 
 the two diseases may so closely resemble each other as to 
 leave the physician in ignorance and doubt. Atrophy may 
 be a complication of cancer, developing during the cachectic 
 period. 
 
 Chronic asthenic gastritis is a painless disease ; the diges- 
 tive symptoms vary with the quality (solid or liquid) of the 
 food, and mucus is secreted in excess. In the uncomplicated 
 cases the nutrition of the body is well preserved, and there 
 is properly no extreme emaciation nor grave, progressive 
 anemia. The course is long and tedious. These symptoms 
 and signs are all in contrast with those of glandular atrophy, 
 which may, however, develop as the anatomical termination 
 of chronic asthenic gastritis. The clinical history and evolu- 
 tion are then the chief distinctive features. Both these forms 
 of atrophy may be accompanied by paroxysms of pain. 
 Chronic hypersthenic gastritis is widely different in its mani- 
 festations, evolution, and objective signs from atrophy of the 
 gastric glands. 
 
 Prognosis. — Atrophy of the gastric glands may not in itself 
 seriously compromise the general health nor shorten life. It 
 calls into activity all the reserve forces of digestion, but the 
 healthy intestines stand between it and inanition. With good 
 digestive hygiene and a proper diet, digestive compensation 
 need not be disturbed. But even when completely compen- 
 sated, the disease constitutes a weakness, and opens the portals 
 to gastro-intestinal infection. 
 
 When digestive compensation is destroyed and the intes- 
 tine fails to do its work, the situation becomes grave. The 
 prognosis is bad when the inanition and anemia are marked 
 and are uncontrollable by proper treatment. The disease is 
 in the stomach, but the prognosis is given by the intestines, 
 by the state of nutrition and of the blood, and by the com- 
 plications, and, when the glandular atrophy is secondary, by 
 the causative disease. Atrophy of the gastric glands does 
 not render the preservation of good health impossible, but it
 
 i140 DISEASES OE THE STOMACH. 
 
 is a constant menace, and may lead to death by inanition 
 within a few months. 
 
 Treatment. — In the treatment of atrophy of the gastric 
 glands physical remedies have no place. Lavage, the intra- 
 gastric douche, intragastric electrization, and massage are not 
 only without purpose, but may injure the exceedingly vulner- 
 able mucous membrane. The stomach must be protected at 
 all hazards, for acute inflammation may be excited and the 
 motor function thus impaired. No effort need be made to 
 excite or to restore secretion. This function of the stomach 
 is irreparably lost. Physiological treatment is useless and 
 harmful. There is no hope of making a degenerate cell work, 
 or of restoring its waning vitality by stimulation and excita- 
 tion. Excitant medication only hastens the death of the cell, 
 or if the cell be already destroyed excitation is altogether out 
 of place. The only local treatment of a degenerate cell which 
 is beneficial is most scrupulous and vigorous protection. But 
 the motor function of the stomach should be carefully guarded 
 and strengthened. 
 
 This can best be done by careful digestive hygiene, h}'dro- 
 therapy, faradism, and in some cases by the use of a few 
 drugs. Rest before and after each meal, the avoidance of 
 overloading the stomach, and the exclusion of innutritions, 
 indigestible, and irritating food and drinks are always neces- 
 sary. Water should be used to tone the neuromuscular 
 systems. The Scottish douche over the abdomen and lower 
 extremities is an excellent procedure the value of which is 
 proven by clinical experience. External faradism may also 
 be employed. The object is twofold — to diminish the work 
 required of the gastric muscle and to keep the muscle 
 more than equal to its work. 
 
 The next object is to aid and to protect the intestines, 
 thus securing and maintaining digestive compensation. The 
 abdomen should be carefully guarded by proper clothing 
 against extremes and changes of external temperature. The 
 food should be finely divided, digestible, and utilizable, freshly 
 prepared and sterilized ; no coarse, irritating food or drinks, 
 and no food liable to ferment or to putrefy. The same policy 
 of careful protection of the intestines should extend to drugs 
 — no irritants, nothing to disorder digestion, no purgatives, 
 and particularly no salines. The bowels should be regulated 
 by the diet, intestinal massage, electricity, and the employ- 
 ment of small laxative rectal injections. 
 
 The work of the intestines may sometimes be lightened by 
 the employment of pancreatin and a little soda or a fresh ex-
 
 GASTRITIS. 441 
 
 tract of pancreas. Papoid sometimes helps. The administra- 
 tion of hydrochloric acid and pepsin, contrary to what might 
 theoretically be expected, does no good. Chemical treat- 
 ment would seem to be strongly indicated, and theoretically 
 this is so. Give pepsin and hydrochloric acid, and give them 
 in sufficient quantities to replace the stomach's lost digestive 
 power, is the plausible rule of practice. Our experience with 
 this method forces us to oppose it obstinately. In some cases 
 it does no very obvious harm, but it does not relieve the sub- 
 jective symptoms, if they exist; it sometimes excites discom- 
 fort; it does not improve nutrition; but it often disturbs in- 
 testinal digestion ; it often increases intestinal putrefaction and, 
 consequently, auto-intoxication ; it arrests ptyalin digestion 
 in the stomach ; and it irritates the vulnerable mucous mem- 
 brane. If chemical treatment is to be employed it is better 
 to give pancreatin and a little soda, a fresh extract of pan- 
 creas, or a vegetable ferment. 
 
 The patient should be as well nourished as possible, and 
 under no circumstances should an insufficient diet be pre- 
 scribed. The disease is in the stomach, but a danger is in 
 starvation. 
 
 The diet is selected by the stomach, by the needs of nutri- 
 tion, and chiefly by the intestines. It is the intestines which, 
 in this disease, have all the food to digest and utilize. The 
 food should be easily evacuated by the stomach, digestible 
 and utilizable by the intestines, and sufficient to supply the 
 demands of the body for nutriment. 
 
 The food should be all very finely divided, fresh, and nutri- 
 tious. Sterilized milk, if well borne, and the fermented pre- 
 parations of milk are suitable. The cereals — rice and the 
 preparations of wheat and of Indian corn are the best — should 
 be cooked all to pieces. Only bread thinlysliced and browned 
 through and through should be permitted. Expressed meat 
 juice, meat broths (small quantity), or clear vegetable soup 
 (either may be thickened with a thoroughly cooked cereal), 
 meat powder, and lean, short-fibered fish are well borne. 
 The lean pulp (Enterprise chopper, old pattern) of the 
 fresh meats and fowl and game — beef, mutton, chicken, 
 white meat of turkey, quail, etc. — may be made into cakes 
 and broiled with a little butter. Eggs often disagree, par- 
 ticularly when much of the yolk is eaten. Spinach, string 
 beans, and fresh garden peas should be thoroughly cooked 
 and passed through the colander or sieve. The juice of a 
 ripe orange, or of a few grapes, or a baked apple may some- 
 times be permitted. Fresh butter, and cream, and breakfast
 
 442 DISEASES OF THE STOMACH. 
 
 bacon are the best forms of fat. Cod-liver oil is suitable if it 
 agrees. Coffee, very weak tea, " vigor chocolate," some- 
 times cocoa, and plain water usually also agree very well. 
 From this list a mixed and supporting, or even restorative, 
 diet may be selected. 
 
 When inanition or anemia begins rest should be ordered 
 to diminish the requirements of nutrition, and the diet should 
 be supplemented by rectal feeding. Every effort must be 
 made to maintain the volume and richness of the blood, and 
 an intestinal complication should receive prompt treatment. 
 
 Briefly stated, the chief indications to be met in the man- 
 agement of chronic atrophy of the gastric glands are : 
 (i) Protect the stomach against all mechanical and chemical 
 irritation ; (2) preserve and strengthen and favor its motor 
 function; (3) maintain intestinal digestive compensation ; (4) 
 maintain the nutrition of the body, the composition of the 
 blood, and the tone and strength of the neuromuscular sys- 
 tems. 
 
 CHAPTER IL 
 
 ULCER OF THE STOMACH. 
 
 Ulceration of the gastric mucosa ma\- occur as an episode 
 in the evolution of acute and chronic gastritis and during the 
 course of neoplasms of the stomach. The mucous membrane 
 maybe studded with punctate erosions; or there may be small 
 ulcers of the size of the head of a pin which e.xtend into or 
 through the mucosa; or there may be superficial and, rarely, 
 deep ulcers running along the course of obliterated blood- 
 vessels. The formation of the erosions of gastritis may often 
 be revealed by the little exfoliations or sloughs, which are 
 rarely larger than i of an inch in diameter, and which 
 are most readily found in the early morning lavage water. 
 The neoplasms of the stomach may also ulcerate. Insignifi- 
 cant or profuse hemorrhages may accompany these forms of 
 secondary ulceration. Primary ulceration may occur as a 
 local bacterial infection in anthrax, in tuberculosis, and in 
 syphilis. Tubercular ulceration of the stomach is rare, and is 
 accompanied, as a rule, by pulmonary or intestinal tubercu- 
 losis. We have been able to collect only 23 authentic cases. 
 Syphilitic ulcer of the stomach is also rare ; and, like the
 
 ULCER OF THE STOMACH. 443 
 
 tubercular ulcer, it is a postmortem discovery, and is conse- 
 quently of no great interest to the physician. Such is not, 
 however, the case with simple ulcer of the stomach. 
 
 Ulcer of the stomach is an anatomical disease, characterized 
 by a sharply limited defect of the mucous membrane, distinct 
 in its genesis, its form, and its evolution. The disease has 
 been given many other names descriptive of some striking 
 peculiarity or embodying a theory of its genesis — simple, 
 round, chronic, perforating, corrosive, rodent, hemorrhagic, 
 peptic. 
 
 The most frequent functional sign is digestive hydrochloric 
 superacidity, but this sign is neither constant nor characteris- 
 tic. As a clinical entity it is a modern disease, and is charac- 
 terized in its typical form by gastric pain, by hemorrhage, and 
 by vomiting. These cardinal symptoms are not constant, and 
 are characteristic only when possessing a number of distinc- 
 tive features. Beneath the play of expression the unity of the 
 disease is preserved by the gross anatomical and microscopic 
 characters of the localized destruction of the mucous mem- 
 brane, tending to go deeper and to involve the other layers. 
 
 Frequency. — The frequency of gastric ulcer varies in dif- 
 ferent parts of the world. Most English and American 
 authors state that in about 5 per cent, of deaths from all 
 causes an ulcer or an ulcer scar can be found. According to 
 Lebert, in about 4 per cent, of the autopsies made in middle 
 Europe either an open ulcer or a cicatrix is found. Of 41 ,688 
 cases treated in the clinics of Zurich and of Breslau by Lebert, 
 about 0.6 per cent, had gastric ulcer. In hospital practice 
 McCall Anderson met with 35 cases of ulcer in 2538 medical 
 cases, or about i in 73. The statistics of autopsies collected 
 by others give important variations from these percentages — 
 for instance, Dahlaup (Copenhagen), 13 per cent.; Nolte 
 (Munich), 1.23 percent.; Waldeyer (Breslau), 1.6 per cent.; 
 Lebert (Breslau), 2.5 per cent.; Jaksch (Prag), 3.2 per cent.; 
 Jaworski and Korczynski (Krakow), 0.24 per cent. ; Hauser 
 (Erlangen), 3.4 per cent.; Steiner (Berlin), 3.6 per cent.; 
 Berthold (Berlin), 2.7 per cent.; Starke (Jena), 10 per cent. 
 Age, sex, occupation, diet, and the prevalence of gastric 
 troubles associated with excessive secretion may explain the 
 differences of the statistics. The personal equation of the 
 pathologist doubtless also comes into play, some searching 
 with greater interest and care for small ulcer scars. Cases 
 are likely to be included in the statistics where the stomach 
 was not carefully examined. In a large private practice, con-
 
 444 
 
 DISEASES OF 11 IE STOMACH. 
 
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 ULCER OF THE STOMACH. 445 
 
 sisting almost exclusively of patients with gastric and intes- 
 tinal diseases, we have found simple ulcer in about i in 134 
 cases. 
 
 Of the 618 deaths from ulcer in New York City (see Table) 
 during the decad 1 887 to 1 896, 306 were male and 312 were fe- 
 male. As regards the age at which death occurred, 97 were 
 under twenty-five years; 231 were between twenty-five and 
 forty-five years; 219 were between forty-five and sixty-five 
 years (or 450 between twenty-five and sixty-five years) ; and 
 71 were between sixty-five and eighty-five years. 
 
 Average number of deaths Average number of deaths 
 Average population of N. Y. annually from all causes, ainiually, from ulcer, 
 
 City for decad 1887-1896. 1S87-1S96. 1887-1S96. 
 
 1,781,301 41,738 62 
 
 Population N. Y. City, 1896. Total deaths, N. Y. City, Deaths from ulcer, N. Y. 
 
 1896. City, 1896. 
 
 1,934,972 40,557 81 
 
 According to these statistics, i in every 763 of the total 
 deaths (i 887-1 896), or i in every 500 of the total deaths 
 (1896), is due to ulcer of the stomach; or i in every 28,730 
 living inhabitants (i 887-1 896), or i in every 23,888 living in- 
 habitants (1896). The death-rate of ulcer, like that of cancer 
 (Bryant), is increasing from year to year. The increase is 
 not due to accident, or to worse methods of treatment, or to 
 the greater and greater frequency of ulcer; but the increasing 
 death-rate may, in all probability, be explained by greater 
 accuracy of death reports. 
 
 Etiology. — The occurrence of gastric ulcer is in close rela- 
 tion with the age, some periods of life being remarkably free 
 from the disease and others conspicuous on account of its 
 frequency. Certainly, these variations can not be attributed to 
 the influence of age itself, but are due to the prevalence at 
 certain periods of life of the many predisposing causes more 
 closely connected with the genesis of the trouble. 
 
 Simple gastric ulcer is very rare before the tenth year. 
 This exemption may be due in part to the diet, to the rarity 
 of chronic disease of the stomach accompanied by the secre- 
 tion of an excessively active and acid gastric juice, to healthy 
 arteries, and to the great resistant and reparative powers of 
 the young. It is also supposed by some that an ulcer, should 
 it occur, would likely remain latent, and heal rapidly under 
 the influence of the bland diet employed in the digestive dis- 
 orders of infancy and childhood. But autopsies made on 
 children before the tenth year reveal, with comparative rare- 
 ness, either an ulcer or an ulcer scar.
 
 44^ DISEASES OF THE STOMACH. 
 
 In drawing conclusions from statistics showing the relation 
 of age to the genesis of simple ulcer of the stomach, errors 
 are likely to be made. Evidently, the cases where only cica- 
 trices are found must be deducted from the statistics of autop- 
 sies, for the time when the ulcer or its scar is found does 
 not represent the date of its commencement. One of the 
 clinical characteristics of ulcer is its chronicity, and the 
 ulcer or its scar may be unexpectedly discovered postmortem 
 a long period after its beginning. If death be due to the 
 ulcer, and the clinical history be known, still, the early period 
 may have been entirely latent. After the correction of the 
 statistics it will be found that more than one-half of the cases 
 begin between twenty and thirty, and about four-fifths be- 
 tween twenty and forty. About nine-tenths of the deaths 
 from gastric ulcer occur between twenty and sixty, but the 
 period of greatest mortality is between forty and sixty. After 
 the sixtieth year the frequency and the mortality are low, as few 
 cases which began at the age when the disease predominates 
 are brought over and credited to the later period. Ulcer in 
 old age is a very fatal disease, on account of the low healing 
 power when life's course is nearly run ; but it is not a frequent 
 disease, possibly on account of the low hydrochloric acidity 
 of the gastric juice. 
 
 Simple ulcer of the stomach is more frequent in the 
 female than in the male, but the statistics taken in different 
 localities at different times give inconstant results. This is 
 very apparent in the statistics of Lebert. Of the 41,688 
 patients treated in the clinics, 21,020 were men (69 cases) and 
 20,688 women (183 cases). According to these figures, the 
 disease is nearly three times more frequent in women (0.32 
 per cent, to o 88 per cent.). In Breslau the proportion is i 
 to 3.5, but in Zurich it is 3 to 4, in favor of its predominance 
 in women. McCall Anderson, in his statistics of 2538 medi- 
 cal cases, of which 927 were women and 161 1 men, records 
 that 32 of the 35 cases of ulcer occurred in women (i in 29) 
 and 3 in men (i in 537). Most authors, including Brinton, 
 give the proportion as about i to 2, but Steiner says 8 to 1 1, 
 and Willigk proposes i to 3 in favor of its greater frequency 
 in women. After the fiftieth year ulcer is more frequent in 
 men than in women. Many circumstances may explain the 
 differences in the statistical reports; such as age, occupation, 
 constitution, diet, and the predominance in women of certain 
 diseases which act as predisposing causes of ulcer, such as 
 gastroptosis, hysteria, and chlorosis. Ulcer is more frequent 
 in hysteria and less frequent in chlorosis (one per cent.,
 
 ULCER OF THE STOMACH. 447 
 
 Hayem) than is popularly believed. Rasmussen claims that 
 tight lacing produces a furrow across the stomach beneath 
 the edge of the right costal border, and he states that ulcer 
 develops frequently along this furrow. Some predisposing 
 diseases are more frequent in men — e. g., arteriosclerosis and 
 hypersthenic gastritis. It is difficult to estimate the exact 
 influence of sex, but clinical 'and postmortem observation 
 establishes the greater frequency of the disease in women. 
 
 Occupation and the social and financial condition seem, 
 directly or indirectly, to exert an influence in the causation of 
 ulcer. It is well known that the disease is frequent in cooks, 
 supposably on account of the pernicious habit of tasting hot 
 dishes, of irregular eating, and, possibly, on account of reflex 
 secretion, and of the presence in the stomach of a quantity 
 of uncombined acid. A delayed dinner in this way often 
 produces a gastric headache. Cooks are often affected with 
 adenohypersthenia, a favorable condition for the develop- 
 ment of ulcer in conjunction with a local disturbance of cir- 
 culation and of nutrition. Traumatism, associated or con- 
 nected with the occupation, is a causative influence, much 
 more frequently active than is commonly believed. House 
 girls are more subject to gastric ulcer than is any other class, 
 since they are so often anemic or chlorotic, and suffer from 
 menstrual disorders. The disease is much more frequent 
 among household servants than among the rich, with the 
 exception of the clinical form of ulcer developing in the 
 anemic girl and proving rapidly fatal by perforation. It is 
 rare among those who live and work in the open air, and 
 who eat largely a vegetable diet. The disease is almost 
 unknown in parts of Russia, in the Rhone Valley, and 
 among the Bavarian Alps, inhabited by a poor peasantry who 
 rarely get an opportunity to taste meats or highly-sweetened 
 articles of food. Yet the disease is very rare among the 
 negro field-laborers of the South, who live on cornbread, 
 molasses, and bacon. The character of the diet is without 
 influence in the production of the disease, unless, in com- 
 bination with other factors, it engenders chronic hypersthenic 
 gastritis. Alcoholism and iced drinks have not the etio- 
 logical influence often attributed to them. Ulcer respects no 
 class, nor condition, nor vocation, but develops most fre- 
 quently in those who are predisposed to local disturbances of 
 the circulation or to a local trophic defect; and it compli- 
 cates most often the diseases, local or general, which are 
 accompanied by a richly acid gastric secretion. 
 
 Age, sex, occupation, diet, and the social and financial con-
 
 44^ DISEASES OF THE STOMAL'//. 
 
 dition are only predisposing causes. More directly and closely 
 related to the genesis of the ulcer are certain cardiovascular 
 diseases, diseases of the blood, infectious diseases, and diseases 
 of the stomach. 
 
 The influence of diseases of the heart and the blood-vessels 
 is unquestionable, ulcer being often the consequence of 
 arteriosclerosis, embolism, thrombosis, hemorrhagic infarct, 
 and intense local inflammation. The circulation of a circum- 
 scribed area is thus cut off, resulting in local death, and in 
 the digestion of the dead tissue. It has long been claimed, 
 both on clinical and anatomical grounds, that chronic ulcer 
 may be caused by a local disease of a blood-vessel of the 
 stomach. This may occur in arteriosclerosis, in the diseases 
 of the red corpuscles, in syphilis, and such other diseases as 
 produce inflammatory or degenerative changes of the arteries. 
 As a result of the fatty degeneration of the arterial wall, of a 
 small aneurysm, of arteriosclerosis, or of endarteritis, a small 
 arterial branch becomes plugged or obliterated, and the area 
 of the mucosa fed by this small artery dies and is cast off or 
 digested, leaving an ulcer of the peculiar shape and form of 
 chronic ulcer of the stomach. This explanation of the 
 genesis of ulcer has been ably defended by Virchow and 
 others. It is denounced by some pathologists on the grounds 
 that ulcer is rare in old age, when arterial disease is frequent ; 
 that it is frequent before the age of forty, when disease 
 of the arteries (non-syphilitic) is rare; that ulcer occurs fre- 
 quently when there is no disease of the arteries ; that diseases 
 of the arteries exist so frequently without an ulcer forming 
 throughout their long course ; that arteriosclerosis may 
 produce atrophic gastritis without causing an ulcer. These 
 facts should be given their due weight ; but it is not claimed 
 that all ulcers are produced by arterial disease, and it is 
 known that some gastric ulcers are caused in this manner. 
 The obliteration of a small artery, be it due to disease of its 
 walls, to embolism, to thrombosis, or to a node-like and 
 intense inflammatory infiltration and compression, may be the 
 cause of ulcer, just as a hemorrhagic infarct may produce 
 the death of a circumscribed part of the muco.sa which lies 
 over it. Ulcer is not a disease with a single cause and one 
 mode of genesis, as is often assumed. 
 
 The etiological influence of the diseases of the blood is 
 questioned by man)' authors, who consider the blood changes 
 secondary. It is doubtless true, if the evidence of close clini- 
 cal study is trustworthy, that the anemia is often hemorrhagic 
 or due to inanition, the ulcer being primary, but prevented
 
 ULCER OF THE STOMACH. 449 
 
 from healing by the dystrophic influence of the thin blood. 
 This is well shown by the evolution of the anemia and by its 
 rapid cure by controlling the hemorrhage and the inanition. 
 That a supposed primary anemia may be the consequence of 
 a latent ulcer is also a possibility. It is equally certain that 
 the anemia is often primary and causative, or is a coeffect. 
 The existence of chlorosis can be explained only as a coinci- 
 dence or as a cause, for neither hemorrhage nor inanition 
 will produce it, and ulcer is far more frequent in chlorosis 
 than in oligocythemia. The diseases of the blood are sup- 
 posed to act by producing a local arterial spasm or fatty 
 degeneration of the arterial walls. Hydrochloric super- 
 acidity is not rare in chlorosis, and could at least make the 
 genesis of the ulcer easier. It may be taken as a clinical fact 
 that oligocythemia and chlorosis may aid in the generation 
 and often play a predominant part in the persistence of ulcer. 
 
 It has been maintained by some that ulcer is a specific 
 process, and bacteriology has been called upon to reveal the 
 unique cause. That ulcer may result from an infectious disease 
 seems established by clinical observation and by experimental 
 pathology. Cases have been reported following diseases 
 associated in their evolution withpus formation or the pro- 
 duction of hemorrhagic infarcts or thrombi, and the patho- 
 genic bacteria have been found in the blood-vessel where the 
 necrotic process was localized (LetuUe). Puerperal fever, 
 typhoid fever, endocarditis, abscess, suppurative peritonitis, 
 pleurisy, tuberculosis, and syphilis, among other infectious 
 diseases, have been mentioned in this connection. It may 
 be admitted that gastric ulcer may be produced by infec- 
 tion through the circulation. The presence of bacteria in the 
 walls of the ulcer (Boettcher) can only be considered accidental 
 and secondary. 
 
 The pathogenic influence of hydrochloric superacidity is 
 still a matter of dispute. Some pathologists make this con- 
 dition essential, and claim that without it ulcer does not occur, 
 or, at least, that no cases which contradict this hypothesis 
 have yet been reported which do not admit of explanation 
 by the well-known intermittent course of the diseases or the 
 affections of the stomach accompanied by excessive secretion. 
 The theory is seductive in its simplicity — a very active and 
 superacid secretion, a diminution of the vitality of a localized 
 area of the mucous membrane, autodigestion and a resulting 
 circumscribed defect of the mucous membrane, the repair of 
 which is delayed or prevented by the irritation or the action 
 of the strongly acid gastric juice. But if its parts be more 
 29
 
 450 DISEASES OF THE STOMACH. 
 
 closely examined, it would seem that the theory is too ex- 
 clusive. 
 
 There is no evidence to prove that excessive hydrochloric 
 acidity always precedes the development of ulcer. Simple 
 adenohypersthenia (a dynamic affection) is rarely complicated 
 by an ulcer; it is, however, different, as we have seen, with 
 hypersthenic ijastritis. It is a fact of which we have no 
 doubt that ulcer may run its entire course without excessive 
 hydrochloric acidity, and where the excessive secretion is 
 not suppressed by hemorrhage, weakness, inanition, or 
 anemia. When in the course of treatment these symptoms 
 disappear, the excessive secretion does not return. The 
 hyperchlorhydria often disappears permanently with the cure 
 of the ulcer, suggesting at least the possibility of its having 
 been excited in a manner probably analogous to the exces- 
 sive lachrymal secretion in a corneal ulcer, or that its cause 
 (ulcer, or not) was removed by the ulcer treatment. That it 
 is not alone an efficient cause is proven by the whole mucous 
 membrane not being involved, and by cases of hyperchlor- 
 hydria running a long course without ulcer being generated, 
 even after injury of the mucous membrane by the use of the 
 tube. In about 70 per cent, of the cases of ulcer there is 
 hydrochloric superacidity. In the remainder of the cases 
 secretion is normal, or there may be hypochylia, or, very 
 rarely, even achylia. The hydrochloric superacidity may 
 have preceded the ulcer; it may have followed the ulcer 
 (obstruction of pylorus, etc.) ; or it may be the irritative 
 expression of the ulcer. It would not be right to assume 
 that at the moment when the ulcer developed there was 
 not, in any of a series of cases, hyperchlorhydria, but it 
 is not highly probable that a temporary hyperchlorhydria 
 would produce an ulcer. Moreover, ulcer is not situated most 
 frequently where the gastric secretion is most acid nor most 
 in contact with the mucous membrane; but where all ana- 
 tomical alterations of the mucous inenibrane are most frequent 
 and most intense. Nor can it be admitted that the occurrence 
 of this peculiar form of ulcer only in the stomach and in the 
 digestive tube close to it, is proof that the gastric juice has 
 anything to do with its causation. Certainly, peptic ulcer can 
 not be produced by autodigestion alone. 
 
 Autodigestion is prevented, not by mucus, not by the 
 alkaline blood nor by active absorption, but by the resist- 
 ance of the living protoplasm of the cell. The mucus does 
 not prevent postmortem digestion nor the peptonization 
 of meat coated by it. The gastric juice is secreted beneath
 
 ULCER OF THE STOMACH. 45 I 
 
 the mucus, and does not digest a part of the mucous mem- 
 brane which is kept free from mucus. Erosions heal and 
 cells are regenerated in the presence of the gastric juice. 
 Germs live in it. Ferment-producing organisms do not 
 digest themselves, and the blood and the tissues of the body 
 destroy ferments. The action is not prevented by the alkaline 
 blood, for the HCl secreted by and in the cell is not neutral- 
 ized ; the pancreatic juice does not digest the intestines, nor 
 does papain digest either an acid or an alkaline-reacting liv- 
 ing tissue. Autodigestion is possible only where the proto- 
 plasm of the cell no longer possesses its normal properties 
 and powers of resistance. 
 
 Though excessive hydrochloric acidity is not a necessary 
 factor in the genesis of ulcer, it can not be doubted that it is 
 often a pathogenic power of great importance, and often ex- 
 erts a pernicious influence on the persistence of the trouble ; 
 and its control is a commanding indication in the treatment. 
 Where the excessive secretion is a symptom of hypersthenic 
 gastritis, the condition exists most favorable to the genesis of 
 ulcer ; the node-like and limited infiltration of the mucous 
 membrane or submucosa being often sufficient to reduce the 
 circulation and nutrition of a local area of the mucous mem- 
 brane so low as to render it unable to resist the digestive 
 power of the excessively acid and very active gastric juice. 
 
 Etiologically, ulcer is primarily dystrophic, the essential 
 conditions of its genesis being the local defect of the circula- 
 tion and of the nutrition in a part exposed to the digestive 
 action of a gastric juice usually excessively acid. The defect 
 is made persistent by the diminished reparative powers of the 
 organism, and by local irritations intimately associated with 
 the functions of the stomach. The etiology gives the com- 
 manding indications in treatment — functional rest, protec- 
 tion, and the improvement of nutrition. 
 
 Pathological Anatomy. — Simple ulcer of the stomach is 
 usually single, but in about one-fifth of the autopsies more 
 than one is found. These may be of different ages, or a fresh 
 ulcer may be found coexisting with an old scar. Sometimes 
 two old ulcers are found corresponding with the areas sup- 
 plied by two branches of a small artery (obstructed), which 
 later unite to form one irregularly shaped ulcer. Conse- 
 quently, a single ulcer or a single scar found at the autopsy 
 may represent the union of two ulcers distinct in their earlier 
 stages. Two, three, four, five, or even more may coexist, and 
 may vary in form, in size, and in age. But cases of multiple 
 peptic ulcers exhibiting these characteristics are rare.
 
 452 DISEASES OF THE STOMACH. 
 
 Ulcer shows a decided preference for certain rejjions of 
 tlie stomach. The favorite localities are the smaller curva- 
 ture, the posterior wall, and the pyloric region. The portions 
 most frequently affected are a small area of the posterior sur- 
 face near the pylorus, and another along the lesser curvature. 
 Often one is located on the lesser curvature, and another close 
 by on the posterior wall. Rarest in the fundus, it is much less 
 frequent on the anterior wall, in the cardiac region, and 
 along the greater curvature than over the favorite localities. 
 About half the cases occur in the p}'loric third of the stom- 
 ach. A plane passing vertically through the cardiac orifice 
 and the tip of the cartilage of the left tenth rib would locate 
 about four-fifths of the ulcers to its right. Brinton gives the 
 following percentages: Posterior surface, 43 per cent.; 
 lesser curvature, 27 per cent.; pyloric extremity, 16 per 
 cent.; anterior and posterior surfaces, 6 per cent.; anterior 
 surface, 5 per cent.; greater curvature. 2 per cent. Welch 
 locates more on the lesser curvature (36 percent.) than on the 
 posterior wall (30 per cent.), and Lebert gives nearly the same 
 percentage (33 per cent.) for the lesser curvature as does 
 Welch. 
 
 The typical peptic ulcer is round or oval, but this form is 
 by no means constant. The borders commonly run in 
 regular curves, but the coakscence of adjacent ulcers may 
 produce a variety of shapes. A comma shape is not rare, 
 and the pylorus may be partly or completely surrounded by 
 a ring. A marked characteristic is the arrangement, of the 
 long axis of the ulcer in the direction of the obliterated 
 artery, the area of the distribution of which corresponds with 
 the form and the extension of the ulcer. The size is likewise 
 very variable, the common size being that of a silver dime or 
 quarter; but some are as small as peas, and, exceptionally, 
 the defect may cover a space as large as the adult hand. 
 
 The other gross anatomical characteristics present slight 
 variations, dependent, seemingly, on the age, the depth, and 
 the genesis of the ulcer. The borders marked by the 
 mucous membrane are usually perpendicular or slightly 
 rounded, and sometimes a little undermined; but t\-pically 
 the appearance is that of a defect left by the removal of a 
 piece of the mucous membrane with a round chisel gouge. 
 The border is usually uninflamed. but may be red and 
 swollen, and is sometimes hard and calloused and formed of 
 new connective tissue. The ulcer may extend no deeper 
 than the mucous membrane, the bottom being smooth and 
 non-granulated. But often the process begins or extends
 
 ULCER OF THE STOMACH. 453 
 
 deeper, and a remarkable appearance results, the ulcer ex- 
 tending obliquely in a funnel shape, one side of which, partic- 
 ularly, may form a stairway descending to the peritoneum, 
 the steps being formed by the mucous membrane, the sub- 
 mucosa, and the muscular layer. But often the descent is 
 gradual, oblique, conical, with here and there little projections 
 of connective tissue. The bottom is grayish-yellow, or is 
 composed of the pale tissue of the layer to which the ulcer 
 extends ; or, it may be occupied by a grayish-black slough. 
 In complicated cases the tissues of an adjacent organ, 
 particularly the pancreas, may be seen in the bottom, or 
 near the apex may be visible the gaping blood-vessel 
 which has caused the fatal hemorrhage. 
 
 The gross anatomical characteristics of the recent ulcer 
 would suggest a defect produced by the digestion of the dead 
 tissue corresponding with the distribution of a small arterial 
 branch, without being followed immediately by inflammatory 
 reaction or by an effort at repair. But sooner or later the 
 edges, the wall, and the base are the seat of a productive inflam- 
 mation. The early stage of the ulcer reveals its dystrophic 
 nature. The inflammation is seldom intense, but, exception- 
 ally, the tissues near the ulcer are secondarily invaded by 
 bacteria. Microscopically, the inflammation about the ulcer 
 is productive, and presents the same characteristics as hyper- 
 sthenic gastritis — more or less infiltration with embryonic 
 cells, preservation of the chief cells, and decrease or increase 
 in number of the border cells, and glandular proliferation. 
 Associated with this local inflammation is often found general 
 chronic hypersthenic gastritis, more intense in the pyloric 
 region and accompanied by more or less interstitial infiltra- 
 tion. The relation of this form of inflammation to the genesis 
 of ulcer has already been discussed. 
 
 The blood-vessels in the region adjacent to the ulcer often 
 show remarkable changes. The process is one of progressive 
 destruction by proliferating endarteritis. The capillaries, the 
 venous radicles, and the arterioles are alike involved, and a 
 thrombus composed of a mass of white cells may be seen 
 plugging the contracted lumen. The wall of the blood- 
 vessel is infiltrated with amorphous matter and with embry- 
 onic cells. The endothelium proliferates and the muscular 
 coat undergoes fatty degeneration. In rare cases of infec- 
 tious origin the clots may contain pathogenic bacteria. 
 There can be no doubt that this devascularizing process is a 
 protection against hemorrhage. But the arterial wall may be 
 softened and may yield to the pressure of the blood before its
 
 454 DISEASES OF THE STOMACH. 
 
 lumen is obstructed. The liemorrhage may be venous, capil- 
 lary, or (nearly al\va\'s) arterial — slow, continuous, recurring, 
 small, or fatal in a few minutes. 
 
 In the majorit}' of cases a plastic peritonitis develops over 
 the apex of the ulcer. The inflammation is circumscribed 
 and productive, the thickened peritoneum being covered by 
 pseudomembrane, often leading to the firm adhesion of the 
 stomach to adjacent parts. Infrequently, the peritonitis extends 
 over a large part of the stomach. The process is a bung- 
 ling effort at conservatism, offering a protection against 
 perforation, but forming adhesions which impair the motor 
 functions of the stomach, and which, while preventing a rap- 
 idly fatal purulent peritonitis, leads to circumscribed abscesses, 
 destruction of an adjacent organ, burrowing of pus, pyemia, 
 cachexia, and usually death. 
 
 In about one-half the cases of ulcer the stomach is bound to 
 an adjacent part by plastic peritonitis. On account of the re- 
 lations of the parts of the stomach most frequently the seat of 
 ulcer, the adhesions, in about seven-eighths of the cases, are 
 between the stomach and the pancreas or the left lobe of the 
 liver. Infrequently, the stomach is united with the diaphragm, 
 the abdominal wall, the omentum, the spleen, or the colon. 
 The adhesions may also be multiple, and often interfere 
 greatly with the churning and the evacuating movements of 
 the stomach. They may also long remain sensitive or may 
 become the seat of stubborn neuralgia. 
 
 In about five per cent, of the cases the ulcer perforates the 
 gastric wall, coming in contact with adherent adjacent tissues 
 or producing encysted or general purulent peritonitis. 
 
 Perforation after adhesions have been formed is most fre- 
 quent where the ulcer is located on the posterior wall, near 
 the lesser curvature, or in the pyloric region. But the com- 
 paratively rare ulcers of the anterior wall perforate more fre- 
 quently, and, on account of the free movements of this part 
 of the stomach, nearly always before adhesions have formed. 
 Death follows this accident — rapidly, from shock, or in a few 
 days, from general purulent peritonitis. 
 
 The opening in the peritoneal coat is small, varying in size 
 from a pin-head to a pea, usually rounded and clear-cut, but 
 sometimes irregular in shape with ragged edges. The open- 
 ing is made by gradual erosion or by necrosis and digestion 
 after the peritoneal blood supply has been cut off Increased 
 intragastric pressure may be the occasion of the perforation. 
 
 Perforation after adhesion with the pancreas brings the 
 resistant tissue of this organ into communication with the
 
 ULCER OF THE STOMACH. 455 
 
 cavity of the stomach and its contents. In the base of the 
 ulcer (the perforation often being large) may be seen the red- 
 dish-yellow glandular structure, interlined by the grayish 
 interstitial framework of the pancreas. The destructive pro- 
 cess may extend into the substance of the gland and form a 
 number of fistulae, or may open a blood-vessel and produce a 
 fatal hemorrhage. 
 
 The liver is much less resistant than the pancreas, and 
 purulent inflammation destroys its substance rapidly, leaving 
 in its stead a cavity containing pus and communicating 
 through a small opening with the cavity of the stomach. 
 The perforation may open a communication with the gall- 
 bladder, the colon, the small intestine, the spleen; with the 
 abdominal wall, resulting in the formation of a gastric fistula; 
 with the diaphragm, through which pus may perforate and 
 invade the organs of the thoracic cavity. 
 
 As a consequence of perforation a generator localized puru- 
 lent peritonitis may be excited. The pathological anatomy 
 is that of perforative peritonitis. Subdiaphragmatic abscess 
 results when the affected area is walled in, and is usually 
 located in the left, but the collection of pus may also be found 
 in the right (rare), hypochondrium, according to the seat of 
 the perforating ulcer. 
 
 An abscess may also be formed when the perforation takes 
 place after adhesions, the new tissue of union yielding to the 
 ulceration and the abscess communicating through the small 
 opening with the cavity of the stomach. The subdiaphrag- 
 matic abscess may open into the peritoneal cavity, or may 
 perforate the diaphragm, the pleura, the pericardium, the 
 heart, or may open through the lung into a bronchus. 
 
 Gastric ulcer either ends in perforation, with its disastrous 
 consequences, or heals, unless interrupted in its course by a 
 fatal accident. 
 
 The appearance and the effects of the cicatrix vary accord- 
 ing to the size, the form, the depth, and the location of the 
 ulcer. If the ulcer heals only after the destruction of the 
 mucous coat, the depression marking the repaired defect may 
 be small or only discoverable on close inspection. But 
 usually the scar is star-shaped, with a central mass of connec- 
 tive tissue sending out in various directions lines of fibrous 
 tissue of variable length. The central depression may be 
 formed of fibrous tissue developing in the organ or the part 
 to which the stomach has been united by plastic peritonitis. 
 The organ is then deformed by being drawn up in folds, and 
 a funnel-shaped sac is created. The mucous membrane may
 
 456 D/S EASES OF 77/ E STOMACH. 
 
 be thrown into irregular folds by the contraction of the scar 
 tissue. 
 
 Certain deformities interfere in a remarkable manner with 
 the functions of the stomach. The pylorus may be drawn 
 almost against the cardia, the round organ thus formed 
 evacuating its contents with difficulty. Or a band may ex- 
 tend transversely around the stomach and divide it into two 
 cavities united by a small opening. Very infrequently the car- 
 dia is obstructed. Pyloric obstruction is common, and may be 
 due to accompanying inflammatory swelling or to the cica- 
 trization of a pyloric ulcer. This is a very grave deformity, 
 and about one-tenth of the deaths due to ulcer are produced 
 in this manner. Gastric ulcer may heal perfectly, or it may 
 leave deformities which impair the functions of the stomach, 
 or which destroy life by inanition and by auto-intoxication. 
 
 Clinical Description. — There is no anatomical disease of 
 the stomach the clinical e.xpression of which is more variable 
 than that of gastric ulcer. The clinical history is more fre- 
 quently the expression of the associations, the accidents, and 
 the com[)lications than of the ulcer itself. The beginning 
 takes its predominant characteristics from the mode of action 
 and the nature of the causes. The evolution is defined by 
 the accompanying gastritis, hyperchlorhydria, hyperesthesia, 
 peritonitis, adhesions, perforation and its consequences, the 
 effects of the deformities and of the inanition. 
 
 The anatomical lesion constitutes the danger, and about 
 its origin and evolution gather the conditions, the accidents, 
 and the diseases which reveal its presence. In typical cases 
 the diagnosis presents no difficulty; in atypical cases it may 
 rest upon a probability ; the latent form may create no suspi- 
 cion of its existence. It is not possible at a given moment to 
 say whether the disease will terminate in a perfect cure, in 
 chronic invalidism, or in death. The variable clinical expres- 
 sion embodied in the modes of beginning, of evolution, and of 
 termination makes clear the variable etiology, genesis, patho- 
 logical anatomy, state of nutrition, and complications. 
 
 Ulcer may have no clinical e.xpression, and may run its 
 entire course without exciting the suspicion of the patient or 
 of the physician, ending in complete recovery. This is the 
 completely latent form, the scar being found at the autop.sy 
 after death from some other cause. If a complete clinical 
 history could be obtained it would probably be found that 
 the disease had not run its course in complete silence, but 
 that the subjective symptoms were not so severe as to cause 
 the patient to consult a physician, or were considered so com-
 
 ULCER OF THE STOMACH. 457 
 
 mon as to be unworthy of notice, of mention, or of treatment. 
 This form is most common among the poor, and must be 
 ignored in the clinical description. 
 
 The subjective symptoms may be suppressed during a part 
 of the course of the disease. These are the purely anatomi- 
 cal periods in the beginning and during the evolution, occur- 
 ring as breaks in the progress of the disease, or during the 
 period of healing, but more frequently in the beginning. The 
 anatomical periods create no suspicion, are deceptive, and 
 induce a false sense of security. 
 
 The period of formation of the ulcer may be latent or 
 anatomical. In this mode of genesis the ulcer develops 
 without a symptom. It may represent a very short period, 
 during which the gastric juice is eating out the circumscribed 
 dead or dying piece of the gastric wall. It may be readily 
 understood why an ulcer, generated rapidly after thrombosis, 
 embolism, or infarct, and unaccompanied by gastritis, by peri- 
 tonitis, or by a complication, might not be manifested by any 
 subjective or objective sign. The genesis of ulcer in the 
 course of an infectious disease may also be concealed, the 
 gastric symptoms being masked or misinterpreted, or sup- 
 pressed by the weakness of the organism. Or, again, the 
 beginning may be characterized by a few irregular, indefinite, 
 and, for diagnostic purposes, meaningless subjective and ob- 
 jective signs. This anatomical period of invasion may end 
 suddenly with perforation or with profuse hemorrhage, or 
 may more slowly assume the common clinical characteristics 
 of ulcer — the special pain, the vomiting, the nervousness, the 
 anemia, and the irritation. About one-fourth of all clinically 
 recognizable cases of ulcer develop in this manner. 
 
 In other cases the clinical expression of the period of 
 invasion is atypical, and the recognition of the disease is de- 
 pendent on the results of the examination. This is the physi- 
 cal mode of beginning. The patient complains of discom- 
 fort, of flatulency after meals, but has no true pain ; at times, 
 possibly, a little nausea and a poor appetite ; or there may 
 be only headache, constipation, and soreness in the epigas- 
 trium. The subjective symptoms are digestive, but have none 
 of the definite characteristics of those typical of ulcer. The 
 clinical history does not suggest gastric ulcer, which is re- 
 vealed by the examination ; or the examination marks the 
 case as doubtful ; and the efficiency of specific treatment or 
 the subsequent developments of the case confirm the sus- 
 picion of an ulcer. The physical mode of beginning charac-
 
 458 DISEASES OF THE STOMACH. 
 
 terizes the early period of about one-fourth of the cases of 
 simple ulcer of the stomach. 
 
 In one-half of the cases the symptoms of the initial period 
 are those of adenohypersthenia gastrica or of hypersthenic 
 gastritis. The clinical description of these diseases has 
 already been given. In the majority of these cases the 
 symptoms of hyperchlorhydria, of hyperch\lia, or of hyper- 
 sthenic gastritis precede the development of those charac- 
 teristic of ulcer. In a small number of cases the symptoms 
 of ulcer and the accompanying diseases seem to begin and 
 to develop together. These diseases, so often found asso- 
 ciated, are, etiologically, points of the same vicious circle. 
 In this mode of invasion the existence of the ulcer may be 
 revealed with certainty from the beginning by the clinical 
 history, standing in clear contrast to the anatomical and 
 the physical modes of development. But in a number of 
 cases, for a longer or shorter period, it is impossible to ex- 
 clude or to detect an ulcer accompanied by hypersthenic gas- 
 tritis or by adenohypersthenia gastrica. 
 
 The evolution of ulcer after it has become a clinical disease 
 may be slow or rapid. Perforation or hemorrhage may be 
 the first revealing sign, and either of these accidents may 
 prove quickly fatal. The rapidly fatal perforative form is 
 most frequent in girls, who may be thus suddenly taken off in 
 the bloom of youth. The hemorrhage may at once or after 
 several recurrences be fatal ; or the patient may recover from 
 the effects of this accident, and the evolution of the ulcer 
 may continue. These rapidly fatal cases are described as 
 acute, but a quick termination by death from a complication 
 should not be considered a characteristic of the morbid pro- 
 cess which is in its nature essentially chronic; The quickly 
 fatal cases are preceded by a longer or shorter anatomical 
 period. 
 
 The evolution of ulcer may be short, and may end within 
 S1.X or eight weeks in cure by cicatrization. These are the 
 true acute cases; the ulcer beginning at a particular moment 
 (after traumatism, for instance), manifesting itself by typical 
 symiptoms and signs, and, under proper treatment, disap- 
 pearing completely and permanently. 
 
 l^ut this is not the usual course, which is slow, chronic, 
 variable, often with exacerbations and remissions, and with 
 certain symptoms predominating and defining various clinical 
 forms of ulcer. The chronic form of ulcer lasts a variable 
 time. The duration may not exceed one or five years, but
 
 ULCER OF THE STOMACH. 459 
 
 frequently the ulcer remains unhealed for fifteen or even 
 twenty-five years. It is the persistence of the anatomical 
 lesion and of its consequences during this chronic course 
 which maintains the clinical unity of the disease beneath 
 its variable play of expression. The distinctive symptoms 
 are the peculiar pain, the hemorrhage, and the vomiting, which 
 are associated with other symptoms occasioned by the func- 
 tional activity of the stomach. 
 
 The early morning, when the stomach is empty after the 
 night's repose, is the most comfortable moment for a patient 
 with ulcer. There is usually, before rising from bed, no pain 
 nor discomfort, and the appetite is commonly preserved. 
 There may, however, be a slight headache, small appetite, or 
 dread of food, and no refreshment from the broken sleep ; the 
 patient may be in some cases worn out by pain, nervous, and 
 weak. But the early morning is still the most comfortable 
 period of the day. After breakfast the digestive symptoms 
 begin, variable in the different cases, but in relation with the 
 quantity and quality of food — pain, heartburn, acid eructa- 
 tions, relieved often by the vomiting of an acid fluid mixed 
 with food, or by the passage of the chyme into the intestines. 
 
 During the interval between the digestive periods the 
 symptoms are comparatively quiescent, but they reappear on 
 the taking of food. In addition to these, there may be other 
 digestive symptoms, of secondary importance, and due to the 
 state of nutrition and of the nervous system, and to the 
 complications. 
 
 The Cardinal Symptoms. — The genesis of the pain of 
 gastric ulcer is very complex. That the constitution and the 
 temperament of the patient exert a great influence there can 
 be no doubt. Some suffer intensely ; others bear severe pain 
 with indifference, and are not subject to neuralgias. This 
 subjective element explains why in gastric ulcer, with prac- 
 tically the same conditions, the intensity of the pain should 
 be so variable. Much depends, also, on the temporary 
 condition of the nervous system. All conditions accom- 
 panied by increased irritability of the nerve-centers sharpen 
 the perception and generalize the effects of the pain. Of 
 these, none are more active than mental and physical fatigue 
 and excitement. Sexual excesses and menstruation have a 
 similar effect. On the other hand, the pain of ulcer is quieted 
 by repose, and in the uncomplicated cases it subsides com- 
 pletely during the night. The means, consequently, adopted 
 to assure mental, physical, and moral repose are important 
 symptomatic remedies.
 
 460 DISEASES OF THE STOMACH. 
 
 The pain of gastric ulcer lias also an anatomical basis. 
 The nerves are uncovered by the eroding process, and more 
 or less neuritis may be present. The inflammatory infiltration 
 of the walls, produced by irritation or by infection, or by an 
 effort at repair, and the contraction of the newly-formed tis- 
 sue, compress the nerve filaments. The traction involved in 
 the production of the deformities and the adhesions of parts 
 normally free are other sources of irritation and pain. The 
 peritoneum may become inflamed and exquisitely sensitive, 
 and perforation may occur, with its resulting purulent inflam- 
 mation, abscess formation, and pus tunneling. The gastric 
 mucous membrane may be hyperesthetic or inflamed, and its 
 secretion may be excessively acid and irritating. The pain 
 is also excited by the chemical, the mechanical, and the 
 thermal irritants introduced into the stomach. The pain of 
 gastric ulcer is thus very complex in its genesis, and, neces- 
 sarily, very variable in its intensity and in its qualities. 
 
 There is no anatomical disease of the stomach in which 
 pain is so predominant as in ulcer. Of all the symptoms it 
 is the most constant, and may be continuous, intermittent, or 
 periodical. It is almost never absent after a meal containing 
 chemical irritants and large enough to distend the stomach. 
 During the interval when the stomach is empty, and particu- 
 larly at night, it usually subsides ; but in some complicated 
 cases (retention, continuous secretion, adhesions, perigastritis) 
 the patient is never entirely free from pain. It may be com- 
 pletely absent during a period of variable length without 
 evident reason, or after a severe hemorrhage. As a rule, the 
 greater the inanition, the anemia, and the nervous exhaustion, 
 the more constant and severe is the pain. The pain may be 
 the only symptom, and, exceptionally, it is scarcely noticeable ; 
 but even in the latent form there has usually been slight, irreg- 
 ular gastric pain, considered by the patient as insignificant. 
 It is commonly severe enough to cause the patient to seek 
 relief. 
 
 The intensity and the quality of the pain are variable, but 
 when characteristic it is paro.xysmal, digestive, severe, and 
 localized. In very old cases (probably with adhesions or 
 contracting scars) the pain may be dull and drawing — a 
 peculiar discomfort like that of gastroptosis. In other cases 
 a peculiar sensation, usually associated with a little pain, is 
 felt, as if the food were arrested and confined to a particular 
 part of the stomach. The description of the patient would 
 seem to indicate a reflex muscular effort to isolate or protect 
 the ulcer. But the characteristic pain of ulcer is paroxysmal,
 
 ULCER OF THE STOMACH. 46 1 
 
 severe, raw, gnawing, burning, sometimes pulsating, often 
 excruciating. 
 
 The spontaneous pain begins in a small area in the epigas- 
 trium (Brinton), or in the back (Cruveilhier), and may be as 
 strictly localized and circumscribed as the tender points. But 
 no negative conclusions should be drawn from the diffusion 
 of the pain, as that of complicated gastric ulcer may extend 
 over a large area. The absence of a point of greatest inten- 
 sity is no evidence against the existence of the ulcer. The 
 epigastric center of spontaneous pain, which maybe as small 
 as a silver quarter or as large as half of the hand, is generally 
 located near the median line and immediately below the ensi- 
 form process; but it may be further to the right, lower to the 
 left, or higher, according to the seat of the ulcer and to the 
 position of the stomach. 
 
 The diffusion of the epigastric pain is greatest when the 
 paroxysms are severe and when the patient is of a nervous 
 temperament. It may be diffused over the whole gastric 
 region, over the abdomen, or over the precardiac region ; it 
 may extend to the left or to the right or directly into the 
 back, or through the brachial plexus into the upper extrem- 
 ity. The excitation may be reflected along the pneumo- 
 gastrics, and may produce dyspnea. The extension of the 
 pain to unusual points may be due to complications involv- 
 ing branches of the pneumogastric, the intercostal, and the 
 phrenic nerves. When, for instance, the stomach is adherent 
 to the diaphragm, and when this muscle or its serous cover- 
 ing is inflamed, the thoracic points of attachment of the dia- 
 phragm may be tender, inspiration may be painful, and the 
 trunk of the phrenic nerve, passing obliquely across the 
 scalenus anticus along the posterior border of the sterno- 
 cleidomastoid, is painful on pressure. In like manner the 
 pain reflected to the right shoulder may be due to adhesions 
 to the liver. 
 
 The dorsal spontaneous pain usually appears later than the 
 epigastric. It is also raw, burning, gnawing, and at times 
 horribly severe. As a rule, it is milder than the epigastric 
 pain, but it may exist alone. The most frequent localization 
 is to the left (sometimes to the right) of the two lower dorsal 
 vertebrae ; but it may be lumbar, even sacral, or may be located 
 higher up, in the dorsoscapular region. The location of the 
 pain is supposed to be determined b\' the seat of the ulcer or 
 by a complication of the ulcer. The dorsal pain may be 
 reflected along the intercostal nerves. An extension to the 
 lower extremities is very infrequent.
 
 462 DISEASES OF THE STOMACH. 
 
 The pain of gastric ulcer is alwa\\s greatest during the 
 period of digestion. The distention and the movements of 
 the stomach, the mechanical, the chemical, and the thermal 
 irritation by the food, the superacid secretion, and the increased 
 flow of arterial blood combine to make the period of functional 
 activity more painful than the period of repose. The pain 
 may occur immediately after eating or may be delayed half 
 an hour or more. It increases with the activity of digestion 
 and subsides with the evacuation of the stomach, lasting about 
 two hours, unless cut short by vomiting or prolonged by 
 stagnation or by retention. 
 
 A close relation exists between the irritating qualities of 
 the food and drinks and the degree of pain. It is least after 
 a bland albuminous liquid, like milk. Alcoholic, very hot and 
 very cold drinks, spices, acids, and coarse, solid food excite and 
 increase the pain. 
 
 The pain of ulcer is increased by the movements of the 
 body and is calmed by repose. Even abdominal breathing 
 may be suppressed in order to keep the stomach still. 
 
 According to the seat of the ulcer, the pain may be increased 
 or relieved by certain positions of the body. The special posi- 
 tion is constantly assumed by the same patient, and is always 
 such as protects the ulcer from pressure and from the contact 
 of the gastric contents or prevents traction on painful adhe- 
 sions. 
 
 Vomiting, though a frequent symptom of ulcer, is much less 
 characteristic than the pain. In some cases it is the pre- 
 dominant symptom, and if complete and persistent may lead 
 rapidly to very grave inanition. In others it occurs irregularly, 
 or is incomplete, or recurs periodically. Seldom is it ab- 
 sent throughout the course of ulcer, but it may be replaced 
 by acid regurgitations or by nausea. The frequency of 
 vomiting is due in part to the constitution or temperament, 
 some people vomiting more readily than others. Like pain, 
 it is also favored by mental and physical fatigue, and by 
 nervous excitement. But the vomiting which occurs in ulcer 
 is more frequently the result of hyperesthesia of the mucous 
 membrane and of hypersthenic gastritis, and is most fre- 
 quent after solid and irritating food. In some cases it is due 
 to continuous secretion, or, particularly in the old cases, to 
 pyloric obstruction or to irritable adhesions. 
 
 However caused, the vomiting of ulcer (except in retention 
 or in continuous secretion) is digestive. The stomach, if 
 hyperesthetic, may be intolerant of all food, and the food is 
 ejected almost immediately. But, as a rule, it occurs from
 
 ULCER OF THE STOMACH. 463 
 
 half an hour to two hours after the meal, during the height of 
 digestion, when the pain is intense, is produced easily without 
 nausea, and the pain is relieved if the stomach be emptied. 
 Vomiting is usually followed by a burning sensation in the car- 
 diac region, lasting a few minutes ; but if the stomach is not 
 completely emptied, the pain is only temporarily diminished. 
 The vomit consists of an acid fluid, mixed with undigested 
 remnants of food, and sometimes a little bile or blood. The 
 vomiting may occur after each meal, or only after large meals 
 containing excitant food. In retention and supersecretion 
 it may take place when the stomach normally should be 
 empty, and the vomit then is characteristic of these two con- 
 ditions. 
 
 Hemorrhage is more frequent during the day than at night, 
 but may occur at any hour. Digestion is supposed to be the 
 most frequent exciting cause, but the blood is often unmixed 
 with food, showing that the hemorrhage occurred when the 
 stomach was empty. The peristalsis and the distention inci- 
 dental to the functional activity of the stomach, the functional 
 hyperemia and the increased blood pressure, the activity of 
 secretion furnishing a strong digestive fluid, the mechanical 
 action of the churned contents, may certainly be the proximate 
 causes of a hemorrhage. Hemorrhage, however, often occurs 
 during the period of gastric repose, and is occasioned in other 
 ways. Among the proximate causes may be mentioned intense 
 excitement, great effort, vomiting, and straining at stool — all 
 increasing arterial pressure, which bursts the thin wall of the 
 blood-vessel or dislodges the clot from its mouth. Menstru- 
 ation is also a proximate cause, and often the first sign of 
 ulcer is a gastric hemorrhage occurring during the menstrual 
 period. The hemorrhage may also be excited by coughing, 
 and it is important to remember this when differentiating 
 gastric hemorrhage from hemoptysis. The use of the stomach- 
 tube is contraindicated in ulcer on account of the danger of 
 producing hemorrhage. The blood-vessel maybe unplugged 
 by the bacterial softening of the clot. The true cause of the 
 hemorrhage of ulcer is the opening of a blood-vessel by 
 erosion, by necrosis, and by digestion of the devitalized tissue, 
 aided sometimes by increased blood pressure and by trauma- 
 tism. 
 
 Next to pain, gastric hemorrhage is the most frequent 
 symptom, and, if small concealed hemorrhage be counted, it 
 is probable that ulcer never runs its course without this sign. 
 But, clinically, the hemorrhage is noted in only about four- 
 fifths of the cases. The vomiting of blood (hematemesi.s)
 
 464 DISEASES OF THE STOMACH. 
 
 occurs in 30 to 50 per cent, of the cases, but this percentage 
 would be increased if the cases with small quantities of blood 
 in the vomit were included. In the suspected cases the fre- 
 quent detection of traces of blood in the vomit (not ingested 
 with the meats nor due to the retching) is a diagnostic sign of 
 great importance. But even a large hemorrhage may not 
 excite vomiting, and with modern conveniences may escape 
 the notice of an intelligent patient. A loss of from 50 c.c. to 
 100 c.c. of blood produces to the layman no perceptible col- 
 oration of the stool, and, on account of the foul odor, if not 
 very evident it is not likely to be sought for carefully by the 
 physician. Hemorrhage is observed in about two-thirds of 
 all cases, but it might be detected if diligently sought for in 
 nearly every case. But a single small hemorrhage would be 
 of very doubtful diagnostic value. Hemorrhage maybe the 
 first sign of ulcer, but it commonly occurs a number of weeks 
 or months after the pain. 
 
 A glance at the rich arterial supply of the stomach, and 
 the relations of the large vessels to the most common seats of 
 ulcer, will explain why this disease should be so frequently 
 accompanied by hemorrhage, sometimes small, frequently 
 dangerous, and not infrequently rapidly fatal. The celiac axis, 
 covered by the lesser omentum and grasped by the lesser cur- 
 vature, furnishes the stomach, directly and indirectly, with its 
 arterial supply through its three branches — gastric, hepatic, 
 and splenic. These three arteries, through their gastric 
 branches, form on the stomach two complete arterial circuits. 
 The one is formed by the coronary branch of the gastric and 
 the pyloric branch of the hepatic passing between the two 
 layers of the lesser omentum along the lesser curvature. 
 The other is formed along the greater curvature, between the 
 folds of the greater omentum, b\' the union of the left gastro- 
 epiploic, given off by the splenic, and the right gastro-epiploic, 
 which is a branch of the gastroduodenal artery, given off 
 by the hepatic. The stomach also receives at its pyloric 
 end small branches from the gastroduodenal artery. The 
 splenic, the largest branch of the celiac axis, after meander- 
 ing along the upper border of the pancreas and giving off 
 the left gastro-epiploic, distributes between tiie two layers of 
 the gastrosplenic omentum several branches to the greater 
 curvature of the stomach, which anastomose with the 
 branches of the left gastro-epiploic and of the gastric arteries. 
 
 The branches of these arterial circuits, and the smaller 
 anastomosing branches, form over the surface of the stomach 
 a network of small arteries, which send branches to the mus-
 
 ULCER OF THE STOMACH. 465 
 
 cular coat, and ramify in the submucous coat, to be finally 
 distributed to the mucous membrane in the form of a net- 
 work of capillaries covering the gastric tubules and passing 
 up between them to encircle the mouths of the ducts. From 
 this superficial encircling network the blood is taken up by 
 the venous radicles, and is returned through the splenic, the 
 superior mesenteric, and the portal veins. The pyloric, the 
 splenic, and the coronary branches of the gastric are the large 
 arteries most frequently opened. Sometimes it is the right 
 epiploic ; the branches of the splenic artery, being distributed 
 to a region of the stomach seldom affected by ulcer, generally 
 escape. The liability to a profuse hemorrhage increases with 
 the depth of the ulcer. 
 
 Clinically, gastric hemorrhage may be rapidly fatal; imme- 
 diately dangerous ; profuse and recurrent ; and small, con- 
 cealed, and dangerous on account of the repetitions. 
 
 Rapidly fatal hemorrhage occurs in about three per cent, 
 of the cases of ulcer, and is due to the opening of a large 
 artery, usually one of the branches of the celiac axis. Some- 
 times an aneurysm has previously formed at the weak point of 
 the eroded wall. Suddenly, without warning, the patient be- 
 comes pale, weak, anxious ; faints, falls unconscious, and dies 
 after vomiting blood, which is very little changed unless the 
 accident happens during digestion. 
 
 Death may occur before vomiting takes place. The hem- 
 orrhage may be profuse and concealed, but not so rapidly fatal, 
 the stomach consuming fifteen or twenty minutes in filling, 
 the vomiting being rapid and effortless, and followed by col- 
 lapse, rolling from side to side, delirium, stupor, and death 
 after a short interval of two or three days. The vomited 
 blood is clotted, pure, unless accidentally mixed with the 
 contents, and may be ejected with such force and in such 
 quantity as to fill the mouth, the nose, and the throat. Some- 
 times, but not often, vomiting does not occur, and the blood 
 is evacuated within twenty-four hours by the bowels, unless 
 death occurs earlier. 
 
 A large and immediately dangerous hemorrhage is more 
 common and characteristic of ulcer. The more profuse a 
 gastric hemorrhage, the more likely is it to be due to ulcer. 
 Three or four ounces of blood at a time are frequently lost in 
 cancer of the stomach, and small gastric hemorrhages occur 
 in a number of diseases ; but a gastric hemorrhage of from 
 one to three pints is nearly always due to ulcer. The dan- 
 gerous form is ushered in by the usual signs of severe hemor- 
 rhage — pallor, weak pulse and heart, vertigo, great thirst, syn- 
 30
 
 466 DISEASES OF THE STOMACH. 
 
 cope. The stomach is full and feels warm ; the blood rises 
 into the mouth, and large quantities are vomited without 
 effort or pain. The blood is dark and clotted, the appear- 
 ance varying according to the time that it has remained in 
 the stomach and to the quantity of HCl with which it has 
 come in contact. Immediately after the cessation of the hem- 
 orrhage the patient is weak, exhausted, the extremities are 
 moist and cold ; he complains of vertigo and of ringing in the 
 ears ; the temperature of the body rises because so little blood 
 goes to the surface, but the fever soon subsides; there may 
 be dark spots in the field of vision, even amaurosis ; palpita- 
 tion is frequent ; dyspnea after the least effort; he is anxious, 
 and has restless nights and broken sleep. The subsequent 
 course is that of hemorrhagic anemia, which may disappear 
 in one or two months. 
 
 The hemorrhage may be profuse and may recur fre- 
 quently, death taking place in four or five days ; or the hem- 
 orrhage may cease after occurring intermittently a number of 
 days or weeks, and the patient may eventually get well. The 
 repeated hemorrhages may be due to the progress of the 
 morbid process, to deficient coagulability of the blood, or to 
 the fact that the blood-vessel is opened and not divided so as 
 allow its coats to retract. The blood vomited represents only 
 a part of that lost, the remainder passing into the intestines. 
 
 Equally pernicious are the small repeated hemorrhages, 
 usually escaping detection. The anemia is severe, and the 
 emaciation and the cachexia are remarkable, the termination 
 often being death. These little hemorrhages may occur early 
 when the ulcer is eating its way through the mucous mem- 
 brane, but sometimes later in the anatomical progress of the 
 ulcer, and they may be venous. There is neither hemate- 
 mesis nor perceptible melena. Traces of blood must be sought 
 for in the gastric contents and in the stools. Infrequently 
 the hemorrhage is slow, and eventually vomiting may be ex- 
 cited by the accumulated blood ; the vomit, then, is brownish- 
 black, like coffee grounds, consisting of blood pigment, debris 
 of cells, fluid, often food, and sometimes sarcinre. This form 
 of hematemesis is most common in the cachectic stage of ulcer 
 and in the retention stage of pyloric obstruction. 
 
 Melena may be the only symptom of ulcer. The blood is 
 small in quantity, and is homogeneously mixed with the con- 
 tents of the bowel, forming a soft, chocolate-colored mass. 
 If a large quantity of blood passes into the duodenum, the 
 stool is tarry, is often blown to pieces with gas, and is exceed- 
 ingly foul. After nearly every gastric hemorrhage blood may
 
 ULCER OF THE STOMACH. 467 
 
 be detected in the stool, and melena may occur without 
 hematemesis. 
 
 In a case of hematemesis or of melena two questions must 
 be answered : Is the hemorrhage gastric ? and is it due to an 
 ulcer? But before searching for the location or the cause of 
 the hemorrhage it is first necessary to detect its existence. 
 This is not so easy as might be supposed, and a small hemor- 
 rhage may escape the close observation of both patient and 
 physician, as hematemesis and visible melena may not occur. 
 In suspected cases it is always essential to examine both the 
 vomit and the stools by the methods already described for 
 detecting therein traces or small quantities of blood, and also 
 to examine the blood itself for characteristic signs of hemor- 
 rhagic anemia. 
 
 Having detected blood either in the vomit or in the stools, 
 or a hemorrhagic anemia, search should next be made for 
 its origin. It should not be forgotten that traces of blood 
 may be introduced with the food. Blood found in the vomit 
 may have originated in the stomach, in the esophagus, the 
 pharynx, the nose, the mouth, the respiratory tract, or even 
 the duodenum. The origin in the mouth, the nose, the throat, 
 and the larynx can be detected or excluded by careful inspec- 
 tion ; and this examination should never be omitted. 
 
 The differentiation of pulmonary and of gastric hemor- 
 rhage may be difficult, but can usually be readily made with 
 certainty. The evidence of the patient is frequently worth- 
 less. Some blood may get into the larynx during the act of 
 vomiting and may be coughed up. The blood coming from 
 the lungs in slight hemorrhage may be all swallowed, and, 
 being afterward vomited, may present difficulties that are not 
 easy to overcome, especially when the signs of pulmonary 
 tuberculosis and painful digestion or ulcer coexist. This is 
 more likely to happen with women. To make the differentia- 
 tion, it is best to proceed in a methodical manner. Do the 
 clinical history and the objective examination reveal a disease 
 of the lungs, or of the heart, or of the esophagus, of the 
 liver, or of the stomach ? If a disease be detected, the evolu- 
 tion of which is accompanied by gastric or pulmonary hemor- 
 rhage, the discovery is strong presumptive evidence of the 
 source of the blood. 
 
 The method of beginning, when carefully observed, is of 
 great importance. Hemoptysis begins with tickling in the 
 throat, with cough, and with the expectoration of red blood. 
 Hematemesis begins with the symptoms of internal hemor- 
 rhage, and with a feeling of distention and of heat in the
 
 468 DISEASES OF THE STOMACH. 
 
 Stomach. The warm blood mounts along the esophagus to 
 the throat, and nausea is followed by vomiting. 
 
 The signs following the hemorrhage may be conclusive. 
 In hemopt\'sis the sputum brought up by coughing con- 
 tinues for several days to be bloody, and for a short period 
 thereafter the blood expectorated is red, and does not consist 
 of particles that have accidentally gotten into the larynx. In 
 hematemesis the sputum becomes quickly clear if the mouth 
 and the throat have been freed from blood. 
 
 In hemoptysis there is frequently fever ; in gastric hemor- 
 rhage fever is ephemeral and due to the loss of blood, and the 
 stools frequently contain blood at some time during the fol- 
 lowing forty-eight hours. Ulcer is an afebrile disease unless 
 it be complicated. 
 
 In hemoptysis the blood is red in the beginning, and is 
 mixed with air. Later the sputum may contain both dark 
 and red blood. In hematemesis the blood is nearly always 
 dark, and presents the changes peculiar to the action of HCl. 
 
 The differentiation of esophageal and of gastric hemor- 
 rhage may be very difficult. The search for the causative 
 disease should first receive attention — cancer, ulcer, varicose, 
 veins, or the rupture of an aneurysm. The use of neither the 
 esophageal nor the gastric sound is permissible. The dis- 
 covery of a disease productive of passive congestion in the 
 portal system is of differential value. The blood from the 
 esophagus is dark, but not chocolate- or coffee-colored, and is 
 expelled without the effort of vomiting. The blood goes also 
 into the stomach and hematemesis or melena, one or the other, 
 or both, may occur. The clinfcal history is of most value. 
 There is, in the one case, a history of esophageal pain, located 
 behind the sternum and extending into the back and shoulders, 
 or of stricture. Both s\'mptoms are manifest during swallow- 
 ing. In the other case the symptoms are located in the stomach, 
 and begin after the food has reached this organ. In all cases 
 of esophageal ulcer there is vomiting. 
 
 Blood found in the stools may have entered at any point 
 of the alimentary canal, and it may be impossible to locate 
 the source of the hemorrhage; but the presumption is in 
 favor of its gastric origin when there is no discoverable in- 
 testinal disease and where there is a history of gastric trouble. 
 The blood, when in too small quantity to excite diarrhea, is 
 intimately mixed with the fecal matter, and so altered as to 
 be often recognizable only by the chemical tests. 
 
 Objective Signs. — The chief positive physical signs of 
 simple ulcer of the stomach, of diagnostic value, are the epi-
 
 ULCER OF THE STOMACH. 469 
 
 gastric and the dorsal tender points. These points are char- 
 acterized by their locaHzation, sharp Hmitation, and very great 
 sensitiveness. 
 
 The epigastric point is located on or very near the median 
 line, close to the ensiform process. The location may vary 
 according to the seat of the ulcer and to the position of the 
 stomach. Consequently, it may sometimes be a little to the 
 right or to the left, or lower down. It is commonly of an area 
 of about the size of a silver dollar, and the location in a given 
 case is constant. 
 
 This small, tender area is sharply limited, and does not cor- 
 respond in form and location with the left lobe of the liver. 
 In some cases the whole epigastric region is sensitive, par- 
 ticularly if the examination be made when the stomach is not 
 empty. The production of the pain, when the stomach con- 
 tains fluid, by the little successive shocks employed to elicit 
 the splashing sounds is a distinctive feature. The epigas- 
 trium may also be hyperesthetic, but with care the small and 
 more sensitive area can be detected and its boundaries can 
 be defined. 
 
 The epigastric point is very sensitive, more so than in any 
 other disease of the stomach, where from two to four times 
 the amount of pressure is needed to produce true pain. But 
 in a number of cases the sensitiveness is not so great as to be 
 characteristic, and the sign alone should not be given too great 
 importance. The degree of sensitiveness varies in different 
 cases and in the same case at different times. The epigastric 
 spot is characteristic in about two-thirds of the cases, and 
 may be present when all subjective signs are absent. 
 
 The dorsal point is about the size of a silver dollar and is 
 located about an inch to the left of the two last dorsal verte- 
 brae. It is sharply limited, but not so sensitive as the epigas- 
 tric point. Sometimes a second sensitive area coexists, to the 
 right of the spine on the same level, but requires greater 
 pressure to elicit true pain. Sometimes the point on the right 
 is the more tender, and it may exist alone. Two similar points 
 may be located on a level with the fourth and the fifth dorsal 
 vertebrae; but this is not characteristic of ulcer, but is due to 
 reflex excitation of the spinal sensory nerves by the irritable 
 sympathetic ganglia. The lower dorsal point exists in about 
 one-third of the cases of ulcer, and its diagnostic value is 
 variously estimated. 
 
 In the same case the degree of sensitiveness of the dorsal 
 point is more variable and the point itself less persistent than 
 the epigastric tender point. Taken in combination with other
 
 470 DISEASES OF THE STOMACH. 
 
 ulcer symptoms, tlie dorsal point is a confirmatory sign of 
 value. 
 
 A physical sign of ulcer, much more common than is gen- 
 erally admitted, is a palpable tumor. If the ulcer be recent, 
 it consists only of a defect of the mucous membrane, but pos- 
 sibly it also extends deeper ; in either case no tumor will be 
 felt. In old ulcer, however, the edges may be thickened and 
 infiltrated, and if then it be located in the part of the anterior 
 wall accessible to palpation, or in another region made acces- 
 sible to the fingers by displacement of the stomach, a flat, thin, 
 and tender tumor can be felt. The pylorus may be thick- 
 ened, or hard and contracted, if the ulcer is located near it. 
 These forms of tumors are not complicated by adhesions, and 
 can be easily fi.xed on expiration. More common and char- 
 acteristic are the tumors formed by inflamed adherent organs 
 and by inflammatory exudation. The localized inflammation 
 and infiltration of the adherent organ produces a circumscribed 
 mass, which is hard and is easily defined by the e.xamining fin- 
 gers. The head of the pancreas, when felt, is deep, immov- 
 able, hard, and enlarged; or the mass may be in the adherent 
 left lobe of the liver, and may ascend and descend with respira- 
 tion in close union with the diaphragm. The ulcer tumor 
 may long remain stationary, or is, at least, not slowly and 
 regularly progressive. It is tender, develops as a consequence 
 of inflammation, and, considered in connection with the clinical 
 history and the syinptoms and other signs, may be very 
 important in the diagnosis of ulcer. The age, the stationary 
 character, the tenderness, and the absence of secondary 
 nodules may be valuable in excluding a suspected cancer. 
 
 In ulcer of the stomach the state of nutrition is variable. 
 In the mild clinical forms, where enough food is taken and 
 retained, and the loss of blood is insignificant, the strength and 
 the weight may be maintained, and the general appearance 
 may be that of excellent health. But such a state of nutri- 
 tion is exceptional, and pain, vomiting, hemorrhage, and the 
 insufficient and exclusively liquid diet spontaneously adopted 
 after a certain length of time produce emaciation and inani- 
 tion. Indeed, in complicated cases, or where little food has 
 been utilized for a long time, the inanition may be fatal. 
 About five per cent, of the deaths from ulcer are due to 
 starvation. An insignificant hemorrhage in this state 
 of extreme emaciation may prove to be a death-stroke. 
 These cachectic cases are more frequent after the fortieth 
 year. Inanition is more frequent, and emaciation ma\' be more 
 pronounced in ulcer than in any other non-malignant disease
 
 ULCER OF THE STOMACH. 47 1 
 
 of the stomach, and the cachexia may be as marked as in ad- 
 vanced carcinoma. 
 
 In round ulcer of the stomach the blood may be normal 
 or it may be diseased ; the disease of the blood may be pri- 
 mary, or it may be secondary, and due to inanition and to 
 hemorrhage. The relations of anemia and chlorosis to the 
 genesis of ulcer have already been discussed. The sympto- 
 matic blood trouble is always oligocythemia. 
 
 A single small hemorrhage may produce a very slight and 
 temporary disturbance; a single large hemorrhage is fol- 
 lowed by greater changes, and the phenomena of regenera- 
 tion of the blood are more marked; repeated hemorrhages, 
 though small, lead in the course of time to very grave 
 oligocythemia. This is very clearly seen in the hemorrhagic 
 form of ulcer, and where there are frequent small and con- 
 cealed hemorrhages without either hematemesis or visible 
 melena. The great recuperative power of the blood is a dis- 
 tinctive characteristic of the blood in ulcer of the stomach. 
 
 After a single small hemorrhage the number of red cells 
 and the percentage of hemoglobin are proportionately dimin- 
 ished, and there is in a few hours a slight increase in the 
 number of the polynuclear white cells, and a few nucleated 
 red cells may appear after a few days. The red corpuscles 
 are all of the normal size. A comparison of the results of the 
 examination of the blood a short time before and after the 
 hemorrhage in a case of ulcer would reveal the occurrence of 
 the hemorrhage. 
 
 After a single large hemorrhage, which is almost sure to be 
 accompanied by hematemesis, the hemoglobin and the num- 
 ber of red cells are diminished, the percentage of hemoglobin 
 divided by the percentage of red cells is equal to unity, and the 
 number of lymphocytes and polynuclear white cells is notably 
 and absolutely increased. After a few hours the blood 
 formula begins to change, and in a few days becomes char- 
 acteristic. The blood is flooded with small nucleated red 
 corpuscles ; the common red corpuscles and the hemoglobin 
 increase, but the cell regeneration is faster than that of the 
 hemoglobin, so that the above fraction is less than unity. The 
 number of red corpuscles are gradually recovered, and the 
 white corpuscles soon drop down to their normal proportion 
 and number. The regeneration is greatly prolonged if re- 
 peated small concealed hemorrhages occur. A sudden arrest 
 or a fall in the regeneration or in the richness of the blood, 
 respectively, would be a sign of hemorrhage. The blood 
 changes are thus revealing signs.
 
 4/2 DISEASES OF THE STOMACH. 
 
 Repeated small hemorrhages are very frequent in ulcer. 
 They may or may not be associated with a severe hemor- 
 rhage. These small and, in themselves, insignificant hem- 
 orrhages cause neither vomiting nor coloration of the stools 
 sufficient to attract the eye. Their repetition renders them 
 serious, and a knowledge of their existence would confirm a 
 provisional diagnosis of ulcer. The blood will be found to 
 have a diminished number of red corpuscles, a diminution of 
 the hemoglobin, and the percentage fraction is less than unity ; 
 the number of small nucleated red corpuscles is increased, and 
 also the number of white corpuscles. There are sudden 
 changes for the worse, and the recurring little blood crises 
 indicate the small concealed hemorrhages. In all cases of 
 gastric ulcer the blood should be carefully watched. In 
 hemorrhagic oligocythemia there are no signs of degenera- 
 tion of the corpuscles, no s.igns of dyshematopoiesis, and no 
 signs of hematocytolysis occurring in the circulating blood. 
 The oligocythemia is due to the loss of blood by hemor- 
 rhage. 
 
 The anemia of gastric ulcer may be due to inanition. Pain 
 in itself may exert an influence, vomiting may rob the organ- 
 ism of some of its nutriment, but the chief cause of the 
 inanition is voluntary starvation. The person feels best when 
 he eats little and gives the irritable, sensitive organ rest. 
 
 The blood formula of inanition anemia is different from 
 that due to hemorrhage. A distinction should be made be- 
 tween the effects of abstinence due to gastric intolerance 
 and a starvation diet. In complete abstinence and in fasting 
 with the exclusion of all but water, in spite of the starved 
 appearance, in the cubic millimeter of blood there is the 
 normal proportion and quantity of red corpuscles and 
 of hemoglobin ; but the number of white corpuscles is 
 rapidly and markedly diminished. This fall may go even 
 below looo to the cubic millimeter. It is well known that 
 digestion destroys and draws from the general circulation 
 to the digestive tube a large number of the white cells ; but 
 the effect of this momentary diminution of the number of 
 the circulating corpuscles is the generation and the entrance 
 into the circulation of an excess of white corpuscles. This 
 is known as digestive leukocytosis. It seems to be a general 
 rule that leukocytolysis is followed by leukocytosis, and this, 
 whether it be the result of using the white cells as phago- 
 cytes, as in the infectious diseases, or in absorption and as- 
 similation. In starvation, this digestive and assimilative use 
 of the white cells is suppressed. The absence of the demand
 
 ULCER OF THE STOMACH. 473 
 
 leads to decreased production, and eventually to diminished 
 productive power. 
 
 In chronic inanition, the conditions are different. The 
 individual is trying to live on insufficient food. The blood 
 may long maintain itself at the expense of the fat and the 
 muscles, and the percentage of formed constituents in the 
 cubic millimeter of blood may even increase. The patient 
 looks starved, and the corpuscular richness of the blood is 
 a surprise. At a later stage the hemoglobin and the cor- 
 puscles all decrease, and maybe reduced, in starvation cache- 
 xia, to one-fifth of the normal number. An emaciated, weak 
 patient with a normal blood formula is suffering from inani- 
 tion. The blood in severe inanition-oligocythemia displays 
 signs of degeneration, of dyshematopoiesis, and of hematocy- 
 tolysis. 
 
 The anemia is not always pure, but may be due to the com- 
 bined influence of inanition and of hemorrhage, and in the 
 complicated cases with pus formation or with retention and 
 fermentation, is partly also the result of auto-intoxication. 
 These mixed forms of anemia may become exceedingly grave. 
 The blood displays the signs of dyshematopoiesis, of hemato- 
 cytolysis, and of degeneration, in combination and in divers 
 degrees. 
 
 The functional signs of ulcer are in no wise characteristic, 
 but may possess a certain diagnostic value. In every case 
 where there is good reason for suspecting the existence of 
 an ulcer, the use of the stomach-tube is contraindicated. 
 While it is true that the tube may be employed without 
 accident, the procedure is dangerous, and may excite hemor- 
 rhage. If the tube be used in a suspicious case, the throat 
 should be sprayed with cocain, the contents aspirated, the 
 stomach left empty, and the tube withdrawn if the patient 
 should make an effort to vomit. The functional exploration 
 is reduced, as a rule, by the contraindication to the use of the 
 tube, to an examination of the vomit, which, in the majority 
 of cases (70 per cent.), will be found more acid than it should 
 be at the moment in the evolution of digestion when the 
 vomiting occurred. In other cases the acidity is normal or, 
 rarely, less than normal. In nineteen cases, studied by the 
 careful use of the tube, we found pyloric obstruction already 
 present in three cases, which will be left out of considera- 
 tion on this account. In 1 1 of the remaining cases there 
 was hydrochloric superacidity, and three of these showed a 
 moderate prolongation of digestion due to supersecretion. In 
 four cases secretion was normal in quantity and in evolution.
 
 474 DISEASES OF 77/ E STOMACH. 
 
 and in one there was hypochylia — the time for the exam- 
 inations being selected so as to eliminate the influence of 
 subnutrition and hemorrhage. In tliree of tiie cases with 
 hydrochloric superacidity secretion became normal during the 
 second week of the ulcer treatment. Hayem reports secre- 
 tion normal in three of a total of 22 cases with no obstruction 
 of the pylorus. The vomit may also show signs characteris- 
 tic of other diseases, or such as are found in the complica- 
 tions of ulcer. In uncomplicated ulcer the motor function 
 is efficient, there is no decrease of absorption, there are 
 no abnormal bacteriological signs, and no variation in 
 digestive activity, except that resulting from the frequent 
 hydrochloric superacidity. The functional signs may be of 
 some value in confirming the existence of ulcer, or in exclud- 
 ing it, by revealing a complication or another disease. This 
 information may be obtained from repeated examinations of 
 the vomit or by the careful use of the stomach-tube. 
 
 Constipation is the rule in ulcer, and the bowels usually 
 require aid in order to prevent fecal accumulation. A few 
 diarrheal movements are sometimes excited by decomposing 
 blood. 
 
 Terminations. — Ulcer may terminate in cure, in death, or 
 in chronic invalidism. The oligocythemia and the inanition 
 resulting from ulcer are favorable to the development of infec- 
 tious diseases, which may prove fatal. 
 
 The healing of the ulcer is characterized by the subsidence 
 of the symptoms and objective signs. Of the cardinal symp- 
 toms, the hemorrhage is the first to disappear. Hemor- 
 rhage proves that the morbid process is progressing, though 
 when it occurs, some parts of the ulcer may be cicatrizing. 
 Vomiting ceases or is accidental and occasional. The pain 
 diminishes, becomes purely digestive, and exists only after 
 solid or irritant food or after physical or mental fatigue. 
 The tender dorsal and epigastric points become less and 
 less sensitive and finally disappear. With the healing of 
 the ulcer disappears also, as a rule, the digestive hyperchlor- 
 hydria. The ulcer before completely healing presents a 
 purely anatomical period without signs or symptoms. About 
 one-half of the cases of ulcer recover without leaving an 
 impairment of the digestive functions as a permanent legacy. 
 
 The mortality from ulcer is usually placed too high. Some 
 authors state that 50 per cent, of the cases terminate fatally ; 
 but the statistics are compiled from cases reported in medical 
 literature. If death from intercurrent diseases (tuberculosis, 
 cancer) be excluded, the mortality of the clinical (non-latent)
 
 ULCER OF THE STOMACH. 475 
 
 forms is about one in seven, and this percentage may be 
 reduced by treatment. Death may be due to perforation 
 (causes death in 80 per cent, of deaths due to ulcer), to severe 
 hemorrhage (two per cent.), or to other compHcations (five per 
 cent.), such as inanition, hemorrhagic anemia, and deformities. 
 
 The remainder of the cases become chronic invalids. The 
 functions of the stomach may be compromised by adhesions 
 or by deformities. The scars may be neuralgic. The sequelae 
 may give persistent trouble without being incompatible with 
 life. Death from the effects of the ulcer is frequently pre- 
 vented only by the intervention of a fatal intercurrent disease. 
 
 Diagnosis. — The diagnosis of ulcer may be sure, doubtful, 
 or, in a third class of cases, there may be only cause to sus- 
 pect the existence of this severe disease. Naturally, the 
 anatomical (latent) form goes unrecognized, and, also, during 
 an anatomical period ulcer would be either unsuspected or 
 would be considered cured. The clinical forms are often 
 atypical in their expression. Whoever waits for all the car- 
 dinal symptoms — pain, vomiting, and hemorrhage — to be 
 present, with their distinctive features, before making the 
 diagnosis of ulcer, will discover it late, and will overlook 
 entirely a majority of the cases. 
 
 The clinical expression of ulcer being so variable, it is 
 difficult to enumerate all the cases which fall under the three 
 divisions — sure, doubtful, and suspicious. " I am inclined to 
 think," wrote Brinton, "that nothing less than a concurrence 
 of the chief symptoms entitles us to pronounce a decided 
 opinion. In other words, unless the pain possess the charac- 
 teristics attributed to it, and is accompanied by an equally 
 characteristic vomiting, and unless there be evidence of con- 
 siderable or repeated hemorrhage in the course of the malady, 
 there is no sufficient ground for affirming the existence of 
 gastric ulcer." These requirements are too exacting. 
 
 Wherever the three cardinal symptoms are present there 
 can be no doubt. If the spontaneous pain and the tender 
 points are present, with the definite characteristics already 
 minutely described, there should be little need of confirmation 
 by the other signs, such as vomiting, hyperchlorhydria, hem- 
 orrhage, and the state of the blood and of nutrition. A large 
 gastric hemorrhage, in the absence of the symptoms of other 
 diseases which might cause it, may also be considered con- 
 clusive. There need be no hesitation if, associated with the 
 gastric hemorrhage, are the special pain, the painful digestion, 
 the vomiting, and the objective signs ; not all these combined 
 need be present, but one or more, with their typical charac-
 
 476 DISEASES OF THE STOMACH. 
 
 teristics. A positive diagnosis can be made in niucli less 
 than a majority of the cases of ulcer. 
 
 But none of the cardinal symptoms may be present in their 
 typical forms, and the symptom-group may leave the case in 
 doubt. The probability increases with the number of more or 
 less characteristic signs and symptoms. Anemia with painful 
 digestion in a girl, presenting traces of blood repeatedly in the 
 stools and in the vomit should excite more than a suspicion. 
 Suggestive signs may also be given by the mode of beginning 
 and the general characters of the evolution of the case. In 
 all the hypersthenic diseases of the stomach the possibility 
 of the development of an ulcer should not be forgotten, and 
 in all the doubtful and suspicious cases the general principles 
 of the treatment of ulcer should govern the medication 
 adopted. " Suspicions which fall far short of a definite diag- 
 nosis," declares Brinton, " may be sufficiently important to 
 dictate the whole plan of treatment. By treating these 
 doubtful cases as ulcer of the stomach, we may often cure 
 what we can not diagnose." 
 
 It is always easier to make a diagnosis of ulcer at the 
 writing-desk than at the bedside. Nothing would seem easier 
 than the recognition of a disease with symptoms and signs 
 possessing so many distinctive features. But the physician 
 is not consulted after the clinical evolution of the disease 
 is complete, but while the disease is beginning or running its 
 course. The severe gastric hemorrhage may be in the future, 
 and of no possible use; or it may be in the past, and with 
 nothing to reveal its source except the recollections of a man 
 half frightened out of his wits when it occurred. The pain 
 may not possess its distinctive features, and the patient's lack 
 of observation may keep them in obscurity when they exist. 
 Vomiting is a symptom of too many diseases to be of much 
 value. The same is true of hyperchlorhydria, the detection of 
 which may be prevented by the opposition of the patient or 
 by the danger of using the tube. When the diagnosis is not 
 made easy by typical symptoms and signs, a probable diag- 
 nosis should be based on a careful consideration of all the 
 symptoms and signs which are present. In some cases the 
 suspicion of ulcer may be so well founded as to demand the 
 subjection of the patient to the inconvenience of a rest-cure ; 
 in other cases the walking treatment should be adopted, and 
 the result of the therapeutic test may confirm or destroy the 
 suspicion. 
 
 A knowledge of the seat of the ulcer may be of value in 
 forming a prognosis and in imposing a stringent application
 
 ULCER OF THE STOMACH. 477 
 
 of a methodic cure so as to avoid the probable dangers by 
 arresting the progress of the ulcer and by causing it to heal. 
 It may also suggest the probable necessity of surgical inter- 
 vention for the relief of a constricting deformity. But the rules 
 for locating the ulcer are so untrustworthy as hardly to enable 
 us to make an intelligent guess. After it has formed, it is 
 easy to diagnose a pyloric or a cardiac obstruction demand- 
 ing surgical treatment. The guides to the localization of the 
 ulcer lead just as often wrong as right, and very little trust 
 can be given them. 
 
 If the ulcer involve the cardia, the pain is immediate on 
 swallowing, particularly after a large bolus of solid food. 
 The cardia is very sensitive to the temperature of food. If 
 the sound be passed, a severe pain behind the ensiform 
 process and extending to the upper dorsal spine and shoulder- 
 blades is complained of as soon as the instrument passes 
 the cardia. The stomach is often intolerant, and immediately 
 ejects whatever is introduced into it. The signs of cardiac 
 obstruction are more trustworthy. 
 
 If the ulcer is located in the pyloric region, the patient is 
 more comfortable when on the left side, and the pain is 
 increased when on the right side. If the ulcer is adherent to 
 the liver, the pain radiates to the right shoulder. The pain is 
 supposed to begin later than when the food is more quickly 
 brought into contact with the ulcer. Strong, visible, peri- 
 staltic waves, and delayed evacuation, which indicate begin- 
 ning pyloric obstruction, are of more value. 
 
 If the ulcer be on the smaller curvature, or near it on the 
 posterior wall, hemorrhage is frequent. The pain is relieved 
 by the sitting posture or by lying on the left side, and is 
 increased by lying on the back or on the right side. The 
 dorsal spontaneous and pressure pain is marked, and is rarely 
 absent if peritonitis (particularly with adhesions) exists. 
 
 If the ulcer is on the anterior wall, hemorrhage is rare, per- 
 foration is frequent, the pain is relieved by the dorsal position, 
 and is located to the left or lower down than the usual point ; 
 a tumor or thickening may sometimes be felt and peritoneal 
 respiratory rubbing may sometimes be detected. 
 
 Differential Diagnosis. — Several painful diseases resemble 
 ulcer in their clinical expression, and make it necessary, 
 particularly in atypical cases of ulcer, to search for differential 
 symptoms and signs. When the cardinal symptoms of ulcer 
 are present, with their usual associations and their distinctive 
 features, the case can be nothing but gastric ulcer. Rut ulcer 
 does not conform its clinical manifestations to the classical
 
 478 DISEASES OF THE STOMACH. 
 
 lines laid down in books, and the practitioner will be con- 
 fronted by difficulties. The diseases most likely to be con- 
 founded with ulcer are gastralgia nervosa, adenohypersthenia 
 gastrica, hypersthenic gastritis (which see), cancer, displace- 
 ment of the stomach with painful digestion, cholelithiasis, and 
 duodenal ulcer. 
 
 In both gastralgia nervosa and in ulcer the pain is gastric, 
 and may be paroxysmal and severe. But the gastralgic 
 attacks are intermittent, begin suddenly, and become rapidly 
 intense ; are in no constant relation with the taking of food, 
 or with its quantity or quality, or with the evolution of 
 digestion; are unassociated with a disorder of secretion; and 
 the attacks, extending alike through the periods of digestion 
 and of functional repose, are separated by days of normal 
 painless digestion. The neuralgic pain coincident with diges- 
 tion may be stilled by anodal sedative galvanization, but this 
 is never true of the pain of ulcer. The special pain of ulcer is 
 e.xcited by food, particularly by solids and by irritants, and is 
 digestive; it is relieved by the evacuation of the stomach, 
 but never by pressure, and is increased by movements and 
 calmed by repose. The epigastric and the dorsal points are 
 localized, sharply limited, and persistent. Digestive super- 
 acidity is frequently present. In gastralgia there is never 
 hemorrhage, secondary anemia, nor inanition ; but there are 
 often neuralgic pains in other parts of the body. It should 
 not be forgotten that gastric neuralgia may be a sequel of 
 ulcer. 
 
 Atypical ulcer may be confounded with the digestive form 
 of adenohypersthenia gastrica. The two prominent symp- 
 toms of this dynamic affection of the stomach are hyper- 
 chlorhydria and painful digestion. Naturally, no doubt can 
 exist when there has been a large gastric hemorrhage or 
 repeated small gastric hemorrhages. The blood signs of 
 hemr)rrhagic anemia are very valuable in the e.xclusion of the 
 non-hemorrhagic diseases of the stomach, provided the 
 source of the hemorrhage can be located in the stomach. 
 But ulcer is often manifested by pain and by hyperchlorhy- 
 dria, the other primary and secondary signs and symp- 
 toms being suppressed. The presence of any anatomical 
 signs would at once exclude the dynamic affection, and signs 
 of inanition would be in favor of ulcer. Hyperchlorhydria 
 is not always present in ulcer, as in the other affection 
 under consideration. But the practitioner may be confronted 
 by a condition where a probable conclusion must be drawn 
 from the characteristics of the pain, which may be sufficient
 
 ULCER OF THE STOMACH. 479 
 
 to suggest the one or to exclude the other. Pain increas- 
 ing with the evolution of secretion and relieved by albu- 
 minous foods, speaks in favor of adenohypersthenia. The 
 pain is acid-produced, and is diminished by combining the 
 free HCl. The pain of ulcer is excited directly by the 
 mechanical and the chemical irritation of the food, though 
 hyperchlorhydria may also be a factor of its genesis. The 
 pain of ulcer, being due to combined influences, is never com- 
 pletely relieved by the administration of albuminous foods. 
 Other special characteristics of the pain of ulcer — such as the 
 relation to the movetnents of the body, to the attitude, etc. — 
 may be present. The epigastric and tender dorsal points of 
 ulcer are present during the period of gastric repose. The 
 causation, the genesis, and the evolution may be in favor of 
 the one or the other disease. In some cases doubt can only 
 be dispelled by time, and in the meanwhile the treatment 
 suitable for the more serious disease should be employed. 
 
 The physician is often called upon to make the differen- 
 tiation of ulcer and of cancer of the stomach. This may be a 
 problem of easy solution, or one that necessitates a close 
 study of the distinctive features of the symptoms common to 
 the two diseases ; or a search for symptoms and signs present 
 only in the one or in the other. There may be general features 
 and little peculiarities and associations which speak in favor 
 of a benign or of a malignant process. These minor points 
 are given in the clinical descriptions of the two diseases, and 
 will often be found of more value at the bedside than tables 
 of contrasting generalities. Some of the more important dis- 
 tinctive features will here be brought together. 
 
 Cancer is most frequent between the ages of forty and sixty, 
 and is rare before thirty. Ulcer is most frequent between 
 twenty and forty, but is by no means rare after this period. 
 The beginning of the* disease before thirty is in favor of ulcer, 
 but it should not be forgotten that carcinoma may rarely 
 occur before the twentieth year. 
 
 The beginning of carcinoma is acute, and most frequently 
 without any previous gastric trouble. A disease of the 
 stomach, beginning somewhat suddenly, without appreciable 
 cause, in a man beyond the fortieth year, is circumstantial 
 evidence in favor of cancer. 
 
 Ulcer frequently begins insidiously, with predisposing and 
 exciting causes ; or else suddenly, with a characteristic cardi- 
 nal symptom. But it must not be supposed that a diseased 
 stomach does not become the seat of cancer. 
 
 The evolution of carcinoma is rapid, progressive, uncon-
 
 480 DISEASES OF THE STOMACH. 
 
 troUable. Tlie disease kills in about two years, and tlie 
 clinical period is about fourteen months. There are no abso- 
 lute breaks in its deadly march, but under proper treatment 
 there may be periods of improvement. Ulcer is a chronic 
 disease, with periods of quiescence and self-improvement, 
 yieldin<j often, as if by charm, to well-regulated treatment. It 
 may also be acute, but its symptoms and signs are then all 
 the more likely to be characteristic, and an early fatal termi- 
 nation may occur in a distinctive manner from profuse hem- 
 orrhage or from perforation, and not from auto-intoxication, 
 cachexia, and inanition. But inanition may also develop 
 rapidly in ulcer, as a consequence of the insufficient diet, or 
 of vomiting, or of hemorrhage. In cancer, also, the small 
 repeated hemorrhages may be very pernicious; but the 
 emaciation often continues in spite of the retention of enough 
 food to mantain the balance of nutrition, because a part is 
 lost by fermentation and by deficient utilization, and because 
 catabolism is e.xcessive. In ulcer, however, inanition and 
 cachexia may be as pronounced as in cancer, and may be the 
 cause of death ; but this does not occur until the disease has 
 lasted much longer than the clinical period of carcinoma, 
 unless a complication develops. 
 
 Pain presents in the two diseases many distinctive features. 
 Naturally, only the painful forms or periods of carcinoma and 
 ulcer come into consideration here. The pain of cancer is 
 not confined to the digestive period, nor does it develop in 
 relation with the evolution of secretion ; it is not excited by 
 the taking of solid food, but its intensity often increases after 
 food is taken which easily undergoes lactic acid fermentation. 
 The pain is most frequently the result of excessive acid-pro- 
 duction (butyric and lactic acid) by bacteria, but local perito- 
 nitis and painful adhesions should not be overlooked. The 
 pain is sharp, lancinating, agonizing, and peisists, and, in- 
 deed, often is most intense during the period when the 
 stomach should be empty and at rest. It is well known that 
 stagnation or retention is nearly always present in cancer, and, 
 consequently, the pain is often due to the irritant contents. 
 But the carcinomatous stomach, when empty, may also be the 
 seat of severe spontaneous pain. All these characteristics are 
 in marked contrast with those of the special pain of ulcer, 
 already so minutely described. It is only in exceptional 
 cases that pain on pressure is localized, circumscribed, and 
 so acute as in ulcer. 
 
 A profuse hemorrhage, with the vomiting of pure blood, 
 is rare in carcinoma, the vomit commonly being " coffee
 
 ULCER OF THE STOMACH. 48 1 
 
 grounds " in appearance and mixed with the very acid and 
 sometimes stinking contents. Small hemorrhages possess no 
 differential value, though melena is much less frequent in 
 cancer. 
 
 The vomiting of ulcer is easy and digestive, and occurs at 
 the climax of the pain, which it relieves. In cancer, vomiting 
 may occur at any moment, and may be repeated soon after 
 the stomach has been thoroughly emptied, and is usually 
 difficult and accompanied by retching. 
 
 A tumor may be felt in either disease, but is very much 
 more frequent in cancer. In the one case a very sensitive 
 inflammatory mass is felt, nearly always firmly adherent to 
 the surrounding parts. The tumor of cancer is frequently 
 mobile, nearly always much less sensitive, and often can be 
 fixed during expiration by the examining fingers. But the 
 mere presence of a tumor is by no means conclusive, and 
 neither is its absence very much in favor of ulcer. 
 
 Ulcer and carcinoma can nearly always be distinguished 
 with certainty by the functional and the bacteriological signs. 
 Ulcer has only one functional sign, and this is not a symptom 
 of the ulcer, but of the associated adenohypersthenia or hyper- 
 sthenic gastritis. Fortunately, this one functional sign — 
 hyperchlorhydria — is never found in cancer except in the 
 very rare cases where it is engrafted on an old ulcer. Some- 
 times, in ulcer, the hydrochloric acidity is normal, but this 
 is very rarely so in cancer. Exceptionally, hypochlorhydria 
 is found at some period of ulcer; but hypochlorhydria is 
 the rule in cancer. In ulcer there is no fermentation, nor 
 excessive nor peculiar germ growth, unless there is retention 
 due to pyloric obstruction or stagnation from motor insuf- 
 ficiency produced by adhesions. But in these complicating 
 conditions hydrochloric superacidity is the rule, and sarcinae 
 may be found in large quantity (retention) ; and there is yeast 
 fermentation, with the formation often of large quantities of 
 gas in the stomach and in the fermentation tubes. The func- 
 tional and the bacteriological signs of cancer are very different 
 — motor insufficiency, diminished secretion, characteristic 
 bacillary growth, and, chiefly, lactic and butyric acid fermenta- 
 tion. Lactic acid is never formed in ulcer after thorough 
 lavage and the oatmeal test of Boas, but it is so formed fre- 
 quently and often at an early period in cancer. The functional 
 signs of cancer are persistent; the functional signs of ulcer 
 may change rapidly under the influence of sedative and pro- 
 tecting medication. 
 
 The displacements of the stomach (vertical displacement 
 31
 
 482 D/SEASES OE THE STOMACH. 
 
 and total descent) are easily determined by their signs and 
 symptoms. The dislocated stomach may become obstructed 
 or myasthenic, and its mucous membrane irritable or even 
 inflamed. Under these circumstances there may be stagna- 
 tion, superacidity, and severe paroxysmal digestive pain. 
 The problem, then, to solve is whether the displaced stomach 
 is also the seat of ulcer. 
 
 The pain of ulcer, associated with a displacement of the 
 stomach, is often atypical. It is often independent of the 
 quality of the food, solid food being eaten without much dis- 
 comfort. There may be little difference in the subjective 
 symptoms excited by the digestion of a solid meal and of 
 one composed exclusively of fluids. The pain, which usually 
 occurs late, rarely culminates in vomiting. 
 
 The painful forms of the dislocations of the stomach have 
 also, as a rule, a tender epigastric point. The discomfort is 
 increased by movement and is relieved by repose. Conse- 
 quently, in this particular condition many of the ulcer char- 
 acteristics are not available, for the ulcer may be present 
 in the dislocated stomach, with stagnant contents, fermenta- 
 tion, and hydrochloric superacidity. In the absence of any 
 of the signs of hemorrhage, the exclusion or the detection of 
 an ulcer may be impossible. But a hypothesis may be built 
 on a study of the tender points. Those of ulcer have already 
 been minutely described. In the painful dislocations the 
 epigastric point is never so sensitive as in ulcer, and is sup- 
 posed to be due to an irritable solar plexus. The frequent 
 association of the epigastric tender point with tender points to 
 either side of and below the umbilicus makes this opinion 
 plausible. Neurasthenic tender points are also often found 
 along the spine, including the cervical and sacral regions. If 
 only one tender point is found over the abdomen, and is located 
 in the epigastrium, and does not correspond in form and area 
 with the left lobe of the liver; if only one tender point is 
 found in the back, and situated to the left of the two lower 
 dorsal vertebrae — if both these points are very sensitive and 
 persistent, the presence of an ulcer is very probable. In 
 ulcer the stomach is always beneath the tender point. The 
 tender point of gastroptosis is above the lesser curvature, and 
 the pain is not produced until the pressure of the finger is 
 exerted on the gastrophrenic ligament. In some cases, with 
 atypical symptoms and signs, the diagnosis or exclusion of 
 ulcer is a mere assertion. 
 
 Cholelithiasis and gastric ulcer often come up for differen- 
 tial diagnosis. A profuse hemorrhage or the detection of a
 
 ULCER OF THE STOMACH. 483 
 
 gall-stone in the feces would be decisive. But it should be 
 remembered that the two diseases may be coexistent. 
 
 The attacks of gall-stone colic are periodical, and are sepa- 
 rated by intervals when an ordinary mixed diet is borne with 
 perfect comfort. During the attack, however, the functions 
 of the stomach may be reflexly disturbed. In some cases 
 the attacks recur with very short intervals, and with marked 
 regularity. But during the short interval one or more mixed 
 meals may be painlessly digested. The course of ulcer may 
 be broken by anatomical periods, but only exceptionally, and 
 never by short periods of severe manifestations and of com- 
 plete silence. 
 
 The pain of gall-stone colic is independent of digestion, 
 and has its center usually to the right of the median line, and 
 radiates to the right into the back and the right shoulder. 
 There is often a sensitive area to the right of the last dorsal 
 vertebra, and the whole hepatic region may be sensitive. If 
 epigastric tenderness exists, it corresponds in form with the 
 usually unenlarged left lobe of the liver. The gall-bladder, 
 situated about two inches to the right and the same distance 
 above the umbilicus, may be exquisitely sensitive and dis- 
 tended ; may produce a visible tumor, and sometimes peri- 
 toneal friction may be detected during the up-and-down 
 movements of respiration ; and, very rarely, the rubbing to- 
 gether of gall-stones may be felt. During or soon after the 
 attack, particularly when the recurrences are frequent, the 
 right lobe of the liver is enlarged, smooth, and sometimes 
 tender. Very important differential signs are the fever and 
 the jaundice which often accompany the attacks of gall-stone 
 colic. The attack also begins without any fixed relation to a 
 meal, and ends in a manner equally inexplicable by a sup- 
 posed location of the trouble in the stomach. 
 
 The most frequent gastric trouble in cholelithiasis is motor 
 insufficiency, which is not a sign of simple primary ulcer ; 
 and gastric secretion may be excessive or continuous. Hyper- 
 chlorhydria is about as frequent in gall-stone colic as in ulcer, 
 but it may subside between the attacks without special treat- 
 ment. Whoever has watched the gastric functional signs in 
 the two diseases will not put much faith in their value as 
 differential signs. 
 
 The clinical expression of ulcus duodeni is very variable 
 and indefinite. This utter lack of distinctive features is its 
 strongest characteristic. Its irregular manifestations are very 
 similar to those of atypical gastric ulcer, and it is very seldom 
 that an opportunity, when it presents itself, is utilized to
 
 484 DISEASES OF THE STOMACJI. 
 
 attempt the differentiation, which nia\' sonietinics be made 
 with probability. Like ulcer of the stomach, tiiat of the 
 duodenum may be completely anatomical, or latent up to the 
 moment of a fatal hemorrhage or of perforation. In the rest 
 of the cases there may be symptoms which, on account of 
 their location, characters, associations, conditions, and gen- 
 eral lack of distinct meaning, may excite suspicion. The 
 following considerations may sometimes render it possible 
 to make a probable differentiation. 
 
 Ulcus duodeni is a much less frequent disease than gastric 
 ulcer; it is more frequent in the male sex; one-tenth of the 
 cases occur before the tenth year; it is common after non- 
 fatal extensive burns of the skin, and is not produced by chlo- 
 rosis or anemia. The pain of duodenal ulcer in about one-third 
 of the cases is a prominent symptom, and is located where the 
 right parasternal line crosses the right costal border; it may 
 be excruciating, and radiate over the abdomen ; it does not 
 entirely subside when the stomach is empty\ is not often re- 
 lieved by vomiting, and may begin as late as two or three 
 hours after a meal and continue during the night. Some- 
 times the taking of food relieves it, and Chvostek notes that 
 the paroxysm of pain was relieved in one of his cases after 
 the ingestion of a glass of wine. If local peritonitis is 
 present, the pain may be severe and continuous, increased by 
 taking food, and the duodenal region may be extremely sen- 
 sitive to pressure. A duodenal tender point exists in most 
 of the clinical cases, but a dorsal point is seldom found. 
 Vomiting is infrequent, painful digestion is uncommon, and in 
 a case observed by Leube hyperchlorhydria did not exist. 
 A profuse hemorrhage occurs in about one-fourth of the 
 cases, and may produce both stormy hematemesis and melena, 
 but melena alone is the rule. Icterus is sometimes produced 
 if the ulcer is near the opening of the common duct, with 
 foul, fatty stools. These signs and symptoms differ from 
 those of gastric ulcer chiefly in their relative frequency, or 
 in peculiarities which are only exceptionally present. Fortu- 
 nately, the treatment of gastric ulcer is appropriate for both 
 diseases. 
 
 Complications. — The complications of ulcer are numerous, 
 antl some are more dangerous than the disease which has 
 caused them. Anatomically, ulcer is either non-perforating 
 or perforating. At any moment during its evolution ulcer 
 may become cancerous. Before perforation, the only other 
 complications are local peritonitis and hypersthenic gastritis. 
 After perforation there may occur ulceration of the adherent
 
 ULCER OF THE STOMACH. 485 
 
 parts, general peritonitis, abscess and its consequences. The 
 secondary oligocythemia, which may be mild, severe, or 
 grave, has been described among the symptoms. 
 
 Engrafted Cancer. — About five per cent, of the cases of car- 
 cinoma of the stomach develop in the border or in the cica- 
 trix of an ulcer. " The edges undergo cancerous degenera- 
 tion or a fungous growth shoots up from the base," wrote 
 Brinton, who was the first to notice this complication. No 
 other disease of the stomach seems to form so favorable a 
 soil for the development of cancer. The ulcer, or scar, 
 seems to be the point of least resistance to the atypical, 
 invading, and unconfined epithelial proliferation. Where 
 cancer of the stomach develops in such conditions, it always 
 selects the border of the ulcer or the cicatrix for its location. 
 On the other hand, the development of a peptic ulcer in the 
 part affected by cancer, or even in the healthy part of a can- 
 cerous stomach, has not been observed. The ulcer is always 
 the primary disease in which the cancer has become en- 
 grafted. 
 
 The diagnosis of the complication during life is most often 
 a happy guess, except where a nodulated tumor can be felt 
 in the pyloric region, increasing in size from day to day, 
 accompanied by uncontrollable and progressive emaciation 
 and cachexia, out of proportion to the amount of food eaten 
 and retained. Hyperchlorhydria is the rule, and is as persis- 
 tent as that of simple ulcer. The functional and the bacterio- 
 logical signs may not be distinctive. The detection of 
 secondary nodules in the liver would be conclusive in favor 
 of cancer, and the previous history might reveal the exist- 
 ence of the ulcer which has undergone malignant degenera- 
 tion. Either the ulcer or the cancer will be overlooked, unless 
 the present signs reveal a cancer and the previous history 
 an ulcer. After the development of the carcinoma, the 
 previously benign clinical evolution becomes malignant and 
 progressive. 
 
 Plastic Peritonitis. — A local plastic or productive peritonitis 
 is a very common complication before perforation occurs, 
 and may be considered a conservative process. Ulcer may 
 heal after perforation if a base is supplied by an adherent 
 organ or muscle ; death, in the natural course of events, is 
 almost certain, if the contents escape into the general peri- 
 toneal cavity. But adhesions do not always form, even after 
 the local peritonitis has long existed ; particularly if the ulcer 
 is located on the anterior wall, which makes large excursions 
 with both movements of respiration.
 
 486 DISEASES OF THE STOMACH. 
 
 The process then can act conservatively only through 
 the possibly increased resistance against perforation made by 
 the thickened peritoneum. At autopsies, gastric adhesions 
 are found in about one-half the cases where ulcer has existed. 
 Including cases where plastic peritonitis exists without 
 adhesions forming, it may be estimated that simple local 
 productive peritonitis occurs in the majority of the cases of 
 ulcer. 
 
 There are no signs or symptoms by which the complication 
 can be recognized. Many of the distinctive characteristics of 
 the special pain of ulcer are in reality due to it, and it is 
 probably present in all cases where the tender points are 
 extremely sensitive, and a dull, aching, deep-seated, spon- 
 taneous pain, causing the patient evident anxiety, persists 
 during the period of gastric repose. In some cases peritoneal 
 rubbing may be felt, or respiratory friction sounds may be 
 heard over the seat of the trouble, furnishing the only con- 
 clusive and revealing signs. Persistent extension of the 
 spontaneous pain into distant or unusual parts, such as the 
 right shoulder, the lumbar region, and the precordium, should 
 excite suspicion. The occurrence of the complication in a 
 recognizable form is a danger-signal, for the ulcer already 
 extends in depth to the peritoneal layer. 
 
 Perforation. — In about four per cent, of the cases of ulcer per- 
 foration takes place. According to Lebert, in three to five per 
 cent, of the cases perforation occurs, and is followed by abscess 
 or by general peritonitis, and is the cause of about one-fourth of 
 the deaths from ulcer. According to the statistics of Brinton, 
 which were compiled from autopsies reported by various 
 authors, perforation occurs in every seven or eight cases of 
 ulcer. However, fatal cases are more frequently reported, 
 and the statistics of Lebert are nearer the truth. About one- 
 twelfth of all ulcers are located on theanterior wall, and sixty 
 per cent, of ulcers so located terminate in perforation. But 
 perforation occurs in only two per cent, of all other ulcers of 
 the stomach. We have found 58 cases (35 women, 22 men, 
 and one, sex not given) of latent ulcer scattered through litera- 
 ture, the first manifestation of which was perforation, and in 
 43 of these cases the ulcer was located on the anterior wall. 
 We have collected 1348 cases in which the situation of the 
 ulcer was given, and find it 923 times on theanterior wall and 
 425 times elsewhere. Weir and Foote report the proportion 
 as 43 to 17, and Comte as 28 to 15, in favor of the anterior 
 surface, in operated cases. Perforation is about three, times 
 as frequent in women as in men (1483 to 461). The cases in
 
 ULCER OF THE STOMACH. 487 
 
 men are scattered all along through life, the average of the 
 collected cases being about 40. Four-fifths of the cases in 
 women occur before the thirty-fifth year. 
 
 Perforation of the stomach may take place when the viscus 
 is full or when it is empty. If perforation occurs during dis- 
 tention of the stomach with food and gas, severe pain is the 
 first symptom. The pain is sudden, severe, often agonizing, 
 and it does not cease when the stomach is empty. The epi- 
 gastric pain is quickly followed by distention of the upper 
 part of the abdomen, which is rigid, and it is accompanied by 
 shock and by anxiety, and sometimes by a subnormal "tempera- 
 ture. The pain may be only dulled by an ordinary dose of 
 morphin, but it frequently moderates spontaneously after a 
 few hours. Vomiting is a symptom in more than half of the 
 cases. The pulse is feeble, the breathing is superficial, rapid, 
 and thoracic, and the temperature soon begins to rise. Death 
 will occur from general peritonitis unless an operation is 
 performed, and an operation is demanded as soon as possible 
 after the development of these symptoms in the course of 
 ulcer. When the abdomen is opened gas escapes, but there 
 is no foul odor, though the sour odor of the escaped gastric 
 contents may be perceptible. 
 
 The stomach may be empty when perforation occurs, and 
 the pain is not likely to be so severe nor the shock so great, 
 nor peritonitis so general and rapid in its beginning and 
 course, as in the cases where perforation takes place during 
 digestion. Indeed, the peritonitis may be circumvallated if 
 the patient is kept quiet and the stomach empty and still. 
 Recovery may take place without an operation, but it is the 
 rule for the peritonitis to become general after a few days of 
 deceptive quietude, and eventually to take the patient off. 
 
 Ulceration. — Perforation may occur after adhesions have 
 been formed. The results of perforation under such circum- 
 stances are ulceration, inflammation, and abscess formation 
 in the adherent part, leaving often a fistulous connection 
 with the stomach. 
 
 The ulceration which has eaten through the gastric wall 
 invades the adherent organ or part. When the pancreas forms 
 the base of the ulcer, — and this is most frequently the case, — 
 purulent inflammation and abscess formation are infrequent, 
 the tissues of this organ being unusually resistant. The ulcer 
 heals, or eats its way gradually, by molecular death, into the 
 glandular structure or into the excretory ducts, producing 
 thus a pancreato-gastric fistula. The liver maybe invaded in 
 the same way ; but this organ is less resistant than the pan-
 
 488 DISEASES OE THE STOMA CI/. 
 
 creas, and the ulceration, progressing eccentrically, forms a 
 large ca\'ity, or the process may be walled in by interstitial 
 inflammation. Biit more frequently a hepatic abscess forms, 
 which is badly drained by its fistulous connection with the 
 stomach. Ulceration may also form a canal of communication 
 between the stomach and the gall-bladder, between the 
 stomach and the intestines, and between the stomach and the 
 external world, through the abdominal wall. The ulceration 
 may extend through adhesions to the spleen, and then com- 
 monly produces a splenic abscess. Another and a very danger- 
 ous route is by way of the diaphragm, causing, as the morbid 
 process advances, productive or purulent inflammation, and 
 filling the traversed cavities with decomposing pus and gas. 
 In this way the pleural cavity (left), the pericardium, the heart, 
 the mediastinum, and the lungs may be involved. It is ex- 
 tremely infrequent that these parts are reached directly by 
 simple ulceration; but far more frequently through the media- 
 tion of a subphrenic abscess. During the extension of the 
 ulceration a blood-vessel may be encountered, and its wall 
 may be eroded. Hemorrhage is the natural result. 
 
 The diagnosis of these many complications is made through 
 the signs of ulcer, of local peritonitis, and of adhesions, and 
 through those furnished by the secondary affection of the 
 particular organ or parts involved. The complications 
 may be accompanied by fever, but uncomplicated ulcer is 
 always an afebrile disease. The signs of ulcer and of local 
 peritonitis have already been given ; the other diagnostic 
 signs will be given in the paragraphs on abscess and on the 
 sequelae. 
 
 Abscess. — Subphrenic abscess is a very serious, but fortu- 
 nately an infrequent, complication of ulcer of the stomach. 
 Maydl (1894) has collected in all 35 cases of gastric origin, 
 three of these being caused by carcinoma and 32 by ulcer; 
 some of the cases enumerated by Nowack being thrown out 
 because the etiological diagnosis was doubtful. Brinton 
 (1859) states that "there are about 20 cases of chronic per- 
 forative abscess on record." These statistics by no means 
 include all the cases of this complication, for as a clinical 
 entity it is a comparatively recent disease (Leyden, 1880), 
 the first clear clinical description (by Barlow, 1845) having 
 attracted little general attention. Cases (chiefly found at 
 autopsies) are reported here and there in medical literature, 
 but the complication, in its clinical and practical aspects, has 
 been best studied by Barlow (1845). Bouchard (1862), Rigal 
 (1874), Cassy (F879), Leyden (1880), Nowack (1881), and
 
 ULCER OF THE STOMACH. 489 
 
 Maydl (1894). The monograph of Maydl is a masterful pre- 
 sentation of the subject. 
 
 Perforation into the peritoneal cavity, according to Lebert, 
 occurs in from three to five per cent, of the cases of ulcer. 
 In some of these, on account of the minuteness of the open- 
 ing, on account of the degree of intragastric pressure at the 
 moment of perforation, and of the protection afforded by an 
 adjacent part, or other accidental circumstance, the peritonitis 
 is circumscribed, and the pus is walled in and confined to the 
 abscess cavity. Perforation after adhesions have formed is 
 more frequent, and the tissue uniting the stomach to the 
 adjacent part may break down or be perforated, and sub- 
 phrenic abscess results. The infection may be conveyed 
 along the lymphatics, and the abscess may form without per- 
 foration of the stomach. The complication, consequently, is 
 not so very infrequent as the small number of authenticated 
 cases would indicate, and its pathology and its diagnosis 
 should be more generally known, for surgical interference 
 gives the only hope of cure. 
 
 In about one-half of the cases the ulcer is located on the 
 lesser curvature and the posterior wall ; more rarely, near the 
 cardia or on the greater curvature. The left lobe of the 
 liver, though it be previously bound to the stomach by adhe- 
 sions, offers little protection against the development of an 
 abscess ; and in about one-tenth of the collected cases the 
 stomach was firmly adherent to the pancreas, which formed 
 the base of the ulcer. 
 
 For anatomical reasons, the abscess due to ulcer of the 
 stomach is nearly always intraperitoneal, and located in the 
 left concavity of the diaphragm. It is sometimes located in 
 the right hypochondrium, or lower down, and separated from 
 the diaphragm by an intervening organ. 
 
 In a vertical section of the body, on about a level with the 
 ninth dorsal vertebra, two oval cavities are formed, surrounded 
 on the surface of the section on all sides by the diaphragm, 
 and separated from each other in the median line by the peri- 
 cardium, the esophagus, and their associated parts. The 
 oval line of the incised diaphragm is separated from the 
 abdominal wall by the pleural cavities and the lungs. The 
 right and larger cavity of the diaphragm is filled by the right 
 lobe of the liver, and the left and smaller cavity by the 
 fundus of the stomach. As the sections are made succes- 
 sively lower down, the diaphragmatic ovals increase in 
 size and the spleen appears on the left side. Much earlier 
 than expected, the splenic end of the transverse colon and
 
 490 DISEASES OF THE STOMACH. 
 
 the splenic flexure appear, and explain why this viscus often 
 forms the lower boundary of the left subphrenic abscess. 
 
 The serous covering of the stomach is not complete, and 
 leaves this organ in immediate contact with the diaphragm at 
 two points, whereby an extraperitoneal subphrenic abscess 
 of gastric origin is made possible. One of these points is 
 situated immediately adjacent to the cardia on the side 
 toward the spleen, and the other between the kidney and 
 the suprarenal .capsule, the posterior layer of the lesser 
 omentum leaving a small space uncovered. 
 
 The boundaries of a subphrenic abscess vary according to 
 its location to the right or left of the suspensory or falciform 
 ligament of the liver, which separates the two diaphragmatic 
 cavities. The abscess in ulcer is seldom situated in the right 
 hypochondrium. The exceptional locations need not be 
 minutely described. 
 
 The left-sided subphrenic abscess is nearly always bounded 
 above by the diaphragm. The remaining constituents of its 
 wall depend on the form and the size of the abscess and on 
 the relative location of the organs in the left h\'pochondrium, 
 which often are displaced or deformed. To the right the 
 abscess is usually bounded by the diaphragm and the left 
 lobe of the liver, but it may extend also as far to the right 
 as the falciform ligament. Below the left lobe of the liver 
 the stomach, the spleen, and also the colon and the lesser 
 omentum, through adhesions to one another and to the 
 abdominal wall, form the lower limit of the abscess cavity, 
 according to the size of the abscess and its extent down- 
 ward. The limiting wall of the abscess cavity is, to a vary- 
 ing depth, infiltrated with pus, and here and there are erosions 
 and often multiple perforations. 
 
 The abscess cavity is filled with pus alone or with pus and 
 gas. The pus is always foul, decomposing, possessing often 
 a fecal odor, when the colon forms a part of the wall. Mixed 
 with the pus is a quantity of granular matter, of false mem- 
 brane, of necrotic tissue of the limiting organs, of bacteria, 
 and, infrequently, of gastric contents. The gas which is pres- 
 ent in two-thirds of the gastric cases may be from three or 
 even four possible sources. In three-fourths of the cases the 
 air enters the abscess cavity through the communication with 
 the stomach. This is always the source when the abscess has 
 resulted from perforation before adhesions have formed, and 
 in cases where the communication was established after the 
 formation of the abscess. The air enters the abscess cavity, 
 in the remaining fourth of the cases, through a communication
 
 ULCER OF THE STOMACH. 49 1 
 
 with a bronchus. The admission of air then occurs suddenly, 
 and late in the evolution of the disease. The other possible 
 sources are through an external fistulous opening through a 
 secondary perforation of the intestines. In none of the re- 
 ported cases have germs been found to be the producers of 
 the gas. Gas-forming micro-organisms may form gas in a 
 completely closed abscess, but no case of the kind has been 
 observed in subphrenic abscess complicating ulcer. It is 
 probable that part of the gas in most of these abscesses is a 
 decomposition product. 
 
 The complications of a subphrenic abscess are numerous. 
 Perforations into the gall-bladder, the colon, and the pericar- 
 dium are extremely rare. But pericarditis without perforation 
 is more frequent, and may be dry, exudative, or purulent, 
 the inflammation being propagated by contiguity. In one- 
 seventh of the cases of abscess occurring as a complication 
 of ulcer the lung is invaded and a bronchial communication 
 is established. 
 
 The diaphragmatic and the pulmonary layers of the pleura 
 adhere, and purulent pneumonitis and necrosis follow perfora- 
 tion, the abscess of the lung communicating eventually with 
 a bronchus. A circumscribed pneumonia may also be pro- 
 duced by extension from an inflamed pleura. 
 
 Possibly, a little more frequently the pleural cavity is 
 perforated, and the contents of the two cavities below and 
 above the perforated diaphragm are the same. Whenever 
 the diaphragm forms a part of the wall of the abscess, — and 
 it is rarely otherwise, — pleurisy without perforation is nearly 
 always present at an early date, and may be pseudomem- 
 branous, exudative (with or without blood), or purulent. 
 
 The diagnostic signs and symptoms may be divided into 
 two classes — those produced by the abscess and those pro- 
 duced by the primary disease of which the abscess is a com- 
 plication. Accordingly, the twofold object is the detection 
 of the subdiaphragmatic abscess and the discovery of its 
 cause. 
 
 The signs and the symptoms which reveal the existence of 
 an abscess beneath the diaphragm are : 
 
 1. The signs and the symptoms of the development of an 
 abscess in the epigastric or the hypochondriac regions. 
 
 2. The nature and the evolution of the diseases developing 
 in consequence of the abscess. 
 
 3. The position of the diaphragm as revealed by inspection. 
 
 4. A cavity containing gas located beneath one containing 
 fluid.
 
 492 DISEASES OF THE STOMACH. 
 
 5. Removal, by puncture at different levels, of fluid pos- 
 sessing different qualities. 
 
 6. The increased pressure to which the fluid is subjected 
 during inspiration. 
 
 7. Certain physical signs. 
 
 The subphrenic abscess of ulcer develops rapidly or insidi- 
 ously. If it be the result of perforation before adhesions 
 have formed, the sudden beginning is marked by severe epi- 
 gastric pain and tenderness, with more or less shock, and 
 sometimes a rigor and a slight elevation of the temperature. 
 The diaphragm and the upper part of the abdominal wall are 
 held rigid, so as to avoid the pain due to movements. Nausea 
 is common, but vomiting is very infrequent. Hiccup and 
 pain on pressure over the course of the phrenic nerve are 
 sometimes present, and may be due to the diaphragmatitis. 
 The abdomen may be but slightly sensitive on pressure, or 
 may be exquisitely tender, particularly over the region of the 
 peritonitis, where the physical signs of peritoneal rubbing or 
 friction may exist. After a day or two the symptoms become 
 localized ; the lower abdomen is no longer distended or 
 tender ; but, in marked contrast therewith, the upper abdomen, 
 particularly over the site of the abscess, is swollen and sensi- 
 tive, and if the pus is in contact with the parietal peritoneum, 
 subcutaneous edema, extending from the hypochondrium into 
 the back, may develop The bowels may be constipated, but, 
 as a rule, move spontaneously or after a laxative if the colon is 
 not involved by the limiting peritonitis. 
 
 The beginning may be insidious, particularly where there 
 has been no perforation, or perforation after the formation of 
 adhesions. The spontaneous and the pressure pains of ulcer 
 are no longer localized, but develop over a new, and, for simjile 
 ulcer, an unusual, region. The effort to immobilize the parts is 
 evident in the rigidity of the trunk and in the shallow thoracic 
 breathing. There may be slight chills, with increase of the 
 dull or the aching pain and the tenderness, and with slight 
 fluctuations of the temperature. All these symptoms, occur- 
 ring in the course of ulcer, should immediately excite sus- 
 picion. If the abscess be situated superficially there may be 
 a well-marked area of dullness (only pus) where normally it 
 should not be found ; or in the usual position on the back, 
 assumed by the patient, the percussion note is tympanitic, and 
 the examination should then be repeated in a sitting posture, 
 and on the side; and it should be observed whether an area 
 of dullness appears where tympanicity before e.xisted (pus 
 and gas). The subsequent course and symptoms are very
 
 ULCER OF THE STOMACH. 493 
 
 variable, partly those of the abscess (emaciation, hectic fever, 
 etc.), but chiefly those of the diseases caused by it, death 
 occurring early or after a long illness. 
 
 A very important sequence of diagnostic value is the de- 
 velopment of the secondary diseases of the thoracic organs 
 after the abdominal trouble has been in activity for a length of 
 time. This fact fixes clearly the etiological relation of the 
 abscess to the pleurisy, to the pneumonitis, and to the pericar- 
 ditis. For a time there are no expectoration, no cough, and 
 no physical signs of thoracic disease. The disease of the lungs 
 and the pleurse develop from below upward. In one series of 
 cases occurs diaphragmatic pleurisy, adhesion of the base of 
 the lung to the diaphragm, pneumonia of the lower lobe, and 
 possibly bronchial perforation with profuse purulent expector- 
 ation — no history or signs of bronchitis, of bronchiectasis, 
 or of phthisis. In another series of cases are found an 
 upward-extending pleurisy, empyema, or pyopneumothorax. 
 An ulcer of the stomach, followed or accompanied by the 
 local signs and symptoms of purulent inflammation in either 
 (rarely the right) hypochondriac region, and invasion of the 
 thorax later by purulent inflammation, always most intense 
 at the base, form a sequence strongly in favor of the existence 
 of a subphrenic abscess as a link in the chain of evolution. 
 
 The existence of the secondary thoracic disease compli- 
 cates the condition but makes the diagnosis easier. This is 
 particularly true when the abscess cavity contains gas. " The 
 circumstances of the air being below the fluid in the chest, and 
 the improbability of the pneumothorax being completely sepa- 
 rated by a false membrane from a large efl"usion into the 
 pleural cavity on the same side," was given by Barlow as one 
 of the important signs of a subphrenic abscess. This brings 
 up one of the most important points in the diagnosis — the 
 location of the diaphragm above or below the collection of 
 pus or of pus and gas. 
 
 The movements of the diaphragm are often visible, and by 
 inspection the position of this muscle may be located by the 
 line of depression which moves up and down with respiration. 
 In subphrenic abscess the diaphragm is higher on the dis- 
 eased than on the healthy side of the chest; its respiratory 
 excursions may be very short, or it may be fixed by adhe- 
 sions or almost completely destroyed by purulent inflamma- 
 tion. 
 
 The removal by acupuncture, at different levels, of fluid of 
 totally different qualities, or on the same level but at different 
 depths, may be an important diagnostic sign. But this is an
 
 494 DISEASES OF THE STOMACH. 
 
 untrustworthy sign, and every precaution should be taken in 
 order to be sure that one specimen is obtained from above 
 and tlie other from below the diaphragm. Naturally, if both 
 specimens consist of the same kind of pus, no conclusion can be 
 drawn therefrom. If gastric contents are mixed with the pus, 
 a connection of the pus cavity with the interior of the stomach 
 is demonstrated ; but if it be freely connected with the interior 
 of the stomach, the abscess cavity will also contain gas. Sac- 
 culated pleurisN' and empyema are as frequent as subphrenic 
 abscess, and it is seldom that this double puncture sign can 
 have much differential value. 
 
 Great importance has been given by Pfuhl to the relation 
 of the changes of pressure in the cavity to inspiration and to 
 e.Kpiration. Jaffe suggests that instead of using a manometer, 
 the changes in the strength of the current running through a 
 cannula be observed. If the flow is greater during inspiration 
 than during expiration, the abscess is in all probability located 
 below the diaphragm. 
 
 Certain physical signs may have a differential value, but are, 
 possibly, present only when the cavity contains air. These two 
 signs are amphoric br^thing and metallic tinkle and bubbling, 
 heard low down below where the diaphragm is normally 
 attached or is situated in the particular case. The signs gain 
 immensely in value if above them there is a zone of dullness, 
 with no breath sounds nor vocal fremitus. 
 
 Before the organs in the thoracic cavity have become 
 involved the diaphragm is pushed up, and moves less during 
 respiration than on the healthy side. There are no abnormal 
 auscultatory signs over the lung if the subphrenic abscess 
 contains no gas ; but the region over the abscess may be dull 
 or tympanitic, this latter sign being attributable to the air- 
 distended stomach in contact with the pus. The normal 
 auscultatory signs cease suddenly when this area is reached. 
 If the subphrenic abscess contain much gas, amphoric 
 breathing and metallic tinkle should be heard, and also suc- 
 cussion sounds. The heart is pushed up, but is not much 
 displaced to the right. 
 
 After the disease has crossed the diaphragm there may be 
 pleurisy, and there is no physical sign of differential value, 
 unless the abscess cavity contains gas, which will be discov- 
 ered below fluid; or there may be pyopneumothorax, but 
 without a history of a disease of the lungs to cause it; or, 
 again, the lungs may be perforated, and the expectoration 
 and the physical signs of the purulent pneumonitis, develop- 
 ing from below upward, will be found, in addition to those 
 furnished by the abscess beneath the diaphragm.
 
 ULCER OF THE STOMACH. 495 
 
 The etiological diagnosis is dependent on : 
 
 1. The clinical history revealing a particular disease which 
 preceded the development of the abscess, and which is known 
 to be a cause of subphrenic abscess. 
 
 2. The location of the abscess. 
 
 3. The contents of the abscess. 
 
 Maydl divides the etiological diseases into 12 groups: 
 Stomach (35 cases), intestines (13 cases), appendicitis (25 
 cases), echinococci (17 cases), traumatism of the abdomen 
 (18 cases), liver (20 cases), perinephritis (11 cases), metastatic 
 abscess (11 cases), open wounds (6 cases), caries of rib (3 
 cases), thoracic diseases (9 cases), and other causes (i i cases). 
 From these statistics it will be seen that about one-fifth of all 
 cases are of gastric origin, and of the gastric cases about 
 95 per cent, result from ulcer. The signs and the symptoms 
 of these causative diseases should be sought for in the clini- 
 cal history and in the examination. 
 
 The location of abscess due to appendicitis, to perfora- 
 tion of the intestines, or to disease of the gall-bladder is 
 almost without exception on the right side. On the contrary, 
 the abscess due to ulcer occurs almost exclusively on the 
 left. Maydl gives 29 on the left, two on the right, and two 
 on both sides. In about one-third of the cases caused by 
 appendicitis and intestinal perforation the abscess cavity con- 
 tains gas. The presence of gas is noted in five-sevenths of 
 the gastric cases collected by Maydl. 
 
 A subphrenic abscess, preceded by gastric symptoms, but 
 by none of the characteristic signs or symptoms of the other 
 etiological diseases, located in the left hypochondrium and 
 containing gas, is due to a perforating ulcer of the stomach. 
 
 SeqiielcE of Ulcer. — Clinically, ulcer terminates in a cure, 
 in death, or in chronic invalidism. Considered as an ana- 
 tomical process, ulcer is either perforating or non-perforat- 
 ing. The non-perforating ulcer may heal with or without 
 deformity, with or without adhesions. Perforation may occur 
 before or after adhesions have formed. If it takes place 
 before adhesions unite the stomach to adjacent parts, there 
 results either general peritonitis or local peritonitis and 
 abscess, which latter may eventually produce a fistula. If 
 adhesions already exist, the result may be healing, or a fis- 
 tula, 'or abscess with its many possibilities. Briefly, the 
 sequeljE of ulcer are: (i) Adhesions; (2) fistulae ; (3) de- 
 formities. 
 
 I. Adhesion of the stomach to adjacent parts is a very 
 common sequel of ulcer, forming either before or after per-
 
 496 DISEASES OF THE STOMACH. 
 
 foration. There are no characteristic symptoms or signs by 
 which the condition can be recognized. It must not, liow- 
 ever, be supposed tliat adhesions produce no symptoms, for 
 the pain and the uncomfortable and indefinite sensations 
 excited by the distention and tlie peristalsis of the stomach, 
 and occurring after the ulcer is healed, should be attributed 
 to adhesions. 
 
 2. FistiiUe are rare sequels of ulcer. The most common 
 are gastro-intestinal and gastro-external. The diagnosis of 
 the latter presents no difficulty. If the cavities of the stom- 
 ach and the colon be united, the result is likely to be starva- 
 tion, on account of the small intestine being excluded from 
 digestion ; but this exclusion is not complete unless the 
 orifice of communication is large. Fecal vomiting, should 
 it occur, would e.xcite suspicion of the existence of the fistula, 
 and the character of this fecal matter might give some clue to 
 its involving the colon or the small intestine. If the per- 
 foration is in the colon, the appearance in the stomach of a 
 colored or easily recognizable fluid introduced into the colon 
 establishes the diagnosis, the introduced fluid being removed 
 from the stomach by the tube. Or the rapid passage of the 
 contents of the stomach into the colon would arouse sus- 
 picion. Communication with the bile-passages would open 
 a way for the constant entrance of bile into the stomach. 
 
 3. The deformity resulting from the loss of substance and 
 from the contraction of the scar affects either the wall of the 
 stomach or one of the two orifices. The deformities may 
 exist in many varieties and degrees, some compromising the 
 motor function very little or not at all and others producing 
 stagnation, retention, or even complete obstruction. 
 
 The deformities of the wall are difficult to recognize during 
 life, and the signs and the symptoms are the result of the 
 insufficiency of the motor function. Stagnation or retention 
 without either myasthenia or supersecretion can be due only 
 to obstruction or to a deformity of the gastric wall. The 
 two common deformities of the wall are the hour-glass con- 
 striction and the shortening of the lesser curvature so as to 
 bring the cardia and the pylorus closer together. The latter 
 condition is not likely to be even suspected during life, but 
 it may be a cause of stagnation or even of retention. The 
 hour-glass stomach, or the division of the viscus into two 
 communicating cavities by a constriction, may be congenital 
 or inherited, or may be due to dissociated and unequal con- 
 traction of the muscular layer. This "physiological" divi- 
 sion of the stomach into two cavities by muscular contraction
 
 ULCER OF THE STOMACH. 497 
 
 only occurs during violent peristaltic effort, and in the other- 
 wise normal stomach is a symptomless condition. It is not 
 so with the cicatricial hour-glass stomach, the constriction 
 being persistent, the communicating orifice sometimes very 
 small, and the mechanical work very imperfectly done. The 
 signs of this deformity which aid in its recognition are not 
 very characteristic. If the abdominal wall be thin and flaccid, 
 inflation of the stomach would make the peculiar deformity 
 evident on inspection and palpation. If the communicating 
 orifice be small, the peristaltic auscultatory intragastric sounds 
 would locate the constriction, which should not be con- 
 founded with the spurting pyloric sounds heard at another 
 point. The alternate relaxation and contraction of the 
 pylorus, which may sometimes be felt during digestion, 
 would aid in the recognition of the pylorus. Another sign 
 is obtained during lavage of the stomach. The cardiac cavity 
 having been thoroughly washed out, during the continuance 
 of lavage the clear water suddenly becomes mixed and 
 cloudy with gastric contents. To detect and to control this 
 sign, which can only be present under special conditions, the 
 lavage should be made during gastric digestion, and when 
 the water comes away clear the contents of the pyloric cavity 
 should be massaged through the communicating orifice and 
 removed by the tube. The existence of the constriction 
 may be demonstrable by the balloon sound of Kuhn. Still 
 another sign is one first noted by Jaworski. This is an in- 
 ability to withdraw anything from the stomach when splash- 
 ing can be demonstrated in it. The fluid and the gas to 
 which the splashing is due are in the pyloric division. The 
 physical signs of this deformity should be sought for in all 
 cases of motor insufficiency following ulcer. 
 
 Obstruction of the pylorus and cardia are the most frequent 
 and serious sequels of ulcer. These diseases are described 
 in another chapter. 
 
 Prognosis. — Ulcer is a dangerous disease, and the prognosis 
 should be very guarded. Brinton gives the high mortality of 
 50 per cent., which includes death during the course of ulcer 
 from intercurrent diseases. About 20 per cent, of the clini- 
 cal cases die, but this high mortality can be reduced one-half 
 by consistent methodical treatment. The death-rate of ulcer 
 is still less, for the purely anatomical form is not rare, and 
 gets well, or is counted only when fatal, since the latent fatal 
 cases are included in the mortality reports. The death-rate 
 of all cases of ulcer which receive treatment is less than 
 ten per cent. 
 32
 
 498 DISEASES OF THE STOMACH. 
 
 Ulcer is a treacherous disease, and, however mild it may be, 
 a guarded opinion should be given. The course of the dis- 
 ease is beset with danger and with possibly fatal accidents. 
 
 The probability of healing increases with the reparative 
 power of the individual organism. Healthy nutrition, a vigor- 
 ous nervous system, rich blood, and good circulation are 
 favorable influences. The prognosis is also better when the 
 patient gets early and proper treatment. Unfortunate cir- 
 cumstances may render it impossible to carry out a strict 
 rest and diet cure, and the mortality is more than doubled by 
 food of bad quality, by forced work, and by unhygienic quar- 
 ters. 
 
 The probability of death increases with the depth of the 
 ulcer. The blood-vessels increase in size from the surface of 
 the mucous membrane to where they empty into the loops of 
 small arteries; and the greater the depth of the ulcer, the 
 more likely is the hemorrhage to be profuse. Another dan- 
 ger-point is reached when the ulcer has eaten down to 
 the peritoneum, and opens up the possibility of adhesions, 
 abscess, perforation, general peritonitis, and other complica- 
 tions. 
 
 The location of the ulcer, where this can be made out, is 
 another guide. Ulcer of the anterior wall is very prone to 
 perforation, and when near the orifices of the stomach may 
 leave obstruction as a sequel. 
 
 The precxistence of advanced hypersthenic gastritis makes 
 the future dark. This disease, be it the cause, or the acci- 
 dental association, or the result of ulcer, is an obstacle to 
 healing. The persistence of symptoms and signs due to this 
 form of gastritis, in spite of proper methodical treatment, is 
 an unfavorable sign. Grave is the outlook when stagnation 
 •or retention exist in consequence of myasthenia or of obstruc- 
 tion ; and chronic invalidism is a very probable sequel wlien 
 a tumor due to perigastritis can be felt. 
 
 Treatment. — Something can be done toward the cure of 
 ulcer by the removal or the treatment of its cause. The 
 destructive lesion persists after the influences that generated 
 it are no longer active. The predisposing and the exciting 
 causes should receive attention, both with a view to prevent- 
 ing a recurrence of the disease and to securing conditions 
 essential to the cicatrization of the ulcer. The anemia should 
 be treated and the hyperchlorhydria should be controlled. 
 
 The indications to be met by the methodical treatment of 
 ulcer are very clear, and fortunately the remedies employed 
 are usuallv sufficient and effective. Ulcer, as soon as it is
 
 ULCER OF THE STOMACH. 499 
 
 recognized, should receive immediate and careful attention, 
 for it is a disease which endangers life, and delays and com- 
 promises are inadmissible. Expectant treatment is a great 
 blunder, for simple ulcer in a vigorous adult has no " innate 
 tendency to heal," and the grave accidents which are too often 
 the heralds of coming death occur somewhat regardless of 
 the age, the constitution, and the general state of nutrition. 
 The treatment must in every case be immediate, methodical, 
 and sufficiently vigorous to be effective. A compromise may 
 mean death or irreparable injury. 
 
 The general indications are: (i) To protect the stomach 
 and the lesion against all sorts of irritation ; (2) to give the 
 stomach functional rest; (3) to maintain nutrition; (4) to 
 treat the gross symptoms ; (5) to treat the complications. 
 
 The means employed to meet these indications are 
 hygienic, dietetic, and medicinal. The treatment, being also 
 protective, consists in part in avoiding injury. The remedies 
 employed are chiefly medical, for it is the business of the 
 physician to treat ulcer. But some of the accidents, compli- 
 cations, and sequelae may demand the aid of the surgeon. 
 
 To obtain the cicatrization of an external open wound, 
 protection against irritation and immobilization are essential, 
 while every precaution is being taken to secure asepsis. The 
 ulcer should be kept clean, still, and protected, and its walls 
 should be maintained in close apposition. Intragastric asepsis 
 is, of course, a chimera, and fortunately unnecessary, inas- 
 much as simple ulcer of the stomach progresses by molecular 
 necrosis without pus formation or excessive inflammatory 
 reaction. But the walls of both the non-perforating and the 
 perforating ulcer do get infected; and an effort to keep the 
 contents of the stomach sweet, and the ulcer as free as pos- 
 sible from purulent infection, would not be unnecessarily made. 
 
 It is only an ordinary precaution to keep the nose, the 
 mouth, and the throat clean, and to prevent the swallowing 
 of purulent discharges. But the surgical principles of more 
 importance in the treatment of ulcer, but capable of only 
 imperfect application, are immobilization and protection 
 against mechanical, chemical, and thermal irritation. 
 
 Partial immobilization of the stomach can be obtained by 
 rest in bed and by keeping the organ perfectly empty. This is 
 a favorable condition for the healing of the ulcer, although the 
 ulcer may cicatrize under conditions much less favorable. All 
 convulsive movements of the diaphragm — coughing, laugh- 
 ing, hiccup — should be controlled ; and all effort or strain- 
 ing should be avoided. This course of conduct not only aids
 
 500 DISEASES OF THE STOMACH. 
 
 healing, but also gives some protection against such accidents 
 as hemorrhage and perforation. Rest in bed is ordinarily an 
 essential part of the treatment, and the so-called " walking 
 treatment " of ulcer is an almost inadmissible compromise. 
 As a rule, it is not necessary to keep the patient in bed longer 
 than two or three weeks, after which time the cure may be 
 completed by a free use of the lounge. Where there is either 
 perigastritis or hemorrhage, or signs and symptoms indi- 
 cating that the ulceration is progressive, absolute rest in bed 
 should be enforced. This rest cure is beneficial in many ways. 
 
 The mechanical effect of rest is evident, and is favorable to 
 healing; it is also a precaution against hemorrhage, perfora- 
 tion, and the extension of perigastritis. But a no less im- 
 portant result is diminution of the needs of nutrition. The 
 body requires much less nutriment when in a state of 
 repose than when in activity. This saving represents so 
 much less digestive work to be done, and makes it easier 
 to maintain the balance of nutrition on the small quantity of 
 unirritating food which it is possible, in ulcer, to give without 
 injury. 
 
 The mucous membrane of the stomach is exposed to many 
 forms of irritation. In ulcer, the influence of extremes of 
 temperature seems to be very injurious. The food and drinks 
 should be neither very cold nor very hot, but as nearly luke- 
 warm as possible without being distasteful. Nothing mechan- 
 ically irritating should be swallowed, and this necessitates a 
 fluid diet, combined or not with completely digestible and 
 nutritive solids in a fine state of subdivision. All drugs must 
 be excluded which irritate the mucous membrane. The diet 
 should contain nothing that is chemically irritating, nor which 
 remains long in the stomach. The secretion of the stomach, 
 on account of its frequent excessive acidity, in ulcer is a 
 chemical irritant; so nothing should be given that excites 
 secretion, and the hydrochloric acid should be at once com- 
 bined or neutralized, and never left free. 
 
 The protection of the stomach against injurious irritation, 
 then, can only be secured by a very strict and proper diet, by 
 the exclusion of most drugs, and by the neutralization of the 
 free acidity or by exclusive rectal feeding. Proper alimenta- 
 tion is of the greatest importance, and the diet will be first 
 considered. 
 
 Milk is not only a valuable food, but also exerts a remedial 
 influence in ulcer. Where milk is well borne, the dietetic 
 treatment in the beginning is an exclusive milk cure. This
 
 ULCER OF THE STOMACH. 50I 
 
 food, when properly given, fulfils admirably the requirements 
 of a nutritive remedy. It is unirritating, combines rapidly 
 the secreted HCl,does not excite secretion excessively, being 
 normally digested without leaving more than a mere trace of 
 HCl free, is rapidly and easily evacuated by the stomach, 
 and, when given fresh, sweet, and sterile, does not ferment in 
 the ulcerated stomach free from stagnation or retention. But 
 unfortunately an exclusive milk diet is a starvation cure, and 
 is only capable of maintaining the balance of nutrition of the 
 inactive body for a short time, when given in the quantity 
 admissible in ulcer. The cure should always be begun with 
 absolute rest and a milk diet; but the development of inani- 
 tion, which constitutes one of the dangers of this disease, 
 should be most stubbornly fought. 
 
 In some cases the stomach is intolerant, or, on account of 
 a hemorrhage or of fresh perforation, must be given complete 
 functional rest. This perfect repose may be secured for a 
 short time by rectal feeding. The best forms of nutrient 
 enemata are given in the section on General Medication. All 
 the water and a little of the nutriment required by the organ- 
 ism may be introduced in this way. But rectal feeding should 
 also be employed to supplement the insufficient milk diet. 
 
 The quantity of milk given by the mouth during the 
 twenty-four hours should not exceed two quarts, and should 
 be perfectly sweet and unskimmed. The emulsionized fat is 
 not objectionable, and adds to the nutritive value of the milk. 
 For the first day, a glass may be slowly sipped every three or 
 four hours, or until it is certain that the milk is well borne 
 even a smaller quantity may be tried. After a few days one 
 glass should be given every two hours, eight glasses being 
 administered during the twenty-four hours. No more than 
 one glass of milk should be given at a feeding, and the inter- 
 vals between the feedings should be long enough to allow the 
 stomach to become empty. It is a good plan to have an 
 interval of four hours after the fourth glass, so as to avoid 
 accumulation and distention of the stomach. This leaves an 
 interval of eight hours between the last evening and the first 
 morning glass. The four pints of milk possess a nutritive 
 value of about 1200 C, and are not quite sufficient to main- 
 tain the balance of nutrition while the patient is resting in 
 bed. One or two tablespoonsful of milk-sugar may be 
 added to the first glass of milk taken in the morning — it 
 is both a food and a laxative. The emaciation which soon 
 begins may be diminished by protecting the body against 
 loss of heat, and by rectal feeding.
 
 502 DISEASES OF THE STOMACH. 
 
 Tlie exclusive milk diet is continued until four or five days 
 after the pain and vomiting subside, and after the tender 
 points become less sensitive. The nutritive value of the 
 fluid diet should then be increased by additions to the milk. 
 The quantity of water in the four pints of milk is sufficient, 
 and should not be increased. Two or three times a day a 
 small quantity of a thoroughly cooked preparation of wheat 
 should be stirred into the milk. If this is well borne, a 
 few days later instead of one of the glasses of milk a cup of 
 meat broth, with a beaten egg slowly stirred in while the 
 broth is not hot enough to coagulate the albumin, may be 
 given. Instead of the egg, two tablespoonsful of freshly 
 prepared meat powder or a teaspoonful of " Somatose " may 
 be used. A liquid diet of this sort should be continued until 
 there is no longer any digestive discomfort, the changes in 
 the diet being suggested not by the lapse of weeks and of days, 
 but by the improvement in the sN'niptoms and the signs. Ten- 
 der meats and the preparations of cereals and fresh butter 
 should be gradually added, and the patient should be held 
 for several months on a mixed, non-irritating diet. The chief 
 components of this diet are milk, eggs, cereals, butter, and the 
 tender meats. Later may be added vegetables, in the form 
 of purees; but acid fruits, alcoholic drinks, rich foods, con- 
 diments, and sweets must long be avoided. 
 
 The diet is sufficient to nourish the body, provided repose 
 is at the same time enforced and the intestines are healthy, 
 and the work of the stomach is greatly reduced. 
 
 Two other conditions demand attention and may be treated 
 by the same remedies — the hydrochloric superacidity and 
 constipation or diarrhea. The inanition, the hemorrhagic 
 anemia, and the favor shown the stomach tend to correct 
 the hyperchlorhydria, the best remedy for which, if it be a 
 reflex sign of the ulcer itself, is to keep the stomach empty 
 for twenty-four hours; but the hydrochloric superacidity is 
 frequently an expression of an associated h\'persthenic gastri- 
 tis. No remedies are then so beneficial as alkalies in large 
 doses, and the contents of the stomach should be kept nearly 
 neutral by their free administration. The three most useful 
 alkalies are the bicarbonate of soda, calcined magnesia, and 
 prepared chalk, and these may be advantageously combined. 
 From two to four drams of the soda should be given during 
 the twenty-four hours, and enough magnesia and chalk should 
 be combined with it to control the constipation or to check a 
 temporary diarrhea. The quantity for the twenty-four hours
 
 ULCER OF THE STOMACH. 503 
 
 should be divided so that one powder is given at the end 
 of each feeding. This neutraHzation and laxative treatment 
 contributes to the relief of the symptoms, favors cicatrization 
 by combining the free HCl, which is a cause of the chronicity 
 of ulcer, promotes the early and easy evacuation of the 
 stomach, and does not lessen the utilization of the milk. 
 The alkaline cachexia is an imaginary danger, and the 
 neutralization method should be employed wherever there is 
 hyperchlorhydria, which is also, in a degree, controlled by 
 small doses of the extract of belladonna. Instead of these 
 alkalies a Carlsbad cure may be employed, or a glass of 
 Celestins vichy, with enough sulphate of soda to regulate the 
 bowels, may be given every morning. 
 
 When the diet is digested without pain, or heartburn, or 
 eructations, or hyperchlorhydria, all drugs should be kept out 
 of the stomach, except possibly nitrate of silver and subni- 
 trate of bismuth, which are supposed to exert a favorable 
 influence on the cicatrization of the ulcer. 
 
 There can be no doubt as to the value of nitrate of silver. 
 The greatest benefit will be obtained from its employment 
 when there is either functional or inflammatory hyperchlor- 
 hydria, or hyperesthesia of the mucous membrane. It often 
 relieves rapidly the pain and the vomiting. There is no reason 
 to believe that it exerts a direct specific action on the ulcer, 
 but clinical experience proves the value of the drug in all 
 hypersthenic states of secretion which are not due to the stag- 
 nation or the retention of irritant contents. One-fourth to one- 
 half of a grain should be given daily, with an intermission 
 after two weeks. This dose, dissolved in a tablespoon ful of 
 distilled water, should be given every morning twenty minutes 
 before the first feeding. In rebellious cases, with no history 
 of hemorrhage, a solution of nitrate of silver (i : 2000) may 
 be used to douche the cleansed stomach. The procedure 
 may be repeated every three days, and controls the excessive 
 secretion of the hypersthenic gastritis better than any other 
 remedy. 
 
 The bismuth treatment has some very warm advocates. 
 The pure subnitrate may be recommended in very large 
 doses. The indications for its employment are the same as 
 those for the nitrate of silver; but it is of less value. 
 One or even two drams should be given daily in a single 
 dose, preferably in the morning half an hour before the first 
 feeding. The patient should lie on the back for ten minutes, 
 and then on the right side, with the fond hope that the bis- 
 muth may fall into the ulcer as a protecting deposit. Small
 
 504 DISEASES OF THE STOMACH. 
 
 doses do no good ; the large doses may not constipate, but 
 should not be given for a long period. Fleiner uses the bis- 
 muth in large doses, and introduces it through the stomach- 
 tube, after lavage in the early morning before breakfast. Two 
 to three drams of pure subnitrate of bismuth are mixed 
 with a glass of water, and the mixture is allowed to flow into 
 the stomach. The patient then occupies various positions — 
 on the back, on the right and left sides, upright, and in the 
 knee-elbow position. After five or ten minutes the water is 
 withdrawn through the tube. The procedure is repeated daily 
 until the pain disappears, and then the intervals are made 
 longer. Fleiner has used from ten to twenty ounces of bis- 
 muth before interrupting the treatment, without producing 
 symptoms of poisoning. The bismuth forms a protecting 
 coating over the ulcer, stimulates granulation, controls the 
 excessive secretion, and Fleiner claims that it is also a hemo- 
 static. Bismuth has given us most excellent results, without 
 employing lavage. There is little gained by withdrawing 
 the small quantity of water (only a small part of the bismuth 
 is recovered after ten minutes), and it would seem that the 
 stomach is already clean, or may be sufficiently cleansed b}' a 
 glass of Carlsbad water administered one hour before the bis- 
 muth is given. We ordinarily give a daily dose of one or two 
 drams for a week or ten days by the mouth, suspended in 
 half a glass of water, and are somewhat timid about using 
 the tube. 
 
 The hemorrhage of ulcer is small or profuse. The most 
 essential part of its treatment is absolute rest in bed, and a 
 continuously empty stomach. No food, or fluids, or ice, or 
 medicine should be given by the mouth. The administration 
 of tannin, acetate of lead, subsulphate of iron, and other 
 locally acting hemostatics is irrational. It is not probable 
 that they will come in contact with the part on which they 
 are intended to act. Worthless, also, is ice, being virtually the 
 same thing as the administration of lukewarm water, and the 
 only certain effect is the dilution of the blood and the pre- 
 vention of its coagulation. The stomach, when it is still and 
 empty, and strongly retracted, is in a most unfavorable con- 
 dition for the continuance of the hemorrhage. As a last 
 resort, in a continuous hemorrhage lasting for several days 
 (very rare in ulcer but more frequent in carcinoma), the 
 stomach may be washed out with ice-cold water and left 
 empty. 
 
 The first object is to arrest the hemorrhage, and the treat- 
 ment is different when the hemorrhage is small and when it is
 
 ULCER OF THE STOMACH. 505 
 
 large. Absolute rest and mental quietude are essential con- 
 ditions. These being secured, an ice-bag is kept over the 
 stomach to cause it to retract, and a hypodermic injection of 
 morphin is given to quiet the circulation and to diminish 
 peristalsis. If the hemorrhage continues, ergot should be 
 given hypodermically. This drug contracts the arteries as 
 large as the radial, and strengthens the tonic contraction of 
 the stomach ; but its action on the muscular fiber of the 
 stomach is feeble in comparison with its action on that of 
 the uterus. Clinical experience demonstrates the value of the 
 drug in checking gastric hemorrhage. 
 
 If, as is usual in ulcer, the hemorrhage be profuse, and the 
 foregoing remedies are not effective, ligatures may be placed 
 around the thighs and drawn tight enough to obstruct the 
 return venous but not the outward arterial circulation. 
 Enough blood may thus be withdrawn temporarily from the 
 circulation to check the hemorrhage and to give time for the 
 clot to form. The dammed-up blood should be allowed to 
 reenter the general circulation slowly. 
 
 The hemorrhage being arrested, collapse may demand im- 
 mediate treatment. The head and the body being placed on 
 a level, the extremities should be raised and the blood mas- 
 saged out, and compressing bandages should be applied. A 
 pint of a warm physiological solution of common salt (0.6 
 per cent.) should be introduced into the rectum and its escape 
 prevented. Another pint of the same solution should be 
 injected into the subcutaneous cellular tissue, the points of 
 election being the lower angle of the scapula and the outer 
 part of the thigh. 
 
 The heart should be aroused by hypodermics of camphor- 
 ated oil and ether. Transfusion might be tried to prevent 
 immediate death, in case the necessary apparatus be at hand. 
 For three or four days after the ces.sation of the hemorrhage 
 rectal feeding should be used exclusively. A little milk 
 may then be given cautiously and tentatively by the mouth, 
 and gradually oral may be substituted for rectal feeding. 
 
 The pain is nearly always relieved by the appropriate treat- 
 ment of the ulcer. Morphin hypodermically, or the extract 
 of opium in suppository, may be required. A very good 
 pain-relieving combination is that of codein, extract of bella- 
 donna, and calcined magnesia. 
 
 Vomiting may be an obstinate symptom, and if not relieved 
 by rest, by diet, and by bismuth or nitrate of silver, the stom- 
 ach should be given complete rest for from twenty-four to 
 forty-eight hours, and oral feeding should be resumed under
 
 5o6 DISEASES OF THE STOMACH. 
 
 the soothing influence of the Winternitz compress. Vomit- 
 ing occurring at the climax of the painful digestive paroxysms 
 is prevented b\' controlling the pain. 
 
 The medical treatment of perforation should be begun with- 
 out delay, the object being to localize the resulting peritonitis. 
 The patient should be kept absolutely still in bed, and a full 
 dose of morphin should be given hypodermically. The 
 morphin must be repeated in full doses at short intervals, so 
 as to immobilize the digestive tube. By rectal administration 
 it is difficult to keep the patient mildly and continuously nar- 
 cotized. Ice-cold applications should be placed over the 
 abdomen. The ice-bag is usually too heavy to be borne. 
 The coil of rubber tubing with a continuous flow of ice-water 
 through it is light and convenient. Often cold is not bear- 
 able, and the Winternitz compress should be substituted for 
 it. Shock following perforation may demand the hypodermic 
 employment of camphorated oil, ether, and strychnin. Food 
 and water during the first four or five days should be 
 given exclusively by rectum, and the first nutrient enema 
 should not be administered until the digestive tube has virtu- 
 ally been put in splints by the free use of opium. The best 
 and most rational treatment is immediate surgical interven- 
 tion. 
 
 Local peritonitis before perforation should be treated on the 
 same principles, as it may be either purulent or plastic. But 
 the treatment, which is exclusively medical, is much less 
 energetic. Absolute rest in bed, cold over the epigastrium, 
 enough opium to relieve pain and to quiet peristalsis, and 
 exclusively rectal feeding for a few days are the chief points 
 of the management. The stomach should be given complete 
 rest for as long a period as the state of nutrition will permit. 
 
 Painful adhesions give a good deal of trouble, and nothing 
 is likely to prove efficient except the gentle influence of time. 
 Counterirritation over the stomach and on either side of the 
 dorsal spine may be tried, and prolonged use of the compress 
 sometimes gives relief. Precautions should be taken to pre- 
 vent the formation of a drug habit if anodynes are prescribed. 
 Many of the complications and sequelae can not be treated by 
 operation. Perforation converts ulcer into a surgical disease; 
 abscess must also be treated with the knife ; and obstruction 
 of the pylorus or of the cardia may require an appeal to the 
 surgeon for relief. 
 
 Some Ulcer Cures. — I. The Rest and Carlsbad Cure. — This 
 ulcer cure is very popular in Germany, and has been carefully 
 formulated by von Ziemssen and Leube. Von Ziemssen does
 
 ULCER OF THE STOMACH. 507 
 
 not enforce absolute rest in bed, but forbids physical and 
 mental overexertion. The abdomen is protected by a flannel 
 bandage. Milk, tender meats, milk- and cereal-thickened 
 soups, and white bread are permitted. In combination with 
 this regime must be used systematically a solution of artificial 
 Carlsbad salts in hot water. Two to four drams (one to two 
 heaped teaspoonfuls) are dissolved in a pint of hot water, 
 and the whole is drunk slowly in four portions, fifteen minutes 
 apart, and finished half an hour before breakfast. One or two 
 stools must follow, and, according to the effect produced, the 
 quantity of salts must be increased or diminished. As a rule, 
 one heaped teaspoonful is sufficient after a day or two. If 
 the hydrochloric acidity be very high, a glass of Giesshiibel, 
 Bilin, or Vichy may be given at night. Three or four weeks 
 are usually required to cause all symptoms to cease and the 
 ulcer to heal. The Carlsbad salts are now stopped, but the 
 glass of mineral water is continued for a few weeks. Von 
 Ziemssen claims that the cure of the ulcer is due to the salts 
 and to the large quantity of hot water. The highly acid 
 contents are neutralized, the acid fermentation is checked, the 
 stagnation is relieved by complete daily evacuation of the 
 stomach, and a daily movement of the bowels is obtained. 
 There is no doubt that the Carlsbad cure, methodically 
 employed, reduces rapidly, after the first few days, the hydro- 
 chloric superacidity, and relieves the constipation. But in 
 ulcer there is neither myasthenia, nor obstruction with 
 stagnation, nor retention and fermentation ; or, if these com- 
 plications be present, the water cure is strongly contra- 
 indicated. Carlsbad salts should not be used if there be 
 anemia. 
 
 Leube conducts the cure with the patient in bed, and all 
 movements requiring effort are forbidden. Hot compresses 
 are kept over the stomach during the day, and a Priessnitz 
 compress at night ; or, in case of hemorrhage, ice-cold appli- 
 cations are substituted. From a glass to a glass and a half of 
 Carlsbad water (Muhlbrunnen) in which from a half to one 
 tablespoonful of artificial Carlsbad salts has been dissolved is 
 given daily one hour before breakfast. But in the beginning 
 the diet consists of the Leube-Rosenthal meat solution, either 
 in bouillon or in milk — both lukewarm. After two or three 
 weeks, pigeon, chicken, puree of potatoes, thickened soups, and 
 bread are permitted for another week, and a normal diet is 
 gradually resumed. 
 
 2. TJie Rest and Rectal Feedbig Cure. — This method is very 
 efficient, and, among others, has been recommended by Wil-
 
 508 DISEASES OF THE STOMACH. 
 
 lianis and by Donkin. Tlie patient is kept quiet in bed, and 
 no nourishment is given by mouth. Every three hours an 
 enema (one ounce of beef tea and two ounces of milk, or three 
 ounces of milk — Donkin) is given. After two weeks the same 
 food is given by mouth, and the number of rectal feedings is 
 gradually diminished. This is essentially a starvation cure, 
 and in many cases is unnecessarily severe, and the inanition 
 increases the dai\ger. The ulceration may progress, and a 
 hemorrhage in this condition of emaciation and weakness 
 may be a very serious menace to life. The composition of 
 the best rectal nutritive enemata are given in the section on 
 General Medication. We often employ exclusive rectal feed- 
 ing for a few days (seldom longer than a week) when the 
 hyperchlorhydria and pain are obstinate, when the motor 
 function is impaired, when a hemorrhage has occurred, and 
 when perigastritis is present. The functional rest and the 
 retraction of the empty stomach both promote healing. 
 
 3. T/ie Milk and Neutralization Method of Debove. — Debove 
 employs an exclusive milk diet and alkalies in sufficient 
 quantity completely to neutralize all the hydrochloric acid 
 secreted. The milk may be given in small quantity, repeat- 
 edly, or in large quantity three times a day. Two to two 
 and one-half liters daily are sufficient to maintain the balance 
 of nutrition, and this quantity should not be exceeded. A 
 glass of pure undiluted milk is given every two hours during 
 the sixteen hours while the patient is awake. A powder or 
 cachet consisting of ten grains of bicarbonate of soda and 
 three grains of prepared chalk is given every hour between 
 getting up and going to bed, and a dose should be given at 
 night if the patient should awake with pain. Or three glasses 
 of milk may be given three times a day. During the three 
 hours succeeding each meal the alkaline powder is given every 
 half hour, and every hour during the remainder of the day. 
 
 Under the influence of this treatment the pain and the 
 vomiting rapidly cease. The Debove meat powder, after a 
 week or two, is added to the alimentation, giving at first one 
 ounce a day. A little later cereal powders prepared in the 
 same way may be used. 
 
 When the pain and vomiting have been absent several 
 weeks, the alimentation is increased by following the table of 
 digestibility arranged by Leube, and 15 grains of bicarbonate 
 of soda, and the equivalent of three grains each of prepared 
 chalk and calcined magnesia, according to the state of the 
 bowels, are given every half hour during the three hours 
 follovvinjr the three meals.
 
 ULCER OF THE STOMACH. 509 
 
 This method is rational, and is sometimes very effective, 
 even where severe hypersthenic gastritis coexists ; but the 
 complete neutralization of gastric acidity is unnecessary for 
 so long a period in the majority of cases. In practice it is an 
 excellent routine method, but the routine treatment of any 
 disease of the stomach is not commendable. The remedies 
 should be selected which in the particular case best fulfil the 
 indications. 
 
 Surgical Treatment. — In certain emergencies the advisabil- 
 ity of an operation must be considered. An appeal to surgery 
 may be made on account of the gravity and the uncontrol- 
 lable evolution of the ulcer, on account of a complication, 
 or on account of a resulting deformity. 
 
 Ulcer may be grave on account of the severity of one or 
 more of its cardinal symptoms — viz., pain, hemorrhage, or 
 vomiting. It can seldom happen that either pain or obstinate 
 vomiting should demand surgical intervention, but an opera- 
 tion should be considered a means of possible relief, and a 
 justifiable procedure when the pain and vomiting are accom- 
 panied by progressive emaciation and loss of strength and 
 by intolerance of rectal feeding. Repeated hemorrhages 
 or a very large hemorrhage may be treated by operation, 
 the bleeding vessel being ligated or cauterized ; or, if the loca- 
 tion of the ulcer is favorable, excision may be better practice ; 
 or gastro-enterostomy may be performed after the arrest of the 
 hemorrhage. The best surgical treatment is made clear only 
 after the stomach has been exposed to view, provided the 
 strength of the patient will permit the surgeon to carry out 
 the best plan. 
 
 An ulcer may be grave on account of its prolonged course 
 and resistance to medication or on account of its location. 
 An ulcer located on the anterior surface and accompanied by 
 local plastic peritonitis should be treated by excision and 
 closure, or possibly by attachment of the stomach with sutures 
 to the anterior abdominal wall — as a prophylactic measure 
 against perforation into the general peritoneal cavity. If the 
 ulcer is unhealed (hemorrhages) and is obstructing the 
 pylorus, it might be well to perform pyloroplasty or gastro- 
 enterostomy. When ulcer is chronic and obstinate, and is 
 accompanied by hypersthenic gastritis, gastro-enterostomy 
 secures rapid evacuation of the stomach and the control of 
 the excessive secretion — two conditions which are very favor- 
 able to the healing of the ulcer and to the cure of the 
 gastritis. Doyen reports 21 successive gastro-enterostomies
 
 5IO DISEASES OF THE STOMACH. 
 
 without a death, but tlie mortality is 50 per cent, in BiUroth's 
 cHnic. Conite reports 1 death in 12 gastro-enterostomies 
 for ulcer, and 6 deaths in 17 cases in which the excision or 
 resection of the ulcer was done. (Collected cases.) 
 
 Perforation converts ulcer into a surgical disease. Perfora- 
 tion may produce a fistula, or an abscess in an attached 
 (adhesions) organ, or a subphrenic abscess, or general 
 peritonitis. An abscess imperatively demands the use of the 
 knife. In 34 reported cases, 15 recoveries have been obtained 
 by operation (Maydl, Comte, Beck, Abbe, Weir, McCosh) ; 
 but without an operation recovery is an accident. When the 
 ulcer is situated on the posterior wall or on the lesser curva- 
 ture, an abscess is the usual result of perforation ; but when 
 the ulcer is situated on the anterior wall perforation occurs, 
 as a rule, into the general peritoneal cavity. While recoveries 
 have been reported from perforating ulcer without operation 
 (the stomach probably containing no food at the time of the 
 perforation), yet it may be laid down as a rule of conservative 
 practice to operate whenever perforation has occurred into 
 the peritoneal cavity. The operation should be done as early 
 as possible ; the perforation should be closed by suture, either 
 from without or from within the stomach (after or without 
 excision of the ulcer); the peritoneal cavity should be thor- 
 oughly washed out and purulent exudate removed, and after- 
 drainage should be invariably employed. Pariser has collected 
 43 operations for perforating ulcer with 1 1 recoveries. Conite 
 increases the number to 65 operations and 19 recoveries, and 
 Weir and Foote more recently reported 23 recoveries in 'j'i 
 collected operations. The following is their interesting table : 
 
 Time ok Operation. Rkcovi-;rv. Death. Mortality. 
 
 Under twelve hours . . I4 9 39 per cent. 
 
 Twelve to twenty-four 
 
 hours 4 l.> 76 " " 
 
 Over twenty-four hours . 4 28 87 " " 
 
 Not stated I 5 
 
 Total 23 55 71 per cent. 
 
 The conclusion might be drawn from these statistics that 
 surgery rescues about 29 per cent, of these patients from 
 death ; but the statistics are based on reports and not on 
 practice. The truth, were it known completely, might greatly 
 alter the percentage. But we think that it is a good rule of 
 practice, for the guidance of physicians, to arrange for an 
 operation by an experienced surgeon as early as possible after 
 the occurrence of perforation.
 
 THE NEOPLASMS OF THE STOMACH. 51I 
 
 Subphrenic abscess is a complication which imperatively 
 demands incision and drainage. Without operation this 
 complication is invariably fatal. Of ten cases operated by 
 free incision and drainage, three (Scheurlen, Debove, Rendu) 
 recovered. 
 
 Ulcer may leave, as a sequel, gastric fistula, cardiac or 
 pyloric obstruction, or a deformity producing retention. 
 Gastro-enterostomy is the proper treatment of the latter con- 
 dition, or adhesions should be broken, and multiple pouches, 
 vi^hich have resulted from constrictions, should be connected. 
 Gastric external fistula should be laid open down to the 
 points where it perforates the parietal peritoneum, and packed 
 so as to favor healing from the bottom. The treatment of 
 obstruction of the orifices is discussed in another chapter. 
 
 CHAPTER ill. 
 
 THE NEOPLASMS OF THE STOMACH. 
 
 The neoplasms of the stomach are malignant or benign. 
 The benign tumors are very rare, and, being curiosities of 
 the dead-house, they are of very little interest to the physi- 
 cian. Lipoma of the stomach is usually multiple, is either 
 submucous or subserous in origin, and consequently may 
 form prominences on either the mucous or the peritoneal 
 surfaces. These encapsulated and sometimes lobulated new 
 growths are ordinarily about the size of a pea or nut, and 
 produce no alteration of the mucosa or of the peritoneum, 
 except the slight nutritive changes due to pressure. Fibroma 
 or fibromyoma may develop toward the peritoneum, or 
 toward the mucosa, forming a polyp. They are ordinarily 
 about the size of a cherry, occur most frequently in old age, 
 and are most commonly located on the anterior wall and in 
 the pyloric region, and may consequently produce obstructive 
 stagnation or retention. Lymphadenoma is rare, but unlike 
 lipoma and fibroma it may ulcerate; this lymphatic disease, 
 be it neoplastic or diffuse, is always associated with the same 
 affection of the intestines; sometimes the liver and spleen are 
 involved, and the rapid cachexia is accompanied by leukemia. 
 Polyadenoma is a benign epithelial neoplasm, which may 
 accompany chronic proliferating glandular gastritis, and 
 which may undergo cancerous transformation.
 
 512 DISEASES OF THE STOMACH. 
 
 The malignant tumors of the stomach are sarcoma and car- 
 cinoma. Sarcoma of the stomach is very rare, but secondary 
 sarcoma of tlie stomach occurs more frequently than does 
 secondary carcinoma. Sarcoma of the stomach presents the 
 same histological characteristics as sarcoma of other organs. 
 We have been able to find only 43 cases in literature. It is most 
 frequent between the ages of fifteen and thirty-five, is nearly 
 twice as frequent in men as in women, and it may suppurate, 
 ulcerate, produce hemorrhage, and cause perforation. Its 
 gastric symptoms and its functional and bacteriological signs 
 are the same as those of cancer. There is oligocythemia, 
 and there may be leukocytosis (polynuclear) as in cancer; 
 but lymphemia is more frequent. The spleen is always 
 enlarged, metastases are frequent and may be accessible to 
 excision and the microscopical examination of a specimen. 
 Sarcoma of the stomach, when it is diffuse, may convert 
 the stomach into a stiff viscus and the pylorus into a rigid 
 canal, producing incontinence instead of retention. Both 
 primary and secondary intestinal sarcomata seldom produce 
 obstruction. 
 
 CANCER OF THE STOMACH. 
 
 The stomach is one of the favorite sites of primary car- 
 cinoma, which is a malignant disease, progressive in its evolu- 
 tion, and fatal in its termination. As a result of modern 
 diagnostic methods, cancer of the stomach may often be 
 surely and early recognized, and a more favorable opportunity 
 is thus offered for radical and palliative surgical treatment. 
 By medical treatment also life may be prolonged and the 
 suffering alleviated. On account of its frequency, malig- 
 nancy, and the great importance of its early diagnosis, both 
 to the physician and to the patient, the disease should receive 
 careful and minute study. 
 
 Frequency. — The number of deaths due to cancer of the 
 stomach varies in different localities, at different ages, and in 
 the two se.ves. 
 
 If reports are to be trusted, cancer of the stomach is very 
 rare in Turkey, in Egypt (Griesinger), and in parts of South 
 America (Heizmann). It is much more frequent in Switz- 
 erland, in Normandy, and in the region of the Black Forest 
 than in other localities of Euroi^e (Antenrieth, Haberlin). 
 In Vienna (Nedopil) there are annually four deaths from 
 cancer in every 5000 inhabitants, and of these one is due to
 
 THE NEOPLASMS OF THE STOMACH. 
 
 513 
 
 cancer of the stomach ; and the mortality percentage due to 
 cancer is 3.2 per cent., and to cancer of the stomach 0.8 per cent. 
 
 The mortality from cancer of the stomach is twice as great 
 in Switzerland as in Vienna and Berlin, one person in every 
 2500 dying annually of it (Haberlin). 
 
 From the statistics of Bryant (official), extending over a 
 period of ten years from 1 884-1 893, we obtain the following 
 figures : 
 
 City. 
 
 Population. 
 
 Average Number 
 OF Deaths An- 
 nually. 
 
 Average Number of 
 
 Deaths Annually 
 
 FROM Cancer. 
 
 New York, . . . 
 Philadelphia, . . 
 Baltimore, . . . 
 
 Boston, 
 
 San Francisco, . . 
 New Orleans, . . 
 
 1,628,151 
 1,022,355 
 
 437,613 
 432,752 
 313,000 
 246,021 
 
 39,943 
 
 21,708 
 
 9,120 
 
 10,273 
 
 5,979 
 6,771 
 
 865 
 
 '487 
 226 
 
 304 
 202 
 152 
 
 Total, .... 
 
 4,079,892 
 
 93,794 
 
 2,236 
 
 In these large cities 2.38 per cent, of all deaths are due to 
 cancer, and Haberlin and Bryant have shown that this per- 
 centage is slowly increasing from year to year. For New 
 York city the percentage is 2.8 in 1896, or i death from 
 cancer to 1697 inhabitants. The average yearly death-rate 
 from cancer in the six cities mentioned is i to 1825 
 inhabitants. From 25 per cent, to 40 per cent, of all cancers 
 are primary cancers of the stomach. Haberlin gives 41.5 
 per cent. ; d'Espine, 42.4 per cent., and Virchow, 35 per cent. 
 About one per cent, of all deaths are caused by cancer of 
 the stomach. 
 
 Cancer of the stomach is a rare disease before the thirtieth 
 year. In 11 50 autopsies performed on old men, Greenfeld 
 found in nine per cent, that death was due to cancer of the 
 stomach. Less than three per cent, of the cases occur before 
 the thirtieth year, more than two-thirds of the cases between 
 forty and seventy, about one-fourth between fifty and sixty, 
 one-sixth between thirty and forty. Nearly one-half of the 
 cases occur between the ages of forty and sixty. Mathieu 
 (1884) collected from literature 32 cases before the thirtieth 
 year. Wilkinson and Widerhofer observed congenital cases. 
 Cullingsworth and Kaulich have reported cases occurring 
 in infancy. Cancer of the stomach is almost unknown 
 before the fifteenth year, but from this age the chances of 
 dying from it increase with each decad. 
 33
 
 514 DISEASES OF THE STOMACH. 
 
 About twice as many cancers occur in women as in men, 
 and this preponderance is chiefly due to the frequency with 
 wliich primary cancer attacks the uterus and the female 
 breast. A compilation of statistics from many sources shows 
 that in women cancer of the stomach is a little more frequent 
 than cancer of the uterus. Cancer occurring in man, in 
 from 40 to 50 per cent, of the cases attacks primarily the 
 stomach ; in women only in from 20 to 30 per cent. Brauti- 
 gam and Haberlin give the proportion as 6 or 7 to 5 ; Brinton 
 gives 9V2 to 7; and Fox, Zy^ to 8. Louis, Valleix, and 
 Lebert claim that cancer of the stomach is slightly more 
 frequent in women. Statistics may be produced to sup- 
 port the contention in favor of the predominance in either 
 sex, and the generally admitted predominance in man is so 
 slight as to be of little moment to the clinician. 
 
 Etiology. — The causation of cancer is unknown. Riches, 
 poverty, season, country, city, hard mental and physical work, 
 and inactivity exert no perceptible influence. 
 
 Clinical observation claims heredity as a predisposing 
 cause. Remarkable instances of the persistence of the dis- 
 ease in members of the same family through several genera- 
 tions are on record, and cancer is not so frequent that the re- 
 currences can be plausibly explained as accidental. But the 
 reference to inherited influences often means nothing more 
 than a confession of ignorance, and heredity is losing more 
 and more of its domain each day as knowledge increases. 
 Lebert reported that seven per cent, and Haberlin claims that 
 eight per cent, of the cases are hereditary. 
 
 Long-continued and repeated irritation is always stated to 
 be a predisposing cause. Some show of reason may be given 
 this contention for cancer in some of its localizations, but on 
 such grounds it would be difficult to explain the genesis of 
 cancer of the stomach. A stomach constantly irritated 
 escapes as often as one which receives better treatment, and 
 one of the characteristics of cancer is its development at an 
 advanced age in a stomach which has previously given no 
 signs of disease. Cancer is a disease which has its favorite 
 sites, and develops exclusively in certain tissues, some of which 
 are remarkably well protected against mechanical and chemi- 
 cal irritation. In this respect it acts like a germ disease. A 
 bacillus has been reported as its cause, and some observers 
 have attributed the disease to sporozoa. or to sporozoa-like 
 bodies, which develop in the epithelial cells. But it is gener- 
 ally admitted that the so-called sporozoa are degenerate cells, 
 or represent endocellular changes in atypical epithelium.
 
 THE NEOPLASMS OF THE STOMACH. 515 
 
 Carcinoma may generally be conveyed from one surface to 
 another with which it is in contact, and metastasis, such as 
 occurs in pyemia and other infections, is frequent. But the 
 metastasis of carcinoma seems to be a cellular transplantation, 
 for the secondary neoplasms consist of the same cell as the 
 mother neoplasm, wheresoever the secondary growths appear. 
 The cancer cell grows and lives like a parasite, and it is hardly 
 possible for a germ to cause the production of cells of a par- 
 ticjLilar kind in organs where these cells do not exist. That 
 the germ of cancer grows in the epithelial cell and imparts to 
 it a malignant reproductive activity is an admissible h}'po- 
 thesis. 
 
 Pathological Anatomy. — Anatomically, cancer of the stom- 
 ach is a disseminating new growth, consisting of a stroma 
 whose interspaces are filled with cylindrical or atypical epi- 
 thelium. The disease is essentially a malignant epithelial 
 invasion. 
 
 The growth of carcinoma, beginning at a single point in the 
 mucous membrane, is best studied along its borders. Pro- 
 ceeding with the microscopic study of the cut through the 
 zone of dissemination toward the center of the new growth, it 
 will first be noticed that the epithelial proliferation is confined 
 within the glands and limited by a basement membrane. The 
 epithelium next pushes out budding projections, over which 
 the basement membrane disappears, and leaves the epithelial 
 cells in direct contact with the very fine and newly-formed 
 stroma, which is usually infiltrated with small round-cells. 
 These projections unite across the tissues separating the 
 glands, and extend into the submucosa and the deeper layers, 
 where cancer cells collect in nests ; or the neoplasm develops 
 in lines along the lymphatic vessels, and the bundles of con- 
 nective tissue and of muscular fibers. 
 
 In the formation of the neoplasm two tissues are chiefly 
 concerned. The periglandular connective tissue is infiltrated 
 with small cells and cell nuclei, and out of it is formed the 
 stroma which is to serve as a framework. Contemporane- 
 ously with the development of new connective tissue new 
 blood-vessels are formed (vascularization), and in some cases 
 the blood-vessels are very numerous. The characteristic 
 feature, however, is the unconfined epithelial proliferation. 
 The starting-point may be the epithelium about the necks of 
 the glands, and the cancer is then cylindrical-celled ; or it may 
 be the epithelium of the fundus, when the epithelium of the 
 new growth is atypical. The new cells stain intensely, and 
 typical and atypical nuclear growth and division (karyokinesis)
 
 5l6 DISEASES OE THE STOMACH. 
 
 is very active. The ducts of some of the glands may be 
 lined with several layers of cylindrical epithelium. The 
 fundus of the glands is usually lined with one layer of new 
 ceils, but here and there may be seen two or more layers, and 
 the lumen of some of the glands may disappear. The 
 epithelial cells invade the extraglandular and interglandular 
 tissues, and form here and there nests of cells. Accordingly 
 as the stroma or the epithelial cells predominate, the cancer is 
 hard or soft. 
 
 Hard cancer, or scirrhus, is the most common anatomical 
 variety of cancer of the stomach. According to Brinton, it 
 constitutes 72 per cent, of the cases. Hard cancer begins 
 almost without exception in the pyloric region, and infil- 
 trates all the layers of the gastric wall without producing 
 any marked prominences. The wall of the stomach is hard 
 and thick, inelastic, and non-retractile. The pylorus is often 
 converted into a rigid and incontinent tube. The hard, flat 
 mass may be located chiefly on the anterior or posterior wall, 
 or, more rarely, may convert the whole stomach into a hard, 
 rigid tube, little larger than the cecum. The mucous mem- 
 brane in the area of the tumor is often ulcerated. The ulcer 
 is superficial, with very low receding edges, and the base is 
 smooth and scarlike or ragged and fibrous. The thickened, 
 indurated wall cries under the knife, and is sometimes white 
 and glistening, with but little milky fluid ; and is sometimes 
 yellow, streaked, or spotted with hard, white, fibrous tissue. 
 All the layers may be eventually replaced by the carcino- 
 matous stroma, with only here and there a few epithelial cells, 
 not resting on a basement membrane and arranged along the 
 coarse fibers of connective tissue. Scirrhus may be con- 
 founded with chronic ulcer or with interstitial gastritis. The 
 differentiation may be made by comparing the evolution ; the 
 extension along the lymphatics ; the presence of epithelial 
 cells in the submucosa and muscular layer, unconfined by a 
 basement membrane ; cancerous nodules in the peritoneal 
 coat, and metastases in other organs. The liard cancer, be- 
 ginning almost without exception in the pyloric region, 
 destroys and replaces the components of the gastric wall by 
 a compact connective-tissue stroma inclosing a few epithelial 
 or giant cells and cancer nodules and very sparingly supplied 
 with blood-vessels. Ultimately, the stomach is contracted, 
 rigid, and functionless, and the pylorus is obstructed or gajiing. 
 
 There are two varieties of soft cancer — adenocarcinoma and 
 medullary carcinoma. The first variety is cylindrical-celled, 
 and grows from the epithelium lining the necks of the glands
 
 THE NEOPLASMS OE THE STOMACH. 517 
 
 and covering the surface of the mucous membrane. The 
 epithelial cells constituting medullary carcinoma are small, 
 irregular, atypical, embryonic, and resemble the chief cells of 
 the gastric glands. 
 
 Adenocarcinoma is a fungoid, vascular, malignant neoplasm 
 morphologically characterized by a delicate, infiltrated, fibrous 
 framework inclosing cylindrical cells so arranged as to form 
 irregular tubules. The favorite location is the pyloric region 
 and the pyloric ring, originating in the epithelium lining the 
 pyloric glands, and, rarely, also in the cells lining the excre- 
 tory ducts of the glands of other regions of the stomach. 
 The tumor presents a soft, fungous, red mass, studded with 
 papillae. The blood-vessels are numerous and often become 
 irregular in caliber, degenerated, and obstructed. Subse- 
 quently, the growth of the neoplasm is accompanied by inter- 
 stitial hemorrhages, necrosis, ulceration, and small hemor- 
 rhages into the cavity of the stomach. On section, cancerous 
 juice exudes, and the soft surface consists almost exclusively 
 of epithelium. The tumor grows along the surface and ex- 
 tends very slowly to the deeper layers. A microscopic cut 
 through the zone of invasion reveals irregular cavities lined 
 by cylindrical epithelium resting directly on a framework of 
 connective tissue infiltrated with small round-cells. Some- 
 times the cavity is filled with epithelium atypical in form and 
 degenerated, the appearance being ultimately very much like 
 that of medullary carcinoma. The glandular arrangement, 
 seen under the microscope, may suggest simple adenoma. 
 But the malignant growth forms a tumor consisting chiefly 
 of cylindrical epithelium without a basement membrane, and 
 invading the layer of the gastric wall beneath the mucous 
 membrane. The formation of cancerous nodes and the 
 occurrence of metastasis are also met with in this variety of 
 malignant disease. 
 
 Medullary carcinoma is a papillomatous malignant neo- 
 plasm, often ulcerated, consisting largely of small atypical epi- 
 thelial cells. It grows with great rapidity and invades exten- 
 sively the glandular system. Like all the anatomical diseases 
 of the stomach, it is more frequent in the pyloric end, but 
 occurs in other parts of the stomach with much greater fre- 
 quency than does adenocarcinoma. At the autopsy it most 
 often presents an ulcerating tumor, with edges exceedingly 
 irregular in height and thickness, occasionally here and there 
 smooth, but more often rugged, with a base varying in 
 appearance accordingly as it is formed by the submucosa or 
 by the muscular or peritoneal coat. A section of the wall
 
 5 1 8 DISEASES OF THE STOMACH. 
 
 usually reveals fatty degeneration, hemorrhages, and necrosis. 
 The epigastric, portal, celiac, retroperitoneal, inguinal, and 
 left supraclavicular glands are usually enlarged, and cancerous 
 nodules and cells are strung along tlie lymphatics in the gas- 
 tric wall. Microscopically, the epithelial invasion is wide- 
 spread, extending in the wall of the stomach and involving 
 all its coats. The embryonic chief-like cells are often found 
 within the bundles of muscular fibers and collected in spindle- 
 shaped nests between them. 
 
 Either form of soft cancer may undergo colloid metamor- 
 phosis, and produce what is often described as a distinct 
 variety. Medullary cancer undergoes this gelatinous trans- 
 formation or degeneration more frequently than does adeno- 
 carcinoma. At the autopsy a tumor appears; commonly as 
 a general thickening of the gastric wall, the inner surface 
 presenting ulcerated, somewhat transparent prominences 
 studded with small, slimy granulations. The outer or peri- 
 toneal surface is nodulated. Microscopically, the neoplasm 
 consists of a grayish, fibrous framework, with the irregular 
 interspaces filled with gelatinous matter and with the gran- 
 ular remains of epithelial cells. From the invasion zone may 
 be obtained cuts presenting the microscopic characteristics of 
 the two varieties of soft cancer. 
 
 The mucous membrane lining the stomach which is free 
 from the cancerous growth always presents microscopic 
 lesions of an inflammatory and degenerative character. 
 The histological changes are most commonly those found 
 in catarrhal and interstitial and atrophic gastritis, and are 
 most probably due in part to stagnation of the contents 
 and to the influence of the malignant neoplasm on nutrition. 
 The relation of the gastritis to the cancer is not known. In 
 some cases the gastritis undoubtedly precedes the carcinoma, 
 just as carcinoma may begin in the edges of an ulcer of the 
 stomach, or it may be preceded by hypersthenic gastritis. 
 It is possible that these diseases form favorable soils for 
 cancer. But the gastric mucosa, as a rule, undergoes the 
 same pathological alterations when cancer affects another 
 organ, such as the breast. The microscopic changes are 
 those which have been already minutely described under 
 chronic catarrhal gastritis, accompanied by more or less inter- 
 stitial inflammation and degeneration or transformation of 
 the peptic glands. The cylindrical surface epithelium is 
 ordinarily preserved, but it may be lost when the mucous 
 division of the mucosa is greatly infiltrated by small round- 
 cells and leukocytes. Many of the cylindrical cells of the
 
 THE NEOPLASMS OF THE STOMACH. 5 I9 
 
 surface and of the ducts (mouths) of the glands are con- 
 verted into beaker cells and ciliated columnar epithelium. 
 The border cells of the peptic glands disappear, and the chief 
 cells are replaced by the cylindrical epithelium which lines 
 the mouths of the glands. The peptic glands are thus trans- 
 formed into mucous glands ; or the fundus of the peptic gland 
 may be destroyed by degeneration and interstitial gastritis, 
 and the cylinder-cell lined ducts elongate and enlarge, and 
 may eventually extend to the depth of the submucosa. 
 Wandering leukocytes and eosinophile corpuscles lie scattered 
 among the infiltrating round cells. The motor insufficiency 
 results from the cancerous infiltration of the muscular layer 
 in the region of the neoplasm or is due to pyloric obstruc- 
 tion. In the latter case the muscular coat may become 
 hypertrophied. In no other anatomical disease of the 
 stomach is the muscular coat so early, profoundly, and gen- 
 erally affected. Consequently, motor insufficiency is an 
 almost constant sign of carcinoma. The alterations of the 
 mucous and muscular coats produce corresponding and char- 
 acteristic functional and bacteriological abnormalities. 
 
 In the majority of the cases of carcinoma of the stomach 
 adhesions to adjacent organs occur before death. Exception- 
 ally, when the disease is already advanced, the stomach re- 
 mains free from adhesions, and the tumor may be moved 
 about in the abdominal cavity. The absence of adhesions is 
 most frequent in the cylinder-celled variety. Unfortunately, 
 adhesions are often extensive, and constitute a serious obstacle 
 to operative interference, forming between the stomach and 
 the liver, pancreas, colon, diaphragm, spleen, omentum, 
 abdominal wall, and other contiguous parts. 
 
 The method and dissemination of carcinoma is strongly in 
 favor of the parasitic nature of the epithelium which enters 
 into its constitution. The neoplasm may spread by continuity, 
 by contact or inoculation, or by the lymphatics and veins. 
 By continuity of tissue and growth the neoplasm extends in 
 the wall of the stomach to the esophagus and duodenum, and 
 invades adjacent organs over the bridges made by adhesions. 
 Detached peritoneal nodules may transplant the malignant 
 growth to other parts of the peritoneal cavity. The most 
 common method of propagation is along the lymphatics 
 originating in the primary and secondary deposits. The 
 abdominal lymphatic glands are nearly always enlarged, and, 
 less frequently, the inguinal and left supraclavicular glands. 
 Cancer may also be disseminated by the blood, and may thus 
 reach the liver, and from this organ, or directly through the
 
 520 DISEASES OF THE STOMACH. 
 
 thoracic duct, it may be carried to the lungs, skin, and other 
 distant organs. The secondary deposits retain the morpho- 
 logical characteristics of the primary carcinoma, and are most 
 frequent in the liver, where they exist in about one-third of 
 the cases. The size of the metastatic growth is in no constant 
 relation with that of the primary carcinoma of the stomach. 
 
 Perforation occurs, on an average, in about six per cent, of 
 the cases. The statistics of various authors range from four 
 to ten per cent. Perforation is the result of ulceration or of 
 gangrene, and opens most frequently into the peritoneal 
 cavity. The perigastritis may be walled in and purulent, the 
 subphrenic abscess usually forming in the right hypochon- 
 drium. Perforation may also occur through adhesions into 
 adjacent solid or hollow organs, producing an abscess or a 
 fistula. A fistulous communication of this kind is most fre- 
 quently established with the transverse colon, and sometimes 
 externally through the abdominal wall. 
 
 About 70 per cent, of cancers of the stomach involve one 
 of the orifices, and 30 per cent, are diffuse or confined to the 
 body of the stomach. It is commonly reported that 50 per 
 cent, to 60 per cent, of cancers are pyloric. But the situation 
 of the tumor at the autopsy does not make its point of origin 
 clear, and Israel rightly maintains that cancer, as a rule, does 
 not originate in the orifices, but that its extension is arrested 
 there. In 40 cases Boas found that the neoplasm began on 
 the lesser curvature twenty-five times and si.x times on the 
 pylorus. However, as revealed by autopsies, the neoplasm 
 remains confined to the lesser curvature in only about 15 per 
 cent, of the cases. 
 
 Clinical Description. — Cancer of the stomach begins insidi- 
 ously with tiie SN-mptoms of chronic asthenic gastritis, usu- 
 ally after the thirtieth year, and often where there has been 
 no digestive trouble, and runs its course rapidly without a 
 stop, and is accompanied by increasing emaciation, which the 
 most careful alimentation is unable to hold in check, under 
 favorable circumstances, for more than a few months. The 
 appetite is early lost, but exceptionally it remains normal. 
 The symptoms are at first digestive, but encroach more and 
 more on the period when the stomach should normally be at 
 rest, and consist of a sensation of heaviness or weight, to which 
 are soon usually added pain, nausea, and vomiting. Indeed, 
 two clinical groups of carcinoma may be distinguished. In the 
 one group pain predominates, and is accompanied by period- 
 ical vomiting. In the other group there are only mild symp- 
 toms, such as digestive discomfort, heaviness, flatulency, and
 
 THE NEOPLASMS OF THE STOMACH. 52 1 
 
 eructations or belching. The commencement is often sudden, 
 and marks the end of a long period of good digestion. The 
 course may be characterized by remissions and short periods 
 of improvement — little breaks in a cloud that never lifts; but 
 death usually occurs, from self-poisoning and starvation, in 
 from twelve to fifteen months after the first clinical manifesta- 
 tions. In some cases there may be no gastric symptoms for 
 a long time, the disease being manifested only by progressive 
 emaciation and weakness. But these latent cases are infre- 
 quent. The clinical picture varies accordingly as the cancer 
 involves the cardia, the body of the stomach only, or the 
 pylorus. 
 
 Carcinoma beginning on and limited to the cardiac orifice is 
 very infrequent, the entrance to the stomach being in nearly 
 every case involved secondarily by extension of the neoplasm 
 from the adjacent region of the esophagus or stomach. The 
 trouble begins with a feeling of fullness beneath the tip of the 
 sternum, usually first noticed during eating or soon after a 
 bolus of solid food is swallowed. A swallow or two of fluid 
 relieves the sensation, which returns from meal to meal, 
 and daily forces itself more and more upon the attention. 
 The appetite begins to fail, and the feeling of fullness and 
 weight becomes more obstinate. The patient soon learns 
 that fluids pass into the stomach more readily than solids, 
 which seem to stick behind the sternum. There are scarcely 
 ever sharp, prolonged attacks of lancinating pain ; indeed, there 
 is seldom any severe pain, but merely at times a little dull, 
 burning sensation, associated with the consciousness of the 
 presence of a foreign body which can not enter the stomach. 
 Neither swallowing nor external pressure with the hand per- 
 ceptibly increases or relieves the peculiar discomfort. Emacia- 
 tion, which began with the first symptom, increases more rapidly 
 as the food is restricted, solids being excluded as a result of 
 observation, and the poor appetite further cuts off the quantity 
 of food. But the emaciation is due not only to the increas- 
 ing cardiac obstruction and to the self-imposed fasting, but also 
 to the increased nitrogenous waste attributable to the cancer 
 itself. As the obstruction increases food collects above it and 
 dilates the esophagus. The fermentation and irritation cause 
 some burning pain and esophagitis. Shooting pains, some- 
 what severe in character, which have no connection with the 
 meals, are sometimes experienced. The food, mixed with 
 mucus, is expressed or regurgitated into the mouth, and 
 chemical analysis shows that it has not entered the stomach.
 
 522 DISEASES OF THE STOMACH. 
 
 If the cancer be of the soft variety, a marked diminution of 
 the obstruction may occur by ulceration, and false hopes may 
 be excited. The inanition and the cancerous intoxication, 
 aided sometimes by slow hemorrhages, bring life to an end in 
 from six to ten months after the first feeling of heaviness was 
 experienced. 
 
 Carcinoma of the body of the stomach begins with loss of 
 appetite, with digestive trouble, consisting chiefly of a sensa- 
 tion of heaviness after meals, or with loss of strength and weight 
 out of proportion to the mild local gastric disturbance. There 
 is often a little belching of gas or regurgitation of a sour and 
 bitter fluid. Fats and meats become particular objects of dis- 
 gust. The signs of fermentation become more pronounced, 
 and pain is added to the heaviness which encroaches more 
 and more on the period of normal rest of the stomach. The 
 pain is usually dull, little influenced by the taking of food or 
 by vomiting, occurs during the period of normal gastric rest, 
 and may persist night and day. The pain as the disease 
 advances may change in character and become at times lanci- 
 nating, and the suffering may be horrible. The food is often 
 vomited, without producing nausea, as a rule, but sometimes 
 with a good deal of retching. The vomit may also consist of 
 mucus and saliva, and is likely, particularly if there is exten- 
 sive ulceration, to contain altered blood and to be a dirty 
 chocolate-brown or like coffee grounds. The patient is now 
 pale, haggard, straw-colored, cachectic. Running throughout 
 the evolution of the disease and preserving its clinical con- 
 tinuity are the progressive loss of strength and the emacia- 
 tion. After twelve to fifteen, or, rarely, eighteen, months the 
 patient dies, a helpless skeleton. Cancer of the body of the 
 stomach may be latent, and throughout the course of the dis- 
 ease there maybe no gastric or digestive symptom to create 
 a, suspicion of the location and nature of the trouble. The 
 only sign, apart from those furnished by the functional and 
 bacteriological examinations, is the progressive and uncon- 
 trollable emaciation. 
 
 Cancer, in contrast with the disease involving the cardia, 
 more frequently affects primarily the pylorus. Primary 
 cancer of the pylorus rarely extends to the duodenum, but 
 may spread to the body of the stomach. Frequently the 
 pylorus is also secondarily involved by the growth of the 
 neoplasm, beginning on the body of the stomach, particularly 
 the lesser curvature. The clinical expression is modified by
 
 THE NEOPLASMS OF THE STOMACH. 523 
 
 the affection of the orifice, and the signs of stagnation or 
 retention appear early and predominate. In cancer of the 
 body of the stomach there is stagnation and retention, but 
 there are no signs of pyloric obstruction. Where the disease 
 involves the pylorus, vomiting is more frequent and copious, 
 fermentation more active and mixed, starvation more rapid, 
 and to the ordinary loss of body fat and the excessive nitro- 
 genous waste and loss of strength are added the pernicious 
 effects of insufficient water to supply the needs of the body. 
 Thirst is often annoying. 
 
 Symptoms. — The clinical commencement of carcinoma is 
 commonly sudden, though the symptoms in the beginning 
 do not often seem to be serious. The middle-aged patient 
 sometimes boasts of the good stomach which he has long and 
 uninterruptedly enjoyed, and is at a loss to explain the causation 
 of his trouble. But it should not be imagined that a disease 
 of the stomach is a protection against carcinoma. Ulcer, 
 indeed, seems to furnish within narrow limits a favorable 
 opportunity for the development of the disease. Traumatism, 
 dietetic excess, or some trivial cause, occasionally marks the 
 beginning of the clinical period. 
 
 The appetite is almost invariably poor. It is better pre- 
 served when the cardia is affected than when the cancer in- 
 volves the body of the stomach or the pylorus, and some- 
 times remains about normal, particularly in carcinomatous 
 ulcer and in cancer in the early period of life. The more 
 active and varied the gastric fermentation and intestinal 
 putrefaction, the more pronounced is the anorexia. There is 
 often a strong disgust for meats and fats, and this may be an 
 early symptom. It seems that the dislike for fats is greatest 
 when butyric acid fermentation exists. The disgust for 
 meats is absolute when the contents of the stomach have a 
 putrefactive odor, and the instinctive exclusion of meats is in 
 keeping with the loss of power to digest them. The anorexia 
 — which, as a rule, tends to become complete — is voluntarily 
 resisted by the patient, and is in vivid contrast with the 
 evident needs of nutrition. 
 
 A sensation of heaviness and fullness is an early symptom 
 of carcinoma which is almost never absent, but is in no 
 respect characteristic of the disease. Like that of chronic 
 gastritis and of myasthenia, it appears soon after taking food. 
 The sensation usually persists as long as food remains in the 
 stomach, and, consequently, increases with the development 
 of stagnation and retention. In cancer of the cardia its loca- 
 tion is beneath the lower end of the sternum, but sometimes
 
 524 DISEASES OF TJ/E STOMACH. 
 
 it is referred lower down. When the neoplasm is situated on 
 the body of the stomach or involves the pylorus, the sensa- 
 tion of weight and fullness may extend over the whole area 
 of the stomach, and is often most distinct at the lowest point 
 of the greater curvature. 
 
 Cancer is preeminently a painful disease, but a few cases 
 run their entire course without pain. These exceptional 
 painless forms are more frequent in old age. The pain of 
 carcinoma is not characteristic, but still has many distinctive 
 features. It is sometimes strictly localized, and this occurs 
 most frequently when the pain is not very intense ; but more 
 often it is diffuse, dull, coming in exacerbations, or lancinat- 
 ing, tearing, and radiating into the back or beneath the 
 sternum. It does not depend for its existence on the taking 
 of food, but may be increased b}' irritating food or by food 
 which becomes so after its sojourn in the stomach. It is not 
 perceptibly, or only temporarily, relieved by vomiting, and it 
 does not cease when the normal period of gastric digestion 
 is passed. It is often a more or less continuous pain, with 
 e.xacerbations occurring independently of digestion during 
 the day and during the night. 
 
 There is no very close and constant relation between the 
 location of the spontaneous pain and the situation of the 
 neoplasm ; but in cancer of the cardia a dull, aching, and 
 sometimes shooting pain is frequent in and about the left 
 shoulder-blade. The coincidence of an interscapular pain 
 with the location of the neoplasm on the lesser curvature 
 has often been noticed. The pain may be in the loins when 
 the neoplasm is located on the posterior wall. Epigastric 
 and dorsal points sometimes exist when the cancer ulcerates. 
 When the cancer involves the pylorus, the pain due to the 
 malignant growth may be located in the ejMgastrium or the 
 left or right hypochondrium, but the pain due to obstruction 
 is often characteristic. The pain, then, often appears during 
 the period of digestion in paroxysms, colicky in character, 
 and coinciding often with gastric peristalsis, visible on the 
 thin abdominal wall. This pain of obstruction is completely 
 relieved by emptying the stomach or by gastro-enterostomy. 
 
 Vomiting is not an early symptom of cancer of the 
 stomach, but occurs irregularly, and usually three or four 
 months after the beginning of the clinical period. When 
 the neoplasm involves the cardia, the fluids may enter the 
 stomach, and the little regurgitant vomiting occurs only 
 during or immediately after a meal of solid food. But at a 
 more advanced period, when the esophagus is dilated above
 
 THE NEOPLASMS OF THE STOMACH. 525 
 
 the obstruction, the regurgitation may recur much later, even 
 during the period of rest of the normal stomach. The food 
 is for a time retained in the esophageal sac. As the 
 obstruction becomes more complete the regurgitations may 
 consist simply of swallowed saliva and mucus. Before the 
 fatal termination the obstruction is sometimes removed by 
 ulceration, and the regurgitation ceases ; but this seldom 
 occurs. 
 
 A few cases of cancer of the body of the stomach, par- 
 ticularly when well treated, run their course without vomit- 
 ing. Vomiting is likely to be infrequent when the neoplasm is 
 located on the posterior wall, or when it is of the hard variety 
 and infiltrates the whole body of the stomach. It is, however, 
 often uncontrollable, and produces great distress when the 
 neoplasm is located on the lesser curvature. The vomiting 
 is most frequent after taking food and during the period of 
 digestion, but it may occur when the stomach should be empty, 
 and may consist of the mucus and saliva swallowed, or par- 
 ticles of retained food may be brought up with much 
 retching. 
 
 Vomiting always occurs when the pylorus is involved, and 
 is often profuse on account of the obstructive retention. In 
 pyloric cancer the vomiting is most common two or three 
 hours after a meal, but may occur at any moment. 
 
 Hematemesis is observed clinically in about 40 per cent. 
 (Brinton) of the cases of carcinoma of the stomach. As a 
 rule, the hemorrhages are small and the blood passes with 
 the gastric contents into the intestines, or it appears in the 
 vomit after having undergone partial digestion or putrefaction 
 in the stomach. The vomit is then more or less colored by 
 it, and is often like coffee grounds. The coffee-ground vomit 
 is in no manner, when taken alone, characteristic of carci- 
 noma, but is met with in ulcer, passive congestion, erosions, 
 ulceration, chronic gastritis, and varicose esophageal veins. 
 The hemorrhage of cancer is seldom sufficient to excite 
 vomiting, but sometimes a large vessel (pyloric artery) is 
 opened and a profuse and fatal hematemesis results. 
 
 Signs. — The physical signs of cancer of the cardia are very 
 important, but not always distinctive. Percussion and pres- 
 sure over the lower end of the sternum are often painful, and 
 sometimes exquisitely so.. No tumor can be felt or seen. The 
 second deglutition sounds are sometimes absent, but they are 
 more often delayed. Rarely, the tumor, by pressure on the 
 aorta, produces a systolic murmur, and makes it difficult to ex- 
 clude the existence of an aneurysm, which should always be
 
 526 DISEASES OF THE STOMACH. 
 
 done before the tube is used. An attempt should first be made 
 to pass a large stomach-tube, and if this passes readily into the 
 stomach, the trouble with swallowing which has prompted the 
 examination is most likely due to spasm of the cardia. But 
 this is not necessarlK' the case, as even a large sound sometimes 
 passes readily in the early stage of carcinoma or where the 
 cardiac orifice is made free by ulceration of the neoplasm. If 
 such be the case, a little blood and mucus will probably be found 
 in the eye of the tube, and sometimes nests of cancer cells or 
 pieces of the neoplasm. If the stomach-tube is arrested, and 
 no contents of the dilated pouch can be aspirated, a little 
 water may be allowed to flow in, while a gentle effort is made 
 to push the tube further on. In case of failure, the fluid 
 should be aspirated and saved for examination, and the tube 
 withdrawn, and the distance to the obstruction from the 
 incisor teeth should be measured. An effort ma}' be made 
 to pass soft and smaller esophageal sounds, and in case of 
 failure, and no evidence of the nature of the obstruction 
 having been obtained, the examination may be repeated 
 after the administration of a dram of bromid of potash in 
 two or three doses. If the obstruction be again met with, 
 and it is situated about 40 cm. from the incisor teeth, if the 
 patient is beyond thirty and the difficulty has been steadily 
 growing since its commencement a few months previous 
 with loss of appetite and emaciation, there is then not much 
 doubt that there is a malignant growth involving the cardiac 
 orifice of the stomach. The stomach itself is abnormally 
 small and retracted, and the intestines are also likely to be 
 empty. The digestive tube becomes more and more con- 
 tracted and empty as the obstruction increases, and the thin 
 abdominal wall recedes as the abdominal contents decrease. 
 In every case of cancer of the stomach a tumor exists. 
 Early in the disease, at the primary site, a neoplastic mass 
 forms ; and later, secondary deposits develop. But the 
 primary tumor can not always be detected. It may be located 
 on a part inaccessible to physical examination, but the dis- 
 placements of the stomach which so frequently exist some- 
 times remove this difficulty. The primary growth may be 
 covered by an enlarged liver or concealed by ascites. The 
 fullness or emptiness of the stomach ma)' reveal or conceal 
 the tumor. In the search for the tumor it is highly impor- 
 tant to proceed systematically. The examination should be 
 made when both the stomach and bowels are empty. Ascitic 
 fluid should be withdrawn. The examination is not com- 
 plete until it has also been made while the stomach is dis-
 
 THE NEOPLASMS OF THE STOMACH. $2^ 
 
 tended with air or gas. The primary growth will in this 
 way be more likely to be detected and properly located. If 
 this plan be adopted, in at least four-fifths of the cases of 
 cancer of the body of the stomach and of the pylorus a 
 tumor will be detected at some time during their evolution. 
 
 A palpable tumor is not an early sign of cancer of the 
 stomach, and is not often detected before the beginning of 
 the last six or eight months, but sometimes earlier and 
 sometimes nearer the end. At first may be noticed a cir- 
 cumscribed, resistant area, which is seldom sensitive. The 
 tumor grows and changes its character, becoming knotty, 
 irregular in consistency, larger, adherent, sometimes exquis- 
 itely tender, but more frequently manifesting only a little 
 more pain on pressure than do the surrounding parts. The 
 neoplasm often feels harder and larger on palpation than it 
 is in reality after allowance is made for the surrounding 
 inflammatory swelling. Even the soft infiltrating cancer 
 produces a palpable tumor. 
 
 The physical signs of cancer of the body of the stomach 
 may be of the greatest diagnostic value. These signs con- 
 sist almost exclusively of the physical evidences of a tumor 
 possessing the particular characters of a malignant growth. 
 Cancer of the posterior wall and of the portions of the 
 anterior surface and the greater curvature which are 
 covered by the left ribs often can not be detected by physical 
 examination. Situated on other parts of the body of the 
 stomach, the characteristic tumor may often be found ; or it 
 is first found when these parts become involved by extension. 
 
 Cancer of the lesser curvature may lie beneath the ribs 
 and the left lobe of the liver, and be inaccessible. But in 
 the large majority of cases, during the second half of the 
 clinical period, it can be detected if the stomach be empty, 
 and much more readily if the stomach, as often happens, is 
 displaced downward or vertically. On inspection, the tumor, 
 well defined above and below, may be seen moving up and 
 down on inspiration and expiration, emerging from be- 
 neath the costal arch toward the end of inspiration and 
 disappearing from view as the diaphragm rises. On palpa- 
 tion, the tumor, visible or invisible, can often be felt, and 
 also fixed on expiration, unless it be firmly adherent to the 
 diaphragm. This relation of the tumor to the movements of 
 the diaphragm is a very important, and, when taken in con- 
 nection with its location beneath or just below the costal 
 arch, and with the position of the body of the stomach below 
 it, is an almost characteristic sign of a tumor of the lesser cur-
 
 528 DISEASES OF THE STOMACH. 
 
 vature of the stomach. If the fingers be laid flat and gently 
 on the abdominal wall, the tumor glides up and down with 
 expiration and inspiration respectivel}'. If at the end of in- 
 spiration the tips of the fingers be gently but firmly pressed 
 above the tumor, the mass can be arrested, and when released 
 near the completion of expiration it slips up from beneath the 
 fingers. Another important characteristic of a tumor of the 
 lesser curvature is its inaccessibility when the stomach is full. 
 It can not be pushed to either side. 
 
 If the cancer is located on the portion of the greater curva- 
 ture uncovered by the ribs, the tumor is situated near or 
 beneath the umbilicus, moves with respiration, is easily 
 fixable on expiration, and is most accessible when the stom- 
 ach is full. The tumor is sensitive, commonly knotty, but 
 is sometimes smooth, and usually possesses a border irreg- 
 ular in consistency but at points very hard and sharply 
 limited. When not adherent it is pretty freely movable up 
 and down, and to a limited extent to either side. 
 
 Cancer of the accessible part of the anterior wall is most 
 easily felt when the stomach is moderately distended with 
 gas, the artificial distention with air or an effervescent 
 powder being far preferable to distention with food. The 
 tumor is more or less sensitive, knotty, and here and there 
 the irregular border is hard. If the cancer is an infiltrating 
 scirrhus, the stomach is smooth, small, and resistant. The 
 wall is non-elastic, and inflation with air or gas produces 
 severe pain without increasing the size of the stomach. If 
 the tumor is situated on the posterior surface, it may be felt 
 when the stomach is empty, but it disappears when the 
 stomach is full or distended. Clinically, what is sometimes 
 felt during life is not in reality the primary growth, but 
 secondary deposits in the omentum or in the left lobe of the 
 liver. 
 
 In cancer of the body of the stomach the organ is normal 
 in size or smaller than the average. If it be enlarged, the 
 increase in size is an accidental association. A tumor of the 
 body of the stomach sometimes pulsates on account of being 
 in contact with the abdominal aorta. The pulsation is lifting, 
 and not expansive as in aneurysm. If the tumor be free, the 
 pulsation ceases in the knee-chest position, and when the 
 mass is pushed to either side so as not to come in contact 
 with the aorta. But the tumor may be adherent, surround 
 or compress the aorta, and produce a systolic blowing and 
 whirring murmur and diminution of the arterial pulse below. 
 The differential diagnosis between an aneurysm and a can-
 
 THE NEOPLASMS OF THE STOMACH. 529 
 
 cerous tumor of the stomach depends in such a case on the 
 other signs or symptoms which are present and belong only 
 to the one or the other disease. 
 
 The tumor of pyloric carcinoma is seen or felt to the 
 right, on, or sometimes to the left of, the median line. It may 
 be invisible and inaccessible to palpation, and lie deep 
 beneath the liver. But, fortunately, in pyloric cancer the 
 stomach is commonly displaced, and its palpation is made 
 thereby possible and easy. The tumor moves with respira- 
 tion, and unless adherent is fixable on expiration. But cases 
 are not rare where the pyloric tumor is exceedingly movable, 
 and may be pushed about in the right iliac fossa (where it is 
 sometimes found) and across the median line. On inflation 
 of the stomach the tumor of the pylorus descends to the 
 right and downward; but it may also be displaced upward 
 and to the right, or simply downward, in case the tumor is 
 bound by adhesions. The stomach is not always increased 
 in size in cancer of the pylorus, even when obstructive 
 retention exists, and peristalsis may be strong and visible. 
 When the cancer converts the pylorus (by ulceration or by 
 infiltration) into a rigid and incontinent ring, the air may be 
 heard rushing through the pylorus with each compression of 
 the inflating bulb. 
 
 Naturally, a gastric tumor is not a pathognomonic sign of 
 cancer, but gathers a good deal of its value from the asso- 
 ciated symptoms and signs. It aids in the location of the 
 disease and in the selection of the proper treatment. 
 
 The emaciation is not characteristic, and may be no greater 
 than in other diseases. But the skin does not preserve its 
 clear and rosy color, as in the extreme emaciation of some 
 nervous affections ; nor is all the fat lost, as in simple chronic 
 inanition. The body albumin early and progressively dis- 
 appears, and the emaciation and cachexia differ from the 
 pale, edematous appearance of chronic nephritis. The ema- 
 ciation of carcinoma resembles that produced by lack of food 
 and water. The body is not soggy, but the skin and both 
 other tissues are abnormally dry. But localized temporary 
 edema is common enough in carcinoma of the stomach. It is 
 first noticed about the ankles, and may appear early in the 
 disease. It occurs without albuminuria or cardiac insuffi- 
 ciency, and comes and goes without any changes in the dis- 
 eased blood. The edema is sometimes confined to one ex- 
 tremity, and is due to phlebitis. The occluding thrombus, 
 favored in its formation by the diminished alkalinity of the 
 blood, is most frequent in the veins of the lower extremities, 
 34
 
 530 DISEASES OF THE STOMACH. 
 
 but may also occur in other veins. Localized edema due to 
 venous thrombosis, or fugacious edema, unassociated with 
 renal or cardiac insufficiency, or with diarrhea should excite 
 suspicion of malignant disease. But, as the rule, the cachectic 
 emaciation of carcinoma is progressive and dry. 
 
 The state of nutrition found in carcinoma of the stomach 
 is due partly to starvation. The appetite is diminished, and 
 nearly always, in all forms and localizations of carcinoma, too 
 little food is eaten to supply the needs of nutrition. Tempor- 
 ary improvement may consequently often be obtained by the 
 prescription of a carefully selected and sufficient diet. The 
 emaciation in obstruction of the cardia and pylorus is also 
 due in part to an insufficient absorption of food. It is very 
 common for increase of weight and strength to follow when 
 the obstructed cardiac entrance is made free by ulceration. 
 Improvement in the state of nutrition may also be obtained 
 by surgical operations facilitating the introduction and utili- 
 zation of food, and sometimes by rectal feeding. Still another 
 factor of the emaciation and loss of strength in cancer of the 
 stomach is the failure to digest and to utilize the small 
 quantity of food which is eaten. The active gastric fermenta- 
 tion entails a heavy loss of non-nitrogenous food, and the 
 almost constantly large quantity of indican in the urine and 
 the foul odor of the stools reveal the activity of putrefaction 
 in the intestines. The continuous absorption of the products 
 of fermentation and putrefaction exerts a deleterious influence 
 on nutrition. 
 
 But there is still a peculiarity of catabolism present in car- 
 cinoma which starvation and fermentation and putrefaction 
 do not explain. This is the e.xcessive nitrogenous elimination 
 due to the active destruction of body albumin. This excessive 
 nitrogenous waste is uncontrollable by diet, is due to the malig- 
 nant growth itself, and creates a close resemblance in this re- 
 spect between carcinoma and the infectious diseases. It seems 
 probable, both from reasoning and experimentation, that a 
 protoplasmic poison is formed by the neoplasm and circulates 
 in the blood, to which is due the chemotaxis.hematocytolysis, 
 leukocytosis, and excessive destruction of the albuminous 
 tissues of the body. 
 
 These many factors of the emaciation, cachexia, and loss of 
 strength are not equally active in all cases of carcinoma of 
 the stomach. Consequently, too great stress should not be 
 laid on the state of nutrition at a particular stage in the evo- 
 lution of individual cases. The bod)' may remain pretty well 
 nourished until late in the second half of the course of the
 
 THE NEOPLASMS OF THE STOMACH. 53 1 
 
 disease. There may be short and temporary improvement 
 and gains, which should not be allowed to deceive. The 
 em'aciation may be gradual and progressive from the begin- 
 ning, or may begin suddenly in the course of the disease and 
 proceed rapidly. The loss of weight, the weakness, the selec- 
 tive nitrogenous waste, and the dry cachexia should, never- 
 theless, excite suspicion of a malignant disease. But these 
 signs are not worth much in the early diagnosis of cancer of 
 the stomach. 
 
 The functional signs of carcinoma of the stomach are very 
 valuable aids to a correct and early diagnosis. Neither the 
 hypochylia, nor the motor insufficiency, nor the diminution of 
 absorption are pathognomonic signs, but they possess both a 
 positive and a negative value. Normal secretion and a good 
 motor function speak emphatically against cancer. Superse- 
 cretion and hydrochloric superacidity possess great negative 
 value and exclude cancer where there is no history of ulcer 
 or of hypersthenic gastritis. 
 
 In respect to the functional signs carcinoma may be divided 
 into three forms, according to the situation of the neoplasm 
 on the body of the stomach or at one of its orifices. In 
 cancer involving the cardiac orifice the functional signs are 
 variable; there may be normal secretion and normal motor 
 activity throughout the disease, except in so far as the func- 
 tions are modified by subnutrition and anemia; or secretion 
 may be diminished if secondary asthenic or atrophic gastritis 
 should develop. In cancer of the cardia the functional gas- 
 tric signs 'are not required for determining the location of 
 the disease, and they give very unimportant information con- 
 cerning the nature of the disease. In regard to the motor 
 function, it makes a great difference whether the neoplasm is 
 confined to the body of the stomach or whether it obstructs 
 the pylorus. In the description of the secretory signs the 
 situation of the cancer on the body of the stomach or close to 
 the pylorus need not be kept in mind ; for the secretory 
 changes are due to the nature and extent of the accompany- 
 ing gastritis, and, to a less degree, are the effect of the sub- 
 nutrition, of the toxemia, and of the anemia. 
 
 Secretion in carcinoma is diminished early in the disease, 
 often before a tumor can be detected; and the diminution is 
 persistent from day to day, and often rapidly progressive. In 
 a small number of the cases of cancer nutrition is fairly well 
 maintained, and the associated gastritis is slight, and secretion 
 can remain moderately active until near the fatal termination. 
 But the rule, nevertheless, stands that in carcinoma of the
 
 532 DISEASES OF THE STOMACH. 
 
 stomacli the free In-drochloric acid soon disappears, and 
 gradually the combined hydrochloric acid decreases in the 
 contents obtained after a test-breakfast. Sinuiltaneously, the 
 pepsin and labfernient and their mother-substances likewise 
 decrease, until eventually the albuminous foods undergo no 
 hydrochloric-pepsin digestion. The ferments, as in asthenic 
 gastritis, diminish in proportion with the diminution of hydro- 
 chloric acid (H + C) secretion. The hypochyliais not due to 
 the malignant growth itself, though the alkaline transudate 
 from the blood-vessels and the cancer juice doubtless often 
 neutralize some of the hydrochloric acid secreted. Nor is it 
 due to the state of nutrition and to the blood alone, though 
 the progressive cachexia ma\' be an active factor. The same 
 secretory changes occur when the cancer affects another 
 organ, as the uterus or the breast. Rut the state of secretion 
 is due chiefly to the associated asthenic gastritis. The secre- 
 tory signs are only indirect manifestations of the cancer, and 
 are in themselves in no wise pathognomonic. Gastric absorp- 
 tion is diminished, and the diminution is persistent and pro- 
 gressive. 
 
 When the cancer is engrafted in ulcer it may be accom- 
 panied by secretion as rich as normal until near its fatal 
 termination ; but it is more common for secretion to 
 diminish as the disease progresses beyond a certain period. 
 In one of our 38 cases the cancer developed during the 
 course of an old hypersthenic gastritis (no ulcer), and 
 hyperchylia persisted to fifteen days before death. In about 
 ten per cent, of the cases of carcinoma secretion remains 
 nearly normal in acid and in ferments until near the end of 
 the disease. In nearly 20 per cent, of the cases hypochylia 
 develops slowly. But in the remainder of the cases (about 
 60 per cent.), hypochylia ben;ins early and develops rapidly, 
 free HCl disappearing, and the digestive power of the con- 
 tents varying from 20 to near o, when estimated b}' the 
 method of Hammerschlag. 
 
 The motor insufficiency is a more direct result of the malig- 
 nant growth. The muscular layer becomes infiltrated with 
 cancerous cells and edematous from obstruction of the 
 lymphatic circulation. Late in the disease the whole mus- 
 cular system becomes weak from toxemia and wasting. The 
 neoplasm often more or less invokes and obstructs the 
 pylorus. The motor insufficiency is, in a large percentage of 
 the cases, an early sign, but it becomes pronounced more 
 rapidly in pyloric carcinoma. For a variable period stag- 
 nation exists ; first stagnation of solids only, and later of
 
 THE NEOPLASMS OF THE STOMACH. 533 
 
 both solids and liquids. Retention follows, and the stomach 
 then always contains food and liquid. Retention occurs 
 early and almost invariably in pyloric carcinoma. The 
 only two exceptions which we have seen were cases of 
 scirrhus — the pylorus being converted into a functionless 
 ring, the stomach being small and evacuating its contents 
 with abnormal rapidity, achylia being complete, and lactic 
 acid persistently absent. In cancer of the body of the 
 stomach stagnation is an early sign in about 60 per cent, 
 of the cases ; in a part of the remainder stagnation appears 
 late in the disease, and about five per cent, of the cases run 
 their course without motor insufficiency. Most important 
 characteristics of the motor insufficiency of cancer are its 
 persistence and its frequently rapid increase. 
 
 The bacteriological signs are in certain circumstances charac- 
 teristic of cancer of the stomach, and may be so even at an 
 early stage, when no tumor can be detected. In no other dis- 
 ease is fermentation more active, for no other disease furnishes 
 so many favorable conditions — stagnation, retention, hypo- 
 chylia, diminished absorption, and prolonged salivary diges- 
 tion. 
 
 The form of fermentation is not always the same. Before 
 the disappearance of the free hydrochloric acid and the be- 
 ginning of motor insufficiency, there is no fermentation except 
 what may occur accidentally and temporarily. As soon as 
 stagnation begins, and before the free HCl disappears, the 
 fermentation is sometimes due to yeast, but is most frequently 
 butyric. In carcinoma of the stomach butyric fermentation 
 is almost as common as lactic acid formation, but it is neither 
 persistent nor characteristic. As the stagnation and hypo- 
 chylia increase, the fermentation becomes bacillaryand chiefly 
 lactic. In no other disease of the stomach is lactic acid so 
 frequently formed in large quantity, when certain precautions 
 are taken to prevent its introduction or its retention in the 
 stomach from a previous meal. In the thoroughly washed 
 stomach lactic acid is formed from food which is perfectly free 
 from it, in quantity greater than one per thousand, in two- 
 thirds of the cases of carcinoma of the stomach. 
 
 The formation of lactic acid takes place in the human 
 stomach only in very special conditions, and these conditions 
 are most frequently present in carcinoma. In the first place, 
 it is absolutely essential that hypochylia exist to such an ex- 
 tent that no free HCl is present in the contents obtained one 
 hour after the test-breakfast. Even the presence of combined 
 HCl in moderate quantity suffices to arrest the formation of
 
 534 DISEASES OF THE STOMACH. 
 
 lactic acid, unless motor insufficiency is so great as to cause 
 retention. Consequently, lactic acid formation is more fre- 
 quently and persistently associated with absent free HCl and 
 nearly normal combined HCl in malignant than in benign 
 obstruction, unless the cancer develops on an old ulcer or in the 
 course of hypersthenic gastritis; for the hypochylia of carci- 
 noma is persistent and progressive, all the constituents of 
 secretion being involved. Lactic acid formation occurs in can- 
 cer at a period when the motor insufficiency is not so great as 
 is required for lactic acid formation in benign diseases. This 
 clinical fact is probably due to the accumulation of lactic acid 
 forming bacilli over the portion of the gastric wall rendered 
 stiff and motionless by the neoplasm, and to the existence of 
 food retention in a smaller quantity, but persistently, in carci- 
 noma, at a period when the general motor insufficiency is com- 
 paratively not great. Lactic acid may be formed in carcinoma 
 if the tumor is extensive (on body) and uneven, at a time 
 when the stomach evacuates its contents in a nearly normal 
 period; but lactic acid formation never occurs, under such 
 circumstances, in a benign disease. The conditions of lactic 
 acid formation are hypochylia with no free HCl, motor in- 
 sufficiency, and the accumulation of vigorous lactic acid pro- 
 ducing germs. These conditions are seldom persistently and 
 progressively fulfilled to such a degree that more than i 
 per lOOO of lactic acid is formed during the digestion of 
 the test-breakfast on the morning following thorough lavage 
 on the preceding evening, unless the disease of the stomach is 
 cancer. 
 
 Lactic acid formation occurs invariably in cancer of the 
 pylorus when the obstruction becomes sufficient to produce 
 retention and there is no free HCl in the contents after the 
 test-breakfast. But lactic acid formation may occur in benign 
 retention with hypochylia, and great precaution must be taken 
 in interpreting lactic acid formation in obstructive retention. 
 In two-thirds of the cases of cancer situated on the body of the 
 stomach there is lactic acid formation in quantity greater than 
 I per lOOO. Consequently, the absence of lactic acid formation 
 does not exclude cancer of the pylorus before retention 
 occurs ; nor does it exclude a cancer of the body of the stom- 
 ach, whatever be the stage of its growth. In 109 cases of 
 disease of the stomach with hypochylia we have found lactic 
 acid in quantity greater than I per 2000 in 44 cases ; 38 of 
 the 109 cases were carcinoma, and in 31 of the 38 cases lactic 
 acid formation was present. In 132 cases with hyperchylia 
 we have found cancer 3 times — 2 engrafted on ulcer and i on
 
 THE NEOPLASMS OF THE STOMACH. 535 
 
 chronic hypersthenic gastritis. Hammerschlag, in 250 cases 
 of diseases of the stomach, found lactic acid in 35, and 29 of 
 these 35 cases were cases of carcinoma. In 153 cases Strauss 
 found lactic acid in 27 and cancer in 22. In 14 cases of cancer 
 of the stomach Klemperer found lactic acid in 12 ; in 42 cases 
 of the same disease Hammerschlag reports no free HCl in 37, 
 digestive power less than 20 per cent, in 30, and lactic acid in 
 26; Boas found lactic acid in 30 out of 40 cases. In 55 cases 
 of cancer of the stomach Hayem found achylia in 6, hypo- 
 chylia with no free HCl in 48, hyperchylia (with disappear- 
 ance of free HCl in one month) in i, and lactic acid in 25. 
 These statistics give a general idea of the frequency and diag- 
 nostic value of lactic acid formation in cancer of the stomach. 
 
 When, in the course of cancer, obstructive retention devel- 
 ops, the fermentation becomes mixed. The gas-forming 
 germs now become active. The kinds of micro-organisms 
 change during the course of cancer, as do the forms of fer- 
 mentation. Sarcinae are only found when retention coexists 
 with secretion so active as to leave HCl free; lactic acid fer- 
 mentation destroys them rapidly, and they are not found in 
 association with it except isolated and dying. Lactic acid 
 formation is accompanied by the bacillus geniculatus. In the 
 mixed fermentations are found bacilli and yeasts. There is 
 no H2S formation in malignant disease of the stomach (Boas). 
 
 The anatomical signs are inconstant, but may be absolutely 
 demonstrative, revealing the malignant disease to the eye. 
 The washings and vomit should be repeatedly and persistently 
 examined for pieces of the tumor. A negative result is with- 
 out meaning, but the discovery of little pieces of the mucous 
 membrane showing the histological characters of asthenic 
 gastritis does not exclude carcinoma. 
 
 Another very important anatomical sign is the presence of 
 pus and cancer cells in the vomit or expressed contents. 
 There is no pepsin-hydrochloric digestion, or very little, 
 in the stage of carcinoma when ulceration is active. Con- 
 sequently, the dead tissue and the inflammatory products 
 are not digested as in ulcer, and the motor insufficiency of 
 carcinoma makes the obtaining of them in the vomit and wash- 
 ings all the more likely. It should not be forgotten that the 
 pus may be swallowed, and it is only a confirmatory sign, 
 except when mixed with the debris of cancerous tissue which 
 can be recognized as gastric. 
 
 The blood changes in cancer of the stomach are not in them- 
 selves characteristic, but are very marked, progressive, and 
 possess some diagnostic value. The anemia may be mild.
 
 536 DISEASES OF THE STOMACH. 
 
 severe, or grave, and is not accompanied, as a rule, by hemic 
 murmurs in the heart and tlie blood-vessels. 
 
 Cancer of the stomach produces greater changes of the 
 blood than does cancer of any other organ of the body. The 
 pathological blood alterations are due to subnutrition, to 
 hemorrhage, to toxemia, and to the low reparative power of 
 the body, and affect the development of the blood, the vitality 
 and resisting power of the corpuscles, and the composition of 
 the plasma. 
 
 Coagulation and fibrin formation are normal or less active 
 than in health. Rapid and excessive fibrin formation does 
 not occur in cancer unless it is complicated by inflammation. 
 
 The specific gravity of the blood is always reduced, and to 
 a greater extent than would be indicated by the diminution of 
 the hemoglobin, unless leukocytosis and other counteracting 
 influences are present. The specific gravity of the blood, 
 which can be easily estimated by the method of Hammer- 
 schlag, is determined by the number and size of the red cor- 
 puscles, by the quantity of hemoglobin, by the quantity of 
 water, by the richness of the plasma in albumin and salts, and 
 by the number of leukocytes. In cancer there is always a 
 diminution of the hemoglobin below the percentage which 
 would be indicated by the number of red corpuscles; but the 
 average size of the red corpuscles may be diminished, the 
 quantity of water may be so greatly reduced as to produce 
 oligemia sicca, the plasma may be poor and thin, and the 
 number of leukocytes may be greatly increased. Conse- 
 quently, the specific gravity does not increase and decrease 
 with the percentage of hemoglobin ; but it may so happen 
 that the combined effect of the other factors is multiplied, or 
 they may work more or less in unison to reduce or increase 
 the specific gravity. The specific gravity of the blood is 
 characteristic of the blood of cancer only when its relation 
 to all the factors which influence it is known. 
 
 In cancer of the stomach the quantity of hemoglobin and 
 the number of red corpuscles steadily decrease from the 
 moment the blood is altered by the malignant disease until 
 death arrests the process. There is in reality progressive 
 descent; but this descent may be masked by the occurrence 
 of oligemia sicca, which may cause the percentage of hemo- 
 globin and the number of corpuscles to approach or return to 
 the normal percentage and number. But the oligemia sicca 
 only masks the anemia, which is easily detected by the micro- 
 scope and by stains. 
 
 The hemoglobin percentage in cancer of the stomach is
 
 THE NEOPLASMS OF THE STOMACH. 537 
 
 always less than the percentage of red corpuscles, because 
 the average size of the red corpuscles is nearly always less 
 than the average normal size, and the regeneration of hemo- 
 globin is deficient. The persistence of this condition in the 
 absence of signs of regeneration of the blood is a marked 
 characteristic of carcinomatous blood. 
 
 The blood's losses in cancer of the stomach are nearly 
 always permanent. Even after an operation, when blood is 
 destroyed by the anesthetic and lost by hemorrhage, the loss 
 is very slowly and incompletely restored, even though the 
 operation greatly improves nutrition and the functions of the 
 stomach. The cancer produces obstinate insufficiency of the 
 blood-building organs. 
 
 The red corpuscles undergo qualitative alterations. The 
 average size is less than normal, and a glance at a specimen 
 under the microscope will reveal the large number of micro- 
 cytes, rendering it seldom necessary to compare the volume 
 percentage given by the hematocrit with the percentage of 
 counted red corpuscles. But in the grave stage of the anemia 
 megalocytes may appear ; but many of these are imbibition 
 corpuscles. The red corpuscles also degenerate and undergo 
 destruction in the circulating blood. The blood becomes 
 poor in chlorids and nitrogenous substances, and a proto- 
 plasmic poison is formed in cancer of the stomach. 
 
 The white corpuscles in cancer of the stomach may undergo 
 quantitative and qualitative alterations. The number of white 
 corpuscles is decreased by the subnutrition and by the low 
 vitality; and their number is increased by hemorrhage, by 
 hematocytolysis, by metastases, by peritonitis, and other 
 inflammatory complications, and by strong reaction of the 
 organism when it still possesses some power of resistance. 
 The number of white corpuscles is the result of the struggle 
 between these factors, and leukocytosis is present in more 
 than half of the cases. But cancer of the stomach, particu- 
 larly when it obstructs one of the orifices, and when it is not 
 accompanied by an inflammatory complication, may run its 
 entire course with a normal or diminished (terminal leuko- 
 penia) number of leukocytes. During the clinical stage of 
 carcinomaof the stomach digestive leukocytosis seldom occurs. 
 The insufficient blood-building organs do not respond to the 
 demands of digestion, absorption, and assimilation. The 
 number of white corpuscles three hours after a rich meal, in- 
 cluding proteids and fats, is not materially different from the 
 number of leukocytes counted before the meal. Myelocytes 
 are frequently found in the blood of cancer, and the leuko-
 
 538 DISEASES Of THE STOMACH. 
 
 cytes undergo degeneration in greater and greater numbers 
 as the blood alterations increase. The nucleus of the lympho- 
 cytes becomes poorer and poorer in chromatin as the cyto- 
 plasm disappears ; loses its form and structure ; enlarges 
 and finally undergoes dissolution. The polynuclear leuko- 
 cytes are affected by hyperchromatosic degeneration. As 
 many as ten per cent, of the leukocytes may be degenerated, 
 and these degenerate corpuscles go to pieces in the circula- 
 tion, appearing as formless protoplasmic masses in the fresh 
 and the stained preparations of the blood. 
 
 The alkalinity of the blood is diminished in carcinoma of 
 the stomach. This is doubtless due, in part, to the increased 
 destruction of body albumin, whereby sulphuric, phosphoric, 
 lactic, and oxybutyric acids are set free. I^ut the exces- 
 sive acid fermentation and the putrefaction of which the diges- 
 tive tube is the theater also exert a noteworthy influence. 
 
 The urine changes in carcinoma of the stomach are very 
 marked, but no one singly, nor all taken together, enable us 
 to infer the existence of the cancer. The normal digestive 
 curve of diminishing acidity, which reaches its highest point 
 between three and five hours after a meal, is seldom found in 
 cancer of the stomach, and this is plausibly explained by the 
 small quantity of hydrochloric acid secreted. The twenty- 
 four hours' urine may be constantly almost neutral, and this 
 may be due to the absorbed organic acids and ammonia pro- 
 duced by gastro-intestinal fermentation and putrefaction. On 
 the other hand, the acidity of the urine is often increased, and 
 uric acid precipitation is frequent. The reaction, though pre- 
 senting variations, is of no diagnostic value. 
 
 The uric acid elimination is sometimes largely increased, 
 as would naturally be expected, in leukocytosis, in active 
 destruction of body albumin, and in acid toxemia. The sec- 
 ondary insufficiency of the liver seems also to exert some 
 influence in causing uric acid precipitation. Almost con- 
 stantly, in cancer of the stomach, more nitrogenous matter 
 is eliminated than is introduced with the food. The excessive 
 nitrogenous elimination represents the excessive destruction 
 of body albumin ; but on account of the insufficiency of the 
 food the total elimination of nitrogenous matter is commonly 
 less than in health. When little food is digested and utilized 
 and the emaciation is advanced, the elimination of urea, and 
 also of the chlorids, falls very low. 
 
 The urine often contains urobilin, particularly when the 
 liver becomes secondarily involved or when the red cells 
 rapidly disintegrate. Indican is largely and almost con-
 
 THE NEOPLASMS OE THE STOMACH. 539 
 
 stantly increased. Albumoses may also be found in the 
 urine, particularly when the neoplasm undergoes rapid ulcera- 
 tion. Acetonuria is a frequent terminal sign, and the urine 
 may contain, particularly where there is coma, traces of oxy- 
 butyric acid. The urine signs demonstrate how severely 
 nutrition is affected, but possess, on account of not being 
 peculiar to cancer of the stomach, an exceedingly small 
 diagnostic value. 
 
 In the majority of the cases of cancer of the stomach the 
 bowels are constipated until the beginning of the last few 
 weeks, when diarrhea commences. Sometimes the stools 
 are frequent, and sometimes dysenteric; but more commonly 
 every one or two days there is a large, foul, and loose move- 
 ment. In about one-third of the cases constipation persists 
 from the beginning to the termination, an incomplete evacua- 
 tion of the bowels occurring every four or five days, and the 
 stool consisting of hard lumps of intestinal secretion, and 
 of a quantity of undigested muscular fibers. The constipa- 
 tion is most obstinate when the cardia is obstructed. In 
 pyloric cancer the course is broken by diarrheal attacks. 
 Unmixed lactic acid fermentation favors constipation. 
 
 The stools sometimes contain blood. Traces of blood are 
 frequently found, and melena is usual when the vomit con- 
 tains much blood or is colored like coffee grounds. 
 
 Carcinoma of the stomach is an afebrile disease. But fever 
 may occur during its course, and may be due to a compli- 
 cation, such as perigastritis, subphrenic abscess, peritonitis-, 
 pleurisy, pericarditis, or to a secondary cancerous deposit 
 which excites inflammation. Fever may also occur as a 
 symptom of an associated disease ; but febrile exacerbations 
 may sometimes be present without any discoverable cause 
 except the cancer itself or an ulceration of the neoplasm. The 
 fever peculiar to cancer is intermittent, beginning with a chill, 
 ending with free perspiration, and recurring irregularly, re- 
 sembling closely a malarial chill, and is most plausibly ex- 
 plained as an acute auto-intoxication. In the cachectic stage 
 the temperature is usually subnormal continuously, but it 
 may rise intermittently to the normal point, the pulse becom- 
 ing more rapid and the patient complaining of feeling hot. A 
 slight rise of temperature during the height of digestion' is 
 quite common. 
 
 Cancer of the stomach sometimes ends in coma, which 
 may be preceded by inanition delirium. The patient falls 
 into a stupor, the breathing becomes deep and stertorous, the 
 pulse rapid, the muscles sometimes twitch, or there may be
 
 540 DISEASES OF THE STOMACH. 
 
 general convulsions. The coma ends fatally in from one to 
 three da\-s. 
 
 Diagnosis — The diagnosis of carcinoma of the stomach 
 may be easy, difficult, or impossible. Consequently, the 
 physician may be certain, doubtful, or without suspicion of the 
 existence of a cancer in a particular case. Modern methods 
 of examination reveal the disease when formerly it would 
 have been overlooked. 
 
 From a diagnostic view-point the cases can be divided 
 into two large classes, accordingly as a tumor can or can not 
 be detected. 
 
 If a tumor be found, the examination should be so con- 
 ducted as to determine whether the tumor is gastric and 
 malignant, and where it is located on the stomach. When no 
 tumor can be detected, the diagnosis may have to be made 
 early in the disease, while radical surgical treatment is prac- 
 ticable ; or late, when palliation is the only aim. But it should 
 not be forgotten that a tumor so located as to be easily 
 accessible to physical examination maybe discovered early in 
 the disease. 
 
 A tumor of the stomach may be found in almost any part 
 of the abdomen to which the displaced or enlarged stomach 
 extends. Consequently, the search should not be limited to 
 the small area of the normal stomach, nor should those 
 tumors found within this area be supposed to belong neces- 
 sarily to this organ. Outside of this narrow field gastric 
 tumors are also found. It is often necessary to differentiate 
 the tumors of the stomach from possible tumors of other 
 abdominal organs, such as the liver, spleen, gall-bladder, 
 duodenum, colon, kidneys, mesentery ; and also to differentiate 
 them from abdominal abscess and from abdominal aneurysm. 
 
 Very valuable information is often furnished by the clinical 
 history. A malignant palpable tumor of the stomach invari- 
 ably produces gastric symptoms and signs. Carcinoma of 
 other organs may disturb their functions in a manner notice- 
 able by the patient. But the subjective symptoms should 
 simply draw the attention in a. particular direction, for they 
 may be due to secondary deposits, to complications, or to 
 associated non-malignant disease. The stomach is more likely 
 to be disturbed than is any other organ, being a center for 
 the expression of so many abdominal diseases. Conse- 
 quently, the total absence of gastric disorder is a very valu- 
 able negative sign. 
 
 The physical signs are often more direct and conclusive. 
 The tumor of the stomach can be seen or felt only in the re-
 
 THE NEOPLASMS OF THE STOMACH. 54I 
 
 gion occupied by the stomach in the particular case. Conse- 
 quently, the exact location of the stomach by percussion, by 
 inflation, by splashing, by filling the organ with water, by pal- 
 pation of the balloon sound, and by electric illumination may 
 be of great value. Not only is the tumor thus located within 
 or without the gastric area, but other valuable information 
 may be obtained. After inflation the tumor may be seen or 
 felt to belong to the stomach, and to be more clearly and 
 widely separated from surrounding organs. The tumor, which, 
 during inflation, was surrounded by a tympanitic area, may, 
 after filling the stomach with water, be surrounded by a duller 
 or flat zone, and be within the area of gastric splashing. The 
 tumor may present a dark spot on the illuminated stomach, a 
 phenomenon which is very interesting, but possesses very 
 little diagnostic value unless clearer and more conclusive 
 methods of examination are neglected. The tumor may be 
 revealed by inflation, or may thereby be made more perceptible, 
 or its position may be changed, or it may be palpable and 
 visible only when the stomach is empty. The tumors of the 
 colon and mesentery are simply pressed downward by inflation 
 of the stomach ; those of the left lobe of the liver are pressed 
 upward and forward ; and those of the spleen, downward, and 
 outward, and forward, against the abdominal wall. The tumors 
 of the greater curvature and the anterior wall are rolled and 
 pressed forward ; those of the lesser curvature disappear 
 upward and backward ; and those of the pylorus are pressed 
 downward and to the right, or to the right and upward, and 
 may be made inaccessible to palpation if the pyloric pouch is 
 much dilated. All these special signs should be noted and 
 taken in evidence when the conclusion is formed. 
 
 The tumors of the stomach also present peculiarities in 
 relation to the movements of the diaphragm during respiration. 
 The closer and more direct the connection of the tumor of 
 the stomach to the diaphragm, the greater and more constant 
 are its respiratory movements. It is easy to demonstrate by 
 the gliding method of palpation that even the greater curva- 
 ture of the stomach moves up and down with the relaxation 
 and contraction of the diaphragm ; and, consequently, the 
 contention that tumors located on this part of the stomach 
 are unchanged in their position by respiration is false. The 
 extent of their mobility is limited by the increase of intra- 
 abdominal pressure. The up-and-down movement is greatest 
 when the lateral expansibility of the abdomen is small, and 
 the intra-abdominal pressure in the part of the abdomen 
 inferior to the tumor is least. Wherever the abdominal
 
 542 DISEASES OF THE STOMACH. 
 
 tumor be located, its respiratory mobility will depend on 
 the solidity of the pressure exerted, directly or indirectly, by 
 the diaphragm ; on the freedom of the organ from restricting 
 ligaments and adhesions ; and on the degree of resistance 
 offered by the parts below the tumor. 
 
 It can easily be inferred that the tumors of the pancreas 
 and kidneys, if firmly and closely attached to these organs, 
 remain stationary during respiration; those of the liver and 
 spleen (except when these organs are displaced and their 
 attachments are weak) follow closely the movements of the 
 diaphragm ; and the tumors of the colon, mesentery, and 
 a large portion of the stomach are not necessarily so greatly 
 changed in their position by the act of respiration. 
 
 The relation of the movable tumors to expiration fur- 
 nishes another differential sign. If at the end of inspiration 
 the tumor be caught along its upper border by the exam- 
 ining fingers, it may or may not be capable of fixation during 
 expiration. The tumors of the liver and spleen, unless these 
 organs be pathologically movable, can not be thus fixed. In 
 order to arrest the expiratory movement of the tumors of 
 the lesser curvature and pylorus when their attachments are 
 not weakened, a good deal of force is required ; but the 
 tumors of the colon, greater curvature, and greater omentum 
 are more easily fixed, and when released slip up with little 
 force. These respiratory peculiarities of abdominal tumors 
 are converted by educated and experienced palpation into 
 valuable differential signs. 
 
 Another palpation sign is valuable in the diagnosis of the 
 tumors of the pylorus, which are often hard and solid to the 
 touch. If the tumor be held beneath the fingers, particularly 
 soon after a meal, gas can be felt bubbling intermittently 
 through it. An intermittent pyloric spurt may often be heard 
 with the stethoscope placed over the point. If the stomach 
 be empty, the signs are best sought after the administration 
 of a glass of water about the time that a meal is usually eaten, 
 for active gastric peristalsis recurs regularly and periodically 
 after each mealtime. When the bubbling is felt and the spurt 
 heard under these conditions, the solid tumor can be only 
 pyloric. The only possible source of error is an annular 
 tumor of the intestines, which, only in very special and rare 
 circumstances, can give rise to somewhat similar signs. 
 
 Percussion may also give some information. Percussion 
 over a tumor of the stomach which is not strictly limited to 
 one of the orifices is never dull if the organ contain gas. 
 Percussion over a solid tumor situated beneath or over a hoi-
 
 THE NEOPLASMS OE THE STOMACH. 543 
 
 low organ is tympanitic. The tumor may often be sur- 
 rounded and separated from adjacent organs by a zone of a 
 different percussion note. Tlie note over the surrounding 
 area may be changed by inflation of the stomach. Valuable 
 differential physical information may often be obtained by 
 inflating the colon with air or by filling it with water; or 
 more information may sometimes be ascertained by simul- 
 taneously filling the stomach with gas and the colon with 
 water; or by palpation of the introduced balloon sound 
 inflated to about the size of the fist. 
 
 The functions of the stomach are never normal when it is 
 the seat of a palpable new growth. Persistently excessive 
 secretion should excite suspicion of a gastric ulcer as the 
 cause of the tumor. A diminution of secretion may be pres- 
 ent in the course of malignant disease, wherever located, and 
 is hardly available as a differential sign. The bacteriological 
 signs may not only locate the tumor in the stomach, but 
 reveal its nature, as would also a piece of the tumor in the 
 vomit or washings. Pus in the contents, if it has not found 
 entrance through the cardia and is present in noteworthy 
 quantity, signifies that an abscess has opened into the stomach 
 or that there is ulceration and pus formation associated with 
 insignificant gastric digestion. Pus is seldom found, but 
 cancer cells are sometimes numerous, and both may aid in 
 connecting the tumor with the stomach. 
 
 Tumors of the stomach must be so often distinguished 
 from those of the liver and transverse colon that a special 
 grouping of the differential signs is desirable. The tumors of 
 the transverse colon produce intestinal stagnation above the 
 obstruction or at the part of the bowel where the muscular 
 coat is rendered inactive by the tumor. The hypertrophied 
 wall may show visible peristaltic waves, and the fingers or 
 the stethoscope placed upon the tumor may enable us to feel 
 or to hear the intestinal contents bubbling through it. The 
 tumors of the pylorus also present these signs, but in relation 
 with visible or palpable gastric peristalsis. The tumors of 
 the colon disturb the motor function of the bowel, but not 
 that of the stomach. By inflation of the colon the tumors 
 of the stomach are displaced upward, while those of the 
 colon do not rise, but may be revealed to a greater extent, 
 and their origin in the colon may be made clearer. By in- 
 flation of the stomach the tumors of the colon are pressed 
 downward, those of the lesser curvature of the stomach 
 disappear, the pyloric tumor goes downward and to the right
 
 544 D/SE.ISES OF rilE STOMACH. 
 
 or is concealetl b)^ the dilated pyloric pouch, and those 
 located on the anterior wall and greater curvature become 
 apparently larger and less sharply defined. It should never 
 be forgotten that the colon may lie between the stomach and 
 the anterior abdominal wall, and before locating a tumor in 
 this region the position of the bowel should be determined 
 by inflation. Tiie tumors of the colon can always be fi.xed 
 on expiration. 
 
 The tumors of the liver can not be fixed on expiration 
 unless the whole organ be prevented from rising, — which only 
 happens when its attachments are weakened, — and they are 
 pushed upward and forward by inflation of the stomach and 
 colon. The tumor of the liver, however, may be secondary. 
 Primary carcinoma of the liver, which is rare, produces rapid 
 and great enlargement of the organ, and icterus often appears 
 early. A tumor of the liver with round margins and a cen- 
 tral cupping is always a secondary cancer, and if the stomach 
 presents the functional and bacteriological signs of carci- 
 noma, this organ is the seat of the primary disease, although 
 no gastric tumor be felt. 
 
 A tumor of the gall-bladder is felt attached to the liver 
 at the normal position of this receptacle. It may often, when 
 the cystic duct is obstructed, be moved some distance to the 
 left, toward the median line, and follows closely the phreno- 
 hepatic respiratory movements. Tiiere is no motor disturb- 
 ance of the stomach unless the duodenum be compressed, 
 when bile may flow continuously into the stomach and gas- 
 tric obstructive retention may develop. The pjdoric tumor 
 may be readily differentiated by the pyloric bubbling, which 
 may be felt with the fingers or heard with the stethoscope. 
 
 A tumor of the stomach is either benign or malignant, and 
 it is of the utmost clinical importance that the two varieties 
 should be sharply differentiated. Fibroma, myoma, adenoma, 
 and gastroliths are very rare. More frequent is a palpable 
 resistant mass formed by the whole stomach or by an inflam- 
 matory exudate. 
 
 The benign neoplasms produce no metastases, are slow in 
 their development, produce often but slight functional dis- 
 turbance, and, except when obstructing an orifice, cause no 
 progressive emaciation and cachexia, develop often at an 
 early age, and are neither nodulated nor hard. 
 
 The gastric tumor may be formed of the whole organ. 
 The tumor formed by the distended stomach disappears when 
 tile organ is emptied. In only three diseases is the tumor
 
 THE NEOPLASMS OF THE STOMACH. 545 
 
 formed by the wall of the stomach — in chronic interstitial 
 or fibrous gastritis, in disseminated scirrhus, and in the small 
 retracted stomach of obstruction of the cardia. Between 
 the benign and malignant affections the clinical history and 
 the evolution often discriminate. Disseminated hard cancer 
 may run a slow course, however, and metastases and enlarged 
 glands often can not be detected. Obstruction of the cardia 
 should excite suspicion of the small retracted stomach which 
 does not lose its peristaltic power. In scirrhus and in cir- 
 rhosis ventriculi the stomach is an almost inert tube. Conse- 
 quently, pyloric bubbling and visible or palpable peristalsis, 
 however excited, decide against hard cancerous infiltration. 
 
 An inflammatory palpable exudate is nearly always the 
 result of gastric ulcer. An ulcer history would decide the 
 nature of the tumor were not cancer sometimes engrafted in 
 an ulcer. The differentiation can not be made unless a sec- 
 ondary cancer deposit be found. Excessive or normal secre- 
 tion, blood crises, digestive leukocytosis, simple inanition 
 without excessive destruction of body albumin, are against 
 the ulcer having become cancerous, which, it should also be 
 remembered, occurs only in a very small percentage of the 
 cases of ulcer. 
 
 The tumor is more likely to be cancerous the more closely 
 the evolution, symptoms, and signs are those of a malignant 
 disease. An unaccountable and insidious beginning in a 
 person beyond the thirtieth year who has previously enjoyed 
 good digestion, progressive evolution, increasing diminution 
 of secretion, motor insufficiency, lactic acid fermentation pro- 
 duced by bacilli, emaciation, and loss of strength, excessive 
 waste of body albumin, the inefficiency of treatment — all 
 favor cancer. 
 
 The difficulty of determining the nature of the tumor is 
 greater when the pylorus is involved. Is the obstruction due 
 to ulcer, to cancer, or to benign muscular hypertrophy? If 
 the tumor extends on to the body of the stomach, it is more 
 likely to be cancer, and is most probably so if the bacterio- 
 logical signs of cancer be present. If the tumor forms and the 
 obstruction develops in the course of ulcer, the tumor is most 
 likel}^ benign, and is most certainly so if there are no functional, 
 bacteriological, or malignant nutritive signs present. 
 
 Annular scirrhus and hypertrophy of the pylorus are so 
 closely alike as to leave nearly always a large place for doubt. 
 If the patient has been long under observation, the slow 
 growth of the smooth hard tumor and the long duration of 
 the trouble speak in favor of hypertrophy. Nutrition may 
 35
 
 546 DISEASES OF 7 HE STOMACH. 
 
 be improved materially by a proper diet and b\' nutrient 
 enemata. But if the characteristic functional and bacterio- 
 logical signs of cancer are not present, the trouble is most 
 probably not malignant. Metastasis, nodulation, and enlarg- 
 ment of the glands close to the pylorus may characterize the 
 annular cancer of the pylorus. The infiltrated, cancerous 
 pyloric ring does not contract or relax perceptibly, as does 
 often the benign hypertrophied pylorus. In both diseases 
 pyloric bubbling may be felt, and the pyloric spurt may be 
 heard, unless the orifice be completely obstructed. 
 
 If no tumor can be detected, one of the most valuable signs 
 of cancer of the stomach is wanting. This may happen at 
 any stage of the disease. The case may be presented for 
 diagnosis before or after the development of emaciation and 
 cachexia. 
 
 The diagnosis of carcinoma of the stomach when no 
 tumor can be discovered, and before nutrition is so reduced as 
 to suggest a serious and perhaps malignant disease, is a mere 
 question of probabilities. But there are certain early signs 
 which should not only excite suspicion, but should cause at 
 least a careful search and a guarded opinion. And here, 
 above all, must be considered the age of the patient, the 
 absence of sufficient cause, and the previous good digestion of 
 an ordinary mi.xed diet. If a person whose other organs are 
 healthy, who is between forty and sixty years of age, who is 
 guilty of no dietetic errors or excesses, without ascrib- 
 able cause loses his appetite, feels a sense of heaviness 
 or discomfort in his stomach, at first during digestion, and 
 later when the organ should be empty and at rest, loses 
 weight and strength in spite of good digestive hygiene and 
 sufficient food — a suspicion of carcinoma is justifiable, and the 
 combination of symptoms and circumstances should lead to a 
 careful search for otlier signs. The form which the emacia- 
 tion takes should be observed, and the excessive waste of 
 the nitrogenous tissues (particularly both the voluntary and 
 involuntary muscles), while the body still retains a good deal 
 of its fat, should be carefully noted. The blood changes 
 should also be recorded from time to time, and the number 
 of white cells should be counted before and about three 
 hours after a mixed meal. The secretory and motor func- 
 tions should be carefully tested, and the quantity and char- 
 acter of the germs noted. If the functional, bacteriological, 
 hemic, and nutritive signs become more and more like those 
 of carcinoma, and in spite of rational treatment and a suffi-
 
 THE NEOPLASMS OF THE STOMACH. 547 
 
 cient diet, and if the clinical picture remains ill-defined and 
 characteristic of no other disease, the suspicion is probably- 
 well founded. The early diagnosis of cancer can some- 
 times be made with a good deal of probability by close 
 observation and study of the case during two or three weeks. 
 The evolution of the symptoms and signs in a particular 
 manner is somewhat characteristic, and in this respect a single 
 examination gives little information. The functional and 
 bacteriological signs develop more rapidly in some cancers 
 than in others. The absence of free hydrochloric acid, the 
 diminution of the ferments, the formation of lactic acid in 
 noteworthy quantity (i : 1000) in the thoroughly washed 
 stomach after a test-meal containing no lactic acid, motor 
 insufficiency, and the presence of lactic-acid-forming bacilli in 
 large numbers — may in themselves, but better in combination 
 with other secondary or confirmatory signs, establish the 
 diagnosis. 
 
 The diagnosis of carcinoma in the absence of a palpable 
 tumor, but after the development of the emaciation and 
 cachexia, can often be made if the functional, bacteriological, 
 hemic, and nutritive signs be taken in connection with the 
 mode of beginning, with the evolution, and with the sub- 
 jective symptoms. These signs and symptoms need not 
 here be repeated, but great emphasis may be laid on their 
 value when combined, and on their lack of meaning when 
 taken singly and without regard to their order of develop- 
 ment and progressive evolution. Naturally, the anatomical 
 signs, if obtained, have the same value as when the tumor 
 can be detected. 
 
 The location of the tumor is important both from a medi- 
 cal and a surgical point of view. 
 
 The tumors of the pylorus are sometimes very movable, 
 sometimes disappear, and may be again found on reexam- 
 ination. On inflation of the stomach they move downward 
 and to the right, or are concealed by the distended pyloric 
 antrum. The most usual site of the tumor is on or to the 
 right of the median line, beneath the loWer border of the left 
 lobe of the liver. It is hard and often annular, and gas can 
 be felt bubbling through it intermittently. Pyloric cancer 
 produces obstructive retention, enlargement of the stomach, 
 and often visible, palpable, and active peristalsis. 
 
 Cancer of the cardia is revealed by the symptoms and the 
 signs of obstruction obtained by the use of the sound. The 
 stomach retracts and is constantly very small.
 
 548 DISEASES OF THE STOMACH. 
 
 Tlie tumors of tlie body of the stomach may be located by 
 the pliysical signs when on tlie accessible parts of the greater 
 curvature, anterior wall, and lesser curvature. A tumor of 
 the posterior wall may sometimes be felt when the stomach 
 is empty and the patient is in the knee-elbow posture ; but it 
 disappears when the stomach is inflated, and the anterior wall 
 will be found free. A tumor of the pancreas should not be 
 mistaken for a cancer of the posterior wall ; the signs have 
 already been given by which it can be determined that the 
 tumor is gastric and malignant. When the tumor is located 
 on the body of the stomach and the pylorus is left free, the 
 weight and strength are longer maintained and treatment is 
 of more avail. 
 
 Differential Diagnosis. — It often happens that when the 
 patient presents himself for examination no tumor can be 
 detected, and no other sign or symptom is present which 
 definitely localizes the disease in the stomach. Consequently, 
 when emaciation is present, carcinoma of the stomach may be 
 easily confounded with Addison's disease, pernicious anemia, 
 forms of tuberculosis, chronic malarial poisoning, certain 
 dynamic affections of the stomach, di.splacements of the stom- 
 ach, non-malignant obstruction of the cardia and pylorus, gas- 
 tric ulcer, and chronic gastritis. ( For the differential diagnosis 
 between cancer of the stomach and ulcer, anorexia nervosa, 
 nervous vomiting, myasthenia, displacements of the stomach, 
 and non-malignant obstruction of the cardia and pylorus see 
 the articles on these diseases.) There remains for considera- 
 tion here the constitutional cachectic diseases and chronic 
 asthenic gastritis. 
 
 Addison's disease is manifested by the bronzed skin, ex- 
 treme weakness of the muscular system, disturbances of the 
 stomach, and a form of emaciation in which the body fat may 
 be partly conserved, as in cancer. Certain forms of tuber- 
 culosis run a slow progressive course without recognizable 
 local deposits. Tuberculosis is also common in cancer of the 
 stomach. Chronic malarial poisoning may develop without 
 chills, and lead in a number of months to pronounced emacia- 
 tion and cachexia. Other particular cases of chronic disease 
 develop without very definite symptoms, and may resemble 
 closely the atypical cases of cancer, which are not few in 
 number. The differentiation can be made only by very care- 
 ful search for distinctive signs and by counting the probabili- 
 ties. In obscure cases of suspected tuberculosis local deposits 
 of the disease should be sought in every part of the body. 
 Sometimes the only detectable local lesion is tubercle of the
 
 THE NEOPLASMS OF THE STOMACH. 549 
 
 choroid or a laryngeal or nasal ulcer. The tubercle bacil- 
 lus should be sought for in the urine when not found in the 
 sputum. The absence of reaction after the use of Koch's 
 tuberculin is decisive. In malarial cachexia the spleen is 
 large and the crescent plasmodium is likely to be present in 
 the blood, and the proper study of the blood would also detect 
 a grave anemia. The other set of differential signs are those 
 which are usually present and more or less characteristic of 
 cancer. Here must be taken into consideration all the sub- 
 jective and objective signs enumerated in the description of 
 cancer of the stomach, particularly the functional, bacterio- 
 logical, and anatomical signs. The weighing of all the evi- 
 dence accumulated by careful study may, in particular cases, 
 leave room for doubt, for any of these diseases may coexist 
 with cancer of the stomach. 
 
 Cancer of the stomach without a palpable tumor may be 
 confounded with chronic gastritis, particularly when the latter 
 is accompanied by emaciation. 
 
 There are many features which differentiate cancer of the 
 stomach from the asthenic form of chronic gastritis, except in 
 the very early stage of cancer, when the two diseases may be so 
 nearly alike as to leave little opportunity for a plausible guess. 
 Cancer begins after thirty, often in persons with good and 
 unconscious digestion, suddenly and without palpable cause. 
 Gastritis begins after an acute attack due to some dietetic or 
 drinking fault, or slowly and irregularly in a stomach which 
 has often shown its weakness, or secondarily to a disease of 
 some other organ. The subjective symptoms of gastritis, ex- 
 cept the morning nausea and vomiting of mucus, are diges- 
 tive. Those of cancer may be worse during digestion, but 
 are often present day and night. The digestive symptoms of 
 gastritis are much worse after solid than after liquid food, and 
 a carefully selected meal may often be digested without dis- 
 comfort. In cancer the heaviness and fullness recur regu- 
 larly, and after all sorts of food. The appetite in cancer 
 diminishes, is lost, never recovered, and often ends in disgust 
 for meats and fats. In chronic asthenic gastritis the appetite 
 is irregular, sometimes good, sometimes bad, and often there 
 is a desire for spicy or sour articles. Vomiting is rare in 
 chronic asthenic gastritis, and when present usually consists 
 not of food, but of a little mucus, which may be stained with 
 fresh blood. In cancer vomiting is much more frequent, 
 alimentary, smelling of organic acids, and colored like coffee 
 grounds with blood which has been long in the stomach. 
 In chronic asthenic gastritis the hemorrhage is an accident
 
 550 DISEASES OF THE STOMACH. 
 
 of sounding or of retching ; in cancer it is often slow, not 
 due to traumatism, and is sometimes profuse. Chronic 
 asthenic gastritis is a painless disease, except sometimes in its 
 atrophic stage. Cancer may be painful during the period 
 when the stomach is functionally active, and also when it 
 should be resting. The one develops slowly, with remissions 
 and subjective intermissions, without a tumor, without 
 cachexia, and without hemorrhages ; the other progresses 
 rapidly and continuously, with only short intervals of im- 
 provement obtainable by treatment. Chronic asthenic gas- 
 tritis extends through years without producing cachexia ; 
 cancer is rapid and progressive in its evolution. Secretion 
 diminishes in both, but free hydrochloric acid may reappear 
 in chronic gastritis. The motor function is long perfectly 
 maintained in chronic asthenic gastritis; in cancer stagnation 
 occurs, as a rule, early, and gastric retention may not be long 
 postponed, even when the neoplasm is situated on the body 
 of the organ. Fermentation is an accident in chronic as- 
 thenic gastritis ; it occurs very frequently, and often early, in 
 cancer, is chiefly lactic, and accompained by a characteristic 
 bacillary growth. In chronic asthenic gastritis the stomach 
 is empty in the early morning before breakfast, or contains 
 only a little fluid, which is rich in mucus and chlorids, and 
 is about neutral in reaction. In cancer the stomach often 
 contains residual fluid in the morning, which may be richer 
 in combined HCl than the filtrate of the test-meal contents ; 
 or which may possess a high acidity due to lactic acid, or 
 which may be colored dark brown by blood. The anatomi- 
 cal signs may reveal the presence of the neoplasm, but a piece 
 of the mucous membrane in the washings showing only gas- 
 tritis would not exclude cancer. 
 
 Chronic hypersthenic gastritis is readily distinguished by 
 its irregular, stormy, and intermittent beginning, by the evo- 
 lution of the digestive symptoms in relation to secretion and 
 to the quality of the food, and by the invariable presence of 
 free HCl after a test-breakfast. The two diseases, in their 
 subjective and objective signs, bear little resemblance, unless, 
 as very seldom happens, the neoplasm is engrafted in an old 
 ulcer. The presence of a tumor is against gastritis, unless the 
 gastritis be accompanied by an ulcer. If the clinical history, 
 duration, and evolution do not differentiate them, the diagno- 
 sis is left in doubt, but with an exceedingly strong presumption 
 against carcinoma. If ulcer can be excluded, carcinoma goes 
 with it. Simple ulcer and chronic hypersthenic gastritis may
 
 THE NEOPLASMS OF THE STOMACH. 55 I 
 
 become complicated by engrafted cancer, which converts 
 them into mahgnant and progressive diseases. 
 
 Prognosis. — Cancer of the stomach is invariably a fatal dis- 
 ease. Life may be made more comfortable and slightly pro- 
 longed by careful management. Early and radical operation 
 may give the patient a few months, or, possibly, one, two, or 
 even five years. The healing art can afford only a little more 
 comfort than unaided nature would give the hopeless patient. 
 
 Treatment. — The treatment of carcinoma of the stomach 
 is medical and surgical. The medical treatment is only pallia- 
 tive, but the surgical treatment may be employed not only 
 with a view to give temporary relief and to prolong life, but 
 also, in the early stage, with a barely possible hope of a per- 
 manent cure. 
 
 The medical treatment is hygienic, symptomatic, and pro- 
 tective. Every means should be employed to preserve the 
 strength and weight and to diminish the excessive nitroge- 
 nous waste. Physical and mental rest are imperative, for the 
 organism has little power for repairing its losses. Attention 
 should be given to the skin and to the nervous system, with 
 a view to maintaining their functions and vigor by hydro- 
 therapy, pure air, sunshine, and pleasant surroundings. 
 Digestive hygiene is also useful, and is briefly comprised in 
 bodily rest before and after meals, in favoring the stomach, 
 and in protection of the intestines. 
 
 It may well be doubted that any drug arrests or influences 
 beneficially the growth of the neoplasm, as has been claimed 
 for condurango, chlorate of soda (Brissaud), sulphate of 
 anilin (Fay), and pyoktanin (Maibaum). Condurango is an 
 excellent bitter which may often be employed with advan- 
 tage, and methylene-blue in some cases seems to be of value. 
 The methylene-blue (Merck) should be given in a capsule of 
 three to five grains daily, and a little powdered nutmeg 
 should be combined with it to correct its slightly irritant 
 action on the urinary tract. Marcus Fay claims that anilin 
 sulphate delays metastasis and cachexia, and relieves the 
 pain better than opium. Given internally, in one to five 
 grains a day, its absorption lasts about two hours, when the 
 nails and lips become blue, and after several days' adminis- 
 tration the urine becomes reddish. In full doses it produces 
 vertigo, shivering, dyspnea, fainting, and tonic contraction of 
 the involuntary muscles. None of these drugs, it must be 
 confessed, is of much value, except condurango as a bitter 
 and methylene-blue, or phenacetin, or codein, or opium and 
 belladonna to relieve the pain.
 
 552 DISEASES OF THE STOMACH. 
 
 But the medical treatment does not consist in the vain 
 search for some specific, nor in efforts to arouse the 
 depressed functions of the stomach. The treatment of the 
 stomacli should be protective and not excitant, irritation of 
 all kinds only doing harm. But the maintenance of the 
 appetite and of the motor function is well worthy of attention, 
 and may be best accomplished by a combination of the 
 infusion of condurango bark and hydrochloric acid with 
 strychnin. The prescription should be ordered half an hour 
 before meals, and is most valuable when lactic acid fermen- 
 tation is present. Hydrochloric acid (but it sometimes is not 
 well borne) may be ordered in repeated doses during the 
 period of gastric digestion. 
 
 Pain is often distressing, and demands relief When the pain 
 is severe, there should be no hesitation in giving codein or 
 morphin, hypodermically or by the mouth, after milder anal- 
 gesics have failed. There is nothing to fear from a possible 
 opium habit when the patient is already the victim of a malig- 
 nant disease. Vomiting may require the usual efforts to con- 
 trol it. No one procedure does more good than lavage. A 
 wet compress, covered with a rubber coil, through which hot 
 water flows, the application being made half an hour before 
 the meal and kept on during the period of digestion, may be 
 beneficial. 
 
 To control fermentation and to remove the products of re- 
 tention, lavage acts better than any other remedy, but it 
 should be employed, when the disease is advanced or when 
 there is hemorrhage, with the greatest care or not at all. 
 This is particularly true when the neoplasm involves the body 
 of the stomach. But in cancer of the pylorus and in infiltrating 
 scirrhus it may be used without danger, but not more than a 
 pint of water should be allowed to flow in before beginning to 
 withdraw it ; the danger of perforating the degenerate wall by 
 overdistention is thus avoided. The lavage should be per- 
 formed thoroughly in the morning, an hour before breakfast, 
 and the hydrochloric acid tonic should be administered a 
 half hour later. 
 
 The diet should be regulated so as to favor the stomach, to 
 protect the intestines, and to maintain nutrition as long as 
 possible. An exclusive or reducing diet in this disease is 
 radically wrong, and the food selected should not excite or 
 irritate the stomach, remain long in it, easily ferment, or be 
 indigestible by the intestines. Milk seldom agrees well, 
 except in the early stage of some cases where stagnation and 
 fermentation are slight. In the stage of gastric retention it
 
 THE NEOPLASMS OF THE STOMACH. 553 
 
 only adds fuel to the flame. Consequently, finely-divided 
 tender meats, lean fresh fish, and white of egg must usually be 
 depended upon to furnish the nitrogenous needs of the body, 
 but should not be given in excess with the vain hope of cov- 
 ering the excessive nitrogenous waste. Fat, in the form of 
 fresh butter or a good emulsion of cod-liver oil, is valuable and 
 digestible in moderate quantity. Meat juice and clear vege- 
 table soups maybe prescribed in order to furnish the requisite 
 quantity of salts. Meat jellies often agree well and supplant 
 the sweets, which must be excluded. Very thoroughly 
 cooked whole wheat, with all the bran removed, and purees of 
 vegetables digestible by the intestines usually agree well when 
 the stomach is kept clean by lavage and the hydrochloric acid 
 tonic is given. Supplementary rectal feeding should be em- 
 ployed early, and not held back as a last resort, when it is too 
 late to be of much value. Alone, it exerts little influence on 
 the progressive inanition of carcinoma. 
 
 The surgical treatment is palliative and prolongs life. In 
 cancer of the cardia gastrostomy should be performed as soon 
 as the patient is no longer able to swallow enough food to 
 nourish the body. An attempt to dilate the obstructed cardia 
 by means of esophageal sounds or dilators is more likely to 
 be injurious than beneficial, on account of the swelling and in- 
 flammation excited and the danger of perforation. Little 
 can be said in favor of the esophageal cannula. Where reten- 
 tion occurs above the obstruction, the constant irritation causes 
 the neoplasm to grow more rapidly, and gastrostomy might be 
 performed early in order to avoid this effect. But, as a rule, 
 gastrostomy should not be performed while the body can be 
 nourished by combined oral and rectal feeding. 
 
 The most frequent operation for cancer of the body of the 
 stomach and of the pylorus is gastro-enterostomy. This is 
 only a palliative operation, which improves the motor function 
 without perceptibly increasing secretion. The operation is 
 often followed by a remarkable improvement in nutrition, 
 and by the subsidence of the inflammatory swelling around 
 the neoplasm. It is the best palliative operation, and should 
 be performed when retention renders it no longer possible to 
 sufficiently nourish the suffering patient. 
 
 Pylorectomy is an effort to produce a radical cure, but thus 
 far it has failed. It is the preferable operation when the neo- 
 plasm is pyloric, without adhesions, enlarged glands, or 
 metastasis, and when the operation can be done in sound 
 tissue wide of the zone of extension. In suitable cases a
 
 554 DISEASES OE T//E STOMACH. 
 
 respite is obtained until tlie tumor recurs, and gastro-enter- 
 ostoniy may be done after the recurrence, to prolong life. 
 
 The mortality of pylorectomy for cancer varies from 55 
 to 27 per cent. Wlicn adhesions and complications exist, 
 the mortality is much higher (60 per cent.) than in properly 
 operable cases (25 per cent.). The reports of Billroth's clinic 
 from 1 880 to 1 894 (Hacker) give 19 deaths in 42 operations; but 
 only 4 of the last 16 cases died. The mortality of pylorectomy 
 done by e.xperienced surgeons does not differ materially from 
 that of gastro-enterostomy. The latter operation appears to 
 give greater immediate relief; and, with very few e.xceptions, 
 the patients have lived as long after it as after pylorectomy. 
 Kocher, Czerny, and Ratimmow report cases in good health 
 from four to eight years after pylorectomy. No radical cure 
 has been obtained in Billroth's clinic, although one patient 
 lived more than five years. 
 
 CHAPTER IV. 
 THE DISPLACEMENTS OF THE STOMACH. 
 
 Transposition of the stomach is a very rare condition, and 
 one which can easily be discovered on physical examination. 
 The fundus is transposed to the right, and the pylorus lies in 
 the left hypochondrium. The other parts of the digestive 
 tube and its accessory glands are correspondingly changed 
 in position. This is an anomaly of development, not a dis- 
 ease, and requires no further mention. 
 
 The pathological displacements of the stomach, particularly 
 frequent in women, are very numerous in their anatomical 
 details. But all of them are deviations from the three grand 
 clinical types — upward displacement, lateral displacement, and 
 total descent. 
 
 The abdominal cavity, formed in part by pliable walls, is 
 subject to the action of atmospheric and other external pres- 
 sure, and the organs and viscera contained within it readily 
 change their form. The stomach is attached by ligaments to 
 the liver, spleen, diaphragm, and transverse colon, and is con- 
 tinuous with the esophagus and duodenum. Consequently, 
 the displacements of the stomach are accompanied by changes 
 in the form of the abdomen and in the form and relative posi- 
 tion of neighboring organs. Its attachments, also, are ren-
 
 THE DISPLACEMENTS OF THE STOMACH. 555 
 
 dered lax or are stretched, tnus causing displacements of at- 
 tached organs and disordering the blood- and lymph-circula- 
 tion. These results often interfere with the nutrition of its 
 coats and with its functions. The interference with nutrition 
 by compression and by traction maybe localized and circum- 
 scribed, and a strong predisposition to ulcer may thus be 
 created. The new relations produce new points of contact 
 and new directions of least resistance, and consequently the 
 viscus is liable to undergo particular changes in form. The 
 churning and evacuation of its contents must be done in un- 
 usual and unfavorable circumstances. The evacuation of the 
 stomach may be specially difficult on account of the traction 
 brought to bear on the beginning of the duodenum and the 
 pyloric region, and on account of the constriction of the duo- 
 denum at its first point of firm attachment. The necessity 
 for increased work at a mechanical disadvantage entails either 
 compensatory hypertrophy of the muscular layer or motor 
 insufficiency. The clinical forms of displacement are three in 
 number — upward, lateral, and downward. 
 
 I. Upward Displacement — The upward displacement of 
 the stomach can occur only in the left concavity of the 
 diaphragm. The part of the stomach to the right of the 
 cardia can not be displaced upward, for the organs above it 
 are solid and fixed. The upward displacement of the stom- 
 ach is less frequent than the other forms of displacement, 
 but it occurs much more frequently than is generally 
 recognized. 
 
 Etiology. — The fundus of the stomach may be situated 
 abnormally high when the left lung is collapsed (atelectasis, 
 sequel of left pleurisy), or the stomach may be forced 
 upward by a large abdominal tumor. But the most frequent 
 cause of this form of displacement is compression and 
 arrested development of the trunk on a line which runs 
 across the abdomen near the umbilicus and below the liver, 
 the splenic flexure of the colon, and the spleen. The costal 
 arch is slightly narrowed, and the lower four or five ribs are 
 forced far inward, so as to make the smallest part of the 
 waist nearly on a line with the iliac crests. 
 
 Clinical Description. — Upward displacement of the stomach 
 may be a latent disease, or, at least, only insignificant sub- 
 jective symptoms may result from it ; but in some cases the 
 distress occurs in paroxysms, and in others the disturbances 
 are persistent. The symptoms vary greatly, and bear a 
 relation to the manner in which the displacement has been 
 produced. There may be only a slight sense of fullness in the
 
 55^ DISEASES OF THE STOMACH. 
 
 left hypochondrium after meals, or great difficulty may be 
 experienced in vomiting, in belching, or in eructation, the 
 cardia being drawn upward and to the left and the esophagus 
 being obstructed at its point of passage through the 
 diaphragm so as to prevent the exit of the contents of the 
 stomach. The upward displacement of the fundus and its 
 distention with gas may produce shortness of breath, 
 palpitations, arrhythmia, left intercostal neuralgia, and pre- 
 cordial pain. These symptoms may occur in paroxysms 
 after eating and after exertion during the digestive period, 
 but are most frequent in the evening after the chief meal of 
 the day. When the displacement results from the creation of 
 the long and low waist, the same gastric symptoms may be 
 present, but to these are added symptoms due to the dis- 
 placement and to compression of the colon ; the transverse 
 colon is shortened and falls into a V-shape, the splenic 
 flexure is made more acute, the hepatic flexure is prolapsed 
 or forced inward, and the colon is compressed against the 
 spinal column and by the tips and borders of the ribs. 
 There results from this compression and deformity a series of 
 troubles — constipation, stagnation, ulceration, pseudomem- 
 branous formation, points of peritonitis, together with all 
 their local and general effects. 
 
 Objective Signs. — In upward displacement of the stomach 
 there may be but little alteration of the position of the greater 
 curvature; but, as a rule, only the pyloric end of the stomach 
 lies in the epigastrium, the pylorus being displaced trans- 
 versely to the left, and the greater curvature lying so high as 
 to create the impression that the stomach is abnormally small. 
 Gastric tapping-splashing can not be elicited for the reason 
 that so little of the stomach lies in the epigastrium. On per- 
 cussion, the superior border of the fundus is abnormally high, 
 and, usually, abnormally broad; and these abnormalities exist 
 when the stomach is only moderately distended with air or 
 gas. It is often possible to produce succussion splashing, and 
 the location of the sound will roughly reveal the situation 
 of the stomach, which may be determined with precision by 
 percussion after inflation and after filling the stomach with 
 water, and by electric illumination. The heart is sometimes 
 displaced to the right by the distended fundus. 
 
 Treatment. — The treatment comprises the removal of the 
 cause so far as possible; the prevention of the accumulation 
 of a large quantity of gas in the stomach ; the avoidance of 
 heavy meals ; and rest, with the clothing loosened, during the 
 period of digestion. The alkaline carbonates and effervescing
 
 THE DISPLACEMENTS OF THE STOMACH. 557 
 
 drinks do harm, and the diet and medication should be so 
 ordered as to obtain rapid evacuation of the stomach and to 
 prevent spasm of the pylorus. The severe respiratory and 
 cardiac paroxysms are relieved, as if by magic, by the with- 
 drawal of the gas from the stomach by means of the stomach- 
 tube. Antispasmodics and carminatives are far more valuable 
 than stimulants and anodynes. Digitalis, strophanthus, and 
 similar heart stimulants increase the palpitation and the 
 arrhythmia. The increase of abdominal tension should be 
 avoided, and intestinal flatulency should be controlled. 
 
 2. Vertical or Lateral Displacement. — In vertical displace- 
 ment of the stomach the position of the cardia and of the 
 line marking the superior border remains as in health. The 
 part of the stomach in the left concavity of the diaphragm, 
 and above a plane cutting across the body on a level with the 
 cardiac orifice, is unchanged in its form and position. The 
 changes characteristic of vertical displacement occur below 
 this line. The greater curvature is displaced downward to the 
 left, cutting the costal border near the tip of the tenth car- 
 tilage. The lesser curvature becomes straighter or is bent 
 near its middle into almost a right angle, accordingly as the 
 pylorus is more or less displaced. The anterior and posterior 
 surfaces of the stomach face more directly forward and back- 
 ward. The axis of the pyloric end runs transversely, or 
 downward toward the right iliac fossa, or more directly 
 upward, the variation corresponding with the particular form 
 which the stomach takes. The greater part of the grand axis 
 of the stomach is almost vertical. The relations of the stomach 
 are changed and its form is greatly modified, particularly the 
 transverse diameter. Such are the general characters of ver- 
 tical displacement. The special anatomical forms will be 
 more minutely described in the paragraphs on the pathological 
 anatomy, and should be carefully studied, with a view to facili- 
 tating the solution of many of the puzzles of difTerential 
 diagnosis. 
 
 Etiology. — Vertical displacement of the stomach is rare in 
 men but quite frequent in women, who seem compelled by 
 fashion to deform their waists in slavery to a false conception 
 of the beautiful. The disease may be a legacy of infancy or 
 of fetal life, the stomach remaining in the position in which 
 it was held by the relatively and excessively large liver of this 
 period. The stomach may also be vertically displaced by en- 
 largement and tumors of the liver, and by other tumors and 
 by pus collections to the right of the lesser curvature ; but 
 by far the most common cause is the corset. In the verti-
 
 558 DISEASES OF THE STOMACH. 
 
 cal displacement produced by the corset the line of greatest 
 compression runs across the liver, the first portion of the duo- 
 denum, the pylorus, and the spleen. The costal arch is very 
 narrow, but the base of the arch may be broad and the costal 
 borders curved outward and forward. The surface of the 
 liver is grooved by the ribs, and the gland is compressed from 
 side to side and elongated downward. The pylorus is 
 obstructed by the compression, as are likewise the duodenum 
 and the cystic and common ducts. The pyloric end of the 
 stomach dilates downward below the constriction, and the 
 stomach may be made bilocular, the area of constriction pass- 
 ing between the spleen, the depressed ribs, the left lobe of the 
 liver, and the vertebral column. 
 
 Genesis and Pathological Anatomy. — The principal parts in 
 the development of vertical displacement of the stomach are 
 played by the left lobe of the liver and by the constriction of 
 the waist in a particular manner. The compression of a tight 
 corset worn during the period of puberty arrests the develop- 
 ment of the constricted part of the body. All the diameters 
 of the abdominal cavit\' throughout the compressed region are 
 shortened and their increase during the period of develop- 
 ment is prevented. The compression of the corset, however, 
 differs from that of a cord or a narrow band, and extends 
 from near the cartilages of the eighth ribs to within a short 
 distance of the breasts. The costal arch is narrowed, ex- 
 cept near the base, where the costal border curves rapidly 
 outward and forward. The results of the cylindrical com- 
 pression are displacement and deformity of the organs 
 brought within its influence. As there can be no lateral 
 expansion, the respiratory movements of the organs of the 
 abdomen are directly up and down. The solid organs, such 
 as the liver, push what is movable before them, and the de- 
 forming pressure of the liver and the distention of the gastric 
 wall occur downward, in the direction of least resistance. 
 The fundus of the stomach is above the area of compression ; 
 but lower down, the costal wall, the spleen, the liver, and the 
 stomach bear the brunt of the pressure. It is here nearly 
 on a level with the ensiform process that the waist is smallest, 
 and the liver is often marked by a furrow running across its 
 anterior surface. The stomach yields its place to the solid 
 liver, there being only sufficient room (provided the corset 
 has been put on early in life and worn tight) between the 
 anterior abdominal wall and the vertebral column for the left 
 lobe of the liver and the pancreas. The lesser curvature of 
 the stomach, which is compressed between the li\'er, the
 
 THE DISPLACEMENTS OF THE STOMACH. 559 
 
 spleen, and the ribs, is forced to the left and downward, and 
 runs along the border of the left lobe. If the spleen and 
 liver be enlarged, the compressed part of the stomach may be 
 reduced to the size of the small intestine. Nearly the whole 
 of the deformed stomach thus lies vertically displaced to the 
 left of the left parasternal line, and it may be bilocular. 
 
 There are three typical anatomical forms of vertical dis- 
 placement of the stomach — the angular, the fish-hook, and 
 the straight. 
 
 The angular fonn is quite common, and is the result chiefly 
 of the form and size of the left lobe of the liver. The lesser 
 curvature, and with it the body of the stomach, are displaced 
 outward to the left and into the left hypochondrium. The 
 pylorus is about on a level with the junction of the middle and 
 lower thirds of the line joining the umbilicus and the xiphoid 
 process, either on the median line or about an inch to the left 
 of it. The pyloric end, forming one side of the angle, runs 
 transversely across the abdomen and close along the lower 
 border of the left lobe of the liver, by which it is not cov- 
 ered. The pancreas may form the limiting and fixing upper 
 wall, the left lobe being a little higher up, with its lower border 
 curved backward on a transverse axis. At the point where 
 the stomach passes beneath the left costal border a constriction 
 often exists, which is yielding and not cicatricial. The greater 
 curvature passes the costal border low down and far to the left. 
 Along and partly covered by the costal border often lies the 
 distended and most capacious part of the deformed stomach. 
 The other side of the angle, represented by the remainder of 
 the long axis of the stomach, passes vertically through the 
 left hypochondrium. The angle, instead of being sharply 
 formed, is sometimes cut off by a short curve. 
 
 1\\e Jish-hook variety is a very serious form of displacement. 
 The pylorus usually remains in its normal position, but the 
 orifice faces almost directly upward. The pyloric extremity of 
 the stomach rises almost vertically over the head of the pan- 
 creas, and is continuous with the duodenum, which runs up- 
 ward and to the right, joins its fixed part at an angle, and pro- 
 duces a constricting kink. The lesser curvature runs below 
 both the left lobe of the liver and all the pancreas but the head. 
 The greater curvature sweeps by the navel and passes under 
 the costal border near the tip of the tenth rib. This curved 
 part of the hook is often dilated, and the greater curvature 
 may extend downward and to the right across the median 
 line. The sharp convexity of the dilated pyloric part points 
 to the right iliac fossa. On account of this particular
 
 560 DISEASES OF THE STOMACH. 
 
 form of the stomach its muscle works at a great disad- 
 vantage in its efforts to overcome the obstruction in the 
 duodenum. The vertical part of the stomach, pushed far 
 into the left hypochondrium, is often compressed between the 
 overlapping lett lobe of the liver and the spleen, and the 
 transverse diameter of the stomach at the point of com- 
 pression may be reduced to i '< or two inches. 
 
 In the straight forjfi the duodenohepatic ligament is elon- 
 gated, and the pj'lorus lies very close to the umbilicus. The 
 lesser curvature bends slightly on its way to the cardia. Nearly 
 the whole of the long axis of the stomach is vertical, and the 
 body of the organ, on account of the particular deformity of 
 the liver which causes the displacement, is usually but slightly 
 compressed. This is the least frequent of the three varieties. 
 
 The vertically displaced stomach may descend in the abdo- 
 men, and the upper limit of the fundus may be lowered. 
 Associated with vertical displacement of the stomach are 
 deformities and displacements of other abdominal organs. 
 The liver rotates on a transverse axis, or descends in the abdo- 
 men, or is pressed out of its normal shape. The right kidney 
 is more or less movable. The spleen is displaced and de- 
 formed. There may be splanchnoptosis or enteroptosis, par- 
 ticularly if the abdominal wall is flabby. 
 
 Clinical Description. — Vertical displacement may exist with- 
 out producing a local or general subjective symptom. It is a 
 disease which is often without an expression. From puberty 
 to old age digestion may be good and the general health 
 e.Kcellent. This latency constitutes its seemingh' harmless 
 nature and also its serious danger. A vertically displaced 
 stomach is a constant menace to health. 
 
 There can be no doubt that a vertically displaced stomach 
 does its work at a great disadvantage, and the motor func- 
 tion upon the integrity of which health depends may easily 
 become insufficient. The organ is in a state of unstable 
 equilibrium. 
 
 One class of subjective symptoms is due, not to the dis- 
 placement of the stomach alone, but to the combined effect of 
 the changed relations and deformities of the abdominal 
 organs. There is sometimes localized peritonitis, traumatic 
 in its genesis. This is manifested by local pain and tender- 
 ness, and by constitutional depression, most often mistaken 
 for visceral neuralgia. The sympathetic nerves are irritated 
 by being stretched and compressed, often producing local dis- 
 comfort, which is most marked after walking and jolting exer- 
 cise ; and dragging sensations may be experienced about the
 
 THE DISPLACEMENTS OF THE STOMACH. 56 1 
 
 loins. The abdominal sympathetic nerve may be so irritated 
 as to cause neurasthenic symptoms. Neurasthenia is a com- 
 mon expression of a developing or unsuspected displacement 
 of the abdominal organs, including vertical displacement of 
 the stomach. 
 
 But the displacement and the constriction that caused it 
 do more : the blood- and lymph-circulations are disordered. 
 The blood-vessels running in the folds of the ligaments are 
 stretched, compressed, and distorted, here producing stasis, 
 there causing anemia. Furthermore, the intra-abdominal 
 tension is modified, and the beneficial effect of respiration 
 on the circulation of the abdomen, particularly that of the 
 lymph, is diminished. The result is that these patients often 
 emaciate, age early, become anemic, lose energy, and are 
 morose, melanchoHc, and sometimes irritable. This change 
 of character and disposition is often a revealing sign. The 
 characteristics of the anemias produced by the displacements 
 of the stomach are that they are rebellious to treatment, are 
 not much benefited by iron or arsenic, but are cured by rest 
 in bed and proper alimentation; and this is likewise true of 
 the neuralgic, neurasthenic, and psychic symptoms produced 
 by the disturbed equilibrium of the abdomen. 
 
 The fish-hook form of vertical displacement may, as has 
 already been stated, produce duodenal obstruction. The 
 symptoms are, then, those of the stages of compensation, 
 stagnation, or retention, as described under pyloric obstruc- 
 tion ; but the distinctive sign is the discovery of a stomach 
 vertically displaced and assuming this particular form. A 
 constant danger of the vertically displaced stomach is motor 
 insufficiency. 
 
 Objective Signs. — The physical signs are characteristic, for 
 they reveal the particular form and position of the stomach 
 which constitute the disease. An important and suggestive 
 sign furnished by inspection is the corset-waist. The 
 costal borders are compressed, and just below the ensiform 
 process is the junction of the two cones, with their bases 
 facing up and down, the patient being viewed from in front. 
 The lower costal borders are somewhat everted. The arch 
 formed by the costal borders is narrowed, the upper por- 
 tion of both borders approaching nearer to the median line. 
 The epigastrium is flat, and the lower part of the abdomen is 
 prominent. The lateral expansion and development of the 
 cavity inclosed by the false ribs have been arrested. Natur- 
 ally, this suggestive form of the abdomen is lacking when the 
 displacement of the stomach has been caused by enlargement 
 36
 
 562 DISEASES OF 77/ E STOMACH. 
 
 of the left lobe of the liver or by tumors of the right hypo- 
 chondrium. 
 
 More conclusive are the signs which reveal the form and 
 position of the stomach. The abdomen should first be exam- 
 ined when the stomach is empty. The organ is next inflated. 
 It will first be noted that the epigastrium has not been dis- 
 tended by this procedure, but retains its flat form. If the 
 abdominal wall is lax, the small portion of the stomach un- 
 covered by the left ribs may be seen outlined as a prominent 
 ridge. On percussion, the upper limit of the fundus of the 
 stomach will be found in its normal position, and the greater 
 tuberosity will reach as high as the fifth interspace. The 
 line of the greater curvature runs far to the left, emerges from 
 under the ribs near the cartilage of the tenth rib or a little 
 higher, and ends at the pylorus, which may be on the median 
 line, to the left or the right of it, or in its normal position, 
 as described under the pathological anatomy. The lesser 
 curvature is displaced downward and to the left, and is 
 located by inspection, palpation, and percussion along the 
 border of the left lobe of the liver. In the median line of the 
 epigastrium only the left lobe of the liver and the pancreas 
 are interposed between the anterior abdominal wall and the 
 spinal column. The aorta can here be easily felt, and its pul- 
 sation is often visible. A glass of water should next be ad- 
 ministered, and by the aid of the splashing sounds confirma- 
 tory evidence of the position and form of the stomach can be 
 obtained. The water and gas can often be felt and heard 
 bubbling through the pylorus. The position of the curvature 
 and of the pylorus reveals the angular, fish-hook, and straight 
 varieties of vertical displacement. 
 
 It will be noted that the transverse diameter of the stomach 
 near the level of the lower border of the left lobe of the liver 
 is very small. The stomach also extends low down in the 
 abdomen, and a great part of it lies in the left hypochon- 
 drium. On account of its position and form and the lines of 
 compression, respiratory gurgling is often produced when 
 the organ contains fluid and air. This symptom is a shock 
 to moclesty, and may be arrested by changing the position of 
 the body, by making the respirations shallow, by loosening or 
 tightening the clothing, or by compressing and lifting the left 
 side of the abdomen. The noise is produced by the forced 
 passage of fluid and gas from one pouch of the stomach into 
 another one separated from it by a constriction. The con- 
 striction is often produced by the border of the ribs and by 
 the colon, while pressure is made alternately on the two
 
 THE DISPLACEMENTS OF THE STOMACH. 563 
 
 pouches by the up-and-down movements of the stomach 
 during respiration. This sign is most common in vertical 
 displacement of the stomach, but is not pathognomonic. 
 
 There are no abnormal functional signs of vertical displace- 
 ment of the stomach. In only one variety — the fish-hook 
 deformity — is the evacuation of the stomach interfered with, 
 and motor compensation may be perfectly established. In 
 many cases of vertical displacement it is impossible for the 
 patient voluntarily to belch or to vomit. The desire may be 
 imperative, but the effort to do either is often a failure. 
 
 The abnormal functional and bacteriological signs found in 
 vertical displacement of the stomach are due to complica- 
 tions. The most frequent of these complications are myas- 
 thenia and gastritis. 
 
 Prognosis. — The vertically displaced stomach, though 
 working at a disadvantage, often performs its work well. 
 With proper digestive hygiene the patient may go through 
 life without digestive trouble. But it constitutes a weakness, 
 a predisposition to disease, and a danger. When it exists, the 
 stomach is more liable to disease, and the cure of such en- 
 grafted disease is rendered difficult. 
 
 Treatment. — Much can be done in the prevention of dis- 
 placement of the stomach by protection of the waist against 
 undue compression. Custom intervenes at an early age and 
 enforces the arrest of the natural development of this part 
 of the female body. No great harm need be done if the lacing 
 be held within limits. A corset which is of the proper size 
 can be fastened during gastric digestion at the end of an 
 ordinary expiration without drawing on either side, and is 
 harmless when this rule is followed from youth. This matter 
 should receive the personal attention of mothers who value 
 the health and beauty of their daughters more highly than an 
 unnaturally small waist. The skirts should be supported 
 from the shoulders, and the corset and clothing should never 
 be pushed down after fastening, with a view to lengthening 
 the waist. 
 
 After the displacement is produced, the excessive con- 
 striction of the waist should be removed, and combined arm 
 and breathing exercises prescribed in order to widen the 
 costal arch and to develop more space in the epigastrium. 
 The abdominal muscles should be strengthened by exercises, 
 massage, and faradism, and the lower abdomen should be 
 snugly supported by a bandage. The abdominal support 
 should always be tightened from below upward before the
 
 564 DISEASES OF THE STOMACH. 
 
 corset is put on, and, in severe cases, while the patient is in 
 the knee-chest posture. 
 
 The treatment of a complicating disease is the same as 
 when the stomach is in its normal position. But if myas- 
 thenia and the secondary anemia require a remedy in addition 
 to those ordinarily employed, rest in bed should be pre- 
 scribed. In the mild form of myasthenia and in mild 
 anemia the patient should recline, with the clothing loosened, 
 during the greater part of the period of gastric digestion. In 
 the severe form of myasthenia with stagnation, in myasthenia 
 with retention, and in advanced and grave anemia, a methodi- 
 cal cure with uninterrupted rest in bed should be employed. 
 
 3. Qastroptosis, or Total Descent of the Stomach. — Gas- 
 troptosis is the most frequent displacement of the stomach, 
 and is usually associated with the displacement of other 
 abdominal organs. The whole stomach is prolapsed, and lies 
 nearly transversely in the abdominal cavity. The pylorus 
 may remain near its normal position, but it is commonly 
 lower down. The horizontal part of the duodenum is the first 
 fixed point, and it is here that angular obstruction is likely to 
 occur. The cardia also descends and lies on a level with the 
 body of the twelfth dorsal vertebra. The fundus of the 
 inflated stomach is below the fifth rib, and the lesser curvature 
 runs across the abdomen in the lower half of the line joining 
 the umbilicus and the ensiform process. The point where 
 the greater curvature crosses the costal border is further down 
 and further to the left than it is normally located, and the lower 
 limit of the stomach runs across the abdomen and the median 
 line below the umbilicus, sometimes as low as the pubic sym- 
 physis. The pyloric antrum or lesser tuberosity is commonly 
 to the right of the median line, and sometimes is larger than 
 it should be. The stomach is not simply enlarged, for there 
 may be no increase in capacitx' ; but the whole organ descends 
 in the abdomen, and this total displacement downward con- 
 stitutes the gastroptosis. 
 
 Etiology. — The abdominal viscera are held in position by 
 ligaments and attachments and by the elasticity of the abdom- 
 inal wall. The stomach is supported, also, by the colon and 
 other organs in the abdominal cavity beneath it, and ma}' be 
 displaced by compression, by traction, and by its own unsup- 
 ported weight when full. 
 
 The greater tuberosity of the stomach lies in close contact 
 with the diaphragm, and may be displaced downward by cer- 
 tain diseases of the thorax, such as left pleuritic effusions, 
 emphysema, or pericardial effusion. The downward displace-
 
 THE DISPLACEMENTS OF THE STOMACH. 565 
 
 ment of the diaphragm, particularly if the abdominal wall is 
 lax or if abdominal tension is reduced by emaciation and by 
 emptiness of the intestines, disturbs the equilibrium of the 
 abdomen, and may inaugurate a series of displacements which 
 will eventually lead to the permanent descent of the stomach. 
 But often the displacements are temporary, and the abdominal 
 equilibrium is restored after the diaphragm returns to its nor- 
 mal position. 
 
 Every severe acute disease leaves the digestive tube and 
 the entire system enfeebled. Typhoid fever, severe influenza, 
 pneumonia, and acute tuberculosis are particularly active in 
 this respect. Overloading the motor-insufficient stomach dur- 
 ing convalescence drags the organ down against the feeble 
 resistance offered by its weak ligaments. Moreover, the acute 
 infectious diseases enlarge the liver and spleen and weaken 
 all the ligaments. The equilibrium of the abdomen is thus 
 disturbed, and the displacement of one organ after another 
 may eventually produce gastroptosis. 
 
 There is no doubt that weak muscular and fibrovascular 
 systems may be inherited or are acquired by disease during 
 infancy. Many persons go through life afflicted with 
 weak hearts, weak digestion, weak lungs, torpid liver, and 
 bad portal and lymph circulations. This inherited or early 
 acquired weakness may affect particularly the peritoneum, 
 and may constitute a particular fibroid dyscrasia ; it is com- 
 monly associated with gastro-intestinal myasthenia and a 
 consequently variable intra-abdominal tension. Be the patho- 
 genesis what it may, there is no question that gastroptosis is 
 frequent in those cursed by such an inheritance or by this 
 legacy of abdominal disease in early life. 
 
 Gastric retention is also a cause of gastroptosis. The 
 weight of the full stomach pulls the organ down, and its 
 descent meets with less resistance from the empty intestines 
 and from the greater space in the abdominal cavity resulting 
 from the accompanying emaciation and utilization of the 
 deposited tissue fat. It is common enough to find gastrop- 
 tosis associated with obstructive and myasthenic retention, 
 and in some of these cases the total descent of the stomach 
 is a result. 
 
 A very flabby abdominal wall associated with low intra- 
 abdominal pressure is another cause of gastroptosis. Preg- 
 nancy, a short lying-in period, sudden and extreme emacia- 
 tion, the removal or absorption of ascitic fluid, and the removal 
 of large abdominal tumors are the chief causes of the flabby, 
 collapsing abdomen. The organs and viscera, unsupported
 
 566 DISEASES OF THE STOMAL//. 
 
 in the erect position, drag on their ligaments and attachments, 
 and descend eventually into the lower abdomen. 
 
 Tight lacing may produce upward, lateral, or down- 
 ward displacement of the stomach, according to the location 
 of the line of greatest constriction and to the shape of waist 
 produced by the corset. The vertically displaced corset- 
 stomach may undergo prolapse. But when tight lacing, aided 
 often by other causes of gastroptosis, produces total descent 
 of the stomach, the line of greatest constriction runs across 
 the conve.x surface of the liver, between the sixth and eighth 
 ribs, and across the abdomen near the ensiform process. 
 The liver, the right kidney, the pylorus, the colon, and the 
 spleen are simultaneously displaced downward, and the whole 
 stomach is pulled and pressed out of the position which it 
 normally occupies. The waists of gastroptosis, of lateral 
 displacement, and of upward displacement may be distin- 
 guished, in their typical forms, at a casual glance. 
 
 Displacements of the various abdominal organs usually 
 occur in association, and displacement of one organ may be 
 the cause of displacement of another. But it is certainly an 
 error to make gastroptosis, as is sometimes done, a mere 
 episode in the evolution of enteroptosis. Glenard maintains 
 that the consequences of prolapse of the hepatic flexure of 
 the colon are descent of the transverse colon, of the pylorus 
 or the stomach, of the liver, and of the right kidney. That 
 such is always the order of development can not be success- 
 fully defended. The vicious circle may begin with any of the 
 organs, and the displacements may develop partly in conse- 
 quence of common causes, partly as the result of changing 
 relations of the organs and viscera, producing new directions 
 of least resistance. The tendency is all downward, on 
 account of the constriction above and of the insufficient sup- 
 port below when in the erect position. In two-thirds of the 
 cases of gastroptosis the hepatic flexure of the colon is not 
 prolapsed. 
 
 Clinical Description, — Gastroptosis is exceedingly variable 
 in its expression. This variability is in keeping with the 
 multiplicity of its causation, the constitutions of its victims, 
 its numerous associated displacements, and the divers dis- 
 eases of the displaced organs. But the course of the di.sease 
 presents one pronounced characteristic — there is no tendency 
 to get well, nor is permanent relief obtained without proper 
 mechanical treatment. 
 
 In the beginning, for a longer or shorter period, digestive 
 compensation may be maintained, and the symptoms be but
 
 THE DISPLACEMENTS OE THE STOMACH. 567 
 
 little influenced by the quality or quantity of the food. Later, 
 during the period of gastric digestion, the patients often com- 
 plain of a sensation of heaviness or fullness, which disappears 
 in the recumbent position but reappears on standing. There 
 is uneasiness, discomfort, and dragging sensations in the 
 epigastrium and back; the patient grows weak, irritable, and 
 pessimistic, and becomes an invalid without knowing any 
 reason for it. The cause is discoverable only by physical 
 examination. 
 
 The motor function of the stomach eventually becomes 
 insufficient. There is gastric stagnation, often heartburn, 
 flatulency, and severe pain. Stagnation in the colon is com- 
 mon, and the constipation may alternate with diarrhea or the 
 stools may consist of hard lumps coated with mucus and 
 mixed with fluid and gas. Certain foods increase the symp- 
 toms, which are now constitutional and local. Vinegar, acid 
 drinks, wine, and milk particularly increase the digestive 
 symptoms, the nervousness, depression, headache, and the 
 insomnia of the second half of the night. Neurasthenic pains 
 and tender points appear. The back aches and the lower 
 extremities are weak. The patient restricts the diet, and 
 loses weight and strength. These symptoms may continue, 
 with exacerbations and remissions, for a number of years. 
 Excessive uric acid formation is sometimes a symptom of the 
 established disease, but more frequently the uric acid is 
 deposited in the urine after standing without an qxcessive 
 formation, the precipitation being due simply to diminished 
 solvent power of the urine or to excessive conversion of the 
 neutral phosphate of soda into the acid phosphate. 
 
 The stagnation eventually may be replaced by retention. 
 The emaciation then increases, and the insomnia becomes 
 complete. The intestines are more and more disordered, and 
 enteritis membranacea, with alternating stenosis and stagna- 
 tion, is quite common. The symptoms become more continu- 
 ous in character and more independent of the digestive period 
 and of the quantity and, to some extent, of the quality of the 
 food. They are but slightly relieved by the recumbent posi- 
 tion and by abdominal support. The dragging sensations, 
 most pronounced during the developmental period, usually 
 disappear in the course of the disease. Vomiting is very infre- 
 quent and exceedingly difficult, the flatulency can not be gotten 
 rid of by belching, and constipation is usually obstinate. The 
 propulsion of the contents of the digestive tube is made more 
 difficult by the low abdominal tension, by the flabby abdomi- 
 nal walls, and by the stenosed fixed points of the digestive
 
 568 DISEASES OF THE STOMACH. 
 
 tube, when they exist. The patient is nervous, weak, irrita- 
 ble, anemic, uriceniic, and often neurasthenic, and suffers 
 from catarrh of more or less all the mucous membranes. For- 
 tunately, the disease seldom arrives at this advanced stage, 
 and is often milder in its expression and amenable to proper 
 treatment. 
 
 Symptomatology. — The digestive symptoms are variable, 
 but present certain characteristics which should excite sus- 
 picion and lead to a careful physical examination of the stom- 
 ach. The heaviness in the stomach after eating or drinking, 
 the heartburn, flatulency, belching, and regurgitation, are 
 symptoms of myasthenia. But rest in bed or rest during 
 the period of gastric digestion causes them to disappear 
 rapidly. The peculiar digestive discomfort and heaviness 
 are relieved, even while the patient is in the erect position, by 
 supporting the stomach, and they return as soon as the organ 
 is released. 
 
 There are local pains independent of digestion and of the 
 quality of the food. These pains are produced by stretching 
 of the nerve filaments in the supporting ligaments, and, possi- 
 bly, by a local peritonitis produced by a tear or detachment 
 of the peritoneum. The latter is not a plausible explanation 
 except when the displacement has been rapidly produced : as, 
 for example, by traumatism or strain. The pain is sometimes 
 severe, and is associated often with a peculiar local uneasiness 
 or discomfort. The severe pain has two common locations — 
 sometimes beneath the ensiform process, and sometimes near 
 the left costal border just above the level of the umbilicus. 
 The pain is excited by effort, by dancing, by jolting, often 
 simply by a short walk. The severe pain may be accom- 
 panied by spasm of the diaphragm, by rapid pulse, by 
 dilatation of the pupils, and by sudden changes in the color 
 of the face. Some of these symptoms are doubtless due 
 to the intense irritation of the abdominal sympathetic 
 nerve. 
 
 Extreme and unaccountable weakness is a common symp- 
 tom of gastroptosis, particularly when the disease is associated 
 with a flabby abdomen and when it develops as a sequel of the 
 puerperium. The mother's attention is fixed on the weak- 
 ness and anemia, both of which increase so that the diges- 
 tive disturbance is overlooked ; while the physician is likely 
 to suspect or incriminate the uterus, which, indeed, is often 
 retroverted or prolapsed. But the chief trouble is the gas- 
 troptosis (sometimes splanchnoptosis) and the diminished
 
 THE DISPLACEMENTS OF THE STOMACH. 569 
 
 abdominal tension. No relief is obtained until these are 
 properly treated. 
 
 Neurasthenia is one of the occasional results of gastrop- 
 tosis. It presents no distinctive characteristics, except its 
 association with the physical signs of the displacement, and 
 its cure by the proper treatment of the gastroptosis. 
 
 Periodical headache is sometimes a symptom of gastrop- 
 tosis, and seems to be due to the irritation of retained food 
 and of excessive secretion. During the premonitory period 
 the patient is nervous and restless, is constipated, and has 
 often a little brow-ache in the morning. During the par- 
 oxysm the headache is severe, and is accompanied by precor- 
 dial pain and great irritability of the sympathetic. The appe- 
 tite is now completely lost. The attack ends with vomiting 
 of food, some of which has been retained for two or three 
 days; the vomit may be excessively rich in hydrochloric 
 acid. This headache of gastroptosis is often confounded 
 with migraine and adenohypersthenia gastrica. Its distinc- 
 tive characteristic is the existence of the causative gastrop- 
 tosis. 
 
 The objective signs are distinctive. On inspection, the 
 form of the abdomen is often suggestive, the lower part being 
 full or flabby and the epigastrium depressed. The contour 
 of the stomach during the period of digestion can often be 
 outlined on the abdominal wall by the practised eye. The 
 lesser curvature runs across the abdomen lower than aormal ; 
 the greater curvature is often below the navel, and may 
 descend even as low as the symphysis. The greater curva- 
 ture is not only lowered, but it extends much further to 
 the left and further to the right of the median line than it 
 should go. 
 
 If the stomach is empty, and, on percussion, the larger 
 part of the semilunar space of Traube is dull, and if this dul- 
 ness does not disappear when the stomach is inflated, the 
 superior limit of the stomach is lowered. Care should 
 naturally be taken to exclude pleurisy, pericarditis with 
 effusion, consolidation of the lower lobe of the left lung, and 
 other thoracic conditions which would diminish the resonance 
 of this same area. 
 
 On inflation the curvatures can usually be located with 
 accuracy. The descent of the lesser curvature and of the 
 fundus are characteristic signs. The greater curvature can 
 naturally be found below the umbilicus when the stomach is 
 simply enlarged by gluttony, by pyloric or duodenal obstruc- 
 tion, in cases of advanced myasthenia, and when the stomach
 
 570 DISEASES OE THE STOMACH. 
 
 is vertically displaced. The pylorus is usually lower than 
 its normal position, and can be located by inspection after in- 
 flation and by palpation ; it can be identified, also, by the 
 periodical bubbling of the contents of the stomach through it. 
 The epigastrium above the lesser curvature is dull on percus- 
 sion, and the pancreas and left lobe of the liver can often be 
 felt lying over the vertebral column and over the pulsating 
 aorta. There often exists a painful, sharp!}' limited, tender 
 and epigastric point like that of ulcer; but a distinguishing 
 sign is the absence of the stomach beneath the tender point 
 of gastroptosis. In extreme gastroptosis with low abdominal 
 tension, the epigastrium may possibly be occupied by coils of 
 the intestines. Electric illumination of the stomach often 
 produces a characteristic picture, but is not required for mak- 
 ing the diagnosis. The other physical signs locate the 
 stomach with greater ease and certainty. 
 
 The prolapsed stomach is not so closely associated with 
 the movements of the diaphragm as when in its normal 
 position. It often moves but little on either inspiration or ex- 
 piration, is easily fi.Ked during expiration, and can be grasped 
 and readily moved about in the often flabby abdomen. 
 
 The left lobe of the liver and the sympathetic ganglia will 
 often be found sensitive to pressure. This is in part due to the 
 ease with which firm pressure can be brought to bear 
 almost directly. When associated with the severe pain of 
 effort beneath the ensiform process, and with neurasthenic 
 tender points, the inexperienced may be led to suspect an 
 ulcer. 
 
 The functional signs are in no manner characteristic of 
 gastroptosis, but are of value in the revelation of complica- 
 tions and in the regulation of the diet and treatment. In 
 the same respect the bacteriological and anatomical signs may 
 be useful. 
 
 Differential Diagnosis. — The prolapsed stomach nia}' become 
 diseased in the same manner as when in its normal position. 
 Associated with it may be found any of the anatomical 
 diseases of the stomach and many of the dynamic affections. 
 The diagnosis of the gastroptosis rests exclusively on its 
 physical signs, and its causal relation to the associated disease 
 often can not be deternn'ned. The clinical history may con- 
 tain some distinctive features in favor of the priority of the 
 displacement of the stomach, which, as may be expected, is 
 very favorable to the development of other gastric troubles. 
 The solution of the problem, however, is of little practical
 
 THE DISPLACEMENTS OF THE STOMACH. 57 1 
 
 moment, for the treatment must be that of the two diseases 
 combined. 
 
 But gastroptosis is liable to be confounded with myasthenia, 
 and with pyloric and duodenal obstruction. There are sev- 
 eral signs which, although not conclusive, are in favor of 
 gastroptosis. The flabby and prominent lower abdomen, the 
 constricted waist, and the development of the gastric trouble 
 as a sequel of pregnancy should create suspicion of the dis- 
 placement. The great relief afforded, particularly during 
 digestion, by the proper support and gentle compression of 
 the abdomen below the umbilicus is another valuable differ- 
 ential sign. The existence of a movable right kidney, of a 
 displaced and deformed liver, of a displaced and chronically 
 inflamed colon, constipation, scybala coated with mucus, 
 membrane-like shreds, alternating enterostenosis and dilata- 
 tion, are most common in association with gastroptosis. But 
 none of these signs is conclusive, and the diagnosis can only 
 be made sure by the accurate delimitation of the stomach, 
 demonstrating the total descent of the organ, which is made 
 clear by the position of its superior border. 
 
 In long-standing cases of myasthenia, particularly in the 
 severe stagnation and retention stages, the stomach, with its 
 often weakened attachments, may become prolapsed. In 
 obstructive stagnation and retention the same displacement 
 may result. In complicated gastroptosis the contents of the 
 stomach may stagnate or be retained. Consequently, the 
 mere presence of gastroptosis does not prove that there may 
 not be a primary myasthenia or obstruction. If there is no 
 stagnation, myasthenia is thereby excluded, as is also a possi- 
 ble compensated obstruction, for the latter does not produce 
 gastroptosis. If there is stagnation or retention, and if the 
 physical signs of gastroptosis are present, the primary trouble 
 may be the displacement, the myasthenia, or the obstruction. 
 
 Gastroptosis may produce a kink obstruction of the first 
 part of the duodenum, and may with great difficulty be dis- 
 tinguished from other forms of obstructive stagnation and 
 retention. In gastroptosis the reposition and support of the 
 stomach remove the obstruction and cure the stagnation or 
 retention, provided the muscular coat is not asthenic ; this is 
 an absolute differential sign. Rest in bed improves digestion 
 in gastroptosis, immediately and greatly ; it is much less 
 beneficial in organic obstruction. The absence of any palpa- 
 ble cause of obstruction is in favor of gastroptosis. When 
 the prolapsed stomach is myasthenic, the differential signs 
 given in the chapter on Pyloric Obstruction become applicable.
 
 572 DISEASES OF THE STOMACH. 
 
 Is tlie niyastlienia or the gastroptosis primary ? The his- 
 tory and the existence of associated displacements may throw 
 some light on the case, but without a knowledge of the 
 evolution, an etiological diagnosis is not possible. 
 
 Prognosis. — Gastroptosis is seldom completely cured — the 
 displacement may be corrected, but it readily returns. A 
 cure is possible in the early stages, particularly when a flabby 
 abdominal wall is the occasion of the prolapse of the organ. 
 However, by proper treatment great and often complete 
 relief can be given in even its most advanced stages. 
 
 Treatment. — The treatment of gastroptosis is simple and 
 methodical, and will usually prove efficient. The indications 
 to be met may be thus formulated: (i) To replace and sup- 
 port the stomach; (2) to regulate abdominal tension ; (3) to 
 nourish the patient properly ; (4) to prevent stagnation; (5) 
 to treat the complication ; (6) to relieve the symptoms. 
 
 Before replacing the stomach it is first necessary to make 
 room for it. Whether it be forced out of position in the man- 
 ner already described, or let fall by its relaxed supports, or 
 dragged out of position by the attached colon, the room 
 which it normally occupies is filled by other organs or by 
 the collapse of the pliable wall of the upper abdominal cavity. 
 Consequently, the spleen and liver, if enlarged, should be 
 reduced in size by proper treatment; a compressing tumor or 
 thoracic effusion should be removed. The constriction, col- 
 lapse, and arrested development of the waist should be cor- 
 rected by properly-fitting clothing, by the support of all skirts 
 from the shoulders, and by methodical breathing exercises, 
 combined with arm and trunk movements. The development 
 and expansion of the upper abdominal wall can also be aided 
 by massage. 
 
 The restoration of the normal space for the stomach, it 
 need not be said, is much more difficult in some cases than 
 in others. A stomach which has recently been dragged 
 down into the flabby lower abdomen by the weight of its 
 stagnant or retained contents or by the attached prolapsed 
 colon is more readily replaced than one which has been 
 forced out of position or one whose normal position has been 
 filled by the hardened, collapsed, and badly developed costo- 
 cartilaginous framework. The prolapsed stomach, like the 
 contents of a hernia, may forfeit its right of domicile. When 
 the gastroptosis occurs in young girls, and the expansion and 
 development of the waist have been arrested by tight cloth- 
 ing, it is exceedingly difficult and often impossible, later in 
 life, to recreate for the stomach its lost normal space. Natu-
 
 THE DISPLACEMENTS OF THE STOMACH. 573 
 
 rally, the stomach can not often be returned to its normal 
 position like a reducible hernia. Gradual replacement of the 
 stomach, however, is essential to a perfect cure ; otherwise 
 the treatment can only be palliative and arrest the further 
 evolution of the trouble. 
 
 In order to support the replaced stomach the elasticity of 
 its ligaments must be restored, the abdominal wall strength- 
 ened, and the intestines — which form a sort of cushion on 
 which the stomach rests when the body is erect — be held well 
 up in the abdomen. Massage, electricity, improved nutrition, 
 and neuromuscular tone are slowly-working but valuable aids 
 to this end. But to give immediate relief, the lower abdomen 
 must be supported by an elastic belt. 
 
 The pelvic or hypogastric belts of Glenard, Teufel, Rarden- 
 heur, and Landau, when made so as to fit, and slightly modi- 
 fied so as to suit each individual case, do well the work which 
 is required of them — an elastic and gentle compression and 
 proper support of the contents of the abdominal cavity below 
 the navel. We have found it best to have the belt made to 
 order, and to adapt it, by modification, to the requirements of 
 each case. The belt should be applied next to the skin in the 
 morning while the stomach is empty, with the patient in bed ; 
 it should be tightened from below upward. In severe cases 
 the bandage should be applied while the patient is in the knee- 
 chest posture. When the abdomen is very flabby it may be 
 necessary to wear the belt day and night; but usually, unless 
 abdominal tension is very low, it may be removed before 
 retiring. 
 
 In nearly every case of gastroptosis which has not been 
 produced by downward pressure and by the excessive weight 
 of the retained contents, intra-abdominal tension is too low. 
 This is one of the causes of the inefficient peristalsis and of 
 the stasis of the contents of the digestive tube. But persist- 
 ent low tension means venous and particularly lymph stasis 
 or congestion. This abdominal stagnation is pernicious in its 
 influence on the nutrition of the abdominal and pelvic organs, 
 and on digestion, absorption, and assimilation. Consequently, 
 the coexistence of gastroptosis and low abdominal tension 
 strongly condemns purgation or reducing treatment of any 
 kind. Rest, massage, electricity, an elastic abdominal belt, a 
 proper diet, supplemented, if need be, by gentle laxatives, are 
 more rational and beneficial. 
 
 Rest in bed is a most valuable remedy. During the devel- 
 opment of gastroptosis — and the displacement may often be 
 detected in its beginning by a careful physical examination —
 
 574 DISEASES OF THE STOMACH. 
 
 the patient should be given a methodical rest-cure. The 
 evolution of the trouble would be at once cut short; the 
 drat^s^ing pains, the tender points, nervousness, neurasthenia, 
 and anemia grow less. Rest is essential in the cure of the 
 secondary anemia and neurasthenia of gastroptosis. The 
 mild cases of total descent of the stomach — and these cases 
 are numerous — may be treated with only the amount of rest 
 requisite to good digestive hygiene — half an hour's rest 
 before and after each meal. Often it will be advantageous to 
 enforce rest on the lounge during the greater part of gastric 
 digestion. 
 
 The diet in gastroptosis is variable on account of the 
 large number of complications, and is determined by the 
 functional power of the stomach, by the state of the intes- 
 tines, and by the needs of nutrition. As a rule, in gastrop- 
 tosis the patient is pale, somewhat emaciated, and badly 
 nourished. Abdominal tension is decreased and the organs 
 are more easily displaced as the mesenteric, omental, and 
 kidney fat disappear. At lea.st a diet of support is an invar- 
 iable rule, and it is best to improve nutrition as rapidly as 
 possible by proper and nourishing food, such as each par- 
 ticular patient can utilize. A reducing and insufficient diet 
 can only do harm in simple gastroptosis, but it may be made 
 necessary by a severe complication, such as chronic colitis. 
 
 Gastroptosis, when associated with healthy intestines and 
 good motor compensation, requires only a nourishing diet, 
 measures to open the way gradual 1\' for the return of the 
 stomach to its normal position, and good digestive hygiene. 
 The diet should consist of plain and nutritious food, tender 
 meats, fish, game, eggs, thoroughly cooked cereals, the 
 more digestible vegetables, and a moderate quantity of sweets 
 and fruits. The fat should not be diminished. In this stage 
 there is no objection to milk, if it is digested by the partic- 
 ular patient. Pastry, rich sauces, coarse vegetables, indiges- 
 tible articles, and most alcoholic drinks should be excluded. - 
 
 Gastroptosis with myasthenia requires a diet suited to the 
 stages of this complication ; this diet has been given in the 
 chapter on Myasthenia Gastrica. The drugs which have 
 a special tonic action on the involuntary muscles should 
 be prescribed — strychnin, hydrastinin, cinchona, and some- 
 times ergot and ipecac ; all in small doses. Electricity and 
 hydrotherapy are even more valuable. Faradism, both gen- 
 eral and gastric, should be used, and the needle bath with 
 hot, followed by cold, water over the abdomen and lower ex- 
 tremities. All hygienic measures which give tone to the
 
 THE DISPLACEMENTS OF THE STOMACH. 575 
 
 neuromuscular system should be employed. Briefly, the 
 treatment is that of the myasthenia (already given) plus the 
 treatment of the displacement. Rest in bed for a variable 
 period is sometimes necessary. 
 
 Gastroptosis associated with chronic colitis requires a very 
 carefully selected diet, abdominal support, digestive hygiene, 
 often rest in bed, the cold or hot compress, the prevention of 
 stasis, and the use of alkalies. The diet, for a short period, 
 should consist almost exclusively of tender or chopped 
 meats and poultry (white meat), either roasted or broiled, a 
 little dry toast, crust of roll, the expressed juice of meats, 
 once a day a i&\w spoonfuls of a clear vegetable soup thick- 
 ened with thoroughly cooked barley gruel, rice, or de- 
 corticated whole meal. No wine, milk, acids, fruits, or 
 vegetables should be allowed. Half an ounce of fresh, 
 unsalted butter should be eaten daily. During the employ- 
 ment of this restricted diet the patient should spend nearly 
 the whole time in bed or on the lounge, in order to reduce 
 the needs of nutrition to a minimum. After a few weeks 
 fresh lean meats, preparations of wheat or rice, the white 
 of eggs with a little of the yolk, the juice of a few grapes, 
 a baked apple, stewed prunes, and the juice of an orange 
 may be added. A {&\\ months later a mixed diet of plain 
 foods should be prescribed, and rigorously adhered to until 
 the patient is well. A glass of Vichy (Celestins, Grande- 
 Grille) should be given daily, an hour before breakfast, par- 
 ticularly when the stools are very acid, contain much fat, or 
 the urine deposits uric acid on standing ; enough sulphate of 
 soda should be added to the Vichy to produce a full and soft 
 stool. The abdominal belt decreases the constipation, and 
 the compress relieves the excessive irritability. If the motor 
 power of the stomach is normal, a dose of Carlsbad salts or 
 other saline (only one movement) may be given daily, or three 
 times a week for one month. Cascara is the most harmless 
 and valuable laxative. Hydrastinin, strychnin, cinchona, 
 ipecac, and possibly belladonna, are often useful in small 
 doses. But only the gentlest measures that are effective in 
 the particular case should be employed to prevent the stasis 
 of the contents of the colon. The localized spasmodic 
 strictures of the colon are sometimes very much benefited 
 by injections of warm pure sweet oil, to which two teaspoon- 
 fuls of oil of hyoscyamus (G. P.) may be added. 
 
 Gastroptosis with neurasthenia requires rest in bed. The 
 digestive tube must be kept perfectly free from irritation by 
 food, by fermentation or putrefaction products, and by drugs.
 
 576 DISEASES OF THE STOMACH. 
 
 A milk- and rest-cure often yields excellent results when com- 
 bined with massage, electricity, hydrotherapy, and proper 
 moral treatment. If pure milk disagrees, it may be tried 
 combined with alkalies, or a fermented preparation of milk 
 may be substituted. Cod-liver oil may often be given at the 
 same time with benefit. White meat of poultry and game, 
 fresh lean fish, preparations of wheat and rice and other 
 cereals, a little dry toast and butter, and sometimes eggs, may 
 be added to the list after a few days. After all the neuras- 
 thenic signs are gone, red meats, green vegetables, and unirri- 
 tating fruit may be permitted; but their digestion, utilization, 
 and subjective effects should be watched. Most drugs are 
 badly borne, and should be employed sparingly, and chiefly 
 to meet functional indications. As in other forms of gas- 
 troptosis, the stomach should be supported and abdominal 
 tension regulated by a suitable hypogastric belt. 
 
 It will thus be readily seen that the treatment of gastroptosis 
 does not consist in the routine use of certain remedies. Each 
 case requires special remedies, particularly when the disease 
 is complicated. Each individual has his own peculiarities and 
 constitution, demanding particular modifications of the medi- 
 cation employed. But all cases are alike in requiring pro- 
 longed and methodical treatment in order to establish and 
 maintain digestive compensation or to effect a cure. Pain, 
 insomnia, headache, nervousness, and uricemia often require 
 symptomatic remedies. 
 
 CHAPTER V. 
 
 OBSTRUCTION OF THE ORIFICES. 
 
 The organic obstruction of the cardia and of the pylorus are 
 diseases — or, more properly, deformities — which may require 
 operation for their relief. The obstruction is nearly always 
 due to ulcer, to cancer, or to toxic gastritis, and is then only an 
 episode or a sequel of these diseases. But there are also other 
 rare causes, and when the obstruction occurs a condition 
 results which has a characteristic symptomatology, demands 
 special treatment, and presents many difficulties in differential 
 diagnosis. The practical value of a close study of this sub- 
 ject is obvious, for the surgeon stands hard by, ready to put 
 the physician's opinion to the test.
 
 OBSTRUCTION OF THE ORIFICES. 577 
 
 I. Obstruction of the Cardia. — Obstruction of the cardia 
 is a very serious condition, usually preventing the ingestion 
 and absorption of enough food to maintain the nutrition of 
 the body. The inanition is more or less complete and rapid, 
 according to the degree of the stenosis. The body may 
 sometimes be nourished on a carefully selected diet after it is 
 no longer possible to swallow solid food. But the obstruction 
 may become so great as to allow only a little or even no 
 liquid nourishment to pass. The beginning of inanition, 
 except in cancerous obstruction, marks a turning-point in the 
 treatment of the condition ; and then feeding by bowel, 
 through an esophageal cannula or through a gastric fistula, 
 must be employed. Surgical interference is imperative when 
 starvation begins. 
 
 Etiology. — Obstruction of the cardia is much less frequent 
 than the same deformity of the pylorus, but both are alike in 
 the multiplicity of their manner of production. 
 
 The causative disease originates in the wall of the digestive 
 tube in the vicinity of the orifice, or the obstruction may be 
 due to the compression of a mediastinal or retroperitoneal 
 tumor, a cold abscess, enlarged glands, or aneurysm. Con- 
 genital atresia is exceedingly rare, the ectodermic esophagus 
 developing and forming a complete and perfect union with 
 the endodermic stomach. Congenital obstructive malforma- 
 tion of this part of the digestive tube is scarcely known. 
 
 Stenosis of the cardia may be spasmodic, and is then com- 
 monly known as esophagismus. Spasmodic stricture is not 
 very rare, and may occur at any age. Organic strictures are 
 often made tighter by spasm of the cardia. 
 
 Cicatricial contraction is one of the common causes of 
 organic obstruction. Tubercular and syphilitic ulcers very 
 seldom occur at this point of the digestive tube. Ulcer of the 
 stomach does not often involve the cardia. Catarrhal and 
 corrosive ulceration is more frequent, the cardia being the 
 first point of arrest in the gullet of corrosive acids, alkalies, 
 or salts. Consequently, these chemicals commonly produce 
 stricture of the lower part of the esophagus. 
 
 The most common cause of cardiac stenosis is cancer, 
 extending to it either from the esophagus or the stomach, and 
 composed histologically of pavement or cylindrical cells. If 
 it be remembered that the number of deaths due to cancer of 
 the stomach is small, and that only a small number of gastric 
 carcinomata involve the cardia, it will readily appear that 
 stenosis of the cardia, including all its varieties, is not a fre- 
 quent deformity. 
 37
 
 578 DISEASES OF THE STOMACH. 
 
 Clinical Description. — The manifestations and evolution of 
 obstruction of the cardia are variable. Some of the symp- 
 toms are due to the obstruction itself and to its conse- 
 quences — dysphagia, esophageal stagnation, and inanition. 
 Others are due to the causative disease located in the wall 
 of the tube or in its vicinity. The modifications of the 
 clinical picture entailed by the method of production will 
 be discussed under the etiological diagnosis. 
 
 The first symptom of obstruction is the arrest of food in 
 the lower portion of the esophagus. The patient states that 
 solid food seems to stick at that point, and that it requires a 
 deep inspiration and repeated efforts at swallowing to force it 
 on. This sensation will most likely be noticed first after a 
 large bolus is swallowed, but later small mouthfuls of solid 
 food and the very rapid gulping of liquids produce the same 
 sensations. Solid food can be made to pass readily only by 
 swallowing a little at a time and washing it down with 
 fluids. The meal can be finished comfortably only when 
 eaten slowly and in small mouthfuls. The obstruction mani- 
 fests itself only during eating. 
 
 Soon the signs of esophageal stagnation appear. After 
 the meal is finished there seems to be, beneath the lower end 
 of the sternum, a foreign body which gives a good deal of 
 discomfort and anxiety from the compression which it exerts. 
 The symptom is in direct relation with the solidity of the 
 food, the rapidity of eating, and the heartiness of the meal. 
 The food frequently regurgitates into the mouth, particularly 
 after coughing. Chemical tests will show that the matter 
 regurgitated has not entered the stomach, but it is often 
 mixed with a good deal of mucus from the local irritation 
 which the stagnation or the causative disease excites. This 
 sensation of a foreign body beneath the sternum may be due 
 in part to the obstructing tumor. 
 
 Later, stagnation is replaced by retention. The food fer- 
 ments, decomposes, irritates, and the contents of the dilated 
 pouch are regurgitated again and again into the mouth, 
 mixed with mucus and saliva; they are sometimes foul, and 
 contain no bile, hydrochloric acid, pepsin, labferment, nor 
 products of gastric digestion. 
 
 The stagnation and retention produce secondary thoracic 
 symptoms. There may be dyspnea, often discomfort or pain, 
 increased by e.xercise, and sometimes attacks of pseudo- 
 angina pectoris. The obstruction may be increased by spasm 
 of the cardia and by inflammatory swelling, or it may be 
 diminished by ulceration. Consequently, organic obstruction
 
 OBSTRUCTION OF THE ORIFICES. S79 
 
 of the cardia usually presents periods of diminution and of 
 increase, and eventually, and more or less rapidly, in keeping 
 with the nature of the cause, may become complete. 
 
 If, on account of the obstruction, too little food is received 
 into the stomach, nutrition suffers. The symptoms are those 
 of simple subnutrition — thirst, hunger, emaciation, weakness, 
 and the particular functional and nervous signs due to a con- 
 stant deficiency of food and water. The stomach and bowels 
 are particularly liable to retract. To the obstructive and 
 denutritive manifestations will naturally be added those ex- 
 pressive of the causative disease ; for the obstruction of the 
 cardia itself may be congenital, or an episode, or a sequel. 
 
 Symptomatology. — One of the earliest signs of obstruc- 
 tion of the cardia is the arrest of solid food in the lower 
 portion of the esophagus. The food sticks at this point and 
 requires repeated efforts to force it on. In the case of ulcer, 
 this arrest is preceded by a period when the swallowing and 
 the movements of active respiration are painful. As the ulcer 
 heals and the cicatrix forms, the pain gives place to obstruc- 
 tion. First solids, and then liquids, are arrested, and, finally, 
 only a small quantity of liquid food or none can be forced 
 into the stomach. Cicatricial constriction often stops before 
 occlusion is complete, and remains for a long time stationary. 
 The obstructions of carcinoma and of growing and com- 
 pressing tumors are progressive. In cancer the obstruction 
 may be diminished by ulceration, and the consequent im- 
 provement in swallowing gives rise to false hopes. The ob- 
 struction is often increased by spasm and swelling, and the 
 food passes more easily when the irritation and inflammation 
 subside. The irritation produced by passing a sound may 
 cause complete occlusion for a few days. The period of com- 
 pensatory hypertrophy of the esophagus is short when car- 
 cinoma is present, and inspiratory compression, instead of 
 forcing the food into the stomach, only brings it up into the 
 mouth. In organic obstruction there are no periods when 
 swallowing is effortless and normal, as there are in esopha- 
 gismus. 
 
 The regurgitation is at first alimentary, and is limited to 
 the period during the taking of food or shortly afterward. 
 Later, as stagnation and retention develop, it occurs between 
 meals, consisting of repeated mouthfuls of food, of saliva and 
 mucus, or of all mixed together, and being sometimes fer- 
 mented and putrid, particularly in carcinoma. The persistent 
 absence of any chemical evidence that the regurgitated 
 matter has entered the stomach is characteristic of esophageal
 
 580 DISEASES OF THE STOMACH. 
 
 vomiting, which in some cases may be accompanied by 
 nausea. Blood may sometimes be brought up when there is 
 ulceration or when there are dilated cardio-esophageal veins. 
 
 Pain may be entirely absent or it may be severe, and where 
 there is no great stagnation or retention it may be confined 
 to the mealtime. Sometimes, however, as the pocket forms 
 and fills, or when there is ulceration, the pain is severe, 
 located near the ensiform process, and radiates into the back 
 and concentrates about the heart. It may be accompanied by 
 dyspnea or hiccup, and is likely to be increased by exer- 
 cise and deep breathing. Sometimes the pain is excited by 
 walking, and disappears as the esophagus empties itself. 
 
 The physical signs are very valuable and characteristic. A 
 tumor of the cardia can neither be felt nor seen. Sometimes 
 the filled esophageal pouch produces dulness posteriorly to 
 the left of the eighth or ninth dorsal vertebra. Depression 
 and percussion over the lower end of the sternum are some- 
 times painful; seldom a painful pressure-point exists pos- 
 teriorly and to the left of the ninth dorsal vertebra. These 
 are, however, only suggestive and not revealing signs. When 
 the stenosis is so great as to prevent the ingestion of enough 
 food, emaciation and loss of strength develop. If water also 
 is more or less excluded, the inanition becomes more marked, 
 and the wasting of the fat and muscles may become extreme; 
 there may be great prostration, sunken abdomen, contracted 
 stomach and intestines, and the general skeleton-like appear- 
 ance of food-and-water starvation. The quantity of urine 
 passed daily is a fair measure of the degree of obstructive 
 retention. 
 
 The swallowing sounds may be of some diagnostic value. 
 There is not likely to be a stenosis when, after a swallow of 
 water, the first and second sounds are both heard, separated 
 by an interval of about twelve seconds. If obstruction is 
 present, both sounds may be absent, or the appearance of the 
 second sound, which marks the completion of the passage of 
 the water swallowed, may be delayed, or, if the esophagus 
 contracts with little force, the second sound may be inaudible. 
 These auscultation signs and the other foregoing physical 
 signs are only suggestive or presumptive. 
 
 The characteristic physical sign is obtained by sounding 
 the esophagus. This should first be attempted with the 
 stomach-tube, using various sizes. For this purpose a tube 
 with a single side-eye near the extremity is preferable, inas- 
 much as it makes it possible to locate and to measure the 
 length of the stenosis more exactly. If the eye be above
 
 OBSTRUCTION OF THE ORIFICES. 58 1 
 
 the stricture, only a little water can be introduced, and this 
 can be removed by siphonage. If the eye be beyond the 
 obstruction, the water passes into the stomach. If the eye is 
 within the stomach, the introduced water can be removed by 
 expression. The stricture of the cardia thus located and its 
 length measured (provided it can be passed), is about 40 
 cm. from the point where the incisor teeth touch the intro- 
 duced sound. The solid, flexible, black-rubber esophageal 
 sounds may also be employed to detect and measure the 
 distance of the stricture from the incisor teeth. The olive- 
 pointed bougies are dangerous. 
 
 A piece of the tumor may be sometimes withdrawn in the 
 eye of the stomach-tube. Blood is more likely to be obtained 
 when the obstruction is due to cancer, and the substances 
 withdrawn on or in the tube in malignant disease are some- 
 times of a foul odor. These anatomical signs, which reveal 
 the malignant nature of the obstruction, are obtained fre- 
 quently enough to attract and deserve attention. 
 
 Diagnosis. — The diagnosis is easy if the clinical history be 
 sufficiently clear to suggest the use of the sound, and if the 
 latter be found to meet with resistance about 40 cm. from 
 the incisor teeth. The slight normal resistance of the cardia 
 to the passage of the sound will produce no suspicion in the 
 mind of one with some experience in the use of this instru- 
 ment. Other symptoms and signs may suggest the situation 
 of the trouble. But, unfortunately, in the early stage the 
 sensations of the patient, and particularly his description 
 of them, are somewhat vague. The patient may only com- 
 plain of a little shortness of breath, fullness and oppression in 
 the chest, a slight irregularity or rapidity of the heart's action, 
 and pain, which is particularly excited by exercise, and which 
 disappears after a few moments in spite of the continuance of 
 the exercise. The layman is most likely to be anxious about 
 his heart, and to have this organ in his mind, often denying any 
 difficulty in swallowing, as there is no pharyngeal trouble. " I 
 fear my heart is diseased ; I care nothing about the regurgita- 
 tions and other dyspeptic symptoms," is a statement some- 
 what frequently made in this early stage. A history of this 
 kind should direct the attention of the physician to the cardia. 
 
 After the certainty of the existence of an obstruction of 
 the cardia is established, the detection of its cause is practi- 
 cally very important, and sometimes difficult. Particular 
 attention should be given to the evolution and persistence of 
 the symptoms and to the character of the signs. Is the 
 stricture organic, and. if so, what is its nature?
 
 582 DISEASES OF THE STOMACH. 
 
 Spasmodic stricture of the cardia occurs chiefly in neuro- 
 paths. It is most common in neurasthenic or hysterical girls, 
 about the age of puberty, and in women during the meno- 
 pause. Men, particularly of the arthritic types, are by no 
 means exempt. But a favorable temperament or constitution 
 can only excite suspicion of the spasmodic nature of the 
 stricture. There are, however, three cardinal and pathogno- 
 monic signs : the obstruction is intermittent ; a large sound 
 passes as readily as a small one after both have been arrested 
 (gentle and sustained pressure is often sufficient to overcome 
 the resistance) ; and antispasmodics relieve the obstruction. 
 If the stomach-tube does not pass after gentle and prolonged 
 pressure, and if no anatomical signs are obtained upon its 
 withdrawal, the patient should be quickly put under the influ- 
 ence of the bromids. The spasm will then relax, and no 
 obstacle will be encountered in passing the tube. To avoid 
 repetition, the reader is referred for other distinctive signs to 
 the article on Spasm of the Cardia. 
 
 The cause of the organic stricture is determined by exclu- 
 sion. The age of the patient, the duration of the trouble, 
 and the signs of a disease likely to cause obstruction, all 
 have a differential value. If a corrosive poison has been 
 swallowed, or if the esophagus has been burned by hot food 
 or water, or if there have been symptoms and signs of an 
 ulcer, the stenosis is most probably cicatricial. In the absence 
 of such a history, the obstruction is most probably cancerous, 
 particularly if there are other constitutional and local signs of 
 malignant disease and if no disease which is likely to com- 
 press the digestive tube at this point can be discovered. 
 
 Prognosis. — The prognosis is dependent on the nature and 
 degree of the stenosis. The auto-intoxication and inanition 
 of carcinoma prove fatal in five or six months. Cicatricial 
 stenosis, after the scar tissue has finished contracting, and 
 when the stricture is of large caliber, may permit the main- 
 tenance of nutrition by careful alimentation. Even a cica- 
 tricial stricture of small caliber leaves room for some hope of 
 relief by surgical treatment. The prognosis is never good 
 and should always be guarded. 
 
 Treatment. — The treatment consists in appropriate alimenta- 
 tion, so as to maintain, as long as possible, the balance of 
 nutrition, the control of fermentation and putrefaction when 
 they exist, the protection of the diseased part against in- 
 jurious irritation, and the employment of surgical procedures 
 to increase the caliber of the stricture, to maintain its per-
 
 OBSTRUCTION OF THE ORIFICES. 583 
 
 meability, or to form an artificial gastric fistula through which 
 the patient can be fed. 
 
 The two important qualities of the food are its nutritive 
 value and its power to pass the obstruction. The caliber of 
 the stricture has the most to do with the selection of the diet. 
 So long as there is present an active inflammation or excess- 
 ive irritability, the food should be warm, fluid, and unirritating, 
 so as not to increase the swelling nor to excite spasm. The 
 artificially digested foods possess no advantages over the fresh 
 fluid preparations. Milk, raw eggs, expressed meat juice, the 
 juice of the grape and pineapple, and of other unirritating 
 and nutritious fruits, meat powder, cocoa, chocolate, and 
 similar fluid preparations suitable to the digestive power 
 and nutritive state of the individual patient should be ord- 
 ered. Nutrient enemata should be employed as soon as 
 alimentation by the mouth is insufficient. 
 
 When stagnation and retention are present, fermentation 
 and putrefaction may be distressing and injurious. The 
 mouth, nose, and throat should be kept as sweet as possible. 
 A little brandy may be given from time to time with advan- 
 tage, and the least irritating antiseptics may be tried. If the 
 esophageal pocket is large and retention is present, the con- 
 tents should be withdrawn before fermentation becomes 
 active, and the cavity should be washed out with warm 
 Thiersch's solution. Methylene-blue may be used when the 
 stricture is cancerous, or the iodid of sodium and arsenic 
 may be prescribed (Boas). Codein may be required to 
 relieve pain or spasm of the cardia. 
 
 The surgical procedures are numerous. In cicatricial 
 stenosis gradual dilatation with flexible rubber esophageal 
 sounds or more rapid dilatation with the balloon catheter may 
 be undertaken. This treatment maybe employed early, while 
 the stricture is of large caliber, and should be conducted 
 on the same principles as the gradual dilatation of a 
 urethral stricture. If the cicatricial stenosis is impermeable, 
 or if its caliber is so small as to prevent the ingestion of suffi- 
 cient food, gastrostomy may be performed and an effort may 
 be made to dilate the stricture from the stomach, with a view 
 to continuing the dilatation later by the mouth. In the 
 meantime the patient should be fed through the fistulous 
 opening. Sometimes the stomach is so small and lies so 
 deep that gastrostomy is impracticable. Jejunostomy should 
 then be performed instead. 
 
 In cancerous obstruction gradual dilatation can serve no 
 purpose. When the quantity of food introduced by mouth
 
 584 DISEASES OF THE STOMACH. 
 
 and rectum is so small as to entail rapid emaciation and loss 
 of strength, gastrostomy may be performed, but with little 
 hope of prolonging life or of diminishing the discomfort. 
 
 2. Obstruction of the Pylorus — Pyloric obstruction is 
 usually described among the causes of "dilatation" of the 
 stomach. It is true that pyloric obstruction may eventually 
 produce enlargement of the stomach ; but the disease should 
 not be named after one of its final effects, for practically and 
 essentially the trouble is the obstruction. The word " ob- 
 struction," however, does not cover the whole period of the 
 genesis and evolution, for before the beginning of the obstruc- 
 tion there may have been some inflammatory or ulcerative 
 process or some local nutritive or developmental trouble. 
 But whether the obstruction be a complication or a sequel, 
 congenital or neoplastic, a new danger is added, and the 
 clinical picture and treatment are changed by it. It becomes 
 practically a morbid process, enforcing changes and conse- 
 quences manifested by a group of symptoms. Nor does the 
 disease begin, as is often tacitly assumed, with " dilatation." 
 The final period of gastric retention is preceded by periods 
 of compensation and of stagnation. 
 
 Neither is pyloric obstruction synonymous with obstruc- 
 tion to the evacuation of the stomach, for stagnation and 
 retention are frequently caused by duodenal obstruction. 
 These two symptoms (stagnation and retention) may be pro- 
 duced by myasthenia, by supersecretion, by pyloric obstruc- 
 tion, and by duodenal obstruction. Pyloric obstruction 
 is a result or accompaniment of a number of distinct dis- 
 eases of the stomach, which are of the very greatest medical 
 and surgical interest. Its forms should be differentiated and 
 carefully studied, with a view to their recognition when met 
 with at the bedside. 
 
 Etiology. — Pyloric obstructi9n may be either organic or 
 due to spasm of the pyloric muscle. The spasmodic form is 
 described in Section iv. 
 
 Congenital atresia of the pylorus is very rare, but is more 
 common than the same defect of the cardia. The digestive 
 tube may be represented at this point by a fibrous cord, or, 
 more frequently, the canal is not completely obliterated, but 
 is of small caliber. The development of the pylorus may be 
 arrested at any stage, and the infant may die of inanition a 
 short period after birth or may grow into manhood by 
 observance of a suitable diet.
 
 OBSTRUCTION OF THE ORIFICES. 585 
 
 Another cause of pyloric obstruction is cellulomuscular 
 hypertrophy and hyperplasia. The increase in size may be 
 so great as to present a veritable tumor, consisting of a large 
 number of circular muscular fibers and increased submucous 
 connective tissue. This benign hypertrophy of the pylorus 
 is of two distinct varieties — simple and inflammatory. The 
 simple hypertrophy is of a purely functional or nutritive 
 nature. The inflammatory hypertrophy or the hyperplasia 
 is a sequel of chronic hypersthenic gastritis, the lumen being 
 made smaller by hyperplastic thickening of the pyloric wall. 
 The productive inflammation and hyperplasia involve the 
 mucosa, the submucosa, and the muscular layer. 
 
 Very seldom the pylorus is obstructed by a foreign body. 
 This may be produced by a wandering gall-stone, a gas- 
 trolith, or a swallowed foreign body which has obtained 
 lodgment in the pylorus. 
 
 Obstruction by a benign tumor is also* very rare. The ob- 
 structing tumor may develop in the gastric wall close to the 
 pylorus, or the canal may be closed by a polyp becoming en- 
 gaged in it. 
 
 Syphilitic and tubercular ulceration is scarcely known at 
 this point of the digestive tube. More frequently the pylorus 
 is obstructed by the contraction of the scar tissue resulting 
 from the destructive action of chemical poisons. 
 
 The pylorus is sometimes compressed by a tumor develop- 
 ing in its vicinity, or by a gall-stone in the common bile 
 duct, or by constricting bands of fibrous tissue resulting from 
 peritonitis, or by displacements of the stomach. Obstruction 
 of the duodenum, however, is more frequently thus pro- 
 duced. 
 
 Ulcer is one of the common causes of pyloric obstruction. 
 During the evolution of the ulcer the obstruction may be 
 due to the inflammatory swelling and thickening of the walls 
 of the ulcer or to pyloric spasm. More frequently the ob- 
 struction is due to the deformity produced by contraction of 
 the ulcer scar. 
 
 The most common cause of pyloric obstruction is undoubt- 
 edly cancer. Here the location and direction of the growth 
 of the neoplasm are more important than its size. The car- 
 cinoma is very often a small annular scirrhus. 
 
 Clinical Description. — Pyloric obstruction presents three 
 stages — the periods of compensation, of stagnation, and of re- 
 tention. The duration of these periods is dependent on the 
 nature and rapidity of the development of the obstruction 
 and the readiness with which the muscular layer of the
 
 586 DISEASES OF THE STOMACH. 
 
 Stomach undergoes compensatory hypertrophy, which may 
 more than double tlie thickness of the stomach wall. The 
 hypertrophic thickenini^ is always greatest near the pylorus. 
 
 The period of compensation is characterized clinically by 
 the very great disturbances produced by dietetic excesses, 
 particularly the eating of large quantities of coarse food. The 
 muscular hypertrophy compensates only on condition that the 
 stomach is not given too much mechanical work to do. A 
 small meal that is hnel)' subdivided by proper preparation 
 and thorough mastication will be comfortably digested. Even 
 a large meal of the same character may be digested and evacu- 
 ated by the stomach without perceptible trouble. Fluids are 
 more readil)' evacuated than solids. During the active period 
 of gastric digestion the stomach can be felt periodically con- 
 tracting. All these characteristics are absent in myasthenia, 
 with which pyloric obstruction is often confounded. But a 
 large meal composed of coarse, solid food, made excitant by 
 condiments, produces stormy peristalsis, colic, and often vomit- 
 ing. The vomit is alimentary, often contains but little fluid, 
 and is frequently excessively acid, not from fermentation, but 
 from secretory irritation. The active churning movements, 
 and the intermittent and somewhat accidental damming of 
 the current, are unfavorable to germ growth. The period 
 of compensation, marked clinically by recurring attacks of 
 motor disturbance produced in a particular manner, may be 
 long or very short. In benign hypertrophy of the pylorus, in 
 congenital stenosis of large caliber, and in moderate cicatricial 
 obstruction, compensation may continue for years. Pyloric 
 spasm may play an important part in the development of the 
 attacks, particularly when an inflamed ulcer is located near 
 the pylorus. The period is usually very short in obstructing 
 carcinoma, in cases of ulcer which rapidly close the canal, 
 and in severe cases of ulceration or of corrosive to.xic gas- 
 tritis. 
 
 The period of stagnation may mark either the beginning 
 of the obstruction or the beginning of failure of compensa- 
 tion. The stomach empties itself slowly, and never contains 
 in the morning before breakfast, as it does in retention, 
 food which was eaten the evening before. Delay in the 
 evacuation of the stomach, which is one of the signs of 
 functional stagnation, may be but slight, or, in the severe 
 cases, the stomach may be found empty at only one period 
 during the twenty-four hours, this being in the earh' morning, 
 during the long interval between the evening meal and break- 
 fast. The stomach trouble may manifest itself, in the same
 
 OBSTRUCTION OF THE ORIFICES. 587 
 
 manner as in the first stage, only during accidental failure of 
 compensation ; or the stagnation may produce symptoms after 
 each meal. The irritation may not be sufficient to cause much 
 disturbance after breakfast, but when the stomach does not 
 empty itself between breakfast and the evening meal, there may 
 result an accumulative effect manifesting itself each afternoon 
 or evening. The irritation of the fermenting contents and the 
 excessively acid secretion may produce, particularly in the cica- 
 tricial stenosis of ulcer, intolerance of food by the stomach and 
 a rebellious form of alimentary vomiting. The vomit contains 
 food mixed with a clear, acid fluid holding a large quantity 
 of albumoses in solution. When no compensatory hyper- 
 trophy has developed there may result an asthenic state, 
 with a sensation of weight, with belching, and with acid 
 regurgitations, particularly in carcinoma. Pain, and some- 
 times very severe pain, is likely to be a symptom of the 
 stagnation. Emaciation, but often very slight, occurs even 
 in the mild cases ; and when the stagnation leads to gastric 
 intolerance, inanition develops rapidly. This stage, also, 
 according to the rapidity of the evolution of the causative 
 disease may be either long or short. 
 
 Retention, or the third period, is characterized by the failure 
 of the stomach to evacuate its contents at any time during the 
 twenty-four hours, by copious vomiting of accumulated foods 
 and large quantities of fluid and digestive products, and by 
 more active fermentation with gas formation. Pain, as in 
 stagnation, not only encroaches on the period of normal gas- 
 tric repose, but also often continues throughout that period. 
 The symptoms due to the absorption of an insufficient quan- 
 tity of nutriment and water are combined with those of 
 gastric auto-intoxication. Emaciation and loss of strength 
 may be very great, and the patient may become markedly 
 cachectic. This stage may result from the obstruction 
 becoming greater and greater or from the failure of the mus- 
 cular layer of the stomach to maintain compensation. 
 
 Congenital atresia proves rapidly fatal. The infant may be 
 well enough at birth, but uncontrollable vomiting soon begins, 
 and death follows without any food or drugs ever having 
 passed through the alimentary canal. 
 
 Congenital stenosis produces symptoms which depend upon 
 the caliber of the stricture. If the canal be very small, the 
 stomach, after enlarging, and without undergoing hyper- 
 trophy, becomes intolerant, and death results in a few months 
 from inanition. If the caliber be larger, the stomach increases 
 in size and strength, and compensation may be established.
 
 588 DISEASES OF THE STOMACH. 
 
 At no time is there a {)alpable pyloric tumor, and the symp- 
 toms of obstruction be^in soon after birth. These children 
 with large and hypertrophied stomachs are in constant danger 
 of the failure of compensation and the development of reten- 
 tion. The obstruction becomes uncompensated during each 
 attack of a severe acute disease, and adds largely to the 
 danger. 
 
 Simple benign hypertrophy of the pylorus is produced in 
 two ways. The one is functional and nutritive, and develops 
 and produces obstruction in the same manner that the strong 
 and irritable anal sphincter causes constipation. The other is 
 due to duodenal stenosis, the pyloric ring developing so as to 
 aid in establishing compensation and prevent the reflux of 
 the contents of the duodenum into the stomach. In the first 
 form gastric compensation may be complete. In the second, 
 compensatory hypertrophy of the muscular layer of the 
 stomach is maintained with greater difficulty, and the stomach 
 may often contain bile and pancreatic juice, the expressed 
 contents after being rendered alkaline, digesting albumin, and 
 also emulsifying oil. Benign hypertrophy may present in its 
 evolution the three stages of compensation, stagnation, and 
 retention. The disease usually develops slowly, and often 
 lasts a number of years. 
 
 The clinical expression varies little, whether the hyper- 
 trophy be functional and nutritive or the result of hyper- 
 sthenic gastritis. The three clinical periods are well marked, 
 and the duration of the disease, which is frequently fatal, is 
 long. During the first period the accidental disturbances 
 of compensation produce the morbid features, the intervals 
 between them being symptomless. These recurring attacks, 
 produced by dietetic excesses or errors, may be short or may 
 last one or two weeks. Three or four hours after the exces- 
 sive meal gastric pain commences, increases in severity, and 
 is greatly relieved by the vomiting which ensues, the charac- 
 teristics of which demonstrate the stagnation of the food in the 
 stomach. The vomit contains food, often a good deal more 
 fluid than was swallowed, and is excessively rich in hydro- 
 chloric acid and mucus. After the vomiting the pain sub- 
 sides, and the following meal may be evacuated properly, 
 demonstrating the reestablishment of compensation. The 
 attacks, however, may last a week or two, and during this 
 period the pain varies in intensity, often completely subsiding 
 for a ^Qv/ hours. The vomiting occurs soon after a meal of 
 solid or liquid food, or later, at the time when the stomach 
 should normally be empty. The bowels are obstinately con-
 
 OBSTRUCTION OF THE ORIFICES. 589 
 
 stipated. These attacks may recur after an intermission of 
 weeks, or even months. 
 
 During the period of severe stagnation the manifestations 
 are more continuous, and pain is likely to recur after each 
 meal, in relation with the evolution of secretion and the 
 activity of peristalsis. The gastritis is increased by the irri- 
 tation of the acid contents, which remain abnormally long in 
 the stomach. The stomach may become intolerant, or vomit- 
 ing may occur only once or twice in the twenty-four hours. 
 Constipation is obstinate. The pylorus is exceedingly sen- 
 sitive, and both anteriorly and posteriorly pain upon pressure 
 is marked, and extends over a large area. 
 
 When retention begins, the clinical picture changes. The 
 vomiting is copious and, usually, less frequent. The pain is 
 very severe, and may continue day and night. Liquids as 
 well as solids are retained too long in the stomach. The 
 vomit is liquid, separates into three layers, and contains pro- 
 ducts of hydrochloric-pepsin-digestion, and organic acids. 
 Gas-formmg fermentation is active in the tube-tests. The 
 bowels are obstinately constipated, and the quantity of 
 urine is small, constituting a rough measure of the degree of 
 stenosis. The appetite is now lost and the emaciation may 
 become cachectic. Death follows from inanition and auto- 
 intoxication. 
 
 Obstruction by benign tumors is exceedingly rare, and pre- 
 sents, like syphilitic and tubercular ulceration, no distinctive 
 clinical expression. Toxic gastritis more frequently produces 
 obstruction of the cardia than of the pylorus. The develop- 
 ment of the usual signs of pyloric obstruction after the swal- 
 lowing of a corrosive chemical reveals the character of the 
 trouble. The stenosis may be of large caliber or may pro- 
 duce complete occlusion. The strictures of large caliber 
 present a period of stagnation or retention, and may become 
 compensated by gastric hypertrophy after a few weeks. The 
 compensatory hypertrophy produces the only improvement, 
 cicatricial stenosis being permanent and the contraction of 
 the scar tissue being often rapid. 
 
 The stenosis of ulcer may occur during the evolution of 
 the ulcer, or during or after its healing. If it occur from 
 inflammatory swelling during the period when the ulcer is 
 still progressive, gastric intolerance is rapidly developed. 
 The vomiting usually occurs in from one-half to two or three 
 hours after the meal, and often contains food eaten eight or 
 ten hours previously. The development of obstruction 
 changes the clinical expression of ulcer — the pain increases,
 
 590 DISEASES OF THE STOMACH. 
 
 vomiting becomes more obstinate, emaciation is rapid, and, 
 with tlie stagnation and retention, fermentation also sets in, 
 and is in no manner prevented by the excessively acid secre- 
 tion. The obstruction may begin as the ulcer commences to 
 heal, and its development is then commonly preceded by a 
 period of improvement. The cardinal symptoms of ulcer, 
 with the exception of hemorrhage, increase, those of obstruc- 
 tion develop, and the hypersthenic gastritis becomes more 
 active. But more frequently obstruction develops after the 
 ulcer has healed. Recovery has been marked by the cessa- 
 tion of all the symptoms of ulcer, the scar tissue is contract- 
 ing, but the patient again becomes ill, and the signs are those 
 of obstruction combined with hypersthenic gastritis. The 
 cicatricial stenosis of ulcer may present the three periods of 
 compensation, stagnation, and retention ; and the keynote of 
 the clinical expression is persistent and often violent pain. 
 
 Cancerous obstruction is the most frequent form. It often 
 develops with great rapidity, and marks a turning-point in 
 the clinical history of carcinoma. Stagnation and retention 
 may occur in cancer from the loss of functional activity 
 of the muscular layer. But when obstruction begins, the 
 denutrition becomes more active, vomiting is likely to be 
 more obstinate, and the fermentation generates large quanti- 
 ties of gas, both in the stomach and in the fermentation 
 tube tests. 
 
 However caused, pyloric obstruction presents three degrees 
 or stages — compensation, stagnation, and retention ; but the 
 clinical expression varies in relation with the nature of the 
 underlying cause. In carcinomatous obstruction even tem- 
 porary compensation is exceedingly rare. 
 
 Symptomatology. — The modifications of the appetite are 
 dependent on many features of the disease. In the later 
 stages the state of nutrition is of great influence. The causa- 
 tive disease exerts its modifying power. Anorexia is com- 
 mon in carcinoma. The appetite is, on the other hand, well 
 preserved or even increased in benign hypertrophy, in ulcer, 
 and in hypersthenic gastritis, the latter being sometimes a 
 cause and sometimes a sequel of the pyloric obstruction. 
 Mental and moral depression and nervous weakness, which are 
 sometimes manifestations of pyloric obstruction, decrease the 
 appetite; but apart from the state of nutrition and of the 
 nervous system, apart from the nature of the causative dis- 
 ease, and in the absence of trouble in any other organ, pyloric 
 obstruction modifies the appetite by the gastric fermentation, 
 and the intestinal putrefaction, resulting from the stagnation
 
 OBSTRUCTION OF THE ORIFICES. 59 1 
 
 and retention. The appetite diminishes as the uncleanh'ness 
 of the stomach increases. During the period of compensation 
 the appetite is good and there is no excessive thirst. In 
 stagnation the appetite is variable. But where pronounced 
 retention exists, the appetite is Hkely to be poor, and thirst 
 may be unquenchable. 
 
 Pain is one of the most common local symptoms, and is 
 due to a variety of circumstances. It may be due to ulcer, 
 to the associated hypersthenic gastritis and excessive secre- 
 tion, or to fermentation. This form of pain is produced by 
 irritation, and may be made severer by the irritable weakness 
 of the nervous system. Another cause of pain is the peri- 
 staltic effort to overcome the obstruction, which is particularly 
 marked during the stages of compensation and stagnation. 
 The pain of retention is due also to irritation. The little 
 accidents which disturb the period of compensation occur 
 during gastric digestion, the peristaltic effort increasing and 
 becoming painful during the height of digestion and subsid- 
 ing after the evacuation of the stomach. During the period 
 of stagnation the pain is both peristaltic and irritative, and 
 may occur after each meal or only after the heartiest meal 
 of the day. It ceases with the evacuation of the stomach. 
 When retention begins, the pain is often paroxysmal, recurring 
 once or twice a day or every few days. In other cases, 
 particularly when there is excessive secretion, the pain hardly 
 ceases day or night, and sometimes is intolerable. 
 
 Vomiting is almost as frequent as gastric pain. During 
 the period of compensation it occurs as a terminal sign of 
 the accidental or temporary muscular insufficiency. It then 
 commonly occurs at the moment when the contents of the 
 stomach should already have been evacuated completely 
 into the duodenum. The peristaltic movements become 
 more and more stormy, and are usually painful until the 
 cardiac orifice is forced and the stomach is emptied by 
 vomiting. This form of vomiting is very rare in myasthenia, 
 but may occur in the muscular insufficiency due to an ex- 
 cessive meal or to nerve or muscle fatigue. The vomit which 
 results from a temporary disturbance of compensation is 
 alimentary and contains but little fluid. During the period 
 of stagnation vomiting may occur a little later than the time 
 when the stomach should normally be empty, either after 
 each meal or, commonly, only once or twice a day, and as the 
 final expression of an attack of peristaltic pain. This is the 
 period when vomiting is most frequent and most obstinate. 
 The stomach often becomes for a few days completely intol-
 
 59^ B/SEASES OF THE STOMACH. 
 
 erant, and both fluids and solids introduced into it are almost 
 immediately rejected. The stomach is completely emptied. 
 Nausea is common during and after these attacks of intoler- 
 ance, and may be associated with an almost neutral or ex- 
 cessively acid gastric juice. Secretion is likely to be very 
 acid during the period of intolerance when an attempt is 
 made to feed by the mouth, and there is then a good deal of 
 pain and nausea. But after the force of the attack is spent, 
 and even while the stomach is given functional rest, nausea 
 is prominent, and is usually accompanied by a nearly neutral 
 secretion and by occasional vomiting. The vomiting, except 
 during the periods of intolerance, is not immediate, but occurs 
 only a long time after meals. The vomit is alimentary, 
 stagnant, and much more fluid than in the stage of com- 
 pensation. The period of stagnation is the period of exces- 
 sive formation of organic acids, and butyric acid is often the 
 cause of the intolerance. During the period of retention the 
 stomach may be intolerant, but only when the muscular 
 layer is hypertrophied and irritable. When myasthenia 
 develops, the stomach yields to distention without a struggle, 
 and the vomiting becomes more copious, more fluid, and 
 more infrequent. Once every few days vomiting occurs, 
 and is usually effortless, painless, and incomplete. The 
 stomach does not completely empty itself. This is the 
 period when the fermentation tube tests yield large quantities 
 of gas in addition to organic acids. The vomit is that of re- 
 tention — overfermented, acid, fluid, and separating on stand- 
 ing into three layers. Many constitutional symptoms and 
 distant effects have been attributed to gastric auto-intoxication. 
 There is no organ of the body, it is said, which may not be 
 affected by toxic products absorbed from the "dilated" 
 stomach. (This theory is discussed in the chapter on Myas- 
 thenia Gastrica and in the section on the Vicious Circles of 
 the Stomach.) Many of these accidents, particularly those 
 which involve the nervous system, are seldom observed in 
 pyloric obstruction not complicated by intestinal putrefaction. 
 The contents of the stomach are neither absorbed nor evacu- 
 ated, to a noteworthy extent, into the intestines, but are 
 periodically removed by vomiting. The obstruction protects 
 both the intestines and the system. But in myasthenic 
 retention the gateway to self-poisoning remains open. Ob- 
 structive retention seldom produces melancholia, hypochon- 
 driasis, delirium, hallucinations of sight, diplopia, hemianopia, 
 formication, cramps in the extremities, dyspnea, tachycardia, 
 arrhythmia, irregularities of the pulse, acne, urticaria, ery-
 
 OBSTRUCTION OF THE ORIFICES. 593 
 
 thema fugax, and other disorders of the nervous, vascular, 
 respiratory, and cutaneous systems, by means of toxic pro- 
 ducts absorbed from the stomach. These symptoms are more 
 frequently due to intestinal toxemia, but indirectly — by 
 mechanical compression, by reflex action, and by inanition — 
 obstructive retention may exert a very pernicious influence 
 on the various functions. The enlarged and distended 
 stomach, filled with gas and acid contents, may compress 
 the heart and limit the movements of the diaphragm. If the 
 fermentation is butyric, acne is common enough, and vaso- 
 motor disorders of the skin may likewise be produced by 
 the reflexes starting from the irritated gastric mucous mem- 
 brane. Many nervous and cardiorespiratory symptoms 
 may be induced by the secondary neurasthenia and anemia. 
 Few of the constitutional symptoms are toxic, but some un- 
 doubtedly result from the inanition. The skin becomes dry 
 and often scaly, the extremities cold, and the body a more 
 easy prey to its environment. There is less resistance to 
 bacterial invasion and diminished endurance of cold weather 
 and of sudden atmospheric changes. The voluntary and in- 
 voluntary muscles become weak, and tonic and painful 
 cramps of the muscles of the forearm and of the calves of 
 the legs are not rare. But these symptoms, with emaciation 
 and loss of strength, constipation, and diminution of urine, 
 are the result of inanition. The food and water are retained, 
 or are lost largely by vomiting. Water may be eliminated 
 in large quantities by excessive gastric secretion. The food, 
 also, instead of being digested, ferments and decomposes. 
 The result is a form of starvation accompanied by dry 
 cachexia. 
 
 The nutritive state varies in the different stages of obstruc- 
 tion, and is influenced, also, by the nature and evolution of 
 the causative disease. In the cicatricial stenosis of ulcer and 
 of toxic gastritis the patient may, in the beginning of the 
 obstruction, be emaciated and anemic. Cancer also pro- 
 duces albuminous denutrition before the pyloric canal is 
 obstructed by the new growth. But, apart from the causa- 
 tive disease, pyloric obstruction affects nutrition in proportion 
 to its degree. During the period of compensation, on a suit- 
 able diet provided it be supporting, there is no loss of weight 
 or of strength. But when compensation fails and stagnation 
 results, nutrition begins to suffer. The loss of weight arid 
 strength, however, during this period is due more to acci- 
 dents, particularly fermentation and vomiting, than to the 
 obstruction, for the stomach eventually empties its contents 
 38
 
 594 DISEASES OF THE STOMACH. 
 
 into the intestines. Wlien retention begins, nutrition fails 
 more rapidly, and the body is not only insufficiently nour- 
 ished, but excessively dry. When the retention is pronounced, 
 the patient is emaciated and the skin is rough and dry. The 
 strength, however, often does not fail so rapidly as might 
 be expected. But when the obstruction is cancerous, or 
 when intestinal auto-intoxication exists as a complication, 
 the muscular weakness develops rapidly. Suddenly develop- 
 ing obstruction produces more rapid and complete starvation 
 than results from any other disease of the stomach. 
 
 The local physical signs are of great diagnostic value. 
 During compensation there may be no sign, unless a tumor 
 of the pylorus can be felt. But after meals the region of 
 the normal stomach is somewhat prominent ; the stomach 
 is more resistant to the fingers, and its form is well preserved, 
 particularly during digestion ; its walls feel elastic and firmly 
 contracted, and the organ may be enlarged. If the abdominal 
 wall is thin and yielding, even in this stage the strong peri- 
 staltic waves are sometimes visible, and the alternate relaxa- 
 tion and contraction of the stomach are often palpable at the 
 height of digestion. During the period of stagnation the 
 peristalsis, provided the stomach is not myasthenic, is strong 
 and active, and is more likely to be visible, and gastric splash- 
 ing may be elicited at the time when the stomach is inactive. 
 But visible peristalsis can not be excited in the empty stomach 
 in the morning before breakfast. During the third stage, or 
 that of retention, two physical conditions may exist. The 
 stomach may be strong and feel firm to the palpating finger, 
 and the splashing sounds may be elicited with greater diffi- 
 culty during peristaltic contraction than during the relaxation 
 of the organ. The alternate relaxation and contraction may 
 also be easily felt ; or, on the other hand, the stomach may be 
 flabby and easily compressible during its contraction, and 
 the splashing sounds may be produced at every moment with 
 equal ease. In both conditions gastric splashing is absent at 
 no time during the twenty-four hours, and the abdominal 
 wall over the stomach is prominent, except when the organ 
 is emptied by the tube or by vomiting, and becomes 
 more and more prominent as the stomach fills by accumula- 
 tion. The comparatively empty and contracted intestines 
 usually occupy but little space, and the stomach is, as a rule, 
 increased in size, and contains a large quantity of gas when, 
 physiologically, it should be retracted and empty. 
 
 A palpable tumor of the prjHorus is a valuable sign of 
 pyloric obstruction. Such a tumor may be formed by a neo-
 
 OBSTRUCTION OF THE ORIFICES. 595 
 
 plasm, by an ulcer with infiltrated walls, or by simple or 
 inflammatory hypertrophy. To detect the tumor, the exami- 
 nation should be made when the stomach is empty and with 
 the patient on his back. When the tumor lies beneath the 
 false ribs it may sometimes be caught by the fingers at the 
 end of a deep inspiration, particularly if the patient lies on 
 the left side. Sometimes the tumor can be felt only when the 
 stomach is moderately filled with gas, and, consequently, infla- 
 tion may aid in locating the tumor. The pyloric tumor can 
 sometimes be felt relaxing and contracting, and gas can be 
 felt and heard bubbling through it synchronously with the 
 peristaltic contraction of the stomach. But the absence of a 
 tumor, even when the pylorus can be felt, does not exclude 
 pyloric obstruction from arrested development and cicatricial 
 stenosis. A small annular scirrhus produces little increase in 
 the size of the pylorus, and the obstructing tumor may be out 
 of reach. Frequently enough, neither the pylorus nor a 
 pyloric tumor can be felt. 
 
 The functional signs vary according to the nature and 
 degree of obstruction and of muscular insufficiency, the char- 
 acter of the contents, and the form, extent, and degree of the 
 inflammation of the mucous membrane. (The functional signs 
 of cancer, of ulcer, and of hypersthenic and asthenic gastritis 
 are described in the chapters on these diseases.) Only the 
 functional signs due solely to the obstruction need here receive 
 attention. During the stage of compensation the obstruction 
 causes no abnormalities in the digestion and evacuation of the 
 test-breakfast and the test-dinner. Only when coarse, solid 
 food is given is the evacuation of the stomach delayed. During 
 the stage of stagnation the contents remain too long in the 
 stomach. This is true both of the test-breakfast and the test- 
 dinner, and of other meals containing much solid food. But 
 a glass of water is evacuated as readily as in health, and this 
 is a differential sign between obstructive and myasthenic 
 stagnation. After a test-meal less fluid is withdrawn than in 
 myasthenia. The stagnation may be of the first degree, the 
 stomach emptying itself after each meal, but later than in 
 health ; or of the second degree, the stomach being empty 
 only in the morning before breakfast. During the stage of 
 retention, the stomach is never empty at any moment during 
 the twenty-four hours. Even if the stomach be washed out 
 in the evening, before the Boas supper is given, on the follow- 
 ing morning it will be found to contain a noteworthy quantity 
 of food, and this is the pathognomonic sign of retention. In 
 obstructive stagnation and retention the evolution of the diges-
 
 59^ DISEASES OE THE STOMACH. 
 
 tion of the test-breakfast is abnormal. Not only is digestion 
 prolonged, — as occurs in obstruction, in myasthenia, in hyper- 
 chylia gastrica, and in hypersthenic gastritis, — but the lines 
 which represent the evolution of the total acidity of the free 
 and of the combined HC1 show sudden rises and falls, which 
 are due to the irregularity in the evacuation of the contents 
 of the stomach. Clinically, two conditions present themselves 
 in obstructive retention, accordingly as the muscular layer is 
 strong or weak. In the one, if the stomach be washed out, 
 two glasses of water will be evacuated within one and one- 
 half hours, as revealed by the cessation of splashing or 
 by the failure to express anything through the tube or to 
 detect anything in the stomach by employing a one per 
 cent, solution of sugar. If the stomach fails to stand 
 this test, myasthenia is not necessarily present, but either 
 the obstruction is great or the muscle is weak. If there is 
 retention in the morning, after the Boas supper has been 
 given on the preceding evening on a clean and empty 
 stomach, and if a pint of water is evacuated within one and 
 one-half hours, there is obstruction, and to that the reten- 
 tion is solely due. In the other condition there is also mus- 
 cular weakness, and the water is retained much longer when 
 given in the same manner. 
 
 A characteristic of the contents of the stomach in reten- 
 tion is the separation on standing into three layers, on 
 account of the gas-forming fermentation — the upper layer 
 being cloudy and frothy ; the middle, clear and fluid ; and the 
 lower, sedimentary. The contents withdrawn after the em- 
 ployment of an ordinary diet are watery, highly acid, and 
 fermented ; on the addition of grape-sugar they yield large 
 quantities of gas in the fermentation tubes. 
 
 The bacteriological signs are variable, but are in keep- 
 ing with the degree of stagnation and retention and with 
 the quality of the diet. In stagnation, with excessive or 
 active hydrochloric acid secretion, there is chiefly yeast 
 fermentation, and usually formation of acetic acid. If there 
 be no free hydrochloric acid after a test-breakfast, the most 
 common form of fermentation is lactic. In retention the 
 same relation obtains, but when there is excessive and active 
 secretion, hydrosulphuric acid and acetone are sometimes 
 found, and sarcinne are numerous. If no free hydrochloric 
 acid is present, the organic acids are chiefly lactic and butyric, 
 sarcinae are rare, and the fermentation is chiefly bacillary. 
 In all forms of retention the germs actively generate gas when 
 the sweetened, unfiltered stomach-contents are placed in fer-
 
 OBSTRUCTION OF THE ORIFICES. 59/ 
 
 mentation tubes and kept for twenty-four hours at the proper 
 temperature. 
 
 Differential Diagnosis and Diagnosis. — During the stage of 
 compensation pyloric obstruction is very likely to be over- 
 looked. Digestion is unconscious, except during the recur- 
 ring periods of disturbed compensation, when both patient 
 and physician are often satisfied with the common explanation 
 that these attacks are due to indigestion. But whenever a 
 patient has had a disease of the stomach which is liable to 
 be followed by pyloric obstruction, the recurring attacks of 
 motor insufficiency should excite suspicion and lead to a 
 careful examination, and the suspicion should be increased 
 whenever a secretory disorder is absent and there is no 
 trouble in the intestines. These attacks are nearly always 
 produced by dietetic excesses of a particular kind. A heavy 
 meal containing irritants and easily fermentable articles of 
 food may disturb a normal stomach, but more readily one that 
 is myasthenic, or that is only just equal to the task of over- 
 coming a resistance to its evacuation. But recurring attacks 
 of gastric indigestion, accompanied by stagnation and peri- 
 staltic pain or vomiting, with little or no fermentation, and not 
 followed by diarrhea or intestinal trouble, and caused like- 
 wise by eating a large meal of coarse, solid food, in the 
 absence of fever or of any constitutional disease, are most 
 often due to obstruction. And the probability is greatly 
 increased if the patient has just recovered from an ulcer or 
 from toxic gastritis and if the stomach feels strong to the 
 palpating finger during its contractions, and does not splash 
 longer than it normally should after the administration of a 
 glass of water while it is empty. Dietetic excesses invariably 
 disturb compensation, for the anatomical obstruction is per- 
 sistent. The detection of a pyloric tumor at once removes 
 all doubt. The possibility of duodenal obstruction producing 
 the same symptoms under the same circumstances should 
 not be forgotten. 
 
 Gastric stagnation and retention are either obstructive, 
 myasthenic, or cancerous, and may be due to cancerous or 
 inflammatory infiltration of the muscular layer. Excessive 
 secretion prolongs digestion. The motor power of the 
 stomach in uncomplicated chronic asthenic gastritis is as 
 good as in health. Chronic hypersthenic gastritis may some- 
 times cause obstruction of the pylorus, and is frequently 
 complicated, particularly in its advanced stages, by motor 
 insufficiency. Cancer may likewise produce the two condi- 
 tions in both ways. When either stagnation or retention is
 
 598 DISEASES OF 7 HE STOMACH. 
 
 chronically present, the search for the causative disease 
 should be made methodically. 
 
 1. Is the motor insufficiency due to obstruction or to my- 
 asthenia ? 
 
 2. Is the stagnation or retention due to obstruction or to 
 supersecretion ? 
 
 3. Is the obstruction pyloric or duodenal? 
 
 4. Is the pyloric obstruction benign or malignant ? 
 
 5. What is the character of the benign process ? 
 
 6. What is the degree of obstruction ? 
 
 I. The first step in the solution of the problem is the 
 search for a pyloric tumor. The examination is greatly facili- 
 tated by the reduction of abdominal tension through evacua- 
 tion of the bowels and bladder. The search should be begun 
 when the stomach is empty. With all the viscera thus empty, 
 the examination of the abdomen is made easier. Any ab- 
 normality of tlie abdominal organs is noted, and special 
 attention should be given to the displacement of the right 
 kidney, the distention of the gall-bladder, and the search for 
 any tumor which might obstruct the duodenum. The pylorus 
 should next be sought, using the act of respiration, and also 
 the posture on the left side, in order, if possible, to bring the 
 pylorus within reach. The stomach should next be moder- 
 ately inflated with air or an effervescent powder, and the 
 pyloric end of the stomach and the position of the whole 
 organ should be noted, as the obstruction may be due to dis- 
 placement of the stomach. If a pyloric tumor is found, the 
 discovery is very important. Stagnation or retention, with 
 the presence of a palpable p\'loric tumor, demonstrates the 
 obstructive nature of the trouble. The presence of the other 
 signs of obstruction, in contradistinction to myasthenia, con- 
 firm the diagnosis. 
 
 If no pyloric tumor can be felt, a search for a displaced 
 organ or for a tumor which might obstruct the duodenum 
 should be instituted. In the absence of an ulcer history, of 
 toxic gastritis, of the signs of cancer, and of congenital 
 stenosis, and if the pylorus can be felt and presents no 
 tumor, duodenal obstruction is the probable cause. 
 
 In the absence of a discoverable pyloric tumor, and of any 
 cause of duodenal obstruction, the differentiation between 
 obstructive and myasthenic stagnation or retention must be 
 made by other symptoms which often have a distinctive and 
 conclusive significance. But at particular moments in the 
 evolution of a number of cases there is a chance to make 
 only a more or less rational guess.
 
 OBSTRUCTION OF THE ORIFICES. 599 
 
 Myasthenic stagnation is a frequent disease of the stomach. 
 Myasthenic retention is rare, and much less common than ob- 
 structive retention. In the one or the other degree of motor 
 insufficiency the probability is in favor of the more frequent 
 cause. 
 
 If the stagnation or retention has been preceded by a dis- 
 ease likely to produce obstruction, such is probably the gene- 
 sis and nature of the trouble. In the absence of such a disease 
 myasthenia is probably the cause, and the probability is greater 
 if the patient has gout, or has recently recovered from an acute 
 infectious disease, like influenza or typhoid fever, and if the 
 common signs of myasthenia are present. 
 
 The evolution of myasthenia is slow and mild. The trouble 
 may exist for months without producing any local symptoms, 
 and may last for years without the development of supersecre- 
 tion. Obstruction is usually rapid, painful, and stormy in its 
 evolution. During the stagnation period the stomach often 
 becomes intolerant; and, as a rule, the urine is much less, 
 diminished in quantity than it is in myasthenia, and fermenta- 
 tion is much less active. But in the retention period fermenta- 
 tion is active in both diseases, and the difference in the quan- 
 tity of urine increases. 
 
 In obstruction the muscular layer of the stomach often 
 undergoes hypertrophy, and the peristalsis during digestion 
 is palpable, sometimes visible and painful. In myasthenia 
 these signs of increased effort and power are not found. 
 
 In myasthenia vomiting is very rare, and pain is nearly 
 always absent during the period of stagnation. In obstruc- 
 tive stagnation both pain and vomiting are very common. 
 During the retention period of myasthenia vomiting is infre- 
 quent and copious, but during the same stage of obstruction 
 vomiting, as a rule, is more frequent, occurs oftener as the 
 climax of the trouble excited by a meal, and is accompanied 
 sometimes by nausea and retching, the stomach frequently 
 retracting after its evacuation. Obstructive retention is much 
 more serious and starves more rapidly than does myasthenic 
 retention. Expression of the contents of the stomach is easy 
 in obstruction ; it is always difficult and incomplete in myas- 
 thenia. 
 
 In myasthenia liquids as well as solid food stagnate or 
 are retained. This peculiarity is so pronounced that the 
 disease was once called the " dyspepsia of liquids." In ob- 
 struction, on the other hand, liquids are evacuated from the 
 stomach much more readily than semi-solid food. This 
 fact constitutes the differential value of the water-test. In
 
 6oO DISEASES OF TJIE STOMACH. 
 
 obstructive stagnation if a pint of water be given when the 
 stoniacli is empty, it is evacuated within one and one-half 
 hours, which is long before the myasthenic stomach ceases 
 to splash or to yield water upon the introduction of the tube. 
 Myasthenia often yields readily to treatment, or, in the 
 stage of retention, can often be so managed as to maintain 
 the balance of nutrition at a low level. Obstruction is much 
 more obstinate, and after compensation is broken it is sus- 
 ceptible of little relief except by operation ; it is never cured 
 by medication, but its ultimate progress may be thus 
 arrested. Other differential signs are enumerated under 
 the retention form of Myasthenia. 
 
 2. The prolonged digestion of hy[)erchylia gastrica and of 
 hypersthenic gastritis may be confounded with that of ob- 
 structive stagnation. In one instance the stagnation is due to 
 excessive secretion ; in the other the stagnation is due to ob- 
 struction. In both a pint of water is evacuated within the 
 normal time. But the contents of the stomach after the test- 
 breakfast are greater and more fluid, and have less of the 
 roll in supersecretion than in obstructive stagnation. The 
 evolution of digestion is abnormal but regular in glandular 
 gastritis and in hyperchylia gastrica; it is subject to sudden 
 and irregular rises and falls in obstruction, as displayed by 
 the irregularity of the lines which represent the evolution of 
 the total acidity and of the free and combined HCl. In 
 obstruction secretion ceases when the stomach no longer 
 contains food ; in the continuous or prolonged secretion 
 the stomach secretes after it has been thoroughly washed 
 out. In obstruction the early morning residual contents 
 may be more acid (H + C) than the contents at the acme 
 of the digestion of the test-breakfast ; but this is never so 
 in hypersthenic gastritis not complicated by obstruction or 
 by myasthenia nor in hyperchylia gastrica. The causation 
 and the evolution of these diseases may be widely different, 
 and the results of treatment may be such as are obtained in 
 only the one or the other disease. 
 
 3. These many signs and symptoms distinguish obstruc- 
 tive from myasthenic stagnation or retention, and from func- 
 tional or organic supersecretion. Is the obstruction pyloric 
 or duodenal ? 
 
 The causes of duodenal obstruction are displacement of 
 the stomach, malignant neoplasms developing in its wall or in 
 the surrounding parts, compression by benign tumors, cica- 
 tricial contraction after ulcer or ulceration, local plastic peri- 
 tonitis, impaction of a gall-stone, and, possibly, a displacement
 
 OBSTRUCTION OF THE ORIFICES. 6oi 
 
 of the right kidney. The obstruction of the duodenum above 
 the orifices of the pancreatohepatic duct can not be distin- 
 guished from pyloric obstruction. But it is in the first part 
 of the duodenum that the traction of a displaced stomach 
 contracts the lumen of the digestive tube; and when the 
 stomach thus displaced is the receptacle of stagnation and re- 
 tention, and its walls are hypertrophied, and no tumor of the 
 pylorus can be felt, and when there are no signs or history of 
 ulcer or cancer of the stomach, it is then reasonable to con- 
 clude that the obstruction to the evacuation of the stomach 
 is in the duodenum, and is due to the traction and bending. 
 Obstruction below the opening of the common duct produces 
 special signs. The clinical history may locate the trouble 
 at this point, which may be more sensitive to pressure than 
 are the other parts of the abdomen. The history of gall- 
 stones or of duodenal ulcer, and the existence of a circum- 
 scribed tender point in the back and to the right of the lower 
 dorsal vertebra, are of particular value in this connection. 
 Search should be made, also, for a distended gall-bladder and 
 for cancer of this organ. The vomit and the contents of the 
 stomach furnish signs of unquestionable value. The vomit 
 almost continuously contains bile, and, indeed, the bile is pre- 
 sent in the first mouthful brought up, showing that it is not 
 pressed into the stomach by the act of vomiting. No signifi- 
 cance should be attached to the presence of bile in the last of 
 the matter vomited ; but this sign is very valuable, when re- 
 peatedly obtained, in excluding obstruction of the pylorus or 
 of the first part of the duodenum. In duodenal obstruction 
 of a high degree the duodenum itself is the site of retention. 
 If the stomach be thoroughly washed out, the later vomiting 
 of the duodenal contents or their removal through the tube 
 after massaging the duodenum is a very valuable sign. It 
 should not be forgotten that it is very difficult to cleanse 
 the stomach completely when food is retained ; but this pro- 
 cedure is much easier when, as is most frequent in obstruc- 
 tion, the stomach is not myasthenic. Another sign is the 
 great variability of the free hydrochloric acidity of the gastric 
 contents, which is due to the variable quantity of the duodenal 
 contents regurgitated into the stomach. The vomit also 
 contains pancreatic juice, except when the pancreas is 
 diseased. The presence of pancreatic juice in demonstrable 
 quantity excludes advanced disease of the pancreas, and 
 consequently it also excludes one of the causes of duodenal 
 stenosis. The frequent vomiting of duodenal contents in 
 association with gastric retention is in favor of obstruction in
 
 602 DISEASES OF THE STOMACH. 
 
 the lower part of the duodenum, and aids in the exclusion 
 of obstruction of the pylorus. Duodenal obstruction being 
 excluded, the benign or malignant nature of the pyloric 
 obstruction should next be determined. 
 
 4. The differentiation of benign and malignant obstruction 
 of the pylorus may be easy or exceedingly difficult, and 
 is sometimes impossible. If the obstruction develops as a 
 sequel of ulcer or of toxic gastritis, the benign and cicatricial 
 nature of the obstruction is almost certain, for, practically, 
 the cancerous degeneration of ulcer is so rare that it may be 
 disregarded. Where a knotty, hard tumor can be felt there is 
 most probably carcinoma; and there is little room for doubt 
 if the functional, bacteriological, blood, and nutritive signs of 
 cancer are present. But too often the clinical history and 
 the signs are not so distinctive. 
 
 The differentiation is frequently dependent on a predomi- 
 nance of probabilities, so that only a rational guess at the 
 truth can be made. If hydrochloric secretion is normal or 
 excessive, the disease is probably benign, but it should not 
 be forgotten that carcinoma of the pancreas and gall-bladder 
 seldom diminishes gastric secretion before the period of 
 cachexia arrives. Lactic acid formation is not a pathogno- 
 monic sign, as it may occur in benign retention accom- 
 panied by asthenic gastritis. But the weight of evidence 
 is in favor of cancer where there is no free hydrochloric acid 
 and where the lactic acid is formed by bacilli. The forma- 
 tion of hydrogen sulphid is also a benign sign. The con- 
 tinued presence of sarcinae for a long period does not occur 
 in carcinoma of the pylorus, this germ disappearing rapidly 
 when lactic acid begins to develop. Butyric acid fermenta- 
 tion is also more frequent in carcinoma. The functional and 
 bacteriological signs do not rapidly change in benign obstruc- 
 tion, as they do during the rapid evolution of carcinoma. 
 These signs maybe so grouped as to produce a preponderant 
 weight of evidence in favor either of the benign or the malig- 
 nant nature of the obstruction. The functional and bacterio- 
 logical signs are of less value when it is not certain that the 
 obstruction is pyloric and that it is primarily so. 
 
 The age of the patient is of very little value, except in the 
 exclusion of congenital atresia or stenosis, if the trouble 
 began after childhood. The age being below twenty is 
 against cancer. The evolution of cancer is rapid and pro- 
 gressive, presenting only short periods of improvement. 
 There is no long period of gastric trouble followed by a 
 period of compensation before the development of stagnation
 
 OBSTRUCTION OF THE ORIFICES. 603 
 
 and retention. Rectal feeding is less beneficial than in 
 benign obstruction, and careful feeding by mouth and rectum 
 is powerless against the progressive loss of strength, the 
 excessive albuminous waste, and the toxic leukocytosis of 
 cancer. The cachexia of benign obstruction is dry, like that 
 of simple starvation, and with it is never found the fugacious 
 edema of malignant disease. 
 
 The dissemination signs of cancer should be carefully 
 sought, and enlargement of the abdominal and supraclavicular 
 glands and secondary nodules in the liver should be con- 
 sidered conclusive. 
 
 The water-test is also of some differential value in the 
 stage of stagnation, water being evacuated much more 
 rapidly in benign than in malignant disease. 
 
 In cases where only a few of these distinctive features are 
 found, the diagnosis should be held in suspense. Cases 
 beginning suddenly, developing rapidly, with pain and circum- 
 scribed tender points, with stagnation or retention, with the 
 presence of free acid, yeast, and sarcinse, without a palpable 
 tumor or with one that is not characteristic of either cancer 
 or ulcer, may be due either to ulcer or to cancer. Under these 
 circumstances the most rational but often incorrect guess is 
 obstruction due to ulcer. 
 
 A positive diagnosis should be given only when the weight 
 of evidence is overwhelming; under other circumstances a 
 probable opinion or no opinion whatever should be expressed, 
 if it be desired to avoid the unpleasant revelations of an 
 exploratory laparotomy. An accidentally correct guess pos- 
 sesses no merit, and a false opinion would only yield chagrin 
 and condemn immodesty. 
 
 5. The causes of benign obstruction are ulcer, ulceration, 
 benign tumors, foreign bodies, arrested development, hyper- 
 trophy, and hyperplasia. The cicatricial obstruction of toxic 
 gastritis is revealed or excluded by the clinical history. 
 Syphilitic and tubercular ulceration and obstruction by benign 
 tumors and foreign bodies are not recognizable. Congenital 
 atresia and stenosis are revealed by the age when they begin, 
 by their evolution, and by the signs and symptoms, already 
 described, which they produce. The hypertrophy and hyper- 
 plasia are characterized by a preceding productive gastritis in 
 the inflammatory form, and by the presence of a smooth, 
 regular, contracting and relaxing, and non-adherent tumor, 
 through which the gastric contents spurt and bubble. The 
 evolution may be rapid after the second degree of stagnation 
 develops. The most common form of benign obstruction is
 
 604 DISEASES OF THE STOMACH. 
 
 caused by ulcer, and its only distinctive signs are those of the 
 ulcer which precedes or accompanies it. 
 
 6. The diagnosis of the degree of obstruction is easy. 
 During the period of compensation the stomach empties 
 itself in about the normal time, without the development of 
 an excessive germ growth. 
 
 The period of stagnation is characterized by the delayed 
 evacuation of the stomach. The test-breakfast and the Leube- 
 Riegel dinner remain longer than the normal period in the 
 stomach, as revealed by the employment of the tube and 
 by splashing sounds, particularly during the relaxation of 
 the walls of the organ. Two degrees of stagnation may be 
 distinguished, and are clinically important. In the mild 
 form the stomach empties itself after each of the three meals. 
 In the severe form the stomach is found empty and free from 
 splashing only before breakfast. 
 
 In retention the stomach never completely empties itself, 
 and splashes before anything is taken into it in the morning. 
 Clinically, a particular test should be adopted as the criterion. 
 If the stomach be thoroughly washed out in the evening and 
 the Boas supper given, food should be found in it the fol- 
 lowing morning. 
 
 The degree of retention is revealed by the quantity of 
 urine passed in the twenty-four hours, provided there is no 
 great loss by perspiration or by an intercurrent diarrhea, and 
 provided, further, that the kidneys are not diseased, the 
 stomach not intolerant, and that three pints of fluid be taken 
 during the day. Another rough measure is the quantity and 
 composition of the feces. The progress of starvation is 
 still another guide. 
 
 Prognosis. — Pyloric obstruction is a very serious disease, 
 and the prognosis is bad. The greater the obstruction, the 
 worse is the outlook. Naturally, the nature and rapidity of 
 development of the causative trouble are modifying factors. 
 Medical treatment is palliative ; surgical treatment may be 
 curative. 
 
 Treatment. — The treatment of pyloric obstruction is med- 
 ical and surgical. 
 
 The medical treatment is only palliative, but is none the less 
 valuable before an operation is indicated, and also when sur- 
 gical intervention is not advisable on account of the possi- 
 bility of maintaining nutrition by the administration of the 
 proper foods in the right manner. 
 
 The diet is the most important part of the treatment. 
 During the stage of compensation digestive hygiene and the
 
 OBSTRUCTION OF THE ORIFICES. 605 
 
 avoidance of dietetic excesses and errors are imperative as 
 prophylactic measures. The diet should consist of the best 
 meats — like beef, mutton, chicken, white meat of turkey, 
 pheasant, grouse, quail, squab, and lean fresh fish. The 
 cereals, particularly the preparations of wheat and rice, 
 thoroughly cooked, are also suitable. Vegetables should be 
 prepared as purees. No fat, except butter or cream or 
 Hauswaldt's " vigor chocolate," should be permitted, and the 
 sweets should be of the simplest sorts. Stewed fruits are 
 permissible in moderation, and, likewise, the preparations of 
 eggs and milk, on condition that they are well borne. The 
 diet in this stage is prophylactic, and in addition to being 
 nutritious, digestible, and utilizable, should make the muscular 
 work of the stomach as light as possible, and not irritate the 
 mucous membrane mechanically or chemically nor favor germ 
 growth. Fine mechanical subdivision, either by previous 
 preparation or by thorough mastication, is an absolute and 
 invariable requisite. A dry diet is a mistake in any stage 
 of obstruction ; and during compensation coffee, weak tea, 
 cocoa, and, if it has been the habit of the patient to take alco- 
 holic drinks, a little old whisky diluted, or old and light wine, 
 should be allowed in such quantity as not to exceed the 
 limits of good hygiene. There is no tendency to water- 
 stagnation or retention as in myasthenia, but coarse, irritating, 
 and solid food is liable to disturb compensation. No incom- 
 pletely fermented nor yeast-containing drinks of any sort 
 should be permitted. During the acute breaks in compensa- 
 tion the stomach should be washed out and given functional 
 rest for twenty-four hours, and the feeding by mouth should 
 be resumed with small quantities of liquid food. There is, 
 during this stage, no indication for drugs, and the stomach 
 should be particularly guarded against medication liable to 
 derange its secretion. The general health should be main- 
 tained by hydrotherapy and by good general and digestive 
 hygiene. 
 
 Stagnation is a sign of danger, and demands strict care and 
 efforts to restore compensation or to check the advance of 
 motor insufficiency. The diet for the stage of compensation 
 should be modified by the exclusion of all food which easily 
 ferments, and sweets, consequently, should be entirely forbid- 
 den in many cases. The food for the twenty-four hours should 
 be divided into three equal portions, and so limited in bulk 
 as to obtain the complete evacuation of the stomach before 
 the next meal. The nourishment should be fluid, and the
 
 6o6 DISEASES OF THE STOMACH. 
 
 liquids should be so increased in proportion to tlie solids as 
 to obtain this end. Rectal feeding should be employed 
 exclusively, during the attacks of intolerance. Strychnin, 
 massage, electricity, and general neuromuscular tonics should 
 be used to restore compensation or to control the increasing 
 insufficiency of the muscular layer. In the mild form of 
 stagnation there is no indication for stomach washing, unless 
 there be excessive fermentation. But in the severe form of 
 stagnation the stomach should be washed out daily with a 
 weak alkaline solution if there be much yeast or sarcina:. 
 The preferable time for the stomach washing is in the early 
 morning before breakfast, so as to remove no nourishment. 
 But if the fermentation can not be thus controlled, the lavage 
 should be performed in the evening with Thiersch's solution, 
 and then with boiled water to remove the residuum of the 
 solution. Three grains of resorcin resub. dissolved in a table- 
 spoonful of chloroform-water should be left in the stomach 
 over night. 
 
 During the period of retention the diet of stagnation 
 should be continued, and the stomach should be daily washed 
 out in the morning before breakfast with water alone, or with 
 an alkaline solution, or with Thiersch's solution and water" 
 A solution of hydrochloric (i : looo) acid should be left in 
 the stomach if too little of it is secreted ; or, in case it is 
 secreted in excess, the stomach should be left empty, or a solu- 
 tion of nitrate of silver or of resorcin, or of any non-irritant 
 anti-fermentative, should be left in the organ. Rectal feeding 
 should be methodically employed. 
 
 Three grand principles control the feeding of a patient with 
 obstruction of the pj^lorus. 
 
 1. The stomach must be empty at the beginning of each 
 meal. 
 
 2. All the food must be very finely divided, readily soluble 
 or easily rendered fluid, and without unsuitable action on 
 secretion or on the motor function. 
 
 3. The diet must be varied and sufficient to support or to 
 improve nutrition. 
 
 If the first principle is violated, and the stomach is not 
 empty at the beginning of each meal, the symptoms will not 
 be relieved and there will be no improvement. In the mild 
 form of stagnation there is no chance to violate this rule. In 
 the severe form of stagnation it may be only necessary to 
 separate the meals by intervals which are longer than our 
 ordinary dietetic habits make them, or it may be necessary
 
 OBSTRUCTION OF THE ORIFICES. 607 
 
 to restrict the number of meals to two in the twenty-four 
 hours. As the stomach regains its tone and power a light 
 lunch may be permitted between breakfast and dinner, but 
 it must consist of food which rapidly leaves the normal 
 stomach and which can be easily evacuated through the nar- 
 row pylorus. In obstructive retention the two-meal system 
 should be adopted without delay, and if the stomach is not 
 empty an hour before these two meals, the stomach-tube 
 must be used to render it so. The contents should be re- 
 moved, the stomach washed out and left empty. 
 
 The physical properties of the food are of the utmost 
 importance. The pyloric opening is small, and all the food 
 must be such as can easily pass through a small canal. 
 Naturally, the state of secretion should control the choice of 
 the articles of the diet, and it may be necessary to embody 
 other dietetic principles in the management of particular 
 cases. But the minute division and the solubility or the fluidity 
 of the food after its preparation are essential properties, which 
 may be readily secured by the method of cooking or by 
 straining the food after it is cooked. The crushed and cooked 
 muscle pulp of meat, eggs but slightly cooked or hard 
 boiled and powdered, fresh fish with loose and short fibers, 
 milk if it agrees well, cream, butter, cheese, zwieback, light 
 cake, cereal (strained) puddings, light custard, oatmeal 
 (strained), cornmeal mush, corn bread made of " round " 
 cornmeal, rice passed through a colander, rice cakes, flour 
 " ball," vegetables passed through a sieve, cooked fruit 
 strained, and similar articles from all the grand classes of 
 food may be ordered. Fed in this manner, patients with 
 pyloric obstruction often improve rapidly and are able to eat 
 and digest a varied diet comfortably. 
 
 The symptoms requiring special medication are vomiting, 
 pain, and constipation. If the pain and vomiting are not 
 relieved by the diet and lavage, and by functional rest of the- 
 stomach obtained by exclusive rectal feeding, codein and 
 atropin should be given hypodermically and a hot or Winter- 
 nitz compress should be placed over the abdomen. Counter- 
 irritation and the locally-acting drugs are useless against 
 vomiting and pain. Bismuth, in a large daily dose when the 
 stomach is empty, is an exception to this general rule. A 
 sedative to both nerve and muscle should be used, and the 
 codein and atropin form the most beneficial combination. 
 The constipation should be treated exclusively by clysters of 
 water, of soapsuds, of water and glycerin, or of water,
 
 6o8 DISEASES OF THE STOMACH. 
 
 glycerin, and oil. The patient should remain quiet in bed, so 
 as to reduce the nutritive needs of the organism and to con- 
 serve the ever-failing vital energy. 
 
 The only hope of a possible cure of pyloric obstruction lies 
 in surgery. Numerous operations have been advocated and 
 performed. Loreta's digital divulsion is not a good operation, 
 since it is often inefficient, only practicable in a few cases, and 
 about as dangerous as the operations which give greater hope 
 of benefit. Gastrostomy and a permanent pyloric tube, 
 through which the patient is fed, can not be said to decrease 
 very much the discomfort of the patient. Bernay's curetting 
 operation has justly found but little favor. Duodenostomy 
 has proved objectionable. Jejunostonn- has only one indica- 
 tion — cancerous degeneration of the body of the stomach, 
 rendering gastro-enterostomy impracticable. There remain 
 pylorectomy, pyloroplast}-, gastro-enterostomy, and combined 
 pylorectomy and gastro-enterostomy. 
 
 The choice of an operation is determined by the nature of 
 the obstruction, the existence of adhesions, the degree of 
 atrophy of the muscular layer, and the strength of the patient. 
 For localized and unadherent carcinoma, pylorectomy and 
 combined pylorectomy and gastro-enterostomy are the opera- 
 tions to be chosen. If the carcinoma is already disseminated 
 or adherent, gastro-enterostomy is the proper palliative opera- 
 tion. The ideal operation for cicatricial stenosis is pyloro- 
 plasty. In case it is not practicable on account of adhesions or 
 induration and thickening, gastro-enterostomy should be per- 
 formed. 
 
 Indications for an operation are present much earlier than 
 are usually admitted by the physician or accepted by the 
 patient, who, as a rule, gives his consent only when death 
 stares him in the face. An operation should be advised in can- 
 cerous obstruction as soon as the nature of the obstruction is 
 recognized, and the earlier it is done, the better are the chances 
 of prolonging life and making the patient more comfortable. 
 Continuous obstructive retention, however caused, demands 
 surgical intervention as soon as the stomach can be prepared 
 for operation, especially if a judicious effort has failed to restore 
 compensation to such a degree as to render it possible to nour- 
 ish the patient. The same rule holds good in the severe form of 
 obstructi\'e stagnation accompanied by much suffering, or by 
 the first stages of starvation, or by rapid progress of the dis- 
 ease. Operation should be deferred in the mild form of benign 
 obstructive stagnation.
 
 OBSTRUCTION OF THE ORIFICES. 609 
 
 The reestablishment of the permeabiHty of the digestive 
 tube relieves all the symptoms due to the stagnation and 
 retention — the appetite improves, the patient gains weight and 
 strength, the vomiting and pain cease. But in carcinoma the 
 secretory function is not restored, a result due in all prob- 
 ability to glandular degeneration or transformation. The 
 motor function is restored and the enlarged stomach retracts, 
 unless the disease is so far advanced as to produce atrophy 
 or degeneration and infiltration of the muscular coat. 
 
 39
 
 SECTION VI. 
 THE ViaOUS CIRCLES OF THE STOMACH. 
 
 CHAPTER I. 
 
 OTHER ORGANS IN THE DISEASES OF THE STOMACH, OR 
 THE STOMACH IN THE CAUSATION OF DISEASE. 
 
 There is no doubt that the diseases of the stomach some- 
 times play an important part in the causation of disease, but 
 we consider it true, also, that the effects of a diseased stomach 
 are often overestimated. Probably no other organ more 
 frequently becomes diseased secondarily, but the vicious 
 circles established between the stomach and the other impor- 
 tant organs of the body seldom, in comparison, begin in the 
 stomach. We strongly oppose the theory which makes the 
 diseased stomach an all-important disease factory. 
 
 Many of the effects of diseases of the stomach are merely 
 passing and variable symptoms ; but other effects are more 
 persistent and constant. It is these constant and persistent 
 effects which we wish to describe, constituting complications 
 or sequelae linked in close causal relation with the disease of 
 the stomach. 
 
 The stomach as a disease-producing organ may act in sev- 
 eral ways — through its influence on intestinal digestion and on 
 nutrition, through its disturbance of physiological chemistr\-, 
 and through auto-intoxication. The influence on intestinal 
 digestion is direct, the abnormal chyme producing abnormal 
 chylification. On all other organs the diseased stomach acts 
 either through the nervous system or through the blood. 
 It is difficult to determine how much disturbance is due to 
 refle.x action ; it is difficult to know how far the peripheral 
 irritation involves the sympathetic and cerebrospinal centers ; 
 it is difficult to discover how far the chemistry of the body 
 is altered in a particular case by the diseased stomach ; and 
 it is far more difficult to estimate with precision the injury 
 done by auto-intoxication. 
 
 The existence of gastric auto-intoxication is only an infer- 
 
 6io
 
 THE VICIOUS CIRCLES OF THE STOMACH. 6ll 
 
 ence, and the correctness of the inference is denied by some 
 writers. It is claimed that the total quantity of the fermen- 
 tation acids formed in the stomach is not great ; that few of 
 them are toxic, even in large quantity; that they are combined 
 and diluted by the blood, that some of them are so harmless 
 as to serve as food ; and that putrefaction, which is the chief 
 source of poisons, occurs in the stomach seldom and irregu- 
 larly and, indeed, almost accidentally. Clinical and experi- 
 mental evidence is not conclusive, it is true, as to the existence 
 of gastric auto-intoxication, but it would seem that iconoclasm 
 threatens to go too far. The toxicity of the gastric juice is 
 much greater in some of the diseases of the stomach than in 
 health ; the toxicity of the urine is often increased in the 
 diseases of the stomach accompanied by toxemic symptoms, 
 although the bowels be healthy and the liver show no signs 
 of functional insufficiency ; there are often present in the 
 diseased stomach, and, indeed, in a state of active and virulent 
 growth, germs which produce poisons in cultures. These are 
 conclusions deduced from our investigations. Hydrogen 
 sulphid formed in the stomach and found in the breath and 
 in the urine gives rise to a special symptom-group on its way 
 through the system. Butyric acid certainly produces local 
 irritation and systemic symptoms. Acetone is sometimes 
 found in the stomach when oxybutyric acid and acetone are 
 found in the urine. Moreover, the toxicity of the urine is no 
 index of the toxemia, for gastric poisons are not eliminated 
 by the kidneys only, and it is probable that some of them, at 
 least, are changed into simpler and non-poisonous compounds 
 during their passage through the body. Furthermore, the 
 absence of a perceptible increase of the toxicity of either the 
 gastric contents or the urine does not exclude the existence 
 of slow, chronic self-poisoning. The denial of the existence 
 of gastric self-poisoning is based on a simple negation, and 
 can not be justly made in disregard of the clinical and 
 experimental evidence which we have, however little it 
 may be. 
 
 I. INFLUENCE ON THE INTESTINES. 
 
 The functions of the intestines may be disordered indi- 
 rectly by the injurious influence of the diseases of the stomach 
 on the nervous system, on the liver, on the blood, on nutri- 
 tion, on the circulation, and on the kidneys ; but there can be 
 no question that their most direct action is on the intestines 
 by reflexes originating in the stomach and conveyed by the
 
 6l2 DISEASES OF THE STOMACH. 
 
 sympathetic and the pneumogastric nerves. These influences, 
 however, are difficult to define, and they may be dismissed 
 with this brief notice in order that we may pass at once to 
 the consideration of the more important disturbances which 
 occur in virtue of the close association of the stomach and 
 intestines in digestion, and of their being but divisions of the 
 digestive tube with one grand work in common. 
 
 Whenever the stomach fails to do its required digestive 
 work an additional burden is thrown on the intestines. If 
 the nitrogenous food is not properly peptonized, and if the 
 bundles of muscular fibers are not unbound, as is the case in 
 insufficiency of the secretory and motor functions, the omitted 
 work must be performed in the bowels. If the action of the 
 saliva is too rapidly arrested in the stomach, the intestines 
 must convert more than their share of the carbohydrates. 
 The healthy intestines, as is well known, are capable of per- 
 forming this e.xtra work perfectly, and the digestion and the 
 utilization of the food may be as good as when both the 
 stomach and intestines do their work normally. But the 
 extra work is a menace to the integrity of the functions of 
 the intestines, and their susceptibility to disease is increased. 
 
 A disease which disorders the digestive work of the 
 stomach, disorders, as a necessary consequence, the secretion 
 and peristalsis of the intestines. It is well known that the 
 saliva and the products of salivarj' digestion are physiological 
 excitants of gastric secretion. If the saliva be excluded from 
 the food and its entrance into the stomach prevented, the 
 activity of the secretion of hydrochloric acid and the two 
 gastric ferments during the digestion of the test-breakfast is 
 reduced to about one-half of what it should be. The products 
 of gastric digestion, also, excite the functions of the stomach. 
 Chyme, on the other hand, as it undergoes conversion into 
 chyle, is the physiological excitant of intestinal secretion and 
 peristalsis, so that an alteration of the composition of the 
 chyme must entail an alteration of intestinal secretion and 
 peristalsis. This alteration may be compensatory or it may 
 be so great as to produce functional insufficiency. 
 
 Now. functional insufficiency of the intestines, whether it 
 be produced by extra work or by disordered gastric secretion 
 and peristalsis, favors intestinal fermentation and putrefaction, 
 and these in turn become active enemies of intestinal health. 
 Thus the diseases of the stomach which are accompanied 
 by disorders of secretion (excessive or diminished) and 
 by disorders of the motor function (excessive or diminished) 
 produce naturally disorders and diseases of the intestines.
 
 THE VICIOUS CIRCLES pE THE STOMACH 613 
 
 If the disease of the stomach be accompanied by excessive 
 gastric secretion, the carbohydrates must be digested by the 
 bowels, and the gastric digestion of albumin is very active. 
 If sweets are not excluded from the diet, gastric fermentation 
 may become active, and, continuing in the intestines, it may 
 prevent intestinal putrefaction ; but even in this condition 
 putrefaction is likely to begin in the cecum, where the con- 
 tents first become nearly neutral or alkaline. The colonic 
 putrefaction is not accompanied by indicanuria, but it is 
 manifested by very foul stools, and by the excessive formation 
 of H2S gas. If sweets be excluded from the diet, gastric 
 fermentation may be controlled, but intestinal putrefaction 
 then begins high up in the small bowel, and the contents 
 become thoroughly rotten in the colon. Indicanuria is very 
 marked, and putrefaction and pancreatic superdigestion are 
 only favored by the excessive gastric peptonization in the same 
 manner as when predigested foods are eaten. If the disease 
 of the stomach be accompanied by diminished gastric secre- 
 tion, salivary digestion is very active and the digestion of the 
 albumins is thrown on the bowels. Fermentation begins 
 high up in the small intestines (even in the stomach, if there 
 be motor insufficiency), and continues as long as the intesti- 
 nal contents contain fermentable matter. Putrefaction does 
 not occur in the small bowel, and the fermentation is usually 
 active enough to prevent excessive putrefaction in the colon. 
 If gastric stagnation or retention be present, there will be in- 
 testinal putrefaction or fermentation according to the reaction 
 of the chyle and its richness in peptones or carbohydrates. 
 Consequently, in diseases of the stomach which are accompan- 
 ied by disorders of secretion and by disorders of the motor 
 function, intestinal secretion and peristalsis may be disturbed, 
 the food may be lost by fermentation and putrefaction (the 
 analysis of the stools showing only an apparently normal 
 utilization), auto-intoxication may be produced, and enteritis, 
 colitis, or enterocolitis may result. Diminished gastric secre- 
 tion also favors enteric infection. 
 
 Finally, gastroptosis may be primary and cause enterop- 
 tosis, and this process is but little less frequent than the pro- 
 duction of gastroptosis by the primary prolapse of the colon. 
 Gastro-enteroptosis may induce chronic changes in the abdo- 
 minal sympathetic and in the nutrition of the intestines. 
 Enteritis membranacea may then be an ultimate effect.
 
 6l4 DISEASES OF THE STOMACH. 
 
 11. INFLUENCE ON THE LIVER. 
 
 Tlie manifold functions of the liver — the largest and most 
 important gland of the body — may be disordered by diseases 
 of the stomach. 
 
 The liver is an organ of assimilation and disassimilation. 
 This nutritive function may be disordered by the products 
 of abnormal digestion and by auto-intoxication, or it may be 
 disturbed on account of the irritation, or the overwork; or 
 the required performance of unusual work. 
 
 The liver is also a poison-destroying organ. It accumu- 
 lates, eliminates, and destroys the poisons which are carried 
 to it by the portal vein. This function can be disturbed by 
 auto-into.xication and by the absorption (without conversion) 
 of the products of peptonization. Peptones and digestive 
 albumoses, when they get into the circulation without being 
 first transformed, act as poisons. 
 
 The liver is also a digestive organ, for the bile exerts a 
 marked influence on the intestinal digestion and utilization of 
 food. The quantity and activity of its secretion is dependent 
 in part on the quantity and quality of the food and on the 
 composition of the chyme, a large mixed meal when it is 
 normally digested by the stomach being the most active 
 cholagogue known. This physiological and purposive secre- 
 tion of bile may be disordered by the diseases of the stomach 
 which require a modification of the diet as regards the pro- 
 portion of the grand classes of food which enter into its 
 composition, which withhold, by retention or by vomiting, 
 the required quantity of food, and which alter by secretion, 
 digestive transformation, fermentation, and putrefaction the 
 normal properties of the chyme. 
 
 The liver is a blood-destroying organ, and it has probably 
 something to do with blood building and with the mainten- 
 ance of the composition of the plasma. This function may 
 be disordered indirectly by the diseases of the stomach 
 through their action on the blood (hematocytolysis) and 
 through the association of disordered functions. If one 
 function of the liver becomes disordered, the other functions 
 may be compromised with it. 
 
 Consequently, the functions of the liver may be disordered 
 by disease of the stomach. Hepatic insufficiency may be 
 thus established, or the organ may become congested and, 
 finally, inflamed. The congestion and inflammation may be 
 acute or chronic. It is likely that the functions of the liver
 
 THE VICIOUS CIRCLES OF THE STOMACH. 615 
 
 may be deranged by reflexes from the diseased stomach, in 
 the same manner that gall-stones produce hyperchlorhydria 
 and hyperchylia gastrica, or that they may be deranged by 
 the action of the diseased stomach on the cardiovascular 
 system. Carcinoma and ulcer of the stomach may produce 
 hepatic complications. 
 
 III. INFLUENCE ON THE BLOOD. 
 
 The injurious, influence of diseases of the stomach on the 
 blood is exerted in several different ways : 
 
 1. Diseases of the stomach frequently produce inanition- 
 anemia, which is the sequel of subnutrition. Inanition 
 acts in two principal ways on the blood. It may produce 
 insufficiency of the hematopoietic organs, just as it pro- 
 duces general functional inactivity ; or it may alter the com- 
 position of the plasma so that it becomes poor in nitrogenous 
 matter, the resistance of the red corpuscles being diminished 
 and the development of the white corpuscles being decreased. 
 Consequently, subnutrition may produce dyshematopoietic 
 oligocythemia, or the dyshematopoiesis may be accompanied 
 by hematocytolysis, as is the case in the grave anemia of 
 atrophy of the gastric glands. 
 
 2. The diminished supply and the diminished absorption 
 of water, and its increased elimination by supersecretion 
 or vomiting, may produce oligemia sicca. The oligemia 
 may be simple, the red corpuscles being normal in number, 
 in coloring (hemoglobin), in size, in form, in resistance, and in 
 their affinities for stains ; or the oligemia sicca may mask a 
 disease of the red corpuscles, the deception being quickly 
 made plain by the use of the microscope. 
 
 3. The loss of blood by hemorrhage (ulcer, carcinoma, 
 erosions) produces an acute or chronic anemia, which may be 
 mild, severe, or grave. Oft-repeated small hemorrhages pro- 
 duce a grave and rebellious form of anemia when the daily 
 or frequent losses of blood exceed the quantity of blood 
 supplied by the hematopoietic organs. 
 
 4. Auto-intoxication does more direct and more extensive 
 injury to the blood than it does to the nervous system, the 
 cytoplasmic poisons destroying the red corpuscles and the 
 activity of the blood-building organs are decreased. Con- 
 sequently, the anemias of auto-intoxication may be dyshema- 
 topoietic or hematocytolytic. 
 
 5. The blood may also be injuriously affected by the influ-
 
 6l6 DISEASES OF THE STOMACH. 
 
 ence of gastric secretion or retention on the percentage of 
 salines in the blood. The sodium chlorid is most reduced 
 in this manner, and the plasma may thus become hema- 
 tocytolytic. 
 
 6. Clinical observation teaches that chronic irritation of 
 the abdominal sympathetic exerts a depressing influence on 
 the regeneration of the blood, particularly as regards the 
 development of the hemoglobin of the red corpuscles. The 
 action of the irritable abdominal s}-mpathetic (gastroptosis, 
 adenohypersthenia gastrica, neurasthenia gastrica) is the most 
 common cause of simple and of chlorotic oligochromemia. 
 
 7. Peptonization and peptone absorption are causes of 
 physiological leukocytosis, and in the advanced stages of some 
 of the diseases of the stomach this digestive leukocytosis is not 
 excited. As a consequence the resisting power (healing and 
 phagocytosis) of the system is diminished, and the normal 
 quantity of albumins in the plasma is not maintained. Leu- 
 kopenia may be produced by subnutrition or by the absorp- 
 tion of the unconverted products of albumin digestion. 
 
 8. Pathological leukocytosis may develop in carcinoma 
 and in the diseases of the stomach with inflammatory com- 
 plications. 
 
 As regards the diseases of the red corpuscles, diseases of 
 the stomach may produce either oligochromemia or oligocy- 
 themia. Oligochromemia is always dyshematopoietic, unless 
 it represents the regeneration period of oligocythemia. The 
 disease and the symptom may be readily distinguished by 
 the clinical history and by the microscopic and staining 
 properties of the blood. Oligocythemia, on the other hand, 
 may be dyshematopoietic, hematocytolytic, or degenerative. 
 The diseases of the stomach never cause the red corpuscles 
 to undergo primary degeneration. Consequently, oligocy- 
 themia of gastric origin is always due either to insufficient 
 and defective development of the blood or to the excessive 
 destruction (or loss by hemorrhage) of the red corpuscles. 
 These two forms of oligocythemia may be readily distin- 
 guished by the signs of dyshematopoiesis and by the signs 
 of hematocytolysis, a discussion of which here would lead 
 too far from the original subject. 
 
 Of the diseases of the white corpuscles, leukemia is never 
 produced by the diseases of the stomach. But digestive leu- 
 kocytosis may not occur, pathological leukocytosis may be 
 persistently present, the white corpuscles may degenerate (as 
 many as ten per cent, of them may display the degenerative 
 changes), or leukopenia may represent the chief alteration of
 
 THE VICIOUS CIRCLES OF THE STOMACH. 617 
 
 the blood. The plasma may be altered qualitatively or quanti- 
 tatively and become as a consequence hematocytolytic, or the 
 total volume of the blood may be decreased. 
 
 The changes of the blood which are produced by the dis- 
 eases of the stomach are not so constant or so characteristic 
 as to enable us to reason back from the disease of the blood, 
 to the particular disease of the stomach which has caused it ; 
 but a particular disease of the blood should direct the search 
 for the group of diseases of the stomach which may cause 
 it, and the blood changes have some diagnostic value in the 
 differentiation of one disease or group of diseases of the 
 stomach from another. The blood changes produced by the 
 particular diseases of the stomach have been described under 
 the symptomatology of those diseases. 
 
 IV. INFLUENCE ON NUTRITION. 
 
 Not every disease of the stomach disturbs nutrition. In 
 some cases the digestion and utilization of the food may be 
 normal; assimilation and disassimilation may go on as in 
 health ; enough food may be ingested and retained to supply 
 the needs of nutrition. But such is not always the case, not 
 even in the dynamic affections of the stomach nor in the mild 
 forms of its anatomical diseases. The acute diseases of 
 the stomach may rapidly affect nutrition, and the chronic 
 diseases seldom run their long course without producing 
 subnutrition or without disturbing the processes of nutrition. 
 The most frequent of these disorders of the processes of 
 nutrition are excessive nitrogenous waste, uricemia, and phos- 
 phaturia. 
 
 Subnutrition may be caused by a disease of the stomach 
 in a number of ways, and it may vary in degree and in the 
 rapidity of its development. The diet is often insufficient on 
 account of loss of appetite, on account of disgust for some 
 one of the grand classes of food, on account of a desire to 
 avoid the pain or discomfort of digestion, or on account of 
 an injurious plan of alimentation. Moreover, when the 
 alimentation is sufficient, a portion of the food may be lost by 
 vomiting, by fermentation, by putrefaction, by diarrhea, or 
 by failure to digest and absorb it to the same degree as in 
 health. In the advanced cases of anorexia nervosa the 
 patient presents a picture of slow and self-inflicted star- 
 vation, and the loss of appetite in the anatomical diseases 
 like carcinoma, chronic asthenic gastritis, and acute gastritis
 
 6l8 DISEASES Of THE STOMACH. 
 
 is one of tlie causes of subnutrition. The pain of ulcer, 
 of chronic hypersthenic gastritis, of adenohypersthenia 
 gastrica, or of carcinoma, the discomfort of neurasthenia 
 gastrica, and of hyperesthesia gastrica, and of the diseases 
 accompanied by retention and by stagnation, often force 
 the patient to diminish the quantity and to contract the 
 variety of the food below the requirements of the body. 
 Moreover, chronic pain itself exerts a depressing influence 
 on digestion and is a cause of emaciation. Frequently 
 repeated alimentary vomiting, whether it be nervous, cen- 
 tral, or refle.x, or symptomatic of a disease of the stomach, 
 may produce subnutrition as surely as does the failure to eat 
 enough to support the body. In myasthenia gastrica and in 
 pyloric obstruction — briefly, whenever motor insufficiency 
 exists — nutrition is in more or less danger; if there be only 
 stagnation, the influence on nutrition is determined by the 
 degree of fermentation of the chyme; while if there be reten- 
 tion, the body may starve for lack of both food and water. 
 It is well known that the intestines are capable of doing all 
 the digestion and absorption that the body requires, but motor 
 insufficiency may withhold the opportunity to establish diges- 
 tive compensation. The disturbances of secretion may also 
 produce subnutrition. If secretion be excessive, — as in adeno- 
 hypersthenia gastrica, in chronic hypersthenic gastritis, and in 
 ulcer, — the digestion of the starches is interfered with in the 
 stomach, and the excessive peptonization of the albumins 
 may increase intestinal putrefaction and produce intestinal 
 irritation and diarrhea. Nature here does what the physi- 
 cian often causes when he prescribes the digestive ferments 
 and peptonized foods. If secretion be diminished, the albu- 
 mins may not be properly digested, but the salivary diges- 
 tion of the starches is more active than in health, and the 
 intestines, if they be healthy, are likely to establish diges- 
 tive compensation. But it often happens that loss of appe- 
 tite, pain, faulty alimentation, vomiting, disorders of secre- 
 tion, motor insufficiency, fermentation, and an abnormal 
 chyme act more or less in concert, and produce subnutrition 
 which is more or less rapid and grave. 
 
 Excessive nitrogenous waste may be caused by a disease 
 of the stomach. In subnutrition not only the body fat but 
 also the body protoplasm is destroyed. The organism eats 
 itself — lives on itself. But in carcinoma, in some cases of 
 acute mycotic gastritis, and, probably, in some forms of gas- 
 tric auto-intoxication, nitrogenous catabolism is in excess of 
 the requirements of the body. The hyperazoturia manifests
 
 THE VICIOUS CIRCLES OE THE STOMACH. 619 
 
 a purposeless waste of albumin. The inference seems plausi- 
 ble that the excessive destruction of cellular protoplasm is due 
 to protoplasmic poisons formed in the neoplasm or in the con- 
 tents of the stomach. 
 
 The diseased stomach may cause accumulation of uric acid 
 in the system by producing acid auto-intoxication. The so- 
 called uric acid diathesis is not a morbid entity with one 
 cause, but it is a chemical condition which is variable in its 
 manifestations and complex in its causation. The accumu- 
 lation or precipitation of uric acid in the organism is the 
 result of pathological chemistry, and is the expression of a 
 series of diseases which are commonly classified as gouty. 
 There is no insufficient oxidation, for uric acid is the end 
 product of nuclein waste. There may or may not be an 
 excessive formation of uric acid. There may or may not 
 be retention of uric acid as a result of the insufficiency of 
 the eliminating organs. There may be no quantitative 
 anomaly, but only a change in the form in which the uric 
 acid exists, as a result of the altered reaction and composi- 
 tion of the fluids of the body. It is probable that uric acid 
 circulates in the body as a quadriurate, or as a biurate in 
 combination with the neutral phosphate of soda. Be this 
 as it may, the precipitation of the uric acid is prevented by 
 the accompaniment of a sufficient proportion of the neutral 
 disodic phosphate. If the biurate or quadriurate increases 
 proportionately beyond a certain limit, or if the neutral phos- 
 phate of soda decreases beyond a certain limit, there will be 
 precipitation. Consequently, the precipitation of the urates is 
 inaugurated either by a diminution of the available neutral 
 phosphate or by an increase of the uric acid. Furthermore, 
 the available neutral phosphate may be decreased by a 
 diminished supply of protecting alkalies or by. an increased 
 supply of converting acids. We therefore recognize three 
 grand forms of the uric acid diathesis or uric acid precipitation : 
 
 1. Gastro-intestinal form. 
 {a) Acid fermentation. 
 
 (^) Excessive pancreatic and intestinal secretion. 
 {c) Diminished gastric secretion. 
 
 2. Nutrition form (excessive formation of acids : phos- 
 
 phoric and organic, or uric acid). 
 {a) Defective alimentation. 
 [b] Excessive catabolism. 
 
 3. Retention form (defective elimination of acids). 
 {a) Insufficiency of the skin. 
 
 {b) Insufficiency of the kidneys.
 
 620 DISEASES OF THE STOMACH. 
 
 The gastro-intestinal form of the uric acid trouble is due to 
 the excessive acidity of the system and to the resulting dim- 
 inution of the quantity of the neutral phosphate of soda 
 which is available for holding the uric acid compounds 
 in solution. The stomach removes the chlorin to form 
 hydrochloric acid, and leaves the alkaline base of the chlorid 
 for the protection of the neutral phosphate. The excessive 
 secretion of the intestines and of the accessory digestive 
 glands removes too much of the protecting alkalies. Fermen- 
 tation produces acid self-poisoning. The result is excessive 
 acidity or diminished alkalinity of the fluids of the body, 
 diminution of the available neutral phosphate of soda, and 
 precipitation of the uric acid compounds. Ninety grains of 
 bicarbonate of soda administered before breakfast is sufficient, 
 in health, to neutralize the acidity of the system and to ren- 
 der the urine secreted during the following two hours neutral 
 in reaction. If the urine, on making this test, does not be- 
 come neutral, its acidity is the exact index of the excessive 
 acidity of the system. The gastric form of gout results only 
 from a chronic disease of the stomach, and is most frequent 
 when the diminished gastric secretion and gastric fermenta- 
 tion are accompanied by excessive intestinal secretion. 
 Chronic asthenic gastritis with motor insufficiency, carcinoma, 
 and myasthenia with diminished secretion are the most com- 
 mon diseases of the stomach which may produce uric acid 
 precipitation and retention. 
 
 As with uric acid in the uric acid diathesis, so is it with 
 phosphoric acid in phosphaturia : it is not the quantity, but 
 the form, of the uric acid and of the phosphates which is 
 important. The acidity of the urine is diminished until it is 
 nearly neutral, or neutral or even alkaline, and the phos- 
 phates precipitate in it either spontaneously or on heating. 
 The quantity of the acid phosphates is diminished and the 
 quantity of the neutral and alkaline phosphates is in excess. 
 Instead of increased there is diminished acidity of the fluids 
 of the body, which is not incidental to alimentation, though 
 it may be produced and controlled by it. but which is a 
 chemical condition due to excessive elimination of acids, 
 accompanied often by diminished removal of alkalies by the 
 intestines. During the period of normal gastric digestion 
 the acidity of the urine is diminished, and this condition of 
 the urine results from the withdrawal of acid from the body 
 by gastric secretion. The degree of change of the acidity of 
 the urine during digestion, and under the same conditions, is 
 a rough index of the amount of acid secreted by the stomach.
 
 THE VICIOUS CIRCLES OF THE STOMACH. 62 1 
 
 In the diseases accompanied by subacidity the diminution 
 of the acidity of the urine is less than in health, and in the 
 diseases accompanied by superacidity the diminution is 
 greater than in health. If the superacid gastric secretion be 
 removed by vomiting or by lavage, the diminution is still 
 more marked, and the total urine of the twenty-four hours 
 may be milky (phosphates), alkaline, and poor in chlorids. 
 Gastric phosphaturia is found in chronic hypersthenic gas- 
 tritis, adenohypersthenia gastrica, and in the other diseases of 
 the stomach accompanied by superacidity or by supersecre- 
 tion, whether they are or are not associated with stagnation, 
 or retention, or vomiting. 
 
 V. INFLUENCE ON THE HEART AND CIRCULATION. 
 
 If it be borne in mind how fine and complex is the mechan- 
 ism of the circulation, how numerous are the influences which 
 control or alter the caliber of the arterioles and the action 
 of the heart, it should cause no wonder that the heart is 
 frequently disturbed by the pathological reflexes and the 
 mechanical compression of an organ so closely situated and 
 so intimately connected with it by an almost common nerve- 
 supply as is the stomach. Normal digestion increases the fre- 
 quency and strength of the heart-beats, and strong excitation 
 of the mucous membrane of the stomach makes the heart's 
 action slow. The close anatomical and physiological rela- 
 tionship would seem to furnish good grounds for expecting 
 the diseased stomach easily and frequently to disorder the 
 heart's action. This natural expectation is only in part ful- 
 filled by clinical observation. 
 
 Tachycardia of gastric origin is so rare that we do not 
 remember to have seen a case. The pulse may be frequent 
 in diseases of the stomach accompanied by fever or by an 
 inflammatory complication, and a weak heart may be excited 
 by normal or by pathological digestion. But the normal 
 heart beats no more frequently in the afebrile or simple dis- 
 eases of the stomach than it does in health. Moreover, a 
 symptomatic increase of the frequency of the pulse does not 
 constitute tachycardia, for it is essential that the neuromuscu- 
 lar apparatus be disordered. Arrhythmia, allorrhythmia, 
 and asymmetry are equally as rare as gastric tachycardia, 
 though they may occur in association with other disturbances 
 of the heart of undoubted gastric origin. It may be possible 
 for a disease of the stomach to produce these disturbances in
 
 622 DISEASES OF THE STOMACH. 
 
 either their paroxysmal or habitual forms, but it would seem 
 wise to ignore the possibility until better proof of their causa- 
 tion is given than we have been able to find. Gastric brady- 
 cardia, however, is the most common form of the slow 
 heart. The heart-beats sometimes fall as low as 35 or 40 
 to the minute, but the milder form with 50 or 60 beats a 
 minute is most frequent. The bradycardia may occur in 
 paroxysms and be accompanied by weak action of the heart, 
 as shown by a small pulse, pallor, cold extremities, fainting, 
 and by loss of consciousness in severe cases ; it may be inter- 
 mittent, the paroxysm occurring in connection with gastric 
 digestion or with an exacerbation of gastric irritation ; or it 
 may become chronic and habitual. It is sometimes observed 
 in neurasthenia gastrica, but it is most common in myasthenia 
 and obstructive retention, in ulcer, in the painful paroxysms 
 of hypersthenic gastritis, and in gastroptosis, particularly 
 when the gastroptosis is accompanied by retention, by neu- 
 rasthenia, and by low abdominal tension. 
 
 Nervous palpitation may be the e.xpression of a disease of the 
 stomach, and, indeed, in either its subjective or its objective 
 form. The subjective form is characterized by normal heart 
 action, the complaints of the patient being due to hyperes- 
 thesia of the sensory nerves of the heart. This pseudopalpi- 
 tation occurs sometimes in ulcer, adenohypersthenia gastrica, 
 chronic hypersthenic gastritis, and gastralgia, the epigastric 
 cutaneous nerves being at the same time hyperesthetic. 
 Objective palpitation is characterized by perceptible over- 
 action of the heart, the frequency of the heart-beats being 
 commonly increased. The palpitation may have in the dis- 
 ease of the stomach its all-sufficient cause or only the occa- 
 sion of the attack. The diagnosis of the cause of palpitation 
 may present almost insuperable difficulties, but the source of 
 the trouble may be located in the stomach by exclusion of 
 the diseases of the heart and blood-vessels, and of other dis- 
 eases and habits (morphinism, alcoholism, abuse of tobacco, 
 excesses in venery, etc.) which may produce it, by the close 
 relation of the attacks to gastric digestion, and by its control 
 or cure under treatment of the disease of the stomach with 
 which it is associated. 
 
 Gastrocardiovascular Symptom-groups. — A well-defined 
 cardiovascular symptom-group of gastric origin is sometimes 
 met with in neurasthenic or nervous patients, between the 
 ages of twenty and forty years, who suffer from bulimia, 
 adenohypersthenia gastrica, myasthenia gastrica, or neuras- 
 thenia gastrica. The trouble is always paroxysmal in its
 
 THE VICIOUS CIRCLES OF THE STOMACH 623 
 
 first stages. The attacks, which begin and end suddenly, 
 last from a few hours to two or three days. Usually, during 
 the night or soon after rising in the morning, a sense of oppres- 
 sion and fullness is felt in the epigastrium, the heart palpi- 
 tates, the pulse becomes irregular, and the patient is suddenly 
 seized with great anxiety. The heart feels overdistended and 
 flutters, and the abdominal aorta palpitates strongly. The 
 patient is weak and depressed, cardiac dyspnea is marked, 
 but there is no precordial pain and no headache. The 
 attacks recur after varying intervals, or the trouble may 
 become continuous and chronic, with constant epigastric dis- 
 tention, dyspnea, bulimia, and anxiety which is likely to pro- 
 duce hypochrondriasis. The disease affects almost exclusively 
 men, and chiefly brain-workers, the attacks recurring after 
 eating an acid or some particular fruit or food. The whole 
 trouble seems to be produced by a reflex from the morbid 
 mucous membrane of the stomach affecting the vagosympa- 
 thetic, and probably also the vasomotor, nerves. In the severe 
 attacks the arterioles are constricted and the left heart is 
 dilated. During the intervals between the attacks the heart 
 and circulation are normal. The cardiovascular paroxysms 
 can be controlled by the proper treatment of the disease of 
 the stomach. 
 
 Another well-defined gastrocardiovascular symptom-group, 
 produced by a disease of the stomach, affects the arterioles of 
 the lesser circulation and causes dilatation of the right side 
 of the heart (Potain). These attacks are more common in 
 neurasthenic and chlorotic girls than in men, and they may 
 or may not be painful. The attacks are sometimes brought 
 on by very mild gastric excitants, even solid food, like diges- 
 tible meats, being sufficient to produce them. The attacks 
 occur during gastric digestion and begin with slight dyspnea 
 and substernal oppression. In the beginning of the attack 
 the second pulmonary sound is accentuated and has a quick, 
 metallic ring. Later, the heart sounds become muffled, and 
 a distinct bruit de galop can be heard to the right of the 
 sternum. In the severe attacks relative tricuspid insuffi- 
 ciency may develop, a systolic murmur being heard at the 
 apex, propagated to the right and accompanied by a systolic 
 distention of the right jugular vein. The heart dulness is 
 then enlarged to the right. The attack may end in half an 
 hour, and may or may not be accompanied by moderately 
 severe pain extending over the thorax from the left clavicle 
 to the umbilicus. The trouble is most common in hyper- 
 esthesia gastrica, neurasthenia gastrica, during the develop- 
 ment of gastroptosis, and in adenohypersthenia gastrica.
 
 624 DISEASES OF THE STOAfACH. 
 
 The influence of the diseases of the stomach on the heart 
 and blood-vessels should not be forgotten, for the gastro- 
 cardiovascular troubles can be cured only by the proper 
 treatment of the disease of the stomach. An acute disease 
 of the stomach or an exacerbation of a chronic disease of the 
 stomach may break compensation, or give the death-stroke 
 in organic disease of the heart, or be the exciting cause of an 
 attack of angina pectoris. It is a good rule to watch the 
 stomach in the management of the diseases of the heart and 
 blood-vessels. 
 
 VI. INFLUENCE ON THE NERVOUS SYSTEM. 
 
 During normal gastric digestion the nervous system is 
 physiologically in repose. It is a natural period of mental 
 and physical rest. The inactivity may be prevented by the 
 use of stimulants, like tea, coffee, alcohol, tobacco, and by a 
 lively environment. But if the mind be not forced into 
 activity, it will seek its physiological repose, and if it be too 
 much excited artificially, the functions of the stomach may 
 be slowly performed. In an analogous manner, pathological 
 digestion may destroy this natural tendency of the mind and 
 body, and the nervous system itself may manifest the dis- 
 ordered digestion. Gastric headache, drowsiness, insomnia, 
 and the many nervous symptoms of the diseases of the 
 stomach, display the influence of the diseased stomach on 
 the nervous system. But not only are nervous symptoms 
 produced, but also special disorders of the nervous system. 
 The principal disturbances of this kind are neurasthenia, ver- 
 tigo, tetany, and epileptiform convulsions. 
 
 There is no question in our mind that both spinal and 
 cerebral neurasthenia may result from the diseases of the 
 stomach. There is no doubt that the reverse is equally true ; 
 that neurasthenia may begin in other organs or in the central 
 nervous system and extend to the stomach. Irritable nerve 
 weakness may readily be propagated from one division of the 
 sympathetic system to another. Then are established the 
 neurasthenic vicious circles of the stomach, and the stomach 
 itself may forge this circular chain. It matters not whether 
 the irritable weakness be caused by self-poisoning, by subnu- 
 trition, by oligocythemia (gastric), by direct propagation along 
 the sympathetic or the pneumogastric nerves, or by the effect 
 of the gastric trouble on the mind or on sleep. The stomach 
 is still the creator of the trouble. The diseases of the stomach
 
 THE VICIOUS CIRCLES OF THE STOMACH. 625 
 
 which are most active in this respect are neurasthenia 
 gastrica, gastroptosis, myasthenia gastrica (with hyper- 
 esthesia, hyperchlorhydria, or fermentation), obstruction of 
 the pylorus, and all the hypersthenic painful affections of the 
 stomach. The disease of the stomach is the primary trouble, 
 and the secondary neurasthenia can be cured only after the 
 control or cure of the exciting causative disease. Like other 
 secondary diseases, the neurasthenia may acquire an inde- 
 pendent existence, and it always requires treatment in itself. 
 But this peculiarity is no evidence against its genesis by the 
 disease of the stomach. 
 
 Vertigo a stomacho laeso (Trousseau) is not frequent. Gas- 
 tric vertigo is in itself without characteristic features, but it 
 occurs in association with the stomach trouble and is relieved 
 by the cure of the stomach disease. It is sometimes possible 
 to bring it on by sudden change of position, and to relieve it 
 by giving a few mouthfuls of food ; it is sometimes associ- 
 ated with nausea, sometimes with frontal headache, sometimes 
 with vasomotor disturbances, and sometimes with hot flushes 
 and a sense of warmth in the stomach. The attacks begin 
 sometimes when the stomach is empty, and sometimes a few 
 hours after a meal. The head first feels light, or heavy, or 
 compressed, the vision becomes cloudy, there is some partic- 
 ular sensation referable to the stomach, and then the sur- 
 rounding objects oscillate and turn about the patient, or the 
 patient loses his sense of equilibrium and of space and feels 
 himself in the air. Consciousness, however, is never lost, 
 and the patient always knows that the movements are mere 
 illusions. Vertigo is a very common symptom, and it is a 
 symptom of many other diseases (particularly of the arteries 
 and the circulation) besides those of the stomach. In the 
 cases of vertigo in which we have been able to find no other 
 cause than the disease of the stomach, the digestion has 
 always been " slow and laborious " (Trousseau), and the myas- 
 thenia has been accompanied by butyric acid fermentation. 
 But we are not prepared to state that gastric vertigo may not 
 occur under other circumstances. 
 
 Tetany is a rare complication of the diseases of the stomach, 
 and we have been able to find only 41 reported cases. 
 But gastric tetany is frequently fatal (73 per cent.), and 
 many cases doubtless occur without being recognized or 
 without being reported. 
 
 Tetany is a motor neurosis characterized by bilateral par- 
 oxysmal tonic spasms affecting chiefly the flexor muscles of 
 the extremities. The muscular cramps are painful, and con- 
 40
 
 626 DISEASES OF THE STOMACH. 
 
 sciousness is never (true tetany) or very seldom (sometimes in 
 gastric tetany) lost. The mind remains clear (true tetany) or 
 there may be some confusion of the intellect and a treach- 
 erous memory (sometimes in gastric tetan)'). There is no 
 fever unless there be a febrile complication, and the attacks, 
 which last for from five to twenty minutes, or possibly several 
 hours, begin and end suddenl)',and are preceded and followed 
 by sensory disturbances, like formication, over the region of 
 the affected muscles. After intermissions the paroxysms may 
 recur, and the trouble may last for several days or weeks. 
 
 Gastric tetany occurs in a mild and in a severe form. In the 
 mild form the cramps affect the muscles of the extremities, 
 sometimes of the upper extremities only, and are confined 
 chiefly to the flexor muscles of the forearms and hands and 
 to the corresponding muscles of the legs and feet. The 
 extensor muscles are also affected, and, while yielding to the 
 stronger flexors, aid in holding the hand rigid and immovable 
 through the influence of the will. A characteristic deformity 
 of the hands was described by Trousseau as the " obstet- 
 rician's hand." The thumb is strongly adducted, the straight 
 finsfers are drawn against one another and are half flexed over 
 the thumb at the metacarpophalangeal joint, and the sides of 
 the palm are turned in to form a cone. The index finger may 
 be flexed to a greater extent than the others, or the thumb 
 alone may be contractured. Frequently, however, the hand 
 assumes the same form as in posthemiplegic contracture. 
 The toes are contracted in an analogous manner, and the foot 
 is commonly in the equinus position. The hands are flexed 
 on the wrist, the arms and legs at the elbows and knees, and 
 the upper arms and thighs may be fixed in strong adduction ; 
 but these contractures may not occur in the mild form. In 
 the severe form the cramps begin in the extremities and 
 extend to the thorax and abdomen ; they may sometimes 
 affect the diaphragm, the muscles of the neck, of the face, of 
 the eyes, of the tongue, of the pharynx, and of the larynx. 
 The pulse is rapid, and the patient may lose his life by 
 suffocation. 
 
 The tendon reflexes are normal, or are not changed in a 
 particular manner, but the skin reflexes are exaggerated. 
 Compression of the main nerve of the extremity (median, 
 sciatic) or compression of the main artery or vein of the 
 extremity, increases the spasm during the stage of contracture 
 and excites an attack during the intermission. It is curious to 
 note that the effect of the compression is reflected to the cor- 
 responding extremity (Trousseau). The galvanic excitability
 
 THE VICIOUS CIRCLES OF THE STOMACH. 627 
 
 of the motor, and sometimes of the sensory, nerves (except 
 the facial nerve) during the continuation of the trouble is 
 always greatly increased, and usually the faradic current pro- 
 duces the same effect as the galvanic current (Erb). The 
 mechanical irritability of the nerves is increased (Trousseau), 
 and Chvostek discovered that it is possible to produce con- 
 traction of the facial muscles by tapping over the facial nerve 
 or by stroking the skin and muscles of the face from above 
 downward, along a line extending from a point midway 
 between the eye and ear to the middle of the horizontal 
 branch of the lower jaw. These signs of Trousseau, of Erb, 
 and of Chvostek are present in only a part of the cases of 
 gastric tetany, and their absence constitutes an important 
 variation from true tetany. 
 
 Gastric tetany and tetany-like cramps result from a very 
 limited number of the diseases of the stomach. And, indeed, 
 when these attacks do occur, they can not be considered a 
 result of the primary disease of the stomach, but of a special 
 secondary condition, which represents an episode in the devel- 
 opment of the primary disease. It is neither ulcer, nor 
 obstruction of the pylorus, nor gastroptosis, nor myasthenia, 
 nor chronic hypersthenic gastritis which directly cause the 
 attacks, but it is the gastric retention that is the essential 
 condition. In the majority of the cases the gastric retention 
 is associated with excessive secretion or with a highly acid 
 condition of the gastric juice. In a small percentage of the 
 cases the retention is accompanied by active fermentation and 
 by the absence of free hydrochloric acid. The retention need 
 not be continuous, for it may be absent before and after the 
 attacks ; but whether the retention be continuous, or only 
 temporary or accidental, it is a condition essential to the 
 occurrence of the attacks. The continuity of secretion is the 
 effect of the retention ; the hydrochloric acidity of the con- 
 tents is a manifestation of the diseased mucous membrane ; 
 and the organic acidity is the result of the retention and of 
 the quality of the diet. The frequency of butyric fermenta- 
 tion in these cases is noteworthy and suggestive. The 
 immediate exciting cause of the attacks may be a vaginal 
 examination, or palpation of the stomach, or the introduc- 
 tion of the tube, or lavage, or the sudden evacuation of the 
 contents of the stomach through the tube or by vomiting, or 
 the attacks may be caused by other forms of mechanical irri- 
 tation. The attacks may be produced by auto-intoxication, 
 or, as some contend, by reflexes from the stomach, or by the 
 extreme poverty of the tissues (muscle and nerve) in water.
 
 628 DISEASES OF THE STOMACH. 
 
 It seems probable that the reflexes and the desiccation are 
 only contributing causes. 
 
 Kussmaul may be considered the father of the desiccation 
 theory, but he has recently abandoned it. There is no ques- 
 tion that as a result of the retention of the excessive secretion, 
 of the diminished absorption, and of the vomiting the system 
 is deprived of much water. As a consequence there is oli- 
 gemia sicca, very dry skin, hard feces, and a small quantity 
 of urine, but the blood is not thickened, as is sometimes stated. 
 Indeed, it is poor in albumin, poor in sodium chlorid, and the 
 number of corpuscles in the cubic millimeter is diminished, — 
 certainly not increased, — and there may be signs of excessive 
 destruction of the red corpuscles, and of degeneration and 
 decrease of the number of white corpuscles. But the rectal 
 administration of water or of salt solution does not prevent or 
 control the attacks ; water starvation and excessive water 
 elimination do not produce them, and the attacks do not 
 occur in relation to the poverty of the system in water. It is 
 easily conceivable how the desiccation and the changes of the 
 blood may stimulate the absorption of the poisons which may 
 be in the stomach, may favor their formation in the body, and 
 may lead to their accumulation in the system by insufficient 
 elimination. 
 
 There is little evidence of the production of these muscular 
 cramps by reflex action. Mechanical irritation may occasion 
 them, but just as readily when other parts of the body are irri- 
 tated as when the irritation acts directly on the mucous mem- 
 brane or on the wall of the stomach. Tetany, due to intestinal 
 worms, is more likely toxic than reflex. Reflex action is the 
 cloak in which ignorance loves to hide itself The theory of 
 reflex action naturally e.xcites distrust, and there seems to be 
 no clinical nor experimental evidence in its favor. 
 
 It seems probable that the attacks of tetany and of tetany- 
 like cramps are due to self-poisoning. Bouveret and Fleiner 
 have extracted from the gastric contents toxins capable of 
 producing convulsions and death of the animal, but the con- 
 vulsions were clonic. The extract of Bouveret and Devic 
 has been shown to be a mixture containing a yellow substance 
 capable of producing mydriasis and vasoconstriction, but it is 
 found, like the ethylendiamin of Kulneff", in cases with no 
 convulsions of any kind. It has also been shown by Fleiner 
 that the alcoholic extract is poisonous when the neutralized 
 contents are not toxic. Bouveret and Devic suggest that the 
 poison may be formed in the stomach by the digestive action 
 of free HCl in the presence of alcohol (swallowed or gener-
 
 THE VICIOUS CIRCLES OF THE STOMACH. 629 
 
 ated by fermentation). It has also been suggested that the 
 poison may be formed by prolonged gastric digestion (pepto- 
 toxin) and may be absorbed slowly and continuously and 
 without special alteration by the diseased or healthy mucous 
 membrane. Ewald and Jacobson extracted the picrate of an 
 alkaloid-like body from the urine of a tetany patient, and 
 Albu found a double gold and platinum alkaloidal salt in the 
 urine during the attack which was absent from the urine in 
 the interval. Consequently, we may conclude that there is 
 no chemical nor experimental evidence in favor of the intoxi- 
 cation theory, for a poison capable of producing the tetany-like 
 cramps has not been found in the stomach contents before 
 and during the attacks, nor in the blood during the attacks, 
 nor in the urine during and after the attacks. These failures 
 exclude the probability of acute self-poisoning, but do not 
 refute the hypothesis of a slow cumulative poisoning. The 
 evidence in favor of the auto-intoxication theory is chiefly 
 clinical. The cramp-producing agent acts like an alkaloidal 
 poison and produces no anatomical lesion except nephritis 
 (toxic) in some cases. Tetany, so far as at present known, is 
 always toxic, occurring in the course of or during the sub- 
 sidence of, infectious diseases, after the extirpation of the thy- 
 roid gland (mucin-toxemia), after the administration of certain 
 chemicals or drugs, and, sometimes, during pregnancy or lac- 
 tation. And gastric and tetany-like cramps occur in close 
 causal relation with gastric retention, the gastric contents con- 
 taining a mixed and active virulent germ growth. 
 
 The convulsicms which result from a disease of the stom- 
 ach may be epileptiform. After a sensation of weight or of 
 painful dragging of the stomach, of nausea, or of regurgita- 
 tion, general tonic, followed by clonic, convulsions begin, and 
 are accompanied by loss of consciousness. The gastric 
 epileptiform attacks should be distinguished from true 
 epilepsy with a gastric aura, and they may occur as the only 
 convulsive manifestation of the gastric disease, or they may 
 occur in a patient who has attacks of tetany-like cramps. 
 Explanations of the production of the cortical irritation are 
 hypothetical, and the prognosis is better than in true epilepsy 
 and in gastric tetany. 
 
 VII. INFLUENCE ON THE SKIN. 
 
 Through the influence of the diseases of the stomach on 
 the vasomotor nerves and on nutrition, and through the irri-
 
 630 DISEASES OF THE STOMACH. 
 
 tation produced by the elimination of the products of self- 
 poisoning, the skin may become diseased. No doubt intesti- 
 nal diseases are more active in the causation of diseases of 
 the skin than are the diseases of the stomach, but in some 
 cases the stomach is the sole source of the skin trouble. 
 Urticaria is popularly supposed to be due to a bad stomach. 
 A fugacious form often results from the eating of berries or 
 shell-fish, and it is difficult to determine whether this angio- 
 neurosis is produced by reflex action or by self-poisoning. 
 The fugacious and chronic forms are most common in chil- 
 dren, as a result of the acute or chronic myasthenia induced 
 by overfeeding. Urticaria may also result from gastric fer- 
 mentation in the adult, but, in our observation, the urticaria 
 is accompanied in nearly all cases of gastro-intestinal origin 
 by intestinal putrefaction and indicanuria. 
 
 Eczema is very rare as a result of a disease of the stomach 
 alone, but it may be excited by acid self-poisoning (fermenta- 
 tion) in patients predisposed to it, and the excessive acidity 
 of the system may be the cause of the obstinacy of certain 
 cases to treatment. We have noticed that eczema seborrhcei- 
 cum is nearly always associated with butyric acid fermenta- 
 tion in the stomach or the formation of y3-oxybutyric acid 
 in the body. The " red nose " (rosacea) is sometimes due to 
 myasthenic fermentation and to the diseases accompanied 
 by hyperchlorhydria. The influence of the diseases of the 
 stomach in the causation of the diseases of the skin has not 
 been thoroughly studied, and it presents an opportunity for 
 the emplo\'ment of modern methods in the correction of 
 errors and in the extension of our knowledefe. 
 
 VIll. INFLUENCE ON THE KIDNEYS. 
 
 The diseases of the stomach modify directly the composi- 
 tion of the urine. In retention the total quantity of the 
 urine maybe reduced to one-fifth of the normal quantity. Its 
 acidity may be increased (diminished gastric secretion) or it 
 may be decreased (excessive secretion). There may be phos- 
 phaturia, or there may be precipitation of uric acid, or the 
 toxicity of the urine may be increased. Functional albu- 
 minuria is frequently caused by the diseases of the stomach 
 which produce supersecretion and phosphaturia. And, finally, 
 the urine may contain gastric ferments and albumoses. But 
 it is doubtful whether these changes do much direct damage
 
 THE SECONDARY DISEASES OF THE STOMACH. 63 I 
 
 to the kidneys by their local action alone, with the exception, 
 possibly, of the unassimilable albumin. 
 
 But indirectly, by their influence on the liver, on the blood, 
 on the cardiovascular system, and on the nourishment of the 
 body, the diseases of the stomach may initiate changes in the 
 glomeruli and the tubules. The process may be degenera- 
 tive, congestive, or inflammatory. Chronic degeneration may 
 result from subnutrition in conjunction with auto-intoxication. 
 The epithelium lining the cortex tubes is swollen and infil- 
 trated with granular matter and fat. There is little albumin 
 in the urine, and only a few casts (there being no changes in 
 the blood-vessels or in arterial tension, no hypertrophy of the 
 left ventricle, and no uremia), the patient's strength and nutri- 
 tion gradually or progressively failing. But besides the 
 chronic degeneration, an exudative or even productive inflam- 
 mation of the glomeruli or of the cortex tubes may result 
 indirectly from the diseases of the stomach. The diseases of 
 the stomach undoubtedly influence the evolution of chronic 
 nephritis, and a therapeutic rule may be drawn from this 
 clinical fact. But the part which the diseases of the stomach 
 play in the causation of the diseases of the kidneys is not 
 definitely known, and it is very likely that their pathogenic 
 influence may easily be exaggerated. 
 
 CHAPTER II. 
 THE SECONDARY DISEASES OF THE STOMACH. 
 
 The secondary diseases of the stomach are produced by 
 the diseases of a large number of other organs, and, as a rule, 
 but not always, bear no marks which would reveal or suggest 
 their origin. When once established, they are capable of an 
 independent existence, and may have their usual evolution. 
 They may, however, be more obstinate than is ordinarily the 
 case, and their cure requires the cure or control of the causa- 
 tive disease or its natural advance to another stage in which 
 it has not the same influence on the stomach. 
 
 The disease of the stomach may be an accidental associa- 
 tion, developing before the beginning or during the course of 
 the disease of the other organ, and as the effect of the same or 
 of totally different causes. They exist together, but the one 
 is not produced by the other.
 
 632 DISEASES OF THE STOMACH. 
 
 In order that tlie disease of the stomach be considered 
 secondary, it must be connected in its origin and evolution 
 with a primary disease. What precedes can not be a result. 
 Its course must be influenced by the primary disease, and it 
 must be observed to follow the primary disease with sufficient 
 frequency to be considered an order of sequence. Naturally, 
 the probability of the etiological relation is greater when an 
 explanation can be given of the mode of genesis. 
 
 In order to throw light on the often obscure relation, it is 
 necessary to know the age and nature of the stomach trouble 
 with more exactness than can be learned from the clinical 
 history, from the physical signs, and from autopsies. Dis- 
 eases of the stomach are too often latent, are too often 
 ill-defined or similar in their subjective manifestations, too 
 often escape a physical search, too often leave no traces per- 
 ceptible after death, and too often change their nature during 
 their terminal period, to have their age and nature revealed 
 without the use of the modern methods of examination. 
 
 1. DISEASES OF THE INTESTINES. 
 
 Clinical observation establishes the fact that a disease 
 (except obstruction) of one of the divisions of the diges- 
 tive tube affects the divisions of the alimentary tract below it 
 much more frequently than those above it. Consequently, 
 secondary disease of the stomach does not often result from 
 intestinal disease, although the stomach is not exempt from 
 intestinal pathogenic influences. 
 
 Symptomatic disturbances — loss of appetite, nausea, vomit- 
 ing, excessive or diminished secretion — of the stomach are 
 very common in diseases of the intestines. Active abdominal 
 plethora may result from the active hyperemia of intestinal 
 irritation or inflammation. Active plethora is as frequent as 
 portal congestion, and in this manner intestinal disease may 
 pro(luce congestion of the stomach or gastritis. 
 
 Duodenal obstruction or chronic stenosis in the upper 
 intestinal tract may produce gastric retention and secondary 
 dilated hypertrophy of the stomach. If the obstruction is 
 below the opening of the common duct, there is regular reflux 
 of bile and of pancreatic juice into the stomach, and there is 
 accompanying hyperchlorhydria or hypochlorhydria accord- 
 ing to the functional power of the gastric glands. In intesti- 
 nal obstruction there is antiperistalsis and excessive gastro-
 
 THE SECONDARY DISEASES OF THE STOMACH. 633 
 
 intestinal secretion above the obstruction, with nausea, vomit- 
 ing, and hydrothionemia. 
 
 Intestinal auto-intoxication may produce paroxysmal or 
 digestive adenohypersthenia gastrica. The paroxysmal 
 attacks may be very severe — nausea, vomiting, cramps, severe 
 headache, anxiety, depression of spirits, collapse, and even 
 stupor. The stools are very foul, there are H2S flatus 
 and indicanuria, and sometimes H2S can be detected in the 
 breath and in the urine. Chronic intestinal auto-intoxication 
 may produce chronic gastritis by its direct and indirect influ- 
 ences. 
 
 Intestinal neurasthenia and the hypersthenic chronic affec- 
 tions of the intestines may produce neurasthenia gastrica, and 
 duodenitis may extend by continuity of structure to the gastric 
 mucous membrane. Enteroptosis, also, may produce gastrop- 
 tosis, but in our opinion the particular pathological influence 
 of enteroptosis has been somewhat exaggerated by Glenard. 
 The enteroptosis is as frequently the result as it is the cause 
 of the displacements of the other abdominal organs, and all 
 these displacements are more frequently the result of a com- 
 mon cause — emaciation and lack of proper support. 
 
 11. DISEASES OF THE LIVER. 
 
 In the diseases of the liver secondary diseases of the 
 stomach are common and have not received the study and 
 recognition which their frequency and clinical importance 
 demand. 
 
 The chemistry of digestion may be disturbed by the reflux 
 of bile into the stomach, which may excite excessive secre- 
 tion, nausea, and vomiting. In all our cases of chronic reflux 
 of bile into the stomach there has been constant hyperchlor- 
 hydria, and such is probably the rule, unless there be ante- 
 cedent asthenic gastritis or gastric atrophy. 
 
 Simple enlargement of the liver may produce vertical dis- 
 placement of the stomach and interfere with the performance 
 of its motor work. Obstructive stagnation is not seldom pro- 
 duced in this manner, the evacuation of the stomach having 
 been delayed in a little more than half of our cases, accom- 
 panied by noteworthy enlargement of the liver from various 
 causes. 
 
 In catarrhal icterus and in infectious cholangitis hyper- 
 chlorhydria is the rule, and in only a few of our cases have 
 we found secretion normal. But we have studied too few of
 
 634 DISEASES OF THE STOMACH. 
 
 these cases to do more than emphasize the desirability of 
 further investigations. 
 
 Hypertrophic cirrhosis produces hyperchlorhydria with 
 more or less stagnation (13 of 18 cases). The chronic hyper- 
 sthenic gastritis (9 of 18) may have been due to the same 
 cause as the hypertrophic cirrhosis, but it is important, at 
 least, to remember the frequency of the association. In 
 severe cases of atrophic cirrhosis we have always found 
 hypochlorhydria, the result probably of portal congestion or 
 of chronic gastritis. 
 
 It is often stated that hyperchlorhydria is an important 
 differential sign between gastric ulcer and cholelithiasis. We 
 have found hyperchlorh\-dria in 17 of 23 cases of gall- 
 stones, and 3 of the 6 remaining ones had chronic asthenic 
 gastritis. Hyperchlorhydria occurs as frequently in chole- 
 lithiasis as in ulcer, but in 5 of the 17 cases it disappeared 
 in the interval between the attacks. The hyperchlorhydria 
 is cured by the passage or removal of the stone, and its per- 
 sistence after an attack of gall-stone colic should exxite sus- 
 picion of stones still remaining in the ducts or in the gall- 
 bladder. 
 
 Pyloric or duodenal stenosis may result from carcinoma 
 of the gall-bladder or from gall-stones. The inflammatory 
 complications of gall-stones may produce cicatricial obstruc- 
 tion, but the pylorus may also be obstructed by the presence 
 of a gall stone in the common duct. If, under such circum- 
 stances, there be gastric retention, pain, vomiting, and super- 
 secretion, ulcer with pyloric obstruction would probably be 
 the diagnosis erroneously made. Or if there be pain, 
 vomiting, gastric stagnation or retention, emaciation, and 
 absence of free HCl, carcinoma would be suspected, and the 
 erroneous suspicion would become a belief if, as often hap- 
 pens, a tumor (the stone) should be felt in the pyloric region. 
 
 III. DISEASES OF THE HEART AND ARTERIES. 
 
 So long as the valvular diseases of the heart are compen- 
 sated the functions of the stomach are not disturbed by them 
 in any manner, and the heart ma}' become moderately or 
 temporarily insufficient without producing an appreciable or 
 more than evanescent diminution of secretion. But in the 
 asystolic stage of chronic valvular disease the passive con- 
 gestion of the stomach causes secretion to become insuffi- 
 cient or the free hydrochloric acid may entirely disappear
 
 THE SECOXDAR Y DISEASES OF THE STOMACH. 635 
 
 from the contents obtained after the test-breakfast. If gas- 
 tritis has not resulted from the congestion of the stomach, 
 the secretion will become normal after the integrity of the 
 circulation is restored by proper medication. If gastritis, on 
 the other hand, has been produced, the gastric secretion will 
 be permanently under the influence of the anatomical changes 
 of the mucous membrane. After cyanosis and dropsy are 
 well established, no medication, in our experience, restores the 
 lost or impaired secretion. The examination in 18 cases 
 during the period of compensation revealed no disease of 
 the stomach nor disturbance of secretion which could not 
 be readily explained by the action of other causes than the 
 disease of the heart. In compensated heart disease gas 
 often accumulates in the stomach, although secretion be nor- 
 mal and no signs of fermentation can be detected. Seven of 
 these 18 cases complained greatly of the flatulency. Twenty- 
 three cases examined when the signs of heart insufficiency 
 were marked showed normal secretion (5), diminished secre- 
 tion (13), and the complete absence of free HCl (5). The 
 ferments do not diminish so rapidly as the free HCl, and in 
 none of the cases of valvular disease examined by us during 
 the stage of broken compensation have we found hyper- 
 chlorhydria or myasthenia. 
 
 Arteriosclerosis and cardiosclerosis, or aortic valvular dis- 
 ease secondary to chronic disease of the arteries, produce 
 three forms of stomach trouble. In eleven cases we found the 
 digestion of the test-breakfast normal, but there was no free 
 HCl after the Riegel test-dinner, albumin digestion being pro- 
 portionately defective. The stomach is capable of doing a 
 small task, but soon becomes exhausted if prolonged work is 
 required of it. Again, we have observed six cases of arterio- 
 sclerosis which presented, from time to time, a peculiar form 
 of gastralgia or gastrospasm. These attacks occur during 
 the digestion of a meal (usually large and somewhat excitant 
 in its physiological action), and resemble the muscle cramps 
 of arteriosclerosis. It is probable that they are due to anemia, 
 produced by the gastric localization of the arteriosclerosis, 
 and are not associated in any regular manner with disturb- 
 ances of secretion. Again, arteriosclerosis may produce 
 chronic interstitial and atrophic gastritis (eight cases), and it 
 is a noteworthy fact that this form of secondary gastritis is 
 sometimes accompanied by motor insufficiency. The relative 
 secretory insufficiency, the digestive gastrospasm, and the 
 mixed gastritis may develop at different periods during the 
 course of the arterial disease. In only three of the cases of
 
 636 J)ISEASES OF THE STOMACH. 
 
 well-marked arteriosclerosis thoroughly studied by us have 
 we found the stomach normal, but in some of the cases (which 
 have been excluded from consideration) the chronic gastritis 
 was in all probability due to the medication or to the ad- 
 vanced nephritis. 
 
 IV. DISEASES OF THE BLOOD. 
 
 The diseases of the white corpuscles (pathological leukocy- 
 tosis, leukemia, and leukopenia) do not produce any special 
 disturbances of the stomach. The enlarged spleen which 
 accompanies leukemia may be the cause of vomiting. The 
 enlarged liver may obstruct the venous circulation of the 
 stomach, and interfere with the proper performance of its 
 mechanical work. Leukemia may, however, produce symp- 
 tomatic gastric hemorrhage. Leukopenia and leukocytosis 
 do not affect the stomach, although either functional or or- 
 ganic disease of the stomach may result from the same cause 
 which produces the leukopenia or the leukocytosis. The 
 symptomatic gastric hemorrhage of scorbutus and of hemo- 
 philia need only be mentioned. 
 
 The diseases of the red corpuscles are responsible for the 
 secondary diseases of the stomach which are due to the dis- 
 eases of the blood. But not all the gastric troubles which are 
 found in the anemias are due to the disease of the blood. The 
 stomach disease and the blood disease may be accidental 
 associations, or they may result from pathogenic causes which 
 affect both, or the gastric trouble may be the effect of the 
 medication employed against the anemia, as the iron, arsenic, 
 and the excitant diet which it is the rule to prescribe. 
 Eliminating, so far as possible, these disturbing factors, our 
 investigations have led to the following conclusions: 
 
 Simple oligochromemia disturbs neither secretion nor the 
 motor function. But this is not the case in chlorosis. In 
 about one-third of the cases of true chlorosis the stomach 
 symptoms predominate in the clinical history; in about one- 
 half of the cases there are gastric symptoms and pain. Vom- 
 iting occurs intermittently in about ten per cent, of the cases, 
 and loss of appetite is the rule. Disturbances of secretion are 
 more frequent than would be indicated by the complaints of 
 the patients, as in only nine per cent, of the cases have we 
 found secretion normal in its degree and in its evolution. 
 Gastric secretion is sometimes normal when the patient com- 
 plains of digestive trouble. 
 
 As regards the nature of the stomach trouble, in 23 per
 
 THE SECONDARY DISEASES OF THE STOMACH. 637 
 
 cent, of the cases we have noted a diminution of secretion — 
 in some cases functional, in other cases due to gastritis. But 
 we can not convince ourselves that the gastritis is due to 
 the chlorosis and not to other causes. In 68 per cent, of the 
 cases we have found the hydrochloric acidity excessive 
 at some period during the digestion of the test-breakfast — 
 excessive free HCl at the expiration of one hour in 1 1 per 
 cent, of the cases, excessive physiological HCl (H -f" C) in 32 
 per cent, of total cases, and an abnormality in the evolution 
 of digestion in the remainder of the cases. No noteworthy 
 myasthenia existed in any of the cases, the results being 
 obtained by using the ordinary methods and by controlling 
 them with the water-test whenever they did not give satisfac- 
 tory results. Briefly, in chlorosis there may be hyperesthesia 
 gastrica, or there may be adenohypersthenia gastrica, and in 
 some cases there is hypersthenic gastritis. Ulcer was present 
 in six per cent, of the total cases, and we have never seen a gas- 
 tric hemorrhage in pure chlorosis that was not due to ulcer. 
 Gastric cramps occur in chlorosis when it is accompanied by 
 gastroptosis or hyperchlorhydria. Associated with the gas- 
 tric trouble is generally found neurasthenia gastrica, which 
 is as it should be when the influence of chronic irritation or 
 irritable weakness of the abdominal sympathetic in the causa- 
 tion of chlorosis is held in mind. 
 
 The disturbing influence of oligocythemia on the stomach 
 is far less than the influence of chlorosis. Hemorrhagic 
 anemia diminishes secretion, and this effect is often seen in 
 ulcer after a severe hemorrhage. But the normal secretion 
 or the hyperchlorhydria returns as the regeneration of the 
 blood advances. In grave oligocythemia secretion may be 
 diminished, and the gastric glands, like the noble elements of 
 other organs, may undergo fatty degeneration and atrophy. 
 Ulcer is much less frequently a result of oligocythemia than 
 of chlorosis. In the study of the effect on the stomach of 
 oligocythemia, be it dyshematopoietic, degenerative, or hema- 
 tocytolytic, we have been unable to discover a thread to guide 
 us in the confusion. In the primary cases it is difficult to 
 eliminate the influence of medication or to estimate the influ- 
 ence of the causative disease in the secondary cases, as in 
 pyemia, in septicemia, and in the anemias due to intestinal 
 putrefaction and auto-intoxication. In a majority of the 
 simple cases of mild and severe oligocythemia the stomach is 
 normal.
 
 638 DISEASES OF THE STOMACH. 
 
 V. DISEASES OF NUTRITION. 
 
 The various diseases of nutrition do not disturb the stomach 
 to an equal degree. Chronic rheumatism produces directly 
 no particular disturbance. Obesity causes little more than 
 diminution of the appetite, the gastric disturbances found in 
 this disorder of nutrition being due to the mode of life and to 
 improper treatment. But many fat people are active, enjoy 
 good appetites, and have excellent digestion. Fasting pro- 
 duces diminution of hydrochloric acid secretion without 
 diminishing the formation of the ferments. The stomach 
 ceases to act, but retains its functional power. In chronic 
 subnutrition there is diminution or loss of HCl secretion with- 
 out a corresponding diminution of the ferments. But in pro- 
 longed subnutrition of a severe degree secretion is not simply 
 in abeyance, but it may be permanently impaired, and the 
 weakness of the stomach muscle is in keeping with the weak- 
 ness of the general muscular system. We would, in this 
 connection, emphasize the very important influence of emacia- 
 tion and loss of muscular strength in the causation of dis- 
 placements of the abdominal viscera — kidneys, liver, spleen, 
 colon, and stomach. 
 
 Diabetes, be it constitutional (nutritive), nervous, pancre- 
 atic, alimentary, or hepatic, may disturb the stomach. In 
 many cases there is only a diminution of HCl secretion. 
 There is often myasthenia in cases of long standing, which 
 may be associated with hyperchlorhydria or with hypo- 
 chlorhydria, but which is most likely the result of excessive 
 eating and drinking rather than of the diabetes. It is the 
 rule to find no serious disturbance of the stomach in diabetes, 
 unless there be great emaciation, advanced cardioarterioscle- 
 rosis, or nephritis. But it should be remembered that the 
 functions of the stomach may be insufficient, and under such 
 circumstances the diet should not be made too exclusively 
 nitrogenous. 
 
 The gastric troubles of gout may be due to the drugs which 
 are commonly employed, to the restricted diet, to the second- 
 ary nephritis and arteriosclerosis, or, finally, to the disease 
 of which the uric acid precipitation is the expression. 
 There may be an associated or, sometimes, a secondary 
 gastritis. But the special gastric trouble of gout is myas- 
 thenia, which may be accompanied either by hyperchlorhydria 
 or by hypochlorhydria, with or without fermentation. If 
 there be hypochlorhydria and fermentation, a vicious circle 
 is established, for this secondary gastric trouble of gout favors
 
 THE SECONDARY DISEASES OE THE STOMACH. 639 
 
 the conversion of the neutral into the acid phosphate of soda, 
 and may cause uric acid precipitation. 
 
 VI. DISEASES OF THE KIDNEYS. 
 
 It is difficult to study the effects of the diseases of the kid- 
 neys on the stomach, for the usual medication of nephritis is 
 likely to do the stomach injury, and the two organs may 
 become diseased from the same causes. But excluding, so far 
 as possible, these sources of error, it may be stated in a gen- 
 eral way that the stomach troubles of nephritis are due to 
 acute or chronic uremia. The retention poisoning may act 
 on the central nervous system and produce vomiting, which is 
 always a most prominent gastric symptom in uremia, whether 
 gastritis be present or absent. The retention poisoning also 
 leads to the elimination of ammonia compounds by the 
 stomach, and the HCl may be neutralized, so that the analy- 
 sis of the contents gives a false conception of the activity of 
 secretion. We have frequently noticed that the hypochlor- 
 hydria of the acute exacerbations of chronic nephritis is 
 replaced by normal secretion, or even by hyperchlorhydria, 
 during the period of quiescence of the Bright's disease when 
 renal sufficiency is reestablished. Indeed, it seems that it is 
 the rule in the early period of chronic nephritis to find the 
 gastric irritation displayed by hydrochloric acid in excess. 
 But later, the hyperchlorhydria is replaced by permanent 
 hypochlorhydria symptomatic of chronic gastritis. The 
 hydrochloric acidity diminishes during the uremic attacks, 
 and the alkaline or nearly neutral vomit may contain ammo- 
 nia (white cloud produced by vapor from a glass rod dipped 
 in HCl). The ferments seem to be destroyed in part, or are 
 secreted in less quantity than would be proportionate to the 
 diminution of the hydrochloric acid secretion. Flatulency is 
 common, although fermentation is rare, and it may possibly 
 be due to the decomposition of carbonate of ammonia. The 
 stomach disturbance is a rough index of the degree of renal 
 insufficiency, and the preservation of the functions of the 
 digestive organs protects the system and the kidneys against 
 injury by gastro-intestinal auto-intoxication. 
 
 Stone in the kidney may either produce no gastric trouble 
 at all or it may excite reflex vomiting. We have sometimes 
 found hyperchlorhydria, or, more frequently, hypochlorhydria. 
 The painful gastroduodenal crises of movable or floating kid- 
 ney are said to be common, but the disturbance certainly
 
 640 DISEASES OF THE STOMACH. 
 
 originates in some cases in the cecum and colon, and in others 
 the signs and symptoms are due to perinephritis. 
 
 VII. SPINAL DISEASES. 
 
 Myelitis, multiple sclerosis, and spinal meningitis may be 
 accompanied by reflex vomiting, by h\-perciilorhydria,and by 
 painful gastric crises. But the gastric troubles caused in this 
 manner are either so rare or so obviously sympathetic that they 
 hardly deserve mention. It is not so, however, with the gas- 
 tric crises of locomotor ataxia, which occur during the course 
 of the sclerosis of the posterior columns, or which may be 
 the first revealing sign (in about five per cent, of cases) of 
 tabes at a period when there are no disturbances of the 
 refle.xes, of sensation, or of coordination. 
 
 The gastric crises begin suddenly, regardless of the state of 
 repose or of functional activity of the stomach, and regardless 
 of the quantity and the quality of the diet. There may be 
 irregular prodromal symptoms — shooting pains, epigastric 
 uneasiness, depression of spirits, and restlessness. The crisis 
 is continuous, and is manifested by pain, by vomiting, and by 
 general weakness and anxiety. In from a few hours to several 
 days the crisis ends as suddenly and as apparently without 
 cause as it began. 
 
 The pain is not always present, and it is variable in quality 
 and intensity. It maybe burning, stabbing, shooting, cramp- 
 like, moderately severe, or almost deadly in its agony. But the 
 pain has always certain distinctive characteristics : it is bilateral 
 in its radiations; it is not relieved by vomiting, by alkalies, or 
 by albuminous food ; it is only temporarily diminished by 
 lavage, and then only in the beginning of the crisis, and mor- 
 phin controls it only during the period of narcotism. Some- 
 times, though seldom, the pain is the only manifestation, and 
 it may then be cramp-like, without vomiting, and with com- 
 plete arrest of secretion. Furthermore, we would emphasize 
 the fact that the quality and the intensity of the pain bear no 
 relation whatever to the hydrochloric acidity of the contents 
 of the stomach. 
 
 Vomiting maybe absent, but usually it is present, obstinate, 
 and accompanied by nausea and by retching. It may be the 
 predominant sj-mptom, and the gastric intolerance may be 
 complete. The vomit consists of whatever may be in the 
 stomach at the time — food, gastric juice, mucus, and, event- 
 ually, bile and pancreatic juice. The crises are usually ac- 
 companied by thirst and by complete loss of appetite.
 
 THE SECONDARY DISEASES OF THE STOMACH. 64 1 
 
 The crises are not always of the same severity, and conse- 
 quently do not always produce the same effects on the gen- 
 eral system. The vomiting and pain may be so severe that 
 complete collapse is produced by the uncontrollable vomiting 
 and the intolerable agony. As a rule, the crises become 
 milder as the spinal disease advances. 
 
 The crises of tabes dorsalis are paroxysmal, spasmodic, and 
 gastralgic. The nerves and the muscle of the stomach are 
 affected to a much greater degree than is secretion. There 
 is pain, loss of appetite, and cramps, but the state of secretion 
 is determined to a greater extent by the antecedent state of 
 the mucous membrane than it is by the spinal sclerosis. If 
 there be no disease of the mucous membrane, in the be- 
 ginning of the crisis there is hyperchlorhydria; but in case 
 the crisis is prolonged or is repeated after short intervals, 
 the vomit contains less and less HCl and ferments. Under 
 such circumstances gastric secretion is normal during the 
 intervals. But it is the rule, as a result of the antisyphilitic 
 or antitabetic medication, to find chronic asthenic gastritis 
 already present. The quantity of hydrochloric acid in the 
 vomit in the beginning of the attack displays the secretory 
 power of the diseased mucous membrane, and the acid is 
 consequently diminished. During the course of the attack 
 the acidity becomes less, and the diminution is due in part 
 to the reflux of the duodenal contents into the stomach, and 
 to the capillary hemorrhage which occurs in some of the very 
 severe attacks. There seems never to be continuous secre- 
 tion, nor is there myasthenia with retention or accumulation 
 of the secretion of the stomach. Medication has no appre- 
 ciable effect in the control or prevention of the crisis. It 
 will be seen at a glance how different are the functional signs 
 of the gastric crises of locomotor ataxia from those of chronic 
 hypersthenic gastritis or from the paroxysmal form of hyper- 
 chylia gastrica, the two diseases with which the gastric crises 
 are most likely to be confounded. 
 
 VIII. CEREBRAL DISEASES. 
 
 Meningitis, — particularly basilar meningitis, — cerebral hem- 
 orrhages, brain abscess, and brain tumor, may be manifested 
 by vomiting. The vomiting, which has the peculiar charac- 
 teristics of cerebral vomiting, is central and symptomatic, and 
 can not be properly considered a secondary affection of the 
 stomach. Cerebral vomiting is easy, projectile, without rela- 
 41
 
 642 DISEASES OF THE STOMACH. 
 
 tion to meals or to the quality of the diet, is not accompanied 
 by disease of the stomacli, and may occur in crises. In every 
 case of obstinate vomitin<j it should be a rule to look for 
 possible cerebral lesions and their other manifestations — 
 vertigo, headache, motor and sensory disturbances, and 
 changes of the optic disc and retina. Brain injury has been 
 known to produce capillary gastric hemorrhage. Hyper- 
 chlorhydria is more frequent in melancholia, in dementia 
 paralytica, in mania, and in paranoia than is normal secretion, 
 though hypochlorhydria is also found. Cerebral fatigue may 
 produce paroxysmal hyperchylia gastrica, but the most com- 
 mon gastric affection which originates in the central nervous 
 system is neurasthenia gastrica. 
 
 It is very difficult to define and explain the gastric troubles 
 of neurastlienia. It may be contended that the disease of 
 the stomach is only an accidental association, be it a dynamic 
 affection or an anatomical disease. It may be contended that 
 the gastric trouble is primary, and that it is the cause of the 
 central neurasthenia. All the hypersthenic diseases of the 
 stomach may produce general neurasthenia, and in latent 
 forms may, during a variable length of time, be manifested 
 by weakness and increased irritability of the central nervous 
 system, even without subjective gastric symptoms. It may be 
 contended, and sometimes with truth, that the central neuras- 
 thenia is primary, and that it ma\' produce functional disturb- 
 ances of the stomach, which in their normal evolution may 
 become transformed into anatomical diseases. It seems wisest, 
 in the prevailing confusion, to avoid partizan theories. If we 
 have found in our experience tliat about one-third of the cases 
 of central neurasthenia develop secondary affections of the 
 stomach, and that about four-fifths of thecases of neurasthenia 
 gastrica (primary) develop some of the signs and symptoms of 
 cerebral and spinal neurasthenia, the observation may be im- 
 puted to the supposed tendency of each specialist to exaggerate 
 the importance and the pathogenic influence of the organs 
 whose diseases it is his particular business to treat. This per- 
 sonal equation may be ver\' great, and we admit its influence ; 
 but we should be more inclined to accept the neurologist's 
 opinion if it were more frequently the custom to examine the 
 stomach by the modern methods. In our experience, the 
 most common secondary disease of the stomach in cerebro- 
 spinal neurasthenia is neurasthenia gastrica. There may be 
 no abnormality of secretion or of the motor function — the 
 patients simply suffer and complain, and are overanxious as a 
 result of the sensations which accompany digestive activity,
 
 THE SECONDARY DISEASES OF THE STOMACH. 643 
 
 just as in primary neurasthenia gastrica. At times there may 
 be hyperchlorhydria — free HCl may appear too early in the 
 course of the digestion of the test-breakfast, or it may be too 
 great at the height of its digestion, or the appearance of free 
 HCl may be delayed and, eventually, become excessive in 
 quantity. More infrequently there may be hypochlorhydria. 
 Or there may be myasthenia with a mild degree of stagnation, 
 the stomach doing its motor work perfectly for a certain 
 period, and then becoming insufficient, as may be clearly 
 shown by the water-test. But the functional abnormality is 
 intermittent and inconstant, for if the central neurasthenia be 
 accompanied by a secretory disorder of a fixed chemical type, 
 an organic change in the mucous membrane is present. The 
 anatomical disease may bean accidental association, or it may 
 have developed in consequence of the predisposition created 
 by the neurasthenia and by the neurasthenic functional dis- 
 order. 
 
 The secondary affections of the stomach produced by hys- 
 teria are more numerous than those of neurasthenia. The 
 most important are anorexia, hyperesthesia gastrica, anes- 
 thesia gastrica, and hysterical vomiting. These hysterical 
 gastric troubles may be the only manifestations of the hys- 
 teria, or the psychosis may affect some of the voluntary and 
 conscious functions of the organism. The monosympto- 
 matic gastric form may present great difficulty in diagnosis. 
 Although hysterical stigmata maybe absent, the gastric affec- 
 tion may possess some peculiar and suggestive characteristic. 
 The anorexia may be an anorexia with a fixed idea or pur- 
 pose. The vomiting is always alimentary and easy. In 
 spite of both anorexia and vomiting, nutrition may be 
 perfectly preserved for a long time, and there is no organic 
 disease of the stomach present to cause them. These affec- 
 tions begin suddenly and without an apparent cause, and end 
 suddenly and in an inexplicable manner. They have no rela- 
 tion to the quality or quantity of the diet, and often run their 
 course irregularly and in a manner typical of no particular 
 disease of the stomach, and in total disregard of all, except 
 suggestive treatment. These and many other well-known 
 hysterical characteristics may suggest the nature of the puz- 
 zling and grotesque affection. 
 
 IX. DISEASES OF THE MOUTH, NOSE, AND THROAT. 
 
 It is exceedingly difficult to determine the relation of the 
 diseases of the mouth, nose, and throat to the diseases of the
 
 644 DISEASES OF THE STOMACH. 
 
 stomach. In the first cliapter of the Vicious Circles of the 
 Stomach no mention was made of the possible causation of 
 diseases of the upper air-passages by the diseases of the 
 stomach, because such a result seems to be very infrequent. 
 Acid regurgitation may affect the throat as it does the esoph- 
 agus, and tlie diseases of the stomach may influence the cir- 
 culation, the nutrition, the nervous system, etc., in such a man- 
 ner as to predispose more or less all the mucous membranes 
 of the body to inflammation. That is about as much as can 
 safely be said without danger of exaggeration. The auto- 
 toxic sore throats due to HjS poisoning are of intestinal 
 origin. 
 
 Diseases of the mouth may disturb gastric digestion by 
 interfering with mastication or by changing the reaction and 
 composition of the mixed secretion of the mouth; and thrush 
 may, under fit circumstances, extend from the mouth to the 
 stomach. 
 
 It is often contended that the frequent coexistence of nose 
 and throat disease with gastric disease demonstrates that one 
 or the other disease is secondary. But the two may be pro- 
 duced by the same cause, or they may be the effects of differ- 
 ent causes. It is hard to find a perfectly normal nose and 
 throat in New York, but diseases of the stomach are by no 
 means so frequent, and in fine climates and in better hygienic 
 surroundings the two classes of diseases are far less frequently 
 associated. 
 
 Diseases of the nose and throat may influence the stomach 
 by reflex action, by local irritation, by infection, or, in some 
 cases, by the influence on the general health. After tabu- 
 lating a large number of cases, we are unable to detect the 
 reality of the reflex pathogenic influence on the stomach. 
 There is no disturbance of secretion or of the motor function, 
 which appears with regularity in connection with diseases of 
 the rhinopharynx. The swallowing of large quantities of 
 mucopus for a long period does affect the stomach, and the 
 pyogenic cocci may grow on the mucous membrane if there be 
 but little HCl secreted; such, anyway, would seem to be the 
 case, as we have seen pyogenic cocci in large numbers on 
 little pieces of the mucous membrane found in the expressed 
 gastric contents. In chronic asthenic gastritis, associated 
 with purulent rhinopharyngeal diseases, the micro-organisms 
 of the stomach are a close reproduction of the micro-organ- 
 isms which are swallowed. The tabulated cases show another 
 noteworthy fact — the diseases of the stomach which are most 
 frequent are associated with the most frequent diseases of the
 
 THE SECONDARY DISEASES OF THE STOMACH. 645 
 
 rhinopharynx. While the etiological relation of the diseases 
 of the stomach and the diseases of the throat, nose, and its 
 accessory sinuses is still an open question, there can be no 
 doubt that it should be the rule of practice to treat both dis- 
 eases simultaneously, 
 
 X. DISEASES OF THE RESPIRATORY ORGANS. 
 
 Acute pleurisy produces no particular disturbance of the 
 stomach, for the visceral congestion of its initial period is but 
 slight, and the fever does not run high. Large effusions may 
 interfere with the aeration and circulation of the blood, and 
 with the movements of the diaphragm, which facilitate the 
 circulation in the abdomen by subjecting the organs to rhyth- 
 mical compression. But gastric digestion proceeds in a nor- 
 mal manner if proper attention be given to the diet, though 
 reflex vomiting sometimes occurs, and the pleuritic pain, as 
 does all severe pain, may depress the functions of the stomach. 
 The disturbance of gastric digestion, if it occurs, passes away 
 in a short time without doing any particular damage. Such 
 is not the case, however, with empyema, for the toxemia de- 
 presses secretion, induces myasthenia, and sometimes leaves 
 chronic asthenic gastritis as a legacy. 
 
 Acute bronchitis affects the stomach to a greater degree 
 than does acute pleurisy. It appears that acute gastric 
 catarrh with hyperchlorhydria, which is the common disturb- 
 ance of the stomach in acute bronchitis, is only an associated 
 disease due to a common cause. Chronic bronchitis and 
 emphysema produce chronic defective aeration of the blood 
 and dilatation of the right side of the heart. Passive conges- 
 tion and catarrh of the stomach may result, and the swallow- 
 ing of the expectoration of putrid bronchitis may disturb 
 secretion and irritate the mucous membrane. 
 
 Pneumonia affects the stomach very seriously, and lobar 
 pneumonia is more active in this respect than is the lobular 
 form. Obstinate reflex vomiting may occur from the irritation 
 of the pneumogastric by the compression of the consolidated 
 lung, and it often follows the cough. The prolonged chill, 
 high fever, defective aeration of the blood, and the insufficiency 
 of the right side of the heart produce the most common dis- 
 ease of the stomach in pneumonia, which is acute gastritis. 
 The gastritis may develop during the onset of the pneumonia, 
 but it often appears later, when the heart insufficiency and 
 cyanosis are most marked. The initial gastritis is accom- 
 panied by hyperchlorhydria (vomit of 17 cases), but the
 
 646 DISEASES OF THE STOMACH. 
 
 terminal gastritis is accompanied by hypochlorhydria (vomit 
 of three cases) or by absence of free HCl (vomit of eight 
 cases). Fortunately, neither pleurisy, bronchitis, nor pneu- 
 monia produce myasthenia. The motor function remains 
 unimpaired, and the stomach empties itself normally through- 
 out these diseases, unless it be maltreated or already diseased. 
 
 Of all the grave organic diseases, pulmonary tuberculosis 
 exerts the greatest influence on the stomach, and thus 
 weakens or destroys the system's defense against the progress 
 of the disease. If nutrition is to be maintained and fortified, 
 — and all agree that this is the essential basis of antitubercu- 
 lar medication, — the integrity of digestion must be preserved. 
 If the drug treatment is to be beneficial, the recuperative and 
 resisting powers of the body must be increased. As soon as 
 the functions of the stomach are lost, the lungs and the whole 
 system are at the mercy of the tuberculosis. 
 
 Not all the gastric troubles which occur in the course of 
 consumption are due to the tuberculosis. The stomach may 
 be already diseased when the tubercular infection begins, and, 
 indeed, gastritis (Hayem) and " dilatation " (Bouchard) create 
 favorable conditions for the development of pulmonary tuber- 
 culosis. Consequently the gastric trouble may be primary 
 and not secondary. And, again, during the course of the 
 tuberculosis the gastric trouble may be produced by ordinary 
 causes, and not only in spite of, but sometimes as the result 
 of, the medication adopted. The stomach is neglected and 
 injured in the absorbing effort to control or cure the pulmon- 
 ary disease. Or the stomach may be affected indirectly by 
 the influence of the pulmonary tuberculosis (mixed infection) 
 on nutrition and on the blood. But, apart from all these 
 possibilities, we maintain that pulmonary tuberculosis fre- 
 quently exerts a direct and injurious influence on the stomach. 
 
 Our conclusions are based on the study of 95 cases. Of 
 these, 47 were first seen during the incipient period, 26 during 
 the stage of consolidation, and 12 during the period of cavity 
 formation. In every case the diagnosis was confirmed by 
 demonstrating the presence of the tubercle bacillus, which 
 was not found in seven of the cases of incipient tuberculosis 
 until several weeks after the patient first came under observa- 
 tion, these cases beginning clinical!)' with circumscribed dry 
 pleurisy of the apex of the lung. 
 
 Of the 47 cases of incipient tuberculosis, ten manifested 
 no subjective nor objective signs of an anatomical disease 
 or of a dynamic affection of the stomach. Three of the 
 remaining cases had chronic asthenic gastritis; there were
 
 THE SECONDARY DISEASES OF THE STOMACH. 647 
 
 absence of free HCl, diminished combined HCl, corre- 
 sponding diminution of the ferments, excessive quantity of 
 mucus, and no (or very slight) impairment of the motor 
 function. Eighteen other cases gave only traces of free 
 HCl, diminished combined HCl, slight diminution of fer- 
 ments, with mild (13) and severe (5) forms of stagnation 
 associated with more or less active fermentation. It is 
 more than probable that the gastric trouble in these 18 
 cases antedated the tuberculosis, but the motor insufficiency 
 was', probably, the effect of the tuberculosis, as primary mild 
 asthenic gastritis of the ordinary type is characterized, with 
 but i&w exceptions, by preservation of the motor function. 
 Retaining the myasthenia as the only tubercular character- 
 istic, these 18 cases may be excluded, along with the 
 three cases of chronic asthenic gastritis, from the study of 
 the gastric troubles of the incipient period. We will return 
 later to the discussion of the evolution of these cases, eight 
 of which complained of only irregular disturbance of the 
 stomach and three seemed perfectly satisfied with their diges- 
 tion. The 16 remaining cases of this group will now be 
 reviewed. Three of them suffered from the digestive form 
 of adenohypersthenia gastrica ; there was free HCl in large 
 excess, diminished or normal combined HCl, excess of fer- 
 ments, no excess of mucus, and a perfectly preserved motor 
 function. Seven other cases had myasthenia with stagnation 
 of the first degree, associated with secretory irritation; they 
 showed free HCl in excess, and delayed evacuation of the 
 stomach. One of these patients had the characteristic pain 
 and tender points of ulcer, and gave the history of hema- 
 temesis, there being no blood coloration of the sputum during 
 the following day. The six remaining cases gave the same 
 functional signs, but fermentation was also present in all of 
 them, and in two of the cases the stomach succeeded in 
 emptying itself only during the night. In these last two 
 cases the free HCl dropped below normal after the stomach 
 was thoroughly washed out and a proper diet had been given 
 to control the fermentation. Briefly, incipient tuberculosis 
 produces simple digestive adenohypersthenia gastrica in about 
 six per cent, of the cases, and myasthenia, with or without 
 fermentation, leading on slowly or rapidly to gastritis, in 
 about 28 per cent, of the cases. If the stomach be already 
 diseased, it becomes myasthenic. 
 
 Of the 26 cases first examined during the stage of con- 
 solidation, in only four was the stomach normal. Five were 
 cases of chronic asthenic gastritis with severe stagnation (4),
 
 648 DISEASES OF THE STOMACH. 
 
 or with retention (i), and with no free HCl (5). It was 
 not possible to determine whetlier the gastritis was secondary 
 to the tuberculosis in all these five cases. Of the remaining 
 17 cases of this group, three displayed excessive hydrochloric 
 secretion, 13 variable (sometimes normal, sometimes excessive, 
 sometimes diminished) HCl secretion, and one gave only a trace 
 of free HCl. Of all 17 cases, myasthenia with fermentation 
 was present in the mild (5) or severe (10) stagnation or in the 
 retention (2) form. Consequently, during the stage of con- 
 solidation there may be myasthenia with secretory irritation, 
 or there may be gastritis with motor insufficiency. 
 
 All the 12 cases first examined during the stage of cavity 
 formation proved to be cases of chronic asthenic gastritis 
 with motor insufficiency. In four of these there was gas- 
 tric retention, and in all of them there was gastric fermenta- 
 tion. 
 
 The evolution of the gastric trouble was followed closely 
 in some of these cases. By lavage and diet the fermentation 
 could be controlled in the cases with cavities or softening, 
 but the functions of the stomach were not perceptibly 
 improved. Little more could be done than adapt the diet to 
 the obstinate trouble. Of the 17 cases in the consolidation 
 group, 1 1 progressed slowly toward complete disappearance 
 of the free hydrochloric acid, and the motor insufficiency 
 increased or remained stationary for a short time. The fermen- 
 tation was controllable, but the functions of the stomach 
 could not be improved. The results of the treatment of 
 the gastric troubles in incipient tuberculosis were more en- 
 couraging. Both the hyperchlorhydia and the fermenta- 
 tion in all 16 cases were controlled by treatment. The 
 three cases of adenohypersthenia developed myasthenia as 
 the pulmonary trouble progressed, and the one which lived 
 longest nearly lost the free HCl before death. Of the remain- 
 ing 13, four have completely recovered their gastric func- 
 tions, and the tubercular process is stationary ; three others 
 developed gastritis before death ; the remaining cases were 
 not further studied by the modern methods of examination. 
 The stomach troubles of incipient tuberculosis are sometimes 
 curable, and by proper treatment the secretory irritation and 
 the fermentation may be controlled. The development of 
 gastritis may be postponed. Myasthenia is the most obstinate 
 and the most characteristic gastric trouble of phthisis. The 
 gastritis may result from the stagnation and secrctor}' irrita- 
 tion, and, clinically, may manifest itself as the hypersthenic 
 or asthenic form. Round-cell interglandular and subglandu-
 
 THE SECONDARY DISEASES OF THE STOMACH. 649 
 
 lar infiltration with cloudy swelling and degeneration of the 
 secretory cells predominates, either ultimately or from the 
 beginning, over productive glandular inflammation and hyper- 
 plasia. The gastritis of phthisis is a mixed gastritis. 
 
 It is very interesting to follow the evolution of the 14 
 cases the functions of whose stomachs were normal when the 
 patients first came under observation, ten being first seen dur- 
 ing the incipient period and four during the stage of consoli- 
 dation. Four of the ten incipient cases complained of great 
 malaise and gastric discomfort after meals, and, beincr anemic 
 and nervous, were probably suffering from neurasthenia gas- 
 trica. All ten cases became myasthenic during the stage of 
 consolidation, and the four living several months longer de- 
 veloped asthenic gastritis. The others died without further 
 exploration of the stomach, having been taken off by tuber- 
 cular pneumonia. Of the four normal cases seen during the 
 stage of consolidation, one had suffered from reflex vomiting, 
 one displayed only mild myasthenia two months before death, 
 and the vomit of another, examined during his last days, con- 
 tained no free H CI two hours after he had taken a glass of milk. 
 But the pre-agonal gastritis should be excluded from the study 
 of the cases of gastritis due to pulmonary tuberculosis. 
 
 But, apart from these gastric troubles of phthisis, — adenohy- 
 persthenia gastrica, myasthenia, and gastritis, — consumptive 
 patients sometimes present a very characteristic form of vom- 
 iting. The vomiting is probably reflex, and is a secondary 
 dynamic affection of the stomach. The vomiting is alimentary, 
 occurs after eating, — not after every meal (exceptions few), but 
 chiefly after the midday or the evening meal, — begins during 
 or after coughing, is without nausea, is performed without 
 effort, and ceases without leaving much discomfort. This 
 peculiar form of vomiting may be the only affection of the 
 stomach which is present at the time, or it may be associated 
 with the adenohypersthenia or with the myasthenia gastrica. 
 It was noted in 17 of the incipient cases. After the de- 
 velopment of gastritis the vomiting changes in character, 
 and may occur without preceding cough, either after eating 
 or when the stomach should be empty, and is accompanied 
 by nausea and retching. If retention be present, it may be 
 projectile, copious, and recur every two or three days, the 
 vomit consisting in part of food which should have long ago 
 been evacuated into the duodenum. It is easy to recognize 
 the reflex vomiting of consumption, and its presence should 
 always direct attention to the lungs. 
 
 The fever of pulmonary tuberculosis is without much influ-
 
 650 DISEASES OF THE STOMACH. 
 
 ence on gastric secretion. The stomach seems to become ac- 
 customed to fever, and is not disturbed by the high tempera- 
 ture, as it is in tlie infectious diseases. The control of the 
 fever by antipyretics does not improve the insufficiency of 
 secretion in puhnonary tuberculosis. However, in the three 
 cases of adenohypersthenia gastrica, excessive acidity dis- 
 appeared when the temperature became persistently high. 
 When the hyperchlorhydria depends upon the local irritation 
 of the stagnant contents it does not subside as the fever rises, 
 nor is the diminished secretion, due to asthenic gastritis, re- 
 stored by the control of the fever. Indeed, the preservation 
 of the appetite, in association with febrile movements and a 
 rapid pulse, should direct attention to the lungs, although the 
 patient may complain only of the stomach.
 
 NDEX. 
 
 Abdomen, appearance of, 53 
 
 inspection of, 55 
 
 palpation of, 61, 62 
 
 support of, 573. Se.& Abdominal belts. 
 Abdominal belts, 250 
 in gastroptosis, 573 
 in myasthenia with retention, 374 
 in vertical displacement, 563 
 
 coil, 236 
 
 massage, 246, 247 
 
 organs, displacement of, 566 
 
 pain, 39 
 
 tension, 58 
 Abscess in purulent gastritis, 387, 388 
 
 metastatic. See Aletasiatic abscess. 
 
 subdiaphragmatic, 455. Same as Abscess, 
 subphrenic. 
 
 subphrenic. See Subphrenic abscess. 
 Absorption, 140 
 
 disorders of, 216 
 
 tests of, 140, 141 
 Abstinence as a remedy, 186 
 Acetate of iron as an antidote to chromic 
 acid, 395 
 
 of lead in hemorrhage from ulcer of 
 stomach, 504 
 Acetic acid, 153 
 
 poisoning by, 395 
 
 fermentation, 153 
 tests of, 153 
 Acetone in pyloric obstruction, 596 
 
 in stomach, 611 
 Acetonuria in cancer of stomach, 539 
 Achylia, 18 
 
 gastrica, 2S7, 438 
 
 lactic acid in, 148 
 Acid. See Acetic acid; Butyric acid; 
 Hydrochloric acid; Lactic acid; Uric 
 acid. 
 
 and soda method of inflation, 72-74 
 Acidity of the system, 620 
 Acids in cardiospasm, 310 
 
 in gastroptosis, 567, 575 
 
 poisonous, action of, on the stomach, 
 392 
 Acne in myasthenia with retention, 366 
 
 in pyloric obstruction, 592, 593 
 Aconite as a gastric sedative, 255 
 
 in gastralgia, 280 
 
 in gastric pain, 251 
 
 in gastrospasm, 315 
 Acoria, 26S, 269 
 
 treatment, 270 
 Active electrode, 241 
 Acupuncture in subphrenic abscess, 493 
 Acute gastritis, 378. See Gastritis. 
 
 mycotic gastritis, 382 
 
 simple gastritis, 378 
 
 toxic gastritis, 391 
 Addison's disease, differentiation of, from 
 
 cancer of stomach, 548 
 Adelomorphous cells, 84 
 
 Adenasthenia gastrica, 286, 301-303 
 clinical description, 301 
 diet in, 303 
 differential diagnosis, 302, 437 
 
 from catarrhal gastritis, 409 
 etiology, 301 
 hydrochloric acid in, 301 
 treatment of, 245, 256, 302 
 Adenocarcinoma of the stomach, 517 
 Adenohypersthenia gastrica, 18, 31, 33, 34, 
 286, 300. See hyperchlorhydria, and 
 Hyperchylia gasti-ica. 
 alkalies in, 260 
 bulimia in, 266 
 diet in, 213 
 differentiation of, from gastralgia, 279 
 
 from ulcer of stomach, 478 
 forms of, 287 
 gastrospasm in, 314 
 in tuberculosis, 647 
 milk diet in, 201 
 
 physiological treatment of, 254, 255 
 Adenoma of stomach, 544 
 Adhesions in cancer of stomach, 519 
 
 in gastric ulcer, 495, 506 
 Aerophagia, 317 
 
 nervosa, 318 
 Air, swallowing of, 304. See Aerophagia. 
 Albu on toxin from the urine of tetany pa- 
 tient, 629 
 Albumin, calorimetric and nutritive value 
 
 , '^^' ^75 
 
 dissimilation of, 179 
 
 products of digestion of, 178 
 Albuminous food in catarrhal gastritis, 412 
 in digestive hyperchylia gastrica, 297 
 preparations, 195 
 Albumins, 177-180 
 
 dissolved, in rectal feeding, 218 
 Albuminuria from disease of stomach, 630 
 Albumoses in myasthenia gastrica, 215 
 
 in urine of cancer of stomach, 539 
 Alcohol, detection of, in stomach-contents, 
 154 
 
 in adenasthenia, 303 
 
 in catarrhal gastritis, 411 
 
 in digestive hyperchylia, 298 
 
 in disorders of absorption, 216 
 
 in gastroptosis, 574 
 
 in hyperchlorhydria, 294 
 
 in hyperesthesia, 212 
 
 in myasthenia with retention, 375 
 
 in myasthenia with stagnation, 361 
 
 in pyloric obstruction, 605 
 
 in rectal feeding, 218 
 
 in subacidity, 215 
 Alcoholic fermentation, 153 
 Algesimeter, Boas', 68 
 Alimentary principles, combinations of, 183 
 
 tables of, 184, 185 
 Alizarin, 105 
 Alkalies, 260 
 
 651
 
 6s2 
 
 INDEX. 
 
 Alkalies iti Ueatinciil of ulcer of stomach, 
 
 502, 50S 
 Alkalinity of blood in cancer of stomach, 538 
 Allorrhythmia from disease of stomach, 621 
 Almond milk, 217 
 
 Animoiiionia>;ncsium phosphate, 260 
 Ammonium chlorid in the stomach-con- 
 tents, 1 14 
 Amphoric breathing in diagnosis of sub- 
 phrenic abscess, 494 
 Anacidity, 301 
 
 hydrochloric, 117 
 Anaerobic bacteria, 154 
 Anatomical diseases, diet in, 216, 217 
 of the stomach, 3^8 
 
 signs, 158-160 
 Anderson, McCall, on ulcer of stomach, 
 
 443. 446 
 Anemia as a cause of stomach disease, 
 636 
 
 gastric hemorrhage in, 15S 
 
 in cancer of stomach, 535 
 
 in diseases of the stomach, 615, 616 
 
 in gastroptosis, 568 
 
 in glandular atrophy, 435 
 
 in ulcer of stomach, 471-473 
 
 in vertical displacement of stomach, 561 
 
 vomiting in, 327 
 Anesthesia gastrica from hysteria, 643 
 Angular form of vertical displacement of 
 
 stomach, 559 
 Anilin sulphate. See Sulphate of aniliu. 
 Annular scirrhus, differenliation of, from 
 
 hypertrophy of pylorus, 545 
 Anorexia as a symptom, 45 
 
 in pyloric obstruction, 590 
 
 nervosa, 271-275 
 clinical description, 272 
 diagnosis, 274 
 differential diagnosis, 274 
 etiology, 271 
 forced feeding in, 187 
 from hysteria, 643 
 treatment, 274 
 with acoria, 269 
 Antacids. 260 
 
 Antenrieth on frequency of cancer of stom- 
 ach, 512 
 Anterior axillary line, 68 
 Anti-albumose, 17S 
 Antifebriii in hyperchylia, 300 
 Antifermentative drugs in myasthenic re- 
 tention, 376. See Antiseptics. 
 Antimony, poisoning by, 397 
 Antipeptone. 178, 293 
 Antiperistalsis from intestinal obstruction, 
 
 632 
 Antiphlogistic effect of cold water, 236 
 Antipyrin in bulimia, 268 
 
 in gastric pain, 251 
 
 in hyperchylia, 300 
 Antisepsis, chemical, 258, 259 
 Antiseptics, 258, 259 
 Antispasmodics in upward displacement 
 
 of stomach, 557 
 Apoplexy, vomiting in, 326 
 Apparatus of Friedlieb, 233 
 
 of Hemmeter, 139 
 
 of Lcube-Rosenthal, 232 
 
 of Moritz, 157 
 
 of Soniervail, 232 
 
 of Soxhelet, 197 
 Appendicitis as 
 
 abscess, 495 
 Appetite, 44 
 
 in asthenia gastrica, 301 
 
 in cancer of stomach, 523 
 
 in eructatio nervosa, 319 
 
 cause of subphrenic 
 
 Appetite in gastritis glandularis prolifer- 
 ans, 417, 418 
 
 in hyperchlorhydria, 2SS 
 
 in myasthenia with retention, 364 
 
 in paroxysmal hyperchylia, 300 
 
 in pyloric obstruction, 589, 590 
 
 loss of, 251, 27! -275 
 
 from disease of intestine, 632 
 in glandular atrophy, 435 
 Aromatic sul])liates, 226 
 Arrhythmia from disease of stomach, 621 
 
 in myasthenia with retention, 366 
 
 in neurasthenia gastrica, 340 
 Arseniate of soda in bulimia, 268 
 Arsenic, hromid of, in bulimia, 268 
 
 in eructatio nervosa, 320 
 
 in gastric pain, 251 
 
 in neurasthenia gastrica, 347 
 
 in obstruction of cardia, 583 
 
 poisoning by, 397 
 Arteries, diseases of, as a cause of stomach 
 
 disease, 634 
 Arteriosclerosis as a cause of stomach dis- 
 ease, 304, 635 
 Artificial feeding, 187 
 Asafetida in nervous vomiting, 332 
 Asepsis, intragastric, 499 
 
 in treatment of ulcer of stomach, 499 
 Asparaginic acid from digestion of albumin, 
 
 178 
 Aspirator of Boas, 91, 92 
 Assimilation, definition of, 171 
 Asthenia aft'ects functions of stomach, 212 
 
 gastrica, electric Ireaiinent, 242-246 
 physiological treatment, 256 
 Asthenic gastritis, chronic, 18, 402-414. 
 
 See Gastritis catarihalis chronica. 
 Asthma dyspepticum, 305 
 Atelectasis, situation of stomach in, 555 
 Atresia of cardia, congenital, 577 
 
 of pylorus, congenital, 5S4, 587 
 Atrophy of the gastric glands. See Gas- 
 tritis glandularis atrophicans. 
 Atropin in cardiospasm, 307, 308. See 
 Belladonna. 
 
 in gastralgia, 280 
 
 in hyperchylia, 300 
 
 in pyloric obstruction, 607 
 Auscultation, 75-80 
 Auscultatory percussion, 72 
 Autodigestion, 450, 451 
 Auto-into.\icatioii, 47 
 
 as a cause of neurasthenia gastrica, 33S 
 
 effect of, on the blood, 615 
 
 gastric, influence of, 610 
 
 in gastric tetanv, 62S 
 
 in intestinal disease from disease of stom- 
 ach, 613 
 
 in myasthenia with retention, 367 
 
 in pyloric obstruction, 592 
 
 intestinal, 633 
 
 use of water in, 227 
 Autotoxic sore throat, 644 
 
 Bacillus acid i lactici, 147 
 
 butyricus, 152 
 
 coli communis, 155 
 
 geniculatus, 144, 146. 147, 14S 
 
 in cancer of stomach, 514 
 Backache in gastroptosis, 567 
 Bacteria of the stomach, 142-157 
 
 putrefactive, 147 
 
 zymogenic, 147 
 Bacteriological signs, 142-157 
 
 treatment. 25S, 259 
 Bacterium coli commune, 147 
 Baked apples, 211
 
 INDEX. 
 
 653 
 
 Balloon sound, Kulm's, 65, 66 
 Bandage, abdominal. 250 
 Bardenhauer, abdominal bandage of, 250 
 Barlow on pneumolhorax in subphrenic 
 abscess, 493 
 
 on subphrenic abscess in ulcer of 
 stomach, 48S 
 Basedow's disease, 266 
 Basilar meningitis, vomiting in, 641 
 Beaumont, investigations of, iSS 
 Bedsores in anorexia nervosa, 273 
 Beef juice, expressed, 196 
 Beefsteak, caloric value of, 196 
 
 digestion of, 193 
 Belching, esophageal, 317 
 
 in digestive hyperchylia gastrica, 295 
 
 in myasthenia gastrica, 350 
 
 in neurasthenia gastrica, 339 
 
 nervous, 316-321 
 Belladonna, 252. See Atropin. 
 
 in cancer of stomach, 551 
 
 in digestive hyperchylia, 298 
 
 in eructatio nervosa, 320 
 
 in gastralgia, 280 
 
 in gastroptosis with chronic colitis, 575 
 
 in gastrospasm, 315 
 
 in hyperchlorhydria, 294 
 
 in hypersthenic gastritis, 428 
 
 in nervous vomiting, 332 
 
 in spasm of pylorus, 313 
 
 in ulcer of stomach, 503 
 Belt, Glenard's, 250 
 
 Belts, abdominal, 250. See Abdominal belts. 
 Bernay's operation in pyloric obstruction, 
 
 608 
 Berthold on ulcer of stomach, 443 
 Bicarbonate of soda as an antacid, 260 
 in hyperchlorhydria, 294 
 in myasthenia, 257 
 in stomach inflation, 72 
 in ulcer of stomach, 502 
 Bief on kefyr, 202 
 Bile in digestion, 614 
 
 in the stomach, 160 
 
 in vomit, 601 
 Biliary colic, 40 
 Bilin water in Carlsbad cure of gastric 
 
 ulcer, 507 
 Bimuriare of quinin in gastralgia nervosa, 
 
 281 
 Binaural stethoscope, 72 
 Biological coefficient, 173 
 Bircher, operation of, 377 
 Bismuth as a gastric sedative, 255 
 
 in acid poisoning, 396 
 
 in digestive hypercliylia, 298 
 
 in hyperchlorhydria, 295 
 
 in mycotic gastritis, 386 
 
 in pyloric obstruction, 607 
 
 subnitrate as a corrective of magnesia, 
 260 
 in ulcer of stomach, 503 
 Biuret reaction, 289 
 Blister in nervous vomiting, 332 
 Blood, alkalinity of, in cancer of stomach, 
 538 
 
 corpuscles in cancer of stomach, ,S37 
 
 diseases of, as a cause of stomach disease, 
 636 
 
 examination of, in neurasthenia gastrica, 
 342 
 
 in anorexia, 273 
 
 influence of disease of stomach on, 615 
 of gastric secretion on, 615 
 
 presence of, in stomach, 158 
 
 specific gravity of, in cancer of stomach, 
 536 
 
 tests for, 158, 159 
 
 Blue litmus pajier, 101 
 
 Boas and Ewald, test-breakfast of, 95 
 
 algesimeter of, 68 
 
 aspirator of, 91, 92 
 
 bandage of, 250 
 
 enema of, 219 
 
 method of, for estimating free HCl, 106 
 of testing for, and estimation of, lactic 
 acid, 152 
 
 on lactic fermentation in cancer of 
 stomach, 535 
 
 on the location of cancer of stomach, 520 
 
 reagent, 103 
 
 stomach-tube, 64 
 
 supper in myasthenia gastrica, 354 
 in pyloric obstruction, 593,596,604 
 
 test of, for labferment and labzymogen, 
 121 
 Boettcher on presence of bacteria in ulcer 
 
 of stomach, 449 
 Bone-marrow, 210 
 Border cells of the stomach, 83, 84 
 
 in the secretion of HCl, 98 
 Botkin bottle, 157 
 Bouchard, nodosities of, 367 
 
 on dilatation favoring development of 
 tuberculosis, 646 
 
 on enlargement of phalangeal joints, 367 
 
 on subphrenic abscess in ulcer of stom- 
 ach, 488 
 
 theory of auto-intoxication, 366 
 Bourget test-meal of, 94 
 Bouveret method of stomach inflation, 72 
 
 on eructatio nervosa, 317 
 
 on toxins from gastric contents, 628 
 Bowel, large, function of, 218 
 Bradycardia from disease of stomach, 622 
 Brain injury as a cause of gastric hemor- 
 rhage, 642 
 Brandy in obstruction of cardia, 583 
 Braun, method of, no 
 Brautigam on influence of sex in cancer of 
 
 stomach, 514 
 Bread, action of, on stomach, 207 
 
 action of, on stomach in disease, 208 
 Brinton on cancer complicating ulcer of 
 stomach, 485 
 
 on diagnosis of ulcer of stomach, 475, 
 476 
 
 on hard cancer of stomach, 516 
 
 on hematemesis in cancer of stomach, 
 
 on influence of sex in cancer of stomach, 
 
 514 
 on mortality in ulcer of stomach, 497 
 on pain in ulcer of stomach, 461 
 on perforation complicating ulcer of 
 
 stomach, 486 
 on subphrenic abscess in ulcer of stom- 
 ach, 4S8 
 on ulcer of stomach, 446 
 Brissaud on chlorate of soda in cancer of 
 
 stomach, 551 
 Bromid of arsenic in bulimia, 268 
 of potassium in cardiospasm, 310 
 of sodium in neurasthenia gastrica, 
 
 347 
 of strontium in bulimia, 268 
 
 in gastric pain, 252 
 
 in neurasthenia gastrica, 347 
 Bromids in cardiospasm, 307, 308 
 in eructatio nervosa, 320 
 in gastrospasm, 315 
 in habitual regurgitation, 322 
 in nervous vomiting, 332 
 Bronchitis as a cause of stomach disease, 
 
 645 
 in myasthenia with retention, 366
 
 654 
 
 INDEX. 
 
 Briicke's test of digestive power (pepsin), 
 
 123 
 Briiii de galop, 194 
 
 ill gastric heart disorders, 623 
 in iieurastlieiiia gastrica,340 
 Brush, fa radio, 246 
 
 Bryant on death-rate of ulcer of stomach, 
 445 
 on mortality from cancer of stomach, 513 
 Bubbling in diagnosis of subphrenic ab- 
 scess, 494 
 Bulimia, 266-269 
 differential diagnosis, 268 
 etiology, 266 
 pathology, 266 
 treatment, 268 
 Busch, investigations of, 188 
 Butler as a food, 210 
 as intesliiuil diet, 217 
 in bulimia, 269 
 in cancer of slomacli, 553 
 in gaslroptosis with neurasthenia, 576 
 in hy|>erchU>rhydria, 294 
 in hypersthenic gastrins, 427, 429 
 in neurasthenia gastrica, 346 
 in obsiruciion of pylorus, 605, 607 
 in ulcer of stomach, 502 
 Butyric acid, 38, 152, 153 
 
 eflfects of presence of, 611 
 fermentation, 1^2 
 formalion of, 200 
 qualitative test for, 102 
 fermentation in cancer of stomach, 533 
 in cardiospasm, 306 
 
 in diagnosis between benign and malig- 
 nant pyloric obstruction, 602 
 
 Caffkin in paroxysmal hyperchylia, 300 
 Calcined magnesia, 260 
 
 in hyperchlorliydria, 294 
 
 in ulcer of slomacli, 502, 505 
 
 Calcuhis as a cause of vomiting, 327 
 
 Calf's brain in catarrhal gastritis, 412 
 
 in digestive hyperchylia, 299 
 
 foot jelly, 217 
 
 in chronic asthenic gastritis, 412 
 Calomel in gastric fever, 391 
 
 in paroxysmal hyperchylia, 300 
 Calorimeiric value of foods, 17.S, 176 
 Calumha In adenasthenia, 303. See Cohnnbo. 
 Camphorated oil and ether in ulcer of 
 stomach, 503 
 in acid-poisoning, 396 
 in mycotic gastritis, 386 
 Cancer of cardia, gastrostomy in, 553 
 of stomach, ,si2-5S4 
 age as a factor in diagnosis of, 546 
 anatomical signs of, 535 
 appetite in, 523 
 
 as a cause of cardiac stenosis, 577 
 of myasthenia, 3^9 
 of pyloric incontinence, 333 
 of pyloric obstruction, 585 
 bacillus geniculatus in, 146 
 bacteriological signs of, 533 
 blr)od changes in, 535 
 
 corpuscles in, 537 
 butyric acid in, 1.^3 
 clinical description of, 520 
 coma in, 539 
 
 complicating ulcer of stomach, 485 
 coiKlition of bowels in, 539 
 diagnosis, 540 
 
 Irom Addison's disease, 548 
 from afleiiasthenia gastrica, 302 
 from atrophy of gastric glands, 
 438 
 
 Cancer of stomach, diagnosis of, from car- 
 diospasm, 308 
 from chronic asthenic gastritis, 549 
 from chronic hypersthenic gastritis, 
 
 423. 550 
 from malarial cachexia. 549 
 from myasthenia gastrica, 35S 
 Irom neurasthenia gastrica, 344 
 from tuberculosis, 548, 549 
 from ulcer of stomach, 479 
 diet in, 552 
 
 differential diagnosis, 548 
 edema in, 529 
 emaciation in, 529 
 etiology, 514 
 fermentation in, 533 
 fever in. 539 
 
 formation of adhesions in, 519 
 frequency of, 512 
 functional signs of, 531 
 functions of stomach in, 543 
 gastro-enlerostomy in, 553 
 hard, 516 
 influence of age upon, 513 
 
 of sex upon, 514 
 involving body of the organ, 522 
 cardia, 521 
 pylorus, 522 
 lactic acid in, 4S1 
 medical treatment, 551 
 medullary, 517 
 
 method of dissemination of, 519 
 mortality ofj 512 
 motor insufliciency in, 519, 532 
 nutrition in, 530 
 pain in, 524 
 
 pathological anatomy, 515 
 perforation in, 520 
 physical signs, 525 
 prognosis, 551 
 pylorectomy in, 553 
 rest in, 164, 551 
 
 secretion of hydrochloric acid in, 531 
 soft, 516 
 
 spasm of pylorus in, 311 
 specific gravity of blood in, ,'536 
 surgical lrealinent,553 
 symptoms, 523 
 treatment, 551 
 tumor in, 525-529 
 urine changes in, 538 
 vomiting in, 524 
 Cane-sug«r, 181 
 
 Cannabis indica in gastralgia, 280 
 in gastric pain, 252 
 in gastrospasm, 315 
 in hyperchlorliydria, 294 
 in hypersthenic gastritis, 429 
 Canthos plaster in nervous vomiting, 332 
 Capsule electrode of Kinhorn, 239 
 Carbohydrates, 181, 182 
 
 digestion of, 141 
 Carbolic acid for vomiting, 253 
 
 in gastric pain, 2jS2 
 Carbonateof magnesia, absorbability of, 140 
 Carbonic acid water as a stomach douche, 
 
 256 
 Carcinoma of stomach. See Cancer of 
 
 stomach. 
 Cardia, 52 
 obstruction of." See Obstruction 0/ cardia. 
 spasm of, 304-311 
 Cardiac orifice of stomach, 51 
 Cardialgia, hot compress in, 235 
 Cardioresi>iratory symptoms in pyloric ob- 
 struction, 593 
 Cardiosclerosis as a cause of stomach dis- 
 ease, 635
 
 INDEX. 
 
 655 
 
 Cardiospasm, 304 
 
 diet in, 310 
 
 differential diagnosis, 308 
 
 treatment, 310 
 
 use of sound in, 307 
 Cardiovascular paroxysms from disease of 
 
 stomach, 623 
 Carlsbad and rest cure in gastric ulcer, 506 
 
 cure in ulcer of stomach, 503 
 
 sails in gastric ulcer, 507 
 
 in gastroptosis with chronic colitis, 575 
 
 water in hypersthenic gastritis, 427 
 Carminatives in upward displacement of 
 
 stomach, 557 
 Cascara in gastroptosis with chronic colitis, 
 
 ^575. ^. 
 
 Casern, digestion of, 199 
 
 Cassy on subphrenic abscess in ulcer of 
 
 stomach, 488 
 Catarrh of stomach from bronchitis, 645 
 Catarrhal gastritis, 405 
 icterus, influence of, on disease of stom- 
 ach, 633 
 Caustic alkalies, poisoning by, 396 
 Cecum, emptying of, by massage, 249 
 Celestins vichy in ulcerof stomach, 503 
 Cell, function of, in nutrition, 170, 171 
 Cells of the nervous system, 264, 265 
 Cellular activity in heat production, 174 
 
 theory of nutrition, 168 
 Cellulomuscular hypertrophy as a cause of 
 
 obstruction of pylorus, 585 
 Central vomiting, 326 
 Cereals, 207 
 as intestinal diet, 217 
 in adenastheni,a, 303 
 in digestive hyperchylia, 299 
 in gastritis glandularis atrophicans, 441 
 in gastro-intestinal fermentation, 209 
 in gastroptosis, 574 
 
 with neurasthenia, 576 
 in gastrospasm, 315 
 in hyperchlorhydria, 294 
 in hypersthenic gastritis, 427 
 in myasthenia with retention, 375 
 
 with stagnation, 361 
 in neurasthenia gastrica, 346 
 in obstruction ot pylorus, 605 
 in ulcer of stomach, 502 
 Cerebral diseases as causes of stomach dis- 
 ease, 641 
 fatigue, 165 
 a cause of hyperchylia gastrica, 642 
 in hyperchlorhydria, 287 
 tumors, vomiting in, 326 
 vomiting, 641 
 Cerebrospinal neurasthenia as a cause of 
 
 neurasthenia gastrica. 642 
 Cerium oxalate in vomiting, 253, 332 
 Cervico-esophageal galvanization, 310 
 Cervicogastric galvanization, 243 
 in nervous vomiting, 332 
 in regurgitation, 322 
 in spasm of the pylorus, 313 
 Chalk as an antidote, 396 
 
 prepared, in ulcer of stomach, 502 
 Champagne in mycotic gastritis, 3S6 
 
 for vomiting, 253 
 Cheese in pyloric obstruction, 607 
 Chemical antisepsis, 25S, 259 
 
 methods of quantitative analysis, 110 
 treatment, 259-261 
 Chewing the cud, 322-325 
 Chibret on action of milk, 198 
 Chicken in catarrhal gastritis, 412 
 in digestive hvperchylia, 299 
 in hvpersthenic gastritis, 426 
 in obstruction of pylorus, 605 
 
 Chicken in ulcer of stomach, 507 
 
 Chief cells, 83, 84 
 
 Chloral hydrate in eructatio nervosa, 321 
 
 in nervous vomiting, 332 
 
 in spasm of the pylorus, 313 
 Chlorate of soda in cancer of stomach, 
 
 551 
 Cblorid of calcium in adenasthenia, 303 
 
 of iron as a test for mucus, 129 
 Chloroform in nervous vomiting, 332 
 
 in vomiting, 327 
 
 water, 280 
 Chlorometric analysis, 105 
 Chlorosis as a cause of stomach disease, 
 
 636 . 
 
 Chocolate in myasthenia with stagnation, 
 
 361 
 
 in obstruction of cardia, 583 
 Cholangitis as a cause of stomach disease, 
 
 633 . . 
 Cholelithiasis as a cause of stomach dis- 
 ease, 634 
 as a cause of vomiting, 327 
 differentiation of, from gastralgia ner- 
 vosa, 279 
 hyperchlorhydria in, 2S7 
 Chomel, method of, for testing motor func- 
 tion of stomach, 135 
 on digestion, 163 
 Chromic acid, poisoning by, 395 
 Chronic asthenic gastritis. See Gastritis 
 catarrhalis chronica. 
 atrophic gastritis. See Gastritis glan- 
 dularis atrophicans. 
 gastritis, 398 
 
 hypersthenic gastritis, 414. See Gastritis 
 glandularis proliferans. 
 Chvostek on duodenal ulcer, 484 
 Chvostek's sign, 627 
 Cider in adenasthenia, 303 
 Cinchona in adenasthenia, 303 
 in gastroptosis, 574 
 
 with chronic colitis, 575 
 Circulation, influence ot disease of stom- 
 ach on, 621 
 Cirrhosis, hypertrophic, influence of. on 
 
 stomach disease, 634 
 Classification of stomach diseases, 18-20 
 Climate in treatment of neurasthenia gas- 
 trica, 345 
 Clinical history, 25-47 
 
 Clothing, arrangement of, in treating gas- 
 troptosis, 572 
 Coal-tar analgesics in gastric pain, 251 
 Coca as gastric sedative, 255 
 extract of, 269 
 in cardiospasm, 310 
 in gastric pain, 252 
 in nervous vomiting, 332 
 in spasm of the pylorus, 313 
 Cocain for vomiting, 253 
 Cocci of the stomach, 144, 145 
 Cocoa in gastritis glandularis atrophicans, 
 442 
 in hyperchlorhydria, 294 
 in myasthenia with stagnation, 361 
 in obstruction of cardia, 583 
 in obstruction of ))ylorus, 605 
 Codein in bulimia, 268 
 in cancer of stomach, 551 
 in gastralgia, 280 
 in gastric pain, 252 
 in gastrospasm, 315 
 in hyv>erchlorhydria, 294 
 in hypersthenic gastritis, 429 
 in obstruction of cardia, 583 
 in pyloric obstruction, 607 
 in ulcer of stomach, 505
 
 656 
 
 INDEX. 
 
 Codein phosphate, 252 
 
 ill mycolic gastritis, 386 
 
 in iiervuus vomiting, 332 
 
 in spasm of the pylorus. 313 
 Cod-liver oil. 210 
 
 in cancer of stomach, 553 
 
 ill gastritis glandularis atrophicans, 
 
 4^2 
 
 in gastroptosis with neurasthenia, 576 
 Coefticient, biological, 173 
 Coffee in adeiiaslhc-nia, 303 
 ill digestive h\ perchylia, 298 
 in gastric sensibility, 213 
 in gastritis glandularis atrophicans, 442 
 ill liyperchlorhydria, 294 
 ill myasthenia with stagnation, 361 
 in obstruction of pylorus, 605 
 ill subacidity, 215 
 Coffee-grounds vomit, 466, 480 
 
 ill cancer of stomach, 525 
 Colalgia in intestinal myasthenia, 351 
 Cold compress, 236 
 rater, action 1 
 douche, 235 
 
 ,23. 
 of. 
 
 water, action of, on stomach, 227, 228 
 
 sedative effect of, 236 
 Colic, gall-stone, 278 
 
 intestinal, 279 
 Colitis associated with neurasthenia gas- 
 
 trica, 342 
 Collapse in gastric ulcer, treatment of, 505 
 Colloid metamorphosis of soft cancer of 
 
 stomach, 518 
 Colon, tumors of, 543 
 
 Color methods of quantitative acid-analy- 
 sis, 105-110 
 Coloration-tilratioii. 105 
 Colunibo ill anorexia nervosa, 275 
 
 in asthenia gastrica. 256 
 Coma in cancer of stomach. 539 
 Combination color method. 107 
 Combined hydrochloric acid. 101 
 Compensation In glandular atrophy, 434 
 
 in pyloric obstruction, 586 
 Compress. 235. 236 
 
 Priessiiitz.236. See Prifssnitz compress. 
 Cotipression myelitis, vomiting in, 326 
 Comte on gastro-enterostomy, 510 
 
 on operations for perforating ulcer of 
 stomach. 510 
 
 on perforation in ulcer of stomach, 486 
 Condinieiits in cardiospasm. 310 
 
 in digestive hyperchylia. 298 
 
 ill gastric sensibility, 212 
 
 in liyperchlorhydria. 287. 294 
 
 ill invasthenia with stagnation, 336 
 
 in subacidity, 215 
 
 in nicer of stomach, 502 
 Condurango in asthenia gastrica, 256 
 
 in cancer of stomach, 551 
 
 in neurasthenia gastrica, 347 
 Congenital atresia of cardia, 577 
 
 stenosis of pylorus, 587 
 Congo-red as a test for HCI, 102 
 Constipation in anorexia. 273 
 
 ill cancer of stomach, 539 
 
 in hyperchlorhydria, 290 
 
 in myasthenia with stagnation, 351, 363 
 
 in neurasthenia gastrica. 347 
 
 in periodical vomiting. 329 
 
 in pyloric obstruction. 588. 589 
 
 in ulcer of stomach, 474 
 
 treatment of, 502 
 Coniiimiition as a cause of stomach disease, 
 
 646 
 Continuous secretion, 285 
 
 ill myasthenia with retention, 371 
 Contraindications to the use of the stomach- 
 tube, 89 
 
 Convulsions from disease of stomach, 629 
 in myasthenia with retention, 366 
 
 Corn bread in pyloric obstruction, 607 
 
 Cornmeal, 2C9 
 in p> loric obstruction, 607 
 
 Corset, abdominal, of Landau, 250 
 as a cause of vertical displacement of 
 
 stomach. 557, 558 
 -stomach. 566 
 
 Cramps in pyloric obstruction, 592 
 
 Cream as intestinal diet, 217 
 in digestive hyperchylia, 299 
 in hyperchlorhydria, 294 
 in obstruction of pylorus, 605, 607 
 
 Creosote as a gastric antiseptic, 25H 
 
 Cruveilhieroii pain in ulcer of stomach, 461 
 
 Cseri method of expressing stomach-con- 
 tents, 248 
 
 Cud-chewing. 322-325 
 
 Cullingsworth on infantile cancer of stom- 
 ach, 513 
 
 Culture soil, change of, 259 
 
 Current, density of, 241 
 I Custard in pyloric obstruction. 607 
 i Cyanid of iron, 113 
 I Cynorexia, 266-269 
 
 Czeriiy on pylorectomv in cancer of stom- 
 I ach, 554 
 
 Dahlaup on ulcer of stomach, 443 
 Debove meat powder in gastric ulcer, 508 
 Debove's neutralization method of treating 
 
 gastric ulcer, 508 
 Decinormal acid silver nitrate solution, 112 
 
 solution of sulphocyanid of ammonium, 
 H3 
 Deformity as a sequel of ulcer of stomach, 
 
 4q6 
 Deglutition sounds and noises, 75 
 Dehio method for estimating elasticity of 
 stomach, 70, 138 
 in myasthenia gastrica, 353 
 Delayed evacuation of stomach, 140 
 Delomorphous cells, 84 
 Descent of the stomach, total, 564 
 D'Espiiie on mortality from cancer of 
 
 stomach. 513 
 Devic extract from stomach-contents, 628 
 Dextrinized bread, 216 
 De Yong, method of testing for lactic acid, 
 
 Diabetes, acoria in, 269 
 
 as a cause of stomach disease, 638 
 Diagnosis and diagnostic methods, 21 
 Diaphragm, movements of, in subphrenic 
 
 abscess, 493 
 Diaphragmatitis in subphrenic abscess from 
 
 ulcer of stomach, 492 
 Diarrhea in anorexia, 273 
 
 in cancer of stomach. 539 
 
 in chronic atrophic gastritis, 435 
 
 in ulcer of stomach, treatment of, 502 
 Diet, 165-226 
 
 correctness or incorrectness of, 223 
 
 general rules for selection of, 168 
 
 in adenasthenia, 303 
 
 in cancer of stomach, 552 
 
 in cardiospasm, 310 
 
 in catarrhal gastritis. 411 
 
 in gastritis glandularis atrophicans, 441 
 
 in gastroptosis. 574 
 with chronic colitis. 575 
 
 in gastrospasm, 315 
 
 in hyperchlorhydria, 293 
 
 in hypersthenic gastritis, 426 
 
 in myasthenia with stagnation, 360 
 
 in neurasthenia gastrica. 345. 346
 
 INDEX. 
 
 657 
 
 Diet in obstruction of cardia, 583 
 of pylorus, 604 
 in regurgitation, 322 
 in retention myasthenia, 374 
 in spasm of pylorus, 313 
 in ulcer of stomach, 500 
 in upward displacement of stomach, 557 
 insufficient, 172 
 prescription of, 223 
 
 selection of, in disease of stomach, 167 
 Digestibility of food, clinical conception 
 of, 191 
 Penzoldt's table of, 190 
 Digestion in neurasthenia gastrica, 337 
 of beefsteak, 193 
 of bread, 193 
 of carbohydrates, 141 
 of meat, 193 
 of milk, 193 
 of proteids, 142 
 of roast beef, 193 
 of test-meals, 95-97 
 Digestive hygiene, 162-165 
 hyperchylia gastrica, 295-299 
 mixtures, 260 
 superacidity in ulcer and neurasthenia 
 
 gastrica, 343 
 symptoms, 36 
 . tube, 48 
 
 work, 141 
 Digitalis in upward displacements of stom- 
 ach, 557 
 Dilatation of stomach, 18, 19 
 
 of stricture of cardia, 583 
 Dimethylamidoazobenzol, 103, 106, 107 
 Diphtheria as cause of myasthenia gas- 
 trica, 348 
 Diphtheric gastritis, 387 
 Diplopia in pyloric obstruction, 592 
 Dirt-eaters, 271 
 
 -eating, 271 
 Diseases of arteries as causes of stomach 
 disease, 634 
 of blood as causes of stomach disease, 636 
 of brain as causes of stomach disease, 641 
 of heart as causes of stomach disease, 634 
 of intestines as causes of stomacli dis- 
 ease, 632 
 of kidneys as causes of stomach disease, 
 
 639 
 of liver as causes of stomach disease, 633 
 of mouth, nose, and throat as causes of 
 
 stomacli disease, 643 
 of nutrition as causes of stomach dis- 
 ease, 63S 
 of respiratory organs as causes of stom- 
 ach disease, 645 
 of spine as causes of stomach disease, 640 
 of stomach, effects of, 610 
 from disease of intestine, 632 
 influence of, on blood, 615 
 on heart and circulation, 621 
 on intestine, 611 
 on kidneys, 630 
 on liver, 614 
 on nervous system, 624 
 on nutrition, 617 
 on skin, 62S 
 secondary, 631 
 Displacement of stomach, downward. See 
 Gastroptosis. 
 lateral. See Displacentcnl of stomach, 
 
 vertical. 
 upward, 555 
 
 clinical description, 555 
 etiology, 555 
 objective signs, 556 
 treatment, 556 
 
 42 
 
 Displacement of stomach, vertical, 557 
 angular form, 559 
 clinical description, 560 
 etiology, 557 
 fish-hook variety, 559 
 genesis, 558 
 objective signs, 561 
 pathological anatomy, 558 
 prognosis, 563 
 straight form, 560 
 treatment, 563 
 Displacements of stomach, 19, 554-576 
 Dispora caucasica, 202 
 
 Dissolved albumins in rectal feeding, 218 
 Donkin on treatment of gastric ulcer, 50S 
 Dorsal tender point in ulcer of stomach, 
 
 469 
 Dorsogastric galvanization, 302 
 Douche, intragastric, 234 
 
 Scottish, 303 
 Doyen on gastro-enterostomy, 509 
 Dragging sensations in gastroptosis, 567 
 Drinking water, action of, on stomach, 227 
 Duck as a food, 195 
 Dulness on percussion in obstruction of 
 
 cardia, 5S0 
 Dunbar tube, 157 
 
 Duodenal obstruction as a cause of gastric 
 retention, 635 
 differentiation of, from pyloric obstruc- 
 tion, 600 
 orifice of stomach, 51 
 tenderness, 67 
 ulcer, 487 
 in differentiation between pyloric and 
 duodenal obstruction, 601 
 Duodenohepatic ligament, elongation of, 
 
 560 
 Duodenostomy in pyloric obstruction, 608 
 Dynamic affections, motor, 304 
 of secretion, 285 
 of stomach, 260 
 meats in, 194 
 sensory, 266 
 Dyscrasia, fibroid, 565 
 Dyshematopoiesisfrom disease of stomach, 
 
 615 
 Dyshematopoietic oligocythemia from sub- 
 nutrition, 615 
 Dyspepsia of liquids, 215, 355 
 Dyspeptic, the, 26 
 Dysphagia, 37 
 in cardiospasm, 305 
 in obstruction of cardia, 578 
 Dyspnea in spasm of cardia, 305 
 
 EcHiNOCocci as a cause of subphrenic 
 
 abscess, 495 
 Eczema from disease of stomach, 630 
 
 in myasthenia with retention, 366 
 
 seborrhceicum from disease of stomach, 
 630 
 Edema in cancer of stomach, 529 
 Edinger sponge-method, 86 
 Egg, 206 
 
 caloric value of, 196 
 
 hard-boiled, 207 
 
 in cancer of stomach, 553 
 
 in digestive hyperchylia, 299 
 
 in gastritis glandularis atrophicans, 441 
 
 in gastroptosis, 574 
 with chronic colitis, 375 
 with neurasthenia, 576 
 
 in hyperchlorhydria, 294 
 
 in myasthenia with retention, 375 
 with stagnation, 361 
 
 in obstruction of cardia, 583
 
 658 
 
 INDEX. 
 
 Egg in pyloric obstruction, 607 
 
 in ulcer of stomach, 502 
 
 poached, 207 
 
 sofl-boiled, 207 
 
 wliite of, 206 
 Einhorn, tapsule electrode of, 239 
 
 gastrograph of. 139 
 
 intragastric spray, 235 
 
 method of illuminating stomach, 58 
 
 stomach-bucket, 85 
 Elastic belts in gastroptosis, 573 
 Elasticity of stomach, estimation of, 138 
 Electric ilhiminalion of the stomach, 58- 
 60 
 
 lamp, ^S, 59 
 Electricity, contraindications to use of, 
 240-242 
 
 duration of application of, 241, 242 
 
 in adenasthenia gastrica, 245, 302 
 
 in asthenia gastrica, 242 
 
 in bulimia, 268 
 
 in chronic gastritis, 245 
 
 in digestive hyperchylia, 298 
 
 in eructatio nervosa, 320 
 
 in gastric hemorrhage, 241 
 
 in gastroptosis, 574 
 with neurasthenia, 576 
 
 in gastrospasm, 245 
 
 in hyperchlorhydria, 290, 293 
 
 in hypersthenia gastrica, 245 
 
 in myasthenia gastrica, 244' 
 with retention, 374 
 with stagnation, 363 
 
 in nervous vomiting, 331 
 
 in neurasthenia gastrica, 242 
 
 in rumination, 325 
 
 uses of, 238-246 
 Electrization, intragastric, 244 
 Electrode, " active," 241 
 
 Eiiihorn's capsule, 239 
 
 nickel-plated, 241 
 
 of Rosenheim, 244 
 
 plate. 243-245 
 
 roller, 243 
 
 Rosenheim's intragastric, 238 
 
 Wegele's spiral, 238, 239 
 Elimination, definition of. 171 
 Emaciation. See Inanition ^n<\ Syniplonia- 
 tology. 
 
 as a symptom, 46 
 
 in carcinoma, 527, 530 
 
 in chronic hypersthenic gastritis, 419 
 
 in gastroptosis. 567 
 
 in hyperchylia gastrica, 296 
 
 in myasthenia with retention, 365 
 
 in neurasthenia gastrica, 338 
 
 in obstruction of cardia, 579 
 of pylorns, 587 
 
 in subphrenic abscess, 493 
 Embolism, vomiting in, 326 
 Emphysema as a cause of stomach disease, 
 
 645 
 Empyema as a cause of stomach disease, 
 64=, 
 in ulcer of stomach, 493 
 Emulsiouized fats in rectal feeding, 218 
 Enema, nutritive, 218 
 
 in obstruction of cardia, 583 
 of Boas, 219 
 of Ewald, 219 
 of Leube, 219 
 Energy, potential, of the body, 173 
 Engrafted cancer, 485 
 
 Enteritis membranacea associated with 
 neurasthenia gastrica, 342 
 from disease of stomach, 613 
 in gastroptosis, 567 
 Hnteroptosis as a cause of gastroptosis, 633 
 
 Enteroptosis caused bv gastroptosis, 61^, 
 
 633 
 Environment as affecting the stomach, 162 
 Epigastric pain, 2S0 
 
 in hyperchlorhydria, 291 
 
 tender point in ulcer of stomach, 469 
 
 tenderness, 67 
 Erb on galvanic excitability in gastric 
 
 tetany, 627 
 Erb's sign. 627 
 Ergot in digestive hyperchylia, 29S 
 
 in gastroptosis, 574 
 
 in hemorrhage from ulcer of stomach, 505 
 
 in hypersthenic gastritis, 428 
 
 in myasthenia with stagnation, 363 
 Eructatio nervosa. 316-321 
 diagnosis, 320 
 etiology, 319 
 treatment, 320 
 Eructation, 316-321 
 Erythema in myasthenia with retention, 366 
 
 fugax in pyloric obstruction, 593 
 Erythrodextrin, 181 
 Esojihageal belching, 317 
 
 hemorrhage, differentiation from gastric 
 hemorrhage in ulcer of stomach, 468 
 
 orifice of stomach, 51 
 
 regurgitation. 322 
 
 stagnation in obstruction of cardia, 578 
 
 veins, varicose. 309 
 I vomiting in obstruction of cardia, 580 
 Esophagismus, 304. 577 
 Esophagus, sacculation of, 309 
 
 sounding of, in obstruction of cardia, 580 
 Ether in vomiting, 327 
 
 spray in nervous vomiting, 332 
 Ethvlendiamine from stomach-contents, 
 I 628 . 
 Eucasin, 196 
 Evacuation of stomach, 139 
 
 delayed, 140 
 Ewald and Boas, test-breakfast of. 95, 207 
 
 and Sievers. method of, for testing motor 
 function of stomach, 134 
 
 enema of, 219 
 
 Einhorn stomach-lamp of. 59 
 
 on toxin from the urine, 629 
 
 Politzer bag of, 91 
 
 salol test of. 134 
 Excitant diet in myasthenia gastrica, 215 
 
 treatment of adenasthenia, 303 
 Excitation in myasthenia gastrica, 215 
 
 of asthenia gastrica, 256 
 Exercise, 163 
 
 effect of, 246 
 
 in myasthenia with stagnation, 362 
 Exhaustion stage of anorexia, 273 
 Exophthalmic goiter, vomiting in, 326 
 Expectant treatment, 'sz 
 Expression method of removing the stom- 
 ach-contents, 93 
 
 Fai.sk hunger, 44 
 Farad ic brush, 246 
 Faradism in myasthenia gastrica, 244 
 
 selection of poles in, 241 
 Fatigue in consumption of potential en- 
 ergy, 175 
 Fats, 210 
 
 digestion and absorption of, 182 
 
 in adenasthenia, 303 
 
 in cancer of stomach. 553 
 
 in catarrhal gastritis. 411 
 
 in gastric fermentation, 216 
 
 in gastric sensibility, 213 
 
 in gastroptosis. 574 
 
 in myasthenia with retention, 375
 
 INDEX. 
 
 659 
 
 Fats in myasthenia with stagnation, 360 
 
 in neurasthenia gastrica, 346 
 
 in obstruction of pylorus, 605 
 
 in subacidity, 214 
 
 nutritive value of, 175 
 Fay on sulphate of anilin in cancer of 
 
 stomach, 551 
 Fecal vomiting in fistula from gastric 
 
 ulcer, 496 
 Feces as a measure of degree of pyloric 
 retention, 604 
 
 swallowing of, 271 
 Feeding, artificial, 187 
 
 forced, 1S7 
 
 through gastric fistula, 583 
 Fenwick on anorexia nervosa, 272 
 Fermentation, acute gastric, 3S3 
 
 gas-forming, in pyloric obstruction, 589, 
 596 
 
 gastric, 147-154. 258 
 
 in cancer of stomach, 533 
 
 in glandular gastritis, 417 
 
 in myasthenia with retention, 365 
 with stagnation, 351 
 
 lactic. See Lactic termeyitatioii. 
 
 lactic acid. See Lactic fermentation. 
 
 meat diet in, 194, 195 
 
 sounds, 76 
 
 theory of nutrition, 169 
 Ferments, 119-12S 
 Fever, gastric, 3S9 
 
 in cancer of stomach, 539 
 Fibrin formation in cancer of stomach, 536 
 Fibroid dysciasia, 565 
 Fibroma of the stomach, 511, 544 
 Fibromyoma of tlie stomach, 511 
 Finger method of introducing the stomach- 
 tube, 90 
 Fish, 196 
 
 -hook variety of stomach displacement, 
 
 .559 
 
 in bulimia, 269 
 
 in cancer of stomach, 553 
 
 in catarrhal gastritis, 412 
 
 in gastritis glandularis atrophicans. 441 
 
 in gastroptosis, 574 
 with neurasthenia, 576 
 
 in hyperchlorhydria, 294 
 
 in hypersthenic gastritis, 4.27 
 
 in myasthenia with retention, 375 
 with stagnation, 361 
 
 in neurasthenia gastrica, 346 
 
 in obstruction of pylorus. 605, 607 
 Fistula as a sequel of ulcer ot stomach, 496 
 Flabby abdominal wall as cause of gastrop- 
 tosis, 565 
 Flaked hominy, 209 
 
 rice, 209 
 Flatulency, 42, 155, 156, 224, 225 
 
 in gastroptosis, 567 
 
 in myasthenia with retention, 364 
 
 in spasm of the pylorus, 312 
 Fleiner on anorexia, 275 
 
 on bismuth in ulcer of stomach, 504 
 
 on toxins from gastric contents, 629 
 
 on use of bismuth, 295 
 
 on use of subnitrate of bismuth, 428 
 Fleischer test for motor function of stom- 
 ach, 135 
 Floating viscera, 250 
 P'lora of the stomach, 143 
 Fluids in catarrhal gastritis, 412 
 Food. See Diet. 
 
 as a remedy, 212-217 
 
 constituents of, 176, 177 
 
 digestibility of, 188-192 
 
 in asthenia gastrica, 256 
 
 indigestible residuum of, 177 
 
 Food, length of sojourn of, in stomach, 18S 
 
 physiological action of, 192-212 
 
 preparations, 195, 196 
 
 value of, to organism, 176 
 Forced feeding, 187 
 
 Foreign body obstructing the pylorus, 5S5 
 Formic acid, poisoning by, 395 
 Fowler's solution in anore.xia, 275 
 Fox on influence of sex in cancer of stom- 
 ach, 514 
 Free hydrochloric acid, 101 
 Freudenreich on milk, 197 
 Friedlieb's apparatus, 233 
 Fruits, 211 
 
 in gastric fermentation, 216 
 
 in gastritis glandularis atrophicans, 441 
 
 in gastroptosis, 574 
 with chronic colitis, 575 
 with neurasthenia, 526 
 
 in hyperchlorhydria, 294 
 
 in myasthenia with retention, 375 
 with stagnation, 361 
 
 in obstruction of p\lorus, 605, 607 
 
 in ulcer of stomach, 502 
 Functional disease of stomach, milk diet 
 in, 201 
 
 disorders, 262 
 
 signs, Si 
 
 Gall-bladdkr, disease of, as a cause of 
 stomach disease, 634 
 tumor of, 544 
 Gall-stone as a cause of stomach disease, 
 
 634 
 colic, 27S 
 
 obstruction of pylorus by, 5S5 
 Galvanism in myasthenia gastrica, 244 
 intragastric, in gastritis, 281 
 selection of poles in, 241 
 Galvanization, cervico-esophageal, 310 
 cervicogastric, 243 
 
 in spasm of the pylorus, 313 
 dorsogastric, 302 
 in asthenia gastrica, 242 
 in excessive peristalsis, 316 
 in gastralgia, 277, 281 
 in gastrospasm, 315 
 in hyperesthesia gastrica. 2S4 
 in hypersthenia gastrica, 245 
 in nervous vomiting, 332 
 of the spine, 243 
 recto-abdominal, 244 
 spinogastric, 245, 246 
 Ganglionic cells, 264, 265 
 Gas formation, 155-157 
 -forming fermentation in pyloric obstruc 
 
 tion, 589, 596 
 in subphrenic abscess, 490 
 ill th» stomach, 225 
 Gastralgia nervosa, 275-2S1 
 
 caused by arteriosclerosis, 635 
 
 clinical description, 276 
 
 diagnosis. 278 
 
 differential diagnosis, 278 
 from ulcer, 478 
 
 electricity in, 245 
 
 etiology, 276 
 
 galvanization in, 277 
 
 malarial, 276 
 
 treatment, 280 
 
 urine in, 277 
 Gastric carcinoma, 69 
 clapping, 78, 79 
 crises, 276 
 
 of locomotor ataxia, 640 
 digestibility a dietetic guide, 216 
 fermentation, 47, 147-154, 558
 
 66o 
 
 /XDEX. 
 
 Gastric feinieiilation, ilit-l in, 216 
 fever, 3S9 
 clinical description, 390 
 diagnosis, 390 
 treatment, 391 
 fistula, feeding; throiigli, 583 
 flatulency, 224. 225 
 
 syniptumatic treatment, 253 
 glands, atrophy of. See Gastritis glan- 
 dularis attophicans. 
 irritability ol, 351 
 gurgling, 77 
 hemorrhage, 158 
 from brain injury, 642 
 in cancer of stomacli, 525 
 in ulcer of stomach, 463 
 hyperesthesia. See Hyperesthi'sia gas- 
 
 trica. 
 irritation, 254 
 
 juice, action of, on albumin, 17S 
 germicidal power of, 142 
 to.xicity of, in diseases of stomach, 
 611 
 muscle in digestion, 130 
 muscular sense, 270 
 neurasthenia. See Neiiraslheuta gas- 
 
 trica. 
 pain, 41, 251 
 phosplialuria, 621 
 putrefaction, 154, 155, 194 
 
 diet In, 216 
 retention as a cause of gastroptosis, 565 
 
 use of water in, 228 
 splashing, 7S-S0 
 
 in myaslhenia with retention, 367 
 in pyloric obstruction, 594 
 stimulation in subacidily, 214 
 symptoms, 35 
 tenderness, 67 
 tetany, 625 
 
 ulcer. See Ulcer of stomach. 
 vertigo, 625 
 Gastritis, 378-442 
 acute, 378 
 diet in, 217 
 milk diet in, 201 
 mycotic, 382 
 
 fermentation form, 383 
 infectious forms, 386 
 purulent, 387 
 simple, 378 
 
 clinical description, 380 
 diagnosis, 381 
 pathological anatomy, 379 
 treatment, 382 
 toxic, 391 
 as a cause of myasthenia gastrica, 349 
 catarrhalis chronica, 402 
 clinical description, 405 
 diet in, 411 
 
 differential diagnosis, 409 
 differentiation of, from adenasthenia 
 gastrica, 409 
 from cancer of stomach, 550 
 from myasthenia gastrica, 359, 409 
 from neurasthenia gastrica, 409 
 pathological anatomy, 402 
 prognosis, 40S 
 symptomatology, 406 
 treatment, 410 
 caused by arteriosclerosis, 635 
 chronic, 398 
 asthenic. See Gastritis calarrluxlis 
 
 chronica. 
 etiology of, 399 
 
 hypersthenic. See Gastritis glandu- 
 laris pi oliferans. 
 pathological anatomy of, 399 
 
 Gastritis, dlfTerenliation of, from adenas- 
 thenia gastrica, 302 
 from gastralgia, 279 
 from hyperclilorliydria, 292 
 from neurasthenia gastrica, 343 
 diphtheric, 387 
 electricity in, 240-245 
 from chlorosis, 637 
 from empyema, 645 
 from pneumonia, 645 
 gastrospasm in, 314 
 glandularis atrophicans, 430 
 anemia in, 435 
 clinical description, 434 
 compensation in, 434 
 diet in, 441 
 
 differential diagnosis, 437 
 differentiation of, from adenasthenia 
 gastrica, 437 
 from carcinoma, 43S 
 from gastritis catarrhalis chronica, 
 
 439 
 inanition in, 435 
 leukopenia in, 436 
 patliological anatomy, 431 
 physical signs in, 436 
 prognosis, 439 
 symptomatology, 435 
 test-breakfast in, 436 
 treatment, 440 
 proliferans, 414 
 appetite in, 417, 418 
 clinical description, 416 
 diagnosis, 423 
 diet in, 425 
 
 differential diagnosis, 423 
 differentiation of, from carcinoma, 423 
 
 from myasthenia, 424 
 fermentation in, 417 
 functional signs in, 419 
 hydrochloric acidity in, 420, 421 
 pain in, 419 
 
 pathological anatomy, 414 
 symptomatology, 418 
 test-meal, 420, 421 
 treatment of, 425 
 urine in. 422 
 vomit in, 422 
 hot water in, 229 
 hypersthenic, diet in, 213, 214 
 differentiation of, from myasthenia, 
 369 
 rectal feeding in, 221 
 relation of, to cancer of stomach, 518 
 Gastrocardiovascular symptom-groups, 622 
 Gastroduodcnal crises, 639 
 Gastro-enteroptosis, 613 
 Gastro-enterostomy in cancer of stomach, 
 524. 553 
 in pyloric obstruction, 608 
 in ulcer of stomach, 509, 511 
 Gastrograph of Einhorn, 139 
 Gastrohepatic omentum, 50 
 Gastro-intestiiial respiration, 43 
 Gastrolitli, obstruction of pylorus by, 585 
 Gastroneurastbenic, the, i6j 
 Gastrophrenic ligament, 50 
 Gastroplegia, 33s 
 diagnosis of, from retention myasthenia, 
 
 369 
 Gastro[)tosis, 5,64-576 
 abdominal belt for, 251 
 clinical description, 566 
 definition, 564 
 diet in, 574 
 
 differential diagnosis, 570 
 differentiation of, from byperchlorhydria, 
 292
 
 lAWEX. 
 
 66 1 
 
 Gastroptosis, differentiation of, from myas- 
 thenia, 357, 571 
 from neurasthenia gastrica, 344 
 from obstructive stagnation and reten- 
 tion, 371 
 
 etiology, 564 
 
 gastric retention a cause of, 565 
 
 in myasthenia, 371 
 with retention, 371 
 
 in pyloric incontinence, 333 
 
 influence of heredity in, 565 
 of various diseases upon, 564, 565 
 
 motor insufficiency in, 567 
 
 objective signs, 569 
 
 prognosis, 572 
 
 replacement of stomach in, 572 
 
 rest in, 164 
 
 retention in, 567 
 
 stagnation in, 567 
 
 symptomatology, 568 
 
 treatment, 572 
 
 uric acid formation in, 567 
 
 with chronic colitis, treatment, 575 
 
 with myasthenia, treatment, 574 
 
 with neurasthenia, treatment, 575 
 Gastrorrhea, 18 
 Gastroscope, 61 
 Gastrospasm, 314, 315 
 
 caused by arteriosclerosis, 635 
 
 diagnosis, 315 
 
 diet in, 315 
 
 electricity in, 245 
 
 etiology, 314 
 
 treatment, 315 
 Gastrosplenic omentum, 50 
 Gastrostomy, 188 
 
 in cancer of cardia, 553 
 
 in obstruction of cardia, 583 
 
 in pyloric obstruction, 60S 
 Gastrosuccorrhea, 285 
 
 continua chronica, 285 
 
 periodica, 285 
 Gastroxia, 299 
 Gastroxynsis, 299 
 
 Gavage in nervous vomiting, 332, 333 
 Gelatin as a food, 183 
 
 in gastric fermentation, 216 
 Gelatinous degeneration of medullary can- 
 cer of stomach, 518 
 Gelsemium in gastralgia, 280 
 
 in gastric pain, 251 
 General medication, 161-261 
 
 secretion of the stomach, 128, 129 
 Genital organs, examination of, in myas- 
 thenia gastrica, 342 
 ' Gentian in adenasthenia gastrica, 303 
 
 in asthenia gastrica, 256 
 Germ growth, lavage in, 231 
 
 -products, 147 
 
 as gastric irritants, 254 
 Germain See, test-meal of, 96 
 Germicidal activity of stomach, 212 
 
 power of the gastric juice, 142 
 Germs, exclusion of, from stomach, 258 
 
 of the stomach. 142-157 
 
 removal of, from stomach, 258 
 Glan, spectrophotometer of, 125 
 Glands of the stomach, 82, 83, 84 
 Glandular atrophy. See Gastritis glandu- 
 laris atrupliicaiis. 
 
 gastritis, 414 
 Glenard, gliding method of, 77, 78, 80 
 
 on displacement of stomach, 566 
 
 on duodenal tenderness, 67 
 
 on influence of enteroptosis on stomach, 
 633 
 
 pelvic belt, 250 
 
 Gluten suppositories in hyperchlorhydria, 
 29.5 
 
 Glycerin suppositories in hyperchlorhydria, 
 295 
 
 Goldschmidt method of estimating stom- 
 ach-contents, 133 
 
 Goose, 195 
 
 Gorse, investigations of, 188 
 
 Gout as a cause of stomach disease, 638 
 use of water in, 227 
 
 Grape juice in obstruction of cardia, 5S3 
 
 Grapes, 211 
 in gastroptosis with chronic colitis, 575 
 
 Greater curvature of stomach, 52 
 
 Green ve.getables, 211 
 
 Greenfeld on cancer of stomach, 513 
 
 Griesinger on frequency of cancer of stom- 
 ach, 512 
 
 Grimm on the vomiting center, 132 
 
 Gross' apparatus, 92 
 
 Grouse, 195 
 in obstruction of pylorus, 605 
 
 Griitzner, investigations of, 218 
 method of, 123 
 
 Giinzburg, 86 
 reagent of, 103 
 
 Haberlin on frequency of cancer of stom- 
 ach, 512 
 
 on intiuence of sex in cancer of stomach, 
 514 
 
 on mortality from cancer of stomach, 513 
 Habitual regurgitation, 321, 322 
 Hacker on pylorectomy in cancer of 
 
 stomach, 554 
 Hallot, method of Mathieu and, 137 
 Hammerschlag, method of, 124 
 
 on lactic fermentation in cancer of stom- 
 ach, 535 
 Hammerschlag's test, 95 
 Hard-boiled egg, 207 
 Hard cancer of stomach, 516 
 Hauser on ulcer of stomach, 443 
 Hauswaldt's vigor chocolate, 294, 361. See 
 
 Vigor chocolate. 
 Hayem and Winter, method of, 11 1 
 
 on gastritis favoring development of 
 tuberculosis, 646 
 
 on lactic fermentation in cancer of stom- 
 ach, 535 
 
 on secretion in ulcer of stomach, 474 
 
 on ulcer of stomach, 447 
 
 theory of, 98, 116 
 Headache in digestive hyperchylia gas- 
 trica, 295 
 
 in gastroptosis, 567, 569 
 
 in paroxysmal hyperchylia, 300 
 Heart, action of, in obstruction of cardia, 
 581 
 
 diseases of, as causes of stomach disease, 
 634 
 
 influence ol diseases of stomach on, 621 
 
 insufficiency of, as a cause of stomach 
 disease, 635 
 
 sounds, 76 
 Heartburn, 38 
 
 in gastralgia, 277 
 
 in gastroptosis, 567 
 
 iti hyperchlorhydria, 288 
 
 iti neurasthenia gastrica, 339 
 Heat-production in the body, 173-175 
 
 -units, 173-175 
 Hectic fever in subphrenic abscess, 493 
 Heizmann on frequency of cancer of stom- 
 ach, 512
 
 662 
 
 INDEX. 
 
 HeitiHtcincsis in cancer of stomach, 525 
 
 ill ulcer ol stomach, 463 
 Hemalocylolysis, 614 
 Hematogenous vomiting, 326 
 Hemi-albumose, 178 
 Hemianopia in pyloric obstruclioii, 592 
 Hemi|ieptone, 178 
 Hemmeter, apparatus of, 139 
 Hemoglobin, diminulioii of, in cancer of 
 
 stomach, 536 
 Hemophilia as a cause of gastric hemor- 
 rhage. 636 
 Hemoptysis, 467 
 
 Hemorriiage, esophageal, differentiation 
 of, from gastric hemorrhage, 468 
 
 gastric, clifferentialion of, from leukemia, 
 636 
 from pulmonary hemorrhage, 467 
 
 in cardiospasm, 30S 
 
 in gastric ulcer, treatment, 504 
 
 in ulcer of stomach, 463 
 
 rectal feeding in, 221 
 Hemostatics in hemorrhage of gastric 
 
 ulcer, 504 
 Hepatic colic, 40 
 
 Heryiig illumination of stomach, 58 
 Hetero-alhumose, 293 
 Hiccup in subphrenic abscess from ulcer of 
 
 stomach, 492 
 Hlasko on motor centers of the stomach, 
 
 132 
 HofTman's anodyne, 280 
 Hot drinks in spasm of pylorus, 314 
 water, action of, on stomach, 228 
 for vomiting, 253 
 in bulimia, 269 
 in gastritis, 229 
 Hour-glass deformity of the stomach, 497 
 Huber on tests for motor insufficiency, 
 
 134 
 Hueppe on bacillus butyricus, 152 
 Hunger-center, 266-269 
 Hunger, false, 44 
 
 in obstruction of cardia, 579 
 
 Hydrastinin in gastroptosis, 574 
 
 with chronic colitis, 57.S 
 
 in pyloric incontinence, 335 
 
 muriate in myasthenia with stagnation, 
 
 363 
 Hydrocephalus, vomiting in, 326 
 Hydrochloric acid, 98 
 
 and pepsin in catarrhal gastritis, 414 
 
 in gastritis glandularis atrophicans, 
 441 
 estimation of the amount of, secreted, 
 
 99, 100 
 excessive secretion of, 116, 287-295 
 ill adenastlienia, 301 
 in combination with proteids, 104 
 in hypochylia, 260, 261 
 in milk diet, 199 
 in rumination, 325 
 
 ill treatment of cancer of stomach, 552 
 neutralization of, 260 
 poisoning by, 394 
 qualitative tests for, loi 
 quantitative estimatiiiii of, 105 
 secretion of, in cancer of stomach, 531 
 
 in myasthenia gastrica, 355 
 
 in pyloric obstruction, 596 
 theories of formation of, 98 
 with pepsin in adenastheiiia gastrica, 
 
 303 
 acidity, 37 
 in differentiation of pyloric from duo- 
 denal obstruction, 601 
 in hyiiersthenic gastritis, 420, 421 
 aiiacidity, 117 
 
 Hydrochloric heartburn, 351 
 secretion in difierentiation between be- 
 nign and malignant pyloric obstruction, 
 602 
 subacidity, 117 
 superacidity, 286 
 
 in ulcer of stomach, 474 
 influence i>f, on ulcer of stomach, 449 
 Hydrogen siilphid as a diagnostic sign, 155 
 formation in differentiation between 
 benign and malignant pyloric ob- 
 struction, 602 
 of, in stomach, 611 
 in cancer of stomach, 53s 
 in pyloric obstruction, 596 
 Hydrotherapy, 34, 235 
 111 anorexia nervosa, 275 
 in eriictatio nervosa, 320 
 in excessive peristalsis, 316 
 in gastroptosis, 574 
 
 with neurasthenia, 574 
 in myasthenia with stagnation, 362 
 in nervous vomiting, 331 
 Hyfirothionemia from intestinal obstruc- 
 tion, 633 
 Hyoscyamus, extract of, 269 
 in cardiospasm, 310 
 
 oil of, in gastroptosis with chronic colitis, 
 575 
 Hyperacidity, 286 
 Hyperazoturia, 618 
 Hyperchlorhydria, 287-295 
 albumins in, 289 
 clinical description, 2S8 
 diagnosis, 290 
 diet in, 293 
 
 differential diagnosis, 291 
 differentiation of, from hyperchylia, 297 
 electricity in, 293 
 ferments in, 289 
 
 from hypertrophic cirrhosis, 634 
 from nejihritis, 639 
 from spinal disease, 640 
 heartburn in, 2S8 
 in cerebral disease, 642 
 in melancholia, 642 
 labferment in, 289 
 labzymogen in, 289 
 rest in, 288, 293 
 splashing in, 289 
 symptoms of, 288 
 thirst ill, 2S8 
 treatment, 293 
 Hyperclulia gastrica, 287, 295-300 
 chemical treatment, 259 
 digestive, 295-299 
 diagnosis, 297 
 differential diagnosis, 297 
 etiology, 295 
 gurgling in, 296 
 splashing in, 296 
 treatment, 298 
 from cerebral fatigue, 642 
 paroxysmal. 299. 300 
 clinical description, 299 
 diagnosis, 300 
 etiology, 299 
 treatment, 300 
 Hyperesthesia gastrica, 281-284 
 and gastralgia, 279 
 diagnosis, 283 
 diet, 284 
 
 differential diagnosis, 283 
 etiology, 281 
 from hysteria, 643 
 hot compress in, 235, 236 
 in neurasthenia gastrica, 339 
 treatment, 284
 
 INDEX. 
 
 663 
 
 Hypetorexia, 266, 267 
 
 Hyperstheiiia gastiica, effect of, on stom- 
 ach, 212 
 electricity in, 245 
 
 Hypersthenia gastiica, massage in, 247 
 physiological treatment of, 254 
 
 Hypersthenic gastritis, j8, 414 
 
 Hypertropliy of pylorus, 585, 5S8 
 
 Hypochlorhydria from neurasthenia, 643 
 
 Hypochondriasis in myasthenia with reten- 
 tion, 366 
 
 Hypochylia, chemical treatment of, 260 
 in cancer of stomach, 532 
 
 Hypogastric belts in gastroptosis, 573 
 
 Hysteria, anorexia in, 273 
 as a cause of stomach disease, 643 
 bulimia in, 266 
 
 Hysterical vomiting, 327 
 
 Ice in treatment of hemorrhage of gastric 
 ulcer, 504 
 -water metliod of I.eube, 93 
 Icterus, catarrhal, influence of, on stomach 
 disease, 634 
 in myasthenia with retention, 366 
 Illumination of stomach in diagnosis of 
 cancer, 541 
 in gastroptosis, 570 
 Immediate symptoms, 36 
 Immobilization in treatment of ulcer of 
 
 stomach, 499 
 Inanition. See Emaciation, Snbnnirition, 
 Cachexia. 
 -anemia from disease of stomach, 615 
 
 in ulcer of stomach, 472 
 delirium, 273 
 in anorexia nervosa, 273 
 in glandular atropln-, 435 
 Incontinence of pylorus, 333 
 Indican in urine, 226 
 
 of cancer of stomach, 53S 
 Indicanuria in intestinal disease from dis- 
 ease of stomach, 613 
 in intestinal obstruction. 633 
 Indications for the use of stomach-tube, 88 
 Individualization, 192 
 Indol in the stomach, 155 
 Inflation of stomach, 72-74 
 
 for diagnosis of cancer. 541 
 
 in gastroptosis, 569 
 
 in vertical displacement of stomach, 
 
 562 
 Strauss' apparatus for, 73 
 test in p\ loric incontinence, 334 
 Influenza as a cause of myasthenia gastrica, 
 
 348 
 Inorganic foods, 177 
 Insomnia in gastroptosis, 567 
 Inspection, 53 
 
 Insufiiciency of stomach, 139 
 Insufficient diet, 172 
 effect of, 186 
 use of, 1S6 
 Intercostal neuralgia, 27S 
 Interrogation in diagnosis, 27 
 Interscapular pain in cancer of stomach, 
 
 524 
 Intestinal colic, 279 
 diet, 217 
 fermentation from disease of stomach, 
 
 613 
 putrefaction from disease of stomach, 
 6>.3 
 meat diet in, 194 
 Intestines, examination of, in neurasthenia 
 gastrica, 342 
 in digestion, 222 
 
 Intestines, influence of diseases of, on dis- 
 eases of stomach, 632 
 of diseases of stomach upon, 611 
 Intragastric asepsis. 499 
 
 douche or spray. 234 
 tube of Rosenheim, 234 
 
 electrization, 244 
 
 electrode, Rosenheim's, 238 
 
 faradization in nervous vomiting, 332 
 in regurgitation, 322 
 
 galvanism in gastralgia, 2S1 
 
 noises, 77 
 Intramural ganglia, electric excitation, 243 
 lodid of sodium in obstruction of cardia, 
 
 5S3 
 lodin in nervous vomiting, 332 
 Ipecac in gastroptosis. 574 
 
 in gastroptosis with chronic colitis, 575 
 
 in hypersthenia gastrica, 257 
 
 111 myasthenia with stagnation, 363 
 
 in vomiting, 253 
 Iron in neurasthenia gastrica, 346 
 
 subsulphate. See Subsulphate of iroit. 
 Irritants in excessive secretion, 214 
 Isolation in anorexia nervosa, 275 
 
 in neurasthenia gastrica, 345 
 
 in treatment of nervous vomiting, 331 
 
 Jacobson, toxin extracted from urine, 
 
 629 
 Jactitation in myasthenia with retention, 
 
 366 
 Jaffe on diagnosis of subphrenic abscess, 
 
 494 
 Jaksch on ulcer of stomach, 443 
 Jaworski and Korcynski on ulcer of stom- 
 ach, 443 
 
 method ot, for estimaiing stomach capac- 
 ity, 74, 124 
 
 sign of, 497 
 
 spiral bodies of, 159 
 
 test-meal of, 94 
 
 test of absorption, 140 
 
 test of Korcynski and, for blood, 159 
 Jejunostomy in obsiruclion of cardia, 583 
 
 in pyloric obstruction, 60S 
 Johnston's beef extract, 196 
 Jukes, suction method of, 91 
 
 Kaulich on infantile cancer of stomach, 
 
 513 
 Kel\ r, 202 
 
 Keliing's method for estimating capacity of 
 stomach, 74 
 of testing for lactic acid, 150 
 Kern, dispora caucasica of, 202 
 Kidneys, diseases of, as causes of stom- 
 ach disease, 639 
 in digestion, 222 
 influence of disease of stomach upon, 
 
 630 
 stone in, as a cause of stomach disease, 
 
 639 
 tumors of. 542 
 
 Kissingen, Saratoga. 258 
 
 klemperer on lactic fermentation in cancer 
 of stumaeh. 535 
 test-meal of, 94 
 
 King, method of, 125 
 
 Knaut on motor centers of the stomach, 
 132 
 
 Knee-chest position, 62 
 
 Kocher on pylorectomy in cancer of stom- 
 ach, 554 
 
 Kola in nervous vomiting, 332 
 
 Kolliker, studies of, 264
 
 664 
 
 IXDEX. 
 
 KiiiiiR on average daily coiisiiniption of 
 
 milk, 197 
 Koroyiiski ami Jaworski, test of, for blood, 
 
 159' 
 Koumiss, 205 
 Kiiline, investigations of, 1S8 
 
 theory of digestion of albumin, 17.? 
 Kuhu's balloon sound. 65. 66 
 
 pyloric sound, 64, 65 
 Kuiiieft"'s ethyleiidiamin. 62S 
 KCussmaul on anorexia nervosa, 275 
 
 on dessication theory, 62S 
 
 Labfer.ment,i99, 120-122 
 Boas' test for, 121 
 Leo's test for, 121 
 Labsecretioii, 122 
 Labzymogen, 120-122 
 
 Lacing, tight, as a cause of stomacli dis- 
 placements, 566 
 Lactic acid, 147-152 
 
 as a sign of cancer, 149 
 
 Boas' test for, 132 
 
 deYoiig's test for, 151 
 
 diagnostic value of, 148 
 
 fermentation. See Lactic Jctmenla- 
 
 lion. 
 in cancer of stomach, 481, 533 
 in differentiation between benign and 
 
 malignant pyloric obstruction, 602 
 in myasthenia with retention, 36S 
 in pyloric obstruction, 596 
 Kelling's test for, 100 
 qualitative lest for, loi 
 Strauss' test for, 150 
 Uffelmann's test for, 150 
 fermentation, 147 
 Landau, abdominal corset of, 250 
 Lateral displacement of stomach. See Z>/j- 
 
 placement of stomach, vertical. 
 Laudanum in rectal feeding, 220 
 Lavage, 229-234 
 for pain in cancer of stomach, 552 
 in arsenical jjoisoiiing, 398 
 in catarrhal gasti itis, 414 
 in gastroplegia, 335 
 in myasthenia with retention, 375, 376 
 in retention myasthenia, 370 
 Laxatives in myasthenia with stagnation. 
 
 363 
 Lead acetate. See Acetatr of Uati. 
 Lebert on influence of sex on cancer of 
 stomach, 514 
 
 on location of ulcer of stomach, 452 
 
 on perforation in ulcer of stomach, 4S6, 
 489 
 
 on ulcer of stomach, 443, 446 
 Leiter's gastroscope, 61 
 Leo's test for labferment, 121 
 Lupine, gastroxia, 299 
 Lesage on bacillus coli communis, 155 
 Lettuce in catarrhal gastritis, 413 
 Letulle on presence of bacteria in ulcer of 
 
 stomach, 449 
 Leube, enema of, 219 
 
 experiments of, 1S9 
 
 methods of, 64,93, 124 
 for testing motor function of stomach, 
 13s 
 
 nutritive enema, 219 
 
 on duodenal ulcer, 484 
 
 on muscular rheumatism, 278 
 
 on rest and Carlsbad cure, 506, 507 
 
 progressive diet of, 1S9 
 
 -Rosenthal apparatus, 233 
 Leucin in the stomach, 155 
 
 Leukemia as a cause of gastric hemor- 
 rhage, 363 
 
 Leukocytes, action of, on albumin, 179 
 in blood in cancer of stomach, 537 
 
 Leukocythemia, digestive, 179 
 
 Leukocytosis from disease of stomach, 616 
 in cancer of stomach, 536 
 
 Leukopenia from subnutrition, 616 
 in glandular atrophy, 436 
 terminal. 537 
 
 Leven on fats, 210, 411 
 on gastroxia, 299 
 
 Levulose, digestion of, 181 
 
 Leydeii on subphrenic abscess in ulcer of 
 stomach, 4SS 
 
 Liebig's meat extract, 196 
 
 Lienteric diarrhea, 334 
 
 Ligation in treatment of gastric hemor- 
 rhage, 505 
 
 Liiiea alba. 53 
 
 Lipoma of the stomach, 511 
 
 Litmus in testing for HCI, loi 
 paper, loi 
 
 Liver, diseases of, as a cause of stomach 
 disease, 633 
 functions ol. 614 
 influence of disease of stomach upon, 
 
 614 
 percussion of, 70 
 tumors of, 544 
 
 ulceration of, from ulcer of stomach, 
 4&S 
 
 Locomotor ataxia, gastric crises of, 640 
 periodical vomiting in, 329 
 
 Loreta's digital divulsion in pyloric ob- 
 struction, 60S 
 
 Loss of appetite, 251 
 
 Louis on influence of sex in cancer of stom- 
 ach. 514 
 
 Lugols solution. 2S9 
 
 Liittke, method of, 112 
 
 Lymphadenoma of the stomach, 511 
 
 Lymphocytes in cancer of stomach, 53S 
 
 Magnesia, calcined, 260 
 
 usta, 2CO 
 as an antidote for acid-poisoning, 396 
 Maibaum on pyoktanin in cancer of stom- 
 ach, 551 
 Malarial cachexia, differentiation of, from 
 cancer of stomach, 549 
 
 gastralgia, 276 
 ^L^Itose, 181 
 Massage. 246-250 
 
 abdominal, 246, 247 
 
 in bulimia, 268 
 
 in digestive hyperchylia, 298 
 
 in gastroptosis with neurasthenia, 576 
 
 in gastrospasm, 315 
 
 in myasthenia with retention, 374 
 with stagnation, 362 
 
 ill nervous vomiting, 331 
 
 in neurasthenia gastrica. 341 
 
 reflex-acting method, 247 
 NLasturbati<in a cause of eructatio nervosa, 
 
 3'9 
 a cause of gastralgia, 276 
 Mathieu emulsion-meal, 296, 354 
 method of, for estimating motor activity 
 
 of stomach. 137 
 on cancer of stomach before thirtieth 
 year, 513 
 Matzoon, 203 
 
 Maydl on subphrenic abscess, 495 
 in ulcer of stomach, 488, 489 
 Meat, 192-196
 
 INDEX. 
 
 665 
 
 Meat, action of, oti secretion, 193 
 broth in ulcer of stomach, 502 
 broths in morbid sensibility, 213 
 commercial preparations of, 195 
 diet, effect of, 180 
 in adenasthenia gastrica, 303 
 in cancer of stomach, 553 
 in catarrhal gastritis, 412 
 in excessive secretion, 214 
 
 of HCl, 194 
 ill gastric fermentation, 216 
 ill gastioptosis, 574 
 
 with chronic colitis, 575 
 in gastrospasni. 315 
 in hypersthenic gastritis, 426 
 in myasthenia with retention, 375 
 
 with stagnation, 361 
 in neurasthenia gastrica, 346 
 in obstruction of pylorus, 405 
 jellies in myasthenia with retention, 375 
 jelly as an intestinal diet, 217 
 juice as an intestinal diet, 217 
 in cancer of stomach, 553 
 in gastritis glandularis atrophicans, 
 
 441 
 in obstruction of cardia, 583 
 powder, 196 
 as an intestinal diet, 217 
 in gastritis glandularis atrophicans, 
 
 441 
 in myasthenia with retention, 375 
 in obstruction of cardia, 583 
 in ulcer, ,soS 
 preparations, 195 
 pulp in pyloric obstruction, 607 
 raw, 195 
 Medullary carcinoma of the stomach, 517 
 Melancholia in vertical displacement of 
 
 stomach, 561 
 Melena in ulcer of stomach, 466 
 Meltzer, experiment of, 239 
 Meltzing's method of palpation, 64 
 
 of stomach illumination, 60 
 Meningitis, cerebral, as a cause of vomit- 
 ing, 641 
 spinal, as a cause of stomach disease, 640 
 vomiting in, 326 
 Menorrhagia, bulimia in, 266 
 Menthol for vomiting, 253 
 in gastric pain, 252 
 in nervous vomiting, 332 
 Merycism, 188. 322-325 
 
 Metallic poisons, action of, on stomach, 
 397 
 tinkling in diagnosis of subphrenic ab- 
 scess, 494 
 Metastatic abscess as a cause of subphrenic 
 
 abscess, 495 
 Method of Boas, 106, 121 
 of Braun, no 
 of Chomel, 135 
 of Cseri for expressing stomach-contents, 
 
 248 
 of Debove for treating gastric ulcer, 508 
 of Dehio, 138 
 ofdeYong, 151 
 ofEwaldand Sievers for testing motor 
 
 function of stomach, 134 
 of Goldschmidt, 133 
 of Griitzner, 123 
 of Hammerschlag, 124 
 of Hayem and Winter, in 
 of Jaworski, 124 
 of Kelling, 150 
 of King, 125 
 of Leo, 121 
 of Leube, 124, 135 
 of Liittke, 112 
 
 Method of Mathieu and Hallot, 137 
 
 of Mathieu and Remond, 133 
 
 of Mintz, 105 
 
 of Oppler for determining pepsin, 126 
 
 of Petizoldt and Faber for estimating 
 absorbability of stomach, 141 
 
 of Reibtnayer for massage, 249 
 
 of Rosenbach, 138 
 
 of Schiff, 123 
 
 of Strauss, 133, 150 
 
 of Topfer, 106 
 
 of Uftelniann for testing for lactic acid, 
 150 
 
 of Volhard, 112 
 
 of von Zieinssen, 242 
 
 of Van Valzah and Nisbet, 138, 140 
 
 of Zabludowski, 247, 248 
 Methylene-blue in cancer of stomach, 551 
 
 in obstruction of cardia, 5S3 
 Methyl-violet, 103, 104 
 
 Micro-organisms, influence of acidity of 
 stomach on, 143 
 
 of the stomach, 142-157 
 quantity of, 146 
 Mikulicz on stomach examination, 61 
 Milk, 197 
 
 action of, on intestines, 200 
 , on stomach, 199, 200 
 
 and neutralization method of treating 
 gastric ulcer, ,so8 
 
 and rest-cure in gastroptosis with neu- 
 rasthenia, 576 
 
 as a culture soil, 197 
 
 as an intestinal ditt, 217 
 
 caloric value of, 196 
 
 composition of, 198 
 
 -cure in morbid sensibility, 213 
 in ulcer and gastritis, 214 
 
 diet, 200, 201 
 
 in acute gastritis, 201 
 in ulcer of stomach, 200 
 value of, 200, 201 
 
 effect of, in gastroptosis, 567 
 
 in bulimia, 269 
 
 in cancer of stomach, 552 
 
 in cardiospasm, 309 
 
 in catarrhal gastritis, 412, 413 
 
 in digestive hyperchylia, 299 
 
 in gastritis glandularis atrophicans, 441 
 
 in gastroptosis, 574 
 with chronic colitis, 575 
 
 in gastrospasni, 315 
 
 in hyperchlorhydria, 290, 294 
 
 in hypersthenic gastritis, 426, 427, 429 
 
 in morbid sensibility. 213 
 
 in myasthenia with stagnation, 361 
 
 in neurasthenia gastrica, 346 
 
 in obstruction of cardia, 583 
 
 in subacidity, 214 
 
 in ulcer of stomach, 500-502, 508 
 
 intestinal digestion of, 200 
 
 nutritive value of, 197, 198 
 
 pasteurization of, 197 
 
 preparations of, 202 
 
 quantity of fat in, 205 
 
 sterilization of, 197 
 
 -sugar, 181, 211 
 Milky urine, 621 
 
 Milliot method of illuminating the stom- 
 ach, 58 
 Mintz, method of, 105 
 Mohr buret, 108 
 Moisture of climate, influence of, 174 
 
 use of, 235 
 Montuuis, belt of, 250 
 Moral atmosphere, 162 
 
 treatment in neurasthenia gastrica, 345 
 Moritz, fermentation test tube of, 157 
 
 43
 
 666 
 
 INDEX. 
 
 Morphiii ill gastralgia, 280 
 in gastric pain, 252 
 in hyperchylia, 300 
 in mycotic gastritis, 386 
 ill nervous vomiting, 332 
 in the perforation of gastric nicer, 506 
 in ulcer of stomach, 505 
 muriate, 280 
 Motor disorders, diet in, 215 
 dynamic affections, 304-336 
 function, 130-140 
 insufficiency, 302 
 
 in cancer of stomach, 532 
 in gastroptosis, 567 
 of stomach from tuberculosis, 647 
 Mouth, diseases of, as causes of gastric dis- 
 ease, 643, 644 
 Movements of the stomach during diges- 
 tion, 130, 131, 132 
 Mucin-toxemia, 629 
 Mucous glands of the stomach, 82, 83 
 
 secretion, lavage in, 231 
 Mucus, 128, 129 
 
 Muhlbrunneii Carlsbad water, 507 
 Multiple sclerosis as a cause of stomach 
 disease, 640 
 hyperchylia in, 300 
 vomiting in, 326 
 Muscular irritability, diet in, 215 
 rheumatism, 27S 
 sense, gastric, 270 
 work, 175 
 Mush, 209 
 Mutton in catarrhal gastritis, 412 
 
 in obstruction of pylorus, 605 
 Myalgia, 278 
 
 Myasthenia gastrica, 18, 27, 29, 31, 347-377 
 bicarbonate of soda in, 257 
 butyric acid in, 153 
 cereals in, 209 
 common salt in, 257 
 diet in, 215 
 
 differentiation of, from carcinoma, 373 
 from catarrhal gastritis, 409 
 from gastroplegia, 369 
 from gastroptosis, 571 
 from hyperchlorhydria, 291 
 from hyperchylia, 297 
 from hypersthenic gastritis, 369, 424 
 from neurasthenia gastrica, 344 
 electricity in, 240, 244 
 etiology, 348 
 flatulency in, 225 
 from diabetes, 368 
 from empyema, 645 
 from tuberculosis, 647 
 gastroptosis in, 371 
 insufficient diet in, 186 
 ipecac and strychnin in, 257 
 rest in, 164 
 
 stomach washing in, 229 
 use of water in, 228 
 with retention, 347 364-377 
 clinical description, 364 
 diagnosis, 368 
 diet in, 374 
 
 differential diagnosis, 368 
 differentiation of, from gastroplegia, 
 
 369 
 from hypersthenic gastritis, 369 
 from obstructive retention, 370-373 
 
 lavage in, 230, 275 
 
 objective signs, 367 
 
 prognosis. 373 
 
 rectal feeding in, 220 
 
 treatment, 374-377 
 with stagnation, 347, 349-363 
 
 diagnosis of, 356 
 
 Myasthenia gastrica with stagnation, dif- 
 ferential <liagiiosis, 356 
 fermentation in, 351 
 prophylaxis of, 359 
 treatment of, 3^9 
 yolk of egg in, 207 
 g;astro-intestinalis, 244 
 iiitestinalis in myasthenia gastrica, 331 
 Myasthenic stagnation. See Myasthenia 
 
 with stagnation. 
 Mycoderma aceti, 1,53 
 Mycotic gastritis, .■?82 
 
 fermentation form, 383 
 infectious forms, 3.S6 
 Myelitis as a cause of stomach disease, 640 
 Myoma of stomach, 544 
 
 Narcotics as a cause of vomiting, 327 
 Nausea, 42 
 from disease of the intestines, 632 
 in catarrhal gastritis, 405 
 in chronic gastritis, 401 
 in excessive peristalsis, 316 
 in myasthenia with retention, 365 
 in i)y]oric obstruction, 592 
 in subphrenic abscess from ulcer of stom- 
 ach, 492 
 Nedopil on frequency of cancer of stomach, 
 
 512 
 Needle-spray, 221, 237 
 Needles, swallowing of, 271 
 Neoplasms of stomach, 57, 5ii-5,s4 
 
 diagnosis of benign from malignant,. ^1)4 
 Nephritis as a cause of stomach disease, 
 639 
 as a cause of vomiting, 327 
 influence of ilisease of stomach on, 631 
 Nervines in neurasthenia gastrica, 346 
 Nervous disorders in pyloric obstruction, 
 593 
 system, influence of disease of stomach 
 on, 624 
 influence of diseases of, on stomach, 640 
 temperament, 264 
 vomiting, 325, 327 
 Neuralgia in neurasthenia gastrica, 339 
 intercostal, 278 
 of abdominal wall, 39 
 pneumogastric, 275 
 Neurasthenia as a cause of gastric disease, 
 642 
 from disease of stomach, 624 
 gastrica, 336-347 
 bulimia in, 266 
 
 cervicogastric galvanization in, 243 
 differential diagnosis, 342 
 differentiation of, from catarrhal gastri- 
 tis, 409 
 from myasthenia gastrica, 356 
 electric treatment, 242 
 etiological treatment, 347 
 etiology, 337 
 forced feeding in, 187 
 from cerebral neurasthenia, 642 
 from gastroptosis, 569 
 hydrotherapy in, 237 
 ipecac and strychnin in, 257 
 peculiar discomfort in, 337 
 prognosis, ,-^44 
 treatment of, 345 
 in gastroptosis, 569 
 
 in vertical displacement of stomach, ,«j6i 
 Neuromuscular tonics in pyloric obstruc- 
 tion, 606 
 Neutralization-method of treating gastric 
 
 ulcer, ,so8 
 Nickel-plated electrode, 241
 
 INDEX. 
 
 667 
 
 Nitrate of silver, 252 
 as a sedative, 255 
 as an antidote to chromic acid, 395 
 douclie, 235 
 in cardiospasm, 310 
 in hyperchlorhydria, 295 
 in hypersthenia gastrica, 284 
 in hypersthenic gastritis, 428 
 in neurasthenia gastrica, 346 
 in spasm of pylorus, 313 
 in ulcer of stomach, 503, 505 
 Nitric acid, poisoning by, 394 
 Nitrogenous waste, excessive, from disease 
 
 of stomach, 618 
 Nitroglycerin in nervous vomiting, 332 
 Nodosities of Bouchard, 367 
 Nolte on ulcer of stomach, 443 
 Nose, diseases of, as causes of gastric 
 
 disease, 644 
 Nowak on subphrenic abscess in ulcer of 
 
 stomach, 488 
 Nutrient enemata, 218 
 Nutriment, definition of, 171 
 Nutrition. See Symptoviatology undei 
 each disease of stomach. 
 diseases of, as a cause of stomach disease, 
 
 638 
 function of the cell in, 170, 171 
 in cancer of the stomach, 530 
 in pyloric obstruction, 593 
 influence of diseased stomach upon, 166 
 
 of diseases of stomach on, 617 
 needs of the organism for, 173 
 theories of, 169 
 waste, 174, 175 
 Nutrose, 196 
 Nux vomica in adenasthenia gastrica. 303 
 
 Oatmeal, 209 
 
 in pyloric obstruction, 607 
 Obesity as a cause of stomach disease, 638 
 Objective signs, 48 
 Obsolete terminology, 19 
 Obstetrician's hand, 626 
 
 Obstruction and hyperchylia, differentia- 
 tion of, 298 
 of the cardia, 577 
 
 clinical description. 578 
 
 diagnosis, 5S1 
 
 diet in, 583 
 
 etiology", 577 
 
 heart's action in, 581 
 
 influence of age on, 582 
 
 prognosis of. 582 
 
 surgical treatment, 583 
 
 swallowing sounds in, 580 
 
 symptomatology, 579 
 
 treatment, 582 
 of the orifices of stomach, 576 
 of the pylorus, 584 
 
 bacteriological signs of. 596 
 
 cancerous, 590 
 
 clinical description, 585 
 
 compensation in, 586 
 
 degree of, 604 
 
 diagnosis, 597 
 
 diet in, 604 
 
 differential diagnosis, 370-373, 597 
 
 differentiation of, from duodenal ob- 
 struction, 59S, 600 
 
 etiology, 584 
 
 local physical signs in, 594 
 
 nervous disorders in, 593 
 
 nutrition in, 593 
 
 period of compensation, 586 
 of retention, 587 
 of stagnation, 586 
 
 prognosis, 604 
 
 Obstruction of pylorus, rules for feeding in, 
 606 
 surgical treatment, 608 
 symptomatology, 590 
 toxic symptoms in, 593 
 treatment, 604 
 of the stomach, differentiation between 
 
 benign and malignant, 602 
 rectal feeding in, 220 
 .Obstructive retention, lavage in, 230 
 
 stagnation, differentiation of, from hyper- 
 chylia gastrica, 600 
 from hypersthenic gastritis, 600 
 with retention, differentiation of, from 
 myasthenic obstruction and reten- 
 tion, 598, 599 
 Oertel, 227 
 Oidium lactici, 152 
 Oligemia sicca from diseaseof stomach, 615 
 
 in cancer of stomach, 536 
 Oligochromemia as a cause of stomach 
 disease, 363 
 from disease of stomach, 616 
 Oligocythemia as a cause of stomach dis- 
 ease, 637 
 from disease of stomach, 616 
 Olive oil, 210 
 Openchowski, dilator fibers of, 323 
 
 on motor centers of the stomach, 132 
 Opiates, 252 
 
 Opium as a cause of vomiting, 327 
 as gastric sedative, 255 
 deodorized tincture of, 280 
 in acid-poisoning, 396 
 in bulimia, 268 
 in cancer of stomach, 551 
 in eructatio nervosa, 320 
 in gastralgia, 280 
 in gastric pain, 252 
 in hyperchlorhydria, 294 
 in hypersthenic gastritis, 429 
 in the peritonitisof gastric ulcer, 506 
 Oppler, method of, for determining pepsin, 
 126 
 on cocci of stomach, 144 
 Orange juice in gastroptosis with chronic 
 
 colitis, 575 
 Orexin in loss of appetite, 251 
 Orexinum basicum, 275 
 in adenasthenia, 303 
 Organic foods, 177 
 Oser on eructatio nervosa, 317 
 Ost's method for estimating capacity of 
 
 stomach, 74 
 Overstudy as a cause of neurasthenia gas- 
 trica, 338 
 Oxalate of cerium, 253 
 
 in nervous vomiting, 332 
 Oxalic acid, poisoning by, 395 
 Oxidation aldehyd test of Boas, 132 
 
 and combustion theory of nutrition, 16S 
 Oxybutyric acid in urine of cancer of stom- 
 ach, 539 
 Oysters, 269 
 in catarrhal gastritis, 412 
 in hyperchlorhydria, 294 
 
 Pain, 39 
 as a cause of inanition, 187 
 epigastric, 280 
 gastric, 251, 275-281 
 in cancer of stomach, 524 
 
 treatment of, 552 
 in differential diagnosis of ulcer of 
 
 stomach and gall-stone, 483 
 in gastric crises, 640 
 in gastroptosis, 567,568 
 in glandular atrophy, 435
 
 668 
 
 INDEX. 
 
 Pain in ^laiiilular gastritis, 419 
 ill hypcrchyliagasirica, 295 
 in obstruction of cardia,5So 
 in pyloric obstruction, 587, 591 
 in the stomach. 39 
 in ulcer of stomach, 459 
 in vertical displacement of stomach, 560 
 Palpable peristalsis, 315 
 Palpation, 61 
 
 Palpitation of heart from disease of stom-. 
 ach, 622 
 in myasthenia with retention, 366 
 in neurasthenia gastrica, 340 
 Pancreas, palpation ot', 64 
 tumors of, 542 
 
 ulceration of, from ulcer of stomach, 487 
 I'ancreatic-juice, action of, on albumin, 178 
 in digestion offals, 182 
 in the stomach, 160 
 in vomit, 601 
 Pancreatin in treatment of atrophy of gas- 
 tric glands. 440 
 Pancreogastric fistula, 155 
 
 from ulceration, 487 
 Panopeptone as intestinal diet, 217 
 Papoid in gastritis glandularis atrophicans, 
 
 44' 
 Pariser on operations for perforating ulcer 
 
 of stomach, 510 
 Parorexia, 270 
 
 treatment, 271 
 Paroxysmal hyperchylia gastrica, 299, 300 
 Pasteurization of milk, 197 
 Pastry in gaslroptosis, 574 
 Peaches, 211 
 
 Pelvic belt of Gl^nard, 250 
 belts in gastroptosis, 573 
 Penzoldt and Fabt-r, method of. for estimat- 
 ing absorbability of stomach, 141 
 method of, 353 
 
 of stomach percussion, 69 
 on action of meat, 193 
 on hyperchlorhydria, 293 
 on orexin, 251 
 on orexinuni basicuni, 275 
 progressive diet of, 190 
 table of digestibility, 190 
 Pepsin, 123-128 
 Pepsinogen, 123-128 
 Peptones as gastric irritants, 2,>4 
 
 as intestinal diet. 217 
 Peptonization, influence of, on blood, 616 
 Peptotoxin, 629 
 Percussion, 68-72 
 
 Perforation from cancerof stomach, 520 
 in ulcer of stomach. 486 
 
 treatment of, 506 
 rectal feeding in, 221 
 Perigastritis, 236, 333 
 
 Perinephritis as a cause of stomach disease, 
 640 
 as a cause of subphrenic abscess, 495 
 Periodical vomiting, 329 
 Peristalsis, 57 
 excessive, 315, 316 
 in pyloric obstruction, 594 
 reflex excitation of, 247 
 sounds, 76 
 visible, 315, 316 
 Peristaltic movements of the stomach, 131 
 
 unrest, 319 
 Peritonitis in gastric ulcer, treatment of, 506 
 plastic, complicating ulcer of stomach, 485 
 Permanganate of potash douche, 235 
 Pfuhl on the diagnosis of subphrenic 
 
 abscess, 494 
 Pharynx, spasm of, 317 
 Pheasant, 195 
 
 j Pheasant in obstruction of pylorus, 605 
 I Pbenacetin in cancer of stomach, 5SI 
 
 in gastric fever, 391 
 I in hyperchylia, 300 
 
 Pheiiolphthaiein, 106, 114, 115 
 Phillip on duodenal tenderness, 67 
 Phloroglucin, 103 
 
 -vanillin paper, 103 
 Phosphate of codein. 252 
 in mycotic gastritis, 386 
 in nervous vomiting, 332 
 Phosphaturia from disease of stomach, 
 
 617, 620, 630 
 Phosphorus, poisoning by, 397 
 Phthisis. See Tuberculosis. 
 Physical examination, 4S 
 ' remedies, 227-251 
 signs, 4S-80 
 Physiological salt solution. 256 
 
 treatment, 253-258 
 Pig's-foot jelly, 412 
 
 Pineapple in obstruction of cardia, 583 
 Pins, swallowing of, 271 
 Piorry's method of stomach-percussion, 69 
 I Pityriasis versicolor in myasthenia with re- 
 j tention, 366 
 
 Plastic peritonitis complicating ulcer of 
 I stomach, 485 
 
 Plate electrode, 243, 244, 245 
 
 Pleurisy as a cause of stomach disease, 645 
 
 in ulcer of stomach, 493 
 Pneumonia as a cause of stomach disease, 
 645 
 following subphrenic abscess from ulcer 
 
 of stomach, 491 
 in ulcer of the stomach, 491 
 Pneumothorax as a sign of subphrenic 
 
 abscess, 493 
 Poached egg, 207 
 
 Points of reference on abdomen, 48, 49 
 Poisoning by acids, 392 
 by antimony, treatment of, 398 
 by arsenic, treatment of, 398 
 by caustic alkalies, 396 
 by metals, 397 
 by sulphuric acid, 394 
 Poisonous acids as a cause of gastritis, 392 
 Polar difference, 241 
 Poles, difl'erence between, 241 
 
 selection of, 241 
 Politzer bag of Ewald, 91 
 Polyadenonia of the stomach, 511 
 Polyphagia, 26S 
 Pork, 195 
 
 Potain on gastrocardiovascular symptom- 
 group, 623 
 Potassium broniid in cardiospasm, 310 
 Potatoes, 210 
 
 Potential energy, atisorption of, by the 
 body, 173-175 
 consumption of, in fatigue, 175 
 Pott's disease a cause of cardiospasm, 308 
 Poultices, hot, in gastralgia, 280 
 Poultry in gastritis with chronic colitis. 575 
 
 in gastroptosis with neurasthenia. 576 
 Prazmowski on bacillus biityricus, 152 
 Pregnancy as a cause of gastroptosis, 565 
 
 as a cause of vomiting, 327 
 Prepared foods, table of, 196 
 Prescription of diet, 223 
 Present symptoms, 35 
 Previous history, .^o 
 I'riessnitz compress, 236 
 Primary gastrospasni,3i4 
 " Primordial basis." 170 
 Progressive diet of Leube. 189 
 
 of Penzoldt, 190 
 Propeptones in asthenic gastritis, 407
 
 INDEX. 
 
 669 
 
 Propeptones in hypersthenic gastritis, 420 
 Proteids, digestion of, 142 
 Protein-chroniogen, 178 
 Protoplasm, chemical composition of, 170 
 Prunes, 211 
 Psychic vomiting, 328 
 Ptyalin, action of, on starch, 181 
 Pulmonary tuberculosis as a cause of stom- 
 ach disease, 646 
 Pulse in perforation of stomach from ulcer, 
 
 487 
 Purgatives in hyperchlorhydria, 295 
 Purjesz's method of measuring stomach, 71 
 Purulent gastritis, 387 
 Pus in esophageal regurgitation. 322 
 Putrefaction, 154, 155 
 
 in the stomach, 47 
 
 meat diet in, 194 
 Putrefactive bacteria, 147 
 Pyelitis as a cause of vomiting, 327 
 Pylorectomy in cancer of stomach, 553 
 
 in pyloric obstruction, 608 
 Pyloric evacuation sound, 75 
 
 glands of the stoinach, 82 
 
 incontinence, 333-335 
 
 obstruction, 584. See Obslruction 0/ 
 pylorus. 
 
 orifice of stomach, 51 
 
 stenosis from carcinoma of gall-bladder, 
 334 
 Pyloroplasty in pyloric obstruction, 608 
 
 in ulcer of stomach, 509 
 Pylorus, auscultation of, 75 
 
 congenital atresia of, 584, 587 
 
 hypertrophy of, 585, 588 
 differentiation of, from annular scir- 
 rhus, 545 
 
 incontinence of, 333 
 
 obstruction of, 576, 584 
 
 palpation of, 62 
 
 spasm of, 311-314 
 Pyoktanin in cancer of stomach, 551 
 Pyopneumothorax in abscess of the lung 
 following ulcer of the stomach, 494 
 
 in ulcer of stomach, 493 
 
 Quail, 195 
 
 in obstruction of pylorus, 605 
 Qualitative tests for hydrochloric acid, loi 
 Quantitative analysis for acids in the stom- 
 ach, 105 
 Quassia douche, 235 
 Quinin, 252 
 
 bimuriate, 281 
 
 in anorexia nervosa, 275 
 
 in gastralgia, 280 
 
 in myasthenia with stagnation, 363 
 
 in rumination, 325 
 
 muriate, 280 
 
 Rasmussen on tight lacing as a cause of 
 
 ulcer of stomach, 447 
 Ratimmow on pylorectomy in cancer of 
 
 stomach, 554 
 Raw meat, 195 
 Reagent of Giinzburg, 103 
 Rectal feeding, 217-221 
 
 in anorexia, 275 
 
 in cancer of stomach, 553 
 
 in digestive hyperchylia, 299 
 
 in excessive secretion, 214 
 
 in gastric putrefaction, 216 
 
 in pyloric obstruction, 6o5 
 
 in ulcer of stomach, 508 
 Recto-abdominal galvanization, 244 
 Red blood corpuscles in cancer of stomach, 
 537 
 
 Red blood-corpuscles, inrtuence of disease 
 of stomach on, 616 
 
 litmus paper, 101 
 
 meats, 194 
 
 it] hyperchlorhydria, 287 
 " Red nose" from disease of stomach, 630 
 Referred pain, 39 
 Reflex vomiting, 327 
 Reflexes in gastric tetany, 626 
 Regurgitation, 43 
 
 esophageal, 322 
 
 habitual, 321, 322 
 
 in obstruction of cardia, 579 
 Reibmayer method of massage, 249 
 Reichman, illumination of the stomach, 58 
 Reichmann's disease, 18, 285, 418 
 Reniastication, 322-325 
 Removal of germs from stomach, 258 
 
 of stomach-contents, 91 
 Resorcin in gastric pain, 252 
 
 Merck's resublimated, 253 
 
 resublimated, in pyloric obstruction, 606 
 
 resublimed, 258 
 Respiratory disorders in pyloric obstruc- 
 tion, 593 
 
 gurgling, 77 
 
 in vertical displacement of stomach, 
 562 
 Rest, 217 
 
 and Carlsbad cure in gastric ulcer, 506 
 
 in anorexia, 275 
 
 in bulimia, 268 
 
 in cancer of stomach, 551 
 
 in digestive hyperchylia, 298 
 
 in eructatio nervosa, 320 
 
 in excessive peristalsis, 316 
 , in gastrotopsis, 573 
 
 with neurasthenia, 575 
 
 in hyperchlorhydria, 288, 293 
 
 in nervous vomiting, 331 
 
 in neurasthenia gastrica, 345 
 
 in treatment of gastric ulcer, 500 
 
 influence of, 164 
 Resublimed resorcin, 258 
 Retention, 19, 33 
 
 acetic acid in, 153 
 
 gas formation in, 156 
 
 in gastroplegia, 335 
 
 in gastroptosis, 567 
 
 in pyloric obstruction, 587 
 
 in spasm of cardia, 306 
 
 lactic acid in, 148 
 
 myasthenia. See Myasthenia with reten- 
 tion. 
 
 stomach washing in, 229 
 
 use of water in, 22S 
 Rheumatism as acause of stomach disease, 
 638 
 
 muscular, 278 
 
 of abdominal wall, 39 
 
 use of water in, 227 
 Rhinopharyn.v, diseases of, as causes of 
 
 gastric disease, 644, 645 
 Rice, 209 
 
 flaked, 209 
 
 in gastroptosis with chronic colitis, 575 
 
 ill myasthenia with retention, 375 
 
 ill obstruction of pylorus. 605 
 Rirliet, investigations of, 188 
 Rickets as a result of myasthenia with 
 
 retention, 367 
 Riegel, test-dinner of, 97 
 
 in digestive hyperchylia gastrica, 296 
 in hyperchlorhydria, 289 
 Rigal on subphrenic abscess in ulcer of 
 
 stomach, 488 
 Roast beef, digestion of, 193 
 Roller electrode, 243
 
 670 
 
 INDEX. 
 
 Rosacea from disease of stoniacli, 630 
 
 Roseiibach, method of, for estimating elas- 
 ticity of stomach, 138 
 
 Rosenheim, abdominal bandage of. 250 
 electrode of, 2J4 
 gastroscope of, 61 
 intragastric electrode of, 238 
 tube of, 234 
 
 Rosenthal on gastroxia, 299 
 
 Rossbach on gastroxia, 299 
 
 Rubiier on consumption of potenlial 
 energy, 175 
 
 Rumination, 332-325 
 treatment of, 325 
 
 Saccharomycks cerevisiae, 202 
 Sacculation of esophagus, 309 
 Sahli-Giinzburg method, 86 
 Salicin as a gastric antiseptic, 238 
 Salicyluric acid, test for, 134 
 Salivary digestion of starch, 181 
 Salol test of Ewald, 134 
 Salt, common, in adenasthenia, 303 
 
 in myasthenia, 257 
 Saratoga Kissingen, 258 
 Sarcinae, 144, 145 
 
 in cancer of stomach, 53s 
 
 in pyloric obstruction, 596 
 
 ventriculi, 144 
 Schiff, method of, for determining albumin. 
 
 123 
 Schrank, method of, for detecting H.>S, 155 
 Schreiber's balloon sound, 66 
 
 method for estimating capacity of stom- 
 ach, 74 
 Scirrhus of stomach, 516 
 Sclerosis, multiple, as a cause of stomach 
 
 disease, 640 
 Scottish douche, 303 
 Secondary diseases of stomach, 631 
 Secretion, 82 
 
 dynamic afTections of, 285 
 
 excessive, lavage in, 231 
 Secretory signs, 18 
 Sedative medication in hypersthenia gas- 
 
 trica, 235 
 Sedentary habits, 163 
 
 Self-abuse as a cause of neurasthenia gas- 
 trica, 338 
 
 -inflation of the stomach, 367 
 Sensibility of the stomach, 212 
 Sexual disease a cause of bulimia, 271 
 
 excess a cause of eructatio nervosa, 319 
 of gastralgia, 276 
 of neurasthenia gastrica. 338 
 of parorexia, 271 
 Signs. See Symptomatology. 
 
 anatomical, 153-160 
 
 bacteriological, 142-157 
 
 functional, 81-142 
 
 physical, 48-80 
 Silver nitrate. See A'itralf 0/ si/ver. 
 Simple bitters, 256 
 Skin, influence of disease of stomach on. 
 
 629 
 Sleep, influence of, 164 
 Social atmosphere. 162 
 
 Sodium bicarbonate. See Bicarbonate of 
 soda. 
 
 bromid. See Bromid of sodium. 
 
 carbonate in acid-poisoning, 396 
 
 chlorate. See Chlorate of soda. 
 
 chlorid, 258 
 
 iodid. See lodid of sodium. 
 Soft-boiled egg, 207 
 Soft cancer of stomach, 516 
 Solar plexus in digestion, ,^36 I 
 
 Solution of Boas, 103 
 Somatose, 196 
 
 as intestmal diet, 217 
 
 in myasthenia with retention, 375 
 
 in ulcer of stomach, 502 
 Somervail. apparatus of, 232 
 Soporifics in neurasthenia gastrica, 347 
 Sound, use of, in cardiospasm, 307 
 Sour foods, 212 
 Soxhelet, apparatus of, 197 
 Spallanzani, investigations of, 188 
 Spasm of the cardia, 304-311 
 stagnation from, 305 
 treatment, 310 
 
 of the pharynx, 317 
 
 of the pylorus, 311-314 
 diet in, 313 
 etiology, 312 
 treatment, 313 
 
 of the stomach, 314 
 Spasmodic stenosis of the cardia, 308 
 Spath method of detecting acid in the 
 
 stomach, 86 
 Spectrophotometer of Glan, 125 
 Spinal diseases as a cause of stomach dis- 
 eases, 640 
 
 meningitis as a cause of stomach dis- 
 ease, 640 
 Spinogalvanization, 243 
 Spiiiogastric galvanization, 245, 246 
 Spiral bodies of Jaworski, 159 
 
 electrode, Wegele's, 238, 239 
 Splanchnoptosis, 568 
 Splashing as a sign of insufliciency, 135 
 
 in digestive hyperchylia gastrica, 296 
 
 in myasthenia gastrica, 353 
 with retention, 367 
 
 in pyloric obstruction, 594 
 Spleen, enlarged, as a cause of vomiting, 636 
 
 ulceration of, from ulcer of stomach, 488 
 Sponge-method of Edinger, 86 
 Sporozoa as a cause of cancer of stomach, 
 
 514 
 Spray, intragastiic, 234 
 Squab, 195 
 
 in catarrhal gastritis, 412 
 
 in digestive hyperchylia, 299 
 
 in hypersthenic gastritis, 426 
 
 in obstruction of pylorus, 605 
 Stagnation, 19 
 
 acetic acid in, 153 
 
 form of spasm of the cardia, 305 
 
 in chronic hypersthenic gastritis, 421 
 
 in digestive liyi)erchylia gastrica, 296 
 
 in gastroptosis, 567 
 
 in pyloric obstruction, 587 
 
 myasthenia, 349-363 
 Starch, digestion of, 181 
 
 in adenasthenia, 303 
 
 in gastric fermentation, 216 
 
 in hyperchlorhydria, 289 
 
 in myasthenia gastrica, 215 
 
 in rectal feeding, 218 
 
 in subacidity, 214 
 Starke on ulcer of stomach, 443 
 Starvation diet, 172 
 Sleiner on ulcer of stomach, 443. 446 
 Stenosis in gastroptosis, 567 
 
 of cardia. See Obstruction of rardia. 
 
 of pylorus. See Obstruction of pylorus. 
 
 rectal feeding in, 220 
 Sterilization of milk. 197 
 Stiller on eructatio nervosa, 3:7 
 Stomach, absoibability of, 140 
 
 action of caustic alkalies upon, 396 
 of metallic poisons on, 397 
 of poisonous acids on, 392 
 
 adenocarcinoma of, 517
 
 INDEX. 
 
 671 
 
 Stomach, anatomical diseases of, 378 
 anatomy and description of, 49, 50, 51, 52 
 arterial supply of, 464 
 artificial inflation of, 313 
 as a disease-producing organ, 6ro 
 auscultation of, 75-80 
 bacteria of, 142-157 
 -bucket, Einhorn,85 
 cancer of. See Cancer of stomach. 
 -contents, methods of obtaining, 85 
 
 normal, after test-meals, 94-98 
 specific gravity of, after test-meals, 
 
 296 
 total quantity of, after test-meals, 
 133 
 
 removal of, 91 
 contraction of, 56 
 determination of empty, 137 
 digestive work of, 141 
 displacements of, 554-576 
 
 and hyperchlorhydria, 291 
 distention of, 56 
 douche in asthenia gastrica, 256 
 dynamic aflfections of, 262 
 emptying of, by massage, 247-249 
 estimation of elasticity of, 138 
 evacuation of, 139 
 excessive activity of, 139 
 
 secretion by, 213 
 flora of, 143 
 functions of, 212 
 gas in, 225 
 gases, 42 
 
 germicidal activity of, 212 
 germs of, 142-157 
 glands of, 82, 83, 84 
 immobilization of, in treatment of gastric 
 
 ulcer, 499 
 in the causation of disease, 610 
 inflation of, 72-74 
 influence of mind on, 264, 265 
 inspection of, 56 
 insufficiency of, 139 
 -lamp, 58, 59 
 
 micro-organisms of, 142-157 
 motor dynamic aflfections of, 304-336 
 muscular irritability, 215 
 neoplasms of, 511 
 " neuroses " of, 262 
 palpation of, 62-68 
 percussion of, 68-72 
 scirrhus of, 516 
 secondary diseases of, 631 
 sensibility of, 212, 213 
 spasm of, 314 
 tonicity of, 139 
 total descent of, 564 
 transposition of, S54 
 -tube, 22, 87, 88, 89, 90 
 
 contraindication to the use of, 89 
 
 in cancer of stomach, 526 
 
 in obstruction of cardia, 581 
 
 in ulcer of stomach, 473 
 
 indications for the use of, 88 
 
 introduction of, 89 
 tumors of, in cancer, 540 
 ulcer of, 442. See Ulcer of stomach. 
 upward displacement of. See Displace- 
 ment of stomach, upward.. 
 vertical or lateral displacement of, 557 
 vicious circles of, 610 
 washing, 229-234 
 
 for removal of germs, 258 
 
 in gastric fermentation, 216 
 
 in gastric retention, 375 
 
 in pyloric obstruction, 606 
 Straight form of vertical displacement of 
 stomach, 560 
 
 Strauss method of estimating tlie stomach- 
 contents, 133 
 of testing for lactic acid, 150 
 on bacillus coli communis, 155 
 on lactic fermentation in cancer of 
 stomach, 535 
 Strauss's apparatus, 73 91, 92 
 Stricture of the cardia, 308 
 Strontium bromid. See Broniid of stron- 
 tium. 
 Strophanthus in upward displacement of 
 
 stomach, 557 
 Strychnin in anorexia, 275 
 in flatulency, 253 
 in gastric fermentation, 221 
 in gastroplegia, 335 
 in gastroptosis, 574 
 
 with chronic colitis, 575 
 in habitual regurgitation, 322 
 in hypersthenia gastrica, 257 
 in myasthenia with stagnation, 363 
 in mycotic gastritis, 3S6 
 in nervous vomiting, 332 
 in pyloric incontinence, 335 
 
 obstruction, 606 
 in rumination, 325 
 Subacidity, 301 
 diet in, 214 
 hydrochloric, 117 
 Subdiaphragmatic abscess. See Subphrenic 
 
 abscess. 
 Subjective symptoms, 35 
 Subnitrate of bismuth in hypersthenic gas- 
 tritis, 42S 
 in ulcer of stomach, 504 
 Subnutrition as a cause of stomach dis- 
 ease, 638 
 eflTect of, 186 
 
 from disease of stomach, 617 
 Subphrenic abscess, diagnosis of, 491-495 • 
 etiology, 495 
 
 from gastric ulcer, operation in, 511 
 gas in, 490 
 
 in ulcer of stomach, 455, 4S8 
 symptoms, 491 
 Subsulphateof iron in ulcer of stomach, 504 
 Suction method of removing stomach-con- 
 tents, 91 
 Sugar, concentrated solutions of, 211 
 digestion of, iSi 
 in catarrhal gastritis, 411 
 -of-lead-cotton method, 155 
 Sulphate of anilin in cancer of stomach, 
 
 551 
 Sulphocyanid of ammonium, decinormal 
 
 solution of, 113 
 Sulphuric-acid poisoning, 394 
 Superacidity, 286 
 
 hydrochloric, 286 
 Supersecretion, 295 
 Surgical treatment of gastric ulcer, 509 
 Swallowing of air, 304 
 
 method of introducing the stomach-tube, 
 90 
 Sweet-bread in catarrhal gastritis, 412 
 
 -oil in gastroptosis with chronic colitis, 
 
 575 
 Sweets, 211 
 in adenasthenia, 303 
 in bulimia, 269 
 in catarrhal gastritis, 412 
 in digestive hyperchylia, 298 
 in gastric fermentation, 216 
 in gastroptosis, 574 
 in hyperchlorhydria, 294 
 in myasthenia with retention, 375 
 
 with stagnation, 360 
 in obstruction of pylorus, 605
 
 672 
 
 INDEX. 
 
 Sweets in ulcer of stomach, 502 
 Sympathetic ganglia, electric excitation of, 
 
 243 
 Symptomatic gastrospasm, 314 
 
 treatment, 251-253 
 
 vomiting, 326 
 Symptomatology. See various diseases in 
 
 Sections IV and V. 
 Symptom-group, 22, 23 
 Symptoms, subjective and objective, 22 
 
 Tabes dorsalis, gastric crises of, 640. 641 
 gastrospasni in, 314 
 vomiting 111,426 
 Tachycardia from disease of stomach, 621 
 in myasthenia with retention, 366 
 in neurasthenia gastrica, 340 
 Tannin in ulcer of slomach]^ 504 
 Tartaric acid as an antidote, 396 
 
 in inflation of stomach, 72 
 Tea in adenasthenia, 303 
 in digestive hyperchylia, 29S 
 in gastritis glandularis atrophicans. 442 
 in hyperchlorhydria, 294 
 in myasthenia with stagnation, 361 
 in obstruction of pylorus, 605 
 Teeth, condition of, 54 
 Temperament, neurotic or nervous, 264 
 Tender points in the differential diagnosis 
 of ulcer and displacement of the 
 stomach, 482 
 in ulcer of the stomach, 469 
 Tenderness, 57 
 Terminal It-ukopenia, 537 
 Test-breakfast in pyloric incontinence, 334 
 obstruction, 604 
 of Ewald and Boas, 9s 
 -dinner in pyloric incontinence, 334 
 
 of Riegel, 97 
 for labferment, 121 
 for salicyluric acid, 134 
 -meals, 93 
 
 in pyloric obstruction, 595 
 normal digestion of, 94-98, 133, 296 
 of Bourget,94 
 of Germain See. 96 
 of Jaworski, 94 
 of Klemperer, 94 
 of absorption. Sev Absorption, 
 of Boas for labferment, 121 
 of Fleischer, 135 
 of Korcynski and Jaworski, 159 
 of Leo, 121 
 
 of motor function. See yfotor futiclion. 
 of secretion. See Sfcreiion. 
 Uffelmann's, for lactic acid, 150 
 Van Deen's, for blood, 15S 
 water-, for motor insufficiency, 13S 
 Weber's, for blood, 159 
 Tetany from disease of the stomach, 625 
 ga.stric,625 
 
 in myasthenia with retention, 366 
 Teufel, bandage of, 250 
 
 Theories concerning the secretion of hydro- 
 chloric acid, 98 
 of nutrition, 169 
 Theory of Hayem.98 
 Thiersch's solution in obstruction of car- 
 
 dia, 583 
 Thirst, 45 
 
 Thomas on the vomiting center, 132 
 Thoracic diseases as a cause of diaphrag- 
 matic abscess, 495 
 " Three-layer " vomit, 29 
 Throat, diseases of, as causes of gastric 
 
 disease, 644 
 Thrombosis, vomiting in, 326 
 
 Tight lacing as a cause of displacements 
 
 of stomach, 566 
 Toast in gastroptosiswith neurasthenia, 576 
 Tobacco a cause of cardiospasm, 304 
 of gastralgia, 276 
 of vomiting, 327 
 
 -poisoning, hyperchlorhydria in, 287 
 Tongue, condition of, 55 
 Tonicity of the stomach, 139 
 Tonics in neurasthenia gastrica, 346 
 Topfer, method of, 106 
 Tormina ventriculi, 240 
 
 nervosa, 315, 316 
 Total acidity, 106 
 Toxemia, vomiting in, 326 
 Toxic gastritis, acute, 391 
 
 as a cause of pyloric obstruction, 589 
 
 symptoms in pyloric obstruction. 593 
 Toxins from stomach-contents, 628 
 Traction sensations, 36 
 Transfusion in the hemorrhage of gastric 
 
 ulcer, 505 
 Transposition of stomach, 554 
 Traumatic shock a cause of gastroplegia, 
 
 335 
 Traumatism, 163 
 
 of the brain, vomiting in, 326 
 Treatment, bacteriological, 258, 259 
 
 chemical, 259-261 
 
 physiological, 253-25S 
 
 symptomatic, 251 
 Troparolin, 103, 104 
 Trousseau diet, 165 
 
 on gastric vertigo, 625 
 Trousseau's sign, 627 
 Tubercular fever, influence of, on gastric 
 
 secretion, 649 
 Tuberculosis, differentiation of, from can- 
 cer of stomach, 548, 549 
 
 pulmonary, as a cause of stomach dis- 
 ease, 646-650 
 
 vomiting in, 649 
 Tumor in cancer of stomach, 540 
 
 in diagnosis of cancer of stomach, 545, 
 .546, 547 
 
 in ulcer of stomach, 470 
 
 obstruction of pylorus by, 585 
 
 of pylorus in pyloric obstruction, 544 
 
 of the stomach, 57 
 benign and malignant, 544 
 differentiation of, from tumors of other 
 organs. 541, 542. 543 
 
 pyloric, in diagnosis of pyloric obstruc- 
 tion, 597 
 Turck's revolving sponge. 64 
 Ty|»hoid fever as a cause of myasthenia 
 
 gastrica, 34S 
 Tyrosin in the stomach, 155 
 
 Uffelman.n's method or test for lactic 
 
 acid, 150 
 Ulcer of stomach. 412 
 
 adhesion from, 495 
 
 anatomical characteristics, 452-456 
 
 anemia in, 471-473 
 
 as a cause of pyloric incontinence. 333 
 pyloric obstruction, 585, 589 
 
 bulimia in, 266 
 
 cardinal symptoms, 459 
 
 cicatrix of, 455 
 
 clinical description, 456 
 
 collapse in, 505 
 
 complicated with cancer, 485 
 with plastic peritonitis, 485 
 
 comiilications of. 484 • 
 
 condition of the blood in, 471 
 
 constipation in, 474
 
 INDEX. 
 
 673 
 
 Ulcer of stomach, defoimity from, 496 
 diagnosis, 475 
 diet in, 500 
 
 diflfereiitial diagnosis of, 477 
 differentiation of, from adenohyper- 
 sthenia gastrica, 478 
 
 from cancer, 479 
 
 from cholelithiasis, 482 
 
 from displacements, 481 
 
 from gastralgia, 279, 283, 284, 478 
 
 from hyperchlorhydria, 292 
 
 from neurasthenia gastrica, 343 
 
 from spasm of stomach, 309 
 
 from ulcer of the duodenum, «^83 
 
 pulmonary and gastric hemorrhage 
 in, 467 
 dorsal tender point in, 469 
 epigastric tender point in, 469 
 evolution of, 458 
 excision of, 509 
 expectant treatment of, 499 
 favorite localities of, 452 
 fistula from, 496 
 forced feeding in, 187 
 formation and development of. 457 
 frequency of, 443 
 functional signs of, 473 
 healing of, 474 
 hematemesis in, 463 
 hemorrhage in, 463 
 immobilization in treatment of, 499 
 inanition anemia in, 472 
 influence of age on, 446 
 
 of diet on, 447 
 
 of disease of blood on, 448 
 
 of diseases of heart and blood-vessels 
 on, 448 
 
 of hydrochloric superacidity on, 449 
 
 of occupation on, 447 
 
 of sex on, 446 
 
 of temperature of food on, 500 
 insufficient diet in, 1S6 
 melena in, 466 
 mortality from, 474, 497 
 nutrition in, 470 
 objective signs of, 46S 
 oligocythemia in, 471 
 pain of, 4,s9 
 
 pathological anatomy, 451 
 perforation in, 454, 486 
 
 treatment of, 508 
 prognosis, 497 
 
 rectal feeding in, 221, 500, 501, 507 
 rest and Carlsbad cure of, 506 
 
 and rectal feeding cure in, 507 
 
 in, 164 
 sequelae of, 495 
 shape of, 452 
 size of, 452 
 
 spasm of pylorus in, 311 
 surgical treatment of, 509 
 table of deaths from, in New York 
 
 City, 445 
 tender points in, 469 
 terminations of, 474 
 treatment, 498-511 
 
 of vomiting in, 505 
 tumor in, 470 
 vomiting in, 462 
 
 of blood in, 463 
 walking treatment in, 500 
 with ulceration of adjacent parts, 
 
 487 
 Ulcus duodeni, differentiation of, from 
 
 ulcer of stomach, 483 
 Umbilicus, 49 
 
 Uncomfortable sensations, 38 
 Units of heat, 173-175 
 
 44 
 
 Upward displacement of stomach. See 
 
 Displacement of stomach, nptvard. 
 Uremia as a cause of neurasthenia gastrica, 
 338 
 
 as a cause of stomach disease, 639 
 Uric acid diathesis, 619 
 
 elimination in cancer of stomach, 538 
 excess of, from disease of stomach. 619 
 formation in gastroptosis, 567 
 Uricemia as a cause of neurasthenia gas- 
 trica, 338 
 
 from disease of stomach, 617 
 
 in gastroptosis, 568 
 
 water in, 227 
 Urine, acidity of, 620 
 
 as a measure of degree of gastric reten- 
 tion, 604 
 
 drinking of, 271 
 
 examination of, in neurasthenia gastrica, 
 342 
 
 excess of uric acid in. 619 
 
 in adenasthenia gastrica, 301 
 
 in asthenic gastritis, 408 
 
 in cancer of stomach, 538 
 
 in gastralgia, 277 
 
 in hyperchlorhydria, 291 
 
 in hypersthenic gastritis, 422 
 
 in myasthenia with retention, 366 
 with stagnation, 352 
 
 influence of disease of stomach on, 630 
 
 phosphates in, 620 
 
 toxicity of, in diseases of stomach, 611 
 Urobilin in urine of cancer of stomach, 538 
 Urticaria in myasthenia with retention, 366 
 
 in pyloric obstruction, 592 
 
 from disease of stomach, 630 
 
 Vagosympathetic irritation, relief of, 250 
 
 nerve, 47 
 excitation of, 242 
 Vagus, irritation of, 323 
 Valentine's meat juice, 196 
 Valerian in nervous vomiting, 332 
 Valleix on influence of sex in cancer of 
 
 stomach, 514 
 Valvular disease as a cause of disease of 
 
 stomach, 635 
 Van Deen's test for blood, 158 , 
 
 Van Valzah and Nisbet, method of, 140 
 Vanillin, 103 
 
 Varicose esophageal veins, 309 
 Vascular disorders in pyloric obstruction, 
 
 593 
 Vegetable albumin, 209 
 
 calorimetric value of, 175 
 Vegetables, 211 
 
 in adenasthenia, 303 
 
 in bulimia, 269 
 
 in digestive hyperchylia, 299 
 
 in gastric fermentation, 216 
 
 in gastroptosis, 574 
 with neurasthenia, 576 
 
 in hyperchlorhydria, 294 
 
 in hypersthenic gastritis, 427 
 
 in myasthenia with stagnation, 361 
 
 in neurasthenia gastrica, 346 
 
 in obstruction of pylorus, 605, 607 
 
 in ulcer of stomach, 502 
 Venison, 195 
 Veratrum viride, 255 
 Vertical displacement of stomach. See 
 
 Displacement of stomach, vertical. 
 Vertigo a stomacho laeso, 625 
 
 gastric, 625 
 Vicious circles of the stomach, 610 
 " Vigor chocolate," 217, 361 
 in catarrhal gastritis, 412
 
 6/4 
 
 INDEX. 
 
 '■ Vigor chocolate " in gastritis glandularis 
 atrophicans, 442 
 in hyperchlorhydria, 294 
 in hypersthenic gastritis, 426 
 
 Vinegar as an antidote to caustic alkalies, 
 
 effect of, in gastroptosis, 567 
 Virchow on influence of diseases of blood- 
 vessels on ulcer of stomach, 44S 
 
 on mortality from cancer of stomach. 513 
 Visible peristalsis, 315 
 Voice, use of. after raeals, 164 
 Vol hard, method of, 112 
 Vomit in catarrhal gastritis, 405 
 
 in hypersthenic gastritis, 422 
 
 ■■ three-layer," 29 
 Vomiting. 44 
 
 as a diflferential sign between pyloric and 
 duodenal obstruction, 601 
 
 as a means of obtaining the stomach- 
 contents. S3 
 
 center, 32.S 
 
 central, 326 
 
 cerebral, 641 
 
 diagnosis of the varieties of, 330 
 
 fecal, in fistula from gastric ulcer, 496 
 
 from disease of intestines, 632 
 
 from hysteria. 643 
 
 from pneumonia. 645 
 
 hematogenous, 227 
 
 hysterical. 327 
 
 in cancer of stomach, 524 
 
 in cardiospasm. 306 
 
 in digestive hyperchylia gastrica, 295 
 
 in excessive peristalsis, 316 
 
 in gastroptosis, 567 
 
 in locomotor ataxia, 640 
 
 in meningitis, 6ji 
 
 in myasthenia with retention, 365 
 
 in obstruction of cardia, 5S0 
 pylorus, 5S^S, 5S9 
 
 in paroxysmal hyperchylia, 299 
 
 in perforation of stomach from ulcer, 487 
 
 in pyloric obstruction, 591 
 
 in spasm of the pylorus, 312 
 
 in subphrenic abscess from ulcer of stom- 
 ach, 492 
 
 in tuberculosis, 649 
 
 in ulper of stomach, 462 
 treatment of, 505 
 
 nervous. 325, 327 
 
 of blood in ulcer of stomach, 463 
 
 periodical, 329 
 
 psychic, 32S 
 
 reflex, 327 
 
 remedies for, 252, 253 
 
 symptomatic, 326 
 treatment of, 253 
 
 treatment of, 331 
 Von Ziemssen method of galvanization, 242 
 on rest and Carlsbad cure, 506. 507 
 
 VValdever on ulcer of stomach, 443 
 Walking treatment of ulcer of stomach, 500 
 
 Warm water in eructatio nervosa, 321 
 Water, action of. on stomach, 227 
 external use of, 235 
 insufficiency, 227 
 -test, 292 
 
 for motor insufficiency, 139 
 
 in diagnosis of myasthenia gastrica, 354 
 
 in differentiation between benign and 
 
 malignant pyloric obstructions, 603 
 
 between myasthenia and digestive 
 
 hyperchylia gastrica, 297 
 between myasthenia and hyper- 
 sthenic gastritis with supersecre- 
 tion, 422 
 between myasthenia and pyloric ob- 
 struction; 358. 373. 595, 599 
 use of, in treating stomach diseases, 227- 
 258 
 Weakness in gastroptosis, 56S 
 Weber's test (or blood, 158 
 Wegele's spiral electrode, 238, 239 
 Weight as a guide to dietetic treatment, 
 
 224 
 Weir ana Foote on operations for perforat- 
 ing nicer of stomach, 510 
 on perforation in ulcer of stomach, 486 
 Welch on localities of ulcer of stomach, 
 
 452 
 Wheaten grits, 208 
 
 White blood-corpuscles in cancer of stom- 
 ach, 537 
 influence of disease of stomach on, 616 
 of egg, 206 
 as an antidote, 396 
 test-meal of Jaworski, 94 
 Widal serum sign in gastric fever. 391 
 Wilkinson on congenital cancer of stom- 
 ach. 513 
 Williams on cure of grastric ulcer, 507 
 Willigk on ulcer of stomach, 446 
 Wine, effect of. in gastroptosis, 567 
 in gastroptosis with chronic colitis, 576 
 in pyloric obstruction, 605 
 Winter, method of Hayem and, iii 
 Winternitz. 236 
 compress of, 253, 284 
 in hyperchylia. 300 
 in hypersthenic gastritis. 429 
 in pyloric obstruction, 607 
 in spasm of the pylorus, 313 
 in the vomiting of gastric ulcer, 506 
 Wirderhofer on congenital cancer ofstom- 
 
 ach. 513 
 Worry as a cause of neurasthenia gas- 
 trica, 33S 
 
 Yeast, 145 
 fermentation, 154 
 
 Zabludowski, method of, 247. 248 
 
 Zuntz on consumption of oxygen by the 
 
 body, 174, 175 
 Zymogenic bacteria. 147
 
 CATALOGUE 
 
 OF THE 
 
 MEDICAL PUBLICATIONS 
 
 OF 
 
 W. B* SAUNDERS, 
 
 No. 925 WALNUT STREET, PHILADELPHIA. 
 
 Arranged Alphabetically and Classified under Subjects. 
 
 ' I "^riE books advertised in this Catalogue as being sold by subscription are usually to be 
 obtained from traveling solicitors, but they will be sent direct from the office of pub- 
 lication (charges of shipment prepaid) upon receipt of the prices given. All the other 
 books advertised are commonly for sale by booksellers in all parts of the United States ; 
 but any book will be sent by the publisher to any address, carriage prepaid, on receipt of 
 the published price. 
 
 Money may be sent at the risk of the publisher in either of the following ways : 
 A post-office money order, an express money order, a bank check, and in a registered 
 letter. Money sent in any other way is at the risk of the sender. 
 
 See pages 30, 31, for a List of Contents classified according to subjects. 
 
 LATEST PUBLICATIONS. 
 
 Amer .Text-Book of Genito-Urinary and Skin Diseases. Page 4. 
 
 Macdonald^s Surgical Diagnosis, just Ready. See page I6. 
 
 Anders^ Practice of Medicine — Revised Edition. See page 6. 
 
 Moore^s Orthopedic Surgery, just Ready. Sec page J7. 
 
 Penrose^s Diseases of Women. See page I8. 
 
 Mallory and Wright^s Pathological Technique. See page I6. 
 
 Van Valzah and Nisbet^s Diseases of the Stomach. See page 28. 
 
 American Year-Book of Medicine and Surgery. See page 6. 
 
 Sennas Genito-Urinary Tuberculosis. See page 25. 
 
 Sutton and Giles^ Diseases of Women. See page 28. 
 
 Stoney^s Nursing — Revised Edition. See page 27. 
 
 Garrigues^ Diseases of Women — Revised Edition. See page n. 
 
 Keen^s Surgical Complications of Typhoid Fever. See page I5. 
 
 Gould and Pyle^s Curiosities of Medicine. See page u. 
 
 De Schweinitz^ Diseases of the Eye — Revised Edition. Page JO. 
 
 Chapin^s Compendium of Insanity, just Ready. See page 8. 
 
 Church and Peterson^s Nervous and Mental Diseases. Page 9. 
 
 Saunders^ Medical Hand-Atlases. See page 2. 
 
 DaCosta^s Surgery — Revised and Enlarged Edition. See page jo.
 
 SPEOAL ANNOUNCEMENT. 
 
 Mr. Saunders is pleased to announce that arrangements have been completed for the 
 publication of an English edition of the world-famous 
 
 Lehmann medicinische Handatlanten. 
 
 For scientific accuracy, pictorial beauty, compactness, and cheapness these books 
 surpass any similar volumes ever published. Each volume contains from 
 
 50 to 100 Colored Plates, 
 
 besides numerous other illustrations in the text. These colored plates have been executed 
 "by the most skilful German lithographers, in some cases twenty or more impressions being 
 required to obtain the desired result. There is a full and appropriate description of each 
 plate (printed, for convenience, opposite the plate), together with a condensed outline of 
 the subject to which the book is devoted. 
 
 The same careful and competent editorial supervision will be secured in the 
 English edition as in the originals. The translations will be directed and edited by the 
 leading American specialists in the different sut)jects. 
 
 The great advantage of natural pictorial representation is indisputable. For lasting and 
 practical knowledge, one accurate illustration is better than several pages of dry 
 description. 
 
 These Atlases offer a ready and satisfactory substitute for clinical observation, avail- 
 able only to the residents of large medical centers ; and with such persons the requisite 
 variety is seen only after long years of routine hospftal service. 
 
 By reason of their projected universal translation and reproduction, affording inter- 
 national distribution, the publishers have been enabled to secure for these Atlases the best 
 artistic and professional talent, to produce them in the most elegant style, and yet to 
 offer them at a price heretofore unapproached in cheapness. The success of the under- 
 taking is demonstrated by the fact that volumes have already appeared in German, English, 
 French, Italian, Russian, Spanish, Danish, Swedish, and Hungarian. 
 
 While appreciating the value of such colored plates, the profession has heretofore been 
 practically debarred from purchasing similar works because of their extremely high price, 
 made necessary by the limited sale and the enormous expense of production. The very 
 low price of these Atlases will place them within the reach of even the novice in practice. 
 
 NOW READY. 
 
 Atlas of Internal iVledicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlaiigen. Edited 
 by .-XuGi-STrs A. KsHNKK, M.D., ProrcssorolCliiiical Medicine in the Philadelphia Polyclinic; At- 
 tending Physician to the Philadelphia Hospital. 68 colored plates, and 64 illustrations in the text. 
 Cloth, I3.00 net. 
 
 Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peter- 
 son, M.D.. Cliniial Professor of Mental DiseasL-s, Woman's .Medical College, New York; Chief 
 of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored fig- 
 ures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, I3.50 net. 
 
 Atlas of Diseases of the Larynx. By Dk. L. Grl'swaid, of Munich. Edited by Charles P. 
 
 Grayson, M.D., Lecturer on Laryngology and Rliinology in the I'niversity of Pennsylvania; 
 Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. 
 With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, J2.50 net. 
 
 IN PREPARATION. 
 
 Atlas of Operative Surgery. By Dr. O. Zuckerkandl. of Vienna. Edited by J. Chal.mers 
 DaCosta, M.D., Clinical Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon 
 to the Philadelphia Hospital. With 24 colored plates, and 217 illustrations in the text. 
 
 Atlas of Syphilis and the Venereal Diseases. By Prof. Dr. Franz MRACEK.of Vienna. Edited 
 bv L. Bolton Bangs, NLD., late Professor of Genito-Urinary and Venereal Diseases, New York 
 Piist-Graduate Medical School and Hos|>ital. With 71 colored plates from original water-colors, 
 and 16 black-and-white illustrations. 
 
 Atlas of External Diseases of the Eye. Bv Dr. O. Haab, of Zurich. Edited by G. E. 
 DE ScHWKiNiTZ, M.D., Professor of Ophthalmology-, Jefl^erson Medical College, Philadelphia. 
 Willi 100 colored illustrations. 
 
 Atlas of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. With 80 colored plates from 
 original water-colors.
 
 «a 
 
 THE AMERICAN TEXT-BOOK SERIES. 
 
 AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 
 
 By 43 Distinguished Practitioners and Teachers. Edited by James C. 
 Wilson, M.D., Professor of the Practice of Medicine and of Clinical 
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 AN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN. 
 
 By 63 Eminent Contributors. Edited by Louis Starr, M.D., Physi- 
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 AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
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 AN AMERICAN TEXT=BOOK OF GENITO-URINARY AND SKIN 
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 AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND 
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 AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXI- 
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 AN AMERICAN TEXT=BOOK OF PATHOLOGY. 
 
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 AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 
 
 By 13 Eminent Professors of Surgery. Edited by William W. Keen, 
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 the Board of Exatniners of the Royal College of Surgeons, England. 
 
 " If this text-book is a fair reflex of the present position of American surgery, we must 
 admit it is of a very high order of merit, and that English surgeons will have to look very 
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 London Lancet. 
 
 AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
 OF MEDICINE. 
 
 By 12 Distinguished American Practitioners. Edited by William 
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 AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 
 
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 and text-books of the leading American and Foreign authors and 
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 ANDERS' PRACTICE OF MEDICINE. Second Edition. 
 
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 BALL'S BACTERIOLOGY. Third Edition, Revised. 
 
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 Medical Publications of W. B. Saunders. 7 
 
 BASTIN'S BOTANY. 
 
 Laboratory Exercises in Botany. By Edson S. Bastin, M.A., 
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 BECK'S SURGICAL ASEPSIS. 
 
 A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to 
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 BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
 OPERATIONS. 
 Obstetric Accidents, Emergencies, and Operations. By L. Ch. 
 
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 BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
 Essentials of Medical Physics. By Fred J. Brockway, M.D., 
 Assistant Demonstrator of Anatomy in the College of Physicians and 
 Surgeons, New York. Crown octavo, 330 pages ; 155 fine illustrations. 
 Cloth, gi.oo net; interleaved for notes, $1.25 net. 
 
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 " It contains all that one need know on the subject, is well written, and is copiously 
 illustrated." — Medical Record, New York. 
 
 BURR ON NERVOUS DISEASES. 
 
 A Manual of Nervous Diseases. By Charles W, Burr, M.D., 
 Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
 Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary 
 for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. 
 ^n Preparation.
 
 8 Medical Publications of W. B. Saunders. 
 
 BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
 MACOLOGY. 
 A Text=Book of Materia Medica, Therapeutics, and Pharma- 
 cology. By George F. Butler, Pw.Ci., iVLD., Professor of Materia 
 Medica and of Clinical Medicine in the College of Physicians and 
 Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, 
 Northwestern University, Woman's Medical School, etc. Octavo, 858 
 pages, illustrated. Cloth, ^4.00 net ; Sheep, $5.00 net. 
 
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 a hearty endorsement from the students of our up-to-date colleges. The book will be found 
 a valuable work of reference for the practitioner." — American Medico-Surgical Bulletin. 
 
 CASSELBERRY ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By W. E. Casselberrv, Pro- 
 fessor of Laryngology and Rhinology in the Northwestern University 
 Medical School, Chicago. In Preparation. 
 
 CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
 Notes on the Newer Remedies, their Therapeutic Applications 
 and Modes of Administration. By David Cerna, M.D., Ph.D., 
 
 formerly Demonstrator of and Lecturer on Experimental Therapeutics 
 in the University of Pennsylvania; Demonstrator of Physiology in the 
 Medical Department of the L'niversity of Te.xas. Rewritten and 
 greatly enlarged. Post-octavo, 253 pages. Cloth, $1.25. 
 
 '•These ' Notes ' will be found ven,- useful to practitioners who take an interest in the 
 many newer remedies of the present day.' — Edinburgh Medical Journal. 
 
 " The appearance of this new edition of Dr. Cerna's ven,' valuable work .shows that it 
 is properly appreciated. The book ought to be in the possession of every practising physi- 
 cian." — New York Aledical Journal. 
 
 CHAPIN ON INSANITY. 
 
 A Compendium of Insanity. By John B. Chapin, ^LD., LL.D., 
 Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
 cian-Superintendent of the Willard State Hospital, New York ; Hon- 
 orary Member of the Medico-Psychological Societv of Great Britain, 
 of the Society of Mental Medicine of Belgium. Cloth, §1.25 net. 
 
 The author has given, in a condensed and concise form, a compendium of Diseases of 
 the Mind, for the convenient use and aid of physicians and students. The work will also 
 prove valuable to members of the legal profession and to those who, in their relations to the 
 insane and to those supposed to be insane, often desire to acquire some practical knowledge 
 of insanity presented iu a form that may be understood by the nonprofessional reader. 
 
 CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
 Second Edition, Revised. 
 Medical Jurisprudence and Toxicology. By Henry C. Chapman, 
 M.D., Professor of Institutes gf Medicine and Medical Jurisprudence 
 in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
 illustrations and 3 full-page plates in colors. Cloth, §1.50 net. 
 
 "The best book of its class for the undergraduate that we know of" — A'ew York 
 Medical Times.
 
 Medical Publications of W. B. Saunders. 9 
 
 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
 Nervous and Mental Diseases. By Archibald Church, M.D., 
 Professor of Mental Diseases and Medical Jurisprudence in the North- 
 western University Medical School, Chicago ; and Frederick Peter- 
 son, M.D., Clinical Professor of Mental Dis^^ases in the Woman's 
 Medical College, New York ; Chief of Clinic, Nervous Department, 
 College of Physicians and Surgeons, New York. In Preparatio7i. 
 
 CLARKSON'S HISTOLOGY. 
 
 A Text=Book of Histology, Descriptive and Practical. By 
 
 Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
 Physiology in the Owen's College, Manchester; late Demonstrator of 
 Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
 22 engravings in the text, and 174 beautifully colored original illustra- 
 tions. Cloth, strongly bound, $6.00 net. 
 
 "The work must be considered a valuable addition to the list of available text-books, 
 and is to be highly recommended." — New York Medical Journal. 
 
 "This is one of the best works for students we have ever noticed. We predict that the 
 book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 
 
 "The volume is a most valuable addition to the armamentarium of the teacher." — 
 Brooklyn Medical Journal. 
 
 CLIMATOLOGY. 
 
 Transactions of the Eighth Annual Meeting of the American 
 Climatological Association, held in Washington, September 22-25, 
 1891. Forming a handsome octavo volume of 276 pages, uniform with 
 remainder of series. (A limited quantity only.) Cloth, $1.50. 
 
 COHEN AND ESHNER'S DIAGNOSIS. 
 
 Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
 fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
 phia Polyclinic; and Augustus A. Eshner, M.D., Instructor in Clinical 
 Medicine, Jefferson Medical College, Philadelphia. Post-octavo, 382 
 pages; 55 illustrations. Cloth, $1.50 net. 
 
 [See Saunders' Question- Competids, page 21.] 
 
 "We can heartily commend the book to all those who contemplate purchasing a 'com- 
 pend.' It is modern and complete, and will give more satisfaction than many other works 
 which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 
 
 CORWIN'S PHYSICAL DIAGNOSIS. 
 
 Essentials of Physical Diagnosis of the Thorax. By Arthur 
 M. CoRwiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
 Medical College, Chicago ; Attending Physician to Central Free Dis- 
 pensary, Department of Rhinology, Laryngology, and Diseases of the 
 Chest, Chicago. 200 pages, illustrated. Cloth, flexible covers, $1.25 net. 
 
 " It is excellent. The student who shall use it as his guide to the careful study of 
 physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
 working knowledge of the subject." — Philadelphia Polyclinic. 
 
 "A most excellent little work. It brightens the memory of the differential diagnostic 
 signs, and it arranges orderly and in sequence the various objective phenomena to logical 
 solution of a careful diagnosis." — Journal of Nervotis and Mental Diseases.
 
 10 Medical Publications of W. B. Saunders. 
 
 CRAQIN'S GYN/ECOLOQY. Fourth Edition, Revised. 
 
 Essentials of Gynsecology. By Edwin B. Cragin, M.D., Attend- 
 ing Ciynjecologist, Roosevelt Hospital, Out-Patients' Department, New 
 York, etc. Crown octavo, 200 pages; 62 fine illustrations. Cloth, 
 $1.00; interleaved for notes, §1.25. 
 
 [See Saunders^ Question- Compemh, page 21.] 
 
 " A handy volume, and a distinct improvement on students' compends in general. No 
 author who was not himself a practical gynecologist could have consulted the student's needs 
 so thoroughly as Dr. Cragin has done." — Medical Record, New York. 
 
 CROOKSHANK'S BACTERIOLOGY. 
 
 A Text-Book of Bacteriology. By Edgar M. Crookshank, M.B.^ 
 Professor of Comparative Pathology and Bacteriology, King's College, 
 London. Octavo volume of 700 pages, with 273 engravings and 22 
 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 
 
 " To the student who wishes to obtain a good resiifne of what has been done in bacteri- 
 ology, or who wishes an accurate account of the various methods of research, the book may 
 be recommended with confidence that he will find there what he requires." — London Lancet. 
 
 DaCOSTA'S SURGERY. 
 
 A Manual of Surgery, General and Operative. By John 
 
 Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jefferson 
 Medical College, Philadelphia; Surgeon to the Philadelphia Hospital, 
 etc. Handsome volume of 810 pages; 1S8 illustrations in the text, 
 and 13 full-page plates. New and Enlarged Edition in Preparation. 
 
 "We know of no small work on sui^ery in the English language which so well fulfils 
 the requirements of the modem student." — Medico-Chirurgical Journal, Bristol, England. 
 
 DE SCHWEINITZ ON DISEASES OF THE EYE. Second Edition^ 
 Revised. 
 Diseases of the Eye. A Handbook of Ophthalmic Practice. 
 
 By G. E. DE ScHWEiNiTZ, ^LD., Professor of Ophthalmology in the 
 Jefferson Medical College, Philadelphia, etc. Handsome royal octavo 
 volume of 679 pages, with 256 fine illustrations and 2 chromo-litho- 
 graphic plates. Cloth, §4.00 net ; Sheep or Half Morocco, $5.00 net. 
 
 " A clearly written, comprehensive manual. One which we can commend to students 
 as a reliable text-book, written with an evident knowledge of the wants of those entering 
 upon the study of this sp>ecial l)ranch of medical science." — British Medical Journal. 
 
 "A work that will meet the requirements not only of the specialist, but of the general 
 practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
 Pepper, M.D.. Professor of the Theory and Practice of Medicine and Clinical Medicine ^ 
 Universily of Pennsykania. 
 
 DORLAND'S OBSTETRICS. 
 
 A Manual of Obstetrics. By W. A, Newman Borland, M.D., 
 .'\ssistant Demonstrator of Obstetrics, University of Pennsylvania ; 
 Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net. 
 
 " By far the best book on this subject that has ever come to our notice." — American 
 Medical Pei'iew. 
 
 " It has rarely been our duty to review a book which has given us more pleasure in its 
 j)erusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
 a gold mine of practical, concise thoughts. ' — American Medico-Surgical Bulletin.
 
 Medical Publications of W. B. Saunders. 11 
 
 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 
 
 Laboratory Guide for the Bacteriologist. By Langdon Froth- 
 INGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, 
 Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 
 
 "It is a convenient and useful little work, and will more than repay the outlay neces- 
 sary for its purchase in the saving of time which would otherwise be consumed in looking 
 up the various points of technique so clearly and concisely laid down in its pages." — Ameri- 
 can Medico- Surgical Bulletin. 
 
 GARRIGUES' DISEASES OF WOMEN. Second Edition, Revised. 
 Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
 fessor of Gynecology and Obstetrics in the New York School of 
 Clinical Medicine; Gynecologist to St. Mark's Hospital and to the 
 German Dispensary, New York City, etc. Handsome octavo volume 
 of 728 pages, illustrated by 335 engravings and colored plates. Cloth, 
 $4.00 net; Sheep or Half Morocco, $5.00 net. 
 
 " One of the best text-books for students and practitioners which has been published in 
 the English language ; it is condensed, clear, and comprehensive. The profound learning 
 and great clinical experience of the distinguished author find expression in this book in a 
 most attractive and instructive form. Young practitioners to whom experienced consultants 
 may not be available will find in this book invaluable counsel and help." — Thad. A. 
 Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 
 
 GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
 Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
 M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
 Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
 ment of the Northern Dispensary, Philadelphia. 208 pages, with 
 114 illustrations. Cloth, $1.00; interleaved for notes, $1. 25. 
 [See Saunders' Question- Compends, page 21.] 
 
 " It is just the book to put into the hands of a student, and cannot fail to give him a 
 useful introduction to ear-affections ; while the style of question and answer which is adopted 
 throughout the book is, we believe, the best method of impressing facts permanently on the 
 mind. ' ' — Liverpool Medico- Chii-urgical Joiirnal. 
 
 GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 
 
 Anomalies and Curiosities of Medicine. By George M. Gould, 
 M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
 rare and extraordinary cases and of the most striking instances of 
 abnormality in all branches of Medicine and Surgery, derived from an 
 exhaustive research of medical literature from its origin to the present 
 day, abstracted, classified, annotated, and indexed. Handsome im- 
 perial octavo volume of 968 pages, with 295 engravings in the text, 
 and 12 full-page plates. Cloth, ^6.00 net; Half Morocco, $7.00 net. 
 Sold by Subscription. 
 
 " One of the most valuable contributions ever made to medical literature. It is, so far 
 as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
 the medical profession has this volume value : it will serve as a book of reference for all who 
 are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
 Journal. 
 
 "This is certainly a most remarkable and interesting volume. It stands alone among 
 medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
 medical literature. It is a book full of revelations from its first to its last page, and cannot 
 but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin.
 
 12 Medical Publications of W. B. Saunders. 
 
 GRIFFIN'S MATERIA MEDICA AND THERAPEUTICS. 
 
 Manual of Materia Medica and Therapeutics. By Henry A. 
 Gkikmn, A.B., M.D., Assistant rhy.-ician to the Roosevelt Hospital, 
 Out-Patient Department, New York City. /// Preparation. 
 
 GRIFFITH ON THE BABY. 
 
 The Care of the Bahy. By J. P. Crozer Griffith, M.D., Clini- 
 cal I'rofessor of Diseases of Children, University of Pennsylvania ; 
 Physician to the Children's Hospital, Philadelphia, etc. i2nio, 392 
 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50. 
 
 " The best book for the use of the young mother with which we are acquainted. . . . 
 There are very few general practitioners who could not read the book through with advan- 
 tage. ' ' — Archives 0/ Pidiatrics. 
 
 "The whole book is characterized by rare good sense, and is evidently written by a 
 master hand. It can be read with benefit not only by mothers but by medical students and 
 by any practitioners who have not had large opportunities for obser^■ing children." — Ameri- 
 can Journal of Obstetj'ics. 
 
 GRIFFITH'S WEIGHT CHART. 
 
 Infant's Weight Chart. Designed by J. P. Crozer Griffith, M. D. , 
 Clinical Professor of Diseases of Children in the University of Penn- 
 sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 
 
 A convenient blank for keeping a record of the child's weight during the first two years 
 of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
 so that any deviation from the normal can readily be detected. 
 
 GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 
 
 Autobiography of Samuel D, Gross, M.D., Emeritus Professor of 
 Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
 niscences of His Times and Contemporaries. Edited by his Sons, 
 Samuel W. Grcss, M.D., LL.D., late Professor of Principles of Sur- 
 gery and of Clinical Surgery in the Jefferson Medical College, and 
 A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
 Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
 two handsome volumes, each containing over 400 pages, demy octavo, 
 extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
 per volume, §2.50 net. 
 
 "X)r. Gross was perhaps the most eminent exponent of medical science that America 
 has yet produced. Ilis Autobiography, related as it is with a fulness and completeness 
 seldom to be found in such works, is an interesting and valual)le book. He comments on 
 many things, especially, of course, on medical men and medical practice, in a very interest- 
 ing way." — 77/1? Spectator, London, England. 
 
 HAMPTON'S NURSING. 
 
 Nursing: Its Principles and Practice. By Isabel Adams Hamp- 
 ton, Graduate of the New York Training School for Nurses attached 
 to Bellevue Hospital ; Superintendent of Nurses, and Principal of the 
 Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 
 i2mo, 484 pages, profusely illustrated. Cloth, $2.00 net. 
 
 " .Seldom have we perused a book upon the subject that has given us so much pleasure 
 as the one before us. We would strongly urge upon the members of our own profession the 
 need of a book like this, for it will enable each of us to become a training school in him- 
 self." — Ontario Medical Journal.
 
 Medical Publications of W. B. Saunders. 13 
 
 HARE'S PHYSIOLOQY. Third Edition, Revised. 
 
 Essentials of Phiysiology. By H. A. Hare, M.D., Professor of 
 Therapeutics and Materia Medica in the Jefferson Medical College of 
 Philadelphia; Physician to the Jefferson Medical College Hospital. 
 Containing a series of handsome illustrations from the celebrated 
 " Icones Nervorum Capitis" of Arnold. Crown octavo, 239 pages. 
 Cloth, $1.00 net; interleaved for notes, $1.25 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "The best condensation of physiological knowledge we have yet seen." — Aledical 
 Record, New York. 
 
 HART'S DIET IN SICKNESS AND IN HEALTH. 
 
 Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
 Student of the Faculty of Medicine of Paris and of the London School 
 of Medicine for Women ; with an Introduction by Sir Henry 
 Thompson, F.R.C.S., M.D., London. 220 pages; illustrated. Cloth, 
 ^1.50. 
 
 " We recommend it cordially to the attention of all practitioners ; both to them and to 
 their patients it may be of the greatest service." — Nezv York Medical Journal. 
 
 HAYNES' ANATOMY. 
 
 A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
 Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
 ment of the New York University, etc. 680 pages, illustrated with 42 
 diagrams in the text, and 134 full-page half-tone illustrations from 
 original photographs of the author's dissections. Cloth, ^2.50 net. 
 
 " This book is the work of a practical instructor — one who knows by experience the 
 requirements of the average student, and is able to meet these requirements in a very satis- 
 factory way. The book is one that can be commended." — Medical Record, New York. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
 fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
 In Preparation. 
 
 HIRST'S OBSTETRICS. 
 
 A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., 
 Professor of Obstetrics in the University of Pennsylvania. In Prepa- 
 ration. 
 
 HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
 DISEASES. 
 Syphilis and the Venereal Diseases. By James Nevins Hyde, 
 M.D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
 gomery, M.D., Lecturer on Dermatology and Genito-Urinary Diseases 
 in Rush Medical College, Chicago, III. 618 pages, profusely illustrated. 
 Cloth, $2.50 net. 
 
 " We can commend this manual to the student as a help to him in his study of venereal 
 diseases. ' ' — Liverpool Medico- Chirurgical Journal. 
 
 "The best student's manual which has appeared on the subject." — St. Louis Medical 
 and Surgical Journal.
 
 14 Medical Publications of W. B. Saunders. 
 
 JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
 THROAT. Second Edition, Revised. 
 Essentials of Refraction and Diseases of the Eye. By Edward 
 Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
 delphia Polyclinic and College for Graduates in Medicine ; and — 
 Essentials of Diseases of the Nose and Throat. By E. Bald- 
 win GllasON, M.D. , Surgeon-in-Charge of the Nose, Throat, and 
 Ear Department of the Northern Dispensary of Philadelphia. Two 
 volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
 $1.00; interleaved for notes, $1-25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Of great value to the beginner in these branches. The authors are both capable men, 
 and know what a student most needs." — Medical Record, New York. 
 
 KEATINQ'S DICTIONARY. Second Edition, Revised. 
 
 A New Pronouncing Dictionary of Medicine, with Phonetic 
 Pronunciation, Accentuation, Etymology, etc. Bv John M. 
 Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
 delphia; Vice-President of the American Pasdiatric Society; Editor 
 "Cyclopaedia of the Diseases of Children," etc.; and Henry 
 Hamilton, Author of '-'A New Translation of Virgil's ./^neid into 
 English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
 Costa, M.D.. and Frederick A. Packard, M.D. With an Appendix 
 containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
 Drugs and Materials used in Antiseptic Surgery; Poisons and their 
 Antidotes ; Weights and Measures ; Thermometric Scales ; New 
 Official and Unofficial Drugs, etc. One volume of over 800 pages. 
 Prices, with Denison's Patent Ready-Reference Index: Cloth, $5. 00 
 net; Sheep or Half Morocco, §6.00 net; Half Russia, §6.50 net. 
 Without Patent Index: Cloth, 54. 00 net; Sheep or Half Morocco, 
 $5.00 net. 
 
 " I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
 ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practice 
 of Medicine, Rush Medical College, Chicago, III. 
 
 " I am convinced that it will be a very valuable adjunct to my study-table, convenient 
 in size and sufficiently full for ordinary' use." — C. A. Lindsi.ey, M.D., Professor of the 
 Theory and Practice of Medicine, Medical Dept. Yale University. 
 
 KEATINQ'S LIFE INSURANCE. 
 
 How to Examine for Life Insurance. By John M. Keating, 
 M.D., Fellow of the College of Physicians of Philadelphia; Vice- 
 President of the American Pediatric Society ; Ex-President of the 
 Association of Life Insurance Medical Directors. Royal octavo, 211 
 pages; with two large half-tone illustrations, and a plate prepared by 
 Dr. McClellan from special dissections ; also, numerous other illustra- 
 tions. Cloth, $2.00 net. 
 
 " This is by far the most useful book which has yet appeared on insurance examination, 
 a subject of growing interest and importance. Not the least valuable portion of the volume 
 is Part II, which consists of instructions issued to their examining physicians by twenty-four 
 representative companies of this country. If for these alone, the book should be at the right 
 hand of every physician interested in this special branch of medical science." — The Medical 
 News.
 
 Medical Publications of W. B. Saunders. 15 
 
 KEEN ON THE SURGERY OF TYPHOID FEVER. 
 
 The Surgical Complications and Sequels of Typhoid Fever. 
 
 By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
 gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
 Corresponding Member of the Societe de Chirurgie, Paris ; Honorary 
 Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
 about 400 pages. Cloth, ^^3.00 net. 
 
 This monograph is the only one in any language covering the entire subject of the 
 Surgical Comphcations and Sequels of Typhoid Fever. It will prove to be of importance 
 and interest not only to the general surgeon and physician, but also to many specialists — laryn- 
 gologists, gynecologists, pathologists, and bacteriologists. 
 
 KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
 An Operation Blank, with Lists of Instruments, etc. Required 
 in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
 Professor of the Principles of Surgery in Jefferson Medical College, 
 Philadelphia. Price per pad, containing blanks for fifty operations, 
 50 cents net. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
 Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
 College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
 Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadelphia 
 Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 LAINE'S TEMPERATURE CHART. 
 
 Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x i^y^ 
 inches. A conveniently arranged Chart for recording Temperature, 
 with columns for daily amounts of Urinary and Fecal Excretions, 
 Food, Remarks, etc. On the back of each chart is given in full the 
 method of Brand in the treatment of Typhoid Fever. Price, per pad 
 of 25 charts, 50 cents net. 
 
 " To the busy practitioner this chart will be found of great value in fever cases, and 
 especially for cases of typhoid." — Indian Lancet, Calcutta. 
 
 lockwood's practice of medicine. 
 
 A Manual of the Practice of Medicine. By George Roe Lock- 
 wood, M.D., Professor of Practice in the Woman's Medical College 
 of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
 the text, and 22 full-page plates. Cloth, $2.50 net. 
 
 " Gives in a most concise manner the points essential to treatment usually enumerated 
 in the most elaborate works." — Massachusetts Medical Journal. 
 
 LONG'S SYLLABUS OF GYNECOLOGY. 
 
 A Syllabus of Gynecology, arranged in Conformity with " An 
 American Text=Book of Gynecology." By J. W. Long, M.D., 
 Professor of Diseases of Women and Children, Medical College of 
 Virginia, etc. Cloth, interleaved, ^i.oo net. 
 
 " The book is certainly an admirable resume of what every gynecological student and 
 practitioner should know, and will prove of value not only to those who have the ' American 
 Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Jourtial.
 
 16 Medical Publications of W. B. Saunders. 
 
 MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 
 
 Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. 
 Edin., L.R.C.S., Kdin., Professor of the Practice of Surgery and of 
 Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
 Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 
 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco^ 
 $6.00 net. 
 
 " The rapid advances made in the art of surgery have caused the literature of the science 
 to grow apace. Systems of surgery in many volumes, and text-books of large dimensions, 
 are now deemed necessary to cover the field. The practical j)art of the surgeon's work is, 
 however, almost limited to two questions which he must answer every time his professional 
 advice or help is sought. The first question is, 'What is the disease or injury?' The 
 second question is, ' What is the proper treatment ? ' 
 
 "While I would not for a moment underestimate the importance of a profound study 
 of the principles of surgery, of surgical pathology, or of bacteriology, the present work will 
 be confined to a solution of the two questions just mentioned, with the view of putting into 
 the hands of students and practitioners a single volume containing the most practical part 
 of practical surgery." — From the Author'' s Preface. 
 
 MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 
 
 Pathological Technique. By Frank B. Mallorv, A.jNI., M.D., 
 Assistant Professor of Pathology, Harvard University Medical School ; 
 and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard 
 University Medical School. Octavo volume of 396 pages, handsomely 
 illustrated. Cloth, $2.50 net. 
 
 " I have been looking forward to the publication of this book, and I am glad to say that 
 I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
 and well up to date." — WiLLiAM H. Welch, Professor of Pathology, Johns Hopkins Uni- 
 versity, Baltimore, Aid. 
 
 MARTIN'S MINOR SURGERY, BANDAGING, AND VENEREAL 
 DISEASES. Second Edition, Revised. 
 Essentials of Minor Surgery, Bandaging, and Venereal 
 Diseases. By Edward Martin, A.M., M.D., Clinical Professor of 
 Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
 octavo, 166 pages, with 78 illustrations. Cloth, $1.00; interleaved for 
 notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " A very practical and systematic study of the subjects, and shows the author's famil- 
 iarity with the needs of students." — Therapeutic Gazette. 
 
 MARTIN'S SURGERY. Sixth Edition, Revised. 
 
 Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
 cal Landmarks, Minor and Operative Surgery, and a complete de- 
 scription, with illustrations, of the Handkerchief and Roller Bandages. 
 By Edward Martin, A.M., M.D., Clinical Professor of Genito- 
 Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
 pages, illustrated. With an Api^endix containing full directions for the 
 preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
 §1.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " Contains all necessary essentials of modem surgery in a comparatively small space. 
 Its style is interesting, and its illustrations are admirable." — Medical and Surgical Peporter^ -
 
 Medical Publications of W. B, Saunders. 17 
 
 MCFARLAND'S PATHOGENIC BACTERIA. 
 
 Text=Book upon the Pathogenic Bacteria. Specially written 
 for Students of Medicine. By Joseph McFarland, M.D., Pro- 
 fessor of Pathology and Bacteriology in the Medico-Chirurgical College 
 of Philadelphia, etc. Octavo volume of 359 pages, finely illustrated. 
 Cloth, $2.50 net. 
 
 " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
 presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
 gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
 students of Trinity College." — H. B. Anderson, M.D. , Professor of Pathology and Bac- 
 teriology, Trinity Medical College, Toronto. 
 
 MEIGS ON FEEDING IN INFANCY. 
 
 Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
 in limp cloth, flush edges, 25 cents net. 
 
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 MOORE'S ORTHOPEDIC SURGERY. 
 
 A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
 Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
 University of Minnesota, College of Medicine and Surgery. Octava 
 volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net. 
 
 A practical book based upon the author's experience, in which special stress is laid 
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 be found in the middle course between the surgeon who operates too frequently and the 
 orthopedist who seldom operates. 
 
 MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fourth 
 Edition, Revised. 
 Essentials of Materia Medica, Therapeutics, and Prescription= 
 Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
 peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
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 MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
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 Essentials of the Practice of Medicine. By Henry Morris, M. D., 
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 delphia ; with an Appendix on the Clinical and Microscopic Examina- 
 tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, 
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 [See Saunders'' Question- Compends , page 21.] 
 
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 18 Medical Publications of W. B, Saunders, 
 
 MORTEN'S NURSE'S DICTIONARY. 
 
 Nurse's Dictionary of Medical Terms and Nursing Treat- 
 ment. Containing Definitions of the Principal Medical and Nursing 
 Terms and Abbreviations ; of the Instruments, Drugs, Diseases, Acci- 
 dents, Treatments, Operations, Foods, Appliances, etc. encountered 
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 Essentials of Anatomy, including the Anatomy of the Viscera. 
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 PENROSE'S DISEASES OF WOMEN. 
 
 A Text-Book of Diseases of Women. By Charles B. Penrose, 
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 " The book is to l)e commended without reserve, not only to the student but to the 
 general practitioner who wishes to have the latest and best modes of treatment explained 
 with absolute clearness." — Therapeutic Gazette.
 
 Medical Publications of W, B. Saunders. 19 
 
 POWELL'S DISEASES OF CHILDREN. Second Edition. 
 
 Essentials of Diseases of Children. By William M. Powell, 
 M.D., Attending Physician to the Mercer House for Invalid Women 
 at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
 Children in the Hospital of the University of Pennsylvania. Crown 
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 Pictorial Atlas of Skin Diseases and Syphilitic Affections 
 (American Edition). Translation from the French. Edited by 
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 Hospital, London. Photo-lithochromes from the famous models in 
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 PYE'S BANDAGING. 
 
 Elementary Bandaging and Surgical Dressing. With Direc- 
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 RAYMOND'S PHYSIOLOGY. 
 
 A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
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 Archives of the Rontgen Ray (Formerly Archives of Clinical 
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 Vol. I., Parts I. to IV.; Vol. II., Part I.
 
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 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Third edition, 
 
 revised and enlarged. ($l.oo net.) 
 
 2. ESSENTIALS OF SURGERY. By Edward Martin, M.D. Sixth edition, 
 
 revised, with an Appendix on Antiseptic Surgery. 
 
 3. ESSENTIALS OF ANATOMY. By Charles B. Nancrede, M.D. Fifth 
 
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 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 
 
 By Lawrence Wolff, M.D. Fourth edition, revised, with an Appendix. 
 
 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 
 
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 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 
 
 Arm and Semplf:, M.D. 
 
 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 
 
 SCRIPTION=WRITING. By Henry Morris, M.D. Fourth edition, revised. 
 
 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 
 
 M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
 Third edition, enlarged by some 300 Essential Formtdre, selected from eminent 
 authorities, by Wm. M. Powell, M.D. (Double number, ^2.00.) 
 
 10. ESSENTIALS OF QYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth 
 
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 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 
 
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 By C. E. Armand Semple, M.D. 
 
 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 
 
 By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 
 
 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 
 
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 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 
 
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 17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 
 
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 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 
 
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 revised. 
 
 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 
 
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 23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 
 
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 Saunders' 
 
 New Series 
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 and 
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 The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior 
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 Any of these Manuals will be mailed on receipt of price (see next page for List).
 
 Saunders^ New Series of Manuals* 
 
 VOLUMES PUBLISHED. 
 
 PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
 and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
 Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^1.25 net. 
 
 SURGERY, General and Operative. By John Chalmers DaCosta, M.D., Clini- 
 cal Professor of Surgery, Jefferson Medical College, Philadelphia; Surgeon to the 
 Philadelphia Hospital, etc. 1S8 illustrations and 13 plates. (Double number.) 
 
 New and enlarged edition in preparation. 
 
 DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITING. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia. Illustrated. Cloth, ^1.25 net. 
 
 SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
 to the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net. 
 
 MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
 tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
 delphia. Illustrated. Cloth, $1.50 net. 
 
 SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
 Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
 Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, 
 Chicago. Profusely illustrated. (Double number.) Cloth, ^2.50 net. 
 
 PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
 Practice in the Woman's Medical College of the New York Infirmary ; Instructor in 
 Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
 (Double number.) Cloth, ^2.50 net. 
 
 MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
 Anatomy and Demonstrator of Anatomy, Medical Department of the New York 
 University, etc. Beautifully illustrated. (Double Number.) Cloth, $2.50 net. 
 
 MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
 Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
 pensary, Pennsylvania Hospital, etc. Profusely illustrated. (Double number.) Cloth, 
 ^2.50 net. 
 
 DISEASES OF WOMEN. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to 
 Middlesex Hospital and Surgeon to Chelsea Hospital, London ; and Arthur E. 
 Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
 London. Handsomely illustrated. (Double number.) Cloth, ^2.50 net. 
 
 VOLUMES IN PREPARATION. 
 
 NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- 
 gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- 
 gist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist to the Philadel- 
 phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
 Diseases, Medico-Chirurgical College. Philadelphia; Pathologist to the Orthopaedic 
 Hospital and Infirmary for Nervous Diseases ; Visiting Physician to the St. Joseph 
 Hospital, etc. 
 
 *** There will be published in the same series, at short intervals, carefully-prepared works 
 on various subjects by prominent specialists. 
 
 Pamphlet containing specimen pages, etc. sent free upon application.
 
 24 Medical Publications of W. B. Saunders. 
 
 SAUNDBY'S RENAL AND URINARY DISEASES. 
 
 Lectures on Renal and Urinary Diseases. By Robert Sauxdby, 
 M.D. Edin., Fellow of the Royal College of Physicians, London, and 
 of the Royal Medico-Chirurgical Society ; Physician to the General 
 Hospital ; Consulting Physician to the Eye Hospital and to the Hos- 
 pital for Diseases of Women; Professor of Medicine in Mason College, 
 Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
 trations and 4 colored plates. Cloth, $--5° "^t. 
 
 " The volume makes a favorable impression at once. The style is clear and succinct. 
 We cannot find any part of the subject in which the views expressed are not carefully thought 
 out and fortified by evidence drawn from the most recent sources. The book may be cordially 
 recommended.'" — British Medical Journal. 
 
 SAUNDERS' POCKET MEDICAL FORMULARY. Fourth Edition, 
 Revised. 
 
 By William ^L Powell, ]\LD., Attending Physician to the Mercer 
 House for Invalid Women at Atlantic City, N. J. Containing 1750 
 formulae selected from the best-known authorities. With an Appen- 
 dix containing Posological Table, Formulae and Doses for Hypo- 
 dermic Medication. Poisons and their Antidotes, Diameters of the 
 Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
 Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
 of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
 Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
 somely bound in flexible morocco, with side index, wallet, and flap. 
 $1.75 net. 
 
 "This little book, that can be conveniently carried in the pocket, contains an immense 
 amount of material. It is very u.seful, and, as the name of the author of each prescription 
 is given, is unusually reliable." — Medical Record, New York. 
 
 SAUNDERS' POCKET MEDICAL LEXICON. Fourth Edition, 
 Revised. 
 A Dictionary of Terms and Words used in Medicine and 
 Surgery. By John M. Keating, JNLD., Fellow of the College of 
 Physicians of Philadelphia; Editor of the *' Cyclopaedia of Diseases 
 of Children," etc.; Author of the "New Pronouncing Dictionary of 
 Medicine;" and Henry Hamilton, Author of "A New Translation 
 of Virgil's ^neid into English Verse;" Co- Author of the "New 
 Pronouncing Dictionary of Medicine." 32mo, 280 pages. Cloth, 
 75 cents; Leather Tucks, 31.00. 
 
 " Remarkably accurate in terminolog)", accentuation, and definition." — Journal of the 
 American Medical Association . 
 
 SAYRE'S PHARMACY. Second Edition, Revised. 
 
 Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
 M.D., Professor of Pharmacy and Materia Medica in the University of 
 Kansas. Crown octavo, 200 pages. Cloth, 31.00; interleaved for 
 notes, $1.25. 
 
 [See Saunders' Question- Compends^ pa^ge 21.] 
 
 " The topics are treated in a simple, practical manner, and the work forms a very useful 
 student's manual." — Boston Medical and Surgical Journal.
 
 Medical Publications of W. B. Saunders. 25 
 
 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
 
 Essentials of Legal Medicine, Toxicology, and Hygiene. By 
 
 C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
 Physician to the Northeastern Hospital for Children, Hackney, etc. 
 Crown octavo, 2 1 2 pages ; 130 illustrations. Cloth, $1.00; interleaved 
 for notes, $1.25. 
 
 [See Saunders^ Question- Compe?ids, page 21.] 
 
 " No general practitioner or student can afford to be without this valuable work. The 
 subjects are dealt with by a masterly hand." — London Hospital Gazette. 
 
 SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 
 
 Essentials of Pathology and Morbid Anatomy. By C. E. 
 
 Armand Semple, B.A. , M.B. Cantab., M.R. C.P. Lond., Physician to 
 the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 
 174 pages; illustrated. Cloth, $1.00; interleaved for notes, $1.25. 
 [See Saundets' Question- Compends, page 21.] 
 
 " Should take its place among the standard volumes on the bookshelf of both student 
 and practitioner." — London Hospital Gazette. 
 
 SENN'S GENITO=URINARY TUBERCULOSIS. 
 
 Tuberculosis of the Genito=Urinary Organs, Male and Female. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
 Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
 Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. 
 
 " An important book upon an important subject, and written by a man of mature judg- 
 ment and wide experience. The author has given us an instructive book upon one of the 
 most important subjects of the day." — Clinical Repoi'ter. 
 
 " A work which adds another to the many obligations the profession owes the talented 
 author." — Chicago Medical Recorder. 
 
 SENN'S SYLLABUS OF SURGERY. 
 
 A Syllabus of Lectures on the Practice of Surgery, arranged 
 in conformity with " An American Text=Book of Surgery." By 
 
 Nicholas Senn, M.D., Ph.D., Professor of the Practice of Surgery and 
 of Clinical Surgery in Rush Medical College, Chicago. Cloth, $2.00. 
 
 " This syllabus will be found of service by the teacher as well as the student, the work 
 being superbly done. There is no praise too high for it. No surgeon should be without 
 it. " — Nezv York Medical Times. 
 
 SENN'S TUMORS. 
 
 Pathology and Surgical Treatment of Tumors. By N. Senn, 
 
 M.D., Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
 Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
 Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
 Joseph's Hospital, Chicago. Octavo volume of 710 pages, with 515 
 engravings, including full-page colored plates. Cloth, $6.00 net; 
 Half Morocco, $7.00 net. 
 
 " The most exhaustive of any recent book in English on this subject. It is well illus- 
 trated, and will doubtless remain as the principal monograph on the subject in our language 
 for some years. The book isliandsomely illustrated and printed, and the author has given a 
 notable and lasting contribution to surgery." — Journal of the American Medical Association.
 
 26 Medical Publications of W. B. Saunders. 
 
 SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
 
 Revised. 
 Essentials of Nervous Diseases and Insanity. By John C. 
 Shaw, M.D., Clinical Professor of Diseases of the Mind and Nervous 
 System, Long Island College Hospital Medical School ; Consulting 
 Neurologist to St. Catherine's Hospital and to the Long Island College 
 Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, 
 31.00; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "Clearly and intelligently written."' — Boston Medical and Surgical Journal. 
 " There is a mass of valuable material crowded into this small compass." — American 
 Medico- Surgical Bulletin. 
 
 STARR'S DIETS FOR INFANTS AND CHILDREN. 
 
 Diets for Infants and Children in Health and in Disease. By 
 
 Louis Starr, M.D., Editor of "An American Text-Book of the 
 Diseases of Children." 230 blanks (pocket-book size), perforated 
 and neatly bound in flexible morocco. 31.25 net. 
 
 The first series of blanks are prepared for the first seven months of infant life ; each 
 blank indicates the ingredients, but not the quantities, of the food, the latter directions being 
 left for the physician. After the seventh month, modifications being less necessarj', the diet 
 lists are printed in full. Kormulse for the preparation of diluents and foods are appended. 
 
 STELWAGON'S DISEASES of THE SKIN. Third Edition, Revised. 
 Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
 M.D., Clinical Professor of Dermatology in the Jefferson Medical 
 College, Philadelphia; Dermatologist to the Philadelphia Hospital; 
 Physician to the Skin Department of the Howard Hospital, etc. 
 Crown octavo, 270 pages; 86 illustrations. Cloth, 31.00 net; inter- 
 leaved for notes, 31.25 net. 
 
 [See Saunders' Question-Compends, page 21.] 
 " The best students manual on skin diseases we have yet seen." — Times and Register. 
 
 STENGEL'S PATHOLOGY. 
 
 A Manual of Pathology. By Alfred Stengel, M.D., Physician 
 
 to the Philadelphia Hospital ; Professor of Clinical Medicine in the 
 Woman's Medical College ; Physician to the Children's Hospital ; 
 late Pathologist to the German Hospital, Philadelphia, etc. In 
 Preparation. 
 
 STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
 Edition, Revised. 
 A Manual of Materia Medica and Therapeutics. By A. A. 
 
 Stevens, A.M., M.D., Lecturer on Terminology and Instructor in 
 Physical Diagnosis in the University of Pennsylvania; Demonstrator 
 of Pathology in the Woman's Medical College of Philadelphia. Post- 
 octavo, 445 pages. Cloth, 32- 25. 
 
 '* The author has faithfully presented modem therapeutics in a comprehensive work, 
 and, while intended particularly for the use of students, it will be found a reliable guide and 
 sufficiently comprehensive for the physician in practice." — University Aledical ^Magazine.
 
 Medical Publications of W. B. Saunders. 27 
 
 STEVENS' PRACTICE OF MEDICINE. Fourth Edition, Revised. 
 A Manual of the Practice of Medicine. By A. A. Stevens, A.M., 
 M.D., Lecturer on Terminology and Instructor in Pliysical Diagnosis 
 in the University of Pennsylvania ; Demonstrator of Pathology in 
 the Woman's Medical College of Philadelphia. Specially intended 
 for students preparing for graduation and hospital examinations. Post- 
 octavo, 511 pages; illustrated. Flexible leather, $2.50. 
 
 "The frequency with which new editions of this manual are demanded bespeaks its 
 popularity. It is an excellent condensation of the essentials of medical practice for the 
 student, and may be found also an excellent reminder for the busy physician." — Buffalo 
 Medicai Journal. 
 
 STEWART'S PHYSIOLOGY. 
 
 A Manual of Physiology, with Practical Exercises. For 
 Students and Practitioners. By G. N. Stewart, M.A., M.D., 
 D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
 of the New Museums, Cambridge University ; Professor of Physiology 
 in the Western Reserve University, Cleveland, Ohio. Octavo volume 
 of 800 pages; 278 illustrations in the text, and 5 colored plates. 
 Cloth, ^3.50 net. 
 
 " It will make its way by sheer force of merit, and amply deserves to do so. It is one 
 of the very best English text-books on the subject." — London Lancet. 
 
 "Of the many text-books of physiology published, we do not know of one that so 
 nearly comes up to the ideal as does Prof. Stewart's volume." — British Aledical Journal. 
 
 STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 
 
 Essentials of Medical Electricity. By D. D. Stewart, M.D., 
 Demonstrator of Diseases of the Nervous System and Chief of the 
 Neurological Clinic in the Jefferson Medical College; and E. S. 
 Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
 strator of Diseases of the Nervous System in the Jefferson Medical 
 College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
 ^i.oo ; interleaved for notes, ^1.25. 
 
 [See Saunders^ Question- Compends, page 21.] 
 
 " Throughout the whole brief space at their command the authors show a discriminating 
 knowledge of their subject." — Aledical Neros. 
 
 STONEY'S NURSING. Second Edition, Revised. 
 
 Practical Points in Nursing. For Nurses in Private Practice. 
 
 By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
 Lawrence, Mass.; late Superintendent of the Training-School for 
 Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
 with 73 engravings in the text, and 8 colored and half-tone plates. 
 Cloth, ^1.75 net. 
 
 " There are few books intended for non-professional readers which can be so cordially 
 endorsed by a medical journal as can this one." — Therapeutic Gazette. 
 
 " This is a well-written, eminently practical volume, which covers the entire range of 
 private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
 meet the various emergencies which may arise, and how to prepare everything ordinarily 
 needed in the illness of her patient." — America}t Journal of Obstetrics and Diseases of 
 Women and Children. 
 
 " It is a work that the physician can place in the hands of his private nurses with the 
 assurance of benefit." — Ohio Medical Journal.
 
 28 Medical Publications of W. B. Saunders, 
 
 SUTTON AND GILES' DISEASES OF WOMEN. 
 
 Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
 Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, 
 London; and Arthur E. Giles, M.D., B.Sc. Lond. , F.R.C.S. Edin., 
 Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
 somely illustrated. Cloth, 32.50 net. 
 
 ' ' The book is very well prepared, and is certain to be well received by the medical 
 public. " — British Medical Jonrtial. 
 
 "The text has been carefully prepared. Nothing essential has been omitted, and its 
 teachings are those recommended by the leading authorities of the day." — Journal 0/ the 
 American Medical Association. 
 
 THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 
 
 Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
 M.D., Visiting Physician to the Home for Friendless Women and 
 Children and to the Newsboys' Home ; Assistant Visiting Physician 
 to the Kings County Hospital. Cloth, $1.50. Send for sample sheet. 
 
 " The idea is good, and the lists are copious." — London Lancet. 
 
 "Its practical usefulness places it among the requirements of every practitioner." — 
 Chicago Medical Recorder. 
 
 THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITING. 
 
 Dose=Book and Manual of Prescription=Writing. By E. Q. 
 
 Thorxtox, M.D., Demonstrator of Therapeutics, Jefferson Medical 
 College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 
 
 "Full of practical suggestions; will take its place in the front rank of works of this 
 sort." — Medical Record, New York. 
 
 VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
 Diseases of the Stomach. By Willia.m W. Van Valzah, M.D. , 
 Professor of General Medicine and Diseases of the Digestive System 
 and the Blood, New Vork Polyclinic; and J. Douclas Nisbet, M.D., 
 Adjunct Professor of General Medicine and Diseases of the Digestive 
 System and the Blood, New Vork Polyclinic. Octavo volume of 670 
 pages. Cloth, 53. 50 net. 
 
 VIERORDT'S MEDICAL DIAGNOSIS. Third Edition, Revised. 
 Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
 cine at the University of Heidelberg. Translated, with additions, 
 from the second enlarged German edition, with the author's permission, 
 by Francis H. Stuart, A.M., M.D. Handsome royal octavo volume 
 of 700 pages; 178 fine wood-cuts in text, many of them in colors. 
 Cloth, S4.00 net; Sheep or Half Morocco, S500 net; Half Russia, 
 $5.50 net. 
 
 " A treasury of practical information which will be found of daily use to every busy 
 practitioner who will consult it." — C. A. LiNDSLEY, M.D., Professor of the Theory and 
 Practice of Aledicine, Yale University. 
 
 " Rarely is a book published with which a reviewer can find so little fault as with the 
 volume before us. Each particular item in the consideration of an organ or apparatus, which 
 is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
 seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
 nervous system- are especially full and valuable. The reviewer would repeat that the book is 
 one of the best — probably the best — which has fallen into his hands." — University Medical 
 Alagazine.
 
 Medical Publications of W. B. Saunders. 29 
 
 WARREN'S SURGICAL PATHOLOGY AND THERAPEUTICS. 
 
 Surgical Pathology and Therapeutics. By John Collins Warren, 
 M.D., LL.D., Professor of Surgery, Medical Department Harvard 
 University; Surgeon to the Massachusetts (reneral Hospital, etc. 
 Handsome octavo vokime of 832 pages; 136 relief and lithographic 
 illustrations, 33 of which are printed in colors, and all of which were 
 drawn by William J. Kaula from original specimens. Cloth, $6.00 
 net; Half Morocco, $7.00 net. 
 
 "There is the work of Dr. Warren, which I think is the most' creditable book on 
 Surgical Pathology, and the most beautiful medical illustration of the bookmaker's art, that 
 has ever been issued from the American press." — Dr. Roswell Park, in the Harvard 
 Graduate Magazine. 
 
 " The handsomest specimen of bookmaking that has ever been issued from the American 
 medical press." — A))ierican Journal of the Medical Sciences. 
 
 " A most striking and very excellent feature of this book is its illustrations. Without 
 exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
 of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
 and detail as almost to give the beholder the impression that he is looking down the barrel 
 of a microscope at a well-mounted section." — Annals of Surgery. 
 
 WEST'S NURSING. 
 
 An American Text=Book of Nursing. By American Teachers. 
 Edited by Roberta M. West, late Superintendent of Nurses in the 
 Hospital of the University of Pennsylvania. In Preparation. 
 
 WOLFF ON EXAMINATION OF URINE. 
 
 Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
 Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, 
 etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
 octavo. Cloth, 75 cents. 
 
 [See Saunders' Question- Compends, page 21.] 
 " A very good work of its kind — very well suited to its purpose." — Times and Register. 
 
 WOLFF'S MEDICAL CHEMISTRY. Fourth Edition, Revised. 
 
 Essentials of Medical Chemistry, Organic and Inorganic. 
 
 Containing also Questions on Medical Physics, Chemical Physiology, 
 Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
 Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
 Philadelphia, etc. Crown octavo, 218 pages. Cloth, ^i.oo; inter- 
 leaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "The scope of this work is certainly equal to that of the best course of lectures on 
 Medical Chemistiy. " — Pharmaceutical Era.
 
 CLASSIFIED LIST 
 
 Medical Publications 
 
 W. B. SAUNDERS, 
 
 925 Walnut Street, Philadelphia. 
 
 ANATOMY, EMBRYOLOGY, 
 HISTOLOGY. 
 
 Clarkson — A Text-Book of Histology, 9 
 Haynes — A Manual of Anatomy, . . . 13 
 Heisler — A Texi-Book of Embryology, 13 
 Nancrede — Essentials of Anatomy, . . 18 
 Nancrede — Essentials of Anatomy and 
 
 Manual of Practical Dissection, . . . iS 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 BACTERIOLOGY. 
 
 Ball — Essentials of Bacteriology, ... 6 
 Crookshank — .A Text-Book of Bacteri- 
 ology, 10 
 
 Frothingham — Laboratory Guide, . . il 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 McFarland — Pathogenic Bacteria, . . 17 
 
 CHARTS, DIET-LISTS, ETC. 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Hart — Diet in Sickness and in Health, . 13 
 
 Keen — Operation Blank, 15 
 
 Laine — Temperature Chart, .... 15 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Starr — Diets for Infants and Children, . 26 
 Thomas — Diet-Lists and Sick-Room 
 
 Dietary, 2S 
 
 CHEMISTRY AND PHYSICS. 
 
 Brockway — Essentials of Medical Phys- 
 ics, 7 
 
 Wolff — Essentials of Medical Chemistry, 29 
 
 CHILDREN. 
 
 An American Text-Book of Diseases 
 
 of Children, . . 3 
 
 Griffith — Care of the Baby 12 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Powell — Essentials of Dis. of Children, I9 
 
 Starr — Diets for Infants and Children, . 26 
 
 DIAGNOSIS. 
 
 Cohen and Eshner — Essentials of Di- 
 agnosis, 9 
 
 Corwin — Physical Diagnosis, .... 9 
 
 Macdonald — Surgical Diagnosis and 
 Treatment, 16 
 
 Vierordt — Medical Diagnosis, .... 28 
 
 DICTIONARIES. 
 
 Keating — Pronouncing Dictionary, . . I4 
 
 Morten — Nurse's Dictionary, . . . . 18 
 
 Saunders' Pocket Medical Lexicon, . 24 
 
 EYE, EAR, NOSE, AND THROAT. 
 
 An American Text- Book of Diseases 
 
 ' of the Eye, Ear, Xose, and Throat, . 3 
 Casselberry — Dis. of Nose and Throat, 8 
 De Schweinitz — Diseases of the Eye. . lO 
 Gleason — Essentials of Dis. of the Ear, il 
 Jackson and Gleason — Essentials of 
 
 Diseases of the Eye, Nose, and Throat, 14 
 Kyle — Diseases of the Nose and Throat, 15 
 
 GENITO=URINARY. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 4 
 
 Hyde and Montgomery — Syphilis and 
 the N'enereal Diseases, I3 
 
 Martin — Essentials of Minor Surgery. 
 Bandaging, and Venereal Diseases, . 16 
 
 Saundby — Renal and Urinary Diseases, 24 
 
 Senn — Genito- Urinary. Tuberculosis, . 25 
 
 GYNECOLOGY. 
 
 American Text- Book of Gynecolog}', 4 
 Cragin — Essentials of Gynecology, . . 10 
 Garrigues — Diseases of Women, ... 11 
 Long — Syllabus of Gynecology, ... 15 
 Penrose — Diseases of Women, .... 18 
 Sutton and Giles — Diseases of Women, 28 
 
 MATERIA MEDICA, PHARMACOL- 
 OGY, AND THERAPEUTICS. 
 
 An American Text-Book of Applied 
 
 Therapeutics 3 
 
 Butler — Text-Book of Materia Medica, 
 
 Therai^eutics and Pharmacology, ... 8 
 
 Cerna — Notes on the Newer Remedies, 8 
 
 Griffin — Materia Med. and Therapeutics, 12 
 
 Morris — Essentials of Materia Medica 
 
 and riierapeutics, . . . . . . 17 
 
 Saunders* Pocket Medical Formulary, 24 
 Sayre — Essentials of Pharmacy, . . 24 
 Stevens — Essentials of Materia Medica 
 
 and Tiierapeutics, 26 
 
 Thornton — Dose-Book and Manual of 
 
 Prescription-Writing, 28 
 
 Warren — Surgical Pathology and Ther- 
 apeutics, 29 
 
 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
 An American Text-Book of Legal 
 Medicine and Toxicology, 4 
 
 Chapman — Medical Jurisprudence and 
 Toxicology, 8 
 
 Semple — Essentials of Legal Medicine, 
 Toxicology, and Hygiene, 25
 
 Medical Publications of W. B. Saunders. 
 
 31 
 
 NERVOUS AND MENTAL 
 DISEASES, ETC. 
 
 Burr — Nervous Diseases, 7 
 
 Chapin — Compendium of Insanity, . . 8 
 Church and Peterson — Nervous and 
 
 Mental Diseases, 9 
 
 Shaw — Essentials of Nervous Diseases 
 
 and Insanity, 26 
 
 NURSING. 
 
 An American Text-Book of Nursing, 29 
 
 Griffith— The Care of the Baby, ... 12 
 
 Hampton — Nursing, 12 
 
 Hart — Diet in Sickness and in Health, I3 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Morten — Nurse's Dictionary, .... 18 
 
 Stoney — Practical Points in Nursing, . 27 
 
 OBSTETRICS. 
 
 An American Text-Book of Obstetrics, 4 
 Ashton — Essentials of Obstetrics, . . 6 
 Boisliniere — Obstetric Accidents, Emer- 
 gencies, and Operations, 7 
 
 Borland — Manual of Obstetrics, , . . lo 
 
 Hirst — Text-Book of Obstetrics, ... 13 
 
 Norris — Syllabus of Obstetrics, .... 18 
 
 PATHOLOGY. 
 
 An American Text-Book of Pathology, 5 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Stengel — Manual of Pathology, ... 26 
 Warren — Surgical Pathology and Thera- 
 peutics, 29 
 
 PHYSIOLOGY. 
 
 An American Text-Book of Physi- 
 ology, 5 
 
 Hare — Essentials of Physiology, ... 13 
 Raymond — Manual of Physiology, . . I9 
 Stewart — Manual of Physiology, ... 27 
 
 PRACTICE OF MEDICINE. 
 
 An American Text-Book of the The- 
 ory and Practice of Medicine, .... 5 
 
 An American Year-Book of Medicine 
 and Surgery, 6 
 
 Anders — Text-Book of the Practice of 
 Medicine, 6 
 
 Lockwood — Manual of the Practice of 
 Medicine, 15 
 
 Morris — Essentials of the Practice of 
 Medicine, 17 
 
 Rowland and Hedley — Archives of 
 the Roentgen Ray, I9 
 
 Stevens — Manual of the Practice of 
 Medicine, 27 
 
 SKIN AND VENEREAL. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 3 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases, 13 
 
 Martin — Essentials of Minor Surgery, 
 Bandaging, and Venereal Diseases, . 16 
 
 Pringle — Pictorial Atlas of Skin Dis- 
 eases and Syphilitic Affections, ... 19 
 
 Stelwagon — Essentials of Diseases of 
 the Skin, 26 
 
 SURGERY. 
 
 An American Text-Book of Surgery, 5 
 An American Year-Book of Medicine 
 
 and Surgery, 6 
 
 Beck — Manual of Surgical Asepsis, . . 7 
 
 DaCosta — Manual of Surgery, .... 10 
 
 Keen — Operation Blank 15 
 
 Keen — The Surgical Complications and 
 
 Sequels of Typhoid Fever, 15 
 
 Macdonald — Surgical Diagnosis and 
 
 Treatment, 16 
 
 Martin — Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . 16 
 
 Martin — Essentials of Surgery, .... 16 
 
 Moore — Orthopedic Surgery, 17 
 
 Pye — Elementary Bandaging and Surgi- 
 cal Dressing, 19 
 
 Rowland and Hedley — Archives of 
 
 the Roentgen Ray, 19 
 
 Senn — Genito-Urinary Tuberculosis, . 25 
 
 Senn— Syllabus of Surgery, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 W^arren — Surgical Pathology and Ther- 
 apeutics, 29 
 
 URINE AND URINARY DISEASES. 
 
 Saundby — Renal and Urinary Diseases, 24 
 Wolff — Essentials of Examination of 
 Urine, 29 
 
 MISCELLANEOUS. 
 
 Bastin — Laboratory Exercises in Bot- 
 any, 7 
 
 Gould and Pyle — Anomalies and Curi- 
 osities of Medicine, 11 
 
 Gross — Autobiography of Samuel D. 
 Gross, 12 
 
 Keating — How to Examine for Life 
 Insurance, 14 
 
 Keen — Surgical Complications and Se- 
 quels of Typhoid Fever, 15 
 
 Rowland and Hedley — Archives of 
 the Roentgen Ray, 19 
 
 Saunders' New Series of Manuals, 22, 23 
 
 Saunders' Pocket Medical Formulary, . 24 
 
 Saunders' Question-Compends, . . 20, 21 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Stewart and Lawrance — Essentials of 
 Medical Electricity, 27 
 
 Thornton — Dose-Book and Manual of 
 Prescription-Writing, . 28 
 
 Van Valzah and Nisbet — Diseases of 
 the Stomach, 28
 
 In Preparation for Early Publication. 
 
 AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, 
 AND THROAT. 
 
 Edited by G. E. DE SCHWEINITZ, M.D. , Professor of Ophthalmology in the Jeffer- 
 son Medical College, Philadelphia; and B. Alexander Randall, M.D., Professor 
 of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia 
 Polyclinic. 
 
 AN AMERICAN TEXT-BOOK OF PATHOLOGY. 
 
 Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid 
 Anatomy in the University of Pennsylvania; and David Riesman, M.D. , Demon- 
 strator of Pathological Histology in the University of Pennsylvania. 
 
 PETERSON AND HAINES' LEGAL MEDICINE AND TOXICOLOGY. 
 
 An American Text=Book of Legal Medicine and Toxicology. Edited by 
 
 • Frederick Peterson, M.D., Clinical Professor of Mental Diseases in the Woman's 
 Medical College, New York ; Chief of Clinic, Nervous Department, College of 
 Physicians and Surgeons, New York ; and Walter S. Haines, M.D., Professor of 
 Chemistr}-, Pharmacy, and Toxicology in Rush Medical College, Chicago. 
 
 STENGEL'S PATHOLOGY. 
 
 A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Phila- 
 delphia Hospital ; Professor of Clinical Medicine in the Woman's Medical Col- 
 leg'e ; Physician to the Children's Hospital ; late Pathologist to the German Hospital, 
 Philadelphia, etc. 
 
 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
 
 Nervous and Mental Diseases. Dy Archibald Church, M.D. , Professor of 
 Mental Diseases and Medical Jurisprudence in the Northwestern University Medical 
 School, Chicago; and Frederick Peterson, M.D. , Clinical Professor of Mental 
 Diseases in the Woman's Medical College, New York ; Chief of Clinic, Nervous 
 Department, College of Physicians and Surgeons, New York. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Professor of 
 Anatomy in the Medico-Chirurgical College, Philadelphia. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Pro- 
 fessor of I.arvngolotry and Khinology, Jefterson Medical College, Philadelphia; Con- 
 sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist 
 to the Philade'phia Orthopedic Hospital and Inlirmary for Nervous Diseases, etc. 
 
 HIRST'S OBSTETRICS. 
 
 A Text-Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of 
 Obstetrics in the University of Pennsylvania. 
 
 WEST'S NURSING. 
 
 An American Text=Book of Nursing. By American Teachers. Edited by 
 Roberta M. West, Late Superintendent of Nurses in the Hospital of the University 
 of Pennsylvania.
 
 1 Date Due | 
 
 
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 Diseases of the stomach 
 
 IVIEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664
 
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