Part 77

Chief among remedial agents may be mentioned the alkaline carbonates. When combined with purgative salines they are specially valuable in gastro-duodenal catarrhs associated with disease of the liver. These are a very numerous class of cases, especially in malarious regions of country, and when present in a chronic form lay the foundation of widespread disorders of nutrition. No treatment in such cases is effective until we diminish engorgements of the liver and spleen, and nothing accomplishes this so well as the use of alkaline saline laxatives. These may be assisted in their action by small doses of mercurials. It was a cardinal principle among the older practitioners, in the absence of more minute means of diagnosis, to look well to the secretions; and what was their strength is, I fear, our weakness.

Wonderful results often follow a course of the Carlsbad, Pullna, or Marienbad waters, taken on an empty stomach, fasting, in the morning. While taking the waters a rigid and restricted diet is enforced. This is an important part of the treatment. And the fact that so many varied ailments are cured by a course of these mineral waters with enforced dietetic regulations only shows the prevalence of gastro-duodenal catarrhs and their relation to a great variety of human ailments. To a certain extent the potassio-tartrate of sodium and other saline laxatives may take the place of these waters if perseveringly used and taken in the same way. In feebler subjects minute doses of strychnia or some of the simple vegetable bitters may be used in conjunction with the laxative salines.

In chronic inflammatory conditions of the gastric mucous membrane, which frequently follow acute attacks, the protracted use of hot water is often followed by excellent results. There can be no doubt of the value {478} of hot water in subacute inflammation of mucous membranes in any locality; and it is specially valuable in gastro-intestinal catarrh associated with lithæmia. Hot water, laxative salines, combined with restricted diet and healthful regimen, accomplish much in correcting morbid conditions of primary assimilation; and by accomplishing this many secondary ailments promptly disappear. A pint of water, hot as the patient can drink it, should be taken on an empty stomach on first rising in the morning, and it may be repeated again an hour before each meal and at bedtime. A few grains of the bicarbonate of sodium and a little table-salt may be added. In some cases three or four drops of tincture of nux vomica or some of the simple bitters may be taken at the same time with benefit. Alkaline bitters are natural to the upper portion of the digestive track. No food should be taken for a half hour or an hour after the hot water. This treatment, to be effective, must be persevered in for a length of time. A most rigid system of dietetics suited to individual cases should be enforced at the same time. This is an important part of the treatment.

In irritable and morbidly sensitive conditions of the mucous membrane the sedative plan of treatment is not unfrequently followed by good results; and of remedies belonging to this class bismuth is the most effective. It is specially indicated in the more irritable forms of gastric disturbance in which there is a sense of uneasiness and pain at the epigastrium after taking food. If there is much acidity present, it may be combined with magnesia or a few grains of finely-pulverized animal charcoal.

Chronic cases of long-continued inflammatory action, with intestinal complication, are often much benefited by the use of mercurials in small doses. The one-fifth of a grain of calomel, combined with bismuth or the bicarbonate of sodium, may be given for weeks without danger of salivation. Excellent results sometimes follow this treatment. In small doses calomel is undoubtedly sedative to the mucous membrane of the upper portion of the digestive track. In cases of long standing that have resisted other modes of treatment the more direct astringents have been found of great value. Of these, nitrate of silver is to be preferred, alike for its sedative, astringent, and alterative properties. It may be given in pill form in from one-quarter to one-grain doses, combined with opium, a half hour before each meal. The writer of this article can speak from much experience of the value of this drug. It proves in many cases a valuable addition to the hot-water and dietetic course already alluded to.

If large quantities of mucus are vomited from time to time, especially in the morning, we may resort with benefit to the use of other astringents, such as bismuth, oxalate of cerium, kino, and opium; and if we have reason to suspect stricture of the pylorus in connection with a catarrhal condition of the mucous membrane, the stomach-pump gives the patient great relief. It should be used about three hours after a meal, injecting tepid water, and then reversing the syringe until the water comes out perfectly clear. Niemeyer speaks highly of it in such cases. He says: "Even the first application of the pump generally gives the patients such relief that, so far from dreading a repetition of this by no means pleasant operation, they clamorously beg for it."

The gastric catarrh of phthisis is difficult to relieve. Artificial digestives may be tried, with dilute muriatic acid, as already indicated; and {479} for the relief of pain and irritation there is no remedy so efficacious as hydrocyanic acid, which may be combined with bismuth and opium in case there is diarrhoea. Hot water may be also tried, with restricted animal food.

Habitual constipation must be overcome by suitable laxatives and by enemata. Castor oil is mild and efficient in these cases, or in cases of unusual torpor of the muscular coat of the bowels small doses of aloes and strychnia may be tried. The free use of diluents toward the close of digestion favors free action of the bowels. All harsh and irritating cathartics are to be carefully avoided.

When there is much tenderness of the epigastrium, benefit may be derived from counter-irritation, and nothing is so effectual as the repeated application of small blisters.

General hygienic measures are in all cases to be insisted upon. In morbid conditions of the liver and the upper portion of the digestive track the free supply of oxygen to the lungs is a remedy of much power. Hence patients should live as much as possible in the open air. They should be warmly clad, and, if not too feeble, frequent cold baths should be resorted to.

After local irritation has been subdued by appropriate treatment, tonics may be tried to counteract the enfeebled state of the stomach. They are such as are appropriate for functional diseases of the stomach. But they should be used with caution and judgment in irritable and inflammatory forms of dyspepsia. If we attempt to force an appetite by their use, and to crowd upon the stomach more food than it has capacity to digest, we may intensify the trouble and thereby add to the patient's general debility. Food and tonics fail to impart strength because the stomach is not in a condition to digest them.

One thing should be mentioned, in conclusion, as an important item in the treatment--namely, patience. Chronic gastric catarrh, it should be remembered, is essentially a chronic disease, and time becomes an important element in its cure.

{480}

SIMPLE ULCER OF THE STOMACH.

BY W. H. WELCH, M.D.

DEFINITION.--Simple ulcer of the stomach is usually round or oval. When of recent formation it has smooth, clean-cut, or rounded borders, without evidence of acute inflammation in its floor or in its borders. When of long duration it usually has thickened and indurated margins. The formation of the ulcer is usually attributed, in part at least, to a disturbance in nutrition and to a subsequent solution by the gastric juice of a circumscribed part of the wall of the stomach. The ulcer may be latent in its course, but it is generally characterized by one or more of the following symptoms: pain, vomiting, dyspepsia, hemorrhage from the stomach, and loss of flesh and strength. It ends frequently in recovery, but it may end in death by perforation of the stomach, by hemorrhage, or by gradual exhaustion.

SYNONYMS.--The following epithets have been employed to designate this form of ulcer: simple, chronic, round, perforating, corrosive, digestive, peptic; ulcus ventriculi simplex, s. chronicum, s. rotundum, s. perforans, s. corrosivum, s. ex digestione, s. pepticum.

HISTORY.--It is only since the description of gastric ulcer by Cruveilhier in the year 1830 that especial attention has been paid to this disease.

In the writings of the ancients only vague and doubtful references to ulcer of the stomach are found (Galen, Celsus). It is probable that cases of this disease were described under such names as passio cardiaca, gastrodynia, hæmatemesis, and melæna.

After the revival of medicine in the sixteenth century, as post-mortem examination of human bodies was made with greater frequency, the existence of ulcers and of cicatrices in the stomach could not escape attention. But only isolated and curious observations of gastric ulcer are recorded up to near the end of the eighteenth century. One of the earliest recorded unmistakable cases of perforating ulcer was observed by John Bauhin, and is described in the Sepulchretum of Bonetus, published in 1679. Other cases belonging to this period were described by Donatus, Courtial, Littré, Schenck, and Margagni.

To Matthew Baillie unquestionably belongs the credit of having first accurately described, in 1793, the anatomical peculiarities of simple gastric ulcer. At a later date he published three good engravings of {481} this disease. Baillie's concise and admirable description of the morbid anatomy of gastric ulcer was unaccompanied by clinical data, and seems to have had little or no influence in directing increased attention to this disease.

A valuable account of the symptoms of gastric ulcer was given by John Abercrombie in 1824. Nearly all of the symptoms now recognized as belonging to this affection may be found in his article. He knew the latent causes of the disease, the great diversity of symptoms in different cases, and the modes of death by hemorrhage, by perforation, and by asthenia. He regarded ulcer simply as a localized chronic inflammation of the stomach, and did not distinguish carefully between simple and cancerous ulceration.

Cruveilhier, in the first volume of his great work on Pathological Anatomy, published between the years 1829 and 1835, for the first time clearly distinguished ulcer of the stomach from cancer of the stomach and from ordinary gastritis. He gave an authoritative and full description of gastric ulcer from the anatomical, the clinical, and the therapeutical points of view.

Next to Cruveilhier, Rokitansky has had the greatest influence upon the modern conception of gastric ulcer. In 1839 this pathologist gave a description of the disease based upon an analysis of 79 cases. The anatomical part of his description has served as the model for all subsequent writers upon this subject.

Since the ushering in by Cruveilhier and by Rokitansky of the modern era in the history of gastric ulcer, medical literature abounds in articles upon this disease. But it cannot be said that the importance of these works is at all commensurate with their number or that they have added very materially to the classical descriptions given by Cruveilhier and by Rokitansky. Perhaps most worthy of mention of the works of this later era are the article by Jaksch relating to symptomatology and diagnosis, that of Virchow pertaining to etiology, the statistical analyses by Brinton, and the contributions to the treatment of the disease by Ziemssen and by Leube. In 1860, Ludwig Müller published an extensive monograph upon gastric ulcer.

ETIOLOGY.--We have no means of determining accurately the average frequency of simple gastric ulcer. The method usually adopted is to observe the number of cases in which open ulcers and cicatrices are found {482} in the stomach in a large number of autopsies. But this method is open to two objections. The first objection is, that scars in the stomach, particularly if they are small, are liable to be overlooked or not to be noted in the record of the autopsy unless special attention is directed to their search. The second objection is, that it is not proven that all of the cicatrices found in the stomach are the scars of healed simple ulcers, and that, in fact, it is probable that many are not. In consequence of these defects (and others might be mentioned) this method is of very limited value, although it is perhaps the best which we have at our disposal.

In 32,052 autopsies made in Prague, Berlin, Dresden, Erlangen, and Kiel, there were found 1522 cases of open ulcer or of cicatrix in the stomach. If all the scars be reckoned as healed ulcers, according to these statistics gastric ulcer, either cicatrized or open, is found in about 5 per cent. of persons dying from all causes.

The Berlin statistics are to be found in dissertations by Plange (abstract in Virchow's Archiv, vol. xviii.), by Steiner, and by Wollmann (abstracts in Virchow und Hirsch's Jahresbericht, 1868), and by Berthold (1883).