Read Ebook: The Cleveland Medical Gazette Vol. 1 No. 4 February 1886 by Various Baker A R Editor Kelley Samuel Walter Editor

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Editor: A. R. Baker S. W. Kelley

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Cleveland Medical Gazette

ORIGINAL LECTURES.

ULCER OF THE STOMACH.

A LECTURE BY PROF. L. OSER OF VIENNA, AUSTRIA.

Gentlemen! The disease which we intend to study to-day is one, the traces of which are found much oftener at post-mortems than the disease itself in the clinic. A great many cases are overlooked and improperly diagnosed for reasons which I shall state hereafter.

The first clause is sustained by the fact that the peptic ulcer is only found in those parts which are brought into direct contact with the gastric juice. It is further proven by the softening of the stomach so frequently found at post-mortem. But as long as the circulation of the blood in the walls of the stomach is normal, ulcers do not form. The formation of an ulcer in the stomach presupposes a local disturbance of the circulation. It is usual to find thrombi and diseases of the bloodvessels in cases where ulcers of the stomach occur. For this reason the latter is more common in anaemic persons where the circulation is retarded and the bloodvessels frequently subject to fatty degeneration.

Pavy claims that the alkalinity of the blood prevents the gastric juice from acting on the walls of the stomach. When he introduced acids into the stomach and allowed the circulation of the blood to continue, no ulcers resulted; if he impeded the circulation, the stomach was digested by its acid contents. Samelson instituted experiments to test the statement of Pavy. He introduced large quantities of various acids into the stomach of his animals without observing ulceration as a result; he also neutralized the blood by the injection of weakened acids into the bloodvessels, but no ulceration followed. But he did not impede the gastric circulation in his experiments, while Pavy did, hence the difference in their results. Clinical experience, however, favors Pavy's views. We can prevent the further progress of the gastric ulcer by the use of alkalies, while acids only favor its growth. These questions still need additional research before they are definitely solved.

Gastric ulcer may occur in any part of the digestive tract which is exposed to the action of the gastric juice; hence it is found in the lower part of the oesophagus, any part of the stomach and the upper part of the duodenum. It is found most frequently in the pyloric end of the stomach, because this part is most frequently subjected to mechanical irritation and to the action of the gastric juice.

The shape of the ulcer is usually conical or terraced, its diameter being largest in the mucous membrane and smallest at its base, in the deeper structures.

The gastric ulcer must be very common. In about five per cent of all cadavers we find ulcers in the stomach or else scars as traces of former ulceration. Ulcer of the stomach is frequently passed over without recognition, because most physicians do not decide upon this diagnosis, unless haematemesis occurs. Gastric hemorrhage, however, is not necessarily a concomitant feature of every gastric ulcer, and the hemorrhage may occur without vomiting, the blood being either digested and absorbed or passing on into the bowel and causing dark stools. Thus occasionally the only symptom of hemorrhage of the stomach is the appearance of darker stools, a symptom of doubtful value when taken alone, but of some importance when in connection with others.

A few years ago an elderly lady was admitted into the hospital on account of severe pain in the stomach and the appearance of dark stools. While in the hospital vomiting of blood set in, continuing three days, and then the patient died. At the post-mortem we found that an ulcer of the stomach had burrowed through the diaphragm and pericardium into the wall of the left ventricle, perforating finally with a small opening into the left ventricle. I can only explain the length of the time between perforation and death by assuming that part of the gastric fistula leading through the walls of the heart was firmly closed during systole, and only allowed a small quantity of blood to ooze through during each diastole.

During these repeated attacks I found that the painful sensation was really divisible into three distinct periods, that of constant increase, during which the ulcer is developing and extending, that of remaining at one height, and that of gradual decrease during the period of healing. I could distinctly tell from these various changes how my ulcer was getting along.

A few days ago I saw an interesting case, where an acute gastritis culminated in the vomiting of a large quantity of pus. The patient had been having high fever for a few days, with incessant vomiting and great tenderness in the epigastrium. Evidently an abscess had formed in the neighborhood of the stomach, and finally opened into this organ, with the given result.

Vomiting of blood alone need not necessarily be caused by a gastric ulcer. There are a great many other conditions which may cause it. It should, however, put you on the guard, and can, in a great many cases, justify a diagnosis of probable ulcer of the stomach.

The localized pain occurs, according to my experience, only in cases of ulceration of the stomach; that is, in gastric or peptic ulcer and in cancer of this organ. In order to differentiate between these conditions, it becomes necessary to observe whether the patient is cachectic or emaciated or not, and whether a tumor can be felt in the region of the stomach. But even these symptoms can be deceptive, as an abnormal hardness or resistance--the result of perigastritic infiltration--may occur in cases of simple ulcer, making the diagnosis almost impossible. This is true especially in cases of ulcer of the pyloric regions, while ulcers of the anterior wall of the stomach are rarely accompanied by such infiltrations.

The pylorus is the most sensitive part of the stomach, and frequently the seat of pain, when no lesion can be detected post-mortem. The other parts of the stomach only become painful when attacked by ulcerative or other pathological processes. Another point worthy of consideration is that all forms of pain in the stomach are usually referred to the pyloric region by the patient, even if they originate in other parts.

From all this you can see that no positive diagnosis can be made where any one of these symptoms is presented unaccompanied by the others. A careful consideration of the symptoms present will frequently, however, be of aid in making a diagnosis. Intelligent patients will tell you that they have a feeling of oppression, a feeling of distress in dyspepsia, but will describe their feeling as that of distinct pain in ulcer. Pure neuralgic pain is not always localized, but radiates into distant parts, is not constant, but sets in all at once and disappears with equal celerity, sometimes intermitting for days and weeks, and then again setting in on the slightest nervous excitement. Such pain is not aggravated by local pressure, shows no relation to the digestive functions, does not depend upon the quality or quantity of food taken, and may as well occur during a fast as during a feast. Often such patients will tell you that their pain does not cease until they have taken a hearty meal.

Another class of cases only presents gastralgic pain without any other symptom. Such are frequently patients who have had gastric ulcer before. Others will come to you with intercostal neuralgia on the left side. They have, perhaps, tried all the usual anti-neuralgic remedies, have gone through a course of treatment by electricity, and spent a large amount of time and money, without obtaining permanent relief, until some physician puts them on a strict milk diet and cures them in this way in a short time.

Some cases of ulcer of the stomach present the queerest symptoms. For instance: they complain of pain after drinking milk, or even after taking a morphine powder, while they can eat the coarsest food without any harm. Others run along without presenting any symptoms at all, until they, as well as their physicians, are surprised by the perforation of a gastric ulcer.

All these abnormal cases, which form about one-fifth of all the cases occurring, are so indistinct that they frequently remain unrecognized throughout their entire course, and baffle the skill of the best diagnosticians.

In order to be able to make a sure diagnosis, there must be a localized pain, together with tenderness on pressure from without on the painful spot. A great many persons in good health are tender in the epigastrium, so that you have to be on your guard in this direction, too. From the occurrence of haematemesis in an otherwise healthy person you can, with great probability, diagnose ulcer of the stomach.

You will frequently be astonished by the success of your treatment if you think of ulcer in doubtful cases of stomach trouble, such as occurs in young girls with chlorosis and institute a strict milk diet with the measures adopted for the cure of ulcer.

Ulcers of the anterior wall of the stomach are more dangerous than such as occur on the posterior wall, for the reason that in the latter case adhesion with the neighboring structures are more easily formed, and thus fatal perforation prevented. The anterior wall takes a much more active part in the peristaltic movement of the stomach, and as a result does not enter so easily into adhesion with its surroundings. Even after an ulcer has healed it always remains a weak point, and cases of rupture of the stomach in old cicatrices are described by Chiari.

Theoretically considered, that form of treatment would seem the best which gives the stomach absolute rest, entire abstinence from food, a fast of several weeks. But this can not be carried out in practice. The patient could be nourished per rectum, you might say, by means of nutrient enemata. In my opinion this method of nourishment does not amount to much. I believe that very little water is absorbed by the rectum, the patient would suffer from thirst and you would then be compelled to allow him to drink water at least.

Luckily we do not need to resort to such extreme measures in the majority of cases. With the exclusive use of the proper bland, liquid food, we usually attain the same results. In the treatment of gastric ulcer I lay the main stress on the restriction and regulation of the diet, and put the patient on an exclusive milk diet. Milk contains all the constituents necessary for the nourishment of the human body.

I begin by giving every half hour to one hour a small quantity of skimmed, boiled milk, which has been cooled on ice. The patient must rest in bed or on a lounge, as he is weakened by the treatment, and can not follow his usual avocation. I forbid all other articles of food. With this diet a patient with ulcer should have no pain and usually has none. Should there be pain it is necessary to find out whether the feeling described as such be not simple oppression, or a feeling of weight in the stomach. Some patients do not seem to digest milk well. It ferments, forms gases and then they have this feeling of oppression. Some drink the milk too fast and take too much at a time, swallowing a lot of air with the milk, thus distending their stomachs unnecessarily. The patient must be instructed to drink the milk slowly, and only take a small quantity at a time . Some patients can not stand iced milk but bear luke warm milk much better. Others seem to prefer milk which has slightly soured.

The patients should adhere to this strict diet as long as possible, regulating the length of time according to the duration and intensity of the disease. They have to observe the above rules one or two weeks at least, several weeks if possible.

After the patient has been free from pain from eight to ten days, I then add to his diet soft boiled eggs with a slight addition of salt, beginning on the first day with one half of an egg. If this is well borne I gradually allow more day by day, until he is able to digest four or five a day without difficulty. Eggs do not agree with some patients. In such cases I pass on the use of meat. I have beefsteak chopped fine, roasted in little meat cakes of the size of a silver half dollar. One of these is given to begin with, and if well borne repeated every two or three hours as long as there is no pain. When eggs agree I prefer to give them for a few days before beginning with the meat, waiting until such patients can digest four or five eggs a day. After the meat has been borne well in small quantities for a while, I gradually increase the quantity taken per day until it reach a pound or two.

You cannot be too careful and should instruct the patient to return to the strict milk diet as soon as any pain is felt, no matter how nicely he may have been getting along up to the time. Not until the patient has been entirely free from pain for several weeks is it advisable to allow the use of cereals boiled in milk, such as rice or tapioca. Then he can also be allowed to take a quarter of a biscuit at each meal. A full meal, however, in the sense in which it is ordinarily understood, a large quantity of food taken at one time, is still to be avoided. It is better to give small quantities of food oftener, in order not to distend the stomach, and thus run the danger of too great a strain upon the newly healed ulcer.

These meat cakes made of beef can be taken for a week or so, and then if well borne other kinds of meat may be occasionally substituted.

Or I sometimes substitute atropia sulph. for the belladonna. At any rate the use of alkalies is the most plausible treatment. But the permanent alkalization of the contents of the stomach by the frequent use of large doses of alkalies, as has been recommended in Paris by Debove is not plausible, as by this the process of digestion would be checked entirely.

It is also good to give a dose of Carlsbad salts in the morning every two or three days, in order to correct the constipation usually attendant upon such a course of diet. These salts also aid in rendering the contents of the stomach more alkaline, and in this way aid the plan spoken of before.

There are unfortunately some patients who are not benefited by any method of treatment hitherto thought of, but luckily they are few, and if you will follow the rules I have laid down you will in a great many cases meet with splendid results.

One important question still remains to be answered, namely: "What should be done in case of hemorrhage of the stomach?" Here the patient must be left quiet just where he happens to be--placed in a horizontal position on his back if possible. Ice bags should be applied to the region of the stomach, small pieces of ice swallowed, and hypodermic injections of ergotin given. This is all that can be done with benefit in such cases. The patient should not be transported for several hours. Monsel's solution can be of no service, as it cannot be introduced into the stomach in a sufficient concentration to be of benefit.

In cases of perforation of an ulcer all that can be done is to give anodynes to ease the pain and make the patient's condition as comfortable as possible. Schlipp recommends that when perforation is threatened on account of gaseous distention of the stomach, the stomach tube should be used to evacuate the organ.

The mechanical treatment, washing out the stomach with the stomach tube or stomach pump is contraindicated in cases of ulcer, as more damage can be done by such procedure than good.

ORIGINAL ARTICLES

THE RECOGNITION OF MORTIFIED BOWEL IN OPERATIONS FOR THE RELIEF OF STRANGULATED HERNIA.

The medical practitioner who has been hastily summoned to operate upon a patient with strangulated hernia finds himself confronted with problems, the gravity of which can alone be appreciated by those who have frequently met them. The medical treatment to be adopted, the extent to which taxis should be employed, and the time it is prudent to delay operative interference when other measures have proved fruitless, are grave questions upon the solution of which the life of the patient depends. The operation decided upon, the particular method to be employed and the manner of dealing with the stricture--with or without opening the sac--are matters of minor consequence, and affairs that should be settled in the mind of every practitioner by a reference to sound surgical principles and the teachings of experience. There are questions connected with the condition of the parts strangulated that must be solved by the surgeon during the progress of the operation, about which much less is said in works on surgery than their importance warrants. These pertain to the vitality of the part that has been strangulated, and the duty of the surgeon in the premises. If the part is still living, it matters not how much damaged by compression, it should be returned at once into the abdomen; upon this step the patient's life depends. If the part is mortified and dead, to return it within the cavity of the belly is to insure the patient's destruction; if he is to have a chance for life, other measures must be adopted.

Again, the decision of the operator can but rarely be guided or aided by aught but the conditions revealed by his knife during the operation. The state of the patient and the history of the case may indicate the imminence of mortification of the bowel; in the end the appeal is to the senses of the surgeon, and upon the conclusion at which he then arrives will depend the fate of the patient.

Under these circumstances it behooves every man who may be placed in position to make such a momentous decision to at least go to the task, sustained by every aid that can be derived from the experience of those who themselves have been placed in this dilemma and compelled to act with such lights as they then possessed--whose records, next to personal experience, become the best guide for those forced to follow in their footsteps.

The history of the case may throw some light upon the state of the intestine. This is especially so in those cases in which the severity of the symptoms suddenly subsides without the rupture having been reduced. The pain is violent, the abdomen distended and singultus and stercoracious vomiting present; suddenly the patient's suffering cease, and were it not for the cold extremities, flickering pulse and persistent tumor--but above all, the teachings of experience--the surgeon could not but acknowledge that all tangible appearances portended a change for the better. Yet, almost invariably gangrene of the gut has taken place, and the fallacious evidences of improvement above noted are in reality its best clinical exponent. Certain almost as these signs are, when present, yet it comparatively seldom happens that the surgeon has their aid in guiding him in the measures he must adopt; they form, but infrequently, a part of the history of cases submitted to operation. If present, the surgeon is reasonably sure of what he will find when he operates; they may be absent and mortification yet exist. The patient's chance of life depends upon the surgeon's ability to recognize mortification of the bowel when he sees it, and his promptitude and skill in dealing with it when present.

It scarcely need be said that mere darkening in color of the bowel, effusion of fluid into the sac, or exudation of lymph about the stricture are of no special significance in this connection, and bear in no way upon the presence or absence of mortification. It has been again and again repeated in manuals treating of hernia operations that a deep, purplish discoloration of the bowel and absence of circulation indicate mortification; that when these physical signs are present the surgeon should press upon the strictured part, and if the color remains unchanged when the finger is removed, the bowel is dead. It requires but little practical experience in dealing with these cases to appreciate the fallacious character of these signs; the gut may be fairly black from congestion and yet alive; the color may remain unchanged under pressure and still that fact have no bearing on the question of mortification, for a band of stricture, as yet unappreciated, may be the sole cause of the persistent hyperaemia.

JABORANDI AS A GALACTAGOGUE.

JOHN H. LOWMAN, M. D.

Professor of Materia Medica in the Medical Department of the Western Reserve University.

There is a decided difference of opinion among therapeutics as to the effect of jaborandi on the mammary gland. Some claim that it has no effect upon the gland. Some claim that it assists in increasing the secretion of milk.

This note is made to show the action of jaborandi as a galactagogue in the recent puerperal state. The preparation used was the fluid extract obtained from Squibb & Co.

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