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The Project Gutenberg eBook of The Cleveland
Medical Gazette, Vol. 1, No. 4, February 1886
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Title: The Cleveland Medical Gazette, Vol. 1, No. 4, February 1886

Author: Various

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Samuel Walter Kelley

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*** START OF THE PROJECT GUTENBERG EBOOK THE CLEVELAND

MEDICAL GAZETTE, VOL. 1, NO. 4, FEBRUARY 1886 ***
VOL. I. FEBRUARY, 1886. No. 4.

ORIGINAL LECTURES.

ULCER OF THE STOMACH.

A LECTURE BY PROF. L. OSER OF VIENNA,
AUSTRIA.
[Translated for the Cleveland Medical Gazette by Dr. C. Rosenwasser].
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.
It has been called by various names. Round ulcer, perforating
ulcer, chronic ulcer, corroding ulcer and simple ulcer are only
different designations for one and the same condition. I prefer to call
it peptic ulcer, as it is always the result of self-digestion of a part of
the walls of the stomach, but is not always round, nor perforating,
nor chronic, nor corroded; nor is it always simple, several ulcers
having occasionally been found in one and the same stomach.
Pathologists have not yet come to a positive decision on the
modus operandi of its origin, but several conditions are mentioned
as necessary for its development.
1. The self-digestion of a part of the stomach by the gastric juice.
2. Disturbances of the circulation of the blood in the walls of the
stomach.
3. The alkalinity of the blood circulating in the walls of the
stomach prevents the digestion of the mucous membrane. If this
action on the walls of the stomach is prevented in any way, the
development of an ulcer is aided. This clause has been accepted
until recently, when it has been rendered somewhat doubtful by the
results of certain experiments.
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.
Virchow regards embolism of a small vessel as the origin of ulcer
of the stomach. Cohnheim disproved this beyond doubt by showing
that there is an abundant circulation in the walls of the stomach by
which the parts affected are again quickly supplied with blood. Klebs
takes for granted a spasmodic contraction of single bloodvessels as
the cause of the retardation of the circulation, while Rindfleich
attributes it to the poor anastomotic connection of the gastric veins.
He calls attention to the frequent coincidence of ulcer and
hemorrhagic infarct in the walls of the stomach. Cohnheim injected
chromate of lead into the gastric branch of the splenic artery in
animals, and when he succeeded in cutting off the arterial supply of
the mucous and submucous layers only, he found as a result large
ulcers with sharp, well-defined margins and a circular base. If the
animals were examined in the second week after the experiment,
they showed several small ulcers in place of the larger one. In the
third week the ulcers were found to have healed. From these
experiments you can see that the gastric ulcer has a natural
tendency to heal when not interfered with. By experiments such as
these it has been proven beyond doubt that disturbances of
circulation of a small part of the stomach may lead to ulcer. But the
causes of these disturbances, and the reasons why some ulcers do
not heal, are still disputed questions.
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 œsophagus, 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 hæmatemesis 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 (three days) 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.
Symptomatology. If you were to rely upon the occurrence of
gastric hemorrhage in making your diagnosis, a great many blunders
would necessarily occur, as this symptom is present in but one
quarter of all the cases. I can give you an exact picture of the
symptoms from experience on myself, having repeatedly been a
sufferer from gastric ulcer and having studied every phase of the
question carefully upon myself, frequently experimenting to get at
various truths.
 One of the most important and characteristic symptoms is the
localized pain or soreness which is felt in a small, well defined area,
and either originates or is increased by chemical or mechanical
irritation. This spot always was sensitive both to warm and cold
food. Salty food, alcoholic or sour articles brought on pain. I could
feel when the food passed the spot. It was always more sensitive
about an hour or two after a meal, when the process of digestion
was most active. My ulcer was on the anterior wall of the stomach,
so that I could greatly ease the pain after meals by lying upon my
back, while lying upon the abdomen greatly aggravated it, as the
food then came in contact with the ulcer. I was a student yet when
first suffering from this trouble, and was treated by one of our
prominent professors for heart disease. He even gave me a
certificate stating that I was suffering from beginning hypertrophy of
the left ventricle. I was not improving under this treatment, and was
taken one day with violent pain in the stomach, followed by vomiting
of a large quantity of blood. Now the state of things was cleared up,
and under the proper treatment (for ulcer of the stomach) I soon
regained my health. I remained well for a long time, but in the
course of the last twenty years have passed through several
relapses. One of these, I distinctly remember, occurred while I was
making a tour through the Alps. I had walked quite a distance that
day and being very thirsty drank three glasses of water in quick
succession. I immediately felt a pain in the stomach, and could
distinctly feel how one of the old scars was again rent asunder.
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.
Two different kinds of pain are felt, the one constant and the
other occasional. The constant pain is usually present where the
ulcer has extended deeper into the tissues or when the surrounding
tissues are implicated. This pain is increased during digestion or
when pressure is made on the parts from without. The occasional
pains are either of a dyspeptic type, caused by the catarrh which
usually accompanies the ulcer, or of a cardialgic (neuralgic) type, the
result of irritation of the exposed nerve-endings with the ulcer. These
cardialgias are acute attacks of very severe, excruciating pain, which
occur during or between the periods of digestion and are felt in the
epigastrium and back mostly, but sometimes radiate over the entire
abdomen, into the chest and even into the limbs. These attacks
differ in no respect from those occurring in some diseases of the gall
bladder, kidneys, peritoneum or uterus, and are consequently not
characteristic of gastric ulcer. The dyspeptic pain partakes more of
the character of feeling of fullness, a sense of oppression in the
epigastrium, heartburn, etc., such sensations as occur in catarrh of
the stomach and are felt during digestion.
The characteristic pain in ulcer of the stomach is a localized
feeling of soreness. It is not always prominent. Chemical or
mechanical irritation of the ulcer brings it on, or if already present,
aggravates it. Especially acids, both mineral and vegetable, have this
effect, while alkalies allay it. This pain only occurs during the process
of digestion, when the food or gastric juice comes in contact with
the ulcer, or when the stomach is distended with gas, and tension
exerted on the tender spot. During the periods when the stomach is
at rest it does not occur.
Vomiting occurs in about three-fourths of all cases of gastric
ulcer; vomiting of blood, however, only in about a quarter of all the
cases. The latter occurs oftener where the ulcer is deep. In cases
where the stomach is dilated, the amount vomited may be
enormous, and contain food which has been retained in the dilated
portion for several days.
As a result, also, of the accompanying catarrh of the stomach
and the consequent diminished absorption of fluids, we find
constipation and diminished secretion of urine in cases of ulcer of
the stomach.
 Perforation of the stomach is most frequently caused by gastric
ulcer, and may be said to be a characteristic symptom; but it usually
occurs too late to be made use of in the treatment of the ulcer. It is
occasionally the first symptom which calls the patient's attention to
the fact that his stomach is and has been seriously diseased. By the
agglutinations of the base of the ulcer with neighboring organs,
through inflammatory processes, perforation can take place into
these organs. The most frequent forms of perforation under such
conditions are those into the liver, spleen or pancreas, but cases
have occurred where perforation into the colon or pleural cavity has
taken place, or even into the pericardium, the heart or lungs. Some
time ago I saw a case of gangrene of the lung, the result of the
perforation of a gastric ulcer into this organ.
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.
Diagnosis. There are two classes of characteristic symptoms—
those originating from the exposure of nerve-endings, and those
caused by ulceration into bloodvessels. The first class includes the
painful sensations, the characteristic soreness, which occurs in about
four-fifths of all the cases; the second class, the hemorrhages,
occurring in only one-fourth of all the cases. You can readily see why
pain occurs more often than hemorrhage. Even a very superficial
abrasion may expose nerve-endings to the irritation of the food,
while it takes a deeper ulceration to lay open a larger bloodvessel. In
order to make a positive diagnosis, these two symptoms should be
present.
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.
In cases of peptic ulcer, you will find that the pain is in direct
relation to the amount and quality of food taken; that the patient
has little or no pain when the stomach is at rest; that coarse foods
as well as acids cause or aggravate the pain, and that indifferent
foods, such as milk, do not bring it about, though they may
sometimes cause a sense of fullness or oppression. Some patients
with ulcer will tell you that the position of their body has an
influence on their pain. If they are so placed that the food, by its
gravity, lies on the ulcer, the pain is brought on or increased, while if
the patient under such circumstances then changes his position, he
is relieved of his pain partially, or even entirely. Yes, some such
patients must assume abnormal positions while their stomach is
active, in order to avoid this suffering. Some patients with gastric
ulcer cannot digest any food without great pain, and frequently live
on a very scanty diet, rather than risk taking more food and
enduring these excruciating pains again.
Anomalous Cases. Occasionally cases will occur in which the
symptoms presented do not justify the diagnosis of ulcer of the
stomach, only those of dyspepsia or else of gastric catarrh being
present, while we are still compelled to assume the diagnosis of
ulcer from the result of the treatment. Such cases resist all kinds of
treatment based upon the diagnosis of dyspepsia or catarrh, and can
only be cured by a strict "ulcer cure."
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 hæmatemesis in an otherwise
healthy person you can, with great probability, diagnose ulcer of the
stomach.
Differential Diagnosis. In order to differentiate between catarrh
and ulcer, it is simply necessary to keep in mind the difference in the
character of the pain, the fact that local pressure is more liable to
aggravate the pain in ulcer than in catarrh, and the occurrence of
hemorrhage in the former. The two conditions, however, frequently
occur in the same patient.
The differentiation between ulcer and neurosis has already been
discussed. The direct connection of the attacks of pain with the
introduction of food, and the character of the pain will soon clear up
the matter. Should you still be in doubt, a course of treatment, such
as an ulcer would demand, will soon clear up the matter. If the case
is one of ulcer, it will have been cured or materially benefited, if it
was a pure neurosis the patient will if anything feel worse than
before.
 By far the most difficult question to decide in making a diagnosis
is whether the case is one of ulcer or cancer of the stomach. Here
close attention to several points will usually clear up the diagnosis.
Cancer sufferers always have a sallow complexion, a worn,
emaciated, cachectic appearance, no matter what or how much they
eat. Ulcer patients frequently have a robust, healthy appearance,
and are emaciated or run down only after repeated hemorrhages, or
when other grave diseases, such as heart disease, chlorosis,
tuberculosis, etc., are also present.
The presence or absence of a tumor is a very important aid to
the diagnosis, though as I have already stated, not always reliable.
Sometimes an ulcer may be covered with granulations, and its
surroundings so infiltrated and hardened, that even post-mortem the
naked eye can not tell whether it is cancer or simple ulcer, and the
question has to be decided by microscope. Such are likely the cases
which form the bases of cancer cures which are reported from time
to time to have been effected by the use of various remedies.
Vomiting of blood is a symptom common to both cancer and
ulcer of the stomach, but is usually more copious in the latter. If the
absence of acid in the gastric juice of cancerous stomachs proves to
be as reliable a symptom as has been recently asserted, this will be
an important feature in the differentiation from ulcer.
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.
Prognosis. From what has been said you can see that in general
the prognosis of ulcer of the stomach is good, that with proper
avoidance of all irritation, the ulcer has a tendency to heal of itself.
This tendency has been observed even in large ulcers, where death
was perhaps the result of some intercurrent disease.
 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.
Treatment. The pain is the most important criterion as a guide
during the treatment. It is the signal by which I judge of the present
condition of the ulcer. According to the variation of its character and
intensity, I can judge whether the ulcer is healing, is remaining
stationary, or is spreading and increasing in size or depth in spite of
the treatment. If the pain has been removed permanently the ulcer
has been healed. From the relation of this symptom to different
kinds of food you can also judge of a progress or improvement of
the ulcer.
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 (about one or two ounces). 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.
Often you will meet with the reply: "I have already tried this diet,
I was put on milk diet once before by Dr. —— and it did not help me
any, I even felt worse afterwards." If you inquire more closely,
however, you will find that they drank milk several times a day, but
ate bread with it, soaking this in the milk. This is what is understood
to be a milk cure. Gentlemen! I am sorry to say that this
misunderstanding is not confined to the general public, but that
some physicians even do not know better, and consider such a
course of diet a milk diet. I cannot impress it upon your minds any
too strongly not to allow yourselves to be diverted from your
purpose by any such assertions, but to order another course of milk
diet, wherever you find it indicated, and see to it that it is carried out
properly this time. You will thereby occasionally meet with excellent
success where a previous wrong attempt in the same direction
failed.
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
(well baked) 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.
Wine and alcoholic liquors in general are to be avoided for
several months.
 Beer should never be taken by one who has suffered from gastric
ulcer. In fact it is well for all who have stomach trouble to avoid the
use of beer, especially such as have had ulcer. Such patients have to
be on their guard in matters of diet through the remainder of their
lives, and must avoid excesses both in eating and drinking. You will
occasionally come across persons who can not stand a milk diet in
any form whatever. They frequently do not bear eggs well. In such
cases I proceed at once, but with great care, to the use of meat in
very small quantities, finally chopped and roasted, and have it taken
several times a day. You will frequently have to try one article of
food and then another, and experiment for awhile before you reach
that form of diet which suits the case best.
There are a number of substitutes, some of which are really
good, while others are worthless. Of them all I prefer the fresh meat
juice ext. carnis recent. pressum, and have it prepared in the
following manner: The meat (beef should be used) is cut into thin
slices, placed between pieces of tissue paper, and pressed in a
hydraulic press. The juice thus obtained is given in teaspoon doses
every half hour or so, just as though it were medicine. In the
majority of cases I have the meat juice made by the druggist, so
that a large number of the patients think it is medicine. It has a
rather pleasant taste and is well borne by the stomach. There are a
great many peptones in the market, a large number of which ought
not to be used, as they are not fresh and more likely to do harm
than good. Of them all the English make is the best, as it is usually
well preserved, being packed dry.
Patients who can only take a small quantity of nourishment by
the stomach can be materially aided by the use of nutritious
enemata given luke warm once or twice a day. When the rectum is
very irritable a suppository containing one-half to one grain of ext.
opii given a half hour before the enema is very serviceable. There
are a great many other remedies recommended in the text books,
but I would advise you not to rely too much on them. Lay your main
stress on the dietetic part of the treatment, and use remedies only
where they are absolutely necessary to support this. Among the
remedies used the alkalies are the most valuable. Bicarbonate of
soda alone, or in combination with ext. belladonna when the
stomach is very irritable.
℞ Sod. Bicarb., ʒiss.
Ext. Belladon., gr ii. Misce et div. in pulv. XVI.
Sig. One in the morning and one in the evening.
Or I sometimes substitute atropia sulph. (1/120 gr. pro dosi) 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.
I do not think it advisable to send patients with gastric ulcers to
health resorts or watering places. They can only regain their health
by a strict enforcement of dietetic measures, and these can be
carried out just as well at the patient's home as at the health resort.
For the treatment of such cases after the ulcer has healed, these
health resorts can be of great benefit, but the patient must be
cautioned not to commit excesses in eating or drinking, especially to
the latter must their attention be called, as it is customary in most
resorts adapted to such cases, to drink large quantities of the
medicated waters in the morning. It is also well to caution the
patients with regard to their diet before sending them away. This
should be unirritating, bland and easily digestible. Among the
European health resorts, Carlsbad is the most suitable for such
cases.
 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.
 By REUBEN A. VANCE, M. D., CLEVELAND,
OHIO.
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 hyperæmia.
It is quite different as regards certain other signs, especially
when two or more of them are seen in conjunction. If the bowel be
dark and mottled with grayish spots, of contracted and shrivelled
aspect, with a slight amount of discolored fluid surrounding the gut,
and a cadaveric odor apparent when the sac is opened, mortification
is certainly present, and the return of the strictured part within the
abdominal cavity dooms the patient to certain death. The surgeon's
duty is to open the sphacelated gut, apply a poultice and favor the
relief of the obstructed bowel by a free discharge of the intestinal
contents through the outlet thus formed. An artificial anus is thus
established, and the patient, for a time, must be content with this
deformity; fortunately it is a condition susceptible of relief, and the
surgeon may ultimately free his patient of even this defect.

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.
M. S., age thirty-five years, a multipara, of fair health, not well
nourished. The babe was two weeks old at the time of this
observation, and in good condition. The secretion of milk by the
mother began gradually to fail until not one-third the average
quantity was produced. The child was then nourished artificially. The
fluid extract of jaborandi was given to the mother. The dose was
eight minims every three hours. About fifty minims were taken in
twenty-four hours. On the second day of the administration of the
drug the milk increased in quantity. By the third day it had increased
still more, so that the child had nourishment from the mother
sufficient to satisfy it. Increased salivary and cutaneous secretions
led to a discontinuance of the drug. The milk flowed in good
quantities for eight days, and then rapidly diminished. Jaborandi was
again used. The plan of administration was the same. Increase of
the milk was again noted. The renewed activity of the mammary
glands continued for five or six days only. For a third time the drug
was used, and its use followed by good effects. In the meantime the
nourishment of the mother had been pushed. Iron, quinine and
mineral acids were also given. The general health of the patient
improved. After the last increased activity the secretion of the gland
remained normal for three weeks, after which the patient passed
from observation. During the last two weeks no jaborandi was used.
Whereas in this case the improved condition of the individual was
responsible for the permanent increase in the supply of milk, the use
of the jaborandi and the temporary increase were apparently more
than coincidental. During the first two stimulations the quality of the
milk deteriorated; the quantity of cream diminished; the specific
gravity fell; no microscopic examination of the milk was made. After
the last increase in the activity of the glands the quality of the milk
was good.
Two similar cases were noted. B., aged nineteen years, primipara,
had a tedious labor. She recovered slowly. She was well nourished
and has previously been well. At the end of the second week of
convalescence the milk began to fail. Jaborandi was used as in the
case just cited. Marked improvement in the milk was noticed the
second day the drug was given. On the fourth day the medicine was
omitted. The milk continued to flow in sufficient quantities for ten
days. The quantity then gradually and rapidly diminished. The
medicine was again given for four days with the desired effect,
which remained for the following ten days that the patient was
under observation.
D., age twenty-five years, a multipara, was a poorly nourished
person, the mother of two children. The confinement was normal.
The milk failed soon after its appearance. Following the use of
jaborandi the milk increased rapidly in quantity, but diminished in
three days on withdrawing the drug. The milk continued to respond
to the jaborandi for the four weeks that the patient was under
observation, but no permanent result was obtained.
On three other cases the jaborandi was used with scarcely
perceptible effect or no effect at all. From a few cases it is
impossible to generalize with expectation of a truthful conclusion.
We can, however, know that the jaborandi has an effect on the
mammary gland, and causes an increase of the milk in puerperal
women. This effect is by no means a constant sequel to the
administration of the drug. As far as my observation is concerned
the effect of jaborandi is temporary, and can be useful only where
there is a tendency in the gland to assume its normal function. This
tendency may at times be subordinated to general influences and
even entirely subdued. In such conditions a timely stimulation of the
gland may tide over the threatening arrest of function. Variation in
the activity of the mammary gland, especially in the early puerperal
state, is not unusual. The close relation of the increase of milk and
the use of jaborandi justifies, however, the assumption of effect and
cause.
No effect was observed on the children. Jaborandi is excreted by
the mammary glands, and it was consequently withheld as soon as
practicable, lest the child should feel its presence.

INDICATIONS FOR OPENING THE

MASTOID PROCESS.
BY A. R. BAKER, M. D., CLEVELAND, OHIO.
The operation of opening the mastoid process is said by some to
have been first performed by Riolan in 1649; according to others, by
Petit in 1750, and later by Jasser, in 1776. During the latter part of
the eighteenth century the operation was performed frequently
without definite pathological indications. But after the unfortunate
death of the Danish physician Berger (1791) the operation was very
seldom or never performed until 1864, by Mayer, following the
suggestions made by Tröltsch some years previous. Berger, for
chronic deafness without suppuration of the middle ear, had the
operation performed upon himself, and died on the twelfth day from
meningitis. During the past twenty years the operation has taken its
place as one of the recognized surgical proceedings owing to the
work of the German physicians Moos, Jacobi, Hartman, Bezold,
Schwartz and others, who have laid down the real indications for the
operation from their extensive clinical observations and pathological
researches. The American otologists, Roosa, Agnew, Buck and others
were among the very first to perform the operation, and have done
much to establish its claim to recognition. And yet it is somewhat
remarkable that some of our text books barely mention the
operation; and as short a time ago as 1883, Strawbridge, at the
meeting of the American Otological Society, said that he had seen
over four thousand cases of purulent middle ear disease within
twelve years, and yet had not trephined in a single case; and several
other authorities looked upon the operation as a questionable one.
Knapp took decided grounds in favor of the operation, and cited
three fatal cases in which he believed an operation would have
saved life. Kipp had seen quite a number of fatal cases in which the
post-mortem had shown the mastoid cells filled with pus, which had
given rise to cerebral abscess. Dr. C. H. Burnett reported a fatal case
which died from pyemia, and he thought if his patient had been
operated a year before his life would have been saved.
Gruening said surgery has established that wherever there is a
focus of purulent discharge it should be removed. This, (removal of
the focus) is a life-saving operation and should be done under all
circumstances. Dr. Roosa said that he believed the revival of this
operation of opening the mastoid process has saved many lives.
Since his first operation not a year has passed that he has not found
it necessary to repeat it several times. He says further that "it is true
that we shall seldom need to open the mastoid if an experienced
practitioner sees a case of acute aural disease early in its course. It
is an operation for neglected cases, where suppuration has been
allowed to advance from the tympanic cavity in consequence of not
having a free outlet through the drum-head. But purulent
inflammation of the mastoid may occur in acute cases that have
been thoroughly treated by leeching, poultices, rest, etc., from the
start."
The most recently stated indications for opening the mastoid
process are:
1. Purulent inflammation in the mastoid process appearing in the
course of suppuration of the middle ear when persistent severe pain
in the bone cannot be subdued by the application of the ice-bag,
leeches, or by Wilds' incision. (Schwartz).
 2. Painful inflammation in the mastoid process occurring in acute
and chronic suppuration of the middle ear, in consequence of
growths filling up the external meatus or the tympanic cavity. When
attempts to remove the obstacle to the free escape of pus have
failed, the operation is imperative. (Grüning). The operation is
indicated even though the soft parts over the mastoid are not
swollen or infiltrated. (Politzer).
3. When the posterior superior wall of the meatus is bulging, and
when after incision the abscess is not emptied and the symptoms of
retention of pus continue. (Toynbee, Duplay).
4. Persistent pain and tenderness in the mastoid process lasting
for days or weeks, in which there is probably an osseous abscess not
communicating with the tympanic cavity. (Politzer).
5. In every suppuration of the middle ear combined with
inflammation of the mastoid process in which fever, vertigo and
headache are developed during the course of the affection, which
may indicate a dangerous complication. In such cases the indication
for the operation is vital. (Politzer, Roosa, Buck.)
As to the time when the operation should be performed, writers
do not agree. While one proposes that the operation should be done
as soon as there are symptoms of inflammation of the mastoid
process, another defers it till the dangerous symptoms (fever,
headache, vertigo, etc.,) set in. The latter proposal must not be
followed, as in many cases it would be too late; on the other hand,
many cases will recover without an operation. As far as it can be
formulated, I would say that in a given case of acute purulent
inflammation of the mastoid process I would first apply leeches,
poultices, cathartics, antiflogistics. If the inflammation is not
promptly subdued, I would make a Wilds' incision, including the
periosteum, if the bone is found softened; or if a fistulous opening is
found, this should be enlarged at once. If the bone is found healthy
and not roughened, if there is no fever, vertigo, headache, etc., I
would wait a few days; if the symptoms, pain, tenderness, etc., do
not subside, I would then perforate the mastoid process.
For the performance of the operation trepans were formerly
used, which were replaced by drills which are still used by Buck,
Jacobi, Lucae and others, but by most operators they have been set
aside, owing to their uncertain and dangerous advance in the deep
parts, and on account of their soiling the wound with splinters. The
most rational and safe method is by means of the chisel, as
recommended by Schwartz, and is performed as follows: The patient
being anæsthetized, a perpendicular incision beginning a little above
the linea temporalis, extending an inch and a half in length
immediately behind the attachment of the auricle. Formerly I
employed a straight incision, but recently have followed the
suggestion of Politzer, and from the superior end of the
perpendicular incision a second one is made backward at right
angles, thus forming a flap, which I have found to simplify the
operation very much, as it affords a better view of the locality and
extent of any pathological changes which may have taken place, and
gives more room for operative procedures, and the periosteum can
readily be removed to any desired extent. The linea temporalis and
the more or less strongly developed protuberance on the posterior
superior orifice of the osseous meatus, so strongly urged by authors,
are very nice guides theoretically or to point out on an exceptional
skull in the class room, but practically are seldom well enough
developed to be of any use to the operator. The best guide to go by
is to take the superior wall of the meatus as the upper boundary,
and the angle formed by the plane of the mastoid with the posterior
wall of the external meatus for the anterior boundary when opening
the mastoid. This is best determined by pressing the finger into the
meatus. Often in children, and when the bone is diseased in adults,
the cortical plate of bone can be removed with the hand chisel, and
we come at once upon the pus cavity, or diplœ, or
cholesteatomatous epidermic masses, or a sequestrum of dead
bone, or bleeding granulation tissue, or whatever the case may
present. Sometimes the external plate is very thick and we have to
chisel our way carefully for almost half an inch before reaching the
diplœ, or may find the entire mastoid process sclerossed. No
absolute rule can be given as to the depth it is safe to penetrate.
Schwartz says "never to go deeper than 25 mm." Buck says "it is
better to place the extreme limit at 20 mm," about three-fourths of
an inch.
Although I do not consider the operation a particularly dangerous
one, especially with the chisel where we can watch each step of the
operation; and even though we opened into the lateral sinus or the
duramater, the injury would not be necessarily fatal. Yet I would not
advise any one to attempt it (unless the indications are imperative)
who has not performed the operation on the dead subject. Politzer
says "no one should operate on the living before having performed
the operation at least forty or fifty times on the dead." I cannot close
this article better than in the words of Dr. St. John Roosa, to whose
admirable work I am indebted for a large portion of this article.
"Yet, hesitation, when the way is plain, or when the chances are
largely on the side of the necessity of the removal of pus, cannot be
too sternly condemned. No drug has yet been discovered which can
be substituted for the scalpel or trephine when pus has actually
formed in the mastoid cells. I wish, however, to repeat what I have
said before on the subject of surgical operations. I am in full accord
with the great English surgeon, Sir James Paget, who, in his
admirable lectures, expresses many times his hesitation to perform
any surgical operation, however trivial, that is not absolutely
required. We have no right, I think, to perform operations to clear
up doubtful diagnosis. If in case the operation proves to have been
unnecessary, the patient will be decidedly the worse for it. If we put
ourselves in the place of our patients, what we may regard as a
trifling thing—"a mere cut"—will not be so esteemed. A mere cut,
when unnecessary, may have the most serious consequences, and
all the history and symptoms should be carefully weighed before
even that is undertaken. Such care will never prevent prompt, rapid
and thorough surgical interference when demanded.
 In teaching medical students, I have always found them, when
fully awakened to the dangers of neglecting certain diseases, to be
more apt to do too much than too little, especially with the knife and
active drugs. It is possible, also, that the crying ignorance and
neglect of the previous decades in regard to the treatment of aural
disease has had a tendency to cause us, who see many of the
afflictions of the ear, to lean toward the side of surgical operations
upon the drum, head and mastoid. This is a leaning no less
dangerous to the cure of some cases than was the steering toward
Scylla or Charybdis to the safe navigation of ancient mariners."

A CASE OF ANOMALOUS
DEVELOPMENT OF THE
ANTERIOR PILLARS OF THE SOFT
PALATE.
BY B. L. MILLIKIN, M. D.,
Oculist and Aurist to Charity Hospital,
Cleveland, O.
Some time since, Mrs. G. D., age about 23, applied to me on
account of deafness and tinnitus of both ears. In pursuing my
examination I found the following unusual anatomical relations of
the anterior pillars of the soft palate, which I deem not unworthy of
record.
The uvula and posterior border of the soft palate are normal in
appearance and formation; but, beginning about the middle of the
anterior pillars, these gradually widen out into thick, heavy, broad,
muscular folds, which attach themselves firmly to the sides and
dorsum of the tongue, extending two or three lines upon the
dorsum. They seem to be intimately connected with the muscle of
the tongue itself, making them very firm. The posterior pillars are
much less well developed than the anterior, and do not control or
prevent the drawing forward of the soft palate when the tongue is
protruded. The tonsils are small in size but normally located.
The attachments of these bands give a peculiar appearance to
the throat. When the tongue is in a state of rest, in the bottom of
the mouth, or, better still, when the tongue is depressed, these
bands hang like two large curtains, narrowing very much the faucial
opening. When the tongue is protruded they are put upon the
stretch, and narrow very greatly the faucial opening by drawing
forward and downward the whole of the soft palate, so that the
posterior border of the soft palate and uvula rest firmly upon the
dorsum of the tongue. When the tongue is thus protruded the
attachments of these membranes are brought forward almost to the
teeth.
In a state of relaxation there is formed back of these folds, on
either side, quite a deep cavity, which often collects quantities of
solid food, to the great annoyance of the patient. She even
sometimes is obliged to remove these obstructions with the fingers,
or, by gulping or swallowing frequently, is able to dislodge them. She
has no difficulty in swallowing liquids.
There is some impediment in her speech, a peculiar lisping as if
she did not have good control of her tongue, which she has always
attributed to the fact that she is of German parentage. Her English
is, however, very good, other than as above indicated.
In looking up what anatomical literature is at my command, I find
no reference to any anomalies of this kind, although I have been
able to consult the standard French, German and English works on
general anatomy. I myself have never seen a case with an
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