The view which has met with the greatest favor is that which attributes the origin of gastric ulcer to impairment or arrest of the circulation in a circumscribed part of the wall of the stomach, and to a subsequent solution by the gastric juice of the part thus affected. Rokitansky first suggested this view by assigning hemorrhagic necrosis of the mucous membrane as the first step in the formation of the ulcer; but it is Virchow who has most fully developed this view and has given it its main support. The first cause of gastric ulcer, according to Virchow, is a hemorrhagic infiltration of the coats of the stomach induced by local disturbances in the circulation. The part the nutrition of which is thus impaired or destroyed is dissolved by the gastric juice.

The affections of the gastric blood-vessels to which importance has been attached are (a) embolism and thrombosis; (b) diseases of the coats of the vessels, as atheroma, obliterating endarteritis, fatty degeneration, amyloid degeneration, and aneurismal and varicose dilatations; (c) compression of the veins by spasm of the muscular coats of the stomach in vomiting and in gastralgia; (d) passive congestion of the stomach by obstruction in the portal circulation.

In support of this view are urged the following facts: First, it has been proven by the experiments of Pavy that parts of the gastric wall from which the circulation has been shut off undergo digestion; second, hemorrhagic infarctions have been observed in the stomach, both alone (Von Recklinghausen, Hedenius) and associated with gastric ulcer (Key, Rindfleisch); third, the hemorrhagic infiltration in the walls of recently-formed ulcers indicates a hemorrhagic origin; fourth, the funnel-like shape of the ulcer resembles the funnel-shaped area of distribution of an artery; fifth, gastric ulcers have been experimentally produced by injecting emboli into the gastric arteries (Panum, Cohnheim).⁹⁶

⁹⁶ Pavy, Philosoph. Trans., 1763, p. 161; V. Recklinghausen, Virchow's Archiv, Bd. 30, p. 368; Axel Key, Virchow und Hirsch's Jahresb., 1870, Bd. ii. p. 155; Rindfleisch, Lehrb. d. path. Gewebelehre, 5te Aufl., Leipzig, 1878; Panum, Virchow's Archiv, Bd. 25, p. 491; Cohnheim, Vorles. über allgem. Path., Bd. ii. p. 53, Berlin, 1880.

The main objections to this view are the infrequency with which the assumed changes in the blood-vessels have been demonstrated, the common occurrence of gastric ulcer at an age earlier than that at which diseases of the blood-vessels are usually present, and the absence of gastric ulcer in the vast majority of cases of heart disease, with widespread embolism of different organs of the body. To meet some of these objections, Klebs⁹⁷ presupposes in many cases a local spasmodic contraction of the gastric arteries, causing temporary interruption of the circulation; Rindfleisch and Axel Key, compression of the gastric veins, with resulting hemorrhagic infiltration by spasm of the muscular coat of the stomach in vomiting and in gastralgic attacks. But these are pure hypotheses.

⁹⁷ Handb. d. path. Anat., Bd. i. p. 185, Berlin, 1869.

What is actually known concerning diseases of the gastric blood-vessels in ulcer of the stomach has already been stated under the morbid anatomy. From this it may be inferred that the origin of gastric ulcer in diseased conditions of the blood-vessels has been established only for a comparatively small group of cases.

Böttcher's⁹⁸ view that gastric ulcer is of mycotic origin, being produced by micrococci, has thus far met with no confirmation.

⁹⁸ Dorpater med. Zeitschr., Bd. v. p. 148, 1874.

There are those who hold an eclectic view concerning the origin of gastric ulcer. They believe that ulcer of the stomach may be produced by a variety of causes, such as inflammation, circulatory disturbances, irritating substances introduced into the stomach, traumatism, etc. The peculiarities of the ulcer are due not to any specific cause, but to the solvent action of the gastric juice, which keeps clean the floor and the sides of the ulcer. These clean edges and floor, which are incident to all ulcers of the stomach, justify no conclusion as to the cause of the ulcer. Engel⁹⁹ over thirty years ago held that gastric ulcer might originate in various ways—that there was nothing specific about it. Brinton was also of similar opinion.

⁹⁹ Prager Vierteljahrschr., 1853, ii.

Gastric ulcers have been produced experimentally in animals in a variety of ways, but these experiments have not materially elucidated the pathenogenesis of ulcer in man. Schiff by lesions of various parts of the brain, and later Ebstein by lesions of many parts of the central and peripheral nervous system by injections of strychnine—in fact, apparently by any means which greatly increased the blood-pressure—produced in the stomachs of animals ecchymoses and ulcers. Müller by ligation of the portal vein, Pavy by ligation of arteries supplying the stomach, likewise produced hemorrhages and ulcers. The results of Pavy could not be confirmed by Roth and others. Panum, and afterward Cohnheim, produced gastric ulcers by introducing multiple emboli into the gastric arteries. Daettwyler under Quincke's direction caused, in dogs with gastric fistulæ, ulcers of the stomach by various mechanical, chemical, and thermic irritants applied to the inner surface of the stomach. Aufrecht observed hemorrhages and ulcers in the stomachs of rabbits after subcutaneous injections of cantharidin.¹⁰⁰

¹⁰⁰ Schiff, De vi motorea baseos encephali, 1845, p. 41; Ebstein, Arch f. exp. Path. u. Pharm., 1874, p. 183; Müller, Das corrosive Geschwür im Magen, etc., p. 273, Erlangen, 1860; Pavy, Guy's Hosp. Rep., vol. xiii., 1867; Roth, Virchow's Archiv, Bd. 45, p. 300, 1869; Panum, loc. cit.; Cohnheim, op. cit.; Daettwyler, Quincke, Deutsche med. Wochenschr., 1882, p. 79; Aufrecht, Centralbl. f. d. med. Wiss., 1882, No. 31.

The most interesting of these experiments are those of Cohnheim and of Daettwyler, who demonstrated that in one essential point all of these experimental ulcers differ from simple gastric ulcer in man—namely, in the readiness with which they heal. To this ready healing the gastric juice, much as it has been accused of causing the spread of gastric ulcers in man, seems to have offered no obstacle. We know that similar losses of substance in the human stomach heal equally well.¹⁰¹ Hence it has been maintained throughout this article that it is unjustifiable to regard all of the scars found in the human stomach as the result of simple ulcer.

¹⁰¹ Portions of the mucous membrane of the stomach, sometimes with some of the submucous coat, have been in several instances removed with the stomach-pump, but thus far no bad effects have followed.

It appears from these experiments, as well as from observations on man, that it is more difficult to explain why ulcers in the stomach do not heal than it is to understand how they may be produced. From this point of view the observation of Daettwyler is of interest, that in dogs which had been rendered anæmic by repeated abstraction of blood not only did slighter irritants suffice to produce ulcers of the stomach, but the ulcers healed much more slowly. Practically, it is important to learn what are the obstacles to the repair of gastric ulcers, but our positive knowledge of these is slight. It is probable that such obstacles are to be found in constitutional causes, such as anæmia and chlorosis, in abnormal states of the blood-vessels around the ulcer, in catarrhal affections of the stomach, in irritating articles of food, in improper modes of living, and in increased acidity of the gastric juice.

DIAGNOSIS.—In many cases the diagnosis of gastric ulcer can be made with reasonable certainty; in other cases the diagnosis amounts only to a suspicion more or less strong, and in still other cases the diagnosis is impossible.

The diagnostic symptoms are epigastric pain, vomiting, and gastric hemorrhage. The characteristics of the pain which aid in the diagnosis are its fixation in one spot in the epigastric region, its onset soon after eating, its dependence upon the quantity and the quality of the food, its relief upon the complete expulsion of the contents of the stomach, its alleviation by changes in posture, and its increase by pressure. That the pain of gastric ulcer has not always these characteristics has been mentioned under the Symptomatology. Vomiting without hæmatemesis is the least characteristic of these symptoms. It aids in the diagnosis when it occurs after eating at the acme of a gastralgic attack and is followed by the relief of pain. Hæmatemesis is the most valuable symptom in diagnosis. The more profuse the hemorrhage and the younger the individual in whom it occurs, the greater is the probability of gastric ulcer. It should not be forgotten that the blood is sometimes discharged solely by the stools.

The simultaneous occurrence of all these symptoms renders the diagnosis of gastric ulcer easy.¹⁰² In all cases in which gastrorrhagia is absent the diagnosis is uncertain; but gastric ulcer should be suspected whenever the ingestion of food is followed persistently by severe epigastric pain and other causes of the pain have not been positively determined. When the course of the ulcer is latent and when the symptoms are only those of dyspepsia, the diagnosis is of course impossible. In cases previously obscure a diagnosis in extremis is sometimes made possible by the occurrence of perforation of the stomach.

¹⁰² That even under the most favorable circumstances absolute certainty in the diagnosis of gastric ulcer is not reached is illustrated by a case reported with great precision and fulness by Banti: A female servant, twenty-one years old, had every symptom of gastric ulcer, including repeated hæmatemesis and the characteristic epigastric pain. She was nourished by enemata. She died from an ulcerative proctitis four days after the last hemorrhage from the stomach. Only a slight catarrhal inflammation of the stomach was found at the autopsy, without trace of ulcer, cicatrix, or ecchymosis ("Di un Caso d'Ematemesi," La Sperimentale, Feb., 1880, p. 168). It would seem as if there must have been an ulcer which had healed so completely as to leave no recognizable scar.

In making a differential diagnosis of gastric ulcer, as well as of any disease, reliance should be placed more upon the whole complexion of the case than upon any fancied pathognomonic symptoms.

The diseases which are most difficult to distinguish from gastric ulcer are nervous affections of the stomach. Like gastric ulcer, most of these are more common in women than in men, and especially in chlorotic women with disordered menstruation and with hysterical manifestations. These nervous affections are manifold and their leading characteristics are not yet well defined. The most important of these affections are nervous dyspepsia, nervous vomiting, nervous gastralgia, and gastric crises.

The leading symptoms of nervous dyspepsia, as described by Leube,¹⁰³ are the ordinary symptoms of dyspepsia without evidence of anatomical alteration of the stomach, and with the proof by washing out the stomach that the process of digestion is not delayed. Nervous dyspepsia is often associated with other nervous affections, and is caused especially by influences which depress the nervous system. Epigastric pain, and especially tenderness on pressure over the stomach, are not common symptoms in nervous dyspepsia. Only those rare cases of gastric ulcer in which hemorrhage from the stomach is absent and epigastric pain is not prominent are likely to be confounded with nervous dyspepsia. In such cases, although the diagnosis of nervous dyspepsia is by far the most probable, the patient may be confined to bed and put upon the strict regimen for gastric ulcer. If in the course of ten days or two weeks essential relief is not obtained, ulcer may be excluded, and the proper treatment for nervous dyspepsia with tonics and electricity may be adopted (Leube).

¹⁰³ Deutches Arch. f. klin. Med., Dec. 18, 1878.

In nervous vomiting, which occurs most frequently in hysterical women, other nervous manifestations are present; there are usually less epigastric pain and tenderness than in ulcer; the nutrition is better preserved; the vomiting is less dependent upon the ingestion of food and more dependent on mental states; and there are longer intervals of relief than in ulcer. Still, it may be necessary to resort to the therapeutical diagnosis as in the preceding instance.

In this connection attention may be called to the importance of searching for reflex causes of vomiting, such as beginning phthisis, ovarian or uterine disease, cerebral disease, and pregnancy; also to certain cases of chronic Bright's disease in which gastric disturbances are the main symptoms.

Of all the nervous affections of the stomach, nervous gastralgia is the one which presents the greatest similarity to gastric ulcer. Its diagnosis from gastric ulcer is often extremely difficult, and may be impossible. The points of difference given in the following table may aid in the diagnosis:

According to Peter,¹⁰⁴ the surface temperature of the epigastrium is elevated in gastric ulcer, but not in nervous gastralgia.

¹⁰⁴ Gaz. des Hôp., June, 1883.

Probably not a single one of the points mentioned in the table is without exception. Nervous gastralgia may be associated with gastric ulcer, and if the ulcer is otherwise latent the diagnosis is manifestly impossible. A diagnosis of purely functional gastralgia has been repeatedly overthrown by the occurrence of profuse hæmatemesis. There is no symptom upon which it is more unsatisfactory to base a diagnosis than upon pain. There is much difference among physicians as regards the frequency with which they diagnose gastric ulcer in the class of cases here described. It is probable that the error is oftenest a too frequent diagnosis of gastric ulcer than the reverse. Nevertheless, when there is doubt it is well to submit the patient for a time to the proper treatment for gastric ulcer.

In several instances gastric crises have been mistaken for gastric ulcer. These gastric or gastralgic crises, as they are called by Charcot, by whom they have been best described,¹⁰⁵ are most frequently associated with locomotor ataxia, but they may occur in connection with other diseases of the spinal cord (subacute myelitis, general spinal paralysis, and disseminated sclerosis), and an analogous affection has been described by Leyden¹⁰⁶ as an independent disease under the name of periodical vomiting with severe gastralgic attacks. Gastric crises have been most carefully studied as a symptom in the prodromic stage of locomotor ataxia. The distinguishing features of these crises are the sudden onset and the atrocious severity of the gastric pain; the simultaneous occurrence of almost incessant vomiting; the habitual continuance of the paroxysms, almost without remission, for two or three days; the normal performance of the gastric functions in the intervals between the paroxysms, which may be months apart; the frequent association with other prodromic symptoms of locomotor ataxia, such as ocular disorders and fulgurating pains in the extremities; and the development after a time of ataxia. Leyden has observed during the attacks retraction of the abdomen without tension of the abdominal walls, obstinate constipation, scanty, dark-colored urine, even anuria for twenty-four hours, and increased frequency of the pulse (also noted by Charcot). Vulpian¹⁰⁷ mentions a case in which there was vomiting of dark-colored blood, and in which naturally the diagnosis of gastric ulcer had been made. In the autopsies of Leyden and of Charcot no lesions of the stomach have been found.

¹⁰⁵ Leç. sur les Maladies du Syst. nerveux, t. ii. p. 32, Paris, 1877.

¹⁰⁶ Zeitschr. f. klin. Med., iv. p. 605, 1882.

¹⁰⁷ Maladies du Syst. nerveux, p. 273, Paris, 1879.

The differential diagnosis of gastric ulcer from gastric cancer will be considered in the article on GASTRIC CANCER.

It has already been said that a part of the symptoms of gastric ulcer are due to an associated chronic catarrhal gastritis. Usually other symptoms are present which render possible the diagnosis of the ulcer. There is usually some apparent external or internal cause of chronic catarrhal gastritis, whereas the etiology of ulcer is obscure; in chronic gastritis gastralgic paroxysms and the peculiar fixed epigastric pain of gastric ulcer are usually absent; in chronic gastritis profuse hæmatemesis is a rare occurrence; and in gastritis the relief obtained by rest and proper regulation of the diet, although manifest, is usually less immediate and striking than in most cases of gastric ulcer.

The passage of gall-stones is usually sufficiently distinguished from gastric ulcer by the sudden onset and the sudden termination of the pain, by the situation of the pain to the right of the median line, by the complete relief in the intervals between the attacks, by the occurrence of jaundice, by the recognition sometimes of enlargement of the liver and of the gall-bladder, and by the detection of gall-stones in the feces.

There is not much danger of confounding abdominal aneurism and lead colic with gastric ulcer, and the points in their differential diagnosis are sufficiently apparent to require no description here. The diagnosis of duodenal ulcer from gastric ulcer will be discussed elsewhere. The different causes of gastric hemorrhage, a knowledge of which is essential to the diagnosis of gastric ulcer, will be considered in the article on HEMORRHAGE FROM THE STOMACH.

PROGNOSIS.—Although a decided majority of simple ulcers of the stomach cicatrize, nevertheless, in view of the frequently insidious course of the disease, the sudden perforations, the grave hemorrhages, the relapses, and the sequels of the disease, the prognosis must be pronounced serious.

The earlier the ulcer comes under treatment the better the prognosis. Old ulcers with thickened indurated margins containing altered blood-vessels naturally heal with greater difficulty than recently-formed ulcers.

Profuse hemorrhage adds to the gravity of the diagnosis. It usually indicates that the ulcer has penetrated to the serous coat of the stomach. A hemorrhage may exert a favorable influence, in so far as to convince the patient of the necessity of submitting to the repose and the strict dietetic regimen which the physician prescribes.

The severity of the pain is of little value as a prognostic sign. Vomiting and dyspepsia, if uncontrolled by regulation of the diet, lead to a cachectic state which often ends in death.

Little basis as there is to hope for recovery after perforation into the general peritoneal cavity, there nevertheless have been a very few cases in which there is reason to believe that recovery has actually taken place after this occurrence.¹⁰⁸

¹⁰⁸ The most convincing case of recovery after perforation of gastric ulcer is one reported by Hughes, Ray, and Hilton in Guy's Hosp. Rep., 1846, p. 332. A servant-girl was suddenly seized with all of the symptoms of perforation. Fortunately, she had eaten nothing for four hours before the attack, and then only gruel. She was placed at once under the influence of opium, was kept in the recumbent posture, and was fed by the rectum. She was discharged apparently cured after fifty-two days. Two months afterward she was again suddenly seized with the same symptoms, and she died in fourteen hours. Shortly before the second perforation she had eaten cherries, strawberries, and gooseberries, which were found in the peritoneal cavity. The autopsy showed, in addition to a recent peritonitis, evidences of an old peritonitis. There were adhesions of the coils of the intestines with each other and between the stomach and adjacent viscera. In the stomach were found a cicatrix and two open ulcers, one of which had perforated.

Other cases in which recovery followed after all of the symptoms of perforation of gastric ulcer were present, but in which no subsequent autopsy proved the correctness of the diagnosis, have been reported by Redwood (Lancet, May 7, 1870); Ross (ibid., Jan. 21, 1871); Tinley (ibid., April 15, 1871); Mancini (La Sperimentale, 1876, pp. 551, 665); and G. Johnson (Brit. Med. Journ., March 26, 1870).

Frazer's two cases, reported in the Dublin Hosp. Gaz., April 15, 1861, are not convincing. The case reported by Aufrecht (Berl. kl. Wochenschr., 1870, No. 21) and the one by Starcke (Deutsche Klinik, 1870, No. 39), which are sometimes quoted as examples of recovery, were cases of circumscribed peritonitis following perforation.

In an interesting case from Nothnägel's clinic reported by Lüderitz, the patient lived sixteen days after perforation into the peritoneal cavity, followed by all of the symptoms of diffuse perforative peritonitis. Death resulted from pneumonia secondary to the peritonitis. At the autopsy were found adhesions over the whole peritoneal surface and streaks of thickened pus between the coils of intestine. The perforation in the stomach was closed by the left lobe of the liver (Berl. kl. Wochenschr., 1879, No. 33).

In estimating the prognosis one should bear in mind the possibility of relapses; of a continuance of gastric disorders, particularly of gastralgia, after cicatrization; of the formation of cicatricial stenosis of the orifices of the stomach; and of the development of dilatation of the stomach.

After the worst has been said concerning the unfavorable issues of gastric ulcer, it yet remains true that the essential tendency of the ulcer when placed under favorable conditions is toward recovery, and that in many cases the treatment of the disease affords most excellent results, and is therefore a thankful undertaking for the physician.

TREATMENT.—In the absence of any agent which exerts a direct curative influence upon gastric ulcer the main indication for treatment is the removal of all sources of irritation from the ulcer, so that the process of repair may be impeded as little as possible.

Theoretically, this is best accomplished by giving to the stomach complete rest and by nourishing the patient by rectal alimentation. Practically, this method of administering food is attended with many difficulties, and, moreover, the nutrition of the patient eventually suffers by persistence in its employment. In most cases the patient can be more satisfactorily nourished by the stomach, and by proper selection of the diet, without causing injurious irritation of the ulcer.

At the beginning of the course of treatment it is often well to withhold for two or three days all food from the stomach and to resort to exclusive rectal feeding. In some cases with uncontrollable vomiting and after-hemorrhage from the stomach it is necessary to feed the patient exclusively by the rectum.

The substances best adapted for nutritive enemata are artificially-digested foods, such as Leube's pancreatic meat-emulsion, his beef-solution, and peptonized milk-gruel as recommended by Roberts.¹⁰⁹ Beef-tea and eggs, which are often used for this purpose, are not to be recommended, as the former has very little nutritive value, and egg albumen is absorbed in but slight amount from the rectum. Expressed beef-juice may also be used for rectal alimentation. The peptones, although physiologically best adapted for nutritive enemata, often irritate the mucous membrane of the rectum, so that they cannot be retained. It has been proven that it is impossible to completely nourish a human being by the rectum.¹¹⁰ Rectal alimentation can sometimes be advantageously combined with feeding by the mouth.

¹⁰⁹ Leube's pancreatic meat-emulsion is prepared by adding to 4-8 ounces of scraped and finely-chopped beef l-2½ ounces of fresh finely-chopped oxen's or pig's pancreas freed from fat. To the mixture is added a little lukewarm water until the consistence after stirring is that of thick gruel. The syringe used to inject this mixture should have a wide opening in the nozzle; Leube has constructed one for the purpose (Leube, Deutsches Arch. f. klin. Med., Bd. x. p. 11).

The milk-gruel is prepared by adding a thick, well-boiled gruel made from wheaten flour, arrowroot, or some other farinaceous article to an equal quantity of milk. Just before administration a dessertspoonful of liquor pancreaticus (Benger) or 5 grains of extractum pancreatis (Fairchild Bros.), with 20 grains of bicarbonate of soda, are added to the enema. This may be combined with peptonized beef-tea made according to Roberts's formula (Roberts, On the Digestive Ferments, p. 74, London, 1881).

Preparatory to beginning the treatment the bowels should be emptied by a clyster, and this should be occasionally repeated. About three to six ounces of the tepid nutritive fluid should be slowly injected into the rectum. The injections may be repeated at intervals of from three to six hours. If necessary, a few drops of laudanum may be occasionally added to the enema.

¹¹⁰ Voit u. Bauer, Zeitschrift f. Biologie, Bd. v.

There is universal agreement that the dietetic treatment of gastric ulcer is of much greater importance than the medicinal treatment. There is hardly another disease in which the beneficial effects of proper regulation of the diet are so apparent as in gastric ulcer. Those articles of food are most suitable which call into action least vigorously the secretion of gastric juice and the peristaltic movements of the stomach, which do not cause abnormal fermentations, which do not remain a long time in the stomach, and which do not mechanically irritate the surface of the ulcer. These requirements are met only by a fluid diet, and are met most satisfactorily by milk and by Leube's beef-solution.

The efficacy of a milk diet in this disease has been attested by long and manifold experience. By its adoption in many cases the pain and the vomiting are relieved, and finally disappear, and the ulcer heals. In general, fresh milk is well borne. If not, skimmed milk may be employed. If the digestion of the milk causes acidity, then a small quantity of bicarbonate of soda or some lime-water (one-fourth to one-half in bulk) may be added to the milk. Large quantities should not be taken at once. Four ounces of milk taken every two hours are generally well borne. Sometimes not more than a tablespoonful can be taken at a time without causing vomiting, and then of course the milk should be given at shorter intervals. It is desirable that the patient should receive at least a quart, and if possible two quarts, during the twenty-four hours. The milk should be slightly warmed, but in some cases cold milk may be better retained. In some instances buttermilk agrees with the patient better than sweet milk. Although many suppose that they have some idiosyncrasy as regards the digestion of milk, this idiosyncrasy is more frequently imaginary than real. Still, there are cases in which milk cannot be retained, even in small quantity.

For such cases peptonized milk often proves serviceable.¹¹¹ The artificial digestion of milk as well as of other articles of food is a method generally applicable to the treatment of gastric ulcer. The main objection to peptonized milk is the aversion to it that many patients acquire on account of its bitter taste. The peptonization should not be carried beyond a slightly bitter taste. The disagreeable taste may be improved by the addition of a little Vichy or soda-water. Peptonized milk has proved to be most valuable in the treatment of gastric ulcer.

¹¹¹ Milk may be peptonized by adding to a pint of fresh milk, warmed to a temperature of 100° F., 5 grs. of extract pancreatis (Fairchild Bros. and Foster) and 20 grs. of bicarb. sodii dissolved in 4 ounces of tepid water. The mixture is allowed to digest for about an hour at a temperature of 100° F., which may be conveniently done by placing the milk in a bowl in a pan of water maintained at this temperature. It is then boiled, strained, and placed on ice, or when the milk is to be taken immediately it is better not to boil it, in order that the partial digestion may continue for a while under the influence of the pancreatic ferment in the stomach. The milk without boiling may be kept on ice without further digestion; and this procedure has the advantage that the pancreatic ferments, although inactive at a temperature near that of ice, are not destroyed. The degree of digestion aimed at is indicated by the production of a slightly, but not unpleasantly, bitter taste. When the digestion is carried to completion, milk has a very bitter and disagreeable flavor. Peptonized milk-gruel, mentioned on page 519, may also be employed.

Leube's beef-solution¹¹² is a nutritious, unirritating, and easily-digested article of diet. It can often be taken when milk is not easily or completely digested, or when milk becomes tiresome and disagreeable to the patient. It is relied upon mainly by Leube in his very successful treatment of gastric ulcer. A pot of the beef-solution (corresponding to a half pound of beef) is to be taken during the twenty-four hours. A tablespoonful or more may be given at a time in unsalted or but slightly salted bouillon, to which, if desired, a little of Liebig's beef-extract may be added to improve the taste. The bouillon should be absolutely free from fat. Unfortunately, not a few patients acquire such a distaste for the beef-solution that they cannot be persuaded to continue its use for any considerable length of time.

¹¹² By means of a high temperature and of hydrochloric acid the meat enclosed in an air-tight vessel is converted into a fine emulsion and is partly digested. Its soft consistence, highly nutritious quality, and easy digestibility render this preparation of the greatest value. The beef-solution is prepared in New York satisfactorily by Mettenheimer, druggist, Sixth Avenue and Forty-fifth street, and by Dr. Rudisch, whose preparation is sold by several druggists.

Freshly-expressed beef-juice is also a fairly nutritious food, which can sometimes be employed with advantage. The juice is rendered more palatable if it is pressed from scraped or finely-chopped beef which has been slightly broiled with a little fresh butter and salt. The meat should, however, remain very rare, and the fat should be carefully removed from the juice.

To the articles of diet which have been mentioned can sometimes be added raw or soft-boiled egg in small quantity, and as an addition to the milk crumbled biscuit or wheaten bread which may be toasted, or possibly powdered rice or arrowroot or some of the infant farinaceous foods, such as Nestle's. Milk thickened with powdered cracker does not coagulate in large masses in the stomach, and is therefore sometimes better borne than ordinary milk.

For the first two or three weeks at least the patient should be confined strictly to the bill of fare here given. Nothing should be left to the discretion of the patient or of his friends. The treatment should be methodic. It is not enough to direct the patient simply to take easily-digested food, but precise directions should be given as to what kind of food is to be taken, how much is to be taken at a time, how often it is to be taken, and how it is to be prepared.

In all cases of any severity the patient should be treated in bed in the recumbent posture, and warm fomentations should be kept over the region of the stomach. Mental and physical fatigue should be avoided.

Usually, at the end of two or three weeks of this diet the patient's condition is sufficiently improved to allow greater variety in his food. Meat-broths may be given. Boiled white meat of a young fowl can now usually be taken, and agreeable dishes can be prepared with milk, beaten eggs, and farinaceous substances, such as arrowroot, rice, corn-starch, tapioca, and sago. Boiled sweetbread is also admissible. Boiled calf's brain and calf's feet are allowed by Leube at this stage of the treatment.

To these articles can soon be added a very rare beefsteak made from the soft mass scraped by a blunt instrument from a tenderloin of beef, so that all coarse and tough fibres are left behind. This may be superficially broiled with a little fresh butter. Boiled white fish, particularly cod, may also be tried.

It is especially important to avoid all coarse, mechanically-irritating food, such as brown bread, wheaten grits, oatmeal, etc.; also fatty substances, pastry, acids, highly-seasoned food, vegetables, fruit, and all kinds of spirituous liquor. The juice of oranges and of lemons can usually be taken. The food should not be taken very hot or very cold.

For at least two or three months the patient should be confined to the easily-digested articles of diet mentioned. These afford sufficient variety, and no license should be given to exceed the dietary prescribed by the physician. Transgression in this respect is liable to be severely punished by return of the symptoms. When there is reason to believe that the ulcer is cicatrized, the patient may gradually resume his usual diet, but often for a long time, and perhaps for life, he may be compelled to guard his diet very carefully, lest there should be a return of the disease. Should there be symptoms of a relapse, the patient should resume at once the easily-digested diet described above.

Medicinal treatment of gastric ulcer, although less efficacious than the dietetic treatment, is not to be discarded. Since its advocacy by Ziemssen the administration of Carlsbad salts or of similarly composed salts belongs to the systematic treatment of gastric ulcer. The objects intended to be accomplished by the use of these salts are the daily evacuation of the contents of the stomach into the intestine by gentle stimulation of the gastric peristaltic movements, the neutralization of the acid of the stomach, and the prevention of acid fermentations in the stomach. Of these objects the most important is the prevention of stagnation of the contents of the stomach. The chief ingredients of the Carlsbad waters are sulphate of sodium, carbonate of sodium, and chloride of sodium. The most important of these ingredients is sulphate of sodium (Glauber's salts), which by exciting peristalsis propels the gastric contents into the intestine, and thus relieves the stomach of its burden, prevents fermentation, and removes from the surface of the ulcer an important source of irritation. The carbonate of sodium neutralizes the acids of the stomach, but the main value of this ingredient and of the chloride of sodium is that in some way they correct the action of the Glauber's salts, so that the latter may be taken in smaller quantity and without the usual unpleasant effects of pure Glauber's salts.¹¹³ The artificial Carlsbad salts are to be preferred to the natural or the artificial Carlsbad water. The natural Carlsbad salts and much of those sold as artificial Carlsbad salts consist almost wholly of sulphate of sodium. It is therefore best to prescribe in proper proportion the leading ingredients of these salts. A suitable combination is sulphate of sodium five ounces, bicarbonate of sodium two ounces, and chloride of sodium one ounce (Leichtenstern¹¹⁴). The relative proportion of the ingredients may of course be varied somewhat to suit individual cases. The salts are to be taken daily before breakfast dissolved in a considerable quantity of warm water. One or two heaping teaspoonfuls of the salts are dissolved in one-half to one pint of water warmed to a temperature of 95° F. One-fourth of this is to be drunk at a time at intervals of ten minutes. Breakfast is taken half an hour after the last draught. After breakfast there should follow one or two loose movements of the bowels. If this is not the case, the next day the quantity of the salts is to be increased, or if more movements are produced the quantity is to be diminished until the desired result is obtained. In case the salts do not operate, an enema may be used. Usually, to obtain the same effect, the quantity of salts may be gradually diminished to a teaspoonful.

¹¹³ Water from the Sprudel spring contains in 16 ounces 18.2 grains of sulphate of sodium, 14.6 grains of bicarbonate of sodium, and 7.9 grains of chloride of sodium, and 11.8 cubic inches of carbonic acid. Its natural temperature is 158° F. The other Carlsbad springs have the same fixed composition and vary only in temperature and amount of CO₂.

¹¹⁴ The second edition of the German Pharmacopoeia contains a formula for making artificial Carlsbad salts, so that the ingredients are in about the same proportion as in the natural water. The formula is as follows: Dried sulphate of sodium 44 parts, sulphate of potassium 2 parts, chloride of sodium 18 parts, bicarbonate of sodium 36 parts. These should be mixed so as to make a white dry powder. The Carlsbad water is imitated by dissolving 6 grammes of this salt in 1 liter of water (Pharmacopoeia Germanica, editio altera, Berlin, 1882, p. 232).

According to a prescription very commonly used in Germany, the Carlsbad salts are made by taking sulphate of sodium 50 parts, bicarbonate of sodium 6 parts, chloride of sodium 3 parts. Dose, a teaspoonful dissolved in one or two tumblers of warm water (Ewald u. Lüdecke, Handb. d. Allg. u. spec. Arzneiverordnungslehre, Berlin, 1883, p. 480).

The Carlsbad salts are directed especially against the chronic gastric catarrh which complicates the majority of cases of ulcer of the stomach. It is well known that the most effective method of treating this morbid condition is the washing out of the stomach by means of the stomach-tube. The propriety of adopting this procedure in gastric ulcer comes, therefore, under consideration. Although the use of the stomach-tube in gastric ulcer is discarded by Leube and by Sée on account of its possible danger, nevertheless this instrument has been employed with great benefit in many instances of this disease by Schliep, Debore, and others.¹¹⁵ No instance of perforation of an ulcer by means of the stomach-tube has been reported, and in general no evil effects have resulted; but Duguet cites a case of fatal hemorrhage following washing out of the stomach.¹¹⁶ In view of the great benefit to be secured by washing out the stomach, and of the comparatively slight danger which attends the process, it seems justifiable to adopt this procedure cautiously and occasionally in cases of gastric ulcer with severe gastric catarrh. Of course only the soft rubber tube should be used, and the siphon process should be adopted.¹¹⁷ The stomach may be washed out with pure warm water or with water containing a little bicarbonate of sodium (one-half drachm to a quart of water). The occasional cleansing of the stomach in this way can hardly fail to promote the healing of the ulcer. Recent or threatened hemorrhage from the stomach would contraindicate the use of the stomach-tube.

¹¹⁵ Schliep, Deutsch. Arch. f. klin. Med., Bd. 13; Debore, L'Union méd., Dec. 30, 1882; Bianchi, Gaz. degli Ospitali, March 26, 1884.

¹¹⁶ Gaz. des Hôp., Apr. 29, 1884. In a case of gastric ulcer of Cornillon severe hemorrhage followed washing out the stomach (Le Prog. méd., Apr. 28, 1883).

¹¹⁷ Soft rubber stomach-tubes are made by Tiemann & Co. in New York, and are sold by most medical instrument-makers. A description of the appropriate tube and of the method of its use is given by W. B. Platt ("The Mechanical Treatment of Diseases of the Stomach," Maryland Medical Journal, March 8, 1884).

Beyond the measures indicated there is little more to do in the way of treatment directed toward the repair of the ulcer. Not much, if anything, is to be expected from the employment of drugs which have been claimed to exert a specific curative action on the ulcer. Of these drugs those which have been held in the greatest repute are bismuth and nitrate of silver. Trousseau¹¹⁸ devised a somewhat complicated plan for administering bismuth and nitrate of silver in succession for several months in the treatment of gastric ulcer. There are few who any longer cherish any faith in these drugs as curative of gastric ulcer. The same may be said of other drugs which have been thought to have similar specific virtue in the treatment of gastric ulcer, such as acetate of lead, arsenic, chloral hydrate, iodoform, etc.

¹¹⁸ Clinique médicale, t. iii. p. 95, Paris, 1865.

It remains to consider therapeutic measures which may be necessary to combat individual symptoms of gastric ulcer.

The pain of gastric ulcer is generally relieved in a few days by strict adherence to the dietetic regimen which has been laid down. When this is not the case, it may be best to withhold all food from the stomach and to nourish by the rectum. But this cannot be continued long without weakening the patient, and sometimes the pain persists in spite of the rest afforded the stomach. Undoubtedly, the most effective means of quieting the pain of gastric ulcer is the administration of opium in some form. Opium should not, however, be resorted to without full consideration of the possible consequences. When the use of this drug is once begun, the patient is liable to become dependent upon it, and may be inclined, consciously or unconsciously, to exaggerate the pain in order to obtain the narcotic. When prescribing opium in this disease the physician should have in mind the danger of establishing the opium habit. Moreover, opium retards digestion, and is anything but an aid to the proper dietetic regimen, which is all-important. If it is decided to give opium, it does not matter much in what form it is administered, but the dose should be as small as will answer the purpose. Hypodermic injections of morphine over the region of the stomach may be recommended. Codeia often produces less disturbance than opium or morphine. A useful powder for the relief of pain is one containing 8 or 10 grains of subnitrate of bismuth, ¹/12 grain of sulphate of morphia, and ¹/5 grain of extract of belladonna. Much of the beneficial effect attributed to bismuth is in reality due to its customary combination with a small quantity of morphine. Before resorting to opium in cases of severe pain it will be well to try some of the other means for relieving the pain of gastric ulcer, although they are less effective. Gerhardt thinks that astringents are better than narcotics to relieve the pain of ulcer, and he recommends for the purpose three or four drops of solution of chloride of iron diluted with a wineglassful of water, to be taken several times daily. Although this recommendation is from high authority and is often quoted, sufficient confirmatory evidence of its value is lacking. Other medicines recommended are hyoscyamus, belladonna, choral hydrate, chloric ether, hydrocyanic acid, bismuth, nitrate of silver, and compound kino powder. Sometimes warm fomentations, at other times a light ice-bag over the epigastrium, afford marked relief of the pain. Counter-irritation over the region of the stomach has also given relief. This may be effected with a mustard plaster or by croton oil. I have known the establishment of a small nitric-acid issue in the pit of the stomach to relieve the pain, but such severe measures of counter-irritation are generally unnecessary. The application of a few leeches over the epigastrium has been highly recommended, but this should be done without much loss of blood. The effect of position of the body upon the relief of pain should be determined. When the pain is due to flatulence or to acid fermentation in the stomach, the treatment should be directed to those states.

The most effective means of controlling the vomiting in gastric ulcer are the regulation of the diet and, if necessary, the resort to rectal alimentation. Absolute rest should be enjoined. Whenever small quantities of milk, peptonized or in any other form, cannot be retained, then exclusive rectal feeding may be tried for a while. There have been cases of gastric ulcer when both the stomach and the rectum have been intolerant of food. In such desperate cases the attempt may be made to introduce food into the stomach by means of the stomach-tube, for it is a singular fact that food introduced in this way is sometimes retained when everything taken by the mouth is vomited.¹¹⁹ The cautious washing out of the stomach by the stomach-tube may prove beneficial. In these cases the attempt has also been made to nourish by subcutaneous injections of food. In a case of gastric ulcer where no food could be retained either by the stomach or by the rectum Whittaker¹²⁰ injected subcutaneously milk, beef-extract, and warmed cod-liver oil. The oil was best borne. The injections were continued for four days without food by the mouth or rectum. The patient recovered. At the best, hypodermic alimentation can afford but slight nourishment, and is to be regarded only as a last refuge. If there is danger of death by exhaustion, transfusion may be resorted to.

¹¹⁹ Debore, L'Union médicale, Dec. 30, 1882, and Gaz. des Hôp., April 29, 1884. For this reason Debore makes extensive use of the stomach-tube in general in feeding patients affected with gastric ulcer. He objects to an exclusive milk diet on account of the quantity of fluid necessary to nourish the patient, which he says amounts to three to four quarts of milk daily. To avoid these inconveniences, he gives three times daily drachm viss of meat-powder and drachm iiss of bicarbonate of sodium (or equal parts of calcined magnesia and bicarb. sod.), well stirred into milk. This is to be introduced by the stomach-tube on account of its disagreeable taste. He believes that the addition of the large quantity of alkali prevents digestion from beginning until the food has reached the intestine. He also gives daily a quart of milk containing grs. xv of saccharate of lime. Debore's method of preparing the meat-powder is described in L'Union médicale, July 29, 1882, p. 160. He also uses a milk-powder (ibid., Dec. 30, 1882; see also Le Progrès méd., July 12, 1884).

¹²⁰ J. T. Whittaker, "Hypodermic Alimentation," The Clinic, Jan. 22, 1876.

Bernutz practised successfully in two cases the hypodermic injection of fresh dog's blood (Gaz. des Hôp., 1882, No. 64).

Krueg (Wiener med. Wochenschr., 1875, No. 34) injected 15 cc. of olive oil twice a day subcutaneously without causing abscesses.

Menzel and Porco were the first to employ hypodermic alimentation (ibid., 1869, No. 31).

Of remedies to check vomiting, first in importance are ice swallowed in small fragments and morphine administered hypodermically. Effervescent drinks, such as Vichy, soda-water, and iced champagne, may bring relief. Other remedies which have been recommended are bismuth, hydrocyanic acid, oxalate of cerium, creasote, iodine, bromide of potash, calomel in small doses, and ingluvin. But in general it is best to forego the use of drugs and to rely upon proper regulation of the diet, such as iced milk taken in teaspoonful doses, and upon repose for the stomach.

Hemorrhage from the stomach is best treated by absolute rest, the administration of bits of ice by the mouth, and the application of a flat, not too heavy, ice-bag over the stomach. The patient should lie as quietly as possible in the supine position, with light coverings and in a cool atmosphere. He should be cautioned to make no exertion. His apprehensions should be quieted so far as possible. All food should be withheld from the stomach, and for four or five days after the cessation of profuse hemorrhage aliment should be given only by the rectum. There is no proof that styptics administered by the mouth have any control over the hemorrhage, and as they are liable to excite vomiting they may do harm. Ergotin, dissolved in water (1 part to 10), may be injected hypodermically in grain doses several times repeated if necessary. If internal styptics are to be used, perhaps the best are alum-whey and a combination of gallic acid 10 grains and dilute sulphuric acid 10 drops diluted with water. Fox praises acetate of lead, and others ergot, tannin, and Monsell's solution. If there is vomiting or much restlessness, morphine should be given hypodermically. If the bleeding is profuse, elastic ligatures may be applied for a short time around the upper part of one or more extremities, so as to shut out temporarily from the circulation the blood contained in the extremity. If syncope threatens, ammonia or a little ether may be inhaled, or ether may be given hypodermically. Brandy, if administered, should be given either by the rectum or hypodermically. Caution should be exercised not to excite too vigorously the force of the circulation, as the diminished force of the heart is an important agent in checking hemorrhage. When life is threatened in consequence of the loss of blood, then recourse may be had to transfusion, but experience has shown that this act is liable to cause renewed hemorrhage in consequence of the elevation of the blood-pressure which follows it. Transfusion is therefore indicated more for the acute anæmia after the hemorrhage has ceased and is not likely to be renewed. It should not be employed immediately after profuse hæmatemesis, unless it is probable that otherwise the patient will die from the loss of blood, and then it is well to transfuse only a small quantity.¹²¹

¹²¹ Michel transfused successfully in a case of extreme anæmia following gastrorrhagia (Berl. klin. Wochenschr., 1870, No. 49). In a case of profuse and repeated hæmatemesis which followed washing out the stomach Michaelis infused into the veins 350 cc. of solution of common salt. Reaction gradually followed, and the patient recovered. This case, which was one of probable ulcer, illustrates the advantages of infusing a small quantity (ibid., June 23, 1884). The dangers are illustrated by a case reported by V. Hacker, who infused 1500 cc. of salt solution in a patient in a state of extreme collapse resulting from hemorrhage from gastric ulcer. The patient rallied, but he died three hours after the infusion from renewed hemorrhage (Wiener med. Wochenschr., 1883, No. 37). In Légroux's case of gastric ulcer renewed hemorrhage and death followed the transfusion of only 80 grammes of blood (Arch. gén. de Méd., Nov., 1880). In a case quoted by Roussel, Leroy transfused 130 grammes of blood in a girl twenty years old who lay at the point of death from repeated hemorrhages from a gastric ulcer. In the following night occurred renewed hemorrhage and death (Gaz. des Hôp., Sept. 22, 1883). According to the experiments of Schwartz and V. Ott, the transfusion, or rather infusion, of physiological salt solution is as useful as that of blood, and it is simpler and unattended with some of the dangers of blood-transfusion. The formula is chloride of sodium 6 parts, distilled water 1000.

Schilling recommends, when the bleeding is so profuse that the patient's life is threatened, to tampon the stomach by means of a rubber balloon attached to the end of a soft-rubber stomach-tube.¹²² The external surface of the balloon is slightly oiled. It is introduced into the stomach in a collapsed state, and after its introduction it is moderately distended with air. When the balloon is to be withdrawn the air should be allowed slowly to escape. Schilling tried this procedure in one case of hemorrhage from gastric ulcer, allowing the inflated bag to remain in the stomach twelve minutes. The hemorrhage ceased and was not renewed. Experience only can determine whether this device, to which there are manifest objections, will prove a valuable addition to our meagre means of controlling hemorrhage from the stomach.

¹²² F. Schilling, Aerztl. Intelligenzbl., Jan. 8, 1884. Schreiber, in order to determine the position of the stomach, was the first to introduce and inflate in this organ a rubber balloon (Deutsches Arch. f. klin. Med., June 5, 1877). Uhler recommends in case of profuse gastric hemorrhage to pass a rubber bag into the stomach and fill it with liquid (Maryland Med. Journ., Aug. 30, 1884, p. 347).

The boldest suggestion ever made for stopping gastric hemorrhage is that of Rydygier, who advocates in case hemorrhage from an ulcer threatens to be fatal to cut down upon the stomach, search for the bleeding ulcer, and then resect it.¹²³ Notwithstanding the great advances made in gastric surgery during the last few years, Rydygier's suggestion seems extravagant and unwarrantable.

¹²³ Berl. klin. Wochenschr., Jan. 16, 1882.

The most effectual treatment of the dyspepsia which is present in many cases of gastric ulcer is adherence to the dietetic rules which have been laid down, aided by the administration of Carlsbad salts and perhaps in extreme cases the occasional and cautious use of the stomach-tube. If eructations of gas and heartburn are troublesome, antacids may be employed, but they should be given in small doses and not frequently, as the ultimate effect of alkalies is to increase the acid secretion of the stomach and to impair digestion. The best alkali to use is bicarbonate of sodium, of which a few grains may be taken dry upon the tongue or dissolved in a little water.

If perforation into the peritoneal cavity occur, then opium or hypodermic injections of morphine should be given in large doses, as in peritonitis. Bran poultices sprinkled with laudanum or other warm fomentations should be applied over the abdomen, although in Germany ice-bags are preferred. Food should be administered only by the rectum. The chances of recovery are extremely slight, but the patient's sufferings are thus relieved. In view of the almost certainly fatal prognosis of perforation of gastric ulcer into the general peritoneal cavity, and in view of the success attending various operations requiring laparotomy, it would seem justifiable in these cases, after arousing, if possible, the patient from collapse by the administration of stimulants per rectum or hypodermically, to open the peritoneal cavity and cleanse it with some tepid antiseptic solution, and then to treat the perforation in the stomach and the case generally according to established surgical methods.¹²⁴ This would be the more indicated if it is known that the contents of the stomach at the time of perforation are not of a bland nature.

¹²⁴ Mikulicz has successfully treated by laparotomy a case of purulent peritonitis resulting from perforation of the intestine with extravasation of the intestinal contents. He says that the operation is not contraindicated by existing peritonitis if the patient is not already in a state of collapse or sepsis. The perforation is closed by sutures after freshening the edges of the opening (abstract in the Medical News, Philada., Sept. 6, 1884). Both Kuh and Rydygier recommend opening the abdomen after perforation of gastric ulcer. The borders of the ulcer are to be resected and the opening closed by sutures (Volkmann's Samml. klin. Vorträge, No. 220, p. 12).

It is important to maintain and to improve the patient's nutrition, which often becomes greatly impaired from the effects of the ulcer. This indication is not altogether compatible with the all-important one of reducing to a minimum the digestive work of the stomach. Nevertheless, some of the easily-digested articles of food which have been mentioned are highly nutritious. By means of these and by good hygienic management the physician should endeavor, without violating the dietetic laws which have been laid down, to increase, so far as possible, the strength of his patient. Starvation treatment in itself is never indicated in gastric ulcer. Inunction of the body with oil is useful in cases of gastric ulcer, as recommended by Pepper.¹²⁵

¹²⁵ North Carolina Medical Journal, 1880, vol. v. p. 5.

In view of Daettwyler's experiments, mentioned on page 514, it is manifestly important to counteract the anæmia of gastric ulcer. Iron, however, administered by the mouth, disturbs the stomach and is decidedly contraindicated during the active stage of gastric ulcer. During convalescence, only the blandest preparations of iron should be given, and these not too soon, lest they cause a relapse. When the indication to remove the anæmia is urgent, and especially when the chlorotic form of anæmia exists, it may be well to try the hypodermic method of administering iron, although this method has not yet been made thoroughly satisfactory. Especially for the anæmia of gastric ulcer would an efficient and unirritating preparation of iron for hypodermic administration prove a great boon. Probably at present the best preparation for hypodermic use is the citrate of iron, given in one- to two-grain doses in a 10 per cent. aqueous solution, which when used must be clear and not over a month old. The syringe and needle shortly before using should be washed with carbolic acid. The injections are best borne when made into the long muscles of the back or into the nates, as recommended by Lewin for injections of corrosive sublimate. A slight burning pain is felt for ten minutes after the injection. This is the method employed by Quincke with good result and without inflammatory reaction.¹²⁶ It is well to remember that Kobert¹²⁷ has found by experiment on animals that large doses of iron injected subcutaneously cause nephritis. Other preparations of iron which have been recommended for hypodermic use are ferrum dialysatum (DaCosta), ferrum pyrophosphoricum cum natr. citrico (Neuss), ferrum pyrophosphoricum cum ammon. citr. (Huguenin), ferrum peptonatum and ferrum oleinicum (Rosenthal).¹²⁸ When it becomes safe to administer iron by the stomach, then the blander preparations should be used, such as the pyrophosphate, lactate, effervescing citrate, ferrum redactum. Leube recommends the following prescription: Ferr. redact. gr. 80, Pulv. althææ gr. 60, Gelatin q. s.; make 90 pills: at first one, and afterward as many as three, of these pills may be taken three times a day. When carefully prepared the pills are about as soft as butter.

¹²⁶ Quincke, Deutsch. Arch. f. klin. Med., Bd. xx. p. 27; Glaenecke, Arch. f. exper. Path. u. Pharm., Bd. 17, p. 466.

¹²⁷ Arch. f. exper. Path. u. Pharm., Bd. 16.

¹²⁸ DaCosta, N.Y. Med. Record, vol. xiii. p. 290; Neuss, Zeitschrift f. klin. Med., Bd. 3, p. 1; Huguenin, Correspondenzbl. f. Schweiz. Aerzte, 1876, No. 11; Rosenthal, Wiener med. Presse, 1878, Nos. 45-49, and 1884, Jan. 20.

Various sequels of gastric ulcer may require treatment. Cicatrization of the ulcer is by no means always cure in the clinical sense. As the result of adhesions and the formation and contraction of cicatricial tissue very serious disturbances of the functions of the stomach may follow the repair of gastric ulcer. The most important of these sequels is stenosis of the orifices of the stomach, particularly of the pyloric orifice. Very considerable stenosis of the pylorus may be produced before the ulcer is completely cicatrized. In three instances a stenosing ulcer of the pylorus has been successfully extirpated.¹²⁹ The most important of these sequels of gastric ulcer will be treated of hereafter. Here it need only be said that during convalescence from gastric ulcer attention to diet is all-important. For a long time the diet should be restricted to easily-digested food. The first symptoms of relapse are to be met by prompt return to bland diet, or, if necessary, to rectal alimentation.

¹²⁹ The successful operators were Rydygier (Berl. klin. Wochenschr., Jan. 16, 1882), Czerny (Arch. f. klin. Chir., Bd. xxx. p. 1), and Van Kleef (Virchow u. Hirsch's Jahresbericht, 1882, Bd. ii. p. 383). Cavazzani cut out by an elliptical incision an old indurated ulcer of the stomach adherent to the anterior abdominal walls. The patient died three years afterward of phthisis (Centralbl. f. Chir., 1879, p. 711). Lauenstein resected the pylorus unsuccessfully for what appears to have been an ulcer of the pylorus with fibroid induration around it (ibid., 1882, No. 9). These four cases (three successful) are all which I have found recorded of resection of gastric ulcer. In my opinion the resection of gastric ulcers which resist all other methods of treatment, and especially those which cause progressive stricture of the pylorus, is a justifiable operation.