in the diagnosis and treatment of mental diseases, we will hope for more brilliant and scientific results from these institutions. The laboratory has become an essential part of a physician's office, and it must be used if we expect to achieve intelligent results in practice. It is necessary in the rest,treatment to make daily observations according to laboratory methods in order to outline treatment. Treatment becomes easy when our diagnosis is established. Rest treatment is applicable in a wide range of cases, especially border-line cases of neurasthenic type, where a prolonged rest of six weeks to three months will give highly satisfactory results. I have treated during this year in general hospitals a number of such cases, strictly following isolation, enforced rest, over-feeding, massage, electricity, etc., etc. The objection I have to the general hospitals is that, even where facilities are all that they need be, there still is that publicity which during the convalescent stages, will not help the patient on his course, because he in a measure is looked upon as a little queer, and those unintentional, but nevertheless, unkind things are said, which to sensitive persons, as many of these cases are, hurt and cause distress. I have used the rest treament in cases of acute mania, restraint of course being necessary for a part of the time. I do not restrain them continuously, but at least for two days at the beginning they are in bed, and then eighteen hours or more a day for a week or more, and then for twelve hours, until their strength is sufficient to permit them to be up. Cases of acute mania represent in spite of their apparent strength, not infrequently profound toxemia and exhaustion, their whole condition proclaims the using of energy, in fact the disease itself is perversion of energy, and the indications are to arrest it and bring it back into normal channels. Rest will do it when combined with proper medication and diet. Too frequently sedatives are heroically given in the treatment of mania with the result that toxemia is promoted, secretions are locked up, and elimination, if it has existed, is brought to a stand-still and danger follows. Acute delirium is too frequently treated this way; this condition above all other acute psychoses needs enforced rest, isolation and quiet. Its mortality under the best of conditions is high, but the burden is increased by the lack of rest and of medication. Rest then is essential in all acute psychoses. In melancholia the rest treatment is especially serviceable and the results very satisfactory. I use it more in accordance with the Weir Mitchell plan. I use rest in all other forms of insanity, also; in circular insanity, it is serviceable during the whole course of the mental depression and part of the period of excitement. In epochial insanities, especially the insanities of adolescence, rest is of special service. I have used it with success in boys and girls just on the border of mental breakdown. The menopause calls for careful observation of patients, and for these cases I prefer the modified rest cure, especially in those neurotic individuals having profound manifestions of the angioneuroses. Elimination, over-feeding and rest will give results here, even when we feel discouraged as to the outlook of the case. Insanities of other forms, such as alcoholic, following drug habits and toxic insanities, post-febrile, and with constitutional or other disease, such as diabetes, Bright's disease, heart affections, etc., rest is indicated and is serviceable, ssociated with other methods of therapeutics. Fortnightly's Post-Graduate Course In this department we will present a series of Practical Papers for the General Practitioner, written expressly for this magazine by the leading Medical Writers of the Twentieth Century. Diseases of the Stomach. BY J. M. G. CARTER, M. A., M. D., Sc. D., PH. D., WAUKEGAN, ILL., Professor of Clinical and Preventive Medicine (formerly Professor of Pathology), College of Physicians and Surgeons, Chicago (School of Medicine, University of Illinois); Fellow of the American Academy of Medicine; Member of the American Medical Association, the Chicago Medical Society, the Chicago Society of Internal Medicine; late President of the Illinois State Medical Society, etc. [CONTINUED FROM PAGE 91.] CHAPTER XV.-ORGANIC DISEASES OF THE STOMACH-DEGENERATION (CONTINUED). EROSIONS OF THE STOMACH. Definition. A condition in which the mucous membrane of the stomach becomes the seat of small superficial ulcerations. These occurrences in connection with "peptic ulcer" have already been mentioned. They occur more frequently, however, under other conditions and hence deserve a separate notice. Etiology. These erosions sometimes occur without apparent cause and may therefore be termed idiopathic. No doubt they accompany those depraved conditions which are characterized by minute ulcerations of the mouth and throat frequently met with in children, and sometimes in adults. Some cases seem to be due to chronic gastric catarrh. Pathology.-Erosions are often found in the stomach at the autopsy Pathologists agree that these abrasions are not so frequent in connection with ulcer as was at one time believed. Sections made through them as a rule show that the base of the ulcerations almost the entire lower half of the mucous membrane is still preserved. Nothing remarkable can be discovered in the epithelium of these remaining glands; the glands at the sides become longer; the first ones that are intact usually curve themselves over the defect and partly cover it. The recovery seems to take place by the simple aftergrowth of the gland remnents (Gerhardt). The Symptomatology.-Einhorn was one of the first to give proper importance to the discussion of the symptoms of this morbid condition. symptoms are chiefly subjective and consist of (a) pain, (b) emaciation, and (c) a sense of weakness. (a) Pains occur immediately after meals, but are not usually intense and are independent of the character of food taken. Intervals of entire freedom from pain during which the patient is perfectly well, occur, but are of variable duration. The pains have no special characteristic, but in rare instances are constant and independent of the ingestion of food. (b) Emaciation.-While patients are usually thin they do not present the cachetic appearance which is observed in malignant diseases. Most cases lose flesh during the first period of their illness, but subsequently retain their weight without material change. The cheeks are thin and somewhat hollow and the jaws protrude. All (c) A feeling of weakness or lassitude is a common symptom. patients complain of weakness, lack of ambition and inability to work. The strength of body is diminished. The height of these symptoms appears soon after meals and after an hour or less begin to decrease. These exacerbations may occur once a week or once in two or three weeks. Anorexia is an accompanying symptom which may last two or three days. During the attacks the patient may be scarcely able to walk and totally unable to take physical exercise. Only one objective symptom or sign is usually recorded, but that is of the greatest importance. It is the discovery of small bits of mucous membrane in the wash-water after lavage. These pieces are of a blood red color and about 0.3 or 0.4 c. m. in length and nearly as much in width. In these cases the microscope shows the cells and glands characteristic of the gastric mucosa, and red blood corpuscles. These appearances are most easily observed in the wash-water of the fasting condition. These occur constantly and not irregularly as is the case with accidents from the use of the tube. In this condition seldom is blood found in the wash-water with the pieces of mucous membrane. The water is not stained red, perhaps because the exfoliations of the mucous membrane occur before the lavage. The spots from which the exfoliations of membrane have taken place must present the erosions and their sensitivenesss may explain the soreness in the stomach of which these patients complain. The wash-water becomes stained with blood if coughing occurs during the operation. The muscular contractions which occur during the coughing probably cause an oozing of blood from the abrasions and this stains the water. If this exfoliation should be general or if it should be recurrent in the same spot, in either case there is a resemblance to similar conditions which sometimes are observed on the skin. This condition sometimes extends to the intestines. I have lately seen a case in which such pieces of mucous membrane were passed in the feces as demonstrated by careful miscroscopic examination. Occasionally the amount of hydrochloric acid is increased as in ulcer; but usually the stomach contents contain a deficient quantity of this acid. Some cases are always characterized by a considerable amount of mucus. The course of the disease is usually chronic; it may extend over several years; yet it may be characterized by intervals of freedom from active symptoms. It does not appear that these erosions ever originate true peptic ulcers. Treatment.-Local treatment is of the greatest importance. Nitrate of silver should be used in solution or spray. The use of this astringent produces excellent results. The effect is soothing, sedative, alterative and healing. It may be used in solution by lavage with apparatus shown in Fig. 8. The evidence that this method of treatment is beneficial is shown by the disappearance of mucus membrane from the wash-water after lavage, and improvement in the patient's feelings and condition, including the disappearance of pain and and weakness. The strength of solution for lavage is a one-tenth or two-tenth per cent, or seven to fifteen grains to a pint (0.5 to 1.00 to 500). Two and a half drachms (10c. c.) of the same solution may be sprayed into the stomach by Einhorn's apparatus (Fig. 13). This may be done once a day or once in two days. Galvanization is an excellent adjuvant to this treatment. When it is desirable to use electricity it may be alternated with the nitrate-of-silver spray. The positive electrode should be intraventral after a pint of sterilized water has been introduced into the stomach, and the negative electrode (stabile) stationary over the epigastrium or (labile) moving from side to side over the epigastric region. The strength of current varies from 10 to 30 milliamperes usually. Diet is important, but only or chiefly as relates to its local effect. Bland food should be prescribed. Nothing that will cause mechanical or chemical irritation should be permitted. Hence hearty meals of meat and vegetables, salads, pastries, pickles, coarse breads and irritating dishes must be avoided. Frequent moderate meals are to be advised. Hygienic regime is desirable, as bathing, calisthenics and moderate out-door exercise. The medicinal treatment is limited to the use of such tonics as nux vomica and mild preparations of iron as Gude's Pepto-mangan and the albuminate of iron, and remedies to meet indications as they arise. horn recommends condurango. CHAPTER XVI. ORGANIC DISEASES OF THE STOMACH. TINUED). CANCER OF THE STOMACH. Ein DEGENERATION (CON Synonyms.-Carcinoma of the Stomach. Carcinoma Ventriucili. Malignant Disease of the Stomach. Gastric Cancer. Varieties. Scirrhus (hard, fibrous); Medullary (soft, fungoid encephaloid); Colloid (gelatinous, mucoid, alveolar); Cylindrical-epithelioid (collumnar or cylindriacal-celled or cylindrical epithelioma, cylindricalcelled cancroid, destructive adenoma). It Definition. A morbid, usually rapidly proliferating, growth, consisting of erratic epithelioid cells contained in connective tissue alveoli. spreads rapidly into surrounding tissues, produces characteristic symptoms, ordinarily occurs in those past middle life, and always terminates fatally. Etiology. The question of heredity is not definitely settled. Undoubtedly heredity exerts a powerful influence in so far as tissue structure is concerned. If the physical characteristics of a family include a faulty mucous membrane, it is rational to suppose that such membrane will be more readily invaded by the agencies of disease, other things being equal, than other and more perfect tissues, when those agencies or causes affect the body. It is a matter of common observation that a case of gastric carcinoma frequently occurs in a family which has a history of that disease. It is sometimes discovered that lupus or some other neoplasm of malignant type has occurred in the family. The recurrence of such experiences make it probable that heredity influence is one of the strongest predisposing causes. The frequency of gastric cancer cannot be accurately stated. Statistics have been compiled by different authors, but while great care has been exercised the nature of the disease, the great number of cases which occur in private practice where post mortem examination is denied, and the frequent obscurity of the disease render statistics unreliable. Welch has made an exhaustive study of this field and estimates that in persons above the age of twenty years cancer of the stomach causes 1 per cent of all deaths. The frequency of cancer in the stomach as compared with the rest of the body is interesting; the author reports in 31,482 cases of primary cancer that 21.4 per cent' were located in the stomach. Many authors agree as to the relative frequency in male and female, and find that sex exerts no appreciable influence, the male being slightly more susceptible, and this apparent showing against them may be caused by their greater liability to exposure to traumatic and other probable causes. Age exerts a greater influence. In children the disease is rare, but it occasionally occurs. It increases in general to the age of 70 after which it decreases. The age most susceptible to cancer lies between 41 and 70, perhaps 75 per cent of all cases occurring within this limit; but the greatest number of deaths occur between 50 and 60. Cancer of the stomach occurs less frequently among negroes than whites in the ratio of, perhaps, 66 to 100. It is more frequent in Europe than in America, and among civilized than uncivilized races. Gastric ulcers, chronic gastritis, traumatisms, the action of corrosive poisons, and occupation have been assigned as causes. It is generally admitted (Hanser) that gastric ulcer, either open or cicatrized, may cause cancer. It is most likely to occur in large and deep ulcers with thick and indurated edges where there is little or no tendency to heal. It is nearly if not quite, impossible to prove that chronic gastritis causes cancer. These two diseases are characterized by similar symptoms, especially in the earlier stages, and until positive elements can be discovered by the microscope we are unable to decide whether cancer ever develops out of a chronic catarrh; that it is possible, however, we may admit. As to traumatic injury, corrosives and occupation we may hold that little is known and nothing proven. In private practice one is frequently led to believe that such agencies do exert an influence. In one case a laborer was struck in the stomach with an ax helve. The stomach remained sore and the epigastrium tender. In a few months he complained of constant pain. Examination revealed a tumor and symptoms of cancer. of which disease he eventually died, Another case in a farmer resembled |